Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods: We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings: Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation: Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding: Bill & Melinda Gates Foundation

Mortality percentages related to heartwater and the economic impact of heartwater disease on large-scale commercial farms in Zimbabwe

A postal questionnaire asking for data concerning heartwater deaths was sent to all large-scale commercial farmers in Zimbabwe's lowveld, where heartwater is endemic. One hundred and fifty returns (24 percent return rate) provided usable data, with 85 farms (57 percent of sample) reporting heartwater deaths in 1990/91. The median heartwater mortality percentage for calves (0.12 months) was 2.3 percent. This was statistically significantly different (Wilcoxon signed rank test, P<0.005) from the median mortality percentage of 0.6 percent for cattle 13 months and older. Heartwater accounted for 51 percent of all mortalities on farms reporting heartwater deaths. There were no meaningful correlations between farm or herd size and heartwater mortality percentages. A plot of the farms reporting heartwater deaths found that the heartwater endemic area in 1991 is essentially unchanged from 1979. Inspection of the geographic distribution of farms reporting heartwater showed no obvious patterns, and distances from communal land farms were not significantly correlated to heartwater mortality percentages. An economic model found that the annual financial impact of heartwater on large-scale commercial farms in Zimbabwe to be some Z$19.4 million (1991 prices). The upper bound, that allowed for inflation since 1991, was Z$33.4 million. The lower bound estimate was Z$8.1 million (Z$3 = US$1, 1991 rates). Eighty-nine percent of these costs can be attributed to the cost of dipping. Since it has been shown experimentally that the carrier state of heartwater may not affect the productivity of cattle, intensive dipping may not be the best means of controlling heartwater

Models for heartwater epidemiology: practical implications and suggestions for future research

We present a simple model of the dynamics of heartwater that we use to explore and better understand various aspects of this disease. We adapted the Ross-Macdonald model for malaria epidemiology so that we could consider both host and vector populations, and evaluate the interactions between the two. We then use two more biologically detailed models to examine heartwater epidemiology. The first includes a carrier state and host mortality, and the second includes density dependence. The results from all three models indicate that a stable equilibrium with high disease levels is probably the standard situation for heartwater (R0 between 5,7 and 22,4). More than 80% of cattle become infected with heartwater if only 12% of infected tick bites produce an infection in cattle, if tick burdens are as low as only five ticks per host per day, or if tick lifespans are as short as 7 d. A host recovery rate of 30 d results in over 50% of the cattle becoming infected with heartwater. Our analyses indicate that it is quite difficult to prevent the establishment and maintenance of high levels of heartwater in a herd, thereby supporting previous suggestions that any attempts at controlling this disease through stringent tick control regimens are not warranted.The articles have been scanned in colour with a HP Scanjet 5590; 600dpi. Adobe Acrobat X Pro was used to OCR the text and also for the merging and conversion to the final presentation PDF-format.UF/USAID/SADC Heartwater Research Project

The effect of subclinical experimental Cowdria ruminantium infection in ewes on the growth and milk consumption of pre-weaning lambs

An alternative control option for heartwater (Cowdria ruminatium infection) is the establishment and maintenance of endemic stability which would lessen the existing dependence on acaricides. In an endemically stable state, animals become infected by vaccination or natural challenge at an early age, following which the immunity so created is boosted by continuing tick challenge. In this study, growth rates, health and hematological parameters were monitored at regular intervals for lambs born to two matched groups of ewes until weaning at 4 mo of age. One group of ewes was infected multiple times with Cowdria ruminantium; the other group remained uninfected. The overall mean leucocyte count of lambs born to infected ewes was significantly lower than that of lambs born to uninfected ewes (P=0.04). However, there were few other significant differences in the other hematological data between the two groups. The mean birth weight of single lambs born to unifected ewes (4.6 kg) was significantly higher than the mean birth weight of single lambs born to infected ewes (4.4 kg) (P=0.02). Trends in milk consumption and growth rates were similar for the two groups, with few significant differences detected. Likewise, there were no significant differences in the incidences of health problems or pre-weaning mortalities between the two groups of lambs. The results of this study indicate that there is no detectable effect on productivity of pre-weaning lambs when their dams are carriers of C. ruminantium - a situation likely to occur in an endemically stable state. Hence, maintenance of endemic stability would be a suitable control option for heartwater

The effect of subclinical experimental Cowdria ruminantium infection on the health and reproductive performance of breeding ewes

This study documented the effect on the productivity of Dorper-Merino cross ewes when they became infected with Cowdria ruminantium as would occur in an endemically stable state. A flock of 152 breeding ewes was randomly divided into two matched groups. One group was infected on multiple occasions with C. ruminantium; the other group remained uninfected. The ewes were bred and monitored for one breeding/lambing/weaning cycle. Hematological, reproductive, and health parameters were recorded at regular intervals. Statistically significant differences in hematological values between the two groups were infrequent and transient. No significant differences in weights, mortality rates or reproductive parameters were detected between the two groups. Subclinical C. rumiantium infection did not negatively affect health and reproductive performance of breeding ewes; endemic stability would be a suitable alternative method of controlling heartwater