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Burden of
Major Diseases
and Risk
Factors
Book list
1
...
Lopez; Colin D
...
Jamison; Christopher J
...
Murray

2
...
Understanding Global Health
Lange Publication

4
...
Definition of Disease Burden
Burden of disease: Burden of disease (BOD) is a general term used in public health and epidemiological literature to
identify the cumulative effect of a broad range of harmful disease consequences on a community, including the health,
social and economic costs to individual and to society
...

Burden: It includes –
•
•
•
•

Frequency: Incidence or prevalence
...

Consequences such as health, social and economic
...
g
...


Impairment: Loss or abnormality of psychological, physiological or anatomical structure or function is called
impairment
...

Handicap: Disadvantage resulting from impairment or disability that limits or prevents the fulfilment of a role that is
normal depending on age, sex, social and cultural factors is called handicap
...
Subsequent national and reginal studies, risk facts or studies were conducted
...
A systematic scientific effort to quantify the comparative magnitude of health loss for
187 countries from 1990 to 2010
...
Covering 291 diseases
and injuries, 1160 resulting effects of these disease and injuries, and 67 risk factors or clusters of risk factors
...
Summary papers published in a dedicated triple
issue of the Lancet December 15th, 2012
...

2
...

4
...

Cause of death transition: Fraction of deaths or years of life lost shifting from communicable, maternal,
neonatal and nutritional to non – communicable diseases and injuries despite the HIV epidemic
...

Risk transition: Shift from risks related to poverty to behavioral risks in risk transition
...

2
...


Prioritizing actions in health and the environment
Planning for preventive action
Assessing performance of healthcare systems

2

4
...

6
...


Comparing action and health gain
Identifying high-risk populations
Planning for future needs
Setting priorities in health research

Applications of burden of disease analysis:
1
...


3
...


5
...
In this application,
burden of disease may be considered analogous to national income and product accounts
...

Debating the appropriate values for, say, disability weights or for years of life lost at different ages helps clarify
values and objectives of national health policy
...

Identifying national control priorities: Many countries now identify a relatively short list of interventions
whose full implementation becomes an explicit priority for national political and administrative attention
...
Because political attention and high-level administrative capacity are in relatively
fixed and short supply, the benefits from using those resources will be maximized if they are directed toward
interventions that are both cost-effective and aimed at problems associated with a high disease burden
...

Creating knowledge: Medical schools offer a fixed number of instructional hours, and training programs for
other levels and types of health workers are similarly limited
...
This implies allocating time to training for
interventions where the disease burden is high and cost-effective interventions exist
...
In particular, whenever a fixed effort will have a benefit proportional not only to
the size of that effort, but also to the size of the problem being addressed, estimates of the disease burden
becomes essential for formulating and implementing research and development priorities
...

Allocating resource across health interventions: A key task for priority-setting analysis n health is to create
the evidence base to stimulate the reallocation of resources to interventions that, at the margin, will generate
the greatest reduction in health loss
...
Similarly, major fixed costs may be associated with the universalization (or major
expansion) of an intervention and, if so, the cost-effectiveness of the expansion will depend in part on the size
of the burden
...
Central objectives:
1
...

2
...
To undertake the quantification of health problems in time-based units that can also be used in
economic appraisal
...
Specific objectives:
1
...

2
...

3
...

4
...


3

5
...


To analyze the contribution of this burden of major physiological, behavioral and social risk factors by
age, sex and region
...


Types of disease burden:
1
...


Disability burden: Disability burden of disease is estimated by DALY
...


Disease burden perspectives:
•
•
•

Individual
Family
Social, national and global

4

2
...

Risk: Risk is the probability of an event among those experiencing the event divided by the number who could
experience it (at risk)
...

Risk conditions: Risk conditions are conditions such as overweight/obesity, which are not behaviors but that
nonetheless contribute to diseases, disability or death
...

Risk exposures: Risk exposures are things that happen to a person that may have negative impacts on health and are
outside of his/control – physical or psychological abuse, for example, developing respiratory disease as a result of
indoor air pollution or becoming infected with Schistosoma haematobium from contact with contaminated water
...
A risk factors is a characteristic, condition or behavior that increases the likelihood of getting a disease
or injury
...
They often coexist
and interact with one another
...
Together, these significantly increase the chance of developing chronic heart disease and
other health related problems
...

There is a risking demand for healthcare, placing the sector under increasing budget pressure which is not always met
...

Types of risk factors: In general, risk factors can be categorized into the following groups:
1
...

3
...

5
...

7
...


2
...
They can
therefore, be eliminated or reduced through lifestyle or behavioral choices
...
They may be
influenced by a combination of genetic, lifestyle and other broad factors
...


4
...


6
...


• Being overweight or obese
• High blood pressure
• High blood cholesterol
• High blood sugar (glucose)
Demographic: Demographic risk factors are those that relate to the overall population
...
Examples include:
• Access to clean water and sanitation
• Risks in the workplace
• Air pollution
• Social settings
Genetic risk factors: Genetic risk factors are based on an individual’s genes
...
Many other diseases such
as asthma or diabetes, reflect the interaction between the genes of the individual and environmental factors
...

Modifiable: These include:
• Smoking
• High blood pressure
• Diabetes
• Physical inactivity
• Being overweight
• High blood cholesterol
Nonmodifiable: Nonmodifiable risk factors are:
• Age: The older one is, the more likely he/she to develop coronary heart disease or to have a cardiac
event
...
Also, people from African Caribbean backgrounds
have a higher than average risk of developing high blood pressure
...
g risk of coronary heart disease
...

It is generally characterized by insulin resistance, where the body does not fully respond to insulin
...
For some people with type 2 diabetes
this can eventually exhaust the pancreas, resulting in the body producing less and less insulin, causing even higher
blood sugar levels (hyperglycaemia)
...

The cornerstone of type 2 diabetes management is a healthy diet, increased physical activity and maintaining a healthy
body weight
...

Risk factors: Several risk factors have been associated with type 2 diabetes and include:
1
...

3
...

5
...

7
...

9
...


Family history of diabetes
Overweight
Unhealthy diet
Physical inactivity
Increasing age
High blood pressure
Ethnicity
Impaired glucose tolerance (IGT)*
History of gestational diabetes
Poor nutrition during pregnancy

6

*Impaired glucose tolerance (IGT) is a category of higher than normal blood glucose, but below the threshold for
diagnosing diabetes
...

Importance of measuring risk factors:
1
...

3
...


Identifying individuals/groups at risk: Ability to predict future disease in individual patients is very limited
even for well-established risk factors e
...
cholesterol and CHD
...

Prevention: To remove causative agent and prevent disease
...
8

2

Tobacco use

8
...
8

4

Physical inactivity

5
...
8

6

High cholesterol

4
...
0

8

Alcohol use

3
...
8

10

Indoor smoke from solid fuels

3
...

Different people and perspectives may assess risk differently
...
The
assessment of risk also depends on time: Is the impact of an activity on current or future health (the adolescent may
significantly discount the future impact of tobacco use)
...
If you are a 10th grader, other high school students are your
peers
...
When you are on par with someone, you are
their peer
...
]
Probability: Probability may be defined as the relative frequency or probable chance of occurrence with which an event
is expected to occur on an average such as of giving birth to a baby in the first pregnancy, chances of one drug being
better than the other etc
...

Odds: It is the probability of an event divided by the probability of the event not happening
...
61
Odds ratio: An odds ratio (OR) is a measure of association between an exposure and an outcome
...
Odds ratios are most commonly used in case control studies
...

PAR:
Proportion of Incidence Attributable to Exposure (Proportional Attributable Risk)
=
=

𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝−𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑛𝑜𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
𝐼𝐴𝑅
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝

Example:

IAR = 28
...
4
10
...
0−17
...
379
= 37
...

Odds: It is the ratio of the probability of having an event to the probability of not having the event
...


Example: 1 out of 5 patients suffer a stroke
...


Interpretation of relative risk or risk ratio (RR):
•
•
•

RR = 1 suggests that, Risk in exposed is equal to risk in non-exposed
...


Interpretation of ODDs ratio
•
•
•

OR = 1 suggests that, odds of exposure is the same for cases and controls (no association between disease and
exposure)
...


Stating ODDs ratio results and Relative Risk (Risk Ratio) results:
OR = 5
...
44 times as likely to have had the exposure compared to those without the disease
...
41
Those with the exposure are 4
...

Components of a measure of health of a community:
•
•
•
•
•
•

Morbidity
Mortality
Disability
Age
Gender
Region

The global burden of disease:
Leading causes of DALYs for low and middle-income countries:

10

•
•
•

Perinatal conditions
Lower respiratory infections
Ischemic heart disease

Leading causes of DALYs for high income countries:
•
•
•

Ischemic heart disease
Cerebrovascular disease
Unipolar depressive disorders

Major epidemiological study designs to estimate the risk:
•
•

Case control (retrospective)
Cohort (prospective)

Risk factors of coronary heart disease and stroke:
A
...
Major modifiable risk factors:
• High blood pressure: Major risk for heart attack and the most important risk factor for stroke
...

• Tobacco use: Increases risks of cardiovascular disease, especially in people who started
young, and heavy smokers
...

• Physical inactivity: Increases risk of heart disease and stroke by 50%
...

• Unhealthy diets: Low fruit and vegetable intake is estimated to cause about 31% of coronary
heart disease and 11% of stroke worldwide; high saturated fat intake increases the risk of heart
disease and stroke through its effect on blood lipids and thrombosis
...

b
...

• Mental ill health: Depression is associated with an increased risk of coronary heart disease
...

• Alcohol use: One to two drinks per day may lead to a 30% reduction in heart disease, but
heavy drinking damages the heart muscle
...

• Lipoprotein: Increases risk of heart attacks especially in presence of HDL cholesterol
...


B
...

• Heredity or family history: Increased risk if a first-degree blood relative has had coronary heart
disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative)
...

• Ethnicity or race: Increased stroke noted for Blacks, some Hispanic Americans, Chinese and
Japanese populations
...

C
...


11

•
•

Inflammation: Several inflammatory markers are associated with increased cardiovascular risk e
...

elevated C-reactive protein (CRP)
...


Estimating the burden of risk factors: Risk factors are identified by determining whether they significantly increase or
decrease the risk of developing a disease
...
Attributable risk fraction represents the incidence or proportion of disease risk that is attributable to the risk
factor
...

Attributable risk (AR) = Risk among risk-positives ⸺ Risk among risk-negatives
Attributable fraction =

𝑅𝑖𝑠𝑘 𝑎𝑚𝑜𝑛𝑔 𝑟𝑖𝑠𝑘 𝑓𝑎𝑐𝑡𝑜𝑟−𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠 ⸺⸺ 𝑅𝑖𝑠𝑘 𝑎𝑚𝑜𝑛𝑔 𝑟𝑖𝑠𝑘 𝑓𝑎𝑐𝑡𝑜𝑟−𝑛𝑒𝑔𝑎𝑡𝑖𝑒𝑠
𝑅𝑖𝑠𝑘 𝑎𝑚𝑜𝑛𝑔 𝑟𝑖𝑠𝑘 𝑓𝑎𝑐𝑡𝑜𝑟−𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠

12

× 100%

3
...
QALY is measured on a scale of 0 to 1 where 0 means death and 1 means perfect health
...
QALYs are therefore expressed in terms of years lived in perfect health
...

2
...


If a person lives in perfect health for 1 year, then that person will have 1 QALY (1 year of life × 1 utility value
= 1 QALY)
If a person lives in perfect health but only for half years, then that person will have 0
...
5 years of
life × 1 utility value = 0
...
5 utility (half of perfect health), then that person
will also have 0
...
5 utility value = 0
...
Part A is the amount of QALYs
gained due to quality improvements
...

In cost effectiveness studies (health economic evaluations), the QALY is used to quantify the effectiveness of, for
instance, a new medicine versus the current one
...

Example:

13

1
...
7, then that person will have 2
...
7 utility value = 2
...
If that person takes the new medicine (say Med A) whereby his/her utility level increases to 0
...
7 QALYs
...
6 QALYs as
this is the increase over the current standard of care (3 years of life × 0
...
6 QALYs)
...
Similarly, if a new medicine (say Med B) prolongs the patient’s life by 2 years at a utility level of 0
...
4 additional QALYs (2 years of additional life × 0
...
4 QALYs)
The beauty of the QALY therefore is that it allows us to compare the health effect of a new cancer therapy with the
health effect of a new anti-depressant (or with any other medical intervention)
...
In the DALY philosophy, every person is born with a certain number of life years potentially lived in optimal
health
...
These losses in healthy life years are exactly what is measured by the DALY metric
...

DALY = YLL + YLD

Here, YLL = Years of life lost due to premature death
YLD = Years of life lived with disability
YLL = w (a ⸺ b)

Where, w = age weight
a = Life expectancy at birth
b = Age at the time of death
YLD = wd

Where, w = Disability weight for the disease
d = Duration of the disability or disease
The disability weights (DWs) are a crucial component of the DALY calculation, as they translate morbidity into healthy
life years lost, thus enabling comparison of morbidity and mortality
...

Living 10 years with a DW of 0
...
20, thus both correspond to losing 1 full healthy life year
...
This
condition has a DW of 0
...
The number of YLDs for
this patient is therefore, calculated as:
YLD

= 1 (60 ⸺ 40) × 0
...
5
...

Continuing the aforementioned example, the life expectancy of the 60-year old female is 22
...
Dying at the age of 60 will thus cause a loss of 22
...
5

14

So, DALY

= YLD + YLL
= 11 + 22
...
5

Uses of DALY:
1
...

3
...

5
...

7
...

Identifying disadvantaged groups and targeting health interventions
...

Rational allocation of scarce resources
...

Provide comparable measure of output for interventions, program and sector evaluation
...


Maths regarding DALY and QALY
Problem 1: A businessman made an accident at the age of 35 and died after suffering from disability for 10 years
...

Assuming life expectancy at birth = 66
...
6
Solution:
Given,
Duration of disability, d = 10 years
Life expectancy at birth, a = 66
...
6
Age at the time of death, b = (35 + 10) years
= 45 years
We know,
DALY = YLL + YLD
= w (a⸺b) + w × d
= 0
...
6⸺45) + (0
...
96
Problem 2: A person developed NIDDM (non-insulin dependent diabetes mellitus) at the age of 37 years and
nephropathy at the age of 48 as a complication of DM (diabetes mellitus)
...
Calculate
DALY loss for the person
...
7 years, disability weight of DM = 0
...
6 for nephropathy, age weight =
0
...

Solution:
Given,
Age at the time of death, b = 60 years
Life expectancy at birth, b = 67
...
6
For NIDDM,
Disability weight, w1 = 0
...
2 × 23
= 4
...
6
Duration of the disease, d2 = (60⸺48) years
= 12 years
So, YLD = w2 × d2
= 0
...
2
YLL for both diseases
= w (a⸺b)
= 0
...
7⸺60)
= 4
...
62 + 4
...
2
= 16
...
62
...
Assuming no discounting
b
...
The
effects of health treatments do not always occur at the same point of time
...

Therefore, if a positive rate of time preference (a preference for benefits today rather than in the future) were
acknowledged, it would look more attractive, compared with the preventive option
...
A simple formula can be applied to do this for any chosen discount rate, normally within
the range of 0 – 10 %
P=

∑𝑛 𝐹𝑛 (1 + 𝑟)−𝑛

= ∑𝑛

Where,

a
...
62 × )
= 0
...


𝐹𝑛
(1+𝑟)𝑛

4

1

Assuming discounting at 5% per annum QALY gain = (0
...
16 QALY

16

Problem 4: Sketch the QALY diagram and determine how many QALYs are gained if a person achieves a eight-years
life extension on home dialysis; where duration: 8 years; Health state: hospital dialysis; weight: 0
...

a
...
Assuming discounting at 5% per annum
Solution:

a
...


Assuming discounting at 5% per annum QALY gain = 0
...
05)4

+
...
65 × 8
= 5
...
05

+

1
(1
...
05)3

+

1
]
(1
...
65 [1 + 7865]
= 4
...
68
...
Assuming no discounting
b
...


Assuming no discounting QALY gained = (1⸺0
...
08

b
...
68) ×
= 0
...
He was introduced a new drug, which
increased quality of life from 0
...
5 level without any change in his life span
...

Solution:

17

Given,
Duration of suffering = 20 years
Initial level of quality of life = 0
...
5
QALY gained

= 20 × (0
...
2)
= 20 × 0
...
Environmental Burden of Disease
Health: Health is a state of physical, mental and social well-being in which disease and infirmity are absent
...
Environmental health comprises all the physical, chemical and biological factors external to
a human that can potentially affect health and behavior
...

Environmental risk factors: Environmental factors are those that pose a risk to health and may cause premature
mortality or disability of affected individual
...
Some of them are:
1
...

3
...

5
...

7
...

9
...

Indoor air pollution from solid fuel use
...

Climate change
Lead (Pb)
Mercury
Occupational carcinogen
Occupational airborne particulates
Second-hand smoke (in preparation)

Examples of some environmental risk factors and diseases:
Environmental risk factors
Contaminated water: lack of latrines, poor hand washing,
inappropriate solid waste management, open defecation,
vector infection etc
...


Indoor air pollution: cooking with biomass fuel, poor
ventilation etc
...


Outdoor or ambient air pollution: Motor vehicle, industry,
construction etc
...


Factors in workplaces: Excess noise, heat, dust, chemicals
...


19

disease,

lower

5
...
The
health transition has been covered by two separate terms:
A
...
Epidemiologic transition
Demography: Demography is the study of statistics such as births, deaths, income, or the incidence of disease, which
illustrate the changing structure of human populations
...

Demographic transition: Demographic transition is a phenomenon and theory which refers to the historical shift from
high birth rates and high infant death rates in societies with minimal technology, education (especially of women) and
economic development, to low birth rates and low death rates in societies with advanced technology, education and
economic development, as well as the stages between these two scenarios
...

It is simply a change in the population dynamics of a country as it moves from high frequency and mortality rates to
low fertility and mortality rates
...
Each stage is characterized by a specific relationship between
birth rate (number of annual births per one thousand people) and death rate (number of annual deaths per one thousand
people)
...
Within this model, a country will progress over time from one stage to the next as certain social and
economic forces act upon the birth and death rates
...
For example, there
are currently no countries in stage 1, nor are there any countries in stage 5, but the potential is there for movement in
the future
...
As a result, population size remains fairly constant but can have major swings with events
such as wars or pandemics
...
Many of the least developed countries today are
in stage 2
...
Population growth continues, but at a lower rate
...

Stage 4: In stage 4, birth and death rates are both low, stabilizing the population
...
Most developed countries are in stage 4
...


20

Fig: Demographic transition model
...
Additionally, there are things the DTM cannot reveal; the impact
of other demographic variables such as migration, are not considered, nor does the model predict how long a country
will be in each stage
...

Epidemiologic transition: A characteristic shift in the disease pattern of a population as mortality falls during the
demographic transition like acute infectious diseases are reduced, while chronic, degenerative diseases increase in
prominence causing a gradual shift in the age pattern of mortality from younger to older ages is called epidemiologic
transition
...

2
...


The age of pestilence and feminine
The age of receding pandemics
The age of chronic diseases

They are discussed below:
First epidemiological transition: The first epidemiological transition occurred in 100 centuries ago when man moved
towards the agricultural society
...
Even the cultivation of soil and the
cleaning of land, people exposed to insect bites, bacteria and parasites
...
In this time, epidemic, famines and wars caused
huge numbers of deaths; infectious diseases were dominant, causing high mortality rates, especially among children
...
Q fever, anthrax, tuberculosis
gained access to human hosts
...
Small pox, cholera, plague, influenza and typhus all became major scourges for humanity
...
C
...
In Europe, near the end of the eighteenth
century, the disease accounted for nearly 400,000 deaths each year
...

The worldwide death toll was staggering and continued well into the twentieth century, where mortality has
been estimated at 300 to 500 million
...
C
...
Over a five-year period from 1347 to 1352,
25 million people died
...

Cholera: The major cholera pandemics age generally listed as:
⸺ First: 1817 – 1823
...


21

⸺
⸺
⸺
⸺
⸺

Third: 1852 – 1859
...

Fifth: 1881 – 1896
...

Seventh: 1961 – 1970
...

Infant mortality rate 200 – 300 deaths per 1,000 live births
...


Second epidemiological transition: This phase was described as age of receding pandemics
...
CDR reaches a level of less than 30 deaths per 1,000
population
...
As a consequence, life expectancy at birth climbed rapidly from about
35 to 50 years
...

This improvement occurred before effective medical treatment and was due to impact of following interventions:
•
•
•
•
•

Clean water
Sanitary sewage
Mosquito suppression (malaria or yellow fever)
Increased food safety – refrigeration and pasteurization
Increased pre and post-natal care
...
g
...

Technology also brought with it smokestack industries, chemical toxins, working indoors, stress, greater access to less
healthful food; besides advances in medicine and sanitation
...

As fertility rates were high, population was growing rapidly at this stage of the health transition
...
As population and ecological pressures
increased, food and water became scarcer, and the lack of ecological and social resources may cause economic
development to stagnate
...

Third epidemiological transition: It began in the late 20th century
...
’ In the third stage, the elimination of infectious diseases makes way for chronic diseases among the elderly
...

While improved healthcare means that these are less lethal than infectious diseases, they nonetheless cause relatively
high levels of morbidity
...
Due to low levels of mortality and fertility, there is little population growth
...
By the end of the third stage, infant mortality reaches a
level of less than 25 deaths per 1,000 live births
...
However, the prevalence of one or more diseases means that such a log life also includes, on
average, a relatively long period of morbidity
...

In developed nations they are also driven by medical technology
...
At the same time, there is
increased demand for healthcare related to the diseases of older people
...

2
...

The destruction of group cohesion
...

4
...

6
...

Crime, delinquency
...

Alarming rise in medical costs
...

•
•
•

Group I: Communicable plus maternal, perinatal and nutritional conditions
...
g
...

Group III: Injuries including motor vehicle accidents, homicide and suicide
...
In developing countries, 55% of deaths are from communicable disease, 37%
of deaths are from noncommunicable disease and 8% from injuries
...
First, communicable disease is still a disproportionate
burden in developing countries
...

Double burden of disease: The coexistence of communicable and noncommunicable diseases (NCDs) is termed as
double burden of disease
...
The
prevalence of noncommunicable diseases has been on the rise in older people with longer life spans and due to
lifestyle and dietary factors as well as occupational and environmental hazards
...

The situation is more a concern in South Asia where the numbers of older people are rapidly growing and while
continuing to live in severe poverty and in difficult living conditions
...


23

Sample Questions and Answers
Q
...
List the major and minor diseases in Bangladesh
...

2
...

4
...

6
...

8
...

10
...
2
...

Q
...
Why to study global burden of disease?
Ans: Objectives
...
4
...

Q
...
What is DALY? How to calculate DALY?
Ans: From note
...
6
...

Ans: From note
...
7
...

6
...

8
...
g
...

Causation (causative agent vs marker)
Risk stratification to identify target population: Example is age>40 for mammography screening
...


Primary or major or common risk factors according to the WHO:
1
...

3
...

5
...

7
...


Unhealthy diet

Individual risk factors:
1
...

3
...


Community risk factors:
1
...

3
...


Social and economic conditions, such as poverty, employment and family composition
...

Culture such as practices, norms and values
...


Q
...
How to classify risk factors? Give examples
...

Q
...
List down the risk factors for type 2 diabetes, gestational diabetes, hypertension and COPD
...

2
...

4
...

6
...


Being over age 45
...

Being overweight
...

Being of a certain racial or ethnic group (African American, Hispanic or Latino American, Native American
or Asian American or Pacific Islander
...

Having had gestational diabetes during pregnancy
...

2
...

4
...

6
...


Being over age 25
...

Being overweight
...

Being of a certain racial or ethnic group (African American, Hispanic or Latino American, Native American
or Asian American or Pacific Islander
...

Having had a stillbirth of unknown cause
...

2
...

4
...

6
...

8
...

2
...

4
...


Exposure to air pollution
Breathing secondhand smoke
Working with chemicals, dust and fumes
A genetic condition called Alpha-1 deficiency
A history of childhood respiratory infection

Q
...
What stands for COPD?

25

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow
that interferes with normal breathing and is not fully reversible
...
COPD is not simply a "smoker's
cough" but an under-diagnosed, life-threatening lung disease
...
11
...
The magnitude of increased or decreased risk is expressed as a relative risk or
odds ratio
...
It represents the amount that could be prevented if the risk factor was eliminated
...
12
...

1
...


Case control (retrospective)
Cohort (prospective)

Q
...
How to calculate relative risk, odds ratio? How to interpret the result?
Ans: From note
...
14
...

Ans: From note
...
15
...

Thus it is high among people who have little health care, chiefly because infections, such as pneumonia, diarrhea and
cholera, are common among their infants
...
The
infant mortality rate in Ethiopia is one of the highest in the world
...

Infant mortality rate

𝑛𝑜
...
𝑜𝑓 𝑡ℎ𝑒 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑟𝑒𝑝𝑜𝑟𝑡𝑒𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙

× 100

Maternal mortality rate:
MMR =

𝑛𝑜
...
𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒

× 100,000

Maternal mortality rate reflects the standards of all aspects of maternal care (antenatal, delivery and postnatal)
...
That means out of 100,000 live births,
around 871 mothers die each year due to pregnancy related causes
...
16
...


26



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