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National Institute
for Public Health
and the Environment
Using DALYs for estimating
environmental burden of disease
in the Netherlands
RIVM – National Institute of Public Health & the Environment
IRAS – Institute of Risk Assessment Sciences, UU
Erik Lebret
The aim of the RIVM is to improve public
health and to safeguard a healthy
environment.
This is achieved by:
1. Research
2. Policy support
3. National coordination functions
4. Specific intervention programs
5. Providing targeted information on health and environment
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 2
political and research responsibilities
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 3
National Vaccin Institute
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 4
Content
• Why do burden of disease estimates?
• What is it
• How to do burden of disease estimation
• Some examples
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 5
A small poll: what causes the highest disease
burden in modern society?
• Soil pollution
• Dioxins and PCB’s in food
• Carcinogens in air
• Ambient air toxics (non-car.)
• Indoor air
• Radiation
• Non-ionising radiation
• Noise
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 6
What is the impact of environmental
pollution on disease burden?
• 0%
• 1- 5 %
• 6 - 10 %
• 10 - 20 %
• > 20 %
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 7
Why: How bad is it?
• To summarise
- Multiple sources,
- Multiple pollutants
- Multiple health endpoints
• To prioritise environmental health problems
• To optimise policy solutions
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 8
What is health?:
• ‘a state of complete physical, mental and social well-
being, and not merely the absence of disease or infirmity’
(WHO charter, 1946)
• that what the doctor can see
• ‘the ability to cope with the demands of daily life’ (the
Dunning Committee on Medical Cure and Care, 1991)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 9
Survival curves through the ages
(adapted from Wills, 1996, Ruwaard & Kramers, 1998)
1995-2000
10 0
1950-1952
1900-1909
1840-1851
80 1623-1662
6500-5300 BC
%surviving
60
40
20
20 40 60 80 10 0
A ge
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 10
Survival & health curves NL
cumulative
percentage
100 survival
curve
80
health
curve
60
40
severe health
moderate
20
mild
0
0 10 20 30 40 50 60 70 80 90 100
age
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 11
Definition of public health
‘Public health is the science and art of
preventing disease, prolonging life and
promoting health through the organised
efforts of society’ (Acheson, 1988)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 12
Dimensions of public health
• quantity of life
• quality of life
• number of people affected
• time is unit of measurement
Global Burden of Disease Project (Murray& Lopez, 1993):
DALY’s=YLL+YLD
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 13
The concept of DALYs
serious annoyance
pneumonia progressive cardio-pulmonary disease
leukaemia
disability
weight
0
population
1
10 20 30 40 50 60 70 80 age
potential healthy life years
'health' loss
National Institute
for Public Health
and the Environm ent 14
Using DALYs for estimating environmental burden of disease 3 December, 2007 14
Estimation of environmental DALYs
• estimate number of people affected
• estimate average duration of the response
• attribute severity weight to responses
• calculate annual public health loss
• uncertainty analysis (Monte Carlo)
n
DALYe.e. k [ Ik fk ( RRik , pi )] S( i ) k D( i ) k
i 1
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007
GBD-study
Disability Severity Indicator conditions
class weights
1 0.00 – 0.02 Vitigilo on face, weight-for-height less
than 2 standard deviations
2 0.02 – 0.12 Watery diarrhoea, severe sore throat,
severe anaemia
3 0.12 – 0.24 Radius fracture in a stiff cast, infertility,
erectile dysfunction, rheumatoid
arthritis, angina
4 0.24 – 0.36 Below-the-knee amputation, deafness
5 0.36 – 0.50 Rectovaginal fistula, mild mental
retardation, Down syndrome
6 0.50 – 0.70 Unipolar major depression, blindness,
paraplegia
7 0.70 – 1.00 Active psychosis, dementia, severe
migraine, quadriplegia
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 16
Presuppositions
• Prognosis must not be taken into the weighing;
• Adaptation must not be included
• Medical ‘standard’ treatment
• Weighing independent of duration
National Institute 17
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 17
EuroQol-5D+
Dimension Level Score
Mobility No problems in walking about 1
Some problems in walking about 2
Confined to bed 3
Self-care No problems with self-care 1
Some problems washing or dressing self 2
Unable to wash or dress self 3
Usual activity No problems with usual activity 1
Some problems with usual activity 2
Unable to perform usual activity 3
Pain/discomfort No pain or discomfort 1
Moderate pain or discomfort 2
Extreme pain or discomfort 3
Anxiety/ Not anxious or depressed 1
depression Moderately anxious or depressed 2
Extremely anxious or depressed 3
Cognition No mental limitations 1
Some mental limitations 2
Extreme mental limitations 3
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 18
for Public Health
National Institute
0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
0,90
1,00
and the Environm ent
Severity
Best imag. health state
Sympt upper resp tract
Basal-cell carc
Disturb neuro-cogn. Develop
Sleepdisturbance
Sev. annoyance
Squam. carcinoma without metas
Mild asthma
Sympt lower resp. tract
Mod asthma
Results weighing
Melanoma, 1 st
OMA
Health state
Squam. carc with metas
Using DALYs for estimating environmental burden of disease
GB-syndr: moderate resid sympt
Melanoma, 2 st
Sev asthma
Sev pneumo
Melanoma, 3 st
Severe COPD
3 December, 2007
Hosp admiss. cor heart dis
AML
Term disease
19
Worst imag health state
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 20
What is special in e-BoD
• Exposure oriented (exception clusters)
• Ubiquitous exposures
• Weak associations in the presence of strong
confounding
• Strong regulatory context
• Strong societal interest and pressures, if not public
outcry
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 21
Pyramid model (ATS, 1989)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 22
Two approaches to estimate DALY’s
• From health data, estimate the share of health
determinants responsible for disease burden
- Take disease-specific health statistics and have experts
estimate fractions for different determinants
• From exposure to determinants, estimate the attributable
number of people affected
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 23
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 24
Epidemiological transition….
Environmental disease burden: more vs less developed world
non-environmental disease burden (DALYs)
environmental DALYs (> 4 years)
environmental DALYs (0- 4 years)
annual loss in DALYs per 1000 capita
250 125 0 0 125 250
less developed
Acute respir. infections
Diarrhoea
Perinatal conditions
Child cluster
Cardiovascular disease
Depression
Malnutrition
Cancer
TBC
Traditional hazards Malaria
more developed
drinking water Modern hazards
household community sanitation Congenital anomalies water pollution
food contamination urban air pollution
Maternal conditions
malnutrition hazardous waste
indoor air pollution STD/HIV chemical & radiation hazards
waste disposal land degradation
natural disasters Road accidents transboundary air pollution
disease vectors climate change
Chronic respiratory disease
15 10 5 0 0 5 10 15
percentage of annual disease burden (DALYs)
non-environmental disease burden
lower estimate
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 25
Finland in WHO Environmental BoD
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 26
Finland in WHO Environmental BoD
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 27
Number of people affected
• Population exposure distribution (p)
• Defining health outcomes
• Quantifying dose response relations
Population Attributive Fraction
PAF = p(RR-1)/p(RR-1)+1
Mortality/morbidity data (B) Number of people
N = B x PAF
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 28
What input data for exposure?
• Exposure characterisation in indicators and proxies that
have the same dimensions as the exposure-response
function
- Dichotomous (no/yes)
- Distance to road, traffic intensity
- Ambient concentration
- Personal exposure
- Dose
- ?Intake fraction?
• Reference or counterfactual exposure scenario
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 29
What data for exposure-response
function
• Data from meta-analyses
• Data from systematic reviews
• Data from expert judgements
But, how to:
• Deal with mixtures and combined exposures
• Local data
• Combine epidemiological and toxicological data
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 30
What else?
• Background incidence and prevalences of relevant health
endpoints
• Estimates of the duration of the effect;
- mortality displacement
- duration of non-lethal effects (typically not studied in
environment epi. or tox. studies)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 31
for Public Health
National Institute
and the Environm ent
annual loss of DALYs
1.000.000
100
1.000
10.000
100.000
1
10
do ov
m er
es all
tic
pa ac
r ti cid
cu en
lat ts
es
lo
ng
- te
tra rm
ffi
c ac
ci
de
no n ts
ise
lea po
llu
d tio
(d n
rin
ki
ng
wa
ter
)
ET fo
od
S -b
(p or
as ne
siv
pa es
r ti m
cu ok
lat in
es g)
sh
or
t-t
er
m
in
do
or
Using DALYs for estimating environmental burden of disease
ra
do
da n
m
p
oz ho
on us
ea es
National Environmental Outlook 1999
UV ir
-A po
/U llu
V tio
-B n
(o
zo
n-
lay
er
)
PA
H
3 December, 2007
be
nz
en
ca
lar
ge e
Environmental Disease burden in the Netherlands
rc
in a cc
og id
en en
i ca ts
ir
po
llu
32
tio
n
Some trends
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 33
Trends in the EDB in the Netherlands 1980-2010
25000
DALYs per million people
20000
15000
10000
5000
0
1980
2000
2010
1980
2000
2020
1980
2000
2020
1980
2000
2020
1980
2000
2020
PM10 long- Noise Radon UV Traffic
term accidents
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 34
Policy intervention
2500
DALYs per million people
2000
1500 Road traffic
Rail traffic
1000 Air traffic
500
0
1980 2000 2020 2020; 5dB
reduction
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 35
Deaths, DALYs, and Dollars? 2003
10,000
Deaths DALYs Euro
1,000
100
10
1
m n es es m s n m
m e
ter zon t ter TS rado ous
m on m
ter zon
e t er se do t ter e
ter ous TS rad TS o u r ra on
ng o or E
or h g E or rt g E h r oz
lo sh do mp lon mp
h
o sh
o o lon m
p o
do M sh
o
PM PM in da M a ind M da in
P d PM P P
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 36
Who wants to?
• Ministry of Health
• Ministry of Environment
• Ministry of Transport
• Food and Consumer Safety Authority
• Advisory Council Dangerous Substances
• Local health authorities
• Ministry of the Interior
Me too!!
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 38
Indicators used by different stakeholders
Science Public
Policy
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 39
Risk perception
Risk perception involves people's beliefs, attitudes,
judgements and feelings
as well as
the wider social or cultural values and dispositions that
people adopt towards hazards and their benefits.
Pidgeon, et al
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 40
Risk aspects
• This risk is considered dreadful by society
• This risk is unknown to science
• Exposure to this risk is involuntary
• This risk is uncontrollable by experts
• The negative effects are unequally distributed across society
• This is a new risk, without history
• Negative effects are likely to occur
• The effects of this risk are immediate
• This risk affects a large number of people
• This risk is associated with severe effects
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 43
Perception of risk & attributes of acceptability
Overall acceptability
45% 31% 25%
text
Voluntary 53% 25% 22% Involuntary
text
Known 23% 62% 16% Unknown
text
Visible 23% 31% 46% Invisible
Controlable 32% 52% 16% Incontrolable
Reversible 63% 19% 19% Irreversible
Natural 34% 32% 34% Manmade
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 44
Disagreement on PM risk aspects
(ratings: means + CI (95%))
7 Disagreement on PTL risk aspects
6 (ratings: means + CI (95%))
7
5
6
4
5
3 4
95% CI
3
2
95% CI
1 2
N= 25 25 25 25 25 25 25 25 25 25
1
dreadful involuntary unequal occur # of people N= 25 25 25 25 25 25 25 25 25 25
dreadful involuntary unequal occur # of people
unknown uncontrollable new immediate effects
unknown uncontrollable new immediate effects
Importance weights risk aspects
(ratings: means + CI (95%))
,20
,18
,16
,14
,12
,10
,08
,06
95% CI
,04
,02
w
w
w
0,00
eig
w
eig
eig
w
w unc
eig
w o
ht
w
w
eig
eig o
ht
ht
w une l lab
eig f p
N= 25 25 25 25 25 25 25 25 25 25
eig
eig
ht
ht
ht ro
eig q l
in
#
ht eo
ht
ht
im
vo
un
ht ual
se ple
nt
m
dr
oc
lu
kn
ne
ve
ed
ea
cu
nt
ow
w
re
d
ia
ar
r
te
n
y
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 45
Attribution of clusters to environmental factors
Environmental factor Percentage
Soil pollution 45
Air pollution 22
Indoor environment 13
Electro-magnetic fields 5
Water pollution 2
Low-frequency noise 1
Other 12
(van Poll & Drijver’99)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 46
Is there a problem with EMF
from power lines? If so, how bad is it?
• There is no conclusive evidence for a causal relation
between EMF and disease at levels in the environment
• Given the uncertainty: NIMBY
• EU reference level of 100 microtesla not exceeded in NL
• In NL 23,000 houses above 0.4 microtesla
• Maximum Tolerable Risk (10-6) exceeded in NL
• In NL 0.5 extra childhood leukaemia cases, 0.15 – 0.25
• In NL there is double the leukaemia risk for children
within 0.4 microtesla area
• In NL 10-30 DALY’s
• Monetary burden 0.15, 2.5 and 15 bill. €, resp. or, 18,
126, 665 k€ per avoided house (depending on efficacy)
• Buy up all electric blankets to acquire emission rights for
power lines
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 47
What ethical decision framework?
Virtual-certainty-required a causal relation between EMF
• There is no evidence for
and disease
• Given the uncertainty : NIMBYPrecautionary principle
Rights-based
• EU reference level of 100 microtesla not exceeded in NL
• In NL 23,000 houses above 0.4 microtesla
• Maximum Tolerable Risk (10-6) exceeded in NL
Rights-based
Public health/utilitarian
• In NL 0.5 extra childhood leukaemia cases, 0.15 – 0.25
• In NL there is double the leukaemia risk for children
Equity/social justice
within 0.4 microtesla area
• In NL 10-30 DALY’s
€, resp. or,
• Monetary burden 0.15, 2.5 and 15 bill. Utilitarian 18,
126, 665 k€ per avoided house (depending on efficacy)
• Buy up all electric blankets to acquire emission rights for
National Institute
power lines
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 48
Minister of Environment
We will launch a 16 M€ research
programme on electromagenetic
fields…….
……., but we don’t think that there are
any risks involved with EMF…….
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 49
NRC Understanding risk 1996
• Getting the science right
• Getting the right science
• Getting the right participation
• Getting the participation right
• Developing accurate, balanced, and informative synthesis
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 50
IRGC Risk Governance Framework
Output: multiple panels (e.g. in
dashboard/cockpit) that summarise info
• Policy panel
- Distance to stated policy targets
- Policy deficit
• Impact panel
- Health
• Listing of effects (number and nature of effects)
• Disease burden (e.g. DALY)
- Economy
• Full cost-benefit analyses
• Impact pathway methodology
• Public acceptability panel
- Psychometric paradigm aspects
- Environmental Equity
• Appraisal panel
- (0verview table)
- Multi-criteria analyses
- CBA
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 51
Framework
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 52
Legends
Context
Variables & Appraisal
Extended Full Chain Approach
Indicators
Input and output
Causal relation Policy feedback
loop
Policy measures and scenarios
Policy interventions Participatory
Policy Policy Policy interventions Policy interventions Policy interventions
Medical advice, decision making
interventions interventions Separation of Protective gear, Separation of
secondary prevention, Consultation,
Emission reduction Stacks, treatment, functions, education, education, advise, functions, education,
medication, health stakeholder
& controls ventilation advise, incentives treatment advise, incentives
care facilities involvement
Activities/
Processes
Processes Physical
Patho- Appraisal/Ethical
Natural (decay, Dispersion & Population processes Valuation &
physicological decision framing
corrosion, etc.) and transformation behavior Dermal, inhalatory, weighing
processes Multi-criteria, risk-
antropogenic Transport, Time activity, diet, dietary uptake, Severity, value of
Pharmaco- benefit, cost-
(industry, transport, conversion product use, etc. pharmaco-kinetics, life, etc.
dynamics, etc. effectiveness, etc.
dumping, leakage, etc.
etc.)
Sources Quality of media Exposure settings Human body Social, cultural, political,
economical &
judicial settings
Soil Occupational Gender
Water Ambient Age
Air Indoor Genetic/acquired
predisposition
Emission/Release Health effects Impacts
hazardous agents Concentration Exposures Dose
Body burden, dose Patho-physiological Policy deficits, “Optimal
Source strength Load Duration & intensity response, Disease Burden,
(Gases, Solids Magnitude of contact at target organ, scenario”
Symptoms, Societal Costs,
Chemicals/ solutes etc effective dose
Morbidity, Mortality Perceptions, etc.
Energy)
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 53
Protocols & Guidelines: step-by-step
Phases in the process of an integrated assessment
Issue framing Design Execution Reporting
Consul-
tation
Initial scoping
Complexification
Interpretation
Prioritisation & Data collection
Quality criteria Communication with
screening Expert elicitation
Methods & models users & stakeholders
(simplification) Modelling & estimation
Data sources Evaluation
Alternatives Uncertainty analysis
Assessment protocols Documentation &
Indicator Testing & validation
presentation
selection
Definition of
scenarios
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 54
Issue framing and design Design and execution Execution and reporting
Pol-Def Emission
Emsta-1
Emsta-2
Emsta-a
Pol-Def concentration/
Policy Deficit quality standard Policy Deficit Index
Consta-1
Indicators Consta-2
Consta-b
Pol-Def ……
Pol-Def general aims and goals
Genaim-1
Genaim-2
Genaim-d
HIA indicator ‘number affected’
Burden of Disease
Health Impact Index
Indicators HIA Indicator ‘severity’
Weighing
Issue framing HIA Indicator …..
&
HIA Indicator 'duration’
Appraisal
EC-Co 'disease’
Economic
Economic consequence Consequence
Index
Indicators EC-Co '…….’
EC-Co 'absenteeism’
Ri-Perc ‘Voluntariness’
Perception &
Risk Perception
Ri-Perc ‘……...’ Acceptability
Indicators
Index
Ri-Perc ‘Dread’
National Institute
for Public Health
Using DALYs for estimating environmental burden of disease 3 December, 2007 55
Issue framing and indicator
and the Environm ent
Selection of methods and Aggregation and summary Weighing and appraisal of
selection estimation process indices indicators and indices
So the source-dose relation
summarised as Intake
Fraction links to a Bayesian
derived ERF to estimate
DALY’s and NUSAP What’s an What’s a What’s a
approach-based Intake Bayesian DALY or
uncertainties….. Fraction? ERF? NUSAP?
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 56
In conclusion
• E-BoD is a good indicator to summarise the variety of
health effects, e.g. to inform the policy debate
• E-BoD is only part of the equation
• E-BoD is hard to communicate
• E-BoD indicators are synthetical, cannot be directly
measured for validation, e.g. like inflation
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 57
Where are we now?
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 58
Where are we now?
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 59
Is the DALY as single metric the Holy Grail?
It depends on your ethical decision framework:
• It will work for people with a utalitarian worldview
• It will not work sufficiently for people with worldviews like:
- Libertarians
- Hierarchists
- Egalitatians
- Fatalists
National Institute
for Public Health
and the Environm ent Using DALYs for estimating environmental burden of disease 3 December, 2007 60
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