1. Non-Communicable Disease: Epidemiology, Prevention & Control Ahmed Mandil, Prof of Epidemiology KSU College of Medicine

2. Headlines Definitions Examples Magnitude of the Problem Risk Factors Sources of Data Prevention & Control Challenges Injury epidemiology & prevention 3 November 20152NCD Epi

3. Definitions (I) Chronic health-related state: a state which lasts for a long time, usually more than 3 months Chronic exposure:prolonged (long term), usually of low intensity. Chronic diseases: those diseases that have uncertain etiology, multiple risk factors, a prolonged course, do not resolve spontaneously, and for which a complete cure is rarely achieved. Non-communicable diseases (NCD): a miscellaneous group of health-related conditions, usually not communicated through infective pathogens, and may cause impairment, disability, handicap or even premature death. 3 November 20153NCD Epi

4. Defintions (II) Risk factor: an aspect of personal behavior / life-style, an environmental exposure, an inborn / inherited characteristic, which on the basis of epidemiologic evidence, is known to be associated with health-related condition(s) considered to important to prevent. Modifiable risk factor: a determinant that can be modified by intervention, thereby reducing the probability of occurrence of disease or other specified outcomes. Latent period: delay between exposure to a disease-causing agent and the appearance of manifestations of the disease. E.g. after exposure to ionizing radiation, there is a latent period of 5 years, on the average, before development of leukemia, and > 20 years before development of certain other malignancies. 3 November 20154NCD Epi

5. Definitions (III): Exceptional NCD Some NCD were recently proven to be of infectious origin, e.g. peptic ulcer (Helicobacter pylori), liver carcinoma (HCV), cancer cervix (Human Papilloma Virus), leukemia (oncogenic viruses), etc. The term chronic may not apply to conditions as: angina pectoris, Acute Myocardial Infarction (AMI), anxiety, acute depression Some infectious diseases are chronic: e.g. T.B., HIV / AIDS 3 November 20155NCD Epi

6. NCD Examples (I) Congenital anomalies Malnutrition (pediatric, geriatric) Endocrinal / metabolic disorders (e.g. diabetes, gout) Cardiovascular diseases (e.g. hypertension; atherosclerosis; ischemic heart disease [IHD]: angina, myocardial infarction). Locomotor system problems: e.g. arthritis (acute, chronic) Chronic respiratory conditions (e.g. bronchial asthma) 3 November 20156NCD Epi

7. NCD Examples (II) Occupational-related conditions (e.g. pneumoconiosis) Neoplasms (benign / malignant; childhood / adult) Injuries (intentional / non-intentional) Sensory loss (e.g. deafness, blindness) Diseases of senescence (degenerative diseases) Psychiatric disorders (neuroses, psychoses) 3 November 20157NCD Epi

8. Magnitude of the Problem (I) NCD are considered the leading causes of death and disability on a global scale, and appear to have been so, for at least the last two decades of the 20 th century. Disease rates (morbidity and mortality) from these conditions are accelerating globally, advancing across regions and social classes, with special burden in less developed nations. 3 November 20158NCD Epi

9. Magnitude of the Problem (II) Among the many NCDs that contribute importantly to the global burden of disease, disability and death, cardiovascular disease (CVD), cancer, diabetes and chronic respiratory diseases are four of the most prominent. These four conditions are linked by common lifestyle determinants such as imbalanced diet, physical inactivity and tobacco consumption. They together contribute to 50% of global mortality. NCD are expected to account for an increasing share of disease burden, rising globally from 43% in 1998 to 73% by 2020. The expected increase is likely to be particularly rapid in less developed nations. 3 November 20159NCD Epi

10. The Regional Situation  The WHO Region for the Eastern Mediterranean, NCD account for 52% of all deaths and 47% of the disease burden in EMR during the year 2005  This burden is likely to rise to 60% in the year 2020  The conventional risk factors may explain 75% of such NCD 3 November 201510NCD Epi

11. Cardiovascular Chronic Respiratory Disease Type 2 Diabetes Cancer Chronic Diseases result in percent of deaths 4 52 EMR Adult Population 3 November 201511NCD Epi

12. STEPwise data from some EM countries CountryYear of field work Diabetes % Hypertension % Overweight & Obesity % Iraq200610.440.466.9 Jordan20071625.567.4 Saudi Arabia200517.926 Syrian Arab Republic 200319.828.856.3 Kuwait200516.724.681.2 Egypt200516.533.476.4 Sudan200519.223.653.9 3 November 201512NCD Epi

13. Risk Factors Aging of the population Use of motor vehicles (automobiles) Life-style changes Poor / unbalanced / unhealthy nutrition Tobacco consumption / addiction Physical inactivity Harmful use of alcohol consumption Obesity Other social and behavioral factors. 3 November 201513NCD Epi

14. NCD RISK FACTORS, EMR Tobacco use 16-65% Hypertension 12-35% Diabetes 7-25% Overweight-obesity40-70% Dyslipidemia30-70% Physical Inactivity 80-90% 3 November 201514NCD Epi

15. Sources of data on NCD Data Mortality statistics Hospital records (especially discharge) Disease registries (e.g. cancer / diabetes / hypertension registries) Interview surveys Occupational medical records Sickness and disability insurance statistics Drugs' dispensing statistics (prescribed, over- the-counter) 3 November 201515NCD Epi

16. NCD Prevention and control (I) Goals: To reduce disease incidence To prevent / delay onset of disability To alleviate severity of disease To prolong the individuals’ life (Inshaa-Allah) 3 November 201516NCD Epi

17. NCD Prevention and control (II) Important issues: One of the most important objectives of NCD control is the change of the public's perception of NCD from one of "inevitability" to that of "preventability". NCD control is based on avoidance of the most important risk factors (e.g. tobacco addiction, physical inactivity, poor nutrition), all of which are behavioral factors, often difficult to change. Healthy behaviors should be promoted early on in life through comprehensive school health education and efforts to change behavior in children and young people. 3 November 201517NCD Epi

18. NCD Prevention and control: (III) Primary prevention Directed at susceptible persons, before they develop a certain NCD, thus aims at reducing incidence. Needs establishment of risk factors, before- hand (community-specific). Examples: Tobacco prevention programs, promotion of physical activity, dietary recommendations (for balanced diets suitable for age, gender, physical activities, growth & development, weather, community). 3 November 201518NCD Epi

19. NCD Prevention and control: (IV): Secondary prevention Directed at asymptomatic individuals, but have developed biological changes resulting from the disease, thus aims at reducing prevalence. Goal: early detection, management, avoiding / reducing undesirable consequences / complications. Examples: screening programs (e.g. for diabetes, hypertension, cancer), recommended when: natural history permits early detection, available screening tests for early detection, acceptable to the population at risk; effective management regimens 3 November 201519NCD Epi

20. NCD Prevention and control: (V): Tertiary prevention Tertiary prevention: Directed at preventing disability in people who have symptomatic disease, thus aims at trying to improve quality of life. Goal: prevention of progression of a disease and its complications; provision of rehabilitation. Examples: screening for / management of diabetic complications (e.g. retinopathy); orthopedic prosthesis (e.g. for fracture-hip); physiotherapy (e.g. for cardiovascular stroke / paralysis / sports injuries’ victims) 3 November 201520NCD Epi

21. NCD Prevention and control: (VI): Role of Different Agencies Public (governmental) agencies: fund/conduct research; establish standards; provide financing for medical care; deliver medical services to the poor; monitor health status of the population. Voluntary (non-governmental): fund research; provide public and professional education; stimulate social and legislative changes; create visibility for prevention and control through their large cadre of volunteers. Medical care sector: delivers services; provides preventive medicine through primary care; establishes professional guidelines that improve the quality of life. 3 November 201521NCD Epi

22. NCD Prevention and control: ( VII) Challenges - 1 Information on NCD (need for establishment /effectiveness of surveillance activities). Applied research Choosing / maintaining healthy behaviors Social and political policies (laws, regulations) 3 November 201522NCD Epi

23. NCD Prevention and control: ( VII) Challenges - 2 Communication of health risk (proper health promotion) High risk and population-based approaches Cost of health care Access to health-care services (cooperation between public / private systems, multi- sectoral cooperation, health insurance initiatives). 3 November 201523NCD Epi

24. INJURY EPIDEMIOLOGY & PREVENTION

25. Definitions Injury “Acute exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and ionising radiation interacting with the body in amounts or at rates that exceed the threshold of human tolerance. In some cases, injuries result from the sudden lack of essential agents such as oxygen or heat.” (Source: Gibson, 1961; Haddon, 1963) 3 November 201525NCD Epi

26. Definitions Violence “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” (Source: WHO, 1996) 3 November 201526NCD Epi

27. The Global Injury Problem 5 million deaths worldwide = 9% of all deaths (2000) 12% of global burden of disease Road traffic “incidents” are the leading cause of injury deaths worldwide 90% of injury deaths occur in low- and middle-income countries Highest number of deaths in S.E. Asia & Western Pacific regions 3 November 201527NCD Epi

28. The Epidemiological Model VectorAgent Host Environment 3 November 201528NCD Epi

29. The Ecological Model IndividualCommunity Relationship Society Complex Linkages Source: Krug E et al., eds., 2002. 3 November 201529NCD Epi

30. 3 November 201530NCD Epi

31. 3 November 201531NCD Epi

32. VIP Public Health Approach Defining Characteristics  Population-based  Multidisciplinary  Evidence-based  Collective action  Prevention 3 November 201532NCD Epi

33. (1) Surveillance What is the problem? (2) Risk factor identification What are the causes? (4) Implementation How is it done? (3) Develop and evaluate interventions What works? The Public Health Approach 3 November 201533NCD Epi

34. Categorizing Injury 3 November 201534NCD Epi

35. Injury Pyramid Deaths Injuries resulting in hospitalization Injuries resulting in ambulatory and emergency treatment Injuries resulting in treatment in Primary care settings Injuries treated by paramedics only (school nurse, physiotherapist, first aid) Untreated injuries or injuries which were not reported 3 November 201535NCD Epi

36. Types of data and potential sources of information 3 November 201536NCD Epi

37. Source: adapted from Krug et al., eds., 2002 3 November 201537NCD Epi

38. Leading Causes of Mortality and Burden of Disease world, 2004 % 1. Ischaemic heart disease 12.2 2. Cerebrovascular disease 9.7 3. Lower respiratory infections 7.1 4. COPD 5.1 5. Diarrhoeal diseases 3.7 6. HIV/AIDS 3.5 7. Tuberculosis 2.5 8. Trachea, bronchus, lung cancers 2.3 9. Road traffic accidents 2.2 10. Prematurity, low birth weight 2.0 % 1. Lower respiratory infections 6.2 2. Diarrhoeal diseases 4.8 3. Depression4.3 4. Ischaemic heart disease 4.1 5. HIV/AIDS3.8 6. Cerebrovascular disease 3.1 7. Prematurity, low birth weight 2.9 8. Birth asphyxia, birth trauma 2.7 9. Road traffic accidents 2.7 10. Neonatal infections and other 2.7 MortalityDALYs 3 November 201538NCD Epi

39. Source: WHO, 2004 3 November 201539NCD Epi

40. Ten leading causes of burden of disease, world, 2004 and 2030 3 November 201540NCD Epi

41. References 1 1. Last J. A dictionary of epidemiology. 5 th Edition. Oxford, New York, Toronto: Oxford University Press, 2008. 2. Remington PL, Brownson RC, Wegner MV. Chronic disease epidemiology and control. 3 rd Edition. Washington, D.C.: American Public Health Association, 2010. 3. WHO. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases. Geneva: WHO, 2008 3 November 201541NCD Epi

42. References 2 4. Fadhil I. Diabetes and other non- communicable diseases: An Eastern Mediterranean Perspective. WHO, 2009 5. Kuh D, Ben Shlomo Y. A life course approach to chronic disease epidemiology. Oxford, New York, Toronto: Oxford University Press, 1997. 6. Newcomer RJ, Benjamin AE. Indicators of chronic health conditions. Baltimore, London: The Johns Hopkins University Press, 1997. 3 November 201542NCD Epi