Disease burden of diabetes mellitus type II in the Netherlands: incidence, prevalence and mortality

A consistent estimate of the prevalence, mortality and incidence of diabetes mellitus type II in the Netherlands was obtained by combining data from several sources using statistical and modelling techniques. In the Netherlands, the prevalence of diabetes in the age-group 30-74 years is 2.7-3.2%. The prevalence increases with age: for men by 7% per year of age and for women by almost 8% per year of age. This age-related increase will give rise to a 36% increase in the prevalence of diabetes in the period 1993-2010. Diabetic patients account for 12% of the total mortality in men and 18% in women; in 2.5% and 5% of the cases respectively, diabetes is the cause of mortality. If this excess mortality could be eliminated then the life expectancy for men with diabetes would increase by 4.7 years at the age of 45 and for women the corresponding increase would be 6.3 years. The estimated incidence per year increases from 8 per 10,000 men (7 for women) in the age group 40-44 years to 80 per 10,000 men (86 for women) in the age group 75-79 years.     

A method for estimating the systemic burden of Pu from urinalyses

It is generally agreed that Langham's model for urinary excretion of Pu substantially overestimates the systemic burden several years after exposure. Improved estimates can be derived from information obtained since the development of that model, including comparative urine and autopsy data for occupationally exposed persons; reanalyzed and updated data for human subjects injected with Pu; and a large body of general physiological and Pu-specific information on the processes governing the behavior of Pu in the body. We examine modeling approaches based on each of these sets of information and show that the three approaches yield fairly consistent estimates of the urinary excretion rate over three decades after contamination of blood. Estimates from the various approaches are unified to obtain a single set of predicted urinary excretion rates that, in effect, is based on all three bodies of information. A simple method is described for using these excretion rates to estimate intakes and systemic burdens of Pu.     

Determining the burden of tuberculosis in Eritrea: a new approach

OBJECTIVE: To obtain an estimate of the prevalence of new cases of smear-positive tuberculosis in Eritrea using a new low-cost approach. METHODS: The study was designed to include a sample of 35,000 people divided between 40 clusters. The clusters were selected by sampling proportional to population size. In each cluster, census data were obtained from eligible individuals. Individuals aged 15 years or more were questioned about cough and its duration and smoking and were asked to provide two samples of sputum (spot and morning) for examination by fluorescence microscopy. FINDINGS: A total of 38,032 individuals were included in the study. Of the 19,197 individuals aged 15 years or more, 18,152 (94.6%) provided at least one sample of sputum. Fifteen individuals fulfilled the case definition, providing a prevalence of new cases of smear-positive tuberculosis of 90 per 100,000 (95% confidence interval, CI, 35-145 per 100,000) individuals aged 15 years or more and 50 per 100,000 (95% CI, 19-80 per 100,000) in the total population. CONCLUSION: The estimated prevalence of new cases of smear-positive tuberculosis obtained from our study is considerably lower than the estimate published by the World Health Organization. The new methodology for surveys to determine the prevalence of tuberculosis that we used is feasible in the field. This methodology should be validated in other countries and compared with other methods for measuring prevalence.     

Accounting for model uncertainty in estimating global burden of disease

Objective

To illustrate the effects of failing to account for model uncertainty when modelling is used to estimate the global burden of disease, with specific application to childhood deaths from rotavirus infection.

Methods

To estimate the global burden of rotavirus infection, different random-effects meta-analysis and meta-regression models were constructed by varying the stratification criteria and including different combinations of covariates. Bayesian model averaging was used to combine the results across models and to provide a measure of uncertainty that reflects the choice of model and the sampling variability.

Findings

In the models examined, the estimated number of child deaths from rotavirus infection varied between 492 000 and 664 000. While averaging over the different models’ estimates resulted in a modest increase in the estimated number of deaths (541 000 as compared with the World Health Organization’s estimate of 527 000), the width of the 95% confidence interval increased from 105 000 to 198 000 deaths when model uncertainty was taken into account.

Conclusion

Sampling variability explains only a portion of the overall uncertainty in a modelled estimate. The uncertainty owing to both the sampling variability and the choice of model(s) should be given when disease burden results are presented. Failure to properly account for uncertainty in disease burden estimates may lead to inappropriate uses of the estimates and inaccurate prioritization of global health needs.     

Years of life lost by mortality: a component of the burden of disease

INTRODUCTION: The register of death by cause, sex and age groups of residents in 1994 in Rio Grande do Sul (RS) and Santa Catarina (SC), two Brazilian southern states, were studied to calculate the years of life lost (YLL), one of the two components that summarize disability adjusted life years (DALY), in RS, SC and Brazil. METHODS: The methodology employed is the same used in the Global Burden of Disease study to quantify the mortality component (YLL) of DALY in the world. RESULTS: The results show that the greatest proportion and rates caused by Group II (Noncommunicable diseases), linked with more advanced stages of the epidemiological transition, in RS, SC and Brazil. But in both states and especially in Brazil, Group I (Communicable, maternal, perinatal and nutritional conditions) causes an important proportion of YLL. The Group III (Injuries) was the second more important group in RS and SC and the third in Brazil. Road traffic accidents are particularly important in SC, where the intentional injury rate is half than the one in RS. The leading causes of YLL were road traffic accidents, ischemic heart disease and cerebrovascular disease in SC, and ischemic heart disease, cerebrovascular disease and road traffic accidents in RS. CONCLUSIONS: Death certification in the southern region of Brazil has a complete coverage and miscoded death proportion is small, providing a reliable mortality information. DALY allow comparing fatal and nonfatal health outcomes to determine the importance of different diseases and to establish health priorities. DALY are also an useful tool to identify disadvantaged groups, target health interventions and provide information for social control of resource allocation.     

Assessment of an approach to estimating aquatic bioconcentration factors using reduced sampling

For a broad range of circumstances, we show that reliable bioconcentration factor (BCF) estimates can be made using a study design that is based on standard regulatory guideline test procedures but that uses significantly fewer animals and resources. This minimized design involves taking tissue samples only twice during a 14-d depuration period. The utility of the minimized test design was first assessed by resampling data from a series of standard guideline tests and calculating the BCF estimates that would have been obtained if the test had been performed using the minimized design. Data from 25 bioconcentration curves giving BCF estimates ranging from approximately 0.3 to over 20,000 were used. The correlation of log BCF estimates from the guideline study with log BCF estimates from the simulated minimized tests was r=0.99, and the slope of the regression line was 0.96. The robustness of BCF estimates to random variation in measurement of chemicals in fish and water (coefficients of variation of concentrations ranging up to 25%) was evaluated using Monte Carlo simulations. For chemicals with depuration half-lives of less than the length of the depuration period, median BCF estimates from the Monte Carlo simulations of the minimized design were always within 7% of the true BCE The ratio of the 95th to the 5th percentile BCF estimates was always less than or equal to 3.7. Furthermore, the span from the 95th to the 5th percentile of BCF estimates was only 15% wider in the minimized test than in the full guideline test, even though animal use and analytical effort was markedly reduced.     

EURRECA's approach for estimating micronutrient requirements

In Europe, micronutrient dietary reference values have been established by (inter)national committees of experts and are used by public health policy decision-makers to monitor and assess the adequacy of diets within population groups. The approaches used to derive dietary reference values (including average requirements) vary considerably across countries, and so far no evidence-based reason has been identified for this variation. Nutrient requirements are traditionally based on the minimum amount of a nutrient needed by an individual to avoid deficiency, and is defined by the body's physiological needs. Alternatively the requirement can be defined as the intake at which health is optimal, including the prevention of chronic diet-related diseases. Both approaches are confronted with many challenges (e. g., bioavailability, inter and intra-individual variability). EURRECA has derived a transparent approach for the quantitative integration of evidence on Intake-Status-Health associations and/or Factorial approach (including bioavailability) estimates. To facilitate the derivation of dietary reference values, EURopean micronutrient RECommendations Aligned (EURRECA) is developing a process flow chart to guide nutrient requirement-setting bodies through the process of setting dietary reference values, which aims to facilitate the scientific alignment of deriving these values.     

Availability and quality of cause-of-death data for estimating the global burden of injuries

Objective

To assess the availability and quality of global death registration data used for estimating injury mortality.

Methods

The completeness and coverage of recent national death registration data from the World Health Organization mortality database were assessed. The quality of data on a specific cause of injury death was judged high if fewer than 20% of deaths were attributed to any of several partially specified causes of injury, such as “unspecified unintentional injury”.

Findings

Recent death registration data were available for 83 countries, comprising 28% of the global population. They included most high-income countries, most countries in Latin America and several in central Asia and the Caribbean. Categories commonly used for partially specified external causes of injury resulting in death included “undetermined intent,” “unspecified mechanism of unintentional injury,” “unspecified road injury” and “unspecified mechanism of homicide”. Only 20 countries had high-quality data. Nevertheless, because the partially specified categories do contain some information about injury mechanisms, reliable estimates of deaths due to specific external causes of injury, such as road injury, suicide and homicide, could be derived for many more countries.

Conclusion

Only 20 countries had high-quality death registration data that could be used for estimating injury mortality because injury deaths were frequently classified using imprecise partially specified categories. Analytical methods that can derive national estimates of injury mortality from alternative data sources are needed for countries without reliable death registration systems.     

Familial associations of lipid profiles: a generalized estimating equations approach

Elevated plasma levels of apolipoproteins A1 (apoA1) and B (apoB) are important protective factors and risk factors, respectively, for atherosclerosis and coronary heart disease. It is well known that both apoA1 and apoB reveal strong familial aggregation. Our goal was to investigate whether exogenous variables influence these associations. We used marginal regression models for the mean and association structure (generalized estimating equations 2; GEE2) to analyse data from 1435 family members within 469 families of different sizes included in the Donolo-Tel Aviv Three-Generation Offspring Study. The usual robust variance matrix was approximated by extensions of jack-knife estimators of variance to GEE2 models. Estimation of standard errors in models with quite complex correlation structures was possible using this approach. All analyses were easily carried out using a menu-driven stand-alone software tool for marginal regression modelling. We demonstrate that a variety of hypotheses can be tested using Wald statistics by modelling regression matrices for the association structure. We show that correlation for apoB between parent-offspring pairs increased with decreasing age difference and that pairs with individuals of the same gender had more similar apoA1 levels than individuals of different gender. Associations between different relative pairs did not all agree with those expected from differences in kinship coefficients. The analysis using GEE2 models revealed structures that would not have been detected by other models and should therefore be used in addition to traditional approaches of analysing family data. GEE2 should be considered a standard method for the investigation of familial aggregation.     

Towards a new approach for estimating indirect costs of disease.

Many researchers in the field of evaluation of health care doubt the usefulness of estimates of indirect costs of disease in setting priorities in health care. This paper attempts to meet part of the criticism on the concept of indirect costs, which are defined as the value of production lost to society due to disease. Thus far in cost of illness studies and cost-effectiveness analyses the potential indirect costs of disease were calculated. In the following a first step will be taken towards a new method for estimating indirect costs which are expected to be effectuated in reality: the friction cost method. This method explicitly takes into account short and long run processes in the economy which reduce the production losses substantially as compared with the potential losses. According to this method production losses will be confined to the period needed to replace a sick worker: the so called friction period. The length of this period and the resulting indirect costs depend on the situation on the labour market. Some preliminary results are presented for the indirect costs of the incidence of cardiovascular disease in the Netherlands for 1988, both for the friction costs and the potential costs. The proposed methodology for estimating indirect costs is promising, but needs further development. The consequences of illness in people without a paid job need to be incorporated in the analysis. Also the relation between internal labour reserves and costs of disease should be further investigated. Next to this, more refined labour market assumptions, allowing for diverging situations on different segments of the labour market are necessary.     

Assessment of a Screening Method for Heart Disease

Gorman D R. Assessment of a screening method for heart disease.Family Practice 1988; 5: 297–301. This study examined the effects of a cardiovascular screeningprogramme on a group of 79 patients in an Edinburgh generalpractice. Serum cholesterol levels were measured two to fourmonths after the original screening interview and risk scoresrecalculated to see if the collection of data was reliable;a control group was used. Patient attitudes to this screeningwere assessed by questionnaire and the repeatability of therisk score calculation investigated. The programme was popularwith patients and was successful in changing their reportedbehaviour. However, it may have been counter-productive in somepatients by sanctioning personal habits detrimental to health.This effect was particularly marked in patients at lower risklevels who it is shown may have raised serum cholesterol levels.It is suggested that the risk score calculation could be improved,in particular by improving the accuracy of the serum cholesterolmeasurement. It is concluded that more research is needed intothe behavioural aspects of cardiovascular screening.     

A call for a gender specific approach to address the worldwide cardiovascular burden

Cardiovascular diseases (CVD) among non-communicable diseases are already a major public health challenge worldwide. A further increase in CVD is projected to occur over the next 25 years as a result of both adverse lifestyle changes and demographic shifts in the population age profile. The adverse impact of these health problems will affect women in particular, given the steady rise in the proportion of the aging population that will be women.The critical issue presently in the management of CVD is that we are not even adequately using the data that are available. Women still remain unaware that they are at risk, and information about women is not easily accessible to their physicians. This is a global issue and the need remains for worldwide initiatives with greater vigilance to identify these factors and make efforts to control them effectively.Currently, in scientific research, it is expected that the results of clinical research be analyzed for sex differences, sex- and gender-appropriateness, and sex- and gender-specific approaches for prevention, diagnosis, treatment, and counseling. To address the care discrepancy, the global community needs to develop a conducive environment within a comprehensive policy and operational framework to achieve favorable lifestyles, and CVD risk factor reduction for both men and women.     

Stroke burden in Mexican Americans: the impact of mortality following stroke

PURPOSE: To estimate ethnic-specific all-cause mortality risk following ischemic stroke and to compare mortality risk by ethnicity. METHODS: DATA from the Brain Attack Surveillance in Corpus Christi Project, a population-based stroke surveillance study, were used. Stroke cases between January 1, 2000 and December 31, 2002 were identified from emergency department (ED) and hospital sources (n = 1,234). Deaths for the same period were identified from the surveillance of stroke cases, the Texas Department of Health, the coroner, and the Social Security Death Index. Ethnic-specific all-cause cumulative mortality risk was estimated at 28 days and 36 months using Kaplan Meier analysis. Cox proportional hazards regression was used to compare mortality risk by ethnicity. RESULTS: Cumulative 28-day all-cause mortality risk for Mexican Americans (MAs) was 7.8% and for non-Hispanic whites (NHWs) was 13.5%. Cumulative 36-month all-cause mortality risk was 31.3% in MAs and 47.2% in NHWs. MAs had lower 28-day (RR = 0.58; 95% CI: 0.41, 0.84) and 36-month all-cause mortality risk (RR = 0.79, 95% CI: 0.64, 0.98) compared with NHWs, adjusted for confounders. CONCLUSIONS: Better survival after stroke in MAs is surprising considering their similar stroke subtype and severity compared with NHWs. Social or psychological factors, which may explain this difference, should be explored.     

Analysis of variance for repeated measures. Data: a generalized estimating equations approach.

Various techniques are available for the analysis of repeated measures data, and the appropriate choice depends on distributional assumptions and study design features. A correct analysis must account for potential dependence between repeated observations on the same subject. Liang and Zeger proposed a more unified approach to the analysis of repeated measures data based on the application of generalized estimating equations. We examine the application of these methods to several types of data in which one estimates the mean response directly for each combination of discrete covariates, and uses an identity link. Computations for fitting this type of model are exceptionally simple. Numerical examples suggest that the proposed approach yields estimation and hypothesis testing results consistent with more specialized methods.     

Disease burden profiles: an emerging tool for managing managed care

As health plans assume financial risk for providing health care services, effectively managing the health of a population remains one of the toughest challenges. This article shows how risk assessment methods can be used to measure disease burden in the full population and to discriminate levels of future health care needs within specific disease cohorts. We also examine and compare the predictive power of claims-based models within a diabetic cohort.     

Disease burden of enterovirus infection in Taiwan: Implications for vaccination policy

ObjectivesThis study aimed to assess the disease burden and economic impacts of human nonpolio enteroviruses (NPEV) and enterovirus A71 (EV-A71) infection in Taiwan.Materials and methodsWe included children under five years old (n = 983,127–1,118,649) with ICD-9-CM codes 0740 (herpangina) or 0743 (hand-foot-and-mouth disease) from the 2006 to 2010 National Health Insurance Database. Severity of enterovirus infection was assessed from outpatient/emergency visits, hospitalization (with/without intensive care unit [ICU] admission), infection with severe complications, and death. We estimated medical costs and indirect costs from the societal perspective.ResultsThe annual rates of NPEV events for children under five years old ranged from 13.9% to 38.4%, of which 5.1–8.8% were hospitalized. EV-A71 accounted for 7.8% of all NPEV medical costs, but 79.1% of NPEV ICU costs. Travel costs and productivity loss of caregivers were $37.1 (range: $24.5–$64.7) million per year. These costs were not higher in the EV-A71 dominant year ($34.4 million) compared with those in the other years. Productivity losses resulting from premature mortality by NPEV infection were $0.8 (range: $0.0–$2.9) million per year, of which 96.3% were caused by EV-A71.ConclusionsDiseases associated with NPEV other than EV-A71 were responsible for most of the medical expenses. In addition, caregiver productivity loss by high rates of NPEV infection impacted the society much more than medical costs. A multi-valent vaccine that includes EV-A71 and other serotypes, for example coxsackievirus A16, may be beneficial to the health of children in Taiwan.     

Ambient particulate air pollution and acute lower respiratory infections: a systematic review and implications for estimating the global burden of disease

Acute lower respiratory infections (ALRI) account for nearly one fifth of mortality in young children worldwide and have been associated with exposures to indoor and outdoor sources of combustion-derived air pollution. A systematic review was conducted to identify relevant articles on air pollution and ALRI in children. Using a Bayesian approach to meta-analysis, a summary estimate of 1.12 (1.03, 1.30) increased risk in ALRI occurrence per 10 μg/m³ increase in annual average PM_2.5 concentration was derived from the longer-term (subchronic and chronic) effects studies. This analysis strengthens the evidence for a causal relationship between exposure to PM_2.5 and the occurrence of ALRI and provides a basis for estimating the global attributable burden of mortality due to ALRI that is not influenced by the wide variation in regional case fatality rates. Most studies, however, have been conducted in settings with relatively low levels of PM_2.5. Extrapolating their results to other, more polluted, regions will require a model that is informed by evidence from studies of the effects on ALRI of exposure to PM_2.5 from other combustion sources, such as secondhand smoke and household solid fuel use.     

湖北省急性胃肠炎疾病人群负担评估

目的 评估湖北省人群急性胃肠炎疾病负担。方法 采用多阶段整群随机抽样的方法抽取调查对象,2012年1-12月每月入户问卷调查其急性胃肠炎发生和就诊情况。结果 共调查3891人,急性胃肠炎月患病率为4.1%(95%CI=3.4%~4.7%),年发病概率为41.7%(95%CI=36.2%~46.6%),年发病率为0.49(95%CI=0.42~0.57)次/人年。按人口结构加权,加权月患病率为4.9%(95%CI=4.2%~5.6%),加权年发病概率为47.8%(95%CI=42.8%~52.8%),加权年发病率为0.65(95%CI=0.56~0.74)次/人年。由此推算,湖北省2012年共有3756.4万人次感染急性胃肠炎,因病就诊2434.1万人次,因病住院296.8万人次。结论 湖北省人群2012年急性胃肠炎疾病负担较重,政府应予以关注和重视。