Non-communicable diseases

Non-communicable diseases (NCDs)

India is experiencing a rapid epidemiological transition with a large and rising burden of chronic diseases, which were estimated to account for 63 per cent of all deaths in 2016. NCDs, especially diabetes mellitus, CVDs, cancer, stroke, and chronic lung diseases have emerged as major public health problems due to an ageing population and environmentally driven changes in behaviour.

Cancer has become an important public health problem in India with an estimated 1.1 million cases occurring every year. At any point of time, it is estimated that there are nearly 3.9 million cases in the country. In India, tobacco related cancers account for about half the total cancers among men and 20% among women. About one million tobacco related deaths occur each year, making tobacco related health issues a major public health concern. In India, more then 12 million people are blind. Cataract (62.6 per cent) is the main cause of blindness followed by Refractive Error (19.70 per cent). There has been a significant increase in proportion of cataract surgeries with Intra Ocular Lens (IOL) implantation from per cent in 1994 to 95 per cent in 2016-17. Oral Health Care has not been given sufficient importance in our country. Most of the district hospitals have a post of dental surgeon but they lack equipment, machinery, and material. Even where the equipment exists, the maintenance is poor, hence service delivery is affected.

Example of Non-communicable diseases (NCDs)

1.Cardiovascular Diseases

Cardiovascular diseases (CVD) comprise of a group of diseases of the heart and the vascular system. The major conditions are ischaemic heart disease (IHD), hypertension, cerebrovascular disease (stroke) and congenital heart disease. Rheumatic heart disease (RHD) continues to be an important health problem in many developing countries.

2. Coronary Heart Disease

Coronary heart disease (syn : ischaemic heart disease) has been defined as “impairment of heart function due to inadequate blood flow to the heart compared to its needs, caused by obstructive changes in the coronary circulation to the heart”. It is the cause of 25-30 per cent of deaths in most industrialized countries. The WHO has drawn attention to the fact that CHD is our modern “epidemic”, i.e., disease that affects populations, not an unavoidable attribute of ageing. CHD may manifest itself in many presentations :

a. angina pectoris of effort b. myocardial infarction c. irregularities of the heart d. cardiac failure e. sudden death

Myocardial infarction is specific to CHD; angina pectoris and sudden death are not. Rheumatic heart disease and cardiomyopathy are potential sources of diagnostic confusion. The natural history of CHD is very variable. Death may occur in the first episode or after a long history of disease.

3. Hypertension

Hypertension is a chronic condition of concern due to its role in the causation of coronary heart disease, stroke and other vascular complications. It is the commonest cardiovascular disorder, posing a major public health challenge to population in socio-economic and epidemiological transition. It is one of the major risk factors for cardiovascular mortality, which accounts for 20–50 per cent of all deaths.

Definition of hypertension is difficult and, by necessity arbitrary. Sir George Peckering first fomulated a concept that blood pressure in a population is distributed continuously as a bell-shaped curve with no real separation between normotension and hypertension. There is also a direct relation between cardiovascular risk and bloodpressure : the higher the blood pressure, the higher the risk of both stroke and coronary events. As a consequence, the dividing line between normal and high blood pressure can be defined only in an operational way.

As intervention trials included only adults aged 18 years or older, definition and classification of hypertension refers to adults not taking anti-hypertensive drugs and not actually ill, and based on the average of two or more readings on two or more occasions after initial screening. Table 1 shows the classification of hypertension by blood pressure level.

Category	Systolic (mm of Hg)	Diastolic (mm of Hg)
Optimal	< 120	< 80
Normal	< 130	< 85
High normal	130-139	85-89
Grade 1 Hypertension	140-159	90-99
Grade 2 Hypertension	> 160	> 100
Hypertensive crisis	≥ 180	> 110
Isolated systolic hypertension	≥ 140	< 90

When systolic and diastolic blood pressure fall into different categories, the higher category should be selected to classify the individual's blood pressure. "Isolated systolic hypertension" is defined as a systolic blood pressure of 140 mm of Hg or more and a diastolic blood pressure of less than 90 mm of Hg.

4. Rheumatic Heart Disease

Rheumatic fever (RF) and rheumatic heart disease (RHD) cannot be separated from an epidemiological point of view. Rheumatic fever is a febrile disease affecting connective tissues particularly in the heart and joints initiated by infection of the throat by group A ẞ haemolytic streptococci. Although RF is not a communicable disease, it results from a communicable disease (streptococcal pharyngitis). Rheumatic fever often leads to RHD which is a crippling disease. The consequences of RHD include : continuing damage to the heart; increasing disabilities; repeated hospitalization, and premature death usually by the age of 35 years or even earlier. RHD is one of the most readily preventable chronic disease.

5. Cancer

Cancer may be regarded as a group of diseases characterized by an (i) abnormal growth of cells (ii) ability to invade adjacent tissues and even distant organs, and (iii) the eventual death of the affected patient if the tumour has progressed beyond that stage when it can be successfully removed. Cancer can occur at any site or tissue of the body and may involve any type of cells.

The major categories of cancer are : (a) Carcinomas, which arise from epithelial cells lining the internal surfaces of the various organs (e.g. mouth, oesophagus, intestines, uterus) and from the skin epithelium; (b) Sarcomas, which arise from mesodermal cells constituting the various connective tissues (e.g. fibrous tissue, fat and bone); and (c) Lymphomas, myeloma and leukaemias arising from the cells of bone marrow and immune systems.

The term "primary tumour" is used to denote cancer in the organ of origin, while "secondary tumour" denotes cancer that has spread to regional lymph nodes and distant organs. When cancer cells multiply and reach a critical size, the cancer is clinically evident as a lump or ulcer localized to the organ of origin in early stages. As the disease advances, symptoms and signs of invasion and distant metastases become clinically evident.

6. Diabetes Mellitus

The term diabetes describes a group of metabolic disorders characterized and identified by the presence of hyperglycaemia in the absence of treatment. The heterogeneous aetio-pathology includes defects in insulin secretion, insulin action, or both, and disturbances of carbohydrate, fat and protein metabolism. The long-term specific effects of diabetes include retinopathy, nephropathy and neuropathy, among other complications. People with diabetes are also at increased risk of other diseases including heart, peripheral arterial and cerebrovascular disease, obesity, cataracts, erectile dysfunction, and non-alcoholic fatty liver disease. They are also at increased risk of some infectious diseases, such as tuberculosis (1).

7. Obesity

Obesity may be defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size (hypertrophic obesity) or an increase in fat cell size (hyperplastic obesity or a combination of both. Obesity is often expressed in terms of body mass index (BMI). Overweight is usually due to obesity but can arise from other causes such as abnormal muscle development or fluid retention.

8. Visual Impairment and Blindness

A compilation published by WHO in 1966, lists 65 definitions of blindness. As might be expected the definitions differed widely. Terms such as total blindness, economic blindness, and social blindness were in vogue. The 25th World Health Assembly in 1972 noted the complexity of the problem and considered the need for a generally accepted definition of blindness and visual impairment for national and international comparability. Taking into consideration existing definitions, the WHO proposed uniform criterion and defined blindness as "visual acuity of less than 3/60 (Snellen) or its equivalent".

The International Classification of Disease 11 (2018) classifies vision impairment into two groups, distance and near presenting vision impairment.

Distance vision impairment :

Mild - Presenting visual acuity worse than 6/12 Moderate - Presenting visual acuity worse than 6/18 Severe - Presenting visual acuity worse than 6/60 Blindness - Presenting visual acuity worse than 3/60

Near vision impairment :

Presenting near vision acuity worse than N6 or M0.8 at 40 cm with existing correction.

A person's experience of vision impairment varies depending upon many different factors. This includes, for example, the availability of prevention and treatment interventions, access to vision rehabilitation (including assistive products such as glasses), and whether the person experiences problems with inaccessible buildings, transport information, etc.

9. Oral Diseases

Oral diseases are the most common non-communicable diseases and affect people throughout their lifetime, causing pain, discomfort, disfigurement and even death. Oral health is a key indicator of overall health, wellbeing and quality of life. WHO defines oral health as "a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing".

10. Accidents and Injuries

An accident has been defined as: "an unexpected, unplanned occurrence which may involve injury". A WHO Advisory Group in 1956 defined accident as an "unpremeditated event resulting in recognizable damage" (2). According to another definition, an accident is that "occurrence in a sequence of events which usually produces unintended injury, death or property damage". Accidents represent a major epidemic of non- communicable disease in the present century. They are no longer considered accidental. They are part of the price we pay for technological progress. Accidents have their own natural history and follow the same epidemiological pattern as any other disease - that is, the agent, the host and the environment interacting together to produce injury or damage. They occur more frequently in certain age-groups, at certain times of day and week and at certain localities. Some people are more prone to accidents than others and susceptibility is increased by the effect alcohol and other drugs as well as physiological state such fatigue. Lastly, a majority of accidents are preventable.

11. TYPES OF ACCIDENTS

i) Road traffic accidents

The number of road traffic deaths continues to rise steadily, reaching 1.35 million in 2016. However, the rate of death relative to the size of the world's population has increasing remained global population and rapid motorization that has constant. When considered in context of the taken place over the same period. This suggest that existing road safety efforts may have mitigated the situation from getting worse. As progress is made in the prevention and control of infectious diseases, the relative contribution of deaths from injuries have increased. Road traffic injuries are the 8th leading cause death for children and young adults aged 5-29 years. A number of countries have seen success in reducing road traffic deaths over the last few years, but progress varies significantly between different regions and countries of the world. With an average rate of 27.5 deaths per 100,000 population, the risk of a road traffic death is more than three times higher in low-income countries than in high-income countries where the average rate is 8.3 deaths per 100,000 population. The variation in rates of death observed corresponds with differences in the types of road users most affected. Vulnerable road users - pedestrians, cyclists and motor cyclists represent more than half of all global deaths. Pedestrians and cyclists represent 26 per cent of all deaths while those using motorized two or three wheelers comprise another 28 per cent. Car occupants make up 29 per cent of all deaths. In addition, there are as many as 20-50 million non-fatal injuries and 10-20 million serious injuries requiring long period of expensive care, nursing and treatment. From a young age, males are more likely to be involved in road traffic crashes than females. They are almost 3 times as likely to be killed in a car crash as young females.

ii) Domestic accidents

By “domestic accident” is meant an accident which takes place in the home or in its immediate surroundings, and, more generally, all accidents not connected with traffic, vehicles or sport. The most frequent causes of domestic accidents are :

i) drowning; ii) burns (by a flame, hot liquid, electricity, crackers or fireworks, chemicals); iii) falls; iv) poisoning (e.g., drugs, insecticides, rat poisons, kerosene); v) injuries from sharp or pointed instruments; and vi) bites and other injuries from animals.

iii) Drowning

Drowning is the process of experiencing respiratory impairment from submersion/ immersion in liquid.

Victims of drowning have a very slim chance of survival approximately. The victim loses consciousness after approximately 2 minutes of immersion, and irreversible brain damage can take place after 4-6 minutes. Therefore, prevention strategies are very important.

In 2016, an estimated 322,000 people died from drowning, making drowning a major public health problem worldwide. Injuries account for nearly 9% of total global mortality. Drowning is the 3rd leading cause of unintentional inhury/ death. It accounts for 7% of all injury-related deaths. It is a common method deaths of suicide.

The global burden and death from drowning is found in all economies and regions, however; low and middle-income countries account for 90% of unintentional drowning deaths; over 50% Pacific of the world's drowning occurs in WHO Western Pacific Region and WHO South-East Asia Region; China and India have particularly high drowning mortality rates and together contribute 43% of the world's drowning deaths and 41% of the total global DALYs (disability-adjusted life years) lost related to drowning.

There is a wide range of uncertainty around the estimate of global drowning deaths. It is important to point out that the global problem is much greater than the above figures reveal; due to the way data are classified, global numbers exclude drowning due to floods (cataclysms), boating and water transport mishaps. Non-fatal drowning statistics in many countries are not readily available or are unreliable.

iv) Burns

A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Thermal (heat) burns occur when some or all of the cells in the skin or other tissues are destroyed by :

• hot liquids (scalds) • hot solids (contact burns), or • flames (flame burns). •

v) Falls

Globally, falls are a major public health problem. An estimated 646,000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries. Though not fatal 37.3 million falls are severe enough to require medical attention. Such falls are responsible for 17 million DALYs lost. Over 80% of fallrelated fatalities occur in low and middle-income countries., with regions of the Western Pacific and South East Asia accounting for more than two-thirds of these deaths. In all regions of the world, death rates are highest among adults over the age of 65 years.

Falls are responsible for the largest number of hospital adults. Falls from rooftops, balconies, windows and stair visits for non-fatal injuries, especially for children and young cases are common. Factors specific to SEAR countries are falls from trees of workers picking fruits or coconuts, tapping toddy, children falling from rooftops while flying kites, high incidence of falls among construction and forestry workers. As life expectancy increases in these countries, the incidence of hip and other fractures due to fall among the elderly are also assuming greater proportions. Some of the risk factors include :

- occupations at elevated heights or other hazardous working conditions; - alcohol or substance use; - socio-economic factors including overcrowded housing, young maternal age; - underlying medical conditions, such as neurological, cardiac or other disabling conditions; - side-effects of medication, physical inactivity and loss of balance, particularly among older people; - unsafe environments, particularly for those with poor balance and limited vision.

vi) Poisoning

Poisoning was responsible for an estimated 252,000 deaths during the year 2008 worldwide. In India about 28,012 poisoning deaths were reported during the year 2010. The most common agents responsible for poisoning are pesticides, kerosene, prescription drugs, and house hold chemicals. Pesticides are widely used in many countries where agriculture is an important part of the economy. Reports from India, Indonesia, Sri Lanka, and Thailand indicate that common availability and use of toxic pesticides is responsible for intentional and unintentional morbidity and mortality.

In Sri Lanka, pesticides are one of the main agents used in attempted suicide in rural areas. The use of organophosphorous insecticides in suicide events has been reported to be as high as 20-30 per cent. Paraquat intoxication is known to cause irreversible damage in patients. Many countries also report accidental ingestion of kerosene as a leading cause of poisoning, especially among children. A study from Thailand revealed that 54 per cent of cases of poisoning among pre-school children involved therapeutic drugs.

vii) Snake bite

Snake bite is a neglected public health issue in many tropical and subtropical countries. About 5 million snake bites occur each year, resulting in upto 2.4 million envenomings (poisoning from snake bites) at least 94,000- 125,000 deaths and around 400,000 amputations and other permanent disabilities. Most of these occur in Africa, Asia and Latin America. In Africa alone there are an estimated 1 million snake bites annually with about half needing treatment. This type of injury is often found among women, children and farmers in poor rural communities in low and middle-income countries.

The outcome of snake bite depends on numerous factors, including the species of snake, the area of the body bitten, the amount of venom injected, and the health condition of the victim. Feelings of terror and panic are common after a snake bite and can produce a characteristic set of symptoms mediated by the autonomic nervous system, such as a tachycardia and nausea. Bites from non-venomous snakes can also cause injury, often due to lacerations caused by the snake's teeth, or from a resulting infection. A bite may also trigger an anaphylactic reaction, which is potentially fatal. First-aid recommendations for bite depends on the snakes inhabiting the region, as effective treatment for bite inflicted by some species can be ineffective for others.

The venom of poisonous snakes may be predominantly neurotoxic or predominantly cytolytic. Neurotoxins cause respiratory paralysis and cytolytic venoms cause tissue destruction by digestion and haemorrhage due to haemolysis and destruction of the endothelial lining of the blood vessels. The manifestations of rattlesnake envenomation are mostly local pain, redness, swelling and extravasation of blood. Perioral tingling, metallic taste, nausea, and vomiting, hypotension and coagulopathy may also occur. Neurotoxic envenomation may cause ptosis, dysphagia, diplopia, and respiratory failure. Venom emitted from some types of cobras, almost all vipers cause necrosis of muscle tissue. Muscle tissues begin to die throughout the body and it results in accumulation of myoglobin in the renal tubules which leads to acute renal failure.

viii) Railway accidents

With the increase in number of trains and passengers, the increase in the number of accidents and casualties resulting therefrom is not unexpected. During 2020, about 8,700 people died of railway accidents in India. The main factor involved in railway accidents in human failure.

ix) Industrial Accidents

There are approximately 580 million workers in the South-East Asia Region. Approximately 60-80 per cent of these workers are employed in agriculture, fisheries, home industries, and small-scale units. Injuries due to these occupations result in an estimated 120 million injuries and 200,000 deaths per year.

Though reliable estimates for work related injuries and deaths in the Region are not available, partly because a majority of the workers are employed in unorganized sectors, few studies indicate that nearly one per cent of deaths and 10 per cent of permanent impairment result from agricultural injuries. Agriculture workers are exposed to wide variety of physical, chemical (pesticide and fertilizers) biological (animal bites and animal related injuries) and mechanical injuries. The estimates from agriculture injury vary from 22-29 per 1000 workers. The incidence rate of injury among agriculture workers in India is estimated to be116 per 100,000 workers. In a study population of 23,000 in rural Haryana, nearly 31 per cent of the injuries were related to agricultural activity. Of these, serious injuries were caused by mechanized equipment and tractors. Rapid industrialization has also resulted in mortality and morbidity of many workers in hazardous industries. The unique features common to the workplace in this region are that the manual labour content is high and the man-machine interaction is unsafe. In addition, there is greater emphasis on attempts to change the worker’s behavior, but designs that provide automatic protection are ignored. Children and people who are challenged physically as well as mentally are at a greater risk of encountering occupational injuries.

x) Violence

Homicide and collective violence account for around 10% of global, injury-related death. In 2016, there were an estimated 477,000 murders. Four fifths of homicide victims are men, and 60% of victims, males age 15-44. The low and middle-income countries of the Region of the Americas has the most homicides, with 28.5 per 100,000 population, while the lowest murder rate, almost 14 times lower (2.1 per 100,000 population), is found in the low-and middle income countries of The Western Pacific Region.

Violence is reported to be increasing rapidly. It also follow the same epidemiological pattern as any other disease (host, agent and environment), i.e., a motivated person who injures; a suitable target; and a suitable environment or the absence of a guardian, all coinciding in time and space. Often, it may only be possible to initiate steps for prevention after an episode of violence has already taken place.

Some of the risk factors for violent behaviour are :

• Exposure to violence and societal acceptability of violence as a means to solve problems. The image of violence as an acceptable and effective tool for solving problems, whether across international borders, on the street, or around the home, may spill over into real behaviour; • Availability of lethal weapons like fire-arms significantly increases the possibility of both fatal and non-fatal injuries; • Consumption of alcohol and other drugs is linked to almost 2/3 of cases of violence according to several studies.

Violence due to war and political unrest is fairly common in several countries. Organized and unorganized, ethnic and communal violence are well known in some places. Suicides have been increasing at an alarming rate in SEAR countries. Crude death rates of 8.7 per lac population In Bangladesh, 14.7 per lac population in India, 6.4 per lac.