THE BURDEN OF HEALTH AND DISEASE IN SOUTH AFRICA BRIEFING TO SELECT COMMITTEE ON SOCIAL SERVICES 15 March 216 Prof Debbie Bradshaw, Dr Pillay-van Wyk, Ms Ntuthu Somdyala and Dr Marlon Cerf
PRESENTATION OUTLINE Trends in health and disease burden Rapid Mortality Surveillance Report 2nd National Burden of Disease Study: Mortality trends SAMRC Eastern Cape Cancer Register Challenges in monitoring health and burden of disease
RAPID MORTALITY SURVEILLANCE REPORT 214 Surveillance system based on numbers of deaths recorded on the National Population Register (obtained monthly from Department of Home Affairs) Adjustments made to account for under-registration of deaths and proportion of population without IDs Key health indicators: Life expectancy at birth (e ) and at age 6 (e 6 ) Adult mortality rate ( 45 q 15 ) Under-5, infant and neonatal mortality rates Maternal mortality ratio RAPID MORTALITY SURVEILLANCE REPORT 214
TRENDS IN NUMBER OF NATURAL AND UNNATURAL DEATHS BY BROAD AGE GROUP 2-214 RAPID MORTALITY SURVEILLANCE REPORT 214
TREND IN LIFE EXPECTANCY AT BIRTH, 2-214 9 year increase in average life expectancy since the low in 25 By 214: Total: 62.9 years Male: 6. years Female: 65.8 years RAPID MORTALITY SURVEILLANCE REPORT 214
TREND IN PREMATURE ADULT MORTALITY, 2-214 Premature mortality between age 15 and 6 years ( 45 q 15 ) has decreased since 25 45q 15 2 25 214 Total 41% 5% 34% Male 48% 55% 4% Female 35% 46% 28% RAPID MORTALITY SURVEILLANCE REPORT 214
TREND IN LIFE EXPECTANCY AT AGE 6 YEARS, 2-214 Little change in average life expectancy at age 6 years (e 6 ) About 19 years for females and about 15 years for males RAPID MORTALITY SURVEILLANCE REPORT 214
TREND IN CHILDHOOD MORTALITY, 2-214 Under-5 mortality rate (U5MR) and infant mortality rate (IMR) increased to a peak in 23 and declined till 211. Levels have stagnated at 4 and 28 deaths per 1 livebirths for the U5MR and IMR respectively. Neonatal mortality rates (NMR) have declined to 11 per 1 livebirths. RAPID MORTALITY SURVEILLANCE REPORT 214
MATERNAL MORTALITY RATIO, 2-214 Maternal deaths are relatively rare and uncertainty about true value of MMR remains. MMR declined from 21 to 155 per 1 live births in 213 based on cause of death data from Stats SA with adjustment for under-registration and under-reporting of maternal causes. RAPID MORTALITY SURVEILLANCE REPORT 214
2 ND NATIONAL BURDEN OF DISEASE STUDY CAUSE OF DEATH PROFILE Mortality estimates by broad cause group and disease categories Age distribution of deaths by broad cause group Leading causes of death for SA in 1997 and 21 Mortality estimates by broad cause group by population group, sex and province for 21 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
METHOD AND DATA SOURCES Figure 1: Schematic of data sources and data adjustments cause of death data STATISTICS SOUTH AFRICA DEATHS DATA BASE INJURY MORTALITY SURVEY 29 Multi nomial modeling of the 5 major injury causes by age, sex, province and population group Data cleaning Based on *IMS, adjust + NIMSS 2 profile to reflect population structure in 2 Proportionally redistributed unknown age, sex, population group Compare with Statistics South Africa and apply polynomial smoothing by age, sex and province for ratio Linear regression to estimate cause profiles between + NIMSS 2 and *IMS 29 Estimate overall profile for other unintentional injuries by age and sex Adjust overall completeness Apply derived injury proportions Apply injury completeness Generate scaling factors allowing for provincial boundary change Adjust National completeness for Africans RE ALLOCATION OF MIS CLASSIFEID HIV/AIDS Identify source causes with miss attributed AIDS deaths Model increase of age specific mortality 1997 23 against lagged HIV ANC prevalence to estimate mortality level without HIV/AIDS Estimate non HIV/AIDS trends from mortality rates in the 75-84 year age group Redistribute ill-defined naturals & garbage ADJUSTED DEATHS Pillay-Van Wyk V, Laubscher R, Msemburi W, et al. Second South African National Burden of Disease Study: Data cleaning, validation and SANBD list. Cape Town: Medical Research Council; 214.
ESTIMATED NUMBER OF AIDS DEATHS BY REPORTED CAUSE OF DEATH AND AGE FOR THE PERIOD 1997-21 (N=2,812,) 5 4 Deaths 3 2 1 1-4 5-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65+ Reported HIV HIV pseudonyms Tuberculosis Lower respiratory Diarrhoeal Other causes Ill-defined 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Number of deaths Age standardised death rates per 1 population NUMBER OF DEATHS (a) AND DEATH RATES (b) BY BROAD CAUSE, SOUTH AFRICA, 1997-21 a. Number of deaths b. Age-standardised death rates 35 3 25 2 15 1 5 8 7 6 5 4 3 2 1 Years Years 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
1-4 5-9 1-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ 1-4 5-9 1-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ Number of deaths Number of deaths 1-4 5-9 1-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ 1-4 5-9 1-14 15-19 2-24 25-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ Number of deaths Number of deaths NUMBER OF DEATHS BY BROAD CAUSE AND AGE GROUP, SOUTH AFRICA 1997, 2, 25 and 21 6 1997 Persons N=416 29 6 2 Persons N=54 934 5 5 4 4 3 3 2 2 1 1 Age group (years) Age group (years) 6 25 Persons N=667 815 6 21 Persons N=594 71 5 5 4 4 3 3 2 2 1 1 Age group (years) Age group (years)
1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Age standardised death rates per 1 population TREND IN DISEASE CATEGORIES, 1997-21 7 6 5 4 3 2 1 HIV/AIDS & TB Infectiouss and Parasitic Other Type 1 Cancers Diabetes Cardiovascular Disease Other Type 2 Unintentional Injuries Intentional Injuries Year 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Age standardised death rates per 1 population TREND IN DISEASE CATEGORIES, 1997-21 4 35 3 25 2 15 1 5 Infectiouss and Parasitic Other Type 1 Cancers Diabetes Cardiovascular Disease Other Type 2 Unintentional Injuries Intentional Injuries Year 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
Age-standardised deaths per 1 population 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Age-standardised deaths per 1 population 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Death rates for cardiovascular diseases, diabetes and renal disease for males (a) and females (b), SA 1997-212 a. Males b. Females 16 14 12 1 8 6 4 2 16 14 12 1 8 6 4 2 Years Years
1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Age-standardised deaths per 1 population 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 Age-standardised deaths per 1 population DEATH RATES FOR CANCERS, SOUTH AFRICA 1997-212 45 4 35 3 25 2 15 1 5 a. Males 45 4 35 3 25 2 15 1 5 b. Females Years Years
LEADING CAUSES OF DEATH, 1997-212 1997 21 Cause of Death Deaths % HIV/AIDS 6336 14.5 Cerebrovascular disease 31472 7.6 Interpersonal violence 3569 7.3 Tuberculosis 26344 6.3 Ischaemic heart disease 23813 5.7 Lower respiratory disease 2198 5.3 Diarrhoeal diseases 18737 4.5 Hypertensive heart disease 15771 3.8 Road injuries 15159 3.6 Diabetes mellitus 11321 2.7 Top 1 causes 25543 61.4 Total deaths 41629 1. Cause of Death Deaths % HIV/AIDS 27728 35. Cerebrovascular disease 4355 6.8 Lower respiratory infections 26429 4.4 Tuberculosis 26246 4.4 Ischaemic heart disease 23377 3.9 Hypertensive heart disease 2337 3.4 Diarrhoeal diseases 1958 3.3 Interpersonal violence 1929 3.2 Diabetes mellitus 1858 3.1 Road injuries 17969 3. Top 1 causes 419738 7.7 Total deaths 59471 1 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
CAUSES OF DEATH IN CHILDREN UNDER-5 YEARS, 21 N=6,56 Congenital 2% Other childhood conditions 13% Injuries 4% Preterm 1% Pneumonia 11% Neonatal deaths 22% Birth asphyxia 5% Tuberculosis 2% Diarrhoea 18% HIV/AIDS 28% Severe infections 3% Other neonatal 4% 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
KwaZulu-Natal Mpumalanga Eastern Cape Free State Limpopo North West Northern Cape Gauteng Western Cape South Africa Deaths per 1 live births UNDER-5 MORTALITY RATE BY PROVINCE 2, 25, 21 12 1 8 6 4 2 66, 6, 6,1 65,8 41,6 54,5 45,3 43,2 24,9 51,8
1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 1997 25 21 Age standardised deaths rates per 1 population DEATH RATES BY BROAD CAUSE GROUP BY PROVINCE 1997, 2, 25 and 21 25 2 15 1 5 South Africa Western Cape Limpopo Gauteng North West Northern Cape Mpumalanga Eastern Cape Free State KwaZulu Natal
LEADING CAUSES OF PREMATURE MORTALITY (YEARS OF LIFE LOST) BY PROVINCE IN 21
OVERVIEW Huge gains with HIV/AIDS, need to continue and strengthen current programmes Decrease in interpersonal violence mortality rates remain high Increase in death rate for renal disease and diabetes mellitus Increase in death rate for prostate and breast cancer Highest deaths rates in adults and children in Kwa-Zulu Natal 2 ND NATIONAL BURDEN OF DISEASE STUDY FOR SOUTH AFRICA: CAUSE OF DEATH PROFILE
CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212 High incidence of cancer of oesophagus was first noticed amongst the Xhosa-speaking people of the Transkei region of the Eastern Cape Province in the early 195s. A register which was dedicated to record each and every cancer case in this area was started in 1955 so that scientists could investigate oesophageal cancer the Bantu Registry in East London. The SAMRC has continued and expanded the population based cancer register and contributes to the international data base on cancers. CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
NINE PROVINCES OF SOUTH AFRICA Qunu Location Of Cancer Registry Within Eastern Cape Province
METHODS Data sources 15 collaborating hospitals in and around registration area 1 pathology laboratory Active and passive data collection CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
Rural but with facilities such as tarred roads, making access to hospitals easy Bambisana Hospital Registry staff visiting Bambisana Hospital
METHODS Data processing Geographic coding and ICD-O coding Capture of data using CANREG 5 Data checking Analysis Rates calculated using census data Age standardised using IARC world standard CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
MOST COMMON CANCERS FOR MALES Males 28-212 Site ICD-1 No. of cases % of total Oesophagus C15 368 3.5 Prostate C61 178 14.8 Oral cavity & pharynx C-C14 96 7.8 Kaposi sarcoma C46 84 7. Lung C33-C34 63 5.2 Liver C22 62 5.1 Larynx C32 47 3.9 Colon-rectum C18-C2 41 3.4 Non-Hodgkin Lymphoma C82-C85 23 1.9 Stomach C16 2 1.7 CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
MOST COMMON CANCERS FOR FEMALES Females 28-212 Site ICD-1 No. of cases % of total Cervix Uteri C53 76 34.5 Oesophagus C15 46 19.9 Breast C5 294 14.4 Kaposi sarcoma C46 78 3.8 Ovary C56 58 2.8 Corpus Uteri C54 47 2.3 Liver C22 41 2. Colon-rectum C18-C2 44 2.1 Lung C33-C34 28 1.4 Non-Hodgkin Lymphoma C82-C85 27 1.3 CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
THE IMPORTANCE OF KEEPING A CANCER REGISTER
TRENDS IN COMMON CANCERS AMONG MALES AGE STANDARDISED RATES PER 1 POPULATION 35 3 25 1998-22 23-27 28-212 2 15 1 5 Oesophagus Prostate Kaposi sarcoma Liver Lung CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
TRENDS IN COMMON CANCERS AMONG FEMALES AGE STANDARDISED RATES PER 1 POPULATION 35 3 25 1998-22 23-27 28-212 2 15 1 5 Cervix Oesophagus Breast Liver Ovary CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
OESOPHAGEAL CANCER RATES BY TOWN AGE STANDARDISED RATES PER 1 POPULATION 6 5 MALES 6 5 FEMALES 4 3 2 1 4 31996-2 2 1998-22 23-27 1 28-212 1996-2 1998-22 23-27 28-212 CANCER INCIDENCE IN SELECTED MUNICIPALITIES OF THE EASTERN CAPE PROVINCE 28 212
CONCLUSIONS 1. Gains in child mortality are consistent with provision of PMTCT, ARTs and immunizations. Improved socio-economic and environmental conditions are needed to reduce rates further and improved health care is needed to improve the outcomes of newborns. 2. Maternal mortality has improved since 21 - quality of health care must be improved to reduce MMR further. 3. Life expectancy gains are consistent with roll out of ARTs and strengthening TB control programme, but also gradual declines in certain non-communicable diseases and injuries. Further gains will need a comprehensive health promotion and disease prevention approach together with improved health services. 4. Cancer surveillance is the tool both to monitor trends of cancers and evaluate cancer control programmes. Oesophageal cancer remains the leading cancer in the area under surveillance. Kaposi s sarcoma and prostate cancer have increased among men while cervical and breast cancer have increased among women.
CHALLENGES 1. Civil registration and vital statistics (CRVS) is well established in South Africa and has improved considerably since 1994. The quality of medical certification and the inclusion of information about the external causes of injuries needs to be improved. 2. Morbidity data systems need to be strengthened there is little data currently available to track the incidence of key conditions. 3. Demographic, epidemiological and biostatistical skills and capacity need to be strengthened. BURDEN OF DISEASE RESEARCH UNIT
BURDEN OF DISEASE RESEARCH UNIT Director: Prof Debbie Bradshaw Mission: To assess and monitor the country's health status and determinants of disease Key projects: 2nd National Burden of Disease Study & Comparative Risk Assessment Improving mortality surveillance South African Demographic and Health Survey (with NDOH and Stats SA) Eastern Cape Cancer Register Evaluation of clinically coded information WHO-FIC Collaborating Centre BURDEN OF DISEASE RESEARCH UNIT
ACKNOWLEDGEMENTS Department of Home Affairs, Stats SA and Department of Health are thanked for providing data the interpretation of the data is that of the authors. Collaborating hospitals in Eastern Cape and KwaZulu Natal and the National Health Laboratory Services. Members of the SAMRC Burden of Disease Research Unit and contributors to the reports presented. BURDEN OF DISEASE RESEARCH UNIT