The challenge of non-communicable disease in our near neighbours: a disease burden perspective Professor Alan Lopez School of Population Health The University.

The challenge of non-communicable disease in our near neighbours: a disease burden perspective

Professor Alan Lopez

School of Population Health

The University of Queensland

Measuring Disease Burden: Some Commonsense Notions

• Mortality, including age at death - lost years of life (ie. age at death matters)

• Ill-health (Morbidity, Disability), including: - incidence of major sequelae of disease- duration of sequelae- severity (disability weight) of sequelae

A: very low child and adult mortalityB: low child and adult mortalityC: low child, high adultD: high child, high adultE: high child, very high adult

14 WHO mortality subregions

Who dies of what?What do we know?

WHO Region

No. of countries with:Complete

VRIncomplete

VRSample

SurveillanceChild but no adult data

SEAR B 1 1 0 1

SEAR D 0 1 2 4

WPR A 4 1 0 0

WPR B 2 11 1 8

Total 7 14 3 13

0

50

100

150

200

250

300

1960 1965 1970 1975 1980 1985 1990 1995 2000

year

prob

abili

ty o

f dyi

ng b

y ag

e 5

per 1

000

live

birth

s

National life table

Census 82

Pop.Samp.surv. 82 (ind.)

Pop.Samp.surv. 87 (ind.)

Census 90 adjusted

Census 90 (ind.)

Nation.Fert.Surv. 88 (dir.)

Fert.Samp.Surv. 92 (dir.)

dsp

CMSSd

survey90-8d

survey95i

census 2000

0

50

100

150

200

250

300

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

year

prob

abili

ty o

f dyi

ng b

y ag

e 5

per 1

000

live

birth

s

Census 71 (ind.)

Fert.Surv.76 (dir.)

Fert.Surv.76 (ind.)

Census 80 (ind.)

Contrac.Prev.Surv.87 (dir.)

Contrac.Prev.Surv.87 (ind.)

DHS 91 (dir.)

DHS 91 (ind.)

Census 90 (ind.)

DHS 94 (ind.)

DHS 94 (dir.)

DHS 97 (dir.)

Susenas (dir.)

0

50

100

150

200

250

300

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000year

prob

abili

ty o

f dyi

ng b

y ag

e 5

per 1

000

live

birth

s

Nat.Fam.Plan.Surv.70 (ind)

Inf.&Child Mort.Surv. 79 (ind.)

Nat.Fam.Plan.Surv.80 (ind.)

Census 81 (ind.)

Nat. Fam.Health Surv.92 (dir.)

Nat. Fam.Health Surv.92 (ind.)

Nat. Fam.Health Surv.98 (dir.)

SRS

China India

Indonesia Pakistan

0

50

100

150

200

250

300

1960 1965 1970 1975 1980 1985 1990 1995 2000

year

prob

abili

ty o

f dy

ing

by a

ge 5

per

100

0 liv

e bi

rths

pgs

pds84 (dir.)

wfs75 (dir.)

lfm80 (dir.)

cen81(ind.)

pds84 (ind.)

cps84 (ind.)

pds88 (ind.)

lsms91 (ind.)

lsms91(dir.)

dhs90 (ind.)

dhs90 (dir.)

ds97

Trends in Child mortality (5q0), selected countries

Adult Mortality

• Success of child health programmes greatly increased survival chances to adulthood

• Enormous lack of interest in measuring levels and trends of adult mortality, let alone causes

• Concept of “premature deaths” equally valid for adults as for children - focus on “young” adults 15-60 years

• As for children, vast differences in risk of adult death across Region

Subregional Age Patterns of Mortality, 2002WprA

0

50

100

150

200

250

300

350

400

450

0-4 5-14 15-29 30-44 45-59 60-69 70+

tho

usa

nd

s

males females

WprB

0

500

1000

1500

2000

2500

0-4 5-14 15-29 30-44 45-59 60-69 70+

tho

usa

nd

s

SearB

0

50

100

150

200

250

300

350

0-4 5-14 15-29 30-44 45-59 60-69 70+

tho

usa

nd

s

SearD

0

200

400

600

800

1000

1200

1400

1600

1800

0-4 5-14 15-29 30-44 45-59 60-69 70+

tho

usa

nd

s

WPR A WPR B

Leading Causes of Death, WHO Western Pacific B Region (largely China), 2002

Cause Deaths (000's) Percent1 Cerebrovascular disease 1,807 16.82 Chronic obstructive pulmonary disease 1,354 12.63 Ischaemic heart disease 863 8.04 Stomach cancer 447 4.15 Lower respiratory infections 376 3.56 Trachea, bronchus, lung cancers 361 3.47 Liver cancer 357 3.38 Tuberculosis 355 3.39 Perinatal conditions 348 3.2

10 Self-inflicted injuries 295 2.711 Road traffic accidents 290 2.712 Hypertensive heart disease 276 2.613 Oesophagus cancer 233 2.214 Diabetes mellitus 173 1.615 Cirrhosis of the liver 171 1.6

Leading Causes of Death, WHO South East Asia Region (largely India), 2002

Cause Deaths (000's) Percent1 Ischaemic heart disease 2,038 13.92 Lower respiratory infections 1,371 9.43 Cerebrovascular disease 1,058 7.24 Perinatal conditions 1,012 6.95 Tuberculosis 690 4.76 Chronic obstructive pulmonary disease 656 4.57 Diarrhoeal diseases 599 4.18 HIV/AIDS 373 2.69 Road traffic accidents 295 2.0

10 Diabetes mellitus 262 1.811 Self-inflicted injuries 246 1.712 Cirrhosis of the liver 203 1.413 Measles 197 1.314 Fires 183 1.315 Trachea, bronchus, lung cancers 173 1.2

Leading Causes of DALYs, Asia-Pacific Region, 2002

Cause DALYs (000's) Percent1 Lower respiratory infections 38,319 5.72 Unipolar depressive disorders 35,493 5.33 Ischaemic heart disease 27,466 4.14 Diarrhoeal diseases 26,657 4.05 Cerebrovascular disease 26,443 3.96 Tuberculosis 21,636 3.27 Road traffic accidents 18,610 2.88 Chronic obstructive pulmonary disease 17,980 2.79 Cataracts 15,622 2.3

10 Hearing loss, adult onset 14,785 2.211 Self-inflicted injuries 13,342 2.012 HIV/AIDS 12,791 1.913 Falls 10,022 1.514 Schizophrenia 9,077 1.315 Measles 8,228 1.2

Asia-Pacific Disease Burden: Summary

• Clear evidence of advancing epidemiological transition

• Major vascular diseases (stroke, IHD) already leading causes of death

• Specific causes of major importance in different regions

(e.g. COPD in China, stomach cancer in Japan, TB and traffic accidents in Thailand/Indonesia)

• Major childhood diseases of poverty (pneumonia, diarrhoea, perinatal causes, TB) still major causes of death in India and neighbours

• No real evidence yet of HIV/AIDS as major cause of death in Region, except South Asia (300,000-400,000 deaths)

• Mental disorders/injuries major cause of non-fatal outcomes

• Considerable UNCERTAINTY around estimates

Comparative Risk Assessment:

The Impact of Risk Factors on the Health of Populations

Three Key Perspectives on Health Risks

- Individual: what does the risk from exposure mean for me?

- Population: what does the population distribution of exposure mean for overall population health

- Intervention: do we know enough to (cost-effectively) modify individual and population exposure?

Basic CRA framework and goalsAll by 224 age, sex and region subgroups

and by levels of poverty

Risk factor levels• current distribution• counterfactual distribution(s)

Disease burden

Risk factor-disease relationships• risk accumulation• risk reversal

Attributable burden in 2000Avoidable burden in 2010 & 2020

0 500 1000 1500

Unsafe health care injections

Vitamin A deficiency

Alcohol

High Body Mass Index

Zinc deficiency

Iron deficiency

Unsafe sex

Physical inactivity

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Fruit and vegetable intake

Cholesterol

Tobacco

Underweight

Blood pressure

Number of deaths (000s)

SOUTH-EAST ASIADeaths in 2002 attributable to selected leading risk factors

0 500 1000 1500 2000

Unsafe sex

Iron deficiency

Unsafe water, sanitation, and hygiene

Occupational risk factors for injury

Occupational particulates

Underweight

Unsafe health care injections

Physical inactivity

Urban air pollution

High Body Mass Index

Indoor smoke from solid fuels

Alcohol

Fruit and vegetable intake

Cholesterol

Tobacco

Blood pressure

Number of deaths (000s)

WESTERN PACIFICDeaths in 2002 attributable to selected leading risk factors

Leading risk factors for disease/injury, Asia-Pacific, 2002

(% of disease burden in each category)

Industrialized countries

Tobacco 8.1

Blood pressure 7.5

Alcohol 4.6

BMI 3.8

Cholesterol 3.7

Low-mortality developing

Alcohol 5.8

Blood pressure 5.3

Tobacco 4.0

Malnutrition 3.3

Indoor air pollution 2.5

High-mortality developing

Malnutrition 12.4

Unsafe water/hygiene 5.2

Indoor air pollution 4.0

Unsafe sex 3.8

Iron deficiency 3.5

Blood pressure 3.5

The next 20 years

Projected changes:

Ratio of Non-Communicable/ Communicable Deaths, India, China, Other Asia-Pacific, 1990-2020

0

1

2

3

4

5

6

7

8

9

10

1990

2000

2010

2020

1990

2000

2010

2020

1990

2000

2010

2020

1990

2000

2010

2020

Rat

io

IndiaChina Other Asia-PacificLatin America & Carribean

Change in Leading Causes of DALYs,India, China & OAP, 1990-2020

Cause DALYs (000's) Cause DALYs (000's)

1 Lower respiratory infections 59,906 COPD 41,582 2 Perinatal conditions 47,935 Ischaemic heart disease 40,888 3 Diarrhoeal diseases 46,876 Unipolar depressive disorders 40,419 4 Unipolar depressive disorders 27,739 Road traffic accidents 34,507 5 Tuberculosis 23,419 Cerebrovascular disease 33,598 6 COPD 21,541 Tuberculosis 18,980 7 Ischaemic heart disease 20,094 Self-inflicted injuries 17,241 8 Cerebrovascular disease 19,534 HIV/AIDS 15,982 9 Falls 18,767 Congenital anomalies 14,702

10 Congenital anomalies 18,759 Lower respiratory infections 14,378

1990 2020

Estimated smoking prevalence by gender and number of smokers in population aged 15 or more, 1995

Region Males Females Overall (millions)(% of all smokers)

Low / Middle Income countries 49 9 29 933 82

High Income countries 39 22 30 209 18

World 47 12 29 1,142 100

Smoking prevalence (%) Total smokers

Note: numbers have been roundedSource. Author’s calculations based on World Health Organization 1997. Tobacco or health: A Global Status Report, Geneva, Switzerland.

Individual risk of premature death(Male smoker versus non-smoker, US Cancer Prevention Study,

1984-88)

0

1

2

3

4

40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

Age

Rel

ativ

e R

isk

DALYs attributable to diarrhoea, HIV and tobacco, 1990-2020 (baseline scenario)

0

20

40

60

80

100

120

140

1995 2000 2005 2010 2015 2020

Year

DA

LYs

(Mill

ions

)

HIV

Diarrhoea

Tobacco

Conclusions I

• Region with vast differences in health status and epidemiological patterns

• Much is known about child mortality levels and trends, MUCH LESS about adult mortality

• Significant progress in reducing child mortality in most countries (primarily vaccine programmes and ORS for diarrhoea)

• Little can be reliably said about trends in adult mortality

• Leading causes of death mixture of “old” and “new” diseases

Conclusions II

• Depression appears by far the leading cause of disability - Other mental health/musculoskeletal conditions also significant

• Vast uncertainty about causes of death patterns and disability due to poor quality of epidemiological data in most countries in Region

• Injuries, especially traffic accidents, significant in all countries (typically 10% of deaths)

• Tobacco already major cause of death in India and China (0.8 million deaths annually in each country) and likely to INCREASE rapidly

• Substantial UNCERTAINTY around HIV/AIDS - May be major cause of disease burden in future?

Conclusions III

• Reduction in large causes of disease burden (tobacco, blood pressure, cholesterol, under-nutrition) will yield largest gains in population health

• Need appropriate policy focus: large, avoidable causes vs possible, but improbable causes

• Urgent research agenda to establish causes of disease burden with greater reliability – implications for cost-effective data collection systems

• More strategic health investments: optimal intervention packages to accelerate health development – much is known, too little is applied