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