HEALTH & DISEASE

8.8.2 GLOBAL DISTRIBUTION OF DISEASES

KEY OBJECTIVES CONTENT SUGGESTED LEARNING SUGGESTED
CONCEPT Learners should be (ATTITUDES, SKILLS AND ACTIVITIES AND NOTES RESOURCES
able to: KNOWLEDGE)
8.8.2  discuss the global - Malaria  Discussing and - Resource
Global distribution of - Tuberculosis evaluating person
distribution diseases - Ebola epidemiological - Print media
of diseases - HIV/AIDS evidence of diseases. - ICT tools
- Cholera  Visiting clinics. - Braille
- Coronary heart disease software/Jaws
(CHD)
- Sickle cell anaemia

What is Health?
The World Health Organization (WHO) defines health as a state of physical, mental
and social well-being and not merely the absence of disease.
- Someone who is healthy feels good physically and has a positive outlook on life, is
well adjusted in society and is able to undertake the physical and mental tasks they
meet daily without too much difficulty.
- To sustain a healthy lifestyle a person needs:
 A balanced diet
 Take enough fluids e.g. water.
 Take exercise
 Proper shelter
 Enough sleep and rest
 Good choices e.g. choosing not to take drugs.
- Good hygiene will reduce the likelihood of infection.
- Access to medical and dental care ensures that health is monitored and illnesses
treated.

Describe whether health is more than simply the absence of a disease

- complete physical, mental and social being
- linked to happiness/fulfilling life
- having a positive outlook in life
- socially well adjusted
- ability to undertake physical/mental tasks without too much difficulty
- feeling good physically/physical fitness
- need for a balanced diet
- need of regular exercises/lack of exercises likely to suffer certain diseases
- both balanced diet and exercise prevent obesity
- access to medical care

Outline the aspects that contribute towards good health

- good health is complete physical, mental, social well being and absence of
disease
- ref. to balanced diet
- regular exercise/regular physical activity
- which ensure body is in best condition
- to combat disease
- limit drug intake/alcohol intake/smoking
- improving ability to cope with stress/other benefits of exercise
- regular sleep/rest + reasons
What is a disease?

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- Disease is a disorder or malfunction of the mind or body, which leads to a
departure from good health.
- Disease can be:
 Unifactorial; this type is caused single factor such as malaria
 Multifactorial; this is caused by many factors such as heart disease
- Diseases are characterized by signs and symptoms.
- Diseases can be differentiated into:
- Acute disease: Sudden and rapid onset. Symptoms disappear quickly e.g.
influenza.
- Chronic disease: Long term. Symptoms lasting months or years e.g.
Tuberculosis.

Sporadic, Epidemic, Endemic and Pandemic

Sporadic:
A disease is sporadic if it recurs in scattered and irregular or unpredictable
instances e.g. stroke.

Endemic:
A disease can become endemic, if the infectious disease is always present in a
population or found among particular people in a certain area e.g. TB and malaria.

Epidemic:
This occurs when a disease suddenly spreads rapidly to affect many people at
a particular time, such as the spread across a country e.g. influenza

Pandemic:
This is when a disease spreads over a large area, such as a continent or even
worldwide e.g. AIDS and TB

Types of Diseases

The diseases may be broadly classified into two types: Congenital and Acquired.

(1) Congenital Diseases: These are anatomical or physiological abnormalities

present from birth. They may be caused by:
(i) a single gene mutation (e.g. alkaptonuria, phenylketonuria, albinism,
sickle-cell anaemia, haemophilia, colour blindness);
(ii) chromosomal aberrations (e.g. Down’s syndrome, Klinefelter’s
syndrome, Turner’s syndrome); or
(iii) environmental factors (e.g. cleft palate, harelip). Unlike the gene-and
chromosome-induced congenital defects, environmentally caused
abnormalities are not transmitted to the children.
(2) Acquired Diseases: These diseases develop after birth. They are further of
two types: Infectious and Non-infectious.
(a). Infectious (Communicable) Diseases: These diseases are caused by
viruses, rickettsias, bacteria, fungi, protozoans and worms.
(b). Non-infectious (Non-communicable) Diseases: These diseases remain
confined to the person who develops them and do not spread to others. The
non-communicable diseases are of seven kinds:
(i). Degenerative Diseases: These diseases are due to malfunctioning of some
of the important organs and are often associated with ageing, e.g. heart
diseases, epilepsy. Heart diseases result from the abnormal working of some

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part of this vital organ. Epilepsy may result from abnormal pressure on
regions of the brain.
(ii). Deficiency Diseases: These diseases are produced by deficiency of
nutrients, minerals, vitamins, and hormones, e.g., kwashiorkor, beriberi,
goitre, diabetes are just a few from a long list.
(iii). Allergies: These diseases are caused when the body, which has become
hypersensitive to certain foreign substance, comes in contact with that
substance. Hay fever is an allergic disease.
(iv). Cancer: This is caused by uncontrolled growth of certain tissues in the body.
(v). Mental diseases: Any disease that affects a person’s mind due to changes
of the mind possibly with a physical cause e.g. Alzheimer’s, Dementia and
schizophrenia.
(vi). Social disease: caused by Social environment or behaviour (People’s living
conditions and their personal behaviour) e.g. Hypothermia, CHD, lack of
choice of food which leads deficiency diseases.
(vii). Self-inflicted diseases: Caused by damage to a person’s health or body by
their own decisions e.g. attempted suicide; choice to smoke or misusing
drugs; eating high fat diet.

TABLE summarizing the Categories of Disease

Category Cause Description Example
Physical Damage to the These involve temporary or Leprosy, multiple
diseases body permanent damage of the body sclerosis
Infectious Organisms Diseases caused by pathogens and Malaria, cholera,
diseases invading the body can be transmitted from person to tuberculosis
(communicable person or from animal to person.
diseases)
Non-infectious Not pathogens. Any Non-infectious diseases are any Sickle cell anaemia,
diseases (Non- cause other than diseases that are not caused by stroke, diabetes,
communicable invasion by pathogen and can’t be transmitted cancer, heart
diseases) pathogens. from one person to another diseases
Deficiency Poor diet Deficiency diseases results from Scurvy, night
diseases (Unbalanced or missing or short supply of essential blindness, anaemia,
(nutritional inadequate diet) nutrients. rickets, kwashiorkor
diseases) They are classified into:
Vitamin deficiency disease
Mineral deficiency disease
Protein deficiency disease
Inherited Faulty genes These diseases are caused by Haemophilia, cystic
diseases (genetic genes and can therefore be passed fibroses, sickle cell
diseases or only from parent to child. anaemia
genetic disorder)
Degenerative Gradual decline in A gradual decline in function, often Alzheimer’s, Stroke,
diseases function associated with ageing. cancer
Repair mechanisms failing.
Immune system begins to attack
itself.
Mental diseases Changes to the Changes to the mind, possibly with Creutzfeldt-Jakob
mind a physical cause. disease (CJD),
Any disease that affects a person’s Alzheimer’s,
mind. Dementia,
schizophrenia,
Social disease Social environment How a person’s life affects their Hypothermia, CHD,
or behaviour health, exposing or protecting them lack of choice of food
(People’s living from certain diseases which leads deficiency
conditions and their diseases

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personal
behaviour)
Self-inflicted Self or person’s Wilful damage to a person’s body Attempted suicide;
diseases own decisions and by their own decisions or actions Choice to smoke or
behaviour misusing drugs;
eating high fat diet

Using named examples for each, explain what is meant by degenerative and
inherited disease

Degenerative
- gradual decline in body functions
- associated with characteristics of ageing
- caused by deficiencies of nutrients during childhood
- e.g. skeletal diseases/cardiovascular/cancers/Huntington‘s disease
Inherited
- an inherited genetic fault
- mutation
- ref to mechanism of mutation
- pattern of inheritance
- e.g. cancer, PKU, cystic fibrosis

EPIDEMIOLOGY AND PATTERNS OF DISEASE DISTRIBUTION

- Epidemiology is the study of patterns of disease and the various factors that affect
the spread/distribution of the disease.
- Epidemiology is the study of the occurrence, distribution, and control of diseases
in populations.
- Data collected on disease (morbidity) and death (mortality) reveal patterns that can
indicate how diseases are spread and their likely cause or causes.
- Three types of data provide information on the spread of diseases - incidence,
prevalence and mortality.
- Incidence refers to the number of new cases per time period.
- Prevalence refers to the number of people in a population with the disease.
- Mortality the amount of people who have died from the disease, respectively.

Uses of epidemiology

- Epidemiology can be used by a variety of people for many things. One of its most
important uses is by governments to increase funding for research into rising
causes of death, such as AIDS was in the 1980s. It can also show differences
between economic levels of separate countries, or promote mass screening to
prevent disease before they start, such as cervical cancer.

GLOBAL PATTERNS OF DISEASES

- The global distribution of diseases often reflects the standards of medical care
and affluence in different countries.
- Infectious diseases are less common in developed countries as compared to third
world (developing) countries. This is as a result of developed countries having
better health care, including vaccination and treatment against serious infectious
diseases such as measles, polio, Tuberculosis (TB) and malaria.
- Most deaths in developed countries are due to chronic degenerative diseases
which are social and self-inflicted in nature e.g. CHD and cancer.

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- In developed countries, disease such as CHD and cancer are much more common
than in third world countries.
- The greater proportion of deaths in third world countries occur as a result of
infectious diseases because due to poverty these countries have poor health
care delivery systems.

MALARIA
Malaria has been for thousands of years a very serious disease of the tropical and
temperate regions.

(a) Symptoms:

- The attack of malaria is preceded by yawning, tiredness, headache and

muscular pain. During the fever, the patient feels chilly and shivers, and has
acute headache, nausea and high temperature. After a few hours, the body
perspires freely and the temperature becomes normal.
- The cycle is repeated if no medicine is taken.
- Blood smear made during fever shows the malarial parasites. No parasites
are seen at other times.
- In chronic cases, there is general weakness and anaemia (paleness) due to
large-scale destruction of red blood corpuscles. This is also accompanied by
enlargement of spleen and liver.

(b) Cause: Malaria is caused by the toxins produced in the human body by the
malarial parasite, Plasmodium.

(c) Transmission: The malarial parasites are carried from the infected to the healthy
persons by the female Anopheles mosquito. The mosquito picks up the parasites
with the blood, when it bites an infected person. When this infected mosquito bites a
healthy person, parasites migrate into his blood with the saliva, which the mosquito
injects before sucking up blood to prevent its clotting.

(d) Types: There are four species of Plasmodium, which cause different kinds of
human malaria:

(1) Plasmodium vivax: It causes benign tertian malaria, which attacks every third
day, i.e., after 48 hours. The fever is mild and seldom fatal. This species is wide-
spread in the tropical and temperate regions.

(2) Plasmodium ovale: It also causes benign tertian malaria, which recurs every 48
hours. This species is found only in West Africa and South America.

(3) Plasmodium malariae: It causes quartan malaria, which recurs every fourth day,
i.e., after 72 hours. This species is found in both tropical and temperate regions, but
it is not very common.

(4) Plasmodium falciparum: It alone is capable of causing three types of malaria, viz.,
quotidian malaria, which attacks almost daily, malignant tertian malaria, which occurs
every 48 hours, but is very severe and often fatal; and irregular malaria. This species
is found only in the tropical region.

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(e) Incubation Period: The incubation period for malaria caused by Plasmodium
vivax is about 10 days.

(f) Life-history: Plasmodium completes its life cycle in two phases and two hosts:
asexual phase in the human host and sexual phase in the female Anopheles
mosquito host.

Table 3: Features of Malaria

Plasmodium
Pathogen (Causative agent)
(P. vivax, P. ovale, P. falciparum, P. malariae).
Transmission method Insect vector: Female Anopheles mosquito.
Incubation 1 week - 1 year.
Site of action of pathogen Liver, red blood cells, brain.
Fever, nausea, headaches, shivering, muscle pain,
Signs and symptoms
sweating, spleen enlargement.
Method of diagnosis Microscopical examination of blood.
Global distribution Throughout the tropics (endemic in 91 countries).
Annual incidence worldwide 500 million. (90% of cases are in Africa).
2.7 million. (In tropical Africa malaria kills 1 million
Annual mortality worldwide
children under the age of 5).

Control

Basically there are 3 main ways of controlling the vector, and thus of controlling
malaria;

1. Avoid being bitten by mosquitoes, either by using insect repellent or mosquito

nets.
2. Reduce the number of mosquitoes, by:

- destroying their breeding grounds, chemically (using a chemical that kills

mosquito larvae) or physically (draining the water areas).
- spreading oil on the ponds or swamps which prevents the larvae or pupa to
breath, and eventually die.
- draining swamps which serve as breeding sites for mosquitoes.
- Introducing fish (Gambusia) into ponds that feed on mosquito larvae and pupae.

3. Use drugs to prevent Plasmodium affecting people.

- Anti-malarial drugs such as chloroquine and quinine are used to treat infected
people.
- Prophylactic (preventive) drugs are taken by healthy people to stop infection
occurring if they are bitten by infected mosquitoes. They are taken before, during
and after visiting an area where malaria is endemic.

Malaria Eradication Program

World Health Organisation (WHO) launched the worldwide malaria eradication

program in 1955 which employed the following methods:
1. Draining stagnant water to deprive mosquitoes of breeding sites.

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2. Destroying the breeding stages of mosquitoes e.g. by spreading oil on
water to block breathing tubes of mosquito larvae and pupae so that they
suffocate and die due to shortage of oxygen.
3. Destroying adult mosquitoes using insecticides.
4. Use of anti-malarial drugs and prophylactics to kill plasmodium in
humans.
 Although the malaria eradication program was expensive and required much effort,
it was successfully used eradicate malaria in Chile, Europe, parts of Asia and North
America.
 However in places like Africa there were many factors which worked against the
eradication of malaria as outlined below.

Failures of the Malaria Eradication Program

Describe factors which worked against the eradication of malaria.

1. Many of the drugs used to treat it are now not working because malaria has
built up a resistance
2. Mosquitoes have become resistant to pesticides used to kill them.
3. Insecticides such as DDT and dieldrin which were once used successfully to
kill mosquitoes were banned because of their bioaccumulation along food
chains which affected tertiary consumers.
4. When the disease was temporarily eradicated, people who had immunity lost
it and when the disease returned (as the program was not successful) they
suffered and some died as a result.
5. There is a large reservoir of malaria in other animals such as monkeys,
reptiles, birds and rodents which makes it difficult to eradicate the disease.
6. National borders are not barriers to mosquitoes and malaria can travel widely
and rapidly.
7. It is difficult to maintain malaria preventive programs in countries with war
zones due to political instability and financial constraints in those countries.
8. Migration of people into new areas can result in rapid infection of people who
were not previously exposed to malaria.

As a result of all these problems in trying to eradicate malaria, in 1969 WHO gave up
the aim of trying to eradicate it and instead settled for a control policy.

GLOBAL/GEOGRAPHIC DISTRIBUTION OF MALARIA

Malaria is widespread in the tropical and subtropical regions which include much
of Sub-Saharan Africa, Asia, and Latin America.

Malaria is prevalent in tropical and subtropical regions because of climatic

factors such high rainfall, consistent high temperatures and high humidity,
along with stagnant waters where mosquito larvae readily mature, providing them
with the environment they need for continuous breeding. Distribution of malaria is
also influenced by altitude, malaria being common at low altitudes.

1. High temperatures favour the development of both the anopheles mosquito

and Plasmodium.

The high temperatures in the tropics allow faster development of Plasmodium to

occur in the mosquitoes. High temperatures in the tropics allow quicker

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development of the mosquito larvae and so mosquito population increases as the
temperature rises.

2. Malaria is common at low altitudes because temperatures are higher and

allow faster development of both the plasmodium and mosquito larvae. At
higher altitudes temperatures are low and not conducive for the breeding of
mosquitoes.

3. High rainfall provides stagnant water collections where mosquitoes breed

in.

Stagnant water collections that support mosquito breeding appear mainly after the
rains, and therefore malaria transmission is highest following the rainy season.

MAP: Global distribution of malaria

Malaria is found in parts of the world where the Anopheles mosquito species that can
act as vectors are found. This is mostly in tropical and subtropical regions where
humidity is high, particularly Sub-Saharan Africa, Asia and Latin America

SICKLE CELL ANAEMIA

Sickle cell anaemia is a congenital form of anaemia occurring mostly in blacks,
characterized by abnormal blood cells having a sickle shape (crescent shape).
Sickle-cell anaemia is particularly common among people whose ancestors come
from sub-Saharan Africa, India, Saudi Arabia and Mediterranean countries.

WHAT CAUSES SICKLE CELL ANAEMIA?

- Sickle cell anaemia is caused by a gene mutation affecting haemoglobin of red

blood cells.
- Haemoglobin is the pigment in red blood cells that carries oxygen around the
body.

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- Haemoglobin is made up of 4 polypeptide chains, each one with an iron-
containing haem group at the centre. Two of these chains are called α chains
and the other two are called β chains.
- The gene that codes for the amino acid sequence of the β chains mutates at
one base pair (Figure 6.17).
- The result of this change is that the base adenine (A) is replaced by thymine
(T) at one position along the coding strand.
- The messenger RNA produced from this DNA contains the triplet code GUG in
place of GAG. This causes the amino acid valine (a non-polar amino acid) to
appear at that point, instead of polar glutamic acid.
- The presence of non-polar valine in the β chain of haemoglobin gives a
hydrophobic spot in the otherwise hydrophilic outer section of the protein. This
tends to attract other haemoglobin molecules to bind to it.
- The haemoglobin molecules stick to each other and form fibres inside the red
blood cells. This makes the red blood cell change into a sickle shape and so they
become very inefficient at transporting oxygen. They become rigid and thus
get stuck in capillaries, blocking them and preventing the circulation of
normal red blood cells. The result is that people with sickle cell anaemia suffer
from anaemia (inadequate delivery of oxygen to cells).This may lead to the
death of the affected person.

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Symptoms of sickle cell anaemia

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 Sickle cell crisis (sudden episode of pain in the body)
 Acute chest syndrome, due to blocked blood vessel in lungs or lung infection
 Swollen hands and feet
 Anaemia
 Jaundice, which is the yellowing of the skin and whites of the eyes
 Kidney problems
 Spleen problems
 Gall bladder disease
 Painful, prolonged erections in men
 Bone and joint problems
 Serious infections
 Leg sores
 High blood pressure in the lungs
 Heart failure
 Eye disease
 Strokes

How is sickle cell disease inherited?

- There are two alleles of the gene important for the inheritance of sickle cell
anaemia: HbA and HbS which can be simply written as A and S.
- The allele HbA (or simply A) is for the normal haemoglobin. The allele Hb S (or
simply S) is for abnormal haemoglobin.
- Homozygous A individuals (HbA HbA) or (AA) have normal haemoglobin, and
therefore normal disc shaped red blood cells.
- Homozygous S individuals (HbS HbS) or (SS) develop sickle cell anaemia and
all their red blood cells are sickle shaped (abnormal).
- Those who are heterozygous for the sickle cell allele (HbA HbS) or (AS) produce
both normal and abnormal haemoglobin.
- Heterozygous (HbA HbS) or (AS) individuals are carriers of the sickle cell gene
and are said to have ‘sickle cell trait’.
- Heterozygous (AS) individuals are usually healthy, but they may suffer some
symptoms of sickle cell anaemia under conditions of low blood oxygen, such as
at high altitudes or during exercise.

Describe what happens to a sickle cell carrier (someone with the sickle cell
trait) when he undertakes sudden physical exercise or moves to a high
altitude.

When a person who is a sickle cell ‘carrier’ undertakes sudden physical exercise (or
moves to a high altitude) the oxygen content of the blood is lowered. In these
conditions the sickle cell haemoglobin molecules readily clump together into long
fibres. These fibres distort the red blood cells into sickle shapes. In this condition the
red blood cells cannot transport oxygen. Also, sickle cells get stuck together,
blocking smaller capillaries and preventing the circulation of normal red blood cells.
The result is that people with sickle cell trait suffer from anaemia – a condition of
inadequate delivery of oxygen to cells.
The effect of the sickle cell trait on death from malaria
- The malarial parasite Plasmodium completes its life cycle in red blood cells but it
cannot do so in sickle red blood cells containing haemoglobin-S (HbS). People
with sickle cell trait are heterozygous for the sickle cell allele (Hb A HbS). They

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are carriers of the sickle cell allele (HbS). They are resistant to malaria and do
not die from malaria.
- When malarial parasites invade the bloodstream of a person with the S allele
(HbS), the red blood cells that contain defective haemoglobin become sickled and
die, trapping the parasites inside them and reducing infection.

Explain how the S allele gives a survival advantage where malaria is endemic,
to people who are heterozygotes compared with homozygotes.

Compared to AS heterozygotes, people with the AA genotype (normal haemoglobin)

have a greater risk of dying from malaria. AA homozygotes who die young may not
pass on their genes to the next generation. Individuals with the AS genotype do not
develop sickle cell anaemia and also are resistant to malaria. They are able to
survive and reproduce in malaria-infected regions. AS heterozygotes pass on A and
S alleles to the next generation, so both the A and S alleles of these people remain
in the population. SS homozygotes have sickle cell anaemia, which usually results in
early death. S alleles are removed from the population’s ‘gene pool’ when SS people
die. In a region where malaria is common, the S allele gives a survival advantage to
AS heterozygotes (people who have one copy of the allele), and the otherwise
harmful S allele is kept in the population at a relatively high frequency.

GLOBAL DISTRIBUTION OF SICKLE CELL ANAEMIA

Sickle-cell anaemia is particularly common among people whose ancestors come
from sub-Saharan Africa, India, Saudi Arabia and Mediterranean countries.
Migration raised the frequency of the gene in the American continent.

Sickle cell anaemia is most common in tropical regions of the world because
carriers (who have sickle cell trait) are strongly protected from malaria – a fact
that has led to a selective advantage through their increased survival. The global
distribution of the disease itself is centred in the tropics. Approximately half of those
affected are born in just three countries: Nigeria, the Democratic Republic of Congo
and India, the vast majority of the remainder being born in West, Central and Eastern
Africa.

Over 300,000 children are born with the condition every year, most in resource
limited settings in Africa and India, where between 50-90% continue to die, most
undiagnosed, before they reach their fifth birthday. This is despite the fact that in
resource rich countries, the majority of those born with SCD today can expect to lead
a reasonable quality of life into late adulthood, largely on the basis of a handful of
reasonably cheap and easily affordable interventions.

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- People with sickle trait (HbA HbS) do not die from malaria. Therefore, where
malaria is endemic in Africa, possession of one mutant allele is advantageous. As
a result, people with sickle cell trait survive to pass on this allele to the next
generation. Therefore over many generations, the S allele becomes more common
in the population where malaria is endemic.

TRY THESE QUESTIONS

1 The diagram shows the alleles of parents and offspring where one of the parents is
a carrier for sickle cell anaemia.

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Draw a similar diagram where one parent is unaffected and the other is homozygous
for the sickle cell allele i.e. SS.
What proportion of the offspring from the second cross
(a) are unaffected
(b) have sickle cell trait (carriers)
(c) have sickle cell anaemia?

2 Use the information in the text to complete the table below:

Genetic make-up Characteristic of Likely outcome Likely outcome
of individual individual with no malarial with malarial
infection infection

AA dies young

AS Sickle cell trait survives

SS

3 Explain why the frequency of sickle cell allele is so much lower in Northern Europe
than in Africa.
ANSWERS
1

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(a) None
(b) 100% /all of them
(c) None

2.
Genetic make-up Characteristic of Likely outcome Likely outcome
of individual individual with no malarial with malarial
infection infection

AA Unaffected Survives Dies young

AS Sickle cell trait Survives Survives

SS Sickle cell disease Dies young Dies young

3 The sickle cell allele only becomes common in areas where it gives an advantage
to people carrying the allele.

In countries, such as Africa where there is malaria, carriers of the sickle cell allele
(AS) are less likely to die of malaria than unaffected people (AA). The A allele
becomes less common as AA people die young of malaria, and the S allele becomes
more common because heterozygotes (AS) survive. In Northern Europe, the S allele
gives no advantage, so remains rare.

ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS):

Acquired Immune Deficiency Syndrome (AIDS) is a syndrome caused by the
retrovirus Human Immunodeficiency Virus (HIV).

AIDS was first noticed in USA in 1981. It is a disorder of cell-mediated immune

system of the body. There is a reduction in the number of helper T-cells which
stimulate antibody production by B-cells.
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This results in the loss of natural defence against viral infection. It is caused by a
virus named HIV (Human Immunodeficiency Virus). The virus was discovered in
1984 by American and French scientists independently.

HIV

HIV pathogens infect and destroy the T helper cells of the immune system, and
without these the immune system does not respond adequately to infection.

When T-Cell numbers are low, the body is particularly vulnerable to infection by
anything from the common cold to tuberculosis. Thus, AIDS is not a disease; HIV is
the virus that causes AIDS which is a syndrome. It affects the CD4 receptor cells.

AIDS, however, is primarily a sexually transmitted disease. Semen can contain the
virus, but more likely an infected lymphocyte does.

Table 4: Features of HIV/AIDS

Pathogen Human immunodeficiency virus (HIV)
Exchange of body fluids (sexual intercourse,
Transmission method
intravenous needle sharing, blood transfusions)
HIV has a few weeks, but AIDs may not develop
Incubation
for up to ten years
HIV - fever and then none AIDs - hugely increased
Symptoms susceptibility to disease, such as pneumonia and
TB.
Annual infected/new incidence/
33.4 million/6 million/2.5 million
mortality worldwide

Symptoms of AIDS: An HIV infection can be divided into 3 stages.

(1) Asymptomatic Carrier:

Only 1%-2% of those newly infected have mononucleosis-like symptoms that may
include fever, chills, aches, swollen lymph glands, and an itchy rash. These
symptoms disappear, and there are no other symptoms for 9 months or longer.

(2) AIDS Related Complex (ARC): The most common symptom of ARC is swollen
lymph glands in the neck, armpits, or groin that persist for 3 months or more.

(3) Full-Blown AIDS: In this final stage, there is severe weight loss and weakness
due to persistent diarrhoea and usually one of several opportunistic infections is
present.

(4) Treatment of AIDS: HIV and subsequently AIDS cannot be cured, but the
spread of AIDs can be slowed down with a variety of drugs, providing an increased
life expectancy. This results in a virus that is difficult control, and is thus best
prevented. People can be educated to use condoms and other means of reducing
the risk of infection during intercourse.

The drug zidovudine (also called azidothymidine, or AZT) and dideoxyinosine (DDI)
prevent HIV reproduction in cells. Proteases are enzymes HIV needs to bud from the

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host cell; researchers are hopeful that a protease inhibitor drug will soon be
available.

A number of different types of vaccines are in, or are expected to be in, human trials.
Several of these are sub unit vaccines that utilize genetically engineered proteins
that resemble those found in HIV. For example, HIV-1, the cause of most AIDS
cases has an outer envelope molecule called GP 120. When GP 120 combines with
a CD4 molecule that project from a helper T lymphocyte, the virus enters the cell.
There are sub unit vaccines that make use of GP 120. An entirely different approach
is being taken by Jonas Salk, who developed the polio vaccine. His vaccine utilizes
whole HIV-1 killed by treatment with chemicals and radiation. So far, this vaccine has
been found to be effective against experimental HIV-1 infection in chimpanzees, and
clinical trials will occur soon.

AIDS Prevention: Shaking hands, hugging, social kissing, coughing or sneezing

and swimming in the same pool do not transmit the AIDS virus. You cannot get AIDS
from inanimate objects such as toilets, doorknobs, telephones, office machines, or
household furniture.

HIV has been isolated from semen, cervical secretions, lymphocytes, plasma,
cerebrospinal fluid, tears, saliva, urine and breast milk. The secretions known to be
especially infectious are semen, cervical secretions, blood and blood products.

Infection is spread:

(a) By sexual intercourse, vaginal and anal

(b) By infected blood, blood products, donated semen and organs

(c) By contaminated needles used:

      (1) During the treatment of patients

      (2) When drug abusers share needles

(d) From an infected mother to her child:

      (1) Across the placenta before birth

      (2) While the baby is passing through the birth canal

      (3) Possibly by breast milk

The following behaviour will help prevent the spread of AIDS:

(1) Do not use alcohol or drugs in a way that prevents you from being in control of
your behaviour. Especially, do not inject drugs into veins, but if you are an
intravenous drug user and cannot stop your behaviour, always use a sterile needle
for injection or one cleansed by bleach.

(2) Refrain from multiple sex partners, especially with homosexual or bisexual men
or intravenous drug users of either sex. Either abstain from sexual intercourse or

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develop a long-term monogamous (always the same partner) sexual relationship
with a partner who is free of HIV and is not an intravenous drug user.

(3) If you are uncertain about your partner, always use a latex condom. Follow the
directions, and also use a spermicide containing nonoxynol-9, which kills viruses and
virus-infected lymphocytes. The risk of contracting AIDS is greater in persons who
already have a sexually transmitted disease.

Diagnosis: Once the host is infected by HIV. HIV detected by the ELISA Test.
(Enzyme–linked immunosorbent assay) a positive Elisa test should be confirmed
using another test called the western blot test.

Statistics

 5.9 million children are estimated to have been orphaned by AIDs

 25% of Zimbabwe is infected with HIV
 34 million people are infected with HIV in sub-Saharan Africa.

Transmission and testing

Transmission is spread by intimate human contact and HIV cannot survive outside
the body - transmission is only possible by direct bodily fluid exchange, most
commonly during sexual intercourse, across the placenta and intravenous needle
sharing. Testing is done via a blood test, but this only becomes available several
days after the initial infection. This testing is offered to those who think they might
have HIV, and they are often asked to contact sexual partners and inform them that
they should get tested, as HIV caught early can be slowed down.

Pregnant women

HIV positive women in countries like the UK are advised to not breastfeed their
children, since HIV can be transmitted this way as well since viral particles have
been found in breast milk.

HIV positive women should take antiretroviral drugs (nevirapine) before delivery to
reduce the chances of mother to child infection during birth.

GLOBAL DISTRIBUTION OF HIV/AIDS

Explain the possible reasons for the global distribution of HIV/AIDS

- is a pandemic disease (globally distributed)
- an epidemic (always present)
- most prevalent in developing countries
- linked to TB
- some of the TB strains becoming more resistant
- AIDS pandemic
- partial treatment due to inability to purchase ARVs
- poor medical facilities
- Highly confined in sub-Saharan Africa
- Rates of infection are lower in other parts of the world, but different subtypes
of the virus have spread to Europe, India, South and Southeast Asia, Latin
America, and the Caribbean. Rates of infection have levelled off somewhat in
the United States and Europe.
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- In Asia the sharpest increases in HIV infections are found in China, Indonesia,
and Vietnam.
- Both the cost of these therapies and the poor health care delivery systems in
many affected countries need to be addressed before antiretrovirals can
benefit the majority of people living with HIV/AIDS.
- Botswana, with the highest rate of infection, has experienced stable,
democratic government and a strong economy since independence in 1966.
- Mozambique, with the lowest rate of infection, experienced sixteen years of
devastating civil war from which it only emerged in 1992.
- While South Africa and Botswana are the two richest countries in Sub-
Saharan Africa (as measured in per capita gross domestic product),
- They include poverty and economic marginalization, poor nutrition,
opportunistic infection, migration, sexual networking and patterns of sexual
contact, armed conflict, and gender inequality. Some of these will be
discussed in more detail below.
- HIV/AIDS, like all communicable diseases, is linked to poverty. The
relationship is bi-directional in that poverty is a key factor in transmission and
HIV/AIDS can impoverish people in such a way as to intensify the epidemic
itself.
- Poverty does seem to be a crucial factor in the spread of HIV/AIDS. It should
be emphasised that poor people infected with HIV are considerably more
likely to become sick and die faster than the non-poor since they are likely to
be malnourished, in poor health, and lacking in health attention and
medications.
- In effect, all factors, which predispose people to HIV infection, are aggravated
by poverty, which ―creates an environment of risk‖.
- Deep-rooted structural poverty, arising from such things as gender imbalance,
land ownership inequality, ethnic and geographical isolation, and lack of
access to services.
- Developmental poverty, created by unregulated socio-economic and
demographic changes such as rapid population growth, environmental
degradation, rural-urban migration, community dislocation, slums and
marginal agriculture.
- Poverty created by war, civil unrest, social disruption and refugees. High
levels of rape and the breakdown of traditional sexual mores are associated
with military destabilisation, refugee crisis and civil war (Walker, 2002: 7).
- closely associated with patterns of human mobility
- Large-scale economic migration has been a feature particularly of the
southern African region
- Massive migration of young, unmarried adults from presumably conservative ‖
rural environments to more sexually permissive African cities in recent years
has been regarded as partly responsible for the much higher infection levels
observed in urban than in rural areas.
Values of Procreation:
- In Africa fertility is seen as demonstrating the masculinity and manliness of
men, as well as proving the significance of women as good wives. Because
procreation is highly valued in African society, both men and women are
refusing to use condoms.
- Even though condoms are successful in preventing the spread of AIDS, they
also prevent reproduction.
- Thus, many individuals are willing to risk contracting AIDS and have
unprotected sex because fertility is so important to social status.

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Myths:
- Myths influence the spread of HIV/AIDS in many ways.
- One strong belief held by a number of Africans is that the West wants to control
the population growth of Africa, and that the West is trying to do this by convincing
Africans to use condoms.
- The West is encouraging African nations to use condoms as protection against
AIDS, but many Africans believe that this is just a ploy to curb reproduction rates.
- Many Christians in Africa believe that God is using AIDS as a weapon to punish
sinners. Since AIDS is often associated with promiscuity, many followers believe
that God will protect the innocent spouse from contracting AIDS, but use AIDS to
punish the spouse that was involved in sexual practices outside of her/his
marriage.
- Two other popular myths are that some Africans believe that regular infusions of
sperm is required if a woman is to grow up to be beautiful, and that sleeping with a
virgin will rid an infected person from the disease.

CHOLERA
As Cholera is a water-borne disease, it occurs where people do not have access to
proper sanitation, a clean water supply or uncontaminated food. The bacteria pass
through the stomach (if the contents are sufficiently acidic (less than PH4.5) the
bacteria is unlikely to survive) and reach the small intestine. Here they multiply and
release a toxin know as choleragen, which disrupts the epithelium functions so that
salts and water leave the blood.

This causes severe diarrhoea which leads to dehydration, and can be fatal within
24 hours. Fortunately, treatment for cholera is relatively simple; the disease can be
controlled by giving a solution of salts and glucose intravenously to rehydrate the
body (Oral Rehydration Therapy). There is a vaccine available for some strains of
cholera, but it only provides short-term protection.

Strains

There are more than 60 different strains of the pathogen that causes cholera, and
there have been 8 pandemics of cholera, mostly caused by untreated sewage
water.

Table 1: Features of Cholera

Pathogen Vibrio cholerae
Method of transmission Food borne, water borne
Global distribution Asia, Africa, Latin America
Incubation period 2 hours to 5 days
Site of infection Walls of small intestine
Clinical features (signs and Severe diarrhoea, loss of water and salt, dehydration
symptoms) and weakness
Method of diagnosis Microscopical analysis of faeces
Control Drinking water should be chlorinated or boiled, ORS
or salt-sugar solution
Maintaining good hygiene in food preparation
Annual incidence/mortality
5.5 million/ 120,000
worldwide

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GLOBAL DISTRIBUTION OF CHOLERA

- Cholera is endemic in many parts of Africa, India, Pakistan, Bangladesh, and

Central and South America.
- The pathogen that causes cholera is a bacterium called Vibrio cholerae.
- Because of poor sanitation and poor disposal of human faeces or sewage in
these developing countries, Vibrio cholerae is transmitted easily.
- This pathogen is typically acquired from drinking water that has become heavily
contaminated by the faeces of patients (or from human ‘carriers’ of the pathogen).
Alternatively, it may be picked up from food contaminated by flies that previously
fed on human faeces. The consumption of raw shellfish taken from waters polluted
with untreated sewage is another common source.

TUBERCULOSIS (TB)

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Pathogen (causative agent): Bacterium [Mycobacterium tuberculosis (M.
Tuberculosis) and Mycobacterium bovis (M. Bovis)]

Transmission: It spreads via droplet infection and unpasteurised milk and is

particularly prevalent in overcrowded areas.

 Air borne droplets: Patient breathes out droplets during coughing which is
inhaled by an uninfected person.
 Drinking infected and untreated milk
Signs and symptoms:
Racking cough, coughing blood, chest pain, shortness of breath, fever, sweating,
weight loss.

Prevention of spread:
 Vaccination programmes or provide BCG vaccine
 Use of early detection methods or screening techniques, like mass X – rays
and Mantoux skin test
 Pasteurisation of milk (treatment of Cattle)
 Screening / treatment of dairy herds
 Use of multiple antibiotics, including streptomycin, to reduce the risk of
cross infection
 Isolation of patients
 Improved living conditions – less overcrowded housing
 Improved diet
 Better health education about how the disease spreads
 Use handkerchief
 No spitting
Why is it on the rise?
 People are less careful about obtaining vaccination
 Antibiotic resistant forms of tuberculosis bacteria emerge.
 Immigration of infected people into the area.
 AIDS and Opportunistic infection by Mycobacterium Tuberculosis
 Breakdown of social conditions, due to wars
 Rapid travel makes spreading the infection much easier
Treatment :
 Good diet
 Rest / no stress
 Use of antibiotics, like streptomycin to reduce the risk of cross infection
 Isolation of patients
Why early detection is important?
 To prevent major lung damage
 To prevent infection from spreading to other body parts
Why might it become an epidemic?
 It spreads rapidly directly from person to person through the air
 It becomes drug resistant
 No vector / intermediate host are needed
 No special conditions are needed

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Resistance

Tuberculosis is unfortunately showing a comeback, and this is thought to be due to a

variety of factors.

These include;

 Breakdown in the tuberculosis vaccination and control program

 Poor housing causing overcrowding
 The AIDs epidemic weakening immune systems and allowing it to be more
prevalent
 Some strains are now resistant to antibiotics

The last bullet point, about resistance, is particularly important. When antibiotics
attack bacteria, any that are resistant to them survive, and thus multiply and possibly
create a new strain of tuberculosis that is antibiotic resistant.

Table 2: Features of Tuberculosis

Pathogen Mycobacterium tuberculosis (M. Tuberculosis)and
mycobacterium bovis (M. Bovis)
Method of transmission Airborne (M. Tuberculosis), via undercooked meat and un-
pasteurized milk from cattle (M. Bovis)
Incubation period Few weeks or months or a year
Site of infection Primary infection in lungs, secondary infection in lymph
nodes, bones and gut
Symptoms/Clinical Racking cough, coughing blood, chest pain, shortness of
features breath, fever, sweating, weight loss
Method of diagnosis Microscopical examination of sputum to check the
presence of the bacteria, Chest X-ray
Treatment and control Avoid close contact with infected people, milk must be
pasteurized, TB in cattle must be eradicated and patients
must be treated ; spitting in public places must be banned;
antibiotics are administered as treatment
Annual
incidence/mortality 8 million/2 million
worldwide

GLOBAL DISTRIBUTION OF TB

TB is found in all countries of the world, including developed countries such as the
USA and the United Kingdom. However, it is most common in areas where living
conditions are poor and people are crowded, or where large numbers of people have
HIV/AIDS.

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Explain the possible reasons for the global distribution of TB

- it is a pandemic disease (globally distributed)
- it is an endemic disease (always present)
- most prevalent in developing countries
- some of the TB strains becoming more resistant
- AIDS pandemic. AIDS weakens the immune system allowing TB to be more
prevalent.
- poor housing
- overcrowding
- breakdown of TB control programme
- partial treatment of TB
- poor sanitation
- poor medical facilities
- TB spread in meat and milk
- high rate of transmission - droplet infection

EBOLA
Ebola a.k.a. Ebola Virus Disease (EVD) is a rare and deadly disease most
commonly affecting people and nonhuman primates (monkeys, gorillas, and
chimpanzees).

Pathogen (causative agent)

It is caused by an infection with a group of viruses within the genus Ebolavirus:

 Ebola virus (species Zaire ebolavirus)

 Sudan virus (species Sudan ebolavirus)
 Taï Forest virus (species Taï Forest ebolavirus, formerly Côte d’Ivoire
ebolavirus)
 Bundibugyo virus (species Bundibugyo ebolavirus)
 Reston virus (species Reston ebolavirus)

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 Bombali virus (species Bombali ebolavirus)

Of these, only four (Ebola, Sudan, Taï Forest, and Bundibugyo viruses) are known to
cause disease in humans. Reston virus is known to cause disease in nonhuman
primates and pigs, but not in people. It is unknown if Bombali virus, which was
recently identified in bats, causes disease in either animals or people.

Ebola virus was first discovered in 1976 near the Ebola River in what is now the
Democratic Republic of Congo. Since then, the virus has been infecting people from
time to time, leading to outbreaks in several African countries.

TRANSMISSION. How Ebola virus is spread:

Transmission of Ebola from animals to humans

 Ebola is considered a zoonosis or zoonotic disease, meaning that it

originated in animals and then spread to humans.
 People are initially infected with Ebola virus through contact with an infected
animal, such as a fruit bat or nonhuman primate. This is called a spill over event.
After that, the virus spreads from person to person, potentially affecting a large
number of people

Transmission of Ebola from animals to humans can occur through:

 Handling infected animals found ill or dead, including chimpanzees, gorillas,

fruit bats, monkeys, forest antelope, and porcupines.
 Direct contact with the blood, body fluids, and tissues of infected animals
or people.
 Handling and eating bush meat i.e. meat from infected wild animals.
 There is also no evidence that mosquitoes or other insects can transmit Ebola
virus.

Transmission of Ebola between humans

Person-to-person transmission occurs after someone infected with Ebolavirus

becomes symptomatic. As it can take between 2 and 21 days for symptoms to
develop, a person with Ebola may have been in contact with hundreds of people,
which is why an outbreak can be hard to control and may spread rapidly.

Transmission of Ebola between humans can occur through:

 Direct contact through broken skin and mucous membranes with the blood,
secretions, organs, or other body fluids of infected or dead people (urine,
saliva, sweat, faeces, vomit, breast milk, and semen).
 People can get the virus through sexual contact as well.
 Indirect contact with environments contaminated with such fluids.
 Exposure to contaminated objects, such as needles.
 Burial ceremonies in which mourners have direct contact with the body of
the deceased.
 Exposure to the semen of people with Ebola or who have recovered from the
disease - the virus can still be transmitted through semen for up to 7 weeks
after recovery from illness.

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 Contact with patients with suspected or confirmed EVD - healthcare workers
have frequently been infected while treating patients.

There is no evidence that Ebola can be spread via insect bites.

Symptoms of Ebola

It takes 2 to 21 days after infection for the symptoms to show up.

Signs and symptoms include: Some patients may experience:

 fever  rash
 headache  red eyes
 joint and muscle aches  hiccups
 weakness  cough
 diarrhoea  sore throat
 vomiting  chest pain
 stomach pain  difficulty breathing
 lack of appetite  difficulty swallowing
 bleeding inside and outside of the
body

TREATMENT

 There is currently no treatment for Ebola.

 Research into a vaccine is ongoing.
 Several vaccines are being tested, but at this time, none are available for
clinical use.

At the moment, treatment for Ebola is limited to intensive supportive care and
includes:

 balancing the patient's fluids and electrolytes.

 maintaining their oxygen status and blood pressure.
 treating a patient for any complicating infections.

Ebola survivors may experience difficult side effects after their recovery, such as
tiredness, muscle aches, eye and vision problems and stomach pain. Survivors may
also experience stigma as they re-enter their communities.

Ebola prevention

 Healthcare workers must wear protective clothing such as masks, gowns,

and gloves.
 Sterilizing medical equipment
 Proper disposal of needles in hospitals
 Use of disinfectants
 Isolating Ebola patients from contact with unprotected persons

Ebola tends to spread quickly through families and among friends as they are
exposed to infectious secretions when caring for an ill individual. The virus can

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also spread quickly within healthcare settings for the same reason, highlighting the
importance of wearing appropriate protective equipment, such as masks, gowns,
and gloves.

When living in or travelling to a region where Ebola virus is present, there are a
number of ways to protect yourself and prevent the spread of EVD.

While in an area affected by Ebola, it is important to avoid the following:

 Contact with blood and body fluids (such as urine, faeces, saliva, sweat,
vomit, breast milk, semen, and vaginal fluids).
 Items that may have come in contact with an infected person’s blood or body
fluids (such as clothes, bedding, needles, and medical equipment).
 Funeral or burial rituals that require handling the body of someone who died
from EVD.
 Contact with bats and nonhuman primates or blood, fluids and raw meat
prepared from these animals (bush meat) or meat from an unknown source.
 Contact with semen from a man who had EVD until you know the virus is
gone from the semen.

These same prevention methods apply when living in or travelling to an area affected
by an Ebola outbreak. After returning from an area affected by Ebola, monitor your
health for 21 days and seek medical care immediately if you develop symptoms of
EVD.

Ebola Virus Disease Distribution Map: Cases of Ebola Virus

Disease in Africa Since 1976

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Ebola Virus Outbreaks by Species and Size, Since 1976

CORONARY HEART DISEASE (CHD)

Link between atherosclerosis and coronary heart disease

- atherosclerosis is the main cause of CHD;
- coronary arteries become narrower;
- therefore blood pressure increases;
- can damage walls of arteries/cause aneurysm, causing wall to burst;
- atheromas roughen lining of arteries causing blood clots/thromboses;

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- clot can block coronary artery;
- clot may break away and lodge where artery narrows/embolism;
- heart muscle is deprived of oxygen and diets;

Evaluate the epidemiology and experimental evidence linking smoking to lung

cancer and early death

Epidemiology
- more smokers died of cancer;
- number of woman developing cancer increased with number of women
smoking
- number of cigarettes smoked per day increased per day linked with death
rate;

Experimental
- carcinogen identified in tar;
- dogs exposed to cigarette smoke developed tumours;
- rate of tumour development reduced when filter tipped brands used;

Discuss the epidemiological and experimental evidence which links smoking

with disease.
- more new diseases in smokers;
- compared to non-smokers
- the higher the number of smokers the higher the number of sufferers
- experimental animals exposed to smoke developed diseases;
- compared to those not exposed to smoke;
- animals exposed to smoke have higher chances of developing disease
- filtered vs. unfiltered

How cigarette smoking can lead to coronary heart disease

- main cause of CHD is atherosclerosis;
- carbon monoxide/nicotine in smoke responsible;
- cholesterol deposited in, inner layers/.linings of artery walls;
- form plaques which lead to restriction of blood flow/clotting which can block
vessels;

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- smoking increases blood cholesterol/fat level;
- nicotine causes constriction of coronary arteries/arterioles;
- rise in blood pressure makes damage to walls more likely;
- increases number of platelets stimulating formation of blood clots;
- nicotine makes platelets more sticky;
- smoking causes rise in ratio of VLDLs/LDLs, to HDLs in blood so more
atherosclerosis/cholesterol deposited;
- decrease concentration of antioxidants/Vitamin C/vitamin E, so increasing
damage to artery walls by free radicals;

Common categories of diseases which could be applied to coronary heart

disease
[Each category should be qualified with a suitable reason]
- physical;
- non-infectious;
- self – inflicted;
- degenerative;
- social;
- links with diet/lifestyle of developed countries;
- inherited;

The difficulty in achieving a balance between prevention and cure of coronary

heart diseases
- due to life style;
- such as smoking/diet/lack of exercise most causes can be avoided;
- government could take steps to encourage change of life;
- a few patients are victims of their own genetic;
- cure is expensive;
- e.g. heart transplants/coronary by-pass/drug treatment;
- ethical problems of who to treat, suitable example;
- since donors are few;
- problems associated with tissue rejection;
- should patient change their life style before treatment is made available

Arguments for diverting funds from the treatment of coronary heart disease to
its prevention
- cure is expensive;
- e.g. heart transplant, coronary by-pass, drug treatment;
- difficult to find enough donor hearts;
- ethical problems of who to treat e.g. father with young family;
- many of the risks are avoidable;
- associated with life style - change will make people less susceptible;

Discuss the factors that should be taken into account when deciding how to
share limited resources between prevention and treatment of coronary heart
disease
- treatment is expensive due to technology and professional expertise of
surgeons;
- after . care also expensive (immunosuppressant drugs, e.t.c.);
- NHS working on tight/limited budget;
- preventive measures cheaper;
- not so dependent on expensive equipment/manpower;
- very expensive to advertise/train/employ health educators;

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- difficulty in disseminating information;
- prevention saves a lot of suffering for potential victims;
- and families;
- e.g. may cause financial difficulties if wage earner affected/fatherless family
e.t.c;
- in terms of years of healthy life gained preventive measures may be better;
- great demand for treatment because heart disease so common;
- moral dimension . if a treatment is available should we not make resources
available to use it;
- more lives can be saved by preventative measures;

GLOBAL DISTRIBUTION OF CHD

Discuss the possible reasons for the global distribution of coronary heart
diseases
- mainly confined to developed/affluent countries;
- mainly due to lifestyle + sedentary work;
- fatty diets;
- high saturated fats;
- cigarette smoking;
- alcohol intake;
- obesity;
- high blood pressure;
- lack of exercise;
- fast foods;
Reasons why coronary heart disease is so common in developed countries
- caused by many factors most of which are common in developed countries;
- smoking is common risk factor;
- carbon monoxide and nicotine are the components responsible;
- carbon monoxide reduces oxygen carrying capacity;
- increasing strain on the cardiovascular system;
- nicotine increases stickiness of platelets, raising risk of clotting;
- diets tend to be rich in saturated fats;
- increased blood cholesterol and hence atherosclerosis;
- cause rise in ratio of LDLs to HHDLs;
- hypertension/high blood pressure common which puts arteries under strain;
- lack of exercise is a risk factor and life style/ occupations often sedentary

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