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Infectious Diseases #16

Tropical medicine Professor Castelli 3 July 2014 Author Luigi Bonini Reviewer EBV

I am Francesco Castelli, doctor in the hospital of Brescia, I am the director of he WHO Collaborating Center for TB/HIV co-infection, and the president of the Italian Society of Tropical Medicine.

I would like to start telling you a story, the story of Awa, a 38 y.o. lady who had 7 pregnancies and 5 living children. She lives in Burkina Faso. Awa is illiterate, and she is also very poor, living in a rural area, and her job is to work the soil. She has never seen a doctor nor a midwife. She also has chronic malaria, with a lot of helminthes in her belly (which means that her Hb level is usually 9-10). She also lives in a very hot country, where there may be 45C.

She gets pregnant again. While she is working in the countryside she sees blood coming out of her legs going down to her feet. So she comes back to the village and she is advised to go to a doctor. So she goes to the nearest health center, which is 3 Km far. Now the Hb level is very low, around 7. Anyway there is no doctor in the health center, nor any midwife, so she has to go to the district hospital. She asks to be carried there, because she is very tired, but there is no possibility. So Awa goes to the district hospital: when she arrives, there is a very young doctor there. She is transfused one unit of blood (only one is available). She has to undergo surgery to deliver the baby, but unfortunately Awa and her baby die. The doctor said that Awa died of antepartum hemorrhage due to placenta previa. So did Awa died due to a tropical disease or due to a poverty related disease?

So, what is a tropical disease? We have many definitions:

The branch of medicine that deals with the diagnosis and treatment of diseases that are found most often in tropical regions.

Science of diseases seen primarily in tropical or subtropical climates. It arose in the 19th century when European colonial doctors encountered infectious diseases unknown in Europe.

In poor countries infectious diseases are the major cause of death.

In 1978 in the capital city of Kazakistan, Alma-Ata, there was a big congress with all the countries in the world, where it was stated that health is a fundamental human right. Health is not sometimes that should be of interest only to the health sector, but also to the social and economic sectors. They also stated that inequality in health status is socially and economically unacceptable. They also stated that they wanted to achieve health for all by the year 2000.

After the Alma-Ata congress, Italy established to have a National Health System, which was intended to be universal and free of charge for everybody.

How can you have health for all?

Education concerning prevailing health problems and the methods of preventing and controlling them

Promotion of food supply and proper nutrition

An adequate supply of safe water and basic sanitation

Maternal and child health care including FP

Immunization against major infectious diseases

Prevention and control local endemic diseases

Appropriate treatment of common diseases

Provision of essential drugs

After graduation I left to Mali, because I decided that I wanted to be part of the system and help reach health for all by 2000.

But in 2000 they recognized that the health for all goals was not reached at all, so they decided to meet in New York and made another set of targets, proposing

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the Millenium Development Goals:

1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Global partnership for development

Goal 1: Eradicate extreme poverty and hunger

This is the Global Rich list

If you earn:

100,000 per year, you are in the top 0.12% 10,000 per year, you are in the top 11% 1000 per year, you are still in the top 20%

100 per year, 8% of the world is still worse off than you (about 500 million people!!!!!!!)

Richness and life-expectancy

If you were born in Sierra Leone, your life expectancy would be 34y, if you happened to live in Japan, your life expectancy would be 82y. The curve shows that by being just a bit richer you increase a lot your life expectancy, if you are in the initial part of the curve, which is very steep. In the last part of the curve, being richer doesnt influence so much the life expectancy. The main message is that redistribution of richness can help increase life expectancy. Anyway it is not so simple, money is important, but it is not the only factor.

If you consider all developing countries, it seems that we are reaching the goal, but if you consider some specific regions, like the Sub-Saharan Africa, we are not very advanced. This is because eastern Asia, and in particular China, has overreached the goal, but Africa is still very poor.

Goal 2: Achieve universal primary education

We are doing something here. Even Africa started with a literacy rate which was 60%, and now we are more than 70%, but still we have countries, like Burkina Faso, where the literacy rate for women is 20%.

Goal 3: Promote gender equality and empower women

I will not comment on that.

Goal 4: Reduce child mortality

We try to decrease child mortality rate in children

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You can see in these images Potts disease (first image) and neonatal tetanus (second image). Tetanus in Africa can be taken when you cut the umbilical cord: after cutting it, poor people put some clay to medicate it, but the problem is that you usually take the clay from water pots, which are often

near feces; and in feces of animals we have Clostridium tetani spores. How can you prevent it? You can vaccinate against tetanus: not the child (because it is too late in case of neonatal tetanus), but you vaccinate the mother, so that also the child will have immunoglobulins against tetanus.

In this table you see the mortality rate.

In this map you can see the countries which will reach the goal.

Goal 5: Improve maternal health.

The goal is to decrease by by 2015 mother mortality rate. You can see in this pie chart why mothers die.

If you are a lady in a developed region, your risk of dying due to delivery is 1:4300, if you are in Italy it is much less, 1/20,000. If you are a lady in a developing country is 1/120. If you are lady in Sub-Saharan Africa, your risk of dying is 1/31. If you are a lady in Sierra Leone or in Afghanistan, your risk of dying is 1/7.

Here you see if we will be able to reach the goal by 2015:

Goal 6: Combat HIV/AIDS, malaria and other

diseases

Achieve universal access to treatment for HIV/AIDS for all those who need it. The number of people having access to antiretroviral therapy is now going up and up. But for every person that reaches treatment, 3 people get infected. So infection is still spreading at a faster rate.

In this malaria map you have that the dimensions of the country reflects the number of people died because of malaria. So far mortality is prevalent in Africa. When you have malaria, your hemoglobin count decreases a lot.

We are doing something for malaria. When I was at your age, the estimate was that 2 million people died for malaria per year, now it is estimated that 600,000 people die for malaria every year.

Africa bears the highest number of tuberculosis infections. Apart from Mycobacterium tuberculosis, there is also Mycobacterium leprae. This one was discovered in Norway, which is not a tropical country, by doctor Hansen (who also gave the name to this disease, which is also called Hansens disease). At the end there will be 1.3 million people dying of tuberculosis in the world.

What are neglected diseases? Various definitions:

NDs are those for which there is an insufficient market or political status to drive adequate private sector or public sector research and development (R&D).

The term ND should not be used for those diseases for which effective and safe drugs exist

http://www.un.org/millenniumgoals/pdf/

report-2013/mdg-report-2013-english.pdf

COUNTRY

MATERNAL

MORTALITY RATIO

(per 100.000 livebirths)

NUMBER OF

MOTHER

DEATHS

Eritrea 1081.3 2107

Liberia 906 1425

Burundi 894.2 2585

Ireland 4.1 3

Austria 4 3

Iceland 1.5 0

I MR < 5 yrs, 2011

COUNTRY DEATHS / 1000 LIFE

BIRTHS

TOTAL N. DEATHS (X

1000)

Equatorial Guinea

191.5 4.9

Guinea Bissau

169.6 9.8

Chad 168.2 84.4

Japan 2.9 3.1

Sweden 2.8 0.3

Iceland 2.6 0

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Stimulating R&D for NDs is important as part of a wider long-term public health strategy and must be addressed simultaneously with resolving more immediate problems of access to medicines and health system sustainability in less developed

Here you see some neglected diseases:

When you see a child with a very big belly, you can think of a very big liver or a very big spleen. There are 2 major possible causes, apart from hepatitis: Schistosoma mansoni or Leishmania.

Sleeping sickness is a neglected disease, caused by the African Trypanosoma (which is transmitted by the Tsetse fly). There is no real drug which can cure the cerebral phase of the trypanosoma. The drug we have is arsenic, so most of the people die because of the drug, not because of the disease. Then a company developed by chance a very effective trypanocydal drug, while trying to develop an anticancer drug (but this drug wasnt effective as anticancer agent). So the company offered this drug, free of charge, to anyone who wanted to produce it, but nobody answered this call, neither the countries where trypanosoma was endemic (they didnt have neither the capacity nor the money to do it). So nothing happened for years, until it was discovered that this drug had another therapeutic effect, which is to treat hirsutism, so to have hair falling from the body; now this drug is contained in every shaving cream, and the company earned such an enormous amount of money by shaving legs, that the income was so huge that the company accepted to produce free the drug for trypanosomiasis. The drug is Afloritine.

This paper says that during the last 25 years of the last century, we had nearly 14 hundreds new chemical entities developed by chemical industries, and of these only 16 for diseases of the poor countries. This is what I mean for neglected diseases.

Goal 7: Ensure environmental sustainability.

We have different subgoals, and one of these is to reduce the number of people who do not have access to safe water by half, by 2015. Every person who lives in a developed country has, on average, 2-3 taps of water each, but this is not the case in poor countries. Without good water you can have diarrhea and many other diseases, and water itself can become a vector of disease. Water can also be the reservoir of diseases, as in the case of onchocerciasis, and schistosomiasis, which is caused by larvae which have as intermediate hosts the snails. These larvae enter then the skin of people.

In Egypt they created a dam, which gave rise to lake Nasser, done to regulate the floods and the fertility of the Nile. Unfortunately those who did the Nile didnt consider that the Nile is plenty of snails in which schistosomas multiplied, and so millions of Egyptians were infected in this way. To treat this they decided to cure the infected patients by intramuscular injections, which was the treatment for schistosomiasis. In this way they infected the people with HCV, so that now 10% of Egypt population has hepatitis C.So to be a good doctor, you should not only consider your patients, but also the environment.

Do you know where the Aesculapius sign come from? It probably comes from the way to cure the infection from guinea worm (dracunculiasis).

Access to care is very important, and the WHO divided access in 3 As:

Availability

o Infrastructure (location, number, etc.)

o Qualified human resources

o Drugs, blood, vaccines

o Transportation

Affordability

o Health expenditure pro capita

o Personal health expenditure

Acceptability

o Culture and tradition

o Traditional medicine

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Keep in mind the story of Awa while reading the previous points.

In Italy we have roughly 200,800 $ per person per year for health expenditure, and the vast majority of this amount is paid by the public service, and a small fraction is private. In the country where Awa was living, Burkina Faso, the health pro-capite expenditure is roughly 10-12 $ per person, and the majority of this amount of money is private, which means that if you go to the hospital you have to pay.

Lets make a small example. In the Hpital National Yalgado, a public hospital in Ouagadougou, the city where Awa was living, patients can stay in 5 categories (the first category being the most expensive), and the 5

th category

means that you can enter the hospital and you can sleep on the ground, but not enter the rooms. For this category you pay 15 cents, so it is very cheap. But patients have to pay 10 days before they go in, so it is already 1.50 ; and if you want to see a doctor, you have to pay the equivalent of 3 , every time you see a doctor. And if the doctor decides that you need ampicillin, or any kind of drug, then you need to pay it by yourself. At the end Awa, in this public hospital, would have paid 30-40 , which she didnt have. So affordability is a problem.

The last point is acceptability, which means taking into consideration culture and tradition.

Now I will tell you another story, the story of Fatima: Fatima is an African woman, living in a town (so not in a rural area like Awa), who has 2 children and is pregnant again. The fertility rate in Italy is 1.3, while in Sub-Saharan Africa it is 7-8. Fatima, after seeing a public signal increasing the awareness of HIV, decides to take the test for HIV, and she is positive. So she is scared, and she doesnt want to tell her husband. At the end anyway she tells the husband that she is HIV infected. The result is that she is expulsed from the family and she goes to a place where all the rejected women like her stay, living of charity, together with her children. In this situation she doesnt have access to physicians and health personnel. She delivered the baby there, and the baby had HIV, because she couldnt be given antiretroviral treatment. Then Fatima got sick and died.

In many African countries many women cannot decide on their health, but it is their husband who can decide, so decide also for their children. This is an obstacle for many health programs.

The sanitary personal in the world. Africa has more than of the global burden

of diseases, but to fight against 27% of diseases we have 3.5% of the health personnel in the world, and we have 1.7 as doctors. To give an example, in Italy we have 409 doctors per 100,000 inhabitants while in Tanzania we have 1 doctor for 100,000 inhabitants. I am not saying we have too many doctors, I am just saying that the inequality is evident.

The training capability of Africa is 6000 doctors per year, in Italy we have 10,000/year. In Brescia province we have 6072 doctors.

Ilpersonalesanitarionelmondo

Africa: 27%delpesocomplessivodimala a 3.5%delpersonalesanitariomondiale 1.7%deimedicialivellomondiale

h p://www.worldmapper.org/display.php?selected=219

Medici:Italia: 409/100.000abitan USA:245/100.000abitan Tanzania:1/100.000abitan

h p://gamapserver.who.int/gho/interac ve_charts/health_workforce/PhysiciansDensity_Total/atlas.html

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In my hospital in Brescia we have roughly 1000 doctors, not considering the resident physicians.

To train a physician in an African country, it costs 21,000 58,7000 $. And if the doctor trains in the country of Awa and then he/she lives, this money is lost. Who is gaining for that? Countries like UK, where it was estimated that the net benefit for importing health personnel was more than 2 billions $/year.

Even when the doctor stays in the origin country, the vast majority (>75%) is working in urban localities, not in the areas where Awa was living: this because you have much more possibilities. So doctors migrate. How can poor countries defend from that? In 2 ways: the first is that they are thinking about preparing mid-level doctors, so that they cannot emigrate, because they wouldnt be accepted by European countries, for example. Another solution is task shifting, so what is done here by doctors (such as anesthesia, more simple surgeries) there is done my nurses.

Q: Could the concentration of doctors in some centers provide benefits in terms of cost?

A: Not in Africa. You could do this here in Italy, where it is easier to move from one place to the other, but in Africa this wouldnt be possible.

Mediciedinfermieriforma allesterochelavoranoneiPaesiOCSE

WHO,2006.h p://www.who.int/whr/2006/whr06_en.pdf

Overthelast30years,thenumberofmigranthealth-workersincreasedbymorethan5%peryearinmanyEuropeancountries

InOECDcountries,around20%ofdoctorsareforeigners

Trainingcostforaphysicianin an African country =21.00058.700US$

Yearly benefit:

- 2.7 billion $ (UK)

- 846 million $ (USA)