The Burden of Pediatric Musculoskeletal Diseases Worldwide

Key points

Global burden of disease

Burden of disease has a variety of definitions and meanings, but in general it refers to the economic and human costs resulting from poor health. The World Health Organization (WHO) measures global burden of disease (GBD) using standard methodology including the disability-adjusted life year (DALY), years lived with a disability (YLD), years of life lost (YLL), and life expectancy. The DALY metric was first developed in 1990 to better describe the burden of disease in a consistent manner across

Why is global burden of disease so important?

Estimation techniques allow one to identify the diseases with the most burden in 171 countries globally.⁸ GBD uses standardized and validated methods to all available databases, adjusting for major sources of bias. The higher the quality of the data, the more likely that the estimation techniques will represent real reported data. It is important to distinguish the diseases that result in death versus those that cause poor health, as there is a major difference in the appropriate response with

What is disability-adjusted life year used for?

DALY is a measure of life lost from premature death and life not lived at 100% health. From the WHO GBD study the DALY became the preferred metric to compare the health burden of various dissimilar diseases. It is applied to populations rather than to individuals. It is a composite of both mortality and morbidity, which is something to be avoided. As opposed to the QALY (quality- adjusted life year) it is a negative measure, a measure of disease within a population. Bickler and colleagues¹¹

Cost-effective analysis

Murrey utilized the DALY to develop cost-effective analysis (CEA) as an analytical tool that correlates the effectiveness of a health intervention to its costs, in terms of dollar per DALY averted.¹³ Recent data for CEA show that surgical care is cost-effective in low- and middle-income countries (LMICs) compared with the much higher surgical care costs in the United States and other high-income countries (HICs). Common relative costs/DALY averted include $48,000/DALY averted for a 60-year-old

What is the global burden of disease for musculoskeletal conditions?

Much research has come out of the 2010 GBD study to estimate the GBD of disease for musculoskeletal conditions.⁹ 2004 estimates showed a burden of nontraumatic musculoskeletal conditions of 2.5% of the entire global burden.¹⁶ By 2010, this had increased to 4.4%, and by 2016 the GDB for nontraumatic musculoskeletal conditions was 5.9% of GDB. However, there are no good data for the common pediatric conditions, especially globally, and estimating GDB for the pediatric musculoskeletal conditions

What are the most common pediatric orthopedic conditions in developing countries?

A quality well-funded Rwanda study of musculoskeletal impairments (MSIs) with validated methodology involved a prospective door to door survey of 6757 individuals of all ages.^18,19 MSIs were identified for all ages, with a total of 352 cases (5.2% overall prevalence). MSI was highest in those over 60 years of age (24%), with most cases 43.7% considered moderate, and most of these (96%) requiring further treatment.¹⁹ For the 3526 children under 16 years of age who were screened, MSI was present

Global musculoskeletal conditions in children that have implications into adult life

Five pediatric orthopedic conditions that contribute to GBD and have implications for MSI later in life are infections, trauma, clubfoot, DDH, and cerebral palsy (Fig. 2). They also have a long period of time of YLD for the individual and DALYs for the population that are important for policymakers to estimate so that relative economic value and policy decisions can be made. These 5 conditions have in common that they can be treated with a combination of early detection, conservative management

Infections

Musculoskeletal infections can be acquired from trauma, hematogenous, or as a result of elective surgical procedures such as arthroplasty. As countries become more developed, post-traumatic and hematogenous infection risk may decline, but the prevalence of iatrogenic infections may increase, so the burden will not go away. Group A streptococcal diseases is 1 example, with a worldwide burden of over 500,000 deaths per year, a total of 111 million cases of pyoderma, although its greatest global

Trauma

Trauma-related conditions are the leading cause of childhood death after 1 year of age in the United States. GBD from trauma is increasing overall.³⁰ Injury mortality is even higher in LMIC, estimated to be double that of HIC. For every reported death, there are many more nonfatal injuries that may result in temporary or permanent disability (Fig. 5). As is true with mortality, disability disproportionately affects LIMC. A survey from Ghana showed a high rate of disability beyond 30 days, much

Clubfoot

Globally, congenital idiopathic clubfoot is the most common serious musculoskeletal birth defect (Fig. 6). Worldwide prevalence is 1 case to 2 cases per 1000 population, resulting in 150,000 to 200,000 infants born with clubfoot. Eighty percent of children with clubfoot are born in countries with limited resources.³⁴ Thousands of children and adults in LMIC have neglected and untreated clubfoot, leading to later problems with shoe wear, pain, difficulty walking, and social and cultural issues.

Developmental hip dysplasia

Developmental hip dysplasia (DDH) is a wide spectrum of conditions from mild instability to frank dislocation at birth, and from asymptomatic dysplasia to frank arthritis in the adult (Fig. 7A). The prevalence is 1.5 cases to 25 cases per 1000 live births. The burden of disease in terms of DALYs and YLD is an important concept for DDH, because this is often a lifelong condition with implications for function and disability during the working and later years. However, there has been little

Cerebral palsy and neuromuscular conditions

The prevalence of cerebral palsy (CP) is as high as 2 to 3 cases per 1000 births worldwide, with many cases undiagnosed or misdiagnosed. On the other hand, approximately 10% of children seen in a CP clinic may have another diagnosis than CP (Fig. 8). In resource-poor environments, total rates of overall disability have been found to be 82 to 160 cases per 1000 population, and neurologic impairment to be 19 to 61 cases per 1000 population for children age 2 to 9 years.³⁶ In high-income countries

Summary

Because of YLD and the large proportion of children in a population, these pediatric musculoskeletal conditions can contribute greatly to the GBD, now and later. The 5 common pediatric conditions (infection, trauma, DDH clubfoot and CP/NM, and others) should be part of future GBD studies. DALYs should be determined so that policy makers can allocate appropriate resources for these conditions that may affect children and families for generations. However, one cannot and should not wait for a GBD

Disclosure

The author has no commercial or financial conflicts of interest related to this article. There was no funding for this article.