Understanding DALYs (disability-adjusted life years)

Incidence and Disability-Adjusted Life Years (Dalys) Attributable to Leishmaniasis In Iran, 2013

Background

Leishmaniasis covers a range of clinical manifestations. Estimation of the burden of leishmaniasis may help guide healthcare management personnel and policy-makers in applying effective interventions. The present study aimed to calculate the incidence and burden of cutaneous and visceral leishmaniasis in Iran in 2013.

Methods

To evaluate the epidemiological aspects of the disease in Iran, published studies over the past 20 years were searched and the viewpoints of relevant specialists in Iran were obtained. Data were collected from the Ministry of Health and from the Tehran University of Medical Sciences. To calculate years of life lost due to premature death, standard expected years of life lost was used. Standard life table of Global Burden of Disease (GBD) 2010 with the life expectancy of 86.02 years for both sexes was used to calculate the remaining potential years of life at any age from death.

Results

The overall incidence of cutaneous and visceral leishmaniasis was calculated as 22 and 0.092 per 100000 population of Iran, respectively. The burden of leishmaniasis was 99.5 years: 95.34 and 4.16 years for cutaneous and visceral, respectively. Sensitivity was analyzed and deaths predicted by the Institute of Health Metrics and Evaluation added, the burden of visceral leishmaniasis was 726 years.

Conclusion

The share of leishmaniasis burden in Iran is lower than the global burden of the disease. GBD 2010 standard method is recommended to calculate the burden of leishmaniasis in different countries and set local priorities on the basis of these measures.

Impact of level and patterns of alcohol drinking on coronary heart disease and stroke burden in Argentina

BACKGROUND

Deaths from cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke are expected to increase in Latin America. Moderate and regular alcohol consumption confers cardiovascular protection, while binge drinking increases risk. We estimated the effects of alcohol use on the number of annual CHD and stroke deaths and disability-adjusted life years (DALYs) in Argentina.

METHODS

Alcohol use data were obtained from a nationally representative survey (EnPreCosp 2011), and etiological effect sizes from meta-analyses of epidemiological studies. Cause-specific mortality rates were from the vital registration system.

RESULTS

There were 291,475 deaths in 2010 including 24,893 deaths from CHD and 15,717 from stroke. 62.7% of men and 38.7% of women reported drinking alcohol in the past year. All heavy drinkers (i.e. women who drank >20g/day and men who drank >40g/day of alcohol) met the definition of binge drinking and therefore did not benefit from cardioprotective effects. Alcohol drinking prevented 1,424 CHD deaths per year but caused 935 deaths from stroke (121 ischemic and 814 hemorrhagic), leading to 448 CVD deaths prevented (58.3% in men). Alcohol use was estimated to save 85,772 DALYs from CHD, but was responsible for 52,171 lost from stroke.

CONCLUSIONS

In Argentina, the cardioprotective effect of regular and moderate alcohol drinking is slightly larger than the harmful impact of binge drinking on CVD. However, considering global deleterious effects of alcohol in public health, policies to reduce binge drinking should be enforced, especially for young people. Studies are still needed to elucidate effects on cardiovascular health.

Cost, energy, global warming, eutrophication and local human health impacts of community water and sanitation service options

We compared water and sanitation system options for a coastal community across selected sustainability metrics, including environmental impact (i.e., life cycle eutrophication potential, energy consumption, and global warming potential), equivalent annual cost, and local human health impact. We computed normalized metric scores, which we used to discuss the options' strengths and weaknesses, and conducted sensitivity analysis of the scores to changes in variable and uncertain input parameters. The alternative systems, which combined centralized drinking water with sanitation services based on the concepts of energy and nutrient recovery as well as on-site water reuse, had reduced environmental and local human health impacts and costs than the conventional, centralized option. Of the selected sustainability metrics, the greatest advantages of the alternative community water systems (compared to the conventional system) were in terms of local human health impact and eutrophication potential, despite large, outstanding uncertainties. Of the alternative options, the systems with on-site water reuse and energy recovery technologies had the least local human health impact; however, the cost of these options was highly variable and the energy consumption was comparable to on-site alternatives without water reuse or energy recovery, due to on-site reuse treatment. Future work should aim to reduce the uncertainty in the energy recovery process and explore the health risks associated with less costly, on-site water treatment options.

Risk-based enteric pathogen reduction targets for non-potable and direct potable use of roof runoff, stormwater, and greywater

This paper presents risk-based enteric pathogen log reduction targets for non-potable and potable uses of a variety of alternative source waters (i.e., locally-collected greywater, roof runoff, and stormwater). A probabilistic Quantitative Microbial Risk Assessment (QMRA) was used to derive the pathogen log10 reduction targets (LRTs) that corresponded with an infection risk of either 10-4 per person per year (ppy) or 10-2 ppy. The QMRA accounted for variation in pathogen concentration and sporadic pathogen occurrence (when data were available) in source waters for reference pathogens in the genera Rotavirus, Mastadenovirus(human adenoviruses), Norovirus, Campylobacter, Salmonella, Giardia and Cryptosporidium. Non-potable uses included indoor use (for toilet flushing and clothes washing) with occasional accidental ingestion of treated non-potable water (or cross-connection with potable water), and unrestricted irrigation for outdoor use. Various exposure scenarios captured the uncertainty from key inputs, i.e., the pathogen concentration in source water; the volume of water ingested; and for the indoor use, the frequency of and the fraction of the population exposed to accidental ingestion. Both potable and non-potable uses required pathogen treatment for the selected waters and the LRT was generally greater for potable use than non-potable indoor use and unrestricted irrigation. The difference in treatment requirements among source waters was driven by the microbial quality of the water - both the density and occurrence of reference pathogens. Greywater from collection systems with 1000 people had the highest LRTs; however, those for greywater collected from a smaller population (~ 5 people), which have less frequent pathogen occurrences, were lower. Stormwater had highly variable microbial quality, which resulted in a range of possible treatment requirements. The microbial quality of roof runoff, and thus the resulting LRTs, remains uncertain due to lack of relevant pathogen data.

"Guilty until proven innocent": the contested use of maternal mortality indicators in global health

The MMR - maternal mortality ratio - has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, 'guilty until proven innocent'. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts' work has also been driven by the need to secure political priority for safe motherhood and by donors' need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators.

Health burden of serious road injuries in the Netherlands

BACKGROUND

The consequences of injuries in terms of disabilities and health burden are relevant for policy making. This article provides an overview of the current knowledge on this topic and discusses the health burden of serious road injuries in The Netherlands.

METHODS

The overview of current knowledge on disabilities following a road crash is based on a literature review. The health burden of serious road injuries is quantified in terms of years lived with disability (YLD), by combining incidence data from the Dutch hospital discharge register with information about temporary and lifelong disability.

RESULTS

Literature shows that road traffic injuries can have a major impact on victims' physical and psychological well-being and functioning. Reported proportions of people with disability vary between 11 and 80% depending on the type of casualties, time elapsed since the crash, and the health impacts considered. Together, all casualties involving serious injuries in The Netherlands in 2009 account for about 38,000 YLD, compared to 25,000 years of life lost (YLL) of fatalities. Ninety percent of the burden of injury is due to lifelong consequences that are experienced by 20% of all those seriously injured in road accidents. Lower leg injuries and head injuries represent a high share in the total burden of injury as have cyclists that are injured in a crash without a motorized vehicle. Pedestrians and powered 2-wheeler users show the highest burden of injury per casualty.

CONCLUSION

Given their major impacts and contribution to health burden, road policy making should also be aimed at reducing the number of serious road injuries and limiting the resulting health impacts.

Quantifying Burden of Disease to Measure Population Health in Korea

Quantitative assessments of the health status of a population are essential to make decisions and set priorities in the field of public health. Changing epidemiologic patterns increase the demand for comprehensive estimates of population health across the full health spectrum, including non-communicable diseases and injuries. Burden of disease (BoD) analysis has helped meet this need. With the success of the Global Burden of Disease (GBD) Study, the BoD technique has become predominantly associated with the GBD approach and its methodology using disability-adjusted life year (DALY) has been rapidly disseminated and generally accepted over the last several years. The first Korean BoD study using the DALY metric was presented in 2002. Various BoD studies have since been conducted, but the DALY concept has remained primarily academic and has not yet been actively utilized in the health policy arena. Here, we review the DALY metric and population-based Korean BoD studies using national health data, with the intent of increasing the understanding of their value and their potential role in strengthening future assessments of the Korean population's health status.

A narrative review of alcohol consumption as a risk factor for global burden of disease

Since the original Comparative Risk Assessment (CRA) for alcohol consumption as part of the Global Burden of Disease Study for 1990, there had been regular updates of CRAs for alcohol from the World Health Organization and/or the Institute for Health Metrics and Evaluation. These studies have become more and more refined with respect to establishing causality between dimensions of alcohol consumption and different disease and mortality (cause of death) outcomes, refining risk relations, and improving the methodology for estimating exposure and alcohol-attributable burden. The present review will give an overview on the main results of the CRAs with respect to alcohol consumption as a risk factor, sketch out new trends and developments, and draw implications for future research and policy.

DALY-Based Health Risk Assessment of Construction Noise in Beijing, China

Noise produced by construction activities has become the second most serious acoustic polluting element in China. To provide industry practitioners with a better understanding of the health risks of construction noise and to aid in creating environmentally friendly construction plans during early construction stages, we developed a quantitative model to assess the health impairment risks (HIA) associated with construction noise for individuals living adjacent to construction sites. This model classifies noise-induced health impairments into four categories: cardiovascular disease, cognitive impairment, sleep disturbance, and annoyance, and uses disability-adjusted life years (DALYs) as an indicator of damage. Furthermore, the value of a statistical life (VSL) is used to transform DALYs into a monetary value based on the affected demographic characteristics, thereby offering policy makers a reliable theoretical foundation for establishing reasonable standards to compensate residents suffering from construction noise. A practical earthwork project in Beijing is used as a case study to demonstrate the applicability of the proposed model. The results indicate that construction noise could bring significant health risks to the neighboring resident community, with an estimated 34.51 DALYs of health damage and 20.47 million yuan in social costs. In particular, people aged 45–54 are most vulnerable to construction noise, with the greatest health risks being caused by sleep disturbance.

Benefit-Risk Analysis for Decision-Making: An Approach

The analysis of benefit and risk is an important aspect of decision-making throughout the drug lifecycle. In this work, the use of a benefit-risk analysis approach to support decision-making was explored. The proposed approach builds on the qualitative US Food and Drug Administration (FDA) approach to include a more explicit analysis based on international standards and guidance that enables aggregation and comparison of benefit and risk on a common basis and a lifecycle focus. The approach is demonstrated on six decisions over the lifecycle (e.g., accelerated approval, withdrawal, and traditional approval) using two case studies: natalizumab for multiple sclerosis (MS) and bedaquiline for multidrug-resistant tuberculosis (MDR-TB).

Assessing the Public's Health

Metrics are an important part of the assessment of public health. They include traditional measures of mortality and newly described summary measures to describe the disability engendered by diseases. Epidemiology has transformed the understanding of risk factors for disease; however, a holistic approach includes recognition of social determinants and the neighborhood and communities where the people most at risk reside.

Burden of ischaemic heart disease and cerebrovascular diseases in Serbia without Kosovo and Metohia, 2000

BACKGROUND

To provide estimates of cardiovascular disease burden to guide future health strategies and interventions and enable improvements in health and performance of the health care system to be monitored.

DESIGN

A descriptive study.

METHODS

The study was performed in Serbia without Kosovo and Metohia for the year 2000. Disability-adjusted life years (DALY) was used to provide a comprehensive assessment of premature mortality (years of life lost; YLL) and disability attributable (years lived with disability; YLD) to ischaemic heart disease (IHD) and cerebrovascular diseases, and to estimate the attributable and avoidable burden of these diseases caused by smoking, hypertension, overweight/obesity, physical inactivity, alcohol consumption and an inadequate consumption of fruit and vegetables.

RESULTS

IHD was responsible for 150 889 DALY (16.28/1000 population), and cerebrovascular diseases were responsible for 136 090 DALY (14.49/1000 population). There were considerably more YLL for both IHD and stroke than YLD. For both diseases DALY rates increased with ageing in men and women. The risk factors most responsible for IHD and stroke burden were smoking, physical inactivity, hypertension and overweight/obesity. Sex and age differences were present in the burden attributable to various risk factors.

CONCLUSION

Despite limitations the DALY estimates represent a useful measure of the size of the health problem. The DALY and related estimates for cardiovascular disease can be used as a guide for the prevention of IHD and stroke as well as the evaluation of future health gains by reducing population exposure to lifestyle and related risk factors.

Research Methods in Epidemiology

Epidemiology is the study of the distribution and determinants of health-related states and in specified populations and the application to control health problems. Classified as either descriptive or analytical, a variety of epidemiologic approaches can be used to allow assessment of hypothesized risk factor exposure with disease outcomes. This article reviews salient aspects of epidemiologic research methods that are used repeatedly in articles in this volume on public health, neuroepidemiology, and health systems.

The Global Burden of Esophageal Cancer: A Disability-Adjusted Life-Year Approach

INTRODUCTION

Esophageal cancer is the eighth most common cancer worldwide and the sixth leading cause of cancer-related deaths. As a significant cause of morbidity and mortality, its burden on society has yet to be fully characterized. The aim of this study is to examine its global burden through estimation of the disability-adjusted life years (DALYs) attributable to it.

METHODS

Global incidence and mortality estimates for esophageal cancer were obtained from the International Agency for Research on Cancer GLOBOCAN 2008 database. DALYs were calculated, using methodology established by the World Health Organization.

RESULTS

In 2008, 3,955,919 DALYs were attributed to esophageal cancer, at a global rate of 0.58 DALYs per 1000 people annually. Years of life lost (YLL) accounted for 96.8 % of DALYs, while years lived with disability (YLD) accounted for 3.2 %. 83.8 % of the global DALYs occurred in less-developed countries, with most accrued in Eastern Asia, comprising 50.9 % of the total. The highest rate of DALY accrual was in Southern Africa, at 1.62 DALYs per 1000 people annually.

CONCLUSIONS

A substantial number of years of life were lost or affected by esophageal cancer worldwide in 2008, with the burden resting disproportionately on less-developed countries. Geographically, the greatest burden is in Eastern Asia. The vast majority of DALYs were due to YLL, rather than YLD, indicating the need to focus resources on disease prevention and early detection. Our findings provide an additional basis upon which to formulate global priorities for interventions that affect DALY reduction in esophageal cancer.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

The Burden of Zoonoses in Kyrgyzstan: A Systematic Review

INTRODUCTION

Zoonotic disease (ZD) pose a serious threat to human health in low-income countries. In these countries the human burden of disease is often underestimated due to insufficient monitoring because of insufficient funding. Quantification of the impact of zoonoses helps in prioritizing healthcare needs. Kyrgyzstan is a poor, mountainous country with 48% of the population employed in agriculture and one third of the population living below the poverty line.

METHODOLOGY/PRINCIPAL FINDINGS

We have assessed the burden of zoonoses in Kyrgyzstan by conducting a systematic review. We have used the collected data to estimate the burden of ZDs and addressed the underestimation in officially reported disease incidence. The estimated incidences of the ZDs were used to calculate incidence-based Disability Adjusted Life Years (DALYs). This standardized health gap measure enhances comparability between injuries and diseases. The combined burden for alveolar echinococcosis, cystic echinococcosis, brucellosis, campylobacteriosis, congenital toxoplasmosis, non-typhoidal salmonellosis and rabies in Kyrgyzstan in 2013 was 35,209 DALYs [95% Uncertainty interval (UI):13,413-83,777]; 576 deaths [95% UI: 279-1,168] were attributed to these infections. We estimate a combined median incidence of ZDs of 141,583 cases [95% UI: 33,912-250,924] in 2013. The highest burden was caused by non-typhoidal Salmonella and Echinococcus multilocularis, respectively 14,792 DALYs [95% UI: 3,966-41,532] and 11,915 DALYs [95% UI: 4,705-27,114] per year.

CONCLUSION/SIGNIFICANCE

The health impact of zoonoses in Kyrgyzstan is substantial, comparable to that of HIV. Community-based surveillance studies and hospital-based registration of all occurrences of zoonoses would increase the accuracy of the estimates.

The burden of road traffic injuries in Kermanshah Province, Iran, in 2010-2011: GBD 2010 method

Deaths, injuries and disabilities resulting from road traffic injuries (RTIs) are a public health major concern. This study aims to calculate the burden of RTIs in Kermanshah Province in Iran. In this study to determine the years of life lost (YLL) related to RTIs, the National Death Registration and Forensics Medicine census data were employed. We use forensic medicine data to calculate the incidence of non-fatal injuries and years lost due to disability (YLD). The cause of death and non-fatal injuries was classified using ICD-10 codes and 23 groupes of global burden of diseases (GBD) 2010. The disability-adjusted life year (DALY) estimated on the guidelines of the GBD 2010 and age and sex structure was taken from the National Statistic Center for the year 2010. Overall, 70.8% of the subjects were males. The fatal and non-fatal injury rates of RTI were 51.3 and 283.6 per 100,000 persons, respectively. YLLs and YLDs were 46613 (24.5 per 1000) and 3405 (1.8 per 1000) in both sexes, respectively. The disability adjusted life years were 40711 in males, 9306 in females and 50018 in both sexes (42.5, 9.8 and 26.3 per 1000, respectively). More than 93% of DALY was from YLL (24.5 per 1000), with a small proportion for YLD (1.8 per 1000). Accounting for more than 50,000 DALY attributed to RTIs, traffic injuries is a major public health and socioeconomic problem in Kermanshah. Designing cost-effective interventions based on comprehensive and multi-sectoral programmes at the national and provincial levels can save many lives and resources that are lost every year. Undoubtedly, establishing a surveillance system at the sub-national level and measuring the burden of injuries, as in this study, can help policy-makers and planners in lessening the burden of RTIs.

Going beyond life expectancy in assessments of health systems' performance: life expectancy adjusted by perceived health status

International comparisons of health systems data have been used to guide health policy. Health systems performance is generally evaluated on how different factors contribute to mortality and longevity. Fewer studies scrutinize the factors that determine morbidity in different countries, partly because indicators that assess morbidity on a country level are not as widely available as mortality and longevity data. We introduce a new health status indicator able to combine mortality and morbidity in a single composite measure for each country and gender at a point in time (LEAPHS), yielding the average number of years that men (women) can expect to live in "good" (or better) health. Using the Sullivan method we combine the mortality risk, calculated for specific age and gender groups, with perceived health status for the same age and gender groups, and we estimate how medical care and various socio-economic, environmental and structural, lifestyle, and technological factors affect LEAPHS and life expectancy at birth for a large panel of thirty OECD countries. We find that some variables (alcohol consumption, urbanization) have a significant effect on both LEAPHS and life expectancy, while one variable (the number of hospitals) has a significant effect for both genders on life expectancy only. However, the effects of many other variables (health expenditure per capita, health expenditure per capita squared, GDP growth, and technology) were only significant predictors for LEAPHS. This leads us to conclude that LEAPHS is able to capture the impact of some health determinants not captured by life expectancy at birth. While we believe this new measure may be useful for health economists and statisticians doing cross-country analyses, further comparisons with other measures may be useful.

Aplicabilidade dos estudos de carga de doença nos distúrbios fonoaudiológicos

RESUMO: A metodologia de mensuração da carga de doença, composta pelo cálculo de indicadores específicos, propõe mensurar os efeitos de agravos (ou de doenças) sobre o bem estar físico, emocional e social, seja a partir dos efeitos da morte prematura e da morbidade, bem como de comorbidades sobre as condições de saúde da população. O estudo teve como objetivo verificar a possibilidade de aplicação dos conceitos de carga de doença no estudo das metodologias e melhor caracterização do cenário de agravos fonoaudiológicos. O estudo envolveu revisão integrativa da literatura nas bases Scielo, Lilacs e Pubmed, com apresentação de conceitos e uma análise crítica dos indicadores de carga de doença e suas potenciais aplicações no campo da fonoaudiologia. Os achados indicam que existe uma carência de estudos utilizando os conceitos relacionados à carga de doença aplicados à comunicação humana e seus distúrbios, bem como às implicações destas na vida do sujeito a partir da metodologia proposta pela Organização Mundial da Saúde. Há oportunidades de aplicação da metodologia foco da pesquisa, tanto para que forneça o impacto dos agravos no indivíduo, como para a avaliação da qualidade de vida e para a mensuração da efetividade das intervenções no campo dos distúrbios fonoaudiológicos.

Cost-effectiveness of club-foot treatment in low-income and middle-income countries by the Ponseti method

Background

Club foot is a common congenital deformity affecting 150 000–200 000 children every year. Untreated patients end up walking on the side or back of the affected foot, with severe social and economic consequences. Club foot is highly treatable by the Ponseti method, a non-invasive technique that has been described as highly suitable for use in resource-limited settings. To date, there has been no evaluation of its cost-effectiveness ratio, defined as the cost of averting one disability-adjusted life year (DALY), a composite measure of the impact of premature death and disability. In this study, we aimed to calculate the average cost-effectiveness ratio of the Ponseti method for correcting club foot in sub-Saharan Africa.

Methods

Using data from 12 sub-Saharan African countries provided by the international non-profit organisation CURE Clubfoot, which implements several Ponseti treatment programmes around the world, we estimated the average cost of the point-of-care treatment for club foot in these countries. We divided the cost of treatment with the average number of DALYs that can be averted by the Ponseti treatment, assuming treatment is successful in 90% of patients.

Results

We found the average cost of the Ponseti treatment to be US$167 per patient. The average number of DALYs averted was 7.42, yielding a cost-effectiveness ratio of US$22.46 per DALY averted. To test the robustness of our calculation different variables were used and these yielded a cost range of US$5.28–29.75. This is less than a tenth of the cost of many other treatment modalities used in resource-poor settings today.

Conclusions

The Ponseti method for the treatment of club foot is cost-effective and practical in a low-income country setting. These findings could be used to raise the priority for implementing Ponseti treatment in areas where patients are still lacking access to the life-changing intervention.

Economic evaluation of mental health interventions: an introduction to cost-utility analysis

Finite resources need to be allocated over an ever-increasing range of competing health policies and interventions. Economic evaluation has been developed as a methodology to inform decision makers on the efficiency of particular resource allocations. In this paper we summarize cost-utility analysis, one of the most widely-used forms of economic evaluation in healthcare. We discuss its main elements, interpretation, limitations and relevance to the domain of mental health.

Cost-Effectiveness and Quality of Care of a Comprehensive ART Program in Malawi

The aim of this study is to assess the cost-effectiveness of a holistic, comprehensive human immunodeficiency virus (HIV) treatment Program in Malawi.Comprehensive cost data for the year 2010 have been collected at 30 facilities from the public network of health centers providing antiretroviral treatment (ART) throughout the country; two of these facilities were operated by the Disease Relief through Excellent and Advanced Means (DREAM) program.The outcomes analysis was carried out over five years comparing two cohorts of patients on treatment: 1) 2387 patients who started ART in the two DREAM centers during 2008, 2) patients who started ART in Malawi in the same year under the Ministry of Health program.Assuming the 2010 cost as constant over the five years the cost-effective analysis was undertaken from a health sector and national perspective; a sensitivity analysis included two hypothesis of ART impact on patients' income.The total cost per patient per year (PPPY) was $314.5 for the DREAM protocol and $188.8 for the other Malawi ART sites, with 737 disability adjusted life years (DALY) saved among the DREAM program patients compared with the others. The Incremental Cost-Effectiveness Ratio was $1640 per DALY saved; it ranged between $896-1268 for national and health sector perspective respectively. The cost per DALY saved remained under $2154 that is the AFR-E-WHO regional gross domestic product per capita threshold for a program to be considered very cost-effective.HIV/acquired immune deficiency syndrome comprehensive treatment program that joins ART with laboratory monitoring, treatment adherence reinforcing and Malnutrition control can be very cost-effective in the sub-Saharan African setting.

Neurology training in sub-Saharan Africa: A survey of people in training from 19 countries

OBJECTIVE

To provide a comprehensive understanding of neurology training from the sub-Saharan African perspective.

METHODS

A 40-question survey was distributed to attendees of the 7th annual sub-Saharan African neurology teaching course in Khartoum, Sudan (2015). Themes included the student body, faculty, curriculum, assessment and examinations, technology, and work hours and compensation.

RESULTS

Of 19 responding countries, 10 had no formal neurology training programs; Burkina Faso, Cameroon, Republic of the Congo, and Mozambique had an adult neurology program; Ethiopia, Madagascar, Nigeria, Senegal, and South Africa had adult and pediatric neurology programs (training duration range = 3-6 years). There was a median of 2.5 full-time neurologists on the teaching faculty at the respondents' training institutions (neurologists on-faculty:in-country ratio = 0.48), with the lowest ratios in Sudan and Nigeria. Neurology was perceived to be a competitive specialty for entrance in 57% of countries, with 78% of respondents reporting a requisite entrance examination. Ninety-five percent had access to a personal smartphone, 62% used the Internet more than occasionally, and 60% had access to online neurology journals. The average number of weekly work hours was 51 (range = 40-75), and average monthly salary among those earning income was 1,191 USD (range = 285-3,560). Twenty percent of respondents reported paying for training. The most common barriers to neurology postgraduate education were few training programs and lack of training in neurodiagnostic tests. Among 17 reporting countries, there is an estimated average of 0.6 neurologists per million people.

INTERPRETATION

Neurology training programs in sub-Saharan Africa are relatively limited in number and have several unmet needs including a small cadre of faculty and an opportunity to standardize curricula and financing of programs. Ann Neurol 2016;79:871-881.

The badness of death and priorities in health

Background

The state of the world is one with scarce medical resources where longevity is not equally distributed. Given such facts, setting priorities in health entails making difficult yet unavoidable decisions about which lives to save. The business of saving lives works on the assumption that longevity is valuable and that an early death is worse than a late death. There is a vast literature on health priorities and badness of death, separately. Surprisingly, there has been little cross-fertilisation between the academic fields of priority setting and badness of death. Our aim is to connect philosophical discussions on the badness of death to contemporary debates in health priorities.

Discussion

Two questions regarding death are especially relevant to health priorities. The first question is why death is bad. Death is clearly bad for others, such as family, friends and society. Many philosophers also argue that death can be bad for those who die. This distinction is important for health priorities, because it concerns our fundamental reasons for saving lives. The second question is, ‘When is the worst time to die?’ A premature death is commonly considered worse than a late death. Thus, the number of good life years lost seems to matter to the badness of death. Concerning young individuals, some think the death of infants is worse than the death of adolescents, while others have contrary intuitions. Our claim is that to prioritise between age groups, we must consider the question of when it is worst to die.

Conclusions

Deprivationism provides a more plausible approach to health priorities than Epicureanism. If Deprivationism is accepted, we will have a firmer basis for claiming that individuals, in addition to having a health loss caused by morbidity, will have a loss of good life years due to mortality. Additionally, Deprivationism highlights the importance of age and values for health priorities. Regarding age, both variants of Deprivationism imply that stillbirths are included in the Global Burden of Disease. Finally, we suggest that the Time-Relative Interest Account may serve as an alternative to the discounting and age weighting previously applied in the Global Burden of Disease.

Temporal changes in alcohol-related mortality and morbidity in Australia

BACKGROUND AND AIMS

Alcohol consumption is an avoidable risk factor for morbidity and mortality. Studies have examined relative risks and outcomes of alcohol-related harms in Australia at discrete times, limiting the ability to examine changes across time. This paper examined alcohol consumption and its contribution to deaths, illness and injury at two time-points, 2001 and 2010.

DESIGN

Alcohol consumption was modelled based on the 2001 and 2010 National Drug Strategy Household Survey, upshifted to reflect alcohol sales data.

SETTING

All data reported are from Australian sources.

MEASUREMENTS

Based on relative risk estimates obtained from meta-analysis, alcohol-attributable fractions were estimated for 42 disease and injury categories in 2001 and 2010 separately for conditions that were not 100% alcohol-attributable. Deaths and hospital separations attributable to alcohol were calculated in 2001 and 2010.

FINDINGS

There was a relatively stable per capita consumption of alcohol across time, with males reporting higher levels of consumption compared with females. While there were increases in the number of abstainers from alcohol across time, the proportion of heavy alcohol consumers also increased. This corresponded with an observed increase in alcohol-attributable burden. For example, alcohol-attributable deaths increased from 4957 [95% confidence interval (CI) = 2867-8770] to 5610 (95% CI = 3398-9408) during the study period.

CONCLUSION

The findings demonstrate that there has been an increase in alcohol-attributable harms between 2001 and 2010 in Australia without a corresponding increase in per capita consumption.

Portable photocatalytic air cleaners: efficiencies and by-product generation

Portable photocatalytic air cleaners were investigated in 24 and 48 m(3) emission test chambers with regard to efficiency and by-product generation. For this purpose, formaldehyde, decane, 1,2-dichlorobenzene, toluene, α-pinene and heptanal were doped at sub-ppm concentration levels into the chambers individually and in mixtures. By way of specified test protocols, efficiencies could be distinguished but were strongly dependant on the choice of test compounds, especially on whether single or multi compound dosing was used, and on long-term effects. Initial clean air delivery rates (CADRs) up to 137 m(3)/h were measured. Typical by-products were found in significant concentrations. The main ones were formaldehyde up to 50 ppb (62 μg/m(3)) and acetone up to 80 ppb (190 μg/m(3)). Other aldehydes were also found, but at smaller levels. The detection of chloroacetone, a strong irritating compound, at concentrations up to 15 ppb (57 μg/m(3)) strengthens the importance of such investigations especially in cases were chloro-organic compounds are involved.

Differing Methods and Definitions Influence DALY estimates: Using Population-Based Data to Calculate the Burden of Convulsive Epilepsy in Rural South Africa

Background

The disability adjusted life year (DALY) is a composite measure of disease burden that includes both morbidity and mortality, and is relevant to conditions such as epilepsy that can limit productive functioning. The 2010 Global Burden of Disease (GBD) study introduced a number of new methods and definitions, including a prevalence-based approach and revised disability weights to calculate morbidity and new standard life expectancies to calculate premature mortality. We used these approaches, and local, population-based data, to estimate the burden of convulsive epilepsy in rural South Africa.

Methods & Findings

Comprehensive prevalence, incidence and mortality data on convulsive epilepsy were collected within the Agincourt sub-district in rural northeastern South Africa between 2008 and 2012. We estimated DALYs using both prevalence- and incidence-based approaches for calculating years of life lived with disability. Additionally, we explored how changing the disease model by varying the disability weights influenced DALY estimates. Using the prevalence-based approach, convulsive epilepsy in Agincourt resulted in 332 DALYs (95% uncertainty interval (UI): 216–455) and 4.1 DALYs per 1,000 individuals (95%UI: 2.7–5.7) annually. Of this, 26% was due to morbidity while 74% was due to premature mortality. DALYs increased by 10% when using the incidence-based method. Varying the disability weight from 0.072 (treated epilepsy, seizure free) to 0.657 (severe epilepsy) caused years lived with disability to increase from 18 (95%UI: 16–19) to 161 (95%UI: 143–170).

Conclusions

DALY estimates are influenced by both the methods applied and population parameters used in the calculation. Irrespective of method, a significant burden of epilepsy is due to premature mortality in rural South Africa, with a lower burden than rural Kenya. Researchers and national policymakers should carefully interrogate the methods and data used to calculate DALYs as this will influence policy priorities and resource allocation.

The Burden of Tick-Borne Encephalitis in Disability-Adjusted Life Years (DALYs) for Slovenia

BACKGROUND

Tick-borne encephalitis (TBE) presents an increasing burden in many parts of Europe, Asian Russia, Siberia, Asian former USSR and Far East. Incidence can be considered as one way to express the burden. A more comprehensive measure concerns disability-adjusted life years (DALYs), better characterizing the full burden of TBE. TBE burden in DALYs has not yet been estimated, nor has it been specified by the Global Burden of Disease (GBD) studies.

OBJECTIVE

The purpose of the present study is to estimate the burden of TBE in Slovenia, expressed in DALYs, both from the population and individual perspectives. We discuss the impact of TBE burden on public health and potential strategies to reduce this burden in Slovenia.

METHODS

The burden of TBE is estimated by using the updated DALYs' methodology first introduced in the GBD project. The DALYs᾽ calculations are based on the health outcomes of the natural course of the disease being modelled. Corrections for under-reporting and under-ascertainment are applied. The impact of uncertainty in parameters in the model was assessed using sensitivity analyses.

RESULTS

From the population perspective, total DALYs amount to 3,450 (167.8 per 100,000 population), while from the individual perspective they amount to 3.1 per case in 2011. Notably, the consequences of TBE present a larger burden than TBE itself.

CONCLUSIONS

TBE presents a relatively high burden expressed in DALYs compared with estimates for other infectious diseases from the GBD 2010 study for Slovenia. Raising awareness and increasing vaccination coverage are needed to reduce TBE and its consequences.

Assessing burden of disease as disability adjusted life years in life cycle assessment

Disability adjusted life years (DALYs) have been used to quantify endpoint indicators of the human burden of disease in life cycle assessment (LCA). The purpose of this paper was to examine the current use of DALYs in LCA, and also to consider whether DALYs as used in LCA have the potential to be compatible with DALYs as used in quantitative risk assessment (QRA) to facilitate direct comparison of the results of the two approaches. A literature review of current usage of DALYs in LCA was undertaken. Two prominent methods were identified: ReCiPe 2008 and LIME2. The methods and assumptions used in their calculations were then critically reviewed. The assumptions used for the derivation of characterization factors in DALYs were found to be considerably different between LCA methods. In many cases, transparency of these calculations and assumptions is lacking. Furthermore, global average DALY values are often used in these calculations, but may not be applicable for impact categories where the local factors play a significant role. The concept of DALYs seems beneficial since it enables direct comparison and aggregation of different health impacts. However, given the different assumptions used in each LCA method, it is important that LCA practitioners are aware of the differences and select the appropriate method for the focus of their study. When applying DALYs as a common metric between LCA and QRA, understanding the background information on how DALYs were derived is crucial to ensure the consistency of DALYs used in LCA and QRA for resulting DALYs to be comparable and to minimize any double counting of effects.

Are brief interventions to increase physical activity cost-effective? A systematic review

Objective

To determine whether brief interventions promoting physical activity are cost-effective in primary care or community settings.

Design

Systematic review of economic evaluations.

Methods and data sources

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit, SPORTDiscus, PEDro, the Cochrane library, National Health Service Economic Evaluation Database and the Cost-Effectiveness Analysis Registry up to 20 August 2014. Web of Knowledge was used for cross-reference search. We included studies investigating the cost-effectiveness of brief interventions, as defined by National Institute for Health and Care Excellence, promoting physical activity in primary care or the community. Methodological quality was assessed using Drummond's checklist for economic evaluations. Data were extracted from individual studies fulfilling selection criteria using a standardised pro forma. Comparisons of cost-effectiveness and cost-utility ratios were made between studies.

Results

Of 1840 identified publications, 13 studies fulfilled the inclusion criteria describing 14 brief interventions. Studies varied widely in the methods used, such as the perspective of economic analysis, intervention effects and outcome measures. The incremental cost of moving an inactive person to an active state, estimated for eight studies, ranged from £96 to £986. The cost-utility was estimated in nine studies compared with usual care and varied from £57 to £14 002 per quality-adjusted life year; dominant to £6500 per disability-adjusted life year; and £15 873 per life years gained.

Conclusions

Brief interventions promoting physical activity in primary care and the community are likely to be inexpensive compared with usual care. Given the commonly accepted thresholds, they appear to be cost-effective on the whole, although there is notable variation between studies.

Burden of road traffic injuries: Disability-adjusted life years in relation to hospitalization and the maximum abbreviated injury scale

BACKGROUND

The consequences of non-fatal road traffic injuries (RTI) are increasingly adopted by policy makers as an indicator of traffic safety. However, it is not agreed upon which level of severity should be used as cut-off point for assessing road safety performance. Internationally, within road safety, injury severity is assessed by means of the maximum abbreviated injury scale (MAIS). The choice for a severity cut-off point highly influences the measured disease burden of RTI. This paper assesses the burden of RTI in terms of disability adjusted life years (DALYs) by hospitalization status and MAIS cut-off point in the Netherlands.

METHODS

Hospital discharge register (HDR) and emergency department (ED) data for RTI in the Netherlands were selected for the years 2007-2009, as well as mortality data. The incidence, years lived with disability (YLD), years of life lost (YLL) owing to premature death, and DALYs were calculated. YLD for admitted patients was subdivided by MAIS severity levels.

RESULTS

RTI resulted in 48,500 YLD and 27,900 YLL respectively, amounting to 76,400 DALYs per year in the Netherlands. The largest proportion of DALYs is related to fatalities (37%), followed by admitted MAIS 2 injuries (25%), ED treated injuries (16%) and admitted MAIS 3+ injuries (18%). Admitted MAIS 1 injuries only account for a small fraction of DALYs (4%). In the Netherlands, the diseases burden of RTI is highest among cyclists with 39% of total DALYs. One half of all bicycle related DALYs are attributable to admitted MAIS 2+ injuries, but ED treated injuries also account for a large proportion of DALYs in this group (28%). Car occupants are responsible for 26% of all DALYs, primarily caused by fatalities (66%), followed by admitted MAIS 2+ injuries (25%). ED treated injuries only account for 5% of DALYs in this group.

CONCLUSIONS

When using admitted MAIS 3+ or admitted MAIS 2+ as severity cut-off point, 54% and 80% of all DALYs are captured respectively. Assessing the influence of different severity cut-off points by MAIS on the proportion and number of DALYs captured gives valuable information for guiding choices on the definition of serious RTI.

Eliminating artificial trans fatty acids in Argentina: estimated effects on the burden of coronary heart disease and costs

Objective

To estimate the impact of Argentine policies to reduce trans fatty acids (TFA) on coronary heart disease (CHD), disability-adjusted life years (DALYs) and associated health-care costs.

Methods

We estimated the baseline intake of TFA before 2004 to be 1.5% of total energy intake. We built a policy model including baseline intake of TFA, the oils and fats used to replace artificial TFAs, the clinical effect of reducing artificial TFAs and the costs and DALYs saved due to averted CHD events. To calculate the percentage of reduction of CHD, we calculated CHD risks on a population-based sample before and after implementation. The effect of the policies was modelled in three ways, based on projected changes: (i) in plasma lipid profiles; (ii) in lipid and inflammatory biomarkers; and (iii) the results of prospective cohort studies. We also estimated the present economic value of DALYs and associated health-care costs of coronary heart disease averted.

Findings

We estimated that projected changes in lipid profile would avert 301 deaths, 1066 acute CHD events, 5237 DALYs and 17 million United States dollars (US$) in health-care costs annually. Based on the adverse effects of TFA intake reported in prospective cohort studies, 1517 deaths, 5373 acute CHD events, 26 394 DALYs and US$ 87 million would be averted annually.

Conclusion

Even under the most conservative scenario, reduction of TFA intake had a substantial effect on public health. These findings will help inform decision-makers in Argentina and other countries on the potential public health and economic impact of this policy.

Critical insights for a sustainability framework to address integrated community water services: Technical metrics and approaches

Planning for sustainable community water systems requires a comprehensive understanding and assessment of the integrated source-drinking-wastewater systems over their life-cycles. Although traditional life cycle assessment and similar tools (e.g. footprints and emergy) have been applied to elements of these water services (i.e. water resources, drinking water, stormwater or wastewater treatment alone), we argue for the importance of developing and combining the system-based tools and metrics in order to holistically evaluate the complete water service system based on the concept of integrated resource management. We analyzed the strengths and weaknesses of key system-based tools and metrics, and discuss future directions to identify more sustainable municipal water services. Such efforts may include the need for novel metrics that address system adaptability to future changes and infrastructure robustness. Caution is also necessary when coupling fundamentally different tools so to avoid misunderstanding and consequently misleading decision-making.

Estimating the burden of foodborne diseases in Japan

OBJECTIVE

To assess the burden posed by foodborne diseases in Japan using methods developed by the World Health Organization's Foodborne Disease Burden Epidemiology Reference Group (FERG).

METHODS

Expert consultation and statistics on food poisoning during 2011 were used to identify three common causes of foodborne disease in Japan: Campylobacter and Salmonella species and enterohaemorrhagic Escherichia coli (EHEC). We conducted systematic reviews of English and Japanese literature on the complications caused by these pathogens, by searching Embase, the Japan medical society abstract database and Medline. We estimated the annual incidence of acute gastroenteritis from reported surveillance data, based on estimated probabilities that an affected person would visit a physician and have gastroenteritis confirmed. We then calculated disability-adjusted life-years (DALYs) lost in 2011, using the incidence estimates along with disability weights derived from published studies.

FINDINGS

In 2011, foodborne disease caused by Campylobacter species, Salmonella species and EHEC led to an estimated loss of 6099, 3145 and 463 DALYs in Japan, respectively. These estimated burdens are based on the pyramid reconstruction method; are largely due to morbidity rather than mortality; and are much higher than those indicated by routine surveillance data.

CONCLUSION

Routine surveillance data may indicate foodborne disease burdens that are much lower than the true values. Most of the burden posed by foodborne disease in Japan comes from secondary complications. The tools developed by FERG appear useful in estimating disease burdens and setting priorities in the field of food safety.

Assessing disability weights based on the responses of 30,660 people from four European countries

BACKGROUND

In calculations of burden of disease using disability-adjusted life years, disability weights are needed to quantify health losses relating to non-fatal outcomes, expressed as years lived with disability. In 2012 a new set of global disability weights was published for the Global Burden of Disease 2010 (GBD 2010) study. That study suggested that comparative assessments of different health outcomes are broadly similar across settings, but the significance of this conclusion has been debated. The aim of the present study was to estimate disability weights for Europe for a set of 255 health states, including 43 new health states, by replicating the GBD 2010 Disability Weights Measurement study among representative population samples from four European countries.

METHODS

For the assessment of disability weights for Europe we applied the GBD 2010 disability weights measurement approach in web-based sample surveys in Hungary, Italy, Netherlands, and Sweden. The survey included paired comparisons (PC) and population health equivalence questions (PHE) formulated as discrete choices. Probit regression analysis was used to estimate cardinal values from PC responses. To locate results onto the 0-to-1 disability weight scale, we assessed the feasibility of using the GBD 2010 scaling approach based on PHE questions, as well as an alternative approach using non-parametric regression.

RESULTS

In total, 30,660 respondents participated in the survey. Comparison of the probit regression results from the PC responses for each country indicated high linear correlations between countries. The PHE data had high levels of measurement error in these general population samples, which compromises the ability to infer ratio-scaled values from discrete choice responses. Using the non-parametric regression approach as an alternative rescaling procedure, the set of disability weights were bounded by distance vision mild impairment and anemia with the lowest weight (0.004) and severe multiple sclerosis with the highest weight (0.677).

CONCLUSIONS

PC assessments of health outcomes in this study resulted in estimates that were highly correlated across four European countries. Assessment of the feasibility of rescaling based on a discrete choice formulation of the PHE question indicated that this approach may not be suitable for use in a web-based survey of the general population.

Disability-adjusted-life-years losses in postmenopausal women with osteoporosis: a burden of illness study

BACKGROUND

To estimate the disability-adjusted life years (DALY) in a nationwide representative sample of postmenopausal women with osteoporosis. The effects of drug-based therapy and risk factors for osteoporotic bone fractures on DALY losses were also explored.

METHODS

DALY were estimated based on participant's clinical characteristics and Health-Related Quality-of-Life (HRQoL) data obtained from a cross-sectional, epidemiological one-visit study (the GINERISK study). The study enrolled postmenopausal women (at least 12-months after their last menstrual period) with osteoporosis, above 18-years old, who attended Spanish outpatient Gynaecology clinics. HRQoL was assessed using the generic SF-12v2 questionnaire, which was used to derive disutility values. Mortality rates were extracted from the Spanish national statistics database. Factors explored to be associated with DALY losses were examined using ANOVA, ANCOVA and MANCOVA models.

RESULTS

DALY could be computed in 2,782 (67%) out of 4,157 postmenopausal women, with a mean (95% CI) age of 61.0 (60.7-61.2) years. Overall individual undiscounted DALY per woman were 6.1 (5.9-6.2), resulting to be significantly higher in women with severe osteoporosis with prior bone fracture; 7.8 (7.2-8.4) compared to osteoporotic women [5.8 (5.6-6.0)] or postmenopausal women with a BMD > -2.5 T-score that received a drug-based therapy [6.2 (5.8-6.5)]; F = 27.0 (P < 0.01). Models explaining the variation in the levels of health based on the use of a selective estrogen receptor modulator (SERM) or possession of risk factors for osteoporotic BF were found (P < 0.05).

CONCLUSIONS

DALY losses were considerable amongst postmenopausal women with osteoporosis. Not having a prior bone fracture, being older, using a SERM and having less osteoporotic risk factors were all linked to less DALY losses.

Disability adjusted life year (DALY): a useful tool for quantitative assessment of environmental pollution

Disability adjusted life year (DALY) has been widely used since 1990s for evaluating global and/or regional burden of diseases. As many environmental pollutants are hazardous to human health, DALY is also recognized as an indicator to quantify the health impact of environmental pollution related to disease burden. Based on literature reviews, this article aims to give an overview of the applicable methodologies and research directions for using DALY as a tool for quantitative assessment of environmental pollution. With an introduction of the methodological framework of DALY, the requirements on data collection and manipulation for quantifying disease burdens are summarized. Regarding environmental pollutants hazardous to human beings, health effect/risk evaluation is indispensable for transforming pollution data into disease data through exposure and dose-response analyses which need careful selection of models and determination of parameters. Following the methodological discussions, real cases are analyzed with attention paid to chemical pollutants and pathogens usually encountered in environmental pollution. It can be seen from existing studies that DALY is advantageous over conventional environmental impact assessment for quantification and comparison of the risks resulted from environmental pollution. However, further studies are still required to standardize the methods of health effect evaluation regarding varied pollutants under varied circumstances before DALY calculation.

The global burden of mental, neurological and substance use disorders: an analysis from the Global Burden of Disease Study 2010

Background

The Global Burden of Disease Study 2010 (GBD 2010), estimated that a substantial proportion of the world’s disease burden came from mental, neurological and substance use disorders. In this paper, we used GBD 2010 data to investigate time, year, region and age specific trends in burden due to mental, neurological and substance use disorders.

Method

For each disorder, prevalence data were assembled from systematic literature reviews. DisMod-MR, a Bayesian meta-regression tool, was used to model prevalence by country, region, age, sex and year. Prevalence data were combined with disability weights derived from survey data to estimate years lived with disability (YLDs). Years lost to premature mortality (YLLs) were estimated by multiplying deaths occurring as a result of a given disorder by the reference standard life expectancy at the age death occurred. Disability-adjusted life years (DALYs) were computed as the sum of YLDs and YLLs.

Results

In 2010, mental, neurological and substance use disorders accounted for 10.4% of global DALYs, 2.3% of global YLLs and, 28.5% of global YLDs, making them the leading cause of YLDs. Mental disorders accounted for the largest proportion of DALYs (56.7%), followed by neurological disorders (28.6%) and substance use disorders (14.7%). DALYs peaked in early adulthood for mental and substance use disorders but were more consistent across age for neurological disorders. Females accounted for more DALYs in all mental and neurological disorders, except for mental disorders occurring in childhood, schizophrenia, substance use disorders, Parkinson’s disease and epilepsy where males accounted for more DALYs. Overall DALYs were highest in Eastern Europe/Central Asia and lowest in East Asia/the Pacific.

Conclusion

Mental, neurological and substance use disorders contribute to a significant proportion of disease burden. Health systems can respond by implementing established, cost effective interventions, or by supporting the research necessary to develop better prevention and treatment options.

Use of DALYs in economic analyses on interventions for infectious diseases: a systematic review

A systematic literature review was performed on full economic evaluations of infectious disease interventions using disability-adjusted life years (DALY) as outcome measure. The search was limited to the period between 1994 and September 2011 and conducted in Medline, SciSearch and EMBASE databases. We included 154 studies, mostly targeting HIV/AIDS and malaria with most conducted for African countries (40%) and <10% in high-income countries. Third-payer perspective was applied in 29% of the studies, 25% used the societal perspective and 12% used both. Only 16% of the studies took indirect effects (i.e. herd immunity) of interventions into account. Intervention, direct healthcare and indirect non-healthcare costs were taken into account in respectively 100%, 81% and 36% of the studies. The majority of the studies followed the Global Burden of Disease method for DALY estimations, but most studies deviated from WHO cost-effectiveness guidelines. Better adherence to freely accessible guidelines will improve generalizability between full economic evaluations.

Quantifying burden of disease to support public health policy in Belgium: opportunities and constraints

BACKGROUND

To support public health policy, information on the burden of disease is essential. In recent years, the Disability-Adjusted Life Year (DALY) has emerged as the most important summary measure of public health. DALYs quantify the number of healthy life years lost due to morbidity and mortality, and thereby facilitate the comparison of the relative impact of diseases and risk factors and the monitoring of public health over time.

DISCUSSION

Evidence on the disease burden in Belgium, expressed as DALYs, is available from international and national efforts. Non-communicable diseases and injuries dominate the overall disease burden, while dietary risks, tobacco smoking, and high body-mass index are the major risk factors for ill health. Notwithstanding these efforts, if DALYs were to be used for guiding health policy, a more systematic approach is required. By integrating DALYs in the current data generating systems, comparable estimates, rooted in recent local data, can be produced. This might however be hampered by several restrictions, such as limited harmonization, timeliness, inclusiveness and accessibility of current databases.

SUMMARY

Routine quantification of disease burden in terms of DALYs would provide a significant added value to evidence-based public health policy in Belgium, although some hurdles need to be cleared.

Road accidents: a third burden of 'disease' in sub-Saharan Africa

Road traffic injuries (RTIs) continue to be a major cause of death and disability throughout low- and middle-income countries (LMICs). The aim of this commentary is highlight some of the major causes of RTIs in sub-Saharan Africa and suggests strategies for better road safety as well as suggestions on how to reduce road accidents in LMICs.

The global burden of mental and substance use disorders: changes in estimating burden between GBD1990 and GBD2010

Background. The main aim of this paper is to compare and contrast the methodological approaches of the new Global Burden of Disease 2010 Study (GBD 2010) with the original study conducted for 1990 (GBD 1990), in terms of calculating burden for mental and substance use disorders. Methods. We reviewed the conceptual and methodological changes to GBD burden calculations in the GBD 2010 study, compared with previous studies. We then discuss the possible implications of these changes with respect to burden estimates for mental and substance use disorders. Results. It is not possible to compare burden estimates arising from the GBD 1990 study with the most recent burden estimates. There have been important advances in the categorisation and definition of mental disorders, and the input and computation of epidemiological models for disease distribution. There have also been major changes to conceptual and social value choices aimed at addressing concerns that arose following publication of earlier GBD studies. Conclusion. Advancements to the GBD conceptual framework and method of calculating burden estimates has led to more accurate and equitable consideration of the burden for mental and substance use disorders. Proposed annual updates of GBD estimates by the Institute of Health Metrics and Evaluation provide an opportunity to continue to advance the evidence base that underpins the quantification of disease burden.