Effects of inappropriate cause-of-death certification on mortality from cardiovascular disease and diabetes mellitus in Tonga.

BACKGROUND: Cardiovascular disease (CVD) and diabetes mellitus are major health issues in Tonga and other Pacific countries, although mortality levels and trends are unclear. We assess the impacts of cause-of-death certification on coding of CVD and diabetes as underlying causes of death (UCoD). METHODS: Tongan records containing cause-of-death data (2001-2018), including medical certificates of cause-of-death (MCCD), had UCoD assigned according to International Classification of Diseases 10th revision (ICD-10) coding rules. Deaths without recorded cause were included to ascertain total mortality. Diabetes and hypertension causes were reallocated from Part 1 of the MCCD (direct cause) to Part 2 (contributory cause) if potentially fatal complications were not recorded, and an alternative UCoD was assigned. Proportional mortality by cause based on the alternative UCoD were applied to total deaths then mortality rates calculated by age and sex using census/intercensal population estimates. CVD and diabetes mortality rates for unaltered and alternative UCoD were compared using Poisson regression. RESULTS: Over 2001-18, in ages 35-59 years, alternative CVD mortality was higher than unaltered CVD mortality in men (p = 0.043) and women (p = 0.15); for 2010-18, alternative versus unaltered measures in men were 3.3/103 (95%CI: 3.0-3.7/103) versus 2.9/103 (95%CI: 2.6-3.2/103), and in women were 1.1/103 (95%CI: 0.9-1.3/103) versus 0.9/103 (95%CI: 0.8-1.1/103). Conversely, alternative diabetes mortality rates were significantly lower than the unaltered rates over 2001-18 in men (p < 0.0001) and women (p = 0.013); for 2010-18, these measures in men were 1.3/103 (95%CI: 1.1-1.5/103) versus 1.9/103 (95%CI: 1.6-2.2/103), and in women were 1.4/103 (95%CI: 1.2-1.7/103) versus 1.7/103 (95%CI: 1.5-2.0/103). Diabetes mortality rates increased significantly over 2001-18 in men (unaltered: p < 0.0001; alternative: p = 0.0007) and increased overall in women (unaltered: p = 0.0015; alternative: p = 0.014). CONCLUSIONS: Diabetes reporting in Part 1 of the MCCD, without potentially fatal diabetes complications, has led to over-estimation of diabetes, and under-estimation of CVD, as UCoD in Tonga. This indicates the importance of controlling various modifiable risks for atherosclerotic CVD (including stroke) including hypertension, tobacco use, and saturated fat intake, besides obesity and diabetes. Accurate certification of diabetes as a direct cause of death (Part 1) or contributory factor (Part 2) is needed to ensure that valid UCoD are assigned. Examination of multiple cause-of-death data can improve understanding of the underlying causes of premature mortality to better inform health planning.

Two decades of chronic kidney disease of unknown aetiology (CKDu) research: Existing evidence and persistent gaps from epidemiological studies in Sri Lanka.

BACKGROUND: Chronic Kidney Disease of unknown origin (CKDu) excludes known primary renal conditions or systemic disease (such as diabetes mellitus or hypertension). Prominence of CKDu has been noted for some decades in Sri Lanka, especially among men in particular rural areas, prompting many studies directed towards environmental causation. This article critically reviews relevant primary studies. METHODS: Articles for this literature review (n = 86) were found by searching Medline, Embase, Global Health and ProQuest databases over 2000-2020 utilizing a standard algorithm. Articles were critiqued according to criteria for diagnosis of CKDu, aetiological agents investigated, analytic methods employed and findings. RESULTS: Criteria for diagnosis of CKDu varied significantly, including pre-selection by proteinuria, eGFR and biopsy proven interstitial nephritis. Prevalence studies have been largely conducted in the North Central Province, with recent studies demonstrating the presence of CKDu in other regions. Aetiological factors investigated in primary studies included water source, use of agrochemicals, agricultural work, heavy metals, snake bites, ayurvedic medication, heat stress, infectious diseases and usage of tobacco and betel leaf. There is no conclusive evidence for any one aetiological agent despite consistent evidence of distal factors such as male sex, rural residence and farming. CONCLUSIONS: The current body of evidence for any aetiological agent as the cause of CKDu in Sri Lanka is limited. Further research with stronger study designs is necessary to increase knowledge of aetiology of CKDu in Sri Lanka to identify and eliminate exposure to possible causative agent(s) prior to concluding that the disease is multifactorial.

Sexual Intercourse and Its Correlates Among School-aged Adolescents in Indonesia: Analysis of the 2015 Global School-based Health Survey.

OBJECTIVES: This study aimed to determine the prevalence and correlates of sexual intercourse among junior secondary and high school students in Indonesia from the 2015 Global School-based Health Survey (GSHS). METHODS: The survey was conducted among 11 110 students from 75 schools in Indonesia using a self-administered questionnaire. Univariate and multivariate analyses were conducted to explore associations between sexual intercourse and socio-demographic variables, substance use, mental distress, and protective factors. RESULTS: Overall, 5.3% of students reported having ever had sex (6.9% of boys and 3.8% of girls). Of students who engaged in sexual intercourse, 72.7% of boys and 90.3% of girls had an early sexual debut (before reaching the age of 15) and around 60% had multiple sex partners. Sexual intercourse was associated with gender, school grade, smoking, alcohol consumption, drug use, suicidal ideation, truancy, peer support, and parental supervision. CONCLUSIONS: These findings indicate a pressing need to develop more comprehensive sexual health education in the national curriculum. An effective strategy should also address other risky behaviours.

Tobacco smoking trends in Samoa over four decades: can continued globalization rectify that which it has wrought?

BACKGROUND: The island country of Samoa (population 188,000 in 2011) forms part of Polynesia in the South Pacific. Over the past several decades Samoa has experienced exceptional modernization and globalization of many sectors of society, with noncommunicable diseases (NCD) now the leading cause of morbidity and mortality. The evolution of risk factor prevalence underpinning the increase in NCDs, however, has not been well described, including tobacco smoking which is related to cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease. METHODS: The present study examines tobacco smoking in relation to different forms and effects of globalization in Samoa using 7 population-based surveys (n = 9223) over 1978-2013. RESULTS: The prevalence of daily tobacco smoking steadily decreased over 1978-2013 from 76% to 36% in men, and from 27% to 15% in women (p < 0.0001 both sexes). During 1991-2013, current tobacco smoking also steadily decreased from 64% to 40% in men (p < 0.0001), and from 21% to 17% in women (p < 0.05). Declines were similar in younger (25-44 years) and older (45-64 years) men and women. Colonial globalization facilitated the introduction and prolific spread of tobacco trade and consumption in the Pacific Islands from the sixteenth century, with many populations inexorably pulled into trade relations and links to the global economy. It has also been a different globalization which may have led to the decline in smoking prevalence in Samoa in recent decades, through global dissemination since the 1950s of information on the harmful effects of tobacco smoking derived from research studies in the USA and Europe. CONCLUSIONS: Over the past 35 years tobacco smoking has steadily declined among Samoan adults; the only NCD risk factor to demonstrate marked declines during this period. By 2013 tobacco smoking in women had decreased to levels similar to Australia and New Zealand (ANZ), however in men smoking prevalence remained more than three times higher than ANZ. The impact on smoking prevalence of the variety of tobacco control interventions that have been implemented so far in Samoa need to be evaluated in order to determine the most effective initiatives that should be prioritized and strengthened.

Differentials in Cardiovascular Risk Factors and Diabetes by Socioeconomic Status and Sex in Kalutara, Sri Lanka.

Since 1950, cardiovascular disease (CVD) has emerged as a leading cause of mortality in Sri Lanka, especially in men. In 2014, a survey in Kalutara to assess CVD and type 2 diabetes mellitus (T2DM) risk factors in adults aged 25 to 64 years (n = 1011), and associations with sex and socioeconomic status (SES), found similar CVD risk factors in both sexes, except for daily tobacco smoking at 19% in men and nil in women, and higher body mass index (BMI) in women than men. With increasing SES in men, there were significant linear increases in mean BMI, waist circumference, mean systolic and diastolic blood pressure, mean fasting plasma glucose, and T2DM prevalence, but decreases in tobacco smoking. Whereas in women higher SES was associated with a significant increase in mean BMI, but a significant decrease in hypertension prevalence. Tobacco smoking is the main risk factor explaining higher CVD mortality in men compared with women.

Declines and Plateaux in Smoking Prevalence Over Three Decades in Fiji.

OBJECTIVES: To examine trends from 1980 to 2011 in daily tobacco smoking by sex, ethnicity, age, and urban/rural in Fiji Melanesian (i-Taukei) and Indian adults aged 25-64 years. METHODS: Unit record data from five population-based surveys (n = 14 528) allowed classification of participants as: (1) never-smoker, ex-smoker, or non-daily smoker; or (2) daily smoker, reporting smoking <20 or ≥20 tobacco products (cigarettes/cigars/pipes) a day. Trends were examined using spline analyses. RESULTS: Over 1980-2011 the prevalence of reported daily tobacco smoking decreased significantly in both sexes and ethnicities, with the greatest decline during 1980-2000. Declines were from 81.7% to 27.0% in i-Taukei men; 55.3% to 26.3% in Indian men; 48.1% to 9.5% in i-Taukei women; and 13.8% to 1.3% in Indian women (p < .0001). Declines were consistent across all age groups in men, while there were greater declines among older age groups in women; and greater declines from higher prevalences in rural compared to urban areas in both sexes and ethnicities. Smoking ≥20 tobacco products per day declined significantly in i-Taukei men from 8.0% to 1.9% (p < .0001); there were also declines in Indian men (4.6% to 2.0%) and i-Taukei women (2.6% to 0.6%), but these were not statistically significant; and Indian women remained <0.2% throughout the period. CONCLUSIONS: Significant declines in daily tobacco smoking have occurred in Fiji in both sexes and ethnicities during the past 30 years, which is consistent with declines in tobacco apparent consumption and household expenditure. However, prevalence remains high in men at around 27% in 2011, with plateau at this level in i-Taukei. IMPLICATIONS: This is the first study to show nationally representative population trends in tobacco smoking in a developing country over such a long period (>30 years) based on empirical unit record data (n = 14 528). Cardiovascular disease is a leading cause of mortality throughout the Pacific Island region. This is the first study to show evidence of substantial declines over several decades in a cardiovascular disease risk factor in a Pacific Island country, and provides important evidence for further research into the interventions and events which may have facilitated this decline.

Absolute cardiovascular risk in a Fiji medical zone.

BACKGROUND: The population of Fiji has experienced emergence of non-communicable disease (NCD) and a plateau in life expectancy over the past 20 years. METHODS: A mini-STEPS survey (n = 2765) was conducted in Viseisei in Western Fiji to assess NCD risk factors (RFs) in i-Taukei (Melanesians) and those of Indian descent aged 25-64 years (response 73 %). Hypertension (HT) was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg or on medication for HT; type 2 diabetes mellitus (T2DM) as fasting plasma glucose ≥7.0 mmol/L or on medication for T2DM; and obesity as a body mass index (kilograms/height(metres)(2)) ≥30. Data were age-adjusted to 2007 Fiji Census. Associations between RFs and ethnicity/education were investigated. Comparisons with Fiji STEPS surveys were undertaken, and the absolute risk of a cardiovascular disease (CVD) event/death in 10 years was estimated from multiple RF charts. RESULTS: NCD/RFs increased with age except excessive alcohol intake and daily smoking (women) which declined. Daily smoking was higher in men 33 % (95 % confidence interval: 31-36) than women 14 % (12-116); women were more obese 40 % (37-43) than men 23 % (20-26); HT was similar in men 37 % (34-40) and women 34 % (31-36), as was T2DM in men 15 % (13-17) and women 17 % (15-19). i-Taukei men had an odds ratio (OR) of 0.41 (0.28-0.58) for T2DM compared to Indians (1.00); and i-Taukei (both sexes) had a higher OR for obesity and low fruit/vegetable intake, daily smoking, excessive alcohol intake and HT in females. Increasing education correlated with lesser smoking, but with higher obesity and lower fruit/vegetable intake. Compared to the 2011 Fiji STEPS survey, no significant differences were evident in obesity, HT or T2DM prevalences. The proportion (40-64 years) classified at high or very high risk (≥20 %) of a CVD event/death (over 10 years) based on multiple RFs was 8.3 % for men (8.1 % i-Taukei, 8.5 % Indian), and 6.7 % for women (7.9 % i-Taukei, 6.0 % Indian). CONCLUSIONS: The results of the survey highlight the need for individual and community interventions to address the high levels of NCD/RFs. Evaluation of interventions is needed in order to inform NCD control policies in Fiji and other Pacific Island nations.

Trends in Sri Lankan cause-specific adult mortality 1950-2006.

BACKGROUND: Although all-cause mortality in Sri Lanka decreased significantly from 1950 to 1970, subsequent declines have been more modest with divergent trends by age and sex. This study investigates these trends through cause of death analysis for 1950-2006 in adults aged 15-64 years. METHODS: Deaths were obtained from the World Health Organisation (WHO) mortality database for 1950 to 2003, and the Department of Census and Statistics Sri Lanka for 1992-95 and 2004-06 where WHO data was unavailable. Adult deaths were categorised by age (15-34 and 35-64 years) and sex into: infectious diseases; external-causes; circulatory diseases; cancers; digestive diseases; respiratory diseases; pregnancy-related; ill-defined; and other-causes. Cause-specific mortality rates were directly age-standardised to the 2001 Sri Lankan Census population. RESULTS: Mortality declined in females aged 15-34 years by 85% over 1950-2006, predominantly due to sharp declines in infectious disease and pregnancy-related mortality over 1950-70. Among males aged 15-34 years the mortality decline was less at 47%, due to a rise in external-cause mortality during 1970-2000. In females aged 35-64 years mortality declined by 67% over 1950-2006, predominantly due to a sharp decline in infectious disease, ill-defined and other cause mortality over 1950-70. Among males aged 35-64 years, decline in mortality is evident to 1960 (19%) from decline in infectious disease mortality, followed by increased mortality from circulatory diseases and external cause mortality, despite continued decline in infectious disease mortality. All-cause mortality in males 35-64 years has stagnated since 1970, with fluctuating increases. Circulatory diseases were the leading cause of death among adults 35-64 years in 2002-06, with the male rate almost three times higher than females. CONCLUSIONS: Significant disparities are demonstrated in Sri Lankan cause-specific adult mortality by sex and age group for 1950-2006. Female mortality progressively declined while male mortality demonstrated periods of increase and stagnation. Among males aged 15-34 years this coincides with periods of civil conflict over 1970-2000. Among males aged 35-64 years the increased mortality from non-communicable disease and external causes are the main reasons for stagnation in all-cause mortality since the 1970's.