Thousands Are Dying of Chronic Kidney Disease in Central America: “The Malady of the Sugar Cane” Presented by: Community Health International Medical Projects for Sustainability (CHIMPS) – Salud Comunitaria Internacional, Proyestos Médicos para Sostenibilidad Mission : To cultivate sustainable public health interventions in partnership with underserved communities in developing countries through collaborative education CHIMPS is a non-profit based in the Seattle area that was founded 10 years ago by pediatric residents at Seattle Children’s Hospital who wanted to have more global health experience during their residency training. It is now mainly supported by community health care providers that organize 2-3 teams that teach village health committees in El Salvador. For the last 2 years we have been working in the La Paz District of El Salvador in area where there are people impacted by this epidemic of CKD    Organizational Values: Purpose: having common and specific goals for each visit. Empowerment: working with communities to identify and advocate for their own needs. Respect: maintaining awareness of the community, culture, and existing infrastructure. Partnership: collaborating over time with local NGOs to do work that the community needs and wants. Teamwork: identifying, valuing, and utilizing community and team member skills and experiences. Sustainability: building capacity to meet challenges within communities and our organization. Feedback: measuring and sharing progress toward team and community goals.

Reuter’s Video

Deaths from Chronic Kidney Disease Increased between 2005 and 2009 Deaths in 2009 and increase in mortality rate over 4 years from 2005-09 Map/data from: http://www.publicintegrity.org/ The first reports of increased CKD in Central America surfaced in 2000. A conference was convened in 2005 to look at the issue and data started to be collected about mortality from CKD in that year within each of the impacted countries.

El Salvador has highest mortality from Chronic Kidney Disease (CKD) in world! Jesus Sosa Mancia, a CKD patient in Bajo Lempa, at home visit by a medical team from the national health ministry. Sasha Chavkin/ICIJ CKD 2nd leading cause of death in men ages 20-60 in El Salvador Dr. Carlos Orantes study in Bajo Lempa in 2009 of 775 individuals in 375 families from 6 communities found evidence of CKD in 25.7% of men and 11.8% of women. Compare this to the 1% prevalence of CKD in the US adult population More recent unpublished data from El Salvador shows CKD is the leading cause of death in men ages 20-60

Social Cost is Enormous & Increasing Renal dialysis and transplant limited availability, costly Families left without financial support…”isla de viudas” in Nicaragua Loss of large portion of population in their most economically productive years Part of the Emergency Room at the Central Hospital in San Salvador, Rosales, was turned into an emergency renal dialysis unit in 2011 due to the large number of people presenting with end stage kidney failure. Peritoneal dialysis is used in about 2/3rd of cases that receive treatment in El Salvador and is considered a less expensive option. Data cited in Orantes study from 2009 says that only 5-15% of patients needing dialysis receive it. In 2008, El Salvador reported 3342 patients on RRT, 715 on continuous ambulatory peritoneal dialysis, 745 on hemodialysis and 1413 on intermittent peritoneal dialysis. By then 469 live-donor kidney transplants had been performed Cost of renal dialysis in the US is $200,000/year

Silent Disease Until Kidneys Fail Hard to prevent as symptoms do not develop until kidneys failing Generalized skin itching Weakness Fatigue and inability to carry out activities of daily living Blood & urine tests can detect it earlier

Kidneys become small and fibrotic in Central American CKD and damage is mainly to tubules. Protein in the urine is found in some of those with most severe kidney failure but it not found in the earlier stages and has not been a useful screening test.

Damage is primarily to kidney tubules Two main causes of kidney tubule damage: Decreased blood flow most commonly from dehydration Exposure to toxins No evidence that this form of CKD is related to hypertension, obesity or diabetes as in the US Studies in Nicaragua have found that sugar cane workers lose on average 2.5 kilos/day (6 lbs) while working on sugar cane plantations. Workers are paid by the weight of the cane that they cut and take few breaks to rehydrate.

Limited Investigations Started in 2009 Mainly found in sugar cane & cotton workers but also in construction, mining, shipping Associated with lower elevation communities (cane workers at higher elevations without CKD) Similar disease in Sri Lanka, India, Egypt Funeral in Costa Rica of sugar cane worker Peraza study in El Salvador found prevalence of decreased GFR in 18-19 % of men in costal sites and 1-4% of men at sites over 500 M; in women 8% at costal sites and 2-3% at other sites. Study done in El Salvador sample of 664 workers from 5 communities (2 costal on sugarcane/cotton plantations and 3 at higher elevations (over 500 M) including urban sites, rural coffee growing and rural sugar cane. Found highest rates of decreased kidney function in workers with over 10 years of residence in costal sites. Abnormal kidney function: SCr level > 1.2mg/dL for men and > 0.9 mg/dL for women; Glomerular filtration rate less than 60 mL/min/1.73meter squared of BSA

Epidemic heavily focused in communities on Pacific side From Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America: A Hot Issue. Am J Kidney Dis 2012; 59:481-484.

Kidney Injury Associated with Years of Work Peraza S et al, Decreased kidney function among agricultural workers in El Salvador Am J Kidney Dis 2012; 59:531-540

Possible factors studied that are not single causes of this epidemic of CKD Heavy metals: lead, cadmium Arsenic (common in volcanic soil/cotton ) Agrichemicals properly manufactured/applied Leptosporosis Medications: pain meds (NSAIDs) and certain antibiotics Alcohol Peraza study in El Salvador did not find that alcohol or use of NSAIDs, both common in the communities studied, were associated with decreased kidney function Common agrichemicals used in El Salvador include: atrazine (highly toxic with renal damage), 2.4-D (component of Agent Orange and toxicity is from dioxin contamination which can be poorly controlled by some manufacturers), terbutryne (highly toxic with renal damage), pendimethalin (use with caution but no occupational exposure limit)

Several Factors Combined May Cause Chronic Kidney Disease Heat exposure and exhaustion – paid by weight of cane cut Pesticides Direct contact Water contamination Predisposition due to Intrauterine stress Acute kidney injury in childhood ? Genetic factors

Causes from Perspective of Workers and Central American Doctors Dr. Carlos Orantes. “There are 3 factors: prohibited pesticides, combinations of pesticides and no protection from pesticides” Lack of any regulation for worker protection from chemicals Concern about water contamination by agra-chemicals Photo from: http://desinformemonos.org/2012/10/miles-de-muertes-en-nicaragua- a-causa-de-un-ingenio-azucarero/nicaragua-central-america-mystery-disease/

Prevention And Interventions Primary Prevention= identifying risk factors and decreasing exposure Secondary Prevention = identifying those with damage to kidneys: Surveillance of people in high risk areas and tracking along with eliminating factors that could increase damage. Try to decrease the progression of disease and prevent kidney failure for as long as possible Tertiary Prevention= Kidney replacement therapy through transplant or renal or peritoneal dialysis From Levey AS, Stevens LA, Coresh J. Conceptual Model of CKD: Applications and And Implications. AJKD 2009; 53: S4-S16

What has been done to control this epidemic in effected countries? Sri Lankan gov’t & WHO conducting large study In CA, only 2 scientific conferences, one in 2005 and fall of 2012 In ES, MOH focus on PAHO to make major health concern; Nefrolempa pilot study on coast MOH of El Salvador with El Salvador & Cuban physicians reviewing pilot study results Cross sectional studies in Nicaragua and El Salvador have defined some of the epidemiology but not the causes Physician on Right is Dr. Carlos Orantes, one of only a few nephrologists in El Salvador. He is leading MOH efforts in El Salvador

Rise in Latino Immigrants in End Stage Kidney Disease in US Increase in Latino immigrants needing dialysis in US University Medical Center in Las Vegas spent $24 million on emergency dialysis treatment for 80 patients in 2010…most undocumented and without medical insurance.

What can we do from US? 1/4th of US sugar imported from CA Educate the public/members of your groups about the CKD epidemic Look at sources of sugar you buy. Urge Puget Consumer Co-op, Trader Joe, Whole Foods, Safeway, etc to find out Do growers have workers with CKD? Do workers have breaks & hydration? Are workers protected from pesticides? Put pressure on World Bank/IMF to force growers to change work conditions: Compliance Advisor/Ombudsman Office (http://www.cao-ombudsman.org/)

Demand Funding for Rigorous Research to Find Main Causes Need a large and well designed case-control study Urge research and forums by: Pan American Health Organization World Health Organization CDC, NIH Support surveillance for kidney injury in workers and longitudinal studies Studies done to date funded by Cuba, Sweden Researchers say that funding has not been available for adequate studies. The 3 major studies that have been done have had outside funding from Sweden and Cuba. There is no evidence of NIH or CDC funding or from US development organizations

Conduct Education About Prevention with Latino Communities in US & CA Protection from agrichemicals when working Avoidance of medications that cause kidney injury Promote good hydration while working Avoidance of water and food contamination by chemicals that can harm kidneys Hesperian Foundation has excellent resources in English and Spanish

Sources of more information http://www.guardian.co.uk/world/2012/oct/14/kidney-disease-killing-sugar-cane-workers-central-america http://openchannel.nbcnews.com/_news/2012/10/16/13866856-mystery-kidney-disease-decimates-central-america-sugarcane-workers?lite (video) Ramirez-Rubrio O, McClean MD, Amador JJ, Brooks DR. An epidemic of chronic kidney disease in Central American, an overview: J Epidemiol Community Health 2013; 67: 1-3 Brooks DR, Ramirez-Rubrio O, Amadar JJ. CKD in Central America: A Hot Issue. Am J Kidney Dis 2012; 59:481-484. Peraza S et al, Decreased kidney function among agricultural workers in El Salvador. Am J Kidney Dis 2012; 59:531-540 Orantes CM et al. Chronic kidney disease and associated risk factors in the Bajo Lempa region of El Salvador: Nefrolempa study 2009. MEDICC Review 2011, 14-22.