Non-communicable diseasesA global overviewDavid Leon

*OutlineDefinition Non-communicable disease mortality worldwideThe Epidemiological TransitionGlobal Burden of Disease StudyMajor risk factorsBlood pressureCholesterolSmokingInfection and non-communicable diseases

*What are non-communicable diseases?

*Classifying deaths and diseases(WHO)Communicable diseases [Group I]Those where death is directly due to the action of a communicable agentNon-communicable diseases Diseases [Group II]Cancer, diseases of various organ systems (eg respiratory, cardiovascular etc.), diabetes, mental health etc.External causes (injuries, poisonings and violence) [Group III]

*Importance of non-communicable diseases mortality

*A global problemIn 2004 there were 59 million deaths world-wideNon-communicable diseases accounted for 60% of these deaths and injuries and violence 10%. By 2020 it is estimated that non-communicable disease will account for 73% of all deathsGBD 2004 Update, 2008

*The epidemiologic transition(Omran, 1971)Change in the balance of disease in a population from communicable diseasesto non-communicable disease

*Decline in proportion of total mortality due to infectious diseases

England & Wales, 1911-94, by age

*Different countries at different stages of the epidemiological transition

*Non-communicable diseases as % of all deaths by global region (all ages)

WORLDWIDE59%N.America; W Europe88%China, W Pacific, + some SE Asia75%Latin America + Caribbean67%S E Asia including India51%Sub-Saharan Africa21%

*Urbanisation

*http://www.indiaimages.com/street/street_life2_large.jpg

*Urbanisation

*Drivers of the epidemiological transition in low and middle income countriesPopulation ageingMajor socio-economic changes (especially urbanisation)changes in risk factors such as diet, physical activity, smoking etc.

*Global Burden of Disease (GBD) Study

*GBD 2001 mortality estimates107 countries had collected useable information on cause of death from registration systems55 countries (42 in sub Saharan Africa) no information on adult mortalityEstimates based on many assumptions and extrapolations

*Global Burden of Disease StudyFirst GBD study started in 1992 by World Bank.Second GBD study (in collaboration with WHO) conducted 2001Extensive synthesis of all available data to give set of mortality estimates by age, sex, region and cause worldwide for the first time2001 GBD study covers 135 causes of death, 17 sub-regions, based on aggregation of country-level information

Global Burden of Disease2004 Update (published 2008)http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf*

Distribution of deaths in the world by sex, 2004*GBD report 2004 update, 2008

Mortality rates among men and women aged 1559 years, region and cause-of-death group, 2004*GBD report 2004 update, 2008

Projected global deaths for selected causes, 20042030*GBD report 2004 update, 2008

Effect of key risk factors on mortality*

Combining data Prospective studies collaboration *

Prospective Studies Collaboration Established chiefly to investigate associations of blood pressure and cholesterol with cause-specific mortality

Individual data on 900 000 participants without any previous history of vascular disease from 61 prospective cohort studies

55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other)

Blood pressure and cardiovascular mortality*

December 02*

Cardiovascular mortality: Age-specific effects for 20mmHg lower usual SBP55 345 deaths at ages 40-89

*

Cholesterol and cardiovascular mortality*

80-8970-7960-6950-5940-49Age atriskUDV3:[VEP.PSC.FIGURES.TCHOL.240907]ihd-by-agesex-hettrend.ctrl: 24-SEP-2007 14:47:08.14 Usual total cholesterol (mmol/L)4050607080051248163264128256Hazard ratio( 95% CI)Ischaemic Heart Disease mortality (33 744 deaths) and total cholesterol

Different for stroke*

UDV3:[VEP.PSC.FIGURES.TCHOL.240907]stroke-by-agecause-trend.ctrl: 24-SEP-2007 14:47:18.56 Usual total cholesterol (mmol/L)4050607080124816326480-89 70-79 60-69 40-59 Age Hazard ratio(& 95% CI)Stroke mortality (11 663 deaths) and total cholesterol by age

*Smoking

*% of deaths aged 35-69 years attributable to smoking in 2000Source : http://www.deathsfromsmoking.net/

MenWomenBelarus33%0%Russia33%3%Ukraine32%3%Central Asia (8)23%4%Estonia31%3%Latvia30%2%Lithuania29%0%United Kingdom25%21%Germany29%11%

*Risk of myocardial infarction increases with every single cigarette smoked per dayNumber of cigarettes smoked per dayOdds Ratio of Myocardial InfarctionNever 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 >=21Source : K. K. Teo et al Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART studyLancet 368 (9536):647-658, 2006.INTERHEART study 52 countries 12 461 cases, 14 637 controls

*Smoking causes more deaths from cardiovascular disease than cancerDeaths attributed to smoking among men (all ages) in Russia, 2000

All cancers = 77,000

Cardiovascular disease = 148,000Source : http://www.deathsfromsmoking.net/

*Things are getting worse not better

*Smoking in men in Russia is not decliningRuralUrbanSt Petersburgh/MoscowSource : Perlman et al Tob.Control 16 (5):299-305, 2007Russian Longitudinal Monitoring Survey

*Smoking in women in Russia is increasingRuralUrbanSt Petersburgh/MoscowRussian Longitudinal Monitoring SurveySource : Perlman et al Tob.Control 16 (5):299-305, 2007

Giving up smoking reduces risk*

*

Some non-communicable diseases have infectious etiology*

Trends in stomach cancer mortality*Source : WHO HFA databaseAge standardised mortality per 100,000

Chart1

198013.2132.5529.2532.9946.45198017.65

198112.7431.9628.2829.4445.53198117.05

198212.0130.5826.929.6745.34198216.19

198311.8629.3926.5728.7744.69198316.38

198411.6428.0126.1329.4643.6198415.94

198510.8126.072528.6341.88198515.23

198610.725.924.1927.1641.21198614.63

16.5910.0124.7923.927.1640.7710.5914.35

15.699.9924.822.9726.8439.9410.2714.07

15.469.2224.2821.8126.8838.899.8513.37

13.669.0324.3621.1826.7538.429.6612.76

13.158.4723.6720.2324.7737.379.4412.21

11.858.1423.5219.9224.8636.58.8511.88

12.048.0222.6918.9523.535.678.1710.79

11.187.4922.0718.3322.134.428.1110.79

10.567.2721.0717.8822.8733.317.189.97

10.57.0619.2916.9721.4431.647.269.51

10.26.7919199720.6230.427.429.15

8.916.8418.91199819.6529.726.628.95

8.376.5918.0115.3920.0329.246.798.45

8.226.2916.7715.2119.4528.246.162000

8.026.0516.5114.6318.6727.266.277.65

8.046.0316.0714.317.9626.136.147.4

7.625.6915.3413.8517.1825.6820036.93

7.66200414.3813.3616.4825.0920046.67

7.43200512.82005200524.120052005

Finland

France

Hungary

Poland

Portugal

Russian Federation

Sweden

United Kingdom

Sheet1

Column1Column2

YearsFinlandFranceHungaryPolandPortugalRussian FederationSwedenUnited Kingdom

198013.2132.5529.2532.9946.4517.65

198112.7431.9628.2829.4445.5317.05

198212.0130.5826.929.6745.3416.19

198311.8629.3926.5728.7744.6916.38

198411.6428.0126.1329.4643.615.94

198510.8126.072528.6341.8815.23

198610.725.924.1927.1641.2114.63

198716.5910.0124.7923.927.1640.7710.5914.35

198815.699.9924.822.9726.8439.9410.2714.07

198915.469.2224.2821.8126.8838.899.8513.37

199013.669.0324.3621.1826.7538.429.6612.76

199113.158.4723.6720.2324.7737.379.4412.21

199211.858.1423.5219.9224.8636.58.8511.88

199312.048.0222.6918.9523.535.678.1710.79

199411.187.4922.0718.3322.134.428.1110.79

199510.567.2721.0717.8822.8733.317.189.97

199610.57.0619.2916.9721.4431.647.269.51

199710.26.791920.6230.427.429.15

19988.916.8418.9119.6529.726.628.95

19998.376.5918.0115.3920.0329.246.798.45

20008.226.2916.7715.2119.4528.246.16

20018.026.0516.5114.6318.6727.266.277.65

20028.046.0316.0714.317.9626.136.147.4

20037.625.6915.3413.8517.1825.686.93

20047.6614.3813.3616.4825.096.67

20057.4312.824.1

*Helicobacter pylori bacterium - a causal factor for stomach cancer

*Marshall BJ,.Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984;1:1311-5.Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch's postulates for pyloric Campylobacter. Med.J.Aust. 1985;142:436-9.

The Helicobacter pylori story ...

SummaryNon-communicable diseases are now the most common cause of death world wideIncreasing rates in low and middle income countries because of change in lifestyles (urbanisation)Key risk factors have very large effectsInterventions are effective and can reduce burdenThe need to combine results and have large studies*

**Here we see the decline over time in the proportion of mortality at different ages attributable to infections ranging from tuberculosis to diuphtheria, measles and gastro-intestinal infections. The downward spike in 1918 is because most excess deaths were from pneumonia rather than influenza. Rates of pneumonia were much lower than those for infectious diseases either side of the 1918 Spanish flu making up less than 10% of all deaths among those aged The sharp decline mid-century is not well understood and is under-researched. The precise role of the introduction and use of anti-biotics is important question.. Mackenbachs work suggesting that this played a role in the Netherlands at least.With the decline of infectious diseases life-expectancy in particular becomes more strongly related to the influence of individual behaviours. This is apparent with the widening gap in male to female life-expectancy over the 20th Century which rose from 4 years in 1900 to a peak of just over 6 years in the late 1960s.

http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf

*The Prospective Studies Collaboration is a collaborative meta-analysis combining data from existing prospective observational studies that recorded both blood pressure and blood cholesterol at baseline and that followed participants for cause-specific mortality. Investigators from around the world have collaborated to combine data from 61 existing prospective studies involving a total of one million participants from Europe, North America, Australia, Israel, China and Japan. During 12.7 million person-years of follow-up there were 120000 deaths involving more than 55000 vascular deaths (12000 stroke, 34000 ischaemic heart disease [IHD], 10000 other vascular) and more than 65000 other deaths.PSC: Age-specific relevance of usual blood pressure to vascular mortalityLancet 2002; 360:1903-13*Figure 1(a): IHD mortality (33 744 deaths) versus usual total cholesterol. Age-specific associationsThe hazard ratios are plotted on a floating absolute scale of risk (so each log hazard ratio has an appropriate variance assigned to it.

NOTES: 1 mmol/L lower total cholesterol was associated with about a half , a third and a sixth lower IHD mortality in both sexes at ages 40-49, 50-69 & 70-89, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold.Although the proportional differences in risk decrease with age, the absolute effects of cholesterol on annual IHD mortality rates are much greater at older than at younger ages. For example, the absolute difference in the annual risk of IHD death for a 1 mmol/L difference in total cholesterol was about 10 times greater at 80-89 than at 40-49 years of age. Figure 4(a). Stroke mortality (11 663 deaths) versus usual total cholesterol. Age-specific associations for total stroke.Conventions as in figure 1(a).

NOTES: There was a weak positive association between total cholesterol and total stroke mortality at ages 40-59 years, but little association at older ages. When the MRFIT and PSC findings were combined (table 2, webfigure 7), there was a weak positive association with total stroke at ages 40-59 and 60-69 years, but not at older ages.http://www.deathsfromsmoking.net/*http://www.deathsfromsmoking.net/**