The Causes and Impacts of Neglected Tropical and Zoonotic Diseases Opportunities for Integrated Intervention Strategies (2011) / Chapter Skim
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Workshop Overview
Workshop Overview
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1 The 13 parasitic and bacterial infections known as the neglected tropical diseases include three soil-transmitted helminth infections (ascariasis, hookworm infection, and trichuriasis) , lymphatic filariasis, onchocerciasis, dracunculiasis, schistosomiasis, Chagas disease, human African trypanoso miasis, leishmaniasis, Buruli ulcer, leprosy, and trachoma.These diseases afflict more than 1.4 billion people, most of whom live on less than $1.25 per day (WHO, 2006)
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Additional neglected zoonotic diseases (NZDs) such as brucellosis, bovine tuberculosis, and rabies, which are not typically included among the NTDs, profoundly affect impoverished people not only through their direct effects on human health but also by sickening and killing the livestock upon which their livelihoods depend (WHO, 2006)
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Sections of the workshop summary not specifically attributed to an individual reflect the views of the rapporteurs and not those of the Forum on Microbial Threats, its sponsors, or the IOM. The contents of the unattributed sections are based on the presentations and discussions at the workshop.
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. In a presentation discussing NTDs in the United States, Peter Hotez, of the George Washington University and the Sabin Vaccine Institute, noted that most NTDs in the Americas -- with the possible exceptions of Chagas disease and trachoma -- were the living legacies of slavery and the slave trade.
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373, Hotez PJ, Fenwick from The A, Savioli L, and Molyneux DH, Rescuing the bottom billion through control of neglected tropical diseases, pp. 1570–1575, Copyright (2009)
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. Early Descriptions of Parasitic Worm Infections Ancient Egyptian papyri represent some of the earliest written descriptions of parasitic worms infecting and causing disease in humans.
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. past decade, as the number of its people who live on less than a dollar a day has declined from 60 percent to 16 percent, there have been equally dramatic decreases in the prevalence of neglected infections of poverty, he stated.
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8 NEGLECTED TROPICAL AND ZOONOTIC DISEASES TABLE WO-1 High-Prevalence and Other Vector-Borne Neglected Tropical Diseases Disability- Approximate Adjusted Global Life-Years Deaths Prevalence Approaches to Control High-prevalence 14.9–52.1 24,000–415,000 1.0–1.2 MDA with rapid effect diseases million billion package Hookworm 1.8–22.1 3,000–65,000 600 million MDA with rapid effect Infection million package or albendazole Ascariasis 1.2–10.5 3,000–60,000 800 million MDA with rapid effect million package or albendazole or mebendazole Trichuriasis 1.6–6.4 3,000–10,000 600 million MDA with rapid effect million package or albendazole or mebendazole Lymphatic 5.8 million <500 120 million MDA with rapid filariasis effect package or diethylcarbamazine+ albendazole or ivermectin+albendazole Schistosomiasis 1.7–4.5 15,000–280,000 200 million MDA with rapid effect million package or praziquantiel Trachoma 2.3 million <500 84 million SAFE strategy with azithromycin Onchocerciasis 0.7 million <500 37 million MDA with rapid effect package or ivermectin Vector-borne 5.0 million 132,000 70 million Integrated vector management protozoan and or case detection and viral diseases management or both Dengue fever 0.7 million 19,000 50 million Integrated vector management Leishmaniasis 2.1 million 51,000 12 million Case detection and management and integrated vector management Chagas disease 0.7 million 14,000 8–9 million Integrated vector management Human African 1.5 million 48,000 <0.1 million Case detection and trypanosomiasis management, and tsetse control NOTE: MDA, mass drug administration. SOURCE: Hotez et al.
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Water may serve as a medium through which parasites such as helminths are transmitted; as a breeding ground for vector species such as mosquitoes and tsetse flies; or as the habitat for intermediate hosts, such as snails that transmit schistosomiasis (see Table WO-2) and, therefore, represents an important route to NTD control.
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Food-borne Bacterial As C above, plus meat diseases Cholera inspection and cooking Campylobacter Salmonellosis and Shigellosis Viral infections Hepatitis A and E Norovirus Helminth infections Trichinellosis Food-borne trematode infections Clonorchiasis Opisthorchiasis Paragonimiasisis Tapeworms Diphyllobothrium infection Taenia solium infection Taenia saginata infection
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(Dr. McDonald's contribution to the workshop summary report can be found in Appendix A, pages 357–388.)
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. that up to one-third of pregnant women in sub-Saharan Africa are infected with hookworms.
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and trichomoniasis shape women's reproductive, sexual, social, and economic health, McDonald stated; they cause sexual dysfunction, increase risk for sexually transmitted infections, decrease fertility, and threaten pregnancy outcome. Stigma and exclusion experienced by people with disfiguring NTDs such as lymphatic filariasis (LF)
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(Dr. Eppig's contribution to the workshop summary report can be found in Appendix A, pages 155–172.)
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"Only by continuing to get finer and finer with the scale of our analyses we can say this is solved," he added, but he also contended that the association between IQ and infectious disease burden had been supported on two very different geographical scales. NTDs and conflict In a presentation titled, "Neglected Diseases, Civil Conflicts, and the Right to Health," Chris Beyrer of the Johns Hopkins University discussed multiple mechanisms through which conflicts specifically increase vulnerability to NTDs, and how conflict situations contribute to an overall increase in neglect.
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. Similarly, he reported that cases of human African trypanosomiasis (HAT; sleeping sickness)
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Clearly, NTDs contribute to a cycle of poverty and disease in which each condition exacerbates and perpetuates the other. Many speakers emphasized that the lack of political voice among those most afflicted by NTDs is a primary reason for their neglect, as Beyrer expressed when he called them "neglected diseases of neglected people." The epidemiological characteristics of NTDs may also contribute to their neglect, several participants observed.
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Profiles of Neglected Diseases Although NTDs have much in common, each disease has its own history, and each presents certain unique challenges and intervention opportunities. As speaker Eric Ottesen, of the Task Force for Global Health, observed, "we know that we are going to deal with these diseases in an integrated fashion .
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LF was also the topic of a workshop presentation by Eric Ottesen, director of the Lymphatic Filariasis Sup port Center at the Task Force for Global Health, discussed below. BOX WO-2 Definitions of Elimination, Eradication, and Control Elimination: cessation of transmission in a country, continent, or other limited geographic area; complete prevention of a clinical manifestation.
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1998 Chagas disease: regional elimination of transmission "as technically feasible" (WHA51.14) 1998; "control and elimination" (WHA63.20)
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21 WORKSHOP OVERVIEW Dracunculiasis Also known as Guinea worm disease, dracunculiasis was the first (and to date, the only) NTD targeted by WHO for eradication, Hopkins said.
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, WHO's regional body in the Americas, targeted this disease in 1991 for interruption of transmission by 2012, Hopkins said. In the Americas, efforts to combat onchocerciasis among people living in 13 disease foci in the six affected countries (see Figure WO-6)
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By combining vector control -- spraying rivers with insecticides to prevent breeding of black flies -- with annual mass administration of ivermectin, transmission of onchocerciasis was completely eliminated across a vast area of Africa. He described that approach as effective but expensive and said
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Countries FIGURE WO-7 Onchocerciasis control programs in Africa. SOURCES: Hopkins (2010)
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25 WORKSHOP OVERVIEW • an effort to eliminate onchocerciasis in an isolated focus of the disease on the Sudanese island of Abu Hamad, in the Nile; • the launching of a nationwide onchocerciasis elimination program in Uganda; and • a 90 percent coverage rate of endemic areas in the Americas with iver mectin administration. Hopkins noted that the presence of the Loa loa parasite presents a barrier to ivermectin use in 10 of the 30 endemic African countries, because people infected with Loa loa can develop potentially fatal neurological complications when treated with ivermectin, or with albendazole, a drug used to treat LF (see below)
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"Halfway to 2020, the global program to eliminate blinding trachoma is still uncertain about how many countries are still endemic, which areas require interventions, and how best to monitor progress." On the other hand, West noted, a recent global scientific meeting hosted by WHO defined both targets and areas for trachoma elimination, and there has been a rapid decline in the number of cases worldwide. Lymphatic filariasis (LF)
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. "This is an excellent investment in global health, with impres sive economic rates of return," Ottesen observed.
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"Most NTDs cannot be eradicated or eliminated, but all can and should be much better controlled. The few NTDs that may be vulnerable to elimination or eradication should be pursued ruthlessly." Human African Trypanosomiasis (HAT)
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(Dr. Jannin's contribution to the workshop summary report can be found in Appendix A, pages 310–323.)
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Chad is reporting between 12 Nifurtimox, manufactured by Bayer, is used to treat Chagas disease (American trypanosomiasis)
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. Although progress has been made in controlling the tsetse fly by various methods, none is ideal or universal; thus, vector control is also a subject of research and development to address HAT.
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Schistosomiasis is closely tied to the unsanitary disposal of human waste, and its spread has been closely linked to the construction of dams and irrigation systems. Following the construction of the Aswan High Dam in Egypt in the 1960s, which was intended to control alluvial flooding and to generate hydro electric power from the Nile River, environmental changes allowed aquatic snails to proliferate (Malek, 1975)
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Therefore, rather than treating entire communities for schistosomiasis, control programs overlooked large numbers of people with subclinical infections and focused on the few with advanced disease, who were identifiable because they were passing high numbers of eggs. Indeed, he noted, some researchers concluded that the vast majority of people infected with schistosomiasis were not ill (Gryseels, 1989)
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Surveillance for Chagas disease is poor, according to Tarleton, who estimated that 10 to 20 million people, most of whom live in Latin America, are infected
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Nevertheless, Hotez observed, Chagas disease transmission does appear to be occurring at low levels in areas of the United States inhabited by reduviid bugs. He noted that zoonotic transmission from dogs is also a concern in the United States, as is the possibility that climate change will expand the geographic range of reduviid bugs, thereby increasing the potential distribution of Chagas disease.
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He noted that several companies, public–private partnerships, and nonprofits have begun to pursue this route. However, he added, inability to determine parasite load represents a major stumbling block to drug development for Chagas disease.
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. Following a database search through PubMed over 25 years using terms such as "neglected diseases" and "poverty," as well as specific geographic regions, racial, ethnic, and socioeconomic groups, and the names of the 30 NTDs listed on the website of PLoS Neglected Tropical Diseases, he estimated disease prevalence rates among selected communities in which studies had been done.
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Hotez called his original estimate of approximately 900,000 cases in African American women "very conservative." Trichomoniasis is associ ated with preterm delivery and low birth weight, he reported, and the disease has also been identified as an important risk factor in the HIV/AIDS epidemic in the American South, because of increased viral shedding associated with co-infection (Kissinger et al., 2008; Sutton et al., 2007)
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"This is probably an extremely important infection that we are just beginning to understand the full extent of," Hotez said, adding that congenital toxoplasmosis is not included in current global burden of disease assessments. Hotez reported on new legislation, titled "The Neglected Infections of Im poverished Americans Act of 2010," which was introduced by Rep.
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Margolis described the response to this outbreak, which included a serologic survey of 240 residents in which 13 were found to be seropositive for DENV-1. At the time of the workshop, Margolis stated that despite intensive vector control efforts a total of 44 locally acquired cases had been reported in 2010.
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aegypti, such as Puerto Rico and Key West, Margolis stated. Turning to the global re-emergence of dengue, Margolis discussed its underrecognition, which represents a significant barrier to addressing the disease.
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On a more positive note, Margolis described some recent improvements in the "dengue toolbox," comprised of integrated vector control, case management, diagnostics, vaccines, and antivirals. Although integrated vector control has been the mainstay of primary prevention for dengue, "it has really not prevented nor has it ever stopped an epidemic that is in progress," he said.
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In response to Margolis' presentation and the ongoing discussion about whether dengue should be included among the NTDs, Dr. Lorenzo Savioli, Director of WHO's Department of Control of the Neglected Tropical Diseases, related discussions at WHO's NTD Strategic and Technical Advisory Group in 2010 that dengue should be distinguished from the NTDs with a special program all its own because of its present expansion.
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Zoonotic diseases such as anthrax, bovine tuberculosis, brucellosis, cysticercosis, echinococcosis (hydatid disease) , and rabies are endemic in many developing countries of Africa, Asia, and South and Central America.
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The lack of animal health infrastructure in many developing countries fosters the perception that zoonotic diseases do not impose a significant health burden. On the contrary, evidence-based studies on some NZDs have determined that their true inci dences can be 100-fold higher than reported (WHO, 2006)
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These include dengue, toxoplasmosis, Chagas disease, and toxocariasis. 20 Highlights of his remarks on some of these diseases, and disease agents not dis cussed elsewhere in this overview, are noted below and in Box WO-6.
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Leishmaniasis Recognized by Hotez as "one of the most important protozoan infections of humans after malaria," leishmaniasis (also known as kala-azar) is actually a complex of diseases involving more than 20 parasite species, more than 30 vector species of sandflies, and a broad range of animal hosts including wild rodents, marsupials, hyraxes, edentates, and dogs, as well as humans.
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"I think that's what is holding back the community in a big way." He suggested that the zoonotic diseases make a "hit-list" of the top five zoonotic infections to be targeted for control in order to focus awareness and galvanize advocacy for this group of truly neglected diseases.
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Control of zoonotic diseases requires coordination between the veterinary and human medical and public health sectors, which is particularly difficult to achieve under conditions of limited resources and inadequate governance structures. The lack of animal health infrastructure in many developing countries fosters the perception that zoonotic diseases do not impose a significant health burden.
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highlight key aspects of current attempts to control neglected diseases of poverty and to mitigate their health and economic consequences. These efforts employ two basic approaches, either singly or in combination: mass drug administration and environmental interventions, encompassing both human-built and natural environments (Spiegel et al., 2010)
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. Reprinted from International Health, 1/1, Fenwick A, Zhang Y, and Stoever K, Control of the Neglected Tropical Diseases in sub-Saharan Africa: the unmet needs, pp.
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(Dr. Ault's contribution to the workshop summary report can be found in Ap pendix A, pages 115–131.)
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Controlling these diseases requires more innovative methods, such as the interventions developed to address dracunculiasis -- a disease for which no vaccine, treatment, or diagnostic tools exist. Hotez pointed out, however, that in reality all NTDs are tool-ready, meaning that there are interventions available for each of the major human NTDs, including the major kinetoplastid infections such as HAT and Chagas disease, while (ironically)
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This adds to sustainability, but it also has allowed us to expand rapidly at very low cost." The mapping of disease-endemic areas, as illustrated in Figure WO-11, has been crucial to these efforts, Hanson explained. Such maps ensure that govern ments satisfy the requirements of pharmaceutical companies that donate drugs, and they support ongoing NTD control efforts by the governments of diseaseaffected countries.
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Savioli of WHO also emphasized the importance of capacity building to ensure that there is an adequate workforce in place to sustain these programs. Noting that many experts in this field -- himself included -- are nearing retirement, he said, "We need a new generation of people that will take over from us." Summing up the impact of USAID's NTD control efforts, Hanson noted that, while they are proud of the number of treatments they have been able to provide, their goal is to reduce NTD prevalence to low enough levels that MDA is no longer necessary.
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Ault predicted that recent successes in controlling such infectious diseases as smallpox, polio, and measles in LAC would bode well for targeted control ef forts to address NTDs. To date, onchocerciasis transmission has been interrupted in 7 of 13 LAC foci; transmission of Chagas disease by both vector and blood transfusion has been significantly reduced, as have dog-transmitted rabies cases, he reported.
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. 2 bitmaps with vector type "neglected diseases and other infections related to poverty," or NIDs, to the first administrative level in 14 LAC countries (PAHO, 2009)
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SOURCE: Ault (2010) , taken from the draft report for the type Executive Committee, 2 bitmaps with vector 144th 2009, on Elimination of Neglected Diseases and Other 10 Infections Related to Poverty.
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He went on to state that the goal of this regional collaboration involving PAHO, the Inter-American Development Bank, and the Global Network for Neglected Tropical Diseases is "to see how well this integration functions and what outcomes we can actually measure as a result of the integrated implementation."
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Examples of infectious diseases that have been successfully controlled in Brazil include vaccine-preventable diseases and Chagas disease, Barreto said. In each such case, he observed, a clearly defined and effective prevention strat egy (e.g., vaccines, elimination of an intradomiciliary vector, and provision of water and sanitation)
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. The global cycle of poverty and substandard living conditions is what we must break in order to address NTDs and make them neglected no more." Taking a closer look at these relationships, Spiegel examined NTDs from a social perspective and urged that integrated control strategies address factors -- such as poverty, lack of infrastructure, and inadequate community-based primary care -- that "predispose the ill health that we are trying to address." Without attention to such social determinants of health, he argued, interventions cannot be ef fectively sustained (Spiegel et al., 2010)
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Therefore, they concluded, efforts to reduce dengue in Havana should involve community religious leaders to help promote safe practices, and local actions to do this were conducted. While cautioning against exclusive reliance on short-term medical solutions to neglected diseases of poverty, Spiegel acknowledged that, in a crisis, affected individuals must be treated as quickly and effectively as possible.
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Moreover, he said, "You really want to build an integrated system that isn't just for 15 infectious diseases, but will work as people transition from one set of health problems to another." Addressing Unmet Needs Increasing recognition of the health and socioeconomic consequences of NTDs and NZDs is spurring efforts to identify and develop medical products, strategic plans, and workforce to reduce this significant burden of disease. The two previous sections of this overview ("Profiles of Neglected Diseases" and "Approaches to Integrated Control of NTDs and NZDs")
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In addition to the significant hurdles that any drug candidate confronts along the development pathway, products targeted to treat NTDs face several additional obstacles, Feinberg observed. First, he noted, it is often difficult for regulatory authorities in the developed world to assess the relative risks and benefits of products targeting diseases that are largely or exclusively present in developing countries.
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Another partnership, involving a new rotavirus vaccine produced by Merck, was launched to show that a vaccine could be rapidly and effectively introduced into a developing country to demonstrably reduce disease burden, Feinberg said. Although almost all children worldwide will become infected with rotavirus before the age of 5 years, the greatest impact of the infection is seen in low-income countries where an estimated 600,000 children die of rotavirus gastroenteritis
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Nevertheless, he added, the rollout of rotavirus vaccines in developing countries has, to date, been disappointingly slow, largely because the current global financial crisis has severely curtailed GAVI's financial resources to support new vaccine introduction. Merck's experiences introducing hepatitis B and rotavirus vaccines to de veloping countries revealed "tremendous opportunities and tremendous needs to develop new and better vaccines for low-income countries," Feinberg said, as well as the potential to develop new and better models to meet these needs.
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organization that establishes partnerships with industry, governments, and private funders to develop new treatments for neglected diseases including malaria, visceral leishmaniasis (VL) , HAT, and Chagas disease (DNDi, 2010)
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has yielded two promising compounds that are orally active against VL, Chang reported, "so we're looking forward to potentially having a VL oral drug." The challenge of Chagas disease Several partnerships are pursuing much sought-after treatments for Chagas disease (see previous discussion in "Profiles of Neglected Diseases") , for which only two drugs are currently available: ni furtimox and benznidazole.
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"There [are] now good evidence and a lot of data showing how neglected tropical diseases impair intellectual and physical development in children," he observed; for ex ample, chronic hookworm infection in childhood has been shown to reduce future wage earning by 40 percent and also to contribute to adverse pregnancy outcomes (Hotez et al., 2009b)
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. Focusing on the human hookworm vaccine, Hotez observed that making a vaccine against a parasite, rather than an antigen, requires a novel approach -- in this case, attempting to interfere with its ability to feed on human blood.
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Thus, he said, as the control program progresses, sampling becomes more systematic, and decision-making demands more robust information. Although "19th-century" microscopic diagnostic techniques currently used in the initial phases of NTD control are adequate for the task, recent advances in genomics, proteomics, and metabolomics could vastly improve monitoring efforts in the late stages of control programs, Lammie said.
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He also drew scientific and policy parallels between the development of medical countermeasures against biological, chemical, radiologi cal, and nuclear threats and emerging infectious diseases (Hamburg, 2010) -- a major initiative undertaken by FDA -- and efforts to develop drugs, vaccines, and diagnostics for NTDs.
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Ideally, it would extend to all diseases of global health importance. In the meantime, the medical countermeasures initiative should benefit the cause of neglected diseases by raising awareness that the health of each country affects the health of the world, and by advancing regulatory science and driving multi-use technological innovations and support ing companies that engage in it.
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standard that says things have to have no risk and 100 percent benefit." Goodman also noted that FDA works with WHO on a number of issues with relevance to NTDs, including vaccine pre-qualification, establishing stan dards (e.g., for regulating blood testing and screening for Chagas disease) , prequalifying drug and vaccine manufacturing facilities, and efforts to reduce drug counterfeiting.
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Since 2000, he said, the British government has been a steady source of support for the Centre for Neglected Tropical Diseases (CNTD) at Liverpool University, the Schistomiasis Control Initiative (SCI)
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Jacobson's contribution to the workshop summary report can be found in Appendix A, pages 293–309.) Within its Global Health Division, the Bill & Melinda Gates Foundation currently awards grants for initiatives directed at a list of neglected diseases that includes WHO's "standard 13" as well as dengue and Japanese encephalitis; since 1998, the Foundation has invested US$544 million to address NTDs, she reported.
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From these highly detailed data, Moran extracted several "big picture" characteristics, beginning with the bottom line: in 2008, she reported, the world spent about US$3 billion to develop new products for neglected diseases, of which nearly three-quarters was spent on HIV/AIDS, TB, and malaria. The NTDs, among which Moran included WHO's list of 15 diseases, collectively receive ap proximately 12 percent of this total, or just under US$350 million; Figure WO-15 shows how that amount was divided among classes of NTDs, with kinetoplastid diseases (Chagas disease, HAT, and leishmaniasis)
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NIH is the biggest funder -- followed by the Bill & Melinda Gates Foundation -- for nearly every disease, Moran said. She also noted that the vast majority of pharmaceutical industry funding is directed at dengue, while nearly all R&D funding for kinetoplastid and helminth diseases and trachoma derives from pub lic and non-profit sources.
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Policy hasn't caught up to provide the tools to stimulate investment, to guide investment, and to make sure innovations get out there quickly." Several crucial pieces of information are needed to fill this funding gap, Moran observed. Funders need accurate assessments of health return on invest ment -- a difficult calculation to make, she added, because the investment needed
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"For every delay in that, I actually think we're starting to be responsible for some of this mortality. We have always pointed at poor infrastructure, or lack of industry investment in R&D for neglected diseases.
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genuine data showing impressive economic rates of return when you can keep people free of these neglected tropical diseases," Hotez replied. "They truly are antipoverty measures." But, Heilman asked, can you really demonstrate that a particular implemen tation measure produced those changes?
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All seven were raised and elaborated upon in subsequent workshop presentations and discussion and thus may be viewed as representative of the thinking behind investment in neglected diseases, a critical component of global health strategy. Focus on women's and children's health As both Emanuel and McDonald noted, women are primarily responsible for childrearing and for providing and seeking health care for their families; they also manage water and nutrition.
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. Country ownership Many participants extolled the importance of national or local management of and participation in NTD control programs.
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. Research and innovation Anticipating a key point Moran made in her presentation, Emanuel noted several disappointing lapses in the adoption of proven measures to improve global health, such as circumcision to prevent mother-to-child HIV transmission.
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He offered the contemporary example of consortia on health decisions between Israel and its Arab neighbors, which have enabled them jointly to pursue leishmaniasis control and to share outbreak data on a day-to-day basis. In Southeast Asia, in southern Africa, and even in North Korea, health consortia are currently working across political divides, he added.
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; eating meat from infected animals (gastrointestinal) ; inhaling spores (inhalation)
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: 807 million people infected, of whom 58 million are considered "highly infected" Prevention: Improved hygiene and sanitation; periodic drug treatment of at-risk populations Treatment: Antihelminthic therapy continued
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Infectious agent: The bacterium Mycobacterium bovis is a close relative of Mycobac terium tuberculosis, which causes most human cases of tuberculosis Routes of transmission to humans: Consumption of unpasteurized milk and under cooked meat from infected animals; close contact with infected animals Health effects: Lesions and progression are largely indistinguishable from M tuber culosis infection.
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. Infectious agent: Various bacteria of genus Brucella Routes of transmission to humans: Contact with infected animals, drinking unpasteurized milk from infected animals Health effects: Recurrent fever (often misdiagnosed as drug-resistant malaria)
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SOURCES: WHO; Chukwuekezie et al., 2007. Originally published in Emerging Infectious Diseases.
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A hemoflagellated protozoan parasite that causes trypanosomiasis (Chagas disease, African sleeping sickness)
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: Highly prevalent in poor com munities in developing countries; incidence of surgical cases ranges from 0.1 to 45 cases per 100,000 and real prevalence ranges between 0.22 percent and 24 percent in endemic areas Prevention: Sanitary slaughter conditions to prevent dogs from eating visceral organs of infected livestock, personal hygiene, avoidance of feces-contaminated water or vegetables, periodic treatment of dogs, meat inspection Treatment: Surgery to remove cysts
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Infectious agent: Tapeworms that infect pigs (Taenia solium) and cattle (Taenia saginata)
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: 50 million cases and 22 million deaths per year; global incidence has risen in recent decades; 40 percent of global population at risk Prevention: Vector control Treatment: No specific treatment; skilled care for DHF saves lives
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Gubb. WO5-10_guinea worm.eps Infectious agent: Dracunculus medinensis, a parasitic worm bitmap Routes of transmission to humans: Eggs live in standing water, such as ponds, and can be ingested by humans Health effects: Pain and disability as worms exit body Incidence, prevalence, and mortality (estimated)
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Routes of transmission to humans: Larvae in contaminated soil enter through skin Health effects: Intestinal blood loss, anemia, protein malnutrition; cognitive impair ment, delayed mental and physical development; maternal morbidity and mortality during pregnancy Incidence, prevalence, and mortality (estimated) : 576 million people infected, of which 60 million are "highly infected," with the largest number of cases in sub-Saharan Africa, South and East Asia, and in tropical regions of the Americas Prevention: Improved hygiene and sanitation; periodic drug treatment of at-risk populations Treatment: Antihelminthic therapy
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Infectious agent: Protozoan parasites of the genus Leishmania Routes of transmission to humans: Insect bites, especially those of sandflies Health effects: Fever, weight loss, skin sores, disfigurement; visceral leishmaniasis can be fatal Incidence, prevalence, and mortality (estimated) : 12 million people infected; up to 50,000 deaths per year Prevention: Vector control Treatment: Several effective drugs, all with serious drawbacks continued
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Infectious agent: Mycobacterium leprae, a bacterium Routes of transmission to humans: Human-to-human contact via respiratory drop lets; may be additional modes Health effects: Loss of sensation leading to damage to extremities and disability; disfigurement Incidence, prevalence, and mortality (estimated) : 900,000 people infected Prevention: None (not highly infectious)
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: 120 million people infected Prevention: Vector control; drug treatment for infected individuals in endemic areas Treatment: Limiting damage from bacterial and fungal superinfection; measures to promote lymph flow; surgery continued
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Infectious agent: Onchocerca volvulus, a parasitic worm Routes of transmission to humans: Blackfly bites Health effects: Severe skin disease with itching; severe eye disease causing blindness Incidence, prevalence, and mortality (estimated) : 37 million people infected, mainly in Africa; includes 350,000 blind and 600,000 with impaired vision Prevention: Vector control Treatment: Anti-parasitic drug
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Infectious agent: Virus Routes of transmission to humans: Bite from infected animal, often a domestic dog Health effects: Fatal if untreated Incidence, prevalence, and mortality (estimated) : 55,000 deaths per year Prevention: Vaccines for animals (especially dogs)
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; mainly in sub-Saharan Africa Prevention: Vector control, improved sanitation and health education; treatment of at-risk individuals Treatment: Anti-parasitic drug (effective, safe, and low-cost)
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Infectious agent: Parasitic roundworm Routes of transmission to humans: Ingestion of eggs from contaminated soil; worm embeds in wall of large intestine Health effects: Some infections cause eye disease that results in blindness; heavy or repeated infections can result in swelling of internal organs or central nervous system Incidence, prevalence, and mortality (estimated) : No global estimates; most common human parasite in the United States; reported to infect 40 percent of the population of some middle-income countries Prevention: Treatment (deworming)
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Incidence, prevalence, and mortality (estimated) : 84 million people infected, of whom 2.9 million become blind and 3.5 million have impaired vision Prevention: Access to clean water; improved sanitation and hygiene (face washing)
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Infectious agent: Trichuris trichiura, a parasitic roundworm Routes of transmission to humans: Ingestion of eggs from contaminated soil; worm embeds in wall of large intestine Health effects: Cognitive impairment, colitis and inflammatory bowel disease, delayed physical and mental development Incidence, prevalence, and mortality (estimated) : 604 million people infected of whom 27 million are "highly infected" Prevention: Improved hygiene and sanitation; periodic drug treatment of at-risk populations Treatment: Antihelminthic therapy continued
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Routes of transmission to humans: Insect bites, especially from tsetse flies Health effects: Central nervous system damage; fatal if untreated Incidence, prevalence, and mortality (estimated) : Limited to Africa; 50,000–70,000 infections and up to 24,000 deaths per year Prevention: Vector control Treatment: First- and second-stage drug treatments; second-stage drugs, which cross the blood–brain barrier, are highly toxic and difficult to administer
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SOURCES: Rinaldi (2008) , previously published in PLoS Neglected Tropical Diseases; WHO.
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Presentation given at the Sep tember 21–22, 2010, public workshop, "The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Implications for Global Health and Opportunities for Novel Intervention Strategies," Forum on Microbial Threats, Institute of Medicine, Washington, DC. Ayele, W
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. PLoS Neglected Tropical Diseases 4(6)
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Keynote Remarks. Presentation given at the September 21–22, 2010, public workshop, "The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Implications for Global Health and Opportunities for Novel Intervention Strategies," Forum on Microbial Threats, In stitute of Medicine, Washington, DC.
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PLoS Neglected Tropical Diseases 4(7)
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Presentation given at the September 21–22, 2010, public workshop, "The Causes and Impacts of Neglected Tropical and Zoonotic Diseases: Implications for Global Health and Opportunities for Novel Intervention Strategies," Forum on Microbial Threats, Institute of Medicine, Washington, DC. Mascarini-Serra, L
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PLoS Neglected Tropical Diseases 2(8)
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2010d. Neglected zoonotic diseases.
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Key Terms
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