Medical Advances Affecting Morbidity and Mortality The institute of Actuaries of Japan October 13, 2005 By Dr. Philip Smalley Vice President and Medical Director RGA International
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Medical Advances Affecting Morbidity and Mortality
The institute of Actuaries of JapanOctober 13, 2005
By Dr. Philip SmalleyVice President and Medical Director
RGA International
Toronto, Canada
St. Louis, USA
AgendaLongevity trendsTrends in Cardiovascular DiseaseObesity and Diabetes epidemicTrends in CancerInfection disease threats
Trends in All-Cause Death Rates,1960-2000
Australian Institute of Health and Welfare 2004 ABS Cat. No. 3201.0; AIHW National Population DatabaseAustralian Institute of Health and Welfare 2004 ABS Cat. No. 3201.0; AIHW National Population Database
Life Expectancy in Japan
Oldest Human
Jeanne Calment lived 122 years 164 days between February 21, 1875 and died August 4, 1997
http://www.wowzone.com/calment.htmhttp://www.recordholders.org/en/list/oldest.html
Genetics of Longevity
1/4 of variation in longevity can be attributed to genetic factorsLongevity genes found in yeast, flies, and wormsLongevity gene(s) linked to chromosome 4
Werner SyndromeIncidence 1-20 per 1,000,000Autosomal RecessiveGenetic defect on chromosome 8Accelerated ageing beginning in adolescence
Picture from National Centre for Biotechnology Information – Genes and Disease
PharmocogeneticsRecombinant DNA to make pure proteinsTailored drug therapies Block the abnormal gene product proteinGive patient a therapeutic gene
“Doctors Are the Third Leading Cause of Death in the U.S.”
Total deaths per year from iatrogenic causes
250,000Medication errors in hospitals7,000Unnecessary surgery12,000Other errors in hospitals45,000Infections in hospitals80,000Non-error, negative effects of drugs106,000
CauseDeaths per Year
Disease Trends in
Japan
Cancer Statistics in Japan 2003
Age AdjustedDiseaseTrends in
Japan
Cancer Statistics in Japan 2003
Atherosclerosis
Cardiovascular RiskCardiovascular RiskCardiovascular Risk
LipidsHTN
Diabetes
LipidsLipidsHTNHTN
DiabetesDiabetes
Behavioral-Smoking-Inactivity
BehavioralBehavioral--SmokingSmoking--InactivityInactivity
HemostaticThromboticHemostaticHemostaticThromboticThrombotic InflammatoryInflammatoryInflammatory GeneticGeneticGenetic
Smoking Trends
in Japan
1988 1993 1998 2003
Chobanian, AV et al. JAMA. May 21, 2003 Vol. 289 No. 19, pg 2560-2571
New JNC VII Blood Pressure Guidelines
Hormone Replacement Therapy
Table from Hulley SB et al, JAMA. 2004;291:1769-1771
Obesity
Swinburn B et al. WHO (2001) www.heartstats.org
Global Prevalence of Obesity
0
10
20
30
40
50
60
70
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Swinburn B et al. WHO (2001)www.heartstats.org
Annual Increase in Prevalence of Obesity, 1980-1998
-0.20 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60
MalaysiaItaly
IndiaFranceJapanChina
CanadaSweden
South AfricaFinland
BrazilNetherlandsSwitzerland
GermanyAustralia
United StatesMauritius
New ZealandUnited Kingdom
KuwaitSamoa
Average % increase per annum
Prevalence of Obesity & Diabetes
Source - JAMA. 2003;289:76-79
Observed and Projected Life Expectancy at Age 65 for U.S. Females (1900 to 2000)
Figure from Olshansky, SJ et al, NEJM, March 17,2005;352 (11):1138
Observed and Projected Life Expectancy at Age 65 for U.S. Females (1980 to 2050)
Figure from Olshansky, SJ et al, NEJM, March 17,2005;352 (11):1138
Age and Amount Requirements 1986 in North America
500,000500,00050,000200,000100,00061+1 M1 M100,000200,000250,00056-601 M1 M250,000200,000500,00051-552 M2 M350,000200,000500,00046-502 M2 M500,000200,000500,00041-45
750,000200,0001 M36-401 M400,0001 M16-35
StressCXRECGBloodPara-MAge
Where is the Fat??
Rexrode KM, et al, JAMA 1998;280:1843-1848
Waist Circumference versus BMI
CH
D
New International Definition for
Metabolic Syndrome
Lancet, Sept 24 2005;366;1059-62
Sattar N et al. Circulation July 2003;108:414-419
Prognosis of Metabolic Syndrome
Sattar N et al. Circulation July 2003;108:414-419
Figure from Sattar N et al. Circulation July 2003;108:414-419
C-Reactive Protein with Metabolic Syndrome
CH
D
Old Heart Attack DefinitionChest painECG changesCardiac enzymes leak into blood stream
New Heart Attack Definition: American ACC/European ESC 2000
Clinical context compatible with ischemic myocardial damageElevated Cardiac Troponin
Impact of New MI Definition
Pell et al showed that “The new criteria increased admissions for myocardial infarction by 58%”
Pell JP, BMJ. 2003 January 18; 326 (7381): 134–135
Age Adjusted Cancer Mortality Trends in Females
Lung Cancer
Lung Cancer Risks
Smoking and Second-hand smokeAsbestos exposure 1940 - 1979Pollution
Thyroid Cancer
37
Thyroid Cancer TrendsMore screening being doneAntiselection potential
Educated public know risk factorsCan be self detected
Seeing more thyroid cancer critical illness claims in Asia then breast cancer claims
Thyroid ultrasound
http://www.nlm.nih.gov/medlineplus/ency/imagepages/18056.htm
Thyroid Cancer Screening
697 women who presented for breast U/S with no thyroid history
246 (35.3%) were found to have thyroid nodules21 (3.0%) found to have thyroid cancerSensitivity of U/S: 80% to 100%Specificity: 91.7% to 33.3%
Lee HK et al, Yonsei Med J. 2003 Dec 30;44(6):1040-4
Singapore Cancer ExclusionsMelanomas of less than 1.5mm Breslow thickness, or less than Clark Level 3Prostate Cancers histologically described as TNM Classification T1a or T1b or Prostate cancers of another equivalent or lesser classificationT1N0M0 papillary micro-carcinoma of the Thyroid less than 1 cm in diameterPapillary micro-carcinoma of the BladderChronic Lymphocytic Leukemia less than RAI Stage 3All tumors in presence of HIV
41
Breast Cancer
Trends in Breast Carcinoma In-Situ
~ 17% of all new breast cancers
Cancer AdvancesMore preventionBetter screeningNew treatments
CuresVaccines
New Cancer insurance products
Screening30%-50% have not had a mammogram in past 2 years27% of women over the age of 65 have never had a PAP smear screen for cervical cancer70% of at risk public not getting colon cancer screening
47
ProstateProstateCancerCancer
IncidenceIncidenceRatesRates
Figure from Oliver SE el al, Lancet 2000 May 20;355(9217):1788-9
Prostate CancerIncidence
PSA Screening Started in USA
Proteomic ScreeningPSA misses about 1/3 of prostate cancersNMP48
Increased specificity and sensitivity compared to PSA with a 91% predictive valuedetected 92% of the PSA missed cancers
St. Jude’s Children’s Research Hospital –Cancer Survival Rates 51
Infection Trends
Successes:PneumoniaHIVHepatitis B
Threats:Antibiotic Resistance InfectionsHepatitis CNew Infections such as variant Creutzfeld Jacob disease, SARS, Avian Flu, etc
Global Emerging and Re-emerging Infectious Diseases
Figure from Morens, DM et al, Nature. 2004 Jul 8;430(6996):242-9
Avian FluInfluenza A (H5N1) is a subtype of the type A influenza virusWild birds are the natural hosts of the virusVirus was first isolated from terns in South Africa in 1961Most infections due to exposure to sick birdsRare human to human transmission
Outbreak Among Poultry in Asia
Avian Influenza in Asia
WHO Cumulative Number of Confirmed Human Cases of Avian Influenza A (H5N1) since 28 January 2004
WHO Communicable Disease Surveillance & Response (CSR) , September 29, 2005
DeathsCasesDeathsCasesDeathsCasesDeathsCasesDeathsCases
12
0
4
8
17
0
5
12
Thailand
116
71
9
35
Total:
4
4
0
0
4
4
0
0
Cambodia
60419134Total:
2821643416.12.04-to date
8440019.07.04-08.10.04
2416230026.12.03-10.03.04
Viet NamIndonesiaDate of onset
Risk of EpidemicBirds are endemically infected and starting in catsH5N1 viruses could gain the ability for efficient and sustained transmission between humansLittle preexisting natural immunity to H5N1 in the human populationResistance to the antiviral medications amantadine and rimantadine
Leaves 2 remaining antiviral medications (oseltamavirand zanamavir) that should still be effective against currently circulating strains of H5N1
Better Prepared – Less MortalityIn 1918, US population was 105,000,000 and flu killed 500,000 = 0.5%In 1957, US population was 170,000,000 and flu killed 70,000 = 0.04%
AntibioticsICUVaccines (now 58% of elderly get vaccinated)Better Surveillance
Deaths from Infections
Source: http://www.cdc.gov/ncidod/eid/vol3no4/lederber.htm
1918
Impact of a Future Pandemic???In World: ? 2-7 M deaths +In Australia:
25% get infected with mortality 0.37-2.5%….4M cases…. 15,000 – 100,000 deaths
In Japan ???
Transplantations
LiverKidneyHeartLungPancreas
Islet CellXenotransplantStem Cell
64
Tissue Regeneration
http://www.discover.com/july_01/featbros.html
SummaryMore screening and preventionNew therapies and curesObesity and diabetes epidemic poses threatOpportunity to fine tune underwritingLiving longer and better quality lives due to medical advances and public health initiatives
Arigato-go-za-ee-ma-shi-ta !!Thank you !!
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