INDICATORS TO MEASURE GLOBAL BURDEN

OF DISEASE - GBD
GLOBAL BURDEN OF DISEASE -
GBD
GLOBAL BURDEN OF DISEASE

 There are some 7 billion people in the world and hundreds of

millions experience disease or injury each year. Taken as a

whole, the combined pain, suffering, loss of productivity and
unrealized hopes and dreams are our world’s burden of
disease.

Dr. Zargari
GLOBAL BURDEN OF DISEASE

 The burden of disease approach is a systematic,

scientific effort to quantify the comparative

magnitude of health loss due to diseases, injuries,
and risk factors by age, sex, and geography for
specific points in time.

Dr. Zargari
GLOBAL BURDEN OF DISEASE

 The burden of disease can be thought of as a

measurement of the gap between current health

status and an ideal situation where everyone lives
into old age, free of disease and disability.

Dr. Zargari
GLOBAL BURDEN OF DISEASE

“Men do not think they know a thing until

they have grasped the why of it.”
 Aristotle

“The purpose of the research into the

global
burden of disease was not only to measure
and describe the health of the world but
also, and more important in many ways, to
explain why these events and phenomena
 Dr. A.D. Lopez
have occurred.”
Dr. Zargari
GLOBAL BURDEN OF DISEASE

 The Global Burden of Disease study, begun in 1992,

involved 100 collaborators in more than 20 countries. It

attempted to quantify disease and injury burden of over 100
conditions and make projections out 30 years for 500
consequences or results of these conditions.

Dr. Zargari
GLOBAL BURDEN OF DISEASE

 The Global Burden of Disease study, published in Science in 1996,

looked at the effect of disease not only on "lifespan" but also on "health
span" for the first time. They did so by moving beyond mortality rates
and creating a new measure called DALY. DALY stands for disability
adjusted life year and is a measure that expresses one year of life lost to
premature death and years lived with a disability of specified severity
and duration; one year of life lost to poor health.

Dr. Zargari
GLOBAL BURDEN OF DISEASE

 The Global Burden of Disease Study 2010 (GBD 2010) has three related

but distinct uses:

 to provide a coherent picture of which diseases, injuries, and risk factors contribute

the most to health loss in a given population;

 to compare population health across communities and over time;

 and to help guide an assessment of where health information systems are strong or

weak by identifying which data sources are missing, are of low quality, or are highly
uncertain

Dr. Zargari
 GLOBAL BURDEN OF DISEASE SURPRISES-
2020

 1. Rapid rise of chronic

disease  4. Alcohol and Tobacco
 73% of GBD by 2020  Tobacco #1 instigator

 2. High level mental illness  Fastest gain, underdeveloped

nations
 3.7% of GBD – depression
 5. Significant increase in
 3. Violence, war, injuries
cancer
 12% deaths worldwide  Number 1 killer in many countries
 41% deaths < 20 years, USA

Dr. Zargari
REASONS TO MEASURE BURDEN OF DISEASE

 Assign priorities between different public health problems.

 Compare strategies on a single public health problem in
terms of impact.
 Choose health interventions that target different health
problems with different strategies.

Dr. Zargari
HEALTH RISKS

 Although there are many possible definitions of

“health risk”, it is defined here as “a factor that

raises the probability of adverse health outcomes”.
The number of such factors is countless.

Dr. Zargari
BURDEN OF DISEASE AND GLOBAL RISK
FACTORS

 Five leading risk factors identified in this report (childhood

underweight, unsafe sex, alcohol use, unsafe water and

sanitation, and high blood pressure) are responsible for one
quarter of all deaths in the world, and one fifth of all DALYs.

Dr. Zargari
BURDEN OF DISEASE AND GLOBAL RISK
FACTORS

 The leading global risks for mortality in the world are:

 High blood pressure (responsible for 13% of deaths globally),
 Tobacco use (9%),
 High blood glucose (6%),
 Physical inactivity (6%), and
 Overweight and obesity (5%).

 These risks are responsible for raising the risk of chronic

diseases such as heart disease, diabetes and cancers. They
affect countries across all income groups: high, middle and
low.
Dr. Zargari
BURDEN OF DISEASE AND GLOBAL RISK
FACTORS

 The leading global risks for burden of disease as measured in disability-

adjusted life years (DALYs) are:
 Underweight (6% of global DALYs) and
 Unsafe sex (5%), followed by
 Alcohol use (5%) and
 Unsafe water, sanitation and hygiene (4%).

 Three of these risks particularly affect populations in low-income

countries, especially in the regions of South-East Asia and sub-Saharan
Africa. The fourth risk – alcohol use – shows a unique geographic and sex
pattern, with its burden highest for men in Africa, in middle-income
countries in the Americas and in some high-income countries.
Dr. Zargari
LIFE SPAN VS. HEALTH SPAN

 Lifespan
 Number of years lived

 Health Span
 Number of healthy years lived

 We increasingly appreciate that disease and disability can

significantly limit an individual's productivity and happiness
and radically alter individual, family and community well
being.

Dr. Zargari
 EXAMINING “LIFESPAN” AND “HEALTH SPAN”

Impact on: “Lifespan” “Health Span”

Cause % Total Deaths % Total

Disability

Malnutrition 11.7 15.9

Malnutrition is responsible for approximately 12% of total deaths worldwide,

radically altering global “lifespan,” but affects “health span” to an even greater
degree, contributing nearly 16% of the world’s total disability.
Source: Murray CJL, Lopez AD. Science 1996

Dr. Zargari
 FOUR KEY DRIVERS OF RAPID CHANGES IN
GLOBAL HEALTH PATTERNS

 Demographic transition – increasing population size,

substantial increase in the average age in most regions and falling
death rates.
 Cause of death transition – fraction of deaths or years of life lost
shifting from communicable, maternal, neonatal and nutritional to
non-communicable diseases and injuries despite the HIV
epidemic.
 Disability transition – steady shift to burden of disease from
diseases that cause disability but not substantial mortality.
 Risk transition – shift from risks related to poverty to behavioral
risks. Dr. Zargari
CHANGING DISEASE BURDEN
Changing Disease Burden
1990–2020

Expected to Decrease Expected to Increase

Lower respiratory infections Depression
Diarrheal disease Heart disease
Perinatal conditions Cerebrovascular disease
Measles Traffic accidents
Congenital anomalies Chronic obstructions/
Malaria pulmonary disease
Malnutrition War, violence, suicide
Anemia HIV
Lung cancer
Source: Murray CJL, Lopez AD. Science 1996;274:740–743

Dr. Zargari
CHANGE IN 20 LEADING CAUSES OF YLD AT
GLOBAL LEVELS, 2000 TO 2011

Dr. Zargari
THE GLOBAL BURDEN OF DISEASE

“The burden of disease is the great oppressor, perhaps the

single greatest cause of loss of personal freedom. Now, more
than any other time in human history, we can influence this
great oppressor with our actions. We have it within our
power to improve the health of people on the earth.”

– John Seffrin, PhD

CEO, American Cancer Society

Understanding the Burden of Disease. The Pfizer Journal. 2000

Dr. Zargari
DALY & QALY
DALY

 The disability-adjusted life year (DALY) is a measure of overall disease burden,

expressed as the number of years lost due to ill-health, disability or early death.
 DALY "extends the concept of potential years of life lost due to premature
death...to include equivalent years of 'healthy' life lost by virtue of being in states
of poor health or disability. In so doing, mortality and morbidity are combined
into a single, common metric.
One

Disability Adjusted Life Year

“One year lost to poor health.”

Dr. Zargari
DALY

 A DALY is a health outcome measure with two main

components
 Quality of life reduced due to a disability
 Lifetime lost due to premature mortality

 It is essential to understand what the DALY-concept measures

and how it is constructed. Burden is measured along two
dimensions: time lived with disability and time lost due to
premature mortality.

Dr. Zargari
DALYS DUE TO LIVING WITH DISABILITY

NO
DISABILITY
Years lived with “disability”-YLD

83 YEARS
Red area measures DALYs.
Red + white is a “normal” life

Dr. Zargari
DALYS DUE TO LIVING WITH DISABILITY

 The x-axis shows life expectancy for the 'normal' life. The "standardized"
maximum life span, 83 years for females and 80 years for males, is taken from
the country with the highest life expectancy in the world: Japan. The y-axis
shows degree of disability. The 'normal' life is quantified as the total area in the
box, a combination of the number of years lived and the quality of life, or degree
of disability. From this ideal state of the world it is possible to calculate the
burden of disease caused by premature death or disability.
 If for example a girl aged 5 happens to become a victim of a mine explosion
causing a below-knee amputation, and she does not die but is rehabilitated to a
health state with some loss of physical functioning, her DALY loss could be
depicted as the red area in the figure. Her loss is 78 years adjusted by a disability
weight i. If this weight is, say, 0.3, her loss is 0.3 x 78 = 23.4.

Dr. Zargari
DALYS DUE TO EARLY DEATH

NO
DISABILITY

Years of life
“lost”-YLL

83 YEARS
Red area measures DALYs.
Red + white is a standard life

Dr. Zargari
DALYS DUE TO EARLY DEATH

 Premature death from a myocardial infarction, say at

age 50, would produce the DALY-loss as depicted
by the read area in the figure. This patient’s loss is
33 years. No adjustment is made for disability
because the patient dies.

Dr. Zargari
YEARS OF LIFE LOST TO PRESENT DEATHS

Survival Life
 Information required
today expectancy
 Age at death
 Sex
 Country / region

 Estimating life expectancy Death Life

today expectancy
 Depends upon age, sex and region
 Obtained in Global Burden of Disease life tables Years of life lost

Years of life lost = Life expectancy - age at death

Dr. Zargari
DALYS DUE TO DISABILITY AND PREMATURE
DEATH COMBINED

NO
DISABILITY

This schematic illustration shows a woman who lives with a 83 YEARS

disability, for instance deafness from the age of 5 and dies
prematurely at the age of 50.

Dr. Zargari
DALY = YLL + YLD

 Traditionally, health liabilities were expressed using one measure: (expected or

average number of) 'Years of Life Lost' (YLL). This measure does not take the
impact of disability into account, which can be expressed by: 'Years Lived with
Disability' (YLD). DALYs are calculated by taking the sum of these two
components in a single formula: DALY = YLL + YLD.

Dr. Zargari
DALY=YLL(N X L)+YLD(I X DW X L)

 The YLL basically correspond to the number of deaths multiplied by the standard life
expectancy at the age at which death occurs. The basic formula for YLL is the following for
a given cause, age and sex:
YLL = N x L
N = number of deaths L = standard life expectancy at age of death in years
 To estimate YLD for a particular cause in a particular time period, the number of incident
cases in that period is multiplied by the average duration of the disease and a weight factor
that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). The
basic formula for YLD is the following (again, without applying social preferences):
YLD = I x DW x L
I = number of incident cases DW = disability weight L = average duration of the case . .

until remission or death (years)

Dr. Zargari
SAMPLE DALY CALCULATIONS DISEASES A
AND B

 A. 100,000 children are stricken for 1 week with a disability weighting

of 0.3; 2% die at 1 year old.
 B. 100,000 adults are stricken for 2 years with a disability weighting of
0.6; 20% die at 80 years old.
 A: YLL (= 2000 x 82) + YLD (=100,000 x (7/365) x 0.3) = 164,000 +
575.3 = 164,600
 B: YLL (= 100,000 x 3) + YLD (=100,000 x 2 x 0.6) = 300,000 +
120,000 = 420,000

Dr. Zargari
 ONE DALY

 The DALY relies on an acceptance that the most appropriate

measure of the effects of chronic illness is time, both time lost
due to premature death and time spent disabled by disease. One
DALY, therefore, is equal to one year of healthy life lost.
 One DALY can be thought of as one lost year of "healthy" life.
The sum of these DALYs across the population, or the burden of
disease, can be thought of as a measurement of the gap between
current health status and an ideal health situation where the
entire population lives to an advanced age, free of disease and
disability.

Dr. Zargari
WORLD DALY
Age-standardized disability-adjusted life year (DALY) rates from All Causes by country (per 100,000 inhabitants)

Dr. Zargari
CHRONIC DISEASES,
MAJOR CAUSE OF DALYS IN DEVELOPED WORLD-2020

Cause % Total DALY

All cardiovascular

18.6
All mental illness

15.4
All cancer

15.0
All respiratory
Source: Murray CJL, Lopez AD. Science 2006; 274:741
4.8
All alcohol

4.7 Dr. Zargari

DALY EXAMPLE

 Looking at the burden of disease via DALYs can reveal

surprising things about a population's health. For example,
the 1990 WHO report indicated that 5 of the 10 leading
causes of disability were psychiatric conditions. Psychiatric
and neurologic conditions account for 28% of all years lived
with disability, but only 1.4% of all deaths and 1.1% of years
of life lost. Thus, psychiatric disorders, while traditionally
not regarded as a major epidemiological problem, are shown
by consideration of disability years to have a huge impact on
populations.

Dr. Zargari
EXAMPLES OF DISABILITY WEIGHTS

1- 0-0.02 Vitiligo on face

2- 0.02-0.12 Diarrhea, sore throat
3- 0.12-0.24 Radius fracture in stiff cast
4- 0.24-0.36 Below the knee amputation
5- 0.36-0.5 Down syndrome, COPD
6- 0.5-0.7 Unipolar depression, tetanus
7- 0.7-1.00 Psychosis, quadriplegia

Dr. Zargari
SOME BASIC DEFINITIONS

 Impairment: loss or abnormality of psychological, physiological, or

anatomical structure or function
 Disability: any restriction or lack of ability to perform an activity in
the manner or within the range considered normal.
 Handicap: disadvantage resulting from impairment or disability that
limits or prevents the fulfillment of a role that is normal (depending
on age, sex, social, and cultural factors).

Dr. Zargari
DALYS AND QALYS

 DALY is a modification of QALY (Quality Adjusted Life Years). Both concepts

combine information about length of life and quality of life.
 A DALY is a negative QALY.
 Whereas DALYs represent a loss and should be minimized, QALYs represent a
gain and should be maximized.
 In the DALY approach, the years are disability weighted on a scale from zero,
which indicates perfect health (no disability), to one, which indicates death.
 In the QALY approach, the scale goes the opposite way: A quality weighting
(sometimes called “utility”) of 1 indicates perfect health, whereas 0 indicates no
quality of life, and is synonymous to death.

Dr. Zargari
QALY

 The quality-adjusted life year or quality-adjusted life-year

(QALY) is a measure of disease burden, including both the
quality and the quantity of life lived.
 The QALY is based on the number of years of life that would
be added by the intervention. Each year in perfect health is
assigned the value of 1.0 down to a value of 0.0 for being
dead. If the extra years would not be lived in full health, for
example if the patient would lose a limb, or be blind or have
to use a wheelchair, then the extra life-years are given a
value between 0 and 1 to account for this.
Dr. Zargari
QALY

 QALY takes into account both the quantity and quality of life
generated by healthcare interventions. It is the arithmetic
product of life expectancy and a measure of the quality of
the remaining life-years. A QALY places a weight on time in
different health states. A year of perfect health is worth 1
and a year of less than perfect health is worth less than 1.
Death is considered to be equivalent to 0; however, some
health states may be considered worse than death and have
negative scores.

Dr. Zargari
QALY

 QALY considers the age at which the disease or death occurs

and the duration and severity of any disability created.
Basically the number of fully healthy life years lost to a
particular disease or risk factor.
 The QALY method helps us measure these factors so that we
can compare different treatments for the same and different
conditions. A QALY gives an idea of how many extra
months or years of life of a reasonable quality a person
might gain as a result of treatment (particularly important
when considering treatments for chronic conditions).
Dr. Zargari
QALY

 A number of factors are considered when measuring

someone's quality of life, in terms of their health. They
include, for example, the level of pain the person is in, their
mobility and their general mood. The quality of life rating
can range from negative values below 0 (worst possible
health) to 1 (the best possible health).

Dr. Zargari
QALY

 Having used the QALY measurement to compare how much

someone's life can be extended and improved, we then
consider cost effectiveness - that is, how much the drug or
treatment costs per QALY. This is the cost of using the drugs
to provide a year of the best quality of life available - it
could be one person receiving one QALY, but is more likely
to be a number of people receiving a proportion of a QALY -
for example 20 people receiving 0.05 of a QALY.

Dr. Zargari
RELATION BETWEEN QALYS AND DALYS

NO
DISABILITY

83 YEARS
DALYs = healthy years lost
QALYs = healthy years gained

Dr. Zargari