National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990-2015: findings from the global burden of disease study 2015

BACKGROUND

Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia.

RESULTS

Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4-30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2-24,917.9), and injuries caused 3781 (95% UI, 2642.9-5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7-4029), 2592.5 (95% UI, 1850.7-3495.1), and 2562.9 (95% UI, 1466.1-4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7-3843.2) and 2159.9 (95% UI, 1369.7-3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage.

CONCLUSIONS

Ethiopia has been successful in reducing age-standardized DALYs related to most communicable, maternal, neonatal, and nutritional deficiency diseases in the last 25 years, causing a major ranking shift to types of non-communicable disease. Lower respiratory infections, diarrheal disease, and tuberculosis continue to be leading causes of premature death, despite major declines in burden. Non-communicable diseases also showed reductions as premature mortality declined; however, disability outcomes for these causes did not show declines. Recently developed non-communicable disease strategies may need to be amended to focus on cardiovascular diseases, cancer, diabetes, and major depressive disorders. Increasing trends of disabilities due to neonatal encephalopathy, preterm birth complications, and neonatal disorders should be emphasized in the national newborn survival strategy. Generating quality data should be a priority through the development of new initiatives such as vital events registration, surveillance programs, and surveys to address gaps in data. Measuring disease burden at subnational regional state levels and identifying variations with urban and rural population health should be conducted to support health policy in Ethiopia.

Causes of death among adults in northern Ethiopia: evidence from verbal autopsy data in health and demographic surveillance system

BACKGROUND

In countries where registration of vital events is lacking and the proportion of people who die at home without medical care is high, verbal autopsy is used to determine and estimate causes of death.

METHODS

We conducted 723 verbal autopsy interviews of adult (15 years of age and above) deaths from September 2009 to January 2013. Trained physicians interpreted the collected verbal autopsy data, and assigned causes of death according to the international classification of diseases (ICD-10). We did analysis of specific as well as broad causes of death (i.e. non-communicable diseases, communicable diseases and external causes of death) by sex and age using Stata version 11.1. We performed logistic regression to identify socio-demographic predictors using odds ratio with 95% confidence interval and a p-value of 0.05.

FINDINGS

Tuberculosis, cerebrovascular diseases and accidental falls were leading specific causes of death accounting for 15.9%, 7.3% and 3.9% of all deaths. Two hundred sixty three (36.4% [95% CI: 32.9, 39.9]), 252 (34.9% [95% CI: 31.4, 38.4]) and 89 (12.3% [95% CI: 10.1, 14.9]) deaths were due to non-communicable, communicable diseases, and external causes, respectively. Females had 1.5 times (AOR = 1.53 [95% CI: 1.10, 2.15]) higher odds of dying due to communicable diseases than males. The odds of dying due to external causes were 4 times higher among 15-49 years of age (AOR  = 4.02 [95% CI: 2.25, 7.18]) compared to older ages. Males also had 1.7 times (AOR = 1.70 [95% CI: 1.01, 2.85]) higher odds of dying due to external causes than females.

CONCLUSION

Tuberculosis, cerebrovascular diseases and accidental falls were the top three causes of death among adults. Efforts to prevent tuberculosis and cerebrovascular diseases related deaths should be improved and safety efforts to reduce accidents should also receive attention.

InterVA versus Spectrum: how comparable are they in estimating AIDS mortality patterns in Nairobi's informal settlements?

Background

The Spectrum computer package is used to generate national AIDS mortality estimates in settings where vital registration systems are lacking. Similarly, InterVA-4 (the latest version of the InterVA programme) is used to estimate cause-of-mortality data in countries where cause-specific mortality data are not available.

Objective

This study aims to compare trends in adult AIDS-related mortality estimated by Spectrum with trends from the InterVA-4 programme applied to data from a Health and Demographic Surveillance System (HDSS) in Nairobi, Kenya.

Design

A Spectrum model was generated for the city of Nairobi based on HIV prevalence data for Nairobi and national antiretroviral therapy coverage, underlying mortality, and migration assumptions. We then used data, generated through verbal autopsies, on 1,799 deaths that occurred in the HDSS area from 2003 to 2010 among adults aged 15–59. These data were then entered into InterVA-4 to estimate causes of death using probabilistic modelling. Estimates of AIDS-related mortality rates and all-cause mortality rates from Spectrum and InterVA-4 were compared and presented as annualised trends.

Results

Spectrum estimated that HIV prevalence in Nairobi was 7%, while the HDSS site measured 12% in 2010. Despite this difference, Spectrum estimated higher levels of AIDS-related mortality. Between 2003 and 2010, the proportion of AIDS-related mortality in Nairobi decreased from 63 to 40% according to Spectrum and from 25 to 16% according to InterVA. The net AIDS-related mortality in Spectrum was closer to the combined mortality rates when AIDS and tuberculosis (TB) deaths were included for InterVA-4.

Conclusion

Overall trends in AIDS-related deaths from both methods were similar, although the values were closer when TB deaths were included in InterVA. InterVA-4 might not accurately differentiate between TB and AIDS deaths.

HIV mortality in urban slums of Nairobi, Kenya 2003-2010: a period effect analysis

BACKGROUND

It has been almost a decade since HIV was declared a national disaster in Kenya. Antiretroviral therapy (ART) provision has been a mainstay of HIV treatment efforts globally. In Kenya, the government started ART provision in 2003 with significantly scale-up after 2006. This study aims to demonstrate changes in population-level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale-up of the national ART program.

METHODS

We used data from 2070 deaths of people aged 15-54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Only deaths for which verbal autopsy was conducted were included in the study. We divided the analysis into two time periods: the "early" period (2003-2006) which coincides with the initiation of ART program in Kenya, and the "late" period (2007-2010) which coincides with the scale up of the program nationally. We calculated the mortality rate per 1000 person years by gender and age for both periods. Poisson regression was used to predict the risk of HIV mortality in the two periods while controlling for age and gender.

RESULTS

Overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53 percent less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods.

CONCLUSIONS

Population-level HIV mortality in Nairobi's slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalized slum populations in Kenya.

Emerging chronic non-communicable diseases in rural communities of Northern Ethiopia: evidence using population-based verbal autopsy method in Kilite Awlaelo surveillance site

INTRODUCTION

In countries where most deaths are outside health institutions and medical certification of death is absent, verbal autopsy (VA) method is used to estimate population level causes of death.

METHODS

VA data were collected by trained lay interviewers for 409 deaths in the surveillance site. Two physicians independently assigned cause of death using the International Classification of Diseases manual.

RESULTS

In general, infectious and parasitic diseases accounted for 35.9% of death, external causes 15.9%, diseases of the circulatory system 13.4% and perinatal causes 12.5% of total deaths. Mortalities attributed to maternal causes and malnutrition were low, 0.2 and 1.5%, respectively. Causes of death varied by age category. About 22.1, 12.6 and 8.4% of all deaths of under 5-year-old children were due to bacterial sepsis of the newborn, acute lower respiratory infections such as neonatal pneumonia and prematurity including respiratory distress, respectively. For 5-15-year-old children, accidental drowning and submersion, accounting for 34.4% of all deaths in this age category, and accidental fall, accounting for 18.8%, were leading causes of death. Among 15-49-year-old adults, HIV/AIDS (16.3%) and tuberculosis (12.8%) were commonest causes of death, whereas tuberculosis and cerebrovascular diseases were major killers of those aged 50 years and above.

CONCLUSION

In the rural district, mortality due to chronic non-communicable diseases was very high. The observed magnitude of death from chronic non-communicable disease is unlikely to be unique to this district. Thus, formulation of chronic disease prevention and control strategies is recommended.