1. Epidemiologic Transition: Changes of fertility and mortality with modernization (3)
Abdel Omran. The Epidemiologic Transition: A Theory of the epidemiology of population change. Milbank Quarterly ;49:
Lecture by Ronald E. LaPorte. Annotated Version on October 1, 2010.
Omran has written several classic papers on the epidemiologic transition. For NCD epidemiology important insight can be gained by understanding this model.
Original Power Point file of this lecture

2. Charles Darwin Evolution of Species Abdel Omran Evolution of Disease
Charles Darwin talked about the evolution of Species. Abdel Omran also dealt with evolution, but the evolution of diseases in populations over time.
Charles Darwin
Evolution of Species

3. Epidemiology Psychiatric Epidemiologists Diabetes Epidemiology
Cardiovascular Epidemiology
Cancer Epidemiology
Infectious Disease Epidemiology
Epidemiology an be categorized into many different silos. Omran argued that in order to understand the patterns of “our” disease, we also have to look at the origins, ups and downs of all diseases.

4. Instead at looking at individual diseases, we need to look at the patterns of diseases
Diseases go up and down in relationship to each other, sometimes there may not be a biologic relationship but the diseases go up and down together, or predict each other over time.

5. Mortality is the fundamental factor in the dynamics of population growth and causes of death.
Mortality has no fixed upper limits. Thus if fertility approached its upper maximum, depopulation would still occur.
A basic concept of the epidemiologic transition has been how the transition can explain population growth.
It is mortality, not fertility that determines population growth. SES, mortality, and morbidity are tied together in a system of disease and population growth. To understand the system, it is essential to understand the total interrelationships.

6. During the epidemiologic transition, a long-term shift occurs in mortality and disease patterns whereby pandemics of infection are replaced by degenerative and man-made diseases...
Omran argued that we can not view diseases in isolation. It is critical to look at the pattern of disease, not a single disease.

7. Age of Pestilence and Famine
Characterized by high mortality rates, wide swings in the mortality rate, little population growth and very low life expectancy
During the age of pestilence the population on a reoccurring basis is being decimated by epidemics of infectious diseases. The mortality rates drive the system. Life expectancy is low, fertility is high, but the high fertility rates are off set by very high mortality rates.

8. Age of Receding Pandemics
Epidemics become less frequent, infectious diseases in general become less frequent, a slow rise in degenerative diseases begin to appear
In this era, the epidemics of TB, plague, malaria, etc. begin to subside. The death rate goes down with little change to the fertility rates, thus population growth occurs. During this time one sees the beginning of non-communicable diseases.

9. The shifts in disease patterns in the 19th century were primarily related to changing SES. With the 20th Century more related with disease control activities independent of SES: e.g. Mexico, China
In the early stages of the transition in the 19th century, the changing mortality patterns are closely associated with improvements in SES. However, in the 20th century major advances have been made by countries with a low socioeconomic status but with an effective public health system.

10. As can been seen in Japan, Since 1900 the birth rated exceeded the death rate, leading to rapid population gains. During WWII, the death rate skyrocketed, but shortly after this there was baby boom.

11. In Sweden a similar patter occurred, in the period of Pestilence and Famine, there was very little population growth, primarily due to rampant epidemics of disease. During the receding pandemic era, the death rate was still high, but epidemics were reduced resulting in increases in populations.

12. In the health transition one sees a rapid decline of infectious diseases followed by a growth of Non communicable diseases

13. For the European model the rapid rise in population growth due to declining death rates.

14. Epidemiologic Transition in Developing and Developed Countries
World wide this century has seen a very rapid improvement in life expectancy. With this improvement there has been major shifts in the causes of death. Most certainly developed countries have a lower life expectancy. However what is often missed is that for both developing and developed countries alike there has been over a 30 increase in life expectancy.

15. 14 years
35 years
In the 1950s there was a 35 year difference between developed and developing countries, now this has shrunk to only 14 years.

16. A second components of the Epidemiologic transition is the unmasking of chromic diseases.

17. The model seen in NY is a generalized model for almost all countries.

18. A clear example is that of Mexico, with declining infectious diseases and the rising chronic disease.

19. Increasing Life Expectancy and
Causes of Death
100
Other 80 60
Violence
CHD 40 CA
One of the most striking predictions by Omran is that given countries have the same life expectancy, there is very little difference in the causes of death. 20
Infection 40 44 48 52 56 60 64 68 72 76
Population Life Expectancy

20. As part of the epidemiologic transition is the rapid increase in Aging populations world wide.

21. Global Homogenety of
Mortality Patterns

22. With the epidemiologic transition, one also sees transitions with SES for risk factors, such as cigarette smoking

23. There also has been a rapid increase in nutritional change
There also has been a rapid increase in nutritional change. Calories are cheap, which has been of benefit of improving immunology, however with cheap calories weight and the prevalence of obesity increases.

24. Epidemiologic Transition
Infectious Diseases
NCD
Mortality Rates
This schematic demonstrates the changes in infectious diseases, and noncommunicable diseases with increase SES
Epidemiologic Transition

25. Death Rates for TB in England and Wales
TB Bacillus
Identified
Chemotherapy
BCG Vaccination
There has been a rapid reduction, for example, of TB in England and many other countries. This could not have been the result of Chemotherapy or BCG Vaccination as the decline began way before vaccinations.

26. Death Rates for Measles in Children in England and Wales
Immunization begun
The same is true for measles, where there has been a rapid decline that is not related to immunization.

27. NIDDM
CHD
Trauma CA
Mortality Rates
Epidemiologic Transition

28. Taiwan has also show the epidemiologic transition with the rapid increase in life expectancy due to the reduced infectious disease

29. At the same time there was major changes in nutrition with rapid increase in meat and dairy intake

30. China is a prime example of the epidemiologic transition
China is a prime example of the epidemiologic transition. Since 1945 life expectancy has raised almost 30 years, now life expectancy is not much different than the US

31. The Causes of death in the US and China are virtually identical

33. High Incidence of NCDs in Developing Countries
Possible Infectious Etiology
Macronodular Cirrhosis
Hepatocellular Carcinoma
Rheumatic Heart Disease
Iron deficiency anemia
Related to Nutrition Deficiency
Endemic Goiter
Malnutrition Related Diabetes.
Developing countries have a very different pattern. Their diseases are primarily associated undernutrition and infection, whereas developing countries are related to overnutrition.

34. High Incidence of NCDs in Developed Countries
Cardiovascular
CHD
Deep Vein Thrombosis
Respiratory
Emphysema
Lung CA
Female Genital
Endometriosis
Endometrial CA
Breast
Breast CA
Fibrocystic Disease
Male Genital
Prostrate CA
Metabolic
NIDDM
There is a pattern of diseases for non-communicable diseases in developed countries in contrast with developing countries.

35. Back to Nature A Healthier Diet, less saturated fats, more fiber
Improved Physical activity
A Healthier Diet, less saturated fats, more fiber
Less Stress
We have heard how we should get back to the good old days…
But how good were they?

36. Nomads Farmers Urban 45 yrs 60 yrs 70 yrs Transition
The good old days of nomadic existence had a remarkably lowlife expectancy.

37. USA 1960 Urban Rural rural urban Developing Countries
In 1960, in developing countries most people lived in rural areas.
Developing
Countries
USA

38. USA 2010 Urban Rural urban rural Developing Countries
Now this has dramatically changed, the “mega” cities of developing countries, such as Mexico City, and Sao Paulo have rapidly emerged.
Developing
Countries
USA

39. Causes of Death Developed Developing Age 15-44 Age 45-54 Age 15-44
Accidents CA
CHD
Age 45-54
Age 15-44
Accidents
CHD CA
Age 45-54
If one looks that the most productive segments of society in developing and developed countries, the causes of death are virtually the same.

40. Conclusion
The epidemiologic transition ties together fertility with rise in SES.
The Second component is that it present the idea that disease appears in populations like a symphony with disease rising and falling, all in relationship to each other

41. Review Questions (Developed by the Supercourse team)
What might the epidemiologic transition tell us about the evolution of chronic diseases?
Over the past 100 years, life expectancy and causes of death have become homogenous world wide. Why is this important?
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