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					       How to Approach
CKD Prevention in Large Country




                              SK Agarwal
 Outline

 Introduction
 Preventive program in other countries
 Proposed prevention program in India
 Healthcare set-up in India
 Government approach to Non-communicable diseases
 Where we need help at present
 Summary
Summary
                   Incidence of ESRD
                       260 / pmp

       RT                                HD
     3 / pmp            CAPD           2 / pmp
                       1 / pmp

    Govt. spend                    RRT /person /yr
    8$/capita/yr                     750-3000 $

          What to rest
           254 pmp ?         Death
   Prevention is only solution
       Preventive Program for Chronic Illness

  Issues involved:

 Is the disease prevalent in the country            Yes
 Are the effects serious to warrant prevention?     Yes
 Is the disease/causes of disease easy to detect?   Yes
 Can disease be easily prevented?                   Yes
 Is the cost of prevention less than the treatment? Yes
 Can the preventable program sustainable?           ???
      Major Causes of Chronic Kidney Disease

60
      AIIMS, New Delhi
      Apollo, Chennai
50
      PGI, Chandigarh
40

30

20

10

 0
     Diabetes            Ht        Parenchymal
                                    (CGN+TID)
                       Etiology of CKD in India
                         Hospital based studies                     Field study
        Agarwal        Mittal et al   Sakuja et al Mani MK          Agarwal et
                                                             Mean   al ( 2002 )
        et al (2000)   (1997)         (1994)       (1993)
No of
          7072            835           453        2028 10388           37
Cases
DN        28.4           23.2           23.8       26.7       25        41
Ht         5.7            4.1           13.5        10       8.3        22
GMn       48.5           28.6           36.6       18.2      32.9       16
TID        7.5           16.5           14.3       27.8      16.5      5.4
PKD        1.9              2           3.5          2       2.3         0
Prevention Program in Other Countries
Can Causes and CKD easily detectable?

Parameters                  KEEP Ivor Sylvia       Hoy WE
                            (USA) (SA) (Singapore) (Australia)
History of Diabetes & Ht                             
Questionnaires                                       
Ht & Wt                                              
Urine for Sugar & Protein                            
Spot urine Alb/Cr                                    
SCr, Blood Sugar, HBA1c                              
mcg Albuminuria ?                  X        X          X
Risk of CKD in Relatives of High Risk Group

Familial aggregation of CKD is high
       Hypertension
       Diabetes mellitus
       IgA Nephropathy
       FSGS
       Systemic lupus



                       Brown WW et al Am J Kid Dis 2003;42:22-35
  Approaches for Prevention Programs for CKD
                                 Selected
                                Community
    High Risk                      Australian
     Group                         Program

 KEEP
 South Africa
                    Whole
                   Population
                                  NKF
                                  Singapore
Proposed Prevention Program in India
     Possible Prevention Program in India
                                    Selected
                                   Community
   High Risk
    Group

• Diabetics
• Ht
• 10 Relatives of
     • CKD
     • Diabetics                      Whole
     • Ht                             Country
         Multiple Level Approach

     Awareness of CKD in Community
 Both Medical, Paramedics, Non-medical


  Start making a
       base                  Start
   For community        early detection
  Level screening      program Of CKD
as part of existing      in “High Risk
  Infrastructure             Group”
 Top 10 Specific Causes of Death in India, 1998

Causes                No in     %     India / World
                   thousands
CAD                   1471     15.8       19.9
Acute LRT Inf.        969      10.4       28.1
Diarrhoeal Dis        711      7.6        32.1
CVA                   557      6.0        10.9
TB                    421      4.5        28.1
ESRD                  250      ???        ???
RT Accidents          217      2.3        18.5
Measles               190      2.0        21.4
HIV/AIDS              179      1.9        7.8
Tetanus               165      1.8        40.3
COPD                  153      1.6        6.8
Total Deaths          9337     100        17.3
Total Population     982223    100        16.7
     Possible Prevention Program in India

  Start program with a network in Urban area initially
    • Diabetes and HT more common
    • It will be easy to educate
    • It will be easy to organise & implement
    • Some networking is existing
    • Positive results are likely in short period
    • Impact of program will be faster

Make a base in rural area utilizing existing infrastructure
    Possible Prevention Program in India
             Central Coordinating Team
                                      Nephrologist
                                      Community Medicine person

                                      Biostatistician
 Nephrologist
                                      Administrator / Ministry
 Community Medicine

 Administrator        Zonal
                    Coordinator          (15)
                      Zonal       Nephrologist / Internist
                     Member       Nurse / Other paramedics



      Medical Colleges / Private Hospital / Pvt. Clinics
                                                Chandi

  Z-1                            HP
                          Punj                                                  Zone-3
                                      Uttar
                                                                      Sikkim
                                                                                            A P
           Z-5                                 UP
                                                    Z-2
               Rajas                                                                Assam
                                                            Bihar
                                                             Z-13                                    Naga

      Z-15                       MP             Z-6         Jhar    Z-14                          Mani
      Gujrat                                                          WB
                                                           Z-7       Megha
                                                                                            Z-4
                               Z-8                                           Trip
                        Maha
                                                                                     Mizo

                                           Z-9
                                          AP

                           Z-10
Goa                                   Z-11          Pond
                                     TN
                 Z-12
      Possible Prevention Program in India
In addition to screening high-risk group

    Multicentric study for prevalence of CKD and its
     etiology in community

    Education program for CKD in community
           Audio-visual aid
           Information booklets
           Posters
           Interactive session with healthcare team
           PEP (Patient-educates-patient)
How to run the program?
  Health Care Set-up in India,


      its changes with time


Government Priorities and Policies
           Transition of Indian Health System

• Demographic       High mortality      Low mortality
                    High fertility      Low fertility

• Epidemiological   Malnutrition        Chronic Non -
                    Communicable Dis.   Communicable Dis.

• Social            Low knowledge       High knowledge
                    Low expectations    High expectations

                    Public sector       Private sector


• Economical        Low cost / event    High cost / event
                       • Diarrhea          • MI
           Indian Health Care System

              RURAL
                             URBAN

  Community Health Center   Dispensaries
           CHC
      By State Govt.

                                       Hospitals
 Primary Health Center
          PHC                    CGHS
     By State Govt.              Railways
                                 ESI
                                 MCD
  Sub-Center                     NDMC
      SC                         Many others
By Central Govt.
Indian Health Care in Rural Area: Infrastructure
                          SC                    PHC                  CHC
                                              ( 6 SC)           (7.5 PHC) (4)
    Number             1,37,311               22,842                 3043

  Population             5400                  32,469              2,40,000
   Covered              (5000)                (30,000)            (1,20,000)
Villages Covered          4.5                   27.8                  201

     Beds                 No                     4-6                   30
   Personnel       • 1 MPW (M)           • 1 Medical Officer   • 4 Medical Officer
                   • 1 MPW (F)           • 1 Technician        • 7 Nurses
                   • 1 Voluntary         • 14 Paramedics       • Pharmacist
                                                               • Lab tech
                                                               • Radiographer

                                   Rural Health Statistics in India 2002, Govt. of India
      Current Health Policy & Problems in India
                                                                 Cont….
• Unplanned increase in urban population
• 35% population is illiterate, thus  education
• Public funding, central and state funding less
• Research utilization only 1.4% of 80,000 Crores (98-99)
• Only “Vertical” implementation of health programs
• Programs NOT having vertical implementation ??
• Absence of disease surveillance network
• Absence of scientific health statistics database

                        Rural Health Statistics in India 2002, Govt. of India
      Demographic Changes in India (1951-2000)

160
140                                                   Life Exp.
                                                      Crude Birth Rt.
120                                                   Crude Death Rt.
                                                      IMR
100
 80
 60
 40
 20
  0
      1951         1981                2000          Goal for 2000

               National Health Policy 1983, Registrar General of India
            Impact of Public Health Expenditure

Indicator       % Population       IMR /1000        % Health         % Public
                with income <                      expenditure      expenditure
                    1$/day                           of GDP           of total
                                                                      Health
                                                                      budget
India               44.2               70               5.2             17.3
China               18.5               31               2.7             24.9
Sri Lanka           6.6                16                3              45.4
UK                                      6               5.8             96.9
USA                                     7              13.7             44.1



                                Rural Health Statistics in India 2002, Govt. of India
        National Health Policy 2002 in India

OBJECTIVES
  To achieve acceptable standard of good health for all
  Establishing new infrastructure in deficient area
  Upgrading infrastructure in existing area
  More equitable health service across the country
  Increasing the contribution by central government
  Contribution of private sector in health to be enhanced
  Prevention & first line curative service at PHC level
  Other traditional system of Indian medicine to be utilised


                         Rural Health Statistics in India 2002, Govt. of India
        National Health Policy 2002 in India

key Points
  55% / 35% & 10% public health budget in Primary,
  secondary and tertiary care
  Health programs should be under single field administration
  Autonomous bodies involvement should be more
  Exclusive staff for individual program + common staff
  Common staff should be trained appropriately
  More in-service training for staff
  Establish a baseline estimates for NCD




                         Rural Health Statistics in India 2002, Govt. of India
           Goal to be achieved in India by 2015
Eradicate Polio & Yaws, Leprosy                                             2005
Eliminate Kala Azar                                                         2010
Eliminate Lymphatic Filaria                                                 2015
Achieve zero level growth of HIV                                            2007
 Mortality by 50% due to TB, Malaria, water borne                          2010
 Prevalence of blindness to 0.5%                                           2010
 IMR to 30/1000 & MMR 100/Lakh                                             2010


 Use of Public Health Facility from <20% to > 75%                          2010
 Govt. health expenditure from 0.9% to 2%                                  2010
 Central Govt. share to at least 25%                                       2010
 State health expenditure from 5.5% to 7% / 8%                         2005 / 2010
Establish integrated system of surveillance & statistics                    2005

                                   Rural Health Statistics in India 2002, Govt. of India
WHO statement on Non-communicable diseases 2001


  The increasing burden of noncommunicable diseases
  (NCD), particularly in developing countries, threatens
  to overwhelm already-stretched health services. The
  factors underlying the major NCDs (heart disease,
  stroke, diabetes, cancer and respiratory
  conditions) are well documented. Primary prevention
  based on comprehensive population-based programes
  is the most cost-effective approach to contain this
  emerging epidemic.
WHO statement on Non-communicable diseases 2001


  In 2000, the 53rd World Health Assembly passed a
  resolution on the prevention and control of non-
  communicable diseases with the goal of supporting
  Member States in their efforts to reduce the toll of
  morbidity, disability and premature mortality related
  to NCDs.
    WHO Stepwise Approach to NCD Surveillance

NCD                  Step-1               Step-2              Step-3

Death           Death rate by age    Death rate by age,   Death rate by
                     & sex           sex and cause of     age, sex and
(The past)                                 death         cause of death
                                      (Verbal autopsy) (Death certificate)
Disease          Hospital / clinic    Rate & principle     Cause specific
                admission by age       conditions in     disease incidence
(The present)        & sex             three groups;        & prevalence
                                      Communicable,
                                       NCD & Injury
Risk factors     Questionare         Questionare plus    Questionare plus
                based report on          physical            physical
(The future)    key risk factors       examination        examination &
                                                           biochemical
                                                             reports
        Risk factors Common to Major NCD

Risk Factor      CVS   Cancer   Diabetes Respiratory   CKD
                                          Diseases
Smoking                                             
Alcohol                           
Nutrition                                           
Physical                                            
Inactivity
Obesity                                             
Hypertension                                          
Diabetes                                             
Hyperlipidemia                                       
Where we need help?
Where we need help?


From WHO
   Recognize CKD importance
   Include CKD in thrust areas of NCDs
   Training in public health issues
Where we need help?
From ISN
A. Include AIIMS as center of excellence
   Govt. recognizes it as center of excellence
   It is strategically placed
   Our group is interested
   We have done work in this field
B. Help organising prevention conference in Delhi
   Initiate enthusiasm in local peoples
   Stress CKD importance in local leaders
Where we need help?

From ISN
A. Help in funding for attending preventive
conferences in world for key peoples
   Keep enthusiasm alive
   Help in building partnership
B. Expertise & funding for
   Research in key areas of local importance
   Help in establishing registries
Summary
 CKD is a public health problem in India
 Diabetes and Hypertension are common causes
 Risk factors for CKD & CKD itself is easy to detect
 Prevention program is the only way to handle CKD
 Education for CKD is urgently needed
 Initially the program can be started in urban areas
 Ultimately it has to go to primary health center level
 A networking approach is correct approach
 International funding is required for this program

				
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