Mberu Blessing, Wamukoya Marylene, Oti Samuel, Kyobutungi Catherine
African Population and Health Research Center, APHRC Campus, Kirawa Road, off Peponi Road,, 10787-00100,, Nairobi, Kenya,
J Urban Health. 2015 Jun;92(3):422-45. doi: 10.1007/s11524-015-9943-6.
What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3% of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6% in 2003 to 8.1% in 2012, and peaking at 13.7% in 2005 and at 12.0% in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15-19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73% of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66% in 2003 to 53% in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5% in 2003 to 21.3% in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11% in 2003 to 22% in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.
在绘制全球疾病负担时，了解世界各地导致人们死亡的因素以及这些因素如何随地点和时间而变化至关重要，因此这是一个相关的公共卫生问题，在发展中国家尤为如此。虽然全球超过三分之二的死亡发生在发展中国家，但对于这些国家的死因却知之甚少。在许多情况下，根本不存在生命登记系统，或者充其量只是初步的，而且即使进行了死亡登记，也缺乏特定当地背景下的死因数据，而这是改善针对具体情况的公共卫生的重要一步。在本文中，我们通过将InterVA - 4软件应用于死因推断数据，研究了内罗毕两个非正式定居点城市贫困人口的死因趋势。我们研究了2003年1月1日至2012年12月31日在内罗毕城市卫生和人口监测系统（NUHDSS）中15岁及以上居民的2646例死因推断死亡数据。这些数据被输入到InterVA - 4计算机程序中，该程序使用概率模型确定死因。结果呈现为2003年至2012年的年度化趋势，并按性别和年龄进行分类。在这10年期间，三大主要死因是结核病（TB）、伤害和艾滋病毒/艾滋病，分别占所有死亡人数的26.9%、20.9%和17.3%。2003年，艾滋病毒/艾滋病是最高死因，其次是结核病，然后是伤害。然而，到2012年，结核病和伤害已超过艾滋病毒/艾滋病成为主要死因。按性别审视时，在所有年份中，女性的艾滋病毒/艾滋病死亡率总体上一直高于男性，通常比例为2比1。就结核病而言，男性和女性在各年份的分布更为均匀。我们发现与伤害相关的死亡存在显著的性别差异，男性死亡人数比女性死亡人数高出约4比1。我们还发现2003年至2012年期间男性因伤害导致的死亡发生率增加了15个百分点。对于女性，在此期间因伤害导致的相应死亡人数保持相当稳定。我们发现心血管疾病在此期间是一个重要死因，总体死亡率从2003年的1.6%稳步上升至2012年的8.1%，在2005年达到峰值13.7%，在2009年达到12.0%。这些死亡在女性中一直更高。我们发现不同年龄段的死因存在显著差异，结核病、艾滋病毒/艾滋病和心血管疾病死亡在年轻居民中最低，并随年龄增长而增加，而与伤害相关的死亡在最年轻的成年人（15 - 19岁）中最高，并随年龄稳步下降。此外，与肿瘤和呼吸道感染（RTIs）相关的死亡在50岁及以上的老年人中尤为突出，特别是自2005年以来。在这个阶段出现的证据表明，在过去10年中，艾滋病毒/艾滋病、结核病、伤害和心血管疾病与内罗毕科罗戈乔和维万达尼贫民窟城市贫困人口中约73%的成人死亡有关。虽然与艾滋病毒/艾滋病相关的死亡率总体上在下降，但我们看到结核病、伤害和心血管疾病导致的死亡比例在增加。总之，在这个当地背景下正在发生重大的流行病学转变，与传染病相关的死亡从2003年的66%下降到2012年的53%，而非传染病导致的死亡从2003年的5%增加了四倍至2012年的21.3%，同时由于外部原因（伤害）导致的死亡又增加了两倍，从2003年的11%增加到2012年的22%。同样重要的是要强调在这种混合情况中明显可见的流行病学转变的性别层面。最后，在我们的分析中，贫民窟居民相对于肯尼亚其他人口亚组的不利程度较高，这继续表明关键城市卫生和社会指标明显恶化，突出了在政策和计划努力中为实现国际目标以及国家卫生和发展目标而对城市贫困人口的健康需求进行有意识战略关注的必要性。
