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MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS FORUM 2009 PAHO, WASHINGTON DC NOVEMBER 6, 2009

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Title: MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS FORUM 2009 PAHO, WASHINGTON DC NOVEMBER 6, 2009


1
MALARIA AND MOBILE POPULATIONS MALARIA IN THE
AMERICAS FORUM 2009 PAHO, WASHINGTON
DCNOVEMBER 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 discussion

CARLOS ESPINAL M.D. Director Public
Health sanofi pasteur Latin America
2
WHY POPULATIONS MOVE ?
Internal conflicts Violence
Migration related to natural resources mining,
agriculture, oil
Natural disasters
Government and irregular Military Forces
Human rights violations
Commerce in frontiers
  • 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

3
Mobile populationsUNHCR definitions and
statistics at a glance 2008 42 million forcibly
displaced people worldwide
  • Refugees
  • Status of Refugees
  • People 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
Stateless No belonging to any recognized state or
Nation 2008 6.6 million Overall about 12
million
Return refugees (returnees) Refugees who returned
voluntarily to their country of origin or
habitual residence 2008 604.000
Returned IDPs IDPs beneficiaries of protection
and assistance to return to their habitual
residence 2008 1.3 million
2008 Global trends UNHCR 2009
4
Populations of concern to UNHCR 2008
Latin America 3.571.620
COUNTRY 26.000.000
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
UNHCR Internally displaced Persons IDPs 2008
5
People displaced and evacuated by sudden-onset
natural disasters 2008
Natural disasters Earthquakes, floods, storms
Hazard type Geophysical Meteorolog Hydrolog Climatol All disasters
No of disasters 21 61 128 11 221
Total displaced and evacuated 15,769.430 8.246.523 11.485.418 561.472 36.062.843
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
6
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

(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
7
IMPORTED INFECTIOUS DISEASES IN MOBILE
POPULATIONS SPAIN
Diagnostic Population n2.198 Sub-Sah Africans Latin America
Malaria (1) Chagas (2) 212 101 199 0 101 13 101
Filariasis Cysticercosis 421 31 418 3 3 28
Latent TB Active TB 716 107 596 52 120 55
HIV Acute Hepatitis 97 31 82 27 15 4
Chronic hepatitis 267 257 10
REMARKS 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
B Monge-Maillo et al. Emerg Infect Dis 2009.
15(11)1745-1752
8
MOBILE POPULATIONS IN LATIN AMERICA 2009
Malaria Latin America 2007 WHO/UNICEF Report 2008
México
Cuba
Guatemala
Nicaragua
Venezuela
Panamá
Colombia
Ecuador

Migrant mine workers
Brasil
Conflicts, violence, IDPs (UNHCR?) Refugees,

Perú
Bolivia

Gold explotation Brazil, Venezuela, Surinam ,
Bolivia, Guyana
Paraguay

Uruguay
Argentina
Castaneros Bolivia (nut harvesters) Brazil
Chile
World Bank. http//web.worldbank.org/WBSITE/EXTER
NAL/TOPICS/EXTOGMC/0,,contentMDK20212491menuPK4
63310pagePK148956piPK216618theSitePK336930,0
0.html
9
Consultancy for Human Rights and Displacement
(CODHES) National estimates 4.629.190 persons
Average
925.838 families
No Persons
www.codhes.org
412.553
380.863
305.966

YEARS
10
HEALTH INDICATORS IN GOLD MINING WORKERS LATIN
AMERICA
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.
  • 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)
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 falciparum 56 (53) HCV 2.1 P vivax 47 (44)
11
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
  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

Epidemiology of malaria in mobile populations
12
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
  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

Surveillance systems
Vector surveillance
13
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
  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.,Bolivias
    successful case study reducing malaria in mobile
    populations in castaneros workers)

Chemotherapy
14
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
  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.

Health services
15
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
  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),
    2009326-35
  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.

Health services
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