Two major areas to cover in the next two weeks: Pandemics Contagion in a very real sense. Threats to global health. Global Health indicators The Double.

Global Health

Two major areas to cover in the next two weeks:

PandemicsContagion in a very real sense.

Threats to global health.

Global Health indicatorsThe Double Burden.How are we doing?

Throughout, to make the connections to globalization processes.

Diseases, communicable or non-communicable, are relatively predictable in their patterns across regions

and time.

Their ‘burden’ can be estimated and incorporated into development goals.

But what about epidemics and pandemics, which are:

Chaotic in time and space.Respect no boundaries.

Burden is shared: like climate change it is unequally and inequitably distributed - caused by some, felt by

all.

Epidemics and Pandemics

Epidemics are considered to be outbreaks of a disease that far exceed the normal ‘base-line

incidence rate’ of that disease.

They can be of communicable (infectious) or non-communicable (not infectious).

They are usually confined within a larger region or nation.

Pandemics are all of the above, but the term is usually reserved for infectious diseases that cross

national boundaries.

In this sense they a phenomenon of globalization.

Epidemics Versus Pandemics

Epidemics and Income

No correlation between wealth and deaths from epidemics

Source: Gapminder

Pandemic

s

1320s?

1338

1340s?

1349

1346

Tibetan Plateau& The Himalaya

Indochina Rivers:Mekong, Chang

Spread of the Black Death in Asia, 1320s-1350

BaghdadHsian

Hangzhou

Beijing

Mecca

Saral

Samarkand

Kaffa

Yersinia pestisBubonic plague bacilli

Rattus rattusBlack rat

Xenopsylla cheopisOriental flea

Debate About The Great PlagueSome researchers believe the Great Plague was either a

viral hemorrhagic fever or bacillus based anthrax and not caused by Yersinia pestis.

But excavation of a plague pit in London, England in 2011 demonstrated that it was Yersinia pestis.

The plague is actually three diseases:Bubonic or lymph system infection

Mortality: 1-15% with treatment, 70-80% withoutSepticemia or blood infection

Mortality: 40-60% with treatment, 100% withoutPneumonic or lung infection

Mortality: 100%

Nursery RhymesRing around the rosyA pocketful of posies

"Ashes, Ashes"We all fall down!

This delightful nursery rhyme came into being around 1665 with the Black Death hit London, England, and it detailssymptoms, ‘treatment’, and outcomes of the disease.

There are still about 1,000 to 3,000 cases each year around the world, and since 1990 there have been 134 cases

reported in the U.S., 65 of them in New Mexico.

Chance of dying from plague today is about 1 in 30 million. In the 14th century it was 1 in 2.

Source: CDC

Source: CDC

CDC

The 1918 Flu Pandemic

Camp Funston, Fort Riley, Kansas

Killed 40 million in just 24 weeks

Killed over 100 million in two years

Killed mostly 15-35 year old cohort

“They were doubly dead in that they died so young.”Dr. Harvey Cushing, prominent surgeon of the day.

An estimated 8-10% of the cohort died

Started at Camp Funston, February 1918

By March 1,100 sick, 237 pneumonia, 37 died

Starting June 1918 troops ship out to Europe

Hundreds of troops transfer between hundreds of camps

Sept to November 1918 the peak deaths period

Pandemic lasted for three years 1918, 1919, 1920

In those 12 weeks over 20 million died

Over that period 60 to 100 million died

Week of Sept 28, 1918 Week of Dec 14, 1918

Deaths Per Thousand

Age Specific Death Rates Per 100,000 Before and During the PandemicCrude death rates in US before and after 1918 pandemic

Year 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923

Rate 10.0 12.3 8.9 15.7 27.0 17.4 301.8 99.0 70.5 11.3 31.0 44.1

Average crude death rate before and after 1918 = 21Average crude death during the flu years = 157

Excess Mortality by Age and Gender

Age cohort 14-40

Number of cases and number of

deaths, Switzerland

U.S. Life Expectancy 1900 to 1960

“The following 72 Inupiat Eskimos are interred in this common grave. Pray, honor and remember these

villagers who lost their lives in the short span of five days in the influenza pandemic November 15-20

1918.”

In 1997, 71 year old retired pathologist Johan Hultin travels to Alaska and retrieves the lungs of an Inuit

victim of the 1918 pandemic.

He sends the samples to molecular biologist Jeffery Taubenberger.

He discovers that the 1918 virus was a mutated bird virus.

Taubenberger uses the lung tissue and tissue from army victims to reconstruct the 1918 virus.

The pathogen of 1918 was a virus of the genus Orthomyxoviridae.

The strain is called H1N1 and is a close relative to the current Avian Flu strain H5N1 - too close a kissing cousin to the virulent

1918 flu for comfort.

Normal mortality rates for flu are about 0.5%. The fatality rate of the 1918 flu was between 2% & 20%.

In some isolated communities it was 100%.

The fatality rate of the recent Avian flu is about 35%.

The concern is a new flu with the virulence of the 1918 flu and the mortality rate of the current Avian flu.

And both came from birds.

The 2009 pandemic was also H1N1 but did not show itself as virulent as the 1918

pandemic.

Antibody tests of 40 people born before 1920 show that they are resistant to the

2009 H1N5 strain.

That is very scary because it shows how genetically close H1N1 and H1N5 are.

Current Avian flu strain first surfaced in Britain in 1959.

First human cases occurred in 1997.18 infected, 6 die, fatality rate of 33%.

In 2003 3 more cases and 2 deaths occur in Hong Kong, but disease does not appear to be human to human.

Later that year big cats at a Thailand zoo became infected and died.

In 2004 a major outbreak occurred among domestic fowl in China and Vietnam, spreading to other South Asian

countries, spread through infected wild waterfowl.

January 2005, Vietnam kills 150 million chickens.

April 2005 – mass die off of migratory waterfowl in Central China.

By the end of 2005 mass die-offs in Central and southern Russia.

During 2006-2007 mass die-offs of migratory wildfowl continued.

Between 2003 and October 2007 there have been 331 cases and 203 deaths for a fatality rate on 63%.

If and when H5N1 or even H1N1 strikes again, it will put 1918 in the shade.

Cholera

From first symptoms to death through hypotensive shock can be as short as 2-4 hours but more usually 4-16 hours. Families would wake

up normal and be dead by evening.

The pathogen is a bacterium called Vibrio cholera.

Its natural hosts are humans and its vector is through human fecal contamination of the water supply.

There have been at least 7 major pandemics in the last 200 years, the first of these starting in Bengal in 1816.

About 10 million people died from the disease over this period.

Endemic to the Indian sub continent, with its major reservoir being the Ganges River.

In 2010 470,000 cases of Cholera occurred in Haiti just after the earthquake, and caused over 6,600 deaths.

Globally there are still 2-5 million cases each year, resulting in 100,000 to 200,000 deaths.

Between 1991 and 1994 in South America, cholera infected over one million people and killing 10,000.

Caused by a ballast discharge from an Indian cargo ship.

Early Epidemiology - Dr. John Snow’s Map of cholera deaths and the Broad Street Pump

Smallpox Eradication

A Story of Global Cooperation

Smallpox is a horrifying and deadly disease that had plagued humanity for thousands of years.

It is also the villain of a success story – the only one that has resulted in the eradication of a disease.

SMALLPOX ERADICATION – A GLOBAL SUCCESS STORY

Caused by a pox family virus called Variola – v. major and v. minor. Both cause disease but v. major is deadly – 35% mortality.

A vaccine for the disease was first discovered in 1796 by Edward Jenner who found that milkmaids with cowpox - a milder cousin -

did not contract smallpox.

By injected people with extracts from cowpox sores he thus prevented them from getting smallpox. Hence the term vaccine –

from the latin word for cow – vacca.

But it is what happened between 1958 and 1974 that is of interest.

SMALLPOX ERADICATION – A GLOBAL SUCCESS STORYBefore 1958 smallpox infected 50 million people a year in over 30

countries, killed about 2 million, and left millions more with horrifying disfigurements.

At the instigation of the Soviet Union, in 1958 the World Health Authority (later to become the WHO) commenced campaign to

eradicate smallpox from the earth.

What makes smallpox a disease that could be eradicated?1. No sub-clinical infections (you caught it, you showed it).

2. No non-human reservoirs or vectors.3. Victims infectious for only 5 days.

4. Effects severely debilitating limiting mobility.5. Clearly recognizable symptoms.

6. Cheap, effective, easily transported vaccine available.7. Once vaccinated, always protected.

A campaign of (1) identify cases, (2) surround and buffer outbreak, (3) immunize everyone was started in 1967.

SMALLPOX ERADICATION – A GLOBAL SUCCESS STORY

While no naturally occurring smallpox virus is alive today, both the U.S. and Russia keep samples in case the other uses it as a weapon.

It is reported that Russia currently has several tons of freeze dried genetically engineered hemorrhagic smallpox virus stored.

In 1978 a photographer working at a government lab in England was accidentally infected and died – the last case to do so. On May 8th

1980 the WHO declared the earth smallpox free.

By 1975 the last case of v. major was cured in Bangladesh, and by 1977 the last case of v. minor was cured in Somalia.

U.N. has voted several times to destroy these samples but the U.S. and Russia refuse. Genome has been sequenced so no reason to

keep the actual virus around.

The Current Ebola Pandemic

Ebola virus budding from dead cell

Ebola Overreaction?Ebola is a disease that has been in the news due to

the recent pandemic in West Africa.

Two things make this epidemic interesting to us:

The direct effect of globalisation on its spread.

The reaction of authorities and people to it.

Because the Ebola epidemic is not one that should have elicited such a response.

Ebola FactoidsNo doubt that this is a scary pathogen:

Ebola prevents clotting so when it buds from a cell the cell disintegrates and you bleed out internally,

leaking from your orifices and other breaches in the dermis.

Mortality Rate is very high - 40-90%.

It is extremely infectious (as few as a single virion can infect you) but not very contagious (it’s hard to catch

since its not airborne).

It’s not very virulent (doesn’t spread easily) but is lethal (you likely will die and quickly).

Ebola FactoidsReservoir is thought to be fruit bats (that remain asymptomatic), and it also effects other primates

such as gorillas and especially chimps.

Spread by direct contact with infected body fluids.

Cultural actions such as corpse washing, kissing, touching spread the disease.

Incubation about 8-10 days, symptoms in last 4-6 days of incubation period, death within 2-4 days of

symptoms presenting.

Corpses remain infectious for as long as there are cells to colonise, but recovered victims do not remain

infectious.

Ebola HistoryFirst came to light in 1976 in villages along the Ebola

River in Zaire (formerly DR Congo).

Several other outbreaks in Zaire, Sudan, Ivory Coast between 1976 and the 2014 outbreak, the most

significant being one that was started by Belgian nuns at a medical mission who used infected needles.

Outbreaks have been caused in most cases by the butchering of infected chimps as bush meat.

Historically the disease is controlled by its lethality – it incapacitates and kills too quickly for it to spread.

So what happened in 2014?

Ebola 2014Globalisation happened.

Population densities increased greatly, especially in cities.

Free trade agreements opened cross border work options for people so they moved further, quicker.

Speed of travel increased due to more and different modes and mediums of travel.

Inadequate governance could not control the infection once it started to spread: inadequate health

facilities and knowledge, corrupt and incompetent officials, poor communication.

Ebola 2014Global Village echoed what was happening around the world, media show up, people see the disease and its

victims, along with the poor response from their governments on their TVs and internet.

Misinformation about the disease spreads through available channels such as TV, internet, cell phones,

resulting in:Proper prevention information is ignored or lost in the

noise.People shy away from what few (and later better) facilities

exist.People hiding sick relatives because they think hospitals

are killing them.Continue with cultural burial practices that spread the

disease.

RECORDED EBOLA CASES, 1976-2014 (Source: CDC)

Date CountryNumber of

human cases

Number of deaths

% Fatality Rate

2014 Multiple Countries, incl. DR Congo 23,472 9,506 40.5%2013 Uganda 6 3 50.0%2012 DR Congo, Uganda 44 17 38.6%2011 Uganda 1 1 100.0%2008 Congo, Philippines, Uganda 187 52 27.8%2007 Uganda, DR Congo 413 224 54.2%2004 Russia, South Sudan 18 8 44.4%2003 DR Congo 178 157 88.2%2002 Gabon, DR Congo 122 96 78.7%2001 Uganda 425 224 52.7%1996 S. Africa, USA, Philippines, Russia, Gabon 100 68 68.0%1995 DR Congo 315 250 79.4%1994 Gabon, Ivory Coast 53 31 58.5%1990 Philippines, USA 7 - 0.0%1979 South Sudan 34 22 64.7%1977 Zaire (now DR Congo) 1 1 100.0%1976 Sudan, Zaire (now DR Congo) 602 431 71.6%

Total Number of Ebola Cases:25,978

Total Number of Deaths:11,091

Fatality Rate:42.7%

Current Ebola 2014-2015 PandemicAs of February 1, 2015:

Guinea – 2,975 cases, 1,944 deathsLiberia – 8,745 cases, 3,746 deathsMali - 8 cases, 6 deaths Nigeria - 20 cases, 8 deaths Senegal - 1 case, 0 deaths (infection originated in Guinea)Sierra Leone – 10,740 cases, 3,276 deathsDR Congo – 66 cases, 49 deathsSpain - 1 case, 0 deathsUnited Kingdom - 1 case, 0 deathsUnited States - 4 cases, 1 death (two infections originated in the United States, one in Liberia and one in Guinea)

Source: World Health Organization and CDC.

Ebola Range

Malaria Range

Malaria:According to WHO data about 3.2 billion people – almost

half of the world's population – are at risk of malaria.

In 2013, there were about 198 million malaria cases and an estimated 584,000 malaria deaths.

That’s about 7,622 times more cases, and 52 times more deaths than Ebola.

World Bank Estimates of Ebola PandemicTreating the Ebola pandemic so far:

$518 million.Cost of recovery packages:

$450 million.Loss to economies:

$1.6 billion.

Putting Things Into Perspective

Cost of Treating Malaria:$60 per case.

$20,547 per death.

Cost of Treating Ebola:$19,939 per case.

$46,704 per death.

Putting Things Into Perspective

And Lest We Forget – The Current Measles Epidemic

This one is close to home and speaks to the complacency of the majority and

the scientific ignorance and irresponsibility of the anti-vaccine

group.

The so called “anti-vaxxers” continue to spread discredited and unfounded rumours and misinformation that is dangerous to everyone and not just

them.

Let’s look at some of their claims.

The Current Measles Epidemic - Anti-vaxxer Claim #1The vaccine (as do all) causes autism:

This myth came from a completely discredited but published study by a UK ex-doctor called Wakefield

who was later struck off the register for using fraudulent data, incompetent statistics and

dangerous claims.

The problem here is partly society’s. We don’t publish papers that don’t find anything. Its called negative

results bias.

Wakefield still wanders the world being paid by anti-vaxxers to talk about his “results” and is seen as a folk

hero to some of them.

The Current Measles Epidemic - Anti-vaxxer Claim #2Thimerosal causes autism:

Thimerosal is a mecury containing preservative occasionally used in vaccines, and a crackpot

organization known as Generation Rescue, which appears bent among other things on “saving” people from vaccinations, along with Robert F. Kennedy Jr.

started rumours that it caused autism.

There had been no studies either way to support of deny the claim, so they were done and found zero correlation between the thimerosal and autism.

And the mercury? There’s more in a tuna fish sandwich – or an Advil.

The Current Measles Epidemic - Anti-vaxxer Claim #3Cases have been decreasing long before vaccines.

This is just wishful thinking on the part of anti-vaxxers.

Yes the number of cases of just about every major infectious disease have been decreasing through better

prophylactic care and public health knowledge. BUT:

The population is not immune from these diseases.The fact that the number of cases decreases does not mean that the disease has gone – it hasn’t. There is no

herd immunity – diseases still sits waiting for an outbreak.

Lower is not the same as zero.Decreasing numbers of cases is not the same as zero

cases. Some people, mostly kids, still die and the disease still lives in the host population.

The Current Measles Epidemic - Anti-vaxxer Claim #4Your own immune system is good enough.

Well, would that it was but if it were we wouldn’t need vaccines to start with.

Your immune system will not protect you against measles, which is just about the most contagious disease in the world, or any other infectious disease. Walk into a doctor’s waiting room two hours after an infected person had been in there and there is a high probability you will

catch the disease.

If you are vaccinated, you are safe unless:You are in chemotherapy.

You are pregnant.You have an otherwise compromised immune system.

The Current Measles Epidemic - Anti-vaxxer Claim #5Everyone else is vaccinated so what’s the problem.

Apart from the selfishness of this claim, it’s ill-informed nonsense. This refers to “herd immunity” which theorizes that if enough people in a population (the herd) are protected, then

the disease cannot easily spread.

But measles, like any disease, continues to exist because of wild reservoirs of the pathogen – in the case of measles the

wild reservoir being unvaccinated people.

But measles is so contagious it requires a “herd” approaching 98% of a population, so even a few unvaccinated people form a

viable reservoir.

As well, you are only protected by herd immunity as long as you stay in the herd. Visit anywhere without herd immunity (such as most of the world) and you can catch the disease.

The Current Measles Epidemic – The Real DangerMeasles is not a harmless disease, but it is not the

crippling killers than tuberculosis, polio, diphtheria, rubella, whooping cough, mumps, chickenpox, etc, are.

Together these diseases accounted for most of the very high infant mortality rates in pre-vaccination days.

More disturbing, antibiotics are getting fewer and less effective, and anti-virals are few and far between or non-

existent, so if people do get these diseases, they will have virtually no effective drug interventions.

That is why we invented vaccines – the single most effective way to prevent illness and death.

Vaccination begins 1963

Widespread vaccination begins

late 1940s.

Pertussis (Whooping Cough) Death Rates 1900-1966

Diphtheria Death Rates 1900-1966

Vaccination begins 1920.

Controlling DeathMeasles Mortality Rate in the United States 1900-1990

Vaccination begins in 1963,

virtually eliminating

disease.

Lower rates stabilize 1942-1964 but still

happen due to extant disease.

Rapidly declining rates 1925-1942 with better prophylactic care. But the disease is still extant are people still die.

Stable high mortality 1900-1925.

DEMOGRAPHIC Transition

Source: CDC.

In the 2000s a backlash against immunization (decrease in vaccination rates), caused a recurrence of and increase in measles until increasing

vaccination rates reduced the incidence rates again.

Vaccination rate

Incidence rate

Controlling Death – An Ongoing BattleMeasles Incidence and Vaccination Rates, England & Wales

18000

16000

14000

12000

10000

8000

6000

4000

2000

01990 1992 1994 1996 1998 2000 2002 2004 2006 2008

100%

95%

90%

85%

80%

75%

DEMOGRAPHIC Transition

Pandemics and GlobalisationFact of life anywhere there is life.

Natural control is infection burn-out.

The higher the virulence, the faster the burn-out, the smaller the spread.

Changes in the speed of transmission now threatens these controls, especially virulence.

Resistance to drugs makes pandemics more likely.

Eight major links to increased threat of pandemics and globalization…

Number of Syphilis Cases, U.S., 2005-2013

Use of online “hook-up” apps such as Tinder, Grindr has led to

significant increase in syphilis cases and other STIs.

Tinder has about 50 million users since 2012 and makes 15 million

matches a day.

About 40% of the increase in syphilis is attributed to hook-ups via these apps, and about 40% of

the rest from a relaxing of attitudes towards safe sex due to

perception that HIV/AIDS is no longer a death sentence.

Source: New Scientists, 2015

Pandemics and Globalisation1. Speed of transmission.2. People’s propensity and means to travel.3. Trade and volume has provided new vectors.4. More wild ecosystems in contact with humans.5. Climate change is increasing insect carrier vector range.6. Industrial agriculture’s abuse of antibiotics.7. Industrial agriculture’s abuse of chemical controls (DDT).8. Environmental concerns limit effective controls (DDT).9. Cultural memory forgets: because we have not experienced disease due to vaccination, we forget its awful consequences.

Global Health

Burden of Disease

Pandemics

Changing DemographicsAging

Demographic transition

Changing EconomicsDevelopment

Industrialisation

Changing TerritoryBorders

More countriesConflict

Changing GeographyGlobal village

TransportationCommunication

Summary

Changing

Culture

Changing

Environment

Now don’t Forget.

Wash your hands!