NCDs lectures11

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Non-Communicable DiseasesCourse title :

PHS 434Code and number:

4344 (4 +0)Credit hours:

CMD 225Prerequisite :

7Level

2


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Distribution of course degrees:

1 - (10) degrees for first midterm examination.

2 - (10) degrees for second midterm examination.3 - (20) the degree of a sudden and short tests andresearch assignments, and workshops to discuss andshare.

4 - (60) degrees for the final test.

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References:

1- S.L. Goel. Education of Communicable and Non-CommunicableDiseases (2009) Publisher: Deep & Deep Publications

2- Judith Carrier. Managing Long-term Conditions and Chronic Illness inPrimary Care: A Guide to Good Practice(2009) Publisher: Routledge; 1edition

3- Patrick L., M.D. Remington, Ross C., Ph.D. Brownson, and Mark V.,M.D. Wegner Chronic Disease Epidemiology and Control(2010)Publisher: American Public Health Association; 3 edition

4- State-based chronic disease control: the Rocky Mountain Tobacco-

Free Challenge.: An article from: Morbidity and Mortality Weekly Report(2005) Publication:Morbidity and Mortality Weekly Report

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Welcome to the contents

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Diseases classification

diseases

communicable non communicable

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Is a disease which is not infectious. Such diseases may result from geneticor lifestyle factors.

A non-communicable disease is an illness that is caused by something

other than a pathogen. It might result from hereditary factors, improper diet, smoking, or otherfactors. Those resulting from lifestyle factors are sometimes calleddiseases of affluence.

Examples include hypertension, diabetes, cardiovascular disease, cancer,and mental health problems, asthma, atherosclerosis, allergy etc.

The non-communicable diseases are spread by: heredity, surroundingsand behavior.


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http://www.indushealthplus.com/ncds-non-communicable-diseases/


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A non-communicable disease, or NCD, is amedical condition or disease, which by

definition is non-infectiousand non-transmissibleamong people. NCDs may bechronic diseases of long duration and slow

progression

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http://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Disease


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Noncommunicablediseases are not spreadby pathogens

May be present at birth In other cases, noncommunicabledisease

may develop as a result of a persons lifestylebehavior

May develop from the effects of substancesin the environment or the cause may be unknown.


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Many noncommunicablediseases arechronic- diseases that are present either

continuously or off and on over a long time. Examples: asthma


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Some noncommunicablediseases cause thebody cells and tissue to break down, or

degenerate. Degenerative diseasesare diseases that

cause further breakdown in body cells,tissues, and organs as they progress.

Example: multiple sclerosis


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Some babies are born with physical or mentaldisabilities that are a result of genetics orbirth defects

The causes of many birth defects areunknown

Some may result from harmful substances in

environment (x-rays), lifestyle behaviors ofthe mother (alcohol), or a defect in genes (down syndrome).


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Some diseases there are certain risk factors. Risk factors are characteristics that increase a

persons chances of developing a disease Risk factors over which people have no

control are heredity, age, gender, and ethnicgroup.


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Lifestyle behaviors are risk factors we havecontrol of:

Eating habits Physical activity

Sleep habits

Healthful lifestyles can prevent, control, or reducethe risk of certain diseases.


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http://vydyaratnakaram.blogspot.com/2011/06/non-communicable-diseases.html


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These substances can cause serious healthproblems or make existing health problems

worse Chemical wasteburied in landfills creates fumes;

illness can occur years after initial exposure.

Construction materials(asbestos) can cause lung

disease long after exposure


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Household chemicals(paints, solvents) can

pollute the indoor air and cause health problems

Secondhand smokecan be harmful to

nonsmokers

Improper waste disposalby manufacturers ofhousehold items like plastics/paint creates water

and air pollution. Oil from cars old aerosol canscan pose health risks too.


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Radona colorless, odorless gas released from soil androcks that contain tiny amounts of radium. Radon canseep into the air through foundations, basements, and

pipes. Exposure over a long period of time increases therisk of lung cancer.

Carbon monoxideis a colorless, odorless gas producedwhen fuel is burned. It is present in fumes from car exhaust

and some furnaces and fireplaces. If fuel burningappliances do not work properly they can producedangerous levels of carbon monoxide which can causeillness or death.


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Allergies Alzheimers disease Arthritis Asthma Cancer Cardiovascular disease Cerebral palsy Cystic Fibrosis Multiple Sclerosis Muscular Dystrophy Sickle-Cell disease


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Approximately, 17 million people die prematurely each year as aresult of the global epidemic of chronic diseases

The risks of high blood pressure and high blood cholesterol,tobacco and excessive alcohol consumption, obesity and physicalinactivity were more commonly associated with affluent societies.

becoming dominant in all middle and low income countries and notlimited to the effluent countries

NCDs, is responsible for almost 60% of world deaths (31.7 milliondeaths) and 43% of the global burden of diseases.


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This increase is clearly related to changes in global dietarypatterns and increased consumption of industrially processedfatty, salty and sugary foods

In its 2003 annual report, MOH stated that it considers (NCDs),caused by unhealthy diets and habits, to be just as serious asthose caused by under-nutrition


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NCD CHALLENGES

Cost Pressures

Disease burden,interventions, drugs

Quality of CareCare teams, medical records,financial incentives

Prevention

Fragmentation, lack of

protocols, lack of financialincentives/support

Poverty

CHANGES NEEDED Comprehensiveness

With policy/legislationsupport

Coordination Information flows

Continuity Organized Care

Communication Orient. on self management

Community linkages


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How to strengthen health

systems for NCDs?Financing (increased, better and sustained

Regulation (assured quality and affordability)Service Delivery (ensured access and

availability)

Governance (improved performance)


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Epidemiology of Non-

Communicable Diseases


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NON- COMMUNICABLE DISEASES INCLUDE

Cardiovascular ( hypertension, coronary artery disease,stroke )

Renal (nephritis, nephrotic syndrome)

Nervous and mental ( mania, depression)

Musculoskeletal ( arthritis)

Respiratory (asthma, emphysema, bronchitis) Cancer

Diabetes

Obesity

Blindness Degenerative disorders

Accidents


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Gaps in the natural history of NCD

1. Absence of known agent: in most of NCD the cause is

not known.2. Multifactorial causation: in absence of causative agents,

risk factorsare studied

An attribute or exposure that is significantly associated

with development of disease.If determinant is modified by intervention, it reduces

possibility of occurrence of disease.

Risk factors can be causative, contributory or predictive.

They can be modifiable or non-modifiableThey can be individual or community risk factors

Epidemiological studies are needed to identify risk

factors

At-risk approach, at-risk groups, risk factors with

diseases


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Web of causation

Changes in life style stress

Abundance of food lack of physical activity smoking emotionaldisturbance

aging

Obesity hypertension

Hyperlipidemia thrombotic tendency

changesartery

wallsCoronary arthrosclerosis coronary occlusion

Myocardial

infarction


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3. Long latent period: it is the period between thefirst exposure to suspected cause and theeventual development of disease. This makes it

difficult to link suspected causes with outcomes.4. Indefinite onset : Most (NCD) are slow in onset

and development. Distinction between diseasedand non diseased may be difficult to establish.


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Prevention of NCD To lessen the impact of NCDs on individuals and

society, a comprehensive approach is needed thatrequires all sectors, including health, finance, foreign

affairs, education, agriculture, planning and others, towork together to reduce the risks associated withNCDs, as well as promote the interventions to preventand control them.

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Other way is via a primary health-care approach tostrengthen early detection and timely treatment.Evidence shows that such interventions are excellent

economic investments because, if applied to patientsearly, can reduce the need for more expensivetreatment.

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Prevention of NCDLevels of prevention1. Primordial

2. Primary

3. Secondary

4. Tertiary

1. Primordial prevention- Prevention of the emergence or developmentof risk factors in countries or population groups in which they havenot yet appeared. Efforts are directed towards discouraging children

from adopting harmful life styles.

2. Primary prevention- Action taken prior to the onset of disease whichremoves the possibility that the disease will ever occur. Can bedivided into population & high risk strategy.

For healthy people

For unhealthy people


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Causation in epidemiology

:is an event, circumstance, condition, risk factor,Causeexposure, characteristic or a combination of thesefactors, which results in producing the disease.

Necessary cause: Vibrio cholerae is necessary for

Cholera.

Sufficient cause: are factors and conditions ,whichare other than the etiological cause of disease.

In sanitary conditions, water conditions, adequate doseof vibrio cholerae,host immunity.


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Association and causation : Association may be defined as

the concurrence of two variablesmore often than would beexpected by chance.

It does not necessarily imply acausal relationship.

Correlation indicates the degreeof association between two

characteristics. The correlation coefficients

range from -1.0 to +1.0

ASSOCIATION

SPURIOUSDIRECT

(CAUSAL)INDIRECT

ONE TO ONE

CAUSAL

MULTI

FACTORIAL


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1.Spurious association:When an observedassociation between adisease and suspectedfactor is not real.

2. Direct (causal):One to one relationship

Germ theory of disease Necessary cause Sufficient cause

Multifactorial causation

3.Indirect association:It is statistical associationbetween a variable and adisease due to presence ofanother factor known orunknown, that is commonto both the variable anddisease. This commonfactor is confounding

factor.

altitude

Iodine deficiency

endemicgoiter


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Criteria for causality

coherence

biological

consistency

specificity

strength

temporal

association


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1. Temporal association: the cause must precede theeffect.

2. Strength of association:

Larger the relative risk greater the likely hood ofcausal relation

Dose response and duration response relationship3. Specificity of association: one to one relationship

between cause and effect.

It is difficult in chronic diseases.lung cancer

ca cervix

Cigarette smoking


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.4Consistency of association:When results are replicated when studied in

different settings and by different methods.

.5Biological plausibility :Association agrees with current understanding ofthe response of cells, tissues, organs and system tostimuli.

Food intake and cancer are correlated. The positiveassociation of intestine and rectal carcinoma islogical whereas positive association of food and Ca.skin makes no biological sense.

.6Coherence of association: Rising consumption of tobacco in form of cigarettesand rising incidence of lung Ca.

Fall in RR of lung Ca when smoking is stopped.


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The next will beExamples of chronic non - communicable diseases

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Diabetes Mellitus


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Definition of DM

Diabetes is a chronic disease that occurs when thepancreas does not produce enough insulin, oralternatively, when the body cannot effectively use the

insulin it produces. Insulin is a hormone that regulatesblood sugar


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Glucose Tolerance Categories

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.2002;25(suppl):S5

FPG 2-hr PG on OGTT

126

100 and


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Etiologic Classification of Diabetes

Mellitusb-cell destruction with lack of

insulinType1

Insulin resistance with insulin

deficiency

Type2

Genetic defects in b-cellexocrinepancreas diseases drug- or chemical

induced, and other rare

forms

Other specific types

Insulin resistance with b-celldysfunction

Gestational

Adapted from The Expert Committee on the Diagnosis and Classification of

Diabetes Mellitus.Diabetes Care.1997;20:1183-1197.


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BrainCerebrovascular disease

Transient ischemicattack

Cerebrovascularaccident

Cognitive impairment

Complications of Diabetes

HeartCoronary artery disease

Coronary syndrome Myocardial infarction Congestive heart

failure

ExtremitiesPeripheral vasculardisease Ulceration Gangrene Amputation

Macrovascular Microvascular

EyeRetinopathyCataractsGlaucoma

KidneyNephropathy

Microalbuminuria Gross albuminuria Kidney failure

NervesNeuropathy

Peripheral Autonomic


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"Diabetes is a major threat to global public health thatis rapidly getting worse, and the biggest impact is onadults of working age in developing countries. At least

171 million people worldwide have diabetes. Thisfigure is likely to more than double by 2030 to reach366 million."

GLOBAL PROJECTIONS FOR THE


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GLOBAL PROJECTIONS FOR THE

DIABETES EPIDEMIC: 2003-2030 (millions)

World

2003 = 194 million

2030 = 366 millionIncrease 75%


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Epidemiology

In 2000, according to the World Health Organization, at least 171million people worldwide suffer from diabetes. Its incidence isincreasing rapidly, and it is estimated that by the year 2030, thisnumber will double.

Prevalence ofDiabetes mellitus among population above 20yearsin 2005was 11%.(WHO, 2006)

Diabetes is in the top 10, and perhaps the top 5, of the most

significant diseases in the developed world.(Wikipedia)


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According to the American Diabetes Association,approximately 18.3%(8.6million) of Americans age 60and older have diabetes. Diabetes mellitus prevalenceincreases with age. (ADA, 2004.)

The National Diabetes Information Clearinghouseestimates that diabetes costs $132billion in the UnitedStates alone every year (Eberhart, MSet al, 2004.)


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Diabetes frequency is dramatically

rising all over the world

The World Health Organization (WHO) estimatesthat more than 180 million people worldwide havediabetes. This number is likely to more than double by2030.

In 2005, an estimated 1.1 million people died from

diabetes. Almost 80% of diabetes deaths occur in low and

middle-income countries.


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The global increase in diabetes will occur because ofpopulation ageing and growth, and because ofincreasing trends towards obesity, unhealthy diets andsedentary lifestyles.

Worldwide, 3.2 million deaths are attributable todiabetes every year.

One in 20 deaths is attributable to diabetes; 8,700deaths every day; six deaths every minute.


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At least one in ten deaths among adults between 35 and 64 yearsold is attributable to diabetes.

Three-quarters of the deaths among people with diabetes agedunder 35 years are due to their condition.

Almost half of diabetes deaths occur in people underthe age of 70 years; 55% of In developing countries thenumber of people with diabetes will increase by 150%in the next 25 years.


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In developed countries most people with diabetes are

above the age of retirement, whereas in developingcountries those most frequently affected are agedbetween 35 and 64.

WHO projects that diabetes deaths will increase bymore than 50% in the next 10 years without urgentaction. Most notably, diabetes deaths are projected toincrease by over 80% in upper-middle income countriesbetween 2006 and 2015.


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In the developed world, diabetes is the most

significant cause of adult blindness in the non-elderly, the leading cause of non-traumaticamputation in adults, and diabetic nephropathyis the main illness requiring renal dialysis in theUnited States.


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Estimated number of adults with diabetes by age-

group in the world


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Estimated number of adults with diabetes by age-

group in developed courtiers


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Estimated number of adults with diabetes

by age-group in developing courtiers


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Prevalence rates of diabetes and hypertension among registered

Population 40 years and above by Field, 2005


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New cases of Diabetes mellitus in West Bank clinicsIn 2005, out of total 2,741 new reported cases of diabetesin the West Bank diabetic clinics, out of them 28.2% wasamong age group of (55-64), 41.0% among age group of35-54 years, 6.3% among age less than 35 years, 24.4%among age 65 years and over.


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6.30%

41.00%

28.20%24.40%

0

0.1

0.2

0.3

0.4

0.5

less than 34 35-54 55-64 65and more

New reported cases of D.M. in WB clinics by age 2005


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Distribution of diabetic (type II) cases by

management in the West Bank healthclinic: 1. About 28.6% of diabetics cases were managed by

insulin treatment.

2. About 5.0% were treated with a combined therapy(insulin and OHA).

3. About 64.7% of diabetics' cases were managed bytablets.

4. Diet control (exclusively managed by lifestylemodification) was 1.7%


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Major risk factors Family history

Obesity

Age (older than 45)

History of gestational diabetes

High cholesterol

Hypertension


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Prevention of effects combination

approach Increased exerciseDecreases need for insulin

Reduce calorie intake

Improves insulin sensitivity

Weight reduction

Improves insulin action


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Triad of Treatment Diet

Medication

Oral hypoglycemics Insulins

Exercise


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Diet Lower calorie

Fewer foods of high glycemic index

Spread meals evenly


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Diabetic Meal Plan Using the Food

Guide Pyramid


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Anti-Diabetic medications Oral hypoglycemic agents

Sulfonylureas

Thiazolidinediones Biguanides

Alpha-glucosidase inhibitors

D-phenylalinine derivatives

Insulins


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Obesity


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Obesityis a condition in which people have an excess ofbody fat. According to (CDC), the prevalence of obesity in the U.S

more than doubled between the years 1960 and 2000, withthe greatest increase from 1980 forward.

According to the National Institutes of Health, almostone-third of Americans are obese.

Obesity is growing problem across the globe. Worldwide, more than 300 million adults are obese,

according to (WHO). obesity is the second-leading cause of preventable death

in the U.S, surpassed only by smoking. At least 300,000Americans die each year as a result of factors attributed toobesity, American Obesity Association


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Obesity is a major risk factor for a number

of serious health conditions, including: Coronary heart disease. Cancer. Diabetes. Fatty liver disease. Gallbladder disease. High blood pressure..

Osteoarthritis. Stroke. Sleep apnea and other breathing problems.


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ClassificationObesity, in absolute terms, is an increase ofbody adipose tissue (fat tissue) mass.

BMIBody mass index or BMI is a simple andwidely used method for estimating body

fat mass. BMI was developed in the 19thcentury by the Belgian statistician


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ClassificationBMI

underweightLess than 18.5

normal weight18.524.9

overweight25.029.9 is

class I obesity30.034.9 is

class II obesity35.039.9


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Questions??


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The surgical literature breaks down "class III" obesity into furthercategories.

Any BMI > 40 is severe obesity

A BMI of 40.049.9 is morbid obesity

A BMI of >50 is super obese

Gabriel I Uwaifo (June 19, 2006). "Obesity". Retrieved on 2008-09-29.


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Cancer

C


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Cancer

medical term: (malignant neoplasm) isa class of diseases in which a group ofcells display uncontrolled growth,invasion and sometimes metastasis(spread to other locations in the bodyvia lymph or blood).


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Cancer may affect people at all ages, even fetuses, but

the risk for most varieties increases with age. Cancer causes about 13% of all deaths.

According to the American Cancer Society, 7.6million people died from cancer in the world during2007.
http://upload.wikimedia.org/wikipedia/en/d/d6/Cancer_rate.gif


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http://upload.wikimedia.org/wikipedia/en/d/d6/Cancer_rate.gif


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2006 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2006.

Men291,270

Women273,560

26%Lung & bronchus

15%Breast

10%Colon & rectum

6%Pancreas

6%Ovary

4%Leukemia

3%Non-Hodgkin

lymphoma

3%Uterine corpus

2%Multiple myeloma

2%Brain/ONS

All other sites 23%

Lung & bronchus 31%

Colon & rectum 10%

Prostate 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4%bile duct

Esophagus 4%

Non-Hodgkin 3%lymphoma

Urinary bladder 3%

Kidney 3%

All other sites 23%


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ypertensionThe Silent killer


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DefinitionHypertension is high blood pressure.

Blood pressure is the force of blood

pushing against the walls of arteries asit flows through them.


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Classification of hypertension :

Essential ( primary ) Hypertension :

It indicates that no specific medical cause can be found toexplain a patient's condition, from the patients diagnosed

with hypertension, 95% fall in the category of essential (or

idiopathic) hypertension.

Secondary Hypertension:

Indicates that the high blood pressure is a result of (i.e.

secondary to) another condition, such askidney disease ortumors, 5% will fall in the category of secondary

hypertension.


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Risk factors for hypertension include:

Modifiable Body weight

Sodium chloride intake

Alcohol intake

Physical activity

Psychosocial factors

Socio-economic status

Hormonal contraceptives

Non-modifiable

Age

Sex/gender

Heredity

Ethnicity/race

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Global burden of hypertension

The biggest increase in prevalence was expected to be in developing(increase of 24%) and third world countries (increase of 80%) as therapidly take on the more western lifestyle.Scientists are now claiming that 1 in 3 adults in the world will have high

blood pressure in 2025. By 2025, the number will increase by about 60%to a total of 1.56 billion as the proportion of elderly people will increasesignificantly.

Kearney PM et al. Lancet 2005; 365:217-223.

Prevalence of hypertension can differ


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Prevalence of hypertension can differ

according to gender and age.

Men are at increased risk for high bloodpressure as compared to women until the age of55. After 55, there is a higher percentage of

women at risk for high blood pressure.

High blood pressure is 2 to 3 times morecommon in women taking oral contraceptives,especially in obese and older women, than in

women not taking them. 64% of men over 75 years old have

hypertension.

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77% of women over 75 years old have

hypertension. Older females have a significant risk of developing

high blood pressure. More than 50% of women

over age 60 have high blood pressure. African-Americans who live in the United States

have the highest prevalence of hypertension in theworld. ( WHO )


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Hypertension disease Mortality in 2005 :Hypertension disease is the fifth-leading cause of

cardiovascular diseases deaths; 12.9% of the total

cardiovascular mortality, with a rate of 13.0 per 100,000.

Hypertension disease is the eight-leading cause of

deaths in total population (4.8%), while it was the ninth

leading deaths in males and females (2.7% and 3.8%) of

males and females deaths respectively.


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Cardiovascular Disease


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Introduction Non communicable disease account for a

large and increasing burden of diseaseworldwide. It is currently estimated that

non communicable disease accounts forapproximately 59% of global deaths and43% of global disease burden. This isprojected to increase to 73%of deaths and60%of disease burden by 2020.


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Introduction, cont.The worldwide burden of cardiovascular disease issubstantial. In most industrialized countries,cardiovascular disease are the leading cause ofdisability and death. Developing countries, withprevious low rate are now seeing increased rates aseconomic develop, infectious disease are conqueredand life expectancy improves.


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CVD are present in many forms and have


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CVD are present in many forms and have

different categories and include:-

Hypertension (high blood pressure)Coronary heart disease (heart attack)

Cerebrovascular disease (stroke)

Peripheral vascular disease

Heart failure

Rheumatic heart disease

Congenital heart disease

Cardiomyopathies

Ri k f t f di l


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Risk factors for cardiovascular

disease Non-modifiable Risk Factors

Age

Gender, men under the age 64 are much more likely to die ofcoronary heart disease than women, although anyone can diefrom it.

Genetic factors/Family history of cardiovascular disease.

Race (or ethnicity), Studies show that blacks are twice as likelyto develop high blood pressure as Caucasians.


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Risk factors, cont.

Environment, your chances can increase because of areas with a lot

of smog or other form of air pollution, including passive smoking.

Modifiable Risk Factors

cigarette smoking, high cholesterol and high blood

Pressure, lack of exercise, diabetes, obesity, alcohol,

certain infections and inflammation, estrogens,

androgens, and certain psychosocial factors.


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Global Burden of Cardiovascular

DiseaseCardiovascular disease is the number one cause ofdeath globally and is projected to remain the leading

cause of death.

An estimated 17.5 million people died from

cardiovascular disease in 2005, representing 30 % of all

global deaths.

Of these deaths, 7.6 million were due to heart attacks

and 5.7 million were due to stroke.


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Statistics, contAround 80% of these deaths occurred in low and

middle income countries (LMIC).

If appropriate action is not taken, by 2015, an

estimated 20 million people will die from

cardiovascular disease every year, mainly from heart

attacks and strokes. (WHO, 2005)


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Percentage breakdown of deaths

from cardiovascular diseases


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Statistics, cont

Angina pectoris (chest pain or discomfort caused

by reduced blood supply to the heart muscle)

9,100,000.

Stroke5,800,000.

Heart Failure5,300,000

Over 142,000 Americans killed by CVD in 2004 are

under age 65


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Statistics, cont

2004 death rates from CVD were 335.1 for white males and 454.0

for black males; for white females 238.0 and for black females

333.6 (Death rates are per 100,000 population.

From 1993 to 2003 death rates from CVD declined 24.7 percent.

Despite this decline in the death rate, in the same 10-year period the

actual number of deaths declined only 8 percent.


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Mortality rate per 100,000 of cardiovascular

diseases was:

All heart diseases 56.8 Rheumatic HD 0.7

Ischemic HD 36.4

Pulmonary HD 1.6

Other heart diseases 18.1 CVA 29.8

Essential hypertension 13

Cardiovascular Disease Mortality Indicator


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Statistics

In 2005, 3,799 persons died from cardiovascular

diseases (1,956 males and 1,843 females), with a

proportion of 36.7% of total deaths, with a rate of101/100,000 population.

Mortality among males was higher than females

(51.5% in males and 48.5% in females).


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Statistics, cont

Cardiovascular mortalities are ranking as following:

1. All heart diseases (Ischaemic, Rheumatic,

Pulmonary and Other Heart diseases), constitute56.8% of cardiovascular diseases with a rate of 54.4

per 100,000 population

2. Ischaemic heart disease constitutes 37.5% ofcardiovascular diseases with a rate of 35.9 per

100,000 population;

St ti ti t


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3. Cerebrovascular disease constitutes 24.4% of CVDswith a rate of 23.4 per 100,000 population.

4. Hypertensive disease constitutes 17.4% of

cardiovascular diseases with a rate of 16.6 per

100,000 population.

5. Other heart diseases constitutes 17.4% of

cardiovascular diseases with a rate of 16.7 per

100,000 population.

Statistics, cont


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Thanks

Documents

NCDs lectures11