American Journal of Medicine and Medical Sciences 2015, 5(4): 150-157

DOI: 10.5923/j.ajmms.20150504.02

Epidemiologic Transition of Diseases and Health-Related

Events in Developing Countries: A Review
Adogu P. O. U.1,*, Ubajaka C. F.1, Emelumadu O. F.1, Alutu C. O. C.2

1
Department of Community Medicine and PHC Nnamdi Azikiwe University Teaching, Hospital/Nnamdi Azikiwe University,
(NAU/NAUTH) Nnewi, Nigeria
2
Faculty of Medicine, Nnamdi Azikiwe University, Nnewi Campus, Nigeria

Abstract Background: Over the past centuries, mortality and morbidity patterns have been changing all over the world
albeit with variations in timing and pace. These changes have been referred to as the epidemiologic transition. The main
features of the transition include a decline in mortality, an increase in life expectancy, and a shift in the leading causes of
morbidity and mortality from infectious and parasitic diseases to non-communicable, chronic, degenerative diseases. The
transition is linked to improvements and advances in nutrition, hygiene and sanitation, and medical knowledge and
technology. As such, the epidemiologic transition is related to the demographic transition and the nutritional transition, and is
part of a more broadly defined health transition. Objectives: This paper was aimed at studying these shifts in pattern of
mortality, life expectancy, and causes of death. Methods: Relevant literature was reviewed from medical journals, library
research, Pub Med search, Google search and search using other internet search engines. The key words for the search were
“Epidemiologic transition”, “Developing countries”, “Diseases” and “health related events”. Result: Several studies have
given perspectives on epidemiologic transition, the factors that are responsible for the transition, the effects on the health of
man, the scenarios in developed world and in the developing countries. Also highlighted are the challenges posed to humanity
and possible measures to arrest the situation. Conclusion: It is obvious that epidemiologic transition is a reality that is present
with humanity. In the developing world we have more problems on our hand as we have not succeeded in controlling the
communicable diseases and the non-communicable diseases mostly nutrition-related are becoming predominant. This calls
for action to prevent the dire consequences of double burden of disease arising from inaction.
Keywords Epidemiologic transition, Developing countries, Diseases, Health related events

1. Introduction diseases increase in prominence, causing a gradual shift in

the age pattern of mortality from younger to older ages. It is
Whereas common infectious and parasitic diseases such as
believed that the epidemiologic transition in industrialized
malaria and the HIV/AIDS pandemic remain major
countries emerged towards the early 1900s, with rising levels
unresolved health problems in many developing countries,
of non-communicable diseases (NCD) that probably peaked
emerging non-communicable diseases relating to diet and
by the mid 1950s, accompanied by a marked fall in
lifestyle have been increasing over the last two decades, thus
infectious-disease morbidity and mortality [2]. Evidence for
creating a double burden of disease and impacting negatively
the emergence of the epidemiologic transition has often been
on already over-stretched health services in these countries.
associated with epidemics of diseases of the heart and blood
Prevalence rates for type 2 diabetes mellitus and CVDs
vessels (including hypertension, ischemic heart disease and
(cardiovascular diseases) in sub-Saharan Africa have seen a
cerebrovascular disease), cancers, type 2 diabetes mellitus,
10-fold increase in the last 20 years [1]. In the Arab Gulf
osteoporosis, neuropsychiatric disorders and other chronic
current prevalence rates are between 25% and 35% for the
diseases [3], which are now major contributors to the burden
adult population, whilst evidence of the metabolic syndrome
of disease in both developed and developing countries. A
is emerging in children and adolescents [1]. Thus, as acute
developing country, also called a lower developed country, is
infectious diseases are reduced, chronic degenerative
a nation with an underdeveloped industrial base, and low
Human Development Index (HDI) relative to other countries
* Corresponding author:
prosuperhealth50@gmail.com (Adogu P. O. U.) [4]. The objective of this review is to study these shifts in
Published online at http://journal.sapub.org/ajmms pattern of mortality, life expectancy, and causes of death in
Copyright © 2015 Scientific & Academic Publishing. All Rights Reserved developing countries.
 American Journal of Medicine and Medical Sciences 2015, 5(4): 150-157 151

2. Methods deaths in developing countries, compared with less than half

today [5, 8].
Relevant literature was reviewed from medical journals, According the World Health Organization's statistics,
library research and other internet search engines such as chronic NCDs such CVDs, diabetes, cancers, obesity and
Pub Med search, Google search, Ageline, AGRIS respiratory diseases, account for about 60% of the 56.5
(Agricultural database), CHBD (Circumpolar Health million deaths each year and almost half of the global burden
Bibliographic Database), Global Health, HubMed, of disease. In 1990, 47% of all mortality related to NCDs was
POPLINE and SSRN (Social Science Research Network). In in developing countries, as was 85% of the global burden of
all these, the key words used were “Epidemiologic disease and 86% of the DALYs (disability adjusted life years)
transition”, “developing countries”, “Diseases” and “health attributable to CVDs. An increasing burden will be born
related events”. mostly by these countries in the next two decades. The
socio-economic transition and the ageing trend of population
in developing countries will induce further demands and
3. Limitation of Study exacerbate the burden of NCDs in these countries. If the
The authors did not do a systematic review. present trend is maintained, it is predicted that, by 2020,
NCDs will account for about 70 percent of the global burden
of disease, causing seven out of every 10 deaths in
4. Results / Discussion developing countries, compared with less than half today. In
1990, approximately 1.3 billion DALYs were lost as a result
For a while, these diseases were associated with economic of new cases of disease and injury, with the major part in
development and so called diseases of the rich. Then, by the developing countries. In 2002, these countries supported
dawn of the third millennium, NCDs appeared sweeping the 80% of the global YLDs (years lost to diseases) due to the
entire globe, with an increasing trend in developing countries double burden of communicable and non-communicable
(Table 1) where, the transition imposes more constraints to diseases. Consequently, their people are not only facing
deal with the double burden of infective and non-infective higher risk of premature life (lower life expectancy) but also
diseases in a poor environment characterized by ill-health living a larger part of their life in poor health [5]. These
system. remarks indicate that NCDs are exacerbating health
In 1990, the leading causes of disease burden were inequities existing between developed and developing
pneumonia, diarrhoeal diseases and perinatal conditions. By countries and also making the gap more profound between
2020, it is predicted NCDs will account for 80 percent of the rich and poor within low and middle-income countries.
global burden of disease, causing seven (7) out of ten (10)

Table 1. Evolution of NCD in Developing Countries (in millions) [5-7]

Communicable diseases +
Non-Communicable
Maternal + Perinatal + Injuries Total
Diseases
Nutritional

1990 18.7 (47%) 16.6 (42%) 4.2 (11%) 39.5 (100%)

2000 25.0 (56%) 14.6 (33%) 5.0 (11%) 45.0 (100%)

2020 36.6 (69%) 09.0 (17%) 7.4 (14%) 53.0 (100%)

Table 2. Deaths caused worldwide by specific diseases (in millions) [5, 6]

2002
Diseases 1990 (%)
Deaths (%)
Ischemic heart disease 7000 (12.6) 6260 (12.4)
Cerebrovascular disease 5400 (9.6) 4380 (8.7)
Lower Respiratory Disease 3700 (6.6) 4300 (8.5)
COPD 2700 (4.8) 2211 (4.4)
Cancer (all types) 7100 (12.6) 6200 (11.2)
Diabetes Mellitus 3200(5.6) 2400 (5.5)

COPD = Chronic Obstructive Pulmonary Disease

152 Adogu P. O. U. et al.: Epidemiologic Transition of Diseases and
Health-Related Events in Developing Countries: A Review

Table 3. Diabetes Prevalence (in millions) [9]

Country 2000 Country 2030

India 31.7 India 79.4
China 20.8 China 42.4
United States 17.7 United States 30.3
Indonesia 8.4 Indonesia 21.3
Japan 6.7 Pakistan 14.9
Pakistan 5.2 Bangladesh 11.8
Russia 4.6 Brazil 11.3
Brazil 4.5 Japan 8.9
Italy 4.2 Italy 5.5
Bangladesh 3.2 Russia 5.3

Figure 1. Global cancer incidence and Proportional mortality rate 2000 and 1990 [10, 11]

Table 4. Cancers: developing countries versus global incidence and death (in millions) in 2000 [10]

Developing % Global % of Developing Developing Global Global

Cancer
incidence of total incidence total (deaths) PMR death PMR
Lung 792 14.7 1239 12.3 522 14.7 1103 17.8
Breast 471 8.8 1050 10.4 184 5.2 373 6.0
Colorectal 334 6.2 945 9.4 252 7.1 492 8.0
Stomach 543 10.1 876 8.7 417 11.7 646 10.4
Liver 457 8.5 564 5.6 443 12.4 546 8.8
Prostate 127 2.4 543 5.4 76 2.1 204 3.3
Cervical 379 7.0 471 4.7 194 5.4 233 3.8
Oesophagus 341 6.3 413 4.1 274 7.7 337 5.4
Head & Neck 262 4.9 390 3.9 154 4.3 207 3.3
Bladder 124 2.3 336 3.3 65 1.8 132 2.1
Other 1546 71.2 3228 32.2 982 27.6 1934 31.1
Total 5376 100.0 10055 100.0 3563 100 6209 100

PMR =Proportional Mortality Rate

 American Journal of Medicine and Medical Sciences 2015, 5(4): 150-157 153

Epidemiologic transition cannot be fully discussed without mentioning the other two well-known transitions in public
health. They are “Demographic transition” and “Nutrition transition”.
Demographic transition is the shift from a pattern of high fertility and high mortality to low fertility and low mortality [12].

Figure 2. Population-Age Pyramids of the Developed and Developed Worlds

154 Adogu P. O. U. et al.: Epidemiologic Transition of Diseases and
Health-Related Events in Developing Countries: A Review

Demographic changes and the epidemiological transition The age of receding pandemics, is a transitional phase.
are closely related. As discussed earlier, mortality levels start During this stage, mortality starts to decline. CDR reaches a
to decline at the beginning of the demographic transition. level of less than 30 deaths per 1,000 population, and life
This is mainly caused by the reduction in mortality from expectancy at birth increase to about 55 years. Improved
infectious diseases and maternal and childhood conditions. sanitation, hygiene, and nutrition, and later also advances in
As the health transition progresses, fertility levels and the medicine and public health programmes, help control
burden of communicable diseases decline, and the average epidemics and pandemics of infectious and parasitic diseases.
age of the population increases. Thus, eventually, there are As a result, an increasing number of people no longer die
more elderly people in the population, and they are more from infections at young ages but from chronic degenerative
susceptible to non-communicable diseases than younger diseases at middle and older ages.
people. The increase in the number of susceptible individuals The age of degenerative and man-made diseases, mortality
at older ages increases the overall incidence and prevalence continues to decline until it stabilizes at a level of less than
of non-communicable diseases, thereby accelerating the 20 deaths per 1,000 population. In addition, life expectancy
epidemiologic transition. The developing countries are at birth increases and exceeds 70 years by the end of the third
undergoing this transition but at a slower pace. There is stage. The major causes of death are the so called chronic
improvement in child survival, increase in life expectancy at degenerative and man-made diseases such as cardiovascular
birth and decreasing fertility in developing countries [13]. diseases, cancer, and diabetes. The term ‘man-made’ disease,
On the other hand, nutritional transition is malnutrition hereby, include diseases related to radiation, accidents, food
resulting not merely from the need for food, but the need for additives, occupational hazards, and environmental
high quality nourishment [14]. Nutrition transition is also pollution.
described as a shift from lack of food, to a rising problem of The hybristic stage reflects a change in the underlying
overabundance and obesity [15]. The term nutrition causes of mortality and morbidity. The term ‘hybris’ refers to
transition has been used to characterize the shift in disease excessive self-confidence or a belief of invincibility. During
patterns towards diet- or nutrition-related the hybristic stage, morbidity and mortality are affected by
non-communicable disease including type 2 diabetes man-made diseases, individual behaviours, and potentially
mellitus, cardiovascular disease, stroke, high blood pressure, destructive lifestyles. Individual behaviour such as physical
gout and certain cancers. This shift in disease patterns is inactivity, unhealthy diet, excessive drinking, and cigarette
associated with changes in behaviours, lifestyles, diets, smoking increase the risk of adverse health outcomes,
physical inactivity, smoking and alcohol consumption. The including heart disease, diabetes, cirrhosis of the liver, and
stages of the nutritional transition include: [12] The lung cancer. Rogers and Hackenberg further remarked that
Hunter-Gatherers (Palaeolithic man) stage, Monoculture while most environmentally-based infectious diseases are
period, Industrialization/Receding famine stage, eradicated during the hybristic stage, some infectious
Nutrition-related Non-communicable diseases stage and diseases are increasing in importance due to individual
Behavioural change stage. lifestyle and man-made causes. A well-known example of
Stages of Epidemiologic Transition such an infectious disease is HIV/ AIDS.
A more widely acknowledged and adopted fourth stage of
Epidemiologic transition has been described to occur in 3 the epidemiological transition is the age of delayed
stages by Omran in 1971, [16] though Rogers and degenerative diseases as proposed by Olshanky and Ault
Hackenberg in 1987, [17] felt that the original theory lacked [18]. After mortality rates for males had stabilized during the
reference to violent and accidental deaths and death due to 1950s and 1960s as a result of ‘epidemics’ of cardiovascular
behavioural causes. They therefore proposed a fourth stage disease, male mortality again began to decline from around
that they called the hybristic stage. The stages include: 1970 onwards. Olshanky and Ault considered this decline as
• The first or pre-transitional stage: the age of pestilence a new stage in the epidemiologic transition. The age of
and famine delayed degenerative disease is characterized by “rapid
• The second stage: the age of receding pandemics. mortality declines in advanced ages that are caused by a
• The third stage: the age of degenerative and man-made postponement of the ages at which degenerative diseases
diseases. tend to kill” [18]. The postponement of deaths from
• The fourth stage: the hybristic stage. degenerative diseases is a result of additional public health
The age of pestilence and famine, is characterized by measures and advances in medical technology. Life
fluctuating mortality in response to epidemics, famines, and expectancy at birth is expected to reach over 80 years by the
war. Crude Death Rate (CDR) is high and ranges from 30 to end this stage.
50 deaths per 1,000 population. Life expectancy at birth is Models of Epidemiologic Transition
low, between 20 and 40 years, and the leading causes of Countries and regions have shown differences in passing
death are infectious and parasitic disease, such as influenza, through the above-mentioned stages, with regard to timing,
diarrhoea, and tuberculosis. pace, and underlying mechanisms. Therefore, Omran [16]
 American Journal of Medicine and Medical Sciences 2015, 5(4): 150-157 155

proposed several basic models of the epidemiologic seen to affect people worldwide with an increasing tendency.
transition. Initially he proposed three models, but later added (Table 5)
a fourth variant.
Table 5. Burden of diseases and risk factors worldwide: year 20004 [19]
• The classical or western model
• The accelerated variant of the classical model Deaths % of total DALYs % of
Risk factor
(* 103) death (* 103) total
• The delayed model
• The transitional variant of the delayed model. Hypertension 7141 12.8 64270 04.5

The classical or western model describes the gradual Tobacco 4907 08.8 59081 04.1
transition experienced by western societies. According to High
4415 07.9 40437 02.8
Omran, this transition started in the 19th century and was cholesterol
accompanied by a process of modernisation and industrial Low fruit &
2726 04.9 26662 01.9
and social change. vegetable
The accelerated variant of the classical model describes Overweight 2591 04.6 33415 02.3
the transition observed in Japan and Eastern Europe. In these Alcohol 1804 03.2 58323 04.0
countries, mortality decline started later but reached the low
Physical
level in a shorter period of time. The changes were based on 1922 03.4 19092 01.3
inactivity
general social improvements (for example in nutrition) as
well as sanitary and medical advances. DALYs = Disability Adjusted Life Years
The delayed model depicts the transition as it occurs in
Globally, many of the risk factors for heart disease,
developing countries. Mortality drop in these countries have
diabetes, cancer and pulmonary diseases are due to lifestyle
mainly been achieved through the application of modern
and can be prevented. Physical inactivity, western diet and
medical technology. Though initially mortality decline was
smoking are prominent causes [20]. Tobacco is the enemy
fast, it slowed down after 1960s, especially in terms of infant
number one. It is the most important established cause of
and child mortality.
cancer but also responsible in CVDs and chronic respiratory
The transitional variant of the delayed model typifies the
diseases. Tobacco and diet are the principal risk factors,
transition in a number of developing countries such as
responsible for more than 40% of cancer deaths and
Singapore, Sri Lanka, Mauritius, and Jamaica. In these
incidence. Obesity and dietary habits are the principal risk
countries, the rapid decline in mortality in the 1940s was
factors for diabetes mellitus type 2.
comparable to that in countries matching the delayed model.
Tobacco: In the 20 the century, approximately 100 million
However, the decline did not slacken to the same extent
people died worldwide from tobacco-associated diseases
Determinants of Epidemiologic Transition such as cancers, chronic lung disease, diabetes and CVDs [5,
There are several factors involved in the epidemiologic 8, 21]. While tobacco consumption is falling in most
transition. The most important are considered below. developed countries, it is increasing in developing countries
Demographic changes: These are composite of changes by about 3.4% per annum. Today, 80% of the 1.2 billion
in both mortality and fertility. As populations become smokers in the world live in poorer countries where smoking
healthier, a reduction in mortality, particularly of infants and prevalence among men is nearly 50% (48%) and 50% of the
children, usually occurs, followed later by a fall in fertility 5million deaths attributed to smoking in 2000 occurred in
rates. Therefore, more people will survive to adulthood and developing countries, also responsible for the increase in
will have the disease patterns of adults, with deaths by more than one million during the last decade.
non-communicable diseases at the top of list. They will also Tobacco remains the most important avoidable risk for the
be exposed to diseases that more frequently affect elderly four classes of NCDs. It increases the risk of dying from
people, such as cancer and cardiovascular diseases. Thus, coronary heart disease and cerebrovascular disease 2–3 fold.
even with constant age-specific incidence rates of It increases the risk of many types of cancer, for lung cancer
non-communicable diseases, the absolute number of cases the risk is increased by 20-30fold. According to studies
and deaths from these diseases increases substantially with conducted in Europe, Japan and North America, 83–90% of
the above-mentioned demographic change. As life lung cancers in men and 57–80 in women, are imputable to
expectancy increases, the number of old people will increase. tobacco. Between 80 and 90 % of oesophagus, larynx and
This will lead to changes in disease patterns and problems oral cavity are caused by tobacco and alcohol [22]. In
characteristic of the elderly and eventually the total number developing countries, an estimated one-third of all cancer
of deaths will increase as a result of the new age structure. deaths was attributable to smoking in 1995. Finally, tobacco
Risk factors: Considering the factors affecting the exacerbates the conditions of people living with COPD and
emergence of non-communicable diseases, they do have a asthma.
common denominator which is the risk factors. Indeed, Lifestyle: About 80% of cases of coronary heart disease,
tobacco, alcohol, high blood pressure, diet and physical and 90% of cases of types 2 diabetes, could potentially be
inactivity were indicated, at different levels, as risk factors in avoided through changing lifestyle factors [8, 23-25].
the development of NCDs. Moreover, these risk factors are One-third of cancers could be avoided by eating healthily,
156 Adogu P. O. U. et al.: Epidemiologic Transition of Diseases and
Health-Related Events in Developing Countries: A Review

maintaining normal weight, and exercising throughout life. It poliomyelitis in Pakistan and is now the case with diphtheria
was estimated that in high-risk populations, an optimum fish in Russia and Ukraine [19].
consumption of 40–60 grams per day would lead to Although therapeutic interventions have been the key
approximately a 50% reduction in death from coronary heart element in saving millions of lives each year and in reducing
disease. A recent study based on data from 36 countries, some of the serious complications that often follow infection,
reported that fish consumption is associated with a reduced they actually do not modify the probability of becoming ill
risk of death from all causes as well as CVD mortality. (except in so far as early treatment reduces the risk of spread
Unfortunately, the fish consumption is very low even in of infection to others). In chronic diseases, this type of
some countries known for their large fish stock like the north intervention actually produces the paradoxical effect of
African region. Daily intake of fresh fruit and vegetables in increasing the absolute morbidity level.
adequate quantity (400–500 grams per day), is recommended On the other hand, the cure-oriented intervention
to reduce the risk of coronary heart disease, stroke and high techniques of modern medicine that permit the liberal use of
blood pressure. But, once more, this is thwarted by the antimicrobials and chemotherapeutic agents and an
western lifestyle invading developing countries. increasing number of manipulative procedures have been
Overweight/Obesity: Overweight and Obesity lead to responsible for some side effects of diseases. In addition to
adverse metabolic changes such as insulin resistance, side effects such as allergy, depression of bone marrow
increasing blood pressure and cholesterol [8, 26]. activity and deafness, excessive use of antibiotics may cause
Consequently, they promote CVDs, diabetes and many types what are described as superimposed infections. The
of cancer. Worldwide, overweight affects 1.2 billion of excessive use of antimicrobials inhibits indigenous
which 300 million are clinically obese. In some developed organisms that compete with external invaders and permits
countries like USA, the prevalence reaches 60% but colonization and proliferation of organisms that are
developing countries like Kuwait have also a very high non-pathogenic under normal conditions.
prevalence. More and more children are suffering from Infections associated with manipulative techniques are
overweight and obesity. However, the most contrasting another example, particularly under conditions where aseptic
phenomenon is to find Overweight/ Obesity and malnutrition techniques are not strictly followed. The most evident of
side by side in low- and middle-income countries and hence these is neonatal tetanus, which occurs through
contributing to the growing burden afflicting these countries. contamination of the umbilical stump. The spread of viral
According to the International Obesity Task Force (IOTF) hepatitis B and C and HIV infection through the use of
and the WHO World Health report 2002, about 60% of contaminated needles and through unscreened blood
diabetes globally can be attributable to overweight and transfusions is another example in which intervention
obesity. In other respects, it is estimated that 60% of world's becomes a source of infectious disease. In addition, the use
population do not do enough physical activity. of equipment such as urethral catheters and endotracheal
Alcohol: Alcohol consumption has also increased in the tubes permits organisms to gain access to otherwise healthy
last decades, with the major part of this increase imputable to sterile organs.
developing countries. In 2000, Alcohol was responsible for
nearly 2 million deaths in the world, representing 4% of the
global disease burden. Moreover, alcohol was estimated to
5. Conclusions and Recommendations
cause 20 to 30 % of oesophagus cancer, liver disease, The changing pattern of diseases observed over recent
epilepsy, motor vehicle accidents and other hazards [8]. years, from acute infectious and deficiency diseases to the
Practices of modern medicine: Several changes have chronic non-communicable diseases, is a continuous
occurred in the quantity, distribution, organization and process of transformation with some diseases disappearing
quality of health services that have contributed to the and others appearing or reappearing.
epidemiologic transition. The discoveries and technological It is clear that infectious diseases are still an important
developments of the twentieth century, such as the public health problem and a major cause of death and of
development of antibiotics and antimicrobial agents, illness and will continue to be so for future generations. At
insecticides, vaccines and diagnostic and therapeutic the same time, non-communicable diseases are coming to
technologies, have resulted in remarkable progress in the the forefront as causes of illness and death, especially in
prevention and control of many diseases and in the effective countries where it used to be possible to control many
management of many others. One of the most dramatic communicable diseases.
victories has been the eradication of smallpox. Another This transition is very vulnerable as many biological,
evident success has been the reduction of morbidity and environmental, social, cultural and behavioural factors have
mortality from diseases for which there are available been responsible for structuring these patterns in the
protective vaccines such as poliomyelitis, diphtheria, tetanus community. It is subject to breaks in continuity, slowdowns
and measles. It must, however, be remembered that or even reversals of the transition.
relaxation of vaccination efforts can very quickly result in Several stages of transition may overlap in the same
the re-emergence of these diseases as happened with country. This represents a challenge to national health
 American Journal of Medicine and Medical Sciences 2015, 5(4): 150-157 157

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