Burden of NCDs in India

Burden of NCDs in India

Dr. Ashoo GroverScientist

ICMR Headquarters, Delhi

EPIDEMIOLOGICAL : NCDS OVERRIDING INFECTIOUS DISEASES AND DOUBLE BURDEN OF DISEASES IN MANY DEVELOPING COUNTRIES

LIFESTYLES: TOBACCO USE IS INCREASING DIETS ARE RAPIDLY CHANGING

PHYSICAL ACTIVITY REDUCINGALCOHOL USE

INCREASING OBESITY, DIABETES, HYPERTENSION ARE INCREASING IN MOST PARTS OF THE WORLD,

WHILE UNDER-NUTRITION REMAINS A SEVERE ISSUEDEMOGRAPHIC : POPULATION AGEING.GLOBALIZATION : INCREASING GLOBAL INFLUENCES

THE WORLD HEALTH IS IN TRANSITION

HEALTH TRANSITION contd……

• Rapid urbanization• Increased industrialization• Rising incomes• Expanded education, and• Improved health care.

• Improved public health measures have resulted in the control of many infectious diseases, and reduction in mortality and fertility

COMMUNICABLE VERSUS NON-COMMUNICABLE DISEASES

Communicable diseases• Sudden onset• Single cause• Short natural history• Short treatment schedule• Cure is achieved• Single discipline• Short follow up• Back to normalcy

Non-communicable diseases• Gradual onset• Multiple causes• Long natural history• Prolonged treatment• Care predominates• Multidisciplinary• Prolonged follow up• Quality of life after treatment

NONCOMMUNICABLE DISEASE CONTRIBUTE 60 % OF DEATHS AND 43 % OF THE GLOBAL BURDEN OF DISEASE. ALREADY 79% OF THESE NCDS ARE OCCURRING IN DEVELOPING COUNTRIES.

BY 2020 THESE DEATHS WILL ACCOUNT FOR 73% DEATHS AND 60% OF THE DISEASE BURDEN.

HALF OF THESE DEATHS ARE ATTRIBUTABLE TO CARDIOVASCULAR DISEASES.

THERE ARE MORE CVD DEATHS IN INDIA OR CHINA THAN IN ALL DEVELOPED COUNTRIES ADDED TOGETHER.

THE GLOBAL NCD REALITY

32.5%

58.5%

9.0%Injuries

(5.1 million)

Noncommunicableconditions

(33.1 million)

WORLD Mortality BY BROAD CAUSE GROUP, 2001

Communicable diseases, maternal

and perinatal conditions and

nutritional deficiencies

(18.4 million)

Total deaths: 56,554,000

Source: WHR 2002

3%3%

5%5%

7% 3% 6%4%

13%

30%9%

DISTRIBUTION OF CAUSES OF DEATH WORLD, 2001

Total deaths: 56,554,000

Cardiovascular diseases

Diabetes

Malignant neoplasmsDigestive diseases

Neuropsychiatric disordersRespiratory diseases

Other NCDs

InjuriesOther CD causes

Nutritional deficienciesMaternal conditions

MalariaChildhood diseases

TuberculosisDiarrhoeal diseasesPerinatal conditions

HIV/AIDSRespiratory infections

Source: WHR 2002

42.0%

45.9%

12.2% Injuries

Noncommunicableconditions

WORLD, DALY’s, BY BROAD CAUSE GROUP, 2001

Communicable diseases, maternal and perinatal

conditions and nutritional deficiencies Source: WHR 2002

6%

6%

4%3%

3%6% 7%

5%

13%

3%

10%4%3%

12% Cardiovascular diseases

DiabetesMalignant neoplasms

Digestive diseases

Neuropsychiatric disorders

Other NCDs

Injuries

Other CD causes

Maternal conditions

MalariaChildhood diseases

Tuberculosis

Diarrhoeal diseases

Perinatal conditions

HIV/AIDS

Respiratory infections

Respiratory diseases

Nutritional deficiencies

Sense organ disorders

Diseases of the genitourinary system

Musculoskeletal diseasesCongenital abnormalities

DISEASE BURDEN (DALY’s) WORLD, 2001

Source: WHR 2002

75%

50%

25%

AFR AMR EMR EUR SEAR WPR

Mortality BY BROAD CAUSE GROUP AND WHO REGION, 2001

Communicable diseases, maternal and perinatal conditions and nutritional

deficienciesNoncommunicable

conditions Injuries

Source: WHR 2002

75%

50%

25%

AFR AMR EMR EUR SEARWPR

DALY’s BY BROAD CAUSE GROUP AND WHO REGION, 2001

Communicable diseases, maternal and perinatal conditions and nutritional

deficiencies

Noncommunicableconditions Injuries

Source: WHR 2002

Major NCDs responsible for some 19 million deaths worldwide annually

both the developed and developing world sharing the burden more or less equally.

All NCDs, account for at least 40 % of all deaths in developing countries and 75% in

industrialized countries Cardiovascular diseases (CVDs) are the first

cause of mortalityCancer is the third one

Estimated and projected proportion of deaths due to non-communicable

diseases, India, 1990-2010

0%10%20%30%40%50%60%70%80%90%

100%

1990 2000 2010Year

Prop

ortio

n (%

)

Injuries

Communicable diseasesNon communicable diseases

No. of cases No.of DALY No. of YLL No. of deaths05

1015202530354045 39.40

16.00

4.950.55

No. in mil-lions

No. of cases

No.of DALY No. of YLL No. of deaths

01234567

1.64

6.365.28

0.63

No. in mil-lions

No. of cases No.of DALY No. of YLL No. of deaths0

10

20

30

40

50

60

70

66.58

2.26 1.15 0.11

No. in mil-lions

Ischemic heart diseases Stroke

Diabetes

Burden of major non-communicable diseases, India, 2004

Six key “risk factors” for Non-Communicable Diseases

• Tobacco use in any form (smoking ,chewing, snuff).

• Alcohol abuse• Life-style changes (easy dietary patterns,

physical inactivity)• Environmental risk factors e.g. air and water

pollution, occupational hazards • Failure or inability to obtain preventing health

services (e.g. for hypertension control, tobacco control, management of diabetes etc.

• Stress factors

Lifestyle Risk factors

• Improper nutrition • Sedentary life• Alcohol and • Tobacco

Cancer Scenario-India

• 2.5-3 million cases of cancer• 8 million detected in 2001• 3-3.5 lakh deaths each year• 500% increase in cancer in India by 2025• 280% due to ageing and 220% due to tobacco

use• Tobacco related cancers 50% (males) and 25%

(females)• 2/3rd are advanced at the time of diagnosis

Estimated Number of Incident Cancers in India, 2001

Site Male Female Both SexesLip, Oral cavity 39,000 31,000 70,000

Pharynx & Larynx

53,000 14,000 67,000

Oesophagus 31,000 26,000 57,000

Stomach 35,000 16,000 51,000

Lung 34,000 7,000 41,000

Breast - 80,000 80,000

Cervix uteri - 100,000 100,000

Others 201,000 139,000 340,000

Total 393,000 413,000 806,000

Cancer facts and figures

• One in about 15 men and one in about 12 women in the urban areas could develop cancer in their lifetime

• Cervical cancer and breast cancer are the commonest in females. The latter is more than former in Mumbai and Delhi

• Cancer lung is the commonest out of all tobacco related cancers in men

• Cancer of the oesophagus highest in women in Bangalore (8.3/100,000)

Tobacco Use – Global Scenario

• 1.2 billion users, expected to rise to 1.6 by the next two decades

• 3.5 to 4 million deaths annually due to tobacco use expected to rise to 10 million in 2020s.

• 7 million in developing countries.

Tobacco Use in India

• No. of tobacco Users in India. 150 Million Men 34 Million women

• No. of smokers 105 Million Men 7 Million Women

• No. of Smokeless Tobacco Users 66 Million Men 30 Million Women

Rural Urban05

101520253035

33.6

23.2

8.8

4.0

Prevalence of Tobacco Use

Men Women

%

CHD prevalence studies in India

Place Year Prevalence

Agra 1996 1.05

Delhi 1962 1.04

Chandigarh 1968 6.60

Rohtak 1975 3.63

Delhi 1990 9.67

Jaipur 1995 7.59

Moradabad 1995 8.55

TVM 1995 12.65

Place Year Prevalence

Haryana 1974 2.06

Vidharabha 1988 1.04

Kerala 1993 7.48

Punjab 1994 3.09

Rajasthan 1994 3.53

Uttar Pradesh

1995 3.09

Urban Rural

Cardio-vascular diseases (CVD)

Morbidity and mortality data• CHD deaths=8 lakhs• Stroke deaths=6 lakhs• Hypertension= 10-15 %• RHD deaths=1.5 lakhs• RHD prevalence=1-5/1000 (5-15 years)• CVD and stroke deaths 23%

• Source: WHO infobase

Burden of Rheumatic Fever/Rheumatic Heart

Disease

Delhi Varanasi Vellore

1.0/100,000

5.4/100,000

2.9/100,000

Social Determinants of Health Inequalities, Marmot M, Lancet 2005

Projected proportional increase in population > 65 years age, 2000-

2030

0% 50% 100% 150% 200% 250%

MexicoChileIndia

ChinaUSAUK

JapanItaly

Proportion (%)

Projected population pyramid of India

Growth of elderly population aged 60 and over, by sex, in India 1901-2001

1901

1911

1921

1931

1941

1951

1961

1971

1981

1991

2001

01020304050607080

Number of Older Persons in India (in milllions)

No.of Older PersonsYear

Popu

latio

n

(Source: ICMR Collaboraitve Studies)

Estimated Load of NCDs in Older Persons

(in millions)

Diseases 1991 2001Cataract 46.47 63.61Hearing Impairment 33.85 46.30Heart Diseases 19.96 27.32Hypertension 5.34 7.33CHD 5.02 6.87Diabetes 2.74 3.75Blindness 2.40 3.30Cancers 1.48 2.10Mental Morbidities 1.10 1.53

(Source: World Bank Health Sectoral Priorities Review)

Estimated and projected mortality rates (per 100,000) by major causes of death in 60+

population INDIAMajor

causes1985 2000 2015

M F M F M FAll causes 1158 1165 879 790 846 745Infections 478 476 215 239 152 175Neoplasms

43 51 88 74 108 91

Circulatory

145 126 253 204 295 239

Pregnancy 0 22 0 12 0 10Perinatal 168 132 60 48 40 30Injury 85 65 82 28 84 29Others 239 293 280 285 167 171

ESTIMATED BURDEN OF NEUROLOGICAL DISORDERS IN INDIA

Disorder

Rate (per one lakh population)

Urban Rural TotalTotal Neurological DisordersEpilepsyHeadacheFebrile convulsionsCerebrovascular disorders Mental retardationTremors

2371

575986198138

105

57

4335

11931254466165

178

378

3348

8821119332151

141

414

Severe mental morbidity in India

Bangalore Baroda Calcutta Patiala0

100

200

300

400

500

600

700

800

Epilepsy Schiz Dep psychosis Org brain synd Mania

Prev

rate

/100

,000

Blindness

Senile Degeneration47%

Metabolic25%

Indefinite17%

Prenatal3%

Infections6%

Injuries2%

Others1%

Etiology of Blindness

Lens75%

Cornea7%

Optic Nerve7%

Others & Unknown6%

Bulbar atrophy4%

Site of blindness Nationwide study in 1970s for the first time

provided figures for blindness in the countryThe national program for control of blindness

was initiated on this basis

Cataract was the commonest --due to senile degeneration

Cataract

Series105

101520253035

2.18 3.566.28

8.6714.26

11.27

29.08

BACKLOG OF CATARACTCases in Lakhs

40-44

45-49

50-54

55-59

60-64

65-69

70 and aboveAge

Study on cataract prevalence found different figures for different areas

Increasing backlog of cataract due to less surgeries

Different strategies applicable to different areas

Burden of diabetes• In the developing countries

majority of people with diabetes are in the age range 45-64 years

diabetes will be increasingly concentrated in the urban areas

Increasingly, there would be more women than men with diabetes

DALYS 5.3 millions

Burden of Diabetes in India

Mortality Number of deaths (000)

Diabetes as a cause 104

Attributable to DM 473.7

DALYS 5.3 millionMurray, Lopez. 1996

Prevalence of Type 2 DM in India

Year Author Place Prevalence

urbanrural

1971 Tripathi Cuttack 1.2 -1972 Ahuja N. Delhi 2.3 -1979 Gupta Multi-centric 3.0

1.31984 Murthy Tenali 4.7 -1988 Ramachandran Kudramukh 5.0 -1989 Rao, PV Multicentric -

2.81992 Ramachandran Chennai 11.6-1997 Reddy, KS Delhi

11.02.72000 NUDS (DESI) Multicentric 13.2-

1995 2000 20250

102030405060

19 23

57

Millions

1995 2000 202501234567

3.8 4

6

Prevalence (in %)

Prevalence of Type 2 diabetes in India

Source: King H et al - Global burden of diabetes 1995-2025 Diabetes Care1998;21:1414-1431.

NON COMMUNICABLE DISEASE PROGRAMMES IN INDIA

A. National cancer control programmeB. National mental health programme C. National blindness control programmeD. Cardiovascular diseases, stroke and diabetes

programme E. Trauma and accident programme F. Oral health programme G. Rehabilitation programme H. Geriatric care programme

Sources of NCD related data in IndiaMortality Medical

Certification of Death

Causes of Death SurveyMOHFW DataCBHI data

Hospital Data

Morbidity Disease Registry (Cancer)AMI Under ProcessDM Under Process

Special SurveyMeta-analysis (Mental Health)NFHSNSSO

Hospital ReportsPGIMER Respiratory Disease SurveyJIPMER (Neuropsychiatricmorbidity)

Risk Factors

No regular surveyIDSP ???

Special Survey (ICMR-NCD Surv)MOHFW 10 Centre Study on ElderlyICMR Substance Abuse SurveyNFHSNSSO

ICMR ad-hoc StudiesMedical College

EXISTING REPORTING SYSTEMS FOR NON COMMUNICABLE DISEASES IN

INDIA• Sentinel surveillance systems

National Cancer Registry Programme• Periodic surveys/studies

Census of India Sample registration systems National sample surveys National family health survey National nutrition monitoring programme

SOURCES OF DATA COLLECTION FOR NON COMMUNICABLE DISEASES IN

INDIA• Mortality data

Medical certificates for death Cause of death surveys Hospital records

• Morbidity data Registry (Cancer) Special surveys Hospital reports

• Risk factors Special surveys

• Registries Cancer (Shift from hospital to community based) RF/RHD (Jai Vigyan Mission) Thalasemia (Jai Vigyan Mission)

NCD Mortality Profile 1998 (Source: WHO NCD Info-base)

Disease No of death (% of death)All cancers 292,557 (3.4)CVD 1,117,994 (13.0) IHD 423,600 RHD 57,272 Stroke 102620 Other HD 52502

Diabetes 21000 (0.2)Injuries 749,983 (8.7) RTA 85,003 Other Injuries including Poisoning

528,486

Suicides 91,324 Homicides 45,170

Chronic Respiratory Disease 577,837Neuro-psychiatric Disorders Not available

NCD Morbidity Profile in India 1998Disease No of casesNeuro-psychiatric Disorders 110,660,782Chronic Respiratory Disease 65,000,000Diabetes 28,702,100CVD NR IHD 25,000,000 RHD 1,882,987 Stroke 1,083,500 Other HD NR

Injuries 6,900,000 RTA 900,000 Other Injuries including Poisoning

6,000,000

Suicides NR Homicides NR

All cancers 593,803 (incidence)

NCD Risk Factors in India

Rask Factor

Definition Prevalence (%) in Urban Areas

Prevalence (%) in Rural Areas

Hypertension > 160/95 mmHg

10-15 (4) 3-8 (4)

Hypertension > 140/90 mmHg

20-30 (6) 15-25 (4)

Overweight BMI > 25 20-40 (2) 10 (1)Hypercholestrolemia

> 220 mg/dl 20 (1) 10 (1)

Sedentary Physical Activity

Varied 50-60 (6) 8-30 (3)

Kerala

Delhi

Jammu & Kashmir

Nagaland

Bihar

High literacy rate, developed

Metropolitan city, highly urbanized, heterogeneous populationNested populationTerrain, relatively underdeveloped

Nested populationUnderdeveloped, Tribes andTerrainIlliterate, Poor populationRural, Agricultural, Tribals

Differentdietary patterns

Differentbody

composition

Differenthabits

HETEROGENEITY OF NON-COMMUNICABLE

RISK FACTORS IN INDIA

Challenges• Huge population• Many programmes• Rural population• Emerging epidemics• Unemployed youth• Burden of non communicable diseases

Opportunity• Good sample size• Different strategies• Complex exposures• Interventions• Trained workforce

Challenges and opportunities

Age

Deve

lopm

ent o

f non

com

mun

icabl

e di

seas

es

Foetallife

Adult Life Adolescence Infancy andchildhood

• SES• Nutrition• Diseases• Linear

growth• Obesity

• Obesity• Lack of

activity• Diet• Alcohol,• Smoking• SE

potential

• Established adult risk factors(behavioural/biological)

• SES• Maternal

nutritional status & obesity,

• Fetal growth

Accumulated risk

Range of individual risk

Accumulated risk

Life course approach for the prevention of non communicable

diseases

Public health interventions

Policy interventions Educational interventions

Health beliefs and behaviours

(Community; Individual)

Desired change

Enabling environment(Financial, Social, Physical)

FACTS ABOUT NCDS

• The burden of diseases due to non communicable diseases in India became almost equal to that due to communicable diseases in 1990

• The burden of non communicable diseases is increasing while it is declining in developed countries because of surveillance and interventions

• The life style related modifiable risk factors for non communicable diseases have been identified and the magnitude of their impact is documented

FACTS ABOUT NCDS

• The major non communicable diseases share common, preventable life style risk factors

• There is sound evidence that non communicable diseases can be reduced through a package of simple, effective and feasible life style changes

• The treatment of non communicable diseases is expensive and therefore the key to control is in its primary prevention

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