Infectious Diseases Endemic to Southwest Asia

Transcription

1 Infectious Diseases Endemic to Southwest Asia Richard Reithinger HealthNet International, Kabul, Afghanistan Thermosurgery Technologies Inc, Phoenix, U.S.A.

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9 Basic Health Indicators Country Life Expectancy at Birth (years) <5 Years of Age Mortality Rate (per 1,000) Births Attended by Skilled Health Personnel (%) Maternal Mortality Ratio (per 100,000 live births) Contraceptive Prevalence (%) Afghanistan Armenia Azerbaijan Bahrain Cyprus Egypt Georgia Iran Iraq Israel Jordan Kuwait Lebanon Oman Pakistan Qatar Saudi Arabia Syria U.A.E Yemen (2003) 97 (2000) 84 (2000) 98 (1995) 69 (2003) 96 (1999) 90 (2000) 72 (2000) 99 (1987) 100 (2002) 98 (1995) 88 (1996) 95 (2000) 99 (1998) 20 (1998) 91 (1996) 76 (1993) 99 (1995) 22 (1997) U.S.A (1997) Source: World Health Organization (2005) World Health Report, Geneva.

10 Basic Health Indicators Country Total Expenditure Health (% GDP) General Government Expenditure on Health (% Total Expenditure) [2001] Per Capita Expenditure on Health (International US$) [2002] Private Expenditure on Health (%) Per Capita Income (US$) Afghanistan Armenia Azerbaijan Bahrain ,860 Cyprus Egypt ,146 1,470 Georgia Iran ,790 Iraq Israel Jordan ,494 1,760 Kuwait Lebanon ,112 3,900 Oman ,306 Pakistan Qatar Saudi Arabia Syria , U.A.E Yemen U.S.A ,400 Source: World Health Organization (2005) World Health Report, Geneva.

11 Burden of Disease Category Infectious and Parasitic Diseases Tuberculosis STI excluding HIV Syphilis HIV/AIDS Chlamydia Gonorrhoea Diarrhoeal diseases Childhood diseases Pertussis Poliomyelitis Diphtheria Measles Tetanus Meningitis Hepatitis B Hepatitis C Malaria Schistosomiasis Leishmaniasis Lymphatic filariasis Leprosy Dengue Encephalitis Trachoma DALY (000) Mortality (000) Source: World Health Organization (2004) World Health Report, Geneva.

12 Tuberculosis Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: 634,000; number of deaths: 138,000. Caused by M tuberculosis and M bovis. Disease risk factors include poor housing and living conditions, prolonged exposure to infectious cases, and ingestion of unpasteurized milk products. Important outbreaks regularly occur (e.g. Afghanistan and Pakistan have some the highest tuberculosis incidences in the world exceeding 200 cases per 100,000), up to 50% of resident population may be latently infected. Increasing resistance to standard therapeutic agents isoniazid, rifampin, ethambutol. Prevention includes vaccination with BCG for all newborn children and children up to 5 years of age.

13 Sexually Transmitted Diseases Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: unknown; number of deaths: 67,000. Syphilis, gonorrhoea, Chlamydia, HIV/AIDS Vastly underestimated case numbers, as in several countries an HIV/AIDS surveillance system does not exist, the disease s burden is belittled or its existence even denied. Increasing trend in number of cases due to poverty and migration. Access to diagnosis, treatment, prevention and health education is limited in most countries due to cultural boundaries (e.g. 70% of women are still deprived of appropriate care). Only a few countries in the region are committed to visible efforts addressing HIV/AIDS target groups (e.g. Iran and Lebanon, where specific programs exist for intravenous drug users, homosexual men and sex workers).

14 Diarrhoeal Diseases Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: >5,000,000; number of deaths: 259,000. Caused by several agents, including V cholera, Salmonella, Shigella, Entamoeba, E. Coli, Campylobacter, Giardia, rotaviridae; however, for majority of infections, the etiological agent is not identified. Risk factors for infection are dilapidated water and sewage systems as well as the lack of potable water. Important outbreaks regularly occur (e.g. >7000 cases of cholera in Kabul in 1999 and >50% of Soviet troops had major gastrointestinal infections). Treatment focuses generally on effective management of dehydrated patients using various antibiotics.

15 Pertussis Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: unknown; number of deaths: 46,000. Caused by B pertussis or B parapertussis. Usually occurs in infants having direct contact with discharges from respiratory membranes from infected cases. Important outbreaks can occur where vaccination programs have been discontinued or disrupted (e.g. 17/115 pertussis cases were reported in Badakshan, Afghanistan, in 2003). Isolation of cases as no treatment available. Erythromycin shortens the period of infectiousness, but does not reduce symptoms, except when given during the incubation period or catarrhal stage of the disease.

16 Poliomyelitis Distribution: Afghanistan, Egypt, Pakistan, Yemen. Estimated cases: <100; number of deaths: 0. Eradication program implemented and significant decrease in number of reported cases has been achieved in the past five years. Cases occur due to poor vaccination coverage.

17 Diphtheria Distribution: Afghanistan, Armenia, Azerbaijan, Egypt, Georgia, Iran, Iraq, Israel, Kuwait, Pakistan, Qatar, Saudi Arabia, Syria, Yemen. Estimated cases: <1,000; deaths: <250. Disease involves primarily involves tonsils, pharynx, larynx, nose, occasionally other mucous membranes, skin, and even conjunctiva and genitalia. Generally occurs in colder months, with non-immunized children <15 years of age at greater risk. Case fatality rate in recent outbreaks ranges from 4-20%. Important outbreaks regularly occur in non-immunes when vaccination programs have been disrupted or discontinued. Treatment for the disease requires administration of antitoxin and and antibiotics (penicillin or erythromycin).

18 Measles Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: unknown; number of deaths: <70,000. The disease is much more severe than in Western settings, with severe complications including pneumonia, bacterial lymphadenitis, otitis media and encephalitis. Is a leading cause of blindness and death for children throughout the region, with case fatality rates often >20%. Important outbreaks due to overcrowding and malnutrition resulting in massive morbidity and mortality (e.g. 12,000 cases were reported in 2000 in Badakshan, Afghanistan). No specific treatment, but many complication can be alleviated by administration of vitamin A. Outbreaks are due to poor and non-continuous vaccination coverage.

19 Tetanus Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: unknown; deaths: 36,000. Infants and elderly are at greatest risk, getting infected through a puncture wound contaminated with C tetani. Case fatality rates can range from %. Important outbreaks regularly occur in non-immunes when vaccination programs have been disrupted or discontinued.

20 Viral Hepatitis Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: unknown; number of deaths: >15,000. Caused by Hepatitis A, B, C and E virus. Transmission is by the fecal-oral route or blood-borne. Risk factors for infection are dilapidated water and sewage systems as well as the lack of potable water. Important outbreaks regularly occur in non-immunes (e.g. 25% of deployed Soviet soldiers had acute viral hepatitis), up to 90% of resident population may be infected. Prevention includes vaccination of population at risk as well as the provision of uncontaminated water, proper sanitation, uncontaminated blood supply, safe sex.

21 Malaria Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: 5,000,000; deaths: 59,000. Most cases are due to P vivax (>70%) Disease is mostly seasonal and hypo/meso endemic at altitudes <1500 m, with transmission common in rice growing areas. Main vectors are A stephensi, A subpictus, A annularis, A fluviatilis, A culifacies. Multiple outbreaks occur throughout the region with point prevalences reaching 30%. Treatment: sulfadoxine pyrimethamine, primaquine, quinine, mefloquine, artesunate, halofantrine. Wide-spread resistance to chloroquine and increasingly to sulfadoxine pyrimethamine Prevention includes residual spraying with insecticides, use of insecticide-impregnated bed nets or top sheets, and repellents.

22 Typhoid Fever Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: 2,000,000; number of deaths: 50,000 Caused by S typhi. Risk factors for infection are dilapidated water and sewage systems as well as the lack of potable water. Important outbreaks regularly occur. Wide-spread resistance of S typhi to traditional antibiotics (ampecillin, chloramphenicol, trimethoprim-sulfamethoxazole); quinolones and cephalosporins used. Prevention includes vaccination of population at risk as well as the provision of uncontaminated water and the adequate disposal of sewage.

23 Schistomiasis Distribution: Egypt, Iran, Iraq, Jordan, Lebanon, Oman, Saudi Arabia, Syria, U.A.E., Yemen. Estimated cases: unknown; number of deaths: 9,000. Caused by S mansoni and S haematobium. Transmission is through a snail host (Biomphalaria and Bulinus). Complications arise from chronic infections: liver fibrosis, portal hypertensions and its sequelae, obstructive uropathy, infertility, bladder cancer; case fatality rates can be as high as 25%. Transmission is through contact with water containing free-swimming Schistosoma cercariae that have developed in the snail host. In some endemic areas up to 89% of the population has been reported to be infected (e.g. Fayum, Egypt, in 1989). Treatment of choice is praziquantel. Prevention includes reduction or destruction of snail habitats, provision of drinking and household water free of cercariae.

24 Leishmaniasis Distribution: Afghanistan, Armenia, Azerbaijan, Bahrain, Cyprus, Egypt, Georgia, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Saudi Arabia, Syria, U.A.E, Yemen. Estimated cases: 500,000; number of deaths: 5,000. Caused by L tropica, L major, L. aethiopica, L donovani, L infantum. Transmission is mainly vector-borne (P papatasi, P sergenti, P caucasicus, P arabicus), either anthroponotic or zoonotic, and tends to be seasonal. Disease risk factors are related to vector exposure. Important outbreaks regularly occur in non-immunes (e.g. 67,500 cases in Kabul and >750 cases in U.S. military forces deployed to Iraq), up to 70% of resident population may have had the disease. Treatment: pentavalent antimony, amphotericin B, thermotherapy, miltefosine, fluconazole. Prevention includes improvement of housing infrastructure and use of insecticide-impregnated bed nets or top sheets.

25 Distribution: throughout the region. Arboviral Diseases Estimated cases: unknown; number of deaths: <5,000. Crimean-Congo hemorrhagic fever, tick-borne encephalitis, hanta virus, sandfly fever, dengue, West Nile virus, sindbis fever. Transmission is via the bite of mosquitoes, sandflies or ticks and tends to be seasonal, with risk factors related to vector exposure. Important outbreaks regularly occur in endemic areas. Prevention includes the use of insecticide-impregnated bed nets and repellents.

26 Other Infectious Diseases Distribution: throughout the region. Estimated cases: unknown; number of deaths: unknown. Q fever, spotted fever, scrub typhus,, epidemic typhus, endemic typhus, anthrax, plague, leptospirosis, rabies. Variable routes of transmission (e.g. vector-borne, exposure to cattle). Important outbreaks regularly occur in endemic areas.

27 Ministry of Health - Websites Country Afghanistan Armenia Azerbaijan Bahrain Cyprus Egypt Georgia Iran Iraq Israel Jordan Kuwait Lebanon Oman Pakistan Qatar Saudi Arabia Syria U.A.E Yemen Web Address [under construction] [not accessible] [English page non existant] [not accessible] [no data] [no data] [English page non existant] [English page non existant] [no data] [English page not accessible] [English page not accessible] [no data, under construction]

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29 Conclusion The true burden of disease in SW Asia is underestimated, due to the limited accessibility and availability of diagnosis and treatment as well as the absence of disease-specific prevention and control programs. Disease notification data is highly variable within the region. Health infrastructure in SW Asia varies between countries, from meeting Western standards to being barely functional. Adequate health information systems and mechanism of surveillance are often amiss and lack critical coordination and funding. Political instability, natural disasters and armed conflicts have led to massive refugee populations leading to large-scale outbreaks of disease. Prevention and control strategies are primarily based on reducing the risk of exposure to infectious agents.