How Simple Everyday Routines Make Us Vulnerable to Dangerous Infectious diseases

Simple everyday routines put us a step closer to contracting infectious diseases.

Simple everyday routines put us a step closer to contracting infectious diseases.

Infectious diseases contribute to poor health and mortality with a huge impact observed in developing countries. In most of these countries rural and poor populations are the most affected. This is mostly due to preexisting conditions e.g their surroundings (environment), weather conditions, lack of or limited health infrastructure and personnel, poor transportation systems and lack of resources within the population.

With such limited resources livelihoods that involve natural resources such as farming, fishing, artisan work and rearing of livestock are common among rural populations and these provide the needed food and income for these communities. These livelihoods also expose populations to various disease causing agents some of which cause serious and often fatal disease. The source of these disease causing agents include domestic and wild animals, birds, the environment, water, food, soil and infected human beings within the population. With the risk of disease, limited health infrastructure and poverty/hardship.

Imagine waking up with a small painless swelling on your limb or upper body. As days go by it ruptures, as you try to treat it with general wound cleaning and dressing agents, it does not seem to respond. Then one day it becomes this big gaping wound that is not healing but keeps growing. With time you are unable to use your limb or the affected area. The wound keeps growing and soon you can see your bone.

Imagine waking up with a small painless swelling on your limb or upper body. As days go by it ruptures, as you try to treat it with general wound cleaning and dressing agents, it does not seem to respond. Then one day it becomes this big gaping wound that is not healing but keeps growing. With time you are unable to use your limb or the affected area. The wound keeps growing and soon you can see your bone. It sounds like a scene from a horror movie, but this is a reality in some parts of the world.

BURULI ULCER

Buruli ulcer also known as Bairnsdale ulcer, Searls ulcer, Daintree ulcer, Kumusi ulcer, and mycoburuli ulcers, is a neglected tropical disease affecting populations in parts of Africa, Australia, South America and the Western Pacific regions. The disease has been reported in 33 countries with 15 regulary reporting to WHO.

It is the third common mycobacterium disease after TB and Leprosy. Buruli ulcer is caused by a bacteria, Mycobacterium ulcerans.

Lesions occur mostly on the limbs (55% on the lower limbs, 35% on the upper limbs) but can also on other parts of the body (10%). Early identification of the lesions helps prevent long hospital stays and is less costly compared to late presentation of disease.

DISEASE CLASSIFICATION
The disease is classified into three categories with regard to severity:

Category 1; Single small lesion (32%)
Category 2; Non-ulcerative and ulcerative plaque and oedematous forms (35%)
Category 3; Disseminated and mixed forms such as osteitis, osteomyelitis, joint involvement (33%).

In developed countries such as Australia and Japan, most lesions (>90%) are diagnosed in Category 1, while approximately 70% of cases are diagnosed at ulceration stage (Category 2) in all the reporting countries.

Until 2005 the only treatment was surgery.

Until 2005 the only treatment was surgery. In some cases people can be hospitalized up to 3 years. Physiotherapy is needed to help return movement in the affected limbs, while community involvement/volunteer and education crucial in early detection of disease

AFFECTED POPULATION

Affecting mostly children under the age of 15, 48% in Africa, 10% in Australia and 19% in Japan, the disease has caused debilitating effects on the affected individuals. Late presentation of the disease could mean excessive loss of tissue, infection of the bone which in turn requires surgical procedures and sometimes amputation of the limb. Since 2005 a combination of antibiotics has been used to treat buruli ulcer, this has helped many people in the affected regions as these antibiotics can cure the disease and in some cases prevent recurrence of the disease.

Antibiotics can cure the disease and in some cases prevent recurrence of the disease

The majority of cases are reported from West Africa, but Australia has seen an increase in cases in recent years.

Even though it is suspected that Buruli ulcer could be contracted from the environment or from an insect bite, the source of infection and mode of transmission is not yet known. It is therefore very difficult to know how to control and prevent the spread of the disease.

Most rural populations in endemic areas are vulnerable to the disease due to lack of knowledge on the source and mode of the disease. As they go about their livelihood they don’t know when the disease will strike.  The patients suffering from the disease are not sure how they got the disease, as most go to the hospital at a later stage, the majority when the ulcer appears. Patient history has allowed researchers and medical personnel to build timelines and suggest the various ways in which the disease could have been contracted. Some people take as long as 2 years from the time of appearance of a nodule (early stage of buruli ulcer) to the time they seek medical attention. During this time the bacteria responsible for the disease, M. ulcerans, is replicating and eating away tissue under the skin. Late identification of disease has resulted in  long hospitalization and is very costly.

Since the disease largely affects the limbs, with the majority on lower limbs (55%), upper limbs (35%) and the upper body (10%), livelihoods and families are disrupted. Children affected by the disease may spend months and sometimes years being treated in hospitals. This not only affects their education but it is a major psychological trauma, and the disease often causes serious disfigurement requiring long periods of rehabilitation. The parents of these children spend most of their income on treatment costs, some losing their businesses and livelihood.

Whilst reviewing some of the buruli ulcer cases in Ghana, most of the narratives associated the disease with marshy areas, water pools (in areas where there was sand and or gold mining), boreholes and insect bites. In Australia, the current cases in Victoria have been associated with the Bellarine and Mornington Peninsulla, where marshy areas also exist. Various avenues are being explored to search for animal reservoirs, as well as studying the environments where people are suspected to have contracted the disease.

While in Australia and Japan (developed countries where the disease is endemic) patients have access to advanced medical care, many in rural areas of developed countries are not able to access such kind of health care. Due to loss of livelihood and income, facing challenges with transportation and movement of the sick, or lack of support from family and the community due to stigma, many report the disease late and or chose to go to herbalists or tribal healers .

The challenges posed by buruli ulcer in rural communities require serious intervention. in Cameroon, Ghana and Benin, village community volunteers trained to identify the early stages of buruli ulcer have succeeded in identifying patients and referring them for treatment at the designated treatment centers.

village community volunteers trained to identify the early stages of buruli ulcer have succeeded in identifying patients and referring them for treatment at the designated treatment centers

This has not only assisted in early identification of disease but also averted serious infections that could have resulted in surgery or amputation of limbs. Community interventions including showing films on buruli ulcer to debunk myths on the disease, have helped bring awareness to the people.

Community interventions including showing films on buruli ulcer to debunk myths on the disease, have helped bring awareness to the people.

Campaigns are also ongoing to help with early identification of disease. It was observed that up to 78% of children infected by buruli ulcer do get cured, but adults usually report the disease at a very late stage and these ulcers are difficult to heal.

FACTS:

  • Parents are the ones who can take their children for treatment, therefore the decision they make regarding treatment is crucial. Bringing awareness to parents and the children regarding buruli and other NTDs and how treatment seeking behaviour plays a role in disease outcome gives them the needed information to understand the importance of early treatment.

 

  • Buruli ulcer affects livelihoods, children drop out of school, adults lose their jobs or are not able to work like they used to due to long treatment and debilitating effects as a result of disease.

 

  • Marshy areas seem to be a common denominator in the affected regions.

 

The plight of certain populations to buruli ulcer and NTDs is to some extent due to preexisting conditions within their surrounding and environment.

The plight of certain populations to buruli ulcer and NTDs is to some extent due to preexisting conditions within their surrounding and environment. Limited resources in poor rural populations have driven people to work in risky environments thereby exposing them to infectious disease causing agents. The lack of knowledge on the source  and mode of transmission of buruli ulcer creates enormous challenges with regard to disease control and prevention.

References 

Sopoh, G. E., Thierry Barogui, Y., Johnson, R. C., Dossou, A. D., Makoutodé, M., Vé Rin, S., … Portaels, F. (n.d.). Family Relationship, Water Contact and Occurrence of Buruli Ulcer in Benin. http://doi.org/10.1371/journal.pntd.0000746

Thierry Barogui, Y., Sopoh, G. E., Johnson, R. C., De Zeeuw, J., Dossou, A. D., Houezo, J. G., … Stienstra, Y. (2014). Contribution of the Community Health Volunteers in the Control of Buruli Ulcer in Bé nin. PLoS Negl Trop Dis, 8(10). http://doi.org/10.1371/journal.pntd.0003200

Ukwaja, K. N., Meka, A. O., Chukwuka, A., Asiedu, K. B., Huber, K. L., Eddyani, M., … Ntana, K. (n.d.). Buruli ulcer in Nigeria: results of a pilot case study in three rural districts. http://doi.org/10.1186/s40249-016-0119-8

WHO | Buruli ulcer. (2017). WHO. Retrieved from http://www.who.int/mediacentre/factsheets/fs199/en/

Yerramilli, A., Tay, E. L., Stewardson, A. J., Kelley, P. G., Bishop, E., Jenkin, G. A., … Johnson, P. D. R. (n.d.). The location of Australian Buruli ulcer lesions— Implications for unravelling disease transmission. http://doi.org/10.1371/journal.pntd.0005800

Survival vs Infectious Disease; Who Wins?

In most developing countries, many survive below the international poverty threshold (poverty line). The poverty threshold is the minimum amount of income sufficient for a person’s nutritional, shelter and clothing needs in a particular country. The international poverty line measures poverty in all countries using the same standard. In 2015, the international poverty line was revised to $1.90 per day from the previous $1.25.

Living below the poverty line, means families have to work hard to survive on a daily basis. With the poor and rural populations surviving on small scale businesses and farming most of which are not sustainable, survival is indeed for the fittest.

 For rural communities, farm produce and livestock are their most valuable assets and source of income.

For rural communities, farm produce and livestock are their most valuable assets and source of income. As such, loss of a crop or animal deprives them of the needed income. This has led to some farmers making tough decisions, most of which overlook the associated risks. Cases have been reported (e.g in India, Bangladesh, Indonesia, Ghana, Kenya) of farmers selling meat from a sick or a dead animal carcass resulting into consumers and handlers being infected with anthrax. Some of the farmers sold the meat despite prior knowledge that the animal could be infected with anthrax. By selling the meat the farmer would make a bit of money than a complete loss of income from the death of the animal.

Does this imply that the need for survival in poor and rural populations surpasses the risk of disease? What is more risky losing money or an infection with a deadly disease or both?

Anthrax is serious bacterial illness caused by Bacillus anthracis. It is a zoonotic disease (i.e can be passed on from animals to humans), acquired through handling and or consumption of sick animals as well as inhaling  bacterial spores. Anthrax exposure can be through broken skin, ingestion of contaminated meat, or inhalation of bacterial spores. The disease develops within 1-7 days of exposure with varying symptoms depending on the route of exposure.

Losing a Job vs Losing a Life

In order to survive, while women tend the family and farms, men usually go to find work to earn money for the family. This is a common trend in rural populations of developing countries. For example there are certain villages where the population is comprised of women and children with their men in cities working. These men send money to their families, they are the survival line for their families. But at what cost? Most of these men will continue working even when they know and feel unwell. Instead of seeking treatment and losing a day at work or risk completely losing their only source of income, they resort to self medicating. This delay in seeking treatment has resulted in higher mortality due to HIV or tuberculosis (TB), and could contribute to ongoing community-level TB transmission before initiating treatment . A study from Blantyre Malawi has shown that as men endeavour to sustain their income, they often ignore their health needs.

Men endeavour to sustain their income, that they often ignore their health needs.

Culture vs Infectious Diseases

Culture and traditions are what make people and places unique. These cultures and traditions come with unique practices some of which may perpetuate the spread of infectious diseases.

For example under age marriages, and domestic violence/ abuse, have affected women’s ability to make choices. In Patriarchal societies, women may have less ability to make their own decisions. In some communities wives have ended up sleeping with their husbands without protection even when they knew that their husbands are HIV positive or have other sexually transmitted infections. Most of these cases go unnoticed because some of the women may not open up to these abuses in fear of stigma and loss of family support.

In some communities wives have ended up sleeping with their husbands without protection even when they knew that their husbands are HIV positive or have other sexually transmitted infections.

In other cultures funeral practices involve contact with dead bodies and or the water used to clean the body. This exposes those in contact with various infectious diseases including the Ebola virus.

Understanding the risks and challenges that culture and traditions pose with regard to infectious diseases in communities is valuable when designing and implementing infectious disease control and prevention strategies.

Who is at Risk

  • Communities in most developing countries are at high risk of consuming tainted food not only with anthrax but also other equally dangerous organisms. Is the money worth the risk? This question has various responses depending on who is being asked. While the public health personnel may lean more towards disease control and prevention, the poor farmer/small scale business owner trying to put food on table may have a different take.
  • The risk that men take in various regions to provide for their families while ignoring their health can not go unnoticed. More so the risks that women take to survive at the cost of contracting infectious diseases due to underlying cultures and traditions.
  • Changing years of culture and traditions is a difficult challenge. Consultation with the affected communities maybe a first step.

 Your Role

It is not about who wins, but finding solutions that can allow for poor and rural communities to meet their needs and reduce the risk of infectious diseases.

This is a challenge not only for the affected countries but also all stakeholders working to improve livelihoods of poor communities worldwide.

Maternal and Neonatal Health in Sub-Saharan Africa; The choice between losing a life and gaining one

Maternal healthChild birth is supposed to be a beautiful thing, a happy moment as a new life is brought into the world. But in most low and middle income countries, child birth is a matter of life and death both for the mother and the child she is carrying. When a woman goes into labour, the family is not celebrating; rather they wait anxiously to hear the outcome. Did she manage to deliver the baby; are both the mother and child alive and well? When the answers to all these questions are positive then the family can celebrate. Complications due to child births have claimed lives of many women and have left many babies orphaned at birth. The statistics on maternal and neonatal deaths vary between countries and regions with sub -Saharan Africa most affected.

More than half of maternal deaths occur in Sub Saharan Africa, a third in South East Asia and more than half of the deaths occur in fragile and humanitarian settings

More than half of maternal deaths occur in Sub Saharan Africa, a third in South East Asia and more than half of the deaths occur in fragile and humanitarian settings (Alkema et al., 2016).

Despite a 44% reduction of the global maternal mortality ratio between 1990 -2015 ( http://data.worldbank.org/indicator/SH.STA.MMRT?end=2015&start=1990&view=chart), there are still many women dying due to complications from pregnancy and child birth ( http://data.worldbank.org/indicator/SH.MMR.DTHS ). The top twenty countries with the highest mortality are in sub-Saharan Africa (Table 1, Figure 1) .

The maternal mortality ratio in developing countries in 2015 was 239 per 100 000 live births versus 12 per 100 000 live births in developed countries

The maternal mortality ratio in developing countries in 2015 was 239 per 100 000 live births versus 12 per 100 000 live births in developed countries. There are several factors that have contributed to these disparities not only between developed and developing countries but also within the individual countries; between the rich and the poor, and urban and rural populations (Alkema et al., 2016).

Table 1: Trends in estimates of maternal mortality ratio (MMR; maternal deaths per 100,000 live births) 1990-2015; Twenty Countries with the Highest Mortalities

Countries/Regions 1990 1995 2000 2005 2010 2015
Sierra Leone 2630 2900 2650 1990 1630 1360
Central African Republic 1290 1300 1200 1060 909 882
Chad 1450 1430 1370 1170 1040 856
Nigeria 1350 1250 1170 946 867 814
South Sudan 1730 1530 1310 1090 876 789
Somalia 1210 1190 1080 939 820 732
Liberia 1500 1800 1270 1020 811 725
Burundi 1220 1210 954 863 808 712
Gambia 1030 977 887 807 753 706
Democratic Republic of the Congo 879 914 874 787 794 693
Guinea 1040 964 976 831 720 679
Cote d’Ivoire 745 711 671 742 717 645
Malawi 957 953 890 648 629 634
Mauritania 859 824 813 750 723 602
Cameroon 728 749 750 729 676 596
Mali 1010 911 834 714 630 587
Niger 873 828 794 723 657 553
Guinea-Bissau 907 780 800 714 570 549
Kenya 687 698 759 728 605 510
Eritrea 1590 1100 733 619 579 501
 Source: WHO, UNICEF, UNFPA, World Bank Group and UNPD (MMEIG) - November 2015

There are several factors that have contributed to these disparities not only between developed and developing countries but also within the individual countries; between the rich and the poor, urban and rural populations

There are several factors that contribute to maternal mortality, these include;

  • Political stability and governance: civil unrest and poor governance has contributed to substandard healthcare and weak healthcare systems. As such the health of the pregnant woman and her pregnancy are poorly monitored; and complications are only discovered too late with no planned or poor interventions .
  • Economic stability : Limited resources have resulted in mediocre health services, due to lack of equipment, medicines and well trained staff in the available health facilities.
  • Access to healthcare: Most rural populations have limited maternal and newborn services. This is partly due to lack of infrastructure required to:
  1. Provide essential Interventions for normal and routine healthcare services
  2. Offer emergency care
  • Ignoring the needs of most rural health facilities and the affected rural communities.
  • Some of the underlying beliefs and socio-cultural factors have been attributed as contributing factor to some of complications associated with child birth in sub-Saharan Africa. These Include: early marriages, rural dwelling, female circumcision, education status, unskilled birth attendants and physical violence during pregnancy   (Gebrezgi, Trepka, & Kidane, 2017)

Despite all these, a reduction in maternal mortality has been observed between 1990- 2015 (Figure 1).

Figure -1: Reduction in Maternal mortality between 1990 and 2015

martenal mortality

Source: World Health Organization, UNICEF, United Nations Population Fund and The World Bank, Trends in Maternal Mortality: 1990 to 2015, WHO, Geneva, 2015.

According to WHO the following are the Key facts

Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth, 99% of all maternal deaths occur in developing countries, Maternal mortality is higher in women living in rural areas and among poorer communities

  • Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth.
  • 99% of all maternal deaths occur in developing countries. 
  • Maternal mortality is higher in women living in rural areas and among poorer communities. 
  • Young adolescents face a higher risk of complications and death as a result of pregnancy than other women. 
  • Skilled care before, during and after childbirth can save the lives of women and newborn babies. 
  • Between 1990 and 2015, maternal mortality worldwide dropped by about 44%.
  • Between 2016 and 2030, as part of the Sustainable Development Goals, the target is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births

What are the situations in some of the low and middle income countries?

Between 1990 and 2015, most of the countries with the highest maternal Mortality have gone through economic hardships, political unrest,and other humanitarian situations.

in 2015, approximately 303 000 women died during and following pregnancy and childbirth with almost all of these deaths occurring in low-resource settings. With the right interventions , most of these deaths could have been prevented ( Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group).

References

Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A.-B., & Gemmill, A. (2016). Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet, 387, 462–474. http://doi.org/10.1016/S0140-6736(15)00838-7

Gebrezgi, M. T., Trepka, M. J., & Kidane, E. A. (n.d.). Barriers to and facilitators of hypertension management in Asmara, Eritrea: patients’ perspectives. http://doi.org/10.1186/s41043-017-0090-4

Useful Links

https://data.unicef.org/topic/maternal-health/maternal-mortality/

http://www.who.int/mediacentre/factsheets/fs348/en/

http://data.worldbank.org/indicator/SH.MMR.DTHS

Welcome to Health Challenges Affecting Billions Blog

This site will highlight the challenges faced by over 1 billion people and how these challenges relate to poverty, healthcare and livelihoods.

More than 1 billion people  live in extreme poverty and hardship in various regions of the world. These billions struggle to access safe drinking water, food, primary healthcare and sustain their livelihoods.

This blog will feature;

  1. Case analysis from various regions of the world,
  2. The various challenges faced by populations in resource poor countries,
  3. How these challenges affect the health and livelihood of these populations,
  4. What is being done to tackle these challenges

 

  1. Mphande-Fig1.1-Poverty Health Livelihoods
Source: Mphande 2016, Infectious Diseases and Rural Livelihood in Developing Countries