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University of Toronto Scarborough
Health Studies
R Song

Lecture 9: Disease of Children March 19, 2012  Six killer diseases of children : tetanus, polio, measles, diphtheria, tuberculosis, whooping cough Under 5 Global Mortality (2000)  Pallapies 2006: Figure 1  As shown in figure 1, just four causes of death account for about 85% of all child deaths globally: neonatal disorders, diarrhoea, pneumonia, and malaria  Almost 50% of these deaths are thought to be related to be underweight Causes of Death Risk Factors Prevention Treatment Pneumonia, Low birth weight Vaccination Appropriate care by a trained or other acute Malnutrition Adequate nutrition health provider respiratory infection Non-breastfed children Exclusive breastfeeding Antibiotics Overcrowded conditions Oxygen for severe illness Non-breastfed children Exclusive breastfeeding Oral rehydration salts (ORS) Childhood diarrhoea Unsafe drinking water and food Safe water and food Zinc supplements Poor hygiene practices Adequate sanitation and hygiene Malnutrition Vaccination Global Under 5 Mortality in 2008 (WHO 2011) Epidemiological Polarization Variables in Human Disease  Biology: genes, degree of immunity, susceptibility (prior illness), nutritional status  Demography: age, sex, ethnicity, SES  Behaviour: nature of risk behaviours, cultural traditions influencing disease transmission and persistence, psychological factors influencing manifestation of disease, interventions/treatments  Environment: physical, biotic, and social-cultural  Pathogen traits: behaviour, evolution, resistance Malaria  Protozoan parasitic infection  Plasmodium falciparum, vivax, ovale, malariae  Transmitted by female Anopheles mosquito  Flu-like symptoms: fever, chills, headache, muscle pains, sweats, tiredness, nausea, diarrhea, anemia, vomiting…..respiratory distress, convulsions, liver damage, coma, death  No vaccine, only prophylactic drugs: quinine, chloroquine and artemisinin derivatives and preventative measures (bed nets, screens, activity timing, insecticides, reducing water sources)  Note: syndemic with other diseases of poverty (relationship ie, w/ undernourished) Malaria Transmission Cycle  Prevalent in Africa, Latin America, Asia (endemic in 100+ countries); persists in a population throughout the year, it’s always there  Over 2/3 malaria cases occur in poorest 1/5 of world’s pop  Affects 300-500 million annually, killing 1-3 million  Majority of malarial deaths: sub-Saharan Africa, with 900,000+ deaths annually, mostly kids  Up to 5% of malaria episodes are severe, with case-fatality rate for severe episodes in epidemics possibly up to 20% (WHO)  Beyond infection (morbidity) and mortality rates, we must now recognize that malaria causes significant morbidity in terms of neurologic and cognitive impairment o This represents a hidden and poorly defined public health consequence of malaria, particularly in Africa (see Mung’ Ala-Odera et al. 2004)  Neurologic impairment: loss of function in cognitive and motor skills, including coordination, speech/language, vision, and hearing, as well as epilepsy and behavioural impairment Other Consequences of Malaria  Life-long impairments in quality of life - due to chronic economic and palliative care burdens to households (cost of drugs, supportive care, which depends on type of disability)  The economic costs of the disability within households may be overt or through the loss of potential earnings  Many children with severe motor impairments are unlikely to attend school, particularly when household resources for education are scarce  As well, their contribution to the household income is limited  Finally, surviving children (of cerebral malaria) are more likely to die than those never exposed to CM, particularly if they have neurologic deficits or epilepsy (see Mung’ala-Odera et al. 2004) Africa Then and Now  1900: o 223 malarial deaths / 100,000 sub-Saharan Africa o 192 deaths / 100,000 in the rest of the world  1997: o 165 / 100,000 sub-Saharan Africa o 1 / 100,000 rest of world  Highest endemicity regions - most insensitive to eradication efforts and are among the poorest nations (overly centralized government, underdeveloped health systems)  Successful eradication tied to degree of investment in public sanitation and public services, “regardless of level and frequency of insecticide saturation and drug treatment” th  2 billion more people susceptible today than before major global eradication campaigns of mid-20 century: o 7 factors: 1. Population increase 5. Inadequate control efforts 2. Demographics (and migration) 6. Climate change: temperature, precipitation 3. Land- & water-use patterns 7. Poverty and poor infrastructure 4. Drug resistance Upstream Determinants (Ultimate factors)  Political, Economic, and Environmental Factors  Malaria Risk as a function of: 1. Environmental change 2. Economic inequality 3. Political economy 4. Health care systems 5. Global health care research Sub-Saharan Africa  Throughout late 20 century: structural adjustment program (SAP) reforms resulting from policies of international financing institutions (IMF, World Bank) had huge impact (Manfredi 1999)  Devolution of health sector (& reduction in health workers) led to greater individual responsibility for treatment and follow-up  Rising income disparity and greater absolute poverty (currency devaluation) reinforced tendency to self-medicate, while rising health care costs delayed treatment-seeking for serious cases (“medical poverty trap”)  Economic deprivation led to environmental degradation and diverted resources necessary to address env. Risk factors for malaria  Worsening women’s health, resulting from uneven allocation of household resources and low status, worsened child/infant health Interventions and Solutions  Proximate or ultimate factors? o Short (prevention/treatment) vs. long-term (underlying source of susceptibility) solutions  Proximal variables: controlling malaria exposure (mosq
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