Dr. Vinitha C.T, MBBS, MD(Com. Med.

Lecture at Blantyre Adventist Hospital 25 Oct 2012

 Study

of Distribution and determinants of health related states or events in specified population and the application of this study to the control of health problems.

 Measure

DALY - calculations are based on best estimates of incidence, prevalence and mortality data

Rank 1 2 3 4 5

6 7 8 9 10

Disease or injury YLL HIV/AIDS 35.8 Lower respiratory infections 13.1 Malaria 9.7 Diarrhoeal diseases 9.1 Conditions arising during the perinatal period 4.1 Tuberculosis 2.2 Road traffic accidents 1.4 Protein-energy malnutrition 1.3 Maternal haemorrhage 0.9 Drownings 0.8

Rank 1 2 3 4
5 6 7 8 9 10

Disease or injury YLD HIV/AIDS 10.1 Cataracts 5.6 Malaria 5.4 Unipolar depressive disorders 4.7 Protein-energy malnutrition 3.7 Abortion 3.1 Conditions arising during the perinatal period 2.7 Lymphatic filariasis 2.5 Asthma 2.5 Iodine deficiency 2.4

Rank 1 2 3
4 5 6 7 8 9 10

Risk factor % total deaths Unsafe sex 34.4 Childhood and maternal underweight 16.5 Unsafe water, sanitation, and hygiene 6.7 Zinc deficiency 4.9 Vitamin A deficiency 4.8 Indoor smoke from solid fuels 4.8 High blood pressure 3.5 Alcohol 2.0 Tobacco 1.5 Iron deficiency 1.3

 HIV-1

and HIV-2 HIV-1 is responsible for global pandemic HIV-2 restricted to W.Africa Within HIV-1 subtype A, C, D present in africa Subtype C responsible for 90% infections in Southern Africa.

 Destroys

CD4+ T lymphocytes Cellular and Humoral responses Cannot eliminate virus but controls replication Immune system burns out Opportunistic infections and malignanciesAIDS

 Acute

infection-first stage no immune response- viral load high CD4 count low. Non specific viral illness. Transmission risk high. Immune response develops- viral load comes down but CD4 not increased to pre HIV levels. Slowly decreases and opportunistic infection develops.

 5-10%

rapid progressors 5-10% non progressors Majority progress in 8-10 years SE conditions like malnutrition and access to health care influences progress

 Malawi-

2 different rapid tests as per recommendation of WHO ELISA for quality control and research purpose For AN surveillance single ELISA test used.

The Southern region - highest prevalence rate among pregnant women[. Significantly higher in urban areas (20.4 percent) than in semi-urban (17.0 percent) and rural areas (13.0 percent). Absolute numbers rural area more. while infection rates are slowing in urban areas, HIV prevalence continues to increase in rural areas.

 womens

epidemic in Malawi, with almost 1.4 times as many women as men infected. 2007 estimates- 4,90,000 women infected

Estimated number of children who have lost their mother or father or both parents to AIDS and who were alive and under age17 in 2001 and 2007 Estimated number of orphans 2001 2007 Current living orphans 240 000 560 000 Low estimate 150 000 480 000 High estimate 340 000 650 000 Source: UNAIDS/WHO, 2008

HIV incidence data are scarce

HIV incidence is 4.2% per year in ANC women and 2.5%-4.2% per year in estate workers The NAC estimate of HIV prevalence based on ANC surveillance is 14.4% for adult Malawians, underestimate of true community prevalence

 The

NAC estimate of number of PLWHA is 9,30,000, > 60% are in the Southern Region Diarrhoea, oral thrush and malaria are the most common problems in HIV positive patients Headache, fever and respiratory complaints are most commonly reported by AIDS patients

 STI
Nutrition Needlestick

accidents & hygiene Blood transfusion Helminth infections Malaria

Age at first sexual contact Number of sexual partners and abstinence Transactional sex Commercial sex Marital status Condom use

Poverty Cultural practices Commercial sex centres Economic environment (trade centres, transport routes) Education

 Biological

Circumcision . Treatment of STIs. Prevention of needlestick injuries. Cotrimoxazole is effective at reducing mortality but resistance reported. ART has huge potential. Vaginal microbicides are being tested in Malawi.

 Behaviour

and social Changing behaviour and cultural practices remains the long term solution Accessibility to VCT

 91

countries endemic. 40% of the population. 9 out of every 10 cases and deaths occur in sub saharan africa. The whole population of Malawi is at risk of malaria(97% at endemic risk and 3% at epidemic risk).

 Approximately

six million suspected cases treated annually 40% of all hospitalization of children less than five years old 34% of all outpatient visits across all ages. Children less than five years old constitute about 50% of the total suspected malaria cases.

60% of all hospital deaths in children less than five years old are attributed to malaria and anemia. 2010 Malaria Indicator Survey (MIS), among children less than five years old, the malaria parasite prevalence by slide microscopy was 43% nationally, and the prevalence of severe anemia (hemoglobin concentration <8 g/dl) was 12%.

 Plasmodium

falciparum is responsible for approximately 98% of malaria infections, with the remaining 2% due to P. ovale, P. malariae and P. vivax.

Map of Malawi showing predicted malaria prevalence rates (2006, Kazembe et al)

 Topographically

three areas :

Lakeshore areas Highlands Lower shire valley

 Social

Housing Hydrologic infrastructure Biologic Immunity and age HIV Sickle cell disease and hemoglobinopathies Pregnancy Drug resistance

 Preventive

strategies

LLINs IRS

Pyrethroid resistance- organophosphate pirimiphos methyl used by PMI

IPTp

 Malaria

diagnostics

640 health centers and 3500 health clinics 25% have microscopy RDT roll out- universal coverage 2007 national treatment policy first line of treatment- AL Facility level Hard to reach villages- 10% population- CCM

Treatment

 ARIs

responsible for one in five childhood deaths in low to middle income countries. TB HIV related

 Highest

child mortality worldwide- sub saharan africa Malawi mortality 23% of the total mortality of under 5 children. Morbidity- second leading cause of health facility attendance. Pneumonias caused by both viruses and bacteria- dual infections not uncommon upto 40% in some series. Leading causes- str.pnemoniae, and NTS (salmonella typhimurium )

 Aetiological

diagnosis unfeasible in low resource settings. recent data from pneumonia causes in Malawi conclude that NTS (Salmonella typhimurium) is the commonest isolate on blood culture from children, particularly during the onset of the rainy season and among children with severe malaria.

 30

to 60% children attending big hospital with pneumonia HIV infected. Bacterial pneumonia, Bronchiectasis, Tuberculosis, mixed infections and LIP are infectious causes. PCP commonest cause but not reported in africa because of diagnosis resources required. Bronco alveolar lavage, IF on nasopharyngeal aspirations and sputum induction main techniques.

 PCP

prophylaxis advocated children born to HIV infected mothers from 6 weeks to 6 months.

 Biological

interventions Improving availability of third generation cephalosporins Universal vaccination-EPI,HiB and pneumococcus(PCV13) Pulse oximeter to detect hypoxemia among infants. Early diagnosis and treatment of PCP. Prophylaxis against PCP.

Improved

nutrition

Vit A at 6 months Behavioural interventions Use of Biomass fuels to be replaced Social interventions Education of health givers

 Between

1970 and 1985, the number of notified TB cases gradually increased from 3492 to 5334.
1985 to 1999, there was an upsurge of TB notifications and TB case rates.

From

TB case notifications plateaued in about 2003 at 26 00027 000 new registered cases per annum.
In 1985, the HIV prevalence in TB patients was 26%, which increased and then also reached a plateau of 75% in 2000

 low

case detection around 64% high levels of HIV-TB co-infection 75% multidrug- resistant TB (MDR-TB) health systems strengthening.

 Poverty
Household HIV Overcrowding Younger

contact

age

INTERVENTIONS
Biological

intervention Vaccination Cotrimoxazole adjunctive therapy Isoniazid prophylaxis Behavioural intervention IEC Social intervention DOTS Control in high risk groups and settings

 52%

of under-five children mortality was due to malnutrition and anaemia contributes 57% to maternal mortality. that in every 4 seconds, a Malawian could be dying of a nutrition related problem.
percent of the under-five children are chronically malnourished (stunted), 3 percent have acute malnutrition (wasting) and 21 percent are underweight.

Estimated

46

 The

WHO classifications of anemia as a public health problem as applied to Malawi show that there is a severe anemia problem (40%) in preschool children, a moderate problem (20.0 - 39.9%) in women and school children and a mild problem (5.0 19.9%) in men.

 In

Malawi, 60 percent pre-school and 38 percent of school children suffer from subclinical Vitamin A deficiency (National Micronutrient Survey, 2001).

Cretinism is estimated at 1 percent nationally and 3 percent in iodine deficient endemic areas within this age which continues to school age.
The

National School Health and Nutrition Baseline Survey of 2006 found 50 percent had iodine deficiency disorders (IDD).

DISEASE RISK FACTORS Diarrhoea disease. Intestinal and Urinary Helminths. Malaria. HIV . Respiratory infections. BEHAVIOURAL RISK FACTORS Inappropriate breastfeeding. Inappropriate complementary feeding practices . Health seeking behaviour. Water supply and sanitation.

 SOCIAL

RISK FACTORS Education Household food security Politics and governance

 INTERVENTIONS

TO IMPROVE DIETARY

INTAKES. Dietary supplementation during pregnancy Promotion of exclusive breast feeding Improving complementary feeding Supplementary feeding Food fortification. School feeding and health programmes

INTERVENTIONS TO REDUCE MORBIDITY Control of Diarrhoea disease Expanded Programme on Immunisations Micronutrient supplementation INTERVENTIONS Water supply and sanitation Child growth monitoring Education

SOCIAL