Noncommunicable diseases: a global problem = Les maladies non transmissibles : un problème mondial [full issue]

WORLD HEALTH QUARTERLY· RAPPORT TRIMES I RIEL DE SANITAIRES MONDIALES NONCOMMUNICABLE DISEASES: A GLOBAL PROBLEM LES MALADIES NONTRANSMISSIBLES: • UN PROBLEME MONDIAL Vol. 41, No. 3/4, 1988 World Health Organization Organisation mondiale de la Santa Genive The World Health Organization is a specialized agency of the United Nations with pri- mary responsibility for international health matters and public health. Through this organi- zation, which was created in 1948, the health professionals of some 160 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 ofa level of health that will permit them to lead a socially and economically productive life. By means of direct technical cooperation with its Member States, and by stimulating such cooperation among them, WHO promotes the development of comprehensive health ser- vices, the prevention and control of diseases, the improvement of environmental conditions, the development of health manpower, the coordination and development of biomedical and health services research, and the planning and implementation of health programmes. These broad fields of endeavour encompass a wide variety of activities, such as developing systems of primary health care that reach the whole population of Member countries; pro- moting the health of mothers and children; combating malnutrition; controlling malaria and other communicable diseases including tuberculosis and leprosy; having achieved the era- dication of smallpox, promoting mass immunization against a number of other preventable diseases; improving mental health; providing safe water supplies; and training health per- SO'lnel of all categories. Progress towards better health throughout the world also demands international cooper- ation in such matters as establishing international standards for biological substances, pes- ticides and pharmaceuticals; formulating environmental health criteria; recommending international nonproprietary names for drugs; administering the International Health Regu- lations; revising the International Classification of Diseases, Injuries, and Causes of Death; and collecting and disseminating health statistical information. Further information on many aspects ofWHO's work is presented in the Organization's publications. The World Health Statistics Quarterly replaces (since l 978) the monthly World Heahh Statistics Report (published since l 967) and its forerunner the Epidemiological and Vital Statistics Report (published since l 94 7). It contains Special Subjects dealing with the detailed analysis of selected health topics of current interesL Annual subscription ( 1988) ......................... . Sw. fr. 8S.- Material from the Quarterly may be reproduced providing due acknowledgement is made. L'Organisation mondiale de la Sante (OMS), creee en l 948, est une institution specialisee des Nations Unies a qui incombe, sur le plan international, la responsabilitC principale en matiere de questions sanitaireset desante publique. Au sein de l'OMS, les professionnels de la sante de quelque l 60 pays echangent des connaissancesetdes donnees d'experience en vue de faire acceder d'ici l'an 2000 tous les habitants du monde a un niveau de sante qui leur permette de mener une vie socialement et economiquement productive. Grice a la cooperation technique qu'elle pratique avec ses Etats Membres ou qu'elle stimule entre eux, l'OMS s'emploie a promouvoir la misc sur pied de services de sante complets, la prevention et l'endiguement des maladies, l'amelioration de l'environnement, le developpement des personnels de sante, la coordination et le progres de la recherche bio· medicale et de la recherche sur les services de sante, ainsi que la planification et !'execution des programmes de sante. Le vaste domaine oil s'exerce !'action de l'OMS comporte des activites tres diverses: developpement des soins de sante primaires pour que toutes les populations puissent y avoir acces; promotion de la sante matemelle et infantile; la lutte contre la malnutrition; lutte contre le paludisme et d'autres maladies transmissibles, dont la tuberculose et la lepre; !'eradication de la variole etant realisee, promotion de la vaccination de masse contre un certain nombre d'autres maladies Cvitables; amClioration de la santC men tale; approvision· nement en eau saine; formation de personnels de santC de toutes categories. 11 est d'autres secteurs encore oll une cool)Cration intemationale s'impose pour assurer un meilleur etat de sante a travers le monde et l'OMS collabore notamment aux taches sui- vantes: etablissementd'etalons internationaux pour les produits biologiques, les pesticides et les preparations pharmaceutiques; formulation de criteres de salubrite de l'environnement; recommandations relatives aux. dCnominations communes intemationales pour les subs- tances phannaceutiques; application du Reglement sanitaire international; revision de la Classification internationale des maladies, traumatismes et causes de deces; rassemblement et diffusion d'informations statistiques sur la sante. On trouvera dans les publications de l'OMS de plus amples renseignements sur de nom- breux aspects des travaux de !'Organisation. Le Rapport trimestriel de Statistiques sanitaires mondiales remplace (depuis 1978) le Rapport de Stalisliques sanitaires mondiales (publie depuis 196 7) et son precurseur le Rapport epidemiologique et demographique (publie depuis 1947). II contient des Sujets speciaux qui presentent des analyses detaillees sur des sujets specifiques d'interet courant. Prix de l'abonnement annuel (1988) ............... . Fr. s. 8S,- La reproduction d'extraits du Rapport trimestriel est autorisee, sous reserve d'indication de la source. IX ISSN 0043 - 8510 PRINTED IN SWITZERLAND 88/7859 - Atar - 6200 Cover design: Fabienne Kiefer * T M F N Symbols used in tables Preliminary, approximate or estimated data. Data not available. Nil or magnitude negligible. Category not applicable. Total. Male. Female. Absolute numbers. © World Health Organization 1988 The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, terri- tory, city or area or of its authorities, or concerning the delim- itation of its frontiers or boundaries. The statistics which relate to the Federal Republic of Ger- many and the German Democratic Republic include the rele· vant statistics regarding Berlin for which separate data have not been supplied. This is without prejudice to any question of status which may be involved. Where the designation "country or area" appears in the headings of tables, it covers countries, territories, cities or areas. Signed articles express the opinions of the authors and do not necessarily represent the findings or policy of the World Health Organization. Couverture: Fabienne Kiefer * T M F N Explication des signes Donnee preliminaire, approximative ou estimative. Donnee non disponible. Zero OU quantite negligeable. Categorie non applicable. Total. Masculin. Feminin. Nombres absolus. © Organisation mondiale de la Sante 1988 Les appellations employees dans cette publication et la pre- sentation des donnees qui y figurent n'impliquent de la part du Secretariat de !'Organisation mondiale de la Sante aucune prise de position quant au statutjuridique des pays, territoires, villes ou zones, ou de leurs autorites, ni quant au trace de leurs frontieres ou limites. Les statistiques se rapportant a la Republique democratique allemande et a la Republique federale d' Allemagne compren- nent les statistiques pertinentes concernant Berlin pour lequel des donnees separees n'ont pas ete fournies. Toute question de statut demeure reservee. Lorsque !'appellation «pays ou zone» apparait dans le titre des tableaux, elle couvre les pays, territoires, villes ou zones. Les articles signes expriment les vues de leurs auteurs et ne correspondent pas necessairement aux conclusions ou a la politique adoptee par !'Organisation mondiale de la Sante. WORLD HEALTH STATISTICS QUARTERLY RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES Vol. 41, No. 3/4, 1988 NONCOMMUNICABLE DISEASES: A GLOBAL PROBLEM CONTENTS [Introduction - The growth of noncommunicable diseases as a global health priority problem] [French only]. Evgueni N. Page Shigan . . . . . . . . . . . . . . . . . . . . . . 104 Cancers of the stomach, lung and breast: mortality trends and control strategies. Kenneth Stanley, Jan Stjernsward & Valentin Koroltchouk . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years. The WHO MONICA Project . . . . . . . . . . . . . 115 Hypertension in developing countries. Aulikki Nissinen, Siegfried Bothig. Helena Granroth & Alan D. Lopez . . . . . . 14 1 Trends in cardiovascular disease mortality in industrialized countries since 1950. Kazuo Uemura & Zbynek Pisa . . . . . 155 Trends in the prevalence and incidence of diabetes: insulin- dependent diabetes mellitus in childhood. Marian Rewers. Ronald E. LaPorte, Hilary King & Jaakko Tuomilehto . . . . . 179 Trends in the prevalence and incidence of diabetes: non-insulin- dependent diabetes mellitus. Hilary King & Paul Zimmet . . . 190 World Health Organization activities in the field of diabetes mellitus. Hilary King & Mikhail P. Mitrofanov . . . . . . . . . 197 Descriptive occupational morbidity statistics. Thomas K. Ng 200 Distribution and control of some genetic disorders. Bernadette Modell & Victor Bulyzhenkov . . . . . . . . . . . 209 The activities of the Hungarian Centre for Congenital Anomaly Control. Andrew Czeizel . . . . . . . . . . . . . . . . . . . . . 219 Smoking trends and effects worldwide [summary]. Robert Masironi & Keith Rothwell . . . . . . . . . . . . . . . . . . . 239 The role of physical activity in the prevention and treatment of noncommunicable diseases. Igor P. Briazgounov . . . . . . . 242 The global prevalence of obesity - an initial overview of avail- able data. Michael Gurney & Jonathan Gorstein . . . . . . . . 251 The global impact of noncommunicable diseases: estimates and projections. Kenneth G. Manton . . . . . . . . . . . 255 Integrated programme for noncommunicable diseases pre- vention and control (NCDI. Evgueni N. Shigan . . . . . . 267 LES MALADIES NON TRANSMISSIBLES: UN PROBLEME MONDIAL SOMMAIRE Introduction - Les maladies non transmissibles dans le monde: un probleme prioritaire de same dont !'importance va croissant. Pages Evgueni N. Shigan . . . . . . . . . . . . . . . . . . . . . . . . 104 Cancers de l'estomac, du poumon et du sein: tendances de la mortalite et strategies de lutte [resume]. Kenneth Stanley, Jan Stjernswlird & Valentin Koroltchouk . . . . . . . . . . . . . . 113 Variation geographique des principaux facteurs de risque de cardiopathies coronariennes chez les hommes et les femmes de 35-64 ans [resume]. Le Projet MONICA de l'OMS . . . . . . . 136 L'hypertension dans les pays en developpement [resume]. Aulikki Nissinen, Siegfried BOthig, Helena Granroth & Alan D. Lopez . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Tendances de la mortalite par maladies cardio-vasculaires dans les pays industrialises, depuis 1950 [resume]. Kazuo Uemura & Zbynek Pisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Tendances observees dans la prevalence et !'incidence du dia- bete: diabete sucre insulino-dependant de l'enfant [resume]. Marian Rewers, Ronald E. LaPorte, Hilary King & Jaakko Tuomilehto . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Tendances observees dans la prevalence et !'incidence du dia- bete: diabete sucre non insulino-dependant [resume]. Hilary King & Paul Zimmet . . . . . . . . . . . . . . . . . . . . . . . 195 [Activites de l'OMS dans le domaine du diabete sucre] [anglais seulement]. Hilary King & Mikhail P. Mitrofanov . . . . . . . . 197 Statistiques descriptives de morbidite professionnelle [resume]. Thomas K. Ng . . . . . . . . . . . . . . . . . . . . . 206 Distribution de certains troubles genetiques et mesures de lutte [resume]. Bernadette Modell & Victor Bulyzhenkov . . . . . . 218 Les activites du centre hongrois de lutte contre les anomalies congenitales [resume]. Andrew Czeizel . . . . . . . . . . . . . 226 Tendances et effets du tabagisme dans le monde. Robert Masironi & Keith Rothwell . . . . . . . . . . . . . . . . . . . . 228 Role de I' activite physique dans la prevention et le traite- ment des maladies non transmissibles [resume]. Igor P. Briazgounov . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Prevalence mondiale de I' obesite - un premier apen;:u des donnees disponibles [resume]. Michael Gurney & Jonathan Gorstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Impact mondial des maladies non transmissibles : estimations et projections [resume]. Kenneth G. Manton . . . . . . . . . . 265 Programme integre de lutte contre les maladies non transmis- sibles [resume]. Evgueni N. Shigan . . . . . . . . . . . . . . . 273 - 104 - INTRODUCTION LES MALADIES NON TRANS[\IIISSIBLES DANS LE MONDE: UN PROBLEME PRIORITAIRE DE SANTE DONT L'IMPORT ANCE VA CROISSANT Evgueni N. Shigana Un systeme de sante peut etre considere comme un vaste ensemble complexe et dynamique forme de sous- systemes interrelies et etroitement associes a d'autres systemes ~xterieurs, socio-economiques, demographi- ques, env,ronnementaux, etc. pour la poursuite d'un o~jectif commun: la sante de la population. II serait pos- sible de classer tous les problemes de sante en fonction des differents niveaux des systemes de sante: soins individuels, soins de sante primaires, systemes de dis- trict, nationaux, regionaux ou mondiaux. Ces niveaux varient pour les pays en developpement et les pays developpes. Malgre les differences entre pays developpes et pays en developpement, les problemes de sante evoluent selon un schema previsible: les taux de mortalite dus aux mala- dies infectieuses declinent alors que la mortalite par pathologie non infectieuse augmente. Les maladies non transmissibles sont actuellement a I' origine de 70-80% des deces dans les pays developpes et de 45-50% dans les pays en developpement. Si cette tendance se maintient, ii est certain que les maladies non transmissibles joueront partout dans le monde un role beaucoup plus important. Or, ii faut supposer que cette tendance se maintiendra pour avoir une idee des proble- mes qui se poseront en priorite a l'avenir, tout en tenant compte de l'epidemie actuelle de SIDA. Du point de vue de la morbidite, les cardiopathies coro- nariennes, les accidents cerebro-vasculaires, le cancer, le diabete, les maladies mentales et les maladies respi- ratoires chroniques doivent etre consideres comme des problemes majeurs de sante. L • approche systemique peut etre utilisee pour degager le caractere multifactoriel des problemes de sante et con- struire un systeme d'activites axe sur les problemes. Bien que differentes, toutes ces maladies ont une struc- ture multifactorielle et, pour reduire la mortalite et la morbidite qui leur sont imputables, ii convient d'agir sur les principaux facteurs d'ordre socio-economique, com- portemental, environnemental et medico-biologique qui leur sont lies pour les eliminer ou du moins en reduire l'impact, ainsi que d'ameliorer l'action des systemes de sante et des autres systemes exterieurs (Fig. 1). L'etude des associations entre facteurs de risque et maladies souleve de nombreuses difficultes: • manque d'information (de donnees dynamiques no- tamment); • caractere qualitatif de nombreux facteurs; • interaction des facteurs de risque; • interaction des etats pathologiques; • concurrence entre les facteurs de risque pour plusieurs maladies; • Directeur, Division des maladies non transmissibles, Organisation mondiale de la Santi!:, Genl!ve. • difference des intervalles entre I' apparition du facteur de risque et celle de la maladie; • absence apparente de collaboration entre differentes specialites, etc. En depit de ces difficultes, on a pu recueillir de nombreu- ses donnees (epidemiologiques, cliniques, statistiques, etc.) qui viennent s'ajouter aux resultats (aussi bien posi- tifs que negatifs) des differents programmes d'interven- tion conc;:us pour prevenir et combattre les maladies non transmissibles. A des fins de gestion, tousles facteurs de risque peuvent etre classes en a) facteurs irreductibles (climat, age, sexe); et b) facteurs « reductibles » lies au mode de vie de l'individu, de la famille et de la communaute, aux soins de sante et a d'autres secteurs d'activite. Aussi, tout programme visant a resoudre des problemes de sante devrait-il comporter trois sous-programmes principaux: i) modification des comportements et modes de vie; ii) soins de sante; et iii) reorientation d' autres secteurs d'activite. Ces trois sous-programmes joueraient un role different selon la situation socio-economique, le niveau culture!, les principes fondamentaux de l'action sanitaire et les autres systemes d'activite existant dans les pays deve- loppes et en developpement. C'est !'instrument de programmation qui doit etre au centre de toute methodologie visant a resoudre les pro- blemes des maladies non transmissibles. L'elaboration des programmes de sante repose a l'heure actuelle sur des methodes epidemiologiques, economiques, mathe- matiques, specialisees et autres qui sont appliquees a differentes etapes du processus de programmation. T ous ces programmes peuvent etre elabores aux ni- veaux mondial, regional, national et communautaire, pour des populations entieres ou des groupes cibles bien definis (ecoliers, etudiants, travailleurs, etc.). II ressort de nombreuses etudes epidemiologiques que dans 70% des cas environ, de nombreuses maladies non transmissibles telles les cardiopathies, !'hypertension, le diabete, la bronchite chronique, le cancer du poumon, etc. peuvent etre imputees a des comportements et modes de vie particuliers. Aussi l'OMS porte-t-elle une attention toute particuliere a I' elaboration de program- mes axes sur les facteurs de risque (programmes antita- bac, d'amelioration de la nutrition et de lutte contre l'al- coolisme par exemple). On dispose deja de nombreuses preuves de leur efficacite. Par ailleurs, les programmes axes sur la maladie jouent un role important dans I' arsenal des mesures prises pour prevenir et combattre les maladies non transmissibles. Ces programmes, par exemple contre le cancer, !'hyper- tension, les cardiopathies ischemiques et le diabete, comportent differentes activites de lutte, notamment des mesures de prevention et de traitement, des recom- mandations en matiere de readaptation, etc. Pour cer- tains des plus developpes de ces programmes, on a Rapp. trimest. statist. sanit. mond., 41 (1988) 105 - FIG. 1 INTERACTIONS FACTEURS-MALADIE A. Facteurs soc10-econom,ques (logement, revenus. etc.) B. Facteurs b,ologiques (Age, sexe, md1ce de poids corporel) C. Facteurs env1ronnementaux (chmat. air, eau) D. Facteurs comportementaux E Facteurs lies aux soms de same F Facteurs medico- b,olog,ques ~.___I H m_alad,e----' f,t, rl -G-. -M-a-la-di-e --,, ~r--11. Ma-ladie ---, FIG. 1 INTERACTION OF DISEASE FACTORS A. Soc,oeconom,c factors (housing. income, etc.) B. Biological factors (age, sex. body-mass index) C Environmental factors (climate. air, water) D Behavioural factors E. Health-care acuv1ty factors F. medico- b,olog,cal factors selectionne certaines taches prioritaires qui ont beneficie d'une mise au point specifique (par exemple le pro- gramme MONICA, b ou le programme de soulagement de la douleur chez les cancereux). Etant donne I' evolution inquietante de la morbidite par diabete dans de nombreux pays developpes et en deve- loppement, l'OMS apporte un soin tout particulier, en collaboration avec la Federation internationale du diabe- te, a !'elaboration de differents programmes de lutte contre cette maladie. b MONICA : MONltoring of trends and determinants in CArdiovascular disease (Surveillance des tendances et des d~terminants des maladies cardio-vasculaires). Vair aussi Variation g1fographique des principaux facteurs de risque de cardiopathies coronariennes chez Jes hommes et les femmes de 35-64 ans [rlisumli), p. 136 du pr~sent num~ro. c Organisation mondiale de la Sant~. Report of a WHO consultation on an integrated noncommunicable disease prevention and control pro- gramme, Geneva, 16-19 .June 1980. (Document NCD/OND/80.1 - anglais seulement). Wld hhh statist. quart., 41 ( 1988) ~I~ H. di-sease----' f-.~, -G-. -d-1se-a-se--~, ~ ~, I. d,s-ease ---, A la suite d • une consultation tenue en 19aoc sur un pro- gramme integre de lutte contre les maladies non trans- missibles, l'OMS a mis sur pied des programmes int~- gres de sante communautaire pour la lutte contre les maladies non transmissibles (lnterhealth). Ce type de programme associe les ressources et les methodes actuellement utilisees pour pr~venir et combattre certai- nes grandes maladies non transmissibles et affections connexes et vise a unifier concriltement les differentes activites qui contribuent a promouvoir la sante au sein des collectivites. La methodologie du programme de lutte contra les mala- dies non transmissibles est suffisamment souple pour pouvoir @tre adaptee aux conditions propres aux R~- gions OMS, aux pays et aux districts, a l'environnement, aux modes de vie, etc. Les programmes de lutte contre les maladies non trans- missibles sont parfois axes sur certains groupes a ris- que, par exemple les femmes enceintes, les enfants, les etudiants, les travailleurs ou les personnes agees. - 106 - T ous ces programmes peuvent par ailleurs fonctionner comme des activites independantes OU etre integres 8 de grands programmes nationaux ou internationaux. Le septieme programme general de travail ( 1984-1989) actuellement en cours et le huitieme programme general de travail (prevu pour la periode 1990-1995) integrent tous les types de programmes conc;:us pour prevenir et combattre les maladies non transmissibles. Plusieurs spheres d'activite doivent etre prises en compte lors de I' elaboration de programmes de lutte contre les maladies non transmissibles. Tous devraient reposer sur des activites de recherche et l'OMS s'em- ploie a recueillir des donnees sur l'epidemiologie, la genetique, l'environnement, le comportement, les soins de sante et d'autres informations grace a un reseau de centres collaborateurs (universites, instituts de recher- che, laboratoires, etc.). Avec l'aide de specialistes de differentes disciplines (maladies non transmissibles, economie, sciences sociales, psychologie, etc.) ainsi que de consultants a court et a long terme, les equipes de l'OMS analysent ces donnees et !'experience acquise dans differents pays afin d'elaborer des directives ayant une base scientifique pour la mise en ceuvre de program- mes nationaux. L'OMS recueille egalement des donnees epidemiologi- ques sur la distribution geographique des facteurs de risque et des maladies, selon les regions, les pays et les localites. Ces donnees sont tres importantes car elles permettent d'etablir des comparaisons a l'echelle inter- nationale et d'adapter aux situations locales les directi- ves universelles formulees pour I' elaboration des pro- grammes nationaux. Dans la mesure ou de nombreux programmes de l'OMS sont deja executes au niveau national ou a celui du district, !'Organisation recueille des donnees statistiques dynamiques sur les facteurs de ris- que et I' evolution des taux de mortalite et de morbi- dite. Avant d'etre appliques a tout un pays, de nombreux programmes demandent a etre testes sur un modele experimental au sein des systemes existants de sante. II s'agit essentiellement de tester des types d'interven- tion, des methodes de gestion, etc. Les resultats, une fois evalues, des points de vue medical, economique et socio-comportemental, peuvent ensuite etre utilises pour !'elaboration de programmes nationaux dans d'au- tres pays. A cette fin, ii taut faire appel a une equipe interdiscipli- naire composee de specialistes de differentes disciplines (epidemiologie. sociologie, psychologie, economie, de- mographie, soins de sante, etc.) et chargee de coordon- ner les activites de nombreux secteurs non medicaux: entreprises industrielles, medias, ecoles, compagnies d'assurances, groupes et mouvements sociaux diffe- rents. Ainsi, l'OMS s'occupe de developper non seule- ment la formation monodisciplinaire d' epidemiologistes, de gestionnaires des soins de sante, etc .• mais aussi la formation pluridisciplinaire. Elle utilise des modules spe- ciaux de formation conc;:us pour fournir a une equipe de differents specialistes la possibilite de simuler toutes les etapes de l'Jlaboration d'un programme et de mettre au point un protocole programmatique simple. La modelisation joue egalement un role important dans !'elaboration des programmes de prevention et de lutte. Differents types de modeles mathematiques ont deja ete mis au point ou sont actuellement mis au point par l'OMS avec l'aide de plusieurs centres collaborateurs. Des modeles descriptifs sont utilises: • pour prevoir les tendances de differents taux de mor- talite et de morbidite et la frequence des facteurs de risque; • pour illustrer les interrelations entre les facteurs de risque, les maladies, leurs effets cumulatifs, de sub- stitution, concurrentiels et autres; • pour etfectuer le depistage precoce des cas nouveaux de maladies non transmissibles. Ces modeles sont tres importants lorsqu'il s'agit de pre- voir le nombre des cas de cancer, de maladies cardio- vasculaires, de diabete et d'autres maladies non trans- missibles; ils aident en effet a eviter de nombreuses erreurs lorsqu'il faut evaluer les ressources necessaires a I' elaboration de programmes nationaux de prevention et de lutte. On utilise un ensemble de modeles cout/efficacite pour comparer differents modes de prevention (modification du mode de vie, prevention secondaire par example), de diagnostic (evaluations pour le choix d'une technologie). de traitement (ditferentes methodes) et de soins (ambu- latoires, hospitalisation, etc.). Etant donne !'importance que revet I' evaluation des pro- grammes d'intervention, l'OMS met au point, avec l'aide de modeles mathematiques, les instruments methodolo- giques qui serviront a en prevoir l'efficacite et l'efficien- ce. Etant donne les options multiples qui s'offrent en matiere d'interventions, ii importe d'en connaitre l'effi- cacite et l'efficience previsibles pour selectionner !'inter- vention la plus acceptable susceptible d'etre utilisee ou mise a I' essai au sein des systemes existants de sante. Pour elaborer tous ces elements de I' ensemble des pro- grammes de lutte contre les maladies non transmissibles dans tous ses bureaux et dans les pays, l'OMS travaille en contact etroit avec plus de 80 centres collaborateurs partout dans le monde et beneficie de la participation d'environ 400 experts de pays developpes et en deve- loppement. Plusieurs organisations non gouvernementales jouent egalement dans ce domaine un role majeur: l'Union inter- nationale contre le cancer, la Ligue mondiale contre !'hy- pertension, I' Association internationale de lutte contre la mucoviscidose, et I' Association internationale d' epide- miologie. II incombe a l'OMS de faire fonction de catalyseur, de coordonner les activites d'organismes nationaux et in- ternationaux et de fournir des conseils et une orienta- tion methodologiques en matiere de lutte contre la maladie. Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 107 - CANCERS OF THE STOMACH, LUNG AND BREAST: MORTALITY TRENDS AND CONTROL STRATEGIES Kenneth Stanley.a Jan Stjernswardb & Valentin Koroltchouka Cancer is one of the three leading causes of death for the productive age group 15-55 years in both developed and developing countries. The other two leading causes of death are accidents and cardiovascular diseases. Cancer rates in developing countries are progressively ap- proaching those in the industrialized countries, mainly because of an increase in the average age of the popu- lation, continued improvement in the control of other major health problems, and a continued increase in tobacco use. The most common cancers worldwide are stomach cancer (670 OOO new cases each year), lung cancer (660 000) and breast cancer (570 000) (1). These three tumours, in addition to being the most frequent, provide valuable examples for illustrating the strengths and weaknesses of current national efforts to control cancer. In general, there are three approaches available for con- trolling a cancer: prevention, early detection and treat- ment. Not all are effective for most tumours; for some cancers, none are effective. Even though about one-third of cancers today are preventable, few effective national prevention programmes have been implemented. Simi- larly, one-third of today's tumours could be cured if they were diagnosed early; but again, only a limited number of countries have established both the early-detection and treatment services necessary to take advantage of the progress in medical science. Although considerable resources have been allocated globally to cancer re- search, efforts to implement the resultant findings are lagging far behind. At present in most countries, cancer control activities lack overall coordination. Usually, most of the resources are used for therapy, often at relatively high cost and with limited effect. In developing coun- tries, the great majority of patients are incurable at the time of diagnosis. While reduction of deaths from cancer is clearly the objective of any national effort, variations in national perspectives lead to major variations in national ap- proaches. For example: in most Western countries, if one were to ask what is the national goal in cancer, the response would be "to find a cure". Indeed, the over- whelming majority of resources for cancer are allocated to precisely that-finding a cure. However, it may be that a better response to the question would be "to prevent cancer" or "to detect cancer early and cure it". The determination of which strategy is best should clearly depend on an objective evaluation of what is effective for a given cancer. However, the situation is more complicated than a simple evaluation. The optimal control strategy may differ among countries for a speci- fic cancer, depending upon the extent of its morbidity and mortality and upon the specific economic, social and political situation. The optimal control strategy in one country may not even be among the top choices of pre- • Scientist, Cancer Unit, World Health Organization, Geneva. b Chief, Cancer Unit, World Health Organization, Geneva. Wld hlth statist. quart., 41 ( 1988) ferred strategies in another. As an example, consider a patient with an advanced cancer: aggressive multidrug chemotherapy may be considered to be the obvious choice by some, while active supportive care and relief of pain in a home-care environment may be a frequent choice by another. Sometimes even doctors in the same community will choose markedly different strategies such as these, based on personal preference. Further, as the proportion of the elderly increases, many societies are developing different strategies for disease control for them. Currently, aggressive therapeutic attempts to achieve a minor prolongation of the act of uncomfortable dying predominate over concerns for quality of life and dignity in death in a familiar environment (2). Care needs to be taken when identifying the criteria used to measure reduction in deaths from cancer. If unad- justed or age-adjusted mortality is used, then the disease pattern in the very elderly dominates. One wishes to avoid in the future having to deal with cancer-control activities which are considered a success, statistically, if elderly patients die from cardiovascular diseases and, conversely, with cardiovascular disease-control activ- ities which are considered a success if elderly patients die from cancer. Similarly, national priorities and strat- egies should not be mainly determined by the death of a few at a young age from a particular disease; the effect of chance variation in disease occurrence can be mis- leading. Occurrence of disease in a mainstream, prod- uctive population group should serve as the foundation for developing national policy. For these reasons, cancer mortality for individuals aged 50-54 years has been chosen as the primary measure for this article. While this statistic does not reveal the whole story. it does not suffer from being overwhelmed by what happens to the elderly population, and for most common cancers its rates are high enough to provide a reliable indicator. Information on cancer mortality trends for selected countries are taken from information made available to WHO by those countries (3). This article will review the mortality trends for each of the three most common tumours globally and the implica- tions of these trends. Effective approaches for control- ling these cancers and their utility for national cancer programmes are also discussed (Table 1). Stomach cancer Stomach-cancer mortality rates for cohorts of indi- viduals aged 50-54 years are given in Figs 1 & 2. Stomach-cancer rates in Japan are the highest in the world and are approximately 6-10 times the rate in the United States of America. Mortality from this disease has been consistently and significantly decreasing, by more than 50%, over the last 30 years. Although the rates for males (Fig. 1) are approximately twice the rates for females (Fig. 2), the relative ranking of the countries and the slope of the trends is nearly identical between the sexes. - 108 - TABLE 1. AVAILABILITY OF EFFECTIVE STRATEGIES FOR THE CONTROL OF THE THREE MOST COMMON CANCERS TABLEAU 1. EFFICACITE DES STRATEGIES DISPONIBLES POUR LUTTER CONTRE LES TROIS CANCERS LES PLUS COURANTS Number Tumour - Tumeur of cases• Nombre decas• Stomach - Estomac . . 670 Lung - Poumon 660 Breast - Sein 570 • Per year, in thousands - Par an, en milliers de cas. There is a surprising uniformity in the downward trends for this cancer in the nine countries analysed, clearly suggesting a common factor in the decline. Not only does this common factor appear to act uniformly over the entire time period in these countries, it also appears to affect both sexes similarly. While improvements in therapy might be the reason for declines in cancer mor- tality, this is not the case for stomach cancer; cancer- incidence trends are virtually identical to mortality trends for this disease and statistics on survival following diag- nosis have remained virtually unchanged over the last 10 years, with a five-year survival rate of approximately 15% (4). There are a number of theories concerning the precise reasons why stomach-cancer rates have been declining .. .., .t: c :, § ~ :;; Q. CD O> .. :;; Q. i t: 0 E CD .., " :, .. I- I § ~ 8. .. CD iii ,:;; lii " .., ,!,! "' u 8. .. d, O> <( FIG. 1 STOMACH-CANCER MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF MALES TENDANCES DE LA MORTALITE PAR CANCER DE L'ESTOMAC: TAUX DE MORTALITE PAR AGE DANS LE GROUPE D' AGE 50-54 ANS, POUR DES COHORTES MASCULINES 180~------------------~ 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 o ', ' 1899- 1900 -. 1904- 1905 --- Australia - Australie -·- Chile - Chili --- Finland - Finlande --- France ~ Japan - Japon ....... ••• ••• Poland - Pologne - Sweden - Sui:de -----· United Kingdom - Ftovaume·Uni •--o United States - EtaU·Unis d'Amirique ................... ·,. ............. ············· 1909- 1910 ···· ... 1914- 1915 1919- 1920 1924- 1925 1929- 1930 Central years of birth cohort - Ann6es centrales de la cohorte de naissance Source : Reference (3) - A616rence (3). Primary Earty Curative Pain prevention detection therapy relief Pr6vention 06pistage Th6rapie Soulagement primaire pr6coce curative de la douleur + ++ +++ ++ ++ ++ ++ worldwide, but none have been proven at this time. However, differences and decreases in stomach-cancer rates are almost certainly due to dietary habits or food preparation or preservation techniques. Theories asso- ciated with the increased use of refrigeration and avoid- ance of cured, pickled or smoked foods appear to be the most likely (5). It is important to note, however, that the medical com- munity cannot claim to have caused this decrease. The reductions appear to be an accidental by-product of gen- eral improvement in living standards and food-preserva- tion techniques. An important question in the control of stomach cancer concerns the effect, if any, of systematic screening .. .., ·g :, § ~ :;; Q. " ~ :;; Q. .., ~ t: 0 E CD .., " :, .. I- I § ~ :;; Q. .. " iii ,:;; lii " .., u "' ·13 CD Q. .. d, O> <( 901 FIG. 2 STOMACH-CANCER MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF FEMALES TENDANCES DE LA MORTALITE PAR CANCER DE L'ESTOMAC: TAUX DE MORTALITE PAR AGE DANS LE GROUPE D'AGE 50-54 ANS, POUR DES COHORTES FEMININES --- Australia - Australie -·- Chile - Chili 8+ --- Finland - Finlande --- France I I ·r 60 I 50 40 30 20 10 .......... _. Poland - Pologne --- Sweden - Suede ·-·---· United Kingdom - Royaume·Uni \,. ' \ ·,. '· -~·-- '·-- ', ~····-=---->'-----·--, ······· . ' ··.. ' ' •·... . ......... .. ,. ............... ·· ... ......... _::::::::········· --:······ -.. ~ i o i ~--~---~---'----~---'----'--" 1899- 1904- 1909- 1914- 1919- 1924- 1929- 1900 1905 1910 1915 1920 1925 1930 Central years of birth cohort - Annees centrales de Ja cohorte de naissance Source Reference (3) - Reference (3). Rapp. trimest. statist. sanit. mond., 41 (1988) - 109 programmes. The early detection of gastric cancer, by barium X-ray or endoscopy, has been widely performed in Japan because of high rates of this disease. In 1970, more than 2 million persons underwent examination for stomach cancer; currently, more than 5 million are screened each year (6). However, there is only limited evidence suggesting a benefit from this screening activ- ity. Comparison of the slopes of the mortality trends between Japan and Chile, where no such population screening has been done (see Figs 1 & 2), suggests that the national screening effort in Japan has only played a minor role, if any, in the observed stomach-cancer mor- tality decreases. Further, as no controlled studies con- clusively show a mortality reduction associated with screening for gastric cancer, it cannot be recommended as routine public health policy (7). Lung cancer Lung-cancer mortality trends for males are given in Fig. 3. For most countries shown (and for virtually all other countries worldwide), the pattern is either of a steady increase or, in a few countries, an increase and a levelling off. The two exceptions are Finland and the United Kingdom, for which marked declines are evident. These trends are nearly entirely attributable to earlier trends in tobacco consumption, as can be seen from Fig. 4. The consumption of cigarettes was high in Finland and the United Kingdom in the 1950s and earlier. This is reflected in their high rates of lung cancer for the earlier cohorts in Fig. 3. However, both countries achieved a significant decrease in tobacco consumption; in Finland, this was a protracted consistent decrease since the 1960s, and in the United Kingdom, it has been a dra- matic decline since the mid-1970s. The effect was the same in both countries-major decreases in the most recent lung-cancer death rates. For Poland, per capita tobacco consumption has reached a high level, which is reflected in striking increases in lung-cancer deaths. Tobacco consumption continues to increase in France, with the predictable increase in lung cancer accompanying it. Recent decreases of tobacco consumption in Sweden and the United States have occurred, and decreases in their lung-cancer rates are expected to appear soon. Fig. 5 gives lung-cancer mortality trends for females. The general picture is one of substantial increases in nearly all countries. The sole decrease occurred recently for women in the United Kingdom. Over the last 20 years, death rates from lung cancer in women more than doubled in Japan, Norway, Poland, Sweden and the United Kingdom; increased by more than 200% in Australia, Denmark and New Zealand; and increased by more than 300% in Canada and the United States (8). During the 1960s, mortality from breast cancer was 3-6 times higher than from lung cancer in these countries. In recent years, this ratio has declined to around 1.5 and indeed it is estimated that lung-cancer deaths will exceed breast-cancer deaths in 1988 in Scotland and the United States. The lung-cancer mortality trends clearly demonstrate that the fight to control this disease worldwide is cur- rently being lost. A re-evaluation of the options and prio- rities is needed. What is the role of screening for lung cancer? Chest radiography and sputum cytology are the only methods available now for the detection of presymptomatic, early-stage lung cancer. Controlled trials involving the Wld hlth statist. quan .• 41 (1988) .: FIG. 3 LUNG-CANCER MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF MALES TENDANCES DE LA MORTALITE PAR CANCER DU POUMON: TAUX DE MORTALITE PAR AGE DANS LE GROUPE D'AGE 50-54 ANS, POUR DES COHORTES MASCULINES 180 ~---------------------, --- Australia - Auuralie 170 -·- Chile - Chili --- Finland - Finlande 2 160 ···---- ---France :s 8 [ .. "' .. ~ Japan - Japan •••••••••• ... Poland - Po\ogne 140 -------- Sweden - Su~e 130 ------· United Kingdom - Royaume·Uni .• •--• United States - Etats·Unis d'Am~rique ./ [ 120 ,----------....... ,. . ~ .. E E ~ " :s "' I- I 8 8 110 90 80 70 .c 40 i 'tl " ..;; " 8. " " ' <( ta i .. ~ >"' ~ c. ... c.!? ..!::3 :S't] 'tl"' "'~ ~"' 8. °: "" .. =~ ~ E! "'" "'"' ·o-s 'tl c: .... :; E -" " .. 'Si c: ~ "'"' ~i 30 20 10 i OL..L--.l.----'----_l__-.,.,.,1:---=~~~i 1899- 1904- 1909- 1914- 1919- 1924- 1929- 1900 1905 1910 1915 1920 1925 1930 Central years of birth cohort - Annt!es centrales de la cohorte de naissance Source Reference (31 - Reference (3}. FIG. 4 CONSUMPTION OF MANUFACTURED CIGARETTES PER ADULT (15 YEARS AND OVER) PER VEAR CONSOMMATION ANNUELLE DE CIGARETTES MANUFACTUREES, PAR ADULTE (15 ANS ET PLUS) 3500j 3000 2500 2000 I 15,,')0.; ! i ; !OOO~ I I 500~ ! / / / / .,.... ....... --..... ................. / -- France United Kingdom Roy au me-Uni Finla~d " Finlande Sweden Suede 1950 1955 1960 1965 1970 1975 1980 1985 Year - Annee Source: WHO - OMS. 110 - .. .., ·2 ::, § ~ :. Q. " a> "" :. Q. .., ·"' ii t: 0 E " .,, >< ::, ., I- I FIG. 5 LUNG-CANCER MORTALITY TRENDS: AGE-SPECIFIC MORT ALITV RATES AT AGES 50-54 FOR COHORTS 50 I OF FEMALES TENDANCES DE LA MORTALITE PAR CANCER DU POUMON: TAUX DE MORTALITE PAR AGE, DANS LE GROUPE D' AGE 50-54 ANS, POUR DES COHORTES FEMININES --- Australia - Australie ~ -·- Chiie - Chili I --- Finland - Finlande --- France ffl~ ~ Japan - Japan ............. Poland - Pologne - Sweden - Suede 30' § 20 ~ 1899- 1900 1904- 1905 1909- 1910 1914- 1915 1919- 1920 1924- 1925 1929- 1930 Central years of birth cohort - Annees centrales de la cohorte de na,ssance Source: Reference (3) - R<!ference (3). periodic application of these two procedures to high-risk populations have so far failed to demonstrate a signifi- cant reduction in lung-cancer mortality. Until screening by radiography and cytology (or other diagnostic meth- ods) can be proved to prolong life and improve its qual- ity, programmes of screening should be confined to well- designed controlled trials (9). Can advances in therapy be relied upon to significantly reduce mortality 7 Unfortunately, chemotherapy for small-cell disease is virtually the only area with recent significant progress. Cure rates remain low and relatively unchanged, with a five-year survival rate for all stages of the disease at approximately 10%. Primary prevention offers the best alternative for con- trolling lung cancer; tobacco is the most important cause of lung cancer. In countries with a history of prolonged cigarette usage, 80-90% of lung-cancer and 30% of all cancer deaths are attributable to tobacco smoking. A clear-cut dose-response relationship has been observed between cigarette smoking and lung cancer, and the risk has been found to be greater among those who started smoking at a young age. Further, the risk of lung cancer in non-smokers is increased by 25-35% due to passive smoking, the breathing of other people's tobacco smoke. It is estimated that in the industrialized world, one-third of all males above age 15 smoke cigarettes; in the devel- oping countries, about one-half. The rate for females in the industrialized world is slightly lower than the rate for males; in the Third World, about 10% of females smoke, but this proportion is rising rapidly. Smoking rates are already high in many developing coun- tries. Eight of the 10 countries with the highest smoking rates among males are developing countries; of the top 30 countries, only 9 are industrialized countries. In the industrial world, smoking among men became widespread at the time of the First World War, 1914- 1918, peaking in the mid-1970s. Women in these coun- tries had been smoking since the Second World War, 1939-1945; but, as a result of advertisements in the 1960s which, for instance, linked smoking to women's rights and proclaimed "You've come a long way, baby", today women are smoking nearly as much as men, if not more. In the Third World, cigarette smoking among men became predominant in the mid-1970s-later than in industrialized countries-and the increase among Third World women has only begun recently . Some 120 countries produce tobacco, and the develop- ing countries now account for 63% of the world tobacco production, compared with 50% in 1961-1963. WHO estimates that 1 tree in 6 is cut to cure tobacco. Yet the short-term profitability of tobacco has up to now out- weighed, politically, most attempts to influence crop choice; a situation reminiscent of the drug trade. The major tobacco-consuming countries are China (915 OOO tons), the United States (64 7 OOO tons), the USSR (360000 tons), India (335 OOO tons), Japan (225 OOO tons) and Brazil ( 164 OOO tons). Nearly half of the world's tobacco production is consumed by coun- tries classified as "developing". Overall, tobacco con- sumption has been slowing at a yearly rate of 1. 1 % in the industrialized nations but continuing to rise at a yearly rate of 2. 1 % in the Third World. The aim of tobacco-control programmes is to establish non-smoking as normal social behaviour, and the key is effective national action. The basic components of a tobacco-control programme are education, legislation and organization. Price increases and bans on advertis- ing are felt to be the most effective; tobacco companies vigorously oppose these measures. However, focus on any single component-such as public education alone-is unlikely to be successful. The optimal strategy is a comprehensive approach, where all major compo- nents are integrated and coordinated. The control of tobacco presents a different problem from most in public health. In this instance, the resist- ance to action is not a vector or a shortage of trained health-care workers, but rather is a well-organized inter- national industry with substantial monetary resources and an active media campaign, and which provides con- siderable revenue for governments and the media indus- try. Therefore, although strategies at the national level have been developed, implementation of these meas- ures meets with considerable resistance. Continuous evaluation of the strategies of tobacco control and coun- terstrategies of the tobacco industry form the basis of the modern public health effort in this area. One of the best measures of national commitment to tobacco control is the extent of national legislation. The enactment of legislation represents a maturity of public concern about the health effects of tobacco and is a significant milestone in national public health policy. Legislation has now been enacted in 64 countries as compared to only 19 in 1976 (10). The changing of personal behaviour requires not only legislation but also a comprehensive education pro- gramme. Mass-media campaigns primarily influence the public's knowledge and beliefs, but personal contact methods are needed to support and sustain improved health behaviour. It is now felt best to approach the risk habit through the same forces that develop and support Rapp. trimest. statist. sanit. mond., 41 (1988) - 111 - it; the key is to establish the correct "image" in the public's mind-a favourable social image for the non- smoker. The strongest evidence of effective national pro- grammes comes from the lung-cancer mortality reduc- tions seen in Finland and the United Kingdom, where comprehensive anti-smoking campaigns have been im- plemented (see Figs 1-3). If such forceful national anti- tobacco programmes are not enacted, a worldwide epi- demic of lung cancer is likely within a decade from the rapidly increasing tobacco consumption in many devel- oping countries. To win the war against lung cancer, we must first win the battle against tobacco. Breast cancer Breast-cancer mortality trends are given in Fig. 6. In gen- eral, mortality is increasing, with a few exceptions. Breast-cancer mortality trends for all age groups com- bined in the United States have been gradually, but gen- erally, increasing over the last 35 years. However, the death rate for women under 50 has been somewhat erratic; a general increase until the 1960s was followed by a steady decline until 1984-1985, when it rose by 5%. For women older than 50 years, the mortality rate has maintained a persistent increase. It is possible to ascribe at least part of the mortality decline in younger women in the 1970s and early 1980s to early detection [ .. ,g, FIG. 6 BREAST-CANCER MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF FEMALES TENDANCES DE LA MORTALITE PAR CANCER DU SEIN: TAUX DE MORTALITE PAR AGE DANS LE GROUPE D'AGE 50-54 ANS, POUR DES COHORTES FEMININES 90---------- ---------- [ --- Australia - Australie -·- Chile - Chih SO --- Finland - Ftnlande --- France ~ Japan - Japon ............. Poland - Pologne ,, ,, ,,, ,, ------- J ,,,----------- l / i [ 60 / I .,,' ..... o ____ o ____ o--.....-~-----,' ........ - ~ ·-........_. Ii ... ·" .; t: 0 E "' :, ., t- 1 8 8 .---· 50 ....-----:~ ! -----c:a,,.,.,,,.=----~°' ,,,. --- .... ~ - ,,. ........ _.,,,, ...... . _..,, ....... . . ·············· .. ;;· ·-. ..;....;.:-~::-i I ~- 20' ---·-__ • ___ _ r---· 10 - Sweden - Suf:de •••-••• United Kingdom - Royaume·Un1 o-United States - Etats·Unis d'AmiriQue 1899- 1900 1904- 1905 1909- 1910 1914- 1915 1919- 1920 1924- 1925 1929- 1930 Central years of birth cohort - Annees centrales de la cohorte de na,ssance Source · Reference (3/ - Reference (3). Wld hlth statist. quan .. 41 ( 1988) and therapeutic advances, because breast-cancer inci- dence in the United States rose by approximately 10% over the last 10 years. Similar observations can be made for Sweden, where the mortality trend for the younger women has been decreasing in spite of a rise in age-adjusted breast- cancer incidence of about 25% over the last 20 years (11). In both countries, considerable public atten- tion has been given to the value of the early detection of breast cancer, notably as promoted by wives of political leaders. However, while record numbers of women in the United States received mammograms last year, this still amounts to less than 16% of the women over 50. Although breast-cancer mortality in Finland in the 50-54 year group has risen by about 20% over the last 20 years, breast-cancer incidence has risen faster, by ap- proximately 65%. The substantial increase in mortality from breast cancer in the United Kingdom appears to be associated with a general increase in breast-cancer inci- dence, especially pronounced in the older age groups (12). In most developed countries and many developing coun- tries, breast cancer is the most frequent cancer and the leading cause of cancer death in women. About 1 in 11 women in industrialized countries will develop breast cancer. However, despite the magnitude ofthe problem, no practical methods of primary prevention are available at present. Once a woman is diagnosed as having breast cancer, her chance of surviving the next five years is approximately 75%. However, the prognosis depends upon the stage of the cancer at the time of diagnosis. About half of the cases are diagnosed as having local disease, where the five-year survival rate is 85%. In the other half of the cases, the disease will have spread to the lymph nodes or beyond, and these cases have a 50% survival rate. Hence screening (secondary prevention), which aims to detect the disease at an earlier stage than it would have been detected if allowed to continue until symptoms prompted a diagnosis, is an important strategy for the control of this disease. The smaller the lesion, the greater the likelihood of cure with local treatment. The three basic techniques for early detection of breast cancer are breast self-examination, physical exami- nation by a medical professional and mammography. In developed countries, approximate costs for breast examination by a physician are US$ 10-25, and for mammography US$ 50-100. Breast self-examination requires only a few minutes each month for a woman. The possibility of a false-positive result is a considerable drawback for breast-cancer screening. As many as 5-10 women who have no cancer will undergo the expense and trauma of an unnecessary biopsy for each case of cancer detected . Programmes to promote early breast-cancer detection and the screening of selected groups of the population have been under way in a number of countries for more than two decades. These studies have consistently reported higher rates of detection of early disease during screening compared with accidental detection by the women themselves in the absence of a screening pro- gramme. A reduction in breast-cancer mortality of ap- proximately 30% was seen among women aged over 50 who were offered screening by mammography and phy- sical examination of the breasts by a physician in the Health Insurance Plan (HIP) trial, initiated in the United States in 1964 (13). Since then, a number of investiga- tions have been started that in general confirm the find- - 112 - ing that mammograph plus physical examination with or without breast self-examination are effective proce- dures in the early detection of breast cancer. However, breast-cancer screening programmes that use imaging technologies are expensive and for this reason cannot be adopted in most countries as a routine public health activity. Further, the validity and cost-effectiveness of screening programmes utilizing mammography in the general female population remains to be demonstrated, because prior investigations have largely dealt with sel- ected and highly motivated women. Despite current efforts to encourage earlier detection of breast cancer, as many as 80-90% of all such cases are accidentally detected by the women themselves. In the absence of public education programmes on breast cancer, detection often occurs at a late stage, especially in developing countries. Breast self-examination (BSE) therefore has been proposed as a means of reducing the breast-cancer problem. Although it is reported to be not as effective as mammography or examination by a trained physician, it may be a valuable approach, particu- larly in countries that cannot afford sophisticated screen- ing services for the entire female population at risk. BSE is simple, inexpensive, non-invasive and non-hazardous. In addition, it promotes responsibility for one's own health. On the other hand, BSE has been questioned by a number of investigators (14). It cannot be recommended for large-scale public health implementation until there is good evidence that it is effective in reducing mortality from breast cancer. Accordingly, prospective controlled FIG. 7 OVERALL CANCER-MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF MALES TENDANCES DE LA MORTALITE GENERALE PAR CANCER: TAUX DE MORTALITE PAR .AGE DANS LE GROUPE D' .AGE 50-54 ANS, POUR DES COHORTES MASCULINES Central years of birth cohort - Annees centrales de la cohorte de na1ssance Source . Reference /3) - Reference /3) trials of BSE were initiated in 1985 in the USSR, under the auspices of WHO, in order to establish the value of this potentially cost-effective technique (15). While the potential reduction in deaths from breast cancer that could be achieved by early detection appears to be substantial, the mortality reduction from improve- ment in treatment is modest, as best. Recent studies have shown some benefit associated with tamoxifen for post-menopausal women and with chemotherapy for premenopausal women with early (operable non-meta- static) breast cancer. These therapies can be safely given in a community setting by appropriately trained but non-specialist doctors and nursing personnel. Total cancers In 1985, WHO reported its study of cancer-mortality trends covering the period 1960-1980 in 28 industrial- ized countries, representing 75% of the population of the developed world (16). Controlling for population size and age structure, cancer deaths among males rose by 19% and among females declined by 2% over this period. The present analysis deals with specific country trends, a longer period of time, and a specifically sel- ected mortality endpoint. This was done in an effort to provide information on the effectiveness of various na- tional strategies and to provide insight into the role the major cancers play in determining the overall cancer pat- terns. Overall cancer-mortality trends are given in Figs 7 & 8. For males, the trends for Finland and the United Kingdom FIG. 8 OVERALL CANCER-MORTALITY TRENDS: AGE-SPECIFIC MORTALITY RATES AT AGES 50-54 FOR COHORTS OF FEMALES TENDANCES DE LA MORTALITE PAR CANCER: TAUX DE MORTALITE PAR .AGE DANS LE GROUPE D'.AGE 50-54 ANS, POUR DES COHORTES FEMININES ~ ~ 280~ ---·-- ------- 1 I ·- ---·-- -----·---1 i:' :, § 8 K :, "' I- I § 8 <I> "' § l 16+ --::_ 1 --- Australia - Auural1e -·- Chtle - Chili --- Finland - F1nlande ~~ ---France ~ Japan - Japan ••••••••••••• Poland - Pologne - -- - --- Sweden - Suene ~ I 120 ~ ------· United Kingdom - Royaume·Un1 I ~ IOOr o--o United States - E,ats·Unts d'Aml!:nque ---- --- - 1: oL ___ . _______ L ----· .1_ _ L ~ 1899- 1904- 1909- 1914- 1919- 1924- 1929- 1900 1905 19·10 1915 1920 1925 1930 Central years of birth cohort - Annees cemrales de la cohorte de na1ssance Source Reference (3) - Reference /3). Rapp. trimest. statist. sanit. mond .. 41 (1988) - 113 - were downward, reflecting the significant role in overall cancer mortality in males that was played by lung can- cer; deaths from lung cancer represented 34-35% of all cancer deaths in males in 1985 in these countries. The two countries with notable increases in cancer mor- tality in males were France and Poland. In France, 36% of this increase was due to lung cancer alone; for Poland, lung cancer accounted for 68% of this increase. For females, the picture was quite different, as moderate declines were seen for nearly all countries. However, declines in breast-cancer mortality, when they did exist, were not large. The majority of the decrease was due to declines in stomach and cervical cancer. Of the decline observed over the last 20 years in the United States and France, 30-35% was due to stomach cancer. In Chile and Japan, more of the decrease was due to stomach can- cer: 81 % and 60%, respectively. The 1985 WHO analysis of mortality trends in 28 devel- oped countries reported a decrease of 30% in mortality from cervical cancer, which is virtually the only common tumour showing a substantial decrease in mortality ow- ing mainly to action taken by the medical community; reductions were seen in countries that had clear screen- ing policies and a well-organized cytological screening system (17). SUMMARY Mortality trends for the three most common tumours- stomach, lung and breast cancer-were evaluated for nine countries. Stomach cancer is decreasing sharply and consistently in the countries studied. However, vir- tually all of this decline can be attributed to improve- ments in food preservation techniques and the resulting change in diet, rather than any action of the medical community. Lung cancer is rapidly increasing in most countries, especially in women, and is likely to become the dominant cancer worldwide by the end of this cen- tury. So far, only comprehensive tobacco-control pro- grammes in the United Kingdom and Finland have suc- ceeded in reversing the upward trend in lung-cancer mortality. Breast-cancer death rates are generally rising, although some recent, but probably short-term, declines have been seen. Effectiveness of the currently available approaches for each of the common cancers is summarized in Table 1. Because about half of worldwide mortality from cancer occurs in developing countries and resources in these countries are severely limited, care needs to be taken in the selection of proper priorities ( 18). The most effective tool we have at this time to deal with these tumours is the control of tobacco for the prevention of lung cancer. Comprehensive national programmes, consisting of leg- islative and education measures, are needed. The greatest decrease in breast-cancer mortality is likely to be the result of early detection and prompt treatment of the disease; public awareness of the value of early detection is an important factor here. Fortunately, mor- tality from stomach cancer is decreasing on its own, as little can be done to control this disease otherwise. The impact of therapy on the two most common cancers, stomach and lung cancer, is very limited, although con- siderable resources are consumed worldwide in this effort. Only by careful evaluation of cost-effectiveness ( 19) and critical analysis of mortality trends can we determine the best strategies for the future. Those ignorant of the mis- takes of the past are, it is still true, destined to repeat them. RESUME Cancers de I' estomac, du poumon et du sein: tendances de la mortalite et strategies de lutte Les tendances de la mortalite pour les trois cancers les plus repandus - estomac, poumon et sein - ont ete evaluees dans neuf pays. Le cancer de I' estomac y accuse une regression marquee et reguliere; toutefois, ce recul peut etre attribue dans sa quasi-totalite aux ameliorations des techniques de conservation des den- rees alimentaires et aux changements d'alimentation qui en ont resulte plutOt qu'a une action de la communaute medicale. La mortalite par cancer du poumon augmente rapidement dans la plupart des pays, surtout chez les femmes. Ce cancer sera probablement le cancer domi- nant dans le monde a la fin de ce siecle. Jusqu'a present, seuls les programmes complets de lutte contre le taba- gisme menes au Royaume-Uni et en Finlande ont ete capables d'inverser la tendance de la mortalite par can- cer du poumon. Le taux des cancers du sein est genera- lement en hausse bien qu'on ait enregistre recemment certains reculs, probablement a court terme. Le tableau 1 fournit un resume de I' efficacite des moyens de lutte actuellement disponibles pour chacun de ces trois cancers. Comme la moitie de la mortalite mondiale par cancer concerne les pays en developpement ou les ressources sont extremement limitees, ii convient Wld hlth statist. quan .• 41 ( 1988) d'operer avec soin la determination des priorites (18). L'arme la plus efficace dont nous disposons aujourd'hui contre ces tumeurs est la lutte contre le tabagisme pour la prevention du cancer du poumon. Des programmes nationaux complets comportant des mesures legislati- ves et educatives sont necessaires. La plus forte dimi- nution de la mortalite par cancer du sein sera probable- ment due au depistage precoce et au traitement rapide de la maladie; un facteur important a cet egard est la prise de conscience par le grand public de la valeur du depistage precoce. II est heureux que la mortalite par cancer de l'estomac regresse d'elle-meme car ii n'y a guere d'autres moyens de maitriser cette maladie. Les effets de la therapie contre les deux cancers les plus courants - estomac et poumon - sont tres limites mal- gre les ressources considerables que I' on consacre par- tout dans le monde a cet effort. Seules une evaluation soigneuse du rapport coOt-effica- cite (19) et une analyse critique des tendances de la mortalite nous permettront de determiner les meilleures strategies a adopter pour l'avenir. Ceux qui ne tiennent pas compte des erreurs commises dans le passe sont - cela reste vrai - condamnes a les repeter. - 114 - REFERENCES - REFERENCES 1. PARKIN. D.M. ET AL. Estimates of the worldwide fre- quency of sixteen major cancers in 1980. Interna- tional journal of cancer, 41: (in press-sous pres- se). 2. STJERNSWARD. J. ET AL. Quality of life of cancer patients-goals and objectives. In: Ventafridda, V. et al. (eds). Assessment of quality of life and cancer treatment. Amsterdam, Excerpta Medica, 1986. 3. WORLD HEAL TH ORGANIZATION. World health statistics annual. Geneva, WHO, 1987. ORGANISATION MONDIALE DE LA SANTE. Annuaire de sta- tistiques sanitaires mondiales. Geneve, OMS, 1987. 4. NATIONAL CANCER INSTITUTE. 1985 annual cancer sta- tistics review. Washington, National Cancer Insti- tute, 1985. 5. MIRVISH, S. The etiology of gastric cancer. Journal of the National Cancer Institute 71 : 629-64 7 (1983). 6. HEALTH AND WELFARE STATISTICS ASSOCIATION. 1987 health and welfare statistics in Japan. Tokyo, Health and Welfare Statistics Association, 1987. 7. CHAMBERLAIN. J. ET AL. UICC workshop of the project on evaluation of screening programmes for gas- trointestinal cancer. International journal of cancer, 37: 329-334 (1986). 8. Female lung cancer increases in developed coun- tries. Weekly epidemiological record, 61 (39): 297- 299 (1986). Le cancer du poumon chez les femmes en augmen- tation dans les pays developpes. Re/eve epidemio- logique hebdomadaire, 61 (39): 297-299 ( 1986). 9. Lung cancer-the situation today: report of a WHO meeting. World health forum, 5: 153-159 (1984). 10. ROEMER. R. Legislative action to combat the world smoking epidemic. Geneva, World Health Organiza- tion, 1982. 11. HAKULINEN, T. ET AL. Trends in cancer incidence in the Nordic countries. Acta pathologica, microbiologica et immunologica scandinavica, 94 (Suppl. 288, Section A): 1-151 (1986). 12. CANCER STATISTICS REGISTRATIONS. Cases of diag- nosed cancer registered in England and Wales, 1984. London, Office of Population Censuses and Surveys, 1988. 13. SHAPIRO. S. Ten-to-fourteen-year effects of breast- cancer screening on mortality. Journal of the Natio- nal Cancer Institute, 69 : 64 7-709 ( 1984). 14. WORLD HEALTH ORGANIZATION. Self-examination in the early detection of breast cancer: Memorandum from a WHO Meeting. Bulletin of the World Health Organization, 62 (6) : 861-869 ( 1984). ORGANISATION MONDIALE DE LA SANTE. L'auto-examen dans la detection precoce du cancer du sein : Memo- randum d'une Reunion de l'OMS. Bulletin de /'Orga- nisation mondiale de la Sante, 63 (3): 495-503 (1985). 15. SEMIGLAZOV. v. F. & MOISEENKO, v. M. Breast self- examination for the early detection of breast can- cer: a USSR/WHO controlled trial in Leningrad. Bulletin of the World Health Organization, 65 (3): 391-396 ( 1987). SEMIGLAZOV. v. F. & MOISEENKO, v. M. Auto-examen des seins dans le depistage precoce des cancers du sein: essai controle URSS/OMS a Leningrad [resu- me]. Bulletin de /'Organisation mondiale de la Sante, 65 (3). 395 (1987). 16. WORLD HEALTH ORGANIZATION. Cancer in developed countries: assessing the trends. WHO Chronicle, 39(3): 109-111 (1985). ORGANISATION MONDIALE DE LA SANTE. Le cancer dans les pays developpes: evaluer les tendances. Chronique OMS, 39 (3): 116-118 (1985). 17. WORLD HEAL TH ORGANIZATION. Control of cancer of the cervix uteri. Bulletin of the World Health Organi- zation, 64 (4): 607-618 (1986). ORGANISATION MONDI ALE DE LA SANTE. Lutte contre le cancer du col de l'uterus [resume]. Bulletin de /'Or- ganisation mondiale de la Sante, 64 (4): 617-618 (1986). 18. ST JERNSWARD, J.Cancer control and the developing countries. Cancer topics, 6 (2): 18-20 (1986). 19. A WHO MEETING. The use of quantitative methods in planning national cancer-control programmes. Bulletin of the World Health Organization, 64 (5): 683-693 (1986). UNE REUNION DE L'OMS. Utilisation des methodes quantitatives pour la planification des programmes nationaux de lutte anticancereuse [resume]. Bulletin de /'Organisation mondiale de la Sante, 64 (5): 692- 693 (1986). Rapp. trimest. statist. sanit. mond., 41 ( 19881 - 115 - GEOGRAPHICAL VARIATION IN THE MAJOR RISK FACTORS OF CORONARY HEART DISEASE IN MEN AND WOMEN AGED 35-64 YEARS The WHO MONICA Projecta Cardiovascular diseases (CVD) are the major cause of premature deaths in most industrialized countries, where they may contribute nearly 50% of all deaths among the population aged 35-64 (1, 2). Much scientific effort has been expended in elucidating the role of various possible risk factors in the development of atherosclerosis and CVD. Although some of the mechanisms still remain unclear, there is a consensus that total serum choleste- rol, blood pressure and smoking are the major risk fac- tors for CVD as shown in numerous large-scale obser- vational and intervention studies (3-7). Knowledge about CVD risk factors has reached a sufficiently high level for WHO and national expert committees in several countries to recommend the initiation of public health policy actions aimed at lowering risk-factor levels (8- 14). The variation in CVD mortality obtaining in different countries and in different populations within countries has been the subject of extensive debate and numerous epidemiological studies. The first major international study in this area was the Seven Countries Study which showed that the differences in CVD incidence and mor- tality observed between populations were strongly as- sociated with levels of serum cholesterol, to some extent with blood pressure, but not with smoking (15). However, CVD rates in different countries are chang- ing (2). Data from population studies suggest that the levels of major risk factors are not stable and that in some countries changes in CVD mortality may be related to changes in risk factors (16-20). However, the evi- dence based on a few isolated observations in selected populations does not allow one to draw firm conclusions but rather stresses the need for further investigation. In the early 1980s, the WHO MONICA Projectb was ini- tiated in 27 countries.c The main objective of the MON- ICA Project is to assess the extent to which trends in coronary heart disease (CHO) and cerebrovascular dis- ease are related to changes in the levels of the major CVD risk factors in well-defined populations. Risk factors in the WHO MONICA Project are monitored through three (two in some populations) independent cross-sectional population surveysd (21). Although the main objective is to evaluate risk-factor trends, the adoption of a standard methodology for the surveys across the MONICA colla- borating centres makes it possible to compare cross- sectional data collected from different MONICA popu- lations. This article presents results from the first cross-sec- tional analysis of levels of the main risk factors in the • Prepared by: Andrzej Pajak. Department of biochemical diagnostics and inpatient clinic of metabolic diseases. Nicolaus Copernicus Medical Academy. Krak6w. Poland; Kari Kuulasmaa. Jaakko Tuomilehto & Esa Ruokokoski. MONICA Data Centre. National Public Health Institute, Department of Epidemiology, Helsinki, Finland. b MONICA-MONltoring of trends and determinants in CArdiovascu- lar diseases. See also reference (1). c For the list of MONICA sites and key personnel. see Annex, p. 138. d World Health Organization. MONICA Manual-Version 1. 1, Decem- ber 1986. (Draft document CVD/MNC/Version 1.1, 1987). • Collection of risk-factor data for the age group 25-34 years was optional. Wld hlth statist. quan., 41 (1988) populations studied in the WHO MONICA Project at the beginning of the study. Study populations and survey methods In the MONICA study, the smallest population groups for which data on risk factors are collected are called "re- porting units". They consist of persons aged 35-64 years,e with current chief residence in a chosen area delineated by clear geographical boundaries. Small re- porting units within some MONICA collaborating centres have been combined for data presentation. The popu- lations included in the present article are listed in Table 1, in which a summary of the population size, sample size, participation rate and survey period is given. The popu- lations studied are not representative of the country as a whole although in some collaborating centres the report- ing units have been chosen as being typical of the entire country. The size of the survey sample did not reflect the popu- lation size. There was a sixfold differential in the popu- lation size between the biggest and the smallest popu- lation, and a fourfold differential between the biggest and the smallest sample size. The sampling strategy was to have representative prob- ability samples within each sex and 10-year age group, at least for the age range 35-64 years. For the collabo- rating centres, the minimal sample size was 200 persons for each sex and 10-year age group. About half of the centres used simple random sampling or systematic ran- dom sampling which can be regarded as very close to simple random sampling in all reporting units. In the rest of the centres multistage sampling was used. The population surveys were carried out in collaborating centres within a period varying from four months to nearly four years and the participation rate achieved varied from 54% to 89% (Table 1). As the methods used have been described in detail else- where d (21), only a brief description of measurements and procedures used in the population survey is given here. Data on smoking were obtained through a standard questionnaire following standard instructions. In the pre- sent analysis responders have been classified into the following categories: regular cigarette smokers, if they reported they smoked cigarettes every day; other cur- rent smokers, if they were not regular cigarette smokers but reported that they smoked cigarettes occasionally or at least 1 g of pipe tobacco per week or at least 1 cigar per week; ex-smokers, if they reported they had smoked cigarettes regularly in the past but did not smoke currently; non-smokers, if they reported that they were not current smokers and had never smoked cigarettes regularly. The number of cigarettes smoked per day per regular or occasional cigarette smoker was used to characterize the current degree of exposure to cigarette smoke. - 116 - TABLE 1. MONICA COLLABORATING CENTRE, COUNTRY, POPULATION SIZE, SAMPLE SIZE, PARTICIPATION RATE AND POPULATION SURVEY PERIOD, BY POPULATION STUDIED TABLEAU 1. CENTRES COLLABORATEURS MONICA, PAYS, TAILLE DE LA POPULATION ET TAILLE DE L'ECHANTILLON, TAUX DE PARTICIPATION ET PERIODE OU A EU LIEU L'ENQUETE DE POPULATION, POUR CHAQUE POPULATION ETUDIEE Population Perth Newcastle Ghent - Gand Charleroi Luxembourg Province Province de Luxem- bourg Beijing Czechoslovakia - Tchecoslovaquie Glostrup North Karelia - Carelie du Nord Kuopio Province - Province de Kuopio Turku/Loimaa Berlin-Lichtenberg Halle County - Comte de Halle Karl-Marx-Stadt County - Comte de Karl- Marx-Stadt DDR MONICA (other surveys - autres enquetes) Bremen - Breme Rhein-Neckar Region - Region Rhin-Neckar Augsburg (urban - ville) Augsburg (rural) Budapest Pees Iceland - lslande Friuli - Friou! Auckland Belfast Tarnobrzeg Voivodship Warsaw - Varsovie Glasgow Catalonia - Catalogne Goteborg Stanford Kaunas Moscow (intervention) - Moscou (intervention) Moscow (control) - Moscou (temoin) Novosibirsk (intervention) Novosibirsk (control - temoin) Novi Sad Vaud/Fribourg Ticino - Tessin Malta - Malte Bas-Rhin Haute-Garonne Brianza Area - Zone de la Brianza Northern Sweden - Sui!de septentrionale 'Men and women, aged 35-64. MONICA Collaborating Centre/code Centre collaborateur MONICA/code 10 Perth 11 Newcastle 12 Ghent/Charleroi 12 Ghent/Charleroi 14 MONICA-Bellux 17 Sino-MONICA-Beijing 18 Czechoslovakia 19 DAN-MONICA 20 FINMONICA 20 FINMONICA 20 FINMONICA 23 ODA-MONICA 23 DDR-MONICA 23 ODA-MONICA 23 ODA-MONICA 24 Bremen 25 Heidelberg 26 Augsburg 26 Augsburg 27 HUN-MONICA 27 HUN-MONICA 28 Iceland 32 Monica-Friuli 33 Auckland 34 Belfast 35 POL-MONICA Krak6w 36 POL-MONICA Warsaw 37 Glasgow 39 MONICA- Catalonia 40 GOT-MONICA 43 Stanford 45 Kaunas 46 Moscow 46 Moscow 4 7 Siberian MONICA 4 7 Siberian MONICA 49 Novi Sad 50 MONICA-Switzerland 50 MONICA Switzerland 52 Malta 54 MONICA Strasbourg 55 MONICA Toulouse 5 7 Area Brianza 60 Northern Sweden Country - Pays Australia - Australia Australia - Australia Belgium - Belgique Belgium - Belgique Belgium - Belgique China - Chine Czechoslovakia - Tchecoslovaquie Denmark - Danemark Finland - Finlande Finland - Finlande Finland - Finlande German Dern. Rep. Rep. dem. allemande German Dern. Rep. Rep. dem. allemande German Dern. Rep. - Rep. dem. allemande German Dern. Rep. - Rep. dem. allemande Germany, Fed. Rep. of - Allemagne. Rep. fed. d' Germany, Fed. Rep. of - Allemagne, Rep. fed. d' Germany, Fed. Rep. of - Allemagne. Rep. fed. d' Germany, Fed. Rep. of - Allemagne, Rep. fed. d' Hungary - Hongrie Hungary - Hongrie Iceland - lslande Italy - ltalie New Zealand - Nouvelle- Zelande Northern Ireland - lrlande du Nord Poland - Pologne Poland - Pologne Scotland - Ecosse Spain - Espagne Sweden - Suede United States of America - Etats-Unis d' Ameri- que USSR - URSS USSR - URSS USSR - URSS USSR - URSS USSR - URSS Yugoslavia - Yougoslavie Switzerland - Suisse Switzerland - Suisse Malta - Malte France France Italy - ltalie Sweden - Suede Population size 8· b Taille de la population a. b 307 500 136 250 85 500 78 500 71 800 268 100 231 400 132000 59800 87 900 74200 75 300 248 400C 259 900C 191 9ooc 73 300C 235 900 95 300 109 500 94000 76 200 29 20oc 384 100 256 700 157 300 185 600 180100 135 100 367 300 153 400 84600 138 200 227 600 88 300 46400 144000 99000 280 200 110900 104400 314 200 296 900 333 200 189 700 Sample size a Taille de rechantillon a 1 535 3 658 1 437 1 391 3 614 1420 2 285 3 563 3085 2 397 3019 1 826C 2 865 1 866 2 118 1 472 1 793c 1 795 1 950 2649 3 373 3 600 1 536 1 046d 1461 1 402 2 086 3 598 1 825 1 720 3045 1448 1 966 1 948 2 249 2 264 1 773 1 501 ' Hammes et femmes, 35-64 ans. Participation rate Taux de participation 85 67 72 59 54 89 85 79 80 85 85 71 86 75 80 80 76 81 81 70 81 74 64 75 75 69 69 67 78 73 69 82 62 79 67 66• 58 71 84 Survey period Periode de renquAte 05.83-10.83 05.83-11.83 02.85-06.87 02.85-08.86 06.83-01.85 08.84-11 .85 03.85-11.85 11.82-02.84 01.82-04.82 01.82-04.82 01.82-04.82 04.84-05.85 11 .83-07 .84 82-11.85 82-11.84 05.84-11.84 09.83-07 .87 10.84-05.85 10.84-05.85 07.82-06.83 07.82-06.83 06.83-11.83 01.86-09.86 01.82-07.82 10.83-09.84 05.83-11.84 12.83-01.85 02.86-10.86 04.86-05.87 02.85-11.86 05.79-04.80 01.83-03.85 02.84-10.86 02.84-02.86 05.85-11.85 11.85-03.86 08.84-12.84 10.84-06.85 11.85-05.86 01.84-06.84 01.85-12.86 05.85-12.86 04.86-12.86 01.86-04.86 b Mid-year estimate of the year closest to survey examination period. Based on official demographic statistics. O Estimation au premier semestre de l'annee la plus proche de la p6riode d'examen de renqu~te. D'apres des statistiques demographiques officielles. c Data from all reporting units are not included in the present article. • Results for a subsample of the sample surveyed are reported. • Participation rate for Bas-Rhin concerns age group 25-64 years. c Le present article ne reproduit pas les donnees de toutes les unites de notifica- tion. • II s'agit des resultats obtenus i partir d'un sous-6chantillon de l'echantillon enqu~te. • Les taux de participation pour le Bas-Rhin concernent le groupe d'Age 25- 64 ans. Rapp. trimest. statist. sanit. mond., 41 ( 1988} - 117 - Height and body weight were measured with the subject in a standing position without shoes and heavy outer garments. Body-mass index (BMI) was calculated as weight divided by height squared (kg/m2) to characterize the relative weight of responders. Blood pressure was measured on the right arm, with the subject in a sitting position and after a minimum of 5 minutes of rest. In 10 collaborating centres random zero devices were used, and simple mercury sphygmoma- nometers were used in the rest of the centres. Two consecutive observations of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded to the nearest 2 mm Hg. DBP was read at the beginning of Korotkoff phase V. The mean value of two readings was used for the present analysis. Participants were asked whether they had ever been told by medical personnel that their blood pressure was high and whether they had been taking drugs for high blood pressure within two weeks prior to the examination. Based on the above information and on blood-pressure measurements at the survey, participants were classif- ied into one of the following categories: I. SBP < 160 mmHg and DBP <95 mmHg, on treat- ment for hypertension; II. SBP > 159 mmHg and/or DBP >94 mmHg, on treat- ment for hypertension; Ill. SBP > 159 mmHg and/or DBP >94 mmHg, not on treatment for hypertension; and IV. SBP <160 mmHg and DBP <95 mmHg, not on treatment for hypertension. A venous blood sample was drawn with the subject in a sitting position, with limited use of tourniquet. It was recommended that total cholesterol should be deter- mined on the day of blood collection. If not, samples should be stored after centrifugation, at 4° C for up to 4 days; if longer storage was necessary, they should immediately be frozen at - 20° C or lower. The enzy- matic method was recommended for cholesterol deter- mination and used by 25 collaborating centres. Other centres used the direct (Liebermann-Burchard) or extrac- tion method. Quality-assurance procedures In the MONICA Project, it was found essential that the survey procedures used within a single collaborating centre at two or three points over a 10-year period be identical so that centres will be able to detect changes in risk factors which are not related to changes in the data collection or measurement procedures. The standards for data collection and quality control were agreed by the Principal Investigators and described in detail in the MONICA Manual. d From 1983 all centres were asked to submit their local project manuals to the MONICA Management Centre and the Steering Commit- tee. During this review process centres received addi- tional advice concerning their survey plans and data col- lection and processing. Special attention was paid to training the survey person- nel. Detailed recommendations and guidelines were pro- vided centrally and training materials were made avail- able. For example, blood pressure observers should be tested by listening to a recorded series of Korotkoff sounds and certified once the difference between the reference value and the average of their readings of time sequences indicating for SBP and DBP is within the allowed limit. The blood pressure observer's code was included in the data file. Wld hlth statist. quan .• 41 ( 1988) Smoking data were collected by a widely used standard questionnaire (22). Measurement of serum thiocyanate was adopted as a control variable for self-reported data on smoking. The MONICA Quality Control Centre for Lipid Measure- ments in Prague, which was standardized to the Centers for Disease Control (CDC) in Atlanta, prepared recom- mendations for intra-laboratory quality-control proce- dures and organized continuous external quality control. Blind sets of samples were sent from Prague periodically to all collaborating laboratories with the exception of three laboratories which were standardized directly to the CDC. Acceptability criteria were based on coefficient of variation (standard deviation/mean) and per cent bias calculated separately for each set. Acceptable range of coefficient of variation depended on the total cholesterol concentration reference value. It varied from 2.4% for reference total cholesterol concentrations ;;;;,,, 10.0 mmol/1, to 6.5% for reference total cholesterol concen- trations ~2.6 mmol/1. The highest acceptable bias, based on total cholesterol concentration reference va- lues, was 5%. It was recommended that laboratories should not begin analysis of MONICA samples before they could show that their analyses of at least two suc- cessive external quality assessments were within the acceptability limits. Data management and statistical analysis Survey data were collected and checked locally by the collaborating centre research team before being trans- ferred to the MONICA Data Centre in Helsinki (Finland). Detailed instructions were prepared for extracting the standard set of variables from the local data files to be transferred from collaborating centres on magnetic tapes to the MONICA Data Centre. There, every variable was routinely checked in order to assure data quality and completeness. Data were included in the main data base only after the necessary corrections had been made by consulting the individual collaborating centres and their completeness for the reporting unit confirmed. As a general rule, data were not included in the present analysis unless they had been collected according to standard procedure and their quality assured by external quality assessment. Data on total cholesterol are given also for collaborating centres in which out-of-limit but stable bias (the difference between the lowest and the highest bias did not exceed 3%) and coefficient of var- iation within the accepted limit were found through external quality assessment. Data from collaborating centres where lipid laboratories were standardized di- rectly to the CDC were included in the analysis. For populations combining more than one reporting unit, data were weighted to yield results which were repre- sentative of the whole population, using the population sizes of particular reporting units. In addition, for all populations, age standardization was based on the world standard population weights-12/31, 11 /31 and 8/31 for the age groups 35-44, 45-54 and 55-64 respectively. Median, 10th and 90th percentile values were used to compare the distributions of particular risk factors between the populations studied. The proportions of persons with 0-3 risk factors were used to present the prevalence of different risk-factor combinations in those study populations for which data on three major risk factors were available. One risk factor was present (score 1) if a participant was classified either as a smoker or into categories 1-111 for blood pres- sure, or had a total cholesterol level ;;;,,,6.5 mmol/1. Every combination of two risk factors present was scored 2. The presence of all three risk factors was scored 3. 118 - FIG. 1 SMOKING Age - standardized proportions of regular cigarette smokers (A), other current smokers (B), ex- smokers (C) and non- smokers (D) Population Northern Sweden Iceland Auckland North Karella Augsburg (rural) Turku/ Loimaa Rhein-Neckar Region Vaud/ Fribourg Goteborg Berl in-Lichtenberg Perth Newcastle Kuopio Province Belfast Bas-Rhm Friuli Augsburg (urban) Haute-Garonne Karl -Marx-Stadt County Halle County Kaunas DDR MONICA (other surveys) Ticino Stanford Luxembourg Province Ghent Bnanza Area Czechoslovakia Glostrup Bremen M oscow (intervention) Ca talonia Moscow (control) Pees Malta Novi Sad M EN - HOMM ES (35-64) Charleroi ,11111111m~~~ft:~=j Budapest ~ Glasgow 11111111111~~~[~~ ~ Novosibirsk (intervention) Tarnobrzeg Voivodship Beijing Warsaw M~WW,M~'I.W'A""i(BJN'?JJ-?-µ'..4-~---1 0 25 Categones A ~ regular cigarette smokers B l2S2S2SJ other current smokers 50 75 100 C lZZZJ ex-smokers D c::::J non-smokers A 23 . 7 26 . 3 28 . 7 29 . 4 29.6 30 . 2 31. 0 32 2 32 . 3 32 . 3 32 . 8 32 . 9 33 . 0 34 .0 34 . 3 34 . 9 36 . 2 36 . 5 36 .8 38 .0 38 . 1 38 . 2 38 . 2 40 . 0 42 . 6 42. 7 43 . 5 44 2 4 4 . 6 4 4 . 8 46.2 47 . 3 48.3 48 .5 48 . 8 48 . 9 50. 2 51 . 9 52 . 4 53 . 4 57 . 9 58 . 58 . 5 58 . 8 B 10 . 7 24. 9 5. 6 7. 6 8 .2 8 . 7 7 .2 6.3 8.5 4 . 2 3 . 2 2 . 1 10 . 4 11 . 7 6 . 9 2 3. 6 . 6 2. 9 5. 3 . 6 .3 5 . 5 3 . 1 8 . 4 9. 1 3. 5 4 . 16. 1 9 3 . 10. 4 1. 3 0 . 7 4. 8 1. 6 5. 4 1. 0 9. 7 0.9 1. 2 2. 8 1 . 4 0.5 c 28 . 4 21 . 5 30 . 2 33 . 6 23 . 8 34 . 5 31 . 9 27.5 31. 6 34 . 2 31. 3 28 . 9 28 .8 27 .3 34 . 8 35 . 9 28. 31 . 4 31. 8 31 . 6 22 2 313 24 . 31 . 4 28 3 2:>. 4 27 .8 24 . 3 16. 33 5 19 . 3 2 2 1 25 . 9 22 . 1 14 . 3 24. 0 27 . 20 . 16 . 22 . 9 18 3 4 . 22 . 0 22 3 D 37.2 27.2 35 . 6 29 .4 38 . 4 26.6 30.0 34.0 27.7 29.3 32.7 36 . 1 27 .8 27.0 24 . 0 26.5 31. 7 25.5 28.6 24.5 36. 1 29.3 32 . 2 25.5 20.7 22 .8 25 . 2 27.3 22.4 19. 8 31 . 4 20 . 3 24.5 28.7 32 . 2 25.5 16.9 2 7 . 1 21. 5 22.8 22. 7 34. 5 18. 1 18. 4 No. obser- vations 640 657 1018 112 7 846 1194 1174 627 525 528 631 1218 969 927 666 719 712 678 804 983 728 978 781 426 990 a 539 618 948 14 56 633 11 63 397 770 607 695 592 384 566 502 601 1250 619 1309 1060 a Those reporting that they smoked less than 1 cigarette a day or less than 1 g of pipe tobacco a week, or less than one cigar a week have been classified as non· smokers. Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 119 - FIG. 1 TABAGISME Proportions (corrigees de l'age) de fumeurs habituels (A), de fumeurs occasionnels (B), d'anciens fumeurs (C) et de non-fumeurs (D) Population WOMEN - FEMMES (35-64) Novosibirsk (intervention) Rr·l---+----+----f-----j Novosibirsk (control) ~ ~jll,-,---+----+-----t----~ Kaunas Catalonia ~\11-.----+---t----t--~ ~Kr',n--;....,--t-----+-----t----~ North Karelia i:x t<) I/ J Moscow (intervention) R'.x:% '\I ~~~~+-----+-----+----4 Kuopio Province 12881:x V /1 Malta ~~ffi-fi,-,lx'l!'-,f--4-----t------!--------, Tarnobrzeg Voivodship Augsburg (rural) Moscow (control) Halle County Karl-Marx-Stadt County Bas-Rh in Haute-Garonne DDR MONICA (other surveys) <X'9x ~f// Turku/Loimaa~ ~OO#; l'>~?l'Jll/7/ ,;jT---t----r------j Beijing ~ Luxembourg Province ~~~,,,.,_~/~ /vJ;;i-----r----,---1 Augsburg (urban) ~000<~::XAA"'l?J-}/ ,;jT---i-----r----j Categories Brianza Area Vaud/Fribourg Rhein-Neckar Region Perth ~ x, / Czechoslovakia ~ r/ ,,1 Berlin-Lichtenberg ~~;,;x,xx xi,xix~r~///fr==E====t===3 Newcastle r"""""" r // Charleroi K ~ !7/ Ticino ~ N;,X,X J-f /,,;j Pees Ix~ '.If Auckland ~-;;;:;-~ ~),'. 1 Ghent~~ .?v ~ Friuli ~m Northern Sweden XXMX 7///1 0 25 50 75 100 A 2.7 3.4 3.8 5.5 8.2 8.7 9 .6 10.2 11.1 12. 0 12. 2 13.9 14.5 14 . 5 17. 4 17. 5 17.5 17 . 5 17 . 8 18 .4 18 .4 20 .6 21. 4 2 1. 9 22.0 22.8 23.3 23. 7 2 4 . 1 24.3 24 9 25 .0 26.4 26.5 27.8 29.3 33.4 33.7 34.5 35. 7 36.8 39.8 43. 7 50.2 A ~ fumeurs habituels C 1ZZZJ anciens fumeurs 8 ~ fumeurs occasionnels D c:::=:J non-fumeurs B 0.2 0. .2 .6 5.8 2.3 4. 7 6.0 0.8 3.4 1. 7 .3 1. 3 3.0 1. 5 0.0 5.0 1. 5 0. 3. 2.2 7. 7 3.5 0.6 3. 1 0.9 0.0 0.2 3 . 9 1. 2 2.5 0.2 2 1 4. 0 3.0 0.0 1. 9 1. 0 4. 3 1. 0 0.4 .6 5.9 1. 8 c 2.7 1. 6 2.5 3.2 6.5 3. 6 6.9 1. 1 2 . 4 9 . 2 5 . 4 6 9 . 0 7 . 1 11. 0 7. 6 9. 3 1 2 10. 1 9 . 7 4. 2 10 14. 4 16. 3 7.5 10.6 10 9 10. 6 9 0 4.9 24.6 10 5 9.5 16. 2 5.9 17 . 4 15 . 1 10 .4 21 . 3 7.4 16. 15 . 5 11. 8 11 . 8 D 94.5 94.6 92.5 89.7 79.4 85.4 78.9 82.8 85.6 75.3 80.7 75.0 77 . 2 75.3 70. 1 74.9 68.3 79.8 72. 0 68.8 75.2 61. 5 60.6 61. 2 67.5 65.7 65.8 65.4 63. 0 69.6 48.0 64.3 62.0 53.3 63.3 53.3 49.6 54.9 39.9 56.0 46.6 40. 1 38.6 36.2 No.- obser- vations 646 1054 735 389 1211 1234 978 756 1472 857 645 1059 897 714 645 1012 1269 641 958 a 679 639 568 1272 661 990 565 124 1 435 769 606 567 495 724 611 539 656 925 1337 564 538 517 704 1361 480 a Les personnes ayant declare qu'elles fumaient moins d'une cigarette par jour, ou mains d'un gramme de tabac par semaine, ou mains d'un cigare par semaine, figurent parmi les non-fumeurs . Wld hlth statist. quan .. 41 ( 1988) - 120 - FIG. 2 SMOKING Number of cigarettes smoked per day by cigarette smoker age-standardized 1 Oth (A), 50th (BI and 90th (Cl percentiles, mean (DI and standard deviation (El MEN - HOMMES (35-64) No. Population A B c D obser- vat ions Beijing 3 11 20 14 8 320 Northern Sweden 1 15 25 14 9 176 Brianza Area 4 15 30 17 12 285 Kaunas 2 15 20 13 8 302 Friuli 4 15 30 17 10 247 DDR MONICA (other surveys) 5 15 20 16 8 378 Karl-Marx-Stadt County 4 15 23 15 7 298 Halle County 5 15 20 14 8 396 Berlin-Lichtenberg 6 15 25 16 7 168 Glostrup 5 15 25 16 8 660 Catalonia 3 17 30 17 11 197 Haute-Garonne 5 20 30 18 11 252 Bas-Rhin 3 20 40 18 12 226 Malta 7 20 40 25 15 333 Ticino 1 20 40 20 14 337 Vaud/Fribourg 1 20 40 20 14 231 Novi Sad 10 20 40 24 11 284 Novosibirsk (control) 8 20 20 17 7 617 Novosibirsk (intervention) 10 20 25 17 7 320 Moscow (control) 7 20 25 17 8 364 Moscow (intervention) 8 20 30 18 8 514 Gllteborg 5 20 30 18 9 171 Glasgow 10 20 40 22 11 258 Warsaw 10 20 30 19 9 757 Tarnobrzeg Voivodship 10 20 30 19 9 718 Belfast 5 20 30 19 11 323 Auckland 3 20 36 21 12 287 Iceland 5 20 35 20 10 160 Pees 10 20 30 21 9 287 Budapest 10 20 40 23 10 290 Augsburg (rural) 1 20 40 18 13 287 Augsburg (urban) 6 20 40 20 12 259 Rhein-Neckar Region 5 20 30 19 10 363 Bremen 10 20 40 22 11 269 T urku/Loimaa 13 20 30 22 9 336 Kuopio Province 10 20 30 20 9 304 North Karelia 10 20 30 19 8 319 Czechoslovakia 3 20 30 17 9 435 Charleroi 7 20 37 21 12 189 Ghent 6 20 40 22 15 227 Newcastle 7 20 40 22 12 409 Perth 5 20 40 21 13 207 Stanford 7 25 40 27 14 154 0 10 20 30 40 50 Percentiles C:J -10th !ZZZl 10th-50th ESSSSl 50th-90th C:J 90th- Rapp. trimest. statist. sanit. mond., 41 (1988) - 121 - FIG. 2 TABAGISME Nombre de cigarettes consommees quotidiennement par fumeur 109 (A), 509 (8) et 909 (Cl centiles, moyenne (D) et ecart type (E), corriges de l'ige Population WOMEN - FEMMES (35-64) Novosibirsk (control) Beijing H'-+i'"'""'....-.:.+---+----+---+----1 Karl-Marx-Stadt County h,l-,;....+~~-l---+--+--+---1 Halle County Malta Kaunas Moscow (intervantion) Augsburg (rural) DDR MONICA (other surveys) l--+4--+'lc\--""¥,-.--.-..---l----+----1 Northern Sweden hr:fr,j~~~---t--+---j Brianza Area /,;ry"'71~*'~'"""""'"Ct---+-----, Haute-Garonne 1-,.1<;.-4-4--t~~~~~"l-------l---1 Novosibirsk (intervention) l-'-15>7"'71~*'~---t---+-----, Moscow (control) 1-.-"'~~~.;,..:...:s..:...---l----+----I Catalonia fL,:....f-~~*'-~--+--+---l Tarnobrzeg Voivodship HK-4-l~~Rl---+--+---1 Friuli h-l..+.,,._.,~*~--+--+----1 Augsburg (urban) µ,:..4-4-l~~Rl---+--+---1 Berlin-Lichentberg North Karelia Czechoslovakia Rhein-Neckar Region Warsaw f-~~rt~ffi--+--+---l Kuopio Province Glostrup Ticino Vaud/ Fribourg Novi Sad GOteborg 1---,,-j--<,,---i,.-',---H*~""'"tr--+--- Belfast h-:!K-7--IK~~~~:,q..--+---l Auckland fl-":...L..-4-lr"4-~~~+--+----J---...j Perth Iceland Ghent f---Ii-7"1:....f-7-1~"'""'e<J,.--+---l Stanford Glasgow f-'-~Hrr:,+ffi~+--J---j Budapest Charleroi f--f:;"717"-;"'7''7+~~*""--+-----, 0 10 20 30 40 50 Gentiles C:J -10• GSSSSJ so•-90• IZZZ] 10•-so• [=:=) 908 - Wld hlth statist. quart., 41 (1988) A B c D 1 5 20 7 7 2 5 15 7 5 2 6 15 8 5 1 6 15 7 5 1 7 25 11 11 1 7 20 8 8 2 8 20 9 6 2 8 20 11 11 4 8 15 9 4 4 10 20 11 6 3 10 20 11 7 2 10 30 13 12 1 10 20 12 9 1 10 20 10 7 2 10 20 9 7 1 10 15 9 7 3 10 20 14 8 3 10 20 10 7 2 10 20 13 9 4 10 20 12 7 5 10 20 13 7 10 20 10 7 4 12 22 14 9 5 13 20 13 7 5 13 20 13 6 5 13 20 13 7 2 15 30 15 11 1 15 30 13 11 3 15 25 15 9 6 15 20 14 7 3 15 30 16 10 1 15 25 15 9 8 15 25 17 8 5 15 30 16 10 8 15 25 16 7 6 15 25 17 10 4 15 25 15 9 5 17 20 15 7 6 17 31 19 13 3 20 30 18 11 7 20 30 18 9 5 20 30 17 8 5 21 30 20 11 No. obser- vations 40 115 119 176 99 35 137 126 139 169 127 115 112 18 72 24 158 182 141 131 93 223 274 451 85 612 214 165 157 194 324 148 128 176 194 287 147 261 120 176 24 1 183 101 - 122 - FIG. 3 BODY-MASS INDEX (KG/M 2 l age-standardized 1 Oth (Al, 50th (Bl and 90th (Cl percentiles, mean (Dl and standard deviation (El Population MEN - HOMMES (35-64) A B c D Beijing 19 . 5 2 3 . 4 2 7 . 6 2 3 . 4 3 . 1 GOteborg J----"1-':..,.£,-...,.,....,f-M~rf-----l---i 2 1 . 6 2 5 . 0 2 9 . 1 2 5 . 3 3 . 1 Tarnobrzeg Voivodship 20. 7 25. 2 30 . 6 25. 4 4. 0 Iceland 21 . 8 2 5. 4 30. 3 2 5 . 9 3. 5 Glasgow 2 1 . 4 2 5 . 4 3 0 . 1 2 5 . 8 4 . 0 Auckland 2 2 . 0 2 5 . 4 2 9 . 5 2 5 . 7 3 . 1 Glostrup 2 1 . 7 2 5 . 4 3 0 . 3 2 5 . 8 3 . 5 Brianza Area 2 1 . 9 2 5 . 5 JO . 3 2 5 . 8 3 . 4 Haute-Garonne 2 1 . 5 2 5 . 5 2 9 . 8 2 5 . 7 3 , 3 Perth J----t-+-f-f-ttm'tt'tJ,--+---1 2 1 . 6 2 5 . 5 2 9 . 8 ·2 5 . 7 3 . 4 Belfast 2 1 . 8 2 5 . 5 3 0 . 2 2 5 . 9 3 . 7 Luxembourg Province 21. 7 25 . 6 30 . 8 26. Q 3. 9 Stanford 217 25.6 29 .9 25.8 3.3 Moscow (control) 2 1 . 6 2 5 . 6 3 0 . 8 2 6 . 0 3 . 6 Northern Sweden 2 2 . 0 2 5 . 6 3 0 . 4 2 6 . 0 3 . 5 Moscow (Intervention) 2 1 . 8 2 5 . 7 3 0 . 4 2 6 . 0 3 . 5 Novosibirsk (control) 2 1 . 8 2 5 . 7 3 1 . 1 2 6 . 1 3 . 8 Budapest 2 1 . 3 2 5 . 8 3 0 . 8 2 6 . 1 3 . 8 Novosibirsk (intervention) 2 1 . 7 2 5 . 9 3 0 . 7 2 6 . 0 3 . 6 Berlin - Lichtenberg 21. 9 25. 9 30. 6 26 . 1 3. 4 Vaud/ Fribourg 22 . 1 2 5 . 9 3 0 . 3 2 6 . 2 3 . 4 Newcastle 2 2 , 2 2 6 . 0 3 0 . 8 2 6 . 4 3 . 6 Ghent 2 1 . 8 2 6 . 1 3 0 . 4 2 6 . I 3 . 5 Pees 2 1 . 3 2 6 . 1 3 1 . 6 2 6 . 4 4 . 3 Rhein·Neckar Region 22 . 4 26. 2 30 . 8 26. 4 3. 4 DDR MONICA (other surveys) 22. 6 26. j 31 . 2 26. 6 J. 5 Karl-Marx-Stadt County 2 2 . 3 2 6 . 3 3 0 . 9 2 6 . 4 3 . 5 Charleroi 2 2 . 5 2 6 . 3 3 1 . 5 2 6 . 9 4 . 2 Friuli 2 2 . 3 2 6 . 3 3 1 . 3 2 6 . 7 3 . 7 Bremen 22.7 26 .3 30 .9 26.6 3.5 Warsaw 2 2 . 1 2 6 . 4 3 1 . 7 2 6 . 7 3 . 9 Kuopio Province 22 1 26 4 31 6 26 8 3 9 t---f--",H-l~~~--t---1 . . . . . Turku/Loimaa 2 2 . 5 2 6 . 5 31 . 6 2 6 . 8 3 . 7 Catalonia 2 2 . Q 2 6 . 5 3 0 . 3 2 6 . 4 3 . 4 Halle County 22 . 8 26. 7 31 . 2 26. 9 3. 5 North Karelia 2 2 . 6 2 6 . 7 3 1 . 7 2 6 . 9 3 . 6 NoviSad 22.0 26.7 31.2 26.7 3.6 Augsburg (urban) 2 3 . 2 2 6 . 8 3 1 3 2 7 . 1 3 . 4 Ticino 2 2 . 7 2 6 . 8 J 1 . 8 2 7 . 0 3 , 6 Czechoslovakia 2 2 . 9 2 7 . 1 3 2 . 4 2 7 . 4 3 . 9 Malta 22 . 5 2 7 . 1 3 2 . 7 2 7 . 5 4 . 3 Bas-Rhin 22 . 8 2 7 . 3 3 2 . 5 2 7 . 4 3 . 7 Augsburg (rural) 2 3 . 4 2 7 . 3 3 1 . 9 2 7 . 5 3 . 5 Kaunas 2 3 . 2 2 7 . 5 3 2 . 1 2 7 . 7 3 . 6 15 20 25 Percentiles c=:J ~ 30 35 !ZZZJ 1 Oth-50th c=:J 90th- 40 No. obser- vations 616 517 1249 656 499 1019 1456 614 675 631 924 955 433 775 647 1145 1060 592 601 525 619 1219 425 608 1186 968 803 276 715 640 1309 976 1202 397 983 1146 606 710 781 946 644 663 839 728 Rapp. trimest. sratisr. sanit. mond., 41 (1988) - 123 - FIG. 3 INDICE DE MASSE CORPORELLE (KG/M 2 ) 108 (Al, 508 (BI et 908 (Cl centiles, moyenne (DI et ecart type (El, corriges de l'age Population WOMEN - FEMMES (35-64) A B c D G~strup 20 . 1 23 .5 30 .0 24 .4 4. 1 Stanford 1-----J-<',-4--+A--'~~"""'n----l----1 1 9 . 7 2 3 . 5 3 1 . 8 2 4 . 8 5 . 2 GOteborg 20. 2 23 . 6 29 . 6 24. 3 4. 0 Haute-Garonne 2 0 . 0 2 3 . 6 3 0 . 2 2 4 . 7 4 . 6 Auckland 2 0 . 2 2 3 . 7 2 9 . 5 2 4 . 5 4 . 2 Perth f---f,-',.-'r~~~--+---1 20. 0 23 . 8 JO . 0 24 . 7 4. 4 Beijing 1 9 . 8 2 3 . 9 2 9 . 5 2 4 . 5 4 . 0 Vaud/ Fribourg 20.1 24 .0 30 .8 24 .8 4.2 Iceland 2 0 . 5 2 4 . 2 3 0 . 5 2 4 . 8 4 . 0 Ticino 20 .2 24 .2 31 .2 25.2 4.8 Brianza Area 1----l"r'r~±><'~~tv---+----i 20 . 1 24. 3 31. 5 25 . 2 4. 7 Rhein-Neckar Region 20 ·. 4 24. 3 30 . 7 25. Q 4. 3 Newcastle l-----+J<,.-4--4---\tM-~~>h------l----1 2 0 . 4 2 4 . 5 3 1. 5 2 5 . 3 4 . 5 Berlin-Lichtenberg 20. 8 24. 7 J2 . Q 25. 7 4, 6 Northern Sweden 2 0 . 6 2 4 . 7 3 1 . 5 2 5 . 5 4 . 5 Belfast 2 0 . 6 2 4 . 8 3 1 . 4 2 5 . 5 4 . 4 Karl-Marx-Stadt County 21 . 0 24. g 32 . Q 25 . 7 4. 4 Catalonia 20.7 25 . 1 32 .4 25.8 4.6 Luxembourg Province l---+,.l<;....4---4---Jt~~~~~--1-----l 2 1 . 1 2 5 . 1 3 2 . 1 2 6 . 0 4 . 5 Augsburg (urban) I --J---1441t:W~~L....jf--L....j 2 0 , 8 2 5 , 2 3 2 , 5 2 6 . 0 4 . 6 Ghent ,- l---+,1-4-4-~~~1.:-.--+--~ 21 . 0 2 5 . 2 3 1 . 4 2 5 . 8 4 . 3 Turku/ Loimaa G 20. 8 25 . 5 32 . 4 26 . 1 5. 0 lasgow t----+-J.-,L,.-4--"i~~~~l.r---1----1 Bremen 21.4 25.5 32 .7 26 .3 4.5 B d , __ ..µ,..',--4....<;.l+\~~+'\.--l---~ 2 0 . 7 2 5 . 5 3 2 . 4 2 6 . 1 4 . 7 u apest ,- Friuli 2 1 · 3 2 5 . 6 3 2 . 6 2 6 . 5 4 . 7 Bas-Rhin 1----+--'-.4-.L,-<,HA,~rt!.'~,.,,._l------l 2 1 . 1 2 5 . 6 3 4 . 2 2 6 . 8 5 . 4 DDR MONICA (other surveys) 21 · 5 25 -8 33 · 6 26 · 8 4 · 9 Augsburg (rural) 2 1 . 5 2 5 . 8 3 3 . 2 2 6 . 7 4 . 7 Kuopio Province 21 . 7 2 5 . 9 3 2 . 7 2 6 . 6 4 . 5 Charleroi 20 . 9 26 . 0 33. 6 26. 8 5. 1 North Karelia 2 1 . 6 2 6 . 2 3 3 . 6 2 7 . 1 5 . 0 HalleCounty 21 .3 26 . 2 34 .2 27 .2 5.1 Catalonia 2 2 . 1 2 6 . 3 3 3 . 4 2 7 . 0 4 . 4 Pees 20 .5 26.4 33.8 26.9 5.4 Warsaw 21.7 26.8 34.3 27 .5 5.1 Czechoslovakia ~--+--.,_,..-¥-7'"<'<''<"-rn-.-------i 22 . 3 2 7 . 2 3 4 . 9 2 8 . 0 5 . 1 Tarnobrzeg Voivodship l---+-1...<~+-4~~~ffi~~----l 21 . 7 27 . 3 34 . 5 27 . 9 5. 1 Novi Sad 2 2 . 6 2 7 . 4 3 4 . 9 2 8 . 0 4 . 9 Moscow (control) 2 2 . 7 2 7 . 8 3 6 . 0 2 8 . 6 5 . 3 Moscow (intervention) 22. 1 28. 0 34. 3 28. 3 4. 9 Malta 22. 0 28 . 6 36. 5 29. 1 6. 0 Novosibirsk (control) 1-------l--..J+,..j<,...,',.-4~~~,.µi,----f 2 3 . 2 2 8 . 9 3 5 . 1 2 9 . 4 5 . 3 Novosibirsk (intervention) 2 3 . 8 2 9 . 1 3 5 . 2 2 9 . 7 5 . 1 Kaunas ~-_(___!:.4LL.'.Ll~~~L__j 23 . 4 29 . 3 35. 5 29 . 8 5. 2 15 Centiles C::J - 1 o• ~ 50'-90' Wld hlth statist. quart .. 41 ( 1988) 20 25 30 35 IZZZJ 10"-50' C::J go•- 40 No. obser- vations 1360 520 560 644 568 661 641 569 704 769 632 1292 1245 562 611 924 894 941 677 348 1282 482 661 580 726 713 1003 852 990 247 1239 1058 389 619 1337 987 14 72 576 650 1218 680 1052 646 735 124 - FIG. 4 SYSTOLIC BLOOD PRESSURE (mmHg) (MEAN OF TWO MEASUREMENTS) age-standardized 10th (Al, 50th (Bland 90th (Cl percentiles, mean (Dl and standard deviation (El MEN - HOMMES (35-64) No. Population A B c D E obser- vations Catalonia 105 121 146 123 18 397 a Iceland 107 123 146 126 16 657 Glostrup 108 125 148 127 17 1456 b Beijing 106 126 162 130 23 618 Ghent 110 126 146 128 16 426 a Stanford 110 127 147 128 16 434 Rhein-Neckar Region 110 128 153 131 17 739 Charleroi 114 129 151 130 15 275 a Newcastle 112 129 156 132 18 1219 a Haute-Garonne 113 130 150 131 16 678 Vaud/ Fribourg 112 130 153 132 16 624 a Tarnobrzeg Voivodship 111 130 160 135 20 1250 b Budapest 110 130 160 131 19 591 Luxembourg Province 114 131 153 13 2 16 985 abc Northern Sweden 112 131 151 131 16 64 7 a Ticino 112 131 156 133 17 781 a Novosibirsk (control) 1 TO 131 162 133 21 1060 Auckland 111 131 155 133 18 1019 Perth 112 131 159 133 19 631 Novi Sad 117 132 160 135 17 606 b Belfast 112 132 163 135 21 927 a Novosibirsk (intervention) 113 132 158 135 19 601 Moscow (control) 109 133 167 136 24 775 Augsburg (rural) 117 133 158 136 17 846 a Moscow (intervention) 115 134 164 137 20 11 65 Kaunas 111 134 165 137 21 728 Glasgow 116 134 165 138 20 498 a Augsburg (urban) 114 134 159 136 18 712 a Czechoslovakia 118 135 163 138 19 943 Brianza Area 115 135 162 137 19 615 b Malta 120 136 162 140 18 656 Pees 116 137 166 139 21 605 Halle County 117 137 164 139 19 982 Karl-Marx-Stadt County 121 138 164 141 19 796 Bremen 118 139 163 140 18 640 a Berlin-Lichtenberg 120 139 163 14 I 19 526 Warsaw 119 140 17 4 144 23 1309 Friuli 120 140 170 14 2 20 713 Turku/ loimaa 120 140 168 14 2 19 1199 DDR MONICA (other surveys) 122 142 163 143 19 529 Bas-Rhin 122 143 170 14 5 19 666 North K arelia 121 143 169 144 19 1144 Kuopio Province 124 145 171 14 7 18 977 100 120 140 160 180 Percentiles c=J -10th IZZZJ 10th-50th ~ 50th-90th C":J 90th- a Random zero devices were used to measure blood pressure . b Blood pressure was measured after venipuncture. c Blood pressure was measured on left arm in recumbent position . Rapp. trimest. statist. sanit. mond., 41 ( 19C8) - 125 - FIG. 4 PRESSION SYSTOLIQUE (mmHg) (MOYENNE DE DEUX MESURES) 108 (Al, 508 (BI et 908 (Cl centiles, moyenne (DI et ecart type (El, corriges de l'ige Population Iceland WOMEN - FEMMES (35-64) f-'-i'-+7'-7"'N~~~~r--t-------, Stanford H~~~~~~~L-f-----i Glostrup Perth H'-7","'7"7i"r~.¥<~<:'l.~...--t-------, Vaud/ Fribourg Auckland l-r",,-',,--4-4-1-.+~~~:,-----l-----i Rhein-Neckar Region Charleroi f-l-4-',--4-4-1~<"ti~~..,,_,.----lt------i Haute-Garonne Newcastle Northern Sweden Ticino Beijing Luxembourg Province ~~ry1-;~~~~~tj--l----j Augsburg (rural) Augsburg (urban) 1--.,.,.,_~-+-'rt~ttt-tt"'~~t-------, Belfast Budapest f--i,..'-,-~r&--'r-1~~~-tt"'~F------, Brianza Area 1----'~~H'-A~~~~tl---- Novosibirsk (control) Glasgow f----K---S-'l--$-~~~~~~~~,--- 1---4,-44-',..-4-~~~~~~;bt-r- Tarnobrzeg Voivodship l---"''-r4-4-''r4-"t'sc~~'l.~,"*"'f'->-''""-'-- Novi Sad Czechoslovakia Bas-Rhin Novosibirsk (intervention) r----'~rl'r""r-';~t-tt-tt"'~~~tt--~ Moscow (intervention) i---~rl',-7"';..--t-,~~"tt°'t«"tt"tt<,,.........----, Turku / Loimaa Moscow (control) r---rnl'r:-,'--r'~~m~~ITT~ Pees Bremen Berlin-Lichtenberg !---v-'-,4"''7",.£.,-',:"s~"""'~~~r-----, Friu1i Malta Warsaw Karl-Marx-Stadt County !----'r?t-',,--'r''r-7-tt-tt"'~+<:-l~~---i Halle County 1-----'"Hf'-7'-7~~~~~~~---i DDR MONICA (other surveys) North Karelia 1----',Y-.,r'--:,'---r-;,L-;l"~·~~·~~..,...,--j Kuopio Province l-----'1-'-<-........,;-4-......,._...,_,_,,_,__,._,_,...._...~ 100 Gentiles c=J - 10' ~50'-90' 120 140 160 !ZZZJ 10'-50' C:=]90•- 180 3 Pour mesurer la pression arterielle, on a utilise le systeme t. zero aleatoire . b La pression arterielle a ete mesuree apres ponction veineuse. A B 102 117 101 118 102 118 105 120 104 121 105 122 106 123 104 123 104 123 107 123 105 125 105 125 107 126 107 126 102 127 108 127 110 128 107 128 108 129 105 129 110 131 109 131 109 131 110 131 113 132 111 132 110 133 113 133 111 133 112 133 114 133 11 2 134 110 134 114 135 115 135 112 136 119 138 114 138 115 138 116 138 118 140 118 141 119 143 c La pression artE!rielle a ete mesuree sur le bras gauche en position allong0e. Wld hlth statist. quart., 41 11988) c D 144 121 146 121 143 120 148 123 147 124 150 126 148 126 150 125 153 126 147 125 150 126 156 128 154 128 154 129 157 129 157 130 157 132 157 130 162 132 160 129 160 134 163 134 166 134 170 13 7 160 135 171 13 7 160 134 166 137 170 138 170 138 166 13 7 179 14 1 170 138 168 138 163 137 166 138 165 141 176 14 2 164 140 172 141 170 143 169 142 176 146 17 18 17 17 17 20 18 18 20 15 18 20 18 20 23 20 20 20 22 21 20 24 22 23 19 24 20 21 24 24 21 28 24 22 21 22 20 25 20 22 20 20 22 No. obser- vations 348 a 389 a 703 520 1361 b 661 566 a 568 784 24 7 a 645 1245 a 614 a 769 a 641 94 9 abc 857a 679 a 923 a 579 630 b 1054 4 78 a 14 72 b 5 76 b 734 990 714 646 1239 1280 650 619 658 a 565 727 687 1337 889 1055 592 1238 988 126 - FIG. 5 DIASTOLIC BLOOD PRESSURE (mmHg) (MEAN OF TWO MEASUREMENTS) age-standardized 1 Oth (Al, 50th (BI and 90th (C) percentiles, mean (DI and standard deviation (El MEN - HOMMES (35-64) No. Population A B c D obser- vations Catalonia 64 74 90 76 11 397 a Luxembourg Province 66 78 93 79 11 985 abc Ghent 67 79 93 79 10 4 26 a Ticino 68 80 95 81 11 781 a Budapest 70 80 100 84 11 591 Glostrup 68 80 94 81 11 1456 b Vaud/ Fribourg 70 81 97 82 11 621 a Auckland 68 81 97 82 11 1016 Iceland 70 81 97 83 10 657 Charleroi 70 81 96 82 10 2 7 5 a Rhein-Neckar Region 69 82 97 82 11 738 Stanford 70 82 98 83 11 434 Northern Sweden 71 83 96 83 10 64 7 a Belfast 70 83 100 84 12 927 a Newcastle 71 83 96 83 10 1217 a Novi Sad 75 84 100 86 10 606 b Augsburg (urban) 71 84 100 85 12 712 a Bremen 70 84 99 85 12 640 Haute-Garonne 75 85 100 86 11 678 Tarnobrzeg Voivodship 70 85 100 86 12 1250 b Augsburg (rural) 71 85 98 85 11 846 a Czechoslovakia 75 85 100 87 11 943 Beijing 70 85 100 86 12 618 Perth 71 85 99 85 11 631 Malta 76 86 100 87 10 656 Novosibirsk (control) 71 86 104 87 13 1060 Halle County 73 86 101 87 11 982 Moscow (intervention) 73 87 103 88 12 1165 Glasgow 72 87 102 87 12 498 a Friuli 75 87 101 88 11 713 Pees 77 87 100 88 11 604 Berlin-Lichtenberg 78 87 102 89 10 526 Turku/Loimaa 72 87 102 87 12 1199 Brianza Area 74 88 100 87 10 615 b Kaunas 75 88 102 88 11 728 DDR MONICA (other surveys) 75 88 105 89 13 529 North Karelia 73 88 103 88 12 1144 Moscow (control) 73 89 107 90 13 775 Warsaw 76 89 105 90 12 1309 Novosibirsk (intervention) 75 90 105 90 12 601 Karl-Marx-Stadt County 78 90 104 90 11 796 Kuopio Province 74 90 106 90 12 977 Bas-Rh in 80 91 108 93 11 666 55 75 95 115 Percentiles c=J - 10th [ZZZ) 1 Oth-50th ~50th-gOth c=] 90th- a Random zero devices were used to measure blood pressure . b Blood pressure was measured after venipuncture. c Blood pressure was measured on left arm in recumbent position. Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 127 - FIG. 5 PRESSION DIASTOLIQUE (mmHg) (MOYENNE DE DEUX MESURESI 1oe (Al, soe (BI et goe (Cl centiles, moyenne (DI et ecart type (El, corriges de l'age Population Ghent WOMEN - FEMMES (35-64) f----r1+-,(-f-~~~<-h:"<r-f------i Auckland j-__!.~~7+1~~~,'>,L-I-----( Glostrup f---·Y~""-*'~M~tr-t------, Ticino Vaud / Fribourg Iceland f----f,-'7-',....<;t-t+~~+i..-t------, Luxembourg Province ,-v;7J/t;~~~q-r----l Charleroi f----,LfL,L74..,,._""'~~r+-------i Perth Belfast f-----f,..;.,...7~~"""~,.,_,-1-------1 Stanford Newcastle Haute-Garonne Budapest Augsburg (rural) ,--r,jt:;T,:t~~~[l~--1 Augsburg (urban) f----'-,,..L,-44-+*H.;~4J,,------I Beijing 1---fr'-ArY~~~,;I?-----( Turku/ Loirnaa Glasgow r---t:r'Th~~~fu-i-----i Friuli Bremen Novi Sad Czechoslovakia Brianza Area Moscow (intervention) r---t7;t//7A~~~~--I Kaunas Warsaw Berlin-Lichtenberg t------.-:t-v-'r'T"Tc~·~ct-<-~---, North Karelia Novosibirsk (control) Pees t-----",&f;ry~1~:'t*~~..__-__, Halle County Kuopio Province Malta Tarnobrzeg Voivodship Bas-Rhin t----...u..-fl,·'--r-7",,y.._>..._"'-<?#&-----1 Moscow (control) Karl-Marx-Stadt County f-----.1,.f,..-",-"'r-',o-+~~-"l~H'.4-'-"-'-'---I DDR MONICA (other surveys) f------.-1•.,;~.L-,,.~:,.,:..,-..,..~.~:i..--.-~--j Novosibirsk (intervention) Centiles 55 c:::=J -10' ~5oe.90• 75 95 IZZZJ 10' -50' c:::=J 90'- a Pour mesurer la pression art0rielle, on a utilise le systeme t.t zero alE!atoire. b La pression artE!rielle a ete mesuree apr0s ponction veineuse . c La pression arterielle a ete mesuree sur le bras gauche en position allongee. Wld hlth sratist. quart. , 41 (1988) 115 A B c D 60 72 87 73 63 74 87 75 63 76 92 77 64 76 90 77 65 77 92 78 65 77 90 78 68 77 91 78 64 77 92 77 65 77 90 78 64 78 94 78 66 78 93 79 67 79 95 80 66 79 90 78 65 79 94 79 68 80 95 80 70 80 95 82 70 80 100 83 68 80 94 81 67 80 96 81 68 80 97 81 68 81 96 82 68 82 100 83 70 82 100 84 68 82 97 83 72 83 98 84 70 83 98 84 71 83 99 84 71 84 101 86 71 84 101 86 71 84 101 85 73 84 99 85 71 84 100 85 71 85 103 86 72 85 101 86 72 85 101 86 72 85 100 86 75 86 100 87 70 86 100 87 74 87 101 88 73 87 109 89 74 87 102 87 76 88 103 89 73 89 107 90 E 10 10 11 10 11 10 10 11 10 12 11 12 10 11 10 11 11 11 12 12 11 12 11 12 10 11 10 13 11 12 11 11 13 12 12 11 10 12 12 14 11 11 13 No. obser- vations 389 a 348 a 567 1361 b 769 a 566 a 703 9 4 9 abc 24 7 a 781 661 923 a 518 124 5 a 614 a 645 579 857 a 679 a 641 1280 4 78 a 727 658 a 576 b 990 630 b 1239 734 1337 565 1238 1054 619 1055 988 688 14 72 b 714 650 889 592 646 128 - FIG. 6 AGE - STANDARDIZED PROPORTIONS OF CATEGORIES a OF BLOOD-PRESSURE INDEX Population Catalonia Ghent Glostrup Luxembourg Province Vaud/ Fribourg Ticino Charleroi Auckland Nonhern Sweden Augsburg (rural) Rhein-Neckar Region Novi Sad Stanford Belfast Beijing Penh Newcastle Haute-Garonne Bremen Moscow (intervention) Augsburg (urban) Tarnobrzeg Voivodship Novosibirsk (control) Kaunas Brianza Area Glasgow ){ )( xx '.JX.<1, x 1' x) x Czechoslovakia v:%'.t>'.l ... X 1.ll) Malta '/ ) 'bi x'x) X'> / • Halle County Friuli / )\, )c Turku / Loimaa ~ !"'.1<'-X/'.1<,/'>1'~1'./'.1<"' MEN - HOMMES (35-64) Novosibirsk (intervention) 1 ')'..r¥, "" ,, "" ~ ~~~xcx~~xJ><xcr--t-----t-------i 1Wl,iV ~ Moscow (control) Berlin-Lichtenberg Warsaw DDR MONICA (other surveys) Karl -Marx-Stadt County Nonh Karelia Bas-Rhin ~ XX/'XVX"-Xrv<vX"-/VlX x )( x Kuopio Province ~~~~.&~~~x~x~x~~:,,>l"1i----t-------j 0 25 50 75 100 Proponion (%) a Categories 2 1 5.3 3. 5. 4.4 3.6 6.5 4 . 4 5 2 2.7 9.3 5.8 7.7 . 8 1. 7 5.3 7 .9 3.8 3.0 1. 5 3.0 .6 . 7 . 2 . 0 4.5 6. 4.0 3.3 3. 4.2 2.0 2 2 6. . 7 . 0 3.8 .7 2.3 2 .9 Ill 12 5. 3. 4. 5 2. 8 8.5 3.3 7.0 3 10. 6 3. 12 . 2 2.4 10 . 5 3. 7 12. 3 . 8 11 . 4 3. 2 15. 7 4. 8. 2 6 . 6 10 . 3 4. 0 11. 8 3. 17 . 6 5 . 4 17 . 4.5 15.4 5.3 12 . 5 5 .6 16.3 2. 7 20.3 3. 21.2 4 . l 20. 6 5.3 17.9 4. 3 23. 7 . 8 18 . 6. 22. 7 3. 23 8 7 .0 18 .9 7. 3 21. 8 6.5 23 .8 6.3 7. 5. 6 .9 12 . 9 7. 9 . 6. 8. 7 7.8 8 . 8 24.5 24 . 28 . 3 27.5 17 .9 28. 22 28. 26. 32 . 2 33 . IV 91. 6 87.0 85. 84.5 82.0 81. 1 80.5 79.9 79 . 6 78.4 78.0 77. 4 76.6 76.3 75 . 4 74 . 9 74.3 74.3 74. 0 73.6 72. 3 72.2 70 . 7 69.6 68.9 68.0 67.6 66.9 66 . 4 66 . 1 64.5 64.3 63 4 62.9 62 62. 6 1 . 2 60.6 57.8 54.7 CZZZJ I Systolic blood pressure < 160 and diastolic blood pressure < 95 ; on treatment for hypenension. ~ II . Systolic blood pressure > 159 and/or diastolic blood pressure > 94; on treatment for hypenension. ~ Ill . Systolic blood pressure > 159 and/or diastolic blood pressure > 94, not on treatment for hypertension. c:::::::J IV. Systolic blood pressure < 160 and diastolic blood pressure < 95 ; not on treatment for hypenension. No. obser- vations 396 390 1380 971 602 745 275 1012 635 846 559 536 4 31 927 618 631 1217 622 633 1093 7 12 1191 1060 728 613 492 942 656 982 708 116 2 601 775 526 1309 529 796 1115 650 948 Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 129 - FIG. 6 PROPORTIONS DES CATEGORIES8 D'INDICE DEPRESSION ARTERIELLE, CORRIGEES DE L'#\GE Population Glostrup Catalonia Vaud/Fribourg Charleroi Ghent Stanford Ticino Rhein-Neckar Region Haute-Garonne Auckland Northern Sweden Penh Augsburg (rural) Augsburg (urban) Luxembourg Province r/ /, X> Belfast ,r/ ,,, rxrv,,v1 v, v' x x Beijing t/,: IX)<) Bremen R>;: X WOMEN - FEMMES (35-64) Turku/Loimaa ~~ ~ >cQ> f+l',ISY,~~~~---t~~~-t-~~--, Brianza Area 8'. ~ ~99'~H:r1-~~~;---~~~-1-~~~~ Newcastle W ~r-<> Glasgow~", Novi Sad Moscow (intervention) Friuli ~8 R'?:x1:x Kaunas t/;,J; /,~:~,;:,.__,&;().1;)Q"----i-----i---, Warsaw Czechoslovakia Novosibirsk (control) Bas-Rhin Berlin-Lichtenberg Tarnobrzeg Voivodship Nonh Karelia Karl-Marx-Stadt County Halle County Malta , / " v1\ XlL/x ',( ) f':11¥',,.' _x.. ; Moscow (ontrol) ~ XXXXl x ;;:;:;,< Kuopio Province I'// (Y ])(~ .. ~ Y'>...7>. Novosibirsk (intervention) ~~ :X X~ ~i'ts>~~~~'7't-~-1-~~~+--~~~~ DDR MONICA (other surveys) · x x" x/l i'-'-'-'-"U.. ..... .f>LS.C.c..L.~-1-~~~+-~~~~ 0 25 50 75 100 Proportion (x) a Categories 6.0 9.4 4.8 10.3 12.0 8. 1 5.4 8.2 .6 9.5 6. 1 7.6 5. 4. 8.2 4 . 7 5.2 3.3 .9 .4 11. 6 3.9 10. 3 6.5 . 6 7. 3. 9. . 7 6.0 9.8 .7 5.0 7 . 1 6.0 6 6. 6 . 5 5.8 8.0 1. 9 1. 2 3.0 1. 8 2.6 2,4 . 0 5.6 5. 2.3 5. 1 5.0 4 . 4. 5.0 .0 4.4 5. 1 5.4 8. 7 6.0 2 10 . 8.6 8 . 13. 9. 10. 8.3 8.3 12. 0 9. 10. 9. 9. 13.3 10. 8 9.0 13. 3 14 . 3 Ill 4.7 2.4 6. 3.6 1. 9 6.2 7. 6 3 . 5 7.6 6.4 7.6 6.5 9.8 10 . 8 6.3 11. 6 11. 9 14.9 14.0 11. 5 7.4 19.4 6 5 12. 9 16. 10. 3 18. 3 12. 0 18. 5 17. 8 10. 5 17. 6 19. 5 18. 20. 16.0 20.7 22 212 18 lZZZ) I Pression systolique < 160 et pression diastolique < 95; sous traiternent pour hypertension. ~ II. Pression systolique > 159 et/ou pression diastolique > 94; sous traitement pour hypertension. ~ Ill . Pression systolique > 159 et/ou pression diastolique > 94 ; hors traitement pour hypertension. c==J IV . Pression systolique < 160 et pression diastolique < 95; hors traitement pour hypertension. Wld hlth statist. quan., 41 ( 1988) IV 87 . 4 86.9 86.0 84.4 83.4 83 . 2 83.0 82.6 82.4 81. 9 81. 3 80.9 80.7 80 .6 80.4 79.7 78.5 76 .7 75.8 75.4 74 . 9 74. 6 72.3 72. 1 70.7 69. 69. 68.7 68.5 67.9 67.6 65.6 65.3 65.3 64.5 63.8 62.4 62.3 59.7 59.5 No. obser- vations 1339 389 551 247 311 518 759 608 626 566 608 661 857 6 79 937 923 64 1 650 1243 630 1245 475 519 1130 720 734 1337 988 1054 713 565 1428 1196 889 1055 687 649 964 646 592 - 130 - FIG. 7 TOTAL CHOLESTEROL (mmol/1) age-standardized 10th (Al, 50th (BI and 90th (Cl percentiles, mean (DI and standard deviation (El Population Beijing Stanford Tarnobrzeg Voivodship Bas-Rhin Ticino Warsaw Brianza Area Auckland Budapest Newcastle Rhein-Neckar Region Perth Haute-Garonne Kaunas Belfast Bremen Charleroi GOteborg Augsburg (rural) Turku/loimaa Iceland Ghent Glasgow Augsburg (urban) Kuopio Province Glostrup Vaud/Fribourg North Karelia Czechoslovakia Luxembourg Province 3 Percentiles c:J -10th ~ 50th-90th 5 MEN - HOMMES (35-64) 7 rzzzl 1 Oth-50th c:=:J 90th- a Samples were frozen before biochemical analysis. 9 b External quality assessment of bias was within the range + 4.6% to + 6 .3%. c External quality assessment of bias was within the range - 7 .4% to - 5 .5%. A B c D 3.3 4. 1 5.4 4.2 0.8 4.2 5 3 6.9 5.4 1. 1 4.2 5.3 6.6 5.4 1.0 4.3 5.5 7.0 5.6 1. 1 4 3 5.5 6.9 5.6 1. 4.4 5.5 6.8 5.6 1.0 4.2 5.6 7. 1 5.6 1. 1 4.5 5.7 7.0 5.7 .0 4.5 5.7 7.3 5.9 .3 4.5 5.7 7.3 5.8 1. 1 4.4 5.7 7.2 5.8 1.2 4.5 5.8 7.1 5.8 1. 4.5 5.9 7.3 5.9 1.2 4.7 5.9 7.4 6.0 1. 1 4.7 5 9 7.4 6.0 1. 1 4.8 6.0 7.7 6. .2 4.7 6 7.7 6. I. 4.7 6. 7.6 6.2 .2 4.8 6. 7.8 6.2 .2 4.9 6. 7.6 6.2 I. 1 5.0 6. 7 5 6.2 1.0 4.7 6. 1 7.7 6.2 1.2 4.9 6.2 7.7 6.3 .2 4.9 6.2 7.8 6.3 .2 4.9 6.2 7.9 6.4 2 4.9 6.2 7.9 6.3 .2 5.0 6.3 8 6.4 .2 5.0 6.3 7.9 6.4 2 5.0 6.3 7.9 6.4 .2 5.0 6.4 8. 1 6.5 .2 No. obser- vations 619 a 432 1238 a 638 a 751 c 1289 616 1005 a 586 a 1201 1158 626 a 659 727 a 916 62 7 a 266 a 499 a 808 1205 656 4 15 a 464 664 977 1454 b 620 1146 948 a 989 Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 131 - FIG. 7 CHOLESTEROL TOTAL (mmol/1) 1oe (Al, soe (BI et 908 (Cl centiles, moyenne (DI et ecart type (El, corriges de l'age Population Beijing Ticino Bas-Rhin Tarnobrzeg Voivodship Brianza Area Warsaw Newcastle Rhein-Neckar Region Haute-Garonne Budapest Charleroi Augsburg (rural) Ghent Kaunas Goteborg Belfast Glostrup Kuopio Province North Karelia Iceland Luxembourg Province Czechoslovakia Glasgow WOMEN - FEMMES (35-64) f-.!L.L.4-A>~~""'-n--+-~~-l t----~--'Lf-;11-+-f-;ltc\-t~~:\--~~-j 1--~~-.-~~+-J~~~~~~----j 1-----~~~.ll:f-:f---f-~tt<c~~~~--j 3 5 7 9 Centi les i==:J - 1 oe ~50•.900 IZZZJ 10'-50' i==:J so•- a Les 0chantillons ont 0t8 conge18s avant les analyses biochimiques . A B 3.3 4 . 2 4.0 5.2 4.0 5. 2 4. 1 5. 4 4.3 5.4 4.2 5.5 4.4 5.5 4.5 5.6 4.4 5.7 4.4 5.7 4.5 5.7 c D 5.5 4.3 6.6 5.3 6.6 5.3 6.8 5.4 6.9 5.5 7.0 5.5 6.8 5.6 7.3 5.8 7.2 5.8 7.4 5.8 7.2 5.8 E 0.9 1. .0 1. 1 1.0 1.1 .0 . 2 .2 1. 1. 4.4 4.4 4.6 5.7 7.2 5.8 7.4 5.8 7.5 5. 8 2 5.8bcl.2 6 . 0 . 2 4.7 5.9 7.5 6.0 1. 4.5 5.9 7.5 5.9 .2 4.6 6.0 7.5 6.0 .2 4.8 6.0 7.5 6.1 1. 1 4.7 6.0 7.9 6.1 .3 4.7 6.0 7.6 6.1 2 4.7 6.0 7.7 6.1 .2 4.7 6.0 7.8 6.2 .2 4.7 6.0 7.8 6.1 .2 4.8 6. 7.8 6.3 1.2 4.7 6.2 8.0 6.3 1.3 4.8 6.2 8.1 6.3 1.3 5.0 6.2 7.8 6.3 1.2 4.9 6 3 8. 1 6.4 .3 5.0 6.3 8.0 6.4 .2 4.8 6.4 8.3 6.4 .4 b L'evaluation externe de la qualit0 montre que le biais est de + 4,6% a + 6,3% . c L'8valuation externe de la quahtl!, montre que le biais est de - 7,4% a - 5 ,5% . Wld hlth starisr. quan., 41 ( 1988) No. obser- vations 641 a 513 731 c 666 a 1462 a 631 1301 1195 1257 606 562 a 650 a 565 a 225 825 330 a 544 735 a 54 7 a 914 623 640 a 1280 1359 b 988 1239 703 954 990 a 424 132 - FIG. 8 AGE-STANDARDIZED PROPORTIONS OF CATEGORIES OF RISK-FACTORS SCORE8 Population Beijing Auckland Ticino Rhein-Neckar Region Stanford Newcastle Penh Tarnobrzeg Voivodship Ghent Augsburg (rural) Brianza Area Kaunas Haute-Garonne Belfast Bas-Rhin Bremen Augsburg (urban) Warsaw Charleroi Luxembourg Province T urku/ Loimaa Glostrup Nonh Karelia Glasgow 0 a Score c::::::J 0 . No risk factors present. tzZZJ 1 1 risk factor present . ~ 2 . 2 risk factors present. 3. 3 risk factors present. 25 MEN - HOMMES (35-64) 50 75 Proportion (x) 100 No. 0 2 3 obser- vations 29.1 55.1 15 .5 0.3 618 42.5 40 .7 14 .5 2.3 997 38.3 44.6 14.8 2.2 715 341 37.5 36.4 36.8 23 .5 29. 1 48.3 43 .7 44.0 42. 1 546 48.2 15 .9 16. 5 17 . 3 19.5 19 . 9 20.8 1.7 2 2 2.3 .6 2.0 1.9 553 422 1196 626 1179 379 32.0 43.6 20.3 4.1 806 28 6 46 .6 21.7 3. 1 611 25.5 49.4 22 .3 2.8 727 32 .4 41.6 21 .9 4.1 603 28.8 43 .8 24 .0 3.3 596 29.8 42 .3 24. 1 3.7 916 26.9 44 .9 25.5 26 .7 44 .8 21.9 27.1 44.1 24.0 20.7 49.5 25.3 25.9 43 .3 28.0 23.8 44 .8 27.4 25. 7 42. 26.6 18 .9 48 .2 28.9 22.8 40.0 30 .5 19.7 42 .4 31.1 19 .4 39 .1 324 2. 7 632 6. 6 611 4.9 664 4.5 1289 2.7 265 4. 0 968 5. 7 1152 3.9 1378 6. 7 1099 6.8 942 9. 1 943 14 . 1 43.3 35.3 7.3 455 Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 133 - FIG. 8 PROPORTIONS DES CATEGORIES DE COTATION DES FACTEURS DE RISQUE,a CORRIGEES DE L'AGE Population Beijing Ticino Brianza Area Ghent Tarnobrzeg Voivodship Stanford Kaunas Augsburg (rural) Haute-Garonne Auckland Rhein-Neckar Region Bas-Rh in Perth Charleroi Augsburg (urban) Warsaw Newcastle Luxembourg Province Vaud / Fribourg Turku / loimaa Belfast Bremen North Karelia Kuopio Province Czechoslovakia Glostrup Glasgow 0 a cote i:::=::::i 0 . Aucun facteur de risque. IZZZJ 1 1 facteur de risque . ~ 2 . 2 facteurs de risque . 3 . 3 facteurs de risque . Wld hlth statist. quart .. 41 ( 1988) 25 WOMEN - FEMMES (35-64) 50 75 Proportion (x) 100 No. 0 2 3 obser- vations 62 .6 32.8 4.5 0. 1 641 52.5 38 . 1 8.3 1. 1 722 50 . 1 38 .6 10.8 0.4 620 45.7 42.2 9.8 2.2 294 4 8 . 7 38 . 7 12 . 1 0. 5 14 19 49 .2 37.8 12.0 1.0 503 45.7 40.6 13 .3 0.5 734 48.9 37.2 12 .9 1.0 825 51 . 2 34 . 6 12 . 9 1. 3 587 46.6 38 .8 13 . 7 0.8 557 43 .4 41.7 14 . 1 0.7 599 47.6 37.5 14.5 0 4 665 52.5 32.2 13.8 1.6 650 50 .6 33.8 13 .3 2.3 225 43 .5 40.1 14.9 .5 623 36 .4 46 .3 15 .2 2. 1 1301 44 .6 38.0 15 .4 2.0 1192 38.6 43 .3 16 .6 1.5 934 38 .2 43 .5 17.5 0.8 525 39.0 40 .3 18. 1 2. 7 12 28 36.4 41 .5 18.9 3.2 912 36.4 40.0 21.8 1.9 623 34 .5 41.9 21. 8 1.9 1171 35 .9 39 .5 22.5 2. 1 950 28.8 43 .4 25.6 2.3 988 28 . 1 43 .7 24.9 3.3 1337 21 .7 40 .5 32.5 5.4 414 134 - Results Smoking. Marked inter-population differences were found in the proportion of smokers which ranged from 34% to 62% in men and from 3% to 52% in women. The proportion of persons who had never smoked ranged from 17% to 38% in men and from 36% to 95% in women (Fig. 1J. The medians of number of cigarettes smoked by ciga- rette smoker were between 12 per day and 25 per day in men. In women, the highest median number of cigarettes smoked by cigarette smoker was 21 per day and the lowest 5 per day (Fig. 2J. Body-mass index. Distribution of BMI by MONICA popu- lations is presented in Fig. 3. The median BMI ranged from 23.4 to 27.5 for men and from 23.5 to 29.2 for women. Blood pressure. A large variation was found both in blood-pressure distribution and in proportion of persons with high blood pressure. Median SBP varied from 121 mm Hg to 146 mm Hg in men, and from 118 mm Hg to 141 mmHg in women. Median DBP varied from 74 mmHg to 91 mmHg in men, and from 72 mmHg to 89 mmHg in women (Figs 4 & 5J. The proportion of per- sons classified into categories 1-111 was between 8% and 44% in men, and between 12% and 40% in women (Fig. 6J. It is worth noting that in those populations with a high prevalence of hypertension (i.e. about 25% or high- er), more than half of the hypertensive subjects under- going treatment (categories I and II combined) still had high blood pressure despite drug therapy. Total cholesterol. Results on serum total cholesterol also showed large inter-population differences. However, the ranges of median total cholesterol values were practi- cally the same in men (4. 1 mmol/1 to 6.4 mmol/1) as in women (4.2 mmol/1 to 6.3 mmol/1) (Fig. lJ. Risk-factor score. Large diversity was found in combina- tions of risk factors. In men, the proportion of partici- pants with none of the risk factors present ranged from 14-43%. The proportion of participants with all three major risk factors varied from < 1-9%. In women, these proportions varied from 22-63% and from 0-5%, re- spectively (Fig. BJ. A summary of the main risk-factor results by population is given in Tables 2 & 3. Discussion Published data from many countries and populations suggest marked cross-country differentials in risk-factor distribution and patterns, but such comparisons have been hampered by methodological and other differ- ences. The findings from the MONICA Project presented here give a unique opportunity to compare risk-factor levels in a large number of populations from different parts of the world, based on common standardized sur- vey methods of data collection and centralized data analysis. However it should be mentioned that because of differences in survey periods the results presented may be affected by the secular changes in risk factors in the populations studied. The populations considered in this article are well de- fined and internally relatively homogeneous. The sample sizes are large enough to give fairly accurate estimates of the risk-factor levels of the studied populations. For some countries, data on cardiovascular risk factors are presented for the first time to a wider readership in a format which allows comparisons with other studies. However, it should be stressed that although a major effort was undertaken to standardize the survey meth- ods among the MONICA centres, they were not identical because different cultural, socioeconomic and technical circumstances between countries and sometimes even within a country had to be taken into account. Therefore, the implications of various possible confounding factors which could influence the present results are not fully identified. Smoking is a common habit in the populations studied, particularly among men. As often reported previously, smoking among women is generally less common than among men. Women smokers consumed on average fewer cigarettes than men in all the populations studied. The present level of smoking is certainly too high in vir- tually all populations studied. Changes in smoking in the MONICA populations will be very interesting to monitor as this risk factor can potentially be eliminated and because a smoke-free population has been listed as one of the main goals in the prevention of cardiovascular diseases (9J. The contribution of obesity to cardiovascular disease risk is still debated. The WHO Expert Committee on Pre- vention of Coronary Heart Disease stressed the impor- tance of weight reduction in populations because of the evidence that it helps to lower elevated levels of blood pressure and total cholesterol (BJ. Body-mass index is an accepted and commonly used measure of obesity in population studies and the value 30.0 can be considered as hazardous for health (23-26J. In the data presented here, a BMI higher than 30.0 in more than 10% of per- sons was found in the vast majority of the MONICA populations. Cardiovascular disease risk increases with increasing blood pressure. It has also been postulated that even a little shift in population blood-pressure distribution may produce a considerable change in coronary heart disease risk (BJ. In most of the populations studied at least a quarter of the subjects had high blood pressure or were on treatment for hypertension; the proportion of uncon- trolled hypertension was also high. There were six male and three female populations in which the median SBP was ;;;;,,, 140 mmHg. High blood pressure is considered as a major risk factor for coronary heart disease and the control and prevention of high blood pressure is essen- tial to the prevention of stroke (9, 10J. The results pre- sented here point out that the effectiveness of blood- pressure control at the community level is still not satis- factory in most MONICA populations. The WHO Expert Committee summarized that popu- lations whose mean total cholesterol value is around 4. 14 mmol/1 have little or no clinical coronary heart dis- ease. The populations with mean total cholesterol rang- ing between 4. 14 and 5. 17 mmol/1 show intermediate or low coronary heart disease rates (BJ. However, these values should not be considered either as exact cut-off points to indicate increased coronary heart disease risk or as specific goals for the population means. It is inter- esting to note that only one of the populations studied had a total cholesterol mean lower than 5.17 mmol/1. In conclusion, the results obtained at the starting point of the long-term international study have already provided a useful basis for further analyses. It was important for the WHO MONICA Project to include populations with diverse trends in cardiovascular disease and risk factors. The present results show that wide variations in risk- factor patterns exist among the MONICA populations. Unfortunately, they also indicate that populations with low levels of risk factors are in the minority. The hazar- Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 135 - TABLE 2. WHO MONICA PROJECT: SUMMARY OF RISK-FACTOR DATA FOR MEN TABLEAU 2. PROJECT MONICA DE L'OMS: RESUME DES DONNEES SUR LES FACTEURS DE RISQUE CHEZ LES SUJETS MASCULINS Median Median Proportion Proportion Median systolic diastolic Proportion Median with at least body-mass with high serum 2 risk current index blood blood blood total factors Population smokers Mediane pressure pressure pressure a cholesterol Proportion Proponion de l'indice Mediane de Mediane de Proportion Mediane du avant de la pression la pression de masse d'hyper- cholesterol au mains fumeurs arterielle arterielle corporelle tensifsa total 2 facteurs systolique diastolique de risque (%) (kg/m') (mm Hg) (mmHg) (%) (mmol/11 (%) Perth 36.0 25.5 131 85 25.1 5.8 21.1 Newcastle 35.0 26.0 129 83 25.7 5.7 19.6 Ghent - Gand 51.8 26.1 126 79 13.0 6.1 22.7 Charleroi .... 55.7 26.3 129 81 19.5 6.1 30.8 Luxembourg Province - Province de Luxembourg 51.0 25.6 131 78 15.5 6.4 31.4 Beijing ........ 61.1 23.4 126 85 24.6 4.1 15.8 Czechoslovakia - Tchecoslovaquie 48.4 27.1 135 85 32.4 6.3 37.9 Glostrup 61.1 25.4 125 80 14.9 6.2 32.9 North Karelia - Carelie du Nord 37.0 26.7 143 88 39.4 6.3 37.2 Kuopio Province - Province de Kuopio 43.4 26.4 145 90 45.3 6.2 41.5 Turku/Loimaa . 38.9 26.5 140 87 35.5 6.1 32.3 Berlin - Lichtenberg ....... 36.5 25.9 139 87 37.1 Halle County - Comte de Halle 43.9 26.7 137 86 33.6 Karl-Marx-Stadt County - Comte de Karl-Marx-Stadt 39.6 26.3 138 90 38.8 DDR MONICA (other surveys - autres enquetes) 39.4 26.3 142 88 37 .... Bremen - Breme . . . . . . . . 46.7 26.3 139 84 26.0 6.0 28.5 Rhein-Neckar Region - Region Rhin-Neckar 38.2 26.2 128 82 22.0 5.7 17.6 Augsburg (urban - ville) 39.9 26.8 134 84 27.7 6.2 28.9 Augsburg (rural) 37.8 27.3 133 85 21.6 6.1 24.4 Budapest 52.8 25.8 130 80 5.7 Pees 49.2 26.1 137 87 Iceland - lslande 51.2 25.4 123 81 6.1 Friuli - Frioul 37.7 26.3 140 87 33.9 Auckland 34.3 25.4 131 81 20.1 5.7 16.8 Belfast 45.7 25.5 132 83 23.7 5.9 27.8 Tarnobrzeg Voivodship - District de Tarnobrzeg 59.0 25.2 130 85 27.8 5.3 21.9 Warsaw - Varsovie 59.9 26.4 140 89 37.5 5.5 29.8 Glasgow ....... 62.2 25.4 134 87 32.0 6.2 42.6 Catalonia - Catalogne 57.7 26.5 121 74 8.4 Gateborg 40.8 25.0 6.1 Stanford 43.2 25.6 127 82 23.4 5.3 18.7 Kaunas 41.7 27.5 134 88 30.4 5.9 25.1 Moscow (intervention) - Moscou (intervention) 49.3 25.7 134 87 26.4 Moscow (control) - Moscou (temoin) 49.6 25.6 133 89 36.6 Novosibirsk (intervention) 54.3 25.9 132 90 35.7 Novosibirsk (control - temoin) 59.3 25.7 131 86 29.3 Novi Sad 50.5 26.7 132 84 22.6 Vaud/Fribourg 38.5 25.9 130 81 18.0 6.3 27.3 Ticino - Tessin 43.7 26.8 131 80 18.9 5.5 17.0 Malta - Malte 53.5 27.1 136 86 33.1 Bas-Rhin .. 41.2 27.3 143 91 42.2 5.5 28.2 Haute-Garonne 43.1 25.5 130 85 25.7 5.9 26.0 Brianza Area - Zone de la Brianza 47.0 25.5 136 88 31.1 5.6 24.8 Northern Sweden - Suede septentrionale 34.4 25.6 131 83 20.4 'Systolic blood pressure at least 160 mmHg; or diastolic blood pressure at least 95 mmHg; or on treatment for hypertension - Pression arterielle systolique d'au moins 160 mmHg; ou diastolique d'au mains 95 mmHg; ou suivant un traitement pour l'hypenension. dous risk-factor pattern identified in many populations studied highlights the need to initiate or intensify pre- ventive measures against cardiovascular diseases in these populations. Finally, from the point of view of international collaboration, the results achieved so far in the WHO MONICA Project are most encouraging. SUMMARY The WHO MONICA Project is designed to measure the trends in mortality and morbidity from coronary heart disease (CHO) and stroke, and to assess the extent to which they are related to changes in known risk factors in different populations in 27 countries. Risk-factor data are collected from population samples examined in at least two population surveys (one at the beginning of the study and the other at the end). The results of the base- line population surveys are presented. In populations Wld hlth statist. quart., 41 ( 1988) studied, the proportion of smokers varied between 34- 62% among men and 3-52% among women. The popu- lation median of systolic blood pressure varied between 121-146 mmHg in men. In women the figures were 118 mmHg and 14 1 mm Hg respectively. In diastolic blood pressure, the variation of median was from 7 4 mm Hg to over 91 mm Hg among men and from 7 2-89 mmHg among women. The third major risk factor con- sidered was total cholesterol, with the population me- - 136 - TABLE 3. WHO MONICA PROJECT: SUMMARY OF RISK-FACTOR DATA FOR WOMEN TABLEAU 3. PROJECT MONICA DE L'OMS: RESUME DES DONNEES SUR LES FACTEURS DE RISQUE CHEZ LES SUJETS FEMININS Population Proportion current smokers Proportion Median body-mass index Mt!diane de l'indice de masse corporelle Median systolic blood Median diastolic blood pressure pressure Mt!diane de Mt!diane de la pression la pression Proportion with high blood pressure a Proportion d'hyper- tensifs• Median serum total cholesterol Mt!diane du cholesterol Proportion with at least 2 risk factors Proportion ayant au mains 2 facteurs de risque de fumeurs artt!rielle artt!rielle total Perth Newcastle ... Ghent - Gand Charleroi .... Luxembourg Province - Province de Luxembourg Beijing ................ . Czechoslovakia - Tchecoslovaquie .. Glostrup ................. . North Karelia - Carelie du Nord Kuopio Province - Province de Kuopio Turku/Loimaa ..... . Berlin - Lichtenberg . . . . . . . . . . . Halle County - Comte de Halle . . . . . Karl-Marx-Stadt County - Comte de Karl-Marx-Stadt DDR MONICA (other surveys - autres enqulltes) Bremen - Brllme . . . . . . . . . . . . . . . Rhein-Neckar Region - Region Rhin-Neckar Augsburg (urban - ville) Augsburg (rural) Budapest Pees ...... . Iceland - lslande Friuli - Frioul Auckland Belfast ..... Tarnobrzeg Voivodship - District de Tarnobrzeg Warsaw - Varsovie Glasgow ....... . Catalonia - Catalogne Goteborg ...... . Stanford ....... . Kaunas ....... . Moscow (intervention) - Moscou (intervention) Moscow (control) - Moscou (temoin) Novosibirsk (intervention) . . . Novosibirsk (control - temoin) Novi Sad Vaud/Fribourg Ticino - T essin Malta - Malte Bas-Rhin ..... Haute-Garonne Brianza Area - Zone de la Brianza Northern Sweden - Suede septentrionale (%) 22.5 23.3 25.2 23.9 17.9 19.0 25.1 49.6 14.1 14.3 22.5 23.7 18.1 15.8 17.5 29.3 24.9 21.5 15.4 36.6 25.5 44.4 28.5 27.4 35.3 11.9 34.7 52.0 7.1 38.8 37.1 5.0 11.0 13.8 2.9 3.8 30.8 28.3 28.0 16.2 17.5 18.9 20.6 30.5 (kg/m') 23.8 24.5 25.2 26.0 25.1 23.9 27.2 23.5 26.2 25.9 25.2 24.7 26.2 24.9 25.8 25.5 24.3 25.1 25.8 25.5 26.4 24.2 25.6 23.7 24.8 27.3 26.8 25.5 26.3 23.6 23.5 29.3 28.0 27.8 29.1 28.9 27.4 24.0 24.2 28.6 25.6 23.6 24.3 24.7 systolique diastolique (mmHg) 122 125 117 123 127 127 133 121 141 143 133 135 138 138 140 135 123 128 128 129 134 118 136 123 129 131 138 131 118 120 132 133 134 133 131 132 123 126 138 133 125 131 126 (mmHg) 78 79 74 77 77 80 83 76 84 85 81 84 85 87 88 82 78 80 80 80 85 77 82 76 79 86 84 82 72 79 84 84 87 89 85 83 77 77 86 87 80 83 80 (%) 19.1 25.1 16.6 15.6 19.6 21.5 31.3 12.6 34.7 37.7 24.2 32.4 35.5 34.7 40.5 23.3 17.4 19.4 19.3 29.3 18.1 20.3 34.4 30.9 25.4 13.0 16.8 30.6 27.8 37.6 40.3 31.5 27.7 14.0 17.0 36.2 32.1 17.6 24.6 18.7 (mmol/1) 5.7 5.6 5.9 5.8 6.3 4.2 6.3 6.1 6.2 6.2 6.0 6.0 5.7 6.0 5.9 5.8 6.2 5.7 6.0 5.4 5.5 6.4 6.0 5.2 6.0 6.0 5.2 5.4 5.7 5.5 (%) 15.4 17.4 12.1 15.6 18.1 4.6 27.8 28.2 23.7 24.6 20.7 23.6 14.8 16.4 13.9 14.5 22.1 12.6 17.2 37.9 13.0 13.8 18.3 9.4 14.9 14.2 11.2 • Systolic blood pressure at least 160 mmHg; or diastolic blood pressure at least 95 mmHg; or on treatment for hypertension - Pression artt!rielle systolique d'au mains 160 mmHg; ou diastolique d'au mains 95 mmHg; ou suivant un traitement pour !'hypertension. dian ranging between 4. 1-6.4 mmol/1 among men and 4-2-6.3 mmol/1 among women. Caution is required when making cross-sectional comparisons between the risk-factor levets as-the MONICA Project was not de- signed for this purpose. Nevertheless, these data de- monstrate clearly the large variety of baseline risk-factor patterns in populations studied in the MONICA Project. RESUME Variation geographique des principaux facteurs de risque de cardiopathies coronariennes chez les hommes et les femmes de 35-64 ans Le projet MONICA de l'OMS a pour objet de mesurer les tendances de la morbidite et de la mortalite par cardio- pathies coronariennes et par accidents vasculaires cere- braux, ainsi que d'evaluer la mesure dans laquelle ces tendances sont liees a la modification des facteurs de risque connus mesures parmi differentes populations de 27 pays. La collecte de donnees relatives aces facteurs est menee a partir d' echantillons de population examines dans au mains deux enquetes de population (au debut et a la fin de l'etude). Les resultats de l'enquete sur la Rapp. trimest. statist. sanit. mond .• 41 (1988) - 137 - population temoin sont egalement indiques. Dans les populations etudiees, la proportion de fumeurs etait de 34-62% chez les hommes, et de 3-52% chez les fem- mes. La mediane, pour les differentes populations, de la pression arterielle systolique etait comprise entre 121- 146 mmHg chez les hommes. Chez les femmes, les chif- fres etaient respectivement de 118 mmHg et 141 mmHg. En ce qui concerne la pression arterielle diastolique, la mediane etait comprise entre 74 mmHg et plus de 91 mmHg chez les hommes et 72-89 mmHg chez les femmes. Le cholesterol total a ete le troisieme facteur essentiel de risque pris en consideration et, pour les dif- ferentes populations, la mediane se situait entre 4, 1- 6,4 mmol/1 chez les hommes et 4,2-6,3 mmol/1 chez les femmes. II convient d' observer une certaine prudence en procedant a des comparaisons transversales entre le niveau des differents facteurs de risque, car le projet MONICA n'a pas ete con<;:u dans ce but. Cependant, ces donnees montrent bien la grande diversite des indica- tions de base relatives aux facteurs de risque parmi les populations etudiees dans le cadre du projet MONICA. REFERENCES - REFERENCES 1. THE PRINCIPAL INVESTIGATORS OF THE MONICA PROJECT. WHO MONICA Project: geographic variation in mor- tality from cardiovascular diseases-baseline data on selected population characteristics and cardio- vascular mortality. World health statistics quarterly, 40 (2): 171-184 (1987). LES PRINCIPAUX CHERCHEURS DU PROJET MONICA. Projet MONICA de l'OMS: variation geographique de la mortalite par maladies cardio-vasculaires - don- nees de base relatives a certaines caracteristiques demographiques et a la mortalite par maladies car- dio-vasculaires. Rapport trimestriel de statistiques sanitaires mondiales, 40 (2): 171-184 (1987). 2. UEMURA. K. & P1~A. Z. Recent trends in cardiovascu- lar disease mortality in 27 industrialized countries. World health statistics quarterly, 38 (2): 142-162 (1985). UEMURA, K. & P1~A. Z. Tendances recentes de la mor- talite par maladies cardio-vasculaires dans 27 pays industrialises. Rapport trimestriel de statistiques sanitaires mondiales, 38 (2): 142-162 ( 1985). 3. KANNEL. w. B. & SCHATZKIN, A. Risk factor analysis. Progress in cardiovascular diseases, 26 (4) : 309- 332 (1983). 4. MOSER, M. Treating hypertension-a review of clini- cal trials. American journal of medicine, 81 (suppl. 6C): 25-32 (1986). 5. TYROLER. H. A. Review of lipid-lowering clinical trials in relation to observational epidemiologic studies. Circulation, 76 (3): 515-522 (1987). 6. WORLD HEALTH ORGANIZATION EUROPEAN COLLABORA- TIVE GROUP. Multifactorial trial in the prevention of coronary heart disease-3. Incidence and mortality results. European heart journal, 4: 141 (1983). 7. BARRETT-CONNOR, E. Obesity, atherosclerosis and co- ronary artery disease. Annals of internal medicine, 6: 1010-1018 (1985). 8. WHO Technical Report Series No. 678, 1982 (Pre- vention of coronary heart disease: report of a WHO Expert Committee). OMS Serie de Rapports techniques N° 678, 1982 (Prevention des cardiopathies coronariennes: rap- port d'un Comite d'experts de l'OMS). 9. WHOTechnicalReportSeriesNo. 732, 1986(Com- munity prevention and control of cardiovascular diseases: report of a WHO Expert Committee). OMS Serie de Rapports techniques N° 732. 1985 (La Jutte communautaire contre Jes maladies cardio- vasculaires: rapport d'un Comite d'experts de l'OMS). 10. WHO Technical Report Series No. 686, 1983 (Pri- mary prevention of essential hypertension: report of a WHO Scientific Group). Wld hlth statist. quart., 41 (19881 OMS Serie de Rapports techniques N° 686, 1983 (Prevention primaire de /'hypertension essentie/le: rapport d'un Groupe scientifique de l'OMS). 11. STUDY GROUP, EUROPEAN ATHEROSCLEROSIS SOCIETY. Strategies for the prevention of coronary heart disease: a policy statement of the European Athe- rosclerosis Society. European heart journal, 8: 77- 88 (1987). 12. THE SURGEON GENERAL. The health consequences of smoking: cardiovascular disease. Rockville, Md., Office on smoking and health, 1983. 13. PUSKA, P. ET AL. The community-based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia Project. Annual reviews of public health, 6: 147-193 (1985). 14. SHEPHERD J. A. L. ET AL. Strategies for reducing coro- nary heart disease and desirable limits for blood limits for blood lipid concentrations: guidelines of the British Hyperlipidemia Association. British medi- cal journal, 295: 1245-1246 (1987). 15. KEYS. A. Seven countries-a multivariate analysis of death and coronary heart disease. Cambridge, Massachusetts/London, Harvard University Press, 1980. 16. JACKSON, R. & BEAGLEHOLE, R. Trends in dietary fat and cigarette smoking and the decline in coronary heart disease in New Zealand. International journal of epidemiology, 16(3): 377-382 (1987). 17. UESHIMA. H. ET AL. Declining mortality from ischaemic heart disease and changes in coronary risk factors in Japan, 1956-1980. American journal of epidemio- logy, 125 (1): 62-72 (1987). 18. FARCHI, G. Spontaneous changes in risk factors and prediction of coronary heart disease. Preventive medicine, 12: 37-39 (1983). 19. PuSKA. P. ET AL. Community control of cardiovascu- lar diseases. Evaluation of a comprehensive com- munity programme for control of cardiovascular diseases in North Karelia, Finland, 1972-1977. Copenhagen, WHO Regional Office for Europe, 1981. 20. PYORALA. K. ET AL. Changing trends in coronary heart disease mortality : possible explanations. Cardiolo- gy, 72: 5-10 (1985). 21. WHO MONICA PROJECT PRINCIPAL INVESTIGATORS.- The World Health Organization MONICA Project (Monitoring trends and determinants in cardiovas- cular disease)-a major international collaboration. Journal of clinical epidemiology, 41 (2) : 105-114 (1988). 22. ROSE. G. A. ET AL. Cardiovascular survey methods. Geneva, World Health Organization, 1982. (Mono- graph Series No. 56). (Second edition). RosE. G. A. ET AL. Methodes d'enquiJte sur Jes mala- dies cardio-vasculaires. Geneve, Organisation man- - 138 - diale de la Santa, 1984. (Serie de monographies N° 56). (Deuxieme edition). 23. LEE. J. ET AL Relative merits of the weight-corrected- for-height indices. American journal of clinical nutri- tion, 34: 2521-2529 (1981). 24. KEYS, A. ET AL Indices of relative weight and obesity. Journal of chronic diseases, 25 : 329-343 (1972). 25. SEIDEL, L. C. ET AL Associations of moderate and severe overweight with self-reported illness and medical care in Dutch adults. American journal of public health, 76 (3): 264-269 (1986). 26. BURTON, B. T. & FOSTER, w. R. Health implications of obesity-an NIH consensus development conferen- ce. Journal of the American Dietetic Association, 85(9): 1117-1121 (1985). ANNEX MONICA sites and key personnel - May 1988 I. MONICA Collaborating Centres Australia University of Western Australia, Nedlands Principal Investigator: M. S. T. Hobbs Key personnel: K. Jamrozik, P. L. Thompson, B. K. Armstrong University of Newcastle, Newcastle Principal Investigator: A. Dobson Former Principal Investigator: S. Leeder (until March 1986) Key personnel: S. Leeder, R. Gibberd, H. Alexander, R. Heller. Belgium Ghent State University, Ghent Principal Investigator: G. de Backer Key personnel: I. De Craene, P. Van Onsem, L. Van Parys Free University of Brussels, Brussels Principal Investigator: M. Kornitzer Key personnel: L. Berghmans, M. Dramaix, H. Darquennes, F. Kittel, R. Lagasse, M. Desqueve lnteruniversity Association for the Prevention of Cardiovascular Diseases, Brussels Principal Investigator: M. Jeanjean Key personnel: C. Brohet, H. Kulbertus, S. Degre, F. Lavenne, D. Janssens, F. Lefebvre, D. Beck, G. Wunsch, F. Bertrand, M. Van Houte, B. Rime, G. Rorive, R. Hannut. A. Andrianne, A. Luyckx Canada Dalhousie University, Halifax, Nova Scotia Principal Investigator: H.K. Wolf Key personnel: B. R. MacKenzie, R. D. Gregor. P. M. Rautaharju, P. Rykers. C. Byrne. M. M. Baxter, H.J. Brown China Beijing Heart, Lung and Blood Vessel Research Institute. Beijing Principal Investigator : Wu Zhaosu Former Principal Investigator: Wu Ying-Kai Key Personnel: Hong Zhao-Kuang, Wu Zhao-Su, Yao Chong- Hwa Czechoslovakia Institute for Clinical and Experimental Medicine, Prague Principal Investigator: Z. Skodova Former Principal Investigator : J. Hurych Key personnel: Z. Pisa, Z. Hejl, D. Grafnetter, L. Berka, Z. Cicha, J. Cerovska, R. Emrova. J. Pikhartova, E. Wiesner, J. Vorlicek, P. Vojtisek. P. Skalka, J. Khun Denmark Copenhagen University Hospital. Glostrup Principal Investigator : M. Schroll Key personnel: M. Kirchhoff, A. Sjel, H. Schnack, M. Madsen, G. Vincents, D. Jeppensen, H. Kirkby, S. Henriksen Finland National Public Health Institute, Helsinki Principal Investigator: J. Tuomilehto Former Principal Investigator : P. Puska Key personnel: E. Vartiainen, J. Kankaanpaa, P. Pietinen, H. Korhonen, U. Uusitalo, J. Pikkarainen. C-G. Gref, J. Huttun- en, L. Kartovaara, A. Nissinen, K. Pyorala. H. Mustaniemi, M. Arstila, E. Kaarsalo, J. Sivenius, E. Narva, K. Salmi, C. Sarti, P. Palomaki. (First Survey) : Principal Investigator : P. Puska Key personnel: J. Tuomilehto, A. Nissinen, H. Korhonen, P. Pietinen, T. Piha. E. Vartiainen, U. Uusitalo, E. Kostiainen, J. Huttunen. J. Pikkarainen. H. Mustaniemi, K. Salmi, K. Pyo- rala, J. Sivenius, M. Arstila. E. Narva, E. Kaarsalo France Country Coordinator : J. Richard National Institute of Health and Medical Research, Paris Key personnel: A. Bingham, R. Rakotovao National Institute of Health and Medical Research, Toulouse Principal Investigator : P. Douste-Blazy Key personnel: J.P. Cambou. J.B. Ruidavets, V. Rouche, M. Duchange, J. Foucault, M. P. Branchu, L. Saulet Institute of Hygiene - Faculty of Medicine, Strasbourg Principal investigator: P. Schaffer Key personnel: D. Arveiler. A. Facello, E. Uetwiller. D. Jacques, C. Veron, C. Rebmann. Pasteur Institute and Study and Research Group on Myocardial Infarction. Lille Principal Investigator: J. L. Salomez Key personnel: M. C. Nuttens, I. Fatout, C. Graux. T. Koslowski, N. Courtiau, P. Timmerman, M. 0. Cornaert, M. Tomczak, J.C. Fruchart, R. Beuscart, J.M. Bard, F. Dehier. J.M. Lecerf, M. Romon-Rousseaux. German Democratic Republic Central Institute of Cardiovascular Research, Berlin Principal Investigators: H. Heine, L. Heinemann Key personnel: I. Martin, D. Eisenblatter, W. Barth, H. Schadlich, J. Muche, H. Schmalfuss, S. Choinowski Germany, Federal Republic of Bremer Institute for Prevention Research and Social Medicine, Bremen Principal Investigator· E. Greiser Co-Principal Investigator: B. Herman Key personnel: K. Giersiepen Department of Clinical and Social Medicine of the University Medical Clinic, Heidelberg Principal Investigator: E. Nossel Co-Principal Investigator: E. OstOr-Lamm Key personnel: R. Scheidt, C. KoppenhOffer, W. Morgenstern, M. Stadler GSF-MEDIS Institute. Institute for Medical Informatics and Health Services Research, Neuherberg/Munich Principal Investigator: U. Keil Key personnel: J. Stieber, H. Lowe!, A. Doring. U. Hartel, M. Lewis, A. Hormann. H. Huss, H. W. Hense. B. Filipiak, S. Perz, J. Gostomzyk, I. D. Bolte. Hungary Hungarian Institute of Cardiology, Budapest Country Coordinator and Principal Investigator: J. Duba Former Principal Investigator: I. Gyarfas Key personnel: P. Makara, E. Benko, E. Boda, M. Simon Medical University of Pees, Institute for Social Medicine. Pees Key personnel: J. Tenyi, I. Szilard. J. Vekassy Iceland Heart Preventive Clinic, Reykjavik Principal Investigator: N. Sigfusson Key personnel: I. I. Gudmundsdottir, I. Stefansdottir. T. Thor- steinsson, H. Sigvaldason. Israel Tel-Aviv University, Holan Principal Investigator: D. Brunner Key personnel: J. Waysbort, E. Yaar, I. Klinger, S. Kreitler, N. Levin-Epstein, S. Susser Rapp. trimest. statist. sanit. mond .. 41 (1988) Italy Country Coordinator: A. Menotti National Institute of Health, Rome - 139 Key personnel: F. Dima. S. Giampaoli, B. Giuli, G. Morisi, A. Verdecchia S. M. Goretti Hospital, Latina Principal Investigator : G. Righetti Key personnel: B. De Pasquale, P. Di Raimo. E. Forte, A. Majetta General Regional Hospital, Udine Principal Investigator: G. A. Feruglio Key personnel: D. Vanuzzo. A. Antonini-Canterin, M. Palmieri, M. Spanghero, M. Scarpa, L. Pilotte, A. Zuliani Research Centre on Chronic Degenerative Diseases of the Uni- versity of Milan, Milan Principal Investigator : G. C. Cesana Key personnel: M. Ferrario, I. Ghezzi, P. Moccarelli, R. Sega. P. Brambilla, 0. Agostoni, F. Duzioni. F. Ferri, P. Cannatelli, G. De Vito, F. Valagussa, A. Grieco, F. Achilli. Japan Institute of Public Health, Tokyo (national coordinating centre) Principal Investigator: S. Hatano Former Principal Investigator: I. Shigematsu Key personnel: H. Horibe, Y. Inagaki, Y. Ito, S. Kagamimori. T. Kawakami, K. Kimura, S. Kodama. Y. Komachi, M. Maruya- ma. M. Minowa, Y. Morisawa, K. Sawai, S. Shibata, K. Suzuki, T. Tajima, T. Takano, H. Tanaka, H. Tashiro, T. Uehata, H. Ueshima, Y. Yamori, H. Yanagawa. Malta Department of Health, Valletta Principal Investigator: J. Cacciottolo Key personnel: J. Mamo, J. Ellul, M. Bellizzi, A. Amato Gauci, A. Vassallo New Zealand University of Auckland, Auckland Principal Investigator : R. Beaglehole Key personnel: R. Jackson, A. Stewart, A. McCallin, J. Yallop, M. Scott, D. Mahon, R. Bonita. Nonhern Ireland The Queen's University of Belfast, Belfast Principal Investigator: A. Evans Key personnel: Z. Mathewson, E. McCrum, C. Canning, A. Walker, T. Falconer, T. Hulme, C. Patterson Poland Nicolaus Copernicus Medical Academy, Krakow Principal Investigator. J. Sznajd Key personnel: M. Magdon. A. Pajak. B. ldzior, M. Malczewska. R. Mizera, A. Celinski, H. Czarnecka, P. Misiowiec, J. Zmelty, U Zeman, E. Baczynska, I. Trznadel. R. Morawski, A. Markiewicz. National Institute of Cardiology, Warsaw Principal Investigator: S. L. Rywik Key personnel: M. Polakowska, G. Broda. A. Kuzminska, H. Wagrowska, W. Kulesza, W. Kupsc, P. Kurjata, B. Jasinski, J. Piwonski, B. Rojewska. Romania Medical Institute, Fundeni Hospital, Bucharest Principal Investigators: C. Carp, I. Orha Key personnel: E. Apetrei, C. Ginghina, I. Coman, C. Daschievici, P. Dumitru, I. Zatreanu. A. Dumitrescu, T. Ionescu, I. Stoian, I. Cinca Scotland University of Dundee, Dundee Scottish Monica Coordinating Centre Principal Investigator: H. Tunstall Pedoe Key personnel: W. C. S. Smith. I. Crombie, R. Tavendale. M. Shewry, K. Barrett. Royal Infirmary, Glasgow Principal Investigator: C. Morrison Former Principal Investigator: Graham Watt Key personnel: B. Fitzpatrick, J. Mackenzie Spain Department of Health and Social Security, Barcelona Principal Investigators. I. Balaguer-Vintro. S. Sans Key personnel: A. PuigdeMbregas, L. Balana, N. Alarcon, J. A. Gomez-Gerique, R. Lopez, J.M. Borras, A. Rod6s, F. Gonzalez-Sastre Wld hlrh srarisr. quart., 41 ( 19881 Sweden Ostra Hospital Preventive Cardiology Unit, GOteborg Principal Investigator: L. Wilhelmsen Key personnel: S. Johansson, P. Harmsen, H. Wedel, A. Tsipog- ianni, K. Romanus, M. Falkman, I. Randulw. Department of Internal Medicine, Kalix Lasarett, Kalix Principal Investigator: F. Huhtasaari Key personnel: B. WilkstrOm, S. Bostrom. V. Lundberg, E. Westerberg. Umea University Hospital, Department of Medicine Principal Investigator: P. 0. Wester Key personnel: K. Asplund, B. Stegmayr, I. Nordqvist Switzerland University Institute of Social and Preventive Medicine. Lausanne Principal Investigator: F. Gutzwiller Key personnel: M. Rickenbach, V. Wietlisbach, F. Barazzoni. B. Tullen, T. Moccetti. F. Paccaud, B. Burnand. Key personnel (first survey): M. Rickenbach, F. H. Epstein, D. Hausser, F. Barazzoni. V. Wietlisback, B. Burnand. United States of America Stanford Center for Research in Disease Prevention, Stanford, California Principal Investigator: S. P. Fortmann Key personnel: M. Winkleby, A. Varady, M. McCormick USSR Research Institute and Republic Practical Centre of Cardiology, Kaunas, Lithuanian SSR Principal Investigator: J. Bluzhas Key personnel: Z. Cepaitis, S. Domarkiene, R. Prochorskas, R. Grazuleviciene, D. Rasteniene. P. Grybauskas, L. Margevi- ciene, E. Stalioraityte, D. Pangonyte, K. Jureniene, A. Gostau- tas. V. Grinius, R. Grybauskiene, A. Janusauskas. Z. Petro- kiene All-Union Cardiology Research Centre, Moscow Principal Investigator: T. A. Varlamova Former Principal Investigator: S. A. Fedotov Key personnel: V. Naumova, M. Osokina, S. Chikovani, E. Bol- shakova, N. Semeikina. E. Avrutskaya, N. Popova, N. Serdyu- chenko, A. Migirov, E. Surkov. Key personnel (first screening): L. Chasova, A. Britov, G. Zhu- kovskii, A. Kalinina, A. Korolkov. V. Konstantinov, E. Konstan- tinov, A. Kapustina, D. Konstantinova, V. Sviderskii. Institute of Internal Medicine, Novosibirsk Principal Investigator: Yu. P. Nikitin Key personnel: N. Serova, V. Gafarov. V. Feigin. T. Filimonova, M. Malyutina, T. Klimenkova, N. Alekseeva, T. Rodigina, I. Ga- gulin, I. Shalaurova, E. Markevich, M. Voevoda. Yugoslavia Health Centre "Novi Sad", Novi Sad Principal Investigator: M. Planojevic Former Principal Investigator: D. Jakovljevic Key personnel: A. Svircevic, M. Mirilov, T. Strasser, M. Stanu- lovic, J. Cikos, S. Trifunovic, P. Terzic, T. Dapic, S. Borkovac, M. Kovac, V. Vukovic, M. Krco, Z. Solak, M. Zikic, M. Ilic, B. Legetic. II. MONICA Management Centre - Geneva World Health Organization, Geneva Responsible Officer: S. BOthig Former Responsible Officers: Z. Pisa, S.R.A. Dodu Key personnel: I. Gyarfas, A. Nissinen, M. J. Watson, M. Hill, M. Karvonen (consultant), 0. D. Williams (consultant) Ill. MONICA Data Centre - Helsinki National Public Health Institute, Helsinki, Finland Responsible Officer: K. Kuulasmaa Former Responsible Officer: J. Tuomilehto Key personnel: J. Torppa, E. Ruokokoski, J. Akkila, L. Palonen. T. Virman-Ojanen. IV. MONICA Quality Control Centres MONICA Quality Control Centre for ECG Coding - Budapest Hungarian Institute of Cardiology, Budapest, Hungary Responsible Officer: A. Madai Former Responsible Officer: P. Ofner MONICA Quality Control Centre for Event Registration - Dundee University of Dundee. Dundee, Scotland Responsible Officer: H. Tunstall Pedoe Key personnel: M. Kenicer. I. Crombie. M. Irving, K. Barrett - 140 MONICA Quality Control Centre for Lipid Determination - Prague Institute for Clinical and Experimental Medicine, Prague, Czechoslovakia Responsible Officer: D. Grafnetter Key personnel: J. Teminova, S. Wimmerova V. MONICA Reference Centres MONICA Reference Centre for Dietary Methods - Helsinki National Public Health Institute. Helsinki, Finland Responsible Officer: P. Pietinen Former Responsible Officer: P. Puska Key personnel: U. Leino. U. Uusitalo, E. Vartiainen. MONICA Reference Centre for Drug Classification - Oslo Norsk Medisinaldepot, Oslo, Norway Responsible Officer: K. 0ydvin Key personnel: S. Sakshaug MONICA Reference Centre for Psychosocial Assessment Copenhagen WHO Regional Office for Europe, Copenhagen, Denmark Responsible Officer: A. Shatchkute Former Responsible Officer: V. Zaitsev Key personnel: F. Kittel. U. Hartel. M. Makara, D. Sykes. L. Heinemann, M. Weiss. S. Sans. MONICA Reference Centre for Physical Activity - Ho/on Edith Wolfson Hospital, Holon, Israel Responsible Officer: D. Brunner Key personnel: N. Meshulam in collaboration with : Behavioral Epidemiology and Evaluation Branch, Health Educa- tion Division. Centers for Disease Control, Atlanta, Ga, USA Responsible Officer: K. Powell Key personnel: C. Casperson, D. Jones VI. MONICA Steering Committee R. Beaglehole, Auckland. New Zealaand U. Keil. Neuherberg, Federal Republic of Germany F. Gutzwiller, Lausanne, Switzelrand H. Tunstall Pedoe, Dundee, Scotland S. BOthig, Chief CVD/WHO, Geneva, Switzerland K. Kuulasmaa. Helsinki, Finland A. Shatchkute, WHO, Copenhagen, Denmark Consultants appointed to the Steering Committee : Z. Pisa. Prague. Czechoslovakia 0. D. Williams, Chapel Hill. North Carolina, USA M. J. Karvonen. Pioppi, Italy (former consultant) Previous Steering Committee Members : S. P. Fortmann, Stanford, USA A. Menotti, Rome, Italy P. Puska, Helsinki, Finland S. L. Rywik, Warsaw, Poland S. Dodu (former Chief CVD/WHO. Geneva) } until V. Zaitsev, WHO, Copenhagen, Denmark 1985 J. Tuomilehto, Helsinki, Finland (former Chief MDC) until 1987 VII. MONICA Advisory Groups Statistical Advisory Group (SAG) L. Chambless, Chapel Hill, NC, United States A. Dobson, Newcastle, NSW 2308, Australia L. Gatewood, Minneapolis, Minn. United States U. Keil. Neuherberg, Federal Republic of Germany K. Kuulasmaa, Helsinki, Finland C. Patterson, Belfast, Northern Ireland H. Schadlich, Zwickau, German Democratic Republic J. Tuomilehto. Helsinki, Finland H. Wedel, Goteborg, Sweden 0. D. Williams, Chapel Hill, NC. United States G. Zhukovsky, Moscow. USSR I. Crombie, Dundee, Scotland } corresponding W. Kupsc. Warsaw. Poland members Stroke Advisory Group (STRAG) P. 0. Wester, Umea, Sweden K. Asplund, Umea, Sweden D. Eisenbllltter, Berlin, German Democratic Republic S. Hatano, Tokyo, Japan M. Schroll, Glostrup, Denmark J. Tuomilehto. Helsinki, Finland } ex-officio H. Tunstall Pedoe, Dundee, Scotland members R. Bonita, Auckland, New Zealand P. Harmsen. Goteborg, Sweden } corresponding members (unofficial) Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 141 - HYPERTENSION IN DEVELOPING COUNTRIES Aulikki Nissinen,a Siegfried Bothig,b Helena Granrothc & Alan D. Lopezd Hypertension as a risk factor of cardiovascular diseases has been recognized in the industrialized countries since the 1950s. Numerous studies have examined blood- pressure levels among different populations; awareness of hypertension and the effects of drug treatment are well documented in most of these countries where anti- hypertensive drug therapy has been established. Many surveys have also been carried out to examine blood- pressure levels and the magnitude of hypertension and related factors in developing countries. The results from the studies carried out in the 1960s have been summar- ized in several literature reviews (1-5). The results show great variations in the mean blood-pressure levels and in the prevalence of hypertension in different cultures. During the last 10-15 years the methodology used for measuring blood pressure in surveys both in developed and developing countries has become more standard- ized, results are also reported in a more uniform manner (e.g. according to age and sex) and the definition of the prevalence of hypertension follows the recommenda- tions laid down by the World Health Organization (WHO) in 1978 (6). This makes the figures more reliable. So far, very few studies from developing countries have re- ported the indicators of hypertension control in the com- munity such as the proportion of persons aware of their hypertension and the proportion of antihypertensive treated persons with adequate blood-pressure values. The reliability of mortality statistics has also improved in the less developed countries which makes it possible to describe mortality trends from hypertensive disease and stroke. The purpose of this article is to describe the mortality rates from the 1960s to the 1980s from hypertensive disease and stroke in 16 developing countries which have reported such data to WHO. In addition, data are presented from 25 surveys on blood-pressure levels, prevalence of hypertension and the status of hyperten- sion control in different cultural settings carried out since the 1970s. Material and methods Mortality statistics To demonstrate the consequences of hypertensive dis- ease, mortality from hypertensive disease and stroke is presented in addition to total mortality, which is the indi- cator of the overall development of mortality. Ill-defined cause of death is also presented to demonstrate the development of diagnostic practice in countries. a Medical Officer. Cardiovascular Diseases. World Health Organiza- tion, Geneva. b Chief, Cardiovascular Diseases, World Health Organization, Geneva. c Intern. Cardiovascular Diseases, World Health Organization, Geneva. d Statistician, Global Epidemiological Surveillance and Health Situation Assessment, World Health Organization, Geneva. Wld hlth statist. quan .. 41 (1988) Data on mortality are derived from the data reported to WHO by 16 countries, classified as developing coun- tries. From the 1960s until the early 1980s, annual age- specific death rates are taken for the calendar year in 10-year intervals for 10-year age groups between 35 and 74 years. During the observation period, the countries use~ the Seventh, Eighth, and Ninth Revisions of the International Classification of Diseases (ICD). These Revisions are comparable with respect to cerebrovascular diseases and ill-defined causes of death. Hypertensive disease includes hypertensive disease · 'with and without the mentioning of heart'', according to ICD-7 and ICD-9, but according to ICD-8 hypertensive disease with heart dis- ease is classified under ischaemic heart disease. This has undoubtedly affected the comparability of mortality data for hypertension and hence the observed trends for this cause in particular should be viewed with prudence. The ICD Revisions used are indicated in the tables. Survey data on hypertension Altogether, 25 studies carried out between the early 1970s and early 1980s are the focus of this analysis. Data given here for the middle-aged population (approx- imately 40-50 years) have been taken from the available surveys only where these have been presented accord- ing to sex. Whenever possible, data for two separate 10-year age groups around 40-50 years are taken to demonstrate the possible rise of blood pressure with aging. Reports of surveys included have used a standardized methodology for the measurement of blood pressure and the fifth phase of Korotkoff sounds is used for the value of diastolic blood pressure. Values have been recorded to the nearest 2 mmHg and the definition of a hypertensive person is given. Surveys with small numbers of persons examined are excluded. For a description of hypertension control in the commu- nity, information from seven available reports is used. An assessment of the costs of antihypertensive drug treatment was made. Costs were calculated for a small daily dose of thiazide diuretics (12.5 mg), first using the annual price of the generic drug and second the average price on the free market (US$3 vs. US$40). In addition to data from developing countries, data from blood-pressure surveys carried out in Finland and Japan are included to illustrate the difference between more developed and less developed countries. Results Mortality Since the 1960s total mortality has decreased in all countries among both males and females (Table 1). However, the decrease has levelled off and an increase is even being observed in some countries like Chile where men in all age groups in 1984 have a somewhat higher - 142 - TABLE 1. AGE-SPECIFIC DEATH RATES PER 100 OOO POPULATION (FROM ALL CAUSES) IN SELECTED DEVELOPING COUNTRIES, MALES AND FEMALES, 35-74 YEARS, 1960-1986 TABLEAU 1. TAUX SPECIFIQUES DE MORTALITE PAR AGE, POUR 100000 HABITANTS, TOUTES CAUSES DE DECES CONFONDUES, DANS CERTAINS PAYS EN DEVELOPPEMENT, HOMMES ET FEMMES AGES DE 35-74 ANS, 1960-1986 MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE o· AGE AGE GROUP - GROUPE o· AGE Rate (average annual number of deaths) Rate (average annual number of deaths) Taux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Mauritius - Maurice ...... 1960 7 584.2 1 398.4 3 841.4 6 375.0 556.2 793.1 2 198.6 5 116.3 1970 8 460.6 1 106.3 2 931.7 7 061.9 411.5 695.9 1 596.9 4016.4 1980 8 590.8 1 314.1 3 117.0 7 294.1 275.4 487.7 1438.9 3 363.6 1984 9 445.8 1 167.1 2 777.4 5 721.1 234.3 501.3 1 363.3 3 965.5 Barbados - Barbade ...... 1960 7 424.5 932.0 1 916. 7 4 862.1 335.7 814.0 1 347.4 2 925.4 1970 8 483.1 791.2 1 770.1 4 925.9 221.3 547.0 1 179.2 3012.2 1980 9 244.7 821.4 1 397.6 4 257.6 190.0 581.0 1028.8 2 688.9 1984 9 154.5 696.2 1 333.3 4 636.4 149.3 415.8 1 132.7 2 521.7 Chile - Chili ..... 1960 7 762.5 1 355.9 2 632.0 5 285.3 499.6 844.4 1 773.0 3 940.6 1970 8 616.2 1 237.5 2 473.7 5 210.5 348.0 712.9 1 596.5 3 701.5 1980 9 418.8 939.8 1 947.8 4 592.8 218.3 539.8 1140.8 2 842.1 1984 9 421.2 958.5 1 979.8 4693.4 183.8 448.2 1029.9 2 637.3 Costa Rica ............ 1961 7 296.4 654.5 1 602.4 3 776.1 361.4 528.4 1 236.9 3 179.1 1970 8 373.0 662.9 1 534.5 3 846.2 281.0 549.6 1 338.2 3 284.9 1980 9 300.0 544.0 1 239.6 3 807.7 155.3 364.0 728.0 2 432.1 1984 9 203.3 476.0 1 164.3 3 301.3 148.5 314.2 795.5 2 288.8 Cuba ..... . ........ 1964 7 236.1 596.9 1 623.5 3 649.0 226.6 455.7 1 033.7 2 508.7 1970 8 252.3 523.4 1 276.8 3 210.4 211.4 436.5 955.5 2 370.5 1980 9 257.7 537.2 1 248.5 3 121.6 181.0 419.5 896.5 2 306.3 1985 9 256.6 543.2 1 306.9 3092.1 195.3 415.5 944.2 2 359.4 Mexico - Mexique ....... 1960 7 784.3 1 220.4 2 208.7 4208.3 552.8 880.6 1 820.3 3 749.8 1970 8 699.7 1 124.2 2 114.6 4250.7 474.0 771.3 1 598.8 3 594.5 1978 8 601.6 989.7 1 852.3 3 786.3 321.7 590.2 1 234.6 2 921.9 1982 9 614.6 990.9 1 762.4 3 393.9 279.7 538.1 1 105.0 2 399.4 Panama .......... 1960 7 363.8 657.1 1 554.2 3 892.9 358.2 650.0 1 213.0 2 800.0 1970 8 312.5 655.4 1 462.2 3 805.6 327.5 596.0 1 309.4 3 164.7 1980 9 240.8 491.2 1 156.0 2 617.2 188.0 340.9 722.9 1 548.3 Trinidad and Tobago ...... 1960 7 453.1 1 098.9 2 492.5 6 171.4 331.1 764.5 1 738.5 3 849.6 T rinite-et· Tobago 1970 8 348.0 1038.0 2 138.2 6 216.0 318.7 743.2 1 683.3 4 440.0 1980 9 432.4 900.9 2077.8 4688.1 293.2 652.1 1 422.2 3 950.5 1983 9 494.8 795.8 2034.3 4 728.6 244.8 560.0 1 457.1 3981.0 Uruguay .......... 1960 7 393.0 881.2 2 176.4 4 282.1 235.6 535.4 1 142.3 2 700.3 1970 8 356.7 900.3 2 139.3 4 967.9 200.7 439.6 1242.2 3002.5 1980 9 328.1 907.2 2 123.4 4690.7 223.7 465.4 975.9 2 530.6 1985 9 289.1 790.0 1 842.3 4245.9 182.8 394.3 843.8 2 243.8 Venezuela ........... 1960 7 462.8 991.3 2 129.7 4015.9 399.4 724.5 1 643.4 3 067.7 1970 8 380.6 822.5 2 131.3 5 450.6 313.5 586.1 1 535.8 3 588.2 1980 9 382.9 795.1 1 766.9 3 922.9 225.9 481.5 1 161.8 2 831.3 1983 9 341.9 727.5 1618.0 3 781.5 195.4 456.3 1 020.5 2 561.9 Hong Kong ............ 1960 7 436.4 1 069.9 2 627.7 5 526.8 287.7 500.0 1 221.1 2 585.9 1970 8 363.2 892.3 2 352.8 5 279.8 199.3 421.2 1 108.8 2 620.3 1980 9 252.8 696.5 1 723.3 4194.6 151.9 344.7 869.8 2 308.6 1986 9 171.4 524.0 1 340.1 3 343.9 95.1 270.0 682.8 1 875.4 Israel - Israel ...... 1980 9 179.8 552.3 1 398.3 3 796.0 109.1 325.6 954.8 2 798.2 1985 9 149.2 477.6 1404.5 3 382.3 105.4 275.6 861.6 2 571.8 Israel, Jewish pop. 1960 7 187.0 500.4 1 519.6 3 679.6 160.5 433.4 1 110.9 3 246.3 Israel, pop. juive 1970 8 232.3 585.7 1 621.7 4 287.3 152.6 447.1 1 181.1 3 514.7 Kuwait - Kowert ........ 1980 9 193.9 603.8 1 772.0 5 285.7 144.6 458.5 1 093.8 3 661.0 1986 9 126.1 435.7 1 425.1 3 887.5 114.7 342.4 1 055.9 2 958.9 Rapp. rrimest. statist. sanit. mond .. 41 ( 19881 - 143 - MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE D' AGE AGE GROUP - GROUPE D' AGE Rate (average annual number of deaths) Rate (average annual number of deaths) Taux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 Annee du CIM 55-64 65-74 35-44 45-54 55-64 65-74 deces Singapore - Singapour 1963 7 377.6 1 073.3 3 160.9 6 926.2 288.9 649.5 1 607.5 3 659.7 1970 8 339.9 962.1 2 604.1 6 157.3 202.2 545.1 1 369.6 3 590.6 1980 9 254.1 827.4 2 193.1 5 194.4 150.9 418.3 1 295.5 3 177.0 1986 9 220.5 641.6 1 815.3 4287.0 125.4 356.0 1024.3 2 687.3 Sri Lanka ....... 1960 7 324.0 648.7 1 839.7 4135.0 391.2 582.0 1 454.4 3 636.9 1968 7 399.1 837.4 1 648.8 4872.0 342.7 572.6 1 223.8 4007.0 1977 8 433.2 931.2 1 824.7 4107.3 290.5 546.9 1 237.1 3 371.5 1982 9 390.2 818.9 1 698.6 3 804.2 212.5 407.3 906.8 2 740.2 total mortality than in 1980. In Cuba, Mexico and Trinidad and Tobago, some age groups among men had slightly higher death rates after 1980. Among older female age groups in Costa Rica, Cuba and Trinidad and Tobago there is also a small increase in total mortality after 1980. The mortality rates for hypertensive disease are pre- sented in Table 2. On the whole, most countries have a downward trend since the 1960s. Hypertension as a cause of death has clearly decreased in Barbados, Chile and Singapore, whereas in Kuwait the rates are upward. The three countries with the highest rates for the 1980s TABLE 2. AGE-SPECIFIC DEATH RATES PER 100 OOO POPULATION (FROM HYPERTENSION) IN SELECTED DEVELOPING COUNTRIES, MALES AND FEMALES, 35-74 YEARS, 1960-1986 TABLEAU 2. TAUX SPECIFIQUES DE MORTAL~TE PAR AGE POUR 100 OOO HABITANTSA P~R HYPERTENSION, DANS CERTAINS PAYS EN DEVELOPPEMENT, HOMMES ET FEMMES GES DE 35-74 ANS, 1960-1986 MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE o· AGE AGE GROUP - GROUPE D' AGE Rate (average annual number of deaths) Rate (average annual number of deaths) Taux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Mauritius - Maurice 1960 7 24.5 55.8 158.6 312.5 5.9 51.7 157.5 162.8 1970 8 5.1 21.9 82.9 103.1 7.8 40.5 45.9 180.3 1980 8 19.4 40.3 113.2 310.9 9.0 35.6 64.9 187.9 1984 9 8.7 23.9 100.0 176.9 5.1 16.0 41.8 178.2 Barbados - Barbade 1960 7 9.4 58.3 83.3 275.9 21.0 54.3 63.2 298.5 1970 8 22.0 126.4 129.6 34.2 75.5 280.5 1980 9 11.9 36.1 90.9 38.5 100.0 1984 9 12.7 13.9 90.9 7.5 40.8 65.2 Chile - Chili 1960 7 4.1 10.8 43.3 143.1 5.3 17.3 50.8 140.8 1970 8 3.9 9.7 40.1 96.4 3.4 9.4 33.4 83.6 1980 9 1.9 5.1 20.9 78.3 1.2 6.6 19.4 55.7 1984 9 1.0 6.0 18.7 69.3 0.5 4.7 14.3 54.9 Costa Rica 1961 7 5.2 9.7 15.7 97.0 1.7 22.2 16.1 97.0 1970 8 1.3 7.6 17.2 44.0 1.3 5.7 31.8 96.8 1980 9 1.9 20.8 69.2 1.9 2.7 14.0 46.4 1984 9 0.8 7.0 8.7 59.6 0.8 1.2 17.2 59.0 Cuba ....... 1964 7 9.7 34.0 113.8 274.3 13.4 26.5 71.5 237.4 1970 8 5.3 14.3 39.4 88.3 6.4 17.7 25.5 87.5 1980 9 2.9 11.4 22.0 44.4 3.8 12.7 15.4 42.3 1985 9 3.7 9.6 25.7 35.0 3.4 10.4 17.8 46.5 Mexico - Mexique . 1960 7 3.0 8.1 23.4 51.3 3.6 10.1 26.8 72.0 1970 8 2.8 9.3 19.9 53.4 4.4 9.2 24.3 69.5 1978 8 1.6 4.2 15.4 36.4 1.5 5.8 16.1 50.3 1982 9 2.1 6.7 15.2 43.6 2.5 6.8 17.6 49.9 Wld hlth sta11sr. quan .. 41 ( 1988) - 144 - TABLE 2 (continued} TABLEAU 2 (suite} MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE o· AGE AGE GROUP - GROUPE o· AGE Rate (average annual number of deaths) Rate (average annual number of deaths) T aux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Panama .............. 1960 7 1.7 11.9 37.5 138.5 12.7 5.6 26.1 125.0 1970 8 1.4 8.9 13.5 66.7 4.3 20.0 28.1 64.7 1980 9 5.1 7.4 18.0 41.4 3.3 4.5 14.6 31.0 1984 9 0.9 5.4 20.2 66.5 3.0 8.4 17.2 50.6 Trinidad and Tobago ....... 1960 7 20.1 101.7 199.0 581.0 4.5 55.0 164.1 458.6 T rinite-et-T obago 1970 8 13.4 1980 9 18.0 1983 9 5.2 Uruguay ............. 1960 7 12.0 1970 8 5.0 1980 9 2.3 1985 9 2.9 Venezuela .... . . . . . . . . . 1960 7 6.4 1970 8 2.7 1980 9 4.7 1983 9 3.5 Hong Kong .... . . . . . . . 1960 7 4.8 1970 8 7.2 1980 9 1.9 1986 9 2.7 Israel - Israel 1980 9 1.1 1985 9 0.4 Israel, Jewish pop. 1960 7 0.9 lsral!I, pop. juive 1970 8 2.3 Kuwait - Kowei't . . 1980 9 4.3 1986 9 1.9 Singapore - Singapour 1963 7 8.2 1970 8 10.7 1980 9 5.2 1986 9 1.1 Sri Lanka .. 1960 7 5.0 1968 7 4.5 1977 8 5.3 1982 9 4.1 in the 55-64 age group are: Trinidad and Tobago 85.7 ( 1983); Mauritius 100.0 ( 1984); and Kuwait 184. 7 (1986). There is also a group of countries including Costa Rica, Cuba, Mexico, Panama, Uruguay and Venezuela where the downward trend of the 1960s lev- elled off in the 1970s. In Sri Lanka, hypertension as a cause of death remained at about the same level throughout the observation period 1960-1982. Mortality rates also indicate a decrease in cerebrovascu- lar diseases in countries such as Chile, Costa Rica, Hong Hong, Mexico, Panama, Uruguay, Singapore and Sri Lanka. In Mexico, Singapore and Sri Lanka the decline started after the 1970s. In Kuwait where statistics are only available for 1980 and 1986, cerebrovascular dis- ease mortality showed a steep downward trend during this time (Table 3}. 49.1 131.6 336.0 25.2 42.0 113.9 340.0 64.7 239.5 544.6 16.2 62.2 134.7 430.7 27.1 85.7 233.3 5.2 17.8 68.6 266.7 31.3 84.1 168.0 4.0 25.2 63.7 161.4 20.2 44.3 92.1 6.5 9.2 32.1 100.3 10.5 25.0 56.4 4.0 5.6 12.0 55.5 7.2 24.3 58.8 1.7 4.6 12.7 53.6 26.5 69.7 178.4 8.4 21.6 63.0 135.4 11.3 40.9 125.3 4.0 9.4 45.6 108.4 12.6 45.9 109.6 3.7 11.7 36.0 111.4 16.0 49.9 122.0 3.6 12.2 38.5 96.4 31.2 116.9 302.4 3.9 6.3 37.4 96.9 27.2 105.7 259.2 3.3 17.2 58.0 166.7 16.1 36.0 137.6 2.8 8.1 27.5 81.5 15.9 49.4 128.4 1.3 6.5 24.4 82.6 1.9 10.6 41.4 1.2 15.7 45.9 7.9 14.7 26.4 0.4 2.8 13.8 46.8 8.4 16.2 74.9 0.9 6.2 20.4 120.2 4.8 11.4 35.3 0.7 3.0 10.0 40.2 22.7 88.1 349.2 10.2 43.3 179.7 525.4 36.6 184.7 387.5 10.3 73.9 180.1 561.6 19.0 107.3 208.1 11.3 15.6 65.0 193.7 48.8 101.5 217.7 7.9 19.7 65.2 152.2 16.5 38.9 107.4 1.5 10.3 49.8 110.3 13.1 38.2 65.0 2.3 10.8 29.4 93.6 19.5 50.9 87.8 2.9 9.9 32.2 67.0 19.4 52.7 115.3 3.9 9.3 33.5 87.6 19.0 59.0 111.6 4.6 9.6 33.1 91.9 19.1 53.3 103.0 2.3 10.3 31.5 72.7 The proportion of ill-defined causes as a cause of death has diminished, except among men of all age groups in Sri Lanka (Table 4}. This, too, is likely to have affected the comparability of mortality trends from hypertension and stroke. Deaths previously coded to ill-defined causes are now more likely to be assigned a specific diagnosis due to improvements in diagnostic and certif- ication procedures in these countries. Table 5 shows trends in hypertension, cerebrovascular diseases and ill-defined causes as a percentage of the total number of deaths for the age group 55-64. For the 1980s, when most countries have fewer ill-defined causes than earlier, the percentage of deaths due to hypertension among 55-64 year-old men was between 0.8% (Costa Rica) and 13.0% (Kuwait). At the same time, the percentage of deaths due to cerebrovascular disease varied from 3. 7% (Kuwait) to 15.3% (Mauritius). Rapp. rrimest. statisr. sanit. mond .• 41 (19881 - 145 - TABLE 3. AGE-SPECIFIC DEATH RATES PER 100 OOO POPULATION (FROM CEREBROVASCULAR DISEASES) IN SELECTED DEVELOPING COUNTRIES, MALES AND FEMALES, 35-74 YEARS, 1960-1986 TABLEAU 3. TAUX SPECIFIQUES DE MORTALITE PAR AGE POUR 100 OOO HABITANTS, PAR MALADIES CEREBRO-VASCULAIRES, DANS CERTAINS PAYS EN DEVELOPPEMENT, HOMMES ET FEMMES AGES DE 35-74 ANS, 1960-1986 MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE D' AGE AGE GROUP - GROUPE D' AGE Rate (average annual number of deathsl Rate (average annual number of deathsl Taux (nombre annuel moyen de decesl Taux (nombre annuel moyen de decesl Year of Country - Pays death ICO 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Mauritius - Maurice ... 1961 7 59.8 187.3 620.7 765.6 26.6 77.6 219.2 627.9 1970 8 33.1 115.6 341.5 814.4 15.6 77.7 204.1 516.4 1980 8 72.6 167.1 471.7 1 252.1 11.3 63.0 187.0 545.5 1986 9 24.5 145.9 425.8 802.7 13.6 77.3 192.9 574.7 Barbados - Barbade ...... 1961 7 37.7 194.2 500.0 1241.4 21.0 131.8 357.9 671.6 1970 8 22.5 65.9 310.3 1018.5 8.2 76.9 198.1 512.2 1980 9 21.3 59.5 204.8 712.1 20.0 38.1 163.5 388.9 1986 9 8.1 126.6 83.3 969.7 14.9 29.7 91.8 402.2 Chile - Chili ........... 1960 7 26.6 82.7 240.1 569.6 26.5 87.5 214.8 509.8 1970 8 21.1 83.7 207.7 598.2 14.4 69.3 194.2 490.4 1980 9 12.7 57.1 184.4 543.9 12.4 56.5 138.7 413.6 1984 9 11.9 55.6 153.4 542.4 10.8 44.5 122.1 402.3 Costa Rica ............ 1961 7 15.6 14.6 110.2 335.8 6.9 44.4 96.4 246.3 1970 8 13.2 34.3 94.8 329.7 19.6 42.0 112.7 279.6 1980 9 10.6 29.3 72.9 261.5 6.8 28.0 86.0 189.3 1984 9 7.1 19.9 66.4 311.3 7.9 16.4 75.6 245.3 Cuba ...... ......... 1964 7 12.0 49.8 170.4 448.2 15.5 46.1 124.3 383.6 1970 8 13.8 40.5 122.6 388.1 15.3 48.0 113.0 342.3 1980 9 17.5 48.8 131.4 324.1 18.2 52.2 111.9 294.6 1985 9 19.1 49.6 130.6 333.6 17.7 54.1 108.4 292.2 Mexico - Mexique . . . . . . . . 1960 7 14.9 37.5 93.9 191.2 16.4 34.9 82.5 191.7 1970 8 16.0 42.8 103.5 251.9 17.2 41.2 97.5 255.0 1978 8 12.2 33.4 89.0 233.1 13.4 33.6 77.4 234.8 1982 9 10.7 32.5 84.6 220.9 12.7 31.8 71.3 185.2 Panama . . . . . . . . . . 1960 7 10.3 35.7 179.2 569.2 12.7 41.7 139.1 416.7 1970 8 16.7 44.6 121.6 377.8 8.7 58.0 109.4 382.4 1980 9 9.2 33.8 106.0 293.1 8.7 31.8 91.7 179.3 1984 9 6.6 24.4 71.7 262.7 9.0 36.3 80.5 278.5 Trinidad and Tobago ....... 1960 7 33.5 141.2 368.2 971.4 49.9 97.9 323.1 601.5 T rinite-et-Tobago 1970 8 21.0 152.0 368.4 1 296.0 44.0 103.7 345.2 1 013.3 1980 9 21.6 64.7 236.5 707.9 16.2 92.2 230.5 767.3 1983 9 31.0 79.2 280.0 761.9 17.2 62.2 182.9 642.9 Uruguay ... . ...... 1960 7 21.2 81.3 191.0 554.7 19.3 77.1 181.6 498.6 1970 8 23.7 80.1 189.2 591.4 12.9 54.3 171.3 478.4 1980 9 20.4 52.5 172.6 491.0 18.5 59.2 111.9 407.3 1985 9 18.8 68.6 145.9 407.0 17.7 46.5 98.0 342.9 Venezuela ............. 1960 7 11.1 48.6 129.7 288.0 14.5 38.2 118.6 255.0 1970 8 11.4 42.2 137.8 422.8 16.0 41.0 136.3 361.2 1980 9 14.3 48.9 139.0 382.8 13.2 46.6 118.2 346.6 1983 9 14.4 46.1 120.6 381.5 14.6 44.6 96.7 301.5 Hong Kong ............ 1960 7 14.5 67.9 347.2 848.8 14.2 45.8 154.2 400.9 1970 8 16.3 61.5 231.7 598.6 9.1 30.4 118.2 334.6 1980 9 13.9 63.5 232.0 625.8 13.2 46.9 136.8 424.7 1986 9 5.5 38.4 130.8 372.0 6.8 31.5 79.7 275.7 Israel - Israel ........ 1980 9 7.3 23.3 132.6 437.5 3.8 26.2 100.6 424.5 1985 9 4.3 21.8 102.2 305.1 2.5 15.9 70.7 312.9 Israel. Jewish pop. ........ 1960 7 2.6 22.8 140.4 422.2 2.6 32.0 156.2 656.9 Israel, pop. juive 1970 8 7.7 44.8 150.3 543.7 6.3 34.3 172.8 629.1 Kuwait - Kowert . . ....... 1980 9 3.5 36.6 176.2 428.6 6.8 32.5 78.1 406.8 1986 9 2.5 11.8 52.3 212.5 4.6 4.9 37.3 164.4 Wld h/th statist. quart., 41 (19881 - 146 - TABLE 3 (continued) TABLEAU 3 (suite) MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE D'AGE AGE GROUP - GROUPE D' AGE Rate (average annual number of deaths) Rate (average annual number of deaths) Taux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 Annee du CIM 55-64 65-74 35-44 45-54 55-64 65-74 deces Singapore - Singapour 1963 7 23.7 93.6 216.7 536.9 18.8 73.6 207.5 486.9 1970 8 31.1 108.7 287.6 641.1 18.7 63.4 208.3 587.0 1980 9 16.2 69.8 248.5 595.9 9.9 48.3 202.2 533.3 1986 9 7.1 46.6 158.9 473.1 8.5 29.8 131.5 430.3 Sri Lanka ...... 1960 7 3.8 17.5 62.9 120.3 6.0 11. 7 34.4 77.7 1968 7 9.9 29.6 80.2 198.1 8.7 20.1 46.8 117.8 1977 8 9.2 25.7 70.2 138.4 6.3 21.0 42.1 107.0 1982 9 7.6 21.6 62.2 134.6 5.4 12.0 36.4 90.4 TABLE 4. AGE-SPECIFIC DEATH RATES PER 100 OOO POPULATION (FROM ILL-DEFINED CAUSES) IN SELECTED DEVELOPING COUNTRIES, MALES AND FEMALES, 35-74 YEARS, 1960-1986 TABLEAU 4. TAUX SPECIFIQUES DE MORTALITE PAR AGE POUR 100 OOO HABITANTS, DE CAUSES MAL DEFINIES, DANS CERTAINS PAYS EN DEVELOPPEMENT, HOMMES ET FEMMES AGES DE 35-74 ANS, 1960-1986 MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE D' AGE AGE GROUP - GROUPE o· AGE Rate (average annual number of deaths) Rate (average annual number of deaths) Taux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Mauritius - Maurice 1961 7 76.1 183.3 800.0 1 687.5 103.6 137.9 561.6 1 883.7 1970 8 48.3 131.3 409.8 1 762.9 62.5 81.1 250.0 1 098.4 1980 8 41.2 112.4 388.7 1 319.3 29.3 46.6 202.3 618.2 1986 9 8.7 31.8 61.3 238.1 10.2 18.7 28.9 132.0 Barbados - Barbade ...... 1961 7 18.9 29.1 55.6 137.9 14.0 31.0 21.1 223.9 1970 8 11.0 34.5 222.2 16.4 18.9 61.0 1980 9 12.0 90.9 9.5 33.3 1986 9 12.7 13.9 151.5 9.9 10.2 54.3 Chile - Chili ........... 1960 7 27.8 70.5 194.7 640.2 36.7 61.5 160.7 524.2 1970 8 14.2 31.7 75.7 235.0 15.0 24.7 48.8 184.5 1980 9 15.4 39.6 129.2 438.3 13.0 32.7 83.0 287.3 1984 9 18.5 48.1 111.6 402.3 9.8 28.3 79.1 231.4 Costa Rica ........ 1961 7 22.5 65.7 153.5 432.8 44.8 46.9 92.4 388.1 1970 8 41.0 53.3 114.9 329.7 20.9 53.4 75.1 301.1 1980 9 12.5 34.7 112.5 311.5 13.6 28.0 28.0 185.7 1984 9 1.6 9.4 26.2 56.3 2.4 2.3 25.8 59.0 Cuba . .............. 1964 7 1.4 2.1 4.4 18.0 1.9 2.7 2.3 9.2 1970 8 1.8 4.9 4.9 18.3 1.4 1.7 3.3 5.6 1980 9 2.2 1.4 2.7 6.2 0.3 1.2 0.6 4.5 1985 9 0.6 2.3 2.0 3.9 0.5 0.6 1.2 2.0 Mexico - Mexique . . . . . . . . 1960 7 70.1 108.5 214.4 758.8 68.5 98.6 214.7 724.1 1970 8 57.3 98.1 214.9 649.4 57.6 86.4 188.4 587.3 1978 8 29.5 53.0 109.4 264.6 28.7 41.3 85.8 218.2 1982 9 20.2 37.0 70.1 158.1 15.7 25.4 47.6 114.3 Panama .... 1960 7 44.8 78.6 312.5 476.9 72.7 136.1 260.9 383.3 1970 8 38.9 98.2 216.2 644.4 58.0 102.0 256.3 664.7 1980 9 15.3 29.4 86.0 220.7 10.9 34.8 81.3 182.8 1984 9 16.0 29.8 73.5 284.8 7.0 22.3 40.2 158.2 Trinidad and Tobago . ...... 1960 7 6.7 5.6 34.8 361.9 9.1 6.1 35.9 180.5 T rinite-et-Tobago 1970 8 1.9 16.6 26.3 288.0 6.3 9.9 39.1 140.0 1980 9 9.0 2.2 9.0 59.4 9.0 4.6 12.0 49.5 1983 9 10.3 14.6 17.1 109.5 1. 7 4.4 5.7 57.1 Rapp. trimest. statist. sanit. mond., 41 (1988) - 147 - MALES - HOMMES FEMALES - FEMMES AGE GROUP - GROUPE D' .AGE AGE GROUP - GROUPE D' .AGE Rate (average annual number of deaths) Rate (average annual number of deaths) T aux (nombre annuel moyen de deces) Taux (nombre annuel moyen de deces) Year of Country - Pays death ICD 35-44 45-54 55-64 65-74 35-44 45-54 55-64 65-74 Annee du CIM deces Uruguay 1960 7 48.6 90.3 180.1 297.9 13.6 37.1 64.6 144.1 1970 8 29.2 83.2 180.4 312.4 13.4 19.1 58.5 144.7 1980 9 25.6 98.6 202.9 379.2 16.8 39.4 60.2 167.5 1985 9 32.3 70.4 180.7 318.8 13.1 29.0 69.6 138.4 Venezuela 1960 7 91.0 205.5 541.1 1 139.6 112.4 196.3 438.3 805.5 1970 8 54.9 130.8 392.4 1 248.1 72.4 117.8 314.9 787.4 1980 9 39.5 107.9 263.3 676.4 29.9 71.3 183.4 475.6 1983 9 6.3 18.8 47.2 128.9 4.7 11.8 26.9 81.7 Hong Kong 1960 7 25.1 87.3 275.5 887.8 22.6 37.3 117.9 427.3 1970 8 8.7 21.9 113.8 534.4 4.1 12.2 43.5 303.3 1980 9 9.7 5.6 18.0 109.7 2.4 1.6 11.2 85.6 1986 9 1.4 2.1 4.2 31.0 0.6 0.4 2.6 26.5 Israel - Israel 1980 9 12.4 54.9 114.6 238.1 6.6 16.9 56.1 151.8 1985 9 12.1 35.7 112.7 220.3 6.3 17.1 46.1 133.1 Israel, Jewish pop. 1960 7 4.3 8.4 48.6 119.8 7.7 13.3 30.7 93.8 Israel, pop. juive 1970 8 13.1 39.2 66.2 162.8 3.5 13.7 37.6 80.4 Kuwait - Kowe'it 1980 9 0.9 1.7 5.2 333.3 5.1 39.1 389.8 1986 9 3.1 1.2 27.9 200.0 2.5 43.5 164.4 Singapore - Singapour .. 1963 7 35.0 70.8 454.9 1 510.1 26.4 57.9 202.5 1 015.7 1970 8 9.8 8.5 138.7 806.5 6.9 21.1 101.4 659.4 1980 9 6.6 6.8 18.0 130.4 0.8 5.1 10.9 110.3 1986 9 6.0 8.2 6.2 38.1 1.7 6.4 39.8 Sri Lanka ...... 1960 7 26.3 46.2 203.4 1 108.1 40.0 75.4 268.3 1408.7 1968 7 45.4 79.4 230.2 1 296.8 41.3 59.3 231.5 1401.6 1977 8 35.7 86.6 246.5 1 252.6 31.0 64.3 227.5 1 325.8 1982 9 40.2 104.8 287.2 1 343.5 30.6 68.9 200.3 1 246.4 TABLE 5- PERCENTAGE OF DEATHS FROM HYPERTENSION, CEREBROVASCULAR DISEASE AND ILL-DEFINED CAUSES, BY SEX AT AGE 55-64, IN SELECTED DEVELOPING COUNTRIES, 1960-1986 TABLEAU 5. POURCENTAGE DES DECES IMPUTABLES A L'HYPERTENSION, AUX MALADIES CEREBRO-VASCULAIRES ET A DES CAUSES MAL DEFINIES, PAR SEXE ET POUR LE GROUPE D'AGE 55-64 ANS, DANS CERTAINS PAYS EN DEVELOPPEMENT, 1960-1986 MALES - HOMMES FEMALES - FEMMES Cerebra- Ill- Cerebra- Ill- vascular defined vascular defined Country - Pays ICD Year Hyper- disease causes Hyper- disease causes CIM Annee tension Maladies Causes tension Maladies Causes cerebra- mal cerebra- mal vasculaires definies vasculaires definies % % % % % % Mauritius - Maurice .. 7 1961 4.1 16.2 20.8 7.2 10.0 25.5 8 1970 2.8 11.6 14.0 2.9 12.8 15.7 8 1980 3.6 15.1 12.5 4.5 13.0 14.1 9 1986 3.6 15.3 2.2 3.1 14.2 2.1 Barbados - Barbade .. 7 1960 4.3 26.1 2.9 4.7 26.6 1.6 8 1970 7.1 17.5 1.9 6.4 16.8 1.6 9 1980 2.6 14.7 0.9 3.7 15.9 9 1984 1.0 6.2 1.0 3.6 8.1 0.9 Chile - Chili 7 1960 1.6 9.1 7.4 2.9 12.1 9.1 8 1970 1.6 8.4 3.1 2.1 12.2 3.1 9 1980 1.1 9.5 6.6 1.7 12.2 7.3 9 1984 0.9 7.8 5.6 1.4 11.9 7.7 Wld hlth statist. quan., 41 (1988) - 148 - TABLE 5 (continued) TABLEAU 5 (suite) MALES - HOMMES FEMALES - FEMMES Cerebra- 111- Cerebra- 111- vascular defined vascular defined Country - Pays ICD Year Hyper- disease causes Hyper- disease causes CIM Annee tension Maladies Causes tension Maladies Causes cerebra- mal cerebra- mal vasculaires delinies vasculaires definies % % % % % % Costa Rica . . ............ 7 1961 1.0 6.9 9.6 1.3 7.8 7.5 8 1970 1.1 6.2 7.5 2.4 8.4 5.6 9 1980 1.7 5.9 9.1 1.9 11.8 3.8 9 1984 0.8 5.7 2.3 2.2 9.5 3.2 Cuba .................. 7 1964 7.0 10.5 0.3 6.9 12.0 0.2 8 1970 3.1 9.6 0.4 2.7 11.8 0.3 9 1980 1.8 10.5 0.2 1.7 12.5 0.1 9 1985 2.0 10.0 0.2 1.9 11.5 0.1 Mexico - Mexique .... 7 1960 1.1 4.3 9.7 1.5 4.5 11.8 8 1970 0.9 4.9 10.2 1.5 6.1 11.8 8 1978 0.8 4.8 5.9 1.3 6.3 6.9 9 1982 0.9 4.8 4.0 1.6 6.8 4.3 Panama ...... . . . . . . . . . 7 1960 2.4 11.5 20.1 2.2 11.5 21.5 8 1970 0.9 8.3 14.8 2.1 8.4 19.6 9 1980 1.6 9.2 7.4 2.0 12.7 11.2 9 1984 2.1 7.6 7.8 2.4 11.2 5.6 Trinidad and Tobago ....... 7 1960 8.0 14.8 1.4 9.4 18.6 2.1 T rinite-et-T obago 8 1970 6.2 17.2 1.2 6.8 20.5 2.3 9 1980 11.5 11.4 0.4 9.5 16.2 0.8 9 1983 4.2 13.8 0.8 4.7 12.5 0.4 Uruguay ................ 7 1960 3.9 8.8 8.3 5.6 15.9 5.7 8 1970 2.1 8.8 8.4 2.6 13.8 4.7 9 1980 1.2 8.1 9.6 1.2 11.5 6.2 9 1985 1.3 7.9 9.8 1.5 11.6 8.2 Venezuela ............... 7 1960 3.3 6.1 25.4 3.8 7.2 26.7 8 1970 1.9 6.5 18.4 3.0 8.9 20.5 9 1980 2.6 7.9 14.9 3.1 10.2 15.8 9 1983 3.1 7.5 2.9 3.8 9.5 2.6 Hong Kong ............... 7 1960 4.4 13.2 10.5 3.1 12.6 9.7 8 1970 4.5 9.8 4.8 5.2 10.7 3.9 9 1980 2.1 13.5 1.0 3.2 15.7 1.3 9 1986 3.7 9.8 0.3 3.6 11.7 0.4 Israel - lsral!I ............. 9 1980 0.8 10.0 8.2 1.6 10.5 5.9 9 1985 1.0 7.3 8.0 1.6 8.2 5.4 Israel, Jewish population ....... 7 1960 1.1 9.2 3.2 1.8 14.1 2.8 lsral!I, population juive 8 1970 0.7 9.3 4.1 0.8 14.6 3.2 Kuwait - Kowert ... . . . . . . . . 8 1972 9.4 4.2 13.6 14.1 6.5 10.9 9 1980 5.0 9.9 0.3 16.4 7.1 3.6 9 1986 13.0 3.7 2.0 17 .1 3.5 4.1 Philippines ........ . . . . . . . 7 1963 3.8 7.7 5.7 4.1 5.6 6.0 7 1969 5.4 7.9 6.3 5.0 7.3 7.8 Singapore - Singapour ....... 7 1963 3.4 6.9 14.4 4.0 12.9 12.6 8 1970 3.9 11.0 5.3 4.8 15.2 7.4 9 1980 1.8 11.3 0.8 3.8 15.6 0.8 9 1986 2.1 8.8 0.3 2.9 12.8 0.6 Sri Lanka ..... . . . . . . . . . . 7 1960 2.8 3.4 11. 1 2.2 2.4 18.4 7 1968 3.2 4.9 14.0 2.7 3.8 18.9 8 1977 3.2 3.8 13.5 2.7 3.4 18.4 9 1982 3.1 7.5 16.9 3.5 4.0 22.1 Rapp. trimest. statist. sanit. mond., 41 (1988) 149 - Blood-pressure level Blood pressure is higher in the older age groups of both sexes. Men have higher values than women, the differ- ence between the sexes being greater among the young- er age group in most countries (Table 6). Blood pressure is highest in developing countries among Indian male petrochemical industrial workers in the early 1980s (136/91 mm Hg at age 50-59); among urban Bantu men in Zaire in 1983-1984 ( 137 /88 mm Hg at age 40-49); TABLE 6. BLOOD PR~SSURE (mm Hg) AND PREVALENCE OF HYPERTENSION(%) IN SUBJECTS AGED APPROXIMATELY 40-55 YEARS, SELECTED SURVEYS TABLEAU 6. TENSION ARTERIELLE (mm Hg) ET PREVALENCE DE L'HYPERTENSION (%) CHEZ LES SUJETS AGES DE 40-55 ANS ENVIRON (DONNEES TIREES DE DIFFERENTES ETUDES) Definition Males - Hammes Females - Femmes WHO Region and Population Year of of hyper· Refer- country/area basis survey tension a Age Prev- Prev- ence Region OMS et Population Annee de Definition (n) BP alence (n) BP alence Refe- pays/zone consideree l'etude de l'hyper- Nombre PS Preva- Nombre PS Preva- re nee tension a lence le nee Africa - Afrique Ethiopia - Ethiopie rural - rurale 1983 x 30-39 60) 110/69 3 51) 107/65 2 (7) 40-49 42) 119/72 11 31) 113/71 3 Kenya rural - rurale 1980- 35-44 280) 117/66 (8) 1981 45-54 35) 121 /71 Malawi rural - rurale 1983 35-44 39) 120/74 57) 112/68 (9) 45-54 22) 116/67 43) 121/70 urban - urbaine 1983 35-44 64) 130/84 36) 123/75 45-54 20) 141/87 Nigeria - Nigeria Bendal State civil servants - 1977 35-39 120) 130/83 23) 124/80 (10) Etat du Bendal fonctionnaires 40-49 110) 134/87 10) 133/83 Bendal State civil servants - 1983 35-39 42) 131/78 10 Etat de Bendal fonctionnaires 40-49 49) 132/77 12 (11) policemen - policiers 1983 35-39 69) 126/74 13 (11) 40-49 38) 133/76 11 South Africa - Afrique du Sud Zulu - Zoulous urban - urbaine 1976 xx 31-40 109) 122/79 17 106) 124/81 25 (12) 41-50 80) 124/83 20 83) 136/89 41 rural - rurale 1976 xx 31-40 80) 119/72 1 163) 122/74 10 41-50 86) 126/77 14 132) 130/79) 19 Tanzania . rural - rurale xx 35-44 88) 125/77 2 94) 119/75 2 (13) Tanzanie 45-54 75) 123/76 3 58) 124/76 Zaire - Zai're Bantu - Bantous urban - urbaine 1983- xx 40-49 21) 137/88 33 34) 133/79 15 (14) 1984 Zambia - Zambie rural - rurale 1979 x 35-44 20) 120/73 5 61) 119/72 11 (15) 45-54 27) 122/75 11 32) 123/74 9 Americas - Ameriques Brazil - Bresil Sao Paulo ... city workers - 1976 x 35-44 796) -/84 30 179) -/80 18 (16) travailleurs urbains 45-54 405) -/86 34 54) -/84 24 South-East Asia-Asiedu Sud-Est India - lnde Haryana urban/rural - xx 35-44 470) 5 395) 4 (18) urbaine/rurale 45-54 316) 8 220) 13 Ludhiana industrial workers - xx 40-45 339) 129/84 6 (19) travailleurs de 50-59 170) 136/91 7 rindustrie Sundergrarh . rural - rurale 1980- xxx 41-50 642) 124/82 5 440) 112/80 2 (20) 1982 51-60 468) 130/84 9 217) 123/85 9 Nepal - Nepal rural - rurale xx 41-50 109) 7 155) 3 (21) 51-60 91) 9 86) 12 Europe Finland - Finlande rural - rurale 1972 xxx 40-44} 699) 146/91 23 }( 716) 148/91 27 (17) 45-49 148/92 32 156/94 37 1977 xxx 40-44} 607) 140/89 19 }( 616) 137/86 14 45-49 146/91 27 145/89 24 1982 xxx 40-44} 366) 141/86 24 }( 412) 136/84 14 45-49 141/88 28 146/87 29 Wld hlth statist. quart., 41 ( 1988) - 150 - TABLE 6 (continued) Definition WHO Region and Population Year of of hyper- country/area basis survey tension a Region OMS et Population Annee de Definition pays/zone consideree l'etude de l'hyper- tension a Western Pacific - Pacifique occidental China - Chine Beijing urban - urbaine 1975 xx Tibet rural - rurale 1979 xx Shanghai petrochemical industry 1979- xx - industrie petro- 1982 chimique Japan - Japan Tsumagoi .. rural - rurale xx Republic of Korea - Republique de Coree Kang Wha ... rural - rurale xx Philippines Quezon urban - urbaine 1976 xx a Definition of hypertension : X - diastolic blood pressure ;;, 90 mm Hg XX - blood pressure ;;, 160 and/or ;;, 95 mm Hg XXX - blood pressure;;, 175 and/or;;, 100 mm Hg or under antihypertensive drug treatment XXXX - blood pressure > 140 and/or 90 mm Hg and among urban Malawian men in 1983 (141/87 mm Hg at age 45-54). These blood-pressure levels are approximately the same among populations represent- ing developed countries, such as the Japanese rural population in the late 1970s ( 139 /81 mm Hg in the 50- 59 age group) and among Finnish men in rural areas in 1982 (141/88 mmHg in the 45-49 age group). Among women in developing countries, the urban Bantu of Zaire in 1983-1984 have a mean blood pressure of 133/79 mmHg among the 40-49 age group. Urban Zulu females at the same age already had a somewhat higher blood- pressure level (136/89 mmHg) in 1976. Again, these values are of about the same magnitude as the blood- pressure values in Finland in 1982 but they are still somewhat higher than those recorded in rural Japan in 1983. The lowest blood-pressure values were found in Ethiopia in 1983 and in the United Republic of Tanzania in the late 1970s. Prevalence of hypertension Prevalence of hypertension ranged from 1 % to over 30%. The number of hypertensives was lowest among rural Zulu men aged 31-40 in 1976 ( 1 %). among the Tanzanian population in the late 1970s (2-3%) and among Ethiopian women (2-3%). The highest preva- lence was for Sao Paulo city workers in 1976 (34%) among 45-54 year-old men, and among urban Bantu men in 1983-1984 (33%), corresponding to figures in Finland during the 10-year period 1972-1982. Countries in the Western Pacific area had a higher prevalence than countries in Africa. TABLEAU 6 (suite) Males - Hommes Females - Femmes Refer- Age Prev- Prev- ence (n) BP alence (n) BP alence Refe- Nombre PS Preva- Nombre PS Preva- rence lence lence 35-44 ( 791) 4 (1 237) 5 (22) 45-54 ( 880) 9 ( 995) 10 35-44 (2 652) 7 (3 392) 9 (23) 45-54 (2 381) 18 (3 241) 20 40-49 (3490) 5 ( 952) 4 (24) 50-59 (1 754) 16 ( 217) 12 40-49 171) 133/79 17 221) 128/75 10 (25) 50-59 186) 139/81 21 257) 137/79 19 40-49 266) 123/82 14 425) 122/79 10 (25) 50-59 116) 131/85 24 227) 128/82 18 40-49 82) 122/82 15 147) 116/76 8 (25) 50-59 82) 128/84 22 98) 126/80 13 a D8finition de !'hypertension X - tension arterielle diastolique ;;, 90 mm Hg XX - tension arterielle ;;, 160 et/ou ;;, 95mmHg XXX - pression arterielle ;;, 175 et/ou ;;, 100 mm Hg au sous traitement medicamenteux anti- hypertenseur XXXX - pression arterielle ;;, 140 et/ou 90mmHg Awareness of hypertension Table 7 shows the level of awareness among hyperten- sive persons from Bangladesh, China, Finland, India, the Philippines, Sri Lanka and Zaire. About the same per- centage (33%) of urban Bantu men knew about their elevated blood pressure in 1983-1984 as did men in the eastern part of Finland in 1972 (39%). At the beginning of 1980, the same proportion of Chinese petrochemical industrial workers knew about their hypertension as did men in Finland. Awareness has increased among Finnish patients of both sexes over the period 1972-1982 to 67% for men and 87% for women. The proportion of men under antihypertensive drug treatment and the pro- portion of patients with normal blood pressure were similar in Finland in 1972 and in urban Bantu men in Zaire in 1983-1984. Cost of antihypertensive drug treatment Estimates of the cost of antihypertensive drug treatment for Bangladesh, Brazil, Finland, Kenya, Sri Lanka, Thai- land and the United Republic of Tanzania are presented in Table 8. Costs range from 0.06% to 4.6% of govern- ment health-care costs if production costs are used as the basis for calculation. If drug costs are based on the market price, the share of antihypertensive drug treat- ment increases remarkably. Discussion Mortality data for this analysis are derived from 16 devel- oping countries, none of which belong to the group of Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 151 - TABLE 7. PREVALENCE OF HYPERTENSION AND AWARENESS OF THE DISEASE AMONG HYPERTENSIVE PERSONS IN SELECTED STUDIES TABLEAU 7. PREVALENCE DE L'HYPERTENSION ET POURCENTAGE DES HYPERTENDUS AVANT CONNAISSANCE DE LEUR ETAT (DONNEES TIREES DE DIFFERENTES ETUDES) Antihypertensive drug Awareness (yes) treatment Year of Prevalence Sujets ayant Sujets recevant Controlled Refer· survey Age Prevalence connaissance un traitement medica· Sujets controles ence Country - Pays Date de (years/ de leur etat menteux ReM· l'enquete annees) antihypertenseur re nee (%1 (%1 (%1 (%1 M F M M F M F Bangladesh early 1980s ;;,,10 7 14 rural debut des (26} annees 80 China - Chine industrial workers 1979-82 ;;,,20 2 68 81 (24} - travailleurs de l'industrie Finland - Finlande rural 1972 30-59 30 35 39 66 12 28 2 3 1977 30-59 23 22 71 87 43 68 20 38 1982 30-59 26 21 67 87 41 52 22 28 (17} India - lnde late 1970s urban - urbaine fin des 20-69 }5 }5 24 6 annees 70 16 4 (18} rural Philippines 1976-78 ;;a,15 urban - urbain 13 10 57 33 18 (27} (Quezon) urban - urbain 13 11 62 23 8 (Davao) Sri Lanka rural early 1980 >35 10 47 (28} debut 1980 Zaire - Zarre urban Bantu - 1983-84 ;;,,20 14 7 33 28 17 7 5 0 (14} urbain (bantou) TABLE 8. ESTIMATED COST OF ANTIHYPERTENSIVE DRUG TREATMENT RELATED TO THE TOTAL HEALTH-CARE EXPENDITURE BY GOVERNMENTS TABLEAU 8. COOT ESTIMATIF DU TRAITEMENT MEDICAMENTEUX ANTIHYPERTENSEUR PAR RAPPORT AU COOT TOTAL DES SOINS DE SANTE FINANCES PAR L'IETAT Hypenensive persons a Cost of antihypenensive Health-care costs Sujets hypenendus • drugs 0 Coat des medicaments Coats de soins de sante antihypertenseurs b %of Estimated number Trade health care Year % of total Population of persons Commercia- costs Country - Pays government ;;.30 years/ans Preva- needing drug %of lises sous Pourcentage Annee le nee treatment Generic health care US$ budget une marque du coOt total Preva- Chiffre estima· Generiques costs (000) % du budget des soins total de le nee tif des personnes Pourcentage de sante l'Etat ayant besoin d'un du coat total traitement US$ des soins US$ (%) medicamenteux (000) de same (000) Bangladesh .. 1979 59 8.5 26000000 7 900000 2.7 4.6 36 61 Brazil - Bresil 1985 45 7.8 47 000000 25 5 900000 17.7 0.04 236 0.5 Finland - Finlande 1982 1 748 10.9 2 800000 24 340000 1.0 0.06 14 0.8 Kenya 1982 89 7.3 4 500000 5 100000 0.3 0.3 4 5 Sri Lanka 1982 39 3.4 5 500000 10 280000 0.8 2.1 11 28 United Rep. of Tanzania 1981 14 5.4 6000000 3 90000 0.3 2.1 3.6 26 - Rep.-Unie de Tanzanie ..... Thailand - Thailande 1983 348 5.1 17 000000 5 430000 1.3 0.4 17 5 • On the assumption that 50% of hypenensive persons need drug treatment - En panant de l'hypothese que 50% des hypenendus sont justiciables d'un traitement medicamenteux. O Antihypenensive drugs hydrochlonhiazide (with daily dose of 12.5 mg). Estimated cost per patient per year using: /1) generic = US$ 3; (2} brand name= US$ 40 - Medicaments antyhypenenseurs hydrochlonhiazide (sur la base d'une prise quotidienne de 12.5 mg). CoOt estimatif du traitement annual pour un patient utilisant: I) un produit generique = US$ 3; 2} un produot commercialise sous une marque = US$ 40. Wld hlth statist. quan .. 41 ( 1988) - 152 - least developed countries (as designated by the United Nations General Assembly). Nine countries are in South America and can be regarded as typical of the region. Seven other countries belong to the most developed countries in their regions, and their mortality trends most probably do not represent the development in their regions. In most of the 16 countries included in the study. the share of ill-defined causes of death has decreased since 1960. This indicates that the diagnoses on death certifi- cates have become more specific with better diagnostic aids. During the period 1960-1986 three Revisions of the International Classification of Diseases were used in each of these countries. These changes in ICD Revisions possibly have not greatly influenced the comparability of cerebrovascular disease mortality or the mortality from ill-defined causes. The problem arises with hypertensive disease as a cause of death: it is defined differently in the Eighth Revision of ICD compared to the Seventh and Ninth Revisions. The most recent data from the 1980s are based on ICD-9 in all these countries and are, natu- rally, more reliable for international comparison. These methodological shortcomings must be considered when analysing the results. Total mortality has decreased in the 35-7 4 age group in all countries but four since 1960: Chile, Cuba, Mexico and Trinidad and Tobago where the decline has levelled off during the 1980s. This may in part reflect better coverage of the fact of death as more and more deaths are captured by the vital registration system. The decline in mortality from hypertensive disease in most of these countries had already started in the 1970s; the same is true for cerebrovascular disease mortality. One typical example is Chile, where a trend analysis of the prevalence of hypertension based on sur- veys carried out in that country since 1936 is also avail- able (29). The prevalence of hypertension is still increas- ing in Chile where rural populations have a steeper upward trend than urban populations and prevalence for both groups was around 20% in 1983-1984. Why this increasing prevalence of hypertension is not followed by an increase in mortality from hypertensive or cerebro- vascular disease deserves further investigation. It would also be interesting to have mortality data from a large number of developing countries in Africa and Asia. For the time being, only data from Singapore and Mauritius could be included in the analysis. Singapore is a relatively developed country where the clear decline of cerebrovascular diseases has been interpreted as a con- sequence of the treatment of hypertension (30). In Mauritius, again a comparatively developed country in the African region, the decline in hypertensive disease started in the 1970s but cerebrovascular disease mor- tality is not declining. This information, together with other mortality statistics of chronic diseases, has been the basis on which the Government of Mauritius has committed itself to fight the increasing problem of non- communicable diseases (31 }. Mortality data are available mainly from Latin American countries in which, on the other hand, there is little infor- mation available on blood-pressure levels and on the prevalence of hypertension among the population. On the contrary, most data on hypertension used for the present review come from African and Asian developing countries, using a standardized methodology. Nonethe- less, comparisons between countries should be made with caution. The survey populations are not always representative, thus influencing the conclusions. How- ever, some rough conclusions can still be drawn. Data from the surveys give more evidence on the earlier find- ings that geographical differences are related to the eco- nomic situations of countries in the developing world, with the poorest countries having the lowest prevalence, e.g. Bangladesh, Ethiopia, United Republic of Tanzania. The prevalence of hypertension, however, increases in developing countries, parallel to affluence, as the trend analysis from Chile shows (29). Prevalence of hyperten- sion is also increasing in Egypt according to studies car- ried out since 1959 (32), and it has doubled between 1958-1959 and 1979-1980 in certain parts of China, increasing from 7.4% to 14.7% in Beijing, from 4.2% to 10.7% in Tianjin and from 3.9% to 10.8% in Liaoning (22). Studies carried out in these countries typi- cally indicate a prevalence of hypertension of between 10% and 20% with this epidemic becoming increasingly apparent over the last two decades or so. It is interesting to note that in some groups in developing countries the prevalence is now of about the same magnitude as in Finland which has one of the highest mortality rates for ischaemic heart disease among the middle-aged popu- lation (17). On the whole and in spite of the relatively low prevalence of hypertension in the least developed countries, the total number of hypertensive persons is comparatively high and it will no doubt increase. In Brazil, for example, roughly 15 million adults are thought to be hypertensive, as are some 2 million in Bangladesh. Therefore it is of paramount importance for these countries to acknow- ledge the emergence of hypertensive disease and its consequences, such as cerebrovascular disease. Treat- ment of hypertension in the developed world relies to a great extent on drug treatment. The cost estimates for drug treatment for 50% of hypertensive patients indicate that developing countries cannot afford equal drug treat- ment for their hypertensive populations. Nonpharmaco- logical therapy avoiding obesity. excess salt and excess alcohol is, in the main, the solution for controlling hyper- tension in developing countries and, in the long term, in the developed countries as well. SUMMARY Population surveys carried out since the 1970s in 15 developing countries including 23 population groups show that the prevalence of hypertension ranges from as low as 1 % in some African countries to over 30% in Brazil. A trend analysis of the mortality statistics for 35- 7 4 year-aids from 16 countries in which data are availa- ble shows a downward trend in mortality from hyperten- sion and cerebrovascular diseases in most of these countries. In spite of the current low prevalence in some countries, the total number of hypertensives in the devel- oping world is high, and a cost assessment of possible antihypertensive drug treatment indicates that develop- ing countries cannot afford the same drug treatment levels as developed countries. Rapp. trimest. statist. sanit. mond., 41 (1988) - 153 - RESUME L 'hypertension dans les pays en developpement Des enquetes effectuees depuis les annees 70 dans 15 pays en developpement et sur 23 groupes montrent que la prevalence de !'hypertension est tres variable, allant de 1 % dans certains pays africains a plus de 30% au Bresil. Une analyse de tendance des statistiques de mor- talite pour le groupe d'age de 35-74 ans dans 16 pays pour lesquels on possede des donnees montre une dimi- nution de la mortalite par hypertension et maladies cerebro-vasculaires dans la plupart de ces pays. En depit de la faible prevalence actuelle dans certains pays, le nombre total des hypertendus dans le tiers monde est eleve et une evaluation du coat de I' application poten- tielle d'un traitement medicamenteux anti-hypertenseur montre que les pays en developpement ne peuvent a I' evidence pas s • offrir de traitement medicamenteux a la meme echelle que les pays developpes. REFERENCES - REFERENCES 1. EPSTEIN, F. H. & ECKOFF R.D. Epidemiology of high blood pressure-geographic distribution and etiolo- gical factors. In: Stamler J. et al. (eds), The epide- miology of hypertension. New York, Grune and Stratton, 1967. 2. SHAPER. A. G. Communities without hypertension. In: Shaper A. G. et al. (eds), Cardiovascular disease in the tropics. London, British Medical Association, 1974. 3. AKINKUBGE, 0. 0. Epidemiology of hypertension and stroke in Africa. In: Hatano, S. et al. (eds), Hyper- tension and stroke control in the community. Geneva, World Health Organization, 1976. 4. KAGAN. A. Epidemiology of hypertension and stroke in Oceania. In: Hatano, S. et al. (eds), Hypertension and stroke control in the community. Geneva, World Health Organization, 1976. 5. CRUICKSHANK. J. K. & BEEVERS, D.G. Ethnic and geo- graphic differences in blood pressure. In Bulpitt C. J. (ed.), Handbook of hypertension-6. Epidemiology of hypertension. Amsterdam/New York/Oxford, Elsevier Science Publisher, 1987. 6. WHO Technical Report Series, No. 628, 1978 (Arterial hypertension: report of a WHO Expert Committee). OMS Serie de Rapports techniques, N° 628, 1978 (L 'hypertension arterielle: rapport d • un Comite OMS d'experts). 7. ZEIN. A. Z. & MEKONNEN, A. Blood pressure levels and hypertension in rural Ethiopian communities. Ethio- pian medical journal, 24: 169-178 ( 1986). 8. PouL TEA. N. R. ET AL. Blood pressure and associated factors in a rural Kenyan community. Hypertension, 6(6): 810-813 (1984). 9. SIMMONS, D. ET AL Blood pressure and salt intake in Malawi: an urban/rural study. Journal of epidemio- logy and community health, 40: 188-192 ( 1986). 10. OVIASU. V. 0. & OKUPA. F. E. Arterial blood pressure and hypertension in Benin in the equatorial forest zone of Nigeria. Tropical and geographical medi- cine, 32: 241-244 (1980). 11. IDAHOSA. P. E. Hypertension: an ongoing health ha- zard in Nigerian workers. American journal of epide- miology, 125( 1) : 85-91 ( 198 7). 12. SEEDAT, Y. K. ET AL. Prevalence of hypertension in the urban and rural Zulu. Journal of epidemiology and community health, 36: 256-261 (1982). 13. VA UGH AN J. P. Blood pressure and heart murmurs in a rural population in the United Republic of Tanzania. Bulletin of the World Health Organization, 57 ( 1): 89-97 (1979). Wld hlth statist. quan .. 41 (1988) VAUGHAN. J.P. Pression arterielle et scuffles cardia- ques dans une population rurale de la Republique- Unie de Tanzania [resume]. Bulletin de /'Organisa- tion mondiale de la Sante, 57 (1): 96 (1979). 14. MBUYAMBA-KABANGU, J. R. ET AL. Epidemiological study of blood pressure and hypertension in a sam- ple of urban Bantu of Zaire. Journal of hypertension, 4: 485-491 (1986). 15. WuRAPA, F. K. Blood pressure distribution in two rural Zambian communities. In : Proceedings of a national seminar on cardiovascular diseases. Zambian Cardiac Society, 1981. 16. RIBEIRO. A. & DESERT RIBEIRO, M. Epidemiological and demographic considerations-hypertension in un- developed countries. Drugs, 31 (4): 23-28 (1986). 17. N1ss1NEN. A. ET AL. Ten-year results of hypertension care in the community. American journal of epide- miology, 127 (3): 488-499 (1988). 18. CUPTA. S. P. & SIWACH. S.B. Epidemiology of hyper- tension in a North Indian population. Jpn heart jour- nal, 25 (1): 65-73 (1984). 19. SHARMA. B. K. ET AL. Hypertension among the indus- trial workers and professional classes in Ludhiana, Punjab. Indian heart journal, 37 (6): 380-385 (1985). 20. DASH. S. C. ET AL. Hypertension epidemiology in an Indian tribal population. JAPI, 34 (8): 567-570 (1986). 21. PANDEY. M. R. ET AL. Prevalence of hypertension in a rural community in Nepal. Indian heart journal, 33 (6): 284-289 (1981). 22. Wu YING-KAI ET AL. Nationwide hypertension screen- ing in China during 1978-80. Chinese medical jour- nal, 95 (2): 101-108 (1982). 23. SUN SHINTU. Epidemiology of hypertension on the Tibetan plateau. Human biology, 58 (4): 507-515 (1986). 24. YU-YING HUANG. Prevalence and unawareness of hy- pertension in the petrochemical industrial popula- tion in China. Preventive medicine, 15: 643-651 (1986). 25. VIZLAYNO. J. S. ET AL. Studies on hypertension and risk factors in selected populations of the Philippi- nes, Japan and Korea. Philippine journal of cardio- logy, 11 (1): 1-10 (1983). 26. ISLAM. N. ET AL. Hypertension in the rural population of Bangladesh-a preliminary survey. Bangladesh Medical Research Council bulletin, 9 ( 1): 11-15 (1983). 27. ICASAS-CABRAL, E. A. ET AL. Epidemiologic studies on hypertension in the Philippines. Proceedings of a - 154 symposium on hypertension, Manila: 39-54 (1978). 28. MOHIDEEN. M. R. & HETTIARACHCHI. J. Utilization of family health workers in screening for hypertension in a rural community in Sri Lanka. Ceylon medical journal, 30: 97-101 (1985). 29. CRUZ-COKE, R. Correlation between prevalence of hypertension and degree of acculturation. Journal of hypertension, 5 (1): 47-50 (1987). 30. HUGHES. K. Trends in mortality from hypertensive and cerebrovascular diseases in Singapore, 1959 to 1983. International journal of epidemiology, 16 ( 1) : 18-24 (1987). 31. FAREED. D.S. Trends in hypertension, stroke and coronary heart disease in Mauritius. In: Amery, A. & Strasser, T. (eds). Control of hypertension in devel- oping countries. Cardiology tropical, 9: 105-110 (1987). 32. BADAWI. H. Hypertension in Egypt. In: Amery, A. & Strasser, T. (eds). Control of hypertension in devel- oping countries. Cardiology tropical, 9: 27-31 (1987). Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 155 - TRENDS IN CARDIOVASCULAR DISEASE MORTALITY IN INDUSTRIALIZED COUNTRIES SINCE 1950 Kazuo Uemuraa & Zbynek Pisab This article presents an updated analysis of the trends in cardiovascular disease mortality which were studied earlier (1, 2). In addition to the inclusion of more recent data which were not available at the time of the previous studies. the period has been extended back to 1950. Data for several countries which were not included pre- viously have also been reviewed, as far as they are avail- able in the WHO data bank. The countries for which data have been analysed in this article are listed in the Annex, together with the period to which the data referred and the country codes used in the tables and graphs. Methods During the period covered by the present analysis four different versions of the International Classification of Diseases (ICD) were used by countries, namely the Sixth, Seventh, Eighth and Ninth Revisions (abbreviated as ICD- 6, ICD-7, ICD-8, ICD-9, respectively). In reporting data to WHO, countries have used short lists, viz. A-list of ICD- 6, ICD-7 and ICD-8 and the Basic Tabulation List (BTL) of ICD-9. The short-list rubrics and the corresponding three-digit ICD code numbers for the disease groups studied in this article are: All cardiovascular diseases lschaemic heart disease Heart disease Cerebrovascular disease ICD-6& 7 A70, A79- 86 (330-334, 400-468) A81 (420-422) A80-82 (410-434) A70 (330-334) ICD-8 ICD-9 A80-88 BTL25-30 (390-458) (390-458) A83 BTL27 (410-414) (410-414) A81, A83, BTL251, A84 27,28 (393-398, (393-398, 410-429) 410-429) A85 BTL29 (430-438) (430-438) The rubrics and code numbers chosen for each disease group are not exactly equivalent. For instance, A81 of ICD-6 and ICD-7 includes chronic endocarditis which A83 of ICD-8 and BTL27 of ICD-9 does not. There are a number of detailed aspects in which ICD revisions differ from each other. The changes in the content of each rubric have thus affected the temporal comparability of statistical data, but their effects varied considerably among countries. Generally speaking, the most serious gaps occurred between ICD-7 and ICD-8, especially regarding ischaemic heart disease. There was hardly any disturbance caused to the time series by the change from ICD-6 to ICD-7, while only a limited degree of disconti- nuity resulted from the change from ICD-8 to ICD-9 (2). In view of this situation, the data coded with ICD-6 & 7 and those coded with ICD-8 & 9 have been analysed sepa- • Director, Division of Epidemiological Surveillance and Health Situa- tion and Trend Assessment, World Health Organization, Geneva. b Preventive Cardiology Research Department, Institute of Clinical and Experimental Medicine, Prague, Czechoslovakia. Wld hlth statist. quan., 41 (1988) rately in this article. As ICD-8 was introduced in most countries in either 1968, 1969 or 1970, changes in mortality have been studied over two 15-year periods, namely 1952-1967 and 1970-1985. For some coun- tries whose data did not cover the full 15-year periods, the percentage change observed in a shorter period has been extrapolated to a 15-year period for the sake of comparison. In the previous studies published by the authors, data for the age group 40-69 years were analysed. However, in view of the importance of monitoring cardiovascular diseases in younger age groups, the age range has been extended to cover 30-69 years. For higher age groups the recent mortality trends for cardiovascular diseases have been studied separately (3). For the analysis presented here, age-standardized death rates per 100 OOO population based on 5-year age groups between 30 and 69 years were used separately for males and females, as well as age- and sex-specific rates. The standard age composition based upon the population of Europe was used since most of the coun- tries studied are European. The weight assigned to each age group was: Age Weight 30-34 0.14 35-39 0.14 40-44 0.14 45-49 0.14 50-54 0.14 55-59 0.12 60-64 0.10 65-69 0.08 30-69 1.00 Results Mortality from all causes Table 1 lists the age-standardized mortality rates for 1985 in descending order of the level of the rate. The highest rate was more than twice the lowest rate recor- ded among the countries studied. Countries in Eastern Europe are ranked high. There does not appear to be much geographical clustering of countries with low rates, except for three of the Nordic countries. Table 2 presents the percentage changes in the age- standardized mortality rates from all causes, for both males and females, during the two periods mentioned above, viz. 1952-1967 and 1970-1985. In almost all countries there was stagnation in the mortality level for males during the first period, and a decline in the second period. Exceptions to these general trends were Japan in which mortality decreased throughout both periods and Hungary in which it rose rapidly during the second. In the second period also the most pronounced decreases - 156 - were registered in Japan (-36%), Australia (-34%) and Luxembourg (-30%). On the other hand, male mortality rose in seven countries during the same period, with the most pronounced increases in Hungary (+34%), Bulgaria ( + 21 %) and Poland ( + 19%). The trends for female mortality were more encouraging, as there was generally a decline throughout both periods and even an accelerated decline during the second. During the same period the largest declines were recorded in Japan (-44%), Iceland (-38%), Australia (-35%), Spain (-34%). Israel (-32%), Finland (-32%), Portugal (-31%), Federal Republic of Germany (-31%) and Malta (-30%). In Hungary female mortality rose slightly ( + 10%). Over the three decades taken as a whole, male mortality was more than halved and female mortality was reduced to less than a third in Japan. Female mor- tality was almost halved in Finland, France, Spain and Switzerland, though the decline in males was somewhat less. On the contrary, male mortality in Hungary showed about a 50% increase during the 30 years. Mortality from all cardiovascular diseases Table 3 presents the age-standardized mortality rates for 1985. Countries are again listed in descending order from the highest to the lowest rate. The highest rate was 3.6 times the lowest rate among males and more than 4 times that among females. In the higher range of the rate are countries in Eastern Europe, Finland, the United King- dom and Ireland. In the lower range some of the South- ern European countries are found, together with Switzer- land and Japan. In 1985 cardiovascular diseases ac- counted for 25-50% of all deaths occurring in these countries in the age groups studied. The changes in rates for cardiovascular diseases are presented in Table 4, for both males and females, for the two 15-year periods studied. Because of the large pro- portion of deaths attributed to those diseases, the trends in mortality followed a similar pattern to that for total mortality. The trends for males in the 1950s and 1960s were practically stable in many countries, while declines occurred during the 1970s and 1980s. In males the most pronounced decreases during the second period occurred in Japan (-52%) and Australia (-47%). and in females in Japan (-58%), Israel (-54%), Australia (-54%). Finland (-46%) and France (-45%). Male mortality increased in seven of the coun- tries studied, with the highest increases registered in Hungary (+49%), Poland (+36%) and Yugoslavia (+35%). Female mortality, on the other hand, showed decreases already in the first period in all countries for which data are available, and the decreases were TABLE 1. AGE-STANDARDIZED MORTALITY FROM ALL CAUSES IN 1985 TABLEAU 1. MORTALITE CORRIGEE DE L'AGE, TOUTES CAUSES, 1985 Rates per 100 OOO population aged 30·69 Taux pour 100 OOO habitants de 30-69 ans Country a - Pays a M F Country a - Pays a HUN 1 521 692 HUN SSR (1986) 1 374 620 ROM (1984) POL 1 342 604 sco CZE 1 318 594 SSR (1986) ROM (1984) 1 154 576 CZE YUG (1984) 1 122 575 POL BUL 1 098 573 YUG (1984) FIN 1060 536 BUL sco 1 055 534 NIR NIR 1030 527 DDR DDR 1008 522 DEN LUX 968 513 IRE IRE 938 506 NEZ MAT 938 488 USA AUT 931 488 E&W BEL (1984) 909 487 LUX POR 907 463 ISR USA 907 459 MAT DEN 893 437 BEL (1984) FRA 874 432 AUT NEZ 871 428 POR DEU 857 410 DEU E&W 855 408 AUS IT A (1984) 828 406 CAN AUS 789 387 FIN CAN 776 375 IT A (1984) NOR 769 368 NET NET 762 357 NOR SPA (1983) 739 356 SWE SWI 710 350 GRE SWE 704 345 FRA ISR 696 339 SPA (1983) GRE 671 334 ICE JPN 616 333 SWI ICE 614 307 JPN a See Annex - Voir r annexe. Rapp. trimest. statist. sanit. mond .. 41 (1988) - 157 - TABLE 2. PERCENTAGE CHANGE IN AGE-STANDARDIZED DEATH RATES FROM ALL CAUSES (AGE 30-69) TABLEAU 2. CHANGEMENTS EN POURCENTAGE DANS LES TAUX DE MORTALITE CORRIGES DE L'AGE, TOUTES CAUSES (30-69 ANS) M F Country a - Pays a 1952-1967 1970-1985 1952-1967 1970-1985 % % % % Northern America - Amerique septentrionale CAN ... USA .. Asia - Asie ISR ... . JPN ... . Eastern Europe - Europe orientale BUL CZE DDR. HUN POL ROM -4.7 -3.8 -27.1 -5.3 1.4 Northern Europe - Europe septentrionale DEN 9.5 FIN -4.7 ICE IRE -6.8 NOR 13.6 SWE -2.9 UNK: E&W -8.1 NIR -7.0 sco -6.8 Southern Europe - Europe meridionale GRE ITA -0.7 MAT POR -5.7 SPA -17.6 YUG Western Europe - Europe occidentale AUT 0.6 BEL 1.8 DEU 5.5 FRA -7.4 LUX NET 16.5 SWI -8.8 Oceania - Oceanie AUS -3.9 NEZ 4.1 a See Annex - Voir !'annexe. Wld hlth statist. quart., 41 ( 1988) -24.2 -23.0 -23.1 -27.3 -16.3 -23.3 -23.5 -32.5 -36.2 -41.5 -44.5 21.0 -6.6 2.1 -25.5 -9.6 -3.1 -10.9 33.8 -22.3 9.5 18.6 0.4 13.5 -4.4 0.5 -15.3 -4.1 -25.0 -25.6 -32.4 -28.9 -37.7 -15.4 -22.5 -25.2 -11.9 -17.3 -15.2 -8.3 -28.0 -19.4 -21.4 -16.5 -14.4 -13.8 -26.1 -19.8 -17.5 -21.7 -13.0 -7.7 -19.1 -17.9 -24.1 -29.0 -16.9 -30.2 -23.3 -18.0 -31.2 -18.9 -31.1 -34.5 1.4 -13.1 -22.8 -17.1 -27.7 -21.8 -17.2 -26.7 -24.1 -18.7 -30.7 -17.1 -27.5 -28.2 -30.3 -25.1 -17.2 -22.8 -21.0 -22.4 -29.7 -28.5 -33.8 -16.3 -34.8 -21.9 -14.8 -17.9 - 158 - TABLE 3. AGE-STANDARDIZED MORTALITY FROM ALL CARDIOVASCULAR DISEASES IN 1985 TABLEAU 3. MORTALITE CORRIGEE DE L'AGE, TOUTES CARDIOPATHIES, 1985 Rates per 100 OOO population aged 30-69 T aux pour 100 OOO habitants de 30-69 ans Country• - Pays• M HUN 651 CZE 590 SSR (1986) 579 POL 564 BUL 529 FIN 528 NIR 524 sea 514 ROM (1984) 500 IRE 456 YUG (1984) 441 MAT 426 E&W 416 DDR 407 LUX 399 NEZ 398 USA 376 AUT 361 NOR 354 DEN 343 DEU 340 AUS 338 SWE 325 BEL (1984) 318 NET 316 CAN 309 ISR 292 ICE 289 POR 287 ITA (1984) 276 GRE 264 SPA (1983) 245 SWI 245 FRA 212 JPN 179 a See Annex - Vair I' annexe. accelerated during the second period. Exceptions to this general pattern were again countries in Eastern Europe where during the second period mortality increased in males and stagnated in females. The increases in male mortality during that period were prominent in Bulgaria (+49%), Poland (+36%) and Yugoslavia (+35%). lschaemic heart disease Table 5 presents the age-standardized rates for 1985. Countries are again listed in descending order from the highest to the lowest rates. In both sexes. the mortality was especially high in the United Kingdom, Ireland and some of the Nordic and the Eastern European countries, while it was low in some countries in Southern Europe, France and Japan. The highest rate was as much as 10 times the lowest rate among the countries studied. Such a large ratio may have resulted at least from statistical artefacts due to the different diagnostic practices used in countries. This aspect is discussed under the next item on heart diseases. The changes in rates are presented in Table 6. Remarkable changes occurred in the trend between the two periods: in the first period, mortality from ischaemic heart disease rose in almost all countries, and indeed rapidly in some, while in the second it declined in a Country a - Pays a 300 ROM (1984) 292 HUN 277 SSR (1986) 267 BUL 250 YUG (1984) 241 CZE 236 POL 230 sea 218 NIR 186 DDR 183 IRE 174 MAT 170 NEZ 161 E&W 160 USA 158 ISR 156 LUX 148 FIN 144 POR 134 AUT 132 AUS 128 BEL (1984) 123 DEU 122 DEN 120 GRE 114 ITA (1984) 112 CAN 108 SPA (1983) 106 NET 100 SWE 100 NOR 96 ICE 90 JPN 76 SWI 69 FRA majority of countries. Countries which registered rapid mortality decreases in males in the second period were the United States of America (-49%), Australia (-46%) and Israel (-45%). and in females Israel (-62%), Japan (-53%). Australia (-51%) and the United States (-48%). It is disquieting, however, that a few countries showed a very rapid increase in mortality. viz. Romania ( + 90%). Poland ( + 72%). Yugoslavia ( + 65%) and Spain ( +49%) in males and Romania ( + 73%) and Poland (+59%) in females. Heart diseases The need for studying the data on all heart diseases as a group arises because of the heterogeneity of cause-of- death recording among countries. Physicians in some countries tend to use specific diagnostic labels such as ischaemic heart disease and acute myocardial infarction more often than their counterparts in some other coun- tries who frequently record causes of death in vague and less specific terms such as heart failure or heart insuffi- ciency. The proportion of heart diseases which fall in the cate- gory other than ischaemic does indeed vary widely; the range observed in 1985 was from 2% (Iceland) to 59% (Japan) in males, and from 10% (Iceland) to 68% (Japan) in females. No doubt part of these related to some spe- Rapp. trimest. statist. sanit. mond., 41 (1988) - 159 - TABLE 4. PERCENTAGE CHANGE IN AGE-STANDARDIZED DEATH RATES FROM ALL CARDIOVASCULAR DISEASES (AGE 30-69) TABLEAU 4. CHANGEMENTS EN POURCENTAGE DANS LES TAUX DE MORTALITE CORRIGES DE L'AGE, TOUTES CARDIOPATHIES (30-69 ANS) M F Country a - Pays a 1952-1967 1970-1985 1952-1967 1970-1985 % % % % Northern America - Amerique septentrionale CAN -6.4 -38.8 -33.3 -42.8 USA -7.9 -38.8 -25.5 -38.9 Asia - Asie ISR -37.1 -54.4 JPN -8.4 -51.7 -31.7 -57.5 Eastern Europe - Europe orientale BUL 49.3 -2.3 CZE 0.8 9.2 -26.2 -6.7 DDR -0.6 -9.8 HUN 13.7 29.5 -21.4 4.9 POL 35.7 12.4 ROM 23.7 -1.4 Northern Europe - Europe septentrionale DEN 21.2 -9.7 -23.7 -24.1 FIN 8.6 -27.5 -23.4 -45.6 ICE -35.0 -30.1 IRE 6.5 -12.3 -24.2 -31.9 NOR 49.7 -16.6 -15.3 -33.5 SWE 2.0 -6.4 -38.0 -30.3 UNK: E&W 5.2 -20.9 -22.0 -26.7 NIA 2.4 -17.1 -30.7 -25.9 sco 2.8 -18.4 -22.7 -24.3 Southern Europe - Europe meridionale GRE 16.7 -13.0 ITA 6.4 -22.6 -28.3 -42.1 MAT -16.6 -43.8 POR -3.1 -27.8 -17.7 -40.7 SPA -11.9 -25.0 -31.5 -43.6 YUG 34.9 12.2 Western Europe - Europe occidentale AUT 7.8 -21.0 -23.6 -34.2 BEL 14.3 -31.6 -22.5 -38.5 DEU 24.1 -19.5 -23.2 -34.0 FAA -15.4 -26.4 -40.4 -44.9 LUX -30.5 -39.4 NET 39.0 -20.3 -25.6 -30.2 SWI -11.2 -21.5 -43.2 -44.1 Oceania - Oceanie AUS 0.3 -46.6 -21.7 -53.9 NEZ 15.7 -31.9 -19.0 -33.6 a See Annex - Voir I' annexe. cific heart diseases which were not ischaemic in origin and which might have occurred with varying frequencies in different countries, but most likely many of the deaths counted in this residual group were due to ischaemic heart disease. Conversely, in countries with a very small proportion falling into the residual group, some of the deaths may have been coded to ischaemic heart disease without objective diagnostic basis. Ranking of countries according to age-standardized death rates from all heart diseases is presented in Table 7. The ratio between the highest and the lowest rates is reduced to 4-5 from the ratio of 10 which was observed for ischaemic heart disease alone. Neverthe- less, the ranking of countries generally follows that for ischaemic heart disease. Countries ranked considerably higher in heart-disease mortality than in ischaemic heart disease alone are Romania, Poland and Yugoslavia, while those ranked considerably lower are Denmark, Iceland and Sweden for which a large majority of deaths from heart diseases are registered as ischaemic. These are the countries in which the nature of a considerably large or small proportion of heart diseases was not spe- cified. W/d hlth statist. quan., 41 ( 19881 - 160 - TABLE 5. AGE-STANDARDIZED MORTALITY FROM ISCHAEMIC HEART DISEASE IN 1985 TABLEAU 5. MORTALITE PAR CARDIOPATHIES ISCHEMIQUES CORRIGEE DE L'AGE, 1985 Rates per 100 OOO population aged 30-69 Taux pour 100 OOO habitants de 30-69 ans Country • - Pays• M NIA 406 sea 398 FIN 390 SSA (1986) 349 CZE 346 IRE 339 HUN 326 E&W 318 NEZ 296 NOR 266 DEN 251 ICE 247 AUS 247 SWE 243 USA 235 POL 230 CAN 230 NET 214 LUX 209 BUL 208 MAT 205 DELI 204 AUT 203 ISR 183 DDR 179 ROM (1984) 176 BEL (1984) 166 YUG (1984) 154 SWI 140 ITA (1984) 136 GRE 135 SPA (1983) 104 POR 104 FAA 94 JPN 38 a See Annex - Voir I' annexe. Table 8 presents the changes in death rates from heart disease during each of the two 15-year periods studied. As in the case of ischaemic heart disease striking chan- ges occurred in the trend between the two periods. During the first period almost all countries registered increases in male mortality, the most prominent being Norway (+71%) and the Netherlands (+64%). In the second period, a majority of the countries regis- tered decreases; the greatest decline was recorded in Australia (-44%). Canada (-37%) and the United States (-36%). For females, decreases in heart-disease mortality were already occurring in the first period in most of the countries for which data are available. The decline was generally accelerated in the second period. The largest decline in the second period was observed in Israel (-51%), Australia (-49%). Italy (-44%) and Malta (-43%). The Eastern European countries register- ed increases in male mortality and little change in female mortality in the second period; comparable data for the first period are, however, available only for Czecho- slovakia and Hungary. F Country• - Pays• 142 sea 130 NIA 125 SSA (1986) 105 HUN 104 IRE 101 CZE 94 NEZ 94 E&W 80 USA 79 FIN 76 AUS 74 ROM (1984) 73 ISR 72 BUL 69 DEN 66 CAN 62 ICE 56 LUX 56 SWE 55 NET 55 NOR 54 POL 52 YUG (1984) 52 AUT 52 DELI 51 DDR 46 MAT 46 BEL (1984) 33 ITA (1984) 33 GRE 32 POR 30 SWI 24 SPA (1983) 20 FAA 13 JPN These trends generally confirm those observed by Thom et al. (4) on heart-disease mortality in the age group 45- 64 over the period 1950-1978. Cerebrovascular disease Table 9 presents the age-standardized rates for 1985. Countries are again listed in descending order from the highest to the lowest rate. The highest rate is 6-7 times the lowest rate among the countries studied. Countries with the highest rates are Bulgaria, Hungary and the Union of Soviet Socialist Republics; those with very low rates are Canada, Iceland and Switzerland. The percent- age changes in rates are presented in Table 10. In contrast to heart diseases, there have been consistent decreases in many of the countries since the early 1950s. The decline was generally even quicker in the second than in the first 15-year period. In males, the rates were more than halved during the second period in Rapp. trimest. statist. sanit. mond., 41 (1988) - 161 - TABLE 6. PERCENTAGE CHANGE IN AGE-STANDARDIZED DEATH RATES FROM ISCHAEMIC HEART DISEASES (AGE 30-69) TABLEAU 6. CHANGEMENTS EN POURCENTAGE DANS LES TAUX DE MORTALITE PAR CARDIOPATHIES ISCHEMIQUES CORRIGES DE L'.AGE (30-69 ANS) M F Country a - Pays a 1952-1967 1970-1985 1952-1967 1970-1985 % % % % Northern America - Amerique septentrionale CAN 7.0 -40.9 -12.4 -43.0 USA 4.1 -48.6 -9.3 -48.1 Asia - Asie ISR -45.0 -62.4 JPN -0.7 -38.8 -30.3 -52.7 Eastern Europe - Europe orientale BUL 42.3 -3.7 CZE 9.6 10.2 -40.9 2.3 DDR 21.1 19.9 HUN 63.9 38.6 17.1 15.2 POL 72.0 59.1 ROM 89.6 72.6 Northern Europe - Europe septentrionale DEN 60.8 -8.0 16.4 -20.9 FIN 23.8 -23.0 -7.5 -31.1 ICE -23.6 -19.8 IRE 16.9 -0.8 -22.1 -15.6 NOR 98.6 -13.6 27.2 -23.3 SWE 32.0 -2.5 -9.9 -25.3 UNK: E&W 23.7 -10.9 -6.3 -2.1 NIA 23.7 -9.4 -8.9 -15.7 sco 16.7 -11.2 -11.0 -5.2 Southern Europe - Europe meridionale GRE 41.4 20.1 ITA 24.2 -12.6 -36.1 -33.9 MAT -7.8 -37.0 POR 91.4 -14.2 44.1 -31.9 SPA -10.7 49.2 -49.4 24.9 YUG 64.8 36.3 Western Europe - Europe occidentale AUT 26.2 -9.8 -14.9 -17.9 BEL 77.1 -36.6 6.9 -40.8 DEU 54.8 -9.3 -6.3 -10.7 FAA 60.3 -8.5 21.0 -28.4 LUX -27.8 -4.7 NET 70.6 -23.4 -9.1 -19.4 SWI 5.5 -10.8 -36.9 -20.3 Oceania - Oceanie AUS 19.3 -46.1 9.8 -50.5 NEZ 39.0 -31.8 14.6 -31.2 a See Annex - Vair rannexe. Japan (-67%). Australia (-55%). the United States (-55%) and Israel (-52%). and in females in as many as 10 countries, of which Malta (-68%) and Japan (-66%) reduced their rates as much as by two-thirds. In spite of this remarkable success, Japan remained in the group of countries with high rates, although in rank it came down from the top place it held in the early 1950s to the eighth for males and the tenth for females in 1985. Comparison of trends between age and sex groups Trends in age-standardized death rates do not reveal variations which may exist among different age groups. For the analysis of such variations it is necessary to examine the trends in age-specific rates. Nevertheless. during the second 15-year period studied several countries recorded increased rates. The most prominent increases occurred in Poland ( + 62 % in males and +38% in females). Hungary (+54% and +24%) and the German Democratic Republic (+48% and +40%). Wld hlth statist. quart., 41 ( 1988) Mortality rates from all causes combined decreased in a majority of countries during the second 15-year period as described above. In these countries the decrease tended to be more rapid in younger age groups, espe- cially under 50, than in older ones. A similar tendency was seen also in mortality from cardiovascular diseases as a whole and mortality from heart diseases. On the - 162 - TABLE 7. AGE-STANDARDIZED MORTALITY FROM HEART DISEASES IN 1985 TABLEAU 7. MORTALITE PAR CARDIOPATHIES CORRIGEE DE L'AGE, 1985 Rates per 100 OOO population aged 30-69 Taux pour 100 OOO habitants de 30-69 ans Country 3 - Pays a M NIA 438 FIN 423 sco 420 CZE 409 HUN 388 SSA (1986) 381 IRE 381 POL 356 E&W 338 NEZ 328 USA 315 YUG (1984) 299 BUL 297 NOR 291 LUX 289 ROM (1984) 287 DEN 277 AUS 276 DEU 268 AUT 268 SWE 266 CAN 263 NET 260 ICE 252 MAT 249 DDR 237 ISR 234 BEL (1984) 231 SWI 193 GRE 192 ITA (1984) 189 SPA (1983) 172 POR 148 FRA 143 JPN 92 a See Annex - Vair I' annexe. contrary. for the few countries in which mortality in- creased during the same period the increase seemed more rapid among younger than among older groups. This may be due to an improvement (or deterioration) in the level of risk factors affecting more directly younger people. Two examples of countries (England & Wales and Hungary) showing such trends in heart-disease mor- tality are presented in Fig. 1. Five-year moving averages are used in this chart to reduce random fluctuations in the trends. For cerebrovascular disease, mortality trends were often more favourable among older age groups. This may be the consequence of more effective hypertension control and patient care in older age groups than in younger ones. It is well known that age-specific (and hence the age- standardized) mortality in industrialized countries is much higher in males than females, and that the differ- ence has been increasing over the last few decades. Around 1985, age-standardized male mortality for all causes combined was about twice the level of female mortality. There are, however, variations among dis- F Country a - Pays a 160 sco 156 NIA 147 SSA (1986) 146 YUG (1984) 141 ROM (1984) 139 HUN 137 CZE 130 IRE 124 BUL 119 USA 117 NEZ 115 POL 109 E&W 109 ISR 98 LUX 94 FIN 92 AUS 86 DDR 84 MAT 84 AUT 84 CAN 84 DEU 82 DEN 80 BEL (1984) 75 NET 69 GRE 69 ICE 67 SWE 66 SPA (1983) 65 NOR 63 ITA (1984) 63 POR 49 SWI 42 JPN 41 FRA eases. The sex differential is particularly large in ischae- mic heart disease mortality which often shows a male/ female ratio of more than 3. Much smaller differentials are seen in cerebrovascular disease mortality. as the ratio was less than 2 around 1985. Nevertheless, the ratio appears to be growing. In fact about half of the countries for which data are available for the early 1950s had lower male mortality than female mortality at that time, a trend which was reversed during the subsequent decades. The factors which had contributed to this rapid change are not clear. Summary of the levels and trends in cardiovascular disease mortality As described above, male mortality from cardiovascular diseases as a whole increased in most of the industria- lized countries during the 1950s and 1960s. This was mainly due to considerable increases in ischaemic heart disease mortality. The adverse trends were reversed in the 1970s and 1980s in many of the countries. Mortality from cerebrovascular disease. on the other hand, show- ed a steady decline in a number of countries from the Rapp. trimest. statist. sanit. mond., 41 (19881 - 163 - TABLE 8. PERCENTAGE CHANGE IN AGE-STANDARDIZED DEATH RATES FROM HEART DISEASES (AGE 30-69) TABLEAU 8. CHANGEMENTS EN POURCENTAGE DANS LES TAUX DE MORTALITE PAR CARDIOPATHIES CORRIGES DE L'AGE (30-69 ANS) M Country a - Pays a 1952-1967 1970-1985 1952-1967 1970-1985 % % % % Northern America - Amerique septentrionale CAN 3.4 -36.6 -16.5 -38.1 USA ...... 1.0 -36.5 -11.4 -33.8 Asia - Asie ISR -32.4 -50.6 JPN .... -17.9 -16.3 -35.3 -37.2 Eastern Europe - Europe orientale BUL 62.0 4.2 CZE -5.7 12.5 -41.2 -2.3 DDR. 14.4 4.1 HUN 24.3 19.5 -16.4 -7.3 POL 36.9 8.6 ROM 18.1 -12.1 Northern Europe - Europe septentrionale DEN 40.6 -8.8 2.5 -23.3 FIN 17.1 -25.7 -9.2 -40.0 ICE -28.1 -10.3 IRE 9.8 0.8 -23.9 -13.4 NOR 70.6 -13.0 8.4 -28.5 SWE ... 19.4 -3.4 -23.1 -28.0 UNK: E&W 18.7 -14.4 -13.1 -15.3 NIR 17.3 -11.2 -13.5 -20.7 sco 11.9 -13.7 -19.0 -14.2 Southern Europe - Europe meridionale GRE 30.3 -1.6 ITA 27.7 -18.5 -21.7 -43.9 MAT -21.0 -43.1 POR ... -15.4 -22.8 -35.0 -39.2 SPA -14.6 -7.2 -39.7 -33.7 YUG 42.8 12.6 Western Europe - Europe occidentale AUT 11.7 -11.4 -18.9 -24.4 BEL 37.6 -32.8 -11.7 -35.4 DEU . 45.6 -10.5 -10.6 -22.2 FRA -4.3 -15.4 -35.2 -34.1 LUX -22.6 -21.7 NET . 63.8 -17.8 -11.0 -19.7 SWI 0.8 -13.4 -36.2 -33.4 Oceania - Oceanie AUS 14.5 -44.4 2.9 -49.3 NEZ 29.9 -29.2 4.3 -27.4 a See Annex - Voir !'annexe. 1950s. Notable exceptions to this tendency were coun- tries in Eastern Europe and a few others in which mor- tality increased from the 1970s onwards. Mortality trends in each country for all causes, all cardiovascular diseases, heart diseases and cerebrovascular disease are shown in Fig. 2. The magnitude of proportional changes in mortality rates is readily noticeable on the logarithmic scale used in the graph. The levels of cardiovascular disease mortality around 1952 and 1982 in each country, together with its latest trends, are also summarized in Table 11. There were 24 countries with data available for studying the trends during the first period 1952-1967. while the data for the second period 1970-1985 were available for 35 coun- tries. The countries have been divided into three equal groups (high, medium and low) according to the level of the age-standardized death rate from all cardiovascular diseases. Thus eight countries were assigned to each of the three groups according to the level of the rates around 1952, and 12, 12 and 11 countries were as- signed to the high, medium and low-rate groups, respec- tively, according to the level around 1985. The trends during the second period were classified into seven cate- Wld hlth statist. quart., 41 ( 1988) - 164 - TABLE 9. AGE-STANDARDIZED MORTALITY FROM CEREBROVASCULAR DISEASE IN 1985 TABLEAU 9. MORTALITE PAR MALADIES CEREBRO-VASCULAIRES CORRIGEE DE L'AGE, 1985 Rates per 100 OOO population aged 30-69 Taux pour 100 OOO habitants de 30-69 ans Country • - Pays • M BUL 182 HUN 170 SSA (1986) 167 CZE 130 ROM (1984) 126 POR 120 YUG (1984) 107 LUX 82 JPN 79 FIN 74 sco 73 POL 72 AUT 66 ITA (1984) 63 NIA 62 GRE 60 SPA (1983} 58 MAT 56 IRE 53 E&W 52 DEU 50 BEL (1984} 48 ISR 46 NEZ 46 FAA 45 AUS 44 DEN 41 DDR 41 NOR 40 SWE 36 NET 35 USA 34 ICE 30 CAN 29 SWI 28 a See Annex - Vair f' annexe. gories according to the percentage change in mortality from ischaemic heart disease and cerebrovascular dis- ease from 1970 to 1985: 50% decrease or more; 30% decrease or more but less than 50% ; 10% decrease or more but less than 30%; change (decrease or increase) within 10% ; 10% increase or more but less than 30% ; 30% increase or more but less than 50%; and 50% increase or more. A number of countries stayed in the same group during the three decades, but several moved up or down in ranking; Portugal and Switzerland in Europe and all five countries outside Europe moved from the "high" or "medium" categories to either "medium" or "low" categories. On the other hand, Czechoslovakia, Poland, Denmark, Norway and the Federal Republic of Germany moved from "medium" or "low" to "high" or "me- dium" categories. The trends in the second 15-year period in mortality from ischaemic heart disease and cerebrovascutar dis- ease have been described above, but Table 11 brings F Country• - Pays• 114 BUL 112 SSA (1986) 97 HUN 95 ROM (1984) 75 CZE 74 YUG (1984) 74 POR 57 sco 50 NIA 47 POL 45 JPN 44 GRE 44 IRE 43 FIN 43 LUX 40 E&W 39 ISR 38 ITA (1984} 38 NEZ 36 AUT 35 SPA (1983} 33 AUS 31 BEL (1984} 29 DEU 29 DEN 28 ODA 27 MAT 26 USA 26 NOR 24 NET 23 SWE 21 CAN 21 ICE 21 FAA 16 SWI out clearly the geographical variation. Overall, the recent trends were favourable towards tower mortality, and the decline observed in the industrialized countries outside Europe was particularly pronounced. As mentioned be- fore, countries in Eastern Europe and a few in Southern Europe showed increases in mortality from these causes. A country's rank according to mortality from ischaemic heart disease was often similar to that for cerebrovas- cular disease. However, there are some exceptions to this tendency: Japan, Portugal, Romania and Yugoslavia have relatively low rates for ischaemic !ieart disease but high rates for cerebrovascutar disease, while the converse applies to Australia, Denmark and Norway. In countries which registered a total mortality decline during the second period, the changes were usually more rapid in cardiovascular disease mortality and particularly so in mortality from cerebrovascular disease. Conse- quently, the proportion of deaths which were attributed to cardiovascular diseases was reduced in these coun- tries, as well as the proportion of cardiovascular deaths which were attributed to cerebrovascular disease. Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 165 - TABLE 10. PERCENTAGE CHANGE IN AGE-STANDARDIZED DEATH RATES FROM CEREBROVASCULAR DISEASE (AGE 30-69) TABLEAU 10. CHANGEMENTS EN POURCENTAGE DANS LES TAUX DE MORTALITE PAR MALADIES CEREBRO-VASCULAIRES CORRIGES DE L'AGE (30-69 ANS) M F Country a - Pays a 1952·1967 1970-1985 1952-1967 1970-1985 % % % % Northern America - Amerique septentrionale CAN -25.6 -49.1 -47.1 -52.6 USA -27.1 -55.1 -37.2 -53.3 Asia - Asie ISR -52.0 -62.5 JPN -5.1 -66.8 -31.5 -66.1 Eastern Europe - Europe orientale BUL 32.3 -9.2 CZE -1.3 3.2 -18.0 -8.7 ODA 48.1 39.7 HUN -17.5 53.8 -40.3 23.9 POL 62.4 38.5 ROM 8.5 -7.8 Northern Europe - Europe septentrionale DEN -29.7 -17.2 -56.5 -23.8 FIN -4.7 -35.2 -28.5 -50.1 ICE -48.0 -60.5 IRE 11.1 -44.1 -20.0 -48.1 NOR 10.2 -39.2 -30.8 -43.5 SWE -33.5 -26.3 -54.4 -40.8 UNK: E&W -19.4 -38.1 -31.0 -38.9 NIA -25.1 -39.1 -48.0 -33.6 sco -16.5 -30.3 -26.2 -37.2 Southern Europe - Europe meridionale GRE -4.0 -19.1 ITA -17.1 -32.8 -33.6 -40.0 MAT -33.9 -68.4 POR 69.3 -18.4 44.3 -27.9 SPA 0.5 -30.4 -10.9 -41.6 YUG 19.2 6.7 Western Europe - Europe occidentale AUT -4.2 -34.9 -36.6 -41.5 BEL 128.9 -44.4 73.2 -48.6 OEU -13.8 -42.1 -39.6 -45.6 FAA -27.9 -45.5 -44.7 -54.8 LUX 4.9 0.3 NET -11.9 -38.4 -37.8 -44.8 SWI -37.1 -46.4 -57.8 -55.7 Oceania - Oceanie AUS -26.8 -55.3 -42.8 -60.8 NEZ -18.3 -43.6 -32.8 -44.9 a See Annex - Vair rannexe. Discussion As stated under Methods, the shift from ICD-7 to ICD-8 caused discontinuity in the A-list-based time-series data for ischaemic heart disease. This gap was assessed by comparing the difference between the last year of use of ICD-7 and the first year of use of ICD-8 with the annual changes observed immediately before and after these years. Thus. by denoting the consecutive annual data as A, 8, C and D where A and B were coded with ICD-7 and C and D with ICD-8, the "bias", b, introduced by ICD-8 was assessed, using the formula: The following are examples of countries whose mortality data on ischaemic heart disease were affected consid- erably: b = 100.((C-B)-((B-A)+(D-C))/2]/[(A+B+C+D)/4]. Wld hlth statist. quan .. 41 (1988) First year of Bias b Country use of ICD-8 M F JPN 1968 -34% -59% OEU 1968 -18% -50% HUN 1969 -27% -40% ITA 1968 -23% -48% The influence of the ICD Revision was particularly mar- ked on female mortality, for which the observed rate was - 166 - TABLE 11. AGE-STANDARDIZED MORTALITY (AGE 30-69) FROM CARDIOVASCULAR DISEASES LEVEL AND TRENDS TABLEAU 11. MORTALITE PAR MALADIES CARDIO-VASCULAIRES CORRIGEE DE L'AGE (30-69 ANS) NIVEAU ET TENDANCES Country c - Pays c Northern America - Amerique septentrionale CAN USA ... Asia - Asie ISR . JPN Eastern Europe - Europe orientale BUL CZE DDR HUN POL ROM SSR Northern Europe - Europe septentrionale DEN FIN ICE . IRE . NOR SWE UNK: E&W NIR sco Southern Europe - Europe meridionale GRE ITA MAT POR SPA YUG Western Europe - Europe occidentale AUT BEL DEU FRA LUX NET SWI Oceania - Oceanie AUS NEZ ...... . • 1 low - faible; 2 : medium - moyenne; 3 · high - elevee. All CVD monality' Monalite due a toutes les MCV' ea. 1952 vers 1952 3 3 2 2 2 1 3 3 1 1 2 3 3 2 1 2 2 1 1 1 2 3 3 ea. 1985 vers 1985 1 2 2 1 3 3 2 3 3 3 3 2 3 1 3 2 1 2 3 3 1 1 3 1 1 3 2 2 2 1 2 1 1 2 2 IHD monality trends T endances de la monalite parCIS 1970-1985b M ++ + + ++ +++ +++ 0 0 0 0 ++ 0 ++ +++ 0 0 0 F 0 0 + + +++ +++ 0 0 + + ++ 0 Cerebrovascular disease monality trends T endances de la monalite par maladies c6r6bro-vasculaires 1970-1985b M ++ 0 ++ +++ +++ 0 ? 0 + 0 F 0 0 ++ + ++ 0 0 0 b - : fall by 10% or more - baisse de 10% ou plus; - - : fall by 30% or more - baisse de 30% ou plus; - - - : fall by 50% or more - baisse de 50% ou plus. O change (either rise or fall) less than 10% - Changement (hausse ou baosse) inferieur a 10%. +: rise by 10% or more - hausse de 10% ou plus; + + rise by 30% or more - hausse de 30% ou plus; + + +: rise by 50% or more - hausse de 50% ou plus. c See Annex - Vair I' annexe. Rapp. trimest. statist. sanit. mond., 41 (1988) 167 - FIG. 1 TRENDS IN MORTALITY FROM HEART DISEASES IN DIFFERENT AGE GROUPS, ENGLAND & WALES AND HUNGARY TENDANCES DE LA MORTALITE PAR CARDIOPATHIES DANS DIVERS GROUPES D'AGE, ANGLETERRE ET PAYS DE GALLES ET HONGRIE 2000,-~~~~~~--. UNK:E &W M ~-69 1000t--""7-::::::,,-=-.;::6~0--6"""'14 ~-49 ~-34 10 ----------; 5,1----------1 F HUN M 65-69 F ' - \. ~-u~ ~-64 55-59 . - - ......., 50-54 ~ 45-49 ~ ,....... ~ 40-44 ~c 0 ~-~ ~v~ .. lS i i 70 80 90 Year - Ann6e halved in Japan, the Federal Republic of Germany and Italy by the introduction of IC0-8. The main factor caus- ing this drop was the inclusion of ICD-7 item 421 (chronic endocarditis not specified as rheumatic) and item 420 (other myocardial degeneration) in the ICD-7 short list rubric A81 ; all of item 421 and part of item 420 were excluded from rubric A83 of ICD-8 which has been taken in this article as the counterpart of A81 of ICD-7. However, when all heart diseases were grouped to- gether, the aggregated data were affected much less by the ICD change. When the data were further lumped into all cardiovascular diseases as a group, hardly any effects of the change were noticed on data continuity. Likewise, the change did not seem to affect the time series for cerebrovascular disease mortality, at least in most of the Wld hlth statist. quan .• 41 ( 1988) countries. Nevertheless. for comparative purposes the trend analysis presented in this article has been made separately for a period in which IC0-6 or ICD-7 was used and for one in which ICD-8 or ICD-9 was in use. Another factor which affected comparability among countries was the varying frequency of the use of general conditions as cause of death, such as essential hyper- tension and atherosclerosis, without providing any fur- ther details on specific complications which led to death, such as cerebral haemorrhage or myocardial infarction. If the latter is mentioned in the death certificate, the death is coded as due to the specific disease and hence even- tually grouped into the broader category of cerebrovas- cular or heart diseases, respectively, which are used in this article. Otherwise, it falls into the broad residual category of "other cardiovascular diseases". - 168 - The frequency of deaths due to hypertension and athe- rosclerosis without mention of more specific diseases has been reviewed by the authors. Examples of the countries which frequently register these general condi- tions as cause of death are listed below, together with England & Wales as a typical example of countries in which the single use of these general terms is rare. Proportion of cardiovascular diseases coded as : Country Essential hypertension Atherosclerosis M F M F DDR 7% 12% 14% 14% MAT 8% 5% 9% 11% POL 2% 5% 15% 16% ROM 8% 11% 4% 4% E&W 0.3% 0.5% 0.3% 0.5% Because of the usefulness of specific diagnostic informa- tion, the rules for selection of cause of death for primary mortality tabulation (5) provide that essential hyperten- sion and atherosclerosis are not to be coded when a more specific condition is also mentioned in the same death certificate, such as ischaemic heart disease or cerebrovascular disease. It is desirable that the use of specific diagnostic terms in the death certificate be pro- moted in all countries when relevant information is avail- able to the certifying physician. This will enhance the usefulness and comparability of mortality statistics. These varying levels and trends of mortality have no doubt been caused by a multitude of risk factors operat- ing in each country and which affect the incidence of cardiovascular diseases and their prognosis. Much is already known through numerous studies on the major risk factors and on the measures to be taken by the health services as well as by individuals for the preven- tion of the diseases and for effective care (6, 7). Morta- lity surveillance in each country and at the international level reveals how each country's situation has been changing and how the country compares with others, thus providing a basis for action, for monitoring its effec- tiveness, and for further investigation. Progress in WHO's MONICA (MONltoring of trends and determi- nants in CArdiovascular disease) project will clarify va- rious aspects of the role played by the risk factors in different communities. c Conclusion The considerable variation observed among the indus- trialized countries in the levels and trends of cardiovas- cular disease mortality points to the possibility for action by countries with high mortality and those with stagnant or increasing mortality. Much of this mortality would seem to be susceptible to reduction through clinical medicine and public health means now available at an affordable cost in these countries. Continuous surveil- lance of mortality trends in each country and at the inter- national level facilitates decision making at the commu- nity level as well as by individuals, with a view to improv- ing health care, promoting health awareness and adop- ting healthier lifestyles. SUMMARY In most industrialized countries, mortality in general, and cardiovascular disease mortality in particular, have shown decreasing trends since around 1970, following stagnation or increases observed during the 1950s and 1960s. In some countries, however (e.g. in Eastern Europe), male mortality from cardiovascular diseases increased during recent years. The levels and trends of mortality from cardiovascular diseases vary considerably among countries. Measured in terms of age-standardized rates, the ratio between the highest and the lowest rates around 1985 was about 2 for total mortality but about 4 for all cardiovascular diseases combined. With further breakdowns the ratio was even greater, i.e. 4-5 for heart diseases and 6-7 for cerebrovascular disease. For ischaemic heart disease alone, the ratio reached as high as 10, though part ofthis wide range should be attributed to artefacts due to the varying diagnostic practices followed in different coun- tries. The speed of mortality changes also differed among countries, ranging from a rapid decrease to a rapid increase. In general, the trends were much more favourable in females than in males. Consequently, sex differentials c See Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years, p. 115 of this issue. have been widened. The male/female ratio in mortality for ischaemic heart disease has now exceeded 3 in a number of countries. The ratio for cerebrovascular dis- eases, which used to be close to 1 in many countries in the early 1950s, has also increased, often reaching the level of 1.5 or higher. Differentials were observed also among different age groups in some countries. There seems to be a tendency for mortality change, either an increase or a decrease, to be quicker in younger age groups than in older ones. These varying levels and trends in cardiovascular dis- ease mortality have no doubt been caused by a multitude of risk factors operating in each country, affecting the incidence of cardiovascular diseases and their progno- sis. Much is already known about these risk factors and about the measures to be taken by the health services as well as by individuals for prevention and effective thera- py. The considerable variation in mortality levels and trends observed among different countries points to the possibility for action by countries heavily affected by cardiovascular diseases. Mortality surveillance in each country and at the international level thus reveals how each country's situation and trends compare with others and provides a basis for action and further research. Progress in WHO' s MONICA (MONltoring of trends and determinants in CArdiovascular disease) project will cla- rify various aspects of the role played by risk factors in different communities. c Rapp. trimest. statist. sanit. mond .. 41 (1988) - 169 - FIG. 2 TRENDS IN AGE-STANDARDIZED MORTALITY RATES FROM CARDIOVASCULAR DISEASES, 1950-1988 TENDANCES DES TAUX DE MOATALITE PAA MALADIES CAADIO-VASCULAIAES COAAIGES DE L'AGE, 1950-1988 Northern America 2000~--------, CAN M 10'---'---'--___J'-----' 1950 60 2000 Asia ISR 70 80 90 50 M 500 - - -- ----- 2 0 -- 0 0 3 0 ~ f-.; 0. .. ~ 100 60 '---- 50 4 70 10L-_.L-_..,___....__~ I 1950 60 70 80 90 50 60 70 1. All causes - Toutes causes. 2. All cardiovascular diseases - Toutes maladies cardio-vasculaires. Wld hlth statist. quan., 41 (1988) F USA 80 9050 60 F JPN \_ 'i: \ '\ " '\4 80 9050 60 Year - Annile 70 M 80 9050 M 60 F 70 80 90 F 70 80 9050 60 3. Hean diseases - Cardiopathiaa. 4. Cerebrovascular disease - Maladies ~r6bro-vasculaires. 2000 Eastern Europe BUL M 100 ---------------< 50 2000 DOR M 100 --------- 50 - 170 - F CZE M F F HUN M F r, -------·-·-· --- J_' ---f_~ 1. All causes - T outes causes. 2. All cardiovucular diseases - Toutes maladies cardio-vasculaires. Year - Anmle 3. Heart diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies c6r6bro-vasculaires. Rapp. trimest. statist. sanit. mond., 41 (1988) 2000rP-O-L~~~~~~M~ ~1 § g 50 10L.....~L---JL---JC......--I 1950 60 70 80 90 50 2000 Northern Europe OEN M 60 70 - 171 - F ROM 80 9050 60 F FIN M ~-------- ~3 70 80 9050 M __ '-, v"" 2 ~3 60 70 80 ~1 F 90 F i i 10 .____._~.__~__.i 1~60 ro 80 9050 60 ro 80 9050 60 ro 80 9050 60 ro 80 90 1. All causes - Toutes causes. 2. All cardiovascular diseases - Tout as maladies cardio-vasculaires. Wld hlth starisr. qua,r., 41 ( 1988) Vear - Ann6e 3. Hean diseases - Cardiopdliea. 4. Cerebrovascular ~ - Maladies ~asculairea. - 172 - F IRE M F 10.__~..._~ ...... ~-'-~-' 1~00 moo oo~ oo moo~~ oo moo~~ oo Moo oo 2000 NOR M F SWE M F 1--------- 4 "' ~ ~ 10 .______.___.~_.____.i 1~00 Moo oo~ oo Moo~~ oo moo oo~ oo moo oo 1. All causes - T outes causes. 2. All cardiovascular diseases - Toutes maladies cardio-vasculaires. Year - Anntle 3. Hean diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies c6r6bro-vasculaires. Rapp. rrinHlsr. srarisr. sanir. mond., 41 ( 1988) 2000~~~~~~~~--. UNK:E&W M 10~~-'-~-'-~~L----J 1950 60 70 80 90 50 60 70 2ooo UNK: SCO M - 173 - F UNK:NIR M 80 90 50 60 70 80 90 50 60 Southern Europe F GRE M F 70 80 90 F ... 'S i 10 ..___.._-----'..__~__.i 1~ 60 M 80 9050 60 M 80 9050 60 M 80 9050 60 M 80 90 1. All causes - Toutes causes. 2. All cardiovascular diseases - T outes maladies cardio-vasculaires. Wld hhh statist. quan., 41 (19881 Year - Ann6e 3. Hean diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies cM6bro-vasculaires. - 174 - F MAT 2000 ~P-O-R~~~~~-M~ F SPA ,__ ____ --· -- M M F F ~ :i 10 .___._____..____._~~ 1~00 M 00 00~ 00 M 00 00~ 00 M 00 00~ 00 M 00 00 1. All causes - Toutes causes. 2. All cardiovascular diseases - Toutes maladies cardio-vasculaires. Year - Ann6e 3. Haan diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies ~r6bro-vasculaires. Rapp. trlmeat. statist. sanit. mond., 41 (1988) - 175 2000..-----------. Western Europe VUG M F AUT g 8 50 ~2 -------- ~3 2000~--------, § g BEL M F -~-= -~ -~=-= ~A~----~~---~- 50 - 4 - -- -------- -- - - 4 - -· - DEU M F M F "' ~ iii 10 ~-...... -~-~-~i 1~ 00 M 00 00~ 00 M 00 00~ 00 M 00 00~ 00 M 00 00 1. All causes - Toutes causes. 2. All cardiovascular diseases - T outes maladies cardio-vasculaires. Wld hlrh statist. quan., 41 ( 1988) Year - Ann6e 3. Hean diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies c6r6bro-vasculaires. 2000 ,----------, § g NET M 10...._ _ _._ _ _,__---''-----' - 176 - F LUX M F F M F 1950 60 70 80 90 50 60 70 80 90 50 60 70 80 90 50 60 1. All causes - Toutes causes. 2. All cardiovascular diseases - Toutes maladies cardio-vasculaires. Year - Ann<le 3. Hean diseases - Cardiopathies. 4. Cerebrovascular disease - Maladies c<lr<lbro-vasculaires. Rapp. lrimasr. srarisr. sanir. mond., 41 (19881 177 2000 Oceania AUS M F NEZ M F ~ ii 10 ._____.._____.~_._~ ..... i 1~00 moo oo~ oo ro oo oo~ oo ro oo oo~ oo ro oo oo 1. All causes - Toutes causes. 3. Heart diseases - Cardiopathies. 2. All cardiovascular diseases - T outes maladies cardio-vasculaires. Year - Ann6e 4. Cerebrovascular disease - Maladies c6r6bro-vasculaires. RESUME Tendances de la mortalite par maladies cardio-vasculaires dans les pays industrialises, depuis 1950 Dans la plupart des pays industrialises, la mortalite en general et la mortalite par maladies cardio-vasculaires en particulier, ant manifeste des tendances a la baisse a partir de 1970 environ, succedant ainsi a la stagnation au aux augmentations constatees pendant les annees 50 et 60. Toutefois, dans certains pays (en Europe orien- tale, par exemple) la mortalite masculine par maladies cardio-vasculaires a augmente au cours de ces dernieres annees. Les niveaux et les tendances de la mortalite par maladies cardio-vasculaires varient beaucoup d'un pays a l'autre. Calcule d'apres les taux corriges de rage, le rapport entre le taux le plus eleve et le taux le plus faible, aux alentours de 1985, etait d'environ 2 pour la mortalite totale mais d'environ 4 pour !'ensemble des maladies cardio-vasculaires. En subdivisant davantage encore le rapport etait mAme plus grand, c'est-a-dire de 4-5 pour les cardiopathies et de 6-7 pour les maladies cardio- vasculaires. Pour les cardiopathies ischemiques envisa- gees isolement, le rapport atteignait 10, bien que la lar- geur de cette fourchette soit en partie imputable a la diversite des pratiques de diagnostic suivies dans les differents pays. Le rythme auquel la mortalite evolue n'est pas non plus le mAme partout, allant d'une diminu- tion rapide a une augmentation rapide. En general, les tendances etaient beaucoup plus favora- bles chez les femmes que chez les hommes. En conse- quence, les differences tenant au sexe se sont creusees. En ce qui concerne la mortalite par cardiopathies ische- c Vair Variation gi§ographique des principaux facteurs de risque de cardiopathies coronariennes chez les hommes et /es femmes de 35-64 ans [ri§sumi§J, p. 136 du prllsent numllro. Wld hlth statist. quart., 41 ( 1988) miques, le rapport hommes/femmes est maintenant superieur a 3 dans un certain nombre de pays. Pour les maladies cerebro-vasculaires, ce rapport, encore proche de 1 dans de nombreux pays au debut des annees 50, a egalement progresse, atteignant souvent ou mAme de- passant 1,5. Des differences ant egalement ete obser- vees entre les differents groupes d'age dans certains pays. II semble que la tendance au changement (qu'il s'agisse d'une hausse au d'une baisse) soit plus rapide chez les groupes d'age inferieurs que chez les groupes d'age superieurs. Cette evolution des niveaux et des tendances de la mor- talite par maladies cardio-vasculaires est sans aucun doute provoquee par une multitude de facteurs de risque presents dans chaque pays qui influent sur !'incidence et sur le pronostic des maladies cardio-vasculaires. On sait deja beaucoup de chases de ces facteurs de risque et des mesures que les services de sante de mAme que les individus doivent prendre pour la prevention et le traite- ment efficace. Les differences considerables qui s'ob- servent d'un pays a l'autre dans les niveaux et les ten- dances de la mortalite incitent a penser que les pays fortement touches par les maladies cardio-vasculaires ant une possibilite d'intervenir. La surveillance de la mor- talite dans chaque pays et au niveau international indi- quent ainsi comment chaque pays se situe par rapport a d'autres et fournit une base a !'action et a la poursuite des recherches. Le projet OMS de surveillance des ten- dances et des determinants des maladies cardio-vascu- laires (projet MONICA- MON/toring of trends and deter- minants in CArdiovascular disease) clarifiera divers as- pects du rOle joue par les facteurs de risque dans diffe- rentes collectivites. c - 178 - REFERENCES - REFERENCES 1. PISA. Z. & UEMURA. K. Trends in mortality from ischae- mic heart disease and other cardiovascular diseases in 27 countries, 1968-1977. World health statistics quanerly, 35 ( 1 ) : 11-4 7 ( 1982). to 1978. International journal of epidemiology, 14: 510-520 ( 1985). 5. WORLD HEALTH ORGANIZATION. Manual of the interna- tional classification of diseases, injuries and causes of death. Ninth Revision. Geneva, WHO, 1977. (Vol. 1, pp. 715-718). P1SA. Z. & UEMURA, K. Tendances de la mortalite par cardiopathies ischemiques et autres maladies cardio- vasculaires dans 27 pays, 1968-1977. Rappon tri- mestriel de statistiques sanitaires mondiales, 35 ( 1) : 11-47 (1982). 2. UEMURA, K. & PISA. Z. Recent trends in cardiovascular disease mortality in 27 industrialized countries. World health statistics quanerly, 38 (2): 142-162 (1985). ORGANISATION MONDI ALE DE LA SANTE. Manuel de la clas- sification statistique internationale des maladies, traumatismes et causes de deces. Neuvieme revi- sion. Geneve, OMS, 1977. (Vol. 1, pp. 715-718). 6. WHO Technical Report Series No. 678, 1982 (Pre- vention of coronary hean disease: report of a WHO Expert Committee). UEMURA. K. & P1SA. Z. Tendances recentes de la mor- talite par maladies cardio-vasculaires dans 27 pays industrialises. Rappon trimestriel de statistiques sa- nitaires mondiales, 38 (2): 142-162 ( 1985). OMS Serie de Rapports techniques N° 678, 1982 (Prevention des cardiopathies coronariennes: rap- port d'un Comite d'experts de l'OMS). 7. WHO Technical Report Series No 732, 1986 (Com- munity prevention and control of cardiovascular dis- eases: report of a WHO Expert Committee). 3. UEMURA, K. International trends in cardiovascular dis- eases in the elderly. European hean journal, 9 (Sup- plement D): 1-8 (1988). 4. THOM, T. J. ET AL. Trends in total mortality and mor- tality from heart diseases in 26 countries from 1950 OMS Serie de Rapports techniques N° 732, 1985 (La lutte communautaire contre les maladies cardio-vas- culaires: rapport d'un Comite d'experts de l'OMS). Code AUS AUT BEL BUL CAN CZE DDR OEN DEU E&W FIN FRA GRE HUN ICE IRE ISR ITA JPN LUX MAT NET NEZ NIR NOR POL POR ROM sea SPA SSR SWE SWI UNK USA YUG ANNEX - ANNEXE NATIONAL DATA USED IN THIS STUDY DONNEES NATIONALES UTILISEES DANS CETTE ETUDE Country - Pays Australia - Australie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Austria - Autriche . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Belgium - Belgique . . . . . . . . . . . . . . . . . . Bulgaria - Bulgarie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Canada Czechoslovakia - T checoslovaquie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . German Democratic Republic - Republique democratique allemande . . . . . . . . . . . Denmark - Danemark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Germany, Federal Republic of - Allemagne, Republique federale d" ........... . England & Wales (United Kingdom) - Angleterre et pays de Galles (Royaume-Uni) Finland - Finlande . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . France . . . . . . . . . . . . . . . . . ............. . Greece - Grece . . . . . . . . . . . . . . . . . . . . Hungary - Hongrie . . . . . . . . . . . . . . . . . . Iceland - lslande . . Ireland - lrlande . . . . . . . . . . Israel - lsral!I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Italy - ltalie . . Japan - Japan . . . . . . . . . . . . . . Luxembourg . . . . . . . . . . . . . . . . Malta - Malte . . . . . . . . . . . . . . . . . . . . . . . . . . . Netherlands - Pays-Bas . . . . . . . . . . . . . . . . . . . . . . . . . . New Zealand - Nouvelle-Zelande . . . . . . . . . . . . . . . . . . . . . Northern Ireland (United Kingdom) - lrlande du Nord (Royaume-Uni) Norway - Norvege . . . . . . . . . . . . . . . . . . . . . . . . . Poland - Pologne . . . . . . . . . . . . . . . . . . . . Ponugal . . . . . . . . . . . . . . . . . . . . . . . . . . ......... . Romania - Roumanie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scotland (United Kingdom) - Ecosse (Royaume-Uni) . . . . . . . . . . . . . . . . . . . . Spain - Espagne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Union of Soviet Socialist Republics - Union des Republiques socialistes sovietiques . . Sweden - Suede . . . . . . . . . . . . . . . . . . . . Switzerland - Suisse . . . . . . . . . . . . . . . . . . United Kingdom - Royaume-Uni . . . . . . . . . . . . United States of America - Etats-Unis d' Amerique Yugoslavia - Yougoslavie .................... . 1950-85 1955-85 1954-84 1964-85 1950-85 1953-85 1973-85 1951-85 1952-85 1950-85 1952-85 1950-85 1961-85 1955-85 1961-85 1950-85 1975-85 1951-84 1950-85 1967-85 1965-85 1950-85 1950-85 1950-85 1951-85 1959-85 1955-85 1969-84 1950-85 1951-83 1986 1951-85 1951-85 1950-85 1950-85 1961-84 Rapp. trimest. statist. sanit. mond., 41 (19881 - 179 - TRENDS IN THE PREVALENCE AND INCIDENCE OF DIABETES: INSULIN-DEPENDENT DIABETES MELLITUS IN CHILDHOOD Marian Rewers, Ronald E. LaPorte, Hilary King & Jaakko Tuomilehto (For The Diabetes Epidemiology Research International Study Group-DERl)a Insulin-dependent diabetes mellitus (IDDM) is a chronic and irreversible disease of any age, characterized by insulinopenia and dependence on injected insulin to sustain life. This clinical entity may be an outcome of different pathological processes; however, the exact etiologic mechanisms remain unknown. About 25-50% of the patients are diagnosed by the age of 15 years (1, 2). In Northern Europe and North America, IDDM is the third most frequent severe chronic disease of childhood, sec- ond only to asthma and cerebral palsy (3). In a population that is at moderate risk, 3 out of 1 OOO children develop IDDM by the age of 20 (4). Lethal prior to the discovery of insulin in 1921, IDDM still leads to severe disabilities, including blindness and renal failure, in the majority of the cases, and to premature death (5). In developed coun- tries, the average costs incurred by a child diagnosed at age 7 through age 40 amount to US$50 OOO (T. Songer, unpublished data). The costs rise after age 40 as the prevalence of complications increases. The incidence of the disease shows a wide variation in geographical and ethnic distribution, which has been interpreted as evidence of both environmental and ge- netic factors in IDDM etiology. Despite the importance of the disease which, in addition, is not difficult to study epidemiologically, IDDM morbidity data have never been consistently collected by national statistics services or an international agency. In the past few years, the World Health Organization (WHO) and several research institu- tions have recognized the importance of population- based registries as the essential tool in etiological re- search and public health administration in the area of diabetes (5). The significance and the methodology of international collaboration have been reviewed during two workshops on IDDM registries, held in Philadelphia in 1983 (6) and in Madrid in 1985 (7). Following the recommendations from those workshops, IDDM regis- tries worldwide have organized themselves into a study group, the objective of which is to standardize collection of data and to assess the international patterns and trends in incidence. Recently, the coordinating centre of the Diabetes Epidemiology Research International (DERI) Study Group at the University of Pittsburgh has been designated as the WHO Collaborating Centre for Diabetes Registries and Training in the Epidemiology of Diabetes Mellitus. Methods Procedures for the collection of data Since 1986, the DERI group has been collecting standard- ized incidence data from recognized IDDM registries worldwide. The standardization procedures include the following criteria for eligibility in DERI research: A registry must be population-based, i.e. ascertain- ing all cases in a target general population rather than in a population served by a hospital or a clinic. A registry must ascertain incident cases of IDDM rather than prevalent patients. A registry must use the standard criteria of IDDM, which are described in the next section. Minimally, registration should cover the age group at highest risk of IDDM, i.e. children aged 0-14 years. The following core data must be collected on each patient: names (or an ID number), address at diagno- sis, sex, date of birth and the date of diagnosis, which is defined as date of the first insulin administration. These data should be stored in the form of individual records, rather than as grouped numerators, to allow for cross-checking with additional sources of infor- mation and updating. Good quality denominator data must be available for the target population, at least by sex and five-year age groups. It is strongly recommended that cases be ascertained through at least two relatively independent sources. An estimate of the completeness of the primary data source should be calculated to evaluate the validity of results. • Members of the group: AUSTRIA: E. Schober - University of Vienna; CANADA: E. Colle - Montreal Children's Hospital, McGill University, Montreal & J. Siemiatycki - Institute Armand-Frappier, Laval-des-Rapides; M. H. Tan & C. Warnell - Dalhousie University, Halifax; CUBA: 0. Diaz Diaz - Institute of Endocrinology. Habana; DENMARK: A. Green - University Institute of Clinical Genetics, Odense; FINLAND: A. Reunanen - Social Insurance Institution, H. K. Akerblom - Children's Hospital, University of Helsinki. J. Tuomilehto & R. Lounamaa - National Public Health Institute, Helsinki; FRANCE: M. Hours & J. Fabry - lnstitut de mt!decine sociale, Lyon; ISRAEL: Z. Laron. M. Karp, B. Bauman & M. Madan - Beilinson Medical Center. Petah Tikva; JAPAN: N. Matsuura - Hokkaido University, Sapporo; T. Kitagawa - Nihon University Hospital. I. Hibi - National Children's Hospital & N. Tajima - Jikei University, Tokyo; MEXICO: C. Robles - National Institute of Pediatrics. Mexico City; NEW ZEALAND: R. B. Elliott - University of Auckland, Auckland; R. S. Scott - Clinical School of Medicine. Christchurch; NORWAY: G. Joner - Askim Hospital, Askim & 0. Sevik - University of Bergen; POLAND: M. Rewers & M. Walczak - Medical University, Poznan • M. J. Wysocki - National Institute of Hygiene. Warsaw ; REPUBLIC OF KOREA: K. W. Ko & H. K. Lee - Seoul National University Hospital, N. H. Cho - University of Pittsburgh; SWEDEN: G. Dahlquist & L. Blom - Sach's Children's Hospital, Stockholm. L. Nystrom & S. Wall - Department of Epidemiology, Umea; GERMAN DEMOCRATIC REPUBLIC: D. Michaelis - Central Institute for Diabetes, Karlsburg; NETHERLANDS: G. J. Vaandrager - National Institute of Preventive Health Care, Leiden & G. J. Bruining - Sophia Chilren's Hospital. Erasmus University, Rotterdam; UNITED KINGDOM: ENGLAND: A. C. Burden - Leicester General Hospital; SCOTLAND: C. C. Patterson -The Queen's University of Belfast & N. Waugh - Tayside Health Board, Dundee; UNITED STATES OF AMERICA: R. E. LaPorte, A. L. Drash & L. H. Kuller - University of Pittsburgh, Pittsburgh, PA; R. F. Hamman &E. Gay - University of Colorado, Denver. CO; L. Wagenknecht & J.M. Roseman - University of Alabama at Birmingham. Birmingham, AL; J. D. Brosseau - Grand Forks Clinic, Grand Forks, ND; D. J. Ballard & L. J. Melton Ill - Mayo Clinic. Rochester, MN; M. Lorenzi - Eye Research Institute, Boston, MA; M. Harris - National Institutes of Health, Bethesda. MD; H. A. Fishbein - Massachusetts Department of Public Health. Boston, MA; WORLD HEALTH ORGANI- ZATION: H. 0. M. King - Division of Noncommunicable Diseases, Geneva. Switzerland. Wld hlth statist. quart., 41 ( 19881 - 180 - During the first year of this collaboration, 30 out of the estimated 40 population-based IDDM incidence regis- tries in existence have submitted their data to DEAi, revised according to the DEAi standardization proce- dures. This article presents a review of the geographical patterns and temporal trends in IDDM prepared on the basis of this standardized data set. Information from selected registries which have not participated in the DEAi project has been extracted from their published reports. Definition of /DOM for epidemiological comparisons Despite current controversies regarding the classifica- tion of diabetes in general (5), the case definition of IDDM in childhood is relatively simple. For population-based registries, the following inclusion criteria have been pro- posed, which are usable in any country, developed or developing: • diagnosis of diabetes stated by a physician; • daily insulin injections at the time of registration; • age at the first insulin administration less than 15 years; • residence by the patient in the area of registration at the time of the first insulin administration. It should be emphasized that childhood IDDM is a chronic disease which is relatively easy to identify and study epidemiologically, with characteristic symptoms, sensi- tive and specific laboratory indices and a unique treat- ment-insulin-that is essential for survival. However, the validity of this clinical definition to define an etiolog- ically homogeneous entity in different populations re- mains to be established. The definition excludes many cases of IDDM which develop after 15 years of age. Table 1 summarizes the scarce information available regarding IDDM incidence in the general population. The inclusion of cases of older onset would progressively reduce specificity. The risk of IDDM in adulthood is difficult to measure epidemiologi- cally due to problems with the definition of the disease. However, it is conceivable that the actual rates lie some- where between the conservative estimates of IDDM incidence (1, 8) and the incidence of insulin-treated diabetes. The Ninth Revision of the International Classification of Diseases (ICD-9) provides a fifth-digit subclassification for use with the category "diabetes mellitus" (250). In the classification, insulin-dependent diabetes mellitus should be coded as juvenile diabetes-fifth digit "1". Validity of the incidence data Differences in classification are less likely to affect inter- national comparison of IDDM rates than differences in reporting and registration practices. The completeness of ascertainment has to be validated and factors related to the selectivity of case inclusion should be identified before the data are compared between registries. The completeness of data is defined as the proportion of all cases in the target population which appear in the reg- istry data base. Usually, the denominator of this propor- TABLE 1. INCIDENCE (PER 100 OOO PERSON/YEARS) OF INSULIN-TREATED AND INSULIN-DEPENDENT DIABETES IN THE GENERAL POPULATION TABLEAU 1. INCIDENCE (POUR 100 OOO PERSONNES/ANNEES) DU DIABl':TE TRAITE A L'INSULINE ET DU DIABl':TE INSULINO-DEPENDANT SUR L'ENSEMBLE DE LA POPULATION Age group Rochester (I} Denmark (8} Age group German Democratic Republic d Sweden 8 Rllpublique dllmocratique Groupe d"3ge Danemark (8} Groupe d"3ge allemanded Suede• Insulin- Insulin- Insulin- treated a dependent" dependent< Insulin-treated Insulin-dependent Traitll a lnsulino- lnsulino- T raitll a I' insuline lnsulino-dllpendant l'insulinea dt\pendant" dllpendant< (years/annlles) (years/ann6es) M F M F 0-9 6.4 7.4 7.8 0-4 5-9 10-19 12.5 8.7 12.5 10-14 15-19 20-29 9.5 5.2 7.2 20-24 25-29 30-39 6.9 4.0 7.8 30-34 35-39 40-49 17.2 10.7 8.0 40-44 45-49 50-59 25.8 10.5 8.0 50-54 55-59 60-69 26.9 9.4 9.0 60-64 65-69 70-79 31.7 10.6 10.6 70-74 75-79 • Rates for 1960-69. b Rates for 1945-69, criteria for IDDM: insulin therapy. evidence of ketosis-prone- ness. relative weight < 1.2. residence in Rochester > 1 year prior to diagnosis. < Criteria for IDDM : symptoms lasting <6 months, weight loss prior to insulin therapy, ketonuria and/or bicarbonate <21 mmol/1, plasma glucose > 12 mmol/1, insulin treatment continued aher discharge from hospital. 2.7 2.3 21.8f 15.6f 7.9 9.0 34_4f 31.6f 8.2 14.4 31.3f 34_3f 9.2 9.7 19.99 10.19 11.4 8.6 18.59 10.49 11.0 8.4 16.99 13.09 19.3 9.8 18.59 7.19 22.1 7.5 23.7 11.1 20.2 12.9 25.6 18.0 27.0 22.0 20.9 28.3 25.7 34.1 32.3 34.7 26.7 28.1 • T aux pour 1960-69. " Taux pour 1945-69. criteres applicables au diabete sucrll insulino-dllpendant: traitement, preuve de prl>disposition a la clltose, poids relatif < 1.2. durlle de rllsidence a Rochester > 1 an avant le diagnostic. < Criteres applicables au diabete sucrll insulino-dllpendant : sympttimes durant moins de 6 mois, pene de poids observlle avant la thllrapie a l"insuline, concen- tration de clltonurie et/ou de bicarbonate <21 mmol/1, de glucose plasmatique > 12 mmol/1. poursuite du traitement a l'insuline apres la sonie de l'htipital. d D. Michaelis - unpublished data from the National Registry, 1986. • Rates for 1983. I G. Dahlqvist et al. - unpublished data from the National Registry. / D. Michaelis - donnlles non publilles du Registre national de 1986. • Taux pour 1983. 9 Reference (9}, criteria for IDDM · no standard definition, diagnosis made by refer- ring physician. I G. Dahlqvist et al. - donnlles non publilles du Registre national. • Rl>Mrence (9}. criteres applicables au diabete sucrll insulino-dllpendant: ii ne s·agit pas d·une dl>finition standard, le diagnostic a lltll lltabli par le ml>decin traitant. Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 181 - tion is not known. Several methods have been proposed to estimate the completeness of the registration, through the use of at least two sources of data (10) (A. Green, unpublished manuscript, 1987). In this article, the estimate of ascertainment (Table 2) represents the proportion of cases identified through the primary data source to the number of cases identified through all available sources. Data from the registries which have not yet validated their completeness (denoted by "?" in Table 2) should be interpreted with caution. Since the majority of the registries are based on reviews of hospi- tal records, the most obvious systematic selection bias in case reporting is omission of patients who are placed on insulin without hospitalization. It should be noted that patterns of hospitalization of diabetic children at onset of the disease vary both with time and geographical loca- tion. It is estimated, for example, that less than 50% of the children are hospitalized at onset in Argentina and Brazil, about 75% in Rochester (Minnesota) and virtually all cases in Finland, Poland, Scotland and Sweden. TABLE 2. AGE-STANDARDIZED INCIDENCE RATES OF INSULIN-DEPENDENT DIABETES MELLITUS UNDER AGE 15 YEARS (PER 100000 POPULATION) AND THE 95% CONFIDENCE INTERVALS, 1965-1986 TABLEAU 2. TAUX D'INCIDENCE CORRIGES DE L'AGE DU DIAB~TE SUCRE INSULINO-DEPENDANT CHEZ LES MOINS DE 15 ANS (PAR 100 OOO HABITANTS) ET INTERVALLES DE CONFIANCE A. 95%, 1965-1986 REGION - R~GION Study period Pt!riode d't!tude INCIDENCE Estimate of ascertainment---------------------- Country and area - Pays et zone AMERICAS - AMERIQUES Canada Montreal - Montreal . . . . . Prince Edward Island - lle du Prince Edward Cuba ..... . Mexico - Mexique Mexico City . . United States - Etats-Unis Allegheny County - Comte d' Allegheny Colorado ................. . Jefferson County - Comte de Jefferson North Dakota - Dakota du Nord . . . . Rochester ................ . San Diego ................ . Wisconsin (part - partie) a . . . . . . ASIA-ASIE Israel b - Israel b . . . . . . . . . . . . . . . Japan - Japon Hokkaido ................ . Kuwaitc - Koweitc ............ . Republic of Korea - Republique de Coree EUROPE Austria d - Autriche d . . . . . . . . . . . . Denmark (part)e - Danemark (partie)e Finland - Finlande . . . . . . . . . . . France Department du RhOne . . 1971-85 1975-86 1978-80 1984-86 1965-85 1978-83 1979-85 1980-86 1965-79 1978-81 1970-79 1975-80 1974-86 1980-81 1985-86 1979-86 1970-76 1970-86 1960-79 German Dern. Rep. - Rep. dem. allemande 1982-84 Netherlands - Pays-Bas . . . . 1978-80 Norway - Norvege ............. 1973-82 Poland - Pologne Warsaw - Varsovie . . . . . . . . . . . 1984-86 Wielkopolska ............... 1970-85 Sweden - Suede . . . . . . . . . . . . 1978-86 United Kingdom - Royaume-Uni Leicestershire . . . . . . . . . . . . . Scotland - Ecosse . . . . Tayside ............. . OCEANIA - OCEANIE 1965-81 1976-83 1980-83 Pourcentage de complt!tude 94% 99% ? >90% >95% 96% ? 100% ? >90% ""100% 93% 88-99% 99% >90% ? 90% 92% ? 96% 93% >90% ""100% ""100% New Zealand 1 - Nouvelle-Zelande I 1968-72 ? Auckland .......... . Canterbury . . . . . . . . . • Reference (11} - Rl!fl!rence (11}. • Reference (12} - R<!fl!rence (12}. c Reference (13} - Rl!fl!rence (13}. d Age group 0-13 years - Groupe d'Age 0-13 ans. • Reference (10} - Rt!f<!rence (10}. 1978-85 ? 1982-85 ""100% I Age group 0-15, reference (14} - Groupe d'age 0-15 ans, r<!f<!rence (14}. Wld hlth statist. quan., 41 ( 1988) M 9.6 27.0 2.5 0.4 15.1 14.8 9.9 21.6 15.8 9.6 20.2 4.4 1.3 3.2 0.5 8.0 14.5 30.4 4.6 7.0 9.9 21.4 5.2 4.7 23.8 8.7 20.0 19.7 8.6 9.0 10.2 (Cases) (Cas) 95%C.I. 1.C. a 95% 461) 8.8-10.5 53) 20.4-35.6 128) 2.1- 3.0 38) 568) 304) 52) 120) 18) 25) 94) 142) 112) 9) 17) 0.3- 0.5 13.9-16.4 13.2-16.6 7.5-13.1 18.0-25.9 9.4-25.0 6.2-14.2 16.4-24.8 3.7- 5.2 1.1- 1.6 1.5- 6.1 0.3- 0.9 ( 431) 7.3- 8.8 (2 684) 29.3-31.6 155) 340) ( 500) (1 039) 3.9- 5.4 6.3- 7.8 9.1-10.8 20.1-22.7 16) 3.0- 8.4 ( 238) 4.1- 5.3 (1 747) 22.7-24.9 140) 7.3-10.3 966) 18.8-21.3 36) 11.0-32.5 212) 7.5- 9.9 109) 7.4-10.9 18) 6.0-16.1 F 10.0 20.8 2.8 0.7 16.0 15.2 14.9 16.2 18.4 9.1 16.2 4.6 2.1 4.7 0.6 7.3 13.4 27.1 4.9 7.0 9.6 19.4 5.5 4.9 22.5 8.6 19.4 22.1 9.1 10.5 12.9 (Cases) (Cas) 95%C.I. I.C. a 95% 458) 9.1-11.0 39) 14.8-28.4 139) 2.4- 3.3 62) 580) 300) 76) 84) 20) 23) 72) 154) 171) 13) 18) 0.5- 0.9 14.7-17.4 13.5-17.1 11.8-18.8 13.0-20.2 11.2-28.3 5.8-13.7 12.8-20.5 3.9- 5.4 1.8- 2.3 2.4- 8.2 0.4- 1.0 ( 379) 6.6- 8.1 (2 292) 26.0-28.2 159) 4.2- 5.7 327) 6.3- 7.8 465) 8.8-10.5 890) 18.2-20. 7 16) 3.1- 8.9 ( 235) 4.3- 5.6 (1 571) 21.4-23.6 132) 7.2-10.2 890) 18.2-20. 7 28) 12.6-35.8 216) 7.9-10.4 124) 8.8-12.5 21) 8.0-19.7 182 - Age-standardization of incidence rates The rates were standardized by the direct method using as the standard the population of "the more developed part of the world" in 1980 (15) and the 95% confidence intervals were calculated (16). The distribution of the standard population at risk was, for both sexes, as fol- lows: Age group (years) Results 0-4 5-9 10-14 Geographical patterns Proportion of the standard population aged 0-14 33% 33% 34% The highest annual average incidence of the disease has been reported from Finland (28.8 per 100 OOO person- years) and the lowest from the Republic of Korea (0.5 per 100 000). If taking into account only registries which proved to be virtually complete, the lowest rate (1. 7 per 100 000) has been reported from Hokkaido (Japan). These data (Table 2) demonstrate that there are marked and unquestionable differences in population determi- nants of IDDM risk. The issue of controversy has been whether the diversity of IDDM risk, of the order which is rarely seen in other chronic diseases, results from ge- netic predisposition, environmental factors or both. Map 1 depicts the geographical pattern of IDDM inci- dence, around 1980. There is a strong south-north gra- dient in incidence, with rates increasing with the latitude. However, there are many factors, both genetic and envi- ronmental, similarly distributed, which could potentially be involved in the etiology of IDDM. Ethnic differences Table 2a presents the ethnic breakdown of the incidence rates shown in Table 2, for the few heterogeneous popu- lations where IDDM incidence has been studied. Comparison of the rates for different ethnic groups living in the same geographical area indicates that those groups are at differential risk of IDDM. Factors asso- ciated with ethnicity influencing IDDM incidence may be either genetic or related to diet, lifestyle and socio- economic status. In Montreal there was significant var- iation among various ethnic groupings of European ori- gin, even after stratification and adjustment for socio- economic status (20). Although not as strong as for inter-ethnic variation there was some evidence of greater risk in the wealthiest as compared to the poorest quintile of the population. This effect was confirmed to the 0-4 age group where the variation was about three- fold. Sex differences The data presented in Tables 2 & 2a suggest that there is a slight excess risk for males in populations where inci- dence is high and a female excess in low-risk ethnic groups, mostly non-Caucasian. However, when the con- fidence intervals were compared, the differences were statistically significant in only two registries: in Finland and in Hokkaido (Japan). Age distribution of clinical onset In both sexes, the incidence is approximately 2.5 times higher in the age group 5-9 years and 3 times higher in 10-14 year-aids, when compared to the age group 0-4 years (Tables 3a & 3b}. It has been shown that, in gen- eral, the relative risks between different areas do not vary with age (21) (M. Rewers et al., unpublished data). TABLE 2a. AGE-STANDARDIZED INCIDENCE OF INSULIN-DEPENDENT DIABETES MELLITUS UNDER AGE 15 YEARS (PER 100 OOO POPULATION) AND THE 95% CONFIDENCE INTERVALS, BY ETHNIC GROUPS TABLEAU 2a. TAUX D'INCIDENCE CORRIGES DE L'AGE DU DIABl':TE SUCRE INSULINO-DEPENDANT CHEZ LES MOINS DE 15 ANS (PAR 100000 HABITANTS) ET INTERVALLES DE CONFIANCE A 95%, PAR GROUPE ETHNIQUE INCIDENCE Area, ethnic group - Zone. groupe ethnique (Cases) 95% C.I. (Cases) 95%C.I. M (Cas) I.C. a 95% F (Cas) I.C. a 95% Allegheny County - Comte d' Allegheny white - blanc .. 16.1 (530) 14.8-17.5 16.4 (520) 15.0-17.9 black - noir . . ......... 8.3 ( 38) 5.9-11.4 13.2 ( 60) 10.2-17.1 Colorado non-Hispanic - non hispanique ....... 16.4 (282) 17.3-18.5 15.9 (260) 14.1-18.0 Hispanic - hispanique ......... 6.6 ( 22) 4.1-10.0 12.3 ( 40) 8.8-16.7 Jefferson County - Comte de Jefferson white - blanc . . . . . . 15.5 ( 48) 11.4-20.6 18.1 ( 54) 13.7-23.8 black - noir .. . . . . . . . . . . . . . . . . 1.9 ( 4) 0.5- 4.9 10.4 ( 22) 6.5-15.7 Auckland white - blanc ............... 12.1 (103) 9.9-14.7 12.8 (110) 10.6-15.5 Maori & Polynesian - maori et polynesien 2.0 ( 6) 0.7- 4.4 4.9 ( 14) 2.7- 8.2 Montreal• - Montreal• French - franc;:ais .. 7.9 (249) 7.0- 9.0 8.1 (242) 7.1- 9.2 British - britannique 15.4 ( 86) 12.4-19.1 16.9 ( 90) 13.7-20.9 Italian - italien 9.8 ( 28) 6.5-14.2 9.5 ( 26) 6.2-14.0 Jewish - juif . . . . . . . . 14.1 ( 19) 8.5-22.0 22.5 ( 29) 15.1-32.4 other - divers .... . . . . . . . . . . . . . 12.8 ( 79) 10.2-16.0 12.2 ( 72) 9.6-15.5 • Reference (20} - Refl!rence (20}. Rapp. trimest. srarisr. sanit. mond .• 41 (1988) PEI RO ND co AC JC so MON CUB 0 10 20 40° - 60° MAP I. MAPPING OF IDDM INCIDENCE WORLDWIDE IN 1980° CARTE I. REPRESENTATION CARTOGRAPHIQUE DE L'INCIDENCE DU DIABETE SUCRE ET INSULINO-DEPENDANT A L'ECHELLE MONDIALE 1980° 0 10 20 30 FIN SWE sco NOR 0 5 . ~ ~HOK • . JPN 1)0 .. . • 1. - 60° - 40° - 20° oo - 20° z::;,!> - 40' • Horizontal bars represent the annual age-adjusted incidence per 100 OOO persons 0-14 years of age in areas denoted as follows: PEI: Canada, Prince Edward Island; RO: USA, Rochester; ND: USA, Nonh Dakota; CO: USA, Colorado; AC: USA, Allegheny Country; JC: USA, Jefferson County ; SD : USA, San Diego ; MON : Canada, Montreal; CUB: Cuba; FIN: Finland; SWE: Sweden; SCO: Scotland, Tayside; NOR: Norway; HOL : Netherlands ; GDR : German Democratic Republic ; POL : Poland, Wielkopolska; FRA: France, Depanement du RhOne; ISR: Israel; HOK: Japan, Hokkaido; JPN: Japan, whole country; AUC: New Zealand, Auckland; CBY: New Zealand, Canterbury. 0 10 a Les barres horizontales representent I' incidence naturelle corrigee de l'age pour 100 OOO personnes agees de 0-14 ans dans les regions abregees comme suit· PEI: Canada, lle du Prince Edward; RO: Etats- Unis, Rochester; ND: Etats-Unis, Dakota du Nord; CO: Etats-Ums, Colo- rado: AC: Etats-Unis, Comte d' Allegheny; JC: Etats-Unis, Comte du Jefferson; SD: Etats-Unis, San Diego; MON: Canada, Montreal; CUB: Cuba; FIN: Finlande; SWE. Suede; SCO: Ecosse, Tayside; NOR: Nor- vege; HOL : Pays-Bas ; GDR : Republique democratique allemande; POL Pologne, Wielkopolska; FRA: France, Depanement du RhOne; ISR Israel; HOK : Japon, Hokkaido; JPN: Japon, ensemble du pays; AUC Nouvelle-Zelande, Auckland; CBY: Nouvelle-Zelande, Canterbury. - 60° CX) w - 184 - TABLE la. AGE-SPECIFIC INCIDENCE RATES OF INSULIN-DEPENDENT DIABETES MELLITUS UNDER AGE 15 YEARS IN MALES, 1965-1986 TABLEAU la. TAUX D'INCIDENCE SPECIFIQUE PAR .AGE DU DIABETE SUCRE INSULINO-DEPENDANT CHEZ LES MOINS DE 15 ANS DE SEXE MASCULIN, 1965-1986 Country and area - Pays et zone Study period Age (years/ annees) Population Periode d'etude 0-4 5-9 10-14 AMERICAS - AMERIQUES Canada Montreal - Montreal .............. 1971-75 6.1 9.3 12.8 1976-80 3.7 7.8 13.6 1981-85 7.7 11.6 14.1 Prince Edward Island - lle du Prince-Edouard 1976-80 12.0 36.8 22.2 1981-85 28.6 31.3 32.2 Cuba ................ 1978-80 1.5 3.4 2.5 United States - Etats-Unis Allegheny County - Comte d' Allegheny white - blanche . . . . . . . . ...... . . . . . . . . 1966-70 10.4 16.4 18.9 1971-75 5.9 23.4 26.3 1976-80 5.2 16.8 21.4 1981-85 10.9 18.1 23.3 black - noire . . . . . ...................... 1966-70 5.4 5.0 5.0 1971-75 3.1 11.1 14.9 1976-80 6.8 6.1 13.7 1981-85 8.6 6.0 16.9 Colorado non-Hispanic - non hispanique 1978-83 9.5 16.5 22.9 Hispanic - hispanique ..... 1978-83 3.3 5.3 11.1 Jefferson County - Comte de Jefferson white - blanche . . . . . . . . 1979-85 7.9 19.3 19.2 black - noire 1979-85 1.4 2.8 1.4 North Dakota - Dakota du Nord . . 1980-86 11.6 23.9 29.0 Rochester ....... 1965-79 13.5 12.2 21.3 San Diego ......... 1978-81 7.0 7.0 14.6 Wisconsin (part - partie) a 1970-79 9.9 17.1 33.1 ASIA- ASIE Israel b - lsral!I b 1975-80 1.6 4.5 6.9 Japan - Japan Hokkaido ... 1976-80 1. 1 1.1 2.4 1981-85 0.5 0.8 2.2 Republic of Korea - Republique de Coree 1985-86 0.4 0.2 1.0 EUROPE Austria - Autriche ............ 1979-85 5.4 7.8 10.6C Denmark (part) d - Danemark (partie) d 1970-76 7.7 13.2 22.7 Finland - Finlande . . . . ...... 1971-75 14.4 27.6 36.4 1976-80 17.2 33.1 39.7 1981-85 19.7 39.0 45.4 France Departement du Rhone .......... 1960-79 2.8 3.4 6.5 German Dern. Rep. - Rep. dem. allemande 1982-84 2.9 7.8 10.2 Netherlands - Pays-Bas 1978-80 7.1 10.0 12.5 Norway - Norvege 1973-82 12.6 23.1 28.5 Poland - Pologne Wielkopolska 1971-75 1.6 3.6 4.7 1976-80 1.3 5.3 8.1 1981-85 2.9 7.2 7.9 Sweden - Suede ........ 1978-86 16.7 24.2 30.4 United Kingdom - Royaume-Uni Leicestershire 1965-81 5.1 8.5 12.3 Scotland - Ecosse 1976-83 13.7 20.4 25.9 Tayside .... 1980-83 17.0 17.7 29.9 OCEANIA - OCEANIE New Zealand - Nouvelle-Zelande Auckland, white - Auckland, blanche 1977-87 9.3 13.9 13.2 Canterbury .... . ....... 1982-85 4.2 5.2 20.9 • Reference (11) - Reference (11). O Reference (12) - Reference (12). c Age group 10-13 - Groupe d'age 10-13 ans. d Reference (10) - ReMrence (10). Rapp. trimest. statist. sanit. mond .. 41 (1988) - 185 - TABLE lb. AGE-SPECIFIC INCIDENCE RATES OF INSULIN-DEPENDENT DIABETES MELLITUS UNDER AGE 15 YEARS IN FEMALES, 1965-1986 TABLEAU lb. TAUX D'INCIDENCE SPECIFIQUES PAR AGE DU DIABETE SUCRE INSULINO-DEPENDANT CHEZ LES MOINS DE 15 ANS DE SEXE FEMININ, 1965-1986 Country and area - Pays et zone Population AMERICAS - AMERIQUES Canada Montreal - Montreal . . . Prince Edward Island - lle du Prince-Edouard Cuba ....... . United States - Etats-Unis Allegheny County - Comte d' Allegheny white - blanche . . . . . . . . . . . black - noire . . . . . . . . . . . . . . . . . . . . . . . . . . Colorado non-Hispanic - non hispanique Hispanic - hispanique . . . . . Jefferson County - Comte de Jefferson white - blanche . . . . . . . . black - noire . . . . . . . . . North Dakota - Dakota du Nord Rochester ....... . San Diego ........ . Wisconsin (part - partie) • ASIA - ASIE Israel b - lsrai!I b Japan - Japon Hokkaido ... Republic of Korea - Rl!publique de Corl!e EUROPE Austria - Autriche . . . . . . . . . . . . Denmark (part)d - Danemark (partie)d Finland - Finlande . . . . . . . . . . . France Dl!partement du Rhone German Dern. Rep. - Rl!p. dem. allemande Netherlands - Pays-Bas Norway - Norvege Poland - Pologne Wielkopolska Sweden - Suede . . . . . . . . United Kingdom - Royaume-Uni Leicestershire Scotland - Ecosse Tayside ...... . OCEANIA - OCEANIE New Zealand - Nouvelle-Zl!lande Auckland Canterbury . . . . . . . . • Reference (11) - Reference {11). O Reference (12) - Ref6rence {12). c Age group 10-13 - Groupe d'age 10-13 ans. d Reference (10) - Reference (10). Wld hlth statist. quan .. 41 ( 1988) Study period P6riode d • etude 1971-75 1976-80 1981-85 1976-80 1981-85 1978-80 1966-70 1971-75 1976-80 1981-85 1966-70 1971-75 1976-80 1981-85 1978-83 1978-83 1979-85 1979-85 1980-86 1965-79 1978-81 1970-79 1975-80 1976-80 1981-85 1985-86 1979-86 1970-76 1971-75 1976-80 1981-85 1960-79 1982-84 1978-80 1973-82 1971-75 1976-80 1981-85 1978-86 1965-81 1976-83 1980-83 1977-87 1982-85 0-4 5.8 5.8 5.8 4.3 8.5 1.9 5.1 8.1 7.8 10.8 2.8 6.4 0.0 6.0 7.1 3.4 4.1 5.5 9.1 8.7 3.6 8.2 2.1 0.6 1.5 0.4 4.8 7.4 10.2 16.0 15.8 3.1 3.2 6.3 11.6 1.7 2.1 3.4 14.0 3.4 12.2 15.6 7.3 10.8 Age (years I ann6es) 5-9 12.2 10.6 11.9 16.0 25.1 3.0 14.0 19.2 18.7 18.9 4.9 2.8 12.4 27.9 19.1 13.8 25.0 15.9 18.5 15.4 11.3 17.0 4.4 1.8 2.6 0.5 6.9 12.9 27.5 32.5 34.9 3.9 6.7 9.5 19.8 4.2 4.5 6.9 25.7 8.2 19.9 20.7 14.6 7.2 10-14 12.2 13.8 11.4 33.5 38.5 3.5 25.1 26.3 21.2 24.9 25.0 17.3 19.4 28.8 21.1 19.5 25.0 9.8 20.8 30.6 12.6 23.3 7.2 2.7 4.2 0.9 10. lc 20.1 33.0 33.7 37.4 7.4 11.1 12.8 26.6 5.3 5.6 9.5 27.6 14.1 25.8 18.2 16.5 20.1 - 186 - Interestingly. there are at least two populations which deviate from this pattern: those of Finland and of Hokkaido (Japan). In Finland, unusual age distribution of IDDM has been demonstrated in data pooled over a period of 10-15 years which may reflect a changing inci- dence by year of birth. Such a "cohort effect" can par- tially be responsible for a secular increase in age- adjusted incidence of IDDM in Finland. On the other hand, the age distribution of IDDM in Japan shows substantial sex differences that have not been observed in any Caucasian population. Time trends The sex- and age-specific incidence rates in Tables 3a & 3b are presented by five-year calendar periods, for reg- istries that have been active for at least 10 years. The incidence rates have been fairly stable since 1966 in Allegheny County and since 1971 in Montreal. Since 1971, however, in both sexes and all three age groups 0-14 years, a marked increase in incidence has been observed in Finland and Poland. For the last 10 years, the rates have also been increasing in Prince Edward Island and among females, but not males, in Hokkaido. The data accumulated by DERI encompass most of the information available regarding time trends in IDDM since 1965, thus making it possible to study this issue in more detail. Analyses focused on disentanglement of the possible cohort and time-period effects are currently in progress. Prevalence of /DOM Whilst registration of incident cases is the optimal tool in descriptive epidemiology of chronic diseases, such a system may not always be feasible for financial. logistic and even ethical reasons. It may be easier to commence IDDM research with an examination of cross-sectional data on the prevalence of the disease. Comparisons based upon prevalence data may be subject to consid- erable bias. since prevalence is determined not only by disease incidence, but also by case survival, which may vary markedly in populations. This argument has often been advanced in the context of the apparently very low prevalence of IDDM in developing countries. Notwith- standing, there are some parts of the world where, in the absence of longitudinally-collected information, preva- lence rates permit interpretation of IDDM frequency. Sel- ected estimates of IDDM prevalence in different popu- lations are compared in Table 4. The international pattern of prevalence was concordant with that shown for the incidence (Table 2). The preva- lence rates in Finland showed a marked increase be- tween 1969 and 1984, similar to that demonstrated in incidence (Tables 3a & 3b). Discussion Table 2 presents information from the majority of the existing IDDM incidence registries. The emerging re- gional pattern clearly reflects the degree of local interest, which is usually related to the frequency of disease, and the availability of research resources. There are no inci- dence data available for Africa and South America. Very few registries are active in Asia. Southern and eastern parts of Europe are also underrepresented. The body of evidence suggests that in those areas IDDM is infrequent or rare. However it should be noted that about 90% of the world's population lack representative population- based studies. Thus it is not unlikely that a substantial number of IDDM patients live in the areas not studied epidemiologically. Ascertainment of all incident cases in a well-defined population during a defined period of time makes it possible to: • provide reliable and standardized estimates of the risk of disease by area, ethnicity. sex, age groups, calendar time and birth cohorts and other strata, for intra- and inter-population comparisons; • conduct analytical studies related to the etiology and natural history of IDDM on representative samples from the target population, avoiding selection biases which often seriously flaw analyses of hospital or clinic series; • properly address intervention studies, which investi- gate whether the controlled alteration of an exposure of interest (causative or protective) has any effect on development of IDDM or on the clinical course of the disease; • estimate the actual direct and indirect costs of IDDM for an individual and society. as well as the needs of the society in terms of specific treatment, education and, possibly, prevention. There has been a growing interest in the investigation of time-dependent changes in IDDM incidence. Perhaps the strongest evidence of an epidemic pattern in IDDM comes from data which have recently been reported from Nordic countries and Poland (18, 19, 30, 35). In a paper published in 1982 (18), researchers from Finland provided the first direct evidence of a marked increase in IDDM incidence which could not be ascribed to changing ascertainment. Incidence in Finnish children aged 0-14 years was shown to be fairly stable from 1970 to 1977- 1978, when it suddenly increased by approximately 5 per 100 OOO in both sexes. The increase was most pro- nounced in the age group 0-4 years. Interestingly, a sim- ilar spike in incidence in 1978 was later reported from Scotland (36). Early in 1984, a registry in the midwestern part of Poland reported an unexplained epidemic of IDDM in children which began in the summer of 1982 (35). Although. compared to a very low average risk in 1970-1981, the age-adjusted incidence rates of IDDM almost doubled in that area during 1982-1985, the absolute change (3-4 per 100 000) was similar to that demonstrated in 1978 in Finland and Scotland. In 1985, the national registries of IDDM children in both Sweden (19) and Finland (30) reported epidemics that were similar in time and magnitude. The most dramatic increase was observed in the age group 5-9 years. Interestingly. preliminary data from Auckland (New Zealand) (3 7) and Allegheny County (Pennsylvania) (M. Rewers et al., unpublished data, 1988). suggest that during 1982-1985 IDDM incidence rose also in these areas, distant geographically from Europe. This pattern of temporal variation suggests a pandemic of IDDM. resembling an infectious disease. Secular trends in IDDM are difficult to study at present because none of the IDDM registries have been using consistent case definitions and registration practices for more than 15-20 years. Moreover, only a handful of reg- istries have been active for 15 years or more. There are some indications that incidence may have been increas- ing since the 1920s in Norway (17) and the United States of America (38), and since the 1950s in Finland (18) and England (39). However, it remains uncertain how much of the suggested increase is due entirely to improved diagnosis and better ascertainment. On the contrary, no systematic trend has been shown in Allegheny Coun- ty (4), Rochester (1), Montreal (40) and in the Departe- ment du Rhane (France) (41), during the last 20 years. In the German Democratic Republic, there was a minimal increase in the rates of insulin-treated diabetes under age 20 between 1960 and 1986 (D. Michaelis, unpublished data, 1986). Rapp. trimest. statist. sanit. mond., 41 (1988) - 187 - TABLE 4. PREVALENCE OF CHILDHOOD INSULIN-DEPENDENT DIABETES MELLITUS (PER 100 OOO POPULATION) IN SELECTED AREAS TABLEAU 4. PREVALENCE DU DIABhE SUCRE INSULINO-DEPENDANT CHEZ L'ENFANT (POUR 100 OOO HABITANTS) DANS DES REGIONS CHOISIES REGION - R~GION Country and area - Pays et zone (Reference - Reference) AMERICAS - AMERIQUES Cuba" .. Dominican Republic - Republique dominicaine Santo Domingo (22) . . . . . . United States - Etats-Unis Age group (years) Groupe d'Age (annees) Study period Periode d'etude 0·14 1979-80 0-24 1980 Estimate of ascertain- ment Pourcentage de completude national sample (23) - echantillon national (23) 0-14 1978 ? Kentucky (24) . 0-17 1978-79 ,,,,100% ASIA-ASIE People· s Republic of China - Republi· que populaire de Chine Shanghai (sample - echantillon) (25) 0-19 Japan - Japon whole country (26) - ensemble du pays (26) Shiga (27) EUROPE Czechoslovakia (28) - Tchecoslova· 0-18 0-18 quie (28) . . . . . . . . . 0-15 Denmark - Danemark Funen County (29) - Comte de Funen (29) . . . . . . . . . . . . . . . 0-14 Finland (18, 30) - Finlande (18, 30) . . 0-14 0-14 0-14 France (28) . . . 0-14 Iceland - lslande Reykjavik (31) . Italy - ltalie Venice (28) - Venise (28) Spain - Espagne Catalonia (28) - Catalogne (28) Sweden - Suede Vasterbotten (32) ...... . Switzerland (28) - Suisse (28) United Kingdom - Royaume-Uni 0-14 0-13 0-14 0·14 0-19 1980 1978 1984 1975 1973 1969 1979 1984 1975 1979 1975 1975 1977 1975 98% ? 99% 99% ,,,,100% Leicester (33) . . . 0-14 1984-85 ""100% Asian - asiatique . . . . . . . white - blanche . . . . . . . . Germany, Fed. Rep. of (28) - Alie· magne, Rep. fed. d' (28) . . . 0-15 1975 Yugoslavia - Yougoslavie Slovenia (28) - Slovenie (28) . OCEANIA - OCEANIE Australia - Australie Tasmania (34) - Tasmanie (34) 0-14 1974 0-14 1984 ' 0. Diaz Diaz - unpublished manuscript/manuscrit non publie, 1985. 94% M 14 20 158 9 95 197 223 58 114 60 (Cases) (Cas) (265) ( 16) ( 49) (927) (976) ( 6) ( 26) ( 33) PREVALENCE - PR~V ALENCE F 16 19 142 11 70 184 199 51 83 55 (Cases) (Cas) (275) 18) ( 34) (831) (835) 5) 18) ( 29) Total 15 19 150 208 5 7 10 39 83 147 191 211 24 141 26 25 300 50 54 99 41 22 57 (Cases) (Cas) ( 540) ( 157) 62) 7) (2219) ( 34) ( 83) (1 633) (1 758) (1 811) (3012) 11) 44) 62) It should be stressed that evidence of either epidemics or relatively rapid secular increase. or of both, strongly favours the existence of environmental determinants of IDDM. Etiological leads The understanding of the reasons for the international and temporal differences in IDDM risk is likely to lead to the solution of the genetic and environmental puzzle of IDDM etiology. Some elements of this puzzle have recently become available as a result of the development and standardization of population-based incidence reg- istries of the disease. Unbiased estimates of the effects of geographical location. race. ethnicity, sex, age, time period and birth cohort on IDDM risk in divergent sam- ples from the world's population are now at our disposal. This allows investigators to propose and test integrated models for determinants of IDDM risk. The most con- stant feature of IDDM incidence in different populations is its age distribution. However, the magnitude of this Wld hlth statist. quan .• 41 (1988) - 188 - reproducible multiplicative effect of unknown exposure differs among populations. Therefore, it is concluded that either the levels of exposure are not the same or that there are genetic reasons for the discrepancies in re- sponse to similar exposure in various ethnic groups. The representative series of IDDM patients, identified through the population-based registries, should be used to test the strength of the association of genetic markers for IDDM, and eventually "IDDM genes", with the occur- rence of the disease in populations. The time trends in IDDM incidence, if decoded, may be pivotal for the identification of environmental exposures causing IDDM. If the changes represent a real increase in exposure rather than improvement in diagnosis and ascertainment, the correlation of the trends with the occurrence of hypothesized etiological factors should be tested. This may be initiated by means of ecological analyses (6, 42), but it must be confirmed in analytical studies operating on the level of individuals. This is crucial to record the temporal changes in divergent populations, because it may be easier to track down and measure the causative factors in a population where the incidence is currently changing. A cohort-related in- crease in incidence leads to very different etiological interpretations and predictions of future rates than a cross-sectional year-to-year shift in incidence. To under- stand the way in which IDDM risk is changing, it is neces- sary to disentangle the interdependent effects of age, cohort and time period on the observed rates. Such evaluation will point to birth cohorts or calendar years characterized by unusual risk of developing IDDM, which may assist in more efficient assessment of the causative exposure. A preventable disease Evidence has accumulated that environmental factors may be decisive in the development of IDDM (43). These factors may be especially important at the earliest stages of ontogeny, because the incidence peaks out during puberty and changes with time most rapidly in children aged 0-9 years (18, 35). Although much remains to be learned about the specific environmental exposures af- fecting the risk of IDDM, intervention on this level, as opposed to the genetic component of diabetogenesis, should be the primary model for the prevention of IDDM. SUMMARY The results of this international collaboration emphasize the importance of population-based incidence registries which, similarly to cancer research, became an indis- pensable tool in etiological investigation and health- delivery planning in the area of insulin-dependent dia- betes mellitus (IDDM). Future collaboration within the DERI project will help to monitor the geographical and temporal variability of IDDM incidence. This collabora- tive effort may provide a frame for more detailed inter- national studies of etiology and natural history of the disease, as well as for evaluation of the costs of IDDM and future prevention programmes. RESUME Tendances observees dans la prevalence et l"incidence du diabete: diabete sucre insulino-dependant de l'enfant Les resultats de la presente collaboration internationale soulignent !'importance des donnees d'incidence por- tant sur I' ensemble de la population, lesquelles sont devenues, comme pour la recherche sur le cancer, un instrument indispensable pour mener des etudes etiolo- giques et elaborer des plans de distribution des soins pour le diabete sucre insulino-dependant. La future col- laboration au sein du projet DERI (Diabetes Epidemiology Research International Study Group - Groupe interna- tional de recherche epidemiologique sur le diabete) per- mettra de mieux surveiller la variabilite dans I' espace et dans le temps de !'incidence de cette maladie. Cet effort de collaboration offrira le cadre d'une etude internatio- nale plus detaillee de l'etiologie et de l'histoire naturelle de cette maladie, ainsi qu'une evaluation des coGts des programmes de lutte contre le diabete sucre insulino- dependant des futurs programmes de prevention. REFERENCES - REFERENCES 1 . MEL TON. J. L. ET AL. Incidence of diabetes mellitus by clinical type. Diabetes care, 6 (1): 75-86 (1983). 2. LAAKSO. M. & PYORALA. K. Age of onset and type of diabetes. Diabetes care, 8 (2): 114-117 (1985). 3. GORTMAKER, s. L. & SAPPENFIELD. w. Chronic child- hood disorders: prevalence and impact. Pediatric clinics of Nonh America, 31 (1): 3-18 (1984). 4. LAPORTE. R. E. ET AL. Differences between blacks and whites in the epidemiology of insulin-dependent dia- betes mellitus in Allegheny County, Pennsylvania. American journal of epidemiology, 123 (4): 592- 603 (1986). 5. WHO Technical Report Series No. 727, 1985 (Dia- betes mellitus: report of a WHO Study Group). OMS Serie de Rapports techniques N° 727, 1985 (Le diabete suer~: rapport d'un Groupe d'etude de l'OMS). 6. LAPORTE, R. E. ET AL. Geographic differences in the risk of insulin-dependent diabetes mellitus: the importance of registries. Diabetes care, 8 (1): 101- 107 (1985). 7. GREEN, A. ET AL. Workshop on diabetes registries: the role of IDDM registries in diabetes research care. In: Serrano-Rios, M. & Lefebvre, P. J. (eds), Dia- betes 1985. Amsterdam, Elsevier Science Publish- er, 1986. 8. CHRISTAU. B. & M0LBAK, A. G. Further epidemiologi- cal evidence of a higher incidence level for the insu- lin-dependent diabetes mellitus in the older age groups. In: Advance abstracts of papers of the 19th Annual Meeting of the Scandinavian Society for the Study of Diabetes, Trondheim, 14-16 June 1984. Acta endocrinologica, 95 (Supplement 263) : 18 (1984). Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 189 - 9. OSTMAN, J. ET AL. Epidemiology of diabetes mellitus in Sweden. Acta medica scandinavica, 220: 437- 445 (1986). 10. CHRIST AU, B. ET AL. Incidence of childhood insulin- dependent diabetes mellitus in Denmark, Finland, Norway and Sweden. A workshop report. Acta endocrinologica, 98 (Supplement 245): 68-80 (1981). 11. ALLEN, C. ET AL. Incidence and differences in urban- rural seasonal variation of type 1 (insulin-dependent) diabetes in Wisconsin. Diabetologia, 29: 629-633 (1986). 12. LARON, Z. ET AL. The incidence of insulin-dependent diabetes mellitus in Israeli children and adolescents 0-20 years of age: a retrospective study, 1975- 1980. Diabetes care, 8 (1): 24-28 (1985). 13. TAHA, T. H. ET AL. Diabetes mellitus in Kuwait: inci- dence in the first 29 years of life. Diabetologia, 25: 306-308 (1983). 14. CROSSLEY,J. R. & UPSDELL, M. The incidence of juve- nile diabetes mellitus in New Zealand. Diabetologia, 18: 29-34 (1980). 15. Vu, M. T. World population projections 1985. Baltimore, Johns Hopkins University Press, 1985. (p. 7). 16. HAENSZEL, W. ET AL. Lung-cancer mortality as related to residence and smoking histories. Journal of the National Cancer Institute, 28: 947-1001 (1962). 17. JONER, G. & S0v1K, 0. Incidence, age at onset and seasonal variation of diabetes mellitus in Norwegian children. Acta paediatrica scandinavica, 70: 329- 335 (1981). 18. REUNANEN, A. ET AL. Prevalence and ten-year (1970- 1979) incidence of insulin-dependent diabetes mel- litus in children and adolescents in Finland. Acta paediatrica scandinavica, 71: 893-899 (1982). 19. DAHLQUIST, G. ET AL. The epidemiology of diabetes in Swedish children 0-14 years - a six-year prospec- tive study. Diabetologia, 28: 802-808 (1985). 20. SIEMIA TYCKI, J. ET AL. Incidence of insulin-dependent (type 1) diabetes by ethnic group and by social class in Montreal, and comparisons with comparable eth- nic groups living elsewhere. Diabetes, 31: 1096- 1102 (1988). 21. REWERS, M. Age at onset of type 1 diabetes in popu- lations showing extremely different attack rates [ ab- stract]. American journal of epidemiology, 126: 771-772 (1987). 22. HAZOURY, B. J. ET AL. [Epidemiology of juvenile dia- betes (type 1) in Santo Domingo, R.D]. lnden, 6: 33-37 (1981). (In Spanish). HAZOURY, B.J. ET AL. [Epidemiologie du diabete juve- nile (type 1) a Santo Domingo, R.D]. lnden, 6: 33-37 (1981). (En espagnol). 23. THE CARTER CENTER OF EMORY UNIVERSITY. Closing the gap: the problem of diabetes mellitus in the United States. Diabetes care, 8 (4): 391-406 (1985). 24. LEICHTER, S. B. ET AL. Diabetes in Kentucky. Diabetes care, 5 (2): 126-134 (1982). 25. YAN C. ET AL. The incidence of juvenile diabetes in Peking and preliminary observations of beta-cell function in normal and diabetic children. In: Proceedings of the International Symposium on Clinico-Genetic Genesis of Diabetes Mellitus, Kobe, 11-12 February 1982. Amsterdam, Excerpta Medica, 1982. (pp. 58-65), 26. KITAGAWA, T. ET AL. The epidemiology of childhood diabetes mellitus in Japan. In: Proceedings of the International Symposium on Clinico-Genetic Gene- sis of Diabetes Mellitus, Kobe, 11-12 February 1982. Amsterdam, Excerpta Medica, 1982. (pp. 51-57). Wld hlrh srarisr. quan .. 41 ( 1988) 27. KIKKAWA, R. ET AL. Epidemiology of insulin-depend- ent diabetes mellitus in a population with high mor- tality rate. In: Serrano-Rios, M. & Lefebvre, P. J. (eds), Diabetes 1985. Amsterdam, Elsevier Science Publisher, 1986. (pp. 425-429). 28. LESTRADET, H. & BESSE, J. Prevalence et incidence du diabete juvenile insulino-dependant en France. Diabete et metabolisme, 3: 229-234 (1977). 29. GREEN, A. ET AL. Epidemiological studies of diabetes mellitus in Denmark - II. A prevalence study based on insulin prescriptions. Diabetologia, 20: 468-4 70 (1981). 30. REUNANEN, A. & AKERBLOM, H. A national drug reg- ister as a data source in the study of the epidemi- ology of IDDM in children in Finland. In: Serrano- Rios, M. & Lefebvre, P. J. (eds), Diabetes 1985. Amsterdam., Elsevier Science Publisher, 1986. (pp. 408-412). 31. HEGLASON, T. & JONASSON, M. R. Evidence for a food additive as a cause of ketosis-prone diabetes. The Lancet, ii: 716-720 (1981). 32. HAGGLOF, B. ET AL. Incidence of insulin-dependent diabetes mellitus among children in a North- Swedish population 1938-1977. Human heredity, 32: 408-417 (1982). 33. SAMANTA, A. ET AL. Prevalence of insulin-dependent diabetes mellitus in Asian children. Diabetic medi- cine, 4: 65-67 (1986). 34. KING, H. ET AL. Type 1 (insulin-dependent) diabetes in Tasmania: prevalence and apparent regional differ- ences. Diabetologia, 31: 93-97 (1988). 35. REWERS, M. ET AL. Apparent epidemic of insulin- dependent diabetes mellitus in Midwestern Poland. Diabetes, 36: 106-113 (1987). 36. GRISSO, J. A. ET AL. Continuing high incidence of dia- betes mellitus in Scottish children. Diabetologia, 28: 183 (1985). 37. ELLIOTT, R. B. & PILCHER, C. c. Childhood diabetes in the Auckland area. New Zealand medical journal, 87: 922-923 (1985). 38. KROLE:"fSKI, A. S. ET AL. Epidemiologic approach to the et1ology of type 1 diabetes mellitus and its com- plications. New England journal of medicine, 317 (22): 1390-1398 (1987). 39. HEARNSHAW, J. R. Childhood and after-a review of childhood diabetes in an English community, 1930- 1985. In: Serrano-Rios, M. & Lefebvre, P. J. (eds), Diabetes 1985. Amsterdam, Elsevier Science Pub- lisher, 1986. (pp. 31-42). 40. SIEMIATYCKI, J. ET AL. The distribution of type 1 (insu- lin-dependent) diabetes mellitus by age, sex, secu- lar trend, seasonality, time clusters, and space-time clusters: evidence from Montreal, 1971-1983. American journal of epidemiology, 124 (4) : 545- 560 (1986). 41. HOURS, M. ET AL. Diabete insulino-dependant juve- nile. Etude descriptive dans le departement du Rhone. Revue d'epidemiologie et de sante publique, 32: 107-112 (1984). 42. DIABETES EPIDEMIOLOGY RESEARCH INTERNATIONAL GROUP. Geographic patterns of childhood insulin- dependent diabetes mellitus. Diabetes, 37: 1113- 1119 (1988). 43. DIABETES EPIDEMIOLOGY RESEARCH INTERNATIONAL. Pre- venting insulin-dependent diabetes mellitus: the en- vironmental challenge. British medical journal, 295: 479-481 (1987). - 190 - TRENDS IN THE PREVALENCE AND INCIDENCE OF DIABETES: NON-INSULIN-DEPENDENT DIABETES MELLITUS Hilary King a & Paul Zimmet b In contrast to insulin-dependent diabetes (IDDM), non- insulin-dependent diabetes (NIDDM) generally has its onset in later life. The two forms of diabetes are now seen as distinct disorders, both etiologically and patho- logically, and this distinction has been of considerable importance in understanding their respective epidemio- logies. Whilst IDDM is rare in developing countries, NIDDM reaches its highest prevalence in non-European commu- nities. Genetic predisposition to NIDDM appears to vary between populations, and in susceptible subjects certain potentially modifiable precipitants of the disease are strongly suspected. Of these, the three most important appear to be obesity, low levels of habitual physical activity, and aspects of the modern diet. The close asso- ciation between these factors and the imprecision of their measurement have hindered the exploration of their influence in different populations. Although there has been considerable research activity in the field of the epidemiology of NIDDM in the present decade, there has been a regional imbalance in this regard, and our knowledge of the subject remains very inadequate for large areas of the world. Epidemiological considerations A serious constraint upon the interpretation of reports of the frequency of diabetes is that criteria for the diagnosis of the disease have varied widely in the past. Many reports failed to record their criteria clearly, and many also failed to distinguish between NIDDM and IDDM. For diabetes epidemiology, therefore, one of the major achievements of the present decade has been the pro- vision of clear and unambiguous guidelines for the clas- sification and diagnosis of the disease ( 1 ). Since it is well known that considerable discrepancies can occur in esti- mates of disease frequency when study methods and diagnostic criteria vary, this review will concentrate on some of the recent studies which have attempted to use the criteria recommended by WHO ( 1 ). For convenience, migrant communities, including the large non-indigenous populations in North America, Australia and New Zealand, will be considered together with other popu- lations in their region of origin. Most of the evidence regarding the frequency of NIDDM in populations comes from surveys carried out at a single point in time. This approach may be used to determine • Consultant, Division of Noncommunicable Diseases, World Health Organization, Geneva. b Director, WHO Collaborating Centre for the Epidemiology of Dia· betes Mellitus, Lions International Diabetes Institute, Caulfield South. Victoria. Australia. c Prevalence of IDDM appears to be so low in most non-industrialized societies that prevalence of diabetes may be taken as an approximation to that of NIDDM in such situations. NIDDM prevalence (i.e. the proportion of the population suffering from the disease at that point in time). The incidence of NIDDM (i.e. the number of new cases occur- ring in the population in a specified period of time) can only be calculated by monitoring the population contin- uously, or by repeated cross-sectional surveys. The resources required for ·such studies are often considera- ble. Furthermore, it is well known that a substantial pro- portion of subjects with NIDDM remain undetected in the community, and incidence estimates based upon routine data sources are much less reliable than they may be for IDDM. For these reasons, comparatively few estimates of inci- dence of NIDDM have been reported. In this review we will therefore consider prevalence estimates for NIDDM first, before discussing the few incidence estimates that are available. Unfortunately, prevalence estimates also present problems in interpretation, even when standard- ized study methods have been used, since prevalence depends on both incidence and survival, and the latter can vary between populations for many reasons. Since diabetes becomes more prevalent with advancing age in almost all communities, differences in age struc- ture between populations can also lead to misleading comparisons, unless these differences are allowed for statistically. Although this has been done in some cases (in a series of standardized surveys in the various com- munities of the Western Pacific, for example), world- standardized rates are not yet available for NIDDM, and most estimates reported here are crude figures. To date, few reports of incidence or prevalence of NIDDM have included confidence intervals or other esti- mates of precision. This creates further difficulties in the interpretation of population comparisons. It is important to be aware of all these constraints when reviewing global patterns of a disease such as NIDDM. Prevalence of NIDDM Some recent estimates of the prevalence of NIDDM, c using the WHO criteria, are summarized in Table 1. Africa Population-based reports of diabetes in Africa are un- common, though a few have appeared recently. Ahren & Corrigan (2) determined the prevalence of dia- betes according to WHO criteria in the north-western part of the United Republic of Tanzania. Prevalence in subjects over the age of 20 was 1.6%. Three separate communities were included in the study, two of which were in rural locations. Interestingly, prevalence was 2.5% in the rural-dwelling Haya tribe, as compared with 0.5% in the rural Sukuma. Prevalence in the urban area of Rapp. trimest. statist. sanit. mond., 41 (1988) - 191 - TABLE 1. SOME RECENT ESTIMATES OF THE PREVALENCE (PER CENT POPULATION) OF NON-INSULIN-DEPENDENT DIABETES (NIDDM) IN VARIOUS POPULATIONS USING CRITERIA RECOMMENDED BY WHO• TABLEAU 1. ESTIMATIONS RECENTES DE LA PREVALENCE (POURCENTAGE DE LA POPULATION) DU DIABETE SUCRE NON INSULINO-DEPENDANT (DSNID) DANS DIFFERENTES POPULATIONS, EN APPLIQUANT LES CRITERES RECOMMANDES PAR L·oMs• Region of origin/population Region d'origine/population Africa - Afrique Bantu - bantoue mixed (rural) - differentes ethnies (rurale) . . . . . mixed (rural) - differentes ethnies (rurale) black - noire . . . . . . Americas - Ameriques Pima .......... . Mapuche ........ . Country - Pays United Rep. of Tanzania - Republique-Unie de Tanzanie Mali Togo United States - Etats-Unis United States - Etats-Unis Chile - Chili South-East Asia - Asie du Sud-Est Indian - indienne rural - rurale . . . . urban - urbaine . . . Indian (urban) - indienne (ur- baine) Indian - indienne Malay - malaise Chinese - chinoise Indonesian (urban) - lndonesie (urbaine) .......... . Europe rural - rurale white - blanche white - blanche Fiji - Fidji South Africa - Afrique du Sud Singapore - Singapour Singapore - Singapour Singapore - Singapour Indonesia - lndonesie Italy - ltalie United States - Etats-Unis Australia - Australie Eastern Mediterranean - Mediterranee orientale Arab - arabe . . Tunisia - Tunisie rural - rurale urban - urbaine Western Pacific - Pacifique occidental Micronesian - micronesienne Micronesian - micronesienne rural - rurale . . . . . . urban - urbaine Polynesian - polynesienne Melanesian (AN)c - melane- sienne (AN) c . . . . . . . . rural - rurale . . . . . . . . urban - urbaine . . . . . . . Melanesian (NAN) d - melane- sienne (NAN) d . . . . . . . . Melanesian (NAN) - melane- sienne (NAN) rural - rurale urban - urbaine Aboriginal (urban) - aborigene (urbaine) ..... . • Reference (1) - Reference (I). Nauru Kiribati Rarotonga Niue Wallis Island - Wallis Fiji - Fidji Papua New Guinea highlands - Papouasie-Nouvelle-Guinee, montagnes Solomon Islands - lies Salomon Australia - Australie b Note discrepancies in age ranges - Observer les difMrences de tranches d'lge. c AN: Austronesian ancestry - d'ascendance austronesienne. d NAN: non-Austronesian ancestry - d'ascendance non austronltsienne. Mwanza was 1.9%. Whilst the authors considered that these differences had implications for the planning of national health services, it appears from the report (2) that the differences between the three groups were not in fact statistically significant after allowing for differ- ences in their age/sex distribution. This emphasizes the Wld hlth statist. quan .. 41 ( 1988) Reference - Reference Ahren & Corrigan (2) Fisch et al. (3) Teuscher et al. (4) Harris et al. (5) Knowler et al. (7) Larenas et al. (9) Zimmet et al. (15) Omar et al. (16) Thai et al. (19) ibid. ibid. Waspadji et al. (20) Verrillo et al. (12) Harris et al. (5) Glatthaar et al. (14) Papoz et al. (11) Zimmet et al. (24) King et al. (25) King et al. (26) ibid. Taylor et al. (2 7) Zimmet et al. (15) King et al. (28) Eason et al. (29) Cameron et al. (30) Age range 0 Tranche d'Age 0 (years/ans) ~ 20 ~ 15 all ages tous ages 20-74 ~ 20 ~ 20 ~ 20 ~ 15 ~ 18 ~ 18 ~ 18 ~ 15 ~ 18 20-74 ~ 25 ~ 20 ~ 20 ~ 20 ~ 20 ~ 20 ~ 20 ~ 20 ~ 20 ~ 18 ~ 20 M (%) 1.3 0.8 0.0 8.6 32.6 0.4 12.7 14.1 7.6 12.5 9.1 4.3 1.8 6.6 5.5 5.1 2.3 4.6 24.6 3.6 8.1 5.5 5.3 1.4 1.7 4.8 0.0 0.0 0.0 16.7 F (%) 1.8 1.0 0.0 11.0 37.2 1.4 12.9 12.3 13.5 4.8 6.1 3.6 1.5 6.8 7.3 3.7 0.6 3.5 23.9 3.6 7.4 8.0 9.1 3.5 1.7 8.2 0.0 1.4 1.5 14.6 need for careful evaluation of apparent differences in rates of disease. A further constraint in this study, which the authors acknowledged, was that fasting blood- glucose concentration was used as an initial screening test for glucose intolerance. This is known to be a rela- tively insensitive measure, as compared with the blood- - 192 - glucose concentration after an oral glucose challenge, and the prevalence of diabetes could therefore have been underestimated. Another study which used the WHO criteria, but was based entirely upon fasting blood-glucose estimation, estimated prevalence of diabetes as 1 % in rural Mali (3). A further report from Western Africa, using WHO cri- teria and random blood-glucose estimation, failed to identify any diabetic subjects among 517 survey respondents in rural Togo (4). However, diabetes was known at the local hospital. These three studies suggest that the prevalence of NIDDM is low in rural Africans at the present time. Although the difficulties attending field surveys in such areas should not be forgotten, these reports also illus- trate some persisting discrepancies in study methods. A report based upon the National Health and Nutrition Examination Survey (NHANES 2) suggests that NIDDM is more prevalent in black than in white North Americans in the United States, with approximately 10% of the former suffering from the disease (5). Thus, it may be that Afri- can genes carry greater underlying susceptibility to NIDDM than do Caucasian genes, and there may be a potential for a rise in the prevalence of NIDDM in Africa, as nations become more industrialized. There was the opposite suggestion, however, from the Mali data (3). In that survey, negroid ethnic groups appeared to be less affected than Caucasian or part-Caucasian communities. This raises the possibility that Caucasian genetic admix- ture might, in part, be responsible for the increased sus- ceptibility of blacks in the United States. A clinic-based report from Soweto (6) suggested a pre- valence of known diabetes of only 0. 1 %. It also found approximately half of the diabetic subjects to be treated with insulin. Taken together, these two findings may suggest considerable under-ascertainment of milder cases of NIDDM in South African blacks. Thus, the real status of NIDDM in the public health of Africa is far from clear. Further population surveys, par- ticularly of urban communities and incorporating the recommended 75 g oral glucose challenge (1) could yield much useful information. The Americas There is abundant evidence that indigenous North Americans are highly susceptible to NIDDM. The com- munity with the highest reported prevalence of NIDDM in the Americas is the Pima Indians of Arizona (7) in which approximately one-third of all adults are affected. It also appears that for indigenous North Americans, susceptibility to NIDDM is related to proportional Amer- indian genetic admixture, with subjects of mixed ethnic- ity having a risk of NIDDM intermediate between that of full-blood American Indians and Caucasians (8). There is some evidence to suggest that the prevalence of NIDDM is increasing in many North American Indian commu- nities and that the Aleuts (related to the Eskimos) who were formerly thought to be relatively resistant to NIDDM, may now be suffering from it also. The picture in South America is not so clear, and in many ways resembles the state of our knowledge of NIDDM in Africa. The prevalence of diabetes in the indigenous Mapuches of Chile was recently estimated as only 1 % (9). A prevalence of 5% has been reported from La Plata City (Argentina) (10) and this may have been an underestimate, since the survey was based upon a 50 g oral glucose challenge. Urban communities throughout Latin America would benefit from further investiga- tion. The Eastern Mediterranean Little information is available on NIDDM in this Region also. A study in Tunisia, using WHO criteria, has recently estimated age-standardized prevalence as a percentage of the population to be 4.6 in males and 3.5 in females in urban Tunis, as compared with 2.3 in males and 0.6 in females in a rural area (11). Since these figures could be conservative.due to the use of fasting blood-glucose estimation only. NIDDM would appear to be of potential public health concern in urban populations in this Region also. Europe, and populations of European origin In Europeans, NIDDM is a relatively common disorder, but it does not reach the frequency seen in high-risk communities in the developing world. There have been surprisingly few population studies of NIDDM using WHO criteria in Europe itself. A survey in rural Italy ( 12) estimated the prevalence of diabetes as 6.8% in females and 6.6% in males. A sur- vey in Finland, a country with the highest reported pre- valence of IDDM in the world, suggested that approxi- mately one-third of elderly male Finns may have NIDDM (13). Recent information from Malta (A. Schranz, personal communication) suggests a prevalence of 10% in the total adult population of the island. For whites in the United States, data on the prevalence of NIDDM were obtained nationwide during the NHANES 2 survey (5). This estimated the prevalence of diabetes in the 20-75 years age range as 6.6%, according to WHO criteria, which is very close to the Italian figure (12). Approximately one-half of subjects were undiagnosed prior to the survey. Prevalence rose from 2% in the 20- 44 years age range, to 18% in the 65-74 years age range. Thus, at the present time, almost one-fifth of white North Americans can expect to develop NIDDM if they live to the seventh decade of life. This somewhat alarming find- ing highlights the potential for an escalation in prevalence of NIDDM in European communities, as a result of the increasing longevity which most industrialized societies are experiencing at present. A somewhat lower estimate of the prevalence of NIDDM has been reported for white Australians (14). South-East Asia Present evidence suggests that there is a spectrum of underlying genetic susceptibility to NIDDM in Asian populations. Several surveys of migrants from the Indian subcontinent have suggested that Indians are the most susceptible. According to WHO criteria, prevalence has been reported as 12-14% in Indian migrants to Fiji (15). A high prevalence has also been reported in Indians living in South Africa (16) and Suriname (17). A number of population studies of diabetes have been reported from South-East Asia itself, but study methods have varied widely. These reports have been reviewed elsewhere (18). Rapp. trimest. statist. sanit. mond .. 41 (19881 - 193 - A recent study in Singapore (19) found prevalence to be lowest in Chinese, highest in Indians and intermediate in Malays. There was also a suggestion of an apparent secular increase in prevalence since a previous survey a decade earlier. A survey in urban Jakarta (Indonesia) (20) found a pre- valence of only 1.6%, slightly lower than the figure of 2. 7% reported for migrant Indonesians in Suriname (17). As already noted for Indians, it is not uncommon for migrant communities to show a higher prevalence of NIDDM than those they leave behind, since migration is often accompanied by socioeconomic advancement. As in the Singapore study, the conclusions of the major- ity of comparative studies in South-East Asia have been that Chinese have the lowest prevalence of diabetes in the Region, with other populations having rates interme- diate between the high rates of the Indians and the low rates of the Chinese. However, recent reports from Taiwan (21) and Hong Kong (22) have recorded a preva- lence of approximately 10% in urban Chinese over the age of 60 years, suggesting that Chinese may be more susceptible than was formerly supposed. The Western Pacific There have been a number of studies of diabetes in the Western Pacific using the WHO criteria, and our knowl- edge of the prevalence of NIDDM in this Region is becom- ing relatively complete. This large data base will be of great value in due course, for monitoring temporal trends and evaluating the effects of interventions aimed at pri- mary and secondary prevention of the disease. Age- standardized prevalence according to WHO criteria in adults in 17 communities from 10 Pacific nations have been published elsewhere (23). The highest prevalence of NIDDM in the Western Pacific has been reported from the Micronesian population of Nauru (24) where approximately one-quarter of all adults are affected. Other Micronesian populations are also very susceptible. In neighbouring Kiribati, approximately 8% of urban residents of both sexes were found to have NIDDM, as compared with 4% of residents of a more traditional island (25). When standardized for age, the risk for urban dwellers was threefold that of the rural community. For Polynesia, a recent report estimated prevalence as approximately 5% in males and 8% in females in both Rarotonga (Cook Islands) and Niue (26). Taylor et al. (27) have demonstrated a low prevalence among traditional- living Polynesians on Wallis Island. There is still some uncertainty as to the true susceptibil- ity of Melanesians to NIDDM. Though the majority (of Austronesian ancestry) may be as susceptible as Poly- nesians (15), there is some evidence that the few Mela- nesian communities that lack Austronesian genetic an- cestry (nonAustronesians) may be relatively resistant to NIDDM (28, 29). NIDDM is now common in urbanized Australian Abori- gines (30). Incidence of NIDDM There have been very few population-based estimates of NIDDM incidence, due to the practical difficulties of ascertaining occurrence of NIDDM in populations, when a substantial proportion of subjects meeting the WHO criteria for the disease remain asymptomatic. For the Wld hlth statist. quart., 41 (1988) United States, an estimate of physician-diagnosed dia- betes-which may be expected to underestimate total incidence by as much as 50% (5)-gave an incidence of 117 per 100 OOO person-years for three communities in Minnesota (31 ). This figure concurs with a previous report from Rochester, Minnesota. Both the Pima Indians of Arizona and the Nauruans of Micronesia have been intensively studied with respect to NIDDM, and incidence estimates are available for each. For the Pimas (7) incidence was reported as 1.85 per 100 person-years at all ages, and for the Nauruans (32) 1 . 6 per 100 person-years in subjects aged 20 years and older (note the thousand-fold difference in the denomi- nator, compared with the Minnesota estimate). From the data published (7) incidence in Pimas aged 25 and over could be calculated as 4.6 per 100 person-years. These high incidence estimates mirror the very high prevalence of NIDDM in these two unusual populations. Since prevalence is the product of average incidence and average duration of disease, and considering their re- spective incidence and prevalence rates, average survi- val with established NIDDM may be calculated as ap- proximately 15 years for the Nauruans, but only 8 years for the Pimas. The reason for the lower apparent life expectancy of Pima diabetics is not at all clear, and this should stimulate further comparisons between longitudi- nal studies of NIDDM in different populations. These may not only lead to further etiological insight, they may also provide greater understanding of important public health aspects of the disease. Impaired glucose tolerance The WHO classification of glucose intolerance ( 1) in- cludes a category that is intermediate between normal tolerance and diabetes mellitus, called impaired glucose tolerance (IGT). Subjects in this range, whilst not con- sidered to be suffering from diabetes, are known to be at substantially higher risk of developing the disease and its complications than are persons who have glucose toler- ance in the normal range. IGT has an unpredictable course, and is thought to repre- sent a heterogeneous group of subjects, some of whom may be in progress towards frank diabetes, some of whom may have a transient abnormality and be destined to return to normality, and some of whom may continue in a steady IGT state. Surveys which have used a 75 g oral glucose challenge and have estimated the two-hour blood-glucose value (but not those which have only studied the fasting, or random blood-glucose value) can assess the prevalence of IGT according to the WHO criteria. Several reports already discussed here with respect to NIDDM have also produced corresponding figures for IGT (Table 2). None of the three African studies mentioned earlier included estimates of IGT. However, for the black popu- lation of the United States (5) NHANES 2 data indicate a prevalence of IGT of 13%, i.e. slightly higher than that of NIDDM. From the same study, prevalence of IGT in the white population was estimated as 11 %, close to the figure for blacks, despite the whites' relatively lower prevalence of NIDDM. The surveys of rural Italians ( 12) and white Austral- ians (14) estimated prevalence of IGT as 6.4% and approximately 4% respectively. In the Western Pacific, the prevalence of IGT in Fiji Indians (15) and Nauruans (24)-approximately 10% - 194 - TABLE 2. SOME RECENT ESTIMATES OF THE PREVALENCE (PER CENT POPULATION) OF IMPAIRED GLUCOSE TOLERANCE (IGT) IN VARIOUS POPULATIONS USING CRITERIA RECOMMENDED BY WHO• TABLEAU 2. ESTIMATIONS RECENTES DE LA PREVALENCE (POURCENTAGE DE LA POPULATION) DE L'ABAISSEMENT DE LA TOLERANCE AU GLUCOSE (ATG) DANS DIFFERENTES POPULATIONS, EN APPLIQUANT LES CRITERES RECOMMANDES PAR L'OMS" Age rangeb Population Country - Pays Reference - R616rence Tranche M F d'Age 0 (%) (%) (years/ans) black - noire United States - Etats-Unis Harris et al. ( 5) 20-74 11.3 13.6 white - blanche United States - Etats-Unis Harris et al. ( 5) 20-74 10.2 11.1 rural - rurale .. Italy - ltalie Verrillo et al. ( 12) ~ 18 5.1 7.7 white - blanche Australia - Australie Glatthaar et al. ( 7 4) ~ 25 4.3 3.3 Indian - indienne Fiji - Fidji Zimmet et al. ( 15) ~ 20 rural - rurale 10.4 10.8 urban - urbaine 9.4 11.2 Micronesian - micronesienne Nauru Zimmet et al. (24) ~ 20 18.4 18.3 Micronesian - micronesienne Kiribati King et al. (25) ~ 20 rural - rurale ... . . . 12.5 14.3 urban - urbaine ..... 15.0 16.9 Polynesian - polynesienne .. Rarotonga King et al. (26) ~ 20 9.7 10.0 Polynesian - polynesienne Niue ibid. ~ 20 6.6 7.2 Polynesian - polynesienne .. Wallis Island - Wallis Taylor et al. (27) ~ 20 4.0 9.3 Melanesian (AN)C - melane- sienne (AN) c Fiji - Fidji Zimmet et al. ( 7 5) ~ 20 rural - rurale ...... 6.2 10.2 urban - urbaine .. . . . . . . 8.0 13.8 Melanesian (NAN)d - melane- Papua New Guinea highlands - sienne (NAN) d .. Papouasie-Nouvelle-Guinee, montagnes King et al. (28) ~ 20 3.5 1.2 Melanesian (NAN) - melane- Solomon Islands - lies Salo- sienne (NAN) . .... . . . man Eason et al. (29) ~ 18 rural - rurale ........ 0.2 0.7 urban - urbaine 0.0 0.0 Aboriginal. urban - aborigene. urbaine ... Australia - Australie Cameron et al. (30) ~ 20 0.7 4.2 'Reference ( 7) - R616rence ( 7). O Note discrepancies in age ranges - Observer les diff6rences dans les tranches d'Age. c AN: Austronesian ancestry - d'ascendance austron~sienne. d NAN: non-Austrones1an ancestry - d'ascendance non austronesienne. and 18% respectively-reflects the high prevalence of NIDDM in these two populations. Prevalence of IGT in several other Pacific populations of Micronesian, Polynesian and Melanesian ancestry (15, 25-30) varied widely. from almost total absence in the Solomon Islands (29) to 17% in urban females in Kiribati (25). IGT was present in the Papua New Guinea highland- ers, although there was an absence of NIDDM (28). Com- pared with the high prevalence of NIDDM, IGT was sur- prisingly uncommon in an urban Australian Aboriginal population (30). Thus, there is a wide variation in the prevalence of IGT in populations, which to some extent mirrors their preva- lence of NIDDM. However, this relationship is not entirely consistent, and the implications of the prevalence of IGT in the emergence of NIDDM in populations are intriguing, and not fully understood. SUMMARY The revision of the classification of diabetes mellitus, to differentiate clearly between insulin-dependent (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM). and the provision of unambiguous guidelines for diagno- sis (1) constitute important recent developments in dia- betes epidemiology. However. our knowledge even of the prevalence of NIDDM remains surprisingly incom- plete for many areas of the world. Whilst NIDDM may still be uncommon in rural Africa, prevalence has been reported as approximately 10% in blacks in the United States, indicating a need for more information regarding the prevalence of NIDDM in urban Africa. There is also little information with regard to urban communities in Latin America. The highest prevalence of NIDDM is found in certain indigenous North American and Western Pacific socie- ties. In extreme cases approximately one-third of the adult population now suffers from the disease. NIDDM is also common (prevalence approximately 5%) in Europe and in communities of European origin. Data from the United States suggest that approximately one- fifth of white North Americans can expect to develop NIDDM if they live to the seventh decade of life. Of populations of South-East Asian ethnicity, Indians appear to be the most susceptible. Indian migrants to Fiji, South Africa and South America all demonstrate preva- lence of NIDDM of 10% or more. Whilst it was formerly believed that Chinese were rarely affected by NIDDM, recent reports cast some doubt on this. Prevalence of NIDDM in the Western Pacific varies widely. However, with the possible exception of certain Melanesian populations, prevalence is high in all corn- Rapp. trimest. statist. sanit. mond., 41 (1988) - 195 - munities which have abandoned their traditional life- style. Very few estimates of the incidence of NIDDM have been published, largely because of the practical difficulties attending the estimation of incidence in this often asymptomatic disease. An intermediate category of impaired glucose tolerance (IGT) has been recommended recently, to define sub- jects whose glucose tolerance, though outside the nor- mal range, is not thought to be sufficiently deranged to warrant their being classified as diabetic. IGT appears to have an unpredictable course, though the risk of subse- quent diabetes is substantially higher than for subjects with normal glucose tolerance. Reports indicate that the prevalence of IGT in different populations varies as widely as does that of NIDDM. RESUME Tendances observees dans la prevalence et l'incidence du diabete: diabete sucre non insulino-dependant La revision de la classification du diabete sucre afin d'etablir clairement la difference entre diabete sucre insulino-dependant (DSID) et diabete sucre non insulino- dependant (DSNID). et la formulation de directives sans ambigurte pour le diagnostic (1) sont des faits notables recemment survenus dans l'epidemiologie du diabete. Toutefois, nos connaissances sur le DSNID dans de nombreuses parties du monde, s'agissant meme de sa prevalence, restent etonnament incompletes. Le DSNID est peut-etre encore rare dans les regions rurales de I' Afrique, mais sa prevalence est evaluee a environ 10% chez les noirs des Etats-Unis d' Amerique, ce qui indique qu'il faudrait reunir davantage de donnees sur sa prevalence dans les zones urbaines de I' Afrique. De meme, on possede peu de renseignements sur le DSNID dans les communautes urbaines en Amerique latine. C' est dans certaines societes indigenes d' Amerique du Nord et du Pacifique occidental que I' on enregistre la plus forte prevalence du DSNID. Dans les cas extremes, envi- ron un tiers de la population adulte est aujourd'hui atteinte de cette maladie. Le DSNID est egalement courant (prevalence d'environ 5%) en Europe et dans les communautes d'origine euro- peenne. Selan des donnees concernant les Etats-Unis, environ un cinquieme des Americains de race blanche peuvent s · attend re a developper un DSNID a partir de 70 ans. Parmi les populations de I' Asie du Sud-Est, les lndiens semblent etre les plus vulnerables. Chez les migrants indiens a Fidji, en Afrique du Sud et en Amerique du Sud, on observe une prevalence du DSNID de 10% ou plus. Alors que I' on pensait que les Chinois etaient rarement atteints de DSNID, de recents rapports remettent en cause cette opinion. La prevalence du DSNID dans le Pacifique occidental est extremement variable. Toutefois, a !'exception possible de certaines populations melanesiennes, elle est elevee dans toutes les communautes qui ont abandonne leur mode de vie traditionnel. Tres peu d'estimations de !'incidence du DSNID ont ete publiees du fait, essentiellement, des difficultes prati- ques que souleve I' evaluation de !'incidence de cette maladie souvent asymptomatique. II a ete recommande recemment d'introduire la categorie intermediaire d'abaissement de la tolerance au glucose (A TG) pour definir les sujets dont la tolerance au glucose se situe en dehors de la fourchette normale, sans etre suffisamment alteree pour qu'ils soient classes dans la categorie des diabetiques. L' ATG semble evoluer de maniere imprevisible, encore que le risque d'apparition d'un diabete soit nettement plus eleve que chez les sujets ayant une tolerance normale au glucose. Selan les rapports, la prevalence de I' ATG chez differentes popu- lations est tout aussi variable que celle du DSNID. REFERENCES - REFERENCES 1. WHO Technical Report Series No. 727. 1985 (Dia- betes mellitus: report of a WHO Study Group). OMS Serie de Rapports techniques N° 727. 1985 (Le diabete sucre: rapport d'un Groupe d'etude de l'OMS). 2. AHREN, B. & CORRIGAN, c. B. Prevalence of diabetes mellitus in North-Western Tanzania. Diabetologia, 26: 333-336 (1984). 3. FISCH. A. Prevalence and risk factors of diabetes mellitus in the rural region of Mali (West Africa): a practical approach. Diabetologia, 30: 859-862 (1987). 4. TEUSCHER. T. ET AL. Absence of diabetes in a rural West African population with a high carbohy- drate/cassava diet. Lancet, i: 765-768 ( 1987). 5. HARRIS, M. I. ET AL. Prevalence of diabetes and impaired glucose tolerance and plasma glucose le- vels in U.S. populations aged 20-74 years. Diabe- tes, 36: 523-534 (1987). Wld hlth statist. quan., 41 ( 1988) 6. GILL. G. V. & HUDDLE. K. A. Patterns and problems of diabetes in Soweto. Central African journal of medi- cine, 30: 189-195 (1984). 7. KNOWLER. W. C. ET AL. Diabetes incidence and pre- valence in Pima Indians: a 19-fold greater incidence than in Rochester, Minnesota. American journal of epidemiology, 108: 497-505 (1978). 8. GARDNER. L. I. ET AL. Prevalence of diabetes in Mexi- can Americans: relationship to percent of gene pool derived from native American sources. Diabetes, 33: 86-92 (1984). 9. LARENAS, G. ET AL. Prevalence of diabetes in an indi- genous (Mapuche) community in the IX Region in Chile. Revis ta medica de Chile, 113: 1121-1125 (1985). 10. HERNANDEZ. R. E. ET AL. Prevalence of diabetes and obesity in an urban population of Argentina. Diabe- tes research and clinical practice, 3: 277-283 (1987). - 196 - 11. P APOZ, L. ET AL. Diabetes mellitus in Tunisia: descrip- tion in urban and rural populations. International journal of epidemiology. (in press-sous presse). 12. VERILLO. A. ET AL. Prevalence of diabetes and impair- ed glucose tolerance in a rural area of Italy. Diabetes research, 2: 301-306 (1985). 13. TUOMILEHTO. J. ET AL. Prevalence of diabetes mellitus in elderly men aged 65-84 years in eastern and western Finland. Diabetologia, 29: 611-615 (1986). 14. GLA TTHAAR, C. ET AL. Diabetes and impaired glucose tolerance. A prevalence estimate based on the Bus- selton 1981 survey. Medical journal of Australia, 143: 436-440 (1985). 15. ZIMMET. P. ET AL. Prevalence of diabetes and impair- ed glucose tolerance in the biracial (Melanesian and Indian) population of Fiji: a rural-urban comparison. American journal of epidemiology, 118: 6 7 3-688 (1983). 16. OMAR. M.A. K. ET AL. The prevalence of diabetes mellitus in a large group of South African Indians. South African medical journal, 67: 924-926 (1985). 17. SCHAAD. J. D. G. ET AL. Diabetes prevalence in the three main ethnic groups in Suriname (South Ame- rica): a population survey. Netherlands journal of medicine, 28: 17-22 (1985). 18. KING. H. ET AL. A review of the epidemiology of dia- betes mellitus in the ASEAN region. International Diabetes Federation bulletin, 28: 4-7 ( 1983). 19. THAI. A. C. ET AL. Changing prevalence of diabetes mellitus in Singapore over a ten-year period. In: Vannasaeng, S. et al. (eds), Epidemiology of diabe- tes mellitus: proceedings of the international sym- posium on epidemiology of diabetes mellitus. Bangkok, Crystal House Press, 1987. (pp. 63- 67). 20. WASPADJI. S. ET AL. Diabetes mellitus in an urban population in Jakarta, Indonesia. Tohuku journal of experimental medicine, 141 : Suppl. 219-228 (1983). 21. T Al, T-Y. ET AL. Epidemiology of diabetes mellitus among adults in Taiwan, R.O.C. In: Vannasaeng, S. et al. (eds), Epidemiology of diabetes me/litus: pro- ceedings of the international symposium on epide- miology of diabetes me/litus. Bangkok, Crystal House Press, 1987. (pp. 42-48). 22. Woo. J. ET AL. The prevalence of diabetes mellitus and an assessment of methods of detection among a community of elderly Chinese in Hong Kong. Dia- betologia, 30: 863-868 (1987). 23. Z1MMET, P. ET AL. Genetic and environmental in- fluence in the epidemiology of non-insulin-depen- dent diabetes mellitus: a global perspective. Annals of the Academy of Medicine of Singapore, 14: 34 7- 353 (1985). 24. ZIMMET, P. ET AL. The high prevalence of diabetes mellitus, impaired glucose tolerance and diabetic retinopathy in Nauru-the 1982 survey. Diabetes research, 1: 13-18 (1984). 25. KING, H. ET AL. Non-insulin-dependent diabetes (NIDDM) in a newly independent Pacific nation: the Republic of Kiribati. Diabetes care, 7: 409-415 (1984). 26. KING. H. ET AL. Glucose tolerance in Polynesia: popu- lation-based surveys in Rarotonga and Niue. Medi- cal journal of Australia, 145: 505-509 (1986). 27. TAYLOR. R. ET AL. The prevalence of diabetes mellitus in a traditional-living Polynesian population-The Wallis Island survey. Diabetes care, 6: 333-340 (1983). 28. KING, H. ET AL. Glucose tolerance in a highland popu- lation in Papua New Guinea. Diabetes research, 1: 45-51 (1984). 29. EASON, R. J. ET AL. Changing patterns of hyperten- sion, diabetes, obesity and diet among Melanesians and Micronesians in the Solomon Islands. Medical journal of Australia, 146: 465-473 (1987). 30. CAMERON, W. I. ET AL. Diabetes mellitus in the Aus- tralian Aborigines of Bourke, New South Wales. Diabetes research and clinical practice, 2: 307-314 (1986). 31. BENDER, A. P. ET AL. Incidence, prevalence and mor- tality of diabetes mellitus in Wadena, Marshall and Grand Rapids, Minnesota: the Three-City Study. Diabetes care, 9: 343-350 (1986). 32. BALKAU, B. ET AL. Factors associated with the devel- opment of diabetes in the Micronesian population of Nauru. American journal of epidemiology, 122: 594-605 (1985). Rapp. trimest. statist. sanit. mond .. 41 (19881 - 197 - WORLD HEAL TH ORGANIZATION ACTIVITIES IN THE FIELD OF DIABETES MELLITUS Hilary Kinga & Mikhail P. Mitrofanovb The recognition that diabetes mellitus is a worldwide problem, that it commonly results in blindness, cardio- vascular and kidney diseases, and that it now reaches its highest frequency in developing countriesc has resulted in a considerable growth in activities relating to the WHO programme for diabetes over the past few years. These activities may be conveniently considered under three broad headings. WHO and its collaborating centres for diabetes As compared with the six existing and the six proposed WHO collaborating centres for diabetes mellitus re- corded in the minutes of a meeting of a working group for the nomination of WHO collaborating centres in the field of diabetes in 1984, there were 26 institutions listed in this capacity by 1987. The nexus of the relationship between WHO and the collaborating centres should be the Diabetes Action Pro- gramme, the preparation of which is now finally ap- proaching fruition. By identifying needs, by formulating strategies and by setting priorities and goals, the Action Programme should not only provide a stimulus and incentive for the collaborative activities of WHO and the centres, it should also act as the yardstick by which progress can be assessed. In developing the collaborating-centre network, continu- ing consideration must also be given to equity, with respect to both regional representation, and the func- tional designation of the various centres. In Table 1, an attempt is made to summarize the present situation, based on the titles of the 26 collaborating centres in the field of diabetes. It demonstrates a considerable regional imbalance and highlights the low level of direct involve- ment of institutions in Africa, South-East Asia and the Western Pacific at the present time. The recent recom- mendation for nomination of a collaborating centre for diabetes in Japan is welcome in this regard. Although the tabulation was hampered by difficulty in categorizing several of the centres according to the broad groupings chosen, and although it underestimates the true level of activity since a number of centres are engaged in work outside their main designation, it would appear that over half of the centres are involved in popu- lation-based activities-descriptive epidemiology, etio- logical research or prevention and control of diabetes. This is well in accord with the policy of WHO that public health efforts relating to noncommunicable diseases should be aimed at disease prevention. It is also impor- tant to note the designation of collaborating centres in complementary areas, including primary health care, • Consultant, Division of Noncommunicable Diseases, World Health Organization, Geneva. b Medical Officer, Division of Noncommunicable Diseases, World Health Organization, Geneva. c See Trends in the incidence and prevalence of diabetes: non- insu/in-dependent diabetes mel/itus, p. 190 of this issue. Wld hlth statist. quan .. 41 (1988) patient education and laboratory technology. It would be narve to suppose that even the most successful pre- ventive approach will eliminate the need for patient- oriented medical care for diabetic subjects in the near future. A meeting attended by 25 directors of WHO collaborat- ing centres in the field of diabetes mellitus was held in Lexington, Kentucky (United States of America) in June 1987. This provided a timely opportunity to evaluate what has been achieved by this growing body of institu- tions to date, and also to define future needs, priorities and directions. It is hoped that such meetings will occur regularly in the future. WHO and the International Diabetes Federation The International Diabetes Federation (IDF) is the major nongovernmental organization in the field of diabetes. Its membership includes national diabetic associations or sections for diabetes in over 70 countries. Individual membership was introduced in 1976 and is now approx- imately 1 OOO strong (1). The IDF publishes a bulletin which now has a print run of over 70 OOO copies and has recently appeared both in English and French. It is of particular note that the IDF entered into official relations with WHO in 1957, being only the second non- governmental organization to do so. Over the last three decades collaboration has extended to a number of impo!1ant activities. These are considered at regular meetings of the WHO/IDF Executive Committee. Closer interaction has been fostered recently by the constitu- tion of a joint WHO/IDF Steering Committee. This meets twice yearly and was convened in Brussels (Belgium) (the IDF headquarters) in September 1986 and 198 7, and in Kaunas (USSR) in May 1987. Specific WHO programme activities in the field of diabetes As with other programmes, WHO activities for diabetes fall conveniently into the three categories of research, education and the strengthening of health services. The following represent specific examples. The WHO Multinational Study of Vascular Disease in Diabetes This major international research project addressed the need to confirm, quantify and explain reports of widely differing rates of vascular complications of diabetes (2). The project was developed in the mid-1970s by the European Diabetes Epidemiology Study Group, the IDF, WHO and representatives of a number of national groups. The final plan was formulated under the aus- pices of WHO, which provided funds and facilities for its coordination, and the WHO Collaborating Centre for the Study and Control of Long-Term Complications of - 198 - TABLE 1. FUNCTIONAL DESIGNATION OF THE WHO DIABETES COLLABORATING CENTRES IN THE FIELD OF DIABETES, AS OF JUNE 1987, ACCORDING TO THE REGIONS SERVED BY THE SIX WHO REGIONAL OFFICES TABLEAU 1. DESIGNATION FONCTIONNELLE DES CENTRES COLLABORATEURS DE L'OMS DANS LE DOMAINE DU DIABlTE, EN JUIN 1987, SELON LES REGIONS DESSERVIES PAR LES SIX BUREAUX REGIONAUX DE L'OMS Epidemiology I Prevention Health services/ Laboratory WHO Region - R<!gion OMS biostatistics and control primary health care Education technology Miscellaneous TOTAL Epid6miologie/ Pr<!vention Services de sant6/ T echnologie de Divers biostatistique et lutte de santlt primaires laboratoire Africa - Afrique Americas - Ameri- ques 4 South-East Asia - Asie du Sud-Est 1 Europe 2 6 Eastern Mediterranean - Mediterranee orientale Western Pacific - Pacifique occidental Total 7 8 Diabetes in London (United Kingdom) which provided leadership. A total of 6 695 diabetic subjects at 14 centres in 13 countries took part in the project. These included Asian and indigenous North American communities, as well as those of European origin. The results confirmed the prior impression of variability in the frequency of both large- and small-vessel disease between centres (2). For large-vessel disease, blood pressure was the most consistently associated of the variables examined in both sexes. For small-vessel dis- ease, duration of diabetes appeared to be the principal risk factor. For proteinuria, as a marker of small-vessel disease of the kidney, blood pressure was once again the most consistent of the factors examined. The study has provided a wealth of information on the morbid consequences of diabetes, and follow-up stud- ies of mortality continue. WHO technical reports on diabetes A WHO Expert Committee on diabetes mellitus met in Geneva in November 1964. The result was the first WHO technical report on diabetes mellitus (3). This con- sidered the natural history of diabetes and its causes, the prevention of diabetes, the control of diabetes as a pub- lic health problem, the employment of diabetics, and diabetes research. It concluded with several recommen- dations. A WHO Expert Committee met again in September- October 1979, and a second report was produced in 1980 (4). This updated the previous statement and, most importantly, introduced guidelines for the diagno- sis and classification of the disease. These included a category intermediate between normal glucose toler- ance and diabetes, termed impaired glucose tolerance (IGT). Other major topics included the epidemiology of diabetes, causes and mechanisms, the management of diabetes, complications, health services and the diabetic in society, education and research. Several new recom- mendations were made. 3 4 0 10 1 2 13 2 2 3 26 The third and latest report (5) followed a WHO study group on diabetes mellitus which was convened in Geneva in February 1985. In addition to further updating the second report in most areas, particular contributions of this publication were further refinements to the diag- nosis and classification of diabetes, and a section de- voted to malnutrition-related diabetes mellitus (MRDM). The three reports provide a clear account of progress in diabetes research, education and health care over the last two decades. WHO/IDF international seminars on the epidemiology and public health aspects of diabetes Three seminars have been held in Cambridge (United Kingdom) on epidemiological methods in relation to dia- betes. The first took place in July 1981 and the last in July 1987. All three have included an international facul- ty, and have attracted students from widely varied national situations. The last seminar was attended by 52 postgraduate students from 36 countries. Topics have included study design, standardization of survey methods, statistical methods and presentation of results, genetics of diabetes, environmental determi- nants of diabetes, and health economics. Students have also attended small group tutorials, and have contrib- uted to short presentations. Telecommunications, diabetes research and patient care Taking advantage of recent technological advances, an important new WHO/IDF joint venture is under way with respect to telecommunications. Rapid dissemination of information can greatly assist both medical research and clinical care, and the development of a variety of tele- communications systems has at last made such com- munication an economic reality. Several of the WHO collaborating centres for diabetes are now in contact with one another through the BITNET /EARN academic network. In a parallel develop- Rapp. trimest. statist. sanit. mond .. 41 (1988) - 199 - ment, IDF has developed its own network, called DIABETESNET, on the commercial TYMNET system. These two networks both have their particular advan- tages. Whereas BITNET /EARN has considerable re- search potential, due to its very low cost and substantial computing power, DIABETESNET enjoys wider geo- graphical coverage, and is more accessible to users in developing countries. WHO and its Collaborating Centre for Diabetes Registries and Training in the Epidemiology of Diabetes in Pittsburgh (United States), are now work- ing in conjunction with the IDF, in an attempt to integrate these two systems for the benefit of scientists, health- care providers and organizations involved in diabetes worldwide. REFERENCES - REFERENCES 1. BAJAJ. J. S. The state of the federation: 1987. Inter- national Diabetes Federation bulletin, 32 : 117 (1987). 2. THE WORLD HEALTH ORGANIZATION MULTINATIONAL STUDY OF v ASCULAR DISEASE IN DIABETICS. Prevalence of small-vessel and large-vessel disease in diabetic pa- tients from 14 centres. Diabetologia, 28 (Supple- ment): 615-640 ( 1985). 3. WHO Technical Report Series No. 310, 1965 (Diabetes mellitus: report of a WHO Expert Com- mittee). OMS Serie de Rapports techniques N° 310, 1965 (Le diabete sucre: rapport d'un Comite d'experts de l'OMS). Wld hlth statist. quan .. 41 (1988) 4. WHO Technical Report Series No. 646, 1980 (WHO Expert Committee on diabetes mellitus: second re- port). OMS Serie de Rapports techniques N° 646, 1980 (Comite OMS d'experts du diabete sucre: deuxieme rapport). 5. WHO Technical Report Series No. 727, 1985 (Diabe- tes mellitus: report of a WHO Study Group). OMS Serie de Rapports techniques N° 727, 1985 (Le diabete sucre: rapport d'un Groupe d'etude de l'OMS). - 200 - DES'CRIPTIVE OCCUPATIONAL MORBIDITY STATISTICS Thomas K. Nga Occupational health statistics is a vast field. It can, first of all, be divided arbitrarily into descriptive and analytical. In recent years, a lot of emphasis appears to have been on the analytical aspect, such as the application of the standardized mortality ratios (SMRs) and the proportion- ate mortality ratios (PMRs) to occupational groups. Des- criptive statistics tend to be neglected. Occupational health statistics can also be divided into three broad areas: occupational morbidity statistics, occupational health hazard statistics and occupational health service statistics. This classification is again arbi- trary, as exemplified by occupational accidents statis- tics. A discussion on the nature of occupational acci- dents statistics will also be provided in this article. The focus of this article however is on descriptive occu- pational morbidity statistics. Mortality is considered here merely as a specific outcome of morbidity. In other words, occupational mortality statistics are treated as a subset of occupational morbidity statistics. The basic unit for counting (enumeration) used in collecting and compiling occupational morbidity statistics will be criti- cally examined, the objective being to eliminate the con- fusion which has existed for years in this particular area of occupational health statistics. Defining occupational morbidity No serious attempt has been made to define occupa- tional morbidity for statistical purposes. Many things on occupational morbidity statistics, including definitions, are taken for granted, thus creating the confusion. The International Statistical Classification of Diseases, Inju- ries and Causes of Death (ICD) has never taken the "oc- cupational" element specifically into consideration. The following statement was found in the Eighth Revision of the International Classification of Diseases (ICD-8) : "Alternative Classification of Accidents, Poisonings and Violence (Nature of Injury) : again, two national proposals came under consideration, one submitted by the United Kingdom and the other by the United States of America. The United States version followed closely the existing N code in the Seventh Revision of ICD, except for the section "Effect of poison", which was considerably expanded. The United Kingdom draft was related to the ILO classification of nature of injury for use in the classification of industrial accidents and introduced a two-digit code for site to be cross- classified with a two-digit code for the main types of injury. The Committee were impressed with argu- ments for the desirability of continuity with the existing classification and for the need for different details in different types of injury which cannot be provided by a standard list of sites. The Committee accordingly favoured the United States proposal and recom- mended it as a basis for the revision of the sec- tion" (1). • Medical Officer, Office of Occupational Health, Division of Noncom- municable Diseases, World Health Organization, Geneva. No similar statement could be found in the Ninth Revision of the International Classification of Diseases (ICD-9). Whilst the World Health Organization (WHO) takes on the responsibility for revising and publishing the ICD, it collaborates with the Council for International Organi- zations of Medical Sciences (CIOMS) in the production of the International Nomenclature of Diseases (IND). The Council is also responsible for the publication of the IND, volume by volume (2). A brief explanation of the difference as well as the rela- tionship between the ICD and the IND is given in each volume of the International Nomenclature of Diseases. The ICD is designed for the statistical classification of diseases, and it is not a nomenclature: that is, the terms used in the ICD are not recommended names. The IND, on the other hand, is a nomenclature, and not a classi- fication : it is a list of recommended names (with defini- tions and rejected synonyms) for diseases, without any attempt to specify the manner in which those diseases should be classified for the purpose of statistical report- ing (2). At present, there is no international nomencla- ture of occupational diseases or morbidity. International Labour Office (ILO) Recommendation No. 97 ( 1953) deals with several matters concerning the protection of the health of workers in places of employ- ment. It covers, inter alia, notification of occupational diseases. It does not provide an international list of occu- pational diseases. Instead, it says: 'The competent authority should after consultation with the workers' and employers' organizations con- cerned draw up a list of notifiable occupational dis- eases or classes of cases, together with a symptoma- tology, and make from time to time such additions or amendments to the list or symptomatology as circum- stances may require or may be found to be desira- ble" (3). An International List of Occupational Diseases can be found in the Annex of ILO Convention No. 121 (1964). This ILO Convention governs benefits in the case of employment injury, with the concept of "employment injuries" broadly defined to cover all injuries resulting from accidents arising out of or in the course of employ- ment (industrial accidents and commuting accidents) and all occupational diseases. This particular list, orig- inally with 15 items, was revised in 1980 (4) to include 29 items (see Annex). It is produced with the purpose of providing benefits to the victims only. The list is not meant to be exhaustive, as the Convention requests each Member State to "include in its legislation a general definition of occupational diseases broad enough to cover at least the diseases listed". It is interesting to note that the word "poisoning" is avoided in the Inter- national List. At present, defining occupational morbidity is primarily a national responsibility. Some countries, because of the need to deal with the causes and the consequences of the morbidity separately, tend to define occupational morbidity according to each purpose it intends to serve. Rapp. trimest. statist. sanit. mond., 41 (1988) - 201 - Some years ago, there were two lists of occupational diseases in the United Kingdom: the list of notifiable occupational diseases ( 16 items) was for prevention purposes; the list of specified occupational diseases (50 items) was for compensation purposes. Recently, an attempt has been made to merge the two lists (5). It is too early to evaluate this change. One important problem with occupational morbidity sta- tistics at present is the absence of a clear-cut model on occupational morbidity. Some people apply a vague model of causation, some an equally vague model of consequence. Others tend to apply a model combining both causation and consequence. To appreciate the problem, it is useful to examine how occupational mor- bidity is counted. Counting occupational morbidity Counting occupational morbidity is not the same as counting morbidity alone. The ICD Manual serves as a universal basis for counting morbidity. In addition to the list of classifications, it provides clear rules for classifi- cation and an alphabetical index to facilitate the task (6). Counting morbidity alone only requires focus on the pathological condition in question. Counting occupa- tional morbidity goes beyond considering the patholog- ical condition, and has to take the "occupational" ele- ment into account. This is where the difficulty begins, because there are problems related both to the purpose and to the method for counting the occupational ele- ment. Moreover, it is more difficult to count occupational diseases than occupational injuries. ILO Recommendation No. 97 ( 1953) suggests that noti- fication of occupational diseases be required for four objectives (3): • initiating measures of prevention and protection and ensuring their effective application; • investigating the working conditions and other circum- stances which have caused or are suspected to have caused occupational diseases; • compiling statistics of occupational diseases; and • allowing the initiation or development of measures designed to ensure that victims of occupational dis- eases receive the compensation provided for such dis- eases. In a nutshell, the ILO Recommendation calls for a system of notification of occupational diseases for the purposes of prevention as well as compensation, with statistics as a by-product. The drafting of the recommendation is flexible enough to cover situations where notification is done for both purposes jointly or separately. Certainly, notification is not done merely for the purpose of com- piling statistics. In the days when the United Kingdom had two separate lists of occupational diseases, one for prevention and one for compensation, two different ways of counting occupational morbidity were used. For prevention pur- poses, when a morbid condition in the statutory list appeared in a worker (for example lead poisoning) it was notified to the appropriate authority (Factory Inspector- ate and later Employment Medical Advisory Service). It was the responsibility of the authority to investigate the causes for the morbid condition and to establish its occupational origin. This is a good example of double counting: first according to the morbid condition, and then by the occupational element, verification of the occupational element being done by experts. Wld hlth statist. quan., 41 (1988) For compensation purposes, the law in the United King- dom specifies not only the occupational diseases but also the corresponding occupational exposures. When a worker suffers from a specified disease and has been subjected to the corresponding occupational exposures, the disease is regarded as occupational unless proved otherwise. This is a good example of combined count- ing : the morbid condition and occupational element are counted simultaneously. As the benefit of the doubt, to a certain extent, has to be given to the workers when they claim compensation, the criteria for counting the occupational element were af- fected. In countries where only one set of statistics in occupational diseases exists, it is likely that the occupa- tional element is counted according to the compensation criteria. An indirect way of counting the occupational element exists in the case of hospital statistics. When hospital records are used for producing occupational morbidity statistics, the information on the morbid condition is extracted with a certain degree of accuracy, but the information on the occupational element is either una- vailable or questionable. This form of combined counting has very limited value, particularly with respect to those occupational diseases with a long latency period. Cancer registers have the same problem when attempt- ing to count the occupational element (7). Most cancer registers rely on existing records only and make no fur- ther investigation. For statistical purposes, the occupa- tional element my be counted according to the last occu- pation or the occupation that has been followed for the longest time. Neither occupation may be responsible for the cancer in question. Thus in setting up mesothelioma registers, a detailed occupational history is specially obtained in order to look for the responsible occupa- tional exposure (8). International standards The value of ICD is primarily for counting and classifying morbidity. Though the Manual contains a section on Classification of Industrial Accidents According to Agency, the ICD is seldom used in compiling occupa- tional morbidity statistics. The ICD makes no direct reference to occupational diseases. Any developments in occupational morbidity statistics are mainly the result of the efforts of the International Conference of Labour Statisticians for over 50 years (9). First, an International Standard Classification of Occupa- tions (ISCO) was produced in 1949. It was then revised in 1966 and 1987. In the latest version (10), it contains 10 major groups which are divided into submajor, minor and unit groups. Four-digit codes are provided for the unit groups. The 10 major groups are as follows: 1 . Legislators, senior officials and managers 2. Professionals 3. Technicians and associate professionals 4. Clerks 5. Service workers and shop and market sales workers 6. Skilled agricultural and fishery workers 7. Craft and related workers 8. Plant and machine operators and assemblers 9. Elementary occupations 10. Armed forces. The ISCO is seldom used directly in the Member States. Each country makes modifications for its own use, chiefly for population censuses and labour surveys (11). - 202 - Different workplaces tend to use their own classification of occupations, rendering record linkage very difficult, if not impossible. Some countries, such as Australia and Canada, have produced dictionaries on occupations in an attempt to overcome this difficulty. The Second International Conference of Labour Statisti- cians in 1925 produced a provisional list of the most important industries for use in labour statistics. The task was taken over by the Statistical Commission of the United Nations which produced the first version of the International Standard Classification of All Economic Activities (ISIC) in 1948 (9) (revised in 1958 and 1968, and currently under revision). ISIC-1968 consists of 10 major divisions, with further divisions, major groups and groups. Four-digit codes are provided for the groups. The 10 major divisions are as follows : 1. Agriculture, hunting, forestry and fishing 2. Mining and quarrying 3. Manufacturing 4. Electricity, gas and water 5. Construction 6. Wholesale and retail trade and restaurants and hotels 7. Transport, storage and communication 8. Finance, insurance, real estate and business services 9. Community, social and personal services 10. Activities not adequately defined. Dealing with economic activities, ISIC is more frequently used in comparison with ISCO. Less modification is required for use in each country. In fact, the statistics on occupational injuries published in the ILO Year Book of Labour Statistics are classified by ISIC and not by ISCO, an indication of the difficulty in obtaining statistics based on occupational groups. Instead, economic activities are used for counting the "occupational element". With respect to the use of ISIC and ISCO, the Tenth International Conference of Labour Statisticians recom- mended in 1962 : "Industrial accident statistics should be classified ac- cording to the industry in which the person injured was employed. The classification to be used should be the International Standard Industrial Classification of All Economic Activities or an industrial classification con- vertible to the international one. From time to time, special inquiries may be found use- ful for the purpose of classifying industrial accidents according to various other characteristics, such as sex, age, occupation, skill and experience, the day of the week and the month of the year, the time of the accident in respect of the work schedule, the size of the establishment, etc. Where industrial accidents are classified according to occupation, the classification used could be the International Standard Classification of Occupations". The contribution by the International Conferences of Labour Statisticians on the development of statistics on employment injuries (9) needs special mention. At the First Conference in 1923, a report was prepared on methods of compiling industrial accident statistics. Even at that time, it was recommended that occupational dis- eases be compiled in separate tables. In 1954, the Eighth International Conference of Labour Statisticians reviewed the standardization of statistics on occupational diseases and made recommendations with respect to the sources of data to be used, the dis- eases to be recorded and the classifications to be estab- lished. In 1962, the Tenth Conference divided employ- ment injuries statistics into three categories: (a) indus- trial accidents, (b) commuting accidents and (c) occupa- tional diseases, and recommended that the statistics should be published separately. It further proposed the classification of statistics on industrial accidents and commuting accidents according to the following conse- quences: (i) fatalities: accidents resulting in death; (ii) permanent disablement: accidents resulting in permanent physical or mental limitation or impair- ment; (iii) temporary disablement: accidents resulting in in- capacity for work for at least one full day beyond the day on which the accident occurred, irrespec- tive of whether the days of incapacity were on days on which the victim would otherwise have been at work; (iv) other cases: accidents resulting in incapacity for work lasting less than the period defined under (iii), and not involving permanent disablement. For the study of circumstances surrounding industrial accidents, classifications on (a) type of accident and (b) agency were recommended by the Tenth International Conference of Labour Statisticians. Further classification according to the bodily location of the injury was also provided. With respect to the nature of the injury, the Tenth Conference recommended following the WHO classification (9). In 1982, the Thirteenth Conference revised some of the earlier recommendations and changed certain defini- tions. Occupational injuries now include "deaths, per- sonal injuries and diseases resulting from work acci- dents". Work accidents are defined as "accidents oc- curring at or in the course of work which may result in death, personal injury or disease" (12). It is too early to note the impact of the changes made. National standards Certain countries have produced their national standards on recording and measuring work-injury experience. The Standards Association of Australia produced the first edition of such a standard in 1933, but revised it in 1966 and 1976. By definition, work injury covers "any injury, occupational disease or work-connected disability which arises out of or in the course of employment and which requires first-aid or medical treatment". The revi- sion in 1976 was considered necessary because "it had not received the wide acceptance which was essential if a standard method of recording and measuring work injury experience was to be adopted throughout Australia" (13). As the third edition follows closely the recommendations proposed by the Tenth International Conference of Labour Statisticians in 1962, further revi- sion is pending. According to the American National Standards Institute, there are four national standards relevant to occupa- tional morbidity statistics. The four standards are as fol- lows: (i) Method of recording and measuring work injury experience (ANSI 216.1-1967 (R 1973)) (ii) Method of recording basic facts relating to nature and occurrence of work injuries (ANSI 216.2- 1962 (R 1969)) (iii) Method of recording and measuring the off-the- job disabling accidental injury experience of em- ployees (ANSI 216.3-1973) (iv) Uniform recordkeeping for occupational injuries and illness (ANSI 216.4-1977). Rapp. trimest. statist. sanit. mond., 41 (19881 - 203 - In the United Kingdom, no similar national standard has been produced by the British Standards Institution (BSI). Recently, the Health and Safety Executive has published a guide to reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR) in 1985. These Regu- lations have replaced the Notification of Accidents and Dangerous Occurrences Regulations of 1980 and also the provisions for the notification of industrial diseases in Section 82 of the Factories Act of 1961 and in asso- ciated regulations and orders (5). Statistics on occupational injuries It is now time to examine the difference between statis- tics on occupational injuries and statistics on occupa- tional accidents. In 1962, the Tenth International Con- ference of Labour Statisticians said the following with respect to counting for industrial accidents statistics: "( 1) The unit of enumeration should be the person killed or injured as a result of a recorded acci- dent; when one person is the victim of two or more distinct recorded accidents during the pe- riod covered by the statistics, each accident should be counted separately, i.e. the same per- son should be counted twice or more. (2) Countries should also consider the compilation of statistics relating to industrial accidents, using the event as the unit instead of the person, and should classify these data according to the num- ber of persons involved" (9). In 1982, the Thirteenth Conference revised the above statements for occupational injuries statistics to read as follows: " ( 1) Where one person is the victim of two or more distinct recorded work accidents during the pe- riod covered by the statistics, each accident should be counted separately, i.e. the same per- son would be counted twice or more. (2) The statistics should normally cover injuries that were sustained during a calendar year; in any case the period covered should be clearly de- fined. (3) The unit of enumeration should be the person killed or injured as a result of a work accident. Countries should also consider the use of the event as another way of presenting the data" (12). It has been mentioned previously that in 1982, the Thir- teenth Conference defined occupational injuries as "deaths, personal injuries and diseases resulting from work accidents" (12). Statistics on occupational injuries thus belong to the domain of occupational morbidity statistics: there is a morbid condition (personal injury or disease which can be either fatal or non-fatal) to be counted; there is also a defined occupational element, namely work accidents, to be counted. Statistics on occupational accidents are somewhat dif- ferent. They are based on events: those unexpected and unplanned events in the workplace that may result in personal injury, property damage or both, depending on the circumstances. Accidents relate to unsafe acts and unsafe conditions on the one side and to personal inju- ries and property damage on the other. Being based on events for enumeration, occupational accident statistics are not occupational morbidity statistics. They are a hybrid between occupational morbidity statistics (occu- pational injuries) and occupational health hazard statis- tics (unsafe acts and unsafe conditions). Besides, some events which are counted as accidents may not neces- Wld hlth statist. quan., 41 (1988) sarily end in personal injury, as evidenced by the need to collect statistics on dangerous occurrences. "Dangerous occurrences" is a legal term used in the United Kingdom and some other countries. The law requires compulsory reporting of certain events in the workplace irrespective of whether there are persons injured or not. The overall list of dangerous occurrences is selective in each country, the aim being to obtain information about incidents which have a high potential to cause death or serious injury, but which happen rela- tively infrequently. This provides the opportunity of learning about the circumstances in which they occur and their causes, thus adding to the wider pool of infor- mation which can be used in accident-prevention work. The current United Kingdom list of dangerous occur- rences is divided into four parts: general ( 17 items), mines (18 items), quarries (5 items) and railways (3 items) (5). Certain workplaces require the reporting of "near acci- dents" in their accident-prevention programme. "Near accidents" are those defined events in the workplace which by chance do not result in personal injuries. Sta- tistics on near accidents are very useful for the individual workplace, but comparison is difficult between work- places because of the difference in the types of events included for reporting. Publication of national statistics on occupational injuries has been undertaken by the ILO for many years. The statistics published are generally based on industrial accident compensation data or on a compulsory acci- dent-reporting system. The statistics have not been adjusted by the ILO to achieve full conformity with the International Recommendations on Labour Statistics, though reporting agencies have been requested to supply information conforming as closely as possible to international standards (14). Publication of national statistics on occupational injuries by the ILO in the Year Book of Labour Statistics takes the form of two tables (28 & 29). The first table gives the number of persons injured as a result of industrial acci- dents classified by industry (major divisions) and in terms of the consequences of the accidents, i.e. fatal injuries or injuries resulting in loss of workdays. For the latter group, the number of workdays lost is also given. The second table gives frequency or incidence rates of fatal industrial accidents occurring in each major division of industry. The Year Book draws attention to the need to exercise caution in making comparisons of these sta- tistics (14). National statistics on occupational diseases have never been published by the ILO, with the exception of statis- tics on pneumoconiosis, as will be described in the next section. Statistics on pneumoconiosis As a result of recommendations made at two meetings of experts held at the ILO in 1952 and 1955, the Inter- national reports on the prevention and suppression of dust in mining, tunnelling and quarrying have since been published periodically by the ILO ( 15-17). Reporting by governments is based on a uniform plan which contains the following headings: Introduction 1. Minerals worked 2. Pneumoconiosis statistics 204 - Part I. Legislation, administration, research 1. Legislation 2. Administration 3. Research Part II. Dust prevention and suppression practices 1 . Introduction 2. Water 3. Methods of operation and working 4. Roof control, mine supports, measures against ground pressure 5. Drilling 6. Breaking down mineral 7. Extraction of mineral 8. Loading, transport and unloading of mineral and dead rock 9. Deposited dust 10. Airborne dust 11. Ventilation 12. Preparation of coal, ores and other minerals 13. Travelling on underground roadways 14. Personal protective equipment 15. Supervision of operations and equipment for dust prevention and suppression 16. Education and training of personnel 17. Special problems 18. Other matters Part Ill. Airborne dust sampling measurement and analysis 1. General 2. Sampling 3. Counting and measurement 4. Analysis 5. Recording of results. Part II helps generate occupational health service statis- tics and Part Ill occupational health hazard statistics. Occupational morbidity statistics, i.e. pneumoconioses statistics, are requested under Introduction. The details of information on pneumoconiosis statistics requested are as follows: Pneumoconiosis statistics 1 . Machinery and procedures for the compilation of sta- tistics of pneumoconioses, especially silicosis. 2. Actual statistics of pneumoconioses, and especially silicosis, showing for each year covered by the report: (a) number of persons exposed to risk; (b) total number of pneumoconiotics; (c) new cases of pneumoconiosis; (d) deaths from pneumoconiosis; (e) other statistics of pneumoconiosis, if possible classified by : (i) place of employment; (ii) type of work ; (iii) duration of exposure to risk. So far, 77 countries have made their national reports on the prevention and suppression of dust in mining, tun- nelling and quarrying to the ILO. Only seven countries, namely Australia, Austria, the Federal Republic of Germany, India, Sweden, the United Kingdom and the United States of America, have submitted their reports continuously. With respect to pneumoconiosis statistics, the following quotation from the Fourth International Report reflects the current situation as later reports only echo the sen- timent of these statements: · 'The reports received from the Member States relat- ing to the present section varied in scope and nature between those wherein no machinery exists for the compilation of such statistics up to those which included both a detailed statement covering such ma- chinery and procedures and a comprehensive series of statistics for the period under consideration. It has been considered advisable to present this infor- mation in an unabridged form in a number of cases for the reasons that it is of interest to compare the differ- ent procedures in use and also that it may be valuable to those countries that are desirous of introducing such a system. As regards the statistics themselves, it will be seen that these are compiled in various fashions and according to different criteria. No attempt has been made to alter their original presentation in order to render them more comparable" (15). These statements indicate that it will take a lot of efforts and also time in a number of countries to improve sta- tistics on pneumoconiosis. Some national statistics on pneumoconiosis related to coal mining have just been published by the ILO for the Twelfth Session of the ILO Coal Mines Committee held in Geneva on 13-21 April 1988 (18). . Pneumoconiosis is the first item on the International List of Occupational Diseases (see Annex). National statistics on the remaining 28 items have never been processed and published in the same manner by the ILO. Statistics on work-related diseases In 1983, a WHO Expert Committee drew the distinction between occupational diseases and work-related disea- ses. It stated: "In occupational diseases, there is a direct cause-and- effect relationship between hazard and disease. In work-related diseases, in contrast, the work environ- ment and the performance of work contribute signifi- cantly, but as one of a number of factors, to the cau- sation of a multifactorial disease. Occupational disea- ses therefore stand at one end of the spectrum of work-relatedness, where the relationship to specific causative factors at work has been fully established and the factors concerned can be identified, meas- ured, and eventually controlled. At the other end, diseases may have a weak, inconsistent, unclear relationship to working conditions; in the middle of the spectrum, there is a possible causal relationship but the strength and magnitude of it may vary" (19). It is important to note that the WHO Expert Committee has adopted a narrow definition of work-related dis- eases, using it in contrast to the definition of (cause- specific) occupational diseases. Many people still tend to use the term work-related diseases to cover the whole spectrum of work-relatedness, rather than to refer it to one end of the spectrum. The WHO Expert Committee discussed the following work-related diseases of public health significance: (1) behavioural responses and psychosomatic ill- ness; (2) hypertension ; (3) ischaemic heart disease; (4) chronic non-specific respiratory disease; and (5) locomotor disorders. Rapp. trimest. statist. sanit. mond., 41 (1988) - 205 - Urging epidemiological study of work-related diseases, the WHO Expert Committee discussed the following two forms: • descriptive studies of morbidity patterns in different occupations, work areas or tasks; and • etiological investigations where the possible causal influences of work on the occurrence of disease are evaluated, and the occupational share in the multi- factorial etiology is then quantified (such investiga- tions also include intervention studies where the effects of preventive measures are evaluated). The WHO Expert Committee did not mention descriptive statistics on work-related diseases. This is because work-related diseases, according to their definition, can- not be subjected to any meaningful counting for the "oc- cupational" element. In fact, the term "occupational" is deliberately avoided for this category of morbid condi- tions. Under this concept of work-related diseases, the basic unit for counting statistically is actually the group rather than the individual. If an occupational group is ascer- tained by epidemiological methods to have one or more work-related diseases, it is then counted as a problem group. Intervention is applied to the group as a whole. The International Conference of Labour Statisticians has never examined the concept of work-related diseases. The ILO concept of employment injury, being a legal concept, does not cover work-related diseases as de- fined by the WHO Expert Committee which is based on an epidemiological concept (4). Statistics on sickness absence The term "sickness absence" has been used rather loosely in industrial administration, leading to statistics which cannot be compared. The two common defini- tions of sickness absence are as follows (20): • sickness absence is absence from work accepted by the employer as attributable to sickness or acci- dent; • sickness absence is absence for which sickness is made the excuse. According to the first definition, a worker is absent because he or she has a morbid condition. Whether this condition arises out of the employment or not is irrele- vant. So long as it develops in the course of employment and requires absence from work, it is sufficient to be counted as sickness absence. Accepting this definition, there is a problem in verifying whether a morbid condi- tion exists which would justify the worker being absent from work. In reality, the second definition refers to overall absence rather than sickness absence. Some components in the overall absence may be excluded, such as annual leave. It is doubtful whether casual leave (permitted leave for causes other than sickness) is included, as it usually depends on the terms of employment. Statistics based on the first definition are morbidity sta- tistics. But they are not quite occupational morbidity statistics because the occupational element has not been specially accounted for. They are morbidity statis- tics in occupation, covering those conditions which are occupational in origin and those which are not. It also includes work-related diseases. Statistics based on the second definition can hardly be considered as morbidity statistics. They should be re- garded as statistics on industrial administration. The basic unit for counting in this case is the percentage of workforce absent on one particular day, based on the sickness-absence definition adopted in that work- place. Conclusions Descriptive occupational morbidity statistics still have their value to indicate the magnitude of occupational health problems in a country, in a community or in a workplace. For these statistics to be useful, each occu- pational health problem has to be defined clearly, with the objective and the method of data collection de- scribed unequivocally. Judging from the current situation of occupational injuries statistics and pneumoconiosis statistics, there is still a long way to go. Perhaps it is time for WHO to consider producing an international nomen- clature of occupational morbidity. SUMMARY In spite of their value to indicate the magnitude of occu- pational health problems, descriptive occupational mor- bidity statistics tend to be neglected. The accuracy of occupational morbidity statistics depends on counting the morbid condition as well as the occupational ele- ment. At present, there is no clearcut model for counting the occupational element. The International Conferences of Labour Statisticians have contributed greatly to the development of statistics on employment injuries. Such statistics are a by-product of the provision of compen- Wld hlth statist. quan .. 41 ( 1988) sation to workers with occupational injuries and disea- ses. Statistics which are a by-product of investigation into occupational injuries and diseases followed by inter- vention seem to have received much less attention. Comments are made on the present situation regarding national statistics on occupational injuries and pneumo- coniosis. The statistical issues with respect to work- related diseases and sickness absence are also exam- ined and discussed. - 206 - RESUME Statistiques descriptives de morbidite professionnelle Bien qu'elles soient tres utiles pour apprecier l'ampleur des problemes qui se posent en medecine du travail, les statistiques descriptives de morbidite professionnelle sont souvent negligees. La precision de ces statistiques depend de la fac;:on dont on opere le denombrement des etats morbides des facteurs professionnels. A l'heure actuelle, ii n'existe pas de modele clairement defini pour le denombrement des facteurs professionnels. Les Conferences internationales des statisticians du travail ont largement contribue au developpement des statisti- ques sur les accidents du travail. Ces statistiques sont un sous-produit des activites relatives a l'indemnisation des travailleurs victimes d'accidents ou de maladies profes- sionnelles. Par contre, ii semble que l'on ait accorde beaucoup moins d'attention aux statistiques compilees a I' occasion des enqu~tes menees sur les circonstances dans lesquelles sont survenus des accidents ou des maladies professionnelles ayant donne lieu a une inter- vention. L'article contient egalement des observations sur la situation actuelle en ce qui concerne les statisti- ques nationales relatives aux accidents du travail et aux pneumoconioses. Enfin, ii examine les problemes poses par I' etude statistique des maladies liees a la profession et des congas de maladie. ANNEX International list of occupational diseases (amended 1980) Occupational diseases 1 . Pneumoconioses caused by sclerogenic mineral dust (sili- cosis, anthracosilicosis, asbestosis) and silicotuberculosis, provided that silicosis is an essential factor in causing the resultant incapacity or death. 2. Bronchopulmonary diseases caused by hard-metal dust. 3. Bronchopulmonary diseases caused by cotton dust (byssi- nosis) or flax, hemp or sisal dust. 4. Occupational asthma caused by sensitizing agents or irri- tants both recognized in this regard and inherent in the work process. 5. Extrinsic allergic alveolitis and its sequelae caused by the inhalation of organic dusts, as prescribed by national legis- lation. 6. Diseases caused by beryllium or its toxic compounds. 7. Diseases caused by cadmium or its toxic compounds. 8. Diseases caused by phosphorus or its toxic compounds. 9. Diseases caused by chromium or its toxic compounds. 10. Diseases caused by manganese or its toxic compounds. 1 1. Diseases caused by arsenic or its toxic compounds. 12. Diseases caused by mercury or its toxic compounds. 13. Diseases caused by lead or its toxic compounds. 14. Diseases caused by fluorine or its toxic compounds. 15. Diseases caused by carbon disulfide. 16. Diseases caused by the toxic halogen derivatives of aliphatic or aromatic hydrocarbons. 1 7. Diseases caused by benzene or its toxic homologues. 18. Diseases caused by toxic nitro- and amino-derivatives of benzene or its homologues. 19. Diseases caused by nitroglycerin or other nitric acid esters. 20. Diseases caused by alcohols, glycols or ketones. 21. Diseases caused by asphyxiants: carbon monoxide, hy- drogen cyanide or its toxic derivatives, hydrogen sulfide. 22. Hearing impairment caused by noise. 23. Diseases caused by vibration (disorders of muscles, ten- dons, bones, joints. peripheral blood vessels or peripheral nerves). 24. Diseases caused by work in compressed air. 25. Diseases caused by ionizing radiations. 26. Skin diseases caused by physical, chemical or biological agents not included under other items. 27. Primary epitheliomatous cancer of the skin caused by tar, pitch, bitumen, mineral oil, anthracene or the compounds, products or residues of these substances. 28. Lung cancer or mesotheliomas caused by asbestos. 29. Infectious or parasitic diseases contracted in an occupation where there is a particular risk of contamination. Work involving exposure to risk a All work involving exposure to the risk concerned. » » » » » )) )) )) » » » )) )) )) » )) » )) » » » » )) All work involving exposure to the action of ionizing radiations. All work involving exposure to the risk concerned. )) » (a) Health or laboratory work. (b) Veterinary work. (c) Work handling animals, animal carcasses. parts of such car- casses or merchandise which may have been contaminated by animals, animal carcasses or parts of such carcasses. (d) Other work carrying a particular risk of contamination. • In the application of this schedule, the degree and type of exposure should be taken into account when appropriate. Rapp. trimest. statist. sanit. mond., 41 ( 19881 - 207 - ANNEXE Liste internationale des maladies professionnelles (amendee en 1980) Maladies professionnelles 1 . Pneumoconioses causees par des poussieres minerales sclerogenes (silicose, anthraco-silicose, asbestose) et sili- co-tuberculose pour autant que la silicose est une cause determinante de l'incapacite ou de la mort. 2. Bronchopneumopathies causees par les poussieres des metaux durs. 3. Maladies bronchopulmonaires causees par les poussieres de coton (byssinose). de lin, de chanvre ou de sisal. 4. Asthme professionnel cause par des agents sensibilisants ou irritants reconnus comme tels et inherents au type de travail. 5. Alveolites allergiques extrinseques et leurs sequelles cau- sees par !'inhalation de poussieres organiques, conforme- ment ii ce qui est prescrit par la legislation nationale. 6. Maladies causees par le beryllium (glucinium) ou ses com- poses toxiques. 7. Maladies causees par le cadmium ou ses composes toxiques. 8. Maladies causees par le phosphore ou ses composes toxiques. 9. Maladies causees par le chrome ou ses composes toxiques. 10. Maladies causees par le manganese ou ses composes toxiques. 11 . Maladies causees par I' arsenic ou ses composes toxiques. 12. Maladies causees par le mercure ou ses composes toxiques. 13. Maladies causees par le plomb ou ses composes toxiques. 14. Maladies causees par le fluor ou ses composes toxiques. 15. Maladies causees par le sulfure de carbone. 16. Maladies causees par les derives halogenes toxiques des hydrocarbures aliphatiques ou aromatiques. 1 7. Maladies causees par le benzene ou ses homologues toxiques. 18. Maladies causees par les derives nitres et amines toxiques du benzene ou de ses homologues. 19. Maladies causees par la nitroglycerine ou d'autres esters de l'acide nitrique. 20. Maladies causees par les alcools, les glycols ou les cetones. 2 1 . Maladies causees par les substances asphyxiantes : oxyde de carbone, cyanure d'hydrogene ou ses derives toxiques, hydrogene sulfure. 22. Atteinte auditive causee par le bruit. 23. Maladies causees par les vibrations (affections des mus- cles, des tendons, des os. des articulations, des vaisseaux peripheriques ou des nerfs peripheriques). 24. Maladies causees par le travail dans l'air comprime. 25. Maladies causees par les radiations ionisantes. 26. Maladies de la peau causees par des agents physiques, chimiques ou biologiques non consideres sous d'autres rubriques. 27. Epitheliomas primitifs de la peau causes par le goudron, le brai. le bitume, les huiles minerales, l'anthracene ou les composes. produits ou residus de ces substances. 28. Cancer pulmonaire ou mesotheliome causes par l'amian- te. 29. Maladies infectieuses ou parasitaires contractees dans une activite comportant un risque particulier de contamina- tion. Travaux exposant au risque a Tous travaux exposant au risque considers. » » » » » » » )I » » » » » » » » )l » » )I » » » Tous travaux exposant ii l'action des radiations ionisantes. Tous travaux exposants au risque considers. » » a} Travaux dans le domaine de la same et travaux de labora- toire. b} Travaux veterinaires. c} Travaux de manipulation d'animaux, de carcasses ou de debris d'animaux ou de marchandises susceptibles d'avoir ate contaminees par des animaux ou des carcasses ou des debris d'animaux. d} Autres travaux comportant un risque particulier de contami- nation. • Dans !'application de ce tableau, ii conviendrait de prendre en consideration, le cas echeant, le niveau et le type d'exposition. Wld hlth statist. quart .• 41 ( 1988) - 208 - REFERENCES - REFERENCES 1. WORLD HEAL TH ORGANIZATION. Manual of the interna- tional classification of diseases, injuries and causes of death. Eighth Revision. Geneva, WHO, 1967. ORGANISATION MONDIALE DE LA SANTE. Manuel de la classification statistique internationale des mala- dies, traumatismes et causes de deces. Huitieme revision. Geneve. OMS, 1967. 2. COUNCIL FOR INTERNATIONAL 0RGANIZA TIONS OF MEDICAL SCIENCES. International nomenclature of diseases. Vol. I/I-diseases of the lower respiratory tract. Geneva. CIOMS. 1979. 3. INTERNATIONAL LABOUR OFFICE. International Jabour conventions and recommendations 1919-1981. Geneva, ILO, 1985. (With supplements). BUREAU INTERNATIONAL DU TRAVAIL. Conventions et recommandations internationales du travail, 1919- 1984. Geneve, BIT, 1985. 4. INTERNATIONAL LABOUR OFFICE. Amendment to the list of occupational diseases appended to the Employ- ment Injury Benefits Convention, 1964 (No. 121). Geneva, ILO. 1980. BUREAU INTERNATIONAL DU TRAVAIL. Amendement de Ja liste des maladies professionnelles annexee a la Convention (n° 121) sur Jes prestations en cas d'ac- cidents du travail et de maladies professionnelles, 1964. Geneve. BIT, 1980. 5. HEAL TH AND SAFETY EXECUTIVE. A guide to the report- ing of injuries, diseases and dangerous occurrences regulations 1985 (RIDDOR). London, HMSO, 1986. (Health and safety series booklet HS(R)23). 6. WORLD HEAL TH ORGANIZATION. Manual of the interna- tional classification of diseases, injuries and causes of death. Ninth Revision. Geneva, WHO, 1977. ORGANISATION MONDI ALE DE LA SANTE. Manuel de Ja classification statistique internationa/e des mala- dies, traumatismes et causes de deces. Neuvieme revision. Geneve, OMS, 1977. 7. MUIR, C. S. & DEMARET. E. Occupational cancer: sta- tistics and registration in /LO encyclopaedia of occupational health and safety, third edition, Vol. I. Geneva, ILO, 1983. 8. FERGUSON, D. A. ET AL. The Australian Mesothelioma Surveillance Programme 1979-1985. Medical jour- nal of Australia, 147 (4): 166-172 (1987). 9. INTERNATIONAL LABOUR OFFICE. International recom- mendations on labour statistics. Geneva, ILO, 1976. BUREAU INTERNATIONAL DU TRAVAIL. Recommanda- tions internationales sur Jes statistiques du travail. Geneve, BIT, 1975. 10. IINTERNATIONAL LABOUR OFFICE. Report of the Four- teenth International Conference of Labour Statisti- cians (1987). Geneva, ILO, 1988. BUREAU INTERNATIONAL DU TRAVAIL. Rapport de Ja qua- torzieme conference internationale des statisticiens du travail (1987). Geneve, BIT. 1988. 11. VELLA. V. & NG, T. Analysis of occupational morta- lity in England & Wales, Scotland, Norway and Finland. La medicina de/ Javoro, 11 (2): 162-171 (1986). 12. INTERNATIONAL LABOUR OFFICE. Report of the Thir- teenth International Conference of Labour Statisti- cians (1982). Geneva, ILO. 1983. BUREAU INTERNATIONAL DU TRAVAIL. Rapport de la trei- zieme conference internationale des statisticiens du travail (1982). Geneve, BIT, 1983. 13. STANDARDS ASSOCIATION OF AUSTRALIA. Recording and measuring work injury experience-Australian Standard 1885-1976. Sydney, Standards Associa- tion of Australia, 1976. 14. INTERNATIONAL LABOUR OFFICE. Year book of labour statistics. Geneva, ILO, 1986 (46th issue). BUREAU INTERNATIONAL DU TRAVAIL. Annuaire de sta- tistiques du travail. Geneve, BIT, 1986. (46e edi- tion). 15. INTERNATIONAL LABOUR OFFICE. Fourth international re- port on the prevention and suppression of dust in mining, tunnelling and quarrying. Geneva, ILO, 1970. (Occupational safety and health series No.24). BUREAU INTERNATIONAL DU TRAVAIL. Quatrieme rapport international sur Ja prevention et la suppression des poussieres dans Jes mines, Jes galeries et Jes carrie- res. Geneve, BIT, 1970. (Serie Securite, hygiene et medecine du travail N° 24). 16. INTERNATIONAL LABOUR OFFICE. Fifth international re- port on the prevention and suppression of dust in mining, tunnelling and quarrying, 1968-72. Geneva, ILO, 1977. (Occupational safety and health series No. 40). BUREAU INTERNATIONAL DU TRAVAIL. Cinquieme rapport international sur la prevention et la suppression des poussieres dans Jes mines, Jes galeries et Jes carrie- res, 1968-1972. Geneve, BIT, 1979. (Serie Securi- te, hygiene et medecine du travail N° 40). 17. INTERNATIONAL LABOUR OFFICE. Sixth international re- port on the prevention and suppression of dust in mining, tunnelling and quarrying, 1973-1977. Geneva, ILO, 1982. (Occupational safety and health series No. 48). BUREAU INTENA TIONAL DU TRA v AIL. Sixieme rapport in- ternational sur Ja prevention et la suppression des poussieres dans Jes mines, Jes galeries et Jes carrie- res, 1973-1977. Geneve, BIT. 1983. (Serie Securi- te, hygiene et medecine du travail N° 48). 18. INTERNATIONAL LABOUR OFFICE. General report of the Twelfth Session of the Coal Mines Committee (1988). Geneva, ILO, 1988. BUREAU INTERNATIONAL DU TRAVAIL. Rapport general de Ja douzieme session de la Commission de J'in- dustrie charbonniere, 1988. Geneve, BIT, 1988. 19. WHO Technical Report Series No. 714, 1985. (Iden- tification and control of work-related diseases: re- port of a WHO Expert Committee). OMS Serie de Rapports techniques N° 714, 1985 (Identification et prevention des maladies liees a la profession: rapport d'un Comite d'experts de l'OMS). 20. TYRER. F. H. & LEE. K. A synopsis of occupational medicine-Chapter 8. Facts and figures. Bristol, Wright, 1985. (Second edition). Rapp. trimest. statist. sanit. mond .• 41 (1988) - 209 - DISTRIBUTION AND CONTROL OF SOME GENETIC DISORDERS Bernadette Modena & Victor Bulyzhenkovb One of the most important objectives of community genetics services is to reduce the frequency and clinical manifestations of severe congenital disorders, i.e. dis- orders that arise at the time of conception or during intra- uterine development, and which can cause lifelong or lethal pathology. These disorders may be roughly di- vided into congenital malformations, chromosomal dis- orders and Mendelian conditions (hereditary anaemias, PKU, cystic fibrosis, hypothyroidism). Although not all congenital disorders are of genetic or hereditary origin, they are usually considered in the context of hereditary diseases. The birth incidence of congenital disorders, including those that are trivial or relatively easily corrected, is gen- erally estimated to be in the range of 25-62 per 1 OOO live births. The incidence of severe congenital disorders that can cause early death or lifelong chronic disease ranges from about 14 per 1 OOO births in most of the more developed countries to about 43 per 1 OOO births in some less developed regions of the world (Table 1). Most infants with a severe congenital disorder (such as haemoglobinopathy, Down's syndrome, congenital mal- formation) are particularly susceptible to infections. As a result, in many parts of the world, the deaths of these children are not detected as being due to congenital dis- orders but rather are attributed to the broader category of infectious and parasitic diseases. Moreover, further reductions in infant mortality would appear to be dependent on better diagnosis and treatment of con- genital disorders and/or on reducing the number of births so affected. This article provides some data on the world distribution of several common sporadic and inherited congenital disorders (Down's syndrome, neural tube defects and haemoglobinopathies) which have a significant impact as a burden on health. • Principal Investigator. WHO Collaborating Centre for the Control of Haemoglobinopathies, London, United Kingdom. b Responsible Officer, Hereditary Diseases Programme, Division of Noncommunicable Diseases, World Health Organization, Geneva. c International Clearinghouse for Birth Defects Monitoring Systems. Annual reports 1980-1985 (ISSN 0743-5701). Available at a price of US$ 5.00 each from Dr Lisbeth B. Knudsen, Coordinator. ICBDMS, S111svinget 34, DK-2635 lsh111j, Denmark. The data on the monitoring of Down's syndrome and neural tube defects as well as other congenital malfor- mations have been collected by the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS) during the past 10-14 years. The ICBDMS is an association of programmes (now about 25) engaged in surveillance or monitoring of birth defects throughout the world. In 1986, the ICBDMS was admitted into offi- cial relations with WHO as a nongovernmental organi- zation. Down's syndrome Down's syndrome is one of the most common chromo- somal abnormalities, involving chromosome 21 in the trisomy or translocation. A large proportion of cases are liveborn and have a relatively good chance of surviving, although with varying degrees of mental retardation. Table 2 shows the rates per 10 OOO births of infants with Down· s syndrome in 1980-1985 registered in the vari- ous monitoring programmes. c There is a very wide var- iation in rates between the programmes. Aside from variable ascertainment. this can be partly explained by different maternal age composition and by different access to and utilization of prenatal diagnosis followed by selective abortion. Fig. 1 shows the large variability between the pro- grammes in the percentage of delivered women aged 35 or more and also, for each programme, a ratio indicating the deviation from the average rate of Down's syndrome that could be expected from the maternal age distribu- tion of that specific programme. Differences in maternal age distribution will cause a 50% higher Down's syn- drome rate in some programmes (Japan, Northern Ireland, South America and Spain) than in others (Czechoslovakia). Table 3 shows, for women aged 35 or more in selected programmes, the number of infants born and the number of fetuses aborted with Down's syndrome. It can be seen that in some programmes prenatal diagnosis de- tects as many or more fetuses with Down's syndrome than infants born with this disorder, whereas in other programmes only relatively few are detected. TABLE 1. ESTIMATED FREQUENCY OF CONGENITAL DISORDERS TABLEAU 1. ESTIMATION DE LA FRIEQUENCE DES TROUBLES CONGIENITAUX Type of disorder - Type de trouble Congenital malformations - Malformations congenitales . Chromosomal aberrations - Aberrations chromosomiques Mendelian disorders - Troubles mendeliens . . . .. Haemoglobinopathies - Hemoglobinopathies . . . . . . . . . . Total Wld hlth statist. quan., 41 ( 19881 All disorders. incidence per 1 OOO binhs Total des troubles, incidence pour 1 OOO naissances 17-30 4-9 4-7 0-16 25-62 Severe disorders. estimated incidence per 1 OOO binhs Troubles graves, incidence estim6e pour 1 OOO naissances 8-15 2-5 4-7 0-16 14-43 - 210 - TABLE 2. RATE PER 10 OOO BIRTHS OF INFANTS WITH DOWN'S SYNDROME REGISTERED IN VARIOUS MONITORING PROGRAMMES, 1980-1985 TABLEAU 2. TAUX POUR 10 OOO NAISSANCES DE NOURRISSONS ATTEINTS DU SYNDROME DE DOWN, ENREGISTRE DANS LE CADRE DE DIVERS PROGRAMMES DE SURVEILLANCE, 1980-1985 Down's syndrome monitoring programme 1980 Programme de surveillance du syndrome de Down Australia - Australie .. Canada ....................... Czechoslovakia - Tchecoslovaquie ........ 9.5 Denmark - Danemark ........ . . . . England & Wales - Angleterre et pays de Galles 7.3 Finland - Finlande ....... 9.5 France (Rhone-Alpes-Auvergne) France (Paris) France (Strasbourg) ..... Hungary - Hongrie . . . . . . . Israel - lsral!I .......... Italy (IPIMC) - ltalie (IPIMC) .. 14.5 Italy (Emilia-Romagna) - ltalie (Emilie-Romagne) Japan - Japan ........ . . . 11.3 Mexico - Mexique ......... New Zealand - Nouvelle-Zelande 8.0 Northern Ireland - lrlande du Nord Norway - Norvege . . ....... 9.7 South America - Amerique du Sud Spain - Espagne ......... 14.3 Sweden - Suede ....... 14.4 United States (Atlanta) - Etats-Unis (Atlanta) 11.3 United States (1 200 hospitals) - Etats-Unis (1 200 hopitaux) . . . . . . . . . . . . . . . Source: International Clearinghouse for Binh Defects Monitoring Systems. A well-known and important risk factor for Down's syn- drome is maternal age. Its impact on the prevalence at birth of Down's syndrome was demonstrated above. In fact, differences in maternal age distribution among populations seem to be a more important factor in dif- ferences in prevalence of Down's syndrome than differ- ences in the level of access to and utilization of prenatal diagnosis followed by selective abortion. However. fur- ther reduction in the number of infants born with serious handicaps-not only Down's syndrome-is possible if such prenatal diagnostic techniques are made available and accepted. 1981 1982 1983 1984 1985 Average Moyenne 11.5 11.5 11.0 12.2 11.5 5.8 5.8 7.8 7.7 9.2 6.7 8.2 6.4 8.3 9.6 9.0 10.2 8.7 7.4 8.4 7.9 7.9 6.7 7.6 8.8 8.3 9.7 8.4 9.0 8.9 6.3 12.4 10.3 11.3 10.7 10.2 9.8 13.6 12.8 10.7 11.7 11.0 8.0 10.8 10.6 10.1 7.0 5.9 8.3 7.1 12.4 15.2 13.5 13.6 12.0 14.4 12.1 10.4 12.3 12.1 14.2 14.2 7.3 14.5 6.9 9.2 11.0 10.0 13.4 9.6 13.5 8.1 11.2 9.4 6.6 8.7 11.2 10.5 9.1 14.9 14.3 14.6 15.1 15.5 14.9 11.2 9.9 9.5 8.5 13.6 10.4 14.3 15.1 16.5 15.7 15.2 15.8 12.7 13.9 15.7 14.5 13.1 12.5 14.3 12.3 13.6 13.4 13.4 8.9 10.4 7.9 9.7 10.2 8.2 9.8 9.0 Neural tube defects Neural tube defects include the specific congenital mal- formations varying from anencephaly to different forms of spina bifida. Table 4 presents, for the various partici- pating monitoring programmes, the annual number of infants registered with anencephaly, spina bifida and encephalocele, respectively. As can be seen from this table, there are very marked variations in rates. These are partly due to genetic differences. For example, it is well-known. and can also be seen in the table, that regions with a predominantly Anglo-Saxon population TABLE 3. NUMBER OF INFANTS BORN WITH DOWN'S SYNDROME, NUMBER OF ABORTED FETUSES WITH THIS CONDITION, AND RATIO BETWEEN NUMBER OF INFANTS AND NUMBER OF ABORTED FETUSES (RESTRICTED TO MATERNAL AGE OF 35 OR MORE) TABLEAU 3. NOMBRE DE NOUVEAU-NES ATTEINTS DU SYNDROME DE DOWN, NOMBRE DE FCETUS AVORTES ATTEINTS DE CETTE AFFECTION ET RAPPORT ENTRE LE NOMBRE DE NOUVEAU-NES ET LE NOMBRE DE FCETUS AVORTES (LIMITE AUX MlRES AGEES DE 35 ANS OU PLUS) Monitoring programme Programme de surveillance Australia - Australie . . . . . . . . . . . . Czechoslovakia - Tchecoslovaquie Denmark - Danemark . . . . . . . . . . . England & Wales - Angleterre et pays de Galles ..... Finland - Finlande . . . . . . . France (Rhone-Alpes-Auvergne) ... France (Paris) . . . . . . . . . . . . . France (Strasbourg) . . . . . . . . . . Italy (Emilia-Romagna) - ltalie (Emilie- Romagne) . . . . ....... . Northern Ireland - lrlande du Nord Sweden - Suede . . . . . . . . . . . Total infants born Total de nouveau-n6s 17 985 5 171 4 187 52300 8 162 6 910 4 552 810 2000 3015 11 487 Source: International Clearinghouse for Binh Defects Monitoring Systems. Infants with Down·s syndrome Nouveau-n,s atteints du syndrome de Down 76 17 2 117 27 26 15 3 13 21 46 Fetuses with Down·s syndrome Fa,tus atteints du syndrome de Down 31 11 21 138 26 18 27 3 1 6 45 Ratio Rappon 2.5 1.5 0.1 0.8 1.0 1.4 0.6 1.0 13.0 3.5 1.0 Rapp. trimest. statist. senit. mond., 41 (19881 211 - FIG. 1 MATERNAL AGE DISTRIBUTION IN RELATION TO RATE OF DOWN'S SYNDROME IN 19 MONITORING PROGRAMMES DISTRIBUTION DES AGES DES M~RES PAR RAPPORT AU TAUX D'INCIDENCE DU SYNDROME DE DOWN DANS 19 PROGRAMMES DE SURVEILLANCE A. Deviation from the average rate of Down's syndrome that could be expected from the maternal age distribution of each programme Ecart par rapport au taux d'incidence moyen du syndrome de Down auquel on peut s'attendre compte tenu de la distribution des ages des meres dans chaque programme c 0 0. 0. .. a: I Q ~ 0 0 0 ___ o ______ ..,.o ----··- 0 0 0 0 0 0 0 0 0 0 0 .5 L---'---L--'----'---'-__j____j __ ~-~-~--'---'---'---'---'---'---'---'---'--' B. Percentage of women delivered at age 35 or more, per programme Pourcentage de femmes ayant accouche a 35 ans ou plus, par programme 10~~~~~~~~--~~~· "' c: .. + "' M "' C> .. g f:! :, ~ I "' iii "' 8 6 ; 4 "' M 8, .. E "' f:! "' 0. 2 0 .'!! " ·~ '!! a lii .. > :, 0 <( .; I 0 u . !!! .., .J:. '!! u I-lii :, I <( .. .. .. > .Q "' 0 .J:. u l!l u Wld hlth statist. quan., 41 ( 1988) "" I "' "' oi .; iii "' "C "' c: c: "i E "' .; e> !l! ~ " .; (!) c: "' c: 3: " ..;: > "' .. "C :, u 0 <( ,II "' c: I > .. ~ "C .. "C "' .... "" c: 0. c: 0. ~; .. iii 'i: < E ~ ~ ..;: " c: c: "' :;; '° 0 .!! .J:. s. C> c: "' <( u c: .t a> cr ii: c: "' "' 1:! " "C "' 0 :, "C C> :, c: :5 ::;; w 0. g c: 0 .., VJ C> i .. .. z i:: .. 0 ~ " :, .Q ..., "' 'iii :, 0 "C 0. "' ::;; N "C z "' ~ .'!! .!!! .!l " "' w ~ I :, ~ ~ c: .; "C g .. c: 0. 0 > ~ > ~ c: " .. u :, .. E ... u ..., ·~ 0 ;:: c: cr ii: " z 0 <( ~ .t w ::;; ::;; i I "C z I ~ "C c: .. > c: .. .!! > ~ !l! ] iii .. ~ "' c: E N :;; <( ;:: .J:. .J:. " c '5 z 0 z 0 VJ Country - Pays "' .; "C ... E :, !l! VJ ~ I "' c: i: "' "C ;) " .. ;:: :;; VJ w .; E !l! ~ "' "' :;; <ii "C l!l i: ;) ~ °' "' ., 0 l: ?:: - 212 - TABLE 4. RATE PER 10 OOO BIRTHS OF INFANTS WITH NEURAL TUBE DEFECTS REGISTERED IN VARIOUS MONITORING PROGRAMMES, 1980-1985 TABLEAU 4. TAUX POUR 10 OOO NAISSANCES DE NOUVEAU-NIES PRESENTANT UNE ANOMALIE DU TUBE NEURAL, ENREGISTRE DANS LE CADRE DE DIVERS PROGRAMMES DE SURVEILLANCE, 1980-1985 Monitoring programme Programme de surveillance Australia - Australie . . . . . . . . Canada ............... . China - Chine . . . . . . . Czechoslovakia - Tchecoslovaquie Denmark - Danemark . . . . . . . . . England & Wales - Angleterre et Galles Finland - Finlande France (Rhl>ne-Alpes-Auvergne) France (Paris) France (Strasbourg) Hungary - Hongrie . . . Israel - Israel Italy (IPIMC) - ltalie (IPIMC) . . . . . . Italy (Emilia-Romagna) - ltalie (Emilie-Romagne) Japan - Japan . . . . . . . . . . Mexico - Mexique . . . . . . . . . New Zealand - Nouvelle-Zelande Northern Ireland - lrlande du Nord Norway - Norvege South America - Amerique du Sud Spain - Espagne . . . . . . . . . . Sweden - Suede . . . . . . . . . . . . . . . United States (Atlanta) - Etats-Unis (Atlanta) United States (1 200 hospitals) - Etats-Unis (1 200 hl>pitaux) . . . . . . . . . . . . . . . Australia - Australie Canada China - Chine . . . . Czechoslovakia - Tchecoslovaquie Denmark - Danemark . . . . . . . England & Wales - Angleterre et Galles Finland - Finlande . . . . . . . France (Rhl>ne-Alpes-Auvergne) France (Paris) . . . . . France (Strasbourg) . . . . . . . Hungary - Hongrie . . . . . . . . Israel - Israel . . . . . . . . . . . Italy (IPIMC) - ltalie (IPIMC) . . . . . . . . . Italy (Emilia-Romagna) - ltalie (Emilie-Romagne) Japan - Japan . . . . . . . . . . Mexico - Mexique . . . . . . . . . . . New Zealand - Nouvelle-Zelande . . . Northern Ireland - lrlande du Nord Norway - Norvege . . . . . . . . . South America - Amerique du Sud . . Spain - Espagne . . . . . . . . . . Sweden - Suede . . . . . . . . . . . . United States (Atlanta) - Etats-Unis (Atlanta) United States (1 200 hospitals) - Etats-Unis (1 200 Mpitaux) . . . . . . . . . . . . . . . Australia - Australie . . . . . . . . Canada .............. . China - Chine . . . . . . . Czechoslovakia - Tchecoslovaquie Denmark - Danemark England & Wales - Angleterre et Galles Finland - Finlande . . . . . . . . . . . . France (Rhl>ne-Alpes-Auvergne) France (Paris) . . . . . France (Strasbourg) . . . . . . . Hungary - Hongrie . . . . . . . . Israel - Israel . . . . . . . . . . . Italy (IPIMC) - ltalie (IPIMC) . . . . . . Italy (Emilia-Romagna) - ltalie (Emilie-Romagne) Japan - Japan . . . . . . . . . . . . Mexico - Mexique . . . . . . . . . New Zealand - Nouvelle-Zelande Northern Ireland - lrlande du Nord Norway - Norvege . . . . . . . . . South America - Amerique du Sud Spain - Espagne . . . . . . . . . . Sweden - Suede . . . . . . . . . United States (Atlanta) - Etats-Unis (Atlanta) United States (1 200 hospitals) - Etats-Unis (1 200 hl>pitaux) . . . . . . . . . . . . . . . 1980 1981 1982 Anencephaly - Anencephalie 5.9 5.7 4.7 4.8 3.4 3.0 5.2 3.0 0.4 4.9 3.3 3.7 5.0 4.0 6.9 16.6 3.5 1.8 3.4 1.8 5.8 3.3 3.5 2.4 3.9 2.2 1.2 6.0 6.7 3.7 5.2 3.9 5.8 17.4 4.5 4.0 3.1 1.2 3.0 Spina bifida 7.3 4.3 3.5 11.4 1.7 4.1 9.9 6.7 4.7 2.5 12.9 12.6 20.1 6.6 5.3 4.3 3.9 7.7 5.2 5.4 3.4 2.6 10.4 2.3 2.9 11.0 9.0 7.5 0.5 11.1 10.9 20.3 5.7 8.6 3.2 5.2 5.6 2.7 2.5 2.6 2.6 0.9 1.5 7.7 7.7 2.7 8.3 4.5 7.0 12.9 2.9 6.6 2.9 1.5 2.5 3.3 7.7 6.3 3.7 3.0 8.1 1.8 3.7 4.1 4.4 12.0 9.9 5.3 2.1 9.5 10.4 20.6 6.4 5.2 4.1 4.5 5.0 4.8 Encephalocele - Encephalocele Source: International Clearinghouse for Birth Defects Monitoring Systems. 1983 5.8 4.7 1.9 1.2 1.8 0.6 1.4 1.3 3.2 6.3 9.0 2.9 11. 1 3.8 3.8 9.1 3.6 5.7 2.3 1.8 3.2 3.0 8.0 6.7 3.6 4.5 6.7 2.8 3.2 4.5 5.6 11.2 3.4 2.9 3.2 10.4 11.5 15.7 4.8 5.5 3.9 4.5 7.5 4.7 1.6 0.9 0.8 1.2 0.8 0.4 0.7 1.3 1.1 0.7 0.5 1.6 0.8 1.5 0.8 3.5 1.3 0.9 2.1 1.2 1984 4.3 3.3 1.2 1.4 1.1 1. 1 0.8 7.0 4.0 5.9 1.7 4.6 3.0 2.8 4.7 2.0 7.2 2.8 1.1 3.8 2.6 6.6 3.3 3.8 5.9 1.8 3.7 1.8 7.0 9.8 11.7 4.0 2.6 13.2 10.6 17.2 5.3 6.9 4.7 4.0 6.5 4.9 1.6 0.6 0.7 0.3 1.3 1.2 1.0 1.0 1.8 0.4 1.8 0.6 2.1 0.8 0.4 1.7 1.2 1985 5.1 5.4 1.5 1.1 0.9 1. 1 0.8 2.3 4.0 3.4 1.9 0.4 4.2 1.8 3.5 7.9 4.3 6.3 2.4 0.7 2.6 2.7 6.5 4.4 3.4 3.5 5.3 1.6 4.5 1.7 3.8 10.2 5.6 4.4 3.3 3.7 10.2 7.2 11.1 4.7 7.1 5.0 5.5 6.1 4.5 1.2 1.4 0.9 0.7 0.6 0.2 0.5 0.7 0.8 0.6 1.1 0.4 2.1 1.4 0.8 1.4 1.9 1.4 1.0 1.0 2.6 1.0 Average Moyenne 5.3 5.0 5.4 2.8 1.9 2.6 1.7 1.0 0.9 3.1 5.5 5.6 2.5 0.4 6.4 3.6 4.9 11.5 3.5 5.9 2.8 1.3 3.5 3.0 7.2 6.4 4.4 3.6 3.5 8.0 2.0 3.7 3.0 5.2 10.7 7.4 4.4 3.3 2.4 11.3 10.5 17.5 5.6 6.7 4.2 4.6 6.4 4.9 1.5 0.9 1.4 0.8 1.0 0.7 0.3 0.6 1.1 0.8 0.0 1.0 0.9 0.4 1.2 1.6 0.7 1.6 1.1 2.3 1.1 0.8 2.1 1.1 Rapp. trimest. statist. sanit. mond., 41 (19881 - 213 - generally have high rates. Non-genetic differences be- tween the populations may also exist. A third source of variation is the level of accessibility to prenatal diagnosis followed by selective abortion. Finally, different defini- tions of stillbirths (especially important for anencephaly) and differences in ascertainment contribute to the varia- tion. The populations studied represent many different types of societies, from highly industrialized countries to devel- oping countries. Not only reproductive patterns but also other risk factors may vary considerably. An example is maternal work during pregnancy and the possible occu- pational risk factors to which pregnant women may be exposed. Long-term trends have repeatedly been observed in the prevalence at birth of neural tube defects, e.g. spina bif- ida. Fig. 2 shows the downward trend in Clearinghouse datac for anencephaly and, to a less marked degree, for spina bifida. It is possible that the marked short-term decrease of anencephaly is rather due to an increasing use of prenatal diagnosis than to actual changes in the prevalence of the malformation. It should be noted, how- ever, that a downward trend of neural tube defects was noticed in many countries long before prenatal diagnosis became so common that it could have an impact. Table 5 compares the number of infants born with a neural tube defect in 1984 and the number of aborted fetuses with such defects in some programmes with information of this kind. The differences in proportion between infants born and fetuses aborted may, to some extent, be due to differences in ascertainment of aborted fetuses but may also illustrate differences in access to prenatal diagnosis. Haemoglobinopathies Haemoglobinopathies are the commonest lethal inher- ited diseases. They include the thalassaemias (the a and the /1-thalassaemias and the Hb E/B-thalassaemia) and the sickling syndromes (homozygous sickle-cell anae- mia, Hb S/C disease and HbS/B-thalassaemia). Haemo- globinopathies are inherited through symptomless car- riers (heterozygotes) in a Mendelian recessive manner; when two carriers mate they have a 1 :4 chance in each pregnancy of producing an affected (homozygous) child. Incidence and distribution Population surveys have been done in most countries where haemoglobinopathies are indigenous. In many other areas (for example, much of South America and North-West Europe), their incidence can be calculated from the ethnic composition of the population, so that it is now possible to provide an estimate of their frequency for almost every country. The approximate global num- bers involved are given in Table 6. FIG. 2 2 1.5 .5 ANENCEPHALV RATIOS OF ANNUAL MALFORMATION RATES DIVIDED BY THE AVERAGE RATE FOR THE WHOLE PERIOD 1980-1985• 0 0 0 00 0 0 0 oO 0 0 0 0 QUOTIENT DES TAUX D'ANENCIEPHALIE ANNUELS PAR LE TAUX MOVEN POUR L'ENSEMBLE DE LA PIERIODE 1980-19858 0 00 0 0 0 go oo 0 0 oO 0 0 0 0 0 Anencephaly - Anenc~phalie 0 0 Oo 0 0 0 0 oo oO 0 0 0 0 a Each programme is marked by a dot and the means for each year are connected by a solid line -Les points indiquent des programmes et les mayennes pour chaque ann~e sont reliees par une ligne continue. Source International Clearinghouse for B1nh Defects Monitoring Systems. Wld hlth statist. quan .• 41 ( 1988) - 214 - TABLE 5. NUMBER OF INFANTS BORN WITH NEURAL TUBE DEFECTS, NUMBER OF ABORTED FETUSES WITH SUCH DEFECTS AND RA TIO BETWEEN NUMBER OF INFANTS AND NUMBER OF ABORTED FETUSES TABLEAU 5. NOMBRE DE NOUVEAU-NES PRESENTANT DES ANOMALIES DU TUBE NEURAL, NOMBRE DE FCETUS AVORTES PRESENTANT DE TELLES ANOMALIES ET RAPPORT ENTRE LE NOMBRE DE NOUVEAU-NIES ET LE NOMBRE DE F<ETUS AVORTES PRESENTANT DE TELLES ANOMALIES Monitoring programme Infants born Aborted fetuses Ratio Programme de surveillance Nouveau-n6s Fcetus avort;\s Rapport Australia - Australie ..... 33a 6 5.5 Denmark - Danemark 26 16 1.7 Finland - Finlande . . . . . . . 21 7 3.0 France (Rhclne-Alpes-Auvergne) 42 18 2.3 France (Paris) .. 15 38 0.4 France (Strasbourg) 5 11 0.5 Norway - Norvege 40 12 3.3 Sweden - Suede 52 40 1.3 a Estimate - Estimation. Source: International Clearinghouse for Birth Defects Monitoring Systems. TABLE 6. GLOBAL NUMBERS OF CARRIERS OF HAEMOGLOBINOPATHIES TABLEAU 6. NOMBRE DE PORTEURS D'HEMOGLOBINOPATHIES DANS LE MONDE % of the population heterozygous for : Population % de la population htlttlrozygote pour : Total% of population in millions Region - Region Population Sickle-cell Pourcentage traits p thalassaemia traits a· thalassaemia en millions total de d'habitants HbS and C P thalass6mie trait la population Dr6panocytose Pthal HbE a· thalassemie HbSet C Africa - Afrique North - Nord . . 116 0.3-2.3 1-4 4.8 North-East - Nord-Est 38 0 0-1 East - Est 82 1-40 11.2 South - Sud ...... 34 Islands - lies . . 11 1.5-20 8.9 Sub-Saharan - Sub-saharienne 212 2-40 0-4 23.3 Total Africa - Total Afrique 493 0-40 0-4 13.3 Americas - Ameriques North - Nord . . 257 1.6 1.2 Central - Centre ... 97 0.6 0.6 South - Sud .. 252 0-5 3.6 Caribbean - Caraibes 31 3-12 1-2 9.7 Total Americas - Total Am6riques ....... 637 0-12 1-2 2.5 Asia - Asie North-West - Nord-Quest 161 0-20 1-16 3.8 South - Sud ...... 924 0-40 1-13 0-10 4.2 North-East - Nord-Est 915 South-East - Sud-Est 663 1-10 0-40 (1.9) 11.6 Total Asia - Total Asia 2663 0-40 0-16 0-40 0-4 4.6 Europe North-West - Nord-Quest 237 0.3 North-East - Nord-Est 79 South - Sud 172 0-25 1-15 2.4 USSR - URSS ..... 270 0-15 1.7 Total Europe - Total Europe 758 0-25 0-15 1.3 Oceania .............. 28 1. 1 Global total - Total mondial 4579 4.6 Number of heterozygotes (millions) Nombre d·heterozygotes (en millions) 5.53 0.33 9.15 1.0 49.4 65.4 3.0 0.6 9.1 3.0 15.7 6.1 39.0 76.6 121.7 0.72 4.13 4.65 9.5 0.3 212.6 Rapp. trimest. statist. sanit. mond .• 41 ( 1988) - 215 - FIG. 3 SPINA BIFIDA RATIOS OF ANNUAL MALFORMATION RATES DIVIDED BY THE AVERAGE RATE FOR THE WHOLE PERIOD 1980-19858 QUOTIENT DES TAUX ANNUELS DE SPINA BIFIDA PAR LES TAUX MOYENS POUR L'ENSEMBLE DE LA PIERIODE 1980-1985• l 0 Sp,na b,f,da 1.5 ~ r i 0 0 0 0 0 0 00 0 0 Oo i Oo 00 I 0 oO ~ 88 L 8g 00 j 0 oO 0 do ·- ~ -----o---- .... . ·88= ___ - -----00----0 ou 0 0 0 og So ~ I o~o--:::=:::::::::~:::::::::~,,,,,.--~~-----------~~;.;;;.._:..;,;.;;.;.:,__:;;.;;_~li:::.:=:....:__...:.:=~ r---:: ~ J ~ oo 0 0 0 00 0 Oo 0 0 00 0 0 00 0 0 00 0 0 o ~I __ __,_ ______ _._ _____ ~~-------1 ____ _ 1 1984 _ ___ _L_ 1980 1981 1982 1983 1985 a Each programme is marked by a dot and the means for each year are connected by a soltd line - Les points indiquent des programmes et les moyennes pour chaque annee sont rehees par une ligne continue. Source lnterna11onal Clearinghouse for Birth Defects Monitoring Systems. At present about 190 million people (4% of the world population) carry a potentially pathological haemoglobi- nopathy gene. More than half are thalassaemia genes, but globally sickle-cell disease is more common than the thalassaemia syndromes, because of the very high den- sity of sickle-cell carriers in Africa and the affected parts of lndia.d Surveys give the carrier frequency, but for public health purposes it is appropriate to calculate the birth rate per 1 OOO of infants with a major (i.e. usually lethal) haemo- globinopathy. Fig. 3 and Table 7 give the results ofthese calculations. At present, each year about 240 OOO in- fants are born with major haemoglobinopathies, about 20% with thalassaemia syndromes and about 80% with sickle-cell disease. Allowance must be made for the fol- lowing factors: 1. Population size and growth. Though at present about 4% of the world population are carriers of haemo- globinopathies, the final figure may be closer to 6-7% because of future differential growth of the populations with the highest incidence. 2. Population movements. Migration has introduced the haemoglobinopathies into many areas where they d World Health Organization. Update of the progress of haemoglobi- nopathies control (Milan 1984/Bangkok 1985). Report of the Third and Fourth annual meetings of the WHO Working Group on the Community Control of Hereditary Anaemias. (Document HMG/WG/85.8). Wld hlth statist. quart., 41 (19881 were not originally endemic. In the United States of America 10% of the population is at risk for sickle-cell disease, and in North-West Europe between 2% and 9% of most populations now belong to ethnic minorities at risk for the haemoglobinopathies. The movement and mixing of populations in many countries will ultimately reduce the homozygote birth rate by dispersing groups with a high carrier frequency among larger populations with a lower frequency. However, in South-East Asian countries where the relatively benign HbE gene is preva- lent in some parts of the population and P-thalassaemia in others, population mixing will substantially increase the amount of genetic pathology. 3. The frequency of consanguinity. The positive con- vention of consanguineous marriage that prevails in large parts of the world increases the homozygote birth rate relative to the heterozygote frequency. 4. The effects of improved primary health care. The haemoglobinopathies are common because the carriers are protected against death from falciparum malaria. Where malaria is common, relatively more of the off- spring of carriers than of non-carriers survive to repro- ductive age, so the frequency of the genes tends to reflect the present or past prevalence of malaria. Where malaria is prevalent, many homozygotes die from ma- laria in infancy, and once malaria is brought under con- trol, the haemoglobinopathies emerge as an important cause of chronic disease. - 216 - TABLE 7. GLOBAL ANNUAL BIRTHS OF INFANTS WITH MAJOR HAEMOGLOBINOPATHIES TABLEAU 7. NOMBRE ANNUEL DE NAISSANCES D'ENFANTS ATTEINTS D'HEMOGLOBINOPATHIES MAJEURES DANS LE MONDE Affected Thousands of annual births of homozygotes with : births Milliers de naissances par an d'homozygotes per 1 OOO porteurs de Region - Region Naissance Total d'enfants a· thalassaemia atteints SS SC SIP thal Pthal HbE/thal a· thalasstlmie pour 1 OOO a· a• HbH (000) Africa - A frique North - Nord 1.17 (--1.6--] 1.17 3.0 5.77 North-East - Nord-Est 0.02 East - Est .. 3.5 13.63 South - Sud .... Islands - lies 2.3 1.05 Sub-Saharan - Sub-saharienne 14.0 110.4 Total Africa - Total Afrique 9.2 126.7 Americas - Ameriques North - Nord 0.25 0.57 Central - Centre 0.04 South - Sud 0.51 2.28 Caribbean - Cara"tbes 2.9 1.47 Total Americas - Total Ameriques 0.47 4.3 Asia - Asie North-West - Nord-Quest 1.28 4.0 South - Sud .. 0.94 14.81 North-East - Nord-Est South-East - Sud-Est . 1.23 Total Asia - Total Asie 1.15 18.8 Europe North-West - Nord-Quest 0.13 0.28 North-East - Nord-Est South - Sud 0.28 USSR - URSS 0.08 Total Europe 0.16 0.3 Oceania - Oceanie 0.21 Global total - Total mondial 2.1 150.1 5. The impact of prevention programmes. In Southern Europe and in the Mediterranean area, large-scale screening and counselling programmes have greatly re- duced the birth rate of infants with thalassaemia major, and the disease is actually disappearing from some areas (Fig. 4). The clinical and financial burden of the disorders is so great that it is highly cost-effective to introduce a control programme along these lines, especially in developing countries. e Control of haemoglobinopathies By using relatively cheap and simple blood tests, it is possible to detect carriers. Consequently. the haemo- globinopathies can be prevented at the community level by population information, carrier screening and genetic • World Health Organization. Community approaches to the control of hereditary diseases. Report of a WHO Advisory Group. October 1985. (Document HDP/WG/85.10). 0.04 0.04 13.63 0.01 1.06 31.6 142.0 31.6 >1.2 >3.1 162.6 0.26 0.13 0.09 1.05 1.04 0.5 0.4 4.22 0.67 0.32 2.48 2.0 0.95 0.5 7.9 1.43 3.1 8.52 14.81 1.84 31.46 7.06 15.3 7.23-16.5 46.1 1.43 25.0 17.1 23.73 86.1 0.12 0.40 0.9 0.9 0.87 0.9 1.89 2.2 0.1 0.1 33.6 3.6 30.6 >17.1 23.7 258.7 counselling, and the offer of prenatal diagnosis with sel- ective abortion of affected pregnancies to couples of carriers. Most couples at risk for thalassaemia choose prenatal diagnosis and selective abortion of affected pregnancies in order to ensure a healthy family, thus many births of affected children can be avoided when screening and counselling are provided. The recent intro- duction of prenatal diagnosis at around nine weeks' ges- tation has considerably increased the acceptability of this approach to prevention. In France and in the United Kingdom about 50% of counselled couples at risk for sickle-cell disease accept prenatal diagnosis. It is there- fore clear that information. counselling and choice should also be provided for sickle-cell disease, and would also be expected to make a considerable impact on its incidence. Acknowlegements The authors wish to express their gratitude to Dr E. Knudsen and Professor B. Kallen, members of the ICBDMS, for their kind assistance in providing the data presented in this article. Rapp. trimest. statist. sanit. mond .. 41 (1988) - 217 - FIG. 4 FALL IN THE BIRTH RATE OF INFANTS WITH THALASSAEMIA MAJOR ASSOCIATED WITH SEVERAL THALASSAEMIA CONTROL PROGRAMMES CHUTE DU TAUX DE NATALITE DE NOUVEAU-NES ATTEINTS DE THALASSEMIE MAJEURE ASSOCIEE A DIVERS PROGRAMMES DE LUTTE CONTRE LA THALASSEMIE ~ :, ., .... E ., E ,., ~.,, 0.,, ·;-12 E1 "' -H ., :, ~E .,, "' "' -~~ .c 'E .!: c. 3:!!J .,, c .c "' t- ·- c .a " o~ ~~ "'c -"' c.,, ~ ·~ ., c c.., -0 -0 ~:, "-0 "c c.., ><::: w"' ., "' "' E "' " 5 0 0.. 100 90 80 70 60 50 40 30 20 10 0 1970 1972 ------, -·,: ---, I L--- ----, . :1: ••••.•• . . L-., ~ .. ~·~·l············· : . . : United Kingdom - Aoyaume-Uni ..... ~~~~~~ ..... ~ ... ----, •.............. . 1974 I I I I I I I ............... Greece - Grece I L---·-·1 Sardinia - , I 1.--------, i._ ~~~n.:... . J I l Cyprus - Chypre I I L---, Ferrara - Ferrare I I I I L----, ---------. L---, I L--- 1976 1978 1980 1982 1984 Year - Annee WHO 851710 Source: WHO/OMS Document HMG/WG/85.8. MAP 1. WORLD DISTRIBUTION OF THE HAEMOGLOBINOPATHIES (THALASSAEMIAS AND SICKLE-CELL DISEASE), 1985 CARTE 1. REPARTITION DES HEMOGLOBINOPATHIES DANS LE MONDE (THALASSEMIE ET DREPANOCYTOSE), 1985 / Births per 1 OOO of infants with a major haemoglobinopathy Naissances pour 1 OOO nouveau-n8s atteints d'h6moglobinopathie majeure D < 0.1 D 0.1 - 0.19 ~ 0.2-0.99 - 1-4.9 - 5-9.9 - 10 - 18.9 - >19 Wld hlth statist. quart., 41 ( 1988) 7---- / ./ \ / ' I I I - 218 - SUMMARY The health burden of genetic disorders varies between ethnic groups within the same country or between coun- tries to a large extent because of genotypic differences at the population level. Genetic services should recog- nize this variability in need and be developed within the traditional context of medical care. All practical ap- proaches require a sound epidemiological basis and underline the importance of early diagnosis for both pre- vention and treatment. Effective control is now possible for some Mendelian conditions and some congenital malformations and should be incorporated into general health care. The development of genetic services within any country depends on the optimal utilization of avail- able resources, both financial and intellectual. RESUME Distribution de certains troubles genetiques et mesures de lutte L'impact des troubles genetiques varie d'un pays a l'au- tre ou a l'interieur d'un m~me pays d'un groupe ethnique a l'autre, en grande partie en raison de differences geno- typiques au niveau de la population. Les services gene- tiques doivent reconnaitre cette variabilite des besoins et se developper dans le cadre du contexte traditionnel des soins medicaux. Toutes les approches pratiques supposent une base epidemiologique solide et souli- gnent !'importance d'un diagnostic precoce pour la pre- vention et le traitement. Une lutte efficace est mainte- nant possible contre certaines maladies transmises se- lon le mode mendelien et contre certaines anomalies congenitales et devrait ~tre incorporee dans les soins de sante generaux. La mise sur pied de services genetiques dans un pays depend de !'utilisation optimale des res- sources disponibles aussi bien financieres qu'intellec- tuelles. Rapp. trimest. statist. sanit. mond .. 41 (19881 - 219 - THE ACTIVITIES OF THE HUNGARIAN CENTRE FOR CONGENITAL ANOMALY CONTROL Andrew Czeizel a In Hungary today congenital anomalies (CAs) are the eighth leading cause of death and the second cause of infant mortality, accounting for 23% of all infant deaths. Altogether, CAs are responsible for 5 OOO years of lost life and about 4 500 years of actually impaired life within the population each year (1). In the early 1960s the grow- ing public health importance of CAs and in particular the thalidomide tragedy prompted Hungarian paediatricians to suggest the establishment of a CA registry. In 1962 the notification of CAs was made compulsory and the Hungarian Congenital Malformation Registry (HCMR) was established. In 1970 the Department of Human Genetics and Teratology of the National Institute of Hygiene was charged with the direction of the HCMR according to the recommendations of WHO and other expert groups. Other systems were later added to the HCMR and the Hungarian Centre for Congenital Anomaly Control (HCCAC) was established in 1973. The Hungar- ian experience might be useful as a possible model for other countries interested in this field of epidemiology and public health. Hungary had a reasonably stable popu- lation size of 10.3-10. 7 million between 1970 and 1986, with an average of about 150 OOO births per year. The HCCAC has three major activities: maintaining a register, conducting surveillance programmes, and carrying out special diagnostic, preventive and rehabili- tation tasks. The Centre is staffed by a team of seven: a physician, a mathematician, a biologist and four techni- cal assistants who work full-time in close collaboration with a group of computer experts and other units, par- ticularly the Epidemiology Unit of the Department of Human Genetics and Teratology of the National Institute of Hygiene. The Registry A genetic register can be defined as a system for the collection, storage and application of data on diseases and/or cases where mutation is the cause of harmful or potentially disadaptive manifestations.b Some uses of registers were outlined by Miller in 1976 (2). The Centre's register function is fulfilled by the HCMR which collects and maintains a computerized permanent record of medical and personal information about malformed newborns and infants born in Hungary since 1970 (3). The study population comprises all births. The purpose of the HCMR is to determine as reliably as possible base- line figures of different types of recorded specific CA entities in order to help plan medical and social services for those affected; to estimate the public health impor- tance of different groups of CAs (Tables 1 & 2) so that • Department of Human Genetics and Teratology, WHO Collaborating Centre for the Community Control of Hereditary Diseases, National Insti- tute of Hygiene, Budapest, Hungary. b World Health Organization. The methodology for binh defects mon- itoring. Report on a WHO consultation, Rome, 3-4 June 1985. (Document HMG/Cons/85.6). c The term "notification" is intentionally used instead of ··report" because the input of data from medical services to the HCMR is called notification while the output of data from the HCMR to medical services is named report. Wld hlth statist. quan .• 41 ( 1988) resources can be allocated properly; to detect temporal and/or spatial changes in birth prevalences; to give adequate information in connection with public concerns (for example, the Chernobyl nuclear plant incident); to organize population-based prevention programmes and to check the efficacy of prenatal and neonatal screen- ings; to help the social rehabilitation of handicapped children through special programmes; and to provide material for research projects. Following are some special features of the HCMR. • The neonatal period, mainly the first days of life, is the usual time for diagnosis and notificationc of CAs; how- ever. the study period covers the interval from birth to the age of 1 year. Recently, prenatally diagnosed and selectively aborted malformed fetuses have also been registered. • Notification of CAs is compulsory as is the case for several infectious diseases. (At present, the number of infant deaths due to CAs is 26 times higher than the total of deaths due to infectious diseases in Hungary.) • Notification is exclusively the task of physicians, mainly obstetricians (in Hungary nearly all deliveries take place in hospital) and paediatricians (who are working in obstetric inpatient clinics and various inpatient and out- patient paediatric clinics). They notify the Congenital Malformation Registry directly using a standard form. In case of death (stillbirths and infant deaths due to con- genital anomalies) the pathologist sends a copy of the detailed autopsy record to the Registry. Autopsy is obli- gatory for all infant deaths. • In addition to the multiple sources of notification out- lined above, notification is made each time an affected child is admitted to any paediatric institution. Although this results in a considerable overlap, duplicate registra- tion on the same child can be eliminated with the help of personal data. At the same time this overlap increases the efficiency of ascertainment and enhances the validity of diagnosis. Furthermore, it provides an opportunity to cross-check the notification. Failure to notify could be detected on the basis of recorded data (paediatric noti- fication forms and autopsy records provide the address of the institution where delivery took place; autopsy records include the address of the paediatric inpatient clinic where death occurred). Additionally, the observed annual total CA rate is compared with the rate expected in each obstetrical and paediatric inpatient clinic. • Submitted data (mainly diagnoses) are critically evalu- ated upon receipt, according to the following proce- dure: (i) Forms with missing or unreliable data are sent back for completing or checking. (ii) CAs are divided into two categories: isolated (sin- ~le, complex or monotopic field defect, polytopic field defect, sequence) and multiple (CA-syndrome, CA-association, unidentified multiple CAs). Distin- guishing between isolated and multiple CAs is - 220 - TABLE 1. TRUE AND REGISTERED BIRTH PREVALENCE OF 10 COMMON CONGENITAL ANOMALIES, COMPLETENESS OF NOTIFICATION, ANNUAL TOTAL YEARS LOST AND ACTUALLY IMPAIRED LIFE, HUNGARY, 1973-1982 TABLEAU 1. PREVALENCE REELLE ET ENREGISTREE A LA NAISSANCE DE 10 ANOMALIES CONGENITALES COURANTES SELON LE POURCENTAGE DES NOTIFICATIONS COMPLETES, LE NOMBRE TOTAL D'ANNEES PERDUES ET LE NOMBRE D'ANNEES DE VIE AVEC UN HANDICAP, HONGRIE, 1973-1982 ICD code Code CIM 740.0- 741.0 745.3-4 749.1-2 750.5 752.5 752.6 754.3 754.5 550.0 758.0 Common congenital anomalies Anomalies cong6nitales courantes Isolated - Anomalies isolees Neural tube defect/anencephalus and/or spina bifida cystica - Anomalie du tube neural/anencephalie et/ou spina bifida cystica Ventricular septa! defect - Communication interventriculaire Cleft lip ± cleft palate - Bee de lievre ± fissure du palais Congenital hypertrophic pyloric stenosis - Stenose congeni- tale hypertrophique du pylore Undescended testis after third month - Ectopie testiculaire apres le troisieme mois Hypospadias - Hypospadias Liability for congenital dislocation of hip - Predisposition a la luxation congenitale de la hanche Congenital structural talipes equinovarus - Pied bot varus equin congenital Congenital inguinal hernia - Hernie inguinale congenitale Multiple - Anomalies multiples Down's syndrome - Syndrome de Down True binh Recorded binh prevalence per prevalence 1 OOO total per 1 OOO binhs total binhs Prevalence Prevalence reelle a la enregistree a naissance la naissance pour 1 OOO pour 1 OOO naissances naissances 1.7 1.5 1.0 1.5 3.6 2.2 28.0 1.3 11.4 1.2 1.6 1.2 1.0 1.3 1.1 1.7 8.6 1.9 3.3 0.9 Completeness of notification % Notifications completes % 94 80 100 87 31 77 31 146 29 75 Total years lost Nombre total d'annees perdues 621 92 22 0 0 0 0 0 4 283 Total years of actually impaired life Nombre total d'annees de vie avec un handicap 189 0 141 0 980 308 180 101 0 536 TABLE 2. TRUE AND REGISTERED BIRTH PREVALENCE OF ISOLATED MODERATELY FREQUENT CONGENITAL ANOMALIES, COMPLETENESS OF NOTIFICATION, ANNUAL TOTAL YEARS LOST AND YEARS OF ACTUALLY IMPAIRED LIFE, HUNGARY, 1973-1982 TABLEAU 2. PREVALENCE REELLE ET ENREGISTREE A LA NAISSANCE D'ANOMALIES CONGENITALES ISOLEES MODEREMENT FREQUENTES, SELON LE POURCENTAGE DES NOTIFICATIONS COMPLETES, LE NOMBRE TOTAL D'ANNEES PERDUES ET LE NOMBRE D'ANNEES AVEC UN HANDICAP, HONGRIE, 1973-1982 ICD code Code CIM 742.1 742.3 745.0 745.1 745.2 745.3 746.3-4 747.0 747.1 747.3 749.0 750.3 751.1 751.2 753.0 753.1 753.2,6 755.0 755.1 755.2-4 756.0 756.7 Common congenital anomalies Anomalies cong6nitales courantes Microcephaly - Microcephalie Congenital hydrocephaly - Hydrocephalie congenitale Common truncus - Trone arterial commun Transposition of great vessels - Transposition des gros vais- seaux Teratology of Fallot - Tetralogie de Fallot Atrial septal defect, type II - Communication interauriculaire. type II Aortic stenosis - Stenose aortique Patent ductus arteriosus - Persistance du canal arterial Coarctation of aorta - Coarctation de l'isthme aortique Pulmonary stenosis - Stenose de l'artere pulmonaire Cleft palate/without Robin - Fissure du palais/sans syndrome de Robin Oesophageal atresia/stenosis ± TE fistula - Atresie de l'c.esophage/stenose ± fistula tracheo-c.esophagienne Atresia/stenosis of small intestine - Atresie/stenose de l'in- testin grele Atresia/stenosis of rectum and anal canal - Atresie/stenose du rectum et du canal anal Renal agenesis/dysgenesis - Agenesie/dysgenesie du rein Cystic kidney disease. type I - Maladie polykystique du rein, type I Obstructive defect of urinary system - Anomalies obstructi- ves de 1 ·uretere Polydactyly - Polydactylie Syndactyly - Syndactylie Reduction anomalies of limbs - Raccourcissement des mem- bres Anomalies of diaphragm - Anomalies du diaphragme Exomphalos/gastroschisis - Exomphale/gastroschisis True binh Recorded binh prevalence per prevalence 1 OOO total per 1 OOO binhs total binhs Prevalence Prevalence reelle a la enregistree a naissance la naissance pour 1 OOO pour 1 OOO naissances naissances 2.0 7.6 1.7 2.9 3.6 7.4 5.0 7.4 3.2 2.9 4.2 1.8 1.6 1.8 2.3 1.8 1.1 3.0 2.6 3.8 1.6 2.0 1.3 6.0 0.4 1.2 1.2 2.9 1.3 2.2 0.6 1.1 3.6 1.8 1.5 2.0 0.8 0.9 0.8 3.8 3.2 3.8 2.2 2.2 Completeness of notification % Notifications completes % 65 79 24 41 33 39 11 30 19 38 86 100 94 111 35 50 73 100 138 110 Total years lost Nombre total d'annees perdues 75 362 60 62 34 43 143 48 85 23 12 52 69 49 71 56 28 0 0 0 36 18 Total years of actually impaired life Nombre total d'annees de vie avec un handicap 49 9 45 141 131 0 82 0 0 76 83 22 0 0 21 13 34 0 0 78 0 22 Rapp. trimest. statist. sanit. mond .• 41 (1988) - 221 - extremely important from the pathogenetic point of view (5) because, in general, isolated CAs (e.g. cleft lip) have a more or less homogeneous origin and probably differ from anomalies that may be part of multiple entities of very heterogeneous origin (e.g. the case of cleft lip as part of trisomy 13 and several other anomalies of monogenic or environmental etiology, such as EEC syndrome (Electrodactyly - Ectodermal dyplasia - Clefting) and fetal hydantoin syndromes (6). (iii) Minor anomalies, such as morphogenetic informa- tive variants (7), and functional anomalies, such as mental retardation, must be excluded because of incomplete information and selective notification. (iv) The registry-diagnosis method is used in the case of 22 well-known congenital anomaly entities on the basis of the notified component (6). It means that some congenital anomalies and CA-association syn- dromes are identified on the basis of predetermined criteria in the HCMR. For example, congenital cataract and congenital cardiovascular malforma- tions, mainly patent ductus arteriosus with or with- out microcephaly but without other major CAs, are diagnosed as congenital rubella syndrome, and cases with three or more VACTERL-typed CAs with- out other major CAs are registered as VACTERL- association. (v) Data are centrally coded according to the Interna- tional Classification of Diseases (ICD) with certain modifications. Since ICD codes refer to isolated or single anomalies, multiple ones are evaluated sepa- rately under a modified version of ICD rubric 759. • The unit of the HCMR is the affected individual. An index patient with two or more CAs is considered a multimalformed person. Component CAs are coded and recorded. Thus, double registration (due to the differ- ence between the number of anomalies and of mal- formed persons) can be excluded. • The deadline for receipt of data for a calendar year is 31 December of the following year. The annual report, pub- lished in May of each year, contains the following infor- mation : the birth prevalence of each anomaly, classified according to ICD-9 four-digit codes; the sex ratio; the outcome (still- and live births, and infant death rates); the proportion of singleton and multiple births; maternal age; birthweight and gestational age; the monthly and geographical distribution (20 administrative units: 19 counties and Budapest, the capital) ; as well as the com- pleteness of notifications of 45 CA groups. However, a preliminary evaluation of data is made by 31 March of the following year and also published in the annual report. The difference between the birth prevalence in these two data sets is about 5-20%. • Other programmes based on the HCMR provide op- portunities to check, revise, complete, and update the data base. The recent annual total birth prevalences of CAs regis- tered in Hungary have exceeded 4 7 per 1 OOO total births. It is estimated that about 60 of all births per 1 OOO exhibit diagnosed congenital anomalies (1). However, the birth prevalences of severe and lethal CAs are about 23 and 5 per 1 OOO total births, respectively, and these cases are nearly all ascertained. The functioning of the HCMR is continuously checked to ensure that the following seven criteria for good regis- tries are fulfilled : d VACTERL - an acronym for Vertebral, Anal, Cardiac, Tracheal, Esophagal, Renal and Limb; used to designate a pattern of congenital anomalies. Wld hlth statist. quart., 41 ( 1988) 1 . Validity of recorded diagnoses. The multiplicity of sources of notifications considerably enhances the accu- racy of notified diagnoses. Additionally, the diagnoses are continuously checked through the Case-Control Sur- veillance System, the nationwide follow-up of multimal- formed babies, the Population Surveillance of Indicator CAs, and ad hocepidemiological studies of common (8) and moderately frequent CAs performed by the Epide- miology Unit. These parallel activities help to limit the well-known dual effect of size which increases statistical power and decreases accuracy. The proportion of mis- diagnosis for different types of CAs ranges from 0% for cleft lip to 22% for ventricular septal defect. 2. Completeness of ascertainment. As a result of ad hoe epidemiological studies and other programmes the ap- proximate true birth prevalences of common (Table 1), moderately frequent (Table 2), and of some rare CAs are known. Furthermore the annual evaluation of data from 20 administrative units offers another opportunity to estimate true birth prevalences, because the major cause of lower rates is incomplete notification. It should be noted that the completeness of notification also depends on the type of anomaly, e.g. it is about100% for cleft lip but only 29% for congenital inguinal hernia. 3. Time factor. There is an inverse correlation between promptness of notification, accuracy of diagnoses and completeness of notification. As a part of the surveil- lance function of the Registry (see below) 45 CA groups are evaluated preliminarily on a quarterly basis but all CA entities are later re-evaluated in detail. Through the Case-Control Surveillance System, several families routinely inform the Centre about changes in the index patients' diagnosis, address, etc. In addition the Central Statistical Office provides the HCMR with infor- mation on all deaths due to CAs. The data from ad hoe epidemiological studies and other programmes are also attached to each patient's file. 4. A pathogenetica/ly-oriented classification. A localiza- tion-oriented anatomic classification was used previous- ly, but an etiologically-oriented nosological classification would be ideal since information on causes is the most useful. However, as the cause is still unknown for several CA entities, a reasonable compromise is a pathogeneti- cally-oriented classification (9). The HCCAC follows this approach (Fig. 1). 5. Continuous evaluation of confounding factors. Any change of pregnancy outcomes other than CAs can con- siderably modify the birth prevalences of some types of CAs. These confounding factors include induced abor- tions (mainly therapeutic), fetal deaths (spontaneous abortion and stillbirths), as well as low and very low birthweight. Thus, it is necessary to continuously evalu- ate pregnancy outcomes. In addition, some demogra- phic variables (e.g. maternal age or differential fertility with respect to socioeconomic status) are also taken into consideration in evaluating CAs. 6. Confidentiality of personal data. The issue of confi- dentiality of records related to reproduction and birth defects is of growing significance and public concern in many parts of the world. In Hungary, data on index patients, without personal identification, are available only to experts. Personal identification numbers, which have been used in this country since 1983, are of great help for record linkage. Additionally, a written informed consent is requested from the parents of index patients and it is obtained in 98% of cases; the names and addresses of the remainder are deleted from the record. - 222 - FIG. 1. EXAMPLES OF CLASSIFICATION SCHEMES FOR CONGENITAL ANOMALIES• EXEMPLES DES SYST~MES DE CLASSIFICATION DES ANOMALIES CONGENITALES• Severity Gravite Lethal CA (e.g., anencephaly) AC mortelle (anencephalie) (8%-5%) Major AC (e.g. omphalocele) AC majeure (omphalocele) (30%-18%) Mild CA (e.g., undescended testicle) AC legere (ectopie testiculaire) (62%-37%1 Minor anomaly or normal variant (e.g .. low-seat ear) Anomalie mineure ou variante de la normalite (oreille implantee bas) Pathogenesis Pathogenie Congenital abnormalities Anomalies congenitales Birth prevalence per 1 OOO births Prevalence ii la na1ssance pour 1 OOO naissances Deformation (pied bot) Dysplasia (e.g., osteogenesis imperfecta) Dysplasie (periostale) Isolated - Anomalies isolees (90%) Tres rares (:$001/5%) Multiple - Anomalies multiples (10%) Single Sequence (e.g. ventricular (e.g., diaphragmatic Complex or mono- topic field defect (e.g., tetralogy Polytopic field defect (e.g., holoprosencephaly) CA-syndrome (e.g., Down) CA-association (e.g., VACTEAL) Associations malformatives (V ACTEAL) 2% Random combination (e.g .. cleft lip and septal defect) defect and Simples its consequences) of Fallot) Anomalies polytopiques (holoprosencephalie) Syndromes malformatifs (Down) 4% anal atres1a) Associations al8atoires (bec-de-lievre et atresie du canal anal) (communication S~quences interventriculaireJ (anomalies 80% du diaphragme et ses cons4quences) 40% Anomalies complexes ou monotopiques 1% des champs morphogenetiques (tetralogie de Fallo!) 5% Manifestation a Mainly congenital abnormalities. i.e. a developmental defect, gross or microscopic, present at birth whether detected at that time or not. Percentage figures indicate the proponion of special groups within the given classification, while binh prevalences are expressed per 1 OOO total binhs. - II s'agit essentiellement d'anomalies cong6nitales, c·est-a-dire d·anomalies du developpement, flagrantes ou invisibles. presentes a la naissance. qu'elles aient alors 6te decelees ou non. Les pourcentages indiquent la proponion de groupes sp6ciaux dans la classification donn6e, tandis que la prevalence a la naissance est exprimM pour 1 OOO naissances. 7. Record linkage. The potential benefits of parallel evaluation of different registries have not yet been exploited. At present, only sib-occurrence is detected by this method on the basis of the maternal data. Multiple births to women in and around Budapest have been recorded by the Budapest Twin Registry since 1 January 1970 (10). Obstetric institutions are required to notify multiple deliveries and the completeness of noti- fications exceeds 90%. Placentas are collected and ex- amined by the pathologist. In like-sexed twins with dichorial placenta, zygosity is determined between ages 3 and 6 years by examining blood and serum protein groups. The zygosity of twins born between 1970 and 1979 was determined in 78.7% of cases. Congenital structural talipes equinovarus, congenital inguinal hernia, hypospadias and undescended testicles are significantly more frequent in twins while congenital hypertrophic pyloric stenosis is significantly less frequent. There is also a voluntary Hungarian Twin Registry involv- ing adult twins, and several scientific studies (e.g. inher- itability of lactose absorption, methane excretion, pep- sinogen, psychosexual development) have been carried out on the basis of the data collected by this institu- tion (11). Surveillance programmes Recently a distinction has been made between the terms surveillance and monitoring (12). Monitoring means to study a population at risk, i.e. exposed to known or suspected environmental factors (mutagens, terstro- gens, carcinogens), while surveillance means to study a population at large to determine the baseline occurrence of diseases and detect changes in it. The HCMR has a national surveillance function. The preliminary quarterly analysis of 45 CA groups based on Rapp. trimest. statist. sanit. mond., 41 (1988) - 223 - notifications received up to the 90th day after birth aims to detect any time and/or space clusters as quickly as possible. In Hungary the two most important findings were a temporary cluster of congenital limb-reduction abnormalities between 1975 and 1978 (13) and a signifi- cant increase in the birth prevalence of hypospadias from 1978 (14). The annual reports contain the main practical conclusions of the surveillance, i.e. changes and clusters in the birth prevalences of different CA groups. Special surveillance systems At present there are three special surveillance systems within the HCCAC based on the HCMR. 1 . The Hungarian Surveillance System of Selected Con- genital Anomalies within the International Clearinghouse for Birth Defects Monitoring Systems. The Clearing- house was established in 1974 (15, 16) with Hungary as one of the 10 founding members. At present the Clear- inghouse comprises 23 systems in 27 countries. Eleven selected CAs and MCA cases are notified within 90 days of birth to the coordinator who collates the data and information which are published quarterly. An annual report with revised data and an evaluation of some CA groups has also been published since 1980. The main purpose of this system is to recognize case-clusters as soon as possible and to identify causes, mainly terato- gens, through case-control epidemiological studies. 2. The Case-Control Surveillance System of Congenital Anomalies attempts to obtain etiological information immediately after the notification of anomalies to the HCMR in order to identify the cause (e.g. teratogens) and assist in prevention. Mild anomalies, such as Ortolani click, inguinal hernia, nevus, and haemangiomas, as well as syndromes of known origin, except for Down's syn- drome, are excluded. This surveillance system was established following a feasibility study in 1979 and has been operating since 1980. Three negative controls (i.e. newborns without anoma- lies) are matched to every index patient according to birth week, sex and district of residence of the parents. The parents of control infants receive the same ques- tionnaire and lists of drugs and diseases, but the text of the explanatory letter is different. The prenatal care log- book and other medical documents are also requested. The response rate is 67%; however, in general, at least one of the three control cases is available for compara- tive evaluation. Index patients, such as those with Down's syndrome, are evaluated by the same method and are considered as positive control cases. In the evaluation, the rates of the total control group are compared with the rates for the 25 CA groups according to the categories of drugs, maternal diseases, and occu- pational exposures; the X2 test is used for statistical evaluation. The rates of each CA group are then com- pared with those of its matched control cases; the McNemar test is used for the statistical evaluation. The final analysis is limited to significant differences and each drug within a category is evaluated separately according to gestational age. So far diazepam, chlordiazepoxide and nitrazepam; allylestrenol ; Bactrim and nitrofuran- toin; reserpin and bromcriptine have been evaluated from the teratogenic point of view. Chemical and other occupational exposures are evaluated separately (17). This case-control surveillance system has some useful supplementary functions as well: (i) to check (and cor- rect, if necessary) ; (ii) to complete the data of the HCMR Wld hlth statist. quan., 41 (1988) (paternal age, birth order, outcome of previous pregnan- cies, marital status, family history); (iii) to get written consent for further registration and action; (iv) to obtain the name and address of the child's paediatrician; (v) to inform parents about possible causes and pathogenesis, time schedule of medical treatment and possible pre- vention of recurrence by means of a special booklet. In the past, parents generally received insufficient explana- tions from medical personnel. Data obtained through the supplementary functions of the Case-Control Surveillance System are also evalu- ated. Thus the sib-occurrence of CAs detected from family history is particularly interesting in multimal- formed babies because it might help to identify the same CA entity. If the nosological diagnosis requires hospital- ization, a special department of the inpatient paediatric clinic is available in Budapest. The sib-occurrence of un- identified MCAs is about 13-15%, and involves three symmetrical proportions: concordant, half-concordant (i.e. only one component anomaly of multimalformed index patients occurs in the sib), discordant (probably random event) sib-occurrences (6). 3. The Mutation Surveillance System is based on the "indicator conditions" of offspring. Indicator conditions in an individual are (or may be) distant phenotypic man- ifestations of altered DNA in the germ cells of the par- ents. The surveillance of germinal mutations in a popu- lation at large through the help of indicator conditions is an attempt to measure the genetic load and any rise in the rate of new germinal mutations. Three types of indi- cator conditions are followed-up within this surveillance system. Sentinel phenotypes Sentinel phenotypes are indicators of germinal genie dominant mutations. They are clinical disorders that occur sporadically as a consequence of a single, highly penetrant mutant gene; they are autosomal, dominant or X-linked traits of considerable frequency and low fit- ness, and are uniformly expressed and accurately diag- nosable with a minimal clinical effort, but a relatively high probability of ascertainment (18). The advantages of using sentinel phenotypes are considerable: (i) the af- fected persons will enter the health-care systems in a developed country and will most certainly be registered in a recording system; (ii) parents of affected children are motivated to cooperate in additional investigations; (iii) when a sentinel phenotype is recognized in the absence of affected parents, the suspicion of a new ger- minal mutation is strong. According to the method of ascertainment, the following three different groups of sentinel phenotypes are distin- guished. Thirteen sentinel anomalies are easily observed at birth, and thus there is a high expected notification. These sentinel anomalies seem to be reasonably satis- factory for study in the Hungarian programme (guidelines on these anomalies including a short description and photos of each were sent to all obstetric and neonatal inpatient clinics). Two sentinel childhood tumours, reti- noblastoma and Wilms' tumour, occur in a well-defined age group and are treated (thus recorded) in centralized medical institutions. The record of the HCMR is com- pleted by the data from the Hungarian Registry of Child- hood Tumours and the Hungarian Institute of Ophthal- mology. Genetic disorders with delayed onset which are readily diagnosed and recorded in various types of genetic disease registries are also sentinel phenotypes. An attempt has been made recently to establish some specific genetic disease registries for patients affected by haemophilia A and B, Huntington's chorea, neurofi- bromatosis and intestinal polyposis. - 224 - The evaluation of 13 sentinel anomalies and two child- hood tumours together as sentinel anomalies consists of the following three steps: The parents of indexed patients are invited to bring the affected child and all other siblings to the Centre. Parents that cooperate and their children are then examined and documented at the Centre, with the help of consultant specialists, if necessary, to con- firm (or exclude) the nosological diagnosis. The other families are visited at home. In the case of deceased index patients, detailed autopsy records are evalu- ated. Family history, including data on the four grand- parents (to decide whether the case is sporadic or familial), environmental history and personal data (e.g. parental age) are obtained by personal interview and recorded by means of a questionnaire. The envi- ronmental histories of familial cases are used as con- trols. If the parents plan to have other children, genetic counselling is offered. The data thus obtained are evaluated annually. An average of 46 possible new mutations per year were found over the five-year study period (1980-1985), i.e. about 35 new mutations per 100 OOO live births (19). Additionally, this programme has highlighted some ano- malies of autosomal origin and has resulted in changes in medical services for treating these defects. Down's syndrome Down's syndrome is an indicator of germinal numerical chromosomal mutations. There are several arguments in favour of Down's syndrome as an indicator condition. Among germinal chromosomal mutations, a much higher proportion is numerical rather than structural (5 : 1 at birth and 30: 1 among feta I deaths). Down· s syndrome is the only common anomaly (1 per 1 OOO births) caused by a chromosome aberration. Two-thirds of patients with Down· s syndrome are liveborn and have a relatively good chance of survival. In general, Down's syndrome is recognizable by its clinical symptoms. Karyotyping pro- vides a reliable confirmation. The validity of the diagno- sis was found to be about 94% in the HCMR. From the standpoint of mutation surveillance, the most important characteristic of Down's syndrome is that it nearly always (98%) occurs as a de novo event. Prenatally diagnosed and selectively terminated fetuses affected by Down's syndrome are recorded in the HCMR and provide a useful complementary source of data within this population-based system. So far, surveillance of Down's syndrome has yielded the following information (20). Firstly. over the past 15 years the true birth prevalence of this syndrome has been in the range of 1.2-1.4 per 1 OOO total births. Secondly, a cyto- genetic analysis was performed on only 23% of the fetuses of mothers aged 40. Thirdly, a slight reducing effect of prenatal diagnosis has only been demonstrated in recent years. Unidentified multiple congenital anomalies Unidentified multiple congenital anomalies (MCAs) are useful as indicators of germinal dominant genie and chro- mosomal mutations. MCAs can be considered to be the most sensitive indicators of environmental factors, i.e. teratogens and mutagens. It is a reasonable postulate that new environmental factors can cause new, undeli- neated MCA entities. Thus, a sensitive surveillance mechanism for the detection of unidentified MCAs is of vital importance. For evaluation purposes, all component CAs within un- identified MCAs involving three, four, or more compo- nents are reduced to pairs, and combined with MCAs involving only two component CAs (21 ). Thus, a pair is a set of two independent component CAs in unidentified MCA cases involving two or more components. The baseline occurrences of CA pairs studied per 100000 total births between 1973 and 1982 ranges from Oto 93, presumably because this is determined by birth prevalence and the different ascertainment of com- ponent anomalies in addition to the liability of each com- bination. Some annual rates of congenital anomaly pairs exceed their 10-year averages considerably but these devia- tions seem to be relatively rare: 4. 1 % of pairs studied at the Centre and 0.4% of those in the 10-year data base. The crucial point is to separate the biologically important clusters from the statistically significant changes. After significant increase is detected, it is possible to deter- mine whether the pair is a component of a given combi- nation of CAs or whether this increase reflects a general trend. The former may indicate a causal effect. while the latter may demonstrate a change in diagnosis and noti- fication. The annual occurrence of pairs within unidentified MCA cases born after 1982 is compared with the baseline rates of CA pairs studied. The surveillance of component CA pairs within unidentified MCA cases may help detect any cluster of CA pairs due to environmental factors. Diagnostic, preventive and social rehabilitation functions The HCCAC fulfils its diagnostic function mainly through specific programmes, such as the Case-Control Surveil- lance System of Congenital Anomalies and the Mutation Surveillance of Sentinel Anomalies. However, the na- tionwide follow-up investigation of multiple anomalies merits a short description (22). The programme has a threefold purpose: (i) to increase the rate of identification of CA syndromes and associa- tions; (ii) to identify additional recognizable CA patterns because their recognition and identification can be useful for estimating prognosis and sib-occurrence; (iii) to pro- vide a special surveillance mechanism for multiple ano- malies since these are the most sensitive indicators of teratogenic and mutagenic factors. Owing to the pleio- tropic effect of mutant genes and the generalized impact of microscopically visible chromosomal aberrations, the majority of genie and autosomal chromosomal muta- tions cause congenital anomaly syndromes, i.e. multiple anomalies. In man, nearly all known teratogens (rubella, alcohol, hydantoin, etc.) also produce multiple anoma- lies. The follow-up investigation of multiple anomalies in- volves the following procedure: • Clinically diagnosed MCA entities are registered on the basis of notification (29.1 %). • New or supplementary information is requested in the case of unspecified MCAs (4.5%); as a result of this, their proportion has been reduced to 2.6%. • On the basis of component CAs, registry-diagnosis is attempted for 22 well-defined CA entities ( 12.8%); apparent but not true instances of MCAs have been excluded (5. 7%). • Surviving infants with unidentified multimalformations are referred to one of eight regional multiple congenital abnormality examination centres established within Rapp. trimest. statist. sanit. mond .. 41 (1988) - 225 - this programme, to be examined by specialists. Each of these centres is staffed with paediatricians inter- ested in syndromology and is equipped with labora- tory facilities for chromosome analysis and other tests; 2.4% of multiple anomalies have been identified and 0. 7% of cases excluded. • The remaining unidentified MCAs (47.3%) involving two or three components are listed annually according to a hierarchical order of 45 anomaly groups in a single table. Cases with four or more anomalies are listed separately. Results The main results of this population-based programme involving 7 049 notified multimalformed cases born be- tween 1973 and 1983 are as follows: • The final count of cases with MCAs was 6 643; this is equivalent to a birth prevalence of 4.0 per 1 OOO total births and to 10% of CA cases recorded during the study period. • The proportion of identified multiple anomaly entities increased from 29% to 4 7 % , and 54 % of the expected number of unbalanced chromosome aberrations was ascertained. • Some new MCA entities were identified, e.g. schisis- association (23). • The tabulation of the component CAs within uniden- tified MCAs reveals clusters of specific combinations, e.g. the association of congenital cardiovascular mal- formations and cataract increased significantly 6-8 months after a large rubella epidemic (Fig. 2). Prevention programmes A national prevention programme established in the late 1970s was initially based on the data collected by the HCMR within the framework of its prenatal screening activities, namely amniocentesis and amniotic alfa-feto- protein determination for women whose previous preg- nancies resulted in babies with anencephaly or spina bifida (24). However, since maternal serum alfa-fetopro- tein (MS-AFP) screening techniques have been devel- oped, amniotic examinations have lost their importance. The ongoing vitamin study seeks to reduce the recur- rence of neural tube defects through periconceptional multivitamin supplementation. In 1987, the number of participants exceeded 500 because information was mailed to all Hungarian women recorded as having had a baby affected by a neural tube defect. As a WHO Collaborating Centre, the Centre is mandated to develop approaches for evaluating the relevance, effect and impact of the hereditary diseases control pro- gramme. In addition, there are four prevention programmes con- cerned with genetically-determined disorders. (i) Maternal serum AFP (M-AFP) is screened at week 16 of gestation and completed by ultrasound examination; if necessary, after repeated positive MS-AFP values with negative ultrasound scanning, an amniotic AFP exami- nation is suggested. This programme became popu- lation-based in 1985, but the efficacy is low. In 1984- 1985, for example, 331 cases with isolated neural tube defects were recorded in the HCMR but the data neces- sary for further analysis were available in 279 of the cases. Only 79 were prenatally diagnosed before week 22 of pregnancy and 74 of these were terminated. The remaining 200 births were examined either by MS-AFP or by ultrasound, or by a combination of both. MS-AFP was positive in 94 cases out of 188 (50%) while ultra- sound demonstrated a neural tube defect in 22 cases out of 161 . The lack of selective abortion was explained by a discrepancy between the results of the two exami- nations, by mothers refusing to terminate their pregnan- cies or by the fact that examinations were performed too late. (ii) Prenatal chromosome examination in fetuses of mothers over 40 is offered, but only 23.4% of eligible pregnant women were examined in 1984-1985 and 16 numerical chromosome aberrations detected (in 2.6% of all fetal chromosome analyses). This is far from the desired goal. FIG. 2. INCREASED NUMBER OF CASES WITH CONGENITAL RUBELLA SYNDROME ASCERTAINED BY THE REGISTRY-DIAGNOSIS METHOD BASED ON THE COMBINATION OF CATARACT AND HEART DEFECTS AFTER A RUBELLA EPIDEMIC, HUNGARY, 1974 AUGMENTATION DU NOMBRE DES CAS ATTEINTS DU SYNDROME DE RUBIEOLE CONGENITALE ET CONFIRMES PAR LA METHODE DU DIAGNOSTIC FONDE SUR LE REGISTRE A. PARTIR DE L'ASSOCIATION CATARACTE-MALFORMATIONS CARDIAQUES APRES UNE IEPIDIEMIE DE RUBIEOLE, HONGRIE, 1974 Rubella epidemic - Rubeole epidemique 50 40 "' ! ~ 30 "' .., c: 20 .. "' :, 0 .t: ... 10 0 ........ ........ Wld hlth statist. quan., 41 (1988) 1974 Congenital rubella syndrome /", Syndrome de ruMole cong<§nitale , ' , ' , ' , ', , \ , \ , \ , \ Ouaners - Trimestres \ \ \ \ 1975 10 8 6 4 2 0 - 226 - (iii) Screening of newborns for phenylketonuria (PKU) became a population-based programme in 1973. Screening for galactosemia and hypothyroidism were added later. These components of the programme seem to work well and the recorded birth prevalence of PKU is 0.9 per 1 OOO. (iv) Orthopedic screening of newborns has resulted in the almost total elimination of Hungary's most common CA, dislocation of the hip. As a matter of fact, intensive screening has resulted in overdiagnosis, which has greatly increased the notified birth prevalence of this anomaly (28 per 1 OOO compared with a prevalence of manifest cases of about 10 per 1 OOO in the 1940s). At present, an effort is being made to improve the reliability of diagnosis. Rehabilitation programme The social rehabilitation programme involves surviving children with major CAs registered in the data base of the HCMR; this concerned about 110 OOO children in 1988. This programme offers a range of services for school- age children with major CAs: (i) a medical examination to provide supplementary treatment if necessary (e.g. bet- ter prothesis in children with limb reduction, or additional logopaedic education for those with oral clefts) ; (ii) psy- chological counselling to overcome a number of prob- lems, including inferiority complex; (iii) employment counselling ; (iv) special counselling for family planning; (v) the organization of special clubs or societies where these individuals can have independent but joint social activity and can help one another. In addition, the Hungarian Twin Society and the Twin Club, under the direction of the HCCAC, promote social activities for twins. Besides the activities outlined above, the HCCAC has helped to launch a number of projects and one of the potential benefits to be derived from this research would be a reduction in the occurrence of CAs. However, the main purpose of the Hungarian Centre for Congenital Anomaly Control is to promote and contribute to the improvement of medical services and to an increase in the efficacy of existing preventive measures. SUMMARY The Hungarian Centre for Congenital Anomaly Control manages a number of surveillance programmes based on the Hungarian Congenital Malformation Registry. No- tification of congenital anomalies, which is compulsory. originates exclusively from physicians working in va- rious health institutions and is based on their diagnosis of malformed patients-newborns and infants. In recent years, the total birth prevalence of registered congenital anomalies has exceeded 4 7 per 1 OOO total births. The notified data are critically evaluated and centrally coded according to the unit of notification, the affected individ- ual. Diagnostic accuracy, completeness of notifications and the effect of confounding variables are continuously checked. The purpose of the Case-Control Surveillance System is to obtain etiological information concerning drug consumption, maternal diseases and occupational hazards during pregnancy. The surveillance of mutations through indicator conditions (sentinel anomalies. Down's syndrome and pairs of components of unidenti- fied multiple congenital anomalies) is an attempt to measure the rate and trend of new germinal mutations. The nationwide follow-up of multimalformed infants helps to increase the proportion of identified congenital anomaly entities, to identify new ones, and to detect clusters caused by new environmental teratogenic or mutagenic factors. RESUME Les activites du centre hongrois de lutte contre les anomalies congenitales Le centre hongrois de lutte contre les anomalies conge- nitales gere un certain nombre de programmes de sur- veillance fondes sur le Registre hongrois des malforma- tions congenitales. La notification des anomalies conge- nitales. qui est obligatoire, est du ressort exclusif des medecins attaches aux divers etablissements de sante et repose sur les malformations qu'ils diagnostiquent chez les nouveau-nes et les nourrissons. Ces dernieres annees, la prevalence totale des anomalies congenitales enregistrees a la naissance a depasse 4 7 pour 1 OOO naissances. Les donnees notifiees font I' objet d'une eva- luation critique et sont codees au niveau central selon l'unite de notification, a savoir le sujet affecte. Un controle permanent sert a assurer que le diagnostic est exact et que les notifications sont completes et a verifier l'effet des facteurs d'erreur. Le systeme de surveillance cas-temoins a pour but d'obtenir des renseignements etiologiques sur les medicaments absorbes, les mala- dies de la mere et les risques professionnels pendant la grossesse. La surveillance des mutations par les mala- dies indicatrices (anomalies sentinelles, syndrome de Down et paires d'anomalies composantes d'anomalies congenitales multiples non identifiees) vise a mesurer la frequence des mutations germinales nouvelles et leur evolution. Le suivi a l'echelle du pays des nourrissons atteints de malformations multiples aide a accroitre la proportion des anomalies congenitales identifiees, a identifier certaines anomalies nouvelles et a depister les anomalies groupees dues a de nouveaux facteurs envi- ronnementaux teratogenes et mutagenes. Rapp. trimest. statist. sanit. mond., 41 (1988) - 227 - REFERENCES - REFERENCES 1. CZEIZEI, A. ET AL. The load of genetic and partially genetic disorders in man. I. Congenital anomalies: estimates of detriment in terms of years of life lost and years of impaired life. Mutation research, 128: 73-103 (1984). 2. MILLER, J. R., Some uses of genetic registers. In: Emery, A.E.H. & Miller, J. R. (eds), Registers for the detection and prevention of genetic disease. New York, Stratton International Medical Book Corpora- tion, 1976. 3. Boo, M. ET AL. Congenital malformation surveillance. Teratology, 24: 277-283 (1981). 4. ROSE, G. ET AL. Epidemiology for the uninitiated, London, British Medical Association, 1986. (Sec- ond edition). 5. CZEIZEL, A. Incidence and prevalence as measures of the frequency of birth defects. American journal of epidemiology, 119 : 14 1-142 ( 1984). 6. CZEIZEL, A. ET AL. Multiple congenital abnormality. Budapest, Akademiai Kiad6, 1988. 7. MEHES, K. Minor malformations in the neonate. Budapest, Akademiai Kiad6, 1983. 8. CZEIZEL, A. ET AL. Aetiological studies of isolated common congenital abnormalities in Hungary. Budapest, Akademiai Kiad6, 1984. 9. SPRANGER, J. ET AL. Errors of morphogenesis: concepts and terms. Journal of pediatrics, 100: 160-165 (1982). 10. CZEIZEL, A. ET AL. The Twin Register of Budapest. Acta geneticae medicae et gemellologiae, 22: 219- 223 (1972). 11. METNEKI, J. ET AL. A study of lactose absorption capacity in twins. Human genetics, 67: 296-300 (1984). 12. WORLD HEALTH ORGANIZATION. Guidelines for the study of genetic effects in human populations. Geneva, WHO, 1985. (Environmental Health Crite- ria No. 46). Wld hlth statist. quan., 41 (1988) 13. CZEIZEL, A. ET AL. An aetiological evaluation of in- creased occurrence of congenital limb reduction in Hungary, 19 75-1978. International journal of epide- miology, 12 : 445-449 ( 1983). 14. CZEIZEL, A. Increasing trends in congenital malfor- mations of male external genitalia. Lancet, i: 462- 463 (1985). 15. FLYNT, J. W. ET AL. International clearinghouse for birth defects monitoring systems. Contributions to epidemiology and biostatistics, 1: 44 (1979). 16. CASTILLA, E. ET AL. Methodology for birth defects monitoring. Binh defects original anic/e series, 22 (5): 1-43 (1986). 17. CZEIZEL, A. Case-control surveillance system of congenital anomalies in relation to occupational ex- posure. In: Sorsa, M. & Norppa, H. (eds), Monitoring of occupational genetoxicants. New York, Alan R. Liss. 1986. 18. MULVIHILL, J. J. ET AL. Perspectives in mutation epi- demiology - 6. A 1983 view of sentinel phenoty- pes. Mutation research, 123: 345-361 (1983). 19. CZEIZEL, A. ET AL. Mutation surveillance of sentinel anomalies in Hungary, 1980-1984. Mutation re- search, 186: 73-79 (1987). 20. CZEIZEL, A. Some epidemiological characteristics of Down's syndrome in Hungary. Acta morphologica hungarica: in press (1988). 21. K1svARGA, A. ET AL. A pairwise evaluation of compo- nent congenital abnormalities in unidentified multi- ple congenital abnormalities. Mutation research: in press (1988). 22. CZEIZEL, A. ET AL. A nationwide evaluation of multiple congenital abnormalities in Hungary. Genetic epide- miology: in press (1988). 23. CZEIZEL, A. Schisis-association. American journal of medical genetics, 10: 25-35 ( 1981). 24. CZEIZEL, A. ET AL. National programme for prevention of the recurrence of neural tube defects. Acta pae- diatrica hungarica, 21: 315-319 (1979). - 228 - TENDANCES ET EFFETS DU TABAGISME DANS LE MONDE Robert Masironia & Keith Rothwellb Le tabagisme est sans conteste une cause majeure de maladie et de deces prematures chez les fumeurs ainsi qu'une source de gene et, probablement, de mauvais etat de sante chez ceux qui sont exposes a la fumee de tabac. Le tabagisme se developpe rapidement dans le monde du fait de la production et de la commercialisation des cigarettes sur une large echelle. L'usage du tabac etait surtout repandu chez les hommes adultes des pays industrialises mais, au cours des annees 50 et 60, ii est devenu de plus en plus commun chez les femmes et les adolescents de ces pays. Dans les pays en developpe- ment, la consommation de cigarettes remplace rapide- ment les usages traditionnels du tabac et elle y augmente tres sensiblement. Les preuves d'une relation de cause a effet entre !'usage du tabac, fume ou chique, et la maladie sont ecrasantes et irrefutables. Elles reposent sur environ 50 OOO publi- cations resultant d'etudes de toutes sortes (prospecti- ves, retrospectives, cliniques de cas temoins, epidemio- logiques, et experimentales) menees dans de nombreux pays. La cigarette est tenue pour responsable de 90% de tous les cas de cancer du poumon, de 75% des cas de bron- chite chronique et d'emphyseme et de 25% des cardio- pathies ischemiques chez les hommes de moins de 65 ans ainsi que d'un certain nombre d'autres types de cancer et d'une augmentation de la frequence des trou- bles respiratoires chez les enfants dont les parents fument. Dans de nombreux pays en developpement, les usages traditionnels du tabac sont largement repandus. En Asie du Sud-Est, on estime que !'usage du tabac a chiquer est responsable d'environ 90% des deces par cancer de la cavite buccale. Ces donnees ont ete etablies de maniere serieuse (1-7). Dans de nombreux pays industrialises, les responsables de la sante publique menent des programmes de lutte contre le tabagisme et les taux tres eleves de consom- mation atteints dans les annees 70 ont ete enrayes par le biais par exemple d'une sensibilisation du grand public, d'une education des fumeurs et des jeunes, d'accords d'autolimitation conclus avec l'industrie du tabac et d'une legislation. Dans la majorite des pays en develop- pement, notamment dans ceux ou la production de tabac est consideree comme une source de recettes d'expor- tation et la production de cigarettes une source de revenu interieur, on s'est peu penche sur les repercus- sions economiques de plus en plus graves de la maladie et, jusqu'a present, la lutte antitabac a rec;u un rang de priorite peu eleve. La rapidite avec laquelle nombre de gouvernements agis- sent quand un produit pharmaceutique ou un additif ali- • Chef, Programme tabac ou sante, Organisation mondiale de la Sante. Geneve. b Consultant, Programme tabac ou sante, Organisation mondiale de la Sante, Geneve. c Organisation mondiale de la Sante. Programme OMS tabac ou santt!. Rapport du Directeur general. (Document EB 77 /22 Add. 1 • 15 novembre 19851. mentaire est soupc;onne d' avoir des consequences noci- ves sur la sante contraste avec leur reticence a s'atta- quer au tabac dont le role en tant que cause de mortalite et de morbidite a ete prouve et depasse largement celui de tout autre produit actuellement offert a la consomma- tion humaine. Le resultat de cette passivite est que les maladies evitables dues au tabac seront de plus en plus repandues dans les pays en developpement avant que les maladies transmissibles et la malnutrition n'aient pu etre maitrisees, ce qui accentuera encore le fosse entre pays riches et pays pauvres (1). Tendances du tabagisme dans le monde Entre 1970 et 1985, la consommation globale de ciga- rettes a progresse plus rapidement que la population et elle est toujours en augmentation (8). Le tableau 1 indi- que la consommation totale de cigarettes et la consom- mation par adulte dans 122 pays entre 1970 et 1985 et le tableau 21' evolution en pourcentage de la consomma- tion totale et de la consommation par adulte pour de grandes zones geographiques. La figure 1 montre I' evo- lution de la consommation totale de cigarettes. Ces chif- fres s'appuient sur des donnees emanant de sources trop nombreuses pour etre citees ici. Dans le cas de nombreux pays en developpement pour lesquels on ne dispose pas de donnees officielles valables, les chiffres obtenus de documents officieux et de rapports de reu- nions ont ete utilises pour essayer d' evaluer I' ampleur du tabagisme dans ces pays. Les tableaux 1 & 2 montrent que la consommation mon- diale de cigarettes par adulte n'a augmente que tres legerement, de 7, 1% entre 1970 et 1985. Elle a recule dans de nombreux pays industrialises qui menent des programmes de prevention methodiques depuis de nombreuses annees; la consommation de cigarettes a baisse de 9% aux Etats-Unis d' Amerique et au Canada, de 6% en Australia et en Nouvelle-Zelande et de 25% au Royaume-Uni (9). En revanche, dans de nombreux pays en developpement, la consommation de cigarettes par adulte, bien que beaucoup plus faible que dans les pays industrialises, a augmente notablement, puisqu'elle a progresse de 42% en Afrique, de 24% en Amerique latine et de 22% en Asie, par exemple. D'apres les donnees de la FAQ et de la Banque mondiale citees dans un rapport de l'OMS,c c' est dans le monde en developpement que !'augmentation de la consommation de tabac est la plus forte et elle devrait le rester. En Egypte, la consommation totale de tabac est passee de 38 500 tonnes en 1978 a 46 OOO tonnes en 1983 (S. Omar, communication personnelle, 1988) alors que, a titre de comparaison, au cours de la meme periode, elle est tombee de 113 OOO a 92 OOO tonnes au Royaume- Uni (9). En Egypte et au Kenya, la consommation de cigarettes augmenterait de 8% par an. En Arabie saou- dite, ou pres de 90 marques de cigarettes sont disponi- bles a la vente, les importations de tabac ont ete multi- pliees par 25 et sont passees de 1 700 a 42 400 tonnes entre 1962 et 1984 (K. Ball, communication person- nelle, 1988). Au Pakistan, la consommation totale de Rapp. trimest. statist. sanit. mond .. 41 ( 19881 - 229 - TABLE 1. TOTAL AND ADULT (15 + YEARS) PER CAPITA CONSUMPTION OF MANUFACTURED CIGARETTES IN 122 COUNTRIES/AREAS IN 1970 AND 1985, BY WHO REGION TABLEAU 1. CONSOMMATION TOTALE ET PAR ADULTE (15 + ANS) DE CIGARETTES MANUFACTUREES DANS 122 PAYS ET TERRITOIRES EN 1970 ET 1985, PAR REGION OMS Africa - Afrique Algeria - Algerie Angola .. Benin - Benin Burkina Faso . . . Cameroon - Cameroun Cape Verde ...... . WHO Region and country/ area Rl!gion OMS et pays/territoire Central African Republic - Republique centrafricaine Chad - Tchad Congo ....... . Cote d'Ivoire ... . Ethiopia - Ethiopie Ghana ..... . Guinea - Guinee Kenya Liberia - Liberia Madagascar Malawi ..... Mauritius - Maurice Mozambique . . Niger ....... . Nigeria - Nigeria . . Reunion - Reunion Senegal - Senegal Sierra Leone South Africa - Afrique du Sud Togo . . . . . . . ..... . Uganda - Ouganda United Republic of Tanzania - Republique-Unie de Tanzanie Zaire - Zarre . . . Zambia - Zambie . . . . . Zimbabwe ........ . Americas - Ameriques Argentina - Argentine Barbados - Barbade Bolivia - Bolivie Brazil - Bresil Canada ..... Chile - Chili . . Colombia - Colombie Costa Rica ..... . Cuba ......... . Dominican Republic - Republique dominicaine Ecuador - Equateur El Salvador . . . Guadeloupe . . . Guatemala Guyana - Guyane Haiti - Harti Honduras ..... Jamaica - Jamai"que Mexico - Mexique Nicaragua .. Panama .. . Paraguay ..... . Peru - Perou . . Suriname ..... . Trinidad and Tobago - Trinite-et-Tobago United States - Etats-Unis Uruguay .................. . Venezuela . . . . . ........... . South-East Asia - Asie du Sud-Est Bangladesh . . . . . . . Burma - Birmanie . . . India - lnde . . . Indonesia - lndonesie Nepal - Nepal . . . . Sri Lanka Thailand - Thailande Wld hlth statist. quan .• 41 ( 1988) Total cigarette consumption (in millions) Consommation totale de cigarettes (en millions) 1970 6300 2 150 1300 300 975 30 280 330 390 2 300 1 OOO 1600 50 2400 300 950 450 600 2 350 250 8 500 400 1600 700 18100 550 1500 2 500 3 550 1150 3000 29350 181 730 72 700 49823 6 590 19000 1 568 20000 2 125 2 300 1846 200 2 100 500 1420 1300 1260 41600 1 330 1 OOO 1 200 2904 187 1050 532 769 3 121 11428 7000 1 512 62000 33000 1 135 3035 15 303 1985 18900 2 550 1 600 130 3400 40 420 400 900 4000 1 450 2 300 90 5 350 530 2 500 1480 1 220 3450 340 18 100 350 2200 1 750 29694 750 2050 3800 3 435 1 415 2 318 37 470 253 1200 146 300 63 518 8366 34590 2200 29000 3645 4800 2 300 260 2 348 600 900 2 340 1 220 54403 2400 1 155 2 150 4110 390 1 270 607 960 3 885 19 760 14 750 2 700 77 780 106 738 1400 5 310 29420 Adult per capita consumption (both sexes combined) Consommation par adulte (pour les deux sexes) 1970 890 500 850 250 210 240 500 720 60 340 20 430 390 240 190 1 260 500 100 280 1620 700 420 1 360 480 290 350 330 500 1060 1 730 1 150 300 1310 3 340 1080 1 670 1680 4000 1100 700 950 1090 740 1 350 540 940 1 270 1 790 1 250 1 180 960 390 1 040 1 900 3650 1 540 1 980 190 95 190 480 170 420 760 308 1508 1985 1 590 530 740 610 210 280 920 710 60 380 30 550 450 450 390 1 700 430 100 370 940 610 830 1 550 460 260 330 210 400 500 1 780 1 380 330 1 700 3 180 1 OOO 1920 1 340 3920 980 880 750 1 080 550 1 OOO 240 1 010 820 1 190 1 380 850 1 OOO 350 1 660 1600 3 270 1 760 1890 270 150 160 1 050 150 500 900 - 230 - TABLE 1 (cont'd) Europe WHO Region and country/area Region OMS et pays/territoire Austria - Autriche . . . . . . . Belgium - Belgique . . . . . . Bulgaria - Bulgarie . . . . . . . Czechoslovakia - Tchecoslovaquie Denmark - Danemark . . . . . . . . Finland - Finlande . . . . . . . . . . Fraoce ......... . German Democratic Republic - Republique democratique allemande Germany, Federal Republic of - Allemagne, Republique federale d' Greece - Grece . . Hungary - Hongrie Iceland - lslande Ireland - lrlande . . Israel - lsralll Italy - ltalie Netherlands - Pays-Bas Norway - Norvege Poland - Pologne Portugal ...... . Romania - Roumanie Spain - Espagne Sweden - Suede . . Switzerland - Suisse Turkey - Turquie United Kingdom - Royaume-Uni USSR - URSS ........ . Yugoslavia - Yougoslavie .. . Eastern Mediterranean - Mediterranee orientale Egypt - Egypte . . . . . . . . . . . . . . . Libyan Arab Jamahiriya - Jamahiriya arabe libyenne Morocco - Maroc Sudan - Soudan . Tunisia - Tunisie ..... Afghanistan .... Cyprus - Chypre Iran (Islamic Republic of - Republique islamique d') Iraq ........ . Jordan - Jordanie Kuwait - Koweit Lebanon - Liban Pakistan ..... . Saudi Arabia - Arabie saoudite Syrian Arab Republic - Republique arabe syrienne Western Pacific - Pacifique occidental Australia - Australie . . . . . . . China - Chine . . . . . . . . . Total cigarette consumption (in millions) Consommation totale de cigarettes (en millions) 1970 13037 17 632 12420 25202 6 357 6480 69886 24 38Qb 118051 15300 22050 254 6070 3868 71 618 23058 5 885a 69 193 8 724 26400 50494 8 975 16 300 37 300 127 900 323 OOO 32072 12027 2800 5 500 1500 3400 120 850 11900 6648 1600 2000 4000 22400 6000 2430 25 938 600000 1985 15 640 16469 17000 30000 8 781 6800 106417 31 5QQb 123 247 28 651 27 280 550 6400 6 725 112 824 19 606 6 357a 92454 13 804 36 200 79 138 11 320 16 470 61 701 96 882 455 100 53000 52 850 5 500 13 890 1 540 6 327 475 2020 15000 8 230 3100 3000 4800 37 259 13 500 11 150 32 675 1 180 600 TABLEAU 1 (suite) Adult per capita consumption (both sexes combined) Consommation par adulte (pour les deux sexes) 1970 2330 2 380 1920 2330 1 690 1 870 1 830 1 86Qb 2 510 2 320 2 740 1 840 2 980 1940 1 770 2430 2 01oa 2900 1410 1 750 2 070 1 620 3470 1 790 3040 1 870 2 170 630 2 560 690 190 1 230 15 2000 780 1 330 1 280 4 700 2 890 630 1 880 760 2 900 1 200 1985 2 560 1 990 2410 2 550 2110 1 720 2400 2 340b 2 380 3 640 3 260 3 100 2 560 2 310 2460 1690 1 92oa 3 300 1 730 2 110 2 740 1660 2 960 1 970 2 120 2 170 3000 1860 2 850 1 070 130 1470 50 4050 620 980 1 700 2 760 2 880 660 2 110 2050 2 720 1 590 Democratic People's Rep. of Korea Rep. populaire democratique de Coree Fiji - Fidji . . . . . . . . . . . . . . ......... . Hong Kong . . . . . . . . . . . . . ......... . Japan - Japan . . . . . . . . . . . . . . . . . . . . Lao People's Democratic Rep. - Rep. democratique populaire lao Malaysia - Malaisie . . . . . . . . . . . . . . . . . New Zealand - Nouvelle-Zelande . . . . . . . . . Papua New Guinea - Papouasie-Nouvelle-Guinee Philippines . . . . . . . . . Republic of Korea -Republique de Coree Singapore - Singapour Viet Nam ....... . • Including hand-rolled - Y compris les cigarettes roulees ii la main. b Estimate - Estimation cigarettes a augmente de 160%, passant de 24 milliards en 1970 a 39 milliards en 1980. En lnde, elle a progresse de 400% au cours de la m~me periode. En Papouasie- Nouvelle-Guinee, la consommation a triple entre 1960 et 1980. En Republique islamique d'lran, la consommation totale de cigarettes est passee de 14 a 32 milliards entre 1980 et 1983. 10000 389 6401 222000 360 7 600 4952 39 700 39 500 2 787 20000 14699 695 6 700 309 180 1 165 17 853 6 325 55 61 914 75 434 4407 24250 1200 1 320 2 570 2800 210 1440 2 570 1 120 2 140 2 190 830 1 180 1600 1 580 3 270 490 2 256 2 510 30 1910 2660 2 280 670 Le tableau 3 reprend les chiffres les plus recants sur la prevalence du tabagisme. Dans de nombreux pays in- dustrialises, la prevalence a commence a reculer, chez les hommes au mains. Ainsi, au Royaume-Uni, le pour- centage d'hommes qui fument est tombe de 65% a 45% entre 1948 et 1985 et celui des femmes qui fument de 45% a 34% entre 1975 et 1985 (9). Aux Etats-Unis, la Rapp. trimest. statist. sanit. mond., 41 (1988) .. .., " " <( I :;; .. >- 120 110 100 90 80 70 60 50 40 30 20 10 0 - 231 - TABLE 2. OVERALL CHANGES IN CONSUMPTION OF MANUFACTURED CIGARETTES BY MAJOR GEOGRAPHICAL AREAS,• 1970-1985 TABLEAU 2. EVOLUTION GENERALE DE LA CONSOMMATION DE CIGARETTES MANUFACTUREES PAR GRANDES ZONES GEOGRAPHIQUES,• 1970-1985 Area - Zone Africa - Afrique ................ . Americasb - Ameriquesb United States and Canada- Etats-Unis et Canada Asia - Asie .... Europec Oceania - Oceanie World total - Total mondial Number of countries considered Nombre de pays consideres 36 26 2 29 25 4 122 Consumption of cigarettes in millions Consommation de cigarettes en millions 1970 91082 226 990 582 592 1 170449 1 100 738 31 279 3 203130 1985 197019 367315 671 478 2 101 260 1411900 39 750 4 788 722 Percentage change in consumption, 1970-1985 Evolution en pourcentage de la consommation. 1970-1985 Total Per adult Totale Par adulte % % 116 41.6 62 24.0 15 -9.3 79 22.1 28 11.0 27 -6.4 50 7.1 a Countries are the same as in Table 1 but the geographical areas are not necessarily the same as the WHO Regions - Les pays et territoires sont les m~mes que dans le tableau 1 mais ne sont pas groupes par Region de rOMS. b Excluding United States and Canada - Etats-Unis et Canada exclus. ' Including USSR - URSS inclus. FIG. 1 CHANGE IN THE TOTAL CONSUMPTION OF MANUFACTURED CIGARETTES IN SIX GEOGRAPHICAL AREAS, 1970-1985 EVOLUTION DE LA CONSOMMATION TOTALE DE CIGARETTES MANUFACTUREES DANS SIX ZONES GEOGRAPHIQUES, 1970-1985 Africa - Afrique 2 Americas (excluding Canada and the United States) Ameriques (~ !'exclusion du Canada et des Etats-Unis) ------ 3. Asia - Asie ....•....•. 4. Oceania - Oceanie 5. Europe 6. Canada and United States Canada et Etats·Unis 3 _____ 2 -- -- -- -- - -- . - -- --- 5 ------. 6 1970 71 72 73 74 75 76 77 78 79 1980 81 82 83 84 85 Percentage change - Pourcentage de variation Wld hlth statist. quart .. 41 ( 1988) - 232 - TABLE 3. SMOKING PREVALENCE AND ADULT PER CAPITA CIGARETTE CONSUMPTION IN THE VEAR SHOWN IN 84 COUNTRIES• TABLEAU 3. PREVALENCE DU TABAGISME ET CONSOMMATION DE CIGARETTES PAR ADULTE POUR L'ANNEE INDIQUEE DANS 84 PAYS• Argentina - Argentine Australia - Australie Austria - Autriche Bangladesh . . Barbados - Barbade Belgium - Belgique Bolivia - Bolivie Brazil - Bresil Canada .... Chile - Chili China - Chine Country/area - Pays/territoire Colombia - Colombie Cook Islands - lies Cook Cote d'Ivoire Czechoslovakia - Tchecoslovaquie Denmark - Danemark Egypt - Egypte . . . . . . . . . . Ethiopia - Ethiopie . . Fiji (Melanesian) - Fidji (melanesiens) Fiji (Indian) - Fidji (indiens) . . . . . . Finland - Finlande . . . . . . France ................ . French Polynesia (Maori) - Polynesie frarn;:aise (maoris) Germany, Federal Republic of - Allemagne, Republique federale d' Ghana .... Greece - Grece Guam ..... . Guatemala Guyana - Guyane Hong Kong Hungary - Hongrie India - lnde . . . . Indonesia - lndonesie Iraq ...... . Ireland - lrlande Israel - lsral!I Italy - ltalie Japan - Japon Kiribati Kuwait - Kowei't Malaysia - Malaisie Mauritius - Maurice Mexico - Mexique Nauru ....... . Nepal - Nepal . . . Netherlands - Pays-Bas New Zealand - Nouvelle-Zelande New Caledonia - Nouvelle-Caledonie Nigeria - Nigeria Niue ........ . Norway - Norvege Pakistan ..... . Papua New Guinea - Papouasie-Nouvelle-Guinee Peru - Perou · Philippines Poland - Pologne Portugal ..... . Republic of Korea - Republique de Coree Romania - Roumanie Senegal - Senegal Singapore - Singapour Spain - Espagne Sri Lanka ...... . Swaziland .... . Sweden - Suede Switzerland - Suisse Thailand - Thailande Tonga ........ . Trinidad and Tobago - Trinite-et-Tobago Tunisia - Tunisie Turkey - Turquie ............. . Tuvalu ................... . Uganda - Ouganda . . . . . . . . . . . . United States of America - Etats-Unis d' Amerique Smoking prevalence (%1 Prevalence du tabagisme (%1 M + F M F 58 18 37 30 27 33 22 70 20 10 28 35 21 73 84 61 59 53 31 28 52 18 30 62 8 43 57 31 38 19 24 1 57 14 43 49 38 16 33 2 15 28 3 76 44 52 13 28 35 17 37 49 26 50 46 36 44 29 25 50 1 54 13 40 36 10 48 4 19 33 4 50 25 52 3 75 5 45 6 35 39 32 32 38 25 35 46 18 66 14 85 70 52 12 21 41 4 58 7 45 47 44 53 59 79 58 41 33 35 29 58 22 53 3 58 17 42 32 29 44 6 85 80 21 34 7 78 63 29 37 10 32 69 7 48 13 43 35 19 35 3 40 58 27 48 2 80 72 28 26 30 46 29 36 59 13 50 62 38 20 35 5 60 6 50 50 51 31 33 27 30 24 Date of prevalence survey Date de I' enquAte de prevalence 1983 1981 1984 1984 1986 1980 1981 1980 1980 1981 1984 1987 1981 1978 1980 1980 1985 1982 1984 1975 1985 1984 1984 1980 1984 1984 1986 1982 1987 1980 1984 1981 1984 1987 1984 1975 1981 1982 1981 1979 1980 1985 1982 1981 1971 1982 1983 1984 1981 1980 1985 1986 1984 1987 1986 1981 1981 1987 1987 1984 1976 1987 Rapp. trimest. statist. sanit. mond., 41 ( 19881 - 233 - Country/area - Pays/territoire United Kingdom - Royaume-Uni Uruguay .... USSR - URSS .......... . Venezuela ..... . Viet Nam . . . . . . . . . . Western Samoa - Samoa occidental . Yugoslavia - Yougoslavie Zambia - Zambie . . . . a Data collected from numerous sources - Oonnl!es provenant de diverses sources. prevalence du tabagisme masculin est passee de 54% a 29% entre 1955 et 1986 et celle du tabagisme feminin de 36% a 24% entre 1944 et 1986 (10). En Norvege, la prevalence du tabagisme masculin est tombee de 53% a 42% entre 1974 et 1984 et en Australie, de 72% a 33% entre 1945 et 1985. Au Canada, le pourcentage d'hom- mes qui fument a recule de 44% a 35% entre 1981 et 1986 et celui de femmes qui fument de 35% a 31%(11). Si, comme ii a deja ete indique, la consommation de cigarettes par habitant adulte est beaucoup plus faible dans la plupart des pays en developpement que dans les pays riches, la prevalence y est frequemment plus ele- vee. En Tunisie, par exemple, 60% des hommes fument et 75% des fumeurs consomment plus de 20 cigarettes par jour (H. Smaoui, these presentee a la Faculte de medecine et de pharmacie de Tunis, 1986, communica- tion personnelle). Le nombre de cigarettes manufacturees consommees par adulte ne donne pas obligatoirement une idee exacte de !'importance de la consommation de tabac dans cer- tains pays en developpement ou l'usage des bidis et d'autres formes de tabac de culture familiale est large- ment repandu et mal documente. Le Bangladesh, l'lnde, le Pakistan et Sri Lanka ant une importante industrie artisanale qui produit des bidis et du tabac a chiquer et ces activites sont difficiles a evaluer. En outre, les ciga- rettes et les bidis consommes dans les pays en deve- loppement ant souvent des concentrations beaucoup plus elevees de goudron, nicotine, oxyde de carbone et autres substances nocives que les cigarettes commer- cialisees dans les pays industrialises ou les cigarettes a faible ou moyenne teneur en goudron et en nicotine sont de plus en plus courantes. Ainsi, le risque lie au taba- gisme dans de nombreux pays en developpement est relativement plus eleve que ne l'indiquent les chiffres concernant la consommation de cigarettes. Ainsi, les cigarettes commercialisees en Chine et en lnde ant des teneurs elevees en goudron (21-33 mg et 18- 28 mg par cigarette respectivement) et en nicotine (0, 7- 1,2 mg et 1-1,8 mg respectivement). Les cigarettes indonesiennes ant une teneur en goudron allant jusqu'a 55 mg et en nicotine (5 mg) encore plus importante, notamment les kretek, dont le tabac est parfume avec des clous de girofle. La situation en Europe Jusqu'au debut des annees 70, la consommation an- nuelle de cigarettes par habitant a progresse reguliere- ment en Europe mais, depuis 1976, elle est demeuree Wld hlth statist. quart .. 41 ( 1988) Smoking prevalence (%) Date of Pr6valence du tabagisme (%) prevalence survey Date de I' enqu~te M + F M F de prevalence 36 32 1984 45 45 45 1985 27 48 11 68 69 67 1984 20 38 2 1984 66 22 1978 57 10 24 39 7 1983 pratiquement constante avec 1 900 cigarettes (12). Comme le montre le tableau 2, entre 1970 et 1985, la consommation par adulte a recule en Belgique, en Finlande, en lrlande, en Norvege, aux Pays-Bas, en Repu- blique federale d' Allemagne, en Suisse et au Royaume- Uni, mais elle a augmente dans tous les autres pays, ce qui donne une faible augmentation, de 11 % en moyenne. C' est au debut des annees 50 que la prevalence du taba- gisme a atteint son niveau le plus eleve; dans de nom- breux pays, plus de 70% de la population adulte mascu- line fumait. Depuis lors, dans la majorite des pays, la prevalence du tabagisme est tombee a 35-40%. Paral- lelement a la prevalence de la consommation de cigaret- tes, la mortalite par cancer du poumon a sensiblement augmente chez les hommes au cours des 20 dernieres annees. Dans tous les pays, les taux de mortalite mas- culine sont importants, le taux le plus eleve etant de 121 pour 100 OOO habitants en Ecosse. Le taux de mortalite par cancer du poumon chez les femmes reste faible mais ii est en augmentation dans de nombreux pays, attei- gnant un maximum (38 pour 100 000) a nouveau en Ecosse. Les pays europeens ou sont observes des signes encourageants sont la Finlande, la Suede et le Royaume-Uni ou des programmes de prevention du tabagisme sont menes depuis plusieurs annees et ou les taux de mortalite par cancer du poumon chez les hom- mes ant aujourd'hui commence a reculer. Dans la population feminine, la prevalence du tabagisme a continue a progresser dans tous les pays europeens jusqu'au milieu des annees 70 et est demeuree, depuis lors, elevee. Dans plusieurs pays, elle depasse 40%. Pour les deux sexes, elle tend a atteindre un maximum dans le groupe d'age 20-30 ans. Dans les groupes d'age plus eleves, le nombre des femmes qui fument est mains important. Dans de nombreux pays, les jeunes fumeurs se repartissent equitablement entre les deux sexes, mais dans certains (Belgique, Danemark, France, lrlande, ltalie, Pays-Bas et Norvege par exemple), le pourcentage de jeunes femmes qui fument depasse celui des jeunes fumeurs. Dans les pays de la Communaute economique euro- peenne (CEE), en moyenne 41 % des hommes (de 32% en Belgique a 61 % en Grece) et 29% des femmes (de 14% au Portugal a 40% au Danemark) fument (13). Problemes de sante publique lies a l'usage du tabac On estime qu'environ 2,5 millions de deces sont im- putables tous les ans dans le monde a l'usage du - 234 - tabac (14). Selan Ravenholt, 485 OOO deces, c'est-a- dire 25% de tousles deces enregistres aux Etats-Unis, sont dus aux consequences du tabagisme, centre 5% a l'alcool et 2% a l'usage d'autres substances engendrant la dependance (15). Les maladies liees a l'usage du tabac representent 7% de tousles deces au Chili et en Equateur, 24% au Venezuela (M. Adrianza, communication personnelle, 1988), 30% a Cuba ( 16), 10% en France, 17% au Canada (44), 15- 20% au Royaume-Uni (17), et jusqu'a 35% chez les blancs d' Afrique du Sud ( 18). Ainsi qu'il a ete indique I ors d'un seminaire de l'OMS tenu en 1987 sur le tabagisme et la sante dans la Region du Pacifique occidental, les pourcentages de deces imputables aux consequences du tabagisme dans cete Region seraient les suivants: 5% aux Tonga, 10% a Hong Kong, 11 % au Japan, 15% en Nouvelle-Zelande, 15-20% en Australie, 18% a Guam et 20% en Malaisie. Lars d'un seminaire semblable orga- nise en Chine, ii a ete indique que le pourcentage de fumeurs parmi les hommes s · echelonnait dans le pays entre 48% pour la province de Liaoning et 76% pour celle de Tianjin (pourcentage superieur a celui de la plupart des pays). mais que les taux de tabagisme feminin n'etaient que de 5-12%. Si la consommation generale de cigaret- tes de fabrication industrielle par habitant parait relative- ment faible du fait que les femmes fument peu, la consommation de tabac est en realite tres elevee, l'usage du tabac cultive par les familles etant tres repandu et rarement officiel. Compte tenu du taux actuel de tabagisme, le nombre total des deces lies a l'usage du tabac pourrait atteindre pres de 2 millions par an en Chine au debut du siecle prochain (R. Peto, communication personnelle, 1987). Maladies cardio-vasculaires Les maladies cardio-vasculaires posent un probleme de sante majeur dans les regions industrialisees du monde et commencent aussi a poser de graves problemes dans les pays en developpement. Aux Etats-Unis, au cours de la periode 1965-1980, plus de 3 millions de deces pre- matures par cardiopathie ant ete attribues a l'usage du tabac et, si l'habitude de fumer dans la population ame- ricaine ne change pas, jusqu'a 10% de toutes les per- sonnes actuellement en vie risquent de mourir prematu- rement de maladies cardiaques imputables a leur taba- gisme (4). Des tendances alarmantes se dessinent aujourd'hui dans de nombreux pays et zones en developpement et en Chine, a Fidji, a Guam, a Hong Kong, en Malaisie, a Maurice, aux Philippines, a Singapour, a Sri Lanka, aux Tonga et au Venezuela, par exemple, les maladies car- dio-vasculaires sont devenues l'une des principales cau- ses de deces. L'influence du tabagisme s'ajoute a celle d'autres fac- teurs de risque, tels que !'hypertension et une forte concentration serique en LDL cholesterol. Le risque rela- tif est d' autant plus grand que les sujets sont jeunes; le risque pour le fumeur augmente avec le nombre de ciga- rettes fumees, mais ii decroit lorsqu'il arrete de fumer, pour approcher. uncertain nombe d'annees plus tard, le niveau de ceux qui n'ont jamais fume. II semble que la cigarette joue un role particulierement important dans l'etiologie des maladies arterielles peripheriques et dans les deces soudains par cardiopathie coronarienne, en particulier chez les hommes de mains de 50 ans (1). d Vair aussi Cancers de /'estomac, du poumon et du sein: tendances de la monalite et srrategies de Jutte [resume). p. 113 du present numero. On avance parfois que le besoin de fumer et les maladies liees a l'usage du tabac sont dus a une predisposition genetique sans relation de cause a effet. Des etudes consacrees a des jumeaux de sexe masculin dont l'un seulement fumait ant cependant montre que, s'ils avaient une vie relativement identique et ne differaient guere sur le plan psychologique, !'incidence de l'angine de poitrine et de l'infarctus du myocarde etait sensible- ment plus elevee chez les fumeurs, ce qui confirme la conclusion selon laquelle la consommation de cigarettes est une cause de cardiopathie coronarienne (19). Cancer L'usage du tabac, sous forme de cigarettes au de tabac a chiquer, joue un role dans !'apparition d'un tiers de tous les cas ce cancer.d La prevention du tabagisme serait done l'une des approches de la lutte centre le cancer offrant le meilleur rapport coOt/efficacite (20,21). Si la cigarette joue un role dans de nombreux types de cancer, sa responsabilite est particulierement frappante pour la grande majorite des cas de cancer du poumon dont le nombre a sensiblement augmente dans tous les pays au les statistiques de mortalite sont fiables. Cette tendance n • est pas limitee aux pays industrialises; on I' observe aussi dans les pays en developpement. La preuve d'une relation de cause a effet est clairement etablie (1, 3, 7). Lorsqu'un fumeur cesse de fumer, le risque relatif de cancer du poumon decline lentement pour atteindre, apres plusieurs annees, presque le meme niveau que pour celui qui n'a jamais fume (1). Parallelement a la prevalence du tabagisme, la mortalite par cancer du poumon chez les femmes de 28 pays developpes a considerablement augmente entre 1960 et 1980 (22). Aux Etats-Unis et en Ecosse, le cancer du poumon est devenu, avec le cancer du sein, la premiere cause de mortalite par cancer chez les femmes (23). Un risque accru de cancer du sein et de cancer du col de l'uterus a egalement ete constate chez les femmes qui fument (24). D'apres des observations de plus en plus nombreuses, le taux de cancer du poumon est aussi en augmentation dans les pays en developpement, par exemple en Arabie saoudite, en Afrique du Sud (18)etau Bangladesh ainsi qu'aux Fidji, en Malaisie et au Soudan, en relation avec !'augmentation de la consommation de cigarettes. En Arabie saoudite, ou, comme indique plus haut, les importations de tabac ont ete multipliees par 25 entre 1962 et 1984, le cancer du poumon vient en deuxieme place parmi les cancers les plus courants et augmente egalement chez les femmes. Sans doute I' aspect le plus important dans le lien entre la consommation de cigarettes et le cancer du poumon est la correlation etroite entre la duree de la consommation reguliere de cigarettes et les taux ulterieurs de cancer du poumon. Si l'on double la duree de l'usage regulier de tabac, !'incidence du cancer du poumon est multipliee par 20 environ. Plus un individu commence a fumer tot, plus ii court le risque de cancer du poumon : le risque est 3 fois plus eleve que pour un non-fumeur, pour celui qui commence a fumer a l'age de 24 ans, mais ii est 15 fois plus eleve pour celui qui commence a !'adolescence. Tous ces liens subsistent lorsque d'autres facteurs, tels que le regime alimentaire, le stress, la pollution atmo- spherique et !'urbanisation, tous egalement lies aux ma- ladies cardio-vasculaires et respiratoires, sont pris en compte, ce qui demontre la responsabilite du tabac. On a calcule que 600 OOO cas nouveaux de cancer du poumon apparaissaient chaque annee dans le monde, la plupart dus a l'usage du tabac (20). En l'an 2000, le nombre annuel des cas nouveaux de cancer du poumon pourrait atteindre 2 millions (25), dont pres de 900 OOO Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 235 - pour la Chine seulement (R. Peto, communication per- sonnelle, 1987). Le fait de fumer aggrave aussi le risque de cancer dans certains groupes professionnels. par exemple celui du cancer des branches chez les travailleurs exposes a l'amiante. D'apres des etudes epidemiologiques, la mise au point et la commercialisation de cigarettes a faible teneur en gou- dron pourraient avoir contribue a la reduction de la mor- talite par cancer du poumon. Par contre, les effets du tabagisme comme I' alteration de la fonction cardio-vas- culaire, les complications de la grossesse et les insuffi- sances respiratoires ne diminuent pas (26). II n'existe pas de cigarette inoffensive. D'autres formes de tabagisme ant aussi un lien avec le cancer. L'habitude de chiquer du tabac et des melanges contenant du tabac, tres repandue en Asie du Sud-Est, est responsable de 90% des cas de cancer de la cavite buccale (21). La vogue du tabac a chiquer et a priser est retombee ii y a plusieurs dizaines d' annees dans les pays industrialises, mais elle reapparait de nouveau et cette habitude, activement encouragee par l'industrie du ta- bac, redevient populaire. Un groupe de travail reuni en 1984 par le Centre inter- national de recherche sur le cancer (CICR) de l'OMS a conclu que le tabac ainsi utilise etait cancerogene pour l'homme (6). Un rapport du Surgeon General des Etats- Unis parvient a des conclusions semblables. Un groupe d'etude de l'OMS sur le tabac sans fumee, reuni a Geneve en 1987. a mis au point des directives a !'inten- tion des gouvernements. Parmi les mesures recomman- dees figurent une interdiction totale de la production, de !'importation et de la commercialisation du tabac sans fumee ou, dans les pays ou cette interdiction ne peut ~tre appliquee, des mesures aussi strictes que pour les ciga- rettes, par exemple des mises en garde contre la nocivite de ce type de tabac, pour des restrictions a son usage dans les lieux publics, !'interdiction de vente aux mi- neurs, etc. Maladies respiratoires aiguiis et chroniques L'usage de la cigarette agit independamment, mais en synergie avec les autres facteurs de risque qui contri- buent aux maladies broncho-pulmonaires non neoplasi- ques. Dans les pays en developpement, elle est relative- ment plus importante que la pollution atmospherique et les expositions professionnelles en tant que cause de maladies respiratoires. L'usage du tabac augmente sen- siblement le risque de bronchite chronique chez les mineurs et les travailleurs des hauts-fourneaux. En ter- mes strictement economiques. la bronchite chronique est la plus coOteuse de toutes les maladies liees a l'usage du tabac (1). Autres maladies et effets n{dastes sur la sante Outre les maladies les plus meurtrieres - cancer du poumon, cardiopathies coronariennes, maladies respira- toires aigu~s et chroniques - plusieurs autres maladies sont provoquees ou aggravees par l'usage du tabac notamment: les cancers de la cavite buccale, de I' ceso- • Belitsky, R. et al. [Etude sur Jes habitudes des femmes enceintes er /eur recours aux substances pharmaceuriques. Description de huit mater- nites dans six pays latino-americains]. Washington, Bureau regional OMS des Ameriques. 1984. (En espagnol). Wld hlth statist. quan., 41 (1988) phage et de la vessie ainsi que d'autres cancers, les maladies du systeme vasculaire peripherique, l'ulcere gastrique, l'hemorragie sous-arachnordienne, les infec- tions bucco-dentaires et, en ce qui concerne les femmes, l'osteoporose postmenopause, les complications de la grossesse et les complications circulatoires chez les femmes utilisant des contraceptifs oraux. L'usage du tabac est aussi la cause indirecte de deces et pertes materielles. Chaque annee, aux Etats-Unis, 65 OOO incendies d'habitations, dont 55% de tous les incendies constates dans les hotels et motels, entrainant environ 2 OOO deces (27% de tous les deces lies aux incendies) et 5 OOO traumatismes par brOlure sont dus a des fumeurs negligeants, essentiellement de cigaret- tes (2 7, 29). On estime que les fumeurs negligeants sont responsables d'un tiers (29) des deces lies aux incendies d'habitations, de 50% en lrlande du Nord (30) et de 10% en Suisse. Tabagisme et reproduction Des donnees recentes tendent a montrer que les conse- quences du tabagisme sont particulierement nefastes sur le plan de la reproduction (21, 24). Un tabagisme important affecte la conception, la grossesse, l'issue de la grossesse, la lactation et le developpement du jeune enfant; ii peut aussi jouer un role dans I' apparition de cancers de I' appareil reproductif des hommes et des femmes. Ainsi, le risque d'infarctus du myocarde chez les femmes utilisant des contraceptifs oraux est beau- coup plus important chez celles qui fument que chez celles qui ne fument pas (2) et les femmes qui consom- ment un nombre important de cigarettes ant egalement un risque accru de dereglement du cycle menstruel. Une forte consommation de cigarettes semble egalement avancer de 2 ou 3 ans l'age de la menopause. Un lien direct a ete etabli entre les troubles de la fecon- dite, les avortements spontanes. la mortalite fcetale et perinatale et le fait que la mere fume en cours de gros- sesse (24). Des etudes montrent une augmentation de 20% du taux de mortalite perinatale chez les enfants de femmes fumant mains d'un paquet par jour et une augmentation de 35% en cas de consommation supe- rieure. Chez les femmes qui fument pendant la grossesse, la proportion des enfants plus petits pour leur terme (mains de 2 500 g) est deux fois plus forte, cette proportion augmentant avec le nombre de cigarettes fumees (1, 2). Le deficit ponderal moyen est de 300 g. Le tabagisme de la mere peut egalement contribuer a une baisse de l'in- dice d' Apgar et favoriser la prematurite, 11 % au mains des naissances avant terme etant imputables a la consommation de cigarettes. Le fait de fumer pendant la grossesse peut egalement nu ire a la sante de I' enfant pendant ses premieres annees: une etude a montre que 65% des enfants de meres non fumeuses apparaissaient en excellente sante contre 52% seulement des enfants dont les meres fumaient. 7.4% des enfants du premier groupe avaient ete alites pendant huit jours au mains contre 12,6% des enfants du deuxieme groupe (24). Aux Etats-Unis, plus de 14% des cas d'insuffisance pon- derale a la naissance sont attribuables au tabagisme pendant la grossesse, soit une depense de sante sup- plementaire d'environ US$ 180 millions par an. Le tabagisme pendant la grossesse est un probleme en Amerique latine ou des enqu6tes montrent que plus de 20% des femmes enceintes vivant en zone urbaine fument.e On estime qu'au Chili, 10% de tousles cas de mortalite non accidentelle de nourrissons sont imputa- bles au tabagisme de la mere. - 236 - Une consommation elevee de cigarettes peut avoir des effets nefastes sur la fecondite masculine, y compris un dereglement de la spermatogenese, de la morphologie et de la motilite des spermatozoides et de la secretion d'androgene (24, 31). Mortalite generale II ressort clairement de ce qui precede que le risque de mortalite, toutes causes confondues, accidents y com- pris, est plus eleve chez les fumeurs que chez les non- fumeurs. Ainsi, le taux de mortalite global chez les fumeurs est d'environ 1,7 par rapport aux non-fumeurs, soit une surmortalite de 70% qui atteint 100% pour les personnes fumant 2 paquets de cigarettes par jour. Les taux de mortalite plus eleves sont particulierement frap- pants chez les fumeurs relativement jeunes. L · esperance de vie des fumeurs est inferieure d'environ 8 ans a celle des non-fumeurs du meme age (1). Chaque annee, le tabagisme est responsable de plus de 500 OOO deces en Europe (ventiles par pays comme indique au tableau 4), d'au mains 630 OOO deces en lnde (32), de 10 OOO deces en Afrique du Sud, 23 OOO en Australie (donnees provenant du Victorian Smoking and Health Programme, 1987), 30000 au Canada (11), 19000 au Venezuela (M. Adrianza, communication personnelle, 1988) et en- viron 400 OOO deces aux Etats-Unis en 1980 ( 15) contra 300 OOO en 1966 et 250 OOO en 1962. Ces chiffres ant ete extrapoles a l'echelle mondiale et l'on estime que 2,5 millions de deces sont tous les ans imputables au taba- gisme (14). Autres formes d'usage du tabac Bien que de nos jours le tabac se consomme le plus souvent sous forme de cigarettes, ii y a d'autres formes de tabagisme. Les pipes a eau, les goza, houkas, nargui- les, bidis, etc., ainsi que le tabac a priser et les feuilles de tabac a chiquer, seules ou melangees ad' autres matieres vegetales ou minerales, sont des formes a la fois tradi- tionnelles et repandues dans de nombreux pays en deve- loppement, et des causes de maladies. On estime qu' en- viron 100 millions de personnes adultes chiquent dans le sous-continent indien (P. Gupta, communication person- nelle, 1988) et 12 millions aux Etats-Unis (6). Les bidis ant une teneur tres elevee en oxyde de carbone, goudron (23-41 mg) et nicotine ( 1, 7-2,9 mg); ils peuvent etre consideres comme une cause majeure de cardiopa- thies ischemiques et d'autres maladies cardio-vasculai- res, de cancer du poumon et de l'oropharynx, de l'ceso- phage et du larynx ainsi que de maladies pulmonaires obstructives chroniques dans les pays en developpe- ment. Ces observations sont d'une importance capitale, non seulement pour ce qui est des formes traditionnelles d'usage du tabac dans les pays en developpement, mais aussi en raison de la tendance croissante, en particulier chez les jeunes femmes de certains pays industrialises, a utiliser du tabac autrement que sous forme de cigarettes, par exemple a chiquer et priser, et a fumer des bidis, croyant a tort eviter les effets nefastes de la cigarette. Ces formes d'usage du tabac engendrent egalement une dependance a I' egard de la nicotine et sont tout aussi dangereuses que la cigarette. TABLE 4. ESTIMATED NUMBER OF DEATHS DUE TO TOBACCO USE IN 27 COUNTRIES OF THE WHO EUROPEAN REGION, REPRESENTING ABOUT 60% OF THE REGIONAL POPULATION• TABLEAU 4. NOMBRE ESTIMATIF DE DECES DUS A L'USAGE DU TABAC DANS 27 PAYS DE LA REGION OMS DE L'EUROPE REPRESENTANT ENVIRON 60% DE LA POPULATION REGIONALE8 Country - Pays Year M F Total Annt!e Austria - Autriche 1985 5 527 3 354 8881 Belgium - Belgique 1984 8905 2664 11 569 Bulgaria - Bulgarie 1984 6 129 3 215 9344 Czechoslovakia - Tchecoslovaquie 1984 14 693 7 363 22056 Denmark - Danemark . . . . . . 1985 5 531 3 311 8842 Finland - Finlande . . . . . . . . . . 1984 4094 1900 5 994 France .......... 1984 25 751 10 102 35 853 GerA1an Democratic Republic - Republique democratique allemande 1984 12 393 6 178 18 571 Germany, Federal Republic of - Republique federale d'Allemagne 1985 49 572 26 433 76005 Greece - Grece .. 1984 5 305 1 718 7 023 Hungary - Hongrie 1985 10 742 5 541 16 283 Iceland - lslande 1984 115 78 193 Ireland - lrlande 1983 2 754 1449 4203 Israel - lsral!I 1984 1416 859 2 275 Italy - ltalie 1981 39489 15 324 54 813 Luxembourg 1985 298 121 419 Malta - Malte 1985 115 54 169 Netherlands - Pays-Bas 1985 12140 3 892 16032 Norway - Norvege 1984 3046 1 553 4599 Poland - Pologne .. 1985 23 858 7 337 31 195 Portugal ....... 1985 3 656 1 778 5434 Romania - Roumanie 1984 12 178 7 907 20085 Spain - Espagne 1980 14492 5 738 20230 Sweden - Suede .. 1985 7 104 4 339 11443 Switzerland - Suisse 1985 4299 1610 5 909 United Kingdom - Royaume-Uni 1984 60764 33 916 94680 Yugoslavia - Yougoslavie 1982 9103 3 732 12 835 Total ... 343469 161 466 504935 • Estimate made by the WHO Regional Office for Europe, based on the fact that tobacco is held responsible for about 90% of all deaths from lung cancer, 75% of bronchitis/emphysema deaths and 25% of all deaths from ischaemic hean disease. The estimate for each country is based on the most current data provided to WHO by the countries themselves. - Estimations du Bureau regional OMS de l'Europe. bast!es sur le fait que le tabac est tenu pour responsable d'environ 90% de !'ensemble des dt!ces par cancer du poumon. de 7 5 % des deces par bronchite ou emphyseme et de 25% de I' ensemble des deces par cardiopathie ischt!mique. L · estimation pour chaque pays est fondee sur les donnt!es les plus rt!centes communiqut!es i l'OMS par les pays eux-m~mes. Source: Reference ( 12) - Rt!ft!rence ( 12). Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 237 - Effets compares de !'inhalation involontaire et de l'inhalation active de la fumee du tabac Si les effets pathologiques decrits ci-dessus sont sou- vent bien admis pour le fumeur direct, on n • a pas accorde suffisamment d'attention a ce que l'on appelle le taba- gisme «passif», c'est-a-dire a l'usage du tabac «impo- se» a autrui. La fumee du tabac est la principale source de pollution a l'interieur des habitations dans les pays riches; elle affecte non seulement directement le fumeur, mais aussi indirectement tous ceux qui sont obliges de respirer dans une atmosphere enfumee. D'apres plu- sieurs etudes, le risque de cancer du poumon serait plus eleve chez les non-fumeuses epouses de fumeurs que chez les non-fumeuses epouses de non-fumeurs (33- 35). D'apres une monographie recente du CIRC, !'inhalation passive de la fumee du tabac exposerait a un risque de cancer (8). Des signes precoces d'alteration de la fonc- tion ventilatoire ant ete observes chez des non-fumeurs exposes de fac;:on continue a la fumee du tabac sur leur lieu de travail (36). On a constate un risque accru de maladie cardio-vasculaire chez les non-fumeurs exposes pendant une longue duree a une inhalation « pas- sive» (37). Les personnes agees, les sujets cardiaques ou asthmatiques et les hypertendus peuvent etre atfec- tes plus serieusement par la fumee presente dans leur environnement que les adultes en bonne sante. Une question importante est celle des effets nefastes de !'inhalation passive de la fumee de cigarettes sur les enfants. II a ete prouve en particulier que !'incidence des infections aigu~s des voies respiratoires chez les jeunes enfants, c' est-a-dire le risque qu'un nourrisson contracte une bronchite ou une pneumonie dans la premiere annee de son existence, etait 2 fois plus eleve lorsque les parents fumaient. Les enfants dont les parents fument risquent davantage de fumer eux-memes plus tard et ils auront alors plus de symptOmes respiratoires que ceux qui n'acquierent pas cette habitude. Chez les femmes enceintes qui fument, les composants toxiques de la fumee parviennent au moyen de la circulation jusqu'au fretus, ainsi soumis a une forte exposition passive au tabac. Ainsi qu'il est indique plus haut, les fumeuses ant plus de chances que les non-fumeuses d'avoir un enfant petit pour son terme (2, 24, 31 ). Un rapport du Surgeon General des Etats-Unis passe en revue de maniere ex- haustive la question du tabagisme involontaire (33). Risques pour la sante mis a part, la fumee du tabac est une nuisance dans I' environnement; elle gene de nom- breux non-fumeurs et est de plus en plus consideree comme socialement inacceptable. En consequence, on tend desormais a separer les fumeurs des non-fumeurs dans les aeronefs. les autres transports publics et les lieux publics clos.Un nombre croissant de compagnies aeriennes interdisent maintenant totalement de fumer sur nombre de leurs vols interieurs. De meme, un nombre croissant d'administrations, no- tamment aux Etats-Unis, adoptent aujourd'hui une poli- tique de lutte contre le tabagisme sur le lieu de travail. Le 7 avril 1987 - Journee mondiale de la sante - !'Orga- nisation mondiale de la Santa a egalement decide d'in- terdire de fumer dans ses locaux. Avantages et couts economiques de la produc- tion et de la consommation de tabac Production de tabac Le tabac se cultive dans environ 120 pays situes dans le monde entier, a !'exception des pays a climat froid W/d hlth statist. quan .• 41 ( 1988) d'Europe du Nord et de quelques pays arabes a climat aride. II est cultive dans les pays developpes comme dans les pays en developpement mais la contribution de ces derniers a la production mondiale de tabac a aug- mente regulierement depuis 20 ans, passant de 50% en 1963 a 63% en 1985 et la Banque mondiale estime que ce chiffre devrait atteindre 68% en 1995. Les principaux pays producteurs (et consommateurs) de tabac sont le Brasil, la Chine, les Etats-Unis, l'lnde, le Japan, la Turquie et l'URSS. A court terme, la production de tabac presente des avan- tages pour les economies de nombreux pays produc- teurs: la production, la transformation et le commerce du tabac font vivre des dizaines de milliers de familles, et le tabac constitue une source de revenus et de devises pour les Etats producteurs, par le biais des exportations. Les gouvernements y trouvent pour leur part une source de dettes fiscales, faciles a obtenir, bien qu'il s'agisse davantage d'un transfert financier que d'un benefice economique net. Si la production et !'exportation de tabac contribuent a accroitre le produit national brut, dans un pays en deve- loppement ces activites peuvent entrainer une diminu- tion de la superficie disponible pour la production alimen- taire et. par consequent. augmenter la dependance du pays vis-a-vis des importations alimentaires. En 1980, 0,3% environ de la terre arable mondiale, soit 4,36 millions d'hectares, dont 72% dans les pays en developpement, etait vouee a la culture du tabac. La grande majorite des produits de tabac manufactures, essentiellement des cigarettes, sont destines a la consommation interieure; environ 10% seulement en- trent dans le commerce international et une petite partie (environ 10%) des exportations mondiales revient aux pays en developpement. La production mondiale s'eleve a environ 5 milliards de cigarettes par an, soit une consommation d'environ 3 cigarettes par jour et par an pour chaque homme, femme et enfant de la planete. L'une des consequences nefastes de la culture du tabac dans la majorite des pays est I' augmentation de la demande au sein du pays producteur. Dans de nombrux pays en developpement, les importations de cigarettes etrangeres grevent fortement les precieuses reserves de devises etrangeres. Les consequences nefastes de la production de tabac sur l'environnement sont nombreuses. L'un des argu- ments les plus souvent avances est que la production de tabac est une cause de deboisement, un nombre impor- tant d' arbres etant coupes chaque an nee pour consacrer des terres a la culture du tabac et obtenir du bois a brOler pour le sechage des feuilles de tabac (38). On estime que, au niveau mondial, 2,5 millions d'hectares de forets sont utilises chaque annee pour secher 2,5 millions de tonnes de tabac (39). lndependamment du deboisement, le bois ainsi utilise pour le sechage du tabac est perdu pour les utilisations traditionnelles comme la cuisine, le chauffage et la cons- truction. II est difficile d'evaluer avec precision !'impact du sechage des feuilles de tabac sur le deboisement, mais la disparition des forets est manifeste dans de nombreux pays. D'apres la Economist Intelligence Unit (40), dans de nombreux pays en developpement dont le Bangladesh, le Brasil, le Kenya, la Malaisie, le Malawi, le Pakistan, la Republique-Unie de Tanzanie et la Sierra Leone, le bois a brOler est le seul combustible efficace pour le sechage du tabac. D'apres un rapport recent (41), ii faut environ un hectare de foret pour secher un hectare de tabac. La plupart des - 238 - pays en developpement qui utilisent le bois pour secher le tabac connaissent au connaitront un deficit de bois a brGler. L'industrie du tabac utilise !'equivalent de 9,2 mil- lions de metres cubes de bois a brGler par an. Meme si ce chiffre est relativement faible par rapport a la consom- mation totale de bois, les consequences du deboise- ment, notamment dans les regions arides et semi-arides, sont graves. Consommation de tabac Du point de vue economique, les avantages apparents de la consommation de tabac peuvent etre resumes comme suit: • recettes fiscales (qui pourraient cependant etre per- i;:ues d'autres manieres); • benefices des detaillants et autres professions partici- pant a la production et a la vente de tabac, a des acti- vites publicitaires, etc. Des 1978, un Comite OMS d'experts de la lutte anti- tabac ( 1) soulignait que les maladies liees au tabac fai- saient peser un lourd fardeau sur les services de soins de sante. Un certain nombre d'etudes ont ete faites dans plusieurs pays industrialises et en developpement pour comparer le coGt sanitaire et social du tabagisme et les avantages economiques de la production et de la consommation de tabac. Toutes ces analyses ont mon- tre que les depenses encourrues pour le traitement des maladies liees au tabagisme, baisse de productivite et les autres pertes economiques resultant d'un nombre plus eleve de deces prematures et d'un surabsenteisme pour raison de maladies liees au tabac, ainsi que les pertes materielles et humaines liees aux incendies dus a la negligence des fumeurs, etaient considerables et bien superieurs a la valeur economique totale des produits du tabac. II est difficile d'evaluer les pertes economiques liees a la morbidite et a la mortalite prematurees dues au tabagis- me. II est toutefois possible de faire quelques estima- tions pour certains pays (42, 46). Les coGts de la consommation du tabac sont essentiel- lement des coGts de traitement des maladies imputables au tabagisme. Couts directs: perte de ressources nationales pour le traitement des maladies liees au tabac et la readap- tation. Le traitement a long terme est coGteux. Couts indirects: perte de la productivite, notamment absenteisme du a des incapacites et deces prematu- res lies au tabagisme. II en resulte pour la collectivite une perte de capacites, de competences et de parti- cipation au travail pour de longues periodes. La surmorbidite des fumeurs entraine un besoin supple- mentaire en soins medicaux, c'est-a-dire soins hospita- liers et ambulatoires, medicaments, traitements chirurgi- caux, etc. Les fumeurs sont plus frequemment malades que les non-fumeurs et I' on a calcule que le nombre de jours de travail perdus etait superieur de 25-50% chez les fumeurs par rapport aux non-fumeurs. Les maladies liees au tabac entrainent une perte de 140 millions de jours de travail aux Etats-Unis, de 50 millions au Royaume-Uni et de plus d'un million en lrlande du Nord (43% de toutes les journees de travail perdues). Quel est le coGt de toutes ces journees de travail perdues pour la societe? Si l'on multiplie le nombre de jours de travail perdus par la valeur monetaire de chacune de ces jour- nees, la perte economique est considerable. Au Royaume-Uni, le traitement des maladies liees au tabac coGte Lstg 370 millions par an. En lrlande du Nord, le marche du tabac est evalue a Lstg 148 millions, mais son coGt pour le pays est de Lstg 179 millions (30). Au cours de la meme annee, on a calcule que les consequen- ces economiques du tabagisme coGtaient aux Etats-Unis le montant considerable de US$ 53, 7 milliards (42). D'apres une nouvelle evaluation de !'Office of Techno- logy Assessment, qui est l'organe consultatif scientifi- que du Congres des Etats-Unis, les depenses de sante et les pertes de productivite liees au tabagisme s'elevent a US$ 65 milliards par an. En Australia, le coGt total des maladies liees au tabagisme depasse $A 2.5 milliards (communication personnelle des Health Promotion and Education Services, Perth, 1987). Au Canada, les pertes sont superieures d'environ $Can 2 milliards aux recettes liees au tabac (43, 44). Au Venezuela, les depenses liees a l'absenteisme et les depenses encourrues pour le trai- tement de maladies liees au tabac representaient !'equi- valent de US$ 69 millions en 1978 et de US$ 110 mil- lions en 1985 (M. Adrianza, communication personnelle, 1988). Le fait que les maladies liees au tabagisme reduisent le nombre de jours de travail signifie que le tabagisme entraine une baisse de la production nationale de biens et de services et reduit par consequent le produit national brut d'un pays. Certaines maladies liees au tabagisme, comme la bron- chite chronique, donnent frequemment lieu a des mala- dies recurrentes qui peuvent bouleverser I' organisation du travail et constituer une charge administrative supple- mentaire, qui vient s'ajouter a l'absenteisme lui-meme. Les depenses de sante et l'absenteisme ne sont pas les seules consequences economiques negatives du tabac. Une analyse detaillee des repercussions economiques du tabagisme doit egalement tenir compte des pertes financieres suivantes: CoOts des incendies domestiques et de forets causes par les fumeurs. 15-20% des incendies qui ant lieu en zone urbaine dans le monde entier sont dus aux ciga- rettes. Aux Etats-Unis, la moitie environ des incen- dies d'habitations sont imputables a l'usage impru- dent de produits du tabac allumes. En lrlande du Nord et en Suisse, 15% et 10% respectivement de tousles incendies seraient dus a cette meme cause. Le nom- bre des deces et traumatismes par incendie du a la negligence des fumeurs a ete indique plus haut. Perte de pouvoir d 'achat faml1ial du fait des depenses consacrees au tabac. Dans de nombreux pays en developpement, on a calcule que la somme depensee par un pere de famille pour l'achat de tabac entrainait un deficit alimentaire pour les enfants. En Egypte, 5% environ du revenu familial est con sac re a I' achat de cigarettes (S. Omar, communication personnelle). Au Bangladesh, en lnde, en Thai1ande et dans d'autres pays en developpement, un grand fumeur peut consacrer 20% de son revenu au tabac. Dans les pays en developpement qui font appel aux importa- tions pour approvisionner le marche interieur, comme en Egypte, ii en resulte une perte de devises fortes. II est tres difficile de proceder a une analyse coGt/avan- tages qui mettrait en parallele les revenus lies au tabac et les coots sanitaires et sociaux lies aux maladies causees par le tabagisme. On trouvera des references bibliogra- phiques supplementaires dans un rapport interne de l'OMS ainsi que des procedures detaillees sur la maniere de calculer les coGts du tabagisme dans un ouvrage de Oster et al. (45). lndependamment des considerations economiques, la sante de la population ne peut etre comparee aux avantages monetaires que procure l'in- Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 239 - dustrie du tabac. La conclusion a laquelle on peut parve- nir est que la production et l'usage du tabac ne peuvent etre consideres a long terme comme un veritable avan- tage economique pour les pays, notamment les pays en r Lewit. E. M. Tobacco in developing countries - An economic ap- proach to policy formulation. Harvard University. Institute for the Study of Smoking Behaviour and Policy. (Paper S-88-19. March 1988). g Nations Unies. Commercialisation et distribution du tabac. Confe- rence des Nations Unies sur le commerce et le developpement. (Docu- ment TD/B/c.1/205, 1978). developpement, non seulement du fait des depenses sanitaires et sociales considerables liees a la consom- mation de produits du tabac dans les pays eux-memes/ mais egalement parce que dans le systeme de commer- cialisation actuel du tabac, les pays en developpement sont totalement a I' ecart du processus de decision en matiere de commercialisation.9 Si les avantages finan- ciers pour le pays sont aleatoires, en revanche, la charge supplementaire que les maladies liees au tabagisme feront peser sur les pays est evidente. RESUME Le tabagisme est sans conteste une cause majeure de maladie et de deces prematures. On peut lui attribuer jusqu'a 90% de tousles cas de cancer du poumon, 75% des cas de bronchite chronique et d'emphyseme et 25% des cas de cardiopathies ischemiques chez les hommes de mains de 65 ans; ii est egalement responsable d'un certain nombre d'autres types de cancer et d'une aug- mentation de la frequence des troubles respiratoires chez les enfants dont les parents fument. En Asie du Sud-Est, on estime que l'usage du tabac a chiquer est responsable d'environ 90% des deces par cancer de la cavite buccale. La consommation de cigarettes par adulte dans le monde n'a que tres legerement augmente, de 7, 1 % entre 1970 et 1985. Elle a diminue dans de nombreux pays industrialises, par exemple, de 9% aux Etats-Unis d' Amerique et au Canada, de 6% en Australie et en Nouvelle-Zelande et meme de 25% au Royaume-Uni. Par contre, dans de nombreux pays en developpement, elle a fortement augmente: de 42% en Afrique, de 24% en Amerique latine et de 22% en Asie. Dans de nombreux pays industrialises la proportion des fumeurs a commence a regresser ces dernieres annees. Ainsi, au Royaume-Uni, le pourcentage d'hommes qui fument est tombe de 65% a 45% et celui des femmes qui fument de 45% a 34%. Aux Etats-Unis, la prevalence du tabagisme masculin est passee de 54% a 29% et celle du tabagisme feminin de 36% a 24%. La prevalence du tabagisme masculin a baisse en Norvege de 53% a 42%, en Australie de 72% a 33% et au Canada de 44% a 35%. En revanche, dans les pays en developpement elle est souvent plus elevee que dans les pays prosperes. En Tunisie, par exemple, 60% des hommes fument. Les maladies liees a l'usage du tabac representent 7% de tousles deces au Chili et en Equateur, 24% au Venezuela, 30% a Cuba, 10% en France, 17% au Canada, 15-20% au Royaume-Uni et jusqu'a 35% chez les sud-africains blancs. On a calcule qu'il se produit chaque annee dans le monde 600 OOO cas nouveaux de cancer du poumon dont la plupart sont dus a l'usage du tabac. Les projec- tions montrent que d'ici l'an 2000 le nombre annuel de cas nouveaux de cancer du poumon dans le monde pour- rait atteindre 2 millions. Le tabagisme a ete responsable en 1980 de 500 OOO deces en Europe, d'au mains 630 OOO en lnde (32), 10 OOO en Afrique du Sud, 23 OOO en Australie, 30 OOO au Canada, 19 OOO au Venezuela et environ 400 OOO aux Etats-Unis. L'hypermorbidite des fumeurs entraine un besoin accru de soins medicaux. Les fumeurs sont plus souvent malades que les non-fumeurs et l'on a calcule que le nombre des journees de travail perdues par les fumeurs etait de 25-50 fois superieur a ce qu'il est pour les non-fumeurs. Aux Etats-Unis, on a estime que les depenses de sante et le coGt des pertes de productivite par suite de maladies liees a I' usage du tabac atteignaient US$ 65 milliards par an. SUMMARY Smoking trends and effects worldwide Smoking is undoubtedly a major cause of illness and premature death. It is responsible for as much as 90% of all cases of lung cancer, 75% of chronic bronchitis and emphysema and 25% of cases of ischaemic heart dis- ease in men under 65 years, as well as for a number of other types of cancer, pregnancy complications and more frequent respiratory ailments in children from smoking families. In South-East Asia, tobacco chewing is estimated to cause about 90% of the deaths due to oral cancer. Worldwide, cigarette consumption per adult has increased only very slightly, by 7 .1 %, between 1970 and 1985. It fell in many industrial countries, e.g. by 9% in the United States of America and Canada, 6% in Aus- tralia and New Zealand, and by as much as 25% in the United Kingdom. On the contrary, in many developing countries adult per capita cigarette consumption has increased markedly, e.g. by 42% in Africa, 24% in Latin America and 22% in Asia. In many industrialized coun- tries, the percentage of smokers has started to fall in recent years. For instance, in the United Kingdom, the percentage of male smokers fell from 65% to 45% and Wld hlth statist. quan .. 41 ( 1988) that of female smokers from 45% to 34%. In the United States, male prevalence decreased from 54% to 29% and female prevalence from 36% to 24%. In Norway, male smoking prevalence decreased from 53% to 42%, in Australia from 72% to 33% and in Canada from 44% to 35%. On the contrary, in developing countries preva- lence of smoking is frequently higher than in the affluent countries. In Tunisia, for instance, 60% of the men smoke. Smoking-related diseases account for 7% of all deaths in Chile and Ecuador and 24% in Venezuela, 30% in Cuba, 10% in France, 17% in Canada, 15-20% in the United Kingdom, and up to 35% among white South-Africans. It has been calculated that 600 OOO new cases of lung cancer occur worldwide every year, most of them due to smoking. Projections show that by the year 2000 the yearly number of new lung-cancer cases worldwide may be as high as 2 mil- lion. 500 OOO deaths are attributable to smoking in Europe, at least 630 OOO in India, 10 OOO in South Africa, 23 OOO in - 240 - Australia, 30 OOO in Canada, 19 OOO in Venezuela and about 400 OOO in the United States in 1980. The hyper- morbidity of smokers causes an extra need for medical care. Smokers are sick more often than non-smokers, and it has been calculated that the number of lost days of work of smokers is 25-50% higher than that of non- smokers. In the United States, the health costs and productivity losses due to smoking-related diseases have been estimated to reach $ 65 OOO million a year. REFERENCES - REFERENCES 1. WHO Technical Report Series No. 636, 1979 (Controlling the smoking epidemic: report of the WHO Expert Committee on Smoking Control). OMS Serie de Rapports techniques N° 636, 1979 (La /utte contre /'epidemie de tabagisme: rapport du Comite d'experts de la lutte antitabac). 2. THE SURGEON GENERAL. The health consequences of smoking for women. Washington D.C., US Depart- ment of Health ad Human Services, 1980. 3. THE SURGEON GENERAL. The health consequences of smoking-cancer. Washington D.C., US Depart- ment of Health and Human Services, 1982. 4. THE SURGEON GENERAL. The health consequences of smoking-cardiovascular diseases. Washington D.C., US Department of Health and Human Services, 1983. 5. THE SURGEON GENERAL. The health consequences of using smokeless tobacco. Washington D.C., US Department of Health and Human Services, 1986. 6. INTERNATIONAL AGENCY FOR RESEARCH ON CANCER. Tobacco habits other than smoking. Lyon, IARC, 1985. (IARC monographs on the evaluation of car- cinogenic risks to humans, No. 37). 7. INTERNATIONAL AGENCY FOR RESEARCH ON CANCER. Tobacco smoking. Lyon, IARC, 1986. (IARC mono- graphs on the evaluation of carcinogenic risks to humans, No. 38). 8. Smoking-worldwide trends and their implications. World health statistics annual: 16-19 ( 1986). Tabagisme - tendances mondiales et implications. Annuaire de statistiques sanitaires mondiales: 16- 19 (1986). 9. WALD. N. ET AL. UK smoking statistics. Oxford, Oxford University Press, 1988. 10. CENTERS FOR DISEASE CONTROL. Cigarette smoking in the United States, 1986. Morbidity and mortality weekly report, 36 (35): September (1987). 11. COLLISHAW. N. E. Cigarette consumption in Canada. In: Proceedings of the Sixth World Conference on Smoking and Health, Tokyo, 9-12 November 1987. Amsterdam, Elsevier, 1988. 12. WORLD HEAL TH ORGANIZATION. A 5 year action plan- smoke free Europe. Copenhagen, WHO Regional Office for Europe, 1988. 13. COMMISSION OF EUROPEAN COMMUNITIES. Europeans and the prevention of cancer. World smoking and health, 13 (1): 12-16 (1988). 14. CHANDLER. W. V. Banishing tobacco. Washington D.C., World Watch Institute, 1986. (World Watch Paper No. 68). 15. RAVENHOLT. R. T. Addiction mortality in the United States, 1980: tobacco, alcohol, and other substan- ces. Population and development review, 10 (4): 697-724 (1984). 16. JOLY. D. J. & ACOSTA. M. R. S. The cigarette- smoking habit among pre-university students in Havana, Cuba, in 1980. Bulletin of the Pan American Health Organization, 17 (2): 158-163 ( 1983). 17. ROY AL COLLEGE OF PHYSICIANS. Health or smoking. London, Pitman, 1983. 18. YACH. D. & TOWNSEND. G. Smoking and health in South Africa. Parow, South African Medical Re- search Council, 1988. (Centre for Epidemiological Research in Southern Africa, Technical Report No. 1). 19. KAPRIO. J. The incidence of coronary heart disease in twin pairs discordant for cigarette smoking. Helsinki, University of Helsinki, Department of Public Health Science, 1984. 20. PARKIN. D. M. ET AL. Estimates of the worldwide fre- quency of twelve major cancers. Bulletin of the World Health Organization, 62 (2): 163-182 (1984). 21. A WHO MEETING. Control of oral cancer in develo- ping countries. Bulletin of the World Health Organi- zation, 62 (6): 817-830 (1984). UNE REUNION DE L'OMS. La lutte contre le cancer de la bouche dans les pays en developpement. Bulletin de /'Organisation mondiale de la Sante, 63 ( 1) : 2 7-42 (1985). 22. Cancer increases in developed countries. Weekly epidemiological record, 60 (17): 125-129 (1985). Le cancer en augmentation dans les pays develop- pes. Re/eve epidemiologique hebdomadaire, 60 (17): 125-129 (1985). 23. US DEPARTMENT OF HEAL TH AND HUMAN SERVICES. Health United States, 1984. Hyattsville, Md., Natio- nal Center for Health Statistics, 1984. 24. ROSENBERG. M. J. (ed.). Smoking and reproductive health. Littleton, Ma., PSG Publishing Co. Inc., 1987. 25. WORLD HEALTH ORGANIZATION. Cancer is a Third World problem too. Geneva, WHO Division of Pub- lic Information and Education for Health, 1986. (A selection of clippings). ORGANISATION MONDIALE DE LA SANTE. Le cancer est aussi un probleme dans le tiers monde. Geneve, OMS Division de !'information du public et de !'edu- cation pour la sante, 1986. (Une selection d'ex- traits). 26. THE SURGEON GENERAL. The health consequences of smoking-the changing cigarette. Washington D. C., US Department of Health and Human Services, 1981. 27. us FIRE ADMINISTRATION. National Fire Protection As- sociation survey data. Washington, D.C., Federal Emergency Management Agency, 1981 . 28. McGUIRE. A. Cigarettes and fire deaths. New York State journal of medicine, 83 ( 13): 1296-1298 (1983). 29. BELL. J. & WHITE. L. Cigarette fires: a preventable menace. World smoking and health, 13 (1): 2-4 (1988). 30. NELSON, H. The economic consequences of smoking in Northern Ireland. Belfast, Ulster Cancer Founda- tion, 1986. 31. ABEL. E. L. Smoking and reproduction: an annotated bibliography. Boca Raton, FI., CRC Press Inc., 1984. Rapp. trimest. statist. sanit. mond .. 41 (19881 - 241 - 32. GUPTA, P. C. Health consequences of tobacco use in India. World smoking and health, 13 ( 1) : 5-9 (1988). 33. THE SURGEON GENERAL. The health consequences of involuntary smoking. Washington D.C., US Depart- ment of Health and Human Services, 1986. 34. HIRAYAMA. T. Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan. British medical journal, 282 : 183-185 (1981). 35. REPAGE, J. L. & LOWREY. A. H. A quantitative esti- mate of non-smokers' lung cancer risk from passive smoking. Environment international: ( 1985). 36. WHITE. J. R. & FROEB. H. F. Small-airways dysfunc- tion in non-smokers chronically exposed to tobacco smoke. New England journal of medicine, 302, (13): 720-723 (1980). 37. HELSING, K. J. & COMSTOCK. G. N. Heart disease mor- tality in persons living with smokers. In: Indoor air 87-Proceedings of the fourth international confe- rence on indoor air quality and climate, Berlin (West), 17-21 August 1987. Berlin (West). Institute for Water, Soil and Air Hygiene, 1987. (pp. 29- 33). 38. ECKHOLM. E. Fuelwood-the energy crisis that won't go away. London, International Institute for Environ- ment and Development, 1984. Wld hlth statist. quan .. 41 (19881 39. MADELEY. J. The environmental impact of tobacco production in developing countries. New York State journal of medicine, 83 ( 13): 1310-1311 ( 1983). 40. ECONOMIST INTELLIGENCE UNIT. Tobacco and food crops in the Third World. London, Economist Intel- ligence Unit Ltd, 1983. (Studies in agriculture and commodities No. 3). 41 .. FRASER. A. I. The use of wood by the tobacco indus- try and the ecological implications. Edinburgh, Inter- national Forest Science Consultancy, 1986. 42. RICE. D. P. ET AL. The economic costs of the health effects of smoking, 1984. The Millbank quarterly, 64 (4): 489-547 (1986). 43. THOMPSON, M. E. & FORBES. w. F. Costs and "bene- fits·· of cigarette smoking in Canada. Canadian Med- ical Association journal, 127 : 831 ( 1982). 44. COLLISHAW, N. E. & MYERS, G. Dollar estimate of the consequences of tobacco use in Canada, 1979. Canadian journal of public health, 75: 192-199 (1984). 45. OSTER, G. ET AL. The economic costs of smoking and the benefits of quitting. Lexington, Ma., Lexington Books, 1984. 46. WARNER, K. E. ET AL. Health and economic implica- tions of a tobacco-free society, JAMA, 258 ( 15) : 2080-2086 (1987). - 242 - THE ROLE OF PHYSICAL ACTIVITY IN THE PREVENTION AND TREATMENT OF NONCOMMUNICABLE DISEASES Igor P. Briazgounova More and more people are turning to exercise to ensure long-term health, and the World Health Organization (WHO) has endorsed this concept (1). Regular physical activity is associated with lower mortality rates. In the Harvard Alumni study, more active alumni lived up to two years longer than less active alumni (2). The best available evidence suggests that an employee fitness programme will result in decreased health-care costs, decreased absenteeism and increased productiv- ity for the employer. A recent study (3) on health-care costs showed positive benefits. This study was con- ducted over one year and used an exercise regime involving 30 minutes of activity, three times per week. The potential savings from the programme averaged 0.57 hospital days per employee per year. The scope of the changes which occur as a consequence of increased physical activity are shown in Table 1 (4). Physical inactivity is associated with increased risk of developing obesity and its disease correlates, including increased risk of coronary artery disease. Appropriate physical activity may be a valuable tool in therapeutic regimes for the control and amelioration (re- habilitation) of cardiovascular diseases (coronary artery disease, hypertension, congenital heart disease, peri- pheral vascular diseases); obesity; chronic obstructive pulmonary disease; diabetes mellitus; musculoskeletal problems; end-stage renal disease; stress and depres- sion/ anxiety, etc. Such physical activity, however, is still not routinely pre- scribed for the treatment of these conditions (5). The goals of the rehabilitation programmes based on recom- mendations of the American College of Cardiology (6) are: • to reverse adverse effects of the physiological decon- ditioning that results from a sedentary lifestyle and that are accelerated by bed rests; • to assist patients with chronic disease to optimize their functional capacity; • to assist patients in adapting to and functioning within the limitations imposed by the disease and/or treat- ment; • to prepare patients and their families for a lifestyle that may reduce the risk of coronary artery disease and hypertensive cardiovascular disease; • to reduce the emotional problems that often accom- pany serious health disorders; and • to prevent premature disability and lessen the need for institutional care of elderly patients. The primary health care physician has the responsibility of carefully screening patients, of referring them to the appropriate exercise setting and of incorporating the rehabilitation results into the patient's long-term care. • Medical Officer. Maternal and Child Health, Division of Family Health, World Health Organization, Geneva. Coronary artery disease Coronary artery disease is recognized as a serious public health problem in the developed countries. In the United States of America it is the greatest cause of morbidity and mortality. The economic costs of heart disease are staggering-totalling more than US$40 billion a year in medical costs alone. Regular physical activity appears to provide direct and independent protection against coronary artery disease and helps protect against early death. The more physical activity, the less the risk of coronary artery dis- ease (7). Exercise training is widely recommended as a way to improve the cardiovascular function of selected patients with coronary artery disease (8). A number of well- designed and carefully analysed observational studies have shown the incidence of coronary artery disease to be approximately twice as high among sedentary men as among men who regularly participate in vigorous leisure- time or occupational physical activity. Some findings from major studies on exercise and cor- onary artery disease are shown in Table 2 (9). Powell et al. ( 10) assessed 43 reports published since 1955 and concluded that inactivity is an important risk factor for coronary artery disease and, also, that there is a corre- lation between high levels of habitual physical activity and a reduced incidence of coronary artery disease. The concept of an exercise threshold for lipid changes is consistent with observations that more vigorous forms of exercise are required for reducing the risk of coronary artery disease. High-density lipoprotein cholesterol (HDL-C) is considered protective, while low-density lipo- protein cholesterol (LDL-C) is implicated in atheroscle- rotic vascular disease. Exercise training consistently raises levels of high-den- sity lipoprotein cholesterol. Some well-designed exer- cise studies using sedentary subjects as controls have shown a decrease in plasma LDL-C values (8-12%). with moderate training (60-85% of maximal heart rate). and the frequency was three times per week (11). In recent studies favourable lipoprotein changes were confined to those who had either been running for at least four years, or had been running 56 km or more per week (12), to those who averaged at least 20 km per week of running ( 13) or to those who ran at least 13 km per week for one year (14). Patients with risk factors for coronary artery disease need more intensive pre-exercise evaluation than those not at risk, and those with known or suspected cardio- vascular disease need the most intensive evaluation and follow-up. More information is needed about the dose-response effect of physical activity on coronary artery disease, the effects on disease of beginning a more active lifestyle in Rapp. trimest. statist. sanit. mond .. 41 (1988) - 243 - TABLE 1. PHYSIOLOGICAL FUNCTIONS AND CAPACITIES WHICH IMPROVE WITH REGULAR EXERCISE (LEFT), AND THE VARIOUS DISEASES AND CONDITIONS WHICH ARE INFLUENCED FAVOURABLY BY THESE CHANGES (RIGHT) CARDIOVASCULAR FUNCTION Cardiac performance Blood pressure regulation SKELETAL MUSCLE Metabolic capacities Nutrient blood supply Contractive properties Strength TENDONS AND CONNECTIVE TISSUES Strength Supportive function THE SKELETON Maintenance of bone mass Adjusting structure to load JOINTS Lubrication Range of movement METABOLIC FUNCTIONS Regulation of energy balance Carbohydrate tolerance Lipid and lipoprotein metabolism PSYCHOLOGICAL FUNCTIONS Mood Self-esteem Psychomotor development Memory Source: Reference (4). the middle or latter years and the factors that affect the risk of sudden death during exercise. Hypertension It has been estimated that over 60 million people in the United States have hypertension. There have been stud- ies which implicate certain factors as predisposing to hypertension. These include: (i) a parent with hyperten- sion; (ii) obesity or weight gain (as fat); (iii) relatively higher blood pressure; and (iv) inactivity ( 15). Wld hlth statist. quan .• 41 ( 1988) Ameliorates the effects of age and chronic disease on heart, lungs and muscle Reduces BP in mild hypenension Attenuates age-dependent rise in BP Increases reserve capacity for exertion Improves stamina Reduces fatigue Improves physical strength Increases joint stability Reduces risk of injury Ameliorates the effects of muscle disease Prevents osteoporosis Maintains bone structure Maintains flexibility Avoids limitation of movement Improves body weight control Prevents obesity Prevents coronary heart disease Improves carbohydrate tolerance Ameliorates late-onset diabetes Contributes to the quality of life Reduces mild anxiety and depression Influences mood favourably Contributes to the quality of care for the mentally handicapped Improves memory in the elderly It is suggested that exercise is useful for weight control and may be helpful in reducing blood pressure for those with uncomplicated hypertension (16). There have been numerous studies conducted which have shown that aerobically trained athletes have lower blood pressure than their sedentary counterparts. A majority of the studies show that training is associated with lower systolic pressures (ranging from 5 to 25 mm Hg) and lower diastolic pressures (ranging from 3 to 15 mm Hg). Population studies show an inverse correlation between physical activity and blood pressure lev- els ( 17). - 244 - TABLEAU 1. FONCTIONS ET APTITUDES PHYSIOLOGIQUES OY'AMIELIORE UN EXERCICE PHYSIQUE RIEGULIER (A GAUCHE) AVEC LES DIVERSE.S MALADIES ET ETATS PATH~LOGIQUES QUI SONT FAVORABLEMENT INFLUENCES PAR CES CHANGEMENTS (A DROITE} FONCTION CARDIO-VASCULAIRE Performance cardiaque R6gulation de la tension an6rielle MUSCLES SQUELETTIQUES Capacites metaboliques Irrigation sanguine Contractilite Force musculaire TENDONS ET TISSUS CONJONCTIFS Force Fonction de soutien SOUELETTE Maintien du poids du squelette Adaptation de la structure a la charge ARTICULATIONS Lubrification Bonne amplitude des mouvements FONCTIONS M~T ABOLIOUES Rl!gulation du bilan 6nerg6tique Tol6rance aux glucides Metabolisme lipidique et lipoprotidique FONCTION PSYCHOLOGIOUE Humeur Respect de soi 06veloppement psycho-moteur Memoire Source : R6ference /4 }. Vigorous sports participation, such as jogging, swim- ming, tennis, etc. are protective against developing hy- pertension, even when other predisposing factors are present. Several studies have been conducted using exercise as a teatment for hypertension. Obesity Obesity is a risk factor that is commonly found in diabe- tics and hypertensives, as well as in many otherwise normal subjects. It may be the result of inadequate exer- cise. Cross-sectional surveys and clinical trials consis- tently support the observation that physical activity has a beneficial effect on weight control. Physical exercise may be of value in weight reduction by: (i) expending calories during activity; (ii) increasing the basal meta- Att6nue les effets de rage et des maladies chroniques sur le cceur, les poumons et les muscles Reduit la tension an6rielle dans les cas d'hypenension 16gere Limite 1·augmentation de la tension an6rielle due a I' age Augmente la capacite d'effon Ameliore la resistance R6duit la fatigue Am61iore la force physique Accrolt la solidite des aniculations RMuit le risque de blessures Anenue les effets des maladies musculaires Pr6vient l'ost6oporose Entretient la structure des os Entretient la souplesse Evite le blocage des mouvements Ameliore la r6gulation du poids corporal Previent I' ob6site Pr~vient les cardiopathies coronariennes Ameliore la tol6rance aux glucides A tt6nue le diaMte de la maturite Contribue a la qualite de la vie Reduit I' anxi6te et les depressions 16geres A une influence b6n6fique sur l'humeur Ameliore I' efficacite des so ins chez les handicap6s mentaux Am61iore la memoire chez les personnes ag6es bolic rate for as long as 48 hours after exercise ; and (iii) increasing diet-induced thermogenesis (18). Diabetes A cross-sectional study of a population on a Pacific island noted a higher prevalence of diabetes among sed- entary than among active populations; the association was independent of obesity. Less insulin is secreted in the trained state. Glucose tolerance changes little, or even improves. Physical training mediates this favourable adaptation through three separate mechanisms : (i) increased sensi- tivity of insulin receptors by increasing insulin bind- ing (19); (ii) depletion of muscle and liver glucogen Rapp. trimesr. statisr. sanit. mand .• 41 (1988) - 245 - TABLE 2. FINDINGS FROM MAJOR STUDIES ON EXERCISE AND CORONARY ARTERY DISEASE Population and observation years Harvard alumni, 1962-1972. Paffenbarger et al. The Framingham Study, 1957-1971. Kannel & Sorlie British civil servants, 1969-1978. Morris et al. North Karelia and Kuopio (Finland). 19 72-19 78. Salonen et al. Puerto Rico Heart Health Program, 1965-1973. Garcia-Palmier et al. Source Reference (9). Number 16 934 4220 17 944 6 665 8 793 Comparison Reported energy expenditure Physical activity index Leisure activity; questionnaire Reported physical activity at work and leisure Physical activity index Conclusion Risk of first heart attack was inversely related to energy expenditure in adult life, indepen- dent of other influences on heart-attack risk. Cardiovascular mortality and morbidity were inversely related to physical activity only in men; this relationship was significant and in- dependent of other major risk factors, but the effect was modest in comparison. The coronary heart disease rates of men who took vigorous exercise were lower for both fatal and nonfatal events ; these findings were most striking in older men. Low physical activity at work was associated with increased risk of acute myocardial infarc- tion, cerebral stroke and death from any cause in men and women, controlling for age and other risk factors; leisuretime physical activity related only to a decreased risk of death. The physical activity index was inversely cor- related to the known coronary risk factors ; multivariate analyses indicated a significant, independent inverse relationship between exercise and the incidence of coronary heart disease ; physical activity appeared to be a separate protective factor against heart at- tack. TABLEAU 2. CONCLUSIONS DES PRINCIPALES ETUDES SUR L'EXERCICE ET LES CORONAROPATHIES Population examin6e et sujet d' observation Etudiants de Harvard, 1962-1972. Paffenberger et al. Etude de Framingham, 1957-1971. Kannel & Sorlie Fonctionnaires britanniques, 1969-1978. Morris et al. Carelie du Nord et Kuopio (Finlande). 1972-1978. Salonen et al. Programme de lutte contra les cardiopathies a Porto-Rico, 1965-1973. Garcia-Palmier et al. Source Reference (9). Effectif examin6 16934 4220 17 944 6665 8 793 Base de comparaison Depenses energetiques signalees lndice d'activite physique Questionnaire sur les activites de loisir Activite physique professionnelle et de loisir signalee lndice de I' activite physique Conclusions Le risque d'un premier infarctus etait inverse- ment proportionnel a la depense d'energie au cours de la maturite, independamment des autres facteurs de risque. La mortalite et la morbidite par maladie cardio- vasculaire n'etaient inversement proportion- nelles a I' activite physique que chez les hom- mes ; cette relation etait significative et inde- pendante des autres grands facteurs de ris- que, mais par comparaison avec ces derniers, I' effet etait modeste. Les taux de cardiopathie coronarienne, fatale ou non, etaient plus faibles chez les hommes se livrant a un exercice physique energique ; cette relation etait particulierement frappante chez les hommes d'Age mOr. Une faible activite physique professionnelle etait associee a un risque accru d'infarctus aigu du myocarde, d'accident cerebro-vascu- laire et de deces dO a toute cause chez l'homme et la femme, les donnees etant corri- gees de I' age et des autres facteurs de risque; une activite physique de loisir n'etait associee qu'a une reduction du risque de deces. L'indice de l'activite physique etait inverse- ment proportionnel aux facteurs de risque connus de la coronaropathie; une analyse a plusieurs variables a fait apparaitre une rela- tion inverse monofactorielle significative entre I' exercice physique et !'incidence des corona- ropathies ; ii semble que I' activite physique confere, independamment de tout autre fac- teur. une protection contre les crises cardia- ques. (creating available glucose storage space); and (iii) en- hanced muscle-cell permeability to glucose (20). Be- cause its glucose-lowering effect is largely independent of insulin secretion, physical training can be useful in the management of cases of diabetes mellitus. Most of type II (adult onset) diabetes patients have ele- vated levels. even though they are hyperglycaemic. Con- sideration of the metabolic abnormalities in patients with type II diabetes indicates they would make excellent candidates for an exercise programme. Wld hlth statist. quan .• 41 ( 1988) - 246 - Physical activity has been shown to improve diabetes and plasma lipids in type II diabetic patients (21). Data are not available with which to estimate whether habitual physical activity might prevent or postpone the develop- ment of non-insulin-dependent diabetes, or its complica- tions. Clinical observations suggest that physical activity im- proves glucose control in children with insulin-depend- ent diabetes mellitus. However, no data are available to estimate changes in the rate of complications from dia- betes. Osteoporosis Osteoporosis is an important health problem for the elderly. About 200 OOO Americans break their hips each year. A recent study showed that 10% of all elderly women will suffer a hip fracture, and that 1 in 7 of these women will die within three months of doing so (23). Usually a woman loses more than 1 % of her skeleton each year after the age of 35. By age 70 she will have lost over one-third of her body's structural framework (24). This leads to crush fractures of the vertebrae, forearm and neck of the femur. The best treatment available at present is prevention. Current literature indicates that a high level of physical activity throughout life can result in increased skeletal mass. Walking, running and other weight-bearing activ- ities correlate with bone density and may also reduce the loss of calcium by postmenopausal women (25). Physi- cal activity may play a previously unrecognized role in preventing colon cancer (26). Recent studies suggest that researchers found an association between occupa- tional inactivity and rectal cancer. Men with sedentary jobs had a risk of colon cancer 16 times higher than that of men whose jobs required a greater degree of activity. Former college athletes had a lower prevalence of breast cancer and cancers of the ovary, cervix, uterus and vag- ina, than non-athletes (28). As a rule, screening for physical inactivity, for heart dis- ease and risk factors by history, physical examination and electrocardiographic stress testing should always be conducted before vigorous aerobic activity is pre- scribed. However, there is no agreement yet on recom- mendations for screening procedures before exercise training for asymptomatic middle-aged men. The American College of Sports Medicine (29) recom- mends an exercise test as part of medical screening before a strenuous exercise programme for sedentary people aged 35 years and above and also for younger people at high risk. The National Institutes of Health (30) recommend that a graduated exercise programme can be initiated without seeing a physician if there is: (i) no history of heart trouble, heart murmur, heart attack, hypertension, arthritis or diabetes; (ii) no family history of premature coronary artery disease; and (iii) no exer- cise-related breathlessness, faintness, dizziness or pain or pressure of the chest, neck, shoulder or arm. In order to determine the initial level of fitness and to make an appropriate exercise prescription, the following steps must be taken (24): • symptomatic persons, or those over the age of 35, should obtain written approval from their primary care physicians; • health history (past illness, sports and physical activity participation) should be obtained; • submaximal stress test (the physical work capacity of the individual) should be given; • body composition should be assessed. A good adult fitness programme has at least two goals (24): (i) to provide an adequate exercise stimulus to achieve physiological adaptation without causing significant pain or discomfort (these physiological adap- tations include improved efficiency of the cardiovascular system, as well as increased oxidative capacity and con- tractile force in skeletal muscle); and (ii) to get the indi- viduals to change their exercise habits permanently, so that exercise becomes a part of their day-to-day life. There are four components of exercise activities: (i) mode or specific type of exercise; (ii) their intensity; (iii) their duration; and (iv) their frequency. The primary and most essential components of an exercise session should be an activity that qualifies as aerobic. Examples include brisk walking, jogging, cycling, swimming and cross-country skiing. Aerobic activity is defined as any activity that works the large muscles and markedly ele- vates the metabolic rate (as determined by Vo2 meas- urement) for a prolonged period of time. Participation in aerobic activity is an efficient means of improving cardio- respiratory fitness, or physical working capacity (PWC). PWC is operationally defined as the maximum rate of oxygen utilization in metabolic processes (Vo2 maxi- mum). Most fitness experts and exercise epidemiologists re- commend that exercise training be performed at a sub- maximal intensity, between 50% and 85% Vo2 maxi- mum. The health benefits of regular participation in mod- erate to vigorous physical activity are well established. Some regular moderate physical activity is much better than no physical activity at all. Beginners should exercise near the lower end of this range, but fit adults can usually exercise comfortably at 75% or more at maximum. Because heart rate and Vo2 responses to exercise are linearly related and heart rate is easily measured by palpation, exercise intensity is often prescribed as a percentage of heart rate (i.e. maxi- mum heart rate minus resting heart rate) ; 60-90% of the heart rate range corresponds to 50-85% Vo2 maxi- mum (29). Maximum heart rate is age-related. It can be estimated by subtracting the person's age from the con- stant 220. Some authors use energy expenditure in assessment of physical activity. The benefits of exercise peaked at 3 500 calories per week, e.g. walks briskly or runs 20 miles and plays singles tennis for 2-3 hours a week (2). Beyond 3 500 calories, the death rates stabilized, per- haps, the authors suggested, because of hazards inher- ent in vigorous activities. Table 3 (31) shows the kilocal- orie assignments used in assessment of physical activ- ity. The selected aerobic activity should be sustained for at least 20 minutes. A gradual progression to 30 or more minutes of aerobic activity is generally recommended. Three to five exercise sessions per week are generally recommended for adults who seek an acceptable level of physical fitness and the associated health benefits. An ideal exercise programme should be conducted a minimum of three times per week and should in- clude (24): • 5-10 minutes of warm-up exercises (flexibility); • 20-60 minutes of aerobics (walking, jogging, etc.); • weight training (muscular strength and endurance); • 5-10 minutes of cool-down exercise (flexibility). Rapp. trimest. statist. sanit. mond .. 41 (1988) - 247 - TABLE 3. KILOCALORIE ASSIGNMENTS USED IN ASSESSMENT OF PHYSICAL ACTIVITY TABLEAU 3. VALEURS EN KILOCALORIES UTILISEES POUR EVALUER L'ACTIVITE PHYSIQUE Kcal/ Activity - Activite min. 4 Walking for pleasure - Marche de loisir 4 Walking to work - Marche pour se rendre au travail 8 Using stairs - Utilisation d'escaliers 7 Cross-country hiking - Randonnee pedestre 8 Backpacking - Marche avec sac a dos 10 Mountain climbing - Alpinisme 8 Bicycling (work/pleasure) - Cyclisme pour se rendre au travail/loisir 6 Dancing - Danse 5 Home exercise - Exercices physiques a domicile 5 Health club exercise - Exercices physiques dans un club specialise 8 Jog/walk - Jogging/marche 14 Running 10 min/mi - Course a pied d'un mile en 10 minutes 6 Weight lifting - Halterophilie 6 Water skiing - Ski nautique 4 Sailing (competition) - Navigation a la voile (competi- tion) 4 Canoeing (pleasure) - Aviron (loisirs) 8 Canoeing (competition) - Aviron (competition) 6 Kayaking, rafting - Canoe-kayak, radeau 8 Swimming in a pool - Natation dans une piscine 6 Swimming at beach - Natation sur une plage 7 Scuba diving - Plongee avec scaphandre autonome 5 Snorkeling - Plongee avec tuba 9 Skiing (downhill) - Ski de descente 12 Skiing (cross country) - Ski de fond 7 Skating - Patinage 7 Sledding - Traineau 4 Bowling, horseshoes - Boules, fer a cheval 4 Volleyball 4 Table tennis - Tennis de table 7 Tennis (singles - simples) 6 Tennis (doubles) 5 Softball, baseball 5 Badminton 8 Paddleball 10 Racketball 7 Basketball (non-game - entrainement) 9 Basketball (game - partie) 6 Basketball (officiating - (arbitrage) 8 Touch football - Football americain 10 Handball 10 Squash 10 Soccer - Football 3 Golf (power cart - avec caddy autotracte) 4 Golf (pulling cart - avec caddy tracte a la main) Source: Reference (31) - Reference (31 ). All exercise programmes involving a chronic disease population should include pre-exercise, exercise and recovery evaluation of symptoms. blood pressure, heart rate and heart rhythm. Practising physicians must take a more active role in prescribing conditioning regimes for those wishing to incorporate exercise into their personal health mainten- ance programme. They are powerful models who, by their own health behaviours. influence their patients and other persons. Exercise prescription should be effective and safe, but it is not always without risk. Exercise becomes a hazard when warning symptoms are ignored or the intensity or duration reaches a level which involves distress rather than discomfort. Sometimes vigorous exercise without proper training can cause sudden death as a result of cardiac arrest. The acute cardiac risk of vigorous activity has been estimated in several studies and is generally Wld hlth statist. quan .. 41 ( 1988) Kcal/ Activity - Activite min. 5 Golf (carrying clubs - en portant les clubs) 3 Mowing lawn (ride mower) - T onte de pelouse (avec tracteur) 4 Mowing lawn (power mower) - T onte de pelouse (avec tondeuse autotractee) 7 Mowing lawn (push mower) - T onte de pelouse (avec tondeuse poussee) 5 Weeding, gardening - Desherbage, jardinage 6 Spading, digging - Bechage, terrassement 5 Raking lawn - Ratissage de pelouse 7 Snow shoveling - Deneigement a la pelle 8 Wood chopping - Coupe du bois a la hache 3 Carpentry (inside) - Menuiserie (interieure) 4 Painting (inside) - Peinture (interieure) 4 Carpentry (outside) - Menuiserie (exterieure) 5 Painting (outside) - Peinture (exterieure) 3 Fishing (bank or boat) - Peche (de la rive ou sur embar- cation) 4 Fishing (wading) - Peche (au lancer) 4 Hunting - Chasse 8 Hockey 6 Horseback riding - Equitation 5 Karate, martial arts - Karate, arts martiaux 5 Car washing - Lavage de voiture 13 Snowshoeing - Marche sur raquettes a neige 4 Whittle ball 5 Frisbee 3 Dirt bike riding - Cyclocross 4 Car and boat repair - Reparation de voiture et de bateau 8 Wood carrying - Transport de bois 3 Sailing (pleasure) - Navigation a voile (loisirs) 5 Coaching sports - Travail d'entraineur sportif 5 Playing with children - Jeu avec des enfants 8 lacrosse 5 Golf-ball hitting - Golf (entrainement au drive) 5 Yard. barn chores - Travaux de ferme 5 Lobstering, clamming - Peche a la langouste et cueil- lette de coquillages 5 Housebuilding - Construction d'une maison 5 Umpiring, referee - Arbitrage 6 Wind surfing - Planche a voile 5 Wheeling (normal pace) - Deplacement sur un fauteuil roulant (allure normale) 10 Wheeling (fast pace) - Deplacement sur un fauteuil roulant (allure rapide) 10 Wheelchair basketball - Basketball sur fauteuil rou- I ant thought to be low (32). The incidence of death during jogging was established to be 7 times greater that during non-vigorous activity. However, nearly all of the sudden deaths occurred in subjects with known cardiovascular disease or in subjects at high risk for coronary artery disease. The absolute risk is only 1 death per 7 620 joggers per year or 1 death per 390 OOO man-hours of jogging. In a Finnish study, 4.5% of sudden cardiac deaths were related to strenuous or unusual physical activity, usually cardiac arrhythmia due to coronary artery disease (33). Siscawith et al. (34) have reported that men who under- took vigorous exercise for less than 20 minutes per week were at 56 times the risk of suffering a primary cardiac arrest while exercising, relative to the time when they were not exercising. The risk of cardiac arrest among the habitually active men was 40% lower than that among sedentary men during, and not during, vigor- ous activity. - 248 - Excessively intense or prolonged exercise can lead to extreme fatigue or exhaustion. Environmental factors are known to add to the risk of exercise-induced hyperther- mia. Extremes of temperature may predispose persons to heat exhaustion or heat stroke in unusually warm weather and non-environmentally controlled facilities. Musculoskeletal injuries have been described in associa- tion with most forms of exercise. The magnitude of this problem is not known precisely, but can be considerable. More than one-third of participants in a 10 km road race had a musculoskeletal injury the year before the race, and one-seventh of these persons had sought medical attention. In some people with a strong family history of allergies, wheezing, asthmatic attacks or urticaria may develop during or after exercising. Experimental evidence suggests that exercise while in- fected by a virus may precipitate subclinical myocardi- tis (35). Some authors reported complications including gross haematuria (36) and gastrointestinal bleed- ing (37). Other hazards of exercise (amenorrhea, "addic- tion" to exercise, etc.) have received scientific atten- tion (38). Regular exercise of moderate duration and intensity sufficient to attain a conditioning effect is most likely to be beneficial. To minimize the possible hazards of exercise, such training should be prescribed by a phy- sician. SUMMARY More and more people are turning to exercise as a means of achieving long-term health. The World Health Organi- zation has endorsed this concept. The best available evidence suggests that an employee fitness programme will result in decreased health-care costs, decreased absenteeism and increased producti- vity for the employer. Regular physical activity is also associated with lower mortality rates. Appropriate physical activity may be a valuable tool in therapeutic regimes for the control and amelioration (re- habilitation) of cardiovascular disease, coronary artery disease, hypertension, congenital heart disease, peri- pheral vascular disease, obesity, chronic obstructive pulmonary disease, diabetes mellitus, musculoskeletal disorders, end-stage renal disease, stress, anxiety and depression, etc. Regular physical activity, independent of other factors, reduces the probability of coronary artery disease and early death. Patients with risk factors for coronary artery disease need more intensive pre- exercise evaluation than those not a risk, and those with known or suspected cardiovascular disease need the most intensive evaluation and follow-up. Participation in vigorous sports activities, such as jog- ging, swimming, tennis, etc., helps to protect against the development of hypertension, even when other predis- posing factors are present. Several studies have been conducted on the use of exercise in the treatment of hypertension. Physical exercise also contributes to the control of body weight. Consideration of the metabolic abnormalities in patients with type II (adult onset) diabe- tes indicates that they would make excellent candidates for an exercise programme. Osteoporosis is an important health problem for the elderly. The best treatment available at present is pre- vention, and a high level of physical activity throughout life can result in a larger skeletal mass during old age. The primary health care physician has the responsibility of carefully screening patients and of referring them to the appropriate exercise setting. This physician should also incorporate the rehabilitation results into the pa- tient's programme of long-term care. When a programme of aerobic activities is begun, exer- cise sessions should be about 20 minutes in duration and be increased, gradually, to sessions of 30 minutes. Adults who seek an acceptable level of physical fitness, and the associated health benefits, should adhere to a programme of 3-5 aerobic activity sessions per week. Exercise that is moderate in duration and intensity and that has a conditioning effect is most likely to be bene- ficial; however. in the interest of minimizing the possible hazards of exercise, it should be prescribed by a physi- cian. RESUME Role de r activite physique dans la prevention et le traitement des maladies non transmissibles De plus en plus de gens prennent de I' exercice pour demeurer longtemps en bonne sante. L'Organisation mondiale de la Sante approuve cette attitude. L'employeur qui instaure un programme d'entretien de la forme physique pour ses employes voit, a en juger par les meilleures etudes qui ont ete faites sur ce sujet, les depenses de sante diminuer, l'absenteisme decroitre et la productivite augmenter. En outre, une activite physi- que reguliere est associee a une baisse des taux de mor- talite. Une activite physique appropriee peut ~tre d'un grand secours pendant un traitement therapeutique conc;:u pour ameliorer l'etat des malades atteints de l'une des mala- dies suivantes (readaptation): maladie cardio-vasculaire, coronaropathie, hypertension, cardiopathie congenitale, acrosyndrome, obesite, bronchopneumopathie chroni- que obstructive, diabete sucre, trouble du systeme os- teo-musculaire, nephropathie au stade terminal, stress, anxiete et depression, etc. lndependamment des autres facteurs, une activite physique reguliere reduit la proba- bilite d'une coronaropathie et d'un deces precoce. Les malades exposes a des facteurs de risque de coronaro- pathie ont plus que les autres besoin d'une evaluation Rapp. trimest. statist. sanit. mond., 41 (1988) - 249 - poussee avant de se lancer dans un programme d'exer- cices physiques. Une evaluation et un suivi maximums etant de rigueur pour toute personne chez qui une mala- die cardio-vasculaire a ete diagnostiquee ou suspec- tee. Des activites sportives energiques comme le jogging, la natation, le tennis, etc. aident a prevenir !'hypertension, meme en presence d'autres facteurs predisposants. Plu- sieurs etudes ont ete faites sur le recours a I' exercice physique pour le traitement de !'hypertension. Une acti- vite physique contribue egalement a stabiliser le poids corporel. L'examen des anomalies du metabolisme chez des malades ayant un diabete du type II (diabete de la maturite) montre qu'un programme d'exercices physi- ques serait, dans leur cas, particulierement indique. L'osteoporose est unimportant probleme de sante chez les personnes agees. Actuellement. la prevention est le meilleur traitement dont on dispose et la pratique d'une importante activite physique pendant toute I' existence peut augmenter le poids du squelette chez les personnes §gees. Le medecin charge des soins de sante primaires doit soigneusement examiner les patients pour leur recom- mander le type d'exercice qui leur convient le mieux. II doit aussi tenir compte des resultats de la readaptation dans le programme de soins a long terme qu'il con9oit pour le patient. Au debut, les seances d'aerobic ne doivent pas depas- ser 20 minutes; elles augmentent ensuite progressive- ment pour atteindre finalement 30 minutes. Les adultes qui desirent acquerir une forme physique acceptable, avec les avantages qui en decoulent pour leur sante, doivent suivre 3-5 seances d'aerobic par semaine. C'est un exercice de mise en forme et d'une intensite moderee qui donne les meilleurs resultats; toutefois, pour minimiser les risques eventuels, ii faut qu'il soit prescrit par un medecin. REFERENCES - REFERENCES 1. WHO Technical Report Series No. 678, 1982 (Pre- vention of coronary hean disease: report of a WHO Expert Committee). OMS Serie de Rapports techniques N° 678, 1982 (Prevention des cardiopathies coronariennes: rap- port d'un Comite d'experts de l'OMS). 2. PAFFENBARGER. R. s. ET AL. Physical activity, all-cause mortality and longevity of college alumni. New England journal of medicine, 314 (10): 605-613 (1986). 3. SHEPARD. R. ET AL. The influence of an employee fit- ness and lifestyle modification programme upon medical care costs. Canadian journal of public health, 73: 259-263 ( 1982). 4. BASSEY. J. ET AL. Reasons for advising exercise. Practitioner, 231: 1605-1610 (1987). 5. Promoting health, preventing disease. Objectives for the Nation: 1-87 ( 1984). 6. PARMLEY. W.W. Recommendations of the Ameri- can College of Cardiology on cardiovascular rehabi- litation. Cardiology, 7: 4-5 ( 1986). 7. PAFFENBARGER. R. S. & HYDE. R. T. Exercise in the pre- vention of coronary heart disease. Preventive medi- cine. 13 (1): 3-22 (1984). 8. GREENBERG. M.A. The role of physical training in patients with coronary artery disease. American heanjournal, 94 (4): 527-534 (1979). 9. OBERMAN. A. Healthy exercise. West journal of medi- cine, 141: 864-871 (1984). 10. POWELL. K. E. ET AL. Physical activity and the inci- dence of coronary heart disease. Annual review of public health, 8: 253-287 (1987). 11. HUTTBRIEN, J. ET AL. Effect of moderate exercise on serum lipoproteins-controlled clinical trial with special reference to serum high-density lipopro- teins. Circulation, 60: 1220-1229 ( 1980). 12. CHRISTIE. R. J. ET AL. High-density lipoprotein (HDL) cholesterol in middle-aged joggers. New Zealand medical journal, 91 : 39-40 ( 1980). 13. PAFFENBARGER. R. S. ET AL. Physical activity as an index of heart attack risk in college alumni. Ameri- can journal of epidemiology, 108 (3): 161-175 (1978). W/d hlth statist. quan .. 41 ( 1988) 14. Wooo. P. D. ET AL. Increased exercise levels and plasma lipoprotein concentrations-a one-year ran- domized controlled study in sedentary middle-aged men. Metabolism, 32: 31-39 (1983). 15. P AFFENBARGER. R. ET AL. Physical activity and inci- dence of hypertension in college alumni. American journal of epidemiology, 117: 245-257 (1983). 16. The 1984 report of the Joint National Committee on detection, evaluation and treatment of high blood pressure. Archives of internal medicine, 144: 1045-1057 (1984). 17. SEALS. D. R. & HAGBERG. J. M. The effect of exercise training on human hypertension : a review. Medical science spons exercise, 16: 207-215 (1984). 18. WIRTH. A. The role of exercise in weight control. In: BENDER. A. E. & BROOKES. L. J. (eds), Body weight control. New York, Churchill Livingstone, 1987. 19. LE BLANC. J. ET AL. Effects of physical training and adiposity on glucose metabolism and 125-J insulin binding. Journal of applied physiology, 46: 235- 239 (1979). 20. HEATH. G. W. ET AL. Effects of exercise and lack of exercise on glucose tolerance and insulin sensitivi- ty. Journal of applied physiology, 55: 512-517 (1983). 21. RUDERMAN. , N. ET AL. The effect of physical training on glucose tolerance and plasma lipids in maturity- onset. Diabetes, 28 (Supplement 1): 89-92 (1979). 22. BUHR. A. & COOK. A. Fracture patterns. Lancet, i: 531-536 (1959). 23. BONN. D. Hormones for healthy bones. New scien- tist, 113 (1548): 32-35 (1987). 24. ULLRICH. J.M. The role of physical activity in disease prevention and treatment. West Virginia medical journal, 81 (2): 35-39 (1985). 25. HASKELL. w. L. & SUPERKO, R. Designing an exercise plan for optimal health. Family community health, 7: 72-88 (1984). 26. GARRABRUANT, D. H. ET AL. Job activity and colon cancer risk. American journal of epidemiology, 119: 1005-1014 (1984). - 250 - 27. GERHARDSSON. M. ET AL. Sedentary jobs and colon cancer. American journal of epidemiology, 123 (5): 775-780 (1986). 28. FRISCH, R. E. ET AL Lower prevalence of breast can- cer and cancers of the reproductive system among former college athletes compared to non-athletes. Journal of cancer, 52 (6): 885-891 (1985). 29. AMERICAN COLLEGE OF SPORTS MEDICINE. Guidelines for exercise testing and prescription, Philadelphia, Lea & Febiger, 1986. (Third edition). 30. us DEPARTMENT OF HEAL TH AND HUMAN SERVICES. Exer- cise and your heart. Washington D.C., Government Printing Office, 1981. N(NIH) 83-1677. 31. WASHBURN, R. A. ET AL Echocardiographic left ven- tricular mass and physical activity: quantification of the relation in spinal cord injured and apparently healthy active men. American journal of cardiology, 58: 1248-1253 ( 1986). 32. EICHNER, E. R. Exercise and heart disease: epidemio- logy of the exercise hypothesis. American journal of medicine, 74: 1008-1023 (1983). 33. LEON, A. S. & BLACKBURN, H. Physical inactivity. In: Kaplan, N. M. & Stamler, J. (eds), Prevention of coronary heart disease. Philadelphia. W. B. Saun- ders, 1983. 34. S1scow1cK, D. ET AL The incidence of primary cardiac arrest during vigorous exercise. New England jour- nal of medicine, 311: 874-877 (1984). 35. YOUNG, A. Exercise in the prevention of disability. In: GRAY, M. & FOWLER, G. (eds), Preventive medicine in general practice. Oxford, Oxford University Press, 1983. 36. DANIELS, J. ET AL Conditions for distance running. New York, John Wiley & Sons, 1987. 37. STEWART,J. G. ET AL Gastrointestinal blood loss and anaemia in runners. Annals of internal medicine, 100: 843-845 (1984). 38. KoPLAN, J.P. ET AL An epidemiologic study of the benefits and risk of running. JAMA, 248: 3118- 3121 (1982). Rapp. trimest. statist. sanit. mond .. 41 (1988) - 251 - THE GLOBAL PREVALENCE OF OBESITY - AN INITIAL OVERVIEW OF AVAILABLE DATA Michael Gurneya & Jonathan Gorsteinb Approaches to measurement Obesity is a condition of excess body fat. Most obese people are so because the energy intake in their diet has, over a period, exceeded their energy expenditure in metabolism, movement and growth. Indirect causes are often complex and are sometimes linked to psychologi- cal factors and social expectations and pressures. In some cultures overweight is a sign of wealth, status and physical attractiveness. However, obesity is a risk factor for a whole range of conditions including cardio- vascular diseases, diabetes mellitus, arthritis, gall- bladder disease, cancer, respiratory dysfunction and various skin conditions. The distribution of body fat is hard to measure. It exists in a subcutaneous layer of varying thickness under most of the body surface and in the abdominal and other cavi- ties. Fat is less dense than other tissues, thus its contri- bution to body weight is not directly in proportion to its volume. It is possible to calculate total body-fat content from estimates of body density, dispersion of a labelled water-soluble substance through the fat-free mass or by tomography, for example. However all these methods are too complex and often too expensive for use in regu- lar public health practice or individual screening. For such purposes the use of anthropometry-in particular the measurements of body weight (mass), lengths, circum- ferences and subcutaneous fatfolds-is the main tool for measurement of nutritional status, including obesity. Anthropometry measures body dimensions but as the distribution of body components such as adipose tissue and musculature differ from one individual to another, it can only estimate relative degrees of "fatness". The risk associated with increased adiposity also de- pends upon the area of the body where the fat cells are located. For instance, fat around the waist and upper trunk is more highly associated with risk of mortality and morbidity than fat located around the thigh and but- tocks (1). Ideally, a number of skinfold measurements are made over various parts of the body so as to take account of the distribution of subcutaneous fat. Propo- sals have been made for such an approach in adults (2, 3). It is recommended that where feasible obesity should be assessed from the waist and hip circumferences, a number of skinfolds, and weight and height. From these measurements various ratios, or other indices which provide more information on the extent and location of body fat, can be calculated. However, only the triceps skinfold is usually measured in nutritional surveys; the undressing which is needed for other skinfolds and cir- • Senior Programme Officer, Nutrition Unit, World Health Organiza- tion, Geneva. b Technical Officer, Nutrition Unit, World Health Organization, Geneva. c World Health Organization. Measuring obesity-classification and description of anthropometric data. Report of a WHO Regional Office for Europe consultation on the epidemiology of obesity, Copenhagen, 1988. (Document EUR/ICP/NUT 125). Wld hlth statist. quart., 41 ( 1988) cumferences is often unacceptable in the context of a survey, especially for women. Anthropometric measurements and indices based on them are interpreted either through comparison with a reference population or with the individual's previous measurements, or in relation to their association with risk factors. Such interpretation is not simple as it often does not take human genetic and environmental variabi- lity into account. Risk factors vary with age, sex, inter- vening variables and probably lifestyle. One can conclude that, while extreme obesity is easy to recognize, lesser degrees of probably harmful excess body fat are much less easy to define in any one indivi- dual. Obesity and overweight in populations can be esti- mated through anthropometry by expressing increased risk of mortality and morbidity as outcomes rather than through summing individual assessments. Comparable indicators A recent WHO consultation on the epidemiology of obe- sity discussed many issues concerning the subject in relation to the description of adult populations.c The consultation recommended that for the classification of obesity in adults, the body-mass index (BMI) is appro- priate. The BMI, also known as Quetelet's index, is cal- culated from body weight (in kilogrammes) divided by the square of height (in metres). A BMI of 30 or more is taken to signify ··a high degree of fatness'· ; it indicates a high relative risk of disease. This cut-off point has been designated as the result of actuarial and prospective studies showing a LI-shaped mortality risk curve accor- ding to BMI, where increased association with morbidity and mortality occurs at both extremes of BMI values. A report of the Royal College of Physicians (4) recom- mended that the BMI is inappropriate for children and adolescents unless different power values for height in the equation are used. This is because of the rapid chan- ges in body shape and composition that naturally occur at this time. The report recommends that for the classi- fication of "overweight" and "obesity" in children, weights should be assessed relative to reference weights at attained heights. It supports the WHO 1983 and 1986 recommendation (5, 6) that to facilitate stan- dardized analysis and presentation in population studies, the international reference population derived from the US National Center for Health Statistics (NCHS) (7) be used for the calculation of anthropometric data. It recom- mended classifying children as overweight when they exceed the median weight-for-height plus two standard deviations. This classification does not represent an analysis of mor- tality or morbidity risk, but rather a comparison with the distribution of values in a reference population. As with adults, a more rigorous anthropometric assessment of fatness requires a measurement of subcutaneous skin- folds. 252 - Global data The WHO Nutrition Programme has been collecting an- thropometric data worldwide and has attempted to stan- dardize the analysis and presentation of data into uni- form formats. In this way it is possible to make inter- and intra-country comparisons of nutritional status indica- tors, as well as to evaluate trends over time (6). This article provides a breakdown of the available information relating to obesity and overweight expressed in the stan- dard formats described above. It is appreciated that other data sets are available, but unfortunately these are not in a form that can be translated into BMls (for adults) or standard deviation scores of the median weight-for- height (for children). d A list of references can be obtained from the World Health Organi- zation, Nutrition Unit, 1211 Geneva 27, Switzerland. The reported prevalence of BMI values above 30 in adults in different countries is presented in Table 1, and the proportion of children above + 2 S.D. of the median weight-for-height for the age group 0-4.99 years is listed in Fig. 1. For the latter. weighted averages have been calculated for the age group, giving equal weight to each age. This preliminary tabulation is intended to display data which is currently available to the WHO Nutrition Programme in compatible formats.d Investigators are urged to analyse data on adults using the body-mass index and on children using standard deviation scores. A standardization in methodology as done here makes it possible to evaluate changes in obesity prevalence over time and, when linked with mortality data, to assess association with mortality patterns. As obesity appears to be rising both in industrialized and in developing coun- tries, the collection and analysis of this information is clearly of public health importance. SUMMARY Methods of measuring obesity are briefly reviewed. The more precise methods of measuring the body-fat mass are too complex and expensive for use in regular public health practice or individual screening. Anthropometry can, however, provide useful informa- tion. Two anthropometric indicators of obesity or over- weight are recommended for classifying obesity. For adults, the body-mass index is reasonably easy to obtain and correlates well with mortality and morbidity risk. For children, "overweight" is indicated by a weight-for- height above the median NCHS value plus two standard deviations. Data compiled by the WHO Nutrition Unit, using these two indicators, are presented for a number of countries worldwide in Table 1 & Fig. 1. TABLE 1. PREVALENCE OF OBESITY IN ADULTS IN NATIONAL SURVEYS AS INDICATED BY A BODY-MASS INDEX (BMI) GREATER THAN 30 TABLEAU 1. PREVALENCE DE L'OBESITE CHEZ LES ADULTES TELLE OU'ELLE RESSORT D'ENOUIETES NATIONALES UTILISANT COMME INDICATEUR UN INDICE DE MASSE CORPORELLE SUPERIEUR A 30 Age group Number measured Percentage obese WHO Region/country (years! Nombre mesure Pourcentage d' obeses Rt\gion OMS/pays Groupe d·age (annees) M F M F Americas - Ameriques Costa Rica 20-25 61 106 0.0 2.8 40-45 52 83 5.7 14.4 El Salvador 20-25 51 77 0.0 1.3 40-45 38 68 0.0 1.5 Guatemala 20-25 81 119 0.0 0.0 40-45 48 89 0.0 5.6 Honduras 20-25 43 105 0.0 1.0 40-45 36 67 2.8 6.0 Nicaragua 20-25 43 100 2.3 3.0 40-45 32 67 3.1 16.4 Panama 20-25 43 71 0.0 0.0 40-45 44 58 2.3 1.7 Trinidad (urban) - Trinite (zone urbaine) 40 32.0 74 27.0 Canada ... 8.5 9.3 United States - Etats-Unis 12.0 15.0 Europe Italy - ltalie . . . 15-44 4.8 3.9 45-64 9.9 11.1 Netherlands - Pays-Bas . 20-34 1.9 2.0 35-49 4.2 5.0 50-64 5.4 10.3 United Kingdom - Royaume-Uni 20-34 4.0 4.7 35-49 7.9 8.6 50-64 7.4 14.3 Western Pacific - Pacifique occidental Australia - Australie 25-34 1006 1004 4.0 5.7 35-44 1030 1 050 6.2 7.5 45-54 873 886 10.2 11.0 55-64 831 884 9.6 12.5 Rapp. trimest. statist. sanit. mond., 41 ( 1988) "' a, .£!? Country - Pays 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 FIG.1 PREVALENCE OF OBESE PRESCHOOL CHILDREN -ABOVE +2 S. D. FROM THE REFERENCE MEDIAN WEIGHT-FOR-HEIGHT (0-59 MONTHS)• PREVALENCE DE L'OBESITE CHEZ LES ENFANTS D'AGE PRESCOLAIRE REVELEE PAR UN POIDS POUR LA TAILLE SUPERIEUR A LA MOVENNE DE REFERENCE +2 E.T. (0-59 MOIS) 8 Country - Pays 1. Papua New Guinea - Papouasie-Nouvelle-Guinee 2. Bangladesh 3. Philippines 4. Burkina Faso 5. Singapore - Singapour 6. Togo 7. Tunisia - Tunisie 8. Rwanda 9. India - lnde 10. Indonesia - lndonesie 11. Belize 12. Jordan - Jordanie 13. Tahiti 14. Nicaragua 15. Brazil - Bresil 16. Saint Lucia - Sainte-Lucie 17. United Kingdom - Royaume-Uni 18. Yugoslavia - Yougoslavie 19. Antigua 20. Zambia - Zambie 21. Venezuela 22. Italy - ltalie 23. Panama 24. Peru - Perou 25. Barbados - Barbade 26. Honduras 27. Lesotho 28. Bolivia - Bolivie 29. Trinidad and Tobago - T rinite-et-Tobago 30. Iran (Islamic Rep. of - Rep. islamique d') 31 . Mauritius - Maurice 32. Canada 33. Jamaica - Jamarque 34. Chile - Chili Notes Kar Kar, Lufa Rural Mossi Tribe - Tribu Mossi Gourma Tribe - Tribu Gourma 1-4.99 years/ans Kerala East Java - Java (Est) Amman (rural) Paraiba Zagorje (rural) 1-4.99 years/ans Suyapa - 0-2.99 years/ans Montero Region - Region de Montero Rural 0-5.99 years/ans > + 2 S.D. (%) - > + 2 E.T. (%) • NCHS reference population - Population de reference NCHS. - 254 - RESUME Prevalence mondiale de I' obesite - un premier aper~u des donnees disponibles L'article passe brievement en revue les methodes em- ployees pour mesurer l'obesite. Les methodes plus pre- cises utilisees pour evaluer la masse lipidique de I' orga- nisme sont trap complexes et trap couteuses pour servir couramment en sante publique ou pour les examens individuels. L'anthropometrie peut cependant fournir des renseigne- ments utiles. Deux indicateurs anthropometriques de I' obesite et de I' exces de poids sont recommandes pour mesurer le degre d'obesite. Chez les adultes, l'indice de masse corporelle est relativement facile a calculer et ii est assez etroitement lie au risque de morbidite et de mortalite. Chez les enfants, l'exces de poids est signale par un poids pour la taille superieur a la mediane NCHS plus deux ecarts types. Les donnees rassemblees par l'Unite de la nutrition de l'OMS sur la base de ces deux indicateurs sont presen- tees pour un certain nombre de pays au tableau 1 et a la figure 1. REFERENCES - REFERENCES 1. NATIONAL INSTITUTES OF HEAL TH. Health implications of obesity. National Institutes of Health consensus de- velopment conference statement, 5 (9): ( 1985). 2. DuRNIN.J.V.G.A. & WOMERSLEY,J. Body fat assessed for total body density and its estimation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years. British journal of nutrition, 32: 77-79 (1974). 3. WOMERSLEY, J. & DURNIN. J.V.G.A. A comparison of the skinfold method with extent of ··overweight'· and various weight-height relationships in the assess- ment of obesity. British journal of nutrition, 38: 2 71- 284 (1977). 4. Obesity-a report of the Royal College of Physicians. Journal of the Royal College of Physicians of London, 17: 5-65 (1983). 5. WORLD HEALTH ORGANIZATION. Measuring change in nutritional status. Geneva, WHO. 1983. ORGANISATION MONDI ALE DE LA SANTE. Mesure des modi- fications de /'etat nutritionnel. Geneve. OMS. 1983. 6. WHO WORKING GROUP. Use and interpretation of an- thropometric indicators of nutritional status. Bulletin of the World Health Organization 64 (6) : 929-941 (1986). GROUPE DE TRAVAIL DE L'OMS. Utilisation et interpreta- tion d'indicateurs anthropometriques de l'etat nutri- tionnel (resume). Bulletin de /'Organisation mondiale de la Sante, 64 (6): 940 (1986). 7. Puauc HEAL TH SERVICE. NCHS growth chans. Rock- ville, Md., Health Resources Administration, 1976. (HRA 76-1120, 25, 3). 8. GORSTEIN. J. & AKRE. J. The use of anthropometry to assess nutritional status. World health statistics quanerly, 41 (2): 48-58 (1988). GoRSTEIN. J. & AKRE, J. L'utilisation de l'anthropome- trie pour evaluer l'etat nutritionnel (resume). Rappon trimestriel de statistiques sanitaires mondiales, 41 (2): 54 (1988). Rapp. trimest. statist. sanit. mond., 41 (19881 - 255 - THE GLOBAL IMPACT OF NONCOMMUNICABLE DISEASES: ESTIMATES AND PROJECTIONS Kenneth G. Mantona The risk of chronic degenerative diseases in a population is driven both by the population age structure, where most chronic disease risks increase roughly exponen- tially with age, and with risk-factor exposures. The first factor suggests that as life expectancy rises in a country, chronic diseases, as a natural consequence, will account for an increasing share of the total health problem facing that population (1). Thus, the public health successes in countries that raise life expectancy to 60 years or more require significant further planning and action for con- trolling the risk of chronic diseases. The need for such planning and action will be even greater in countries with effective population-control programmes because these programmes accelerate the shift towards an older age structure. The second factor suggests that we currently have effective strategies for controlling the level of chronic disease risks at each age in a country. Further- more, since the prevalence of certain risk-factor expo- sures is likely to increase as economic development occurs and disposable individual income increases (e.g. smoking, alcohol consumption), it will be cost-effective to intervene early in the development process in order to prevent the broad dissemination of unhealthy lifestyle practices and consumption patterns before they become fully ingrained in the society and culture. In order to illustrate these arguments two types of ana- lyses are presented in this article. The first is demogra- phic. In these analyses it will be shown that the impact of chronic disease on a society necessarily increases as life expectancy increases and that, when life expectancy reaches 60 years in a country, the health burden of chronic disease in the population is likely to be quite high already. The second type of analysis will illustrate the economic consequences of chronic disease in an adult population. In addition, we will show the possible economic benefits of controlling risk factors that have an impact on multiple chronic diseases in a population. Methods As indicated above, two basic methodologies were util- ized in these analyses. The first type is an extension of familiar life-table analyses (2). The second analysis re- quires a methodology for analysing longitudinal data on chronic-disease risks and risk-factor change, and pro- ducing estimates for the impact of those diseases (3). Life-table models and the effects of chronic diseases First, the survival characteristics of persons dying of a given disease will be described in a series of multiple decrement life tables (4). These tables describe the sur- vival experience of persons in the population who would die of the disease given the current cause-specific mar- a Research Professor, Center for Demographic Studies, Duke Univer- sity, Durham, North Carolina, United States of America. Wld hlth statist. quan., 41 ( 1988) tality rates. In interpreting these life tables two parame- ters will be examined. The first (lx.J is the portion of the life-table population surviving to a given age x when the only cause of death is disease A. Since the multiple decrement life table describes the survival experience of persons who will die of the condition, the value of this parameter at birth is the portion of all deaths in the life- table cohort that will be due to cause A (2). The sum of these portions at birth (l0A) for the multiple decrement tables for each cause will equal the life-table radix 10 for the total population (e.g. 100 OOO). In order to determine if a disease is becoming more or less important after a given age x, the lxA must be divided by Ix - the total probability of surviving to that age. If persons are dying at earlier ages from other conditions, Ix will decline more rapidly than lxA and a higher proportion of survivors to age x can expect to die of the condition. A second type of parameter which can be examined from the multiple decrement table is exA• the life expec- tancy at age x in the table for cause of death A. It can also be interpreted as the mean age at death in the life-table population from cause A. It is different from the mean age at death for all persons who actually died from cause A because the effects of population structure have been removed. Thus, exA can be compared across causes, conditions or time. In examining the effect of life-expectancy increases on the cause-specific mortality experience of a population, it will be determined (i) if the mean age at death from specific diseases has changed; and (ii) if the specific conditions cause proportionately more or fewer deaths. For example, recent increases of 2-3 years in life expec- tancy in the United States of America resulted from an increase in the mean age at death for each of the major chronic diseases (5). Simultaneously with these in- creases the proportion of deaths from cancer increased moderately and the proportion of deaths from stroke declined. Since these quantities are based on life-table populations, the effects of differences in population structure are removed, so that they can be compared cross-nationally and over time. A third type of life-table parameter to be examined is the gain in life expectancy among persons who are expected to die of the disease. This is different from standard cause-elimination life tables in that the person-year gains in the standard approach are averaged over the entire population (Ix) while in our approach they are averaged only over the number of persons who are expected to die of the condition under study flxAJ (2). Thus this second approach gives a more realistic picture of the impact of successful control of the condition on the survival of individuals. Models for assessing the effects of risk factors Life-table models are useful for determining the effects of specific diseases on survival. However, they do not provide insights on the linkage of cause-specific mortal- ity with risk factors and their change. To assess this - 256 - linkage a different type of model is needed. This model has two components. The first component is the hazard function. This function relates the risk of disease or death to the values of the risk factor. Some standard types of hazard function are the logistic and Cox regression (6). Since projections of morbidity and mortality will be conducted in order to calculate the future costs of disease, a specific type of hazard function is required. This hazard function models the risk of disease over the follow-up interval both as a quadratic function of the risk factors and as a Gompertz function of age. The first component of the model (hazard function) is familiar in concept to students of chronic disease epidemiology. However, if one is going to project future morbidity and mortality risks as a function of risk factors one also needs a model to project changes in those risk- factor values. Projecting risk-factor values requires a second component. These are linear regression equa- tions which describe the change in risk-factor values over time. These equations predict the future values of the risk factors as a function of their past values, a con- stant change and stochastic error. The second compo- nent makes it possible to predict how risk factors will change with time as a function of their previous mean levels and their variances, while the first component makes it possible to determine the level of risk given the risk-factor values existing at any given time. These com- ponents can be combined to calculate the survival prob- abilities of a cohort, from multiple decrement life tables mentioned earlier. The probability of surviving from age a0 to age ar is a function of changes in the risk factors as well as the hazard function. The changes in risk-factor means and variances are found by first adjusting them for the effects of mortality and then projecting forward the values of the risk factors for survivors. With the life-table values for the cohort it is possible to calculate both the costs of the disease and the effect of the disease on life expectancy within a specific age inter- val (5). Also, by manipulating the component dealing with risk-factor change one can determine the effect on survival of various types of risk-factor interventions (e.g. reduction in mean risk-factor levels, reduction in the var- iance of risk factors, controlling the increase in risk- factor values with age). This type of model represents several different impor- tant features of mortality and morbidity processes often not captured in attempts to forecast future health changes. For example, the model includes the effects of the variances of the risk factors as well as their means. Thus the model is sensitive to the effect of altering the risk-factor level of persons at extreme levels and in sel- ect subpopulations. The model also describes the age change in the effect of risk factors on chronic disease. It is known, for example, that many risk factors are less predictive of risk at advanced ages (7). Without repre- senting this change one may mis-estimate the impact of the risk-factor interventions-especially those that oc- cur in later life. Finally, the model can describe the inter- action of disease processes because multiple disease outcomes can be modelled simultaneously (i.e. by esti- mating a hazard function for each disease). The depend- ency of competing risks is represented in the cause- specific hazard function which links the risk of each dis- ease to a common set of risk-factor values for the indi- vidual. This dependent competing risk effect may ex- plain why certain interventions evaluated in community trials did not have their anticipated effect. Saving per- sons by reducing the force of mortality from a condition may increase the mortality risk of a second condition because more high-risk-factor persons are saved. This effect is small at age 30 before there is a significant mortality from chronic diseases, but increases strongly with age. Data Several sources of data will be used in this article. Firstly, for life-table computations cause-specific mortality data and population estimates provided by WHO will be used. From that file age-specific rates were calculated for the following diseases: cancer (WHO 8-list Nos 808-814) ; diabetes (8181); cirrhosis (834 7); stroke (829); and heart disease (826 & 827). The WHO mortality files contain data on almost 80 countries. However, not all countries have accurate cause-specific mortality. About 45 countries were found to have acceptable cause- specific mortality data (i.e. which had less than 20% of deaths at all ages attributed to senility and ill-defined conditions). Of course, in the detailed analyses to be presented it was not possible to present the results from all countries with reliable cause-specific mortality data. Consequently, we selected a small number of countries that represented the general patterns observed (8). These countries tended to overrepresent highly and moderately developed nations. Less developed nations were analysed by combining a general set of cause- specific mortality rates with the population estimates and projections for 1960, 1980 and 2000 produced by the United Nations Population Division to provide indi- rect estimates of mortality rates. The analysis of the indirectly estimated rates shows the possible variation in chronic disease risk due simply to differences in population structure. They say little about differences in the mortality risks of specific chronic dis- eases in different countries because a common rate structure is applied to all countries. Secondly, to assess the potential effects of various risk- factor interventions, data from the Framingham Study of cardiovascular disease were used. In particular the 20- year follow-up experience of 2 336 males aged 29-62 in 1950 was analysed. Assessments of risk factors were made every two years. Risk factors used are serum cho- lesterol, diastolic blood pressure, systolic blood pres- sure, smoking, Ouetelet index, blood sugar, haemoglo- bin, vital capacity and age. The outcome criteria are deaths due to cancer (ICDA 140-239), heart or other circulatory disease (ICDA 390-458) and all other condi- tions. Results The effects of noncommunicable diseases on mortality In assessing the effects of noncommunicable diseases on mortality the first type of data examined is the mul- tiple decrement life tables for selected major chronic diseases. The following five diseases were selected because of their high prevalence at death and the possi- bility of primary intervention. • Cancer - may be controlled by reduction of smoking (for lung cancer) and possibly reduction of certain die- tary exposures (for cancer of the stomach, resopha- gus, liver, etc.). • Diabetes - adult onset diabetes is controllable by weight reduction and dietary management. • Cirrhosis - may be controlled by reduction in alcohol consumption. Rapp. trimest. statist. sanit. mond., 41 (1988) - 257 - • Stroke - may be controlled by treating hypertension, weight reduction and dietary control (also by control of diabetes and smoking). • Heart disease - may be controlled by reduction of hypertension, management of diabetes, dietary con- trol and smoking reduction. The first set of data examined is the life expectancies and proportions of deaths for each of the several diseases for six countries in 1980 (Table 1). In the table the total life expectancy and the ratio of the highest to lowest values of life expectancy for each dis- ease were also included. It can be seen that the countries selected represent a fairly broad range of life expectan- cies; male (8.8 years; 65.7-74.5) and female (8.2 years; 72.0-80.2). The 65. 7-year life expectancy for Hungarian males and 72.0-year life expectancy for Chilean females represent countries which have average life expectan- cies significantly below those of most Western devel- oped nations. By examining the ratios it is seen that, for each disease and for both males and females, there is an equal or greater range in total life expectancy than there is in the life expectancy for each cause. The smallest range appears for stroke and cancer. This suggests a greater commonality of the impact of major noncom- municable diseases than for other diseases. Stated dif- ferently this suggests that there is a greater commonality in the burden faced by both developed and developing countries for noncommunicable diseases which are po- tentially preventable than there is for other diseases. Across diseases, cirrhosis has the lowest mean age at death. Stroke has the highest and cancer, diabetes and heart disease are intermediate. Greater differences occur in the proportion of deaths affected by each disease across countries than occur in the mean age at death. These figures are comparable across countries since they are derived from life tables so that population-composition effects have been re- moved. For example, the proportion of deaths from cirr- hosis varies 8-fold for males and 15-fold for females. Cancer, interestingly, has the smallest range of variation across countries. In addition to examining the proportion of deaths ex- pected for each of the five conditions, which tells us something about the need for specific types of pre- vention activities in different countries, it is informative to examine the proportion of all deaths that the five con- ditions cause in total. The proportion of deaths that can be expected from these five conditions varies by 27% for males and 15% for females-proportionately much less than for the individual chronic diseases. Indeed, TABLE 1. MEAN AGE AT DEATH AND PERCENTAGE OF DEATHS EXPECTED FROM FIVE CONDITIONS FOR SIX COUNTRIES, AND RATIO OF LARGEST TO SMALLEST VALUE TABLEAU 1. AGE MOVEN AU MOMENT DU DIEC~S ET POURCENTAGE DE DIECES ATTENDUS POUR CINQ MALADIES DANS SIX PAYS, ET RAPPORT ENTRE LA VALEUR LA PLUS GRANDE ET LA PLUS PETITE Disease Maladie Chile Chili Hungary Hongrie Japan Japon Norway Norv~ge Mean age at death - Age moyen au moment du deces Cancer .................. . Diabetes - Diabete . . . . Stroke - Accidents cerebro-vasculaires Heart disease - Cardiopathies . . . . . . Cirrhosis- Cirrhose . . . ............. . Total Cancer . . . . . . . . . . . . . ... Diabetes - Diabete . . . . . . . . . . Stroke - Accidents cerebro-vasculaires Heart disease - Cardiopathies . Cirrhosis- Cirrhose Total .............. . Males - Hommes 69.7 70.8 73.4 74.5 58.5 65.9 66.8 66.8 72.1 68.3 59.6 65.7 Females - Femmes 71.0 73.0 77.8 79.8 60.3 72.0 68.9 71.9 77.1 76.8 61.9 73.3 70.7 72.8 77.2 77.4 65.3 74.5 72.0 76.7 81.7 82.7 64.5 80.2 72.5 72.6 78.7 73.0 61.5 72.4 73.1 79.6 83.1 80.8 66.7 79.3 Percentage of deaths - Pourcentages de deces Males - Hommes Cancer . . . . . . . . . . . 13.8 Diabetes - Diabete . . . . . . . . . 1.6 Stroke - Accidents cerebro-vasculaires 7 .8 Heart disease - Cardiopathies . . . . . . . . 9.8 Cirrhosis - Cirrhose . . . . . . . . . . 5.8 Sum for 5 Diseases - Total pour les 5 mala- dies . . . . . . . . . . . . . . . . . . . . . . . . 38.8 19.8 0.8 14.7 21.1 2.7 59.1 Females - Femmes Cancer . . . . . . . . . . . . . . . . . . . 17 .8 Diabetes - Diabete . . . . . . . 2.2 Stroke - Accidents cerebro-vasculaires 10. 7 Heart disease - Cardiopathies . . . . . . . . . . . . 15.0 Cirrhosis- Cirrhose . . . . . . . . . . . . . . . . . . 6.2 Sum for 5 Diseases - Total pour les 5 mala- dies . . . . . . . . . . . . . . . . . . . . . . . . . . 51.9 Wld hlth statist. quart .• 41 ( 1988) 18.0 2.0 19.7 20.5 2.9 63.1 22.1 1.0 24.3 10.1 2.3 59.8 16.0 0.5 29.1 11.7 1.1 58.4 21.3 0.9 11.6 31.5 0.7 66.0 19.4 1.2 17.2 24.3 0.4 62.5 Ponugal 67.8 69.1 75.8 71.3 62.5 67.5 69.7 73.3 79.6 77.2 65.4 74.3 16.7 0.8 26.7 14.6 4.0 62.8 11.1 1.2 38.0 14.4 1.5 66.2 United States Etats-Unis 70.3 72.0 77.7 74.1 59.2 70.1 71.7 76.7 83.0 82.2 61.3 77.7 21.1 1.4 7.5 32.5 1.6 64.1 18.4 2.2 12.4 32.9 0.9 66.8 Ratio Rappon 1.09 1.09 1.09 1.13 1.12 1.13 1.06 1.11 1.07 1.08 1.11 1.11 1.32 2.50 3.56 3.22 8.05 1.27 1.78 4.40 3.55 2.81 15.50 1.29 - 258 - even in Chile and Hungary, the countries with the lowest life expectancy, the majority of deaths at all ages are attributable to these five conditions. In order to assess how the impact of noncommunicable diseases in a population has changed, tables containing measures of the impact of several diseases on survival are presented. Table 2 presents the gain in life expec- tancy attributable to the elimination of the cause-both for the general population (columns labelled "average") and for the subpopulations expected to die of each dis- ease (columns labelled "saved"). The standard cause elimination (i.e. average) measure varies considerably between countries. For example, for male cancer in 1980 there is a difference of almost one year between Portugal and the United States. For fe- males the difference is 1. 1 year. This variation is even larger for cirrhosis ( 10-fold in 1980 from Chile to Norway) and heart disease (7 .5 times higher in the United States compared to Japan in 1950). This varia- tion occurs because this measure is highly sensitive to the proportion of deaths from a cause expected in a country (i.e. lxA; see Table 1). A comparison of the life expectancy gains for persons who actually die of the condition (i.e. the "saved" popu- lation measure) is far less variable because the effects of lxA have been removed. It is also evident that the adjusted measure is much larger since it reflects the change in survival due to elimination of the condition only in the subgroups affected by the conditions. Thus it is more representative of the actual effects of elimination of the condition for individuals. For example, a surgical cure of cancer in Norway is more likely to increase an individual's life expectancy by 13.2 years in 1980 than the 2. 7 years which is the gain that could be expected on average for the entire population. The reduction in this measure from 13.7 to 13.2 years during the 30-year interval is a reflection of both increasing numbers of deaths due to cancer expected in 1980 and a higher mean age at death expected in the new cancer deaths- which in part arise because of mortality reductions for other causes. It can be seen that the number of years that would be gained by the individual due to the elimination of a given condition does not vary strongly with the total life expec- tancy in the country nor does it usually change much TABLE 2. AVERAGE YEARS GAIN IN LIFE EXPECTANCY AND YEARS GAIN IN LIFE EXPECTANCY FOR SAVED PERSONS FOR FIVE DISEASES, MALES AND FEMALES AT BIRTH IN SIX COUNTRIES TABLEAU 2. GAIN MOYEN (EN ANNIEES) DE L'ESPIERANCE DE VIE ET GAIN DE L'ESPIERANCE DE VIE POUR LES PERSONNES GUIERIES POUR CINQ MALADIES, HOMMES ET FEMMES A LA NAISSANCE POUR SIX PAYS Chile Hungary Japan Norway United States Chili Hongrie Japon Norvege Portugal Etats-Unis Disease/year Maladie/annee Average Saved Average Saved Average Saved Average Saved Average Saved Average Saved Moyenne Gueris Moyenne Gueris Moyenne Gueris Moyenne Gueris Moyenne Gueris Moyenne Gueris Males - Hammes Cancer 1950 ....... 1.6 13.6 2.0 13.3 1.2 13.2 2.7 13.7 1.2 12.7 1.9 14.0 1980 2.1 14.0 2.6 13.1 2.7 13.8 2.7 13.2 1.9 13.1 2.8 14.4 Diabetes - Diabete 1950 ......... 0.1 11.8 0.1 13.3 0.0 13.9 0.1 12.8 0.1 12.2 0.2 12.2 1980 .......... 0.2 13.1 0.0 12.1 0.1 11.2 0.1 12.6 0.1 11.3 0.2 12.1 Heart disease - Cardio- pathies 1950 . . . . . . . 1.3 12.5 2.3 11.0 0.8 11.4 2.3 11.4 1.3 9.3 6.2 15.6 1980 ... 1.6 12.1 2.9 11.8 1.0 9.5 4.4 13.5 1.3 10.4 6.0 16.0 Stroke - Accidents cerebro-vasculaires 1950 .. 1.0 14.2 1.5 9.7 1.6 10.4 1.5 9.4 1.2 9.2 1.1 10.6 1980 ......... 1. 1 12.0 1.2 9.6 3.3 11.5 1.2 9.3 2.5 9.8 1.0 10.5 Cirrhosis - Cirrhose 1950 0.5 18.0 0.1 14.6 0.1 12.8 0.1 16.5 0.5 14.7 0.2 16.8 1980 ......... 1.0 19.3 0.3 15.4 0.4 15.9 0.1 16.0 0.7 16.3 0.3 19.3 Females - Femmes Cancer 1950 ......... 2.3 15.1 2.2 14.6 1.5 16.1 2.8 14.5 1.5 14.3 2.5 16.2 1980 . . . . . . . . . 2.8 15.6 2.6 14.6 2.3 15.7 2.8 15.6 1.9 14.6 3.0 17.5 Diabetes - Diabete 1950 ......... 0.1 12.5 0.1 13.9 0.1 16.3 0.1 10.3 0.1 11.8 0.3 13.1 1980 ......... 0.3 13.0 0.1 10.7 0.2 12.1 0.1 10.5 0.1 10.9 0.3 13.0 Heart disease - Cardio- pathies 1950 ....... 1.2 11.4 2.7 10.8 1.0 12.2 1.9 9.8 1.7 9.2 5.7 14.7 1980 ........ 1.8 11.9 2.8 10.6 1.1 9.0 2.6 10.7 1.1 8.9 6.4 16.6 Stroke - Accidents cerebro-vasculaires 1950 ...... 1.4 13.5 1.9 10.3 2.1 11.3 2.0 9.7 1.6 9.4 1.7 11.3 1980 ......... 1.5 12.3 1.6 9.5 3.7 11.6 2.0 10.0 3.9 10.6 1.8 11.9 Cirrhosis - Cirrhose 1950 . . . . . . 0.3 20.5 0.1 14.4 0.1 13.6 0.0 19.8 0.3 15.9 0.1 18.6 1980 .......... 0.5 20.9 0.2 15.9 0.2 13.3 0.1 14.8 0.4 17.5 0.2 23.6 Rapp. trimest. statist. sanit. mond .• 41 (1988) - 259 - within countries between 1950 and 1980. This again suggests that the effects of chronic diseases on the sur- vival of adult individuals will be reasonably similar in both developed and less developed countries. Table 2 shows how the risk of individual diseases changes over time. It is important also to ask how the set of conditions relates to changes in overall life expectan- cy. Two questions are pertinent: (i) at what ages are the increases in life expectancy manifest?; (ii) what dis- eases are contributing most to these age-specific contributions? Clearly the reasons why such questions are important is that they tell us the rate at which chronic diseases will become important as life expectancy in- creases. These changes can be assessed by using Pollard's decomposition of life-expectancy change which decomposes the change in life expectancy be- tween two time points (here 1950-1980) into the age- (and cause-) specific components (9). The age-specific contributions to life-expectancy change are presented in Table 3 for four countries and three age groups. Table 3 shows that a large component of the gain between 1950 and 1980 in life expectancy for females (up to 39.5%) occurred after age 65. Even in Hungary 14.4% of the female gain occurred after age 65. In the United States only 22.0% of the female gain occurred at age 0-4 years. Thus for females at least chronic diseases are likely to be greatly increased in significance due to a life-expectancy gain at later ages in the interval 1950 to 1980. For males there is less gain after 65 but there is perhaps even more reason to be concerned about chronic diseases. It can be seen in both Hungary and Norway that life expectancy after 65 decreased over the interval. Indeed, for Hungary, there were major declines in life expectancy in adult life that nearly wiped out the benefits of major reductions in infant mortality. This sug- gests that a major reason why it will be difficult to achieve the life-expectancy goal of 60 years or greater in some countries is that chronic diseases may increase in risk in middle and late life. The noncommunicable dis- eases associated with such gains and losses are shown in Table 4 for the period 1970-1980. Table 4 shows that changes in prevalence of cancer and cirrhosis have tended to decrease life expectancy while changes in circulatory diseases have contributed to life expectancy increases in three of the countries, with Hungary (and most Eastern European countries) being the exception. The pattern of change for Hungary is par- ticularly disturbing given its intermediate position on the economic development spectrum. That is, the explana- tion for such elevated noncommunicable disease risks seems to be increased smoking and alcohol consump- tion as formerly rural, agricultural populations rapidly shift to urban residence and industrial occupations. This is an intermediate stage in economic development which most countries can be expected to experience. To this point our analyses have been limited to countries with reasonably high quality cause-specific mortality data. This excludes many of the larger developing na- tions (e.g. Brazil, China, India and most African coun- tries). In order to examine these countries a set of indi- rect estimates of the effect of noncommunicable disease risks was produced. It has already been shown that there is a fair degree of similarity in how these diseases affect adults in developing and developed countries. A com- mon set of mortality rates is taken and applied to observed (and projected) population figures in order to show the effect of different population trends on the importance of noncommunicable disease. This is, in effect, the reverse of the earlier life-table analyses where population composition was held constant. These figures are presented in Table 5 for three major noncommunicable diseases in Brazil, China, Hungary, India, Japan, Kenya and the USSR. The measures pre- sented are indirectly estimated mortality rates. Tremendous increases in mortality rates from these three major noncommunicable diseases are projected in both developing and developed countries, with the ex- ception of India and Kenya. In India the rate decline is due to high fertility and rapid population growth from 1960 to 1980. The increase for the period 1980-2000 reflects an effective control of fertility postulated for the future. Likewise Kenya manifests a decline between 1960 and 1980 but stability thereafter. Brazil, despite fairly rapid population increases, shows a significant increase in the risks of the three conditions. We see that the increase in chronic disease risks between 1980 and 2000 is among the highest for China. We also see that the change in mortality rates for China is a complex function of age structure differentially affecting the causes, with the male rates increasing 43.6% for cancer, 52.4% for heart TABLE 3. DECOMPOSITION OF GAINS IN LIFE EXPECTANCY IN YEARS FOR MALES AND FEMALES FROM 1950 TO 1980, FOR THREE AGE GROUPS TABLEAU 3. DECOMPOSITION DES GAINS (EN ANNEES) DE L'ESPERANCE DE VIE POUR LES HOMMES ET LES FEMMES ENTRE 1950 ET 1980, POUR TROIS GROUPES D'AGE Total ...... . 0-4 years/ans 5-64 years/ans 65 + years/ans .. Total 0-4 years/ans Age 5-64 years/ans .. . 65 + years/ans ........ . Hungary Japan Hongrie Japon Gain % Gain Males - Hammes 0.54 100.0 15.97 3.06 570.0 6.10 -1.71 -320.0 7.86 -0.81 -150.4 2.01 Females - Femmes 4.01 100.0 18.19 2.74 68.2 6.22 0.70 17.4 9.01 0.58 14.4 2.97 • Initial data for 1951 - Donnees initiales pour 1951. Wld hlth statist. quan., 41 ( 1988) Norway• United States Norvege• Etats·Unis % Gain % Gain % 100.0 1.48 100.0 4.74 100.0 38.2 1.71 115.6 1.76 37.1 49.2 0.36 24.2 2.04 43.0 12.6 -0.59 -40.0 0.94 19.8 100.0 4.99 100.0 6.86 100.0 34.2 1.48 29.8 1.51 22.0 49.5 1.67 33.8 2.64 38.5 16.3 1.83 36.7 2.71 39.5 - 260 - TABLE 4. DECOMPOSITION OF GAINS IN LIFE EXPECTANCY IN YEARS FROM 1970 TO 1980, FOR THREE AGE GROUPS AND FIVE CONDITIONS TABLEAU 4. DECOMPOSITON DES GAINS (EN ANNEES) DE L'ESPERANCE DE VIE ENTRE 1970 ET 1980, POUR TROIS GROUPES D' AGE ET CINQ MALADIES Hean Stroke All Country Cancer Diabetes disease Accidents Cirrhosis causes % Pays Diabete Cardiopathies v~!~~~;;~;s Cirrhose Toutes les causes Males - Hommes All ages - Tous Jes ages Hungary - Hongrie .. -0.46 -0.06 -0.37 -0.40 -0.27 0.84 100.0 Japan - Japon ..... 0.04 0.03 0.30 1.44 0.00 4.14 100.0 Norway - Norvege ... 0.06 -0.01 0.39 0.44 -0.06 1.38 100.0 United States - Etats-Unis . . . . . . . . ...... -0.04 0.05 1.54 0.40 0.06 2.99 100.0 0-49 Hungary - Hongrie ......... . ...... -0.15 0.02 -0.23 -0.07 -0.12 0.40 -47.6 Japan - Japon ............ . ...... 0.05 0.00 0.04 0.10 -0.01 1.65 39.8 Norway - Norvege ...... 0.16 0.02 0.09 0.04 -0.04 0.79 57.6 United States - Etats-Unis .... . ...... 0.07 0.01 0.24 0.05 0.03 1.40 46.9 50-64 Hungary - Hongrie ..... -0.23 -0.02 -0.27 -0.18 -0.11 -0.96 114.3 Japan - Japon ....... 0.04 0.01 0.09 0.43 -0.01 0.94 22.8 Norway - Norvege ..... 0.00 -0.02 0.09 0.06 -0.02 0.17 12.0 United States - Etats-Unis . . ...... -0.01 0.02 0.58 0.11 0.03 0.87 29.0 65+ Hungary - Hongrie .............. -0.08 -0.02 0.13 -0.15 -0.04 -0.28 33.3 Japan- Japon .... . ............. -0.05 0.02 0.17 0.91 0.02 1.55 22.8 Norway - Norvege .. -0.10 -0.01 0.21 0.34 0.00 0.42 30.4 United States - Etats-Unis . . . . . . . . . . . . . . . . -0.10 0.02 0.72 0.24 0.00 0.72 24.1 Females - Femmes All ages - Tous /es /Jges Hungary - Hongrie ....... -0.10 -0.11 0.25 -0.23 -0.13 0.66 100.0 Japan - Japon ......... 0.27 0.04 0.33 1.42 0.04 4.27 100.0 Norway - Norvege ...... 0.13 0.00 0.46 0.68 -0.02 1.97 100.0 United States - Etats-Unis . . . 0.05 0.12 1.54 0.66 0.05 3.13 100.0 0-49 Hungary - Hongrie .... -0.03 0.00 -0.05 -0.04 -0.07 0.75 114.5 Japan - Japon ...... 0.11 0.01 0.02 0.04 0.01 1.33 31.1 Norway - Norvege .... 0.18 0.00 0.00 0.04 -0.01 0.55 28.3 United States - Etats-Unis 0.11 0.02 0.05 0.06 0.03 1.21 38.8 50-64 Hungary - Hongrie .... -0.08 -0.04 -0.04 -0.09 -0.05 -0.31 -47.0 Japan - Japon ... 0.13 0.02 0.09 0.31 0.01 0.86 20.2 Norway - Norvege .... 0.01 0.00 0.06 0.07 -0.01 0.18 8.9 United States - Etats-Unis ............ -0.02 0.03 0.27 0.10 0.02 0.49 15.5 65+ Hungary - Hongrie .... 0.01 Japan - Japon ...... 0.03 Norway - Norvege .... -0.05 United States - Etats-Unis .......... -0.04 diseases and 59.9% for stroke. These changes in dis- ease reflect both age-specific changes in life expectancy and the large reductions in fertility. Cross-country comparisons show that the cancer rate for Brazil in 1980 (98.6 per 100 OOO person-years expo- sure) is less than half that for Hungary (233.2). Since the same rate structure was assumed for both countries, this reflects the differences in age composition of the two populations. The differences between countries at age 20 are less because the age structure after 20 is less variable. -0.07 0.34 -0.10 -0.01 0.21 32.5 0.01 0.22 1.07 0.02 2.08 48.7 0.00 0.40 0.57 0.00 1.24 62.8 0.07 1.18 0.50 0.00 1.43 45.7 In the preceding analyses, we examined (i) the effects of noncommunicable diseases holding population compo- sition constant, and (ii) the effects of population compo- sition on noncommunicable disease risks holding the same age- and cause-specific rate structures constant. In analysing noncommunicable disease risks in less de- veloped countries we are handicapped by a lack of good quality cause-specific mortality data. Thus. we do not possess good quality data on how mortality risks vary across developing countries for specific chronic dis- eases. Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 261 - TABLE 5. ESTIMATED CRUDE MORTALITY RATES (PER 100 OOO PERSON-YEARS EXPOSURE) FROM THREE DISEASES (ASSUMING UNITED STATES 1979 MORTALITY RATES) FOR SEVEN COUNTRIES IN 1960, 1980 AND 2000 (MALES AND FEMALES)a TABLEAU 5. ESTIMATION DES TAUX BRUTS DE MORTALITE (POUR 100 OOO PERSONNES/ANNEES D'EXPOSITION) POUR TROIS MALADIES (D'APRES LES TAUX DE MORTALITE ETABLIS AUX ETATS-UNIS EN 1979) DANS SEPT PAYS EN 1960, 1980 ET 2000 (HOMMES ET FEMMES)• Disease/year Brazil China Hungary India Japan Kenya USSR Maladie/annee Brasil Chine Hongrie lnde Japon UASS Males - Hommes Cancer 1960 78.2 81.8 191.9 96.2 129.2 60.4 119.6 1980 98.6 106.5 233.2 90.8 180.3 51.7 148.1 2000 125.3 152.9 250.6 119.7 278.0 51.5 198.0 (27%) (44%) (7%) (32%) (57%) (") (34%) Heart disease - Cardiopathies 1960 152.1 152.8 403.1 201.2 261.1 116.4 248.6 1980 202.3 210.0 509.6 175.9 387.9 97.4 315.8 2000 ............. 267.4 320.0 549.7 240.4 607.2 97.3 412.4 (32%) (52%) (8%) (37%) (57%) (") (31%) Stroke - Accidents cerebro-vasculaires 1960 19.3 18.0 53.9 27.7 34.0 15.0 33.5 1980 27.1 26.9 71.2 22.1 53.3 12.4 43.2 2000. 36.8 43.0 76.8 31.2 84.2 12.4 55.0 (36%) (60%) (8%) (41%) (58%) ("} (27%) Females - Femmes Cancer 1960 59.1 76.0 146.3 63.6 99.1 51.8 124.4 1980 70.4 82.0 183.4 62.0 143.6 41.5 162.1 2000 90.2 108.4 209.4 83.5 208.7 40.0 177.5 (28%) (32%) (14%) (35%) (45%) (-4%) (10%) Heart disease - Cardiopathies 1960 88.6 114.9 275.7 114.7 186.2 82.2 243.2 1980 122.3 142.2 420.0 88.9 300.2 62.7 367.9 2000 173.4 207.9 513.3 130.5 488.5 58.8 424.4 (42%) (46%) (22%) (47%) (63%) (-7%) (15%) Stroke - Accidents cerebro-vasculaires 1960 18.2 23.5 56.9 23.9 38.9 16.9 50.7 1980 25.5 29.3 88.4 18.2 63.1 13.0 77.6 2000 ....... 36.5 43.6 108.7 26.7 103.0 12.2 89.6 (43%) (49%) (23%) (47%) (63%) (-7%) (15%) a figures in parentheses indicate percent increase or decrease in rates 1980 to 2000; asterisk indicates less than 1 % change - Les chiffres entre parenth~ses correspondent a une augmentation ou ii une diminution en pourcentage des taux entre 1980 et 2000 ; I' ast~risque indique un changement inf~rieur ii 1 % . Potential effects of risk-factor control The question of what kind of health changes can be accomplished by various types of risk-factor controls will now be examined by using the second analytic strat- egy where risk factors are directly introduced into the life-table computations, so that the effect of altering the trajectory of risk-factor changes in cause-specific survi- val can be determined. This was done with data on 2 336 Framingham males followed for 20 years. The basic life-table estimates with risk factors are illustrated in Table 6. In addition to the standard life-table paramet· ers, the means of the risk factors are listed. The change in these risk factors is produced both by the temporal dynamics of the risk factors as well as by the systematic selection of persons by mortality. Table 6 shows that life expectancy at age 30 is 44.5 years and the expected indirect cost (the estimate of lost wages and productivity) of premature mortality is US$ 10000 (10). Pulse pressure, blood sugar and hae- moglobin are projected to rise with age, while diastolic blood pressure, Ouetelet index and serum cholesterol first rise then decline with age. Both vital capacity and smoking rapidly decline. These tables thus reflect both survival decreases and the health status of the popu- lation surviving to a given age as described by their risk- factor distribution. Wld hlth statist. quan .. 41 ( 1988) In order to use these tables for analysis of likely health- status changes, they must first be estimated for specific causes. Table 7 presents the age-specific life expectan- cies for the multiple decrement tables for the three causes, and the increase in life expectancies for the three causes with smoking eliminated (i.e. the mean and var- iance of the variable describing the number of cigarettes consumed are both set to 0.0). One can see the increase in the mean age at death for each of the conditions. The effect on total life expectancy is 1.5 years (to about 46.0 years) with 0.36 years of that coming from cancer reduc- tions (new life expectancy for persons dying of cancer of 44.24). 0.96 years coming from heart-disease reduction (45.84) and 0.15 years coming from other causes (44.01). The majority of the impact of smoking, 0.79 years, occurs between 50 and 69. The interaction of diseases and risk factors is illustrated in Table 8. The effects of dependency between compet- ing risks (column C versus column A) are small at the early ages (e.g. negligible up to age 50; the increase in life expectancy assuming dependency is 6.9% less for heart disease overall). but increases rapidly with age. There is an age increase in the dependency of causes because when one disease is eliminated, there are more high-risk survivors at later ages. This can also be illus- trated for the elimination of smoking (column B).When smoking is eliminated, the effect of the subsequent elim- - 262 - TABLE 6. BASELINE ESTIMATES OF LIFE-TABLE PARAMETERS AND PARAMETERS OF RISK-FACTOR DISTRIBUTION FOR FRAMINGHAM MALES TABLEAU 6. ESTIMATIONS DES PARAMETRES DES TABLES DE MORTALITE ET DES PARAMIETRES DE LA REPARTITION DES FACTEURS DE RISQUE POUR LES HOMMES DE FRAMINGHAM MEAN V ALLIES - V ALEURS MOYENNES Indirect costs Pulse Diastolic Cigarettes Age CoOts Ouetelet Vital L, e, pressure blood index Cholesterol Blood Haemoglobin capacity per day indirects Pression pressure sugar Nombre de differen- Pression lndice de Cholesterol Glycemie Hemoglobine Capacite cigarettes (US$) tielle anerielle Quetelet vitale par jour 30 100000 44.52 10800 45.83 79.57 261.88 215.22 79.35 142.11 139.29 13.24 40 98 366 35.17 12 809 41.22 83.18 273.30 241.46 78.48 147.73 138.61 14.46 50 94 588 26.35 11 670 47.78 83.42 277.01 241.08 83.92 149.60 129.95 12.64 60 83 306 18.34 6 856 55.30 83.37 274.25 233.10 91.04 150.43 116.30 9.16 70 69071 11.53 3 315 62.80 82.91 266.97 223.21 98.37 150.76 99.54 4.72 80 38 708 6.39 1 554 69.92 82.01 258.00 213.52 105.47 150.88 81.30 0.00 90 8061 3.13 841 76.37 80.55 250.80 205.65 111.63 151.64 62.66 0.00 TABLE 7. BASELINE AGE-SPECIFIC LIFE EXPECTANCIES FOR THREE DISEASES AND LIFE EXPECTANCY WITH SMOKING ELIMINATED TABLEAU 7. DONNEES DE BASE SUR L'ESPERANCE DE VIE EN FONCTION DE L'AGE POUR TROIS MALADIES ET SUR L'ESPERANCE DE VIE APRES ELIMINATION DU TABAC Coronary hean disease and stroke Residual Cancer Cardiopathies ischemiques et Autres maladies Age accidents cerebro-vasculaires (years/annees) Baseline Smoking eliminated Baseline Smoking eliminated Baseline Smoking eliminated Oonnees de base T abac elimine Oonnees de base T abac elimine Oonnees de base Tabac elimine 30 43.88 44.24 44.88 45.84 43.86 44.01 40 34.69 35.01 35.45 36.31 34.61 34.75 50 26.01 26.26 26.58 27.26 25.82 25.95 60 18.12 18.27 18.52 18.94 17.85 17.96 70 11.42 11.48 11.64 11.80 11.16 11.21 80 6.37 6.37 6.44 6.45 6.24 6.25 90 3.13 3.13 3.14 3.14 3.07 3.07 TABLE 8. AGE-SPECIFIC CONTRIBUTION (IN YEARS) TO LIFE-EXPECTANCY GAINS AT AGE 30 FROM THE ELIMINATION OF CANCER, CIRCULATORY DISEASE OR RESIDUAL DISEASE OPERATING INDEPENDENTLY (A AND B) AND DEPENDENTLY (Cl, FRAMINGHAM MALES• TABLEAU 8. CONTRIBUTION (EN ANNEES) EN FONCTION DE L'AGE AUX GAINS DE L'ESPERANCE DE VIE A. 30 ANS DU FAIT DE L'ELIMINATION DU CANCER, DES MALADIES CIRCULATOIRES OU DES AUTRES MALADIES, VARIABLES INDEPENDANTES (A ET B) ET DEPENDANTES (Cl, HOMMES DE FRAMINGHAM8 Cancer Circulatory disease Residual disease Maladies circulatoires Autres maladies Age interval A B c A B c A B c lntervalles d'ages Smoking Smoking Smoking Baseline eliminated Baseline Baseline eliminated Baseline Baseline eliminated Baseline Oonnees Tabac Oonnees Donnees Tabac Donnees Oonnees Tabac Oonnees de base elimine de base de base elimine de base de base elimine de base 30-39 0.158 0.117 0.158 0.357 0.270 0.357 0.119 0.113 0.119 (0) (0) (0) 40-49 0.250 0.118 0.250 0.704 0.540 0.704 0.187 0.188 0.187 (0) (0) (0) 50-59 0.380 0.304 0.378 1.183 0.960 1.182 0.300 0.291 0.299 (0.5) (0.1) (0.3) 60-69 0.521 0.458 0.514 1.808 1.603 1.799 0.431 0.411 0.425 (1.4) (0.5) (1.4) 70-79 0.572 0.563 0.547 2.450 2.385 2.402 0.474 0.470 0.452 (4.6) (2.0) (4.9) 80-89 0.365 0.396 0.332 2.513 2.614 2.395 0.278 0.304 0.247 (9.9) (4.9) (12.6) 90-99 0.076 0.084 0.062 1.487 1.564 1.197 0.050 0.055 0.038 (22.6) (24.2) (31.6) 100+ 0.002 0.002 0.001 0.384 0.410 0.199 0.001 0.001 0.001 {*)b (93.0) {")b Total 2.324 2.112 2.242 10.885 10.345 10.186 1.840 1.834 1.768 (3.7) (6.9) (4. 1) a figures in parentheses are percentage differences between columns A and C - Les chiffres entre parentheses representent les differences en pourcentages entre les colonnes A et C. b Estimate too imprecise at this advanced age - Estimation trap impr6cise a cet Age avanc6. Rapp. trimest. statist. sanit. mond .. 41 (1988) - 263 - ination of cancer drops 10% (i.e. from 2.324 to 2. 112). This drop is due to the dependency of the cancer and smoking risks. A large residual effect for cancer can still be seen after eliminating smoking. The majority of the smoking effect occurs before age 60 with smoking elim- inating about one-third of the total cancer impact before that age. These results illustrate the effect of disease and risk- factor dependency in a relatively long-lived population. In a shorter-lived population the dependency effect will be strong at much younger ages. Also, it should be recognized that our estimates of disease dependency are probably a minimum since there are other unmeas- ured risk factors likely to produce an even greater dependency than we estimated here. Disease and risk-factor dependence may be a major rea- son why mortality reductions become more difficult at advanced ages and why community trials have often produced less than the anticipated effect. This also argues for an integrated approach to primary prevention so that all diseases may be affected simultaneously. Otherwise a prevention programme may not show much effect. Having illustrated the importance of disease and risk- factor dependence in making estimates of the effect of risk-factor control we can now examine the likely effects of different types of risk-factor intervention. These are illustrated in Table 9. This table presents the life-expectancy change due to control of risk factors in various ways. For example, the effect on overall life expectancy of smoking elimination is 1.5 years. This is concentrated at ages 40-60. The con- trol of blood sugar has a smaller impact (0.425 years). The effect of restricting the decline in vital capacity is nearly as large as the smoking effect, 1. 143 years. The effect of vital capacity control is concentrated more at later years and is greatest for heart disease (0.699 years) and similar for cancer (0.212 years) and other causes (0.232 years). Obviously, the greatest impact results from preventing all risk factors from increasing with age simultaneously. This increases life expectancy by 4.22 years. Table 10 shows the decomposition of the changes in indirect costs of these various risk-factor interventions for different age intervals. The cost impacts of various interventions in different age intervals are quite different from their effects on life expectancy in those intervals due to the different age-specific economic weightings. For example, though the control of vital capacity and smoking elimination have roughly similar impacts on life expectancy ( 1. 14 years vs. 1.5 years), smoking elimina- tion has a much larger economic effect (i.e. US$ 2 273 vs. US$ 182). This is because smoking elimination has most of its effect at younger ages where wage earnings are higher. Thus while only 27.9% of the effect on life expectancy due to smoking elimination occurs before TABLE 9. GAINS IN LIFE EXPECTANCY DUE TO RISK- FACTOR CONTROL TABLEAU 9. GAINS DE L'ESPERANCE DE VIE CONSECUTIFS A LA DIMINUTION DES FACTEURS DE RISQUE Years - Ans Smoking control Blood sugar Vital capacity All variables Contrllle du tabagisme Glycemie Capacite vitale T outes les variables 30-39 0.153 -0.002 -0.001 0.155 40-49 0.265 0.003 0.011 0.266 50-59 0.380 0.026 0.069 0.397 60-69 0.409 0.088 0.214 0.629 70-79 0.244 0.164 0.395 1.018 80-89 0.022 0.125 0.359 1.125 90-99 0.002 0.021 0.094 0.635 100+ 0.000 0.000 0.003 0.134 Total 1.474 0.426 1.143 4.358 TABLE 10. DECOMPOSITION OF CHANGES IN INDIRECT COSTS OF PREMATURE MORTALITY FROM CONTROL OF SELECTED RISK FACTORS TABLEAU 10. DECOMPOSITION DE L'EVOLUTION DES COUTS INDIRECTS DES DECES PREMATURES A LA SUITE DES SCENARIOS DE LUTTE CONTRE CERTAINS FACTEURS DE RISQUE Age interval lntervalles d'age 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+ Total % reduction in total cost at age 30 ($10 800) - Diminution en pourcentage du coOt total a 30 ans ($10 800) ...... . Wld hlth statist. quan., 41 ( 1988) Smoking elimination Elimination du tabac 863.79 794.45 479.44 121.55 13.98 0.27 0.0 0.0 2 273.48 12% Savings due to risk-factor control Economies dues a la lutte centre les facteurs de risque Vital capacity Blood sugar All risk factors Ensemble des facteurs Capacite vitale Glycemie de risque -5.35 -8.78 891.14 29.47 6.04 813.02 78.63 29.86 502.39 55.95 22.70 174.49 19.96 8.29 51.34 3.85 1.40 11.10 0.12 0.03 0.82 0.0 0.0 0.26 182.63 59.54 2444.55 2% 1% 23% - 264 - age 49, 72.9% of its economic effect (US$ 1 658) oc- curs before age 49. This type of cost evaluation helps us to understand how best to target our interventions to maximize economic gain (10). Alternative strategies for evaluating the eco- nomic and social benefits of health promotion have been proposed (5). Those procedures involve more subjec- tive judgement on valuing lives but perhaps better reflect intangible benefits. Other ways of weighting life expec- tancy for quality have been proposed (5, 11, 12). Discussion This article has attempted to show (a) that noncommun- icable diseases are currently a significant health problem even for many less developed countries-indeed a ma- jority of the global burden of noncommunicable diseases is currently in developing countries; (b) that as life expectancy increases and fertility is controlled the public health impact of noncommunicable disease will rapidly increase in developing countries; and (c) that there is significant evidence that substantial benefits can accrue to risk-factor control implemented in an integrated pro- gramme. The first result was demonstrated by examining a wide range of evidence on cause-specific mortality risks. A considerable degree of similarity was shown in the effect of major noncommunicable diseases on the life expec- tancy of adult individuals in developed and developing countries. The primary difference between countries was in the proportion of deaths that could be expected from diseases-and not in the age-at-death distribution for each condition. The latter is a better measure of the impact of the disease on the individual. The cause-speci- fic mortality data on which these conclusions were based were primarily from highly and moderately devel- oped countries. Nonetheless, the mortality experience from countries with life expectancies at least 8 years less than those in highly developed countries could be exam- ined. Furthermore, the basic relation held in those coun- tries, even in 1950-a time during which life expectancy in those countries was equivalent to that found in many developing countries today. Indeed, the mortality data examined represented life expectancies of about 60 years at birth-the target for life expectancy in all coun- tries of the world by the year 2000. Thus the cause- specific mortality patterns studied are representative of the survival conditions hoped for in most developing countries in the relatively near future. Secondly, it was shown that (a) numerically there are currently more chronic disease deaths in developing than in developed countries; and (b) as fertility control is dis- seminated and life expectancy increases, significant population aging can be expected in developing coun- tries and even greater proportions of the global chronic disease burden in developing countries. This was de- monstrated by calculating indirect estimates of mortality rates for all countries of the world. It should be noted that, of the countries studied, China had among the fas- test rates of increase in noncommunicable disease risk. Given the current and future magnitude of the chronic disease problem, the second question addressed is whether risk-factor controls are likely to be cost-effec- tive. This was examined in a series of analyses of the Framingham data. In those analyses, the effect of differ- ent risk-factor control strategies in survival were stud- ied, together with the indirect cost of disease. The effects of risk-factor controls are often hidden by dependency between various causes of death and risk factors, and the economic impact of an intervention depended strongly on the ages at which the intervention had the greatest effect. For example, there was a large economic impact for smoking control, but only a small impact for control of reduction in vital capacity-despite the fact that each factor's overall impact on survival was similar. The results of those simulations demonstrated the importance of an integrated approach to risk-factor control and disease reduction. It also suggested why there may be problems in demonstrating the impact of singular interventions. The general conclusion to be reached from the evidence is that it is very important to begin strategic planning of prevention activities for noncommunicable diseases in developing as well as developed countries. The evi- dence suggests that the noncommunicable disease and mortality burden is already high in developing countries in absolute terms and will naturally be increased by suc- cesses in improving infant and maternal health, reducing the risks of infectious diseases and reducing the rate of population growth. The effects of such health and demo- graphic factors will be magnified in countries which reach the transitional stage from rural agrarian to urban industrial societies as changing lifestyles tend to greatly increase individual risk. Acknowledgements The research reported in this article was supported by NIA grant no. AG-01159 and HCFA grant no. 18-C- 98641. SUMMARY With the aging of populations in developing countries there is both a demographic and an epidemiological transition which affects the impact of chronic degenera- tive diseases on the health status of the populations. Demographic transition takes place in countries where there are effective programmes of disease control which allow for survival during the early years of childhood and adolescence. This results in an increase in life expec- tancy which places larger proportions of the population in the age range (60 years and older) in which chronic degenerative diseases become the major determinants of health status. Epidemiological transition in diseases may also be brought about by shifts in social and eco- nomic patterns which favour detrimental changes in risk factors for the chronic degenerative diseases. Such changes may include health-related behaviour which augments dietary consumption of fats and alcohol, in- creases obesity, increases smoking and decreases phy- sical activity. Such changes in risk-factor levels increase the prevalence of chronic degenerative diseases which manifest themselves at later ages, and for which early preventive actions could be cost-effective. In order to illustrate the impact of both demographic and risk-factor effects, analyses are made of the impact of increases in life expectancy on cause-specific mortality Rapp. trimest. statist. sanit. mond., 41 (1988) - 265 - in both developing and developed countries. It is shown that there is great similarity in the effect of major non- communicable diseases on the life expectancy of adults in both developed and developing countries. The major differences are seen to be in the proportions of deaths expected from such diseases as cancer, diabetes, heart disease, stroke and cirrhosis; but not in the distribution of age at death which is the better measure of disease impact. Demographic analyses, computing indirect estimates of mortality, also demonstrate that there are currently more chronic disease deaths in developing than developed countries and that as expectation of life increases in developing countries the global chronic disease burden will be greatly concentrated in the developing coun- tries. Analyses of risk-factor reduction by feasible intervention strategies, e.g. smoking cessation campaigns, treat- ment of high blood pressure, using relationships be- tween risk factors and diseases established in longitudi- nal studies carried out in developed countries, point out that the effect of risk-factor control in long-living popu- lations can be hidden by the dependency of risk factors and various related causes of death, e.g. smoking has an impact on lung cancer, ischaemic heart disease and emphysema, but at different ages. The economic impact of risk-factor control depends also on the age at which the intervention has the greatest effect. It was found, for example, that control of smoking, which has a similar overall impact on survival as control of vital capacity, has a greater economic impact because smoking control has its greatest effect at young ages (30-45 years), while control of vital capacity only shows an effect on mortal- ity reduction after age 50. The overall conclusion is the great importance to com- mence planning for prevention and control activities in developing as well as developed countries. In develop- ing countries preventive actions will be most cost-effec- tive when they intervene early in the development pro- cess and thus avoid the broad dissemination of unheal- thy lifestyle practices and consumption patterns before they become ingrained in the society and culture. RESUME Impact mondial des maladies non transmissibles: estimations et projections Le vieillissement des populations des pays en develop- pement marque une transition a la fois demographique et epidemiologique qui inflechit !'impact des maladies chro- niques degeneratives sur l'etat de sante. II y a transition demographique dans les pays ou des programmes effi- caces de lutte contre la maladie favorisent la survie au cours des premieres annees de l'enfance et de !'adoles- cence. II en resulte une augmentation de l'esperance de vie et done du pourcentage de la population dans les groupes d' age (60 ans et plus) pour lesquels les maladies chroniques degeneratives deviennent les principaux de- terminants de l'etat de sante. II peut aussi y avoir une transition epidemiologique lorsqu'une modification des schemas sociaux et economiques favorise une augmen- tation des facteurs predisposant aux maladies chroni- ques degeneratives. On peut ainsi constater une evolu- tion des comportements se traduisant par une consom- mation accrue de graisses, d'alcool et de tabac, des cas d'obesite et une diminution de l'activite physique. Ces modifications de !'importance des facteurs de risque entrainent une augmentation de la prevalence des mala- dies chroniques degeneratives qui se manifestent chez les personnes d'un certain age et contre lesquelles des actions preventives precoces seraient d'un bon rapport coOt/ efficacite. A fin d'illustrer !'impact de !'evolution demographique et de celle des facteurs de risque, on a analyse l'effet de I' augmentation de I' esperance de vie sur certaines cau- ses particulieres de mortalite dans des pays en develop- pement et des pays developpes. L'effet des principales maladies non transmissibles sur I' esperance de vie des adultes est sensiblement le meme dans les pays deve- loppes et les pays en developpement. Les principales differences tiennent aux pourcentages de deces atten- dus de maladies telles que le cancer, le diabete, les car- diopathies, les accidents cerebro-vasculaires et la cirr- hose; en revanche, elles ne concernent pas la repartition des ages au moment du deces, qui constitue la mesure la plus fiable de l'impact de la maladie. Des analyses demographiques reposant sur des estima- tions indirectes de la mortalite montrent egalement que Wld hlth statist. quart .• 41 ( 1988) le nombre des deces par maladie chronique est actuel- lement plus eleve dans les pays en developpement que dans les pays developpes et qu'avec !'augmentation de l'esperance de vie dans les premiers, le fardeau que representent les maladies chroniques dans le monde se fera essentiellement sentir dans les pays en developpe- ment. Des analyses de la diminution des facteurs de risque a la suite d'interventions realisables (campagnes antitabac, traitement de !'hypertension, etc.) sur la base des rela- tions entre les facteurs de risque et les maladies etablies a l'aide d'etudes longitudinales conduites dans des pays developpes montrent que les effets de la lutte contre les facteurs de risque au sein de populations dont la duree de vie est elevee peuvent etre masques en ce sens que la relation entre ces facteurs de risque et differentes causes de deces (impact du tabagisme sur le cancer du poumon, les cardiopathies ischemiques et I' emphysema par example) se manifeste a des ages differents. L'impact economique de la reduction des facteurs de risque est egalement fonction de rage auquel !'intervention a son effet maximal. On a constate par example que la lutte contre le tabagisme, dont !'impact global sur le taux de survie est le meme que celui des mesures tendant a preserver la capacite vitale, a un impact economique plus grand car ses effets se font le plus sentir entre 30 et 45 ans - alors que !'influence de la preservation de la capa- cite vitale sur la mortalite ne se fait sentir qu'apres 50 ans. En conclusion, ii est extremement important de com- mencer a planifier des activites de prevention et de lutte dans les pays en developpement comme dans les pays developpes. Dans les pays en developpement, le rapport coOt/efficacite des actions de prevention sera d'autant plus grand que des mesures seront prises au debut du processus de developpement et que I' on evitera ainsi la generalisation de modes de vie et de schemas de consommation nocifs avant qu'ils ne deviennent trap solidement ancres dans les structures sociales et cultu- relles. - 266 - REFERENCES - REFERENCES 1. OMRAN. A. R. The epidemiologic transition: a theory of the epidemiology of population change. Millbank Memorial Fund quarterly, 49: 509-538 (1971). 2. MANTON. K. G. & STALLARD, E. Recent trends in mor- tality analysis. Orlando Fla, Academic Press, 1984. 3. MANTON. K. G. & WOODBURY, M.A. A continuous- time multivariate Gaussian stochastic process mod- el of change in discrete and continuous state varia- bles. In: Tuma, N. (ed.), Sociological method- ology 1985, San Francisco, Jossey-Bass, 1985. (pp. 277-315). 4. PRESTON, S. H. ET AL. Causes of death: life tables for national populations. New York/London, Seminar Press, 1972. 5. MANTON. K. G. Past and future life expectancy in- creases at later ages: their implications for the link- age of chronic morbidity, disability and mortality. Journal of gerontology, 41: 672-681 (1986). 6. MANTON, K. G. & STALLARD, E. Chronic disease risk modelling: measurement and evaluation of the risks of chronic disease. London, Charles Griffin Ltd, 1988. 7. KANNEL, w. B. & GORDON. T. Cardiovascular risk fac- tors in the aged: the Framingham Study. In: Haynes, S. G. & Feinleib, M. (eds), Second conference on the epidemiology of aging. Bethesda Md., National In- stitutes of Health, 1980. (NIH-80-969). 8. MANTON. K. G. Mortality patterns in developed coun- tries. In: Tomassen R. F. (ed.). Comparative social research. Greenwich Conn., JAI Press, 1984. 9. POLLARD. J. H. The expectation of life and its rela- tionship to mortality. Journal of the Institute of Actuaries, 109: 225-240 (1982). 10. RICE. D. P. & HODGSON. T. A. Social and economic implications of cancer in the United States. Washington D.C., US Government Printing Office, 1981. (Rainbow series 3, No. 20, DHHS No. (PHS) 81-1404). 11. WILKINS, R. & ADAMS, 0. Healthfulness of life. Montreal, Institute for Research on Public Policy, 1983. 12. KATZ. S. ET AL. Active life expectancy. New England journal of medicine, 309(20): 1218-1223 ( 1983). Rapp. trimest. statist. sanit. mond .. 41 ( 1988) - 267 - INTEGRATED PROGRAMME FOR NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL (NCD) Evgueni N. Shigan3 It is well known that health conditions depend upon many factors-socioeconomic, demographic, behav- ioural, environmental and others. That is why changes in existing external and internal health systems lead to changes in priorities for dealing with health problems. In spite of the difference between developed and develop- ing countries, health conditions evolve according to a predictable pattern : the mortality and morbidity rates due to infectious diseases decline while the rates related to non-infectious pathology increase. A good example of such trends is the experience of China over the past 10 years (Table 1). According to the 1984 World health statistics annual, 16 developing countries of the WHO Western Pacific Region reported, for the first time, more deaths from noncommunicable diseases than from infectious and parasitic diseases. More recent data indicate similar trends in other regions. There is no doubt that if this trend continues the same noncommunicable diseases will play an increasingly important role in the future. Tak- ing into account the importance of noncommunicable diseases, the majority of countries are developing a set of disease-oriented programmes: cancer prevention and control, diabetes mellitus, stroke prevention, heart dis- ease, etc. The degree of development of these pro- grammes varies: in some countries they have just started, whereas in others they have already yielded • Director. Division of Noncommunicable Diseases, World Health Organization, Geneva. good results (mortality and morbidity rates have de- creased). Some of these programmes cover the entire country, others only small districts, communities or towns. Some are being developed by, are under the supervision of, or are in close contact with WHO headquarters and with divisions, units and programmes of Regional Offices. In spite of differences among noncommunicable dis- eases, they all have a multifactorial etiology. In order to decrease mortality or morbidity rates the influence of leading negative socioeconomic, behavioural, environ- mental, and medico-biological factors should be elimi- nated, or at least reduced, and both internal and external health-care systems should be improved. Ta king into account the importance of such risk factors for many noncommunicable diseases, in addition to dis- ease-oriented programmes, a second group of pre- vention programmes is being developed, namely factor- oriented programmes. There is much activity at present in programmes dealing with: anti-smoking, alcohol and drug abuse, diet, physical activity, hypertension, lipids, etc. WHO has paid great attention to the development of the most important factor-oriented programmes. Several years ago a new programme was started in WHO-the Integrated Programme for Community Health in Noncommunicable Diseases (lnterhealth). This pro- TABLE 1. LEADING CAUSES OF DEATH, SHANGHAI COUNTY (CHINA), 1960-1962 AND 1978-1980 TABLEAU 1. PRINCIPALES CAUSES DE DECES, COMTE DE SHANGHAI (CHINE), 1960-1962 ET 1978-1980 Rank Rang 1 2 3 4 5 6 7 8 9 10 1960-1962 Cause of death Cause de deces Infectious diseases infectieuses Accidents Maladies Respiratory diseases - Maladies des voies respiratoires Digestive diseases - Maladies de I' appareil digestif Neonatal deaths - Deces neona- tals Malignant tumours - Tumeurs malignes Cerebrovascular diseases - Ma- ladies cerebro-vasculaires Heart diseases - Maladies cardia- ques Endocrine diseases - Maladies du systeme endocrinien Urinary diseases - Maladies de I' appareil urinaire Total• 78 67 49 40 29 23 19 14 7 6 (M, F)' (95, 70) (79, 54) (61. 37) (45. 35) (33, 25) (25. 22) (19, 18) (13. 14) 6, 8) 5, 7) Rank Rang 1 2 3 4 5 6 7 8 9 10 • Annual monality rate per 100 OOO - T aux de monalite annuel pour 100 OOO habitants. 1978-1980 Cause of death Cause de deces Malignant tumours - Tumeurs malignes Cerebrovascular diseases - Ma- ladies cerebro-vasculaires Heart diseases - Maladies car- diaques Respiratory diseases - Mala- dies des voies respiratoires Accidents Infectious diseases - Maladies infectieuses Digestive diseases - Maladies de I' appareil digestif Mental/neurological diseases - Troubles mentaux/neurologi- ques Urinary diseases - Maladies de I' appareil urinaire Neonatal deaths - Deces neo- natals Total• 142 105 103 68 49 35 28 13 10 8 (M, F)• (178, 109) ( 88, 122) (101. 105) 73, 64) 60, 39) ( 46, 24) 27. 29) 12. 14) 10, 10) 9, 7) Source: Gu. X. Y. & Chen, M. L. Vital statistics. In Hinman, A. R., et al. (eds), Health services in Shanghai County. American journal of public health 72 (9 supplement)· 19-23 (1982). . ' . Wld hfth statist. quan .. 41 ( 1988) - 268 - gramme combines, in an operationally feasible manner, resources and approaches currently being devoted to the prevention and control of selected noncommu- nicable diseases and related conditions, and it permits the managerial unification of a set of preventive and other control activities that should lead to the prevention and control of major noncommunicable diseases and to the promotion of health in entire communities. Concepts Several important concepts form the basis of Inter- health; they are outlined below. Prevention and control of common risk factors for a group of noncommunicable diseases. There is a great deal of reliable evidence to show that some factors have an influence on several diseases and therefore could be considered as common risk factors for them (Fig. 1). Total community involvement. This means that the en- tire community should be included in investigation and intervention activities. It is also important after experi- mental testing on sample areas (district, community, etc.) to evaluate the efficacy and effectiveness of all intervention programmes and extend them to the whole country. Integration of different health promotion intervention stategies. The following main strategies have been used for the development and realization of lnterhealth : popu- lation strategy, high-risk strategy, screening for early detection of disease, prevention strategy, intersectoral and interdisciplinary collaboration. Integration of different categories of intervention. De- pending on the socioeconomic situation, the cultural lev- el, the basic principles of health care and other systems, activity in developed and developing countries, the role of intervention programmes could be different. Taking into account the differences between WHO Member States and between WHO Regions, programmes in headquarters pay attention to the development of all intervention programmes: • Change in lifestyle : smoking, alcohol consumption; physical activity; dietary habits; psychosocial behaviour; working activity, rest, sleep, etc. • Reorganization of health care: development of primary health care, community and district services; creation of new types of medical enterprise; teamwork and training. • Reorganization/reorientation of other sectors: creation of social environment; air /water pollution; - integration of new sectors, groups and move- ments into health problem solving. Implementation of prevention and control activities through existing primary health care systems and other health and community structures. Although it is obvious that the development and application of NCO interven- tion programmes can lead to the construction of new types of intersectoral health-oriented enterprises, lnterhealth was initially aimed at existing health-system infrastructures and principles of health-care manage- ment. Methodology The systems approach will bring to light the multifacto- rial nature of health problems and facilitate the develop- ment of a set of activities for problem solving. In spite of differences among noncommunicable diseases, all have a multifactorial structure and in order to decrease FIG. 1 RISK FACTORS AND NONCOMMUNICABLE DISEASES MAIN LINKS LIENS PRINCIPAUX ENTRE LES FACTEURS DE RISQUE ET LES MALADIES NON TRANSMISSIBLES Smoking - T abag1sme Diet - Regime alimenta,re Excessive alcohol consumption Consommat1on excessive d'alcool Physical mact1v1ty lnact1v1te physique Environmental pollution Pollution Raised blood pressure Hypertension artenelle Hyperltpidaem1a Hyperhp1demie Blood glucose Glycemie Coronary heart disease Card1opath1e coronarienne Stroke - Attaque cerebrale Diabetes - D,abete Lung cancer Cancer du poumon Chronic bronch1t1s Bronchne chron1que Liver cirrhosis Cirrhose du fo1e Gall-bladder disease Maladie de la vE!:s1cule b1liaire Peptic ulcer Ulcere gastroduodenal WHO 1!1151 Rapp. trimest. statist. sanit. mond .. 41 (1988) - 269 - mortality or morbidity the influence of leading negative socioeconomic, behavioural, environmental and medi- cobiological factors should be eliminated or at least decreased. Such multifactorial understanding of health problems will give us the opportunity: • to emphasize the importance of interdisciplinary team work; • to study the health problem from different points of view: interaction of factors; interaction of diseases; one factor-one disease; group of factors-one disease; one factor-group of diseases; group of factors-group of diseases. There are many difficulties encountered in the investiga- tion of "factor-disease" interrelation: lack of informa- tion (especially dynamic); qualitative nature of many fac- tors; differing lag times between appearance of risk fac- tor and onset of disease; competing risks between dis- eases; the gap in interaction among different specialists, etc. From the managerial point of view all these factors could be subdivided into two categories: uncontrollable fac- tors (climate, age, sex, genetic) and controllable factors (depending on individual, family and community life- styles, health care and other sectors of activity). There- fore a programme designed as an instrument for health problem solving would include three main subpro- grammes: changes in behaviour and lifestyle, health- care activity and reorientation of other sectors of activ- ity. Although the programming method is rather carefully elaborated, the development of systems analysis, ex- pert systems, simulation, etc. gives an impetus to its development. At present the methodological tool of health programme development consists of medical, economic, mathematical, expert and other methods which are used at different stages of the programming procedure. This procedure includes the following steps: identification of noncommunicable disease prob- lems; situation analysis (baseline information) ; formulation of aims and objectives; elaboration of a set of intervention programmes; intervention; monitoring and evaluation; implementation of the results. The universal lnterhealth methodology developed at WHO headquarters should be adapted to the situation of the WHO Regions, their environment. lifestyle, and so on. This methodology should therefore be flexible and provide opportunities to include (or exclude) some fac- tors or diseases, as well as permit linkages with other ongoing programmes. Atthe country level the process of adaptation will be related to the specifics of the health- care systems, health legislation and existing infrastruc- ture. In large countries with widely differing regional or community characteristics, some additional compo- nents (related specifically to district or community) should be taken into account (Fig. 2). The following disease and risk factors have been in- cluded in the core of lnterhealth: • Diseases-heart diseases; stroke; diabetes; cancer; respiratory diseases. • Common risk factors-diet; tobacco; alcohol; physi- cal activity; environment; oral hygiene; blood pres- sure; lipids; glucose. FIG. 2 INTERHEALTH METHODOLOGY ADAPTATION ADAPTATION DE LA METHODOLOGIE INTERHEALTH WHO/headquaners programme Programme OMS/Siege WHO/Regional Off,ce programme Programme OMS/Bureau regional National programme Programme national District programme Programme de d1str1ct Wld hlth statist. quan., 41 (1988) WHO a111sa - 270 - The lnterhealth programme is being developed as a dynamic system, consisting of four main in~erlinked activities: experimental testing (demonstration p~o- jects); mathematical modelling; training ; research activ- ities with a set of supporting systems. Experimental testing-demonstration projects Taking into account regional, social, demographic, geo- graphical, cultural a~d other differences. among WHO Regions and countries, as ~ell as the. inadequacy of information about the effectiveness of integrated NCD programmes, WHO headquarter~ prom?ted ~he estab- lishment of a series of demonstration proJects mall WHO Regions. At present there are 18 demonstration projects in 15 countries. Structure of demonstration projects Experimental and reference areas (communities, districts) ; . management board (national programme coordina- tor, programme manager, experts, working groups); supporting systems. The demonstration projects are being developed by local ministries of health in close contact with WHO Regional Offices under the supervision of the head- quarters team. Types of data (national and demonstration project levels) Sociodemographic; mortality rates; morbidity (e.g. incidence and prevalence rates, trends, distribution in populations, causes); disability associated with NCD; personal habits; risk factors associated with NCD; health education of the public (assessment of actual and potential capacity in NCD control, evaluation of impact); . medical care facilities (assessment of capacity, per- formance and potential) ; medical care utilization measurements; costs; evaluation of intervention programmes. Clearly these may be included at varying dew~es of complexity according to the nature of a spec1f1c pro- gramme. Also, other categories may be pertinent for some programmes, and some of the above may not be useful for others. Nevertheless, for some programmes the general collection of data would be important in that it would provide a frame of reference. Sources of data • Information from communities: Data routinely available-such as those from regis- tration statistics, health-service systems, commu- nity-based registries, censuses. Data that can be obtained from review of existing primary information such a~ that derived fr<:>m hos- pital records, or consumption data, e.g. cigarette sales. • Information from individuals: -Data derived from questionnaires: (i) postal sur- veys; (ii) interviews. Data derived from physical examinations or labora- tory tests. • Information about medical staff opinion. Time points for data collection Data are collected for baseline evaluation purposes just before a programme begins, and at one or more moni- toring points during or at the end ofthe programme. T~o sources of data are likely to be needed : the community and the individual. A core set of information should be collected at baseline from all sources. This core set, which could be common to all communities, will need to be supplemented by other information, depending on the programmes and the particular community. Also, the collection of baseline information could be repeated or supplemented at the monitoring points. Intervention programmes All intervention programmes of lnterhealth are sub- divided according to the following elements: • risk factors: anti-smoking programmes; anti-alcohol programmes; nutrition programmes. • target groups: children, schoolchildren, teachers, par- ents, pregnant women, workers, students, ~lde.rly. • place of application: family, school, plant, institute, etc. Taking into account the number of risk factors, target groups and places, many specific intervention pro- grammes such as anti-smoking school programmes for children, separately for parents, for teachers, etc., could be developed (some already exist). At prE:sent W~O. together with some collaborating centres, 1s collecting different versions of intervention programmes. Such a menu of intervention programmes will give decision makers at different levels (national, district, primary health care) the opportunity to select an acceptable ver- sion and adapt it to the local situation (Fig. 3). Utilization of demonstration-project results The results of the demonstration project, after evalu- ation from the medical, economic and sociobehavioural points of view, could be estimated .on ~he basi~ .of national intervention programmes, leg1slat1on, adminis- trative and other decisions if positive. Even the negative results of some intervention programmes will be quite useful for decision makers and will assist them in devel- oping new approaches and alternatives. The result of the demonstration project, its programme design, supporting systems, etc., will be useful for: other lnterhealth demonstration projects; decision mak- ers, medical staff, primary health care workers from other communities or districts in the same country; and representatives of other countries. Modelling activity Modelling activity plays an important role in developing lnterhealth. Modelling activity can be developed for va- rious purposes: • describing the interrelation among risk factors, among diseases as well as between the two; Rapp. trimest. statist. sanit. mond., 41 (1988) - 271 - FIG. 3 EXAMPLES OF DIFFERENT COMBINATIONS OF INTERVENTION PROGRAMME VERSIONS EXEMPLES DE DIFFERENTES COMBINAISONS DE PROGRAMMES D'INTERVENTION Anti-smoking programmes Programmes antitabac Anti-alcohol programmes Nutrition programmes Programmes de lutte contre I' alcoolisme Programmes de nutrition 1 -------- I 2 2 ------- 2 Japan - Japon 3 , 3 / 3 Finland - Finlande ......................... ·· .. ,,"'" ' . /·· .. 4 '-,/ 4 ,/ ..... 4 USSR - URSS .·' ,,, •• ' ,,I' •• ..... ,I' .· ' ,,, 5 ..... '5' 6 6 7 • forecasting trends of different mortality. morbidity rates, risk-factor frequencies; • early detection of new cases of noncommunicable diseases; • clustering and regionalization of countries, for select- ing model districts or communities and for deciding on the organization of demonstration projects, the adap- tation of intervention programmes to local situations, etc. Taking into account the importance of intervention-pro- gramme evaluation, a new activity was initiated at WHO headquarters-the development of a methodological tool for the prediction of efficacy and effectiveness of intervention programmes. This activity is very important taking into account that noncommunicable diseases are processes evolving over a long period of time and chang- ing drastically in their nature and severity. Moreover according to the results of some natural experiences in the United States of America, Finland and the USSR, it takes a long time to perceive a significant change in morbidity, mortality rates, risk-factor frequency caused by activity of intervention programmes. With such a wide selection (or menu) of intervention programmes, it is very important to be able to predict their efficacy and effectiveness and to select the most acceptable for uti- lization or for demonstration-project testing. The development of this direction in lnterhealth model- ling activity is very important given the competing risk between diseases and between risk factors. as well as the involvement of the economic and other external sys- tems in "factor-diseases" relations. An example of a typical situation : a campaign against risk factor X will have positive influences on morbidity rates caused by diseases A and through some substitution or other effects it will increase the frequency rate of risk factor Y, which in turn will lead to increasing morbidiy rates cau- sed by disease B, etc. If economic aspects are taken into consideration (for example in the case of countries pro- ducing tobacco or alcohol), the situation becomes more Wld hlth statist. quan .• 41 ( 1988) 5 WHO MHS6 difficult for modelling. Nonetheless, the model will help to estimate positive and negative relationships, cumula- tive and substitution effects and will provide an oppor- tunity for testing different scenarios in advance. Training activity In addition to health education programmes, oriented to different target groups, training courses oriented to dif- ferent categories of personnel involved in noncommuni- cable diseases programmes are being developed. In connection with the development of prevention pro- grammes all these training courses could be divided into monodisciplinary and multidisciplinary types. Monodisciplinary training courses are designed for a homogeneous group of participants; for example, cour- ses for community health workers. demonstration pro- ject managers, national programme coordinators. etc. Such training seminars are offered on a permanent basis in North Karelia (Finland), Stanford (California, United States) and in other places. In 1988 a training course on epidemiological, statistical and operational research me- thods in developing noncommunicable diseases pro- grammes was organized in Moscow. Taking into account that the development of lnterhealth requires teamwork and the active participation of many specialists from different professions, sec- tors and agencies, the Division of Noncommunicable Diseases of WHO headquarters is working on the devel- opment of a multidisciplinary training course for national teams responsible for NCO programmes in their own country. It is obvious that such national teams should consist at least of the national programme coordinator (or manager), a scientist, an educator and a user (e.g. general practitioner). The aim of such multidisciplinary training is to give, with the help of special training mod- ules, opportunities to a team of different specialists to - 272 - simulate all steps in programme development and to create a simple programme protocol. The procedure for designing such training technology is as follows: division of the health problem into subproblems and tasks ("tree" of problems); constitution of a multidisciplinary team responsible for leading tasks and branches of this "tree"; carrying out a set of monodisciplinary seminars for monodisciplinary task solving, bidisciplinary seminar for bidisciplinary tasks, and finally the simulation of all steps of the programming process by all specialists together. The training programme is made up of five compo- nents: introduction (several background lectures and dis- cussions); monodisciplinary seminars, held separately for pro- gramme managers, scientists, teachers and users (e.g. general practitioners, community health work- ers); bidisciplinary seminars, for discussion of common problems between programme managers and scien- tists, scientists and teachers from different coun- tries; multidisciplinary seminars, for national teams to de- velop a programme protocol; discussion about national programme protocols, cor- rection and finalization. Research activity This activity will be dedicated to further epidemiological investigation of new risk factors (genetic, environmen- tal, behavioural) and their interaction with the lnterhealth core group of risk factors and diseases. Taking into account the geographical differences be- tween WHO Regions and Member States, the investiga- tion of the frequency of different risk factors and disea- ses in different localities will be continued. There is potential for international comparative studies in this area. Many interesting new ideas for research could be taken from ongoing demonstration projects and mod- elling activities. Supporting programmes Progress in the development of lnterhealth depends upon the activity of supporting programmes. Organizational support Several collaborating centres are developing different aspects of lnterhealth activity. Some new centres deal- ing with mathematical modelling, evaluation of preven- tion programmes and training are being considered as possible collaborating centres. As mentioned earlier there is a network of demonstration projects with a team of responsible workers. All these participating parties are helping medical offi- cers working in WHO headquarters and Regional Offices to develop lnterhealth at the global, regional and national levels. Financial support There are several sources of financial support, the main one being the national health authorities, followed by the Regional Offices of WHO, and headquarters. The money is used for developing demonstration projects, for conducting meetings, seminars and training courses, for consultantships, for purchasing technical equipment, etc. Information support This includes information for monitoring and evaluation, data processing and other activities. Given the importance of a systems approach for health programme development, the Division of Noncommuni- cable Diseases of WHO is developing activities in co- operation with other divisions of the Organization invol- ved in health information systems, epidemiology, mod- elling and health-care management with the collabora- tion of national and international centres. SUMMARY In spite of the difference between developed and devel- oping countries, health conditions change in a predict- able pattern: the mortality and morbidity rates caused by infectious diseases decline while the rates related to non-infectious pathology increase. Taking into account the increasing importance of noncommunicable disea- ses, the majority of countries are developing a set of disease-oriented (cancer, cardiovascular diseases, dia- betes, etc.) prevention and control programmes as well as factor-oriented programmes such as anti-smoking, alcohol abuse and nutrition. The Integrated Programme for Community Health in Noncommunicable Diseases, which is being developed both in WHO headquarters and in the Regional Offices, aims to amalgamate into one programme activities directed at influencing a group of risk factors common to several of the most important noncommunicable disea- ses. The four main directions being developed for the realization of this programme are: experimental testing, mathematical modelling, training activity and research development: At present WHO headquarters: • has established 18 demonstration projects in 15 coun- tries for experimental testing of different intervention programmes; • is collecting mathematical models for prediction of efficacy and effectiveness of different alternatives and scenarios; • is developing different types of training courses; • is investigating the competing risk among noncommu- nicable diseases and time lag for different intervention programmes, etc. In order to develop all these directions many collabora- ting centres are participating, and close cooperation with some nongovernmental organizations has been estab- lished. Rapp. trimest. statist. sanit. mond., 41 ( 1988) - 273 - RESUME Programme integre de lutte contra les maladies non transmissibles Malgre tout ce qui distingue les pays industrialises des pays en developpement, la situation sanitaire evolue selon un schema previsible: tandis que la mortalite et la morbidite dues aux maladies infectieuses regressent, les taux lies a la pathologie non infectieuse augmentent. Compte tenu de !'importance croissante des maladies non transmissibles, la majorite des pays mettent en place un ensemble de programmes de lutte axes sur les maladies (cancer, maladies cardio-vasculaires, diabete, etc.) et de programmes axes sur differents facteurs tels que les programmes antitabac, de lutte contre l'alcoo- lisme et de nutrition. Le Programme integre de sante communautaire concer- nant les maladies non transmissibles, actuellement mis au point au Siege de l'OMS et dans les Bureaux regio- naux, vise a regrouper en un seul et m~me programme les activites destinees a agir sur un groupe de facteurs de risque commun a plusieurs des principales maladies non transmissibles. La realisation de ce programme suit quatre grandes directions: essais experimentaux, Wld hlth statist. quan., 41 ( 19881 modeles mathematiques, activites de formation et deve- loppement de la recherche. Actuellement, le Siege de l'OMS: • a cree 18 projets de demonstration dans 15 pays dif- ferents pour la mise a l'essai, a titre experimental, de differents programmes d'intervention; • rassemble des modeles mathematiques pour prevoir I' efficacite et I' efficience des differents scenarios et solutions possibles ; • met au point differents types de cours de forma- tion; • analyse la concurrence entre maladies non transmissi- bles sur le plan des risques et le decalage des diffe- rents programmes d'intervention, etc. Pour mener a bien toutes ces tAches, de nombreux centres collaborateurs ant ete appeles a participer au programme et une cooperation etroite s'est instauree avec certaines organisations non gouvernementales. - 274 - WORLD HEALTH STATISTICS QUARTERLY Cancer ANNUAL TABLE OF CONTENTS VOL. 41, 1988 Cancers of the stomach, lung and breast: mortality trends and control strategies. Kenneth Stanley, Jan Stjernsward & Valentin Page Koroltchouk . . . . . . . . . . . . . . . . . . . 107 Cardiovascular diseases Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years. The WHO MONICA Project . . . . . . . . . . . . . . . . . . . . . . 115 Hypertension in developing countries. Aulikki Nissinen, Siegfried BOthig, Helena Granroth & Alan D. Lopez . . . . . . 141 Trends in cardiovascular disease mortality in industrialized countries since 1950. Kazuo Uemura & Zbynek Pisa 155 Diabetes Trends in the prevalence and incidence of diabetes: insulin- dependent diabetes mellitus in childhood. Marian Rewers, Ronald E. LaPorte, Hilary King & Jaakko Tuomilehto . . . . . 179 Trends in the prevalence and incidence of diabetes: non-insulin- dependent diabetes mellitus. Hilary King & Paul Zimmet . . . 190 World Health Organization activities in the field of diabetes mel- litus. Hilary King & Mikhail P. Mitrofanov . . . . . . . . . . . . 197 Diarrhoeal diseases Control of diarrhoeal diseases. C. Ann Martinez, Dhiman Barua & Michael H. Merson . . . . . . . . . . . . . . . . 74 Epidemiological surveillance A method for evaluating systems of epidemiological surveil- lance. Stephen B. Thacker, R. Gibson Parrish, Frederick L. Trowbridge & Surveillance Coordination Group . 11 Local Area Monitoring (LAM). Thomas D. Kirsch 19 Community-based health reporting. Wolf Scott 26 Genetic disorders Distribution and control of some genetic disorders. Bernadette Modell & Victor Bulyzhenkov . . . . . . . . . . . . . . . . . . 209 The activities of the Hungarian Centre for Congenital Anomaly Control. Andrew Czeizel . . . . . . . . . . . . . . . . . . . . . 219 Immunization Expanded Programme on Immunization. Ko Keja, Carole Chan, Gregory Hayden & Ralph H. Henderson ........... . Information support Introduction: epidemiological approaches to health planning, management and evaluation. John P. Woodall ....... . International Classification of Diseases International Statistical Classification of Diseases and Related Health Problems-Tenth Revision. Gerlind R. Bramer International Health Regulations The International Health Regulations : results and prospects 59 2 32 RAPPORT TRIMESTRIEL DE STATISTIOUES SANITAIRES MONDIALES TABLE ANNUELLE DES MATIERES VOL. 41, 1988 Activite physique ROie de l'activite physique dans la prevention et le traitement des maladies non transmissibles [resume]. Igor P. Pages Briazgounov . . . . . . . . . . . . . . . . . . . . . . . . 248 Appui informationnel Introduction : approches epidemiologiques de la planification sanitaire: gestion et evaluation [resume]. John P. Woodall 9 Cancer Cancers de l'estomac, du poumon et du sein: tendances de la mortalite et strategies de lutte (resume]. Kenneth Stanley, Jan Stjernsward & Valentin Koroltchouk . . . . . . . . 113 Classification internationale des maladies Classification statistique internationale des maladies et autres probli!mes de sante - Dixii!me revision [resume]. Gerlind R. Bramer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Diabete Tendances observees dans la prevalence et !'incidence du dia- bi!te: diabi!te sucre insulino-dependant de l'enfant [resume]. Marian Rewers, Ronald E. LaPorte, Hilary King & Jaakko Tuomilehto . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Tendances observees dans la prevalence et !'incidence du dia- bete: diabete sucre non insulino-dependant [resume]. Hilary King & Paul Zimmet . . . . . . . . . . . . . . . . . . . . . . . 195 [Activites de l'OMS dans le domaine du diabi!te sucre] [anglais seulement]. Hilary King & Mikhail P. Mitrofanov . . . . . . . . 197 Maladies cardio-vasculaires Variation geographique des principaux facteurs de risque de cardiopathies coronariennes chez les hommes et les femmes de 35-64 ans [resume]. Le Projet MONICA de l'OMS . . . . . . . 136 L'hypertension dans les pays en developpement [resume]. Aulikki Nissinen, Siegfried BOthig, Helena Granroth & Alan D. Lopez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Tendances de la mortalite par maladies cardio-vasculaires dans les pays industrialises depuis 1950 (resume]. Kazuo Uemura & Zbynek Pisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 77 Maladies diarrheiques Lutte contra les maladies diarrheiques [resume]. C. Ann Martinez, Dhiman Barua & Michael H. Merson ..... . Maladies non transmissibles Introduction - Les maladies non transmissibles dans le monde : un probli!me prioritaire de sante dont !'importance va croissant. 81 Evgueni N. Shigan . . . . . . . . . . . . . . . . . . . . . . . . 104 Impact mondial des maladies non transmissibles: estimations et projections [resume]. Kenneth G. Manton . . . . . . . . . . 265 Programme integre de lutte contre les maladies non transmis- sibles [resume]. Evgueni N. Shigan . . . . . . . . . . . . . . 273 Maladies sexuellement transmissibles (summary]. Alain Vessereau .................. . 44 La lutte contra les maladies sexuellement transmissibles (MST). Malaria Malaria control activities in the last 40 years (summary]. Malaria Action Programme . . . . . . . . . . . . . . . . . . . . . . . . 73 Georges Causse & Andre Meheus . . . . . . . . . . . . . . . Medecine du travail Statistiques descriptives (resume]. Thomas K. Ng . de morbidite professionnelle 82 206 Rapp. trimest. statist. sanit. mond., 41 (1988) - 275 - Noncommunicable diseases (Introduction: the growth of noncommunicable diseases as a global health priority problem] [French only]. Evgueni N. Shigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 The global impact of noncommunicable diseases: estimates and projections. Kenneth G. Manton . . . . . . . . . . . 255 Integrated programme for noncommunicable diseases pre- vention and control (NCO). Evgueni N. Shigan . . . . . . 267 Nutrition Nutrition L·utilisation de l'anthropometrie pour evaluer l'etat nutritionnel [resume]. Jonathan Gorstein & James Akre . . . . . . . . . . 54 Obesite Prevalence mondiale de I' obesite - un premier aperc;u des don- nees disponibles [resume]. Michael Gurney & Jonathan Gorstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Paludisme Activites antipaludiques: les 40 dernieres annees. Programme The use of anthropometry to assess nutritional status. Jonathan Gorstein & James Akre . . . . . . . . . . . . . . 48 d'action antipaludique ..................... . 64 Obesity Reglement sanitaire international The global prevalence of obesity-an initial overview of avail- Le Reglement sanitaire international: bilan et perspectives. able data. Michael Gurney & Jonathan Gorstein . . . . . . . . 251 Alain Vessereau . . . . . . . . . ......... . 37 Occupational health Surveillance epidemiologique Descriptive occupational morbidity statistics. Thomas K. Ng 200 Une methode d'evaluation des systemes de surveillance epide- miologique [resume]. Stephen B. Thacker, R. Gibson Parrish, Physical activity Frederick L. Trowbridge & Surveillance Coordination Group 16 The role of physical activity in the prevention and treatment of Surveillance locale (LAM) [resume]. Thomas D. Kirsch . . . . 24 noncommunicable diseases. Igor P. Briazgounov . . . . . . . 242 Sexually transmitted diseases Control of sexually transmitted diseases (STDs) (summary]. Georges Causse & Andre Meheus . . . . . . . . . . . . . Smoking Smoking trends and effects worldwide (summary]. Robert 100 Masironi & Keith Rothwell . . . . . . . . . . . . . . . . . . . . 239 Wld hlth statist. quart., 41 ( 1988) Notification de la situation sanitaire fondee sur la communaute [resume]. Wolf Scott ...................... . 30 Tabagisme Tendances et effets du tabagisme dans le monde. Robert Masironi & Keith Rothwell . . . . . . . . . . . . . . . . . . . . 228 Troubles genetiques Distribution de certains troubles genetiques et mesures de lutte [resume]. Bernadette Modell & Victor Bulyzhenkov . . . . . . 218 Les activites du centre hongrois de lutte contre les anomalies congenitales [resume]. Andrew Czeizel 226 Vaccination Le Programme elargi de vaccination [resume]. Ko Keja, Carole Chan, Gregory Hayden & Ralph H. Henderson . . . . . . . . . 63 PUBLICATIONS OF THE WORLD HEALTH ORGANIZATION 1989 WORLD HEALTH FORUM An international journal of health development (Separate editions in English, French, Spanish, Arabic, Chinese and Russian) World health forum is a quanerly journal for policy-makers, health planners, adminis- trators, health educators, and public health workers ofall kinds. It provides a medium for the presentation and discussion of new concepts in public health and new approaches to health problems, and it is devoted to the improvement of health through the promotion of health services covering the entire population and the undenaking of a wide variety of public health measures, whether or not they are supponed by WHO. The Forum is the main organ of WHO's Member States for the international exchange of health information and an active instrument in technical cooperation among developing countries. Subscription (4 numbers) Price per copy . . . . . . . BULLETIN Sw. fr. 55.- Sw. fr. 16.- OF THE WORLD HEALTH ORGANIZATION The Bulle1in is the principal scientific organ of WHO; its role is to review progress in medical and related sciences ("update" anicles) and to bring to light new knowledge by publishing original papers on scientific research in the laboratory and field. The Bulletin contains original anicles in either English or French, with a summary in the other language. One volume is published annually, consisting of six numbers. Subscription (6 numbers) .... Price per copy . . . . . WEEKLY EPIDEMIOLOGICAL RECORD (Bilingual: English and French) Sw. fr. 130.- Sw. fr. 22.- Prepared for the guidance of health administrations and health authorities, the Weekly epidemiological record contains notifications made under the International Health Regula- tions and information concerning their application. The Record also contains epi- demiological information on communicable diseases of international imponance. Annual subscription .................. . Sw. fr. 150.- WORLD HEALTH STATISTICS QUARTERLY The World health s1a1is1ics quar1erly replaces (since 1978) the World hea/1h s1alis1ics reporl (published since 1967) and its forerunner the Epidemiological and vital s1a1is1ics reporl (published since 1947). It deals with the detailed analysis of selected health topics of current interest. Staning with Vol. 41 (1988), the Quarlerly will contain anicles in eilher French or English with a summary in both languages. Annual subscription Price per copy . . WORLD HEALTH STATISTICS ANNUAL (Bilingual: English and French) Sw. fr. 85.- Sw. fr. 23.- The forerunner of this series was the Annual epidemiological reporl of the League of Na1ions. It was followed by the Annual epidemiological and vital sta1is1ics issued by the World Health Organization. Latest publications: 1983, Vital statistics and causes of death, morbidity, health resources (single volume), 804 pages . . . . . . . . . . . . . . . . . . . . . . . . . . Sw. fr. 57.- 1984, Vital statistics and life tables, morbidity, causes of death (single volume), 402 pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sw. fr. 40. - 1985, Vital statistics and life tables, environmental health, causes of death (single volume), 531 pages . . . . . . . . . . . . . . . . . Sw. fr. 80.- 1986, Vital statistics and life tables, evaluation of the Global Strategy for Health for All, causes of death (single volume), 692 pages . . . . . . . . . . . . Sw. fr. 90.- 1987, Vital statistics and life tables, oral health and care, causes of death (single volume), 455 pages . . . . . . . . . . . . . . . . . . . . . Sw. fr. 90.- PUBLICATIONS DE L'ORGANISATION MONDIALE DELASANTE 1989 FORUM MONDIAL DE LA SANTE Revue internationale de developpement sanitaire (Editions separees en fran,ais, anglais, espagnol, arabe, chinois et russe) Forum mondial de la sant~ est une revue trimestrielle destinee aux responsables des politiques sanitaires, aux planificateurs, administrateurs et educateurs sanitaires, enfin aux travailleurs de la sante publique de toutes categories. Tribune pour la presentation et la discussion de nouveaux concepts en sante publiq ue et de nou velles approches des problemes de santC, Forum se consacre a l'amClioration de la santC par la promotion de services de santC couvrant la population tout entiere et d'une vaste gamme de mesures de sante publique, qu'elles soient ou non soutenues par l'OMS. II est le principal organe a la disposition des Etats Membres de l'OMS pour l'echange international d'informations sanitaires en meme temps qu'un instrument de cooperation technique entre pays en developpement. Abonnement (4 numeros) Le numero ...... . BULLETIN Fr. s. SS.- Fr. s. 16.- DE L'ORGANISA TION MONDIALE DE LA SANTE Le Bullelin est le principal organe scientifique de l'OMS; ii a pour role de passer en revue les progres des sciences medicales et apparentees (anicles de la rubrique «Le point») et de mettre en lumiCre les connaissances nouvelles en pl"Csentant dans des articles originaux les resultats de recherches scientifiques au laboratoire et sur le terrain. Le Bulletin contient des anicles originaux en fran-"is ou en anglais, accompagnes d'un resume dans l'autre langue. Un volume est publiC annuellement, Ctant formC de six numCros. Abonnement (6 numeros) .. . Le numCro ......... . RELEVE EPIDEMIOLOGIQUE HEBOOMADAIRE (Bilingue: fran,ais et anglais) Fr. s. 130.- Fr. s. 22.- Destine aux administrations sanitaires et aux services de sante, le Re/eve epidemiologique hebdomadairecontient les notificationsexigees par le Reglement sanitaire international, ainsi que d'autres renseignements concernant !'application de ce reglement. Le Re/eve contient egalement des informations epidemiologiques concernant les maladies transmissibles d'une importance intemationale. Prix de l'abonnement annuel ........................ . Fr. s. 150.- RAPPORT TRIMESTRIEL DE ST ATISTIQUES SANIT AIRES MONDIALES Le Rapport Lrimestriel de slalisliques sanilaires mondiales, remplace (depuis 1978) le Rapport de stalistiques sanitaires mondiales (publie depuis 196 7) et son precurseur le Rapport epidemiologique et demographique (publie depuis 194 7). II presente des analyses detaillees sur des sujets specifiquesd'interet courant. A compterdu Vol. 41 (1988), le Trimestrie/ presentera des articles originaux en fran~is ou en anglais, accompagnCs d'un resume dans tes deux langues. Prix de l'abonnement annuel Le numCro ... ANNUAIRE Fr. s. 85.- Fr. s. 23.- DE ST ATISTIQUES SANIT AIRES MONDIALES (Bilingue: fran,ais et anglais) Cet annuaire remplace les Sta1is11ques epidemiologiques el demographiques annuelles publiees par !'Organisation mondiale de la Sante et qui avaient, elles-memes, remplace le Rapport epidemio/ogique annue/ publie par la Societe des Nations. Publications recentes: 1983, Mouvement de la population et causes de deces, morbidite, resources de sante ( I seul volume), 804 pages . . . . . . . . . . . . . . . . . . Fr. s. 57.- 1984, Mouvements de la population et tables de survie, morbidite, causes de deces (I seul volume), 402 pages Fr. s. 40. - 1985, Mouvement de la population et tables de survie, salubrite de l'environnement, causes de deces ( I seul volume), 531 pages . . . . . . . . . . . . . . . . . . . Fr. s. 80. - 1986, Mouvement de la population et tables de survie, evaluation de la Strategic mondiale de la sante pour tous, causes de deces ( I seul volume), 692 pages . . Fr. s. 90. - 1987, Mouvement de la population et tables de survie, sante et soins bucco-dentaires, causes de deccs (l seul volume), 455 pages . . . . . . . . . . . . . . Fr. s. 90.- WHO publications may be obtained, direct or through booksellers, from: Les publications de l'OMS peuvent etre commandees, soit directement, soit par l'intermediaire d'un libraire, aux adresses suivantes : ALGERIE: Entreprise nation.ale du Livre (ENAL), 3 bd Zirout Youcef, ALGER ARGENTINA: Carlos Hirsch SRL, Rorida 165, Galerias Gilemes, Escritorio 453/465, BUENOS AIRES AUSTRALIA: Hunter Publications, SBA Gipps Street, COLLINGWOOD, VIC 3066 AUSTRIA: Gerold & Co., Graben 31, 1011 WIEN I BAHRAIN: United Schools International, Arab Region Office, P.O. Box 726, BAHRAIN BANGLADESH: The WHO Programme Coordinator, G.P.O. Box 250, DHAKA S BELGIQUE: Pour toute commande hors abonnement: Office International de Librairie s.a., avenue Mamix 30, 1050 BRUXELLES. Abonnements: Office International des Pcriodiques, avenue Louise 485, I 050 BRUXELLES BHUTAN: see India, WHO Regional Office BOTSWANA: Botsalo Books (Pty) Ltd., P.O. Box 1532. GABORONE BRAZIL: Centro Latinoamericano de Informa~o em Ciencias de Saude (BIREME), Organizacao Panamerica- na de Saude, Sector de Publicacoes, C.P. 20381 - Rua Botucatu 862, 04023 SAO PAULO, SP BURMA: see India, WHO Regional Office CAMEROON: Cameroon Book Centre, P.O. Box 123, South West Province, VICTORIA CANADA: Canadian Public Health Association, 1335 Carling Avenue, Suite 210, OTTAWA, Ont. KIZ 8N8. (Tel: (613) 725-3769. Telex: 21-053-384[) CHINA: China National Publications Import & Export Corporation, P.O. Box 88, BEIJING (PEKIN) DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA: see India, WHO Regional Office DENMARK: Munksgaard Export and Subscription Ser- vice, Nerre Segade 35, 1370 K0BENHA VN K (Tel: +45 1 12 85 70) ESPAGNE: Comercial Atheneum S.A., Consejo de Ciento 130-136, 08015 BARCELONE; General Moscardo 29, MADRID 20 - Libreria Diaz de Santos, P.O. Box 6050, 28006 MADRID; Balmes 417 y 419, 08022 BARCE- LONE FIJI: The WHO Representative, P.O. Box 113, SUVA FINLAND: Akateeminen Kirjakauppa, Keskuskatu 2, 00101 HELSINKI 10 FRANCE: Arnette, 2, rue Casimir-Dclavigne, PARIS 75006 GERMAN DEMOCRATIC REPUBLIC: Buchhaus Leip- zig, Postfach 140, 70 I LEIPZIG GERMANY, FEDERAL REPUBLIC OF: Govi-Verlag GmbH, Ginnheimerstrasse 20, Postfach 5360, 6236 ESCHBORN - Buchhandlung Alexander Hom, Kirch- gasse 22, Postfach 3340, 6200 WIESBADEN GRECE: G.C. Elefiheroudakis S.A., Librairie inter- nationale, rue Nikis 4, 105-63 ATHENES HONG KONG: Hong Kong Government Information Ser- vices, Publication (Sales) Offi.ce, Information Services Department, No. I, Battery Path, Central, HONG KONG HUNGARY: Kultura P.O.B. 149, BUDAPEST 62 ICELAND: Snaebjorn Jonsson & Co., Hafnarstraeti 9, P.O. Box 1131, IS-101 REYKJAVIK INDIA: WHO Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Road, NEW DELHI 110002 IRAN (ISLAMIC REPUBLIC OF): Iran University Press, 85 Park Avenue, P.O. Box S4/SSl, TEHERAN IRELAND: TDC Publishers, 12 North Frederick Street, DUBLIN I (Tel: 744835-749677) ISRAEL: Heiliger & Co., 3 Nathan Strauss Street, JERU- SALEM 94227 IT ALIE: Edizioni Minerva Medica, Corso Bramante 83-85, 10126 TURIN; Via Lamarmora 3, 20100 MI- LAN; Via Spallanzani 9, 00161 ROME JAPAN: Maruzen Co. Ltd, P.O. Box 5050, TOKYO Inter- national 100-31 JORDAN: Jordan Book Centre Co. Ltd., University Street, P.O. Box 301, (AI-Jubeiha), AMMAN KENYA: Text Book Centre Ltd, P.O. Box 47540, NAIROBI KUWAIT: The Kuwait Bookshops Co. Ltd, Thunayan Al- Ghanem Bldg, P.O. Box 2942, KUWAIT LAO PEOPLE'S DEMOCRATIC REPUBLIC: The WHO Representative, P.O. Box 343, VIENTIANE LUXEMBOURG: Librairie du Centre, 49 bd Royal, LUXEMBOURG MALAYSIA: The WHO Representative, Room 1004, I Oth Floor, Wisma Lim Foo Yong (formerly Fitzpatrick's Building), Jalan Raja Chulan, KUALA LUMPUR 05-10; P.O. Box 2250, KUALA LUMPUR 01-02 - Parry's Book Center, 124-1 Jalan Tun Sambanthan, P.O. Box 10960, 50730 KUALA LUMPUR MALDIVES: see India, WHO Regional Office MAROC: Editions La Porte, 281 avenue Mohammed V, RABAT MEXICO: Libreria lnteracademica S.A., A v. Sonora 206, 06100-MEXICO, D.F. MONGOLIA: see India, WHO Regional Office NEPAL: see India, WHO Regional Office NETHERLANDS: Medical Books Europe BY, Noorder- wal 38, 7241 BL LOCHEM NEW ZEALAND: New Zealand Government Printing Office, Publishing Administration, Private Bag, WEL- LINGTON; Walter Street, WELLINGTON; World Trade Building, Cubacade, Cuba Street, WELLINGTON. Gov- ernment Bookshops at: Hannaford Burton Building, Rutland Street, Private Bag, AUCKLAND; 159 Hereford Street, Private Bag, CHRISTCHURCH; Alexandra Street, P.O. Box 857, HAMILTON; T & G Building, Princes Street, P.O. Box 1104, DUNEDIN - R. Hill & Son Ltd. Ideal House, Cnr Gillies A venue & Eden St., New-Market, AUCKLAND I NORWAY: Tanum - Karl Johan A.S., P.O. Box 1177, Sentrum, N-0107 OSLO I PAKISTAN: Mirza Book Agency, 65 Shahrah- E-Quaid E-Azam, P.O. Box 729, LAHORE 3 PAPUA NEW GUINEA: The WHO Representative, P.O. Box 646, KONEDOBU PHILIPPINES: World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, MANILA; National Book Store Inc., 701 Rizal Avenue, P.O. Box 1934, MANILA PORTUGAL: Livraria Rodrigues, 186 Rua do Ouro, LISBOA 2 REPUBLIC OF KOREA: The WHO Representative, Cen- tral P.O. Box 540, SEOUL SAUDI ARABIA: World of Knowledge for Publishing and Distribution, P.O. Box 576, JEDDAH SINGAPORE: The WHO Representative, 144 Moulmein Road, SINGAPORE 1130; Newton P.O. Box 31,SINGA- PORE 9122 SOUTH AFRICA: Contact major book stores SRI LANKA: see India, WHO Regional Office SUISSE: Medizinischer Verlag Hans Huber, Uinggass- strasse 76, 3012 BERN 9 SWEDEN: For books: Aktiebolaget C.E. Fritzes Kungl. Hovbokhandel, Regeringsgatan 12, 103 27 STOCK- HOLM. For periodicals: Wennergren-Williams AB, Box 30004, 104 25 STOCKHOLM THAILAND: see India, WHO Regional Office UNITED KINGDOM: H.M. Stationery Office; 49 High Holborn, LONDON WClV 6HB; 71 Lothian Road, EDINBURGH EH3 9AZ; 80 Chichester Street, BELFAST BT! 4JY; Brazennose Street, MANCHESTER M60 BAS; 258 Broad Street, BIRMINGHAM BI 2HE; Southey House, Wine Street, BRISTOL BS I 2BQ. All mail orders should be sent to: HMSO Publications Centre, 51 Nine Elms Lane, LONDON SW8 SDR UNITED STATES OF AMERICA: Copies of individual publications (not subscriptions): WHO Publications Cen- ter USA, 49 Sheridan Avenue, ALBANY, NY 12210. Subscription orders and co"espondence concerning sub- scriptions should be addressed to the World Health Or- ganization. Distribution and Sales Service, 1211 GENE- VA 27, Switzerland. Publications are also available from the United Nations Bookshop, NEW YORK, NY 10017 (retail only) USSR: For readers in the USSR requiring Russian editions: Komsomolskij prospekt 18, Medicinskaja Kniga. MOS- COW - For readers outside the USSR requiring Russian editions: Kuzneckij most 18, Meidunarodnaja Kniga, MOSCOW G-200 VENEZUELA: Libreria Medica Paris, Apartado 60.681, CARACAS 106 YOUGOSLA VIE: Jugoslovenska Knjiga, Terazije 27/11, 11000 BEOGRAD ZIMBABWE: Textbook Sales (PVT) Ltd, I Norwich Union Centre, MUTARE Special terms for developing countries are obtainable on application to the WHO Representatives or WHO Regional Offices listed above or to the World Health Organization. Distribution and Sales Service, 1211 Geneva 27. Switzerland. Orders fron countries where sales agents have not yet been appointed may also be sent to the Geneva address, but must be paid for in pounds sterling, US dollars, or Swiss francs. Unesco book coupons may also be used. Prices are subject to change without notice. Des conditions speciales sont consenties pour les pays en developpement sur demande adressee aux Representants de l'OMS ou aux Bureaux regionaux de l'OMS enumeres ci-dessus ou bien a !'Organisation mondiale de la Sante, Service de Distribution et de Vente, 1211 Geneve 27. Suisse. Dans les paysou un depositaire n • a pas encore ete design e. les commandes peuvent l!tre adressees egalement a Gen eve, mais le paiement doit alors etre effectue en francs suisses. en livres sterling ou en dollars des Etats-Unis. On peut egalement utiliser les bans de livres de l'Unesco. Prix sujets a modification sans pr,§avis. Price: Sw. fr. 23.- 8/1 /88 Prix: Fr. s. 23. -