Estimates of global and regional potential health gains from reducing multiple major risk factors

[Epidemiology of acute coronary syndrome in France]

Coronary artery disease remains a major cause of death in France. Epidemiology of acute coronary syndromes (ACS) encompasses the study of trends of mortality, incidence and case fatality. Methodology includes data from populational and hospital registries of ACS. Incidence and mortality rates of ACS are significantly higher in the North than in the South of France. Significant improvement of ACS mortality and hospital case fatality were registered from 1997 to 2002. However, a slow down in ACS incidence rates was shown during the same period and particularly in the South of France. Sudden death continues to be a major health concern due to problems of prevention. Pre-hospital management is also a major source of health inequalities and this merits further analysis of those disparities. Recent data have shown large improvement in acute coronary care but the relatively high rates of ACS incidence stress the need to promote primary prevention and the screening of minor atherosclerosis lesions.

The Hitchhiker's Guide to Tobacco Control: A Global Assessment of Harms, Remedies, and Controversies

One in three adults worldwide (>1.1 billion people) smokes; 80% live in low- and middle-income countries. Tobacco use causes five million deaths each year and, if current smoking patterns continue, will kill 10 million persons annually by 2020. From 1970 to 2000, tobacco leaf production decreased by 36% in developed countries but more than doubled in developing countries. China is the world's leading producer and consumer of tobacco. Seven multinational tobacco companies dominate the world cigarette market, led by Altria, British American Tobacco, and Japan Tobacco, which collectively manufacture more than 2 trillion cigarettes per year. Extensive knowledge exists about effective tobacco control interventions. However, dissemination of best practices and adoption and implementation of recommended policies are fragmentary. The Framework Convention on Tobacco Control (ratified by 140 countries as of October 1, 2006) provides a template outlining the ingredients for a comprehensive tobacco control campaign.

Deaths and years of life lost due to suboptimal breast-feeding among children in the developing world: a global ecological risk assessment

OBJECTIVE

We estimate attributable fractions, deaths and years of life lost among infants and children < or = 2 years of age due to suboptimal breast-feeding in developing countries.

DESIGN

We compare actual practices to a minimum exposure pattern consisting of exclusive breast-feeding for infants < or = 6 months of age and continued breast-feeding for older infants and children < or = 2 years of age. For infants, we consider deaths due to diarrhoeal disease and lower respiratory tract infections, and deaths due to all causes are considered in the second year of life. Outcome measures are attributable fractions, deaths, years of life lost and offsetting deaths potentially caused by mother-to-child transmission of HIV through breast-feeding.

SETTING

Developing countries.

SUBJECTS

Infants and children < or = 2 years of age.

RESULTS

Attributable fractions for deaths due to diarrhoeal disease and lower respiratory tract infections are 55% and 53%, respectively, for the first six months of infancy, 20% and 18% for the second six months, and are 20% for all-cause deaths in the second year of life. Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breast-feeding in developing countries. Offsetting deaths caused by mother-to-child transmission of HIV through breast-feeding could be as high as 242,000 (18.8 million years of life lost) if relevant World Health Organization recommendations are not followed.

CONCLUSIONS

The size of the gap between current practice and recommendations is striking when one considers breast-feeding involves no out-of-pocket costs, that there exists universal consensus on best practices, and that implementing current international recommendations could potentially save 1.45 million children's lives each year.

Using epidemiological models to estimate the health effects of diet behaviour change: the example of tailored fruit and vegetable promotion

Objective

To explore the use of epidemiological modelling for the estimation of health effects of behaviour change interventions, using the example of computer-tailored nutrition education aimed at fruit and vegetable consumption in The Netherlands.

Design

The effects of the intervention on changes in consumption were obtained from an earlier evaluation study. The effect on health outcomes was estimated using an epidemiological multi-state life table model. Input data for the model consisted of relative risk estimates for cardiovascular disease and cancers, data on disease occurrence and mortality, and survey data on the consumption of fruits and vegetables.

Results

If the computer-tailored nutrition education reached the entire adult population and the effects were sustained, it could result in a mortality decrease of 0.4 to 0.7% and save 72 to 115 life-years per 100 000 persons aged 25 years or older. Healthy life expectancy is estimated to increase by 32.7 days for men and 25.3 days for women. The true effect is likely to lie between this theoretical maximum and zero effect, depending mostly on durability of behaviour change and reach of the intervention.

Conclusion

Epidemiological models can be used to estimate the health impact of health promotion interventions.

The burden of cardiovascular disease and cancer attributable to low fruit and vegetable intake in the European Union: differences between old and new Member States

Objective

To estimate the burden of disease attributable to low fruit and vegetable intake in the 15 countries that were members of the European Union (EU) before May 2004 (EU-15) and the 10 countries that then joined it (EU-10).

Design

Data on fruit and vegetable intake, target levels of intake and estimates of relative risks, deaths and disability were combined to obtain the burden of ischaemic heart disease, ischaemic stroke and four types of cancer (lung/bronchus/trachea, stomach, oesophagus, and colon/rectum) attributable to low fruit and vegetable consumption.

Setting

EU-15 and EU-10 Member States.

Results

The number of lives potentially saved annually from the selected outcomes if fruit and vegetable intake increased to 600 g person−1 day−1 reached 892 000 and 423 000 in the EU-15 and EU-10, respectively; total disease burden could decrease by 1.9% and 3.6%, respectively. The burden of ischaemic heart disease and stroke could be reduced by up to 17% and 10%, respectively, in the EU-15 and by 24% and 15%, respectively, in the EU-10; potential reductions for the selected cancers varied from 1% to 12% in the EU-15 and from 2% to 17% in the EU-10.

Conclusions

The potential health gain of increased fruit and vegetable intake is particularly large in the new Member States, and particularly high for cardiovascular diseases, a main cause of health divide in Europe. This stresses the need for better nutrition programmes and policies that take account of economic, social and cultural specificities.

Association between polymorphisms of ACE, B2AR, ANP and ENOS and cardiovascular diseases: a community-based study in the Matsu area

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in most countries of the world. In this study, associations between CVDs and polymorphisms of angiotensin-converting enzyme (ACE), atrial natriuretic peptide (ANP), beta(2)-adrenal receptor (B2AR) and endothelial nitric oxide synthase (ENOS) genes were explored in a community-based setting.

METHODS

Between March and May 2001, 1740 subjects > or =35 years from the Matsu area in Taiwan were recruited to this study, representing 71.6% of the target population in Matsu. After informed consent was obtained during an interview, physical examination, resting ECG, serum biochemical profile and a questionnaire survey were used to obtain information. Genomic DNA was also collected and analyzed. Owing to technical limitations, 1186 samples were analyzed. Genetic polymorphisms of the genes in question were investigated using PCR and restriction fragment length polymorphism (RFLP). The distribution of allele frequencies for these genes was derived for stroke, coronary artery disease, hypertension, diabetes, hypercholesterolemia, hypertriglyceridemia and overweight subgroups.

RESULTS

The ENOS Glu298Asp polymorphism was associated with hypercholesterolemia (odds ratio 0.658, 95%CI 0.460-0.940; p=0.025) and the ACE D/I variant was associated with hypertriglyceridemia (odds ratio 0.722, 95%CI 0.536-0.973; p=0.033). Polymorphisms of the other genes were not associated with any of the disease groups.

CONCLUSIONS

This community-based study reveals that genetic factors might play a role in the metabolism of lipids. The genetic risk for CVDs needs further investigation.

Sexual behaviour in context: a global perspective

Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.

Estimating health-adjusted life expectancy conditional on risk factors: results for smoking and obesity

Background

Smoking and obesity are risk factors causing a large burden of disease. To help formulate and prioritize among smoking and obesity prevention activities, estimations of health-adjusted life expectancy (HALE) for cohorts that differ solely in their lifestyle (e.g. smoking vs. non smoking) can provide valuable information. Furthermore, in combination with estimates of life expectancy (LE), it can be tested whether prevention of obesity and smoking results in compression of morbidity.

Methods

Using a dynamic population model that calculates the incidence of chronic disease conditional on epidemiological risk factors, we estimated LE and HALE at age 20 for a cohort of smokers with a normal weight (BMI < 25), a cohort of non-smoking obese people (BMI>30) and a cohort of 'healthy living' people (i.e. non smoking with a BMI < 25). Health state valuations for the different cohorts were calculated using the estimated disease prevalence rates in combination with data from the Dutch Burden of Disease study. Health state valuations are multiplied with life years to estimate HALE. Absolute compression of morbidity is defined as a reduction in unhealthy life expectancy (LE-HALE) and relative compression as a reduction in the proportion of life lived in good health (LE-HALE)/LE.

Results

Estimates of HALE are highest for a 'healthy living' cohort (54.8 years for men and 55.4 years for women at age 20). Differences in HALE compared to 'healthy living' men at age 20 are 7.8 and 4.6 for respectively smoking and obese men. Differences in HALE compared to 'healthy living' women at age 20 are 6.0 and 4.5 for respectively smoking and obese women. Unhealthy life expectancy is about equal for all cohorts, meaning that successful prevention would not result in absolute compression of morbidity. Sensitivity analyses demonstrate that although estimates of LE and HALE are sensitive to changes in disease epidemiology, differences in LE and HALE between the different cohorts are fairly robust. In most cases, elimination of smoking or obesity does not result in absolute compression of morbidity but slightly increases the part of life lived in good health.

Conclusion

Differences in HALE between smoking, obese and 'healthy living' cohorts are substantial and similar to differences in LE. However, our results do not indicate that substantial compression of morbidity is to be expected as a result of successful smoking or obesity prevention.

Hypertension in the developing world: A consequence of progress

Hypertension is one of the leading causes of death and disability in developing countries. The increasing burden of hypertension in these countries has been attributed to several indicators of economic progress such as increased life expectancy, urbanization and its attendant lifestyle changes, and the overall epidemiologic transition these countries are experiencing currently. The public health response to this challenge must be to promote health among all sections of the populations of these countries, and a concerted effort to promote awareness about hypertension, its risk factors, and risk behaviors. The health policies of these countries need to be reoriented to include chronic diseases in their ambit. These efforts have the potential to reduce the emergence or lessen the toll of hypertension and its complication in many parts of the developing world.

An epidemiologic model of severe morbidity and mortality caused by Plasmodium falciparum

The intensity of Plasmodium falciparum transmission has multifarious and sometimes counter-intuitive effects on age-specific rates of severe morbidity and mortality in endemic areas. This has led to conflicting speculations about the likely impact of malaria control interventions. We propose a quantitative framework to reconcile the various apparently contradictory observations relating morbidity and mortality rates to malaria transmission. Our model considers two sub-categories of severe malaria episodes. These comprise episodes with extremely high parasite densities in hosts with little previous exposure, and acute malaria episodes accompanied by co-morbidity or other risk factors enhancing susceptibility. In addition to direct malaria mortality from severe malaria episodes, the model also considers the enhanced risk of indirect mortality following acute episodes accompanied by co-morbidity after the parasites have been cleared. We fit this model to summaries of field data from endemic areas of Africa, and show that it can account for the observed age- and exposure-specific patterns of pediatric severe malaria and malaria-associated mortality in children. This model will allow us to make predictions of the long-term impact of potential malaria interventions. Predictions for children will be more reliable than those for older people because there is a paucity of epidemiologic studies of adults and adolescents.

Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States

BACKGROUND

The gap between the highest and lowest life expectancies for race-county combinations in the United States is over 35 y. We divided the race-county combinations of the US population into eight distinct groups, referred to as the "eight Americas," to explore the causes of the disparities that can inform specific public health intervention policies and programs.

METHODS AND FINDINGS

The eight Americas were defined based on race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate. Data sources for population and mortality figures were the Bureau of the Census and the National Center for Health Statistics. We estimated life expectancy, the risk of mortality from specific diseases, health insurance, and health-care utilization for the eight Americas. The life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was 20.7 y in 2001. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 y for males (Asians versus high-risk urban blacks) and 12.8 y for females (Asians versus low-income southern rural blacks). Mortality disparities among the eight Americas were largest for young (15-44 y) and middle-aged (45-59 y) adults, especially for men. The disparities were caused primarily by a number of chronic diseases and injuries with well-established risk factors. Between 1982 and 2001, the ordering of life expectancy among the eight Americas and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged. Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. Crude self-reported health-care utilization, however, was slightly higher for the more disadvantaged populations.

CONCLUSIONS

Disparities in mortality across the eight Americas, each consisting of millions or tens of millions of Americans, are enormous by all international standards. The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. Because policies aimed at reducing fundamental socioeconomic inequalities are currently practically absent in the US, health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

National and sub-national under-five mortality profiles in Peru: a basis for informed policy decisions

Background

Information on profiles for under-five causes of death is important to guide choice of child-survival interventions. Global level data have been published, but information at country level is scarce. We aimed at defining national and departmental trends and profiles of under-five mortality in Peru from 1996 through 2000.

Methods

We used the Ministry of Health registered under-five mortality data. For correction of under-registration, a model life-table that fitted the age distribution of the population and of registered deaths was identified for each year. The mortality rates corresponding to these model life-tables were then assigned to each department in each particular year. Cumulative reduction in under-five mortality rate in the 1996–2000 period was estimated calculating the annual reduction slope for each department. Departmental level mortality profiles were constructed. Differences in mortality profiles and in mortality reduction between coastal, andean and jungle regions were also assessed.

Results

At country level, only 4 causes (pneumonia, diarrhoea, neonatal diseases and injuries) accounted for 68% of all deaths in 1996, and for 62% in 2000. There was 32.7% of under-five death reduction from 1996 to 2000. Diarrhoea and pneumonia deaths decreased by 84.5% and 41.8%, respectively, mainly in the andean region, whereas deaths due to neonatal causes and injuries decreased by 37.2% and 21.7%. For 1996–2000 period, the andean, coast and jungle regions accounted for 52.4%, 33.1% and 14.4% of deaths, respectively. These regions represent 41.0%, 46.4% and 12.6% of under-five population. Both diarrhoea and pneumonia constitute 30.6% of under-five deaths in the andean region. As a proportion, neonatal deaths remained stable in the country from 1996 to 2000, accounting for about 30% of under-five deaths, whereas injuries and "other" causes, including congenital anomalies, increased by about 5%.

Conclusion

Under-five mortality declined substantially in all departments from 1996 to 2000, which is explained mostly by reduction in diarrhoea and pneumonia deaths, particularly in the andean region. There is the need to emphasize interventions to reduce neonatal deaths and emerging causes of death such as injuries and congenital anomalies.

Potential new risk factors for ischemic stroke: what is their potential?

BACKGROUND AND PURPOSE

About 60% to 80% of all ischemic strokes can be attributed to increasing blood pressure, blood cholesterol, cigarette smoking, carotid stenosis, and diabetes mellitus (atherosclerotic ischemic stroke), and atrial fibrillation and valvular heart disease (cardiogenic ischemic stroke). The aim of this review was to examine the potential role of other risk factors in the etiology of ischemic stroke.

SUMMARY OF REVIEW

About 10% to 20% of atherosclerotic ischemic strokes can probably be attributed to recently established, causal risk factors for ischemic heart disease: raised apoB/apoA 1 ratio, obesity, physical inactivity, pyschosocial stress and low fruit and vegetable intake. However, their causal role remains to be proven. The direct genetic contribution of any single gene towards ischemic stroke is likely to be modest and apply in selected patients only and in combination with environmental factors or via other epistatic (gene-gene or gene-environmental) effects.

CONCLUSIONS

Research resources should not be allocated disproportionately to emerging novel risk factors that may account for up to only 20% of all strokes at the expense of researching the determinants of the relatively few established causal factors that account for up to 80% of all strokes.

Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data

BACKGROUND

Our aim was to calculate the global burden of disease and risk factors for 2001, to examine regional trends from 1990 to 2001, and to provide a starting point for the analysis of the Disease Control Priorities Project (DCPP).

METHODS

We calculated mortality, incidence, prevalence, and disability adjusted life years (DALYs) for 136 diseases and injuries, for seven income/geographic country groups. To assess trends, we re-estimated all-cause mortality for 1990 with the same methods as for 2001. We estimated mortality and disease burden attributable to 19 risk factors.

FINDINGS

About 56 million people died in 2001. Of these, 10.6 million were children, 99% of whom lived in low-and-middle-income countries. More than half of child deaths in 2001 were attributable to acute respiratory infections, measles, diarrhoea, malaria, and HIV/AIDS. The ten leading diseases for global disease burden were perinatal conditions, lower respiratory infections, ischaemic heart disease, cerebrovascular disease, HIV/AIDS, diarrhoeal diseases, unipolar major depression, malaria, chronic obstructive pulmonary disease, and tuberculosis. There was a 20% reduction in global disease burden per head due to communicable, maternal, perinatal, and nutritional conditions between 1990 and 2001. Almost half the disease burden in low-and-middle-income countries is now from non-communicable diseases (disease burden per head in Sub-Saharan Africa and the low-and-middle-income countries of Europe and Central Asia increased between 1990 and 2001). Undernutrition remains the leading risk factor for health loss. An estimated 45% of global mortality and 36% of global disease burden are attributable to the joint hazardous effects of the 19 risk factors studied. Uncertainty in all-cause mortality estimates ranged from around 1% in high-income countries to 15-20% in Sub-Saharan Africa. Uncertainty was larger for mortality from specific diseases, and for incidence and prevalence of non-fatal outcomes.

INTERPRETATION

Despite uncertainties about mortality and burden of disease estimates, our findings suggest that substantial gains in health have been achieved in most populations, countered by the HIV/AIDS epidemic in Sub-Saharan Africa and setbacks in adult mortality in countries of the former Soviet Union. Our results on major disease, injury, and risk factor causes of loss of health, together with information on the cost-effectiveness of interventions, can assist in accelerating progress towards better health and reducing the persistent differentials in health between poor and rich countries.

Blood pressure and the global burden of disease 2000. Part II: estimates of attributable burden

OBJECTIVES

To provide estimates of the global burden of disease attributable to non-optimal blood pressure by age and sex for adults aged > or = 30 years, by WHO subregion.

METHODS

Estimates of attributable burden were made using population impact fractions, which used data on mean systolic blood pressure levels, disease burden [in deaths and/or disability-adjusted life years (DALYs)] and relative risk corrected for regression dilution bias. Estimates were made of burden attributable to a population distribution of blood pressure with a mean systolic blood pressure of greater than 115 mmHg.

RESULTS

Globally, approximately two-thirds of stroke and one-half of ischaemic heart disease were attributable to non-optimal blood pressure. These proportions were highest in the more developed parts of the world. Worldwide, 7.1 million deaths (approximately 12.8% of the global total) and 64.3 million DALYs (4.4% of the global total) were estimated to be due to non-optimal blood pressure. Overall approximately, two-thirds of the attributable burden of disease occurred in the developing world, approximately two-thirds in the middle age groups (45-69 years) and approximately one-half occurred in those with systolic blood pressure levels between 130 and 150 mmHg.

CONCLUSIONS

The burden of non-optimal blood pressure is almost double that of the only previous global estimates, which is largely explained by the correction for regression dilution adopted in these analyses. High blood pressure is a leading cause of global burden of disease, and most of it occurs in the developing world.

Success in control of hypertension in a low-resource setting: the Cuban experience

BACKGROUND

Pharmacologic control of hypertension is an essential component of the current strategy to control cardiovascular diseases. Much concern has been focused in recent years on the challenge that cardiovascular disease poses for developing countries. Available medical therapies should be equally effective in low- and high-resource settings; however, this has not yet been demonstrated. Cuba has a well-organized primary-care system and has made reduction of cardiovascular diseases a priority, particularly through detection and treatment of hypertension.

METHODS

To determine current hypertension control rates a population-based sample of 1667 persons aged 15-74 years was examined in the city of Cienfuegos.

RESULTS

The prevalence of hypertension, weighted to the age structure of the sampled population, was 20%. Among all hypertensives, 78% were previously aware of the condition, 61% were currently taking medications, and 40% had systolic/diastolic blood pressures < 140/90 mmHg (men = 29%, women = 49%). Among treated hypertensives, 62% had blood pressures < 140/90 mmHg.

DISCUSSION

The level of control documented in this survey is higher than reported previously from population surveys in other countries. If confirmed in broader samples in Cuba, these findings would suggest that effective control of hypertension is highly feasible in low-resource settings.

Smoking particles enhance endothelin A and endothelin B receptor-mediated contractions by enhancing translation in rat bronchi

Background

Smoking is known to cause chronic inflammatory changes in the bronchi and to contribute to airway hyper-reactivity, such as in bronchial asthma. To study the effect of smoking on the endothelin system in rat airways, bronchial segments were exposed to DMSO-soluble smoking particles (DSP) from cigarette smoke, to nicotine and to DMSO, respectively.

Methods

Isolated rat bronchial segments were cultured for 24 hours in the presence or absence of DSP, nicotine or DMSO alone. Contractile responses to sarafotoxin 6c (a selective agonist for ET_B receptors) and endothelin-1 (an ET_A and ET_B receptor agonist) were studied by use of a sensitive myograph. Before ET-1 was introduced, the ET_B receptors were desensitized by use of S6c. The remaining contractility observed was considered to be the result of selective activation of the ET_A receptors. ET_A and ET_B receptor mRNA expression was analyzed using real-time quantitative PCR. The location and concentration of ET_A and ET_B receptors were studied by means of immunohistochemistry together with confocal microscopy after overnight incubation with selective antibodies.

Results

After being cultured together with DSP for 24 hours the bronchial segments showed an increased contractility mediated by ET_A and ET_B receptors, whereas culturing them together with nicotine did not affect their contractility. The up-regulation of their contractility was blunted by cycloheximide treatment, a translational inhibitor. No significant change in the expression of ET_A and ET_B receptor mRNA through exposure to DMSO or to nicotine exposure alone occurred, although immunohistochemistry revealed a clear increase in ET_A and ET_B receptors in the smooth muscle after incubation in the presence of DSP. Taken as a whole, this is seen as the presence of a translation mechanism.

Conclusion

The increased contractility of rat bronchi when exposed to DSP appears to be due to a translation mechanism.

Cardiovascular disease and global health: threat and opportunity

The transition in global health from infectious to chronic disease, especially cardiovascular disease, poses a threat to the economies of the less developed world. As a more sophisticated workforce becomes a highly valued and harder-to-replace economic investment, the increasing prevalence of cardiovascular risk factors becomes a threat to economic development. The next two decades offer a critical period for intervention to blunt the impact of these diseases. The response of the global assistance community has been inadequate and without impact. A new global health assistance paradigm is needed to support long-term prevention strategies to combat this epidemic.

Psychosocial work environment and registered absence from work: estimating the etiologic fraction

BACKGROUND

Evidence is growing that an adverse psychosocial work environment increases sickness absence, but little is known on the magnitude of this problem or the impact of specific factors.

METHODS

Psychological demands, decision authority, skill discretion, social support from colleagues or supervisor, predictability, and meaning of work were assessed with questionnaires at baseline and sickness absence was followed-up in employers' registers for 1,919 respondents (response rate 75.2%, 68% women, mainly low-skilled jobs) from 52 Danish workplaces during a 2-year period. Etiologic fractions (EFs) were calculated with the most favorable quartiles as reference.

RESULTS

In the fully adjusted model, the following EFs were found: decision authority: 12%; social support from supervisors: 8%; psychological demands: 6%; and predictability: 5%. In total, the seven psychosocial factors explained 29% of all sick-leave days.

CONCLUSIONS

The results suggest that improving the psychosocial work environment among the less favorable 75% may prevent substantial amounts of absence.

The association between burnout, depression, anxiety, and inflammation biomarkers: C-reactive protein and fibrinogen in men and women

Following the demonstrated association of employee burnout or vital exhaustion with several risk factors for cardiovascular disease (CVD) and CVD risk, the authors investigated the possibility that one of the mechanisms linking burnout with CVD morbidity is microinflammation, gauged in this study by high-sensitivity C-reactive protein (hs-CRP) and fibrinogen concentrations. Their sample included 630 women and 933 men, all apparently healthy, who underwent periodic health examinations. The authors controlled for possible confounders including 2 other negative affective states: depression and anxiety. In women, burnout was positively associated with hs-CRP and fibrinogen concentrations, and anxiety was negatively associated with them. In men, depression was positively associated with hs-CRP and fibrinogen concentrations, but not with burnout or anxiety. Thus, burnout, depression, and anxiety are differentially associated with microinflammation biomarkers, dependent on gender.

Nutrition and the burden of disease in New Zealand: 1997-2011

OBJECTIVE

To estimate the burden of disease due to selected nutrition-related risk factors (high total blood cholesterol, high systolic blood pressure, high body mass index (BMI) and inadequate vegetable and fruit intake) in 1997, as well as the burden that could potentially be avoided in 2011 if small, favourable changes in the current risk factor distribution were to occur.

DESIGN

Data on risk factor levels, disease burden and risk associations were combined using comparative risk assessment methodology, a systematic approach to estimating both attributable and avoidable burden of disease. Disease outcomes assessed varied according to risk factor and included ischaemic heart disease, stroke, type 2 diabetes mellitus and selected cancers.

SETTING

New Zealand.

RESULTS

Approximately 4500 deaths (17% of all deaths) in 1997 were attributable to high cholesterol, 3500 (13%) to high blood pressure, 3000 (11%) to high BMI and 1500 (6%) to inadequate vegetable and fruit intake. Taking prevalence overlap into account, these risk factors were estimated jointly to contribute to approximately 11 000 (40%) deaths annually in New Zealand. Approximately 300 deaths due to each risk factor could potentially be avoided in 2011 if modest changes were made to each risk factor distribution.

CONCLUSIONS

High cholesterol, blood pressure and BMI, as well as inadequate vegetable and fruit intake, are major modifiable causes of death in New Zealand. Small changes in the population distribution of these risk factors could have a major impact on population health within a decade.

Joint Effects of Systolic Blood Pressure and Serum Cholesterol on Cardiovascular Disease in the Asia Pacific Region

BACKGROUND

Although interest in multifactorial interventions for cardiovascular disease is increasing, data on the strength and shape of the joint effects of blood pressure and cholesterol levels on the risk of cardiovascular disease are scarce, confined primarily to coronary heart disease (CHD) mortality in early middle-aged Western populations.

METHODS AND RESULTS

This analysis included 29 cohorts from Asia (78% of the total 380,216 participants) and 7 from Australia and New Zealand, with a total of 2,547,447 person-years of observation. Stratified time-dependent Cox proportional-hazards analyses were used to regress time until first event against baseline systolic blood pressure (SBP) and total cholesterol levels. A total of 3079 CHD and 4247 stroke events occurred; stroke subtypes were confirmed by CT, MRI, or necropsy in 1471 (35%) stroke events. Usual values of SBP were strongly linearly associated with ischemic stroke, hemorrhagic stroke, and CHD. The slope of the association with SBP became steeper with decreasing levels of cholesterol for ischemic stroke (P=0.007) and CHD (P< or =0.0001). For example, for the cholesterol groups of <4.75, 4.75 to 5.49, 5.50 to 6.24, and > or =6.25 mmol/L, each 10-mm Hg-higher systolic pressure was associated with 34% (95% CI, 30% to 37%), 28% (95% CI, 21% to 35%), 25% (95% CI, 18% to 32%), and 21% (95% CI, 13% to 27%) higher CHD risk, respectively. Adjustments for other leading cardiovascular risk factors made no appreciable differences in these results.

CONCLUSIONS

In Asia-Pacific populations, there are hazards of increasing SBP at all cholesterol levels and hazards of increasing cholesterol at all levels of SBP, but the associations of SBP with CHD risk and ischemic stroke risk are slightly steeper among those with low cholesterol levels. The joint effects of SBP and total cholesterol on cardiovascular disease seem consistent across various Western and Asian populations.

Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study)

BACKGROUND

Acute coronary, cerebrovascular, and peripheral vascular events have common underlying arterial pathology, risk factors, and preventive treatments, but they are rarely studied concurrently. In the Oxford Vascular Study, we determined the comparative epidemiology of different acute vascular syndromes, their current burdens, and the potential effect of the ageing population on future rates.

METHODS

We prospectively assessed all individuals presenting with an acute vascular event of any type in any arterial territory irrespective of age in a population of 91 106 in Oxfordshire, UK, in 2002-05.

FINDINGS

2024 acute vascular events occurred in 1657 individuals: 918 (45%) cerebrovascular (618 stroke, 300 transient ischaemic attacks [TIA]); 856 (42%) coronary vascular (159 ST-elevation myocardial infarction, 316 non-ST-elevation myocardial infarction, 218 unstable angina, 163 sudden cardiac death); 188 (9%) peripheral vascular (43 aortic, 53 embolic visceral or limb ischaemia, 92 critical limb ischaemia); and 62 unclassifiable deaths. Relative incidence of cerebrovascular events compared with coronary events was 1.19 (95% CI 1.06-1.33) overall; 1.40 (1.23-1.59) for non-fatal events; and 1.21 (1.04-1.41) if TIA and unstable angina were further excluded. Event and incidence rates rose steeply with age in all arterial territories, with 735 (80%) cerebrovascular, 623 (73%) coronary, and 147 (78%) peripheral vascular events in 12 886 (14%) individuals aged 65 years or older; and 503 (54%), 402 (47%), and 105 (56%), respectively, in the 5919 (6%) aged 75 years or older. Although case-fatality rates increased with age, 736 (47%) of 1561 non-fatal events occurred at age 75 years or older.

INTERPRETATION

The high rates of acute vascular events outside the coronary arterial territory and the steep rise in event rates with age in all territories have implications for prevention strategies, clinical trial design, and the targeting of funds for service provision and research.

Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors

INTRODUCTION

With respect to reducing mortality, advances in cancer treatment have not been as effective as those for other chronic diseases; effective screening methods are available for only a few cancers. Primary prevention through lifestyle and environmental interventions remains the main way to reduce the burden of cancers. In this report, we estimate mortality from 12 types of cancer attributable to nine risk factors in seven World Bank regions for 2001.

METHODS

We analysed data from the Comparative Risk Assessment project and from new sources to assess exposure to risk factors and relative risk by age, sex, and region. We applied population attributable fractions for individual and multiple risk factors to site-specific cancer mortality from WHO.

FINDINGS

Of the 7 million deaths from cancer worldwide in 2001, an estimated 2.43 million (35%) were attributable to nine potentially modifiable risk factors. Of these, 0.76 million deaths were in high-income countries and 1.67 million in low-and-middle-income nations. Among low-and-middle-income regions, Europe and Central Asia had the highest proportion (39%) of deaths from cancer attributable to the risk factors studied. 1.6 million of the deaths attributable to these risk factors were in men and 0.83 million in women. Smoking, alcohol use, and low fruit and vegetable intake were the leading risk factors for death from cancer worldwide and in low-and-middle-income countries. In high-income countries, smoking, alcohol use, and overweight and obesity were the most important causes of cancer. Sexual transmission of human papilloma virus is a leading risk factor for cervical cancer in women in low-and-middle-income countries.

INTERPRETATION

Reduction of exposure to key behavioural and environmental risk factors would prevent a substantial proportion of deaths from cancer.

Improvement in household stoves and risk of chronic obstructive pulmonary disease in Xuanwei, China: retrospective cohort study

OBJECTIVE

To test whether improvement in household coal stoves affected the incidence of chronic obstructive pulmonary disease (COPD) in Xuanwei County, China.

DESIGN

Retrospective cohort study (follow-up 1976-92) comparing incidence of COPD between groups with and without chimneys.

PARTICIPANTS

20,453 people born into homes with unvented coal stoves;16,606 (81.2%) subsequently changed to stoves with chimneys.

INTERVENTION

Installation of a chimney in households in which unvented stoves had been used previously.

RESULTS

Installation of a chimney was associated with distinct reduction in the incidence of COPD. Compared with people who did not have chimneys, the Cox-modelled risk ratio (relative risk) was 0.58 (95% confidence interval 0.49 to 0.70, P < 0.001) in men and 0.75 (0.62 to 0.92, P = 0.005) in women. Modelled risk ratios were robust to different Cox model specifications. Relative risks decreased with time since stove improvement. In both sexes, the reduction in risk became unequivocal about 10 years after stove improvement.

CONCLUSIONS

In Xuanwei, incidence of COPD decreased markedly after household coal stoves were improved.

Therapeutic lifestyle changes and drug treatment for high blood cholesterol in China and application of the Adult Treatment Panel III guidelines

The prevalence of elevated blood cholesterol in China has increased during the past several decades. We estimated the percentage of the Chinese population for whom therapeutic lifestyle changes and drug therapy to lower blood cholesterol should be considered by applying the United States' National Cholesterol Education Panel's Adult Treatment Panel III guidelines to a nationally representative sample of the Chinese population from the International Collaborative Study of Cardiovascular Disease in Asia. Serum samples were collected for 14,919 Chinese adults, 35 to 74 years old, in 2000 and 2001, after an overnight fast of > or =8 hours and their low-density lipoprotein (LDL) cholesterol level was calculated using the Freidewald equation. Using the Adult Treatment Panel III guidelines, 85.9 million Chinese adults (18.2%) should initiate therapeutic lifestyle changes to lower their LDL cholesterol and 35.0 million (7.4%) should be considered for lifestyle changes and lipid-lowering drug therapy. Of those for whom drug therapy should be considered, 4.7 million (13.4%) reported having been told they had "high cholesterol" by a healthcare provider and 1.6 million (33.7% of those aware of their high cholesterol) were receiving lipid-lowering medication-leaving 33.4 million Chinese adults with untreated elevated LDL cholesterol (95.5% of those with elevated LDL cholesterol). A 10% population-wide reduction in LDL cholesterol would reduce the number of Chinese adults who should be considered for drug therapy by 45% to 19.3 million (4.1% of adults). In conclusion, most adults in China with an elevated LDL cholesterol remain untreated.

[Total risk for cardiovascular disease. At what point is medical prophylactic medication useful?]

Despite the epidemiological importance of coronary artery disease: cardiovascular events are rare from the individual viewpoint. There is considerable uncertainty when to start medical treatment. A given risk factor modification results in a relative risk reduction independent of the global risk. Therefore the global risk determines the absolute benefit of a preventive measure. The global risk can be estimated using different scoring systems. Using the global risk and the expected relative risk reduction, the number needed to treat (NNT) to avoid one event or cardiac death can be calculated. The NNT is a measure for the usefulness of a preventive intervention. A NNT of <200 appears acceptable for primary prevention. This can be achieved with pharmacological preventive strategies if the global risk of 10 years is > or =20%. As age is one of the most important risk predictors the need for treatment at comparable risk factor constellations is age dependent. Risk stratification with estimation of the NNT is therefore important for the decision to treat or not to treat.

Role of smoking in global and regional cancer epidemiology: current patterns and data needs

Although smoking is widely recognized as a major cause of cancer, there is little information on how it contributes to the global and regional burden of cancers in combination with other risk factors that affect background cancer mortality patterns. We used data from the American Cancer Society's Cancer Prevention Study II (CPS-II) and the WHO and IARC cancer mortality databases to estimate deaths from 8 clusters of site-specific cancers caused by smoking, for 14 epidemiologic subregions of the world, by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.42 (95% CI 1.27-1.57) million cancer deaths in the world, 21% of total global cancer deaths, were caused by smoking. Of these, 1.18 million deaths were among men and 0.24 million among women; 625,000 (95% CI 485,000-749,000) smoking-caused cancer deaths occurred in the developing world and 794,000 (95% CI 749,000-840,000) in industrialized regions. Lung cancer accounted for 60% of smoking-attributable cancer mortality, followed by cancers of the upper aerodigestive tract (20%). Based on available data, more than one in every 5 cancer deaths in the world in the year 2000 were caused by smoking, making it possibly the single largest preventable cause of cancer mortality. There was significant variability across regions in the role of smoking as a cause of the different site-specific cancers. This variability illustrates the importance of coupling research and surveillance of smoking with that for other risk factors for more effective cancer prevention.

Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis

BACKGROUND

Few studies have tried to assess the combined cross-sectional and temporal contributions of a more comprehensive set of amenable factors to population health outcomes for wealthy countries during the last 30 years of the 20th century. We assessed the overall ecological associations between mortality and factors amenable to public health. These amenable factors included addictive and nutritional lifestyle, air quality, public health spending, healthcare coverage, and immunizations.

METHODS

We used a pooled cross-sectional, time series analysis with corrected fixed effects regression models in an ecological design involving eighteen member countries of the Organisation for Economic Cooperation and Development during the period 1970 to 1999.

RESULTS

Alcohol, tobacco, and fat consumption, and sometimes, air pollution were significantly associated with higher all-cause mortality and premature death. Immunizations, health care coverage, fruit/vegetable and protein consumption, and collective health expenditure had negative effects on mortality and premature death, even after controlling for the elderly, density of practicing physicians, doctor visits and per capita GDP. However, tobacco, air pollution, and fruit/vegetable intake were sometimes sensitive to adjustments.

CONCLUSION

Mortality and premature deaths could be improved by focusing on factors that are amenable to public health policies. Tackling these issues should be reflected in the ongoing assessments of health system performance.

Role of Smoking in Global and Regional Cardiovascular Mortality

Background— Smoking is a major cause of cardiovascular disease mortality. There is little information on how it contributes to global and regional cause-specific mortality from cardiovascular diseases for which background risk varies because of other risks.

Method and Results— We used data from the American Cancer Society’s Cancer Prevention Study II (CPS II) and the World Health Organization Global Burden of Disease mortality database to estimate smoking-attributable deaths from ischemic heart disease, cerebrovascular disease, and a cluster of other cardiovascular diseases for 14 epidemiological subregions of the world by age and sex. We used lung cancer mortality as an indirect marker for accumulated smoking hazard. CPS-II hazards were adjusted for important covariates. In the year 2000, an estimated 1.62 (95% CI, 1.27 to 2.04) million cardiovascular deaths in the world, 11% of total global cardiovascular deaths, were due to smoking. Of these, 1.17 million deaths were among men and 450 000 among women. There were 670 000 (95% CI, 440 000 to 920 000) smoking-attributable cardiovascular deaths in the developing world and 960 000 (95% CI, 770 000 to 1 200 000) in industrialized regions. Ischemic heart disease accounted for 54% of smoking-attributable cardiovascular mortality, followed by cerebrovascular disease (25%). There was variability across regions in the role of smoking as a cause of various cardiovascular diseases.

Conclusions— More than 1 in every 10 cardiovascular deaths in the world in the year 2000 were attributable to smoking, demonstrating that it is an important preventable cause of cardiovascular mortality.

Health utility ratings for a spectrum of alcohol-related health states

BACKGROUND

Preference-based utility ratings for health conditions are important components of cost-utility analyses and population burden of disease estimates. However, utility ratings for alcohol problems have not been determined.

OBJECTIVES

The objectives of this study were to directly measure utility ratings for a spectrum of alcohol-related health states and to compare different methods of utility measurement.

DESIGN, SETTING, AND SUBJECTS

The authors conducted a cross-sectional interview of 200 adults from a clinic and community sample.

METHODS

Subjects completed computerized visual analog scale (VAS), time tradeoff (TTO), and standard gamble (SG) utility measurement exercises for their current health, a blindness scenario, and for 6 alcohol-related health state scenarios presented in random order. The main outcome measures were the utility ratings, scaled from 0 to 1, and anchored by death (0) and perfect health (1).

RESULTS

The 200 subjects were middle-aged (mean, 41 +/- 14 years), 61% women, and racially diverse (48% black, 43% white). Utility ratings decreased as the severity of the alcohol-related health state increased, but differed significantly among the VAS, TTO, and SG methods within each health state. Adjusted mean (95% confidence interval) utility ratings for alcohol dependence (VAS, 0.38 [0.34-0.41]; TTO, 0.54 [0.48-0.60]; SG, 0.68 [0.63-0.73]) and alcohol abuse (VAS, 0.53 [0.49-0.56]; TTO, 0.71 [0.65-77]; SG, 0.76 [0.71-0.81]) were significantly lower than utility ratings for nondrinking, moderate drinking, at-risk drinking, current health, and blindness.

CONCLUSIONS

Utility ratings for alcohol-related health states decrease as the severity of alcohol use increases. The low utility ratings for alcohol abuse and alcohol dependence are similar to those reported for other severe chronic medical conditions.

Rethinking the "diseases of affluence" paradigm: global patterns of nutritional risks in relation to economic development

BACKGROUND

Cardiovascular diseases and their nutritional risk factors--including overweight and obesity, elevated blood pressure, and cholesterol--are among the leading causes of global mortality and morbidity, and have been predicted to rise with economic development.

METHODS AND FINDINGS

We examined age-standardized mean population levels of body mass index (BMI), systolic blood pressure, and total cholesterol in relation to national income, food share of household expenditure, and urbanization in a cross-country analysis. Data were from a total of over 100 countries and were obtained from systematic reviews of published literature, and from national and international health agencies. BMI and cholesterol increased rapidly in relation to national income, then flattened, and eventually declined. BMI increased most rapidly until an income of about ID 5,000 (international dollars) and peaked at about ID 12,500 for females and ID 17,000 for males. Cholesterol's point of inflection and peak were at higher income levels than those of BMI (about ID 8,000 and ID 18,000, respectively). There was an inverse relationship between BMI/cholesterol and the food share of household expenditure, and a positive relationship with proportion of population in urban areas. Mean population blood pressure was not correlated or only weakly correlated with the economic factors considered, or with cholesterol and BMI.

CONCLUSIONS

When considered together with evidence on shifts in income-risk relationships within developed countries, the results indicate that cardiovascular disease risks are expected to systematically shift to low-income and middle-income countries and, together with the persistent burden of infectious diseases, further increase global health inequalities. Preventing obesity should be a priority from early stages of economic development, accompanied by population-level and personal interventions for blood pressure and cholesterol.

Origins of the "black/white" difference in blood pressure: roles of birth weight, postnatal growth, early blood pressure, and adolescent body size: the Bogalusa heart study

BACKGROUND

The determinants of differences in blood pressure that emerge in adolescence between black Americans of predominantly African descent and white Americans of predominantly European descent are unknown. One hypothesis is related to intrauterine and early childhood growth. The role of early blood pressure itself is also unclear. We tested whether differences in birth weight and in carefully standardized subsequent measures of weight, height, and blood pressure from 0 to 4 or 5 years were related to black/white differences in blood pressure in adolescence.

METHODS AND RESULTS

Two Bogalusa cohorts who had complete follow-up data on birth weights and early childhood and adolescent anthropometric and blood pressure measures were pooled. One hundred eighty-five children (48 black and 47 white boys and 41 black and 49 white girls) were followed up and studied after 15 to 17 years. Birth weights were a mean 443 and 282 g lower in black boys and girls, respectively, than in whites (P<0.001). Blood pressures in adolescence were 3.4/1.9 and 1.7/0.6 mm Hg higher, respectively, and tracked from early childhood. In regression analyses, birth weight accounted for the ethnic difference in adolescent blood pressure, which was also independently predicted, in decreasing impact order, by adolescent height, adolescent body mass index, and systolic blood pressure at 4 to 5 years and inversely by growth from 0 to 4 to 5 years.

CONCLUSIONS

If these results can be replicated in larger and independent samples, they suggest that efforts to improve intrauterine growth in black infants as well as lessen weight gain in adolescence might substantially reduce excess high blood pressure/hypertension in this ethnic group.

[Possible ways of managing cardiovascular prevention: polypharmacy, additional payment or application of evidence based medicine?]

The financial balance of the health care system has changed dramatically due to a longer life expectancy and improved treatment options in elderly patients. More than 80% of cardiovascular events are lifestyle related and potentially preventable. Lifestyle modification is therefore the causal approach to decrease cardiovascular events. Improvement of nutrition and activity habits and prevention of cigarette smoking should start in the kindergarten, school and later at the workplace. A co-operation between medical societies and government institutions is necessary to achieve a population wide modification of lifestyle habits to lower the incidence of cardiovascular events in the population. Individual risk stratification is the basis for pharmacological prevention of cardiovascular events. The concept of the polypill has to be tested in controlled randomised studies.

Underweight, obesity and exercise among adults with intellectual disabilities in supported accommodation in Northern England

BACKGROUND

Significant deviation from normal weight (obesity and underweight) and lack of physical exercise have been identified as three of the most significant global behavioural risks to health.

METHODS

Body mass index (BMI) and levels of physical activity were measured in a sample of 1542 adults with intellectual disabilities (ID) receiving supported accommodation in nine geographical localities in Northern England. Comparative population data were extracted from the Health Survey for England 1998 and 2001.

RESULTS

Men and women with ID living in supported accommodation are at increased risk of being significantly underweight and physically inactive. Women with ID living in supported accommodation are at increased risk of obesity. Within the population of people with ID living in supported accommodation increased behavioural health risks are associated with gender, severity of ID, age and location.

CONCLUSION

Significant deviation from normal weight and lack of physical exercise are significant behavioural risks to health among people with ID.

Is liver disease a threat to patients with metabolic disorders?

The association of metabolic disorders with liver disease is receiving increasing attention in the gastroenterological community. Cohort studies have shown that advanced liver disease may stem from metabolic disorders, via fatty liver, non-alcoholic steatohepatitis, cryptogenic cirrhosis, and eventually hepatocellular carcinoma. In both obesity and diabetes, deaths from cirrhosis are higher than expected, mainly in subjects with no or moderate alcohol consumption, but high rates of fatty liver disease have been associated with all features of the metabolic syndrome. Also the risk of hepatocellular carcinoma is higher than normal, being dependent on body mass index (BMI) in obesity, and independent of age, BMI, gender and race in diabetes. Finally, metabolic liver disease may interact with hepatitis C virus infection, increasing the risk of steatosis and liver disease progression, as well as reducing the chances of an effective antiviral treatment. There is evidence that treatments aimed at reducing insulin resistance are also effective in improving liver histology. Although cardiovascular disease remains the major cause of increased morbidity and excess mortality in metabolic disorders, the risk of progressive liver disease should no longer be underestimated, being a threat to millions of people at risk in the present epidemics of obesity and diabetes, and therapeutic strategies need to be tested.

Global patterns of healthy life expectancy in the year 2002

BACKGROUND

Healthy life expectancy--sometimes called health-adjusted life expectancy (HALE)--is a form of health expectancy indicator that extends measures of life expectancy to account for the distribution of health states in the population. The World Health Organization reports on healthy life expectancy for 192 WHO Member States. This paper describes variation in average levels of population health across these countries and by sex for the year 2002.

METHODS

Mortality was analysed for 192 countries and disability from 135 causes assessed for 17 regions of the world. Health surveys in 61 countries were analyzed using new methods to improve the comparability of self-report data.

RESULTS

Healthy life expectancy at birth ranged from 40 years for males in Africa to over 70 years for females in developed countries in 2002. The equivalent "lost" healthy years ranged from 15% of total life expectancy at birth in Africa to 8-9% in developed countries.

CONCLUSION

People living in poor countries not only face lower life expectancies than those in richer countries but also live a higher proportion of their lives in poor health.

The global mortality of infectious and parasitic diseases in children

Although considerable advances in the reduction of global child morbidity and mortality have been made since 1970, when more than 17 million children died, the burden of child mortality is still intolerably high today. An estimated 10.5 million younger than the age of 5 years died in the year 2002 from largely preventable diseases, such as those having infectious, parasitic, and perinatal causes. The reductions in rates of mortality observed did not take place uniformly across time and regions of the world, but the success stories in developing countries demonstrate clearly that low mortality levels are achievable in those settings. If the whole world came to share the current child mortality experience of Northern European countries, more than 10 million deaths of children could be prevented each year. This work aims to answer the questions concerning where and why so many of the world's children still succumb to largely preventable causes.