Dutch DALYs, current and future burden of disease in the Netherlands

The global burden of neglected zoonotic diseases: Current state of evidence

The majority of emerging infectious diseases are zoonoses, most of which are classified as "neglected". By affecting both humans and animals, zoonoses pose a dual burden. The disability-adjusted life year (DALY) metric quantifies human health burden since it combines mortality and morbidity. This review aims to describe and analyze the current state of evidence on neglected zoonotic diseases (NZDs) burden and start a discussion on the current understanding of the global burden of NZDs. We identified 26 priority NZDs through consulting three international repositories for national prioritization exercises. A systematic review of global and national burden of disease (BoD) studies was conducted using pre-selected databases. Data on diseases, location and DALYs were extracted for each eligible study. A total of 1887 records were screened, resulting in 74 eligible studies. The highest number of BoD was found for non-typhoidal salmonellosis (23), whereas no estimates were found for West Nile, Marburg and Lassa fever. Geographically, the highest number of studies was performed in the Netherlands (11), China (5) and Iran (4). The number of BoD retrieved mismatched the perceived importance in national prioritization exercises. For example, anthrax was considered a priority NZD in 65 countries; however, only one national study estimating BoD was retrieved. By summing the available global estimates, the selected NZDs caused at least 21 million DALYs per year, a similar order of magnitude to (but less than) the burden due to foodborne disease (included in the Foodborne Disease Burden Epidemiology Reference Group). The global burden of disease landscape of NZDs remains scattered. There are several priority NZDs for which no burden estimates exist, and the number of BoD studies does not reflect national disease priorities. To have complete and consistent estimates of the global burden of NZDs, these diseases should be integrated in larger global burden of disease initiatives.

The Burden of Disease due to COVID-19 (BoCO-19): A study protocol for a secondary analysis of surveillance data in Southern and Eastern Europe, and Central Asia

INTRODUCTION

The COVID-19 pandemic has had an extensive impact on public health worldwide. However, in many countries burden of disease indicators for COVID-19 have not yet been calculated or used for monitoring. The present study protocol describes an approach developed in the project "The Burden of Disease due to COVID-19. Towards a harmonization of population health metrics for the surveillance of dynamic outbreaks" (BoCO-19). The process of data collection and aggregation across 14 different countries and sub-national regions in Southern and Eastern Europe and Central Asia is described, as well as the methodological approaches used.

MATERIALS AND METHODS

The study implemented in BoCO-19 is a secondary data analysis, using information from national surveillance systems as part of mandatory reporting on notifiable diseases. A customized data collection template is used to gather aggregated data on population size as well as COVID-19 cases and deaths. Years of life lost (YLL), as one component of the number of Disability Adjusted Life Years (DALY), are calculated as described in a recently proposed COVID-19 disease model (the 'Burden-EU' model) for the calculation of DALY. All-cause mortality data are collected for excess mortality sensitivity analyses. For the calculation of Years lived with disability (YLD), the Burden-EU model is adapted based on recent evidence. Because Covid-19 cases vary in terms of disease severity, the possibility and suitability of applying a uniform severity distribution of cases across all countries and sub-national regions will be explored. An approach recently developed for the Global Burden of Disease Study, that considers post-acute consequences of COVID-19, is likely to be adopted. Findings will be compared to explore the quality and usability of the existing data, to identify trends across age-groups and sexes and to formulate recommendations concerning potential improvements in data availability and quality.

DISCUSSION

BoCO-19 serves as a collaborative platform in order to build international capacity for the calculation of burden of disease indicators, and to support national experts in the analysis and interpretation of country-specific data, including their strengths and weaknesses. Challenges include inherent differences in data collection and reporting systems between countries, as well as assumptions that have to be made during the calculation process.

Use of Utility and Disability Weights in Economic Evaluation of Pediatric Vaccines

OBJECTIVE

To describe how utility weights and disability weights have been used in the context of quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs)-based cost-effectiveness analysis (CEA) of pediatric vaccines for infectious diseases and assess the comparability between weights.

METHODS

A systematic review was conducted of CEAs of pediatric vaccines for 16 infectious diseases, published between January 2013 and December 2020 and using QALYs or DALYs as outcome measure. Data on values and sources of weights for the estimation of QALYs and DALYs were extracted from studies and compared across similar health states. Reporting was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

Out of 2154 articles identified, 216 CEAs met our inclusion criteria. Of the included studies, 157 used utility weights and 59 used disability weights in their valuation of health states. In QALY studies, the source, background, who's preferences (adults'/children's) were applied and adjustments made to utility weights were poorly reported. In DALY studies, the Global Burden of Disease study was most often referenced. Valuation weights for similar health states varied within QALY studies and between DALY and QALY studies, but no systematic differences were identified.

CONCLUSIONS

This review identified considerable gaps in the way valuation weights are used and reported on in CEA. The nonstandardized use of weights may lead to different conclusions about cost-effectiveness of vaccines and policy decisions.

The Effect and Cost-Effectiveness of Offering a Combined Lifestyle Intervention for the Prevention of Cardiovascular Disease in Primary Care: Results of the Healthy Heart Stepped-Wedge Trial

OBJECTIVE

To evaluate the effectiveness and cost-effectiveness of offering the combined lifestyle programme "Healthy Heart", addressing overweight, diet, physical activity, smoking and alcohol, to improve lifestyle behaviour and reduce cardiovascular risk.

DESIGN

A practice-based non-randomised stepped-wedge cluster trial with two-year follow-up. Outcomes were obtained via questionnaires and routine care data. A cost-utility analysis was performed. During the intervention period, "Healthy Heart" was offered during regular cardiovascular risk management consultations in primary care in The Hague, The Netherlands. The period prior to the intervention period served as the control period.

RESULTS

In total, 511 participants (control) and 276 (intervention) with a high cardiovascular risk were included (overall mean ± SD age 65.0 ± 9.6; women: 56%). During the intervention period, 40 persons (15%) participated in the Healthy Heart programme. Adjusted outcomes did not differ between the control and intervention period after 3-6 months and 12-24 months. Intervention versus control (95% CI) 3-6 months: weight: β -0.5 (-1.08-0.05); SBP β 0.15 (-2.70-2.99); LDL-cholesterol β 0.07 (-0.22-0.35); HDL-cholesterol β -0.03 (-0.10-0.05); physical activity β 38 (-97-171); diet β 0.95 (-0.93-2.83); alcohol OR 0.81 (0.44-1.49); quit smoking OR 2.54 (0.45-14.24). Results were similar for 12-24 months. Mean QALYs and mean costs of cardiovascular care were comparable over the full study period (mean difference (95% CI) QALYs: -0.10 (-0.20; 0.002); costs: EUR 106 (-80; 293)).

CONCLUSIONS

For both the shorter (3-6 months) and longer term (12-24 months), offering the Healthy Heart programme to high-cardiovascular-risk patients did not improve their lifestyle behaviour nor cardiovascular risk and was not cost-effective on a population level.

Burden of infectious disease studies in Europe and the United Kingdom: a review of methodological design choices

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the disability-adjusted life years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3053 studies of which 2948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

Disability-adjusted life years associated with chronic comorbidities among people living with and without HIV: Estimating health burden in British Columbia, Canada

Life span of people living with HIV (PLWH) has increased dramatically with the advent of modern antiretroviral therapy. As a result, comorbidities have emerged as a significant concern in this population. To describe the burden of chronic comorbidities among PLWH and HIV-negative individuals in British Columbia (BC), Canada, we estimated disability-adjusted life years (DALYs) related to these comorbidities. Based on a population-based cohort in BC, antiretroviral-treated adult PLWH and 1:4 age-sex-matched HIV-negative controls were followed for ≥1 year during 2001-2012. DALYs combined years of life lost to premature mortality (YLLs) and due to disability (YLDs), and were estimated following the Global Burden of Diseases' approaches. DALYs associated with non-AIDS-defining cancers, diabetes, osteoarthritis, hypertension, dementia, cardiovascular (CVD), kidney, liver and chronic obstructive pulmonary diseases were each measured for 2008-2012. Among PLWH, DALYs attributed to non-AIDS-related cancers were also estimated for 2013-2020. We observed that at baseline, our matched cohort consisted of 82% males with a median age of 40 years (25th-75th percentiles: 34-47). During 2008-2012, 7042 PLWH and 30,640 HIV-negative individuals were alive, where PLWH experienced a twofold higher DALYs associated with chronic comorbidities (770.2 years/1000 people [95% credible intervals: 710.2, 831.6] vs. 359.0 [336.0, 382.2]). Non-AIDS-defining cancers and CVD contributed the highest DALYs in both populations, driven by YLLs rather than YLDs. Among PLWH, we estimated increasing DALYs attributable to non-AIDS-defining cancers with 91.7 years/1000 people (77.4, 106.0) in 2013 vs. 97.6 (81.0, 115.2) in 2020. In this study, we showed that PLWH experience a disproportionate burden of chronic comorbidities compared to HIV-negative individuals. The observed disparities may relate to differential health behaviors, residual HIV-related inflammation, and ART-related toxicities. As aging shapes future healthcare needs, our findings highlight the need to enhance prevention and management of comorbidities as part of HIV care.

The estimated disease burden of acute COVID-19 in the Netherlands in 2020, in disability-adjusted life-years

The impact of COVID-19 on population health is recognised as being substantial, yet few studies have attempted to quantify to what extent infection causes mild or moderate symptoms only, requires hospital and/or ICU admission, results in prolonged and chronic illness, or leads to premature death. We aimed to quantify the total disease burden of acute COVID-19 in the Netherlands in 2020 using the disability-adjusted life-years (DALY) measure, and to investigate how burden varies between age-groups and occupations. Using standard methods and diverse data sources (mandatory notifications, population-level seroprevalence, hospital and ICU admissions, registered COVID-19 deaths, and the literature), we estimated years of life lost (YLL), years lived with disability, DALY and DALY per 100,000 population due to COVID-19, excluding post-acute sequelae, stratified by 5-year age-group and occupation category. The total disease burden due to acute COVID-19 was 286,100 (95% CI: 281,700-290,500) DALY, and the per-capita burden was 1640 (95% CI: 1620-1670) DALY/100,000, of which 99.4% consisted of YLL. The per-capita burden increased steeply with age, starting from 60 to 64 years, with relatively little burden estimated for persons under 50 years old. SARS-CoV-2 infection and associated premature mortality was responsible for a considerable direct health burden in the Netherlands, despite extensive public health measures. DALY were much higher than for other high-burden infectious diseases, but lower than estimated for coronary heart disease. These findings are valuable for informing public health decision-makers regarding the expected COVID-19 health burden among population subgroups, and the possible gains from targeted preventative interventions.

Burden of Disease of COVID-19: Strengthening the Collaboration for National Studies

Objectives

Quantifying the combined impact of morbidity and mortality is a key enabler to assessing the impact of COVID-19 across countries and within countries relative to other diseases, regions, or demographics. Differences in methods, data sources, and definitions of mortality due to COVID-19 may hamper comparisons. We describe efforts to support countries in estimating the national-level burden of COVID-19 using disability-adjusted life years.

Methods

The European Burden of Disease Network developed a consensus methodology, as well as a range of capacity-building activities to support burden of COVID-19 studies. These activities have supported 11 national studies so far, with study periods between January 2020 and December 2021.

Results

National studies dealt with various data gaps and different assumptions were made to face knowledge gaps. Still, they delivered broadly comparable results that allow for interpretation of consistencies, as well as differences in the quantified direct health impact of the pandemic.

Discussion

Harmonized efforts and methodologies have allowed for comparable estimates and communication of results. Future studies should evaluate the impact of interventions, and unravel the indirect health impact of the COVID-19 crisis.

Cost-effectiveness analysis of implementing an integrated neonatal care kit to reduce neonatal infection in rural Pakistan

OBJECTIVE

To evaluate the cost-effectiveness of distribution of the integrated neonatal care kit (iNCK) by community health workers from the healthcare payer perspective in Rahimyar Khan, Pakistan.

SETTING

Rahimyar Khan, Pakistan.

PARTICIPANTS

N/A.

INTERVENTION

Cost-utility analysis using a Markov model based on cluster randomised controlled trial (cRCT: NCT02130856) data and a literature review. We compared distribution of the iNCK to pregnant mothers to local standard of care and followed infants over a lifetime horizon.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was incremental net monetary benefit (INMB, at a cost-effectiveness threshold of US$15.50), discounted at 3%. Secondary outcomes were life years, disability-adjusted life years (DALYs) and costs.

RESULTS

At a cost-effectiveness threshold of US$15.50, distribution of the iNCK resulted in lower expected DALYs (28.7 vs 29.6 years) at lower expected cost (US$52.50 vs 55.20), translating to an INMB of US$10.22 per iNCK distributed. These results were sensitive to the baseline risk of infection, cost of the iNCK and the estimated effect of the iNCK on the relative risk of infection. At relative risks of infection below 0.79 and iNCK costs below US$25.90, the iNCK remained cost-effective compared with current local standard of care.

CONCLUSION

The distribution of the iNCK dominated the current local standard of care (ie, the iNCK is less costly and more effective than current care standards). Most of the cost-effectiveness of the iNCK was attributable to a reduction in neonatal infection.

Redistributing ill-defined causes of death - a case study from the BURDEN 2020-project in Germany

BACKGROUND

The cause of death statistics in Germany include a relatively high share (26% in 2017) of ill-defined deaths (IDD). To make use of the cause of death statistics for Burden of Disease calculations we redistribute those IDD to valid causes of death.

METHODS

The process of proportional redistribution is described in detail. It makes use of the distribution of the valid ICD-codes in the cause of death data. We use examples of stroke, diabetes, and heart failure to illustrate how IDD are reallocated.

RESULTS

The largest increases in the number of deaths for both women and men were found for lower respiratory infections, diabetes mellitus, and stroke. The numbers of deaths for these causes more than doubled after redistribution.

CONCLUSION

This is the first comprehensive redistribution of IDD using the German cause of death statistics. Performing a redistribution is necessary for burden of disease analyses, otherwise there would be an underreporting of certain causes of death or large numbers of deaths coded to residual or unspecific codes.

Reflections on key methodological decisions in national burden of disease assessments

BACKGROUND

Summary measures of population health are increasingly used in different public health reporting systems for setting priorities for health care and social service delivery and planning. Disability-adjusted life years (DALYs) are one of the most commonly used health gap summary measures in the field of public health and have become the key metric for quantifying burden of disease (BoD). BoD methodology is, however, complex and highly data demanding, requiring a substantial capacity to apply, which has led to major disparities across researchers and nations in their resources to perform themselves BoD studies and interpret the soundness of available estimates produced by the Global Burden of Disease Study.

METHODS

BoD researchers from the COST Action European Burden of Disease network reflect on the most important methodological choices to be made when estimating DALYs. The paper provides an overview of eleven methodological decisions and challenges drawing on the experiences of countries working with BoD methodology in their own national studies. Each of these steps are briefly described and, where appropriate, some examples are provided from different BoD studies across the world.

RESULTS

In this review article we have identified some of the key methodological choices and challenges that are important to understand when calculating BoD metrics. We have provided examples from different BoD studies that have developed their own strategies in data usage and implementation of statistical methods in the production of BoD estimates.

CONCLUSIONS

With the increase in national BoD studies developing their own strategies in data usage and implementation of statistical methods in the production of BoD estimates, there is a pressing need for equitable capacity building on the one hand, and harmonization of methods on the other hand. In response to these issues, several BoD networks have emerged in the European region that bring together expertise across different domains and professional backgrounds. An intensive exchange in the experience of the researchers in the different countries will enable the understanding of the methods and the interpretation of the results from the local authorities who can effectively integrate the BoD estimates in public health policies, intervention and prevention programs.