BIOE 301 Lecture Two:BIOE 301 Lecture Two:

Health Problems in the Health Problems in the Developed and Developed and

Developing World: Ages Developing World: Ages 0-40-4

Louise OrganLouise Organ

1.11.071.11.07

Review of Lecture OneReview of Lecture One

Course goalsCourse goals Four main questions we aim to Four main questions we aim to

addressaddress Technology assessmentTechnology assessment Introduction to world healthIntroduction to world health Health data and usesHealth data and uses

World Health Organization: WHOWorld Health Organization: WHO

Established by charter of the UN after Established by charter of the UN after World War IIWorld War II

Headquartered in GenevaHeadquartered in Geneva Mission:Mission:

• ““Attainment by all peoples of the highest Attainment by all peoples of the highest possible level of health”possible level of health”

Website:Website:• http://http://www.who.intwww.who.int/en//en/

Functions of the WHOFunctions 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 Member countries must provide certain info in regular reportscertain info in regular reports• Disease outbreaksDisease outbreaks• Health of populationHealth of population• Steps to improve healthSteps to improve health

Lecture TwoLecture Two

Health problems in developed and Health problems in developed and developing world: ages 0-4developing world: ages 0-4• Unit 1-What are the major health Unit 1-What are the major health

problems worldwide?problems worldwide?• Differences between developed and Differences between developed and

developing worddeveloping word• Understand disease/condition causes, Understand disease/condition causes,

treatments, and preventiontreatments, and prevention

World Mortality Rates (2002)World Mortality Rates (2002)

6.4%7.8%

85.8%

Developed Countries

9.5%

40.1%

50.4%

Developing Countries

Group 1 = communicable diseases, maternal/perinatal conditions, malnutritionGroup 2 = Non-communicable diseases (cardiovascular, cancer, mental disorders)Group 3 = Injuries

Infant and Child MortalityInfant and Child Mortality 8 UN Millennium Development Goals 8 UN Millennium Development Goals

(MGDs)(MGDs)• Goal 4: Reduce Child Mortality Goal 4: Reduce Child Mortality • Reduce by two-thirds, between 1990 Reduce by two-thirds, between 1990

and 2015, the under-five mortality rate and 2015, the under-five mortality rate WHO World Health Report 2005: WHO World Health Report 2005:

Make Every Mother and Child CountMake Every Mother and Child Count• Almost 11 million children under five will Almost 11 million children under five will

die in 2005 from causes that are largely die in 2005 from causes that are largely preventablepreventable

• 4 million babies who will not survive the 4 million babies who will not survive the first month of life first month of life

Causes of Child MortalityCauses of Child MortalityWHO 2005 World Health ReportWHO 2005 World Health Report

Causes of Child Mortality by RegionCauses of Child Mortality by Region

WHO 2005 World Health ReportWHO 2005 World Health Report

Leading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4 Developing worldDeveloping world

1.1. Perinatal conditionsPerinatal conditions

2.2. Lower respiratory infectionsLower respiratory infections

3.3. Diarrheal diseasesDiarrheal diseases

4.4. MalariaMalaria Developed worldDeveloped world

1.1. Perinatal conditionsPerinatal conditions

2.2. Congenital anomaliesCongenital anomalies

3.3. Lower respiratory infectionsLower respiratory infections

4.4. Unintentional injuriesUnintentional injuries

Perinatal ConditionsPerinatal Conditions

Period from 22 weeks of pregnancy Period from 22 weeks of pregnancy through the first week of lifethrough the first week of life

2.5 million children die from perinatal 2.5 million children die from perinatal conditionsconditions

> 500,000 women die as a > 500,000 women die as a consequence of pregnancy and consequence of pregnancy and childbirthchildbirth• Leading cause of death for women of Leading cause of death for women of

childbearing age in developing countrieschildbearing age in developing countries

Perinatal ConditionsPerinatal Conditions

3.3 million stillborn 3.3 million stillborn infants per yearinfants per year

Likely underestimates Likely underestimates as vital registration as vital registration rates and practices varyrates and practices vary• Countries with the Countries with the

highest mortality rates highest mortality rates tend to also have the tend to also have the lowest rates of vital lowest rates of vital registrationregistration

Common Perinatal Conditions Common Perinatal Conditions

Premature deliveryPremature delivery Low birth weightLow birth weight Birth asphyxiaBirth asphyxia

• Entangled umbilical Entangled umbilical cordcord

• Breech birthBreech birth

Common Perinatal Conditions Common Perinatal Conditions Birth traumaBirth trauma

• Mechanical forces encountered during Mechanical forces encountered during decent through the pelvic regiondecent through the pelvic region

• DALYDALY InfectionsInfections

• Umbilical cordUmbilical cord Non-sterile instrumentsNon-sterile instruments

• Organisms in the maternal genital tractOrganisms in the maternal genital tract• PATH kitPATH kit

http://www.path.org/http://www.path.org/

World Health Report: 1995 vs. 2005World Health Report: 1995 vs. 2005

37% Mortality Due to Neonatal 37% Mortality Due to Neonatal CausesCauses

Challenges to Reducing Perinatal Challenges to Reducing Perinatal ConditionsConditions

Lack of skilled birth attendants Lack of skilled birth attendants

Challenges to Reducing Perinatal Challenges to Reducing Perinatal ConditionsConditions

No adequate way to predetermine No adequate way to predetermine difficult birthsdifficult births

Cultural isolationCultural isolation• ““Birth” may not be celebrated until after Birth” may not be celebrated until after

perinatal period is overperinatal period is over Vital registration ratesVital registration rates Isolation may be positiveIsolation may be positive Delaying medical care can be negativeDelaying medical care can be negative

Lower Respiratory InfectionsLower Respiratory Infections

#2 in developing world & #3 in #2 in developing world & #3 in developeddeveloped

1 million children per year1 million children per year PneumoniaPneumonia

• Lung infectionsLung infections• Fever, cough, chest pain, weaknessFever, cough, chest pain, weakness

Until 1936 pneumonia was the Until 1936 pneumonia was the leading cause of death in the USleading cause of death in the US

Causes of PneumoniaCauses of Pneumonia A group of infectionsA group of infections

• Viruses, bacteria, and fungiViruses, bacteria, and fungi 50% bacterial50% bacterial

• Streptococcus pneumoniaeStreptococcus pneumoniae, , Haemophilus Haemophilus influenzaeinfluenzae, , Staphlococcus aureusStaphlococcus aureus, and , and pertussis (whooping cough)pertussis (whooping cough)

50% viral50% viral• SARSSARS• InfluenzaInfluenza• MeaslesMeasles

Coinfection is an increasing concernCoinfection is an increasing concern

Pneumonia: PhysiopathologyPneumonia: Physiopathology Bacteria or virus invades lungsBacteria or virus invades lungs Immune response causes fluid and Immune response causes fluid and

puspus Filled alveoli have limited gas Filled alveoli have limited gas

exchangeexchange

Identifying PneumoniaIdentifying Pneumonia Etiology affects treatment Etiology affects treatment Chest X-raysChest X-rays Blood testsBlood tests Examine Examine

sputum/secretionssputum/secretions Direct Fluorescence Assay (DFA)Direct Fluorescence Assay (DFA)

• Collect sample and separate cellsCollect sample and separate cells• Fix cells onto slide and immerse in Fix cells onto slide and immerse in

alcoholalcohol• Apply solution containing antibodiesApply solution containing antibodies• Apply second antibody coupled to Apply second antibody coupled to

fluorescent dyefluorescent dye• View with fluorescent microscopeView with fluorescent microscope

Pneumonia: TreatmentPneumonia: Treatment Viral Viral

• Usually resolves on its ownUsually resolves on its own• Severe cases: oxygen and antiviral drugsSevere cases: oxygen and antiviral drugs

BacterialBacterial• Treat with antibioticsTreat with antibiotics

Because the etiologies are hard to detect Because the etiologies are hard to detect WHO recommends antibiotics for all WHO recommends antibiotics for all children with pneumoniachildren with pneumonia• Proven to reduce mortality in developing worldProven to reduce mortality in developing world• May also foster the development of resistant May also foster the development of resistant

strainsstrains

Diarrheal DiseaseDiarrheal Disease

#3 in developing world#3 in developing world Gastrointestinal disorders Gastrointestinal disorders

characterized by frequent, watery characterized by frequent, watery stoolsstools

Bacterial infectionBacterial infection• Escherichia coliEscherichia coli• Vibrio choleraeVibrio cholerae

Viral infectionViral infection• RotavirusRotavirus

Diarrheal Disease: CholeraDiarrheal Disease: Cholera

Spread by water or food Spread by water or food contaminated with bacteriacontaminated with bacteria

Often a result of inadequate Often a result of inadequate sewage and water treatmentsewage and water treatment

Outbreaks were Outbreaks were common, historically, common, historically, and remain a concernand remain a concern• Rwandan refugeesRwandan refugees

Diarrheal Disease is often a result Diarrheal Disease is often a result of unsafe water sourcesof unsafe water sources

Access to Safe Water (2000)Access to Safe Water (2000)

Diarrheal DiseaseDiarrheal Disease

Normally, 98% of the water intake from Normally, 98% of the water intake from food or liquid is reabsorbed by epithelial food or liquid is reabsorbed by epithelial cells in the lower digestive tractcells in the lower digestive tract

Diarrheal disease rapidly leads to extreme Diarrheal disease rapidly leads to extreme dehydration and deathdehydration and death

The loss of body fluid leads to dangerously The loss of body fluid leads to dangerously low blood pressurelow blood pressure

10% loss of volume is sufficient to cause 10% loss of volume is sufficient to cause deathdeath

Treatment must effectively and efficiently Treatment must effectively and efficiently replace fluidsreplace fluids

Diarrheal Disease: PhysiopathologyDiarrheal Disease: Physiopathology

Epithelial cells line the entire GI tractEpithelial cells line the entire GI tract Different regions have varying specific Different regions have varying specific

mechanisms but all work to reabsorb mechanisms but all work to reabsorb osmotically active nutrients and salts osmotically active nutrients and salts

To maintain osmotic balance, water To maintain osmotic balance, water follows and is eventually reabsorbed into follows and is eventually reabsorbed into the blood vesselsthe blood vessels

Toxins produced by bacteria inhibit sodium Toxins produced by bacteria inhibit sodium uptake from the lumen and cause uptake from the lumen and cause epithelial cells to secret chloride into the epithelial cells to secret chloride into the lumen lumen • Double whammy!Double whammy!

Oral Rehydration Therapy (ORT)Oral Rehydration Therapy (ORT) A simple, inexpensive mixture of A simple, inexpensive mixture of

water, salt, and sugarwater, salt, and sugar• 1 liter boiled water, 1 tsp. salt, 8 tsps. 1 liter boiled water, 1 tsp. salt, 8 tsps.

sugarsugar Developed in 1960s and responsible Developed in 1960s and responsible

for a dramatic decrease in the for a dramatic decrease in the mortality rates of diarrheal diseasesmortality rates of diarrheal diseases

Why Does ORT Work?Why Does ORT Work?

Giving sterile water or salt water Giving sterile water or salt water alone is not sufficientalone is not sufficient

Discovery of a sodium reabsorption Discovery of a sodium reabsorption mechanism that is coupled to mechanism that is coupled to glucose transportglucose transport• 1950s1950s• Unaffected by cholera toxinUnaffected by cholera toxin

In 1960s shown to result in a net In 1960s shown to result in a net reabsorption of water into the reabsorption of water into the bloodstreambloodstream

Oral Rehydration TherapyOral Rehydration Therapy 1975 WHO and UNICEF standard1975 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 centsPacket of ORT costs ~10 cents ORT treats a symptom ORT treats a symptom

(dehydration) not the disease (dehydration) not the disease (or organism)(or organism)• The volume of diarrhea usually The volume of diarrhea usually

remains unchangedremains unchanged

ORT use in the USORT use in the US Rarely usedRarely used More expensive and More expensive and

painful IV therapy is far painful IV therapy is far more commonmore common• Even when ORT is Even when ORT is

sufficient and acceptable sufficient and acceptable treatmenttreatment

Likely due to initial troubles with original Likely due to initial troubles with original formulations (50’s-60’s)formulations (50’s-60’s)• Elevated sodium levelsElevated sodium levels• Inaccurate mixingInaccurate mixing

Diarrheal Disease in the USDiarrheal Disease in the US

Second leading cause of US pediatric Second leading cause of US pediatric emergency room visitsemergency room visits

E. coliE. 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

RotavirusRotavirus• Causes ~30% of diarrheal disease deathsCauses ~30% of diarrheal disease deaths• Ubiquitous and highly contagiousUbiquitous and highly contagious

Rotavirus VaccineRotavirus Vaccine Almost every child will be infected with a Almost every child will be infected with a

rotavirusrotavirus• 50,000 child hospitalizations annually50,000 child hospitalizations annually

Vomiting also occurs, so ORT can be Vomiting also occurs, so ORT can be difficult although still effectivedifficult although still effective

RotaShield was FDA approved in 1998RotaShield 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 concernsEthical concerns• Complications vs. potential lives savedComplications vs. potential lives saved• Mortality disparity in developed vs. developing Mortality disparity in developed vs. developing

worldworld

MalariaMalaria #4 mortality rate of children under 5 in #4 mortality rate of children under 5 in

developing worlddeveloping world Spread by Spread by AnophelesAnopheles mosquitoes which mosquitoes which

carry a parasite that infects humanscarry a parasite that infects humans 300 million cases 300 million cases

annuallyannually African children: 1.6-African children: 1.6-

5.4 episodes/year5.4 episodes/year 1 million under the 1 million under the

age of 5 die each age of 5 die each yearyear

CDC/ James Gathany

Malaria: PhysiopathologyMalaria: Physiopathology Mosquito transfers sporozoites which infect Mosquito transfers sporozoites which infect

and rupture liver cells releasing merozoitesand rupture liver cells releasing merozoites Invade RBCs and either repeat a similar Invade RBCs and either repeat a similar

cycle or form gametocytescycle or form gametocytes Gametocytes are Gametocytes are

free in bloodfree in blood Ingested during biteIngested during bite Reproduce in Reproduce in

mosquito to form mosquito to form new sporozoitesnew sporozoites

http://www.cdc.gov/malaria/biology/life_cycle.htm

Malaria: PhysiopathologyMalaria: Physiopathology Blood stage is time of clinical Blood stage is time of clinical

manifestation and diagnosismanifestation and diagnosis Burst RBCs result in anemiaBurst 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 RBC Gametocyte

Malaria: Drug TreatmentsMalaria: Drug Treatments

Chloroquine, sulfadoxine-Chloroquine, sulfadoxine-pyrimethamine, quininepyrimethamine, quinine

Relatively inexpensiveRelatively inexpensive• Cents/courseCents/course

Malaria parasites now show resistanceMalaria parasites now show resistance• Chloroquine resistance in AfricaChloroquine resistance in Africa

New therapy development is slowNew therapy development is slow• Non-syntheticNon-synthetic• ExpensiveExpensive

Malaria: PreventionMalaria: Prevention Insecticide treated netsInsecticide treated nets Cheap ~ $2Cheap ~ $2 Must be retreated, ~ 5 centsMust be retreated, ~ 5 cents Shown to reduce low birth weights by Shown to reduce low birth weights by

25%25% Proven to reduce mortality rate in Proven to reduce mortality rate in

young children by 20%young children by 20% April 25, 2007 is April 25, 2007 is

Malaria AwarenessMalaria Awareness

DayDay

Leading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4 Developing worldDeveloping world

1.1. Perinatal conditionsPerinatal conditions

2.2. Lower respiratory infectionsLower respiratory infections

3.3. Diarrheal diseasesDiarrheal diseases

4.4. MalariaMalaria Developed worldDeveloped world

1.1. Perinatal conditionsPerinatal conditions

2.2. Congenital anomaliesCongenital anomalies

3.3. Lower respiratory infectionsLower respiratory infections

4.4. Unintentional injuriesUnintentional injuries

Congenital AbnormalitiesCongenital Abnormalities

2-3% of all children have birth defect2-3% of all children have birth defect 400,000 deaths annually400,000 deaths annually As general health increases, As general health increases,

congenital abnormalities rise as a congenital abnormalities rise as a cause of mortalitycause of mortality• #2 in developed world#2 in developed world

Congenital Abnormalities: CausesCongenital Abnormalities: Causes

Can be roughly Can be roughly grouped into 3 grouped into 3 categoriescategories

Maternal age is Maternal age is a risk-factora risk-factor• Over 35Over 35• More common More common

in developed in developed worldworld

CauseCause ClassificationClassification ExampleExample

GeneticGenetic ChromosomalChromosomal Down Down syndromesyndrome

   Single geneSingle gene Cystic Cystic fibrosisfibrosis

EnvironmentalEnvironmental Infectious Infectious diseasedisease

Congenital Congenital rubella rubella

syndromesyndrome

   Maternal Maternal nutritional nutritional deficiencydeficiency(folic acid)(folic acid)

Neural tube Neural tube defectsdefects

ComplexComplex Congenital Congenital malformations malformations

involving involving single organ single organ

systemsystem

Congenital Congenital heart heart

diseasedisease

Unintentional InjuriesUnintentional Injuries

Similarly, increased general health Similarly, increased general health results in a higher percentage of results in a higher percentage of injury fatalitiesinjury fatalities

15,000/year in developed and 15,000/year in developed and 273,000/year in developing (#9)273,000/year in developing (#9)

DrowningsDrownings Road traffic accidentsRoad traffic accidents

MDG #4: Making progress?MDG #4: Making progress?

WHO World Health Report 2005: Make every mother and child count

Reducing child mortality depends largely on Reducing child mortality depends largely on every mother and every child having the right every mother and every child having the right to access health care from pregnancy through to access health care from pregnancy through childbirth, the neonatal period, and childhoodchildbirth, the neonatal period, and childhood

MDG #4 : Making progress?MDG #4 : Making progress?

How to Foster the Decline in Child How to Foster the Decline in Child Mortality?Mortality?

Complicated with multiple factors Complicated with multiple factors involvedinvolved• NutritionNutrition• Maternal healthMaternal health• Both viral and bacterial causes for Both viral and bacterial causes for

respiratory and diarrheal diseaserespiratory and diarrheal disease Encourage medical care while Encourage medical care while

discouraging overmedicatingdiscouraging overmedicating• Antibiotic resistanceAntibiotic resistance

Summary of Lecture TwoSummary of Lecture TwoLeading causes of mortality: ages 0-4Leading causes of mortality: ages 0-4

Developing worldDeveloping world1.1.Perinatal conditionsPerinatal conditions2.2.Lower respiratory infectionsLower respiratory infections3.3.Diarrheal diseasesDiarrheal diseases4.4.MalariaMalaria

Developed worldDeveloped world1.1.Perinatal conditionsPerinatal conditions2.2.Congenital anomaliesCongenital anomalies3.3.Lower respiratory infectionsLower respiratory infections4.4.Unintentional injuriesUnintentional injuries

Next Class and Questions?Next Class and Questions?

Homework 1 is Due on 1/16Homework 1 is Due on 1/16 Leading Causes of Mortality: ages 15-Leading Causes of Mortality: ages 15-

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