EPIDEMIOLOGY OF

NONCOMMUNICABLE
DISEASES

PLM – FCM2
1
 LEARNING OBJECTIVES
1. Differentiate noncommunicable from
communicable diseases in terms of the ff:

1.1. Characteristics of the agent

1.2. Time frame between exposure
and disease
1.3. Nature of the disease
1.4. Interaction of agents of disease

2
2. Explain some important methodological
issues
2.1. Natural history
2.2. Case identification
2.3. Measuring exposure
2.4. Issues of conflicting findings
2.5. Investigation of causal factors

3. Give examples of major categories of

etiologic agents of non-communicable
diseases

4. Explain the important considerations in the

investigation of environmental and
occupational exposures
3
 EPIDEMIOLOGY OF NCD
I. Comparison of communicable and non-
communicable diseases

II. Methodological issues in the study of non-

communicable diseases

III. Major categories of etiologic agents

IV. Approaches to the control of non-

communicable diseases

4
 Non-Communicable Diseases
• Includes all “traditionally” defined NCDs
such as CVD, cancer, chronic respiratory
diseases, mental health as well as injuries
and violence
• In all WHO regions (except sub-Saharan
Africa), NCDs today constitute the largest
contributor to burden

5
 Situationer: NCD
• rising trends in non-communicable diseases as a
result of demographic and epidemiological
changes, as well as economic globalization

• increase in life expectancy combined with changes

in lifestyles are leading to epidemics of non-
communicable diseases (NCD), mainly
cardiovascular diseases, cancer and diabetes

• In 1998, NCD accounts for 63% of global deaths

• 43% of all DALY globally were attributed to NCD

6
 Causes of Death Worldwide: estimates for 1999
(in thousands)
Communicable diseases 17,380
Non-communicable diseases 33,484
Injuries 5,101
Cardiovascular diseases 16,970
Cancers 7,065
Respiratory diseases 3,575
Digestive diseases 2,409
Neuropsychiatric disorders 911
Genitourinary diseases 900
Source: Adapted from The World Health Report 2000, WHO

7
Burden of Disease Worldwide: Estimates for 1999 (in thousands)
Disability-Adjusted Life Years

Communicable diseases 615,105

Non-communicable diseases 621,742
Injuries 201,307
Cardiovascular diseases 157,185
Neuropsychiatric disorders 158,721
Cancers 84,500
Respiratory diseases 70,017
Congenital abnormalities 36,557
Source: Adapted from The World Hedalth Report
2000, WHO

8
 Trend of Leading Causes of Mortality
, 1975 -1995

RANK 1975 1980 1985 1990 1995

1 Pneumonias Pneumonias Pneumonias Heart Diseases Heart Diseases

2 TB, all forms Heart Diseases Heart Diseases Pneumonias Diseases of the
Vascular system

3 Heart Diseases TB, all forms TB, all forms Diseases of the Pneumonias
Vascular System

4 Diseases of the Diseases of the Diseases of the TB, all forms Malignant
Vascular System Vascular system Vascular System Neoplasm

5 Malignant Malignant Neoplasm Malignant Malignant TB, all forms

Neoplasm Neoplasm Neoplasm
6 Gastroenteritis Diarrheas Diarrheas Diarrheas Accidents
and colitis
7 Avitaminosis and Accidents Accidents Septicemia Chronic
other nutritional Obstructive
deficiencies Pulmonary
Disease
8 Accidents Avitaminosis and Measles Nephritis, Other diseases of
other nutritional nephritic the respiratory
deficiencies syndrome and system
nephrosis

9 Bronchitis Measles Avitaminosis and Accidents Diabetes

other nutritional mellitus
deficiencies

10 Tetanus Nephritis, nephrotic Nephritis, Measles Diarrheal

syndrome and nephrotic diseases
nephrosis syndrome, and
nephrosis

Source: Phil. Health Statistics

9
 MORTALITY

Ten Leading Causes of Mortality by Sex

Number, Rate/100,000 Population & Percentage
, 2003

Both Sexes
Cause Male Female
Number Rate Percent*

1. Heart Diseases 38,677 29,019 67,696 83.5 17.1

2. Vascular System Diseases 29,054 22,814 51,868 64.0 13.1

3. Malignant Neoplasm 20,634 18,664 39,298 48.5 9.9

4. Accidents 27,720 6,246 33,966 41.9 8.6

5. Pneumonia 15,831 16,224 32,055 39.5 8.1

6. Tuberculosis, all forms 18,367 8,404 26,771 33.0 6.8

7. Symptoms, signs and

abnormal clinical, laboratory
findings, NEC 10,740 10,623 21,363 26.3 5.4

8. Chronic lower respiratory

12,998 5,907 18,905 23.3 4.8
diseases
9. Diabetes Mellitus 6,823 7,373 14,196 17.5 3.6
10. Certain conditions
originating in the perinatal
period 8,397 5,725 14,122 17.4 3.6

Source: The 2003 Philippine Health Statistics

* percent share from total deaths, all causes,
10
 MORTALITY
Ten Leading Causes of Mortality by Sex
Number, Rate/100,000 Population & Percentage
, 2002
Both Sexes
Cause Male Female
Number Rate Percent*
1. Heart Diseases 39,502 30,636 70,138 88.2 17.7

2. Vascular System Diseases 27,536 21,983 49,519 62.3 12.5

3. Malignant Neoplasm 20,440 18,381 38,821 48.8 9.8

4. Pneumonia 16,729 17,489 34,218 43.0 8.6

5. Accidents 27,448 6,169 33,617 42.3 8.5

6. Tuberculosis, all forms 19,293 9,214 28,507 35.9 7.2

7. Chronic obstructive
pulmonary diseases and 13,007 6,313 19,320 24.3 4.9
allied conditions

8. Certain conditions
originating in the perinatal 8,520 5,689 14,209 17.9 3.6
period

9. Diabetes Mellitus 6,524 7,398 13,922 17.5 3.5

10. Nephritis, nephritic

5,358 3,834 9,192 11.6 2.3
syndrome and nephrosis

Source: 2002 Philippine Health Statistics

11
 MORTALITY

Ten Leading Causes of Mortality by Sex Number, Rate/100,000 Population &

Percentage , 2000

Total % of Total
Cause Male Female Rate
Number Deaths
1. Diseases of the
34,356 26,061 60,417 79.1 16.5
heart
2. Diseases of the
27,197 21,074 48,271 63.2 13.2
vascular system
3. Malignant Neoplasm 19,597 16,817 36,414 47.7 9.9
4. Pneumonia 16,549 16,088 32,637 42.7 8.9
5. Accidents 26,009 6,346 32,355 42.4 8.8
6. Tuberculosis, all
18,590 8,967 27,557 36.1 7.5
forms

7. Chronic obstructive
pulmonary diseases 10,770 5,134 15,904 20.8 4.3
and allied conditions

8. Certain conditions
originating in the 9,083 6,015 15,098 19.8 4.1
perinatal period

9. Diabetes Mellitus 5,147 5,600 10,747 14.1 2.9

10. Nephritis, nephritic
syndrome and 4,642 3,321 7,963 10.4 2.2
nephrosis
12
 Ascendancy of noncommunicable
diseases
•“epidemiologic transition”

•trend in many countries have been impacted

by a new epidemic disease – HIV/AIDS

13
Ascendancy of noncommunicable diseases

• this leaves many countries with a double

burden of health problems:
• a new epidemic of infectious disease and
unresolved infectious conditions
• a growing set of noncommunicable diseases.

14
Ascendancy of noncommunicable diseases

•Epidemiologic transition in the Philippines

•Epidemiologic transition varies; reflecting the

social, cultural, economic, and health resource
factors

15
• NCDs accounted for 60% of all deaths in
1999 and 43% of all DALYs with injuries
adding 9% of all deaths and 14% of all
DALYs
• By 2020, 10 out the top 15 causes of
DALYs lost will be attributable to NCDs,
mental health and injuries/violence

16
• The top five positions will be occupied by
Ischemic Heart Disease, depression, road
traffic injuries, cerebrovascular disease
and Chronic Obstructive Pulmonary
Disease (COPD)
• 15th place: trachea, bronchus and lung
cancers (better known as tobacco
cancers)

17
18
 GROUP OF NCDs
• Cancers
• Lifestyle-related (CVD, diabetes)
• Injury (unintentional, intentional)
• Genetic disorders
• Disabling disorders
• Occupational disorders
• Nutritional conditions
• Endocrine disorders
• Substance abuse

19
 REASONS FOR THE
PROMINENCE OF NCD
1. Aging of the population
2. Impact of automobiles
3. Lifestyle changes
4. Tobacco addiction
-single largest cause of preventable morbidity
and mortality
5. Physical activity
6. Social and behavioral factors

20
 I. NATURAL HISTORY
A. CHARACTERISTICS OF THE AGENT
e

– Absence of a single necessary agent

– most NCDs are classified on the basis of

manifestations rather than on etiology (e.g.,
CVD, renal disease, neoplasms)

– known “causes” are risk factors

e.g. obesity, elevated cholesterol levels,
hypertension

21
B. TIME FRAME
- take years or decades before illness is
apparent
- no multiplication of causative agent is
involved
- multiple low-dose exposures (some
chemicals)
- some conditions seem to evolve
subsequent to chronic conditions or high
risk states such as obesity, smoking,
diabetes and high blood cholesterol

22
 Disease Induction and Latency
Interval

“Emperical induction time” = time since first exposure

Disease induced

Induction Period Latency Period

Exposure

Case or Death
First exposed Identified
TIME 23
C. NATURE OF THE DISEASE
– chronic in nature
– “chronic disease”
(1957 Commission on Chronic Disease)
» permanent
» leaves residual disability
» caused by nonreversible pathological
alterations
» requires special training of the patient
for rehabilitation
» requires long periods of supervision,
observation or care.

24
– Chronicity
•function of the long latency period
•slow disease process  adaptive
responses to stresses (may be
detrimental over the long term)

CD can be chronic (e.g. rheumatic

heart disease)
NCD can be acute (e.g. chemical
poisoning)

25
D. Synergism in Disease Causation

> Asbestos and lung cancer (RR=8)

> Smoking + asbestos and lung
cancer (RR=90)

- Presence of synergism  decreased

latency (produce illness in the prime of
life even with low level exposures)

- Role of initiators and promoters

26
 SUMMARY OF DIFFERENCES:
INFECTIOUS DISEASE
Single necessary agent
Agent-disease specificity
Causes are known
Short incubation period
Single exposure usually
sufficient
Usually produce acute disease
Acquired immunity possible
Diagnosis based on tests
specific to disease agent
NON-INFECTIOUS DISEASE
No single necessary agent
Seldom agent-disease specificity
Causes are unknown
Intervention often based on risk
factors
Long latency period
May require multiple exposure to
same or multiple agents
Most often produce chronic
disease
Acquired immunity unlikely
Diagnosis often dependent on
non-specific symptoms or tests
27
 Methodological Issues in the Study of NCD

“Emperical induction time” = time since first exposure

Disease induced

Induction Period Latency Period

Exposure

Case or Death
First exposed Identified
TIME 28
 II. Methodological Issues in
the Study of NCD
A. Natural history
- lack of a single necessary agent causing the
disease makes it more difficult to isolate the effect
of any individual factor
- synergistic effects of other agents and effects of
known causes must be controlled
- long latency period recall problems
- chronic nature and low frequency of occurrence 
prevalent cases studied rather than incident cases 
difficult interpretation of causality
29
B. CASE IDENTIFICATION
- presence or absence of a cluster of
symptoms
- criteria for diagnosis may vary by
institution or by physician  research
using medical records problematic

C. MEASURING EXPOSURE
- quantification is important but
problematic
- acuteness or chronicity/high dose or
low dose

30
- Is dose a function of a metabolite, enzymatic
alteration, level of the original agent?

- environmental levels or body levels?

- plasma levels, brain concentration, kidney, or some

other organ tissue?

- Precise quantification identifies levels hazardous to

health  important for planning control measures.

- Demonstration of dose effect helps establish causal

role for the agent

- Constancy or intermittence of the exposure

- relevant time or period of exposure

31
D. CONFLICTING FINDINGS AND
CAUSALITY

- publication bias

- criteria for causality:

strength of association
temporal correctness
dose-effect relationship
biological plausibility
consistency of findings
specificity of relationships
32
 Problems in investigating disease
etiology
1. Absence of a known agent
– especially a problem for chronic diseases;

– makes diagnosis difficult;

– absence of good tests may make distinction

between diseased and non-diseased persons
very difficult;

33
 Problems in investigating disease
etiology (con’t.)
2. Difficulty of measuring and characterizing
exposure

– Quite problematic in environmental

exposures;

– Technology to accurately detect/measure

exposures may not be available;

34
 Problems in investigating disease
etiology (con’t.)
3. Multi-factorial nature of etiology

– Relevant factors may be both environmental

and constitutional;

– Relevant factors may also interact with other

factors;

35
 Problems in investigating disease
etiology (con’t.)
4. Long latent period

– Presence of a long latent period during which

host and environmental factors interact before
the disease becomes manifest;

– The long latent period makes it difficult to link

antecedent events with the outcomes;

36
 Problems in investigating disease
etiology (con’t.)
5. Indefinite onset

– Most chronic diseases, for example, are

characterized by indefinite onset;

– The problem of identifying the time of onset of

the disease makes collection of incidence
data difficult;

37
 Problems in investigating disease
etiology (con’t.)
6. Differential effect of factors on incidence and
course of disease

the nature of the exposure-disease

relationship may be different during the initial
development of the disease and the later
course of the disease (i.e., factors may act
differently at various stages of the disease

38
Problems in investigating disease
etiology (con’t.)
example– cancer of the breast and SES
Incidence of breast cancer is generally higher
among women with high SES than women with low
SES;
Studies from the California Tumor Registry have
shown that, within stage, survival of patients with
breast cancer was better for more advantaged
women (e.g., those treated in private rather than
country hospitals). Lower incidence among low
SES but better prognosis among those with high
SES.
39
 Major Categories of
Etiological Agents

A. Occupational

B. General environmental

C. Lifestyle and Illness

40
OCCUPATIONAL
- chemical
- metals and naturally occurring minerals

41
Investigating occupational exposures

• agent factors to be considered

–size and shape of particles
–route of exposure
–free or compound form
–organic vs inorganic form
–liquid or vapor form

42
• environmental factors
– conditions in the work environmental
that will influence the likelihood that
workers will come in contact with an
agent
– general cleanliness and ventilation
– lighting, temperature

• Host factors
– lifestyle behaviors that may increase
the risk of disease from occupational
exposure to an agent
– genetic constitution

43
ENVIRONMENTAL

• sources of exposure
– contamination of air, water and soil by
industrial activities or inadequate waste
disposal
– lower dose of exposure than in
occupational environments
•pesticides
•housing materials
•automobile exhausts
•radiation
44
• Investigating environmental exposures
– dose
– data on levels of exposure
– mobility of subjects
– confounders

• additional considerations
– wide range of ages
– length of exposure
– meterological conditions
– seasonal effects

45
LIFESTYLE
- poverty, stress, exercise, drug and alcohol
use, nutrition

46
OUTCOME MEASURES: (HEALTH
STATUS)

-MORTALITY RATE

-MORBIDITY RATE

-DALY

47
Disability Adjusted Life Year (DALY)

Health gap measure that extends the concept

of potential years of life lost due to premature
death (PYLL) to include equivalent years of
“healthy” life lost by virtue of being in states
of poor health or disability.

48
 Disability Adjusted Life Year (DALY)

Calculated as the sum of the years of life lost due to

premature mortality (YLL) in the population and the
years lost due to disability (YLD)

DALY = YLL + YLD

YLL = N x L
WHERE: N – number of deaths
L – standard life expectancy at age of
death in yrs
YLD = I x DW x L
Where: I – number of incident cases
DW – disability weight
L – average duration of the case until remission or
Death (years)
49
 CONTROL OF NCD

A. PRIMARY PREVENTION
- removal of agent from environmental or
minimizing the amount of agent present
- Protection of the susceptible host from
exposure

B. SECONDARY PREVENTION
- screening tests

C. TERTIARY PREVENTION
- lifestyle modification
50
• A small core of risk factors explains the increases in
CVD, certain cancers and their closely linked
conditions of obesity, type II diabetes:
– tobacco, diet/nutrition, physical inactivity and
alcohol
• A substantial proportion of chronic respiratory
diseases and death are driven by tobacco use
• Alcohol is obviously a major contributor to all causes
of injuries and violence

51
 Tobacco trends are not hopeful
• There are 1.2 billion smokers in the world
with smoking rates in 13 to 15 year olds
being about 20% in diverse cities from
developed and developing countries
• Tobacco causes 4 million deaths per year, a
figure that will increase to 10 million per year
by the late 2020s
• The public health impact is widespread and
increasing fast in developing countries
52
Alcohol Use
• Trends in alcohol use:
– steady increases in many developing
countries with continued very high rates of
binge drinking in many east and central
European countries.

53
Obesity
• has tripled in youth in several Chinese cities,
and rapidly increased over the last 15 years in
the major cities of countries like Malaysia,
Brazil, Indonesia and South Africa
• But these have occurred as underweight
persists in the rural areas
• Often underweight is common in the same
neighborhoods as obesity is increasing
• Thus both being underweight and being
overweight are associated with poverty

54
Obesity (con’t)
• Epidemics of obesity and type II diabetes
have been well documented in most
Pacific Island States and are probably
fuelled by a combination of factors:
– increased imports of high fat foods
particularly cheap off-cuts as well as
increased consumption of sodas in societies
where physical activity levels have
plummeted.
• Devastating economic impact of diabetes’
complications are recently being
determined for several of these countries
55
• The problems of obesity and diabetes
are caused by many factors

• Solutions similarly need to be

multidimensional and avoid focusing on
just one aspect or on behavior change
alone

56
• Mental health:
– 450 million people who suffer from
mental or neurological disorders or
from psychosocial problems such as
those related to alcohol and drug abuse

57