BANGLADESH: Chronic Illnesses Main Cause Of Death in Rural Aged

DHAKA, (The New Nation), November 11, 2007: As the population of Bangladesh ages, greater numbers of people are likely to be living with chronic illnesses. We assessed population-based data on prevalence of chronic disease and causes of death from two rural sub districts in Bangladesh. Overall, 73% of those surveyed in Mirsarai and 44% in Abhoynagar reported being diagnosed with at least one chronic condition. Arthritis (37%) and hypertension (27%) were the most common chronic conditions reported. Verbal autopsy data show that at least 42% of all deaths in these areas in this age group were due to chronic conditions. In contrast, hospitalizations of persons aged over 60 in the upazila health complexes were rare. In order to improve the lives of older people in Bangladesh, the national health system should allocate resources and design strategies to prevent and treat chronic disease. The age structure of Bangladesh's population is changing markedly. Rapid fertility declines in the 1980s have decreased the proportion of young persons, and reductions in child mortality have increased life expectancy from 44 years in 1975 to 60 years in 2001. The population aged over 60 years currently represents about 7% of the 140 million population of Bangladesh and is projected to represent 16% of the total population by 2050. As the older population grows, the prevalence of chronic disease is also likely to grow. Understanding the burden of chronic disease in Bangladesh will guide the design of strategies to prevent chronic illness and provide health care to increasingly larger numbers of older people with chronic conditions. In order to asses the burden of chronic disease in people over 60 years of age in Bangladesh, we examined the prevalence of chronic disease and causes of hospitalization and death in this age group using data from Mirsarai Upazila of Chittagong District and in Abhoynagar Upazila of Jessore District. To assess the prevalence of chronic illness we surveyed persons aged over 60 currently enrolled in ICDDR,B's surveillance sites in Mirsarai and Abhoynagar. In these two sites, demographic events, marriage, pregnancies, births, deaths and migration are routinely collected. All people aged over 60 years in the households were listed and then divided into three age groups, 60-69, 70-79, and over 80. Two hundred and fifty males and 250 females from each of these age groups were randomly selected from the populations of each surveillance site for inclusion in the survey. From July to October 2005 respondents were asked to report having ever been medically diagnosed with selected chronic diseases. We obtained data on causes of hospitalization for persons aged over 60 years from 2002 to 2005 from the Bangladesh government's statistics from Mirsarai and Abhoynagar upazila health complexes. Data on causes of death were also obtained from the government system at these two facilities from 2002 to 2005. Cause of death data from verbal autopsies carried out at the Mirsarai and Abhoynagar surveillance sites from 2000 to 2003 were also examined. Two public health physicians following the 9th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-9) assigned causes of death from verbal autopsies. Surveillance data on causes of death from 2004 to 2005 were not included because of the revision in data collection methods since 2004. A total of 1515 people over age 60 enrolled in surveillance in Mirsarai and Abhoynagar, out of the 3000 selected for the study, were surveyed. We were unable to survey all persons selected for the study due to resource constraints. The proportion of participants from each age group included in the survey was similar to the proportion of that age group in the population under surveillance. The majority of respondents lived with extended families. Although life expectancy for men and women in Bangladesh is similar, many more women than men had experienced the loss of a spouse. Smoking was commonly reported by male respondents. Overall, 73% of those surveyed in Mirsarai and 44% in Abhoynagar reported being diagnosed with at least one chronic condition; prevalence varied by sex. Participants most frequently reported being diagnosed with arthritis (54% in Mirsarai, 17% in Abhoynagar) and hypertension (32% in Mirsarai, 20% in Abhoynagar). Women in Mirsarai reported the highest rates of chronic disease (82%). From 2002 to 2005, 988 persons aged over 60 years were admitted to the Upazila Health Complex in Mirsarai, representing 5% of total hospitalizations for that time period. The majority were males (57%) and 21% of hospitalizations were due to chronic disease complaints, including hypertension and lung and heart problems. During the same time period, 1,554 people aged over 60 were admitted in Abhoynagar, representing 7% of all hospitalizations at that facility. The majority (66%) were also males and 38% of those hospitalizations were due to chronic disease complaints. Verbal autopsy data from the Mirsarai and Abhoynagar surveillance sites showed that at least 42% of all deaths in persons aged over 60 from 2000-2003 were due to chronic conditions. Cardiovascular diseases (26%), senility (22%), respiratory diseases (15%), malignancy (7%) and neurological conditions (6%) were the most common causes of death in people aged over 60 years during this time period. It is quite likely that many deaths categorized here as respiratory disease and senility were also caused by chronic conditions. There were 67 deaths among people over age 60 years at the upazila health complexes in Mirsarai and Abhoynager combined from 2000-2005. Cardiovascular diseases (33), bronchial asthma (19), and cerebrovascular accidents (10) accounted for almost all deaths. Evidence from Mirsarai and Abhoynagar suggests that chronic illness is common in persons aged over 60 in Bangladesh. This population-based survey found that 73% of persons aged over 60 were living with at least one chronic disease complaint in Mirsarai and 44% were doing so in Abhoynagar. It is unclear why differences in disease prevalence existed between the two sites surveyed and between males and females; however, other studies have also observed higher proportions of females with chronic illness than men. Estimated prevalences reported here and in other studies from Bangladesh based on reported illness are likely to be underestimates given that they are based on participant reports and that this population traditionally has poor access to regular medical care necessary to diagnose chronic illnesses. Studies conducted with similar populations in neighbouring India, which included a physician diagnosis, report that nearly all persons aged over 60 surveyed were living with some morbidity. Further studies, including physician exams, are required to accurately document the prevalence of chronic disease in Bangladesh. Causes of death from verbal autopsies showed that at least 42% of all deaths in ICDDR,B's surveillance sites in Mirsarai and Abhoynagar are due to chronic conditions. Deaths reported as respiratory illness and senility were also likely caused by chronic disease. Future reports might be better able to categorize deaths due to chronic disease because the definition used for senility was revised in 2004, based on the 10th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Almost all deaths recorded at the health complexes in these two upazilas were attributed to chronic disease. Our ability to compare causes of death between verbal autopsy data and data from the health complexes is limited due to differences in definitions of cause of death and the extremely small numbers of deaths that occurred in the health complexes. Hospitalizations of persons over the age of 60 accounted for only 5% of all hospitalizations in Mirsarai and 7% in Abhoynagar. Despite the fact that most deaths at these facilities in people over 60 are attributed to chronic illness, hospitalizations for this age group for chronic illness were rare. Another study from Bangladesh found similarly low proportions of hospital admissions from this age group. This could be explained in a number of ways. It is possible that these people are receiving treatment elsewhere since upazila health complexes usually do not have the resources to treat chronic conditions. Another possibility is that these people simply are not seeking care for their illnesses, either because they do not have the resources to do so or because they are unaware of their condition and the need to seek treatment. Anecdotal evidence suggests that community members are reticent to seek care for older members of the family. While conducting the survey for this study, interviewers were often requested by younger adults in the household to collect information on the health of younger family members instead. They said, "What is the use of collecting such data for older people, as no intervention is likely to bring them back to a normal life. It is better to keep him/her with the family and leave them alone to perform rituals as long as they survive". As Bangladesh's population ages, increasing numbers of people will be living with chronic conditions. The Government of Bangladesh is committed to sustainable improvements in health, nutrition and family welfare especially for vulnerable groups such as the elderly. These commitments are outlined in the Health, Nutrition and Population Sector Programme (2003-2010) and the national Strategy for Accelerated Poverty Reduction. Given evidence of the current burden of chronic disease and the predictions for growing numbers of people with chronic illness, the government should work to increase resources for diagnosis and treatment of these conditions and initiate strategies, such as lifestyle change, for preventing them. One step could be to discourage smoking, a common habit among men found in this study and others in Bangladesh. The future holds many challenges for Bangladesh's health care system, which will have to cope with high rates of infectious disease and increasing rates of chronic disease. Further studies to generate more accurate estimates of the chronic disease burden and track trends will assist the government in facing this challenge.