Ministry of Health and Medical Services, Kiribati Annual Report, 2011 by Pacific Health Information Network

2011

annual report Kiribati

Contents Preface �� 4 Key points – Kiribati’s health 2011 �� 5 1..Introduction �� 7 2..The health of I-Kiribati – an overview �� 11 3..Determinants: keys to prevention ��19 4..Health across the life stages �� 35 5..Health services �� 45 6..Methods and definitions �� 59 7.Annexes ��61

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Preface Mauri, the Ministry of Health and Medical Services is happy to present the first Annual Report produced for over ten years now. The Health Information Unit, who is responsible for the production of this report, stores much data in the system that has never been analysed. In this year, 2012, expertise from the University of Queensland, Brisbane, has assisted the Ministry of Health and Medical Services in Kiribati to produce this report. The Ministry would like to thank the head of the University of Queensland for allowing staff from the Ministry to come over and work in their office and finish the report with the assistance from their expertise.

in Pacific Island Countries, and the Ministry of Health and Medical Services is thankful for this.

The main purpose of this report is to assess the status of our population’s health. It is also going to serve the need from health donors on any kind of information they might need. In addition, the Ministry of Health and Medical Services required this report to assess its performance towards the health status of the population, and to better or improve its future plans and budget. There is no doubt that this report will help improve plans for the future. This report also plays a crucial role in documenting all information from past years that never been documented.

Mr Elliot Ali Permanent Secretary

The Ministry of Health and Medical Services wishes to give its sincere gratitude to the team at the Health Information Systems Knowledge Hub, University of Queensland, for their assistance in producing this report, alongside our Senior Health Information Officer, Mr Teanibuaka Tabunga: Professor Alan Lopez Nicola Hodge

Ministry of Health and Medical Services

Fallon Horstmann

Michael Buttsworth Jillian Ridley. Also words of thanks to the team from the Australian Bureau of Statistics, and the Working Committee of the Pacific Health Information Network for your great support. Last, but not the least to the staff of the Health Information Units in Nawerewere for their assistance from home. Without your individual support, this report would have never been done. But your great commitment is indicated in the completion of this report, and it is one way of many to help improve Health Information Systems

Kiribati • Annual Report • 2011

Finally, to Mr Tabunga’s mentor, Nicola Hodge, for her great support and advice: many thanks for the fantastic lessons; they have given our health information staff a new understanding of statistics.

Dr Kautu Tenaua Minister of Health & Medical Services

Key points – Kiribati’s health 2011 This section presents selected key findings from the report.

Table 1 Main indicators, 2011 Indicator Total population

Males

Females

Both sexes

51,002

52,464

103,466

23.3

48.3

Percent of population less than 15 years of age

Percent of population aged 15-24

Percent of population aged 25-59

Percent of population living in South Tarawa

Percent of population older than 60 years of age

Crude birth rate (per 1,000 people)

28.7

5.4

3.9

4.6

Crude death rate (per 1,000 people) Infant mortality rate (per 1,000 births) Under-five mortality rate (per 1,000 births) Life expectancy at birth (years) Fertility rate

47.3

80.1

75.1

2.7

Source: National Statistics Preliminary Census 2010; Health Information Unit, MHMS 2011

General Life expectancy and death The crude death rate in 2011 was 4.6 deaths per 1,000 people

•

Life expectancy in Kiribati is currently 80 years for females and 70 for males

•

The total fertility rate in Kiribati was 2.7 per female in 2010. The rate is lower than those of neighbouring Pacific Island Countries and Territories

•

The leading causes of death in 2011 were digestive (8.7%) and cardiovascular (8.5%) diseases

Ministry of Health and Medical Services

•

Diseases •

28.1% of the adult population is estimated to have diabetes

•

In 2011, 12.3% of the new cases seen at clinics were for acute respiratory infections

Kiribati • Annual Report • 2011

Health risks •

61.3% of the adult population are ‘current smokers’, and of these, 59% smoke daily

•

25.5% of the adult population consumed alcohol in the past 12 months (in the year leading up to 2006)

•

50.1% of the population have low-levels of physical activity each week

•

99.3% of the population consume less than five servings of fruit and vegetables per day

•

17.3% of the population have high blood pressure

•

27.7% of the population have high blood cholesterol

Babies and children •

There were 2,971 births in 2011, which is approximately eight babies born per day

•

The infant mortality rate is 34 deaths per 1,000 live births

•

The under-five mortality rate is 47 deaths per 1,000 live births

•

These rates have not increased or decreased significantly over the past 20 years

•

Kiribati is currently not on track for achieving Millennium Development Goal 4 (Reduce child mortality)

Ministry of Health and Medical Services

Health services

•

Approximately 29,000 people visit an outpatient clinic each month

•

Over 700 pregnant women are seen by antenatal clinics each month

•

Just under 10,000 home visits were conducted by public health nurses in 2011, the majority for treating sick patients, followed by care for infants under-one

•

In 2011, under 700 patients were referred to Tungaru Central Hospital from the outer islands, the majority by plane

•

There is an increasing number of patients registered at hypertension and diabetes clinics each year

Kiribati • Annual Report • 2011

•

In 2011, 30,000 patients were registered with a hypertension clinic, and 24,000 with a diabetes clinic

•

There are four Main Hospitals: Betio Hospital, Tarawa Central Hospital (TCH), Southern Kiribati Hospital (SKH), and Kiritimati Hosptal

•

There are 34 Health Centres (eight in South Tarawa, four in Betio, and 22 from Outer Islands)

1. Introduction How.... •

good is the health of people living in Kiribati?

•

does it vary between the different islands?

1.1

Understanding health

What...

What is health?

•

things influence health?

•

is being done to improve health, and how well is that working?

Ideas continue to change about what it means to be healthy or unhealthy. One view focuses mostly on the individual and emphasises the presence or absence of disease or sickness. Another view of health includes a wide range of social and economic risk and protective factors, along with various aspects of wellbeing. This report is based on an idea of health as described by the Australian Institute of Health and Welfare (AIHW); that it is:

These are the big questions behind the Annual Report 2011, the first report of its kind produced by the Ministry of Health and Medical Services in over ten years. As a report to the nation, the Annual Report 2011 brings together the latest available national statistics compiled by the Ministry of Health from many data sources. Its target readers are interested members of the public, clinicians, researchers, students, policy makers and government. We can see from this report that there are some answers to these questions. The health of I-Kiribati is generally good, is improving (in some areas), and compares well with other countries in the Pacific.

An important part of wellbeing, of how people feel and function; that it contributes to social and economic wellbeing; that it is not simply the absence of illness or injury, and there are degrees of good and bad health; and that health should be seen in a broad social context. Overall, it can be said that healthy people feel and function well in body and mind and are in a condition to do so for as long as possible.1

But the ‘simple’ big-picture answers have a complex background. They depend on many statistics that are derived from a large amount of data compiled by many people throughout Kiribati and its extended health system. Contributors include people working in hospitals and other health facilities, in research agencies, in government health departments, and in special health registries.

A framework

Ultimately, it is all people from Kiribati who contribute to this report because there would be no data without them. Through them we also learn about the exceptions to the generally good news. These exceptions include the high infant mortality and under-five mortality rates, which have not reduced for over 20 years. Young males are also dying at much higher rates than young females, mostly from accidents and other external causes of injuries. Non-communicable diseases are a growing concern in the Pacific, and many people are already suffering from conditions such as diabetes.

There are many determinants of health and they interact in complex ways. They include behaviours such as smoking, diet and physical activity, and much broader factors such as our social and environmental background. Interventions can range from personal services to treat us when we are sick, to prevention campaigns aimed at determinants.

Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

This first chapter begins by discussing what health is, why health information is important and presenting a brief picture of Kiribati today.

This report is based on a conceptual framework of health, as shown in Figure 1. It shows that levels of health and wellbeing (‘how good is Kiribati’s health?) depend on two forces: determinants (‘what things influence health?’) and interventions and their resources (‘what is being done to improve health?’).

Determinants Biomedical and genetic factors

Health and wellbeing

Resources

Life expectancy, mortality

Human

Subjective health

Material

Functioning, disability Health behaviours

Illness, disease, injury

Socioeconomic factors

Interventions

Financial Research Evaluation Monitoring

Prevention and health promotion Environmental factors

Treatment and care

Surveillance Technology Other information

Rehabilitation

Figure 1 Conceptual framework of health2 2

Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

1.2

Health information

Ministry of Health and Medical Services

What is a health information system, and why is it important?

Health information systems (HIS), defined by the World Health Organization as integrated efforts to ‘collect, process, report and use health information and knowledge to influence policy making, programme action and research’, are essential to the effective functioning of health systems worldwide.3 Routine HIS, such as those operated through health information departments or national statistics offices, provide information on risk factors associated with disease, mortality and morbidity, health service coverage, and health system resources.4 Governments rely on the information provided to them from HIS for the production of high-quality, userfriendly statistical information on the health status of the community; the use and need of health services; 3

AbouZahr C and A Commar. 2008. Neglected Health Systems Research: Health Information Systems. Alliance for Health Policy and Systems Research: World Health Organization

Lewin S, Oxman A, Lavis J, Fretheim A, Marti S and MunabiBabigumira S. 2010. Chapter 11: Fidning and using evidence about local conditions. In A Oxman, J Lavis, S Lewin and A Fretheim (eds.), pp 164-183, SUPPORT Tools for Evidence-Informed Policymaking. Report Number 4, 2010. Norwegian Knowledge Centre for the Health Services: Oslo

Kiribati • Annual Report • 2011

formulating, monitoring and evaluating health policies; and measuring progress made in the provision of health services.5 HIS can also identify health problems; help to form effective health policies; respond to public health emergencies; select, implement and evaluate interventions; and allocate resources.6 Collecting, analysing and sharing health information is a difficult process that requires a clear understanding of its underlying components and how these components interact. The Health Metrics Network provides a conceptual representation of the six components and standards of a HIS: 1. HIS resources – such as appropriately trained staff, finance, logistics support and context-specific technologies. These resources (or inputs) must be situated within the broader legislative, regulatory and planning framework of a country 5

World Health Organization Regional Office for the Western Pacific Region (WPRO). 2003. Chapter 5: Data quality of statistical reports. In Improving Data Quality: A guide for developing countries, pp 54-67. World Health Organization: Geneva

Pappaioanou M, Malison M, Wilkins K, Otto B, Goodman R, Churchill R, White M and Thacker S. 2003. Strengthening capacity in developing countries for evidence based public health: The data for decision making project. Social Science and Medicine 57(10): 1925-1937

2. Indicators – the basis of a HIS strategic plan must include a core set of indicators and related targets that can provide a picture of the determinants of health, health system condition, and the status of population health 3. Data sources – such as civil and vital registration (births, deaths and cause-of-death), censuses and surveys, medical records, service records and financial and resource tracking 4. Data management – includes data collection, storage, quality, flow, processing, compilation and analysis

5. Information products – the transformation of data into information and therefore into a tool for evidence-based decision-making that will lead to improved health 6. Dissemination and use – increasing the value of health information by making it accessible to decision-makers and providing incentives for the use of health information.7

Health Metrics Network (HMN). 2008. Framework and Standards for Country Health Information Systems, 2nd Edition. World Health Organization: Geneva

Components and standards of a Health Information System

INPUTS HIS Resources

HIS resources Indicators

OUTPUTS Dissemination and Use

PROCESSES Indicators

Data sources Data management Information products

OUTPUTS Information Products PROCESSES Data Management

Figure 2 Components and standards of a health information system7

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Dissemination and use

PROCESSES Data Sources

1.3

Kiribati health system

The government of Kiribati is the main provider of health services in the country. As of 2011, government health facilities included four main hospitals (Betio Hospital, Tungaru Central Hospital, Kiribati Southern Hospital and Kiritimati Hospital), 34 health centres operated by Medical Assistants from South Tarawa, Betio and outer islands, and 66 Clinics manned by Public Health Nurses. There are six other health care providers that also report to the Health Information Unit, including the Integrated Management of Children’s Illness (IMCI) clinic, Gynaecology clinic, Diabetic clinic, Kiribati Family Health Association (KFHA), Reproductive Health Development and Adolescent Health Development. Kiribati is comprised of 33 atoll islands divided among three island groups; the Gilbert Islands, the Phoenix Islands and the Line Islands. Of the 33 islands of Kiribati, 24 are inhabited. There are no private health care providers. All heath care services are provided free to all Kiribati residents by the Government and there is very minimal out-of-pocket spending for health.

Ministry of Health and Medical Services

In 2009, the Government spent approximately 16.5% of its total recurrent budget on health, taking the second largest share next to education. In addition to the recurrent budget, significant amounts of resources from external sources contribute to financing health services and activities through the government’s Development Fund and through other channels such as nongovernmental organizations (NGOs).

Kiribati • Annual Report • 2011

2. The health of I-Kiribati – an overview How.... •

healthy are the people of Kiribati?

•

does Kiribati compare with other countries?

•

is this changing over time?

This chapter describes Kiribati’s health using general measures of health status, for example, life expectancy, birth and death rates, and chronic disease prevalence. The population is considered as a whole, with some key differences highlighted for people living on remote and outer islands.

2.1

Kiribati’s changing population

To understand a population’s health, it is useful to start with its demographic features: the size of a population, the ratio of males to females, its age structure, and how these characteristics are changing. These features are an important aspect of health monitoring, as they reflect past health events and also provide insight into the current and future health of the population.

Other helpful insights come from statistics about fertility, mortality and life expectancy. Birth and death rates are major drivers of a population’s age structure, whereas life expectancy summarises the outlook on life based on current mortality patterns. Migration also contributes to changes in the size, structure and health of the population.

Population growth The bar graph below shows the crude death rates and the crude births rates. It highlights a very important message that more babies are born than people died every year. Again the number of deaths still remains unchanged for the last 20 years whereas the births of babies started to increase from the year 2010 and 2011. The birth rates in 2011 are worrisome because comparing with baseline births during the past 20 years the births remains around 20 births per 1000. In 2006 the number of births increases to 25 births per 1000, then decrease 2007, 2008 and 2009. Again the decreasing could have to do with missing of data. Hence, 2010 and 2011 the births again increase.

Births Vs Deaths Rates by Years 35.0

25.0 20.0 15.0

Crude Death Rate

10.0

Crude Birth Rate

5.0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

0.0

Years Figure 3 Birth and death rates by year. Source: MHMS, Health Information Unit 2011

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Rates per 1000

30.0

Age and sex structure The estimated resident population of Kiribati in 2010 was 103,466, having grown by 11.8% since the last census in 2005. Since 1990, the population has increased by 43 percent. Overall, natural increase (that is, the number of births exceeding the number of deaths) has stayed the same over the past 20 years. The average rate of natural increase is 1.6 percent.

sure that the health services are efficient and adequate to the public, especially those living on remote outer islands.

Figure 4 (below) indicates that the population of Kiribati is young and still growing. It also indicates that there are more females in the older age groups than males (from about age 25 upwards), due to the higher mortality rates among young males. The 2010 census (tables provided in annexes at the end of the report) shows that 48.3% of the total population resides in South Tarawa, with the remaining population living on the different outer islands. The Ministry of Health and Medical Services will have to plan to make

Age structure of the I-Kiribati population, 2010 75+ yrs 70-74 yrs 65-69 yrs 60-64 yrs 55-59 yrs

Ministry of Health and Medical Services

Age group

50-54 yrs

45-49 yrs 40-44 yrs 35-39 yrs

Females

30-34 yrs

Males

25-29 yrs 20-24 yrs 15-19 yrs 10-14 yrs 5-9 yrs 0-4 yrs 8.00

6.00

4.00

2.00

0.00

2.00

4.00

6.00

8.00

Percent of population

Figure 4 Population pyramid. Source: National Statistics Preliminary Census, 2010

Kiribati • Annual Report • 2011

Fertility

Mortality

Two different measures are commonly used to describe trends and patterns in fertility: the number of children born to each female, and the age of mothers giving birth.

Data on death and its causes are important measures of a population’s health. Examining trends and patterns in mortality can help explain changes and differences in health status, evaluate health strategies, and guide planning and policy making. Cause-specific mortality provides further insight into the events contributing to deaths, and changes in the pattern of these causes reflects changes in behaviours, exposures, and social and environmental circumstances as well as the effects of medical and technological advances.

Total fertility rate The total fertility rate (TFR) is a summary measure used to describe the number of children a female could expect to give birth to during her lifetime, if she experience the current age-specific fertility rates throughout her childbearing life. The TFR in Kiribati was 2.7 per female in 2010. The rate is lower than those of neighbouring Pacific Island Countries and Territories.

Table 2 (below) shows that Kiribati continues to have high infant mortality, especially among males. Mortality declines in childhood and adolesence (five to 19 years of age), before increasing steadily and peaking in the 70 years and over age group. Of concern is the high number of young boys (aged five to 19) and men (20 to 29) dying, compared to girls and women of the same age.

Table 2 Deaths by age and sex, 2011. Source: MHMS, Health Information Unit, 2011 2011

Males

Age

Number

Females Rate

Sex ratio

Number

Rate

Crude

Rate ratio

1070.2

836.1

132

128.0

5 – 19 years

56.9

24.1

250

236.4

20-29 years

257.1

104.3

240

246.5

30-39 years

248.9

200.2

115

124.3

40-49 years

673.7

386.7

161

174.2

50-59 years

1307.6

869.3

131

150.4

60-69 years

2183.7

1025.1

170

213.0

70 and over

5269.8

3136.4

168.0

279

547.0

202

385.0

138

142.1

Total

Note: of the 494 deaths in 2011, only 481 deaths had data on age and/or gender recorded

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Less than 5

Trends There were 494 deaths recorded by the Health Information Unit in Kiribati in 2011. Figure 5 shows the national total number of deaths from the year 1991 to 2011. It includes all ages and both sexes. The downfall in 2009 on the number of deaths is the outcome of the missing data during this year. This is when the reporting tool was renewed.

However, looking at the graphs it tells us that the number of deaths for the past 20 years until the 2011 is stable. An average of 4.7 per 1000 people die in Kiribati per year.

No. of deaths

National Number of Deaths by year - 1991 - 2011 700 600 500 400 300 200 100 0

Years Number of Deaths

Three year moving average

Ministry of Health and Medical Services

Figure 5 Number of deaths (absolute and three-year moving average) by year. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Table 3 Crude death rate by year. Source: MHMS, Health Information Unit, 2011 Year

Total number of deaths

Crude Death Rate / 1000

1991

413

4.0

1992

536

5.2

1993

547

5.3

1994

421

4.1

1995

453

4.4

1996

416

4.0

1997

442

4.3

1998

465

4.5

1999

445

4.3

2000

526

5.1

2001

500

4.8

2002

509

4.9

2003

444

4.3

2004

508

4.9

2005

609

5.9

2006

619

6.0

2007

482

4.7

2008

512

4.9

2009

338

3.3

2010

599

5.8

2011

494

4.8

2.2

Causes of death

This section provides an overview of the leading causes of death in Kiribati. Cause-of-death statistics are usually based on the underlying cause, which is the disease or injury that initiated the train of events leading directly to an individual’s death – in other words, the condition believed to be the primary cause-of-death. Any other

condition or event that is not the underlying cause, but is still considered to contribute to the death, is known as an associated cause. Leading causes of death For the population as a whole, the top 10 causes presented here have been listed as specific causes rather than at the broader International Classification of Diseases (ICD) chapter level. Information on cancer deaths, for example, have been provided by individual cancer type rather than for cancer overall. The top 10 causes of death were responsible for 64% of all deaths in 2011. The leading cause-of-death was ‘other digestive diseases’. ‘Other cardiovascular diseases’ is second, followed by cerebrovascular diseases and lower respiratory infections.

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

The table above indicates the number of deaths from 1991 to 2011. The total population used is from the preliminary census in 2010 from the national statistical office. The crude death rate (number of deaths per 1000 people) peaks in 2005 and 2006. The low number of deaths recorded in 2009 (338) is likely due to the change in reporting forms that year, which resulted in missing data.

Table 4 Leading underlying specific causes of death, all ages, 2011. Source: MHMS, Health Information Unit, 2011 All ages, both sexes Rank

Cause of death

Ill-defined diseases

16.6

Other digestive diseases

8.7

Other cardiovascular diseases

8.5

Cerebrovascular diseases

6.9

Lower respiratory infections

6.2

Diabetes mellitus

5.4

Diarrhoeal diseases

3.5

Other infectious diseases

3.5

Endocrine diseases

3.3

Protein-energy malnutrition

2.9

Total leading causes

316

64.0

All deaths

494

100.00

Ministry of Health and Medical Services

Major causes of death by life stage

% of all deaths

Number of deaths

The statistics for various age groups are provided here at the broad ICD chapter level, rather than at the specific disease level, to give a better picture of the broad distribution of causes of death. Overall, the relative contribution of different underlying causes-of-death varies with age. For infants, the main cause-of-death for both males and females relates to conditions originating in the perinatal period. Infectious and parasitic diseases; endocrine, nutritional and metabolic diseases; and diseases of the respiratory system are the main causes of death for children aged 1-14 years. For young adults, the main cause-of-death differs for males (external causes) and females (neoplasm’s). As people age, diseases of the circulatory and digestive system cause more deaths. Ill-defined conditions account for a higher proportion of assigned causes-of-death as people age; representing 45.5% of all deaths for females aged over 85 years; and 32.7% of all deaths for males aged 65-84.

Kiribati • Annual Report • 2011

Table 5 Leading underlying broad cause-of-death by age group, 2011. Source: MHMS, Health Information Unit Males Age group

Infants (<1 year)

1-14

% of deaths 62.3

Conditions originating in the perinatal period

65.1

Cause-of-death

% of deaths

Conditions originating in the perinatal period

Endocrine, nutritional and metabolic diseases

11.3

Endocrine, nutritional and metabolic diseases

11.6

Ill-defined conditions

11.3

Diseases of the respiratory system

9.3

Infectious and parasitic diseases

7.5

Infectious and parasitic diseases

7.0

Endocrine, nutritional and metabolic diseases

25.8

22.6

Endocrine, nutritional and metabolic diseases

23.5

12.9

Diseases of the respiratory system

23.5

15-24

Cause-of-death

Females #

Infectious and parasitic diseases

23.5

Diseases of the respiratory system

External causes of morbidity and mortality

9.7

External causes of morbidity and mortality

43.8

Diseases of the digestive system

31.3

Infectious and parasitic diseases

16.7

Endocrine, nutritional and metabolic diseases

16.7

Infectious and parasitic diseases 3

6.3

Diseases of the circulatory system Neoplasm’s (cancer)

11.8 33.3

Diseases of the circulatory system

25-44

45-64

Diseases of the circulatory system

6.3

Diseases of the respiratory system

6.3

Ill-defined conditions

6.3

Diseases of the circulatory system

21.3

Diseases of the digestive system

21.3

Diseases of the circulatory system

16.7

Ill-defined conditions

21.3

Ill-defined conditions

13.3

Infectious and parasitic diseases

10.6

Diseases of the genitourinary system

10.0

Diseases of the circulatory system

40.0

Diseases of the circulatory system

20.0

17.7

Endocrine, nutritional and metabolic diseases

18.0

85 and over

16.7

Diseases of the digestive system

30.0

Endocrine, nutritional and metabolic diseases

12.7

Diseases of the digestive system

8.9

Neoplasm’s (cancer)

12.0

Ill-defined conditions

32.7

Diseases of the circulatory system

26.0

Diseases of the circulatory system

21.2

Ill-defined conditions

23.9

Endocrine, nutritional and metabolic diseases

11.5

Diseases of the respiratory system

11.5

Diseases of the skin and subcutaneous tissue

100.0

Diseases of the respiratory system Infectious and parasitic diseases Ill-defined conditions

18.0

15.2 8.7 45.5

Diseases of the circulatory system

18.2

Diseases of the respiratory system

18.2

Infectious and parasitic diseases

9.1

Note: Broad causes of death refer to ICD-10 Chapter-level headings Percent of deaths are calculated within each age and sex group

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

65-84

Ill-defined conditions

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

3. Determinants: keys to prevention Many things can affect how healthy we are. They range from society-wide influences right down to highly individual factors such as blood pressure and genetic makeup – they also include the health care we receive. This chapter focuses on these various influences, which are known as health determinants because they help determine how likely we are to stay healthy or become ill or injured.

3.1

What are health determinants?

A person’s health and wellbeing has many aspects. They result from the relationship between social, environmental, socioeconomic, biological and lifestyle factors, nearly all of which can be affected (to some extent) by health care and other interventions.

negative. A high daily intake of fruit and vegetables, for example, or being vaccinated against disease are known as protective factors. Things that increase our risk of ill health are known as risk factors. Examples include behaviours such as smoking or being physically inactive. Measuring and monitoring determinants helps to explain trends in health. This information can then be used to help understand why some groups have poorer health than others, and to develop and evaluate policies and interventions to prevent disease and promote health.

It is important to note that some determinants are positive in their effects on health and others are

Table 6 Relationship between selected chronic diseases (conditions) and risk factors (determinants)8 Risk factor

Condition COPD

(a)

CHD

(b)

Depression

Type 2 diabetes

Stroke

Behavioural Tobacco smoking

Physical inactivity

Alcohol misuse

Poor nutrition

a a

Obesity

High blood pressure

High blood cholesterol

(a).

COPD Chronic obstructive pulmonary disease

(b).

CHD Coronary heart disease (also known as ischaemic heart disease)

Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

aBiomedical

3.2

Health behaviours

Many things can influence a person’s health-related behaviours. A person’s knowledge, attitudes and beliefs may make a particular behaviour more or less likely. Further, behaviours may be affected by the presence of disease or disability. Changing health behaviours is a primary goal of health promotion, which often operates at a population level. Other population health interventions such as legislation, regulation or price control may make it harder for people to continue with unhealthy behaviours. Ultimately, individuals make their own choices about health-related behaviours based on this mix of determinants, interventions and other influences, and consequently have more power to change their own behaviours than many of the other determinants discussed in this chapter. The following sections describe the levels, patterns and trends of the health-related behaviours that have been shown to have a major influence on health.

Tobacco smoking

Ministry of Health and Medical Services

Tobacco smoking is a major risk factor for coronary heart disease, stroke, peripheral vascular disease, cancer and a variety of other diseases and conditions. The usual measure of population smoking rates is ‘daily’ smoking (those who smoke any tobacco product every day), as this reflects the pattern of smoking most harmful to health.

Estimates from the latest STEPS Report (see Box 1) show that in 2006, 61.3% of the population were ‘current smokers’9 and among current smokers, 59.0% smoked daily. Males were more likely to be daily smokers (74.0%) than females (45.4%). The mean age people started smoking was 19.1 years; men started smoking at a marginally younger age than women (18.2 and 20.5 years, respectively).

Current smokers are defined as those who had smoked any tobacco product (such as cigarettes, cigars or rolled tobacco) in the past 12 months

Kiribati • Annual Report • 2011

Box 1: WHO STEPwise Approach to Surveillance of Risk Factors for NCDs (STEPS Report) The STEPS Report is a WHO surveillance tool for chronic disease risk factors and chronic disease-specific morbidity and mortality to be used at the national level. To date, 106 countries and territories throughout the world have used the WHO national STEPS tool. The STEPS approach gathers information on key risk factors in a representative sample of the population using interviews and questionnaires, obtaining simple physical measurements, and collecting blood samples for biochemical assessment. The data gathered enables Governments to put emphasis in the right place when planning and implementing activities to reduce NCD risk factors. National STEPS results can also be used to evaluate the impact of NCD interventions, monitor national trends and judge a country’s overall performance by comparing results with other countries. Data used in the Kiribati STEPS Report are based on a national representative population-wide sample of I-Kiribati. The survey was carried out in South Tarawa and four outer islands (Butaritari, Makin, Onotoa and Beru) from May 2004 to September 2006. A total of 1,755 individuals (response rate 88%) participated in the survey.

Prevalence of 'current smokers', Kiribati and selected countries 100

Percent

80 60 40 20 0 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country

Figure 6 Prevalence of ‘current smokers’ in Kiribati and selected Pacific Island Countries and Territories, 2009. Source: STEPS Report, WPRO

Alcohol consumption Excessive alcohol consumption is a major risk factor for a variety of health problems such as stroke, coronary heart disease, high blood pressure, some cancers, and pancreatitis.10 It also contributes to motor vehicle accidents, drowning, homicides and falls. Measuring the health risks posed by different levels and patterns of drinking is complex and informed by a large body of research.

The STEPS Report shows that 25.5% of the I-Kiribati adult population had consumed alcohol in the past 12 months (defined as ‘current drinkers’). The survey shows that heavy drinking is more common among I-Kiribati men than women. Overall, greater proportions of males in all age groups drank six or more standard drinks per drinking day, with the highest proportion found in the 25-34 years age group (Table 7).

10 Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Age group (years)

Males

Females

Total (N)

% one drink

% twothree drinks

% fourfive drinks

% six or more drinks

Total (N)

% one drink

% twothree drinks

% fourfive drinks

% six or more drinks

25-34

1.1

11.7

87.2

5.9

29.4

64.7

35-44

2.5

15.0

80.0

20.0

40.0

45-54

6.2

12.3

81.5

6.7

33.3

26.7

33.3

55-64

8.0

20.0

72.0

25.0

50.0

25-64

264

0.7

2.8

13.3

83.1

7.5

16.9

24.9

50.7

11 World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Table 7 Number of standard drinks per day among current drinkers by age group, 2004-200611

Prevalence of 'current drinkers', Kiribati and selected countries 100

Percent

80 60 40 20 0 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country

Figure 7 Prevalence of ‘current drinkers in Kiribati and selected Pacific Island Countries and Territories, 2009. Source: STEPS Report, WPRO

Ministry of Health and Medical Services

Physical inactivity

Physical inactivity is linked to poor health, including many chronic conditions and injuries, excess body weight and low bone-mineral density. Conversely, regular physical activity is associated with maintaining good health, and is important in helping to prevent the onset of some chronic diseases. It helps with better maintenance and control of certain conditions such as arthritis and Type 2 diabetes; and for those who have experienced heart attacks, physical activity can improve recovery and reduce the likelihood of further cardiovascular events.12 Participating in regular physical activity, in conjunction with a healthy diet, helps to maintain a healthy body weight and reduce body fat, helping to prevent or eliminate obesity. National guidelines from Australia for physical activity, for both adults and children, provide recommendations about how much physical activity should be undertaken to gain a health benefit (see Box 2). The latest data about physical activity also come from the 2004-2006 STEPS Report, which included questions about how often (frequency) and how long (duration) people were engaged in three domains of physical activity: during recreation or leisure time, work, and transport 12 Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Kiribati • Annual Report • 2011

in a typical week. In the work and leisure domains, respondents were asked how many days per week and how many hours/minutes per day they participate in moderate- and vigorous-intensity activities. In the transport domain, respondents were asked how often and how long they either walk and/or cycle to and from places. Box 2: National Physical Activity Guidelines for Australians12 The National Physical Activity Guidelines for Australians are guidelines for adults and recommend at least 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week. The recommendations for children and adolescents advise at least 60 minutes of moderate to vigorous activity every day and no more than two hours of screen-time activity each day. Examples of moderate-intensity activity are brisk walking, swimming, doubles tennis and mediumpaced cycling. More vigorous physical activity includes jogging and active sports like football and rugby.

Levels of physical activity

reported high-level of total physical activity compared to women (30.1% and 16.6% respectively) (Table 8). Overall, most physical activity in Kiribati was undertaken as part of work, and to a lesser extent, as part of transport. Leisure-time physical activity contributed to very little of the total time spent in physical activity.

The survey found that 50.1% of I-Kiribati reported lowlevel total physical activity, that is, engaged in physical activities of less than 600 MET (metabolic equivalent) minutes per week.13 A greater proportion of women (57.3%) undertook low-level of physical activity compared to men (41.8%). Conversely, a higher proportion of men 13 600 MET minutes per week equals 30 minutes of moderate-intensity physical activity for five days per week, or 20 minutes of vigorous activity for three days per week

Table 8 Categories of total physical activity by age group14 Age group (years)

Males Total (N)

% Low

Females

% Moderate

% High

Total (N)

% Low

% Moderate

% High

25-34

147

39.5

28.6

32.0

216

54.2

25.5

20.4

35-44

165

36.4

33.3

30.3

231

59.3

27.3

13.4

45-54

149

49.7

20.1

30.2

179

61.5

25.1

13.4

55-64

50.6

25.9

23.5

120

55.0

26.7

18.3

25-64

542

41.8

28.1

30.1

746

57.3

26.1

16.6

Prevalence of 'low level physical activity', Kiribati and selected countries 100

60 40 20 0 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country

Figure 8 Prevalence of ‘low level physical activity’ in Kiribati and selected Pacific Island Countries and Territories, 2009. Source: STEPS Report, WPRO

14 World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Percent

Dietary behaviours

fruit and vegetables in a typical week, and how many servings of each that they consumed on one of those days. The survey showed that average consumption of fruit and vegetables among I-Kiribati was well below the recommended levels. The mean number of days per week fruit and vegetables were consumed on were 1.5 and 1.9 days respectively. When fruit and vegetables were consumed, the self-reported mean number of combined fruit and vegetable servings was 0.8 serves. The overall prevalence of those consuming less than five combined servings of fruit and vegetables per day was 99.3%.

The food we eat plays a major role in our health and wellbeing. The dietary guidelines for Australians provide guidance on healthy food choices and lifestyle patterns that promote good nutrition and health. The guidelines have a clear emphasis on enjoying a wide variety of nutritious foods from the five food groups: 1) vegetables and legumes; 2) fruit; 3) cereals; 4) dairy; and 5) meat or meat alternatives. They also recommend that care should be taken to limit saturated fat and restrict total fat intake, to choose foods low in salt and to limit sugar intake.

Fruit and vegetable consumption In the STEPS Survey, eating behaviours were assessed by asking respondents how many days they consumed Box: How much is a serve? By convention, a serve of fruit is 150g and a serve of vegetables is 75g. The table below sets out some examples of everyday fruit and vegetables in terms of a ‘serve’. Fruit

Vegetables

1 medium apple, orange or banana

1 medium potato, ½ medium sweet potato

2 items of small fruit, such as apricots or plums

1 cup of salad vegetables

1 cup of canned fruit

½ cup tomatoes, capsicum or cucumber

½ cup of fruit juice

½ cup spinach, cabbage or broccoli

Table 9 Mean number of combined servings of fruit and vegetables consumed per day of the week15 Males

Ministry of Health and Medical Services

Age group (years)

Kiribati • Annual Report • 2011

25-34

Total (N)

Females

Mean number of servings

Total (N)

Total

Mean number of servings

158

0.9

218

0.7

35-44

177

0.7

233

45-54

159

0.7

180

55-64

0.7

25-64

578

0.8

Total (N)

Mean number of servings

376

0.8

410

0.8

0.7

339

0.7

119

0.7

204

0.7

750

0.8

1,329

0.8

World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Proportion of adults who consumed less than five combined servings of fruit and vegetables per day of the week 100 99.5

Percent

99 Males

98.5

Females

Both sexes

97.5 97 25-34

35-44

45-54

55-64

Age group (years)

Figure 9 Proportion of people who consumed less than five combined servings of fruit and vegetables per day of the week. Source: STEPS Report, WPRO

Prevalence of adults consuming less than five servings of fruit and vegetables, Kiribati and selected countries 100

Percent

80 60 40 20 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country

Figure 10 Prevalence of adults consuming less than five servings of fruit and vegetables in Kiribati and selected Pacific Island Countries and Territories, 2009. Source: STEPS Reports, WPRO

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

3.3

Biomedical factors

Unlike behaviours and other determinants discussed earlier in this chapter, biomedical factors represent actual bodily states. Biomedical factors such as high blood pressure and high blood cholesterol can be regarded as relatively ‘downstream’ in the process of causing ill health. They carry relatively direct and specific risks for health, and they are often influenced by behavioural factors, which are in turn influenced by other ‘upstream’ determinants. Health behaviours tend to interact with each other and influence a variety of biomedical factors. Both physical activity and diet, for example, can affect body weight, blood pressure and blood cholesterol. They can each do this independently, or, with greater effect, they can act together. Further, behavioural and biomedical risk factors tend to increase each other’s effects when they occur together in an individual. Note that several of the biomedical risk factors discussed here are often highly interrelated in causing disease. Excess body weight, high blood pressure and high blood cholesterol, for example, can all contribute to the risk of heart disease and amplify each other’s effects if they occur together. In addition, obesity can in itself contribute to high blood pressure and high blood cholesterol.

Ministry of Health and Medical Services

Body weight

There are health problems associated with being either underweight or having excess weight (overweight and obesity) (see Box 3 for definitions). Being significantly underweight may lead to malnutrition and a range of health problems such as osteoporosis and the inability to fight infections. As Table 10 shows, measurements in the 2004-2006 STEPS Survey suggest that 81.5% of the population is overweight, and from this group, 50.6% is considered obese. Females were more likely to be overweight or obese than males. Although underweight can be a serious risk to health, the material presented here focuses on excess body weight, as the scale of this problem is markedly greater than that of underweight. Excess weight, especially obesity, is a risk factor for cardiovascular disease, Type 2 diabetes, some musculoskeletal conditions and some cancers. As the level of excess weight increases, so does the risk

Kiribati • Annual Report • 2011

of developing these conditions. In addition, being overweight can hamper the ability to control or manage chronic disorders. Rates of overweight and obesity are high in Kiribati and overseas. The WHO has estimated that by 2015 there will be 2.3 billion adults who are overweight, and more than 700 million who will be obese.16 Once considered a problem only in developed countries, obesity is now an increasing concern in developing countries, where problems associated with it often exist along with the effects of under-nutrition.

Box 3: Classifying body weight Body mass index (BMI) and waist circumference are the two main measures used for monitoring body weight. The BMI assesses people’s weight in relation to their height, and is more commonly used in surveys than the waist circumference. The BMI is calculated by dividing a person’s weight in kilograms by the square of their height in metres (kg/m2). The standard classification of BMI recommended by the World Health Organization for adults is based on the association between BMI and illness and mortality and is as follows: •

Underweight: BMI < 18.5

•

Healthy weight: BMI ≥ 18.5 and BMI <25

•

Overweight but not obese: BMI ≥ 25 and BMI < 30

•

Obese: BMI ≥ 30.3

This classification may not be suitable for all ethnic groups and it is unsuitable for children, so should be used with caution. For adults, a waist circumference of 94cm or more in males and 80cm or more in females indicates increased risk. A waist circumference of 102cm or more in males and 88cm or more in females indicates substantially increased risk. This classification is not applicable to people aged under 18 years and the cutoff points may not be suitable for all ethnic groups.

16 World Health Organization (WHO). 2006. Obesity and overweight. Fact sheet no. 311. Geneva: WHO

Excess weight arises through an energy imbalance over a sustained period. Although many factors may influence a person’s weight, weight gain is essentially due to the energy intake from the diet being greater than the energy expended. Energy expenditure occurs in three ways: basal metabolism (that is, the energy used to maintain vital body processes), thermic processes (that is, the energy taken to digest and absorb food), and physical activity. Physical activity is the most variable component of energy expenditure, and the only component a person has any direct control over. In a normally active person, physical activity contributes about 20% to daily energy expenditure.17

In the 2004-2006 STEPS Survey, the majority of adults (81.5%) has a body mass index (BMI) (based on measured data) that indicated they were overweight or obese. A larger proportion of females than males were overweight or obese (84.5% compared with 78.2%).

17 Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Table 10 Body mass index based on measured data, by age and sex, persons aged 25-64 (percent)18 Sex and BMI

Age group (years) 25-34

35-44

45-54

55-64

Total 25-64

Males Underweight

0.5

0.6

0.3

Normal

24.7

19.0

20.1

20.7

21.6

Overweight

37.6

33.7

35.4

42.5

36.5

Obese

37.7

46.7

43.9

36.8

41.7

100.0

99.9

100.0

100.1

0.5

0.4

2.4

0.6

Normal

14.0

13.8

12.6

23.2

14.8

Overweight

24.2

27.2

27.0

24.8

25.7

Total males Females Underweight

Total females

61.4

58.6

60.4

49.6

58.9

100.1

100.0

18 World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Obese

A person’s waist circumference can be used to measure what is known as abdominal obesity. Waist circumference is regarded as an important independent risk factor for Type 2 diabetes and the risk increases with increasing waist circumference. In 2004-2006, all age groups for both genders (except for 25-34 year-old males), were at an increased risk of ill health due to high waist circumference measurements. While mean waist circumference increased with age among males, the pattern was more stable with females, peaking in the 4554 year-old age group.

Table 11 Mean waist circumference (cm) and risk level by gender and age group19 Age group (years)

Males Mean (cm)

Females Risk level

Mean (cm)

Risk level

25-34

91.4 --

96.8 Substantially increased

35-44

95.8 Increased

96.9 Substantially increased

45-54

95.5 Increased

99.3 Substantially increased

55-64

96.9 Increased

96.4 Substantially increased

25-64

94.2 Increased

97.3 Substantially increased

19 World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Prevalence of 'overweight' and 'obese', Kiribati and selected countries

80 Percent

Ministry of Health and Medical Services

100

60 40

Overweight

Obese

0 American Cook FSM Kiribati Solomon Tokelau Samoa Islands (Pohnpei) Islands Country

Figure 11 Prevalence of ‘overweight’ and ‘obese’ in Kiribati and selected Pacific Island Countries and Territories, 2009. Source: STEPS Report, WPRO

Kiribati • Annual Report • 2011

Blood pressure High blood pressure (often referred to as hypertension; see Box 4) is a major risk factor for coronary heart disease, stroke, heart failure and chronic kidney disease. Studies have shown that the lower the blood pressure, the lower the risk of cardiovascular disease, chronic kidney disease and death.20 When high blood pressure is controlled, the risk is reduced, but not necessarily to the levels of unaffected people.21 Worldwide, high blood pressure has been found to be responsible for more deaths and disease than any other biomedical risk factor.22 Major causes of high blood pressure include diet (particularly a high salt intake), obesity, excessive alcohol consumption and insufficient physical activity. Attention to health determinants such as body weight, physical activity and nutrition plays an important role in maintaining healthy blood pressure. Despite the definition of high blood pressure, blood pressure is a continuum with no threshold level of risk as it rises. Starting from quite low levels, as blood pressure increases so does the risk of stroke, heart attack and heart failure. This means that, for people’s usual, day-today blood pressure, the lower the better. This is true with rare exceptions.

20 National Health Foundation of Australia (NHFA). 2009. Position statement: build environment and walking. Melbourne: NHFA 21 World Health Organization – International Society of Hypertension (WHO-ISH). 1999. 1999 World Health Organization – International Society of Hypertension statement on management of hypertension. Journal of Hypertension 21: 1983-92

The survey found an estimated 17.3% of I-Kiribati had high blood pressure. While raised blood pressure increased with age, this condition was more common among men than women.

Box 4: High blood pressure Blood pressure represents the forces on the wall of the arteries, and is written as systolic/diastolic (for example 120/80 mmHg, stated as ‘120 over 80’). Systolic blood pressure reflects the maximum pressure in the arteries when the heart muscle contracts to pump blood; diastolic blood pressure reflects the minimum pressure in the arteries when the heart muscle relaxes before the next contraction. There is a continuous relationship between blood pressure levels and cardiovascular disease risk. This makes the definition of high blood pressure somewhat arbitrary. The World Health Organization and STEPS Survey define ‘high blood pressure’ as: •

Systolic blood pressure of 140 mmHg or more, or

•

Diastolic blood pressure of 90 mmHg or more, or

•

Receiving medication for blood pressure.

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

22 Lopez et al. 2006. Global and regional burden of diseases and risk factors, 2001: systematic analysis of population health data. Lancet 367: 1747-57

As part of the STEPS Survey, all survey participants had their blood pressure measured. Participants were also asked if they had their blood pressure measured in the last 12 months, within the last one to five years or longer, whether they had ever been told in the last 12 months by a health worker that they had high blood pressure, and if they were currently receiving any medical treatment for high blood pressure.

Proportion of adult I-Kiribati population with high blood pressure 45 40 35 Percent

30 25

Males

Females

Both sexes

10 5 0 25-34

35-44

45-54

55-64

Age group (years)

Figure 12 Proportion of adults with high blood pressure (SBP ≥ 140 and/or DBP ≥90 mmHg or currently on medication for high blood pressure) by gender and age group. Source: STEPS Report, WPRO, 2009

Prevalence of adults with high blood pressure, Kiribati and selected countries 100

Percent

80 60 40

Ministry of Health and Medical Services

0 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country

Figure 13 Prevalence of adults with high blood pressure in Kiribati and selected other Pacific Island Countries and Territories, 2009. Source: STEPS Report, WPRO, 2009

Kiribati • Annual Report • 2011

Blood cholesterol High blood cholesterol (see Box 5) is a major risk factor for coronary heart disease and ischaemic stroke. It is a basic cause of plaque, the process by which the blood vessels that supply the heart and certain other parts of the body become clogged. For most people, saturated fat in the diet is the main factor that raises blood cholesterol levels. Genetic factors can also affect blood cholesterol, severely in some individuals. Physical activity and diet play an important role in maintaining a healthy blood cholesterol level.

The STEPS Survey estimated that 27.7% of the population of I-Kiribati had elevated blood cholesterol levels. There was a higher proportion of females (30.6%) with elevated cholesterol as compared to males (23.8%). The prevalence of high blood cholesterol increased with age to a peak for females aged 45-54 years. Among males, the prevalence increased dramatically in the 35-44 age group, before declining again in the older age groups (Figure 14).

Box 5: High blood cholesterol Cholesterol is a fatty substance produced by the liver and carried by the blood to the rest of the body. Its natural function is to provide material for cell walls and for steroid hormones. If levels in the blood are too high, this can lead to artery-clogging plaques that can bring on heart attacks, angina or stroke. The risk of heart disease increases steadily from a low base with increasing blood cholesterol levels. For the STEPS Report, levels of ‘high’ blood cholesterol are based on a total cholesterol level of 5.0 mmol/L or more.

Proportion of I-Kiribati adults with raised total blood cholesterol levels 50 45 40 30 25

Males

Females

Both sexes

10 5 0 25-34

35-44

45-54

55-64

Age group (years)

Figure 14 Proportion of I-Kiribati adults with raised total blood cholesterol (≥ 5.0 mmol/L) by gender and age group24

Ministry of Health and Medical Services

Percent

24 World Health Organization Western Pacific Region (WPRO). 2009. Kiribati NCD Risk Factors: STEPS Report. Fiji: Excellence Fiji Ltd

Kiribati • Annual Report • 2011

Blood glucose Every cell in the body depends on glucose for energy. Insulin is a hormone that helps regulate the movement of glucose from the bloodstream and into the cells. Changes in the production and action of insulin can affect glucose regulation.23 Impaired glucose regulation is the metabolic state between normal glucose regulation and failed regulation. Failed glucose regulation is known as diabetes. There are two categories of impaired glucose regulation: impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). IFG and IGT are risk factors for the future development of diabetes and cardiovascular disease. The 2004-2006 STEPS Survey measured levels of fasting blood glucose among adults. It found that the overall prevalence of diabetes (defined as raised fasting blood glucose levels) among I-Kiribati aged 25-64 was 28.1%.

Ministry of Health and Medical Services

The prevalence of diabetes increases with age across both genders (Figure 15). For males, a substantial and significant increase in diabetes occurs between the age of 35-44 years and 45-54 years, from 27.7% to 49.6% respectively. For females, diabetes prevalence almost doubles between 25-34 and 35-44 years. The prevalence rate peaks for both genders in the oldest age group.

23 Australian Institute of Health and Welfare (AIHW). 2010. Australia’s’ health 2010. Australia’s health series no. 12. Cat no. AUS 122. Canberra: AIHW

Kiribati • Annual Report • 2011

Prevalence of diabetes by gender and age group 70 60

Percent

50 40

Males

Females Both sexes

20 10 0 25-34

35-44

45-54

55-64

Age group (years)

Figure 15 Prevalence of diabetes by gender and age group (raised blood glucose or currently on medication for diabetes and/or diagnosed with diabetes). Source: STEPS Report, WPRO, 2009

Prevalence of diabetes, Kiribati and selected countries 100

60 40 20 0 American Samoa

Cook Islands

FSM (Pohnpei)

Kiribati

Solomon Islands

Tokelau

Country Figure 16 Prevalence of diabetes in Kiribati and selected other Pacific Island Countries and Territories, 2009. Source: STEPS Reports, WPRO, 2009

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Percent

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

4. Health across the life stages

Health can be discussed in many ways, and this chapter presents a ‘life stages’ view of the health of the I-Kiribati people. It covers a range of age groups, from babies (and their mothers), through to early childhood and adolescent stages to the ‘working years’ and finally to those aged 65 years and over. Why take this life stage perspective? First, several of these age groups are already a long established focus of the health system. For example, there are specialist health professionals and services dedicated to expectant mothers and childbirth, to infants and other children, and to the elderly. This chapter should be of special interest to those professionals. Second, this approach can help to lay out a whole-of-life story that is difficult to obtain in other ways. It can be seen that some health problems are largely confined to certain age groups but a range of problems—such as injury—run throughout life and only their prominence varies with age. Also, many problems may only become pronounced in older ages but their seeds begin in childhood with factors such as smoking, poor diet and obesity. Information such as this provides a long-range view that is important for health planning.

4.1

How does health vary with age?

Most aspects of health vary with age, with problems usually increasing over the life stages. As shown in Figure 17, deaths rates increase markedly with age. The exception is in the infant group (aged under one year) where death rates are much higher than for children overall. After infancy and childhood, the death rate drops dramatically; progressively increasing after 10-14 years. The leading causes of death also vary with age, reflecting different exposure to environmental factors and to the underlying ageing processes. For example, the most common causes of death for infants are conditions originating in the perinatal period. Children and young people (aged 1-14 years) most commonly die of endocrine and nutritional diseases (including malnutrition) and infectious and parasitic diseases. In the young adult age group (15-24 years) the main cause-of-death differs markedly for males and females: for males their primary cause-of-death is external causes (including accidents), while in 2011 the primary cause-of-death for females was neoplasm’s (cancer). From age 25 and above, the leading cause-of-death is diseases of the digestive and circulatory system. For more information see Table 5.

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Figure 17 Age distribution of reported deaths. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

4.2

Births

Mothers and babies

Maternal mortality Figure 18 shows the maternal mortality ratio (MMR) in Kiribati since 1991. The MMR is the number of maternal deaths divided by the number of live births, multiplied by 100,000. It reflects the risk faced by women in relation to each pregnancy. In 2010 and 2011 there were two maternal deaths recroded each year, which produces a MMR of 33 deaths per 100,000 live births. Apart from the peak in 2004, the MMR has remained relatively low since 1991.

In 2011, there were 2971 births reported to the Health Information Unit, an average of eight babies born per day. These births included 1187 live births, one stillbirth and one IUD. Another 1725 births had incomplete or no data relating to birth status (if the baby was born dead or alive) and 57 were incorrectly recorded. Over the last 20 years, the number of births fluctuated between 1611 and 2971 per year (see Figure 19).

MMR per 100,000

Maternal Deaths by years per 100,000 400.0 350.0 300.0 250.0 200.0 150.0 100.0 50.0 0.0

Years

Figure 18 Maternal mortality ratio, 1991-2011. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Figure 19 Total number of births by year. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services

The overall trend of the graph shows an increasing number of births from the year 1991 to 2011 and this is worrying if compared with the limited number of resources and the high rate of unemployment.

Kiribati • Annual Report • 2011

Figure 20 Births by location, 1991-2011. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services

Figure 20 shows the number of births in Tungaru Central Hospital (TCH) is increasing. In the years 1991 to 1999 the number of births in TCH increased, while deliveries on the outer islands decreased. This graph indicates that more women are being referred to TCH for delivery, either through referral by a doctor or nurse, or selfreferral to the hospital.

Kiribati • Annual Report • 2011

Fertility rate

Birth weight

The total fertility rate, which is the number of babies per female, was 2.7 in 2010. Kiribati’s rate is lower than those of neighbouring Pacific Island Countries and Territories. The world average is 2.5 babies per female.25

A key indicator of infant health is the proportion of babies with low birth weight. This is because these babies have a greater risk of poor health and dying, require a longer period of hospitalisation after birth and are more likely to develop significant disabilities. For babies, a ‘low birth weight’ means less than 2,500 grams, ‘very low birth weight’ means less than 1,500 grams and ‘extremely low birth weight’ means less than 1,000 grams.

Sex On average, there is an equal number of male and female babies born each year in Kiribati. In 2010, male births accounted for 44.7% of total births. However, 1245 births did not have the sex of the babies recorded (Annexes: Table 6).

Ministry of Health and Medical Services

25 World Bank. 2009. Available at www.data.worldbank.org

Figure 21 Total fertility rate, selected countries, 2010. Source: WHO World Indicator Compendium, 2010

Kiribati • Annual Report • 2011

The graph of low birth weight by year from 1991 – 2006 shows the number of babies born with low birth weight appears to be decreasing (Figure 21). From the year 2006 we can’t say if the number of low birth weight babies is continuing to get lower or increasing, since this when most of data are incomplete. However data from 2011 seem to be similar with data from 2005, indicating that the number of babies born with low birth weight has been decreasing steadily.

Figure 22 Birth weight of babies, 1992-2011. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Perinatal mortality

Ministry of Health and Medical Services

Perinatal deaths are those that occur in the period shortly before or after birth. The three years 2009 to 2011 show the average number of perinatal deaths is over 20 cases every year, which is quite a lot. In 2009, 50% of perinatal deaths were male infants and 50% female. There is an increase in deaths in 2010, but more females than males. The total number of perinatal deaths decreased in 2011. However, there is no clear trend to tell whether the perinatal mortality is increasing or decreasing.

Figure 23 Perinatal deaths. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

4.3

Infants and children

Under-five mortality In the last 20 years, the under-five mortality seems to have slightly decreased. During 1991 to 2005, the average number of deaths per year is 145, which is a bit high for the country of a small population. In the years 2006 to 2009, there is a dramatic decrease in mortality; however, this was when the reporting tools changed, and this is likely the reason why the number of under-five deaths decreased. In 2010 and 2011, the number comes back again to over 100 deaths per year.

The under-five mortality rate represents the number of children dying per year, for every 1,000 live births in that same year. As shown in Figure 25, there is a steep downfall in the year 2006 and this again could be related to revision of the reporting tools that year. In the years 2010 and 2011 the death starts to come up again to the usual number of death every year.

The achievement for the millennium development goals is to reduce under-five mortality by two-thirds. Underfive mortality is gradually decreasing. The question is: are we going to achieve the millennium development target? The Ministry of Health & Medical Services done quite well in the last 20 years, but more work still needed to reach the target in 2015.

Ministry of Health and Medical Services

Figure 24 Number of under-five deaths by year, Kiribati, 1991-2011. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Under 5 mortality rates by years per 1000 120.0 Rates per 1000

100.0 80.0 60.0

infant Mortality Rate

40.0

Child Mortality Rate

20.0

< 5 yrs Mortality Rate 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

0.0 Years

Figure 25 Child mortality rates by year. Source: MHMS, Health Information Unit, 2011

Table 12 Mortality rates for infants and children, 1991-2011. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services

Year

Deaths < Infant 1yr Mortality Rate

Deaths 1 4 yrs

1-4yrs Mortality Rate

Deaths < 5yrs

Child Mortality Rate

Live Births

1991

48.9

25.6

134

74.5

1799

1992

135

71.0

30.0

192

101.0

1901

1993

135

60.8

30.6

203

91.4

2222

1994

49.3

20.6

122

69.9

1746

1995

102

55.6

22.9

144

78.5

1835

1996

106

46.0

18.2

148

64.3

2302

1997

112

50.6

19.0

154

69.5

2215

1998

41.2

19.2

132

60.5

2183

1999

25.9

23.1

108

49.0

2204

2000

57.7

38.5

155

96.2

1611

2001

46.8

25.7

144

72.4

1988

2002

44.9

20.4

128

65.3

1961

2003

48.8

27.2

137

76.0

1803

2004

46.7

21.5

127

68.1

1864

2005

110

48.0

28.4

175

76.4

2290

2006

8.0

19.5

27.5

2617

2007

1.4

20.3

21.7

2072

2008

1.5

18.6

20.1

2043

2009

20.6

14.3

34.8

1751

2010

27.3

17.2

106

44.5

2380

2011

104

13.1

143

48.1

2971

Kiribati • Annual Report • 2011

Figure 25 also shows the infant mortality rate. The infant mortality rate is the number of deaths per year of babies aged less than one year, in relation to the total number of live births for the same year. From the years 1991 to 2005, the infant mortality rate was gradually decreasing. There is a down fall from the years 2005 to 2008. This again is to do with lost data during these years and the other reason was when the reporting tool was renewed. The overall picture of the infant mortality rate is decreasing and this is the outcome of the public health nurses and their medical assistances.

Leading causes of death Table 13 shows the most common causes of death in the year 2011. The table is done by using WHO system where all deaths coding of diseases entered and automatically calculating the rankings of deaths by their causes. The number one leading cause-of-death in 2011 for children under-five years is protein-energy malnutrition. Protein-energy malnutrition (or protein calorie malnutrition) refers to a form of malnutrition where there is inadequate protein intake, and 10.4% of children under-five years died of protein-energy malnutrition.

The second one is lower respiratory infection: nine percent of under-fives died of lower respiratory infection followed by diarrhoeal diseases, which is 8.2%. Ill-defined diseases are the reporting error where diagnosis not labelled or the forms of the patients filled incompletely. This is also a challenge that needed to be addressed. After the ill-defined diseases are Endocrine disorders at 7.5%, with non-specific type indicated in this cause. Other infectious diseases are 3.7% followed by other digestive diseases. The least common causes include iron deficiency anaemia, leukaemia, other respiratory disease, transport accident and drowning.

Malnutrition Figure 26 shows the number of malnutrition cases is increasing for the three years of 2009 to 2011. The graph supports the number one leading cause-of-death for children under-five years is protein energy malnutrition. With the increasing number of malnutrition cases and also malnutrition being the number one leading causeof-death among children under-five, there is a need to look into this problem.

Table 13 Leading causes of death. Source: MHMS, Health Information Unit Leading causes of death, both sexes combined, 0-4 yrs Both sexes

Protein-energy malnutrition

Number of deaths 14

% total 0-4yr 10.4

Lower respiratory infections

9.0

Diarrhoeal diseases

8.2

Ill-defined diseases (ICD10 R00-R99)

8.2

Endocrine disorders

7.5

Other infectious diseases

3.7

Other digestive diseases

1.5

Iron deficiency Anaemia

0.7

Leukaemia

0.7

Other respiratory diseases

0.7

Transport accidents*

0.7

Drowning

0.7

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Health Information Systems Knowledge Hub

Figure 26 Malnutrition cases by year. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

5. Health services This chapter presents an overview of health services in Kiribati, which are grouped into five broad categories: clinical services, immunisation, family planning, Tungaru Central Hospital visits and chronic disease visits.

5.1

Clinical services

Clinical services are defined as outpatient, antenatal, and postnatal services, child health care for infants under one and children aged one to four years, and the MCH services. On average over 29,000 people visit clinics for outpatient services every month. This equals over 1,000 people every day visiting the outpatient clinics.

Figure 27 shows visits to health clinics from all islands in Kiribati. There was a high number of visits in March, and this could be the result of an outbreak around the month where more people regularly visited the clinics. Comparing the number of first visits against re-visits, more people visit clinics for their first time to get assistance from nurses in the clinics. Overall, the number of people visiting clinics every month for 2011 is more than 29,000. This is approximately over 1,000 people seen by nurses and doctors every day. The number of re-visits in July is 16.2%, which is the highest proportion compared with other months.

Most health centres and clinics are manned by only one staff nurse, particularly on the outer islands. If the standard ratio of nurse to patient is 1:6, then looking at the number of outpatient visits is overwhelming. The Ministry needs to further look into this and decide other possible ways to avoid the loading of one staff on each island and particularly inside the wards.

Health Information Systems Knowledge Hub

Figure 27 Number of visits to outpatient clinics by month, 2011. Source: MHMS, Health Information Unit

• Number 0.7 • 0.7

Antenatal and postnatal services Antenatal services are provided by all public health nurses within and outside the hospital. The graph (Figure 28) shows most pregnant women come back for these services. This can be seen in the re-visit figures, which show most pregnant women regularly come back every month for their antenatal clinic visits. On average, over 700 pregnant women attend the antenatal clinics every month. Everyday approximately over 25 pregnant women are seen by each clinic. This number is quite high since the antenatal clinics are done once a week.

Maternal and child health care services

Ministry of Health and Medical Services

Figure 29 indicates the number of services provided by nurse aides in the clinics. The main jobs performed by nurse aides include basic procedures like dressings, scaling of children, census, vital observation taking, and helping the nurse staff to carry out other programs and services.

Figure 28 Antenatal visits by month, 2011. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Nurse aides provided services to over a thousand people every month in 2011. Nurse aides are paid by the council on every island and play an active role in providing health care services to the public.

Vitamin A coverage Vitamin A is a group of compounds that play an important role in vision, bone growth, reproduction, cell division, and cell differentiation (in which a cell becomes part of the brain, muscle, lungs, blood, or other specialized tissue). Vitamin A helps regulate the immune system, which helps prevent or fight off infections by making white blood cells that destroy harmful bacteria and viruses. Vitamin A also may help lymphocytes (a type of white blood cell) fight infections more effectively.

Number of Visits

Clinical Service provided by Nurse aides - 2011 2000 1800 1600 1400 1200 1000 800 600 400 200 0

MCH aides Re-Visit MCH aides 1st Visit

Months

Figure 29 Number of visits by nurse aids per month, 2011. Source: MHMS, Health Information Unit, 2011

Vitamin A Distribution for Years & Age Groups No. of People given Vit A

16000

14524

14000 12000 10000

6 to <=12 mths

8000

4000 2000

1 - <=6 yr

4888

6000

2656

Mothers Postpartum

2085

793

448

363 2009

2010

2011

Years

Figure 30 Vitamin A distribution by age. Source: MHMS, Health Information Unit, 2011 Since Kiribati is a country with high infant and child mortality, it is necessary to carry out Vitamin A prophylaxis to help reduce illness. Figure 30 shows an increasing coverage of Vitamin A prophylaxis for children, however more work is needed on coverage for mothers.

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

77 554

Child health care services

Home visits

Child health care services involve all services offered to children under-one year of age, particularly immunization and children’s illness. Throughout the months from January to December the average number of first visits is around 25 percent. This indicates a high number of children are coming back to the services to receive follow-up care, such as their booster immunisations.

Home visits done by all the public health nurses are shown in Figure 31. Most visits are done to sick patients in their homes. There were more than 5,000 visits to treat sick patients in their homes There were about 3,000 home visits done by the public health nurses to provide child health care services to children under 1 year old. The service includes vaccinations and health educations.

The very high number of revisits in March (19173) is most likely a data error problem. Data entry officers can make an error while entering and this could lead to the poor quality of the data and this was always the problem.

On average, over 35 home vists are made each day throughout Kiribati. The number seems good, and it indicates that all nurses and Medical Assistance are doing well in their home visits activities.

Looking at the table for the year 2011 total number of visits is 34,639, shows that the most mothers are visited clinics more often to seek help from the nurses or medical assistances.

Antenatal and postnatal care services visit done by public health nurses was less than 2,000 visits in 2011.

Table 14 Child health care visits, 2011. Source: MHMS, Health Information Unit, 2011 Child Health - under 1 - 2011

Ministry of Health and Medical Services

1st visit

Revisit

Total visit

% 1st visit

% Revisit

Jan

403

1112

1515

26.6

73.4

Feb

361

1195

1556

23.2

76.8

Mar

392

19173

19565

2.0

98.0

Apr

330

973

1303

25.3

74.7

May

413

1055

1468

28.1

71.9

Jun

348

833

1181

29.5

70.5

Jul

356

735

1091

32.6

67.4

Aug

426

1073

1499

28.4

71.6

Sep

373

1393

1766

21.1

78.9

Oct

426

768

1194

35.7

64.3

Nov

304

1002

1306

23.3

76.7

Dec

289

906

1195

24.2

75.8

Kiribati • Annual Report • 2011

Total Number of Home Visits - 2011 Number of Visits

6000 5000 4000 3000 2000 1000 0

Sick Patients treated

Family planning

Antenatal

Postnatal Child health - Child Health under 1 - 1 to 4 yr

Health Services provided Figure 30 Home visits by service provided, 2011. Source: MHMS, Health Information Unit, 2011

Immunisation The national immunization coverage in 2011 seems great. Pentavalent 1, 2, &3 reached over 100% coverage in 2011. OPV 1, OPV 2 and OPV 3 also reached over 100% coverage. Measles and Rubella vaccination is 90% coverage. BCG is 91% and Hepatitis B is 84% coverage. This is the national coverage of Kiribati, and shows very great results after the hard work done by all public health nurses and medical assistances.

National Immunization Coverage - 2011 140%

114% 91%

100% 80% 60% 40% 20%

113%

106%

111%

109%

103%

90%

64% 20%

Ministry of Health and Medical Services

Coverage

120%

Vaccines

Figure 31 National immunisation coverage, 2011. Source: MHMS, Health Information Unit 2011

Kiribati • Annual Report • 2011

Figure 32 represents the immunization coverage by districts, where most districts comprises of four islands. Northern and Banaba district reached 85% coverage in total average. The islands include Abaiang, Butaritari, Makin Marakei islands. The Southern districts reached 83% coverage and the islands include, Arorae, Beru, Nikunau and Tamana. Betio only district reached 80% coverage. Central districts reached 81% coverage and the islands include Abemama, Kuria, Aranuka, & Maiana. South-West districts reached over 100% coverage and the islands include Nonouti, Onotoa, Tab–North and Tab– South. Linnix district coverage is very low (31%) and this district needs to be looked into it issues and challenges. It is understandable that the Linnix islands are very far but more needs to be done to improve coverage. Considering this kind of coverage is very low, children from the Linnix districts may be very prone to outbreaks or preventable diseases.

Immunisation coverage by year Figure 33 shows national immunization coverage between 1980 and 2011, which has been increasing. The trend of the immunization coverage is encouraging as there is an increasing number of less than 1 year old child been immunized throughout the years. However, there are some vaccines with zero coverage. This is because some vaccines are new and just initiated during the years 2009 upwards. The immunization program is done by medical assistants and public health nurses on all islands throughout Kiribati. Most Initial immunization doses were done by nurses in the obstetric wards.

Immunization District Average Coverage - 2011 160%

139%

140% 120% Coverage

100%

85%

83%

80%

81%

80% 60%

31%

40%

Ministry of Health and Medical Services

20%

92%

Districts Figure 32 Immunisation coverage by districts. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

National Immunization Coverage by year 120

Coverage (%)

100 80

BCG

DPT 1 DPT 3

Hep B3

20 0 1980 1985 1990 1995 2000 2005 2006 2007 2008 2009 2010 2011

Year

Figure 33 Immunisation coverage by year, BCG, DPT 1, DPT 3 and Hep B3. Source: MHMS, Health Information Unit, 2011

National Immunization Coverage by year 120

80 Hib 3

MCV

Polio 3

TT2 + (PAB)

Ministry of Health and Medical Services

Coverage (%)

100

Kiribati • Annual Report • 2011

0 1980 1985 1990 1995 2000 2005 2006 2007 2008 2009 2010 2011 Year

Figure 34 Immunisation coverage by year, Hib 3, MCV, Polio 3 and TT2 + (PAB). Source: WHO/UNICEF estimate 2008; MHMS, Health Information Unit, 2011

Family planning The graph below shows family planning methods used in 2011. The majority of women use Depo Provera, with a high number of continuing users month-to-month, and also high numbers of new clients using this method. the most popular methods used by women beside Depoprovera is Jadell. 94.7% of the women are using Jadell. Only 2.5% using norplant, likewise with IUCD. Majority of women in the year 2011 used this Jadell method where only a few using other methods. Since other methods are not popular by the women to use, the Ministry will need to look into this and probably order more Jadell or promote the use of other methods.

Family Planning Coverage - 2011 90.0 80.0 Percentage

70.0

60.0 50.0 40.0 30.0 20.0 10.0 0.0 Neo-gyon

Eugynon

Microlute

Microgynon

Ministry of Health and Medical Services

Methods

Continuers from last month

New Clients

Transfer in

Restart

Discontinuers

Transfer out

Lost contact

Figure 35 Family planning coverage. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Depo Provera

Methods Used & Removed - 2011 600

525

No. of Users

500 400 300 200 100

0 Norplant Inserted

Norplant Removed

IUCD Inserted IUCD Removed Jadell Inserted Jadell Removed Methods Used & Removed

Figure 36 Methods used and removed. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Tungaru Central Hospital Figure 37 represents the number of referrals from outer island to Tungaru Central Hospital on South Tarawa. On average, over 660 pateints were referred each year between 2009 and 2011. The Ministry covers the costs of transport, rations, foods and drinks while patients stay in the hospital. This is one of the biggest expenses made by the government, since everything provided to the public is for free. However, it is not only patients that are entitled to meals and rations, but their caretakers as well. The Ministry of Health has been trying its best to tackle this problem but this still exists.

Figure 38 indicates the number of referrals from outer islands to Tungaru Central Hospital by month from 2009 to 2011. Every month, over 50 patients are referred to Tungaru Central Hospital on South Tarawa from all outer islands. These referrals are quite a lot and the Ministry needs to look into this. Figure 39 shows the total number of patients referred to the main hospital on South Tarawa. The three years presented show more females are referred than males. The new hospital on Tabiteuea North is planned to take a number of referrals to help reduce the burden on the main hospital, however the graphs indicate referrals to Tungaru Central Hospital haven't decreased much yet.

Total Number of Referrals to TCH- 2011 900

775

No. of Cases referred

800 700 600

657 570

500 400 300 200 100 0 2009

2010

Ministry of Health and Medical Services

Years

Figure 37 Referrals to Tungaru Central Hospital. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

2011

Total No.of Referral Cases 2009 - 2011 120

No.of Referrals

100 80 60 40 20 0

Months & Years

Figure 38 Referrals by month, 2009-2011. Source: MHMS, Health Information Unit, 2011

Figure 39 Referrals to TCH by gender. Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Ministry of Health and Medical Services

Male

No.of Referral Cases

Total No. of Referrals by Plane & Ships by Years 450 400 350 300 250 200 150 100 50 0

Plane Ships

2009

2010 Years

Figure 40 Total number of referrals by transport type. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services

The above graph shows the majority of referrals are by plane. The Ministry of Health and Medical Services pay for these air fares, which are believed to be one of the major expenses of this Ministry.

Kiribati • Annual Report • 2011

2011

Chronic diseases Hypertension & Diabetes Patient visit by Years 35000

Number of Patient

30000 25000 20000 15000 10000 5000 0 Registered Pts

1st & Revist

Registered Pts

2009

1st & Revist

2010

Registered Pts

1st & Revist

2011

Years Hypertension

Diabetes

Figure 41 Hypertension and diabetes case visits by year. Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services

The above graph shows the registered cases and number of visits for hypertension and diabetes cases. Every year the number of hypertension and diabetes cases have increased, but hypertension is more common. Looking at the first visit and this is when they first registered, the numbers are very high. What worrisome is the revisit for treatment or regular check-ups. The graph shows that the visit number of revisits are very low. In 2009 only 23.9 percent of registered patients attended a clinic for a revisit. In 2010, this increased to 30 percent and by 2011 it had increased to 38 percent. The graph also shows that the revisit attendance is very poor but is increasing. However, it is obvious that it quite a large number of patients do not turn up for regular checks and medications and this could be a reason for the high mortality in heart diseases.

Kiribati • Annual Report • 2011

6. Methods and definitions Details of methods used in particular sections of the report are included in the text and boxes, and in footnotes to figures and tables. Some general methods are also described here.

Annual population growth rate (%) Average exponential rate of annual growth of the population over a given period.

Crude death rate The crude (i.e. unadjusted) number of deaths per 100,000 (or 1,000) people in a population over a specified time period (usually one year). Crude death rates are impacted by age distribution, and most countries will eventually show a rise in the overall death rate (as the population ages).

Crude birth rate The average number of births during a year per 100,000 (or 1,000) people in a population. A country’s birth rate is usually the dominant factor in determining the rate of population growth.

Life expectancy at birth

Ministry of Health and Medical Services

The average number of years that a newborn could expect to live, if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her birth, for a specific year, in a given country, territory or geographic area.

Life expectancy at birth reflects the overall mortality level of a population. It summarises the mortality pattern that prevails across all age groups – children, adolescents, adults and the elderly.

Total fertility rate (per woman) The average number of children a hypothetical cohort of women would have at the end of their reproductive period if they were subject during their whole lives to the fertility rates of a given period and if they were not subject to mortality. It is expressed as children per woman.

Kiribati • Annual Report • 2011

Under-five mortality rate (probability of dying by age five per 1,000 live births) The probability of a child born in a specific year or period dying before reaching the age of five, if subject to agespecific mortality rates of that period. The under-five mortality rate as defined here is strictly speaking not a rate (i.e. the number of deaths divided by the number of population at risk during a certain period of time) but a probability of death derived from a life table and expressed as rate per 1000 live births). Under-five mortality rate measures child survival. It also reflects the social, economic and environmental conditions in which children (and others in society) live, including their health care.

Maternal mortality ratio (per 100,000 live births) The maternal mortality ration (MMR) is the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, per 100,000 live births, for a specified year.

Effects of rounding Entries in columns and rows of tables may not add to the totals shown, because of rounding. Unless otherwise stated, derived values are calculated using unrounded numbers.

Classification of diseases ICD-10 is used.

Presenting dates and time spans Periods based on full calendar years (1 January to 31 December) are written as, for example, 2011 for one year. When there are two or more calendar years in the period, the first and final years are written in full. For example, 2009-2009 is a two calendar-year span, and 2007-2009 covers three calendar years.

Symbols %

Percent

Gram

More than

Less than

≥

More than or equal to

≤

Less than or equal to

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

7. Annexes Preliminary Census Results 2010 Total Population 2010 Age Groups 0-4

Female

Male

6817

7008

% Female

13825

6.6

% Male

% Total Population

6.8

13.4

5-9

5313

5779

11092

5.1

5.6

10.7

10-14

6059

6199

12258

5.9

6.0

11.8

15-19

5245

5596

10841

5.1

5.4

10.5

20-24

5165

5239

10404

5.0

5.1

10.1

25-29

4420

4095

8515

4.3

4.0

8.2

30-34

3532

3287

6819

3.4

3.2

6.6

35-39

2961

2740

5701

2.9

2.6

5.5

40-44

3191

2947

6138

3.1

2.8

5.9

45-49

2757

2545

5302

2.7

2.5

5.1

50-54

2117

1840

3957

2.0

1.8

3.8

55-59

1564

1372

2936

1.5

1.3

2.8

60-64

1067

911

1978

1.0

0.9

1.9

65-69

884

646

1530

0.9

0.6

1.5

70-74

684

435

1119

0.7

0.4

1.1

75+

687

362

1049

0.7

0.3

1.0

0.0

not stated Total

Ministry of Health and Medical Services

Source: National Statistics Office, 2011

Total

Kiribati • Annual Report • 2011

103,466

Population by gender and age, 2010 Age

Males

Females

Total

% male

% female

% Total

0-4 yrs

7008

6817

13825

6.77

6.59

13.36

5-9 yrs

5779

5313

11092

5.59

5.14

10.72

10-14 yrs

6199

6059

12258

5.99

5.86

11.85

15-19 yrs

5596

5245

10841

5.41

5.07

10.48

20-24 yrs

5239

5165

10404

5.06

4.99

10.06

25-29 yrs

4095

4420

8515

3.96

4.27

8.23

30-34 yrs

3287

3532

6819

3.18

3.41

6.59

35-39 yrs

2740

2961

5701

2.65

2.86

5.51

40-44 yrs

2947

3191

6138

2.85

3.08

5.93

45-49 yrs

2545

2757

5302

2.46

2.66

5.12

50-54 yrs

1840

2117

3957

1.78

2.05

3.82

55-59 yrs

1372

1564

2936

1.33

1.51

2.84

60-64 yrs

911

1067

1978

0.88

1.03

1.91

65-69 yrs

646

884

1530

0.62

0.85

1.48

70-74 yrs

435

684

1119

0.42

0.66

1.08

75+ yrs

362

687

1049

0.35

0.66

1.01

0.00

51002

52464

103466

49.29

50.71

100.00

Not stated Total

Source: National Statistics Office, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Population by gender and island, 2010 Island Preliminary Data by Gender, for 2010 Census Island Banaba Makin

Female 117

2010 94

% 211

0.2

910

903

1813

1.8

Butaritari

2288

2119

4407

4.3

Marakei

1341

1397

2738

2.6

Abaiang

2822

2849

5671

5.5

North Tarawa

3045

3079

6124

5.9

South Tarawa

24104

25906

50010

48.3

1001

1032

2033

2.0

Kuria

515

471

986

1.0

Aranuka

520

537

1057

1.0

Abemama

1684

1677

3361

3.2

Nonouti

1297

1301

2598

2.5

Tab North

1762

1931

3693

3.6

Tab South

680

624

1304

1.3

Onotoa

724

737

1461

1.4

Beru

1055

1041

2096

2.0

Nikunau

1003

904

1907

1.8

Tamana

587

624

1211

1.2

Arorae

621

651

1272

1.2

Maiana

Teeraina

914

787

1701

1.6

Tabuaeran

1019

971

1990

1.9

Kiritimati

2976

2815

5791

5.6

0.0

51002

52464

103466

100.0

Kanton Total

Ministry of Health and Medical Services

Source: National Statistics Office

Male

Kiribati • Annual Report • 2011

20 Leading Causes-of-deaths, all ages, 2011 20 leading causes of death, all ages

Both sexes

Number of deaths

% total

Ill-defined diseases (ICD10 R00-R99)

16.6

Other digestive diseases

8.7

Other cardiovascular diseases

8.5

Cerebrovascular disease

6.9

Lower respiratory infections

6.2

Diabetes mellitus

5.4

Diarrhoeal diseases

3.5

Other infectious diseases

3.5

Endocrine disorders

3.3

Protein-energy malnutrition

2.9

Tuberculosis

1.9

Chronic obstructive pulmonary disease

1.7

Iron deficiency Anaemia

1.2

Cervix uteri cancer

1.2

Hypertensive disease

1.2

Self-inflicted injuries

1.2

Ischaemic heart disease

1.0

Peptic ulcer

1.0

Breast cancer

0.8

Other neuropsychiatric disorders

0.8

Skin diseases

0.8

Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Population Statistics Population by year Year

Total population

1990

% change (per census)

72335

% change (19902010)

N/A

Average annual growth rate (%) N/A

1995

77658

7.4

1.5

2000

84494

8.8

1.8

2005

92533

9.5

1.9

2010

103466

11.8

2.4

Population by year and gender Year

Total population

Males

Females

1990

72335

35770

36565

1995

77658

38478

39180

2000

84494

41646

42848

2005

92533

45612

46921

2010

103466

51002

52464

Population by age group and gender, 2005 and 2010

Ministry of Health and Medical Services

Census

Percent of population

2005

<15 yrs

15-24 yrs

25-59 yrs

60+yrs

Total %

Males

100

Females

100

Total

100

2010

<15 yrs

15-24 yrs

25-59 yrs

60+yrs

Total %

Males

100

Females

100

Total

100

Source: National Statistics Office, 2011

Kiribati • Annual Report • 2011

Crude birth rate, death rate, and rate of natural increase Year

Crude Death Rate

Crude Birth Rate

Natural Increase Rate

1991

4.0

17.4

1.3

1992

5.2

18.4

1993

5.3

21.5

1.3 1.6

1994

4.1

16.9

1.3

1995

4.4

17.7

1.3

1996

4.0

22.2

1.8

1997

4.3

21.4

1.7

1998

4.5

21.1

1.7

1999

4.3

21.3

1.7

2000

5.1

15.6

2001

4.8

19.2

1.4

2002

4.9

19.0

1.4

2003

4.3

17.4

1.3

2004

4.9

18.0

1.3

2005

5.9

22.1

1.6

2006

6.0

25.3

1.9

2007

4.7

20.0

1.5

2008

4.9

19.7

1.5

2009

3.3

16.9

1.4

2010

5.8

23.0

1.7

2011

4.8

28.7

2.4

Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Vaccination Coverage by Islands Vaccinnation Coverage by Islands - 2011 Islands Banaba Makin Butaritari Marakei Abaiang Nth.Tarawa Sth.Tarawa Betio Maiana Abemama Kuria Aranuka Nonouti Tabiteuea.Nth Tabiteuea.Sth Onotoa Beru Nikunau Tamana Arorae Teeraina Tabuaeran Kiritimati Kanton

HepB HepB (<24 hrs) (≥24 hrs) 0% 22% 74% 18% 25% 26% 128% 14% 0% 87% 57% 6% 25% 25% 160% 179% 44% 39% 200% 63% 10% 0% 53% 0%

0% 24% 22% 67% 47% 55% 10% 9% 19% 1% 0% 33% 67% 15% 0% 7% 22% 32% 0% 4% 0% 49% 2% 0%

BCG 80% 97% 101% 90% 71% 78% 140% 26% 64% 97% 67% 47% 92% 91% 180% 186% 67% 80% 233% 54% 24% 69% 63% 0%

Ministry of Health and Medical Services

Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

Failed BCG PENTA PENTA PENTA OPV 1 OPV 2 OPV 3 MR 1 (no scar) 1 2 3 0% 17% 2% 0% 9% 1% 2% 6% 0% 3% 5% 0% 3% 0% 33% 7% 11% 2% 0% 0% 1% 14% 1% 0%

100% 125% 128% 145% 96% 101% 120% 121% 99% 128% 119% 122% 116% 138% 253% 300% 115% 117% 211% 71% 30% 69% 74% 0%

60% 120% 132% 142% 95% 93% 120% 118% 89% 129% 162% 106% 108% 143% 247% 271% 104% 102% 244% 71% 42% 58% 76% 0%

220% 98% 126% 114% 83% 81% 114% 117% 84% 137% 181% 58% 100% 144% 260% 236% 85% 102% 178% 88% 35% 31% 72% 0%

80% 124% 112% 130% 99% 90% 118% 120% 85% 118% 95% 119% 107% 133% 247% 264% 119% 122% 211% 54% 47% 69% 78% 0%

80% 95% 117% 126% 93% 80% 119% 121% 86% 129% 119% 100% 99% 138% 253% 293% 93% 102% 233% 67% 38% 37% 76% 0%

120% 85% 108% 96% 104% 80% 112% 116% 72% 128% 129% 86% 96% 138% 260% 207% 81% 110% 178% 88% 24% 17% 73% 0%

220% 92% 90% 102% 66% 70% 96% 108% 78% 125% 100% 75% 76% 117% 87% 229% 0% 85% 100% 79% 18% 31% 73% 0%

Clinical Services

Jan Outpatients 28564 Antenatal 244 Postnatal 120 Child health - under 1 403 Child health - 1 to 4 yr 210 MCH aides 776

Feb 31620 226 127 361 267 1033

Mar 38931 289 138 392 642 1280

Clinical Services - 2011 1ST VISIT Apr May Jun Jul 29376 32993 31656 22369 230 233 254 193 148 160 151 181 330 413 348 356 506 377 243 297 813 865 608 452

Jan 4135 632 41 1112 1048 548

Feb 4017 740 38 1195 1149 374

Mar 5762 781 36 19173 1347 502

Apr 4488 864 43 973 1123 424

Jan Outpatients 32699 Antenatal 876 Postnatal 161 Child health - under 1 1515 Child health - 1 to 4 yr 1258 MCH aides 1324

Feb 35637 966 165 1556 1416 1407

Mar 44693 1070 174 19565 1989 1782

Apr 33864 1094 191 1303 1629 1237

Outpatients Antenatal Postnatal Child health - under 1 Child health - 1 to 4 yr MCH aides

Aug 31945 260 215 426 310 680

Sep 28570 242 166 373 310 650

Oct 28332 246 148 426 319 1001

Nov 26854 224 133 304 214 1112

Dec 27520 211 117 289 184 1046

RE-VISITS May Jun 3827 3768 770 862 37 28 1055 833 1048 1076 505 458

Jul 3624 693 75 735 1207 243

Aug 3325 872 90 1073 1030 351

Sep 3443 998 31 1393 1238 445

Oct 2942 625 100 768 1169 565

Nov 2467 636 74 1002 1116 673

Dec 2745 596 64 906 854 600

Jul 25993 886 256 1091 1504 695

Aug 35270 1132 305 1499 1340 1031

Sep 32013 1240 197 1766 1548 1095

Oct 31274 871 248 1194 1488 1566

Nov 29321 860 207 1306 1330 1785

Dec 30265 807 181 1195 1038 1646

TOTAL May 36820 1003 197 1468 1425 1370

Jun 35424 1116 179 1181 1319 1066

Source: MHMS, Health Information Unit, 2011

Ministry of Health and Medical Services Kiribati • Annual Report • 2011

Births by Gender and Year Gender and Data Gaps Proportions Years

(blank)

% Blank

Grand Total

886

49.2

913

50.8

1799

1992

896

47.1

1005

52.9

1901

1993

1047

47.1

1175

52.9

2222

1994

887

50.8

859

49.2

1995

885

48.2

950

51.8

1835

1996

1142

49.6

1160

50.4

2302

1997

1102

49.8

1113

50.2

2215

1998

1121

51.4

1062

48.6

2183

1999

1148

52.1

1056

47.9

2204

2000

796

49.4

815

50.6

1611

2001

951

47.8

1037

52.2

1988

2002

982

50.1

979

49.9

1961

2003

934

51.8

869

48.2

1803

2004

951

51.0

913

49.0

1864

2005

1156

50.5

1125

49.1

0.4

2290

2006

1351

51.6

1258

48.1

0.3

2617

2007

1080

52.1

990

47.8

0.1

2072

2008

1062

52.0

962

47.1

0.9

2043

2009

498

28.4

434

24.8

819

46.8

1751

2010

628

26.4

507

21.3

1245

52.3

2380

2011

1501

50.5

1431

48.2

0.5

2971

Ministry of Health and Medical Services

1991

Source: MHMS, Health Information Unit, 2011

Kiribati • Annual Report • 2011

3495 334

ARI - No Pneumonia (3)

ARI - Pneumonia (4)

36565

Source: MHMS, Health Information Unit, 2011

Total

121

34455

Tinea Vesicolor (16)

216

102

152

Tinea Coporis (15)

153

Night Blindness (14)

3530

24372

Fish Poisoning (13)

38649

22319

105

307

180

110

4777

727

2 1040

686

7801

482

899

MAR

317

4931

508

1196

24084

Mental Illness (12)

Others (17)

Acute Fever + Rash (9) 68

1310

Acute Fever, No Rash (8)

Hypertension (11)

153

STI (7)

Diabetes (10)

1142

Conjunctivitis (6)

442

Dysentery (2)

Meningitis (5)

2924

Diarrhoea (1)

FEB

34667

22934

339

201

285

2710

897

832

4693

502

917

APR

38013

24982

210

315

191

2399

921

794

5536

596

1735

MAY

2011

Diseases (new cases) JAN

Total cases by age group - New cases (first visit) only

13. MORBIDITY REPORTING

2011

NATIONAL MORBIDITY REPORT

National Morbidity Report 2011

Ministry of Health and Medical Services

Kiribati • Annual Report • 2011

36634

24695

274

100

1831

766

795

5662

501

1491

JUN

29564

19790

302

274

1396

120

933

626

3974

511

1338

JUL

38220

27589

346

327

116

1601

1230

562

3874

503

1665

AUG

34990

26072

151

337

132

101

1412

1125

655

3056

508

1149

SEP

34297

24291

145

336

2439

1094

672

3593

444

884

OCT

32003

25014

172

391

126

784

1153

414

2624

396

707

NOV

32026

24189

182

420

124

1060

1343

458

2603

573

907

DEC

420083

290331

2016

3688

1584

676

734

871

809

25249

799

12371

126

7145

51842

5966

15812

TOTAL

National Morbidity Report by Age Group, 2011

Kiribati • Annual Report • 2011

Fish Poisoning (13)

Night Blindness (14)

Tinea Coporis (15)

Tinea Vesicolor (16)

14563

12896

5295

1639

315

702

3265

168

1411

Source: MHMS, Health Information Unit, 2011

Total

5490

Mental Illness (12)

Others (17)

Hypertension (11)

Acute Fever + Rash (9)

Diabetes (10)

1901

382

Acute Fever, No Rash (8)

STI (7)

Conjunctivitis (6)

Meningitis (5)

1030

ARI - Pneumonia (4)

185

3893

Dysentery (2)

ARI - No Pneumonia (3)

1577

36311

15746

3951

1152

1567

8319

1017

4251

14835

3678

1100

1457

7851

872

3534

33660

1-4

< 1 yr

Diarrhoea (1)

Diseases (new cases)

27133

16444

114

228

318

2557

1297

505

4405

379

700

5 - 14

27316

17158

152

206

214

2391

1305

390

4220

397

652

13. MORBIDITY REPORTING Total cases by age group - New cases (first visits) only

NATIONAL MORBIDITY REPORT BY AGE GROUPS - 2011

Ministry of Health and Medical Services

72 77349

62146

478

972

484

191

139

123

128

2929

143

2012

373

5375

823

1009

946

1112

91626

73608

543

1076

299

194

154

122

3082

402

2639

427

6809

15 - 44

23383

18642

175

305

139

124

860

522

154

1719

269

303

157

335

124

196

912

610

168

2133

322

312

27930

22453

45 - 54

12062

9588

142

356

245

965

174

197

109

378

338

100

1054

169

210

13961

11307

55 - 64

9336

7399

265

176

851

106

229

350

278

983

139

315

12658

10220

65 +

420184

290331

2016

3688

1584

676

835

871

809

25249

799

12371

126

7145

51842

5966

15812

1st Visit

Total

5250

ARI - No Pneumonia (3)

165

Hypertension (11)

Mental Illness (12)

Fish Poisoning (13)

Night Blindness (14)

Tinea Coporis (15)

Total

Others (17)

32468

21550

18827 25972

30584

191

101

813

565

548

3337

509

659

21924

200

1085

753

674

3814

583

1010

125

115

Source: MHMS, Health Information Unit, 2011

Diabetes (10)

123

102

Acute Fever + Rash (9)

Tinea Vesicolor (16)

1846

670

Acute Fever, No Rash (8)

STI (7)

Conjunctivitis (6)

Meningitis (5)

783

680

Dysentery (2)

ARI - Pneumonia (4)

966

Diarrhoea (1)

31195

22581

195

331

137

1208

103

742

472

3792

522

839 533

863

30858

21731

224

409

154

1187

173

850

495

3984

MAY

JAN

APR

2010

Diseases (new cases) MAR

Total cases by Months - New cases (first visits) only

13. MORBIDITY REPORTING FEB

2010

NATIONAL MORBIDITY REPOT

National Morbidity Report 2010

Ministry of Health and Medical Services

Kiribati • Annual Report • 2011 125

235

144

101

1767

975

545

4551

460

1230

32258

21927

JUN

172

124

1529

801

461

4025

388

984

30356

21496

JUL 465

1195

33178

22790

221

318

146

1765

841

672

4418

AUG

236

339

143

1868

464

833

525

4153

439

892

35714

25600

SEP 371

890

30109

21958

222

216

136

100

1536

806

375

3235

OCT 357

960

29555

20957

162

202

113

2169

915

391

3021

NOV 429

1687

30847

20918

127

138

148

1598

1146

496

3949

DEC

373094

262259

1973

2916

1459

667

673

804

633

18371

1272

9897

221

6437

47529

5736

12175

TOTAL

2160

ARI - No Pneumonia (3)

128

112

255

197

Diabetes (10)

Hypertension (11)

Mental Illness (12)

Fish Poisoning (13)

Night Blindness (14)

Tinea Coporis (15)

Tinea Vesicolor (16)

25644

Source: MHMS, Health Information Unit, 2011

Total

18652

Acute Fever + Rash (9)

Others (17)

1071

855

Acute Fever, No Rash (8)

STI (7)

Conjunctivitis (6)

Meningitis (5)

616

392

Dysentery (2)

ARI - Pneumonia (4)

925

Diarrhoea (1)

162

210

119

109

116

3155

777

544

2765

461

2556

37862

26731

FEB

34500

23668

669

191

159

216

179

101

2845

806

517

2603

493

1958

MAR 409

887

31572

22178

452

195

115

123

124

102

1676

803

1697

2638

APR

32041

23719

201

254

146

134

121

1654

882

591

2595

500

1030

MAY

JAN

2009

Diseases (new cases)

Total cases by Months - New cases (first visits) only

13. MORBIDITY REPORTING

2009

National Morbidity Report 2009

Kiribati • Annual Report • 2011

NATIONAL MORBIDITY REPORT

Ministry of Health and Medical Services

74 432

1231

30306

22365

280

205

129

108

1418

786

575

2552

JUN

177

176

108

3278

838

603

4715

647

1147

42394

30442

JUL

520

933

40614

27338

167

278

132

110

4342

857

526

5177

AUG

426

965

30742

21872

239

232

113

105

1379

667

613

3850

SEP

333

794

28018

20859

119

237

1642

605

515

2558

OCT

22302

15817

167

261

149

105

872

644

596

2481

373

600

NOV

434

755

26371

17596

162

256

1552

826

641

3832

DEC

382366

271237

2992

2750

1408

704

106

1109

1287

843

24884

380

9346

159

8034

37926

5420

13781

TOTAL

Mental Illness (12)

Fish Poisoning (13)

Night Blindness (14)

Tinea Coporis (15)

Tinea Vesicolor (16)

12962

13521

13820 31870

5163

12189

16376

222

215

309

2648

1029

539

2973

376

665

402

602

26297

17498

245

204

221

2419

1070

481

2954

5 - 14

30151 25563

107

134

3760

956

1635

6048

878

2917

110

3879

998

1814

6411

1052

3520

1850

286

775

2536

141

1274

Source: MHMS, Health Information Unit, 2011

Total

5137

Hypertension (11)

Others (17)

Acute Fever + Rash (9)

Diabetes (10)

1927

318

Acute Fever, No Rash (8)

STI (7)

Conjunctivitis (6)

894

ARI - Pneumonia (4)

Meningitis (5)

2848

152

Dysentery (2)

ARI - No Pneumonia (3)

1546

1-4

< 1 yr

Total cases by age group - New cases (first visits) only

Diarrhoea (1)

Diseases (new cases)

13. MORBIDITY REPORTING

NATIONAL MORBIDITY REPORT - 2009

National Morbidity Report by Age Group, 2009

Ministry of Health and Medical Services

Kiribati • Annual Report • 2011

71978

59444

723

666

356

171

188

195

2651

1464

478

3831

709

901

81937

67643

724

696

228

174

252

259

2820

107

1758

558

4789

809

1004

15 - 44

23173

19039

229

240

171

189

698

381

175

1277

232

300

212

240

213

295

835

402

224

1491

251

304

24255

19587

45 - 54

11043

9050

112

129

354

151

107

614

122

152

102

112

135

381

213

734

115

166

302

112

117

647

178

8944

360

208

138

773

102

252

11878 8021 11049

65 +

9663 6352

55 - 64

382366

271237

2992

2750

1408

704

106

1109

1287

843

24884

380

9346

159

8034

37926

5420

13781

1st Visit

Total

Kiribati annual report