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1

Cancer prevalence in developing vs. the developed world

-Cancer is a leading cause of morbidity and mortality worldwide

- 70% of deaths occur in low- and middle-income countries with around ⅓ of deaths due to the

2

Opioid availability and which countries have met their opioid needs or have NOT met their opioid needs (only a few countries that have met or exceeded their opioid needs

Met: US

Unmet: Haiti, Nigeria, India/Indonesia, Russia, China, Uganda

3

Of these countries talk about how much of their opioid needs: be ready to rank countries based on their opioid availability (Nigeria, India, Uganda, Indonesia, Haiti, Australia, US, UK)

Ranking based on need
Haiti (<1%)
Nigeria (0.2%)
India/Indonesia (4%)
Russia (8%)
Uganda (11%)
China (16%)

4

Prevalence of cancer in developing words

Lower or higher

Lower

5

Prevalence of NCDs in the developing world

Lower or higher

Fewer NCDs (which are cancer risk)

6

Death rate in developing world

low or high

VERY HIGH death rates

7

Which has higher NCD’s developed or developing?

Developed world has higher NCDs (total) but developing world NCDs are growing at extremely high rates

8

Disparities in incidence of cancer and cancer survival: some places have lower incidence of cancer but higher death rates and vice versa. Have some idea of which continents have these types of disparities

Continents

- Africa
- SE Asia
- E Medit

9

Disparities in incidence of cancer and cancer survival: some places have lower incidence of cancer but higher death rates and vice versa. Have some idea of which countries have these types of disparities

COUNTRiES

- Libya (40%) to Norway (70%) for cervical cancer

- Jordan (16%) to USA (90%) for AML

10

Common barriers to opioid or morphine availability (4)

1. Doctors get no palliative training

2. Legislators or police oppose importation or make prescribing difficult

3. “Opiophobia” - doctor unwillingness or fear to prescribe medication

4. Pharma companies uninterested in marketing generic morphine (cheap=low profit)

11

Characteristics of oral morphine use

Diluting syrup with morphine so the concentration is not enough to get someone high or dependent but it effectively relieves pain

Can’t even get addicted to it if you take a lot

12

Structure of Uganda Morphine Program
1. Who can administer
2. Details of Program

Who can administer
Nurses with special training
Details of Program
AIDS patients had been dying screaming from cryptococcal meningitis or Kaposi’s sarcoma.
Allowed nurses with special training to prescribe morphine
Outside a private charity overseen by the government distributed oral morphine free of cost with two strengths. (0.5g or 5g per 500mL). This was so people who have to drink gallons to get high.

13

Risk factors for cancer in the developing world (10)

1. HPV/Hepatitis/HIV (Communicable diseases)
2. Tobacco/alcohol
3. Obesity/Sedentary lifestyle
4. Diet low in fruit/vegetables
5. Occupational hazards
6. UV exposure
7. Urban air pollution
8. Indoor smoke
9. Cultural behaviors like skin bleaching
10. Late presentation (caused by distrust)

14

Difference between the 2 components of early detection

Screening vs. Early detection

Screening
- Identifying individuals with abnormalities suggestive of a specific cancer or pre-cancer who have NOT yet developed symptoms and refer them for diagnosis/treatment.
- This is a more complex public health intervention compared to early diagnosis

Early detection
Programs designed to reduce delays/barriers to care to access treatment in a timely manner.

15

When is screening effective

when correct test are implemented effectively and are linked with other steps in the screening process.

16

Describe screening for cervical cancer in low-income areas

Visual inspection with acetic acid (VIA) for cervical cancer in low-income settings

17

Examples of screening

1. Visual inspection with acetic acid (VIA) for cervical cancer in low-income settings
2. HPV testing for cervical cancer
3. PAP cytology test for cervical cancer in middle- and high-income settings
4. Mammography screening for breast cancer in settings with strong or relatively strong health systems

18

Three steps that must be integrated and provided for early detection

Awareness and accessing care
Clinical evaluation, diagnosis, and staging
Access to treatment

19

T/F Early diagnosis means less morbidity, less expensive treatment, greater probability for surviving, and more likely to respond to effective treatments.

True

Early diagnosis means less morbidity, less expensive treatment, greater probability for surviving, and more likely to respond to effective treatments.

20

T/F

Early screening is not relevant in all setting and the majority of cancers.

False

Early screening is relevant in all setting and the majority of cancers.

21

What is the “See and Treat” approach for screening women,

4 benefits

An alternative which would screening women and simultaneously treating them if they have any abnormality

1. Cheap and easy to operate equipment
2. Specialist surgical skills not required
3. Rare complications
4. Women diagnosed with lesion are not lost to follow-up

22

Approaches to cervical cancer for high income (3)

1. Pap smear for screening requires follow up and requires a skilled healthcare professional who knows how to evaluate results

2. Surgical conistation for treatment that requires hospital admission

3. Mammogram machines- high resource areas

23

Approaches to cervical cancer for low income (2)

1. VIA (visual inspection with acetic acid)- use vinegar to identify normal cell spots→ doesn’t require follow up and treatment can be completed on the same day

2. Loop cryotherapy for treatment- using a rod with liquid nitrogen to get rid of abnormal growths

24

Possible detection and screening protocols best suited for low-resourced setting

In low resource settings, use a “See and Treat” methodology→ screen, diagnose, and treat them at the same time since follow up may not be as feasible

25

Possible detection and screening protocols best suited for well-resourced vs. low-resources

Consider Pap Smear (High) vs. HPV vaccine (high)

VIA method (low resource) vs. contraception + education

26

What are the most important risk factors for cancer in the world

Tobacco
(22% of cancer)

27

Common symptoms for HIV and AIDS

1. Cough
2. Diarrhea
3. Anorexia, Nausea, Vomiting
4. Pruritus - dry skin, drug reactions, scabies, folliculitis
5. Malaise, Weakness, Pyrexia
6. Psychological Distress

28

What are the 4 ways that stigma manifests for people with HIV

1. Physical Stigma - Isolated, shunned, neglected and forced to live apart because of violence

2. Social Stigma - Voyeurism, social death, loss of standing in society

3. Verbal Abuse - Gossip/taunting

4. Institutionalized Stigma - Barred from jobs, scholarships, visas, health care, harassed by police

29

Burden of pediatric HIV now and the historic burden; compare current vs. past burden for kids with HIV

Current Burden: 160K in 2016

Historic Burden: 300K in 2010

Comparison: The burden is decreasing but still 400 children are infected every day due to
90% mother to child transmission, sexual abuse, child marriage, iv drug abuse, transfusions, unsterilized needles

30

Of the children infected with HIV whats the most common way

90% mother to child transmission