ANDHRA PRADESH BURDEN OF DISEASE AND COST EFFECTIVENESS STUDY
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ANDHRA PRADESH BURDEN OF DISEASE
AND COST EFFECTIVENESS STUDY - extracted text
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ANDHRA PRADESH BURDEN OF DISEASE
AND COST EFFECTIVENESS STUDY
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REPORT
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CENTRE FOR SOCIAL SERVICES
ADMINISTRATIVE STAFF COLLEGE OF INDIA
BELLA VISTA HYDERABAD -49
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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Andhra Pradesh Burden of Disease and
Cost Effectiveness Study
I. Introduction
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There is no doubt that considerable improvement in the health status of the communities
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did occur during the past few decades. However, much more still remains to be done. While
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communicable diseases are still common in developing countries, the health systems need to cope
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up with the ageing population suffering from non communicable degenerative diseases.
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Emergence of illnesses like AIDS started to throw new challenges upon the systems.
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Any discussion of the health policy should start with scaling of a problem which aids in
setting health priorities and targeting the health services to the needy and disadvantaged groups of
the society. Most of the assessments of relative importance of different diseases, so far, are based
on how many deaths they cause. This has certain merits as death is an unambiguous event and the
vital registration systems of many countries routinely provide the data required. Even this
approach has lacunae as there are no consistent estimates of adult mortality in many developing
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countries and the available mortality estimates generally confine to infancy and childhood. There
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are, however, many non fatal conditions which are responsible for great loss of ’healthy life'.
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Disability has not been included in estimating the burden as it is considered a problem only in
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societies that had undergone epidemiological transition.
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With expanding role of cost-effectiveness in health care planning, the need for more
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comprehensive measurement of burden of disease has become more urgent. Thus, there is an
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urgent need for a process through which every disease or health problem would be evaluated in
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objective fashion so that the programm
k)t be ignored.
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So far, only one systematic effo
e in Ghana for
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48 causes. Recently, Christopher Mur
o quantify the
burden of disease which was used by th
)bal Burden of
Disease (GBD)1. This new indicator, th
:s the standard
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Community Health Cell
Library and Information Centre
1
World Development Report 1993
367, “ Srinivasa Nilaya ”
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Phone: 5531518/5525372
e-mail:sochara@ vsnl.com '
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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expected years of life lost (YLL) on model life table West level 26. The value of time lived at
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different ages is captured in calculating the DALYs using an exponential function which reflects
the dependence of the young and the elderly on adults. The time lived with disability is made
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comparable with the time lost due to premature mortality. For this, six classes of severity of
■ disability have been defined and each class was assigned a disability weight between 0 and 1.
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Considering the fact that DALY measures the future loss, a social discount rate of three percent
discount has been applied. Details of assumptions used in DALY estimation were summarised in
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Global comparative assessments in the health sector edited by CJL Murray and AD Lopez2.
About 109 categories of diseases (ICD 9), which are responsible for more than 95% of all causes
of death and disability, have been included in this study.
II. Genesis of Andhra Pradesh Burden of disease and Cost
Effectiveness Study:
Subsequent to the Global Burden of. Disease study. National Burden of disease studies
have been planned to provide more insight to the Burden of Disease Approach (BDA). The
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countries where National burden of disease studies have been initiated include: Mexico, Columbia,
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South Africa and India. While in other countries these studies have been planned at National level,
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in India - considering the vast population and reported diversity in disease pattern - it was felt
appropriate to make estimations at state/regional level to begin with. This resulted in the genesis
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of the Andhra Pradesh Burden of disease and Cost effectiveness of Health Interventions study.
Supported by the World Bank, this study has been undertaken by the Administrative Staff College
of India in technical Collaboration with the Harvard Centre for Population and Development
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studies.
III. Area and People:
The State of Andhra Pradesh, located in the coastal south India extending on to the
deccan plateau, is the fifth largest state in India with a population of 66.3 million3. The state has
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23 districts spread over three distinct geographical regions which include Coastal Andhra with
large coastal plains and fertile deltas, Rayalaseema which is drought prone and interior dry
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Global Comparative Assessments in the Health Sector; Disease burden, expenditures and intervention packages Edited by
CJL Murray and AD Lopez WHO 1994
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Paper 1 of 1992, Final Population Totals, Census of India 1991; Registrar General & Census Commissioner
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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Telangana region. While the coastal plains constitute the most developed part of the state,
Telangana region is more backward in terms of social development. Lack of rains and chronic
hunger is a common feature of Rayalaseema. A large majority of the state's population (73%)
reside in rural areas consisting of about 29,400 villages. About 27% of the state's population
reside in 250 urban towns and cities, a trend more or less common to the rest of the country.
About 80% of the urban population is residing in 66 towns having population more than 50,000
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and the three corporations of Hyderabad, Vijayawada and Visakhapatnam
About 15.9% of the population
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belong to scheduled castes while scheduled tribes
constitute 6.3%. According to 1991 census, the estimated percentage of literates among
population aged seven years and above was 45.11% (Males: 56.2%; Females: 33.7%) compared
to the national average of 52.1%. From a strong agricultural base, the state economy has, over the
years, diversified into industry and science. The National Sample Survey Organisation's estimates
of poverty during 1977-78 (32nd round) and 1983-84 (38th round) indicate that rural poverty in
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the state has declined from 45.45% to 38.67%. The corresponding decline in the urban poverty
during the same period was from 37.02% to 29.4%.
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IV. Objectives:
♦ To estimate the burden caused by common diseases including injuries and
accidents in the State of Andhra Pradesh, India
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Compare the disease burden of urban and rural areas AP and
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Study the cost effectiveness of selected health interventions using DALYs
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as measure of effectiveness
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V. Approach:
The essential approach used in Andhra Pradesh Burden of Disease Study was to gather
relevant information from different sources, discuss with respective experts and to arrive at the
preliminary set of estimates on mortality and disability for each disease. This was followed by a
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consistency check to validate the estimates made. The disease experts were approached again to
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give their comments. Thus, the entire exercise - which involved several rounds discussions and
series of workshops with disease experts, researchers, demographers and programme managers went through an extensive consultative process.
For estimation of YLL demographic data on age, sex and cause specific mortality rates are
required while YLD requires epidemiological data on incidence, prevalence, severity and
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complications or sequelae. The epidemiological estimates are also used to check the consistency
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of demographic estimates and vice versa. The estimates of burden in APBD study are made for
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1991 as it happens to be the Census year and hence provides true population distribution.
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Considering the variations in living conditions and access to health and related services, separate
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estimates have been made for urban and rural areas. The census definition of urban areas was used
to distinguish from the rural areas.
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VI. Demographic Estimates:
A Age specific mortality:
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A preliminary workshop was conducted to identify the sources of mortality data. Two
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important sources of population distribution and age specific mortality identified were the 1991
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Census and Sample Registration Scheme (SRS). In addition, community based studies undertaken
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from Andhra Pradesh which provided information mortality were listed during the workshop.
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The final population totals for AP from 1991 census are not yet available. However, the
primary census abstract provides preliminary data on population by sex below 6 years and above 6
years separately for urban and rural areas. Enquiry with Registrar General's office indicated that it
may take one more year to complete the detailed analysis of 1991 AP Census data. Hence, the
Sample Registration Scheme (SRS) estimates for urban and rural Andhra Pradesh were used to
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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develop life tables for males and female?. When the actual population distribution is made
available from 1991 Census data, the SRS estimates will be replaced by them.
B Preliminary disease list preparation:
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A preliminary list of diseases was prepared after reviewing the available data and
discussing with the local disease experts and demographers. The GBD norm of grouping the
diseases in to three groups on the basis of epidemiological transition was followed. The Group I
included the pre- transition diseases: Communicable, Maternal and Perinatal. Considering the fact
that nutrition deficiency disorders tend to be predominate in pre-transition period, they have been
included in group I. The Group II consisted of non communicable and degenerative disorders
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while Injuries and accidents were included in Group III. As the cause of death and disease pattern
emerged this preliminary disease list was modified to ensure that it captures all the major causes
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of mortality and morbidity in AP.
C Cause of Death determination:
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Like many developing countries the Vital Registration System in India is p„Or both in
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terms of coverage as well as content. The usual option in such situation is either to use cause of
death models or to estimate the cause of death pattern using epidemiological approach. The
model based estimates may not capture the true cause of death pattern in developing countries as
they are mostly based on past mortality patterns observed in developed countries. They are also
influenced by changes in ICD revisions and diagnostic practices.
In case of epidemiological
estimates, adequate data may not available for all diseases to make estimations. Another option is
to make the cause of death estimates using data from sample registration schemes or disease
surveillance systems. In India two schemes provide information on cause of death pattern. Survey
of Cause of Death (SCD) provides cause of death information for broad cause groups in nira!
areas usmg Verbal Autopsy techniques while Medical Certification Cause of Death (MCCD)
provrdes physician certified cause of death information from selected hospitals. This data is
available in three digit ICD 9 coding.
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Annexure I
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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Cause of death estimation for rural AP:
The SCD Scheme- started as Model Registration Scheme in 1960s by the Registrar
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General, India - provides cause of death information for rural India using " lay reporting " method.
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In each state sampling units, covering 3-5 thousand rural residents each, are selected using
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standard guidelines to ensure representativeness. The state of Andhra Pradesh at present has 150
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sampling units covering a population of 0.675 million which constitutes about 1% of the total
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population.
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The field work is restricted to the sample village and carried out by para medical worker
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(called Field Agent) of the selected Primary Health Centre trained in the verbal autopsy
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techniques. A set of guidelines for classification of diseases by a non-medical list of causes of
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death prepared by the office of the Registrar General of India is provided. The cause of death
determination process involves isolation of major cause groups by way of elimination and final
identification of specific cause in stages. The medical officer of the PHC scrutinises the deaths
recorded by the field agent every month and investigates independently at least two deaths or 10%
of deaths recorded to validate the information collected by the field agent.
Constraints of SCD data:
A. Methodological:
The verbal autopsy technique is essentially based on two assumptions:
♦ Each disease will have unique set of symptoms at the time of death
♦ The attendants can provide detailed description of events that led to death
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Both these assumptions may not always hold good. There is often overlap of symptoms or
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the attendants may not be in a position to provide the detailed description of symptoms at the time
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of death. Another important determinant of quality of verbal autopsy technique is the skill of the
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interviewer to extract the required information from the attendants.
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B. Large number of Unclassified deaths :
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Under SCD the cause of death determination is done in a phased manner. Each death is
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initially classified under 10 major groups and then specific cause is determined. In case of deaths
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with inadequate information, the general tendency is to include the death in one of the major
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groups without further probing. Since, BDA requires specific cause of death information, there
was no choice but to include deaths under the categoiy of "not classified".
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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A preliminary analysis of SCD data from the state of AP for a period of six years
(1988-93) had shown that out of a total 10,770 deaths (Males: 5979; Females: 4791) reported
during this period, more than a third ( 37.5%) come under the 'not classifiable' category. Two
thirds of the deaths included under 'not classifiable' category and 25% of the total deaths were
due to senility4.
C. Cause of death information restricted to few diseases:
Like any Verbal Autopsy technique the SCD provides cause of death information only for
few diseases. Even among them some of the causes which are described more on the basis of
symptoms are difficult to classify. Conditions such as jaundice, convulsions, paralysis, congestive
heart failure etc., fall under this category. Similarly all cancers were included in a single group.
Unless some additional information is provided it is not possible to classify these deaths. Though
SCD protocol insists on recording such information by the field agent, it is often not enforced
which makes it difficult to classify these deaths.
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Expert opinion and field enquiry to Improve the quality of SCD data:
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With all these constraints SCD still happens to be the single largest source of cause of
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death information from the rural community. In the APBD study an attempt was made to explore
the scope to further improve the quality of SCD data. This is done in four stages.
♦ Initial review of cause of death description given for the unclassified deaths
by medical experts
♦ Field enquiry of 301 deaths included in not classifiable category during
1992-93 (all the deaths with records available covered)
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Separate survey of 139 deaths classified under 'senility’ during 1994 by
trained experienced investigators to get more detailed description on events
that led to death and symptoms at the time of death.
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Review of the field data by committee of experts (Physician, Paediatrician
and Public Health Specialist)
Out of a total 440 deaths subjected to expert opinion and field enquiry 436 (99%) could
be classified. Based on this feedback few more categories of diseases were to the SCD list. For
example, enquiry revealed that 'electric shock' is an important cause of death in rural males. Using
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
this data an algorithm was developed to classify the deaths included in not classifiable category of
SCD deaths5.
ii. Estimation Cause of death for Urban AP:
Preliminary analysis of vital registration data from one circle in Hyderabad City indicated
that content is poor as cardiorespiratory failure was reported to be the cause of death in as many
as 40% of the deaths registered.
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Review of MCCD data had shown that only one third of the total urban deaths are being
covered under this scheme in AP. However, in the neighbouring state of Maharashtra more than
80% of the urban deaths are medically certified. Considering the proximity of the states and
genetic similarity of population, we have assumed that the cause of death pattern in urban
Maharashtra closely resembles that of urban AP. MCCD data from Maharashtra state covering a
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period of five years (1986 -90) was obtained and aggregate cause specific proportionate mortality
rates were calculated for APBD age groups separately for both sexes. These rates were applied to
the estimated deaths for Urban AP in each age and sex group to arrive at the first estimates of
cause specific deaths in urban AP.
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VII.Final APBD disease list and cause of death estimates:
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After going through the list of major unclassified deaths in rural and urban AP, the disease
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list was finalised6. Where ever felt necessary, new disease was added and some diseases were
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excluded. For example, Japanese encephalitis was added in communicable diseases while
Leishmaeniasis was excluded. Similarly electric shock and bites by venomous snakes were added
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in injuries and accidents. Since available cause of death data can not distinguish between acute
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and persistent diarrhoea, we have included all the diarrhoea's in one group. This decision was also
influenced by the fact that interventions for diarrhoea - irrespective of the clinical forms - are
similar.
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In both urban and rural areas the estimated deaths by cause were matched with the APBD
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list of diseases. Appropriate algorithm was developed separately for rural and urban areas to
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distribute all the remaining deaths which are responsible for more than 0.1% of total deaths7.
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Annexure III
Annexure II
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Annexure IV
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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VIII. Epidemiological Estimates of mortality and disability :
Epidemiological estimates on disability and mortality were made for each of the disease
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included in the list. Considering the fact that SCD data can provide only broad leads the data was
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further validated for each disease using epidemiological approach. Similarly, the estimates of
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cause of death in urban areas made on the basis of Maharashtra MCCD data were also validated.
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A Disease experts and Literature review:
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For each of the disease included in the list experts have been identified through references
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and contacting National laboratories. The first round of communication was sent to them which
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described the methodology with a request to provide first set of estimates on incidence,
prevalence, case fatality and remission rates for their respective diseases. The experts were also
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requested to quote the sources on which their estimates are based and give their opinion on
quality of available data. This was followed by personal visit of project team members to different
parts of the state and some of the National laboratories to clarify any doubts and to get more
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information on available epidemiological data in the state/country.
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Meanwhile, a detailed literature search was undertaken to compile the epidemiological
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studies on each disease giving first preference to community based studies undertaken in AP.
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Information was also obtained from Post graduate dissertations and small scale surveys
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undertaken in different parts of the State through departments of community medicine. If there
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are no good community based studies available from the State, studies undertaken in neighbouring
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States or at National level were considered. For example, in case of cancers, the reported
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incidence from Madras cancer registry was used for epidemiological estimates. If adequate
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information is not available even at National level, data from comparable studies in neighbouring
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countries was considered. For example, in case of Chlamydia we could not get any community
based studies from India and all the studies reviewed were hospital based.
Hence, reported
prevalence figures from Asian population in Singapore were used to arrive at the preliminary
estimates. If no data is available from neighbouring countries, the GBD approach of using data
from other comparable country was used. Use of hospital based studies was essentially restricted
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for estimation of case fatality and remission rates.
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For all diseases with National programmes surveillance data was obtained from the
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concerned programme manager. This information was particularly useful in case of vaccine
preventable diseases as immunisation coverage significantly alters the disease burden. The details
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of quality of reviewed studies are presented in Table. As it is evident from the table that better
epidemiological data is available for Group I diseases8. The estimates for some of the Group n
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diseases hence were based on small scale studies and studies published from other countries. To
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make the approach used more explicit
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include Tuberculosis with good epidemiological data and Non Insulin Dependent Diabetes
two examples of epidemiological estimations, which
Mellitus with poor epidemiological data, are presented in Annexure’.
After first round of literature review, expert comments and programme data analysis a
workshop was held. The participants included core expert, local disease experts, programme
managers and public health specialists. The first set of epidemiological estimates of all chronic
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diseases made were subjected to consistency using the Harvard disease model (DISMOD) which
uses the known relationships between incidence, prevalence, case fatality and remission10 In case
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of acute diseases responsible for large number of deaths, consistency of epidemiological estimates
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were checked with the cause of death models.
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B Final estimates of cause of death:
A combination of sources were used to estimate the cause of death pattern. Firstly all
estimations of injury and accidents based on survey reports for rural and urban areas were taken
as such. Then the proportionate distribution of deaths in group I and group n from
epidemiological approach was compared with that of survey data. In urban areas only marginal '
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differences were noticed between the two sets of estimates. Hence, the survey distribution for
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group I and H was taken as such while the distribution of deaths within each group was based on
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epidemiological estimations.
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In case of rural areas, however, some inconstancies were noticed. As mentioned earlier the
SCD data provides information only for broad cause groups and some of the cause of death
descriptions such as convulsions, congestive heart failure, jaundice etc. essentially describe
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symptoms which may occur due to many diseases. The major discrepancy was noticed in case of
Annexure V
Annexure VII
♦
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CJL Murray & A D Lopez; Quantifying disability: data methods and results; Bull of WHO 1994, 72 (3): 431-494
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Diarrhoea and ARI where the SCD data tended to underestimate the deaths particularly in 0-4 yrs.
The reported validity of verbal autopsy for childhood deaths varied considerably between studies.
Studies in Kenya have shown that the sensitivity of verbal autopsy techniques was low for ARI11
The deaths estimated from epidemiological approach were also compared with model based
■)
estimates using Preston's cause of death models of countries with comparable mortality pattern.
Preston12 made an estimate of Cause Specific Mortality Rate for 12 major causes of death using
data from 48 Nations with a range of life expectancies from 27 to 77 yr. From this data
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proportionate mortality rates due to diarrhoea for three countries which had general mortality
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rates comparable to India were calculated. All these estimates suggest a proportionate mortality
due to diarrhoea was between 23-29% in the 0-4 years which is consistent with the
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epidemiological estimates. Studies on diarrhoea mortality report
aa cause
cause specific mortality
between 0.8 to 1.5/1000 among children in 5-14 and 0.4 to 2.5 per 1000 per year in case of
. Hence, for diarrhoea and ARI we have based the estimates more epidemiological
adults
approach.
The Maternal deaths were taken as reported from the survey data far both urban and rural
r
areas as the expert felt that MMR estimates seemed to be quite plausible. However, in case of
Perinatal Mortality the SCD data seemed to be an over estimate. An estimation of neonatal
mortality was made on the basis of observed relationship between the neonatal and post-neonatal
mortality . The estimates suggested that perinatal mortality estimates based on survey data were
higher in rural areas while in urban areas they matched fairly well. Considering these constraints
we have essentially used the epidemiological approach to estimate the cause of death pattern in
rural areas while estimates based SCD data were used as such for injuries & accidents, Maternal
it
12
13
Snow RW et al Childhood deaths in Africa: uses and limitations of verbal autopsies. Lancet 1992 340:351-55
Samuel H Preston; Causes of Death, Life tables for National Populations; Seminar Press 1972 ISBN 0-12-895550-3
El Alamy MA et al. The incidence of diarrhoeal disease in a defined population of rural Egypt. American Journal of Tropical
Medicine and Hygiene, 35:1006-1012 1986
Nazir HZ M et al., The incidence of diarrhoeal diseases and diarrhoeal diseases related mortality in rural swampy low-land area
of south Sumatra, Indonesia. J of Tropical Paediatrics, 31:268-272
Shaikh K et al. Pattern of diarrhoeal deaths during 1966-1987 in
a demographic surveillance area in rural Bangladesh. J of
Diarrhoeal Diseases Research 8: 147-154 (1990)
CJL Murray & Jose Luis Bobadilla; Epidemiological Transitions in the Formerly Socialist Economies: Divergent Patterns of
Mortality and Causes of Death; Health Transition Working Paper Series No.94.07 1994
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Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
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Mortality and for checking the total estimated deaths under broad groups such as Gastrointestinal,
Chronic respiratory disorders. Neuropsychiatric diseases etc.
IX.Results
A Probability of dying:
The first round of estimates suggest that probability of dying in 0-14 years in AP is less
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compared to all India average for both sexes (Males: 13% Vs 15%; Females: 11% Vs 16%) Both
urban and rural AP fared better than all India average. This trend, however, altered for the later
age groups. While marginal differences were noticed among males in 15-59 years (Males: AP:
28%, India 27% ), no difference was noticed among females. In 60-69 years age group the
probability of dying in AP was higher than that of all India averages for both sexes (Males: AP:
40%, India: 32%; Females: AP: 29%, India 26%).
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Between the urban and rural areas, probabilities of dying were lower for all age groups in
urban areas. Lower child mortality and higher adult mortality in AP compared to India suggest
that health interventions targeted at children are more effective in AP. This also indicates that the
demographic transition process is more advanced in AP compared to the National average
B Cause of death
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A. Cause of death pattern :
The estimated cause of death patient for all age groups in urban and rural AP is presented
m the figure L Whiie Group ! diseases predominated in rural areas, Group I! diseases were
responsible for hrgher mortality in urban areas. About 11% of deaths in rural and S% in urban
areas were due to injuries and accidents. In both rural and urban areas unintentional injuries
constituted the majority of Group in deaths. The proportion of deaths constituted by intentional
mjunes was hrgher m mral areas compared to urban areas (28% Vs 7%). Eighty seven percent of
estimated intentional deaths in rural areas were self Micted compared to 37% in urban areas
indicating a higher suicide rate among rural residents.
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Fig 1
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1) .
CAUSE OF DEATH PATTERN IN AP
52.0%
42.4%
2)
10.8%
RURAL AP
SCD+EPD
0
8.4%
49.3%
37.2%
URBAN AP
ICCD+EPD
■ GROUP I £3 GROUP II ■ GROUP III
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When the cause of death pattern in AP for all ages and both sexes was compared with that
of India the proportion of deaths due to Group I (50.1% Vs 43.3%) and Group in (10.3% Vs
6.5%) diseases was higher in AP. Considering the lower probabilities of dying in 0-4 years in AP,
where Group I diseases predominate, this trend is surprising.
B. Cause of death pattern by sex
Similar trend was obseiwed when cause of death pattern was compared between the sexes.
While Group I deaths predominated among both sexes in rural areas, deaths due to Group Q
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were higher in urban areas. In both areas proportion of deaths due to Group II was higher among
females. This difference was more marked in case of urban area. This is quite plausible
considering the fact that females are considered to be genetically stronger than males and hence
less vulnerable to infectious diseases. Proportionate mortality due to Group HI deaths between
the two sexes was more or less similar in rural areas while in urban areas males tended to have
marginally higher mortality due to Injuries and accidents compared to females.
C. Cause of death pattern by age:
0-4 Years:
About 90% of the estimated deaths in this age group were due to Group 1 diseases. The
proportion of deaths due to Group I diseases was higher in rural areas compared to urban areas
(91 /o Vs 85/o). The leading causes of death included Perinatal conditions (M: 27.4%, F: 26.6%)
ARI (M:22.2%, F: 23.9%), Diarrhoea (M: 19.1%, F: 18.9%) and Measles (M: 6.6%, F: 7.5%) in
rural areas.
Even in urban areas, excepting Measles, the same causes were responsible for
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maximum number of deaths. The higher proportion of Group II deaths in urban areas was mainly
due to congenital anomalies. While proportion of Group III deaths are comparable between rural
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and urban areas among male children, in case of female children however, the corresponding
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proportion was higher among rural residents compared to their urban counterparts. Most common
cause of the Group III deaths among rural girl children was "fall". It is difficult to say to what
O'
extent this is due to gender discrimination and female infanticide. This aspect, however, requires
o
o
o
o
the estimated deaths in urban areas were due to Group II causes, only about a tenth of the total
0
deaths were due to non communicable diseases in rural areas. The leading causes of Group I
□
further in-depth studies.
5-15 Years:
In this age group also the Group I causes of death predominated. While about a quarter of
deaths included ARI, Anaemia, Diarrhoea and Measles in rural areas and ARI in urban areas.
The proportion of deaths due to Injuries and accidents in this age group was much higher in rural
0
areas compared to urban areas (Males: 38% Vs 17%; Females: 24% Vs 17%). The leading cause
of accidents in rural areas was "Drowning" while in urban areas it was " Motor Vehicle
Accidents".
15-45 Years:
5
While the Group I diseases still predominated the cause of death at state level, the
3
difference between the proportionate mortality due to Group I and Group II diseases was less
5
marked in urban areas compared to rural areas. Tuberculosis was the leading cause of death
3
among Group I diseases among males and females in both rural and urban areas. However, in
9
rural areas deaths due to maternal conditions contributed equal number of deaths. Marked
9
difference in proportionate mortality due to maternal conditions was noticed between rural and
9 '
urban areas (32.3 /'o Vs
9
digestive disorders, cardiovascular diseases and cancers in both urban and rural areas while the
3
leading Group II causes among females included cancers and cardiovascular diseases. The most
3
3
)
6.5%), The leading causes of Group II deaths among males included
common cancers among males were that of Mouth & oropharynx, Oesophagus, Stomach and
Lymphomas & Leukaemias. In females Cancers of Cervix, Breast and Oesophagus were more
common.
)
14
!
5
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
5
Deaths due to injuries and accidents constituted a major cause of death in this age group.
In rural areas higher proportion of deaths were caused by unintentional injuries among males
compared to intentional injuries (18% Vs 12.7%). The leading cause of unintentional injury
among males in rural areas was "Motor Vehicle Accidents" while "Self Inflicted" predominated
2?
among intentional injuries. In case of rural females the proportionate mortality due to intentional
J
injuries was higher than that of unintentional (13.2% Vs 11.7%). The leading causes of death
were Fires and Self Inflicted respectively among non intentional and intentional injuries. In urban
2)
areas the unintentional injuries predominated in both sexes (Males: 23.5% Vs 2.4%, Females:
3
31.6% Vs 1.8%). Similar to rural areas, the Motor Vehicle Accident was the leading cause of
death among unintentional injuries in urban males.
2)
J
In case of females, however, Fires were
reported to be the leading cause. Thus Fires emerge as a leading cause of Group III death among
females irrespective of the place of residence. Some of the deaths reported under unintentional
Fires could be due to suicide or even homicide. It is, however, difficult obtain reliable information
5
5
3
on exact cause of death in such circumstances.
45- 59 Years:
In both rural and urban areas the Group II deaths predominated in this age group. It is
however, interesting to notice that still a third of total deaths from rural areas were estimated to
be due to Group I conditions both among males and females while in urban areas about a quarter
>
of deaths in this age group were estimated to be due to Group I conditions. The most common
Group I cause of death was Tuberculosis among males and females irrespective of their place of
>
residence. Among Group II conditions EHD, Cancers and Cirrhosis were estimated to be the
leading causes among males in both rural and urban areas. Among females Cancers, Cerebro
Vascular Accident and HD were the leading causes of death. Group III deaths were more or less
)
uniformly distributed. In rural females deaths reported under the category of "Self Inflected"
tended to be higher.
60 + years:
>
>
Majority of the deaths in this age group were due to Group II conditions. The proportion
of Group I deaths among rural males was higher than urban males (25% Vs 22%) while no such
>
difference was observed among females.
Tuberculosis, Respiratory Infections and Diarrhoea
1
were the leading Group I cause of deaths in this age group. Among Group II diseases, Ishaemic
15
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Heart Disease, Cerebro Vascular Accidents, Cancers, COPD and Cirrhosis Liver were the leading
causes of death among males. More or less similar trends were noticed among females except for
lower estimates of deaths due to Cirrhosis. In urban males also deaths due to cirrhosis were less.
■o
C Disability Adjusted Life Years Lost in AP:
i.
Total DALYs lost:
The preliminary estimates indicate that 17,657,518 total DALYs were lost in Andhra
Pradesh during the year 1991l7. Out of the total DALYs lost 14,037,909 (79.5%) were estimated
o
o
o
o
o
o
to be from rural areas and the rest (20.5%) were contributed by residents of urban areas.
Considering the fact that rural population constituted 73% of the total State's population, it is
evident that disease burden is higher among rural residents. About 52% of the total DALYs lost
were contributed by males and the rest by females.
ii.
DALYs lost per 1000 population:
Fig 2
DISTRIBUTION OF DALYs IN INDIA & AP
3
5
J3445
INDIA
3
267.1
AP ALL
3
H i
AP RURAL
3
3
292.5
197.4
AP URBAN
5
LAC
?
0
5
■ GROUP I
)
100 200 300 400 500
GROUP II ■ GROUP III
)
)
When the APBD preliminary results were compared with that of GBD it is evident that
♦
DALYs lost per 1000 persons in the State of AP were less than all India estimates (267 Vs. 345)
as shown in Fig 2. It is also evident that there is significant difference in the disease burden in
Urban and Rural areas (197 Vs. 293). Since GBD estimates are made at country level for all the
17
Annexure VI
16
I
-;i
■J
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
o
6
o
o
o
o
□
States without distinguishing between urban and rural areas, these trends seem quite plausible.
Also, the fact that SCD cause of death pattern - which is based on rural deaths - was used for
Group I, II and III distribution in GBD estimates which could have influenced the estimates more
in favour of rural areas.. DALYs estimated to be lost/1000 population in Urban AP (197) indicates
that disease burden among residents of Urban AP is marginally lesser than the GBD estimates for
Latin American Crescent (231).
3
iii. DALYs lost due to YLL:
a
3
Fig 3
3
3
3
3
3
3
3
3
DISTRIBUTION OF YLL & YLD DALYS
■ YLL
□ YLD
APALL
RURAL ALL
URBAN ALL
AP MALE
RURAL MALE
URBAN MALE
AP FEMALE
RURAL FEMALE
URBAN FEMALE
0
3
40
20
80
60
120
100
3
3
3
At the aggregate level DALYs lost due to YLL were responsible for two thirds (68.2%)
of total DALYs lost. In both rural and urban areas YLL contributed a majority of total DALYs
lost. In the GBD study also similar trends were observed in most of the developing countries. The
proportion of DALYs lost due to YLL was higher in rural AP compared to urban AP (69.3% Vs
)
63.6%). Between the sexes, males lost higher DALYs due to YLL in both rural and urban areas
I
(Rural:MaIes:72%, Females:66.5%; Urban: Males:67.3%, Females:59.18%).
17
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
iv. DALYs lost by major Groups:
Fig 4
O
aSTRIBUTlON OF CXLYS BY U*JOR GROUPS: A P
CRCXJPI
o.
o
GROUP H
CROUP I
3
More than a half of the total DALYs lost (54%) were due to Group I disorders. Since
3
3
YLL happens to be the major contributor of the DALYs lost, this trend is not surprising. About
30% and 16% of the total DALYs lost were due to non communicable diseases, injuries and
accidents respectively. Between the areas, the burden caused by Group I and Group III was more
■3
'3
in rural areas compared to Urban areas. In urban areas also burden caused by Group I diseases is
responsible for maximum loss of DALYs. However, the burden caused by Group II disorders was
relatively higher in urban areas indicating that the urban residents are in a more advanced phase of
epidemiological transition (Fig. 5).
Fig 5
3
3
DISTRIBUTION OF DALYS BY SEX AND AREA
53.9%
49.4%
3
3
28.9%
12.1%
17.2%
36.5%
RURAL MALE
3 .
3
3
3
URBAN MALE
58.2%
51.8%
18.4%
12.5%
27.4%
35.9%
RURAL FEMALE
■ GROUP I
URBAN FEMALE
GROUP II ■ GROUP III
3
3
9
7
18
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
X. Leading causes of DALY loss
As shown in the above figures the major causes of DALY loss in Group I diseases include
Perinatal, ARI and diarrhoeal disorders. Burden due to TB was much higher in case of males.
Females residing in rural areas lost nearly double the DALYs /1000 population due to Maternal
0
conditions compared to their urban counterparts. DALYs lost due to Measles, Tetanus were
lower in urban areas which could be attributed to better immunisation coverage and cleaner
delivery practices. DALYs lost due to diarrhoea in urban areas were nearly half that of rural areas
indicating better access to safe water and sanitation.
Fig 6
Group I diseases AP
3.65
13 03
3J7
18 68
12J1
1836
9.84
10.65
17.98
1932
338
3.46
J
21S2
5.15
Males
3.98
Females
r~
■
Diarrhoeal
Diseases ■ Tetanus ■ Measles ■ Meningitis
Maternal —
■ PerinatalI
E3 Anemia S PEM
■ Others
a tb
ARI
Fig 7
J
Leading causes for DALYs lost in Group II
J
Group II Diseases : AP
5
17.9%
J
17.I*A
12.7%
3
11.9%
10.7%
14.0%
4.4%
14.5%
5.4%
4.4%
J
2.4%
3.1%
1.5%
14.3%
5.5%
5.4%
3.0%
8.9%
7
7
Males
■ Malgnant
83 Chronc Raaorutcry
Females
C
___
Of
Hojro-PiyOMatic
D ■ Cataract n»fal*d bil ■ IHD
■ CVD
Q PEMC
■ CJnho** w
of. ha .v
lv
—
S2 Nachnfia
0 CoAgarvtW ahnermaU H Oral Kaalth B Otbar*
7
7
*)
19
v9
^9
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
o
o
o
o
o
o
o
o
Figure 8
Leading causes of burden in Group III
25.5%
38.1%
14.4%
8.6%
5.0%
*
8.9%
19.5%
14.3%
Males
3
13.6%
5-2\o%
13.7%
12.4%
3.3%
Females
■ MVA
Falta
■ Fires
vwih,
■ ^
Drowning
■ Venamous Animato API
El Electric Shock B Self -Inflicted ■ Homicide & Violence S Others
3
3>
Among the Group II disorders the leading causes of burden include Ischaemic Heart
disease, Cancers, Cerebro-vascular accidents, Congenital disorders and Cirrhosis in both rural and
5
urban areas. Falls and Fires were the most common causes of burden among Group III disorder's
3
in case of females residing in rural and urban areas respectively. Self inflicted injuries were more
3
commonly reported from rural areas among both sexes.
XI.Discussion:
9
9
The preliminary results of the APBD study indicate that the epidemiological transition
9
process in AP is at a more advanced stage compared to that of India. Like many other developing
9
countries the DALYs lost due to premature mortality contributed more to the disease burden. The
fact that urban residents had lesser burden of disease compared to their rural counter parts is not
r .
surprising considering the better access to health care and infrastructural services such as safe
water supply. Burden caused by pre-transition disorders such as infectious diseases, maternal and
/
perinatal conditions and
nutritional deficiencies contributed to more than a half of the total
DALYs lost. This calls for an exhaustive review and total revamping of the existing intervention
programmes. The fact that nearly 16% of the DALYs lost were due to injuries and accidents
20
■
3
5
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
J
D
needs special attention by the policy makers particularly the reported high mortality rates due to
falls, fires and suicides.
The APBD study summarises the experience of estimating the disease burden in a
3
developing country with several constraints of data. The basic objective of the study is to estimate
the burden making use of the 'available data' rather than waiting for the "best data". The
consultative process which involved Disease experts. Researchers, Public health specialists and
Health programme managers .and the consistency checks enforced at different levels helped to
3
make the best plausible estimates. The study team, however, would like to continue the dialogue
with the Reserachers/Disease experts. Based on their feed back on the preliminary estimates next
5
revision will be made.
5
5
□
J
5
5
5
21
3
3
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
0
Annexure I
3
0
Life Table for AP Rural Male
x
n
Mx
ax
qx
Px
lx
dx
Lx
Tx
ex
3
3 .
0
1
0.08
0.3
0.07
0.93
100000
7396.17
94822.68
5725792.3
57.26
1
4
0.01
0.4
0.03
0.97
92603.83
2972.01
363282.49
5630969.62
60.81
5
5
0
0.5
0.01
0.99
89631.82
803.07
446151.4
5267687.13
58.77
0
10
5
0
0.5
0.01
0.99
88828.74
795.88
442154.03
4821535.73
54.28
15
5
0
0.5
0.01
0.99
88032.87
1223.89
437104.6
4379381.7
49.75
20
5
0
0.5
0.02
0.98
86808.97
1718.99
429747.4
3942277.09
45.41
25
5
0
0.5
0.02
0.98
85089.98
1392.5
421968.68
3512529.7
41.28
30
5
0
0.5
0.02
0.98
83697.49 • 1903.16
413729.55
3090561.02
36.93
35
5
0.01
0.5
0.03
0.97
81794.33
2099.36
403723.26
2676831.47
32.73
40
5
0
0.5
0.02
0.98
79694.97
1928.9
393652.61
2273108.21
28.52
45
5
0.01
0.5
0.05
0.95
77766.07
4015.2
378792.37
1879455.6
24.17
0.07
0.93
73750.87
5022.4
356198.38
1500663.23
20.35
3 •
3
3
3
3
3
3
3
50
5
0.01
0.5
55
5
0.02
0.5
0.1
0.9
68728.48
6918.54
326346.04
1144464.85
16.65
60
5
0.05
0.5
0.21
0.79
61809.94
13047.54 276430.86
818118.81
13.24
65
5
0.06
0.5
0.27
0.73
48762.4
13142.54 210955.67
541687.95
11.11
70
5
0.11
(3NA
1
-• 0
35619.87
35619.87 330732.27
330732.27
9.29
x
n
Mx
ax
qx
Px
lx
dx
Lx
Tx
ex
o
i
0.07
0.3
0.06
0.94
100000
6217.12
95648.02
6147638.88
61.48
Life Table for AP Urban Male
0
3
3
3
3
3
i
4
0.01
0.4
0.03
0.97
93782.88
2369.25
369445.31
6051990.86
64.53
5
5
0
0.5
0
1
91413.63
455.93
455928.31
5682545.55
62.16
0
1
90957.7
363.1
453880.73
5226617.24
57.46
52.68
10
5
0
0.5
15
5
0
0.5
0
1
90594.59
451.84
451843.36
4772736.52
20
•5
0
0.5
0.01
0.99
90142.75
1119.79
447914.29
4320893.16
47.93
25
5
0
0.5
0.01
0.99
89022.96
753.49
443231.09
3872978.87
43.51
965.65
438933.22
3429747.78
38.86
3
30
5
0
0.5
0.01
0.99
88269.47
3
35
5
0
0.5
0.01
0.99
87303.82
1256.79
433377.11
2990814.56
34.26
40
5
0.01
0.5
0.04
0.96
86047.02
3374.39
421799.14
2557437.45
29.72
3
45
5
0.01
0.5
0.03
0.97
82672.63
2683.91
406653.38
2135638.31
25.83
3 .
50
5
0.02
0.5
0.07
0.93
79988.72
5819.46
385394.94
1728984.93
21.62
55
5
0.02
0.5
0.11
0.89
74169.26
8429.52
349772.49
1343589.99
18.12
3
60
5
0.03
0.5
0.15
0.85
65739.74
10104.47 303437.52
993817.51
15.12
3 '
65
5
0.05
0.5
0.24
0.76
55635.27
245251.35
690379.99
12.41
70
5
0.1
($NA
1
0
42465.27
42465.27 445128.63
445128.63
10.48
3
3
3
3
3
3
3
3
22
13170
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Life Table for AP Rural Female
I-X
Tx
ex
7125.89
95011.88
6072352.14
60.72
92874.11
2194.09
366230.63
5977340,27
64.36
90680.02
902.29
451144.39
5611109.64
61.88
5159965.25
57.47
ax
qx
Px
lx
dx
0.07
0.93
100000
x
n
Mx
0
1
0.08
0.3
0.02
0.98
0.01
0.99
I
4
0.01
0.4
5
5
0
0.5
10
5
0
0.5
0.01
0.99
89777.73
626.25
447323.03
15
5
0
0.5
0.01
0.99
89151.48
1327.32
442439.11
4712642.22
52.86
20
5
0
0.5
0.02
0.98
87824.16
1394.03
435635.73
4270203.11
48.62
25
5
0
0.5
0.02
0.98
86430.13
1541.87
428295.98
3834567.38
44.37
30
5
0
0.5
0.01
0.99
84888.26
928.66
422119.66
3406271.4
40.13
35
5
0.01
0.5
0.03
0.97
83959.6
2400.03
413797.93
2984151.74
35.54
40
5
0
0.5
0.02
0.98
81559.57
1814.68
403261.17
2570353.81
31.52
45
5
0.01
0.5
0.03
0.97
79744.9
2240.8
393122.49
2167092.64
27.18
50
5
0.01
0.5
0.05
0.95
77504.1
4111.92
377240.68
1773970.15
22.89
5543.7
353101.64
1396729.46
19.03
55
5
0.02
0.5
0.08
0.92
73392.18
60
5
0.02
0.5
0.11
0.89
67848.48
7711.15
319964.53
1043627.83
1538
65
5
0.04
0.5
0.2
0.8
60137.33
1 1845.85 271072.05
723663.29
12.03
70
5
0.11
(fl|NA
1
0
48291.49
48291.49 452591.24
452591.24
9.37
x
n
Mx
ax
qx
Px
Lx
Tx
ex
0
1
0.05
0.3
0.05
0.95
100000
4550.3
96814.79
6707644.78
67.08
1
4
0
0.4
0.01
0.99
95449.7
1030.25
379326.22
6610829.99
69.26
5
5
0
0.5
0
1
94419.45
282.83
471390.19
6231503.77
66
0
470330.36
5760113.58
61.19
Life Table for AP Urban Females
1
1
10
5
0
1
94136.62
141.1
15
5
0
0.5.
0.01
0.99
93995.52
842.17
467872.18
5289783.23
56.28
20
5
0
0.5
0.01
0.99
93153.35
649.8
464142.26
4821911.05
51.76
25
5
0
0.5
0.01
0.99
92503.55
737.08
460675.06
4357768.79
47.11
30
5
0
0.5
0.01
0.99
91766.47
640.12
457232.05
3897093.73
42.47
35
5
0
0.5
0.01
0.99
91126.35
861.61
453477.72
3439861.68
37.75
40
5
0
0.5
0.01
0.99
90264.74
853.46
449190.05
2986383.96
33.08
45
5
0
0.5
0.01
0.99
89411.28
1331.19
443728.43
2537193.91
28.38
50
5
0.01
0.5
0.03
0.97
88080.09
2859.46
433251.81
2093465.48
23.77
55
5
0.01
0.5
0.07
0.93
85220.63
5723.93
411793.34
1660213.67
19.48
60
5
0.03
0.5
0.12
0.88
79496.7
9843.87
372873.85
1248420.33
15.7
12.57
10.19
I
)
65
5
0.05
0.5
0.21
0.79
69652.83
14395.86 312274.53
875546.48
70+
5
0.1
@NA
1
0
55256.98
55256.98 563271.95
563271.95
Region
Sex
Rural
Male
Female
Male
Female
Urban
Probability of Dying
5q0
0.1037
0.0932
0.0859
0.0558
9
)
23
7
dx
0.5
I
I
lx
45ql5
0.2979
0.23895
0.2744
0.1543
2>
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Annexure II. APBD Disease List
I. Communicable, Maternal
A. Infectious & Parasitic
5
5
■3
-J
64
1. Rheumatic Heart Disease
32
2. Iodine Deficiency
65
2. Ischemic Heart Disease
33
3. Vitamin A
66
3. Cerebrovascular Disease
2
a. Syphilis
34
4. Anemias
67
4. PEMC
3
b. Chlamydia
II. Noncommunicable
4
c. Gonorrhea
A. Malignant Neoplasms
5
3. HIV
35
1. Mouth and Oropharynx
6
4. Diarrhoeal Diseases
36
2. Esophagus
5. Childhood Cluster
37
3. Stomach
70
71
H. Chronic Respiratory Diseases
68
1. COPD
69
2. Asthma
/. Diseases of the Digestive System
1. Peptic Ulcer Disease
7
a. Pertussis
38
4. Colon/Rectum
8
b. Polio
39
5. Liver
9
c. Diptheria
40
6. Pancreas
72
10
d. Measles
41
7. Trachea/Bronchus/Lung
73
11
e. Tetanus
42
8. Melanoma and Other Skin
12
6. Meningitis
43
9. Breast
74
1. Rheumatoid Arthritis
13
7. Hepatitis
44
10. Cervix
75
2. Osteoarthritis
14
8. Malaria
45
11. Corpus Uteri
76
9. Tropical Cluster
46
12. Ovary
15
a. Lymphatic Filariasis
47
13. Prostate
77
1. Dental Caries
16
10. Leprosy
48
14. Bladder
78
2. Periodontal Disease
79
2. Cirrhosis of the Liver
J. Diseases of the Gemto-Urinary
System
1. Nephritis/Nephrosis
2. Benign Prostatic Hypertrophy
A.'. Diseases of the Musculo-Skeletal
System
L. Congenital Abnormalities
M. Oral Health
11. Trachoma
49
15. Lymphoma
12. Intestinal Helminths
50
16. Larynx
III. Injuries
18
a. Ascaris
51
B. Other Neoplasm
A. Unintentional
3. Edentulism
19
b. Trichuris
52
C. Diabetes Melltus
80
1. Motor Vehicle Accidents
20
c. Hookworm
53
D. Other Endocrine
81
2. Poisonings
21
13. Japanese encephalitis
E. Neuro-Psychiatric
82
3. Falls
B. Respiratory Infections
54
1. MAD
83
4. Fires
22
1. Acute Respiratory Infections
55
2. BAD
84
5. Drowning
23
2. Otitis Media
56
3. Psychoses
85
6. Venamous animals and plants as
cause of poisoining
C. Maternal Conditions
57
4. Epilepsy
86
7. Foreign body and accidental
aspiration
24
1. Hemmorhage
58
5. Alcohol Dependence
87
25
2. Sepsis
59
6. Alzheimer's and other dementia
D
□
1. Protein-Energy Malnutrition
1. Tuberculosis
17
□-
31
2. STD's Excluding HIV
1
5
5
G. Cardiovascular Diseases
E. Nutritional/Endocrine
Perinatal
8. Electric Shock
B. Intentional
26
3. Eclampsia
60
7. Parkinson's Disease
88
1. Self-inflicted
27
4. Hypertension
61
8. Drug Dependence
89
2. Homicide and Violence
28
5. Obstructed Labor
F. Sense Organ
90
3. Legal intervention
29
6. Abortion
62
1. Glaucoma-related Blindness
24
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
5
T)
Annexure HI ESTIMATION OF CAUSE OF DEATH IN RUKAL AP
Distribution of as reported by SCD AP (1988-93)
SCD CODE
5
5
5
3
3
3
3
3
3
3
CAUSE OF DEATH
Females
Males
All
Not class.
100
ACCIDENTS & INJURIES NOT : CLASSIFIABLE
66
39
105
III
SNAKE BITE
53
36
89
112
SCORPION BITE
8
3
11
113
RABIES
19
14
33
121
DROWNING
71
55
126
122
FALL FROM HEIGHT
38
24
62
123
VEHICULAR ACCIDENTS
128
42
170
124
BURNS
20
46
66
130
SUICIDE
162
122
284
140
HOMICIDE
22
10
32
151
EXCESSIVE HEAT
8
15
23
152
EXCESSIVE COLD
0
0
0
153
NATURAL CALAMITY
10
13
23
200
MATERNAL: NOT CLASSIFIABLE
0
25
25
210
ABORTION
0
9
9
221
TOXAEMIA
0
13
13
222
ANAEMIA
0
13
13
231
BLEEDING OF PREGNANCY
0
28
28
232
MALPOSITION OF CHILD
0
8
8
233
PUERPERAL SEPSIS
0
5
5
300
FEVERS : NOT CLASSIFIABLE
225
223
448
311
MALARIA
8
6
14
321
INFLUENZA
14
22
36
331
TYPHOID
33
36
69
DIGESTIVE DISORDERS : NOT CLASSIFIABLE
35
28
63
G ASTRO-ENTERITIS
71
108
179
400
' 411
412
CHOLERA
4
5
9
413
FOOD POISONING
22
9
31
414
DYSENTERY
59
66
125
421
PEPTIC ULCER
64
28
92
431
ACUTE ABDOMEN
87
73
160
500
COUGHS : NOT CLASSIFIABLE
22
25
47
511
TUBERCULOSIS OF LUNGS
432
196
628
513
BRONCHITIS & ASTHMA
578
346
924
3
521
PNEUMONIA
31
20
51
530
WHOOPING COUGH
6
4
10
3
600
CNS DISORDERS : NOT CLASSIFIABLE
24
16
40
610
PARALYSIS
344
259
603
620
MENINGITIS
20
21
41
630
CONVULSIONS
76
64
140
700
CONGESTIVE & OTHER HEART DISEASES
156
99
255
710
ANAEMIA
87
98
185
730
HEART ATTACK
489
232
721
J
□
□
3
3
3
3
3
3
3
3
25
105
25
448
63
47
40
255
•
)
)
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
)
800
J
)
3
5
0
5
s
OTHER MEDICALLY CERTIFIED DEATHS
3
0
3
17
45
66
811
CIRRHOSIS & CHRONIC LIVER DISEASES
42
24
812
JAUNDICE
151
92
243
821
CHICKENPOX
0
1
I
822
MEASLES
8
21
29
823
LEPROSY
23
8
31
831
TETANUS
8
13
21
841
POLIOMYELITIS
2
3
5
851
MENTAL DISEASE
18
21
39
861
CANCER
189
251
440
871
DIABETES
55
28
83
881
HYPERPLASIA OF PROSTATE
15
9
24
882
URAEMIA
32
12
44
890
OBSTRUCTED HERNIA
4
0
4
900
INFANT DEATHS : NOT CLASSIFIABLE
213
176
389
910
PREMATURITY
174
146
320
922
CONGENITAL MALFORMATION
15
7
22
923
BIRTH INJURY
12
4
16
931
RESPIRATORY INFECTIONS OF THE NEW BORN
PERINATAL
87
79
166
932
CORD INFECTION
13
13
26
933
DIARRHOEA OF NEW BORN
41
49
90
1000
J
3
28
389
SENILITY
1357
1313
2670
2670
Total
5979
4791
10770
4042
Details of Unclassified deaths from SCD subjected to expert opinion and
field enquiry
Description
SCD code
No. subjected for
EO&FE
27
No. Classified
6
6
27
J
1.00
2.00
Accidents and injuries not classifiable
Maternal not classifiable
5
3.00
Fevers not classifiable
107
107 •
J .
J
4.00
Digestive disorders not classifiable
12
12
5.00
Coughs not classifiable
10
10
6.00
CNS disorders not classifiable
4
4
J
7.00
Congestive and other heart diseases
53
53
J
8.00
Bums
11
J
9.00
Causes peculiar to infancy not classifiable
11
71
68
J
10.00
Senility
139
136
440
434
J
TOTAL
J
26
a
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
$
SCD
Deaths
Codes
1.13 31.61
Algorithms used to classify the SCD estimated deaths responsible for >0.1%
%
Cum %
Diseases
Solution
0.29%
0.29%
Rabies
Added to Group la total
1.51
32.15
0.30%
0.59%
3
1.53
22.33
0.21%
0.80%
Excessive Heat Added to Unintentional Injuries (Group HJa) total
Natural
Added to Unintentional Injuries (Group IHa) total
Calamity
2
5
4.31
179.89
1.67%
2.47%
Acute Abdomen [Added to Digestive (Group D i) total
5.13
1321.68
12.28%
14.75%
Bronchitis &
Asthma
To follow the distribution of Bronchitis & asthma from 26
6.1
1217.91
11.34% 26.09%
Paralysis
> 45 yrs to include in Stroke. < 45 to distribute in meningitis and
encephalitis as per ICD distribution
6.3
158.21
1.48%
27.57%
Convulsions
<15 as per ICD distribution in meningitis & encephalitis 15-45Epilepsy, 45-60:50% epilepsy, 50% stroke, >60: Stroke ’
8.12
267.49
2.48%
30.05%
Jaundice
To distribute <5 yrs. under hepatitis and for the remaining age groups
to follow ICD age wise distribution of Hepatitis, Cirrhosis & Cancer
Liver
5
3
5
8.51
114.26
1.06% 31.11%
8.61
831
7.74% 38.86%
Mental Disease To include in 'Neuropsychiatric total
Cancer
To include in Cancer total
3
5
Y
)
5
1
1
27
7
’
countries
J
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Annexure IV
3
ESTIMATION OF CAUSE OF DEATH LN URBAN AP
Algorithms used to classify the MCCD estimated deaths responsible for >0.1% in Urban AP
ICD Codes Deaths
%
Cum%
Disease discription
Solution
71
1092
0.16%
0.16% Rabies
To move over to Group la total
161
1378
0.21%
0.37% Malignant neoplasm of
larynx
To add to the APBD list
200,202,203
505
0.08%
0.45% All other Malignant
neoplasm of lymphatic and
haempoietic tissue
To combine with Hogdkins and
Leukaemias
190-199
5860
0.88%
264-269
4242
0.64%
1.33% Malignant neoplasm of other To proportionately distribute to all
and unspecified sites
listed cancer sites including 'other
cancers'
1.97% All other Nutritional
To move over to Group HE totals
deficiencies
286-289
658
0.10%
290
801
302,-316
1100
323-339,341344,346-359
10949
3
402^04
2154
3
401,405
4545
415-429
40846
0
0
0
0
0
0
□
3
3
3
□
3
3
3
3
3 ’
444
838
411-443,446448
1413
3
3
3
3
5
2.07% All other diseases of blood To move over to Group HE totals
____ and blood fonning organs
0.12%
2.19% Senile and presenile, organic To move over to dementias including
psychotic conditions
Alzheimers
0.17%
2.36% All other Mental disorders To add to Group HF(Neuropsychiatric)
for the present and to develop some
algorithm to get Alzheimers
1.65%
4.01% All other diseases of
To add to Group IIF(Neuropsychiatric)
Nervous System
for the present and to develop some
algorithm to get deaths due to
alcoholism and drug dependence
0.32%
4-33% Hypertensive heart Diseases To add to APED list
0.68%
5.02% All other Hypertensive
To add to Hypertensive diseases list
Diseases
6.16% 11.17% Diseases of Pulmonary
To add to the Group
Circulation and other forms IIG(Cardiovascular Total) for the
of heart disease
present and develop appropriate
algorithm on the basis of autopy series
from India
0.13% 11.30% Arterial embolism and
To add to the Group
thrombosis
IIG(Cardiovascular Total) for the
present and develop appropriate
algorithm on the basis of autopy series
from India
0.21% 11.51% Other diseases of Arteries,
To add to the Group
Arterioles & capillaries
IIG(Cardiovascular Total) for the
present and develop appropriate
algorithm on the basis of autopy series
from India
)
)
)
28
)
)
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
455
718
0.11%
11.62% Haemorrhoids
To add to the Group
IIG(Cardiovascular Total) for the
present and develop appropriate
algorithm on the basis of autopy series
from India
445,449,450,
456-459
982
0.15%
11.77% All other diseases of
Circulatory system
To add to the Group
IIG(Cardiovascular Total) for the
present and develop appropriate
algorithm on the basis of autopy series
from India
19367
2.92%
To use alogorythem developed on the
14.69% Bronchitis, Chronic and
unspecified emphysema and basis of observed relationship between
bronchitis and asthma in 26 developed
asthama
countries
511
725
0.11%
14.80% Pleurisy
To move to Group IIH(Respiratoiy) for
the present
488,489,497510,512-519
9638
1.45%
16.25% All other Diseases of
Respiratory system
To move to Group IIH(Respiratory) for
the present
560
2481
0.37%
16.62% Intestinal obstruction
without Mention of Hernia
To add to the APBD list
567
2103
0.32%
16.94% Peritonitis •
To add to the APBD list
530,534,536539,544-549,
554-559,561566,568-570,
572,573,576579
12466
1.88%
18.82% All other diseases of the
other parts of the digestive
system
To move to Group III (Digestive) total
for the present and to develop
591,593,595599
715
)
)
490-496
3
3
3
3
0.11%
algorithm
18.93% All other diseases of Urinary To move to the Group II J (Genito
Urinary) total
System
797
26624
4.01% 22.94% Senility without mention of To follow the standard algorithm
already developed under GBD to
psychosis
distribute to Group I& II
780-796,798,
799
44754
6.74% 29.68% All other sign symptoms and To follow the standard algorithm
already developed under GBD to
ill defined conditions
distribute to Group I& II
E900-E909rE
911-E918JE9
21JE923-E92
9
4072
0.61% 30.30% All other accidents including To add to Group Illa (unintentional)
for the present
late effects
5
E980-E981
7711
1.16% 31.46% Injury undetermained
whether accidentally or
purposely inflicted
To proportionately distribute to Group
Illa & IHb deaths
5
E970-E979
1136
0.17% 31.63% All other types of violence
To add to the Group IHb total and
include under War/legal intervention
5
J
5
5
5
5
3
29
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Annexure V
Group
Communicable
O '
Quality of data available for APBD estimates1 I
___________ Disease
India
AP
Tuberculosis
STD excluding HIV
HIV
***
** *
Diarrhoea
Childhood cluster
***
**
**
Meningitis
o
***
Japanese Encephalitis
Hepatitis
A
A
AAA
AAA
AA
AA
A
A
o
o
Malaria
AAA
AAA
O
Filaria
AAA
AAA
Leprosy
AAA
AAA
Trachoma
AA
Intestinal Parasitcs
AA
AA
AAA
AAA
A
A
A
A
AAA
AAA
Enteric Fever
a
5
[Maternal
Perinatal
□
□
0
Nutritional
Acute Rcsp.Infections
Maternal
Perinatal
PEM
Anaemia
IDD
AAA
AAA
AAA
AAA
Vita. A deficiency
AAA
AAA
Good community based studies; ** Community based studies; * Hospital Based data
5
5
5 .
5
5
Quality of data available for APBD estimates1 II
■)
30
)
)
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Group
Disease
Cancers
Cancers
India
**
Endocrinal
Diabetes
***
Neuro-psychiatirc
Major Affective Disorders
AP
*
AA
AA
Bipolar Affective Disorders
Psychosis
AA
Epilepsy
AA
Alcoholism
A
Drug dependence
A
Dementias
Sense organs
Cataract
AAA
AAA
AAA
AAA
Glaucoma
Cardiovascular
J
Rheumatic Heart disease
Ischaemic heart disease
Cerebrovascular disease
Peri Endo Myocarditis and
cardiomyopathies
0
0
5
5
5
J
J
J
Chronic Respiratory
COPD
A
Asthma
A
Peptic Ulcer
A
Cirrhosis of liver
A
Hernia
A
____________
Appendicitis
A
Genitourinary
Nephritis & Nephrosis
AA
Digestive
)
A
BPH
Muskulo Skeletal
[congenital
J
A
Oral Health
Rheumatoid arthritis
A
Osteoarthritis
A
Congenital
A
Dental carries
AAA
AAA
Periodontal disease
AAA
AAA
A
A
Eduntulism
AAA
Good community based studies; ** Community based studies; * Hospital Based data
)
31
(J d d
u u u d d d u w o" d d d <j d
A A z
d d d <j c/ </ d d q <j d' d
& MH
(j (J.
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
Annexure VI Disability Adjusted Life Years(DALYs)
REGI
ON
AP
DISEASE
N
o Sum
AP
ALL
ALLM
ALLF
MO
M5
M15
M45
M60
FO
F5
F15
F45- 4
-J
17,657,518
9,159,641
8,497,877.
3,395,371
754,549 2,511,708
1,318,827
1,179,187
3,297,589
665,098
2,476,426
915,340
I.Communicable, Maternal 8.
Perinatal
1,143,423
9,528,102
4,852,049
4,676,054
2.880,158
394,568
954,294
376,283
246,746
2,669,881
391,872
1,146,691
273,742
193,867
A. Infectious & Parasitic
4,513,587
2,571,091
1,942,496
1,025,683
271,704
798,072
320,827
154,805
919,953
243,123
494,903
1. Tuberculosis
183,085
101,433
1,370,483
910,529
459,953
12,156
46,750
489.094
252,985
109,545
8,373
37,968
233,567
128,505
91,155
51,540
31,776
59,379
1,144
284
29,910
394
_____ 44
1,001
500
56,999
793
____ 85
AP
2
AP
3
AP
4
AP
AP
AP
AP
/ AP
5
a. Syphilis
59,711
28,558
31,153
1,057
244
26,895
326
____ 36
944
260
6
29,323
b. Chlamydia
567
____ 59
24,226
2,769
21,457
_______ 6
____ 32
2,674
____ 50
8
192
7
c. Gonorrhea
__7
21,010
221
____ 26
7,219
450
6,769
______ 82
_____ 8
341
____ 17
__1
_____ 49
____ 48
6,666
_____ 6
_____ 1^
AP
AP
XX AP
AP
AP
AP
AP
/ AP_
AP
AP
AP
AP
AP
2. STD's Excluding HIV
8
3. HIV________________
9
4. Diarrhoeal Diseases
1C
5. Childhood Cluster
11
B. Respiratory Infections
21,402
1,207,987
818,806
118,387
96,821
8.503
358,030
237,065
207,971
152,601
49,654
39,766
39,766
39,510
24,501
150,564
81,267
36,741
32,555
57,766 '
1,825,738 "
1. Acute Respiratory
Infections
1.764,354
_______
a. Pertussis
12
b. Polio
13
c. Diptheria
14
d. Measles
15
e. Tetanus
16
6. Meningitis
17
7. Hepatitis
18
8. Malaria
19
9. Tropical Cluster
20
a. Lymphatic Filariasis
21
10. Leprosy
22
11. Trachoma
V/AP
23
AP
24
AP
25
b. Trichuris
AP
26
c. Hookworm
AP
27
AP
28
AP
29
12. Intestinal Helminths
a. Ascaris
13. Japanese encephalitis
12,939
8,463
267
____ 52
12,052
501
____ 68
274
____ 56
8,080
____ 42
____ 12
632,288
575,699
490,071
39,856
67,179
15,030
20,152
444,097
38,994
60,016
13,404
19,189
424,095
394,711
334,488
40,474
42,519
4,944
1,669
307,551
43,445
37.443
4.594
61,714
56,673
55,984
5,730
______ 0
' 0
_____ 0
51,149
5,524
51,602
45,219
50,421
1,021
160
44,176
902
4.145
3,312
841
205
835
181,154
155,888
20,988
______ 0
___ q
___ q
3,093
176,876
___ q
___ q
___ q
_____ 0
4,358
156,552
24,601
129,545
___ q ___ q
141
___ q
217 ___ q
___ q ____ c
107,520
83,909
68,883
11,895
42,154
4,944
1,669
52,581
11,583
37,085
4,594
124,063
56,369
29,857
32,312
3,739
1,785
47,156
14,294
20,023
1,855
580
89,807
62,793
49,545
6,551
23,761
7,250
2,700
31,798
3,752
20,181
4,489
2,574
28,344
21,310
5,227
4,514
16,178
1.919
506
3,878
3,860
11,725
1,461
385
25,176
14,590
______ 0
_____ 0
10,227
13,789
1,160
______ 0
_____ 0
_____ 0
12,434
2,156
25,176
14,590
______ 0
_____ 0
10,227
13,789
1,160
______ 0
_____ 0
___ q
12,434
2.156
19,370
20,140
2,071
15,900
1,121
254
____ 24
2,032
16,855
1,094
131
8,715
______ 0
_____ 0
3,880
2,826
2,008
___ q
____ 27
15,786
_____ 0
7,494
1,328
6,965
76,063
74,501
306
61,471
12,491
1,254
541
301
59,571
12,959
560
41,290
39,977
306
40,984
______0
_____ 0
___ q
_____ 0
18,064
______ 0
18,383
225
____ 70
39,676
17,859'
_____0
18,677
___ q
301
___ q ___ q
1,110
0
16,460
______ 0
25,379'
2,104
12,266
1,184
541
___ q
1,044
560
4,755
60,325 ~
5,911
100,751 '
100,751 '
1,000
30,221 '
456
80,731 '
13,974
2,035
2,216'
139
12,820'
____ 65
16,096
37,501 '
3,018
495
562
646,956
68,843
83,300
31,365
30,221 '
73,662
80,731
616,520
68,843
83,300
31,365
73.662
921,613 ~
890,665
20,265
904,125"
873,689 ’
649,584
618,637'
60,325
32
1,678
_____ 0
_____ 0
___ q
___ q
1,678
I
*
CT
I
/
(j' 0* C' C1
O
I
J J d J (J u u d d d u (jd d d u (j a u M (J (J
G' C O' C* ’<J
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
AP
30
AP
31
AP
2, Otitis Media__________
61,384
C. Maternal Conditions
32
1. Hemmorhage
AP
33
2. Sepsis
AP
34
AP
35
AP
38
AP
37
AP
38
AP
39
AP
40
30,947
30,436
498,163
0
498,163
0
0
27,245
£
27,245
£
0
169,389
0
169,389
0
0
3. Eclampsia
4,623
0
4,623
0
4. Hypertension
6,308
0
6,308
0
5. Obstructed Labor
125,808
0
125,808
0
6 Abortion ,
37,012
0
37,012
0
0
0
0
D. Perinatal Conditions
1,778,021
937,262
840,759
937,262
___£
_____ 0
_____ 0
D. Nutritional/Endocrine
912,593
422,083
490,510
267,630
62,539
55,470
25,235
1. Protein-Energy
Malnutrition
374,260
188,358
185,903
178,789
1,800
4,738
1,702
2,961
30,947
30.436
0
0
0
0
0
0
0
464,622
29,163
4,378
£
0
25,811
1,434
0
£
£
£
156,273
13.115
0
01
'0
0
0
0
4,552
72
0
0
0
0
0
6,308
0
0
0
0
0
0
115,518
10,290
0
0
0
_____ 0
35,820
1,192
0
_____ 0
840,759
___£ ___ £
0
0
11,209
262,213
79,907
103,867
30,130
14,393
1,257
1,773
177.529
2,682
2.856
677
2,159
824
387
39,728
1,973
3,031
329
239
0
0
£
£
£
0
0
0
0
0
0
0
0
£
0
0
AP
41
2. Iodine Deficiency
91,683
46,383
45,299
40,510
AP
42
3. Vitamin A
37,660
19,324
18,336
19,324
0
0
18,336
AP
• 43
4. Anemias
408,990
168,018
240,972
29,007
59,037
47,771
23,154
9,048
26,620
AP
44 II. Noncommunicable
AP
45
AP
___ £ ___ £
___ £ ___ £
0
0
75,252,
97,980
29,125
11,995
5,288,634
2,849,878
2,438,757
301,009
119,392,
821,191
791,123
817,163
260,576
102,481
745,160
552,500
778,041
A. Malignant Neoplasms
595,259
304,933
290,326
7,645
6,336
102,889
120,194
67,869
2,274
2,366
108,414
132,726
44,546
46
1. Mouth and Oropharynx
48,307
32,205
16,103
• 0
0
9,571
14,191
8,442
0
0
6,270
7,115
2,718
AP
47
2. Esophagus___________
67,634
40,196
27,439
0
0
12,683
18,453
9,060
0
0
10,148
11,988
5,302
AP
48
3. Stomach
59,861
40,579
19,282
2
6
13,868
16,734
9,970
0
0
7,236
9,137
2,908
AP
49
4. .Colon/Rectum
26,296
15,121
11,175
0
24
3,122
7,528
4,447
29
71
1,810
6,125
3,140
AP
50
5. Liver
22,310
15,779
6,530
126
190
3,933
8,774
2,755
28
94
1,593
3,231
1,585
AP
51
6. Pancreas
13,021
8,259
4,761
0
0
1,850
4,058
2,351
O'
26
1,454
2,376
906
AP
52
7.
T rachea/Bronchus/Lung
64,529
55,845
8,684
30
24
17,687
27,856
10,248
28
28
921
5,648
2,060
AP
53
8. Melanoma and Other
Skin
1,663
934
729
13
31
196
407
287
52
6
210
316
145
AP
54
9. Breast
56,808
0
0
0
0
1
2
23,913
27,210
5,683
10. Cervix_________ ,
84,364
___ 0
0
_____ 0
0
0
32,830
42,727
8,806
56
11. Corpus Uteri
5,545
_____ 0
£
;0
_____ 0
0
0
2,394
1,539
1,612
AP
57
12. Ovary_______________
12,349
_____ 0
0
_____ 0
_ ____ 0
72
72
5,184
5,715
1,305
AP
58
13. Prostate____________
11,903
11,903
0
_£
__ £
_J£•
_J£!
0
AP
£
£
£
55
56,808
84,364
5,545
12,349
____ 0
0
AP
190
2,715
8,998
0
_£
_____ 0
___£
0
AP
59
14. Bladder
11,111
6,899
4,212
__ 0
___ 24
1,362
2,659
2,854
__ 29
70
317
1,139
2,658
AP
60
15. Lymphoma
83,864
59,962
23,902
7,473
6,037;
34,399
7,765
4,287
2,036
1,997
11,816
4,456
3,596
AP
61
16. Larynx______________
25,694
17,251
8,443
____ 0
0
4,029
9,053
4,169
___ 0
0
2,316
4,004
2,123
AP
62
B. Other Neoplasm
11,142
7,357
3,785
731
639
5,054
558
374
259
96
2,653
522
254
AP
63
C. Diabetes Melltus
118,907|
67,165
51,743
66
115
17,100
21,830
28,053
0
30
13,990
12,108
25,614
0
33
I d d d d u u d J d d (j (
j
(j
.
d d <j <j u
,
■
-
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Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
AP
64
D. Other Endocrine______
1,091
663
428
___ 66
____ 38
337
150
____71
____ 0
0
153
AP
65
E. Neuro-Psychiatric
915,987
478,911
437,076
14,619
40,002
273,818
83,230
67,243
13,532
26,704
286,262
AP
AP"
66
1. MAD_______________
255,457
85,506
169,950
____ 0
_____ 0
73,194
10,128
2,185
____ 0
_____ 0
145,187
67
2. BAD_______________
17,122
8,660
8,462
____ 0
0
7,528
928
204
____ 0
_____ 0
AP
66
3. Psychoses__________
178,392
82,404
95,988
___ 23
116,
76,448
3,708
2,109
__ 25
139
AP
69
4. Epilepsy____________
152,529
90,673
61,856
9,917
36,200
38,718
3,641
2,198
6,757
24,260
AP
70
5. Alcohol Dependence
• 142,976
125,106
17,869
0
____ 0
69,954
38,657
16,496
_____ 0
0
AP
71
6. Alzheimer's and other
dementia
149,503
74,141
75,362
4,668
3,455
3,727
22,906
39,385
6,724
2,232
7,311
93,003
26,823
9,904
2,502
119
52,890
20,122
921
733
2,653
5,551
20,355
AP
72
7. Parkinson's Disease
13,272
7,428
5,844
11
21
80
2,743
4,573
25
0
64
2,379
3,376
AP
73
8. Drug Dependence
6,737
4,993
1,745
__ 0,
211
4,169,
520
___ 93
0
73
1,469
176
___ 27
AP
74
F. Sense Organ_________
160,080
81,232
78,848
843
0
8,460
40,946
30,983
823
0
6,660 • 36,969
34,396
AP
75
1. Glaucoma-related
Blindness
32,916
18,860
14,056
0
0
1,513
14.204
3,143
0
0
0
10,405
3,651
AP
76
2. Cataract-related
Blindness
127,164
62,372
64,792
843
0
6,947
26,742
27,840
823
0
6,660
26,564
30,745
AP
77
G. Cardiovascular
Diseases
1.855,050
959,952
895,098
19,820
13,196
131,374
305,706
489,857
23,341
21,553
120,433
199,344
530,427
AP
76
1. Rheumatic Heart
Disease
169,503
58,929
110,573
981
6,274
20,598
15,729
15,348
1,481
7,332
27,801
35,286
38,673
AP
79
796,479
487,627
308,853
250
121
64,251
171,388
251,617
157
134
16,473
64,919
227,169
AP
80
622,440
282,178
340,262
4,331
2,850
40,568
65,954
168,475
4,331
5,138
45,426
69,837
215,530
AP
81
AP
82
AP
83
1. COPD
AP
84
2. Asthma
AP
85
AP
86
AP
87
AP
86
AP
89
AP
90
AP
91
2. Ischemic Heart Disease
3. Cerebrovascular
Disease
4. PEMC
__________
156
57,688
4,641
230
2,088
1,362
2,415
43,549
266,628
131,218
135,410
14,259
3,952
5,957
52,635,
54,416
17,372
8,949
30,734
29,302
49,053
. 291,341
160.364
130,976
13,625
24,564
34.615
31,438
56,121
12,240
18,729
37,126
31,046
31,836
155,604
93,051
62,553
8,157
2,192
6,140
23,655
52,907
7,135
1,596
4,673
67,314
68,423
5,468
22,372
28,476
7,784
3,215
5,105
17.132
32,453
475,609
333,473
142,136
12,136
4,544
158,975
118,414
39,404
5,751
3,757
66,677
21,141
9,905
41,147
28,008
135,737
1. Peptic Ulcer Disease
94,457
339
826
33,503
20,107
7,737
458
666
16,919
9,538
4.364
263,570
62,512
189,000
31,944
2. Cirrhosis of the Liver
74,570
2,432
1,436
82,954
76,062
26,117
2,983
2,652
31,755
26,505
10,676
202,769
121,319
81,450
4,411
21,411
23,143
46,982
25,372
2,702
21,508
27,608
15,697
13,935
H. Chronic Respiratory
Diseases
■
I. Diseases of the Digestive
System
J. Diseases of the
Genito-Urinary System
1. Nephritis/Nephrosis
3,828
24,804
169,131
87,681
81,450
4,411
21,402
23,136
21,420
17,312
2,702
21,508
27,608
15,697
2. Benign Prostatic
Hypertrophy
13,935
33,638
33,638
0
0
8
7
25,562
8,060
0
.0
0
0
0
K. Diseases of the
Musculo-Skeletal System
54,242
18,296
35,946
0
1
11,565
5,304
1,426
.0
0
20,772
12,490
2,684
34
/
d d d d <
u/
U7
kJ
kU
V4/
kJ
kJ
kJ
kJ
W
kJ
kJ
'J
W
*
kJ
kJ
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
AP
92
1. Rheumatoid Arthritis
18,074
8,411
9,663
0
0
7,023
854
533
0
0
6,829
2,287
547
AP
93
2. Osteoarthritis
36,168,
9.885
26,283
______ 0
__ 0
4.542
4,450
893
0
____ 0
13,942
10,203
2,137
AP
94
L. Congenital Abnormalities
461,397
243,084
218,313
225,752
5,947
11,119
229
_____ 37
198,390
5,249
13,476
1,131
_____ 68
AP
95
M. Oral Health
145,760
73,128
72,632
1,294
2.601
42,741
16,139
10,353
1,264
2,489
40,936
16,311
11.632
AP
96
1. Dental Caries
25,356
12,807
12,549
1,294
2,601
5,500
2,170
1,243
_
2,489
5,267
2,151
1,378
AP
97
2. Periodontal Disease
90,382
45,889
44,493
___ q
0
6,491
2,157
______ 0
0
6,434
2,391
AP
98
3. Edentulism
30,022
14,432
15,590
o
AP
99 III. Injuries
2,840,781
1,457,715,
1,383,066
214,204
AP
100
A. Unintentional
2,343,779
1,181,261
1,162,517
210,652
AP
101
1. Motor Vehicle
Accidents
279,704
210,234
69.470
18.012
____ 0
240,588
221,230
40.299
37,241
_ ___ 0
736,223
526,176
128,455
AP
102
2. Poisonings
34,361
14,178
20,183
2,989
1,971
7,699
1,262
256
2,228
1,319
14,252
1,873
511
AP
103
3. Falls
899,015
371,961
527,054
70,974
68,502
107,781
41,803
82,901
282,524
61,831
34,593
15,001
133,104
AP
104
4. Fires
394,584
124,944
269,640
36,833
13.412
64,417
7,870
2,411
7,673
28,152
213,779
14,061
5,976
AP
105
5. Drowning
200,649
129,193
71,456
29,070
43,586
48,175
6,018
2,345
8,801
25,960
28,106
4,035
4,553
AP
106
6. Venamous animals and
plants as cause of poisoining
120,249
79,214
41,036
3,334
27,345
39,658
8,348
529
0
11,642
21,902
5,644
1,848
AP
107
7. Foreign body and
accidental aspiration
35,394
21,341
14,053
17,780
3,560
0
0
0
14,053
0
0
0
0
AP
108
8. Electric Shock
65,439
65,439
0
AP
109
B. Intentional
497,003
276,454
220,549
AP
110
1. Self-inflicted___________
371,196
199,855
171,341
AP
in
2. Homicide and Violence
113,630
68,274
45,356
AP
112|
3. Legal intervention
12,177
8,325
3.852|
_ 0
3,552
101
2.596
855
7,479
6,953
0
0
151,421
115,278
367.132
170,745
115,479
107,724
363.910
163,174
35,668
____ 0
584,575
407,334
18,388
5,081
9.288
19.896
23,817
7,727
7,863
89,098
171,516
60,741
167,358
6,783
9,686
0
49,436
13,435
2,568
0
0
0
0
0
19,358
210,047
35,942
7,554
3,223
7,571
177,241
28,357
4.158
14,064
155,610
24,471
5,609
__ 34
6,925
148,740
12,715
2,926
4.608
48,170
10,980
1,920
2,307
178
26,245
15,424
1,202
687
6,266
492
24
881
468
2,256
218
29
35
(JUUUUUUUUUWUUUU (J
u
U
M
u
V
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
REGIO
N
Rural
DISEASE
N
0 Sum________________________
ALL
ALLM
ALLF
14,037,909 7.184.267 6,853,642 2,688,456
M45
M15
M5
MO
M60
612,608 1,911,313 1,008.885
F45
F60
573,104 1,932,551
737,666
889,365
145.657
F15
F5
FO
963,005 2,720,956
7,781,109 3.921.409 3,859,700 2.320,412
324,217
769.944
301.541!
205.295 2,191^67
340,807
952.455
229.014
A. Infectious & Parasitic
3,805,990 2,137,602 1,668,388
881,835
222,379
646,586
257,194
129,608
806,747
210,391
419,525
155,826
75,900
I. Tuberculosis
~2. STD's Excluding HIV
1,137,636
743,935
393,701
10,369
39,279
397,492
205,334
91.461
33,328
203,783
112,278
37,288
70,950
24,170
46,780
882
198
22,768
296
26
7,023
78?
402
45,090
460
47
21,881
24,732
834
170
20,610
247
20
749
221
23,449
287
26
Rural
1 I Communicable, Maternal &
Rural
2
Perinatal__________________ _
Rural
3
Rural
4
Rural
5
a. Syphilis______________
46.614
Rural
6
b. Chlamydia
18,654
1,984
16,670
3
23
1.914
38
6
5
146
16,331
168
20
7
c. Gonorrhea
8 ~~ 3. HIV
5,682
305
5,377
45
5
244
11
1
28
35
5,310
4
1
12,020
7,674
4,345
201
35
7,080
311
48
214
47
4,050
26
8
Rural
9
4. Diarrhoeal Diseases
1.024.113
531.358
492.755
413.358
32,015
55,835
12.396
17,753
380,519
34.424
51,159
11.158
15,495
Rural
10
5. Childhood Cluster
739,942
379,914
360,027
303,700
35,343
35,394
4,021
1,456
282,318
40,455
32,165
3,764
1,327
104,456
54,109
50,347
49,646
4,453
0
0
0
45,839
4,508
0
0
0
707
115
0
0
Rural
Rural
Rural
11
a. Pertussis
75,725
40,034
35,691
39,113
796
125
0
0
c. Diptheria
7,208
3.667
3,542
2,850
702
114
0
0
2,674
724
144
0
0
168,832
174,813
148,920
19,911
0
0
0
150,770
24,043
0
0
0
Rural
12
b. Polio
Rural
13
34,869
Rural
14
d. Measles
343.644
Rural
15
e. Tetanus
208.908
113,273
95,636
63,171
9,471
35,154
4,021
1,456
48,166
10,473
31,906
3,764
1,327
106,627
74,389
48,677
25,057
28,092
3,197
1,603
41.213
13,224
17,866
1,602
484
1.903
Rural
16
6. Meningitis
181.016
Rural
17
7. Hepatitis___________,
137.261
79,399
57,862
47,113
5,583
18,983
5,639
2,081
30,843
3,574
17,748
3,794
8. Malaria
46,368
26,360
20,009
5,046
4,092
14,997
1,755
471
3,723
3,643
10,961
1,336
345
Rural
Rural
Rural
18
19
20
9. Tropical Cluster
a. Lymphatic Filariasis
27.726
17,292
10,434
o1
0
6,745
9.672
875
0
0
0
8,847
1,587
27,726
17,292
10,434
0
0
6,745
9.672
875
0
0
0
8,847
1,587
1,498
12,327
787
100
21
802
192
19
0
0
2,777
2,129
1,607
0
0
5,391
1,012
5,459
58,102
240
47,033
9,713
995
485
238
46,036
10,464
864
501
14,734
18,375
6,513
11,862
116,567
58.465
21
10. Leprosy______________
28.820
Rural
22
II. Trachoma
1,510
11,564
14,086
Rural
Rural
23
12. Intestinal Helminths
Rural
24
a. Ascaris
63,716
32,223
31,493
240
31,983
0
0
0
238
31,255
0
0
0
b. Trichuris
26,975
13,622
13,353
0
13,407
163
52
0
0
13,189
115
49
0
25,876
12,620
13,256
0
1,643
9,550
943
485
0
1,592
10,348
815
501
42,310
27,132
15,178
18,451
3,267
4,406
682
326
10,326
1,826
2,346
337
344
1,409,260
703.767
705,493
495,509
43,658
76,188
22,582
65,829
505,255
58,291
65,002
23.715
53,230
1,363,428
680,843
682,584
472,586
43,658
76.188
22,582
65,829
482,346
58,291
65.002
23,715
53,230
Rural
25
Rural
26
c. Hookworm
Rural
27
13. Japanese encephalitis
Rural
28
B. Respiratory Infections
Rural
29i
1. Acute Respiratory
Infections
36
■
•
(J (J ui J J J J J J'd d' (J <ji
!
»
■
—■
“
J d d d <J
J J (j
•«
----- —------------ i
------ —
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(j (j
.
|
•
(j'd
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
45,833
22,923
22,909
22,923
o
o
o
o
22,909
o
o
0
o
411,882
0
411,882
0
0
0
0
0
0
0
385,018
22,486
4,378
1. Hemmorhage
20,015
0
20,015
0
0
0
0
0
0
0
18,944
1.072
0
33
2. Sepsis__________
130,816
0
130,816
0
0
0
0
0
0
0
121,013
9,803
0
Rural
34
3. Eclampsia
3,342
0
3,342
0
0
0
0
0
0
0
3,288
54
0
Rural
35
4. Hypertension
5,767
0
5,767
0
0
0
0
0
0
0
5,767
0
0
Rural
36
5. Obstructed Labor
96,138
0
96,138
0
0
0
0
0
0
0
88,447
7.691
0
Rural
37
6. Abortion
31,649
0
31,649
0
0
0
0
0
0
0
30.758
891
0
Rural
38
D. Perinatal Conditions
1,387,682
725,972
661,710
725,972
0
0
0
0
661.710
0
0
0
0
Rural
39
E. Nutritional
766,295
354.068
412,227
217,094
58.180
47.171
21,765
9,858
218,056
72,125
82.910
26,987
12,149
Rural
40
1. Protein-Energy
Malnutrition
312,139
154,391
157,747
147,584
1,139
3,754
536
1.379
. 151,507
2.516
2.115
356
1,253
Rural
41
~42
2. Iodine Deficiency
67,524
33,926
33,599
29,582
1,236
2,176
616
316
29,362
1,532
2,280
250
174
Rural
3. Vitamin A
26,810
13,808
13,001
13,808
0
0
0
0
13,001
0
0
0
0
Rural
43
4: Anemias
359,822
151,943
207,880
26,120
55,804
41,241
20,614
8,163
24,185
68,077
78,514
26,382
10,721
Rural
44 II. Noncommunicable
75 A. Malignant Neoplasms
3,960,604 2,104,230 1.856,374
204,066
79,738
581,702
585,469
653,255
191,764
78,735
566,635
435,762
583,478
Rural
30
2. Otitis Media
Rural
31
C. Maternal Conditions
Rural
Rural
32
Rural
457,662
222,954
234,708
4,361
4,060
68,544
89,706
56,283
1,526
1,946
87,988
109,161
34,087
Rural
Rural
46
1. Mouth and Oropharynx
36,707
24,058
12,648
0
0
6,804
10,505
6,749
0
0
4,620
5,622
2,406
47
2. Esophagus
52,163
30,237
21,926
0
0
9,130
13,801
7,306
0
0
8,359
9,611
3,956
Rural
48
3. Stomach
45.432
30,146
15,286
1
4
9,815
12,359
7,966
0
0
5.887
7,250
2,149
Rural
49
4. Colon/Rectum
20,205
11,365
8,840
0
23
2,218
5,715
3,409
29
55
1,454
4,840
2,462
Rural
Rural
50
5. Liver
6. Pancreas
16,871
11,721
5,150
60
113
2,819
6.519
2,210
28
78
1,299
2,576
1,170
9,91’8
6,160
3,758
0
0
1,291
2,991
1,878
0
26
1,181
■ 1,888
662
Rural
7. Trachea/Bronchus/Lung
45,384
38,470
6,914
30
24
7,352
21,000
10,065
28
27
758
4,552
1,549
Rural
52
53
1,263
696
567
7
19
139
301
229
33
5
171
251
107
Rural
54
9. Breast
44,520
0
44,520
0
0
0
0
0
0
1
18,394
22,401
3,723
Rural
55
10. Cervix
71,762
0
71,762
0
0
0
0
0
0
0
27,623
36,793
7,347
Rural
56
11. Corpus Uteri
4,519
0
4,519
0
0
0
0
0
0
0
2,064
1,239
1,216
Rural
Rural
57
12. Ovary_____
9,995
0(
9,995
0
0
0
0
0
29
. 56
4,281
4,533
1,097
58
13. Prostate
9,555
9,555
0
0
0
140
2,007
7,407
0
0
0
0
0
Rural
59
14. Bladder
8,333
5.197
3,137
0
23
958
1,966
2,249
29
54
246
836
1,972
Rural
60
15. Lymphoma
61,559
42,487
19,072
4,262
3,853
25,021
5,869
3,483
1,350
1,644
9,775
3,595
2,708
57
8. Melanoma and Other
Skin
37
Il
u u
|J(J(J(JUU(JU(J(JWW(JUUUUUU</UUUU
V
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
Rural
61
16. Larynx
19,476
12,862
6,615
5,623
3,067
462
0
2,857
6,673
3,332
o
o
1,876
3,174
1,565
443
3,985
435
298
172
80
2,227
409
178
0
Rural
62
B. Other Neoplasm
8,690
Rural
63
C. Diabetes Melltus
87,116
48,202
38.913
0
0
12,404
13,557
22,241
0
0
12,195
8,097
D. Other Endocrine
0
0
0
0
0
0
0
0
0
0
0
0
Rural
Rural
64
65
E. Neuro-Psychiatric
18,622
~
0
670,817
349,027
321,790
9,698
28,588
196,423
52,662
5.335
19,775
207,824
40,216
61,765
123.425
0
0
52,387
61.656
7,630'
44,640
1,748
0
0
104,449
15,338
3,638
Rural
66
1. MAD
185,190
Rural
67
2. BAD
12.394
6,248
6.146
0
0
5,387
697
163
0
0
5,265
704
178
Rural
68
3. Psychoses
128.493
59,190
69,303
12
71
54,688
2,735
1,685
16
114
67,059
584
1,530
Rural
69
4. Epilepsy
112,245
65,678
46.567
7,128
26,271
27.790
2,735
1,755
4.950
17,772
20.765
2.037
1,042
Rural
70
5. Alcohol Dependence
104,518
91,405
13,114
0
0
51,024
28,292
12,088
0
0
7,280
4.070
1,764
2,049
15,556
33,904
2.567
Rural
71
6. Alzheimer’s and other
dementia
113.689
55,992
57.697
2,552
Rural
72
7. Parkinson's Disease
10,241
5,787
4,454
6
8. Drug Dependence
4,046
2,962
1,084
0
Rural
73
2.642
17,188
31,505
4.353
13
57
2.057
3,655
16
0
52
1,819
130
2,448
321
62
0
53
906
108
17
2,105
1,835
128,167
64,905
F. Sense Organ_____________
63,262
609
0
6,415
32,040
25,841
602
0
5,133
29.333
28,194
25,087
14.296
10,791
0
0
1,083
10,700
2,514
0
0
0
7.931
2,860
Rural
74
75
Rural
76
2. Cataract-related
Blindness____________________
103,080
50,608
52,472
609
0
5,332
21,340
23,327
602
0
5,133
21,402
25,334
Rural
77
G. Cardiovascular Diseases
1,411,033
730,950
680,084
11,022
8,825
93,323
226,382
391,398
15,215
17,017
96,366
157,540
393,945
Rural
78
1 Rheumatic Heart
Disease________________ ,
128,610
43,570
85.040
580
4.479
14,645
11.607
12,259
980
5,541
22.082
28.091
28,346
Rural
79
2. Ischemic Heart Disease
607,506
373,934
233,571
143
78
45,634
127,029
201,050
104
106
13,108
51,141
169,112
475.112
216,603
258,508
2,469
1,835
28,811
48.873
134,615
2,865
4,073
36,193
55,041
160,337
Rural
1. Glaucoma-related
Blindness____________________
Rural
80
3. Cerebrovascular Disease
Rural
81
4. PEMC
199,806
96,842
102,964
7,830
2,433
4,233
38.872
43,473
11,266
7,297
24,984
23,266
36,151
Rural
82 H. Chronic Respiratory
D i s e a s es_____________________
216,529
117,314
99,214
7,856
16,608
24,666
23.339
44,845
8,092
14,361
28,611
24,386
23,765
Rural
83
1. COPP__________________
117,293
70,018
47,276
4,497
1,363
4,355
17,527
42.276
4,639
1,295
3,784
16,669
20,889
Rural
84
2. Asthma_________________
99,235
47,296
51,939
3,359
15,246
20,310
5.812
2,569
3,453
13,066
24,827
7,717
2,876
232.575
104,119
1,542
1,480
112,745
86,849
29,960
2,379
2,710
49,271
31,459
18,301
24,694
190
572
23,848
14,935
6,182
297
522
13,168
7,482
3,224
20,869
1,948
2,127
25,450
20,889
7.968
1,812
16,712
21,563
12,278
10,478
Rural
85
I. Diseases of the Digestive
System
_______________
336,694
Rural
86
~B7
• 1. Peptic Ulcer Disease
70,420
45,726
196,770
138,388
58,382
1,352
908
58,890
56,368
151,577
88,733
62.844
2,593
14,224
16,459
35,180
Rural
Rural
88
2. Cirrhosis of the Liver
J. Diseases of the
Genito-Urinary System
38
20,277
J J J J (J u J udd'Uwuu'dd u u u
i ’
'
'
'■
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
Rural
boTI
Rural
90
Rural
91
1. Nephritis/Nephrosis
125,871
63,027
62,844
2,593
14,219
16,454
15,925
13,836
1,812
16,712
21,563
12,278
10,478
2. Benign Prostatic
Hypertrophy
25,706
25,706
0
0
&
5
19,255
6,441
0
0
0
0
0
40.025
13.412
26,613
0
0
8,276
3,995
1,141
0
0
14,970
9.545
2,098
Rural
K. Diseases of the
Musculo-Skeletal System
92
1. Rheumatoid Arthritis
13,224
6,094
7,130
0
0
5,025
643
426
0
0
4.940
1,767
423
Rural
93
2. Osteoarthritis
7,318
19,483
0
0
3,251
3,352
714
0
0
10,030
7,777
1,675
Rural
94
L. Congenital Abnormalities
176,668
168,006
164,980
3,618
7.872
173
26
151,698
4,313
11,038
906
51
Rural
95
M. Oral Health
26,801
344.674 [
107.620j
53,868
53,753
943
1,891
30.591
12.159
8.283
932
1.820
29,450
12.433
9.117
Rural
96
1. Dental Caries
9,400
9,261
943
1,891
3,936
1,635
994
932
1,820
3,789
1.640
1,080
Rural
97
2. Periodontal Disease
33,270!
32,438
0
0
26,655
4.890
1,726
0
0
25,660
4.904
1,874
Rural
98
3. Edentulism
11,197
12,053
0
0
o
5,634
5,553
0
0
0
5.890
6.163
Rural
99 III. Injuries
2.296.196' 1.158,628 1,137,568
163,978
208,653
559,666
121.874
104.455
337.424
153,563
413.461
72.891
160,230
1,827,902
900,492
927,410
163,561
190,128
361.711
87,630
97,462
336,987
146,483
241,475
45.670
156,796
8.680
Rural
100
A. Unintentional
18.661 j
65.709'
__________ I
23,2501
Rural
101
1. Motor Vehicle Accidents
236.574
176,699
59.875
13,728
37,523
107.191
14,419
3,838
8,190
18.958
18,859
5,187
Rural
102
24,795
7.556,
17,239
1,578
1,082
4,088
675
132
1.577;
970
12,568
1,658
466
Rural
816,344
310,866
505,478
58,432
59,818
77.678
35,516
79,421
275,927
58,594
28,147
12,768
130,041
Rural
103
104
2. Poisonings
3. Falls
~
4. Fires
210,280
71,723
138,558
26,482
8.747
30,787
4,083
1,623
0
22,091
106,083
7.976
2,408
Rural
105
5. Drowning
189,028
120,294
68,734
27,554
42,116
43,126
5,319
2,179
8.251
25,658
26,555
3,878
4,392
Rural
106
6. Venamous animals and
plants as cause of poisoining
120.249
79,214
41,036
3,334
27.345
39,658
8.348
529
0
11.642
21,902
5.644
1,848
Rural
107
7. Foreign body and
accidental aspiration
35,394
21,341
14,053
17,780
3,560
0
0
0
14,053
0
0
0
0
Rural
108
8. Electric Shock
0
0
0
0
Rural
109
B. Intentional
Rural
110
Rural
Rural
65,439
65,439
0
0
0
49,436
13,435
2,568
0
468,294
258,136
210,158
418
18,525
197.955
34.244
6,994
437
7,080
171,987
27,221
3,433
1. Self-inflicted
364.121
195,226
168,895
0
14.026
151,690
24.021
5.489
0
6,850
146,703
12.491
2.853
111
2. Homicide and Violence
98,439
59,005
39,433
0
4,165
43,460
9,888
1,493
0
0
24,265
14.600
567
112
3. Legal intervention
5.734
3,905
1,829
418
334
2,806
335
12
437
230
1,019
130
13
39
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
REGI
ON
N
DISEASE
ALL
ALLM
ALLF
MO
M5
M15
M45
M60
FO
F5
F15
F45
F60
Urban
0 Sum
3.619,609 1.975,375 1.644.235
706 915
141.941
600.395
309,942
216.182
576.634
91.994
543.875
Urban
1 I. Communicable. Maternal &
Perinatal
1.746,993
177.674
254,058
559.747
70.351
184.349
74.742
41,451
478,114
51.066-
194,237
44.728
48.209
Urban
2
Urban
3
Urban
4
A Infectious & Parasitic
1. Tuberculosis
2. STD’s Excluding HIV
930.639
816.354
I
I
707,598
433,489
274,108
143,847
49.325
151,486
63,633
25,197
113,206
32.732
75,378
232,847
166,595
27.259
25.533
66.252
1,787
7.471
91.602
47,651
18,083
1,350
4,640
29,784
7,606
16.227
12,599
14.251
262
86
7,142
98
18
220
98
11,909
334
39
20,205
Urban
5
a. Syphilis
13,097
6.677
6,420
223
74
6.285
79
16
195
Urban
6
b. Chlamydia
39
5,874
5.572
279
785
4,787
33
3
9
760
12
1
3
46
4,680
53
6
Urban
7
c. Gonorrhea
1,536
144
1,392
37
3
97
7
0
Urban
8
3. HIV
22
9,383
4.118
2
0
66
17
___ ]?!_
1,355
5,265
4.972
190
20
60
____ 9l.
4,030
15
4
Urban
9
4. Diarrhoeal Diseases
183.875
100,930
82,945
76.713
7.841
11,343
2,633
2.399
63.578
Urban
10
5. Childhood Cluster
4.570'
78,865
8,857
44.181
2.246
3.694
34,684
30,789
5,131
7.125
923
213
25,233
2,991
5,279
830
351
Urban
77
a. Pertussis
13,931
7,605
6,326
6,339
1,266
0
0
0
Urban
12
b. Polio
5,310
1.017
21,096
0
11,568
0
9,528
0
• 11,309
225
35
0
0
9,308
194
27
0
0
Urban
13
c. Diptheria
1,294
691
604
461
139
91
0
0
Urban
14
d. . Measles
419
14,386
111
8,045
74
6.341
0
0
6.968
1,077
0
0
0
5,782,
559
0
0
0
Urban
15
e. Tetanus
28.157
16.272
11.885
VI3
2.424
7.000
923
213
Urban
16
6. Meningitis
4,414
26,956
1,110
17,436
5,179|
9.519
830
351
7.692
4.801
4.220
542
182
5.942
1,070
2.157
10.409
4.931
254
97
2.431
969
4.778
1.611
620
956
177
2,433
1.984
694
1,301
671
182
422
1,180
164
36
155
218
764
7.883
124
4.156
41
0
0
3,483
4,117
284
0
0
0
3.587
569
Urban
Urban
Urban
17
18
19
7. Hepatitis
8. Malaria
9. Tropical Cluster
15,340
3.285
12,040
Urban
20
a. Lymphatic Filariasis
12.040
7.883
4,156
0
0
3,483
4,117
284
Urban
10. Leprosy
0
21
0
10,689
0
5,283
3.587
5.406
569
561
4,336,
319
63
5
534
4.528
6.125
307
2,201
31
3.924
6
0
0
1,103|
697
401
0
33,997
0
2,103
17,598
316
16.399
1,506
67
14,438
2,778
259
56
64
13,535
17,552
2,495
9,067
246
8,485
59
67
9.000
0
0
0
64
9.766
8,421
0
5,055
4.711
0
0
0
4.976
62
18
0
0
4.670
24
17
0
Urban
Urban
Urban
Urban
22
23
24
25
11. Trachoma
12. Intestinal Helminths
a. Ascaris
b. Trichuris
Urban
26
c. Hookworm
6,679
3,476
3.203
0
462
2,716|
241
56
Urban
27
13. Japanese encephalitis
0
15.456
444
2,471
10,369
229
5,087
59
6,927
1,488
1,505
318
130
3,648
390
672
158
218
Urban
28
B. Respiratory Infections
416,477
217.846
198.632
154,075
16,667
24,564
7,639
Urban
14,902
29
1. Acute Respiratory
Infections
141,701
400,927
10,552
209,822
18,298
191,105
7.649
146,051
20,432
16,667
24.564
7.639
14,902
134,174
10,552
18,298
7,649
20,432
40
I
(J (J J (J (J u d (J (J-J V’ V o
d d <J d q a d d d
u
d d d c/ c<
d d d u
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
lurban I
Urban
Urban
Urban
Urban !
Urban I
Urban ■
Urban j
Urban I
Urban |
Urban ,
30
2. Otitis Media
21
C. Maternal Conditions
32
1. Hemmorhage
2. Sepsis
33
34
~35
3. Eclampsia
4. Hypertension
5. Obstructed Labor
22
37'
6. Abortion
38"
15,551
8.024
7.527
8.024
0
0
0
0
7,527
86.281
0
86.281
0
0
0
0
0
0
0
7.230
0
0
0
0
0
0
38.572
7)
0
0
0
0
0
0
1,281
0
1.281
0
0
0
0
0
541
0
_541
0
0
0
0
0
29,670
0
29.670
0
0
0
0
0
5,363
0
5.363
0
0
0
0
0
7,230
38.572
0
0
0
0
79,604
6,677
(0)
0
6,868
362
0
0
35.260
3,312
0
0
0
1,263
18
0
0
0
541
0
0
0
0
27,071
2.599
0
0
0
5,062
301
0
0
D. Perinatal Conditions
390,339
211,289
179.049
211,289
0
0
0
0
179,049
0
0
0
0
146,299
68,015
78.284
50,535
4,360
8,299
3.470
1,351
44.158
7,782
20,957
3,143
2 244
__ J
D. Nutritional/Endocrine
40 "
1. Protein-Energy
Malnutrition
33.966
28.156
31,205
661
984
722
394
26.023
166
741
321
906
Urban •
41
2, Iodine Deficiency
24.159
12,458
11.701
10,928
Urban
466
785
208
42
3, Vitamin A________
72
10,365
441
750
79
65
10.850
5,516
5.335
5,516
0
0
0
0
5,335
0
0
0
0
49,168
16,075
33,093
2,887
3,233
6,530
2.540
886
2,435
7.175,
19,466
2.743
1.274
1.328.031
745.648
582,383
96,943
39,654
239,488
205.653
163,909
68,812
23,746
178,525^
116,738
194.563
137,597
81,979
55.617
3,284
2.276
34,345
30,489
11,586
748
420
20,425
23,565
10.459
11,601
8,146
3,455
0
.0
2,767
3,686
1,693
0
0
1,650
1,492
312
Urban
Urban
39’
43
44 II, Noncommunicable
Urban
45
Urban
46
~47
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
48
49
~50
51
53
54
56'
Urban
Urban
A. Malignant Neoplasms
1. Mouth and Oropharynx
2. Esophagus
3. Stomach
4. Colon/Rectum
5. Liver
6. Pancreas
H 7. Trachea/Bronchus/Lung
Urban
Urban
4. Anemias
58'
62.122
15,472
9,959
5.513
0
0
3,553
4.652
1,754
0
0
1,789
2,378
1.347
14,430
10,434
3,996
0
2
4.052
4,375
2.004
0
0
1.349
760
6.091
1,887
3,756
2.335
0
0
904
1,814
1,037
0
16
356
1,285
• 678
5,439
4.059
1,380
66
77
1,114
2,255
546
0
7e
295
655
415
2,099
17,375 '
1,004
0
0
559'
1,067
473
0
0
272
488
244
1,770
0
0
10,335
6,856
239
162
6
12|
57
106
184
~58
3,103
19.145~
0
0
163
1,095
511
18
1
319
65
39
0
0
0
5,519
4,809
1,959
0
0
0
0
5,207
5,935
1.460
0
0
K
0
0
350
300
395
0
0
0
0
43
17
9013
1,183
209
8. Melanoma and Other Skin
9. Breast
12,288
0
12,288
0
0
0
0
10. Cervix
12,602
0
12,602
0
0
0
1,026
0
1,026
0
0
0
2,354'
0
11. Corpus Uteri
12. Ovary
13. Prostate
Urban
59'
Urban
60’
15. Lymphoma_____
Urban [
61 ’
16. Larynx
14. Bladder
401
2,354 ‘
2,348
2,778 ’
22,304
6,218 ’
2,348
0
0
0
49
707
1,591
0
0
(0
0
0
1,702
1,076
0
0
404
694
604
0
16
71
302
686
17,474
4.830
3,211
2,184
9,378
1,897
805
686
353
2,042
861
889
4,389
1,829
0
1,172
2,380
837
0
0
44'1
830
558
41
__
U (J U (J (j .C V O (J C U
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
Urban
62
B. Other Neoplasm
2,453
1,735
718
270
196
1,069
123
77
87
16
426
113
76
4,696
8,273
5,812
0
30
1,796
4,011
6,992
119
156
Urban
63
C. Diabetes Melltus
31,792
18,962
12,829
66
115
Urban
64
D. Other Endocrine
1,091
663
428
66
38
337
150
71
0
0
153
Urban
65
E. Neuro-Psychiatric
245,170
129,884
115,286
4,921
11,413
77,396
21,574
14,581
4,197
6,929
78.438
12.674
13,048
Urban
66
1. MAD
70,266
23,742
46,525
0
0
20,807
2,498
437
0
0
40,737
4,784
1.003
Urban
67
2. BAD
4,728
2,412
2,316
0
0
2,141
230
41
0
0
2,046
2T7
52
Urban
68
3. Psychoses
49,899
23,214
26,685
10
45
21,761
973
424
9
25
25,945
149
558
Urban
69
4. Epilepsy
40,284
24,995
6.488
6.058
616
320
15,289
2,789
9,929
10.928
906
443
1,807
4,407
0
0
2,625
1,480
651
453
4.799
9.644
560
810
Urban
70
5. Alcohol Dependence
38,457
33,702
4,756
0
0
18.930
10,364
Urban
71
6. Alzheimer's and other
dementia
35,814
18.149
17,665
2,116
1,350
1,085
5,718
7,880
2,372
396
Urban
72
7. Parkinson's Disease
3,030
1,640
1,390
5
8
23
686
918
9
0
.12
Urban
73
1,720
199
31
0
20
563
68
9
Urban
74
6,201
Urban
75
Urban
2,691
2.031
660
0
81
31,912
16.327
15,585
234
0
2,045
8,906
5,142
221
0
1,527
7.636
1. Glaucoma-related
Blindness
7,828
4,563
3,265
0
0
430
3,504
629
0
0
0
2.474
791
76
2. Cataract-related
Blindness
24,084
11.764
12.320
234
0
1,615
5,402
4,513
221
0
1,527
5,162
5,411
Urban
77
G. Cardiovascular Diseases
215,015
8,798
4,371
38,051
79,324
98,459
8,126
4,535
24,068
41.805
136.481
Urban
78
10.328
8. Drug Dependence
F. Sense Organ
444,017
229,003
1. Rheumatic Heart Disease
40,893
15,359
25,534
401
1,795
5,953
4,122
3,089
501
1,790
5,719
7,195
107
43
18,616
44,359
50,567
53
28
3.365
13.778
58.057
1.065|
9.233
14.796
55.194
Urban
79
2. Ischemic Heart Disease
188,974
113,692
75,282
Urban
80
3. Cerebrovascular Disease
147,329
65,575
81,754
1,861
Urban
81
4. PEMC
66,822
34,377
32,445
6,429
Urban
82
74,812
43,050
31,762
5,769
Urban
83
38,310
23,033
15,277
3,660
Urban
84
36,502
20,017
16,485
2,109
Urban
85
I. Diseases of the Digestive
System
138,915
100,898
38,017
10,593
3,064
46,230
31,566
9,444
3.372
Urban
86
1. Peptic Ulcer Disease
24,037
16,786
7,251
149
254
9,656
5,171
1,556
Urban
87
2. Cirrhosis of the Liver
66,801
50,612
16,188
1,079
528
24,064
19,694
5.247
Urban
88
51,192
32,586
18,606
1,818
7,187
6,685
11,802
5,095
890
4,796
Urbgn
89
43,261
24,655
18,606
1,818
7,183
6,683
5,495
3,476
890
4,796
H. Chronic Respiratory
Diseases
1. COPD
2. Asthma
J. Diseases of the
Genito-Urinary System
1. Nephritis/Nephrosis
1,015
42
11,757
17,081
33,860
1,466
1,518
1,724
13.762
10,943
6,105
1,652
5.750
6.035
12.903
7,956
9,949
8,100
11,276
4,148
4,368
8.515
6,661
8,071
830
1,784
6,128
10,631
2,496
301
889
4,472
7,119
7,126
8,165
1,972
646
1,652
4,067
2,188
951
1.047
7,626
7MG7
9,687
6.503
160
144
3.751
2.056
1,140
1,035
525
6,305
5,616
2.708
6.045
3,418
3,457
6,045
3,418
3,457
a
>
J J J (J (J U <J c/ c/ o u .c o (7 o' O U U Q </ <7 o O 0 O’ (J O O •</ O. O O O o O </' c/ o' '
Preliminary results of Disease Burden - NOT FOR QUOTATION 18 May 1995
Urban
90
2. Benign Prostatic
Hypertrophy
7,932
7,932
0
0
3
2
6,307
1,619
0
0
0
0
0
Urban
91
K. Diseases of the
Musculo-Skeletal System
14,217
4,884
9,333
0
0
3,289
1,309
286
0
0
5,802
2,945
586
Urban
92
1. Rheumatoid Arthritis
4,850
2,317
2,533
0
0
1,998
212
107
0
0
1,890
520
124
Urban
93
2. Osteoarthritis
9,367
2,567
6,800
0
0
1,291
1,098
179
0
0
3,912
2,426
462
Urban
94
L. Congenital Abnormalities
116,723
66,416
50,308
60,773
2,330
3,246
56
10
46,692
936
2,438
225
17
Urban
95
M. Oral Health
38,140
19,260
18,879
351
709
12,150
3,981
2.070
322
669
1 1.486
3.878
2.515
Urban
96
1. Dental Caries
6,695
3.407
3,288
351
709
1,563
535
248
332
669
1,478
511
298
Urban
97
2 Periodontal Disease
24,673
12,619
12,055
0
0
10,587
1,601
431
0
0
10,008
1,530
517
Urban
.98
3 Edentulism
6.772
3,235
3.537
0
0
0
1,845
1,390
0
0
0
1,837
1,700
Urban
99 III. Injuries
544,585
299,087
245,498
50,225
31,935
176.557
29,547
10,823
29.708
17,183
171,114
16,207
1 1,286
515,877
280,770
235,107
47.091
31,102
164,465
27,849
10.263
26.922
16,692
165,859
15,071
10.562
43,130
33,536
9,595
4,285
2,775
21,264
3,969
1,243
1.098
938
4,957
1.596
1,005
Urban
100
Urban
101
A. Unintentional
1. Motor Vehicle Accidents
Urban
102
2. Poisonings
9,566
6,622
2,944
1,411
889
3,610
587
125
651
349
1,684
215
45
Urban
103
3. Falls
82,670
61,095
21,575
12,542
8,683
30,104
6,287
3,479
6,597
3,237
6,446
2.233
3,062
Urban
104
4. Fires
184,303
53,221
131,082
10,351
4,665
33,630
3,787
788
7,673
6,060
107,696
6.085
3,568
Urban
105
5. Drowning
11,621
8,900
2,722
1,516
1,470
5,049
699
166
550
303
1,551
157
161
Urban
106
6. Venamous animals and
plants as cause of poisoining
0
0
0
0
0
0
0
0
0
0
0
0
0
Urban
107
7. Foreign body and
accidental aspiration
0
0
0
0
0
0
0
0
0
0
0
0
0
Urban
108
8. Electric Shock
0
0
0
0
0
0
0
0
0
0
0
0
0
Urban
109
B. Intentional
28,709
18,318
10,391
3,135
833
12,092
1,698
560
2,785
491
5,254
1,136
724
Urban
110
1. Self-inflicted
7,075
4,629
2.446
101
38
3,920
449
121
34
76
2,037
224
74
Urban
111
2. Homicide and Violence
15,191
9,269
5,923
2,596
443
4,711
1,092
427
2,307
178
1,980
823
634
Urban
112
3. Legal intervention
6,443
4,420
2,023
438
352
3,461
156
13
444
237
1,237
88
16
43
J
3
3
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Annexure VII
3
3
TUBERCULOSIS
3
3
3 '
3
5
5
9
Tuberculosis is one of the major infectious diseases in India. A wealth of epidemilogical
data is avaialble in the country due to significant contributions made by two pioneering
institutions the National Tuberculosis Institute (NTI) and the Tuberculosis Research Centre
(TRC). In addition to the wide ranging studies undertaken by these institutions, longitudianl
studies have been undertaken by Pamra et al in New Delhi and Fromot Moller et al in Andhra
)
Pradesh. Few cross sectional studis undertaken in different parts of AP provide useful information
5
3
on TB prevalence in the State.
i
Natural History
>
Tuberculosis is caused by Mycobacterium tuberculosis, which most commonly affects the
lungs. The infection is usually transmitted from persons with pulmonary tuberculosis to other
5
persons by droplets . The bacilli reaching the lungs cause a local non-specific inflammatory
response known as primary complex in the lung and in the corresponding lymph nodes. In most
instances both the lesions of the primary complex heal spontaneously leaving dormant bacteria
>
which may get reactivated during the later part of the life. Thus, the clinical disease may occur
)
weeks to years after primary infection. The usual incubation period from infection to primary
lesion is between 4-12 weeks. Allergy and immunity against tuberculosis are produced within
)
6-8 weeks. This results in formation of granulomas around the focus of bacilli. The most
)
important aspect of the natural history of the tuberculosis is that infection may lead to relatively
»
)
small proportion of cases at a later date. Occasionally, in case of new borne and small children,
’
the infection may progress resulting in serious forms of tuberculosis such as milliary tuberculosis
♦
or tuberculous meningitis. Rarely the infection is through the digestive tract due to consumption
of contaminated milk containing Mycobacterium bo vis from cows suffering from tuberculosis
I. Steps for the estimation:
To beginwith a detailed review of epidemilogical studies on Tuberulosis was undertaken
and core expert was identified This is followed by a two day workshop. Participants included
Core expert, Disease experts, Programme managers and Public health Specialists. The following
44
8
■xS
3
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
3
3
3
steps have been followed to estimate the incidence , duration and case fatality rates of
3
tuberculosis in Andhra Pradesh.
1. Case definition for adult pulmonary and extrapumonary tuberculosis was arrived at.
3
3
3
3
3
3
3
3
3
>
3
3
>
>
>
>
«
2. The age specific incidence pattern of tuberculosis (but not necessarily the magnitude) was
determined using the data from cohort stuides undertaken in India.
3. A review of trends of Tuberculosis over the last 30 years was undertaken.
4. Adjustment factors for screening method were arrived after establishing relationship of
true prevalence to different screening methods.
5. Adjustment factor for extrapulmonary tuberculosis were arrived after establishing
relationship between prevalence of pulmonary tuberculosis and extrapulmonary
tuberculosis.
6. Prevalence of pulmonary tuberculosis in rural AP was estimated from studies after
adjusting for deficiency in screening method.
7. Estimates of age specific remission (or duration) and
J
u T SpeC
remission (or Oration) and case fatality rates were made using
a anapa e ata after adjusting for improved remission rates reported from recent
evaluation study of district TB control'programme.
8. Cause specific deaths due to TB were estimated from SCO and MCCD data sets.
9. The age sex specific incidence pattern (step 2), remission & case fatality rate (step 7) and
cause specific deaths (step 8) were used as inputs to DISMOD. By an Iterative process the
incidence rates were adjusted to match close to the estimated prevalence and cause
specific mortality for urban and rural AP.
Case definition
1. Pulmonary tuberculosis:
In epidemiological surveys a case of pulmonary tuberculosis is identified on the basis of
smear positivity (either on direct
- - mr
microscopy or culture) and or X-ray abnormality suggestive of
tuberculosis. All the cases diagnosed on the basis of X-ray abnormality need not be due to
tuberculosis. Reliability and validity of X-ray readings have been demonstrated to be low by
various epidemilogical studies. The cohort studies undertaken by Tuberculosis Research Centre
(BCG trial), and National Tuberculosis Institute included only the bacillary cases for arriving at
the incidence of tuberculosis. In addition to satisfying Koch's postuales, a smear positive case
requires identification and treatment on a priority basis to reduce the chances of further spread.
Also, untreated smear negative cases would eventually become smear positive. Hence, only the
bacillary cases were included for estimation of incidence and prevalence of pulmonaiy
45
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
o
o
o
o
o-
o'
o
o
o
o
o
o
o
tuberculosis among the adults in A.P. However, in case of children suffering from pulmonary
tuberculosis, due to difficulty in obtaining sputum samples, bacillary cases alone may not reflect
. .. the true burden.
.
The BCG trial, after undertaking a detailed review, has defined bacillary case of
tuberculosis as : a) cases positive on two cultures b) cases positive on one culture only and c)
cases positive on smear only, excluding those showing 1-3 Acid Fast Bacilli on entire smear
The BCG trial classified an individual whose sputum is positive on smear and negative on
culture as a bacillary case of tuberculosis. The ICMR-National Sample Survey and NTI studies
did not classify individuals who are positive on direct smear and negative on culture as cases of
tuberculosis. We have used the BCG trial definition for the bacillary cases for the following two
reasons. If the the time lag between the collection of the sample and setting up the culture is
longer, the chances of getting a negative culture will be more even in the presence of bacilli. The
second factor is the strength of NaoH used for preparing the sputum for culture. A stronger
0
NaoH may destroy the live bacilli and hence may not yield a positive culture. Since the definition
□
of the bacillary case already excludes the sputum samples demonstrating 1-3 bacilli in the entire
3
smear, it is less likely that there is a reading error in smear examination. Hence, it is desirable to
D
include the smear positive and culture negative cases for epidemiological estimates.
3
2. Extrapulmonary tuberculosis:
)
All cases diagnosed on clinical an'd or X-ray basis as suffering from active extrapulmonary
tuberculosis have been included in this group.
Age sex distribution of Tuberculosis incidence:
The four cohort studies provide information on incidence of tuberculosis in India have
•
been summerised in Table 1. These include Tuberculosis Prevention Trial undertaken by
Tuberculosis Research Centre (TRC), Madras. NTI study near Bangalore (1961-68)', Frimodt
Moller'S study in Madanapalle’ (1930-55) and Pamra's study in Delhi’. A summary of these studies
is presented in the Table 2.1
473-W7 Tuberc ■l0S'S ln a rUral populatlon of South lndia: a five year epidemiological study, NTI, Bangalore; Bull. WHO 1974, 51. pp.
t
Pp 61-17C)J Fr'mOdt M°"er' A COmrT’un'ty Wlde luberculosis study in a south Indian rural population, 1950-55; Bull WHO 1960, 22.
i
vol., No,2. ppXeT
Chan9eS
PreVa'enCe
inCidenCe °f pulmonary 'oberculosis in Delhi in recent years; Ind. J. Tuberculosis
46
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Table 2.1 Review of Tuberculosis incidence studies undertaken in India
BCG trial
Study
NTI
Madanapalli
Pamra
Year
1968
Study location
Tamil Nadu
Karnataka
Area
Chingleput district
119 randomly
Population residing
selected villages from within 10 miles of
three taluks of
Madanapalli town
Banglore district
including accessible
villages and small
towns
Population covered
1961-68
1950-55
Andhra Pradesh
1962-70
Delhi
Urban Population
under surveillance of
New Delhi
Tuberculosis centre
360000
62000
60,000
30,0000
Duration
7.5
5
6
8
No. of follow-up
rounds
Duration between
two follow-up
rounds (yrs.)
3
3
4
3
2.5
1.5-2
0.7-1.6
2-2.5
AU individuals > 5
yrs
All individuals > 5
years
Eligibility criteria
All individuals >10 All individuals > 5
yrs____________
yrs_____________
Methodology
Initial X ray. Film
Initial X ray. Film
read by two readers read by two
From individuals
independent readers
whose films
From individuals
interpreted as
whose films
abnormal by either of interpreted as
two readers sputum abnormal by two,
specimens were
any of two and
collected and
technically
subjected to direct
inadequate two
microscopy and two samples of sputum
cultures
collected and
subjected to direct
microscopy and
culture
Definition of a case Eligible individual
Eh’gible individual
with a normal X-ray who was culture
at the intake aijd .
negative with normal
becomes smear /
or abnormal X ray in
culture positivelater all the preceding
surveys and who
becomes culture
positive with X ray
abnormality in
current survey
Crude
131-366
13,1-176
incidence/1000
47
Initial MMR
Initial X ray. Film
Film read by one
read by two
experienced reader
independent readers
X ray abnonnals
From Individuals
subjected for larger X whose films
ray and smear direct interpreted abnormal
microscopy
by either of readers
Sputum culture only sputum samples
for admitted cases
collected and
subjected for direct
microscopy and
culture.
Fresh cases detected
after an initial
normal MMR.
Separate analysis
done for bacillary
(direct smear) and X
ray abnonnals.
Fresh case among
previously X ray
negative. Separate
analysis done for
bacillary (direct
smear & culture) and
X ray abnonnals.
16-49
90-100
Preliminary results of Disease Burden -NOT FOR QUOTATION 7 October 1995
In all the studies reviewed (except Pamra's study) the incidence tended to increase with
3
3
3
3
age. This is in sharp contrast with'the total absence of peak in young adulthood (between 25-30
yrs) generally noticed in the west4'. This brings out the issue to what extent the new cases
occurring in the later parts of adult life are due to new infection or due to flare up of old
'3,
endogenous infection acquired earlier. Fimodt Moller observed that 66% of the new cases
3
detected at Madanapalle had an earlier tuberculin reaction of 10 mm or more suggesting that
3*
majority of the new cases could be due to reactivation of old infection. Review of NTI data by
3
3
W Krishnamurthy et al" also had shown that 72% of the new cases came from a reservoir of
previously infected population. Since a large reservoir of infected cases are existing in the
community, it is not surprising to notice that most of the incidence cases occur with advancing
3
age when the resistance of an individual is likely to go down there by resulting in reactivation of
3
3
3
3
3
3
3
3
existing infection. Though Pamra's study shows a peak in the younger age groups, the study
covered a population residing in urban slums of Delhi which is more likely to be biased towards
younger and fit individuals. Hence, we have decided to follow the incidence pattern and need not
necessarily the magnitude of TRC, NTI and Madanapalli studies.
Irdcteroecf tteukss (nfaes)
fa~ap3tdcf255egs(B3Gtrid, CTtpjpJ)
hxfenogcf titeaicss (fairies)
2ID|—
3
3
3
3
3 .
^1.
.411-
|tID2D -
| an-
I■P °L*'M
3
Z» S41
XAs
XAc
3 ■
3
J
3
3
3
)
Cochrane AL Cox J G and Jarman T F; 1955 British Medical Journal 1.. 371
s
Groth Peterson,E. Knudsen J el al 1957 Nord Med 58 1361
.
Knshna Murthy et al. Incidence of Tuberculosis among newly infected population and in relation to the duration of infected
status, Indian J Tuberculosis Vol. XXIII No.1.
1
)
48
'S
Preliminary results of Disease Burden -NOT FOR QUOTATION 7 October 1995
3
d
'IrdcfeTEcfTBikTnNn sLd/. Fera
an
tD ■
C>
O
tota -
14D
o
ffl-
o1-1-
3
4)514
514
■534
3554
XAs
3
5
5
Though Madanapalle study was from A.P. the population covered in each age group is
small and nearly four decades have passed since the survey. Pamra's study is also confined to a
small urban population of 30,000 which is influenced by urban migration. In the NTI study the
3
incidence was calculated from difference noticed between two prevalence surveys and hence
missed the new cases occurring between the surveys which either got cured or died. The TRC
study covered a large population and also ensured that new cases appearing between the surveys
5
are not missed. It is also more recent and hence provides a more realistic estimate of incidence.
We have used the age and sex distribution of incidence cases reported from the BCG trial.
Tuberculosis Trends:
=)
)
J
It is difficult to get correct data on occurrence of new cases of adult tuberculosis from the
same area on a continuous basis. Hence, prevalence of tuberculosis infection obtained through
repeated tuberculin testings in children, over a period of time, is recognised to be a reliable
indicator of tuberculosis incidence and its trend in a community7. This is considered to be
)
)
■)
independent of efficiency of tuberculosis control programme. A WHO study group 8 has
recommended that such survey can be undertaken once in five years.
■»
Styblo.K., Recent advances in epidemiological research in tuberculosis. Adv. Tuberc. Res. 20; 1980. 1.
WHO Report of the South East Asian Research Study Group on tuberculosis 1S81 p.11.
49
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
3
3
3
Recently the TRC has undertaken a study which followed up two panchayat unions
3
3
covered in the BCG trial and repeated tuberculin testing among the children aged 1-9 yrs.
3
Tuberculin testing was done twice at intervals of 10 and 15 yrs9. The results of the study have
3
•
clearly shown that risk of tuberculosis infection remained unchanged over a period of 15 yr. Risk
3
of new infection experienced by a child aged 1-9 yr. in 1984 was same as that experienced by his
3 .
counterpart 15 yr. Studies carried out in other parts of the country also suggest that the
3
tuberculosis incidence remained more or less constant. Gothi et al have reported that the
3
prevalence of tuberculosis infection remained constant over a twelve year period (1961-73)10. No
3
decline in prevalence of infection was noticed among the.children aged 0-9 yrs over a period of
3
five years (1974-79) in a study undertaken by Chakraborty et al in Bangalore district of Karnataka
3
state
3
No appreciable change in tuberculosis situation was noticed over a period of 15 yrs
(1962-77) in another study undertaken at Delhi12. In the state of Andhra Pradesh no such studies
1
were undertaken. However, considering the similarities in population characteristics,
5
socio-economic situation and geographical proximity of A.P. to Tamil Nadu and Karnataka, we
have assumed that the tuberculosis situation in A.P. also remained constant. This assumption
permitted us to compare the different studies undertaken in AP.
3
Adjustment for Screening methods:
9
Conventionally two screening methods are used to detect a case of tuberculosis in the
9
9
surveys. The yield of the tuberculosis cases in population based surveys is determined by the type
9
of screening method adopted. These screening methods are summarised herewith.
1. Initial screening of all eligible persons is done with X-ray. All those with X-rays read as
abnormal are subjected to sputum and/or culture examination. This approach will miss the
sputum positive cases which do not exhibit any radiological abnormalities.
)
2. The second approach, which is currently being followed in the National programme,
identifies the symptomatics first. The symptomatics are then subjected to sputum
examination followed by an X-ray. Since all the cases suffering from tuberculosis need not
be symptomatic, this approach will miss the asymptomatic cases.
•
)
)
Mayurnath S. et al. Prevalence study of tuberculosis infection over fifteen years in a rural population in Chingleput district
)
*
9
1
*
*
(south India); Indian J Med. Res. (A) 93, March 1991, pp 74-80
10
Gothi.G.D., A.K.Chakraborty et al., Prevalence of tuberculosis in a south Indian district- Twelve years after initial survey. Indian
J Tuberc. 26 (1979), pp 121.
ii
Chakraborthy A.K. et al, Tuberculosis in rural population of south India: Report on five surveys. Indian J Tuberc. 29 (1982), pp
152
12
Goyal SS et al Tuberculosis trends in an urban community. Indian J Tuberc 25 (1978) pp..
50
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
3
3
3
3
3
3
3
3. Another screening method used in few studies screened the symptomatics first and
subjected them to X-ray. Only symptomatics having abnormal X-rays were subjected to on
spot sputum microscopy. This screening method will miss the cases among asymptomatics
and also the symptomatic cases with normal X-rays.
If the relationship of cases to different screening methods is known, it will be possible to
3
3
3
North Arcot district, Tamil Nadu13 provides useful data to estimate this relationship. The results
3
3
About 25,688 individuals were included in the study out of whom sputum samples were
derive more accurate estimates of prevalence from almost all studies. A recent TRC study from
of this study help to estimate the missing cases.
collected from 6007 on the basis of symptomatic status or X-ray abnormality. The 205 sputum
positive cases detected from this study gives a prevalence of 800 per 100,000. If only X ray is
used for screening, 144 cases would have been identified which gives a prevalence of
560/100,000. Similarly if screening is confined only to detection of symptomatics it would yield
3
135 cases which gives a prevalence of 526/100,000. Thus, either methods of screening would
3
3
miss about a third of the existing tuberculosis cases. About a half of the smear positive cases did
■ not show any bacilli on direct microscopy and were detected on the basis of positive culture.
About 15% of the smear positive cases, though positive on direct-microscopy, did not yield any
positive culture. Based on these relationships we have arrived at adjustment factors to correct for
3
cases missed by each of the screening method.
Adjustment factor for type of screening procedure
3
Screening method
No. of
+ve
cases
Adjustm
ent
factor1
5
Symptom survey followed by smear e.xamination
73
2.8
5
Symptom survey followed by smear examination and culture
112
1,8
X-ray survey followed by smear examination for X-ray abnonnaIs
73
2,8
X-ray survey followed by smear examination and culture for X-ray abnonnals
Symptom survey followed by X-ray and smear examination for X-ray abnonnals
Symptom survey followed by X-ray. smear examination & culture for X-ray abnonnals
Total smear and culture positive cases
Tomi population
133
1.5
47
71
4,4
2.9
9
3
3
9
Total smear & culture positive cases/Cases detected by screening method
9
9
13
)
5
Tuberculosis prevalence survey in North Arcot District, Annual Report of TRC 1990 pp 107-118.
51
205
25688
<7
Preliininai'y results of Disease Burden -NOT FOR QUOTATION 9 October 1995
3
3
Establishing relationship between pulmonary and extrapulmonary
tuberculosis:
o
□
□'
□
Very little population based data is available on the prevalence of extrapulmonary
tuberculosis. The intensified case detection camp held in Bhadrachalam (A.P.) in 1982 shows that
out of the total tuberculosis cases detected, 15% were constituted by persons suffering from
extrapulmonary tuberculosis. An analysis of all tuberculosis patients attending different
departments at Gandhi Hospital, Hyderabad14 indicated that 16% of the total cases were
extrapulmonary. This, however, may not reflect the community situation. The pulmonary
tuberculosis patients are more likely to receive domicilliary treatment and only more complicated
5
cases tend to come to hospitals. On the contrary, higher proportion of extrapulmonary
tuberculosis patients will attend hospitals. We may not be far off from truth if we assume that one
out of three cases of pulmonary tuberculosis will attend hospital. In case of extrapulmonary
tuberculosis we can assume that either all the affected or at least half of the affected will attend
hospital. We have taken average of these two and applied this relationship to arrive at the
adjustment factor for extrapulmonary tuberculosis.
Adjustment factor for Extrapulmonary tuberculosis
Place
Pulmonary
Extra
pulmonary cases
cases
3
Total
cases
3
Hospital
84
16
1001
5
Community with higher prevalence of extrapulmonary
TB
2522
323
284
Community with lower prevalence of extrapulmonary TB
252
16
268
Community average
252
24
276
Adjustment factor for extrapulmonary tuberculosis
1
Total cases were assumed to be 100
2
Pulmonary cases in hospital X 3
3
1.1
Extrapulmonary cases in hospital X 2
2)
Review of TB prevalence studies from A.P.
Out of the published studies, the National sample survey (ICMR in 1953-58) is a large
scale study which followed a well standardised protocol. Recently, two population based surveys
were undertaken in the districts of Khammam and Medak by the TB control programme officers.
3
3
14
Personal communication from Dr.Eswariah, State TB Officer, Govt, of Andhra Pradesh
52
ICO
3
0 ?y49
CA
An
>
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
>
>
The emphasis of the Khammam study was on tribal population while the Medak study covered the
rural population. We have summerised these studies herewith.We, however, restricted the data
>
from these studies only to population above 15 yrs. to make them comparable with other studies.
>
This is also influenced by the fact that pulmonary tuberculosis is less common below 15 yrs.
1. ICMR National Sample Survey (1955-59):
>
The first major attempt to assess the magnitude of tuberculosis in the community was
undertaken by ICMR in 1955-59. The survey covered a population of 116,539,000 aged above
five years. Two zones (Hyderabad & Madanapalle) out of the total six zones covered in the study
included parts of A.P. Each zone was further stratified in to city, towns and villages. Entire
3
population residing at the selected sampling unit was listed. AU those above the age of five years
constituted the eligibles and were subjected to a miniature radiogram.. Each X-ray film was read
3
3
3
by two independent readers. A sample of the abnormals was sent to a central reader for
consistency check. Bacteriological examination (on spot specimen) was carried out in all cases
which were considered abnormal by one or both readers. The material collected for
bacteriological examination consisted of sputum (two slides) for direct smear examination,
sputum (2 tubes) for culture. If sputum was not available laryngeal swabs (2 tubes) were collected
for culture. The group that undertook the survey in Madanapalli zone was involved in the
3
tuberculosis control activities for a long time. Hence, the bacillary case yield was noticed to be
3
higher compared to Hyderabad zone. The reported prevalence of bacillary cases in Madanapalle
3
zone was 1144/100000 and 850/100000 in towns.and villages respectively.
5
3
5
3
3
3
3
3
3
2. Tuberculosis prevalence survey in Rural Medak district 1992:
To assess the prevalence of tuberculosis in the rural community a survey was undertaken
in Medak district during the year 1992. The study also aimed to understand the epidemiological
pattern of the disease and assess extent of utilisation of health services available for TB control.
The study was undertaken in thirty three villages selected by random sampling method. A
door to door survey was undertaken covering all the residents aged above five years in the
selected villages to identify chest symptomatics. NTI protocol which is standardised for health
workers bias was used for symptomatic survey. The proportion of symptomatics above the age of
3
15 yrs. reported in the study is comparable to that of North Arcot and Raichur studies
9
undertaken by TRC. On the spot sputum was collected and a single sputum examination done to
3
53
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
detect Acid Fast Bacillus (AFB) by Zeihl Nelson's stain. No culture or concentration techniques
have been used. During the second phase chest symptomatics identified were subjected to MMR.
The MMR was read by a single reader trained at National Tuberculosis Institute (NTI).
A total of 48,223 individuals were listed from the 31 villages covered. The total
population above 15 yrs was 30,863. Out of the population above 15 yrs. 1196 symptomatics
were identified. Out of the chest symptomatics identified 847 (70.82%) could be subjected for
sputum examination and successfill MMRs could be taken for 662 (55%). A total of 50 smear
positive cases were detected. This gives a prevalence rate of 162/100,000 for sputum positive
cases. The prevalence rates were higher among males (male female ratio = 7:3).
Summary of Mcdak study finding: ________
________ __________ Descrip t i o n
Number
Total population enumerated
48223
Population above 15 yrs.
30863
Chest symptomatics listed
1196
No. of symptomatics subjected to sputum examination
Prevalence of smear positives
No. of symptomatics subjected to MMR
~
~
No.of MMRs technically adequate
MMR Positives
Extra pulmonary tuberculosis
$
□
~ ~
Percent
100
3.9
847
70,82*
50
0.2
712
59,53*
631
52.76*
129
0.4
2
0
Expressed as percent of symptomatics listed
s>
3. Intensified TB case finding in Bhadrachalam Division, Khammam District
(1982):
2>
An intensified case finding activity was undertaken in Bhadrachalam division of Khammam
■
2)
district in 1982 by the TB control programme of A.P. Initial enumeration of population was done
to list the population aged above five years. A door to door survey was undertaken by the
2)
paramedics to identify the chest symptomatics among the listed population. The symptomatics
2)
listed were subjected to MMR. The films were read by one reader trained at NTI. Only the
3
individuals diagnosed to be having abnormal MMR were subjected to sputum examination which
3
included direct microscopy ofon the spot sputum sample. Out of the total 1,46,449 population
3
surveyed, 92,263 individuals above the age of fifteen years were listed. The screening for
3
symptomatics yielded 5,189 symptomatics. Out of the symptomatics listed 5,183 were subjected
3
3
54
Preliminai'y results of Disease Burden -NOT FOR QUOTATION 9 October 1995
for MMR. Among the individuals subjected for MMR, 1465 were diagnosed as radiologically
abnormal. Out of the 1465 radiologically abnormal individuals identified, sputum examination
was done for 1267 and 473 persons were detected to be smear positives. The study gives a
prevalence rate of 513/100,000. Out of the detected cases the male female ratio was around 2:1.
O
O
O
O
O
The prevalence of tuberculosis among tribals and non tribals was similar.
|
Summary of Bhadrachalam study findings
I
Description
Number
[Total population
146449
[Population above 15 yrs.
92263
Chest symptomatics listed
5189
No. of symptomatics subjected to MMR
5183
[MMR Positiyes
1465
No. of symptomatics subjected to onspot sputum exam
1267
Sputum positives
473
Extra pulmonary tuberculosis
84
* percent of symptomatics listed
Percent
100
5.6
99’.9*
1.6
24.42*
0.5
0.1
o
□
3
3
S
J
5
5
4. Prevalence of Tuberculosis after adjusting for screening methods in rural AP:
As a first step we have applied the adjustment factor appropriate for the type of screening
method used to estimate the true prevalence of TB .
Prevalence of TubercuIosis/1000 population
Survey
Before adjustment
After adjustment
ICMR Sample Sun’cy __ __________ 850 ____________ 1642
Medak survey
162
706
Bhadrachalam survey.
513
2832
5. Estimates for current prevalence of tuberculosis in rural A.P.
Out of the three studies, Medak study is most recent. The ICMR sample survey was
2
conducted nearly four decades back when there was no National programme for tuberculosis
2
control and anti tuberculosis drugs were not freely available. This makes it inconsistent with the
2
burden of disease methodology which estimates the burden at the current operational efficiency of
2
2
2
2
2
the intervention programme. The Bhadrachalam study was undertaken in tribal area. As the tribal
population constitutes about 6% of the total population of the State, the results of this study can
55
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
not be applied for the entire State. The population residing in tribal areas are included in the rural
population in census data. The rural population constitutes about 73% of the total State's
population. Out of the rural population, 8.65% was constituted by Scheduled tribes. We have
arrived at the mean prevalence of tuberculosis for rural population by applying prevalence rates of
Medak study to the non tribal rural population (91.35%) and prevalence rates of Bhadrachalam to
the tribal population (8.65%).
Estimated prevalence of TB in rural A.P.
= (706 X 0.9135) + (2832 X 0.0865)
= 890/100,000 adults
This estimate is close to the results of recent survey undertaken by TRC at Raichur district
o
o
in Karnataka15 ( 1090/100,000 population).
6.
3
3
Deriving age & sex specific incidence of Tuberculosis in rural and urban A.P.
using DISMOD
The burden of disease methodology requires estimation of age specific incidence and
O
□
duration of disability to estimate the DALYs lost. In addition, the consistency of epidemiological
3
estimates need to be checked. A disease model built on known relationships between different
3
epidemiological parameters by the Burden of Disease Unit (DISMOD) helps in achieving these
3
objectives. The model requires instantaneous remission and case fatality rates of the disease to be
3
used as inputs. Estimation of these instantaneous rates requires follow-up studies. Out of three
3
studies undertaken in rural south India, Madanapalle study was from Andhra Pradesh. It also
provides age specific data on remission and case fatality. The results of the study are presented in
the table.
Out come of the newly diagnosed cases on Tuberculosis
from Madanapally study
•
Age
group
5
15-24
25-34
35-44
45-54
55+
15
Initial 1st Year
cases No.died No.TB+
No.TB-
5th year
No.died No.TER No.TB167 ______ 14 _____ 54 ______ 99 ____ 40
34
93
337 _____ 22
129
186 _____ 93_
78
166
298 _____ 26
110
162
108 _____ 52
138
210
29 _____ 86 _____ 95
90
33
87
144
19
53
72
74
26
44
Tubercufosis prevalence in Raichur District Annual report cl Tuberculosis Research Institute (ICMR) 1989 pp 120-131. '
56
&
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Out come of the newly diagnosed cases on Tuberculosis from
Madanapalle study (percent)
Initial 1st Year
Age
5th year
group cases Mortality Persistance Remission Mortality
Persistance Remission
rate
rate
rate
rate
rate
rate
15-24
167
8.38
32.34
59.28
23.95
20.36
55,69
25-34
337
6.53
38.28
55,19
27.6
23.15
49.26
35-44
298
8.72
36.91
54,37
36.24
17.45
46,31
$
45-54
210
13.81
40,95
45,24
42,86
15.71
41,43
55+
144
13.19
36.81
50
51.38
18.06
30.56
Instantaneous remission and case fatality rates were calculated from this data using the
outcome at fifth year.
Age specific instantaneous rates from
Madanapalle study
Age group
Instantaneous Instantaneous
remission
case fatality rate
15-24
0.23
0.1
25-34
0.19
0.11
o
o
o
o
35-44
0.2
0.15
45-54
0.18
0.18
3
55+
0.13
0.21
3
A1I
0.19
0.14
The Madanapalle study was undertaken in early sixties and subsequently there has been a
phenomenal change in Tuberculosis chemotherapy which may influence the outcome. Hence, we
have reviewed recent studies which assessed the outcome of newly detected tuberculosis cases.
5
Dr.Manjula datta et al
3
treatment under District Tuberculosis Control programme in North Arcot district, Tamil Nadu.
have assessed the outcome of 2257 smear positive cases registered for
This study also captures the outcome of the defaulters and hence consistent with the burden of
disease approach of estimating the disability and mortality at the current operational efficiency of
the intervention programmes. When we compared the aggregate remission and case fatality (after
excluding general mortality rate), we found that mortality rates of Madanapalle are comparable
with North Arcot while remission rates in North Arcot are 2.5 times higher. Though both cohorts
received treatment, the North Arcot patients had access to better Chemotherapy (69% received
18
Manjula Datta et al. Critical assessment of smear-positive pulmonary tuberculosis patients after chemotherapy under the
district tuberculosis programme. Tubercle and Lung Disease 74. 1993 pp 180-186.
57
3
M
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Short Course Chemotherapy) which explains better remission. The marginal difference between
mortality rates could be due to the known observation that even INAH mono therapy has
favourable impact on mortality reduction. Considering the fact that Madanapalle study was
a
undertaken in Andhra Pradesh and provides age specific follow-up data we have used it as an
input to DISMOD after applying an adjustment factor of 2.5 to correct for current treatment
<
practices and patient compliance. While Madanapalle data on outcome is not available by sex ,
North Arcot study gives only information on deaths by sex. Hence, we have used NTI data to
arrive at adjustment factors for sex.
Using these instantaneous rates as inputs we have adjusted the instantaneous incidence
rates to get the best match for the estimated prevalence and deaths.
DISMOD outputs for Rural AP
Age group Male
Female
Annual
incidence/
100000
3
3
O
Annual
Annual age SCD
prevalence/ specific
estimated
100000
deaths
deaths
Annual
incidence/
100000
Animal
Annual age SCD
prevalence/ specific
estimated
100000
deaths
deaths
0-4
15,8
15.2 ______ 34
509
11.9
13.6 _____ 27
218
5-14
20
28
131
185
19
28,9
115
316
15-44
439,5
617,8
7775
•6268
233
45.7
1227.5
1846.8
9582
14296
655.2
1298.5
4166
5627
4199
45-59
60+
1555.5
2918.2
8385
9784
735.2
2078,4
All
465.1
714.7
25907
31042
248.2
532,3
3819
13754
10590
5296
20619
The DISMOD outputs suggest that ’we have to go for higher age specific incidence rates
than reported to arrive closer to the estimated deaths and prevalence. Even than the estimated
O
d
deaths are lower than the deaths estimated from Survey of Cause of Death suiweys. Considering
the fact that SCD data is based on lay reporting there is more likelihood of overestimating the
tuberculosis deaths we felt the DISMOD outputs are fairly representative of prevailing cause
specific mortality due to tuberculosis.
When we applied the same rates in urban areas, the death estimates were found to be very
high. Our estimates of prevalence are based on surveys undertaken in rural areas. Though the
National Sample Survey reported higher prevalence in urban areas, we felt that the urban residents
have better access to treatment and hence better remission rates. Hence, we have adjusted the
remission rates of the rural areas by a factor of 1.25 and then adjusted the incidence rates to
match the deaths estimated from MCCD data. These results are presented in table.
□
2
58
Preliniin:ii7 results of Disease Burden -NOT FOR QUOTATION 9 October 1995
DISMOD outputs for Urban AP
Age group Male
Female
Annual
Annual age MCCD
Annual
xAnnual
Annual age MCCD
prevalence/ specific
estimated incidence/ [prevalence/ specific
estimated
100000 • deaths
deaths
100000
100000
deaths
deaths
14,3
12.2 _______ 10
479
10,7
11.1
8
257
Annual
incidence/
100000
*3
0-4
3
5-14
15-44
3
3
45-59
60+
All
18
20.7
398,6
1019,2
470.3
36
2354
1301,3
2231
1666,1
388.4
2683
498.6
1881
6512
136
13,5
21.7
32 _______ 72
2370
2211
141
384
233.1
616.9
840
730
837
651
1867
881,9
163.2
211,5
301.7
1054
2664
1119
2936
7063
3
The estimated age specific incidence rates in urban areas are comparable with the
3
incidence rates reported from BCG trial. It is, however, evident that in both urban and rural areas,
3
3
3
3
3
3
the number of deaths reported in the Fess than 15 years are less than the reported deaths. In fact,
we tried to match the annual incidence rates in these two age groups as close as possible to the
age specific incidence reported from the longitudinal studies reviewed. Even then the DISMOD
estimated deaths remained much lower than the deaths estimated from registration schemes.
Tuberculosis experts often argue that it is difficult to get samples of sputum from this group.
3
Also, the proportion of extra-pulmonary forms of tuberculosis would be higher in this group
3
which are not captured by the community based surveys.
3
3
The outputs from DISMOD were used as inputs to the worksheets to estimate the Years
of Life Lost and Years Lived with Disability due to Tuberculosis.
3
3
3
£
J
)
Y
59
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
DIABETES MELLITUS
Diabetes mellitus is a common endocrinal disease resulting in several complications. Our
estimates are for Non-insulin dependent diabetes (NIDDM) which accounts for 80-90% of all
diabetes world-wide. While Insulin dependent diabetes (IDM) is considered to be relatively rate in
most developing countries the epidemiology of third form of diabetes, the malnutrition related
diabetes mellitus is poorly understood. The WHO case definition of diabetes is based on
biochemical criteria.
Case of Diabetes1
Nature of sample
Glucose (mg/dl)
Whole Blood
3
Plasma
Venous
Capillary
Venous
Capillary
Fasting
>120
>120
>140
>140
2 hr after glucose load
>180
>200
>200
>200
WHO 1985; Technical Report Series No.727
1CD Codes:
□
The ICD 9 classifies the Diabetes Mellitus as adult onset type and juvenile onset type. The
corresponding code for Diabetes ICD 9 is 250. The tenth revision introduced a new coding
system which distinguishes between insulin dependent (E10), non insulin dependent (El 1),
malnutrition related diabetes (EI2), other specified (E 13) and unspecified (E14) Diabetes.
o
Gestational diabetes is recorded elsewhere. As per ICD norms if a mention of Diabetes is made in
d
part I of death certificate, it should be considered as the underlying cause.
Natural History
The details of natural history of diabetes and its complications are presented in a tabular
form in next page.
60
5
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
>
>
3
Risk Factors
Genetic, Environmental
Parental history
Diet (>fat).
Lifestyles (<Phy.activity)
Obesity
Migrant studies, Studies in
low income urban areas
Incidence
Between 30-69 yrs. there is a
straight line relationship of log
odds of NIDDM to age with a
slope of 0.066 year-1.
Low and high prevalence
populations varies only in
constant terms used in model
Age specific incidence
pattern
Review article of Paul
McKingue
Prevalence
Among adults prevalence rates
increased with age. Prevalence
was less among females
Age and sex specific
prevalence rates
Community based surveys
undertaken in different parts
of India
Remission
Nil_____________________
Treatment
Percent receiving treatment
About 50% of the cases
detected were known cases
Hospital based studies
Complicatio
ns
Specific
>Incidence of blindness
incidence of nephropathy
>Diabetic foot
Follow-up studies. Hospital
based studies
Non specific
>MyocardiaI infarction
>Stroke
Follow-up studies, hospital
based studies
Case fatality
Age and sex specific case
fatality rates
Estimating case fatality on
the basis of known
prevalence and reported
deaths due to diabetes
RR
Influence of increased RR on
age and sex specific
mortality rates
Follow-up studies
undertaken at Fiji
3
3
3
3
3
3
3
3
3
3
Mortality
5
5
5
9
9
3
3
3
i
t
3
£
Source of information
Description
>
3
Out come
Natural
History
61
Az' • >
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Review of studies undertaken in India:
Year
Author
'3
3
Diabetes prevalence studies undertaken in India
Population
Screening
Place
Prevalenc
e (%)
____ 2A
2.3
Patel et al
1959 Bombay
18243 volunteers
Post prandial glycosuria
Ganguly et al
1964 Lucknow
1445 rural hh survey
Post prandial glycosuria
Ahuja et al
1966 Delhi
1027 volunteers
PP glycosuria and bl. glucose
Berry et al
1966 Chandigarh
3846 urban hh survey PP glycosuria
2.9
Satynarayana
Dutta et al
Ahuja et al
Jayarao et al
ICMR
1966 Hyderabad
<\
1968 Pondicherry
19.72 New Delhi
1972 Hyderabad
1972-75 6 urban centres
21396 volunteers
PP glycosuria
2694 urban hh survey PP glycosuria
1639 urban hh survey Post glucose blood sugar
2006 rural hh survey Post prandial glycosuria
19077 hh survey
Post glucose blood sugar
4.1
0.7
2.7
Post glucose blood sugar
1.5
0.9
3.1
2.4
5 rural centres
15177 hh survey
6.2
2.4
2.1
Tripathy et al
1979 Koraput
Patel
1986 Bhadran, Gujarat
2296 tribal volunteers Post glucose boood sugar
3374 rural h h survey Post prandial glycosuria
Verma et al
1986 Delhi
6878 hh survey
Inquiry for known diabetes
Rao et al
1987 Eluru AP
3579 lili survey
Inquiry for known diabetes
Murthy et al
1984 Tenali AP
Urban
4.7
Ramachandran
et al
1992 Madras
Urban
Rural
8.2
2.4
3,8
Several studies have been undertaken in India to know the prevalence of diabetes. The
criteria used to define a case of diabetes varied from verbal enquiry for known diabetes to WHO
suggested case definition for diabetes. Hence, it is difficult to compare the prevalence rates
reported by these studies.
The largest survey covering 34,194 persons above the age of 14 years was undertaken by
the Indian Council of Medical Research (1972-75). The case definition used by the ICMR study is.
those with blood glucose values more than 130 mg/dl in the capillary blood after oral
administration of 50g of glucose. So far this is the largest survey undertaken in the country and
considered to be representative. The other studies demonstrated increasing prevalence with age.
3
Males were more frequently affected with a sex ratio of 1:0.6 or even less among females. The
estimated average duration of disease is about 8.1 years17.
17
PV Rao; Risk factor analysis in diabetes mellitus as related to social progress in Indian Populations 1994
62
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
Estimation of prevalence and mortality due to diabetes:
Prevalence :
Survey undertaken by Jayarao et al in rural Hyderabad estimated a prevalence of 2.4%
'3
which is higher than the ICMR aggregated rural prevalence. Since Jaya rao’s study is undertaken
in AP and covered 2006 households we have considered it to be representative of rural AP. We
3
have taken the prevalence reported by Jayarao's study as such for rural AP. Even though this is
*3
higher than the ICMR estimates for rural India, a recent study (Ramachandran et al) in rural Tamil .
'3
Nadu suggests that the prevalence in rural areas are around 2.4%. We have assumed that crude
3
prevalence of diabetes among rural males above 14 yrs will be 2.4%. In case of females GBD
3
estimates used the same prevalence as males. However, studies undertaken in India suggest that
3
the prevalence of diabetes among females is lesser than males. Hence we have applied and
O
adjustment factor of 0.75 on the estimated incidence of males get the corresponding values for
the females.
Considering the reported higher prevalence in urban areas we have assumed that both
incidence and prevalence in urban AP are higher than the rural areas. The ICMR survey suggested
that prevalence of diabetes is 1.4 times higher in urban areas. By applying a factor of 1.4 to the
©
reported prevalence of this study we have estimated the prevalence of diabetes in urban AP. This
gave a prevalence of 3.4% which is slightly higher than the ICMR estimates of urban areas but
closer to small scale studies undertaken in urban AP and Madras. We have assumed that urban
males above 14 years will have a crude NIDDM prevalence of 3.4%. Considering reported lower
©
prevalence among females an adjustment factor of 0.75 was applied for the estimated incidence
among males to arrive at the corresponding rates for females.
Mortality:
We have taken the APBD estimated deaths in urban areas for males and females as such.
The CSMR rates are closely comparable with the GBD India estimates. In case of rural areas we
have noticed that in case of males in 60+ age group the SCD estimates gave a cause specific
©
©
©
mortality rate of 4 per thousand which we felt is an over estimate. Hence, we have assumed that
the CSMR in rural males above 60 Ys in rural areas would closer to that of urban areas. Since the
incidence and prevalence in rural areas are lesser than urban areas this assumption gives higher
63
33
.
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
case fatality in rural areas which is quite plausible. For other age groups we have used the SCD
estimated death numbers as such which are close to CSMR of urban areas.
*
Estimation of Incidence and Consistency Check:
The above estimates on prevalence, cause specific mortality and remission were used to
estimate the incidence rates and duration of diabetes through DISMOD. Through an iterative
process the incidence and case fatality rates were adjusted to achieve the estimated prevalence and
reported deaths. The results of the outputs from DISMOD are presented in the table.
Estimates of age and sex specific incidence and prevalence of Diabetes from DISMOD
Age group Annual Incidence rate/1000
Annual prevalence rate/1000
j
Rural Male Rural
Urban
Urban
Rural Male Rural
Urban
Urban
I
Female
Male
Female
Female
Male
Female
15-44
0.38 ______ 0.26
0.71 _______ 0.54
5.47 ______3.77
10.44
7.88
7.49
45-59
5.25
13.22
10.22
45.52
64,61
118.43
92.16
60+
11.37 ______ 8.38 _______ UX9
14.19
211.59
154.29
375.14
300,25
Crude rates
1.84
1.39
2.53
2.14
24.11
18.48
34.06
29.95
Estimates of cause specific mortality due to diabetes from DISMOD
Age group Annual Cause specific mortality rate /1000
Annual cause specific deaths
Rural Male Rural
Urban
Urban
Rural Male Rural
Urban
Urban
Female
Male
Female
Female
Male
Female
15-44 ___________ 0.02
0.01
0.02 ______ 0.01
187 ________ 124
76 _________ 54
45-59 ________ 0.31
0.19
o.3l
0.2
952
588
308
193
[60+
___________ 1.84
1.41
I.X
1.4
2374
2863
683
661
Estimation of disability:
The complications of diabetes could be specific affecting eyes, kidneys and feet. These
complications include retinopathy and other changes in eye like cataract, diabetic nephropathy and
neuropathic ulcer in the legs and feet leading to prolonged immobilisation and sometimes
a>
amputation. These complications do not occur in non diabetics. In addition, the non specific
complications of diabetes include the conditions such as increased risk from stroke and ischemic
heart disease. In hospital based studies undertaken in India , 72% of the hospitalised diabetics died
due to vascular complications. Renal disease is an important cause of death1*. The incidence of
major complications due to diabetes increases exponentially with increasing duration of diabetes.
it
P V Rao Risk factor analysis in Diabetes Mellitus as related to social progress in Indian Populations New Delhi 1994
64
3
Preliminary results of Disease Burden -NOT FOR QUOTATION 9 October 1995
1. Blindness:
Follow-up study in Wisconsin USA showed that 4% of diabetic patients develop
blindness19. Another study in UK had estimated the incidence of blindness in diabetics to be
around 5/1000 person years2".
2. Renal Failure:
3
In a cohort study undertaken in Germany the cumulative risk of developing renal failure
requiring transplant was 2% after 15 years of diabetes, 5% after 20 years of diabetes and 10%'
*3
after approximately 25 years of diabetes21.
3. Diabetic foot:
Development of neuropathic ulcers is one of the commonest complications of diabetes
These lesions require prolonged immobilisation and nursing care. In a study undertaken in elderlydiabetic patients in UK the prevalence of foot ulcers was 3%. US national data for 1987 show that
lower extremity amputations for non traumatic conditions is about 8 per 1000 diabetic individuals
4. Diabetes as a risk factor for other diseases:
Estimates of routine US data for diabetes and follow up study undertaken in Chile22
suggest that diabetes is an important risk factor for many diseases.
Diabetes as a risk factor
Disease / complication
Relative Risk
Coronary' bean disease
2-5
Stroke
2-3
6&
Tuberculosis
6
Blindness
20
End Stage Renal disease
Amputation
o
•
25
______40
The estimates of disability weights are based on all these factors. For the sake of
comparability the same disability weights used for the GBD estimates have been used for APBD
study also.
Moss S E el al: The incidence of vision loss in a diabetic population; Ophthalmology 1988 95; 1340-1348
JO
Dia^r
b
b
b
3
°L
a': A P0PUla,i°n baSed S'Udy Of 'he inCidenCe of complications associated with Type 2 d^t*
uiaoetic Med 1991; 8 928-933
in me elderjy
tti
aftln9 9r0UP’ Prevalence of sma11 vessel and targe vessel disease in diabetic patients from 14 centres. The WHO
muft.nat.onal study of vascular disease in diabetics. Diabetolgia 1985; 28; 615-640
1989; 117-979.983
TUberCUl°S'S 3nd dlabe{es melltlus : a longitudinal retrospective study in a teaching hospital. Rev Med Chil
65
*
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