malaria and mobile populations malaria in the americas forum 2009 paho, washington dc november 6,...
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MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS
FORUM 2009 PAHO, WASHINGTON DC
NOVEMBER 6, 2009
Presentation outline
-Definitions and statistics at a glance
-Health implications of mobile populations: refugees, displaced
populations and infectious and tropical diseases
-Mobile populations and impact on malaria transmission
-Key elements for discussionCARLOS ESPINAL M.D. Director Public Healthsanofi pasteur Latin America
WHY POPULATIONS MOVE ?
Internal conflicts Violence
Internal conflicts Violence
Natural disasters
Natural disasters
Migration related to natural resources:
mining, agriculture, oil
Migration related to natural resources:
mining, agriculture, oil
Human rights
violations
Human rights
violations
Commerc
e in frontiers
Commerc
e in frontiers
Government and irregular
Military Forces
Government and irregular
Military Forces
REMARKS
•Medicine and public health focused on pathogens
•Today focus should be in globally move populations that move pathogens across international borders and internally
•Human mobility has always been associated with the spread of diseases: Influenza H1N1, avian FLU, dengue, malaria, TB, HIV, SARS
•Impact of migration patterns is a great challenge for modern epidemiology and public health programs
Mobile populationsUNHCR definitions and statistics at a
glance 2008: 42 million forcibly displaced people
worldwideRefugees
Status of RefugeesPeople crossed international border
2008: 15 million
Asylum-seekers
Claimants for refugee status pending of approval
2008: 827.000
Internally displaced
persons (IDPs)
People forced to leave habitual residence, who have not crossed international borders
2008: 26 million
Natural Migrants (borders
populations)
Individuals or groups with residence within the international borders, with a wide circulation across the frontiers
Return refugees
(returnees)Refugees who returned voluntarily to their country of origin or habitual residence
2008: 604.000
Returned IDPsIDPs beneficiaries of protection and assistance to return to their habitual residence
2008: 1.3 million
2008 Global trends UNHCR
2009
StatelessNo belonging to any recognized state or Nation
2008: 6.6 million Overall about 12 million
COUNTRY 26.000.00026.000.000
SUDAN 4.900.000
COLOMBIA* 2.650.00-4.360.000
IRAQ 2.840.000
PAKISTAN 2.400.000
DEMOC REP CONGO 2.000.000
SOMALIA 1.300.000
ZIMBABWE 1.000.000
AZERBAIJAN 603.251
KENYA 400.000
AFGANISTAN 235.000
ETHIOPIA 200.000-300.000
PERU* 150.000
UNHCRInternally displaced
Persons IDPs 2008
UNHCRInternally displaced
Persons IDPs 2008
Populations of concern to UNHCR 2008
Latin America: 3.571.620
Latin America: 3.571.620
Hazard type
Geophysical
Meteorolog
Hydrolog Climatol All disasters
No of disasters
21 61 128 11 221
Total displaced
and evacuate
d
15,769.430
8.246.523 11.485.418
561.472 36.062.843
People displaced and evacuated by sudden-onset natural disasters 2008
Natural disasters: Earthquakes, floods, storms
Country Total displaced and evacuated
China 19.979.423
India 6.705.085
Philippines 2.736.389
USA 2.014.473
Cuba 980.000
Country Total displaced and evacuated
Myanmar 800.000
Indonesia 400.815
Brazil 381.035
Mozamb 289.486
Thailand 202.680
MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND TROPICAL DISEASES
MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND TROPICAL DISEASES
•Denmark: TB incidence in foreign-born persons rose from 18% in 1986 to 60% in 1996 (1)
•England: TB, 40% of new cases occur in people from Indian subcontinent (1)
•Germany: 14% of HIV/AIDS cases are detected in migrants from Africa, USA, Asia, and Latin America (1)
•USA: Polio, in 2005 Minnesota State Health Department detected vaccine-derived poliovirus infection in 4 children, in unvaccinated community, probably originated in a person vaccinated with OPV in another country (2)
•Polio: 2003-2006, polio imported to 24 polio-free countries (2)
•USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000 in foreign-born persons
•Denmark: TB incidence in foreign-born persons rose from 18% in 1986 to 60% in 1996 (1)
•England: TB, 40% of new cases occur in people from Indian subcontinent (1)
•Germany: 14% of HIV/AIDS cases are detected in migrants from Africa, USA, Asia, and Latin America (1)
•USA: Polio, in 2005 Minnesota State Health Department detected vaccine-derived poliovirus infection in 4 children, in unvaccinated community, probably originated in a person vaccinated with OPV in another country (2)
•Polio: 2003-2006, polio imported to 24 polio-free countries (2)
•USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000 in foreign-born persons
(1) M Caballero A Nerukar Em Inf Dis 2001. 7(3):556-560
(2) E Yanny et al. Em Inf Dis 2009. 15(11):1715-1719
IMPORTED INFECTIOUS DISEASES IN MOBILE POPULATIONS SPAIN
B Monge-Maillo et al. Emerg Infect Dis 2009. 15(11);1745-1752
Diagnostic Population n=2.198
Sub-Sah Africans
Latin America
Malaria (1)
Chagas (2)
212 101
199 0
101 13 101
Filariasis Cysticercosis
42131
4183
328
Latent TBActive TB
716107
59652
12055
HIVAcute Hepatitis
9731
8227
154
Chronic hepatitis
267 257 10REMARKS:
2008: EU 1.9 million immigrants. Spain 700.000.
Total Immigrants in Spain by 2008: 5.2 million
(1) Malaria: 15 patients (7.1%) were asymptomatic. P falciparum most frecuent in Africans.
(2) Chagas: 95% of positive patients from Bolivia. Study in Spain estimated between 37.000-122.000 immigrants potentially infected with T cruzy
Migrant mine workers
MOBILE POPULATIONS IN LATIN AMERICA 2009
México
Guatemala
Chile Argentina
Brasil
Bolivia
Perú
Venezuela
Colombia
Uruguay
Panamá
Paraguay
Conflicts, violence, IDPs (UNHCR?) Refugees,
Nicaragua
Cuba
Gold explotation: Brazil, Venezuela, Surinam , Bolivia, Guyana
Ecuador
World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTOGMC/0,,contentMDK:20212491~menuPK:463310~pagePK:148956~piPK:216618~theSitePK:336930,00.html
Castaneros Bolivia (nut harvesters): Brazil
Malaria Latin America 2007
WHO/UNICEF Report 2008
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 20070
50000
100000
150000
200000
250000
300000
350000
400000
450000
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007
www.codhes.org
YEARS
No Persons
380.863
412.553
Consultancy for Human Rights and Displacement (CODHES) National estimates: 4.629.190 persons
Average: 925.838 families
305.966
HEALTH INDICATORS IN GOLD MINING WORKERS LATIN AMERICA
Bolivar State, Venezuela. L Faas, et al. Pan Am J Public Health , 5(1) 1999
Totals
893 STDs (1 or 2): 178 (19.6%)
Syphilis: 148 (16.6%)
Population profile: Concentration of men, ages 20y-45y, very limited female population, miners in permanent migration, rise of violence, alcohol and drug abuse. Inadequate housing, living in tents, poor sanitation.
Guyana, Amazon Region. CJ Palmer et al. Emerging Infectious Diseases 8(3), 2002
Totals
216 HIV+: 14 (6.5%) Impact of co-infection HIV-Malaria
Apiacas, Mato Groso, Brazil. FJ Dutra et al. Hepatitis B markers in malaria-exposed gold miners. Mem Inst Oswaldo Cruz, 96, 2001. Garimpo satelite: 16 gold mine campus
Totals
Malaria
569 Age 20-40y
99.4 % with previous episodes
HBV markers 82.9%
610 (20%) positive for
malaria
HBsAg 7.1%
P falciparum56 (53%)
HCV 2.1%
P vivax47 (44%)
1. Mass population movements could occur in endemic areas., e.g., the Amazon frontiers.
2. Industry – mining, rubber, agriculture, oil fields, attract migrant workers to new areas
3. Incidence and burden of disease will depend upon immunity, intensity of malaria transmission, vectors, and health care services
4. Malaria can be responsible for high rates of morbidity and mortality
5. Displacement exacerbates rapid urbanization in marginal areas, with poor housing condition and sanitation, inadequate vectorborne control, and amplification of malaria to epidemic proportions
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
Epidemiology of malaria in
mobile populations
Epidemiology of malaria in
mobile populations
1. Health service personnel trained in malaria
2. Demography data, determine high risk groups or vulnerable populations (pregnant women, children)
3. Case definition and case management. Active reporting and high quality data
4. Active vs passive surveillance
5. Rapid diagnostic tests. Blood smears and microscopy routine technique. Asymptomatic case detection by PCR (MS Suarez et al Rev Inst Med Trop S Paulo 49(3) 2007. 20% detection in P vivax)
6. Monitoring of drug efficacy and resistance
7. Hospital-based surveillance for clinical complicated malaria and fatal cases
1. Health service personnel trained in malaria
2. Demography data, determine high risk groups or vulnerable populations (pregnant women, children)
3. Case definition and case management. Active reporting and high quality data
4. Active vs passive surveillance
5. Rapid diagnostic tests. Blood smears and microscopy routine technique. Asymptomatic case detection by PCR (MS Suarez et al Rev Inst Med Trop S Paulo 49(3) 2007. 20% detection in P vivax)
6. Monitoring of drug efficacy and resistance
7. Hospital-based surveillance for clinical complicated malaria and fatal cases
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
Surveillance systems
Surveillance systems
Vector surveillance
Vector surveillance
1. Selection of antimalarial drug and appropriated regimens. Effective drug combinations. Artesunate combinations. High levels of acceptability in the community and adhesion to treatment
2. Mass drug treatments upon arrival at camps vs selective treatment to febrile patients?
3. Treatment only in confirmed cases?
4. Train local community leaders in techniques for rapid diagnosis and treatment. ( e.g.,Bolivia’s successful case study: reducing malaria in mobile populations in castaneros workers)
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
ChemotherapyChemotherapy
1. Overburdening of existing health structure: insufficient personnel, hospitals or clinics, problems with access to medicines including antimalarial drugs, deficiency in lab diagnosis, equipments
2. Malaria control strategies integrated to global health interventions in displaced population, refugees, and mobile workers
3. Very few interventions measure the impact . Effectiveness is not consider it or limited in methods to evaluate their success.
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
Health servicesHealth services
1. Large gap in the evidence of what works for change the behavior of public and private health providers. Pay attention to health system constraints that impact effectiveness and sustainability of malaria interventions. LA Smith et al . Improve effective treatment malaria: Do we know what works? Am J Trop Med Hyg. 80(3), 2009:326-35
2. Resettlement or repatriation: possible introduction or reintroduction of multi-drug resistant malaria. Mass screening strategies?, mass treatment before departure?
3. How to achieve sustained high coverages of control measures: rapid diagnosis and effective treatments with simple schedules, insecticide residual spraying, preventive treatment in vulnerable groups, long-lasting insecticide treated mosquito nets.
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
Health servicesHealth services