Society and the disease burden


            Society and the disease burden…. 

By: Hina Farzana

 So, how many people are infected with Helminthiasis or Tuberculosis (TB)?

Tuberculosis (TB) remains the leading single microbial ailment globally and infects 23% of the world population with Mycobacterium tuberculosis (M. tuberculosis, m.tb). In 2015, 10.4 million individuals fell sick with TB (1, 11 & 15).

Helminthiasis is worm infection of any macro parasitic disease of humans and animals. Soil-transmitted helminthiasis (STH) and schistosomiasis are the most important helminth diseases of current time. Helminths infection falls in the classification of Neglected Tropical Diseases (NTD). More than 1.5 billion people or 24% of the world’s population are infected with soil-transmitted helminth infections. Worldwide schistosomiasis affects almost 240 million people of tropical and sub-tropical areas. Soil-transmitted helminths infections and schistosomiasis are endemic in the poorest and most deprived communities of the tropics where clean water and adequate sanitation are scarce (13, 14).

Do these two diseases occur in the same places?

It is evaluated that tuberculosis (TB) infects 1/3rd of the total world population, bringing about two million deaths every year. Moreover, helminths diseases are weighed to occur in 2 billion individuals worldwide in areas where TB is endemic. (1, 11, 15, 19)



Considering this geographic intersection of helminths and Mycobacterium tuberculosis (Mtb) diseases, primarily it is important to know capacity of helminths infection in terms of host protection to deal with respiratory Mtb infection at immune level. This is because responses induced by the extracellular helminths and intracellular Mtb are often mutually antagonistic leading towards impaired or cross-regulated host responses to either of the infecting pathogens (1, 11, 15, 19)



Figure 1. Interaction of protective immune responses, to Mycobacterium tuberculosis, H. pylori and A. lumbricoides. Source: Mucosal Immunology, 2011 4, 246-251 (10)

Which countries are most affected?
These worms are exceedingly endemic in parts of the world where Mycobacterium tuberculosis (M.tb) is also endemic especially Sub-Saharan Africa (SSA) (1, 2 & 4). More than 95% of TB deaths come to pass in low income and developing Countries. Six nations represented 60% of the new TB cases like India, Indonesia, China, Nigeria, Pakistan, and South Africa (1, 11 & 15, 20). Similarly disease burden estimated for schistosomiasis was more than 2 million deaths per year (14).


 Figure 2. TB High burden Country (HBC) list of 30 countries with highlighted Helminth endemic countries. Adapted from, Use of high burden country lists for TB by WHO in the post-2015 era (20).




Figure 3. Global map representing prevalence & geographic distribution of Helminth and Tuberculosis co-infection in adults. Adapted from “effect of helminth-induced immunity on infections with microbial pathogens” (3)

What are the socioeconomic impacts of infection?
As per discussed above tuberculosis is a disease of poverty and overcrowding. Infected people may have to feed big families, are unable to pay treatment costs, since treatment is lengthy and expensive. Same applies to helminth infections in terms of poverty association and hygiene issue in the form drinking water. Though the treatment of some worm infections is cheap but again disproportionately affects those with the least ability to pay for treatment. Together these situations build certain socioeconomic problems like;

  • Bearing the treatment cost. Patients and their families suffered from this economic burden because of treatment inclination for private sector or unfamiliarity of accessible public TB and Helminths treatment services.
  • Non-treatment costs endured by patients and their families: Earning loss and deaths by these infections are ordinarily substantially more prominent than the immediate expenses of treatment.
  • Physiological and social costs: Additional costs in terms of financial and mental aspects can occur because of discrimination of diseased people from their families, friends and society Furthermore, approximately 70% of infected people couldn't talk about the sickness with their neighbors. The cost of being alone is both mental and financial. Discrimination, regardless of whether experienced or expected, has been observed to be related with expanded nervousness and wretchedness, lower life fulfillment, and in addition with higher unemployment and lower salary.


Figure 4. Socioecomic impacts of  Neglected Tropical Diseases (NTD). Adapted from, Trends in parasitology Volume 28, Issue 5, p195–201, May 2012 (9)

 What can we conclude?
In general both helminthes and Tuberculosis are infections affecting poor people and endemic in low salary regions with higher hunger conditions. Disease burden is measured through disability-adjusted life years (DALYs), which refer to the times of healthy life lost due to impulsive death or years lived with a disability (6, 7).DALYS caused by Tuberculosis are 4.2 million (21), STH are 5.2 million DALYs, of which 62% are attributable to hookworm. Similarly Schistosomiasis is estimated to cause 3.3 million DALYs (16, 17). At the point when measured utilizing DALYs, NTDs are second in significance to HIV/AIDs, Malaria and Tuberculosis in DALYs lost as appeared in given picture (6, 7).

Figure 5. Disability adjusted years (DALYs) of TB and NTD. Adapted from, Social and Economic Impact Review on Neglected Tropical Diseases November 2012.

These individual morbidity and mortality rates of both infections clearly illustrate the worst picture where TB and Helminth infections are in the state of co-occurrence. Co-prevalence of these infections will mount the risk of ailment, treatment response, morbidity and mortality rates with elevated socioeconomic issues for infected population.
There is prime need of multi approach in terms of social awareness, efficient diagnosis and development of potent vaccines to address the severity of disease outcome.      

References:
        
1.Vanessa O. Ezenwa and Anna E. Jolles, 2015, Opposite effects of anthelmintic treatment on microbial infection at individual versus population scales, sciencemag.org SCIENCE, VOL 347 ISSUE 6218
2. Julius A. Potian, Wasiulla Rafi, Kamlesh Bhatt, Amanda McBride, William C. Gause, and Padmini Salgame, 2011, Preexisting helminth infection induces inhibition of innate pulmonary anti-tuberculosis defense by engaging the IL-4 receptor pathway, J. Exp. Med. Vol. 208 No. 9 1863-1874.
3. Padmini Salgame, George S Yap and William C Gause, Effect of helminth-induced immunity on infections with microbial pathogens, Nat Immunol. 2013 November ; 14(11): 1118–1126
4. Zilungile L. Mkhize-Kwitshana, Rebecca Tadokera and Musawenkosi H.L. Mabaso, Helminthiasis: A Systematic Review of the Immune Interactions Present in Individuals Coinfected with HIV and/or Tuberculosis, 2017, http://dx.doi.org/10.5772/106429. 
5. Philippe Glaziou, Charalambos Sismanidis, Katherine Floyd, and Mario Raviglione, Global Epidemiology of Tuberculosis, Cold Spring Harb Perspect Med2015;5:a017798
6. WHO: Global Burden Data 2004: DALYs by age, sex and cause for the year 2004
7. Jeremiah Norris, Carol Adelman, Yulya Spantchak, Kacie Marano, Social and Economic Impact Review on Neglected Tropical Diseases, Hudson Institute’s Center for Science in Public Policy, November 2012
8. Dennis A. Ahlburg, The economic impacts of tuberculosis, WHO/CDS/STB/2000.5
9. Elizabeth Litt, Margaret C. Baker, David Molyneux, Neglected tropical diseases and mental health: a perspective on comorbidity, Trends in parasitology Volume 28, Issue 5, p195–201, May 2012
10. S Perry, R Hussain and J Parsonnet, The impact of mucosal infections on acquisition and progression of tuberculosis, Mucosal Immunology (2011) 4, 246–251; doi:10.1038/mi.2011.11
11. Houben RMGJ, DoddPJ, 2016, The GlobalBurdenofLatentTuberculosisInfection:A Re-estimationUsingMathematicalModelling, LoSMed13(10):e1002152.doi:10.1371/journal pmed.1002152
12. https://clipartfox.com/categories/view/65a60ffe71fa2adae0ece264d55bde90a5ab2820/world-map-clipart-with-country-names.html
13. http://www.who.int/gho/neglected_diseases/soil_transmitted_helminthiases/en/
14. http://www.who.int/schistosomiasis/epidemiology/en/
15. http://www.who.int/mediacentre/factsheets/fs104/en/
16. PATH. Soil-Transmitted Helminths: The Business Case for New Diagnostics: Seattle: PATH; 2016.
17. http://www.thiswormyworld.org/worms/global-burden
18. http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31460-X.pdf
19. Subash Babu and Thomas B. Nutman, Helminth-Tuberculosis Co-infection: An Immunologic Perspectiv, Trends in immunology, Volume 37, Issue 9, p597–607, September 2016
20. Use of high burden country lists for TB by WHO in the post-2015 era, WHO’s Strategic and Technical Advisory Group for TB (STAG-TB) 2015.
21. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life  expectancy (HALE), 1990–2015:  www.thelancet.com  Vol 388 October 8, 2016

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