Ten Great Public Health Achievements — Worldwide, 2001–2010

Morbidity and Mortality Weekly Report (MMWR)

Worldwide, a child born in 1955 had an average life expectancy at birth of only 48 years (1). By 2000, the average life expectancy at birth had increased to 66 years and, if past trends continue, is projected to rise to 73 years by 2025 (1). These improvements in longevity have resulted from improved living conditions overall, advances in medical science, and a number of population-level interventions. However, major disparities persist. During the past decade, in low-income countries, average life expectancy at birth increased from 55 to 57 years (3.6%), while increasing from 78 to 80 years (2.6%) in high-income countries (2). Analogous to the recent MMWR report highlighting 10 public health achievements that occurred in the United States over the first 10 years of the new century, this report describes global public health achievements during the same period (3). Experts in global public health were asked to nominate noteworthy public health achievements that occurred outside of the United States during 2001–2010. From them, 10 have been summarized in this report. As with the previous report, the 10 global public health achievements are not ranked in any order. Additional information regarding these achievements is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5_addinfo.htm.

Reductions in Child Mortality

Child mortality, a key measurement of United Nations Millennium Development Goal 4, is defined as deaths in children aged <5 years and serves as a major indicator of a nation's health and development, tracking health services and outcomes as well as important social and economic indicators. Currently, an estimated 8.1 million children die each year before reaching their fifth birthday, a decrease of approximately 2 million during the past decade. From 77 deaths per 1,000 live births in 2000, the child mortality rate declined to 62 per 1,000 in 2009. The annual rate of decline in the child mortality rate has increased substantially, from 1.3% per year in the 1990s to 2.2% since 2000. Approximately 99% of all childhood deaths occur in low-income and middle-income countries, with 49% occurring in sub-Saharan Africa and 33% in southern Asia.

Approximately 68% of deaths among children aged <5 years are attributable to infectious diseases, most notably diarrhea, pneumonia, malaria, and acquired immunodeficiency syndrome (AIDS). Undernutrition contributes to at least one third of all childhood deaths, usually in interaction with infectious causes. The vast majority of gains in child survival have been accomplished through scale-up of interventions such as immunization, micronutrient supplementation, access to safe water, insecticide-treated bednets, oral rehydration therapy, antibiotics, antimalarial therapy, and antiretroviral therapies. Increased financial resources, strong partnerships, intensified country support, and innovations in service delivery approaches have made these gains possible. Because of the success in reducing the number of deaths caused by infection, 41% of childhood deaths now occur among neonates; leading causes of neonatal death are preterm birth complications, birth asphyxia, and sepsis (4).

Vaccine-Preventable Diseases

Expanded vaccination coverage is one of the most cost-effective ways to advance global welfare (5). In the first decade of the 21st century, an estimated 2.5 million deaths were prevented each year among children aged <5 years through the use of measles, polio, and diphtheria-tetanus-pertussis vaccines. Expanded coverage with measles vaccine resulted in a 78% decline in measles mortality from 2000 to 2008, averting an estimated 12.7 million deaths. Polio eradication efforts decreased the number of countries with endemic disease from 20 to four, with fewer than 1,500 cases reported in 2010. Global coverage with the third dose of diphtheria-tetanus-pertussis vaccine (a performance measure for vaccination programs) increased from 74% to 82%. Newer vaccines, including hepatitis B vaccine and Haemophilus influenzae type B (Hib) vaccine also are now widely used in national immunization programs globally. The number of countries using hepatitis B vaccine increased from 107 in 2000, to 178 in 2009; with global vaccination coverage of 70% achieved by the end of the decade, at least 700,000 deaths from cirrhosis and liver cancer are expected to be averted in each annual birth cohort in these 178 countries. During 2000–2009, the number of countries using Hib vaccine worldwide increased from 62 to 161; the resulting global coverage of 38% prevented an estimated 130,000 pneumonia and meningitis deaths annually among children aged <5 years.

Studies of disease burden and vaccine efficacy and creation of innovative financing mechanisms accelerated development and use in developing countries of vaccines licensed during the decade. As a result, new and underutilized vaccines for global use (i.e., pneumococcal conjugate [PCV], rotavirus, and rubella vaccines), and vaccines recommended for introduction in certain regions or in countries where certain criteria are met (e.g., Japanese encephalitis, human papillomavirus, meningococcal group A conjugate, and typhoid vaccines) are expected to be available around the world much more quickly than they have been in the past. By the end of 2009, 44 countries had introduced PCV (11% of the global birth cohort), 23 had introduced rotavirus vaccine (11% of the global birth cohort), and 130 had introduced rubella vaccine (42% of the global birth cohort). Substantial work remains for these vaccines to be more widely introduced in developing countries.

Access to Safe Water and Sanitation

Water-related diseases, principally the 2.5 billion cases of diarrhea that occur annually, are the second leading cause of childhood mortality worldwide (6). Diarrhea, almost 90% of which is related to inadequate water, sanitation, and hygiene (WASH), kills 1.5 million children aged <5 years annually, more children than AIDS, malaria, and measles combined (6). From 2000 to 2008, the world’s population increased from 6.1 billion to 6.7 billion, while the proportion of the world’s population with access to improved drinking water sources increased from 83% to 87% (covering an additional 800 million persons), and the proportion with access to improved sanitation increased from 58% to 61% (covering an additional 570 million persons) (7). These gains were made through WASH initiatives to increase water and sanitation coverage and promote hygienic behaviors (e.g., handwashing), as well as through maintaining existing services.

During the previous century, in Europe, North America, and Japan, drinking water treatment virtually eliminated waterborne diseases such as cholera and typhoid (8,9). More recently, although improved WASH access has resulted in significant progress in controlling water-related disease in certain countries (e.g., Mexico and Chile), neglect of WASH infrastructure has contributed to large, deadly, waterborne outbreaks in others (e.g., cholera in Zimbabwe) (10). Continued improvements in global WASH coverage require intensifying current efforts, including long-term, multisectoral commitment to constructing and maintaining water and sanitation systems, behavior change promotion, and WASH-related disease surveillance.

Malaria Prevention and Control

Malaria is the fifth leading cause of death from infectious disease worldwide and the second leading cause in Africa, after human immunodeficiency virus/(HIV)/AIDS (11). The Roll Back Malaria partnership launched in 1998 is a coordinated response to malaria (additional information available at http://www.rollbackmalaria.org). During 2003–2010, financial assistance to malaria-endemic countries increased from approximately $100 million annually to nearly $1.8 billion annually, enabling increased coverage with insecticide-treated bednets, indoor residual spraying, rapid diagnosis and prompt treatment with artemisinin combination therapy, and intermittent preventive treatment during pregnancy (12). As a result, in sub-Saharan Africa, household ownership of insecticide-treated bednets increased from 3% in 2000 to 42% in 2009, protecting approximately 75% of the at-risk population. Protection with indoor residual spraying increased from 13 million households in 2005 to 75 million in 2009. Over the course of the past decade, the estimated number of malaria cases worldwide peaked at 244 million in 2005 but declined to 225 million in 2009. This decline was associated with a 21% decrease in estimated global malaria deaths, from approximately 985,000 in 2000 to 781,000 in 2009.

Prevention and Control of HIV/AIDS

The HIV epidemic continues to be a major global health challenge, with an estimated 33.3 million persons living with HIV at the end of 2009, compared with 28.6 million in 2001 (13). In 2009, 68% of persons living with HIV (22.5 million) were in sub-Saharan Africa (13). Despite this increase, the number of new infections annually has declined from an estimated 3.1 million in 2001 to 2.6 million in 2009. A decline also has been observed in the estimated number of AIDS-related deaths worldwide, from a peak of 2.1 million in 2004 to an estimated 1.8 million deaths in 2009 (13). Public health interventions possibly contributing to decreasing global HIV incidence have included the expansion of programs for provider-initiated HIV testing and counseling, prevention of mother-to-child HIV transmission, which covered an estimated 53% of pregnancies in HIV-positive mothers in 2009 (14), expanded availability and use of condoms and sterile injection equipment, improved blood safety, and antiretroviral therapy (ART). The scale-up of these interventions, including the provision of ART to 5.25 million persons in low-income and middle-income countries in 2009, has been concurrent with the decline in mortality (15). By averting new infections and offering improved health and longer lives to those already infected, these programs have enabled millions to contribute productively to families, communities, and economies.

Tuberculosis Control

During the past decade, 81 million new tuberculosis (TB) cases and 10 million deaths from TB occurred, largely in sub-Saharan Africa and Asia (16). In 1995, the World Health Organization (WHO) published its directly observed therapy, short-course (DOTS) strategy for TB control, focusing on finding and successfully treating TB cases with standardized regimens and rigorous treatment and program monitoring (16,17). Since 1995, DOTS has resulted in 41 million cases cured and 6 million deaths prevented (16). Since 2000, case detection and treatment success rates each have risen nearly 20%, with incidence and prevalence declining in every region. The world is on track to reduce TB mortality to 50% of 1990 levels by 2015 (16). DOTS also is cost effective: in sub-Saharan Africa, implementation of DOTS at a cost of $12 billion (U.S.) would produce $129 billion in economic benefits to the region in 10 years (18).

Despite these successes, HIV-related and multidrug-resistant TB threaten to undermine progress, and TB incidence is declining, but slowly. HIV infection is the primary reason for failure to meet TB control targets in settings with high HIV prevalence, and TB is a major cause of death among persons living with HIV/AIDS. Interventions such as initiation of antiretroviral therapy in TB patients coinfected with HIV can decrease mortality. To address the threat of multidrug-resistant TB, DOTS-Plus strategies, which incorporate practical steps to improve infection control and special guidance on use and quality control of second-line drugs, have been implemented in countries with a high prevalence of this disease (18).

Control of Neglected Tropical Diseases

Neglected tropical diseases affect approximately 1 billion persons worldwide. Three of these diseases have been targeted for elimination or eradication: dracunculiasis (Guinea worm disease), onchocerciasis (river blindness) in the Americas, and lymphatic filariasis. Of these programs, those targeting dracunculiasis and onchocerciasis in the Americas are on the verge of success. In 1986, an estimated 3.5 million cases of dracunculiasis occurred in 20 countries. Using filters, safe water sources, larvicide, and most importantly, health education to encourage water filtration and prevention of water contamination, dracunculiasis transmission has been interrupted in all but four countries (Southern Sudan, Mali, Ethiopia, and Ghana), with most remaining cases in Southern Sudan. With only 1,797 cases reported in 2010, including 10 cases from an outbreak in Chad, the goal of eradication in 2012 is within reach.

The Onchocerciasis Elimination Program in the Americas began in 1992 to use mass drug administration to reduce blindness from onchocerciasis among the 500,000 persons at risk in six countries. By 2010, new cases of onchocercal blindness were eliminated in all 13 regional foci, and Onchocerca volvulus transmission was interrupted completely in eight of these. The goal is to eliminate transmission in all foci in the Americas by 2012.

In 2000, 1.34 billion persons in 72 countries were at risk for lymphatic filariasis and required mass drug administration, and 120 million were infected. With elimination targeted for 2020, the Global Programme to Eliminate Lymphatic Filariasis, begun in 2000, has delivered approximately 3 billion courses of antifilarial treatment at a cost of $0.05–$0.50 per person. Nine of the 72 countries have reached the WHO target for stopping mass drug administration. During 2000–2007, the program prevented infection in an estimated 6.6 million newborns, prevented disease in 9.5 million persons, and averted 32 million disability-adjusted life years.

Tobacco Control

In 2000, 4.8 million premature deaths were attributable to tobacco use (19). By the end of the decade, that number had risen to 5.4 million (20). In 2003, commitments were made through the WHO Framework Convention on Tobacco Control (WHO FCTC), WHO’s first global health treaty, which was adopted by 168 countries by 2010 (21) and four more by June 2011. In addition, WHO developed a package of strategies called MPOWER (monitor tobacco use, protect from tobacco smoke, offer help to quit, warn about the dangers, enforce marketing bans, and raise taxes on tobacco) to support WHO FCTC (20). By 2010, 163 countries had completed youth surveys, and 14 had completed adult surveys as part of the Global Tobacco Surveillance System (22). Survey findings enable countries to track tobacco use and respond with interventions such as price increases; smoke-free policies; bans on tobacco advertising, promotion, and sponsorship; and tobacco-related health information provided via mass media campaigns and graphic health warnings (20).

Smoke-free environments, a component of WHO FCTC and MPOWER, protect persons from tobacco smoke. The U.S. Surgeon General’s report conclusion that no safe level of exposure to tobacco smoke exists (23) and studies showing that smoke-free laws do not harm businesses have heightened worldwide interest in smoke-free policies. By the end of the decade, about half of the world’s population was protected in health-care and educational facilities, although only about 5% of persons were protected by laws encompassing all public places (24). The total global population covered by comprehensive smoke-free laws increased from 3.1% in 2007 to 5.4% in 2008, providing protection for an additional 154 million persons (24).

Increased Awareness and Response for Improving Global Road Safety

Since 2000, when the International Federation of the Red Cross International Disasters Report raised an alarm regarding the worldwide impact of road traffic injuries, significant progress has been made in establishing a global response strategy (25,26). In 2001, WHO launched a 5-year plan to improve global road safety; in 2004, along with the World Bank, WHO issued the World Report on Road Traffic Injury Prevention (26). From 2001 to 2009, the number of annual traffic-related fatalities in the European Union declined 36%, from 55,700 to 34,900 (27). The largest declines in the traffic-related mortality rates from 2000 to 2009 were observed in Spain and Portugal; rates decreased 59.2% in Spain, from 14.5 deaths per 100,000 population to 5.9, and 47% in Portugal, from 12.9 to 6.8 (28).

Despite such advances in road safety in developed countries, approximately 1.3 million persons die on the world’s roads each year (3,000 every day), and this number is projected to double by 2030. Much of the projected worldwide increase is expected to come from low-income and middle income countries, which already account for 90% of global road deaths despite having less than half of the world’s vehicles, and where the number of autos in use in rapidly emerging economies is expected to expand sixfold by 2018, potentially without corresponding improvements in road infrastructure or traffic safety. The Commission for Global Road Safety issued recommendations in 2006 and 2010, further raising the profile of global road traffic injuries and culminating in 2009 with adoption of a United Nations General Assembly resolution proclaiming the period 2011–2020 as the Decade of Action for Road Safety (29,30). The resolution established a 2020 goal of stabilizing and then reducing the forecasted growth of road traffic fatalities around the world by increasing road safety activities, including improved road and vehicle design, speed control, seat belt and helmet use, improved public transport, reduced alcohol-impaired driving, and more effective care of the injured at the national, regional, and global levels. If this goal is achieved, over the decade it could save 5 million lives and $3 trillion and prevent 50 million serious injuries.

Improved Preparedness and Response to Global Health Threats

Pandemic diseases and emerging diseases such as AIDS, severe acute respiratory syndrome, and influenza continue to cause fear, economic instability, severe illness, and premature death. In the past decade, the public health community has improved preparedness for and detection of pandemic threats and is now responding more effectively than before. The 2005 International Health Regulations, which entered into force in 2007, have modernized the international legal framework to improve systematic preparedness and response to pandemic and other emerging public health threats. Use of the Internet and other media for public health surveillance has expanded, and the Global Public Health Information Network, CDC’s Global Disease Detection Operations Center (GDDOC), additional international influenza response networks, and other systems routinely detect and respond to clusters of unusual disease earlier than traditional surveillance. Laboratory and epidemiologic capacity also has improved. For example, since 2006, GDDOC worked with ministries of health to add availability of 185 new diagnostic tests in 59 countries, enabling these countries to conduct tests for pathogens they could not previously perform. Since 2000, a total of 21 new Field Epidemiology Training Programs have been established, three of which are now self-sustained. From 2000 to 2010, these new programs graduated approximately 500 epidemiologists. Cooperative agreements with ministries of health, regional training conducted in collaboration with WHO and other international organizations, and vital public health work to reduce transmission at the animal-human interface also have contributed to reducing the risk of influenza pandemics.

As a result of these and other efforts, the global response to the 2009 influenza A (H1N1) pandemic, which affected more than 214 countries and territories, was the most rapid and effective response to an influenza pandemic in history. The pandemic virus was rapidly identified and characterized. Epidemiologic investigations were conducted to characterize the severity and risk groups, and surveillance data were used to estimate the burden of disease and guide the response in real time. Within weeks of detecting the pandemic virus, diagnostic reagents were provided to laboratories in 146 countries, and laboratory and clinical training was provided, in collaboration with partners, to more than 6,100 health professionals in 34 countries. A vaccine was developed within 20 weeks of virus detection, and through an international donation program, made available to 86 countries. The lessons and experiences of the 2009 H1N1 response continue to inform preparedness efforts for future influenza pandemics as well as future public health emergencies.

Conclusion

During the previous century, great progress was made in raising life expectancy and reducing mortality among infants and young children through improvements in living conditions and activities to combat major infectious causes of death. Collectively, interventions such as those described in this report have contributed to the shifts in major causes of death observed in the new century, with chronic, noninfectious causes increasingly prevalent not only in affluent countries, but also in lower-income and middle-income countries. Noncommunicable diseases and health conditions are expected to account for an estimated 75% of all deaths worldwide by the year 2030 (31). The achievements described in this report demonstrate the capacity of public health agencies to harness and adapt the scientific, technical, legal, and political resources necessary to respond effectively to the problems at hand. This capacity will be tested in the years ahead as public health agencies continue to address communicable diseases while responding to the increasing prevalence of cardiovascular disease, diabetes, cancer, and other noncommunicable conditions and injuries that will require innovative responses to ensure significant public health achievements in the future.

Reported by

Global Public Health Achievements Team, CDC. Corresponding contributor: Ram Koppaka, MD, PhD, Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology, and Laboratory Svcs, CDC; rkoppaka@cdc.gov, 347-396-2847.

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인도서 말라리아로 매년 20만5000명 사망…WHO통계의 13배

| 기사입력 2010-10-21 18:01

【싱가포르=로이터/뉴시스】정의진 기자 = 인도에서 말라리아로 매년 20만5000여명의 사람들이 사망한다는 새로운 연구 결과가 21일 나왔다. 이는 세계보건기구(WHO)의 발표보다 무려 13배 이상 많은 수다.

WHO는 인도에서 거의 1만5000명의 사람들이 말라리아로 사망한다고 밝혔다. 또 세계적으로 성인들은 10만여 명이 사망한다고 발표했다.

이에 인도 말라리아 조사협회 비노드 샤르마는 “말라리아 예방 지원에 차질이 없도록 서로 다른 두 개의 말라리아 사망 통계는 빨리 수정되어야 할 것”이라며 “이 같은 통계를 정확하게 알고 발표하는 것은 매우 중요하다”고 밝혔다.

WHO에 따르면 말라리아로 한 해에 약 86만 명이 사망한다. 그러나 이날 발표된 새 연구 결과를 고려한다면 사망자 수는 세계적으로 100만 명 이상이 될 수 있다. 또 WHO가 인도 말라리아 사망자 수 통계를 적게 추산한 것이라면 말라리아 예방 계획에 상당한 변화가 생길 수 있다.

샤르마는 “WHO는 말라리아 사망자 수 통계시 인도 정부가 제공하는 결과에 기초를 두고 있다”며 “인도는 오직 매년 말라리아로 인한 사망을 약 1000건 정도 추적해낼 뿐이다”고 밝혔다.

말라리아 사망자 수 통계에 대한 새 연구는 캐나다 토론토 대학 프라바트 자 교수가 이끈 것으로 랜싯 의학 잡지(The Lancet medical journal)에 실렸다.

이 연구팀은 인도의 각 지역 6671곳에서 2001년부터 2년 간 말라리아로 사망한 12만2000명의 가족들을 인터뷰했다. 연구 결과에 따르면 매년 인도에서는 20만5000여명의 사람들이 사망했다. 이 중 5살 이하 사망자 수는 5만5000여명, 5살~14살은 3만여 명, 15세 이상은 12만여 명이다.

그러나 WHO는 이들의 연구 결과에 반박했다.

WHO 관계자 로버트 뉴맨은 “비록 우리의 조사 방법이 한계를 갖고 있지만 인도에서 말라리아로 20만 이상이 사망했다는 것은 상당히 의심이 간다”며 “이 연구에서 사용된 구두 조사 방법 때문이다”고 밝혔다.

이어 그는 “구두 조사방법은 신뢰할 만한 것이 아니다”며 “말라리아 증상은 다른 흔한 고열 증상과도 많은 부분 일치한다”고 말했다.

한편 캠리 대학 밥 스노우 교수는 “미얀마, 방글라데시, 파키스탄, 인도 등은 말라리아 존재량에 대한 자료가 상당히 부족하다”며 “이들 나라와 같이 인구밀도가 높은 외진 지역은 특히 말라리아에 쉽게 노출돼 있고 의료 시설에 접근하기도 쉽지 않다”고 밝혔다.

jeenjung@newsis.com

Deep in a lab, in carefully sealed incubators, mosquitos, which normally are malaria carriers, may this time actually be part of the solution.

Kai Matuschewski and his research team from the Max Planck Institute for Infection Biology in Berlin used mosquitoes to infect test mice with malaria. At the same time, they gave the mice antibiotics for three days and the mice showed no signs of the disease.

Matuschewski says this means that he and his research team may have discovered the first so-called “needle-free” malaria vaccine. Their research was published last month in the journal Science Translational Medicine.

If successful, the vaccine would use a combination of drugs and the mosquito itself to prevent the onset of malaria. It could be a boon to billions of people worldwide who are at risk for the disease, which mainly affects people living in temperate climates.

Matuschewski said the idea behind their research was to “combine a classical prophylaxis aspect – which is antibiotic treatment – (that travelers use to protect themselves against malaria), together with a natural exposure.”

“The mosquito is our sort of syringe that delivers the pathogen and we stop the parasite from growing in the liver through antibiotic prophylaxis,” he said.

‘The mice don’t get sick’

While feeding, a malaria-carrying mosquito injects something called a sporozoite, which is the cell form that infects the new host.

In this case, that would be the mouse. In the real world, it could be a human. The sporozoites migrate to the liver, where they replicate massively and mature to the disease-causing blood stage cells called merozoites.

In this new German study, the merozoites continued to develop in the liver cells, but the antibiotics prevented them from infecting the red blood cells, which meant that the mice didn’t get malaria symptoms.

With this treatment the mice not only didn’t get sick, but they also developed long-term immunity.

The mice were infected with sporozoites again after 40 days, four months, and six months, this time without adding antibiotics, and all the animals had complete protection against malaria.

Antibiotic resistance

The antibiotics the scientists used were clindamycin and azithromycin, that are both generic, cheap and readily available. This is good news for poorer countries, but Dr. Michael Knappik, from the Berlin Center for Tropical and Travel Medicine, pointed out that there are drawbacks with using antibiotics in the long term.

“We have growing resistance against the malaria drugs we use at the moment,” he said, “and that’s a big problem especially in Southeast Asia, and this of course can also arise in these new antibiotic treatments.”

Matuschewski and his team hope to reduce the likelihood of antibiotic resistance by administering the drugs once a year – at the onset of the rainy season. He added that antibiotic resistance isn’t as pronounced in Africa as it is in Western countries, so the benefits could outweigh the concerns.

Clinical trials to begin next year

If successful, this new treatment could dramatically lower the one million deaths worldwide from malaria every year.

Around 600 Germans contract the disease each year, and Sebastian Hofmann was one of the unlucky ones. Seven years ago at age 19, Hofmann went backpacking across West Africa, and, despite the usual malaria prevention measures – including medicine, insect repellent and mosquito nets – he still contracted the disease.

“I was hallucinating. I was sweaty,” he remembered, “I thought I was somehow in the state of being really drunk and having a really bad flu.”

Hofmann contracted the worst strain of malaria and fell into a coma for three days, although he eventually recovered. While this new treatment isn’t targeted at travelers in general – because you need to be infected with malaria first for it to work – it could make a big difference for people living in severely affected regions.

“In endemic areas in Kenya, in East Africa, people live there for 20 years, get infected probably sometimes 100 times a year and they always develop parasites,” Matuschewski said. “So to achieve something like anti-parasitic sterile immunity is almost impossible. So what we want is to protect against disease.”

Put another way, even if children living in malaria regions are protected daily with bed nets, according to Matuschewski all this does is delay their potential exposure to the disease and subsequent symptoms and complications.

So rather than trying to prevent all mosquito bites – which is virtually impossible – this new treatment uses the infection as a part of the solution in combination with the antibiotic.

Because the antibiotics are readily available, Matuschewski and his research team hope that clinical trials could start in sub-Saharan Africa, as early as the beginning of summer next year.

While they’re excited about their findings, scientists like Dr Johannes Friesen from the Max Planck Institute for Infection Biology in Berlin, were careful to point out that their research is just “one component to fight the disease.”

Author: Cinnamon Nippard


Editor: Cyrus Farivar

=================

참고 : 말라리아를 예방하는 항생제
http://radar.ndsl.kr/tre_View.do?cn=GTB2010070554

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말라리아는 이탈리아어로 나쁜(또는 미친)의 뜻을 가진 ‘Mal’과 공기를 뜻하는 ‘aria’가 결합한 용어로, 19세기 말엽까지도 말라리아가 나쁜 공기를 통해 전파된다고 믿어서 그런 이름이 붙었다.

======================

감염된 모기(학질모기)가 사람을 물면 모기의 침샘에 있던 말라리아 원충이 혈액 내로 들어간다. 이렇게 들어간 원충은 사람의 간으로 들어가서 성장하며 잠복기가 끝나면 사람의 적혈구로 침입하여 발열하게 된다. 원충이 적혈구에서 다시 성장하면서 암수 생식모체라는 것이 만들어지는데 이 때 말라리아 매개모기인 중국 얼룩날개모기가 사람의 피를 흡혈하면 이들이 다시 모기를 감염시킴으로서 점차 전파된다.

World Malaria Report 2009

Half of the world’s population is at risk of malaria, and an estimated 243 million cases led to nearly 863 000 deaths in 2008. The advent of long-lasting insecticidal nets and artemisinin-based combination therapy, plus a revival of support for indoor residual spraying of insecticide, presents a new opportunity for large-scale malaria control. The World malaria report 2009 describes the global distribution of cases and deaths, how WHO-recommended control strategies have been adopted and implemented in endemic countries, sources of funding for malaria control, and recent evidence that prevention and treatment can alleviate the burden of disease.

<과학> 인류는 지금도 진화 중

(서울=연합뉴스) 흔히들 인류의 진화가 최근에는 멈춘 것으로 생각하지만 인류는 두뇌를 비롯, 여러 방면에서 지금도 진화하고 있으며 심지어 진화에 가속도가 붙고 있다는 증거까지 나타나고 있다고 라이브사이언스 닷컴이 최신 연구를 인용 보도했다.

   미국 위스콘신 주립대의 존 호크스 교수는 광범위한 인간 게놈 연구를 통해 지난 1만년간 인류의 진화에 변화가 일어나고 있으며 두뇌는 특히 최근에 진화하고 있음을 알게 됐다고 밝혔다.

   호크스 교수는 그러나 놀랍게도 사람의 두뇌 크기는 지난 5천년 동안 줄어든 것으로 나타났다면서 “유럽과 중국, 남아프리카, 호주 등지에서 수집된 고고학적 자료로 미뤄 볼 때 평균 뇌 크기는 1천350cc에서 150cc가 줄어 평균 1천200cc가 됐다”고 말했다.

  그는 인류의 뇌가 이처럼 줄어든 이유는 과거 수렵-채집 사회와 달리 대규모 사회에 살면서 생활의 많은 부분을 다른 사람들에게 의존할 수 있게 됐고 행동의 분화도 광범위하게 일어나 전처럼 많은 뇌 용량이 필요 없게 됐기 때문인 것으로 보인다고 설명했다.

   호크스 교수는 인류 두뇌가 최근에도 진화하고 있다는 가장 뚜렷한 증거는 말라리아에서 볼 수 있다면서 혈류 장애를 일으켜 조직에 손상을 가져오는 겸상(鎌狀)적혈구 빈혈증이 말라리아 병원충의 감염을 막아준다고 지적했다.

   그는 “겸상세포 빈혈증은 아프리카에 흔한 것으로 알려져 있지만 인도-파키스탄 변종 역시 지난 3천~4천년 동안 함께 진화해 인구의 10~15%에 나타난다”고 지적했다.

   이밖에 유당(乳糖) 허용도 비교적 최근에 일어난 진화적 변화의 예로 제시됐다.

   세계 대부분 지역 주민들은 우유를 소화시키지 못하는 유당불내증을 갖고 있지만 약 7천500년 전 유럽에서 유당허용 진화가 일어나 이 지역 사람들이 다른 동물들의 젖으로 풍부한 영양분을 섭취하게 됐다는 것이다.

   이밖에 인체를 2형 당뇨병으로부터 보호하는 유전자와 관련된 농산물을 먹게 된 것도 인체 소화기관이 생존의 필요에 따라 적응하게 됐음을 보여주는 사례로 지적됐다.

   호크스 교수는 인류의 진화가 단순히 계속되기만 하는 것이 아니고 최근 그 속도가 빨라졌음을 보여주는 신호도 있다면서 지난 4만년간 일어난 많은 새로운 돌연변이 현상이 이처럼 빠른 변화를 말해주는 것이라고 강조했다.

   그는 “인간의 생태는 변화하고 있다. 가장 큰 변화는 농업과 그에 따른 결과, 즉 이전에는 중요하지 않았던 음식에 의존하게 된 새로운 생존 패턴과 수렵-채취 시대의 음식으로부터의 급격한 변화”라고 지적했다.

   예를 들어 농촌 주민들은 탄수화물 소화에 관여하는 침 속의 아밀라제 생성 유전자를 더 많이 갖고 있다는 것이다.

   youngnim@yna.co.kr

2009/11/16 10:17 송고

===========================

Humans Still Evolving as Our Brains Shrink 

By Charles Q. Choi, Special to LiveScience

출처 : 라이브사이언스 posted: 13 November 2009 08:38 am ET
http://www.livescience.com/history/091113-origins-evolving.html

Editor’s Note: This is Part 9 in a 10-part LiveScience series on the origin, evolution and future of the human species and the mysteries that remain to be solved.

Evolution in humans is commonly thought to have essentially stopped in recent times. But there are plenty of examples that the human race is still evolving, including our brains, and there are even signs that our evolution may be accelerating.

Shrinking brains

Comprehensive scans of the human genome reveal that hundreds of our genes show evidence of changes during the past 10,000 years of human evolution.

“We know the brain has been evolving in human populations quite recently,” said paleoanthropologist John Hawks at the University of Wisconsin at Madison.

Surprisingly, based on skull measurements, the human brain appears to have been shrinking over the last 5,000 or so years.

“When it comes to recent evolutionary changes, we currently maybe have the least specific details with regard the brain, but we do know from archaeological data that pretty much everywhere we can measure — Europe, China, South Africa, Australia — that brains have shrunk about 150 cubic centimeters, off a mean of about 1,350. That’s roughly 10 percent,” Hawks said.

“As to why is it shrinking, perhaps in big societies, as opposed to hunter-gatherer lifestyles, we can rely on other people for more things, can specialize our behavior to a greater extent, and maybe not need our brains as much,” he added.

Mutations against malaria

In contrast to our limited but growing knowledge regarding the modern evolution of the human brain, the best example we see of evolution of humans in recent history is linked with malaria, Hawks said. Since the disease often targets humans early in life, there was a strong pressure to evolve defenses from malaria — any genetic factor that confers resistance against it would give descendents a chance to have offspring, while those without such protection were more likely to not reproduce.

There are lots of examples of defenses against malaria. Sickle cell anemia is the best known —the disorder deforms red blood cells into sickle shapes, which can impair blood flow, thus damaging tissues, this malformation also prevents the malaria parasite from infesting blood cells.

“Although sickle cell is best known in Africa, there is also an India-Pakistan variant of it that seems to have evolved separately,” Hawks explained. “Both variants have evolved very recently, in the last three or four thousand years, and in that time have risen to as much as 10 to 15 percent of the populations. That’s pretty rapid change.”

Food and drink

Lactose tolerance is another recent example of a recent evolutionary change.

Most of the world remains lactose intolerant, unable to digest the complex milk sugar lactose as adults, but the evolution of lactose tolerance perhaps some 7,500 years ago in Europe enabled people there to take advantage of non-human milk, a highly nutritious food source one can sustainably procure instead of slaughtering animals.

Other evolutionary changes linked with diet appear to deal with genes conferring protection against type II diabetes.

“When you develop agricultural diets, you might need adaptations to survive on them, the way the digestive systems are regulated,” Hawks said.

Is our evolution accelerating?

There are signs that human evolution may not only be continuing, but that its rate has even accelerated in recent times. Hawks and his colleagues have found evidence of rapid change, with a host of new mutations originating in the last 40,000 years.

So what might explain this apparent acceleration?

“The ecology of humans has been changing,” Hawks said. “The biggest changes have to do with agriculture and its consequences — dealing with a new subsistence pattern that caused people to rely on foods that were never very important before, a radical shift from hunter-gatherer diets. For instance, agricultural populations tend to have more copies of a gene for salivary amylase, which helps them digest starch.”

2008년 말라리아 발생 현황 및 2009년 대책

Malaria situation in 2008 and plan for 2009

 질병관리본부 전염병대응센터 전염병관리팀       
 

출처 : 주간건강과질병, 2009-04-24 /제2권  17호, 질병관리본부 Ⅰ. 들어가는 말   말라리아는 열원충(Plasmodium) 속(屬) 원충이 적혈구와 간 세포내에 기생함으로써 발병되는 급성 열성 감염증이며, 적혈구가 파괴되면서 주기적인 열 발작, 빈혈, 비종대 등의 전형적인 증상이 나타나는 특징을 가지고 있다. 사람에게 감염을 일으키는 말라리아는 4종으로 보고되어 왔으나, 최근 Plasmodium knowlesi 종이 추가되어 총 5종으로 분류되고 있다. 이중 삼일열 원충(Plasmodium vivax)과 열대열 원충(Plasmodium falci-parum)이 전 세계 말라리아의 95% 이상을 차지하고 있다. 세계 인구의 약 40%에 달하는 24억 명 가량의 인구가 말라리아 유행지역에 살고 있으며, 매년 약 3-5억 명의 말라리아 환자가 발생하고 그중 100만 명 이상이 사망하고 있는 이유로 말라리아는 세계보건기구(World Health Organization ; 이하 WHO)가 선정한 6대 열대병 중에서 가장 중요한 질환으로 인정되고 있다[1].   말라리아의 전파 경로는 얼룩날개모기 속의 암컷 모기가 인체를 흡혈하면서 원충, 즉 포자소체(sporozoite)를 주입함으로써 전파되며, 드물게 수혈, 주사기 공동 사용 등에 의해서도 전파된다. 우리나라의 삼일열 말라리아 매개모기는 총 8종으로 그중 Anopheles sinensis, An. lesteri, An. pullus, An. kleini 등 4종에서 감염 능력이 확인되었다.   과거 우리나라의 말라리아는 학질, 하루거리 등으로 불리는 토착질환의 하나였으나, 1960년대부터 1970년대까지 WHO의 지원과 우리 정부의 적극적인 퇴치사업이 성공적으로 수행되어 1970년대 말부터 1990년대 초까지는 말라리아 환자가 발생하지 않았다. 그러나 1993년 휴전선 인근 지역에서 근무하던 현역군인 1명을 시작으로 다시 발생하게 된 말라리아는 지속적으로 증가하여 2000년에는 4,142명의 환자가 보고되었다. 질병관리본부에서는 2015년까지 우리나라에서 말라리아를 퇴치하고자 10만 명당 1명 이하의 말라리아 환자 발생이라는 목표를 다시 설정하고 말라리아 퇴치사업을 추진하고 있다.   이에 본 글에서는 우리나라 2008년 말라리아 발생 현황과 2009년의 말라리아 관리사업에 있어 주요 내용을 소개하고자 한다.     Ⅱ. 몸 말   2000년 4,142명이 보고되었던 우리나라 말라리아 환자는 2001년부터 2004년까지 감소 추세를 보이며 864명으로 저점에 다다른 후 2005-2007년 다시 증가 추세로 돌아서는 양상을 나타내었으나[2], 지난해인 2008년에는 전년 대비 53%가 감소한 1,023명이 보고되어 환자 발생이 크게 줄어든 것으로 나타났다(Figure 1). 특히, 민간인의 경우는 2008년에는 2007년에 비해 56%의 환자발생 감소를 나타내었다(Table 1).   2008년 보고된 민간인 환자를 성별로 구분하여 인구 10만 명 당 발생률을 비교해보면 남성 1.7명, 여성 0.6명으로 남성의 발생률이 여성에 비해 2.8배 높게 나타났다. 또한 연령별 발생을 성별로 나누어보면 남성에서 40대 > 30대 > 50대 > 20대 순으로 나타났으며, 여성에서는 40대 > 50대 > 30대의 순으로 나타났다(Figure 2).   2008년 말라리아 환자의 발생시기는 6-9월 사이에 집중되어 있으며, 이 시기의 발생건수가 전체 발생의 76.7%를 차지하였다. 또한 민간인 환자는 8월, 전역자는 7월, 현역군인은 9월로 환자 발생의 유행정점이 각각 다르게 나타났다(Figure 3). 2008년 발생현황을 직업(신분)별로 구분해서 살펴보면, 민간인 말라리아 환자가 가장 많이 보고된 지역은 경기, 인천, 서울 순이었다. 이를 다시 지역별 인구 10만 명 당 말라리아 환자 발생률로 비교해보면 인천이 5.3명으로 가장 높았으며 이어 경기와 강원이 각각 2.5명, 서울 0.8명 순으로 나타났다. 전역자 중 발생한 말라리아 환자가 가장 많이 보고된 지역은 경기, 서울로 나타났다. 이는 실제 감염된 지역과는 달리 전역자 대부분이 전역 후 복학 등을 이유로 대도시로 이동함으로써 실 거주지인 대도시를 포함한 수도권 지역에서 환자 보고가 많이 이루어진 현상으로 이해된다.   반면 현역군인 중 말라리아 환자가 가장 많이 보고된 지역은 경기, 강원, 인천으로 휴전선 인접 지역에서 복무하는 군인들에서 대부분 발생하는 것으로 나타났다. 이는 북한의 말라리아 발생 상황과 밀접한 영향이 있는 것으로 분석되고 있어, 특히 현역군인의 말라리아 감소를 위해서는 북한과의 지속적인 말라리아 방제 협력사업이 필요한 것으로 인식되고 있다.   국내 말라리아 환자가 2008년 큰 폭으로 감소한 원인으로 생각할 수 있는 것은 지난 수년간 국내 위험지역에 대한 집중관리를 통한 환자 발생 감소로 인해 위험지역의 감소(Figure 4) 특히, 진단소요일 단축을 위한 노력과 각 지역 현장에 적합한 매개모기 종합방제 실시, 그리고 주민과 민간 의료기관들에 대한 다양한 교육 홍보 실시, 개성공단 및 금강산 관광지역에 대한 예방관리, 기후영향 등 다양한 요소들이 복합적으로 작용했을 것으로 분석된다. 매주 주간 점검회의를 통한 결과를 위험지역 시·도 및 시·군·구에 환류함으로써 취약점을 보완하고 구체적인 자료를 토대로 집중 방제 및 환자 관리를 강화하고 GIS를 이용한 환자 발생 현황을 분석하여 cluster 발생 및 재발·재감염의 상황을 파악하여 과학적인 환자 관리를 수행할 수 있었던 것으로 분석된다. 또한, 매개모기 밀도 감시사업을 강화하여 기존 감시 지점을 확대하여 보다 구체적인 자료의 수집 등을 통해 매개체의 밀도 및 원충감염률 조사를 통한 방제사업을 실시하고 주의보 등의 발령으로 주민 개개인의 개인방어 등 홍보를 강화한 점은 환자 감소에 큰 영향을 미쳤던 것으로 분석된다(Figure 5). 이와 더불어 2001년부터 지속해 온 대북 말라리아 관리사업 지원, 특히 2007년 대북지원사업 일환으로 휴전선에 인접한 황해남·북도와 강원도 등 3개 지역 주민 500만 명을 대상으로 실시한 예방화학요법으로 인해 휴전선 인접지역에서 전염원이 감소된 것이 2008년 환자 발생 감소에 기여한 것으로 추정하고 있다. 그럼에도 불구하고 2008년에 북한지역, 특히 휴전선에 인접한 남한 지역이 직·간접적으로 영향을 받을 것으로 예상되고 있어 2008년 환자 감소에 따른 안이한 대처보다는 과학적인 기반위에 더욱 정교한 퇴치사업 수행이 요구되고 있다.    북한의 말라리아 발생은 국내 말라리아의 재출현에 영향을 미치는 것으로 분석되고 있다. 이러한 이유로 우리 정부는 2001년부터 WHO를 통해 대북 말라리아 방역사업을 지원해오고 있다. 그 결과 북한에서는 2001년 30만 명에 달하는 환자발생을 보고한 이후 매년 큰 폭으로 환자 발생 보고가 감소하고 있으며 2007년에는 2001년 대비 97.5% 이하로 감소된 7,436명의 민간인 환자 발생을 보고하였다. 이처럼 2005년 이후 북한에서는 전체적인 환자 발생 감소를 보고하고 있으나, 개성과 황해남·북도 등 휴전선 인접지역의 환자 발생은 여전히 증가하고 있음을 보고하였다. 특히 2008년에는 북한의 말라리아 환자가 2001년 이후 처음으로 전년 대비 3배 이상 크게 증가되었음을 보고하였다(Table 3).   질병관리본부에서는 이와 같은 북한의 말라리아 발생 현황을 감안하여 2015 말라리아 퇴치사업 계획을 수립하여 추진하고 있다. 2009년도의 말라리아 퇴치사업 목표는 전년대비 말라리아 환자발생 20% 감소로 정하고 지금까지 추진하여 왔던 말라리아 퇴치사업을 더욱 강화시키고 주민 의식을 높여 체계적인 환자 관리 및 예방 사업을 전개해 나갈 것이다[3]. 이와 관련하여 2009년의 중점 추진 전략으로 말라리아 예방 관리를 위한 인프라 강화, 고위험지역에 대한 집중 관리 및 효율 극대화, 철저한 환자 발견 및 치료 사업을 통한 전파 연결 고리 차단, 민·관·군과의 파트너쉽 구축을 통한 관리 성과 제고, 그리고 군 부대와의 협력을 통한 현역 및 전역자 관리 강화, 진단키트, 교육 및 홍보자료 등의 지원 강화 등의 사업을 추진하도록 하겠다.   Ⅲ. 맺는 말   2015 말라리아 퇴치계획이 성공적으로 달성되려면 국민 개개인(특히 위험지역 주민, 여행자), 의료기관, 보건기관, 군부대, 학계 및 중앙과 지방간의 조화로운 협력이 요구된다. 지금까지는 국가나 지방자치단체의 보건기관이 해야 할 일을 중심으로 기술하였으나 국민 개개인마다 말라리아 예방에 대한 인식과 실천 또한 중요하다. 가장 확실한 예방법은 모기에 물리지 않는 것이므로 모기에 물리지 않기 위한 개인방어 방법의 적극적 실천을 비롯해 방충망 정비 등 주거 환경개선, 위험지역 거주 및 여행 후에 발열을 동반한 감기증상이 발생 시에는 신속하게 말라리아 검진을 받아 타인에게 2차 전파를 방지하려는 노력이 선행되어야 한다[3].   말라리아 퇴치를 위해 보건 의식 제고를 비롯해 보다 구체적인 시행 방안으로 진단소요일 단축을 포함한 진단체계 개선, 환자 조기 발견 및 관리 사업 강화, 환자 발생지 지도(spot map) 작성 및 환류, 매개모기 감시사업의 질적 향상, 효과적인 방역소독 실시, 보건소 및 병의원 검사 교육 및 정도관리 지속 추진, 교육 및 홍보 강화, 민·관·군 협력 강화, 외부 유입 최소화 및 역학조사를 강화하여 추진할 것이다. 뿐만 아니라, 환자 발생지 지도(spot map) 작성 및 환류를 통해 조기 주의보 및 경보체계(early warning system)를 더욱 강화토록 할 것이다. Ⅳ. 참고문헌  1. WHO. Vector control for malaria and other mosquito-borne diseases. 1995  2. 질병관리본부. 2009년 말라리아 관리지침. 2009  3. WHO. Malaria vector control and personal protection. 2006