The Complexity of Communicable and Non-Communicable Diseases in Vulnerable Populations

Introduction

On a broad spectrum, acute, chronic, communicable and non-communicable diseases may increasingly tend towards undetermined global epidemic proportions. Comorbids or multiple, complex, and syndemic phenomena are characteristics of these untoward events. These may be inextricably linked with gene-environment interactions, physiologic, psychologic, familial, sociocultural, economic and political factors which merge to obfuscate these non-compliant health and sustainable events. Broad interactions influence these conditions, inter alia health impact in conurbations, fetal life, maternal physiology, and the thrifty genotype as well as perception of augmented body mass as in diabetes and obesity intermingled with malaria and typhoid fever [1, 2].

The contemporaneous interactive occurrence of health encomberance, constraints and challenges in transition economies or populations per sociocultural-economic contexts provide for conceptual frameworks in sustainable development and improvement as well as understand risk factors to better design, formulate and implement optimum prevention and intervention strategies to harness co-morbidities in disease presentation. The syndemic concept propounded by medical anthropologists makes provision to prevent, treat and control comorbidities as synergistic health perturbations which contextually impact on the health of populations in the face of persistent social, economic and political inequities or inequalities. It is pertinent to provide research and systems of medical care to the potential beneficial application of syndemic care to patients with interactions in infectious and non-infectious diseases [3].

Reemerging Communicable Diseases

Globally, the complex interplay between infectious and non-communicable diseases including several life changing factors have been increasing persistently and disproportionately, displaying an expansive untoward resultant impact on LMICs [4]. The population of Africa presents inimical and cryptic constraints and challenges with particular reference to the heightened encumbrance of infectious diseases and non-communicable diseases with accelerated progression in the continent [5]. For instance, Ebola and meningitis have combined to enhance the vulnerability of Africa to debilitating infectious diseases which are re-emerging [6]. The first index case of the deadly Ebola virus disease was reported in 2014 in Nigeria as introduced from Liberia by an infected male subject. The disease was initially detected in Sudan, Zaire and other East African countries in 1976, where more than 284 persons were infected, with a mortality rate exceeding 53 percent in Sudan and Zaire alone. Following the next discovery was in 1994 in Cote d’Ivoire insidiously self-infecting a female etiologist performing necropsy on a Tai Forest chimpanzee. The 2014 West African outbreak was the most expansive and deranging and intricately complex Ebola incident since the first report of the 1976 incident. The 2014 outbreak excoriated Guinea, Liberia, Mali, Nigeria, Senegal, and Sierra Leone with gross morbidity and mortality impacts. In 2015 and 2016, Lassa fever was a scourge in several Nigeria States. Nigeria, for instance, has demonstrated strong political will to stem the tide regarding these re-emerging infectious diseases. These diseases are seasonal and Nigeria tends to provide sustainable settings for improved and safer ambient for the population [6].

In addition, cerebrospinal meningitis, a disease producing inflammatory response to the brain and spinal cord linings re-emerged in Sokoto and Zamfara States of Nigeria, and infiltrated over fourteen other States with concomitant disability and death. Nigeria intends to budget an estimated $1.1 billion for vaccination of 22 million persons in five Northern States against meningitis, and for all the 16 States affected as an expenditure of $3.3 billion dollars for vaccination services.

Risk Factors

Infectious or communicable diseases frequently share risks or are in coexistence with non-infectious or non-communicable diseases with increased risk or excruciating consequences of each other and on the Society. These provide the impetus to rationalize the implementation of preventive, management and screening modalities among healthcare providers. Africa has a multifarious climate varying from a broad desert ambient to tropical rain forest which is susceptible to fertile and suitable milieu for a vast majority of disease vectors. Other factors include lack of research funding, ignorance of life history of vectors and accompanying disease life, internecine conflicts, overpopulation in endemic and erstwhile sterile areas, inadequate nutrition and food insecurity result in reduction of the viability of the immune system to fight reemerging infectious diseases. High-income countries have been able to harness or curb the SARS epidemic due to augmented immune system and other attributes [7].

Obesity with cigarette smoking has been evidenced to be detrimental to health and healthcare in high-income countries and obesity levels have accelerated globally in most populations [8, 9]. In 2013, a fifth of global adult population in high-income countries was estimated to have obesity of a body mass index, BMI of approximately 30kg/ m2 [10]. It was reported that both smoking and obesity severally or jointly contribute to low life expectancy differentials of the USA in comparison to European countries and to within country mortality rate disparities using variables, such as socioeconomic status [8, 11-13].

Notwithstanding widespread concerns in health-related risks and behavioural patterns, there is anecdotal information on persons or populations of diverse countries exposed to differential categories of risks. It is perspicuously expressed that to compare mortality and morbidity risks across countries from expressed behaviours may determine how characteristics of health systems and epidemiological features modulate or exacerbate health effects of risk-associated behaviours. These were depicted by means of an evaluation during 1971-2014 in the USA and Finland studying both current and previous cigarette smokers linked with extant and erstwhile obesity using representative samples to elucidate the cross-sectional disparities in mortality risks due to a combination of cigarette consumption and obesity. In 1990, the approximate midpoint of the investigation, the mortality risks from continuous smoking were nearly 55% greater in USA women than in Finnish women but indicated identical observations for male subjects in both countries. Mortality risks due to smoking were significantly elevated for female persons in the two countries with no corresponding increase in risks among male subjects. There was no marked disparity for mortality risks from obesity in both countries, while no remarkable trend was observed in both countries [14]. Although, country study or international comparative analyses may elucidate if health system and cohort behaviour modulate or exacerbate risks in combined smoking with obesity, it is perspicuous that the USA and Finland study did not take in-depth consideration of the expansive pluralistic USA society that contradicts the almost homogenous Finnish clime with the former’s distinct ethnic and racial disparities which are not clearly delineated in the latter which ought to be extrapolated to other contexts, such as elevated level of poverty, diet and nutrition in the USA among indigenous Americans, African Americans, Hispanics or Latinos and other immigrants from low socioeconomic background not supported by a preponderant social security system as obtainable in Finland.

Multifacted risk models are extant which validly predict incident diabetes in specific adult populations [15, 16]. Valid application of these risk models in appropriate clinical settings adequately identified adults at increased risk of diabetes development for better preventive settings. Also, evaluation of diverse adult diabetes risk calculation techniques to predict the development of incident diabetes and pre-diabetes among a bi-racial, young adult population indicated that diabetes risk scores in middle-aged, racially homogenous adult community are can be applied to younger adult populations with good specificity but resultant poor sensitivity. The results suggested greater diabetes risk for blacks for incident diabetes and pre-diabetes in comparison to whites with equivalent risk scores. The inclusion of race did not relate in higher predictive potentials; thus, future research becomes imperative for a more sensitive risk score to predict diabetes in the younger adult populations [17].

Elevated non-communicable comorbidity and multimorbidity were detected in tuberculosis patients predicted by differentials, whereby active tuberculosis was associated with defective immune surveillance and corresponding links with other infectious and non-communicable diseases, such as oncological diseases, alcohol consumption disorders, smoking, chronic lung diseases, cardiovascular disease, diabetes, depression and hypertension. Persons with chronic infectious diseases, such as tuberculosis and HIV/AIDS are more susceptible to comorbidity with non-communicable diseases [18]. Due to the rapid dissemination and exacerbation of chronic communicable and non-communicable diseases, there is extant expansive encumbrance on health and healthcare services.

In almost all human species with their organs and systems, obesity exacerbates morbidity and mortality etiologies due to its predictive multifarious debilitative impacts. Obesity adverts impairments on the immune system via diverse immune mediators with concomitant susceptibility to infections. Most obese people are more vulnerable than non-obese persons or normal persons to acquire and develop a variety of infections, such as nosocomial infections in postoperative infections and other confounding complications [19]. Obesity and diabetes are correlated with elevated odds of mortality due to invasive group A Streptococcus, and IGAS infections after adjusting for age group, gender, race and other underlying variables in comparison, respectively to normal weight and nondiabetic patients [20]. Obesity is strongly linked with elevated risks of type 2 diabetes, cardiovascular disease and other presenting chronic non-communicable disorders. This observation needs to be extrapolated in studies related to reemerging and emerging infectious diseases [6].

Interactions in vulnerable populations Prevalence estimates are well-documented for metabolic disorders for several populations but these are anecdotal in the Alaska population [12]. An investigation aggregated data from three Alaska Native study cohorts to assess disparities in obesity prevalence and connectedness with cardiometabolic risk factors by sex [12]. It was revealed that cardiometabolic risk factors in female subjects were minimally associated with obesity, higher obesity and central adiposity than in male persons; and women presented elevated HDL-C and triglycerides than the men. Relative disposition to increased blood pressure, LDL-C and glucose were observed in men than in women. It is a suggestive instance that obesity prevalence among indigenous peoples in the circumpolar regions of Alaska, Canada and Greenland is a debilitative attribute and of major health challenge and constraint for sustainable living and lifestyle in these vulnerable populations [21, 22].

Latinos are vulnerable to elevated risk for obesity and type 2 diabetes mellitus. Although, there has been a paucity of available literature, it is perspicuous that technology interventions, properly designed and articulated information technology interventions are correlated with efficacious diabetes self-management per Latinos. There are few studies on the most feasible modalities on the discrete and unique sociocultural linguistic attributes which are amenable to the adoption, utilization and benefit among Latinos. Sustainable e-health programmes correlating frequency in communication, bidirectionality or feedback and multimodal delivery of the interventions correlate to the strategy. The utilization of community health workers has consistently improved type 2 diabetes outcomes in Latinos. The inclusion of community health workers in e-health interventions facilitates to dissipate the barriers encountered with the limitations in technology awareness and literacy with the corresponding improvement in patient activation, satisfaction, adherence and compliance. Also, purposeful directed approach or tailoring to fit their needs in these interventions tend to be increasingly beneficial for the improvment of patient activation. It is extremely feasible and important that tailoring is not merely linguistic translation but involves intervention to the Latinos with optimum pertinence to focus on educational language, literacy and acculturization contents contemporaneously with discrete and unique illness beliefs, norms, mores, customs and attitudinal disposition concerning type 2 diabetes in the Latino sociomedical concept and context in the community. Interventions require expansiveness beyond solitary participants via inculcating shared decision-making models of friends, family and other interests in the community [23].

The special patient populations with comorbid presentations require pertinent adjustments in their nutritional needs and care. Since several comorbids correlated with type 2 diabetes mellitus are linked with micro- and macrovascula requelae, it is crucial to extrapolate and to restrict diabetes care to merely glycaemic control but to, also, check for iron deficiency anaemia attributed to malaria [24].

Detection and Diagnosis

There is extant epidemiological disease transition in the African population with rising incidence of non-communicable diseases superimposed on a health system employing community-based modality for mostly cases of acute and chronic communicable diseases. The persistent emerging and reemerging novel pathogenic agents provide latitude for the manifestations of comorbidities due to interactions between communicable and non-communicable diseases [25]. The extant non-infectious and infectious disease intervention settings are susceptable to leverage for non-communicable disease intervention for diagnosis and care of acute and chronic diseases for veritable health and healthcare systems in vulnerable populations. There has been a marked improvement in the life expectancy of HIV patients as a result of augmented access to antiretroviral therapy leading to encumbrance of non-communicable and chronic diseases [26]. It was demonstrated that chronic non-communicable disorders present negative correlations on the kinetics of CD4+ cells count in HIV subjects on antiretroviral therapy. It is suggested that integrated HIV-chronic non-infectious strategies enhance the harnessing or curbing of increasing encumbrance of chronic impairment. Studies have demonstrated relationships between detectable HIV viral load and non-communicable diseases in HIV-infected subjects on antiretroviral drugs in high income ambients, accompanied by elevated risk of comorbidity development but an investigation in South Africa depicted lack of association probably due to under-diagnosis of none: communicable diseases in the country at that particular period [27]. Also, it has been shown in Uganda that the encumbrance of non-communicable diseases among persons having HIV is highly unquantified, and necessitates early diagnosis and treatment of non-communicable diseases [28].

These make it imperative for an integrated HIV and primary care setting towards authentic monitoring and evaluation of non-communicable disorders in HIV-infected subjects [29].

Psychiatric disorders frequently coexist with other non-infectious diseases, and share several risk factors. Thus, mental health, welfare and wellbeing constitute the focus to mitigate the worldwide encumbrance of non-infectious diseases which involve environmental attributes and mental disorders [30]. The five-by-five approach to confront non-communicable diseases, taking into cognizance disease types which tend to comorbid or multimorbid involves cardiovascular diseases, diabetes, oncological or carcinogenic problems, chronic respiratory diseases, mental disorders and other mental derangements. The risk factors tend to cluster together and include tobacco consumption, unhealthy diet, deficient physical activity, prohibitive alcohol consumption, environmental attributes and risk factors [31]. Stringent focus on encompassing risk factors, and integration of treatment and care of mental perturbations and other non-communicable diseases are liable to induce improvement and sustainable progress in confronting these assaults, and ameliorating associated overlapping morbidity

Discussion

The inextricably-linked complex epidemiological, clinical and biological interfaces of non-communicable chronic diseases, such as obesity and diabetes with re-emerging infections have restricted published and researched history. The resultant impact of obesity and diabetes on the immune system, whether jointly or severally, is fulminant and complex effecting incidence and severity of infections. Obesity and diabetes predominate in the pandemic of non-communicable diseases, non-communicable diseases currently exacerbating globally with debilitating impact in low- and middle-income countries, LMICs with special effect in select conurbations [32]. It is perspicuous that there is greater frequency, contraints and challenges to effectively tend to persons with diabetes and/or obesity particularly in the presence of opportunistic organisms.

One major constraint is that a vast majority of the data on the epidemiology of the interface between infectious and non-communicable diseases with socioeconomic factors emerge from developed countries, whereas the population at risk are in LMICs. Adequate prevention of infections in obesity and diabetes constitute a vital objective. Inasmuch as it is well-nigh impossible to determine the encompassing morbidity and mortality, the extant evidence and data are ominous of a combined chronic and acute diseases as an exacerbating public health concern. The resultant premise is that the chronic inflammatory posture of diabetes and obesity results in debilitative immune responses with extant infections. Research, preventive, newfangled therapeutic strategies are required in a global scale, particularly in LMICs where there is vast emergence of the greatest risk coupled with least availability of detection, treatment and control; and especially in extant comorbidity that also involves cardiovascular diseases and hypertension [33]. The adverse sequelae of non-communicable diseases, such as diabetes and obesity may present deranging impacts on the global health and healthcare encumbrance of emerging and reemerging infectious diseases

References