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transcript
Povertà e
patologie riemergenti
Piero ValentiniClinica Pediatrica U.C.S.C. - Roma
19 novembre 2010
Epidemiologic or health transition
• Age of pestilence and famine
• Age of receding pandemics
• Age of degenerative and man-madediseases
Omran A, 1971
“As the control program for a
disease approaches eradication
of that disease,
the control program rather than
the disease may be eradicated”Ingall D, et al. “Syphilis” In Remington and Klein, 4° Ed., 1995
HIV/AIDS (1981)
Cholera (Peru, 1991)
Plague (India, 1994)
Ebola (Zaire, 1995)
Dengue (Cuba, 1983)
SARS (China, 2001-2003)
West Nile Fever (Grecia, 2010)
1997 World Health Day
“Emerging Infectious DiseasesGlobal Alert, Global response”
“…in a global village, no nation is immune”
Fauci A. 1997
“Many infectious diseases have emerged; others have unexpectedly
reappeared. Reasons include urban crowding, environmental changes,
altered sexual relations, intensified food production and increased
mobility and trade.
Foremost, however, is the persistence of poverty and the exacerbation of
regional and global inequality.
Life expectancy has unexpectedly declined in several countries….
In some regions, declining fertility has overshot that needed for optimal
age structure, whereas elsewhere mortality increases have reduced
population growth rates, despite continuing high fertility.”
McMichael AJ, Butler CD. Health Prom Int, 2007
Millennium Development Goals
• Eradicate extreme poverty and hunger
• Reduce child mortality
• Improve maternal health
• Combate HIV/AIDS, malaria and other diseases
• Ensure environmental sustainability
• Develop a global partnership
• Achieve universal primary education
• Promote gender equality
The disease profile of poverty
S. Accorsi, et al. Trans R Soc Trop Med Hyg 2005
Tasso di mortalità delle principali malattie (Uganda settentrionale)
S. Accorsi, et al. Trans R Soc Trop Med Hyg 2005
From the recent lessons of the Malagasy foci towards a global understanding of the factors involved in plague reemergence
Duplantier J-M. Vet Res 2005
The reduction or discontinuance of surveillance and control, as well as poverty and
insalubrity are the main factors in the re-emergence of human cases, allowing increased
contacts with infected rodents and fleas. Environment changes (i.e. climatic changes,
deforestation, urbanization) induce changes in flea and rodent populations by (i)
extension of rodent habitats (for example by replacing forests by steppes or farmlands);
(ii) modifications in population dynamics (possible outbreaks due to an increase of
available food resources); but also, (iii) emergence of new vectors, reservoirs and new Y.
pestis genotypes. Numerous and spontaneous genomic rearrangements occur at high
frequencies in Y. pestis, which may confer selective advantages, enhancing the ability of
Y. pestis to survive, to be transmitted to new hosts, and to colonize new environments.
“Patterns of future urban growth, combined with advances in the treatment of traditional
scourges of communicable diseases, will cause a shift in the burden of disease toward
category 2 (non communicable) and 3 (injury) conditions over the next 30 years.
Communicable diseases, particularly HIV/AIDs, will continue to be the most important
killers among the poor. However, new risks will emerge for several reasons.
First, the marked sprawl of cities in the developing world will make access to care more
difficult. Second, increasing motor vehicles and the likelihood of inadequate infrastructure
will make air pollution and accidents in road traffic more common than in the past.
Third, impoverished urban populations have already shown a propensity toward
undernourishment, and its obverse, obesity, is already emerging as a major risk.”
Campbell T, Campbell A. J Urban Health 2007
‘The DoubleBurden
ofDisease’
Incidenza media annuale di polmoniti batteriche invasive in adulti in base a etnia ed area di residenza
Burton DC. Am J Public Health, 2010
24,2/100.000/year
10,1/100.000/year
RR = 2.40;CI = 2.24, 2.57
Williams DR Pediatrics 2009
Social Determinants: Taking the Social Context of Asthma Seriously
Nonwhite children residing in urban areas and children living in poverty
have a significantly higher risk of asthma and higher disease morbidity
than do white children; for example, asthma prevalence, hospitalization,
and mortality rates are higher for black children than for white children.
Puerto Rican individuals have an elevated risk of asthma, compared with
other Hispanic populations. Indicators of area deprivation also are
positively related to childhood asthma prevalence and hospitalization
rates, which suggests that SES (Socioeconomic status) characteristics at the
individual, household, and community level affect a child’s risk of asthma.
Climate change is increasing the global burden of disease and in the year
2000 was responsible for more than 150,000 deaths worldwide.
Of this disease burden, 88% fell upon children.
Documented health effects include changing ranges of vector-borne diseases
such as malaria and dengue; increased diarrheal and respiratory disease;
increased morbidity and mortality from extreme weather; changed exposures
to toxic chemicals; worsened poverty; food and physical insecurity; and
threats to human habitation. Heat-related health effects for which research is
emerging include diminished school-performance, increased rates of
pregnancy complications, and renal effects.
Global Climate Change and Children’s Health:Threats and Strategies for Prevention
Sheffield PE, Landrigan PJ. ehp, 2010
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Casi di tubercolosi nella fascia 0-17 anni (1990 - 2007)
italiani
stranieri
Studio multicentrico GLNBI (NO, PD, GE, RM-UCSC, RM-OPBG, NA, BA)
0
5
10
15
20
25
30
35
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Italians
Not Italians
Total
Italiani Stranieri Stranieri + NN
Notifiche casi di tubercolosi (1999-2008)
Tubercolosi pediatrica a Roma: 1999-2009
Buonsenso D, et al. ISCOMS, 2010
1999: 8,5/100.000nati vivi affetti da Sifilide congenita
Incidenza di sifilide primaria e secondaria nei paesi dell’ex-Unione Sovietica
1991: 0,9/100.000nati vivi affetti da Sifilide congenita
Simms I, Broutet N. JDDG 2008
Notifiche di sifilide in Norvegia ed alcuni paesi dell’Unione Europea
Simms I, Broutet N. JDDG 2008
Notifiche di sifilide per anno (ISTAT: 1955-1999)
Nu
mer
o c
asi
1955 1999
Notifiche di sifilide per anno (ISTAT)
Lombardia
BolzanoPiemonte
Veneto
Valle D’Aosta
• Immigrant women were more likely to be seropositive than Italian women
(relative risk 28.17, 95% confidence interval (CI)14.97 to 53.02, p 0.001).
• Of the seropositive Italian women, 9 of 11 were treated before pregnancy, while the
remaining 2 were treated during the first trimester of pregnancy. Women untreated at
delivery were more likely to be from eastern Europe (9/10) than from other countries
(p,0.05): 4 women were from Romania, 3 from Moldova, 1 from Ukraine and 1 from
Russia.
• The mother’s age ranged from 18 to 42 years. Untreated women with first-time
diagnosis at delivery were younger than the adequately treated women
(median standard deviation (SD) age 25 (4.6) v 29.2 (5.7) years; p 0.05).
• The overall syphilis seroprevalence in pregnant women was 0.44%, but it was 4.3%
in women from eastern Europe and 5.8% in women from Central–South America
Tridapalli E, et al. Sex Transm Infect 2007
• Periodo: 1 luglio 2006 – 30 giugno 2007
• Prevalenza sifilide materna al parto: 0.17%
• 207 nati da 203 madri sieropositive per sifilide
• 25 neonati con sifilide congenita (20/100.000 nati vivi), di cui
11 (44%) prematuri, 6 (24%) di peso < 2000 g, 19 (76%) con
madre straniera
• Fattori di rischio materni: età < 20 anni, nessuna cura
prenatale o trattamento inadeguatoTridapalli E, et al. Arch Dis Child Fetal Neonatal Ed, 2010
TBC del SNC e del polmone
Sifilidecongenita
“About 1 to 2 percent of sera from patients with secondary
syphilis will exhibit a prozone phenomenon….due to an excess
amount of reagin antibody present in the patient’s undiluted
serum…. The prozone effect can be overcome by diluting the
serum before testing, after which the serum will usually
exhibit titers of 1:16 or greater”
Int J Dermatol, 1982 – JAMA, 1964 - N Engl J Med, 1971
Coinfezione HIV/TBC
AIDS
Health promotion must, of course, continueto deal with the many local and immediate
health problems faced by individuals, families and communities.
But to do so without also seeking to guide socio-economic development and
the forms and policies of regional andinternational governance is to risk being
‘penny wise, but pound foolish’.
McMichael AJ, Butler CD. Health Prom Int, 2007