Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO

 
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
Integrated Sustainable
Framework for the Elimination
of Communicable Diseases
in the Americas
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
An integrated, Sustainable Framework to Elimination
of Communicable Diseases in the Americas.
Concept Note
PAHO/CDE/19-008

© Pan American Health Organization 2019

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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.

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Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
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
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
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
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
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
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
1
Introduction: Integrated,
Sustainable Communicable
Disease Elimination
Framework and Linkages
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
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
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
Malaria testing in Dominican Republic

                                        9
Integrated Sustainable Framework for the Elimination of Communicable Diseases in the Americas - IRIS PAHO
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.

                                                                      10
2
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

                                                                   12
2. 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

                                                                         13
3
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

                                                    14
3
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

                                                                  16
Integrated healthcare campaign to prevent leprosy, trachoma blindness,
and STHs among school-age children, Pernambuco, Brazil

                                                                         17
INTEGRATED 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)

                                                                      18
3. 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.

                                                                              19
INTEGRATED 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.”

                                                                               20
3. 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-       to
INTEGRATED 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.

                                                                                     22
3. 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” to
When disease
transmission ends,
then new generations
of individuals will
not be facing the
premature deaths,
illness, and disability
associated with
those diseases.

               24
3. 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,

                                                                                           25
4
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.

                                                    26
4
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

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