Medical Advances Affecting Morbidity and Mortality

The institute of Actuaries of JapanOctober 13, 2005

By Dr. Philip SmalleyVice President and Medical Director

RGA International

Toronto, Canada

St. Louis, USA

AgendaLongevity trendsTrends in Cardiovascular DiseaseObesity and Diabetes epidemicTrends in CancerInfection disease threats

Trends in All-Cause Death Rates,1960-2000

Australian Institute of Health and Welfare 2004 ABS Cat. No. 3201.0; AIHW National Population DatabaseAustralian Institute of Health and Welfare 2004 ABS Cat. No. 3201.0; AIHW National Population Database

Life Expectancy in Japan

Oldest Human

Jeanne Calment lived 122 years 164 days between February 21, 1875 and died August 4, 1997

http://www.wowzone.com/calment.htmhttp://www.recordholders.org/en/list/oldest.html

Genetics of Longevity

1/4 of variation in longevity can be attributed to genetic factorsLongevity genes found in yeast, flies, and wormsLongevity gene(s) linked to chromosome 4

Werner SyndromeIncidence 1-20 per 1,000,000Autosomal RecessiveGenetic defect on chromosome 8Accelerated ageing beginning in adolescence

Picture from National Centre for Biotechnology Information – Genes and Disease

PharmocogeneticsRecombinant DNA to make pure proteinsTailored drug therapies Block the abnormal gene product proteinGive patient a therapeutic gene

“Doctors Are the Third Leading Cause of Death in the U.S.”

Total deaths per year from iatrogenic causes

250,000Medication errors in hospitals7,000Unnecessary surgery12,000Other errors in hospitals45,000Infections in hospitals80,000Non-error, negative effects of drugs106,000

CauseDeaths per Year

Disease Trends in

Japan

Cancer Statistics in Japan 2003

Age AdjustedDiseaseTrends in

Japan

Cancer Statistics in Japan 2003

Atherosclerosis

Cardiovascular RiskCardiovascular RiskCardiovascular Risk

LipidsHTN

Diabetes

LipidsLipidsHTNHTN

DiabetesDiabetes

Behavioral-Smoking-Inactivity

BehavioralBehavioral--SmokingSmoking--InactivityInactivity

HemostaticThromboticHemostaticHemostaticThromboticThrombotic InflammatoryInflammatoryInflammatory GeneticGeneticGenetic

Smoking Trends

in Japan

1988 1993 1998 2003

Chobanian, AV et al. JAMA. May 21, 2003 Vol. 289 No. 19, pg 2560-2571

New JNC VII Blood Pressure Guidelines

Hormone Replacement Therapy

Table from Hulley SB et al, JAMA. 2004;291:1769-1771

Obesity

Swinburn B et al. WHO (2001) www.heartstats.org

Global Prevalence of Obesity

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Swinburn B et al. WHO (2001)www.heartstats.org

Annual Increase in Prevalence of Obesity, 1980-1998

-0.20 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60

MalaysiaItaly

IndiaFranceJapanChina

CanadaSweden

South AfricaFinland

BrazilNetherlandsSwitzerland

GermanyAustralia

United StatesMauritius

New ZealandUnited Kingdom

KuwaitSamoa

Average % increase per annum

Prevalence of Obesity & Diabetes

Source - JAMA. 2003;289:76-79

Observed and Projected Life Expectancy at Age 65 for U.S. Females (1900 to 2000)

Figure from Olshansky, SJ et al, NEJM, March 17,2005;352 (11):1138

Observed and Projected Life Expectancy at Age 65 for U.S. Females (1980 to 2050)

Figure from Olshansky, SJ et al, NEJM, March 17,2005;352 (11):1138

Age and Amount Requirements 1986 in North America

500,000500,00050,000200,000100,00061+1 M1 M100,000200,000250,00056-601 M1 M250,000200,000500,00051-552 M2 M350,000200,000500,00046-502 M2 M500,000200,000500,00041-45

750,000200,0001 M36-401 M400,0001 M16-35

StressCXRECGBloodPara-MAge

Where is the Fat??

Rexrode KM, et al, JAMA 1998;280:1843-1848

Waist Circumference versus BMI

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New International Definition for

Metabolic Syndrome

Lancet, Sept 24 2005;366;1059-62

Sattar N et al. Circulation July 2003;108:414-419

Prognosis of Metabolic Syndrome

Sattar N et al. Circulation July 2003;108:414-419

Figure from Sattar N et al. Circulation July 2003;108:414-419

C-Reactive Protein with Metabolic Syndrome

CH

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Old Heart Attack DefinitionChest painECG changesCardiac enzymes leak into blood stream

New Heart Attack Definition: American ACC/European ESC 2000

Clinical context compatible with ischemic myocardial damageElevated Cardiac Troponin

Impact of New MI Definition

Pell et al showed that “The new criteria increased admissions for myocardial infarction by 58%”

Pell JP, BMJ. 2003 January 18; 326 (7381): 134–135

Age Adjusted Cancer Mortality Trends in Females

Lung Cancer

Lung Cancer Risks

Smoking and Second-hand smokeAsbestos exposure 1940 - 1979Pollution

Thyroid Cancer

37

Thyroid Cancer TrendsMore screening being doneAntiselection potential

Educated public know risk factorsCan be self detected

Seeing more thyroid cancer critical illness claims in Asia then breast cancer claims

Thyroid ultrasound

http://www.nlm.nih.gov/medlineplus/ency/imagepages/18056.htm

Thyroid Cancer Screening

697 women who presented for breast U/S with no thyroid history

246 (35.3%) were found to have thyroid nodules21 (3.0%) found to have thyroid cancerSensitivity of U/S: 80% to 100%Specificity: 91.7% to 33.3%

Lee HK et al, Yonsei Med J. 2003 Dec 30;44(6):1040-4

Singapore Cancer ExclusionsMelanomas of less than 1.5mm Breslow thickness, or less than Clark Level 3Prostate Cancers histologically described as TNM Classification T1a or T1b or Prostate cancers of another equivalent or lesser classificationT1N0M0 papillary micro-carcinoma of the Thyroid less than 1 cm in diameterPapillary micro-carcinoma of the BladderChronic Lymphocytic Leukemia less than RAI Stage 3All tumors in presence of HIV

41

Breast Cancer

Trends in Breast Carcinoma In-Situ

~ 17% of all new breast cancers

Cancer AdvancesMore preventionBetter screeningNew treatments

CuresVaccines

New Cancer insurance products

Screening30%-50% have not had a mammogram in past 2 years27% of women over the age of 65 have never had a PAP smear screen for cervical cancer70% of at risk public not getting colon cancer screening

47

ProstateProstateCancerCancer

IncidenceIncidenceRatesRates

Figure from Oliver SE el al, Lancet 2000 May 20;355(9217):1788-9

Prostate CancerIncidence

PSA Screening Started in USA

Proteomic ScreeningPSA misses about 1/3 of prostate cancersNMP48

Increased specificity and sensitivity compared to PSA with a 91% predictive valuedetected 92% of the PSA missed cancers

St. Jude’s Children’s Research Hospital –Cancer Survival Rates 51

Infection Trends

Successes:PneumoniaHIVHepatitis B

Threats:Antibiotic Resistance InfectionsHepatitis CNew Infections such as variant Creutzfeld Jacob disease, SARS, Avian Flu, etc

Global Emerging and Re-emerging Infectious Diseases

Figure from Morens, DM et al, Nature. 2004 Jul 8;430(6996):242-9

Avian FluInfluenza A (H5N1) is a subtype of the type A influenza virusWild birds are the natural hosts of the virusVirus was first isolated from terns in South Africa in 1961Most infections due to exposure to sick birdsRare human to human transmission

Outbreak Among Poultry in Asia

Avian Influenza in Asia

WHO Cumulative Number of Confirmed Human Cases of Avian Influenza A (H5N1) since 28 January 2004

WHO Communicable Disease Surveillance & Response (CSR) , September 29, 2005

DeathsCasesDeathsCasesDeathsCasesDeathsCasesDeathsCases

12

0

4

8

17

0

5

12

Thailand

116

71

9

35

Total:

4

4

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0

4

4

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Cambodia

60419134Total:

2821643416.12.04-to date

8440019.07.04-08.10.04

2416230026.12.03-10.03.04

Viet NamIndonesiaDate of onset

Risk of EpidemicBirds are endemically infected and starting in catsH5N1 viruses could gain the ability for efficient and sustained transmission between humansLittle preexisting natural immunity to H5N1 in the human populationResistance to the antiviral medications amantadine and rimantadine

Leaves 2 remaining antiviral medications (oseltamavirand zanamavir) that should still be effective against currently circulating strains of H5N1

Better Prepared – Less MortalityIn 1918, US population was 105,000,000 and flu killed 500,000 = 0.5%In 1957, US population was 170,000,000 and flu killed 70,000 = 0.04%

AntibioticsICUVaccines (now 58% of elderly get vaccinated)Better Surveillance

Deaths from Infections

Source: http://www.cdc.gov/ncidod/eid/vol3no4/lederber.htm

1918

Impact of a Future Pandemic???In World: ? 2-7 M deaths +In Australia:

25% get infected with mortality 0.37-2.5%….4M cases…. 15,000 – 100,000 deaths

In Japan ???

Transplantations

LiverKidneyHeartLungPancreas

Islet CellXenotransplantStem Cell

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Tissue Regeneration

http://www.discover.com/july_01/featbros.html

SummaryMore screening and preventionNew therapies and curesObesity and diabetes epidemic poses threatOpportunity to fine tune underwritingLiving longer and better quality lives due to medical advances and public health initiatives

Arigato-go-za-ee-ma-shi-ta !!Thank you !!