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CIDs (WHAT?, REPONSES Prevention / Interventions / Control strategies /…

- - - - 3 Viruses of Major PH Importance & associated Disease
        
        Bunyaviridae
        
        Rift Valley Fever
        
        Crimean-Congo haemorrhagic fever
        
        La Crosse encephalitis
        
        Ross River
        
        Togaviridae
        
        Chikungunya
        
        Eastern Equine Encephalitis
        
        Western Equine Encephalitis
        
        Venezuelan Equine Encephalitis
        
        Flaviviridae (carried by 2 deadliest vectors)
        
        Dengue
        --> Vaccine trying to be devlpd for decades but not as effective
        
        Japanese encephalitis (JE)
        --> vaccine
        
        Tick-borne encephalitis
        
        West Nile fever
        --> everywhere apart from Asia
        
        Yellow fever
        --> mandatory vaccination (success story of contral activity from 1940s); typically from spillover
        
        Zika
        
        --> But also Malaria & H1N1 influenza
        
        Malaria
        = a vector-borne parasitic disease that continues to contribute largely to morbidity and mortality in LMICs
        --> Used to be an NTD but no longer negelcted, although benefits from similar control & prevention measures
        
        Hist
        An ancient disease caused by the “Plasmodium” organism
        
        Parasite has existed since before humans = found in >15-20M yo mosquitoes in amber
        
        Mentioned in ancient Roman, Chinese, Indian & Egyptian manuscripts & Shakespearean plays
        
        Hippocrates (”Father of Medicine” - 460-370 BC) provided classic descriptions of malaria in ancient Greece in the 4-5th C BC
        
        = from the Anopheles genus of mosquito (coined in 1818 from greek = An (not) + opheles (profit) = usless!)
        
        (Possible) famous victims = Tutankhamun & his family (1323 BC); Alexander the Great (356-323 BC); Genghis Khan (-1227); George Washington (1732-1799)
        
        Treatment known for long time = Quiinine = bark of S Am tree (brought to Europe in 17th C from Peru
        ==> After 150+ years of malaria studies = still very clueless to what's going on
        
        5 Human Malaria Species
        
        Plasmodium falciparum (Pf) = deadliest (highest mortality by far, esp in SSA) + Very drug resistant
        
        P. vivax (Pv) = most abundan outside SSA
        --> Both pose greatest threat
        
        P. malariae (Pm)
        
        P. ovale (Po) = latest parasite with 2 distinct species
        
        P. knowlesi = latest parasite in SEA
        
        Symptoms
        
        General = benign BUT acute, febrile illness
        
        Malaise
        
        Muscle & joint aches
        
        Rash
        
        Headache
        
        Anorexia
        
        Nausea & Vomiting
        :green_book: Influenza, Covid, measles, meningitis, leptospirosis, malaria, viral hepatatis, etc.
        
        Severe = no cure, only supportive treatment
        
        Polyarthrisis & rash (Chiku & Ross River)
        
        Haemorrhagic fever (Devere dengue & Yellow fever)
        
        Acute encephalitis (JE, West Nile fever)
        
        Foetal dvlpt defects / Guillain Barre Syndrme (GBS) (Zika)
      - Epidemic prone diseases requiring Inter Health Regulation (IHR) frameworks (bc high risk of rapid spread inter health pandemic
        From one year to the other huge spike for no apparent reason
        
        Major disruption in health services
        
        Social, political, and economic instability
        
        Risk to international security
        
        Egs
        
        2009 = H1N! influenza pandemic
        
        2014 = Setbacks in polio eradication efforts
        
        2014 = West african Ebola epidemic
        
        2016 = Zika virus outbreak (during Brasil olympics)
        
        2018 = Kivu Ebola epidemic
        
        2019 = SARS-CoV-2
        
        Resurgence (Concerns since 70s)
        
        Re-emergence of previously controlled diseases (eg Zika known for decades, but new manif)
        
        Mosquitoes =
        
        Adaptation to host & habitat
        
        Mvt & spread (surge in nbs)
        
        Insecticide resistance
        
        Bio =
        
        Adaptation of vector & host
        
        Increased inefectivity / virulence
        
        Humans =
        
        Behaviorl changes
        
        Mvt (travel, trade...) eg used tires from Asia to Am
        
        Density = urbanization
        
        External factors =
        
        Habitat changes
        
        Health care failure
        
        War & unrest
        
        Pollution & Climate change
        
        Disasters
        
        Emergence of novel diseases / in new areas
        
        Expansion of geo range
        
        Intensified acute epidemic activity
    - - Hist
        --> From "other diseases" (MDG 6 - Combat AIDS, TB, malaria & other diseases) to NTDs
        
        2004 = 1st polic papers on GBD of NTDs
        
        2006 = USAID NTD prog
        
        2007 = WHO Global Partners meeting on NTDs
        
        2011 = WHO Roadmap setting targets for 2020
        
        2012 = London Declaration on NTDs - coaltion of partners (w/ incl. of pharmal companies as a game changer - funding studies + donating drugs to LICs)
        
        2015 = SDG 3.3 End epidemocs of AIDS, TB, Malaria & NTDs... (officially named as NTDs (put on the map)
        
        2020 = WHO Roadmap for NTDs
        
        2022 = Kigali Decla on NTDs
        --> BUT difficult to secure funding l-t (most funding continues to go into DM & HIV/AIDS)
        
        Jan 30, 2023 - World NTD Day
        
        7 Pathogenes (infectious agents)
        
        Helminths (worms) [8]
        
        Cysticercosis / Taeniasis
        
        Echinococcosis
        
        Foodborne trematodiases
        
        Soil-transmitted helminthiases (STH)
        
        Dracunculiasis (Guinea-worm disease)
        
        Lympathic filariasis (elephantiasis) = e.g. caused by Wuchereria bancrofti
        
        Schistosomiasis
        
        Onchocerciasis (River blindness)
        --> Last 4 VBDs
        
        Bacteria [4]
        
        Buruli Ulcer (Mycobacterium ulcerans infection)
        
        Leprosy
        
        Trachoma (e.g. caused by Chlamydia trachomatis) --> VBD
        
        Yaws (incl. syphilis, bejel, pinta)
        
        Protozoa [3]
        
        Chagas disease (e.g. caused by Trypanosoma cruzi)
        
        Leishmaniasis
        
        Trypanosomiasis (Human African / sleeping sickness)
        --> All VBDs
        
        Viruses [2]
        
        Rabies
        
        Dengue & Chikungunya fevers --> VBD
        
        Fungi [1] = Mycetoma, chromoblastomycosis, deep mycosis (e.g. caused by Acrium strictum)
        
        Venom [1] = Snakebite envenoming
        
        Ectoparasites [1] = Scabies & Myiasis (e.g. caused by Sarcoptes scabiei)
        
        Dengue
  - - - Signs & Symptoms
        
        Coughing lasting >3 weeks
        
        Chest pain, pain when breathing / coughing
        
        Loss of appetite
        
        Chills
        
        Unintentional weight loss
        
        Fatigue
        
        Night sweats
        
        Fever
        
        Coughing up blood
        
        From infection to disease
        
        Exposure
        
        Infection VS No Infection
        
        If infection
        
        No disease (90%) = Latent TB
        
        Disease (10%) = Early (5%) + Late (5%)
        
        2 clinical manifestations of TB = PTB / EPTB
        
        PTB = Pulmonary TB (most common)
        
        EPTB = Extrapulmonary TB (involves organs other than lungs)
        --> 7 grps
      - Diagnosis
        -> ~10K bacilli/mL
        
        TB vs NonTB Mycobacteria (NTM)= atypicaly
        -> Early NTM warning mycobacteria
        
        Fast
        
        Contagious
        
        Diagnositic methods
        
        PCR / DNA = Fast, Specific, Many systems
        
        Culture = slow, dependent on cult media / conditions, alive & reproducible, sensitive 'gold standrad'
        
        IGRAs / MTX = low sensitivity, latent TB OR disease that may progress to active disease; advanced lab
        --> Best we have
      - Drug resistant TB
        
        Mono-resistance
        
        Poly-resistance
        
        Multi-drug resistant (MDR) TB
        
        Rifampicin resistant (RR) TB
        
        Pre-Extensively drug-resistant (XDR) TB = MDR + fluoroquinolone
        
        XDR-TB = MDR + fluri + other
        
        --> Esp in Asia (India & China) + Russia
        
        Huge costs w/ greater resistance to drugs
        
        Prdty loss during treatment
        
        Case mngt & social work
        
        Housing & transport
        
        Direct treatment costs
        
        Drugs & diagnosis
        
        Hospitalization
        
        Growing immunosuppressive drug market
        
        People live longer
        
        Increasing incidence of chronic conditions
        
        Increasing organ replacements
        
        New treatment opportunities (eg steroids, antibodies, calcineurin inhibitors...)
        ==> Perfect storm for NTM infections to increase
- - - - Access = availability, affordability & suitability of medicines at a national & clinic-level + Whether people are able to engage w/ meds on sustained basis for decades
        Benefits of supressing viral load
        
        Improve qual of life
        
        Prolong survival
        
        Improve immun function
        
        Prevent growth of virus
        
        Prevent transmission (Pre-exposure prophylaxis [PrEP])
        
        Reduce HIV-related morbidity
        
        "There are often substantial differences in HIV treatment access b/w districts in the same country, suggesting that people living in some parts of the country are not benefiting equally."
        
        Making tools equally available
        
        "Must speed-up & harmonize processes to ensure ince prdts are deemed safe & effective, they can be brought to the Bs who need it"
        
        Currently available
        
        HIV treatment for PLHIV
        
        Oral PrEP w/ TDF/FTC
        
        PrEP
        
        Voluntary medical male curcumcision
        
        Male & female condoms
        
        Syringe exchange progs
        
        In dvlpt
        Efficacy trials underway
        
        Oral PrEP w/ F/TAF
        
        Preventive vaccines
        
        Long-acting injectable
        
        Broadly neutralizing antibodies
        
        In regulatory review
        
        Davipirine vaginal ring
        
        In dvlpt
        Various pre-clinical & clinical trials
        
        Long-acting oral PrEP
        
        Preventive vaccines
        
        Long-acting implants
        
        Broadly neutralizing antibodies
        
        Inserts
        
        Patches
        
        Multipurpose vaginal ring
        
        Combo oral PrEP/OC
        
        :!: Limits of biomedical solutions
        We have the biomedical tools to end the epidemic BUT they are inaccessible to most people
      - Understanding Multidimensional Systems for Health
        5 factors shaping access to health (HIV case) - see HEALTH SYSTEMS Sheet
        
        Many obstacles to accessing ARVs = more than what is normally made accessible by health systems
        
        Calls for a broader understanding of 'access' & a 'system for health' approach
        
        Access to HIV treatment & prevention services must be considered in context of many influential elements & delivered through differentiatied service delivery models
        
        Towards Differentiated Care & a Client-centered Approach
        to make health services more accessible
        
        A 1-size-fits-all model of HIV services does not work
        
        Adapting & simplifying HIV services so that they are person-centered (& overcome barriers to access)
        
        The Building Blocks of HIV testing, prevention & treatment
        Differentiated PrEP service delivery
        PrEP initiation
        
        PrEP initiation
        
        PrEP initial follow-up (0-3 months)
        
        PrEP re-initiation after discontinuation
        
        PrEP continuation (3+ months)
        
        PrEP refill
        
        Follow-up
        
        Where?
        Service location
        
        PHC facility
        
        Community setting
        
        Virtual setting
        
        Who?
        Service provider
        
        Physician
        
        Nurse
        
        Pharmacist
        
        Peer
        
        When?
        Service frequency
        
        Monthly
        
        Every 3 months
        
        What?
        Service package
        
        HIV testing
        
        Clinical monitoring
        
        PrEP prescription & dispensing
        
        Comprehensive services
  - - - WHO 2014: End the Global TB Epidemic Strategy by 2035
        
        Integarted, patient-centered care & prevention
        
        Early diagnosis
        
        Uni DST
        
        Screening risk grps
        
        Treatment of TB
        
        Treatment of TBI
        
        Vaccination
        
        Co-morbidities
        
        Bold policies & supportive systems
        
        Pol commitment & res
        
        Poverty & SDHs
        
        Multilevel engagement
        
        Uni health coverage
        
        Intensified R & Inn
        
        "New tools"
        
        Implimentation of R
        
        Relatively successful
        = GBD falling globally BUT not fast enough to reach 2020 milestones of strategy
        --> Overall decrease of deaths since 2005 (esp Europe (49%)
      - Conseq'
        
        Lockdowns & supply chain disruptions
        
        Increased poverty
        
        Less diagnosis of other CIDs (ie TB)
        
        Less collection of medicines for other CIDs (ie TB patients)
  - - - All interventions affected by Covid
        BUT also pol-econ factors
        
        Sri Lanka = after civil war, rise in econ status + vectors not as powerful as in Af
        
        EU no more since 1975 = but 2011 epidemic in Greece w/ fin crisis = no longer focus to spray, etc.
      - WASH
        
        Behavior
        
        Toilet use & maintenance
        
        Hygiene measures
        
        Hand & face washing & personal hygiene
        
        Laundry
        
        Food hygiene
        
        Env
        
        Construction of safe sanitation systems (to reduce release of pathogens into env)
        
        Water mngt for vector control
        
        Waste disposal
        
        Mngt of animal mvt & waste
        
        Safe water supply to prevent consumption of contaminated water, reduce contact w/ surface water & enable hygiene behaviors
      - Targets - Control / Elimination / Eradication (WHO Roadmap)
        
        Control = keep under wraps, manage prevalence = 9
        
        Elimination (as a PH pb) = 8
        
        Elimination (interuption of transmission) = 3 (Human African Trypanosomiasis; Leprosy; Onchocerciasis)
        
        Eradication = globally (ie smallpox) = 2 (Dracunculiasis & Yaws)
        
        --> NEED FOR PARTNERSHIPS to fight NTDs (for drug distri)
      - Rationale to linking control strategies across NTDs & Malaria
        
        Mass Treatment (MDA) = may target several pathogens, simultaneously
        
        Vector control interventions = may target several vectors, simultaneously
        
        WASH interventions = may target several pathogens and vectors, simultaneously
        
        ==> Integration = 'Grouping or “packaging” of several diseases, depending on their burden in countries, to facilitate joint delivery of interventions through a common platform such as preventive chemotherapy and use of multiplex diagnostics, and integrated monitoring, evaluation and reporting for all relevant endemic NTDs’
        
        Integrating - across NTDs for joint delivery of interventions that are common to several diseases
        
        Strengthening Health Systems - national, regional & global = improving capacity to deliver & extending overall support for progs
        
        Mainstreaming = w/ national health systems to imrpove qual of NTD mngt for uni health coverage
        
        Coordinating among stakeholders - w/ all sectors in & beyond health
- - - - On TB: (2019-2020)
        
        Notifications = In 30 high TB burden countries
        --> India, Indonesia, Philippines, China, Bangla, Paki, Mynmar, SA, Russia...
        
        Diagnosis & Treatment =
        
        2019 = 7.1M diagnosed + 5.5M treated
        
        2020 = 5.8M diagnosed + 4.5M treated
        -->1.4 not treated due to covid
        
        Mortality: increased for 1st time in decade = 1.5M (while they had been decreasing since 2005)
        
        ==> According to WHO (2021) "Covid has reversed years of global progress in tackling TB"
      - Lessons learned from COVID-19 - preventive strategies, surveillance & pub engagement
        
        Successes during pandemic
        
        Global gvnce frameworks & initiatives
        
        Preventive strategies / activities for general pub
        
        Initiatives to increase vaccine uptake (esp among hard to reach inds)
        
        Inistiatives to increase testing / contact tracing
        
        Reduce wider health impact of pandemic
        
        Must be careful w/ data reporting / surveillance mechanisms
        
        Number of reported cases by HC services might not be an adequate epi indicator of pandemic status at local / national level
        
        Mortality might not be best indicator of human health impact of pandemic
    - - :flag-ua: 3rd highest TB incidence in WHO Euro region
        
        30K new TB cases / year
        
        7:100K deaths
        
        ~25% MDR-TB
        *~7% XDR-TB
        
        Conseq'
        
        Interruption of hospitals, clinics & vaccine programs
        
        Effect on other CIDs:
        
        2nd highest rate of new HIV
        
        5% Hepatitis C
        
        Hepatitus B
        
        Diphteria
        
        Childhood vaccines = among lowest coverage
        
        Polio outbreak in 2021
        
        Measles 2nd highest
        
        Diphteria
        
        Covid
  - - - HIV progression
        
        0-3 weeks = Primary infection
        
        3-9 weeks = Acute HIV syndrome
        
        Wide dissemination of virus = spike in RNA copies + plummeting of CD4 counts (tracks immune system health)
        
        Seeding of lymphoid organs
        
        Week 9 - Year 7 = Clinical latency (plateau)
        
        Cont' decrease of CD4s
        
        Plateau of RNA copies
        --> Could be years long depending on health & lifestyle
        
        Year 8 = Constitutional symptoms
        
        Cont' decrease of CD4 towards non-existence
        
        Start of increase of RNA copies
        
        Year 10 = opportunistic diseases
        
        Year 11 = death
        
        Risk factors / SDHs
        
        Girls out of school due to covid = more women married off at younger age & blesser relationships
        
        GBV
        3. Power imbalance
        --> Concurrent relationships + Women not empowered to ask "blessers" to wear a condom + if asked, men would assume accusation of being HIV-pos
        4. Limited opps & poverty = Prositution
      - TB Risk factors
        
        Close contacts of a person with infectious TB disease
        
        Persons who have immigrated from areas of the world with high rates of TB.
        
        Children under-5 who have a positive TB test.
        
        Groups with high rates of TB transmission, such as homeless persons, injection drug users, and persons with HIV infection
    - - VBD Transmission Cycle
        --> How the pathogen travels from 1 host to another - host must be at certain "life stage" to be "infectious"
        
        Urban epidemic cycle = human-vector-human (+ sexual hum-hum for Zika)
        
        Enzootic cycle = Direct spillover from animals-vector-humans
        
        Epizootic cycle = Amplification in domesticated animals-vector-human
        
        Vector Reservoir & Host Ecology + WASH Concerns
        
        Must know about vector ecology (where & how he lives) to determine who's at risk (greatest exposure = low-res settings)
        
        Importance of Water & Sanitation Hygiene (WASH)
        
        Malaria
        
        about 460 species recognized
        
        +100 can transmit human malaria
        
        only 3-40 commonly transmit plasmodium parasite
        
        Mosquito survival dependent on =
        
        Temp (the higher the quicker / non under 15-18 degrees)
        
        Rainfall (humidity)
        
        Altitude
        
        Duration of transmission season = dependent on climate = can be epidemic-prone or endemic
        
        Climate change effects
        --> Math modeling of optimal temp' & precipitation for longer transmission season
        
        But if too much rain washes everything away
        
        Projection = increase risk in E Af & maybe Europe
        --> Dengue increase all over (Malaria mosq more sensitive to weather)
- - - - :warning:Distributed all around the globe
        
        Leading cause of death by CIDs for decades (only recently overtaken by Covid but might become #1 again soon)
        
        Top 10 of all death causes
        
        10M new cases/year
        
        1.5M deaths
        
        1/4 of world's pop infected
        
        Where
        
        8 countries = 2/3 world cases
        --> India, China, Indonesia, Philippines, Pakistan, Nigeria, Bangla & SA (most heavily pop countries)
        
        90% in dvlpg countries - the poorest people from poorest countries are most affected
        
        Highest incidence:
        
        Africa = SA
        
        Asia = Myanmar
        
        Am = Haiti
        
        Eastern Europe = Kyrgystan
        
        Conseq
        
        Leading killer of people w/ HIV (9%) - esp in SSA
        
        Increased poverty - a person w/ TB loses about 20-30% of annual household Y due to illness
        
        Lives saved
        
        38M people cured + 6M lives saved (1995-2008)
        
        ==> BUT Multidrug-resistant TB (MDR-TB) remains a serious concern
        
        :flag-dk: 1992-2007
        
        7K new cases
        
        5k confirmed cultures
        
        5.6K adult cases
        
        Gender = 59% males
        
        Ethnicity:
        
        Danes = 37%
        
        Somali = 19%
        
        Greenlanders = 14%
        
        Asians = 12%
        
        Others = 18%
        
        Gendered & age differences in prevalence & treatment
        
        Among children:
        
        Infants & young children more likely than older children & adults to develop life-threatening forms
        
        B/w 4-14 :female_sign: more vulnerable
        
        B/w 10-16 yo, :male_sign: begin reporting more
        
        Among adults:
        
        Overall, affects & kills more :male_sign: (male-to-female ratio of 1.6:1, globally)
        
        1 of top 5 killers of :female_sign: (20-59yo)
        
        6-10% of all maternal mortality in low-HIV prevalence settings & 15% in high-HIV prevalence settings
        
        Progresses more quickly in :female_sign: of repro age than in men of same age grp
        
        :female_sign: often have less access to treatment & prevention services
        
        :female_sign: more likely to complete treatment
        
        Migration (refugees) & MDR TB
        Exposures & Barriers
        
        During travel:
        
        Poor / dangerous travel conditions
        
        Overcrowded housing
        
        Poor access to healthcare during flight
        
        After arrival:
        
        Langugage barriers
        
        Lack of knowledge regarding HC system & patient rights
        
        :green_book: European Migrant Crisis (2015) arrival in :flag-dk:
        
        142K (1993-2015)
    - - 2022
        
        609M confirmed cases
        
        6.5M deaths
    - - :!!: A new infection every 2min
        --> disproportionately affecting AGYW
        
        50% HIV pos = women (esp in SSA)
        
        Demog w/ highest increase of prevalence = adolescent grils (15-24)
        
        Prevalance (15-49yo)
        
        Africa
        
        Americas
        
        Europe
        
        SEA
        
        Western PAcific
        
        Eastern Med
        
        :flag-za: Mental disorders
        
        Any disorder = 30%
        
        Alcohol = 14%
        
        Mood disorder = 9.8%
        
        Drug = 4.5%
        
        PTSD = 2%
        
        Among PLHIV
        
        Any disorder = 43.7%
        
        Depression = 41%
        
        Mild = 30%
        
        Major = 11%
        
        Alcohol = 15%
        
        PTSD = 5%
        
        Drugs = 2%
        
        Depression & low med adherence = accelerated disease progression
        
        x3 more likely to be non-adherent
        
        Few iinterventions for adherence of inds w/ MH pbs
        
        Causes
        
        Workforce gaps in LMICs
        
        Low gvt expenditure on MH
    - - A global burden
        
        241M cases
        
        627K deaths
        
        Children under-5 = most vulnerable
        
        77% of all malaria deaths
        
        In 2020 = 87%
        
        Other high risk grps =
        
        Women during pregnancy
        
        Non-immune travalers
        
        Refugees & migrants laborers
        
        Few countries sharing most of the burden
        
        Esp in SSA, LAm, SEA
        
        SSA = 94% of all deaths (esp Nigeria & DRC)
    - - 1B affected (esp in SSA, L Am, Asia)
        
        Burden disproportionately affecting 20-30s = most prdtv members of society**
        
        Stark increase starting 5yo
        
        Little inv as doesn't affect HICs as much - "people w/ no voices"
        
        "Neglected People's Neglected Diseases"
        
        Vulnerability = Conditions caused by poverty
        
        Unsafe water
        
        Inadequate nutrition
        
        Poor housing, sani & disposal
        
        Poor pers hygiene
        
        Lack of access to health services
        
        Insufficient / lack of disease prevention efforts
        
        Infection = Conditions creating poverty
        
        Poor health status
        
        Arrested dvlpt
        
        School absenteeism & low literacy
        
        Work absenteeism
        
        Social stigma
        
        Common Characteristics
        
        Afflict the poorest people = w/out access to the safe water, sanitation, and basic health services required in order to protect themselves against infection [.. ] High-income groups are rarely affected.
        
        Many are chronic, slowly developing conditions that become progressively worse if undetected and untreated.
        
        The damage they cause can be irreversible.
        
        They can cause severe pain and life-long disabilities, with long-term consequences for the person and also for family members who have to care for the person.
        
        People with NTDs are often stigmatised and excluded from society, and this can affect their mental health.