Harmonization of ICTs policies and programmes in East Africa Subregion and Prospects
THE NEED OF PREVENTION PROGRAMMES IN AFRICA
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THE NEED OF PREVENTION PROGRAMMES
IN AFRICA
SARALA NAICKERDivision of Nephrology
University of Witwatersrand
Johannesburg, South Africa
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MAJOR PROBLEMS IN AFRICA
Poverty Rapid urbanization Overcrowding Lack of clean water Inadequate sanitation Wars, crime, violence
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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
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Major causes of death
23.1
WHO,1997
7.77. Other/unknown
01.56. Maternal causes
19.15. Perinatal & Neonatal causes
8.14.84. Respiratory diseases
219.53. Cancers
45.624.52. Disease of the circulatory system
1.2431. Infections & parasitic diseases
Developed world (%)Developing World (%)Causes of death
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World
19902020
10.6 m20.2 m
4.1 m5.6 m
Developed Developing
6.5 m14.5 m
4.1
5.7
1.40.6
1.30.6
3.6
1.6
3.9
2.0
0.82.0
1990
2020
* In million subjects
37%
144%
130%
119%
96%
139%
THE GLOBAL BURDEN OF CARDIOVASCULAR DISEASE MORTALITY (1990-2020)
2.10.8
157%
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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).
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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
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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
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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
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LOW BIRTH WEIGHT AND IMPAIRED RENAL DEVELOPMENT
REDUCED FILTRATION
SURFACE AREA
POVERTY, MATERNAL MALNUTRITION, MATERNAL HT
GLOMERULAR/SYSTEMIC
HYPERTENSION
ACQUIRED GLOMERULOSCLEROSIS
OTHER “HITS”
DM, HT, Pyelonephritis, obesity, environmental factors, diet, stress
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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
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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)
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CRF IN TROPICAL AND EAST AFRICA
Aetiology Chronic GN Hypertension
(Nseka and Tshiani, 1989
McLigeyo and Kaying,1993)
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PRIMARY RENAL DISEASE CAUSING ESRD IN S AFRICA
Number of PatientsSADTR 1994
0 500 1000 1500 2000
GN
HPT
Unknown
Multisystem
CIN
Drugs
Cystic disease
Other
Hereditary
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SADTR DATA
• Causes of ESRD in 8576 patients– GN 23%– Hypertension 21%
• 25% of adult population• Malignant hypertension: 16% of hospital
admissions
SADTR, 2000
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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
THE FACTS
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World
20002025
154 m300 m
55 m72 m
Developed Developing
99 m228 m
16.724.5
39.3
18.2
38.430.7
21.8
9.1
57.2
22.8
37.5
18.6
0.4 0.7
2000
2025
* In million subjects
47%
116%
25%
140%
150%
102%
64%
THE GLOBAL BURDEN OF DIABETES (2000-2025)
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DIABETIC NEPHROPATHY
• South Africa 14-16%
• Zambia 23.8%
• Egypt 12.4%
• Sudan 9%
• Ethiopia 6.1%
Amos et al (1997). Diabetic Medicine
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Type 2 Diabetes Mellitus
Type 2 DM prevalence: 13.7% I 6.7% B
Amod, SEMDSA abstracts 1996
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Retinal Prot.-uria HPT GFR Creat.
Blacks
Indians
Total (n=172)
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MICROVASCULAR COMPLICATIONS of DIABETES MELLITUS
Type 1 DM
0%
10%
20%
30%
40%
50%
60%
Retinal Prot.-uria HPT GFR Creat.
Blacks
Total (n=47)
Indians
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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
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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
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GN
• Sudan 36.6%
• Cote d’Ivoire 49.1%
• Egypt 11%
• Saudi Arabia 28%
Barsoum, 2002
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RENAL DISEASE IN NORTH AFRICA
• GN 18-24%
• Interstitial nephritis 14-32%
• Diabetic nephropathy 5-20%
• Nephrosclerosis 5-18%
Barsoum, 1998
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PREVALENCE OF HbsAg in CHILDREN
• Urban 6.3%
• Rural 18.5%
• Institutionalised 35.4%
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MEMBRANOUS GN
• 306 Black children with NS• 43% with membranous GN
• 86.2% HBV antigens
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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
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RRT IN SUB-SAHARAN AFRICA HD CAPD IPD TP
Namibia 7 20
Zimbabwe 59 38 4
Botswana 4 3
Sudan 200 150 300
Congo 2 30 6
Kenya 80 20 Variable ± 2/week
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Table 2. Renal replacement therapy in Africa (1993 – 1996)
Country Population
(millions
GNP per capita
(US dollars)
Dialysis
(pmp)
Algeria 28.0 2170 78.5
Egypt 60.0 1000 129.3
Libya 5.1 1800 30.0
Morocco 27.0 1010 55.6
Tunisia 8.7 1260 186.5
S Africa 34.4 2560 99.0
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Frequency of HD
0
10
20
30
40
50
60
70
80
90
100
Thailand Egypt Tunisia S. Africa India Pakistan Argentina Mexico Venzuala
Per
cent
of p
atie
nts
1 session/wk 2 sessions/wk 3 sessions/wk
Barsoum, 2002
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USA: 283,000
Latin Am: 82,000
Europe: 317,000
India: 20,000
China: 30,000
AU/NZL: 11,000
Japan: 167,000
Schena, Kidney Int (Suppl 74), 2000
World-ESRD (1996)
PrevalenceIncidence
1,000,000 220,000
DIALYSIS PATIENTS WORLD-WIDE (1996)
10,000
South Africa2560 (25%)
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United States
30
15
10$
( bi
llion
s)
2000 2005 2010
Costs
20
25
700
600
500
400
300
Pat
ient
s (
x 1,
000)
2000 2005 2010
Dialysis
Xue et al., J Am Soc Nephrol, 2001
Growth to year 2010 projected on the basis of historical data (1982-1997) by stepwise autoregression and exponential smoothing models
$
$
$
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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
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Prevention: Tackling the problems
Diabetes
Hypertension
Glomerular Disease
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LIFESTYLE MEASURES
Public education and commitment to healthSmoking
hypertensionhastens progression to kidney failure
Dietary saltObesityPrudent dietExercise
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HIGH RISK GROUPS
• Identified at early stage
• Effective management at all levels
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Kidney Disease Renoprotection Programmes
Locate People at riskDiabetes, Hypertension, Elderly, HIV
Initiator / InjuryProtein leakage, Proteinuria
Prevent ProgressionKDRP Programmes
ESRDPreparing people
TxDialysis
Chronic Kidney Disease
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Study before PPP was startedBlood Pressure was poorly controlled
81.6%
18.4%
Controlled Uncontrolled
Percentage of controlled patients if 80% of the readings are
= or < 140/90 Gauteng Health Department Report 2000
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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
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HBV VACCINE
• Vaccine coverage rates– 1st dose 85.4%– 2nd dose 78.2%– 3rd dose 62%
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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
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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
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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
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A WORLD-WIDE STRATEGY REQUIRING INTERNATIONAL
PARTNERSHIPS
• Government ministries of health (and education)
• International Agencies
• Academic centers
• Foundations