Journey into International Health -Seminar of Public Health - Univ Miami May 2015

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Totoro, Ya Hariri!A Journey to International Health

Leopoldo Villegas MD, DTM&H, MSc, DrPH, AdvPHM

Senior International Health Advisor

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1

Content

The beginning

2 The opportunity

3 The consolidation

4 The expertise

5 The way forward

The beginning

Advantages:

• Ability to provide service and support to others

• Save lives

• Continuous learning

• Opportunity to appreciate medical science

• Teach students and patients about medicine

• Rewarding

• Decent salary

• High status occupation

Disadvantages:

• DEBT

• Long education.

• Long process to acquire a license

• Difficult

• Stressful

• Depressing when you are unable to help

• Time consuming

• Long hours

• A great deal of responsibility

• Managed care means more difficulty earning a

high salary

• Very significant student loans (hundreds of

thousands of dollars)

Studying Medicine

Yanomami

https://bluestockingbrazil.files.wordpress.com/2011/08/yanomami2peq.jpg

Health Problems

• Fever

• ARI

• Otitis

• Diarrhea

• Malnutrition

• Malaria

• Onchocerciasis

• Helminths

• Tungiasis

• Scabies

7Yanomami

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9

Parasites Mosquitoes Human

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Malaria 1993-1995 0135

Alto Orinoco – Ministerio de Salud - Venezuela

95%Main cause of death

64%Splenomegaly

21%Malaria Prevalence

High Anemia rate >60% (2-9 years)

associated with Hyperreactive Malarious Syndrome (HMS)

Actions

Why so many deaths after using the right treatment?

Why so many cases of severe anemia?

How to solve the problem?

Documented the malaria epidemiology Vectors

Parasites

Ecology

Human

?

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Results

Investigated malaria response to treatment (in vitro)

Identified poor response and 100% resistance in vitro to chloroquine –

first line treatment for malaria

Disseminated the findings

No well-received by politicians at MOH

No changes in treatment policies – death rate increased over time

New treatment provided by religious missions

Rapid improvement after treatment – children < 5 y

Changed MOH staff – recognition of “resistant” of the MOH

Temporary policy change for treatment of malaria in the Yanomami area

The Opportunity

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18

MSc 1996 – DTM&H 1996 – DrPH 2001

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20

Umpang

B U R M A

C H I N A

I N D I A

PAKISTAN

I N D O N E S I A

S U M A T R A

T H A I L A N D

B U R M A

L A O S

M A

L A Y S I A

SINGAPORE

C A M B O D I A

V I E T N A

M

G U L F O F S I A M

G U L F

O F

T O N K I N

A N D A M A N

S E A

B A Y

O F

B E N G A L

S O

U T

H C

H I

N A

S E

A

Singapore

Phnom

Penh

Bangkok

Vientiane

Hanoi

Rangoon

Kuala Lumpur

HO CHI MINH CITY

N

Country Capital-

BURMA, THAILAND, LAOS,

CAMBODIA, VIETNAM,

SINGAPORE and MALAYSIA

0 50 100 150 200 MI

0 50 100 200 300KM

Huey Haeng

Mae Ok Hu

Pop Pra

Maela Camp Mae Ra Mat Tak

Mae Sod

Perng Klerng

Ti Po Ji

Wa Lay

UmPiem Camp

Saw-O

Myawady

Tee No Ko

Huey Plakong

No Bo

Ta song Yang

HueyMi

Huey Namkun

Nu Po Camp

Munruchai

Mae Jan

Thai-Karen villages

Mae La camp

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Host

Parasite

Drug

Inmune Response Pharmacodynamics

Pharmacokinetics

Malaria Treatment

Resistance to antimalarial drugs

E %

C

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C H I N A

I N D I A

PA KISTAN

I N D O N E S I A

S U M A

T R A

T H A I L A N D

B U R M A

L A O S

M A

L A Y S I A

SIN GA POR E

C A M B O D I A

V I E T N A M

G U L F O F S I A M

G U L F

O F

T O N K I N

A N D A M A N

S E A

B A Y

O F

B E N G A L

S O

U T

H

C H

I N

A

S E

A

Singapore

Phnom

Penh

Bangkok

Vientiane

Hanoi

Rangoon

Kuala Lumpur

HO CHI MINH CITY

N

Country Capital-

BURMA, THAILAND, LAOS,

CAMBODIA, VIETNAM,

SINGAPORE and MALAYSIA

0 50 100 150 200 MI

0 50 100 200 300KM

Resistance in vivo

F (SP)

MSP

Q

M

CQ

Multidrug resistant Malaria SE Asia

Art

24

50

60

70

80

90

100

M15

M25

MAS3

Efficacy (%)

25

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

PF

PV

MIX

M25

MAS3

% of patients treated with M+A combination

IBN

cases/person/yr

year

26

50 60 70 80 90 100

Cure rate (%)

0

0.2

0.4

0.6

0.8

1

1.2P.f. infections/ person/ year

r2 = 0.68

SHOKLO

27

28

5 lost to follow up

1 refused

1 placenta previa

1 abortion

450 completed surveillance

1 poor compliance

33 lost to follow up

4 withdrew consent

3 side effects +1 died

492 received placebo

500 assigned placebo

3 lost to follow up

1 delivery

1 cerebral malaria

3 abortions

460 completed surveillance

2 poor compliance

23 lost to follow up

6 withdrew consent

1 side effect

492 received chloroquine

500 assigned chloroquine

1000 pregnant women

randomised

2946

Pregnant women available Figure 6.4. Kaplan-Meier intent-to-treat analysis of parasite-free survival.

403020100

1.00

.90

.80

Cum

ula

tive

pro

port

ion a

par

asit

aem

ic

Log Rank test =36.82; df =1; p<0.0001

Placebo

Chloroquine

Time since started prophylaxis (weeks)

Chloroquine prophylaxis against vivax malaria among

pregnant women – CP trial

The Consolidation

Instituto de Altos Estudios

“Dr. Arnoldo Gabaldon”

South American Network

Sentinel site

RAVREDA/AMI

25

50

75

100

Efficacy

%CQ AMO SP Q M CQSP AMOSP QDOX QCL ASSP ASDOX ASM ARTLUM

Overall Results Efficacy studies P. falciparum

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Antimalarial drug resistance in the Amazon basin, 2006

CQ

SP

Q (+D, Cl)

M

AMO

MAS

P. falciparum

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Antimalarial drug resistance profiles

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Artesunate+Mefloquine

vs. Coartem®

Artesunate + Mefloquine

Coartem®

First line treatment for P. falciparum in the Amazon región

Artesunate + SP

The Expertise

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Smallest independent country in South America

• part of the Guyanan Shield

• 163 821 km2

80% of the territory is tropical rainforest

Estimated population (2010)= 524,000 inh.

Mixed population:

• Creole, Chinese, Amerindians, Indians, Javanese,

Lebanese, Jewish, Brazilian and Dutch descendants.

Economy based mainly in bauxite, caolin, and gold.

Suriname

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Malaria has been a public health problem in Suriname

Successful malaria control program eradicated malaria

from the coastal area (1968)

Malaria transmission has been mainly in communities

living in the interior

Parasites species: Pf > Pv > Pm > Mixed

Vectors: Anopheles darlingi – primary vector

Excellent environmental conditions

Malaria in Suriname

Coastal

Interior

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Malaria Strategy – until 2005The country strategy for malaria control includes:

Adequate and prompt diagnosis and effective treatment

Vector control: Insecticide-treated nets, entomological surveillance

Information, Education and Communication– Behavior Change

Communication (IEC/BCC)

Intelligent surveillance, detection and respond to epidemics

• Stratification and implementation of tailored-made interventions

Monitoring and Evaluation: interventions, drug and insecticide resistance and

operational research

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Malaria in Suriname, 1965-2004

0

2000

4000

6000

8000

10000

12000 Guerilla war

CQ

resistance

War

ended

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0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Gold miner

s

LLNs, ACD, IRS, Media, KOTAB, P

What happened between 2000-2004?

Pre ACT ACT Plus

Flooding

•Several epidemics in the interior

• Treatment failures – Quinine

•Stock out of medicines -common

•Limited funding for operational activities

•Malaria control - case management

•ACT trials in 2003

•Approved R4 GF

•No previous experience on performance-

based funding

•Malaria cases started going down

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Stratification

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18th Meeting of the RBM Partnership

Monitoring and Evaluation Reference Group (MERG)

cases %

STOELMANSEILAND 963 15,3

APOEMA 679 10,8

GAKABA 679 10,8

DRIETABIKI 523 8,3

BROWNSWEG 434 6,9

LANGATABIKI 319 5,1

KWAMALASAMUTU 276 4,4

Total 3873 61,6

7 Poli = 61,6% malaria

63 localities - 60% malaria

Priorities

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Methodology similar to the malaria eradication program - 1950s

Interventions

• IRS

• Diagnosis

• Treatment

• Local/community participation

Important

• Good logistic system

• Adequate funding

• Knowing your population

• Adapt and implement what works

• Supervision - Monitoring

Management

• Strong leadership

• Commitment

• Political will

• Trained fully dedicated staff

• Strong surveillance system

• Stratification to the lowest ADM level

possible

• Mapping

• Priorities

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ACD/PCD

IRS

ACT+P

Mobile surveys

LLINs

BCC/IEC

PCD

ACT+P

LLINs

BCC/IEC

PCD

ACT+P

LLINs

BCC/IEC

Combination of interventionsMOH Suriname, 2004

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0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

MSDPf/Pv RDT

LLNs, ACD, IRS, Media, KOTAB, P

LLINsReplacement

Malaria Interventions in Suriname, 2000-2013Pre ACT ACT Plus

Flooding

2013

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2000

47

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2001

48

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2002

49

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2003

50

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2004

51

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2005

52

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2006

53

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2007

5418th Meeting of the RBM Partnership

Monitoring and Evaluation Reference Group (MERG)

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2010-2013

55

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Measuring impact

0

100

200

300

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

API AFI AVI AFI AVI

API

0

10

20

30 SPR %

y = -1813x + 18347R² = 0.8807

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Malaria cases

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0

2000

4000

6000

8000

10000

12000

14000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Pf/Mi…Pv

Cases by species

0

5000

10000

15000

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

PF/MIX

PV/PM

0

100

200

300

400

0.00

200.00

400.00

600.00

800.00

200020012002200320042005200620072008

Hospitalization

Deaths

Measuring impact

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Changing scenarios

Malaria cases by age-groups

(%)

Malaria cases by sex (%)

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Autochthonous vs. imported malaria

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Authocthonous Imported

2014

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0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

RBM target 50% MDGs

target

75%

Reaching Targets RBM 2010 & MDGs 2015

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Cross border impactMalaria impact along the Suriname-French Guyana

border

• Cooperation between countries

• Financial and technical support

• Close collaboration with health authorities

• Malaria risk decreased along the border areas in both

countries

• Gold miners remains the challenge!

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Malaria among gold miners

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Road map for malaria elimination

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

MAL R4

MAL R7 Gold miners

Elimination Phase 1

CONSOLIDATION MAL ARIA EFFORTS

elimination – cross cutting research-leadership

2020

Phase 2

Suriname a malaria-free country by 2020

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Malaria contextual factors & macro picture

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Sub-Regional Picture

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Similar mining

activities in the

Guyanan

Shield

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http://en.wikipedia.org/wiki/Gold_reserve

World Gold reserves per capita

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Epicenter multidrug resistance

Border areas in the Guyanan Shield: malaria transmission areas

Malaria Update

Control Pre-elimination EliminationPrevention of

reintroductionMalaria free

SPR<5% <1 case/1000 pop at risk 0 locally acquired cases 3 years

From Control to Elimination

Control Pre-elimination EliminationPrevention of

reintroductionMalaria free

National: DHS, MICS, MIS, RMIS

State: DHS, MICS, MIS, RMIS

District: RMIS

Facility/Sentinel: RMIS

Community/Individual: RMIS

No households surveys (2011-2013)

At least 1households surveys (2011-2013)

Measuring Malaria

Artemisinin

Resistance

80%

3.4 BPopulation at

risk

200 MCases

600 KDeaths

Financial

>3.3 MDeaths prevented

50%# children dying

Cases

Deaths

Funding

2000 2012

Impact

NigeriaDR Congo

Madagascar

South East Asia – Mekong Subregion

Kenya

% Deaths <5 y #cases PW #cases >5 y

Democratic Republic of Congo

The Way forward

Big

Data

Big Data

Datasets generated from a variety

of instruments

Large

Diverse

Complex and/or longitudinal

Large data – requires special

distributing computing to process

and analysis

1 Petabyte = 1 quadrillion bytes

1 Terabyte = 1 trillion bytes

1 Gigabyte = 1 billion bytes

1 Megabyte = 1 Million bytes

Characteristics of Big Data

Volume Variety Velocity

Data at scale

TB to petabytes

Data in many forms

Text, structured, mixed

Data in motion

Analysis of streaming

data for decision

Veracity

Data uncertainty

Managing the reliability and predictability of imprecise data

Sources of Big Data

http://www.micscompiler.org/

http://www.childinfo.org/mics4_surveys.html

World Development Indicators

Sustainable Development

“Development that meets the needs of the present without

compromising the ability of future generations to meet their own

needs."

Rational use of natural resources and energy, pollution, and climate

change.

In development terms, sustainability means responsible growth—

when social and environmental concerns are aligned with people's economic needs.

EasyPol Issue 102, 2011

Sustainable Development

Big Data for Results® - Health

National State/Province District PHC facilities Health sub-centers Communities

Civil registration Census National records Population surveys Service records

Other routine and non-routine data

Climate – Infrastructure – Migration & Important events – Natural disasters – Development projects

Technical Review Panel

To support the Global Fund in financing effective programs, the Board relies

on an independent panel of international experts: the Technical Review

Panel (TRP).

• The TRP comprises the Chair, two Vice-Chairs and a pool of experts.

• The TRP consists of experts in HIV/AIDS, tuberculosis, malaria, health

systems, community systems and cross-cutting development issues.

Takeaways

“It’s being in the right place at the right

time and taking the advantage of your

opportunities”

Lee Majors

“Choose a job you love, and you will never

have to work a day in your life.”

Confucius

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Leopoldo VillegasMD, DTM&H, MSc, DrPH, AdvDPHM

[email protected]

leopoldovillegas

@LeopoldVillega

www.linkedin.com/in/leopoldovillegas

Thank you!

Q&ACredits:Photos: several Google images (search Yanomami), Dr. Salvatore Ferraro, Dr. Leopoldo Villegas; LSHTM; SMRU; Wellcome

Trust; ICF international/MEASURE Evaluation; Global Fund; World Bank; CDC; DHS program; EasyPol Issue 102,

2011; PAHO/WHO; MOH (Venezuela, Suriname, Peru, Colombia, Ecuador, Bolivia); Google maps; Camara Andina de

Fomento; AMI/RAVREDA; bluestockingbrazil.

Infographics: Dr. Leopoldo Villegas

Icons: www.flaticom.com