Double Burden of Disease emphasis on developing countries and ...


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Double Burden of Disease emphasis on developing countries and ...

  1. 1. Double Burden of Diseases emphasis on developing countries and emerging economies Ib Bygbjerg
  2. 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. 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. 4. Interactions between ACTs for malaria and cART for hiv/aids in co-infected patients in Muheza, Tanzania Acronym: InterACT
  5. 5. A blessing in disguise: protection from dying from malaria by sickle trait Map courtesy of MARA Malaria endemicity
  6. 6. HIV and opportunistic cancer:
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 16. End anaemia, malaria, eclampsia, gestational diabetes… And not only Malaria!