Medical/Public health interventions

[raula]

I have noticed not much health talk around this forums-therefore thought we ought to have one since many of the somalis ladies-I being one [predominately major in medicine and health related majors-Or is it just a predisposed [inclined] fate (providence) enforced by parents or society that habitually reckons LEGITIMATE careers for a woman as being either a teacher, nurse/doctor, or stay home wife. Then again, it might be just pure interest in the most competitive [or viable] careers existent]. Well here is some of my gumbo {rather the current public health intervention in combating Malaria endemic countries)-enjoy

CAVEAT: this is summary research paper compilled by RAULA [in one of my Public health classes](Edited by RAULA on September 9th, 2004).

 

Title: MICRONUTRIENT SUPPLEMENTATION IN COMBATING PLASMODIUM FALCIPARUM.

 

Abstract

Malaria is the leading cause of morbidity and mortality globally, and involves serious and sometimes grave detriments such as anemia and complications of plasmodium falciparum and their serious complications. Also, malnutrition and micronutrient deficiencies such vitamin A, iron, vitamin E, and zinc, that are essential to immune defenses, is highly prevalent in malaria-endemic regions. Recent studies reveal that micronutrient supplementation or dietary fortification with micronutrients such as vitamin A, iron and zinc, has demonstrated to enhance immune modulation. Zinc specifically, has been linked to reduce the risks of malarial parasitemia and acute forms of diarrhea and pneumonia. It has also been illustrated to reduce clinical visits associated with malarial syndromes or conditions in parts where malarial is endemic. However, further work needs to assess the impact of zinc supplementation in combating abnormal growth and stunting in children well as its beneficial effects in the prevention of morbidity and mortality resulting from plasmodium falciparum.

[TEXT]

In developing countries, Malaria is the leading cause of morbidity and mortality and accounts for nearly 400 million cases and more than one million child mortalities (World Health Organization (WHO, 1999). It is imperative to put these disease problem approximates in perspective. As indicated by WHO, there are 10.8 million child mortality cases per year, globally. Higher rates of poverty, micronutrient deficiencies and lack of adequate health services contribute to why malaria remains a major cause of morbidity and mortality in some regions of the world, in particular the sub-Saharan Africa. The figure established to zinc, vitamin A, and iron shortage is 2 082 000, or 19% of the total. When compared to malaria for example, it causes less than one million child deaths a year and “2.7% of global DALY’s (disability-adjusted life years), compared to roughly 6% by iron, vitamin A and zinc deficiencies (WHO, 2002; Ezzati et al., 2002).

Despite renewed mechanisms in controlling malaria, the victory against malaria remains limited and existing apparatus like drugs and insecticides are loosing their efficacy. Consequently, because of increasing prevalence associated with morbidity and mortality in children, and progressive increase in the resistance of the parasite to antimalarial drugs, new options are desperately needed. “New tools for malaria control would thus be very welcome, and nutritional interventions have been considered to be promising candidates (Shankar 2000). Therefore, what are the some of the nutritional status evidence at being effective in reducing the risk of malaria?

The female anopheles mosquito is the vector that carries the malaria’s plasmodium germs. The germs grow in the host for several days then travel to the mouth just before the mosquito stings. The microbes grow and multiply in the liver then penetrate the red blood cells and start proliferation there as well. The red blood cells then rupture; as the parasite disperse and pollute other cells, the toxin disseminate and this is when the individual begins experiencing the symptoms and signs of malaria (symptoms begin 10days to 4 weeks after infection, although a person might feel sick 8 days up to a year later). The symptoms and signs of malaria include: fever, flu-like illness, shaking chills, headache, muscle aches, and fatigue, nausea, diarrhea, and vomiting. Malaria can also result in jaundice, and anemia due to the depletion of the red blood cells. Plasmodium Falciparum in particular if not treated promptly can lead to kidney failure, seizures, mental confusion, coma and death.

Insufficiency of some micronutrients are extremely prevalent in low-and middle-income countries and may influence the risk of illness or death from infectious disease by reducing immune and non-immune functions and by compromising normal physiological developments. While deficiencies in any of the essential micronutrients can result in health problems, there are a few that are particularly important.

Micronutrients such as vitamin A and Zinc are essential for the immune functioning, but are most common deficiencies in children of the developing world (Levin et al. 1993, Shankar & Prasad 1998). Zinc deficiencies in humans has been linked to cause “ growth retardation, thymic atrophy, lymphopenia, impaired T and B lymphocyte function, impaired chemotactic activity of neutrophils, and a reduction in thymulin activity, interferon-γ concentrations, and the number of CD4 (helper) lymphocytes†(Shankar & Prasad 1998). And so, if these cellular and humoral functions are distorted, they may increase host susceptibility to Plasmodium Falciparum.

Earlier studies have looked at malaria’s association with protein-energy malnutrition (PEM). A number of epidemiological studies in the early 1950’s up to 1980’s, provided substantial evidence that PEM was significantly associated in reducing malarial morbidity and mortality, however, recent studies have not proved this yet (Tshikuka et al. 1997; Man et al. 1998; Shankar 2000). Still children less than 5 years of age in malaria-endemic countries are at the highest risk of PEM as well as deficiencies in micronutrient, including zinc. Earlier studies also reveal that iron; Vitamin A and Zinc have been associated to malaria. A meta-analysis that included 13 trials concluded that Iron was not directly associated with malaria morbidity or infection but positively associated with rise in hemoglobin levels by an average of 1.2g/dl and a reduction in anemia by 50% (Shankar 2000).

Findings

In recent years, there has been an increased importance given to the role of nutrition in malaria, since micronutrient deficiencies has been associated with malarial morbidity and mortality from infectious diseases. Several randomized studies reveal that individuals with malaria have lower micronutrient plasma concentration when compared with controls (Adelekan et al., 1997; Das et al., 1996; Davis et al., 1993). Although “malnutrition and anorexia during infection can affect micronutrient concentration, a study in Nigeria suggests that acute malaria may be a more significant factor in lowering the plasma concentrations of antioxidant vitamins than malnutrition†(Adelekan et al., 1997).

Clinical trials assessing the impact of several micronutrient supplementation on malarial imply that Vitamin A plays a role in the pathogenesis of malaria through exerting an effect on the immune system, and upon modulation of iron metabolism. Hematological improvements, and increased hemoglobin and serum iron concentrations, resulted from supplementation of Vitamin A in pregnant women and children (Fishman et al., 2000).

Some in vitro studies found that Vitamin A does not alter erythropoietin (a hormone in the kidneys that is released into the bloodstream in response to anoxia and regulates the production of erythrocytes) production in humans but perhaps operates by way of other mechanisms such as enhancement of Iron metabolism. Nonetheless, Vitamin A assists in iron absorption; “increased uptake of iron by the liver and spleen, impaired bone marrow uptake of iron and low iron binding capacity and transferring saturation†(Roodenburg et al., 1994; Sijtsma et al., 1993; Mejia and Arroyave, 1983; Bloem et al., 1989). The same mechanisms also might exacerbate the consequences of developing anemia from malaria due to poor nutrition and deficiency in Vitamin A.

Some placebo-randomized trials suggest that the association between zinc and parasitemia suggest a possible correlation between zinc status and malarial anemia. Although a trial in Papua New Guinea did not find any correlation in the mean hemoglobin concentrations and the number of anemic children, but in Gambia there was a correlation in the clinical visits for malaria with zinc supplementation. In fact, the number of clinical visits associated with malaria was significantly reduced in the zinc supplemented group in Gambia (Bates, 1979).

Another similar study meta-analysis, randomized, placebo controlled trial that included eleven trials was reviewed by Black & associates in 2003. However, only three of the study, in three different counties namely Gambia, Papua New Guinea and Burkina Faso, focused on effect of zinc supplementation on malaria. Gambia, Papua New Guinea and Burkina Faso revealed that Zinc supplementation to children verified a trend toward fewer health care visits for malaria by 32% and 38% and 2%, (Bates, Evans, Dardenne et al. 1993; Shankar, Genton, Baisor et al. 2000).

This illustrates that due to the insufficient technological and data collection novelty in detecting the malarial incidences earlier on, hospital visits or clinical syndrome related to malaria parasitemia are considered significant in determining the statistics regarding malaria in some endemic regions. Moreover, given the extremely high rate of malarial parasitemia in some endemic populations, clinical visits regarding malaria are a valid measure of malarial incidence that has been used by WHO to estimate malarial burden of disease. However, there was no significant study based on “malaria†as ascertained from community-based surveillance but hospital visits.

Supplementation of zinc has also been associated to with reduction of diarrheal diseases, acute respiratory infections, and malaria. A study implemented by The Zinc against Plasmodium Study Group (Sempá»rtegui et al. 2002; Yeboah-Antwi & Addo-Yabo et al. 2002; Premji et al. 2002; Ssengooba et al. 2002; Hamer et al. 2002; Mwanakasale et al. 2002) using pooled analysis revealed a reduction in the overall incidence of diarrhea in the zinc supplemented group being 18% (95% CI, 7-28%) less than in children who did not receive zinc. The same study also revealed a decrease in the incidence of pneumonia (41%; 95% CI, 17-5%) in the zinc-supplemented children than the control group.

Discussion

In most of the randomized placebo-controlled trials that has been conducted or reviewed, micronutrient supplementation was found to be essential for routines involving immune functioning. Recent evidence indicates that fortification or supplementation with iron, Vitamin A, and zinc are among the most cost-effective interventions available, even in areas that of low socio-economical status or have rates of HIV infection, in particular in sub-Saharan Africa.

The outcomes of the studies insinuate that zinc was found to be adjuvant in treating uncomplicated forms of malaria but not the acute types. In contrast, for zinc supplementation to be effective in combating acute forms of malaria, there needs to be an improvement of the functioning of the immune system. Also, zinc supplementation was associated with one-third decline in hospital visits to in rural parts of Gambia- a valid measure that has been recognized and is implemented by WHO when estimating malarial incidence in endemic countries.

Additionally, there is apparent indication that zinc is effective in treating diarrhea and some forms of acute diarrhea. The World Health Organization again has already made recommendations into implementing zinc to treating persistent diarrhea.

Future research should evaluate blending of zinc with vitamin A, or iron as opposed to utilization of a various micronutrient supplement. When assessing the efficacy of these micronutrients, studies can be generated separately that reflect on whether the beneficial effects of vitamin A and zinc are additive or synergistic. Also to determine whether the use of zinc helps limit the increase in malaria parasitemia seen during iron supplementation, and to evaluate the impact on anemia and growth in children in malaria-endemic regions. Even so, prospective exploration should consider public health interventions aimed at preventing or correcting micronutrient deficiencies that will also assist or can be expected to reduce both mortality and disability substantially among populations, especially in children.

 

• References

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[Gaasira]

Raula,

 

This was difficult, but informative read (all that medical jargon had my head spinning!).

 

This study is particularly applicable to me because most of the females in my mother’s side of the family suffer from Iron deficiency and, in some cases, acute anemia. If, as the study suggested, Zinc and Vitamin A supplements boost the immune system and thereby increase the body’s chances of fighting Malaria (and other diseases?), then this is very good news. Perhaps all those Somali parents who are sending their children home for some Reacculturation can arm them with these vitamins along with the Malaria pills.

 

Do you know if there are foods grown in the Malaria endemic regions that may contain these nutrients (so perhaps people could be encouraged to grow and consume these foods instead of becoming dependent on supplements from drug companies)?

 

Thanks.

[Viking]

Also, zinc supplementation was associated with one-third decline in hospital visits to in rural parts of Gambia- a valid measure that has been recognized and is implemented by WHO when estimating malarial incidence in endemic countries.

If the zink reduced the diarrhoea, then it is only natural that the visits to the hospital declined. Dehydration through vomitting, fever and diarrhoea (I thought) were the main reason malaria patients visited the doctor.

 

The children who are "luckiest" are those with sickle (hemoglobin) cell traits (not the disease) for they have a natural protection against malaria and usually don't die of it.

 

Gaasira,

Good sources of zink are meat and wholemeal.

[raula]

Gaasira -along w/the sources mentioned by VIKINGS there is also CALF's LIVER(this is considered to be the purest and most excellent source of Zn because it has less toxic accumulation-pesticides, hormones etc-unlike older animals). Some studies show also that Iron deficiency is concurrent with Zn deficiency(one of the signs is dry/rusty hair). On the other hand, due to the syndrome associated with PICA(a habit of eating non-food items like sand (ciidda bacaadka ah-reddish in color and mostly found in the center of hills, charcoal, chalk)[-in africa mostly consumed by youngsters/youth, and a significant number of pregnant women]; it has been shown that individuals with this weird sense of inclination to non-food items CONCURRENTLY suffer from Iron deficiency. (foods that are rich in Iron -meat(but avoid the fatty/oily parts of meat-best way to not accumulate much of the transfatty acids or saturated fat in beef/poultry is to roast and grill the meat-and Vit. A-foods rich in beta carotene [i.e carrots, winter squash,melons, etc].

 

VIKING -those are minor symptoms of malaria, however complicated forms of plasmodium falciparum can lead to kidney failure, seizures, mental confusion, coma and death. Besides,when malnutrition and PEM(protein-energy malnutrion) is a major problem in those regions, it exercebates the disease to endemic/epidemic proportions. But, I understand your point(myself been a victim of a mild case of malaria when I was back home almost 13yrs ago).

 

*Excuse my long writings; its in my future interest to work in the infectious disease depart. -interesting stuff

[Viking]

raula,

How about introducing sicle cell traits to future generations? Does it sound crazy or is it a viable option? Is it too risky? Who knows, you can get a Nobel Prize for saving a million lives annually

[Grad Student]

Girl, how many sources did u use.? :eek: what a serious woman. now i am glad i am no physical science major.

so we need vitamins to fight malaria right? :confused:

[Alle-ubaahne]

Our # 1 public health priority should be tackling the foreign imported deceases. Its a very sad reality that Somalians are introduced experimental drugs, some are even expired. Think about the junk expired food they (UN Agencies) donate us! Each and every so-called humanitarian assistance is an attempt to further complicate our well-being as a sociaty.

 

I beleive the civil unrest is outweighted by the other health crisis in our country. Let's find a meaninful solution to solve the overwhelming problems we're faced now.

[Gaasira]

Thanks Raula and Viking. It's nice to have in-house resident experts. What's supposedly good for us today may be rendered harmful by a new research, making it difficult for the average person to keep track.

 

Raula, I too became interested in the control of infectious diseases, particularly sexually transmitted infections, after doing a research on sexual health among immigrant communities (including Somalis) last year. I was petrified to discover the complete lack of information among Somali youth and their parents (I conducted focus groups with boys, girls, and their parents, separately). Sexually transmitted infections have strong social stigmas attached to them and this is particularly so in our community. This kind of stigma results in lack of compassion for those infected. Worse, those infected may not seek treatment and continue to behave irresponsibly (as we’ve heard time and again) by spreading the infection to others.

 

After that research I knew that I had to somehow get involved in the prevention of sexually transmitted diseases. How to get there is what I’m working on now. Perhaps our paths will cross one of these days. Cheers.

[Coloow]

ASC,

 

Glad to note that we have medical students/practitioners on SOL.

 

A swedish friend of mine who happens to me an MD told me that there is an increase of hepatises b and c cases among somalis.

 

Could any of you shed some light on the extent of Hepatices cases among somali communities overseas? How this disease is transmitted in the somali community? Could the chewing of qaad be a factor?

 

He told me also there is no known cure for this disease.Any drugs on the way?

[Viking]

Caaqil,

I am not an expert, but I think you should ask your friend how he came about this information. I know that in Sweden Somalis have had a rather high prevalence of tuberculosis but haven't heard about them having Hep B and C. Hep A is more common and they say that 97% of Somalis have had it some time in their lives. I don't think it's qat-related because Hep B and C viruses are transmitted mainly through blood contamination, copulation etc. Here's a link that may be of help...

 

 

http://www.immunize.org/catg.d/p4075abc.htm

[Mutakalim]

A very informative paper. Hats off.

 

P.S. What school of medicine do you attend?

[raula]

^^thx walaalo-and FYI Iam not a med-student rather a prospect public health practitioner(EPIDEMIOLOGY to be precise).

 

InandOUT -I hope you are still not wandering the hallways meddling with them KENYATIâ€s looool…the reference is greatly vital to the credibility of the paper as well as abiding by scholarstic/academic styles-besides the TEXT of the paper is review not the complete paper..

 

Gaasira -its encouraging and soothing (not to mention rousing) to see young educated Somalis undertaking the leadership responsibility (by investigating on issues such as “risky behaviors†consequential to STDs in our community that could lead to devastating health detriments). I say you are very daring to take upon such role in spite of our rigid culturally embedded-perceptions (Mansha-allah and may your efforts be rewarded).

 

Caaqil - along with VIKING (Iam imagining that he is learned in the medical field than I, or is fanatical about health-related interests..lol..Iam Joking ndugu). Most of the HBV (Hepatitis A, B, C etc virus) can attack any parts of the body but are predominant on lungs or liver. There symptoms are much similar for all categories (signs include: fatigue, jaundice, nausea, abdominal pain, loss of appetite, vomiting ….). However, they vary on Transmittion modes:-

Type A:-is mostly a food-borne-meaning that its transmitted through mouth transmission from feces(stool)-i.e. eating foods that are not washed properly(that has been in contact with contaminated water sources) or not properly washing hands after changing a diaper, or attending to latrines/toilets. Good personal hygiene and proper personal sanitation is the best primary prevention of this type, however, VACCINE is the long-term prevention.

Type B & C-generally the virus attacks the liver and can result in cirrhosis (scarring) of the liver, cancer, liver failure or even death. Same signs/symptoms as Type A but transmission is primarily through contaminated blood (hemodialysis or blood transfusion), or other bodily fluids such in the course of sex, IDU (injecting drug-users) and to un-born child from an infected mother. The groups at risk of this disease are also at risk of HIV infection. Condoms use can assist the preventing the transmission but its EFFICACY in preventing the infection is UNKNOWN (Note the difference!).

****mostly the Vaccine is the best prevention possible in alleviating this disease. Moreover like Viking said, the most common one is type A because it’s easily diffusible into our water and food systems.

 

Viking - interesting enough you convey about the issue of TB in Somalis (whether in Europe or other parts of the Diaspora). I reason that the high prevalence rates in Somalis with TB is an outcome of the fact that TB is a LATENT disease (where TB bacteria is alive but inactive in the body) until activated. Hence, the individual does not display any symptoms/signs of illness, cannot spread TB and when given a TB-test comes back negative (unless it’s the TUBERCULIN Skin test-best measure when checking Latent type). Here is a study that I came across about the incidence rates (new cases) of Somalis with TB in DENMARK:-enjoy!

http://www.cdc.gov/ncidod/EID/vol8no7/pdf/01-0482.pdf

*one more thing-I heard of the sickle-cell trait in malaria prevention but haven't researched on it yet. Once I do that I wont hesistate to share my implications with you and anyone.

 

Till then folks-as zanzibari swahilis say: Masalkheri/sabalkheri.

[Coloow]

ASC, Viking and Rauli (good luck with your studies) thanks for the info. This friend of mine was a doctor who specialised in infectious diseases. I am suspecting that he met many somalis whose blood contained traces of HBV.

 

Could mosquoitoes be the carrying agents of HBV?

 

Another friend of mine (this one a somali nurse) in London told me (six years ago) that he was involved in a public health project in south-east london to investigate the general health of somalis. They visted Qaad houses and found that 67 percent of the somalis they investigated had either; TBC, HBV and other communable diseases. I tried to call this guy last night and ask him whether the study was published..but apparently he is in Somalia and working on a similar project!

[Libaax-Sankataabte]

Originally posted by Caaqil:

Rauli

[Coloow]

Ina Libaax sankataabte thanks bro,

I appologise!

 

Raula :lol: