Disease and Mortality in Sub-Saharan Africa pot

Disease and Mortality
in Sub-Saharan Africa
Edited by
Dean T. Jamison, Richard G. Feachem, Malegapuru W. Makgoba,
Eduard R. Bos, Florence K. Baingana, Karen J. Hofman, and Khama O. Rogo
Second Edition

Disease and Mortality in Sub-Saharan Africa
Second Edition

Disease and Mortality
in Sub-Saharan Africa
Second Edition
Editors
Dean T. Jamison
Richard G. Feachem
Malegapuru W. Makgoba
Eduard R. Bos
Florence K. Baingana
Karen J. Hofman
Khama O. Rogo
THE WORLD BANK
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©2006 The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW
Washington, DC 20433
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Internet: www.worldbank.org
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1 2 3 4 09 08 07 06

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ISBN-10: 0-8213-6397-2
ISBN-13: 978-0-8213-6397-3
eISBN: 0-8213-6398-0
DOI: 10.1596/978-0-8213-6397-3
Library of Congress Cataloging-in-Publication data has been applied for.
Contents
v
Foreword xiii
Acknowledgments xv
Contributors xvii
Abbreviations and Acronyms xxi
Chapter 1 Changing Patterns of Disease and Mortality in Sub-Saharan

Africa: An Overview 1
Florence K. Baingana and Eduard R. Bos
Chapter 2 Levels and Trends in Mortality in Sub-Saharan Africa: An Overview 11
Jacob Adetunji and Eduard R. Bos
Chapter 3 Trends in Child Mortality, 1960 to 2000 15
Kenneth Hill and Agbessi Amouzou
Chapter 4 Levels and Trends of Adult Mortality 31
Debbie Bradshaw and Ian M. Timaeus
Chapter 5 Causes of Death 43
Chalapati Rao, Alan D. Lopez, and Yusuf Hemed
Chapter 6 Population and Mortality after AIDS 59
Rodolfo A. Bulatao
Chapter 7 Levels and Patterns of Mortality at INDEPTH Demographic
Surveillance Systems 75
Osman A. Sankoh, Pierre Ngom, Samuel J. Clark, Don de Savigny, and Fred Binka
Chapter 8 Trends and Issues in Child Undernutrition 87
Todd Benson and Meera Shekar
Chapter 9 Diarrheal Diseases 107
Cynthia Boschi-Pinto, Claudio F. Lanata, Walter Mendoza, and Demissie Habte
Chapter 10 Developmental Disabilities 125
Geoff Solarsh and Karen J. Hofman
Chapter 11 Acute Respiratory Infections 149
Shabir A. Madhi and Keith P. Klugman
Chapter 12 Vaccine-Preventable Diseases 163
Mark A. Miller and John T. Sentz
Chapter 13 Tuberculosis 179
Christopher Dye, Anthony D. Harries, Dermot Maher, S. Mehran Hosseini,
Wilfred Nkhoma, and Felix M. Salaniponi
Chapter 14 Malaria 195
Robert W. Snow and Judy A. Omumbo

Chapter 15 Onchocerciasis 215
Uche Amazigo, Mounkaila Noma, Jesse Bump, Bruce Benton, Bernhard Liese,
Laurent Yaméogo, Honorat Zouré, and Azodoga Seketeli
Chapter 16 Maternal Mortality 223
Khama O. Rogo, John Oucho, and Philip Mwalali
Chapter 17 HIV/AIDS 237
Souleymane Mboup, Rosemary Musonda, Fred Mhalu, and Max Essex
Chapter 18 Lifestyle and Related Risk Factors for Chronic Diseases 247
Krisela Steyn and Albertino Damasceno
Chapter 19 Diabetes Mellitus 267
Jean-Claude Mbanya and Kaushik Ramiaya
Chapter 20 Cancers 289
Freddy Sitas, Max Parkin, Zvavahera Chirenje, Lara Stein, Nokuzola Mqoqi,
and Henry Wabinga
Chapter 21 Cardiovascular Disease 305
Anthony Mbewu and Jean-Claude Mbanya
Chapter 22 Mental Health and the Abuse of Alcohol and Controlled Substances 329
Florence K. Baingana, Atalay Alem, and Rachel Jenkins
Chapter 23 Neurological Disorders 351
Donald Silberberg and Elly Katabira
Chapter 24 Violence and Injuries 361
Brett Bowman, Mohamed Seedat, Norman Duncan, and Olive Kobusingye
Index 375
Boxes
1.1 Synopsis of the Key Concerns for DMSSA-1 2
1.2 The Health-Related Millennium Development Goals and Indicators 7
13.1 The WHO Stop TB Strategy 186
13.2 Main Constraints to Improving TB Control, as Identified by National Program
Managers in Africa 190
16.1 Model of Three Levels of Delay 233

19.1 Organization of Diabetes Care 282
Figures
1.1 Real GDP per Capita Growth, by Region, 1991–2015 4
1.2 Real GDP per Capita, by Developing Region, 1980–2003 4
1.3 Population below Age 15, 2003 6
1.4 Median Age of Population, 1990 and 2003 6
1.5 Total Fertility Rate, 1990 and 2003 6
1.6 Age Pyramid for Botswana, 2005, with and without AIDS 6
2.1 Infant Mortality Rate in Selected Countries, 1960–2005 13
vi | Contents
2.2 Life Expectancy in Selected Countries 14
3.1 Contrasting Data Availability: The Republic of Congo and Kenya 16
3.2 Estimated Levels of Under-Five and Infant Mortality, by Region of Africa, 2000 18
3.3 Trends in Under-Five Mortality, by Five-Year Period and Region, 1960–2000 19
3.4 Annual Rate of Change in Under-Five Mortality, by Five-Year Period, 1965–2000 20
3.5 Relationships between CHMR and IMR, by Country 20
3.6 Estimated Relationships between CHMR and IMR, by Region 21
3A.1 Fitted Trends Using Different Numbers of Knot Parameters 23
3B.1 Examples of “Quality” Categories for Selected Countries 29
4.1 Probabilities of Dying between Exact Ages 15 and 60 in Sub-Saharan Africa, by Sex 35
4.2 Conditional Probabilities of Dying between Ages 30 and 65 in Zimbabwe,
by Sex, from Different Data Sources, 1969–90 36
4.3 Conditional Probabilities of Dying between Ages 15 and 60 in South Africa,
by Sex, from Different Data Sources, 1980–2000 36
4.4 Age Distribution of Reported Adult Deaths on the National Population Register
of South Africa, by Sex, 1998–2003 37
4.5 Trend in the Estimates of the Probabilities of Dying between Ages 15
and 60 (
45
q

15
), by Sex and WHO Region, from DHS Sibling Histories 38
5.1 Global Mortality Strata for GBD 2000 Regions 48
5.2 Estimated Age-Specific Death Rates for Zambia, 2000 49
5.3 Model-Based Predictions of GBD Cause–Group Composition of Mortality
by Age and Sex, Zambia, 2000 49
5.4 Summary of GBD Process for Estimating Cause-Specific Mortality in African
Countries 53
6.1 Projected Population, Sub-Saharan Africa and Three Selected Countries 62
6.2 Projected Crude Birth Rate, Sub-Saharan Africa and Botswana 64
6.3 Distribution of Women of Reproductive Age in the UN Projection
and the No-AIDS Scenario, Botswana 64
6.4 Mortality Effects on Population, Relative to the No-AIDS Scenario,
in Different Projections 64
6.5 Projected Life Expectancy, Sub-Saharan Africa and Three Selected Countries 65
6.6 HIV Prevalence and Maximum Loss in Life Expectancy in Alternative Projections 66
6.7 Female Advantage in Life Expectancy, Sub-Saharan Africa and Three
Selected Countries 67
6.8 Adult Mortality (
45
q
15
) by Sex in UN Projections, Sub-Saharan Africa and Lesotho 68
6.9 Sex Ratios by Age from UN Projections, Zimbabwe 68
6.10Dependency Ratio,Sub-Saharan Africa and Three Selected Countries69
6.11 Consistency among Alternative Estimates of Current Adult Mortality (
45
q
15
)70

6.12HIV Prevalence in 2001 and 200370
6.13 Alternative Population Projections, Zambia and Botswana 72
6.14 Alternative Projections of Life Expectancy in Zambia and Botswana 72
7.1 Standard Population Age Structure from INDEPTH, Segi, and WHO 78
7.2 Crude Death Rate and Expectation of Life at Birth 79
7.3 Child Mortality: Probability of Dying between Birth and Age Five (
5
q
0
)80
7.4 INDEPTH Mortality Patterns 1–7, ln(
n
q
x
)83
8.1 The UNICEF Conceptual Framework of the Determinants of Nutritional Status 89
8.2 The Burden of Undernutrition through the Life Cycle and across Generations 91
8.3 Prevalence of Stunting in Children Age 6 to 60 Months, by Country 93
8.4 Subnational Estimates of the Prevalence of Underweight Preschool Children
and Area Density of Underweight Children 94
8.5 Stunting Prevalence among Preschoolers, by Urban or Rural Residence,
Selected Countries 95
Contents | vii
8.6 Prevalence of Underweight Preschool Children by Wealth Quintile,
Selected Countries 95
8.7 Under-Five Mortality Rates and Progress Being Made in Reducing Under-Five
Mortality, by Country 96
8.8 Scatter Plot of National Under-Five Mortality and Underweight Prevalence Rates 96
8.9 Daily Dietary Energy Supply Available and Food Production Index, by Country 97
8.10 Access to Safe Water and Adequate Sanitation, by Country 98

8.11 Health Services, by Country 99
8.12 Female Adult Literacy Rates and Girls’ Net Primary Enrollment Rates, by Country 100
8.13 Proportion of Infants Receiving Only Breast Milk in the First Year of Life,
Selected Countries 101
8.14 Effect of Economic Growth on Attaining the Millennium Development Goal
of Reducing the Prevalence of Underweight Preschool Children, Tanzania 105
9.1 Slowing Progress in Child Mortality 108
9.2 Sites with Available Under-Five Diarrhea Mortality Data 109
9.3 Medians of Diarrheal Proportional Mortality among Children under Five
in the African Region, 1980–95 111
9.4 Medians of Diarrheal Proportional Mortality among Children under
Five in the African Region and Other Developing Regions, 1980–95 111
9.5 Change in Sanitation Coverage by Region, 1990–2000 115
10.1 Relationship between Impairment, Disability, and Handicap (ICIDH) 126
10.2 Relationship between Body Functions, Activities, and Participation (ICF) 126
10.3 Research Steps in the Development of Public Health Interventions 133
10.4 Causal Pathways for Developmental Disabilities 141
12.1 Percentage of Target Population in Africa Vaccinated, by Vaccine Type, 1980–2002 164
12.2 Immunization Coverage with Measles-Containing Vaccines, 2003 166
12.3 Maternal and Neonatal Tetanus Elimination Status, 2002 169
12.4 Global and Regional Immunization Coverage, Three Doses DTP, 1980–2001 169
12.5 Epidemics of Yellow Fever in Africa Reported to the WHO, 1980–2003 170
12.6 African Nations Using Hepatitis B Vaccine in a National Infant Immunization
Campaign, 2002 171
12.7 Number of Childhood Vaccines Routinely Used in Developing and Established-
Market Countries 173
13.1 Relative Incidence of TB in HIV-Infected Individuals as a Function
of CD4
ϩ
Cell Count 183

13.2 Estimated Incidence Rates of New TB Cases and Percentages of TB Patients
Infected with HIV, by Country, 2004 183
13.3 Trends in TB (All Forms) Case Notifications in the WHO African Region
Contrasted with Trends in Other Parts of the World 184
13.4 Estimated TB Incidence in Relation to Estimated HIV Prevalence in Adults
Age 15 to 49 for 42 Countries in the WHO African Region 184
13.5 Prevalence of HIV in TB Cases (All Forms) in Relation to HIV Prevalence
in Adults Age 15 to 49 185
13.6 Progress toward the Target of 70 Percent Case Detection in the WHO African
Region, Compared with the Average Progress Worldwide 187
13.7 Expected Reductions in the Number of TB Cases in Kenya over 10 Years 189
13.8 Proportional Reduction in the Incidence of TB over 20 Years among HIV-Positives
as a Function of Effective Coverage and the CD4
ϩ
Count per Microliter
at Which People Start ARV Therapy 189
14.1 Malarial Risks in Children Age 0 to 14 Years in a Stable Endemic Area
of the Kenyan Coast 196
14.2 Public Health Effects of Plasmodium falciparum Malaria 196
viii | Contents
14.3 Fuzzy Climate Suitability Membership for Malaria 198
14.4 Malaria-Specific and All-Cause Mortality Estimates per Year for Children
under Five 207
14.5 Malaria-Specific, Nonmalaria, and All-Cause Mortality Rates
among Children under Five 208
15.1 Prevalence of Onchocerciasis Infection in 1974 and Gradual Expansion, 1977–92 218
15.2 Prevalence of Onchocerciasis Infection in 2002 219
15.3 Scaling Up with Additional Interventions 219
16.1 Major Causes of Maternal Mortality in Sub-Saharan Africa 229
16.2 Relation between Skilled Attendant at Delivery and MMR for All Countries, 1995 231

16.3 Effects of the Introduction in Romania of an Anti-Abortion Law
in 1966 and Legalization of Abortion in 1989 232
17.1 Disease Burden and Treatment of AIDS in Relation to Global Population
and Economy 238
17.2 Global Burden of HIV-1 Infection 238
17.3 Distribution of Major HIV-1 Subtypes and Circulating Recombinant Forms
in Africa 241
18.1 Fat and Carbohydrate Intake as Functions of Proportion of Life Spent in a City 251
18.2 Macronutrient Intakes in South Africans, per Capita, 1993 and 1999 251
19.1 Prevalence of Diabetes with Increasing Age in Cameroon 276
19.2 Mean Fasting Blood Glucose by Tertiles of Walking Energy Expenditure
in Women: The Cameroon Study 277
19.3 Cost of Different Types of Insulin in Relation to the Gross National Product 282
20.1 Distribution of Radiation Therapy Services in Africa 290
20.2 Major Cancer Types in Sub-Saharan Africa, Both Sexes, All Ages 292
20.3 Number of Cigarettes Consumed per Adult 300
21.1 Cardiovascular Disease, Age-Standardized Rates in the World, 1994–2000 308
21.2 Probability of Death by Broad Cause in Men between the Ages of 15 and 60 Years
in Tanzania 317
Tables
1.1 Gross National Income, per Capita, 1980, 1990, 2003 5
1.2 Overview of Health Worker Vacancy Rates for Four Countries 8
1.3 Conflict-Related Deaths by Region 9
2.1 Life Expectancy at Birth for World and UN Regions, 1960–2005 12
2.2 Infant Mortality Rates for World and UN Regions, 1960–2005 13
2.3 Infant Mortality Rates for Sub-Saharan Africa and UN Subregions, 1960–2005 13
2.4 Life Expectancy at Birth for Sub-Saharan Africa and UN Subregions, 1960–2005 13
3B.1 Estimates of Under-Five Mortality, by Country and Year 26
3B.2 Estimates of Infant Mortality, by Country and Year 27
3B.3 Countries and Data Sources 28

4.1 Probabilities of Dying between Ages 15 and 60 (
45
q
15
) in Sub-Saharan Africa 34
4.2 Probabilities of Dying between Ages 15 and 60 (
45
q
15
), by Sex, according to
Intercensal Survival, Malawi 35
4.3 Orphanhood Estimates of Person-Years Lived and Lost at Ages 35–75 (Men)
and 25–75 (Women), Kenya 35
4.4 Estimates of the Probability of Dying between Ages 15 and 60(
45
q
15
), from
DHS Sibling Histories 40
5.1 Proportion of Deaths Due to Diseases and Injuries in Children under Five Years,
by Source of Data 44
5.2 Proportion of Deaths Due to Diseases and Injuries in Children Age 5 to 14 Years,
by Source of Data 44
Contents | ix
5.3 National Vital Records Data: Proportionate Distribution of Cause of Death
of Children under Five 46
5.4 National Vital Records Data: Proportionate Distribution of Cause of Death
at Age 5 to 14 Years 46
5.5 National Vital Records Data: Proportionate Distribution of Cause of Death
at Age 15 to 44 Years 47

5.6 National Vital Records Data: Proportionate Distribution of Cause of Death
at 45 Years of Age and Older 47
5.7 Epidemiological Estimates of Malaria Mortality in Nonpregnant African
Population, 1995 50
5.8 Estimates of Diarrheal Deaths of Children under Five, 2000 50
5.9 GBD Estimates of Leading Causes of Death, by Sex, 2000 53
5.10 GBD Estimates of Leading Causes of Death in AFR D and AFR E, 2000 54
5.11 GBD Estimates of Leading Causes of Death at Age 0 to 14 Years, 2000 55
5.12 GBD Estimates of Leading Causes of Death at Age 15 to 59 Years, Subregional
Comparison, 2000 55
5.13 GBD Estimates of Leading Causes of Death in AFR E at Age 15 to 59 Years:
Comparison between Males and Females, 2000 56
5.14 GBD Estimates of Leading Causes of Death at Age 60 Years and Older:
Comparison between Males and Females, 2000 56
6.1 Effects of Demographic Factors in Producing Differences between Projections 63
6.2 Estimates of HIV Prevalence among Adults Age 15 to 49, 2001–03 71
7.1 Summary of Mortality Data from INDEPTH Sites, 1995–99 77
7.2 Crude Death Rates and Expectation of Life at Birth 79
7.3 Infant and Child Mortality 80
7.4 Adult Mortality and Child and Adult Mortality Ratio 81
8.1 Percentage of Total Estimated Annual Burden of Disease in Africa Attributed
to Major Risk Factors 88
8.2 Indicators of Nutritional Status 90
8.3 Effects of Deficiency of Micronutrients and Principal Dietary Sources 92
8.4 Projected Impact of Economic Growth and Direct Large-Scale Nutrition
Intervention Programs on Stunting and Poverty, Kagera Region, Tanzania, 2015 102
9.1 Median Estimates of Episodes of Diarrhea per Child per Year in the African Region,
by Age Group 110
9.2 Estimated Number and Proportion of Deaths Due to Diarrhea among Children
under Five 112

9.3 Available Etiology Data, by Country and Study Setting 113
9.4 Median of the Proportions of Etiological Agents among Children under Five
in the AFR D Subregion, by Study Site 113
9.5 Median of the Proportions of Etiological Agents among Children under Five
in the AFR E Subregion, by Study Site 114
9.6 Feces Disposal Practices at Home, by Urban and Rural Residences in Four
African Countries 115
9.7 Prevalence (Median) of Diarrheal Disease, the Two Weeks before Survey,
by Urban and Rural Site of Residence in AFR D and AFR E 116
9.8 Children under Five Taken to Health Facilities or Receiving Treatment
for Diarrheal Disease in the Two Weeks before Survey, by Sex 116
9.9 Cases and Deaths Due to V. c h o l e r a e Reported to WHO, 1996–2001 116
9A.1 Regional Reporting Categories for Global Burden of Disease 2000: WHO
African Subregions 117
9A.2 Main Characteristics of the Studies Included in the Morbidity Review 117
9A.3 Main Characteristics of the Studies Included in the Mortality Review 118
x | Contents
9A.4 Main Characteristics of the Studies Included in the Etiology Review 119
10.1 Prevalence of Disability in Sub-Saharan Africa 129
10.2 Prevalence of Disability in Other Developing Countries 130
10.3 Prevalence of Hearing Disability in Sub-Saharan Africa 131
10.4 Estimated Birth Prevalence of Infants with Serious Congenital Disorders,
by WHO Region 133
11.1 Results of Lung Aspirations of Children Who Had Not Received Antibiotics
and Not Mentioned Underlying Illness 154
11.2 Estimated Incidence of Organism-Specific, Bacteremic, Community-Acquired
Severe LRTI in HIV-1-Infected and HIV-1-Uninfected Children Age 2 to 24 Months 154
11.3 Estimated Incidence for Specific Viral-Associated Severe LRTI in HIV-1-Infected
and HIV-1-Uninfected Children Age 2 to 23 Months 155
12.1 WHO-Estimated Deaths and DALYs from Vaccine-Preventable Diseases, 2002 164

12.2 Potential Deaths Averted by HBV, Hib, Rotavirus, and SP Vaccine Implementation 174
13.1 The Contribution of Sub-Saharan Africa to the Global TB Epidemic 184
14.1 Populations at Risk During 2000 199
14.2 Median and Interquartile Ranges of Malaria-Specific Mortality Estimates
per 1,000 People per Year 201
14.3 Estimated Numbers of Malaria-Specific Deaths and Interquartile Ranges
during 2000 202
15.1 Scaling up APOC, 1996–2003 220
16.1 Maternal Mortality Measures, 1990, 1995, and 2000 226
16.2 Maternal Mortality Measures in Sub-Saharan Africa, by Country, 1990–2000 227
17.1 HIV-1 Prevalence in Representative Regions and Countries 239
18.1 Exposure to Tobacco Products of Participants, Age 13–15 Years, in the Global
Youth Tobacco Survey, 1999–2001 249
18.2 Prevalence of Adults Who Smoke Cigarettes, by Country 250
18.3 Anthropometric Indicators, by Country 254
18.4 Large Prevalence Studies on Hypertension since 1997, by Country 256
18.5 Mean Lipid Levels and Prevalence of Dyslipidemia in Black Subjects 259
18.6 The Clustering of NCD Risk Factors in Nigerian Subjects 260
19.1 Data Sources for the Prevalence of Type 2 Diabetes and IGT, by Year of Study 268
19.2 Data Sources for Prevalence Estimates of Diabetes Mellitus and IGT,
by Country, 2003 269
19.3 Data Sources for the Prevalence of Diabetes Complications, by Disease and Year 271
19.4 Prevalence Estimates of Diabetes Mellitus, by Country, 2003 274
19.5 Prevalence Estimates of IGT, by Country, 2003 275
19.6 Projections of Diabetes and IGT from 2003 to 2025 in the Age Group
of 20 to 79 Years 276
19.7 Calculated Estimates of the Costs of Diabetes Care, by Country 281
20.1 Estimated Percentages of Deaths, by Cause, 2002 290
20.2 Cumulative Incidence of Cancer in Women up to 64 Years of Age, 1993–97 290
20.3 Estimated Number of New Cases and Age-Standardized (World) Incidence Rates

for the Leading Cancers in Males and Females, 2002 291
20.4 Prevalence of Hepatitis C Virus IgG Antibodies in Sub-Saharan Africa, 2000 296
21.1 The Epidemiological Transition in the Seychelles, 1976 and 1994 306
21.2 Incidence of Stroke 310
21.3 The Relation between CVD, Risk Factors, Behaviors, and Determinants 314
21.4 Risk Factors for CHD Reported from Hospital Patients 315
21.5 Prevalence of Hypertension, by Country 316
21.6 Prevalence of Diabetes, by Country 318
21.7 Prevalence of Tobacco Smoking, by Country 318
Contents | xi
21.8 Prevalence of Alcohol Consumption, by Country 318
21.9 Prevalence of Obesity, by Country 319
21.10 Prevalence of Obesity in Women Age 15 to 49 Years, by Country 319
22.1 Age-Standardized Incidence, Prevalence, and Mortality Rate Estimates for WHO
AFRO Epidemiological Subregions, 2000 332
22.2 YLD, YLL, and DALY Estimates for WHO AFRO Epidemiological Subregions, 2000 333
22.3 Summaries of Selected Studies on Suicide and Parasuicide 336
22.4 Selected Studies on the Psychosocial and Mental Health Consequences of HIV/AIDS 340
22A.1 Selected Sub-Saharan Africa Data on Mental Health Disorders 345
24.1 Cause of Injury by Outcome: Mukono District, Uganda 366
24.2 Cause of Injury by Outcome: Kawempe Division, Kampala District, Uganda 366
24.3 Cause of Injury by Outcome: Gulu District, Uganda 367
24.4 Top Three Causes of Injury, by Age, Rural District (Mukono), Uganda 367
24.5 Top Three Causes of Injury, by Age, Urban Division (Kawempe), Uganda 368
xii | Contents
Foreword
More attention is now focused on improving the health of the
population of Sub-Saharan Africa than at any previous time. In
the years since the publication of the first edition of Disease and
Mortality in Sub-Saharan Africa in 1991,numerous reports have

been issued by national governments, development agencies,
and researchers addressing the health status of African popula-
tions and proposing strategies to more effectively combat poor
health with improved delivery of health services to prevent and
cure diseases. Prime among these was the World Bank’s 2005
report Improving Health, Nutrition and Population Outcomes in
Sub-Saharan Africa—The Role of the World Bank, which gave
rise to the publication of this book.Increased funding for health
from governments, multilateral and bilateral donors, as well as
new public-private partnerships and foundations has become
available for assisting African countries to deliver more effective
health interventions. The Millennium Development Goals have
focused the attention of the world on achieving a clear set of
goals—several of which are directly concerned with improving
health outcomes—to be achieved by 2015.
Yet the sobering reality is that life expectancy has decreased
by almost five years for the continent as a whole since the 1991
publication, and by much more in some countries. As the chap-
ters in this volume document, children under five are dying at
unacceptably high rates from causes for which effective inter-
ventions exist, and adult mortality from infectious diseases
has risen to extraordinary levels. HIV/AIDS has spread from
eastern Africa to the rest of the continent, affecting southern
African countries the most. Malaria mortality of children
increased during the 1990s, and TB has reemerged as a leading
cause of death for adults, largely due to the spread of AIDS. Not
surprisingly, at this time Sub-Saharan Africa is not on track to
reach any of the health Millennium Development Goals.
It is important to recognize that not all trends have been neg-
ative. The prevalence of HIV/AIDS has significantly decreased

in several African countries, including Uganda, one of the
worst-affected countries at the time of the publication of the
first edition. Measles mortality has been virtually eliminated in
the countries of southern Africa in the past decade. Enormous
strides continued to be made in the control of onchocerciasis
during the 1990s. Although many factors contributed to these
successes, a common theme in these and other successful pro-
grams has been the emphasis on the monitoring of disease indi-
cators and the effectiveness of programs to address them.
Without knowledge of disease incidence, prevalence, and sever-
ity, setting policies for prioritizing interventions risks misallo-
cating resources to combat causes of ill health that contribute
little to the overall health status of a population. Good epidemi-
ological information does not ensure good policy decisions or
effective implementation, but without reliable epidemiological
data, efforts to design cost-effective strategies and to implement
technologies are no more than theoretical exercises.
Since the publication of the first edition of Disease and
Mortality in Sub-Saharan Africa, many new sources of health
and demographic information have become available, includ-
ing data on trends in HIV infection from antenatal clinic sur-
veillance sites, the first set of African life tables from a growing
number of demographic surveillance sites, injury statistics
from a small number of injury mortality surveillance registers,
and cancer data from cancer registers. Improved methods for
estimating the incidence of several other diseases, including
tuberculosis, maternal mortality, and chronic diseases, have
also improved the reliability of health statistics. Verbal autopsy
studies have linked with demographic surveillance sites, adding
to our knowledge on changes in the cause-of-death composi-

tion in several countries.
Notwithstanding these advances in health statistics, a theme
that emerges from all the chapters in this volume is that too
little is known about trends in the diseases and conditions
included here in order to monitor and evaluate the effective-
ness of programs intended to produce better health outcomes.
As we get closer to the 2015 end point of the Millennium
Development Goals, reaching the goals will become increas-
ingly challenging. The continued improvement of disease sur-
veillance and other regularly published health information
remains as important a priority for African health systems as it
was for the first edition.
Callisto Madavo
Former Vice-President
Africa Region
The World Bank
xiii

This publication consists of the contributions of 70 authors,
coordinated by a group of editors at the World Bank (Florence
Baingana, Eduard Bos, and Khama Rogo), the U.S. National
Institutes of Health (Karen Hofman and Dean Jamison), the
Global Fund to Fight AIDS, Tuberculosis, and Malaria (Richard
Feachem), and the South African Medical Research Council
(Malegapuru Makgoba). Management of the publication was
carried out jointly at the World Bank and, for a subset of chap-
ters, at the South African Medical Research Council.
The editors are grateful to the chapter authors, named at the
beginning of each of their respective chapters, who worked
tirelessly to produce the various drafts and revisions.

The editors thank the following reviewers of draft chapters:
Larry Barat (World Bank, USA), George Bicego (South Africa
CDC, South Africa), Gretchen Birbeck (Michigan State
University, USA, and The Gambia), Martien Borgdoff (The
Netherlands), Julie Cliff (Mozambique), Jerry Coovadiah
(University of Natal, South Africa), Andrew Grulich
(University of New South Wales, Australia), David Gwatkin
(World Bank, USA), Kenneth Hill (Johns Hopkins University,
USA), Adnan Hyder (Johns Hopkins University, USA), Jean-
Claude Mbanya (Yaounde University, Cameroon), Samuel
Lantei Mills (World Bank, USA), Pindile Mntla (Medical
University of Southern Africa, South Africa), David Ndetei
(Nairobi University, Kenya), Steven Obaro (Imperial College
School of Medicine, UK), Robert Redfield (University of
Maryland, USA), Brian Robertson (Cape Town University,
South Africa), Daniel M. Sala-Diakanda (IFORD, Cameroon),
Eugene Sobngwi (Yaounde University, Cameroon), David
Thomas (Fred Hutchinson Cancer Research Center, USA), and
Mark Wainberg (McGill University, Canada).
The publication of this volume was made possible by the
generous support of the government of the Netherlands
through the Bank-Netherlands Partnership Program (BNPP)
at the World Bank. The editors are grateful to Julie McLaughlin
and Ok Pannenborg of the Africa Region of the World Bank
for initiating and subsequently overseeing the whole process
leading to the publication of this book. Administrative and
logistical support was provided by Carole Roberts of the South
African Medical Research Council and Richard Babumba of
the World Bank. Rifat Hasan of the World Bank guided the
manuscript through the final stages and produced an

“Executive Summary” for distribution at the High-Level
Forum on the Health Millennium Development Goals meeting
in Paris, 2005. Anne-Sophie Ville and Willyanne DeCormier
Plosky also provided support.
The editors are also grateful to the World Bank and the
Fogarty International Center of the U.S. National Institutes of
Health, which allowed the editors and authors from these insti-
tutions to dedicate staff time to contribute to this publication.
xv
Acknowledgments

Volume Editors
Dean T. Jamison, Professor, Institute for Global Health,
University of California, San Francisco
Richard G. Feachem, Executive Director, Global Fund to
Fight AIDS, Tuberculosis, and Malaria; and Director, Institute
for Global Health, University of California, San Francisco
and Berkeley
Malegapuru W. Makgoba, Vice-Chancellor and Principal,
University of KwaZulu-Natal, South Africa
Eduard R. Bos, Lead Population Specialist, Human
Development Network, The World Bank, Washington, DC
Florence K. Baingana, Senior Health Specialist, Human
Development Network, The World Bank, Washington, DC
Karen J. Hofman, Director, Division of Advanced Studies and
Policy Analysis, Fogarty International Center, National
Institutes of Health, Washington, DC
Khama O. Rogo, Lead Specialist, Africa Region, The World
Bank, Washington, DC
Chapter Authors

Jacob Adetunji, Technical Adviser, U.S. Agency for
International Development, Washington, DC
Atalay Alem, Psychiatrist, Amanuel Psychiatric Hospital,
Faculty of Medicine, Addis Ababa University, Ethiopia
Uche Amazigo, Director, African Programme for
Onchocerciasis Control, Ouagadougou, Burkina Faso
Agbessi Amouzou, PhD Candidate, Department of Population
Dynamics, John Hopkins University, Baltimore, Maryland
Florence K. Baingana, Senior Health Specialist, The World
Bank, Washington, DC
Todd Benson, Research Fellow, Food Consumption and
Nutrition Division, International Food Policy Research
Institute, Washington, DC
Bruce Benton, Public Health Adviser, Human Development
Department, Africa Region, The World Bank,
Washington, DC
Fred Binka, Executive Director, INDEPTH Network, Accra,
Ghana
Eduard R. Bos, Lead Population Specialist, Human
Development Network, The World Bank, Washington, DC
Cynthia Boschi-Pinto, Medical Officer, Department of Child
and Adolescent Health and Development, World Health
Organization, Geneva
Brett Bowman, Senior Researcher, Institute for Social and
Health Sciences, University of South Africa
Debbie Bradshaw, Director, Burden of Disease Research Unit,
Medical Research Council, South Africa
Rodolfo A. Bulatao, Independent Consultant, Washington, DC
Jesse Bump, Consultant, Onchocerciasis Coordination Unit,
Human Development Department, Africa Region, The World

Bank, Washington, DC
Zvavahera Chirenje, Lecturer/Consultant, Department of
Obstetrics and Gynaecology, College of Health Sciences,
University of Zimbabwe, Harare
Samuel J. Clark, Assistant Professor, Department of
Sociology, University of Washington, Seattle; Research
Associate, Institute of Behavioral Science, University of
Colorado at Boulder; and Research Officer, MRC/Wits Rural
Public Health and Health Transitions Research Unit
(Agincourt), School of Public Health, University of the
Witwatersrand, South Africa
Albertino Damasceno, Professor of Cardiology, Faculty of
Medicine, Eduardo Mondlane University, Mozambique
Don de Savigny, Head of Unit, Clinical and Intervention
Epidemiology, Swiss Tropical Institute, Basel, Switzerland
Norman Duncan, Chair, Department of Psychology,
University of the Witwatersrand, South Africa
xvii
Contributors
Christopher Dye, Coordinator, Tuberculosis Monitoring and
Evaluation, Stop TB Department, World Health Organization,
Geneva
Max Essex, Chair, Department of Immunology and Infectious
Diseases, Harvard AIDS Institute, and the Botswana-Harvard
AIDS Institute Partnership, Harvard School of Public Health,
Boston, Massachusetts
Demissie Habte, International Director, James P. Grant
School of Public Health, BRAC University, Bangladesh
Anthony D. Harries, Technical Adviser, HIV Care and
Support, Ministry of Health, Lilongwe, Malawi

Yu s uf H emed, Coordinator, MEASURE Evaluation, Dar es
Salaam, Tanzania
Kenneth Hill, Professor, Department of Population and
Family Health Sciences, Johns Hopkins University, Baltimore,
Maryland
Karen J. Hofman, Director, Division of Advanced Studies and
Policy Analysis, Fogarty International Center, National
Institutes of Health, Bethesda, Maryland
S. Mehran Hosseini, Epidemiologist, Stop TB Department,
World Health Organization, Geneva
Rachel Jenkins, Director, World Health Organization–United
Kingdom Collaborating Centre, Institute of Psychiatry, Kings
College London
Elly Katabira, Neurologist, Department of Neurology,
Makerere Medical School, Kampala, Uganda.
Keith P. Klugman, Codirector, Medical Research Council
Respiratory and Meningeal Pathogens Research Unit, National
Institute of Communicable Diseases, University of the
Witwatersrand, Johannesburg, South Africa; and Professor,
Department of Global Health, Rollins School of Public Health
and Division of Infectious Diseases, School of Medicine,
Emory University, Atlanta, Georgia
Olive Kobusingye, Adviser, Violence and Injury Prevention,
and Disabilities, World Health Organization Regional Office
for Africa, Brazzaville, Congo
Claudio F. Lanata, Senior Researcher, Instituto de Investigación
Nutricional, Lima, Peru
Bernhard Liese, Public Health Adviser, Human Development
Department, Africa Region, The World Bank,
Washington, DC

Alan D. Lopez, Professor and Head of School, School of
Population Health, University of Queensland, Herston,
Australia
Shabir A. Madhi, Codirector, Medical Research Council
Respiratory and Meningeal Pathogens Research Unit, National
Institute of Communicable Diseases, University of the
Witwatersrand, Johannesburg, South Africa
Dermot Maher, Medical Officer, Stop TB Department, World
Health Organization, Geneva
Jean-Claude Mbanya, Endocrine and Diabetes Unit,
Department of Internal Medicine and Specialities, Faculty of
Medicine and Biomedical Sciences, University of Yaoundé I,
Yaoundé, Cameroon
Anthony Mbewu, President, Medical Research Council, South
Africa; and Visiting Professor in Medicine and Cardiology,
University of Cape Town, South Africa
Souleymane Mboup, Professor of Microbiology, Laboratory
of Bacteriology and Virology, CHU Le Dantec, Université
Cheikh Anta Diop, Dakar, Senegal
Walter Mendoza, Researcher, Instituto de Investigación
Nutricional, Lima, Peru
Fred Mhalu, Professor of Microbiology and Immunology,
Muhimbili University College of Health Sciences, Dar es
Salaam, Tanzania
Mark A. Miller, Director, Division of International
Epidemiology and Population Studies, Fogarty International
Center, National Institutes of Health, Bethesda, Maryland
Nokuzola Mqoqi, National Cancer Registry and Cancer
Epidemiology Research Group, National Health Laboratory
Service, Johannesburg, South Africa

Rosemary Musonda, Director, National AIDS Council,
Lusaka, Zambia
Philip Mwalali, International Health Consultant and Medical
Adviser, African Economic Foundation, Los Angeles,
California
Pierre Ngom, Senior Research Adviser, Family Health
International, Nairobi, Kenya
Wilfred Nkhoma, Regional Adviser (Tuberculosis), World
Health Organization, Harare, Zimbabwe
Mounkaila Noma, Chief, Epidemiology and Vector
Elimination Unit, African Programme for Onchocerciasis
Control, Ouagadougou, Burkina Faso
Judy A. Omumbo, Research Fellow, Public Health Group,
Kenya Medical Research Institute-Wellcome Trust
Collaborative Program, Nairobi, Kenya
John Oucho, Professor of Demography and Chairman,
African Population and Environment Institute, Nairobi, Kenya
xviii | Contributors
Max Parkin, Chief, Unit of Descriptive Epidemiology,
International Agency for Research on Cancer, Lyons, France
Kaushik Ramiaya, Consultant Physician and Assistant
Medical Administrator, Shree Hindu Mandai Hospital,
Dar es Salaam, Tanzania
Chalapati Rao, Lecturer, School of Population Health,
University of Queensland, Herston, Australia
Khama O. Rogo, Lead Specialist, Africa Region, The World
Bank, Washington, DC
Felix M. Salaniponi, Programme Director, National
Tuberculosis Control Programme, Ministry of Health,
Lilongwe, Malawi

Osman A. Sankoh, Manager, Communications and External
Relations, INDEPTH Network Secretariat, Accra, Ghana
Mohamed Seedat, Director, Institute for Social and Health
Sciences, University of South Africa, and South African
Medical Research Council-University of South Africa Crime,
Violence and Injury Lead Programme
Azodoga Seketeli, Medical Entomologist, Former Director,
African Programme for Onchocerciasis Control,
Ouagadougou, Burkina Faso
John T. Sentz, Research Assistant, Division of International
Epidemiology and Population Studies, Fogarty International
Center, National Institutes of Health, Bethesda, Maryland
Meera Shekar, Senior Nutrition Specialist, Human
Development Network, The World Bank, Washington, DC
Donald Silberberg, Professor of Neurology, University of
Pennsylvania, Philadelphia
Freddy Sitas, Director, Cancer Research and Registers
Division, The Cancer Council of New South Wales,
Australia
Robert W. Snow, Professor, Tropical Public Health, Centre for
Tropical Medicine, University of Oxford, United Kingdom;
and Head, Public Health Group, Kenya Medical Research
Institute-Wellcome Trust Collaborative Program, Nairobi,
Kenya
Geoff Solarsh, Professor and Head of School, Monash
University School of Rural Health, Bendigo, Australia
Lara Stein, Acting Director, National Cancer Registry and
Cancer Epidemiology Research Group, National Health
Laboratory Service, Johannesburg, South Africa
Krisela Steyn, Director, Chronic Diseases of Lifestyle Unit,

Medical Research Council, South Africa
Ian M. Timaeus, Head, Centre for Population Studies and
Professor of Demography, London School of Hygiene and
Tropical Medicine
Henry Wabinga, Professor, Kampala Cancer Registry,
Department of Pathology, Makerere University, Kampala,
Uganda
Laurent Yaméogo, Coordinator, Office of Programme
Director, African Programme for Onchocerciasis Control,
Ouagadougou, Burkina Faso
Honorat Zouré, Biostatistic and Mapping, African
Programme for Onchocerciasis Control, Ouagadougou,
Burkina Faso
Contributors | xix

ADR adverse drug reactions
AFB acid-fast bacilli
AIDS acquired immune deficiency syndrome
AMMP Adult Morbidity and Mortality Project
anti-GAD glutamic acid decarboxylase antibodies
APOC African Programme for Onchocerciasis
Control
AR androgen receptor
ARI acute respiratory infections
ARV antiretroviral
AUDIT Alcohol Use Disorders Identification Test
BCG bacillus Calmette-Guérin
BMI body mass index
BOMA Burden of Malaria in Africa
BOSTID Board of Science and Technology for

International Development
CBR community-based rehabilitation
CDTI community-directed treatment with
ivermectin
CHD coronary heart disease
CHMR child mortality rate
CI confidence interval
CIESIN Center for International Earth Science
Information Network
CIN cervical intraepithelial neoplasia
CM cerebral malaria
CMD common mental disorders
CMO chronic otitis media
CNS central nervous system
CRF circulating recombinant forms
CRS congenital rubella syndrome
CSO Central Statistical Office
CTL cytolytic T cell
CVD cardiovascular disease
CWIQ Core Welfare Indicators Questionnaire
DALY disability-adjusted life year
DCCT Diabetes Control and Complication Trial
DCM dilated cardiomyopathy
DHS Demographic and Health Survey
DMSSA-1 Disease and Mortality in Sub-Saharan Africa,
first edition
DMSSA-2 Disease and Mortality in Sub-Saharan Africa,
second edition
DOTS directly observed treatment, short course
DSS demographic surveillance system

DTP diphtheria, tetanus, pertussis
EAEC entero-adherent pathogenic Escherichia coli
EIR entomological inoculation rates,
EMF endomyocardial fibrosis
EmOC emergency obstetric care
EPI Expanded Program on Immunization
EPTB extrapulmonary tuberculosis
ETEC enterotoxigenic Escherichia coli
FAO Food and Agriculture Organization of the
United Nations
FCS fuzzy climate suitability
FWCW Fourth World Conference on Women
GAVI Global Alliance for Vaccines and Immunization
GHQ general health questionnaire
GIS Geographical Information System
GBD global burden of disease
GDM gestational diabetes mellitus
GDP gross domestic product
GHQ General Health Questionnaire
HAART highly active antiretroviral therapy
HAV hepatitis A virus
HBIG hepatitis B immunoglobin
HBV hepatitis B
HES hypereosinophilic syndrome
HHV8 human herpesvirus-8
Hib Haemophilus influenzae type B
HIC high-income country
HIPC heavily indebted poor country
HIV human immunodeficieny virus
HMIS health management information systems

HPV human papillomavirus
HSCL Hopkins Symptom Checklist
ICA islet cell antibodies
xxi
Abbreviations and Acronyms
ICD-10 International Statistical Classification of Diseases
and Related Health Problems, 10th revision
IDD iodine deficiency disorder
IFG impaired fasting glycemia
IGT impaired glucose tolerance
IHD ischemic heart disease
IMR infant mortality rate
INCLEN International Clinical Epidemiology Network
IPD invasive pneumococcal disease
IPT isoniazid preventive treatment
IPTT Initiative for Technology Transfer
IPV inactivated poliovirus vaccine
IQI interquartile intervals
IQR interquartile ranges
IUATLD International Union against TB and Lung Disease
IUGR intrauterine growth retardation
IVIG intravenous immunoglobulin
LBW low birthweight
LMIC low- to middle-income country
LRTI lower respiratory tract infections
MDG Millennium Development Goal
MDR multidrug resistance
MICS Multiple Indicator Cluster Surveys
MMR maternal mortality ratio
MOTT mycobacteria other than tuberculosis

MR mental retardation
NCD noncommunicable disease
NDS National Demographic Survey
NEPAD New Partnership for Africa’s Development
NGDO nongovernmental development organization
NGO nongovernmental organization
NIMSS National Injury Mortality Surveillance System
NNRTI nonnucleoside reverse transcriptase inhibitor
NNT neonatal tetanus
NRTI nucleoside analogue reverse transcriptase
inhibitor
NVP nevirapine
OCP Onchocerciasis Control Programme
OEPA Onchocerciasis Elimination Program for the
Americas
OPV oral poliovirus vaccine
OR odds ratio
ORT oral rehydration therapy
OSD onchocercal skin disease
PA-ICPD Programme of Action of the International
Conference on Population and Development
PCP Pneumocystis carinii pneumonia
PEM protein-energy malnutrition
PMDF proportion of deaths of women of reproductive
ages due to maternal causes
PPP international dollars
PRSP poverty reduction strategy paper
PSE Present State Examination
PTB pulmonary tuberculosis
PTSD posttraumatic stress disorder

PYO person-years of observation
RAMOS Reproductive Age Mortality Studies
REMO Rapid Epidemiological Mapping of
Onchocerciasis
RHD rheumatic heart disease
RR relative risk
RTI road traffic injury
SADC Southern African Development Community
SAVVY Sample Vital Registration and Verbal Autopsy
SIR Susceptible-Infected-Removed
SIV simian immunodeficiency virus
SMA severe malarial anemia
SRQ-25 Self Report Questionnaire—25 item version
SSRI selective serotonin reuptake inhibitor
STD sexually transmitted disease
TB tuberculosis
TCA tricyclic antidepressant
TFR total fertility rate
TMP-SMX trimethoprim-sulfamethoxazole
TT tetanus toxoid
U5MR under-five mortality rate
UKPDS United Kingdom Prospective Diabetes Study
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNICEF United Nations Children’s Fund
URTI upper respiratory tract infection
VA verbal autopsy
VAD vitamin A deficiency
VAPP vaccine-associated paralytic poliomyelitis
VR vital statistics registration system

WFS World Fertility Survey
WHO World Health Organization
YLD years lived with disability
xxii | Abbreviations and Acronyms
1
Fifteen years have passed since the first edition of Disease
and Mortality in Sub-Saharan Africa (DMSSA-1) was pub-
lished. Its main purpose was to assist the World Bank’s work
in the health sector by describing conditions and diseases
that contributed most to the overall burden of disease and
by identifying ways to prevent and manage these causes of ill
health. The volume was timely because of the adverse effect
the economic downturn of the early 1980s had on health in
Africa and because of the need to evaluate the impact of pri-
mary health care strategies that had been promoted in the
preceding decade. Epidemiologic information coming from
demographic surveillance sites that had not previously been
fully compared and disseminated provided a new source for
assessing trends in mortality. All this occurred against a
backdrop of increasing concern about how the human
immunodeficiency virus/acquired immune deficiency syn-
drome (HIV/AIDS), then still a relatively new and geo-
graphically more limited disease, could potentially affect
health and development in Africa.
In the years since the publication of DMSSA-1 in 1991,
epidemiological and demographic changes have occurred
that require an update if the volume is to remain useful for
policy makers in addressing the “Key Concerns” shown in
box 1.1. The most significant impact on disease and mortal-
ity in Africa has been the growth of the HIV/AIDS epidemic,

which has infected more than 30 percent of adults in some
countries while spreading across the continent. Its impact
has changed trends in many of the diseases covered in this
volume and dramatically worsened the overall level of mor-
tality in many African countries. The potential impact of
HIV/AIDS was anticipated in DMSSA-1; the current volume
documents the burden the disease is currently inflicting on
Africa.
APPROACH
Although the second edition (hereafter called DMSSA-2)
has the same overall objective of informing policy makers
(at the World Bank as well as in countries and among other
development partners), the approach taken to compile the
information was quite different from that for the first edi-
tion. DMSSA-1 was organized in three broad sections, cov-
ering patterns of mortality, diseases and conditions, and
longitudinal studies of mortality in demographic surveil-
lance sites. In DMSSA-2, the number of chapters covering
Chapter 1
Changing Patterns of Disease
and Mortality in Sub-Saharan
Africa: An Overview
Florence K. Baingana and Eduard R. Bos