Estimates of antibiotic resistance in Italy and Western Europe in 2019: a MICROBE-based comparative analysis.

BACKGROUND: antimicrobial resistance (AMR) will cause 10 million deaths per year worldwide by 2050, with economic costs of up to 100 trillion dollars. Antibiotic resistance (ABR) constitutes the majority of this health threat. Globally, 1.27 million people died in 2019 as a direct result of ABR. One in 5 deaths occurred in children under five, and 6 bacterial pathogens accounted for more than 70% of ABR-associated deaths. OBJECTIVES: to compare ABR estimates in terms of death and disability-adjusted life-years (DALYs) in 2019 in Italy and in Western Europe (WE) by grading the infectious syndromes and the bacterial pathogens involved, with the aim to identify the most urgent healthcare needs in Italy. DESIGN: the estimates of the burden of ABR in 2019 in WE and Italy, extracted from the Measuring Infectious Causes and Resistance Outcomes for Burden Estimation (MICROBE) tool by the Institute for Health Metrics and Evaluation (IHME; Seattle, USA), reported deaths and DALYs associated with 33 bacterial pathogens across 12 infectious syndromes, as well as deaths and DALYs associated with and attributable to ABR for 23 bacteria and 86 pathogen-drug combinations. The comparison between WE and Italy was performed in steps. First, among the 12 groups of infectious syndromes from the Global Burden of Diseases (GBD) study 2019, the most impacting in terms of deaths and DALYs were ranked based on the magnitude of rates, and the corresponding ABR-associated burden was reported. Then, the burden of the leading pathogens (bacteria, viruses, fungi, and polymicrobial infections) for all infectious syndromes was compared between the two areas. Death and DALY rates associated with ABR were reported for each bacterium, together with the percentage of ABR-attributable burden. Although it is known that Italy is one of the WE countries with the largest share of elderly, crude rates were reported instead of age-standardized rates, in order to quantify the actual burden of ABR in the two areas. SETTING AND PARTICIPANTS: Italy and Western Europe. MAIN OUTCOMES MEASURES: death and DALYs rates per 100,000 inhabitants. RESULTS: the largest difference between ABR-associated death rates in the two areas was found for bloodstream infections (25.2 and 18.8 per 100,000 in Italy and WE, respectively), followed by peritoneal and abdominal infections (15.1 and 12.2 in Italy and WE, respectively). However, the percentages of deaths and DALYs attributable to ABR were always higher in Italy for all the infections considered. Regarding pathogens, Escherichia coli accounted for the greatest burden associated to ABR, in terms of both deaths and DALYs, in both areas. The highest ABR-attributable percentage of deaths was found for Acinetobacter baumannii (28.4% in WE and 31.9% in Italy), accounting also for the highest percentage of ABR-attributable DALYs (28.4% in WE and 31.7% in Italy). The pathogen-drug combination with the highest burden associated with AMR was Escherichia coli-Aminopenicillin, while the greatest AMR-attributable burden was found for Staphylococcus aureus-Methicillin (MRSA). On average, 55.4% of Escherichia coli was resistant to Aminopenicillin in WE, with Italy ranking third (67.6%). Nordic countries showed smaller values, with Sweden in last place (32.8%). The average percentage of MRSA in WE was 16%, with Italy exceeding it by more than 13 pointsConclusions: despite similar sepsis mortality rates in Italy and other WE countries, the proportion of ABR-associated and attributable deaths was higher in Italy. Targeted strategies aimed at reducing the circulation of bacteria and resistant microorganisms together with other interventions could lead to an overall reduction in deaths associated with ABR.

National and subnational burden of female and male breast cancer and risk factors in Iran from 1990 to 2019: results from the Global Burden of Disease study 2019.

BACKGROUND: Breast cancer (BC) is one of the most burdensome cancers worldwide. Despite advancements in diagnostic and treatment modalities, developing countries are still dealing with increasing burdens and existing disparities. This study provides estimates of BC burden and associated risk factors in Iran at the national and subnational levels over 30 years (1990-2019). METHODS: Data on BC burden for Iran were retrieved from the Global Burden of Disease (GBD) study from 1990 to 2019. GBD estimation methods were applied to explore BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to risk factors based on the GBD risk factors hierarchy. Moreover, decomposition analysis was performed to find the contribution of population growth, aging, and cause-specific incidence in the total incidence change. Age-standardized rates (per 100,000 population) and 95% uncertainty intervals (UI) were reported based on sex, age, and socio-demographic index (SDI). RESULTS: Age-standardized incidence rate (ASIR) increased from 18.8 (95% UI 15.3-24.1)/100,000 in 2019 to 34.0 (30.7-37.9)/100,000 in 2019 among females and from 0.2/100,000 (0.2-0.3) to 0.3/100,000 (0.3-0.4) among males. Age-standardized deaths rate (ASDR) increased slightly among females from 10.3 (8.2-13.6)/100,000 in 1990 to 11.9 (10.8-13.1)/100,000 in 2019 and remained almost the same among males-0.2/100,000 (0.1-0.2). Age-standardized DALYs rate also increased from 320.2 (265.4-405.4) to 368.7 (336.7-404.3) among females but decreased slightly in males from 4.5 (3.5-5.8) to 4.0 (3.5-4.5). Of the 417.6% increase in total incident cases from 1990-2019, 240.7% was related to cause-specific incidence. In both genders, the BC burden increased by age, including age groups under 50 before routine screening programs, and by SDI levels; the high and high-middle SDI regions had the highest BC burden in Iran. Based on the GBD risk factors hierarchy, high fasting plasma glucose (FPG) and alcohol were estimated to have the most and the least attributed DALYs for BC among females, respectively. CONCLUSIONS: BC burden increased from 1990 to 2019 in both genders, and considerable discrepancies were found among different provinces and SDI quintiles in Iran. These increasing trends appeared to be associated with social and economic developments and changes in demographic factors. Improvements in registry systems and diagnostic capacities were also probably responsible for these growing trends. Raising general awareness and improving screening programs, early detection measures, and equitable access to healthcare systems might be the initial steps to tackle the increasing trends.

Population health outcomes in Nigeria compared with other west African countries, 1998-2019: a systematic analysis for the Global Burden of Disease Study.

BACKGROUND: Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries. METHODS: In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository. FINDINGS: Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64·3 years (95% uncertainty interval [UI] 62·2-66·6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18·6 in 2001 to $83·75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176·3 YLLs per 100 000 people, 95% UI 2464·0-9591·1) and neonatal disorders (4818·8 YLLs per 100 000, 3865·9-6064·2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491·8 deaths per 100 000, 95% UI 1986·1-3140·1) and female individuals (2117·7 deaths per 100 000, 1756·7-2569·1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians. INTERPRETATION: Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health. FUNDING: The Bill & Melinda Gates Foundation.

Addressing discrepancies in estimates of road traffic deaths and injuries in Ethiopia.

BACKGROUND: There are large discrepancies between official statistics of traffic injuries in African countries and estimates from the Global Burden of Disease (GBD) study and WHO's Global Status Reports on Road Safety (GSRRS). We sought to assess the magnitude of the discrepancy in Ethiopia, its implications and how it can be addressed. METHODS: We systematically searched for nationally representative epidemiological data sources for road traffic injuries and vehicle ownership in Ethiopia and compared estimates with those from GBD and GSRRS. FINDINGS: GBD and GSRRS estimates vary substantially across revisions and across projects. GSRRS-2018 estimates of deaths (27 326 in 2016) are more than three times GBD-2019 estimates (8718), and these estimates have non-overlapping uncertainty ranges. GSRRS estimates align well with the 2016 Demographic and Health Survey (DHS-2016; 27 838 deaths, 95th CI: 15 938 to 39 738). Official statistics are much lower (5118 deaths in 2018) than all estimates. GBD-2019 estimates of serious non-fatal injuries are consistent with DHS-2016 estimates (106 050 injuries, 95th CI: 81 728 to 130 372) and older estimates from the 2003 World Health Survey. Data from five surveys confirm that vehicle ownership levels in Ethiopia are much lower than in other countries in the region. INTERPRETATION: Inclusion of data from national health surveys in GBD and GSRRS can help reduce discrepancies in estimates of deaths and support their use in highlighting under-reporting in official statistics and advocating for better prioritisation of road safety in the national policy agenda. GBD methods for estimating serious non-fatal injuries should be strengthened to allow monitoring progress towards Sustainable Development Goal target 3.6.

Drug-use disorders in the Eastern Mediterranean Region: a glance at GBD 2019 findings.

PURPOSE: The aim of this study is to investigate drug use disorders which are a major cause of Disability Adjusted Life Years (DALYs) in the Eastern Mediterranean Region (EMR). METHODS: This article is a part of the global burden of diseases (GBD), injuries, and risk factors 2019 study. The GBD modeling approach was used to estimate population-level prevalence of drug use disorders. We combined these estimates with disability weights to calculate years of life lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 1990-2019. RESULTS: It is estimated that in 2019 in EMR around 3.4 million people have drug use disorder which has increased by 137% compared to 1990. Also, in 2019, DALY number for drug use disorders was 1217.9 (95% UI: 940.4, 1528.9) thousand years and 7645 (95% UI: 6793.7, 8567.9) deaths occurred. The DALY rate increased 39.6% in the region since1990, whereas the global rate increased by 24.4%. United Arab Emirates, Libya, and Iran were most affected by drug use disorders with the highest rates of age-standardized DALY in EMR in 2019. The most prevalent drug use disorder in the region is opioid use which is accountable for 80% of all drug use disorders DALYs. CONCLUSION: Despite many interventions, drug use disorders are still responsible for high rates of DALY in the region which has increased since 1990 in both males and females; more comprehensive policies, better control measures and proper education could reduce the adverse effects.

Life Expectancy for White, Black, and Hispanic Race/Ethnicity in U.S. States: Trends and Disparities, 1990 to 2019.

BACKGROUND: Life expectancy (LE) differences within and between states by race/ethnicity have not been examined. OBJECTIVE: To estimate LE for selected race/ethnicity groups in states from 1990 to 2019. DESIGN: Cross-sectional time-series analysis. SETTING: United States. PARTICIPANTS: Deidentified death records and Census data were used to construct regression models with smoothed time series of mortality from 1990 to 2019. MEASUREMENTS: LE at birth, by sex and year, for subgroups of people reporting Hispanic, non-Hispanic Black, or non-Hispanic White race/ethnicity. RESULTS: Disparities in LE across states were 8.0 years for females and 12.2 years for males in 1990 and 7.9 years for females and 7.8 years for males in 2019. When race/ethnicity groups were accounted for, disparities across states were 20.7 years for females and 24.5 years for males in 1990, decreasing to 18.5 years for females and 23.7 years for males in 2019. Disparities across states increased within each race/ethnicity group between 1990 and 2019, with the largest increase for non-Hispanic White males and the smallest for Hispanic females. The disparity between race/ethnicity groups within states decreased for most of the 23 states with estimates for all 3 groups but increased for females in 7 states and males in 5 states. LIMITATION: Because of small sample size, LE was not estimated for 37 of 153 state-race/ethnicity groups. CONCLUSION: Disparity in LE across states was greater when race/ethnicity groups were considered. Disparities across all state-race/ethnicity groups in general have decreased over the past 3 decades. Within each race/ethnicity group, disparities across states have increased. Although racial/ethnic disparities decreased in most of the 23 states for which LE was estimated for all 3 groups, they increased for females in 7 states and males in 5 states. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

The burden of bacterial antimicrobial resistance in Croatia in 2019: a country-level systematic analysis.

AIM: To deliver the most wide-ranging set of antimicrobial resistance (AMR) burden estimates for Croatia to date. METHODS: A complex modeling approach with five broad modeling components was used to estimate the disease burden for 12 main infectious syndromes and one residual group, 23 pathogenic bacteria, and 88 bug-drug combinations. This was represented by two relevant counterfactual scenarios: deaths/disability-adjusted life years (DALYs) that are attributable to AMR considering a situation where drug-resistant infections are substituted with sensitive ones, and deaths/DALYs associated with AMR considering a scenario where people with drug-resistant infections would instead present without any infection. The 95% uncertainty intervals (UI) were based on 1000 posterior draws in each modeling step, reported at the 2.5% and 97.5% of the draws' distribution, while out-of-sample predictive validation was pursued for all the models. RESULTS: The total burden associated with AMR in Croatia was 2546 (95% UI 1558-3803) deaths and 46958 (28,033-71,628) DALYs, while the attributable burden was 614 (365-943) deaths and 11321 (6,544-17,809) DALYs. The highest number of deaths was established for bloodstream infections, followed by peritoneal and intra-abdominal infections and infections of the urinary tract. Five leading pathogenic bacterial agents were responsible for 1808 deaths associated with resistance: Escherichia coli, Staphylococcus aureus, Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa (ordered by the number of deaths). Trimethoprim/sulfamethoxazole-resistant E coli and methicillin-resistant S. aureus were dominant pathogen-drug combinations in regard to mortality associated with and attributable to AMR, respectively. CONCLUSION: We showed that AMR represented a substantial public health concern in Croatia, which reflects global trends; hence, our detailed country-level findings may fast-track the implementation of multipronged strategies tailored in accordance with leading pathogens and pathogen-drug combinations.

COVID-19 impact on life expectancy in Mexico. An analysis based on the Global Burden of Disease 2021 study.

BACKGROUND: Between 2020 and 2021, Mexico documented 2.21 million fatalities, out of which 25.3% were attributable to SARS-COV-2 infection. OBJECTIVES: To evaluate COVID-19 mortality during 2020-2021, determine its impact on national- and state-level life expectancy at birth, and in a group of selected countries of the region, as well as to analyze it according to sociodemographic profiles. MATERIAL AND METHODS: Data from the Global Burden of Disease 2021 study were used to report mortality, the impact on life expectancy and underlying causes between 2019 and 2021. These data were evaluated from the perspective of response to the pandemic and according to the sociodemographic structure based on a quadratic regression model. RESULTS: Between 2020 and 2021, 708,971 excess deaths were recorded, which decreased life expectancy at birth by 4.6 years; 76% of this reduction was attributed to COVID-19. The COVID-19 mortality rate was higher than expected according to the sociodemographic conditions of the states. CONCLUSIONS: In Mexico and the countries of the region, the pandemic was devastating and generated regressions in life expectancy at birth, which varied from two to nine years. It is not clear why the effect was so different between countries and within Mexico.

ANTECEDENTES: Entre 2020 y 2021, México experimentó 2.21 millones de defunciones, de las cuales 25.3 % estuvo relacionado con infección por SARS-COV-2. OBJETIVOS: Evaluar la mortalidad por COVID-19 en 2020-2021, determinar su influencia en la esperanza de vida al nacer a nivel nacional, estatal y en países seleccionados de la región, así como analizarla en función del perfil sociodemográfico. MATERIAL Y MÉTODOS: Se utilizaron datos del Global Burden of Disease 2021 para reportar la mortalidad, el impacto en la esperanza de vida y las causas subyacentes entre 2019 y 2021. Se usó una regresión cuadrática para evaluar la mortalidad en exceso como indicador de la respuesta de los estados a la pandemia, considerando su estructura sociodemográfica. RESULTADOS: Entre 2020 y 2021, se registraron 708 971 muertes en exceso, que disminuyeron la esperanza de vida al nacer en 4.6 años; 76 % de esta reducción se atribuyó a COVID-19. La tasa de mortalidad por COVID-19 fue superior a la esperada conforme a las condiciones sociodemográficas de las entidades. CONCLUSIONES: En México y los países de la región, la pandemia fue devastadora y generó regresiones en la esperanza de vida al nacer, que variaron de dos a nueve años. Se requiere más investigación para entender las variaciones en sus efectos.

Trends and patterns of disparities in diabetes and chronic kidney disease mortality among US counties, 1980-2014.

INTRODUCTION: Diabetes and chronic kidney diseases are associated with a large health burden in the USA and globally. OBJECTIVE: To estimate age-standardized mortality rates by county from diabetes mellitus and chronic kidney disease. DESIGN AND SETTING: Validated small area estimation models were applied to de-identified death records from the National Center for Health Statistics (NCHS) and population counts from the census bureau, NCHS, and the Human Mortality Database to estimate county-level mortality rates from 1980 to 2014 from diabetes mellitus and chronic kidney disease (CKD). EXPOSURES: County of residence. MAIN OUTCOMES AND MEASURES: Age-standardized mortality rates by county, year, sex, and cause. RESULTS: Between 1980 and 2014, 2,067,805 deaths due to diabetes were recorded in the USA. The mortality rate due to diabetes increased by 33.6% (95% UI: 26.5%-41.3%) between 1980 and 2000 and then declined by 26.4% (95% UI: 22.8%-30.0%) between 2000 and 2014. Counties with very high mortality rates were found along the southern half of the Mississippi river and in parts of South and North Dakota, while very low rates were observed in central Colorado, and select counties in the Midwest, California, and southern Florida. A total of 1,659,045 deaths due to CKD were recorded between 1980 and 2014 (477,332 due to diabetes mellitus, 1,056,150 due to hypertension, 122,795 due to glomerulonephritis, and 2,768 due to other causes). CKD mortality varied among counties with very low mortality rates observed in central Colorado as well as some counties in southern Florida, California, and Great Plains states. High mortality rates from CKD were observed in counties throughout much of the Deep South, and a cluster of counties with particularly high rates was observed around the Mississippi river. CONCLUSIONS AND RELEVANCE: This study found large inequalities in diabetes and CKD mortality among US counties. The findings provide insights into the root causes of this variation and call for improvements in risk factors, access to medical care, and quality of medical care.

Estimates of road traffic deaths in Tanzania.

INTRODUCTION: There is considerable uncertainty in estimates of traffic deaths in many sub-Saharan African countries, with the Global Burden of Disease (GBD) and the Global Status Report on Road Safety (GSRRS) reporting widely differing estimates. As a case study, we reviewed and compared estimates for Tanzania. METHODS: We estimated the incidence of traffic deaths and vehicle ownership in Tanzania from nationally representative surveys. We compared findings with GBD and GSRRS estimates. RESULTS: Traffic death estimates based on the 2012 census (9382 deaths; 95% CI: 7565 to 11 199) and the 2011-2014 Sample Vital Registration with Verbal Autopsy (8778; 95% CI: 7631 to 9925) were consistent with each other and were about halfway between GBD (5 608; 95% UI: 4506 to 7014) and WHO (16 252; 95% CI: 13 130 to 19 374) estimates and more than twice official statistics (3885 deaths in 2013). Surveys and vehicle registrations data show that motorcycles have increased rapidly since 2007 and now comprise 66% of vehicles. However, these trends are not reflected in GBD estimates of motorcycles in the country, likely resulting in an underestimation of motorcyclist deaths. CONCLUSION: Reducing discrepancies between GBD and GSRRS estimates and demonstrating consistency with local epidemiological data will increase the legitimacy of such estimates among national stakeholders. GBD, which is the only project that models the road-user distribution of traffic deaths in all countries, likely severely underestimates motorcycle deaths in countries where there has been a recent increase in motorcycles. Addressing police under-reporting and strengthening surveillance capacity in Tanzania will allow a better understanding of the road safety problem and better targeting of interventions.

Comparing estimates of road traffic deaths and non-fatal road traffic injuries in Cambodia.

INTRODUCTION: Timely, accurate and detailed information about traffic injuries are essential for managing national road safety programmes. However, there is considerable under-reporting in official statistics of many low and middle-income countries (LMICs) and large discrepancies between estimates from the Global Burden of Disease (GBD) study and WHO's Global Health Estimates (GHE). We compared all sources of epidemiological information on traffic injuries in Cambodia to guide efforts to improve traffic injury statistics. METHODS: We estimated the incidence of traffic deaths and injuries and household ownership of motor vehicles in Cambodia from nationally representative surveys and censuses. We compared findings with GDB and GHE estimates. RESULTS: We identified seven sources for estimating traffic deaths and three for non-fatal injuries that are not included as data sources in GBD and GHE models. These sources and models suggest a fairly consistent estimate of approximately 3100 deaths annually, about 50% higher than official statistics, likely because most hospital deaths are not recorded. Surveys strongly suggest that the vehicle fleet is dominated by motorcycles, which is not consistent with GBD estimates that suggest similar numbers of motorcyclist and vehicle occupant deaths. Estimates of non-fatal injuries from health surveys were about 7.5 times official statistics and 1.5 times GBD estimates. CONCLUSION: Including local epidemiological data sources from LMICs can help reduce uncertainty in estimates from global statistical models and build trust in estimates among local stakeholders. Such analysis should be used as a benchmark to assess and strengthen the completeness of reporting of the national surveillance system.

Heart failure describing the underlying cause of death: a misconception, lack of information on the true underlying causes, or both?

AIM: The underlying cause of death represents the most important information on death certificates. Often, conditions that cannot represent a true underlying cause of death are listed as such. This phenomenon affects the quality of vital statistics and results of studies using cause-specific mortality as endpoints. We aimed at exploring the magnitude and factors associated with the use of heart failure to describe the underlying cause of death. METHODS: In this cross-sectional, register based study we linked data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry. We used logistic regression models to analyse the association between external factors and heart failure listed as the underlying cause of death. RESULTS: Heart failure was listed as the underlying cause of death in 3.6% of all deaths. The odds of heart failure increased: (a) by 35% for 5-year increment in age; (b) by 78% for deaths occurring at nursing homes (compared with in-hospital deaths); and (c) by 602% for deaths not followed by an autopsy (compared with those followed by an autopsy). Deceased with a previous hospitalisation with heart failure as the discharge diagnosis had 514% higher odds of having heart failure listed as their underlying cause of death. Of the deceased with heart failure listed as the underlying cause of death, 9.4% did not have any, and 69.2% had only irrelevant additional information for assessing the true underlying cause of death in their death certificates. CONCLUSIONS: Heart failure listed as the underlying cause of death was associated with age, place of death, autopsy and previous hospitalisations - all factors that should not influence coding procedures. Better completion of death certificates in accordance with the World Health Organization rules will help reduce the use of heart failure to describe the underlying cause of death.

Mongolia health situation: based on the Global Burden of Disease Study 2019.

BACKGROUND: Over the past few decades, economic, political, and social changes have directly and indirectly affected the health of the Mongolian population. To date, no comprehensive analysis has been conducted on the burden of diseases in this country. Thus, we aimed to describe the leading causes of death and disabling conditions and their trends between 1990 and 2019 in the Mongolian population. METHODS: We used the data from the Global Burden of Disease (GBD) 2019 study. In the current study, we examined life expectancy at birth, healthy life expectancy, the 20 leading causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted-life-years (DALYs), and the contribution of major risk factors to DALYs in Mongolia. FINDINGS: The life expectancy at birth in Mongolia has gradually increased since 1995 and reached 63.8 years for men and 72.7 for women in 2019. The highest increase in the age-standardised death rate between 1990 and 2019 occurred in alcohol use disorders (628.6%; 95% UI 10.0-1109.6) among men, and in liver cancer (129.1%; UI 65.3-222.4) among women. Ischaemic heart disease and stroke showed the highest rates of death, YLLs, and DALYs among both men and women. In 2019, the highest age-standardised rates of DALYs were attributable to high systolic blood pressure and dietary risks. INTERPRETATION: Although Mongolia saw substantial improvements across many communicable diseases, maternal and neonatal disorders, and under-5 mortality between 1990 and 2019, non-communicable diseases remained leading causes of mortality. The mortality from the most preventable causes such as injury, alcohol use, and dietary risks remain substantially high, suggesting that individual and social efforts are needed to tackle these diseases. Our analyses will support the development of policy priorities and action plans in multiple sectors to improve the overall health of the Mongolian population. FUNDING: Bill & Melinda Gates Foundation.

Redistribution of garbage codes to underlying causes of death: a systematic analysis on Italy and a comparison with most populous Western European countries based on the Global Burden of Disease Study 2019.

BACKGROUND: The proportion of reported causes of death (CoDs) that are not underlying causes can be relevant even in high-income countries and seriously affect health planning. The Global Burden of Disease (GBD) study identifies these 'garbage codes' (GCs) and redistributes them to underlying causes using evidence-based algorithms. Planners relying on vital registration data will find discrepancies with GBD estimates. We analyse these discrepancies, through the analysis of GCs and their redistribution. METHODS: We explored the case of Italy, at national and regional level, and compared it to nine other Western European countries with similar population sizes. We analysed differences between official data and GBD 2019 estimates, for the period 1990-2017 for which we had vital registration data for most select countries. RESULTS: In Italy, in 2017, 33 000 deaths were attributed to unspecified type of stroke and 15 000 to unspecified type of diabetes, these making a fourth of the overall garbage. Significant heterogeneity exists on the overall proportion of GCs, type (unspecified or impossible underlying causes), and size of specific GCs among regions in Italy, and among the select countries. We found no pattern between level of garbage and relevance of specific GCs. Even locations performing below average show interesting lower levels for certain GCs if compared to better performing countries. CONCLUSIONS: This systematic analysis suggests the heterogeneity in GC levels and causes, paired with a more detailed analysis of local practices, strengths and weaknesses, could be a positive element in a strategy for the reduction of GCs in Italy.

Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study.

BACKGROUND: Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection. It is considered a major cause of health loss, but data for the global burden of sepsis are limited. As a syndrome caused by underlying infection, sepsis is not part of standard Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimates. Accurate estimates are important to inform and monitor health policy interventions, allocation of resources, and clinical treatment initiatives. We estimated the global, regional, and national incidence of sepsis and mortality from this disorder using data from GBD 2017. METHODS: We used multiple cause-of-death data from 109 million individual death records to calculate mortality related to sepsis among each of the 282 underlying causes of death in GBD 2017. The percentage of sepsis-related deaths by underlying GBD cause in each location worldwide was modelled using mixed-effects linear regression. Sepsis-related mortality for each age group, sex, location, GBD cause, and year (1990-2017) was estimated by applying modelled cause-specific fractions to GBD 2017 cause-of-death estimates. We used data for 8·7 million individual hospital records to calculate in-hospital sepsis-associated case-fatality, stratified by underlying GBD cause. In-hospital sepsis-associated case-fatality was modelled for each location using linear regression, and sepsis incidence was estimated by applying modelled case-fatality to sepsis-related mortality estimates. FINDINGS: In 2017, an estimated 48·9 million (95% uncertainty interval [UI] 38·9-62·9) incident cases of sepsis were recorded worldwide and 11·0 million (10·1-12·0) sepsis-related deaths were reported, representing 19·7% (18·2-21·4) of all global deaths. Age-standardised sepsis incidence fell by 37·0% (95% UI 11·8-54·5) and mortality decreased by 52·8% (47·7-57·5) from 1990 to 2017. Sepsis incidence and mortality varied substantially across regions, with the highest burden in sub-Saharan Africa, Oceania, south Asia, east Asia, and southeast Asia. INTERPRETATION: Despite declining age-standardised incidence and mortality, sepsis remains a major cause of health loss worldwide and has an especially high health-related burden in sub-Saharan Africa. FUNDING: The Bill & Melinda Gates Foundation, the National Institutes of Health, the University of Pittsburgh, the British Columbia Children's Hospital Foundation, the Wellcome Trust, and the Fleming Fund.

Burden of multiple sclerosis in Iran from 1990 to 2017.

BACKGROUND: Multiple Sclerosis (MS) is a burdensome, chronic and autoimmune disease of the central nervous system. We aimed to report the incidence, prevalence, mortality, and Disability Adjusted Life Years (DALYs) of MS in Iran at a national level for different age and sex groups over a period of 28 years (1990-2017). METHODS: Data were extracted from the Global Burden of Disease study (GBD) from 1990 to 2017, published by the Institute for Health Metrics and Evaluation. The incidence of DALYs and prevalence of MS were estimated to report the burden of MS based on sex and age in Iran from 1990 to 2017. RESULTS: At the national level, the Age-Standardized Incidence Rate (ASIR), Age-Standardized Prevalence Rate (ASPR), Age-Standardized DALYs Rate (ASDR) and the Age-Standardized Mortality Rate (ASMR) in Iran in 2017 were 2.4 (95% Uncertainty Interval [UI]: 2.1 to 2.7), 69.5 (62.1 to 77.8), 29.1 (23.6 to 34.7), and 0.4 (0.3 to 0.4) per 100,000 population, respectively. During the period of 1990 to 2017, all measures increased, and were higher among females. The incidence rate began upward trend at the age of 20 and attained its highest level at the age of 25. CONCLUSION: In Iran, all of the age-standardized MS rates have been increasing during the 28 years from 1990 to 2017. Our findings can help policy makers and health planners to design and communicate their plans and to have a better resource allocation, depending on the incidence and prevalence of the growing numbers of MS patients in Iran.

The burden of neck pain in Brazil: estimates from the global burden of disease study 2019.

BACKGROUND: This study analyzed neck pain estimates in Brazil and its states between 2000 and 2019, in view of the country's lacking epidemiological data. METHODS: An analysis was performed of the GBD 2019 estimates by location, sex, and age, per 100,000 population, with uncertainty intervals (95% UI). Brazilian estimates were compared to global, Mexican, English, and American rates. RESULTS: Global, Brazilian, and Mexican prevalence numbers were statistically homogeneous and stable in the period. Throughout the period analyzed in the study, Brazilian neck pain prevalence (2241.9; 95%UI 1770.5-2870.6) did not show statistical differences when compared to global (2696.5; 95%UI 2177.0-3375.2) or Mexican (1595.9; 95%UI 1258.9-2058.8) estimates. Estimates observed in the USA (5123.29; 95%UI 4268.35-6170.35) and England (4612.5; 95%UI 3668.8-5830.3) were significantly higher. In 2019, when compared to the USA and England, age-standardized prevalences were lower globally, in Brazil, and in Mexico. Prevalences in Brazilian states were similar, being that Roraima (1915.9; 95%UI 1506.5-2443.1) and the Federal District (1932.05; 95%UI 1515.1-2462.7) presented the lowest and highest values respectively. The exception was the state of São Paulo (3326.5; 95%UI 2609.6-4275.5). There was no statistical difference by sex, but the prevalence tended to increase with aging. In 2019, the Brazilian prevalence was 2478.6 (95% UI 1791.0-3503.8), 5017.2 (95%UI 3257.26-7483.8), and 4293.4 (95% UI 2898,8-6343.9), for those aged 15 to 49, 50 to 69, and 70+ years. There was no statistical difference among the YLDs in all locations and times. CONCLUSIONS: Brazil is going through a fast-paced process of populational aging; a higher prevalence of neck pain in middle-aged individuals and the elderly highlights the need for lifelong prevention initiatives. The higher rates observed among higher-income populations and the homogeneity of the Brazilian estimates suggest a lack of robust epidemiological data in lower-income countries.

Public health utility of cause of death data: applying empirical algorithms to improve data quality.

BACKGROUND: Accurate, comprehensive, cause-specific mortality estimates are crucial for informing public health decision making worldwide. Incorrectly or vaguely assigned deaths, defined as garbage-coded deaths, mask the true cause distribution. The Global Burden of Disease (GBD) study has developed methods to create comparable, timely, cause-specific mortality estimates; an impactful data processing method is the reallocation of garbage-coded deaths to a plausible underlying cause of death. We identify the pattern of garbage-coded deaths in the world and present the methods used to determine their redistribution to generate more plausible cause of death assignments. METHODS: We describe the methods developed for the GBD 2019 study and subsequent iterations to redistribute garbage-coded deaths in vital registration data to plausible underlying causes. These methods include analysis of multiple cause data, negative correlation, impairment, and proportional redistribution. We classify garbage codes into classes according to the level of specificity of the reported cause of death (CoD) and capture trends in the global pattern of proportion of garbage-coded deaths, disaggregated by these classes, and the relationship between this proportion and the Socio-Demographic Index. We examine the relative importance of the top four garbage codes by age and sex and demonstrate the impact of redistribution on the annual GBD CoD rankings. RESULTS: The proportion of least-specific (class 1 and 2) garbage-coded deaths ranged from 3.7% of all vital registration deaths to 67.3% in 2015, and the age-standardized proportion had an overall negative association with the Socio-Demographic Index. When broken down by age and sex, the category for unspecified lower respiratory infections was responsible for nearly 30% of garbage-coded deaths in those under 1 year of age for both sexes, representing the largest proportion of garbage codes for that age group. We show how the cause distribution by number of deaths changes before and after redistribution for four countries: Brazil, the United States, Japan, and France, highlighting the necessity of accounting for garbage-coded deaths in the GBD. CONCLUSIONS: We provide a detailed description of redistribution methods developed for CoD data in the GBD; these methods represent an overall improvement in empiricism compared to past reliance on a priori knowledge.

Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. METHODS: We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). FINDINGS: Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (-3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). INTERPRETATION: China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. FUNDING: China National Key Research and Development Program and Bill & Melinda Gates Foundation.

Mapping the global endemicity and clinical burden of Plasmodium vivax, 2000-17: a spatial and temporal modelling study.

BACKGROUND: Plasmodium vivax exacts a significant toll on health worldwide, yet few efforts to date have quantified the extent and temporal trends of its global distribution. Given the challenges associated with the proper diagnosis and treatment of P vivax, national malaria programmes-particularly those pursuing malaria elimination strategies-require up to date assessments of P vivax endemicity and disease impact. This study presents the first global maps of P vivax clinical burden from 2000 to 2017. METHODS: In this spatial and temporal modelling study, we adjusted routine malariometric surveillance data for known biases and used socioeconomic indicators to generate time series of the clinical burden of P vivax. These data informed Bayesian geospatial models, which produced fine-scale predictions of P vivax clinical incidence and infection prevalence over time. Within sub-Saharan Africa, where routine surveillance for P vivax is not standard practice, we combined predicted surfaces of Plasmodium falciparum with country-specific ratios of P vivax to P falciparum. These results were combined with surveillance-based outputs outside of Africa to generate global maps. FINDINGS: We present the first high-resolution maps of P vivax burden. These results are combined with those for P falciparum (published separately) to form the malaria estimates for the Global Burden of Disease 2017 study. The burden of P vivax malaria decreased by 41·6%, from 24·5 million cases (95% uncertainty interval 22·5-27·0) in 2000 to 14·3 million cases (13·7-15·0) in 2017. The Americas had a reduction of 56·8% (47·6-67·0) in total cases since 2000, while South-East Asia recorded declines of 50·5% (50·3-50·6) and the Western Pacific regions recorded declines of 51·3% (48·0-55·4). Europe achieved zero P vivax cases during the study period. Nonetheless, rates of decline have stalled in the past five years for many countries, with particular increases noted in regions affected by political and economic instability. INTERPRETATION: Our study highlights important spatial and temporal patterns in the clinical burden and prevalence of P vivax. Amid substantial progress worldwide, plateauing gains and areas of increased burden signal the potential for challenges that are greater than expected on the road to malaria elimination. These results support global monitoring systems and can inform the optimisation of diagnosis and treatment where P vivax has most impact. FUNDING: Bill & Melinda Gates Foundation and the Wellcome Trust.