Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas
An integrated, Sustainable Framework to Elimination of Communicable Diseases in the Americas. Concept Note PAHO/CDE/19-008 © Pan American Health Organization 2019 All rights reserved. Publications of the Pan American Health Organization are available on the PAHO website (www.paho.org). Requests for permission to reproduce or translate PAHO Publications should be addressed to the Publications Program through the PAHO website (www.paho.org/permissions). Suggested citation. Pan American Health Organization. An integrated, Sustainable Framework to Elimination of Communicable Diseases in the Americas. Concept Note. Washington, D.C.: PAHO; 2019. Cataloguing-in-Publication (CIP) data. CIP data are avail- able at http://iris.paho.org. Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provi- sions of Protocol 2 of the Universal Copyright Convention. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its au- thorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manu- facturers’ products does not imply that they are en- dorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the Pan American Health Organ- ization be liable for damages arising from its use.
I Acronyms 5
II Background 6
1 Introduction: Integrated, Sustainable Communicable Disease
Elimination Framework and Linkages
7
2 Conceptual Framework and Objective 11
3 Mapping out the Framework of Communicable Disease
Elimination
15
4 Snapshot of Communicable Disease Elimination in the Americas 27
5 Vision, Goal, and Targets for Integrated Communicable Disease
Elimination
39
6 Lines of Action for Integrated Communicable Disease Elimination 43
7 Proposed Organizational Structure and Implementation for
Integrated Communicable Disease Elimination
55
III References 59
IV Annexes
Annex 1. PAHO, WHO, and United Nations Strategies and Plans of Action Most
Relevant to Communicable Disease Elimination in the Americas
61
Annex 2. Suggested Key Activities for Proposed Actions at PAHO Headquarters
Level
Annex 3. Table 2. Options for Integrated Response for Disease Elimination
Based on Array of Interventions
CAICET Servicio Autónomo Centro Amazónico de Investigación y Control de
Enfermedades Tropicales "Simón Bolívar" (Venezuela [Bolivarian Republic of])
CD Communicable disease
CDE Communicable Diseases and Environmental Determinants of Health (PAHO)
DALYs Disability-adjusted life-years
EMTCT Elimination of mother-to-child transmission
EMTCT+ Elimination of mother-to-child transmission Plus
EOT Elimination of transmission
EPHP Elimination as a public health problem
FPL Family, Health Promotion and Life Course (PAHO)
HA Health Analysis Unit, Evidence and Intelligence for Action in Health
Department (PAHO)
HBV Hepatitis B virus
HCV Hepatitis C virus
HIV Human immunodeficiency virus
HPV Human Papilloma virus
HSS Health Systems and Services (PAHO)
IDB Inter-American Development Bank
IMS-dengue Integrated Management Strategy for Dengue (PAHO)
ITFDE International Task Force for Disease Eradication, of the Carter Center
IVM Integrated vector management
LF Lymphatic filariasis (parasite Wuchereria bancrofti)
MDA Mass drug administration
MMDP Morbidity management and disability prevention
MOH Ministry of health
MTCT Mother-to-child transmission
NGO Non-governmental organization
NMH Noncommunicable Diseases and Mental Health (PAHO)
NIDs Neglected infectious diseases
NTDs Neglected tropical diseases
PAHO Pan American Health Organization
PANAFTOSA Pan American Foot-and-Mouth Disease Center (PAHO)
PCT Preventive chemotherapy
PHC Primary health care
PHE Public Health Emergencies (PAHO)
SDGs Sustainable Development Goals
STH Soil-transmitted helminthiasis
TB Tuberculosis
USAID United States Agency for International Development
WASH Water, sanitation, and hygiene
WG Working group
WHO World Health Organization
YF Yellow fever
5
1
BRIEF HISTORY OF COMMUNICABLE nation will also directly support the United
DISEASE ELIMINATION IN THE AMERICAS Nations Sustainable Development Goals
(SDGs), as we discuss next.
In the 1870s, a yellow fever epidemic struck
Argentina, Brazil, Paraguay, and Uruguay,
and within eight years, had spread to the UNITED NATIONS SUSTAINABLE
United States, where it killed more than DEVELOPMENT GOALS AND HEALTH
20,000 people. Maritime transport, which
was expanding rapidly along with interna- As the countries of the world transition
tional trade, was the main channel for the from the United Nations Millennium De-
international spread of disease at the end velopment Goals (MDGs, 2000-2015) to
of the 19th century. The need to control the current 17 Sustainable Development
the spread of epidemics from one country Goals (SDGs, 2016-2030), United Nations
to another to protect people’s health and Member States are adopting new lan-
countries’ economies led to the creation guage to match the paradigm shift: as
in December 1902 of what is today known there is now a recognized need to ensure
as the Pan American Health Organization sustainability of their efforts to reach the
(PAHO). During its more than 110-year his- new goals, many of which are health-relat-
tory, PAHO has played a key role in impor- ed. However, even throughout this transi-
tant hemispheric and world disease elim- tion, old threats persist and new ones are
ination achievements, including leading impacting the Region, such as the intro-
the eradication of smallpox and polio from duction, spread, and endemization of Chi-
the Americas, and supporting countries in kungunya and Zika viruses, the rise of the
the elimination of endemic transmission of burden of important noncommunicable
measles and rubella, as well as congenital diseases and conditions (diabetes, can-
rubella syndrome. Today, the world stands cers, and obesity), and extensive environ-
on the edge of a historic public health mental degradation and climate change,
success with the imminent eradication which create space for the emergence or
of dracunculiasis (guinea-worm disease) re-emergence of zoonotic diseases that
and polio. Additionally, the countries of could become epidemic or pandemic
the Americas, together with their global threats (Ostfeld 2017).
partners and with technical support from
PAHO, are approaching the regional elim- SDG 3 (Ensure healthy lives and pro-
ination of malaria and several neglected mote well-being for all at all ages) directly
infectious diseases including leprosy, lym- targets specific maternal and child health
phatic filariasis, and onchocerciasis (river improvements and communicable diseas-
blindness), and have achieved substan- es control and elimination. SDG 3.1 is set to
tial reductions in the adverse impact of reduce the global maternal mortality ratio
Chagas disease, soil-transmitted helmin- to less than 70 per 100,000 live births by
thiasis, schistosomiasis, and fascioliasis 2030. SDG 3.2 focuses on reducing neo-
in children and other populations at risk. natal mortality and ending deaths of new-
Regarding mother-to-child transmission borns and children under 5 years of age
(MTCT) of viral and bacterial diseases, one by proper preventive public health action.
of the best examples comes from Cuba: SDG 3.3 focuses on ending the epidem-
in 2015 Cuba was validated by PAHO/ ics of AIDS, tuberculosis, malaria, and ne-
World Health Organization (WHO) as the glected tropical diseases, and combating
first country to have eliminated MTCT of hepatitis, waterborne diseases, and other
HIV and syphilis (Caffe et al. 2016). Elim- communicable diseases, which include
inating MTCT of HIV, syphilis, hepatitis B, vector-borne diseases, by the year 2030.
and Chagas disease in the Americas is now
within reach. These success stories high-
light the huge comparative advantage this
Region has in disease elimination. Region-
al successes in disease control and elimi-
6
1 Introduction: Integrated, Sustainable Communicable Disease Elimination Framework and Linkages
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
1. Introduction: Integrated, Sustainable
Communicable Disease Elimination
Framework and Linkages
VALUE OF LINKAGE TO THE SDGS health and health systems strengthening.
As such, the framework can benefit from
With the adoption of the SDGs by the Mem- the Health in All Policies approach.
ber States of the United Nations, WHO and
its Regional Offices have a mandate to de- Exploring the relation between our in-
velop ways and means to accomplish SDG tegrated CD elimination framework and
3, including SDG 3.3, by 2030. PAHO, as the wider SDGs, we first look in more de-
the WHO Regional Office for the Amer- tail at SDG 3. WHO and academic partners
icas, will prioritize not only ending these recently described how the cross-cutting
epidemics but eliminating these diseases. efforts to end neglected tropical disease
Moreover, the World Health Assembly has (NTD) transmission will contribute directly
committed to achieving universal health to the attainment of SDG 3.3 and, directly
coverage in a framework of health servic- or indirectly, of nearly all other SDGs (Ban-
es delivery, which includes improved ac- gert et al. 2017). Similar points have been
cess to medicines, health care workforce made regarding the contribution of the
development, strengthening laboratory elimination of malaria and HIV, and com-
systems, integrated and equitable ser- bating viral hepatitis (targeted for region-
vice provision (including primary health al elimination in the Americas). SDG 3.7 is
care strengthening), and financing. The set to ensure “by 2030, universal access to
framework for communicable disease sexual and reproductive health-care servic-
(CD) elimination described in this con- es, including for family planning, informa-
cept note aligns closely with SDG 3.3 (and tion and education, and the integration of
other health-related SDGs), and envisions reproductive health into national strategies
making progress towards the SDGs using and programs,” to which the elimination of
a life course approach, which allows the MTCT of HIV, hepatitis B virus (HBV), syphi-
integration and sustainability of health lis and Chagas disease will contribute. SDG
services delivery through a broad range of 3.8 sets out to “achieve universal health
actions. coverage, including financial risk protec-
tion, access to quality essential health-care
Interventions to eliminate not only services and access to safe, effective, qual-
the transmission but the negative health ity and affordable essential medicines and
effects of CDs will need to be sustained vaccines for all.” Articulation of primary
through 2030 and beyond, into the care services and of higher levels of health
post-elimination period for each disease services that deliver medicines, vaccines,
eliminated. In order to ensure sustainabil- and treatments needed for the elimination
ity, the framework for disease elimination of several CDs such as malaria, leprosy,
will need to be in alignment with PAHO’s MTCT of HIV, HBV, and Chagas disease,
Strategy for Universal Access to Health will contribute to the latter part of SDG 3.8.
and Universal Health Coverage (2014), and
WHO’s Framework for Action on Strength- SDG 3 is linked to SDG 5, which seeks
ening Health Systems to Improve Health to achieve gender equality and empower
Outcomes (2007), look for opportuni- all women and girls. SDG 5 aims to pro-
ties to pursue integrated CD elimination vide women and girls with equal access to
through a Health in All Policies advocacy education, health care, decent work, and
position, and utilize these for financing and representation in political and economic
other resource mobilization. Also, Member decision-making processes. Equal access
States have committed to the United Na- to primary health care needed for elimina-
tions SDGs, in which they have agreed to tion of CDs can be effectively addressed
try to achieve universal health coverage by through enhanced health care services
2030. The framework for regional disease to women and girls (such as for HIV, HPV,
elimination by 2030 developed here out- HBV, hepatitis C virus (HCV), syphilis, Cha-
lines an objective and a bold agenda for gas disease, and toxoplasmosis) and will
2030, promoting both universal access to contribute to SDG 5. Disabilities, stigma,
8
Malaria testing in Dominican Republic
9
2
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
1. Adapted and discrimination linked to HIV/AIDS, lep- The strategies and plans of action of
from personal rosy, and other NTDs disproportionately PAHO and WHO are the result of signifi-
communication
from Dr. Mirta affect women and girls directly and as car- cant public health work and serve not only
Roses Periago, egivers for others affected in their families as a basis for integrated disease elimina-
former Director
of PAHO, 5 Sep-
and communities. Meanwhile, anemia and tion, but help shape its vision, goal, and
tember 2017. malnutrition resulting from some NTDs im- targets. Thus, the integrated disease elim-
2. Adequate pair the developmental and cognitive ca- ination framework described in this con-
access to clean pacity for better educational achievement cept note encompasses United Nations
water supply
is needed to and represent another added burden on and WHO global strategies and articulates
repair walls, women and girls.1 across PAHO’s regional resolutions, strat-
floors, cracks,
and crevices of
egies, and their accompanying plans of
houses where Access to adequate supplies of safe action and targets. Among the most im-
some Chagas and potable water and basic sanitation in portant are those listed in Annex 1. In 2017,
vectors shelter
and hide. at-risk communities is needed to reduce the WHO Director-General established five
or help stop transmission of schistosomi- WHO Flagship Initiatives to contribute sig-
asis, soil-transmitted helminthiasis (STH), nificantly to the attainment of the SDGs
trachoma, cholera, and even Chagas dis- by 2030, one of which is a “Fast-track to
ease2, and bring and end to open defeca- Elimination.” In August 2017, the draft first
tion. Two of the eight targets for SDG 6 on report of the WHO Working Group on In-
clean water and sanitation (Ensure availa- itiatives for Change presented an outline
bility and sustainable management of wa- for the Fast-track to Elimination initiative,
ter and sanitation for all) will be supported which is expected to include reporting
by successful elimination of these five dis- and validation, communications and part-
eases in the Americas: “By 2030, achieve nership, strategic information, fundrais-
universal and equitable access to safe and ing, management and human resources,
affordable drinking water for all” and “By and norms; all WHO Regions have been
2030, achieve access to adequate and eq- invited to participate in the initiative. The
uitable sanitation and hygiene for all and integrated framework to disease elimina-
end open defecation, paying special atten- tion described in this concept note, with
tion to the needs of women and girls and proposed progressive target dates up to
those in vulnerable situations.” Those lead- 2030, is well aligned with the draft outline
ing the CD elimination effort should exam- of the fast-track initiative.
ine how it and the projects it will generate
can be used to report back to WHO and
the United Nations on its impact towards In the work ahead to eliminate the burden
achieving the SDGs. of multiple CDs, we need to remain very
cognizant of how it will link and be framed
VALUE OF LINKAGES WITH GLOBAL AND not only by the SGDs but also by ongoing
REGIONAL STRATEGIES United Nations, WHO, and PAHO global
In the work ahead to eliminate the burden and regional strategies for improving
of multiple CDs, we need to remain very health and well-being.
cognizant of how it will link and be framed
not only by the SGDs but also by ongoing
United Nations, WHO, and PAHO glob-
al and regional strategies for improving
health and well-being. These strategies, as
well as the SDGs and their indicators, may
be particularly useful to offer insights to
intersectoral and community-based inter-
ventions, in the context of poverty reduc-
tion, disease control, and universal access
to health care.
102 Conceptual Framework and Objective
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
2. Conceptual Framework and Objective
CONCEPTUAL FRAMEWORK tralization, equity, patient and community
participation, and optimal use of available
The conceptual framework for integrated human resources will facilitate achieve-
CD elimination aims to reduce the burden ments of elimination.
and tackle the elimination of a set of CDs
prevalent in the Americas. This framework
is both strategic and standardized and can The conceptual framework for integrated
be adopted, adapted, and implemented CD elimination aims to reduce the burden
by PAHO Member States, Associate Mem-
bers, and Participating States with territo- and tackle the elimination of a set of CDs
ries in the Region. Indeed, for Region-wide prevalent in the Americas.
CD elimination to occur, elimination will
have to be achieved in all 52 Member In many cases, the prevention of trans-
States and territories in the Americas. The mission requires sequential interventions
framework will require focused, long-term targeted to specific life course phases
political and financial commitment, as (e.g., during pregnancy, mothers and their
historically observed (globally) in country infants, preschoolers, school-age children,
commitment to polio and measles eradi- adolescents, adult workers in agriculture,
cation in the Americas. commerce and industry, and the elderly).
Complementary interventions undertaken
Additionally, public-health approaches by direct action or through collaboration
promoted by WHO based on the principles can be targeted to other key populations
of simplification, standardization, decen- at risk: indigenous and Afro-descendant
FIGURE 1. CONCEPTUAL FRAMEWORK: LINES OF ACTION FOR INTEGRATED COMMUNICABLE DISEASE ELIMINATION
IN THE AMERICAS THROUGH THE LIFE COURSE
PREGNANCY CHILD & WORKING
SENIOR
& NEONATAL ADOLESCENT ADULT
1 | Strengthening the Integration of Health Systems and Service Delivery
4 2 | Strengthening Strategic Health Surveillance and Information Systems INTEGRATION
TO IMPACT
——
LINES TARGETS BY
OF ACTION 3 | Addressing the Environmental and Social Determinants of Health DISEASE
4 | Strengthening Governance, Stewardship, and Finance
Cross-cutting: Human Rights, Gender Equality, Key Populations
PROGRAMMATIC
OBJECTIVES BY DISEASE
122. Conceptual Framework and Objective
communities, the disabled, the unem- measured in disease burden studies. Col-
ployed, those living in dwellings of poverty lectively, the burden of disease and these
or the homeless, and the incarcerated. The difficult-to-measure social costs prevent
conceptual framework builds on these in- the full achievement of health as a human
terventions and focuses on these relevant right, and reveal the ethical case for step-
populations, and it is composed of five ping up disease elimination efforts in the
lines of action coherent with the principles Americas, to benefit individuals, families,
of human rights, gender equality, equity and communities that are the most ne-
and civil society and community engage- glected and deprived in today’s society.
ment for poverty reduction (Figure 1).
OBJECTIVE
MEANING OF DISEASE
The objective of this concept note and the ELIMINATION FOR
framework it outlines is the elimination INDIVIDUALS, FAMILIES,
of a group of CDs and related conditions
and the negative health effects they gen-
AND COMMUNITIES IN THE
erate (diseases listed in Table 1 below), AMERICAS
which together create a tangible burden
on affected individuals, their families and Though disease names are listed
communities, and on health care systems in Table 1, each disease is really a
throughout the Region. story of individuals and families, and
of neglected populations. It is the
migrant family from Brazil’s dry interior
One can deduce that there is an intangible now living by the lakeside favela of
social cost of misery, hopelessness,and Lagoa do Olho d'Agua in Jaboatão dos
Guararapes (next to Recife) where they
despair among individuals, families,and fish for dinner and work as laborers
entire communities, which is not measured and street vendors, or the Yanomami
in disease burden studies. clan family hunting, gathering, and
farming along the rainforest border
3. DALYs: Disa- Though there is no unified consen- of Brazil and Venezuela. It is the story
bility-adjusted sus on the best measures to use for the of the hungry young rural couple
life years, a sum-
mary measure public’s health and a nation’s epidemio- scratching out a living in a village
of population logic situation, it is common for the dis- in the dry tropical forest near Villa
health based
on estimates
ease burden to be measured by disease Nueva, Chinandega, in northern
of premature rates (incidence, prevalence, etc.), dis- Nicaragua, or the migrant family from
mortality and ease-specific death rates, comparative southern Mexico living in a colonia of
non-fatal health
loss. DALYs
morbidity and mortality rates, geograph- Hidalgo County, South Texas, without
estimate the ic distribution, and disability-adjusted life household water and sewerage, or
number of years years (DALYs).3 The current epidemiolog- the undernourished Haitian family
of life lost due
to premature ical situation, including data on disease surviving with their goats in their
death, as well as rates or geographic distribution for the hut on the denuded hillsides near
years of healthy
life lost due to
diseases in Table 1, is discussed below in Léogâne. These individuals and
disability from Section 4. Hotez et al. (2008) were the families tell us the true hard story of
disease/ill-health first to review and compare the burden of being neglected, the existing inequity
and injury.
DALYs in Latin America and the Caribbe- they live in, the remaining wide
an—for NTDs, HIV/AIDS, malaria, and TB— burden of communicable diseases
as it existed about 10 years ago. Though in our Region, and epitomize why we
the regional burden of TB, malaria, and must eliminate those diseases.
neglected infectious diseases (NIDs) is
somewhat less than it was 10 years ago,
work (and schooling) continue to be lost The CD elimination framework is one
to illness and premature death or disabil- suited to benefiting populations living
ity, and the need for stepping up disease in vulnerable conditions (where most of
elimination efforts is evident in all com- these diseases occur) and supporting
munities living in vulnerable conditions. abolition of inequity (expressed in health
rights). As such it works in line with the
One can deduce that there is an intan- poverty reduction strategies of the World
gible social cost of misery, hopelessness, Bank and the Inter-American Development
and despair among individuals, families, Bank (IDB), wherein some of their current
and entire communities, which is not programs supporting conditional cash
133
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
transfers for health and education and only from CD but other areas of public
housing and urban development, or the health. By doing this, a real opportunity to
Piso Firme program for housing improve- integrate (and make operational) universal
ment, urban development and health, can access to health and the elimination of in-
support or link to specific activities in the fectious diseases is presented, and quan-
CD elimination agenda (STH and Chagas titative and qualitative measurements can
disease, for instance). be established.
Taking these data and information to- The existing PAHO CD elimination agen-
gether, the elimination of this set of CDs da will need to be accelerated, especially
should be able to reduce disease rates to in the face of the continuing epidemiolog-
zero or near zero. It should also indirect- ic transition with the concomitant rise of
ly help reduce those difficult-to-measure the burden of noncommunicable diseases
social costs—if done together with health (some of which already overlap or inter-
care systems strengthening in each coun- act with CDs) and growing resource con-
try, access to sufficient financing, and straints both in the countries and in PAHO;
sufficient political and managerial capital otherwise, there is a real risk of slowing or
invested in CD elimination through 2030. losing the gains we have made in the Re-
The framework challenges the ways in gion towards the near-elimination of CDs
which health care is currently provided such as lymphatic filariasis (LF), trachoma,
and outlines some ways to change what Chagas disease, malaria, and TB. It is time
is currently done and lead us to a regional to move to the next stage in the disease
goal of eliminating CDs; it compiles and elimination agenda of the Region.
organizes interventions that are current-
ly scattered or loosely grouped together.
The framework will, therefore, facilitate
and promote linkages, synergies, and in-
terdepartmental collaboration, aiming at
the pursuit of a well-identified organiza-
tional goal. The list of existing health risks
and health problems in the Americas ex-
tends beyond the diseases listed in Table 1,
and as such, this concept note will not be
addressing, for instance, the common vac-
cine-preventable diseases of childhood
(such as neonatal tetanus and mumps),
nor certain other CD problems such as an-
timicrobial resistance and selected NIDs
causing lesser disease burdens). We will il-
lustrate and demonstrate the what (what is
possible) more than the how (exactly how
it can be done). In suggesting what is pos-
sible we are drawing on lessons learned,
best practices, and successful outcomes
from evidence-driven interventions, not
143 Mapping out the Framework of Communicable Disease Elimination
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
3. Mapping out the Framework of
Communicable Disease Elimination
A map of the framework for CD elimination includes a set of definitions and common terminology to be
used, and a description of diseases, dimensions, and deadlines proposed here, along with a discussion
of the investment case for CD elimination.
DEFINITIONS disease elimination and eradication from
the recent work of the WHO Strategic and
Beginning with the work of the Interna- Technical Advisory Group for Neglected
tional Task Force for Disease Eradication Tropical Diseases (2014-2015) and of other
(ITFDE) at the Carter Center in the 1980s recent WHO expert committees, adviso-
and extending to the more recent work of ry committees or technical programs on
the WHO Strategic and Technical Adviso- malaria, TB, HIV, and sexually transmitted
ry Group for Neglected Tropical Diseases, infections.
we have seen an evolution of specific sci-
entific definitions for terms such as con- In sum, we now have new scientific
trol, elimination, and eradication during clarity and agreement in the public health
the last three decades (see Box 1 in the community that elimination and eradica-
Annex). Definitions have evolved (and im- tion are not synonyms (and that elimina-
proved) as we discovered ever more com- tion is nuanced). Moreover, there is a real
plex epidemiological situations for some biological distinction between elimination,
diseases and new understanding of the nu- eradication, and extinction. Challenges
ances of disease transmission cycles, new yet remain as these three terms are ones
vectors or reservoirs, and new interven- which members of the media and layper-
tions for prevention, treatment, and cure. sons often confuse during common dis-
For example, the definition of elimination course, in conversation and writing.
has evolved from cessation of transmis-
sion of a disease in a single country, con- Understandingly, historically much of
tinent, or other limited geographic area the focus of CD control and prevention
(ITFDE’s early definition) to today’s more has been to stop disease transmission,
nuanced terms and definitions as used by through development and deployment of
WHO: elimination as a public health prob- vaccines, insecticides, quarantine, or oth-
lem (EPHP) is defined by the achievement er technical or clinical measures. However,
of measurable global targets set by WHO elimination of the negative health effects
in relation to a particular disease (e.g., for of CDs goes beyond stopping transmission
MTCT of syphilis, LF), and when reached, and should also include other dimensions
continued actions are required to maintain which more fully reflect WHO’s definition
the targets or advance towards elimination of health: “Health is a state of complete
of transmission. The process of documen- physical, mental and social well-being
tation of EPHP is called validation. Elimi- and not merely the absence of disease or
nation of transmission (EOT) is defined as infirmity.” These are captured in the four
the reduction to zero of the incidence of dimensions discussed in the next section.
infection caused by a specific pathogen in
a defined geographical area, with minimal
risk of reintroduction, as a result of delib- DISEASES, DIMENSIONS, AND DEADLINES
erate efforts. The process of documenta-
tion of EOT is called verification. EPHP and To expand our regional efforts in disease
EOT are distinguished from eradication, elimination under this framework, some
which is the permanent reduction to zero new dimensions of elimination are pro-
of a specific pathogen as a result of delib- posed. The framework as shown in Table
erate efforts, with no more risk of reintro- 1 (below) sets out a list of diseases, a de-
duction. The process of documentation of scription of dimensions of existing and
eradication (e.g., for yaws) is called certifi- proposed (new) elimination actions, and
cation. See Box 1 for further details. deadlines (not mere targets) for each dis-
ease, consistent with existing PAHO and
The framework in this concept note WHO target dates for elimination, while
will rely on a set of common definitions of suggesting new elimination deadlines for
16Integrated healthcare campaign to prevent leprosy, trachoma blindness,
and STHs among school-age children, Pernambuco, Brazil
17INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
diseases or dimensions not previously rosy, LF, and chronic Chagas disease, we
covered in current PAHO and WHO resolu- must not only continue to reach EPHP but
tions and action plans. tackle in a broader way the dimensions of
mortality (deaths), morbidity (illness), and
Along with EPHP, this framework in- disability. For each disease, target dates
cludes four other dimensions of CD elim- set by PAHO/WHO or new deadlines being
ination. These are emphasized so that we suggested for consideration by PAHO are
will have a different way to look at what shown; these range from the period 2015
we are trying to achieve by stretching our (target dates overdue) to different inter-
public health work to eliminate the burden vals up to 2030. Deadlines for the elimina-
of each disease by the year 2030: depend- tion of some diseases in some countries
ing upon the disease, its modes of trans- are “low-hanging fruit,” such as the elimi-
mission, and epidemiological situation. nation of schistosomiasis in Saint Lucia, or
These dimensions give us a more quanti- of trachoma in Guatemala.
tative view of elimination, i.e., factors that
can be easily counted, are more inclusive
of all ages and key populations, and which
focus on improving quality of life, consist-
ent with today’s ethical standards for pub-
lic health agencies, the SDGs, and WHO’s
concept of Health for All.
When disease transmission ends, then
new generations of individuals will not be
facing the premature deaths, illness, and
disability associated with those diseases.
During the process to reach no transmis-
sion, and given the legacy or ongoing
health burden of many CDs, such as lep-
FIGURE 2. FOUR DIMENSIONS OF ELIMINATION OF THE BURDEN OF COMMUNICABLE DISEASES
——
1 ——
2
NO TRANSMISSION NO MORTALITY
by direct contact (deaths)
(including sexual, mother-to-child,
person-to-person transmission),
or by vector/intermediate host, dog,
fomite or media (water, soil, food, air, waste)
——
3 ——
4
NO MORBIDITY NO DISABILITY
(illness) (either prevented, corrected,
limited or minimized)
183. Mapping out the Framework of Communicable Disease Elimination
TABLE 1. COMMUNICABLE DISEASES AND CONDITIONS - CANDIDATES FOR REGIONAL ELIMINATION IN THE AMERICAS: CURRENT
TARGET DATES, DIMENSIONS OF WHAT IS POSSIBLE TO ACHIEVE BY THE YEAR 2030, ASSOCIATED PROPOSED DEADLINES, AND
DESCRIPTIONS
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
2022 – Proposed fast-track-
2030: WHO target
ing in the Americas, add no
of ending dog-me-
mortality from dog-mediated
diated rabies
rabies virus infection. [Possi-
deaths by 2030
bly reachable by 2020]. If no
2022: PAHO target
no deaths dog-mediated rabies trans-
of 35 countries to
HUMAN RABIES from dog-me- mission occurs (due to high
have eliminated
dog-mediated diated human dog vaccination coverage and
dog-mediated hu-
rabies by 2022 all dog-bite victims quickly
man rabies and put
getting post-exposure proph-
in place measures
ylaxis), no mortality should
to prevent disease
occur. Implement PAHO POA
resurgence or
CD55/15 (2016) and reach
reintroduction
indicator targets.
2020 – Add no mortality in
2030: WHO children arising from MTCT,
target of EMTCT since this pathway is to be
(validation) no deaths in eliminated, and any MTCT
HIV - MTCT 2020: PAHO target children from pediatric cases are to have
to reduce rate of MTCT by 2020 access and treatment with
MTCT of HIV to 2% HIV antiretroviral therapy.
or less Implement PAHO EMTCT Plus
Strategy (2017).
2020 – Add no pediatric
deaths and no severe
2030: WHO disability in Region which
target of EMTCT would require transplanta-
(validation) tion in children, since new
no severe
2020: PAHO target pediatric cases which arise
disability in
to reduce hepatitis no deaths in should not progress to death
HBV - MTCT children which
B surface antigen children by 2020 or to a clinical stage where
would require
prevalence among transplantation is needed, due
transplantation
4-to 6-year old to receiving pediatric vaccina-
children to 0.1% tion, screening, and adequate
or less clinical management.
Implement PAHO EMTCT Plus
Strategy (2017).
2018-2030 – This establishes
a Maintenance EOT goal for
2018-2030, maintaining that no
new urban YF epidemics shall
no new epidem- occur (transmitted by Aedes
no deaths
YELLOW FEVER No WHO target ics of urban YF aegypti); made possible by full
among new cas-
EPIDEMICS exists (2017) transmitted (by implementation of vector com-
es, 2018-2030
Aedes aegypti) ponents of PAHO IMS-dengue
strategy. Add no mortality aris-
ing from new cases of urban YF,
result of rapid case detection
and rapid case management.
19INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
2030: PAHO
target of EPHP, to
reduce cervical
Note: No additional interven-
CERVICAL CAN- cancer incidence
tions or dates are added.
CER (from HPV) to < 4/100,000 and
Pursue PAHO target of 2030.
premature mortality
(deaths) by one-
third by 2030.
2015: AHO target
of EOT by blood
transfusion; target
was achieved
2020: PAHO target
of EMTCT with ≥90% 2025 – Add no neonatal
of children cured morbidity, through rapid
of Chagas infection congenital case treatment of
with post-treatment infected newborns (neonates).
negative serology Add new routine pre-natal
no neonatal
CHAGAS DISEASE 2020: PAHO/WHO screening and treatment of
morbidity by
Trypanosoma cruzi target of EOT of at-risk women before preg-
2025
principal interdomi- nancy. Implement PAHO POA
ciliary vectors CD55/15 (2016) and reach
indicator targets. Implement
2022: PAHO target
PAHO EMTCT Plus Strategy
of 16 countries to
(2017).
have eliminated
Chagas disease,
and put in place
measures to prevent
disease resurgence
or reintroduction
2030: WHO
2030 – Add no mortality from
target of EOT of
P. falciparum and P. vivax in
P. falciparum and
children at risk [if measurable],
P. vivax
since timely screening and
2016: PAHO POA rapid treatment should allow
CD55/13 targets avoidance of mortality and
further reduction contribute to EOT.
of malaria mor-
no deaths Implement PAHO POA CD55/13
bidity and deaths
MALARIA from P. falcipar- on malaria elimination (2016)
by 40% or more
Plasmodium um and and reach indicator targets on
(based on 2015
falciparum and P. vivax in chil- reduction in malaria morbidity,
official figures);
Plasmodium. vivax dren at risk by deaths, and malaria [transmis-
and “implemen-
2030 sion] elimination, as well as
tation of efforts to
implementation of innova-
eliminate malaria
tive approaches to address
in 18 of the 21
challenges in countries where
endemic countries
progress has been limited; pre-
and attainment of
vention of the reestablishment
malaria-free status
of malaria in countries that have
in at least four
been declared malaria-free.
countries.”
203. Mapping out the Framework of Communicable Disease Elimination
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
2030 – Add no morbidity in
at-risk children under age 10,
LEISHMANIASIS
an indicator of successful
- CUTANEOUS/ 2022: PAHO target
no morbidity surveillance, screening and
MUCOCUTANE- to reduce the pro-
in at-risk children treatment of children in at-risk
OUS (C/MCL) portion of children
under age 10 by areas. Implement PAHO POA
Leishmania brazil- with C/MCL in 8
2030 CD55/15 (2016) and reach
iensi; L. mexicana countries by 50%.
indicator targets. Implement
complexes
new PAHO (2017) leishmania-
sis control action plan.
2030 – Add reduce lethality
rate to zero in urban areas, by
improved clinical case manage-
ment, and control of dog res-
2022: PAHO target
LEISHMANIASIS reduce lethali- ervoirs to reduce transmission,
to reduce lethality
- VISCERAL (VL) ty rate to zero in complemented by improved
rate of visceral
Leishmania cha- urban areas by solid waste management for
leishmaniasis in 8
gasi/infantum 2030 vector control. Implement
countries by 50%.
PAHO POA CD55/15 (2016)
and reach indicator targets.
Implement new PAHO control
action plan (2017).
2030 – Add no new mortality
and no new cases of neu-
2015: WHO target ro-schistosomiasis. Possible
of EOT in Caribbean through screen, test and treat at-
[EOT underway, risk populations and/or targeted
SCHISTOSOMI- overdue]. preventive chemotherapy (PCT)
no deaths in from neu-
ASIS or mass drug administration
at-risk popula- ro-schistosomia-
Schistosoma (MDA) of at-risk populations. If
2020: WHO target tions by 2030 sis by 2030
mansoni EOT occurs by 2020, no new
of EOT in all Latin mortality; and no new cases of
America and the neuro-schistosomiasis should
Caribbean. occur after 2030. Implement
PAHO POA CD55/15 (2016) and
reach indicator targets.
2030 – Add no mortality from
ascariasis (bowel obstruction)
reported in children, per
Current WHO
hospital records. If PCT or MDA
guidelines: Reduce
anthelmintic coverage for at-risk
SOIL-TRANSMIT- toINTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
Now to 2030 – Add a
Maintenance goal for no new
2015: PAHO/ blindness cases, now to 2030
WHO target of (and beyond), since elimination
EOT (verification); (prevention) of new cases of
[EOT underway but blindness was achieved prior
overdue; only two to 2009.
ONCHOCERCIASIS foci remain] Add elimination of ocular mor-
(river blindness) 2022: PAHO target no ocular mor- no blindness, bidity by 2022, which is nearly
Onchocerca of six countries to bidity, by 2022 now to 2030 achieved in the remaining two
volvulus have eliminated active foci since MDA is admin-
onchocerciasis and istered up to four times a year.
put in place meas- [Possibly reachable by 2020]
ures to prevent Use of 2016 WHO Guidelines for
disease resurgence verification of elimination of hu-
or reintroduction man onchocerciasis. Implement
PAHO POA CD55/15 (2016) and
reach indicator targets.
2025 – Add no acute attacks
and no untreated lymphede-
ma through provision of
2020: WHO target no acute primary health care (PHC)
of EPHP, globally attacks, also services. Add no disability
(validation) known as acute from hydrocele, result of
2022: PAHO target dermatolym- completing the backlog of hy-
LYMPHATIC FILA- no disabling
of six countries to phangioadenitis, drocele surgeries. Use of 2017
RIASIS (LF) WHO target of hydrocele by
have eliminated by 2025; WHO guidelines for validation
Wuchereria ban- EPHP, globally 2025 (disability
LF and put in of EPHP of LF, which includes
crofti no morbidity
prevention) vector transmission, infection
place measures to from untreated
prevent disease and a minimum care package
lymphedema by
resurgence or of morbidity management and
2025 (morbidity
reintroduction disability prevention (MMDP).
management)
Implement PAHO POA
CD55/15 (2016) and reach
indicator targets.
2030 – Add no mortality in
children, through improved
early case detection and
management and treatment, as
measured by hospital/clinical
records and death certificates.
2020: WHO target Add no morbidity in commu-
to ensure coverage no new cases nities at risk, via PCT or MDA
no morbidity against T. solium adult worms,
CYSTICERCOSIS with PCT of at no deaths in of neuro-cystic-
in communities as measured by PCT program
from Taenia solium least 75% of the children by 2030 ercosis in chil-
at risk by 2030 records. Add no new cases of
global population dren by 2030
requiring it neuro-cysticercosis in children,
through improved case de-
tection and management, and
evidenced in hospital records.
Implement PAHO POA
CD55/15 (2016) and reach
indicator targets.
223. Mapping out the Framework of Communicable Disease Elimination
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
2030 – Add no deaths in at-risk
school-age children, through
screening and early treatment
or PCT/MDA , as measured
by hospital/clinical records
and death certificates. Add
2020: WHO target no severe morbidity (hepatic
to ensure coverage no deaths in no morbidity damage and severe anemia) in
FASCIOLIASIS
with PCT of at at-risk school- in at-risk school- at-risk school-age children and
from Fasciola
least 75% of the age children by age children and adults, through screening and
hepatica
global population 2030 adults by 2030 early treatment or periodic PCT/
requiring it MDA, as measured by program
and PCT records. Complement-
ed by food safety (vegetables),
health education, and livestock
management. Implement PAHO
POA CD55/15 (2016) and reach
indicator targets.
Note: No additional inter-
ventions or dates are added.
Pursue WHO target of 2020.
EPHP, by reduction in preva-
2015: PAHO target lence of cases of trachoma tri-
of EPHP, using the chiasis “unknown to the health
SAFE strategy* system” toWhen disease
transmission ends,
then new generations
of individuals will
not be facing the
premature deaths,
illness, and disability
associated with
those diseases.
243. Mapping out the Framework of Communicable Disease Elimination
DIMENSIONS OF WHAT IS POSSIBLE BY 2030
PROPOSED PAHO RE-
ELIMINA- GIONAL DEADLINES
CURRENT TION AS NO TRANS- (elimination dates) and
WHO/PAHO A PUBLIC
DISEASE/ MISSION TO description of dimensions of
TARGET DATES HEALTH
INFECTION/ HUMANS what is possible by the year
FOR ELIMI- PROBLEM NO NO
CONDITION (incl. elimination 2030 at latest (for diseases
NATION (OR NO
(EPHP) of transmission MORTALITY MORBIDITY or dimensions not previously
ERADICATION) DISABILITY
[EOT], and elimina- (deaths) (illness) targeted for elimination by
tion of mother-to- PAHO)
child transmission
[EMTCT])
No evidence of transmission in
the Americas. Yaws is targeted
YAWS
for global eradication. The con-
Treponema 2030: WHO global
firmation of global eradication
pallidum ssp. target
will require certification through
perentue
WHO, including evidence from
each WHO Region.
2030 – Add no mortality, result
of adequate screening, test and
TUBERCULOSIS no deaths treatment of suspect cases and
(TB) from TB by 2030 high-risk populations.
Mycobacterium (multidrug-resist-
Note: Indicators will need to ex-
tuberculosis ant TB excluded)
clude or address mortality from
multidrug-resistant TB.
2030 – Add, eliminate deaths
2030: WHO target from epidemic cholera in the
no deaths Americas.
CHOLERA of EPHP by reduc- WHO target of
from epidemic
Vibrio cholerae ing cholera deaths EPHP (WHO target to reduce chol-
cholera by 2030
by 90% by 2030 era deaths by 90% by 2030,
was set in October 2017)
Eradication
FOOT-AND- 2020: in the 2020 - No transmission to
in domestic
MOUTH DISEASE Americas humans (already a rare event).
bovids
OPEN
DEFECATION
2030 - Coincides with SDG
(environmental 2030 EPHP by 2030
6.2.
determinant of
health)
POLLUTING BIO-
MASS COOKING
2030 - Conincides with SDGs
FUELS (environ- 2030 EPHP by 2030
3.9 and 7.1.
mental determi-
nant of health)
means adding the disease or characteristic, to a list of what is possible to achieve by the year 2030 compa-
red to current goals, targets, or practices, while being evidence-based or science-based.
* Trachoma SAFE: S, Surgery, for all trachoma trichiasis cases. A, Antibiotics, to reduce reservoir of eye infec-
tion. F and E, Face-washing and environmental improvement, to reduce transmission.
The interventions and recommendations In summary, this concept note anticipates
in this concept note for elimination of CDs the elimination of a large number of CDs, ex-
will reduce important burdens of transmis- panding the list from the elimination of eight
sion, mortality, morbidity, and /or disability, neglected infectious diseases (and the con-
and thus reduce the cycle of poverty and trol of five others) in the Plan of Action for the
benefit the lives of many neglected or vulner- Elimination of Neglected Infectious Diseases
able individuals and populations. The diseas- and Post-Elimination Actions 2016-2022, and
es selected are those for which, per criteria adds several viral infections transmitted from
noted by Hopkins (2013), there is evidence mother to child, as well as malaria, cholera,
of the scientific feasibility of elimination and and preventing YF epidemics. It also incorpo-
which are seen by PAHO as amenable (with rates the recommendations and conclusions
some variation) to political will and popular of the PAHO Regional Consultation on Dis-
support. ease Elimination in the Americas (PAHO 2015,
254
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
draft available from PAHO/CDE). This effort is calculated the favorable economic benefit to
not starting from zero: the countries of the individuals of achieving the 2020 targets for
Region have made significant advances in five preventive chemotherapy NTDs (LF, on-
disease elimination and control this century, chocerciasis, schistosomiasis, STH, and tra-
as is noted in Box 2 (in the Annex) and in PA- choma): the net benefit in productivity gain
HO’s 2017 Health in the Americas report. is expected to be US$ 27.4 and US$ 42.8 for
every dollar invested during the periods 2011-
2020 and 2021-2030, respectively. The im-
INVESTMENT CASE pact varies between NTDs and regions, since
it is determined by disease prevalence and
The investment case for elimination of these the extent of disease-related productivity loss
diseases in the Americas will need to be fur- (Redekop et al. 2017). The investment case
ther developed, but already some research- has been made for the elimination of some
ers have done so for several diseases, at the specific NIDs in the Americas; for example,
global level. For example, in a global system- the cysticercosis disease burden in Latin
atic review of malaria control versus elimina- America was described by Torres (2015),
tion, Shretta et al. (2016) calculated that the while WHO (2016) has described three prin-
annual per capita cost of malaria control to ciple reasons to invest in the elimination of
a health system ranged from US$ 0.11 to US$ neurocysticercosis resulting from Taenia soli-
39.06 (median: US$ 2.21) while that for malar- um infection, a leading cause of preventable
ia elimination ranged from $0.18 to $27 (medi- epilepsy. The general investment case for
an: $3.00). Meanwhile, the benefit-cost ratios leprosy elimination is laid out by Tiwari and
of investing in malaria control and elimination Richardus (2016).
ranged from 2.4 to over 145. A fact sheet of
the WHO Stop TB program in 2014 notes Where possible, the expected return on
that TB was identified as one of the best buys investment, the projected costs of inaction
among the MDGs with a return of $43 for (status quo or control, no elimination), and
each dollar in diagnosis and treatment, while the expected positive benefits on poverty
the Stop TB Partnership estimates the five- reduction should be developed, estimated,
year Global Plan to End TB 2016-2020 would understood, and compared to the projected
produce a US$ 1.2 trillion overall economic costs of elimination for our Region. These are
return on investment and US$ 85 return on tasks well-suited to health economists and
each dollar invested. The TB investment case WHO Collaborating Centers. Research and
is further described by Kunii et al. (2016). development may be needed to fill knowl-
edge gaps, such as in modeling of CD elim-
The global investment case for elimina- ination, costing and cost-effectiveness analy-
tion of NTDs was described for 17 diseases in sis of packages of interventions, and climate
the Third WHO Report on Neglected Tropical change impacts on the pace and sustainabili-
Diseases, Investing to Overcome the Global ty of CD elimination for our Region.
Impact of Neglected Tropical Diseases (WHO,
2015a), in which the investment case is The investment case for integrated CD
made on both cost-effectiveness and equity elimination also needs to be made by econo-
grounds. The report notes NTDs will need to mists and natural resource experts in the face
be an integral part of universal health cover- of global and regional climate change, where
age, and without it the effort may fail. Holling- the expectation is to see greater variation and
sworth et al. (2015) developed the investment systemic changes in ecosystems resulting in
case to support achievement of the WHO the potential to increase transmission or dis-
2020 global elimination goals for nine NTDs, persion of NIDs and other CDs (see Moreno
using quantitative analyses and modeling of 2006), more communities displaced by cli-
transmission and control measures. De Vlas mate change, and greater human intrusions
et al. (2016) describe how much health will into previously undisturbed natural habitats
be gained (in terms of mortality avoided and and the diseases, vectors, and reservoirs
lower DALYs lost due to disability) by con- they harbor. Though the economic costs of
certed efforts to control or eliminate NTDs. extreme weather events on health in Latin
For the period 2015-2030, per WHO (2015a), American and the Caribbean are not yet well
recent estimates for domestic investment in estimated (Schmitt et al. 2016), given the di-
NTDs elimination and control to be achieved rection of most climatic trend analyses, the
through universal coverage are US$ 33 bil- opportunity cost for the elimination of the
lion, plus an additional US$ 4.3 billion from diseases we target in this effort will only in-
the international donor community including crease as climate change intensifies. The
continuing pharmaceutical donations. Glob- opportunity costs of delaying the rapid and
ally, for five major NTDs treated by mass drug scaled-up implementation of CD elimination
administration (MDA), Redekop et al. (2017) efforts are important to consider.
264 Snapshot of Communicable Disease Elimination in the Americas
INTEGRATED SUSTAINABLE FRAMEWORK FOR THE ELIMINATION OF COMMUNICABLE DISEASES IN THE AMERICAS
4. Snapshot of Communicable Disease
Elimination in the Americas
The number and scope of CDs in the Americas is large and wide, so the framework presented here will
focus only on a key group presenting a significant disease burden on the more vulnerable populations
in the Region, and does not focus on all the common childhood vaccine-preventable diseases nor on
the control of other NIDs such as cystic echinococcosis and strongyloidiasis. Several highlights of
regional progress in CD elimination for the period of 2009-2017 are shown in Box 2.
The current epidemiological situation of sure prophylaxis from health care provid-
each is briefly described here, while some ers) are critical and should accompany all
key needed responses are described here dog vaccination campaigns.
and further on, set out in a manner which
shows interventions that can be taken HIV/AIDS. An estimated 2 million people in Latin
both within and outside the health sector, America and the Caribbean are living with
revealing how an integrated framework HIV. Latin America and the Caribbean has
to elimination of the CD burden can be the highest coverage of antiretroviral treat-
reached (see Table 2 in the Annex). Note ment among low- and mid-income settings
that not all CDs in the elimination agenda worldwide (55% in 2015), which is respon-
are present in every country. Each coun- sible for a 25% reduction in AIDS-related
try will analyze its own epidemiological deaths since 2010, but insufficient to curb
situation and determine which diseases the steady occurrence of new infections.
they will tackle or step up actions and in- An estimated 100,000 new HIV infections
terventions. For example, Mexico has now have occurred in the Region each year since
eliminated onchocerciasis and trachoma, 2008, with 64% concentrated in key popu-
but still faces challenges with malaria, lep- lations and their sexual contacts. “Cham-
rosy, human rabies by dog bite, Chagas pion” countries in the Region, like Brazil,
disease, TB, and cysticercosis. It is impor- were fast in implementing WHO’s “treat all”
tant to note that not all these diseases are recommendation, which will decrease the
present in every country and territory, so it treatment gap and contribute to a reduction
will not be necessary to work in all coun- in new infections. In addition, countries are
tries on each disease. Schneider et al. advancing towards adopting a “combination
(2011) mapped out the presence of several prevention” approach and to implementing
NIDs in the Region, and subsequent spe- scalable prevention interventions with a fo-
cific studies on the current distribution of cus on key populations. As such, strength-
leishmaniasis, STH, schistosomiasis, ra- ening intersectoral work to address struc-
bies, malaria, and yellow fever, have been tural barriers to key populations’ access to
published by PAHO staff. services and retention in care, including
stigma and discrimination, remains a chal-
HUMAN RABIES (dog-mediated). Remarkable lenge to reaching elimination by 2030.
efforts over the last four decades by the en-
demic countries, PAHO, and other partners HIV—MTCT. One of the greatest public health
have reduced the human rabies burden in success stories, globally and in particular
Latin America from 285 cases in 1970 to in the Americas, has been the develop-
just 10 cases in 2016 (reported only from ment and implementation of interventions
Guatemala and Haiti). Almost all cases of to prevent mother-to-child transmission
human rabies result from dog bites, so the (MTCT) of HIV. Antiretroviral treatment
elimination of canine rabies must be part coverage among pregnant women living
of the regional effort to eliminate deaths with HIV rose from 55% in 2010 to 88%
from dog-mediated rabies in humans. If in 2015, and the estimated MTCT rate de-
so-called hot spots of dog-maintained ra- creased from 15% in 2010 to 8% in 2015.
bies are still present and free-roaming dog New HIV infections in children (0-14 years
populations remain large, people living in old) declined by 55% between 2010 and
hot spots will remain at risk (Velasco-Vil- 2015, from 4,700 in 2010 to 2,100 in 2015,
la et al. 2017). Educational interventions and an estimated 28,000 new HIV infec-
about avoiding dog bites and about what tions were averted in the same period.
to do if bitten (i.e., quickly seek post-expo- However, in order to achieve and sustain
28You can also read
