William Msemburi

Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study

BACKGROUND The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality. METHOD We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison. FINDINGS All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence. INTERPRETATION This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data. FUNDING South African Medical Research Councils Flagships Awards Project.

Second National Burden of Disease Study South Africa: national and subnational mortality trends, 1997–2009

Abstract Background Global Burden of Diseases, Injuries, and Risk Factors Study 2010 results show continued limitations of data quality and availability in most of the African region. Focused efforts in South Africa, however, have contributed to improved completeness and availability of mortality data, such that South Africa is currently undertaking a second National Burden of Disease Study. Mortality estimates have been developed nationally and for the nine provinces for 1997–2009. Methods Vital registration data obtained for 1997–2009 were adjusted for completeness using indirect demographic techniques. A regression approach was used to identify misclassified AIDS deaths, and garbage codes were proportionally redistributed by age, sex, and population group. Injury deaths were estimated from additional data sources. Age-standardised mortality rate (ASMR) trends for the nine provinces were calculated using ASSA 2008 population estimates and the WHO age standard. Findings All-cause mortality peaked in 2006 and thereafter started to decline. ASMRs showed a two-fold difference between the highest-affected and lowest-affected provinces for the 1997–2009 period. ASMR from HIV/AIDS increased threefold since 1997 with provincial variation, while mortality from non-HIV-related tuberculosis declined. Mortality rates from non-communicable diseases decreased over the period nationally but increased for some provinces and remained stable for others as a result of differing trends in hypertensive heart disease and respiratory diseases. Nationally, preliminary analyses for 2009 show that HIV/AIDS was responsible for the highest number of deaths (31·2%; n=194 322 of 622 300 deaths), followed by cerebrovascular disease (6·2%; n=38 666), tuberculosis (5·4%; n=33 375), lower respiratory infections (5·2%; n=32 568), and ischaemic heart disease (4·4%; n=27 688). However, tuberculosis and interpersonal violence ranked among the top five causes for males, while hypertensive heart disease and ischaemic heart disease featured for females. Interpretation The downward trend in HIV/AIDS mortality can be attributed to the extensive antiretroviral treatment rollout since 2005. Differential provincial mortality trends reflect the different stages of epidemiological transition and differential health services in the provinces, providing relevant information for policy makers to address inequalities. Funding South African Medical Research Council.

South African child deaths 1990-2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4?

Objective:To analyse trends in under-five mortality rate in South Africa (1990–2011), particularly the contribution of AIDS deaths. Methods:Three nationally used models for estimating AIDS deaths in children were systematically reviewed. The model outputs were compared with under-five mortality rate estimates for South Africa from two global estimation models. All estimates were compared with available empirical data. Results:Differences between the models resulted in varying point estimates for under-five mortality but the trends were similar, with mortality increasing to a peak around 2005. The three models showing the contribution of AIDS suggest a maximum of 37–39% of child deaths were due to AIDS in 2004–2005 which has since declined. Although the rate of progress from 1990 is not the 4.4% needed to meet Millennium Development Goal 4 for child survival, South Africas average annual rate of under-five mortality decline between 2006 and 2011 was between 6.3 and 10.2%. Conclusion:In 2005, South Africa was one of only four countries globally with an under-five mortality rate higher than the 1990 Millennium Development Goal baseline. Over the past 5 years, the country has achieved a rate of child mortality reduction exceeded by only three other countries. This rapid turnaround is likely due to scale-up of prevention of mother-to-child transmission of HIV, and to a lesser degree, the expanded roll-out of antiretroviral therapy. Emphasis on these programmes must continue, but failure to address other aspects of care including integrated high-quality maternal and neonatal care means that the decline in child mortality could stall.

Injury-related mortality in South Africa: a retrospective descriptive study of postmortem investigations.

Abstract Objective To investigate injury-related mortality in South Africa using a nationally representative sample and compare the results with previous estimates. Methods We conducted a retrospective descriptive study of medico-legal postmortem investigation data from mortuaries using a multistage random sample, stratified by urban and non-urban areas and mortuary size. We calculated age-specific and age-standardized mortality rates for external causes of death. Findings Postmortem reports revealed 52 493 injury-related deaths in 2009 (95% confidence interval, CI: 46 930–58 057). Almost half (25 499) were intentionally inflicted. Age-standardized mortality rates per 100 000 population were as follows: all injuries: 109.0 (95% CI: 97.1–121.0); homicide 38.4 (95% CI: 33.8–43.0; suicide 13.4 (95% CI: 11.6–15.2) and road-traffic injury 36.1 (95% CI: 30.9–41.3). Using postmortem reports, we found more than three times as many deaths from homicide and road-traffic injury than had been recorded by vital registration for this period. The homicide rate was similar to the estimate for South Africa from a global analysis, but road-traffic and suicide rates were almost fourfold higher. Conclusion This is the first nationally representative sample of injury-related mortality in South Africa. It provides more accurate estimates and cause-specific profiles that are not available from other sources.

Emerging trends in non-communicable disease mortality in South Africa, 1997 - 2010

OBJECTIVES National trends in age-standardised death rates (ASDRs) for non-communicable diseases (NCDs) in South Africa (SA) were identified between 1997 and 2010. METHODS As part of the second National Burden of Disease Study, vital registration data were used after validity checks, proportional redistribution of missing age, sex and population group, demographic adjustments for registration incompleteness, and identification of misclassified AIDS deaths. Garbage codes were redistributed proportionally to specified codes by age, sex and population group. ASDRs were calculated using mid-year population estimates and the World Health Organization world standard. RESULTS Of 594 071 deaths in 2010, 38.9% were due to NCDs (42.6% females). ASDRs were 287/100 000 for cardiovascular diseases (CVDs), 114/100 000 for cancers (malignant neoplasms), 58/100 000 for chronic respiratory conditions and 52/100 000 for diabetes mellitus. An overall annual decrease of 0.4% was observed resulting from declines in stroke, ischaemic heart disease, oesophageal and lung cancer, asthma and chronic respiratory disease, while increases were observed for diabetes, renal disease, endocrine and nutritional disorders, and breast and prostate cancers. Stroke was the leading NCD cause of death, accounting for 17.5% of total NCD deaths. Compared with those for whites, NCD mortality rates for other population groups were higher at 1.3 for black Africans, 1.4 for Indians and 1.4 for coloureds, but varied by condition. CONCLUSIONS NCDs contribute to premature mortality in SA, threatening socioeconomic development. While NCD mortality rates have decreased slightly, it is necessary to strengthen prevention and healthcare provision and monitor emerging trends in cause-specific mortality to inform these strategies if the target of 2% annual decline is to be achieved.

Persistent burden from non-communicable diseases in South Africa needs strong action

Continued effort and politcal will must be directed towards preventing, delaying the onset of and managing non-communicable diseases in South Africa.