The global burden of neglected zoonotic diseases: current state of evidence

 

The majority of emerging infectious diseases are zoonoses, most of which are classified as “neglected”. By affecting both humans and animals, zoonoses pose a dual burden. The disability-adjusted life year (DALY) metric quantifies human health burden using mortality and morbidity. This review aims to describe and analyze the current state of evidence on the burden of neglected zoonotic diseases (NZDs) and start a discussion on the current understanding of the global burden of NZDs. We identified 26 priority NZDs through consulting the CDC One Health Zoonotic Disease Prioritization Exercise, the Joint External Evaluation reports, and the WHO roadmap for NTDs. A systematic review of global and national burden of disease (BoD) studies for these priority NZDs was conducted using pre-selected databases. Data on diseases, location and DALYs were extracted for each eligible study. A total of 1887 records were screened, resulting in 72 eligible studies (58 national or sub-national, 12 global, and 2 regional studies). The highest number of BoD studies was found for non-typhoidal salmonellosis (23), whereas no estimates were found for West Nile, Marburg and Lassa fever. Geographically, the highest number of studies were found in the Netherlands (11), China (5) and Iran (4). The number of BoD studies retrieved mismatched the perceived importance in national prioritization exercises. For example, anthrax was considered a priority NZD in 73 countries, but only one national estimate was retrieved. By summing the available global estimates, these diseases would cause at least 10 million DALYs in total. The burden of NZDs at the global level remains scattered, and trends were challenging to identify. There are several priority NZDs for which no burden estimates exist, and the number of BoD studies does not reflect national disease priorities. To have complete and consistent estimates of the global burden of NZDs, these diseases should be integrated into larger global BoD initiatives.

Key messages

• There is a mismatched between the estimated retrieved in the search and the perception of the importance of these disease. This amplify the need for a comprehensive program.

• No complete list of zoonoses exist, and the definition used is vague. A stricter definition of zoonoses and what defines them will help provide a clear view of dealing with and controlling them.

Etiologic and prognostic roles of frailty, multimorbidity and socioeconomic characteristics in the development of SARS-CoV-2 infection and related severe health outcomes: systematic reviews of population-based studies

The study had 2 objectives, to: 1) evaluate the etiologic roles of frailty, multimorbidity and socioeconomic status on SARS-CoV-2 infection probability, hospitalization, intensive care unit (ICU) admission, mechanical ventilation and COVID-19 related mortality; 2) investigate the prognostic roles of mentioned risk factors on the likelihood of hospitalization, ICU admission, mechanical ventilation, COVID-19 mortality, functioning, quality of life, disability, mental health and work absence. Three systematic reviews were performed, for each risk factor. The reviews shared first screening steps relying on a common population-based approach. Initial search took place on 7 April 2021 in PubMed, Embase, PsycINFO and WHO Covid-19 database. An update was performed for frailty only, on 1 February 2022, due to the scarce literature retained initially. Prospero registration number: CRD42021249444. Initial search retrieved 10 139 records; 411 studies were read in full text. An update for frailty retrieved 565 records. Finally, the total number of included studies was: for multimorbidity, objective 1 N = 2, objective 2 N = 13; frailty, objective 1 N = 2, objective 2 N = 3; socioeconomic characteristics, objective 1 N = 57, objective 2 N = 30. The risk of severe short-term outcomes such as mortality, ICU admission or hospitalization increased with increasing disease burden and socioeconomic deprivation. Literature on long-term impacts was not identified. The evidence indicates a dose-effect association across all risk factors and outcomes. There is a lack of work conducted on population-based representative samples accounting for frailty and multimorbidity. Measures of multimorbidity and frailty were heterogeneous between studies. Most of the studies observing socioeconomic determinants were performed in the USA and the UK; hence the need for more research in different contexts. Further evidence is required in order to estimate the impact of crisis among general population.

Years of life lost for 137 causes of death in Belgium by age, sex, and region, 2004-2018

Information on years of life lost (YLLs) due to premature mortality is necessary to assess the fatal impact of disease, crucial for the calculation of Belgian disability-adjusted life years (DALYs). This study presents a novel method to redistribute cause of death data. Belgian cause of death data are obtained from Statistics Belgium (Statbel). After mapping the ICD-10 codes defining the underlying cause of death to the GBD cause list, we redistributed ill-defined deaths (IDDs) to specific causes using a four-step probabilistic redistribution process developed to fit the Belgian context: internal redistribution, redistribution using predefined ICD codes, redistribution using multiple causes of death data, and redistribution to all causes. Finally, we used the GBD 2019 standard life expectancy table to calculate the years of life lost at age of death. In Belgium, between 2004 and 2018, IDDs increased from 31% to 34% of all deaths, reflecting increases in the average age at death. The majority was redistributed using predefined ICD codes (13%), followed by the redistribution using multiple causes of death data (10-11%). The total number of YLLs decreased from 1.83 to 1.77 million. In 2018, the top causes of YLLs were ischemic heart disease and lung cancer with a share of 8.4% each, followed by dementia and cerebrovascular disease with a share of 5.5% each. All results are stratified by age, sex, region, and year, and can be explored via an online tool: https://burden.sciensano.be/shiny/mortality.

Future trends of overweight and obesity in Belgium using Bayesian age-period-cohort models

Background

Considering the current overweight and obesity epidemic and its associated increase in non-communicable diseases and healthcare costs, the current study aimed to project the trends in prevalence of overweight and obesity in Belgium using a Bayesian age-period-cohort (APC) model to support policy planning.

Methods

Height and weight of 58,369 adults aged 18+ years, collected in six consecutive cross-sectional health interview surveys between 1997 and 2018, were evaluated. Criteria used for overweight and obesity were defined as body mass index (BMI) ≥ 25, and BMI ≥ 30. A Bayesian APC model was applied to evaluate past trends and associated socio-demographic risk factors, and to forecast trends to 2019-2029. All analyses were performed based on integrated nested Laplace approximation (INLA) and took the complex survey design into account.

Results

The prevalence of overweight and obesity has increased between 1997 and 2018. If current trends continue, it is likely to that a further increase in the prevalence of overweight and obesity in the population will be seen by 2029 with a probability of growth of 51.2% and 73.3%, respectively. Forecasts indicated a potential prevalence of 50.1% [16.2%; 84.4%] in 2029 for overweight, and 21.4% [9.0%; 43.4%] for obesity. Among survey participants, middle-aged men with no higher education and a middle income showed the highest risk of overweight and obesity.

Conclusions

We projected an alarming increase in the prevalence of overweight and obesity. A decrease in cases seems very unlikely. There is an urgent need to target younger age groups for prevention and implementation of public educational programs to limit the increasing trend in overweight and obesity.

Key messages

• The occurence of obesity is likely to increase in the following 10 years.

• Projection of trends can serve as a useful tool for policy planning on the mid- and longer term.

Methodological choices in brucellosis burden of disease assessments: A systematic review

Background

Foodborne and zoonotic diseases such as brucellosis present many challenges to public health and economic welfare. Increasingly, researchers and public health institutes use disability-adjusted life years (DALYs) to generate a comprehensive comparison of the population health impact of these conditions. DALY calculations entail several methodological choices and assumptions, with data gaps and uncertainties to accommodate. The following review identifies existing brucellosis burden studies and analyses their methodological choices and assumptions.

Methods/Findings

A systematic search for brucellosis burden calculations was conducted in pre-selected international and grey literature databases. Using a standardized reporting framework, we evaluated each estimate on a variety of key methodological assumptions necessary to compute a DALY. One study reported estimates at the global level, the rest (13) at national or subnational. Most studies retrieved brucellosis epidemiological data from administrative registries. Incidence data were often estimated based on laboratory-confirmed tests. Not all studies included mortality estimates (YLLs) in their assessments due to the lack of data or the assumption that brucellosis is not a fatal disease. Only two studies used a model with variable health states and corresponding disability weights. The rest used a simplified singular health state approach. Wide variation was seen in the duration chosen for brucellosis, ranging from 2 weeks to 4.5 years, irrespective of whether a chronic state was included.

Conclusions

Available brucellosis burden assessments vary widely in their methodology and assumptions. Further research is needed to characterize better the total clinical course of brucellosis and estimate case-fatality rate. In addition, reporting of methodological choices should be improved to enhance transparency and comparability of estimates. These steps will increase the value of these estimates for policymakers.

Key messages

• Inconsistencies in reporting methods and assumptions are found, which hinder transparency and understanding of the methodological choices and the reuse of estimates for prioritization purposes.

• Thus, there is a need for a more standardized reporting system for DALY estimates, which could resemble a checklist that reports the methodological choices and assumptions.

COVID-19 vaccination uptake in Belgium: socioeconomic and sociodemographic disparities

Background

Recent studies have identified important social inequalities in SARS-CoV-2 infection and related COVID-19 outcomes in the Belgian population. This study aims to investigate socioeconomic and -demographic characteristics associated with the uptake of COVID-19 vaccine in Belgium.

Methods

We conducted a retrospective analysis of the uptake of the first dose of COVID-19 vaccine among 5,341,584 adults (≥ 18 years) tested for COVID-19 in Belgium until August 31, 2021. We integrated four national data sources: the Belgian vaccine registry (vaccination status), COVID-19 Healthdata (laboratory test results), STATBEL (socioeconomic/-demographic data) and the Common Base Registry for HealthCare Actors (people licensed to practice a healthcare profession in Belgium). Unvaccinated and vaccinated people (with at least one dose) were compared using multivariate logistic regression analysis.

Results

During the study period, 53,887 people (10%) did not receive the first COVID-19 vaccine dose in Belgium. Migrant background was associated with vaccine uptake (e.g., non-Europeans were almost three times [2.96-3.00] more likely to be unvaccinated compared to Belgian nationals). Single parents (OR 1.27 [1.26-1.28]) and people living alone (OR 1.18 [1.17-1.19]) were more likely to be unvaccinated compared to couples with children. Having a low or moderate education level (OR 1.36 [1.35-1.38] for low; OR 1.30 [1.29-1.32] for moderate) and income (OR 2.36 [2.34-2.38] for low; OR 1.54 [1.52-1.55] for moderate), being unemployed, (OR 1.50 [1.49-1.51), and having low health literacy (OR 1.41 [1.39-1.43]) led to a greater likelihood of being unvaccinated.

Conclusions

Migrants, people living alone, single parents or socioeconomically disadvantaged groups have lower uptake of COVID-19 vaccine in Belgium. The identification of these socioeconomic and -demographic disparities is critical to develop strategies guaranteeing a more equitable COVID-19 vaccination coverage in Belgium.

Key messages

• The study highlight important determinants in the uptake of the first dose of COVID-19 vaccine in Belgium.

• These results highlight the importance to focus efforts on socioeconomically disadvantaged groups currently under-represented in COVID-19 vaccination uptake in Belgium.

The economic burden of Diabetes Mellitus in Belgium from 2013 to 2017

Background

Considering the growing prevalence of chronic disease and diabetes mellitus (DM) in Belgium, alongside population aging, insight into the economic burden of DM is essential for decision makers. To the best of our knowledge, there is no research on the subject in Belgium. Thus, our aim was to estimate the direct and indirect costs associated to DM in Belgium between 2013 and 2017.

Methods

On a first phase, we performed a retrospective observational study, calculating the direct (i.e., ambulatory care, hospitalizations and medications) and indirect (work absenteeism, by multiplying mean daily wage and days absent from work) costs in the Belgian population with DM in 2013-2017. Data was retrieved from the Belgian Intermutualistic Agency (which manages compulsory health insurance) database and the Belgian Health Interview Survey database, namely DM prevalence, healthcare costs, days absent from work and sociodemographic and health factors. Subsequently, negative binomial regression models were used to assess the association of mean yearly costs to DM and adjustments for age, education level, physical activity, sugared drink consumption and body-mass index were included. Mean incremental costs were estimated through recycled predictions, considering the observed DM prevalence in Belgium in the study period and a counterfactual scenario with null prevalence.

Results

We found a direct mean yearly incremental cost of €2 477 per DM patient, in Belgium, associated with age, low educational level and low physical activity. In the total Belgian population, the total yearly incremental healthcare cost of DM was €1.5 billion. Indirect yearly incremental cost of DM resulted to be not significantly different from the population without DM.

Conclusions

DM has a major economic burden in Belgium, one that is expected to continue to rise in the future, alongside population aging. These results are essential for health planning and resource allocation.

Key messages

• DM has a major economic burden in Belgium, especially when it comes to direct health expenditures with ambulatory care, hospitalizations and medications.

• Considering the growing prevalence of DM and population aging, these results are essential for health planning and resource allocation.

Measuring health expectancy in the European Union

Background

Healthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).

Methods

We performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman's r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.

Results

Correlation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.

Conclusions

We showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Acknowledgements: This presentation was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020)

Key messages

• Different methods for evaluating health expectancy lead to significantly different results.

• There is a systematic tendency with countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

Reporting guidelines for burden of disease studies: why and how?

Background

The Disability Adjusted Life Year (DALY) is a frequently used metric to assess burden of disease (BoD). Many independent BoD studies have been performed across Europe, showing wide variations and inconsistencies in the application and reporting of DALY specific methods. The European Burden of Disease Network (burden-eu) aims to develop guidelines for reporting DALY calculation studies which may enhance transparency and comparability of BoD estimates across Europe and beyond.

Methods

A burden-eu working group of experts generated a list of potential reporting items based on existing literature, guidance for developing guidelines and consultations with BoD experts. To pilot the drafted product, we asked BoD experts and non-experts to apply it to existing BoD studies. We received feedback and we revised the guidelines accordingly.

Results

The guide for DALY calculation studies comprises about 25 items that should be reported in BoD studies. We included information about the study setting, data input sources including methods for data corrections, DALY-specific methods (e.g., YLL life table, YLD approach, disability weights etc), data analyses, and data limitations. We also included information on how users can compare their new estimates with previously available BoD estimates.

Conclusions

We introduced a reporting instrument for DALY calculations that can be used to document input data and methodological design choices in BoD studies. The application of such guidelines will enhance usability of BoD estimates for decision-makers as well as global, regional, and national health experts.

Key messages

The burden of musculoskeletal disorders in Belgium: a national population-based study

Background

According to WHO, approximately one in three people worldwide live with a chronic, painful musculoskeletal (MSK) disorder. Low back pain (LBP), neck pain (NKP), osteoarthritis (OST) and rheumatoid arthritis (RHE) are among the most disabling MSK disorders. According to the Global Burden of Disease (GBD) study, LBP was the leading global cause in terms of years lived with disability and OST showed an increase in prevalence and is predicted to be one of the leading future causes. Our study aimed to analyse the burden of these MSK disorders in Belgium, providing a summary of morbidity and mortality outcomes from 2013 to 2018.

Methods

Prevalence and disability-adjusted life years (DALY) were computed using data from the Belgian health interview surveys from 2013 and 2018, the INTEGO database (Belgian registration network for general practitioners) and GBD study 2019. Mortality data was retrieved from the Belgian statistical office for people dying from RHE. Following GBD methodology, LBP, NKP and OST were assumed to not generate any deaths.

Results

The prevalence of MSK disorders increased from 2013 to 2018 with OST being the disorder with the highest number of cases (1.7 million cases in 2018). The burden was higher in women and the gender disparities increased with age. Women died also more frequently due to RHE compared to men. In total MSK disorders contributed to 180,746 comorbidity-adjusted DALYs for female and 116,063 comorbidity-adjusted DALYs for men in 2018, with LBP being the largest contributor (140,031 DALY).

Conclusions

The burden of MSK disorders has increased over the years. In 2018, 2.5 million Belgians were affected by at least one MSK disorder that resulted in almost 300,000 DALY. Our study provides valuable information of a part of the health burden that is known to have a great impact on the total burden of disease but that is sometimes disregarded by public health institutions.

Key messages

• MSK disorders represent a major health problem in Belgium.

• Acting on risk factors associated to these disorders is crucial to mitigate their burden.

Direct and indirect costs attributable to musculoskeletal disorders in Belgium

Background

Within the European Union, musculoskeletal (MSK) disorders represent the most prevalent and costly work-related health problems affecting about 45 million workers. Since middle-aged people during their formative and peak income-earning years are predominantly affected, MSK disorders are the major contributors to the loss of productive life years in the workforce compared with other non-communicable diseases. This study aimed to summarize the average yearly economic impact of low back pain (LBP), neck pain (NKP), osteoarthritis (OST) and rheumatoid arthritis (RHE) in Belgium from 2013 to 2017.

Methods

Direct costs, measured by reimbursed expenditures for medical services and medications, were derived by the national health insurer. Indirect costs were computed by multiplying the mean number of days absent from work (derived by the Belgian health interview survey, as prevalence data) with the average gross daily wage. Multivariate regression models were used to explore the extent to which average yearly costs were associated with MSK disorders. The method of recycled predictions allowed to estimate the marginal effect of each MSK disorder on costs.

Results

25% of Belgian adults were affected by at least one MSK disorder that incurred on average to 1,524€ per capita. LBP was the most costly disorder (2,405€ per capita) followed by NKP (2,260€ per capita). In the working population, 15% had at least one MSK disorder with an average indirect cost of 3,083€ per capita. People with LBP were the only showing a significantly higher indirect cost compared to a population without LBP, with an adjusted cost per capita of 5,875€.

Conclusions

The adult Belgian population is largely affected by MSK disorders. Every year the total adjusted healthcare cost amounted to more than 3 billion Euros. Additionally, on average every year Belgium spends around 2 billion Euros for work absenteeism related to one of the MSK disorders.

Key messages

Validity of self-reported data to assess the prevalence of overweight, hypertension and cholesterol

Background

Accurate data on the risk factors of non-communicable diseases is essential to build evidence-based prevention programs. In Belgium, this is assessed through self-reported (SR) data from the Belgian health interview surveys (BHIS) in a wide population sample or through objective measures from small-scale surveys (such as the Belgian health examination survey [BHES]). It has been shown, however, that relying on SR data leads to a prevalence underestimation. The objective of this study is to assess the agreement between SR and measured overweight, hypertension and high cholesterol and to provide information to do a valid correction for measurement error.

Methods

The BHIS/BHES 2018 database was used (n = 1184). Kappa coefficient was used to assess the agreement between SR and measured hypertension (systolic BP > 140 mmHg, diastolic BP > 90 mmHg, or reported use of medication for hypertension) and ICC was used to assess the agreement between SR and measured BMI. SR high cholesterol was compared to a measured total serum cholesterol >190 mg/dl.

Results

Risk factor prevalence based on SR data is severely underestimated. The agreement between SR and measured data is high for BMI (ICC: 0.92), moderate for hypertension (Kappa: 0.49) and poor for cholesterol (Kappa: 0.05). Using SR data, 45% of the people with a measured hypertension and 22% of the people with a measured high cholesterol are detected. With regressions based on the SR risk factor, age, sex and education, the measured BMI and hypertension can be predicted with a good accuracy (BMI: R2: 87%, HBP: AUC: 86%). A lower accuracy is observed for the cholesterol model (AUC: 65%). Using predicted values instead of SR data yields higher estimates of people suffering from overweight (+8% relative increase), obesity (+12%), hypertension (+24%) and cholesterol (+36%).

Conclusions

Using SR data yields to an underestimation of the prevalence of obesity, hypertension and high cholesterol in Belgium

Key messages

Relying on SR data to assess the prevalence of overweight, hypertension and high cholesterol requires a correction for measurement error. Using the predicted values from regression models based on the SR risk factor, age, sex and education, yields higher estimates of people suffering from overweight, hypertension and cholesterol.

Cost of hospitalization for ischaemic heart and cerebrovascular diseases in Belgium

Background

Cardiovascular diseases (CVDs) are the leading cause of global mortality and a major contributor to disability. According to European Cardiovascular Disease Statistics, in 2017 there were 108.7 million people living with CVDs in Europe resulting in about 4,681 disability-adjusted life years per 100,000 inhabitants. Among these, ischaemic heart and cerebrovascular diseases (IH&CBD) represent the highest burden in terms of morbidity, mortality and health care costs. CVDs were estimated to cost the EU €210 billion a year, where 28% was attributable to IH. The aim of this study was to assess the financial burden at societal level of IH&CBD in Belgium based on hospital discharge data, considering that inpatient hospital care costs accounted for about 51% of the total healthcare costs in CVDs.

Methods

IH&CBD were identified based on ICD-10 codes following the definition provided in the Global Burden of Disease study in 2017. IH: angina pectoris (AP) I20 and I25, acute myocardial infarction (AMI) I21-I24; CBD I60-I68. Mean annual number of patients and direct hospitalization costs from 2016 to 2018 were retrieved from the Belgian hospital discharge dataset, considering both primary and secondary diagnoses.

Results

Within the observed diseases, AP was the most common reason for hospitalizations with an average of 41,439 hospitalized patients per year. Yearly, 27,630 patients were hospitalized for CBD and 14,928 patients were hospitalized for AMI. The yearly hospitalization cost for AP and AMI in Belgium was on average respectively €219,688,254 and €133,343,881. CBDs accounted for the largest direct hospitalization cost with €301,900,539 per year.

Conclusions

In Belgium, on average almost 84,000 people are hospitalized yearly due to IH&CBD; On average, Belgium spends around €655 million a year for these hospitalizations.

Key messages

IH&CBD represent a high health and financial burden in Belgium. Since IH&CBD can be linked to several behavioral risk factors, this burden could be reduced with target health interventions.

A systematic literature review of burden of disease studies in Europe: next steps and implications for researchers

Facing the considerable variation in the computation of disability-adjusted life years (DALY), the European Burden of Disease Network (burden-eu) launched a series of systematic literature reviews (SLR) to explore the key variations in the assumptions used in the European burden of disease (BoD) assessments. The studies were evaluated in terms of pre-defined criteria, focusing on data sources used and on specific methodological and normative choices to assess BoD. Preliminary results show a wide variety in methodological assumptions used to quantify DALYs, but also important inconsistencies in the reporting of methods and particular assumptions. For instance, the quantification of uncertainties is not a common practice, even though most authors seem to be aware of the uncertainty in their DALY estimates and discuss uncertainties as an important study limitation. When uncertainties were quantified, different approaches were used, and described using inconsistent nomenclature. The results of the SLR show that there is a clear need for standardized reporting guidelines for DALY estimates. Such a tool could be based on quality assessment checklists already in place for clinical trials and observational studies (PRISMA, STROBE, CRD), and would require inclusion of the DALY's key methodological and normative choices. Standardized DALY reporting guidelines could serve multiple purposes. First and foremost, they would allow to increase the quality of reporting, thereby increasing the transparency and comparability of BoD studies. As a reference document, such guidelines would also help to harmonize nomenclature, which would further increase transparency and comparability. Last but not least, it would also serve as a capacity building tool, supporting researchers in understanding which methods and assumptions underlie the DALY metric. To address this need, the burden-eu network aims to play a driving role in the development of standardized DALY reporting guidelines.

Mortality attributable to housing deprivation in Belgium between 1991 and 2015

Background

Poor housing condition is associated with increased mortality. Our aim is to measure the inequality in mortality attributable to housing deprivation in Belgium.

Methods

We utilized data on housing conditions from the 1991 population census, and data on mortality from the National Register in Belgium between Jan 1, 1991 and Dec 31, 2015. An area-level composite score was developed and computed for 18 267 statistical sectors in Belgium. The score was based on indicators encompassing multiple dimensions: occupancy status and its density, absence of central heating, bathroom, toilet, kitchen, double glazing. These indicators were combined to a score, ranked and assigned to deciles. The mortality attributable to housing inequality was calculated as the difference between the observed and expected deaths. The expected deaths were computed by applying mortality in the least deprived decile to other deciles, stratified by 5-year age group, sex, and time.

Results

Our results show that 20% of all deaths, equating to 2 564 289 deaths, occurring between 1991-2015 can be attributable to inequalities in housing. The proportion of deaths attributable to inequality in housing increased over time and was higher for men (26%) than for women (14%). The difference in age-standardized mortality rates between the most and the least deprived groups increased over time from 31 to 37% and from 10 to 26% for men and women, respectively.

Conclusions

Housing conditions play an important role in mortality inequalities and ensuring good housing conditions is necessary for reducing inequalities.

Key messages

Poor housing condition is associated with increased mortality. Our results show that 20% of all deaths, equating to 2 564 289 deaths, occurring between 1991-2015 can be attributable to inequalities in housing.

A systematic literature review of studies estimating the risk factor attributable burden in Europe

Along with the computation of disability-adjusted life years (DALY), the Global Burden of Disease (GBD) study uses the comparative risk assessment method to estimate the burden attributable to risk factors (RF). The methodology used for GBD studies has undergone continuous improvements through the years and across many independent studies. The European burden of disease network launched a series of systematic literature reviews (SLR) to explore key assumptions used in the European burden of disease (BoD) assessments. The SLR will give an overview of existing studies, including those estimating the BoD attributable to RF and focus on the different computational approaches. The SLR will also help to identify ways to harmonize computational procedures to enhance the comparability of RF attributable burden. The SLR involved four parallel reviews: non-communicable diseases, communicable diseases, injuries and RF. For the latter, we used a search strategy with terms describing the population (GBD area “European region”) and terms specifically used in comparative risk assessments (comparative risk assessment [CRA], attributable mortality/burden/risk). Studies published between January 1990 and April 2020 were included, without language restrictions. The search strategy was run in PubMed, Web of Science, Cochrane, and Embase. OpenGrey, OAIster, CABDirect, WHO, and targeted public health agency websites were screened for indexed grey literature. In addition, burden-eu members were asked to supplement the list of publications with any material available in their national public health institutes. The title, abstract, and full-text screening resulted in the final inclusion of 114 publications. The list of publications includes peer-reviewed articles and reports showing a variability in CRA analysis (e.g. use of exposure-response function, relative risks) and other methodological choices. Further data extraction and analysis is in process and will be presented during the workshop.

The state of health in the European Union in 2019

Background

The European Union (EU) faces many health-related challenges. Accurate and timely data on mortality and morbidity from diseases and injuries and their trends over time are essential for health planning and priority setting.

Methods

We use the GBD 2019 study estimates and 95% uncertainty intervals for the whole EU and each country to evaluate age-standardized death, YLL, YLD and DALY rates for Level 2 causes. We evaluate trends by comparing estimates for the year 2019 with those for the year 2010.

Results

In 2019, the age-standardized death and DALY rates in the EU were 465.8 and 20 251.0 per 100 000 inhabitants, respectively. Between 2010 and 2019, there were significant decreases for age-standardized, death and YLL rates across EU countries. However, YLD rates remained mainly unchanged, with increases in the Netherlands and the ‘. The largest decreases in age-standardized DALY rates were observed for HIV/AIDS and sexually transmitted diseases and transport injuries (both -19%). On the other hand, only diabetes and kidney diseases showed a significant increase for age-standardized DALY rates in the EU (3.5%). Mental disorders showed an increasing age-standardized YLD rate, as well.

Conclusions

Overall, there was a visible trend of improvement in the health status in the EU with substantial differences between countries. EU health policy makers need to tackle incidence of diseases and injuries, with specific attention to causes such as mental disorders. There are many opportunities for mutual learning among otherwise similar countries with different patterns of disease.

Burden of diseases and injuries attributable to risk factors in the European Union in 2019

Background

In addition to information on mortality and morbidity from diseases and injuries, it is important to identify the attributable burden of risk factors to allow for health planning and prioritization.

Methods

For the whole EU and each country, using estimates and 95% uncertainty intervals from the GBD 2019 study, we report attributable (all-cause and by level 2 risk factors) age-standardized death and DALY rates, as well as summary exposure values (SEV). We evaluate trends by comparing estimates for the year 2019 with those for the year 2010.

Results

Age-standardized death and DALY rates attributable to risk factors declined by 10.7% (95%UI 13.8%-7.6%) and 9.1% (95%UI 12.0%-6.3%), between 2010 and 2019 in the EU. While there was a decreasing trend for both age-standardized death and DALY rates for almost all risk factors, some showed an increasing trend on SEV, including low physical activity and intimate partner violence.

Conclusions

Despite the improvement of health metrics attributable to risk factors, several modifiable behavioral and metabolic risk factors remain unchanged over the years. It is crucial to ensure a swift implementation of evidence-based policies and interventions in EU member states to achieve the targets of the Sustainable Development Goals.

An overview of burden of disease studies in Europe

Facing the considerable variation in the computation of disability-adjusted life years (DALY) in the numerous updates of the Global Burden of Disease (GBD) study and many independent studies, the European burden of disease network (burden-eu) launched a series of systematic literature reviews (SLR) to explore the key assumptions used in the European burden of disease (BoD) studies. The SLR will provide an overview of the existing BoD studies and the computational variations used and will also help identifying ways to harmonize the approaches enhancing the comparability of BoD estimates. The SLR was split in four parallel reviews: non-communicable diseases (NCDs), communicable diseases (CDs), injuries and risk factors. For the first three, the search strategy included terms describing the population (GBD area “European region”) and the BoD measures (years lived with disability, years of life lost, and DALYs). We included studies published between January 1990 and April 2020, without language restrictions. The search strategy was run in PubMed, Web of Science, Cochrane, and Embase. OpenGrey, OAIster, CABDirect, WHO and targeted public health agency websites were screened for grey literature. In addition, burden-eu members were asked to supplement the list of publications with any material available within their national public health institutes. Data extraction focused on methodological information. The title, abstract and full-text screening resulted in the final inclusion of 165 papers regarding NCDs, 189 with CDs, and 124 papers regarding injuries. The final list includes peer-reviewed articles and reports showing a variability in data sources used (e.g. patient medical records, disease registries, insurance claims sources) and model assumptions (e.g. use of multi-morbidity adjustments, use of disability weights). Further data extraction and analysis is in process, and will be presented during the workshop.

Global Burden of Animal Diseases: a novel approach to understanding and managing disease in livestock and aquaculture

Investments in animal health and Veterinary Services can have a measurable impact on the health of people and the environment. These investments require a baseline metric that describes the burden of animal health and welfare in order to justify and prioritise resource allocation and from which to measure the impact of interventions. This paper is part of a process of scientific enquiry in which problems are identified and solutions sought in an inclusive way. It poses the broad question: what should a system to measure the animal disease burden on society look like and what value would it add? Moreover, it aims to do this in such a way as to be accessible by a wide audience, who are encouraged to engage in this debate. Given that farmed animals, including those raised by poor smallholders, are an economic entity, this system should be based on economic principles. These poor farmers are negatively impacted by disparities in animal health technology, which can be addressed through a mixture of supply-led and demand-driven interventions, reinforcing the relevance of targeted financial support from government and non-governmental organisations. The Global Burden of Animal Diseases (GBADs) Programme will glean existing data to measure animal health losses within carefully characterised production systems. Consistent and transparent attribution of animal health losses will enable meaningful comparisons of the animal disease burden to be made between diseases, production systems and countries, and will show how it is apportioned by people's socio-economic status and gender. The GBADs Programme will produce a cloud-based knowledge engine and data portal, through which users will access burden metrics and associated visualisations, support for decisionmaking in the form of future animal health scenarios, and the outputs of wider economic modelling. The vision of GBADs, strengthening the food system for the benefit of society and the environment, is an example of One Health thinking in action.

Pathogenic potential of Escherichia coli O157 and O26 isolated from young Belgian dairy calves by recto-anal mucosal swab culturing

AIMS

The purpose of this study was to investigate the occurrence of Escherichia coli O157 and O26 on Belgian dairy cattle farms, the presence of virulence genes in the confirmed isolates and the association of E. coli O26 presence with calf diarrhoea.

METHODS AND RESULTS

In total, 233 recto-anal mucosal swabs (RAMS) were obtained from healthy and diarrheic dairy calves on three farms, each alternately visited three consecutive times. RAMS were analysed for presence of E. coli O157 and O26, and stx1, stx2 and eae virulence genes. Overall, 19% of RAMS tested positive for E. coli O157, while 31% tested positive for E. coli O26. The majority of isolates possessed both stx and eae, denoting a high pathogenic potential to humans. While both serogroups persisted at farm level, persistence within the same animal over time appeared to be relatively rare. Interestingly, E. coli O26 was already abundantly present at a younger age compared to E. coli O157. Calf diarrhoea could not be associated with presence of E. coli O26.

CONCLUSIONS

Young dairy calves are important on-farm reservoirs of potentially pathogenic E. coli O157 and O26. A role of E. coli O26 in calf diarrhoea could not be confirmed.

SIGNIFICANCE AND IMPACT OF THE STUDY

O157 and O26 are responsible for the majority of human STEC infections. Gaining more epidemiological information regarding their occurrence and persistence on cattle farms will contribute to a better understanding of STEC ecology and risk of human transmission.

Occurrence of 'gang of five' Shiga toxin-producing Escherichia coli serogroups on Belgian dairy cattle farms by overshoe sampling

Shiga toxin-producing Escherichia coli (STEC) are foodborne pathogens responsible for global outbreaks. This study was conducted to investigate the occurrence of 'gang of five' STEC serogroups (O26, O103, O111, O145, O157) on Belgian dairy cattle farms by overshoe (OVS) sampling, and to evaluate the presence of virulence genes in the obtained isolates. A total of 88 OVS, collected from the pen beddings of 19 Belgian dairy cattle farms, were selectively enriched in mTSBn, followed by immunomagnetic separation and plating onto CT-SMAC for O157 STEC isolation, as well as in Brila broth, followed by a selective acid treatment and plating onto CHROMagar^TM STEC and chromID^TM EHEC for non-O157 STEC isolation. Overall, 11 of 19 farms (58%) tested positive for presence of 'gang of five' STEC. O26 STEC was most frequently isolated from OVS (11/88; 12·5%), followed by O157 (10/88; 11·5%), O145 (3/88; 3·5%) and O103 (3/88; 3·5%). Additionally, 35% of the OVS collected from pens housing young cattle 1-24 months of age tested positive for 'gang of five' STEC, indicating that this age category is more likely to harbour STEC compared to new-born and adult cattle. Importantly, half of the obtained 'gang of five' STEC isolates (48%) possessed the eae and stx2 gene, suggesting a high pathogenic potential to humans.

Belgian population norms for the EQ-5D-5L, 2013 and 2018

Background

Health-related quality of life outcomes are increasingly used to monitor population health and health inequalities, and to assess the (cost-)effectiveness of health interventions. The EQ-5D-5L has been included in the Belgian Health Interview Survey (BHIS), providing a new source of population-based self-perceived health status information. The aim of this study is to estimate Belgian population norms for the EQ-5D-5L by sex, age, and region, and to analyse its association with educational attainment.

Methods

The BHIS 2013 and 2018 provided EQ-5D-5L data for a nationally representative sample of the Belgian population. The dimension scores and index values were analysed using logistic regression and linear regression, respectively, taking into account the survey design.

Results

The majority of respondents reported problems of pain/discomfort, while over a quarter reported problems of anxiety/depression in both surveys. The average index value was 0.81 in 2013 and decreased significantly to 0.79 in 2018. Women reported more problems on the dimensions, but particularly on anxiety/depression and pain/discomfort, resulting in significantly lower index values. Problems with mobility, self-care, and usual activities showed a sharp increase after the age of 80 years. Consequently, index values decreased significantly by age. Lower education was associated with a higher prevalence of problems for all dimensions except pain/discomfort in 2013 and anxiety/depression in 2018, and with a significantly lower index value.

Conclusions

This paper presents the first nationally representative Belgian population norms using the EQ-5D-5L. Inclusion of the EQ-5D in future surveys will allow monitoring over time of self-reported health, disease burden, and health inequalities.

Key messages

This study is the first to provide Belgian population norms for the EQ-5D-5L and consequently increases the evidence base regarding country-specific population norms. Our results help policy makers in understanding and monitoring the self-perceived health status of the Belgian population according to age, gender, and educational attainment.

Data inputs and assumptions in calculating the non-fatal burden in burden of disease studies

Years Lived with Disability (YLD) is a component of the Disability-Adjusted Life Year (DALY), and measures the healthy time that is lost because of living with a disease or disability. YLDs are calculated by multiplying the prevalence and/or incidence of a disorder by the short- or long-term loss of health associated with that disability (the disability weight) and disease severity (severity distribution).

The process of calculating a YLD involves several components and in this presentation each step will be highlighted through a sequential walk through for each step in the YLD calculation, including counting disease occurrencethe relationship between disability weights, health states and severity distributionsadjusting for comorbiditiesdealing with uncertainty

The aim of this presentation is to provide a simple step by step guide on the key components in the YLD calculation. Using the real-life example of cerebrovascular disease, the presentation will outline the key choices and assumptions that underline each data input in the YLD calculation. Participants in this session will also be provided with links to resources to help facilitate this decision-making process. The workshop will end with an interactive session where the presenters will discuss the implications of the different methodological choices with the audience.

The burden of low back pain in Malta at a population level

Background

Low back pain (LBP) is a leading global cause of all-age years lived with disability (YLD). Studies conducted in Malta reported that musculoskeletal complaints were the commonest in primary care. The aim was to estimate for the first time the burden of LBP at population level in Malta in terms of disability-adjusted life years (DALYs) and compare to estimates obtained by the Global Burden of Disease (GBD) study.

Methods

LBP prevalence data were obtained from the Maltese European Health Interview Survey dataset for 2015 through representative self-reported history of chronic LBP for 12 months in combination to the extent of daily activities limitation. Proportions of LBP severity (with and without leg pain -mild, moderate, severe and most severe) and their corresponding disability weights followed values reported in GBD study. YLDs for LBP were estimated for the whole population by sex. Since LBP does not carry any mortality, YLDs reflected DALYs. The estimated local DALYs per100,000 were compared to the GBD study for Malta for the same year.

Results

Point prevalence of LBP causing a limitation was of 6.3% (5.6% males; 7.0% females), contributing to a total of 27,006 Maltese suffering from LBP. Global LBP DALYs were of 783 per100,000. Females experienced higher LBP burden per100,000 (876 DALYs) than males (689 DALYs). On comparing these DALYs to those reported by GBD study, a discrepancy was observed per 100,000 (Global LBP 1,828 DALYs; Males 1,657 DALYs; Females 1,999 DALYs).

Conclusions

LBP imposes substantial burden in Malta, which is expected to increase with the ageing population. Since etiology of LBP is multifactorial, it is suggested that a multi-disciplinary targeted preventive and management approach is considered. Differences observed between local estimates and those of the GBD study suggest the integration of locally sourced data into the model in order to improve the DALYs estimates of each country.

Key messages

Low back pain is a public health burden. Locally sourced data is suggested to be integrated with the GBD study to improve the DALYs estimation for each country.

Use of general health care by people with substance use disorders in Belgium (2008-2017)

Background

Substance use disorders (SUD) are associated with an increased use of general health care services (e.g. use of emergency departments (ED), visits to GP or use of inpatient services). However, little is known about the extent to which people with SUD are using these services compared to people without SUD.

Methods

Data from the national register of people who were in specialized treatment for SUD between 2011 and 2014 (N = 30,905) was linked to health insurance data. Four comparators were matched on sex, age and region to each subject in treatment for SUD (N = 123,620). For people with alcohol (AUD), opiate (OUD), cocaine (CoUD) and cannabis (CaUD) use disorders and their respective comparators we analyzed the contacts with GP, psychiatrist, ED and days in hospital between 2008 and 2017. Negative binomial regression was used to obtain incidence rate ratios (IRRs) in the four different settings both for all drugs combined and for each drug separately.

Preliminary results

People with SUD were significantly more likely to contact a GP (IRR 1.9 95%CI 1.9-2.0, p < 0.0001), a psychiatrist (IRR 7.4 95%CI 7.0-7.7, p < 0.0001), an ED (IRR 4.2 95%CI 4.2-4.3, p < 0.0001) or to be hospitalized (IRR 6.4 95%CI 6.3-6.5, p < 0.0001), compared to people who were not in specialized treatment for SUD. Differences were stable over time and always highest for people with AUD and lowest for people with CaUD, except for visits to the GP where the differences were highest for people with OUD (IRR 2.6 95%CI 2.5-2.7, p < 0.0001).

Conclusions

People with SUD have between 2 and 7 times more contacts with general health services than people without SUD. SUD is not a specialty health issue but affects all health service settings.

Key messages

People with SUD have a 2-7 times higher use of general health care services than people without SUD. All health professionals should have the competencies to support people with SUD adequately.

Validity of air pollution annoyance to assess long-term exposure to air pollution in Belgium

Background

In environmental epidemiology, air pollution exposure is often estimated at the population level. To avoid the risk of exposure misclassification, one possibility is to interpolate air pollution measures at the residence through Geographical Information Systems. However, this might imply cumbersome administrative procedures. Data on air pollution annoyance from surveys can be an alternative to assess individual exposure to air pollution. This study investigates the association between air pollution annoyance and individual air pollution exposure.

Methods

Analyses were carried out based on a linkage of data from the Belgian Health Interview Survey (HIS 2008 and 2013; >15 years; n = 9347) and annual means of air pollution concentration at the residence. Self-reported air pollution annoyance was assessed through a five-point Likert scale. Statistical analyses included Spearman correlation coefficient, analysis of variance and multivariable ordinal logistic regressions (OLR).

Results

A significant exposure-response relationship was observed between long-term air pollution exposure and self-reported air pollution annoyance. However, Spearman coefficients were low (0.18-0.24), meaning a high heterogeneity of annoyance levels for a given exposure. In multivariable OLR, the odds of being annoyed by air pollution was 2.10 (95% CI: 1.86-2.67) times higher for each Interquartile range (IQR) increase in NO2 concentration (PM2.5: 1.77 [95% CI: 1.53-2.07], PM10: 1.61 [95% CI: 1.33-1.67], black carbon: 1.45 [95% CI: 1.27-1.67]). Air pollution annoyance depended largely on individual factors especially health status.

Conclusions

Air pollution exposure has a significant influence on self-reported air pollution annoyance. However, many other factors were found to influence annoyance, independently of the exposure. We found a limited validity of self-reported air pollution annoyance to assess individual long-term exposure to air pollution.

Key messages

Significant exposure-response relationship between individual long-term air pollution exposure and self-reported air pollution annoyance. Limited validity of self-reported air pollution annoyance for assessing individual long term exposure to air pollution.

The burden of cancer in Belgium, 2004-2017

Background

Monitoring the health status of a population requires consistent and comparable data on the morbidity and mortality impacts of a disease. The Disability-Adjusted Life Year (DALY) is an increasingly used disease burden indicator, combining healthy life years lost due to living with disease (Years Lived with Disability; YLDs) and due to dying prematurely (Years of Life Lost; YLLs). In Belgium, as in many other developed countries, cancer is a major contributor to the overall burden of disease. To date, however, local estimates of the burden of cancer are lacking.

Methods

We estimated the burden of 48 cancers in Belgium from 2004 to 2017 in terms of DALYs, using national population-based cancer registry data and international disease models. We developed a microsimulation model to translate incidence- into prevalence-based estimates, and used expert elicitation to integrate the long-term impact of surgical treatment.

Results

In 2017, in Belgium, breast cancer was the cancer with the highest disease burden among women, followed by lung cancer and colorectal cancer. Among men, lung cancer had the highest disease burden, followed by colorectal cancer and prostate cancer. Between 2004 and 2017, the burden of lung cancer increased by more than 50% in women, while in both sexes, significant increases were observed in melanoma and skin cancer burden. The majority of the cancer burden remained linked to premature mortality.

Conclusions

Cancer maintains a major impact on the health of the Belgian population. Current resources allocated for their prevention and treatment will need to be maintained to further reduce the cancer burden. Lung cancer remains a crucial challenge, among both men and women, calling for strengthened tobacco control policies. Integrating the current study in the Belgian national burden of disease study (BeBOD) will allow monitoring the burden of cancer over time, highlighting new trends and assessing the impact of public health policies.

Key messages

Burden of disease studies allow assessing and monitoring the impact of diseases and risk factors in a comparable way. Cancer maintains a major impact on the health of the Belgian population; lung cancer in particular remains a crucial challenge.

Data inputs and assumptions in calculating the fatal burden in burden of disease studies

Years of Life Lost (YLL) is a measure of premature mortality used in the calculation of the Disability-Adjusted Life Year (DALY), as well as stand-alone measure in itself. The concept of years of life lost is to estimate the length of time a person is expected to have lived had they not died prematurely. The YLL is based on comparing the age of death to an external standard life expectancy curve, and can incorporate time discounting and age weighting. Furthermore, YLL can be calculated for specific causes of death. In this way the indicator can be used to compare the relative importance of different causes of premature death within a particular population. Thus, it can be used by health planners to define priorities for the prevention interventions.

The process of calculating a YLL involves several components and this presentation will provide a sequential walk through each step in the YLL calculation, including causes of death statisticsdefinition of ill-defined deathsmethods of redistribution of ill-defined deathsthe use of life tablessocial weighting

The aim of this presentation is to outline a simple step by step guide on the key components in the YLL calculation. Using the real-life example of cerebrovascular disease, the presentation will outline the key choices and assumptions that underline each data inputs in the YLL calculation. Participants in this session will also be provided with links to resources to help facilitate this decision making process. The workshop will end with an interactive session where the presenters will discuss the implications of the different methodological choices with the audience.

Impact of overweight on the burden of non-communicable diseases in Belgium: the WaIST project

Issue

Excess weight status is one of the main metabolic risk factors for non-communicable diseases. According to the Belgian health interview survey of 2018, 49.3% of the adult population suffered from overweight. Despite the great national burden, and apart from isolated actions, there is not anymore a comprehensive nutritional and physical activity health plan in Belgium. Consequentially, Belgium requires action-oriented research to support the implementation of evidence-based policies for the prevention of excessive weight gain.

Description of the Problem

The WaIST project aims to assess the contribution of excess weight status to the societal impact of non-communicable diseases, disability and multi-morbidity, and to model and compare the potential impact of internationally recommended health policies. The project also aims to support knowledge translation and policy transfer through a close interaction with national decision makers and stakeholders.

Results

The disease burden of diabetes, cardiovascular diseases, cancer and musculoskeletal disorders will be estimated in terms of disability-adjusted life years (DALYs) and healthcare expenses from a societal perspective. For this purpose, survey, registry, health insurance, and hospital discharge data will be used. Subsequently, health interventions tackling overweight will be selected considering scientific evidence and stakeholder priorities. Health impact assessments will then be conducted projecting the future impact of the interventions on health outcomes and costs related to excess weight status.

Lessons

The use of national data for the computation of the burden of disease provides better estimates for DALYs and costs compared to European or global study results. Moreover, the results of the project will allow to explore the impact of health intervention specific for the Belgian case.

Key messages

Considering the burden associated with overweight-related diseases, preventing obesity is important from a public health and financial perspective. Integrating these results into evidence-based policies could provide governments and partners with a key tool for effective health interventions.

Perceived utility and feasibility of pathogen genomics for public health practice: a survey among public health professionals working in the field of infectious diseases, Belgium, 2019

BACKGROUND

Pathogen genomics is increasingly being translated from the research setting into the activities of public health professionals operating at different levels. This survey aims to appraise the literacy level and gather the opinions of public health experts and allied professionals working in the field of infectious diseases in Belgium concerning the implementation of next-generation sequencing (NGS) in public health practice.

METHODS

In May 2019, Belgian public health and healthcare professionals were invited to complete an online survey containing eight main topics including background questions, general attitude towards pathogen genomics for public health practice and main concerns, genomic literacy, current and planned NGS activities, place of NGS in diagnostic microbiology pathways, data sharing obstacles, end-user requirements, and key drivers for the implementation of NGS. Descriptive statistics were used to report on the frequency distribution of multiple choice responses whereas thematic analysis was used to analyze free text responses. A multivariable logistic regression model was constructed to identify important predictors for a positive attitude towards the implementation of pathogen genomics in public health practice.

RESULTS

146 out of the 753 invited public health professionals completed the survey. 63% of respondents indicated that public health agencies should be using genomics to understand and control infectious diseases. Having a high level of expertise in the field of pathogen genomics was the strongest predictor of a positive attitude (OR = 4.04, 95% CI = 1.11 - 17.23). A significantly higher proportion of data providers indicated to have followed training in the field of pathogen genomics compared to data end-users (p < 0.001). Overall, 79% of participants expressed interest in receiving further training. Main concerns were related to the cost of sequencing technologies, data sharing, data integration, interdisciplinary working, and bioinformatics expertise.

CONCLUSIONS

Belgian health professionals expressed favorable views about implementation of pathogen genomics in their work activities related to infectious disease surveillance and control. They expressed the need for suitable training initiatives to strengthen their competences in the field. Their perception of the utility and feasibility of pathogen genomics for public health purposes will be a key driver for its further implementation.

Slowing improvements in life expectancy across European Economic Area countries

Background

Life expectancy improvements have slowed down in several European countries since around 2011. The relative contributions from changes in specific conditions (e.g. cancers) and broader risk factors (e.g. smoking or austerity) remain unclear. We aimed to explore the different potential causes in 17 European Economic Area (EEA) countries.

Methods

We compared Global Burden of Disease (GBD) study estimates for life expectancy, years of life lost (YLLs) and population attributable fractions (PAFs) for risk factors, for 2005-2011 and 2011-2017 for 17 EEA countries. Three countries with the largest absolute improvements and three with the smallest were selected for analysis by gender, age, condition and risk factors.

Results

Norway, France and Belgium had the largest improvement in life expectancy (+1.5, +1.2 and +1.2 years respectively) from 2011 to 2017, and Germany, Iceland and the UK the smallest (+0.1, +0.2 and +0.2 years). Life expectancy reduced slightly for women aged over 80 in Germany and UK, men aged over 50 in Germany, and for men in all age groups up to 90 years in Iceland. Norway, France and Belgium saw faster improvements in YLLs from lung cancer and Norway and France for COPD in both men and women, and from self-harm in men, after 2011 than before. PAF for tobacco declined faster after 2011. Germany, Iceland and the UK saw slower improvements in cardiovascular disease and in Germany and the UK lung cancer. In Iceland, YLLs for cancers, self harm, respiratory disease, cirrhosis and dementia all worsened after 2011. PAF for tobacco remained high or declined less after 2011 in all 3 countries. PAFs for alcohol and drug use remained high in Iceland and UK.

Conclusions

Differential changes in major fatal diseases and risk factors help explain national changes in life expectancies, but national differences in data availability may affect results. Further research is needed into the ‘causes of the causes’, such as the 2008 economic crash in Iceland.

Key messages

Differential changes in major fatal diseases and risk factors help explain national changes in life expectancies. Norway, France and Belgium had the largest improvement in life expectancy from 2011 to 2017, and Germany, Iceland and the UK the smallest.

Health impact of substituting red meat by fish: addressing variability in risk-benefit assessments

Background

Sufficient intake of fish and limited red meat intake is commonly encouraged by national dietary guidelines to prevent various lifestyle diseases. One way to fulfill these guidelines would be to substitute red meat by fish. However, quantitative evidence of the public health gain of such substitution is lacking. Moreover, contaminants in these foods may compromise nutritional benefits. We aimed to estimate the health impact of substituting red meat by fish in the Danish diet in a risk-benefit assessment (RBA). Our study can support policy makers in defining evidence-based public health strategies.

Methods

We quantified the health impact of substituting red meat by fish among Danish adults in terms of Disability-Adjusted Life Years (DALY) using data from a national dietary survey and food monitoring. We investigated the use of probabilistic methods to model variability in individual substitution behaviors and to assess health impact distributions in RBA of food.

Results

Health impact of the substitution varied largely by the type of fish consumed and by age and sex of the consumer. We estimated that 134 (95% uncertainty interval: 102; 169) DALYs/100,000 could be averted per year if a mix of lean and fatty fish is consumed in the Danish recommended amounts and intake of red meat decreased among Danish adults. The highest benefit was estimated for women in the childbearing age and for men above 50 years of age. However, a small fraction of women were assigned an overall health loss due to methylmercury exposure during pregnancy and the associated adverse effects in unborn children.

Conclusions

Our study estimated an overall health gain of substituting red meat by fish in the general Danish adult population, while providing insight in the variability in health impact at the level of individual consumers. Our approach can be applied in other RBAs and the results support the need for targeted public health strategies to ensure consumer health and safety.

Key messages

The health impact of substituting red meat by fish in Danish adults was quantified in terms of disability-adjusted life years (DALYs), while accounting for variability between individuals. We estimated that young women and men above 50 years of age will experience the largest health gain while a small fraction of the women were assigned a health loss due to chemical exposure.

Development of composite indicators to monitor burden of disease across Member States

Background

The burden of disease (BoD) methods are not part of routine public health activities and policy development process across all Member States (MSs). The main reasons for this are varying levels of knowledge, experience, and capability to apply and use BoD methods. Therefore, MSs need support, guidance and training to adopt and integrate BoD approaches in their public health systems. In this context, two workshops have been organised by InfAct. The main objectives of the workshops are to raise awareness, share knowledge and experience, and to provide mutual support to to integrate BoD indicators in the public health policies across Europe.

Methods

The workshops were about the BoD concept and methodologies, and the use of BoD data in public health policy. These workshops were supported by technical presentations describing methods and the use of BoD data in health policy with various case studies, followed by expert exchange with facilitated discussions and group work. The case studies included national BoD studies from Belgium, Germany, Netherland, and Scotland.

Results

Two workshops were held at Santé Publique France, and attended by 16 BoD experts and 40 participants from 25 MSs. The workshops were well received by the participants particularly with regards to the diversity of the group and the possibility to share knowledge and experience from various perspectives. Three areas of action were highlighted: 1. the need for methodological trainings to strengthen skills in interpreting and calculating BoD estimates; 2. the encouragement of more collaborations across MSs to share or exchange good practices on BoD; and 3. the importance of the implications of BoD data to guide policies across MSs.

Conclusions

The workshops highlighted the need for capacity building activities to implement BoD approaches across MSs in routine public health activities and to use BoD data to guide health policy. More collaborations among MSs on BoD activities are needed in the future.

An online health status report to support public health in Belgium

Issue

Monitoring population health is crucial for policymakers. In Belgium, health monitoring only existed at regional level, with no integrated view at country level.

Policy/tool

The Health Status Report (HSR) project developed a tool for centralizing key health indicators. The HSR aims to support policymakers in multiple ways: as a ’warning signal’, by contributing to the planning of health policies, and as an assessment tool for those policies. Rather than being exhaustive, the HSR selects key indicators to highlight important needs. These indicators have been identified through literature and consultations with experts and stakeholders. Topics include life and health expectancies, mortality, morbidity, and lifestyles, with an important focus on socioeconomic inequalities. Good results and health gaps are underlined with international comparisons, trend analyses, and comparisons with reference values. By disaggregating the data by sex, age, geographic level or socio-economic level, specific health needs are identified.

Results

The main outcome of the project is a continuously updated website: www.healthybelgium.be. The report highlighted that, although the Belgian health status is rather good, there is room for improvement: for some indicators Belgium lags behind other European countries; regional disparities remain important, with most indicators revealing a better health status in Flanders than in Brussels and Wallonia. Socioeconomic disparities also remain very important, and for some indicators even tend to worsen. Comparing the Belgian health status to that of the EU-15 results in more severe conclusions than in international reports.

Conclusions

We developed a new tool to support public health policy in Belgium through benchmarking and trend and disparity analyses of several health indicators. The tool will be expanded in the next years, integrating for instance the results of the Belgian national burden of disease study.

Key messages

We developed an online health status monitoring tool to inform policymakers. The rather good health status hides important regional and socioeconomic disparities in Belgium.

Monitoring of non-communicable diseases in Belgium

Key messages

There is currently no national plan to prevent and monitor the health impact of non-communicable diseases in Belgium. The Belgian Health Status Report and the Belgian National Burden of Disease Study provide new opportunities for monitoring non-communicable diseases in an integrated and comparable way.

Taenia solium control in Zambia: The potholed road to success

The taeniosis/cysticercosis neglected zoonotic disease complex is caused by Taenia solium, and is associated with significant economic and public health impacts. This paper reviews the current knowledge on T. solium in Zambia and the control strategies already studied, covering almost 20 years of research, and explores the way forward. Studies on occurrence of porcine cysticercosis indicated very high prevalences, ranging from 15 to 34% based on detection of circulating antigens, and of 46% to 68% based on full carcass dissection in slaughter age pigs. Taeniosis prevalences have been reported to range from 6.3% to 12% based on copro-Ag-ELISA. Human cysticercosis prevalence results ranged from 5.8% to 13% based on serum Ag-ELISA, and from 34% to 39% based on sero-antibody detection. Later on, a study in people with epilepsy suggested neurocysticercosis to be the single most important cause of epilepsy in this T. solium endemic area, with 57% of the people with active epilepsy diagnosed with probable or definite neurocysticercosis. While the need to reduce the disease burden of T. solium in Zambia is obvious, the exact short and long term goals, and the strategies to achieve these goals, are not clear. We have selected the most promising control/elimination strategies from reviews and assessed these for feasibility via discussions with local stakeholders from both medical and veterinary sectors. The proposed measures were evaluated using the newly developed agent-based disease transmission model, cystiSim and optimised using Zambian demographic and disease data. As a control option, yearly porcine treatments were selected as best option, while the preferred strategy for elimination was determined to be the combination of human and porcine mass drug administration combined with porcine vaccination of all eligible people and pigs, in a schedule of six iterations of four monthly interventions. These interventions are currently being field tested, combined with education. Several other hurdles to control, such as cost and socio-political factors and the need for an improved advocacy and awareness creation are discussed.

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously.

This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted.

The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition.

Changes in health in Belgium, 1990-2016: a benchmarking analysis based on the global burden of disease 2016 study

BACKGROUND

Despite increasing of the Belgian health expenditures, several indicators related to population health showed poor results. The objectives of this study were to perform an in-depth analysis of the secular trend of Belgian health status using the Global Burden of Disease (GBD) 2016 study results for Belgium, and to compare these results with other European countries.

METHODS

We collected results of the Global Burden of Disease 2016 study through the GBD results and visualization tools. We benchmarked Belgian GBD results with the other initial members of the European Union (EU15).

RESULTS

Belgium performed significantly better in 2016 than in 1990 in terms of age-standardized (AS) Year of Life Lost (YLL) rates but not significantly different in terms of AS Year Lived with Disability (YLD) and Disability-Adjusted Life Year (DALY) rates. The contribution of AS YLDs to total of AS DALYs increased from 1990 (42%) to 2016 (54%). Although AS YLD and DALY rates did not seem to differ between Belgium and the EU15 from 1990 to 2016, the ranking of Belgium among the EU15 in terms of AS DALY and YLL rates was worse in 2016 than in 1990. Belgium had significantly higher AS YLL rates for lower respiratory infections (B: 264 AS YLLs [95% uncertainty interval [UI] 231-301] per 100,000; EU15: 188 AS YLLs [95%UI 168-212] per 100,000), chronic obstructive pulmonary disease (B: 368 AS YLLs [95%UI 331-407] per 100,000; EU15: 285 AS YLLs [95%UI 258-316] per 100,000) and tracheal, bronchus, and lung cancer (B: 785 AS YLLs [95%UI 699-879] per 100,000; EU15: 613 AS YLLs [95%UI 556-674] per 100,000).

CONCLUSION

Belgium's ranking among the EU15 in terms of AS YLL and DALY rates decreased from 1990 to 2016. Significant health gains appear possible by acting on risk factors directly linked to a significant part of the Belgian burden of diseases, i.e., alcohol and tobacco consumption, and high body mass index. National burden of disease estimates can help defining Belgian health targets and are necessary as external validity of GBD results is not always guaranteed.

Re-visiting the detection of porcine cysticercosis based on full carcass dissections of naturally Taenia solium infected pigs

Background

Taenia solium is a neglected zoonotic parasite. The performances of existing tools for the diagnosis of porcine cysticercosis need further assessment, and their shortcomings call for alternatives. The objective of this study was to evaluate the performance of tongue palpation and circulating antigen detection for the detection of porcine cysticercosis in naturally infected pigs of slaughter age compared to full carcass dissections (considered the gold standard). Additionally, alternative postmortem dissection procedures were investigated. A total of 68 rural pigs of slaughter age randomly selected in the Eastern Province of Zambia were dissected. Dissections were conducted on full carcasses (or half carcass in case cysticerci were already detected in the first half), including all the organs. Total cysticercus counts, location and stages were recorded and collected cysticerci were identified morphologically and molecularly. All sera were analysed with the B158/B60 antigen detecting ELISA (Ag-ELISA).

Results

Key findings were the high occurrence of T. solium infected pigs (56%) and the presence of T. solium cysticerci in the livers of 26% of infected animals. More than half of the infected carcasses contained viable cysticerci. Seven carcasses had T. hydatigena cysticerci (10%), out of which five carcasses were co-infected with T. hydatigena and T. solium; two carcasses (3%) had only T. hydatigena cysticerci. Compared to full carcass dissection, the specificity of the Ag-ELISA to detect infected carcasses was estimated at 67%, the sensitivity at 68%, increasing to 90% and 100% for the detection of carcasses with one or more viable cysticerci, and more than 10 viable cysts, respectively. Tongue palpation only detected 10% of the cases, half carcass dissection 84%.

Selective dissection of the diaphragm, tongue and heart or masseters can be considered, with an estimated sensitivity of 71%, increasing to 86% in carcasses with more than 10 cysticerci.

Conclusions

Depending on the aim of the diagnosis, a combination of Ag-ELISA and selective dissection, including investigating the presence of T. hydatigena, can be considered. Full carcass dissection should include the dissection of the liver, kidneys, spleen and lungs, and results should be interpreted carefully, as small cysticerci can easily be overlooked.

Present status of laboratory diagnosis of human taeniosis/cysticercosis in Europe

Human cysticercosis (CC) is a parasitic zoonosis caused by the larval stage (cyst) of the Taenia solium. Cysts can establish in the human central nervous system (neurocysticercosis, NCC) and other organs and tissues; they also develop in pigs, the natural intermediate host. Human taeniosis may be caused by T. solium, Taenia saginata and Taenia asiatica tapeworms; these infections are usually asymptomatic, but show a significant relevance as they perpetuate the parasites’ life cycle, and, in the case of T. solium, they are the origin of (N)CC. In European Union (EU) member states and associated countries, the occurrence of autochthonous T. solium cases is debated, and imported cases have significantly increased lately; the status of T. asiatica has been never reported, whereas T. saginata is prevalent and causes an economic impact due to condemned carcasses. Based on their effects on the EU society, the specific diagnosis of these pathologies is relevant for their prevention and control. The aims of this study were to know the diagnostic tests used in European laboratories for human taeniosis/cysticercosis by means of a questionnaire, to determine potential gaps in their detection, and to obtain preliminary data on the number of diagnosed taeniosis/CC cases.

Mapping EQ-5D utilities to GBD 2010 and GBD 2013 disability weights: results of two pilot studies in Belgium

Background

Utilities and disability weights (DWs) are metrics used for calculating Quality-Adjusted Life Years and Disability-Adjusted Life Years (DALYs), respectively. Utilities can be obtained with multi-attribute instruments such as the EuroQol 5 dimensions questionnaire (EQ-5D). In 2010 and 2013, Salomon et al. proposed a set of DWs for 220 and 183 health states, respectively. The objective of this study is to develop an approach for mapping EQ-5D utilities to existing GBD 2010 and GBD 2013 DWs, allowing to predict new GBD 2010/2013 DWs based on EQ-5D utilities.

Methods

We conducted two pilot studies including respectively four and twenty-seven health states selected from the 220 DWs of the GBD 2010 study. In the first study, each participant evaluated four health conditions using the standard written EQ-5D-5 L questionnaire. In the second study, each participant evaluated four health conditions randomly selected among the twenty-seven health states using a previously developed web-based EQ-5D-5 L questionnaire. The EQ-5D responses were translated into utilities using the model developed by Cleemput et al. A loess regression allowed to map EQ-5D utilities to logit transformed DWs.

Results

Overall, 81 and 393 respondents completed the first and the second survey, respectively. In the first study, a monotonic relationship between derived utilities and predicted GBD 2010/2013 DWs was observed, but not in the second study. There were some important differences in ranking of health states based on utilities versus GBD 2010/2013 DWs. The participants of the current study attributed a relatively higher severity level to musculoskeletal disorders such as ‘Amputation of both legs’ and a relatively lower severity level to non-functional disorders such as ‘Headache migraine’ compared to the participants of the GBD 2010/2013 studies.

Conclusion

This study suggests the possibility to translate any utility derived from EQ-5D scores into a DW, but also highlights important caveats. We observed a satisfactory result of this methodology when utilities were derived from a population of public health students, a written questionnaire and a small number of health states in the presence of a study leader. However the results were unsatisfactory when utilities were derived from a sample of the general population, using a web-based questionnaire. We recommend to repeat the study in a larger and more diverse sample to obtain a more representative distribution of educational level and age.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-017-0174-z) contains supplementary material, which is available to authorized users.

Comorbidities and factors associated with central nervous system infections and death in non-perinatal listeriosis: a clinical case series

Background

Listeriosis is a rare disease caused by the bacterium Listeria monocytogenes and mainly affects at risk people. Listeriosis can lead to sepsis, central nervous system (CNS) infections and death. The objectives of this study were to describe and quantify comorbidities and neurological sequelae underlying non-perinatal listeriosis cases and to describe the factors associated with death and CNS infections in non-perinatal listeriosis.

Methods

We retrospectively collected clinical data through computerized, paper or microfilmed medical records in two Belgian university hospitals. Logistic regression models and likelihood ratio tests allowed identifying factors associated with death and CNS infections.

Results

Sixty-four cases of non-perinatal listeriosis were included in the clinical case series and 84 % were affected by at least one comorbid condition. The main comorbidities were cancer, renal and severe cardio-vascular diseases. Twenty-nine patients (45 %) suffered from a CNS infection and 14 patients (22 %) died during hospitalization, among whom six (43 %) had a CNS involvement. Among surviving patients, eleven suffered from neurological sequelae (22 %) at hospital discharge; all had CNS infection. Five of these patients (45 %) still suffered of their neurological sequelae after a median follow-up of one year (range: 0.08–19). The factor associated with death during the hospitalization was the presence of a severe cardiovascular disease (OR = 4.72, p = 0.015). Two factors inversely related with CNS infections were antibiotic monotherapy (OR = 0.28, p = 0.04) and the presence of renal disease (OR = 0.18, p = 0.02).

Conclusions

In a public health context these results could be a starting point for future burden of listeriosis studies taking into account comorbidity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1602-3) contains supplementary material, which is available to authorized users.

Human migration and pig/pork import in the European Union: What are the implications for Taenia solium infections?

Taenia solium taeniasis/cysticercosis is a neglected zoonotic disease complex occurring primarily in developing countries. Though claimed eradicated from the European Union (EU), an increasing number of human neurocysticercosis cases is being detected. Risk factors such as human migration and movement of pigs/pork, as well as the increasing trend in pig rearing with outside access are discussed in this review. The entry of a tapeworm carrier into the EU seems a lot more plausible than the import of infected pork. The establishment of local transmission in the EU is presently very unlikely. However, considering the potential changes in risk factors, such as the increasing trend in pig farming with outdoor access, the increasing human migration from endemic areas into the EU, this situation might change, warranting the establishment of an early warning system, which should include disease notification of taeniasis/cysticercosis both in human and animal hosts. As currently human-to-human transmission is the highest risk, prevention strategies should focus on the early detection and treatment of tapeworm carriers, and should be designed in a concerted way, across the EU and across the different sectors.