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WORLD HEALTH DAY

Emerging Infectious Diseases in South-east Asia Region
***In August 1995, during the border meeting involving districts from Bangladesh, Bhutan, India and Nepal, malaria and kala-azar were identified as common health problems. The meeting, which was organized by WHO/SEARO, developed a district joint action plan to address kala-azar problems in border areas between Bangladesh, India and Nepal.
1HE Global eradication of smallpox in-1977 and the discovery of anti-s and vaccines led to optimism and a sense of complacency that infectious diseases, as public health problems, could be eradicated or elimi naled. This complacency has had adverse consequences, and. at present, infactious diseases are the leading cause of death, world-wide. Today, at least 17 million people die annually from infectious diseases. The South-east Asia Region (SEAR) unfortunately, accounts for almost 41 per cent (7 million) of these tragic deaths. Even so. this figure is an underestimation since some non-communicable diseases too. such as certain types of cancer and malnutrition. can be contracted as a result of an infection.
Today, in SEAR countries, the spectrum of infectious diseases is changing rapidly in conjunction with dramatic socio-economic and ecological changes. While the age-old diseases, such as cholera and tuberculosis, continue to dominate the disease pattern in the region, others like malaria, plague and kala-azar. which were on the verge of eradication, have reappeared. New diseases. such as a new strain of cholera (cholera O 139) and HIV infection, are being reported in the Region.
In addition, diseases which were once of no public health concern, such as meliodosis. are assuming importance in association with HIV in some countries. These diseases also exact a staggeringly high economic price from individuals, families and communities in terms of health care and loss of productivity. In response to these trends. WHO has formulated a strategy to strengthen national and international capacities in the surveillance and control of communicable diseases which represent new. emerging and re-emerging public health problems, including the problem of antimicrobial resistance.
There have been notable successes in the never-ceasing battle against infectious diseases. Significant progress has been made in the region towards achieving the goals of eradication of poliomyelitis and guineaworm disease, and the elimination of neonatal tetanus and leprosy as public health problems by the year 2000. A significant reduction in morbidity and mortality associated with other vaccine-preventable diseases like measles, diphtheria and whbopfng co^Ji jhas also beep achieved. Yet. 'new. emerging arid re-entetgmg infectious diseases pose serious health problems in almost all the countries of the Region.
New Diseases
The pandemic of HIV/A1D§ reached this region' relatively late but has spread rapidly in the last few years. The virus is spreading quickly and more than three million persons in the region are estimated to have been infected since the beginning of the pandemic. By the end of the century. 8-10 million men. women and children are likely to become infected with HIV within the region, accounting for over 25 of the global cumulative HIV infections.
The available epidemiological data show that AIDS cases arc increasing very rapidly, particularly in Thailand and India. As of 1 January 1997. about 49,000 AIDS cases have been reported (see Table) from the region, 80 per cent of which were reported over the last three
years. Furthermore. 85 per cent of cases have occurred in the most productive age group : 25-40 years. The. studies show that the HIV epidemic has now started spreading into the general population as well. For example. in Bombay, India. 2.5 per cent of pregnant women are now HIV positive, in Chiang Mai. northern Thailand. 16 per cent of military conscripts and 8 per cent of pregnant women are HIV positive.
However, in many other countries, including Bhutan. Maldives and Sri Lanka the HIV transmission continues to remain at a low level. But there is no room for complacency, given the experiences of some of the countries of the region. WHO estimates that more than 3 million people in the region have already been infected; 2.5 million in India; 800.000 in Thailand and 350.000 in Myanmar.
Cholera, caused by the El Tor strain, has been reported from all the countries in the region, except DPR Korea. A new strain, no\v labelled V. cholerae O 139. was first reported in October 1992 and spread rapidly to many countries in South-east Asia as well as to countries in other WHO regions. The new strain, which almost completely replaced the O 1 El Tor strain in 1993. however, largely disappeared from the countries in 1995-96. Few isolations have been still reported in India and Bangladeshi in 1996.
Emerging Diseases
Tuberculosis (TB) still kills adults more than any other disease. Since 80 per cent of these deaths is among the most productive age group (15-59 years), it has a serious impact on socioeconomic development. It is estimated that 3.5 million new cases would have occurred in the South-east Asia region during 1995, which represents about 40 per cent of the global burden of the disease. An estimated 1.2 million people would have also died from TB in the region in 1995, which is also nearlv 40 per cent of the global TB-deaths. By (he year ?000. TB/HIV co infection is expected to Increase dramatically to nearly to a level of one-in-five of all TB cases in the South-East Asia region. Emergence ol drug-resistance tuberculosis in the region is now a serious coh-cern.
Malaria is another ancient scofirjOWhat still dominates the disease pattern in the region. It is estimated that 1.2 billion people in the region live in malarious areas. The number of malaria cases in 1995 in the region was estimated at 23.6 million, with almost 40.000 deaths. An alarming feature is the increase in the proportion of P. falciparum cases. The development of resistance of the parasite to the commonly available anti-malarial drugs is emerging as a serious problem in many countries. Development of resistance of the mosquito vectors to insecticides is another problem hampering the control programmes.
Dengue/Dengue Haemorrhagic Fever (DHF) is a leading cause of hospitalisation and death among children in many countries of the region. It was estimated that there were 400.000 cases and 8.000 deaths from DHF in the region in 1995. During 1996. an increasing trend in morbidity associated
with dengue and DHF has been observed in India. Indonesia and Srl Lanka. In an outbreak in Delhi alone, during August-November (1996). about 10.000 cases and 400 deaths were reported.
In October 1995, a Regional Consultative Meeting on Prevention and Control of Dengue/ DHF was organized at WHO/ SEARO. This meeting reviewed the present situation and developed a revised strategy and plan of action for prevention and control of this disease at the national and regional levels. Development of a training module for case management of Dengue/DHF/DSS is in process.
WHO provided technical support to the countries of the region in containment of dengue outbreaks. A special Consultative Meeting on Management of Dengue Epidemic was conducted in November 1996 in WHO/SEARO where recommendations for the management of dengue epidemic is being developed.
Tetravelent live attenuated Sue vaccine has been devel-by Mahidol University in land, with support from WHO. and clinical trials of this vaccine in children are under way. This is the first time a developing country has successfully carried out the development of a vaccine for human use.
Hepatitis B is a growing problem in the region. It is estimated that there are more than 80 million carriers (more than 5 per cent of the total population) in the region. These carriers will help to spread this disease in the general population and infected mothers will pass on the disease to their babies. The majority of those infected are likely to die of liver cancer and cirrhosis.
Re-emerging Diseases
The sudden re-appearance of human plague in India, in 1994, after a period of 27 years caused global concern. It created a sense of panic, both within and outside the country, and led to the imposition of unwarranted trade and travel restrictions by several countries. There is a need to be vigilant since the natural foci of infectious plague exist in India. Indonesia Myanmar and possibly Nepal.
Kala-azar almost disappeared from the South-East Asia region during the early 1960s due to insecticide spraying under the malaria control programme (MOP). Subsequently. as the MCP entered the maintenance phase, insecticide spraying was withdrawn and kala-azar vectors started breeding profusely. Kala-azar continues to be a health problem of importance in primarily the rural areas of India. Bangladesh and Nepal, where approximately 110 million people are at risk. It was estimated that 100.000 cases and 5.000 deaths occurred in these three countries in 1995.
Why Are These Diseases Emerging?
There is no single factor re-Sonsible for the emergence of ese diseases but rather the interaction of multifactors. Poverty is on the increase and millions of people, by virtue of their living conditions, are exposed daily to the hazard of infectious diseases. Environmental degradation is another factor that contributes to the increasing disease burden.
Rapid population growth combined with uncontrolled urbanisation means that millions of city-dwellers are forced to live in overcrowded and unhygienic conditions lacking clean water and adequate sanitation. These conditions pro-
vide ample breeding grounds for infectious diseases.
Migration and displacement of people due to wards, civil strife and natural disasters like floods and earthquakes, also provide fertile breeding grounds for these diseases. The rapid increase in international travel and growing trade and tourism have implications for the spread of infectious diseases from one country to another. Also, mutation results in new strains of infectious agents and antimicrobial resistance. These, together with vector-resistance to insecticides, are also important factors in the emergence of new diseases.
But. perhaps one of the most important factors contributing to the emergence of infectious diseases 4s the low priority and support given to public health services in many countries.
Priority Areas for Action
Strengthening National Capabilities: There is no doubt that countries will continue to face outbreaks due to emerging infectious diseases. The only way to combat this threat is to recognise these diseases early and take preventive and control measures rapidly. Thus, countries would necessarily have to develop an early warning system and a rapid response mechanism. if they are to protect their citizens from the unnecessary suffering and staggering economic losses that such outbreaks cause.
To achieve this, epidemiological and laboratory services in most countries need to be strengthened. In fact, the World Health Assembly held in May 1995. through its resolution on communicable diseases prevention and control (WHA 48.13). urged the member-countries to strengthen their national and local programmes of active surveillance for infec-
tious diseases. The district health systems in countries should be strengthened. Early action for the prevention and control of infectious diseases, before they assume epidemic proportions, must be taken at the district level.
Intersectoral Collaboration: The effective control of these new. emerging and re-emerging infectious diseases calls for close coordination between health ministries and other ministries like agriculture, education and urban development. A classic example of poor intersectoral coordination is where irrigation facilities have been promoted without any consideration of health implications. This has given rise to mosquitogenic conditions leading to outbreaks of malaria — a distinct epidemiological situation referred to as irrigation malaria.'' The health implications of projects implemented by other ministries call for a constant dialogue between the concerned ministry and the health ministry right from the planning stage. Well-planned intersectoral collaboration will not only further health objec-• fives but also accelerate the process of development.
Intercountry Collaboration: Disease-causing microbes are no respects of international boundaries. With the ever increasing speed and volume of international travel and trade every opportunity exists for the rapid spread of infectious agents among countries. Because of trade and travel restrictions imposed on countries reporting infectious diseases, some countries are reluctant to provide information on disease occurrence in their countries.
In fact, imposition of restrictions on affected countries is not the solution to the prevention and control of the spread of disease. On the contrary. the rapid flow of disease surveillance and other relevant data among countries is the only way countries can be prepared to control the spread of diseases.
WHO Report