Taavi Lai

New Methodology for Estimating the Burden of Infectious Diseases in Europe

Mirjam Kretzschmar and colleagues describe the BCoDE project, which uses a pathogen-based incidence approach to better estimate the infectious disease burden in Europe.

The state of the art in European research on reducing social exclusion and stigma related to mental health: A systematic mapping of the literature

Stigma and social exclusion related to mental health are of substantial public health importance for Europe. As part of ROAMER (ROAdmap for MEntal health Research in Europe), we used systematic mapping techniques to describe the current state of research on stigma and social exclusion across Europe. Findings demonstrate growing interest in this field between 2007 and 2012. Most studies were descriptive (60%), focused on adults of working age (60%) and were performed in Northwest Europe-primarily in the UK (32%), Finland (8%), Sweden (8%) and Germany (7%). In terms of mental health characteristics, the largest proportion of studies investigated general mental health (20%), common mental disorders (16%), schizophrenia (16%) or depression (14%). There is a paucity of research looking at mechanisms to reduce stigma and promote social inclusion, or at factors that might promote resilience or protect against stigma/social exclusion across the life course. Evidence is also limited in relation to evaluations of interventions. Increasing incentives for cross-country research collaborations, especially with new EU Member States and collaboration across European professional organizations and disciplines, could improve understanding of the range of underpinning social and cultural factors which promote inclusion or contribute toward lower levels of stigma, especially during times of hardship.

The pathogen- and incidence-based DALY approach: An appropriated methodology for estimating the burden of infectious diseases

In 2009, the European Centre for Disease Prevention and Control initiated the ‘Burden of Communicable Diseases in Europe (BCoDE)’ project to generate evidence-based and comparable burden-of-disease estimates of infectious diseases in Europe. The burden-of-disease metric used was the Disability-Adjusted Life Year (DALY), composed of years of life lost due to premature death (YLL) and due to disability (YLD). To better represent infectious diseases, a pathogen-based approach was used linking incident cases to sequelae through outcome trees. Health outcomes were included if an evidence-based causal relationship between infection and outcome was established. Life expectancy and disability weights were taken from the Global Burden of Disease Study and alternative studies. Disease progression parameters were based on literature. Country-specific incidence was based on surveillance data corrected for underestimation. Non-typhoidal Salmonella spp. and Campylobacter spp. were used for illustration. Using the incidence- and pathogen-based DALY approach the total burden for Salmonella spp. and Campylobacter spp. was estimated at 730 DALYs and at 1,780 DALYs per year in the Netherlands (average of 2005–2007). Sequelae accounted for 56% and 82% of the total burden of Salmonella spp. and Campylobacter spp., respectively. The incidence- and pathogen-based DALY methodology allows in the case of infectious diseases a more comprehensive calculation of the disease burden as subsequent sequelae are fully taken into account. Not considering subsequent sequelae would strongly underestimate the burden of infectious diseases. Estimates can be used to support prioritisation and comparison of infectious diseases and other health conditions, both within a country and between countries.

Measuring burden of disease in Estonia to support public health policy

BACKGROUND Many countries have an overview on mortality and morbidity but few have performed contextualized national burden of disease studies. The objective of the present study is to provide a first set of national and sub-national burden of disease estimates for Estonia. Further, we present the causes and age-gender distribution of the burden. We conclude with the description of result uptake and impact of the study in Estonian public health policy arena. METHODS A burden of disease estimation procedure modified for best fit to country situation was used. That included disease classification reflecting Estonian disease profile, national disease severity assessments, mortality and morbidity prevalence data. Calculations were performed on national and sub-national levels. RESULTS Estonian population lost 446 361 (327/1000 persons) disability adjusted life-years in 2002. Premature mortality caused majority of the burden and cardiovascular diseases, external causes (e.g. suicide and injuries) and cancers were main sources of burden. Working age population (16-64 years) shouldered 60% of the burden. Sub-national levels of burden range from 114 to 725 disability adjusted life-years per 1000 persons and are correlated to regional socioeconomic development. CONCLUSION Cardiovascular disease and injuries, premature mortality, working age population, male and people from economically less developed regions should be the priority targets for public health interventions. Estonian main public health strategies now address burden of disease concerns highlighted by our study.

Health impact assessment of particulate pollution in Tallinn using fine spatial resolution and modeling techniques

BackgroundHealth impact assessments (HIA) use information on exposure, baseline mortality/morbidity and exposure-response functions from epidemiological studies in order to quantify the health impacts of existing situations and/or alternative scenarios. The aim of this study was to improve HIA methods for air pollution studies in situations where exposures can be estimated using GIS with high spatial resolution and dispersion modeling approaches.MethodsTallinn was divided into 84 sections according to neighborhoods, with a total population of approx. 390 000 persons. Actual baseline rates for total mortality and hospitalization with cardiovascular and respiratory diagnosis were identified. The exposure to fine particles (PM2.5) from local emissions was defined as the modeled annual levels. The model validation and morbidity assessment were based on 2006 PM10 or PM2.5 levels at 3 monitoring stations. The exposure-response coefficients used were for total mortality 6.2% (95% CI 1.6–11%) per 10 μg/m3 increase of annual mean PM2.5 concentration and for the assessment of respiratory and cardiovascular hospitalizations 1.14% (95% CI 0.62–1.67%) and 0.73% (95% CI 0.47–0.93%) per 10 μg/m3 increase of PM10. The direct costs related to morbidity were calculated according to hospital treatment expenses in 2005 and the cost of premature deaths using the concept of Value of Life Year (VOLY).ResultsThe annual population-weighted-modeled exposure to locally emitted PM2.5 in Tallinn was 11.6 μg/m3. Our analysis showed that it corresponds to 296 (95% CI 76528) premature deaths resulting in 3859 (95% CI 10236636) Years of Life Lost (YLL) per year. The average decrease in life-expectancy at birth per resident of Tallinn was estimated to be 0.64 (95% CI 0.17–1.10) years. While in the polluted city centre this may reach 1.17 years, in the least polluted neighborhoods it remains between 0.1 and 0.3 years. When dividing the YLL by the number of premature deaths, the decrease in life expectancy among the actual cases is around 13 years. As for the morbidity, the short-term effects of air pollution were estimated to result in an additional 71 (95% CI 43–104) respiratory and 204 (95% CI 131–260) cardiovascular hospitalizations per year. The biggest external costs are related to the long-term effects on mortality: this is on average €150 (95% CI 40–260) million annually. In comparison, the costs of short-term air-pollution driven hospitalizations are small €0.3 (95% CI 0.2–0.4) million.ConclusionSectioning the city for analysis and using GIS systems can help to improve the accuracy of air pollution health impact estimations, especially in study areas with poor air pollution monitoring data but available dispersion models.

Decline in Alcohol Consumption in Estonia: Combined Effects of Strengthened Alcohol Policy and Economic Downturn

AIMS To describe alcohol policy changes in parallel to consumption changes in 2005-2010 in Estonia, where alcohol consumption is among the highest in Europe. METHODS Review of pertinent legislation and literature. RESULTS Alcohol consumption decreased since 2008, while alcohol excise tax, sales time restrictions and ad bans have increased since 2005. An economic downturn started in 2008. CONCLUSION The precise roles of policy changes and the economic downturn in the decline of alcohol consumption, and whether the decrease will be sustained, are still unclear.

Avoidable mortality in Estonia: Exploring the differences in life expectancy between Estonians and non-Estonians in 2005–2007

OBJECTIVES A considerable increase in social inequalities in mortality was observed in Eastern Europe during the post-communist transition. This study evaluated the contribution of avoidable causes of death to the difference in life expectancy between Estonians and non-Estonians in Estonia. STUDY DESIGN Descriptive study. METHODS Temporary life expectancy (TLE) was calculated for Estonian and non-Estonian men and women aged 0-74 years in 2005-2007. The ethnic TLE gap was decomposed by age and cause of death (classified as preventable or treatable). RESULTS The TLE of non-Estonian men was 3.53 years less than that of Estonian men, and the TLE of non-Estonian women was 1.36 years less than that of Estonian women. Preventable causes of death contributed 2.19 years to the gap for men and 0.78 years to the gap for women, while treatable causes contributed 0.67 and 0.33 years, respectively. Cardiorespiratory conditions were the major treatable causes of death, with ischaemic heart disease alone contributing 0.29 and 0.08 years to the gap for men and women, respectively. Conditions related to alcohol and substance use represented the largest proportion of preventable causes of death. CONCLUSIONS Inequalities in health behaviours underlie the ethnic TLE gap in Estonia, rather than inequalities in access to health care or the quality of health care. Public health interventions should prioritize primary prevention aimed at alcohol and substance use, and should be implemented in conjunction with wider social policy measures.

The incidence-based and pathogen-based disability-adjusted life-years approach for measuring infectious disease burden in Europe: the Burden of Communicable Diseases in Europe (BCoDE) project

Abstract Background Most estimates of disease burden due to infectious diseases focus on the impact of acute infections and do not fully capture the effects of (long-term) sequelae. To provide evidence-based and comparable estimates, the European Centre for Disease Prevention and Control (ECDC) initiated the Burden of Communicable Diseases in Europe (BCoDE) project. Methods Disability-adjusted life-years (DALYs) were used in an incidence-based and pathogen-based approach to accommodate infectious disease characteristics. This approach involves outcome trees representing the natural history of diseases and links future sequelae to the initial infection by conditional probabilities. For calculating years of life lost (YLLs), life expectancy at birth for males and females was set to 79·9 and 82·5 years, respectively (Global Burden of Disease [GBD] 2004 study standards). For YLLs due to disability, disability weights were taken from the 2004 GBD study and from additional sets or proxies. Multiplication factors (MFs) were used to adjust for underestimation of country-specific incidences (average reported cases 2005–2007). Disease models for 32 pathogens were built in Excel, where @Risk was used to model uncertainty. No time discounting or age weighting was applied. Findings Taking the example of hepatitis B in Germany, a loss of 7745 DALYs per year (95% CI 5527–10 256) was estimated, resulting in 9·4 DALYs per 100 000 (95% CI 6·7–12·4). 2·2% (170·4) of DALYs were due to acute infections. Chronic infections resulted in a loss of 2852 DALYs per year (95% CI 2455–3275). The disease burdens due to compensated liver cirrhosis, decompensated liver cirrhosis, and hepatocellular carcinoma were estimated at 637 DALYs per year (95% CI 478–792), 2150 DALYs per year (1294–3049), and 1790 DALYs per year (464–3376), respectively, together accounting for 59% (4577) of the overall DALYs. Interpretation The BCoDE methodology quantifies the burden of short-term and long-term sequelae due to present infection. Quality of notification data and choice of appropriate MFs are crucial as these are the most sensitive inputs. Funding The BCoDE consortium has been funded by the European Centre for Disease Prevention and Control (Specific agreement No. 1 to Framework Partnership Agreement GRANT/2008/003) for the conduct of burden of infectious disease studies in Europe. The funding source had no influence on writing the manuscript or on the decision to submit the abstract for publication. The corresponding author did not get any payment for writing the abstract from a pharmaceutical industry or other agency. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Country-Wide Health Impact Assessment of Airborne Particulate Matter in Estonia

This study is aimed to assess the health impacts of outdoor PM2.5 concentrations to entire population of Estonia. As the air quality monitoring network in Estonia is rather sparse (six urban, three rural and a few industrial sites), the exposure assessment was based on long-term modelling, controlled by monitoring data from existing stations. The model runs were performed with IairViro modelling system, including the Eulerian MATCH model for country-wide run with 5 km grid resolution and AirViro urban model with 200 m grid resolution for five major cities. The database of pollution sources includes industrial, transport and domestic heating emissions. The average annual PM2.5 concentrations were found 7–9 μg/m3 at most of rural and in 9–13 μg/m3 typically at urban areas, up to 30 μg/m3 in some parts of capital city Tallinn. To estimate the health risks, the base-line national health statistics and exposure-response coefficients from previous epidemiological studies (ACS, APHEIS), were applied. It was found that on average 600 (CI 95 % 155–1,061) premature deaths per year are caused by PM2.5 pollution in Estonia, which has population nearly 1.3 million. On average 5 months of life are lost, maximum 14 months in some parts of Tallinn. About 900 additional hospitalizations due to pulmonary and cardiovascular diseases occur per year.