Burden Of Disease Approach Research Articles

6.Q. Skills building seminar: Integrating social inequalities in the burden of disease framework

Abstract Driven by the influential Global Burden of Disease (GBD) study, the burden of disease (BOD) approach has gained wide interest at national and international level to quantify the state of health and health inequalities. Central to the BOD approach is the Disability-Adjusted Life Year (DALY) metric, which quantifies the health impact of diseases, injuries and risk factors as the number of healthy life years lost compared to a counterfactual scenario of perfect health all life long. The BOD approach offers a valuable platform to quantify social inequalities in health, i.e., differences in health status by socioeconomic and sociodemographic characteristics. This is highly relevant, as health inequalities penalising socially disadvantaged groups are one of the most consistent, and persistent, findings in epidemiology, for almost every health outcome and socioeconomic indicator. Monitoring social inequalities in health is therefore a key priority for national health authorities. There are different ways by which social inequalities can be integrated in the BOD framework, but all come with important data challenges. Individual-level stratification is a common approach for quantifying inequalities by age and sex, but is more challenging for other sociodemographic and socioeconomic indicators. Area-level stratification allows for ecological analyses between BOD estimates and indices of social deprivation. Social inequalities can also be assessed using comparative risk assessment, by which the relative risk for adverse health outcomes in function of social position is to be quantified. This skills building workshop will present the methods that have been applied in different national burden of disease studies to include social inequalities, including a discussion of their strengths and weaknesses. By providing a step-by-step presentation of how the methods have been applied, attendees will gain unique insights in the different ways by which social inequalities can be integrated in the BOD framework. Key messages • The burden of disease framework offers a valuable platform to quantify and monitor social inequalities in health, which is a key priority for health authorities. • Attendees will receive an overview of the different ways by which social inequalities can be integrated in the burden of disease framework, including a discussion of their strengths and weaknesses.

Recommendations to plan a national burden of disease study

BackgroundThe InfAct (Information for Action) project is a European Commission Joint Action on Health Information which has promoted the potential role of burden of disease (BoD) approaches to improve the current European Union-Health Information System (EU-HIS). It has done so by raising awareness of the concept, the methods used to calculate estimates and their potential implications and uses in policymaking. The BoD approach is a systematic and scientific effort to quantify and compare the magnitude of health loss due to different diseases, injuries, and risk factors with estimates produced by demographic characteristics and geographies for specific points in time. Not all countries have the resources to undertake such work, and may therefore start with a more restricted objective, e.g., a limited number of diseases, or the use of simple measures of population health such as disease prevalence or life expectancy. The main objective to develop these recommendations was to facilitate those countries planning to start a national burden of disease study.ResultsThese recommendations could be considered as minimum requirements for those countries planning to start a BoD study and includes following elements: (1) Define the objectives of a burden of disease study within the context of your country, (2) Identify, communicate and secure the benefits of performing national burden of disease studies, (3) Secure access to the minimum required data sources, (4) Ensure the minimum required capacity and capability is available to carry out burden of disease study, (5) Establish a clear governance structure for the burden of disease study and stakeholder engagement/involvement, (6) Choose the appropriate methodological approaches and (7) Knowledge translation. These were guided by the results from our survey performed to identify the needs of European countries for BoD studies, a narrative overview from four European countries (Belgium, Germany, The Netherlands and Scotland) and the summary of a comparative study of country health profiles with national health statistics.ConclusionsThese recommendations as minimum requirements would facilitate efforts by those European countries who intend to perform national BoD studies.

30.L. Workshop: European burden of disease network: strengthening the collaboration

Abstract The burden of disease (BoD) approach has become one of the foundations of descriptive epidemiology. Central to this approach is the use of the Disability-Adjusted Life Year as a comprehensive and comparable summary measure of population health. Driven by the impact of the Global Burden of Disease (BoD) study, several researchers and health institutes across the world have adopted the BoD approach to assess the health impact of diseases and risk factors, supporting a more rational allocation of available resources. Despite the increasing prominence of the BoD approach, several challenges remain. The BoD methodology is complex and highly data intensive, which has led to major disparities across researchers and nations in their capacity to perform BoD studies, to interpret the soundness of available BoD estimates, or to advocate for the use of BoD methods. Often, these disparities follow geographical boundaries–for instance, over half of all published BoD studies in Europe were set in the Netherlands, Spain and UK, while only 15% were set in eastern European countries. BoD as a generally standardized approach nonetheless requires different methodological choices, and lack of harmonization in these may hamper comparisons across studies. This is further aggravated by the fact that different BoD initiatives have remained scattered–there is for instance little interaction between infectious disease, nutritional and environmental epidemiologists, even though several methodological issues transcend the boundaries of diseases and risk factors. Finally, many BoD researchers are struggling to find optimal ways to translate their findings and communicate them adequately and comprehensively to decision makers and other stakeholders. In response to these needs, several countries and BoD researchers have set up ad hoc partnerships. In 2016, the WHO Regional Office for Europe (WHO-EURO) launched a European BoD network, aiming to intensify links between WHO, IHME and the WHO-EURO member states. In 2019, our group has launched a COST Action that aims to serve as a technical platform to integrate and strengthen capacity in BoD assessment across Europe and beyond. At the moment of writing, the “burden-eu” COST Action joins over 200 participants from 38 European countries, as well as several observers from non-European countries and international organizations. In this workshop, we give an overview of the current status and initial accomplishments of the COST Action, with a focus on the key challenges that the Action aims to address - i.e., increased interaction between existing efforts, methodological advances and technical capacity building at country level, and an actionable understanding of the process underlying knowledge translation. The different sessions will include interactions with the audience to learn about the needs and expectations of the attendees, and how these can be addressed by the COST Action. Key messages The burden of disease approach is increasingly used to generate comparable and comprehensive estimates of the health impact of diseases and risk factors. The 'burden-eu' COST Action offers a technical platform for integrating and strengthening capacity in burden of disease assessment across Europe and beyond.

32.L. Workshop: Deconstructing the DALY: step by step guide to calculating YLL and YLD

Abstract A Burden of Disease (BoD) approach can be used to summarise the debilitating effects of morbidity and premature mortality in a population in a consistent and comparable manner. Summary measures of population health such as the Disability-Adjusted Life Year (DALY) have become key metrics for quantifying burden of disease. DALYs quantify the health gap between a life lived in perfect health and current health status, as the number of healthy life years lost due to illness (Years Lived with Disability, YLDs) and premature death (Years of Life Lost, YLLs). DALYs combine the effects of morbidity and mortality in an equitable way, and can therefore be used to identify the leading causes of disease or injury that cause BoD and to quantify the relative importance of specific risk factors. BoD studies are becoming an increasingly popular way to assess national and local population health as a means to influence national and local policy decisions. The increasing prominence of the burden of disease approach, however, comes at a cost. Calculations of DALYs involve multiple components and as such can be difficult for people to interpret. Burden of disease methodology is complex and highly data intensive, which has led to major disparities across researchers and nations in their capacity to perform studies, to interpret the soundness of available estimates, or to evidence and advocate for the use of particular methodological choices. In this skills-building seminar, we will give an overview of the methodology of calculating the DALY. It will outline the single steps to be undertaken, and the necessary assumptions that have to be taken, on the way to the calculation of the DALYs. This workshop will be supported by technical presentations from burden of disease experts about different choices of estimation methods to calculate both the fatal burden (YLL) and the non-fatal burden (YLD). Throughout the presentations, cerebrovascular disease will be used as a case study, giving a complete, real-life example of how DALYs are calculated. Overall, the aim is to demonstrate the importance of the choices researchers make when designing and interpreting BoD studies as a means of supporting evidence-based decision making. The workshop will foresee ample time for interaction with the audience and discussion of the implications of the different methodological choices. Key messages Although burden of disease methodology is complex, with calculations of DALYs involving multiple components, simple roadmaps can be created to enhance methodological knowledge. The choices and assumptions researchers make are important when designing and interpreting burden of disease studies.

Development of composite indicators to monitor burden of disease across Member States

Abstract Background The burden of disease (BoD) methods are not part of routine public health activities and policy development process across all Member States (MSs). The main reasons for this are varying levels of knowledge, experience, and capability to apply and use BoD methods. Therefore, MSs need support, guidance and training to adopt and integrate BoD approaches in their public health systems. In this context, two workshops have been organised by InfAct. The main objectives of the workshops are to raise awareness, share knowledge and experience, and to provide mutual support to to integrate BoD indicators in the public health policies across Europe. Methods The workshops were about the BoD concept and methodologies, and the use of BoD data in public health policy. These workshops were supported by technical presentations describing methods and the use of BoD data in health policy with various case studies, followed by expert exchange with facilitated discussions and group work. The case studies included national BoD studies from Belgium, Germany, Netherland, and Scotland. Results Two workshops were held at Santé Publique France, and attended by 16 BoD experts and 40 participants from 25 MSs. The workshops were well received by the participants particularly with regards to the diversity of the group and the possibility to share knowledge and experience from various perspectives. Three areas of action were highlighted: 1. the need for methodological trainings to strengthen skills in interpreting and calculating BoD estimates; 2. the encouragement of more collaborations across MSs to share or exchange good practices on BoD; and 3. the importance of the implications of BoD data to guide policies across MSs. Conclusions The workshops highlighted the need for capacity building activities to implement BoD approaches across MSs in routine public health activities and to use BoD data to guide health policy. More collaborations among MSs on BoD activities are needed in the future.

A Quantification of the Net Consumer Surplus from Gambling Participation.

Gambling exposes people to risk for harm, but also has recreational benefits. The present study aimed to measure gambling harm and gambling benefits on similar scales using two novel methods adapted from the Burden of Disease approach (McCormack et al. in Psychol Med 18(4):1007-1019, 1988; Torrance et al. in Health Serv Res 7(2):118-133, 1972) to find whether gambling either adds or subtracts from quality of life. A Tasmanian population-representative survey of 5000 adults (2534 female) from random digit dialling (RDD) of landline telephones in Tasmania (50%), as well as pre-screened Tasmanian RDD mobiles (17%) and listed mobile numbers (33%), measured gambling benefits and harms amongst gamblers (59.2%) and a non-exclusive set of people who were "affected" by someone else's gambling (4.5%). The majority of gamblers indicated no change to their quality of life from gambling (82.5% or 72.6% based on direct elicitation or time trade off methods, respectively). Nevertheless, a weighted average of all the positive and negative influences on quality of life, inclusive of gamblers and affected others, revealed that the quality of life change from gambling is either a very modest + 0.05% or a more concerning - 1.9% per capita. Gambling generates only small or negative net consumer surpluses for Tasmanians.

Bladder Cancer Burden from Exposure to Trihalomethanes in Drinking Water in the European Union

BACKGROUND and AIM: Trihalomethanes (THMs) are prevalent chemicals in drinking water (DW). Exposure is through ingestion, inhalation and dermal absorption and has consistently been associated with increased bladder cancer (BC) risk. We assessed THMs levels in DW and estimated the burden of bladder cancer in the European Union (EU). METHODS: We obtained annual mean THM levels in municipal DW in the 28 EU countries in 2010-2017 through a standardized questionnaire and calculated the population-weighted EU mean. We used published THM levels in countries where THM data was not provided for further imputations. We estimated the attributable BC cases following the burden of disease approach. The dose-response function was obtained from the largest international pooled-analysis on THM exposure and BC and was used to estimate the odds ratio for each country, with an alternative exposure scenario of <5µg/L. We calculated the country annual number of attributable BC cases using incidence rates from GLOBOCAN. RESULTS: The amount of data, representativeness and accuracy was heterogeneous among countries. Mean THM level in drinking water in EU-28 was 11.9µg/L (SD 11.1), ranging from 0.0µg/L (Denmark) to 66.2µg/L (Cyprus). The EU 28 average population attributable fraction was 4.6%, and the maximum was 24% in Romania (95%CI 13-34) and 23% in Cyprus (95%CI 12-33). In total, 5,708 (95%CI 2,940-8,318) annual BC cases were attributable to THM exposure in the EU (ranging from 0 in Denmark to 1,498 in Spain). If THM levels in DW were reduced to the EU mean of 11.9 µg/L among countries above this level, 2,438 (95%CI 1,287-3,469) cases of BC could be avoided annually in the EU. CONCLUSIONS: Although the country mean THM levels were below the legal limit (100μg/L), the attributable BC burden and related costs are considerable and can be further lowered by improvements in the quality of DW, especially in countries with higher THM levels.Funding: FP7 EXPOsOMICS Project and CIBERESP.

BURDEN 2020-Burden of disease in Germany at the national and regional level.

Evidence-based policy measures need non-interest-guided information about the health status of apopulation and the diseases that affect the population the most. In such cases, anational burden of disease study can provide reliable insights at the regional level. This article presents the potential of the BURDEN 2020 project and its expected outcome for Germany at the national and regional level. The BURDEN 2020 project uses several indicators including years of life lost (YLL) to cover the impact of mortality and years lived with disability (YLD) to cover morbidity. The sum of both is the measure of population health called disability adjusted life years (DALY). The study ranks individual diseases and risk factors based on their impact on population health. The burden of disease approach is assumed to be sensitive to subnational differences and may generate immediate benefits for regional planning. The BURDEN 2020 study will pilot anational burden of disease study for Germany that will later be transformed into acontinuous data processing and visualization tool. This is done by using, modifying and supplementing the methodology employed by the Global Burden of Disease (GBD) study to better fit the needs of health policy in Germany. This study is aimed at calculating the disease burden for up to 17preselected diseases. Furthermore, the estimates of burden of disease are attributed to aselected set of risk factors. The Burden 2020 study will provide the results of anew, health-related data processing system to the public. This includes anoninterest-guided presentation of the burden of disease (DALY) in Germany at the national and regional level.

Health impact assessment of increasing public transport and cycling use in Barcelona: A morbidity and burden of disease approach

Background: Transportation is a major source of air pollutant emissions and car use, promotes physical inactivity and sedentary lifestyle which are associated with obesity, cardiovascular disease, diabetes, cancer, and other diseases. Both physical inactivity and air pollution have been classified as two of the 20 leading risk factors of burden of disease worldwide in 2010. Aims: Quantify the health impacts on morbidity and burden of disease of reduced car trips and increased public transport and cycling trips. Methods: A health impact assessment study of morbidity of replacing short and long duration car trips with bicycle and public transport trips in the Barcelona metropolitan area (1.6 million inhabitants) was performed. Through 8 different scenarios, the number of cases of disease or injuries related with particulate matter air pollution < 2.5 mm (PM2.5), physical activity and traffic incidents in travelers was estimated. An air dispersion model was used for estimating PM2.5 exposure and cases of disease related to PM2.5 in the general population. To estimate the burden of disease in travelers and the general population of these scenarios, a disability adjusted life years (DALYs) approach was applied. Results: A 40% reduction in long-duration car trips substituted by public transport and cycling trips resulted in annual reductions of 127 cases of diabetes, 44 of cardiovascular diseases, 30 of dementia, 16 minor injuries, 11 of breast cancer and 3 of colon cancer, which resulted in a reduction of 302 DALYs per year in travelers. The reduction in PM2.5 exposure in the general population associated with the 40% reduction of long-duration car trips resulted in annual reductions of 7 cases of low birth weight, 6 of preterm birth, 1 of cardiovascular disease and 1 of lower respiratory tract infection. Conclusions: Transport policies to reduce car trips and increase public transport and cycling trips can produce important health benefits in terms of burden of disease.

Health impact assessment of increasing public transport and cycling use in Barcelona: A morbidity and burden of disease approach

ObjectiveQuantify the health impacts on morbidity of reduced car trips and increased public transport and cycling trips. MethodsA health impact assessment study of morbidity outcomes related to replacing car trips in Barcelona metropolitan (3,231,458 inhabitants). Through 8 different transport scenarios, the number of cases of disease or injuries related to physical activity, particulate matter air pollution <2.5μm (PM2.5) and traffic incidents in travelers was estimated. We also estimate PM2.5 exposure and cases of disease in the general population. ResultsA 40% reduction in long-duration car trips substituted by public transport and cycling trips resulted in annual reductions of 127 cases of diabetes, 44 of cardiovascular diseases, 30 of dementia, 16 minor injuries, 0.14 major injuries, 11 of breast cancer and 3 of colon-cancer, amounting to a total reduction of 302 Disability Adjusted Life Years per year in travelers. The reduction in PM2.5 exposure in the general population resulted in annual reductions of 7 cases of low birth weight, 6 of preterm birth, 1 of cardiovascular disease and 1 of lower respiratory tract infection. ConclusionsTransport policies to reduce car trips could produce important health benefits in terms of reduced morbidity, particularly for those who take up active transportation.

DYNAMO-HIA-2: a tool to calculate the complete counterfactual disability-adjusted life-years (DALYs) of risk factor exposure

BackgroundMany risk factors, such as smoking, affect multiple diseases. Calculating a disability-adjusted life-year (DALY) for such risk factors should take comorbidity into account. We aim to provide a tool for such calculations, using a counterfactual approach. MethodsWe defined a DALY in the original terms as a metric “to quantify loss of healthy years of life due to dying prematurely or to living with the health consequences of diseases, injuries or risk factors”, rather than use its operational form (the sum of healthy years lost through mortality and through disease). As a DALY reflects the effect of risk factor exposure in a particular year only, we calculate this by comparing future population health in the current situation and in the situation where the risk factor is absent in the particular year but returns to the value it would have had in the current situation after 1 year. We derived disability weights for comorbidity by multiplying (1 – disability weight) of the separate diseases. We also included disability weights greater than 0 for those without risk-factor-related disease, reflecting disability from all other diseases. We incorporated the calculation in the DYNAMO-HIA-2 programme, which implements a risk factor–disease Markov model. This reduces the computational burden on the user from entering the data. FindingsOur method delivers a lower DALY than the WHO burden of disease approach, as the latter assumes that the years gained by elimination of the risk factor would all have been healthy years, while our method takes into account that part of these years would have been spent with disease. InterpretationThe proposed method delivers a straightforward metric in terms of interpretation, fully taking competing mortality, morbidity, and comorbidity into account. However, handling of interaction effects (that is, those spared in one year are at risk in later years) needs further discussion. FundingThis research was funded by the National Institute for Public Health and the Environment (RIVM) and partly by the Netherlands Organisation for Health Research and Development. The first version of DYNAMO-HIA was partly funded by the Directorate General for Health and Consumers of the European Commission.

The burden of disease profile of residents of Nairobi's slums: Results from a Demographic Surveillance System

BackgroundWith increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System.MethodsData from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected between January 2003 and December 2005 were analysed. Core demographic events in the NUHDSS including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality (YLL) were calculated by multiplying deaths in each subcategory of sex, age group and cause of death, by the Global Burden of Disease standard life expectancy at that age.ResultsThe overall mortality burden per capita was 205 YLL/1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV/AIDS and tuberculosis accounted for about 50% of the mortality burden.ConclusionSlum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.

The use of nominal group technique in identifying community health priorities in Moshi rural district, northern Tanzania

This article highlights issues pertaining to identification of community health priorities in a resource poor setting. Community involvement is discussed by drawing experience of involving lay people in identifying priorities in health care through the use of Nominal Group Technique. The identified health problems are compared using four selected village communities of Moshi district in Kilimanjaro region, Tanzania. We conducted this study to trace the experience and knowledge of lay people as a supplement to using 'health experts' in priority setting using malaria as a tracer condition. The patients/caregivers, women's group representatives, youth leaders, religious leaders and community leaders/elders constituted the principal subjects. Emphasis was on providing qualitative data, which are of vital consideration in multi-disciplinary oriented studies, and not on quantitative information from larger samples. We found a high level of agreement across groups, that malaria remains the leading health problem in Moshi rural district in Tanzania both in the highland and lowland areas. Our findings also indicate that 'non-medical' issues including lack of water, hunger and poverty heralded priority in the list implying that priorities should not only be focused on diseases, but should also include health services and social cultural issues. Indeed, methods which are easily understood and applied thus able to give results close to those provided by the burden of disease approaches should be adopted. It is the provision of ownership of the derived health priorities to partners including the community that enhances research utilization of the end results. In addition to disease-based methods, the Nominal Group Technique is being proposed as an important research tool for involving the non-experts in priority setting in Tanzania.