( c ) Disease patterns .sx Compared with those in the white population , considerable variations in the disease patterns amongst the black and ethnic minority groups have been noted .sx There are also variations between the different minority groups .sx These need to be recognised to ensure that appropriate services are provided .sx It is also important to monitor changes that may occur over time .sx Apart from the important implications for the health services needed by the black and ethnic minority community , these changes may also provide valuable information about the causation of some diseases .sx Coronary heart disease and stroke .sx Balarajan found an excess coronary heart disease mortality ( see Figure 3.6 ) in those born in the Indian Subcontinent of 36% for men and 46% for women aged 20-69 years compared with the rates for England and Wales as a whole in 1979-83 ; hospital-based studies have shown an even greater excess risk .sx Furthermore , in this group coronary heart disease mortality increased between 1970-72 and 1979-83 , and is predicated to rise further due to the effects of demographic change .sx The causes of these findings are not fully understood , but they have important implications for the planning of services .sx Research into the causes may help in the development of health promotion strategies and also throw more light on the causes of coronary heart disease in general .sx Ethnic differences in conventional risk factors , such as smoking , raised blood pressure and high serum cholesterol , cannot adequately explain the data , although other variables , including hypothyroidism and stress , have been suggested .sx It has also been argued that Asians may be predisposed to a physiological disturbance characterised by insulin resistance that , under certain conditions , can lead to both coronary heart disease and non-insulin-dependent diabetes mellitus .sx It is interesting that both disorders may be more common in urban than in rural parts of India , but further systematic research is required .sx Furthermore , it is puzzling that whilst Caribbeans also show abnormalities of glucose and insulin metabolism , their rates of coronary heart disease are comparatively low .sx For stroke , on the other hand , Balarajan found that , in those born in the Caribbean , there was an excess of deaths of 76% for men and 110% for women compared with the rates for England and Wales as a whole in 1979-83 .sx There were also increased risks ( 63% for men and 39% for women ) for those born in the African Commonwealth .sx The next highest risk was for those born in the Indian Subcontinent , with excesses of 53% and 25% for men and women respectively .sx All groups experienced a reduction in mortality from stroke between 1970-72 and 1979-83 , particularly those from Africa and the Caribbean .sx However , those from the Indian Subcontinent experienced a comparatively small reduction ( 3% and 25% for men and women respectively) .sx It is not possible to attribute all of the excess deaths from stroke in those of African origin in this country to higher levels of blood pressure .sx Similarly it is difficult to explain the low levels of coronary heart disease in this group on the basis of the known distribution of the conventional risk factors .sx Communicable disease .sx Immunisation .sx Immunisation uptake data are collected according to District Health Authority ( DHA ) areas , and are not available according to ethnic origin .sx Although Districts with the lowest immunisation uptake tend to be those with the greatest socio-demographic problems , there are Districts with significant black and ethnic communities where immunisation uptake is equal to , or better than , the national average .sx The Asian community has been particularly affected by rubella infections in pregnancy .sx In England in 1991 , the lowest ever number of laboratory confirmed rubella infections in pregnancy was reported .sx Of the 16 such infections , six ( 37% ) were in Asian women ; this compares with 19 out of 96 ( 11% ) in the period 1988-90 .sx Of the 25 Asian women infected in the period 1988-91 , seven were recent immigrants who were pregnant on arrival in the UK and had contracted rubella in their country of origin .sx Only ten of the 25 cases presented during pregnancy , the remaining 15 being diagnosed retrospectively following the birth of a congenital rubella-affected infant .sx Immigration into the UK before pregnancy , but after the age at which rubella vaccine is offered at school , has also contributed to the high rate of susceptibility to rubella infection in Asian women .sx The promotion of selective rubella immunisation in the Asian community therefore needs to be continued .sx In the UK the anticipated interruption of rubella circulation will prevent rubella-susceptible pregnant women from being exposed to rubella , but elimination of all cases of congenital rubella will only be achieved when rubella immunisation programmes are introduced in developing countries .sx Tuberculosis In the first six months of 1988 nearly 40% of the patients notified as having tuberculosis were of Indian , Pakistani or Bangladeshi origin .sx Although , for these groups , the number of notifications has declined over the last ten years by an average of 6% per year , this decline is less than that recorded in the white population , in whom the rate of infection is 25 times lower .sx The spectrum of disease also varies with ethnic origin .sx For example , those from the Indian Subcontinent have more non-respiratory disease , particularly tuberculous lymphadenitis and abdominal tuberculosis .sx The Department of Health ( DH ) recommends that people coming from countries with a high prevalence of tuberculosis , and their children and infants wherever born , should have a Heaf test followed by BCG vaccination if indicated .sx New-born babies should be vaccinated within a few days of birth , without having a Heaf test performed .sx There is a need for continuing health education about tuberculosis directed at black and ethnic minority groups .sx Hepatitis B .sx Africa , the Far East and some parts of the Caribbean are areas of high edemicity for hepatitis B , and more than 8% of their resident populations carry the virus .sx The Indian Subcontinent is an area of intermediate endemicity , and 2-7% of people living there are carriers .sx In the Far East , many children are infected at birth .sx On the other hand , infections in Africa commonly occur in early childhood , mainly within the household .sx The extent to which the latter pattern of transmission will survive migration to the UK is not yet clear .sx However , perinatal transmission will continue , because the children born to infectious carrier mothers are themselves likely to become infectious carriers unless immunised shortly after birth .sx Antenatal clinics in the UK have a screening programme to identify women who are carriers of the hepatitis B virus , so that their babies can be immunised .sx The prevention of perinatal transmission leads to significant health benefits , as it is people infected as babies who are most likely to become carriers and be at risk of chronic liver disease .sx HIV infection and AIDS .sx WHO estimates that , during the 12-month period beginning in April 1991 , over one million people world-wide will have been newly infected with HIV , and that 90% of these infections will have occurred in the developing countries .sx Data on reports of HIV infection and AIDS in this country , published each month by DH and by the Communicable Disease Surveillance Centre , reflect the nature of this global epidemic , a number of the cases reported being of people infected in , or by people from , countries where prevalence is already high ( see pages 83-88) .sx Fortunately the numbers are still low , but they underline the importance of the national and local educational initiatives that were developed with the black and ethnic minorities in 1991 , and which are described on page 92 .sx Blood diseases .sx Haemoglobinopathies , or defects of haemoglobin production , are inherited disorders found primarily in the black and ethnic minorities .sx They may be divided into two main groups -those caused by abnormal haemoglobins , for example sickle cell disease , in which there is a single amino acid change in one of the globin chains , and the thalassaemias , in which there is an imbalance in production of globin chains .sx Sickle cell disease primarily affects the Afro-Caribbean population , although there is also a low incidence in people from the Mediterranean and Arabia .sx The estimated number of people with all types of sickle cell disease in the UK is about 5,000 .sx The number of cases of beta-thalassaemia major in the UK is estimated to be about 350 .sx This disorder primarily affects people from the Mediterranean , the Indian Subcontinent and the Middle East .sx In view of the uneven distribution of the different black and ethnic minority groups across the country ( see page 56 ) , there is a concentration of people with these blood disorders in some areas .sx Many of these are in inner cities , often in deprived areas .sx For both sickle cell disease and thalassaemia , the number of individuals with the trait ( carriers ) is well in excess of the number of individuals with the disorder .sx Although individuals with the trait do not usually have any clinical problems , if their partner also has the trait each of their children has a 1 in 4 chance of having the disorder .sx Screening may be performed before at-risk individuals plan to have a family , during the early stages of pregnancy , or soon after birth .sx Some Districts with a high proportion of members of the relevant black or ethnic minority screen all neonates .sx Opportunistic screening should be undertaken when at-risk individuals are seen in hospital .sx Cards stating that the holder has the disorder or trait are issued to individuals so identified .sx Where it is relevant , some DHAs provide funds for counselling centres .sx These provide advice and education to people who have haemoglobinopathies or are at risk .sx Counsellors , usually nurses or health visitors , also arrange contacts with social workers to ensure adequate housing , as sickle crises may sometimes be related to cold or damp .sx Management of the many and varied clinical problems associated with the haemoglobinopathies is complex , and involves not only the patient's general practitioner ( GP ) but also hospital consultants in various specialities .sx The Standing Medical Advisory Committee has set up a Working Party to look at the clinical management of sickle cell disease ; the first meeting is due to be held early in 1992 .sx Mental health .sx There are marked differences in the incidence of mental illness in the black and ethnic minority groups .sx The incidence of schizophrenia appears to be 3-6 times higher amongst Caribbean people in England compared with that in the general population and in Caribbeans living in Jamaica .sx Misdiagnosis has not been confirmed , although it is difficult to exclude entirely cultural biases .sx Alternative explanations include differential psychosocial stress through the effects of racism , unemployment and possibly biological correlates .sx Caribbean people are also more likely to be admitted to hospital compulsorily , particularly by the police , with whom they will have had greater contact prior to admission than matched controls .sx Conversely , studies of hospital admission rates , GP consultation rates and community surveys suggest that , in general , Asians have rates of psychiatric morbidity that are similar to , or lower than , those of the native-born population .sx However , Ineichen has pointed out that some of these findings could be due to reluctance on the part of the Asians to present to conventional practitioners with mental health problems , or to failure on the part of GPs to recognise them if they do .sx A recent survey of mental health provision in Newham also found that , whilst Asians were underrepresented amongst those being given mental health care in the National Health Service ( NHS ) , they were more likely to be found amongst the clients of voluntary agencies that either accepted self-referrals or offered a specific service to the Asian community .sx Similar agencies for immigrants in other European countries are now operating .sx Diabetes mellitus .sx The prevalence of diabetes mellitus in England in people of Asian and Caribbean origin is twice as high as it is in the general population .sx In Asians alone it is increased fivefold .sx It is usually the non-insulin-dependent type of the disease , which occurs at or after middle age , and is associated with insulin resistance and central obesity , and with an increased risk of death or disablement from complications unless well-controlled .sx There is some scope for the prevention of non-insulin-dependent diabetes mellitus by controlling obesity , increasing physical activity , and maintaining an appropriate diet and a healthy lifestyle .sx