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DEPARTMENT
OF HEALTH & FAMILY WELFARE
|
|
HIMACHAL PRADESH
Himachal Burden of Disease
- A Study
|
1
Executive Summary:
1.
The total “Disability Adjusted Life Year “ (
2.
The total DALYs lost per 1000 population in Himachal Pradesh were
379 ,which was slightly higher than India (344 per 1000 population) and lower
(537 per 1000 population ) as compared to rural Andhra Pradesh. The
estimates of Himachal Pradesh are comparable to
3. Among the children (0-4 years), diarrhoeal diseases, low birth weight and lower respiratory infections are still the leading causes of disease burden.
4. Among the reproductive age group (15-45 years) ,road accidents ,other unintentional injuries, iron deficiency anemia, tuberculosis, chronic obstructed pulmonary diseases and upper respiratory infection are the leading causes of diseases burden.
5. Among the elderly (more than 60 years) ,the main causes of disease burden are cronic obstructed pulmonary disease, ischaemic heart disease ,tuberculosis ,asthma, other infectious diseases and other unintentional injuries.
6. The overall leading causes of disease burden in both sexes are chronic obstructed pulmonary disease, asthma iron deficiency anemia, dental caries ,other unintentional injuries and diarrhoeal diseases.
7. The premature mortality and disability (YLL:YLD) ratio is higher among males as compared to females in different age groups. It means that burden of disease is more contributed by the premature mortality compared to disability in them.
8. The common leading causes of premature mortality (YLL) in males and females are road accidents, diarrhoeal and other infectious diseases , ischaemic heart disease ,self inflicted and other unintentional injuries, tuberculosis and chronic obstructed pulmonary disease.
9. The common leading causes of disability (YLD) in both sexes are chronic obstructed pulmonary disease ,ischaemic heart disease, diarrhoeal diseases ,and other unintentional injuries.
The current analysis cannot be
considered to be exhaustive on any count but it certainly gives interesting
leads and suggestion for improvement. Deficiency in availability of local data
is highlighted to draw attention to the need for improving vital statistics,
cause of death and epidemiological
surveillance system. To overcome the inadequacy in available data ,a survey of
cause of death is being carried out in
2.
Introduction
The Global Burden of Disease (BOD)
was first estimated by Christopher Murray in 1992 with expectation that result
will help to bring about the reform in health sector ,planning and developments,
Burden of disease is now sought to be quantified by summary measures, which
combines information on mortality morbidity and disability.
The Word Bank in collaboration
with WHO sponsored the first BOD study by the team led by Christopher Murray to
provide the disease burden estimated for World Development Report 1993.The
general willingness to embark on estimation despite enormous deficiencies in
data, the tenacity to provide methodological solutions to indirectly estimate
epidemiological parameters, the use of internal consistency tools to seek more
plausible estimates and to lay emphasis on the overall picture rather than on
single diseases entity or solitary interventions were the main hallmark of
study. It provides lot of scope for health policy analysis. The study of disease
prevalence helps in decoupling epidemiological assessment from advocacy. The
single measure of the health outcomes enables comparison of cost effectiveness
of all interventions within the health sector.
Disability –Adjusted Life
Years(DALY) that includes both the mortality as well as the morbidity component
has been developed as the measurement unit for the global burden of disease
study. This was build upon the time based measures of health status that also
incorporated non-fatal health outcomes. It is a measure of health gap from a
chosen life expectancy in perfect health. Disability associated with the state
of perfect health or well being is assigned a weight of 0 and disability due
death is assigned a weight of 1.Annual incidence of DALY is computed from
demographic data like age and cause specific mortality as well as from the
descriptive epidemiological knowledge about the age of onset, incidence and
duration of different diseases. DALY estimation requires collaboration of skills
between experts from various disciplines having knowledge of economics,
demography and epidemiology. The incorporation of age weighting and discounting
in DALY measure has often been criticized. he formulation presented by
3.
Methodology:
3.1
General Demographic inputs for the estimation of disease burden in
Himachal Pradesh.
The population censes is the
natural source of the population data, but the census in our country is done
once in 10 years. If the reference years of the National Burden of Disease (NBD)
study coincides with the census year, then the figures mentioned in the census
can be taken and used straightway. Primarily census abstracts gives the total
population counts in five age groups. Thus it is necessary to arrive at age
–specific distribution of population becomes mandatory from which
interpolation can be done. In
3.2
Demographic profile for Himachal Pradesh
Himachal Pradesh has a total population of 60,77,247(2001 census).Average density of population is 109 persons/sq. Km. and ranges from 2 in district spiti & Lahaul to 369 in district Hamirpur. Majority of the population is rural (91.3%).Most of the villages have small dwellings with population less than 500 (81.5%).Only 5 villages have population greater than 5000.The state’s population tabulated by the five age groups seven age groups and five –years age groups are given in appendix1(A-C).
Fertility is gradually coming
down over the years as is evidenced by numerous surveys. The state has achieved
a considerable success in bringing down the CBR from 37.3/1000 in 1971 to
23.8/1000 as per SRS data 2001.(Table 1)
Table 1: Crude Birth Rate of
Himachal Pradesh from 1971-2001
|
Year |
CBR |
SOURCE |
|
1971 |
37.3 |
SRS |
|
1981 |
31.5 |
SRS |
|
1991 |
28.5 |
SRS |
|
1995 |
25.2 |
SRS |
|
2001 |
23.8 |
SRS |
3.2.2 Mortality
changes in Himachal Pradesh
Crude Death Rate (CDR) has been
declining gradually since 1971.It was 15.6/1000 in 1971,according to SRS
estimate in 2001 it is around 9/1000.
Table 2:Crude Death Rate of
|
Year |
CD |
SOURCE |
|
1971 |
15.6 |
SRS |
|
1981 |
11.5 |
SRS |
|
1991 |
9.4 |
SRS |
|
2001 |
9.0 |
SRS |
Reasonably accurate data on age
composition of local population helps in identifying closely related stable
population, by comparing the age composition of the local population with age
composition of the stable populations.
For
Group I includes infectious ,maternal ,prenatal and nutritional diseases.
Group II includes non-communicable and congenital diseases.
Group III includes injuries and accidents.
Age at death is the required input for calculation of YLL. Age at death(a) in each age interval is arrived at as follows:
A= Initial age of the interval + Ax-(x+n)
Where Ax-(x+n) = Average no. of years lived in the age interval by those dying during the interval x-(x+n).
Total DALYs lost /1000 persons
were estimated to be 379 for the year 2001 in Himachal Pradesh, which was lower
than the rural A.P. (537/1000 persons) and slightly higher than India as a
whole(344/1000 persons).
4.1 Top Ten Causes of Diseases Burden
|
Rank |
0-4 yrs |
5-14 yrs |
15-44 yrs |
45-59 yrs |
60 +yrs |
|
1 |
Diarrhoeal diseases |
Iron-deficiency anaemia |
Other unintentional injuries |
Chronic Obstructive Diseases |
Chronic Obstructive Pulmonary Disease |
|
2. |
Low birth weight |
Other unintentional injuries |
Road accident |
Other unintentional injuries |
Other unintentional injuries |
|
3. |
Lower Respiratory Infectious |
Asthma |
Iron –deficiency anaemia |
Ischaemic heart disease |
Other unintentional injuries |
|
4. |
Other infectious diseases |
Other infectious diseases |
Chronic Obstructive Pulmonary Diseases |
Tuberculosis |
Ischaemic heart disease |
|
5. |
Iron deficiency anaemia |
Diarrhoeal diseases |
Self-inflicted injury |
Road accident |
Tuberculosis |
|
6. |
Dental caries |
Otitis Media |
Tuberculosis |
Other infectious diseases |
Road accident |
|
7 |
Upper Respiratory Infections |
Dental caries |
Asthma |
Peptic ulcer |
Iron-deficiency anaemia |
|
8. |
Asthma |
Upper Respiratory Infections |
Other infectious diseases |
Iron deficiency anaemia |
Cataracts |
|
9. |
Otitis Media |
Lower Respiratory Infections |
Upper Respiratory Infections |
Asthma |
Asthma |
|
10 |
Other unintentional injuries |
Vitamine A Deficiency |
Dental carrier |
Dental carrier |
Dental carrier |
Table 4: Top ten causes of burden of diseases (
|
Rank |
0-4 yrs |
5-14 yrs |
15-44 yrs |
45-59 yrs |
60 +yrs |
|
1 |
Diarrhoeal diseases |
Iron-deficiency anaemia |
Iron-deficiency anaemia |
Chronic Obstructive Pulmonary Disease |
Chronic Obstructive Pulmonary Disease |
|
2. |
Low birth weight |
Diarrhoeal diseases |
Other unintentional injuries |
Iron-deficiency anaemia |
Other infectious diseases |
|
3. |
Other infectious diseases |
Other infectious diseases |
Chronic Obstructive Pulmonary Disease |
Other unintentional injuries |
Other unintentional injuries |
|
4. |
Lower Respiratory Infectious |
Other unintentional injuries |
Self-inflicted injury |
Other infectious diseases |
Rheumatic heart disease |
|
5. |
Iron deficiency anaemia |
Otitis Media |
Tuberculosis |
Tuberculosis |
Ischaemic heart disease |
|
6. |
Dental caries |
Asthma |
Road accidents |
Ischaemic heart disease |
Iron-deficiency anaemia |
|
7 |
Upper Respiratory Infections |
Dental caries |
Peptic Ulcer |
Dental caries |
Dental caries |
|
8. |
Otitis Media |
Road accident |
Dental caries |
Asthma |
Diarrhoeal diseases |
|
9. |
Other unintentional injuries |
Upper Respiratory Infections |
Lower Respiratory Infections |
Road accident |
Tuberculoses |
|
10 |
Other digestive injuries |
Lower Respiratory Infections |
Other infectious diseases |
Cataracts |
Asthma |
Table 5: Leading causes of diseases burden (DALY) in male and female of Himachal Pradesh.
|
Male |
% |
Female |
% |
|
Chronic Obstructive Pulmonary Disease |
15.22 |
Iron deficiency anemia |
12.95 |
|
Iron deficiency anemia |
8.28 |
Chronic Obstructive Pulmonary Disease |
11.03 |
|
Other unintentional injuries |
7.14 |
Diarrhoeal diseases |
8.39 |
|
Dental caries |
4.13 |
Other unintentional injuries |
8.16 |
|
Diarrhoeal diseases |
3.59 |
Other infectious diseases |
7.48 |
|
Asthma |
3.46 |
Dental caries |
4.70 |
|
Other infectious diseases |
3.05 |
Asthma |
3.77 |
|
Upper Respiratory Infections |
2.80 |
Tuberculosis |
3.61 |
|
Lower Respiratory Infections |
1.89 |
Road accident |
3.46 |
|
Otitis media |
1.33 |
Upper Respiratory Infections |
3.07 |


Table
6 : Leading
|
Rank |
0-4 yrs |
05-14 yrs |
15-44 yrs |
45-59 yrs |
60+yrs |
All age group |
|
1 |
Diarrhoeal diseases |
Iron deficiency anaemia |
Iron deficiency anaemia |
Chronic Obstructive
Pulmonary Diseases |
Chronic Obstructive
Pulmonary Diseases |
Chronic Obstructive
Pulmonary Diseases |
|
2 |
Lower birth weight |
Other unintentional
injuries |
Other unintentional
injuries |
Other unintentional
injuries |
Other infectious diseases |
Iron deficiency anaemia |
|
3 |
Other infectious diseases |
Diarrhoeal diseases |
Road accidents |
Ischaemic heart diseases |
Other unintentional
injuries |
Other unintentional
injuries |
|
4 |
Lower Respiratory Infection |
Other infectious diseases |
Chronic Obstructive
Pulmonary Diseases |
Iron deficiency anaemia |
Ischaemic heart diseases |
Diarrhoeal diseases |
|
5 |
Iron deficiency anaemia |
Asthma |
Self inflicted injury |
Tuberculosis |
Cataracts |
Other infectious diseases |
|
6 |
Dental caries |
Otitis Media |
Tuberculosis |
Other infectious diseases |
Iron deficiency anaemia |
Road accidents |
|
7 |
Upper Respiratory Infection |
Dental caries |
Asthma |
Road accidents |
Tuberculosis |
Dental caries |
|
8 |
Otitis Media |
Upper Respiratory Infection |
Other infectious diseases |
Dental caries |
Dental caries |
Asthma |
|
9 |
Asthma |
Road accidents |
Upper Respiratory Infection |
Asthma |
Road accidents |
Tuberculosis |
|
10 |
Other unintentional
injuries |
Upper Respiratory Infection |
Dental caries |
Peptic ulcer |
Diarrhoeal diseases |
Ischaemic heart diseases |
4.2 Ratio of YLL and YLD
The YLL:YLD ratio in different
age group is shown in figure 5 .The YLL:YLD ratio is higher (1.01:1) in 0-4yrs
age group.This is mostly due to premature mortlity,which can be inferred from
high YLL to YLD ratio in 0-4 age group.In adult age group of 15-44,the situation
gets reversed (0.62:1.0).
Figure 5: DALYs as YLL & YLD in different age groups

Figure 6 : YLL:YLD Ratio by age sex groups, H.P.

Table
7: Leading causes of premature mortality (YLL) in male and Female of Himachal
Pradesh
|
Male |
% |
Female |
% |
|
Road accident |
12.75 |
Diarrhoeal diseases |
13.25 |
|
Diarrhoeal diseases |
10.77 |
Other unintentional injuries |
11.32 |
|
Other unintentional injuries |
9.34 |
Road accident |
9.67 |
|
Ischaemic heart diseases |
9.09 |
Lower birth weight |
9.23 |
|
Tuberculosis |
6.54 |
Tuberculosis |
8.32 |
|
Lower birth weight |
5.85 |
Ischaemic heart diseases |
7.87 |
|
Self inflicted injury |
5.78 |
Self inflicted injury |
7.44 |
|
Other unintentional injuries |
5.48 |
Other unintentional injuries |
6.23 |
|
Chronic Obstructive
Pulmonary Diseases |
4.12 |
Other digestive diseases |
4.82 |
|
Other digestive diseases |
3.32 |
Chronic Obstructive Pulmonary Diseases |
3.55 |
Table 8: Leading causes of disability (YLD) in male and female of
Himachal Pradesh
|
Male |
% |
Female |
% |
|
Chronic Obstructive
Pulmonary Diseases |
26.09 |
Iron deficiency anaemia |
20.13 |
|
Iron deficiency anaemia |
14.19 |
Chronic Obstructive Pulmonary Diseases Other unintentional injuries |
17.15 |
|
Other unintentional injuries |
12.24 |
Diarrhoeal diseases |
13.04 |
|
Dental caries |
7.08 |
Other unintentional injuries |
12.68 |
|
Diarrhoeal diseases |
6.15 |
Other infectious diseases |
11.64 |
|
Asthma |
5.92 |
Dental caries |
7.31 |
|
Other unintentional injuries |
5.23 |
Asthma |
5.87 |
|
Upper Respiratory Infection |
4.80 |
Tuberculosis |
5.61 |
|
Lower Respiratory Infection |
3.24 |
Road accident |
5.38 |
|
Otitis media |
2.28 |
Upper Respiratory
Infection |
4.78 |
Distribution of
deaths by broad cause groups indicates that the higher proportion of deaths took
place in group I (42.8%) i.e. infectious including perinatal and nutritional
diseases followed by group II (39.2 %) i.e. injuries and accidents as shown in
figure 7 .The pattern shows about the transition phase that the state is
undergoing. Non –communicable diseases are gradually emerging as the result of
the ongoing demographic transition leading to rising longevity. Simultaneously
infections and communicable diseases are still accounting for heavy mortality
and morbidity.
Figure
7: Distribution of different broad cause groups of diseases burden

Group II includes non-communicable and congenital diseases.
Group III includes
injuries and accidents.
A brief account of main causes of disease burden in different group of causes is given below.
Group I causes (infections, maternal ,prenatal and nutritional diseases)
The leading cause of diseases burden among males and females due to group I diseases are :
1. The major causes in this group include diarrhoeal diseases, other infectious diseases, low birth weight and ARI .This indicates a profound gap in safe motherhood and child survival interventions that require immediate attention.
2. Tuberculosis continues to be one of the leading causes of burden in both sexes despite having a national programme for control of this major public health problem.
3. There is no record of maternal deaths in reproductive age group ,which is to be taken with caution.


Group II causes(non –communicable and congenital diseases)
1. It was observed that ischaemic heart diseases ,COPD and digestive disorders are the common causes of burden in both the sexes.
2. Among cancers, cancer breast and cancer of the genito urinary tract are the leading cause of death among females whereas stomach cancer and liver cancer are the major causes in males.
3.
Diabetes mellitus is also among the ten leading cause of death in
both sex.
All this calls for
changes in both life style and behavior and inculcating healthy habits.
Figure
10:Leading cause burden of diseases (

Figure
!!: Leading cause burden of diseases (

The leading cause
of burden of disease among males and female in group III are :
1. Both among the males and females road accidents traffic (RTA) is the leading cause of death. WHO estimates that for every single death due to RTA there will be about 10 persons with major injuries and another 50 with minor injuries.
2.
Suicide and falls are other major causes of mortality in this
group.
Figure
12: Leading cause of burden among
Males in group III


5.
Summary:
The burden of
Disease estimates study was undertaken in the state of
1 The total disability adjusted life (DALYs) lost in Himachal Pradesh were 2305295; 55.8 % (1288461) were lost in males and 44.1% (1016834) in females.
2
The total DALYs lost per 1000 population Himachal Pradesh were 379
,which was slightly higher than
3 Among the children (0-4 years),diarrhoeal diseases, low birth weight and lower respiratory infections are still the leading causes of disease burden.
4 Among the reproductive age group (15-45 years),road accidents, other unintentional injuries, iron deficiency anemia, tuberculosis, chronic obstructed pulmonary disease and upper respiratory infection are the leading cause of disease burden.
5 Among the elderly (more than 60 years),the main cause of disease burden are chronic obstructed pulmonary disease, ischaemic heart disease, tuberculosis, asthma ,other infectious diseases and other unintentional injuries.
6 The overall leading cause of disease burden in both sexes are chronic obstructed pulmonary disease, asthma ,iron deficiency anemia ,dental caries ,other unintentional injuries and diarrhoeal diseases.
7 The premature mortality and disability (YLL:YLD) ratio is higher among males as compared to females in different age groups. It means that burden of disease is more contributed by the premature mortality’s compared to disability in them.
8 The common leading cause of premature mortality (YLL) in males and females are road accidents, diarrhoeal and other infectious diseases, ischaemic heart disease ,self inflicted injuries and other unintentional injuries, tuberculosis and chronic obstructed pulmonary disease.
9
The common leading cause of disability (YLD) in both sexes is
chronic obstructed pulmonary disease, ischaemic heart disease, diarrhoeal
diseases and other unintentional injuries.
6.
Limitations of the study
1. the current analysis cannot be considered to be exhaustive on any count but it certainly gives interesting leads and suggestion for improvement.
2. Deficiency in availability of local data is highlighted to draw attentions to the need for improving vital statistics, cause of death and epidemiological surveillance system.
3. In the survey of cause of death(rural),numbers of death reported were 714 in 1996 ,729 in year 1997 and 331 in 1998 in Himachal Pradesh. We were unable to get the detailed cause of these deaths from SRS as the sample size was very less as per RGI and it was difficult to classify them properly.
4. We have used annual report of the registration of births and deaths ,for the year 2000.We have taken date of the “death by cause medically certified or otherwise “,but in this data death due to unclassified causes were 60.8% (19591 out of 32213).This was the major reason that we have stared a sample survey to collect primary data on the causes of deaths using verbal autopsy ,which is taken to be completed by this year-end.
5.
Epidemiological estimates of the disease incidence and prevalence
have been taken Indian estimates in the Global Burden of Disease study 1996 done
by
6. For calculating YLD, morbidity reports for HP for the year 1999 was used ,as there were very few studies available on prevalence of various diseases .In this report, data according to age and sex was also not available.
7.
Health state valuation studies should be undertaken to assign the
disability weight and also to understand what the communities actually feels
about that particular disease. For the present study however the disability
weight has been taken from the GBD study.
7.
Future Plans:
This is the first draft of the estimation based on the available secondary data for the year 2001.To overcome the inadequacy in available data ,a survey of cause of death is being carried out in Himachal Pradesh by using 30 cluster techniques covering approximately 1.5 lakhs population. By the end of August about 20 clusters have been covered and the rest are likely to be covered in next 2 months. The final estimates for burden of disease and recommendation will be made after the completion of this survey.
8.
Refeences:
· Sample Registration System (STRS) ,Registrar General ,India New Delhi ,for the years 1993-1998.
·
Survey of causes of Death(rural),
·
Compendium of
·
Health Information of
·
· Annual statistical report 2000,prepared by the Government of Himachal Pradesh.
·
·
· Census of Himachal Pradesh for the year 1991 and primary census abstruct for the year 2001.
·
World Development Report 1993,Investing in Health.