Trends in prevalence, mortality, and morbidity associated with high systolic blood pressure in Brazil from 1990 to 2017: estimates from the "Global Burden of Disease 2017" (GBD 2017) study.

BACKGROUND: Hypertension remains the leading risk factor for cardiovascular disease (CVD) worldwide, and its impact in Brazil should be assessed in order to better address the issue. We aimed to describe trends in prevalence and burden of disease attributable to high systolic blood pressure (HSBP) among Brazilians ≥ 25 years old according to sex and federal units (FU) using the Global Burden of Disease (GBD) 2017 estimates. METHODS: We used the comparative risk assessment developed for the GBD study to estimate trends in attributable deaths and disability-adjusted life-years (DALY), by sex, and FU for HSBP from 1990 to 2017. This study included 14 HSBP-outcome pairs. HSBP was defined as ≥ 140 mmHg for prevalence estimates, and a theoretical minimum risk exposure level (TMREL) of 110-115 mmHg was considered for disease burden. We estimated the portion of deaths and DALYs attributed to HSBP. We also explored the drivers of trends in HSBP burden, as well as the correlation between disease burden and sociodemographic development index (SDI). RESULTS: In Brazil, the prevalence of HSBP is 18.9% (95% uncertainty intervals [UI] 18.5-19.3%), with an annual 0.4% increase rate, while age-standardized death rates attributable to HSBP decreased from 189.2 (95%UI 168.5-209.2) deaths to 104.8 (95%UI 94.9-114.4) deaths per 100,000 from 1990 to 2017. In spite of that, the total number of deaths attributable to HSBP increased 53.4% and HSBP raised from 3rd to 1st position, as the leading risk factor for deaths during the period. Regarding total DALYs, HSBP raised from 4th in 1990 to 2nd cause in 2017. The main driver of change of HSBP burden is population aging. Across FUs, the reduction in the age-standardized death rates attributable to HSBP correlated with higher SDI. CONCLUSIONS: While HSBP prevalence shows an increasing trend, age-standardized death and DALY rates are decreasing in Brazil, probably as results of successful public policies for CVD secondary prevention and control, but suboptimal control of its determinants. Reduction was more significant in FUs with higher SDI, suggesting that the effect of health policies was heterogeneous. Moreover, HSBP has become the main risk factor for death in Brazil, mainly due to population aging.

Inequalities in the burden of female breast cancer in Brazil, 1990-2017.

BACKGROUND: Breast cancer is the most frequently diagnosed cancer in women and the leading cause of cancer death among females worldwide. In recent decades, breast cancer death rates have been stable or decreasing in more developed regions; however, this has not been observed in less developed regions. This study aims to evaluate inequalities in the burden of female breast cancer in Brazil including an analysis of interregional and interstate patterns in incidence, mortality and disability-adjusted life years (DALYs) rates from 1990 to 2017, and mortality-to-incidence ratio (MIR), and their association with the Socio-demographic Index (SDI). METHODS: Using estimates from the global burden of disease (GBD) study, we applied a spatial exploratory analysis technique to obtain measurements of global and local spatial correlation. Percentage changes of breast cancer incidence, mortality, and DALYs rates between 1990 and 2017 were calculated, and maps were developed to show the spatial distribution of the variables. Spatial panel models were adjusted to investigate the association between rates and SDI in Brazilian states. RESULTS: In Brazil, while breast cancer mortality rate have had modest reduction (-4.45%; 95% UI: -6.97; -1.76) between 1990 and 2017, the incidence rate increased substantially (+39.99%; 95% UI: 34.90; 45.39). Breast cancer incidence and mortality rates in 1990 and 2017 were higher in regions with higher SDI, i.e., the most developed ones. While SDI increased in all Brazilian states between 1990 and 2017, notably in less developed regions, MIR decreased, more notably in more developed regions. The SDI had a positive association with incidence rate and a negative association with MIR. CONCLUSION: Such findings suggest an improvement in breast cancer survival in the period, which may be related to a broader access to diagnostic methods and treatment. This study also revealed the inequality in breast cancer outcomes among Brazilian states and may guide public policy priorities for disease control in the country.

On the road to universal health care in Indonesia, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: As Indonesia moves to provide health coverage for all citizens, understanding patterns of morbidity and mortality is important to allocate resources and address inequality. The Global Burden of Disease 2016 study (GBD 2016) estimates sources of early death and disability, which can inform policies to improve health care. METHODS: We used GBD 2016 results for cause-specific deaths, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth, healthy life expectancy, and risk factors for 333 causes in Indonesia and in seven comparator countries. Estimates were produced by location, year, age, and sex using methods outlined in GBD 2016. Using the Socio-demographic Index, we generated expected values for each metric and compared these against observed results. FINDINGS: In Indonesia between 1990 and 2016, life expectancy increased by 8·0 years (95% uncertainty interval [UI] 7·3-8·8) to 71·7 years (71·0-72·3): the increase was 7·4 years (6·4-8·6) for males and 8·7 years (7·8-9·5) for females. Total DALYs due to communicable, maternal, neonatal, and nutritional causes decreased by 58·6% (95% UI 55·6-61·6), from 43·8 million (95% UI 41·4-46·5) to 18·1 million (16·8-19·6), whereas total DALYs from non-communicable diseases rose. DALYs due to injuries decreased, both in crude rates and in age-standardised rates. The three leading causes of DALYs in 2016 were ischaemic heart disease, cerebrovascular disease, and diabetes. Dietary risks were a leading contributor to the DALY burden, accounting for 13·6% (11·8-15·4) of DALYs in 2016. INTERPRETATION: Over the past 27 years, health across many indicators has improved in Indonesia. Improvements are partly offset by rising deaths and a growing burden of non-communicable diseases. To maintain and increase health gains, further work is needed to identify successful interventions and improve health equity. FUNDING: The Bill & Melinda Gates Foundation.

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.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

Cause-specific mortality for 249 causes in Brazil and states during 1990-2015: a systematic analysis for the global burden of disease study 2015.

BACKGROUND: Reliable data on cause of death (COD) are fundamental for planning and resource allocation priorities. We used GBD 2015 estimates to examine levels and trends for the leading causes of death in Brazil from 1990 to 2015. METHODS: We describe the main analytical approaches focused on both overall and specific causes of death for Brazil and Brazilian states. RESULTS: There was an overall improvement in life expectancy at birth from 1990 to 2015, but with important heterogeneity among states. Reduced mortality due to diarrhea, lower respiratory infections, and other infectious diseases contributed the most for increasing life expectancy in most states from the North and Northeast regions. Reduced mortality due to cardiovascular diseases was the highest contributor in the South, Southeast, and Center West regions. However, among men, intentional injuries reduced life expectancy in 17 out of 27 states. Although age-standardized rates due to ischemic heart disease (IHD) and cerebrovascular disease declined over time, these remained the leading CODs in the country and states. In contrast, leading causes of premature mortality changed substantially - e.g., diarrheal diseases moved from 1st to 13th and then the 36th position in 1990, 2005, and 2015, respectively, while violence moved from 7th to 1st and to 2nd. Overall, the total age-standardized years of life lost (YLL) rate was reduced from 1990 to 2015, bringing the burden of premature deaths closer to expected rates given the country's Socio-demographic Index (SDI). In 1990, IHD, stroke, diarrhea, neonatal preterm birth complications, road injury, and violence had ratios higher than the expected, while in 2015 only violence was higher, overall and in all states, according to the SDI. CONCLUSIONS: A widespread reduction of mortality levels occurred in Brazil from 1990 to 2015, particularly among children under 5 years old. Major shifts in mortality rates took place among communicable, maternal, neonatal, and nutritional disorders. The mortality profile has shifted to older ages with increases in non-communicable diseases as well as premature deaths due to violence. Policymakers should address health interventions accordingly.

A feasibility study on using smartphones to conduct short-version verbal autopsies in rural China.

BACKGROUND: Currently there are two main sources of mortality data with cause of death assignments in China. Both sources-the Ministry of Health-Vital Registration system and the Chinese Disease Surveillance Point system-present their own challenges. A new approach to cause of death assignment is a smartphone-based shortened version of a verbal autopsy survey. This study evaluates the feasibility and acceptability of this new method conducted by township health care providers (THP) and village doctors (VD) in rural China, where a large proportion of deaths occur in homes and cause of death data are inaccurate or lacking. METHODS: The Population Health Metrics Research Consortium mobile phone-based shortened verbal autopsy questionnaire was made available on an Android system-based application, and cause of death was derived using the Tariff method (Tariff 2.0); we called this set of tools "msVA." msVA was administered to relatives of the deceased by six THPs and six VDs in 24 villages located in six townships of Luquan County, Hebei Province, China. Subsequently, interviews were conducted among 12 interviewers, 12 randomly selected respondents, and five study staff to assess the feasibility and acceptability of using msVA for mortality data collection. RESULTS: Between July 2013 and August 2013, 268 deaths took place in the study villages. Among the 268 deaths, 227 VAs were completed (nine refusals, 31 migrations and one loss of data due to breakdown of the smartphone). The average time for a VA interview was 21.5 ± 3.4 min (20.1 ± 3.5 min for THP and 23.2 ± 4.1 min for VD). Both THPs and VDs could be successful interviewers; the latter needed more training but had more willingness to implement msVA in the future. The interviews revealed that both interviewers and relatives of the deceased found msVA to be feasible, acceptable, and more desirable than traditional methods. The cost of conducting a new VA was $8.87 per death. CONCLUSIONS: Conduction of msVA by VDs in their own villages was feasible and acceptable in rural northern China. Broader implementation of msVA across rural China could potentially improve the coverage and quality of cause of death data, allowing for better national health evaluation and program planning.

What is the optimal recall period for verbal autopsies? Validation study based on repeat interviews in three populations.

BACKGROUND: One key contextual feature in Verbal Autopsy (VA) is the time between death and survey administration, or recall period. This study quantified the effect of recall period on VA performance by using a paired dataset in which two VAs were administered for a single decedent. METHODS: This study used information from the Population Health Metrics Research Consortium (PHMRC) Study, which collected VAs for "gold standard" cases where cause of death (COD) was supported by clinical criteria. This study repeated VA interviews within 3-52 months of death in PHMRC study sites in Andhra Pradesh, India, and Bohol and Manila, Philippines. The final dataset included 2113 deaths interviewed twice and with recall periods ranging from 0 to 52 months. COD was assigned by the Tariff method and its accuracy determined by comparison with the gold standard COD. RESULTS: The probability of a correct diagnosis of COD decreased by 0.55 % per month in the period after death. Site of data collection and survey module also affected the probability of Tariff Method correctly assigning a COD. The probability of a correct diagnosis in VAs collected 3-11 months after death will, on average, be 95.9 % of that in VAs collected within 3 months of death. CONCLUSIONS: These findings suggest that collecting VAs within 3 months of death may improve the quality of the information collected, taking the need for a period of mourning into account. This study substantiates the WHO recommendation that it is reasonable to collect VAs up to 1 year after death providing it is accepted that probability of a correct diagnosis is likely to decline month by month during this period.

The paradox of verbal autopsy in cause of death assignment: symptom question unreliability but predictive accuracy.

BACKGROUND: We believe that it is important that governments understand the reliability of the mortality data which they have at their disposable to guide policy debates. In many instances, verbal autopsy (VA) will be the only source of mortality data for populations, yet little is known about how the accuracy of VA diagnoses is affected by the reliability of the symptom responses. We previously described the effect of the duration of time between death and VA administration on VA validity. In this paper, using the same dataset, we assess the relationship between the reliability and completeness of symptom responses and the reliability and accuracy of cause of death (COD) prediction. METHODS: The study was based on VAs in the Population Health Metrics Research Consortium (PHMRC) VA Validation Dataset from study sites in Bohol and Manila, Philippines and Andhra Pradesh, India. The initial interview was repeated within 3-52 months of death. Question responses were assessed for reliability and completeness between the two survey rounds. COD was predicted by Tariff Method. RESULTS: A sample of 4226 VAs was collected for 2113 decedents, including 1394 adults, 349 children, and 370 neonates. Mean question reliability was unexpectedly low (kappa = 0.447): 42.5 % of responses positive at the first interview were negative at the second, and 47.9 % of responses positive at the second had been negative at the first. Question reliability was greater for the short form of the PHMRC instrument (kappa = 0.497) and when analyzed at the level of the individual decedent (kappa = 0.610). Reliability at the level of the individual decedent was associated with COD predictive reliability and predictive accuracy. CONCLUSIONS: Families give coherent accounts of events leading to death but the details vary from interview to interview for the same case. Accounts are accurate but inconsistent; different subsets of symptoms are identified on each occasion. However, there are sufficient accurate and consistent subsets of symptoms to enable the Tariff Method to assign a COD. Questions which contributed most to COD prediction were also the most reliable and consistent across repeat interviews; these have been included in the short form VA questionnaire. Accuracy and reliability of diagnosis for an individual death depend on the quality of interview. This has considerable implications for the progressive roll out of VAs into civil registration and vital statistics (CRVS) systems.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success. METHODS: We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030. FINDINGS: We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone. INTERPRETATION: Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030. FUNDING: Bill & Melinda Gates Foundation, US Agency for International Development.

Improving performance of the Tariff Method for assigning causes of death to verbal autopsies.

BACKGROUND: Reliable data on the distribution of causes of death (COD) in a population are fundamental to good public health practice. In the absence of comprehensive medical certification of deaths, the only feasible way to collect essential mortality data is verbal autopsy (VA). The Tariff Method was developed by the Population Health Metrics Research Consortium (PHMRC) to ascertain COD from VA information. Given its potential for improving information about COD, there is interest in refining the method. We describe the further development of the Tariff Method. METHODS: This study uses data from the PHMRC and the National Health and Medical Research Council (NHMRC) of Australia studies. Gold standard clinical diagnostic criteria for hospital deaths were specified for a target cause list. VAs were collected from families using the PHMRC verbal autopsy instrument including health care experience (HCE). The original Tariff Method (Tariff 1.0) was trained using the validated PHMRC database for which VAs had been collected for deaths with hospital records fulfilling the gold standard criteria (validated VAs). In this study, the performance of Tariff 1.0 was tested using VAs from household surveys (community VAs) collected for the PHMRC and NHMRC studies. We then corrected the model to account for the previous observed biases of the model, and Tariff 2.0 was developed. The performance of Tariff 2.0 was measured at individual and population levels using the validated PHMRC database. RESULTS: For median chance-corrected concordance (CCC) and mean cause-specific mortality fraction (CSMF) accuracy, and for each of three modules with and without HCE, Tariff 2.0 performs significantly better than the Tariff 1.0, especially in children and neonates. Improvement in CSMF accuracy with HCE was 2.5%, 7.4%, and 14.9% for adults, children, and neonates, respectively, and for median CCC with HCE it was 6.0%, 13.5%, and 21.2%, respectively. Similar levels of improvement are seen in analyses without HCE. CONCLUSIONS: Tariff 2.0 addresses the main shortcomings of the application of the Tariff Method to analyze data from VAs in community settings. It provides an estimation of COD from VAs with better performance at the individual and population level than the previous version of this method, and it is publicly available for use.

A shortened verbal autopsy instrument for use in routine mortality surveillance systems.

BACKGROUND: Verbal autopsy (VA) is recognized as the only feasible alternative to comprehensive medical certification of deaths in settings with no or unreliable vital registration systems. However, a barrier to its use by national registration systems has been the amount of time and cost needed for data collection. Therefore, a short VA instrument (VAI) is needed. In this paper we describe a shortened version of the VAI developed for the Population Health Metrics Research Consortium (PHMRC) Gold Standard Verbal Autopsy Validation Study using a systematic approach. METHODS: We used data from the PHMRC validation study. Using the Tariff 2.0 method, we first established a rank order of individual questions in the PHMRC VAI according to their importance in predicting causes of death. Second, we reduced the size of the instrument by dropping questions in reverse order of their importance. We assessed the predictive performance of the instrument as questions were removed at the individual level by calculating chance-corrected concordance and at the population level with cause-specific mortality fraction (CSMF) accuracy. Finally, the optimum size of the shortened instrument was determined using a first derivative analysis of the decline in performance as the size of the VA instrument decreased for adults, children, and neonates. RESULTS: The full PHMRC VAI had 183, 127, and 149 questions for adult, child, and neonatal deaths, respectively. The shortened instrument developed had 109, 69, and 67 questions, respectively, representing a decrease in the total number of questions of 40-55%. The shortened instrument, with text, showed non-significant declines in CSMF accuracy from the full instrument with text of 0.4%, 0.0%, and 0.6% for the adult, child, and neonatal modules, respectively. CONCLUSIONS: We developed a shortened VAI using a systematic approach, and assessed its performance when administered using hand-held electronic tablets and analyzed using Tariff 2.0. The length of a VA questionnaire was shortened by almost 50% without a significant drop in performance. The shortened VAI developed reduces the burden of time and resources required for data collection and analysis of cause of death data in civil registration systems.

Trend of the Burden of Larynx Cancer in Brazil, 1990 to 2019.

INTRODUCTION: Larynx cancer is one of the most common head and neck cancers, whose main risk factors are smoking and alcohol use, and its occurrence and prognosis depend on adequate and timely preventive measures. This study aimed to investigate the burden of larynx cancer in Brazil and its states. METHODS: Using estimates from the Global Burden of Disease Study 2019, this study analyzed the trends of incidence, mortality, and disability-adjusted life years (DALYs) for larynx cancer between 1990 and 2019, besides the mortality-to-incidence ratio and the socio demographic index. RESULTS: Incidence and mortality due to larynx cancer in Brazil, which are approximately eight-fold higher for men, showed a declining trend between 1990 and 2019 (APPC: -0.4% and -1.0%, respectively). The DALYs also showed negative variation between 1990 and 2019 for both sexes in Brazil, mainly due to the decrease in premature deaths, with the greatest reduction in the state of São Paulo. For the states of Brazil in 2019, the higher age-standardized incidence rate (Rio Grande do Sul, 3.83 cases per 100,000 inhabitants) is twice the lowest rate (Piauí, 1.56 cases per 100,000 inhabitants). CONCLUSIONS: A fall in the burden of larynx cancer was observed in Brazil over the past 30 years, which may be attributed to a reduction in smoking and to an improvement in treatment. However, the regional inequalities in the country remain evident, especially for males. This data can guide public policy priorities to control the disease in Brazil.

Health disparities across the counties of Kenya and implications for policy makers, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provided comprehensive estimates of health loss globally. Decision makers in Kenya can use GBD subnational data to target health interventions and address county-level variation in the burden of disease. METHODS: We used GBD 2016 estimates of life expectancy at birth, healthy life expectancy, all-cause and cause-specific mortality, years of life lost, years lived with disability, disability-adjusted life-years, and risk factors to analyse health by age and sex at the national and county levels in Kenya from 1990 to 2016. FINDINGS: The national all-cause mortality rate decreased from 850·3 (95% uncertainty interval [UI] 829·8-871·1) deaths per 100 000 in 1990 to 579·0 (562·1-596·0) deaths per 100 000 in 2016. Under-5 mortality declined from 95·4 (95% UI 90·1-101·3) deaths per 1000 livebirths in 1990 to 43·4 (36·9-51·2) deaths per 1000 livebirths in 2016, and maternal mortality fell from 315·7 (242·9-399·4) deaths per 100 000 in 1990 to 257·6 (195·1-335·3) deaths per 100 000 in 2016, with steeper declines after 2006 and heterogeneously across counties. Life expectancy at birth increased by 5·4 (95% UI 3·7-7·2) years, with higher gains in females than males in all but ten counties. Unsafe water, sanitation, and handwashing, unsafe sex, and malnutrition were the leading national risk factors in 2016. INTERPRETATION: Health outcomes have improved in Kenya since 2006. The burden of communicable diseases decreased but continues to predominate the total disease burden in 2016, whereas the non-communicable disease burden increased. Health gains varied strikingly across counties, indicating targeted approaches for health policy are necessary. FUNDING: Bill & Melinda Gates Foundation.

Mortality and years of life lost due to breast cancer attributable to physical inactivity in the Brazilian female population (1990-2015).

The aims of this study were as follows: to estimate the mortality and years of life lost, assessed by disability-adjusted life years (DALYs), due to breast cancer attributable to physical inactivity in Brazilian women; to compare the estimates attributable to physical inactivity and to other modifiable risk factors; and to analyse the temporal evolution of these estimates within Brazilian states over 25 years (1990-2015), compared with global estimates. Databases from the Global Burden of Disease Study for Brazil, Brazilian states, and other parts of the world were used. Physical inactivity has contributed to a substantial number of deaths (1990: 875; 2015: 2,075) and DALYs (1990: 28,089; 2015: 60,585) due to breast cancer in Brazil. Physical inactivity was responsible for more deaths and DALYs (~12.0%) due to breast cancer than other modifiable risk factors (~5.0%). The Brazilian states with better socioeconomic indicators had higher age-standardized rates of mortality and morbidity due to breast cancer attributable to physical inactivity. From 1990 to 2015, mortality due to breast cancer attributable to physical inactivity increased in Brazil (0.77%; 95%U.I.: 0.27-1.47) and decreased (-2.84%; 95%U.I.: -4.35 - -0.10) around the world. These findings support the promotion of physical activity in the Brazilian female population to prevent and manage breast cancer.

Mortality and years of life lost by colorectal cancer attributable to physical inactivity in Brazil (1990-2015): Findings from the Global Burden of Disease Study.

INTRODUCTION: The aims of this study were to estimate all-cause and cause-specific mortality and years of life lost, investigated by disability-adjusted life-years (DALYs), due to colorectal cancer attributable to physical inactivity in Brazil and in the states; to analyze the temporal trend of these estimates over 25 years (1990-2015) compared with global estimates and according to the socioeconomic status of states of Brazil. METHODS: Databases from the Global Burden of Disease Study (GBD) for Brazil, Brazilian states and global information were used. It was estimated the total number and the age-standardized rates of deaths and DALYs for colorectal cancer attributable to physical inactivity in the years 1990 and 2015. We used the Socioeconomic Development Index (SDI). RESULTS: Physical inactivity was responsible for a substantial number of deaths (1990: 1,302; 2015: 119,351) and DALYs (1990: 31,121; 2015: 87,116) due to colorectal cancer in Brazil. From 1990 to 2015, the mortality and DALYs due to colorectal cancer attributable to physical inactivity increased in Brazil (0.6% and 0.6%, respectively) and decreased around the world (-0.8% and -1.1%, respectively). The Brazilian states with better socioeconomic indicators had higher rates of mortality and morbidity by colorectal cancer due to physical inactivity (p<0.01). Physical inactivity was responsible for deaths and DALYs due to colorectal cancer in Brazil. CONCLUSIONS: Over 25 years, the Brazilian population showed more worrisome results than around the world. Actions to combat physical inactivity and greater cancer screening and treatment are urgent in the Brazilian states.

Causes of death among children aged 5-14 years in the WHO European Region: a systematic analysis for the Global Burden of Disease Study 2016.

BACKGROUND: The mortality burden in children aged 5-14 years in the WHO European Region has not been comprehensively studied. We assessed the distribution and trends of the main causes of death among children aged 5-9 years and 10-14 years from 1990 to 2016, for 51 countries in the WHO European Region. METHODS: We used data from vital registration systems, cancer registries, and police records from 1980 to 2016 to estimate cause-specific mortality using the Cause of Death Ensemble model. FINDINGS: For children aged 5-9 years, all-cause mortality rates (per 100 000 population) were estimated to be 46·3 (95% uncertainty interval [UI] 45·1-47·5) in 1990 and 19·5 (18·1-20·9) in 2016, reflecting a 58·0% (54·7-61·1) decline. For children aged 10-14 years, all-cause mortality rates (per 100 000 population) were 37·9 (37·3-38·6) in 1990 and 20·1 (18·8-21·3) in 2016, reflecting a 47·1% (43·8-50·4) decline. In 2016, we estimated 10 740 deaths (95% UI 9970-11 542) in children aged 5-9 years and 10 279 deaths (9652-10 897) in those aged 10-14 years in the WHO European Region. Injuries (road injuries, drowning, and other injuries) caused 4163 deaths (3820-4540; 38·7% of total deaths) in children aged 5-9 years and 4468 deaths (4162-4812; 43·5% of total) in those aged 10-14 years in 2016. Neoplasms caused 2161 deaths (1872-2406; 20·1% of total deaths) in children aged 5-9 years and 1943 deaths (1749-2101; 18·9% of total deaths) in those aged 10-14 years in 2016. Notable differences existed in cause-specific mortality rates between the European subregions, from a two-times difference for leukaemia to a 20-times difference for lower respiratory infections between the Commonwealth of Independent States (CIS) and EU15 (the 15 member states that had joined the European Union before May, 2004). INTERPRETATION: Marked progress has been made in reducing the mortality burden in children aged 5-14 years over the past 26 years in the WHO European Region. More deaths could be prevented, especially in CIS countries, through intervention and prevention efforts focusing on the leading causes of death, which are road injuries, drowning, and lower respiratory infections. The findings of our study could be used as a baseline to assess the effect of implementation of programmes and policies on child mortality burden. FUNDING: WHO and Bill & Melinda Gates Foundation.

Mortality due to cirrhosis, liver cancer, and disorders attributed to alcohol use: Global Burden of Disease in Brazil, 1990 and 2015. / Mortalidade por cirrose, câncer hepático e transtornos devidos ao uso de álcool: Carga Global de Doenças no Brasil, 1990 e 2015.

INTRODUCTION:: Alcohol use is one of the main preventable risk factors affecting mortality and premature disability. OBJECTIVE:: To describe the estimates of mortality and years of life lost as a result of premature death (YLL) due to cirrhosis, liver cancer, and disorders attributed to alcohol use in Brazil and its federated units in 1990 and 2015. METHODS:: Descriptive study using data from the Global Burden of Disease Study (2015) and the Mortality Information System (SIM). Statistical models were used to obtain corrected mortality estimates for selected causes. Rates were standardized by age. RESULTS:: In 1990, 16,226 deaths were estimated for the three conditions (17.0/100 thousand inhabitants), while in 2015 there were 28,337 deaths (15.7/100 thousand inhabitants). There was a reduction in mortality (per 100 thousand) due to cirrhosis (from 11.4 to 9.5), stability in mortality rates related to liver cancer (1.5 and 1.9), and stability in mortality rates caused by alcohol use disorders (4.1 and 4.3). Mortality rates were 5.1 times higher among men, and the five states with the highest mortality rates and YLL were from the Northeast Region: Sergipe, Ceará, Pernambuco, Paraíba, and Alagoas. Mortality and YLL rates for the three conditions studied increased in the ranking of causes of death in both sexes, with the exception of cirrhosis in the female population. CONCLUSION:: The three conditions studied are responsible for a significant burden of premature mortality in Brazil, especially among men and residents of the northeast region. These results reinforce the urgent need for public policies that address harmful alcohol consumption in Brazil.

The Burden of disease attributable to mental and substance use disorders in Brazil: Global Burden of Disease Study, 1990 and 2015. / A carga dos transtornos mentais e decorrentes do uso de substâncias psicoativas no Brasil: Estudo de Carga Global de Doença, 1990 e 2015.

INTRODUCTION:: Mental and substance use disorders (MD) are highly prevalent and have a high social and economic cost. OBJECTIVE:: To describe the burden of disease attributable to mental and substance use disorders in Brazil and Federated Units in 1990 and 2015. METHODS:: Descriptive study of the burden of mental and substance use disorders, using age-standardized estimates from the Global Burden of Disease Study 2015: years of life lost due to premature mortality (YLL); years lived with disability (YLD); and disability-adjusted life year (DALY=YLL+YLD). RESULTS:: In Brazil, despite low mortality rates, there has been a high burden for mental and substance use disorders since 1990, with high YLD. In 2015, these disorders accounted for 9.5% of all DALY, ranking in the third and first position in DALY and YLD, respectively, with an emphasis on depressive and anxiety disorders. Drug use disorders had their highest increase in DALY rates between 1990 and 2015 (37.1%). The highest proportion of DALY occurred in adulthood and in females. There were no substantial differences in burden of mental and substance use disorders among Federated Units. CONCLUSION:: Despite a low mortality rate, mental and substance use disorders are highly disabling, which indicates the need for preventive and protective actions, especially in primary health care. The generalization of estimates in all the Federated Units obtained from studies conducted mostly in the south and southeast regions probably does not reflect the reality of Brazil, indicating the need for studies in all regions of the country.

The burden of diabetes and hyperglycemia in Brazil and its states: findings from the Global Burden of Disease Study 2015.

INTRODUCTION AND OBJECTIVE:: The global burden of disease (GBD) 2015 project, extends GBD analyses to include Brazilian federative units separately. We take advantage of GBD methodological advances to describe the current burden of diabetes and hyperglycemia in Brazil. METHODS:: Using standard GBD 2015 methods, we analyzed the burden of diabetes, chronic kidney disease due to diabetes and high fasting plasma glucose in Brazil and its states. RESULTS:: The age-standardized rate of disability-adjusted life years (DALYs) which was lost to high fasting plasma glucose, a category which encompasses burdens of diabetes and of lesser hyperglycemia, were 2448.85 (95% UI 2165.96-2778.69) /100000 for males, and 1863.90 (95% UI 1648.18-2123.47) /100000 for females in 2015. This rate was more than twice as great in states with highest burden, these being overwhelmingly in the northeast and north, compared with those with lowest rates. The rate of crude DALYs for high fasting plasma glucose, increased by 35% since 1990, while DALYs due to all non-communicable diseases increased only by 12.7%, and DALYs from all causes declined by 20.5%. DISCUSSION:: The worldwide pandemic of diabetes and hyperglycemia now causes a major and growing disease burden in Brazil, especially in states with greater poverty and a lesser educational level. CONCLUSION:: Diabetes and chronic kidney disease due to diabetes, as well as high fasting plasma glucose in general, currently constitute a major and growing public health problem in Brazil. Actions to date for their prevention and control have been slow considering the magnitude of this burden.