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

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

Mortality trends and diff erentials 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 notifi cations 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 misclassifi ed 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 diff erences 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 diff erentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Diff erences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data

Reducing the Burden of Cervical Cancer in a Rural Setting of South Africa : Understanding the Incidence of this Disease and Building Infrastructure towards Intervention

Tarttumattomat sairaudet eli kansantaudit kattavat noin 40% tautitaakasta pieni- ja keskituloisissa maissa ja näiden sairauksien taakka kasvaa jatkuvasti. Kohdunkaulan syöpä on koko maailmassa ilmaantuvuudeltaan ja kuolleisuudeltaan naisten neljänneksi yleisin syöpä. Kohdunkaulan syöpä koskettaa erityisesti pieni- ja keskituloisia maita, joista Saharan eteläpuoleinen Afrikka on korkeimman ilmaantuvuuden alueita. Alueella on muitakin haasteita, kuten HIV-infektion leviäminen ja toimivan kohdunkaulasyövän seulontaohjelman puuttuminen. Etelä-Afrikka on ainoa maa Saharan eteläpuoleisessa Afrikassa, jossa naisilla on kansallisesti mahdollisuus hakeutua maksuttomaan kohdunkaulan irtosolutestiin (ns. Papa-testi) syövän esiasteiden ja varhaisen toteamisen mahdollistamiseksi. Tästä huolimatta kohdunkaulasyöpä on toiseksi yleisin syöpä ilmaantuvuudeltaan ja kuolleisuudeltaan ja vaikuttaa merkittävästi myös laatupainotettujen elinvuosien menetykseen. Irtosolutestiin perustuvan seulonnan huono toimivuus on yksi syy kohdunkaulasyövän korkeaan ilmaantuvuuteen. Väitöstutkimuksella haluttiin selvittää, onko väestön irtosolutestiin perustuva seulonta toimiva itäisen provinssin (Eastern Cape Province) alueen maaseutuväestössä. Tutkimuksella selvitettiin myös alueen kohdunkaulasyövän aiheuttama tautitaakka ilmaantuvuuden alueellisten erojen, seulonnan kattavuuden ja potilaiden elossaololukujen valossa. Tavoitteena on voida kehittää toimiva kohdunkaulasyövän ehkäisyohjelma. Itäisen provinssin väestöpohjaisen syöpärekisterin tietojen avulla tutkittiin kohdunkaulasyövän ilmaantuvuutta ja sen muutoksia kahdella maantieteellisellä alueella, eteläisellä ja pohjoisella. Vaikka koko itäisen provinssin alueella nähtiin kohdunkaulasyövän ikävakioidun ilmaantuvuuden selkeä ja jatkuva kasvu vuosista 1998-2002 vuosiin 2008-2012, eteläisellä osa-alueella ilmaantuvuus pysyi lähes ennallaan (arvosta 20/100 000 arvoon 19/100 000) ja pohjoisella osa-alueella se kasvoi merkittävästi (arvosta 24/100 000 arvoon 39/100 000). Kohdunkaulasyövän seulontaa kuvaamaan raportoitiin irtosolutestissä käyneiden 30-vuotiaiden tai sitä vanhempien naisten osuus kalenterivuoden ja alueen mukaisissa ositteissa. Testausta koskevat tiedot saatiin terveyspalveluiden käytön rutiiniseurantajärjestelmästä vuodesta 2007 alkaen. Irtosolutestauksessa käyneiden naisten osuus kaikista alueen 30-vuotta täyttäneistä naisista oli tietojen perusteella vähäinen pohjoisella alueella vuosina 2007-2009 ja saavutti vajaat 15% vuoteen 2012 mennessä. Eteläisen alueen kaksi terveysaluetta, Mbhashe ja Mnquma raportoivat selkeästi korkeamman seulonnan kattavuuden, vajaa 8% vuonna 2007 mutta jo 41% vuonna 2012. Itäisen provinssin väestölähtöinen syöpärekisteri on niitä harvoja Saharan eteläpuoleisen Afrikan rekistereitä, jotka ovat pystyneet raportoimaan syöpäilmaantuvuutta maaseutuväestössä. Väitöstutkimus korostaa syövän rekisteröinnin tärkeyttä naisten syöpätaakan seurannassa. Koska olemassa oleva irtosolutestaus on alueella vähäistä eikä toimi optimaalisesti, ovat kohdunkaulan syövät todettaessa usein levinneitä. Tämä puolestaan johtaa huonoon ennusteeseen. Tutkimuksella pyrittiin tuottamaan tietoa päätöksentekoa varten. On tärkeää tiedottaa kansallisia tahoja kohdunkaulasyövän taakan jatkuvasta kasvusta, jotta sen ehkäisyyn voidaan panostaa. Kohdunkaulasyövän ilmaantuvuus- ja kuolleisuusluvut ovat kasvaneet irtosolutestin tarjonnasta huolimatta. Nykyinen maksuton irtosolutestitoiminta, joka on käynnistetty jo yli 20 vuotta sitten Etelä-Afrikassa, tulee uudistaa.Non-communicable diseases (NCDs) currently in low-middle-income countries (LMICs) account for 40% of the total burden of disease. They are recognized as a significant threat to health and the economy. Cancer is among NCDs challenging the LMICs today with projected trends that are continuously increasing. Cervical cancer is estimated as the fourth cause of global incidence and mortality. Women experience high incidence and mortality rates due to this cancer in LMICs, with the highest burden borne by countries in Sub-Saharan Africa (SSA). The problem of cervical cancer was elevated to a severe level of the SSA region by the onset of the Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). In addition, many women are unscreened or under-screened because there are no organized screening programs for the early detection of pre-cancerous lesions. South Africa is the only country in the SSA region that offers the national cytology-based screening. Yet, cervical cancer is ranked the second most common cancer and cause of death among women and 8th of the top 10 contributors to Disability Adjusted Life Years (DALYs). Poor screening performance is one of the reasons for the high invasive cervical cancer, which remains a health challenge. Given South Africa’s disparate distribution of public healthcare resources, it is essential to know whether the mass population-based cytology screening program is available to the rural population of the Eastern Cape Province of South Africa. This research aims to understand the burden of cervical cancer in this population. The objectives include describing the incidence of cervical cancer, investigating geographical differences, assessing screening coverage, and examining the survival rate using collaborative studies results in the region and internationally to develop an appropriate intervention program. Using a population-based cancer registry, an observational study, Study I, reported cervical cancer as the most common cancer in women, consistently and progressively increasing in the rural population of the Eastern Cape Province. This Study also investigated trends in the age-standardized and age-specific incidence rates of cervical cancer in two distinct geographic areas, the southern and northern covered by the cancer registry. Results identified distinct differences in these two areas. In relation to the overall age-standardised incidence rates (ASRs) per 100,000 women were 22.0 (95% CI:20.0-24.0) in 1998-2002, 24.4 (95% CI:22.4-26.4) in 2003-2007 and 29.2 (95%CI:27.3-31.6) in 2008-2012. While the ASRs in the entire region showed a progressive increase, the southern area slightly decreased over the same period. They were 20.0 (95% CI:18.5-21.4) in 1998-2002, 19.1 (95% CI:16.5-21.7) in 2003-2007 and 18.8 (95%CI:16.2-23.4) in 2008-2012. In contrast, the ASRs in the northern area increased significantly from 24.0 (95% CI: 21.1-27.0) in 1998-2002, to 29.7 (95% CI: 26.6%-32.8%) in 2003-2007 and 39.0 (95% CI: 35.6-42.5) in the period 2008-2012. Study II described cervical cancer screening program trends based on routinely collected health service data for women 30 years and older reported by health sub-district and year. It is important to note that these service health data were only included in the routine information systems from 2007, with deficient coverage in the northern area at 2.2% in 2007 and 4.3% in 2008. A steady increase was observed from 2009 to 2012 to only 14.8% in 2012. The southern area, which spans two health sub-districts, Mbhashe and Mnquma, reported slightly better coverage of the screening program, with an average of 7.7% in 2007. There was an increase to 41.0% in 2012, with an anomalous coverage of 69.0% reported for the Mbhashe sub-district in 2010. Furthermore, this sub-district had almost twice the screening percentage of the Mnquma sub-district (52.3% vs. 29.7%) in 2012. LMICs struggle to generate historical cancer incidence data over a period due to little investment committed to sustaining this critical infrastructure needed for cancer control in these countries. There are also many competing health demands in SSA that cripple the establishment and maintenance of PBCRs, the source of these historical cancer incidence data. Hence, notably in SSA, only a few cancer incidence data are reported. Despite the challenges, SSA faces in cancer registration compared to other LMICs, directed investment towards staff training and infrastructure limitations can improve the current situation. These critical areas need international investment, including the member states, to sustain and support cancer registration. The Eastern Cape Province PBCR is among the few SSA registries that survived those challenges and reports data on cancer incidence of a rural population. This research highlights the importance of cancer registration which tracked the high cervical cancer incidence experienced by women in the rural Eastern Cape Province that progressively increased over time. Important suggesting pointers of the low or non-existence of screening in this population include low survival to this cancer due to an advanced stage at diagnosis that many women present with, showing that clinical signs and symptoms made diagnosis rather than prompt screening. This information significantly impacts decision-making and a statistical infrastructure for health information. It is also essential to inform the national government about a more targeted control program to reduce cervical cancer burden, improve survival, and review the current cytology-based screening program policy rolled out more than 20 years ago in South Africa

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

No Abstrac

Cancer incidence in older adults in selected regions of sub‐Saharan Africa, 2008–2012

Although the countries of Sub‐Sharan Africa represent among the most rapidly growing and aging populations worldwide, no previous studies have examined the cancer patterns in older adults in the region as a means to inform cancer policies. Using data from Cancer Incidence in Five Continents, we describe recent patterns and trends in incidence rates for the major cancer sites in adults aged ≥60 years and in people aged 0–59 for comparison in four selected population‐based cancer registries in Kenya (Nairobi), the Republic of South Africa (Eastern Cape Province), Uganda (Kyadondo country), and Zimbabwe (Harare blacks). Over the period 2008–2012, almost 9,000 new cancer cases were registered in older adults in the four populations, representing one‐third of all cancer cases. Prostate and esophageal cancers were the leading cancer sites in older males, while breast, cervical and esophageal cancers were the most common among older females. Among younger people, Kaposi sarcoma and non‐Hodgkin lymphoma were common. Over the past 20 years, incidence rates among older adults have increased in both sexes in Uganda and Zimbabwe while rates have stabilized among the younger age group. Among older adults, the largest rate increase was observed for breast cancer (estimated annual percentage change: 5% in each country) in females and for prostate cancer (6–7%) in males. Due to the specific needs of older adults, tailored considerations should be given to geriatric oncology when developing, funding and implementing national and regional cancer programmes

Prostate cancer survival in sub-Saharan Africa by age, stage at diagnosis, and human development index: a population-based registry study

Objectives!#!To estimate observed and relative survival of prostate cancer patients in sub-Saharan Africa (SSA) and to examine the influence of age, stage at diagnosis and the Human Development Index (HDI).!##!Patients and methods!#!In this comparative registry study, we selected a random sample of 1752 incident cases of malign prostatic neoplasm from 12 population-based cancer registries from 10 SSA countries, registered between 2005 and 2015. We analyzed the data using Kaplan-Meier and Ederer II methods to obtain outcome estimates and flexible Poisson regression modeling to calculate the excess hazards of death RESULTS: For the 1406 patients included in the survival analyses, 763 deaths occurred during 3614 person-years of observation. Of patients with known stage, 45.2% had stage IV disease, 31.2% stage III and only 23.6% stage I and II. The 1 and 5-year relative survival for the entire cohort was 78.0% (75.4-80.7) and 60.0% (55.7-64.6), while varying between the registries. Late presentation was associated with increased excess hazards and a 0.1 increase in the HDI was associated with a 20% lower excess hazard of death, while for age at diagnosis no association was found.!##!Conclusions!#!We found poor survival of SSA prostatic tumor patients, as well as high proportions of late stage presentation, which are associated with inferior outcome. This calls for investment in health-care systems and action regarding projects to raise awareness among the population to achieve earlier diagnosis and improve survival

Colorectal cancer survival in sub‐Saharan Africa by age, stage at diagnosis and Human Development Index: A population‐based registry study

International audienceThere are limited population-based survival data for colorectal cancer (CRC) in sub-Saharan Africa. Here, 1707 persons diagnosed with CRC from 2005 to 2015 were randomly selected from 13 population-based cancer registries operating in 11 countries in sub-Saharan Africa. Vital status was ascertained from medical charts or through next of kin. 1-, 3- and 5-year overall and relative survival rates for all registries and for each registry were calculated using the Kaplan-Meier estimator. Multivariable analysis was used to examine the associations of 5-year relative survival with age at diagnosis, stage and country-level Human Development Index (HDI). Observed survival for 1448 patients with CRC across all registries combined was 72.0% (95% CI 69.5-74.4%) at 1 year, 50.4% (95% CI 47.6-53.2%) at 3 years and 43.5% (95% CI 40.6-46.3%) at 5 years. We estimate that relative survival at 5 years in these registry populations is 48.2%. Factors associated with poorer survival included living in a country with lower HDI, late stage at diagnosis and younger or older age at diagnosis (<50 or ≥70 years). For example, the risk of death was 1.6 (95% CI 1.2-2.1) times higher for patients residing in medium-HDI and 2.7 (95% CI 2.2-3.4) times higher for patients residing in low-HDI compared to those residing in high-HDI countries. Survival for CRC remains low in sub-Saharan African countries, though estimates vary considerably by HDI. Strengthening health systems to ensure access to prevention, early diagnosis and appropriate treatment is critical in improving outcomes of CRC in the region