The cost of premature death from cancer attributable to alcohol: Productivity losses in Europe in 2018

BackgroundMore than 1.9 million people die from cancer each year in Europe. Alcohol use is a major modifiable risk factor for cancer and poses an economic burden on society. We estimated the cost of productivity lost due to premature death (under 65 years of age) from alcohol-attributable cancer in the European Union (EU) plus Iceland, Norway, Switzerland, and the United Kingdom (UK) in 2018.MethodsWe estimated cancer deaths attributable to alcohol using a Levin-based population attributable fractions method and cancer deaths in 2018 from the Global Cancer Observatory. Lost productivity was estimated for all alcohol-attributable cancer deaths by sex, cancer site, and country. Productivity losses were valued using the human capital approach.ResultsAn estimated 23,300 cancer deaths among people aged less than 65 in the EU plus Iceland, Norway, Switzerland and the UK in 2018 were attributable to alcohol (18,200 males, 5100 females). This equated to €4.58 billion in total productivity losses in the region and 0.027 % of the European Gross Domestic Product (GDP). The average cost per alcohol-attributable cancer death was €196,000. Productivity lost to alcohol-attributable cancer per capita was highest in Western Europe. Hungary, Romania, Slovakia, Latvia, Lithuania, and Portugal had the highest rate of premature mortality from alcohol-attributable cancer and the highest productivity lost as a share of national GDP.ConclusionOur study provides estimates of lost productivity from alcohol-attributable cancer death in Europe. Cost-effective strategies to prevent alcohol-attributable cancer deaths could result in economic benefits for society and must be prioritised.     

Economic valuation of air pollution mortality: A 9-country contingent valuation survey of value of a life year (VOLY)

This paper provides a key element for the calculation of the damage costs of air pollution, namely the valuation of mortality, important because premature mortality makes by far the largest contribution. Whereas several studies have tried to quantify the cost of air pollution mortality by multiplying a number of deaths by the ‘value of prevented fatality’ (also known as ‘value of statistical life’), we explain why such an approach is not correct and why one needs to evaluate the change in life expectancy due to air pollution. Therefore, an estimate for the monetary value of a life year (VOLY) is needed. The most appropriate method for determining VOLY is contingent valuation (CV). To determine VOLY for the EU, we have conducted a CV survey in 9 European countries: France, Spain, UK, Denmark, Germany, Switzerland, Czech Republic, Hungary, and Poland with a total sample size of 1463 persons. Based on the results from this 9-country CV survey we recommend a VOLY estimate of 40,000 € for cost–benefit analysis of air pollution policies for the European Union. As for confidence intervals, we argue that VOLY is at least 25,000 € and at the most 100,000 €.     

Evaluation of a proposed breast cancer screening regimen.

The Forrest working group on breast cancer screening recommended routine mammography for women in the United Kingdom at ages 50, 53, 56, 59, 62, and 65. Benefits were costed at about 3000 pounds for each life year recovered, but there was no estimate of the cost of each life saved, and the consequent reduction in mortality from breast cancer in the general population of the United Kingdom was not estimated. The present study addressed both of these issues using an interactive computer modelling process. Long term savings were calculated at 900 deaths a year in England and Wales--that is, about 8% of the total deaths from breast cancer--and 9% of life years currently lost. The cost of each death saved from breast cancer was estimated at 39,000 pounds.     

Economic impact of a nationwide outbreak of salmonellosis: cost-benefit of early intervention.

The recognition and investigation of an outbreak of food poisoning in 1982 due to chocolate contaminated with Salmonella napoli enabled the food that carried the salmonella to be identified and four fifths of the implicated consignment of chocolate to be withdrawn. The economic benefits of prompt intervention in the outbreak have been assessed. The cost of the outbreak was over 0.5 pounds m. It is estimated that five deaths were prevented by the intervention and that 185 admissions to hospital and 29,000 cases of S napoli enteritis were avoided. This successful investigation yielded a 3.5-fold rate of return to the public sector and a 23.3-fold return to society on an investment in public health surveillance. A methodology is described that can be used to estimate the benefits of early intervention in outbreaks of foodborne illness and topics for further research are suggested. It is concluded that public health authorities and industry have much to gain by collaborating in the research into the design of cost effective programmes to prevent foodborne infections.     

Weight Loss and Premature Death: The 1946 British Birth Cohort Study

Objective

The relationship between weight loss and mortality has important clinical and public health significance but has proved to be complex. Evidence is mixed and particularly limited on the association between weight loss in mid-life and premature death (i.e. before 65 years of age), a small albeit important segment of total mortality. We aimed to study the association between midlife weight change and mortality accounting for health and lifestyle characteristics, and also considering potential bias due to preexisting chronic diseases and smoking status.

Design

Longitudinal, population-based, ‘the 1946 British’ birth cohort study.

Subjects and Measures

In 2750 men and women, mortality from age 53 through 65 years was analyzed according to categories of measured 10 year weight change between 43 and 53 years. Cox''s hazard ratios (HR) were progressively adjusted for socio-demographic, lifestyle and health characteristics.

Results

Nearly 20% of participants lost weight and over 50% gained 5 kg or more in midlife. There were 164 deaths. Compared to those who gained between 2 and 5 kg, those who lost 5 kg or more had an increased risk of premature death independently of midlife physical activity, socio-economic circumstances and educational attainment. This association was unaltered when highest weight loss (lost more than 15 Kg) (p = 0.04) and early deaths were excluded (p<0.001), but was no longer significant after adjustment for cardiovascular risk factors and health status (HR = 1.8; 95% CI: 0.9 to 3.5).

Conclusion

The inverse association between weight loss in midlife and higher risk of premature death may be explained by vascular risk factors and ill health. In consideration of the burden of premature death, closer monitoring of weight loss in mid-life is warranted.     

Years of potential life lost caused by prostate cancer deaths in the United States—Projection from 2004 through 2050

BackgroundThe purpose of this study is to estimate and project the number of years of potential life lost (YPLL) among males who die of prostate cancer in the United States from 2004 through 2050 and compare the projections by race/ethnicity and age, accounting for demographic changes and population growth.MethodsWe applied the life expectancy method to estimate YPLL caused by deaths of prostate cancer and all cancers in men by using 1999–2004 national mortality data, 2008 census population demographic projections, and 2004 U.S. life tables. We performed sensitivity analyses by varying death rate and population projections, and examined increase in YPLL from population growth, changes in demographics, and death rates.ResultsThe number of YPLL caused by prostate cancer deaths was projected to increase by 226.1%, from 291,853 in 2004 to 951,753 in 2050. Hispanics were projected to have the fastest growth in YPLL (977.1% from 2004 to 2050) caused by prostate cancer, followed by non-Hispanic blacks (543.1%), and non-Hispanic others (269.7%). People aged 75 or older was projected to account for 62.0% of YPLL from prostate cancer in 2050 compared with 50.8% in 2004. Of the projected increase in YPLL caused by prostate cancer deaths by 2050, 9.8% were due to changes in demographic composition, 26.8% because of mortality change, and 63.4% because of population growth.ConclusionsYPLL due to prostate cancer deaths are projected to increase dramatically, and become a greater burden in the future. The projections highlight the importance of comprehensive cancer control and research on cancers including prostate cancer and racial/ethnic-specific estimates.     

LCA of Multicrystalline Silicon Photovoltaic Systems - Part 2: Application on an Island Economy (8 pp)

- Part 1: Present Situation and Future Perspectives Part 2: Application on an Island Economy Goal, Scope and Background In the first part of this paper, we developed a methodology to incorporate exposure and risk concepts into life cycle impact assessment (LCIA). We argued that both risk assessment and LCIA are needed to consider the impacts of increasing insulation for single-family homes in the US from current practice to the levels recommended by the 2000 International Energy Conservation Codes. In this analysis, we apply our model to the insulation case study and evaluate the benefits and costs of increased insulation for new housing. Results and Discussion The central estimate of impacts from the complete insulation manufacturing supply chain is approximately 17 premature deaths, 470 asthma attacks, and 8.100 restricted activity days nationwide for one year of increased fiberglass output. Of the health impacts associated with increased insulation manufacturing, 83% are attributable to the supply chain emissions from the mineral wool industry, which is mostly associated with the direct primary PM2.5 emissions from the industry (98%). Reduced energy consumption leads to 1.3 premature deaths, 36 asthma attacks, and 610 restricted activity days avoided per year, indicating a public health 'payback period' on the order of 13 years. Almost 90% of these benefits were associated with direct emissions from power plants and residential combustion sources. In total, the net present value of economic benefits over a 50-year period for a single-year cohort of new homes is $240 million with a 5% discount rate, with 49 fewer premature deaths in this period. Conclusion Recommendation and Outlook. We have developed and applied a risk-based model to quantify the public health costs and benefits of increased insulation in new single-family homes in the US, demonstrating positive net economic and public health benefits within the lifetimes of the homes. More broadly, we demonstrated that it is feasible to incorporate exposure and risk concepts into I-O LCA, relying on regression-based intake fractions followed by more refined dispersion modeling. The refinement step is recommended especially if primary PM2.5 is an important source of exposure and if stack heights are relatively low. Where secondary PM2.5 is more important, use of regression-based intake fractions would be sufficient for a reasonable risk approximation. Uncertainties in our risk-based model should be carefully considered; nevertheless, our study can help decision-makers evaluate the costs and benefits of demand-side management policy options from a combined public health and life cycle perspective.     

A Risk-Based Approach to Health Impact Assessment for Input-Output Analysis, Part 2: Case Study of Insulation (8 pp)

Goal, Scope and Background In the first part of this paper, we developed a methodology to incorporate exposure and risk concepts into life cycle impact assessment (LCIA). We argued that both risk assessment and LCIA are needed to consider the impacts of increasing insulation for single-family homes in the US from current practice to the levels recommended by the 2000 International Energy Conservation Codes. In this analysis, we apply our model to the insulation case study and evaluate the benefits and costs of increased insulation for new housing. Results and Discussion The central estimate of impacts from the complete insulation manufacturing supply chain is approximately 14 premature deaths, 400 asthma attacks, and 7000 restricted activity days nationwide for one year of increased fiberglass output. Of the health impacts associated with increased insulation manufacturing, 83% is attributable to the supply chain emissions from the mineral wool industry, which is mostly associated with the direct primary PM2.5 emissions from the industry (98%). Reduced energy consumption leads to 1.2 premature deaths, 33 asthma attacks, and 600 restricted activity days avoided per year, indicating a public health “payback period” on the order of 11 years. Over 90% of these benefits were associated with direct emissions from power plants and residential combustion sources. In total, the net present value of economic benefits over a 50-year period for a single-year cohort of new homes is $190 million with a 5% discount rate, with 49 fewer premature deaths in this period. Conclusion Recommendation and Outlook. We have developed and applied a risk-based model to quantify the public health costs and benefits of increased insulation in new single-family homes in the US, demonstrating positive net economic and public health benefits within the lifetimes of the homes. More broadly, we demonstrated that it is feasible to incorporate exposure and risk concepts into I-O LCA, relying on regression-based intake fractions followed by more refined dispersion modeling. The refinement step is recommended especially if primary PM2.5 is an important source of exposure and if stack heights are relatively low. Where secondary PM2.5 is more important, use of regression-based intake fractions would be sufficient for a reasonable risk approximation. Uncertainties in our risk-based model should be carefully considered; nevertheless, our study can help decision-makers evaluate the costs and benefits of demand-side management policy options from a combined public health and life cycle perspective.     

The Impact of Dietary and Metabolic Risk Factors on Cardiovascular Diseases and Type 2 Diabetes Mortality in Brazil

Background

Trends in food availability and metabolic risk factors in Brazil suggest a shift toward unhealthy dietary patterns and increased cardiometabolic disease risk, yet little is known about the impact of dietary and metabolic risk factors on cardiometabolic mortality in Brazil.

Methods

Based on data from Global Burden of Disease (GBD) Study, we used comparative risk assessment to estimate the burden of 11 dietary and 4 metabolic risk factors on mortality due to cardiovascular diseases and diabetes in Brazil in 2010. Information on national diets and metabolic risks were obtained from the Brazilian Household Budget Survey, the Food and Agriculture Organization database, and large observational studies including Brazilian adults. Relative risks for each risk factor were obtained from meta-analyses of randomized trials or prospective cohort studies; and disease-specific mortality from the GBD 2010 database. We quantified uncertainty using probabilistic simulation analyses, incorporating uncertainty in dietary and metabolic data and relative risks by age and sex. Robustness of findings was evaluated by sensitivity to varying feasible optimal levels of each risk factor.

Results

In 2010, high systolic blood pressure (SBP) and suboptimal diet were the largest contributors to cardiometabolic deaths in Brazil, responsible for 214,263 deaths (95% uncertainty interval [UI]: 195,073 to 233,936) and 202,949 deaths (95% UI: 194,322 to 211,747), respectively. Among individual dietary factors, low intakes of fruits and whole grains and high intakes of sodium were the largest contributors to cardiometabolic deaths. For premature cardiometabolic deaths (before age 70 years, representing 40% of cardiometabolic deaths), the leading risk factors were suboptimal diet (104,169 deaths; 95% UI: 99,964 to 108,002), high SBP (98,923 deaths; 95%UI: 92,912 to 104,609) and high body-mass index (BMI) (42,643 deaths; 95%UI: 40,161 to 45,111).

Conclusion

suboptimal diet, high SBP, and high BMI are major causes of cardiometabolic death in Brazil, informing priorities for policy initiatives.     

The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol,tobacco and illicit drug use in Canada

BACKGROUND: In 1996 the number of deaths and admissions to hospital in Canada that could be attributed to the use of alcohol, tobacco and illicit drugs were estimated from 1992 data. In this paper we update these estimates to the year 1995. METHODS: On the basis of pooled estimates of relative risk, etiologic fractions were calculated by age, sex and province for 90 causes of disease or death attributable to alcohol, tobacco or illicit drugs; the etiologic fractions were then applied to national mortality and morbidity data for 1995 to estimate the number of deaths and admissions to hospital attributable to substance abuse. RESULTS: In 1995, 6507 deaths and 82,014 admissions to hospital were attributed to alcohol, 34,728 deaths and 194,072 admissions to hospital were attributed to tobacco, and 805 deaths and 6940 admissions to hospital were due to illicit drugs. INTERPRETATION: The use and misuse of alcohol, tobacco and illicit drugs accounted for 20.0% of deaths, 22.2% of years of potential life lost and 9.4% of admissions to hospital in Canada in 1995.     

Cost of mental and behavioural disorders in Kenya

BACKGROUND: The health and economic impact of mental and behavioural disorders (MBD) is wide-ranging, long-lasting and large. Unfortunately, unlike in developed countries where studies on the economic burden of MBD exist, there is a dearth of such studies in the African Region of the World Health Organization. Yet, a great need for such information exists for use in sensitizing policy-makers in governments and civil society about the magnitude and complexity of the economic burden of MBD. The purpose of this study was to answer the following question: From the societal perspective (specifically the families and the Ministry of Health), what is the total cost of MBD patients admitted to various public hospitals in Kenya? METHODS: Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health care system and the family in directly addressing the problem of MBD; and (b) the indirect costs, i.e. loss of productivity caused by MBD, which is borne by the individual, the family or the employer. The study was based on Kenyan public hospitals, either dedicated to care of MBD patients or with a MBD ward. RESULTS: The study revealed that: (i) in the financial year 1998/99, the Kenyan economy lost approximately US$13,350,840 due to institutionalized MBD patients; (ii) the total economic cost of MBD per admission was US$2,351; (iii) the unit cost of operating and organizing psychiatric services per admission was US$1,848; (iv) the out-of-pocket expenses borne by patients and their families per admission was US$51; and (v) the productivity loss per admission was US$453. CONCLUSIONS: There is an urgent need for research in all African countries to determine: national-level epidemiological burden of MBD, measured in terms of the prevalence, incidence, mortality, and, probably, the disability-adjusted life-years lost; and the economic burden of MBD, broken down by different productive and social sectors and occupations of patients and relatives.     

Effect of changing mortality on the working life of American men and women, 1970–1990

Abstract

The mortality patterns of men and women of working age, in terms of the major causes of death, have changed over the past three decades. This study assesses the extent to which mortality among persons of working age represents an economic loss to society. This economic loss is measured by the per capita loss of productive working life, defined as the number of years, on the average, a person can expect to be an active member of the labor force. Causes of death affecting primarily older Americans (heart disease, cancer, stroke) had a relatively small and declining impact on the working lives of men and women. Major causes of death affecting the young (motor vehicle accidents, homicide, AIDS), although accounting for fewer deaths, were responsible for many more years of lost productivity. Gender and socioeconomic differentials in mortality suggest that different strategies are necessary for future reductions in lost work‐years.     

Estimate of Venous Thromboembolism and Related-Deaths Attributable to the Use of Combined Oral Contraceptives in France

Purpose

To estimate the number of venous thromboembolic events and related-premature mortality (including immediate in-hospital lethality) attributable to the use of combined oral contraceptives in women aged 15 to 49 years-old between 2000 and 2011 in France.

Methods

French data on sales of combined oral contraceptives and on contraception behaviours from two national surveys conducted in 2000 and 2010 were combined to estimate the number of exposed women according to contraceptives generation and age. Absolute risk of first time venous thromboembolism in non-users of hormonal contraception and increased risk of thromboembolism in users vs. non-users of hormonal contraception were estimated on the basis of literature data. Finally, immediate in-hospital lethality due to pulmonary embolism and premature mortality due to recurrent venous thromboembolism were estimated from the French national database of hospitalisation and literature data.

Results

In France, more than four million women are daily exposed to combined oral contraceptives. The mean annual number of venous thromboembolic events attributable to their use was 2,529 (778 associated to the use of first- and second-generation contraceptives and 1,751 to the use of third- and fourth-generation contraceptives), corresponding to 20 premature deaths (six with first- and second-generation contraceptives and fourteen with third- and fourth-generation contraceptives), of which there were eight to nine immediate in-hospital deaths. As compared to the use of first- and second-generation contraceptives, exposure to third- and fourth-generation contraceptives led to a mean annual excess of 1,167 venous thromboembolic events and nine premature deaths (including three immediate in-hospital deaths).

Conclusions

Corrective actions should be considered to limit exposure to third- and fourth-generation contraceptives, and thus optimise the benefit-risk ratio of combined oral contraception.     

Abridged life tables for Pakistan based on the 1971 Population Growth Survey

A new set of abridged life tables for Pakistan is presented. Data from the 1971 Population Growth Survey were 1st analyzed to estimate the degree of completeness of the reporting of male and female deaths; female deaths were substantially more underreported than male deaths. Age-sex specific mortality schedules were adjusted accordingly. Life expectancy was around 50 years at birth, but increased by 8-9 years for those surviving the substantial risks of dying in the 1st year of life. No significant sex differential in mortality could be discerned from the life tables. The present life tables exhibit mortality levels which are very similar to those observed in the life tables based on the 1962-64 Population Growth Estimation data. The only exception in the present life tables is the lack of a significant improvement in female mortality beyond the reproductive ages possibly because the extent of underreporting of femal deaths found in the 1971 Population Growth Survey was substantially higher than that for males.     

Years of Life Lost Due to External Causes of Death in the Lodz Province,Poland

Background

The aim of the study is the analysis of years of life lost due to external causes of death, particularly due to traffic accidents and suicides.

Materials and Methods

The study material includes a database containing information gathered from 376,281 death certificates of inhabitants of the Lodz province who died between 1999 and 2010. The Lodz province is characterized by the highest mortality rates in Poland. The SEYLL_p (Standard Expected Years of Life Lost per living person) and the SEYLL_d (per death) indices were used to determine years of life lost. Joinpoint models were used to analyze time trends.

Results

In 2010, deaths due to external causes constituted 6.0% of the total number of deaths. The standardized death rate (SDR) due to external causes was 110.0 per 100,000 males and was five times higher than for females (22.0 per 100,000 females). In 2010, the SEYLL_p due to external causes was 3746 per 100,000 males and 721 per 100,000 females. Among males, suicides and traffic accidents were the most common causes of death (the values of the SEYLL_p were: 1098 years and 887 years per 100,000 people, respectively). Among females, the SEYLL_p values were 183 years due to traffic accidents and 143 years due to suicides (per 100,000 people).

Conclusions

A decrease in the number of years of life lost due to external causes is much higher among females. The authors observe that a growing number of suicides contribute to an increase in the value of the SEYLL_p index. This directly contributes to over-mortality of males due to external causes. The analysis of the years of life lost focuses on the social and economic aspects of premature mortality due to external causes.     

Premature Mortality in the Kingdom of Saudi Arabia Associated with Particulate Matter Air Pollution from the 1991 Gulf War

The State of Kuwait oil fires and military operations associated with the 1991 Gulf War resulted in substantially increased levels of airborne particulate matter (PM) in the Kingdom of Saudi Arabia (KSA) during 1991 and 1992. Using quantitative risk assessment methodology, this article estimates the increase in premature deaths in citizens of the KSA associated with the Gulf War–related increase in PM air pollution levels. Meta-analysis of daily time-series studies of non-accidental mortality associated with increased PM₁₀ levels using two alternative methodologies yielded exposure-response relative risk functions of 2.7% and 3.5% per 50 μ g/m³ increase in PM₁₀ concentration. Combining these exposure-response functions with estimates of the magnitude and duration of the increased PM₁₀ exposure, the size of the exposed population and baseline mortality rates provided an estimate of approximately 1,080 to 1,370 excess non-accidental deaths of Saudi citizens during 1991–1992 associated with the Gulf War–related increase in PM levels.     

The effects of prorating risk in the development of life‐tables

This study used computer models to investigate two different strategies for assessing risk in the development of age‐based life‐tables from studbook data sets. One methodology is similar to that currently employed in American Zoo and Aquarium Association population management, which prorates animals at risk within age‐classes. The other follows the method used in human life‐tables that assumes animals are at risk for the entire age‐class. This study concludes that prorating risk may invalidate population growth projections by significantly and unequally over‐estimating fecundity and mortality rates. This effect is most pronounced in species that have distinct breeding seasons (birth pulse populations), seasonal mortality, and small data sets. Recommendations include using a non‐prorated methodology, tabulating life‐tables using only completely known age‐class data, and combining population parameters for emigrations, releases, and deaths for population growth projections. Zoo Biol 20:279–291, 2001. © 2001 Wiley‐Liss, Inc.     

The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths

Background

Envenoming resulting from snakebites is an important public health problem in many tropical and subtropical countries. Few attempts have been made to quantify the burden, and recent estimates all suffer from the lack of an objective and reproducible methodology. In an attempt to provide an accurate, up-to-date estimate of the scale of the global problem, we developed a new method to estimate the disease burden due to snakebites.

Methods and Findings

The global estimates were based on regional estimates that were, in turn, derived from data available for countries within a defined region. Three main strategies were used to obtain primary data: electronic searching for publications on snakebite, extraction of relevant country-specific mortality data from databases maintained by United Nations organizations, and identification of grey literature by discussion with key informants. Countries were grouped into 21 distinct geographic regions that are as epidemiologically homogenous as possible, in line with the Global Burden of Disease 2005 study (Global Burden Project of the World Bank). Incidence rates for envenoming were extracted from publications and used to estimate the number of envenomings for individual countries; if no data were available for a particular country, the lowest incidence rate within a neighbouring country was used. Where death registration data were reliable, reported deaths from snakebite were used; in other countries, deaths were estimated on the basis of observed mortality rates and the at-risk population. We estimate that, globally, at least 421,000 envenomings and 20,000 deaths occur each year due to snakebite. These figures may be as high as 1,841,000 envenomings and 94,000 deaths. Based on the fact that envenoming occurs in about one in every four snakebites, between 1.2 million and 5.5 million snakebites could occur annually.

Conclusions

Snakebites cause considerable morbidity and mortality worldwide. The highest burden exists in South Asia, Southeast Asia, and sub-Saharan Africa.     

Burden of Chagas disease in Brazil, 1990–2016: findings from the Global Burden of Disease Study 2016

Chagas disease continues to be an important cause of morbidity, mortality and disability in several Latin American countries, including Brazil. Using findings from the Global Burden of Disease Study 2016 (GBD, 2016), we present years of life lost, years lived with disability, and disability-adjusted life years due to Chagas disease in Brazil, by sex, age group, and Brazilian states, from 1990 to 2016. Results are reported in absolute numbers and age-standardized rates (per 100,000 population) with 95% uncertainty intervals. In 2016, 141,640 disability-adjusted life years (95% uncertainty intervals: 129,065–155,941) due to Chagas disease were estimated in Brazil, with a relative reduction of 36.7% compared with 1990 (223,879 disability-adjusted life years (95% uncertainty intervals: 209,372–238,591)). Age-standardized disability-adjusted life year rates declined at the national level (?69.7%) and in all Brazilian states between 1990 and 2016, but with different regional patterns. The decrease in the disability-adjusted life year rates was driven primarily by a consistent reduction in the years of life lost rates, the main component of total disability-adjusted life years for Chagas disease. The highest fatal and non-fatal burden due to Chagas disease was observed among males, the elderly, and in those Brazilian states encompassing important endemic areas for vector transmission in the past. Despite the consistent reduction in its burden during the period, Chagas disease is still an important and neglected cause of health lost due to premature mortality and disability in Brazil. Efforts should be made to maintain the political interest and sustainability of surveillance and control actions for Chagas disease, prevent the risk of re-emergence of vector transmission in endemic areas, and provide health care to chronically infected individuals, including early diagnosis and treatment interventions.     

Costs associated with gunshot wounds in Canada in 1991.

OBJECTIVE: To estimate the costs (in 1993 dollars) associated with gunshot wounds in Canada in 1991. DESIGN: Cost analysis using separate estimates of gunshot incidence rates and costs per incident for victims who died, those who survived and were admitted to hospital and those who survived and were treated and released from emergency departments. Estimates were based on costs for medical care, mental health care, public services (i.e., police investigation), productivity losses, funeral expenses, and individual and family pain, suffering and lost quality of life. SETTING: Canada. OUTCOME MEASURES: Costs per case, costs by type of incident (e.g., assault, suicide or unintentional shooting) and costs per capita. RESULTS: The total estimated cost associated with gunshot wounds was $6.6 billion. Of this, approximately $63 million was spent on medical and mental health care and $10 million on public services. Productivity losses exceeded $1.5 billion. The remaining cost represented the value attributed to pain, suffering and lost quality of life. Suicides and attempted suicides accounted for the bulk of the costs ($4.7 billion); homicides and assaults were the next most costly ($1.1 billion). The cost per survivor admitted to hospital was approximately $300,000; this amount included just over $29,000 for medical and mental health care. CONCLUSION: Costs associated with gunshot wounds were $235 per capita in Canada in 1991, as compared with $595 in the United States in 1992. The differences in these costs may be due to differences in gun availability in the two countries. This suggests that increased gun control may reduce Canada''s costs, especially those related to suicide.