National mortality burden due to communicable,non-communicable,and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015

Background

Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years.

Methods

GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015.

Results

CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015.

Conclusions

Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country’s performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.

     

Health risk factors and mortality in Pécs City, Hungary in the 1990s

In the period of 1990-1994 an increase of all causes mortality for 35-74 years old males was observed both in Pécs and in all Hungary. From 1994 to 1997 the mortality decreased. Similar changes, but of smaller dimension, were observed in the female population. The increasing mortality of the early 1990s is attributed primarily to the extra psycho-social stress of this period. The data of the population survey at Pécs in 1995-96 were compared to the data of earlier surveys. The mean blood total cholesterol levels and the prevalence of smoking decreased from 1990 to 1996. The prevalence of hypertension and male obesity increased. Physical inactivity, unhealthy diet and lack of improvement of diet still represent significant health problems. High prevalence of increased gamma-glutamyl transferase indicate high prevalence of excess alcohol consumption. The risk factor profile of 18-25 year old males is very unfavourable. Smoking prevalence in females aged 26-35 years exceeds that of males of the same age group. Preventive efforts should be focused to young males and females.     

Molecular characterization of rotavirus diarrhea among children aged under five years in the Philippines, 2013–2015

With the availability of new and existing rotavirus vaccines, credible and reliable data on burden of rotavirus-associated disease are needed to enable evidence-based decision making regarding the introduction of rotavirus vaccines. The national rotavirus surveillance program in the Philippines, a sentinel-based surveillance, was established in 2012 to determine the proportion of laboratory-confirmed rotavirus cases among children under five years with acute gastroenteritis and to describe the geographic distribution and molecular epidemiology of rotavirus in the country. During 2013 to 2015, rotavirus infection was the cause of acute gastroenteritis among children under five years admitted to hospitals or evaluated in emergency rooms, constituting more than one-third of gastroenteritis hospitalizations at the sentinel site hospitals. The predominant genotype observed was G1P[8]. Although a rotavirus surveillance network has been established, findings suggest the need to strengthen the network in the country and to continue monitoring prevalent rotavirus strains to help identify the possible emergence of new strains.     

Hypertension and risk of death from external causes in the Physicians’ Health Study enrollment cohort

Objectives  

To address the recent hypothesis that hypertension increases the risk of death from external causes.     

Trends in maternal mortality in Switzerland among Swiss and foreign nationals, 1969–2006

Objectives  

To test whether maternal mortality was higher among immigrant women than Swiss women.     

Incidence and epidemiology of intussusception among children under 2 years of age in Chenzhou and Kaifeng,China, 2009–2013

IntroductionIn China, rotavirus is the leading cause of diarrhea hospitalizations among children aged <5 years. A locally manufactured rotavirus vaccine is available for private market use, but little is known about its coverage. Given the impending availability of newer rotavirus vaccines, we evaluated intussusception rates among children aged <2 years to better understand intussusception epidemiology for future vaccine safety monitoring.MethodsWe conducted a retrospective review at 4 hospitals in Chenzhou City of Hunan Province and Kaifeng City of Henan Province. We identified intussusception cases admitted during 2009–2013 by reviewing medical records with the ICD-10 discharge code for intussusception and extracting demographic and clinical information from the electronic clinical record systems.ResultsDuring 2009–2013, 1715 intussusception hospitalizations among 1,487,215 children aged <2 years occurred in both cities. The average annual intussusception hospitalization incidence was 112.9 per 100,000 children aged <2 years (181.8 per 100,000 children <1 year; 56 per 100,000 children 1 to <2 years). Intussusception incidence was low among infants aged <3 months and peaked at age 6–8 months. No clear seasonality was observed. Ultrasound was used to diagnose 95.9% of cases. Enema reduction was performed in 80% cases; 25% of cases in Chenzhou and 16% in Kaifeng required surgical intervention. No deaths were reported. The median time between symptom onset and admission was 1 day.ConclusionsThis study provides information on intussusception incidence and epidemiology in two cities of China during 2009–2013. Monitoring intussusception rates in this population will be important in the post-rotavirus vaccine era.     

Diabetes mellitus and risk of all-cause mortality among patients with tuberculosis in the state of Georgia, 2009–2012

PurposeTo estimate the association between diabetes mellitus (DM) and all-cause mortality during tuberculosis (TB) treatment.MethodsFrom 2009 to 2012, a retrospective cohort study among reported TB cases in Georgia was conducted. Patients aged 16 years or older were classified by DM and human immunodeficiency virus (HIV) status at the time of TB diagnosis and followed during TB treatment to assess mortality. Hazard ratios were used to estimate the association between DM and death.ResultsAmong 1325 patients with TB disease, 151 (11.4%) had DM, 147 (11.1%) were HIV-infected, and seven (0.5%) had both DM and HIV. Patients with TB-DM were more likely to have cavitary lung disease compared with those with TB alone (51.0% vs. 34.7%) and those with TB-HIV were more likely to have military/disseminated disease (12.9% vs. 3.4%) and resistance to rifampin or isoniazid (21.8% vs. 9.0%) compared with those without HIV infection (P < .05). In multivariable analysis, DM was not associated with death during TB treatment (hazard ratio, 1.22; 95% confidence interval, 0.70–2.12) or any death (adjusted odds ratio, 1.05; 95% confidence interval, 0.60–1.84).ConclusionsAmong TB patients in Georgia, the prevalence of comorbid DM and coinfection with HIV was nearly identical. In adjusted models, TB patients with DM did not have increased risk of all-cause mortality.     

Trends in mortality from diseases of the circulatory system and cancer by site in Antwerp,Belgium 1900–1975

After studying the shortcomings of source materials, crude and age-adjusted death rates for diseases of the circulatory system and cancer by site in Antwerp have been compared for the period 1900–1975. Although the crude death rates of the most important causes of death show an increase until 1964, after age-adjustment it is possible to divide these in two groups. The first group shows after age-adjustment a decreasing trend suggesting crude mortality increases appear mostly in the oldest age-groups. The second group consists of mortality causes which after age-adjustment continue to increase. These increases appear to be linked to factors other than the ageing of the population. The evolution of the total cancer mortality shows that until 1940, it was dominated by the first group, while after 1950 a switch to the second group can be noticed.     

Inflammation, coagulation and risk of locomotor disability in elderly women: findings from the British Women’s Heart and Health Study

This study investigated associations between chronic inflammation and coagulation and incident locomotor disability using prospective data from the British Women's Heart and Health Study. Locomotor disability was assessed using self-reported questionnaires in 1999/2000, and 3 and 7?years later. Scores for inflammation and coagulation were obtained from summation of quartile categories of all available biomarkers from blood samples taken at baseline. 534 women developed locomotor disability after 3?years, 260 women after 7?years, while 871 women remained free of locomotor disability over the whole study period. After adjustment for demographic characteristics, lifestyle factors and health conditions, we found associations between inflammation and incident locomotor disability after three (OR per unit increase in score?=?1.08, 95?% confidence interval (CI): 1.03, 1.13) and 7?years (OR?=?1.10, 95?% CI: 1.03, 1.18) and between coagulation and incident locomotor disability after 3 (OR?=?1.06, 95?% CI: 0.98, 1.14) and 7?years (OR?=?1.09, 95?% CI: 1.00, 1.18). This corresponds to ORs between 1.8 and 2.4 comparing women with highest to lowest inflammation or coagulation scores. These results support the role of inflammation and coagulation in the development of locomotor disability in elderly women irrespective of their lifestyle factors and underlying age-related chronic diseases.     

Tuberculosis and HIV are the leading causes of adult death in northwest Ethiopia: evidence from verbal autopsy data of Dabat health and demographic surveillance system, 2007–2013

Background

Reliable data on causes of death form the basis for building evidence on health policy, planning, monitoring, and evaluation. In Ethiopia, the majority of deaths occur at home and civil registration systems are not yet functional. The main objective of verbal autopsy (VA) is to describe the causes of death at the community or population level where civil registration and death certification systems are weak and where most people die at home without having had contact with the health system.

Methods

Causes of death were classified and prepared based on the International Classification of Diseases (ICD-10). The cause of a death was ascertained based on an interview with next of kin or other caregivers using a standardized questionnaire that draws information on signs, symptoms, medical history, and circumstances preceding death. The cause of death, or the sequence of causes that led to death, is assigned based on the data collected by the questionnaire. The complete VA questionnaires were given to two blinded physicians and reviewed independently. A third physician was assigned to review the case when disagreements in diagnosis arose.

Results

Communicable diseases (519 deaths [48.0%]), non-communicable diseases (377 deaths [34.8%]), and external causes (113 deaths [10.4%]) were the main causes of death between 2007 and 2013. Of communicable diseases, tuberculosis (207 deaths [19.7%]), HIV/AIDS (96 deaths [8.9%]) and meningitis (76 deaths [7.0%]) were the most common causes of death.

Conclusion

Tuberculosis, HIV/AIDS, and meningitis were the most common causes of deaths among adults. Death due to non-communicable diseases showed an increasing trend. Increasing community awareness of infections and their interrelationships, tuberculosis case finding, effective local TB programs, successful treatment, and interventions for HIV are supremely important.

     

Trends in mortality from coronary heart and cerebrovascular disease in Switzerland, 1969–87

Summary Trends in age-specific and age-standardized death certification rates from all ischaemic heart disease and cerebrovascular disease in Switzerland have been analysed for the period 1969–87, i.e. since the introduction of the Eighth Revision of the International Classification of Diseases for coding causes of death. For coronary heart disease, overall age-standardized rates of males in the mid-late 1980's were similar to those in the late 1960's, although some upward trend was evident up to the mid 1970's (with a peak rate of 120.4/100 00, World standard, in 1978) followed by steady declines in more recent years (103.8/100 000 in 1987). These falls were larger in truncated (35 to 64 years) rates. For females, overall age-standardized rates were stable around a value of 40/100 000, while truncated rates tended to decrease, particularly over most recent years, with an overall decline of over 25%. Examination of age-specific trends showed that in both sexes declines at younger ages were already evident in the earlier calendar period, while above age 50 some fall became evident only in most recent years. Thus, in a formal log-linear age/period/cohort model, both a period and a cohort component emerged. In relation to cerebrovascular diseases, the overall declines were around 40% in males (from 67.4 to 41.2/ 100 000, World standard) and 45% for females (from 56.6 to 31.7/100 000), and were proportionally comparable across subsequent age groups above age 45. The estimates for the age/period/cohort model were thus downwards both for the period and the cohort component although, in such a situation, it is difficult to disentangle the major underlying component. These persistent declines in stroke mortality are remarkable, since certified mortality is now lower in Switzerland than in any other industrialized country, and correspond to the avoidance of over 4000 deaths per year, as compared with the rates of the late 1960's or early 1970's. The recent falls in ischaemic heart disease mortality are similar to those observed in several other western European countries with a 10 to 15 year delay in comparison with the USA, and are of major public health relevance, too, since they correspond to the avoidance of about 1300 deaths per year.

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Zusammenfassung Die vorliegende Arbeit befasst sich mit Veränderungen der altersstandardisierten Sterberaten für koronare Herzkrankheit sowie für zerebrovaskuläre Krankheiten in der Schweiz in der Zeitperiode von 1969 bis 1987 (seit der Einführung der 8. Revision der internationalen Klassifikation der Krankheiten). Die Sterblichkeit an koronarer Herzkrankheit ist seit Mitte der 80er Jahre wieder auf das Niveau der späten 60er Jahre zurückgegangen, nachdem in den 70er Jahren eine Zunahme zu verzeichnen war. Die höchste Rate wurde mit 120,4 pro 100 000 im Jahr 1978 erreicht und ist in der Zwischenzeit auf 103, 8 pro 100 000 (1987) zurückgegangen (standardisiert nach der Weltbevökerung). Der Rückgang war bei den mittleren Jahrgängen (35–64 Jahre) noch deutlicher. Die Sterblichkeit bei Frauen war über diese Zeitperiode relativ stabil (40/100 000); bei den mittleren Jahrgängen zeigte sich auch hier ein deutlicher Rückgang um rund 25%. Die nähere Analyse altersspezifischer Trends zeigt, dass der Rückgang der Sterblichkeit bei jüngeren Altersgruppen beider Geschlechter schon früher nachweisbar ist, während eine Reduktion des Sterberisikos vom 50. Altersjahr an erst kürzlich sichtbar geworden ist. In einem statistischen Modell (Alters-, Zeitperiode-, Kohorten-Modell) zeigt sich daher ein Beitrag zur sterberisikoabnahme sowohl aufgrund eines Zeitperioden-als auch eines Geburtskohorten-Effektes. Die zerebrovaskulären Erkrankungen zeigen einen deutlicheren Rückgang: Er betrug ungefähr 40% bei der Sterblichkeit der Männer (67,4 auf 41, 2 pro 100 000) und ungefähr 45% bei frauen (von 56,6 auf 31,7 pro 100 000). Aehnliche Rückgänge ergeben sich für die verschiedenen Altersgruppen vom 45. Altersjahr an. Die kontinuierliche Reduktion der Schlaganfallsterblichkeit ist besonders bemerkenswert, da die Sterblichkeit an dieser Krankheit in der Schweiz nun niedriger als in irgendeinem anderen industrialisierten Land ist. Würden heute noch die Sterberaten von 1960 oder anfangs 1970 vorherrschen, so träten jährlich rund 4000 Todesfälle pro Jahr mehr auf. Der kürzliche Rückgang, auch bei der Sterblichkeit der koronaren Herzkrankheit ist mit der Entwicklung in anderen westeuropäischen Ländern vergleichbar. Wenn hier noch die früheren Raten gelten würden, müsste mit rund 1300 Todesfällen pro Jahr mehr gerechnet werden.

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Résumé Les tendances des taux suisses de mortalité, spécifiques et corrigés pour l'âge, attribués à l'ensemble des maladies ischémiques du coeur et des affections cérébrovasculaires ont été analysées pour la période de 1969 à 1987, ceci notamment depuis l'introduction de la Huitième Révision de la Classification Internationale des Maladies. Chez l'homme, la mortalité corrigéc par maladie ischémique du cour relevée dans la deuxième moitié des années 80 était superposable à celle des années 60. Cette situation était précédée par une phase de progression des taux jusqu'à la moitié des années 70 (culminant à 120.4/100 000, standard mondial, en 1978) et suivie d'une diminution constante des taux au cours des années plus récentes (103.8/ 100 000 en 1987), plus marquée dans la population tronquée entre 35 et 64 ans d'âge. Chez la temme suisse, les taux corrigés pour tous les âges étaient stables autour de 40/100 000, alors que la mortalité tronquée tendait à décroître, surtout dans les années les plus récentes, avec une diminution globale de plus de 25%. L'inspection des tendances par groupes dâges a montré que, pour les deux sexes et aux plus jeunes âges, les diminutions étaient évidentes déjà au début de la période considérée, alors qu'après 50 ans quelques diminutions devenaient manifestes seulement dans les années les plus récentes. Par conséquent, l'analyse par un modèle log-linéaire âge/période/cohorte a mis en évidence une composante de période autant que de génération. Les affections cérébro-vas-culaires ont globalement diminué d'environ 40% chez l'homme (de 67.4 à 41.2/100 000, standard mondial) et de 45% chez la femme (de 56.6 à 31.7/ 100 000), et, proportionnellement, d'une manière comparable à travers les groupes d'âge successifs audelà de 45 ans. Les estimations à partir du modèle âge/période/cohorte étaient donc en diminution pour la composante de période autant que de cohorte bien que, dans une telle situation il soit difficile de déterminer quelle est la principale composante sousjacente. La persistance de ces diminutions de mortalité par maladie cérébro-vasculaire est remarquable, le niveau de ces affections en Suisse n'étant dépassé par aucun autre pays industrialisé. Par rapport à la situation de la fin des années 60 ou du début des années 70, les diminutions représentent plus de 4000 décès évités par année. Les reculs de la mortalité par maladies ischémiques du coeur ressemblent à ce que l'our observe dans d'autres pays d'Europe occidentale, avec toutefois un décalage de 10 à 15 ans par rapport aux Etats-Unis. Dans une optique de santé publique, ces baisses revêtent donc aussi une importance considérable.

     

Usage of quadrivalent influenza vaccine among children in the United States, 2013–14

Annual influenza vaccination is recommended for everyone ≥6 months in the U.S. During the 2013–14 influenza season, in addition to trivalent influenza vaccines, quadrivalent vaccines were available, protecting against two influenza A and two influenza B viruses. We analyzed 1,976,443 immunization records from six sentinel sites to compare influenza vaccine usage among children age 6 months–18 years. A total of 983,401 (49.8%) influenza vaccine doses administered were trivalent and 920,333 (46.6%) were quadrivalent (unknown type: 72,709). Quadrivalent vaccine administration varied by age and was least frequent among those <2 years of age.     

National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990–2015: findings from the global burden of disease study 2015

Background

Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia.

Methods

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia.

Results

Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4–30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2–24,917.9), and injuries caused 3781 (95% UI, 2642.9–5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7–4029), 2592.5 (95% UI, 1850.7–3495.1), and 2562.9 (95% UI, 1466.1–4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7–3843.2) and 2159.9 (95% UI, 1369.7–3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage.

Conclusions

Ethiopia has been successful in reducing age-standardized DALYs related to most communicable, maternal, neonatal, and nutritional deficiency diseases in the last 25 years, causing a major ranking shift to types of non-communicable disease. Lower respiratory infections, diarrheal disease, and tuberculosis continue to be leading causes of premature death, despite major declines in burden. Non-communicable diseases also showed reductions as premature mortality declined; however, disability outcomes for these causes did not show declines. Recently developed non-communicable disease strategies may need to be amended to focus on cardiovascular diseases, cancer, diabetes, and major depressive disorders. Increasing trends of disabilities due to neonatal encephalopathy, preterm birth complications, and neonatal disorders should be emphasized in the national newborn survival strategy. Generating quality data should be a priority through the development of new initiatives such as vital events registration, surveillance programs, and surveys to address gaps in data. Measuring disease burden at subnational regional state levels and identifying variations with urban and rural population health should be conducted to support health policy in Ethiopia.

     

Blood lead levels and risk factors in young children in France, 2008–2009

BackgroundThe exposure of children to lead has decreased in recent years, thanks notably to the banning of leaded gasoline. However, lead exposure remains a matter of public health concern, because no toxicity threshold has been observed, cognitive effects having been demonstrated even at low levels. It is therefore important to update exposure assessments. A national study was conducted, in 2008–2009, to determine the blood lead level (BLL) distribution in children between the ages of six months and six years in France. We also assessed the contribution of environmental factors.MethodsThis cross-sectional survey included 3831 children recruited at hospitals. Two-stage probability sampling was carried out, with stratification by hospital and French region. Sociodemographic characteristics were recorded, and blood samples and environmental data were collected by questionnaire. Generalized linear model and quantile regression were used to quantify the association between BLL and environmental risk factors.ResultsThe geometric mean BLL was 14.9 μg/l (95% confidence interval (CI) = [14.5–15.4]) and 0.09% of the children (95% CI = [0.03–0.15]) had BLLs exceeding 100 μg/l, 1.5% (95% CI = [0.9–2.1] exceeding 50 μg/l. Only slight differences were observed between French regions. Environmental factors significantly associated with BLL were the consumption of tap water in homes with lead service connections, peeling paint or recent renovations in old housing, hand-mouth behavior, passive smoking and having a mother born in a country where lead is often used.ConclusionsIn children between the ages of one and six years in France, lead exposure has decreased over the last 15 years as in the US and other European countries. Nevertheless still 76,000 children have BLL over 50 μg/l and prevention policies must be pursued, especially keeping in mind there is no known toxicity threshold.