Journal Club 10/18/21: The Global Burden of Disease

Global Health and the Global Burden of Disease presented by Denise Manfrini

Global burden of disease is the quantity of disease (conditions, illnesses, injuries) and their impact on a population. The impact is measured in disability-adjusted life years (DALYs), which is the years of life lost from premature death and years of life lived in less than full health. There are other metrics used as well to compare countries, such as incidence, prevalence, mortality, and fertility rate.

In order to determine these metrics to measure global burden of disease and see where a country’s health system should focus, disease surveillance is required. This led to the creation of the Global Burden of Disease (GBD) Project in 1992. It aims to develop a consistent way to estimate disease burden in eight global regions (established market economies and formerly socialist economies) using the metrics described above, particularly the DALY. The project initially quantified 107 conditions and over 400 sequelae and has been expanding and updating its findings in the following years. This level of detail has allowed tracking of disease changes over the years and given insight into which interventions are effective. Initial results have shown high disease burden, premature mortality, and health disparities when comparing established market economies and impoverished countries; notably, developing countries suffered more from infectious and parasitic diseases, respiratory infections, and maternal and perinatal disorders. Developed countries suffered more from diseases due to poor lifestyle, such as cardiovascular disorders. Results from 2019 indicate shifts. Overall health is improving worldwide since those results in 1994 (GBD 2019 Diseases and Injuries Collaborators 2020). As seen in the chart, diseases affecting primarily children, such as respiratory infections, diarrheal infections, measles, neonatal disorders, tetanus, malaria, have decreased significantly. The prevalence of diseases affecting older adults, such as ischemic heart disease, diabetes, stroke, lung cancer, has increased and indicates that health care systems need to be prepared to manage an older patient population.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Change in worldwide burden of disease from 1990 to 2019. Red - infections/perinatal/maternal conditions; Blue - noncommunicable disease; Green - Injuries/accidents. Source: GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.

Once burden of disease can be quantified, how do we decide how to tackle it? Enter priority setting to determine how to best allocate resources. A few models have been proposed. In 1971, Abdel Omran posited four stages through which developing countries progress, called the epidemiological transition. The four stages are: age of pestilence and famine; age of receding pandemics; age of degenerative and manmade disease; and age of delayed chronic disease. Developed countries would be categorized in this final stage. However, the stages do not have clear divisions nor is the progression so clear-cut; a country can be in more than one stage simultaneously. For example, developed countries are currently suffering from the Covid pandemic and from chronic diseases. Thus, priority setting based only on the epidemiological transition would provide incomplete aid to countries encountering more than one stage. Another model is the idea of cost-effectiveness. For an intervention to be considered cost-effective, it must cost no more than 3x the per capita health costs. This is difficult to achieve in countries where the per capita health cost is extremely limited and not enough to cover a worthwhile intervention. After recognizing that poor health leads to limited economic development and to address the challenge of figuring out which interventions need investing, the Disease Control Priorities (DCP) Project was created. It aimed to enable countries to choose and prioritize interventions that maximally impact disease burden and that are supported by their health budgets. The latest DCP project promotes equity and advocates for universal health coverage. Both the DCP and GBD projects are ongoing.

Discussion Questions:

To what extent should developed countries provide economic support to developing countries?

Which diseases can we anticipate becoming a larger portion of the burden of disease and what can we do to prepare? 

Tuberculosis: Global Policy and Impacts of COVID-19 presented by Andrew McAward

Prior to the current COVID-19 pandemic, tuberculosis was the leading cause of death from a single infectious disease. In 2020, 1.5 million people worldwide succumbed to TB, while an additional 10 million were infected with primary TB. However, major global health organizations agree that tuberculosis is both curable and preventable. For this reason, combating tuberculosis continues to remain at the forefront of global health efforts today.
The pathology of the TB is caused by Mycobacterium tuberculosis infection, which classically results in the development of granulomatous lesions in lung tissue. This disease can be latent, acute, or systemic/miliary in nature. Updated treatment protocols continue to recommend using derivations of the “RIPE” therapy regime for up to 6 months. The BCG vaccine is widely used in countries with high TB burden, providing strong protection against tuberculosis meningitis and miliary TB spread in children. However, this vaccine’s lack of effectiveness in adults and contraindication in both pregnant women and the immunocompromised has prompted the WHO to initiate new vaccine development. Additionally, the rising concern of multidrug-resistant TB has increased global efforts to establish new treatment options and a more effective vaccine.

Global health organizations have renewed their ambitions to mitigate the spread of TB. In 2014, the World Health Organization’s “End TB Strategy” set a goal to reduce TB incidence by 80% and death by 90% by 2030. The organization’s intention was to embolden local governmental policies and increase research efforts such as through the development of a new adult candidate TB vaccine, M72/AS01E. Similarly, the United Nations joined the WHO’s response by including the elimination of the tuberculosis epidemic on a list of 17 Sustainable Development Goals (SDGs) to be achieved by the year 2030. Despite these efforts, the progress made in battling TB has been halted by COVID-19. New cases of tuberculosis markedly fell in 2020 due to lack of access to diagnostic services, while global deaths increased for the first time in over a decade. The current COVID pandemic has also worsened prognostic outcomes of patients currently undergoing treatment for tuberculosis. Prior successes of global TB health policy, such as maintaining steady drug supply chain or providing healthcare personnel to assist with direct observation drug therapy, have been disrupted due to the economic and social implications of the current pandemic.
Since 2000, over 66 million lives worldwide have been saved through the diagnosis and successful treatment of tuberculosis. Despite dramatic setbacks caused by COVID-19, the global health community should remain optimistic about the long-term mitigation of this disease.

Discussion Questions:

How can global health policies help to overcome the challenges caused by COVID-19 in the diagnosis and treatment of TB?

How can healthcare professionals continue to further the progress made against TB burden in their own communities?

Journal Article: Five insights from the Global Burden of Disease Study 2019 Presented by Rachael Kantor

1. Double Down on Catch-up Development
Improvements in SDI have increased universally at an exponential rate since the 1950s. Originally (and predictably) we saw high SDI countries developing at a much faster rate than low SDI countries BUT since the start of the millennium counties of lower SDIs have been progressing at a rate much faster than those of high SDI statuses showing catch-up development. To close the gap, we must “double down” by increasing economic growth, expanding access to education, and improving the status of women in lower SDI countries. **Socio-demographic Index (SDI) is a measure used in the GBD to identify where a geographic area sits on the spectrum of development.
2. The Minimum Development Goal Health Agenda HAS been working
It’s no secret that since the early 2000s the global health community has focused heavily on decreasing mother and child mortality and decreasing the burden of communicable diseases (specifically TB, HIV, and malaria). The good new is these efforts have been incredibly successful BUT we owe it to ourselves to pay close attention to non-communicable disease (NCD) trends. Population growth and aging have led to a steady increased in NCDs.
3.Health Systems need to be more agile to adapt to the rapid shifts to NCDs and disabilities
As health profiles and SDI rankings change, universal health coverage must adapt to meet current health needs. This means increased focus on NCD coverage and greater attention to disorders causing functional health loss (MSK, substance abuse, mental health, etc.) to reduce the massive policy gap.
4. Public health is failing to address the increase in crucial global health risk factors
As global SDI has increased, many risk factors have seen a sharp decline. However, risk factors including High SBP, FBG, and BMI, as well as alcohol and drug use have increased alarmingly by > 0.5% a year.
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
The GBD has estimated that by 2100 there will be over 150 countries whose death rate exceeds its birth rate; this compared to 34 countries in 2019. Many country populations will decrease—resulting in tremendous controversy regarding workforce maintenance, the ongoing immigration debate, and fertility incentivization2.

Discussion Questions:

Many editorials/opinions call the neglect of chronic illness, and the exponential rise of preventable risk factors the “perfect storm” to fuel the COVID-19 pandemic.   What sort of policies (concrete or abstract) should be put into place to take urgent action against this “failure of public health,” making countries more resilient to future pandemic threats?

The authors of this study have concluded that exposure to/smoking tobacco has fallen 1-2% a year worldwide since 2010 due to the major efforts to implement international tobacco control policies rather than providing information to consumers about the harms of tobacco. However, the rate of exposure to other risk factors are increasing by more than 0.5% a year. Given the successes/failures of the efforts to decrease tobacco exposure, what place does government and international legislation have in the efforts to reduce these other risk factor exposures?   

~This second discussion question provided an excellent conversation on the importance of individual autonomy and governmental policy influence, as well as those factors, including social determinants of health that limit both the individual and a government’s ability to take viable action to reduce risk factor exposure.  

 

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Denise Manfrini, MS4

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

  • Mukherjee, J. (2017). Chapter 4: Global Health and the Global Burden of Disease. In An Introduction to Global Health Delivery (pp. 89–105). book, Oxford University Press.
  • GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.
  • Global Health CEA registry database with publications from different countries about cost-saving interventions – https://cevr.shinyapps.io/LeagueTables/
  • Kant, Surya, and Richa Tyagi. “The Impact of Covid-19 on Tuberculosis: Challenges and Opportunities.” Therapeutic Advances in Infectious Disease, vol. 8, 9 June 2021, p. 204993612110169., https://doi.org/10.1177/20499361211016973.
  • Kirby, Tony. “Global Tuberculosis Progress Reversed by COVID-19 Pandemic.” The Lancet Respiratory Medicine, 2 Nov. 2021, https://doi.org/10.1016/s2213-2600(21)00496-3.
  • Roy, A., et al. “Effect of BCG Vaccination against Mycobacterium Tuberculosis Infection in Children: Systematic Review and Meta-Analysis.” BMJ, vol. 349, no. aug04 5, 2014, https://doi.org/10.1136/bmj.g4643.
  • “Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Oct. 2021, https://www.cdc.gov/tb/default.htm.
  • “Tuberculosis (TB).” World Health Organization, World Health Organization, 14 Oct. 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
  • GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1135-1159. doi: 10.1016/S0140-6736(20)31404-5. PMID: 33069324; PMCID: PMC7116361.
  • Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396: 1160-1203

 

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Cite this article as: Global EM Student Leadership Program, "Journal Club 10/18/21: The Global Burden of Disease," in International Emergency Medicine Education Project, December 13, 2021, https://iem-student.org/2021/12/13/journal-club-the-global-burden-of-disease/, date accessed: November 28, 2022

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