sri lanka - current situation in control strategies and health systems in asia
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Current Situation in Control Strategies and Health Systems in Asia - Sri Lanka by Rasnayaka M Mudiyanse, Senior Lecturer in Paediatrics at the University of Peradeniya and Consultant Paediatrician at the Teaching Hospital in Peradeniya.TRANSCRIPT
Thalassaemia in Sri Lanka; l d iPrevalence and Prevention
Rasnayaka MMudiyanseRasnayaka M Mudiyanse
Country – Sri LankaCountry Sri Lanka• Size – 65 610 km2
• Population – 20 653 million• Per capita income 2399 USD• Per capita income 2399 USD• Nine province 25 Districts Grama Seva divisions
ffi 500 1000 f ilione officer per 500 – 1000 families • Nine Provincial Directorates of Health 291 Medical Officer of Health (MOH) 43 PHM per 100 000 population
• Total Births (2010) ‐ 364 565• Total Marriages (2010) ‐ 200 985Total Marriages (2010) 200 985
Country – Sri LankaCountry Sri Lanka
• Life expectancy – M 68 1 F 76 6 yrs• Life expectancy – M‐68.1, F ‐76.6 yrs • Literacy ratio ‐ 92%. y• Vaccination coverage ‐ 90%. • CMR – 10.4 per 1000 live births• IMR 8 5 per 1000 live births• IMR – 8.5 per 1000 live births• NMR ‐ 5.9 per 1000 live births p• MMR ‐ 14.2 per 100 000 births
History of Thalassaemia in Sri LankaHistory of Thalassaemia in Sri Lanka
• 1950 – four cases of Cooley’s anemia in Sinhalees by C C De Silva at ely
• 1959 – 15 cases of HbE beta thalassaemia C C De Silva and NagarathnamDe Silva and Nagarathnam
• 1962 – Three families with Hb S • 1995 – 2011 – more advanced studies 1 C C d SILVA d C E S WEERATUNGE COOLEY'S ANAEMIA IN SINHALESE1. C. C. de SILVA and C. E. S. WEERATUNGE , COOLEY'S ANAEMIA IN SINHALESE CHILDREN , Achieves of disease of childhood 19502. N. SAHA and B. BANERJEE idence of Abnormal Haemoglobins in Different Ethnic G f I di H tik 11 300 303 (1971)Groups of Indians Humangenetik 11,300‐‐303 (1971)3. C. C. DE SILVA, M.D., F.R.C.P. D. T. D. BULUGAHAPITIYA, M.B., B.S. JUSTIN DE SILVA SINHALESE FAMLY WITH HAEMOGLOBIN S BY BRITISH MEDICAL JOURNAL June 2 1962
Thalassaemia in Sri Lanka ‐ Prevalence Sri Lanka Wayamba
Beta thalassaemia 2350 220
Hb E /b t th l 1060 260Hb E /beta thal.. 1060 260
Total number of pts 3410 480Total number of pts 3410 480
Gene frequency beta 0 011 0 0125Gene frequency beta 0.011 0.0125
Gene frequency e bata 0.0025 0.0075
1. Anuja Premawardana, Life Sciences & Medicine, Human Molecular Genetics Volume13, Thalassemia in Sri Lanka: a progress report ,2 Shanthimala de Silva Lancet 2000: 355: 786 91 Thalassaemia in Sri Lanka:2. Shanthimala de Silva, Lancet 2000: 355: 786–91, Thalassaemia in Sri Lanka: implications for the future health burden of Asian populations
National Survey on Prevalence ofNational Survey on Prevalence of thalassaemia in Sri Lanka ‐ 2011
ObjectivesObjectives
• To establish national prevalence dataT l t th tt f d• To evaluate the pattern of drugs usage by institutionusage by institution
• To evaluate serum ferritin levels• To predict the minimal incidence
MethodologyMethodology
• Permission from the ministry of health SL• Contacted all the institutions with facilities for blood transfusion
• Collect data• Collect data – Age or date of birth– Sex– Diagnosis (beta thalassaemia, E beta, HB S or other)– Last ferritin level– Amount of chalation drugs used by the institution g y
ResultsResults
• Total number of institutions contacted –42 out of 8142 out of 81
• Hospitals with at least one patient ‐19• Total number of patients traced ‐ 1547
(• Details available up to date – 1379 ( 11 hospitals)hospitals)
Evaluation of 1379 patientsEvaluation of 1379 patients
• Male ‐ 668 (48.4%) F l 711 (51 6%)• Female ‐711 (51.6%)
• beta thalassaemia – 926 (67 1%)• beta thalassaemia – 926 (67.1%) • e beta thalassaemia ‐ 305 (22.1%)e beta thalassaemia 305 (22.1%) • Others – 148 ( 10.7%)
Average age after evaluation of 1231 patients
• Global average age ‐ 12.6 (SD 5.9) yrs• Beta thalassaemia• Beta thalassaemia
– male 11.9 ( SD 3.8) yrs– female 11.4 (SD 4.8) yrs
• HbE/Beta thalassaemia• HbE/Beta thalassaemia – Male ‐ 5.3 (SD 6.0) yrs– Female 16.1 (SD 5.6) yrs.
Thalassaemia in Sri Lanka ‐ Prevalence
Lancet 2000 National survey 2011 ‐ 20122011 2012
Beta thalassaemia 2350 1020 ( 64.8%)/ ( )Hb E /beta thal 1060 348 ( 22.1%)
Total patients 3410 1574 Total patients 34 0 574
Gene frequency B t
0.011(CR 2 2%)
0.0073( C R 1 45%)Beta (CR 2.2%) ( C.R. – 1.45%)
Gene frequency E 0.0025 0.0013 beta (C.R. ‐0.5%) ( C.R.‐ 0.257%)Incidence 60‐80 66
Shanthimala de Silva at el Lancet 2000: 355: 786–91, Thalassaemia in Sri Lanka; ……..
Age Frequency Distribution1231 patients
250
300
200
150Series1
100
0
50
0‐4 yrs 5‐9 yrs 10‐14 yrs
15‐19 yrs
20‐24 yrs
25‐29 yrs
30‐34 yrs
35‐39 yrs
40‐44 yrs
45‐49 yrs
50‐54 yrs
55‐59 yrs
60‐64 yrs
65‐69 yrs
70‐74 yrs
75‐79 yrs
Incidence of thalassaemia in SL?450
Incidence of thalassaemia in SL?
350
400
250
300
200
250
100
150
0
50
5‐9 yrs 10‐14 yrs 15‐19 yrs
Live Deaths
Th l i P tiThalassaemia Prevention
Teenage screening and promoting safe marriages by motivating the
bli th h d tipublic through education
Thalassaemia PreventionThalassaemia Prevention
• Education campaign• Screening protocol • Strategy of Prevention• Monitoring the progress
Education to Promote ScreeningEducation to Promote Screening
• School children – Examination question • Higher education institutionsHigher education institutions• General public
– Media– Lectures
• ProfessionalsH lth– Health
– Registrar of marriages, GS
Screening ProtocolRoutine process
• Step 1 – FBC – above 15 yrs, volunteer – Green card if MCV > 80 fl and MCH > 27 pg– Iron therapy if MCV = or < 80 fl or MCH = or < 27 pg
• Step 2 – Repeat FBC after 3 mo Iron therapyStep 2 Repeat FBC after 3 mo Iron therapy– Green card if MCV > 80 fl and MCH > 27 pg
HPLC if MCV 80 fl MCH 27– HPLC if MCV = or < 80 fl or MCH = or < 27 pg
• Step 3 – HPLC for confirmation– Pink card and counseling for confirmed carriers– If HPLC is negative hematologists opinion g g p
Screening Protocolwho need early results
• Step 1 – FBC and HPLC – Green card if MCV > 80 fl and MCH > 27 pgpg– Red card for HPLC positive thal traits Iron therapy if MCV or < 80 fl or MCH or < 27– Iron therapy if MCV = or < 80 fl or MCH = or < 27 pg
• Step 2 – Repeat FBC and HPLC after 3 mo of Iron therapy– Evaluate for false positive HPLC or MCV/MCH
Counseling and EducationCounseling and Education
Monitoring the Prevention ProgramMonitoring the Prevention Program
• Percentage of screen coverage (by PHM division)
• Incidence of high risk marriages• Incidence of high risk marriages• Incidence of high risk pregnanciesIncidence of high risk pregnancies• Incidence of thalassaemia births
Percentage of ScreeningPercentage of Screening
• At PHM level • 1000 families per PHM• 1000 families per PHM• Indicator of success of educational campaign
f• Indicator of success• 50% screening 75% reduction of• 50% screening 75% reduction of incidence high risk pregnancies
Incidence of High Risk MarriagesIncidence of High Risk Marriages
• To be reported by the registrar of marriages• One registrar of marriage register 500 – 1000One registrar of marriage register 500 1000 marriages per year
• When to inquire about thalassaemia statusq• Maintaining confidentiality• Both partners have the right to know
Incidence of High Risk PregnanciesIncidence of High Risk Pregnancies
• All the mother are registered• From antenatal clinicFrom antenatal clinic• Late to know but help to monitor
Incidence of Thalassaemia BirthsIncidence of Thalassaemia Births
• To be reported by pediatricians• Late indicatorLate indicator• Helps to plan the management
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