Info about Malaria, Tuberculosis, Birth Control Access in Developing Countries

Extra info for Exam 3

Malaria - vector

mosquitos (Anopheles gambiae complex)

Malaria - parasite

Plasmodium falciparum

Malaria - signs and symptoms

flu-like, high fevers, chills, enlarged spleen, muscle pain

Malaria - primary populations

• US: black men 25-44 from 1st or 2nd generation African immigrants

• Poor (sub)tropical areas

• Africa: young children, pregnant women, travelers, those with HIV, malnourished families, elders

Malaria - health outcomes: 2018 deaths

• 405,000 total deaths worldwide

• 67% of deaths from children under 5

• 94% malaria deaths in Africa

• 93% cases in Africa

Malaria - health outcomes: costs

• ACTs, $2.00 to $2.50 for an adults treatment dose

• ITNs, $2

• Insecticides, $0.50 per treatment

• LLINs, $5-$6

• Total Economic loss for Africa estimated to $12 billion annually

Malaria - risk factors: individual’s SES

• accessibility for preventative measures (LLIN, ACT, Insecticides, etc.)

• travel expenses

• job policies (days off work)

• income

• productivity loss

Malaria - risk factors: Government’s Economy

• supply and staff health facilities

• purchase drugs

• cover preventative strategies in public facilities

• lower GDP because of productivity loss

• low tourism, less funds

Malaria - risk factors: geography

• local weather conditions: hot and moist

• stagnant water

• absence of trees

• nearby maize (corn)

• livestock location

• swamps

Malaria - risk factors: education

• how to protect themselves

• what preventative measures to use

• congenital malaria

Malaria - prevention: nets (ITN, LLIN)

• reduced death of children under 5 by 20%

• insecticides

• distribution campaigns

Malaria - intermittent preventive treatment: pregnant women

• antimalarial drug dose

• second trimester

• folic acid regulation

• increase immunity

Malaria - intermittent preventive treatment: infants

• same drug as mom (sulfadoxine-pyrimethamine)

• vaccine schedule

• prevent 6 million cases

Malaria - indoor residual spraying

• fumigating houses

• residual insecticide

• need over 80% houses to do it to be effective

• health outcomes

Malaria - what’s next

• address macro-influences

• SES preventing best prevention

• increase funding/housing conditions

Malaria - why should we care

• 2,000 annual deaths in US

• low stock of antimalarial drugs

• travelers/immigrants spread it

Tuberculosis (TB) - a brief history

• been around for over 70,000 years

• Egyptian mummies have signs of TB (deformities, lesions, etc.)

• Aristotle called it “king’s evil”; guessed it was contagious and found from farm animals

• middle age’s cure was a “king’s touch”

• “Tuberculosis” wasn’t coined until the mid 19th century by Johann Lukas Schönlein

• Robert Kock isolated the bacteria (1882)

Tuberculosis (TB) - what it is

• infectious, communicable disease caused by a bacteria

• indirect route of transmission → through particles in the air after someone infected has coughed/sneezed

  • has to be ingested

• no just a respiratory disease…

  • can affect anywhere in the body through transportation from the blood stream

• 2 types

  • laten TB infection (LTBI)

  • TB disease

• drug resistant?

  • MDR and XTR strains

Tuberculosis (TB) - current stats

• included as a top 10 cause of death worldwide and leading cause of death from a single infectious agent

• ¼ of the world’s population is infected

• affects both sexes, all ages, all races and ethnicities

• poverty = increased environmental risk factors = higher TB rates

• top 5 infected countries

  • India (1.7 million cases)

  • China (804k cases)

  • Pakistan (331K cases)

  • Indonesia (330k cases)

  • South Africa (294k cases)

Tuberculosis (TB) - outcomes: cost of treatment

• high income countries → $14,659

• low income countries → $258

Tuberculosis (TB) - outcomes: mortality rate of TB (excluding HIV), 2017

• highest → Gabon (South Africa) → 98 per 100,000 population

• lowest → Iceland → 0 per 100,000 population

Tuberculosis (TB) - outcomes: drug-resistance has been increasing globally

caused by being exposed to TB from someone already going through treatment, in-completed treatment, alcoholism, tobacco use

Tuberculosis (TB) - drug resistant TB

• India, China, Indonesia, South Africa, and Eastern Europe are most affected

• over 400,000 new cases resistant to the most-effective, first-line drug

Tuberculosis (TB) - social determinants

• while it can affect everyone, TB is described as “a disease of the poor”

• most prevalent in underdeveloped and developing countries

• can be found in richer nations in the urban, denser, and poorer areas

• strong link to environmental/social risk factors

  • indoor and outside air pollution

  • tobacco and drug usage

  • malnutrition

  • heavy alcohol use

  • poor sanitation

Tuberculosis (TB) - trends and associations: drastic declines in the…

• 1800s → Great Sanitary Awakening, sanitation efforts increased, public health systems established

• early 1900s → increased living and working standards, public health seen as “indicator of poor social and environmental conditions,” increased education and care for TB (clinics established)

• mid 1900s → first-line drugs discovered and introduced

• 2000s → WHO’s Stop TB Strategy launched (including DOTS)

Tuberculosis (TB) - trends and associations: increased rates during the…

• early/mid 1800s → industrialization, slums and tenants, urbanization

• 1980s → surge of HIV/AIDs, reduced public health funding (DHHS budget cut by 25%), increased immigration rates

Tuberculosis (TB) - poverty compromises efficacy

• the latent TB is an evolution of the strain → not as dangerous…

  • until immune systems are compromised by poverty-induced conditions

• TB strains that can be eliminated with drugs takes 6 consecutive months of a strict antibiotic routine

• takes dedication and consistency

  • hard to afford whole package, not just the antibiotics

  • inefficient hospital (adequate tests, diagnostics, clinical education)

  • lack of transportation systems

  • weaker social, community, and family support

  • DOTS method requires individuals to take medications in the presence of a health care worker (to confirm each dosage)

Tuberculosis (TB) - development of MDR and XDR

• so what if they miss some pills, don’t comply with protocol, or can’t finish the treatment…

  • the drug-susceptible strains die, the multi-drug resistant (MDR) and even extensively drug-resistant (XDR) strains become lethal

• HIV/AIDs accelerates TB and makes MDR/XDR lethal almost 100% of the time

  • immune response is severely eradicated, 5x more lethal

• even if treatment is completed, there is still a chance of re-infection from a new strain either not treated for (due to drug choice) or from another’s MDR infection

Tuberculosis (TB) - MDR/XDR

• going back to countries most affected by TB and higher percentages of MDR

  • India - poverty, urbanization

  • China - ineffective healthcare system, poverty

  • South Africa - high concentration of HIV/AIDs, poverty (1,300 cases per 100,000)

  • Eastern Europe - health services broke following the collapse of the Soviet Union, overcrowded prisons in Russia, alcoholism (5,000 cases per 100,000)

  • USA - immigration influx (70.2% reported cases from non-US natives), cost of health care, prescription-heavy

Tuberculosis (TB) - primary prevention

• BCG vaccine

  • not widely used nor required

  • recommended for health care workers, in countries with high TB rates, and infants

  • not recommended for those with HIV/AIDs

  • doesn’t 100% prevent TB

    • only prevents serious complications, mostly just in children

Tuberculosis (TB) - protecting yourself from TB

• get ready for BCG vaccine

• be healthy

• stop smoking

• good hygiene

• open the window

• avoid prolonged contact

Tuberculosis (TB) - other prevention efforts

• preventing spread in hospital/clinic settings

  • Ultraviolet Germicidal Irradiation (UVGI)

  • proper ventilation systems

  • abide by sanitation, disinfectant, and water quality requirements

• international awareness/education

  • world TB day

• United Nations’ Sustainable Development Goals (SDGs)

  • $13 billion annually for universal access to TB diagnosis, treatment and care by 2022

  • $2 billion for TB research

  • end TB strategy

Tuberculosis (TB) - WHO’s end TB strategy: 4 barriers

• weak health systems

• underlying determinants

• lack of effective tools

• continuous unmet funding needs

Tuberculosis (TB) - WHO’s end TB strategy: core of the strategy → DOTS

• political commitment and increased/unstained funding

• improved, quality case detection

• standardized, supervised treatment with patient support

• effective drug supply and management system

• proper monitoring and evaluation system to measure impact

Tuberculosis (TB) - DOTS successes and failures

• lacked attention to HIV/AIDs implications along with MDR, but goal and targets have been readjusted

• success in most affected countries

  • China → cure rates and level of drug resistance reached target, more research needed to improve case-detection

  • South Africa - “DOTS Supporters” used to assist TB control in low income and high prevalence rate countries

• failures come from…

  • lack of education

  • refusing compliance with WHO guidelines

  • ex. Pakistan

Birth Control Access - unmet needs for contraception are a huge public health crisis

this problem is magnified among poorer populations in developing countries

Birth Control Access - in developing countries…

1 in 4 sexually active women who want to avoid becoming pregnant have an unmet need for contraception

• this accounts for 82% of unintended pregnancies in the developing world

Birth Control Access - how does this affect women’s health

• 308,000 women die each year from pregnancy related causes in developing countries

  • abortion is a major consequence of unintended pregnancy

    • abortions are illegal in many developing nations

    • unsafe abortions can result in women dying/suffering serious injuries

• economic/personal freedom

  • ability to pursue education and career

  • ability to choose family size and lifestyle

Birth Control Access - women at risk

• adolescent women in poor countries (10-19)

  • physically immature (partly due to malnutrition)

    • increases risk of obstetric complications

    • increases infant mortality and risk of premature babies

  • less likely to receive good prenatal care

  • in Africa: only 2% of sexually active girls age 15-19 use contraception

• older women in poor countries (40+)

  • many suffer from anemia, malnutrition, damage to reproductive system (often from previous births)

    • increases infant mortality

Birth Control Access - infant mortality in developing nations

• 7.5 million babies die before their first birthday in developing nations

• infant mortality rate

  • developed nations: 8/1,000

  • developing nations: 61/1,000

Birth Control Access - infant mortality rate

• Japan infant mortality rate: 2/1,000

• US infant mortality rate: 5.8/1,000

• Sub-Saharan Africa (the world’s poorest region) infant mortality rate: 78/1,000

Birth Control Access - poverty

• in countries where per capita income is lower, infant mortality is substantially higher

  • poverty creates conditions in which babies are less likely to survive:

    • lack of clean water

    • low health care spending

    • malnutrition

    • poor sanitation

    • poor or no primary health care services

Birth Control Access - what we can change with birth control

• the age at which women become pregnant can greatly reduce the risk of infant mortality

  • birth control allows women to choose when they will become pregnant

• the length of the interval between births can greatly reduce the risk of infant mortality

  • birth control allows women to control the timing of their pregnancies

Birth Control Access - why do women who want to prevent pregnancy not use birth control

• access

• stigma, knowledge, perceptions

Birth Control Access - access

• limited access to contraception, lack of supplies

• lack of information about where to obtain contraception

• inability to afford contraceptives

• inability to obtain contraceptives

  • cost/time to travel to clinic or pharmacy

Birth Control Access - stigma, knowledge, perceptions

• religious or cultural opposition to contraception

• opposition by partner/family

• lack of knowledge about methods

• fear of side effects

• perception that they could not get pregnant (due to infrequent sex, postpartum amenorrhea, breastfeeding, etc)

Birth Control Access - Centers for Disease Control and Prevention

• CDC’s Division of Global Reproductive Health works with WHO to improve health knowledge and services around the globe

  • prevent maternal deaths

  • improve family planning

  • provide technical assistance

  • produce tools/publications

Birth Control Access - United Nations population fund

• UNFPA works to support family planning by:

  • providing quality and reliable contraceptives

  • strengthening national health systems

  • advocating for family planning policies

  • gathering data

Birth Control Access - family planning in Bangladesh

• 1976: rapid population growth was declared Bangladesh’s biggest problem

  • the nation was very poor

  • over 90% of population was Muslin and highly conservative

  • many opposed birth control for religious reasons

• authorities invested in family planning

  • launched door-to-door campaigns to raise public awareness

  • Bangladesh continues to provide free birth control to women

• fertility rate (births per woman):

  • 1973: 6.904

  • 2018: 2.036

• infant mortality rate:

  • 1973: 167.8

  • 2018: 26.8

Birth Control Access - increased access to contraception improves health & society

• reduces maternal deaths

• reduces infant mortality

• empowers women and enhances education

• key factor in achieving gender equality and reducing poverty