Global Health, Epidemics

and Physicians’ Response

Ravinder Mamtani, MD, M Sc, FACPM, FACOEM, FACLM
Professor of Population Health Sciences and Professor of Medicine

Sohaila Cheema, MBBS, MPH, CPH, Dip IBLM

Assistant Professor of Population Health Sciences and
Assistant Dean, Institute for Population Health

Objectives
1. To discuss the concept of global health.
2. Identify factors that affect the dynamics of infectious
disease transmission and spread, and summarize the
emerging pattern of infectious disease trends.
3. To describe the concept of universal precautions
necessary for controlling diseases such as Ebola and Flu,
Hepatitis B, HIV.
4. Discuss the public health aspects of SARS CoV2)
infection.
5. To summarize ethical issues involved in the response of
the physician to epidemics or other health care
emergencies.

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 1. Any health activity is a global health
activity
High Income

Middle Income

Low Income

Relationship between health and economic

development
COSTA RICA

75 CHINA CZECH REPUBLIC

Life Expectancy at birth

65

55

45
RWANDA
SIERRA LEONE
35
1000 2000 3000 4000

©rm/nymc/2000
GNP per capita ($)

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 Spectrum: health and disease
Low Income : Malnutrition; High Income: Obesity
one child dies every 30 sec and Diabetes
due to malaria
Middle Income

Face Double-Edged
Sword

©rm/nymc/2000
Source: Google Images

Health and disease : nation /

region specific issues

©rm/nymc/2000

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 Here is another way to look at
things
• Disease are world wide phenomena . Only
their frequencies differ.

• We live in an interconnected world.

Disease in one country can cause epidemics
in otherwise stable disease - free countries.
Example - H 1N1

• Countries learn/ benefit from each other ?

1. Technology (Western nations) – Medicines, MRI and
CT - commonly used in Dg countries
2. Acupuncture (China) and Yoga (India) – Increasing use
in the West.

•
©rm/nymc/2000

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 Ideas that advance human health move in all
directions, from which everyone benefits

Any health activity anywhere is directly/

indirectly connected to this planet, its
environment and all its people no matter where
they live
One world, one people and one health:
GLOBAL HEALTH
©rm/nymc/2000

Global health initiatives can produce

miraculous results.

“The global eradication of smallpox in

1977 ranks as one of the greatest triumphs
in medicine”.CDC

Source: Google Images

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 2. Emergence of infectious
diseases and dynamics of their
transmission

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Global Health Threats, 2019 (WHO)

• Non-communicable diseases (heart, cancer,
diabetes) 70 % (> 41 m 2017 ) . Dying
prematurely, living with pain and suffering
• 22 % people in vulnerable settings: conflict,
drought, famine, poverty, displaced settings
• Air pollution (7 m deaths)
• Communicable: Infectious diseases
• Weak healthcare care. Affordability !
Sources- https://www.who.int/emergencies/ten-threats-to-global-health-in-2019; (WHO)
https://www.healio.com/infectious disease/antimicrobials/news/online/%7Bb1234d9f-90fb-467c-8b77-
333d757af5e4%7D/who-announces-10-threats-to-global-health-in-2019?page=2(Helio, Infectious Dis News)
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 A rapidly changing, complex world
• Population & density
• Increased travel (Flu)
• Deforestation: change
in habitat
• Shared environment - Avian flu
Corona V
contact with animals

Sources: WHO and Business Insider

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Zoonotic diseases (shared

between animals and people )
• 60 % of infectious diseases in humans are
spread from animals

• Zoonotic diseases cause 2.5 billion cases of

illness and 2.7 million deaths worldwide each
year (Salmonella, Influenza, Leishmaniasis,
Echinocc, Ebola, Malaria so on)
Source: CDC, USA
https://www.cdc.gov/globalhealth/healthprotection/fieldupdates/winter-2017/prevent-
zoonotic-diseases.html

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 Infectious diseases
Success
•Small pox – Eradicated
•Polio – almost there
•HIV –medications
•Vaccines
Challenges remain
1.Re-emergence
2.Emergence
3.Persistence of serious infections
4.Antimicrobial resistance common
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Essentially, we are dealing with

• Emergence – H1N1, SARS, H5N1

• Re-emergence – flu, malaria & TB (resistant

strains), measles & pertussis (poor
compliance with vaccination), Ebola, Zika

• Persistence of many infections – HIV/

AIDS, Hepatitis B, C

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 Corona viruses
• Due to - SARS CoV2- a new
coronavirus- not previously
identified; causes COVID-19.
Source:Harvard

• MERS, SARS ( and SARS CoV2) – Bat viruses

MERS - Camels
SARS – Civet Cats
SARS CoV 2- Pangolin

• Corona viruses- a large family- circulating in humans

- mild illness, like the common cold.

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Dynamics of their transmission:

concepts and definitions
Infection ?
Natural history
Incubation Period

Epidemic/Endemic

Elimination/ Eradication

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 INFECTIOUS AGENT

ENTRY IN A HOST

AGENT DOES AGENT

NOT ESTABLISH ESTABLISHES

INFECTION RESULTS

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INFECTION SPECTRUM
SYMPTOMS AND SIGNS
INFECTION
INAPPARENT INFECTION. INFECTIOUS DISEASE
COLONIZATION

Infection State Disease State

TB Infection (PPD) TB Disease
HIV Infection (Serology) AIDS

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 Natural History of Infectious Diseases

RECEIPT OF INFECTION
INCUBATION PERIOD
COVID 19= 14 d; average = 6d

INFECTIOUS DISEASE
Communicability

OUTCOME- RECOVERY,
COMPLICATIONS, DEATH

Infection spread and its effects on the community – direct

and indirect – determined by many factors

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Agent, Host and Environment

Environment
• Biological, physical, geography and climatic
conditions
Example – mosquitoes in monsoons.
• Food/ water/air
Host
Immunity status
•

History of immunization/ disease status; example-

previous history of rubella/ measles- immunity
• Nutrition –malnutrition
• Behavior - STD
Genetics

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 Progression of inf. dis. depends on human, env,
and infectious agent factors

1. INFECTIVITY 2. VIRULENCE 3. PATHOGENICITY

INVADE AND MULTIPLY SEVERE DISEASE CLINICAL APPARENT

DISEASE
Deaths/ Cases. Flu=0.1%, Avian
Flu= 50 %, COVID = 0.05-1.3 %

4. ABILITY TO MUTATE 5. IMMUNOGENICITY

NEW STRAINS PRODUCE IMMUNITY:

SUCCESS WITH VACCINE

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IMMUNE RESPONSE,
IgM, IgG
I
M
M IgM IgG
U
N
E
R
E
S

Agent TIME

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 IMMUNOGENICITY, IgG
IgG is a surrogate of immunity for many diseases
(Neutralizing antibodies –determine immunity)

I
M
M
U
N VIRUS
R
BACTERIA
E
S

PARASITE

TIME

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Reproductive rate (Ro)

Average # of people infected by each sick person

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 Spread of disease, its dynamics
depend on these factors
• Disease origin, transmission and its
cessation- a dynamic process
• Geographical extent. (Epidemic-
pandemic)
Avian flu Zika H1N1 COVID

Small pox

No disease Endemic Epidemic Pandemic

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Endemic/ Epidemic/Pandemic
• Endemic- refers to “ constant presence ” or
the “usual prevalence of disease”.

• Epidemic “ the occurrence in a region of an

illness clearly in excess of normal
expectation” (Benenson 1980)

• Pandemic – Global outbreak of disease when

a new agent appears or emerges in the
human population. Example : Pandemic flu.

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 Levels of control- elimination/
eradication
• Eradication: complete global cessation of
transmission of infection in an irreversible
manner. Example: ?
• Elimination: Cessation of infectious disease
from a defined geographical region.

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Factors favor eradication

(The Dahlem Workshop)
• An effective intervention to interrupt
transmission of the agent (Vaccine )
• Practical diagnostic tools to detect infection
• Humans are essential for the life-cycle of
the agent, which has no other vertebrate
reservoir
• Economic, social and political
considerations.
https://www.cdc.gov/mmwr/preview/mmwrhtml/su48a7.htm

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 Likely disease candidates for
eradication (and challenges)
• Polio
Challenges: OPV strains in environment
• Measles
Challenges: susceptible populations, in-apparent carriers, HIV
• Rubella
Challenges: inapparent/ subclinical infection, lack of awareness

Source: Considerations for Viral Disease Eradication: Lessons Learned and Future
Strategies: Workshop Summary, 2002. national Academy of Sciences

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3. Universal Precautions (UP)

• Blood Borne Pathogens ?
• Blood Borne Pathogen Regulations.
• What are UP ? How are they different from
Standard Precaution (SP) ?

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 Universal Precautions (1985-88)
: focus on blood borne pathogens
Bloodborne pathogens are “ infectious
microorganisms present in blood that can cause
disease in humans”

They include: HBV, HCV, HIV.

They present risk to HCW

Blood Borne Pathogen Standard (US: OSHA)

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Significance

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 The US Blood Borne Pathogen
Standard Requires Employers to
Establish an exposure control plan; workplace
controls
Availability of Hep B Vaccination
Post –exposure evaluation and management
Training of those at risk
Implement use of universal precautions treating
human blood and other potentially inf material
(OPIM) as if they were infceted
(Use of PPE -masks, gloves, gowns and eye)

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Other potentially infectious

material (OPIM)
• Semen/vaginal secretions
• CSF (spine), synovial fluid (joints)
• Pleural, peritoneal, pericardial
• Vomit, urine, feces, sweat and tear – not
included unless accompanied by blood

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 Universal Precautions (1985-88)

Standard Precautions (1996)

Broader focus than universal precautions including

bloodborne, airborne and epidemiologically
important pathogens.

Emphasizes that they are the absolute basis for

practice: use them for everything that we’re doing
in patient care. Protects HCW and patients.

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Universal Standard
• Regulatory requirement • CDC recommendation
(OSHA) for all infection
• Scope – blood borne prevention
infections; consider • Scope – broad, covers all
blood and OPIM of all patients and its scope
patients who are includes all fluids (except
infectious. tears)

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 Summary
• Basics: natural history, agent properties and
dynamics of infection diseases and spread.
• Federal regulations (US) : Blood Borne Pathogen
Standard
• Universal and Standard Precautions (Broader in
its scope – aims for not just blood borne but also
other infections.

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