Contagious Economics: Global burdens of infectious diseases, Malaria and Tuberculosis

Contagious Economics

Global burdens of infectious diseases, Malaria and Tuberculosis

Mi Sol Kim, Yeon Jung Choi, Etinosa Obanor, Catharina van Haastregt

1. Introduction

    When we look at the global population, increased public health initiatives and availability of health care services have contributed to increased lifespans and health statuses. However, something that persists as a hinderance of both length and quality of life are infectious diseases. As a leading cause of death (particularly in low-income nations), infectious diseases are still of serious concern in the global health sphere. And while deaths due to non-communicable diseases (lung diseases, cancer, cardiovascular diseases, and diabetes) are on the increase worldwide, infection diseases are still responsible for the most deaths in low-income nations, and continue to challenge human populations through new strain formations and increasing treatment resistance.

    Infectious diseases are caused by pathogenic organisms, and typically can be spread in a multitude of ways, including via air, water, food vectors, or bodily fluids. The transmission of such diseases can often lead to health crises, such as epidemics, in which the disease is spread rapidly to many individuals within a given geographic region, or even pandemics, which is an epidemic that gets spread over several countries or continents.

    When an area faces an infectious disease crisis, many aspects of its society are affected. While the more direct implications can be seen on the individual level as well as in the public health setting, many of the deep-rooted burdens that the area has to face are within the economic sector. The intention of this article is to work through what kind of economic demands and costs are associated with the event of an large-scale infectious disease crisis. To do this, we will analyze the different aspects of two different disease crises: malaria and tuberculosis. Here we will present literature finding that have focused on the economical aspects of these infectious diseases, then use this information to construct a series of policy recommendations aimed at mitigating the social and economic burdens caused by these diseases.

2. Malaria

   

Malaria is caused by Plasmodium parasites, which spread to people through female Anopheles mosquito bites. According to the World Health Organization, there are five parasite species that especially transmit malaria to human beings, two posing the greatest threats: P.falciparum and P.vivax.  The intensity of transmission depends on factors related to the parasite, the vector, the human host, and the environment.

    Symptoms of malaria typically appear within 10~15days. The first symptoms of malaria include a high fever, headaches, and chills within the body. These symptoms are hard to distinguish as malaria at first sight, leading to much severe illness for those under P.falciparum. If not treated under 24 hours, P.falciparum malaria can progress to severe aftermaths, most likely leading to death.

Most malaria cases and deaths occur in sub-Saharan regions, but South-East Asia, Latin America and the Middle East are also at risk. In 2015, 91 countries and areas had continuous malaria transmission. Some population groups have a higher possibility of contracting malaria, including infants, pregnant women, and HIV/AIDS patients. Those who travel to these areas are also under risk. National malaria control programmes are necessary to prevent malaria contraction to these specific population groups, as they are more susceptible to disease transmission.

    Economic Implications

    Economical aspects of malaria have been closely reported by health studies conducted by social scientists and health organizations. Like many infectious diseases, malaria poses an economic threat to households that need to burden the cost for prevention, treatment, and others that may arise as a result of infection. The economic costs can be divided into direct costs and indirect costs.

The direct costs of malaria are generally defined as expenditure on preventing transmission of malaria and the direct treatment of it by households and health-providing services. Household expenditures on prevention of malaria usually consist of mosquito repellants, sprays, and mosquito coils, since the transmission of malaria is through mosquito bites. According to Chima and Goodman’s (2003) thesis, monthly per capita household expenditures on malaria-preventive methods differ by countries, but range from $0.05 in rural Malawi to $2.1 in Cameroon. The data provided in this thesis showed highly skewed expenditures, and that expenditure level was “highly affected by per capita income, with only 4% of very low income households spending money on malaria prevention as opposed to 16% of other households”. This shows that although household preventive methods are necessary for people to prevent mosquitoes from reaching the public, relatively low-income country households are economically burdened to actually attempt prevention.

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A more significant economic burden comes from the direct treatment and process of  seeking treatment. This is suggested by Williams and Jones’ (2004) work, which reviewed 117 published papers in order to divest this analysis. Although household treatments and non-authorized tribal treatments have decreased, the costs for health facilities force women and mothers to turn to household drug treatments initially. A study from Ghana examining clinical management of malaria by medical assistants also showed a decrease in knowledge of malaria treatment, incurring for more investment in education of malaria treatment as well. Together with unendorsed malaria treatment, poverty in households have indirectly pushed people in sub-Saharan Africa to purchase local treatments that are cheap.

Apart from household costs, government prevention costs are also a key component of direct costs. While the direct costs of malaria prevention in health facilities are limited in data, according to the World Malaria Report 2016, vector control (insecticide-treated mosquito nets and indoor residual spraying) in countries usually have a budget line for specific purchases, such as insecticide. Total funding for malaria control and elimination in 2015 was approximately calculated to US $2.9 billion, with endemic countries providing 32%. Sales of insecticide-treated mosquito nets(ITNs) and rapid diagnostic tests (RDTs) in sub-Saharan Africa for 2015 exceeded the minimum amount required to achieve universal access to an ITNs. However, RDT sales decreased, with Asian purchases significantly decreasing to ‘falciparum-only’ tests. WHO interprets this as a success in malaria control for Asian countries. The potential economic benefits or cost-effectiveness are hard to distinguish, but Goodman and Coleman’s (1999) work shows a glimpse of the cost benefit analysis they’ve conducted. The WHO Roll Back Malaria campaign cost-effectiveness data is sparse, but their interpretation using mathematical models, with child mortality rates and pregnancy deaths as factors, concluded that package of interventions are not affordable to low-income countries. In a very-low income country, the cost-effectiveness range of usage of ITNs  was US $4-10 per person, suggesting that cost-effective interventions are available in form of ITNs and residual spraying, but the combined cost is heavy for households to bear.

3. Tuberculosis

   

Tuberculosis (TB) is an airborne infectious disease, caused by the bacterium Mycobacterium tuberculosis. TB mainly manifests as an infection in the lungs, but it can affect other parts of the body. Symptoms include coughing, fever, loss of weight and appetite, and fatigue. Symptoms can be very mild for the first few months, often leading to late diagnosis and high rates of contagion. Someone with active TB can infect 10-15 other people over the course of a year.

TB can occur in one of two forms: active and latent. Someone with active TB is contagious and will show symptoms. Someone affected with latent TB will not show symptoms and is not contagious. However, latent TB can become active TB.

The standard treatment for TB is a mix of 4 antibiotics, which have to be taken for 6 months. Due to this treatment, the United Nations initially predicted that TB would be eliminated worldwide by 2025 (MCintosh, 2017). However, as is the problem with many diseases that are treated with antibiotics, antibiotic-resistant strains have appeared. Multidrug-resistant TB (MDR-TB) occurs when an antibiotic fails to kill the bacteria, and the bacteria developing resistance against it. MDR-TB is treatable only with very specific anti-TB drugs, which are not always readily available. Some strains of TB are even more aggressive, and are deemed extensively drug-resistant TB (XDR-TB), as they are resistant to at least four of the core anti-TB drugs (WHO, n.d.). The surfacing of these strains of TB caused the number of TB cases to rise again in the mid 1980s; so much so, that the WHO declared TB to be a global emergency by 1993--the first time that a disease was labeled as such.

It is believed that about one third of the world population has latent TB. TB occurs in every part of the world. The largest number of new TB cases occurred in Asia, with 61%, followed by Africa with 26% of new cases (WHO, n.d.). In 2015 60% of new TB cases were found in six countries: India, Indonesia, China, Nigeria, Pakistan, and South Africa.  

Economic Implications

    Since tuberculosis is more prevalent and chronic in underdeveloped or developing countries, it has been imposing economic burden to those societies. In TABLE 3, except for Malawi, households in most countries spend $50 to about $140 on average for treatment which lasts about 6 to 30 months. These expenditures account for 8% to 20% of each household’s annual income, and this is financially fatal considering that they are already in impoverished condition.

Besides direct medical costs consumed, additional and non-medical costs are disbursed. Transportation cost to go to hospitals, diet cost for therapy, decrease in household income due to lost in labor are all indirect costs caused by TB. Indirect costs are quite high (TABLE 7) because the disease is chronic, proper diagnosis takes time and mainly because the disease can be transmitted by person, infected one cannot participate in any economic activity.

      

    Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XTR-TB) are two typical types of drug-resistant TB. By 2050, MDR-TB could cost the world $16.7 trillion and XTR-TB would cost more since it is more drug-resistant. According to World Health Organization report in 2016, there were an estimated 480,000 new cases of multidrug-resistant TB. More and more drug-resistant TB will be developed and each of them would cost billions and trillions to treat, create vaccines, etc. Whatever the cost may be, it will be a tremendous burden to each household suffering from various kinds of TB.

4. Intervention Strategies

    After considering the social and economic implications associated with the incidence and prevalence of these two infectious diseases, we have come up with specific intervention methods that we feel would help alleviate the burden that these diseases bring upon society.

1. Malaria

In order to begin to control the spread of malaria, we believe that grand policy application should be implemented. Policies that must be realized include vector control, insecticide resistance, surveillance, and financial support. Among these numerous actions, vector control is the most essential component in preventing malaria.

We advocate for widespread distribution of long-lasting insecticidal nets (LLINs). Men and women of all ages are most vulnerable to mosquitoes when they are asleep, when mosquitoes can feed on their blood while transmitting malaria parasites to humans. LLINs keep such situation from occurring. World Health Organization (WHO) recommends one LLIN be distributed for every two people who are on the verge of being infected with malaria. Most countries where malaria is prevalent are underdeveloped or developing countries, and each household who are being affected by malaria might not afford to purchase LLINs. Also, a number of countries in Africa suffer from difficulty in accessing LLINs. (Figure 4.1 and 4.5) Therefore,we recommend that accessibility and distribution of LLINs should be done free of charge to individuals.

Additionally, eliminating larvae, pupae, and imagoes of malaria mosquitoes is significant. Both removing as many standing water as possible and spraying insecticides over standing water to kill them are essential. Countries with substantial risk of malaria should divide each country into accessible districts and undertake inspection for still water. Standing water with no creatures must be removed immediately, but with creatures must be dealt with insecticides. This measure blocks the number of vectors from increasing in advance. For imagoes of malaria mosquitoes, indoor residual spraying (IRS) must be carried out. It can instantly and rapidly reduce the number of mosquitoes, and thus malaria incidence. WHO recommends “the spraying of at least 80% (and ideally 100%) of houses, structures and units in the targeted area in any round of spraying”.

Measures against insecticide resistance also need to be taken.According to WHO’s World Malaria Report 2013,  “Current vector control tools remain effective; however, if left unchecked, insecticide resistance could lead to a substantial increase in malaria incidence and mortality. The global malaria community needs to take coordinated action to prevent insecticide resistance from emerging at new sites, and to urgently address it at the sites where it has been identified.” In 64 countries, Anopheles mosquitos have already shown resistance to insecticides. Before insecticide resistance takes place in other regions, regular entomological and resistance monitoring must be conducted. We recommend districts meetings at least every six months to present feedback on the current vector control and develop advanced and more effective measures to complement the current ones. Malaria-endemic countries are urged to develop and implement insecticide resistance management (IRM), in which each district in a country conduct close, regular checks on the efficacy and condition of LLINs and IRS every 6 months. IRS should be equipped with different insecticides in different regions and in each region the kinds of insecticides must be changed regularly.

The WHO World Malaria Report 2013 also mentions “International disbursements to malaria-endemic countries increased from less than US$ 100 million in 2000 to US$ 1.60 billion in 2011; they were estimated to be US$ 1.94 billion in 2012 and US$ 1.97 billion in 2013 (Figure 3.1).” Financial problem is a big issue in the case of malaria. Since malaria is an endemic disease and usually an outbreak occurring in underdeveloped and developing countries, households that suffer from malaria are not capable of handling the full cost of malaria prevention and treatment programme, and thus government assistance is vital.

In addition, the WHO report also explains the gap between expenditure and funding: “Combining both domestic and international funds, the resources available for malaria control globally were US$ 2.5 billion in 2012. Global resource requirements for malaria control were estimated to exceed US$ 5.1 billion per year between 2011 and 2020 in the GMAP of 2008, leaving an annual funding gap of US$ 2.6 billion. Projections of available domestic and international resources indicate that total funding for malaria control will reach about US$ 2.85 billion between 2014 and 2016, which is still substantially below the amount required to achieve universal access to malaria interventions.” Since many malaria-endemic countries cannot afford the enormous amount of cost needed for malaria prevention and treatment, funding from global companies is inevitable. Companies (especially international ones) hold ‘corporate social responsibility’, thus funding for intervention programme against malaria is somewhat obligatory in ethical perspective for overall healthiness and goodness for the globe. WHO must cooperate with UN, inform the seriousness of and the difficulty in raising funds for malaria, and urge developed countries to take action for malaria. Financial support from the world would lessen the burden for endemic countries, and funds can also be used to create vaccine for malaria which has not been found yet.

2. Tuberculosis

With regards to TB, there are a number of problems that need addressing with policies. These include prevention,diagnostic information, and antibiotic-resistance strains.

As is the case with malaria, an important way to prevent TB from spreading is to prevent contact with someone infected with TB. Thus similar contact precautions can be taken for TB as for malaria. But because TB is an airborne disease, it is more easily transmitted from one person to the next, especially between friends or family members. It is very important to diagnose someone with TB as soon as possible and isolate them. The people they come into contact with, for instance doctors and family members, should wear a face mask to avoid contamination.

Information supply is also very important. Populations in TB high areas should be informed on the symptoms of TB so it can be treated quickly. From the studies we analyzed previously, it is noticed that self-treatment is often used. Self-medication leads to two problems: it is not usually effective, and it can increase the emergence of MDR-TB and XDR-TB. These drug-resistant strains of TB are becoming a very big problem, as conventional medication will not always work for them. Because of this, we strongly recommend increased information campaigns and availability of formal treatments be issued by a nation’s public health sector of the government.

After announcing TB to be a global emergency, the WHO promoted TB control via DOTS: directly observed therapy (WHO, n.d.). DOTS have five elements:

• Government commitment to control activities
• Case detection by sputum smear microscopy
• Standardized treatment regimens lasting 6-8 months directly observed for 2 months
• Regular, uninterrupted supply of anti-TB drugs
• Standardised recording and reporting systems

According to the WHO, the key element in TB treatment is forming a close bond between patient and caretaker, to make sure that the treatment is successfully completed (Tuberculosis control, WHO).The standardized nature of DOTS makes the treatment of TB easier to administer and has decreased its costs. A big problem with DOTS, however, is that it is not implemented enough, as only 27% of people diagnosed with TB receive DOTS. DOTS have a high cure-rate, so we highly advocate for governments to fully supply hospitals with this treatment. DOTS, however, is often not effective for MDR-TB or XDR-TB.

Globalization has also had a major role in the spreading of TB. Populations are no longer isolated, and one person can spread TB from one country to another. This leads to a prisoner’s dilemma for governments, they are faced with the choice invest in TB prevention, not knowing whether their neighbouring countries will do the same. To bridge this gap, we also recommend that worldwide organizations step it to make deals between countries to make sure everyone is doing all they can to prevent the further spread of TB.

5. Conclusion

    As we have seen through works from the existing literature, infectious diseases still pose very challenging threats onto the health and economic stability of our global society. For us, the economic burdens imposed by malaria and tuberculosis were of particular interest among the various infectious diseases. The existing body of work on these two diseases provided insight on different economic aspects of these disease crises, like the prevention and treatment burdens on households. From here, we analyzed the findings of the literature and used its information to construct a series of targeted policy recommendations in order to tackle these diseases. Our recommendations included reducing potential of spread in human populations, increased treatment availability, heightened vector surveillance, public campaigns to increase awareness of early diagnosis and treatment, and cooperation of multinational bodies and organizations.

    While we are confident about our policy proposals, there are some areas that we feel could be more efficiently tackled through policy inclusion.These include things such as the effect of treating animals (e.g. livestock) with antibiotics and the rate of increased antibiotic resistance. For these areas, we will look towards the scientific community and await further studies that will guide our future policies in the most directed and efficient fashion possible.

References

Introduction:

1. Baylor College of Medicine. Introduction to Infectious Diseases. Retrieved May 28, 2017, from https://www.bcm.edu/departments/molecular-virology-and-microbiology/emerging-infections-and-biodefense/introduction-to-infectious-diseases
2. Dye, C. (2014). After 2015: infectious diseases in a new era of health and development. Philosophical Transactions B Royal Society Publishing, 369 (1645).

Malaria

3. World Health Organization. Media Centre Malaria Facts Sheet. Updated April 2017.
   Retrieved 29 May 2017, from http://www.who.int/mediacentre/factsheets/fs094/en/
4. Williams, Holly. Jones, Caroline. A critical review of behavioral issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made? Social Science & Medicine 59. (2004) 501-523
5. Goodman, C.A. Coleman, P.G. Cost-effectiveness of malaria control in sub-Saharan Africa. The Lancet. Vol 354. (1999).
6. Chima, Reginald. Goodman, Catherine. Mills, Ann. The economic impact of malaria in Africa: a critical review of the evidence. Health Policy 63. (2003) 17-36
7. D’Souza, Bianca. Newman, Robert. Strengthening the policy setting process for global malaria control and elimination. Malaria Journal. (2012)
8. Morbidity and Mortality Weekly Report - Malaria Surveillance. CDC. (2009)
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Tuberculosis:

12. Tuberculosis (TB). (n.d.). Retrieved June 06, 2017, from http://www.who.int/mediacentre/factsheets/fs104/en
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16. Russell, S. (2004). The economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome. The American journal of tropical medicine and hygiene, 71(2 suppl), 147-155.
17. World Health Organization. (2016). Global tuberculosis report 2016.
18. Tuberculosis control. (n.d.). Retrieved June 05, 2017, from http://www.who.int/trade/distance_learning/gpgh/gpgh3/en/
19. MCintosh, J. Tuberculosis: causes, symptoms, and treatments. (2017). Retrieved June 05, 2017, from http://www.medicalnewstoday.com/articles/8856.php

Who did what

The initial research and choosing of the topic was done by the four of us. Finding of initial sources and coming up with a research question was done together. After doing this together, we split the rest of the essay in even parts.

Etinosa wrote the introduction, conclusion and did the last proofreading and editing work.

Catharina the introduction to TB and the policy proposal for the same disease.

연정 wrote the part on economic costs of TB and the policy implications for malaria.

미솔 focused on the introduction for malaria and the economic costs of malaria.