Blue Marble Health and the Global Burden of Disease Study 2013

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Abstract

The concept of blue marble health emerged as a novel framework for global health in 2013 [1, 2]. Succinctly put, today most or at least one-half of the world’s neglected diseases occur among the poor living in wealthy countries, especially in the group of 20 (G20) nations and Nigeria [1–4]. Based on data mostly compiled and released by the WHO (and other published sources), approximately one-half of the major helminth infections occur among the G20 countries and Nigeria, as well as most of the dengue, leishmaniasis, leprosy, Chagas disease, and possibly other neglected tropical diseases (NTDs) [1–3]. In addition, most (57%) of the tuberculosis (TB) cases are found in these countries, as are almost one-half of the malaria (45%) and HIV/AIDS (44%) cases [4]. The term “blue marble” is based on a famous Earth photograph taken by astronauts from an Apollo mission, which has since become an important symbol for the health of our planet [5]. We sometimes refer to the G20 nations and Nigeria as the blue marble health countries. An important policy implication of blue marble health is that because these neglected diseases are endemic to wealthy nations with high gross domestic products (GDPs), in many cases the resources to combat these diseases through treatment and prevention measures, as well as resources for research and development for new technologies, should be available [6]. By taking greater ownership of their own public health control and policy efforts, the blue marble health countries could eliminate at least one-half of the world’s neglected diseases [6]. In addition, we found that the blue marble health countries account for approximately 70% of the deaths from noncommunicable diseases [7]. Shown in Figs 1–3 is an analysis of data from the GBD 2013 that focused on the disability-adjusted life years (DALYs) due to NTDs and HIV/AIDS, TB, and malaria [8]. The GBD 2013 largely confirms the conclusions of the WHO and other data analyzed previously. Thus, the G20 nations and Nigeria together account for 51% of the global DALYs due to NTDs and helminth infections and most of the DALYs resulting from Chagas disease, dengue, and leprosy (Figs 1 and 2). 10.1371/journal.pntd.0004744.g001 Fig 1 Comparison of DALYs due to NTDs in the G20 countries and Nigeria compared to global NTD DALYs. Original figure based on data from IHME. [8] 10.1371/journal.pntd.0004744.g002 Fig 2 Percentage of the DALYs of the major NTDs found in the G20 countries and Nigeria. Original figure based on data from the Institute for Health Metrics and Evaluation (IHME) [8]. * Helminth Infections: Lymphatic Filariasis + Food-borne trematodiases + Cysticercosis + Cystic Echinococcosis + Onchocerciasis + Schistosomiasis + Ascariasis + Trichuriasis + Hookworm Disease. In addition, the blue marble health countries account for approximately 60% of the global TB DALYs and 43% and 42% of the malaria and HIV/AIDS DALYs, respectively (Fig 3). 10.1371/journal.pntd.0004744.g003 Fig 3 Comparison of DALYs due to malaria, tuberculosis (TB), and HIV/AIDS in the G20 countries and Nigeria (orange) compared to global malaria, TB, and HIV/AIDS DALYs (blue). Original figure based on data from IHME. [8] Shown in Table 1 is a comparison of the estimates based on either WHO (and other) data and GBD 2013 data. It is interesting to note that for the helminth infections, for example, despite the fact that the WHO PCT data evaluates children or children and adults at risk who require mass drug administration, whereas the GBD 2013 estimates DALYs from actual infections, the two estimates of the percentage found in G20 countries and Nigeria are almost the same. Indeed, with the exception of visceral leishmaniasis, the results show a relatively high concurrence between GBD 2013 and WHO or other estimates, in terms of the high percentage of NTDs, HIV/AIDS, TB, and malaria found in G20 countries together with Nigeria. The basis for the different results for visceral leishmaniasis is under investigation, while the fact that the dengue estimates are identical between GBD 2013 and those reported earlier based on studies conducted by Bhatt et al. may reflect their use of similar or identical sources of data [9]. 10.1371/journal.pntd.0004744.t001 Table 1 Comparison of WHO (and other sources) and GBD 2013 disease burden estimates in terms of percentage in G20 countries a and Nigeria. WHO and other sources data from references [2–4]. Source of Data Percentage of NTDs in G20 + Nigeria Percentage of HIV/AIDS in G20 + Nigeria Percentage of Tuberculosis (TB) in G20 + Nigeria Percentage of Malaria in G20 + Nigeria WHO and Other Published Sources 50% Helminth infections, 61% dengue fever, 61% Chagas disease, 67% visceral leishmaniasis, and 77%–78% leprosy 44% 57% 45% GBD 2013 52% Helminth infections, 61% dengue fever, 78% Chagas disease, 45% visceral leishmaniasis, and 73% leprosy 42% 60% 43% a The G20 nations include 19 countries—Argentina, Australia, Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Mexico, Russia, Saudi Arabia, South Africa, South Korea, Turkey, the United Kingdom, and the United States of America—in addition to the European Union. A further analysis of the NTD DALYs in the blue marble health countries is shown in Fig 4. It shows that India has the highest disease burden, led by leishmaniasis, followed by China, mostly due to food-borne trematodiases. Nigeria exhibited the third highest NTD burden, followed by Indonesia, Brazil, South Africa, Mexico, Argentina, South Korea, Turkey, and Russia. However, the disease burdens for some blue marble health countries may be underestimated in the GBD 2013. For example, the US has a substantial burden of Chagas disease and cysticercosis that is not represented in the GBD 2013, while for other neglected diseases that are widespread in the US, such as toxoplasmosis and toxocariasis, there are no specific DALYs assigned in either the GBD 2010 or GBD 2013 [8]. 10.1371/journal.pntd.0004744.g004 Fig 4 The DALYs from NTDs in the blue marble health countries. The figure was generated from the GBD Compare website: IHME. GBD Compare. Seattle, Washington: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare. Accessed 3 January 2016. [8] Finally, Fig 5 shows some recent changes in the ranking of the NTDs and malaria in the G20 countries and Nigeria since 1990. Regarding the G20 countries, ascariasis exhibited the greatest drop in rank, possibly due to mass drug administration using anthelminthic drugs, whereas the food-borne trematodiases, visceral leishmaniasis, hookworm, lymphatic filariasis, dengue, Chagas disease, and cysticercosis went up in rank. For Nigeria there appeared to be no major shifts in the rankings since 1990 [8]. 10.1371/journal.pntd.0004744.g005 Fig 5 NTDs ranked in terms of DALY count. The figure was generated from the GBD Compare website: IHME. GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare. Accessed 3 January 2016. [8] In summary, information using DALYs from the GBD 2013 confirms the findings related to blue marble health that were previously derived using WHO and other data. The concurrence provides further impetus for pursuing public policies related to a framework for blue marble health for the G20 countries and Nigeria. Among those policies is greater engagement by G20 government leaders to provide mass drug administration for the major NTDs affecting their vulnerable populations, in addition to preventive measures for HIV/AIDS, TB, and malaria [6]. There is also heightened urgency to increase commitments for neglected diseases research and development (R&D) among the G20 leaders [6].

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NTDs V.2.0: “Blue Marble Health”—Neglected Tropical Disease Control and Elimination in a Shifting Health Policy Landscape

Peter Hotez (2013)

The concept of the neglected tropical diseases (NTDs) was established in the aftermath of the Millennium Development Goals. Here, we summarize the emergence of several new post-2010 global health documents and policies, and how they may alter the way we frame the world's major NTDs since they were first highlighted. These documents include a new Global Burden of Disease 2010 Study that identifies visceral leishmaniasis and food-borne trematode infections as priority diseases beyond the seven NTDs originally targeted by preventive chemotherapy, a London Declaration for access to essential medicines, and a 2013 World Health Assembly resolution on NTDs. Additional information highlights an emerging dengue fever pandemic. New United Nations resolutions on women and the non-communicable diseases (NCDs) have not yet embraced NTDs, which may actually be the most common afflictions of girls and women and represent a stealth cause of NCDs. NTDs also have important direct and collateral effects on HIV/AIDS and malaria, and there is now a robust evidence base and rationale for incorporating NTDs into the Global Fund to Fight AIDS, Tuberculosis, and Malaria. “Blue marble health” is an added concept that recognizes a paradoxical NTD disease burden among the poor living in G20 (Group of Twenty) and other wealthy countries, requiring these nations to take greater ownership for both disease control and research and development. As we advance past the year 2015, it will be essential to incorporate global NTD elimination into newly proposed Sustainable Development Goals.

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Blue Marble Health Redux: Neglected Tropical Diseases and Human Development in the Group of 20 (G20) Nations and Nigeria

Peter Hotez (2015)

Updated information from the World Health Organization confirms that the neglected tropical diseases (NTDs) exert an important and adverse impact on human development in the Group of 20 (G20). The NTDs represent a group of at least 17 chronic parasitic and related infections that comprise the most common afflictions of the world’s poorest people. Recent information released by the Global Burden of Disease Study (GBD) confirms the high disease burden from NTDs worldwide. For example, the GBD 2010 found that the NTDs affect more than 1 billion people and were associated with 26.06 million disability-adjusted life years (DALYs) [1], while GBD 2013 linked the NTDs to 142,400 deaths [2]. In the years following the launch of the Millennium Development Goals, the NTDs were originally conceived as infections mostly affecting the poor living in sub-Saharan Africa and elsewhere in the most impoverished countries [3]. While, indeed, the NTDs are ubiquitous in low-income countries in sub-Saharan Africa, a surprising number of these diseases are actually found among the poor living in wealthy countries, including the world’s wealthiest G20 countries [4]. My previous analysis found that the largest number of cases of many of the world’s NTDs, including Chagas disease, food-borne trematodiases, leishmaniasis, and leprosy, are actually found in in the G20 (together with the nation of Nigeria), in addition to almost one-half the cases of human hookworm infection [4]. Indeed, except for a few diseases that are mostly or almost exclusively found in sub-Saharan Africa, such as onchocerciasis and schistosomiasis, most of the world’s NTDs are found in pockets of poverty in the G20, including wealthy countries such as the United States [4]. I have invoked the term “blue marble health” to refer to an observation that the world’s global health picture is rapidly shifting. The old concept of NTDs and other tropical infections occurring predominantly in the lowest-income countries of sub-Saharan Africa is giving way to rapid economic growth everywhere (including Africa), but this growth leaves behind the poorest segments of the society, living on less than US$1.25 and US$2 per day [4]. Thus NTDs are, increasingly, health disparities in poor societies that live amidst wealth. The most glaring examples of such neglected health disparities can be found in North America and Europe. Further analysis using updated data sheds additional light on the concepts of blue marble health. Shown in Table 1 are some of the major demographic features and economic indicators of the G20 and the nation of Nigeria [5–7]. At approximately US$65 trillion the G20 (including the European Union) comprise most of the world’s wealth based on gross domestic product (GDP) [5]. Moreover, except for Argentina (ranking 25th in GDP) and South Africa (ranking 34th in GDP) the G20 nations comprise the world’s largest economies [5]. With regards to Nigeria, although it is not currently considered a G20 country, it is a very large economy that ranks 23rd, ahead of South Africa and Argentina, in terms of its GDP [5]. Together these nations account for approximately two-thirds of the world’s population, but 86% of the global economy [5–7]. 10.1371/journal.pntd.0003672.t001 Table 1 Updated economic indicators for the G20 nations and Nigeria. Country GDP Rank [5] GDP 2014 (US Dollars) [5] Population Rank [7] European Union 1 18.46 trillion [6] ND United States 2 17.42 trillion 3 China 3 10.36 trillion 1 Japan 4 4.60 trillion 10 Germany 5 3.85 trillion 16 United Kingdom 6 2.94 trillion 21 France 7 2.83 trillion 22 Brazil 8 2.35 trillion 5 Italy 9 2.14 trillion 23 India 10 2.07 trillion 9 Russia 11 1.86 trillion 2 Canada 12 1.79 trillion 37 Australia 13 1.45 trillion 51 South Korea 15 1.41 trillion 27 Mexico 16 1.28 trillion 11 Indonesia 17 0.89 trillion 4 Turkey 19 0.80 trillion 18 Saudi Arabia 20 0.75 trillion 44 Nigeria 23 0.57 trillion 32 Argentina 25 0.54 trillion 7 South Africa 34 0.35 trillion 25 All G20 countries + Nigeria 66.95 trillion a Global 77.89 trillion Percentage in G20 + Nigeria 86% a number obtained by adding the GDP 2014 dollars per country, but subtracting Germany, France, United Kingdom, and Italy, in order to avoid counting the numbers in the European Union twice. ND = Not determined With respect to their human development indices (HDIs), a complex metric that encompasses the economy, living standards, education, and quality of life, all but three of the G20—India, Indonesia, and South Africa—rank in the high or very high HDI category, while Nigeria is in the low HDI category [8]. Shown in Table 2 are the major helminthic NTDs in the G20 and Nigeria, based on the World Health Organization’s (WHO’s) Preventive Chemotherapy and Transmission Control (PCT) database updated for the years 2012 and 2013 [9–15]. The information shows that one-half of the school-aged children (for soil-transmitted helminths and schistosomiasis) and total population (for lymphatic filariasis and onchocerciasis) who require mass drug administration for these helminthic diseases live in the G20 and Nigeria. 10.1371/journal.pntd.0003672.t002 Table 2 2013 WHO PCT data among the G20 nations and Nigeria. a Country Total Helminth Infections [9,11,13,15] a European Union <0.1 million United States 0 China 18.7 million Japan 0 Germany 0 France 0 United Kingdom 0 Brazil 10.5 million Italy 0 Russia 0 India 646.6 million Canada 0 Australia 0 South Korea 0 Mexico 7.4 million Indonesia 148.0 million Turkey 0 Saudi Arabia 0 Argentina 0 Nigeria 234.0 million South Africa 5.1 million All G20 countries + Nigeria 1,070.3 million Global 2134.9 million [10,12,14,15] Percentage in G20 + Nigeria 50% aThe total helminth infections was calculated by adding the number of school-aged children requiring treatment for soil-transmitted helminth infections and schistosomiasis, together with the total population requiring treatment for lymphatic filariasis and onchocerciasis. All of these numbers were based on the 2013 WHO PCT database, together with newly released information on onchocerciasis from WHO. Specifically, for the soil-transmitted helminth infections, there were almost 300 million school-aged children who required (periodic and annual) deworming in these countries in 2013, accounting for almost one-half of such children globally [9,10]. Similarly, the G20 and Nigeria accounted for more than approximately one-quarter of the world’s school-aged children requiring mass treatment with praziquantel for schistosomiasis [11,12], and over one-half of the total population who required mass treatment for lymphatic filariasis [13,14], as well as approximately 30% of the population at risk for onchocerciasis [15]. Together, the soil-transmitted helminth infections, schistosomiasis, lymphatic filariasis, and onchocerciasis account for approximately 11.77 million DALYs or more than 45% of the global disease burden of NTDs [1]. Previously, these WHO PCT data were used to calculate a “worm index” of human development, which is derived by adding the total number of school-aged children requiring mass treatment for soil-transmitted helminth infections and schistosomiasis to the number of adults who require mass treatment for lymphatic filariasis—this number is then divided by country population [16]. It was found that a nation’s worm index correlates strongly and inversely with its HDI, particularly when the worm index exceeds 0.500 [16]. The worm indices for the 25 largest countries, which also include all of the helminth-endimc G20 countries (and Nigeria) were reported previously [16]. The worm index exceeds zero in six G20 countries in addition to Nigeria. These seven nations roughly account for more than one-half of the world’s helminthic NTDs. Their worm index is highest in the nations with an HDI in the “medium” or “low” category—India, Indonesia, and Nigeria—each with a worm index that exceeds 0.500 [16]. In addition, the worm index is positive in three countries placed in the “high” HDI category—Brazil, China, and Mexico [16]. Beyond the helminthic NTDs, new information has been also recently published for dengue fever and leprosy (Table 3) [17,18]. The dengue fever data is not WHO-derived but was published by Bhatt et al. in 2013 [17]. The G20 nations and Nigeria account for most of the world’s dengue cases [17], while the WHO leprosy data confirm an earlier observation that these countries account for most of the leprosy cases. 10.1371/journal.pntd.0003672.t003 Table 3 Other high disease burden NTDs in the G20 countries. Country Dengue in 2010 [16] Leprosy (registered prevalence) in 2013 [17] European Union None reported None reported United States None reported 289 China 6,523,946 1,908 Japan None reported 2 Germany None reported None reported France None reported None reported United Kingdom None reported None reported Brazil 5,371,268 28,485 Italy None reported None reported Russia None reported None reported India 32,541,392 86,147 Canada None reported None reported Australia None reported 0 South Korea None reported 210 Mexico 1,987,320 451 Indonesia 7,590,213 19,730 Turkey None reported None reported Saudi Arabia 152,009 4 Argentina 254,470 538 Nigeria 4,153,338 3,626 South Africa None reported None reported All G20 countries + Nigeria 58,573,956 141,390 Global 96 million 180,618 Percentage in G20 + Nigeria 61% 78% Previously, I suggested that the concept of blue marble health should be linked to accountability. If the G20 and Nigeria took greater responsibility for their own autochthonous NTDs, most of the world’s NTD burden could be controlled or eliminated [3,19]. Success on this front is essential for achieving London Declaration and World Health Assembly targets for NTDs. Simultaneously, the global economy could improve significantly through the lifting of the bottom segment of the G20 economies out of poverty. The new data presented here and their links to worm indices for human development reinforce this concept and the urgency to bring NTDs to the attention of the leaders of the G20 countries. While it is too late to put such ideas on the agenda for the 2015 G20 summit in Turkey, an emphasis for the anticipated 2016 summit in China could be paradigm shifting and a major breakthrough in global public health.

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Blue marble health and "the big three diseases": HIV/AIDS, tuberculosis, and malaria.

Peter Hotez (2015)

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Journal ID (nlm-ta): PLoS Negl Trop Dis

Journal ID (iso-abbrev): PLoS Negl Trop Dis

Journal ID (publisher-id): plos

Journal ID (pmc): plosntds

Title: PLoS Neglected Tropical Diseases

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Print): 1935-2727

ISSN (Electronic): 1935-2735

Publication date (Electronic): 27 October 2016

Publication date Collection: October 2016

Volume: 10

Issue: 10

Electronic Location Identifier: e0004744

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[1 ]Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development, National School of Tropical Medicine at Baylor College of Medicine, Houston, Texas, USA

[2 ]Department of Biology, Baylor University, Waco, Texas, USA

[3 ]Center for Health and Biosciences, James A Baker III Institute for Public Policy, Rice University, Houston, Texas, USA

[4 ]Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA

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The authors have declared that no competing interests exist.

* E-mail: hotez@ 123456bcm.edu

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Peter J Hotez http://orcid.org/0000-0001-8770-1042

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Publisher ID: PNTD-D-16-00050

DOI: 10.1371/journal.pntd.0004744

PMC ID: 5082884

PubMed ID: 27788134

SO-VID: 4f468a85-5ce3-40cf-95c2-7ca093d753a1

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NTDs V.2.0: “Blue Marble Health”—Neglected Tropical Disease Control and Elimination in a Shifting Health Policy Landscape

Blue Marble Health Redux: Neglected Tropical Diseases and Human Development in the Group of 20 (G20) Nations and Nigeria

Blue marble health and "the big three diseases": HIV/AIDS, tuberculosis, and malaria.

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