SK Agarwal How to Approach CKD Prevention in Large Country.
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Transcript of SK Agarwal How to Approach CKD Prevention in Large Country.
Outline
Introduction
Preventive program in other countries
Proposed prevention program in India
Healthcare set-up in India
Government approach to Non-communicable diseases
Where we need help at present
Summary
SummaryIncidence of ESRD
260 / pmp
RT3 / pmp CAPD
1 / pmp
HD2 / pmp
Govt. spend8$/capita/yr
RRT /person /yr750-3000 $
What to rest 254 pmp ? Death
Prevention is only solution
Preventive Program for Chronic Illness
Is the disease prevalent in the country
Are the effects serious to warrant
prevention?
Is the disease/causes of disease easy to
detect?
Can disease be easily prevented?
Is the cost of prevention less than the
treatment?
Can the preventable program sustainable?
Issues involved:
Yes
Yes
Yes
Yes
Yes
???
Major Causes of Chronic Kidney Disease
0
10
20
30
40
50
60
Diabetes Ht Parenchymal
AIIMS, New Delhi
Apollo, Chennai
PGI, Chandigarh
(CGN+TID)
Agarwal
et al (2000)
Mittal et al
(1997)
Sakuja et al
(1994)
Mani MK
(1993)Mean Agarwal et
al ( 2002 )
No of Cases
7072 835 453 2028 10388
37
DN 28.4 23.2 23.8 26.7 25 41Ht 5.7 4.1 13.5 10 8.3 22GMn 48.5 28.6 36.6 18.2 32.9 16TID 7.5 16.5 14.3 27.8 16.5 5.4PKD 1.9 2 3.5 2 2.3 0
Etiology of CKD in India
Hospital based studies Field study
Can Causes and CKD easily detectable?
Parameters KEEP(USA)
Ivor(SA)
Sylvia(Singapore)
Hoy WE(Australia)
History of Diabetes & Ht
Questionnaires Ht & Wt Urine for Sugar & Protein
Spot urine Alb/Cr SCr, Blood Sugar, HBA1c
mcg Albuminuria ? X X X
Familial aggregation of CKD is high
Hypertension Diabetes mellitus IgA Nephropathy FSGS Systemic lupus
Brown WW et al Am J Kid Dis 2003;42:22-35
Risk of CKD in Relatives of High Risk Group
Approaches for Prevention Programs for CKD
Whole Population
Selected Community
High Risk Group
KEEP South Africa
Australian Program
NKF Singapore
Possible Prevention Program in India
Selected Community
High Risk Group
Whole Country
• Diabetics• Ht• 10 Relatives of
• CKD• Diabetics• Ht
Awareness of CKD in CommunityBoth Medical, Paramedics, Non-medical
Multiple Level Approach
Startearly detection
program Of CKD in “High Risk
Group”
Start making a base
For communityLevel screening
as part of existingInfrastructure
Top 10 Specific Causes of Death in India, 1998
Causes No in thousands
% India / World
CAD 1471 15.8 19.9
Acute LRT Inf. 969 10.4 28.1
Diarrhoeal Dis 711 7.6 32.1
CVA 557 6.0 10.9
TB 421 4.5 28.1
ESRD 250 ??? ???
RT Accidents 217 2.3 18.5
Measles 190 2.0 21.4
HIV/AIDS 179 1.9 7.8
Tetanus 165 1.8 40.3
COPD 153 1.6 6.8
Total Deaths 9337 100 17.3
Total Population 982223 100 16.7
Possible Prevention Program in India
Start program with a network in Urban area initially
• Diabetes and HT more common
• It will be easy to educate
• It will be easy to organise & implement
• Some networking is existing
• Positive results are likely in short period
• Impact of program will be faster
Make a base in rural area utilizing existing infrastructure
Central Coordinating Team
Possible Prevention Program in India
Nephrologist Community Medicine person Biostatistician Administrator / Ministry
Zonal
Member
Medical Colleges / Private Hospital / Pvt. Clinics
Nephrologist Community Medicine Administrator
Nephrologist / Internist Nurse / Other paramedics
Zonal Coordinator (15)
Hary
HP
Uttar
UP
Naga
Chat
t
Punj
Rajas
GujratMP
Maha
APKarna
Goa Kera
laTN
Megha
A P
Jhar
Bihar
WB
Orrisa
Assam
Sikkim
Trip
Mizo
Mani
Pond
Chandi
Z-1
Z-2
Zone-3
Z-4
Z-5
Z-6
Z-7Z-8
Z-9
Z-10Z-11
Z-12
India with Zones for CKD Prevention Program
Z-13
Z-14 Z-15
Education program for CKD in community
Audio-visual aid
Information booklets
Posters
Interactive session with healthcare team
PEP (Patient-educates-patient)
Possible Prevention Program in India
In addition to screening high-risk group
Multicentric study for prevalence of CKD and its
etiology in community
Transition of Indian Health System
• Demographic High mortalityHigh fertility
Low mortalityLow fertility
• EpidemiologicalMalnutritionCommunicable Dis.
Chronic Non -Communicable Dis.
• Social Low knowledgeLow expectations
Public sector
High knowledgeHigh expectations
Private sector
• Economical Low cost / event• Diarrhea
High cost / event• MI
Indian Health Care System
Community Health CenterCHC
By State Govt.
Primary Health CenterPHC
By State Govt.
Sub-CenterSC
By Central Govt.
RURALURBAN
Dispensaries
Hospitals CGHS Railways ESI MCD NDMC Many others
SC PHC
( 6 SC)
CHC
(7.5 PHC) (4)Number 1,37,311 22,842 3043
Population
Covered5400
(5000)
32,469
(30,000)
2,40,000
(1,20,000)Villages Covered
4.5 27.8 201
Beds No 4-6 30
Personnel • 1 MPW (M)
• 1 MPW (F)
• 1 Voluntary
• 1 Medical Officer
• 1 Technician
• 14 Paramedics
• 4 Medical Officer
• 7 Nurses
• Pharmacist
• Lab tech
• Radiographer
Indian Health Care in Rural Area: Infrastructure
Rural Health Statistics in India 2002, Govt. of India
Current Health Policy & Problems in India
Rural Health Statistics in India 2002, Govt. of India
• Unplanned increase in urban population
• 35% population is illiterate, thus education
• Public funding, central and state funding less
• Research utilization only 1.4% of 80,000 Crores (98-99)
• Only “Vertical” implementation of health programs
• Programs NOT having vertical implementation ??
• Absence of disease surveillance network
• Absence of scientific health statistics database
Cont….
Demographic Changes in India (1951-2000)
0
20
40
60
80
100
120
140
160
1951 1981 2000 Goal for 2000
Life Exp.Crude Birth Rt.Crude Death Rt.IMR
National Health Policy 1983, Registrar General of India
Impact of Public Health Expenditure
Indicator % Population with income <
1$/day
IMR /1000 % Health expenditure
of GDP
% Public expenditure
of total Health budget
India 44.2 70 5.2 17.3
China 18.5 31 2.7 24.9
Sri Lanka 6.6 16 3 45.4
UK 6 5.8 96.9
USA 7 13.7 44.1
Rural Health Statistics in India 2002, Govt. of India
National Health Policy 2002 in India
Rural Health Statistics in India 2002, Govt. of India
OBJECTIVES
To achieve acceptable standard of good health for all
Establishing new infrastructure in deficient area
Upgrading infrastructure in existing area
More equitable health service across the country
Increasing the contribution by central government
Contribution of private sector in health to be enhanced
Prevention & first line curative service at PHC level
Other traditional system of Indian medicine to be utilised
National Health Policy 2002 in India
Rural Health Statistics in India 2002, Govt. of India
key Points 55% / 35% & 10% public health budget in Primary,
secondary and tertiary care Health programs should be under single field administration Autonomous bodies involvement should be more Exclusive staff for individual program + common staff Common staff should be trained appropriately More in-service training for staff Establish a baseline estimates for NCD
Goal to be achieved in India by 2015
Eradicate Polio & Yaws, Leprosy 2005
Eliminate Kala Azar 2010
Eliminate Lymphatic Filaria 2015
Achieve zero level growth of HIV 2007
Mortality by 50% due to TB, Malaria, water borne 2010
Prevalence of blindness to 0.5% 2010
IMR to 30/1000 & MMR 100/Lakh 2010
Use of Public Health Facility from <20% to > 75% 2010
Govt. health expenditure from 0.9% to 2% 2010
Central Govt. share to at least 25% 2010
State health expenditure from 5.5% to 7% / 8% 2005 / 2010
Establish integrated system of surveillance & statistics 2005
Rural Health Statistics in India 2002, Govt. of India
The increasing burden of noncommunicable
diseases (NCD), particularly in developing
countries, threatens to overwhelm already-
stretched health services. The factors underlying
the major NCDs (heart disease, stroke,
diabetes, cancer and respiratory conditions)
are well documented. Primary prevention based
on comprehensive population-based programes is
the most cost-effective approach to contain this
emerging epidemic.
WHO statement on Non-communicable diseases 2001
In 2000, the 53rd World Health Assembly passed
a resolution on the prevention and control of non-
communicable diseases with the goal of
supporting Member States in their efforts to
reduce the toll of morbidity, disability and
premature mortality related to NCDs.
WHO statement on Non-communicable diseases 2001
WHO Stepwise Approach to NCD Surveillance
NCD Step-1 Step-2 Step-3
Death
(The past)
Death rate by age & sex
Death rate by age, sex and cause of
death
(Verbal autopsy)
Death rate by age, sex and
cause of death
(Death certificate)
Disease
(The present)
Hospital / clinic admission by age
& sex
Rate & principle conditions in three groups;
Communicable, NCD & Injury
Cause specific disease incidence
& prevalence
Risk factors
(The future)
Questionare based report on key risk factors
Questionare plus physical
examination
Questionare plus physical
examination & biochemical
reports
Risk factors Common to Major NCD
Risk Factor CVS Cancer Diabetes Respiratory
DiseasesCKD
Smoking Alcohol
Nutrition Physical Inactivity
Obesity Hypertension Diabetes Hyperlipidemia
From WHO
Recognize CKD importance
Include CKD in thrust areas of NCDs
Training in public health issues
Where we need help?
From ISN
A. Include AIIMS as center of excellence
Govt. recognizes it as center of excellence
It is strategically placed
Our group is interested
We have done work in this field
B. Help organising prevention conference in Delhi
Initiate enthusiasm in local peoples
Stress CKD importance in local leaders
Where we need help?
From ISN
A. Help in funding for attending preventive conferences in world for key peoples
Keep enthusiasm alive
Help in building partnership
B. Expertise & funding for
Research in key areas of local importance
Help in establishing registries
Where we need help?
CKD is a public health problem in India
Diabetes and Hypertension are common causes
Risk factors for CKD & CKD itself is easy to detect
Prevention program is the only way to handle CKD
Education for CKD is urgently needed
Initially the program can be started in urban areas
Ultimately it has to go to primary health center level
A networking approach is correct approach
International funding is required for this program
Summary