Epidemiology of Non-

Communicable Diseases
Adora F. Mendoza-Abat, M.D.,
CFP
 Definitions
 Environmental Epidemiology – the
study of environmental factors that
influence the distribution of diseases
in the human population

 OccupationalEpidemiology – the
study of workplace exposures on the
frequency and distribution of
diseases and injuries in the
population
 Infectious Diseases Non-Infectious
-Single necessary agent Diseases
-No single necessary
agent
-Specificagent-disease
relationship -One-to-one
correspondence
between agent and
disease very rare
-Causes are relatively
well understood
-Causes unknown,
intervention usually
based on risk factors
-Short incubation period
-Long latency period
 Infectious Diseases Non-Infectious
Diseases
-Single exposure usually -May require multiple
sufficient exposure to same or
multiple agents

-Usually produce acute -Mostoften produce

disease chronic disease

-Acquired immunity -Acquired immune

possible unlikely

-Dxbased on tests
specific to disease -Dxoften dependent on
agent nonspecific symptoms
Classification of Etiologic Agents
or Risk Factors
 1. Environmental Factors that may
Affect Health
 A. Psychological Factors
 B. Biological Factors
 C. Chemical Factors
 D. Physical Factors
 E. Accidental Factors
Classificat’n of Etiologic Agents or Risk
Factors
2. Environmental Components & Health
Hazards
Components Health Hazards
Physical : air, water, Physical: heat and cold,
soil, radiation, noise
food, climate and Chemical: metals,
weather, noise level, chemical substances
radiation level Biological:
microorganisms, flora
Social: work, transport, and fauna
leisure, housing, family Social; culture/customs,
and community interpersonal relations,
social and political
 Environmental Hazards
1. Site and location (earthquakes, flood,
wind, storms, drought)
2. Biological (animal, insect,
microbiological, vegetation)
3. Chemical (poisons and toxins, allergens,
irritants)
4. Physical (vibration, radiation, forces and
abrasion, humidity)
5. Psychological (stress, boredom, anxiety,
discomfort, depression)
6. Sociological (overcrowding, isolation)
 Uses of Environmental /
Occupational Epidemiology
1. Identify etiologic factors
2. Monitoring trends and changes on
health consequences/impact
3. Planning, management and evaluation
of programs (projections and risk
assessment)
4. Communicate information regarding
environmental hazards
5. Basis for establishing safety standards
or thresholds
6. Others (eg. Elucidating mechanisms of
 Causes of Under-recognition of
Occupational/Environmental
Dse.
 1. Inherent difficulty in diagnosing
occupational diseases
 2. Difficulty in establishing cause and
effect relationships
 3. Lack/incomplete evaluation of
chemicals for potential toxicity
 4. Inadequate pre-market evaluation of
newly developed chemical substances
 Causes of Under-recognition of
Occupational/Environmental
Dse.
 5. Long latency between occupational /
environmental exposure and onset of
illness
 6. Lack of awareness among health
practitioners about hazards found at work
and in the environment
 7. Limited ability of many workers to
provide an accurate report of their toxic
exposures
 Causes of Under-recognition of
Occupational/Environmental
Dse.
 8. Resistance of employers to recognize
the work relatedness of a disorder
because of possible litigations suits
 9. Usually involves small group of
people
 10. Lack of knowledge about many
aspects of behavior of environmental
pollutants
 11. Potential difficulties in defining
 Major Types of Occupational
Diseases
 1. Lung diseases
 2. Cancer
 3. Skin disorders
 4. Infectious diseases
 5. Reproductive disorders
 6. Musculo-skeletal disorders
 7. Severe traumatic injuries
 8. Hearing loss
 Surveillance Activities in
Environmental / Occupational
Epidemiology
1. (Occupational) Hazard Surveillance
a. Provides a means of assessing toxic
occupational exposures to a population
and thus of assessing risk
b. Will identify chemicals in use, the
industries and occupations where they
are used, and the extent and magnitude
of worker exposure
c. Also provides a means of identifying
changes in the patterns of exposure and
 Surveillance Activities in
Environmental / Occupational
Epidemiology
2. (Occupational) Disease Surveillance
a. Provides a means of assessing the
amount and types of occupational
disease, time trends and distribution
according to geography, industry and
occupation

b. Can consist of 2 types of surveillance

b.1. Biological monitoring
 Biological Monitoring
 The systematic collection of biological
specimens (blood, urine, breath,
fingernails, hair, saliva) for the purpose of
estimating exposure to environmental
agents and hence determine the risk of
disease before it occurs
 Interpretation - requires detailed
knowledge of the kinetics and
metabolism of chemicals
 Limitations: due to the rapid excretion of
certain chemicals, only the most recent
 Medical Screening
 Theperiodic examination (clinical or
laboratory) to detect diseases (or
health problems) present among
apparently healthy subjects

 Issues:validity, predictive values,

cost-effectiveness, acceptability of
procedure
 Measurements of Exposure and
Outcome : Some Issues /
Considerations
1. Exposures are usually measured
quantitatively
2. Dimensions of exposure: level, duration,
level-duration combined
3. Current Vs. long term exposures
a. Acute Effects – current exposures are
relevant (e.g. London smog epidemic in
1952)
b. Cumulative Effects
2 Types of Cumulative Effects
 1. Chemical / substances that
accumulate in the body (e.g.
cadmium)
 2. Hazards with cumulative effects
(e.g. radiation, noise)
Measurements of Exposure and Outcome
: Some Issues / Considerations
4. Individual measurements vary with time
a. Has implications on the frequency,
time and method used to estimate
exposure or dose
5. Exposure or dose varies between
individuals
a. Different work habits
b. Differences in the local distribution
of pollutants
c. Differences in individual absorption
and excretion rates for the chemical
. d. People with the same external dose
 Measurements of Exposure and
Outcome : Some Issues /
Considerations
 6. Internal dose (absorbed dose) is
usually different from external dose
(environmental measurements)
 7. Dose-effect relationship – the higher
the dose the more severe and intense is
the effect; data are useful for establishing
safety standards
Set safety standard at a level where
the less severe effects are prevented
Measurements of Exposure and
Outcome : Some Issues /
Considerations
 8.Dose-Response Relationship
Response – the proportion in an
exposed group that develops a
specific effect
 Environmental Exposures
 Doses are at concentrations far below
those experienced by workers who are
directly handling the materials
 Will require larger population for study in
order to detect the smaller health effects
likely to result
 Problems with confounding variables may
be more serious
 Estimation of exposure doses is
complicated by the lack of routine data
on air and water pollution
 Environmental Exposures
 Use of place of residence as surrogate for
exposure may lead to exposure
misclassification because population may
be highly mobile
 Common to use ecologic data or
correlational studies
 Longer exposure of residents to
household ‘toxin’ compared to workers
 Children are more susceptible than
working adults since they have faster
metabolism and absorption of the toxin
 Risk Assessment
 The use of epidemiological methods
and principles to estimate the
potential health risks of industrial or
agricultural development projects,
both before they are implemented
and while they are in operation.
 Used to predict potential health
problems in the use of new chemicals
or technologies
 Steps in Risk Assessment
1. Identify which environmental hazard
may be created by the technology or
project under study (Hazard
Identification)
2. Analyze the type of health effect that
each hazard may cause (Hazard
Assessment)
3. Measure or estimate the actual
exposure levels for the people
potentially affected, including the
general population and the work force
(Measure Actual Exposure)
 Steps in Risk Assessment
4. Calculate the likely health risk in
the population
- For each hazard identified, the
exposure data for subgroups of the
exposed population are combined
with the dose-effect and dose-
response relationships
 BURDEN OF NCDs
 rising trends in non-communicable diseases as a
result of demographic and epidemiological
changes, as well as economic globalization

 increase in life expectancy combined with changes

in lifestyles are leading to epidemics of non-
communicable diseases (NCD), mainly
cardiovascular diseases, cancer and diabetes

 In 1998, NCD accounts for 63% of global deaths

 43% of all DALY globally were attributed to NCD

Non-Communicable Diseases
 Includes all “traditionally” defined
NCDs such as CVD, cancer, chronic
respiratory diseases, mental health
as well as injuries and violence
 In all WHO regions (except sub-
Saharan Africa), NCDs today
constitute the largest contributor to
burden
 NCDs accounted for 60% of all
deaths in 1999 and 43% of all DALYs
with injuries adding 9% of all deaths
and 14% of all DALYs
 By 2020, 10 out the top 15 causes of
DALYs lost will be attributable to
NCDs, mental health and
injuries/violence
 The top five positions will be
occupied by Ischemic Heart Disease,
depression, road traffic injuries,
cerebrovascular disease and Chronic
Obstructive Pulmonary Disease
(COPD)
 15th place: trachea, bronchus and
lung cancers (better known as
tobacco cancers)
 GROUP OF NCDs
 Cancers
 Lifestyle-related (CVD, diabetes)
 Injury (unintentional, intentional)
 Genetic disorders
 Disabling disorders
 Occupational disorders
 Nutritional conditions
 Endocrine disorders
 Substance abuse
 REASONS FOR THE
PROMINENCE OF NCD
1. Aging of the population
2. Impact of automobiles
3. Lifestyle changes
4. Tobacco addiction
-single largest cause of preventable morbidity
and mortality
5. Physical activity
6. Social and behavioral factors
 I. NATURAL HISTORY
A. CHARACTERISTICS OF THE AGENT
e

 Absence of a single necessary agent

 most NCDs are classified on the basis of

manifestations rather than on etiology (e.g.,
CVD, renal disease, neoplasms)

 known “causes” are risk factors

e.g. obesity, elevated cholesterol levels,
hypertension
B. TIME FRAME
- take years or decades before illness is
apparent
- no multiplication of causative agent is
involved
- multiple low-dose exposures (some
chemicals)
- some conditions seem to evolve
subsequent to chronic conditions or high
risk states such as obesity, smoking,
diabetes and high blood cholesterol
C. NATURE OF THE DISEASE
chronic in nature
“chronic disease”

(1957 Commission on Chronic Disease)

permanent
leaves residual disability
caused by nonreversible pathological
alterations
requires special training of the patient
for rehabilitation
requires long periods of supervision,
observation or care.
Chronicity
function of the long latency period
slow disease process → adaptive
responses to stresses (may be
detrimental over the long term)

CD can be chronic (e.g. rheumatic

heart disease)
NCD can be acute (e.g. chemical
poisoning)
D. Synergism in Disease Causation

> Asbestos and lung cancer (RR=8)

> Smoking + asbestos and lung
cancer (RR=90)

- Presence of synergism → decreased

latency (produce illness in the prime of
life even with low level exposures)

- Role of initiators and promoters

 Major Categories of
Etiological Agents

A. Occupational

B. General environmental

C. Lifestyle and Illness

OCCUPATIONAL
- chemical
- metals and naturally occurring minerals
Investigating occupational exposures

 agent factors to be considered

size and shape of particles
route of exposure
free or compound form
organic vs inorganic form
liquid or vapor form
 environmental factors
conditions in the work environmental
that will influence the likelihood that
workers will come in contact with an
agent
general cleanliness and ventilation
lighting, temperature

 Host factors
lifestylebehaviors that may increase
the risk of disease from occupational
exposure to an agent
genetic constitution
ENVIRONMENTAL

 sourcesof exposure
contamination of air, water and soil by
industrial activities or inadequate waste
disposal
lower dose of exposure than in
occupational environments
pesticides
housing materials
automobile exhausts
radiation
 Investigating environmental exposures
dose
data on levels of exposure
mobility of subjects
confounders

 additional
considerations
wide range of ages
length of exposure
meterological conditions
seasonal effects
LIFESTYLE
- poverty, stress, exercise, drug and alcohol
use, nutrition
 CONTROL OF NCD

A. PRIMARY PREVENTION
- removal of agent from environmental or
minimizing the amount of agent present
- Protection of the susceptible host from
exposure

B. SECONDARY PREVENTION
- screening tests

C. TERTIARY PREVENTION
- lifestyle modification
A small core of risk factors explains the
increases in CVD, certain cancers and their
closely linked conditions of obesity, type II
diabetes:
 tobacco, diet/nutrition, physical inactivity
and alcohol
A substantial proportion of chronic respiratory
diseases and death are driven by tobacco use
 Alcohol
is obviously a major contributor to all
causes of injuries and violence
 Tobacco trends are not
hopeful
 There are 1.2 billion smokers in the
world with smoking rates in 13 to 15
year olds being about 20% in diverse
cities from developed and developing
countries
 Tobacco causes 4 million deaths per
year, a figure that will increase to 10
million per year by the late 2020s
 Thepublic health impact is
widespread and increasing fast in
Alcohol Use
 Trends in alcohol use:
steady increases in many developing
countries with continued very high
rates of binge drinking in many east
and central European countries.
Obesity
 has tripled in youth in several Chinese
cities, and rapidly increased over the last
15 years in the major cities of countries
like Malaysia, Brazil, Indonesia and South
Africa
 Butthese have occurred as underweight
persists in the rural areas
 Oftenunderweight is common in the
same neighborhoods as obesity is
increasing
 Thusboth being underweight and being
overweight are associated with poverty
Obesity (con’t)
 Epidemics of obesity and type II
diabetes have been well
documented in most Pacific Island
States and are probably fuelled by a
combination of factors:
increased imports of high fat foods
particularly cheap off-cuts as well as
increased consumption of sodas in
societies where physical activity levels
have plummeted.
 Devastating economic impact of
diabetes’ complications are recently
being determined for several of
 Theproblems of obesity and
diabetes are caused by many
factors
 Solutionssimilarly need to be
multidimensional and avoid
focusing on just one aspect or on
behavior change alone
 Mentalhealth:
450 million people who suffer
from mental or neurological
disorders or from psychosocial
problems such as those related to
alcohol and drug abuse