Global Burden of Respiratory Disease Lessons from Afar Scott Barnhart, MD, MPH June 18, 2010

Transcription

1 Global Burden of Respiratory Disease Lessons from Afar Scott Barnhart, MD, MPH June 18, 2010 Scott Barnhart, MD, MPH June 18, 2010

2 Three Goals An Overview of the global burden of respiratory disease relative to the burden of disease; What s it like out working out there; Lessons learned from global health.

3 Ethiopia

4 Tuberculosis Prevalence Ethiopia & United States What s wrong with this picture? Year Ethiopia United States /100,000 7/100, /100,000 4/100, /100,000 3/100,000

5 So, how bad can it be? Approximately 1 billion people live in extreme poverty Risks include being small, having bad neighbors, civil conflict = development in reverse, excess of natural resources, bad governance The poor die young

6 Income Levels Across the Globe

7 Per cent distribution of age at death by region, 2004

8 Child mortality rates by cause and region, 2004

9 Leading Causes of Mortality and Burden of Disease world, 2004 Mortality % 1. Ischaemic heart disease Cerebrovascular disease Lower respiratory infections COPD Diarrhoeal diseases HIV/AIDS Tuberculosis Trachea, bronchus, lung cancers Road traffic accidents Prematurity, low birth weight 2.0 DALYs % 1. Lower respiratory infections Diarrhoeal diseases Depression Ischaemic heart disease HIV/AIDS Cerebrovascular disease Prematurity, low birth weight Birth asphyxia, birth trauma Road traffic accidents Neonatal infections and other 2.7

10 Leading causes of attributable global mortality and burden of disease, 2004 Attributable Mortality % 1. High blood pressure Tobacco use High blood glucose Physical inactivity Overweight and obesity High cholesterol Unsafe sex Alcohol use Childhood underweight Indoor smoke from solid fuels 3.3 Attributable DALYs % 1. Childhood underweight Unsafe sex Alcohol use Unsafe water, sanitation, hygiene High blood pressure Tobacco use Suboptimal breastfeeding High blood glucose Indoor smoke from solid fuels Overweight and obesity million total global deaths in billion total global DALYs in 2004

11 Deaths attributed to 19 leading factors, by country income level, 2004

12 Tuberculosis A Case Study 2.5% Global Mortality Prevalence increasing in some areas Interaction with HIV MDRTB, XDRTB increasing Many countries have virtually no culture facilities- MDRTB <-> Treatment Failures

13 Controlling the Tb Epidemic Prevalence is rapidly rising Control is all about breaking transmission Treating active cases Preventing recurrence

14 Ethiopia Literacy rate: 40% Per capita GNP: $780 Population living on < $1 per day: 39%

15 Ethiopia 2010 Perhaps a model for moving up and out of the bottom billion 83 million 2,000 physicians 15,000 nurses Life expectancy 57 Maternal Mortality 720 / 100,000 live births Under 5 Mortality 12% Underweight Children (< 5 y o) 36%

16 TB Burden by Country

17 Tb in Ethiopia Rapidly escalating incidence and prevalence Extremely limited culture facilities Rate of MDRTB not well characterized Good adherence to treatment and treatment failure and best indication of Tb resistance Limited diagnostic treatment services

18 What do these two have in common?

19 WHO Tb Control The I s Intensified Case Finding (and treatment) Infection Control IPT How does this translate into effective control of Tb?

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22 Gondar: High for a reason!

23 Gondar Altitude 6,000 ft Above malaria Wind common Any roof / attic area will be pressurized both positively and negatively So what? This is an isolation ward for MDRTB

24 Public Health and Health Care Keep it simple if you can. Prevention of Tb isn t simple Prevention Diagnosis Treatment All require integration of multiple components. A systems approach is needed.

25 Controlling Global Respiratory Diseases A Health Systems Approach Human Resources Delivery Systems Information Systems Financing Technology / Drugs Leadership and Governance

26 Infection Control A Health Systems Approach Human Resources Delivery Systems Information Systems Financing Technology / Drugs Leadership and Governance Trained IC staff N 95 masks Tracking positive pts Essential Change takes leadership.

27 Intensified Case Finding A Health Systems Approach Human Resources Delivery Systems Information Systems Financing Technology / Drugs Leadership and Governance Trained lab technicians Culture media, slides Tracking patients Funding staff, supplies Rapid dx systems Complex system requires integration requires leadership

28 IPT Easy to say, hard to do. A Health Systems Approach Human Resources Delivery Systems Information Systems Financing Technology / Drugs Leadership and Governance Ruling out active tb Keeping INH in stock Keeping track!! Essential INH works fine How to overcome provider resistance and ensure integrity of all components of the systems.

29 Systems Approaches Can Work

30 Systems Approaches Can Work

31 Sense Making in Global Health Global Health - The dream Exotic travel Opportunity to work with fabulous people in country and out of country Work worth doing Global Health the reality Severe poverty Huge disparities in wealth Way to many dollars chasing too little human, financial, physical infrastructure Unsafe Deteriorating trends Some notable successes- it isn t hopeless

32 Sense Making in Global Health Look at the data Don t deny the realities Respect that we are guests Be an optimist Celebrate small successes

33 Sense Making in Global Health Looking at the Data Keep it simple Focus on what counts Comparative Effectiveness A needed conversation

34 Percentage of deaths over age 30 caused by tobacco, 2004

35 Deaths (millions) 12 Global projections for selected causes, 2004 to 2030 Cancers 10 8 Ischaemic HD Stroke Acute respiratory infections Road traffic accidents Perinatal HIV/AIDS TB Malaria Updated from Mathers and Loncar, PLoS Medicine, 2006

36 Ten leading causes of burden of disease, world, 2004 and 2030

37 Comparative Effectiveness Total Development Assistance 2007: $21.8 billion HIV / AIDS: $5.1 billion Tuberculosis: $ 0.7 billion Malaria: $0.8 billion Health Sector Support: $0.9 billion

38 Comparative Effectiveness

39 Hard Choices Lie Ahead HIV, TB and Malaria prevention and care are key drivers of health related foreign aid. Continued enrollment of patients with HIV on ARV s will require approximately 50% of the Foreign Aid Budget by 2016; In Ethiopia the prevalence of HIV is 2%. Where should the money go?

40 Summary Global Burden Respiratory Disease Pneumonia Tuberculosis COPD Risk Factors Underweight Children Lack of immunization Poverty Tobacco Poor infrastructure