MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS FORUM 2009 PAHO, WASHINGTON DC NOVEMBER 6, 2009 Presentation outline -Definitions and statistics.

MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS

FORUM 2009 PAHO, WASHINGTON DC

NOVEMBER 6, 2009

Presentation outline

-Definitions and statistics at a glance

-Health implications of mobile populations: refugees, displaced

populations and infectious and tropical diseases

-Mobile populations and impact on malaria transmission

-Key elements for discussionCARLOS ESPINAL M.D. Director Public Healthsanofi pasteur Latin America

WHY POPULATIONS MOVE ?

Internal conflicts Violence

Internal conflicts Violence

Natural disasters

Natural disasters

Migration related to natural resources:

mining, agriculture, oil

Migration related to natural resources:

mining, agriculture, oil

Human rights

violations

Human rights

violations

Commerc

e in frontiers

Commerc

e in frontiers

Government and irregular

Military Forces

Government and irregular

Military Forces

REMARKS

•Medicine and public health focused on pathogens

•Today focus should be in globally move populations that move pathogens across international borders and internally

•Human mobility has always been associated with the spread of diseases: Influenza H1N1, avian FLU, dengue, malaria, TB, HIV, SARS

•Impact of migration patterns is a great challenge for modern epidemiology and public health programs

Mobile populationsUNHCR definitions and statistics at a

glance 2008: 42 million forcibly displaced people

worldwideRefugees

Status of RefugeesPeople crossed international border

2008: 15 million

Asylum-seekers

Claimants for refugee status pending of approval

2008: 827.000

Internally displaced

persons (IDPs)

People forced to leave habitual residence, who have not crossed international borders

2008: 26 million

Natural Migrants (borders

populations)

Individuals or groups with residence within the international borders, with a wide circulation across the frontiers

Return refugees

(returnees)Refugees who returned voluntarily to their country of origin or habitual residence

2008: 604.000

Returned IDPsIDPs beneficiaries of protection and assistance to return to their habitual residence

2008: 1.3 million

2008 Global trends UNHCR

2009

StatelessNo belonging to any recognized state or Nation

2008: 6.6 million Overall about 12 million

COUNTRY 26.000.00026.000.000

SUDAN 4.900.000

COLOMBIA* 2.650.00-4.360.000

IRAQ 2.840.000

PAKISTAN 2.400.000

DEMOC REP CONGO 2.000.000

SOMALIA 1.300.000

ZIMBABWE 1.000.000

AZERBAIJAN 603.251

KENYA 400.000

AFGANISTAN 235.000

ETHIOPIA 200.000-300.000

PERU* 150.000

UNHCRInternally displaced

Persons IDPs 2008

UNHCRInternally displaced

Persons IDPs 2008

Populations of concern to UNHCR 2008

Latin America: 3.571.620

Latin America: 3.571.620

Hazard type

Geophysical

Meteorolog

Hydrolog Climatol All disasters

No of disasters

21 61 128 11 221

Total displaced

and evacuate

d

15,769.430

8.246.523 11.485.418

561.472 36.062.843

People displaced and evacuated by sudden-onset natural disasters 2008

Natural disasters: Earthquakes, floods, storms

Country Total displaced and evacuated

China 19.979.423

India 6.705.085

Philippines 2.736.389

USA 2.014.473

Cuba 980.000

Country Total displaced and evacuated

Myanmar 800.000

Indonesia 400.815

Brazil 381.035

Mozamb 289.486

Thailand 202.680

MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND TROPICAL DISEASES

MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND TROPICAL DISEASES

•Denmark: TB incidence in foreign-born persons rose from 18% in 1986 to 60% in 1996 (1)

•England: TB, 40% of new cases occur in people from Indian subcontinent (1)

•Germany: 14% of HIV/AIDS cases are detected in migrants from Africa, USA, Asia, and Latin America (1)

•USA: Polio, in 2005 Minnesota State Health Department detected vaccine-derived poliovirus infection in 4 children, in unvaccinated community, probably originated in a person vaccinated with OPV in another country (2)

•Polio: 2003-2006, polio imported to 24 polio-free countries (2)

•USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000 in foreign-born persons

•Denmark: TB incidence in foreign-born persons rose from 18% in 1986 to 60% in 1996 (1)

•England: TB, 40% of new cases occur in people from Indian subcontinent (1)

•Germany: 14% of HIV/AIDS cases are detected in migrants from Africa, USA, Asia, and Latin America (1)

•USA: Polio, in 2005 Minnesota State Health Department detected vaccine-derived poliovirus infection in 4 children, in unvaccinated community, probably originated in a person vaccinated with OPV in another country (2)

•Polio: 2003-2006, polio imported to 24 polio-free countries (2)

•USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000 in foreign-born persons

(1) M Caballero A Nerukar Em Inf Dis 2001. 7(3):556-560

(2) E Yanny et al. Em Inf Dis 2009. 15(11):1715-1719

IMPORTED INFECTIOUS DISEASES IN MOBILE POPULATIONS SPAIN

B Monge-Maillo et al. Emerg Infect Dis 2009. 15(11);1745-1752

Diagnostic Population n=2.198

Sub-Sah Africans

Latin America

Malaria (1)

Chagas (2)

212 101

199 0

101 13 101

Filariasis Cysticercosis

42131

4183

328

Latent TBActive TB

716107

59652

12055

HIVAcute Hepatitis

9731

8227

154

Chronic hepatitis

267 257 10REMARKS:

2008: EU 1.9 million immigrants. Spain 700.000.

Total Immigrants in Spain by 2008: 5.2 million

(1) Malaria: 15 patients (7.1%) were asymptomatic. P falciparum most frecuent in Africans.

(2) Chagas: 95% of positive patients from Bolivia. Study in Spain estimated between 37.000-122.000 immigrants potentially infected with T cruzy

Migrant mine workers

MOBILE POPULATIONS IN LATIN AMERICA 2009

México

Guatemala

Chile Argentina

Brasil

Bolivia

Perú

Venezuela

Colombia

Uruguay

Panamá

Paraguay

Conflicts, violence, IDPs (UNHCR?) Refugees,

Nicaragua

Cuba

Gold explotation: Brazil, Venezuela, Surinam , Bolivia, Guyana

Ecuador

World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTOGMC/0,,contentMDK:20212491~menuPK:463310~pagePK:148956~piPK:216618~theSitePK:336930,00.html

Castaneros Bolivia (nut harvesters): Brazil

Malaria Latin America 2007

WHO/UNICEF Report 2008

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 20070

50000

100000

150000

200000

250000

300000

350000

400000

450000

1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

www.codhes.org

YEARS

No Persons

380.863

412.553

Consultancy for Human Rights and Displacement (CODHES) National estimates: 4.629.190 persons

Average: 925.838 families

305.966

HEALTH INDICATORS IN GOLD MINING WORKERS LATIN AMERICA

Bolivar State, Venezuela. L Faas, et al. Pan Am J Public Health , 5(1) 1999

Totals

893 STDs (1 or 2): 178 (19.6%)

Syphilis: 148 (16.6%)

Population profile: Concentration of men, ages 20y-45y, very limited female population, miners in permanent migration, rise of violence, alcohol and drug abuse. Inadequate housing, living in tents, poor sanitation.

Guyana, Amazon Region. CJ Palmer et al. Emerging Infectious Diseases 8(3), 2002

Totals

216 HIV+: 14 (6.5%) Impact of co-infection HIV-Malaria

Apiacas, Mato Groso, Brazil. FJ Dutra et al. Hepatitis B markers in malaria-exposed gold miners. Mem Inst Oswaldo Cruz, 96, 2001. Garimpo satelite: 16 gold mine campus

Totals

Malaria

569 Age 20-40y

99.4 % with previous episodes

HBV markers 82.9%

610 (20%) positive for

malaria

HBsAg 7.1%

P falciparum56 (53%)

HCV 2.1%

P vivax47 (44%)

1. Mass population movements could occur in endemic areas., e.g., the Amazon frontiers.

2. Industry – mining, rubber, agriculture, oil fields, attract migrant workers to new areas

3. Incidence and burden of disease will depend upon immunity, intensity of malaria transmission, vectors, and health care services

4. Malaria can be responsible for high rates of morbidity and mortality

5. Displacement exacerbates rapid urbanization in marginal areas, with poor housing condition and sanitation, inadequate vectorborne control, and amplification of malaria to epidemic proportions

MALARIA AND HUMAN POPULATION MOVEMENT

CHALLENGES FOR PUBLIC HEALTH INTERVENTION

Epidemiology of malaria in

mobile populations

Epidemiology of malaria in

mobile populations

1. Health service personnel trained in malaria

2. Demography data, determine high risk groups or vulnerable populations (pregnant women, children)

3. Case definition and case management. Active reporting and high quality data

4. Active vs passive surveillance

5. Rapid diagnostic tests. Blood smears and microscopy routine technique. Asymptomatic case detection by PCR (MS Suarez et al Rev Inst Med Trop S Paulo 49(3) 2007. 20% detection in P vivax)

6. Monitoring of drug efficacy and resistance

7. Hospital-based surveillance for clinical complicated malaria and fatal cases

1. Health service personnel trained in malaria

2. Demography data, determine high risk groups or vulnerable populations (pregnant women, children)

3. Case definition and case management. Active reporting and high quality data

4. Active vs passive surveillance

5. Rapid diagnostic tests. Blood smears and microscopy routine technique. Asymptomatic case detection by PCR (MS Suarez et al Rev Inst Med Trop S Paulo 49(3) 2007. 20% detection in P vivax)

6. Monitoring of drug efficacy and resistance

7. Hospital-based surveillance for clinical complicated malaria and fatal cases

MALARIA AND HUMAN POPULATION MOVEMENT

CHALLENGES FOR PUBLIC HEALTH INTERVENTION

Surveillance systems

Surveillance systems

Vector surveillance

Vector surveillance

1. Selection of antimalarial drug and appropriated regimens. Effective drug combinations. Artesunate combinations. High levels of acceptability in the community and adhesion to treatment

2. Mass drug treatments upon arrival at camps vs selective treatment to febrile patients?

3. Treatment only in confirmed cases?

4. Train local community leaders in techniques for rapid diagnosis and treatment. ( e.g.,Bolivia’s successful case study: reducing malaria in mobile populations in castaneros workers)

MALARIA AND HUMAN POPULATION MOVEMENT

CHALLENGES FOR PUBLIC HEALTH INTERVENTION

ChemotherapyChemotherapy

1. Overburdening of existing health structure: insufficient personnel, hospitals or clinics, problems with access to medicines including antimalarial drugs, deficiency in lab diagnosis, equipments

2. Malaria control strategies integrated to global health interventions in displaced population, refugees, and mobile workers

3. Very few interventions measure the impact . Effectiveness is not consider it or limited in methods to evaluate their success.

MALARIA AND HUMAN POPULATION MOVEMENT

CHALLENGES FOR PUBLIC HEALTH INTERVENTION

Health servicesHealth services

1. Large gap in the evidence of what works for change the behavior of public and private health providers. Pay attention to health system constraints that impact effectiveness and sustainability of malaria interventions. LA Smith et al . Improve effective treatment malaria: Do we know what works? Am J Trop Med Hyg. 80(3), 2009:326-35

2. Resettlement or repatriation: possible introduction or reintroduction of multi-drug resistant malaria. Mass screening strategies?, mass treatment before departure?

3. How to achieve sustained high coverages of control measures: rapid diagnosis and effective treatments with simple schedules, insecticide residual spraying, preventive treatment in vulnerable groups, long-lasting insecticide treated mosquito nets.

MALARIA AND HUMAN POPULATION MOVEMENT

CHALLENGES FOR PUBLIC HEALTH INTERVENTION

Health servicesHealth services