WHO Report Shows Gains Are Levelling


After unprecedented global success in malaria control, progress has stalled, according to the World malaria report 2017. There were an estimated 5 million more malaria cases in 2016 than in 2015. Malaria deaths stood at around 445 000, a similar number to the previous year.

“In recent years, we have made major gains in the fight against malaria,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “We are now at a turning point. Without urgent action, we risk going backwards, and missing the global malaria targets for 2020 and beyond.”

The WHO Global Technical Strategy for Malaria calls for reductions of at least 40% in malaria case incidence and mortality rates by the year 2020. According to WHO’s latest malaria report, the world is not on track to reach these critical milestones.
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A major problem is insufficient funding at both domestic and international levels, resulting in major gaps in coverage of insecticide-treated nets, medicines, and other life-saving tools.

Funding shortage

An estimated US$ 2.7 billion was invested in malaria control and elimination efforts globally in 2016. That is well below the US $6.5 billion annual investment required by 2020 to meet the 2030 targets of the WHO global malaria strategy.
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In 2016, governments of endemic countries provided US$ 800 million, representing 31% of total funding. The United States of America was the largest international funder of malaria control programmes in 2016, providing US$1 billion (38% of all malaria funding), followed by other major donors, including the United Kingdom of Great Britain and Northern Ireland, France, Germany and Japan.

The global figures

The report shows that, in 2016, there were an estimated 216 million cases of malaria in 91 countries, up from 211 million cases in 2015. The estimated global tally of malaria deaths reached 445 000 in 2016 compared to 446 000 the previous year.

While the rate of new cases of malaria had fallen overall, since 2014 the trend has levelled off and even reversed in some regions. Malaria mortality rates followed a similar pattern.

The African Region continues to bear an estimated 90% of all malaria cases and deaths worldwide. Fifteen countries – all but one in sub-Saharan Africa – carry 80% of the global malaria burden.
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“Clearly, if we are to get the global malaria response back on track, supporting the most heavily affected countries in the African Region must be the primary focus,” said Dr Tedros.

Controlling malaria

In most malaria-affected countries, sleeping under an insecticide-treated bednet (ITN) is the most common and most effective way to prevent infection. In 2016, an estimated 54% of people at risk of malaria in sub-Saharan Africa slept under an ITN compared to 30% in 2010. However, the rate of increase in ITN coverage has slowed since 2014, the report finds.

Spraying the inside walls of homes with insecticides is another effective way to prevent malaria. The report reveals a steep drop in the number of people protected from malaria by this method – from an estimated 180 million in 2010 to 100 million in 2016 – with the largest reductions seen in the African Region.

The African Region has seen a major increase in diagnostic testing in the public health sector: from 36% of suspected cases in 2010 to 87% in 2016. A majority of patients (70%) who sought treatment for malaria in the public health sector received artemisinin-based combination therapies (ACTs) – the most effective antimalarial medicines.
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However, in many areas, access to the public health system remains low. National-level surveys in the African Region show that only about one third (34%) of children with a fever are taken to a medical provider in the public health sector.

Tackling malaria in complex settings
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The report also outlines additional challenges in the global malaria response, including the risks posed by conflict and crises in malaria endemic zones. WHO is currently supporting malaria responses in Nigeria, South Sudan, Venezuela (Bolivarian Republic of) and Yemen, where ongoing humanitarian crises pose serious health risks. In Nigeria’s Borno State, for example, WHO supported the launch of a mass antimalarial drug administration campaign this year that reached an estimated 1.2 million children aged under 5 years in targeted areas. Early results point to a reduction in malaria cases and deaths in this state.

A wake-up call
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“We are at a crossroads in the response to malaria,” said Dr Pedro Alonso, Director of the Global Malaria Programme, commenting on the findings of this year’s report. “We hope this report serves as a wake-up call for the global health community. Meeting the global malaria targets will only be possible through greater investment and expanded coverage of core tools that prevent, diagnose and treat malaria. Robust financing for the research and development of new tools is equally critical.”

Malaria control and elimination investments

In 2016, an estimated US$ 2.7 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners.

The majority (74%) of investments in 2016 were spent in the WHO African Region, followed by the WHO regions of South-East Asia (7%), the Eastern Mediterranean and the Americas (each 6%), and the Western Pacific (4%).

Governments of endemic countries contributed 31% of total funding (US$ 800 million) in 2016.
The United States of America (USA) was the largest international source of malaria financing in 2016, providing US$ 1 billion (38%), followed by the United Kingdom of Great Britain and Northern Ireland (United Kingdom) and other international donors, including France, Germany and Japan.
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More than half (57%) of resources in 2016 were channelled through the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

Investment outlook

Although funding for malaria has remained relatively stable since 2010, the level of investment in 2016 is far from what is required to reach the first milestone of the GTS, which is a reduction of at least 40% in malaria case incidence and mortality rates globally when compared to 2015 levels.

To reach this milestone, the GTS estimated that annual funding would need to increase to US$ 6.5 billion per year by 2020. The US$ 2.7 billion invested in malaria in 2016 represents less than half (41%) of that amount.
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Stepping up investments in malaria research and development is key to achieving the GTS targets. In 2015, US$ 572 million was spent in this area, representing 83% of the estimated annual need for research and development.

Deliveries of malaria commodities
Insecticide-treated mosquito nets

Between 2014 and 2016, a total of 582 million insecticide-treated mosquito nets (ITNs) were reported by manufacturers as having been delivered globally.

Of this amount, 505 million ITNs were delivered in sub-Saharan Africa, compared with 301 million bednets in the preceding 3-year period (2011–2013).
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Data from national malaria control programmes (NMCPs) in Africa indicate that, between 2014 and 2016, 75% of ITNs were distributed through mass distribution campaigns.

Rapid diagnostic tests

An estimated 312 million rapid diagnostic tests (RDTs) were delivered globally in 2016. Of these, 269 million were delivered in the WHO African Region.
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The number of RDTs distributed by NMCPs increased between 2010 and 2015, but fell from 247 million in 2015 to 221 million in 2016. The decrease was entirely in sub-Saharan Africa, where distributions dropped from 219 million to 177 million RDTs over the 2015–2016 period.

Artemisinin-based combination therapy

An estimated 409 million treatment courses of artemisinin-based combination therapy (ACT) were procured by countries in 2016, an increase from 311 million in 2015. Over 69% of these procurements were reported to have been made for the public sector.
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The number of ACT treatments distributed by NMCPs to the public sector increased from 192 million in 2013 to 198 million in 2016. Most of the NMCP distributions of ACTs (99%) in 2016 occurred in the WHO African Region.

Vector control

Across sub-Saharan Africa, household ownership of at least one ITN increased from 50% in 2010 to 80% in 2016. However, the proportion of households with sufficient nets (i.e. one net for every two people) remains inadequate, at 43% in 2016.

More people at risk of malaria in Africa are sleeping under an ITN. In 2016, 54% of the population was protected by this intervention, an increase from 30% in 2010.

Fewer people at risk of malaria are being protected by indoor residual spraying (IRS), a prevention method that involves spraying the inside walls of dwellings with insecticides. Globally, IRS protection declined from a peak of 5.8% in 2010 to 2.9% in 2016, with decreases seen across all WHO regions. In the WHO African Region, coverage dropped from 80 million people at risk in 2010 to 45 million in 2016.
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The declines in IRS coverage are occurring as countries change or rotate insecticides to more expensive chemicals.

Preventive therapies

To protect women in areas of moderate and high malaria transmission in Africa, WHO recommends “intermittent preventive treatment in pregnancy” (IPTp) with the antimalarial drug sulfadoxinepyrimethamine. Among 23 African countries that reported on IPTp coverage levels in 2016, an estimated 19% of eligible pregnant women received the recommended 3 or more doses of IPTp, compared with 18% in 2015 and 13% in 2014.
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In 2016, 15 million children in 12 countries in Africa’s Sahel subregion were protected through seasonal malaria chemoprevention (SMC) programmes. However, about 13 million children who could have benefited from this intervention were not covered, mainly due to a lack of funding. Since 2012, SMC has been recommended by WHO for children aged 3-59 months living in areas of highly seasonal malaria transmission in this subregion.

Accessing care

Prompt diagnosis and treatment is the most effective means of preventing a mild case of malaria from developing into severe disease and death. Among national-level surveys completed in 18 countries in sub-Saharan Africa between 2014 and 2016 (representing 61% of the population at risk), a median of 47% (interquartile range [IQR]: 38–56%) of children with a fever (febrile) were taken to a trained medical provider for care. This includes public sector hospitals and clinics, formal private sector facilities and community health workers.
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More febrile children sought care in the public sector (median: 34%, IQR: 28–44%) than in the private sector (median: 22%, IQR: 14–34%). However, the surveys from Africa also indicate that a high proportion of febrile children did not receive medical attention (median: 39%, IQR: 29–44%). Possible reasons include poor access to health-care providers or lack of awareness among caregivers.

Diagnosing malaria

Among 17 national-level surveys completed in sub-Saharan Africa between 2014 and 2016, the proportion of children with a fever who received a finger or a heel stick – suggesting that a malaria diagnostic test may have been performed – was greater in the public sector (median: 52%, IQR: 34–59%) than in both the formal and informal private sector.
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Testing of suspected cases in the public health system increased in most WHO regions since 2010. The WHO African Region recorded the biggest rise, with diagnostic testing in the public health sector increasing from 36% of suspected cases in 2010 to 87% in 2016.

Treating malaria

Among 18 household surveys conducted in sub-Saharan Africa between 2014 and 2016, the proportion of children aged under 5 years with a fever who received any antimalarial drug was 41% (IQR: 21–49%).
A majority of patients (70%) who sought treatment for malaria in the public health sector received ACTs, the most effective antimalarial drugs. Children are more likely to be given ACTs if medical care is sought at public health facilities than in the private sector.

To bridge the treatment gap among children, WHO recommends the uptake of integrated community case management (iCCM). This approach promotes integrated management of common life-threatening conditions in children – malaria, pneumonia and diarrhoea – at health facility and community levels. In 2016, 26 malaria-affected countries had iCCM policies in place, of which 24 had started implementing those policies. An evaluation from Uganda found that districts with iCCM experienced a 21% increase in care-seeking for fever compared with districts without an iCCM policy in place.
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Outside the WHO African Region, only a handful of countries in each of the other regions reported having such policies in place, though data on the level of implementation are unavailable for most countries.

Malaria surveillance systems

Effective surveillance of malaria cases and deaths is essential for identifying the areas or population groups that are most affected by malaria, and for targeting resources for maximum impact. A strong surveillance system requires high levels of access to care and case detection, and complete reporting by all health sectors, whether public or private.

In 2016, 37 out of 46 countries in the WHO African Region indicated that at least 80% of public health facilities had reported data on malaria through their national health information system. Rates vary within other WHO regions. For example, in the WHO Eastern Mediterranean Region, only 3 out of 8 countries had 80% or more public health facilities reporting in 2016.
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Among 55 countries where the burden of malaria was estimated, 31 countries have a malaria case reporting rate by surveillance systems of less than 50%. This includes the high-burden countries of India and Nigeria.

Malaria cases

In 2016, an estimated 216 million cases of malaria occurred worldwide (95% confidence interval [CI]: 196–263 million), compared with 237 million cases in 2010 (95% CI: 218–278 million) and 211 million cases in 2015 (95% CI: 192–257 million).

Most malaria cases in 2016 were in the WHO African Region (90%), followed by the WHO South-East Asia Region (3%) and the WHO Eastern Mediterranean Region (2%).

Of the 91 countries reporting indigenous malaria cases in 2016, 15 countries – all in sub-Saharan Africa, except India – carried 80% of the global malaria burden.

The incidence rate of malaria is estimated to have decreased by 18% globally, from 76 to 63 cases per 1000 population at risk, between 2010 and 2016. The WHO South-East Asia Region recorded the largest decline (48%) followed by the WHO Region of the Americas (22%) and the WHO African Region (20%).

Despite these reductions, between 2014 and 2016, substantial increases in case incidence occurred in the WHO Region of the Americas, and marginally in the WHO South-East Asia, Western Pacific and African regions.

Plasmodium falciparum is the most prevalent malaria parasite in sub-Saharan Africa, accounting for 99% of estimated malaria cases in 2016. Outside of Africa, P. vivax is the predominant parasite in the WHO Region of the Americas, representing 64% of malaria cases, and is above 30% in the WHO South- East Asia and 40% in the Eastern Mediterranean regions.
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New data from improved surveillance systems in several countries in the WHO African Region indicate that the number of malaria cases presented in this year’s report are conservative estimates. WHO will review its malaria burden estimation methods for sub-Saharan Africa in 2018.

Malaria deaths

In 2016, there were an estimated 445 000 deaths from malaria globally, compared to 446 000 estimated deaths in 2015.

The WHO African Region accounted for 91% of all malaria deaths in 2016, followed by the WHO South- East Asia Region (6%).

Fifteen countries accounted for 80% of global malaria deaths in 2016; all of these countries are in sub-Saharan Africa, except for India.

All regions recorded reductions in mortality in 2016 when compared with 2010, with the exception of the WHO Eastern Mediterranean Region, where mortality rates remained virtually unchanged in the period. The largest decline occurred in the WHO regions of South-East Asia (44%), Africa (37%) and the Americas (27%).
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However, between 2015 and 2016, mortality rates stalled in the WHO regions of South-East Asia, the Western Pacific and Africa, and increased in the Eastern Mediterranean and the Americas.

Globally, more countries are moving towards elimination: in 2016, 44 countries reported fewer than 10 000 malaria cases, up from 37 countries in 2010.

Kyrgyzstan and Sri Lanka were certified by WHO as malaria free in 2016.

In 2016, WHO identified 21 countries with the potential to eliminate malaria by the year 2020. WHO is working with the governments in these countries – known as “E-2020 countries” – to support their elimination acceleration goals.
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Although some of E-2020 countries remain on track to achieve their elimination goals, 11 have reported increases in indigenous malaria cases since 2015, and 5 countries reported an increase of more than 100 cases in 2016 compared with 2015

Some of the challenges impeding countries’ abilities to stay on track and advance towards elimination include lack of sustainable and predictable international and domestic funding, risks posed by conflict in malaria endemic zones, anomalous climate patterns, the emergence of parasite resistance to antimalarial medicines and mosquito resistance to insecticides.

WHO is supporting malaria emergency responses in Nigeria, South Sudan, Venezuela (Bolivarian Republic of) and Yemen, where ongoing humanitarian crises pose serious health risks. In Nigeria’s Borno State, WHO supported the launch of a mass antimalarial drug administration campaign that reached an estimated 1.2 million children aged under 5 years in targeted areas. Early results point to a reduction in malaria cases and deaths in this state.

Funding
In 34 out of 41 high-burden countries, which rely mainly on external funding for malaria programmes, the average level of funding available per person at risk in the past 3 years (2014–2016) reduced when compared with 2011–2013. Exceptions were Democratic Republic of the Congo, Guinea, Mauritania, Mozambique, Niger, Pakistan and Senegal, which recorded increases.
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Among the 41 high-burden countries, overall, funding per person at risk of malaria remains below US$ 2.

Histidine-rich protein 2 deletions
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In some settings, increasing levels of histidine-rich protein 2 gene (HRP2) deletions threaten the ability to diagnose and appropriately treat people infected with falciparum malaria. An absence of the HRP2 gene enables parasites to evade detection by HRP2-based RDTs, resulting in a false-negative test result. Although the prevalence of HRP2 gene deletions in most high-transmission countries remains low, further monitoring is required.

Drug resistance

ACTs have been integral to the recent success of global malaria control, and protecting their efficacy for the treatment of malaria is a global health priority.

Although multidrug resistance, including artemisinin (partial) resistance and partner drug resistance, has been reported in five countries of the Greater Mekong subregion (GMS), there has been a massive reduction in malaria cases and deaths in this subregion. Monitoring the efficacy of antimalarial drugs has led to timely treatment policy updates across the GMS.
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In Africa, artemisinin (partial) resistance has not been reported to date and first-line ACTs remain efficacious in all malaria endemic settings.

Insecticide resistance

Of the 76 malaria endemic countries that provided data for 2010 to 2016, resistance to at least one insecticide in one malaria vector from one collection site was detected in 61 countries. In 50 countries, resistance to 2 or more insecticide classes was reported.

In 2016, resistance to one or more insecticides was present in all WHO regions, although the extent of monitoring varied.

Resistance to pyrethroids – the only insecticide class currently used in ITNs – is widespread. The proportion of malaria endemic countries that monitored and subsequently reported pyrethroid resistance increased from 71% in 2010 to 81% in 2016. The prevalence of confirmed resistance to pyrethroids differed between regions, and was highest in the WHO African and Eastern Mediterranean regions, where it was detected in malaria vectors in over two thirds of all sites monitored.

ITNs continue to be an effective tool for malaria prevention, even in areas where mosquitoes have developed resistance to pyrethroids. This was evidenced in a large multicountry evaluation coordinated by WHO between 2011 and 2016, which did not find an association between malaria disease burden and pyrethroid resistance across study locations in 5 countries.
 

​Source:  WHO

Dr Ryan Donnelly, from the School of Pharmacy at Queen's University Belfast, demonstrates his microneedle technology that could revolutionize the way drugs are delivered -- from small molecules to vaccines and biological compounds.

​The microneedle patches, which can range from the size of a phone sim card to the size of a mobile phone, are applied to the skin like a normal medical plaster. What makes Donnelly's system special compared to similar emerging 'needleless injection' platforms is that his array of just over 300 microneedles -- each just over half a millimeter high -- are made of biocompatible hydrogels that are not toxic to the human body, but can also take up biological fluids and so lead to new ways to monitor metabolites, such as blood sugar in diabetes, in the sick and healthy.

A new pain-free microneedle has the potential to help athletes, soldiers and others ward off dehydration and severe exhaustion before it is too late.
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A team of researchers from Sandia National Laboratory and the University of New Mexico (UNM) have developed microneedles that are painless and minimally invasive, and can be left in a subject’s arm for hours or even an entire day without causing irritation, allowing constant monitoring of important biomarkers.

The researchers have developed a small, wearable monitor that could help endurance athletes meet their training goals, by tracking dehydration or severe exhaustion, and also help soldiers track their physiological conditions on strenuous missions, alerting them before they become too exhausted.
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The sensors could also be used in emergency rooms and critical care facilities to determine which salts are out of balance in cases of severe dehydration or track the response of a septic patients to a course of antibiotics.

“There are a lot of great uses for these microneedle sensors,” said Dr. Justin Baca, Ph.D., an assistant professor of emergency medicine at UNM who leads the human testing of the sensor, said in a statement. “It has the ability to help a lot in the medical sphere and in national security but it could also be something that’s useful to somebody who’s just trying to improve their performance as a cyclist.”
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The new development could enable the continual sampling of important biomarkers in the interstitial fluid including electrolytes, salts like potassium and sodium, glucose and lactose that could help monitor and diagnose several diseases and disorders.

Microneedles can capture the clear fluid between cells in the middle layer of skin—below the top most layer of dead skin cells and above the layer of skin where veins and nerves reside.

During the experiment, a volunteer had five microneedles, clasped in a 3D printed holder, inserted into her forearm for 30 minutes with very little pain.

The researchers tested three different lengths of needles in the subject and determined that the best microneedles are 1.5-millimeters long.

“Now we have a pretty good sense of what the average length we should use for most people but some people’s skin is a little thicker or a little thinner in that area and the flow rate may be decreased,” Baca said.
 
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Source:  BBSRC and RDMag

00:13
Please meet Jane. She has a high-risk pregnancy. Within 24 weeks, she's on bed rest at the hospital, being monitored for her preterm contractions.

00:25
She doesn't look the happiest. That's in part because it requires technicians and experts to apply these clunky belts on her to monitor her uterine contractions. Another reason Jane is not so happy is because she's worried. In particular, she's worried about what happens after her 10-day stay on bed rest at the hospital. What happens when she's home? If she were to give birth this early it would be devastating. As an African-American woman, she's twice as likely to have a premature birth or to have a stillbirth. So Jane basically has one of two options: stay at the hospital on bed rest, a prisoner to the technology until she gives birth, and then spend the rest of her life paying for the bill; or head home after her 10-day stay and hope for the best. Neither of these two options seems appealing.

01:24
As I began to think about stories like this and hear about stories like this, I began to ask myself and imagine: Is there an alternative? Is there a way we could have the benefits of high-fidelity monitoring that we get with our trusted partners in the hospital while someone is at home living their daily life?

01:42
With that in mind, I encouraged people in my research group to partner with some clever material scientists, and all of us came together and brainstormed. And after a long process, we came up with a vision, an idea, of a wearable system that perhaps you could wear like a piece of jewelry or you could apply to yourself like a Band-Aid. And after many trials and tribulations and years of endeavors, we were able to come up with this flexible electronic patch that was manufactured using the same processes that they use to build computer chips, except the electronics are transferred from a semiconductor wafer onto a flexible material that can interface with the human body.

02:25
These systems are about the thickness of a human hair. They can measure the types of information that we want, things such as: bodily movement, bodily temperature, electrical rhythms of the body and so forth. We can also engineer these systems, so they can integrate energy sources, and can have wireless transmission capabilities.

02:50
So as we began to build these types of systems, we began to test them on ourselves in our research group. But in addition, we began to reach out to some of our clinical partners in San Diego, and test these on different patients in different clinical conditions, including moms-to-be like Jane.

03:10
Here is a picture of a pregnant woman in labor at our university hospital being monitored for her uterine contractions with the conventional belt. In addition, our flexible electronic patches are there. This picture demonstrates waveforms pertaining to the fetal heart rate, where the red corresponds to what was acquired with the conventional belts, and the blue corresponds to our estimates using our flexible electronic systems and our algorithms.

03:40
At this moment, we gave ourselves a big mental high five. Some of the things we had imagined were beginning to come to fruition, and we were actually seeing this in a clinical context.

03:52
But there was still a problem. The problem was, the way we manufactured these systems was very inefficient, had low yield and was very error-prone. In addition, as we talked to some of the nurses in the hospital, they encouraged us to make sure that our electronics worked with typical medical adhesives that are used in a hospital. We had an epiphany and said, "Wait a minute. Rather than just making them work with adhesives, let's integrate them into adhesives, and that could solve our manufacturing problem."

04:26
This picture that you see here is our ability to embed these censors inside of a piece of Scotch tape by simply peeling it off of a wafer.  Ongoing work in our research group allows us to, in addition, embed integrated circuits into the flexible adhesives to do things like amplifying signals and digitizing them, processing them and encoding for wireless transmission. All of this integrated into the same medical adhesives that are used in the hospital.

04:57
So when we reached this point, we had some other challenges, from both an engineering as well as a usability perspective, to make sure that we could make it used practically.

05:09
In many digital health discussions, people believe in and embrace the idea that we can simply digitize the data, wirelessly transmit it, send it to the cloud, and in the cloud, we can extract meaningful information for interpretation. And indeed, you can do all of that, if you're not worried about some of the energy challenges. Think about Jane for a moment. She doesn't live in Palo Alto, nor does she live in Beverly Hills. What that means is, we have to be mindful about her data plan and how much it would cost for her to be sending out a continuous stream of data.

05:44
There's another challenge that not everyone in the medical profession is comfortable talking about. And that is, that Jane does not have the most trust in the medical establishment. She, people like her, her ancestors, have not had the best experiences at the hands of doctors and the hospital or insurance companies. That means that we have to be mindful of questions of privacy. Jane might not feel that happy about all that data being processed into the cloud. And Jane cannot be fooled; she reads the news. She knows that if the federal government can be hacked, if the Fortune 500 can be hacked, so can her doctor.

06:27
And so with that in mind, we had an epiphany. We cannot outsmart all the hackers in the world, but perhaps we can present them a smaller target. What if we could actually, rather than have those algorithms that do data interpretation run in the cloud, what if we have those algorithms run on those small integrated circuits embedded into those adhesives?

​06:50
And so when we integrate these things together, what this means is that now we can think about the future where someone like Jane can still go about living her normal daily life, she can be monitored, it can be done in a way where she doesn't have to get another job to pay her data plan, and we can also address some of her concerns about privacy.

07:12
So at this point, we're feeling very good about ourselves. We've accomplished this, we've begun to address some of these questions about privacy and we feel like, pretty much the chapter is closed now. Everyone lived happily ever after, right? Well, not so fast.

07:31
One of the things we have to remember, as I mentioned earlier, is that Jane does not have the most trust in the medical establishment. We have to remember that there are increasing and widening health disparities, and there's inequity in terms of proper care management. And so what that means is that this simple picture of Jane and her data -- even with her being comfortable being wirelessly transmitted to the cloud, letting a doctor intervene if necessary -- is not the whole story.

07:59
So what we're beginning to do is to think about ways to have trusted parties serve as intermediaries between people like Jane and her health care providers. For example, we've begun to partner with churches and to think about nurses that are church members, that come from that trusted community, as patient advocates and health coaches to people like Jane.

08:21
Another thing we have going for us is that insurance companies, increasingly, are attracted to some of these ideas. They're increasingly realizing that perhaps it's better to pay one dollar now for a wearable device and a health coach, rather than paying 10 dollars later, when that baby is born prematurely and ends up in the neonatal intensive care unit -- one of the most expensive parts of a hospital.

08:47
This has been a long learning process for us. This iterative process of breaking through and attacking one problem and not feeling totally comfortable, and identifying the next problem, has helped us go along this path of actually trying to not only innovate with this technology but make sure it can be used for people who perhaps need it the most.

09:07
Another learning lesson we've taken from this process that is very humbling, is that as technology progresses and advances at an accelerating rate, we have to remember that human beings are using this technology, and we have to be mindful that these human beings -- they have a face, they have a name and a life. And in the case of Jane, hopefully, two.

​Source:  TED

​Illness is universal — but access to care is not. Physician Raj Panjabi has a bold vision to bring health care to everyone, everywhere. With the 2017 TED Prize, Panjabi is building the Community Health Academy, a global platform that aims to modernize how community health workers learn vital skills, creating jobs along the way.

Why you should listen

Raj Panjabi was nine years old when civil war broke out in his native country of Liberia. His family fled, eventually resettling in High Point, North Carolina. As a medical student in 2005, he returned to Liberia. He was shocked to find a health care system in total devastation. Only 50 doctors remained to treat a population of four million.

With a small team of Liberian civil war survivors, American health workers and $6,000 he'd received as a wedding gift, Panjabi co-founded Last Mile Health in 2007. Initially focused on care for HIV patients, Last Mile Health has grown into a robust organization that partners with the government of Liberia to recruit, train, equip and employ community health workers who provide a wide range of services to their neighbors in Liberia's most remote regions. In 2016, Last Mile Health workers treated 50,000 patients, including nearly 22,000 cases of malaria, pneumonia and diarrhea in children. While the organization focuses on integrated primary care, its network can be leveraged in a crisis. In the fight against Ebola, Last Mile Health supported government response by training 1,300 health workers in southeastern Liberia.

Panjabi is a physician in the Division of Global Health Equity at Harvard Medical School, Brigham and Women's Hospital and an advisor to the Clinton Global Initiative. He was ranked as one of "The World’s 50 Greatest Leaders" by Fortune in 2015 and named to TIME's list of the "100 Most Influential People in the World" in 2016. As the winner of the 2017 TED Prize, Raj is creating the Community Health Academy, a global platform to train, connect and empower community health workers. The academy will be prototyped in Liberia and a handful of key countries, and will go global from there.
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​Where did Zika come from, and what can we do about it? Molecular biologist Nina Fedoroff takes us around the world to understand Zika's origins and how it spread, proposing a controversial way to stop the virus — and other deadly diseases — by preventing infected mosquitoes from multiplying.

Our pertinent blogs

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​21 APRIL 2017 | GENEVA, AMSTERDAM - New WHO data reveal that an estimated 325 million people worldwide are living with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. The WHO Global hepatitis report, 2017 indicates that the large majority of these people lack access to life-saving testing and treatment. As a result, millions of people are at risk of a slow progression to chronic liver disease, cancer, and death.

"Viral hepatitis is now recognized as a major public health challenge that requires an urgent response," said Dr Margaret Chan, WHO Director-General. "Vaccines and medicines to tackle hepatitis exist, and WHO is committed to helping ensure these tools reach all those who need them."

Increasing mortality, new infections
Viral hepatitis caused 1.34 million deaths in 2015, a number comparable to deaths caused by tuberculosis and HIV. But while mortality from tuberculosis and HIV has been declining, deaths from hepatitis are on the increase.

Approximately 1.75 million people were newly infected with HCV in 2015, bringing the global total of people living with hepatitis C to 71 million.
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Although overall deaths from hepatitis are increasing, new infections of HBV are falling, thanks to increased coverage of HBV vaccination among children. Globally, 84% of children born in 2015 received the 3 recommended doses of hepatitis B vaccine. Between the pre-vaccine era (which, according to the year of introduction can range from the 1980s to the early 2000s) and 2015, the proportion of children under 5 years of age with new infections fell from 4.7% to 1.3%. However, an estimated 257 million people, mostly adults born before the introduction of the HBV vaccine, were living with chronic hepatitis B infection in 2015.

Epidemics in regions and "hotspots"

Hepatitis B levels vary widely across WHO regions with the WHO African Region and WHO Western Pacific Region sharing the greatest burden.

• WHO Western Pacific Region: 6.2% of population (115 million people)
• WHO African Region: 6.1% of population (60 million people)
• WHO Eastern Mediterranean Region: 3.3% of population (21 million people)
• WHO South-East Asia Region: 2% of population (39 million people)
• WHO European Region: 1.6% of population (15 million people)
• WHO Region of the Americas: 0.7% of population (7 million people)

Today, unsafe injections in health care settings and injecting drug use are considered to be the most common routes of HCV transmissions. HCV prevalence by WHO region is:
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• WHO Eastern Mediterranean Region: 2.3% of population (15 million people)
• WHO European Region: 1.5% of population (14 million people)
• WHO African Region: 1% of population (11 million people)
• WHO Region of the Americas: 1% of population (7 million people)
• WHO Western Pacific Region: 1% of population (14 million people)
• WHO South-East Asia Region: 0.5% of population (10 million people)

Treatment access is low

There is currently no vaccine against HCV, and access to treatment for HBV and HCV is still low.
WHO's Global Health Sector Strategy on viral hepatitis aims to test 90% and treat 80% of people with HBV and HCV by 2030.

The report notes that just 9% of all HBV infections and 20% of all HCV infections were diagnosed in 2015. An even smaller fraction – 8% of those diagnosed with HBV infection (1.7 million people) were on treatment, and only 7% of those diagnosed with HCV infection (1.1 million people) had started curative treatment during that year.

HBV infection requires lifelong treatment, and WHO currently recommends the medicine tenofovir, already widely used in HIV treatment. Hepatitis C can be cured within a relatively short time using the highly effective direct-acting antivirals (DAAs).
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"We are still at an early stage of the viral hepatitis response, but the way forward looks promising," said Dr Gottfried Hirnschall, Director of WHO's Department of HIV and the Global Hepatitis Programme. "More countries are making hepatitis services available for people in need – a diagnostic test costs less than US$ 1 and the cure for hepatitis C can be below US$ 200. But the data clearly highlight the urgency with which we must address the remaining gaps in testing and treatment."

Country progress

WHO's Global hepatitis report, 2017 demonstrates that despite challenges, some countries are taking successful steps to scale-up hepatitis services.

China achieved high coverage (96%) for the timely birth dose of HBV vaccines, and reached the hepatitis B control goal of less than 1% prevalence in children under the age of 5 in 2015. Mongolia improved uptake of hepatitis treatment by including HBV and HCV medicines in its National Health Insurance scheme, which covers 98% of its population. In Egypt, generic competition has reduced the price of a 3-month cure for hepatitis C, from US$ 900 in 2015, to less than US$ 200 in 2016. Today in Pakistan, the same course costs as little as US$ 100.
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Improving access to hepatitis C cure received a boost at the end of March 2017, when WHO prequalified the generic active pharmaceutical ingredient of sofosbuvir. This step will enable more countries to produce affordable hepatitis medicines

Baseline for elimination

WHO's Global hepatitis report, 2017 aims to provide a starting point for hepatitis elimination by indicating baseline statistics on HBV and HCV infections, including mortality, and coverage levels of key interventions. Hepatitis B and C – the 2 main types out of 5 different hepatitis infections – are responsible for 96% of overall hepatitis mortality.

Notes for editors
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World Immunization Week (24–30 April): WHO recommends the use of vaccines against 26 diseases, which include 3 vaccine-preventable types of viral hepatitis (A,B and E) out of 5 types of viral hepatitis (A,B,C,D,E).

World Hepatitis Day 2017 and World Hepatitis Summit 2017: WHO and partners will organize 2 high-profile global initiatives to advocate for an urgent response to viral hepatitis. World Hepatitis Day 2017 will be commemorated on 28 July under the theme “Eliminate hepatitis”. The World Hepatitis Summit 2017, the principal convention of the global hepatitis community, is being co-organized by WHO, the Government of Brazil and the World Hepatitis Alliance. It will be held on 1–3 November 2017 in São Paulo, Brazil.
 
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Source:  World Health Organization

CDC Report’s Abstract (U.S. Department of Health and Human Services - Centers for Disease Control and Prevention)

Background: In collaboration with state, tribal, local, and territorial health departments, CDC established the U.S. Zika Pregnancy Registry (USZPR) in early 2016 to monitor pregnant women with laboratory evidence of possible recent Zika virus infection and their infants.

Methods: This report includes an analysis of completed pregnancies (which include live births and pregnancy losses, regardless of gestational age) in the 50 U.S. states and the District of Columbia (DC) with laboratory evidence of possible recent Zika virus infection reported to the USZPR from January 15 to December 27, 2016. Birth defects potentially associated with Zika virus infection during pregnancy include brain abnormalities and/or microcephaly, eye abnormalities, other consequences of central nervous system dysfunction, and neural tube defects and other early brain malformations.

Results: During the analysis period, 1,297 pregnant women in 44 states were reported to the USZPR. Zika virus–associated birth defects were reported for 51 (5%) of the 972 fetuses/infants from completed pregnancies with laboratory evidence of possible recent Zika virus infection (95% confidence interval [CI] = 4%–7%); the proportion was higher when restricted to pregnancies with laboratory-confirmed Zika virus infection (24/250 completed pregnancies [10%, 95% CI = 7%–14%]). Birth defects were reported in 15% (95% CI = 8%–26%) of fetuses/infants of completed pregnancies with confirmed Zika virus infection in the first trimester. Among 895 liveborn infants from pregnancies with possible recent Zika virus infection, postnatal neuroimaging was reported for 221 (25%), and Zika virus testing of at least one infant specimen was reported for 585 (65%).

​Conclusions and Implications for Public Health Practice: These findings highlight why pregnant women should avoid Zika virus exposure. Because the full clinical spectrum of congenital Zika virus infection is not yet known, all infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy should receive postnatal neuroimaging and Zika virus testing in addition to a comprehensive newborn physical exam and hearing screen. Identification and follow-up care of infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy and infants with possible congenital Zika virus infection can ensure that appropriate clinical services are available.

Pregnant women infected with Zika risk giving birth to babies with an abnormally small head and brain. Credit: Flickr, bra_j
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Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). There is no vaccine for Zika virus disease yet, which causes symptoms like mild fever, skin rash, conjunctivitis, muscle and joint pain, malaise, or headache. The symptoms subside after 3-7 days but the biggest threat Zika possess is to pregnant women. It’s well established now that pregnant women infected with Zika risk giving birth to babies with microcephaly, a condition that causes babies to be born with abnormally small heads and brains, and Guillain-Barré syndrome.

“Zika virus can be scary and potentially devastating to families. Zika continues to be a threat to pregnant women across the U.S.,” said CDC Acting Director Anne Schuchat, M.D. “With warm weather and a new mosquito season approaching, prevention is crucial to protect the health of mothers and babies. Healthcare providers can play a key role in prevention efforts.”

The CDC report confirms previous studies which found women infected in the first trimester of their pregnancy are the most vulnerable. Some 15% of American women known to be infected with Zika during their first trimester had babies with birth defects. Overall, 10% of infected pregnant American women gave birth to babies with brain damage or other birth defects, so getting infected later in pregnancy can also be risky.

In total, the report covered 1,297 pregnancies which were tracked from Jan. 15 through Dec. 27, 2017. Of these pregnancies, 972 were confirmed to be Zika infected by lab evidence, which resulted in 895 live births and 77 losses (abortions, miscarriages, stillbirths).  Every 50 state and Washington, D.C, had at least once case of Zika-infected pregnancy.

Overall, 51 babies were born with birth defects. For the 250 cases or so where the presence of the Zika virus was confirmed, 24 pregnancies or 10 percent resulted in birth defects, most of which involved microcephaly. In eight cases, the damage included other brain malformations and dysfunctions in the central nervous system.

The report comes with a couple of caveats. Only 25 percent of the babies included in the study had their brains scanned, despite the CDC’s recommendation that all babies born to women with potential Zika infections should have their brains scanned. This limitation means we’re likely underestimating the birth defects that follow Zika in pregnancy. For instance, some babies that look fine at birth, i.e. with a normally sized head, might later be diagnosed with some congenital Zika syndrome.
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“CDC recommends that pregnant women avoid travel to areas with risk of Zika and unprotected sex with a partner who has traveled to an area with Zika to prevent Zika-related birth defects in their babies,” said Peggy Honein, Ph.D., the Zika Response’s Pregnancy and Birth Defects Task Force co-lead. “CDC continues to work closely with health departments on the U.S. Zika Pregnancy Registry to follow up infants with possible congenital Zika virus infection and better understand the full range of disabilities that can result from this infection.”

​Key findings from the CDC's report

• Forty-four states reported pregnant women with evidence of Zika in 2016.
  • Most of these women acquired Zika virus infection during travel to an area with Zika.
• Nearly 1,300 pregnant women with evidence of possible Zika infection were reported to the U.S. Zika Pregnancy Registry.
  • Of the 1,000 pregnancies that were completed by the end of the year, more than 50 had Zika-related birth defects.
• Among pregnant women with confirmed Zika infection, about 1 in 10 had a fetus or baby with birth defects.
  • Confirmed infections in the first trimester posed the highest risk – with about 15% having Zika-related birth defects.
• About 1 in 3 babies with possible congenital Zika infection had no report of Zika testing at birth.
• Only 1 in 4 babies with possible congenital Zika infection were reported to have received brain imaging after birth.

 
Source:  ZME Science and CDC

​Viral hepatitis infection is widely spread, affecting 400 million people worldwide – over 10 times the number of people infected with HIV. Globally, about 1.4 million people die each year from hepatitis. It is estimated that only 5% of people with chronic hepatitis know of their infection, and less than 1% have access to treatment.

Yet, hepatitis is fully preventable and treatable: there are effective vaccines and treatments for hepatitis B, and over 90% of people with hepatitis C can be cured with treatment. The vision of eliminating hepatitis as a public health threat by 2030 can be achieved, if people and countries affected by this disease were better equipped and enabled to "know hepatitis" and "act now".

Know hepatitis - Are you at risk?

• Anyone could be at risk of hepatitis due to the size of the global epidemic (at least 10 times the HIV epidemic).
• Hepatitis B and C infections are transmitted through contaminated blood as well as through contaminated needles and syringes in healthcare setting and among people who inject drugs. The viruses can also be transmitted through unsafe sex and from an infected mother to her newborn child.
• With better information and knowledge about hepatitis risks, people can prevent themselves from getting infected and passing the infection on to others. To do this, people should seek testing and learn if they need treatment.

Know hepatitis - Get tested

• Increasing access to hepatitis testing is key to scaling up hepatitis treatment and care.
• An estimated 95% of people with hepatitis are unaware of their infection, in part due to a lack of awareness and lack of access to testing services in countries.

WHO will release its first hepatitis testing guidelines in 2016. The guidelines will provide guidance on who should be tested, and will recommend simple testing strategies to help country efforts to scale up hepatitis testing, treatment and care.

Know hepatitis - Demand treatment

• Globally, most people who need treatment have not been treated, largely due to a lack of awareness, and access to hepatitis treatment services.
• Over 90% of people with hepatitis C can be completely cured of the virus within 3–6 months.
• Appropriate treatment of hepatitis B and C can prevent the development of the major life-threatening complications of chronic liver disease: cirrhosis and liver cancer.

Hepatitis A is a liver disease caused by the hepatitis A virus. The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with unsafe water or food, inadequate sanitation and poor personal hygiene.

Unlike hepatitis B and C, hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is often fatal.

Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences. The hepatitis A virus is one of the most frequent causes of foodborne infection. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people1. Hepatitis A viruses persist in the environment and can withstand food-production processes routinely used to inactivate and/or control bacterial pathogens.

The disease can lead to significant economic and social consequences in communities. It can take weeks or months for people recovering from the illness to return to work, school, or daily life. The impact on food establishments identified with the virus, and local productivity in general, can be substantial.

Geographical distribution

Geographical distribution areas can be characterized as having high, intermediate or low levels of hepatitis A virus infection.

Areas with high levels of infection

In developing countries with poor sanitary conditions and hygienic practices, most children (90%) have been infected with the hepatitis A virus before the age of 10 years 2. Those infected in childhood do not experience any noticeable symptoms. Epidemics are uncommon because older children and adults are generally immune. Symptomatic disease rates in these areas are low and outbreaks are rare.

Areas with intermediate levels of infection

In developing countries, countries with transitional economies, and regions where sanitary conditions are variable, children often escape infection in early childhood and reach adulthood without immunity. Ironically, these improved economic and sanitary conditions may lead to accumulation of adults who have never been infected and who have no immunity. This higher susceptibility in older age groups may lead to higher disease rates and large outbreaks can occur in these communities.

Areas with low levels of infection

In developed countries with good sanitary and hygienic conditions, infection rates are low. Disease may occur among adolescents and adults in high-risk groups, such as injecting-drug users, men who have sex with men, people travelling to areas of high endemicity, and in isolated populations, such as closed religious communities. However, when the virus gets introduced in such communities, high levels of hygiene stops person-to-person transmission and outbreaks die out rapidly.

Transmission

The hepatitis A virus is transmitted primarily by the faecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water.

The virus can also be transmitted through close physical contact with an infectious person, although casual contact among people does not spread the virus.

Symptoms

The incubation period of hepatitis A is usually 14–28 days.

Symptoms of hepatitis A range from mild to severe, and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the skin and whites of the eyes). Not everyone who is infected will have all of the symptoms.

Adults have signs and symptoms of illness more often than children. The severity of disease and fatal outcomes are higher in older age groups. Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. Among older children and adults, infection usually causes more severe symptoms, with jaundice occurring in more than 70% of cases. Hepatitis A sometimes relapses. The person who just recovered falls sick again with another acute episode. This is, however, followed by recovery.

Who is at risk?

Anyone who has not been vaccinated or previously infected can get infected with hepatitis A virus. In areas where the virus is widespread (high endemicity), most hepatitis A infections occur during early childhood. Risk factors in intermediate and high endemicity areas include:

• poor sanitation;
• lack of safe water;
• use of recreational drugs;
• living in a household with an infected person;
• being a sexual partner of someone with acute hepatitis A infection; and
• travelling to areas of high endemicity without being immunized.

Diagnosis

Cases of hepatitis A are not clinically distinguishable from other types of acute viral hepatitis. Specific diagnosis is made by the detection of HAV-specific Immunoglobulin G (IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA, and may require specialised laboratory facilities.

Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and may take several weeks or months. Most important is the avoidance of unnecessary medications. Acetaminophen / Paracetamol and medication against vomiting should not be given.
Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhea.

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.
The spread of hepatitis A can be reduced by:

• adequate supplies of safe drinking water;
• proper disposal of sewage within communities; and
• personal hygiene practices such as regular hand-washing with safe water.

Several injectable inactivated hepatitis A vaccines are available internationally. All are similar in terms of how well they protect people from the virus and their side-effects. No vaccine is licensed for children younger than 1 year of age. In China, a live oral vaccine is also available.

Nearly 100% of people develop protective levels of antibodies to the virus within 1 month after injection of a single dose of vaccine. Even after exposure to the virus, a single dose of the vaccine within 2 weeks of contact with the virus has protective effects. Still, manufacturers recommend 2 vaccine doses to ensure a longer-term protection of about 5 to 8 years after vaccination.

Millions of people have received injectable inactivated hepatitis A vaccine worldwide with no serious adverse events. The vaccine can be given as part of regular childhood immunizations programmes and also with other vaccines for travellers.

Immunization efforts

Vaccination against hepatitis A should be part of a comprehensive plan for the prevention and control of viral hepatitis. Planning for large-scale immunization programmes should involve careful economic evaluations and consider alternative or additional prevention methods, such as improved sanitation, and health education for improved hygiene practices.

Whether or not to include the vaccine in routine childhood immunizations depends on the local context. The proportion of susceptible people in the population and the level of exposure to the virus should be considered. Generally speaking, countries with intermediate endemicity will benefit the most from universal immunization of children. Countries with low endemicity may consider vaccinating high-risk adults. In countries with high endemicity, the use of vaccine is limited as most adults are naturally immune.
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• Countries with immunization schedules that include hepatitis A

As of June 2016, 16 countries used hepatitis A vaccine in routine immunization of children nationally (including 6 countries in the American region, 3 in the Eastern Mediterranean region , 4 in the European region and 3 in the Western Pacific region.

While the 2 dose regimen of inactivated hepatitis A vaccine is used in many countries, other countries may consider inclusion of a single-dose inactivated hepatitis A vaccine in their immunization schedules. Some countries also recommend the vaccine for people at increased risk of hepatitis A, including:

• users of recreational drugs;
• travellers to countries where the virus is endemic;
• men who have sex with men; and
• people with chronic liver disease (because of their increased risk of serious complications if they acquire hepatitis A infection).

Regarding immunization for outbreak response, recommendations for hepatitis A vaccination should also be site-specific. The feasibility of rapidly implementing a widespread immunization campaign needs to be included.
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Vaccination to control community-wide outbreaks is most successful in small communities, when the campaign is started early and when high coverage of multiple age groups is achieved. Vaccination efforts should be supplemented by health education to improve sanitation, hygiene practices and food safety.

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus. It is a major global health problem. It can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.

A vaccine against hepatitis B has been available since 1982. The vaccine is 95% effective in preventing infection and the development of chronic disease and liver cancer due to hepatitis B.

Geographical distribution

Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia, where between 5–10% of the adult population is chronically infected. High rates of chronic infections are also found in the Amazon and the southern parts of eastern and central Europe. In the Middle East and the Indian subcontinent, an estimated 2–5% of the general population is chronically infected. Less than 1% of the population of Western Europe and North America is chronically infected.

Transmission

The hepatitis B virus can survive outside the body for at least 7 days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine. The incubation period of the hepatitis B virus is 75 days on average, but can vary from 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B.

In highly endemic areas, hepatitis B is most commonly spread from mother to child at birth (perinatal transmission), or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first 5 years of life. The development of chronic infection is very common in infants infected from their mothers or before the age of 5 years.

Hepatitis B is also spread by percutaneous or mucosal exposure to infected blood and various body fluids, as well as through saliva, menstrual, vaginal, and seminal fluids. Sexual transmission of hepatitis B may occur, particularly in unvaccinated men who have sex with men and heterosexual persons with multiple sex partners or contact with sex workers. Infection in adulthood leads to chronic hepatitis in less than 5% of cases. Transmission of the virus may also occur through the reuse of needles and syringes either in health-care settings or among persons who inject drugs. In addition, infection can occur during medical, surgical and dental procedures, through tattooing, or through the use of razors and similar objects that are contaminated with infected blood.

Symptoms

Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. A small subset of persons with acute hepatitis can develop acute liver failure which can lead to death.

In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.

Who is at risk for chronic disease?

The likelihood that infection becomes chronic depends upon the age at which a person becomes infected. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections.

In infants and children:

• 80–90% of infants infected during the first year of life develop chronic infections; and
• 30–50% of children infected before the age of 6 years develop chronic infections.

In adults:

• less than 5% of otherwise healthy persons who are infected as adults will develop chronic infection; and
• 20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer.

Diagnosis

It is not possible, on clinical grounds, to differentiate hepatitis B from hepatitis caused by other viral agents and, hence, laboratory confirmation of the diagnosis is essential. A number of blood tests are available to diagnose and monitor people with hepatitis B. They can be used to distinguish acute and chronic infections.

Laboratory diagnosis of hepatitis B infection focuses on the detection of the hepatitis B surface antigen HBsAg. WHO recommends that all blood donations be tested for hepatitis B to ensure blood safety and avoid accidental transmission to people who receive blood products.

• Acute HBV infection is characterized by the presence of HBsAg and immunoglobulin M (IgM) antibody to the core antigen, HBcAg. During the initial phase of infection, patients are also seropositive for hepatitis B e antigen (HBeAg). HBeAg is usually a marker of high levels of replication of the virus. The presence of HBeAg indicates that the blood and body fluids of the infected individual are highly contagious.
• Chronic infection is characterized by the persistence of HBsAg for at least 6 months (with or without concurrent HBeAg). Persistence of HBsAg is the principal marker of risk for developing chronic liver disease and liver cancer (hepatocellular carcinoma) later in life.

Treatment

There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea.
Chronic hepatitis B infection can be treated with drugs, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival.

WHO recommends the use of oral treatments - tenofovir or entecavir, because these are the most potent drugs to suppress hepatitis B virus. They rarely lead to drug resistance as compared with other drugs, are simple to take (1 pill a day), and have few side effects so require only limited monitoring.

In most people, however, the treatment does not cure hepatitis B infection, but only suppresses the replication of the virus. Therefore, most people who start hepatitis B treatment must continue it for life.
Treatment using interferon injections may be considered in some people in certain high-income settings, as this may shorten treatment duration, but its use is less feasible in low-resource settings due to high cost and significant adverse effects requiring careful monitoring.

There is still limited access to diagnosis and treatment of hepatitis B in many resource-constrained settings, and many people are diagnosed only when they already have advanced liver disease. Liver cancer progresses rapidly, and since treatment options are limited, the outcome is in general poor. In low-income settings, most people with liver cancer die within months of diagnosis. In high-income countries, surgery and chemotherapy can prolong life for up to a few years. Liver transplantation is sometimes used in people with cirrhosis in high income countries, with varying success.

Prevention

The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by 2 or 3 doses to complete the primary series. In most cases, 1 of the following 2 options is considered appropriate:

• a 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent) being given at birth and the second and third (monovalent or combined vaccine) given at the same time as the first and third doses of diphtheria, pertussis (whooping cough), and tetanus – (DTP) vaccine; or
• a 4-dose schedule, where a monovalent birth dose is followed by three monovalent or combined vaccine doses, usually given with other routine infant vaccines.

The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. Protection lasts at least 20 years and is probably lifelong. Thus, WHO does not recommend booster vaccination for persons who have completed the 3 dose vaccination schedule.

All children and adolescents younger than 18 years-old and not previously vaccinated should receive the vaccine if they live in countries where there is low or intermediate endemicity. In those settings it is possible that more people in high-risk groups may acquire the infection and they should also be vaccinated. They include:

• people who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations;
• people interned in prisons;
• persons who inject drugs;
• household and sexual contacts of people with chronic HBV infection;
• people with multiple sexual partners;
• health-care workers and others who may be exposed to blood and blood products through their work; and
• travellers who have not completed their hepatitis B vaccination series, who should be offered the vaccine before leaving for endemic areas.

The vaccine has an excellent record of safety and effectiveness. Since 1982, over 1 billion doses of hepatitis B vaccine have been used worldwide. In many countries where between 8–15% of children used to become chronically infected with the hepatitis B virus, vaccination has reduced the rate of chronic infection to less than 1% among immunized children.

As of 2014, 184 Member States vaccinate infants against hepatitis B as part of their vaccination schedules and 82% of children in these states received the hepatitis B vaccine. This is a major increase compared with 31 countries in 1992, the year that the World Health Assembly passed a resolution to recommend global vaccination against hepatitis B. Furthermore, as of 2014, 96 Member States have introduced the hepatitis B birth dose vaccine.
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In addition, implementing of blood safety strategies, including quality-assured screening of all donated blood and blood components used for transfusion, can prevent transmission of HBV. Safe injection practices, eliminating unnecessary and unsafe injections, can be effective strategies to protect against HBV transmission. Furthermore, safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), also protect against transmission.

Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infection is usually asymptomatic, and is only very rarely associated with life-threatening disease. About 15–45% of infected persons spontaneously clear the virus within 6 months of infection without any treatment.
The remaining 55–85% of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis of the liver is between 15–30% within 20 years.

Geographical distribution

Hepatitis C is found worldwide. The most affected regions are Africa and Central and East Asia. Depending on the country, hepatitis C infection can be concentrated in certain populations (for example, among people who inject drugs) and/or in general populations. There are multiple strains (or genotypes) of the HCV virus and their distribution varies by region.

Transmission

The hepatitis C virus is a bloodborne virus. It is most commonly transmitted through:

• injecting drug use through the sharing of injection equipment;
• the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings; and
• the transfusion of unscreened blood and blood products.

HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however these modes of transmission are much less common.

Hepatitis C is not spread through breast milk, food, water or by casual contact such as hugging, kissing and sharing food or drinks with an infected person.

Symptoms

The incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).

Screening and diagnosis

Due to the fact that acute HCV infection is usually asymptomatic, few people are diagnosed during the acute phase. In those people who go on to develop chronic HCV infection, the infection is also often undiagnosed because the infection remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage.

HCV infection is diagnosed in 2 steps:

1. Screening for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
2. If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV ribonucleic acid (RNA) is needed to confirm chronic infection because about 15–45% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies.

After a person has been diagnosed with chronic hepatitis C infection, they should have an assessment of the degree of liver damage (fibrosis and cirrhosis). This can be done by liver biopsy or through a variety of non-invasive tests.

In addition, these people should have a laboratory test to identify the genotype of the hepatitis C strain. There are 6 genotypes of the HCV and they respond differently to treatment. Furthermore, it is possible for a person to be infected with more than 1 genotype. The degree of liver damage and virus genotype are used to guide treatment decisions and management of the disease.

Getting tested

Early diagnosis can prevent health problems that may result from infection and prevent transmission of the virus. WHO recommends screening for people who may be at increased risk of infection.

Populations at increased risk of HCV infection include:

• people who inject drugs;
• people who use intranasal drugs;
• recipients of infected blood products or invasive procedures in health-care facilities with inadequate infection control practices ;
• children born to mothers infected with HCV ;
• people with sexual partners who are HCV-infected;
• people with HIV infection;
• prisoners or previously incarcerated persons; and
• people who have had tattoos or piercings.

Treatment

Hepatitis C does not always require treatment as the immune response in some people will clear the infection, and some people with chronic infection do not develop liver damage. When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given.

The standard of care for hepatitis C is changing rapidly. Until recently, hepatitis C treatment was based on therapy with interferon and ribavirin, which required weekly injections for 48 weeks, cured approximately half of treated patients, but caused frequent and sometimes life-threatening adverse reactions.

Recently, new antiviral drugs have been developed. These medicines, called direct antiviral agents (DAA) are much more effective, safer and better-tolerated than the older therapies. Therapy with DAAs can cure most persons with HCV infection and treatment is shorter (usually 12 weeks) and safer. Although the production cost of DAAs is low, these medicines remain very expensive in many high- and middle-income countries. Prices have dropped dramatically in some countries (primarily low-income) due to the introduction of generic versions of these medicines.

Much needs to be done to ensure that these advances lead to greater access to treatment globally.

Prevention

Primary prevention
There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings and in higher risk populations, for example, people who inject drugs, and through sexual contact.
The following list provides a limited example of primary prevention interventions recommended by WHO:

• hand hygiene: including surgical hand preparation, hand washing and use of gloves;
• safe handling and disposal of sharps and waste;
• provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment;
• testing of donated blood for hepatitis B and C (as well as HIV and syphilis);
• training of health personnel; and
• promotion of correct and consistent use of condoms.

Secondary and tertiary prevention
For people infected with the hepatitis C virus, WHO recommends:

• education and counselling on options for care and treatment;
• immunization with the hepatitis A and B vaccines to prevent coinfection from these hepatitis viruses and to protect their liver;
• early and appropriate medical management including antiviral therapy if appropriate; and
• regular monitoring for early diagnosis of chronic liver disease.

Screening, care and treatment of persons with hepatitis C infection
In April 2016, WHO updated its "Guidelines for the screening, care and treatment of persons with chronic hepatitis C". These guidelines complement existing WHO guidance on the prevention of transmission of bloodborne viruses, including HCV.
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They are intended for policy-makers, government officials, and others working in low- and middle-income countries who are developing programmes for the screening, care and treatment of people with HCV infection. These guidelines will help expand of treatment services to patients with HCV infection, as they provide key recommendations in these areas and discuss considerations for implementation.

​WHO response

In May 2016, The World Health Assembly adopted the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2021”. The strategy highlights the critical role of Universal Health Coverage and the targets of the strategy are aligned with those of the Sustainable Development Goals. The strategy has a vision of eliminating viral hepatitis as a public health problem and this is encapsulated in the global targets of reducing new viral hepatitis infections by 90% and reducing deaths due to viral hepatitis by 65% by 2030. Actions to be taken by countries and WHO Secretariat to reach these targets are outlined in the strategy.
WHO is working in the following areas to support countries in moving towards achieving the global hepatitis goals under the Sustainable Development Agenda 2030:

• raising awareness, promoting partnerships and mobilizing resources;
• formulating evidence-based policy and data for action;
• preventing transmission; and
• scaling up screening, care and treatment services.

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WHO also organizes World Hepatitis Day on 28 July every year to increase awareness and understanding of viral hepatitis


Source:  World Health Organization

​Overview


Key facts

• Vector-borne diseases account for more than 17% of all infectious diseases, causing more than 1 million deaths annually.
• More than 2.5 billion people in over 100 countries are at risk of contracting dengue alone.
• Malaria causes more than 600 000 deaths every year globally, most of them children under 5 years of age.
• Other diseases such as Chagas disease, leishmaniasis and schistosomiasis affect hundreds of millions of people worldwide.
• Many of these diseases are preventable through informed protective measures.

Main vectors and diseases they transmit

Vectors are living organisms that can transmit infectious diseases between humans or from animals to humans. Many of these vectors are bloodsucking insects, which ingest disease-producing microorganisms during a blood meal from an infected host (human or animal) and later inject it into a new host during their subsequent blood meal.
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Mosquitoes are the best known disease vector. Others include ticks, flies, sandflies, fleas, triatomine bugs and some freshwater aquatic snails.

Mosquitoes are one of the deadliest animals in the world. Their ability to carry and spread disease to humans causes thousands of deaths every year. In 2015 malaria alone caused 438 000 deaths. The worldwide incidence of dengue has risen 30-fold in the past 30 years, and more countries are reporting their first outbreaks of the disease. Zika, dengue, chikungunya, and yellow fever are all transmitted to humans by the Aedes aegypti mosquito. More than half of the world’s population lives in areas where this mosquito species is present. Sustained mosquito control efforts are important to prevent outbreaks from these diseases. There are several different types of mosquitoes and some have the ability to carry many different diseases. Click below to see which diseases are transmitted by the Aedes, Culex, and Anopheles mosquitoes.

​Areas at risk:

The female Aedes aegypti and Aedes albopictus are found in the Americas, Europe, Africa, Asia and the Indian subcontinent. Chikungunya is in over 60 countries in Asia, Africa, Europe and the Americas. Mosquito breeding sites that are close to homes are a significant risk factor for chikungunya. In recent decades, these mosquitoes have spread to Europe and the Americas. In 2007, a localized outbreak in north-eastern Italy, and outbreaks in France and Croatia, were recorded subsequently.

Transmission:

The virus is transmitted by the bite of an infected female mosquito. Aedes bites during daylight hours, but peaks in activity at dawn and dusk. Both species are found biting outdoors, but Aedes aegypti will also feed indoors.

Symptoms:

Symptoms include fever and severe joint and muscle pain, headache, nausea, fatigue and rash. Joint pain is often debilitating and can vary in duration. The onset of chikungunya, after a mosquito bite, usually occurs between 4 and 8 days, but can also range from 2 to 12 days. Often symptoms are mild and the infection may go unrecognized, or misdiagnosed in areas where dengue also occurs. Most patients recover fully, but in some cases joint pain may persist. Rare cases of eye, neurological and heart complications have been reported, as well as gastrointestinal complaints. Serious complications are not common, but in older people, the disease can lead to arthritic pains of longer duration and may cause death.

Protect your health:

There is no specific antiviral drug treatment for chikungunya. Treatment is directed primarily at relieving the symptoms, including the joint pain using anti-pyretics, optimal analgesics and fluids. There is no commercial chikungunya vaccine. Personal protection with repellents, clothing that covers exposed skin and use of nets when resting during the day; window screens and destruction of mosquitoe breeding sites in and around houses and place of work is advised.

​Areas at risk:

The female Culex is 1 of 3 most common mosquitoes to be found worldwide, except for the extreme northern parts of the temperature zone. West Nile virus is found in Africa, Europe, the Middle East, North America and West Asia. The Culex also transmits Japanese encephalitis.

Transmission:

These mosquitoes feed on infected birds and transmit the disease to humans and horses. They bite from dusk until dawn.

Symptoms:

West Nile virus can cause a fatal neurological disease. Approximately 80% of those infected will not show any symptoms, but after 3-14 days, 20% of people infected may develop symptoms of severe disease including headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, and paralysis. People over 50-years- old, and those who are immunocompromised, are at highest risk.

Protect your health:

No vaccination exists for humans. Recommended personal protection and mosquito control includes repellents, clothing that cover exposed skin, window screens, destruction of breeding sites, especially polluted water bodies. Treatment for patients with neuro-invasive West Nile virus includes hospitalization, intravenous fluids, respiratory support, and prevention of secondary infections.

​Areas at risk:

In 2015, more than 3.2 billion people were at risk, and ongoing malaria transmission was found in 95 countries and territories. Sub-Saharan Africa carries a disproportionately higher share of the global malaria burden with 88% of cases and 90% of global malaria deaths. The female Anopheles transmits malaria parasites; P.falciparum is the most prevalent parasite in Africa and is responsible for most malaria deaths globally. The female Anopheles mosquitoe is an efficient vector that likes tropical, rural, and urban conditions. Anopheles that carry P. vivax are found mostly outside Africa.

Transmission:

Anopheles mosquitoes are the primary vector of malaria. These mosquitoes bite mainly at night, from dusk to dawn. Children and pregnant women are at a higher risk of disease in countries with higher rates of malaria transmission.

Symptoms:

In a non-immune individual, symptoms appear 7 days or more (usually 10-15 days) after the bite of an infected mosquito. The first symptoms are fever, headache, chills and vomiting. These symptoms may be mild and difficult to recognize as malaria. P. Falciparum malaria can progress rapidly to severe forms of the disease, especially in people with no or low immunity. Severe falciparum malaria is almost always fatal without treatment. Access to early diagnosis and prompt, effective treatment within 24-48 hrs of the onset of malaria symptoms is critical. Infants, children under 5 years of age, pregnant women and patients with HIV/AIDS, as well as non-immune migrants, mobile populations and travellers are especially vulnerable.

Protect your health:

Antimalarial medicines can also be used to prevent malaria. For travellers, malaria can be prevented through chemoprophylaxis. People living in malaria endemic areas develop partial immunity, reducing the risk of severe disease. National control programmes support the widespread use of long-lasting insecticidal nets and indoor residual spraying in targeted areas to control mosquitoes. Intermittent preventive treatment for pregnant women and infants are also recommended. Personal and household protection includes repellents, clothing that covers exposed skin, window screens, etc.

​Areas at risk:

The female Aedes also transmits yellow fever found in Africa, Latin America, in urban, jungle, forest, semi-humid conditions, and around houses. Yellow fever is mainly transmitted through the bite of the Aedes aegypti mosquito, but other "tiger mosquitoes" -Aedes albopictus also transmit yellow fever. In May 2016 a WHO Emergency Committee called for intensified national action and international support for yellow fever outbreaks in Angola and Democratic Republic of the Congo.

Haemagogus species occurs in Central and South America, Trinidad, Brazil, and Argentina, and carry the sylvan or "jungle" yellow fever, which is carried by monkeys.

Transmission:

Mosquitoes infect monkeys and then go on to transmit the disease from monkeys to humans, and from human to human. It bites mostly during the day.

Symptoms:

After 3-6 days symptoms include fever, muscle pains, backache, headache, shivers, loss of appetite, nausea or vomiting. Roughly 15% of patients enter a second, more toxic phase within 24 hours. Symptoms of this phase may include high fever, jaundice, and abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach and blood appears in the vomit and faeces, and kidney function may deteriorate. Half of the patients who enter the toxic phase die within 10-14 days, the rest recover without significant organ damage.

Yellow fever can be difficult to diagnose and is confused with severe malaria, dengue, leptospirosis, viral hepatitis or other haemorrhagic fevers, such as West Nile virus and Zika, as well as poisoning.

Protect your health:

Vaccination is available for humans. A single dose of yellow fever vaccine can provide sustained immunity and life-long protection against yellow fever disease. One fifth of a regular dose may be used in emergencies and is found to provide up to 12 months of protection. Vector control including destruction of breeding sites and personal protection with repellents, clothing that covers exposed skin and the use of nets and window screens, is recommended.

Areas at risk:

Female Aedes aegypti, and albopictus are found in Latin America, the United States of the America, Europe, Africa and Asia. Dengue is widespread throughout the tropics, in rural and urban areas. Recently, cases were reported in Florida, the USA and Yunnan province of China and Japan. Dengue is also common in South American countries, Costa Rica, Honduras and Mexico. In Asia, Singaporeand Lao People's Democratic Republic have reported a recent increase in cases, as well as China, the Cook Islands, Fiji, Malaysia and Vanuatu.

Transmission:

Dengue is endemic in more than 128 countries, with 3.9 billion people at risk.The Aedes aegypti mosquito is the primary vector of dengue. The virus is transmitted to humans through the bite of an infected female mosquito. Aedes aegypti bites mostly during the day.

Symptoms:

Flu-like symptoms occur 4-10 days after the bite of an infected mosquito; high fever accompanied by severe headache, pain behind the eyes, muscle and joint pains, nausea, vomitting, swollen glands or rash may occur. The disease can develop into severe dengue which is a leading cause of serious illness and death among children in some Asian and South American countries. Symptoms of severe dengue include decrease in temperature, severe abdominal pain, persistent vomiting, rapid breathing, bleeding gums, fatigue, restlessness and blood in vomit. Medical care is critical for the next 24-48 hours after symptoms are recognized to avoid complications and risk of death.

Protect your health:

There is no specific treatment for dengue and severe dengue. Early detection and access to proper medical care lowers fatality rates to below 1%. A dengue vaccine has been licensed in a few countries by some National Regulatory Authorities for people 9-45 years of age, living in endemic settings.

Areas at risk:

Outbreaks of Zika virus disease have been recorded in Africa, the Americas, Asia and the Pacific. Female Aedes aegypti, and Aedes albopictus are found in over 130 countries. There has been a steep rise in local Zika transmission in the Americas; since 2015, 62 countries and territories reported mosquito transmitted Zika virus. WHO announced a Public Health Emergency of International Concern on 1 February 2016.

Transmission:

Mosquitoes infect humans and people can infect each other through sexual transmission. Zika has been detected in blood, saliva, semen, spinal and other body fluids. Mother to child transmission in early pregnancy has also been reported. Aedes bites mostly during the day.

Symptoms:

Sympoms are usually mild and can include mild fever, skin rash, inflammation of the eyes (conjunctivitis), muscle and joint pain, malaise or headache. Symptoms normally last for 2 - 7 days. Zika infection during pregnancy causes microcephaly, babies born with small heads, and other fetal brain malformations. Zika is also a cause of Guillain-Barré Syndrome - a neurological condition that can lead to paralysis and death.

Protect your health:

The best form of prevention is protection against mosquito bites. Personal protection with repellents, clothing that covers exposed skin and use of nets when resting during the day; window screens and destruction of breeding sites are recommended. There is no specific treatment or vaccine currently available.

To reduce the risk of sexual transmission and potential pregnancy complications related to Zika virus infection people living in/travelling to/or returning from affected areas should practice safer sex, including wearing condoms.

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Source:  World Health Organization