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Instituto Nacional de Salud Pública Centro de Investigacion es en Sistemas de Homicide/fatal violence in the Global Burden of Disease 2010 Rafael Lozano MD 6th Milestones of a Global Campaign for Violence Prevention Mexico City November 13th 2013

Homicide/fatal violence in the Global Burden of Disease 2010

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Homicide/fatal violence in the Global Burden of Disease 2010 . Rafael Lozano MD 6th Milestones of a Global Campaign for Violence Prevention Mexico City November 13th 2013. What are we measuring ? . The Global Burden of Interpersonal Violence. - PowerPoint PPT Presentation

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Page 1: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Homicide/fatal violence in the Global Burden of Disease 2010

Rafael Lozano MD6th Milestones of a Global Campaign for

Violence PreventionMexico City November 13th 2013

Page 2: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

• The Global Burden of Interpersonal Violence

What are we measuring ?

What is the global burden of disease, injuries and risk factors?

• A systematic scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex, geographies for specific points in time

Page 3: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Health loss is the key GBD concept: how do we measure it?

• Usually we count deaths and events (cases) as health loss, but we cannot add them.

• Thus, to combine them in a summary measure, we calculate the time loss due to premature mortality and the time lived with disability

3

DALYs = YLL + YLD

Health loss Health loss due to premature mortality

Time lived with disability

Page 4: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud 4

GBD terminology

1) DALYs = Years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs).

2) Years of life lost due to premature mortality due to a death at age x is the standard life expectancy at age x. A death at age 5 years counts as 81.4 YLLs, while a death at age 50 counts as 27.8 YLLs.

3) Years lived with disability for a cause in an age-sex group equals the prevalence of the condition times the disability weight for that condition.

4) Disability weights quantify the impact from any short-term or long-term health loss.

5) In the GBD 2010, DALYs are not discounted or age-weighted.

Page 5: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Background

– In 1991 the World Bank commissioned the first study to C. Murray (Harvard U.) and A. Lopez (WHO). In 1993, results were published in the World Report "Investing in Health“

– In 1996, final results were disseminated in 2 books and subsequently published in The Lancet

– Under the leadership of Dr. Gro Brundtland, WHO issued annual updates of the GBD from 1998-2002

– This activity continued in 2004 and 2008

5

Page 6: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

GBD 2010: new methods, wider scope

• “GBD 2010 study” initiated in 2007 and was funded by Bill & Melinda Gates Foundation.

• IHME head institution: shaped by University of Queensland, WHO, Harvard University, Johns Hopkins University, Imperial College London, University of Tokyo.

• Final study with 486 authors from 50 countries.

• Seven summary papers and an overview were published in a dedicated triple issue of the Lancet on December, 2012; and more than hundred detailed publications in submission or preparation.

• Systematic attempt to quantify health loss from all major diseases, injuries and risk factors for 187 countries overtime from 1990 to 2010.

• By the numbers: 291 diseases and injuries; 1,160 sequelae of these diseases and injuries; and 67 risk factors or clusters of risk factors.

Page 7: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

GBD Causes of Injury Categories

Unintentional

Transport Injury Road Injury PedestrianBicyclistMotorcyclistCar occupantOther

Other transportNon-transport Injury Falls

DrowningFirePoisoningsExposure to mechanical forces Firearm

OtherAdverse effects of medical RxAnimal contact venomous

non venomous‐Exposure to forces of natureOther unintentional injuries

Intentional

Self-harm and interpersonal violence

Self-harmInterpersonal violence Assault firearm

Assault sharp objectAssault other means

Forces of nature, war & legal intervention

Collective violence and legal intervention

Forces of nature

LEVEL II LEVEL IVLEVEL III LEVEL V

Page 8: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Sources and Methods for Interpersonal violence

SourcesDeaths: • Country Years• Vital Registration 2,705• Verbal Autopsy 71 • Surveillance Systems 17• Survey/Census 49• Police Reports 1,070

Non fatal outcomes:• Surveys for 61 countries• tabulations of hospital admissions from 27

different countries disaggregated by age, sex, external cause and sequela.

E/N code Matrrx• Brazil SIHSUS (2006-2009), Canada DAD data

(2004-2009), Mexico SINAIS data (2003-2009), and US NHDS data (1980-2008)

MethodsDeaths: Similar strategy to other GBD causes • Cause of death ensemble model (CODEM)

for Interpersonal violence, assault due to firearms, sharp objects and other means.

Non fatal outcomes:Same strategy to other injuries • Incidence by external cause and

incidence by nature of the injury (23 conditions)

• N/E code matrix• Probability of permanent disability• DW from the household survey and

adjusted from cohort studies in order to capture severity

Sources: Lozano R, et al 2012; Vos T. et al 2012; Murray CJL et al 2012

Page 9: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

For 2010, we have estimated 456.3 (359-611) thousand homicides in the world• 86% in developing countries• 43% related with firearms • 28% related with sharp

objects• 81% in males• 70% occurred before 40

years old

The Global Burden of Intentional Violence

Source: Lozano R, et al 2012

Mortality (age-adj) due to homicides, both sexes

1990 1995 2000 2005 20100.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Rate

x 1

00,0

00 p

op

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 800.0

5.0

10.0

15.0

20.0

25.0

Mortality by age and sex, 2010

Male Female

Rate

s x 1

00,0

00 p

op

Page 10: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

The Global Burden of Intentional Violence

• In 2010, estimates displayed 25.5 (20-33) million of DALYs due to interpersonal violence in the world, meaning 1% of the total burden

• Globally 94% were YLL and 6% YLD. In developed countries, health loss due to non fatal outcomes was 10%

• GBD estimated 31.3 million population with some sequelae of interpersonal violence. 78% male and 22% female.

• 55% were related with lacerations, multiple wounds, eye injuries; 26% fractures and 7% long term sequelae

Percent of DALYs due to interpersonal violence, 2010

< 10y 10-19y 20-49y 50-69 70+0.0

2.0

4.0

6.0

8.0

10.0

12.0

male female

Global Prevalence rate of interpersonal violence by age and sex, 2010

Rate

per

1,0

00 p

op

Source: IHME, 2012

Page 11: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

What is the leading cause of premature death in men in 2010?

Source: IHME, 2012

Page 12: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

The place of homicide within the leading causes of premature mortality in men, 2010

Source: IHME, 2012

Page 13: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Mortality rate(age-adj) due to Homicides by sex and mechanisms, GBD Regions 2010

Asia Pacific High IncomeEurope Western

AustralasiaAsia East

Europe CentralNorth Africa-Middle East

Asia SouthNorth America High Income

SubSaharan Africa-WestOceania

Asia SoutheastAsia Central

Latin America SouthernSub Saharan Africa East

LatinAmericaAndeanEurope Eastern

Sub S Africa CentralCaribbean

Sub S Africa SouthernLatin America TropicalLatin America Central

0.0 10.0 20.0 30.0 40.0 50.0 60.0

Firearm Sharp Other

Male

Europe Western

Asia Pacific High Income

Europe Central

Asia South

Asia Central

Asia Southeast

SubSaharan Africa-West

Sub Saharan Africa Central

Latin America Tropical

Latin America Central

Sub Saharan Africa Southern

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0

Firearm Sharp Other

Female

Rate per 100,000 male Rate per 100,000 female

Source: IHME, 2012

Page 14: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

The burden of Interpersonal Violence by Sex and Mechanism in Latin American Countries, 2010

Rate per 1,000 male Rate per 100,000 female

UruguayCubaPeruChile

BoliviaArgentina

C RicaNicaragua

R DomPanama

BeliceParaguay

EcuadorMexico

JamaicaBrasil

HondurasColombia

VenezuelaGuatemalaEl Salvador

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Firearm

Sharp

Other

ChileUruguay

C RicaArgentina

PeruCuba

NicaraguaBolivia

ParaguayMexico

EcuadorPanama

BrasilR Dom

VenezuelaColombia

BeliceJamaica

GuatemalaEl Salvador

Honduras

0.0 2.0 4.0 6.0 8.0 10.0 12.0

Firearm

Sharp

Other

Source: IHME, 2012

MALE FEMALE

Page 15: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

To understand where you are, you have to know where you come from

1990 1995 2000 2005 20100

10

20

30

40

50

60

70

80

90

El SalvadorGuatemalaVenezuelaColombiaSouth AfricaBrazilMexicoRussia

YLL

per 1

000

pop

Rate of YLL (age-adj) due to Interpersonal Violence in Male, 1990- 2010

Source: IHME, 2012

Page 16: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Homicide mortality in Male, Mexico 1955-2011

19551959

19611964

19671970

19731976

19791982

19851988

19911994

19972000

20032006

20090.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

f(x) = − 1.14885565385417 x + 77.7290150265946R² = 0.948037624185136

2005-2011 1955-2004 Linear (1955-2004)

Rate

per

100

,000

men

*Rate per 100,000 males (age adj)Sources: WHO, 1955-1978; SSA/INEGI, 1979-2011. CONAPO, Population Estimates 1955-2011

What happens after 2004?

What did you do to decrease homicides in the second half of the last century?

Page 17: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Rate per 100,000 pop

Source: INEGI, Boletín de Prensa 288/13

Yucatán

Baja California Sur

Querétaro

Chiapas

Tabasco

Quintana Roo

Guanajuato

San Luis Potosí

México

Oaxaca

Jalisco

Nayarit

Morelos

Colima

Tamaulipas

Sinaloa

Guerrero

0 10 20 30 40 50 60 70 80

Brazil 31 x 100,000

Guatemala 62 x 100,000Colombia 46 x 100,000

USA 6 x 100,000

Central Europe 2.2 x 100,000

Homicide mortality both sexes, Mexico 2012

National Averages hide disparities

Page 18: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Male Female

As all the world, homicides in Mexico are a matter of young males

1980 2011 1980 20110

80

30-40% of all deaths are due to homicides

Page 19: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Interpersonal Violence is the lead cause of DALYS in Mexico in males, 2010

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

Page 20: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Leading causes of DALYs for both sexes in Latin American and Caribbean countries, 2010

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

Page 21: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Final remarks

• For purposes of violence prevention, it would be convenient to incorporate the GBD framework. – Using an holistic approach, interpersonal violence is located at the top of the

health losses in several countries– We have to measure the burden by type of violence and not only by mechanism

• Premature mortality and young population are key for measurable targets• Violence related with firearms is spreading significantly in LAC countries.

The burden of this mechanism is over 70% in Venezuela, Colombia and El Salvador.

• An update of the “GBD 2010 study” is coming soon (GBD2013), but it demands more collaboration

• To analyze health disparities it is imperative to do subnational studies (Mexico, UK and China are on track)

Page 22: Homicide/fatal violence in the Global Burden of  Disease 2010

Instituto Nacional de Salud Pública

Centro de Investigaciones en Sistemas de Salud

Crime and violence statistics portrait reality crudely, but we must not ignore

that behind each number there is a person, a family, and therefore, a tragedy that we must respect ....

when we prevent and avoid violencewe show respect