Kenji Shibuya

WHO Framework Convention on Tobacco Control: development of an evidence based global public health treaty

Many health problems require international action, but getting governments to agree on strategies for prevention or treatment is difficult. By making use of scientific evidence on the effects of tobacco, the member states of WHO have negotiated their first global health treaty. If the treaty can be implemented effectively, it could act as a possible model for tackling other health issues nnWhen Dr Gro Harlem Brundtland became director general of the World Health Organization in 1998, she clearly stated that the tobacco epidemic should be tackled by an international collective action and that WHO should take a leadership role.1 In 1999, WHO started work on the WHO Framework Convention on Tobacco Control, which was endorsed by member states on 21 May 2003. It is the first time WHO has used its constitutional authority in global public health to develop a legal instrument aimed at improving population health. The initiation and negotiation of the framework convention was based strongly on the accumulation of scientific evidence.2 We review the development and scientific basis of the convention and discuss its implications and the potential of international collective action against threats to global public health.nnThe structural basis for framework conventions is to use an incremental process in making law. It begins with a framework convention that establishes a general consensus on the relevant facts and the system of governance for an issue. This is followed by the development of more specific commitments and institutional arrangements in subsequent protocols.3 However, depending on the political will, framework conventions can also include quite specific provisions. In the case of the WHO Framework Convention on Tobacco Control, the powerful political momentum behind the treaty has ensured that several detailed provisions have been incorporated into the final text.4nnThe framework convention is the first …

Chronic obstructive pulmonary disease: current burden and future projections

SERIES “THE GLOBAL BURDEN OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” nnEdited by K.F. Rabe and J.B. Soriano nnNumber 2 in this Series nn### Summarynn⇓Information about the comparative magnitude of the burden from various diseases and injuries is a critical input into building the evidence base for health policies and programmes. Such information should be based on a critical evaluation of all available epidemiological data using standard and comparable procedures across diseases and injuries, including information on the age at death and the incidence, duration and severity of cases who do not die prematurely from the disease. A summary measure, disability-adjusted life yrs (DALYs), has been developed to simultaneously measure the amount of disease burden due to premature mortality and the amount due to the nonfatal consequences of disease. nnApproximately 2.7 million deaths from chronic obstructive pulmonary disease (COPD) occurred in 2000, half of them in the Western Pacific Region, with the majority of these occurring in China. About 400,000 deaths occur each year from COPD in industrialised countries. The increase in global COPD deaths between 1990 and 2000 (0.5 million) is likely to be partly real, and partly due to better methods and more extensive data availability in 2000. The regional (adult) prevalence in 2000 varied from 0.5% in parts of Africa to 3–4% in North America.nn### IntroductionnnHealth systems must increasingly address a broad spectrum of health issues, ranging from epidemic outbreaks to advanced therapeutic care. They must, or should, also support disease prevention and health-promotion activities. Recognising that resources for health were unlikely to grow as quickly as demand, in 1993, the World Bank proposed a series of intervention packages for countries at different stages of development which, if implemented, would probably lead to the greatest gains in population health at affordable cost. The evidence for these recommendations was based …

Global Mortality Associated with Rotavirus Disease among Children in 2004

BACKGROUNDnAs new rotavirus vaccines are being introduced in immunization programs, global and national estimates of disease burden, especially rotavirus-associated mortality, are needed to assess the potential health benefits of vaccination and to monitor vaccine impact.nnnMETHODSnWe identified 76 studies that were initiated after 1990, lasted at least 1 full year, and examined rotavirus among >100 children hospitalized with diarrhea. The studies were assigned to 5 groups (A-E) with use of World Health Organization classification of countries by child mortality and geography. For each group, the mean rotavirus detection rate was multiplied by diarrhea-related mortality figures from 2004 for countries in that group to yield estimates of rotavirus-associated mortality.nnnRESULTSnOverall, rotavirus accounted for 527,000 deaths (95% confidence interval, 475,000-580,000 deaths) annually or 29% of all deaths due to diarrhea among children <5 years of age. Twenty-three percent of deaths due to rotavirus disease occurred in India, and 6 countries (India, Nigeria, Congo, Ethiopia, China, and Pakistan) accounted for more than one-half of deaths due to rotavirus disease.nnnCONCLUSIONSnThe high mortality associated with rotavirus disease underscores the need for targeted interventions, such as vaccines. To realize the full life-saving potential of vaccines, it will be vital to ensure that they reach children in countries with high mortality. These baseline figures will allow future assessment of vaccine impact on rotavirus-associated mortality.

Global and regional estimates of cancer mortality and incidence by site: II. Results for the global burden of disease 2000.

BackgroundMortality estimates alone are not sufficient to understand the true magnitude of cancer burden. We present the detailed estimates of mortality and incidence by site as the basis for the future estimation of cancer burden for the Global Burden of Disease 2000 study.MethodsAge- and sex- specific mortality envelope for all malignancies by region was derived from the analysis of country life-tables and cause of death. We estimated the site-specific cancer mortality distributions from vital records and cancer survival model. The regional cancer mortality by site is estimated by disaggregating the regional cancer mortality envelope based on the mortality distribution. Estimated incidence-to-mortality rate ratios were used to back calculate the final cancer incidence estimates by site.ResultsIn 2000, cancer accounted for over 7 million deaths (13% of total mortality) and there were more than 10 million new cancer cases world wide in 2000. More than 60% of cancer deaths and approximately half of new cases occurred in developing regions. Lung cancer was the most common cancers in the world, followed by cancers of stomach, liver, colon and rectum, and breast. There was a significant variations in the distribution of site-specific cancer mortality and incidence by region.ConclusionsDespite a regional variation, the most common cancers are potentially preventable. Cancer burden estimation by taking into account both mortality and morbidity is an essential step to set research priorities and policy formulation. Also it can used for setting priorities when combined with data on costs of interventions against cancers.

No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths

OBJECTIVEnFewer than 3% of 4 million annual neonatal deaths occur in countries with reliable vital registration (VR) data. Global estimates for asphyxia-related neonatal deaths vary from 0.7 to 1.2 million. Estimates for intrapartum stillbirths are not available. We aimed to estimate the numbers of intrapartum-related neonatal deaths and intrapartum stillbirths in the year 2000.nnnMETHODSnSources of data on neonatal death included: vital registration (VR) data on neonatal death from countries with full (> 90%) VR coverage (48 countries, n = 97,297); studies identified through literature searches (> 4000 abstracts) and meeting inclusion criteria (46 populations, 30 countries, n = 12,355). A regression model was fitted to cause-specific proportionate mortality data from VR and the literature. Predicted cause-specific proportions were applied to the number of neonatal deaths by country, and summed to a global total. Intrapartum stillbirths were estimated using median cause-specific mortality rate by country (73 populations, 52 countries, n = 46,779) or the subregional median in the absence of country data.nnnFINDINGSnIntrapartum-related neonatal deaths were estimated at 0.904 million (uncertainty 0.65-1.17), equivalent to 23% of the global total of 4 million neonatal deaths. Country-level model predictions compared well with population-based data sets not included in the input data. An estimated 1.02 million intrapartum stillbirths (0.66-1.48 million) occur annually, comprising 26% of global stillbirths.nnnCONCLUSIONnIntrapartum-related neonatal deaths account for almost 10% of deaths in children aged under 5 years. Intrapartum stillbirths are a huge and invisible problem, but are potentially preventable. Programmatic attention and improved information are required.

Verbal autopsy: current practices and challenges

Cause-of-death data derived from verbal autopsy (VA) are increasingly used for health planning, priority setting, monitoring and evaluation in countries with incomplete or no vital registration systems. In some regions of the world it is the only method available to obtain estimates on the distribution of causes of death. Currently, the VA method is routinely used at over 35 sites, mainly in Africa and Asia. In this paper, we present an overview of the VA process and the results of a review of VA tools and operating procedures used at demographic surveillance sites and sample vital registration systems. We asked for information from 36 field sites about field-operating procedures and reviewed 18 verbal autopsy questionnaires and 10 cause-of-death lists used in 13 countries. The format and content of VA questionnaires, field-operating procedures, cause-of-death lists and the procedures to derive causes of death from VA process varied substantially among sites. We discuss the consequences of using varied methods and conclude that the VA tools and procedures must be standardized and reliable in order to make accurate national and international comparisons of VA data. We also highlight further steps needed in the development of a standard VA process.

Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015

BACKGROUNDnGlobal efforts have increased the accuracy and timeliness of estimates of under-5 mortality; however, these estimates fail to use all data available, do not use transparent and reproducible methods, do not distinguish predictions from measurements, and provide no indication of uncertainty around point estimates. We aimed to develop new reproducible methods and reanalyse existing data to elucidate detailed time trends.nnnMETHODSnWe merged available databases, added to them when possible, and then applied Loess regression to estimate past trends and forecast to 2015 for 172 countries. We developed uncertainty estimates based on different model specifications and estimated levels and trends in neonatal, post-neonatal, and childhood mortality.nnnFINDINGSnGlobal under-5 mortality has fallen from 110 (109-110) per 1000 in 1980 to 72 (70-74) per 1000 in 2005. Child deaths worldwide have decreased from 13.5 (13.4-13.6) million in 1980 to an estimated 9.7 (9.5-10.0) million in 2005. Global under-5 mortality is expected to decline by 27% from 1990 to 2015, substantially less than the target of Millennium Development Goal 4 (MDG4) of a 67% decrease. Several regions in Latin America, north Africa, the Middle East, Europe, and southeast Asia have had consistent annual rates of decline in excess of 4% over 35 years. Global progress on MDG4 is dominated by slow reductions in sub-Saharan Africa, which also has the slowest rates of decline in fertility.nnnINTERPRETATIONnGlobally, we are not doing a better job of reducing child mortality now than we were three decades ago. Further improvements in the quality and timeliness of child-mortality measurements should be possible by more fully using existing datasets and applying standard analytical strategies.

Global and regional estimates of cancer mortality and incidence by site: I. Application of regional cancer survival model to estimate cancer mortality distribution by site

BackgroundThe Global Burden of Disease 2000 (GBD 2000) study starts from an analysis of the overall mortality envelope in order to ensure that the cause-specific estimates add to the total all cause mortality by age and sex. For regions where information on the distribution of cancer deaths is not available, a site-specific survival model was developed to estimate the distribution of cancer deaths by site.MethodsAn age-period-cohort model of cancer survival was developed based on data from the Surveillance, Epidemiology, and End Results (SEER). The model was further adjusted for the level of economic development in each region. Combined with the available incidence data, cancer death distributions were estimated and the model estimates were validated against vital registration data from regions other than the United States.ResultsComparison with cancer mortality distribution from vital registration confirmed the validity of this approach. The model also yielded the cancer mortality distribution which is consistent with the estimates based on regional cancer registries. There was a significant variation in relative interval survival across regions, in particular for cancers of bladder, breast, melanoma of the skin, prostate and haematological malignancies. Moderate variations were observed among cancers of colon, rectum, and uterus. Cancers with very poor prognosis such as liver, lung, and pancreas cancers showed very small variations across the regions.ConclusionsThe survival model presented here offers a new approach to the calculation of the distribution of deaths for areas where mortality data are either scarce or unavailable.

Setting international standards for verbal autopsy

In many countries most deaths occur at home. Such countries often have civil registration systems that are limited or non-existent and therefore most deaths go unrecorded. Countries that cannot record the number of people who die or why they die cannot realize the full potential of their health systems. Health systems need reliable numbers and causes of death to function properly. But in these circumstances – in the absence of a complete picture of the population’s health – there are tools and techniques that can be used to obtain a fairly accurate representation of mortality trends. n nIt takes a long time for countries to achieve a fully functioning civil registration system with medical certification of cause of death. In the meantime, more and more countries are using verbal autopsies (VA) to meet the information needs of their health systems.1 Verbal autopsy is a method of ascertaining probable causes of a death based on an interview with primary caregivers about the signs, symptoms and circumstances preceding that death. n nDifferent institutions have been researching and developing all aspects of the verbal autopsy process over the past two decades. We have also been working on this process, particularly to improve the questionnaire and the methods of analysing the resulting information. However, this has been a largely uncoordinated effort and one that has not reached consensus on what to cover in the interview and how to analyse the results, despite previous attempts to promote standard tools.2–4 The main consequence of this failure to agree on a standard approach is that now we cannot compare results from different countries. Currently, 36 Demographic Surveillance Sites (DSS) in 20 countries, the Sample Registration System (SRS) sites in India, and the Disease Surveillance Points (DSP) in China regularly use VA on a large scale, primarily to assess the causes-of-death structure of a defined population.1 Despite such a widespread use of verbal autopsy, we are unable to assess how consistent and reliable the data are. We are also unable to replicate procedures used to assign cause of death. Because verbal autopsy data sets are not widely shared, it is impossible to independently assess the quality of the assignment. Really useful validation studies are rare and verbal autopsy research is often done on small and non-representative samples of the population. n nThe Millennium Development Goals (MDG) have put pressure on countries to track their progress in terms of population health. But to track that progress, countries need reliable numbers. In other words, they need a strong empirical basis for cause-specific mortality data. This is essential for evaluating the impact of disease control programmes and major global health initiatives. One way of dealing with incomplete information is to use models of mortality patterns. But cause-of-death information predicted by such models is not suitable for monitoring progress on what works and what does not.5 That leaves verbal autopsy as the only practical option in these countries and one that will play a key role in tracking progress towards the MDGs. Agreement on a core set of verbal autopsy tools (including technical standards and guidelines for their use) and their widespread adoption is needed now. n nTo tackle this challenge, WHO led an expert group of researchers, data users, and other stakeholders, with sponsorship from the Health Metrics Network (HMN), in developing the necessary standards. The expert group systematically reviewed, debated, and condensed the accumulated experience and evidence from the most widely-used and validated procedures. This synthesis was done to achieve a high degree of consistency and comparability across verbal autopsy data sets. n nWHO has now published the results of this collaboration as: Verbal autopsy standards: ascertaining and attributing cause of death. n n nThe new standards include: n n nVerbal autopsy questionnaires for three age groups (under four weeks; four weeks to 14 years; and 15 years and above); n n nCause-of-death certification and coding resources consistent with the International Classification of Diseases and Related health Problems, tenth revision (ICD-10); and n n nA cause-of-death list for verbal autopsy prepared according to the ICD-10. n n n nThe content is freely available on the WHO web site (www.who.int) and will be distributed in print; and incorporated into HMN’s resource kit. n n nThis is an important publication, but it is not the last word on verbal autopsy methods. Research is needed to validate these standard core procedures in several countries with different patterns of mortality. Other areas of research include further development of items included in questionnaires, and automated methods for assigning causes of death from verbal autopsy that remove human bias, while producing replicable and valid results.6 Operational issues need addressing: sampling methods and size when using verbal autopsy tools in research demographic surveillance sites; sample or sentinel registration; censuses; and household surveys. Research is also required when adapting these questionnaires to specific situations in different countries, taking into account relevant cultural, epidemiological and administrative considerations. WHO is working with partners to do this research and develop guidelines on these issues. With time, this guidance and experience will better inform the users of verbal autopsy, and improve the comparability and consistency of its results. For the present, we urge that these new international consensus standards become the foundation of verbal autopsy practices wherever possible. ■

Interim measures for meeting needs for health sector data : births, deaths, and causes of death

Most developing countries do not have fully effective civil registration systems to provide necessary information about population health. Interim approaches—both innovative strategies for collection of data, and methods of assessment or estimation of these data—to fi ll the resulting information gaps have been developed and refined over the past four decades. To respond to the needs for data for births, deaths, and causes of death, data collection systems such as population censuses, sample vital registration systems, demographic surveillance sites, and internationally-coordinated sample survey programmes in combination with enhanced methods of assessment and analysis have been successfully implemented to complement civil registration systems. Methods of assessment and analysis of incomplete information or indirect indicators have also been improved, as have approaches to ascertainment of cause of death by verbal autopsy, disease modelling, and other strategies. Our knowledge of demography and descriptive epidemiology of populations in developing countries has been greatly increased by the widespread use of these interim approaches; although gaps remain, particularly for adult mortality. However,these approaches should not be regarded as substitutes for complete civil registration but rather as complements,essential parts of any fully comprehensive health information system. International organisations, national governments, and academia all have responsibilities in ensuring that data continue to be collected and that methods continue to be improved.