Protecting Health fromOld and New Threats

Hanoi Medical University

November 14, 2012

Thomas R. Frieden, MD, MPHDirector

Centers for Disease Control and Prevention

Infectious disease burden decreasing… but still cause >1/4 of all global deaths

• ~15 million deaths/year worldwide from all infectious diseases

• HIV, TB, pneumonia, diarrheal diseases, and malaria are leading infectious disease killers

• Disproportionally affect low-income countries

• Cause nearly 2/3 of all child deaths

• Most from pneumonia, diarrheal disease

• Influenza pandemics and emerging infectious diseases an increasing concern

Clean water and sanitation still abasic unmet need

• Nearly 800 million people still have no reliable access to clean water, 2.5 billion have no access to sanitation systems

• >2.5 million people die each year from water-borne infectious diseases – most of them children under age 5

• Each dollar spent on clean water/improved sanitation returns $10 in health & economic benefits

1.5M

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WHO, Global Burden of Disease 2008. Updated estimates

* vaccine preventable component caused by Streptococcus pneumoniae, Haemophilus influenzae type b, JE^, Japanese Encephalitis

Estimated vaccine-preventable disease deaths averted and still occurring

Annually among children <5 years, 2008

TB: 8.8M incident cases, 1.5M deaths worldwide in 2010

WHO. Global Tuberculosis Control: WHO Report 2011.

Prevalence

MDG target

WHO. Global Tuberculosis Control: WHO Report 2011.

Projected

TB prevalence and mortality rates are declining rapidly…

but incidence is barely declining

Mortality

MDG target

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Number of people living with HIV continues to increase…

even as new cases and deaths decline

UNAIDS. World AIDS Day Report 2011.

Artemisinin drug resistance isgrowing in South-East Asia

WHO. Update on artemisinin resistance, April 2012. Circles represent data before November 2010; triangles data after November 2010.

Percentage of cases positive for malaria on day 3 after ACT • Anti-malarial ACT

drug therapies increasingly ineffective

• No new drug class expected for >5 years

• Need for better control of malaria to

• Prevent worsening drug resistance

• Slow disease spread

Increasing risk of infectious disease from other sources

• Foodborne disease (from contaminated foods)

• May cause billions of illnesses and up to 1 million deaths each year

• Healthcare-associated infections (lack of basic hygiene, e.g., hand washing, sterilization)

• Affects about 1 in 10 patients (hundreds of millions of people/yr)

• Emerging diseases (new pathogens)

• West Nile virus, SARS, H5N1, ???

For the first time in human history…

• More people live in urban than rural areasMore people are overweight than underweightMore deaths occur among adults than childrenNon-communicable diseases (e.g., diabetes, heart disease, stroke) kill more people globally than infectious diseases

• Higher rates of NCDs in low/middle- than in high-income countries – rapid rise threatens economic/social development

40 years ago, there were about the same number of deaths worldwide among both

children and adults…Now, there are more than 3x as many deaths among adults as there are among children

The unfolding global pandemic

Non-Communicable Diseases•Heart disease, stroke•Cancer•Injuries•Obesity, diabetes•Chronic lung disease

Risk Factors•Tobacco•Inactivity•Nutrition•Alcohol

Global burden of tobacco

• Tobacco killed 100 million people worldwide in the 20thCentury

• Leading preventable cause of death – kills up to half of people who use it

• Unless urgent action is taken

• By 2030 tobacco will kill more than 8 million people each year – more than 80% of whom will be in developing countries

• Tobacco could kill 1 billion people during the 21st Century – unless we act now

Smoking and second-hand smoke damage every part of the body

Smoking

Second-Hand Smoke

World Health Organization

Tobacco is now the world’s leading single agent of death

Tobacco kills more people worldwide each year than HIV, TB, and malaria combined

No more than 10% of the world’s peopleare covered by even a single effective

tobacco control policy

9% or less benefit from effective interventions to reduce use

Share of world population

World Health Organization

Global Tobacco Surveillance System

• Enhance country capacity to design, implement and evaluate tobacco control interventions

• Monitor key articles of WHO Framework Convention on Tobacco Control (FCTC) and components of the WHO MPOWER technical package

• Includes collection of data through four surveys:

• Global Youth Tobacco Survey

• Global School Personnel Survey

• Global Health Professions Student Survey

• Global Adult Tobacco Survey

Smoke-free laws save lives and don’t hurt business

• Save lives and prevent heart attacks• Up to 17% average reduction in heart

attack hospitalizations in places with smoke-free laws

• Help motivate smokers to quit• Worker safety issue, not “personal

nuisance”• Allworkers deserve equal protection• Only way to protect non-smokers from

secondhand smoke

• Smoke-free workplace laws don’t hurt business• No trade-off between health and economics

Active liquor licenses and restaurant/bar employment increased in NYC after

implementation of SFAA

License Data: State Liquor Authority data on all active licenses. Employment Data: NYC Economic Development Corp.Average annual employment calculated from monthly totals.

SFAA effective3/03

Warn about the dangers of tobacco

• Despite overwhelming evidence of the dangers of tobacco, most people are unaware of the full extent of health risks of tobacco use and secondhand smoke exposure

Brazilian pack warning

• Graphic, pictorial pack warnings are effective in encouraging cessation

• Media efforts help change image of smoking:

• Anti-tobacco advertising through mass media campaigns

• Obtain free media coverage of anti-tobacco activities

Enforce bans on tobacco advertising, promotion, and sponsorship

• Tens of billions of dollars spent annually on tobacco marketing and promotion

• Tobacco control expenditures just a small fraction of this total

• Need to ban all advertising in all media

• Including at point-of-sale

• Need to ban all promotions and sponsorships

Street in Indonesia, before and after ad ban

Plain (generic) packaging prevents use of package

as a marketing device

Tobacco taxes reduceconsumptionRelationship between cigarette consumption

and excise tax rate in South Africa

Source: van Walbeek C. Tobacco excise taxation in South Africa: tools for advancing tobacco control in the XXIst century: success stories and lessons learned. Geneva, World Health Organization, 2003. Additional information obtained from personal communication with C. van Walbeek.

MPOWER interventions reduced smoking prevalence in Uruguay

• One of the sharpest declines ever reported

• Coordinated package of interventions• Smoking ban (first

country in Americas to go 100% smoke-free)

• Comprehensive ad ban• Large pictorial warning

labels• Cessation services• High taxes Data: Global Adult Tobacco Survey

1 in 4 smokers quit

Heart disease and stroke will continueto kill the most people worldwide

2004(actual)

2030(projected)

Proportion of people worldwide who die from heart disease and stroke is unlikely to change over the next two decades

Clinical and public health progress contributed about equally to decreased

US heart disease deaths, 1980-2000

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Ford ES, et al. NEJM 2007:356;23.

Clinical interventions = ~50%

Risk factor reductions = ~50%

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Changes in CHD risk factors contributed79% of life-years gainedEngland & Wales, 1981-2000

Unal B, et al. AJPH 2005;95:103-108.

67 million US adults havehigh blood pressure…

but less than half have it controlled

CDC Vital Signs, Sept. 2012; NHANES 2003-2010.

67M

53M47M

31M

47%

Hypertension control in Canada,the UK, and the US

Data for Canada: McAlister et al. CMAJ 2011;183:1007-1013.Data for UK: Ramsey et al. BMJ 1999; 319:630-635.Data for US:CDC Vital Signs, Sept. 2012; NHANES 2003-2010.

Percentage of people with hypertension who have their condition under control

Ontario, Canada

US

UK

Million Hearts: Prevent 1Mheart attacks and strokes in US by 2017

Road Traffic SafetyA winnable battle in global public health

• Large and growing burden • Road traffic accidents kill

1.2 million, injure up to 50 million annually worldwide

• Epidemic is still increasing in most parts of the world

• Legal interventions are proven effective

• Relatively inexpensive and highly cost-effective

Road traffic injuries to be 5th leading cause of death globally by 2030

2004(actual)

2030(projected)

Road traffic crashes currently cause more than 1.3 million deaths a year – but by 2030 will kill an estimated 2.4 million people per year

Evidence-based interventionsOnly 15% of countries have sufficiently comprehensive

road safety laws covering all five critical safety risk factors

• Drunk driving– BAC limits

• Seatbelts– drivers and passengers

• Child restraints– age/weight limits; safety standards

• Helmets– riders and passengers (also bicycles); safety standards

• Speed limits– under 50 km/h in urban areas

Rapid detection & characterization

Scalableresponse Recovery

Core attributes of NPHIs

• National scope of influence

• National recognition

• Scientific basis

• Shielded from political influence

• Focus on major public health problems

• Adequate human and financial resources

• Adequate infrastructure support

• Linkages and networks

• Accountability

Role of NPHIs

• Monitor and respond to health threats• Provide information, oversight, and program

implementation• Coordinate public health strategy, policy advice,

and program delivery• Need to adapt to meet new challenges

• Increasing complexity of health care• Budgetary constraints• New and emerging infectious disease threats• Growing burdens of NCDs diseases and injuries

• Success depends on accurate collection, analysis, and dissemination of data to improve health

Public health is local…so NPHI relationships with local

agencies are critical

• Strong relationships and successful engagement with subnational/local agencies• Depends on whether direct supervisory

role over local or if local has greater autonomy

• Level of subnational public health support• Funds and personnel (long/short term)• Reference laboratory services• More comprehensive oversight and

support

Field Epidemiology Training Programs

• Two-year, full-time postgraduate program• Modeled after CDC’s Epidemic

Intelligence Service

• Since 1980, 41 FETPs trained >2,600 epidemiologists• Residents assigned to positions

that provide epidemiologic service to MOH

• >80% stay in-country after graduating

• Effective, low-cost, practical – but has trained only small proportion of numbers needed

Global Disease Detection and Emergency Response

Helping people when they need help most

• Response to disease outbreaks and complex emergencies around the world

• Monitor, detect, and contain emerging health threats

• Re-establish and strengthen public health systems in wake of catastrophic events

• Deploy CDC experts 24/7 at country request

Healthier, safer, longer, andmore productive lives worldwide

Healthier, safer, longer, andmore productive lives worldwide