Prevalence of noncommunicable diseases in Zimbabwe - results from analysis of data from the National Central Registry and Urban Survey 2

Michigan State University, Ист-Лансинг, Michigan, United States
Ethnicity & disease (Impact Factor: 1). 02/2006; 16(3):718-22.
Source: PubMed
ABSTRACT
The disease burden from noncommunicable diseases (NCDs) in Africa is rapidly increasing based on projections from a limited number of reports. In the absence of national health surveys in Zimbabwe, all data nationally generated between 1990 and 1997 were analyzed. From 1990 to 1997, prevalence rates (expressed per 100,000 people) of hypertension increased from 1000 to 4000, rates of diabetes increased from 150 to 550, and rates of cerebrovascular accidents (CVA) increased from 5 to 15. The case fatality rate (CFR) for CVA decreased substantially during the period of study, implying improved case management of the disease, while the CFR for most other diseases did not change significantly throughout the study period. The observation of increased prevalence of some NCDs during the study period was corroborated by findings from a blood pressure survey subsequently conducted in an urban environment of Zimbabwe, which revealed a hypertension (blood pressure > or =140/90 mm Hg) prevalence of 35% in women and 24% in men. In spite of the limitations of the centrally generated hospital-based data, its analysis is still valuable. Countries are therefore encouraged to utilize this easily accessible resource for policy formulation and resource mobilization.

Full-text

Available from: Jephat Chifamba
PREVALENCE OF NONCOMMUNICABLE DISEASES IN ZIMBABWE:RESULTS FROM
ANALYSIS OF DATA FROM THE NATIONAL CENTRAL REGISTRY AND URBAN SURVEY
The disease burden from noncommunicable
diseases (NCDs) in Africa is rapidly increasing
based on projections from a limited number of
reports. In the absence of national health
surveys in Zimbabwe, all data nationally
generated between 1990 and 1997 were
analyzed. From 1990 to 1997, prevalence
rates (expressed per 100,000 people) of
hypertension increased from 1000 to 4000,
rates of diabetes increased from 150 to 550,
and rates of cerebrovascular accidents (CVA)
increased from 5 to 15. The case fatality rate
(CFR) for CVA decreased substantially during
the period of study, implying improved case
management of the disease, while the CFR for
most other diseases did not change significant-
ly throughout the study period. The observa-
tion of increased prevalence of some NCDs
during the study period was corroborated by
findings from a blood pressure survey sub-
sequently conducted in an urban environment
of Zimbabwe, which revealed a hypertension
(blood pressure $140/90 mm Hg) prevalence
of 35% in women and 24% in men. In spite of
the limitations of the centrally generated
hospital-based data, its analysis is still valuable.
Countries are therefore encouraged to utilize
this easily accessible resource for policy
formulation and resource mobilization. (Ethn
Dis. 2006;16:718–722)
Jacob Mufunda, MBChB, PhD, MBA;
Rufaro Chatora, MBChB, MPH; Yustina Ndambakuwa, BSc, MBA;
Peter Nyarango, MBChB, MMed, MPH;
Jephat Chifamba, BSc, MPhil; Andrew Kosia, MD, PhD, MPH;
Harvey V. Sparks, MD
INTRODUCTION
Limited epidemiologic studies in-
dicate that noncommunicable diseases
(NCDs) are emerging as a major disease
burden in Africa.
1
This NCD epidemic
has emerged at a time when communi-
cable diseases still require tremendous
human and material resources, with no
respite in sight.
2
The developing coun-
tries in Africa are faced with a double
burden of disease from preexisting
communicable diseases and the emerg-
ing NCD epidemic. Most governments
have already put in place disease pre-
vention and control programs for com-
municable diseases, but few standard-
ized studies on NCDs in Africa have
been conducted, and prevention and
control programs for NCDs are a distant
prospect.
3
Estimations of the burden of NCDs
in Africa are based on a combination of
reports from a limited number of
studies conducted in some countries in
Africa and extrapolation from reports
done in Western countries.
4
Few Afri-
can countries have conducted and
published studies from national surveys
of NCD risk factors.
5
The NCDs of
particular concern are the cardiovascular
diseases, such as diabetes mellitus and
hypertension, and events that result
from target organ d amage, such as
stroke and myocardial infarction. An-
other disease is rheumatic heart disease
(RHD), which has been resurging in
some countries.
6
The pathogenesis of most of these
NCDs is not well established, which
makes instituting effective national con-
trol programs difficult. The available
prevalence data from published studies
conducted among Africans of all races in
the continent reveal a variety of NCD
features: the metabolic or insulin re-
sistance syndrome,
7
urbanization-related
hypertension,
8
and sodium sensitivity.
9
Most hypertensive patients are obese,
exhibit insulin resistance, and may have
diabetes mellitus and lipid disorders.
7,10
This cluster of risk factors used to be
referred to as insulin resistance/metabolic
syndrome.
7
Initially it was thought to be
a common pathway for essential hyper-
tension, but the existence of hypertension
in lean subjects has somewhat clouded this
hypothesis an d called for alternative
mechanisms.
11
Observations of higher blood pres-
sure and prevalence of hypertension in
urban compared with rural su bjects
have been consistent throughout Africa,
with a few exceptions where the oppo-
site was true.
12,13
A number of factors
have been attributed to this urbaniza-
tion-related hypertension, including in-
creased psychosocial stress, dietary salt,
and Western lifestyles and diet.
14
Most countries are rapidly decentra-
lizing their economies and government
structures. This economically justified
development has essentially transformed
previously rural areas into regions in
transition to urban areas and is associated
From the Orotta School of Medicine,
Eritrea (JM, PN); WHO Country Represen-
tative, Asmara, Eritrea (AK); WHO Regional
Office for Africa, The Congo (RC); Univer-
sity of Zimbabwe College of Health
Sciences (JC); Anchor Trust, London (YN);
Michigan State University, East Lansing,
Michigan (HS).
Address correspondence and reprint
requests to Jacob Mufunda, MBChB, PhD,
MBA; Orotta School of Medicine; P.O. Box
10549; Asmara, Eritrea; +291-1-151322
(fax); mufunda@yahoo.com
Few African countries have
conducted and published
studies from national surveys
of NCD risk factors.
5
718 Ethnicity & Disease, Volume 16, Summer 2006
Page 1
with concomitant increases in NCDs,
especially hypertension.
15
No risk factor
intervention programs have been imple-
mented to curtail the NCD excess baggage
that comes with urbanization. Therefore,
baseline studies must be conducted to
determine the initial magnitude of the
burden of NCDs in African countries.
Ideally, NCD risk factor surveys would be
conducted according to the World Health
Organization (WHO) NCD surveillance
tool;
16
however, the cost and logistics may
be beyond the scope of many countries.
Fewer than 10 African countries have
conducted and published the outcome of
surveys conducted according to these
guidelines. Most countries in Africa have
central registration of health information
that is generated nationwide from all
healthcare service facilities. Electronic
health management information systems
have replaced manual recording in other
African countries, but using these data to
generate national health indicators has
some limitations.
In spite of these drawbacks and in
the absence of cross-sectional health
survey-based in formation, researchers
from some countries have analyzed
and published hospital-based data to
highlight the trend of diseases in these
countries, raise awareness among practi-
tioners, and guide resource mobilization
and allocation.
The objective of this study was to
determine the prevalence rates of com-
mon NCDs in Zimbabwe by using
centrally compiled public hospital-based
data generated from 1990 to 1997.
Zimbabwe is a country in southern
Africa with an estimated population of
11.6 million, according to estimates
from a national census in 2002.
17
The
country has a viable and competitive
health insurance service through many
companies, the largest of which is under
government control and draws most of
its membership from government em-
ployees.
18
In addition to public hospi-
tals, an active private healthcare service
delivery system is not included in this
analysis. As of 1997, an estimated 20%
of health care is paid through health
insurance, primarily through user fees
payment and cost recovery.
19
METHODS
Data Collection
The records originated from the
peripheral hospitals both catering for
inpatient and outpatient services. These
data were submitted regularly to the
provincial health offices for compilation
before being sent to the headquarters.
The data collection was considered to be
.80% timely and .80% complete
throughout the study period.
Hypertension was defined as a blood
pressure .140/90 mm Hg on at least
three different occasions; patients taking
antihypertensive medication were also
considered to be in the hypertensive
group. Diabetes was defined as fasting
glucosuria . 11 mmol/L. The other
diseases were defined according to the
Zimbabwean national guidelines, which
are annually reviewed to reflect the
international trends and WHO guide-
lines.
The denominator for prevalence
calculations was the national population
based on the most recent census for
the year. The data were presented as
prevalence per 1 00,000 people. The
case-fatality rate (CFR) was calculated
as a percentage of deaths per number
of cases recorded with the disease.
The least squares method was used to
determine the strength of change of
outcome measures over time; the closer
R
2
was to one, the greater the change.
A random, house-to-house blood
pressure surve y was conducted in Mar-
ondera, a city 50 km from Harare, the
capital city of Zimbabwe, as previously
described in detail elsewhere.
8
RESULTS
All data in 1992 and 1993 appear to
have been consistently poorly recorded,
and we cannot explain this apparen t
system atic observation. Although the
prevalence of hypertens ion remained
constant in the first th ree years of
recording, the rate increased steeply
thereafter. The hypertension prevalence
increased four-fold during the study
period with R
2
5.84 (Figure 1).
The prevalence of diabetes decreased
in the first years, especially in 1993, but
then increased until 1997. The overall
prevalence of diabetes increased three-
fold (Figure 2).
The prevalence rate for cerebrovas-
cular accident (CVA) increased mark-
edly during the study period (R
2
5.59),
whereas that for RHD tended to de-
crease. The prevalence rate for myocar-
dial infarction (MI) was stable through-
out the study period, except for a surge
in 1995 (Figur e 3).
The CFR for hypertension, diabetes,
and MI remained steady or declined
during the study period until 1996. A
Fig 1. Prevalence of hypertension
Fig 2. Prevalence of diabetes mellitus
NON-COMMUNICABLE DISEASE IN ZIMBABWE - Mufunda et al
Ethnicity & Disease, Volume 16, Summer 2006 719
Page 2
sudden increase in CFR was seen in
1997 for all diseases except CVA, the
rate of which was already high. The
overall trend during the period showed
a dramatic increase in CFR for RHD
(R
2
5.69), while that for CVA decreased
(R
2
5.57) (Table 1).
With data from the urban blood
pressure survey, we confirmed the high
disease burden from hyperten sion in-
dicated by data from the central registry.
The hypertension prevalence rates were
significantly higher in women than in
men throughout the entire range of age
groups (Figure 4).
DISCUSSION
This was a retrospective study of
hospital-based data centrally compiled
by the Ministry of Health, Zimbabwe,
from 1990 to 1997. The salient findings
from the study were that the prevalence
rates of hypertension and diabetes in-
creased three-fold during the study
period. A follow-up urban blood pres-
sure survey confirmed the status of
hypertension as an epidemic, with
a pre valence of 35% in women and
24% in men. Analyzing and interpret-
ing hospital-based data was found to be
a cost-effective proxy of national prev-
alence rates for NCDs. However the
information does not guide preventive
Fig 3. Prevalence of CVA, MI and RHD. MI5myocardial infarct; CVA5cardiovascular accident; RHD5rheumatic heart disease
Table 1. Case-fatality rate for noncommunicable diseases in Zimbabwe, 1990–1997
Disease
Case Fatality Rate (CFR) (%)
R
2
1990 1992 1993 1994 1995 1996 1997
Hypertension 2.8 4.2 3.4 3.1 2.7 3.8 8.0 .2252
Diabetes mellitus 4.7 10.4 10.4 1.4 2.1 2.2 12.4 .2547
Myocardial infarct 9.5 18.6 10.2 11.1 4.2 6.9 10.5 .1598
Cerebrovascular accident 29.4 23.9 26.5 17.3 17.7 22.4 18.9 .5682
Rheumatic heart disease - - - 5.1 5.7 5.8 11.4 .6883
The salient findings from the
study were that the prevalence
rates of hypertension and
diabetes increased three-fold
during the study period
(1990–1997).
NON-COMMUNICABLE DISEASE IN ZIMBABWE - Mufunda et al
720 Ethnicity & Disease, Volume 16, Summer 2006
Page 3
interventions b ecause it did not charac-
terize the risk factors and was anony-
mous, which makes tracing the source
of the diseases difficult.
The decline in prevalence of NCDs
from 1992 to 1994 was probably related
to inadequate personnel to compile data
at the headquarters. The increase in
prevalence rates appeared to have been
genuine and was unlikely to have been
due to increased data collection or
increased visitation of facilities by
patients. In addition, although the
timeliness and completeness of the
records had not been formally evaluat-
ed, both were believed to have been
.80%. Therefore, the increased trends
may have been actual and reflective of
increased disease burden from NCDs
and their risk factors.
Awareness, case detection, and man-
agement of NCDs or their risk factors
are low in developing countries.
20
Part
of the explanation is that during the
early stages of NCDs such as hyperten-
sion, disease is asymptomatic until target
organ damage occurs. In addition, de-
veloping countries in Africa are among
the poorest in the world, and most of
their health resources are targeted at the
prevention and control of communica-
ble diseases. NCD risk factor surveys
have been conducted in ,10 countries
and published in fewer than half of
these.
21
Hospital-based data can be used as
a gauge for national prevalence and
incidence rates,
22
despite some limita-
tions in the representativeness of these
data. In spite of the shortcomings,
hospital-based data are easily available
and a cost-effective measure of health
statistics in any country.
The publication of reports on new
trends of diseases that use hospital data
can increase the awareness of healthcare
providers and improve case detection
and management of those diseases.
However, the factors responsible for
increase in the prevalence of NCDs in
this report have not been examine d.
Prevention and management of NCDs
are distinctly different than those for
infectious diseases in Africa.
Most infectious diseases, such as
tuberculosis (TB), malaria, and HIV/
AIDS, are amenable to prevention
interventions because the predisposing
and risk factors are known. In the case
of NCDs, while some risk factors may
be known, that information is based on
studies from developed countries. The
impact of the risk factors is variable
among different populations and racial
groups.
23
Most studies have documen-
ted increased blood pressures and hy-
pertension prevalence in urban com-
pared to rural environments.
8
Some of
the explanations given for this observa-
tion are increased stress,
24,25
adoption
of Western lifestyles and diets, obesity,
and insulin resistance.
8
The observation
of a 400% increase in the prevalence in
an eight-year period in this study was
exceptionally high. By their nature,
hospital-based data do not provide
information on risk factors. The value
of this information was as a surveillance
tool to alert researchers of a developing.
From the survey results, we saw that
obesity and psychosocial stress played
a role in hypertension, especially in
explaining the sex difference in blood
pre ssure.
8
The incidence of MI re-
mained unchanged during the study
period. This finding was surprising
because the rate was expected to be
increasing because of increased afflu-
ence. Most cases may have been admit-
ted in the private sector, where data
were excluded from these public central
records. Even then, the incidence rate of
MI was double that recently reported in
the Horn of Africa with a sim ilar source
of data.
22
Although the prevalence of MI, one
form of target organ damage, remained
steady, that of CVA increased almost by
300%. The propensity in Blacks for
CVA instead of MI has been reported
before.
23
Low renin in most Black
hypertensive patients may protect them
from developing myocardial infarction,
although this finding has not been
substantiated.
24
The level of CVA in
the current study was five times that
reported from Eastern Africa during the
same period.
22
In that report, the
prevalence of hypertension was 18%.
Case fatality rates (CFR) of all the
reported NCDs except CVA significant-
ly inc reased from 1990 to 1997. The
reason for the decreased CFR for CVA
was not investigated. The CFR was
already high for CVA compared to
other diseases under study, and the
increase in CFR was predominantly
due to the uniform ly high rate of all
the other diseases recorded in 1997. The
decline in CFR could have been a re-
flection of improved case management,
but to a ssume the impr oved case
management was limited to one NCD
in a short space of time is not plausible.
This area needs to be further evaluated
in the future.
The prevalence of RHD, like that of
MI, remained stable, but the CFR for
RHD increased. This finding could be
explained in part by increased re-in-
fection, particularly against the back-
ground of the HIV/AIDS pandemic and
opportunistic infections that cause early
decompensation. However, this expla-
nation is speculative and needs further
investigation.
The prevalence of diabetes incre ased
by 400% during the study period.
However, the CFR was consistent with
that of other NCDs. No risk factor
profile was examined to explain this
sudden increased disease burden. The
Fig 4. Hypertension prevalence from
the urban blood pressure survey
NON-COMMUNICABLE DISEASE IN ZIMBABWE - Mufunda et al
Ethnicity & Disease, Volume 16, Summer 2006 721
Page 4
interrelationsh ip of diabetes mellitus
with hypertension and adverse events is
well recognized and should be prevented
at all costs, whether through primary or
secondary prevention.
25
In spite of the recognized limitations
of the questionable reliability of hospi-
tal-based data, in the absence of national
surveys or between surveys, these data
can be used as a proxy for national
prevalence data on NCDs.
A
CKNOWLEDGMENTS
The authors are indebted to the WHO
Regional Office for Africa for supporting
this study and the Ministry of Health,
Government of Zimbabwe, for granting
permission to access the centrally based data.
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AUTHOR CONTRIBUTIONS
Design concept of study: Mufunda, Chifamba,
Sparks
Acquisition of data: Mufunda, Chifamba,
Sparks
Data analysis interpretation: Mufunda, Nyar-
ango, Chatora, Kosia, Chifamba, Ndam-
bakuwa, Sparks
Manuscript draft: Mufunda, Nyarango, Cha-
tora, Kosia, Chifamba, Ndambakuwa,
Sparks
Statistical expertise: Mufunda, Nyarango,
Sparks
Acquisition of funding: Mufunda, Kosia,
Chifamba, Sparks
Administrative, technical, or material assis-
tance: Mufunda, Chatora, Chifamba,
Ndambakuwa, Sparks
Supervision: Mufunda, Chatora, Kosia,
Ndambakuwa, Sparks
NON-COMMUNICABLE DISEASE IN ZIMBABWE - Mufunda et al
722 Ethnicity & Disease, Volume 16, Summer 2006
Page 5
  • Source
    • "In Zimbabwe, three consecutive readings at least 4 hours apart are used for diagnosis after which a Medical Doctor can commence treatment. However a single systolic blood pressure (SBP) above 180 mmHg or a diastolic blood pressure (DBP) above 110 mmHg is indication for treatment [11]. Trend analysis of hypertension between Mazowe District, Mashonaland Central Province and Zimbabwe from 2004 to 2011 showed that the district trend is slowly declining out of keeping with the national trend (Figure 1). "
    Full-text · Dataset · Feb 2015
  • Source
    • "Diabetes was ranked fourth (after hypertension, asthma and epilepsy) amongst the non-communicable diseases (NCDs) recorded in outpatient visits in Zimbabwean public hospitals in 2006 (Ministry of Health and Child Welfare 2009), National health survey data from which to examine the burden of diabetes in Zimbabwe are limited (Mufunda et al. 2006); one sub-national health survey conducted in three of the ten provinces estimated diabetes prevalence to be 10.2 %, with females more likely to report a history of diabetes compared to males (Hakim et al. 2005). Another study of central-hospital based data estimated that the prevalence of diabetes (expressed per 100,000 people) had increased from 150 to 550 from 1990 to 1997(Mufunda et al. 2006). Resource limitations mean that there are no comprehensive population surveys evaluating the prevalence of diabetes throughout Zimbabwe, and estimates from the IDF have been based on a single 2005 sub-national survey (International Diabetes Federation 2013) and may thus not be nationally representative. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Diabetes appears to be a growing problem in the African region. This study aims to estimate the prevalence of diabetes in Zimbabwe by collating and analyzing previously published data. Methods: Systematic review and meta-analysis of data reporting prevalence of diabetes in Zimbabwe was conducted based on the random effects model. We searched for studies published between January 1960 and December 2013 using MEDLINE, EMBASE and Scopus and University of Zimbabwe electronic publication libraries. In the meta-analysis, sub-groups were created for studies conducted before 1980 and after 1980, to understand the potential effect of independence on prevalence. Results: Seven studies were included in the meta-analysis with a total of 29,514 study participants. The overall pooled prevalence of diabetes before 1980 was 0.44 % (95 % CI 0.0–1.9 %), after 1980 the pooled prevalence was 5.7 % (95 % CI 3.3–8.6 %). Conclusions: This study showed that the prevalence of diabetes in Zimbabwe has increased significantly over the past three decades. This poses serious challenges to the provision of care and prevention of disabling co-morbidities in an already disadvantaged healthcare setting.
    Full-text · Article · Jan 2015 · International Journal of Public Health
  • Source
    • "In Zimbabwe, three consecutive readings at least 4 hours apart are used for diagnosis after which a Medical Doctor can commence treatment. However a single systolic blood pressure (SBP) above 180 mmHg or a diastolic blood pressure (DBP) above 110 mmHg is indication for treatment [11]. Trend analysis of hypertension between Mazowe District, Mashonaland Central Province and Zimbabwe from 2004 to 2011 showed that the district trend is slowly declining out of keeping with the national trend (Figure 1). "
    [Show abstract] [Hide abstract] ABSTRACT: Background From 2005 to 2011 Mazowe District recorded a gradual decline in prevalence of hypertension in the face of rising incidence of complications like stroke. This raised questions on whether diagnosis and management of hypertensive patients is being done properly. Methods We conducted an analytic cross sectional study at three hospitals in Mazowe District where we randomly selected 201 of 222 patients from out patients departments and interviewed a convenience sample of 23 healthcare workers. Structured interviewer administered questionnaires were used to collect data on demographic characteristics and knowledge from patients, as well as knowledge and practices from health workers. Physical measurements were done on all patients. Frequencies; proportions, odds ratios, Chi square test and stratified & logistic regression analysis were done using Epi info version 3.5.4 while graphs were generated using Microsoft excel®. Calculations were done at 95% confidence interval. Results Prevalence, awareness, control, compliance, and complication rate of hypertension were: 69.7%, 56.2%, 22.0%, 59.8% and 20.7% respectively. Independent risk factors for hypertension were age (POR 3.09; 95% CI: 1.27-7.5), obesity (POR 4.37; 95% CI: 1.83-10.4), and previous high blood pressure reading (POR 19.86; 95% CI: 8.61-45.8). Complications included cardiac failure (8.6%), visual defects (4.3%) and stroke (3.6%). Co-morbid human immunodeficiency virus (10.7%) and diabetes mellitus (12.1%) were identified among respondents. Knowledge was poor in 47.7% of health workers. Conclusions Risk factors found in this study are consistent with other studies. Health service factors are the main reasons for poor diagnosis and management of hypertension. Health workers need training on diagnosis and management of hypertension. Guidelines, digital sphygmomanometers and adequate drug supply are needed. District has since purchased digital BP machines and requested assistance with training on clinical features of hypertension, use of digital machines, and how to properly measure BP. A policy document on non-communicable diseases including hypertension was subsequently developed by the Ministry of Health and Child Care and currently awaiting endorsement by parliament.
    Full-text · Article · Aug 2014 · BMC Cardiovascular Disorders
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