Health Transition Global Burden of Mortality and Disease Overnutrition
Burden of disease: Concepts and applications. Session Aims 1.to introduce the concept “burden of...
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Transcript of Burden of disease: Concepts and applications. Session Aims 1.to introduce the concept “burden of...
Burden of disease:
Concepts and applications
Session Aims1. to introduce the concept “burden of disease”2. to examine patterns and trends in mortality
in Southern African settings3. to discuss and evaluate the concept of
“health transition”4. to introduce the concept of “priority setting”
and its relation to burden of disease studies5. to examine the implications of South African
mortality patterns for the provision of health care in the country.
Data to measure burden of disease
Industrialised versus developing settingsNational data
eg census, vital registration
Health facilitiesSurveys
eg household surveys: DHS
Sentinel site dataeg India, China, HDSS, verbal autopsy
Models
The disability-adjusted life year (DALY)
A single measure of disease burden
Expresses years of life lost due to premature death and years lived with a disability (ie years of healthy life lost due to poor health)
DALY: Values and methods
How “long” should people live?Is a year of healthy life now worth more than in 30 years’ time?Are we – all people – equal?How to compare years of life lost due to premature death, and years lived with disabilities of differing severities?
Trends in life expectancyAgincourt 1992-2003
52
66
60
72
50
55
60
65
70
75
1992-93 1994-95 1996-97 1998-99 2000-01 2002-03
Year
Lif
e e
xp
ecta
ncy
Female
Male
Relative increase in mortality, Agincourt 2002-2003 compared to baseline 1992-1993
0
1
2
3
4
5
6
7
0-4 '5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84
Age group
2002
-200
3 / 1
992-
1993
Female
Male
Trends in under-five mortality
0.0000.0100.0200.0300.0400.0500.0600.0700.0800.0900.100
1992-93 1994-95 1996-97 1998-99 2000-01 2002-03
Period
Death
rate
0-4
Female
Male
Trends in adult mortality Age 20-34
0.000
0.050
0.100
0.150
1992-93 1994-95 1996-97 1998-99 2000-01 2002-03
Period
Death
rate
20-3
4
Female
Male
Trends in cause specific mortality:Infectious & parasitic disease
0.0000
0.0005
0.0010
0.0015
0.0020
0.0025
1992-1994 1995-1997 1998-2000 2001-2003
Period
AS
DR
Diarrhoeal diseases
Acute respiratory infection
HIV/AIDS
Tuberculosis
Malaria
Other Infectious and parasitic diseases
Trends in adult mortality Age 50-64
0.000
0.100
0.200
0.300
0.400
0.500
1992-93 1994-95 1996-97 1998-99 2000-01 2002-03
Period
Death
rate
50-6
4
Female
Male
Trends in cause specific mortality:Women 50-64, broad categories
0.0000
0.0010
0.0020
0.0030
0.0040
0.0050
0.0060
0.0070
0.0080
0.0090
1992-1994 1995-1997 1998-2000 2001-2003
Period
AS
DR
Infectious and parasitic
Non-communicable
External
Ill defined or unknown
Age-standardised death rates, broad cause and broad health care categories, Agincourt 1992-2005
Top five causes of death, 50-64 years Agincourt 1992-2005
Top five causes of death, children and older adults, Agincourt 1992-2005
Prevalence of stroke survivors:South Africa, Tanzania, New Zealand
Comparison of age-standardised rates in three prevalence studies
0
100
200
300
400
500
600
700
800
900
1000
Male Female Total MalesNeeding Help
FemaleNeeding Help
Total NeedingHelp
Stroke Survivors
Pre
vale
nce
/ 10
0,00
0 A
ge-
Sta
nd
ard
ised
to
S
egi P
op
ula
tio
n
Auckland, New Zealand
Tanzania
Agincourt, South Africa
Sub-district services based on network of clinics staffed by primary care nurses with limited supportdrug supply irregularmedical supervision sporadic
Poor capacity to manage chronic illnessNo functional system secondary prevention
103 stroke survivors – only 1 on aspirin85 hypertensives – 8 on treatment; only 1 controlledGeneral pop ≥ 35 – 43% hypertension; 24% of these treated in past week; half with BP controlled
Missed diagnosesMajority of deaths with active TB had previously presented to clinic2/3 TB patients seen at a clinic self-referred to hospital
Care-seeking pluralistic – allopathic, traditional, faith-based most first visits to local clinics = pivotal role
Managing chronic NCDs in Agincourt
Age-standardised death rates by health care
categories, Agincourt sub-district 1992-2005
PHC in Practice: Integrating HAART & chronic NCD care
Age and sex standardized death rates, by social strata, Agincourt 1992-2000
0.000
0.001
0.002
0.003
0.004
0.005
0.006
Highest Higher Medium Lower Lowest
Strata
ASD
R
Age-specific death rates by nationality of household head
Age-specific death rates by nationality of household head, Agincourt, 2000-2001
0
0.0002
0.0004
0.0006
0.0008
0.001
0.0012
0.0014
0.0016
0-1 1-2 2-3 3-4 4-5
Age in years
Ag
e s
pecif
ic d
eath
rate
South African
Mozambican
Reasons given for non-consultation: no money, ineffective care
0
10
20
30
40
50
60
70
80
90
100
Reasons for not takingtreatment action
Other non-access barriers
Feeling better
Illness not serious enough
Other access barriers (Too far,nobody to go with patient, no time)
Health system access barriers (Healthcare can do nothing, drugs don'twork, no drugs at clinic)
No money
25%
18%
26%
7%
Household survey dataNo money
Implications of mortality patterns for health system
Shift orientation of service provision: chronic, long-term care as well as acute, episodic care
Tackle (prevent/control) increasing burden of non-communicable disease and riskStrengthen HIV/AIDS (and TB) prevention, treatment and careSimultaneously maintain and improve on gains in child and maternal health
• Strengthen primary care provision + referral system
• Address differential access to care
Epidemiological Transition
Epidemiologic transition theory: 3 stagesPestilence and famineReceding pandemicsMan-made or degenerative disease
CritiqueNot same direction: reversals in mortality “counter transition”Not sequential: stages may overlap, co-existence different diseases “prolonged/protracted transition”Too general: insufficient attention to subgroup differences “epidemiologic polarisation”
Rethinking epidemiologic transition: mortality patterns in rural South Africa
Counter transitionMortality increasing in children and young adults
Protracted or prolonged transitionSimultaneous emergence of HIV/AIDS together with increasing non-communicable disease
Epidemiologic polarisationPoorest experience highest burden of mortality
Why is burden of disease information necessary?
“priority setting” and its relation to burden of diseaseProgramme planningProgramme evaluation