National Burden of Disease Study: SA Medical Research Council briefing

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08 March 2017
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The South African Medical Research Council's unit on National Burden of Disease (NBD) presented its report on the second National Burden of Disease Study and comparative risk assessment research. The Unit has a mandate to assess and monitor the country's health status and determinants of disease. It aims to improve the mortality surveillance system and data availability in South Africa, and works in this regard with Statistics South Africa, the Department of Health, and international comparative institutions. The second NBD Study compared findings on various disease indicators from 1997 to the year 2012. The four groups of diseases that were identified and compared were; HIV/AIDS and Tuberculosis (TB) as communicable diseases, maternal causes, perinatal conditions and nutritional deficiencies, Non-communicable diseases and injury.

The results presented noted that the top five causes of death in South Africa were: HIV/AIDS, cerebro-vascular diseases, lower respiratory infections, Ischemic heart disease and TB. Though HIV/AIDS w still the highest cause of death from communicable diseases, findings showed a decline over the years, from about 300 000 in 2006 to 153  000 in 2012. The decline was attributed to the roll-out of Antiretroviral drugs and the earlier efforts towards Prevention of Mother to Child Transmission interventions. There had also been a 49% reduction in deaths from injury, over the 16 year period, which was associated with more political stability and the implementation of the Firearms Control Act of 2000.

The report also identified that infant and neo-natal (within a months of birth) mortality remained a significant cause of deaths overall. The most significant factors responsible for infant mortality were HIV/AIDS (19.5%), diarrhoea (16%), lower respiratory infections (12.3%), malnutrition (4.9%), injuries (5.5%) and neonatal causes (27.5%), which included pre-term births, asphyxia at birth, severe infections, congenital disease and maternal health factors. The number of deaths of non-communicable disease such as diabetes, renal diseases, breast cancer and prostate cancer had increased over the years, and now accounted for the highest number of deaths overall. The group classified as non-communicable disease now account for the highest number of deaths in South Africa. The report then went on to identify the most prevalent causes of death per province;, although HIV/AIDS was the highest ranked cause of death across all the provinces, the other causes varied from province to province.

The unit recommended that neonatal conditions should be addressed through better care for mothers and new born babies, to address the leading risk factors for non-communicable diseases. They suggested the need to re-evaluate data presented by Statistics South Africa (StatSA), and the Global Burden of Disease (GBD) assessments, noting that because they used different indicators they may not represent the true state of the situation. It was recommended that all provinces need to prioritise AIDS awareness, and HIV reduction programmes, including access to treatment. It was further suggested that if a “years of life lost” formula was used to analyse mortality, which would take into account the years lost to infant mortality, then interventions should vary by province as each one should attending to its own prevailing causes of death.

The questions asked by the Committee members included whether there was a record of neonatal and post neonatal mortality, broken down, and Members asked that the statistics be forwarded to them. They asked about the possible interventions to reduce death, wanted more explanation for the suggestion why the data from StatsSA could not be accepted at face value, and which of the data produced was the most accurate. They also asked what were the plans to achieving prevention of non-communicable diseases, and why it had not been possible to prevent TB, rather than treating it. One Member suggested the need to research problems arising from lack of proper hospital records for pregnant migrants and another suggested that obesity should be considered more holistically, taking into account not only diet but also lack of exercise and ingredients into products sold to consumers. They asked whether more information could be given on the main reasons for improvements in the findings, and wondered if the Unit had sufficient capacity and was intending to expand. They noted the importance of the research informing future actions and interventions, and joint actions. They also urged that mental health must be researched more fully, asked about the conditions of hospitals, and wondered if there was any real hope of tackling TB, given that many interventions so far had not effected truly positive change, as well as urging that talk shops should be set up in schools to address a number of issues.

Meeting report

National Burden of Disease Study: SA Medical Research Council briefing
Prof Debbie Bradshaw, Unit Director, National Burden of Disease (NBD) Unit, SA Medical Research Council, said the Burden of Disease Unit is one of the eleven internal units in the SA Medical Research Council (SAMRC) and it has a mission to assess and monitor the country's health status and determinants of disease, a very large task for a small team.

The unit, as part of its work on the national burden of disease, tries to assess the contribution of modifiable risk factors, improve the mortality surveillance system and improve data availability in South Africa. The unit has been working with the National Department of Health (DOH), and Statistics South Africa on the South Africa demographic and health survey. This survey included visits to 15 000 households to collect information.

The NBD Unit also runs the only population-based cancer register in South Africa, in the rural areas of the Eastern Cape. It is also working on a control case study of cancer with data collected from patients in Johannesburg, which is studying genetics and viral roles in cancer. A further study is ongoing into the vitality and quality of clinically coded information in the public sector hospital, which is important information to guide the National Health Insurance (NHI) programme. Finally, she noted that the NBD Unit is a collaborating center for the World Health Organization (WHO), which is termed WHO-FIC Collaborating Centre.

Dr Victoria Pillay-van Wyk, Specialist Scientist, SAMRC, expanded on the presentation. She noted that this presentation would present the findings on the second NBD Study. The Study was done, and the report outlined the results of 16-year trends in mortality. The implications for planning and policy was highlighted for each province.

She noted that the four major cause groupings are; HIV/AIDS and TB, Communicable diseases, Maternal causes, perinatal conditions and nutritional deficiencies; Non-communicable diseases and injury. Among the top ten causes of death in the country, HIV contributed to 153 661 (29%) of deaths. The second highest group was stroke or cerebro-vascular disease and ischemic heart disease. Over 153 000 people died from HIV/AIDS in 2012, compared with 300 000 in 2006. The decline in the death rate can be linked to the anti-retroviral treatment, and prevention of mother to child transmission intervention. Although gains had been made fight against the HIV/AIDS epidemic, it still counts as the leading single cause of death in the country. Therefore efforts to provide access to treatment must be enhanced.

She noted that because of the sizeable number of deaths associated with TB, efforts to strengthen and integrate a TB programme into the HIV programme are also needed.

The findings on the overall death trends for cardiovascular, diabetes and renal disease shows that strokes account for the highest number of death both in males and females. Death due to diabetes and renal diseases had increased for both males and females. Deaths from cerebro-vascular and Ischemic heart diseases had decreased. Death from prostrate cancer for men, and from breast and cervical cancer had increased and these were, for women, the leading cause of death.

She wanted to stress that non-communicable diseases, as a group, now accounted for the highest number of deaths in South Africa. Cardiovascular conditions are the leading category of non-communicable disease deaths in South Africa. Differing trends in non-communicable diseases were also observed. Tobacco related mortality had declined, but deaths from diabetes has been increasing, to the point where diabetes was now the sixth leading cause of death. Deaths from renal disease has also been on the increase. This suggested that it will be essential to address leading risk factors such as smoking, alcohol, physical inactivity and diet to address the problems with non-communicable diseases.

The largest proportion of the deaths in the group for communicable diseases - which includes maternal causes, perinatal conditions and nutritional deficiencies – are seen in children under the age of five years. There had been a slight increase in the death rate for this group up till year 2009, but then a downward trend was seen. From year 2012 there were over 48 000 deaths in children under the age of five years, for which HIV/AIDS contributed 19.5%, diarrhoea 16%, lower respiratory infection contributed 12.3%. 27% of deaths occurred in children under the age of one month (neonatal death). She indicated that neonatal conditions needed to be addressed, to improve care for mothers and their new born babies.

There had been a massive decline in deaths from injury over the 16 years period although the comparison of all global interpersonal violence rates showed that South Africa had a higher death rate from interpersonal violence than the average global rate. The decline in deaths from injury can be associated with the political stabilisation, and the implementation of the Firearms Control Act of 2000.

Prof Bradshaw said the years of life lost to premature mortality are higher than those lost to the death of an adult, and urged policy makers to take into account the years of life lost when making decisions. The percentage of deaths from HIV/AIDS, road injuries and interpersonal violence will increase when the years of life lost formula is used, because of the number of infants in the death records. She said that years of life lost should be used to help identify activities that will affect the upstream causes of disease, as well as strengthening the health system response required to reduce premature loss of life.

Prof Bradshaw re-affirmed that HIV/AIDS was the leading cause of death across all provinces in 2012 (varying from 20% to 40%). The findings showed that the cause of death in each province differed, so this should be the background taken into consideration for decision maker,s to create different tailor-made solutions for each province, according to the differing needs. She said the study started from data supplied by Statistics South Africa (StatSA), and this in turn had been compiled using the information in the death forms processed at the Department of Home Affairs. Although it was noted that 30% of the forms did not specify the cause of death (which is often due to reluctance to write certain unpalatable information on the death notification form) the Department was training all doctors to encourage them to write the cause of death on the death notification form. Information about injuries is also not well documented by StatSA, because  the forms are not designed to obtain all relevant and necessary information detailing the cause of death.

Dr Bradshaw pointed out that the South Africa National Burden of Disease (SANBD) estimate differed from the estimate generated by the Global Burden of Disease (GBD) statistics, because SA NBD used adjusted data to generate estimates while GBD applied models to data and then predicted estimates for years where no data was available. This resulted in the information given by GBD on the number of HIV/AIDS infected people in South Africa, and the trend, being incorrect.

She concluded by saying that though mortality estimates are available for South Africa, the reported cause of death data from Statistics South Africa cannot be taken at face value. In addition, global estimates for South Africa should also be better calibrated to local data

Dr W James (DA) asked if the infant mortality rate was broken down into neonatal and post neonatal, and if so, asked what the numbers were for each. He added that there is a need to talk about the appropriate interventions that are required, because infant mortality in South Africa is  particularly high and should be preventable.

Prof Glenda Gray, Chief Executive Officer, SAMRC, said that the NBD Unit did have further information on neonatal and infant mortality rates that can be given to Dr James. She added that there is a decline in post-neonatal deaths because of certain interventions made by the SAMRC.

The Chairperson asked that this information be made available to all Members.

Ms C Ndaba (ANC) welcomed the report and observed that the one of the factors that could contribute to infant mortality was linked to border issues. She cited the fact that in Limpopo province, a number of pregnant Zimbabwean women would cross the border and attend hospitals in Limpopo without bringing in any antenatal information, which made it very difficult for the hospitals to ascertain their prior medical history. She suggested that there was a need to do a research about cross border issues.

Ms Ndaba asked the SA NBD delegates to clarify which information was most correct – that from StatsSA or that from the NBD Unit, and asked them to expand on why they were suggesting that information from StatsSA could not be taken at face value.

Ms Ndaba noted that it had been said that large intakes of sugar could lead to obesity, but asked why obesity was not being considered more holistically. She noted that inactivity and lack of exercise by children is also a major contributor to this health challenge. She also asked if SA NBD had done any research into the food eaten in South Africa, such as the ingredients in some foods, and preservatives, in order to assess their impact on the health of South Africans.

Mr D Khosa (ANC) asked how the research of StatSA can be reconciled with SA NBD so that there will be only one credible source of information on subjects. He also asked if the SA NBD was able to track the source of improvements in the findings, and what specifically was the main contributory factor to the decline in the death rate due to HIV/AIDS between 2006 and 2012. He noted that the Unit is presently small and consists of a few people, but asked if it was planning to expand so as to have the capacity to deal with different diseases in the country.

Dr P Maesela (ANC) asked if the findings of the research actually were made known to practitioners or policy maker, so that they could then use this information to effect the necessary changes. He asked why consideration was given to reducing death rates rather than preventing deaths altogether, and asked if this was a plot by the pharmaceutical companies. He also asked if the statistics would lead to preventive measures or were being produced only for academic reasons, because non-communicable diseases can be prevented. He asked why, if South Africa has one of the best diagnostic tools to stop TB, why it had been impossible to eliminate it and why the interest had been focused on treatment rather than prevention. He recommended that the different stakeholders from different institutions should meet together so that they are able to work together in combating the diseases rather than working alone.

Ms L James (DA) asked the delegates for the possible causes of diseases like maternal death, perinatal deaths and diarrhoea. She asked whether mental health was considered when doing the research into the burden of diseases, because most of the occurrences are in the areas with predominantly poor people. She also asked the delegates to identify necessary interventions in terms of planning that are needed to combat the diseases. She asked why it had been difficult to further reduce HIV/AIDS, and what intervention was still needed to reduce HIV/AIDS.

Mr W Maphanga (ANC) asked what the current condition of the hospitals was, given that there was a recommendation to prevent neonatal death and infectious diseases needs to be addressed through better conditions for mothers and new born babies.

Ms D Senokoanyane (ANC) noted that TB had been a major cause of death in South Africa for a long time and this had continued despite several interventions, so she asked if there was a hope of tackling TB since all the interventions had seemingly made very little positive changes. She observed that the nation was also not winning the war against neonatal death, because several interventions had been targeted at children under the age of five years but there had been very little impact. She asked if non-communicable diseases could be prevented, and what were the plans to achieve that. She also appreciated the availability of information on the cause of death identified per province, which can be of help in addressing these diseases

The Chairperson asked for the full meaning of the acronym GBD and NBD. She said that she, as a health activist, had always been concerned that South Africa is projected as having the highest number of the HIV/AIDS in the world. She asked if the delegates would not deem it important to request an audience with StatSA in regards to how correct the information was. She said no research had been done to set up talk shops in the schools, to discuss matters such as what children are fed in schools, what parents packed into their children lunch boxes, what was the impact of poverty and stress levels on non-communicable diseases. She asked what the importance of eating according to blood type was, and also requested more research on juvenile diabetes.

Ms Gray said the SAMRC had 11 units, and the NBD Unit looks at the statistics, and alerts the country about the state of diseases. The infant mortality rate had stagnated. Since 2000 the country had not impacted on the number of neonatal mortality (first 28 days of life) and this accounted for a large percentage of the infant mortality rates for infants under five years old. To prevent still births, it is important to identify high risk pregnancies. The Doppler ultrasound device was developed to monitor and manage high risk pregnancies, with the aim of reducing neonatal mortality. Another reason for neonatal mortality was infection like Group B streptococcal (group B strep) which leads to premature babies. Neonatal death can be prevented if infections such as pre-eclampsia and prematurity are prevented. Infant mortality is influenced by communicable diseases like TB and diarrhoea and it is important to roll out retro-viral vaccinations to prevent diarrhoea. ~

She noted that maternal mortality could be due to hypertension, hemorrhage and HIV. To prevent maternal mortality, there are interventions on the way to handle hypertension and hemorrhage. Maternal death rates had declined as a result of improved HIV management. The findings of the research are used to motivate changes in the Department of Health, and to search for possible solutions to the identified challenges of diseases. It had been difficult to institute student exercises because of the insecurity and poverty. Children cannot be left to play around their environment for fear of being shot or kidnapped. Many students have only one school uniform, and would shy away from exercising so as to keep it clean. South Africa should celebrate the fact that mortality due to interpersonal violence had reduced, which is an effect of gun control and the tobacco legislation. The way to prevent HIV is to understand epidemics, which is difficult. HIV can be reduced when the vulnerability of young women had been addressed. Young women get HIV because of inter-generational sex. When they grow up they have same-age relationships with men who become infected. These men in turn have affairs with young women and the cycle continues. The best way to break the cycle is to prevent infection by use of condoms, test for HIV infection and the use of ART for the treatment of infected people.

She also noted that microbicides had shown protective benefits against HIV and present an opportunity to prevent new HIV infections among young women, to promote the use of condoms and medical male circumcision and pre-exposure prophylaxis. The greatest bottleneck to HIV had been people not knowing their status, which had been linked to stigmatisation. UNAIDS suggested that it is possible to do 90% diagnoses for HIV, that the epidemic can be controlled by 2020, and it would be possible to put an end to HIV by 2030, although in fact no country in the world had been able to eliminate HIV/AIDS. One of the breakthroughs for HIV management is the approval of the use of HIV self- testing kits by the World Health Organisation.

TB had not so far been treated as a medical emergency in South Africa. The unit is working with people to develop TB vaccines, but industries are not interested because they are not profitable to them. Otherwise, there is a need for a TB vaccine because one third of the budget of SAMRC is spent on Multi Drug Resistant TB which makes up only 0.3% of all cases, but is the most expensive. The SAMRC's Cochrane Unit works on translating evidence into policies. There also a need for all the information to be taken up and translated into practice by the Department of Health. Also, she agreed that the units would go and see what was being sold in the talk shops. The issue of poverty has a great impact on health, and that should be better articulated. People needed to find a diet that suited their lifestyle, culture, body type and something that suited their family. There was a need to pay attention to how diet is linked to health. There is a non-communicable disease unit in MRC, and there is a need to invite them to the Committee meeting to expound on non -communicable diseases like diabetes. There is a need to look at non-communicable diseases beyond controlling sugar, tobacco and alcohol and there is also a need to look at the genetic components of diseases.

Prof Bradshaw explained that GBD stands for Global Burden of Diseases, and the NBD means the National Burden of Disease. Both have similar methodology and involve taking available data sets and assess where they would be deficient, and the GBD had been done for all the countries separately in Washington.

She confirmed that mental health is an important part of the burden of disease, but it does not show up when death is considered. The unit is in the process of going beyond using the year of life lost as a measure, by adding the non-fatal component, which will be able to give indicators for mental health. The death rate for HIV had dropped by 49% in the last few years. The estimate of the impact of HIV had been adjusted downwards since 2000, by UNAID, because they were probably over-estimating the impact of the disease in the past. She asked the public to take note of the model TEMBISA that was developed by researchers at UCT to track the HIV epidemic. The unit works closely with StatSA. She said it was not StatSA’s fault that the statistics they reported on are not as robust as they would like these to be, because the challenge was with what the doctors were writing on the forms. There was also a discussion with the Department of Health on the training of doctors in that regard. She said the unit is also working with the Department of Home Affairs and DoH to change the form for reporting the cause of death and bring it in conformity with the recommendations of the World Health Organisation. She said the implementation of regulations on salt would help to impact positively on hypertension.

Ms Beatrice Nojilana, Scientist, SAMRC, added that in addition to having controls there is a need for stricter enforcement so that the implementation will not lag. She also noted that the sugar tax is a move in the right direction towards improving the state of diseases in South Africa.

The Chairperson asked said it is important also to work together with the Departments of Agriculture and Basic Education so that all necessary issues can be addressed. She promised that the Committee will arrange a meeting with the DOH in order to have more robust interaction around the issues of health that were used. She encouraged the unit to include mental health in its future research.

The meeting was adjourned.

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