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Chapter I: the burden of communicable diseases.

A. Background

The Central Asia region countries--Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan--include more than 60 million ethnically, culturally, and religiously diverse people distributed over a geographical area twice the size of continental Europe. Located at the center of the Eurasian continent, these landlocked countries, which became independent when the Soviet Union dissolved in 1991, comprise one of the poorest regions of the world. The 2004 Gross National Income (GNI) per capita varied from a low US$270 in Tajikistan, US$400 in the Kyrgyz Republic, US$470 in Uzbekistan, to US$2,270 in Kazakhstan. Shrouded for decades from public knowledge, these countries recently became the focus of international attention due to their geopolitical importance and long-term economic potential, including from large hydrocarbon reserves and other natural resources.

Newly emerged and re-emerging communicable diseases threaten the entire global community and extract a heavy human, economic, and social toll on parts of it. (6,7) Communicable diseases (also known as "infectious diseases") are each caused by a specific infectious agent or its toxic products that arise through transmission of that agent or its products from an infected person, animal, or inanimate source to a susceptible host, either directly or indirectly through an intermediate plant or animal host, vector, or the inanimate environment. (8) Agents that enter the body through intravenous (by vein) or intramuscular (by muscle) means are referred to as "parenteral."

Accounting for more than 13 million deaths a year--one death in two in developing countries--communicable diseases are among the world's biggest killer of children and young adults. (9) About 32 percent of all deaths worldwide are caused by communicable diseases, maternal and perinatal conditions and nutritional deficiencies. (10,11) Almost 90 percent of these deaths are caused by pneumonia, tuberculosis (TB), diarrheal diseases, malaria, measles, and the human immunodeficiency virus (HIV). HIV infection can lead to acquired immune deficiency syndrome (AIDS), rendering the victim unable to fend off "opportunistic infections" (such as TB and pneumonia). Sexually transmitted infections (STIs) can facilitate transmission of HIV and TB. Communicable diseases are leading causes of ill health and disability worldwide, and ill health due to communicable diseases is strongly associated with poverty. New opportunities for the spread of communicable diseases have arisen from accelerating trade, travel, and migration; (12) climate change will exacerbate the situation. The spread of communicable diseases has been linked to global security: (13)

* Highly prevalent communicable diseases have the potential to sicken and kill a significant portion of a country's population and could be particularly ominous for economies if they affect workers in key sectors of the economy (e.g., mining, manufacturing, agriculture) and military personnel.

* Outbreaks of disease or even the perceived threat of an outbreak can have significant repercussions on trade and travel for affected nations; overall economic effects of endemic diseases such as malaria can be significant.

* Significant social and governmental disruptions can be caused by fear and anxiety over disease threats.

* Bioterrorism risks raise the importance of communicable diseases to a global imperative.

The growing global attention to the prevention and control of communicable diseases is demonstrated by the fact they dominate the public health agenda of world leaders (e.g., meetings of the Group of Eight countries, (14) and the Davos Economic Forum); international agencies (e.g., WHO, the World Bank; the Global Fund to Fight AIDS, TB and Malaria; the United States President's Emergency Plan for AIDS Relief [PEPFAR]; and philanthropies (e.g., the Gates and Google Foundations).

B. Communicable diseases in Central Asia

1. Overview

In 2002, the population of the Europe and Central Asia region lost an estimated total of 150.3 million disability-adjusted life years (DALYs);15 communicable diseases accounted for 9 percent--a little over half of which is related to HIV and TB, external causes of injury and poisoning for 14 percent, and noncommunicable diseases for 77 percent of the total. (16) However, given the short time-lag between exposure and occurrence, communicable disease epidemics can develop very fast with the potential of endangering the health of large populations across countries. Knowledge, attitudes, and practices related to prevention of communicable diseases among population groups most at risk and health care personnel in Central Asian countries are lower than in other FSU and Eastern European countries. (17)

The importance of communicable diseases remains great in Central Asia due to: (18)

* a growing TB epidemic, including multi-drug-resistant TB spreading from prisoners to the general population; (19) growing rates of HIV incidence related to increased drug use; and a high prevalence of STIs;

* endemic viral hepatitis, both B and C;

* a continuing threat from other, mainly epidemic-prone, diseases: (i) water-borne diseases, such as diarrheal diseases, hepatitis A, and typhoid fever; and (ii) vector-borne diseases such as malaria, which has re-emerged in Tajikistan and in the south of the Kyrgyz Republic and has the potential to spread throughout Central Asia; and

* emerging threats, such as Avian Influenza or SARS.

The factors that increase the risk of communicable disease outbreaks and epidemics in Central Asia include:

* high poverty levels in some countries,

* relatively poor access to basic water and sanitation services,

* underfunded and inefficient public health services,

* deteriorated health care infrastructure and medical equipment,

* weak public health laboratory networks,

* limited human resources bases in the health systems,

* poor quality health services, including the unsafe use of blood and its products and unsafe injections in medical settings, and

* local health systems that fail to use epidemiological information for decision-making and provide little feedback to those who collect data and issue reports using such data (20) (significant manipulation of communicable disease data occurs in these countries: some disease cases are never reported, and even outbreaks of special pathogens have been controlled without reporting).

2. HIV/AIDS in Central Asia

Globally, HIV is the fourth leading cause of the burden of disease. Central Asia is experiencing four overlapping epidemics--drug use, HIV, STIs, and TB. (21) This region's HIV epidemic is concentrated, affecting less than 1 percent of adults, but even so, about 90,000 people are estimated to have the virus. The driver of the HIV epidemic in Central Asia is injecting drug use. Other modes of HIV transmission include unprotected sexual relations and mother-to-child perinatal transmission. Transfusions of infected blood or its products and nosocomial infection are other important modes of HIV transmission in Central Asia. These countries also have some of the highest incidence rates of TB and multi-drug-resistant TB in the Europe and Central Asia region. TB/HIV co-infection is associated with higher morbidity and mortality and increased TB transmission among the general population.

Box 1 describes the stage of the HIV/AIDS epidemic by country.
Box 1: The HIV Epidemic in Four Central Asian Countries, 2007

Uzbekistan: This country has about 30,000 HIV cases--the largest number
in Central Asia. HIV is spreading most rapidly among the country's
100,000 IDUs; other at-risk groups include prisoners (about 100,000),
sex workers (about 20,000), and men who have sex with men (MSM) (about
15,000). The number of newly reported HIV diagnoses rose exponentially
between 1999 and 2006: from 28 to 2205. Almost one in three (30
percent) IDUs tested HIV positive in a 2003-2004 study in Tashkent,
the nation's capital.

Kazakhstan: About 15,000 people are estimated to have HIV. The
country has a fast-growing, IDU driven epidemic: 74 percent of all
HIV cases are due to IDU (130,000). Newly registered HIV cases
increased between 2004 and 2006 from 699 to 1745, attributed in part
to expanded HIV testing (in correctional settings, among most at-risk
groups, and among pregnant women). A 2005 study in Temirtau found 17
percent of IDUs to be HIV-positive. Sentinel surveillance in 23 towns
and cities in 2005 indicated that a little more than 3 percent of IDUs
nationally were infected with HIV. A nosocomial * HIV outbreak that
infected more than 130 children in the Shymkent region was reported in

Tajikistan: More than 10,000 people are estimated to be infected with
HIV. Prevalence among IDUs increased between 2005 and 2006 from 16
percent to 24 percent in the cities of Dushanbe and Khujand. Also of
concern is the sudden rise in prevalence among sex workers in those
cities (from 0.7 percent to 3.7 percent over the same period).

Kyrgyz Republic: Estimates indicate that more than 4,500 people have
HIV. The epidemic is concentrated largely among IDUs. Sentinel surveys
in Bishkek and Osh in 2006 found HIV prevalence of 0.8 percent among
IDUs, 3.5 percent among prisoners, 1.3 percent among female sex
workers, and 1 percent among MSM.

Source: Adapted from UNAIDS 2007 AIDS Epidemic Update. Geneva: UNAIDS,

* Nosocomial infections are those that result from treatment in a
health care facility and are secondary to the patient's original
condition. Infections are considered nosocomial if they first
appear at least 48 hours after admission or within 30 days of
discharge (Source: Wikipedia Free Encyclopedia).

Straddling major drug-trafficking routes, Uzbekistan's epidemic is driven by increasing prevalence among injection drug users (IDUs); this group reports low rates of condom use, raising both the risk of sexual transmission to partners and the likelihood that the epidemic will bridge to the general public. Much smaller epidemics are under way in the Kyrgyz Republic and Tajikistan, but the incidence of HIV in Central Asia has grown in recent years (Figure 1). A contributing cause is the increased heroine and opium trade since the 2001 start of military conflict in Afghanistan, which triggered a rapid growth in drug use. Drug trafficking and injecting drug use (IDU) are increasing throughout Central Asia, especially along the Northern Corridor between Afghanistan and Russia. (22,23) Most of the estimated 500,000 drug users share needles, exposing them to the risk of contracting HIV, as well as other blood borne infections.


Figure 2 shows the cumulative number of registered HIV cases since 1997. Over 2001-2006, total HIV cases registered in the four countries increased two to six-fold.


Blood donors are increasingly infected with HIV in Central Asia. In Kazakhstan, for example, their HIV prevalence rate (i.e., cumulative total) increased in 2002-2006 from 0.03 percent to 0.8 percent (Figure 3). Similarly, in Uzbekistan, the number of blood-transmitted HIV cases is estimated to have increased because most paid donors belong to high risk groups, capacity for blood screening is low, and blood and its components are not rationally used in the health care system. (24) It is estimated that during 2003-2006, HIV prevalence was 104-112 per 100,000 donors tested in Uzbekistan: more than 100 times European Union rates.


3. Refined estimates from second-generation HIV surveillance (SGHS)

Routine epidemiological surveillance of HIV is typically based on data obtained in screening general population segments (e.g., pregnant women, army conscripts). (25) SGHS (26) of HIV began in 1998 in four Central Asian countries. (27) After recognizing the limitations of data obtained through routine surveillance, WHO recommended this method. (28)

There are major limitations of data obtained from surveillance screening for HIV infection in concentrated HIV epidemics. Data quality strongly depends on: the tested groups (general population and risk groups, the latter often inadequately tested); the availability and accessibility of testing services (e.g., availability of test kits, test fees); the country's screening policies (mandatory versus voluntary); economic and fiscal conditions; and the government's political orientation and preferences.

Since the main driver of the HIV epidemic in Central Asia is IDU, knowing the prevalence of IDU and of HIV among IDUs enables a better estimate of HIV prevalence in the general population. Table 1 compares HIV data based on routine surveillance, HIV prevalence among IDUs based on SGHS, and estimated HIV prevalence for the general population in four Central Asian countries. The data suggest that HIV prevalence may be much higher than indicated by traditional surveillance methods.

4. Nosocomial transmission of HIV in Central Asia

An HIV outbreak was reported in 2006 among children in health facilities in Shymkent, a region in southern Kazakhstan. As of December 1, 2007, this region had 143 registered HIV cases among children aged one month to three years and who had been hospitalized. The Kazak Ministry of Health (MOH) and CDC/CAR implemented two hospital--and population-based case-control studies to analyze the phenomenon. Although the hospitalized children received different treatments, which may influence study findings, transfusion of blood and its components was identified as a significant risk factor for HIV transmission (OR (29)=47.3), as was the administration of intravenous infusions with unclean syringes (OR=8.8), hospital stay exceeding 25 days (OR=6.1), and subclavian vein catheterization (OR=3.7).

This situation was replicated in late 2007 in the Osh oblast of the Kyrgyz Republic, when the Ministry of Health (Prikaz 400/13.11.2007) initiated a formal investigation of a HIV outbreak in collaboration with CDC/ CAR and USAID. The screening of children exposed to infectious risk during 2006-2007 in the oblast hospitals (screened 50.5 percent of total 10,400 exposed children), and detected 86 HIV positive cases with the highest infection rate between 12 to 23 months of age (predominantly in Nookat rayon). The number of hospitalizations (range 1-13, median 4.2) and invasive procedures performed (including intravenous injections, catheterization, and blood transfusions) were associated with HIV infection among children.

C. Prevention and control of communicable diseases: key for achieving the Health Millennium Development Goals (MDGs) in Central Asia

The failure to address communicable disease spread in Central Asia has in part contributed to the region's sluggish progress in achieving the health MDGs. (30) Some countries have seen deterioration in infant, under-five, and maternal mortality indicators, while others have experienced modest yet insufficient improvements over the last decade. The same worrisome trends have been observed for the MDGs for HIV/AIDS, TB, and other diseases (see Annex 1).

It is well documented that the spread of communicable diseases puts additional pressures on any health care system, but especially those that are fragile and underfunded. The pressures arise from increased hospitalizations, specialized medical consultations, more requests for laboratory tests, and more--often costly--medications. On the patient side, indirect costs include transportation to access diagnosis, treatment, and follow-up care; work missed by both the ill person and caretakers; and, of particular importance in Central Asia, increased out-of-pocket expenses associated with health care. This situation perpetuates a vicious cycle of poverty, preventable diseases, and premature death that investments in public health activities and strengthening health care systems could improve.

It will be difficult for Central Asian countries to meet the MDGs by 2015 unless an effective strategy to prevent and control communicable diseases, including the spread of HIV through contaminated blood transfusions, is adopted soon. Blood safety contributes to the achievement of MDGs 4, 5, 6, and 8. (31) As the HIV epidemic in this region is predominantly among IDU, there is the potential for very rapid increases in incidence. The opportunity to improve blood safety has particular urgency because of this potential.
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Publication:Blood Services In Central Asian Health Systems: A Clear and Present Danger of Spreading HIV/AIDS and
Date:May 1, 2008
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Next Article:Chapter II: why are blood transfusion services important in a health system?

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