Epidemiology of NonCommunicable Diseases

Adora F. Mendoza-Abat, M.D., CFP

Definitions

Environmental Epidemiology the study of environmental factors that influence the distribution of diseases in the human population Occupational Epidemiology the study of workplace exposures on the frequency and distribution of diseases and injuries in the population

Infectious Diseases -Single necessary agent

-Specific

Non-Infectious Diseases -No single necessary agent One-to-one correspondence between agent and disease very rare
-

agent-disease relationship

-Causes are relatively well understood

-Causes

unknown, intervention usually based on risk factors

-Long

-Short incubation period

latency period

Infectious Diseases
-Single

Non-Infectious Diseases
-May

exposure usually sufficient

require multiple exposure to same or multiple agents

-Most

-Usually

disease

produce acute

often produce chronic disease

-Acquired -Dx

immunity possible -Acquired immune unlikely

based on tests specific to disease agent

-Dx

often dependent on nonspecific symptoms or test

Classification of Etiologic Agents or Risk Factors

1. Environmental Factors that may Affect Health A. Psychological Factors B. Biological Factors C. Chemical Factors D. Physical Factors E. Accidental Factors

Classificatn of Etiologic Agents or Risk Factors

2. Environmental Components & Health Hazards
Components Physical : air, water, soil, food, climate and weather, noise level, radiation level Health Hazards Physical: heat and cold, radiation, noise Chemical: metals, chemical substances Biological: microorganisms, Social: work, transport, leisure, housing, family and flora and fauna community Social; culture/customs, interpersonal relations, social and political structure, housing factors

Environmental Hazards
1. Site and location (earthquakes, flood, wind, storms, drought) 2. Biological (animal, insect, microbiological, vegetation) 3. Chemical (poisons and toxins, allergens, irritants) 4. Physical (vibration, radiation, forces and abrasion, humidity) 5. Psychological (stress, boredom, anxiety, discomfort, depression) 6. Sociological (overcrowding, isolation)

Uses of Environmental / Occupational Epidemiology

1.

2.
3. 4.

5.
6.

Identify etiologic factors Monitoring trends and changes on health consequences/impact Planning, management and evaluation of programs (projections and risk assessment) Communicate information regarding environmental hazards Basis for establishing safety standards or thresholds Others (eg. Elucidating mechanisms of toxicity, describe dose-response relationships)

Causes of Under-recognition of Occupational/Environmental Dse.

1. Inherent difficulty in diagnosing occupational diseases 2. Difficulty in establishing cause and effect relationships 3. Lack/incomplete evaluation of chemicals for potential toxicity 4. Inadequate pre-market evaluation of newly developed chemical substances

Causes of Under-recognition of Occupational/Environmental Dse.

5. Long latency between occupational / environmental exposure and onset of illness 6. Lack of awareness among health practitioners about hazards found at work and in the environment 7. Limited ability of many workers to provide an accurate report of their toxic exposures

Causes of Under-recognition of Occupational/Environmental Dse.

8. Resistance of employers to recognize the work relatedness of a disorder because of possible litigations suits 9. Usually involves small group of people 10. Lack of knowledge about many aspects of behavior of environmental pollutants 11. Potential difficulties in defining potential risks

Major Types of Occupational Diseases

1. 2. 3. 4. 5. 6. 7. 8.

Lung diseases Cancer Skin disorders Infectious diseases Reproductive disorders Musculo-skeletal disorders Severe traumatic injuries Hearing loss

Surveillance Activities in Environmental / Occupational Epidemiology

1. (Occupational) Hazard Surveillance a. Provides a means of assessing toxic occupational exposures to a population and thus of assessing risk b. Will identify chemicals in use, the industries and occupations where they are used, and the extent and magnitude of worker exposure c. Also provides a means of identifying changes in the patterns of exposure and of noting emerging toxic hazards

Surveillance Activities in Environmental / Occupational Epidemiology

2. (Occupational) Disease Surveillance a. Provides a means of assessing the amount and types of occupational disease, time trends and distribution according to geography, industry and occupation b. Can consist of 2 types of surveillance b.1. Biological monitoring b.2. Medical Screening

Biological Monitoring
The systematic collection of biological specimens (blood, urine, breath, fingernails, hair, saliva) for the purpose of estimating exposure to environmental agents and hence determine the risk of disease before it occurs Interpretation - requires detailed knowledge of the kinetics and metabolism of chemicals Limitations: due to the rapid excretion of certain chemicals, only the most recent exposure to them are measurable; may reflect recent exposure or cumulative exposure

Medical Screening

The periodic examination (clinical or laboratory) to detect diseases (or health problems) present among apparently healthy subjects Issues: validity, predictive values, costeffectiveness, acceptability of procedure

Measurements of Exposure and Outcome : Some Issues / Considerations

1.
2.

3.

Exposures are usually measured quantitatively Dimensions of exposure: level, duration, levelduration combined Current Vs. long term exposures a. Acute Effects current exposures are relevant (e.g. London smog epidemic in 1952) b. Cumulative Effects

2 Types of Cumulative Effects

1. Chemical / substances that accumulate in the body (e.g. cadmium) 2. Hazards with cumulative effects (e.g. radiation, noise)

Measurements of Exposure and Outcome : Some Issues / Considerations

4. Individual measurements vary with time a. Has implications on the frequency, time and method used to estimate exposure or dose 5. Exposure or dose varies between individuals a. Different work habits b. Differences in the local distribution of pollutants c. Differences in individual absorption and excretion rates for the chemical . d. People with the same external dose may end up with different internal doses

Measurements of Exposure and Outcome : Some Issues / Considerations

6. Internal dose (absorbed dose) is usually different from external dose (environmental measurements) 7. Dose-effect relationship the higher the dose the more severe and intense is the effect; data are useful for establishing safety standards Set safety standard at a level where the less severe effects are prevented

Measurements of Exposure and Outcome : Some Issues / Considerations

8. Dose-Response Relationship Response the proportion in an exposed group that develops a specific effect

Environmental Exposures
Doses are at concentrations far below those experienced by workers who are directly handling the materials Will require larger population for study in order to detect the smaller health effects likely to result Problems with confounding variables may be more serious Estimation of exposure doses is complicated by the lack of routine data on air and water pollution

Environmental Exposures
Use of place of residence as surrogate for exposure may lead to exposure misclassification because population may be highly mobile Common to use ecologic data or correlational studies Longer exposure of residents to household toxin compared to workers Children are more susceptible than working adults since they have faster metabolism and absorption of the toxin

Risk Assessment
The use of epidemiological methods and principles to estimate the potential health risks of industrial or agricultural development projects, both before they are implemented and while they are in operation. Used to predict potential health problems in the use of new chemicals or technologies

Steps in Risk Assessment

1.

2.

3.

Identify which environmental hazard may be created by the technology or project under study (Hazard Identification) Analyze the type of health effect that each hazard may cause (Hazard Assessment) Measure or estimate the actual exposure levels for the people potentially affected, including the general population and the work force (Measure Actual Exposure) - Use data on environmental and biologic monitoring, relevant hx of exposure and changes over time

Steps in Risk Assessment

4. Calculate the likely health risk in the population - For each hazard identified, the exposure data for subgroups of the exposed population are combined with the doseeffect and dose-response relationships

BURDEN OF NCDs

rising trends in non-communicable diseases as a result of demographic and epidemiological changes, as well as economic globalization increase in life expectancy combined with changes in lifestyles are leading to epidemics of noncommunicable diseases (NCD), mainly cardiovascular diseases, cancer and diabetes In 1998, NCD accounts for 63% of global deaths 43% of all DALY globally were attributed to NCD

Non-Communicable Diseases
Includes all traditionally defined NCDs such as CVD, cancer, chronic respiratory diseases, mental health as well as injuries and violence In all WHO regions (except sub-Saharan Africa), NCDs today constitute the largest contributor to burden

NCDs accounted for 60% of all deaths in 1999 and 43% of all DALYs with injuries adding 9% of all deaths and 14% of all DALYs By 2020, 10 out the top 15 causes of DALYs lost will be attributable to NCDs, mental health and injuries/violence

The top five positions will be occupied by Ischemic Heart Disease, depression, road traffic injuries, cerebrovascular disease and Chronic Obstructive Pulmonary Disease (COPD) 15th place: trachea, bronchus and lung cancers (better known as tobacco cancers)

GROUP OF NCDs

Cancers Lifestyle-related (CVD, diabetes) Injury (unintentional, intentional) Genetic disorders Disabling disorders Occupational disorders Nutritional conditions Endocrine disorders Substance abuse

REASONS FOR THE PROMINENCE OF NCD

1. 2. 3. 4. Aging of the population Impact of automobiles Lifestyle changes Tobacco addiction

-single largest cause of preventable morbidity and mortality

5. Physical activity 6. Social and behavioral factors

I. NATURAL HISTORY
A. CHARACTERISTICS OF THE AGENT
e

Absence of a single necessary agent

most NCDs are classified on the basis of manifestations rather than on etiology (e.g., CVD, renal disease, neoplasms) known causes are risk factors e.g. obesity, elevated cholesterol levels, hypertension

B. TIME FRAME - take years or decades before illness is apparent

- no multiplication of causative agent is involved

- multiple low-dose exposures (some chemicals) - some conditions seem to evolve subsequent to chronic conditions or high risk states such as obesity, smoking, diabetes and high blood cholesterol

C. NATURE OF THE DISEASE chronic in nature chronic disease

(1957 Commission on Chronic Disease) permanent leaves residual disability caused by nonreversible pathological alterations requires special training of the patient for rehabilitation requires long periods of supervision, observation or care.

 Chronicity
function

of the long latency period slow disease process adaptive responses to stresses (may be detrimental over the long term)

CD can be chronic (e.g. rheumatic heart disease) NCD can be acute (e.g. chemical poisoning)

D. Synergism in Disease Causation

> Asbestos and lung cancer (RR=8) > Smoking + asbestos and lung cancer (RR=90) - Presence of synergism decreased latency (produce illness in the prime of life even with low level exposures)

- Role of initiators and promoters

Major Categories of Etiological Agents

A. Occupational

B. General environmental
C. Lifestyle and Illness

OCCUPATIONAL
- chemical - metals and naturally occurring minerals

Investigating occupational exposures

agent factors to be considered size and shape of particles route of exposure free or compound form organic vs inorganic form liquid or vapor form

environmental factors
conditions

in the work environmental that will influence the likelihood that workers will come in contact with an agent general cleanliness and ventilation lighting, temperature

Host factors
lifestyle

behaviors that may increase the risk of disease from occupational exposure to an agent genetic constitution

ENVIRONMENTAL

sources of exposure contamination of air, water and soil by industrial activities or inadequate waste disposal lower dose of exposure than in occupational environments pesticides housing materials automobile exhausts radiation

Investigating environmental exposures dose data on levels of exposure mobility of subjects confounders additional considerations wide range of ages length of exposure meterological conditions seasonal effects

LIFESTYLE
- poverty, stress, exercise, drug and alcohol use, nutrition

CONTROL OF NCD
A. PRIMARY PREVENTION
- removal of agent from environmental or minimizing the amount of agent present - Protection of the susceptible host from exposure

B. SECONDARY PREVENTION
- screening tests

C. TERTIARY PREVENTION
- lifestyle modification

A small core of risk factors explains the increases in CVD, certain cancers and their closely linked conditions of obesity, type II diabetes:

tobacco, diet/nutrition, physical inactivity and alcohol

A substantial proportion of chronic respiratory diseases and death are driven by tobacco use Alcohol is obviously a major contributor to all causes of injuries and violence

Tobacco trends are not hopeful

There are 1.2 billion smokers in the world with smoking rates in 13 to 15 year olds being about 20% in diverse cities from developed and developing countries

Tobacco causes 4 million deaths per year, a figure that will increase to 10 million per year by the late 2020s The public health impact is widespread and increasing fast in developing countries

Alcohol Use

Trends in alcohol use:

steady

increases in many developing countries with continued very high rates of binge drinking in many east and central European countries.

Obesity

has tripled in youth in several Chinese cities, and rapidly increased over the last 15 years in the major cities of countries like Malaysia, Brazil, Indonesia and South Africa But these have occurred as underweight persists in the rural areas Often underweight is common in the same neighborhoods as obesity is increasing Thus both being underweight and being overweight are associated with poverty

Obesity (cont)

Epidemics of obesity and type II diabetes have been well documented in most Pacific Island States and are probably fuelled by a combination of factors:
increased

imports of high fat foods particularly cheap off-cuts as well as increased consumption of sodas in societies where physical activity levels have plummeted.

Devastating economic impact of diabetes complications are recently being determined for several of these countries

The problems of obesity and diabetes are caused by many factors

Solutions similarly need to be multidimensional and avoid focusing on just one aspect or on behavior change alone

Mental health: 450 million people who suffer from mental or neurological disorders or from psychosocial problems such as those related to alcohol and drug abuse