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Health or Disease The Balance of Environment, Policy, and Science

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First Joint Meeting of Ministers of Health and Environment from South ... Lives saved, debility prevented. Diseases of the Most Impoverished. The DOMI Program ... – PowerPoint PPT presentation

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Title: Health or Disease The Balance of Environment, Policy, and Science


1
Health or Disease?The Balance of Environment,
Policy, and Science
  • Margaret A. Liu, M.D.
  • First Joint Meeting of Ministers of Health and
    Environment from South East and East Asia
  • August 9, 2007

2
  • Organization of talk
  • Status quo
  • What are the realities and challenges?
  • What are the issues?
  • Paradigms to support and emulate
  • International Vaccine Institute

3
Global Health in the 21st Century
  • Impact of Infectious Diseases
  • 13 million deaths annually
  • 50 of all deaths in developing countries
  • Despite progress (e.g., smallpox, polio)
  • Failure to control certain diseases
  • Inadequate usage of existing technologies
  • Re-emergence of diseases
  • Emergence of new diseases
  • What is the role of the environment?

4
The Impact of the Environment on Infectious
Diseases
  • 5-6 million annual deaths from water- borne
    diseases and air pollution
  • Poor environmental quality is a factor in 25 of
    all preventable illness
  • Indoor air pollution a factor in 60 of the 2.2
    million deaths/yr in children 5 due to acute
    respiratory infections

5
Paradigms for success
  • Eradication of smallpox

Courtesy of T Sharrar, Smithsonian Institution
6
Paradigms for success
Near-eradication of Polio
Courtesy of T Sharrar Smithsonian Institution
7
Eradicating polio achievements
8
Why do Infectious Diseases still kill so many
people?
  • Poverty/Lack of infrastructure
  • Lack of access to clean water, vaccines
  • Inadequate eradication strategies
  • Malnutrition

9
Why do Infectious Diseases still kill so many
people?
  • Biological Scientific challenges/Ecosystem
  • Persistence of diseases
  • failure to develop preventions,
  • treatments
  • Emergence of new diseases
  • e.g. HIV

10
Why do Infectious Diseases still kill so many
people?
  • Biological Scientific challenges/Ecosystem
  • Re-emergence of diseases
  • 20 diseases have re-emerged or spread
    geographically
  • e.g., malaria, Tuberculosis
  • New forms of old diseases antibiotic- resistant
    bacteria
  • MDR-Tb, XDR-Tb, MRSA

11
Why do Infectious Diseases still kill so many
people?
  • Interplay of many factors environmental,
    scientific, and political
  • This complexity poses challenges, but also means
  • There are many solutions
  • Solutions can synergize so 11 can 3

12
Scientific challenges that hinder conquering
infectious diseases
  • Emergence of new diseases
  • Novelty
  • Rapidity of global transmission
  • Diseases that mutate quickly
  • Immune escape from vaccines
  • Treatment escape drug resistance
  • -also due to misuse of existing therapies
  • Diseases requiring new technologies to conquer
  • New type of vaccine Cell-based immunity

13
Impact of environment on diseases
  • Environment changes and lack of change
  • Transmission
  • Vectors
  • Global warming
  • Proximity of humans to animals/loss of habitat
  • Globalization
  • human travel
  • Animal/insect/pathogen hitchhiking
  • War
  • Mistrust

14
Impact of environment on diseasesTransmission
Polio reservoirs
  • Sewage

Drinking water
Sewage
15
Impact of environment on diseases Vector-borne
diseases (which have both Mortality and often
extensive Morbidity)
Malaria (1 million annual deaths) Dengue (50
million infections, including about 400,000
cases of dengue haemorrhagic fever ) Yellow
fever Encephalitis West Nile Virus
Japanese Encephalitis Eastern Equine
encephalitis Western Equine encephalitis
La Crosse encephalitis St. Louis
encephalitis Rift Valley fever
16
Natural and Man-made Mosquito habitats
17
Environmental factors in current Southeast Asian
dengue outbreak
  • Increased mosquito breeding
  • warmer weather
  • heavy rains
  • "Factors leading to the spread of dengue include
    population explosion, migration and rapid growth
    of urban areas, which place a heavy strain on
    public health services and access to drinkable
    water."
  • John Ehrenberg, WHO regional adviser.

18
The complexities of environment and health
interventions
  • Some countries eliminated/controlled malaria by
    draining swamps and spraying for mosquitoes
  • But potential link between DDT and breast cancer

19
The complexities of environment and health (Part
2)
  • Hygiene hypothesis
  • Many infectious diseases have been largely
    controlled in countries with high standards of
    living
  • These countries have noted increases in allergic
    and autoimmune diseases

20
T Helper (TH)Subtypes
TH1
Help to generate CTL
IL-2, g-IFN, TNF b
1L-12
TH0
TH2
Help to Generate Antibodies
1L-4
IL-4, 5, 6, 10
21
Impact of environment on diseases
  • Environment changes and lack of change
  • Transmission
  • Vectors
  • Malaria, dengue, encephalitides and the role of
    persistent mosquito breeding grounds
  • Global warming
  • Proximity of humans to animals/loss of habitat
  • Globalization
  • human travel
  • Animal/insect/pathogen hitchhiking
  • War
  • Mistrust

22
Impact of environment on diseases
  • Proximity of humans to animals/loss of habitat
    Animal reservoirs of pathogens
  • Pathogen transmission, jumps, and
    recombinations to form new strains

23
Impact of environment on diseases
  • Proximity of humans to animals/loss of habitat
    Animal reservoirs of pathogens
  • Transmission
  • HIV, Ebola
  • Monkeypox (US pet stores) African rodents
    (source) ? pet prairie dogs ? humans
  • Lyme disease (suburban housing developments)
    Deer ?ticks ?humans
  • Jumps and Recombinations
  • SARS, Avian/pandemic influenza

24
Origins of Pandemic Influenza
Belshe, NEJM 2005
25
Impact of environment on diseases
  • Vectors
  • Malaria, dengue, encephalitides and the role of
    persistent mosquito breeding grounds
  • Global warming
  • Proximity of humans to animals/loss of habitat
  • Transmission
  • Recombination to form new strains
  • HIV, Ebola, Hanta virus, influenza
  • Globalization
  • human travel SARS and the cough heard around
    the world
  • Animal/insect/pathogen hitchhiking
  • War
  • Mistrust

26
Examples of Emerging and Re-emerging Infectious
Diseases
Multi-Drug Resistant TB
H5N1 Avian flu
Diptheria
E. Coli O157-H7
Lyme
E. Coli O157-H7
Typhoid
West Nile
Vancomycin-Resistant S. Aureus
Hanta
HIV
Ebola
Dengue HF
Plague
Cholera
Nipah virus
Drug-resistant Malaria
27
Roadmap for conquering Infectious Diseases
  • Scientific advances
  • New paradigms
  • Multi-disciplinary
  • Scientific disciplines
  • Policy makers
  • Public and private sectors
  • Multi-national
  • Co-partnering of stakeholders

28
Key elements of success
  • Scientific advances
  • Prioritization of health and prevention
  • Public and private sector involvment
  • Multinational/multisector engagement
    and cooperation
  • Example Rapid identification of novel
    coronavirus as etiology of SARS

29
  • November 16, 2002
  • Initial cases of SARS appear.
  • March 17, 2003
  • WHO forms global network to simultaneously
    determine the etiology of SARS and develop a
    diagnostic test. Investigators share results in
    real time via secure website.
  • March 24, 2003
  • Scientists at the CDC and in Hong Kong announce
    that a new coronavirus has been isolated from
    patients with SARS.
  • April 12, 2003
  • Canadian researchers announce successful
    sequencing of the coronavirus genome. Scientists
    from the CDC confirm report.
  • This incredibly rapid identification of the
    causative agent of SARS was enabled by an
    unprecedented collaboration of 13 laboratories in
    10 countries

30
International Vaccine Institute
  • Founded on the belief that vaccine science is a
    key tool for closing the gap in health between
    rich and poor
  • Worlds only international research organization
    dedicated exclusively to research on new
    vaccines for the worlds poorest people

31
IVI Background and Governance
  • In 1997 the IVI became an International
    Organization under the Vienna Convention
  • The Institute is autonomous and independent
  • The Institute is governed by a Board of Trustees
    - a majority of whom are chosen in their
    individual capacity

32
IVI Modus Operandi
  • IVI brings together countries, developing and
    industrialized
  • IVI brings together public institutions,
    international organizations (such as WHO and
    GAVI), and companies in public-private
    partnerships

33
Signatories to Establishment Agreement(As of
March 2007)
  • Bangladesh Kazakhstan Netherlands Spain
  • Bhutan Korea Oman Sri Lanka
  • Brazil Kuwait Pakistan Sweden
  • Cote DIvoire Kyrgyzstan Panama Tajikistan
  • China Lebanon PNG Thailand
  • Ecuador Liberia Peru Turkey
  • Egypt Malta Philippines United Arab
    Emirates
  • Indonesia Mongolia Romania Uzbekistan
  • Israel Myanmar Senegal Vietnam
  • Jamaica Nepal Slovakia WHO

34
IVIs Strategy for Narrowing the Vaccine Gap
between Rich and Poor
  • Lab science ? Make Vaccines
  • In-country studies ? Provide data to Formulate
    policy

35
IVIs Strategy for Narrowing the Vaccine Gap
between Rich and Poor
  • Gather epidemiological and socio- economic data
    that provide evidence to address policy
    uncertainties, and which can be utilized for
    formulating and supporting vaccine usage policy

36
IVIs Strategy for Narrowing the Vaccine Gap
between Rich and Poor
  • Synergize individuals, organizations, and
    governments from around the globe
  • Accelerate affordable vaccine introduction
  • -into poor countries and
  • -for diseases which are a global burden

37
IVIs Strategy for Narrowing the Vaccine Gap
between Rich and Poor
  • Bring together partners from all sectors to
    optimally benefit from, and synergize with,
    their differing expertise, capacities, and
    political and real capital.
  • Mine the scientific capabilities of all partners
    to develop vaccines that address the needs and
    fit the realities of developing countries

38
IVIs Encephalitis vaccine program
  • Japanese encephalitis
  • Mortality rates 35 in developing countries
  • Worldwide 10,000 deaths/yr
  • 33-50 of surviving symptomatic patients have
    major neurologic sequelae at 1 year
  • Mosquito-borne
  • Insufficient incidence data for certain regions
    for MOH to make decisions about immunization
    programs

39
IVI impact on JE vaccination
  • IVI demonstrated that incidence of JE in
    Balinese children is among the highest in the
    world
  • These findings contradict previous assumptions
    of low incidence
  • Outcomes of Nov. 2006 policymakers mtg held by
    IVI, Bali authorities, PATH, CDC
  • Pilot introduction of JE vaccine in Bali
  • JE control program under development

40
IVI impact on JE vaccination
  • IVI extending observations to other parts of
    Indonesia
  • Bali mainly Hindu
  • Other areas mainly Muslim
  • Pigs are the reservoir and amplifying host for
    JE, so incidence may be different

41
Lessons learnedRoadmap for successful outcome
  • IVI generated needed epidemiologic data
  • Clarified reality of human cost of disease
  • Evaluating effect of environment
  • Crucial relevant parties engaged
  • Informed policy enacted
  • Lives saved, debility prevented

42
Diseases of the Most Impoverished
  • The DOMI Program
  • A program to accelerate the development and begin
    the introduction of new vaccines against cholera,
    shigellosis, and typhoid fever

43
Industrialized Country Research and Technical
Institutions Participating in the DOMI Program
  • Country
  • Australia
  • Canada
  • France
  • Sweden
  • United Kingdom
  • Institutions
  • TGA
  • University of Western Ontario
  • Institut Pasteur
  • Epicentre
  • MSF
  • University of Goteborg
  • NIBSC
  • Sanger Institute

44
Industrialized Country Research Institutions
Participating in the DOMI Program
  • Country
  • United States
  • Institutions
  • Harvard University
  • Johns Hopkins University
  • NIH
  • University of Maryland
  • University of North Carolina
  • Walter Reed Army Institute of Research
  • Wayne State University
  • West Virginia University

45
The DOMI Network A Resource for Coordinated,
Multi-Country Field Studies
  • Institutions
  • ICDDR,B
  • Chinese Academy of Preventive Medicine
  • Guangxi Province Health Service
  • All India Institute of Medical Sciences
  • National Institute of Cholera and Enteric
    Diseases
  • National Institute of Health Research and
    Development, Ministry of Health
  • U.S. NAMRU-2
  • MOH
  • Aga Khan University
  • Mahidol University
  • NIHE
  • Country or Setting
  • Bangladesh
  • China
  • India
  • Indonesia
  • Mozambique
  • Pakistan
  • Thailand
  • Vietnam

46
Vaccine Producer/Developer Participationin the
DOMI Program
  • Amson, Pakistan
  • AVANT Immunotherapeutics, United States
  • BioFarma, Indonesia
  • Emergent Solutions, US/UK
  • GlaxoSmithKline, Belgium
  • IVAC, Vietnam
  • Lanzhou Institute of Biological Products, China
  • Sanofi Pasteur, France
  • SBL Vaccins
  • Shantha, India
  • VaBiotech,Vietnam
  • Wuhan Institute of Biological Products, China

47
Expertise of IVIs Scientific Staff
  • Epidemiology
  • Clinical trials
  • Computerized data management
  • Geographic information systems
  • Biostatistics
  • Health economics
  • Sociobehavioral studies
  • Policy analysis
  • Immunology
  • Molecular microbiology
  • Bioinformatics
  • Polysaccharide-protein biochemistry
  • Vaccine process and scale-up, and technology
    transfer

48
IVI Resource Base
  • Korean government
  • Building 18,000 sq m with pilot plant
  • 30 of operating budget
  • KOICA
  • Korean Science Foundation
  • Government of Sweden
  • Government of Kuwait
  • U.S. National Institutes of Health
  • U.S. National Science Foundation
  • Rockefeller Foundation
  • Bill and Melinda Gates Foundation
  • UBS Foundation
  • PATH
  • Industry (Aventis, Berna Biotech, CJ, Novartis,
    Merck, Microscience, Nonghyup, Sartorius, GSK,
    Wyeth, LG, )
  • Korean public

49
Partners in the DOMI Program
  • Broad inclusiveness
  • WHO
  • Ministries of Health

50
Strategy to Enable Development and Access to
Vaccines
  • Increase availability of low-cost vaccines
    (preferably with technology transfer for local
    production)
  • Technical assistance and training for
    professionals in developing countries
  • Vaccine demonstration projects
  • Develop an investment case, based on evidence
  • Burden of disease studies (including compilation
    analysis of existing data)
  • Cost-effectiveness studies

51
IVI DOMI Program
C
52
Summary
  • The IVI DOMI program is successfully making a
    reality of providing vaccines for diseases like
    cholera and typhoid for endemic regions
  • Accomplished by partnerships with diverse
    entities globally
  • IVI paradigm demonstrates
  • multi-etiology problem ? multi-disciplinary,
    multi-partner solution

53
Summary
  • Vaccine science efforts would synergize with
    efforts to improve the environment and
    infrastructure
  • 113

54
Conclusions
  • The environment and infectious diseases are
    inextricably linked
  • A new era of innovative global multi- disciplinary
    approaches are providing solutions
  • We must continue to be aggressive, creative, and
    comprehensive in our efforts

55
What you have, Mrs. Jones, sounds highly
contagious. Youd better see another doctor.
56
Recommendations
  • Prioritization of education, training, research
  • Ensure that specialists have a broad view and
    global understanding
  • Involvement and integration of all sectors
    (public and private), levels (local, regional,
    global), and disciplines
  • Health, environmental, and development efforts
    must be concerted

57
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