1. Communicable Disease
Chapter 12
Chapter 12: Communicable Disease
1
The Importance of Communicable Diseases
31% of the burden of disease in low- and middle-income
countries and 40% of all DALYS.
Disproportionately affect the poor.
Enormous economic consequence.
Relevance to MDGs.
Burden of communicable disease is unnecessary, many can be
prevented or treated.
DiseaseMortalityHIV/AIDS1.5 millionTB1.5
millionDiarrhea800,000Malaria550,000
Communicable disease account for 31% of the disease burden in
low and middle income countries. This burden is
disproportionately high in Africa and in low income people.
People with higher education are more likely to protect
themselves from the disease in compare to low income and less
educated people. The economic consequences of infectious
diseases are high. In addition to the high cost of the treatment
which forces people to live below the poverty level, it also has
negative consequences of the economic growth of the country.

2. This high burden of the disease in unnecessary because many of
these condition could easily be prevented with low cost
interventions like vaccinations.
2
Key Terms, Definitions, and Concepts
Communicable diseases are the ones that are transmitted from
human to human, animal to animal, and animal to human. They
could be transmitted directly such as through inhalation or
indirectly through a vector like mosquito. The control of
communicable disease also depends on a number of factors.
Among them are vaccination, vector control, improved
sanitation, chemotherapy, disease recognition and improved
care seeking, and behavioral change.
3
Communicable disease- transmitted from animal to animal,
animal to human, or human to human
Spread (direct and indirect) and contracted through food, water,
bodily fluids, vector, inhalation, non-traumatic contact, and
traumatic contact
Controlled with vaccination, mass chemotherapy, vector
control, improved water and sanitation, improved care seeking
and disease recognition, case management, and behavioral
change

3. This table contains communicable disease key terms which we
need to be familiar with as it relates to the discussion on
communicable diseases.
4
The Burden of Communicable Diseases
31% of total deaths, 40% of total DALYs lost annually in low-
and middle-income countries
Relative importance compared to non-communicable diseases
and injuries varies by region (refer to slide 6-7).
South Asia and sub-Saharan Africa have highest relative burden
of deaths from communicable diseases.
Relative importance of specific communicable diseases varies
by age, too.
In low and middle income countries, 36% of total deaths and

4. 40% of total DALYs lost annually because of communicable
diseases.
5
Deaths from Selected Infections and Parasitic Diseases, as
Percent of Total Deaths, by Region 2008
Source: http://vizhub.healthdata.org/gbd-compare/ Accessed Jan
19 2016, .
South Asia and Sub-Saharan Africa shares the highest relative
burden form communicable diseases.
6
Cause of death by country
Source: http://vizhub.healthdata.org/gbd-compare/ Accessed Jan
19 2016, .
Here you can see the leading causes of death specific to several
countries, as measured by gender per 100,000 DALYS.
7
Leading Causes of Death in Low- and Middle-Income Countries
by Broad Age Groups
Source: http://vizhub.healthdata.org/gbd-compare/ Accessed Jan
19 2016, .

5. However, the importance of communicable disease in global
health in respect to non-communicable and injury related
mortality and morbidity, varies across age groups.
8
The Costs and Consequences of Communicable Diseases
Constrain health and development of children, having an effect
on education and productivity.
Strong stigma and discrimination associated with HIV, TB, and
others.
Limit productivity of adult workers.
Costs of treatment burden families.
High rates reduce investment in a country’s development.
The cost and consequences of communicable diseases are very
high. It constrains health and development of children, having
an effect on education and productivity. It is associated with
strong stigma and discrimination associated with HIV, TB, and
others. Communicable diseases limit productivity of adult
workers and the costs of treatment burden families. Lastly, high
rates reduce investment in a country’s development.
9
(1) have not occurred in humans before (this type of emergence
is difficult to establish and is probably rare);
(2) have occurred previously but affected only small numbers of
people in isolated places (AIDS and Ebola hemorrhagic fever
are examples); or
(3) have occurred throughout human history but have only

6. recently been recognized as distinct diseases due to an
infectious agent (Lyme disease and gastric ulcers are examples).
Question: Do you know what SARS and MERS stands for?
The Leading Burdens of Communicable DiseasesOutbreak
YearDiseasePlace1967MarburgGermany &
Yugoslavia1976EbolaZaire(Democratic Republic of
Congo)1993CryptosporidiasisMilwaukee,US1993HantavirusNe
w Mexico, Arizona, Colorado1996Mad Cow
DiseaseUK1997H5N1(avian influenza)HongKong,
China1999Nipah virusMalaysia &
Singapore2002SARSChina2012MERSArabian Peninsula
Emerging Infectious Diseases
Global health has been threatened from time to time with the
emerging of new infectious disease. The emerging infectious
diseases are the ones that have not occurred in humans before
(this type of emergence is difficult to establish and is probably
rare); have occurred previously but affected only small numbers
of people in isolated places (e.g. AIDS); or have occurred
throughout human history but have only recently been
recognized as distinct diseases due to an infectious agent (Lyme
disease and gastric ulcers are examples).
10
Are diseases that once were major health problems globally or
in a particular country, and then declined dramatically, but are
again becoming health problems for a significant proportion of
the population (malaria and tuberculosis are examples).
They have spread to the places in which they had not appeared
before .

7. Have taken on new forms.
The Leading Burdens of Communicable DiseasesYear of
OutbreakDiseasePlace1994PlagueIndia1997CholeraPeru1998Rif
t Valley FeverEthiopia2003Human monkeypoxTexas ,
US2009DengueFlorida, US2014EbolaWest Africa
Re-emerging Infectious Diseases
Reemerging infectious disease are the ones that once were
major health problems globally or in a particular country, and
then declined dramatically, but are again becoming health
problems for a significant proportion of the population (malaria
and tuberculosis are examples) or they have spread to the places
in which they had not appeared before and or have taken on new
forms.
11
The Burden of Emerging and Re-Emerging Infectious Diseases
Resistant forms of disease emerge or re-emerge when bacteria,
parasites, and viruses are genetically altered.
Critical global health problems because they can arise
anywhere, at anytime, and spread rapidly.
Drug resistance limits ability to treat infection.
Study findings 1940-2004
60% of the infectious diseases were related to Zoonoses.
23% were related to vector borne disease.

8. Emerging and reemerging infectious diseases are critical global
health problem as they can happen anywhere anytime and can
spread rapidly within and across countries. Diseases have
emerged from the genetic alteration of the disease agents, from
the increased drug resistance and due to a number of factors that
we are going to see in next slides.
12
Outbreak Example: SARS in 2003
Dr. KANUPRIYA CHATURVEDI
13
This map is showing how SARS, an emerging disease, spread so
quickly throughout the world.
SARS was first recognized at the end of February 2003 in
Hanoi, Viet Nam. A middle-aged man business man who has
traveled extensively in South-East Asia before becoming
unwell, was admitted to hospital in Hanoi on 26 February 2003
with a high fever, dry cough, myalgia and mild sore throat.
Over the following 4 days he developed symptoms of adult
respiratory distress syndrome, requiring ventilator support, and
severe thrombocytopenia. Despite intensive therapy he died on
March 13 after being transferred to an isolation facility in Hong
Kong SAR. On the basis of data from the SARS foci in Hanoi
and Hong Kong SAR, the incubation period has been estimated
to be 2.7 days, but usually 3.5 days. Attack rates of >56%
among health care workers caring for patients with SARS is
consistent in both the Hong Kong and Hanoi foci.

9. The table here listed some of the reasons that have contributed
to the epidemics of emerging and reemerging diseases.
14
Consequences of Emerging and Re-Emerging Infectious
Diseases
Direct costs of treating disease.
Indirect costs include declines in tourism and trade.
Increased costs of treating a drug resistant case.
The cost of emerging and reemerging diseases could be
enormous on the low and middle income countries. In addition
to the direct cost of treating the disease which includes
medicine and hospitalization, it leads to bigger economic
consequences. For example, 1991 cholera epidemic in Peru lead
a decline in the tourist business of that country that plays a
major role in country’s economic sector. The plague in India in
1994 resulted major short-term decline in trade and commerce
between India and rest of the world. For Mad cow disease, UK
government had to kill many livestock in order to convince the

10. world that beef would be safe in future.
15
Addressing Emerging and Re-Emerging Infectious Diseases
Sensitive surveillance systems.
Rapid detection of new outbreaks.
Mechanisms for effective containment.
Willingness to share information with other countries.
To address the challenges of EID (emerging infectious disease)
and re-EID national and international actions are very much
required. Highly sensitive national surveillance systems and
public health laboratories could identify the outbreaks in a
timely manner. Proper sharing of the information by the
affected countries will make the mechanics for containment
easier.
16
The Leading Burdens of Communicable Diseases
Future Challenges
Impact of economic crisis on governments’ ability to fund
public health functions.
Rapidly evolving pathogens, population growth, climate change
will increase number of emerging diseases.
Possibility of a major pandemic .
Accelerating drug resistance.

11. Limited number of anti-infective drugs being developed.
Though there is concern regarding the economic impact of
government’s willingness or ability to fund public health
functions to address the crisis, however, it is more profitable to
fund programs that are capable of addressing the challenges of
possible disease outbreaks because the economic burden of
facing the outbreak will not be any less distress than the funded
one. The challenges are perpetual one because of the rapidly
changing pathogens, population growth, and the climate
changes. All these trends are becoming worse by poverty, war,
environmental degradation and raise the possibility of major
pandemic.
17
HIV/AIDS
The Burden of HIV/AIDS
Spread through unprotected sex, birth or breastfeeding, blood,
or transplanted tissues.
Attacks the immune system, leaving the body susceptible to
opportunistic infections.
Main routes of transmission vary by location.
Highest rates are in Central and Southern Africa.
The epidemic of this time attacks the human immune system.
The time from becoming infected to getting diagnosed with
HIV/AIDS vary from 1 year to 15 years. The efficacy of the

12. transmission depends on various routes. Blood transfusion risk
of HIV is significantly higher. Sharing needles also carries
relatively higher risk. In case of sexual transmission, type of
sexual act and the gender of the affected person plays role in
determining the risk. The route of transmission varies by
location too. In high income countries and Brazil the epidemic
started among men who have sex with man. In Sub-Saharan
Africa the diseases had started through having unprotected sex
with those who are engaged in high risk behavior like having
sex with commercial sex workers and having sex with multiple
partner. In China the epidemic was centered in a group of
people who received HIV infected transfusion of blood. In
former Soviet Union the epidemic was being driven by injecting
drug users who are HIV positive.
18
Read about 10 facts on HIV:
http://www.who.int/features/factfiles/hiv/facts/en/
HIV/AIDS remains one of the world's most significant public
health challenges, particularly in low- and middle-income
countries.
As a result of recent advances in access to antiretroviral therapy
(ART), HIV-positive people now live longer and healthier lives.
In addition, it has been confirmed that ART prevents onward
transmission of HIV.
At the end of 2014, 14.9 million people were receiving ART
worldwide; this represents 40% [37–45%] of the 36.9 million
[34.3–41.4 million] people living with HIV.
Progress has also been made in preventing and eliminating
mother-to-child transmission and keeping mothers alive. In
2014, a little over 7 out of 10 pregnant women living with HIV,
or 1 070 000 women, received antiretrovirals (ARVs).
HIV/AIDS

13. There are 35 million people living with HIV/AIDS today.
19
HIV/AIDS,
Cost and consequences
HIV has social and economic consequences. Its effects go
beyond morbidity and mortality and affects almost each of the
sector of life. In the absence of treatment, the infected person
becomes sicker every day, progress to full blown AIDS and dies
from opportunistic infections. The cost of treatment, longer
hospital stay affects an individual’s income and at the same
time the burden becomes heavy on government. As prevalence
of disease go up , there is more demand for treatment, more
usage of health service facility , increased demand for hospital
bed which cumulatively account for significant expenditure for
government. HIV infected person lose their job, or work with
limited productivity that leads to limited family income. Since
the expenditure for treatment become more and more, there is
decreased spending for education or other basic necessities.
From the social perspective HIV is considered with stigma in
low income countries as the believe that people acquire HIV
through high risk behavior that society disapproves for instance
injecting drug use, having sex with commercial sex workers.
This stigma led to an unwillingness to allow people with HIV to
attend school or to be employed, to get health care or to live in
certain places.

14. 20
Cost of care
Longer hospital stay
In Sub Saharan Africa >50% hospital beds occupied with HIV
related disease
Increased demand of care
Shortage of Beds
A full blown AIDS cannot work and become completely
dependent on others for care
Decreased family income
Decreased spending on basic necessities, education
Create exceptional number of orphans
Decrease in school enrollment
Children become caretaker of those sick with HIV
Children in the workforce to make up for lost income
Decline life expectancy
Health sector /Direct Cost
Household Burden

15. Educational and social sector
Addressing the Burden of HIV/AIDS
Focus on prevention of new infections.
Successful efforts have included strong political leadership and
open communication.
Approach to prevention must vary with nature of epidemic.
Efforts need to combine education and behavioral change, bio-
medical approaches, and structural approaches.
VIDEO: HIV Treatment: Saving Lives, Preventing New
Infections (5:27)
http://www.cdc.gov/globalhealth/video/hiv_treatment/hiv_treat
ment.htm
VIDEO: Alicia Keys, Empowering women with HIV/AIDS

16. (28:00)
https://www.youtube.com/watch?v=5oF9nq8ykek
To address the burden of HIV/AIDS we need to focus on
prevention of new infections. We need to find out the nature of
epidemic whether it is concentrated one or generalized one and
to design interventions accordingly. Approach to prevention
must vary with nature of epidemic. Combination of approaches
with different weight given on different activities depending
on the nature of epidemic is crucial. Efforts need to combine
education and behavioral change, bio-medical approaches, and
structural approaches
21
Critical Challenges in HIV/AIDS
Developing a vaccine to prevent the 1.5 million new infections
per year.
Cost-effective approaches to prevention in different settings.
Universal treatment for all those who are eligible.
Management of TB and HIV co-infection.
HIV/AIDS faces a number of challenges. First, we are seeing

17. the difficulty in finding a vaccine for HIV. Given that there are
1.5 million new infections every year, the importance of
searching for a vaccine bears importance. Greater attention
should be paid to prevent new infections. To learn about cost-
effective approaches to prevention in different settings will
have impact on incidence reduction. The effort to provide
universal treatment for all those who are eligible should
continue. Finally, the management of TB and HIV co infection
is essential to face the HIV/AIDS challenge.
22
Tuberculosis
11 million people living with TB.
Spread through aerosol droplets.
HIV dramatically increases chance of developing active TB.
Risk factors include living in crowded circumstances,
undernutrition, inadequate health care.
Increase in multi-drug resistant cases.
11 million people are living with TB, caused by bacteria
Mycobacterium tuberculosis. It spreads through aerosol droplets
which is why living in a crowded environment with a TB
infected person raises the risk for quick transmission. Other risk
factors for TB include under-nutrition, inadequate health care,
infection with HIV, weakened immune system. HIV
dramatically increases chance of developing active TB. There is
also increased incidence in multi-drug resistant cases.
23
About one third of the world’s population is infected with
tuberculosis (TB) bacteria. Only a small proportion of those

18. infected will become sick with TB.
People with weakened immune systems have a much greater risk
of falling ill from TB. A person living with HIV is about 26 to
31 times more likely to develop active TB.
The Millennium Development Goal to reverse the tuberculosis
epidemic by 2015 has been achieved. The WHO End TB
Strategy, adopted by the World Health Assembly in May 2014,
is a blueprint for countries to end the TB epidemic by driving
down TB deaths and TB incidence. It includes global impact
targets to reduce TB deaths by 90% and to cut new cases by
80% between 2015 and 2030, and to ensure that no family is
burdened with catastrophic costs due to TB.
Tuberculosis
Read about 10 facts on TB:
http://www.who.int/features/factfiles/tb_facts/en/
These are current facts relating to TB incidence in the world.
Currently, there are 11 million people living with TB and 9
million new TB cases every year. There are 1.5 million deaths
resulting from TB.
24
The Costs and Consequences of TB
Costs to families, communities, and countries is very high.
Large number of people sick, long course of illness
Stigmatized condition.
Economic growth of a country inversely correlated with the rate
of TB.

19. The costs of TB to families, communities, and countries are
very high. Large number of people sick with TB, long course of
illness and stigmatized condition make the disease a challenge
for individual and for country’s health system. Several studies
have shown that people who are infected with TB lost their
wages, took debt to pay the care for TB, and spent significant
amount of money in compare to national income per capita.
Economic growth of a country inversely correlated with the rate
of TB.
25
Addressing the Burden of TB
Directly Observed Therapy, Short-Course (DOTS)
Political commitment to TB program.
Access to quality-assured sputum spears and microscopy.
Standardized regimens of directly observed chemotherapy.
Regular supply of TB drugs.
Monitoring and evaluation for program supervision.
The treatment strategy for TB is known as DOTS or Directly
Observed Therapy, Short-Course (DOTS). It has five essential
components which are:
Political commitment to TB program
Access to quality-assured sputum spears and microscopy
Standardized regimens of directly observed chemotherapy
Regular supply of TB drugs
Monitoring and evaluation for program supervision
26

20. TB in the world
The map here shows TB distribution in the world with highest
prevalence in Sub-Saharan Africa. More than half the new
cases occur in South-East Asia and the Western Pacific. India
accounts for about 24 percent of new cases. 60 percent of cases
are among men.
27
Management of TB/HIV Co-infection
TB is an opportunistic infection of HIV.
Leading cause of death of adults who are HIV-positive and not
on antiretroviral therapy.
WHO recommends testing all HIV-positive people for TB, and
all those with TB for HIV.
TB is an opportunistic infection of HIV. As the immune system
of an HIV positive person decline, TB can develop specially
people with latent TB infection. It is a leading cause of death of
adults who are HIV-positive and not on antiretroviral therapy.
WHO recommends testing all HIV-positive people for TB, and
all those with TB for HIV.
28

21. Challenges in TB Control
Need for more effective vaccines, inexpensive and rapid
diagnostics, and drug therapy that will lessen duration of
treatment.
Improving identification and treatment of MDR-TB and XDR-
TB.
Linking providers of TB diagnosis and treatment with a national
TB control program.
Even though we had progress in TB diagnostics, there is need
for more effective vaccines, inexpensive and rapid diagnostics,
and drug therapy that will lessen duration of treatment. In
regions of Eastern Europe and Central Asia there is a large gap
in diagnosis multidrug resistance TB (MDR-TB) and extended
drug resistance TB (XDR-TB). Efforts need to address
improving identification and treatment of MDR-TB and XDR-
TB. A significant amount of TB diagnosis and treatment is
carried out in the private sector that often does not follow the
guidelines. There is an increased need for linking providers of
TB diagnosis and treatment with a national TB control program.
29
Malaria
2.2% of global DALYs lost annually.
10th leading cause of death in low- and middle-income
countries.
Malaria is the leading cause of DALYs in sub-Saharan Africa in
all age groups.
Caused by parasites carried from one person to another by
Anopheles mosquito.
Pregnant women and fetuses are at high-risk of anemia and

22. death from malaria.
Malaria is responsible for 2.2% of global DALYs lost annually
. It is the 10th leading cause of death in low- and middle-
income countries. Malaria is caused by parasites carried from
one person to another by Anopheles mosquito. The most
important risk factor for malaria is being bitten by mosquitos
that carry malaria parasite. Pregnant women and fetuses are at
high-risk of anemia and death from malaria. 45 million of
pregnancies are occurred in malaria endemic countries like
Africa and causes malaria related anemia in mother and low
birth weight in babies.
30
WHO report on malaria
Cases
214 million malaria cases reported worldwide in 2015
Progress report
Incidence
37% global decrease in malaria incidence between 2000 and
2015
Key facts
Mortality
60%decrease in global malaria mortality rates between 2000 and
2015
Read more
The WHO has the most recent numbers on malaria.
31

23. The map here shows the condition of malaria worldwide
32
Costs and Consequences of Malaria
Individuals often have malaria up to 5 times per year.
Indirect costs are greater than direct costs of treatment because
due to lost days of work.
Roll Back Malaria suggests that economic costs in countries
with a high burden are equal to 1.3% of GDP per year
Progress towards objectives: Azerbaijan and Sri Lanka reported
0 indigenous cases for the first time and 11 other countries
maintained 0 cases.
Cost to individual & familiesPurchase of drugs
Expense for travel to , and treatment at
dispensaries and clinic,
Lost days of work
Absent from school
Expense for preventive measure
Expense for burial in case of death
Cost to Government Maintenance of health facilities
Purchase of drugs and supplies
Public health interventions such as insecticide spraying or
distribution of insecticide treated bed nets
Lost opportunities for joint economic ventures and
tourismDirect CostHas been estimated to be at last US$12
billion/ year

24. The cost of malaria is substantial because there are cases of
reinfection frequently. Individuals lost work from malaria, loss
school. There is also indirect cost of dealing with illness more
than the direct cost of treatments and each episodes of malaria
probably cost an adult 2% of his annual income.
33
Cost of malaria
Available funds are unlikely to increase at the necessary pace to
achieve the goals for malaria control and elimination proposed
by the Roll Back Malaria.
34
Addressing the Burden of Malaria
Prompt treatment of those infected.
Intermittent preventative therapy for pregnant women.
Long-lasting insecticide-treated bed nets for people living in
malarial zones.
Indoor residual spraying of homes.
Getting artemisinin into use to delay advent of resistance.
VIDEO: Herbs and Empires: A Brief, Animated History of
Malaria Drugs (2:45)
http://www.npr.org/blogs/health/2012/12/13/167188333/herbs-
and-empires-a-brief-animated-history-of-malaria-drugs

25. There is a widespread agreement on the key interventions for
addressing the burden of malaria. The interventions include
Prompt treatment of those infected
Intermittent preventative therapy for pregnant women
Long-lasting insecticide-treated bed nets for people living in
malarial zones
Indoor residual spraying of homes
Getting artemisinin into use to delay advent of resistance
35
Challenges in Addressing Malaria
100% coverage for people at risk with bed nets, indoor residual
spraying, and intermittent therapy for pregnant women.
Encouraging behavioral change to ensure bed nets are being
used properly.
Bridging gaps in diagnosis and treatment.
Developing a safe, effective, affordable vaccine.
New drugs to keep up with drug resistance.
Interventions like 100% coverage for people at risk with bed
nets, indoor residual spraying, and intermittent therapy for
pregnant women have much significance in reducing malaria
burden. It is also essential to encourage behavioral change to
ensure bed nets are being used properly. There are substantial
gaps in the diagnosis and treatment of malaria so bridging gaps
in diagnosis and treatment is another step needs to be taken.
Finally, the look out of for malaria vaccine should continue
with the goals of developing a safe, effective, affordable
vaccine. In addition, new drugs to keep up with drug resistance

26. are critical given the speed with which malaria has developed
resistance to the present drugs.
36
Diarrheal Disease
The Burden of Diarrheal Disease
760,000 deaths in 2013.
Significant decline over past 30 years due to better nutrition,
disease recognition, oral rehydration therapy.
Most significantly impacts the poor because of poor housing,
lack of refrigeration, poor personal and community hygiene.
There were 760,000 deaths due to diarrheal disease in 2013.
There has been significant decline over past 30 years due to
better nutrition, disease recognition, and oral rehydration
therapy. As we have discussed previously, this disease caused
by bacteria, virus, and/or parasites that are transmitted by
contaminated water or food through the fecal oral route. It can
also spread through dirty utensils, dirty hands and flies. This
disease most significantly impacts the poor because of poor
housing, lack of refrigeration, poor personal and community
hygiene.
37
The map here lists 10 high diarrhea burden countries in the
world, 2008.
38

27. Addressing the Burden of Diarrhea
There are five major disease prevention strategies for diarrhea,
which include promotion of exclusive breastfeeding for the first
6 months, improved complementary feeding, and introduced at 6
months, rotavirus immunization, measles immunization and
access to clean water supply and sanitation. The case
management interventions can significantly reduce the severity
and mortality of diarrheal disease. The use of ORT is the most
cost effective one especially if it is a home -made one. Zinc
supplement during an acute diarrhea has proven to be effective.
Antibiotic is given in the cases of bloody diarrhea that are
caused by bacteria.
39
Disease prevention strategies
Promotion of exclusive breastfeeding for the first 6 months
Case management interventions
Oral rehydration therapy
Improved complementary feeding, introduced at 6 months
Rotavirus immunization

28. Measles immunization
Access to clean water supply and sanitation
Zinc supplementation
Antibiotic
Neglected Tropical Diseases
The Burden of Neglected Tropical Diseases
More than 1 billion people infected with one or more of the
NTDs.
Most common afflictions of world’s poorest people.
Impede child development, harm pregnant women, cause long-
term debilitating illness.

29. More than 1 billion people,1/6th of world’s population infected
with one or more of the NTDs. Thirteen diseases which are
shown in next slide are called as neglected tropical diseases
which affect world’s poorest population. NTDs have dire effects
on health including impede child development, harm pregnant
women, and causing long-term debilitating illness .
40
NTD facts
General Fast Facts
One hundred percent of low-income countries are affected by at
least five neglected tropical diseases simultaneously
Worldwide, 149 countries and territories are affected by at least
one neglected tropical disease (NTD)
Neglected tropical diseases kill an estimated 534,000 people
worldwide every year
NTDs are a major cause of disease burden, resulting in
approximately 57 million years of life lost due to premature
disability and death
Individuals are often afflicted with more than one parasite or
infection
Treatment cost for most NTD mass drug administration
programs is estimated at less than US fifty cents per person per
year
Source: http://www.cdc.gov/globalhealth/ntd/fastfacts.html
NTD fast facts as reported by the CDC.
41
Neglected Tropical Diseases, by ranking
Ascariasis

30. Trichuriasis
Hookworm infection
Schistosomiasis
Lymphatic filariasis
Onchocerciasis
Trachoma
Chagas disease
Leishmaniasis
Leprosy
Human African trypanosomiasis
Buruli ulcer
Dracunculiasis
The table here lists the major NTDS that are ranked by
prevalence.
42
Small amount of money could gain significant health in the
battle against NTDs. The existing rapid impact package of four
drugs is capable to treat seven or more NTDS. USAID and a
number of organizations have coordinated to eliminate or
control 10 NTDs by the end of the decade.
43

31. A number of vectors are responsible for transmission of NTDs.
To eliminate or to eradicate NTDs one of the goal is to
eradicate the breeding places for the vectors. The pictures here
show vectors that are spreading the diseases among affected
population.
44
Countries with Five or More Neglected Tropical Diseases
This map shows the distribution of NTDs around the world.
45
The Consequences of the Neglected Tropical Diseases
Major impact on health including, but not limited to blindness,
anemia, growth retardation, and permanent disability.
Increase susceptibility to other infectious diseases, people are
often simultaneously infected with two or more diseases.
Social stigma.
Impact on productivity.
NTDs and poverty follow a cycle.
NTDs have major impact on health including, but not limited to
blindness, anemia, growth retardation, and permanent disability.
It increase susceptibility to other infectious diseases, people are
often simultaneously infected with two or more diseases. NTDs
coexist with poverty because they thrive where access to clean

32. water and sanitation are limited and people live without
protection from disease vectors. The NTDs also are recognized
as a contributor to poverty since they can impair intellectual
development in children, reduce school enrollment, and hinder
economic productivity by limiting the ability of infected
individuals to work Social stigma associated with disfigurement
and disability result in individual being shunned by their
families and communities. NTDs also has impact on
productivity of individual in the form of missed work, missed
school, drop out from school or poor school performance.
46
Interventions addressing NTDs
Rapid-impact package of drugs for the seven most common
NTDs.
Guinea worm- teaching people to filter water.
Trachoma- SAFE strategy.
Lymphatic filariasis- annual administration of donated drugs.
Periodic de-worming of young children.
Considerable progress has been achieved in NTDs.
Onchocerciasis has been eliminated from 10 countries in West
Africa. Guinea worm is nearing eradication through efforts that
focused on health education and teaching people to filter their
water through finely woven cloth. To combat Trachoma WHO
had developed a strategy known as SAFE through which world’s
trachoma incidence has declined significantly. Lymphatic
filariais has been controlled in China, Thailand, Sri Lanka,
Suriname and Solomon Islands. Periodic deworming of the

33. children is considered as a best buy in global health since it is
the single most cost effective means to improve school
attendance, cognitive skills and higher productivity among
adults.
These photos show community members in line to receive drugs
during a mass drug administration (MDA) in Mali and a young
boy during a free de-worming from Nandir Williams, during a
campaign program for under-five-year-olds organized by Global
Medical Missions in Zarazon, Nigeria.
47
Future Challenges
Hookworm and schistosomiasis vaccine.
Develop new drugs to combat the NTDs more effectively and
combat resistance.
Introduce underlying risks such as hygiene, unsafe water
supply, worm and parasite breeding sites.
It is important to invest in technologies that could help to
address NTDs in more effective ways. There is work underway
to produce vaccines for Hookworm and schistosomiasis. It is
also critical to develop new drugs to combat the NTDs more
effectively and combat resistance. At the same time we need to
address some underlying risk associated with NTDs that are
prevalent in poor communities. Unsanitary living conditions as
inadequate hygiene, unsafe water supply, worm and parasite
breeding sites are some important issue that communities to

34. need to understand and work together to improve the situation
to reduce the morbidity burden of NTDs.
48
Ebola
Key facts
Ebola virus disease (EVD), formerly known as Ebola
haemorrhagic fever, is a severe, often fatal illness in humans.
The virus is transmitted to people from wild animals and
spreads in the human population through human-to-human
transmission.
The average EVD case fatality rate is around 50%. Case fatality
rates have varied from 25% to 90% in past outbreaks.
The first EVD outbreaks occurred in remote villages in Central
Africa, near tropical rainforests, but the most recent outbreak in
West Africa has involved major urban as well as rural areas.
Community engagement is key to successfully controlling
outbreaks. Good outbreak control relies on applying a package
of interventions, namely case management, surveillance and
contact tracing, a good laboratory service, safe burials and
social mobilisation.
Early supportive care with rehydration, symptomatic treatment
improves survival. There is as yet no licensed treatment proven
to neutralise the virus but a range of blood, immunological and
drug therapies are under development.
There are currently no licensed Ebola vaccines but 2 potential
candidates are undergoing evaluation.
Source: http://www.who.int/mediacentre/factsheets/fs103/en/
Case fatality of Ebola has been as high as 90% and can occur
rapidly, from 2 to 21 days.
49

35. Ebola control
Controlling infection in health-care settings:
Health-care workers should always take standard precautions
when caring for patients, regardless of their presumed
diagnosis. These include basic hand hygiene, respiratory
hygiene, use of personal protective equipment (to block
splashes or other contact with infected materials), safe injection
practices and safe burial practices.
Health-care workers caring for patients with suspected or
confirmed Ebola virus should apply extra infection control
measures to prevent contact with the patient’s blood and body
fluids and contaminated surfaces or materials such as clothing
and bedding. When in close contact (within 1 metre) of patients
with EBV, health-care workers should wear face protection (a
face shield or a medical mask and goggles), a clean, non-sterile
long-sleeved gown, and gloves (sterile gloves for some
procedures).
Laboratory workers are also at risk. Samples taken from humans
and animals for investigation of Ebola infection should be
handled by trained staff and processed in suitably equipped
laboratories.
Source: http://www.who.int/mediacentre/factsheets/fs103/en/
Community engagement is key to successfully controlling
outbreaks. Good outbreak control relies on applying a package
of interventions, namely case management, surveillance and
contact tracing, a good laboratory service, safe burials and
social mobilisation.
50

36. Future Challenges to the Control of Communicable Diseases
Continued cooperation in and among countries to combat
infectious diseases.
Strengthening health systems in low- and middle-income
countries.
Sustained political and financial support.
Strengthening surveillance at local, national and global levels.
Adequately trained and appropriately deployed human
resources.
Reaching a balance between prevention and treatment.
Technical challenges including new vaccines, treatment and
diagnostics.
To address the challenges of communicable disease as a whole
there is a number of challenges still remain. It is critical to
continue cooperation in and among countries to combat
infectious diseases. As low and middle income countries share
the burden of communicable diseases more, it is important to
strengthening health systems in low- and middle-income
countries. Some other area that are of importance to address the
challenges are to have sustained political and financial support,
to strengthening surveillance at local, national and global
levels, to adequately trained and appropriately deployed human
resources, and to reaching a balance between prevention and
treatment. Some of the technical challenges including new
vaccines, treatment and diagnostics are also issues of concern in
global health.
This photo shows a Ugandan family in who benefits from
USAID’s support for NTD control.
51

37. SARS Cases 19 Februaryto5 July 2003China (5326)Singapore
(206)Hong Kong (1755)Viet Nam (63)Europe:10 countries
(38)Thailand (9)Brazil (3)Malaysia (5)South Africa (Canada
(243)USA (72)Colombia (1)Kuwait (1)South Africa (1)Korea
Rep. (3)Macao (1)Philippines (14)Indonesia (2)Mongolia
(9)India (3)Australia (5)New Zealand (1)Taiwan (698)Mongolia
(9)Russian Fed. (1)Total: 8,439 cases, 812 deaths,30 countries
in 7-8 months Source: www.who.int.csr/sars
SARS Cases
19 February to 5 July 2003
China (5326)
Singapore (206)
Hong Kong (1755)
Viet Nam (63)
Europe:
10 countries (38)
Thailand (9)
Brazil (3)
Malaysia (5)
South Africa (
Canada (243)
USA (72)
Colombia (1)
Kuwait (1)
South Africa (1)
Korea Rep. (3)
Macao (1)
Philippines (14)
Indonesia (2)
Mongolia (9)
India (3)

38. Australia (5)
New Zealand (1)
Taiwan (698)
Mongolia (9)
Russian Fed. (1)
Total: 8,439 cases, 812 deaths,
30 countries in 7-8 months
Source: www.who.int.csr/sars

44. Non communicable Diseases
Chapter 13
“When you are willing to make sacrifices for a great cause, you
will never be alone.”
Chapter 13: Non Communicable disease (NCDs)
1

45. The Importance of Non communicable Disease
Growing importance worldwide.
Burden of non communicable diseases greater than burden of
communicable diseases in low-, middle-, and high-income
countries.
Cardiovascular disease, diabetes, cancer, and mental disorders
are most important in low- and middle-income countries.
Often prevented at low cost, but expensive to treat.
Chronic disease…..the public health
Challenge of the 21st century
The burden of non-communicable diseases is greater than
burden of communicable diseases in low-, middle-, and high-
income countries. According to WHO estimation the burden of
non-communicable disease will almost equal to burden of
communicable diseases by 2020 in Sub-Saharan Africa. The
burden of diseases that low and middle income countries face is
cardiovascular disease, diabetes, cancer, and mental disorders.
The risk factors for NCDs are closely related to life styles
which mean it is within people’s control. These diseases are
prevented at a very low cost while treating the diseases is very
costly.
2
Key Definitions
Non communicable disease cannot be spread by an infectious
agent, they last a long time and they are often disabling.
Include cancers, diabetes, endocrine disorders, neuropsychiatric
disorders, and sense organ disorders.
NCDs are opposite of communicable diseases in many aspects.

46. They do not spread by an infectious agent though they might be
associated with one, they last for a long period of time, in some
cases life long, and they can be very disabling meaning they
might seriously impair people’s ability to engage in day to day
life.
3
Proportion of global NCD deaths under the age of 70,by cause
of death
Source: Global status report on non communicable diseases
2010, WHO
Of the 57 million global deaths in 2008, 36 million, or 63%,
were due to NCDs, principally cardiovascular diseases,
diabetes, cancers and chronic respiratory diseases. As the
impact of NCDs increases, and as populations age, annual NCD
deaths are projected to continue to rise worldwide, and the
greatest increase is expected to be seen in low- and middle-
income regions. While popular belief presumes that NCDs affl
ict mostly high-income populations, the evidence tells a very
different story. Nearly 80% of NCD deaths occur in low-and
middle-income countries and NCDs are the most frequent causes
of death in most countries, except in Africa. Even in African
nations, NCDs are rising rapidly and are projected to exceed
communicable, maternal, perinatal, and nutritional diseases as
the most common causes of death by 2030.
4
Let us know about some key terms that are used in non-
communicable disease discussions. Additional terms include:
Body Mass Index – body weight in kilograms divided by height

47. in meters squared. Obesity- A BMI equal to or greater than 30.
Overweight- A BMI equal to or greater than 25 but less than 30.
5
The Costs and Consequences of Non-communicable Diseases
Direct costs of treatment.
Indirect costs from lost productivity.
Low-income countries are simultaneously facing burden of
communicable diseases and non-communicable diseases.
The economic cost of NCDs is substantial given the fact that the
burden of these diseases are increasing. Cost include direct cost
of treatment which occurs for a long period of time and indirect
cost that are resulted from lost productivity and disability.
6
The Burden of Non communicable Diseases
Cardiovascular disease
Cause of about 25% of all deaths worldwide.
Leading cause of death in low- and middle-income countries in
2010.
Was responsible for 10.5% of deaths among all age groups and
for sexes.
Ischemic heart disease was the second leading cause of death in
these countries and responsible for about 10% of deaths.
Cardiovascular diseases (CVDs) are the leading cause of death
worldwide. Almost 25% of the deaths are attributed to CVDs.
Not only in high income countries, CVD is affecting low
income countries as well. Rates of CVD vary by region.

48. 7
The Costs and Consequences of Cardiovascular Disease
Study found that men die 56% more at the same age of CVD
than men in high-income countries and women die 86% more at
the same age of CVD than women in high-income countries.
Estimated that the countries involved would lose $84 billion in
economic production between 2006 and 2015 from CVD.
Mean age of Heart Failure Patients
Ghana: 42 years old
Minnesota: 77 years old
Sources:
Amoah and Kallen. Cardiology. 2000
Senni et al. Circulation.1998
The age of CVD occurrence vary disproportionately in low and
middle income countries and high income countries. One study
in Africa found that direct cost of treating CVDs were about
25% of healthcare cost which translates into 2-3% of GDP of
that country. People in low income countries are affected by
CVDs at much lower age than high income countries.
8
The Burden of Non communicable Diseases
Diabetes
382 million people worldwide suffer from diabetes.
11.4% of population in north American and the Caribbean have
diabetes versus 5.1% in Africa.
Prevalence is rapidly increasing due to obesity.
Costly complications including blindness, kidney failure,
amputation of lower extremities, stroke, and others.
1.3 million people died of diabetes in 2010.

49. 200 million people worldwide suffer from diabetes. Prevalence
of diabetes is rapidly increasing because of increasing obesity
in high income countries and in the high income group of low
and middle income countries. Diabetes has a number of
complications that includes blindness, kidney failure,
amputation of lower extremities, stroke and others. Almost
2/3rd of the people with diabetes face some form of disability
than people without such condition. Which is why the DALYs
lost from diabetes are far greater than the prevalence of disease.
Diabetes was the 8th leading cause of DALYs in high income
countries in 2010 and the 16th leading cause of LAMI countries.
9
The Costs and Consequences of Diabetes
Cost of treating diabetes varies between 2.5% and 15% of health
expenditures in different countries.
In India, paying for diabetes care can cost low income
households about 1/3 of their incomes.
Latin America and the Caribbean have highest expenditures,
sub-Saharan Africa has the lowest.
Indirect costs are probably high because many people do not
receive proper treatment.
Quick fact:
About 150 million people each year suffer
financial catastrophe and around 100 million are
pushed under the poverty line because of
payment for health care. More than 90% of these
people live in low income countries.

50. The cost of treating diabetes varies between 2.5% and 15% of
health expenditures in different countries .In India, paying for
diabetes care can cost low income households about 1/3 of their
incomes .In Latin America and the Caribbean have highest
expenditures, sub-Saharan Africa has the lowest. Indirect costs
are probably high because many people do not receive proper
treatment and therefor suffer from.
10
The Burden of Non communicable Diseases
Cancer
Most important worldwide are lung, colon, breast, prostate,
liver, stomach, and cervix.
15 percent of all deaths for all age groups and both sexes in
2010.
In 2012 there were 14.1 million new cancer cases in 2012 and
8.2 million cancer-related deaths.
All forms of cancer made up 7.6 percent of all DALYs in 2010.
Tobacco use is the single largest preventable cause of cancer
worldwide.
There are many different from of cancers worldwide. Among
them the most important in terms of burden of disease are lung,
colon, breast, prostate, liver, stomach, and cervix cancers. The
risk factors for cancers vary a lot. In general, they are more
likely to be associated with tobacco use, lifestyle factors and
the presence of some infectious agents.
11
The Cost and Consequences of Cancer
Cancer causes the highest economic loss of all the 15 leading
causes of death worldwide.

51. The total economic impact of premature death and disability
from cancer was 1.5% of the world’s GDP in 2008.
Cancer causes the highest economic loss of all the 15 leading
causes of death worldwide. The total economic impact of
premature death and disability from cancer was 1.5% of the
world’s GDP in 2008.
12
The Burden of Non communicable Diseases
Mental Disorders
Includes neurological disorders like epilepsy, drug and alcohol
abuse, and mental disorders.
Responsible for 7.4% of DALYs lost in low- and middle-income
countries.
Start at relatively young ages, go on for a long time, often
cannot be cured, and produce large amounts of disability.
Unipolar depressive disorders are growing in importance.
Neurological disorders like epilepsy, drug and alcohol abuse,
and mental disorders account for 7.4% of DALYs in low and
middle income countries. Four mental illness share the largest
burden of mental disorders and these are Unipolar depressive
disorders or depression, schizophrenia, panic disorder and
bipolar affective disorder. Depression is of growing important,
as it’s the 2nd leading cause of DALYs.
13

52. This table lists definitions of the four major mental health
disorders.
14
The Costs and Consequences of Mental Disorders
Little data from low- and middle-income countries indicative of
unappreciated costs of mental illness
Mental and behavioral disorders are very important to the
burden of disease, causing about 7.4% of all DALLYs in LAMI
countries.
Four mental disorders contribute to the largest share: unipolar
depressive disorders, such as depression, schizophrenia, anxiety
disorders, and bipolar affective disorder.
Source:
http://www.who.int/whr/2001/media_centre/press_release/en/
There are relatively little data from low- and middle-income
countries indicative of unappreciated costs of mental illness.
One in four people in the world will be affected by mental or
neurological disorders at some point in their lives. Around 450
million people currently suffer from such conditions, placing
mental disorders among the leading causes of ill-health and
disability worldwide. Treatments are available, but nearly two-
thirds of people with a known mental disorder never seek help
from a health professional. Stigma, discrimination and neglect
prevent care and treatment from reaching people with mental
disorders, says the World Health Organization (WHO). Where
there is neglect, there is little or no understanding.
15
The Burden of Non communicable Diseases
Vision and Hearing Loss

53. Aging of populations globally and improved life expectancy
increase importance.
Vision loss responsible for .8% of all DALYS globally.
Hearing loss responsible for .64% of DALYS globally.
Adult-onset hearing loss will be in the top 10 causes of the
burden of disease worldwide, ranging from 2.6% in LAMI
countries to 4% in high income countries.
Aging of populations globally improved life expectancy which
in turn has increased the importance of vision and hearing loss
as the cause of the disease burden. Vision loss is responsible for
3.3% of the burden of disease and hearing loss is responsible
for 1.7% of the burden of disease. The major reasons for vision
loss included refractive disorders, cataract, glaucoma, trachoma
and onchocerciasis. For hearing, childhood onset hearing loss is
related with congenital conditions, infections of the ear, or
complications of other diseases. Adult onset hearing loss is
related with exposure to noise and chemicals, as well as aging.
It has been projected that hearing loss will be in top 10 causes
of the burden of disease in 2030.
16
The Costs and Consequences of Hearing and Vision Loss
Very little data available.
Associated costs could include constraints to the education of
children, school days missed by children with disabilities, cost
of additional medical visits, high cost of education for students
with hearing loss, difficulties for adults with finding
employment, lower income levels.

54. Unfortunately, very little data available about the economic
costs of vision and hearing loss specially in low and middle
income countries. Associated costs could include constraints to
the education of children, school days missed by children with
disabilities, cost of additional medical visits, high cost of
education for students with hearing loss, difficulties for adults
with finding employment, lower income levels.
17
The Burden of Non communicable Disease
Tobacco Use
5 million deaths annually associated with tobacco use, half of
those in low- and middle-income countries.
Most common tobacco-related deaths are CVD, diseases of the
respiratory system, and cancer.
Rates of smoking vary by region and across regions according
to sex, age, socioeconomic status, and other factors.
Usage increasing in men in low- and middle-income countries
and women in all regions.
5 million deaths annually associated with tobacco use, half of
those in low- and middle-income countries. The most common
tobacco-related deaths are CVD, diseases of the respiratory
system, and cancer. Rates of smoking vary by region and across
regions according to sex, age, socioeconomic status, and other
factors. The usage of tobacco is increasing in men in low- and
middle-income countries and women in all regions.
18

55. The Costs and Consequences of Tobacco Use
Tobacco Use
Estimates from high-income economies suggest that costs of
smoking range from 0.1% to 1.1% of GDP.
Economic costs are increasing in low- and middle-income
countries.
Disproportionate impact on relatively poor people because they
tend to smoke at higher rates.
Estimates from high-income economies suggest that costs of
smoking range from 0.1% to 1.1% of GDP with higher economic
cost in low- and middle-income countries. There is evidence
that cigarette consumption has declined significantly in higher
income countries. Tobacco use consequences has
disproportionate impact on relatively poor people because they
tend to smoke at higher rates.
19
The Burden of Non communicable Disease
Abuse of Alcohol
Responsible for .7% of DALYS globally.
Increases risk for hypertension, liver damage, heart disease, and
other problems.
Intoxication associated with injuries and high-risk sexual
encounters.
Prevalence of high-risk drinking varies by region with men in
Europe and Central Asia having the highest rates.
Alcohol abuse is responsible for 4% of burden of disease and
increases risk for hypertension, liver damage, heart disease, and
other problems. Alcohol intoxication is associated with injuries

56. and high-risk sexual encounters like accidents, injuries, first
sexual encounter of teens, unprotected sex and intimate partner
violence. The prevalence of high-risk drinking varies by region
with men in Europe and Central Asia having the highest rates.
20
Addressing the Burden of Non-communicable Diseases
Tobacco Use
Taxing cigarettes at higher rates would be effective for reducing
consumption.
Legal restrictions on smoking.
Ban on cigarette advertising.
Biggest impact in high-income settings has come from
comprehensive control programs.
Abuse of Alcohol
Very few countries have made coherent efforts to reduce
alcohol consumption.
Limiting hours when alcohol can be bought or sold and
checking sobriety of drivers has showed some success.
Taxing can reduce consumption but could lead to smuggling and
consumption of illicit alcohol.
Individual counseling shows some success, but would be
difficult for countries with limited resources.
Evidence suggests that a number of steps can be taken to reduce
the use of tobacco. Taxing cigarettes at higher rates would be
effective for reducing consumption. Methods like legal
restrictions on smoking and ban on cigarette advertising has
shown to have achieved success. High income countries have
had the biggest impact comprehensive control programs. In the
area of alcohol abuse very few countries have made coherent
efforts to reduce alcohol consumption. Some interventions like
limiting hours when alcohol can be bought or sold and checking
sobriety of drivers have showed some success. Intervention like

57. taxing can reduce consumption but could lead to smuggling and
consumption of illicit alcohol. Individual counseling shows
some success, but would be difficult for countries with limited
resources.
21
Addressing the Burden of Non communicable Disease
High Blood Pressure, High Cholesterol, and Obesity
Large-scale health education campaigns to promote healthier
eating habits with greater intake of fruits and vegetables and
less fat and salt.
Public policies and community layouts that promote physical
activity.
Cancer
Tobacco control is first priority.
Addressing infectious agents associated with cancer like
H.pylori and schistosomiasis.
The majority of the risk associated with cardiovascular disease
relates to combination of high blood pressure, high cholesterol,
high body mass index, low intake of fruits and vegetables,
physical inactivity and tobacco and alcohol use. Large-scale
health education campaigns to promote healthier eating habits
with greater intake of fruits and vegetables and less fat and salt
are very much needed to address the concerns. Public policies
and community layouts that promote physical activity are
essential to face the challenges of CVD. In controlling cancer,
tobacco control is first priority as it relates to a number of
diseases. In low and middle income countries, addressing
infectious agents associated with cancer like Helicobacter pylori
and schistosomiasis should be of high priority to cost

58. effectively control cancer.
22
Addressing the Burden of Non communicable Disease
Mental Disorders
Little progress in low- and middle-income countries due to lack
of understanding, low funds, and stigma.
Creating a mental health policy and budget is the first step.
Integrating mental health into community-based primary care
and psychosocial supports instead of large, centralized hospitals
has demonstrated success.
Oral Health
Dental caries are present in 90% of the global population
Interventions focused on cost-effective prevention methods that
combine social policy and individual action will have the most
impact.
Include oral health in comprehensive chronic disease programs.
Unfortunately, despite the growing importance of mental
disorders, little progress has been made in low- and middle-
income countries due to lack of understanding, low funds, and
stigma associated with it. WHO recommends that in low and
middle income countries creating a mental health policy and
budget is the first step. In addition to that integrating mental
health into community-based primary care, training primary
health care in mental health, proper budgeting for mental health
care are necessary to address the challenge. Oral health also
needs to be addressed, since the majority of the population
worldwide has dental caries. If left untreated, diseases can
advance, infection can ensue and diseases can contribute to
childhood morbidity and have a negative impact on their quality
of life.
23

59. Future Challenges
Number of new cases of non communicable disease will grow
because of aging, urbanization, globalization and lifestyle
changes.
Number of people with disease will also rise because the
diseases are chronic.
Low-income countries will have to deal with communicable and
non communicable disease simultaneously, as well as with
injuries.
The number of new cases of non-communicable disease will
grow because of aging, urbanization, globalization and lifestyle
changes. Number of people with disease will also rise because
the diseases are chronic. Related to this low-income countries
will have to deal with communicable and non-communicable
disease simultaneously, as well as with injuries. Low income
countries will need to incorporate prevention and control of
NCDs in the primary care setting.
24
Child Health
Chapter 10
Chapter 10: Child Health
1
The Importance of Child Health
6.3 million children under the age of 5 die each year.
Many of these deaths are preventable.
Children are a particularly vulnerable population.
Closely linked with poverty.

60. Insufficient progress has been made in certain parts of the world
in reducing childhood morbidity and mortality.
Improvements in child health are a good measure of societal
progress—hence the Millennium Development goals contains a
specific goal explicitly stating the need to reduce childhood
mortality as well as other goals relating to children as well (i.e.
improving education rates, reducing poverty rates). Infant and
child mortality rates have traditionally been (and still are) used
as sensitive markers for the overall health of nations as a whole.
More than 17,000 children under 5 die every day. A lot of these
deaths are preventable and could be avoided through low cost
interventions. Children are put on global health agenda because
of their vulnerability, poverty, lack of access to education and
the disparity they face because of belonging to particular
geographical location.
2
Since 1980 to 2011 there has been significant progress in under
5 child mortality however to reduce MDG4 we still need to put
emphasis on certain sectors.
3
Source: UNICEF
http://www.childmortality.org/files_v20/download/IGME%20re
port%202015%20child%20mortality%20final.pdf Accessed Jan

61. 17, 2016
The world has made substantial progress in improving child
survival in the past 25 years. The global under-five mortality
rate dropped 53 (50, 55) percent, from 91 (89, 92) deaths per
1,000 live births in 1990 to 43 (41, 46) in 2015 (Table 1).
4
Key Terms
Perinatal : first week of life Neonatal :
referring to the first month of life
Infant : referring to the first year of life Under-5 :
referring to children 0-4 years old
Let us focus on some key terms that we will be referring to for
this chapter.
5
Selected Terms Relating to Causes of Child Illness and Death

62. We also need to familiarize ourselves with some key definitions
as applied to diseases and death for children.
6
The Burden of Childhood Illness
Children Under 5 Years
99% of childhood deaths are in low- and middle-income
countries.
Half of these deaths occur in India, Nigeria, Democratic
Republic of the Congo, Pakistan, and China.
44% of under-5 child deaths occur among neonates.
Rates and causes vary across and within countries.
General trend is decline, but rates of decline also vary
considerably by region.
Almost half of the under five deaths occur in 5 large countries,
India, Nigeria, Democratic Republic of the Congo, Pakistan, and
China. 44% of these deaths occur in neonates and more than one
third of these deaths occur within the very first day of their life.
Neonatal mortality rates are highest in Africa, SE Asia and
Eastern Mediterranean region. Sub Saharan Africa has 12 times
more under-five mortality rate than high income countries. The
differences we see in the rural and urban area child health is
also important. Rural population in Latin America and
Caribbean are about 1.7 times more likely to die than the urban
population.
7
Underlying Causes/Determinants of Disease and Malnutrition

63. Poverty
Inadequate/Relative Poverty
Lack of access to care
Lack of maternal education
Conflict/War/Disaster
A number of reasons act as underlying causes for children death
and they are
Poverty
Inadequate/Relative Poverty
Lack of access to care
Lack of maternal education
Conflict/War/Disaster
8
Neonatal Mortality Rate, by WHO Region, 2010
This slide shows the neonatal mortality rates among different
WHO region. As we have discussed earlier, neonatal mortality
rates are higher among Africa, Eastern Mediterranean and
South-East Asia.
9
Neonatal, infant, and Under-5 Mortality
Source: UNICEF www.data.unicef.org
Global under-five, infant and neonatal mortality rates and
number of deaths, 1990-2015.
10

64. Causes of Neonatal Deaths, by Percentage, 2008
Every year nearly 45% of all under 5 child deaths are among
newborn infants, babies in their first 28 days of life or the
neonatal period.
Three quarters of all newborn deaths occur in the first week of
life.
In developing countries nearly half of all mothers and newborns
do not receive skilled care during and immediately after birth.
Up to two thirds of newborn deaths can be prevented if known,
effective health measures are provided at birth and during the
first week of life.
Source: WHO www.who.int
So many newborn babies die for reasons that are preventable.
The implementation of several proven interventions before
birth, during delivery, and in the minutes, hours and days after
birth could significantly improve the likelihood of survival for
newborns.
11
Leading causes of death in post-neonatal children: risk factors
and response
Children under the age of five:

65. Under-five deaths are increasingly concentrated in sub-Saharan
Africa and Southern Asia, while the proportion in the rest of the
world dropped from 32% in 1990 to 18% in 2013.
Children in sub-Saharan Africa are more than 15 times more
likely to die before the age of five than children in developed
regions. About half of under-five deaths occur in only five
countries: China, Democratic Republic of the Congo, India,
Nigeria and Pakistan. India (21%) and Nigeria (13%) together
account for more than a third of all under-five deaths.
Children are at greater risk of dying before age five if they are
born in rural areas, poor households, or to a mother denied basic
education.
More than half of under-five child deaths are due to diseases
that are preventable and treatable through simple, affordable
interventions. Strengthening health systems to provide such
interventions to all children will save many young lives.
Malnourished children, particularly those with severe acute
malnutrition, have a higher risk of death from common
childhood illness such as diarrhoea, pneumonia, and malaria.
Nutrition-related factors contribute to about 45% of deaths in
children under five years of age.
12
Declines in Under-5 Child Mortality, by Region, 2015
There is marked reduction in child mortality over the 20th
century. From 1990 to 2008 period, Europe had the lowest
mortality and that reduced further. Europe and Latin America
have achieved significant success in reducing child mortality.

66. South Asia and Middle East have been achieving success at a
lower rate. Africa has done poorly in terms of reducing maternal
mortality , part of the reason of it is AIDS epidemic within
different regions of Africa.
13
Additional Comments on Selected Causes
of Morbidity and Mortality
Acute Respiratory Infections
Leading cause of death in low- and middle-income countries.
More severe and cause higher rates of death in low- and middle-
income countries than in high-income countries.
Upper respiratory tract infections include the common cold and
ear infections, lower respiratory infections include bronchiolitis
and pneumonia.
Pneumonia is the leading cause of infectious death globally in
children under 5 years.
Nutrition (exclusive breastfeeding, Vit A, and Zinc supplement)
avoidance of indoor pollution, early recognition of symptoms
and appropriate administration of full course antibiotic could
reduce ARI death significantly.
Acute respiratory tract infections namely pneumonia is one of
the leading causes of death in low and middle income countries.
Upper respiratory tract infections, common cold, ear infections
are also responsible for child mortality and morbidity.
Pneumonia kills an estimated 1.2 million children under the age
of five years every year – more than AIDS, malaria and
tuberculosis combined. Pneumonia can be caused by viruses,
bacteria or fungi. The most common forms of bacterial
pneumonia are Streptococcus pneumonia, and Haemophilus
influenza. Pneumonia can be prevented by immunization,

67. adequate nutrition and by addressing environmental factors.
14
Diarrhea
Caused by bacteria, viruses, protozoa, and helminths.
Causes dehydration, loss of nutrition or wasting, and damage to
the intestines.
Infants 6-11 months are particularly vulnerable because they
have been introduced to unsafe water and foods.
Death occurs due to
Dehydration
Electrolyte imbalance
Interventions like adequate supply of water, sanitation
and access to clean water could reduce mortality.
A number of different agents are responsible for diarrhea.
Among them are virus, bacteria, protozoa, and helminthes.
Diarrhea is transmitted by fecal oral route and generally a result
from unsafe water, poor sanitation, and poor hygiene. Rapid
diarrhea due to loss of fluid or dehydration could be fatal. An
estimated 4 million cases of acute infectious diarrhea occurs
worldwide. Children younger than 5 years in developing
countries have 3-4 episodes of diarrhea each year. They are
specially vulnerable to the dehydration and electrolyte loss
which can result to death. Diarrhea is defined by the passage of
3 or more loose or liquid stools per day, or more frequently than
is normal for the individual. 16% of post-neonatal death under-5
globally occur due to diarrheal disease.
15
Diarrhea Treatment Interventions

68. ORT
Continued breastfeeding
It is estimated that ORT is saving 1 million lives/year.
Zinc supplement
Question:
How much does a sachet of ORS cost?
Answer: 5-10 cents
Prevention and treatment of diarrhea is to replace the water loss
through oral rehydration therapy. Homemade sugar/salt/water
solutions, increased fluid intake and consumption of oral
rehydration salts reduce the mortality risk. ORT is safer and
much less costly. It is also important to continue feeding the
baby as diarrhea leads to malnutrition and make susceptible to
other infections. Zinc supplement given for 10-14 days during
acute diarrhea episode reduces duration and severity of
episodes.
16
Malaria
600,000 children die from malaria each year.
Malaria is the leading cause of death in children under 5 years
of age in sub-Saharan Africa.
People in endemic areas of sub-Saharan Africa will have almost
five episodes of malaria a year.
Associated with premature birth and intrauterine growth
retardation, which reduce chances of survival.
Malaria prevention interventions include vector control.
Insecticide treated nets can reduce overall under five
mortality rates about 20% in malaria endemic countries.

69. Malaria has enormous impact on child mortality and morbidity.
It is estimated that in Sub Saharan Africa a child is likely to
have case of malaria every 40 days. The direct fatal effect of
malaria is cerebral malaria that has a case fatality rate of 20%.
Malaria has adverse effects on fetus health if pregnant mothers
contract malaria. It is associated with premature birth,
intrauterine growth retardation, low birth weight, and increased
child and maternal mortality.91% of death from Malaria
happens in Africa. Malaria prevention measures should include
vector control that is control of mosquito. Other measures such
as insecticide treated bed nets, insecticide spraying, and
availability of antimalarial drugs have proven to be effective to
reduce mortality from malaria.
17
HIV/AIDS
Can be transmitted from mother to child during birth or
breastfeeding.
Number of HIV-infected children has generally declined with
the use of antiretroviral drugs.
There are 200,000 newborns infected with HIV and more than
90%of them were in sub-Saharan Africa.
About 2% of deaths of children under 5 globally are a result of
HIV infection.
Video: WHO strategy on HIV/AIDS for 2011-2015:
http://www.youtube.com/watch?v=n61IAf07VAQ&feature=plcp
Question: Has anything changed since then?

70. The significance of HIV/AIDS in respect to child’s health is its
capability of transmission from mother to child. This
transmission could take place during delivery or during
breastfeeding.
18
Measles
Acute respiratory infection with complications including
pneumonia, diarrhea, encephalitis, and blindness.
Measles is a leading cause of vaccine preventable disease.
Children who are vitamin A deficient or infected with HIV are
more at risk of death.
Extremely contagious if a population is not vaccinated.
Deaths from measles has decreased by 75% globally between
2000 and 2013.
Still accounts for about 2% of deaths of children under 5 years.
Video : The last Measle
http://www.measlesrubellainitiative.org/videoalbums/the-last-
measle-2/
Measles is an acute respiratory disease but it can lead to
complications like diarrhea, pneumonia or encephalitis that are
responsible for children mortality. It is a leading cause of
vaccine preventable diseases. Children who are HIV positive
and are vitamin A deficient are at increased risk of death. It is
highly contagious and in the absence of vaccination, almost
100% of the population will get the disease.

71. The number of measles deaths decreased globally by 75%
between 2000 and 2013. Despite this global progress, some
populations remain unprotected.
19
Helminths
880 million children were t risk of infectious from soil-
transmitted helminths.
Only 305 of these children receive appropriate treatment.
Infections can lead to severe morbidity, such as iron deficiency
anemia.
The burden of several species of worms is highest in children
around 6 or 7 years old.
The most common infections come from roundworm,
hookworm, and whipworm. 880 million children were at risk of
helminth exposure in 2012.
20
Additional Comments on Neonatal Mortality
44% of children under 5 who die annually, actually die in the
first month.
Little progress in reducing neonatal death rate.
Every day that a child lives increases the likelihood that he or
she will stay alive.
To reduce childhood death rates, the world needs to focus more
precisely on when the deaths occur.
Figure: The share of neonatal deaths among under-five deaths
has increased in all regions
Proportion of under-five deaths occur in neonatal period
(percent), by UNICEF region, 1990 and 2011

72. 2.8 million children under 5 who die annually, actually die in
the first month. To reduce the under-five mortality, it is
therefore essential to reduce neonatal mortality. Every day a
child lives, increases the likelihood that he or she will stay
alive. To achieve this goal, we need to focus on where, how and
when the deaths are taking place.
21
Risk Factors for Neonatal, Infant and Child Deaths
Nutrition status.
Household income and education of mother.
Access to trained healthcare provider to attend birth and provide
counseling.
Water quality and sanitation.
Risk factors that are established for neonatal, infant and child
deaths are nutrition status, household income and education of
mother, access to trained healthcare provider to attend birth and
provide counseling, water quality and sanitation.
22
The Cost and Consequences of Child Morbidity and Mortality
High costs of caring for a sick child.
Potential long-term disability.
Poor school attendance and performance.

73. There are enormous costs and consequences to child morbidity
and mortality. The direct and indirect costs of caring for a sick
child can be very high, as parents have to spend parts of their
limited financial resources to buy medical care or are unable to
work because they are attending to a sick child. Also,
childhood illnesses can lead to permanent disability and the
related costs to families and to society that are associated with
it. Additionally, in order to have children that will survive to
adulthood, many poor families will have more children than
they would have otherwise.
23
Future Challenges
Seven countries reduced the rate of under-5 child mortality by
more than two-thirds between 1990 and 2012.
Either other countries have decreased the rate of under-5 child
mortality by more than 50%, but less than 66% at the same time.
However, challenges to improving health in children remain.
Two thirds of childhood deaths that occur every year could be
prevented by effective implementation of simple technology
(e.g. ORT, bednets, etc).
Most of the progress that we have seen in reducing childhood
mortality was targeted towards children between 1-5 years of
age. Neonatal mortality has not been targeted to reach the target
of MDGs. Interventions that are low cost and effective in
reducing morbidity has not been implemented in the most
needed areas.
24
Progress in Child Health
The global polio eradication initiative (Polio is now only
endemic in three countries.)
Progress against measles (548,000 deaths in 2000 to 158,000 in

74. 2011).
Progress towards universal immunization of children (in 2013,
111 million infants, or 84% of children, were vaccinated).
Some changes that occurred in global health: polio, measles,
and immunizations.
25
Addressing Key Challenges in Child Health
Critical Child Health Interventions
Ensuring nutrition and health of the mother and mother-to-be.
Essential newborn care, extra care for small babies, and
emergency care for newborns.
Preventing and managing diarrhea with hygiene, proper
nutrition, measles vaccinations, and ORT.
Basic vaccinations.
Health care worker should inform the parents about:
Necessary immunizations and the schedule to follow
How to avoid anemia and parasitic disease in children over 6
months of age
Why deworming is important
Ways to ensure enough nutrient consumption such as iron and
vitamin A.
To implement critical child health interventions we need to
focus more precisely on the target population. The first of these
categories are the mother and mother to be. It is essential to
ensure nutrition and health of the mother and mother-to-be for
example they should get enough nutrient, have proper antenatal
care, and have the birth delivered by skilled birth attendant. As

75. the first month is the most vulnerable period of a child’s life,
the extra emphasis should be given on care for babies like early
and exclusive breastfeeding, infection control, educate the
mother about emergency preparedness and such. Diarrhea, the
second leading cause of death, could easily be avoided by
following some simple low cost interventions like to be engage
in better personal hygiene, hygienic food preparation, ensuring
proper nutrition, measles vaccination, and the use of ORT in
cases of diarrhea.
26
Addressing Key Challenges in Child Health
Community-Based Approaches to Improving Child Health
Women’s groups to raise awareness of maternal, fetal, and
neonatal issues.
Community-based promotion of hygiene, umbilical cord care,
and keeping the baby warm
Video: Community project: Mothers helping mothers fight HIV
(18:30)
http://www.ted.com/talks/mitchell_besser_mothers_helping_mot
hers_fight_hiv.html
Community based interventions could lead to significant gain in
health. Community awareness and the engagement of women’s
group have been highly effective in improving health and
survival of newborn. Integrated management approach in
childhood illness is another notion in global child health which
bases on the idea that a child should be viewed as whole and
should be taken into account all the possible factors that are
responsible for overall good health of a child. To achieve this
goal, healthcare workers were trained at all level in particular
home and community based workers. This approach is
increasingly acknowledged as it has the potential of reducing

76. children mortality at a minimal cost.
The video link here is an example of community based approach
where a group of mother united to combat the challenge of
HIV/AIDS in Africa.
27
Addressing Key Challenges in Child Health
Integrated Management of Childhood Illness
Integrated healthcare approach for children because of many
interrelated factors.
Healthcare workers trained at all levels, particularly home and
community-based .
In order to help tackle the challenge of child health there needs
to be an integrated healthcare approach for children due to the
many interrelated factors, as well as the need to have more
healthcare workers trained at all levels, particularly home and
community-based.
28
Adolescent Health
Chapter 11
Chapter 11: Adolescent health
1
Importance of Adolescent HEalth
There are 1.2 billion adolescents in the world.
90% live in LAMI countries.

77. Important because:
Adolescent make up an important share of the population.
The burden of disease for adolescents is a unique one and needs
to be addressed direction (e.g. sexuality and reproductive
health, mental health, violence, road safety.)
Adolescence is a period during which health behaviors are set.
There are 1.2 billion adolescents in the world.
2
MDGs and adolescence
What progress has been made on MDG 5?
Progress towards MDG 5 on maternal health is monitored
through achievement of two targets and their associated
indicators. The monitoring framework for MDG 5 was revised
following the review of progress at the 2005 World Summit,
with one new target and four new indicators . The current
situation on the range of indicators defined to monitor progress
shows that accelerated action is needed to achieve MDG 5.
Source:
http://www.who.int/maternal_child_adolescent/topics/maternal/
mdg/en/
The Millennium Development Goals (MDGs) were set at the
2000 Millennium Summit to accelerate global progress in
development. Sexual and reproductive health is a prerequisite of
all goals, particularly those related to gender and health. The
most direct link is with MDG 5 of improving maternal health.
Progress towards MDG 5 is monitored through achievement of
two targets and their associated indicators for monitoring under
MDG 5.
3

78. Mortality rates
Mortality rates are low in adolescents compared with other age
groups. The rates have declined in the past decade, although the
decline has been slight, especially among 10–14 year olds.
Despite the rates being relatively low, there is still significant
mortality during the adolescent years.
In 2012 an estimated 1.3 million adolescents died, down from
1.5 million in 2000.
The mortality rate decreased from 126 to 111 per 100,000
between 2000 and 2012.
Mortality rates dropped in all regions and for all age groups
except 15–19 year old males in the Eastern Mediterranean and
the Americas regions.
Mortality continued to be highest in the African Region,
increasing from 34% to 43% of global mortality in 10-19 year
olds between 2000 and 2012.
Source:
http://www.who.int/maternal_child_adolescent/topics/maternal/
mdg/en/
Mortality rates are low in adolescents compared with other age
groups. The rates have declined in the past decade, although the
decline has been slight, especially among 10–14 year olds.
Despite the rates being relatively low, there is still significant
mortality during the adolescent years.
4
Leading causes of death
The leading causes of death among adolescents in 2012:
Road injury,
HIV,
Suicide,
Lower respiratory infections, and

79. Interpersonal violence.
Source:
http://www.who.int/maternal_child_adolescent/topics/maternal/
mdg/en/
The leading causes of death among adolescents in 2012 were
road injury, HIV, suicide, lower respiratory infections and
interpersonal violence.
5
Risk factors
Alcohol use
Unsafe sex
Lack of contraception
Iron deficiency
Illicit drug use
Unsafe water, sanitation, and hygiene
Data from the WHO, Health for the World’s Adolescents: A
second chance in the second decade. Geneva: WHO; 2014.
The risk factors for communicable diseases that affect
adolescents are well known.
6
Consequences of poor adolescent health
These consequences are immense and could include:
Unlikely to have a healthy and productive adulthood.
May fall ill with disease or conditions (e.g. mental health,
alcohol, or substance abuse disorders).

80. These consequences are immense and could include:
Unlikely to have a healthy and productive adulthood.
May fall ill with disease or conditions (e.g. mental health,
alcohol, or substance abuse disorders).
7
Interventions
Promote education.
Invest in water, sanitation , and hygiene.
Encourage job creation and productive employment.
Address adolescent health needs.
Reduce the burden of disease through improved licensing
requirements for driving.
Keep girls in school longer.
Improve knowledge about reproductive health and family
planning.
Enhance access to family planning and maternal health services.
Provide psychosocial support to reduce mental health
conditions.
Ways to improve upon adolescent health, include:
Promote education.
Invest in water, sanitation , and hygiene.
Encourage job creation and productive employment.
Address adolescent health needs.
Reduce the burden of disease through improved licensing
requirements for driving.
Keep girls in school longer
Improve knowledge about reproductive health and family
planning
Enhance access to family planning and maternal health services
Provide psychosocial support to reduce mental health

81. conditions.
8
Women’s Health
Chapter 9
Chapter 9: Women’s Health
1
The Importance of Women’s Health
Being born female can be:
dangerous to your health, especially in low- and middle-income
countries,
discriminatory,
more likely to have unique health problems, and
related with having economic and social negative consequences
as a result of morbidity, premature death and disability.
There are several key health issues related to the health of
women in low- and middle-income countries, including
nutrition, sex-selective abortion, discriminatory healthcare
practices toward young girls, sexually transmitted infections,
female genital cutting, and violence against women. Mental
health issues are also very important.
2
Table 9.2: Selected Definitions on Women’s Health
Data from University of Kentucky HealthCare. Glossary Index.

82. Available at:
http://www.ukhealthcare.uky.edu/content/content.asp?pageid=P
00527.Accessed April 15, 2007; University of New South
Wales. UNSW Embryology Glossary Index
This table lists some selective definitions on women’s health as
it relates to our discussion on this chapter.
3
The Determinants of Women’s Health
Biological Determinants
Iron-deficient anemia related to menstruation or inability to
consume proper amounts of iron.
Complications of pregnancy:
Eclampsia /preeclampsia, uterine prolapse, fistula, PPH.
Increased susceptibility to some infections
Conditions, such as ovarian cancer, specific to women.
Women faces a number of health related conditions that are
unique to women only. Diseases like anemia, eclampsia, uterine
prolapse, fistula are some examples that make women morbidity
and mortality rates higher. Women are more biologically
susceptible for having sexually transmitted infections and HIV
than male. There are certain health conditions like uterine
cancer or ovarian cancer that are very specific to women.
4
The Determinants of Women’s Health
Social Determinants
Related to gender norms and roles:
Female abortion or infanticide
Often fed less nutritious food than male children
Male dominance leads to physical and sexual abuse

83. Cooking with poor ventilation contributes to respiratory disease
Low social status limits access to health care
Fortunately, awareness is spreading. Video: Call to life,
Pakistan and Maternal Health (5:01)
http://www.youtube.com/watch?v=DfRDFSlQctU&list=PL2674
ECE1194603EE&index=1
Social determinants are the most important determines in
women’s health in particular in low income countries. Culture
where there is different values for male and females, female
suffers the disadvantage of being a female. Societies where
male preference is very strong, such as India and China,
families determine the sex of the child through sonogram and if
the fetus is not a male child then the husband decides to abort
the child for the hope of a male child in next pregnancy. Female
child is often fed less food than male child. Women suffer more
physical and sexual abuse because of their low social status
with limitation for access to health care.
5
The Burden of Health Conditions for Females
Sex-Selective Abortion
Skewed ratios of males to females in some countries, including
China, India, Taiwan, Singapore, South Korea.
Rising incomes and levels of education have led to more sex-
selective abortion in these countries (Example: Punjab state,
India).
Video: Female Infanticide- How can it be prevented? (3:43)
https://www.youtube.com/watch?v=u9w_NFVa5uc
Video: The village where they kill their daughters (5:08)
https://www.youtube.com/watch?v=QatckHHtx7c

84. Sex selective abortion phenomenon is highly prevalent in India
and China. According to some studies in last 20 years in India
there was close to 1 million sex selective abortion though
anecdotal reports suggest a much higher number than this. The
consequence of sex selective abortion is the skewed number of
male female ratio. For instance it is expected that there would
be about 105 females born for every 100 males. However, in
China there are about 120 males born for every 100 males. Same
pattern has been shown in Taiwan, Singapore, and parts of
India. Though it is thought that with income and education the
incidence of female infanticide should go down however, this
may not be the case. As technologies like ultrasound became
much more available, people in India and China misuse this
technology to find out the sex of unborn child and then to kill
the child.
6
The Burden of Health Conditions for Females
Female Genital Cutting
Estimated 100-140 million worldwide have had some form of
genital cutting performed on them.
Practice appears to be diminishing.
Can initially cause shock, infection or hemorrhaging.
Long-term problems include retention of urine, infertility, and
obstructed labor.
Video: Female genital mutilation: (2:27)
https://www.youtube.com/watch?v=3CR7Abg8UuE
Female genital cutting or mutilation is a practice existed in
Africa region that has various forms. This practice is carried on
girls of 4-14 years of age with razor blades, knives, or glass that

85. are likely to be unsterilized. It has been estimated that as many
as 3 million girls in Sub-Saharan Africa and in Egypt have such
cutting performed on them. The practice varies from region to
region, for instance in Egypt it is highly prevalent and in Niger
the prevalence is low. This practice has a number of health
morbidity associated with it like shock, infection, and
hemorrhage. In the long run it risks problems like retention of
urine, infertility, and obstructed labor.
The above is of a woman holding a poster and promoting the
Saleema Campaign at a community meeting in El Khatmia
Village, Gadaref State. El Khatmia is one of five villages in
Gadaref that have agreed to collectively abandon FGM/C.
7
The Burden of Health Conditions for Females
Sexually Transmitted Infections
Biologically more susceptible.
Risk factors for women are young age, sex with high risk
partners, and inability to use a condom.
1.9% of total DALYs lost to women aged 15-44 were due to
STIs.
Inappropriately and late treatment of PID, chronic pain, ovarian
abscess, ectopic pregnancies, infertility, chlamydia leads to
significant maternal morbidity and infant mortality &
morbidity.
Biologically women are more susceptible to sexually
transmitted infections (STI) because of more exposed mucosal
surface. Women suffer more because most of the time STIs are
asymptomatic and women are less likely to access health care
because of STIs. If STIs are not treated appropriately then it
could have long term effects on women health like pelvic
inflammatory disease, chronic pain, ovarian abscess, ectopic

86. pregnancies and such. If a pregnant women get STIs and not
treated properly then it could lead to miscarriage, stillbirth, low
birth weight babies, eye and lung damage of the babies and
congenital anomalies. In recent times Chlamydia is of much
more concern because it is 9 times more prevalent in women
than men.
8
The Burden of Health Conditions for Females
Violence and Sexual Abuse Against Women
UNAIDS estimates 10-50% of women worldwide have been
abused physically by a partner.
Can lead to injuries, unwanted pregnancy, STIs, depression,
disability, and death.
Risk factors include low socioeconomic status, young age of
the male partner, proximity to alcohol, and gender inequality.
Other forms of violence against women.
Violence and sexual abuse occur among women worldwide with
remarkable frequency. Violence most of the time is associated
with sexual abuse. Sexual abuse can include rape, sexual
assault, sexual molestation, sexual harassment, and incest.
Studies have indicated varied number of statistics in sexual
abuse for women in the form of intimate partner violence. In
addition, rape has been used as “tool of war” in a number of
conflicts. Risk factors for violence against women include low
socioeconomic status, young age of the male partner, proximity
to alcohol, and gender inequality.
9
The Burden of Health Conditions for Women
Maternal Morbidity and Mortality
Estimates suggest that there are about 289,000 maternal deaths
per year

87. 99% of maternal deaths occur in low- and middle-income
countries.
60% of all maternal deaths: India, Nigeria, Democratic Republic
of the Congo, Ethiopia, Indonesia, Pakistan, Tanzania, Kenya,
China, and Uganda.
20% of maternal deaths are from indirect causes, 80% are from
direct causes.
Risk factors include general health and nutrition, level of
education and income, ethnicity, location, age, and having a
skilled birth attendant present
Video: Birth in Nepal (23:40)
http://www.youtube.com/watch?v=qZ76DB1NSfE
Maternal deaths are the deaths that occur during pregnancy,
childbirth, or until 42 days after child is born. Birth is the time
that is highly risky for both mother and the child . 42% of
maternal death happens during childbirth or the first day after
birth. Maternal mortality ratio has been declined worldwide .
Maldives is one of the countries that achieved high decline in
maternal mortality ratio. The countries that comprised 50% of
all maternal death are Nigeria, Pakistan, Afghanistan, Ethiopia,
and the democratic republic of Congo. About 80% of maternal
death cause from direct cause like hemorrhage, infection,
eclampsia, and obstructed labor. Rest 20% are from indirect
cause, diseases like malaria, anemia, HIV/AIDS and CVDs that
complicate the pregnancy. A number of risk factors are
attributable for maternal death. General health condition,
nutritional status, education, income, age of the mother,
geographic location, not having a skilled birth attendant all are
critically related with mothers’ death.
10
The Burden of Health Conditions for Women

88. Unsafe Abortion
A “safe” abortion is one performed by a trained healthcare
provider, with proper equipment, technique, and sanitary
standards.
13% of total maternal deaths that occur annually worldwide are
due to unsafe abortions.
Rates of unsafe abortion vary among regions: 60% occurs in
Africa.
According to WHO, A “safe” abortion is one performed by a
trained healthcare provider, with proper equipment, technique,
and sanitary standards whereas unsafe is the opposite of this
definition. 13% of total maternal death occurs because of unsafe
abortion.
11
The Burden of Health Conditions for Women
Obstetric Fistula
Condition in which a hole opens up between bladder and vagina
or rectum and vagina.
50,000 to 100,000 women each year will suffer a fistula.
Women with fistulas are often stigmatized or abandoned.
One of the four major causes of maternal mortality and
morbidity.
Risk factors are those associated with an obstructed delivery.
Obstetric fistula is a condition in which a hole opens up
between bladder and vagina or rectum and vagina usually
happens as a result of prolonged childbirth or failed childbirth.
As an outcome of this condition urine and feces leak through

89. vagina. Women with fistula face terrible social and economic
consequences as they are often stigmatized and/or abandoned.
12
Differences Between the Health of Men and Women
Greater focus has recently been put on the extent to which
gender discrimination affects women’s health.
19 conditions disproportionately affect women- some are
specific to women, some are related to women’s higher life
expectancy, some are a result of gender discrimination.
Source: Women and Health Initiative, Harvard School Of Public
Health
For last couple of decades women health gained special
attention especially in reproductive health because “women are
child bearer”. More recently focus has been shifted towards the
inequality women faces that disproportionately affect women
health.
13
The Cost and Consequences of Women’s Health Problems
Violence, STIs, and fistula tend to isolate women socially.
When a woman dies in childbirth, her family is typically left
without a primary caregiver.
Substantial economic costs from women’s health issues.
The social cost of women health problems is huge. When
women die of childbirth it put the health of the young child or
other children in the family in danger. Fistula, violence, STIs
tend to isolate women socially. Studies have examined that the
economic costs of women health issues ranges from 1.6% to 2%

90. of country’s GDP.
14
Addressing Future Challenges
Female Genital Cutting
Efforts that promote change need to be specifically tailored to
local practices and beliefs.
Promote female empowerment, education, and control over
economic resources.
Since 1997,WHO has been trying to raise global concern to stop
the practice. In 2008, they passed a resolution on the
elimination of FGC.
Read the story of Sudan: Religious leader speaks out against
female genital mutilation/cutting
http://www.unicef.org/protection/sudan_29886.html
Female genital cutting (FCG) is a social norm. A practice very
widely spread among different ethnicities of Africa. Efforts that
promote change need to be specifically tailored to local
practices and beliefs. For some cultures FCG is a prerequisite
for marriage and if people start to abandon the practice then
they risk marriage for their girls. One way to reduce the
incidence of FCG could be to promote female empowerment,
education, and control over economic resources which could
lead to elimination of this harmful cultural practice.
15
Addressing Future Challenges
Violence Against Women
Protecting women through legislation.
Shelters for abused women.
Ensuring police, judges, and healthcare workers are trained to
deal with violence against women in effective ways.
Video: Bangladesh Ministry of Women and Children Affairs

91. Communications Campaign on Violence Against Women (6:57)
http://www.youtube.com/watch?v=eUe9W7sbpFY
There is very little evidence on what will work to reduce the
violence against women in a cost effective way. Studies have
shown that in high income countries legislation to protect
women against violence had positive impact. Shelters for
abused women can also help to reduce the violence against
women. Ensuring police, judges, and healthcare workers trained
to deal with violence against women in effective ways have
proven to be useful.
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These are some suggested measures to reduce intimate partner
violence.
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Addressing Future Challenges
Sexually Transmitted Infections
Surveillance of STIs.
Program of health education.
Appropriately trained health workers to provide proper
treatment.
The importance to reduce STIs is enormous because STIs
increases the chances of HIV/AIDS. The goals of any program
to reduce the incidence of STIs should integrate the goals of
reducing the infection, reduce the complications of infections,
and reduce the spread of infection to the newborn. To do it more