Guía de Salud Global: Segundo Parcial

Nutrition and Global Health

 What is the importance of nutrition to the MDGs?

 What are stunting and wasting?

Stunting: falla para alcanzar el potencial de crecimiento lineal por nutrición

inadecuada o pobre salud. Se mide con altura para edad dos “z-scores” debajo de la
referencia internacional. Bajo para su edad
Wasting: peso para altura, bajo peso para altura, normalmente relacionado con
ausencia aguda de comida e infección.

 What are some of the direct and indirect causes of undernutrition?

Dos más importantes:
Ingesta dietética inadecuada
Enfermedad (sin agua limpia y sanación = diarrea)
Acceso inadecuado de comida en el hogar
Dieta de la madre
Causa básica = raíz del problema: estado socioeconómico, ingreso de la familia,
nivel de conocimiento acerca de salud, control sobre vida propia
 What are some of the direct and indirect causes of overweight and obesity?
Azúcar agregada
Falta de ejercicio
Exceso de consumo de ácidos grasos saturados y trans

 What are the links between nutrition and health?


  How are growth charts used to gauge nutrition status?
Peso y estatura en una gráfica (internacional) para comparar con media

 What are the most important micronutrient deficiencies and what health
problems do they cause?
En embarazadas son: vitamina A, hierro, yodo, zinc y calcio.
Falta de yodo se relaciona con crecimiento de la tiroides (goiter) con falla de
alcanzar crecimiento intelectual potencial.

 Why is anemia a special risk in pregnancy?

Mujeres con deficiencia de hierro tienen a tener riesgo aumentado de tener bebé
prematura o bajo peso al nacer o morir durante parto.
Falta de hierro= fatiga y debilidad
También relacionada a pobre desarrollo mental y disminución de función
inmunológica

 Why is exclusive breastfeeding for the first 6 months so important?

promueve salud
 Mejor desarrollo cognitivo
Reduce el riesgo de infecciones y el riesgo de muerte por infecciones

 What parts of the world have the worst nutritional problems?

· Bajo peso al nacer: Asia del Sur y África Sub-Sahara
· Stunt: África
· Wasting: Asia del Este
· Micronutrientes: África
· Obesidad: adultos en Americas y niños menores de 5 años Europa
Antes obesidad era en países de alto ingreso y ahora es en medio y bajo ingreso
también

 What are the links between nutrition and economic development?

Personas bien nutridas viven más y pueden contribuir a la economía

 What are some of the most important cost-effective interventions that could be
made to address undernutrition in under-5 children?
· Promover lactancia maternal
· Introducir comida complementaria adecuada
· Comida rica en micronutrientes
· Suplementos de ácido fólico y hierro
· Sal con yodo
· Suplementos

 What are some of the most important cost-effective interventions that could be
made to address overweight and obesity?
· Impuestos para bebidas endulzadas y comida alta en grasa
· Menos sal y reemplazar grasa trans con polinsaturadas
· Hacer obligatorio etiquetas de alimentos
· Aumentar conciencia pública a través medios con campañas para dieta y
actividad física
· Aconsejar y dar terapia para personas con alto riesgo de desarrollar ataques del
corazón y ACV
Aspirina para ataques del corazón

Women’s Health

 What are some of the key diff erences in the burden of disease between males
and females?
- Mujeres viven más que hombres → Alzheimer, osteoarthritis, ECV,
alteraciones en vista.
- En estudio, salio que mujeres tienen una elevada incidencia a
enfermedades. Algunas propias de la mujer (ej. Algunos Ca).
- Mayor tendencia a padecer depresión y migraña.

 South Asia is the region of the world in which females are the least healthy compared
to males.

 What are the sources of those differences?

La mayoría de los problemas en las mujeres están determinados por los factores
biológicos (ej. Cáncer de ovario) y sociales (aborto por que su hijo es niña en vez de
niño).
 Biológicos  Sociales
 - Deficiencia de hierro
(menstruación).
- Embarazo y
complicaciones
relacionadas.
 Prolapso uterino o fístula
obstétrica.
 Hemorragia, es la causa
principal de mortalidad
maternal.
 Aumento de riesgo en
embarazo: Tras contraer
enfermedades (malaria,
hepatitis, obesidad).
- Mujeres mayor riesgo
de tener una STD
comparadas con
hombres.
 Mayor área mucosa expuesta
durante las relaciones.
 - Mayor riesgo a enfermedad
cardiac que hombres.
- Aborto selectivo (tras
conocer el sexo del
bebé).
- Mujeres son
alimentadas menos
que los hombres (en
todas las edades).
 Más susceptibles a retraso de
crecimiento y menor tamaño
pélvico.
- Abuso sexual.
 Dominancia masculina, el
hombre escoge cuándo tener
relaciones.
 Dowry death; la novia debe de
dar regalo al novio cuando se
casan. Si el novio no esta
conforme, queman a la esposa.
- Mayores niveles de
depresión.
- Disconfort
ginecológico sin
explicación.
- Mujeres viudas o
divorciadas sufren a
veces discriminación.
- Cocinar al interior.
 - Algunas mujeres no
pueden usar servicios de salud
sin permiso de marido o de un
hombre en su familia.

 What are the three delays and why are they important?
+ Delay in deciding to seek care
+ Delay in identifying and reaching medical facility.
+ Delay in receiving appropriate care at health facilities.
They are important because they determine the quaility, timing and success of medical
interventions.

 What steps do countries need to take to deal with the complications of unsafe
abortions?
- Provide hygienic and appropriate post- abortion care at the lowest level of
the health system.
Be able to provide: Antibiotics, anesthesia, transfuse blood.
Vacuum aspiration is a more cost- effective way to deal w/ incomplete abortion.
- Prevención de aborto: Universal access to family planning services,
including after abortion.
- Women also need to know that legal abortion is available.

 What measures might be taken to reduce intimate partner violence?

- Más legislaciones.
- Refugios para las afectadas.
- Personal entrenado para lidiar con víctimas (more sensitive and more
effective way).
 How could one reduce the risk to women of sexually transmitted infections?
Based on prevention.
- Education.
- Target to people at most risk.
- Trained health workers
- Partners of the infected can also be tested and treated.
- Condom promotion.
 What are some of the most cost-eff ective investments that should be made to
improve the health of women in low-income countries?
- Mejorando: Nutrición, aboliendo aborto selective educando a la comunidad,
evitando mutilaciones, family planning, prenatal care.

Health of Young Children

 What are the most important causes of child death globally?
Preterm birth complications, pneumonia, malaria, diarrhea

 How do causes of death diff er for neonates, infants, and children younger than
5 years?
Neonatal deaths are due to:
Preterm birth complications
Birth asphyxia and birth trauma
Sepsis & other infections of the newborn

While in infancy deaths are due to:

Lower respiratory infections (pneumonia)
Diarrheal disease
Malaria

Younger than 5 years

Preterm birth complications
Congenital abnormalities
Lower respiratory infections

 Why are there diff erent levels of child illness and death in diff erent parts of the
same country?
Because it depends on the income group, the access to healthcare facilities, the access to
vaccination and other factors that differ between different regions of the same country.

 What is the link between nutrition and child health?

If a child is malnourished or low birthweight, it is more susceptible to deficiencies and
infectious diseases. In addition, if a baby is not breastfed, it is more likely to die from
infectious causes.

 How does the health of young children in low-income countries vary with the
income of the family?
The higher income of the family, the healthier the child because he is more likely to receive
care.

 How does the health of young children in low-income countries vary with the
mother’s level of education?
The more educated the mother is, the more likely the child is to live.

 What is the importance to neonatal health of having a skilled birth attendant at

delivery?
It reduces the risk of neonatal death if the health profesional is trained on neonatal
resucitation

 What are some of the most cost-eff ective interventions for saving the lives of
newborns?
-Early and exclusive breastfeeding
-Postpartum Vitamin A provided to mothers
-neonatal resuscitation if not breathing at birth

 What are some of the most cost-eff ective interventions for saving the lives of
children younger than 5 years?
- breastfeeding for 6 months
- introduction of complementary foods
- immunizations
- bed nets for malaria
- oral rehydration for malaria

 What measures can families take, even in the absence of additional income or
health services, to keep their children healthy?
-vaccines
-learn to diagnose pneumonia so that it can be treated
-use Oral Rehydration Therapy
-sleep under a bednet
-use antiretroviral therapy to prevent mother-to-child HIV
Communicable Diseases
● Case→ An individual with a particular disease.
● Case fatality rate→ % proportion of persons with a particular condition (cases) who
die from that condition.
● Control (disease control) →Reducing the incidence and prevalence of a disease to
an acceptable level
● Elimination (of disease) →Reducing the incidence of a disease in a specific area to
zero.
● Emerging infectious disease→ A newly discovered disease.
○ Ej: SARS (2002)
○ Middle East Respiratory Syndrome: MERS (2012)
● Eradication (of disease) →Termination of all cases of a disease and its transmission
globally.
● Parasite→ An organism that lives in or on another organism and takes its
nourishment from that organism.
● Reemerging infectious disease→ An existing disease that has increased in
incidence or has taken on new forms.
○ Ej: Dengue (2009)
○ Ebola (2014)

The following list, which includes examples of diseases spread in each manner:
● Foodborne: Salmonella, Escherichia coli, Entamoeba histolytica
● Waterborne: Cholera, rotavirus
● Sexual or bloodborne: Hepatitis, HIV
● Vector-borne: Malaria, onchocerciasis
● Inhalation: Tuberculosis, influenza, meningitis
● Nontraumatic contact: Anthrax
● Traumatic contact: Rabies In addition, it is critical to understand

Leading Causes of Death from Selected Communicable Diseases

Lower Respiratory Conditions
HIV/AIDS
Diarrheal Diseases
Tuberculosis
Malaria
Measles

Control de enfermedades transmisibles:

● Vacunación: viruela, poliomielitis, sarampión, difteria, tos ferina, tétanos, hepatitis B,
fiebre amarilla, meningitis, influenza

● Quimioterapia de masas: Oncocercosis, anquilostomiasis, filariasis linfática

● Control vectorial: Malaria, dengue, fiebre amarilla, oncocercosis, virus del Nilo
Occidental

● Mejora del agua, saneamiento, higiene: Enfermedades diarreicas

 ● Mejora de la búsqueda de atención, reconocimiento de la enfermedad: Salud
materna, salud neonatal, enfermedades diarreicas, enfermedad respiratoria.

● Manejo de casos (tratamiento) y mejor cuidado: Enfermedad diarreica,

enfermedad respiratoria, VIH / SIDA, tuberculosis

● Vigilancia de casos, notificación y contención: Influenza aviar, meningitis, cólera

● Cambio de comportamiento: VIH, infecciones de transmisión sexual, gusano de

Guinea, virus Ébola.

VIH/SIDA
HIV is a virus that can be spread through:
● Unprotected sex—primarily vaginal and anal intercourse
● Mother-to-child transmission, during birth or through breastfeeding
● Blood, including by transfusion, needle sharing, or accidental needle stick
● Transplantation of infected tissue or organs

Factores de riesgo de VIH/SIDA

- Hombre no circuncidado
- Mujer
- ETS

Vías de transmisión varía con ubicación:

FIRST PHASES of the epidemic
In high-income countries and Brazil → unprotected sex between men and
men.

In sub-Saharan Africa → unprotected sex between men and women

High-risk behaviors**
- Sex workers and their clients
- Men engaging in sex with multiple female partners.

In China→ People who received transfusions from blood that had been infected with the
blood of HIV-positive people.
- Sex between men and women
- Injecting drug use.

In Russia and the former Soviet Union→ injecting drug users

- Sharing needles with HIV-positive
- The epidemic is now spreading through unprotected sex.

Consecuencia de VIH→ huérfanos

TB
Tuberculosis is caused by the bacteria Mycobacterium tuberculosis
- Active TB = characterized by a persistent cough for more than 3 weeks, decreased
appetite, general weakness, and profuse night sweats.
Untreated person with active pulmonary TB can infect 10 to 15 people annually.

TB remains latent in the bodies of about 90 % of those infected and they will not
develop TB disease.
- People with latent TB do not spread TB

TB was the 10th most important cause of death worldwide for all age groups
and both sexes.

There has been an increase in TB infections that are resistant to one or more TB drugs =
Drug-resistant TB
- Multidrug-resistant TB (MDR-TB) = resistance to isoniazid and rifampicin, with or
without resistance to other first-line drugs.
- Extensively drug- resistant TB (XDR-TB) = resistance to at least isoniazid and
rifampicin, and to any fluoroquinolone, and to any of the three second-line injectables
(amikacin, capreomycin, and kanamycin).

TB is an opportunistic infection of HIV.

- As the immune system of an HIV + person declines, TB is one of the diseases that
can develop.

WHO recommendations to prevent and manage TB and HIV co-infection → “scaling up the
three Is”:
1. Intensified case finding to ensure that all of those who are HIV-positive are tested
for TB and all of those with TB are tested for HIV
2. Giving isoniazid, an antibiotic, to people with HIV to help prevent their getting TB
3. Enhancing infection control in healthcare settings so that TB does not spread
among those who are infected with HIV.

Malaria
Malaria is caused by parasites in the genus Plasmodium, five species of which infect
humans:
- P. falciparum → dominates in Africa
- P. vivax → occurs in temperate zones
- P. ovale → South Asia and tropical Africa
- P. malariae
- P. knowlesi → is the least common form and primarily affects macaques however, it
can also infect humans, especially in forested areas of Southeast Asia.

Malaria is spread by the bite of the female Anopheles mosquito. Essentially, the mosquito
carries the parasite from an infected person to an uninfected person..

Key interventions required to roll back malaria. These include:

- Prompt treatment of those infected, based on confirmed diagnosis
- Intermittent preventive therapy for pregnant women
- Long-lasting insecticide-treated bednets for people living in malarial zones
- Indoor residual spraying of the homes of people in malarial zones
Diarrea
Poor recognition of the extent of illness, failed home care, and lack of knowledge
about simple therapies increase the severity of diarrhea → DEATH.
- Impact the poor, especially children in low- and middle- income countries.

Diarrheal disease mortality has decreased significantly in the past 30 years

- Improved nutrition of infants
- Better disease recognition by families and healthcare providers
- Improved care seeking
- Appropriate use of oral rehydration therapy
- Increasing rates of coverage of the measles vaccine
- Growing use of the rotavirus vaccine.

Diarrhea is a major cause of death and sickness for children younger than 5 years.

Estrategias de prevención (5)

1. Lactancia por 6 meses
2. Introducción de alimentos después de 6 meses de lactancia
3. Vacuna rotavirus
4. Vacuna sarampión
5. Aumento en el acceso de agua potable

Uso de terapia de rehidratación oral

Suplementos de zinc
Antibióticos para diarrea sanguinolenta (Shigella)

Noncommunicable diseases

 How important are noncommunicable diseases to the global burden of

disease?
Carga de enfermedades no comunicables es mayor que comunicables en países de
bajo, medio y alto ingreso (excepción: África Sub-Sahara)
Aumentará en países de bajo y medio ingreso conforme mejore la economía
Más importantes: cardiovascular, cáncer, enf mentales, enf musculoesqueléticas,
DM enf pulmonar crónica

 Why are noncommunicable diseases less important to the burden of disease in

sub-Saharan Africa than in other regions?
Porque aquí sigue prevaleciendo las enfermedades comunicables

 What are the leading risk factors for cardiovascular disease?

· H tienen mayor riesgo que M premenopáusicas pero la misma que posmenopáusicas
· Aumenta riesgo con familiar masculino con enf cardiovascular antes de los 55 @ y
femenina antes de los 65 @
· Africanos y asiáticos
· Mayor edad
· Sociales (pobreza, estrés, depresión y aislamiento social)

 What are the most important cancers that aff ect low-income countries?
· Cancer pulmonar
· Mundial: pulmonar, mama y colorrectal.
· Países de bajo y medio ingreso: primera causa de muerte es cáncer de mama

 What are the most important risk factors for cancers?

· Países de alto ingreso: sedentarismo, alto consumo de grasa
· Aumenta cáncer de mama en países de bajo ingreso por cambios en la reproducción,
dieta y factores hormonales
· Mejor calidad de vida = viven más = aumenta tasa de incidencia en país de alto
ingreso
· Mortalidad alta en países de bajo y medio ingreso por falta de detección oportuna y
tx. Sufren doble carga por cánceres causados por agentes infecciosos y cánceres
asociados a riesgos del comportamiento
· Tabaco: pulmón, y aumenta mama y próstata
· Alcohol: hígado, tracto digestivo superior, mama y colorrectal
· Dieta alta en carne roja y procesada y baja en fibra: colorrectal
· Obesidad: mama (posmenopausia), colorrectal, endometrio, riñón, esófago y
páncreas.

 What factors are causing the epidemic of diabetes that is occurring worldwide?
Diabetes I - se asocia a una historia familiar de diabetes, factores ambientales, peso alto,
edad materna avanzada, exposición a infecciones virales
Diabetes II - historia familiar, dieta, sedentarismo, obesidad, resistencia a la insulina, raza y
edad avanzada.

 Why are mental disorders so important to the burden of disease if so few

people die of them?
· Importante para carga, por causar 7.4% de todos los DALYs (AVISA) en países de
bajo y medio ingreso (2010). Mayor causa global de DALYs de 15-49 @
· Depresión, Ansiedad, Bipolaridad y esquizofrenia.
· Prevalentes en jóvenes, no se curan y dan discapacidades
· Mortalidad por suicidio

 What measures have proven eff ective in reducing the use of tobacco?

· Impuestos en cigarros
· Quitar publicidad
· Información de efectos negativos
· Programas comprensivos del control del tabaco (alto ingreso)
6 elementos

 What lessons of Uganda’s approach to mental health concerns are important

for other resource-poor countries?
Desórdenes mentales son importantes en países de bajos recursos, especialmente los que
son afectados por desastre, emergencias complejas y VIH/SIDA. Países aún con recursos
limitados pueden tomar medidas para mejorar los servicios de salud. Es posible diseñar e
implementar una estrategia para afrontar los desórdenes mentales.

 What measures have been eff ective in reducing the abuse of alcohol?

· Políticas, leyes e impuestos
· Restricción de ventas, tiempo y límite de edad
· Control de publicidad
· Alcoholímetros
· Aumentar precio de alcohol
· Promover asesoramiento por cuidadores de salud

The Environment and Health

 Why are environmental health issues important in global health? Which of
them are the most important and why?
25-33% de la carga de enfermedad global se atribuye a factores de riesgos al medio
ambiente.
OMS calcula que el medio ambienta afecta más del 80%
Tercera causa principal de muertes en países de bajo y medio ingreso es EPOC,
cuarta es infecciones del tracto respiratorio inferior y quinta enf diarreicas, todas
estas íntimamente ligadas a cambios del medio ambiente

 Why would the burden of disease from household air pollution in low- and
middle-income countries be larger than that from ambient air pollution?
Contaminación de aire ambiente = contaminación de materia particulada.
 Contaminación en el hogar por combustibles sólidos (combustible de carbón,
combustible de biomasa, estiércol de vaca, madera, sobras de cultivo). Esto es más
utilizado en segmentos más pobres de la sociedad

 In what regions of the world would the burden from household air pollution be
the
Países de bajo y medio ingreso
Sureste de Asia (India y China) y Pacifico (oeste)

 What are the diff erent ways in which unsafe water is related to the spread of
disease?
Give some examples of specific diseases that are spread in various water-related
ways.
Transmisión fecal-oral
Ejemplos: tracoma (moscas como vector), parásitos (lombrices), áscaris y

 What are some of the health problems associated with ambient air pollution?
· ACV
· Enf cardiovascular (isquemia)
· Infecciones agudas del tracto respiratorio inferior
· Cáncer de pulmón
· EPOC
· Alguna evidencia de relación con cataratas y tuberculosis
· Por confirmar: mal resultado de embarazo (bajo peso) y dos tipos de cáncer de
pulmón
 Why is it important to promote handwashing?
Disminuir transmisión de patógeno por agua por falta de higiene. Se relaciona el lavado de
manos en varios estudios con la disminución de infecciones agudas respiratorias

 What approach would you take in a low-income African country to enhance the
access of the poor to better water supplies? Why?
Mejorar la calidad del agua no tanto la cantidad, se ha visto en estudios que invertir en
saneamiento o higiene ayuda a disminuir aprox. 30% la morbilidad por diarrea
· Primero se debe promover la higiene. Esto es necesario para aumentar el valor que va
adquirir el invertir en el saneamiento del agua y mejor suministro de agua.
· Gobierno debe promover esquemas de saneamiento de bajo costo.

 How would you try to expand access to low-cost sanitation in Nepal? Why?

Con apoyo del gobierno para proveer queroseno

 What would constrain poor people in Nepal from investing their own resources
in improved low-cost sanitation? How could those constraints be overcome?

Están informados acerca de lo que deberían es más conveniente para el ambiente y su

salud pero al carecer de dinero, compran lo más barato y no invierten en material nuevo
(estufa). Además su ingreso se invierte más en el tratamiento de sus enfermedades y no en
la prevención.

Una forma de mejorar se bajo costo, es la creación de chimeneas para que haya una salida
del humo que generan al cocinar. Esto tendría impacto positivo sobre su salud, aunque para
el medio ambiente seguirá siendo negativo