Timothy Brewer MD MPH University of California Los Angeles May 10 2017 No relevant disclosures Typical day in the clinic 24 year old female presents with acute fever myalgia arthralgia and pruritic rash ID: 784922
Download The PPT/PDF document "Global health: health care in an interco..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Global health: health care in an interconnected world
Timothy Brewer, MD, MPHUniversity of California, Los AngelesMay 10, 2017
No relevant disclosures
Slide2Typical day in the clinic
24 year old female presents with acute fever, myalgia, arthralgia and pruritic rashNo significant PMH or allergiesSocial/Family HistoryNo travel or animal exposures, one long-standing sexual partner who had returned 10 days previously from Carnival in Rio de
Janerio
D’Ortenzio
. N
Engl
J Med 2016;374:2195.
Slide3Additional data
Physical ExamT-36.6° CDiffuse fine maculopapular rash in abdomen, arms and legs
D’Ortenzio
. N
Engl
J Med 2016; 374:2195;
Driggers. N Engl J Med 2016; 374:2142.
Slide4Next steps
Appropriate management of this patient would include:Hospital admission for observationICU admission with isolation, antibioticsScreening for pregnancy, counseling
None of the above
Slide5What information is essential for a well-rounded healthcare worker today?
GBD 2015. Lancet 2016; 388: 1459.
Janeway
CA, et al.
Immunobiology
. 5th ed. New York: Garland Science; 2001.
Slide6Global Health: A Working Definition
“…an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care.”
Koplan. Lancet 2009;373:1993.
Slide7Outbreaks happen
Zika (March 10th)
79 countries/territories with outbreaks, 61 for first time in 2015 or 2016
H1N1 Influenza (March 2009-Aug 2010)
214 countries/territories, 18,449 lab confirmed deaths
Ebola (March 2014-March 27, 2016; 10 countries)
28,646 cases, 11,323 deaths (40% case fatality)
http://www.who.int/csr/disease/en/
Sands. New
Engl
J Med 2016;374: 1281.
Slide8Travel is faster, and more people are traveling
1.184 billion people traveled internationally in 20154% increase every year since 2010
http://statistics.unwto.org/en
Dallas to Sydney
8578 miles, 17 hours
http://www.hopper.com/articles/1049/the-worlds-20-longest-non-stop-flights
http://www.statista.com/statistics/209334/total-number-of-international-tourist-arrivals/
Slide9Globalization of vectors
Kraemer et al.
eLife
2015;4:e08347
Aedes
aegypti
A.
albopictus
Slide10Zika
Arthropod-borne virus (arbovirus)Vertebrate host and a hematophagous arthropodFlavivirus
(yellow);
family
Flaviviridae
53 known virus species
Zika
first described in 1947 in Zika Forest, Uganda; first human cases in Nigeria, 1953
Musso
.
Clin
Microbiol
Rev 2016;29:487: Petersen. New
Engl J Med 2016;Mar 30th.
Flaviviridae
Single stranded enveloped RNA viruses
Yellow Fever, Dengue, West Nile and Japanese encephalitis virus
http://www.cdc.gov/vhf/virus-families/flaviviridae.html
Chikungunya
is an Alphavirus (also arbovirus)
Slide11US Status (2015 to mid-April 2017)
5,238 US cases1,762 pregnant women58 live births with birth defects
217 cases of local transmission in FL; 6 local transmission cases in TX
https://www.cdc.gov/zika/intheus/maps-zika-us.html
Petersen. New
Engl
J Med 2016;March 30
th
.
https://www.cdc.gov/zika/intheus/maps-zika-us.html
Slide12West Nile Virus, the other
FlavivifusSingle stranded RNA virus (
Flavivirus
)
Member of Japanese encephalitis
serocomplex
Includes St. Louis encephalitis
Initially described in humans in 1937 in Uganda
Confined to Africa, the Middle East and Europe.
First North American case reported in August, 1999 in Queens, New York
Peterson et al. Ann Intern Med 2002;137:173.
Slide132016 LA County West Nile cases
153 cases131 hospitalizations108 with neuroinvasive
disease
5 deaths
53 cases (35%) in July & August
US totals 2,038 cases and 94 deaths
http://publichealth.lacounty.gov/acd/VectorWestNile.htm
West Nile virus disease incidence reported by county, United States, 2016
https://diseasemaps.usgs.gov/mapviewer/
Slide14Why outbreaks emerge
National Academies Press. Improving Food Safety through a One Health Approach. Workshop Summary. 2012
http://www.onehealthinitiative.com/publications/IOM%20One%20Health%20Workshop%20Summaryt.pdf
Slide15When should you be thinking about an emerging disease?
Uncommon exposuresTravel, animals, unusual foods, etc.Common diseases in uncommon patients
Severe acute pneumonia in young, healthy adults in San Luis Potosí, Mexico
Cordova. MMWR. 2009;58(Jun 5):585.
Clusters of uncommon diseases
Two cases of encephalitis reported in August, 1999 in Queens, New York
Nash. New
Engl
J Med 2001;344:1807.
Rare diseases
Anthrax pneumonia in a older man
Bush. New
Engl
J Med 2001;354:1607.
Slide16Bruins, burgers and global health
Slide17Bruins, burgers and global health
576 calories
21% of daily needs for males
26% of daily needs for females
Slide18Prevalence of Self-Reported Obesity* Among U.S. Adults
,1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
Slide19Prevalence of Self-Reported Obesity Among U.S. Adults,
1995
No Data <10% 10%–14% 15%–19%
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
Slide20Prevalence of Self-Reported Obesity Among U.S. Adults,
1999
No Data <10% 10%–14% 15%–19%
≥20%
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
Slide21Prevalence of Self-Reported Obesity Among U.S. Adults,
2005
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
http://www.cdc.gov/obesity/data/trends.html
Slide22Prevalence of Self-Reported Obesity Among U.S. Adults
, 2011
http://www.cdc.gov/obesity/data/prevalence-maps.html
Slide23Prevalence of Self-Reported Obesity Among U.S. Adults
, 2012
http://www.cdc.gov/obesity/data/prevalence-maps.html
Slide24Prevalence of Self-Reported Obesity Among U.S. Adults
, 2013
http://www.cdc.gov/obesity/data/prevalence-maps.html
Slide25Prevalence of Self-Reported Obesity Among U.S. Adults
, 2014
http://www.cdc.gov/obesity/data/prevalence-maps.html
Slide26Prevalence of Self-Reported Obesity Among U.S. Adults
, 2015
http://www.cdc.gov/obesity/data/prevalence-maps.html
Slide27An interconnected world
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Obesity_2014_Male.png
Slide28Global burden of disease
Three WHO categoriesCommunicable diseases, maternal and perinatal conditions and nutritional deficiencies (Group I)Infectious diseases
Non-communicable conditions (Group II)
Cancer, diabetes, cardiovascular disease, etc.
Injuries and violence (Group III)
Accidents, suicides, homicides, wars
Slide29Life Expectancy in 2015
71.8 (71.5–72.2) years globally10.2 year increase since 1980Female 74.8 years; males 69.0 years
37.7 year difference between highest and lowest countries
Andorra 84.8 years
Lesotho 47.1 years
76.2 years in China
79.1 years in USA
GBD 2015. Lancet 2016; 388: 1459. http://www.healthdata.org/data-visualization/life-expectancy-probability-death
Oeppen
. Science 2002; 296: 1029.
Slide30Global is local: ethnicity and life expectancy
2011/2012 Life expectancy in LA County82 years for Asians & whites (Australia)If separate country, 11
th
overall
71 years for Blacks & Hispanics (Honduras)
If separate country, 147
th
out of 224, < life expectancy of Iraq, Vietnam or Jamaicahttp://publichealth.lacounty.gov/docs/mortalityrpt11.pdfhttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html
Slide31Death: the eventual outcome of life
Estimated 55.8 (55·0 to 56·6) million deaths in 201571.3% of deaths (39.8 million; 39·2 to 40·5) from non-communicable diseases13.1% decrease age-standardized rate since 2005
Total deaths increased due to changes in population growth and aging
GBD 2015. Lancet 2016; 388: 1459.
Slide32What people die from
30 leading global causes of death
Los Angeles County deaths
GBD 2015. Lancet 2016; 388: 1459.
http://publichealth.lacounty.gov/phcommon/public/reports/rptspubdisplay.cfm?unit=dca&ou=ph&prog=hae
Slide33Disability is a “loss of health”
Health is thought of in terms of functional capacitymobility, cognition, hearing and vision
Disability Adjusted Life Year (DALY)
Years of life lost (YLL) + Years living with disability (YLD)
Salomon. Lancet 2012;380:2129; GBD 2015. Lancet 2016; 388: 1545.
Slide34Non-communicable disease DALYS (premature mortality and illness)
59.7% of global DALYs in 2015 due to Group II diseases1.5 billion DALYs in 201530.1% of DALYs due to communicable diseases
10.1% due to injuries
GBD 2015. Lancet 2016; 388: 1603.
Slide35Non-communicable diseases-summary
72% of all NCD deaths (28 million) occur in LMICs16 million premature deaths (< 70 years old)82% in LMICs
NCDs account for 9 out of 10 leading causes of death in LA County
Tobacco use, physical inactivity, alcohol use and unhealthy diets are major risk factors
http://www.who.int/mediacentre/factsheets/fs355/en/
Slide36Socioeconomic determinants: neglected tropical diseases
NTDs are diseases of extreme povertyInadequate sanitation, housing, clean waterApproximately 1 billion people in 150 countries affected
Targeted treatment of 7 diseases costs $0.40/person/year
Receive about 0.6% of development assistance (36.3% for HIV)
Mackey.
Clin
Microbiol Rev 2014;27:949.
GBD 2015. Lancet 2016; 388: 1459.
Slide37Tale of two city regions, LA County, 2012 ( deaths per 100,000 population)
West
AV
Diff
Coronary
heart disease
94
142
1.51
COPD
18
62
3.44
Lung
Cancer
27
39
1.44
Stroke
27
43
1.59
All cause mortality
480
739
1.54
http://publichealth.lacounty.gov/phcommon/public/reports/rptspubdisplay.cfm?unit=dca&ou=ph&prog=hae
Slide38Trouble breathing
16 year old female presents to her PCP in July having woken up with shortness of breath, chest tightness and a non-productive coughPMHAsthma treated with salbutamol prn, no episodes in previous month
NKA, nonsmoker
SH/FH
No animal exposures; Mother smokes
Slide39Physical and lab data
PEAudible wheezing by not in acute distress, R-18, P-78, T-37.0°CCentral trachea, diffuse wheezes, no focal findingsSoft calves, no ankle edema
No blood tests drawn
Peak expiratory flow 240 L/min
expected for height 400 L/min
Improves to 320 L/min 15 minutes after salbutamol treatment
Abelson. CMAJ 2002;166(9):1161.
Slide40Next steps
The step most likely to determine the etiology of the exacerbation is:Environmental exposure history (Community, Home, Hobbies, Occupation, Personal habits, Diet and Drugs)Spirometry
Chest x-ray/CT scan
Bronchoscopy
Slide41Health and the environment
http://www.thelancet.com/commissions/planetary-health
Slide42Multifactorial effects
Whitmee
. Lancet 2015; 386: 1973.
Slide43Environment and health: air pollution
Study of fine particulate air pollution (PM2.5) on mortality in 6 US cities from 1979-1998
158,978 person-years of follow-up, 2732 deaths
10
μ
g/m
3
increase in PM2.5 associated with 16% increase in all cause mortality (1.16, 95% CI 1.07-1.26)Reduction associated with reduced risk (RR, 0.73; 95% CI, 0.57–0.95)
Laden. Am J
Respir
Crit
Care Med 2006;173(6): 667.
Slide44Global effects of air pollution
WHO estimates that 3 million deaths in 2012 due to ambient air pollutionParticulate matter, ozone, nitrogen dioxide and sulfur dioxide2/3rds of all deaths in Western Pacific and Southeast Asia
92% of world’s population lives with unhealthy air quality (annual PM
2.5
> 10
μg
/m
3)http://www.who.int/mediacentre/news/releases/2016/air-pollution-estimates/en/
Slide45Selected city air, 2014
City
Mean annual
PM
2.5
Mean annual PM
10
Beijing
85
108
Delhi
122
229
Los Angeles
11
20
Mexico City
20
45
http://www.who.int/phe/health_topics/outdoorair/databases/cities/en/
http://maps.who.int/airpollution/
Slide46LA/Long Beach/Riverside Air
#1 for ozone pollution#4 for year-round particle pollutionhttp://www.stateoftheair.org/2013/city-rankings/most-polluted-cities.html
10% reduction in PM
2.5
would result in 443 deaths (280-613) avoided in LA
>1,500 deaths in CA
http://ephtracking.cdc.gov/showIndicatorPages.action
Slide47Samet
. N
Engl
J Med 2017;376:1182-1188.
Changes in Economic Indicators and Pollutant Emissions, 1970–2015.
Slide48Global Health: the recurrent summary
Everything moves easily around the world, including people, diseases, diets and culturesHealth is linked to development and equity
Low-income countries and people in poverty tend to have worst health
Our ecosystem affects our health
Slide49Last thought
“…health is an indicator, a measure of how well we are doing as a society.”Marmot. Lancet 2013;381:1090.