Spending on emergency care due to nontraumatic dental conditions in the United States, 1996 through 2016.

BACKGROUND: Emergency department (ED) use for oral health care is a growing problem in the United States. The objective of the study was to describe spending on ED visits due to nontraumatic dental conditions (NTDCs) in the United States and to quantify changes in spending and its drivers. METHODS: Spending estimates for ED visits due to NTDCs according to type of payer were analyzed for the period from 1996 through 2016 and estimates about the drivers of change were analyzed for the period from 1996 through 2013. NTDCs included caries, periodontitis, edentulism, and other oral disorders. Estimates were calculated according to age, sex, and type of payer (that is, public, private, and out of pocket), adjusted for inflation, and expressed in 2016 US dollars. The estimate of expenses was decomposed into 5 drivers for the period from 1996 through 2013 (that is, population, aging, prevalence of oral disorders, service use, and service price and intensity). RESULTS: The total change in spending from 1996 through 2016 amounted to $540 million, an increase of 216%. The drivers of changes in spending from 1996 through 2013 were price and intensity ($360 million), service use ($220 million), and population size ($68 million). CONCLUSIONS: Spending on ED visits due to NTDCs more than tripled during the study period, with price and intensity representing the main drivers. This increase was primarily in adults and paid via the public sector. PRACTICAL IMPLICATIONS: Possible solutions include strengthening the oral health care safety net, especially for the most vulnerable populations.

Current dichotomous metrics obscure trends in severe and extreme child growth failure.

Historically, the prevalence of child growth failure (CGF) has been tracked dichotomously as the proportion of children more than 2 SDs below the median of the World Health Organization growth standards. However, this conventional "thresholding" approach fails to recognize child growth as a spectrum and obscures trends in populations with the highest rates of CGF. Our analysis presents the first ever estimates of entire distributions of HAZ, WHZ, and WAZ for each of 204 countries and territories from 1990 to 2020 for children less than 5 years old by age group and sex. This approach reflects the continuous nature of CGF, allows us to more comprehensively assess shrinking or widening disparities over time, and reveals otherwise hidden trends that disproportionately affect the most vulnerable populations.

Prevalence, incidence, and years-lived with disability due to oral disorders in Brazil: an analysis of the Global Burden of Disease Study 2019.

INTRODUCTION: Epidemiological surveys revealed that Brazil has a high burden of oral diseases. However, no prior study has reported estimates of untreated dental caries, periodontitis, and edentulism over a three-decade period. The objective of this study is to report the trends of prevalence, incidence, and years-lived with disability (YLDs) due to untreated dental caries in primary and permanent teeth, periodontitis, and edentulism in Brazil between 1990 and 2019. METHODS: Estimates of prevalence, incidence, and YLDs due to dental caries in primary and permanent teeth, periodontitis, and edentulism were produced for Brazil, by sex and age, between 1990 and 2019, using Dismod-MR 2.1, as part of the Global Burden of Disease Study 2019 (GBD 2019). Trends of oral disorders were analyzed using generalized linear regression models applying the Prais-Winsten method. RESULTS: Almost 100 million Brazilians presented at least one oral disorder in 2019, which was equivalent to a prevalence of 45.3%. All oral diseases combined ranked eighth among all causes of disability, causing more than 970,000 YLDs. Untreated dental caries in primary teeth were estimated to affect 13.5 million children, and untreated dental caries in permanent teeth affected more than 52 million people. Periodontitis affected 29.5 million people, and edentulism affected almost 22 million. The generalized linear regression models revealed a trend of stability of oral disorders between 1990 and 2019. CONCLUSIONS: The burden of oral diseases in Brazil is extremely high. Oral disorders, edentulism in particular, caused disability at levels that are comparable to other important chronic diseases.

Anemia prevalence in women of reproductive age in low- and middle-income countries between 2000 and 2018.

Anemia is a globally widespread condition in women and is associated with reduced economic productivity and increased mortality worldwide. Here we map annual 2000-2018 geospatial estimates of anemia prevalence in women of reproductive age (15-49 years) across 82 low- and middle-income countries (LMICs), stratify anemia by severity and aggregate results to policy-relevant administrative and national levels. Additionally, we provide subnational disparity analyses to provide a comprehensive overview of anemia prevalence inequalities within these countries and predict progress toward the World Health Organization's Global Nutrition Target (WHO GNT) to reduce anemia by half by 2030. Our results demonstrate widespread moderate improvements in overall anemia prevalence but identify only three LMICs with a high probability of achieving the WHO GNT by 2030 at a national scale, and no LMIC is expected to achieve the target in all their subnational administrative units. Our maps show where large within-country disparities occur, as well as areas likely to fall short of the WHO GNT, offering precision public health tools so that adequate resource allocation and subsequent interventions can be targeted to the most vulnerable populations.

The Coronavirus Disease 2019 Pandemic's Effect on Critical Care Resources and Health-Care Providers: A Global Survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.

Real-time assessment of COVID-19 impact on global surgical case volumes.

Importance: The COVID-19 pandemic has disrupted global surgical capacity. The impact of the pandemic in low and middle income countries has the potential to worsen already strained access to surgical care. Timely assessment of surgical volumes in these countries remains challenging. Objective: To determine whether usage data from a globally used anesthesiology calculator mobile application can serve as a proxy for global surgical case volume and contribute to monitoring of the impact of the COVID-19 pandemic, particularly in World Bank low income countries where official data collection is not currently practical. Design: Subset of data from an ongoing observational cohort study of users of the application collected from October 1, 2018 to April 18, 2020. Setting: The mobile application is available from public sources; users download and use the application per their own clinical needs on personal mobile devices. Participants: No user data was excluded from the study. Exposures: Events with impacts on surgical case volumes, including weekends, holidays, and the COVID-19 pandemic. Main Outcomes and Measures: It was previously noted that application usage was decreased on weekends and during winter holidays. We subsequently hypothesized that more detailed analysis would reveal impacts of country-specific or region-specific holidays on the volume of app use. Results: 4,300,975 data points from 92,878 unique users were analyzed. Physicians and other anesthesia providers comprised 85.8% of the study population. Application use was reduced on holidays and weekends and correlated with fluctuations in surgical volume. The COVID-19 pandemic was associated with substantial reductions in app use globally and regionally. There was strong cross correlation between COVID-19 case count and reductions in app use. By country, there was a median global reduction in app use to 58% of baseline (interquartile range, 46%-75%). Application use in low-income continues to decline but in high-income countries has stabilized. Conclusions and Relevance: Application usage metadata provides a real-time indicator of surgical volume. This data may be used to identify impacted regions where disruptions to surgical care are disproportionate or prolonged. A dashboard for continuous visualization of these data has been deployed.

Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments.

BACKGROUND: Estimates of children and adolescents with disabilities worldwide are needed to inform global intervention under the disability-inclusive provisions of the Sustainable Development Goals. We sought to update the most widely reported estimate of 93 million children <15 years with disabilities from the Global Burden of Disease Study 2004. METHODS: We analyzed Global Burden of Disease Study 2017 data on the prevalence of childhood epilepsy, intellectual disability, and vision or hearing loss and on years lived with disability (YLD) derived from systematic reviews, health surveys, hospital and claims databases, cohort studies, and disease-specific registries. Point estimates of the prevalence and YLD and the 95% uncertainty intervals (UIs) around the estimates were assessed. RESULTS: Globally, 291.2 million (11.2%) of the 2.6 billion children and adolescents (95% UI: 249.9-335.4 million) were estimated to have 1 of the 4 specified disabilities in 2017. The prevalence of these disabilities increased with age from 6.1% among children aged <1 year to 13.9% among adolescents aged 15 to 19 years. A total of 275.2 million (94.5%) lived in low- and middle-income countries, predominantly in South Asia and sub-Saharan Africa. The top 10 countries accounted for 62.3% of all children and adolescents with disabilities. These disabilities accounted for 28.9 million YLD or 19.9% of the overall 145.3 million (95% UI: 106.9-189.7) YLD from all causes among children and adolescents. CONCLUSIONS: The number of children and adolescents with these 4 disabilities is far higher than the 2004 estimate, increases from infancy to adolescence, and accounts for a substantial proportion of all-cause YLD.

Burden of disease in francophone Africa, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Peer-reviewed literature on health is almost exclusively published in English, limiting the uptake of research for decision making in francophone African countries. We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to assess the burden of disease in francophone Africa and inform health professionals and their partners in the region. METHODS: We assessed the burden of disease in the 21 francophone African countries and compared the results with those for their non-francophone counterparts in three economic communities: the Economic Community of West African States, the Economic Community of Central African States, and the Southern African Development Community. GBD 2017 employed a variety of statistical models to determine the number of deaths from each cause, through the Cause of Death Ensemble model algorithm, using CoDCorrect to ensure that the number of deaths per cause did not exceed the total number of estimated deaths. After producing estimates for the number of deaths from each of the 282 fatal outcomes included in the GBD 2017 list of causes, the years of life lost (YLLs) due to premature death were calculated. Years lived with disability (YLDs) were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae. Disability-adjusted life-years (DALYs) were calculated as the sum of YLLs and YLDs. All calculations are presented with 95% uncertainty intervals (UIs). A sample of 1000 draws was taken from the posterior distribution of each estimation step; aggregation of uncertainty across age, sex, and location was done on each draw, assuming independence of uncertainty. The lower and upper UIs represent the ordinal 25th and 975th draws of each quantity and attempt to describe modelling as well as sampling error. FINDINGS: In 2017, 779 deaths (95% UI 750-809) per 100 000 population occurred in francophone Africa, a decrease of 45·3% since 1990. Malaria, lower respiratory infections, neonatal disorders, diarrhoeal diseases, and tuberculosis were the top five Level 3 causes of death. These five causes were found among the six leading causes of death in most francophone countries. In 2017, francophone Africa experienced 53 570 DALYs (50 164-57 361) per 100 000 population, distributed between 43 708 YLLs (41 673-45 742) and 9862 YLDs (7331-12 749) per 100 000 population. In 2017, YLLs constituted the majority of DALYs in the 21 countries of francophone Africa. Age-specific and cause-specific mortality and population ageing were responsible for most of the reductions in disease burden, whereas population growth was responsible for most of the increases. INTERPRETATION: Francophone Africa still carries a high burden of communicable and neonatal diseases, probably due to the weakness of health-care systems and services, as evidenced by the almost complete attribution of DALYs to YLLs. To cope with this burden of disease, francophone Africa should define its priorities and invest more resources in health-system strengthening and in the quality and quantity of health-care services, especially in rural and remote areas. The region could also be prioritised in terms of technical and financial assistance focused on achieving these goals, as much as on demographic investments including education and family planning. FUNDING: Bill & Melinda Gates Foundation.

Measuring population ageing: an analysis of the Global Burden of Disease Study 2017.

BACKGROUND: Traditional metrics for population health ageing tend not to differentiate between extending life expectancy and adding healthy years. A population ageing metric that reflects both longevity and health status, incorporates a comprehensive range of diseases, and allows for comparisons across countries and time is required to understand the progression of ageing and to inform policies. METHODS: Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, we developed a metric that reflects age-related morbidity and mortality at the population level. First, we identified a set of age-related diseases, defined as diseases with incidence rates among the adult population increasing quadratically with age, and measured their age-related burden, defined as the sum of disability-adjusted life-years (DALYs) of these diseases among adults. Second, we estimated age-standardised age-related health burden across 195 countries between 1990 and 2017. Using global average 65-year-olds as the reference population, we calculated the equivalent age in terms of age-related disease burden for all countries. Third, we analysed how the changes in age-related burden during the study period relate to different factors with a decomposition analysis. Finally, we describe how countries with similar levels of overall age-related burden experience different onsets of ageing. We represent the uncertainty of our estimates by calculating uncertainty intervals (UI) from 1000 draw-level estimates for each disease, country, year, and age. FINDINGS: 92 diseases were identified as age related, accounting for 51·3% (95% UI 48·5-53·9) of all global burden among adults in 2017. Across the Socio-demographic Index (SDI), the rate of age-related burden ranged from 137·8 DALYs (128·9-148·3) per 1000 adults in high SDI countries to 265·9 DALYs (251·0-280·1) in low SDI countries. The equivalent age to average 65-year-olds globally spanned from 76·1 years (75·6-76·7) in Japan to 45·6 years (42·6-48·2) in Papua New Guinea. Age-standardised age-related disease rates have decreased over time across all SDI levels and regions between 1990 and 2017, mainly due to decreases in age-related case fatality and disease severity. Even among countries with similar age-standardised death rates, large differences in the onset and patterns of accumulating age-related burden exist. INTERPRETATION: The new metric facilitates the shift from thinking not just about chronological age but the health status and disease severity of ageing populations. Our findings could provide inputs into policymaking by identifying key drivers of variation in the ageing burden and resources required for addressing the burden. FUNDING: National Institute on Aging of the National Institutes of Health.

Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990-2016.

BACKGROUND: Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016. METHODS: Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset. FINDINGS: From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings. INTERPRETATION: Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries. FUNDING: Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation.

Chronic Pain and Associated Factors in India and Nepal: A Pilot Study of the Vanderbilt Global Pain Survey.

BACKGROUND: Evaluation and treatment of chronic pain worldwide are limited by the lack of standardized assessment tools incorporating consistent definitions of pain chronicity and specific queries of known social and psychological risk factors for chronic pain. The Vanderbilt Global Pain Survey (VGPS) was developed as a tool to address these concerns, specifically in the low- and middle-income countries where global burden is highest. METHODS: The VGPS was developed using standardized and cross-culturally validated metrics, including the Brief Pain Inventory and World Health Organization Disability Assessment Scale, as well as the Pain Catastrophizing Scale, the Fibromyalgia Survey Questionnaire along with queries about pain attitudes to assess the prevalence of chronic pain and disability along with its psychosocial and emotional associations. The VGPS was piloted in both Nepal and India over a 1-month period in 2014, allowing for evaluation of this tool in 2 distinctly diverse cultures. RESULTS: Prevalence of chronic pain in Nepal and India was consistent with published data. The Nepali cohort displayed a pain point prevalence of 48%-50% along with some form of disability present in approximately one third of the past 30 days. Additionally, 11% of Nepalis recorded pain in 2 somatic sites and 39% of those surveyed documented a history of a traumatic event. In the Indian cohort, pain point prevalence was approximately 24% to 41% based on the question phrasing, and any form of disability was present in 6 of the last 30 days. Of the Indians surveyed, 11% reported pain in 2 somatic sites, with only 4% reporting a previous traumatic event. Overall, Nepal had significantly higher chronic pain prevalence, symptom severity, widespread pain, and self-reported previous traumatic events, yet lower reported pain severity. CONCLUSIONS: Our findings confirm prevalent chronic pain, while revealing pertinent cultural differences and survey limitations that will inform future assessment strategies. Specific areas for improvement identified in this VGPS pilot study included survey translation methodology, redundancy of embedded metrics and cultural limitations in representative sampling and in detecting the prevalence of mental health illness, catastrophizing behavior, and previous traumatic events. International expert consensus is needed.

Population health and regional variations of disease burden in Japan, 1990-2015: a systematic subnational analysis for the Global Burden of Disease Study 2015.

BACKGROUND: Japan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level. METHODS: We used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations. FINDINGS: Life expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from -32·4% (-34·8 to -30·0) to -22·0% (-20·4 to -20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015. INTERPRETATION: Japan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment. FUNDING: Bill & Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund.

The Global Burden of Anemia.

Anemia is an important cause of health loss. We estimated levels and trends of nonfatal anemia burden for 23 distinct etiologies in 188 countries, 20 age groups, and both sexes from 1990 to 2013. All available population-level anemia data were collected and standardized. We estimated mean hemoglobin, prevalence of anemia by severity, quantitative disability owing to anemia, and underlying etiology for each population using the approach of the Global Burden of Disease, Injuries and Risk Factors 2013 Study. Anemia burden is high. Developing countries account for 89% of all anemia-related disability. Iron-deficiency anemia remains the dominant cause of anemia.

Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study.

IMPORTANCE: The literature focuses on mortality among children younger than 5 years. Comparable information on nonfatal health outcomes among these children and the fatal and nonfatal burden of diseases and injuries among older children and adolescents is scarce. OBJECTIVE: To determine levels and trends in the fatal and nonfatal burden of diseases and injuries among younger children (aged <5 years), older children (aged 5-9 years), and adolescents (aged 10-19 years) between 1990 and 2013 in 188 countries from the Global Burden of Disease (GBD) 2013 study. EVIDENCE REVIEW: Data from vital registration, verbal autopsy studies, maternal and child death surveillance, and other sources covering 14,244 site-years (ie, years of cause of death data by geography) from 1980 through 2013 were used to estimate cause-specific mortality. Data from 35,620 epidemiological sources were used to estimate the prevalence of the diseases and sequelae in the GBD 2013 study. Cause-specific mortality for most causes was estimated using the Cause of Death Ensemble Model strategy. For some infectious diseases (eg, HIV infection/AIDS, measles, hepatitis B) where the disease process is complex or the cause of death data were insufficient or unavailable, we used natural history models. For most nonfatal health outcomes, DisMod-MR 2.0, a Bayesian metaregression tool, was used to meta-analyze the epidemiological data to generate prevalence estimates. FINDINGS: Of the 7.7 (95% uncertainty interval [UI], 7.4-8.1) million deaths among children and adolescents globally in 2013, 6.28 million occurred among younger children, 0.48 million among older children, and 0.97 million among adolescents. In 2013, the leading causes of death were lower respiratory tract infections among younger children (905.059 deaths; 95% UI, 810,304-998,125), diarrheal diseases among older children (38,325 deaths; 95% UI, 30,365-47,678), and road injuries among adolescents (115,186 deaths; 95% UI, 105,185-124,870). Iron deficiency anemia was the leading cause of years lived with disability among children and adolescents, affecting 619 (95% UI, 618-621) million in 2013. Large between-country variations exist in mortality from leading causes among children and adolescents. Countries with rapid declines in all-cause mortality between 1990 and 2013 also experienced large declines in most leading causes of death, whereas countries with the slowest declines had stagnant or increasing trends in the leading causes of death. In 2013, Nigeria had a 12% global share of deaths from lower respiratory tract infections and a 38% global share of deaths from malaria. India had 33% of the world's deaths from neonatal encephalopathy. Half of the world's diarrheal deaths among children and adolescents occurred in just 5 countries: India, Democratic Republic of the Congo, Pakistan, Nigeria, and Ethiopia. CONCLUSIONS AND RELEVANCE: Understanding the levels and trends of the leading causes of death and disability among children and adolescents is critical to guide investment and inform policies. Monitoring these trends over time is also key to understanding where interventions are having an impact. Proven interventions exist to prevent or treat the leading causes of unnecessary death and disability among children and adolescents. The findings presented here show that these are underused and give guidance to policy makers in countries where more attention is needed.

A Cost-Effectiveness Analysis of a Pilot Neonatal Screening Program for Sickle Cell Anemia in the Republic of Angola.

OBJECTIVE: To assess the cost-effectiveness of a pilot newborn screening (NBS) and treatment program for sickle cell anemia (SCA) in Luanda, Angola. STUDY DESIGN: In July 2011, a pilot NBS and treatment program was implemented in Luanda, Angola. Infants identified with SCA were enrolled in a specialized SCA clinic in which they received preventive care and sickle cell education. In this analysis, the World Health Organization (WHO) and generalized cost-effectiveness analysis methods were used to estimate gross intervention costs of the NBS and treatment program. To determine healthy life-years (HLYs) gained by screening and treatment, we assumed NBS reduced mortality to that of the Angolan population during the first 5 years based upon WHO and Global Burden of Diseases Study 2010 estimates, but provided no significant survival benefit for children who survive through age 5 years. A secondary sensitivity analysis with more conservative estimates of mortality benefits also was performed. The costs of downstream medical costs, including acute care, were not included. RESULTS: Based upon the costs of screening 36,453 infants and treating the 236 infants with SCA followed after NBS in the pilot project, NBS and treatment program is projected to result in the gain of 452-1105 HLYs, depending upon the discounting rate and survival assumptions used. The corresponding estimated cost per HLY gained is $1380-$3565, less than the gross domestic product per capita in Angola. CONCLUSIONS: These data demonstrate that NBS and treatment for SCA appear to be highly cost-effective across all scenarios for Angola by the WHO criteria.

The burden of selected congenital anomalies amenable to surgery in low and middle-income regions: cleft lip and palate, congenital heart anomalies and neural tube defects.

OBJECTIVE: To quantify the burden of selected congenital anomalies in low and middle-income countries (LMICs) that could be reduced should surgical programmes cover the entire population with access to quality care. DESIGN: Burden of disease and epidemiological modelling. SETTING: LMICs from all global regions. POPULATION: All prevalent cases of selected congenital anomalies at birth in 2010. MAIN OUTCOME MEASURES: Disability-adjusted life years (DALYs). INTERVENTIONS AND METHODS: Surgical programmes for three congenital conditions were analysed: clefts (lip and palate); congenital heart anomalies; and neural tube defects. Data from the Global Burden of Disease 2010 Study were used to estimate the combination of fatal burden that could be addressed by surgical care and the additional long-term non-fatal burden associated with increased survival. RESULTS: Of the estimated 21.6 million DALYs caused by these three conditions in LMICs, 12.4 million DALYs (57%) are potentially addressable by surgical care among the population born with such conditions. Neural tube defects have the largest potential with 76% of burden amenable by surgery, followed by clefts (59%) and congenital heart anomalies (49%). Sub-Saharan Africa and South Asia have the greatest proportion of surgically addressable burden for clefts (68%), North Africa and Middle East for congenital heart anomalies (73%), and South Asia for neural tube defects (81%). CONCLUSIONS: There is an important and neglected role surgical programmes can play in reducing the burden of congenital anomalies in LMICs.

Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions.

BACKGROUND: To quantify the burden of digestive diseases avertable by surgical care at first-level hospitals in low- and middle-income countries (LMICs). METHODS: We examined 4 digestive diseases from the Global Burden of Disease (GBD) 2010 STUDY: Appendicitis, intestinal obstruction, inguinal and femoral hernia, and gallbladder and bile duct disease. Using demographic and epidemiologic data from the GBD 2010 STUDY, we calculated the potential decrease in burden of digestive diseases if quality surgical services were available universally and accessible at first-level hospitals. The lowest case fatality rates for each age and sex grouping from all GBD regions were assumed to reflect the best possible state of full surgical coverage and treatment. These best scenario rates were applied to the GBD 2010 results from all LMIC regions to estimate surgically avertable burden. RESULTS: Overall, 4.8 million disability-adjusted life-years (DALYs) or 65% of burden related to the 4 digestive diseases are avertable potentially with first-level surgical care in LMICs. Sub-Saharan Africa has the greatest avertable burden in absolute DALYs (1.7 million) and avertable proportion (83%). Intestinal obstruction accounted for the largest portion of avertable burden among the 4 digestive diseases (2.2 million DALYs; 64% avertable). CONCLUSION: Improving the capacity of surgical services at first-level hospitals is essential for averting the burden of digestive diseases in LMICs. Practicable strategies for scaling up surgical capacities in rural districts are available potentially, which must be given due attention.