Environmental burden of disease calculation

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Environmental burden of disease calculation

This chapter provides information about methods to calculate the environmental burden of disease, and the assumptions and choices that need to be made. Table 2-1 provides an overview of these baseline assumptions underlying the calculations as performed in the EBoDE project. The remainder of this chapter describes the specific models used for calculating the EBD and explains the different parameters and data used.

TABLE 2-1. Baseline facts and assumptions underlying environmental burden of disease calculations as carried out in the EBoDE project.

Parameter of assumptions	Choise made	Motivation	Remarks
Year	2004	Most redcent year with relatively good data availability	Exposure trends were evaluated till 2010 for a qualitative policy analysis
Environmental stressors	Benzene, dioxins (including furans and dioxin-like PCBs), second-hand smoke, formaldehyde, lead, noise, ozone, particulate matter (PM) and radon
Countries	Belgium, Finland, France, Germany, Italy and the Netherlands	Integration of national projects	EBoDE working group and methodology is open for other countries
Age weighing & discounting	Main results without discounting and age-weighing; alternative results with discounting (3%) and age-weighing (standard)		Ethical reasons. Supplementary discounted and age-weighed results presented for comparability with WHO estimates
Standard Life Expectancy	80 years for men and 82.5 for women	Comparability with WHO estimates
Lag time	Calculations carried out with and without lag times	For certain diseases there is a relatively long lag between exposure and the effect. When using discounting, the lag should be accounted for	Lag times are based on author judgement and serve as rough estimates
Uncertainty analyses	Qualitative and partly quantitative	It is essential to assess whether the substantial inherent uncertainties affect the order of magnitude of the results or the ranking of stressors	Data availability and limited resources allowed only for qualitative approach. Additional quantitative analyses are recommended as a part of follow-up research

Basic calculation of the environmental burden of disease

The DALY measures health gaps (i.e. years of life lost due to death or disability) as opposed to health expectancies. It measures the difference between a current situation and an ideal or alternative situation. The DALY combines the time lived with disability and the time lost due to premature mortality in one measure:

DALY = YLL + YLD

where: YLL = Years of Life Lost due to premature mortality. YLD = Years Lost due to Disability.

Years of Life Lost (YLL) in a case of individual death is calculated as the difference between the standard life expectancy at the age of death and the actual age at death. When population data is tabulated for age categories, YLL can be calculated as:

L = LE (agedeath, gender) -agedeath The basic formula for calculating the population-wide YLL is: YLL = N x L

where: LE(age,gender) = life-expectancy at age of death, accounting for gender agedeath = age at death N = number of deaths in a given age category L = remaining years to standard life expectancy at age of death (in years).

Methods for calculating YLL are further described in section Years of Life Lost, co-morbidity and multi-causality

To estimate the Years Lost due to Disability (YLD), the number of disability cases is multiplied by the average duration of the disease and a disability weight (see further discussion below). The basic formula is:

YLD = n x DW x L

where: YLD = Years Lost due to Disability n = number of incident cases. DW = disability weight. L = average duration of disability (years)

The formulas above describe undiscounted, non-weighted DALYs. DALYs are sometimes attributed a discounting rate, and weightings according to age, in which case the formulas become more complex. These so-called social preferences are discussed in section 2.3.

Disability weights

(DW) Disability weights are used to make different health effects with varying degrees of severity comparable. They are weight factors that reflect the severity of the disease on a scale from 0 (perfect health) to 1 (equivalent to death). These factors have been determined in expert panels using standardized surveys.

Duration estimates

(L) Besides disability weights, estimates of DALYs for morbidity (Years Lost due to Disability – YLD) also take into account the duration of the disease derived from health statistics, registries, expert judgments, etc. In some cases, prevalence data are used in burden of disease calculations instead of incidence data. In that case, the duration of disease is set to 1 year in the calculation, assuming a steady-state situation in which prevalence equals incidence times duration. For mortality, the duration estimate equals the YLL (Yers of life lost).

Relative Risk, Unit Risk and Odds Ratio

Relative risk models to estimate the environmental burden of disease

Unit risk models to estimate the environmental burden of disease

Models for estimating the environmental burden of disease

The general methodology for the environmental burden of disease calculations as carried out in EBoDE follows the Comparative Risk Assessment Approach (Ezzati et al., 2002; Prüss-Üstün et al. 2003). In general, information about population exposure, an exposure response function and (in some cases) background incidence data are needed in order to estimate the environmental burden of disease (EBD). In EBoDE, three different methods for deriving the EBD are used. They are presented in Figures 2-1a and 2-1b (methods 1A, 2A and 2B). Model 1B is not used in EBoDE, but complements the other three methods. The methods differ in how they derive the population attributable fraction (using a unit risk (UR) or a relative risk (RR) – see Textbox 1), and in whether burden of disease figures are derived from the WHO database or estimated using disability weights (DW) and duration factors (L).

• Model 1A is the primary model used in EBoDE. Exposure data and a relative risk derived from epidemiological data are used to derive the population attributable fraction (PAF). This fraction is applied to the burden of disease figures as given in the WHO global burden of disease database.
• In model 2A, the PAF is derived indirectly. The unit risk and exposure information are used to estimate the attributable incidence (AI). The PAF is indirectly estimated from dividing the total incidence by this AI. Subsequently, the PAF is applied to the WHO burden of disease data for both YLL and YLD.
• In model 2B, the AI is derived similarly as in model 2A. However, for the factors for which this approach has been used, no appropriate burden of disease data were available from WHO and the EBD was calculated by multiplying the estimated number of attributable cases with WHO disability weights (DW) and corresponding estimates of duration (L).
• Model 1B, which was not used in EBoDE, could be used when the PAF is derived using a RR risk, and the EBD is calculated using disability weights (DW) and estimates of duration (L).

The conceptual basis of the different methods is the same. Which exact method is chosen for a specific calculation mainly depends on the available data. In principle, these different means should come to the same end. If one would use all different approaches for the same calculation, they would ideally result in the same number. However, in reality it is hardly ever possible to perform all these different calculations because of unavailability of data. Even if possible, the different methods will rarely result in the same number. This stresses the importance of interpreting burden of disease figures as crude ranges and not as absolute infallible numbers. More information about uncertainty is presented in Uncertainty analysis.

Years of Life Lost, co-morbidity and multi-causality

DALY calculations for mortality outcomes include an estimate of the Years of Life Lost, i.e. the number of years a person would have continued to live, had this person not died due to the environmental exposure. In the WHO Global Burden of Disease programme and in the current work a standard life expectancy, defined as a population with highest known life-expectancy, is used. This ensures that all populations globally are treated equally when addressing the disease burden. However, in the current context where the focus is set on specific environmental causes of burden of disease, it can be argued that if all environmental causes of burden of disease were removed, the population in question still would not reach this optimal life expectancy. This is due to the fact that all factors affecting the population health (including also genetic factors, lifestyle, the health care system, etc.) contribute to the national life expectancy. Thus it could be argued that a national life expectancy should be used in estimating the impacts of given single factors. This difference in approaches is highlighted in Figure 2-2. In the EBoDE project we have chosen to use the standard life expectancy in order to allow for better comparison between countries.Figure 2-2. Estimating the years of life lost due to lung cancer.