Aging: Situation in South East Asia

The 1989 WHO Expert Committee on the Health of the Elderly reported that by the year 2000, about 67% of the world’s 600 million elderly people will be living in developing countries, compared with about 50% in 1960. A marked increase is anticipated in the elderly population of Asia, primarily as a result of the rapid increase foreseen in China and India. These two countries alone are projected to have about 270 million more elderly citizens by the year 2020, and it is expected that Indonesia will have 20 million more people over 60 years of age.

Life expectancy in SEA 1960-1964

Life expectancy in SEA 1995-1999

Demographic trends reflect dramatic increases not only in the proportions of older people in the total population but also in life expectancy. These trends will result in changes in the age structure of the workforce. In developing countries, the rates of participation of 60- to 64-year-old men in the workforce tend to be much higher than in industrialized countries. In addition, many developing countries are experiencing the effects of rapid urbanization and modernization together with related socio-economic and cultural changes. In the migration from rural to urban areas, the elderly are often left behind, and if they move, the elderly are often more likely to encounter difficulties in adapting to the new conditions than their younger counterparts.

Ageing and urbanization: The case of the Philippines

Like many developing countries, the Philippines is experiencing both rapid urbanization and an increasing number of elderly people. The census projected the median age to increase to 19.5 years and life expectancy to increase to 63 years by the year 2000. About 2.2 million people (3% of the population) are over 65, and the United Nations Economic and Social Commission for Asia and the Pacific has projected that this number will increase to 2.8 million by the year 2000. As the elderly population increases, particularly in the urban poor sector, there are several implications in regard to the country’s response to their needs. Paguio has pointed out inadequate provisions for meeting the needs of the elderly, including inadequacies in health facilities, specialized training of health personnel to manage the sick elderly, geriatric clinics in urban centres, homes for the abandoned elderly, social security provisions, implementation of social regulations for the elderly, and recreational facilities.

Surveys have shown that the elderly in the Philippines are at risk for malnutrition and specific nutrient deficiency disorders. Nutritional anaemia was found in 25% of the elderly. However, there is still a lack of comprehensive studies of the health and nutritional state and the quality of life of elderly people in the Philippines. The four-country study on ageing in Asia/Oceania, in which the Philippines participated, underscored the need to emphasize policy and programme development that recognizes the positive characteristics of the ageing population- their physical and mental capabilities and their contribution to the family and community.

(Overview of ageing, urbanization, and nutrition in developing countries and the development of the reconnaissance project - http://www.unu.edu/Unupress/food/V183e/ch03.htm)


Social and economic implications of population aging

These include demand for health services, long-term care requirements, changes in family support, needs for social security and welfare benefits, and the special vulnerabilities of older persons arising from the AIDS epidemic, conflict situations and emergencies (such as natural disasters). Population aging affects many aspects of life, for old and young persons alike, the recommendations span a wide range of issues. Taken together, they provide a solid rationale for the need to mainstream population aging into development policies, programmes and strategies.

Although it tends to characterize family support as being in decline, citing reductions of co-residence with adult children as evidence, it also recognizes that in many settings in the region, the shift has been modest and that traditional family ties largely remain strong. An important point is that technological change, particularly in communications and transportation, allows family members to maintain relationships and crucial services over a geographical distance that previously required co-residence or physical proximity. A recent research in Thailand has revealed, the advent of mobile phones has radically improved the extent to which contact and social support are maintained between elderly parents and their adult children who live away.
At the same time, advances in transportation have facilitated migrant children’s return in times of urgent need, while financial support across almost any distance has been facilitated by instantaneous electronic transfers of remittances. Thus, the significance and meaning of living arrangements for the welfare of elderly parents are being transformed as a result.

(Population Ageing in East and South-East Asia: Current Situation and Emerging Challenges
Asia-Pacific Population Journal, Vol. 21, No. 3 - http://cst.bangkok.unfpa.org/docs/bkbookreview.pdf)


More on Ageing of Rural Populations in South-East and East Asia
http://www.fao.org/sd/wpdirect/WPan0028.htm

Trends of osteoporosis worldwide

Osteoporosis (http://en.wikipedia.org/wiki/Osteoporosis#Risk_factors)

Osteoporosis is a disease affecting many millions of people around the world. It is characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and a consequent increase in risk of fracture.

The incidence of vertebral and hip fractures increases exponentially with advancing age (while that of wrist fractures levels off after the age of 60 years). Osteoporosis fractures are a major cause of morbidity and disability in older people and, in the case of hip fractures, can lead to premature death. Such fractures impose a considerable economic burden on health services worldwide.

Worldwide variation in the incidence and prevalence of osteoporosis is difficult to determine because of problems with definition and diagnosis. The most useful way of comparing osteoporosis prevalence between populations is to use fracture rates in older people. However, because osteoporosis is usually not life-threatening, quantitative data from developing countries are scarce. Despite this, the current consensus is that approximately 1.66 million hip fractures occur each year worldwide, that the incidence is set to increase four-fold by 2050 because of the increasing numbers of older people, and that the age-adjusted incidence rates are many times higher in affluent developed countries than in sub-Saharan Africa and Asia.

In countries with a high fracture incidence, rates are greater among women (by three- to four-fold). Thus, although widely regarded in these countries as a disease that affects women, 20% of symptomatic spine fractures and 30% of hip fractures occur in men. In countries where fracture rates are low, men and women are more equally affected. The incidence of vertebral and hip fractures in both sexes increases exponentially with age. Hip-fracture rates are highest in Caucasian women living in temperate climates, are somewhat lower in women from Mediterranean and Asian countries, and are lowest in women in Africa. Countries in economic transition, such as Hong Kong Special Administrative Region (SAR) of China, have seen significant increases in age-adjusted fracture rates in recent decades, while the rates in industrialized countries appear to have reached a plateau.

(http://www.who.int/nutrition/topics/5_population_nutrient/en/index25.html)

A Worldwide Problem and the Implications in Asia

Osteoporosis is a condition characterised by low bone mineral density, microarchitectural deterioration of bony tissue, and a consequent increase in fracture risk. With rapid ageing of the Asian population, osteoporosis has become one of the most prevalent and costly health problems. The public health impact of osteoporosis stems from its association with fractures of the hip, spine and forearm. Between 10% and 20% of patients sustaining a hip fracture die within a year of the event, and among those who survive, almost two-thirds remain disabled. The medical costs of osteoporosis and its attendant fractures have been placed at $5.2 billion each year in the US and £615 million each year in the UK. The cost of treating hip fractures in Hong Kong exceeds 1% of the total hospital budget. It has been projected that this cost will rise exponentially as the population ages.

In the 1960s, there were pronounced geographical variations in hip fracture incidence, with rates being much higher in Caucasians living in Northern Europe and North America than in Asian and Negroid populations. In the 1960s, the age-adjusted incidence of hip fracture in Hong Kong Chinese was approximately 13% to 30% of that observed in Caucasians. However, with socio-economic development in many Asian countries, the incidence of hip fractures has risen considerably. For instance, the incidence of hip fractures in Hong Kong Chinese increased by more than 2-fold in the last 2 decades. In Singapore, the incidence of hip fracture increased from 7 per 10,000 in women who were 60 years of age and older in 1957 7 to 15 per 10,000 in 1985.

The results of the Asian Osteoporosis Study, which is the first multi-centre epidemiological study conducted in Asia, confirmed that the hip fracture incidence rates in Hong Kong and Singapore were approaching those observed in American Caucasians. Although the rates in Malaysia and
Thailand were much lower, these are likely to increase with urbanisation and ageing.

According to projections by the World Health Organization, there will be a total of 900 million men and women who are 65 years of age and older in Asia by the year 2050. As a result, while only 30% of all hip fractures in the world occurred in Asia in 1990, more than 50% of all hip fractures will occur in this continent by the year 2050. By then, the total number of subjects with hip fracture in Asia will be approximately 3.2 million per year. There is no doubt that primary preventive strategies for osteoporosis should be implemented in Asia. However, more challenging issues include rationing of bone mineral density measurements and finding the money to treat osteoporosis.

The results of the Asian Osteoporosis Study suggested that many lifestyle factors might be associated with osteoporosis. To name a few, these include a low dietary calcium intake, a sedentary lifestyle, cigarette smoking and alcoholism. There is no doubt that public health policies should address these issues. What is more doubtful is the extent to which individuals within populations can be persuaded to change their behaviour, and to sustain such changes.

(http://annals.edu.sg/pdfJan02/LauEMC.pdf)

The relationship between tobacco and osteoporosis can be found at this website:
http://www.who.int/tobacco/research/osteoporosis/en/

Onchocerciasis: Current global situation

Onchocerciasis (River Blindness)

What is it?
A parasitic disease caused by the microscopic filarial nematode worm Onchocerca volvulus. Adult worms live up to 14 years in nodules under the skin and release millions of microfilariae.

What are the symptoms?

Adult worms lodge in nodules under the skin, releasing large numbers of microfilariae into surrounding tissues. Immature worms move through the body and after dying, cause a variety of conditions including serious visual impairment and blindness, skin rashes, lesions, intense itching and depigmentation of the skin, lymphadenitis (resulting in hanging groins and elephantiasis of the genitals) and general debilitation.

How is it spread?
Nematodes are transmitted via the bite of infected blackflies (Simulium spp.) that carry immature larval forms of the parasitic worms from human to human

What is the magnitude of the problem?
17.7 million people are infected in 37 tropical countries of Africa and Latin America, according to WHO estimates. 500,000 individuals are visually impaired and an additional 270,000 are blind, making onchocerciasis the second leading cause of infectious blindness worldwide after trachoma. Morbidity is estimated at 951,000 DALYs.

(global distribution of onchocerciasis)

What are current treatment options, prevention and control?
Drug treatment: The development of ivermectin in the 1980s provided a safe, effective drug for killing microfilariae in infected people. Ivermectin (1 dose at 150 µg/kg) is used to treat infected individuals, curing skin itching and preventing further damage to the eyes and skin. Annual treatments of entire populations can reduce circulating microfilariae thereby disrupting disease transmission. These treatments do not kill adult worms. There are no vaccines or macrofilaricidal drugs available. Vector control: Insecticide spraying to control blackflies has proved successful in certain areas.

Current control strategy
Onchocerciasis control is based on two interventions: large-scale ivermectin treatment and vector control. In most of Africa, the principal strategy to control onchocerciasis as a public health problem is annual community-directed treatment (ComDT) with ivermectin in high-risk areas. In the Americas, the strategy involves six-monthly treatment in all endemic areas with the aim to eliminate onchocercal morbidity and, where feasible, to interrupt transmission. In the OCP areas, the main control strategy is vector control, through aerial application of larvicides to vector breeding sites over a period of at least 14 years, to interrupt transmission and eliminate the parasite reservoir. In a few isolated foci in APOC areas, ground larviciding is used with the aim of local vector eradication within a period of 1-2 years. However, following the introduction of ivermectin, OCP combined vector control and ComDT with the objective of interrupting transmission and eliminating the parasite reservoir within 12 years. Where elimination has been achieved, active control is replaced by surveillance and, if and when necessary, by recrudescence control with ivermectin treatment.

(http://www.who.int/tdr/diseases/oncho/direction.htm)

Current global strategies for combating the disease
Since 1987, Merck has provided annual doses of ivermectin in Africa and Latin America as part of the Mectizan Donation Program, the largest medicine donation program in history. Other partners include WHO, endemic countries, and the Carter Center. Ongoing annual treatments are required as the drug does not kill the adult worm. From 1974 - 2002, WHO and the World Bank also worked to control onchocerciasis in West Africa by aerial spraying of insecticides to kill blackfly larvae. While this effort succeeded in opening 25 million hectares of arable river valley farmland to settlement and cultivation, closure of the program places the entire burden of disease control on ivermectin treatment. A 2002 conference considered whether the aim of onchocerciasis programs could be changed from control to elimination. The conference concluded that onchocerciasis cannot be eliminated from Africa with current technology, but may be eradicable in the Americas and Yemen.

(http://www.divergence.com/Investors/paper.html)

Onchocerciasis Control Programme in West Africa (OCP)

A major control initiative launched in 1974 in an area encompassing 7 countries in west Africa. In 1986, the programme was extended to include a further 4 countries, with a total operational area of 1.23 million sq. km, and a combined human population of 30 million. Jointly sponsored by the WHO, World Bank, UNDP and FAO, plus a coalition of 20 donor countries and agencies, the OCP is scheduled to come to an end by 2002.

OCP’s principal method for controlling onchocerciasis involved interrupting transmission by eliminating the blackfly vector. Simulium larvae are killed by applying insecticides via aerial spraying over breeding sites in fast-flowing rivers. Following interruption of transmission, the reservoir of adult worms dies out in humans after 14 years. To complement vector control activities, OCP also distributes ivermectin.

African Programme for Onchocerciasis Control (APOC)

Following the success of the OCP, the same co-sponsors and donors created APOC in 1995. The objective is to create, by 2007, sustainable community-directed distribution systems using ivermectin. These will ultimately cover 59 million people in 17 non-OCP countries, where the disease remains a serious public health problem and some 15 million people are infected. In a few isolated foci, APOC aims to eliminate the blackfly through insecticide spraying.

The Onchocerciasis Elimination Programme in the Americas (OEPA)

Created in 1992 to reach the goal of eliminating pathology and disease in the region.

(http://www.who.int/tdr/diseases/oncho/diseaseinfo.htm)

Documentary film on Onchocerciasis

A small team has begun pre-production and fundraising for a documentary film on the subject of African river blindness, the world’s second leading infectious cause of blindness. Please visit http://www.37millionandcounting.com/ to find out more!!

More pictures on Onchocerciasis

http://www.icp.ucl.ac.be/~opperd/parasites/onch1.html