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This presentation is a keynote address delivered by me in regional level conference of indian association of preventive and social medicine(IAPSM) in oct.2013 at goverment medical college haldwani,uttrakhand
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1
ESCALATING BURDEN OF CHD-an overview
DR HARIVANSH CHOPRA
D.C.H.,M.D
PROFESSOR
COMMUNITY MEDICINE
LLRM MEDICAL COLLEGE MEERUT
2
THREE REAL STORIESEighteen year
old smart boy son of a doctor suffered from myocardial infarction and could not be saved despite getting best available treatment
3
Thirty eight year old a famous specialist doctor, son of professor of Medicine Died at home on the first floor. Unfortunately no medical assistance was possible due to acuteness of episode
THREE REAL STORIES
4
THREE REAL STORIESFourty two year old
faculty member of a medical college had an episode of impending infarction and fortunately was given treatment in private sector in first thirty minutes and survived.
5
Facts 50% of Mortality in MI / CHD occurs in first thirty minutes
CHD is occurring a decade earlier in india as compared to developed countries.
Risk factor assessment is not prevalent in public health system
Deaths below 70 Years
• Gupta R. Burden of coronary heart disease in India. Indian Heart J 2005; 57 : 632-8.• Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 :
807-10.
Western countries India
23%
52%
Deaths due to NCDs
Deaths below 70 Years age
7
8
Non communicable diseases
50%Communicable diseases
40%
Injuries10%
Estimated percentage of deaths by cause in India, 2008
Source: Global Health Observatory. World Heath organization 2011
9
0%
10%
20%
30%
40%
50%
60%
70%
80%
38%
50%
16%15%
75%
14%
20042030
Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PloS Medicine, 2006, 3(11):e442.
Trends in estimated percentage of deaths by cause of death,
South-East Asia region, 2004 and 2030
10
Estimated burden of CHD in India
Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004; 328 : 807-10.
19902010
0
0.5
1
1.5
2
2.5
1.17
2.03
CHDs Burden In millions
11
0%
2%
4%
6%
8%
10%
12%
14%
12%
9%
3%
1%
Percentage of deaths due to CVDs* of subtype CVD, India, 2008
CVDs: Cardiovascular diseasesSource: Global Health Observatory. World Heath Organization 2011.
12
AGE
HYPERTENSION
SMOKING
DIABETES
DYSLIPIDEMIA
OBESITY/LACK OF EXERCISE
PREMATUREFAMILY HISTORY OF CAD
TRADITIONAL RISK FACTORS
NON TRADITIONAL RISK FACTORS
ABNORMAL ABI
HOMOCYSTEINUREA
METABOLIC SYNDROME
LVH
RENAL DISEASE
CALCIUM SCORE
CHRONIC INFLAMATION
CHRONIC INFLAMATORY DISEASE
LIPOPROTIEN a
HIV
BNP FIBRINOGEN
13
CRP
14
Schematic representation of an iceberg for NCDs
15
28%
72%
IDSP DATAMedicine OPD LLRM MEDICAL
COLLEGE,MEERUT 2012-13
NCD CD
16
57%16%
5%
22%
IDSP DATA OF MEDICINE OPD(Aug.2012-July 2013)
HTIHDDM IDM II
17
17%
3%
80%
OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM
medical college,meerut 2008
HTHT+DMOTHERS
18
26%
9%66%
OPD DATA ANALYSIS UHC,COMMUNITY MEDICINE,LLRM medical college,meerut
2009
HTHT+DMOTHER
19
TRADITIONAL RISK FACTORS
DIABETES
DIABETES
DIABETES
20
Diabetes mellitus: In India
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21 : 1414-31.
1995 2025
19.3
57.2
DM in Millions
20
21
ICMR estimates
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51.
Rural areaUrban area
3.80%
11.80%
Prevalence of Diabetes
21
22
MalesFemales
0%
2%
4%
6%
8%
10%
12%
11%11%
Percentage of adult population with raised blood glucose level*,
India, 2008
* Fasting glucose> 7.0 mmol/L or on medication for diabetesSource: World Health Organization. Global status report on non communicable diseases, 2010. Geneva, 2011
23
Diabetes: Top 10 Countries (absolute numbers)
24
PECULARITY OF CHD IN DIABETES
24
DIABETIC SUBJECTS HAVE 2-4 TIMES MORE RISK OF CHD
CHD MAY BE SILENT
OCCURS AT YOUNGER AGE
RESULT IN MICROVASCULAR ANGINA
WORSE OUTCOME FOLLOWING REVASCULARISATION
25
TRADITIONAL RISK FACTORS
HYPERTENSION
HYPERTENSION
HYPERTENSION
26
Males Females0%
5%
10%
15%
20%
25%
30%
35%
40%36%
34%
Percentage of adult population with high blood pressure*, India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability*Systolic BP>140 mmHg and stroke or diastolic BP>90 mmHg or using medication to lower BP
27
Hypertension:
• Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18 : 73-8.
Urban Rural0%
5%
10%
15%
20%
25%
30%
35%
40%
40%
17%
28
2000 2025
No. of Persons with HYPERTENSION
118 Million 214 Million
No. of Persons Dying from TOBACCO
900,000 2 Million +
Rising Chronic Disease Burdens
Source: Jha et al, NEJM, Feb 2008 . WHO infobase
29
TRADITIONAL RISK FACTORS
SMOKING SMOKING
SMOKING
30
Cigarette smoking
An alarming rate of current tobacco use of
56 % among
Indian men aged
12-60 yr.
31
Survey of sixth and eighth graders attending school in an urban setting revealed that the prevalence of tobacco use (any history of use or current use) was 2-3 times higher among sixth graders compared with eighth graders.
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005; 366 : 1746-51.
32
0%
10%
20%
30%
40%
50%
60%
70%
Males
Females
68%
61%
49%
30%
32%
22%
11%
4%
Percentage of adults, who are current users of tobacco products, by education, India,
2009
MalesFemales
Source: India Global Adult Tobacco Survey 2009
33
TRADITIONAL RISK FACTORS
NUTRITIONALDYSLIPIDEMIA
FAMILIALDYSLIPIDEMIA
METABOLICDYSLIPIDEMIA
34
Males Females0%
5%
10%
15%
20%
25%
30% 26%
29%
Percentage of adult population with raised total cholesterol,
India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability
35
TRADITIONAL RISK FACTORS
OBESITY
FAMILIAL METABOLIC
ENDOCRINAL
36
OBESITY RUNS IN THE FAMILY
NO BODY RUNS IN THE FAMILY
37
Overweight(BMI>=25 kg/m2)
Overweight(BMI>=30 kg/m2)
0%
2%
4%
6%
8%
10%
12%
14%
10.00%
1.30%
13.00%
2.50%
11.00%
1.90%
Percentage of adult population that is overweight and obese, India, 2008
MaleFemaleBoth sexes
Source: World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, 2011.Data adjusted for 2008 for comparability
38
Childhood obesity is an emerging issue.
In a Mysore (India) study on 43 152 school children, obesity and overweight prevalence was 3.4% and 8.5%, respectively.
39
NUTRITIONAL STATUS OF CHILDREN (5-15 YRS) IN URBAN MEERUT
48%
39%
10%
4%
Under weightNormal weightOver weightObese
40
Physical activity
Daily moderate intensity physical activity (e.g., the equivalent of briskly walking 35-40 min per day) is associated with
a 55 percent lower risk for CHD.
Rastogi T, Vaz M, Spiegelman D, Reddy KS, Bharathi AV, Stampfer MJ, et al. Physical activity and risk of coronary heart disease in India. Int J Epidemiol 2004; 33 : 759-67.
41
Male Female0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
14%
19%
Percentage of adults with in-sufficient physical activity,
India, 2008
Source: World Health Organization. Global status report on non communicable diseases 2010. Geneva, 2011.Data adjusted for 2008 based for comparability*Less than 30 minutes of moderate-to-vigorous activity at least five days a week.
42
Males Females0%
5%
10%
15%
20%
25%
21%
2%
Percentage of adults consum-ing alcohol*, by sex, India,
2007
Source: National NCD risk-factor surveys in Member countries*People who have consumed alcohol in the past 30 days.
43
2010 20500%
10%
20%
30%
40%
50%
60%
30%
55%
Projected mid-year popula-tion, residing in urban areas,
India, 2010-2050
Series 1
Source: World Urbanization Prospects. The 2007 Revision. Highlights. Department of Economic and Social Affairs Population Division.United Nations New York, 2008.
44
2006 2015 Cumulative GDP loss by 2015
0
4
8
12
16
20
1.35 1.96
17
Projected cost of cardiovascular disease in terms of lost GDP, India, 2006 and 2015
Fore
gon
e G
DP
*(U
S$
billion
s)
Source: Abegunde DO, et al. The burden and cost of chronic diseases in low-income and middle-income countries.Lancet 2007;370:1929-38.*GDP: Gross Domestic product
45
Cardiovascular disease
Hypertension Diabetes0
20
40
60
80
100
120
140
80
130
110
4232
55
20
0 1
Annual income loss from missed work, time for caregiving, and premature death among
household with a member suffering from NCD, India, 2004
Missed work
Caregiving
Premature death
Incom
e loss (
billion
ru
pees)
46
The total income loss due to chronic diseases in India was between Indian Rupee (INR) 1094–1113 billion.
Income loss due to hypertension : INR 199 billion
Due to diabetes: INR 163 billion
Due to CVDs : INR 144–158 billion
47
Physicians 2000-2010
Nursing and midwifery personnel 2000-2010
Public health workers 2000-2010
Community health workers2000-2010
Number
Density*
Number Density*
Number Density*
Number Density*
660801
6.0 1430555
13 --- --- 507150
0.5
Source: World Health Statistics 2011, World Health Organization 2011*per 10 000 population
Health workforce in India
Source: Global Health Observatory. World Heath organization 2011
All India Uttar Pradesh
Medical Colleges
381 27
M.B.B.S seats
44,418 2909
M.D- General Medicine
2266 122
D.M- Cardiology
269 23
Mch- Cardio-thorasic surgery
80 3
Annual Intake of medical students in India and Uttar Pradesh
Source: Medical Council of India
49
National Programme for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS)
Ministry of Health & Family Welfare GOI
c.
50
Objectives of NPCDCS
Prevent and control common NCDs through behavior and life style changes,
Provide early diagnosis and management of common NCDs,
Build capacity at various levels of health care for prevention, diagnosis and treatment of common NCDs,
51
Train human resource within the public health setup viz doctors, paramedics and nursing staff to cope with the increasing burden of NCDs, and
Establish and develop capacity for palliative & rehabilitative care.
Objectives of NPCDCS
52
India Map showing the States to implement NPCDCS
21 STATES
100 DISTRICTS
53
Packages of services to be made available at different levels under NPCDCS
At Sub Center Level:
Health promotion for behavior change
‘Opportunistic’ Screening using B.P measurement and blood glucose by strip method
Referral of suspected cases to CHC
54
At CHC Level:
Prevention and health
promotion including counseling
Early diagnosis through clinical
and laboratory investigations (Common lab investigations:
Blood Sugar, lipid profile, ECG, Ultrasound, X ray etc.)
55
At CHC Level:
55
Management of common CVD, diabetes and
stroke cases (out patient and in patients.)
Home based care for bed ridden chronic cases
Referral of difficult cases to District Hospital/
higher health care facility
At District Hospital Level:
Early diagnosis of diabetes, CVDs, Stroke and Cancer
Investigations: Blood Sugar, lipid profile, Kidney Function Test (KFT),Liver Function Test ( LFT), ECG, Ultrasound, X ray, colposcopy , mammography etc. (if not available, will be outsourced)
Medical management of cases (out patient , inpatient and intensive Care )
56
57
At District Hospital Level:
Follow up and care of bed ridden cases
Day care facility Referral of
difficult cases to higher health care facility
Health promotion for behavior change
58
Cardiac Care Unit (CCU) Support of Rs. 1.5 crores Functional in 20 districts so far
58
CCU at Pattanamthita, Kerala
CCU at Kupwara, J&K
Issues: Procurement of equipments Non availability of specialists Lack of space in some district hospitals
60
During 2010-12:
The strategies proposed will be implemented in
20,000 Sub Centres and 700 Community Health
Centre in 100 Districts across 21 States
61
Districts Covered during 2010-11 TOTAL
States- 21Distt.- 30 CHCs- 205 Sub Centers- 6482
62
Uttar Pradesh
Distt. Rae Bareli CHCs-11 Sub Centers-
377
Distt. Sultanpur CHCs-14 Sub Centers-
403
63
Screening for Diabetes and Hypertension -1 Logistics & training provided:
63
2010-11 2011-12 Total Glucometers 6617 21500 28117
Glucostrips 1.3crore 4.3 crore 5.6crore
Lancets 1.6crore 4.9crore 6.5crore
Training to Health Workers : completed in 82 districts (out of 100 districts, 4 districts of TN : logistics not required)
Target population : 5.6 crore
Screened: 1.02 crore, 3.48 to be screened
Suspected for diabetes : 7.5 lakh (7.4%)
Suspected for hypertension :6.5 lakh (6.5%)
64
MISSING LINK
Stress
Strength
Traffic
control
Redesign
Erase
Share
Surrender to God
STRESS
65
“Live sensibly - among a thousand people, only one dies a natural death; the rest succumb to irrational modes of living.” - Maimonides
66
Avoid alcohol Be physically active
Cut down on salt and sugar
Don’t use tobacco products
Eat plenty of fruits and vegetables
Being healthy is as easy as ABCDE
67