-Caveat Lector- http://www.who.org/infectious-disease-report/pages/textonly.html World Health Organization Report on Infectious Diseases REMOVING OBSTACLES TO HEALTHY DEVELOPMENT CONTENTS BURDEN OF INFECTIOUS DISEASES The biggest killer of the young Six diseases cause 90% of infectious disease deaths Infectious diseases are also among the biggest disablers AFFORDABLE TO PREVENT Avoidable at a low cost Controllable in any country The end of the line for some infectious diseases? INADEQUATE RESPONSE Investing in healthy development Many countries do not yet use WHO recommended policies Many factors contribute to the spread of infectious diseases UNCERTAIN FUTURE Diseases continue to catch the world off guard Near misses Medicines are losing their effectiveness The world is becoming a smaller place for microbes STAYING PREPARED Development of new drugs and vaccines The need for intensified research A CALL FOR HEALTHY DEVELOPMENT By Dr Gro Harlem Brundtland Table 1: Priority steps for overcoming the burden of infectious diseases Notes: 1. Throughout this report, the term "infectious disease" is used to refer to all communicable diseases, including parasitic and zoonotic diseases, and some forms of respiratory infections and diarrhoeal diseases. 2 $ refers to US dollars. 3. The term "billion" is used to mean a thousand million. 1.1 THE BIGGEST KILLER OF THE YOUNG An infectious disease crisis of global proportions is today threatening hard-won gains in health and life expectancy. Infectious diseases are now the world's biggest killer of children and young adults. They account for more than 13 million deaths a year - one in two deaths in developing countries. Over the next hour alone, 1 500 people will die from an infectious disease - over half of them children under five. Of the rest, most will be working-age adults - many of them breadwinners and parents. Both are vital age groups that countries can ill afford to lose. Most deaths from infectious diseases occur in developing countries - the countries with the least money to spend on health care. In developing countries, about one third of the population - 1.3 billion people - live on incomes of less than $1 a day. Almost one in three children are malnourished. One in five are not fully immunized by their first birthday. And over one third of the world's population lack access to essential drugs. Against this backdrop of poverty and neglect it is little wonder that deadly infectious diseases have been allowed to gain ground. Today some of the poorest countries are paying a heavy price for the world's complacency and neglect. All this has been made worse by the huge increase in mass population movements over the past decade. In 1996, as many as 50 million people - 1% of the world's population - had been uprooted from their homes. Not only are refugees and displaced people especially vulnerable to infectious disease; their movement can help spread infectious diseases into new areas. Meanwhile, the growth of densely populated cities with unsafe water, poor sanitation and widespread poverty has created the perfect breeding ground for outbreaks of disease. In deprived inner-city areas children are less likely to be immunized against killer diseases and parents are less likely to be able to pay for health care when they get sick. Under these circumstances, diseases that were once under control can rapidly gain a foothold and re-establish themselves. In addition, many diseases once thought unrelated to infectious diseases - especially cancers - are now known to be the result of chronic infections. Cervical cancer, for example - one of the most common cancers among women in the developing world - is now known to be associated with human papillomavirus infection. Meanwhile, chronic infectious hepatitis B and hepatitis C can both cause liver cancer and it is estimated that over 6% of the world's population is at risk. And bladder cancer can result from chronic infection with schistosomiasis. But infectious diseases are not just a developing country problem. Unless checked, the crisis threatens the industrialized countries as well. Old scourges such as tuberculosis and diphtheria have occurred in explosive epidemics in Europe and other industrialized countries. And a 1996 outbreak of polio in Albania, Greece and the Federal Republic of Yugoslavia showed how easily a disease can be reintroduced to countries once free of the disease if immunization coverage is allowed to drop. A rapid increase in air travel has meant that diseases can now be transported from one continent to another in a matter of hours. Even today, no country is safe from the threat of infectious diseases. This is happening at a time when the arsenal of drugs available to treat infectious diseases is being progressively depleted due to increasing resistance of microbes to antimicrobial drugs. Because the scale and complexity of the infectious disease crisis is so great, and the causes linked so closely to poverty, there is a tendency for some to be fatalistic about the situation. But the situation is far from hopeless. Efforts to prevent and control those diseases are among the most practical and achievable ways of alleviating poverty and furthering social and economic development. This report argues that we have a window of opportunity to make dramatic progress against ancient diseases, and to establish an early warning system to protect us from new and unexpected diseases. If we fail, increased drug resistance and the emergence of new bacteria and viruses threaten to make the control of infectious diseases both scientifically and economically unlikely in the future. The role of The World Health Organization The World Health Organization (WHO) can help mobilize the partners and develop the policies that will prevent and control infectious diseases. There is still a window of opportunity to make dramatic progress against the diseases that have been with us for thousands of years and to establish an early warning system to protect from new and unexpected diseases. WHO was created in 1948 and today, with over 190 Member States, it is the lead agency in international health. WHO's goal is to foster the attainment by all peoples - especially the poor and most vulnerable - of the highest possible standards of health. The guiding principles of WHO are: • "We can't do it alone, so we work in partnership with others." • "We can't do it all at once so we set priorities. Priority setting helps focus the world's attention, resources and actions on innovative and cost-effective public health action with specific goals and measurable results." WHO is the health conscience of the world. - General WHO information can be accessed at www.who.int 1.2 SIX DISEASES CAUSE 90% OF INFECTIOUS DISEASE DEATHS Most deaths from infectious diseases - almost 90% - are caused by only a handful of diseases. And most of them have plagued mankind throughout history, often ravaging populations more effectively than wars. In an age of vaccines, antibiotics and dramatic scientific progress, these diseases should have been brought under control. Yet, in developing countries today they continue to kill at an alarming rate. And at times - as in recent outbreaks of influenza - they also kill at an alarming rate in the industrialized countries. No more than six deadly infectious diseases - pneumonia, tuberculosis, diarrhoeal diseases, malaria, measles and more recently HIV/AIDS - account for half of all premature deaths, killing mostly children and young adults. Every three seconds a young child dies - in most cases from an infectious disease. In some countries, one in five children die before their fifth birthday. Every day 3 000 people die from malaria - three out of four of them children. Every year 1.5 million people die from tuberculosis and another eight million are newly infected. Behind each of these deaths lies a human tragedy. Because these diseases affect mainly young children and adult breadwinners, their impact on families can be catastrophic. Children may lose one or both parents to an infectious disease. The AIDS epidemic alone has left over eight million children orphaned. To make matters worse, families risk being driven into debt through lost earnings and high health care costs - trapping them in a vicious circle of poverty and ill-health. Pneumonia Acute respiratory infections (ARIs) are responsible for many deaths. Pneumonia, the deadliest ARI, kills more children than any other infectious disease. Most of these deaths (99%) occur in developing countries. Yet in industrialized countries childhood deaths from pneumonia are rare. Pneumonia often affects children with low birth weight or those whose immune systems are weakened by malnutrition or other diseases. Without treatment, pneumonia kills quickly. The influenza virus is another cause of pneumonia. There is very little information available on the number of influenza deaths in developing countries. However, in the United States alone, the disease kills 10 000-40 000 people in an average influenza season. HIV/AIDS Over 33 million people are living with HIV/AIDS worldwide. There is still no cure on the horizon. Worst affected is sub-Saharan Africa. In some countries, up to one in four of the adult population are now living with HIV/AIDS. In Zimbabwe, 20%-50% of pregnant women in some areas are infected with HIV and risk infecting their children. An increasing number of maternal deaths are now due to infections contracted by HIV-positive women during delivery. In many countries, life expectancy and child survival rates have plummeted. In Botswana life expectancy at birth has fallen from 70 to around 50 years. Diarrhoea Diarrhoeal diseases claim nearly two million lives a year among children under five. They are so widespread in developing countries that parents often fail to recognize the danger signs. Children die simply because their bodies are weakened often through rapid loss of fluids and undernourished through lack of food. Diarrhoeal diseases impose a heavy burden on developing countries - accounting for 1.5 billion bouts of illness a year in children under five. The burden is highest in deprived areas where there is poor sanitation, inadequate hygiene and unsafe drinking water. In certain developing countries, epidemics of diarrhoeal diseases such as cholera and dysentery strike down adults and children alike. Other major diarrhoeal diseases include typhoid fever and rotavirus which is the main cause of severe dehydrating diarrhoea among children. Tuberculosis (TB) Tuberculosis, a disease once thought to be under control, has bounced back with a vengeance to kill 1.5 million people a year - even more when in combination with HIV/AIDS. Nearly two billion people - one-third of the world's population - have latent TB infection. Together they constitute a huge potential reservoir for the disease. TB kills more adolescents and adults than any other single infection. It is also a leading cause of death among women. To make matters worse, infection with HIV weakens the immune system and can activate latent TB infection. It is also believed to multiply the risk of initial infection with TB. About one-third of all AIDS deaths today are caused by TB. Malaria Malaria kills over one million people a year - most of them young children. Most malaria deaths occur in sub-Saharan Africa, where malaria accounts for one in five of all childhood deaths. Women are especially vulnerable during pregnancy. They are more likely to die from the disease, suffer miscarriages or give birth to premature, low-weight babies. Malaria can rapidly overwhelm a young child causing high fever, convulsions and breathing difficulties. With the onset of cerebral malaria - an acute form of the disease - the child lapses into a coma and may die within 24 hours. The high incidence of malaria cases - over 275 million a year globally - can impose a huge economic burden on both families and governments through lost productivity, missed education and high health care costs. Measles Measles is the most contagious disease known to man. It is a major childhood killer in developing countries - accounting for about 900 000 deaths a year. The measles virus may ultimately be responsible for more child deaths than any other single microbe - due to complications from pneumonia, diarrhoea and malnutrition. WHO initiative: Combating childhood deaths Children are among the most vulnerable to infectious diseases, and child infections demand rapid and effective treatment. WHO's Integrated Management of Childhood Illnesses (IMCI) strategy permits immediate treatment at the very periphery of health care systems. IMCI is disease control through management of the five most common causes of childhood deaths - pneumonia, diarrhoeal diseases, malaria, measles and malnutrition. The IMCI treatment guidelines have been developed to assist health workers to recognize easily signs of illness and take appropriate action, even if there are co-existing health conditions. IMCI also helps prevent illness through promoting improved nutrition and vaccination. Research & Development being conducted by the Special Programme for Research and Training in Tropical Diseases (TDR) is developing new drugs and studying drug combinations to make IMCI even more effective. - Information on IMCI can be accessed at www.who.int/chd/ 1.3 INFECTIOUS DISEASES ARE ALSO AMONG THE BIGGEST DISABLERS The high death toll from infectious diseases is only part of the story. The scale of individual pain and suffering inflicted by these diseases is immense. At any one time, hundreds of millions of people - mainly in developing countries - are disabled by infectious diseases. Some infectious diseases can cause sudden repeated bouts of debilitating illness throughout the year - keeping children away from school and preventing adults from working or caring for their children. Other diseases result in severe deformities - covering the body with gaping sores, mutilating the facial features, causing the loss of fingers and toes and leading to withering or grotesque swellings of the limbs and other body parts. Those affected not only suffer from excruciating pain and severe handicap but are also victims of stigmatization, shame and anguish. Meanwhile, the economic impact of repeated episodes of illness and long-term disability is a major cause of underdevelopment in many countries today. The economic burden of malaria alone has cost Africa billions of dollars this decade. In addition to the cost of lost working days, the cost of treatment for repeated bouts of malaria can also be a huge burden for the poorest families. In Nigeria, it has been estimated that subsistence farmers spend as much as 13% of total household expenditure on malaria treatment. Measles can lead to severe disability among children who survive the disease. Measles infection can result in blindness, deafness, brain and lung damage, and stunted growth and development. Lymphatic filariasis is second only to mental illness as the world's leading cause of long-term disability. A mosquito-borne disease involving infection with parasitic worms, it can cause grotesque enlargement of the limbs and genitals and damage to internal organs. It affects about 120 million people. At least one billion people are at risk - one in six of the world's population. Over 40 million people are severely disfigured and disabled by filariasis. In addition, the social and psychological impact can be enormous - often destroying marriages and family relationships. Another widespread parasitic worm disease, schistosomiasis, causes chronic urinary tract disease and often results in cirrhosis of the liver and bladder cancer. Over 200 million people are infected worldwide and up to three times as many are at risk. This debilitating disease is spread by water snails and contracted through contact with stagnant water sources. It can spread to new areas through dam-building and irrigation projects. Children and rural workers are most at risk and the disease can cause high absenteeism at school and work. In some of the worst-affected areas over 90% of children can be affected simply as a result of wading through water. More than 12 million people are infected with leishmaniasis, another insect-borne parasitic disease. The disease can cause internal organ damage, skin lesions and mutilation of the nose and mouth. People disfigured by the disease often have to endure rejection by their families as well. Today there is alarm at the sharp increase in cases of visceral leishmaniasis - a deadly form of the disease - due to emerging co-infections with HIV and an upsurge in epidemics in countries such as India and Sudan. In addition, millions of people are incapacitated by infectious diseases which cause blindness. An estimated 5.6 million people today have been blinded or visually disabled by trachoma and an additional 154 million are infected - mainly in Africa and Asia. The disease is transmitted through person-to-person contact due to poor hygiene. In addition, over 85 million people in Africa, Latin America, and the Arabian Peninsula are threatened by onchocerciasis (river blindness). This parasitic disease, transmitted by blackflies, causes visual impairment, blindness, unbearable itching and skin lesions. The itching can be so intense that people scratch themselves with knives or stones to stop it. Some have even been driven to suicide. In sub-Saharan Africa, sleeping sickness threatens 55 million people in 36 countries. A parasitic disease transmitted by the tsetse fly, sleeping sickness causes long-term debilitating illness and mental suffering. Without treatment, the disease is fatal. In the worst-affected countries over half the people in some villages become ill. In some provinces the disease is reported to have claimed more lives than AIDS. Leprosy - one of the oldest scourges known to humanity - is still a problem in many countries in South-East Asia, Africa, and Latin America. Over half a million cases occur every year. About two million people are currently disabled by leprosy, which can cause severe mutilation of the face and extremities as well as damage to bones, eyes, nerves, and internal organs. Although the disease is not highly contagious, even today leprosy sufferers can become social outcasts. Guinea-worm disease (dracunculiasis) is a parasitic disease transmitted by a tiny crustacean. During 1998, there were almost 72 000 cases of guinea-worm disease in Africa. The countries worst affected today are Ghana, Nigeria and Sudan. This debilitating disease causes joint pain, fever and vomiting. When the mature guinea-worm slowly emerges through the skin - by then up to a metre long - it causes excruciating pain and frequent infections at the exit point. The disability prevents people from going to work or school. In Latin America, up to 18 million people are infected with Chagas disease, a deadly parasitic disease transmitted by blood-sucking insects. The disease can also be transmitted through blood transfusions and from mother to baby. The chronic stage of the disease can last for years as parasites invade the internal organs - causing irreversible damage to the heart and intestines. The disease is very difficult to treat with existing drugs. In some parts of Latin America it is the leading cause of cardiac death in young adults. One hundred million people are at risk. In Santa Cruz, Bolivia, over 50% of the blood in blood banks was infected with the parasites. In 1995, four Sexually transmitted infections (STIs) - gonorrhoea, chlamydia, syphilis, and trichomonas - accounted for an estimated 333 million new cases of curable STIs. These four infections and their complications are among the top ten causes of disease burden. WHO initiative: Rolling back malaria Partnerships strengthen advocacy and help unify public health action while making more resources available for the fight against infectious diseases. Roll Back Malaria is one of WHO's best examples of how global partnerships help control infectious diseases. Through a global coalition involving UNDP, UNICEF, WHO and the World Bank, Roll Back Malaria is helping health systems deliver cost-effective interventions including: better health care, insecticide-treated bednets and improved environmental management. At the same time Roll Back Malaria is harnessing the support of both the public and private sector in developing new malaria drugs and vaccines. The Roll Back Malaria partnership is working in all countries where malaria is a health problem, and focusing its greatest efforts in Africa where most malaria deaths occur. – Information on Roll Back Malaria can be accessed at www.who.int/rbm 2.1 AVOIDABLE AT A LOW COST Most of the 13 million deaths a year from infectious diseases can be prevented. Low-cost health interventions already exist to either prevent or cure the infectious diseases which take the greatest toll on human lives. And most of these interventions have been widely available for years. Unfortunately for a number of reasons they are not being used. Inadequate funding of health care in developing countries is one reason. Government failure to prioritize, lack of cross-sectoral collaboration and the inability of weak health service delivery systems to reach the entire population - particularly the most vulnerable and difficult-to-reach - are contributing factors. Integrated Management of Childhood Illnesses (IMCI) This radical, low-cost strategy can dramatically reduce the 70% of deaths from pneumonia, diarrhoea, malaria, measles, malnutrition and other infectious diseases such as meningitis. Seriously ill children are often suffering from more than one condition at the same time - making exact diagnosis difficult. For these children combined therapy can be life-saving. Treatment may include oral rehydration salts to treat diarrhoea, low-cost antibiotics to treat pneumonia, antimalarial drugs, and vitamin and mineral supplements. Another key focus is prevention through promoting immunization, breastfeeding and better feeding practices. Millions of lives could be saved every year through the IMCI approach. Correct management of pneumonia and diarrhoeal diseases alone could prevent up to three million deaths a year. Childhood vaccinations More widespread use of low-cost vaccines could prevent 1.6 million deaths a year among children under the age of five. Yet today, one in five children are still not fully immunized against the six major killer diseases: diphtheria, whooping cough, tetanus, polio, measles and TB. DOTS Millions of TB deaths could be averted through the use of DOTS (Directly Observed Treatment, Short-course) - an inexpensive strategy for the detection and treatment of TB. This highly-effective health care package involves detection of TB cases through low-cost sputum smear tests, followed by 6-8 months of treatment with a combination of inexpensive drugs. A key component is regular ongoing support to the patient. This includes observation to ensure that patients follow the treatment correctly and follow-up sputum tests to determine whether it has been successful. The strategy can detect and cure disease in up to 95% of infectious patients, even in the poorest countries. Impregnated bednets One in four child deaths from malaria could be prevented if children at risk slept under bednets at night to avoid mosquito bites. Bednets dipped in an insecticide cost about $10 each and $0.50 to $1 a year for a supply of insecticide to re-treat the net. Dip-it-yourself kits are now available for re-treating the nets at home. The cost of a net and one year's supply of insecticide is less than one hour's parking in New York, Paris or Tokyo. Availability of essential drugs Millions of people in developing countries are dying needlessly from diseases that could be easily treated with safe, inexpensive drugs. More than one-third of the world's population lack regular access to essential life-saving drugs. Drugs may be too expensive for those on the lowest incomes, or they may not be available. In Africa, where many of the poorest countries have no more than $1 per capita each year to spend on drugs, fewer than half have access to the basic drugs they need. User-friendly packaging of drugs is a low-cost way of increasing compliance with antimalarial drug therapy. Studies in Ghana show that over 80% of patients given a course of antimalarial drugs packaged in a numbered blister pack finished the course of treatment. Of those receiving loose, unpackaged drugs - the way they are usually dispensed in developing countries - only 65% completed the treatment. A simple packet of fast-acting drugs made widely available to parents - together with training to recognize malaria symptoms - could save the lives of many children with severe malaria. Prevention strategies for HIV/AIDS While expensive antiretroviral drug therapy for HIV/AIDS is still way beyond the means of most developing countries, well-targeted, low-cost HIV prevention and care strategies can have a major impact on the spread of HIV. Millions of new infections could be prevented through low-cost interventions including: - access to cheap condoms and, where necessary, safe drug injecting equipment - use of essential drugs to treat other sexually transmitted infections (which amplify the risk of subsequent infection with HIV) - HIV testing and counselling (which can lead to safer sex) - counselling and support for HIV-positive mothers along with antiretroviral drugs and counselling on safe alternatives to breastfeeding - promotion of safe injection practices – sex education at school and beyond. Other important strategies Inexpensive vitamin and mineral supplements can also save lives. As many as one in four child deaths from infectious diseases - mainly from measles and diarrhoea - could be prevented by giving children vitamin A supplements. Malaria deaths among children could be reduced through the use of iron supplements to treat anaemia. Yet these inexpensive remedies are not always available where they are needed most. Effective health education can also save countless lives - by promoting safe sex, good nutrition and hygiene, immunization and ensuring parents know what to do when a child is sick. WHO initiative: Stopping TB The STOP TB Initiative is mounting a political and social movement against TB throughout the world by promoting the use of cost-effective Directly Observed Treatment, Short-course (DOTS). Despite the DOTS policy, there are obstacles to countries adopting its use. These include lack of political will and commitment to support TB control programmes, inadequate financing and human resources, poor organization of and management capacity for programmes, and interrupted supplies of high-quality anti-TB drugs. STOP TB, based at WHO, is a partnership of countries with serious TB problems, UN and other international organizations, bilateral donors, scientific and public health institutions and NGOs. The partnership is: • ending social apathy towards TB • expanding the global coalition of partners involved in TB control • pushing TB issues higher on both international and national health agendas • increasing investment in DOTS. - check out www.stoptb.org 2.2 CONTROLLABLE IN ANY COUNTRY Wherever a low-cost strategy is available to prevent or treat infectious diseases, individual countries - even low-income countries - can make dramatic progress in getting them under control. But few countries have succeeded without strong political commitment at the highest level, a health care system that can deliver services to the entire population, and public demand for action. During the 1980s the success of mass campaigns against polio in the Americas showed what could be achieved against all the odds with strong political commitment. The WHO Regional Office for the Americas and its partner organizations worked with governments and civil society throughout the Americas to carry out a massive social mobilization campaign. Parents were educated about the need for immunization and millions of health workers and volunteers were mobilized. In war-torn countries, negotiators worked with the warring factions to ensure that children's health would not become another casualty of the war. And the ceasefire for immunization worked. It worked in the poorest countries, in a densely populated country like Brazil, and even in countries where armed conflict was terrorizing populations and reducing health centres to rubble. Within six years a disease had been eliminated from the Americas. It could be done. In Viet Nam, a four-year onslaught on malaria between 1992 and 1996 succeeded in reducing malaria deaths by over 90% and malaria cases by 40%. A decade earlier the situation was dire. An economic recession had dealt a body blow to health services, donations of insecticide had been stopped, resistance to antimalarial drugs was rising fast and migrant workers were carrying malaria into areas where it had once been eliminated. In 1991 alone, there were 144 epidemics of malaria. Through government commitment, increased funding, and the widespread use of locally produced low-cost tools, health workers have today succeeded in turning the situation around. Locally produced high-quality drugs are now being used to treat cases of severe and multidrug-resistant malaria. Throughout Viet Nam, about 12 million people are protected by house spraying and insecticide-impregnated bednets. In areas where malaria is endemic, insecticide impregnation is provided as a public service - free of charge. The success of the p ================================= Robert F. Tatman [EMAIL PROTECTED] [EMAIL PROTECTED] Remove "nospam" from the address to reply. NOTICE: In accordance with Title 17 U.S.C. Section 107, this material is distributed without profit to those who have expressed a prior interest in receiving the included information for research and educational purposes. For more information go to: http://www.law.cornell.edu/uscode/17/107.shtml POSTING THIS MESSAGE TO THE INTERNET DOES NOT IMPLY PERMISSION TO SEND UNSOLICITED COMMERCIAL E-MAIL (SPAM) TO THIS OR ANY OTHER INTERNET ADDRESS. 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