SK Agarwal

SK Agarwal

How to Approach CKD Prevention in Large

Country

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 ESRD260 / pmp

RT3 / pmp CAPD

1 / pmp

HD2 / pmp

Govt. spend8$/capita/yr

RRT /person /yr750-3000 $

What to rest 254 pmp ? Death

Prevention is only solution

Preventive Program for Chronic Illness

Is the disease prevalent in the country

Are the effects serious to warrant prevention? Is the disease/causes of disease easy to detect? Can disease be easily prevented? Is the cost of prevention less than the treatment? Can the preventable program sustainable?

Issues involved:

YesYesYesYesYes???

Major Causes of Chronic Kidney Disease

0

10

20

30

40

50

60

Diabetes Ht Parenchymal

AIIMS, New DelhiApollo, ChennaiPGI, Chandigarh

(CGN+TID)

Agarwal et al (2000)

Mittal et al(1997)

Sakuja et al(1994)

Mani MK(1993)

Mean Agarwal et al ( 2002 )

No of Cases

7072 835 453 2028 10388

37

DN 28.4 23.2 23.8 26.7 25 41Ht 5.7 4.1 13.5 10 8.3 22GMn 48.5 28.6 36.6 18.2 32.9 16TID 7.5 16.5 14.3 27.8 16.5 5.4PKD 1.9 2 3.5 2 2.3 0

Etiology of CKD in IndiaHospital based studies Field study

Prevention Program in Other Countries

Can Causes and CKD easily detectable?

Parameters KEEP(USA)

Ivor(SA)

Sylvia(Singapore)

Hoy WE(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

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

Risk of CKD in Relatives of High Risk Group

Approaches for Prevention Programs for CKD

Whole Population

Selected Community

High Risk Group

KEEP South Africa

Australian Program

NKF Singapore

Proposed Prevention Program in India

Possible Prevention Program in India

Selected Community

High Risk Group

Whole Country

• Diabetics• Ht• 10 Relatives of

• CKD• Diabetics• Ht

Awareness of CKD in CommunityBoth Medical, Paramedics, Non-medical

Multiple Level Approach

Startearly detection

program Of CKD in “High Risk

Group”

Start making a base

For communityLevel screening

as part of existingInfrastructure

Top 10 Specific Causes of Death in India, 1998

Causes No in thousands

% India / World

CAD 1471 15.8 19.9Acute LRT Inf. 969 10.4 28.1Diarrhoeal Dis 711 7.6 32.1CVA 557 6.0 10.9TB 421 4.5 28.1ESRD 250 ??? ???RT Accidents 217 2.3 18.5Measles 190 2.0 21.4HIV/AIDS 179 1.9 7.8Tetanus 165 1.8 40.3COPD 153 1.6 6.8Total Deaths 9337 100 17.3Total Population 982223 100 16.7


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

Central Coordinating Team


Nephrologist Community Medicine person Biostatistician Administrator / Ministry

Zonal Member

Medical Colleges / Private Hospital / Pvt. Clinics

Nephrologist Community Medicine Administrator

Nephrologist / Internist Nurse / Other paramedics

Zonal Coordinator (15)

Hary

HP

Uttar

UP

Naga

Chat

t

Punj

Rajas

GujratMP

Maha

APKarna

Goa KeralaTN

Megha

A P

Jhar

Bihar

WB

Orrisa

Assam

Sikkim

TripMizo

Mani

Pond

Chandi

Z-1

Z-2

Zone-3

Z-4

Z-5

Z-6

Z-7Z-8

Z-9

Z-10Z-11

Z-12

India with Zones for CKD Prevention Program

Z-13

Z-14 Z-15

Education program for CKD in community Audio-visual aid Information booklets Posters Interactive session with healthcare team PEP (Patient-educates-patient)


In addition to screening high-risk group Multicentric study for prevalence of CKD and its etiology in community

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 mortalityHigh fertility

Low mortalityLow fertility

• EpidemiologicalMalnutritionCommunicable Dis.

Chronic Non -Communicable Dis.

• Social Low knowledgeLow expectations

Public sector

High knowledgeHigh expectations

Private sector

• Economical Low cost / event• Diarrhea

High cost / event• MI

Indian Health Care System

Community Health CenterCHC

By State Govt.

Primary Health CenterPHC

By State Govt.

Sub-CenterSC

By Central Govt.

RURAL URBAN

Dispensaries

Hospitals CGHS Railways ESI MCD NDMC Many others

SC PHC( 6 SC)

CHC(7.5 PHC) (4)

Number 1,37,311 22,842 3043

PopulationCovered

5400(5000)

32,469(30,000)

2,40,000(1,20,000)

Villages Covered

4.5 27.8 201

Beds No 4-6 30 Personnel • 1 MPW (M)

• 1 MPW (F)• 1 Voluntary

• 1 Medical Officer• 1 Technician• 14 Paramedics

• 4 Medical Officer• 7 Nurses• Pharmacist• Lab tech• Radiographer

Indian Health Care in Rural Area: Infrastructure

Rural Health Statistics in India 2002, Govt. of India

Current Health Policy & Problems in India


• 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

Cont….

Demographic Changes in India (1951-2000)

0

20

40

60

80

100

120

140

160

1951 1981 2000 Goal for 2000

Life Exp.Crude Birth Rt.Crude Death Rt.IMR

National Health Policy 1983, Registrar General of India

Impact of Public Health Expenditure

Indicator % Population with income <

1$/day

IMR /1000 % Health expenditure

of GDP

% Public expenditure

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


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

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

Goal to be achieved in India by 2015 Eradicate Polio & Yaws, Leprosy 2005Eliminate Kala Azar 2010Eliminate Lymphatic Filaria 2015Achieve 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 / 2010Establish integrated system of surveillance & statistics 2005


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 statement on Non-communicable diseases 2001

WHO Stepwise Approach to NCD Surveillance

NCD Step-1 Step-2 Step-3

Death (The past)

Death rate by age & sex

Death rate by age, sex and cause of

death(Verbal autopsy)

Death rate by age, sex and

cause of death(Death certificate)

Disease(The present)

Hospital / clinic admission by age

& sex

Rate & principle conditions in three groups;

Communicable, NCD & Injury

Cause specific disease incidence

& prevalence

Risk factors(The future)

Questionare based report on key risk factors

Questionare plus physical

examination

Questionare plus physical

examination & biochemical

reports

Risk factors Common to Major NCD

Risk Factor CVS Cancer Diabetes RespiratoryDiseases

CKD

Smoking Alcohol

Nutrition Physical Inactivity

Obesity Hypertension Diabetes Hyperlipidemia

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 ISNA. 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 ISNA. 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

Where we need help?

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

Summary

SK Agarwal

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