title: Estimating the burden of disease attributable to four selected environmental risk factors in South Africa.
abstract: BACKGROUND
  The first South African National Burden of Disease study quantified the underlying causes of premature mortality and morbidity experienced in South Africa in the year 2000. This was followed by a Comparative Risk Assessment to estimate the contributions of 17 selected risk factors to burden of disease in South Africa. This paper describes the health impact of exposure to four selected environmental risk factors: unsafe water, sanitation and hygiene; indoor air pollution from household use of solid fuels; urban outdoor air pollution and lead exposure.
  
  
  METHODS
  The study followed World Health Organization comparative risk assessment methodology. Population-attributable fractions were calculated and applied to revised burden of disease estimates (deaths and disability adjusted life years, [DALYs]) from the South African Burden of Disease study to obtain the attributable burden for each selected risk factor. The burden attributable to the joint effect of the four environmental risk factors was also estimated taking into account competing risks and common pathways. Monte Carlo simulation-modeling techniques were used to quantify sampling, uncertainty.
  
  
  RESULTS
  Almost 24 000 deaths were attributable to the joint effect of these four environmental risk factors, accounting for 4.6% (95% uncertainty interval 3.8-5.3%) of all deaths in South Africa in 2000. Overall the burden due to these environmental risks was equivalent to 3.7% (95% uncertainty interval 3.4-4.0%) of the total disease burden for South Africa, with unsafe water sanitation and hygiene the main contributor to joint burden. The joint attributable burden was especially high in children under 5 years of age, accounting for 10.8% of total deaths in this age group and 9.7% of burden of disease.
  
  
  CONCLUSIONS
  This study highlights the public health impact of exposure to environmental risks and the significant burden of preventable disease attributable to exposure to these four major environmental risk factors in South Africa. Evidence-based policies and programs must be developed and implemented to address these risk factors at individual, household, and community levels.
authors.affiliation: School of Population Health, University of Queensland, Brisbane, Australia. r.norman@uq.edu.au
authors.forename: Rosana
authors.initials: R
authors.lastname: Norman
authors.forename: Debbie
authors.initials: D
authors.lastname: Bradshaw
authors.forename: Simon
authors.initials: S
authors.lastname: Lewin
authors.forename: Eugene
authors.initials: E
authors.lastname: Cairncross
authors.forename: Nadine
authors.initials: N
authors.lastname: Nannan
authors.forename: Theo
authors.initials: T
authors.lastname: Vos
mesh_terms: D017677:Age Distribution; D000393:Air Pollutants / Q000633:toxicity; D000397:Air Pollution / Q000009:adverse effects*; D003296:Cooking / Q000379:methods; D004777:Environment; D004781:Environmental Exposure / Q000009:adverse effects*; D014943:Global Health; D015438:Health Behavior; D006801:Humans; D007855:Lead Poisoning / Q000453:epidemiology*; D009010:Monte Carlo Method; D018570:Risk Assessment; D012499:Sanitation / Q000706:statistics & numerical data*; D013019:South Africa; D014881:Water Supply / Q000706:statistics & numerical data*
chemical_list: D000393:Air Pollutants