The group was established in February 2019 to disseminate GBD-generated data on cancer at the Italian level and to fill some gaps in this area of epidemiological data and indicators needed for prevention and treatment interventions.
In the beginning, the group consisted of about a dozen researchers and later expanded with the addition of about 20 other researchers from Italian research centers and universities.
Among the activities carried out by the group is the production of an article based on GBD 2017 estimates. Incidence, mortality but also years lived with disability, years of life lost, and disability-adjusted life years are reported for all cancers overall and for 30 cancer sites, in terms of absolute numbers, raw rates, and age-standardized rates for both sexes. For mortality, in addition to values for the latest available year, trends from 1990 to 2017 were also analyzed.
A second activity was to make a comparison of GBD estimates for cancers with Italian national and regional data. The results, discussed at an Italian GBD initiative Workshop held in early 2020 and later with IHME collaborators, showed discrepancies in the data mainly due to the redistribution of NOS malignancies and NOS liver tumors (“garbage codes”).
For the near future, the group plans to conduct analyses and produce publications on specific cancers, including GBD estimates at the regional level. These include a proposed pattern analysis of colorectal, breast, and uterine cancers in relation to the prevalence of screening; analysis of some cancers related to behavioral, environmental, and occupational risk factors with a focus on the working population (18-64 years old); and analysis on squamous cell cancers of the skin originating from actinic keratoses.
Objectives: 1. To investigate the global burden of neurological disorders in Italy by assessing the time trend of the most prevalent diseases in the entire country and comparing the 20 administrative districts; 2. Compare the burden of neurological disorders in Italy to other European Union countries and to the global level.
Past activities: 1. Italy’s health performance, 1990-2017: results from the Global Burden of Disease Study 2017 (doi: 10.1016/S2468-2667(19)30189-6); 2. The burden of neurological diseases in Europe: an analysis for the Global Burden of Disease Study 2017 (doi: 10.1016/S2468-2667(20)30190-0; 3. Incidence, prevalence, and disability associated with neurological disorders in Italy between 1990 and 2019: an analysis based on the Global Burden of Disease Study 2019 (doi: 10.1007/s00415-021-10774-5).
Present Activities: Following the survey on the burden of neurological diseases in the European Union (EU), a study sponsored by the European Academy of Neurology on care management in the EU (NeuroCare) is underway to investigate whether and to what extent the most common neurological diseases are managed by the health care systems of different countries. Latest estimates of the burden of these diseases will be compared with available systems and services (n beds for neurological diseases diagnostic equipment, treatment).
Future Activities: The investigation of risk factors of neurological disorders in Italy is still an unexplored field as well as the epidemiological distribution differentiated by region. Future goals of the group will be to present the spectrum of environmental and lifestyle risk factors in Italy (as a whole and comparing data from the regions) and to compare Italy with other European countries and neuroepidemiological assessment of the distribution of neurological diseases in the country
The Italian GBD Skin and Subcutaneous Diseases Group focuses on analyzing Italian GBD estimates of dermatologic conditions, nationally and subnationally.
More than 3,000 nosographic entities are described in Dermatology, a number greater than that of any other specialty. Skin disorders are, on the whole, extremely common in the general population, and at least a quarter of individuals have a skin disease at any point in their lives. Dermatological conditions, whether acute (e.g., scabies) or chronic (e.g., psoriasis), can lead to social stigma, poor quality of life, and decreased work productivity.
Despite their high incidence and prevalence, good quality data are generally lacking.
This subgroup aims to assess currently available data, highlighting knowledge gaps and promoting research in these gray areas. Assessing the burden of dermatologic disorders can contribute to the empowerment of patient associations and physicians and increase attention to skin conditions and their high economic burden in terms of out-of-pocket expenses.
This topic group hosts clinicians from different specialties (e.g., dermatologists, occupational physicians, epidemiologists).
The group’s planned activities include:
- National and subnational analyses of Italian data on skin diseases, and an evaluation of corresponding GBD estimates;
- A review of the nosographic categories included at Level 2 Skin and Subcutaneous Diseases groups of the GBD study and a critical evaluation of the weights used to calculate DALYs, as well as the risk factors attributed;
- A promotion of GBD estimates among young researchers to reward deserving researchers and involve them in dermatoepidemiology and public health;
- Increase the awareness of Dermatology Scientific Societies about the GBD initiative and their involvement in supporting research in this field and ad hoc fellowships for young researchers.
The Italian Global Burden Disease (GBD) working group on musculoskeletal disorders (MSK) was formed because of concerns about their impact on health in Italy and around the world. In GBD 2019, musculoskeletal disorders in Italy were the leading cause of years lived with disability (YLD) and the third leading cause of disability-adjusted life years (DALY).
Although there have been major advances in the diagnosis and treatment of some MSK disorders in recent decades, it is still difficult to give a precise definition, which is necessary for uniform reporting of epidemiological data. In fact, estimating the prevalence and incidence of these disorders and their health burden is closely related to case definition and severity.
There are two main issues related to the definition of MSK disorders: 1) Objective diagnoses are not always possible: different pathological conditions present similar clinical pictures, while reported symptoms are not always confirmed by imaging or other diagnostic tools; 2) the same MSK disorder can present significantly different levels of disability, varying from person to person.
Assessment of the experience of living with a health condition, and the determinants of that experience, carried out by the World Health Organization’s International Classification of Diseases, could be a great help for musculoskeletal case-definition.
In addition, only a small percentage of MSK disorders may be associated with specific risk factors (i.e., less than 40 percent for low back pain and none for cervicalgia), resulting in a negative effect on the design of prevention strategies.
For all the above reasons, the main objective of the working group is to investigate the prevalence and incidence of MSK disorders with more focus on case definition (i.e., prevalence of cervical disc herniation in the Italian population, instead of prevalence of neck pain), and degree of severity. We hope that this approach will lead to an improvement in the accuracy of YLD estimates.
RISK FACTORS: OVERWEIGHT AND OBESITY
Overweight and obesity are two major public health problems and have now assumed the dimension of a global epidemic, also referred to as “globesity.” Obesity is a complex condition that indiscriminately affects all age groups, low-, middle-, and high-income countries and is also associated with an increased risk of noncommunicable diseases such as diabetes, coronary heart disease, stroke, cancer, and comorbid conditions, including obstructive sleep apnea and osteoarthritis. Obesity is largely preventable, and stopping its increase is one of the main goals of the World Health Organization’s (WHO) Global Action Plan for the Prevention of Noncommunicable Diseases.
In this context, the group has among its goals:
- Provide IHME with data on overweight and obesity in Italy collected from population studies and surveillance systems;
- collect and compare the different definitions of obesity and overweight used for different populations and ethnicities in order to propose equivalent and comparable classes of GBD estimates;
- test the possibility of reconstructing historical trends in obesity prevalence in Italy to compare different areas of the country and describe the transition, in northern and southern regions;
- monitor estimates produced by the Institute for Health Metrics and Evaluation (IHME) regarding exposure to overweight and obesity;
- Scientifically assess and disclose the impact of overweight and obesity in the Italian context.
The group consists of researchers from different institutions with extensive experience on the topic, has already contributed to the GBD’s provision of measured and self-reported BMI (overweight and obesity) estimates for the general Italian population, and has participated in several GBD publications. Starting this year, the group will be able to use all data sources already available at the national and regional levels, being able to provide estimates from school age to old age.
MATERNAL AND DEVELOPMENTAL HEALTH
To date, the Working Group on Maternal, Child and Adolescent Health has focused on two important issues: maternal mortality estimation and adolescent health. The issue related to the GBD estimate of maternal mortality in Italy was discussed with IHME researchers. In fact, the Italian Obstetric Surveillance System (ItOSS) of the National Institute of Health (ISS) has shown that the official figure for maternal mortality in Italy significantly underestimates the phenomenon. The advanced surveillance system, developed by ISS, found an underestimation of 60 percent through record-linkage procedures of health care streams (Mortality Registries and SDOs) and assigned the causes of deaths through confidential investigations of incident cases. Coverage in 2021 was 95% of national births. So far, however, due to the specific characteristics of the phenomenon, surveillance data could not be considered, and GBD estimates are still based on official data. Regarding adolescent health, the Italian group looked in detail at the burden in Europe of both nontransmissible diseases and the specific burden of mental health, self-harm and drug abuse. Within the GBD 2021 study, the working group also planned to analyze the relationship between pandemic COVID-19 and mental health in adolescents in five European countries at national and subnational levels, and the burden of diabetes mellitus type 1 and 2 and its main risk factors, at the European and Italian regional level.
CHRONIC KIDNEY DISEASE
HEALTH ECONOMICS & HAQ INDEX
The group deals with research topics related, in general and from a micro and macroeconomic perspective, to the analysis of health supply and demand and the effective and efficient allocation of resources in health care.
Relative to the demand for health and distinctly for high- and low-income countries, socioeconomic, trade and intergenerational determinants are analyzed on the one hand, and derived demand for health services influenced by income and prices, among others.
About health delivery, particular attention is paid to health systems undergoing the challenge of reorganization consistent with changing health needs. Of health systems, organization, performance and financing are examined in view of the pressing issue concerning the compatibility between expenditures and resources. Organizational models, including by type of provider, funding sources, allocation mechanisms, and technical and allocative efficiency are studied.
The economy has important effects on health and health systems. Here, the bidirectional relationship between growth, economic development and health is analyzed. We focus, among other things, on the unequal distribution of income and the effects on unequal health.
Finally, evaluation methodologies of health policy interventions are explored.
The group periodically contributes, through data provision and review of methods and results, to national and subnational estimates of the Healthcare Access and Quality (HAQ) index, health expenditures, and all economic indicators.
Research is currently being conducted on: the causal relationships between socioeconomic development, health care expenditures and Type II Diabetes and Dementia in European Union countries; the sustainability of European and, for Italy, regional health care systems; and the effective and efficient allocation of resources for Italy and individual Italian regions based on the mechanisms of health fund allocation and the epidemiological results obtained.
INFECTIOUS DISEASES AND AMR
The Infectious Diseases and Antimicrobial Resistance (AMR) group of the Italian GBD Initiative was established in late 2022-coinciding with the publication of the first GBD estimates of mortality associated with 33 bacterial pathogens and 11 types of infection-with the goal of deepening burden assessments at the regional level, allowing variability within our country to be highlighted.
Estimates of bacterial-caused infections and AMR, produced using GBD methodology, as well as their geographic and temporal distribution, are an essential tool for guiding public health interventions against what represents one of the greatest health threats in our country as well.
The National Plan to Combat Antibiotic-Resistance (PNCAR) 2022-2025 itself emphasizes the extreme importance of this phenomenon and identifies stakeholders, strategic lines, goals and approaches to counter it, including surveillance, integrated monitoring, information, communication and transparency, and national and international cooperation. Therefore, the assessment and proper use of available data and evidence are crucial elements in the direction of AMR enforcement actions.
With this in mind, the working group is responsible for contributing to the harmonization of information sources with epidemiological surveillance data from the main Italian and regional institutions and for the evaluation of estimates produced by the Institute for Health Metrics and Evaluation (IHME), with the aim of identifying critical national and subnational/regional issues and indicating potential areas of intervention to inform relevant, clinical and prevention decisions, in line with PNCAR guidance.
The group brings together multidisciplinary and cross-sectoral expertise of researchers from various Italian institutions and universities, who bring their different experiences to bear on the careful scientific dissemination of the evidence produced.
The group aims to study temporal trends in the cardiovascular diseases of greatest impact on the Italian general population (heart attack, stroke, peripheral arterial disease, atrial fibrillation, heart failure, hypertensive heart disease, cardiomyopathy, and aneurysms) through estimates of prevalence, incidence, mortality, disability, and life expectancy produced using GBD methodology.
The group also aims to assess the different burden of cardiovascular disease between Italy and other nations. In addition, the new GBD estimates will allow for more in-depth assessments at the regional level as well, allowing differences and inequalities within our country to be highlighted.
Through the GBD’s elaborations, studies conducted by the group also include assessment of the burden of cardiovascular disease in relation to lifestyles and risk factors collected in the general population.
The ultimate goal is to create and disseminate valuable evidence-based support for individual and community-based health planning and prevention (primary, primary, and secondary), reduce inequalities, and improve knowledge of cardiovascular disease. Great emphasis is placed on a work on harmonization of official national statistics and the estimates produced by the GBD methodology.
The group consists of researchers of different professional backgrounds and from different institutions who wish to share their expertise on cardiovascular disease from a public health perspective.
MENTAL HEALTH AND SELF-HARM
Mental health represents an important aspect of public health. Mental disorders are among the leading causes of disability in various European countries, and the first in young people aged 10 to 24. The group is composed of various health care professionals from diverse backgrounds with a specific interest in the epidemiology and impact of mental disorders, substance abuse, and self-injurious behaviors. The group has recently been enriched, including through the involvement of several researchers from the Istituto Superiore di Sanità.
One goal of the group is to review the present literature on the topic of mental health at the national and regional levels, so as to ensure that the Global Burden of Diseases (GBD) Project continually improves the quality, usability and breadth of epidemiological data and knowledge, from which to derive scientifically validated and accurate Italian estimates. Another goal, therefore, is to promote targeted epidemiological research using up-to-date national or regional data, which is as necessary as ever to direct evidence-based mental health policies. This appears even more relevant in the post-pandemic period, in which a significant increase in psychopathological and psychosocial problems is expected at all levels of the population.
As part of the scientific production implemented with data derived from the GBD, the group produced one scientific publication (The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: findings from the Global Burden of Disease Study 2019), with the support of an extensive network of GBD collaborators across Europe. The article was published in The Lancet Regional Health Europe in May 2022. The group is also engaged in a new European study design in line with GBD 2021 estimates: Subnational paper proposal.
ENVIRONMENTAL EXPOSURES & SHOCKS
The group, established in 2020 when the regional estimates produced by the GBD Study for the year 2019 were evaluated, focuses on the impact of environmental risk factors, declined into three specific subgroups:
- air pollution,
- suboptimal temperatures,
- Shocks/natural disasters, such as earthquakes and hydrogeological events.
In addition to contributing to the review of estimates that are produced annually by the Institute for Health Metrics and Evaluation, the group is dedicated to the evaluation and scientific dissemination of the impact of the above risk factors in the Italian context.
Activities in the area devoted to air pollution have included the study of the time trend of the burden of outdoor environmental pollution, declined in terms of atmospheric particulate matter and ozone, since 1990. With the release of the new regional-level estimates, it will address the description and discussion of geographic differences in the burden attributable to air pollution, with a particular focus on noncommunicable diseases.
The strand concerning suboptimal temperatures aims to compare estimates produced in the context of the GBD Study with national estimates, in terms of exposure data, risk estimates and consequently impact estimates. Among future goals, it intends to delve into the temporal trend of temperature burden to highlight potential impacts associated with ongoing climate change and adaptation measures introduced.
Finally, in the area of shocks, the group intends to examine the sources used by the GBD Study to produce the estimates for Italy. It also wants to develop an impact study based on local data, in collaboration with the other entities involved in the Italian GBD Initiative, that can provide new evidence useful for future GBD estimates.
RISK FACTORS: ALCOHOL
Alcohol consumption is a major risk factor for preventable death. The WHO European Region has the highest alcohol consumption in the world, with a major health and social impact on more than 200 health conditions (diseases and injuries) that result in nearly one million deaths each year.
The Italian ALCOHOL GBD-ITA group was established in 2019 and will be developed in 2022 to monitor GBD-generated data on alcohol consumption in Italy at the national and regional levels.
The group, initially formed by a dozen or so researchers, now has more than 20 Italian researchers, mostly epidemiologists and gastroenterologists, experienced in alcohol and free from conflicts of interest with the alcohol industry.
Prevalent activity of the working group is the comparison of international GBD alcohol estimates with national and regional data from the main national epidemiological surveillance and monitoring systems. The existence of differences between the national estimates produced by the GDB in the past and the official estimates of formal national monitoring systems such as the SISMA of the National Alcohol Observatory of the Istituto Superiore di Sanità suggested the need to develop new activities aimed at ensuring more effective coordination and better integration between the available databases, the elaboration and preparation of baseline estimates, and the publication and dissemination of more consistent and more representative data of the Italian national and regional landscape.
The multidisciplinary and diverse expertise of the researchers in the ALCOHOL GBD-ITA group will facilitate in collaboration with HME the optimal use of alcohol data from the “Multiscope Survey of Households, Aspects of Daily Life” conducted by ISTAT and the integration of formal sources by fostering the alignment of GBD alcohol estimates with the existing national and international scientific literature with the shared commitment to improve quality verification, adherence and compliance of data at the regional and macro-area levels.
RISK FACTORS: SMOKING
Tobacco smoking continues to be the leading avoidable risk factor for disease and mortality in high-income countries such as Italy. The Italian GBD thematic group on Tobacco-first integrated into the Alcohol and Tobacco thematic group-was established and developed in February 2019 to monitor GBD-generated data on tobacco smoking in Italy, at national and regional levels. The group now consists of more than 15 Italian researchers with expertise in tobacco control.
The prevailing activity of this thematic group is the comparison of international GBD smoking estimates with national and regional data from major surveillance and epidemiological monitoring systems. During 2019-2021, researchers in this thematic group assisted the IHME in a more adequate evaluation of smoking data from ISTAT Multiscope surveys by facilitating the alignment of GBD estimates with the scientific literature.
The Italian GBD group on Tobacco also contributes to the integration of new original data. Researchers in this thematic group thus assured IHME of the ready availability of disaggregated data from a survey conducted as part of the TackSHS project on ETS exposure in 12 European countries.
The need for further effort to update and align GBD data with official data from major surveillance systems at regional and macro-area levels is highlighted. Once we obtain consistent estimates of tobacco smoking prevalence over the past decades in Italy, we can publish them not only in scientific journals but also in popular journals in order to inform the general population from a health promotion perspective.
Finally, the thematic group promotes the monitoring of new nicotine-containing products such as e-cigarettes and heated tobacco products. The group aims to maintain an objective approach, untainted by any conflict of interest with the tobacco industry.
NUTRITIONAL RISK FACTORS
Estimates of the health impact of risk factors published by the Global Burden of Disease (GBD) study group have quantified, for the first time, the crucial role of nutrition in preserving human health. Nutritional risk factors are one of the major modifiable risk factors to date globally and especially in high-income countries. The GBD studied 15 dietary risk factors that affect health status (excess dietary sodium, diet low in fruits and vegetables, whole grains, nuts and seeds, fiber, legumes, polyunsaturated fatty acids, milk, and calcium, high consumption of red and processed meat, sugar-rich beverages, and trans fatty acids). The Nutrition Risk Factors Thematic Group was established in February 2019 with the goal of monitoring the estimates produced by the Institute for Health Metrics and Evaluation (IHME) in Washington DC regarding exposure to nutritional risk factors and to actively contribute to new data sources at the Italian level. The work is of particular importance for the validation of regional estimates, whose data for Italy used for GBD estimates have yet to be expanded.
The group’s activities include integrating data identified from national cohorts and sampling into the IHME databases and continuing to implement them with new sources. In addition, we aim to publish existing estimates in order to identify potential gaps with the literature or international estimates and to improve their consistency across regions. The results obtained will serve to highlight critical national and subnational/regional issues regarding the impact of nutritional risk factors on chronic diseases and identify potential areas of intervention for policy makers.
DIABETES TYPE 1 AND 2
The group deals generally with issues related to the epidemiology of Diabetes Type I and II and its health management.
Given that the clinical and public health burden of Diabetes type I and II is high and growing, the distribution by age, sex, ethnic group, area of residence along with genetic factors, behavioral factors and their interaction are observed over time. Special attention is paid to the link between type II diabetes and other diseases, whether or not modulated by socioeconomic factors. Complications and their evolution are studied.
Particularly burdensome is the pharmacological and health management of the disease for which the responses of the health care system, in terms of prevention and treatment, and the resulting costs are analyzed.
In addition, with respect to incidence, prevalence, DALYs YLDs, YLLs, and mortality, and distinctly for high- and low-income countries, socioeconomic, trade, and intergenerational determinants are analyzed on the one hand, and derivative demand for diabetes health services on the other.
By providing data and reviewing methods and results, the group periodically contributes to estimates of type I and type II diabetes by age group.
Current research concerns: causal relationships between socioeconomic development, health care expenditures, and Type II diabetes in some European countries; and the transition from a milder to a more severe complication for Type II diabetics in different Italian regions.
The Global Burden of Disease (GBD) “Occupational Health Working Group” aims to estimate the burden of occupational diseases and understand both the magnitude and relative importance of different occupational hazards to provide essential information for risk reduction.
The last few decades have been characterized by occupational exposure to dust (asbestos or silica) and the burden of associated pulmonary and extrapulmonary diseases; occupational injuries have also been a still relevant issue. Nowadays, many thousands of workers around the world are exposed to hazardous substances in both high-income countries even low- and middle-income countries.
Despite the lack of data, particularly with regard to exposure information (title estimates through overall burden are likely underestimated), new methods have been developed to estimate the burden of occupational diseases that take into account the latency of many chronic diseases and trends in workforce exposure and turnover. The results of these studies have shown in several countries and globally that despite improvements in technology, practices and workplace exposure in recent decades, occupational hazards remain an important cause of illness and mortality.
Our idea is that labor-related problems, especially in the future, will be associated with occupational environmental conditions and labor disparities, so it would be important to implement data on these issues: (i) We will perform analyses taking into consideration the Socio-Demographic Index (SDI) to assess its impact on occupational health; (ii) we aim to assess a percentage of the nonresident and/or transient workforce; (iii) We will try to find out any local (regional) differences on occupational risk factors and, if any, estimate their impact on workers’ health.
If our data confirm the differences in mortality between manual and nonmanual workers, it could be a starting point for understanding the causes and trying to reduce the impact on workers’ lives.
AGING AND FRAILTY
The Italian GBD Group on Healthy Aging and Frailty aims to contribute to the health and social emergency brought about by the current demographic transition through as comprehensive an epidemiological assessment of elderly well-being as possible. The approach with which the working group approaches the topic of aging and frailty is oriented toward the psycho-physical well-being of the elderly, as a diachronic balance between individual resources and living environment, according to current World Health Organization guidelines.
From this perspective, healthy aging is understood as the process of developing and maintaining functional capacity, i.e., the combination and interaction between the surrounding environment and intrinsic capacity (i.e., the totality of individual physical and cognitive resources), throughout the life span. Frailty, which is often mistakenly regarded as synonymous with disability and multimorbidity, fits into the process as a complex, multifactorial, age-related and potentially reversible entity characterized by increased vulnerability to adverse events of endogenous and exogenous origin, which exposes the individual to a kind of acceleration of the natural process of depletion of functional capacity due to advancing age.
The work of the working group aims to provide useful guidance for the prioritization of interventions targeting the elderly population, using GBD estimates made available by the Institute of Health Metrics and Evaluation (IHME), pursuing the following main purposes:
- verification of available data and GBD estimates to date on aging in order to highlight any gaps and promote necessary additions, including proposing other sources at the national or regional level;
- insights into the burden of disease attributable to chronic diseases and functional decline, understood as a proxy for frailty, in the elderly population;
- assessment of temporal variations, geographic differences, and factors associated with selected outcomes, with particular attention to inequalities related to sex/gender, age group, and socioeconomic status.