Non-communicable diseasesNon-communicable diseasesA global overviewA global overview

David Leon

2

OutlineOutline

• Definition • Non-communicable disease mortality

worldwide• The Epidemiological Transition• Global Burden of Disease Study• Major risk factors

– Blood pressure– Cholesterol– Smoking

• Infection and non-communicable diseases

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What are non-What are non-communicable diseases?communicable diseases?

4

Classifying deaths and diseasesClassifying deaths and diseases(WHO)(WHO)

• Communicable diseases [Group I]– Those where death is directly due to the

action of a communicable agent

• Non-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]

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Importance of non-Importance of non-communicable diseases communicable diseases

mortalitymortality

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A global problemA global problem

• In 2004 there were 59 million deaths world-wide

• Non-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 deaths

GBD 2004 Update, 2008

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The epidemiologic transitionThe epidemiologic transition(Omran, 1971)(Omran, 1971)

Change in the balance of disease in a population

from

communicable diseases

to

non-communicable disease

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Decline in proportion of total Decline in proportion of total mortality due to infectious diseases mortality due to infectious diseases

England & Wales, 1911-94, by ageEngland & Wales, 1911-94, by age

0

0.1

0.2

0.3

0.4

0.5

0.6

1911 1921 1931 1941 1951 1961 1971 1981 19910

0.1

0.2

0.3

0.4

0.5

0.6

1911 1921 1931 1941 1951 1961 1971 1981 1991

MalesMales FemalesFemales

1-141-14

25-4425-44

45-6445-64

65-7465-74

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Different countries at different Different countries at different stages of the epidemiological stages of the epidemiological

transitiontransition

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Non-communicable diseases as % of all Non-communicable diseases as % of all deaths by global region deaths by global region

(all ages(all ages))

WORLDWIDE 59%

N.America; W Europe 88%

China, W Pacific, + some SE Asia 75%

Latin America + Caribbean 67%

S E Asia including India 51%

Sub-Saharan Africa 21%

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UrbanisationUrbanisation

12http://www.indiaimages.com/street/street_life2_large.jpg

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UrbanisationUrbanisation

0

10

20

30

40

50

60

70

80

90

100

1950 1960 1970 1980 1990 2000 2010 2020 2030

Urb

an p

op

ula

tio

n a

s %

of

tota

l

North AmericaLatin America & Caribbean

Europe

Oceania

Asia

Africa

WORLD

20

07

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Drivers of the epidemiological Drivers of the epidemiological transition in low and middle transition in low and middle

income countriesincome countries

• Population ageing

• Major socio-economic changes (especially urbanisation)– changes in risk factors such as diet, physical

activity, smoking etc.

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Global Burden of Disease Global Burden of Disease (GBD) Study(GBD) Study

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GBD 2001 mortality estimatesGBD 2001 mortality estimates

• 107 countries had collected “useable” information on cause of death from registration systems

• 55 countries (42 in sub Saharan Africa) no information on adult mortality

• Estimates based on many assumptions and extrapolations

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Global Burden of Disease StudyGlobal Burden of Disease Study• First GBD study started in 1992 by World

Bank.• Second GBD study (in collaboration with

WHO) conducted 2001• Extensive synthesis of all available data to

give set of mortality estimates by age, sex, region and cause worldwide – for the first time

• 2001 GBD study covers 135 causes of death, 17 sub-regions, based on aggregation of country-level information

Global Burden of DiseaseGlobal Burden of Disease2004 Update 2004 Update (published 2008)(published 2008)

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

GBD_report_2004update_full.pdf

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Distribution of deaths in the world Distribution of deaths in the world by sex, 2004by sex, 2004

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GBD report 2004 update, 2008

Mortality rates among men and women aged 15–Mortality rates among men and women aged 15–59 years, region and cause-of-death group, 200459 years, region and cause-of-death group, 2004

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GBD report 2004 update, 2008

Projected global deaths for selected Projected global deaths for selected causes, 2004–2030causes, 2004–2030

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GBD report 2004 update, 2008

Effect of key risk factors on Effect of key risk factors on mortalitymortality

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Combining data …Combining data …

Prospective studies collaboration

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Prospective Studies Prospective Studies Collaboration 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 Blood pressure and cardiovascular mortalitycardiovascular mortality

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December 0226

Cardiovascular mortality: Age-specific effects for 20 mmHg lower usual SBP

55 345 deaths at ages 40-89Numberdeaths

414 0·36 (0·32-0·40)

1372 0·38 (0·35-0·40)

2939 0·43 (0·41-0·45)

4327 0·50 (0·48-0·52)

2636 0·67 (0·63-0·71)

1322 0·49 (0·45-0·53)

5594 0·50 (0·49-0·52)

10 450 0·54 (0·53-0·55)

10 852 0·60 (0·58-0·61)

5649 0·67 (0·64-0·70)

Stroke

IHD

Othervascular

386 0·43 (0·38-0·48)

1377 0·50 (0·47-0·54)

2549 0·53 (0·51-0·56)

3227 0·64 (0·61-0·67)

Age

40-49

50-59

60-69

70-79

80-89

40-49

50-59

60-69

70-79

80-89

40-49

50-59

60-69

70-79

80-89 2251 0·70 (0·65-0·75)

0·25 0·35 0·5 0·7 1·0

Relative risk (& 95% CI) for20 mmHg lower usual systolic BP

Cholesterol and Cholesterol and cardiovascular mortalitycardiovascular mortality

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80-89

70-79

60-69

50-59

40-49

Age atrisk

Usual total cholesterol (mmol/L)

4·0 5·0 6·0 7·0 8·00·5

1

2

4

8

16

32

64

128

256H

azar

d r

atio

( 95

% C

I)

Ischaemic Heart Disease mortality (33 744 deaths) and total cholesterol

Different for strokeDifferent for stroke

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Usual total cholesterol (mmol/L)4·0 5·0 6·0 7·0 8·0

1

2

4

8

16

32

64

80-89

70-79

60-69

40-59

Age

Haz

ard

rat

io(&

95%

CI)

Stroke mortality (11 663 deaths) and total cholesterol by ageStroke mortality (11 663 deaths) and total cholesterol by age

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SmokingSmoking

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% of deaths aged 35-69 years % of deaths aged 35-69 years attributable to smoking in 2000attributable to smoking in 2000

Men Women

Belarus 33% 0%

Russia 33% 3%

Ukraine 32% 3%

Central Asia (8) 23% 4%

Estonia 31% 3%

Latvia 30% 2%

Lithuania 29% 0%

United Kingdom 25% 21%

Germany 29% 11%

Source : http://www.deathsfromsmoking.net/

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Risk of myocardial infarction increases with Risk of myocardial infarction increases with every single cigarette smoked per dayevery single cigarette smoked per day

Number of cigarettes smoked per day

Odd

s R

atio

of

Myo

card

ial I

nfar

ctio

n

Never 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 >=21

Source : 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

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Smoking causes more deaths from Smoking causes more deaths from cardiovascular disease than cancercardiovascular disease than cancer

Deaths attributed to smoking

among men (all ages) in Russia, 2000

All cancers = 77,000

Cardiovascular disease = 148,000

Source : http://www.deathsfromsmoking.net/

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Things are getting worse Things are getting worse not better not better

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Smoking in men in Russia Smoking in men in Russia is not decliningis not declining

Rural

Urban

St Petersburgh/Moscow

Source : Perlman et al Tob.Control 16 (5):299-305, 2007

Russian Longitudinal Monitoring Survey

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Smoking in women in Russia Smoking in women in Russia is increasingis increasing

Rural

Urban

St Petersburgh/Moscow

Russian Longitudinal Monitoring Survey

Source : Perlman et al Tob.Control 16 (5):299-305, 2007

Giving up smoking reduces riskGiving up smoking reduces risk

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Some non-communicable Some non-communicable diseases have infectious diseases have infectious

etiologyetiology

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Trends in stomach cancer mortalityTrends in stomach cancer mortality

41Source : WHO HFA database

Age

sta

ndar

dise

d m

orta

lity

per

100,

000

42

Helicobacter pylori bacterium - a causal factor for stomach cancer

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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 The Helicobacter pyloriHelicobacter pylori story …... story …...

SummarySummary

• Non-communicable diseases are now the most common cause of death world wide

• Increasing rates in low and middle income countries because of change in lifestyles (urbanisation)

• Key risk factors have very large effects• Interventions are effective and can reduce

burden• The need to combine results and have large

studies44