1. BIOE 301 Lecture Two: Health Problems in the Developed and Developing World: Ages 0-4 Louise Organ 1.11.07

2. Review of Lecture One Course goals Course goals Four main questions we aim to address Four main questions we aim to address Technology assessment Technology assessment Introduction to world health Introduction to world health Health data and uses Health data and uses

3. World Health Organization: WHO Established by charter of the UN after World War II Established by charter of the UN after World War II Headquartered in Geneva Headquartered in Geneva Mission: Mission: “Attainment by all peoples of the highest possible level of health”“Attainment by all peoples of the highest possible level of health” Website: Website: http://www.who.int/en/http://www.who.int/en/http://www.who.int/en/

4. Functions of the WHO Services to governments: Services to governments: Epidemiologic intelligenceEpidemiologic intelligence International standardization of vaccinesInternational standardization of vaccines Reports of expert committeesReports of expert committees Data on world health problemsData on world health problems Member countries must provide certain info in regular reports Member countries must provide certain info in regular reports Disease outbreaksDisease outbreaks Health of populationHealth of population Steps to improve healthSteps to improve health

5. Lecture Two Health problems in developed and developing world: ages 0-4 Health problems in developed and developing world: ages 0-4 Unit 1-What are the major health problems worldwide?Unit 1-What are the major health problems worldwide? Differences between developed and developing wordDifferences between developed and developing word Understand disease/condition causes, treatments, and preventionUnderstand disease/condition causes, treatments, and prevention

6. World Mortality Rates (2002) Developed CountriesDeveloping Countries Group 1 = communicable diseases, maternal/perinatal conditions, malnutrition Group 2 = Non-communicable diseases (cardiovascular, cancer, mental disorders) Group 3 = Injuries

7. Infant and Child Mortality 8 UN Millennium Development Goals (MGDs) 8 UN Millennium Development Goals (MGDs) Goal 4: Reduce Child MortalityGoal 4: Reduce Child Mortality Reduce by two-thirds, between 1990 and 2015, the under-five mortality rateReduce by two-thirds, between 1990 and 2015, the under-five mortality rate WHO World Health Report 2005: Make Every Mother and Child Count WHO World Health Report 2005: Make Every Mother and Child Count Almost 11 million children under five will die in 2005 from causes that are largely preventableAlmost 11 million children under five will die in 2005 from causes that are largely preventable 4 million babies who will not survive the first month of life4 million babies who will not survive the first month of life

8. Causes of Child Mortality WHO 2005 World Health Report

9. Causes of Child Mortality by Region WHO 2005 World Health Report

10. Leading causes of mortality: ages 0-4 Developing world Developing world 1.Perinatal conditions 2.Lower respiratory infections 3.Diarrheal diseases 4.Malaria Developed world Developed world 1.Perinatal conditions 2.Congenital anomalies 3.Lower respiratory infections 4.Unintentional injuries

11. Perinatal Conditions Period from 22 weeks of pregnancy through the first week of life Period from 22 weeks of pregnancy through the first week of life 2.5 million children die from perinatal conditions 2.5 million children die from perinatal conditions > 500,000 women die as a consequence of pregnancy and childbirth > 500,000 women die as a consequence of pregnancy and childbirth Leading cause of death for women of childbearing age in developing countriesLeading cause of death for women of childbearing age in developing countries

12. Perinatal Conditions 3.3 million stillborn infants per year 3.3 million stillborn infants per year Likely underestimates as vital registration rates and practices vary Likely underestimates as vital registration rates and practices vary Countries with the highest mortality rates tend to also have the lowest rates of vital registrationCountries with the highest mortality rates tend to also have the lowest rates of vital registration

13. Common Perinatal Conditions Premature delivery Premature delivery Low birth weight Low birth weight Birth asphyxia Birth asphyxia Entangled umbilical cordEntangled umbilical cord Breech birthBreech birth

14. Common Perinatal Conditions Birth trauma Birth trauma Mechanical forces encountered during decent through the pelvic regionMechanical forces encountered during decent through the pelvic region DALYDALY Infections Infections Umbilical cordUmbilical cord Non-sterile instruments Non-sterile instruments Organisms in the maternal genital tractOrganisms in the maternal genital tract PATH kitPATH kit http://www.path.org/ http://www.path.org/

15. World Health Report: 1995 vs. 2005

17. 37% Mortality Due to Neonatal Causes

18. Challenges to Reducing Perinatal Conditions Lack of skilled birth attendants Lack of skilled birth attendants

21. Challenges to Reducing Perinatal Conditions No adequate way to predetermine difficult births No adequate way to predetermine difficult births Cultural isolation Cultural isolation “Birth” may not be celebrated until after perinatal period is over“Birth” may not be celebrated until after perinatal period is over Vital registration rates Vital registration rates Isolation may be positive Isolation may be positive Delaying medical care can be negative Delaying medical care can be negative

22. Lower Respiratory Infections #2 in developing world & #3 in developed #2 in developing world & #3 in developed 1 million children per year 1 million children per year Pneumonia Pneumonia Lung infectionsLung infections Fever, cough, chest pain, weaknessFever, cough, chest pain, weakness Until 1936 pneumonia was the leading cause of death in the US Until 1936 pneumonia was the leading cause of death in the US

23. Causes of Pneumonia A group of infections A group of infections Viruses, bacteria, and fungiViruses, bacteria, and fungi 50% bacterial 50% bacterial Streptococcus pneumoniae, Haemophilus influenzae, Staphlococcus aureus, and pertussis (whooping cough)Streptococcus pneumoniae, Haemophilus influenzae, Staphlococcus aureus, and pertussis (whooping cough) 50% viral 50% viral SARSSARS InfluenzaInfluenza MeaslesMeasles Coinfection is an increasing concern Coinfection is an increasing concern

24. Pneumonia: Physiopathology Bacteria or virus invades lungs Bacteria or virus invades lungs Immune response causes fluid and pus Immune response causes fluid and pus Filled alveoli have limited gas exchange Filled alveoli have limited gas exchange

25. Identifying Pneumonia Etiology affects treatment Etiology affects treatment Chest X-rays Chest X-rays Blood tests Blood tests Examine sputum/secretions Examine sputum/secretions Direct Fluorescence Assay (DFA) Direct Fluorescence Assay (DFA) Collect sample and separate cells Fix cells onto slide and immerse in alcohol Apply solution containing antibodies Apply second antibody coupled to fluorescent dye View with fluorescent microscope

26. Pneumonia: Treatment Viral Viral Usually resolves on its ownUsually resolves on its own Severe cases: oxygen and antiviral drugsSevere cases: oxygen and antiviral drugs Bacterial Bacterial Treat with antibioticsTreat with antibiotics Because the etiologies are hard to detect WHO recommends antibiotics for all children with pneumonia Because the etiologies are hard to detect WHO recommends antibiotics for all children with pneumonia Proven to reduce mortality in developing worldProven to reduce mortality in developing world May also foster the development of resistant strainsMay also foster the development of resistant strains

27. Diarrheal Disease #3 in developing world #3 in developing world Gastrointestinal disorders characterized by frequent, watery stools Gastrointestinal disorders characterized by frequent, watery stools Bacterial infection Bacterial infection Escherichia coliEscherichia coli Vibrio choleraeVibrio cholerae Viral infection Viral infection RotavirusRotavirus

28. Diarrheal Disease: Cholera Spread by water or food contaminated with bacteria Spread by water or food contaminated with bacteria Often a result of inadequate sewage and water treatment Often a result of inadequate sewage and water treatment Outbreaks were common, historically, and remain a concern Outbreaks were common, historically, and remain a concern Rwandan refugees

29. Diarrheal Disease is often a result of unsafe water sources Access to Safe Water (2000)

30. Diarrheal Disease Normally, 98% of the water intake from food or liquid is reabsorbed by epithelial cells in the lower digestive tract Normally, 98% of the water intake from food or liquid is reabsorbed by epithelial cells in the lower digestive tract Diarrheal disease rapidly leads to extreme dehydration and death Diarrheal disease rapidly leads to extreme dehydration and death The loss of body fluid leads to dangerously low blood pressure The loss of body fluid leads to dangerously low blood pressure 10% loss of volume is sufficient to cause death 10% loss of volume is sufficient to cause death Treatment must effectively and efficiently replace fluids Treatment must effectively and efficiently replace fluids

31. Diarrheal Disease: Physiopathology Epithelial cells line the entire GI tract Epithelial cells line the entire GI tract Different regions have varying specific mechanisms but all work to reabsorb osmotically active nutrients and salts Different regions have varying specific mechanisms but all work to reabsorb osmotically active nutrients and salts To maintain osmotic balance, water follows and is eventually reabsorbed into the blood vessels To maintain osmotic balance, water follows and is eventually reabsorbed into the blood vessels Toxins produced by bacteria inhibit sodium uptake from the lumen and cause epithelial cells to secret chloride into the lumen Toxins produced by bacteria inhibit sodium uptake from the lumen and cause epithelial cells to secret chloride into the lumen Double whammy!Double whammy!

32. Oral Rehydration Therapy (ORT) A simple, inexpensive mixture of water, salt, and sugar A simple, inexpensive mixture of water, salt, and sugar 1 liter boiled water, 1 tsp. salt, 8 tsps. sugar1 liter boiled water, 1 tsp. salt, 8 tsps. sugar Developed in 1960s and responsible for a dramatic decrease in the mortality rates of diarrheal diseases Developed in 1960s and responsible for a dramatic decrease in the mortality rates of diarrheal diseases

33. Why Does ORT Work? Giving sterile water or salt water alone is not sufficient Giving sterile water or salt water alone is not sufficient Discovery of a sodium reabsorption mechanism that is coupled to glucose transport Discovery of a sodium reabsorption mechanism that is coupled to glucose transport 1950s1950s Unaffected by cholera toxinUnaffected by cholera toxin In 1960s shown to result in a net reabsorption of water into the bloodstream In 1960s shown to result in a net reabsorption of water into the bloodstream

34. Oral Rehydration Therapy 1975 WHO and UNICEF standard 1975 WHO and UNICEF standard 90 mM sodium90 mM sodium 20 mM potassium20 mM potassium 80 mM chloride80 mM chloride 30 mM bicarbonate30 mM bicarbonate 111 mM glucose111 mM glucose Packet of ORT costs ~10 cents Packet of ORT costs ~10 cents ORT treats a symptom (dehydration) not the disease (or organism) ORT treats a symptom (dehydration) not the disease (or organism) The volume of diarrhea usually remains unchangedThe volume of diarrhea usually remains unchanged

35. ORT use in the US Rarely used Rarely used More expensive and painful IV therapy is far more common More expensive and painful IV therapy is far more common Even when ORT is sufficient and acceptable treatmentEven when ORT is sufficient and acceptable treatment Likely due to initial troubles with original formulations (50’s-60’s) Likely due to initial troubles with original formulations (50’s-60’s) Elevated sodium levels Inaccurate mixing

36. Diarrheal Disease in the US Second leading cause of US pediatric emergency room visits Second leading cause of US pediatric emergency room visits E. coli E. coli Spinach outbreak in Sept.-Oct. 2006Spinach outbreak in Sept.-Oct. 2006 Taco Bell outbreak in Nov.-Dec. 2006Taco Bell outbreak in Nov.-Dec. 2006 Rotavirus Rotavirus Causes ~30% of diarrheal disease deathsCauses ~30% of diarrheal disease deaths Ubiquitous and highly contagiousUbiquitous and highly contagious

37. Rotavirus Vaccine Almost every child will be infected with a rotavirus Almost every child will be infected with a rotavirus 50,000 child hospitalizations annually50,000 child hospitalizations annually Vomiting also occurs, so ORT can be difficult although still effective Vomiting also occurs, so ORT can be difficult although still effective RotaShield was FDA approved in 1998 RotaShield was FDA approved in 1998 80-100% effective80-100% effective 1 in 12,000 have severe complication1 in 12,000 have severe complication Vaccine was voluntarily withdrawn in 1999Vaccine was voluntarily withdrawn in 1999 Ethical concerns Ethical concerns Complications vs. potential lives savedComplications vs. potential lives saved Mortality disparity in developed vs. developing worldMortality disparity in developed vs. developing world

38. Malaria #4 mortality rate of children under 5 in developing world #4 mortality rate of children under 5 in developing world Spread by Anopheles mosquitoes which carry a parasite that infects humans Spread by Anopheles mosquitoes which carry a parasite that infects humans 300 million cases annually 300 million cases annually African children: 1.6-5.4 episodes/year African children: 1.6-5.4 episodes/year 1 million under the age of 5 die each year 1 million under the age of 5 die each year CDC/ James Gathany

39. Malaria: Physiopathology Mosquito transfers sporozoites which infect and rupture liver cells releasing merozoites Mosquito transfers sporozoites which infect and rupture liver cells releasing merozoites Invade RBCs and either repeat a similar cycle or form gametocytes Invade RBCs and either repeat a similar cycle or form gametocytes Gametocytes are free in blood Gametocytes are free in blood Ingested during bite Ingested during bite Reproduce in mosquito to form new sporozoites Reproduce in mosquito to form new sporozoites http://www.cdc.gov/malaria/biology/life_cycle.htm

41. Malaria: Physiopathology Blood stage is time of clinical manifestation and diagnosis Blood stage is time of clinical manifestation and diagnosis Burst RBCs result in anemia Burst RBCs result in anemia Is particularly dangerous for mother and childIs particularly dangerous for mother and child Malaria can be transmitted across the placentaMalaria can be transmitted across the placenta US Public Health Image Library Infected RBC Ruptured RBCGametocyte

42. Malaria: Drug Treatments Chloroquine, sulfadoxine- pyrimethamine, quinine Chloroquine, sulfadoxine- pyrimethamine, quinine Relatively inexpensive Relatively inexpensive Cents/courseCents/course Malaria parasites now show resistance Malaria parasites now show resistance Chloroquine resistance in AfricaChloroquine resistance in Africa New therapy development is slow New therapy development is slow Non-syntheticNon-synthetic ExpensiveExpensive

43. Malaria: Prevention Insecticide treated nets Insecticide treated nets Cheap ~ $2 Cheap ~ $2 Must be retreated, ~ 5 cents Must be retreated, ~ 5 cents Shown to reduce low birth weights by 25% Shown to reduce low birth weights by 25% Proven to reduce mortality rate in young children by 20% Proven to reduce mortality rate in young children by 20% April 25, 2007 is April 25, 2007 is Malaria Awareness Day

44. Leading causes of mortality: ages 0-4 Developing world Developing world 1.Perinatal conditions 2.Lower respiratory infections 3.Diarrheal diseases 4.Malaria Developed world Developed world 1.Perinatal conditions 2.Congenital anomalies 3.Lower respiratory infections 4.Unintentional injuries

45. Congenital Abnormalities 2-3% of all children have birth defect 2-3% of all children have birth defect 400,000 deaths annually 400,000 deaths annually As general health increases, congenital abnormalities rise as a cause of mortality As general health increases, congenital abnormalities rise as a cause of mortality #2 in developed world#2 in developed world

46. Congenital Abnormalities: Causes Can be roughly grouped into 3 categories Can be roughly grouped into 3 categories Maternal age is a risk-factor Maternal age is a risk-factor Over 35Over 35 More common in developed worldMore common in developed world CauseClassificationExample GeneticChromosomal Down syndrome Single gene Cystic fibrosis Environmental Infectious disease Congenital rubella syndrome Maternal nutritional deficiency (folic acid) Neural tube defects Complex Congenital malformations involving single organ system Congenital heart disease

47. Unintentional Injuries Similarly, increased general health results in a higher percentage of injury fatalities Similarly, increased general health results in a higher percentage of injury fatalities 15,000/year in developed and 273,000/year in developing (#9) 15,000/year in developed and 273,000/year in developing (#9) Drownings Drownings Road traffic accidents Road traffic accidents

48. MDG #4: Making progress? WHO World Health Report 2005: Make every mother and child count

49. Reducing child mortality depends largely on every mother and every child having the right to access health care from pregnancy through childbirth, the neonatal period, and childhood Reducing child mortality depends largely on every mother and every child having the right to access health care from pregnancy through childbirth, the neonatal period, and childhood MDG #4 : Making progress?

50. How to Foster the Decline in Child Mortality? Complicated with multiple factors involved Complicated with multiple factors involved NutritionNutrition Maternal healthMaternal health Both viral and bacterial causes for respiratory and diarrheal diseaseBoth viral and bacterial causes for respiratory and diarrheal disease Encourage medical care while discouraging overmedicating Encourage medical care while discouraging overmedicating Antibiotic resistanceAntibiotic resistance

51. Summary of Lecture Two Leading causes of mortality: ages 0-4 Developing world Developing world 1.Perinatal conditions 2.Lower respiratory infections 3.Diarrheal diseases 4.Malaria Developed world Developed world 1.Perinatal conditions 2.Congenital anomalies 3.Lower respiratory infections 4.Unintentional injuries

52. Next Class and Questions? Homework 1 is Due on 1/16 Homework 1 is Due on 1/16 Leading Causes of Mortality: ages 15-44 Leading Causes of Mortality: ages 15-44