Come evolve la salute delle popolazioni?

Introduzione alla teoria della transizione epidemiologica

Carlo Mamo Servizio sovrazonale di Epidemiologia, ASL TO3

Journal Club25 gennaio 2012, Grugliasco

Riflessioni di partenza

W. RicciardiPiù vicini o più lontani, una storia di successo per la sanitàpubblica italiana nel contesto europeo?Congresso AIE 2011

W. Ricciardi, AG. de Belvis, M. Marino, A. Santoro, A. SilenziLo sviluppo disuguale della sanità nell’Italia che si avvia al federalismo.Epidemiol Prev 2011; 35 (5-6), settembre-dicembre. Suppl. 2

70

75

80

85

1970 1980 1990 2000 2010 2020

DenmarkFinlandFranceGermanyItalyNorwaySpainSwedenUnited KingdomEuropean Region

Life expectancy at birth, in years

Migliora lo stato di salute delle popolazioni occidentali

Crescita economica nell’Unione Europea

(Fonte: OECD, 2011)

Crescita di servizi sanitari nell’Unione Europea

0

100

200

300

400

500

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Dea

ths

per 1

00.0

00

DIGINF

TUM

CARD + CER

ACC

EMS

RESP

1407

Italia: tassi di mortalità per grandi cause

(S. De Flora, 2005)

Come si modifica il profilo epidemiologico

Si evidenziano disuguaglianze geograficheUn indice riassuntivo di cronicità nell’Indagine

Multiscopo Istat sulla salute del 2005

peggiore

migliore

(Cislaghi et al, 2009)(Cislaghi et al, 2009)

Prevalenza obesiPrevalenza obesi. Italia, 2007

(Fonte: Health for All - Istat)

Uomini Donne

Gradienti geografici nei fattori di rischio

Diabete: prevalenze per regione Italia, 2005

Uomini Donne

(Mamo et al, 2010)

Gradienti geografici nelle malattie croniche

0.0

0.5

1.0

1.5

2.0

Nord-Ovest Nord-Est Centro Sud Isole ITALIA

Medio Basso

0.0

0.5

1.0

1.5

2.0

Nord-Ovest Nord-Est Centro Sud Isole ITALIA

Diabete: prevalenze per livello di istruzioneItalia, 2005

Uomini

Donne

(Mamo et al, 2010)

Gradienti sociali nelle malattie croniche

Diabete: tassi di ospedalizzazione Italia, 2005

Uomini Donne

(Mamo et al, 2010)

Gradienti geografici nella gestione dei pazienti

Le diseguaglianze si accentuano in tutta Europa...

1

1. 2

1. 4

1. 6

1. 8

2

2. 2

Fi nl a ndi a Nor v e gi a Da ni ma r c a Tor i no

1981-85 1991-95

RR mortalità basso vs alto livello di istruzione, uomini

(Mackenbach et al, 2003)

1

1 . 2

1 . 4

1 . 6

1 . 8

Fi nl andi a Nor vegi a Dani mar ca T or i no

1981-85 1991-95

…soprattutto nelle donne

RR mortalità basso vs alto livello di istruzione, donne

(Mackenbach et al, 2003)

<= 85<= 81<= 77<= 73<= 69No data

Min = 65

European Region75.24

Disuguaglianze ovest-est Europa: attesa di vita alla nascita

(Fonte: Health for All - Europa)

Omran AR.Changing patterns of health and disease during the processof national development.Chapter 5 in: Albrecht GL, Higgins PC (eds.). Health, illness

and medicine: a reader in medical sociology. Chicago, Rand McNally, 1979

Graziella Caselli, France Meslé and Jacques Vallin.Epidemiologic transition theory exceptions. Genus: Journal of Population Sciences 9: 9–51. 2002

Teorie sull’evoluzione dei quadri epidemiologici:la transizione per fasi socio-economiche

Comprehensive, organized health services; curative and preventive;Rigorous sanitary measures;Screening for certain diseases;Widespread measures to prevent infectious diseases (pesticide use, immunization);Health system improvements.

Improving nutrition & rising living standards;Sanitary revolution begins.Quarantine more strictly enforced;antiseptic practice makes operations possible;Immunization invented;Organized health services.

Health Care Systems: Indigenous systems; traditional healers;Isolation & quarantine only effective therapies against infectious disease;No immunization;No environmental sanitation.

Morbidity overshadows mortality as the main issue;Chronic disease, mental illness, man-made diseases, pollution rise in importance;Infectious disease mainly in certain pockets of population;Geriatric problems;Electrical or chemical hazards become main occupational health dangers;Rising costs of medical care.

Epidemics & famines somewhat reduced in frequency;People live long enough for heart disease & cancer;Infection & parasitism somewhat reduced;Occupational health problems rise;Sanitation begins to improve;Accidents at home & industry.

Frequent epidemics; famines;Endemic infections & parasitic diseases;Chronic malnutrition;Maternal & child health problems;Serious environmental health problems: unsafe water, fecal waste contamination, insects & rodents, poor housing.

Age of degenerative diseases

Age of receding pandemics

Age of pestilence & famine

Progressive aging of the population as fertility declines and more people (especially females) survive to old age. Male:Female ratio decreases.Increasing old age dependency ratio.Urban residence; rapid growth of cities and alarming formation of slums, environmental pollution, with social & political problems.

Population still young, but proportion of older people begins to increase.Male to female ration near unity, but improved female health leads to excess of females.Exodus from farm to factory. Migration to new colonies relieves population pressures in some countries, but upsets age-sex composition.

Predominantly young.Large young, and small old dependency ratios.Slight excess of males.Mainly rural, but a few crowded, unsanitary, epidemic ridden cities.

Population composition

Mortality declines rapidly to < 20 per 1,000; then decline slows.Fertility falls below 20 per 1,000 (but occasional rises, as after 1945).Population growth small but persistent.

Mortality continues high but peaks less frequent and general level begins to decline to about 30 per 1,000.Fertility remains high until several decades after mortality declines.Population growth explosive

Pattern of cyclic growth until about 1650.Mortality dominates, with crude death rates between 30-50*1,000.Fertility high, at 40+ per 1,000 population

Population growth

Age of degenerative diseases

Age of receding pandemics

Age of pestilence & famine

Scientific expertise & technology produce rise in productivity.High mass consumption. Welfare spending rises.

Improvements in agriculture, Development of transportation and communication networks encourage industrialization. New economic sectors

Subsistence economies; agrarian societies and manual cultivation.Labour with debilitating diseases

Economic profile

People conscious of nutrition, especially for women and children.Tendency to overnutrition

Crop rotation improve availability of food.Women & children still at nutritional disadvantage.

Food for the masses is of poor quality; Chronic shortages; children and women most affected.

Nutrition

Progressive rises in living standards by large segments of population.

Standards still quite low, but hygiene and sanitation improve, except in city slums

Standards are low; unsanitary conditions;comforts & luxuries limited

Living standards

Nuclear families and small family size. Women emancipated and better educated

Extended family systems in rural areas. Nuclear families common in urban centres.Women begin involvement outside home

Clan or extended family structures; home centered lifestyles.Women in mother role with few responsibilities

Family & Women

Rational, purposive lifestyles prevail.Bureaucracy & depersonalization.

Emerging middle classes develop faith in reason.Rising expectations.

Traditional societyrigid social structuresSociety

Age of degenerative diseases

Age of receding pandemics

Age of pestilence & famine

Cosa prevede la teoria: riequilibrio finale tra mortalità e natalità

Attesa di vita: convergenze nord-sud e divergenze sud-sud

AIDS + crisi economica

Incremento in attesa di vita per periodi

La seconda fase di Omran in Africa non è ancora finita

Esplosione demografica

Contrazione demografica

Attesa di vita e trend demografici

Attesa di vita in Africa

Proiezioni dell’attesa di vita nei paesi più colpiti da AIDS

(United Nations, 2001)

Proiezioni dell’attesa di vita nelle regioni africane

(United Nations, 2001)

L’eccezione dell’Europa orientalealla teoria di Omran

Incremento di malattie cardiovascolari e man-made diseases

in Europa orientale

Europa orientale:attesa di vita nei maschi

Europa orientale:attesa di vita nelle femmine

Trend di mortalità per cause cardiovascolari in Europa

CAUSE DALY

Cardiovascular disease 34.760.019

Ischaemic heart disease 16.825.931

Neuropsychiatric conditions 28.932.409Depressive disorders 8.446.229

Alcohol use disorders 4.999.976

Malignant neoplasms 17.085.911Trachea, bronchus, lung cancers 3.264.161

Colon and rectum cancers 1.894.627

Breast cancer 1.737.542

Unintentional injuries 14.544.921Road traffic accidents 3.677.947

Cause di morte e disabilità. Europa, 2004 (fonte: WHO)

Priorità europee per le politiche sanitarie?

CAUSE % su totale Europa

% su totale Italia

Ischaemic heart disease 10.5 6.6

Cerebrovascular disease 7.2 5.7

Depressive disorders 6.2 6.8

Alcohol use disorders 3.1 3.4

Hearing loss, adult onset 2.6 4.0

Road traffic accidents 2.4 2.7

Lung cancer 2.2 3.5

Osteoarthritis 2.1 2.6

Alzheimer and dementia 2.0 4.5

Diabetes mellitus 1.5 3.7

GRAZIE!

carlo.mamo@epi.piemonte.it