全球癌症发病与死亡流行现状和变化趋势

癌症作为全球第二大常见死亡原因,已成为当前全球共同面对的持续性公共卫生挑战.不同国家和地区、不同癌症类型的发病率和死亡率具有一定差异,这与经济发展水平、生活方式和环境因素等密切相关.已有大量流行病学研究集中在癌症负担、流行模式、病因学及其预防等方面,这对于国家制定以医学证据为基础的癌症防治方针和政策以及保护人口健康至关...     

Mathematical Models for Human Cancer Incidence Rates - Application to Results from Europe,including North Cyprus

The overall cancer incidence rate declines at very old age. Possible causes of this decline include the effects ofcross-sectional data that transform cohort dynamics into age patterns, population heterogeneity that selectsindividuals susceptible to cancer, a decline in some carcinogenic exposure in older individuals, underdiagnosis,and the effects of individual aging that slow down major physiological processes in an organism. Here severalmathematical models contributing to the explanation of this phenomenon are discussed with extension of theStrehler and Mildvan model of aging and mortality to the analysis of data on cancer incidence at old age (datasource: International Agency for Research on Cancer). The model can help explain the observed time trendsand age patterns of cancer incidence rates.     

Cancer Incidence Rates in the Kurdistan Region/Iraq from 2007-2009

Cancer is a disease of gradual increase in incidence overall the world. Kurdistan Region in Iraq has beenexposed to several carcinogenic hazards. There are few reports about the increased risk of cancer in different citiesin Iraq. These reports did not cover Kurdistan region. The aim of this paper was to study cancer incidence and toidentify possible risks of cancer in this region. Cancer registries from 9 hospitals in three cities of Kurdistan wereused as a source of data. Information on these cases was subjected to careful verification regarding repetition,place of residence and other possible errors. Overall registered cases in 2007, 2008 and 2009 were 1444, 2081,2356 respectively. 49% of registered cases were males and 51% were female. The Age Standardized Rate ofcancer was 89.83/100 000 among male and 83.93/100 000 among female. The results showed major variationin incidence rates of different types of cancer in the three governorates of Kurdistan. Furthermore, there wasevidence of increased risks of cancer in Kurdistan Region in Iraq. Hematological malignancies were the mostcommon cancer among male (21.13% of all cancer in males) and second most common in female (18.8% of allcancer in female), only exceeded by breast cancer. To reach sound conclusions about extent and determinantsof cancer in Kurdistan, enormous multi-spectrum efforts are now needed.     

Cancer Incidence in North Cyprus (1990-2004) Relative to European Rates

Cancer incidence in North Cyprus (NC), deemed an interesting epidemiological case due to possiblecontrasting prevailing factors in relation to South and North Europe (SE and NE), was evaluated for the period1990-2004. Age standardized rates (ASRs) and average age of incidence (AAI) values were determined for 12different cancers, separately for males and females. Annual trends were analyzed using linear regression slopes.Absolute values were compared by two-tailed t-tests. The order of prevalence for incidences of male (M) cancerswere: lung, skin, colorectal, prostate, brain, bladder, liver and stomach. Similarly, for females (F) they were:breast, gynaecological, skin, colorectal, lung, liver, brain, stomach and bladder. The following cancer cases weremore common than in SE and NE: lung (M) and skin (both genders). Breast (F), prostate, stomach (F), bladder(both sexes), cervix and corpus were less frequent; the rest were comparable. There was no difference in theannual trends of ASR or AAI for NC, compared with SE or NE. Thus cancer incidence in NC shares manyquantitative features with the rest of Europe. The worst cases could be improved by reducing smoking andprotection from the sun.     

河北省肝癌发病和死亡40年变化趋势分析

目的 评估河北省肝癌的疾病负担,分析肝癌40年间的死亡率变化趋势。方法 按照全国肿瘤登记中心制定的审核方法和评价标准对河北省9个登记处上报的肿瘤登记数据进行评估、审核与合并。按性别和年龄别分层,计算发病率和死亡率,以1/10万表示。分析河北省三次全死因回顾调查的肝癌数据。采用Joinpoint回归模型分析磁县肿瘤登记处1988-2012年肝癌发病和死亡趋势。结果 河北省2010-2012年肝癌新发病例2 552例,死亡病例2 447例。肝癌发病率为18.26/10万（男性24.89/10万,女性11.40/10万）,世标率（ASIRW）15.32/10万,占癌症发病的第五位。肝癌死亡率为17.51/10万（男性23.71/10万,女性11.09/10万）,世标率（ASMRW）为15.05/10万,位于死亡顺位的第四位。河北省40年间死亡率总体上升了15.95%。磁县男女的肝癌发病和死亡趋势大致相同。结论 河北省肝癌的发病率和死亡率远高于世界平均水平,河北省肝癌负担依旧严重,应继续加强肝癌防治工作。     

2013年湖北省肿瘤登记地区恶性肿瘤发病与死亡分析

目的 分析2013年湖北省肿瘤登记地区恶性肿瘤的发病与死亡情况。方法 收集2013年湖北省9个肿瘤登记处上报的恶性肿瘤发病与死亡数据以及人口资料,并用相关工具对数据进行审核与质量评估。各项质量评价指标均按国家标准纳入。结果 2013年,湖北省9个肿瘤登记地区新发病例数29 738例,发病率为284.85/10万,中标率为188.08/10万,世标率为203.59/10万。肺癌、消化系统肿瘤乳腺癌的发病率和死亡率均居前列。2013年,湖北省肿瘤登记地区恶性肿瘤死亡病例数17 986例,死亡率172.28/10万,中标率和世标率分别为107.97/10万和122.54/10万。男性发病率与死亡率均高于女性,城市地区发病率与死亡率均高于农村地区。结论 2013年湖北省肿瘤登记地区恶性肿瘤发病中标率较2012年略下降,死亡率略低于全国水平。肺癌、消化系统恶性肿瘤（肝癌、胃癌、食管癌、结直肠癌）以及乳腺癌是湖北省肿瘤防治工作的重点癌种,需重点针对这些癌种加强居民防癌核心知识的健康教育。     

Cancer Incidence and Mortality: District Cancer Registry,Trivandrum, South India

Background: Cancer is emerging as a major cause of morbidity and mortality in low and middle-income countries. Cancer registry figures help for planning and delivery of health services. This paper provided the first results of cancer incidence and mortality [Crude (CR) and age-standardized (ASR)] rates (world-standard population) of Trivandrum district, South India and compared with other registries under the network of National Cancer Registry Programme (NCRP), Government of India. Materials and Methods: Trivandrum district cancer registry encompasses a population of 3.3 million, compiles data from nearly 75 sources (hospitals and diagnostic laboratories) and included under the NCRP in 2012. During 2012-2014, registry recorded 15,649 incident cases and 5667 deaths. Proportion of microscopic diagnosis was 85% and ‘Death certificate only’ was 8%. Results: Total cancer incidence (CRs) rates were 161 and 154 (ASR: 142.2 and 126) and mortality rates were 66 and 49 (ASR: 54 and 37) per 105 males and females respectively. Common cancers in males were lung (ASR:19), oral cavity (ASR:15), colo-rectum (ASR:11.2), prostate (ASR:10.2) and lymphoma (ASR:7) and in females, breast (ASR:36), thyroid (ASR:13.4), cervix-uteri (ASR:7.3), ovary (ASR:7) and colo-rectum (ASR:7). Nationally, the highest CRs for breast, prostate, colo-rectum, corpus-uteri and urinary bladder cancers and low incidence of cervix-uteri cancer were observed in Trivandrum. Conclusion: Cancer incidence (CR) in Trivandrum was the highest in both genders in India (except Aizwal). This is mainly due to the highest life-expectancy in Kerala. Also, an epidemiologic transition in cancer pattern is taking place and is changing to more similar to "western" jurisdictions.     

Estimation of Esophageal Cancer Incidence in Tehran by Loglinear Method using Population-based Cancer Registry Data

Background: Having knowledge or estimation of cancer incidence is necessary for planning and implementationof any cancer prevention and control programs. Population-based registries provide valuable information toachieve these objectives but require extra techniques to estimate the incidence rate. The present study aimed toestimate the esophageal cancer incidence using a log-linear method based on Tehran population-based cancerregistry data. Materials and Methods: New cases of esophageal cancer reported by three sources of pathologyreports, medical records, and death certificates to Tehran Metropolitan Area Cancer Registry Center during2002-2006 were entered into the study and the incidence rate was estimated based on log-linear models. We usedAkaike statistics to select the best-fit model. Results: During 2002-2006, 1,458 new cases of esophageal cancerwere reported by the mentioned sources to the population-based cancer registry. Based on the reported cases,cancer incidence was 4.5 per 100,000 population and this was estimated to be 10.5 per 100,000 by the log-linearmethod. Conclusions: Based on the obtained results, it can be concluded that an estimated incidence for 2004 of8.3 per 100,000 population could be a good benchmark for the incidence of esophageal cancer in the populationof Tehran metropolis.     

中国11市县肿瘤发病和死亡登记资料统计分析（1988年—1992年）

目的：研究我国肿瘤登记资料,掌握人群肿瘤发病,死亡规律和特征。方法：根据国际癌症研究中心和国际癌症登记协会推荐的肿瘤登记方法,结合我国肿瘤浒病学研究的具体情况和需要,汇集,整理,审核和分析了我国１１市县肿瘤登记处１９８８年－１９９２年的肿瘤发病和死亡资料。结果：研究期间的内,１１市县肿瘤登记处覆盖人群合计１０６１８３１７３人年,肿瘤新病例２１２５０２例,死亡病例１５３９３４例。通过审核合格进行入分     

A Single Measure of Cancer Burden Combining Incidence with Mortality Rates for Worldwide Application

We attempted to develop an indicator combining incidence with mortality rates (single measure of cancer burden, SMCB) and to compare the magnitudes of cancer burden by world region. The SMCB was used to measure the size of cancer burden summarizing the incidence and mortality. The incidence and mortality were divided in equivalent forms and were split. The criteria dividing the size of cancer burden were used as the maximum incidence and mortality by men and women according to the world database, and the value corresponding to 10% of each maximum was set as the cut-off value. In SMCB, the size of cancer burden was highest for men with lung cancer (SMCB=18) and for women with breast cancer (SMCB=14) in MDR (more developed regions) compared to the size of burden in LDR (lower developed regions) (lung, SMCB=11, breast, SMCB=8). For men, the size of cancer burden by region was highest in EURO (SMCB=18, lung), followed by WPRO (SMCB=16, lung), PAHO (SMCB=14, prostate), AFRO (SMCB=8, prostate) and SEARO (SMCB=7, lung). Moreover, for women, the size of cancer burden was greatest in EURO (SMCB=14, breast), followed by PAHO (SMCB=13, breast), AFRO (SMCB=11, cervix uteri), EMRO (SMCB=9, breast) or SEARO (SMCB=8, cervix uteri) and WPRO (SMCB=7, lung). The summary indicator will help to provide a priority setting for reducing cancer burden in health policy.     

Institution-based Cancer Incidence in a Local Population in Pakistan: Nine Year Data Analysis

At present no national level of cancer registry program exists in Pakistan and the data available from differentsources, necessary for incidence, prevalence, morbidity/mortality, and etiological assessment of cancer and cancercontrol programs, are from hospital or institutional databases. Karachi Institute of Radiotherapy and NuclearMedicine (KIRAN) is a comprehensive healthcare facility for diagnosis, treatment and research of all cancers.This is a retrospective analysis of the cancer patients of both genders of all age groups to determine frequenciesof different cancers presented to this Institute from 1st January 2000 to 31 December 2008. A total of 16,351cancer patients were registered at KIRAN during the nine year period. Male cancers accounted for 48.1% andfemale cancers 51.8%. Some 558 (3.4%) were in children (0-15 years). The mean ages at presentation for malesand females were 50±9.6 and 47±7.4 years respectively. In males the five most frequent malignancies were headand neck (32.6%), lung (15%), gastrointestinal tract (GIT) (6.9%), lymphoma (6.1%), and bone and soft tissue(4.9%). In females breast cancer was the most common cancer accounting for 38.2% followed by head & neck(15.1%), cervical (5.5%), ovarian (4.9%) and GIT cancer (4.9%) respectively. Cancer prevalence in differentage groups with respect to gender and the epidemiologies of most common cancers with reference to our culturaland environmental factors and dietary habits are also discussed. Overall cancer incidence in nine years in thistertiary care cancer institution showed that head and neck cancers in males and breast cancers in females aremost common, at rates almost highest in Asia. Mean age and male to female ratio in all other cancers areessentially comparable to other developing countries.     

Cancer Prevalence in Aichi,Japan for 2012: Estimates Based on Incidence and Survival Data from Population-Based Cancer Registry

Background: Cancer is the leading cause of death among both men and women in Japan. Monitoring cancer prevalence is important because prevalence data play a critical role in the development and implementation of health policy. We estimated cancer prevalence in 2012 based on cancer incidence and 5-year survival rate in Aichi Prefecture using data from a population-based cancer registry, the Aichi Cancer Registry, which covers 7.4 million people. Methods: The annual number of incident cases between 2008 and 2012 was used. Survival data of patients diagnosed in 2006–2008 and followed up until the end of 2012 were selected for survival analysis. Cancer prevalence was estimated from incidence and year-specific survival probabilities. Cancer prevalence was stratified by sex, cancer site (25 major cancers), and age group at diagnosis. Results: The estimated prevalence for all cancers in 2012 was 68,013 cases among men, 52,490 cases among women, with 120,503 cases for both sexes. Colorectal cancer was the most incident cancer with 6,654 cases, accounting for 16.0% of overall incident cases, followed by stomach cancer with 5,749 cases (13.8%) and lung cancer with 5,593 cases (13.4%). Prostate cancer was the most prevalent among men, accounting for 21.5%, followed by colorectal and stomach cancers. Breast cancer was the most prevalent among women, accounting for 28.6%, followed by colorectal, stomach, and uterine cancers. Conclusion: This study provides cancer prevalence data that could serve as useful essential information for local governments in cancer management, to carry out more practical and reasonable countermeasures for cancer.     

湖北省肿瘤登记地区2012年宫颈癌发病及死亡分析

目的 分析湖北省肿瘤登记地区2012年女性宫颈癌发病及死亡情况。方法 运用描述流行病学研究,对2012年湖北省肿瘤登记地区的宫颈癌发病及死亡资料进行分析,计算城乡之间肿瘤发病率和标化率,并进行比较。结果 2012年湖北省肿瘤登记地区的女性宫颈癌发病率为20.88/105,中标率为14.85/105,世标率为14.54/105,累积率（0~74岁）为1.36%。20岁以上女性宫颈癌各年龄段发病率农村地区高于城市。宫颈癌的死亡率为5.50/105,中标率为3.60/105,世标率为3.75/105,累积率（0~74岁）为0.37%。农村地区死亡粗率、中标率,世标率等均高于城市地区。年龄别死亡率总体呈上升趋势,在80岁组达到死亡率最高峰值（22.48/105）。7个肿瘤登记地区中,死亡率最高的是五峰县,最低是钟祥市,五峰县中标死亡率是钟祥市的11.62倍。结论 湖北省肿瘤登记地区宫颈癌发病农村高于城市,不同地域发病差别较大,应积极开展宫颈癌防治知识的健康教育,同时继续推进宫颈癌高危人群的筛查工作。     

Prostate Cancer Incidence in Turkey: An Epidemiological Study

Background: This study aimed to determine the incidence of prostate cancer in Turkey in a population-basedsample, and to determine clinical and pathological characteristics of the cases. Materials and Methods: Allnewly diagnosed prostate cancer patients were included in this national, multi-centered, prospective and noninterventionalepidemiological registry study conducted in 12 cities representing the 12 regions of Turkey fromJuly 2008 to June 2009. The population-based sample comprised 4,150 patients with a recent prostate cancerdiagnosis. Results: Age-adjusted prostate cancer incidence rate was 35 cases per 100,000 in Turkey. At the timeof diagnosis, median age was 68, median PSA level was 10.0 ng/mL. Digital rectal examination was abnormal in36.2% of 3,218 tested cases. Most patients had urologic complaints. The main diagnostic method was transrectalultrasound guided biopsy (87.8%). Gleason score was ≤6 in 49.1%, 7 in 27.8% and >7 in 20.6% of the cases.There was a statistically significant positive correlation between serum PSA level and Gleason score (p=0.000).The majority of patients (54.4%) had clinical stage T1c. Conclusions: This is the first population-based nationaldata of incidence with the histopathological characteristics of prostate cancer in Turkey. Prostate cancer remainsan important public health concern in Turkey with continual increase in the incidence and significant burdenon healthcare resources.     

Time Trends of Ovarian Cancer Incidence in China

The aim of this study was to examine the trend of ovary cancer incidence from 1999 to 2010 in China andpredict the burden up to 2020. Crude incidence, age specific incidence and age-adjusted incidence rates werecalculated. Joinpoint regression was performed to obtain estimated annual percentages and Bayesian age-periodcohortmodeling was used to predict the incidence rate until the year 2020. In China, the crude rate of ovarycancer was 7.91/100,000 and the age-adjusted rate was 5.35/100,000 overall during period 1999-2010. The ratesin urban regions were higher than in rural regions. A significant rising trend during 1999-2006 was followedby a drop during 2006-2010 in age-adjusted rates for urban females. In contrast, constant rise was observed inrural women. The decrease in ovary cancer of urban areas tended to be restricted to women aged 50 years andyounger. In contrast, increases of ovary cancer in rural areas appeared in virtually all age groups. Although theage-adjusted incidence rate for ovary cancer was predicted to be reduced after year 2011, the crude rate waslikely to be relative stable up to 2020. The burden of ovary cancer in China will continue to be relative stabledue to the aging population.     

Cumulative Risk and Trends in Prostate Cancer Incidence in Mumbai,India

Background: Information relating to cancer incidence trends in a community forms the scientific basis for the ‍planning and organization of prevention, diagnosis and treatment of cancer. We here estimated the cumulative risk ‍and trends in incidence of prostate cancer in Mumbai, India, using data collected by the Bombay Population-based ‍Cancer Registry from the year 1986 to 2000. ‍Methods: During the 15 year period, a total of 2864 prostate cancer cases (4.7% of all male cancers and 2.4% of ‍all cancers) were registered by the Bombay Population-based Cancer Registry. For evaluation of the trend, we ‍applied a linear regression model based on the logarithm of the observed incidence rates. The annual percentage ‍changes were also computed for the evaluation. Cumulative incidence rates percentages were calculated by adding ‍up the age specific incidence rates at single ages and then expressed as a percentage. ‍Results: Analysis of the trends in age-adjusted incidence rates of prostate cancer during the period 1986 to 2000 ‍showed no statistically significant increase or decrease and the rates proved stable across the various age groups (00- ‍49, 50-69 and 70+) also. The probability estimates indicated that one out of every 59 men will contract a prostate ‍cancer at some time in his whole life and 99% of the chance is after he reaches the age of 50. ‍Conclusion: The stability in age adjusted-incidence rates indicates that there are no changes in the etiological ‍factors for prostate cancer in Mumbai, India. These findings may be of general interest because changes in diagnostic ‍practices are confounded in the time trends of prostate cancer change in many western countries preventing inferences ‍on the changes in risk. ‍     

Cancer Incidence in Volcanic Areas: A Systematic Review

Background: There are more than 1,000 active volcanoes worldwide with inhabitants within 100 km of them. Volcanoes spill several toxic metals and spew pollution through gasses, causing soil and water contamination. The dangerously active volcanoes place the nearby population at risk for volcanic hazards. This review aimed to determine whether people living in these volcanic areas have higher risk of cancer and more attention should be given to this danger. Methods: A systematic literature search was conducted of PUBMED, Science Direct, SCOPUS, Proquest, and Google Scholar, and from citation searching. We assessed the quality of the studies and extracted the incidence rate of cancer in the volcanic areas compared to non-volcanic areas. Results: The search identified 360 articles, with 11 studies meeting our selection criteria. The results reported the incidence of cancer in children was predominantly in volcanic areas with girls suffering as much as 1.4 per 100,000 per year. The highest cancer age standardized incidence rates for females, males, and overall calculation in volcanic areas were reported as 31.7/100,000/year in Catania, 10.34/100,000/year in Furnas, and 38.3/100,000/year in Catania-Messina-Enna for thyroid cancer. We observed the increasing incidence of carcinoma for some types of cancer in volcanic areas. Conclusion: Cancer incidence in volcanic areas was higher than non-volcanic areas and it is caused by multifactorial conditions. The concentrations of hazardous elements of volcanic products vary among volcanoes and are related to the harmful risk for the inhabitants. The negative effects of volcanic products to human health should be given more consideration.     

An Epidemiological Study on Marital Status and Cancer Incidence

The relationship between marital status and cancer incidence was examined based on 49,191 incident cases aged 30 or over in 1980–1984 by using the data from Aichi Cancer Registry and census data. Although married and widowed people did not show increased incidence for any cancer site studied, single and divorced people showed statistically significantly increased or decreased risks for several sites of cancer. Single males showed an increased risk for esophageal cancer and a decreased risk for lung cancer. Divorced males showed increased risks for cancers of the mouth & pharynx, esophagus, liver, skin and brain. Single females showed increased risks for cancers of the esophagus, stomach, small intestine, liver, pancreas, lung, breast, corpus uteri, ovary & fallopian tube and other female genital organs and a decreased risk for cervical cancer. Divorced females showed increased risks for cancers of the larynx, breast, all parts of uterus and cervix uteri and a decreased risk for biliary tract cancer. The increased risk for breast cancer in single females was more pronounced in older age groups and the increased risks for several sites of cancer in divorced people were more pronounced in younger age groups. These findings may be partly explained by differences in reproductive factors and life style, especially smoking and drinking habits.     

Patterns and Trends with Cancer Incidence and Mortality Rates Reported by the China National Cancer Registry

National cancer registration reports provide a huge potential for identifying patterns and trends of important policy, research, prevention and treatment significance. As summary reports written on an annual basis, the China Cancer Registry Annual Reports (CCRARs) fall short from fully addressing their potential. This paper attempts to explore part of the patterns and trends hidden behind published CCRARs. It extracted data for cancer incidence rates (IRs) and mortality rates (MRs) for 2004, 2006 and 2009 from relevant CCRARs and portrayed 4 kinds of indicators in line graphs. The study showed that: a) all of the line graphs of age-specific IRs and MRs characterized typical “growth curves or histogram”; b) graphs of IRs and MRs for males and urban areas had higher peaks than that for females and rural regions; c) most of the line graphs of IR/MR ratios comprised a starting peak, a secondary peak and a decreasing tail and the secondary peaks for females and urban areas were higher than those for males and rural areas; d) most of the urban versus rural IR ratios valued above one, but most the urban versus rural MR ratios, below one; e) the accumulative IRs and MRs showed a stable increasing trend from 2004 to 2009 for urban areas, but mixed for rural regions.     

Trends and Analysis of Cancer Incidence for Common Male and Female Cancers in the Population of Punjab Province of Pakistan during 1984 to 2014

Background: The Pakistan Atomic Energy Commission Cancer Registry (PAECCR) program has madeavailability of a common cancer incidence database possible in Pakistan. The cancer incidence data from nuclearmedicine and oncology institutes were gathered and presented. Materials and Methods: The cancer incidencedata for the last 30 years (1984-2014) are included to describe a data set of male and female patients. The dataanalysis concerning occurrence, trends of common cancers in male and female patients, stage-wise distribution,and mortality/follow-up cases is also incorporated for the last 10 years (2004-2014). Results: The total populationof provincial capital Lahore is 9,800,000. The total number of cancer cases was 80,390 (males 32,156, females48,134). The crude incidence rates in PAECCR areas were 580.8/105 during 2010 to 885.4/105 in 2014 (males354.1/105, females 530.1/105). The cancer incidence rates for head and neck (15.70%), brain tumors (10.5%),and non-Hodgkin lymphoma (NHL, 9.53%) were found to be the highest in male patients, whereas breastcancer (46.7%), ovary tumors (6.80%), and cervix (6.31%) cancer incidence rates were observed to be the mostcommon in female patients. The age range distribution of diagnosed and treated patients in conjunction with thepercentage contribution of cancer patients from 15 different cities of Punjab province treated at the Institute ofNuclear Medicine and Oncology, Lahore are also included. Leukemia was found to be the most common cancerfor the age group of 1-12 years. It has been identified that the maximum number of diagnosed cases were foundin the age range of 51-60 years for males and 41-50 years for female cancer patients. Conclusions: Overallcancer incidence of the thirty years demonstrated that head and neck and breast cancers in males and in femalesrespectively are the most common cancers in Punjab province in Pakistan, at rates almost the highest in Asia,requiring especial attention. The incidence of brain, NHL, and prostate cancers among males and ovarian andcervix cancers among females have increased rapidly. These data from a major population of Punjab provinceshould be helpful for implementation of appropriate planning, prevention and cancer control measures and fordetermination of risk factors within the country.