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THE NEED OF PREVENTION PROGRAMMES IN AFRICA

THE NEED OF PREVENTION PROGRAMMES IN AFRICA. SARALA NAICKER Division of Nephrology University of Witwatersrand Johannesburg, South Africa. MAJOR PROBLEMS IN AFRICA. Poverty Rapid urbanization Overcrowding Lack of clean water Inadequate sanitation Wars, crime, violence.

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THE NEED OF PREVENTION PROGRAMMES IN AFRICA

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  1. THE NEED OF PREVENTION PROGRAMMESIN AFRICA SARALA NAICKER Division of Nephrology University of Witwatersrand Johannesburg, South Africa

  2. MAJOR PROBLEMS IN AFRICA Poverty Rapid urbanization Overcrowding Lack of clean water Inadequate sanitation Wars, crime, violence

  3. HEALTH PROBLEMS IN AFRICA Infectious diseases 43% in Africa 1.2% in developed world tuberculosis malaria acute respiratory infections diarrhoeal diseases HIV/AIDS Trauma/ violence Increase in non-communicable/ chronic disease

  4. Major causes of death Causes of death Developing World (%) Developed world (%) 1. Infections & parasitic diseases 43 1.2 2. Disease of the circulatory system 24.5 45.6 3. Cancers 9.5 21 4. Respiratory diseases 4.8 8.1 5. Perinatal & Neonatal causes 9.1 1 6. Maternal causes 1.5 0 23.1 WHO,1997 7. Other/unknown 7.7

  5. 1990 2020 THE GLOBAL BURDEN OF CARDIOVASCULAR DISEASE MORTALITY (1990-2020) 5.7 3.9 4.1 2.0 2.1 96% 3.6 0.8 37% 1.6 157% 119% 2.0 1.3 0.6 0.8 1.4 130% 139% 0.6 144% * In million subjects World Developed Developing 1990 2020 10.6 m 20.2 m 4.1 m 5.6 m 6.5 m 14.5 m

  6. CHRONIC RENAL FAILURE High incidence in Afro-Americans (Easterling 1977; Mausner et al, 1978; Rostand et al, 1982) Impression : 3 - 4 x more prevalent in Africa (Barsoum et al, 1974; Abdulla, 1979; Abdullah 1981).

  7. Birth weight and Renal disease • 2000 Lackland et al. USA: • Black 30% of population but 69% of ESRD population • 70% of ESRD attributed to HT • Low birth weight associated with ESRD of all causes • 1998 Hoy et al. Australia: Aborigines • 21 x renal disease • High rate of low BW, HT, T2 DM, CVD, obesity

  8. People of African Origin • 1996 Forrester et al. Jamaica: 1610 kids 6-16y • SBP inversely related to BW • ↑ HbA1c in children shorter at birth • 1999 Levitt et al. Soweto: 849 5y olds • SBP ↓ by 3.4 mmHg for every 1Kg ↑ BW • 1999 Longo-Mbenza et al. DRC: 2648 school children • Odds ratio of 2 for ↑ BP with low birth weight

  9. People of African Origin • 1998 Woelk et al. Zimbabwe: 756 6-7y.o. • SBP ↑ by 1.73 mmHg for every 1Kg ↓ BW • 2000 Olatunbosun et al. Nigeria: 988 adults • Negative correlation with height and IGT but not BP • 2000 Steyn et al. Soweto (BTT): 964 5y.o. • SBP and DBP significantly higher in black children

  10. POVERTY, MATERNAL MALNUTRITION, MATERNAL HT LOW BIRTH WEIGHT AND IMPAIRED RENAL DEVELOPMENT OTHER “HITS” DM, HT, Pyelonephritis, obesity, environmental factors, diet, stress REDUCED FILTRATION SURFACE AREA ACQUIRED GLOMERULOSCLEROSIS GLOMERULAR/SYSTEMIC HYPERTENSION

  11. GN IN CHILDREN • 20 year review- 636 children with NS Indian: Total 286 minimal change 46.8% FSGS 20.6% (prev. 1.8%) Black: Total 306 minimal change 14.4% FSGS 28.4% (prev. 5%) Bhimma et al, Ped Nephrol,1997

  12. CRF IN NIGERIA 10 year study 368 patients / 10% of medical admissions Aetiology : Undetermined 62% Rest- Hypertension 61% DM 11% Chronic GN 5.9% (Mabayoje et al,1992)

  13. CRF IN TROPICAL AND EAST AFRICA Aetiology • Chronic GN • Hypertension (Nseka and Tshiani, 1989 McLigeyo and Kaying,1993)

  14. PRIMARY RENAL DISEASE CAUSING ESRD IN S AFRICA Hereditary Other Cystic disease Drugs CIN Multisystem Unknown HPT GN 0 500 1000 1500 2000 Number of Patients SADTR 1994

  15. SADTR DATA • Causes of ESRD in 8576 patients • GN 23% • Hypertension 21% • 25% of adult population • Malignant hypertension: 16% of hospital admissions SADTR, 2000

  16. THE FACTS 40 % of diabetics are at risk of overt nephropathy Diabetic patients with renal disease have a 5-6 fold increased mortality rate as compared to diabetic patients with no signs of renal disease or healthy subjects

  17. 2000 2025 THE GLOBAL BURDEN OF DIABETES (2000-2025) 38.4 37.5 30.7 18.6 24.5 57.2 16.7 25% 102% 22.8 47% 21.8 150% 9.1 39.3 140% 18.2 0.4 0.7 64% 116% * In million subjects World Developed Developing 2000 2025 154 m 300 m 55 m 72 m 99 m 228 m

  18. DIABETIC NEPHROPATHY • South Africa 14-16% • Zambia 23.8% • Egypt 12.4% • Sudan 9% • Ethiopia 6.1% Amos et al (1997). Diabetic Medicine

  19. Type 2 Diabetes Mellitus 90.00% Blacks 80.00% Indians 70.00% Total (n=172) 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Retinal Prot.-uria HPT GFR Creat. Type 2 DM prevalence: 13.7% I 6.7% B Amod, SEMDSA abstracts 1996

  20. MICROVASCULAR COMPLICATIONS of DIABETES MELLITUS 60% Blacks Indians 50% Total (n=47) 40% 30% 20% 10% 0% Prot.-uria HPT GFR Retinal Creat. Type 1 DM

  21. NEPHROTIC SYNDROME • greater frequency, compared to temperate regions • hospital admissions Zimbabwe 0.5% Kwazulu Natal , S Africa 0.2% Uganda 2% Nigeria 2.4% Seedat,1996

  22. RENAL DISEASE IN EAST AFRICA 2-3% of medical admissions poor response to treatment progression to renal failure Presentation: commonly – nephrotic syndrome; age of onset 5-8 years Infectious aetiology : p malariae, schistosomiosis, HBV, streptococcal infections, syphilis, leprosy, filariasis, hydatid disease Mc Ligeyo, 1990

  23. GN • Sudan 36.6% • Cote d’Ivoire 49.1% • Egypt 11% • Saudi Arabia 28% Barsoum, 2002

  24. RENAL DISEASE IN NORTH AFRICA • GN 18-24% • Interstitial nephritis 14-32% • Diabetic nephropathy 5-20% • Nephrosclerosis 5-18% Barsoum, 1998

  25. PREVALENCE OF HbsAg in CHILDREN • Urban 6.3% • Rural 18.5% • Institutionalised 35.4%

  26. MEMBRANOUS GN • 306 Black children with NS • 43% with membranous GN • 86.2% HBV antigens

  27. HIV AND RENAL DISEASE • Asymptomatic patients screened: 76 • Proteinuria > 1gm: 17 • Proteinuria < 1gm: 6 • Microalbuminuria: 27 • Haematuria: 9 • Histology • HIVAN 48% Han et al, 2004

  28. RRT IN SUB-SAHARAN AFRICAHD CAPD IPD TP

  29. Table 2. Renal replacement therapy in Africa (1993 – 1996)

  30. Frequency of HD Barsoum, 2002

  31. Europe: 317,000 China: 30,000 USA: 283,000 Japan: 167,000 India: 20,000 Latin Am: 82,000 AU/NZL: 11,000 World-ESRD (1996) Prevalence Incidence 1,000,000 220,000 DIALYSIS PATIENTS WORLD-WIDE (1996) 10,000 South Africa 2560 (25%) Schena, Kidney Int (Suppl 74), 2000

  32. $ $ $ United States 700 30 Dialysis Costs 600 25 Patients ( x 1,000) 500 20 $ ( billions) 400 15 300 10 2000 2005 2010 2000 2005 2010 Growth to year 2010 projected on the basis of historical data (1982-1997) by stepwise autoregression and exponential smoothing models Xue et al., J Am Soc Nephrol, 2001

  33. Renal replacement therapy is so costly that there is minimal probability for the vast majority of the world’s population to take advantage from it

  34. Prevention: Tackling the problems Diabetes Hypertension Glomerular Disease

  35. LIFESTYLE MEASURES Public education and commitment to health Smoking  hypertension hastens progression to kidney failure Dietary salt Obesity Prudent diet Exercise

  36. HIGH RISK GROUPS • Identified at early stage • Effective management at all levels

  37. Tx Dialysis ESRD Preparing people Prevent Progression KDRP Programmes Initiator / Injury Protein leakage, Proteinuria Locate People at risk Diabetes, Hypertension, Elderly, HIV Kidney Disease Renoprotection Programmes Chronic Kidney Disease

  38. Study before PPP was startedBlood Pressure was poorly controlled Percentage of controlled patients if 80% of the readings are = or < 140/90 Gauteng Health Department Report 2000

  39. Kidney disease detection and renoprotection programme in Johannesburg • 11 intervention clinics • 4 “usual” care clinics 795 pts evaluated: 35% proteinuria 25% albuminuria 10% micro-albuminuria

  40. HBV VACCINE • Vaccine coverage rates • 1st dose 85.4% • 2nd dose 78.2% • 3rd dose 62%

  41. Impact of HBV vaccination on NS in children • 1984 – 2001 119 children with HBV MN aRR 0.25/ 105 • 1984 – 1994 0.22 • 2000 – 2001 0.03 pre-vaccine post-vaccine • 0 – 4 years 0.16 0.00 • 5 – 10 years 0.46 0.19 Bhimma et al, 2003

  42. WHAT IS THE GLOBAL STRATEGY NEEDED IN LESS-DEVELOPED WORLD? • Identify apparently healthy subjects at risk of developing renal and cardiovascular diseases later in life • Build regional or national prevention strategies by developing therapeutic intervention programs

  43. PREVENTION STRATEGIES • Public education • Free antenatal care for pregnant women and children • Ban on smoking • Screening for hypertension and diabetes • Eradication of Schistosomiasis • HBV vaccine in EPI since 1995 • Effective intervention programmes

  44. A WORLD-WIDE STRATEGY REQUIRING INTERNATIONAL PARTNERSHIPS • Government ministries of health (and education) • International Agencies • Academic centers • Foundations

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