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  • 1. Double Burden of Diseases emphasis on developing countries and emerging economies Ib Bygbjerg
  • 2. Double Burden of infectious diseases (communicable) • HIV plus TB → 4-8-fold higher risk of active TB • HIV plus HBV → 2-fold higher risk of cirrhosis • HIV plus HPV → 8-fold higher risk of c. cervicis • Malaria increases risk of HIV progression • Leishmaniasis becomes (almost) untreatable in HIV • HBV increases risk of Schistosomiasis hepatic fibrosis • Double ’burden’ of drugs: Interaction: additive, synergistic, antagonistic effects, increased or decreased side-effects, example: ACT (artemisinin combination antimalarials) + ARV (antiretrovirals) ??
  • 3. Map courtesy of MARA HIV Prevalence with emphasis on Africa, vs. Malaria Endemicity in Africa source: WHO/HIV/2004.08 Map courtesy of MARA
  • 4. Interactions between ACTs for malaria and cART for hiv/aids in co-infected patients in Muheza, Tanzania Acronym: InterACT
  • 5. A blessing in disguise: protection from dying from malaria by sickle trait Map courtesy of MARA Malaria endemicity
  • 6. HIV and opportunistic cancer:
  • 7. Double burden of NCD and CD • Table 1 Evolution and projection of communicable and non-communicable diseases deaths in developing countries (in millions) Year Non- CD + maternal +perinatal Injuries Total Comm.Dis + nutritional n (%) 1990 18.7 (47) 16.6 (42) 4.2 (11) 39.5 (100) 2000 25.0 (56) 14.6 (33) 5.0 (11) 45.0 (100) 2020 36.6 (69) 09.0 (17) 7.4 (14) 53.0 (100) • Sources: Burden of Disease Unit, 1990; Mathers et al., 2003; WHO, 2003a.
  • 8. Question1: which NCDs may negatively impact CDs – and vice versa? • Very recent example: Padmakumar et al, SE Asian J Trop Med Pub Health 2010;41:85-96 • Overweight and Obesity as risk factor for Chikungunya sequelae: • Obesity independent risk factor for arthritis, OR 2.0
  • 9. Question2: which NCDs may negatively impact CDs – and vice versa? • Very old example: Avicenna ca. 980 AD Diabetes increases the Risk for TB
  • 10. Old –almost forgotten knowledge on DM & TB interaction • ’At autopsy every case of diabetes had tubercles in the lungs’. Bouchardat,1883. • ’In latter half of 19th century, the diabetic pt. appeared doomed to die of pulmonary TB if he succeeded in escaping coma’ Root, 1934: • 1121 DM autopsies: TB occured 2 – 3 x more frequently than expected
  • 11. DM increases the risk of TB: a systematic review of 13 observational studies. Jeon CV & Murray MB. Plos Med 2008 Systematic review and meta-analysis of total of 1.786.212 participants with 17.698 TB cases • DM was associated with increased risk of TB, regardless of study design and population • Cohort studies: RR = 3,11 (95% CI 2.27-4.26) • Case-Control studies: OR = 1.16-7.83 • Estimates higher in non-N-American studies
  • 12. What we do not know, or do not know enough of: • Does TB increases risk of DM as much as DM increases risk of TB? • Who should be screened for DM and who for TB and who for both? • Where, When and How to screen for DM and TB if resources are few? • How and where and by whom should ptt. with both diseases be managed if resorces few? • How do DM and TB interact (pathophysiology, immune-mechanisms, drugs)?
  • 13. Conclusion & Implications 2. • Of several key research questions, we identified 4 high priority research areas: • whether and how to screen for TB in patients with DM and how and when to screen for DM in TB patients; • impact of DM on TB treatment outcomes and deaths; • implementation and evaluation of the TB “DOTS” model for DM management; • (and the development and evaluation of point-of-care glycosylated haemoglobin (Hb1AC) tests for all patients with DM). May 2009 second systematic review, followed in November by an expert meeting in Paris
  • 14. Last question: CD in mother increasing risk for developing NCD in child? • Very crazy example: ongoing • If low birth weight (LBW) due to placental insufficiency, twins and hunger in pregnancy is associated with premature development of insulinresistance and DM, • Would LBW from malaria not be associated? • Could DM be prevented by preventing malaria in pregnancy?
  • 15. Placental malaria • A malaria-infected human placenta is unable to carry out normally its main functions: • to provide O2 & nutrients to the foetus Malaria-infected human placenta examined under the microscope. The intervillous spaces are filled with red blood cells, most of which are filled with malaria parasites (black dots)
  • 16. End anaemia, malaria, eclampsia, gestational diabetes… And not only Malaria!