Collaborating WHO Center
Janice Dorman, Ph.D. Director Molecular Epidemiology Ronald LaPorte, Ph.D. Director Disease Monitoring and Telecommunications
GSPH
The Importance of IDDM Registries
Diabetes Epidemiology Team in Pittsburgh
Y Allan Drash, M.D. Y Dorothy Becker, M.D. Y Janice Dorman, Ph.D. Y Lewis Kuller, M.D., Dr.PH Y Ronald LaPorte, Ph.D. Y Trevor Orchard, M.D. Y Thomas Songer, Ph.D. Y Massimo Trucco, M.D.
Type I Diabetes the Epidemiologist's Dream Disease
Easy to Diagnosis Frequent but not too frequent Severe but not too severe Insulin Dynamic Epidemiology
Excess Mortality
9 8 7 6 5 4 3 2 1 0 Type I Type II
Chronic Diseases in Children
16 14 12 10 8 6 4 2 0 Type I CA CF MS JRA MD
Y Identical Twins = 35% Y HLA Identical = 18% Y non asp 57 = 2%
The Search for the Magic Bullet to Prevent Type I Diabetes
Prevention of Type I
Toxic!!!
Let observations with extensive view Survey mankind from China to Peru
S. Johnson, 1749
The Environmental
Challenge
in Preventing Diabetes
Environmental Etiology of Type I diabetes
Environmental agents causes disease in animals Geographic Variation Temporal Variation Migrants take on risk of new environment Environmental Factors Found to Cause Disease in the Population
Prevention:
Reducing the incidence of disease
Last, Dictionary of Epidemiology
Environmental Etiology of Type I diabetes
Environmental agents causes disease in animals Geographic Variation Temporal Variation Migrants take on risk of new environment Environmental Factors Found to Cause Disease in the Population
Type I diabetes Incidence
PRC MEX JPN Cuba PLD DEN UK US NOR SCO SWD CAN FIN 0 5 10 15 20 25 30 35 40
Environmental Etiology of Type I diabetes
Environmental agents causes disease in animals Geographic Variation Temporal Variation Migrants take on risk of new environment Environmental Factors Found to Cause Disease in the Population
Allegheny County, PA
25 20 15 10 5 0 65-69 70-74 75-79 80-84 85-89 White Males NW Males
US Virgin Islands
30 25 20 15 10 5 0 1979 1981 1983 1985 1987
Environmental Etiology of IDDM
Environmental agents causes disease in animals Geographic Variation Temporal Variation Migrants take on risk of new environment Environmental Factors Found to Cause Disease in the Population
Migration Effects
16 14 12 10 8 6 4 2 0 Chinese Jewish Source Migrant French
Asian Migration to UK
18 16 14 12 10 8 6 4 2 0 1972 1974 1976 1978 1980 1982 1984
English Asian-English
A Public Health Approach Towards Prevention of IDDM
Green mountains range beyond the northern wall White water rushes round the eastern town right here is where, alone and restless, he begins a journey of a thousand miles.
While travelers' intents are fleeting clouds, A friend's affection is a setting sun. He waves good-bye, and as he goes from here, His dappled horse lets out a lonely neigh.
Where will the agent be found?
30 25 20 15 10 5 0 1979 1983 1981 1985 1987
The Importance of IDDM Registries
Establishment of Population Based Registries for 1990-99 ` Diagnosed as IDDM ` On Insulin at Hospital discharge ` Diagnosed between 1/1/90 and 31/12/99 ` Age at onset 014 ` Member of a defined community ` Secondary Source of Case Identification
WHO DiaMond Project
WHO DiaMond Project WHO Multinational Project for Childhood Diabetes WHO Diabetes Mondiale
` 155 Centers
` 70 Countries ` 7.2% of the World's Children
16000 New Cases
At China rate = 56 Cases
The south sweet, the north salt the east pungent and the west sour
Chinese Academy of Preventive Medicine
Incidence Japan 1/100,000 Finland 40/100,000
Epidemic +4/100,000 5/100,000 +4/100,000 44/100,000
Percent due to Epidemic
80%
8%
WHO DiaMond Project
Yang Ze Beijing Hospital
To evaluate the incidence of IDDM in China
WHO DiaMond Project WHO DiaMond Project
Set up a collaborative registry network; Based on DiaMond standard protocol 22 I DDM registry centers in China.
Type I Diabetes Registry Network in China
PITT WHO Center Advisory Committee Collab. Center in China Chinese IDDM Research Group 1990 Census in China Population < 15 yrs IDDM Registry Hospitals Cases Incidence IDDM Registry Schools
A gracefully executed work
Jan Alice Lew
Yang Ze
Logistics of Registration
Y Research Workers 233 Y Registry Sources 6 Y Hospitals 753 Y Schools 12557 Y Population covered 83,575,028 Y Population <15 yrs 20,659,472
Percent Ascertainment by Center
100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Overall = 94.5%
Global Incidence of IDDM
PRC MEX JPN Cuba PLD DEN UK US NOR SCOT SWD CAN FIN
0
5
10
15
20
25
30
35
Geographic Variation Within China
r iha q Qi an al i D ai gh an Sh qu um l Wu n ena H an hu Sic an Jin uh uh W u zoh n La a gsh an Ch yi un Z 0
0.5
1
1.5
2
Age at Onset
2.5 2 1.5 1 0.5 0 0 1 2 3 4 5 6 7 8 9 10 11 1 2 13 14 Fe m al es M al es
North South variation
0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 N o rt h Sou t h
Ethnic Group
Mongol Ulguir Hui Korean Man Han Zhuang 0 0.5 1 1.5 2 2.5
5-Fold
If one does not store up vital forces in the winter, he will be sure to suffer from an epidemic in the spring
Gulin
1.4 1.2 1 0.8 0.6 0.4 0.2 0 89 90 91 92 93 94
Chinese Migrants
H ong K ong Si ngapor e T ai w an PRC
4-fold
0 0.5 1 1.5 2 2.5
Tracking Down the Etiology of IDDM in China
Molecular Epidemiology Studies (WHO DiaMond, Jan Dorman) Ecologic Relationships CaseCrossover Investigations
Public Health Prevention
Monitor Incidence Rapidly Identify Epidemics Outbreak Investigations Reduction of factor
Prevention
Reduction of Precipitating Factors Identification of Precipitating Factors Monitoring IDDM Incidence
Prevention
Diabetes Epidemiology
Information Superhighway