The Global Burden of Diseases, Injuries, and Risk Factors Study

Assistant Professor of Family Medicine

Introduction 1

GLOBAL BURDEN OF DISEASE

For more information about the authors and reviewers of this module,

What is the GBD (1)?

Introduction 1

There are some 6 billion people in the world, and hundreds of millions experience disease or injury each year. Taken as a whole, the combined pain, suffering, loss of productivity and unrealised hopes and dreams are our worlds burden of disease !
In other words, the burden of disease is a measurement of the gap between the current health of a population and an ideal scenario where everyone completes their full life expectancy in full health. The Global Burden of Disease project attempts to measure this total disease burden.

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What is the GBD (2) ?

The GBD study is a collaboration between the WHO, the World Bank and the Harvard School of Public Health. GBD is a measure of the amount of disease, disability, and death in the world today. It is a product of complex and interwoven demographic, economic, social, political, religious and environmental factors. It refers to the collective impact of disease on the world population. Disease burden can be attributed to either specific diseases (e.g. HIV, TB, obesity, diabetes) and also risks for ill health (unsafe sex, overcrowding, smoking, excess cholesterol). Therefore, the measurement of GBD allows us to address preventable diseases in each region of the world - how much of risks to health could be avoided in future years.

An important development of this project was a single indicator of total disease burden the DALY.

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Disability-Adjusted Life Years (DALYs)

DALY= YLL + YLD
Years of Lost Life (due to premature mortality) Years Lost to Disability (due to injury or illness)
The DALY is the internationally-accepted measure of death and disability and is increasingly cited as a powerful tool for decision makers in international health. It is the sum of the number of years lost to premature mortality and the number of productive years lost to disability. One DALY is equivalent to one lost year of healthy life. Calculation of DALYs is based on the assumption that everyone in the world has a right to the best life expectancy in the world. The only differences in the rating of a death or disability should be due to age and sex and not to income, culture, location or social class. Its attractiveness lies in the fact that it combines information about mortality and morbidity in a single number. DALY allows the losses due to disability and the losses due to premature death to be expressed in the same unit. Hence, DALYs facilitate comparisons of different health states or

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Sample DALY calculations for a disease

Example A: 100,000 children are stricken for 1 week with a disease with a disability weighting* of 0.3; 2% die at 1 year old. = YLL + YLD DALYs = (2000 X 80) + (100,000 X 7/365 X 0.3) = 160,000 + 575 = 160,600
Example B: 100,000 adults are stricken for 2 years with a disease with disability weighting* of 0.6; 20% die at age 80 years. = YLL + YLD DALYs = (20,000 x 2) + (100,000 x 2 x 0.6) = 40,000 + 120,000 = 160,000

*There are STANDARDISED DISABILITY RATINGS for various conditions e.g deafness= 0.33, Down syndrome=0.5, Diarrhoea=0.12

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Why are DALYs important?

DALYs attempt to provide an appropriate, balanced attention to the effects of non-fatal as well as fatal diseases on overall health. In the absence of such assessments, conditions which cause decrements in function but not mortality tend to be neglected. DALYs help to inform debates on priorities for health service delivery, research and planning. For example, DALYs can be used to: Compare the health of one population with another and allow decision makers to focus on health systems with the worst performance

Compare the health of the same population at different points in time

Compare the health of subgroups within a population - to identify health inequalities

Classification of countries
The major diseases that affect people vary markedly in different world regions. Three major groupings of countries can be defined by geography, state of economic and demographic development, and mortality patterns.
Group I developing countries with high mortality developing countries with low mortality Sub-Saharan Africa South-East Asia China Latin America

Group II

Group III

developed / industrialised countries

Europe North America

Source: WHO World Health report 2002

Risks rather than specific diseases

An alternative way of looking at ill health is to consider risks for disease rather than diseases themselves A risk is defined as the probability of an adverse health outcome or a factor that raises this probability A single risk factor may underlie several diseases; e.g. unsafe sex is a risk for HIV/AIDS, many other sexually transmitted diseases and teenage pregnancy It is often more useful to direct health interventions against risks rather than specific diseases DALYs have been assigned to health risks as well as diseases

Factors which threaten health and are widely spread in populations have been identified in different regions of the world. These risks are strongly related to patterns of living and particularly to consumption. The vast majority of threats to health occur more frequently in the poor and in those with little education and lowly occupations. Therefore, the leading risks to health identified in developing countries are also the leading health risks at the global level:
Introduction 1

Relationship between risks to health and disease burden

Underweight the leading risk factor for disease and death in the world today. Particularly affects young children, women during pregnancy and the elderly. Unsafe sex - the main factor in the spread of HIV/AIDS. > 99% of HIV infections in Africa are attributable to unsafe sex. Unsafe water. Poor sanitation and hygiene - about 2 million deaths from childhood infectious diarrhoea still occur every year in the developing countries of the world. Iron deficiency. In-door smoke. Half of the worlds population is exposed to in -door pollution, mainly the result of burning solid fuels for cooking and heating. Globally, it is estimated that 36% of all lower respiratory infections and 22% of chronic obstructive pulmonary disease are associated with in-door pollution.

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What are the major risks to health in the developed world? Overweight and obesity are important determinants of health which lead to adverse metabolic changes, including elevated blood pressure, unfavourable cholesterol levels and increased resistance to insulin. They raise the risk of coronary heart disease, stroke, diabetes mellitus and many forms of cancer. According to the WHO World Health Report 2002, obesity on its own accounts for about 200,000 deaths in the United States of America and Canada alone, and about 320,000 deaths in the 20 countries of Western Europe. Tobacco and excess alcohol consumption are major risks to health in the developed world. Alcohol was estimated to cause 20-30% of oesophageal cancer, liver disease, epilepsy, motor vehicle accidents, and homicide The world is living worldwide. dangerously, says Dr Gro Brundtland (Former Director General, WHO) either because it has little choice, which is often the case among the poor, or because it is making the wrong choices in terms of its consumption and its activities.

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The concept of epidemiological transition

As life expectancy increases, the major causes of death and disability shift from communicable, maternal and perinatal causes to chronic, non-communicable ones.

In the developing world: According to the World Health Report 2002, there has been an increase in the consumption of alcohol and tobacco and an adoption of unhealthy lifestyles synonymous with a Western life style. This has led to an increased incidence of obesity, diabetes mellitus, cardiovascular diseases and conditions linked to them. Meanwhile, the burden of infectious disease remains. The resultant burden, consequent on the combined impact of communicable and non-communicable diseases, has been described as a double whammy.

Burden of disease attributable to 10 selected leading risk factors, by level of development

Introduction 1

Burden of disease attributable to 10 selected leading risk factors, by level of development

Source of data: WHO World Health report 2002

Burden of disease attributable to 10 selected leading risk factors, by level of development

Introduction 1

Source of data: WHO World Health report 2002

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What strategies can reduce risks to health?

Any health action promotive, preventive, curative, or rehabilitative activity, where the primary intent is to improve health.
Most riskreducing strategies involve a component of behaviour change.

The population Reduce risks in the population as a whole Legislation, tax, financial incentives by government Health promotion campaigns Engineering solutions; e.g. safety belts in vehicles, provision of piped water

The individual Target individuals within a particular

population Change health behaviours of individuals through personal interaction with a health provider

Overview
GBD
What is it? Why does it matter? Method Critiques

New GBD project

What is it? Why does it matter? Injury in the project Opportunity to participate

GBD: What is it?

Global Burden of Diseases, Injuries and Risk Factors One of several methods to summarise impact of diseases and injuries in populations Decreased duration of life and decreased functional capacity are combined and presented in units of DALYs Initial project: commissioned by the World Bank, led by Murray & Lopez; with WHO involvement, reported in 1996 on burden in 1990. Subsequent national & regional studies, risk factor study, WHO regular updates for 14 regions, etc.

GBD: Why does it matter?

Fairly wide-spread use for health sector priority-setting and related processes. This seems likely to increase. A force for improving knowledge of health status and burden, especially for parts of the world where this has been lacking.

GBD Goal
To produce new, robust, and reliable estimates of burden for all major diseases, injuries, and risks that are widely disseminated, understood, and easily used by policymakers, researchers, funders, and practitioners.

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Key Attributes
Producing specific DALY, YLL, and YLD estimates for over 300+ diseases/injuries and 40+ risk factors by age and sex for 21 regions for the years 1990, 2005, and 2010. Providing a consistent time trend (methods for current 00, 02, 04 estimates are not comparable to 90). Providing first comprehensive revision of Disability weights since 1996. Providing improved analytical tools to facilitate Burden estimates and policy use.
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Collaborating Partners

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GBD: Method (1)

YLL: years of life lost due to condition(s) of interest. YLD: years lived with disability due to condition(s) of interest.
(In GBD disability means reduced functional capacity)

YLL + YLD = DALYs

(Disability Adjusted Life Years)

A period with reduced functional capacity is equated to a period of lost life by means of Disability Weights

GBD: Method (2)

Disability Weights:
A summary of overall decrease in health related to a disease or a particular consequence of a disease. Several variations in method to obtain & apply weights:
Six domains (certain activities of daily living, procreation, occupation, education, recreation); values assigned were average ratings of a panel of public health experts. Panel of health professionals evaluated 22 indicator conditions using two types of person trade-off; clustered into 7 severity classes; distribution of these estimated for each of c 500 disabling Sequelae. Where relevant, done separately for treated & untreated cases and for age groups. Dutch disability weights study: similar method, plus health state distributions in terms of EQ-5D instrument. .1

.2

.3

GBD: Practical difficulty

Data deficiencies:
non-existent, scanty, incomplete, unreliable, hidden, inaccessible, etc.

This constrains:
Estimating incidence or prevalence of conditions Assessing duration & degree of decrements in functioning due to conditions Making Disability Weights

Risk Factors
Addictive substances Tobacco use Alcohol use Illicit drug use Environmental Unsafe water, sanitation, and hygiene Urban ambient air pollution Household air pollution from solid fuel use Lead exposure Passive smoking / Environmental tobacco smoke Food contamination Road and vehicle safety Violence related Sexual violence Intimate partner violence Collective violence Possession of firearms Occupational

Risks for injuries Carcinogens Airborne particulates Ergonomic stressors Noise Pesticides Other

Metabolic, nutritional and lifestyle

High blood pressure High cholesterol High blood glucose Dietary fats High BMI Low intake of fruit and vegetable

Under nutrition (child and maternal) Folic acid deficiency Anaemia and/or iron deficiency Small-for-gestational age Growth retardation Suboptimal breasfeeding Vitamin A deficiency Zinc deficiency Reproductive and sexual Unsafe sex Unwanted pregnancies Risks related to medical practice Genetic Systemic Global climate change Socioeconomic factors Other selected risks to health Osteoporosis 25

Physical inactivity

21 GBD Regions

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Sources: Gathering COD Data

Data providers

Types of sources Verbal Autopsies Household Surveys

WHO mortality database

(Geneva)
PAHO, EMRO, WPRO

Hospital Records
Sentinel Registration Demographic Surveillance Systems Sample Registration Systems Vital Registration with Certification of Cause of Death

mortality databases National Ministries of Health Networks: INDEPTH,

Matlab, India, etc.

Researchers

Literature Review

VA Literature Search Process

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VA Literature Screening Criteria

Four criteria: Population based study.1 Using verbal autopsy method.2 Open to any age group .3 Open to any set of causes.4

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Types of Studies in the Cause of Death Verbal Autopsy Database

80 70

60

Number of Studies

50

40

30

20

10

0 All Child Study Category Maternal

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Using VR data for 2005

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Disability Weights Measurement Disability weights provide the bridge between

mortality and non-fatal outcomes in disability adjusted life years (DALYs)

Disability weights quantify overall health levels associated with different states, on a continuum between perfect health (which has a value of 0) and death (which has a value of 1)
Construct reflects decrements from perfect health, distinct from broader notions of well-being or social value Must be measured on meaningful cardinal scale
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Disability Weights Measurement Survey components

Community surveys in 6 sites (Tanzania, Indonesia, Bangladesh, Peru, South Africa, United States), focusing on random paired comparison and time trade-off questions for 108 sequelae Open access Web-based surveys including all sequelae, and paired comparison, time trade-off and population equivalence questions Community surveys are using computer-assisted personal interview approach with laptops
Household interview in Pemba, TZ 10/23/2009
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GBD: Critiques
Numerous. For example:
Is it meaningful to equate unhealthy with shortened life? Are available input data too deficient to allow meaningful estimates? Are Disability Weights conceived and developed appropriately? Do they account adequately for:
Late consequences? Minor consequences of very frequent conditions?

Are GBD methods documented sufficiently?

Leading Causes of Mortality and Burden of Disease world, 2004

Mortality
Ischaemic heart disease 12.2 Cerebrovascular disease
9.7 Lower respiratory infections 7.1 COPD 5.1 Diarrhoeal diseases 3.7 HIV/AIDS 3.5 Tuberculosis 2.5 Trachea, bronchus, lung cancers 2.3 Road traffic accidents % .1 .2 .3 .4 .5

DALYs
Lower respiratory infections
6.2 Diarrhoeal diseases 4.8 Depression 4.3 Ischaemic heart disease 4.1 HIV/AIDS 3.8 .7 .8 .9 Cerebrovascular disease 3.1 Prematurity, low birth weight 2.9 .6 % .1 .2 .3 .4

.6

.5

.7

Distribution of age at death and numbers of deaths, world, 2004

Per cent distribution of age at death by region, 2004

Distribution of deaths by leading cause groups, males and females, world, 2004

Child mortality rates by cause and region, 2004

Distribution of causes of death among children aged under five years and within the neonatal period, 2004

Adult mortality rates by major cause group and region, 2004

High income Western Pacific Americas Eastern Mediterranean South East Asia Europe Africa 0 2 4 6 8 10 Death rate per 1000 adults aged 1559 years 12
Cardiovascular diseases Cancers Other noncommunicable diseases Injuries HIVAIDS Other infectious and parasitic diseases Maternal and nutritional conditions

Burden of disease by broad cause group and region, 2004

Age distribution of burden of disease by income group, 2004

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Global projections for selected causes, 2004 to 2030

Cancers Ischaemic HD Stroke

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Deaths (millions)

Acute respiratory infections Road traffic accidents Perinatal HIV/AIDS TB Malaria

2005 2010 2015 2020 2025 2030
Updated from Mathers and Loncar, PLoS Medicine, 2006

0 2000

Ten leading causes of burden of disease, world, 2004 and 2030