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Table of Contents
Preface ........................................................................................................................................................................vi
Affiliations and acknowledgements............................................................................................................................vii
Abbreviations ............................................................................................................................................................ viii
Summary..................................................................................................................................................................... 1
1. Background .................................................................................................................................................... 2
1.1 Introduction ........................................................................................................................................ 2
1.2 Comparative risk assessment ............................................................................................................ 3
1.3 Definition of the risk factor.................................................................................................................. 4
1.4 Measurement of the risk factor........................................................................................................... 5
1.5 Defining the counterfactual exposure................................................................................................. 7
2. Methods........................................................................................................................................................ 10
2.1 Outcomes to be assessed................................................................................................................ 10
2.2 Estimation of risk factor-disease relationships ................................................................................. 12
2.3 Evaluation of population attributable fraction ................................................................................... 14
2.4 Development of disease models ...................................................................................................... 17
3. Burden of Disease Assessment ................................................................................................................... 18
3.1 Diseases with pre-existing BOD analyses completed...................................................................... 18
3.2 Diseases where adequate epidemiological data are available ........................................................ 18
3.3 Diseases with scanty global data ..................................................................................................... 19
4. Outcome assessment for diseases caused by excessive UVR exposure.................................................... 20
4.1 Cutaneous malignant melanoma ..................................................................................................... 20
4.2 Squamous cell carcinoma ................................................................................................................ 27
4.3 Basal cell carcinoma ........................................................................................................................ 35
4.4 Chronic sun damage/solar keratoses............................................................................................... 42
4.5 Sunburn............................................................................................................................................ 46
4.6 Cortical cataract ............................................................................................................................... 50
4.7 Pterygium ......................................................................................................................................... 55
4.8 Carcinoma of the cornea and conjunctiva........................................................................................ 61
4.9 Reactivation of herpes labialis ......................................................................................................... 67
5. Potential disease burden caused by complete removal of UVR exposure................................................... 72
6. Sources of error or uncertainty ..................................................................................................................... 77
7. Conclusion.................................................................................................................................................... 78
8. Future directions........................................................................................................................................... 80
References................................................................................................................................................................ 83
Annexes .................................................................................................................................................................... 88
Annex 1 Literature Review ............................................................................................................................. 88
Annex 2 Epidemiologic studies used for estimation of population attributable fraction and descriptive
studies of disease distribution ........................................................................................................ 163
Annex 3 Disease worksheets ....................................................................................................................... 173
Annex 4 WHO subregions by latitude .......................................................................................................... 198
Annex 5 Distribution of skin pigmentation .................................................................................................... 201
Annex 6 Estimation of disease incidence/prevalence for diseases with scanty epidemiological data ......... 204
Annex 7 Summary results for the year 2000 ................................................................................................ 206
List of tables
Table 2.1 Candidate, and selected, health outcomes to be assessed for the burden of disease related to
ultraviolet radiation. ............................................................................................................................. 11
Table 4.1 Incident cases of Malignant Melanoma 2000 ........................................................................................22
Table 4.2 Mortality from Malignant Melanoma 2000 (0.1% of total global mortality).............................................23
Table 4.3 Disease burden due to malignant melanoma in DALYs (000) ..............................................................24
Table 4.4 Disease burden from malignant melanoma attributable to ultraviolet radiation DALYs (000) –
upper estimates.....................................................................................................................................25
Table 4.5 Disease burden from malignant melanoma attributable to ultraviolet radiation DALYs (000) –
lower estimates .....................................................................................................................................26
Table 4.6 Incident cases of SCC...........................................................................................................................30
Table 4.7 Deaths from SCC ..................................................................................................................................31
Table 4.8 Disease burden due to SCC in DALYs (000) ........................................................................................32
Table 4.9 Disease burden from SCC attributable to ultraviolet radiation DALYs (000) – upper estimates ...........33
Table 4.10 Disease burden from SCC attributable to ultraviolet radiation DALYs (000) – lower estimates............34
Table 4.11 Incident cases of BCC...........................................................................................................................37
Table 4.12 Deaths from BCC in 2000 .....................................................................................................................38
Table 4.13 Disease burden due to BCC in DALYs (000) ........................................................................................39
Table 4.14 Disease burden from BCC attributable to ultraviolet radiation DALYs (000) – upper estimates ...........40
Table 4.15 Disease burden from BCC attributable to ultraviolet radiation DALYs (000) – lower estimates............41
Table 4.16 Prevalent persons with solar keratoses.................................................................................................44
Table 4.17 Burden of disease due to solar keratoses (=attributable BOD) DALYs (000) .......................................45
Table 4.18 Incident cases of sunburn 2000 ............................................................................................................48
Table 4.19 Burden of disease due to sunburn (attributable BOD) DALYs (000).....................................................49
Table 4.20 Incident cataracts 2000 (from GBD 2000, (99)) ....................................................................................51
Table 4.21 Burden of disease from cataract DALYs (000) (from GBD 2000, (99)) .................................................52
Table 4.22 Burden of disease due to cortical cataract DALYs (000).......................................................................53
Table 4.23 Disease burden from cataract attributable to UVR DALYs (000) ..........................................................54
Table 4.24 Prevalence (persons) of pterygium 2000 ..............................................................................................57
Table 4.25 Burden of disease from pterygium DALYs (000)...................................................................................58
Table 4.26 Disease burden from pterygium attributable to UVR DALYs (000) – upper estimates..........................59
Table 4.27 Disease burden from pterygium attributable to UVR DALYs (000) – lower estimates ..........................60
Table 4.28 Incident cases of SCCC (2000).............................................................................................................63
Table 4.29 Burden of disease from SCCC DALYs (000) ........................................................................................64
Table 4.30 Disease burden from SCCC attributable to UVR DALYs (000) – upper estimates ...............................65
Table 4.31 Disease burden from SCCC attributable to UVR DALYs (000) – lower estimates................................66
Table 4.32 Incident herpes labialis 2000.................................................................................................................68
Table 4.33 Burden of disease from RHL DALYs (000) ...........................................................................................69
Table 4.34 Disease burden from RHL attributable to UVR DALYs (000) – upper estimates ..................................70
Table 4.35 Disease burden from RHL attributable to UVR DALYs (000) – lower estimates...................................71
Table 5.1 Proposal for staging of vitamin D deficiency1
........................................................................................73
Table 5.2 Incident cases of vitamin D deficiency 2000 under a scenario of zero UVR exposure .........................75
Table 5.3 Potential disease burden due to complete removal of UVR exposure, DALYs (000) ...........................76
Table 7.1 Burden of disease due to excessive UVR exposure, DALYs (000) and deaths....................................78
List of figures
Figure 1.1 Causal Web for Health Impacts due to Ultraviolet Radiation ..................................................................3
Figure 1.2 Monthly averaged annual ambient erythemally weighted UVR, 1997-2003............................................6
Figure 2.1 Schematic diagram of the relation between ultraviolet radiation (UVR) exposure and the burden of
disease 6
Figure 2.2 Distribution of UVR exposure in a theoretical population ......................................................................16
Figure 2.3 Distribution of UVR exposure in two different (theoretical) populations ................................................16
Figure 3.1 Methods of calculating attributable burden............................................................................................18
Figure 4.1 Disease model for SCC.........................................................................................................................29
Figure 4.2 Disease model for BCC – all regions ....................................................................................................36
Figure 4.3 Disease model for solar keratoses ........................................................................................................43
Figure 4.4 Disease model for sunburn ...................................................................................................................47
Figure 4.5 Disease model for pterygium.................................................................................................................56
Figure 4.6 Disease model for SCCC - ABC regions...............................................................................................62
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