Comparative Risk Assessment Research Articles

Health risk assessment associated with priority potentially hazardous chemical compounds detected in canned meat and meat-and-vegetable food for infants

Assessment of public health safety associated with chemical contaminants consumed with food is an important component for solving the tasks of ensuring the sanitary and epidemiological well-being of the population. For these purposes, it is necessary to establish priority potentially dangerous compounds among the identified undeclared and unintended chemical contaminants for further consumers risk assessment. In conditions of unacceptable levels of health risk, it is necessary to decide whether it is advisable to develop new or change existing hygiene standards for these substances. The aim of the study was to assess the health risk associated with priority potentially dangerous unintended chemical components of contamination in canned meat and meat-and-vegetable products for infants (using the example of N-nitrosoamines). Material and methods. The selection of priority chemical compounds and public health risk assessment were carried out in accordance with the procedure for identifying undeclared and potentially dangerous unintended chemicals in food and using modified approaches based on the results of previous studies. Health risk assessment for infants consuming canned meat and meat-and-vegetables containing priority chemicals was carried out in accordance with the methodology approved by the Eurasian Economic Commitee, as well as using the Guidelines for assessing risks to public health when exposed to environmental pollutants. To characterize the calculated risk levels, the classification proposed in the draft document «Guidelines for assessing risks to public health when exposed to environmental pollutants» was used. Results. N-nitrosoamines are classified as chemical contaminants that are a priority for public health risk assessment, identified on the basis of the potential hazard category. A comparative health risk assessment for the target group consumers of canned meat and meat-and-vegetables sold on the territory of the Russian Federation and the Socialistic Republic of Vietnam showed the presence of an unacceptable risk to the health of the Russian population in relation to non-carcinogenic adverse health effects associated with the intake of N-nitrosodimethylamine (NDMA) (hazard quotient HQ=1.1) and N-nitrosodibuthylamine (HQ=5.25). Many experimental (animal) researches confirm the formation of negative effects and potential harm to humans, formed by the consumption of N-nitrosoamines with food. At the same time, the level of the exposure of N-nitrosoamines during oral administration was assessed mainly from the side of carcinogenic effects, however, this study reflects the hazard, including from non-carcinogenic risks associated not only with NDMA and N-nitrosodiethylamine, for which there is a hygienic standard, but also for other N-nitrosoamines, for which there is no hygienic regulation. In turn, the European Food Safety Agency's (EFSA) study notes that it is necessary to conduct a risk assessment for human health in relation to other N-nitrosoamines identified in food, and, if necessary, rationing of these compounds, which is also confirmed by this study. Conclusion. The conducted health risk assessment of the target population of Russia (infants from 6 months to 3 years) consuming the studied types of products containing N-nitrosoamines showed the presence of unacceptable levels of non-carcinogenic health risks in relation to the development processes and impaired liver function. In connection with the identified risks to the health of the target population, it is advisable to establish maximum permissible levels not only for the amount of NDMA and N-nitrosodiethylamine, but also for other N-nitrozoamines identified by the results of the study, with their subsequent regulation.

A carga epidemiológica da redução do sal no Paraguai: um estudo de modelagem

ABSTRACT Objective This study aims to estimate the epidemiological burden of excessive salt intake reduction and achieve the World Health Organization salt reduction target for 2025 in Paraguay, in 2019. Methods We used the Preventable Risk Integrated Model, a comparative risk assessment macro-simulation model, to estimate the averted deaths, disease incidence, and disability-adjusted life years from cardiovascular disease attributable to salt intake in the population of Paraguay for different salt reduction policy scenarios. Results As a result, in Paraguay, excessive salt intake (over 5 g/day) is responsible for approximately 2,656 cardiovascular disease deaths (95% Uncertainty Interval: 1,250-3,765), 4,816 cardiovascular disease cases (95% UI: 2,251-6,947), and 60,529 disability-adjusted life years (95% UI: 27,828-86,258) per year. By reducing salt consumption by 30%, as recommended by the World Health Organization until 2025, approximately 1,188 deaths (95% UI: 520 to 1,820), 2,100 incident cases (95% UI: 923-3,234), and 27,272 disability-adjusted life years (95% UI: 11,999-41,675) from cardiovascular disease could be averted every year. Conclusion In conclusion, the burden of cardiovascular disease attributable to excessive salt intake is significant and salt reduction policies must become a priority in Paraguay.

S-47-4: THE BURDEN OF CARDIOVASCULAR DISEASE ATTRIBUTABLE TO HIGH SYSTOLIC BLOOD PRESSURE ACROSS CHINA AND ITS PROVINCES FROM 2005 TO 2018

Background: The temporal trends and geographical disparity in the burden of cardiovascular diseases (CVD) attributable to high systolic blood pressure (SBP) have not been fully discussed before in Chinese population. The current study was performed to quantify the CVD burden attributable to high SBP in China, which is crucial to inform and improve blood pressure control measures. Methods: We evaluated death numbers, age-standardized mortality rate and years of life lost (YLLs) and corresponding estimated annual percentage changes (EAPC) for CVD and its subcategories attributable to high SBP from 2005 to 2018. We polled data from China Chronic Disease and Risk Factor Surveillance, the China Health and Nutrition Survey and China Hypertension Survey to estimate the BP level between 2005 and 2018. A comparative risk assessment method was applied to compute the deaths and health burden attributable to high SBP for CVD and its subtypes by age, sex, year and provinces. Findings: We estimated that 2·67 million (95%UI 2·61 to 2·73) CVD deaths in China were attributable to elevated SBP in 2018. Age-standardized CVD mortality rate associated with high SBP decreased by 17·89% for China overall between 2005 and 2018, and the EAPC was -1·50 (95% UI -1·55 to -1·45). The death numbers for ischemic heart disease, ischemic stroke due to high SBP showed a relative growth in most provinces, while age standardized mortality rates declined in 2018 compared with 2005 in most provinces, which were in line with the national trend. YLLs for total CVD attributable to high SBP increased from 40·13 million (95%UI, 39·70 to 40·52) in 2005 to 48·16 million (95%UI, 47·44 to 48·90) in 2018 for China overall. YLL rates varied considerably across provinces, ranging from 3217·15 per 100 000 (95%UI 2947·43 to 3441·83) in Fujian to 7196·20 per 100 000 (95%UI 6864·28 to 7498·94) in Heilongjiang in 2018. Age-standardized YLL rates for ischemic heart disease and ischemic stroke attributable to high SBP were high in northeast provinces, including Heilongjiang, Liaoning and Jilin. Interpretation: The deaths and YLLs for CVD attributable to high SBP increased substantially in recent years, especially for the elderly, although age-standardized CVD mortality rate has decreased in China between 2005 and 2018. Preventive interventions should be implemented to lower the prevalence of high SBP among Chinese overall in order to reduce the SBP-related CVD adverse health effect.

THE SOCIAL COST OF MODIFIABLE RISK FACTORS IN SINGAPORE

Abstract Close to half of total disease burdens are attributable to modifiable risk factors, indicating that many illnesses are preventable by modifying behaviours such as increasing physical activity levels or maintaining a healthy diet. This study measures the social costs attributable to modifiable risks in Singapore, one of the most rapidly ageing populations in the world. Measuring the social cost of modifiable risk factors can help public health policymakers prioritise public health programmes and allocate resources. Our study builds on the comparative risk assessment framework from the Global Burden of Disease study. We used a prevalence-based cost-of-illness approach to estimate the social cost attributable to modifiable risk factors. We included healthcare costs from inpatient hospitalisation and productivity losses from absenteeism and premature mortality. Our results found that metabolic risks had the highest social cost of S$2.20 billion in 2019, followed by lifestyle risks of S$1.98 billion and substance risks of S$1.56 billion. Across the risk factors, the social costs were largely driven by productivity losses, heavily skewed towards the older working-age group. For metabolic risks, approximately 80% of the total cost (S$1.82 billion) was from those aged above 45 years old. This study provides evidence of the high social cost of modifiable risks and highlights the importance of developing holistic public health promotion programmes. Our findings suggest that implementing effective population-based programmes targeting multiple modifiable risks would have a strong potential to manage rising disease burdens and healthcare costs, especially with an ageing population.

Cardiometabolic deaths attributable to poor diet among Kuwaiti adults.

Nutrition transition towards a Western diet is happening in parallel with the rapidly increasing rates of cardiovascular disease and its risk factors in Kuwait. The cardiometabolic deaths attributable to poor diet have not been quantified among Kuwaiti adults. Using a Comparative Risk Assessment model that incorporated dietary intake data from Kuwait's first national nutrition survey, number of cardiometabolic deaths from the World Health Organization, and estimated associations of diet with cardiometabolic deaths from the Global Burden of Disease project, we estimated the number and proportion of cardiometabolic deaths attributable to suboptimal intake of 10 dietary factors among Kuwaiti adults ages 25+ years, and by population subgroups. An estimated 1,308 (95% uncertainty interval [UI] = 1,228-1,485) cardiometabolic deaths were attributed to suboptimal diet, accounting for 64.7% (95% UI = 60.7%-73.4%) of all cardiometabolic deaths in Kuwait in 2009. The low intake of nuts/seeds was associated with the highest estimated number and proportion of cardiometabolic deaths (n = 380, 18.8%), followed by high intake of sodium (n = 256, 12.6%), low intake of fruits (n = 250, 12.4%), low intake of vegetables (n = 236, 11.7%), low intake of whole grains (n = 201, 9.9%), and high intake of sugar-sweetened beverages (n = 201, 9.9%). The estimated proportions of cardiometabolic deaths attributable to suboptimal diet were higher in men (67.7%) than women (57.8%) and in younger adults aged 25-34 years (84.5%) than older adults aged ≥55 years (55.6%). Suboptimal dietary intake was associated with a very substantial proportion of cardiometabolic deaths among Kuwaiti adults in 2009, with young adults and men experiencing the largest proportion of diet-associated cardiometabolic deaths in Kuwait.

Pollinator Deficits, Food Consumption, and Consequences for Human Health: A Modeling Study.

Animal pollination supports agricultural production for many healthy foods, such as fruits, vegetables, nuts, and legumes, that provide key nutrients and protect against noncommunicable disease. Today, most crops receive suboptimal pollination because of limited abundance and diversity of pollinating insects. Animal pollinators are currently suffering owing to a host of direct and indirect anthropogenic pressures: land-use change, intensive farming techniques, harmful pesticides, nutritional stress, and climate change, among others. We aimed to model the impacts on current global human health from insufficient pollination via diet. We used a climate zonation approach to estimate current yield gaps for animal-pollinated foods and estimated the proportion of the gap attributable to insufficient pollinators based on existing research. We then simulated closing the "pollinator yield gaps" by eliminating the portion of total yield gaps attributable to insufficient pollination. Next, we used an agriculture-economic model to estimate the impacts of closing the pollinator yield gap on food production, interregional trade, and consumption. Finally, we used a comparative risk assessment to estimate the related changes in dietary risks and mortality by country and globally. In addition, we estimated the lost economic value of crop production for three diverse case-study countries: Honduras, Nepal, and Nigeria. Globally, we calculated that 3%-5% of fruit, vegetable, and nut production is lost due to inadequate pollination, leading to an estimated 427,000 (95% uncertainty interval: 86,000, 691,000) excess deaths annually from lost healthy food consumption and associated diseases. Modeled impacts were unevenly distributed: Lost food production was concentrated in lower-income countries, whereas impacts on food consumption and mortality attributable to insufficient pollination were greater in middle- and high-income countries with higher rates of noncommunicable disease. Furthermore, in our three case-study countries, we calculated the economic value of crop production to be 12%-31% lower than if pollinators were abundant (due to crop production losses of 3%-19%), mainly due to lost fruit and vegetable production. According to our analysis, insufficient populations of pollinators were responsible for large present-day burdens of disease through lost healthy food consumption. In addition, we calculated that low-income countries lost significant income and crop yields from pollinator deficits. These results underscore the urgent need to promote pollinator-friendly practices for both human health and agricultural livelihoods. https://doi.org/10.1289/EHP10947.

The burden of cardiovascular disease attributable to high systolic blood pressure across China, 2005–18: a population-based study

Temporal trends and geographical variations in cardiovascular disease attributable to high systolic blood pressure in China are not yet fully understood. The aim of this study was to quantify the cardiovascular disease burden attributable to high systolic blood pressure at national and provincial levels in China. In this population-based study, we evaluated systolic blood pressure and estimated the number of deaths, age-standardised mortality rates, and years of life lost (YLLs) due to cardiovascular disease and its subcategories (including ischaemic heart disease, ischaemic stroke, haemorrhagic stroke, and other cardiovascular diseases) attributable to high systolic blood pressure, at the national level and by 31 provincial levels, in China, from 2005 to 2018. We pooled blood pressure data of 1·30 million adults aged 25 years and older from the China Chronic Disease and Risk Factor Surveillance project, the China National Nutrition Survey, and the China Hypertension Survey. We applied a temporal-spatial Bayesian hierarchical model to estimate age-specific, sex-specific, province-specific, and year-specific average systolic blood pressure, and a comparative risk assessment method to compute the cardiovascular disease burden attributable to high systolic blood pressure by age, sex, year, and province. Nationally, age-standardised mean systolic blood pressure was 132·5 mm Hg (95% uncertainty interval [UI] 124·6-140·3) in men and 129·4 mm Hg (121·7 to 137·2) in women. 2·67 million (95% UI 2·61 to 2·72) cardiovascular disease deaths in China were attributable to high systolic blood pressure, including 1·12 million deaths (1·07 to 1·16) due to ischaemic heart disease, 0·63 million deaths (0·60 to 0·65) due to ischaemic stroke, 0·58 million deaths (0·57 to 0·60) due to haemorrhagic stroke, and 0·34 million deaths (0·32 to 0·36) due to other cardiovascular disease. The age-standardised cardiovascular disease mortality rates associated with high systolic blood pressure were 268·99 per 100 000 people (95% UI 264·11 to 273·51) in 2005 and 220·84 per 100 000 people (216·30 to 224·76) in 2018, a percentage change of -17·90%; the rate changed by an average of -1·50% (95% UI -1·55% to -1·45%) per year from 2005 to 2018 nationally. YLL rates for total cardiovascular disease caused by high systolic blood pressure varied substantially across provinces, ranging from 3078·33 (95% UI 2807·40 to 3303·57) per 100 000 people in Beijing to 7189·98 (95% UI 6817·18 to 7507·99) per 100 000 people in Heilongjiang in 2018. Age-standardised YLL rates for ischaemic heart disease and ischaemic stroke attributable to high systolic blood pressure were particularly high in northeastern provinces, including Heilongjiang, Liaoning, and Jilin. The deaths and YLLs for cardiovascular disease attributable to high systolic blood pressure in China increased between 2005 and 2018, and age-standardised cardiovascular disease mortality rates decreased in the same timeframe. Our findings could help policy makers in promoting blood pressure control measures and implementing effective and locally adapted preventive interventions to reduce the prevalence of high systolic blood pressure and reduce the burden of systolic blood pressure-related cardiovascular disease in China. China National Key Research and Development Program, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China. For the Chinese translation of the abstract see Supplementary Materials section.

Improvements in protective measures in factories with acetylene hydrochlorination and ethylene oxychlorination techniques declined risk assessment levels and affected liver health status.

Acetylene hydrochlorination and ethylene oxychlorination are the two most common methods of producing vinyl chloride monomer (VCM), which has been linked to liver impairment, hepatocellular carcinoma (HCC), and angiosarcoma of the liver (ASL) in occupational settings. However, whether and how these impairments could be effectively improved from workplace root causes has yet to be discovered. This study aimed to evaluate whether improvements in protective measures in groups Y (408 subjects) and Z (349 subjects) could have an influential impact on the alleviation of liver impairment by comparing risk assessment levels under several semi-quantitative models and results from liver ultrasound detection and liver function tests before and after the improvement. Importantly, significant differences in constituent ratio involved in parameters among age, length of employment, weekly exposure time, smoking status, alcohol consumption, and sleeping quality were found between Y and Z before improvement took place in 2020 (P < 0.05 or P < 0.001), and population distribution by gender between Y and Z was in a large homogeneity with differences in age and length of employment. CSTE involves ore breaking, acetylene generation, steam stripping, outward processing, and welding maintenance, was disqualified in 2020 compared to OEL, and was said to have declined to meet OEL requirements by 2021. Further, a negative correction of fresh air requirement and ventilation air changing rate with ambient concentration toward hazards in Y was stronger in 2021 than in 2020. Significant differences in risk levels in Y between 2020 and 2021 were found as ore breaking, acetylene generation, steam stripping, outward processing, VCM polymerization, welding, and repairing, decreasing to relatively lower risk levels in 2021 from the original ones in 2020 only under the semi-quantitative comprehensive index model. Abnormal rates toward other hepatic symptoms decreased in the majority of positions after the improvement, as referred to by alterations such as ALT, AST, and GGT. Overall, the effect of improvements on protective measures effectively reduced positions' risk assessment levels through ventilation enhancement and airtight strengthening, which further affected abnormal rates toward other hepatic symptoms, and alterations such as ALT, AST, and GGT were much more significant in Y than effect in Z.

The estimated burden of ultra-processed foods on cardiovascular disease outcomes in Brazil: A modeling study.

Ultra-processed foods (UPF) have been associated with an increased risk of cardiovascular diseases (CVD). This study aimed to estimate CVD premature deaths, incident cases, and disability adjusted life-years (DALYs) attributable to the consumption of UPF in Brazilian adults in 2019. A validated a comparative risk assessment model was adapted to estimate the burden of major CVD outcomes (coronary heart disease and stroke) attributable to the consumption of UPF in Brazilian adults aged 30 to 69 years. The model inputs included nationally representative data of the UPF contribution to the total energy of the diet, national official demographic records, CVD outcomes (incidence, deaths and DALYs) from the Global Burden of Disease study for 2019, and relative risks from meta-analysis studies. We estimated that approximately 19,200 premature deaths (95% uncertainty intervals - UI, 7,097 to 32,353), 74,900 new cases (95% UI, 25,983 to 128,725), and 883,000 DALYs/year (95% UI, 324,279 to 1,492,593) from CVD were attributable to the consumption of UPF in Brazil, corresponding to about 22% of the premature deaths from CVD and to 33% of the total premature all-cause deaths attributable to UPF intake among Brazilian adults. Reducing UPF consumption by 10% in the adult population would avert approximately 11% of the premature CVD deaths, equivalent to 2,100 deaths/year (95% UI, 697 to 4,511). A 20% reduction in UPF intake would avert approximately 21% of the premature CVD deaths or 4,100 deaths (95% UI, 1,413 to 8,047), and a 50% reduction in UPF intake would avert about 52% of the premature CVD deaths, corresponding to 9,900 deaths/year (95% UI, 3,682 to 17,820). If UPF consumption among adults was reduced to that of the first quintile of UPF intake in the baseline scenario, approximately 81% of the premature CVD deaths would be averted, corresponding to some 15,600 deaths/year (95% UI, 5,229 to 27,519). Our study estimated a high burden of premature CVD outcomes attributable to the consumption of UPF in Brazil. Our findings support food policies aimed at reducing the consumption of UPF, such as fiscal and regulatory policies, which are imperative to prevent CVD in Brazil.

Imidacloprid: Comparative toxicity, DNA damage, ROS production and risk assessment for aquatic non-target organisms

Imidacloprid is a neonicotinoid systemic insecticide used worldwide. Despite its hazardous impact on non-target organisms, few studies have been conducted concerning the potential eco-genotoxic effects in invertebrates of surface waters where this pesticide is detected from units of ng/L to tens of μg/L. The aim of the present work was to determine the acute, the sub-chronic and the chronic toxicity of imidacloprid in producers and primary consumers of the freshwater trophic chain. The organisms under investigation were the green alga Raphidocelis subcapitata, the rotifer Brachionus calyciflorus, the cladoceran crustacean Ceriodaphnia dubia and the benthic ostracod Heterocypris incongruens. In addition, potential DNA damage and ROS production were evaluated in C. dubia.Furthermore, in accordance with European guidelines, toxicological risk assessment of imidacloprid was performed for all continents considering its global occurrence in surface waters. In addition, we assessed the genotoxicological risk and median inhibition of reproduction was observed at units of mg/L for rotifers and daphnids. Algae showed the lowest level of sensitivity to the pesticide with effective concentrations from units to hundreds of mg/L. DNA lesions were marked from 7 μg/L with a significant increase in damage as concentrations increased. Chronic toxicity risk quotient values were generally below to a threshold value of 1, with no consequential environmental concern other than for the Canadian areas. On the contrary, the genotoxicological risk quotient values were found higher than the threshold value in all continents.

Premature Deaths Attributable to the Consumption of Ultraprocessed Foods in Brazil

Ultraprocessed foods have been associated with an increased risk of noncommunicable diseases, such as diabetes, cardiovascular diseases, and cancer as well as all-cause mortality. The study aimed to estimate premature deaths attributable to the consumption of ultraprocessed food in Brazil. A comparative risk assessment model was developed on the basis of RRs from a recent meta-analysis, national food consumption for 2017-2018, and demographic and mortality data for 2019. Population attributable fractions for all-cause mortality were then estimated within each sex and age stratum according to the distribution of the ultraprocessed food contribution to the total energy of the diet. Analysis was conducted in February 2022-April 2022. The contribution of ultraprocessed foods to the total energy intake of the diet across sex and age stratum of Brazilian adults ranged from 13% to 21% of the total energy intake. A total of 541,160 adults aged 30‒69 years died in 2019. The consumption of ultraprocessed foods was responsible for approximately 57,000 premature deaths (95% uncertainty interval=33,493, 82,570) or 10.5% of all premature deaths in adults aged 30‒69 years. Reducing the contribution of ultraprocessed foods to the total energy intake by 10%‒50% could potentially prevent 5,900 deaths (95% uncertainty interval=2,910, 10,613) to 29,300 deaths (95% uncertainty interval=16,514, 44,226), respectively. The consumption of ultraprocessed foods represents a significant cause of premature death in Brazil. Reducing ultraprocessed food intake would promote substantial health gains for the population and should be a food policy priority to reduce premature mortality.

Development and application of the TFA macrosimulation model: a case study of modelling the impact of trans fatty acid (TFA) elimination policies in Brazil

IntroductionThe consumption of trans-fatty acids (TFA) is directly associated with cardiovascular disease risk and is responsible for a significant health burden globally. The policy strategies for reducing TFA include limiting their content in foods and eliminating partially hydrogenated oils (PHO) in the market. This study aims to describe a comparative risk assessment macrosimulation model and to apply this tool to estimate the potential reductions in CVD mortality gained from the compared scenarios of TFA reduction/elimination in Brazil.MethodologyWe developed and implemented a comparative risk assessment macrosimulation model estimates the potential CVD mortality reduction (coronary heart disease – CHD- and stroke) if TFA intake is reduced in diets. The TFA macrosimulation model estimates the change in the annual number of NCD deaths between baseline with current TFA consumption levels and alternate or counterfactual scenarios, such as considering different limits to TFA content in foods and the elimination of PHO in Brazil in 2018. The model incorporated additional outputs related to other impacts of TFA reduction on DPP, such as Years of Life Lost, Years of Productive Life Lost, and related economic impacts of premature deaths.ResultsIn 2018, a 2% limit for TFA in the oils and fats and a 5% limit of TFAs for other foods could avert or postpone approximately 2,000 deaths (UI 95% 1,899-2,142) and save US$ 32.1 million savings in productivity losses to the economy associated to premature deaths. An intermediate scenario, applying a 2% limit of TFA in all food products In Brazil could prevent or postpone approximately 6,300 deaths (UI 95% 5,925-6,684) and the premature deaths prevented would represent US$ 100.2 million in economic saving. Finally, by banning PHO, approximately 10,500 deaths could be prevented or postponed (UI 95% 9,963 − 10,909), corresponding to US$ 166.7 million in savings to the economy because of premature deaths.ConclusionThe TFA macrosimulation model can efficiently compare different policy scenarios for trans fats reduction policies at the country level and proves that the elimination of PHOs from the food market in Brazil may significantly reduce the health burden of trans fatty acids in the country compared to other policy options. The model also represents a useful public health tool to support TFA reduction and elimination policies in other countries.

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.

Reducing educational inequalities in mortality: a comparative risk assessment approach

Abstract Educational inequalities in mortality are increasingly recognized as one of the main challenges for health policy. Studies comparing European countries have shown that such inequalities are substantial almost everywhere, but that there are important variations between countries, suggesting great scope for reduction. However, identifying this scope is difficult because it requires comparative information about the educational distribution of mortality rates, risk factors and relative risks. In this presentation I show how this can be done, by quantifying the impact of a theoretical equalization of the distribution of several known risk factors for mortality, in a comparative risk assessment approach. Harmonized data set on mortality (from register data) and risk factors (from survey data) by educational level for 21 European populations in the early 2000s were applied. The impact of the risk factors on mortality in each educational group was determined using Population Attributable Fractions (PAF). The impact on inequalities in mortality was estimated applying two counterfactual scenarios: a theoretical upward levelling scenario in which it is assumed that inequalities in the risk factor were completely eliminated, and a more realistic best practice scenario, in which it is assumed that inequalities in a risk factor were to be reduced to those seen in the country with the smallest inequalities for that risk factor. The analysis shows how information on risk factors, mortality rates and relative risks can be combined from different data sources and provide a meaningful analysis of the European mortality burden that can be linked to educational inequalities in risk factors. The analysis also shows that upward levelling scenarios and best practice scenarios demonstrate a theoretical potential for reducing inequalities in mortality.

Epidemiological trends of female breast and gynecologic cancers in adolescents and young adults in China from 1990 to 2019: Results from the Global Burden of Disease Study 2019.

BackgroundResearch on the incidence, mortality, and disability-adjusted life years (DALYs) of female breast and gynecologic cancers (FeBGCs) and the relevant risk factors for adolescents and young adults (AYAs) are valuable for policy-making in China. We aimed to estimate the incidence, deaths, and DALYs and predict epidemiological trends of FeBGCs among AYAs in China between 1990 and 2019.MethodsData from the 2019 Global Burden of Disease (GBD) study between 1990 and 2019 in 195 countries and territories were retrieved. Data about the number of FeBGC incident cases, deaths, DALYs, age-standardized rates (ASRs), and estimated annual percentage changes (EAPCs) were extracted. A comparative risk assessment framework was performed to estimate the risk factors attributable to breast cancer deaths and DALYs, and autoregressive integrated moving average (ARIMA) models were fitted for time-series analysis to predict female cancer morbidity and mortality among Chinese AYAs until 2030.ResultsIn 2019, there are 61,038 incidence cases, 8,944 deaths, and 529,380 DALYs of FeBGCs among the AYAs in China, respectively. The estimated annual percentage change (EAPC) values were positive scores (>0) in ASIRs and negative scores (<0) in ASMR and ASDR. Furthermore, in 2030, the incidence rate of FeBGCs would grow to 30.49 per 100,000 in China, while the mortality rate would maintain a steady state. Of the deaths and DALYs, diet high in red meat was the greatest contributor to breast cancer, while a high body mass index (BMI) was the greatest contributor to cervical, ovarian, and uterine cancers.ConclusionThe increasing Chinese FeBGC burden is mainly observed in AYAs and non-red meat diet, and the control of body weight could reduce FeBGC burden in China.

Health impacts from TRAPs and carbon emissions in the projected electric vehicle growth and energy generation mix scenarios in Malaysia

Road transport contributes over 70% of air pollution in urban areas and is the second largest contributor to the total carbon dioxide emissions in Malaysia at 21% in 2016. Transport-related air pollutants (TRAPs) such as NOx, SO2, CO and particulate matter (PM) pose significant threats to the urban population's health. Malaysia has targeted to deploy 885,000 EV cars on the road by 2030 in the Low Carbon Mobility Blueprint (LCMB). This study aims to quantify the health co-benefits of electric vehicle adoption from their impacts on air quality in Malaysia. Two EV uptake projections, i.e. LCMB and Revised EV Adoption (REVA) projections, and five electricity generation mix scenarios were modelled up to 2040. We used comparative health risk assessment to estimate the potential changes in mortality and burden of diseases (BoD) from the emissions in each scenario. Intake fractions and exposure-risk functions were used to calculate the burden from respiratory diseases (PM2.5, NOx, SO2, CO), cardiovascular diseases and lung cancer (PM2.5). Results showed that along with a net reduction of carbon emissions across all scenarios, there could be reduced respiratory mortality from NOx by 10,200 mortality (176,200 DALYs) and SO2 by 2600 mortality (45,400 DALYs) per year in 2040. However, there could also be additional 719 mortality (9900 DALYs) per year from PM2.5 and 329 mortality (5600 DALYs) from CO per year. The scale of reduction in mortality and BoD from NOx and SO2 are significantly larger than the scale of increase from PM2.5 and CO, indicating potential net positive health impacts from the EV adoption in the scenarios. The health cost savings from the reduced BoD of respiratory mortality could reach up to RM 7.5 billion per year in 2040. In conclusion, EV is a way forward in promoting a healthy and sustainable future transport in Malaysia.

Comparative and Health Risk Assessment of Heavy Metals in Mangrove Forest and Farm - Bred African Giant Snails (Archachatina Marginata)

Snails are good source of protein for different classes of people. The aim of this work is to compare and assess the health risk of the heavy metals in mangrove forest and farm - bred snails, as sources of protein. Twelve snails (six mangrove forest and six farm - bred) of two sizes (big and small) were sourced from Bayeku mangrove forest and Snail Farm at Second gate of Lagos State University of Science and Technology (LASUSTECH) respectively. The, Fe, Cd, Cr, Ni, Cu, Pb, and Zn concentration of the snails were evaluated using standard analytical methods. The data obtained were subject to differential and inferential statistics using a statistical package (SPSS 22.0 version) and compare with Food and Agriculture Organization (FAO) limit. Fe (732.32 - 734.24 mg/kg), Cu (145.17 - 145.19 mg/kg), Zn (62.38 - 62.51 mg/kg) of big snail from mangrove forest were the highest compared with Fe, Cu, and Zn in mangrove forest (small), farm bred (big and small) snail. Cr (77.20 - 77.46), Ni (21.14 – 21.28), and Pb (1.20 - 1.22) mg/kg in small snail (mangrove forest) were the highest. Cadmium (6.83 - 6.84 mg/kg) of the farm bred (big snail) was the highest. Mangrove forest bred snail; Fe (733.26±0.96), Cr (38.01±0.78), Ni (50.32±0.37), Cu (145.18±0.01), and Zn (62.43±0.07) mg/kg were significantly higher than their corresponding FAO Limits. Farm - bred snail Cr (38.99±0.21), and Zn (36.80±0.01) mg/kg were significantly higher than their corresponding FAO permissible limits. However, farm bred has lower heavy metal concentrations than mangrove forest bred. Hence, farm bred are better product.

Risk Assessment for Longitudinal Trajectories of Modifiable Lifestyle Factors on Chronic Kidney Disease Burden in China: A Population-based Study

BackgroundChronic kidney disease (CKD) is an important contributor to morbidity and mortality from noncommunicable diseases. We aimed to examine the longitudinal trajectories in risk factors, estimate their impact on CKD burden in China from 1991 to 2011, and project trends in the next 20 years.MethodsWe used data from a cohort of the China Health and Nutrition Survey and applied the comparative risk assessment method to estimate the number of CKD events attributable to all non-optimal levels of each risk factors.ResultsIn 2011, current smoking was the leading individual attributable factor for CKD burden in China responsible for 7.9 (95% confidence interval [CI], 7.5–8.3) million CKD cases with a population-attributable fraction of 8.7% (95% CI, 6.0–11.6), while the rates of smoking have reduced and may have mitigated the increase in CKD. High triglyceride (TG) and high systolic blood pressure (SBP) were the leading metabolic risk factors responsible for 6.8 (95% CI, 6.4–7.1) million and 5.8 (95% CI, 5.5–6.1) million CKD-attributable cases, respectively. Additionally, the number of CKD cases associated with high body mass index (BMI), high diastolic blood pressure (DBP), high plasma glucose, and low high-density lipoprotein cholesterol (HDL-C) was 5.4 (95% CI, 5.1–5.6), 3.9 (95% CI, 3.7–4.1), 3.0 (95% CI, 2.8–3.1) and 2.6 (95% CI, 2.5–2.8) million, respectively.ConclusionCurrent smoking, high TG, and high SBP were the top three risk factors that contributed to CKD burden in China. Increased BMI, DBP, plasma glucose, and decreased HDL-C were also associated with the increase in CKD burden.

Estimated Benefits and Risks of Using a Reduced-Sodium, Potassium-Enriched Salt Substitute in India: A Modeling Study.

Salt substitution (ie, replacement of table and cooking salt with potassium-enriched salt substitutes) is a promising strategy to reduce blood pressure and prevent cardiovascular disease, particularly in countries like India where there is high sodium intake, mainly from discretionary salt, and low potassium intake. Life-threatening hyperkalemia from increased potassium intake is a postulated concern for individuals with chronic kidney disease. We used comparative risk assessment models to estimate the number of (1) cardiovascular deaths averted due to blood pressure reductions; (2) potential hyperkalemia-related deaths from increased potassium intake in individuals with advanced chronic kidney disease; and (3) net averted deaths from nationwide salt substitution in India. We evaluated a conservative scenario, based on a large, long-term pragmatic trial in rural China; and an optimistic scenario informed by our recent trial in India. Sensitivity analyses were conducted to assess the robustness of the findings. In the conservative scenario, a nationwide salt substitution intervention was estimated to result in ≈214 000 (95% uncertainty interval, 92 764-353 054) averted deaths from blood pressure reduction in the total population and ≈52 000 (22 961-80 211) in 28 million individuals with advanced chronic kidney disease, while ≈22 000 (15 221-31 840) hyperkalemia-deaths might be caused by the intervention. The corresponding estimates for the optimistic scenario were ≈351 000 (130 470-546 255), ≈66 000 (24 925-105 851), and ≈9000 (4251-14 599). Net benefits were consistent across sensitivity analyses. Modeling nationwide salt substitution in India consistently estimated substantial net benefits, preventing around 8% to 14% of annual cardiovascular deaths. Even allowing for potential hyperkalemia risks there were net benefits estimated for individuals with chronic kidney disease.

Estimating the changing burden of disease attributable to high body mass index in South Africa for 2000, 2006 and 2012.

A high body mass index (BMI) is associated with several cardiovascular diseases, diabetes and chronic kidney disease, cancers, and other selected health conditions. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high BMI in persons aged ≥20 years in South Africa (SA) for 2000, 2006 and 2012. The comparative risk assessment (CRA) methodology was followed. Meta-regressions of the BMI mean and standard deviation from nine national surveys spanning 1998 - 2017 were conducted to provide estimates by age and sex for adults aged ≥20 years. Population attributable fractions were calculated for selected health outcomes using relative risks identified by the Global Burden of Disease Study (2017), and applied to deaths and DALY estimates from the second South African National Burden of Disease Study to estimate the burden attributed to high BMI in a customised Microsoft Excel workbook. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis. BMI was assumed to follow a log-normal distribution, and the theoretical minimum value of BMI below which no risk was estimated was assumed to follow a uniform distribution from 20 kg/m2 to 25 kg/m2. Between 2000 and 2012, mean BMI increased by 6% from 27.7 kg/m2 (95% confidence interval (CI) 27.6 - 27.9) to 29.4 kg/m2 (95% CI 29.3 - 29.5) for females, and by 3% from 23.9 kg/m2 (95% CI 23.7 - 24.1) to 24.6 kg/m2 (95% CI 24.5 - 24.8) for males. In 2012, high BMI caused 58 757 deaths (95% uncertainty interval (UI) 46 740 - 67 590) or 11.1% (95% UI 8.8 - 12.8) of all deaths, and 1.42 million DALYs (95% UI 1.15 - 1.61) or 6.9% (95% UI 5.6 - 7.8) of all DALYs. Over the study period, the burden in females was ~1.5 - 1.8 times higher than that in males. Type 2 diabetes mellitus became the leading cause of death attributable to high BMI in 2012 (n=12 382 deaths), followed by hypertensive heart disease (n=12 146), haemorrhagic stroke (n=9 141), ischaemic heart disease (n=7 499) and ischaemic stroke (n=4 044). The age-standardised attributable DALY rate per 100 000 population for males increased by 6.6% from 3 777 (95% UI 2 639 - 4 869) in 2000 to 4 026 (95% UI 2 831 - 5 115) in 2012, while it increased by 7.8% for females from 6 042 (95% UI 5 064 - 6 702) to 6 513 (95% UI 5 597 - 7 033). Average BMI increased between 2000 and 2012 and accounted for a growing proportion of total deaths and DALYs. There is a need to develop, implement and evaluate comprehensive interventions to achieve lasting change in the determinants and impact of overweight and obesity, particularly among women.