introduction neuro disorders public h challenges

Neurological disorders: public health challenges describes and discusses the increasing global public health importance of common neurological disorders such as dementia, epilepsy, he

ISBN 92 4 156336 2

Neurological disorders are common and represent a

major public health problem For example, 50 million

people have epilepsy It is projected that the number

of people affected by dementia will double every 20

years.

Neurological disorders and some of the other

con-ditions with neurological impairments and sequelae

constitute over 6% of the global burden of disease

This burden is especially high in many low and middle

income countries.

Neurological disorders: public health challenges

describes and discusses the increasing global public

health importance of common neurological disorders

such as dementia, epilepsy, headache disorders,

mul-tiple sclerosis, neuroinfections, neurological disorders

associated with malnutrition, pain associated with

neurological disorders, Parkinson’s disease, stroke

and traumatic brain injuries The document provides

the public health perspective for these disorders and

presents fresh and updated estimates and predictions

of the global burden borne by them.

This report provides information and advice on

public health interventions that may be applied to

re-duce the occurrence and consequences of

neurologi-cal disorders It offers health professionals and

plan-ners the opportunity to assess the burden caused by

these disorders in their country and to take

appropri-ate action.

RECOMMENDATIONS FOR ACTION

Commitment from decision makers is the

fi rst essential step to decrease the burden caused by neurological disorders.

Societal and professional awareness of pub-lic health aspects of neurological disorders needs to be raised through global and local campaigns and initiatives.

Innovative strategies to address the associ-ated stigma and discrimination needs to be part of the public health activities for neuro-logical disorders.

The most promising approach for reducing the burden of these disorders is to strengthen neurological care within the existing health systems.

Rehabilitation needs to complement the other key strategies for neurological care such as promotion, prevention and treatment.

Defi ning the priorities for research, building national capacity and intensifying interna-tional collaboration are some of the impor-tant ways for bringing about the changes that people with neurological disorders need.

The above recommendations need to be imple-mented across a wide range of sectors and dis-ciplines appropriately adapted to local condi-tions and capacities.

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A clear message emerges from this report:

unless immediate action is taken globally,

the neurological burden is likely to become an

even more serious threat to public health.

DISORDERS

public health challenges

WHO Library Cataloguing-in-Publication Data

Neurological disorders : public health challenges

1.Nervous system diseases 2.Public health 3.Cost of illness I.World Health Organization

ISBN 92 4 156336 2 (NLM classifi cation: WL 140)

ISBN 978 92 4 156336 9

© World Health Organization 2006

All rights reserved Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int) Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int)

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement

The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication However, the published material is being distributed without warranty of any kind, either expressed or implied The responsibility for the interpretation and use of the material lies with the reader In no event shall the World Health Organization be liable for damages arising from its use

Printed in Switzerland

Foreword v Preface vii Acknowledgements ix Abbreviations xi Introduction 1

Chapter 1

Public health principles and neurological disorders 7

Chapter 2

Global burden of neurological disorders:

Chapter 3

3.1 Dementia 42 3.2 Epilepsy 56 3.3 Headache disorders 70 3.4 Multiple sclerosis 85 3.5 Neuroinfections 95 3.6 Neurological disorders associated with malnutrition 111 3.7 Pain associated with neurological disorders 127 3.8 Parkinson’s disease 140 3.9 Stroke 151 3.10 Traumatic brain injuries 164

Chapter 4

Annexes

Annex 1

List of WHO Member States by region and mortality stratum 183

Annex 2

Country income groups used for reporting estimates and projections 185

Annex 3

Global Burden of Disease cause categories, sequelae and case defi nitions for neurological disorders 186

Neurological disorders: public health challenges

iv

Annex 4

Table A.4.1 Burden of neurological disorders, in DALYs, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030 189

Table A.4.2 Burden of neurological disorders, in DALYs, by cause and country income category, projections for 2005, 2015 and 2030 193

Table A.4.3 Deaths attributable to neurological disorders, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030 194

Table A.4.4 Deaths attributable to neurological disorders, by cause and country income category, projections for 2005, 2015 and 2030 198

Table A.4.5 Burden of neurological disorders, in YLDs, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030 199

Table A.4.6 Burden of neurological disorders, in YLDs, by cause and country income category, projections for 2005, 2015 and 2030 203

Table A.4.7 Prevalence (per 1 000) of neurological disorders, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030 204

Table A.4.8 Prevalence (per 1 000) of neurological disorders, by cause and country income category, projections for 2005, 2015 and 2030 208

Annex 5

International nongovernmental organizations working

in neurological disorders 209

In the 19th century and at the beginning of the 20th, brain research belonged to many different areas that dif-fered in methodology and targets: the morphological, the physiological and the psychological The latter used to consider the brain as a black box where only the input and output were known but not at all the neuronal com-ponents and the way they interact with each other

At the beginning of the third millennium, due to pro-longed ageing, neurodevelopmental disorders are growing and a much deeper knowledge of the brain is necessary Scientifi c and technological research, from molecular to behavioural levels, have been carried out in many different places but they have not been developed in a really interdisciplinary way

Research should be based on the convergence of different interconnected scientifi c sectors, not in isolation, as was the case in the past

As this report demonstrates, the burden of neurological disorders is reach-ing a signifi cant proportion in countries with a growreach-ing percentage of the population over 65 years old

With this report go my best wishes that it be disseminated worldwide and that it receive the deserved attention of the Global Health Community in all the countries of the world

Rita Levi-Montalcini

1986 Nobel Prize in Medicine

Within its remit to provide leadership on all matters concerning health, one of the core

functions of the World Health Organization (WHO) is to engage in partnerships where joint

action is needed WHO plays an important role in bringing crucial health-related topics to

the agenda of policy-makers and health planners and in raising awareness of them among

health-care professionals and all who have an interest in health matters

WHO’s Department of Mental Health and Substance Abuse carries out this role for

the three different sets of issues for which it is responsible: mental disorders, substance

abuse and alcohol-related issues, and neurological disorders Two recent publications

have focused attention on its work The world health report 2001 – Mental health: new

understanding, new hope is an advocacy instrument to shed light on the public health

as-pects of mental disorders, and the report Neuroscience of psychoactive substance use and

dependence produced by the department in 2004 tackles the area of substance abuse and

alcohol We realized a similar exercise is needed in the fi eld of neurological disorders

The Global Burden of Disease study, the ongoing international collaborative project

between WHO, the World Bank and the Harvard School of Public Health, has produced

evi-dence that pinpoints neurological disorders as one of the greatest threats to public health

A clear message emerges that unless immediate action is taken globally, the neurological

burden is expected to become an even more serious and unmanageable problem in all

countries There are several gaps in understanding the many issues related to neurological

disorders, but we already know enough about their nature and treatment to be able to

shape effective policy responses to some of the most prevalent among them

To fi ll the vast gap in the knowledge concerning the public health aspects of

neurologi-cal disorders, this document Neurologineurologi-cal disorders: public health challenges fulfi ls two

roles On one hand, it provides comprehensive information to the policy-makers and on the

other hand, it can also be used as an awareness-raising tool The document has unique

aspects that should be stressed It is the result of a huge effort bringing together the most

signifi cant international nongovernmental organizations working in the areas of various

neurological disorders, both in a professional capacity and in caring for people affected

by the conditions It is the fruit of healthy interaction and collaboration between these

organizations and WHO, with its network of country and regional offi ces: health experts on

Neurological disorders: public health challenges

viii

one hand working together with the extensive and competent world of professionals and researchers on the other Some of these organizations have also contributed fi nancially

to this endeavour This exercise thus demonstrates that such collaboration is not only possible but can also be very productive

The document is distinctive in its presentation as it provides the public health per-spective for neurological disorders in general and presents fresh and updated estimates and predictions of the global burden borne by them Separate sections discuss some of the most important disorders in detail: dementia, epilepsy, headache disorders, multiple sclerosis, neuroinfections, neurological disorders associated with malnutrition, pain as-sociated with neurological disorders, Parkinson’s disease, stroke and traumatic brain injuries

The document makes a signifi cant contribution to the furthering of knowledge about neurological disorders We hope it will facilitate increased cooperation and innovation and inspire commitment to preventing these debilitating disorders and providing the best possible care for people who suffer from them

Benedetto Saraceno

Director, Department of Mental Health and Substance Abuse

The following people, listed in alphabetical order, participated in the production of this document,

under the guidance and with the support of Catherine Le Galès-Camus (Assistant Director-General,

Noncommunicable Diseases and Mental Health, World Health Organization), to whom we express

our sincere gratitude

PROJECT TEAM

WRITING GROUP

Johan A Aarli, Tarun Dua, Aleksandar Janca, Anna Muscetta

MANAGEMENT GROUP

José Manoel Bertolote, Tarun Dua, Aleksandar Janca, Frances Kaskoutas-Norgan,

Anna Muscetta, Benedetto Saraceno, Shekhar Saxena, Rosa Seminario

EDITORIAL COMMITTEE

Johan A Aarli, Giuliano Avanzini, José Manoel Bertolote, Hanneke de Boer, Harald Breivik,

Tarun Dua, Nori Graham, Aleksandar Janca, Jürg Kesselring, Colin Mathers, Anna Muscetta,

Leonid Prilipko, Benedetto Saraceno, Shekhar Saxena, Timothy J Steiner

AUTHORS AND CONTRIBUTORS

INTRODUCTION

Tarun Dua, Aleksandar Janca, Anna Muscetta

CHAPTER 1 PUBLIC HEALTH PRINCIPLES

AND NEUROLOGICAL DISORDERS

Tarun Dua, Aleksandar Janca, Rajendra Kale, Federico Montero, Anna Muscetta, Margie Peden

CHAPTER 2 GLOBAL BURDEN OF NEUROLOGICAL DISORDERS:

ESTIMATES AND PROJECTIONS

Tarun Dua, Marco Garrido Cumbrera, Colin Mathers, Shekhar Saxena

CHAPTER 3 NEUROLOGICAL DISORDERS:

A PUBLIC HEALTH APPROACH

3.1 Dementia

Amit Dias, Cleusa Ferri, Nori Graham (chair), Bernard Ineichen, Martin Prince,

Richard Uwakwe

3.2 Epilepsy

Giuliano Avanzini (co-chair), Ettore Beghi, Hanneke de Boer (co-chair), Jerome Engel Jr.,

Josemir W Sander, Peter Wolf

3.3 Headache disorders

Lorenzo Gardella, Zaza Katsarava, David Kernick, Hilkka Kettinen, Shireen Qureshi,

Krishnamurthy Ravishankar, Valerie South, Timothy J Steiner (chair), Lars Jacob Stovner

3.4 Multiple sclerosis

Ian Douglas, Jürg Kesselring (chair), Paul Rompani, Bhim S Singhal, Alan Thompson

3.5 Neuroinfections

Reyna M Duron, Hector Hugo Garcia, Ashraf Kurdi, Marco T Medina (chair),

Luis C Rodriguez

acknowledgements

Neurological disorders: public health challenges

x

3.6 Neurological disorders associated with malnutrition

Amadou Gallo Diop (chair), Athanase Millogo, Isidore Obot, Ismael Thiam, Thorkild Tylleskar

3.7 Pain associated with neurological disorders

Michael Bond, Harald Breivik (chair), Troels S Jensen, Willem Scholten, Olaitan Soyannwo, Rolf-Detlef Treede

3.8 Parkinson’s disease

Mary Baker (chair), Oscar S Gershanik

3.9 Stroke

Julien Bogousslavsky (chair), Ming Liu, J Moncayo, B Norrving, A Tsiskaridze,

T Yamaguchi, F Yatsu

3.10 Traumatic brain injuries

Armando Basso (chair), Ignacio Previgliano, Franco Servadei

CHAPTER 4 CONCLUSIONS AND RECOMMENDATIONS

José Manoel Bertolote, Tarun Dua, Aleksandar Janca, Anna Muscetta, Benedetto Saraceno, Shekhar Saxena

EXTERNAL REVIEWERS

Mario A Battaglia, Donna Bergen, Gretchen Birbeck, Carol Brayne, Vijay Chandra, Amit Dias,

M Gourie-Devi, Rajendra Kale, Maria Lucia Lebrao, Itzhak Levav, Girish Modi, Theodore Munsat,

Donald Silberberg (whole document); Daniel O’Connor, Carlos Lima (Dementia); Satish Jain, Bryan Kies (Epilepsy); Anne MacGregor, Fumihiko Sakai (Headache disorders); Chris

H Polman, Ernie Willoughby (Multiple sclerosis); Peter G E Kennedy (Neuroinfections);

Redda Tekle Haimanot (Neurological disorders associated with malnutrition); Ralf Baron, Maija Haanpää (Pain associated with neurological disorders); Zvezdan Pirtosek, Bhim S Singhal, Helio Teive (Parkinson’s disease); Vladimir Hachinski, David Russell (Stroke); Vladan Bajtajic, Jacques Brotchi, Jeremy Ganz, Haldor Slettebø (Traumatic brain injuries)

PEER REVIEWERS IN WHO

Regional Offi ce for Africa: Thérèse Agossou Regional Offi ce for the Americas: José Miguel Caldas De Almeida, Itzhak Levav Regional Offi ce for South-East Asia: Vijay Chandra

Regional Offi ce for Europe: Matthijs Muijen Regional Offi ce for the Eastern Mediterranean: R Srinivasa Murthy, Mohammad Taghi Yasamy Regional Offi ce for the Western Pacifi c: Xiandong Wang

Headquarters: Bruno de Benoist, Siobhan Crowley, Denis Daumerie, Dirk Engels,

Jean Georges Jannin, Daniel Olivier Lavanchy, Dermot Maher, Kamini Mendis, Shanthi Mendis, François Meslin, William Perea, Pascal Ringwald, Oliver Rosenbauer, Michael J Ryan, Perez Simarro, Jos Vandelaer, Marco Vitoria

PRODUCTION TEAM

Production coordination: Caroline Allsopp Editing: Barbara Campanini

Design and layout: Reda Sadki Proofreading: Susan Kaplan Indexing: David McAllister Maps: Steve Ewart Printing coordination: Raphặl Crettaz