Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity

Abstract

Background: The South-East Asia region (SEAR) accounts for one-quarter of the world's population, 40% of the global poor and ∼30% of the global disease burden, with a disproportionately large share of tuberculosis (35%), injuries (30%), maternal (33%) and <5-year-old mortality (30%). In this article, we describe the disease burden and status of epidemiological research and capacity in the SEAR to understand, analyse and develop capacity in response to the diverse burdens of diseases in the region.

Methods: Data on morbidity, mortality, risk factors, social determinants, research capacity, health education, workforce and systems in the SEAR were obtained using global data on burden of disease, peer-reviewed journals, World Health Organization (WHO) technical and advisory reports, and where available, validated country reports and key informants from the region.

Results: SEAR countries are afflicted with a triple burden of disease-infectious diseases, non-communicable diseases and injuries. Of the seven WHO regions, SEAR countries account for the highest proportion of global mortality (26%) and due to relatively younger ages at death, the second highest percentage of total years of life lost (30%). The SEAR exceeds the global average annual mortality rate for all three broad cause groupings-communicable, maternal, perinatal and nutritional conditions (334 vs 230 per 100 000); non-communicable diseases (676 vs 573 per 100 000); and injuries (101 vs 78 per 100 000). Poverty, education and other social determinants of health are strongly linked to inequities in health among SEAR countries and within socio-economic subgroups. India, Thailand and Bangladesh produce two-thirds of epidemiology publications in the region. Significant efforts to increase health workforce capacity, research and training have been undertaken in the region, yet considerable heterogeneity in resources and capacity remains.

Conclusions: Health systems, statistics and surveillance programmes must respond to the demographic, economic and epidemiological transitions that define the current disease burden and risk profile of SEAR populations. Inequities in health must be critically analysed, documented and addressed through multi-sectoral approaches. There is a critical need to improve public health intelligence by building epidemiological capacity in the region.

Figure 1

Age-standardized mortality rates for CDs, NCDs and injuries in SEAR countries compared with averages for the world and high-income countries. Source: World Health Statistics 2011, WHO

Figure 2

Trends in infant and <5-year-old mortality rates among 11 SEAR countries from 1990–2009 for meeting MDG 4. Source: World Health Statistics 2011, WHO

Figure 3

Prevalence^a of selected risk factors comparing SEAR countries to the global averages. Source: Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks, Geneva World Health Organization 2009. ^aEstimates are for the population most relevant to the risk factor—alcohol, physical inactivity are for ages 15+ years; blood pressure, cholesterol, overweight and fruits and vegetables are for ages 30+ years; iron, vitamin A and underweight are for <5 years and females 15–44 years for lack of contraception. Many risk factors were characterized at multiple levels—here they are collapsed to show exposure or no exposure, or a selected level, or means or prevalence exceeding a commonly used threshold. ^bPrevalence of stunting defined as height for age >2 years standard deviations below the WHO reference standard for children aged 0–4 years. ^cIron deficiency anaemia defined in terms of blood haemoglobin level. ^dPrevalences were estimated based on the percentage of children <5 years old living in areas classified as vitamin A deficient based on population survey data for low plasma or tissue retinol levels and xerophthalmia, with information on coverage of vitamin A supplementation programmes. ^eNot exclusively breastfed to 6 months (%). ^fFor persons aged ≥30 years, systolic blood pressure ≥140 mmHg (%) ^gFor persons aged ≥30 years, 1 mmol/l = 38.7 mg/dl; 6 mmol/l = 232 mg/dl. ^hFor persons aged ≥30 years, 5.55 mmol/l = 100 mg/dl; 7 mmol/l = 125 mg/dl. ⁱFor persons aged ≥30 years. Body mass index (BMI) is defined as weight (kg) divided by height (m) squared. ^jPersons aged ≥30 years, less than 5 servings per day (%). ^kPersons aged ≥15 yrs, inactive (%). ^lPersons aged ≥15 years. ^mPersons aged ≥15 years. Average serving assumed to correspond to 80 g. ⁿProportion of women who want to prevent or space conception and are not using modern contraceptive methods. ^oProportion of the population with improved or regulated water supply. ^pProportion of the population with improved sanitation coverage or full sewage treatment. ^qConcentration of particles less 10 µm (µg/m³). ^rProportion using biofuel

Figure 4

Health inequities in SEAR: births attended by skilled health personnel in SEAR countries according to geographical residence, wealth and mother’s education (higher ratios and steeper slopes indicate greater health inequities). Source: World Health Statistics 2011, WHO

Figure 5

Epidemiological published literature for 11 member countries of the SEAR