Infectious Disease Movement in a Borderless World Workshop Summary (2010) / Chapter Skim
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2 Travel, Conflict, Trade, and Disease
2 Travel, Conflict, Trade, and Disease
Pages 88-131
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The network gathers information on ill international travelers and migrants from 42 travel and tropical medicine clinics on six continents in order to provide early alerts about unusual infections or infections in unusual locations or populations. Studying travelers can help characterize "global microbial traffic," Wilson concludes.
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Like travel, globalized trade is vast, rapid, on the rise, and a significant risk factor for infectious disease emergence. In the chapter's third essay, workshop speaker Ann Marie Kimball, of the University of Washington, and co-author Jill Hodges present case studies of several emerging infectious diseases, including H5N1 influenza and bovine spongiform encephalopathy (BSE)
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. Characteristics of Global Travel Global travel has increased as reflected in Figure 2-1, showing numbers of international tourist arrivals from 1950 though 2005 and the projections until 2020.
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Census Bureau and the United Nations World Tourism Organization (UNWTO, 2008c) , one can calculate that the world population between 1950 and 2007 increased 2.6-fold, whereas the international tourist arrivals increased 35-fold.
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Today, the global human population is the largest ever recorded -- and so is the population of food animals. About half of the people on Earth live in urban areas, the largest fraction ever (Wilcox et al., 2008)
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. Animals have been the origin of many of the recently identified emerging infectious diseases, including HIV/AIDS, H5N1 avian influenza, severe acute respiratory syndrome (SARS)
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. Recently, swine-origin H1N1 has spread globally, its move ment hastened by global air travel.
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This seasonality is influenced by the humidity; recent studies suggest that absolute humidity is a more useful measure than relative humidity. The absolute humidity affects influenza virus transmission and virus survival.
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INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD December, 2006 Countries with XDR-tuberculosis cases June, 2008 Countries with XDR-tuberculosis cases FIGURE 2-5 Countries with XDR tuberculosis cases in December 2006 and June 2008. SOURCE: Reprinted from Lancet Infectious Diseases, Jassal and Bishai (2009)
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Populations may be immune because of vaccination or prior infec tion. Human behavior and activities influence exposure to a number of infections (e.g., sexually transmitted infections)
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Today, the dengue viruses have a much larger host population in which to replicate, recombine, and mutate than ever before, given the size of the human population. Zanotto and colleagues (1996)
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Human population size, millions (○) 5000 50 4000 40 3000 30 2000 20 1000 10 0 0 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 Year FIGURE 2-7 Global population size and lineages of dengue virus over time.
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Chikungunya virus was found in Aedes albopictus, the presumed mosquito vector in this outbreak. Textbooks describe chikungunya fever as a self-limited illness with fever, polyarthralgia, headache, and rash, but in the recent outbreaks excess mortality was also reported (Figure 2-8; Mavalankar et al., 2008)
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. mosquito had not been considered a particularly efficient vector, it was identified as the primary vector in some of the recent chikungunya virus outbreaks (Reiter et al., 2006)
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.Those who seek medical treatment abroad often undergo major procedures, such as heart bypass graft surgery, heart valve replacement, hip replace ments, and bone marrow and liver transplantation, procedures that frequently require support by transfusions of blood and blood products. Some international institutions are seeking accreditation by the Joint Commission International 4 to increase patient confidence in the quality of care.
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. The GeoSentinel Surveillance Network,5 a worldwide communication and data collection network of travel and tropical medicine clinics started more than a decade ago, systematically gathers information on ill international travelers and migrants and has been able to provide early alerts about unusual infections or infections in unusual locations or populations.
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ARMED CONFLICT AND INFECTIOUS DISEASE Barry S Levy, M.D., M.P.H. Tufts University School of Medicine This paper is designed to stimulate discussion on a complex set of issues associated with armed conflict (war)
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Two studies from the recent civil war in the Democratic Republic of Congo demonstrated that infectious diseases are frequent causes of death during wartime. One study found that diarrhea, respiratory infections, and suspected malaria were among the most frequent causes of death (Van Herp et al., 2003)
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Damage to the Health-Supporting Infrastructure and the Environment During war and in the immediate aftermath of war, damage to the healthsupporting infrastructure is often the main reason for poor health and excessive numbers of deaths. Food safety and supply, sewage treatment, water safety and supply, electrical power, transportation, and communication may be adversely affected.
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They suffer from loss of sociocultural support systems and reduced access to safe food and water, inadequate medical care and public health services, and inadequate clothing and shelter, and they are at increased risk for many infectious diseases. For example, in 1980 at a camp for Cambodians in Thailand, the leading diagnoses in the emergency ward of a 1,000-bed field hospital were predominantly infectious diseases (Table 2-2)
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1 million refugees from Rwanda fled to Zaire in less than one month; many of them died from cholera or dysentery soon after arrival in refugee camps there. In 2005, mortality among internally displaced persons and others in Darfur, Sudan, was mainly due to infectious diseases (Table 2-3; World Health Organization and Federal Ministry of Health, Sudan, 2005)
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Preparedness for bioterrorism should be placed more appropriately among U.S. national priorities for prevention and control of infectious diseases.
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Evaluation of prevention and control measures for infectious diseases related to war, and for measures to help prevent armed conflict; 3. Protection of medical care and public health services and maintenance of their neutrality during war and the aftermath of war; 4.
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But it is just one of a growing number of cases that demonstrate how the pressures and incentives of global trade and travel can threaten the biosecurity of the global population. The following discussion will focus on other recent examples that highlight some of the areas of greatest con cern, specifically food production, processing, and distribution; the use of anti microbials in food animals; and xenotransplantation.
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The families maintain their food animals in backyard farms with poor sanitation and water supply -- an opportune blend for the emergence of bird flu. Further compounding the risk
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.eps Figure 2-10 of spread is the nearby introduction of intensive poultry agriculture operations that raise thousands of birds from hatching through slaughter. Between 1980 and 2000, poultry exports from Far East Asian countries leapt from less than 200,000 tons of exports to nearly 1,800,000 tons (Figure 2-10; Kimball, 2006)
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provides another example of the potential consequences of the pressures that result from global trade. In this case, the chain of events arguably began when the United Kingdom entered the World Trade Organization (WTO)
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Long incubation period of up to 10 years al lowed extensive circulation of meat and bone meal-infected product in the global market Figure 2-11.eps prior to identification of risk. SOURCE: Reprinted from Beisel and Morens (2004)
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Beyond Food: xenotransplantation Another growing facet of global trade in services that poses a significant microbial risk is xenotransplantation, or the transplantation of animal parts into humans. Implanting animal organs or valves in humans introduces yet another level of cross-species exposure to pathogens.
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, which took effect in 2007, provides some important safeguards to help limit the international spread of infectious disease. The IHR require countries to conduct surveillance for and report to the WHO a "public health emergency of international concern," that is, an event "that may cause international disease spread." If WHO determines such a threat exists, as it did with the recent H1N1 outbreak, it may issue recommendations to curb the spread of disease, such as quarantine or travel restrictions for affected or potentially affected individuals.
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The full engagement of the private sector as a stakeholder would bring a key "driver" of global trade into the discussion and implementation of public health protection. In conclusion, there are some key questions raised by these case studies for which critical information is missing: (1)
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One challenge is that many of those foreign foodproducing countries may lack food safety standards on a par with ours. Approximately 15 percent of all food consumed in the United States is imported.
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, and therefore its price. The use of this adulterated wheat gluten in pet foods manufactured in the United States resulted in animal deaths due to kidney failure.
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FIGURE 2-13 Salmonella Saintpaul outbreak traceback and distribution. Partial view s the traceback and distribution of peppers from Figure 2-13 COLOR.ep of Mexico, July 16-22, 2008.
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. The only associated change in pet food formulation was the source of the wheat gluten it contained.
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Suppliers Poultr y Ingredients Farms Fe ed 3 Feed Ingredient & Meals Feed Manufacturers Mill Hog Scraps Farms Scraps 5 U.S. 14 Pet Food Importers Manufacturers 5 Rendering Scraps Plants Pet Food FIGURE 2-14 Sequence of events -- different routes of melamine-contaminated wheat gluten into the United States.
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Increased Foreign Presence Another way the FDA is supporting a more proactive stance on addressing threats to the globalized food supply is by establishing a greater foreign presence. To that end, we recently opened three offices in China -- in Beijing, Shanghai, and Guangzhou -- staffed by about a dozen permanent FDA employees.
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Conclusion The regulatory challenges involved in providing safe food to the United States will increase as globalization of the food system continues. The complexi ties of the food supply are enormous, and there is considerable economic benefit in making food distribution as rapid and efficient as possible.
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Emerging Infectious Diseases 11(5)
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2008. Global trends in emerging infectious diseases.
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Emerging Infectious Diseases 12(10)
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2008. Urbanization and the social ecology of emerging infectious diseases.
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Clinical Infectious Diseases 38(5)
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2006. Risky trade: infectious diseases in an era of global trade.
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