Preventing disease Promoting and protecting health

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Patience Boyd
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1 Preventing disease Promoting and protecting health

2 CHIKV IN THE CARIBBEAN: PROJECTIONS OVER THE NEXT YEAR ENDEMICITY, PAIN AND MISERY.. Dr. C. James Hospedales Executive Director CARPHA Preventing disease, promoting and protecting health

3 Outline Global spread Epidemiology CARPHAs Role Projections over the next year Transition from acute to chronic phase of response Features of the chronic phase Economic impact The way forward including research into new approaches Preventing disease, promoting and protecting health

4 Globalisation Caribbean - most tourism dependent region in the world -50 MILLION ARRIVALS/YEAR; ½ air, ½ cruiseships Health in the Caribbean affected by health of others Globalisation has highlighted the interconnectedness of health Communicable diseases travel faster and further Media attention, political concern and public anxiety Regional health security important International Health Regulations identification, alert, preparedness and response Preventing disease, promoting and protecting health

8 Epidemiology In December 2013, first cases of chikungunya (CHIKV) in the Americas reported from Saint Martin/Sint Maarten. Totally susceptible population AND widespread mosquito vectors As of 27 October 2014: Chikungunya confirmed in all OECS Member States 23/24 CARPHA Member States (CMS) affected The total number of confirmed/probable cases stands at 15,837 in the Region of the Americas with 2,432 of these in CMS. Estimated total cases >720,000 Deaths 152 only one of these in CMS May be confused with dengue viral infection Long-term impact = persistent arthralgia after acute infection 43% to 75%, 24 months later; 12%, 3-5 years later Preventing disease, promoting and protecting health

11 ACUTE CHIKUNGUNYA ICEBERG Lab confirmed/probable cases Clinical symptoms/suspected cases: Home care Mild/ Sub-clinical Asymptomatic Preventing disease, promoting and protecting health

12 Projection for Chikungunya virus over the next year While the number of cases reported to CARPHA and PAHO have levelled off there are countries that have failed to report their confirmed and suspected cases. It is not known what percent of the population has been affected by Chikungunya due to the number of unreported cases and subclinical cases. Given the difficulties that the countries in the Caribbean are having in controlling vector populations it is anticipated that the number of cases will continue for the present year and into the next. Preventing disease, promoting and protecting health

13 Projection for Chikungunya virus over the next year In the epidemic in La Reunion it is estimated that 30% of the population was affected. From 2006 to 2009 no confirmed cases were reported however in August 2009 a cluster of cases were identified. If the epidemic in La Reunion can be used as an example and the percent affected in the Caribbean is similar it may be expected that the number of cases reported will be fewer after the second season of transmission. Sequelae as a result of infection may be prolonged in certain sections of the population Preventing disease, promoting and protecting health

14 CHIKV CARPHA response Coordination CARPHA quickly established an incident management team to coordinate the response among member states, and with partners The response was multidisciplinary and multifaceted Partnership with PAHO/WHO CARPHA worked closely with PAHO in response to the outbreak Laboratory response CARPHA provides diagnostic testing for member states Field response Communication Convening role Preventing disease, promoting and protecting health

15 Transition from emergency response to long-term response Number of identified cases Low Position in 2013 Nature of the response Emergency response Sustained response 2014 onwards High Preventing disease, promoting and protecting health

16 Transition from a public health approach to individualised care Position in 2013 Public health approach High Complexity of treatment Low High 2016/7 onwards Low Preventing disease, promoting and protecting health

17 CHRONIC PAIN most patients with ChikV recover in 1 to 2 weeks, BUT a percentage develop chronic joint pains which can persist for 2 to 3 years those most likely to develop chronic joint pains tend to be patients older than 45 years of age, to have pre-existing osteoarthritis or other conditions current WHO guidelines suggest the use of NSAIDs like ibuprofen or naproxen for treating the pain in one study in la reunion, 75% of patients with chronic pain had a moderate or good response to normal analgesics; 25% had a poor response the pain seems to be of two types; joint pains, and nerve pain or neuropathic pain. the latter seems to respond less well to normal analgesics insufficient research to give clear guidelines for treating chronic pain, especially when the person has existing chronic illnesses such as sickle cell disease, or is immunosuppressed due to HIV, or cancer chemotherapy an urgent need for research and trials into this as it will become an increasing problem in the months and years ahead as Chikungunya continues to spread in the region Preventing disease, promoting and protecting health

18 General care in chronic phase General Care in Chronic Phase (> d90) : Information : disease, treatments, social impact Symptomatic treatment -NSAIDs and analgesics (class 3) - Identify neuropathic element : clinical score, targeted treatment - Seek expertise if pain killers have no effect - Avoid surgery on ductal syndromes Psychologic care D9 +++Assessment : Chronic Inflammatory rheumatic disorders? - Clinical condition, clinical score - NF, CRP, VS, uric acid, 1-21OH vitamin D, transaminases, creatinine, FR, AC anti-ccp - Imaging of painful joints +/- other imaging, examination of osteoporosis if FdR (sex, age, corticosteroids) Preventing disease, promoting and protecting health

19 Chronic pain Risk greater in persons >45 years, females, pre-existing osteo arthritis 20% at 2 years = tens of thousands of people in OECS Virus invades lining of joints, and sometimes nerves Immune response subsequently causes inflammation, nociceptive and neuropathic pain; former responds to NSAIDs, latter harder to treat Chronic disability decreases home and occupational ability Mental health issues, gets you down; depression Preventing disease, promoting and protecting health

45 Impact of chikungunya ECONOMIC Tourism Gross Domestic Product Workforce wellness National insurance payments HEALTH Pressure on healthcare services Long-term disability Psychological effect Blood supply SOCIAL Physical and social activities Preventing disease, promoting and protecting health

46 The way forward Sustained commitment - substantial challenges ahead; Strengthen epidemiological and laboratory surveillance systems, and vector control response capability; Use a coordinated multisectoral approach - include education, tourism, media, local government and other sectors and capabilities, including private enterprise; Provide timely and accurate information to help avoid confusion or miscommunication; Educate the public, and visitors, tourism fraternities on the importance of protecting themselves from being bitten by mosquitoes; Preventing disease, promoting and protecting health

47 The way forward Protect hospitals - in-patients, staff and visitors; Individuals and communities to take responsibility for their immediate environment - regular inspection of homes to eliminate vector breeding sites; Build on the opportunity provided by chikungunya to strengthen health systems and prepare for long-term morbidity Need for long-term research (cohort studies) and publications CARPHA will continue to coordinate CHIK response and facilitate a meeting of experts in November 2014; CARPHA in partnership with CARICOM and PAHO to establish annual Caribbean Mosquito Awareness Week Preventing disease, promoting and protecting health

Thank you for your attention frederch@carpha.

48 Thank you for your attention Preventing disease, promoting and protecting health

Preventing disease Promoting and protecting health

Preventing disease Promoting and protecting health WHAT IS CARPHA? Integrated PH agency, manifestation of One Caribbean Combines the functions of five Caribbean Regional Health Institutes CEHI CAREC) CFNI