NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL STRATEGIES IN SOME INDIAN STATES. REPORT OF THE ICMR - WHO WORKSHOP At BANGALORE - KARNATAKA
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- Title
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NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL
STRATEGIES IN SOME INDIAN STATES.
REPORT OF THE ICMR - WHO WORKSHOP
At
BANGALORE - KARNATAKA
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NON-COMMUNICABLE DISEASE PREVENTION AND CONTROL
STRATEGIES IN SOME INDIAN STATES.
REPORT OF THE ICMR - WHO WORKSHOP
At
BANGALORE - KARNATAKA
icmr-who workshop
PREVENTION & CONTROL OF NON-COMMUNICABLE DISEASES
, ORGANISED by
ST. JOHN'S MEDICAL COLLEGE
1719 OCTOBER 2005
VENUE: CARDINAL GRACIAS HALL
OCTOBER 17th TO 19th, 2005
Sponsored By:
INDIAN COUNCIL OF MEDICAL RESEARCH & WORLD HEALTH
ORGANISATION, NEW DELHI
Organised By:
ST. JOHN’S MEDICAL COLLEGE BANGALORE
091 o
Non- Communicable Disease Prevention And Control Strategies in some
Indian States. Report of the ICMR - WHO Workshop at
Bangalore Karnataka
Coordinators:
Dr. D K Shukla. Deputy Director General (SG) ICMR. New Delhi. Dr. L.M. Nath,
Professor of Community Medicine & former Dean AIIMS New Delhi. Dr. Prem Pais.
Dean. St. John's Medical College. Bangalore.
Resource Faculty:
Dr. C Shivaram. Dr. Thelma Narayan, Dr. Vivek Benegal. Dr. Pratima Murthy, Dr. Prom
Pais, Dr Girish N. Dr R. Bingi, Dr S.S. Iyengar. Dr. G Bantwal, Dr. Nagraj Desai. Dr.
Prasanna Kumar. Dr. Nandakumar. Dr. Elizabeth V, Dr. Dominic Misquith. Dr Ravi
Narayan.
From:
Indian Council for Medical Research (1CMR), New Delhi. National Institute of Mental
Health and Neuro Sciences (NIMHANS), Jayadeva Institute of Cardiology, Vydehi
Institute of Medical Sciences. MS Ramaiah Medical College. National Cancer Registry.
(ICMR) Bangalore. Community Health Cell, Kormangala. St. John's Medical College.
Bangalore.
Participants:
Dr. Ncela Biradar. Deputy Director (Nutrition), Dr. K S Murthy. Deputy Director. Dr. A.
V. Srinivasa. Dr. Karur B. V. Deputy Director, Dr. Amaresh Kolur. District Surveillance
Officer (DSO), Gulbarga. Dr. Rohini, (DSO) Udipi, Dr. S.S. Halkurki, (DSO). Haveri.
Dr. N.N. Rajagopal. (DSO) Hassan. Dr. Jayaraju, (DSO). Shimoga. Dr. S.S. Mathiwad,
(DSO). Bclgaum. Dr. R. Srinivasalu. Consultant, Integrated District Surveillance Project
(IDSP). Bangalore. Dr. Savitha S.K. Director, UHRTI Training Center BMP. Dr. Sr.
Aquinas. Project Director. Holy Cross Hospital Kamagere, Dr. N. Girish, Assistant
Professor Epidemiology & Dr. Mathew Vargheese. Professor Psychiatry NIMHANS. Dr.
Alben Sigamani. Programme Officer Clinical trials. SJIPHCR, Dr. Joseph Rajcndhran.
Assistant Professor internal medicine, SJMC, Dr. A.K. Roy. Professor. Neurology and
the following faculty of Community Medicine from different government and private
medical colleges in the stale. Dr M P Sharada. Professor and Head. Dr A G Umakanth.
Professor. Dr Vijayasimha. Associate Professor. Dr. Ranganath, Assistant Professor. Dr
Mudassir Aziz. Associate Professor. Dr. Dayanand M.. Associate Professor. Dr.
Ramakrishna Goud. Assistant Professor. Dr. Mansoor Ahmed. Lecturer. Dr Ramesh
Maslhi N. R.. Assistant Professor. Dr. Shobha Karikatti. Assistant Professor,
ICMR WHO Workshop NCD Prevention & Cc
17lh 19"' October St. John’s Medical College Bar
Community Health Cell
Library and Information Centre
# 367, “Srinivasa Nilaya”
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Phone ; 553 15 18/ 552 53 72
e-mail : chc@sochara.org
w
Acknowledgements
1 his report will not be complete without mention of the people who made this workshop
possible:
Dr. D K Shukla Deputy Director General (SG), Indian Council for Medical Research
(ICMR). New Delhi for having extended the invitation on behalf of ICMR to St. John's
Medical College to organize the workshop, also his valuable inputs in setting the tone of
this workshop and for technical and financial assistance from ICMR.
Dr. Chcrian Verghese National Professional Officer WHO Office for having extended the
invitation on behalf of WHO to St. John’s Medical College to organize this workshop
Dr. L. M. Nath. Professor of Community Medicine and former Dean of AIIMS, New
Delhi who made it his duty to encourage the participants to participate and brought clarity
to the participants on the expected output of the workshop.
Mr. Thangaraj IAS. Principal Secretary - Health Govt, of Karnataka for inaugurating the
workshop and readily agreed to depute the Doctors from the Government and also
offered support and encouragement for the workshop.
The Director of Health and Family Welfare Services, the Director of Medical Education
Govt, of Karnataka and the Chief Medical Officer of Bangalore Mahanagar Pallike for
having deputed the Doctors from the Government service, Government Medical Colleges
and Urban Health training Institute.
1 he Deans / Principals and the Heads of Department of Community Medicine of the
various private and government medical colleges who deputed faculty to attend this
workshop so as to make it a success.
1 he Management of St. John's Medical College, who are a source of encouragement and
willingly offered support in the smooth running of this workshop.
1 he resource faculty from the different Institutions who realizing the importance of NCD
prevention and control immediately agreed to provide their valuable inputs for this
workshop so as to make the strategy that was developed more meaningful.
Dr. 1 hclma Narayan and Ravi Narayan of Community Health Cell for helping to set the
framework for developing the strategy.
1 o the participants of this workshop goes the credit for developing this strategy; their
sense of owner ship is reflected in this report.
Last but not the least goes credit to the invisible participants of this workshop who
worked behind the scenes - Ms. I'reda Xavier, Ms. Nandini. Ms. Pranjali. Ms. Mary. Mr.
Swami Durai and others for their tireless effort in making this workshop a success.
Dr. Prem Pais.
Dean.
St. John's Medical College.
ICMR Wl IO Workshop NCD Prevention & Control Strategies in Karnataka
I?"1
19th October Si. John's Medical College Bangalore
3
1CMR - WHO Workshop on Prevention and control of NCI)
Cardinal Gracias Hall, St. John’s Medical College, Bangalore
I?"*, IS'”, 19lh October 2005
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Chief Executive Officer
Continued Medical Education
Community Health Centre
Cardio Vascular Disease
Disability Adjusted Life Years
Department of Community Medicine
Deputy Director General
Diabetes Mellitus
Director of Health Services
Director of Medical Education
Department of Community Health
District Surveillance Officer
T)irectorate of School Education Research andJTraining
Electro Cardio Gram
Electro Convulsive Therapy
Heart Diseases
Head of Department
Government of Karnataka
Government of India
Health Education
Histo Pathological Examination
Hypertension
International Classification of Diseases-10
Indian Council lor Medical Research
Information Education Communication
Integrated Disease Surveillance Project
Ischemic Heart Diseases
Jawaharlal Nehru Medical College
Jagatguru Shri Shivarathreeswara Medical College
Kempe Gowda Institute of Medical Sciences
Master of Education
Member of Legislative Assembly
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ICMR Wl IO Workshop NCD Prevention & Control Strategics in Karnataka
17"’ I9111 October St. John's Medical College Bangalore
I
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Non Governmental Organization
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Obstetrics and Gynecology_________________
Poly Cystic Ovarian Disease
Postgraduate
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St John’s Medical College_______________
St John’s Medical College Hospital___
St. John’s National Academy of Health Sciences
State Surveillance Unit_____ ________
State Institute of Health and Family Welfare
Standard Operative Procedure
Tread Mill Test_____________________________
Urban Health Research and Training Institute
Undergraduate_______________________
World Health Organization
ICMR - WHO Workshop NCD Prevention & Control Strategies in Karnataka
17lh - 19
19"th October St. John’s Medical College Bangalore
5
TABLE OF CONTENTS
2.
3.
4.
5.
6.
6.1.
6.2.
6.3
6.4
6.5
6.6
7.
8.
1
2
4
6
7
8
9
10
11
Non-Communicable Disease Status in India:
Risk Factor levels of Non-Communicable Disease in India:
Risk Factor levels and Non-Communicable Disease Status in
Karnataka.
Non-Communicable Disease Policy in Karnataka
Overview of the deliberations of the 3-day workshop
Key issues on developing a State NCD strategy
I lealth Education Strategies to reduce risk factor in NCD
Minimum diagnosis and treatment facilities / guidelines
recommended for managing surveillance, early diagnosis and
treatment of NCD
Recording and Reporting of NCD in state disease surveillance
system
Other strategies /policies (in health and beyond) that have a
bearing on reducing the NCD
Recommendations for investigation and convergence of NCD
Prevention and Control strategies in the State
Role of Govt, health sector at district and state level and medical
colleges in implementing NCD control.
Conclusion
References
Annex urc
Primacy of PHC Medical Officers role
Issues / Concerns / Solutions discussed during the workshop
Programme Schedule for 3 days of Workshop.
Fist of Faculty/Resource persons for the Workshop
Fist of Participant/Delegates for the Workshop
Agenda for the Group Work for drafting the Action Plan for the
Control of NCD.
Fist of Names of members in the three Groups formed for
working on specified topics.
News Paper Clippings covering the ICMR-WI10 Workshop.
I extract on NCD - Final Report of the Task Force on Health and
family Welfare, Government of Karnataka. 2001 April.
Extract from Karnataka Inleerated Health Policv.
The Bangkok Charter on Health Promotion
7
7
8
9
9
11
11
12
13
13
14
15
15
16
J
ICMR
WHO Workshop NCD Prevention & Control Strategies in Karnataka
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1. Non-Communicable Disease Status in India:
India is experiencing a rapid health trapsition, -’Th large and rising burdens of chronic
diseases, which arc estimated to account tor 53% of ail deaths and 44% of disabilityadjusted lilc-years (DALY's) lost in 2005. Many of these deaths occur at relatively early
ages. Compared with other countries, India suffers the highest loss in potentially
productive years of life, due to deaths from cardiovascular disease in people aged 35-64
years (9-2 million years lost in 2000). Cardiovascular diseases and diabetes are highly
prevalent in urban areas. The estimated prevalence of coronary heart disease is around 34% in rural areas and 8—10% in urban areas among adults older than 20 years,
representing a twofold rise in rural areas and a six-fold rise in urban areas over the past
lour decades. About 29-8 million people were estimated to have coronary heart disease in
India in 2003, 141 million in urban areas and 15-7 million in rural areas. The prevalence
ol stroke is thought to be 203 per 100 000 population among people older than 20 years.
A national cancer control programme, initiated in 1975, has established 13 registries and
increased the capacity for treatment. Data on cancer mortality arc available from six
centres across the country, which are part of the National Cancer Registry Programme of
the Indian Council of Medical Research (ICMR). About 800 000 new' cases of cancer are
estimated to occur every year. The age-adjusted incidence rates in men vary from 44 per
100 000 in rural Maharashtra to 121 per 100 000 in Delhi. The major cancers in men are
mostly tobacco-related (lung, oral cavity, larynx, oesophagus, and pharynx). Tobacco
consumption, in diverse smoked and smokeless forms, is common, especially among the
poor and rural population segments. In women, the leading cancer sites include those
related to tobacco (oral cavity, oesophagus, and lung), and cervix, breast, and ovary
cancer. India has the largest number of oral cancers in the world, due to the widespread
habit ofchewing tobacco.
India also has the largest number of people with diabetes in the world, with an estimated
19-3 million in 1995 and projected 57-2 million in 2025. The prevalence of type 2
diabetes in urban Indian adults has been reported to have increased from less than 3-0%
in 1970 to about 12-0% in 2000. On the basis of recent surveys, the ICMR estimates the
prevalence of diabetes in adults to be 3-8% in rural areas and 1 1-8% in urban areas. The
prevalence of hypertension has been reported to range between 20-40% in urban adults
and 12—17% among rural adults. The number of people with hypertension is expected to
increase from 118-2 million in 2000 to 213-5 million in 2025, with nearly equal numbers
of men and women.
2. Risk Factor levels of Non-Communicable Disease in India:
1 hese advancing epidemics are propelled by demographic, economic, and social factors,
of which urbanization, industrialization, and globalization, arc the main determinants.
Urbanization and industrialization are changing the patterns of living in ways that
increase behavioral and biological risk factor levels in the population. Substantial
variations exist between different regions, but risk levels are rising across the country,
most notably in urban areas of dcmographically and economically more advanced states
of India.
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A high frequency of diabetes, central obesity, and other features of the metabolic
syndrome (especially the characteristic dyslipidaemia of reduced IIDL cholesterol and
raised triglycerides) have been reported in migrant and urban Indian population groups.
Nationally representative distribution data are available for a few risk factors. Several
community-based surveys, done in different parts of India at different times, have
contributed to a patchwork profile of risk in segments of the population, but there have
been very few multicentric studies with standardized methodology. In the Indian
component of the Global Youth Tobacco Survey (2000-04), 25-1% of the students aged
13-15 years reported that they had ever used tobacco, whereas current use was reported
by 17-5%. A national survey in 2002, reported that the overall prevalence of current
tobacco use in men and boys aged 12-60 years was 55-8%. ranging from 21-6% in those
aged 12-18 years to 71-5% in the 51-60 year age group.
Though the prevalence of obesity (BMI >30) is usually lower than that observed in the
western population, the overweight category (BMI >25) includes almost a third to half
the population in every survey.
The few available standardized studies of physical activity revealed low levels in urban
areas (compared with rural) and in the upper-income and middle-income groups
(compared with low-income). Low levels of physical activity have been reported in 61
66% of men and 51 75% of women, in urban surveys.
Levels of awareness, treatment, and adequate control are low for hypertension, diabetes,
and dyslipidaemia. especially in rural areas. With advancing health transition, the poor
are increasingly affected by chronic diseases and their risk factors. Low levels of
education and income now predict not only higher levels of tobacco consumption, but
also increased risk of coronary heart disease. Since India's daily consumption of fruits
and vegetables is 130 g per person per day, poor people may also have deficiencies of
protective phytonutrients. Urban slums in Delhi have high rates of diabetes and
dyslipidaemia. Lack of awareness of risk factors and diseases, and inadequate access to
health care, increase the risk of early death or severe disability in such disadvantaged
groups.
3. Risk Factor levels and Non-Communicable Disease Status in Karnataka.
I he report ol the Karnataka Task Force on Health comments on the paucity of reliable
data on non-communicable diseases. The crude prevalence rate of Diabetes Mcllitus type
ll in Bangalore city was 13.2% between the ages of 20 80 years. The Karnataka rural
diabetic survey conducted in four districts gave a crude prevalence of 7.77% and age
adjusted rate of 6.42% for the age group 20 - 85 years. The prevalence for men and
women was almost equal.
A study done by the Sri Jayadcva Institute of Cardiology on the class III and IV
employees of Bangalore Mahanagar Pallike showed that of the 3976 screened 293 (7.4
%) were diabetic. 993 (25%) were hypertensive. 409 (10.3%) had HID. 36 (0. 9%) had
ICMR W I IO Workshop NCD Prevention & Control Strategies in Karnataka
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RHD. 2350 (59%) were tobacco users. 146 (36.7%) used alcohol and 589 (14.8%) had a
high ictal scrum cholesterol. This shows that the prevalence of diabetes and hypertension
are consistent with data from other parts of the country. The risk factors arc often
combined and that the urban poor are as prone to non-communicable disease as any other
segment of the population.
4. Non-Communicable Disease Policy in Karnataka
Based on the report of the Task Force on Health, Karnataka in its Integrated State Health
Policy included a chapter on the Prevention and Control of non -communicable diseases.
In brief, the policy states that to prevent and control non-communicable diseases it will
provide:
i. Greater support.
ii. Adopt a public health approach to reduce risk factors.
iii. Adopt health education methods to promote healthier life styles.
iv. Initiate policies to discourage the use of tobacco and alcohol.
v. Fhe deleterious effects of tobacco and alcohol to be included in school and
college curricula.
vi. Diagnosis and treatment to be made available at Primary health care level.
vii. Recording and reporting of NCD to be included in the diseases surveillance
system.
viii. Cancer control programme to be strengthened.
5. Over- view of the deliberations of the 3-day workshop on NCI) in Bangalore:
The 3 day workshop was attended by Senior Programme Officers of the Directorate of
Health Services (DHS) and Senior Faculty Members of Departments of Community
Medicine from Government Medical Colleges under the Directorate of Medical
Education (DME), Government of Karnataka and Senior Faculty Members of
Departments of Community Medicine from Private Medical Colleges and Consultants
from few Non Governmental Organizations (NGO) working in the field of public health.
The Principal Secretary Health Govt, of Karnataka, Mr. Thangaraj, IAS, inaugurated the
workshop and also offered support and encouragement for the workshop. Directors of
Health and Medical Education too were supportive and readily deputed the doctors for
the workshop. The response from the Private Medical Colleges and NGOs loo was
encouraging.
The Faculty for the workshop was carefully chosen for this important workshop, fhe
faculty members were well known and recognized professionals in their respective
chosen fields of specialty and subject. The institutions from which faculty were invited
was from N1MHANS. MS Ramaiah Medical College and Memorial Hospital. Jayadeva
Institute of Cardiology. Community Health Cell and from St John's Medical College and
1 lospital among others.
Over the three days the faculty and delegates deliberated the epidemiological, operational
aspects of data collection, current situation of selected NCI) and strategics to tackle them.
Dr. 1) K Shukla, Deputy Director General (SG) ICMR. New Delhi set the tone bv
1CMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
17’" 1911' October St. John's Medical College Bangalore
9
emphasizing that Non-Communicable Diseases (NCD) is gaining increasing importance
in India as a major cause of morbidity, mortality and loss of working hours ?nd that there
is a growing need for the state and Central Governments to initiate NCD control
programmes. I hus the objective of this workshop was to address this issue and help
foimulatc a state level draft plan for implementation of a NCD control program in the
state.
Di C Shivaram, Professor ol Community Medicine and Principal of Vydchi Institute of
Medical Sciences and Research emphasized the need for assessing the NCD Burden in
the state where there is a paucity of this data. He also suggested few measures for
addressing the problem of NCD.
Faculty from NIMHANS emphasized the need for increasing community awareness and
the need to target the young and school children for IEC activities. They emphasized the
need lor Quality Life Skills Education in schools rather than a compartmentalized IEC
activity. Other participants shared this view also. The deliberations were also focused on
the limited role of legislative measures with respect to Tobacco Control and Prevention
of Alcohol Abuse.
Dr Nanda Kumar from ICMR Cancer Registry dwelled on the role and contributions of
the Population and Hospital Based Cancer Registries in assessing the Cancer Diseases
Burden.
Dr R. Bingi from Jayadeva Institute of Cardiology gave his experiences with studying the
urban poor of Bangalore Mahanagar Pallike. Dr Prasanna Kumar. Endocrinologist of
MSRMC and Memorial Hospital shared with the delegates the findings of the study
undertaken by his team with regards to Diabetes Mellitus in Rural Karnataka.
Dr Prem Pais, Dean of SJMC, Dr G Bantwal, Associate Professor of Endocrinology. Dr
Elizabeth, Professor ol OBG of St. John’s Medical College and Hospital also shared their
experiences with the delegates of the workshop. Dr. Thelma Narayan, Dr. S.S. Iyengar
and Dr. Dominic Misquith moderated the discussions at the end of each session
respectively. A C.D. containing all the presentations and some important articles
pertaining to NCD was given to the participants at the end of the workshop.
1 hese discussions helped in developing a common framework that was used in the group
work to develop a draft action plan for the state on the third day. Dr Ravi Narayan of
Community Health Cell. Dr L.M. Nath and Dr Shukla of ICMR facilitated the
deliberations. The groups presented their discussions on final day. The three groups were:
Group I - Alcohol. Tobacco and Neuro-Psychiatric Problems
Group 2- Cardio Vascular Diseases, Diabetes Mellitus
Group 3- Cancer Control
1 he Gioups identified a core team ol members who would refine the presentations made
on final day and prepare a Draft Action Plan that would be submitted to ICMR-WHO
New Delhi and to the Principal Secretary-Health Govt, of Karnataka.
ICMR
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While the groups looked at different sets of non-communicable diseases and made
recommendations lor each set - the final recommendations presented here are integrated
into strategies for NCD in general, in keeping with the overall thrust of the discussions
which recommended integration and convergence. (See also Annexure 1 and 2.)
6. Key issues on developing a state NCD prevention & control strategy were:
6.i. Health education strategies required to reduce risk factors in NCD.
6.ii. The minimum diagnosis and treatment facilities / guidelines to be recommended
for managing surveillance, early diagnosis and treatment
6.iii. Recording and Reporting of NCD in state disease surveillance system
6.iv. Other strategies /policies (in health and beyond) that have a bearing on reducing
the NCD
6.v. Recommendations for investigation and convergence of NCD Prevention and
Control strategies in the State.
6.vi. Role of Govt, health sector at district and state level and medical colleges in
implementing NCD control with the existing resources/existing system, and what
needs additional planning and resources.
6.i. Health Education Strategies to reduce risk factor in NCD
a) In Health System
• Develop IEC materials/tools like Booklets, Pamphlets, Posters. Banners and
make this available to the various cadres of Health Care Providers at all the
Levels of Health Care Delivery. The IEC materials should also to be provided
to general public, officials like Secretaries, law makers, MLA's. ministers,
judges, police officers, Deputy Commissioner, CEO's of Zilla Parishad etc
• Increase Public awareness with respect to NCD through Street Play. Role
Model and Mass media.
• Anti risk advertisement or Pro benefit advertisement e.g. alcohol, tobacco, 10
ways to reduce stress, tips for healthy living.
• The IEC material developed should contain the common risk factor
knowledge, signs / symptoms / warning signals of common NCD.
• Common risk factor knowledge and signs / symptoms /warning signals of
common NCD to be imparted to Health workers, Anganwadi workers, and all
paramedical workers enabling them to give health education session supported
with audio-visual aids
• Equip the doctors to undertake adequate supervision of primary health care
• Review in the monthly meeting the difficulties and challenges and host a
yearly Continuing Education Programme to update the information
b)
In the Education System
• To include in school curriculum information regarding common risk factors
signs / symptoms /warning signals of common NCD.
ICMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
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©
•
•
•
•
•
•
•
•
Teachers should be encouraged to organize debates, essay writing among
children.
Observation of World NCD Day (after a day gets designated for this).
Opportunities for improving awareness regarding NCD should also be
attempted in non-formal education settings.
The School Library should have a resource book on NCD and Risk factors.
The Books should be for both children and teachers.
The Module on Life Skill Education to 8tl1. 9th and 10th standard students and
teachers which is already accepted by Government of Karnataka and being
developed by NIMH ANS for DSERT could be consulted / used for adoption.
Such a book should be prepared by experts/doctors with feed back from
children and teachers.
Use both formal and informal methods of teaching (cartoons, films, games,
etc.)
Need for regular health education sessions in schools e.g. tobacco hazards like
it is being done in USA. In USA School children have about 12 sessions
dedicated to improve awareness regarding hazards of tobacco use
Lessons to be learnt from successful experiences e.g. PARIVARTANA
Project by MS Ramaiah Medical College regarding tobacco use. Health
education sessions were conducted for School children (in about 35 schools)
regarding hazards of tobacco use.
6.ii. The minimum diagnosis and treatment facilities / guidelines to be
recommended for managing surveillance, early diagnosis and treatment.
It was unanimously recommended that training and skill enhancement of all health
care providers in the early diagnosis and management / referral for persons with
NCD should be conducted. The training and reorientation should be through
Continued Medical Education (CME) of para medical personellc.
Infrastructure and Equipment at
Primary Care Level
• Minimum facilities and basic equipment like Blood Pressure Monitoring
Devices (Sphygmomanometers, Electronic machines etc). Weighing
machines. Measuring tapes and Blood Glucometers.
• Along with Essential drugs as recommended by WHO for primary care level,
certain essential drugs for treating NCD like thiazide diuretics, beta blockers,
oral hypoglycemic agents, insulin, aspirin should be made available at all
levels of health care delivery.
• A simple 20-point checklist, which includes quantity and frequency of use
data about Tobacco, alcohol, common mental disorders and early symptoms
of these disorders (e.g. cough, pain abdomen, sleep, appetite disturbance etc)
for all the different staff at the PHC.
•
Early Detection/Brief intervention (and Referral if needed) of cases of
alcohol, tobacco. Depression/ Anxiety / Psychosis.
ICMR Wl K) Workshop NCD Prevention & Control Strategies in Karnataka
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•
•
•
Common antidepressants, anxiolytics and anti-psychotics to be made
available (IMN 25mg, FLXT 20rng. DZM 5rng, RSDN 2/4mg etc) at the
PI IC as per the existing drug list.
Proper I listory taking regarding danger signs and risk factors for cancers.
Undertake / supervise: Breast self examination. Visual inspection for Cancer
cervix and Oral cancers
Secondary Care Level - District.
• That is at District Level Blood Glucometers for estimating Blood Sugar
levels. Llectro Cardio Gram machines. Tread Mill Test (TMT), Lipid profile.
Radiography (X- ray); Ophthalmoscope etc should be made available for
CVD.
• Well-equipped laboratory with pathologist who could do a 1 listo-pathological
examination.
• Recognize the level as first referral level for NCD: e.g. provides pain relief,
radio-therapy, chemotherapy for cancer, inpatient care, ECT/Drugs (all drugs
to treat mental disorders), counseling facilities to be available
• Equip with a mobile NCD detection and management set up which could do
fixed periodical visits to places at Taluka and sub taluka level.
Tertian Care Level
•
•
•
•
Referral services should be strengthened between the Primary. Secondary and
Tertiary Care levels.
That is al State/Referral/Regional facilities level. Cardiac Catheterization lab.
and Laser facilities for Cataract surgeries especially patients with Diabetes
Mellitus.
Advanced care and management of persons with cancer to be available.
Training. De-addiction centers, treat difficult cases. Policymaking. Lducation.
1LC material. Research, Drug Trials for persons with mental disorders.
6.iii. Recording and Reporting of NCD in state disease surveillance system
• To integrate with Integrated Disease Surveillance system.
• for Recording and Reporting, the diseases should be coded as per
International Classification of Diseases-10 (ICD-10) recommendations.
• Monthly reporting to higher level should specify the mortality and morbidity
and any special cases of NCD and feed back should be given to the primary
source.
• The attempt should be to form registries for all the common disorders in the
NCD.
•
•
District level registry for NCD.
Develop sentinel centres for the Cancer / NCD for the district
I ('MR
WHO Workshop NCD Prevention & Control Strategies in Karnataka
17"’
19" October St. John's Medical College Bangalore
13
6.iv. Other strategics /policies (in health and beyond) that have a bearing on
reducing the NCD
• Involvement of Medical Professional Bodies like Indian Medical Association,
Association of Cardiologist, Physicians etc.
• fhe involvement of these groups should be in conducting specialist camps,
screening camps and health melas. These professional bodies should be
utilized for advocacy and I EC campaigns.
• fhe Professional bodies can also be engaged in a dialogue with Health
Insurance Companies to workout a mutually beneficial scheme(s) without
compromising the interests of the patients.
• Policy and Legislative measures at Government level like:
> Nutrition policies
r- Tobacco policy
r- Alcohol policy
• Occupational health infrastructure to be strengthened to reduce occupational
hazards and improves safety.
• Surveillance systems for detecting emerging cancers and changing trends
• Private - Public Partnership should be encouraged.
• Involvement of NGOs and private sector in diagnosis, training, awareness,
whenever possible.
• Involvement of civil societies e.g. Consortium of Tobacco Free Karnataka in
creating an awareness, when possible.
• Individual and professional responsibility is a key aspect is towards the
prevention of NCD e.g. use of tobacco.
• I ligh taxation of any product related to increasing the risk of NCD. E.g.
tobacco, fast food chains.
• Restrict advertising and sponsorship of any product related to increasing the
risk of NCD. E.g. by tobacco companies, as done in countries like Australia.
New Zealand etc.
6.v. Recommendations for investigation and convergence of NCD Prevention and
Control strategies in the State.
• Establishment of NCD Cells at District level and State Level.
• 1 Existing personnel to be utilized: Re-designate a district level programme
officer as the NCD officer who is in-charge for the district.
• Improve staffing and other infrastructure (for HPE would also benefit other
programmes)
• To start registries for HDs. Hypertension, Cancer, Stroke and Diabetes.
• Involving and integrating the other Indian Systems of Medicine, especially in
treatment and recording and reporting of NCD.
ICM l< WHO Workshop NCD Prevention & Control Strategies in Karnataka
I7,h 19" October St. John’s Medical College Bangalore
14
6.vi. Role of Govt, health sector at district and state level and medical colleges in
implementing NCD control with the existing resourc^s/cxisti^g system, and what
needs additional planning and resources.
• At District and State level training of Medical officers and other staff for proper
diagnosis and recording and reporting of NCD and Risk factors.
• Medical Colleges could contribute in the form of conducting Continuing Medical
Education for General Practioners, Government Medical officers and others.
• Medical colleges should coordinate with government with respect of information
sharing, recording and reporting of NCD in prescribed formats.
• At Medical colleges the departments of Internal Medicine, Cardiology,
Endocrinology, Community Medicine, should work as team and provide an
integrated package of Health Promotive, Preventive, and Curative services.
Level
District
Slate
Medical
College
With existing resources________
Formulation of a comprehensive
District training plan.
Unified reporting system
SOP for integrated case finding
(warning signs plus approach)
Integration of IEC materials and
approach including training______
Training of Students (UG and PG)
and Paramedical staff
With additional resources
Establishment of Peripheral
Cancer centre with mobile
infrastructure
Preparation and uninlcrrupled
supply of I EC material
Upgrading diagnostic and
treatment facility
Others:
a. Creation of a National Institute for Non-communicable diseases
b. Website may be started for questions, integrated manual for different levels. District
specific plan.
c. Financial support for all this would be from state funds, central funds, and specificpi lot projects
d. Institute systems for keeping an eye on emerging cancers related to life style and stress
c.g. PCOD leading to Ovarian or uterine cancer.
7. Conclusion
The groups recognized the fact that Non Communicable Diseases (NCD) is gaining
increasing importance in India as a major cause of morbidity, mortality and loss of
working hours. The groups kept in mind the ‘Challenges of NCD’ when addressing this
issue and formulating a state level draft plan for implementation of a NCD control in the
state. Thus an integrated and convergent approach to the prevention and control of NCD
is recommended rather than vertical and competing programmes as seen with
programmes for communicable diseases. The focus is on lifestyle changes and the
emphasis in the approach to NCD control is on prevention and health promotion rather
diagnosis and treatment. The implementation of NCD control in the state is possible by a
creative extension of existing resources, use of personnel and services rather than
developing a separate cadre.
ICMR Wl IO Workshop NOD Prevention & Control Strategies in Karnataka
I?"1 19" October St. John's Medical College Bangalore
15
References:
K'ucual V.: k-rha Alcohol and Public Health 2005 Society for the Study of Addiction
doi.10.11 11/j. 1360-0443.2005.01176.x Addiction
Govt, of India. National Cancer Control Programme-Guidelines. Ministry of Health and
family Welfare. May 2005.
Gururaj G.. Girish N.. Isaac M.K., Mental, Neurological and Substance Abuse Disorders:
Strategies towards a System Approach. National Commission on Macroeconomics
and Health-Back Ground Paper Burden of Disease in India September 2005 pages
226 250
ICMP - Development of An Atlas of Cancer in India First All India Report -2001 -2002
An Overview. National Council registry Programme (NRCP) 2004 (ICMR)
ICMR - Guidelines for Management of Type 2 diabetes. Outcome of ICMR WI IO
Workshop 2nd 4th May 2003 Chennai. ICMR 2005
ICMR - National Cancer Registry Programme 1981-2001 An Overview National
Council registry Programme (NRCP) 2002 (ICMR)
K Srinath Reddy, Bela Shah, Cherian Varghese, Anbumani Ramadoss. Responding to the
threat of chronic diseases in India Chronic Diseases 3 Published online October 5.
2005 DOI: 10.1016/50140-6736 (05) 67343-6
Pekka Puska Successful prevention of non-communicable diseases: 25 year experiences
with North Karelia Project in Finland.
Sudarshan H. Risbud G.A. et al; Final Report of the Task Force on Health and Family
Welfare, fowards Equity. Quality and Integrity in Health. Govt, of Karnataka. 2001.
I he Karnataka State Integrated Health Policy. Department of Health & Familv Welfare
(after discussion in the High Level Co-ordination Committee Meeting on 1 1.4.2003 )
World Health Organization. Avoiding Heart Attacks WHO 2005
World Health Organization. Bangkok Charter on Health Promotion Conference Version
Bangkok Thailand 7-11 August 2005
World Health Organization. Global Strategy on Diet, Physical Activity and Health WHO
2004
ICMR
WHO Workshop NCD Prevention & Control Strategies in Karnataka
19 October St. John's Medical College Bangalore
16
Anncxurc
1
Primacy of PHC Medical Officers role - The National Health, Population and Rural
Health Mission statement - but arc PHC Medical officers overburdened ?
This issue was discussed after the first session in the context that the Prevention and
Control of Non communicable diseases will depend on the Primary Health Center
Medical Officer.
Response-
•
Dr L M Nath and Dr C Shivaram opined that PHC MOs arc not overburdened
and they should only reorient their time and address NCD also.
•
Budgeting time for Promotive, Preventive and Curative work is the key.
•
Health work al Primary Health Centre and at Primary care level is a team
effort and should not be doctor centric and curative oriented.
•
Need for enhancing their skills that will meet the challenges of primary health
care.
•
Ways and means to improve infrastructure at PHC level also needs to be
looked into
•
The stress laid on the implementation of targeted programmes c.g. pulse polio
etc. disrupts the routine functioning of the PHC.
•
There is a need to develop an integrated public health approach to the
management of communicable and non-communicable diseases w here time
and effort is spent depending on the public health problem of that particular
disease. A monthly routine for the same should be developed.
•
The government and local bodies should look at innovative mcans/facililies of
attracting medical officers to work at Primary health centers.
•
Training of medical undergraduates requires reorientation to emphasize the
need of primary health care.
•
Compulsory Rural Service for all Medical Undergraduate e.g. as in St John's
Medical College. Bangalore, Karnataka and Christian Medical College.
Vellore. Tamilnadu.
ICMR Wl l() Workshop NCD Prevention & Control Strategies in Karnataka
17"’ 19" October St. John's Medical College Bangalore
17
Annextirc .2.
Issues/Conccrns/solutions discussed by members during the three-day workshop.
I. Non-availability of data with respect to NCI) in Karnataka.
2. Use of Bangkok Charter on I lealth Promotion activities.
3. Role of Social Determinants of Health also need to be addressed by future
National Programme for Control of NCD. Phis especially in the light of
recommendations of WHO Commission on Social Determinants of Disease.
4. Social measure has the potential to impact the conscious of an individual and
the collective conscious of community. For example banning of smoking in
public places. A person smoking in a public place if told to stop smoking
would in all probability oblige.
5. Social sanctions e.g. tobacco by banning the depiction of Smoking Scenes in
Motion Pictures and television should be accepted and supported.
6. The impact of media and advertising and the existing problem of NCD and
NCD Risk factor burden.
7. Alcohol consumption, tobacco use and junk food consumption are examples
of “Communicated Diseases". This can be attributed to ad\ ertising b\
concerned manufacturers of these products.
8. Advocacy lor NCD by prominent Public Personalities like Actors and
Sportsmen, as is being done for Eye donation. Pulse polio. I uberculosis etc.
9. All government funding to organizations should come with a rider that 1% of
funds would be kept aside for Health Promotion activities.
10. Need for a comprehensive measures to tackle the problem of tobacco and not
just legislations and prohibitions.
II. Role of Yoga, and its proven efficiency in reducing Blood Pressure/Blood
Sugars and stress coping capacity should be explored to the maximum.
12. Early life and early fetal life interventions for prevention of NCD.
13. Need to cluster and compartmentalize Common Risk factors for specified
groups of NCD for example for Accidents and CVD. DM. I U N etc.
14. Need to integrate and include mental disorders in to NCD control strategics
and importance to improve public awareness.
15. Efforts should be made to measure Blood Sugars in all settings both at I lealth
C arc settings level and even in Out Reach activitiesCommunity Based
activities.
16. The Interventions and strategies for addressing the problem of l ype 1 and
I yPc 2 DM are different and that should be borne in mind when planning
interventions.
17. Moderate drinking which is currently debated might be true and of relevance
to Western Population and not for developing countries as we arc ethnically
and genetically prone for CVD.
18. DM is definitely preventable and most complications of DM are definitely
avoidable.
19. The need for Opportunistic Screening/Invcstigalion of people should be
explored. E.g. diabetes.
I ('MR
WHO \\ orkshop NCD Prevention & Control Strategics in Karnataka
I7,h
19"' October St. John's Medical College Bangalore
18
Anncxure 3
ICMR - WHO Workshop on Prevention and control of NCD
Cardinal Gracias Hall, St. John’s Medical College, Bangalore
17'", 18"', 19"’October 2005
Time Schedule for the threc-day workshop
1; ly0' October, Monday
Inauguration session
One and half hours
Time: H:00 am to 1 pm
LUNCH 1:00 to 2:00 pm
Session I
Topic
__________ Speaker______
NCD Epidemiology. RE & ’ Dr. D K Shukla
status at national level
PPG (SG), ICMR , N. Delhi
Prof. Dr. Shivaram
Current Status of NCD Principal - Vydehi Institute
State Level
of Medical Sciences
Bangalore________________
Dr. Thelma Narayan*
Discussion
Community Health Cell
Bangalore
TEA 4. p.m.
Day 2: 18th October Tuesday
Session II
________ Topic__________
Tobacco Control & Experience
of Cessation Clinic
Alcohol Dependence
Pro bl ems & Contro 1
Neuro Psychiatric Disorders.
Problems & Control
Discussion
Prevention strategies for CVD
Risk factor prevention
experience
local
M.S R.M.C, Bangalore
Dr SS Iyengar*? SJMC
Bangalore
Time
45 min
2:00 to 2:45 pm
45 min
2:45 to 3:30 pm
30 min
3:30 to 4:00 pm
________ Speaker________
Duration
Dr. Pratima Murthy
30m in
N1MHANS. Bangalore
Dr. Vivek Benegal
30 min
NIMHANS, Bangalore
Dr. Girish N
30 min
NIMHANS, Bangalore
Dr Thelma Narayan*
30 min
CHC, Bangalore________
~TEA~ 11:00 to H -B^am
Dr. Prem Pais. Dean.
30 min
SJMC. Bangalore_____
Dr R. Bingi
30 min
Jayadeva Institute of
Cardiology, Bangalore
LUNCH 12:45 to 1:15 pm’
Hpidcmiology of Hypertension
CVD control Strategies for the
state: Discussion
* Moderator
Duration
Time
9:30 to T0:00 am
10:00 to 10:30 am
10:30 to 11:00 am
1 1:00 to 1 1:45 am
1 1:45 to 12:15 am
12:15 to 12:45 pm
30 min
1:15 to 1:45 pm
30 min
1:45 to 2:15pm
ICMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
I7,h I9lh October St. John's Medical College Bangalore
19
Session 111
______ Topic_____ _______ Speaker
J Duration
Epidemiology of
Dr. Prasanna Kumar,
: 30 min
Diabetes Mellitus in
MS Ramaiah Medical
country and state
College, Bangalore_____
Prevention of
Dr. G Bantwal
30 min
complications of DM
St Johns Medical College.
Bangalore________
Strategies for DM control Dr. Prasanna Kumar
45 min
and Discussion
MS Ramaiah Medical
College, Bangalore____
TEA 4.15 p.m?
Fellowship Dinner 7:00pm - 10:00 pm
Day 3: 19th October, Wednesday
Session IV
____ Topic________ __________ Speaker________
Du ration
Cancer epidemiology Dr. Nandakumar, Project
30 min
in country & state
Officer, National Cancer
Registry. (ICMR) Bangalore.
Cancer Control in
Dr. Elizabeth V.
30mins
state - experience
St. John’s Medical College,
with cancer cervix
Bangalore
Cancer control
Dr. Dominic*
30 min
Strategies for the
St. John’s Medical College.
state: Discussion
Bangalore.
Tea 20 min lUPO to 1H:2O am
Developing a unified
Dr L M Nath
40 min
NCD Control
Prof. HOD Community
Program
Medicine, AIIMS, New Delhi
Briefing on Group
Dr. Ravi Narayan.
15 min
Task Work
International coordinator
PHM. Bangalore._____________
_ ~ tUNCH 12:15 to 12:45 pm
Session V
________ Topic_______
Strategy for NCD
prevention at state level.
Plenary session
_________ Speaker
(Group task)
Dr Ravi Narayan*
International coordinator
HIM. Bangalore
Valedietory b'unclion
Time
2:15 to 2:45 pm
2:45 to 3:15 pm
3:45 to 4:15 pm
Time
9:30 to 10:00 am
10: 00 to 10:30
am
10:30 to 1 1:00 am
ji
11:20 am to 12
Noon
12 noon to 12.1 5
J
60 min
Time
1 p.m. to 2:30 pm
60 min
2:30 to 3:30 pm
30 min
3:30 to 4:00 pm
TEA 4.00 pm
* Moderator
ICMR WHO Workshop NCD Prevention & Control Strategics in Karnataka
17"’ 19" October St. John’s Medical College Bangalore
20
i
___ Annexure
ICMR - WHO Workshop on Prevention and control of NCI)
Cardinal Gracias Hall, St. John5s Medical College, Bangalore
I7f., 18(h, ,9’1’October 2005
SI.
_No.
1.
!
2-
3.
4.
5.
6.
7.
<S.
9.
10.
11.
12.
13.
14.
15.
16.
17.
ICMR
17".
Name
List of Faculty
Designation and Place of Work
Dr L M Nath
Professor of Community Medicine,
Former Dean of All India Institute of Medical Sciences.
New Delhi.
Dr. D K Slink la
Deputy Director General (SG).
Indian Council for Medical Research (ICMR). New Delhi.
I Dr. C Shivaram
Professor of Community Medicine,
Principal, Vydehi Institute of Medical Sciences Bangalore
Dr. Thelma
Coordinator
Narayan.
Community Health Cell. Kormangala.
Bangalore- 560 034
Dr. Vivek Benegal
Professor. Department of Psychiatry.
National Institute of Mental Health and Neuro Sciences
__ (^NIMHANS), Hosur Road. Bangalore
Dr. Pratima Murthy' Brolessor, Substance abuse. NIMHANS, Bangalore
| Dr Girish N
. Asst- Brofessor, Epidemiology, NIMHANS. Bangalore
| Dr. Prom Pais,
Dean, St John's Medical College. Bangalore
Dr R. Bingi
Professor of Cardiology, Jayadeva Institute of Cardiology.
Bangalore
Dr S.S. Iyengar.
Professor of Cardiology, St John's Medical College, Bangalore
Dr. Prasanna
Professor of Endocrinology MS Ramaiah Medical College.
' Kumar
Bangalore
Dr. G Bantwal
Associate Professor of Endocrinology. St John's Medical College.
Bangalore
Dr. Nagraj Desai
M.S Ramaiah Medical College, Bangalore
Dr. Nandakumar
Project Officer, National Cancer Registry,
(ICMR) Bangalore
Dr. T’li/.abcth V..
Professor -1 lead of Gynae-oncology. St John's Medical College.
Bangalore
Dr. Dominic M.
Professor, Head-Community Medicine. St John's Medical
College. Bangalore
Dr Ravi Narayan
International Coordinator. Peoples I lealth Movement. Community
| 1 lealth Cell, Bangalore
Wl IO Workshop NCD Prevention & Control Strategies in Karnataka
I1)’1' October St. John's Medical College Bangalore
21
’V
)
)
)j
> S //
*
4
SI.
No.
1.
3.
4.
i 5.
6.
7.
8.
9.
10.
1 1.
12.
13.
i 14.
Annex urc
ICMR - WHO Workshop or. Pie.
and control of NCI)
Cardinal Gracias Hah St. John’s Medical College, Bangalore
17"' to 19'" October 2005
List of Participants
Name & Designation
Place of Work.
5
Govt, of Karnataka-Directorate of Health and Family Welfare nominees:
Dr. Neela Biradar
Directorate of Health &
Deputy Director (Nutrition)
Family Welfare Services, Ananda Rao
Circle, Bangalore.
Dr. K S Murthy
State Institute of Health & Family Welfare,
Deputy Director
Magadi Road, Leprosy Hospital
Compound. Bangalore.____
Dr. A. V. Srinivasa
State Institute of Health & f amily Welfare.
Magadi Road, Leprosy Hospital
Compound, Bangalore.
Dr. Karur B. V.
State Institute of Health & Family Welfare.
Deputy Director.
Magadi Road, Leprosy Hospital
Compound, Bangalore.
Dr. Amaresh Kolur
District Surveillance Unit. Gulbarga
District Surveillance Officer (DSO)
Dr. Rohini
District Surveillance Unit. Udupi.
District Surveillance Officer (DSO)
Dr. S.S. 1 lalkurki
District Surveillance Unit. 1 laveri.
District Surveillance Officer (DSO)
Dr. N.N. Rajagopal
District Surveillance Unit. Hassan.
District SjirveiHance Officer (DSO)
Dr. Jayaraju
District Surveillance Unit. Shimoga
District Surveillance Officer (DSO)
Dr. S.S. Mathiwad
District Surveillance Unit. Belgaum
District Surveillance Officer (DSO)
Dr. R. Srinivasalu
State Surveillance Unit (SSU).
Consultant. Integrated District
IDS Project Office
Surveillance Project (IDSP).
Directorate of Health and Family Welfare
I
Services, Bangalore.
Govt, of Karnataka-Directorate of Medical Education nominees:
Dr. Ranganath
Department of Community Medicine.
i Assistant Professor and Head
Bangalore Medical College. Port.
Bangalore
Dr M P Sharada
Department of Community Medicine.
, Professor and I lead.
Mysore Medical College.
Mysore
.
:---| Dr Mudassir Aziz
Department of Community Medicine.
| Associate Professor
Mysore Medical College. Mysore
ICMR \X I IO Workshop NOD Prevention & Control Strategies in Karnataka
I7lh 19" Oetober St. John's Medical College Bangalore
SI.
No.
15
16
17
18.
19.
20.
21
22.
23
24.
25.
26
27.
28.
Name
Designation
Place of Work.
Bangalore Mahanagar Pallike nominee
Urban Health Research and Training
Dr. Savitha S.K,
Institute, Vyalikaval,
Director,
Bangalore_____________
National Institute of Mental Health nominees
Department of Epidemiology.
Dr. N. Girish,
NIMHANS
Assistant Professor
Bangalore 560 029.
Department of Psychiatry.
Dr. Mathew Vargheese
NIMHANS
Professor
Bangalore 560 029
Non-governmental Organisation
Holy Cross Hospital, Kamgere,
Dr. Sr. Aquinas
Chamrajnagar district
Project Dhector
Private Medical College nominees
Department Of Community Medicine,
Dr Vijayasimha,
J.S.S. Medical College
Associate Professor.
Mysore______________
Department Of Community Medicine. JJM
Dr A G Umakanth,
Medical College, Post and Dist Davcngere
Professor
Department Of Community Medicine.
Dr. Shobha Karikatti,
Jawaharlal
Nehru Medical College. Nehru
Assistant Professor,
N agar, Post & Dist: Belgaum.
Pin code - 590 01 OJBelgaum
Department of Community Medicine,
Dr Ramesh Masthi N. R.
KIMS, K R Road, VV Puram
Assistant Professor.
Bangalore - 560 004
Department Of Community Medicine. M S
Dr. Dayanand M.
Ramaiah Medical College,
Associate Professor,
MSR Nagar, MSRff Post. Gokula.
Mathikere, Bangalore- 560 054
St. John^sjyiedical College nominees
Department Of Community Medicine. St.
Dr. B. Ramakrishna Goud
John
’s Medical College, Bangalore.
Assistant Professor____________
Department Of Community Medicine. St.
Dr. Mansoor Ahmed
John
’s Medical College. Bangalore.
Lecturer______________________
St. John’s Institute of Population Health
Dr. Al ben Sigamani
and
Clinical Trials
Programme Officer Clinical trials
Department of Neurology. St. John's
Dr. A.K. Roy.
Medica
l College, Banga 1 orc
Professor,_______
Department of Medicine
Dr. Joseph Rajendran
St. John's Medical College. Bangalore
Assistant Professor
a
1CMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
17,h 19,h October St. John’s Medical College Bangalore
23
Annex me
6
ICMR - WHO Workshop on Prevention and control of N( D
Cardinal Gracias Had St. .John’s Medical College, Bangalore
17,h to 19th October 2005
Group Task Framework for Formulating Draft Recommendations for strategies for
Prevention and Control of Non-Communicable Diseases at state level.
Group A - CVD 1 leart Disease / Hypertension / diabetes
Group B - Tobacco / Alcohol/Mental Health
Group C Cancer Control
1.
What are the health education strategies to reduce risk factor in NCI)?
a.
In the Health system
b.
In the education system
What arc the minimum diagnosis and treatment facilities/guidelines recommended
by you for managing surveillance, early diagnosis and treatment al?
a. Primary Health Care level (PHC’s & GP’s)
b. District Level
c. State Hospital / Institution Level
3.
What are your recommendations for recording and reporting of NCD in the state
disease surveillance system?
4.
W hat are the other strategies/policies that have a bearing on reducing the risk of
NCD (in health and beyond health)?
5.
What arc your recommendations for investigation and convergence of NCD
presentation and control strategies in the state?
6.
Specify role of different section represented in workshop
District level
State level
Medical College level
Any other
(In all the above specify what can be done
a. With the existing resources / existing system.
b. What needs additional planning and resources?
ICMR
W I IO Workshop NCD Prevention & Control Strategies in Karnataka
I7,h
I9lh October St. John's Medical College Bangalore
24
c
3
Annexure
ICMR - WHO Workshop on Prevention and control of NCI)
Cardinal Gracias Hall St. John’s Medicai College, Bangalore
17"’to 19th October 2005
I earns Members for Group Work for Formulating Draft Recommendations for
strategies for Non Communicable Diseases
Group 1- Alcohol, Tobacco and Neuro Psychiatric Problems
Facilitators: Dr Mathew V. and Dr Vivek Senegal
1. Dr K S Murthy- (SIHFW, GoK, Bangalore)
2. Dr Amaresh Kolur-(DSO, Gulbarga, GoK)
3. Dr Jayaraju- (DSO, Shimoga, GoK)
4. Dr Ranganath-(DCM, BMC, Bangalore)
5. Dr Ramesh Masthi N R- (DCM, KIMS, Bangalore)
6. Dr Mudassir Aziz-(DCM, MMC, Mysore)
7. Dr 1' L Gayathri-(BMP)
8. Dr Karur B V-(SIHFW. GoK)
9. Dr A K Roy- (SJMCH)
Group 2- Cardio-vascular Diseases, Diabetes Mellitus
Facilitators: Dr S S Iyengar and Dr Thelma N.
1. Dr Ganapathi Bantwal-(Endocrinologist, SJMCH)
2. Dr Neela Biradar-(JD, DHS, GoK)
3. Dr A V Srinivas- (SIHFW, GoK)
4. Dr Rohini -(DSO, Udipi, GoK)
5. Dr S S Mathiwad-(DSO, Belgaum, GoK)
6. Dr Dayananda M-(DCM, MSRMC)
7. Dr Savitha S K- (UHRTI. BMP)
8. Dr Joseph Rajendran- (SJMCFI)
9. Dr. Mansoor Ahmed -(SJMCH)
Group 3- Cancer Control
Facilitators: Dr Elizabeth V, Dr Dominic M. and Dr Girish N.
1. Dr R Srinivasulu- (IDSP, DHS, GoK)
2. Dr Sharada M. P. (Prof. HOD of Community Medicine)
3. Dr S S Halkurki- (DSO, Haveri, GoK)
4. Dr N N Rajagopal- (DSO, Hassan, GoK)
5. Dr A G Umakanth-(DCM, JJMC, Davengere)
6. Dr Shobha Karekatti-(DCM, JNMC, Belgaum)
7. Dr Vijayasimha-(DCM, JSSMC, Mysore)
8. Dr Albcn Sigamani-(Clinical Trials Division, IPHCR)
9. Dr. B. Ramakrishna Goud- (SJMCH, Bangalore)
ICMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
17"’
I9lh October St. John's Medical College Bangalore
7
Expert Facilitators for over all supervision of group work.
1. Dr Shukla D.K.:
2. Dr L M Nath
3. Dr Prem Pais
4. Ravi Narayan
ICMR WHO Workshop NCD Prevention & Control Strategies in Karnataka
17"’ 19" October St. John’s Medical College Bangalore
26
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iod of ten years. .Theu?fo^
Bangalore, Oct 17: The workshop, which focuses prevent the non^cotnmun■:World Health-Organisation *1t>hgpxevpntiv<e?smeasuresj7^lgkble^^^8S^> which
(WHO), in association with would Hijcuss in detail.the .^ause hot nnly;rnorbidity
. the ,/Indian ; Council pf n4e ^f tolfe^q,.unheajthy ^
ajso
Medical Research (ICMR) diet, physical inactivity,:'y3§s'working
on Monday began a three-hypertension,;
. •
day expert consultation at cohcehtratioh bt glucos^^^pe^^ig^pn^the occaSt Johns Medical College and cl^lest^rpl^jn ,fin-;, si
here to formulate a state- creasing the population of iCTdRdisclosed that a
level draft plan to fight patients of non-com- national level action plan
non-communicable dis- municable diseases. ' , would J)e^formulated later
eases, including diabetes,
It would also formulate, ^.dn;, the basis of re
heart diseases, stroke and campaign methods • to ; pbmmepdatibhs from die
cancer.
create awamess among state-level
workshops.
As many as 35 delegates, the people on healthy life ..“This U for the first time
including senior pro- style..The.draft proposals, ...\WQt|s.Uhdert^ng such
gramme officers and seni- . woujCalsb Work as a
fight nonor faculty members of ludjato formulating ^n^lW^wwe^jjiiseases.
'departments of com- -^.tegr^te^hatiohaljeyejpio^^a^
PP
; munity medicine in both gramme 4
Government and select ; risk factors.,
W*6
adc^s
; private medical colleges in
Inaugurating,
..
: Karnataka are participat- w6rkshp^,^)pr>Thahlc^aji ^^^^P?WW^^ >\
; ing in the workshop. The principal. secretary
Jpose; severe
twkshopassumes/gn^
ance in the backdrop of rec- hope ^that ~ JBnal, r acjionr
;. r ent disclosure of WHO that plan wotild.,be. ready Jjy A/StJplm^s.^aUoiial Acabhon-communicable dis-' ‘the end "of December. '
demy qf fjealu^ Sciences
eases would kill about 60
He also expressed hap-, directorTr.Thomas Kalam
ipilliori citizens of the' piness’over.the.intervene ^osp^ke.. ^/;^
\^.
•• - •
—
j"—
.
* ,x*i*
. jf,;' • y?
*' ' ;
-..•••»-»
AJlowru.ce likely for doctors in rural ureas
Funds for the project to be pbtained through a World Bank scheme
■
.:,
.
■ ^im!n^n ThSiedfamidhere
'SX
—
Although the proposal for the
Jldiy »uigc, AVAX-
/
the Government hopes to implement it sbdh. He said the funds
' for the project will be obtained
through a proposed World Bank
hmds>r.upgratog:fadlite at
-i:
..
...
'.•
<
the il^ic&CoI&g? andSospftti^
tasc'S orgamsea cy uic .
:a :h Organisation
y-<-.—o-n
acr*^ ^sjllie
tnp stare:
Stab
ne ile
saiusaid
piahhingftjBxaw up
esearen uvMivr-jwr. -x
tackling
ij said most of the 1,600 PHds^nAfipi^ de - plan
^Ocable;d§has^us'
^:v?wlth non-communlcablej'■ withn non-commumuauie
non-communicable uj
disease; mgn
;
thMfthe poor are; different Stites, ■'•’y■■■7.
j
MVdiseaSeS^^7.^t?:>.. es;He
: added
■••■•of me
the proDienia
problems ui^ftruwu
of k . Prem Pai, Dean
.Johns
01
—
y”/ i!
• not aware micable diseases and Medical College and Hospitay
c r___ it. — Agi||gc
^^oArMmnrtipnWp
Primary Health Centres (PHCs). Sd^seek«enttath^
communicable- dik« J’>
...aa CS
« ISaRTOV
« ^wWingproblem irilr/Lx
,,^,1______ A„«.
jsAiAn avtrtiicfh tvwSXi <
rtnrSThehospital,he said.hasuncei':years
of"lCMR,-New
;Delhi, said
said lh<?f
thei: talreiwrista
^kenastttdydnprnspecthnroTO
croresis expected to cost Ks. 680 of
ICMR, New-.Delhi,
■ - Ah ■ .• h»n-rriral-^
^P^csji
f
or
' -
SSSSS^
„ -'... y
.jftW .»J -
■'~
sswriBIII®
>
□
r»
*
c
ex
KARNATAKA STATE INTEGRATED HEALTH POLICY
6.5 Prevention and control of non-communicable diseases
Karnataka carries a double burden of communicable and non-communicable diseases. The latter
include in particular cardiovascular diseases, including hypertension, cancers and diabetes.
These have on the whole received less public sector and policy attention due to the magnitude of
other problems and issues. However, keeping in view the future perspective especially
considering rising life expectancies, growing urbanization and industrialization in the state, and
rapidly changing life styles including diets the state will provide greater support to the prevention
and control of non-communicable diseases.
It will use a public health approach by adopting strategies to reduce the risk factor for
these diseases and by using health education to promote healthier life styles.
• It will initiate polices to discourage the use of tobacco and alcohol, which is on on an
increasing, curve due to intensive advertisement and aggressive marketing. Over 25
seiious diseases are associated with the use of tobacco and several diseases and social
problems are linked to alcohol. These are described as communicated diseases. They
are both addictive substances.. Policies that would reduce consumptions of these include
bans on sponsorship of sports and entertainment; bans on direct and indirect advertising;
higher taxation, sales to be barred within certain distances from educational institutions;
and public education, especially among children and youth as part of life skills
education; education of health personnel.
•
In the case of tobacco, measures include banning smoking in public place to prevent passive
smoking and working towards alternative crops and alternative employment for those
engaged in its cultivation and production. Chewed tobacco in particular is a growing
problem with widespread use among women (40-60% in different groups) and even among
children as its addictive nature is not widely known. Comprehensive tobacco control
includes smoked and chewed tobacco. The appropriate measures would be taken to the
extent feasible to mitigate the use of tobacco.
In the case of alcohol there is a need for strategies to help women and children cope with
men who drink heavily. De-addiction strategies using group therapy such as alcoholic
anonymous groups will be supported, besides individual therapy and counseling.
Education regarding the deleterious effects of tobacco and alcohol will be included in school
and college curricula.
•
•
•
Diagnosis and treatment for non-communicable diseases will be made available at
primary health care level. This will require preparation of treatment guidelines and
supply of diagnostic equipment and drugs.
Recording and reporting of non-communicable diseases as per the international
classification of Diseases will be introduced into the diseases surveillance system
The cancer control programme will also be strengthened by discouraging the use of
tobacco, health education, early detection and provision of treatment. Facilities will be
made available at regional level and later in a phased manner in some districts where
medical colleges exist. Grants provided by the national programme will be fully utilized.
m witx u»x
r?cr..'
TH!- . .\SK FORCE
Public Hec
. NON-COMMUNICABLE DISEASES
,-\:i early definition of non-communicable chronic diseases was that they included an impairment of bod
stiucture and/or function that required modifications in the patient’s normal life and which persisted over
extended period of time. They often cause residual disability and require a long period of supervise
observation and care.
Most of these diseases cannot be cured but have to be relieved and managed lifelong. There are no relia
d.ra available at present, regarding the prevalence of these diseases in the community in Karnataka. There
inadequate planning either to prevent or manage these diseases. The basis of our strategy should be to devel
pi eventive strategies regarding the nsk factors and to treat patients at or near their homes with proper refer
systems for complicated cases.
5.6.1
DIABETES MELLITUS
Si I nation analysis: Burden of the Disease
T1 ere are only few surveys in Karnataka indicating the burden of the disease. The crude prevalence rate
Di betes Meilitus Type II in Bangalore City is 13.2% between the ages of 20 to 80 years, (part of natioi
di. betes survey). The Karnataka Rural Diabetic Survey conducted by Diabetic Club, Bangalore at B.R Hi.'
Sr kgeri, Hariharpura and Udupi, between th age groups 20-85 years gave a crude prevalence rate
7.' ?% and age adjusted rate of 6.42%. The prevalence in men and women (7.83% & 7.71%) is almost I
sai le.
Table 5.13: Prevalence of Diabetes Meilitus
Place
N
Prevalence
B.R. Hills
1288
2.95%
Sringen
1380
7.65%
Hariharpura
479
14.6 %
Udupi
500
11.8 %
Crude prevalence for women
7.83%
Crude prevalence for men
7.71%
Age adjusted prevalence
6.42%
Thi fcurvey is an ongoing survey and subjects will be followed up for 3 years duration.
Ap; T from the large number of diabetics requiring treatment, it must be remembered that diabetes meilitus a
hl§ blood pressure are risk factors tor coronary artery disease. Further, inadequate and improper treatmf
ma; yesult in complications like renal failure, cardiac failure, gangrene of the legs and retinopathy leading
bliri Iness. The state or individuals/ families have been spending large amount of money for managing the
con I Plications, and hence primary and secondary prevention assumes great importance.
'REPORT of the task force
Public Health ; i^
———————i-----t
prevention and care strategies: A population strategy aims to prevent the emergence of risk factors. Health
education should particularly promote maintenance of normal body weight, through healthy nutritional habits and
physical exercise. In the high-risk strategy, persons at risk would be advised to avoid alcohol that indirectly
increases the risk further, avoid diabetogenic drugs like orai coraraceptives; and reduce factors promoting
atherosclerosis, like smoking. Secondary prevention measures recommended include good management of
diabetes with patient education and self care.
Recommendations
Epidemiological surveys may be undertaken in rural, and urban areas to understand the “burden"
of diabetes mellitus and for proper planning for control and prevention of diabetes mellitus. The
survey may be confined to the 20-90 year age group, using fasting blood sugar levels above 126mg/
dl as the criterion. Surveys of hypertension, coronary artery disease and stroke may be undertaken
along with diabetic surveys.
Laboratory facilities: It is essential to provide minimum facilities to diagnose diabetes mellitus even
at PHC level. This includes a colorimeter, glucostrips or Benedict’s solution. The colorimeter is
not costly, and the expenditure for glucose estimation is not more than Rs.2/-. The instrument may
also be usedfor estimating blood urea and creatinine.
Constant supply of essential drugs like insulin and oral hypoglycemic compounds are necessary.
The conventional insulin may be used instead of costly ones like purified / human insulin except in
certain special circumstances.
Continuing Medical Education (CME) and other training ^programmes: Diabetes being a
common disease, it is necessnrv that doctors / nnrc/’c
i/tn/tm oYnncpS t/t r~'A/iP
programmes regarding the early detection, treatment and preventive measures. Die course may be
oj 3-5 days duration.
Referral System: It is practical that most patients are treated at PHC level. Occasionally patients
need to be transferred to the CHC / Taluka hospital for specialist opinion and treatment. The cases
with emergencies like diabetic coma and gangrene should be transferred to higher levels of care.
Other cases with chronic complications may be referred or specialist’s visits may be organised
at PHC’s on regular basis. Some guidelines may be formed for referral / treatment (See
Appendix).
Health Education: Health education regarding early symptoms, complications, foot care, diet,
exercise and prevention of diseases and their complications is required. There is a need for
orientation courses for health workers / IEC staff regarding various aspects of diabetes mellitus
with special emphasis on the above.
o
In view of the burden of the disease, it is necessary to develop District Diabetic Control
Programme
/**/*v. to starti with one
vnc. A/f/yrti/^ni
jvi
......
——
: —1.1. j:---------- ---UL Hit U-lSiriCI
nvn ^uimillHULUUlC
may be designated to supervise detection, drug supply and health education programmes.
-i-
114 REPORT OF THE TASK FORCE
Appendix
DIABETIC CARE
r~Treatment :by ciet.
Exercise, Oral
Hypoglycaemic drugs
& Insulins
PRIMARY CARE
PHYSICIAN
1
Detection of DM facilities for Urine
examination
/Blood glucose
(PHCS & PRIVATE CLINICS)
HEALTH
EDUCATION
TRAINING - by
CME, Workshops
Specialists
visits
Emergencies &.
Complications
CHC / Tai oka Hospital
TERTIARY
CARE
for
complications:
Dialysis,
transplant & Retinal Treatment
5.6.2
CARDIOVASCULAR DISEASES (CVD)
Among all the non-communicable diseases, cardiovascular diseases taken together are the leading causeof
morbidity and mortality. India and Karnataka are currently in the rising phase of an epidemic of cardiovasct^
diseases, propelled by a shift in the population distribution of risk factors. It would be prudent for the stated
initiate measures to prevent cardiovascular diseases. The cost of diagnostics and therapeutics is high, wiffi
treatment being required on a long-term basis. This is unaffordable for most people. It would therefore^
appropriate to spend resources on primordial and primary prevention, namely, avoiding or reducing
modifying risk factors associated with CVD. Attention should also be given to Rheumatic Heart Disease tSl
is still widely prevalent in the country/state.
|||l|
5.6.2.1 Coronary Artery Disease (CAD)
-g
Situation analysis. Coronary heart disease is becoming a major health problem in India, reaching almostan
epidemic proportion. However, there is no national programme on prevention in the offing. As per the cun^J
esiimaies at least 30 million patients are suffering from CAD. A population survey gave a prevalence rate3
10.9% in urban and 5.5% in rural males between the age group of 35-64 years. The corresponding figures®
females are 10.2% and 6.4% for urban and rural populations respectively (Reddy K.S. Cardio-vascular diseases
in India-World Health Statistics 1993).
Reliable measurements of prevalence may be difficult There could be coronary artery disease without sympton?
and ECG changes; ECG changes may be false positive for coronary artery disease. The hospital-based statist!^
especially from tertiary care hospitals may not represent the true picture.
O
- 3-
lCtors include diabetes mellitus, high blood pressure, smokine. ooshive family hist™,
;
aihT~DrCl“°iireStylC LiPidriSk faCt°rS ,nclLlde total cholesterol level, triglycerides level, lowHDLC and
he management and treatment of coronary artery disease is costly and may end up with costly investigation
management, eke echocardiography, coronary angiography and coronary artery bvoass surserv Prevention
' coronmy artery disease is the need of the day and there has been a consistent decline ^coronary artery
sease in USA using preventive measures.
Recommendations
Epidemiological sample surveys regarding the prevalence of risk factors in Karnataka need to be
conducted especially for diabetes mellitus, high blood pressure, positive family history, smoking etc
which will help developing prevention strategies. However preventive measures may be initiated
now itself based on available data.
Case detection and emergency management of ischaemic heart disease, to be done at PHC / general
practitioner’s level. The patient has to be transported to CHC / Taluka Level Hospital for
confirmation of diagnosis and further management.
Essential drugs like N’ltroglycerine Tab, Pethidine, Morphine, parenteral diuretics, oxygen etc must
always be available. Well-equipped ambulance services to shift the patient to referral centres
should be available.
Preventive measures: To achieve the goal of preventing coronary artery disease it is important
o avoid major risk factors which is the basis of “success stories”, in ESA
and------other■ western
----- -----countries.
(a)
Controlling intake of salt, saturated fats and calories. Smoking is one of the most important
r^^ jactors. Smoking is seen in 75% of those with coronary artery disease and 80% of
smokers have CHD. Community surveys conducted with urban and rural populations suggest
that 50-55% of adult males smoke. Smoking control measures include increase in government
xes on cigarettes & beedies, ban on smoking in work and public places, ban on advertising
and sponsorship of sports and games and cultural events by tobacco companies, limitation of
tobacco crop subsidies and support for crop conversion to other crops and community education
programme. (See section 5.10for details).
(b)
Increasing leisure time physical activity & practice ofyoga and regular exercise.
(c)
Increasing consumption of “heart healthy" food such as fruits, vegetables, high fibre cereals,
oils containing poly & mono-unsaturated fats, (eg. mustard-rapeseed oils, soya bean oil and
avoiding hydrogenated oils)
Proper control of diabetes, high blood pressure and lipid levels:
Use of lipid lowering agents are proved to be beneficial. However, the need for life long treatment,
with high cost of drugs makes it difficult for government or the patients to afford them.
Health education/ health promotion programmes have to be strengthened with special training for
‘ea th Staff on DM, HBP
jjpp and CAD. Co-ordination with NGOs and private sectors is
essential.
Lb-
tf&l KtrUKl UP l tit lASK KOKCt
Public Heaifi
5.6.2.2 Hypertension
S“alyS1S: ^yPTenS'°n 1S a maJorcontributorto cardio-vascular morbidity and mortality in India. There
p
y
arge, authentic epidemiological studies in India, involving the age group of 18-80 yean; from different
pairs ot the country Die prevalence rate vanes from 1.24 to 11.59% in urban and 0.52 to 7% in reral areas. -nJ
u es ave lot of slic.armings, in terms of differing examination techniques and diagnostic criteria employed. The
y con uc e by Diabetic Association of Karnataka in rural areas, involving the ase sroup of20-85 years, gives
acrudeprevalencerateofl6.35%andl8.12%forWomenandmenreSpectively.
Die cardio-vascular & cerebro-vascularcomplications in untreated hypertension are significant and management of
these complications is costly. Hence there is need for proper guidelines and policies regarding the deration and
-anagement of the disease. Health education regarding prevention of disease and its complications is an essentia
part or health management. •
'
Recommendations
There is needfor multiple sample surveys to be conducted, to have some idea of the " burden ’’ of the 2
disease, for prooer nlanninv of our stratf>oy> fnr
i
j
~
~ ~
“ypvi tension. 1 here is need to take
support ofNGO s and specialist organisations. Estimation and recording ofblood pressure must be a
part oj routine examination by the doctor.
There is need for uniform method of taking blood pressure, criteria for
diagnosis, evaluation of the i
Patient and guidelines for management. A protocolfor diagnosis a.
\nd management may be suggested I
for all doctors working at various levels. (Tables I -IV).
>. As majority of hypertensives are mild, they ■.
should come under the purview ofprimary health care either in 'urban or niral areas.
Facilities. There is a needfor well maintained standard
mercury sphygmomanometers and with standard 1
cuffin all centres. There is no need to buy any other type ofsphygmomanometers. Routine investigations j
of urine and blood should be done in all PHC's. For investigations like ECG and chest X-ray the ■4s
patients may be referred.
■i
Constant supply of anti-hypertensive drugs must be maintained. Less expensive drugs with minimum
frequency of dosage are preferred which increases the patient's compliance (Table 4).
Health education programmes are very essential for both primary and secondary prevention. Special
stress on control of smoking, restriction of salt, saturatedfat intake and reduction of weight has to be
There is need for conducting frequent continuing medical education programmes for doctors and
health education workers.
I
Table 5.14: Classification and criteria for hypertension
CATEGORY
T QVQTnr
tt^a
—•
^xuui.1 AXgy
DIASTOLIC (mm Hg)
Normal
<130
<85
<-» 1
130-139
85-89
Hypertension:
Stage 1
140-159
90-99
Stage 2
160-179
100-109
Stage 3
> 180 _________________ > 110_______
(Based on. 2-3 blood pressure readings taken at least on two visits after initial screening.)
A
J
5‘-
i
1
10
1.
Instrument
Standard mercury Sphygmomanometer
cuff: Bladder - 12 cm x 35 cm
Bladder should cover 2/3rd of length of the arm.
Accuracy to be checked against standard mercury
sphygmomanometer.
Aneuroid Sphygmomanometer
2.
Measurement:
3.
To refrain from smoking / drinking
coffee 30 min before measurement.
4.
Position:
5.
Measure the B.P in both arms and
take the higher reading.
First appearance of the sound - systolic BP (Korotkoff)
Disappearance of sound - Diastolic
Supine or Sitting
To keep the arm at the level of the heart.
V Table 5.16 : Management - Protocol
?•'
r.t.c
Hypertension
Stage III
Stage I & II
L
Life style changes
Repeated BP examination
for months
tf
■VJ-
Norma]
No change
Continue Non
drug Therapy
Drugs
T
DRUGS
Life style changes
■a
i
ft/
a i.
Life style changes include stoppage of smoking, alcohol intake, reduction of ob^^ity, Low saicand fat
diet, exercise and relaxation.
2.
If there is target organ involved, drug therapy to be instituted.
3.
Refer: when there is secondary hypertention, resistant cases and emergencies aft^r initial treatment.
6
lable 5.17: Drugs
• • >. - -
i?
r-iist inie:
Thiazide di uretics
Beta-blockers
Calcium Channel block..ers , t0 avai iable at the Primary Health Centre.
Alpha blockers
}- may be considered in referral centre^
ACE-inhibitors
I
Other Drugs
Alphadopa
Hydralazine
Clonidine
Reserpine
5-6.23 Rheumatic fever / heart diseases
XiraXr
ofschooichiidre
”°f5rare-Mof^
Jdj Iron, Vellored\
showed
a prevalence
5 4 /1000°and 6
“ previue"“ ”re of 0.56%. A pilo
e
U aeeacKs ot R.F. may lead to R H D
SJrSlcal procedures.
sreplococcalinfecnonandBenzafhInePenIcminpS?'''''"10"
““ of P'"™" » prevent
dfier sorgtcal or denta! procedure are to be ,Z ' f
On.“ “ 3
isAntlb,ones poor and
ececr .ai cnuocaraius propylaxis.
Recommendations
• xtxzz izt" "mc ,mi and be
P"f’k^ P^ramme.
me duration ofprophylauie is ‘f^iersial buUl
e
^rgety and other interventions.
P
^mls for special investigations.
S.S.2.4 Thrombo angitis obliterans (Berger,s
»XZ»»'v7dalne‘,s“d'“'” ““ “““ °“™» "
and gangrene of Jegs/toes are common Thfe^T15tOmrSand.SIgns occlusive disease will
10 “P™1 cause. Treatment entails
1S not known. but use
r.r,L
deedsXXd'“mba"™Pa'h“,Omyr™>'Si'-^
p
“ .
ion-
Discourage use of tobacco as a
’
'
v-e-f—rtro. gangrene or toes and legs
Recommendations
definite measure to prevent fihe disease.
jo
atony system fo*m on^ j .uic vUHiuiun causes ioi OPD treatment and inpaucui ddinissiun.
Chronic bronchitis and bronchial asthma form
.J major contributors for morbidity. Reliable data regarding the
prevalence are not available.
Bronchial Asthma
I .
fodia alone has 20 million asthmatics; this is increasing every year. A survey conducted in Bangalore (1991)
between ages of 15-65 years gives a prevalence rate of 2.99% (Omprakash and S.Rao) In majority of people,
^e disease starts at a young age. There are a number of precipitating factors that are responsible for the attack
jf asthma.
[a)
jb)
Inhalation of coldair-seasonal
Respiratory tract infections
ft*
'c)
^d)
e)
Allergens: House dust, Pollens, Moulds etc.
Environmental pollution: Cigarette smoke, fumes of petrol, vapours and strong scents &- perfumes.
Exerase
Drugs - NS AIDS especial ly Aspiri n
\n acute attack of asthma is being treated mostly on an outpatient basis with administration of parenteral
iionchodiiators / steroids in most of the clinics with occasional admissions. The use of Ephedrine is very much
educed and metered dose inhalers (MDI) are not popular yet, especially in the rural areas. Nebulisers u treat
ne acute attack ore not available in most of the rural centres. The patients are maintained on bronchoc ;lator
ablets. Preventive measures like avoiding allergens like pollen, chemicals, dust and food allergy and drugs are
)ften discussed on individual levels.
E
c
£
Recommendations
Every health centre / practitioner must have the drugs and facilities always available to treat
asthmatics. Drug supply should include injections of Deriphylline, Aminophylline, Adrenaline,
Steroids and tablets of Salbutomol, terbutaline.
It is desirable to supply pressurised aerosol nebuliser in eveiy health centre, so that an acute attack
may be relieved, even at subcentre levels.
, Preventive measures .and health education may be addressed individually. Lowering environmental
/ industrial pollution should be taken up as a part of wider health issues.
I
hronic bronchitis:
-hionic bronchitis is the commonest lung disorder after tuberculosis and equally prevalent in rural and urban
“cas. me various factors causing this condition are:
Smoking. It is the most common single factor leading to chronic bronchitis. Hooka and beedi smoking
is as harmful as cigarette smoking.
Occupational exposures: to organic and inorganic dusts or noxious gases.
Air pollution: Industrial effluents, smoke from wood fires
]
1
•
iKdiciy,gdicucanu lamiu ai concuuons
TO
condition is usuany recognised even at the peripheral centres and clinics. Chest X-ray is occasionally
prescribed to rule out associated pulmonary tuberculosis.
2?ece V: meMatio ns
Every primary care doctor / medical centre must be able to handle cases of chronic bronchitis and
its acute exacerbations. There must be a constant supply of drugs like bronchodilatiors (injections
& tablets). Nebulising solutions /nebulisers, antibiotics and oxygen.
Preventive measures, health education regarding smoking and control of air pollution are important
from individual / community's point of view.
^-6.4 CANCER
Situation Analysis
With the increase in life expectancy and increasing exposure to certain chemicals, cancer has become a public
health problem. Cancer is a major cause of death m India. Nearly 45,000 new cases of cancer are delected
in Karnataka every year. It is estimated that the prevalence is about 1.5 to 2 lakh cases.
The common cancers in women are c incer of the cervix and breast cancer. With increasing tobacco use in the
form of smoking and use of gutka, esj ecially by men, oral, oesophageal and lung cancers are more commonly
encountered.
1 here is need for looking at the proolem of cancer in Karnataka in a 1broader perspective encompassing
prevention, early detection, access to treatment and utilisation. Presentation of cancers often occurs in advanced
stages due to a combination of lack of awareness, poor economic condition, fear of disease and inadequate
diagnostic facilities.
Presently only one third of cancer patients receive treatment in specialised centres. There is need to establish
more cancer treatment centers with low cost, high quality7 care. Involvement of the non-governmental agencies
is very crucial.
Plan of Action
The Director, Kidwai Memorial Institute of Oncology has prepared comprehensive recommendations for
Karnataka State cancer control programme, which is quite self-explanatory and practical and should
be acted upon (Annexure - 1).
However, this booklet covers only government departments catering to oncological care. A genera] view
must be taken to encourage non-profit oncological institutions. Private-for-profit institutions must also be
taken into confidence as they also cater to sizable part of the population.
Government should consider exemption from taxation on anti-cancer drugs and certain sophisticated
oncology equipments such as Telecobalt units.
The government of India under the cancer control programme gives some grants to establish radiotherapy
centers and cancer detection centers in government hospitals, medical college hospitals and non-profit
- CV
?
J
j
j
extent, as it win neip to nave oeiection anu u caiinct h uci uci m
control programmes should he
vuon ivl »- - - -
Oncology care should be comprehensive. Patients in their terminal stages need close nursing attention and
an empathic treatment. The concept of hospices must be encouraged m all divisional centers with the help
cf voliiniary organisations. The Government should help them in granting the r^qumed laiiu and also
financially assist these centers.
As half of all new cancers diagnosed are tobacco related. The government should discourage
tobacco production, manufacture of tobacco products and sales, through education and legislation,
(see 5.10).
It is advisable io encourage the use of well-established non-allopathic methods such as ayuneda,
homeopathy, siddha, yoga and naturopathy, at least in the centers of excellence established for oncology
care. This can be done scientifically with a research approach and documented. However, the exploitation
of gullible people by quacks for these chronic diseases must be disallowed.
With this multi faceted approach, and through imparting oncological concepts at primary & secondary
health care levels, along with establishing few zonal centers of excellence, one can work towards
satisfactory cancer control and care.
The cancer registry' is doing good work and must be further developed.
Tiic programme should have a strong component regarding prevention of exposui C iibr< laCtGiS iiHu tO
early detection.
Cancer control among women
Special attention is needed, as women tend to seek treatment late and come in advancedstages of the d's^ase.
Health education, early detection and management of the more prevalent cancers such as cancer cervix, breast
and oral cancers by trained health personnel should be taken up as an integrated programme- In addition, women
can be taught to conduct self-examination of the breast.
1.
Health education programmes regarding commonly occurring cancers, and their aetiological and risk
factors, such as tobacco and alcohol use; poor reproductive hygiene; techniques for prevention and
importance of early detection should be undertaken. Health promotion should facilitate safe hygiene
practice, safe sex practice and also encourage women to demand visual inspection of the cervix from the
trained health workers.
2.
Screening and early detection programmes for cervical cancer as recommended by KM1O should be
effected by ensuring the following:
promote early detection and down-staging through appropriate screening methods.
target women 35-64 years of age groups.
maintain a cancer registry
refeiial and follow up services.
3.
Women health personnel (both health workers and lady medical officers) should be responsible for and
trained to perform visual inspection of the cervix and triaging of its appearance into normal, abnormal and
suspicious of malignancy; and make appropriate referrals.
io-
J.U
marking pencil
^“ning cvioioav w>th dides, a slide box, a glass
~
3t the PHC- Primaiy Health Unit, and the village school or at the
tamesrfthe women'
4.
smear/Fine Needle Aspiration Cytology) can be
drawn at the PHC
P^ormthe 1 FRUhS'
5.
reqUJrinS radiatiOil
- be
d°WnStage Cervical canccr>"is ^tical to
ensure thea'vXbility^draibnSof
and palhative care. Ids no u^ e " '!^^rapeut.c series- early detection, treatment, referral networks
Treatment of early starchs not "s
’^^-^^^^^tment.e not guaranteed,
6.
however, it is more effective because of ^XpenS,Ve’or ess technology intensive, than late stage disease;
discharges which occur in late stages can tl avoided
IVa'
CUre- Bleed,n2 and foul-smelling
-j
" SUffenngpCan b£-d^ ^early 80-90 per cent
o^n
treated by either surgery ormdi--^ LmnJ im
m aS7m'
5'diSeaS£besucc«sfully
palliation are useful. “ '
'
tbe‘apy’ but ln the advanced stages, only radiation therapy and
8.
Public-private partnerships in all these
u- o
government doctors; radiation theranv
’ Eg' SpeciaIlsls t0 augment services of
institutions at nighttime or dunng other lean penods/'holidays h™31
“S'"2
faC'IitieS ofPrivate
Recommendations
Prnria ry' preventcon
i
-
Intende anti-tobacco cSnpaiZZCf ' P
and anganWadi WOrkers and voluntary organiiarions’
•
t-
1
5
teacherS’ social ^rker
Orientation programmes in the problems of tobacco use
for all people's representatives and
otHer decision makers.
Legislation to reduce lobaa
'co use md other measures. (See Chapter 5.10)
Secondary prevention
and delect cancer.TfL^ystaf^
*
reduce use of
signals.
°f VoLu’l&,y organisations to create awareness
Have cancer detection units in hospitals
Tertian)' prevention
41C
Have multidisciplinary treatment facilities at
Kidwai and other identified centers: surgical,
medical, radiationoiimlnoyt
- ---- QJ
ou.^utiive systems
lalhative care for terminally ill cancer patients.
Have a District Cnnr^r-
s
,o be „ and Unt ,aier w epidmMogicai
- fl -
«='ma
'em.
JI aj
a
:5pn.
I
I/Y I tu A
-
rvrEQK vrED model ' ™ U-MKOL PR0GR-UlMEPROl>OSEDC0MPREHENSm
Preamble
r
7716 ne^for^'detection of■
doX^*"
"'omi"y ,s we"
probaMX"tXakXer'i0
;No
■■ significant
—‘nsive work
A lc Conventional Models
OpportunisticScreenino
rXiT
,n a
«-i mapeatin,. Mclhod. „
e;^stinghealth mfm.rn^..a.■
“z™xb;rojd'
method was studied in KAflO m a
XwmTprobte
IC’MR - WHO project
’
projK' “s,ns ",c
Hence the personna! wcre ve0‘>Ver b"r,J'“'d »ilh National a ad State health proms
8
b.
coZJaedTvo Id;S,In§ beallh ]n^O«^ 'X^e Nm0^'
In. The Problems wth EL^ModT0^'"^0"'
b-
Efficiency
&-
f
COST
L
No' oftesTeaTTk)
-----
j
PAP TEST
I
40,000 women
I
I
Rs.20 (minimum cost)
Rs.8.0 lakhs
I,
Rs4^iokho
- •
A 4UU VI I o
j
16 patients /taluk
-
Cost per PAP smear at
I
cost for one taluk
I Total cost for one district of 6 TQ
L
------- ‘‘‘^^40/100^000
Efreaire Ms( per pauen(
j-
aP test only: Rs.50,000.
J
taD
P“S“: S,aff
+ additional TA & Da
ta^'»”ofICMRstud,es:Th.mMhoj;&DA,' transport etc
unacceptable on cost effective basis.
t0 “demand
1
Logistic Problems
(For the detection of 16 patients of carcinoma cervix in a year)
Total number of population to be examined in a taluk
40,000
@ 50% compliance rate for examination
Effective working days
20,000
No. of patients to be examined per day
91
No. of doctors needed on duty (@ 4 pts per hr.
3
220
Other requirements:
Nurses, survey team, education team, attenders, driven,
Cxio-technicians
Transport?
Stay?
Organisation of camp site?
Salary burden of entire team?
Repeat visit team?
Putting together dedicated team of KMJO, PHC’s and NGO’s etc
3.
Ethical problems
■ft ith organised screening programme less than 3% are expected to have dysplasias, where immediate treatment
may not be necessary', but they need to be followed very scrupulously. Fora population of 40,000 eligible female
population, 1200 persons are expected to have dysplasias. This burden increases every year. After 5 years
this would become an unmanageable load. This would lead to an ethical problem because we have created a
fear that some thing is not normal and cannot provide the adequate treatment facility at the same time. We
u ould have created a population with “worry”, who otherwise would be living happily.
Summary. All trials based on Existing Models have been unsuccessful in India!!
It has lead to only intense and prolonged scientific discussion with almost no benefit to the community.
III.
PROPOSED COMPREHENSIVE-EDUCATION, EARLY DETECTION AND
TREATMENT-INTEGRATED MODEL FOR KCCP-
This model is comprehensive because it encompasses the concepts of education for cancer awareness and
prevention of disease; specified, regular, fixed timeplace cancer detection clinics for early detection; and
provision of cost-effective treatment as near to patient’s home as possible.
Il is integrated because it involves participation of existing Government health infrastrnrtnrp Psnrhovnth; Pai
system, NGO’s and KMIO.
"
.
Ii is in a way incorporation of practical features of various models, that are described earlier, to suit our set up.
A.
THE BASIS OF CONCEPT
The answerfor all our national problems-the answerfor all the problems of the world-comes from a
single word. The word is education. ”
.Lyfldo/l B JohnsotL
- 13-
•• 1OU CHll IMIIJ urn V.
-------------- r
Main theme is “Population based systematic health education with early detection clinics . Ji nuns sigiiincam
paradigm shift from “ACTIVE INTERVENTION” TO “ACTIVE MOTIVATION and SELF
OWERMENT”. With this model primary thrust is motivation in orderto make people take measures to Pr^e" L?‘"“rS
(and othc •- diseases by “bystander effect”) and come soon for examination resulting in ear } e aon.
message that will be conveyed to the person in the remote village - “you are responsi le oi your
”
i
i health”.
Power of Panchayati Raj System:
Karnataka Panchayati Raj Act of 1993 has a provision which says that gram pimchayats may also cany
measures which are likely to promote health, safety, education or social and economic weu-oei =
■I
I
I-
inhabitants.
Subsequent notification of July 1994, listed schemes for Zilla and Taluk panchayats with t^lns^1'
to specific areas. Forty two schemes have been identified under the Zilla Pane ay
cancer control.
July 1994 notification also brought PHC’s under the control of Zilla Panchayats.
1 ■
i» B. Components:
r
I'
FD ,LD UNIT AT DISTRICT CENTRE + DISTRICT HOSPITAL (ZILLA PANCHAYAT LEV EL)
Bj-
programme.
t i
!■
Ed ication Team: The team would be located at the district hospital and ^ould^
nui iber. But the operational level of the unit would be at the taluk panchayat level,
under each district. The team will visit each taluk under the distnet, 2 days eveiy
panchayat will have 40-50 Gram panchayats. From each gram panchayat 1 peW,
/
the educational session. The person would be a health worker/ Ang“W7ai ^ZTthe'oarticular <mam
Agricultural extension worker/ NGO’s / social worker / elected member as dead
y ,P
= ven
panchayat. Those who attend the education camp would be given simple pictorial pamp
=
to the village person. The next batch will give the feed back about the
batches. This will set in place an effective feed back system to assess the
• The mode of education would be group type,
XXAK,
W*
_ ______________________ ________________________ O---r
fe level
1 programs for the gram panchayat members. In addition bus exhibition, one to one inte™e
charts, pamphlets, encouragement of “word of mouth”, media (news paper,
employed.
Will have 1 nerson
0?" One education team will
person from KMIO to co-ordinate the whole operation an
Zillapanchayat
Clinical Team: This team will be formed from the existing staff of Jstnct
D.
training at KMIO if necessary. The other facilities to be organised from the
District Hospital are:
Facilities for detailed clinical examination of oral cavity, breast and cervix and Pap smear.
<e
Other investigations (based on symptoms).
" ‘H-
persons rom
of
Ti^diment facility foi diagnosed cases.
1. . Radiotherapy at PCC’s
2.
Surgery by district hospital surgeons trained at KMIO.
3.
Chemotherapy by trained staff.
4.
Active Pain reliefmeasures by trained staff.
5.
Referral to KMIO if absolutely necessary.
Dysplasia and leukoplakia clinic to keep the patients on follow-up.
Computer network to co-ordinate the programme instantly.
IL
EARLI CANCER DETECTION CLINIC (ECDC): The team madeof district and taluk hospital personnel MU
attend cancer detection camps at taluk level in order to “Reach the Unreached”. The duration of carnp
could be 1-2 days every month depending on the response at each taluk under the district. The concept
is - prc'-ision of clinical facility' for the persons who re motivated by the education, who otherwise do not
know where to go or what to do. Once the education process is initiated, it is obligatory to provide such
a facility. No attempt should be made to have organised screening procedure that has ethical implications
and opportunistic screening which is not cost effective.
The purpose of the ECDC team
a)
Provide early detection facility for the village individual at a reasonable distance;
b)
Act as reinforcements and catalysts to activities of PHC’s and taluk hospitals. T ie ECDC camp
can be coincided with the visit of education team camp.
rn
IV.
v.
R ANDOM SURVEY TEAM. This is done at selected places in random fashion, covering the Gram
Panchayaths, villages and PHC’s/Taluk hospitals, to monitor the effect of control programme. Already
existing Management Information Evaluation System (MES) of Govt, of Karnataka cln also collect the
leedback information.
ADVISORY COMMITTEE AND WORFQNGCOMMnTEE: These committees will help in providins finances,
organisation of education and ECDC camps.
GRAM PANCHAYATS: The individuals from the Gram panchayats who have been trained will educate the
other personnel of gram panchayats. They in tum will educate the village individuals. The personnel who
can undergo the educational training
trainingare:
,
a)
b)
c)
d)
e)
f)
VI.
\-r£J
health workers
anganwadi workers
school teachers
agricultural extension workers,
elected members
NGO’s decided bv th.e srrarn panchats
1
I
PHC’s AND TALUK HOSPITALS: Taluk hospital will be a nodal point foreducation and ECDC camps.
. oth PHC s and Taluk hospitals will provide the visual inspection and PAP smear facility' to the individuals
who seek clinical examination. The PAP smears will be then sent to the cytology lab at district hospital.
ECDC’s will act as reinforcements and catalysts to the activities of PHC’s and tal.uk hospitals.
p - ---------BASE UNIT AT KMIO: The Base Unit at KMIO will initiate, monitor, analyse and coordinate the programme
and train the personnel. Network of computers will facilitate the acquisition of data.
I
V-
■s
- (S-
f■
rut/ut
77 OF THL TASK FORCE
U. DIRECTOR KAflO: The Director of KMIO will be in charge of the entire programme and report the
progress to the Government of Karnataka.
HEALTH SECRETARY TO GOVT. OF KARNATAKA: Secretary, Health and Familk welfare.
Government of Karnataka will help to co-ordinate Government Health infrastructure with KCCP. He will
also coordinate between the feedback information received from KMIO and MBS.
METHODS:
iree-pronged strategy will be adopted.
Education to use proper food items and personal hygiene: Fresh vegetables and fruits decrease the
incidence of cancer very significantly. Effective slogans will be coined to convey the message.
Anti-tobacco education programmme: Enough experience has accumulated by KMIO regarding this.
Existing Anti-Tobacco Cell at KMIO will be used to organise this. Anti tobacco education in Kolar District
spanning over 3 years, has shown significant decrease in the use of tobacco.
WHO warning signals: Symptomatic persons, especially having Persistent and Progressive Symptoms need
to attend the PHC /Taluk hospital / field unit at district centre for examination. Awareness encourages people
to come in the beginning of symptoms resulting in Early Detection.
ADVANTAGES
Cost would be phenomenally minimal versus )ther methods.
Logistically easy to maintain a team in one permanent place.
The field units of District centres can be established immediately with minimum personnel and cost, al all the
districts of Karnataka to cover the entire 5 million population.
Cumulative salary burden and overheads would be low.
Can be started simultaneously in strategically different places with very large population coverage.
No ethical problems since people come on their own and are advised follow-up.
Can be easily duplicated in any other place and disease.
Will reduce the patient load at KMIO.
By “bystander effect” there will be influence on incidence of:
Cardiovascular disease due to anti-tobacco and diet education,
AIDS due to sexual hygiene education
Nutritional and infectious diseases due to diet education.
Once this model is established all over Karnataka, it will form a template for engraftment of any other control
programme to be implemented in Karnataka.
IMPLEMENTATION
he model is suitable to be implemented over entire Karnataka. But it is desirable to take this as a pilot project
t 3 or 4 places such as Mandya, Gulbarga, Kanakapura, Chikkamagalur. Since these places have treatment
enters and population based programs, it is easy to implement at these centers. After 6 months to 1 year, it
an be extended to entire Karnataka in a phased manner.
ft '
5.6.5 OTHER NON-COMMUNICABLE DISEASES
‘ 5.6.5.1 ENDEMIC FLUOROSIS
uonoffluondes. It 1S a welMefinedchnjcal entity ch^^sedhydenui 3!>d ^leul changes.
hmVXXorideconf
“’'a
1 PPm * the maximum penmss.ble
t. When fluonde content is high the fluonde gets deposited in the teeth and skeleton.
Epidemiology
7 °f 25 T10
200 milli°n
“ -d more 400 tniilion
ZZ
Ko
17X10^77
T
T
SiS
’
Kan,alaka
’
1S
m°St,y f0Und ln nOrth Ka™taka
Xha-tf n r f r
pans of Tumkurd1Stnct. In a house to house survey conducted at Mundargi Taluka
XsXT?' aX (preSent,y7a?f d'StriCt) ab°Ve the ag£ Of One y£ar the crude prevalence rate was as hmb
villao °
6 7 fl™'5 a"?
f°r SkeIeta'f]uorosisM„ Hande H.S. et al JAPI1977). The three
oes surveyed are hyperendemicand fluonde concentration of well water varied from 5.4-8.74 ppm
XXZIer Z°tn7 and CHnqaTd higher PrcValenCe is noted
higherconcentration of fluonde
popX^~“POS"re
hard n,a”al
Dental fluorosis
ePX?iUs0^^0""? en7eH iS
"d easily
of"®-P— **
s,s, of fluorosis, espeeialiy
Skeletal fluorosis
‘ beST? Ormav
X
"*h »S"«y»P>oms like join, pains, pain the neck and baek. it
XmemXsXt'd™'0 “ ?S'
W'1|-estab““l
show postural defects, limitation of
o ememof the spine andexostosiseastlyappreoiaiedinthetibiaandspine. Recently .enu-valmm deformity
neeXcSST^’^T' ““"f'’'’'1'
°fSPm' may C0,”press “’"P1”1 “rd ”d ™»“
neurological deficits like, lahculopalhy, paraplegu or quadnplegia may disable the patient.
XSZL'' f1?"”"' m
in
Ver,eta' C‘,IUm"- Pelvis a"d f°rea™ “ otosclerosis,
obieopnyie Tormation and calcification of ligaments
Management
««■s’tomw'dX"’™';‘”7“'''°f'n‘ie,°iC”“OrOSiSiSofP™™impomnce. Theeffecti.e
“ppm)
',°P
Wa“r n0‘COn,aininS ™re
1 PP”> of finoride (preferably 0.5-
*7due wdls^rJZrn7IOr reying and mappin8 areas with a high content °f boride m water in
Manv/ fuch
7 X’ S°
aPPrOpria,e preVenti Ve measures ™y be undertaken.
- iy such surveys are conducted by Geological survey of India in various parts of the country.
Surface water supply
usually surface water contains less fluonde than ground water. The water may be supplied to the village from
- (7-
--------------- ----------------- ----------------------------
!
ri vers, culms or CHnnis •lhiss''hem
■he Gerton,
nkm^ water technology
of deeper tube well £ the m£st
Research 1987).
'Vi’1
nt
maintained at 1 ppm' The technology
effec"ve and acceptable to the peopte (Teotia, Indian J. Med^
’
»»«cos, effect
^T,rf‘“nkinS
"hou.d^ve^SuLXZZX “„Xi7 Tr indiVidUal Wh°iS“>hi^—
per ay, this may be increased to 2 grams to lactating mother.
Recommendations
lhe fluoride comeri is more Ihai "l Z
PP"1 °^uoride 10
people living in areas where
Offluoride.
1 PPm- S,lrface water
dams and ionols) has less content
§
-eX.’
Ueep bore water also has less offluoride content
bp
5.6.O.2. HANDIGODU DISEASE
fis Sh'mogaandChikkamaealurdistricteh^Kar° St^art^ttlar system, which is geographically restricted to
’* ZlfX was r™”8 “dCl’a'”d‘
ZZSSf"
dlS“Se ,'redOmi'
'■ persons have been affected tn Shim^d,gU.dU V'l]age ln SaSar Taluk of Shimoga district in January 1975. 362
f 2000. since fte fct .pXeXta <Un'" 1997,”d349 P™S " Chikkans.salnrd.smcUnn, Sep,.
•TTa d" d
: system with basic defect of d
m°StIy In an autosomal dominant pattern affecting the skeletal
: Affected heterozygotes are usuallv Z
Spin£’ hlpS’ kneeS and otheysites on the io^ bones.
Q Besides the genetic aetiology, there is a st rforms and se^gate ln the
family.
S' ev,dence that, deficient dietan- intakes and"! nUtntl°"a1’ melabohc, endocrine and bone histomorphometric
disease. A study earned out
T
hypeiP^yroidiSm had aggravated the
Clinically and radioing .2 marked defic—y - the intake of dietary calcium in the population sun-eyed.
’ ^WtomaticbutonspiiLL^mZ’io51^^!’5
°f age' At this stagg the disease is largeJy
of the patients present in youno aoe The d' * ’ In Sittln§ cross’leSSed and squatting is obsei ved. Majoriiy
secondary osteoarthritic changes in him - ’ i^356 3S 3 §radual onset and a Progressive course. In late stages
of the hip and spine.
P
)eM t0 inc:apacitation and patients develop flexion deformit.es
measure has been undertakeiTiV^T*6^^ ^ard fortrea!in£ Handigudu Syndrome patients. Rehabilitation
Chikkamagalurdistrict.
istrict but the same is not available for those affected in
IS-
AlcStlltCnt *171 d Prevention
G
ku/c.
u
Cases having mild to moderate disability are treated with analgesics, steroids and rest. Those with severe
disabilities neeti sarg.cai conection. The quality of life after operati ve procedures is poor. Physiotherapy should
be provided to the affected individuals.
Genetic counseling regarding marriage, child bearing, risk estimates on the basis of pedigree analy sis should be
provided. The affected should be advised about dietary- supplementation with calcium.
Rec online ndatio ns
Early detection, physiotherapy and surgical correction facilities are to be provided to all the affectea
people.
Genetic counseling regarding marriage, child bearing, risk estimates on The basis of pedigree
analysis should be provided
Vacancies in the Handigodu Disease Unit at Sagar Hospital to be filled up and made fully functional
along with the mobile unit. Disease surveillance system should be introduced.
Patients with Handigodu Disease should be provided with supplementary calcium in dietary' anc
tablet forms.
Socio Economic rehabilitation of the people disabled due to Handigodu Disease.
5.7 ORAL HEALTH
Oral health constitutes a major component of the health care system. However, with inadequate recognition i
still receives relatively low priority in health planning and financing, in the country and state. This is mainly due
to the following reasons:
•
Lack of awareness among the public and health policy makers about the high prevalence, severity o
consequences of oral diseases.
•
Oral diseases are not life threatening or severely debilitating initially. They are not regarded as seriou
health problems by the government and community.
There is no State level survey of oral diseases but, based on scanty reports, the following diseases are commonl
seen:
•
Periodontal disease: found in 90% of the population resulting in early loss of teeth.
•
Dental caries: seen in 70% children upto 12 years.
•
Oral cancers: prevalent in 18-20 per 1.00,000 population (dealt with separately).
•
Fluorosis: seen mostly in north Karnataka districts, Kolar and Pavagada.
Facilities available and situation analysis
Oral health services are offered by the government, private and organised sectors, like industry' and militai
establishments.
-
tci'
fAnfie.
'd re.
11
Bangkok Charter
for
Health Promotion
3
- ■•
. ’ .x^i
Hlifa
1
-d
7.'^ ‘
-'l-,L' ^-'y<28«K
■mih^TE
. :,.. .
.yf<i‘.
:i?s
i^SSQj World Health
1W Organization
a
ofe
The Bangkok Charter for Health Promotion
in a globalized world
Introduction
The Bangkok Charter identifies the strategies and commitments that are required to
address the determinants of health in a globalized world through health promotion. It
affirms that policies and partnerships to empower communities, and to improve health
and health equality should be at the centre of global and national development
The Bangkok Charter complements and builds upon die values, principles and action
strategies of health promotion established by the Ottawa Charterfor Health Promotion
and the recommendations of the subsequent global health promotion conferences. These
are shared by activists and practitioners around the world and have been confirmed by
Member States through the World Health Assembly.
The Bangkok Charter reaches out to people, groups and organizations that are critical to
the achievement of health. This includes governments and politicians at all levels, civil
society, the private sector and international organisations.
Health promotion
The United Nations recognize that the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without discrimination.
Health promotion is based on this critical human right. It offers a positive and inclusive
concept of health as a determinant of the quality of life, and encompasses mental and
spiritual well being. Health promotion is the process of enabling people to increase
control over their health and its determinants, and thereby improve their health. Health
promotion is a core function of public health and contributes to tackling communicable
and noncommunicable diseases and other threats to health. It is an effective investment in
improving health and human development. It contributes to reducing both health and
gender inequities.
Addressing the determinants of health
The context for health promotion has changed markedly since the development of the
Ottawa Charter. Increasing inequalities within and between countries, new patterns of
consumption and communication, commercialisation, environmental degradation, and
urbanization are some of the critical factors that influence health. Rapid and often adverse
social change affects working conditions, learning environments, family patterns and the
culture and social fabric of communities. Evolving patterns of health and demographic
transitions have also contributed to change. Women and men are affected differently by
these developments; the vulnerability of children and exclusion of marginalised, disabled
and indigenous peoples have increased.
1
09148
(
11
Globalization can open up new opportunities for cooperation to improve health for
example through improved mechanisms for global governance and enhanced information
technology' and communication, ana sharing of experiences. Health promotion strategies
can address avoidable transnational health risks by enabling policies and partnerships
which ensure that benefits for health from globalization are maximised and equitable and
the negative effects are minimised and mitigated.
To manage the challenges of globalisation, policy must be coherent across all levels of
governments, United Nations bodies and other organizations, including the private sector.
I nis will strengthen compliance, transparency and accountability with international
agreements and treaties that affect health. The global commitment to reduce poverty by
addressing all of the Millennium Development Goals is a critical entry point for health
promotion action. The active participation of civil society is crucial in this process.
Progress has been made in placing health at the centre of development, but much more
remains to be achieved.
Strategies for health promotion in a globalized world
1 rogress towards a healthier world requires strong political action, broad participation
and sustained advocacy. Health promotion has an established repertoire of proven
Cxfectix e strategies which need to be fully utilised. To make further advances all sectors
and settings must act to:
/‘.dvocace for health based on human rights and solidarity;
invest m sustainable policies, actions and infrastructure to address the determinants of
health;
Build capacity for policy development, leadership, health promotion practice, knowledge
transfer and research, and health literacy;
Regulate and legislate to ensure a high level of protection from harm and enable equal
opportunity for health and well being for all people;
Partner and build alliances with public, private, nongovernmental organizations and civil
society to create sustainable actions.
Commitments to health for all
Make the promotion of health central to the global development agenda
Government and international bodies must act to close tlic gap in health between rich and
poor. Strong intergovernmental agreements that increase health and collective health
security need to be in place. Effective mechanisms for global governance for health are
needed to address all harmful effects of trade, products, services and marketing strategies.
Health promotion must become an integral part of domestic and foreign policy and
international relations, including in situations of war and conflict. This requires actions to
promote dialogue and cooperation among nation states, civil society, and the private
sector. These efforts can build on the example of existing treaties such as the World
Health Orgamzation Framework Convention for Tobacco Control.
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Make the promotion of health a core responsibility for ail of government
Health detenniiies socio-economic and political development. Therefore governments at
all levels must tackle poor health and inequalities as a matter of urgency. The health
sector has a key role to provide leadership in building policies and partnerships for health
promotion. Responsibility to address the determinants of health rests with the whole of
government, and depends upon actions by many sectors as well as the health sector. An
integrated policy approach within government, and a commitment to working with civil
society and the private sector and across settings, is essential to make progress in
addressing these determinants. Local, regional and national governments must give
priority to investments in health, within and outside the health sector, and provide
sustainable financing for health promotion. To ensure this, all levels of government
should make the health consequences of policies and legislation explicit, using tools such
as equity focussed health impact assessment, and intersectoral national or local health
plans.
Make the promotion of health a key focus of communities and civil society
Communities and civil society often lead in initiating, shaping and undertaking health
promotion. They need to have rights, resources and opportunities so that that their
contributions are amplified and sustained. Support for capacity building is particularly
important in less developed communities. Well organized and empowered communities
are highly effective in determining their own health, and are capable of making
governments and the private sector accountable for the health consequences of their
poticies and practices. Civil society needs to exercise its power in the marketplace by
giving preference to the goods, services and shares of companies that exemplify
corporate social responsibility. Grass roots community projects, civil society groups, and
women’s organizations have demonstrated their effectiveness in health promotion, and
provide models of practice for others to follow. Health professional associations have a
special contribution to make.
Make the promotion of health a requirement for good corporate practices
The private sector has a direct impact on the health of people and on the determinants of
health through their influence on local settings and national cultures, environments and
wealth distribution. The private sector, like other employers and the informal sector, has a
responsibility to ensure health and safety in the workplace, and promote the health and
well being of their employees^ their families and communities. They also contribute to
wider global health impacts, such as those associated with global environmental change.
The private sector must ensure that its actions comply with local, national and
international reguiauons and agreements that promote and protect health. Ethical and
responsible business practices and fair trade exemplify the type of business practice that
should be supported by consumers and civil society, and by government incentives and
regulations.
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A global pledge to make it happen
Meeting these commitments requires better application of existing, proven strategies, as
well as the use of new entry points and innovative responses. Partnerships, alliances,
networks and collaborations provide exciting and rewarding ways of bringing people and
organizations together around common goals and joint actions to improve the health of
populations. Each sector - government, civil society and private - has a unique role and
responsibility. Progress in addressing the underlying determinants of health in many
cases will only occur by working together so that resources can be used more effectively
and efficiently to achieve lasting results.
Since the adoption of the Ottawa Charter, a significant number of resolutions at national
and global level have been signed in support of health promotion, but this has not always
been followed by action. The participants of this Bangkok Conference forcefully call on
Member States and the World Health Organization to close this implementation gap and
move to policies and partnerships for action. This will require political leadership.
Conference participants expect the World Health Organization, in collaboration with
others, to work with Member States to allocate resources, in tiate a plan of action,
monitor performance through appropriate indicators and tar: :ets, and report on progress at
regular intervals. To support this process United Nations on anisations are asked to
explore the benefits of developing and implementing a Global Treaty for Health.
i his Bangkok Chaner urges everyone to join in a worldwide partnership to promote
health, with both global and local engagement and action.
We, the participants of the Global Conference on Health Promotion in Bangkok,
Thailand, pledge to advance these commitments to improve health and to advocate for the
required resources, policies and practices.
11 August 2005
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