Glimpses of Tribal Health in India: ICMR Initiatives

Transcription

1 Glimpses of Tribal Health in India: ICMR Initiatives Dr Tapas Chakma Scientist G & Director Grade Scientist tapas_chakma@rediffmail.com ICMR-National Institute For Research in Tribal Health; Jabalpur

2 Structure of Presentation Nutritional disorders and Fluorosis Non-communicable disease-hypertension Genetic disorders Vector Borne disease Malaria Filaria Dengue Japanese Enchephalitis Tuberculosis Traditional medicine

3 DIET AND NUTRITIONAL STATUS OF TRIBAL POPULATION UP Survey not conducted GUJ M.P. WB Survey conducted MAH ORI KAR A.P. KER TN

4 Average Daily Household Intake Of Food Stuffs as % Of RDA Cereals 91 Pulses GLVeg Other Veg Roots & Tubers Milk & MP Fats & Oils Sugar & Jaggery Per cent of RDA

5 Average Daily Household Intake Of Nutrients as % of RDA Protein Energy Calcium Iron Vitamin A Thiamin Riboflavin Niacin Vitamin C Free F.Acid Per cent RDA

6 Percent deficit (%RDA) in the median daily intake of nutrients among 4-12 year children Nutrient Age Groups (Years) / Sex 4-12 Year pooled B + G B + G Boys Girls Protein Energy Total Fat Calcium Iron Vitamin A Thiamine Riboflavin Niacin Free Folic Vit. C Laxmaiah et al 2010

7 Prevalence (%) of Undernutrition (<Median 2SD) among Preschool children (1-5yrs) State N Underweight Stunting Wasting Kerala Tamil Nadu Karnataka Andhra Pradesh Maharashtra Gujarat Madhya Pradesh Orissa West Bengal Pooled

8 Gaps Identified Protein and energy deficiency in diet across all the tribes Micronutrient deficiencies like calcium, Iron, vitamin C, vitamin A are deficient among tribals across all the states. At present employment generating programmes like MNREGA or Forest dept development programmes are not linked to health programmes.

9 Fluorosis Fluorosis emerged as a new public health problem in many tribal areas 26 districts of MP and 8 districts of CG are endemic for fluorosis Prevalence of Dental fluorosis is about 50% Skeletal fluorosis is about 10%-40% Non-skeletal fluorosis is about 60-70%

10 1995 Impact of nutritional intervention on Knock Knee Baseline Post- Intervention Current status

11 Impact of nutritional intervention on Bow leg Baseline Post- Intervention Current Status

12 mg Mean Micronutrient intake of Fluorosis affected Patients (n=17) in Mandla, Central India, Patients value RDA

13 Effect of intervention on fluorosis in Seoni after 2 year intervention Pre intervention Post Intervention % +/- P value No. Exam. No. (%) No. Exam. No. (%) Dental Fluorosis (18.9) (17.8) >0.05 Genu valgum (9.3) (6.8) <0.001 Skeletal Fluorosis (3.4) (2.4) <0.01 Non skeletal Fluorosis (16.7) (6.2) < Other Symptoms (11) (2.3) <0.0001

14 Gaps identified Fluorosis control requires multi-sectoral approach simultaneously like Health and family welfare, Public Health Engineering and Women and Child Development Department. At present there is no committee to coordinate the activities in the district. This is a major drawback in the National Programme for fluorosis Prevention and Control.

15 Prevalence (%) of Hypertension among Adult men By State

16 Prevalence (%) of Hypertension among Adult women By State

17 Percentage Prevalence (%) of NCDs among urban men 18 years by Community SC OBC Others ST Hypertension Diabetes OW & Obesity Waist Circumference NNMB Urban Nutrition surveys

18 Prevalence (%) of NCDs among urban women 18 years by Community Percentage 80 SC ST OBC Others Hypertension diabetes OW & Obe WC

19 Percentage Percentage Distribution (%) of Blood pressure >20years Age among tribes of Mandla according to Migration Characteristics Systolic BP Normal Pre Hyperten Never Expos.(n=1116) Occa. Migration (n=1003) Urban Tribe (n=971) Gr I Hyperten Gr II Hyperten Normal Diastolic BP Pre Hyperten Never Expos.(n=1116) Occa. Migration (n=1003) Urban Tribe (n=971) Gr I Hyperten Gr II Hyperten t-5.221; df-3088; P<0.0001

20 Percentage Percentage Distribution of Urinary Iodine (μg/l) in various tribal groups of Mandla < > Never Exposed (n=143) Occasional Migration (n=167) Urban Tribe (n=105)

21 Risk factors identified Alcohol intake, Tobacco Smoking and Chewing, High salt intake BMI >25 and BMI <18 are the major risk factors among the tribals.

22 Hemoglobin Disorders in India

23 Sickle Cell Disease among Tribals ICMR s survey identified 20% children with sickle disease died by the age of two year. 30% children with sickle cell disease among tribals die before adulthood. Controlling these highly life shortening diseases requires screening and management of these vulnerable populations at village, district and state levels. *Colah et al., IJMR, 2015

24 ICMR-New initiatives Antenatal screening & Prenatal diagnosis for Hemoglobinopathies First Sickle Cell Clinic and Diagnostic facility in Madhya Pradesh Interim Satellite Centre for Hemoglobinopathies at Chandrapur, Maharashtra Study on effective use of hydroxyurea in sickle cell anemia and β-thalassemia Evaluation of genetic modifiers and clinical heterogeneity among sickle cell disease patients in India

25 HbE Disease Hemoglobin E (HbE) is the most common Hb variant in Southeast Asia and results from production of structurally abnormal Hb and at a reduced rate and behaves like a mild form of β-thalassemia. In India, HbE is mostly restricted to North-Eastern states. HbE homozygous disease behaves like β thalassemia

26 Glucose-6-phosphate dehydrogenase Deficiency G6PD deficiency causes increased susceptibility of red blood cells to oxidative stress and leads to hemolytic anemia, favism, chronic nonspherocytic hemolysis, spontaneous abortions and neonatal jaundice. Prevalence varies from 5.7 to 27.9% in different population groups. G6PD deficiency can cause significant problems, especially in malaria treatment. Dapsone, used in combination therapy for the treatment of Plasmodium falciparum and primaquine, used to eliminate the hypnozoite reservoirs of P. vivax and P. ovale, can induce serious hemolytic events.

27 Malaria Prevalence (API wise) and Percent of Tribal Population in the District Districts with 30 percent or more tribal population comprising about 8 percent country s population contributed to 46 percent of total malaria cases, 70 percent P. falciparum and 47 percent malarial deaths in the country

28 Malaria Surveillance Studies Conducted by ICMR Institutes The prevalence was 1-50% in different study depending up on various factors. P. falciparum accounts for 30 90% of the infections in the forested areas inhabited by ethnic tribes Malaria disease burden is high in the foothills, forested and deforested hills of the northeastern states that are dominated by tribal people. P. falciparum malaria risk was 31.6%, which is four times higher compared with that of P. vivax malaria (7.8%). Case fatality rate was 21% from central India region due to cerebral malaria

29 Insecticide resistance of An. Culicifacies and An. fluviatilis

30 Insecticide resistance of An. Culicifacies and An. fluviatilis

31 Insecticide resistance of An. Culicifacies and An. fluviatilis

32 Insecticide resistance of An. Culicifacies and An. fluviatilis

33 Filariasis Operational Project carried out among the Nicobarese with double fortified salt (Iodine +DEC) for one year; supplementary strategy to MDA Significant reduction in Mf prevalence (<1%) Policy Implications This activity may be extended to other areas

34 Viral diseases Japanese Encephalitis (JE) Repeated JE out break in Odisha 2013 out break in tribal areas like Malkangiri, Mayur Bhanj, Keonjhar, Jajpur district Mosquito pools were positive for JE Policy Implications All four districts are now covered under vaccination programme Developed JE

35 Japanese Encephalitis in Northeast India Regional Medical Research Centre, Dibrugarh First clinical case of JE in India: 1955 (Tamil Nadu) 21 Indian states endemic JE in north-eastern India RMRC, Dibrugarh - first laboratory to undertake diagnostic and research work on JE in NE India Serves as advanced referral laboratory for NVBDCP, Govt. of India for diagnosis and quality control of JE

36 ICMR s Contributions in prevention and control of JE JE Intervention strategies Diagnostic Assays developed for JE Forecasting JE by use of Early Warning System Use of Insecticide Treated Mosquito Nets (ITMN) for breaking JE transmission cycle Impact of JE immunization programmes Indigenously developed vaccine for JE- JENVAC

37 Pulmonary Paragonimiasis in North Eastern Region (NER) of India Regional Medical Research Center, Dibrugarh Paragonimiasis is lung fluke infection with a differential diagnosis of pulmonary TB Developed animal model of paragonimiasis for development of diagnostic test Developed a highly sensitive and specific diagnostic kit for detection of IgG antibodies Carried out Interventional studies in a remote hill district of Arunachal Pradesh and demonstrated a declining prevalence of pulmonary paragonimiasis in a hyper endemic area of paragonimiasis following treatment & community education.

38 Dengue 2013 Dengue out break in 18 tribal dominated village of Mandla district, MP Phylogenetic analysis revealed DENV-2 cosmopolitan genotype Policy Implications Active vector surveillance and control activities needs to be continued

39 Burden of TB in tribal population Area Prevalence/1,00,000 Jawadhu tribals, North Arcot District, Tamil Nadu, Tribal population of Car Nicobar, A& N islands, All tribes, Madhya Pradesh, Arunachal Pradesh 370 Assam 780 Bihar 476 Baiga PVTG Dindori district, Madhya Pradesh, Bharia PVTG Chhindwara district, Madhya Pradesh, Pooled prevalence 703 Datta et al 2001, Murhekar et al 2004, Bhat et al 2009, Yadav et al 2010, Rao et al 2010, Thomas et al, 2015

40 TB task force study Multicentric task force study to estimate the burden of TB in tribal population. 6 tribal dominated states Andaman, Chhattisgarh, Jharkhand, Madhya Pradesh, Maharashtra and Odisha in 1 st phase 2 nd phase initiated Quantitative and qualitative survey done

41 State Population Screened (>15Y) TB prevalence Symptomatics Sputum collected No. positives Prevalence per 100,000 Andaman 3302(87%) 95(3%) 80(84%) 13(16%) 394 Chhattisgarh 5873(88%) 335(6%) 330(99%) 20(6%) 341 Jharkhand 7295(95%) 247(3%) 219(89%) 9(4%) 123 Madhya Pradesh 14391(90%) 659(5%) 640(97%) 71(11%) 493 Maharashtra 7004(82%) 144(2%) 140(97%) 4(3%) 57 Odisha 5053(93%) 99(2%) 72(73%) 18(25%) 356 Total 42918(89%) 1579(4%) 1481(94%) 135(9%) 315

42 Qualitative assessment Lack of accessibility to healthcare facilities (poor/inadequate transportation) Limitations of non-tribal health staff in working with the tribal population (dialect, migration, over dependence on ASHA) Difficulties faced by ASHA workers, ANM (poor incentives for ASHA), poor commitment due to lack of monetary rewards Deep rooted belief in Traditional healing practices (Faith healers), cultural beliefs Housing poor ventilation, overcrowding Alcohol use, tobacco, Smoking Indoor air pollution (cooking inside, biomass fuel) Poor education facilities and government services

43 Prevalence of TB amongst Saharia PVTG District Year Findings Sheopur /100,000 Risk of infection 16.9% Sheopur /100,000 ARTI 3.9% Gwalior /100,000 Shivpuri /100,000 Chakma et al 1996, Rao et al 2010,2015 Prevalence of TB is alarmingly high in the tribe

44 Traditional Medicine Two selected ethnomedicines, used by Onge and Nicobarese tribes, were studied and it was found that both folk-medicines have bioactivity in vitro and in animal model showing anti-inflammatory, antipyretic, and selected antibacterial activity. Policy Implications The compound is ready for clinical validation A validation study was done on traditional preparation by Birhore and Kattabhai tribes on Miyadi bukhar. The in vitro and animal efficacy studies revealed that the preparation has antibacterial, especially anti-salmonella enterica Serovar Typhi activity; and significantly reduced bacterial count in blood and organs of treated animal challenged with mouse virulent S. typhimurium. Policy Implications The work leads to one US and one Indian Patent with the tribal group and is now in clinical trial pipeline.

45 Thank you