Come evolve la salute delle popolazioni? Introduzione alla teoria della transizione epidemiologica - Carlo Mamo - Dors
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Journal Club
25 gennaio 2012, Grugliasco
Come evolve la salute
delle popolazioni?
Introduzione alla teoria
della transizione epidemiologica
Carlo Mamo
Servizio sovrazonale di Epidemiologia, ASL TO3
Riflessioni di partenza W. Ricciardi Più vicini o più lontani, una storia di successo per la sanità pubblica italiana nel contesto europeo? Congresso AIE 2011 W. Ricciardi, AG. de Belvis, M. Marino, A. Santoro, A. Silenzi Lo sviluppo disuguale della sanità nell’Italia che si avvia al federalismo. Epidemiol Prev 2011; 35 (5-6), settembre-dicembre. Suppl. 2
Migliora lo stato di salute delle popolazioni occidentali
Life expectancy at birth, in years
85
80
Denmark
Finland
France
Germany
Italy
Norway
Spain
Sweden
United Kingdom
European Region
75
70
1970 1980 1990 2000 2010 2020Crescita economica nell’Unione Europea
(Fonte: OECD, 2011)Crescita di servizi sanitari nell’Unione Europea
Come si modifica il profilo epidemiologico
Italia: tassi di mortalità per grandi cause
1407
500
CARD + CER
Deaths per 100.000
400
300 TUM
200
100 RESP ACC
DIG
INF EMS
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
(S. De Flora, 2005)Si evidenziano disuguaglianze geografiche
Un indice riassuntivo di cronicità nell’Indagine
Multiscopo Istat sulla salute del 2005
migliore
peggiore
(Cislaghi et al, 2009)Gradienti geografici nei fattori di rischio
Prevalenza obesi.
obesi Italia, 2007
Uomini Donne
(Fonte: Health for All - Istat)Gradienti geografici nelle malattie croniche
Diabete: prevalenze per regione
Italia, 2005
Uomini Donne
(Mamo et al, 2010)Gradienti sociali nelle malattie croniche
Diabete: prevalenze per livello di istruzione
Italia, 2005
2.0
1.5
1.0
Uomini
0.5
0.0
Nord-Ovest Nord-Est Centro Sud Isole ITALIA
2.0
Donne
1.5
1.0
0.5
0.0
Nord-Ovest Nord-Est Centro Sud Isole ITALIA
Medio Basso
(Mamo et al, 2010)Gradienti geografici nella gestione dei pazienti
Diabete: tassi di ospedalizzazione
Italia, 2005
Uomini Donne
(Mamo et al, 2010)Le diseguaglianze si accentuano in tutta Europa...
RR mortalità basso vs alto livello di istruzione, uomini
2. 2
2
1. 8
1. 6
1. 4
1. 2
1
Fi nl a ndi a N or v e gi a Da ni ma r c a Tor i no
1981-85 1991-95
(Mackenbach et al, 2003)…soprattutto nelle donne
RR mortalità basso vs alto livello di istruzione, donne
1. 8
1. 6
1. 4
1. 2
1
Fi nl andi a Nor vegi a Dani mar ca T or i no
1981-85 1991-95
(Mackenbach et al, 2003)Disuguaglianze ovest-est Europa:
attesa di vita alla nascitaTeorie sull’evoluzione dei quadri epidemiologici:
la transizione per fasi socio-economiche
Omran AR.
Changing patterns of health and disease during the process
of 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. 2002Age of pestilence Age of receding Age of degenerative
& famine pandemics diseases
Morbidity overshadows mortality
Frequent epidemics; famines; Epidemics & famines somewhat as the main issue;
Endemic infections & parasitic reduced in frequency; Chronic disease, mental illness,
diseases; People live long enough for man-made diseases, pollution
Chronic malnutrition; heart disease & cancer; rise in importance;
Maternal & child health Infection & parasitism Infectious disease mainly in
problems; somewhat reduced; certain pockets of population;
Serious environmental health Occupational health problems Geriatric problems;
problems: unsafe water, fecal rise; Electrical or chemical hazards
waste contamination, insects & Sanitation begins to improve; become main occupational
rodents, poor housing. Accidents at home & industry. health dangers;
Rising costs of medical care.
Improving nutrition & rising Comprehensive, organized
Health Care Systems:
living standards; health services; curative and
Indigenous systems; traditional
Sanitary revolution begins. preventive;
healers;
Quarantine more strictly Rigorous sanitary measures;
Isolation & quarantine only
enforced; Screening for certain diseases;
effective therapies against
antiseptic practice makes Widespread measures to
infectious disease;
operations possible; prevent infectious diseases
No immunization;
Immunization invented; (pesticide use, immunization);
No environmental sanitation.
Organized health services. Health system improvements.Age of pestilence Age of receding Age of degenerative
& famine pandemics diseases
Mortality continues high but
Mortality declines rapidly to <
Pattern of cyclic growth peaks less frequent and
20 per 1,000; then decline
until about 1650. general level begins to
slows.
Mortality dominates, decline to about 30 per
Population Fertility falls below 20 per
with crude death rates 1,000.
growth 1,000 (but occasional rises,
between 30-50*1,000. Fertility remains high until
as after 1945).
Fertility high, at 40+ several decades after
Population growth small but
per 1,000 population mortality declines.
persistent.
Population growth explosive
Progressive aging of the
Population still young, but population as fertility
proportion of older people declines and more people
begins to increase. (especially females) survive
Predominantly young.
Male to female ration near to old age.
Large young, and small
unity, but improved female Male:Female ratio
old dependency ratios.
Population health leads to excess of decreases.
Slight excess of males.
composition females. Increasing old age
Mainly rural, but a few
Exodus from farm to factory. dependency ratio.
crowded, unsanitary,
Migration to new colonies Urban residence; rapid
epidemic ridden cities.
relieves population pressures growth of cities and alarming
in some countries, but upsets formation of slums,
age-sex composition. environmental pollution, with
social & political problems.Age of pestilence Age of receding Age of degenerative
& famine pandemics diseases
Rational, purposive
Emerging middle classes
Traditional society lifestyles prevail.
Society develop faith in reason.
rigid social structures Bureaucracy &
Rising expectations.
depersonalization.
Extended family systems in
Clan or extended family
rural areas. Nuclear families and
structures;
Family Nuclear families common in small family size.
home centered lifestyles.
& Women urban centres. Women emancipated
Women in mother role with
Women begin involvement and better educated
few responsibilities
outside home
Standards are low; Standards still quite low, but Progressive rises in
Living
unsanitary conditions; hygiene and sanitation improve, living standards by large
standards
comforts & luxuries limited except in city slums segments of population.
Food for the masses is of People conscious of
Crop rotation improve
poor quality; nutrition, especially for
availability of food.
Nutrition Chronic shortages; women and children.
Women & children still at
children and women most Tendency to
nutritional disadvantage.
affected. overnutrition
Subsistence economies; Improvements in agriculture, Scientific expertise &
agrarian societies and Development of transportation technology produce rise
Economic
manual cultivation. and communication networks in productivity.
profile
Labour with debilitating encourage industrialization. High mass consumption.
diseases New economic sectors Welfare spending rises.Cosa prevede la teoria: riequilibrio finale tra mortalità e natalità
Attesa di vita: convergenze nord-sud
e divergenze sud-sud
AIDS + crisi economicaIncremento in attesa di vita per periodi
La seconda fase di Omran
in Africa non è ancora finitaAttesa di vita e trend demografici
Esplosione demografica
Contrazione demograficaAttesa 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 orientale
alla teoria di Omran
Incremento di
malattie cardiovascolari
e man-made diseases
in Europa orientaleEuropa orientale: attesa di vita nei maschi
Europa orientale: attesa di vita nelle femmine
Trend di mortalità per cause cardiovascolari in Europa
Priorità europee per le politiche sanitarie?
Cause di morte e disabilità. Europa, 2004 (fonte: WHO)
CAUSE DALY
Cardiovascular disease 34.760.019
Ischaemic heart disease 16.825.931
Neuropsychiatric conditions 28.932.409
Depressive disorders 8.446.229
Alcohol use disorders 4.999.976
Malignant neoplasms 17.085.911
Trachea, bronchus, lung cancers 3.264.161
Colon and rectum cancers 1.894.627
Breast cancer 1.737.542
Unintentional injuries 14.544.921
Road traffic accidents 3.677.947% su totale % su totale
CAUSE
Europa 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 3.7GRAZIE! carlo.mamo@epi.piemonte.it
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