Stillbirth undercount in the sample registration system and national family health survey, India.

Objective: To assess the extent of under-reporting of stillbirths in India by comparing stillbirth and neonatal mortality rates from two national data sources and to review possible reasons for undercounting of stillbirths. Methods: We extracted data on stillbirth and neonatal mortality rates from the annual reports for 2016-2020 of the sample registration system, the Indian government's main source of vital statistics. We compared the data with estimates of stillbirth and neonatal mortality rates from the fifth round of the Indian national family health survey covering events from 2016-2021. We reviewed the questionnaires and manuals from both surveys and compared the sample registration system's verbal autopsy tool with other international tools. Findings: The stillbirth rate for India from the national family health survey (9.7 stillbirths per 1000 births; 95% confidence interval: 9.2-10.1) was 2.6 times higher than the average rate reported in the sample registration system over 2016-2020 (3.8 stillbirths per 1000 births). However, neonatal mortality rates in the two data sources were similar. We identified issues with the definition of stillbirth, documentation of gestation period, and categorization of miscarriages and abortions that could result in undercounting stillbirths in the sample registration system. In the national family health survey only one adverse pregnancy outcome is documented, irrespective of the number of adverse pregnancy outcomes in the given period. Conclusion: For India to attain its 2030 target of single-digit stillbirth rate and to monitor actions to end preventable stillbirths, efforts are needed to improve the documentation of stillbirths in its data collection systems.

Increase in birthweight coverage of neonatal deaths is needed to monitor low birthweight prevalence in India: lessons from the National Family Health Survey.

BACKGROUND: Low birthweight (LBW), defined as birthweight < 2500gms, is the largest contributor to the malnutrition disability-adjusted-live-years in India. We report on the inadequacy of birthweight data, which is a significant barrier in the understanding of LBW epidemiology, to address malnutrition in India. METHODS: Data from the recent round of the National Family Survey (NFHS-5) were utilised. Birthweight of livebirths in the last 5 years was documented in grams either from the health card or based on mother's recall. We computed the coverage of birthweight measurement availability and the extent of heaping (values of 2500, 3000 and 3500gms) by the place of delivery and by the survival of newborn during the neonatal period. Heaping of > 55% was considered as poor-quality birthweight data. LBW prevalence per 100 livebirths was estimated and extrapolated for under-reporting of birthweight. Findings are reported for India and its 30 states. RESULTS: Birthweight measurement coverage irrespective of the place of delivery was (89·8%; 95% CI 89·7-90) for India, and varied by 2 times among the states with the highest coverage in Tamil Nadu (99·3%) and the lowest in Nagaland (49·7%). Home deliveries had the least coverage of birthweight measurement (49.6%; 95% CI 49.0-50.1) as compared with public health facility (96.3%; 95% CI 96.2-96.3) and private health facility (96%; 95% CI 95.8-96.1) deliveries. This coverage was 66·5% (95% CI 65·2-67·7) among neonatal deaths as compared with 90.4 (95% CI 90.3-90.6) for livebirths who survived the neonatal period for India. The proportion of health card as the data source increased for livebirths born in year 2015 to year 2020 but then dropped for livebirths born in year 2021 (p < 0.001). The proportion of heaping was 52·0% (95% CI 51·7-52·2) in the recorded birthweight for India, and heaping > 55% was seen in 10 states irrespective of the type data source; and 3 states in addition had heaping > 55% in mother's recall. LBW prevalence was estimated at 17·4% (95% CI 17·3-17·6) for India, and ranged from 4.5% in Nagaland and Mizoram to 22.5% in Punjab for livebirths for whom birthweight was available. We estimated LBW at 77.8% for whom birthweight was not available, and the adjusted LBW prevalence for all livebirths was estimated at 23.5% (95% CI 23.3-23.8) for India. CONCLUSIONS: Without measuring birthweight for every newborn irrespective of the survival and place of delivery, India may not able to address reduction in low birthweight and neonatal mortality effectively to meet global or national targets.

Domestic violence in Indian women: lessons from nearly 20 years of surveillance.

BACKGROUND: Prevalence of self-reported domestic violence against women in India is high. This paper investigates the national and sub-national trends in domestic violence in India to prioritise prevention activities and to highlight the limitations to data quality for surveillance in India. METHODS: Data were extracted from annual reports of National Crimes Record Bureau (NCRB) under four domestic violence crime-headings-cruelty by husband or his relatives, dowry death, abetment to suicide, and protection of women against domestic violence act. Rate for each crime is reported per 100,000 women aged 15-49 years, for India and its states from 2001 to 2018. Data on persons arrested and legal status of the cases were extracted. RESULTS: Rate of reported cases of cruelty by husband or relatives in India was 28.3 (95% CI 28.1-28.5) in 2018, an increase of 53% from 2001. State-level variations in this rate ranged from 0.5 (95% CI  - 0.05 to 1.5) to 113.7 (95% CI 111.6-115.8) in 2018. Rate of reported dowry deaths and abetment to suicide was 2.0 (95% CI 2.0-2.0) and 1.4 (95% CI 1.4-1.4) in 2018 for India, respectively. Overall, a few states accounted for the temporal variation in these rates, with the reporting stagnant in most states over these years. The NCRB reporting system resulted in underreporting for certain crime-headings. The mean number of people arrested for these crimes had decreased over the period. Only 6.8% of the cases completed trials, with offenders convicted only in 15.5% cases in 2018. The NCRB data are available in heavily tabulated format with limited usage for intervention planning. The non-availability of individual level data in public domain limits exploration of patterns in domestic violence that could better inform policy actions to address domestic violence. CONCLUSIONS: Urgent actions are needed to improve the robustness of NCRB data and the range of information available on domestic violence cases to utilise these data to effectively address domestic violence against women in India.

Administrative data deficiencies plague understanding of the magnitude of rape-related crimes in Indian women and girls.

BACKGROUND: This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India. METHODS: Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed. RESULTS: The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India's capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases. CONCLUSIONS: The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls.

Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016.

BACKGROUND: The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases. METHODS: We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate. RESULTS: The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation. CONCLUSIONS: In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe. (Funded by the Bill and Melinda Gates Foundation.).

Health Effects of Overweight and Obesity in 195 Countries over 25 Years.

BACKGROUND: Although the rising pandemic of obesity has received major attention in many countries, the effects of this attention on trends and the disease burden of obesity remain uncertain. METHODS: We analyzed data from 68.5 million persons to assess the trends in the prevalence of overweight and obesity among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body-mass index (BMI), according to age, sex, cause, and BMI in 195 countries between 1990 and 2015. RESULTS: In 2015, a total of 107.7 million children and 603.7 million adults were obese. Since 1980, the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries. Although the prevalence of obesity among children has been lower than that among adults, the rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally, nearly 40% of which occurred in persons who were not obese. More than two thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden related to high BMI has increased since 1990; however, the rate of this increase has been attenuated owing to decreases in underlying rates of death from cardiovascular disease. CONCLUSIONS: The rapid increase in the prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem. (Funded by the Bill and Melinda Gates Foundation.).

The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.

BACKGROUND: Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls. METHODS: Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records. RESULTS: Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence was 5186 (4622-5849) per 100 000 in 2017, representing a decline of 6.5% (7.6 to 5.4) from 1990 to 2017. Age-standardised mortality rate was 9.2 (8.5-9.8) per 100 000 which equated to 695 771 (644 927-741 720) deaths in 2017. Globally, falls resulted in 16 688 088 (15 101 897-17 636 830) YLLs, 19 252 699 (13 725 429-26 140 433) YLDs and 35 940 787 (30 185 695-42 903 289) DALYs across all ages. The most common injury sustained by fall victims is fracture of patella, tibia or fibula, or ankle. Globally, age-specific YLD rates increased with age. CONCLUSIONS: This study shows that the burden of falls is substantial. Investing in further research, fall prevention strategies and access to care is critical.

The burden of unintentional drowning: global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study.

BACKGROUND: Drowning is a leading cause of injury-related mortality globally. Unintentional drowning (International Classification of Diseases (ICD) 10 codes W65-74 and ICD9 E910) is one of the 30 mutually exclusive and collectively exhaustive causes of injury-related mortality in the Global Burden of Disease (GBD) study. This study's objective is to describe unintentional drowning using GBD estimates from 1990 to 2017. METHODS: Unintentional drowning from GBD 2017 was estimated for cause-specific mortality and years of life lost (YLLs), age, sex, country, region, Socio-demographic Index (SDI) quintile, and trends from 1990 to 2017. GBD 2017 used standard GBD methods for estimating mortality from drowning. RESULTS: Globally, unintentional drowning mortality decreased by 44.5% between 1990 and 2017, from 531 956 (uncertainty interval (UI): 484 107 to 572 854) to 295 210 (284 493 to 306 187) deaths. Global age-standardised mortality rates decreased 57.4%, from 9.3 (8.5 to 10.0) in 1990 to 4.0 (3.8 to 4.1) per 100 000 per annum in 2017. Unintentional drowning-associated mortality was generally higher in children, males and in low-SDI to middle-SDI countries. China, India, Pakistan and Bangladesh accounted for 51.2% of all drowning deaths in 2017. Oceania was the region with the highest rate of age-standardised YLLs in 2017, with 45 434 (40 850 to 50 539) YLLs per 100 000 across both sexes. CONCLUSIONS: There has been a decline in global drowning rates. This study shows that the decline was not consistent across countries. The results reinforce the need for continued and improved policy, prevention and research efforts, with a focus on low- and middle-income countries.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar.

BACKGROUND: The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. METHODS: Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. RESULTS: The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days. CONCLUSIONS: To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births.

BACKGROUND: The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population. METHODS: Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach. RESULTS: A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43). CONCLUSIONS: We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.

Risk profile for drowning deaths in children in the Indian state of Bihar: results from a population-based study.

BACKGROUND: We report on incidence of drowning deaths and related contextual factors in children from a population-based study in the Indian state of Bihar which estimated the causes of death using verbal autopsy (VA). METHODS: Interviews were conducted for deaths in 1-14 years population that occurred from January 2012 to March 2014 in 109 689 households (87.1% participation) in 1017 clusters representative of the state. The Population Health Metrics Research Consortium shortened VA questionnaire was used for interview and cause of death was assigned using the SmartVA automated algorithm. The annualised unintentional drowning death incidence, activity prior to drowning, the body of water where drowning death had occurred and contextual information are reported. FINDINGS: The survey covered 224 077 children aged 1-14 years. Drowning deaths accounted for 7.2%, 12.5% and 5.8% of all deaths in 1-4, 5-9 and 10-14 years age groups, respectively. The adjusted incidence of drowning deaths was 14.3 (95% CI 14.0 to 14.7) per 100 000 children, with it being higher in urban (16.1, 95% CI 14.8 to 17.3) areas. Nearly half of the children drowned in a river (5.9, 95% CI 5.6 to 6.1) followed by in a pond (2.8, 95% CI 2.6 to 2.9). Drowning death incidence was the highest while playing (5.1, 95% CI 4.9 to 5.4) and bathing (4.0, 95% CI 3.8 to 4.2) with the former accounting for more deaths in 1-4 years age group. Sixty per cent of children were already dead when found. None of these deaths were reported to the civil registration system to obtain death certificate. INTERPRETATION: The findings from this large representative sample of children document the magnitude of and variations in unintentional drowning deaths in Bihar. Urgent targeted drowning interventions are needed to address the risk in children. Gross under-reporting of drowning deaths in children in India needs attention.

Completeness of death registration in the Civil Registration System, India (2005 to 2015).

Background & objectives: In many developing countries including India, the civil registration data are incomplete, inadequate and not timely, therefore, compromising the usefulness of these data. The completeness of registration of death (CoRD) in the Indian Civil Registration System (CRS) was assessed from 2005 to 2015 at State level to understand its current status and trends over time and also to identify gaps in data to improve CRS data quality. Methods: CoRD for each year for each State was calculated from the CRS reports for 2005-2015. Data were analyzed nationally by geographic region and individual State. The availability of CoRD by age group and sex was also reported. Results: About 40 per cent increase in CoRD was documented for India between 2005 and 2015, with CoRD of 76.6 per cent in 2015. CoRD was >90 per cent in the western and southern regions and the eastern, central and northeastern regions had CoRD lower than the Indian average in 2015. Among the 29 States, 16 (55.2%) State had CoRD >80 per cent and five (17.2%) <50 per cent and 10 States recorded 100 per cent CoRD. Despite the highest per cent increase during 2005-2015 (108.5%), CoRD in Uttar Pradesh was 44.2 per cent in 2015. Varying levels of progress in 2015 were seen between the State with similar CoRD estimates in 2015. Nagaland (-63.3%), Manipur (-33.1%) and Tripura (-30.3%) were the only States that documented a decrease in CoRD during 2005-2015. The age non-availability for India ranged from 37.0 per cent in 2009 to 37.9 per cent in 2015, an average of 41.5 per cent over the seven years and was an average of 35.6 and 36.6 per cent for males and females, respectively. Age was available for all registered deaths only in five (17.2%) of the 29 States in 2009 and four (13.8%) in 2015. Sex non-availability for the recorded deaths was much lower as compared with that for age. Interpretation & conclusions: Despite the significant progress made in CoRD in India, critical differences between the States within the CRS remain, with poor availability of reporting by age and sex. Concentrated efforts to assess the strengths and weaknesses at the State level of the CRS processes, quality of data and plausibility of information generated are needed in India.

Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015.

BACKGROUND: Exposure to ambient air pollution increases morbidity and mortality, and is a leading contributor to global disease burden. We explored spatial and temporal trends in mortality and burden of disease attributable to ambient air pollution from 1990 to 2015 at global, regional, and country levels. METHODS: We estimated global population-weighted mean concentrations of particle mass with aerodynamic diameter less than 2·5 µm (PM2·5) and ozone at an approximate 11 km × 11 km resolution with satellite-based estimates, chemical transport models, and ground-level measurements. Using integrated exposure-response functions for each cause of death, we estimated the relative risk of mortality from ischaemic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, lung cancer, and lower respiratory infections from epidemiological studies using non-linear exposure-response functions spanning the global range of exposure. FINDINGS: Ambient PM2·5 was the fifth-ranking mortality risk factor in 2015. Exposure to PM2·5 caused 4·2 million (95% uncertainty interval [UI] 3·7 million to 4·8 million) deaths and 103·1 million (90·8 million 115·1 million) disability-adjusted life-years (DALYs) in 2015, representing 7·6% of total global deaths and 4·2% of global DALYs, 59% of these in east and south Asia. Deaths attributable to ambient PM2·5 increased from 3·5 million (95% UI 3·0 million to 4·0 million) in 1990 to 4·2 million (3·7 million to 4·8 million) in 2015. Exposure to ozone caused an additional 254 000 (95% UI 97 000-422 000) deaths and a loss of 4·1 million (1·6 million to 6·8 million) DALYs from chronic obstructive pulmonary disease in 2015. INTERPRETATION: Ambient air pollution contributed substantially to the global burden of disease in 2015, which increased over the past 25 years, due to population ageing, changes in non-communicable disease rates, and increasing air pollution in low-income and middle-income countries. Modest reductions in burden will occur in the most polluted countries unless PM2·5 values are decreased substantially, but there is potential for substantial health benefits from exposure reduction. FUNDING: Bill & Melinda Gates Foundation and Health Effects Institute.

Global Cardiovascular and Renal Outcomes of Reduced GFR.

The burden of premature death and health loss from ESRD is well described. Less is known regarding the burden of cardiovascular disease attributable to reduced GFR. We estimated the prevalence of reduced GFR categories 3, 4, and 5 (not on RRT) for 188 countries at six time points from 1990 to 2013. Relative risks of cardiovascular outcomes by three categories of reduced GFR were calculated by pooled random effects meta-analysis. Results are presented as deaths for outcomes of cardiovascular disease and ESRD and as disability-adjusted life years for outcomes of cardiovascular disease, GFR categories 3, 4, and 5, and ESRD. In 2013, reduced GFR was associated with 4% of deaths worldwide, or 2.2 million deaths (95% uncertainty interval [95% UI], 2.0 to 2.4 million). More than half of these attributable deaths were cardiovascular deaths (1.2 million; 95% UI, 1.1 to 1.4 million), whereas 0.96 million (95% UI, 0.81 to 1.0 million) were ESRD-related deaths. Compared with metabolic risk factors, reduced GFR ranked below high systolic BP, high body mass index, and high fasting plasma glucose, and similarly with high total cholesterol as a risk factor for disability-adjusted life years in both developed and developing world regions. In conclusion, by 2013, cardiovascular deaths attributed to reduced GFR outnumbered ESRD deaths throughout the world. Studies are needed to evaluate the benefit of early detection of CKD and treatment to decrease these deaths.

Global Mortality From Firearms, 1990-2016.

Importance: Understanding global variation in firearm mortality rates could guide prevention policies and interventions. Objective: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. Design, Setting, and Participants: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. Exposures: Firearm ownership and access. Main Outcomes and Measures: Cause-specific deaths by age, sex, location, and year. Results: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P < .001; R2 = 0.21) and homicide (P < .001; R2 = 0.35). Conclusions and Relevance: This study estimated between 195 000 and 276 000 firearm injury deaths globally in 2016, the majority of which were firearm homicides. Despite an overall decrease in rates of firearm injury death since 1990, there was variation among countries and across demographic subgroups.

Identification of factors associated with stillbirth in the Indian state of Bihar using verbal autopsy: A population-based study.

BACKGROUND: India was estimated to have the largest numbers of stillbirths globally in 2015, and the Indian government has adopted a target of <10 stillbirths per 1,000 births by 2030 through the India Newborn Action Plan (INAP). The objective of this study was to use verbal autopsy interviews to examine factors associated with stillbirth in the Indian state of Bihar and make recommendations for the INAP to better inform the setting of priorities and actions to reduce stillbirths. METHODS AND FINDINGS: Verbal autopsy interviews were conducted for deaths including stillbirths that occurred from January 2011 to March 2014 in a sample of 109,689 households (87.1% participation) in 1,017 clusters representative of the state of Bihar. The Population Health Metrics Research Consortium shortened verbal autopsy questionnaire was used for each interview, and cause of death was assigned using the SmartVA automated algorithm. A stillbirth was defined as a foetal death with a gestation period of ≥28 weeks wherein the foetus did not show any sign of life. We report on the stillbirth epidemiology and present case studies from the qualitative data on the health provider interface that can be used to improve success of improved, skilled care at birth and delivery interventions. The annualised stillbirth incidence was 21.2 (95% CI 19.7 to 22.6) per 1,000 births, with it being higher in the rural areas. A total of 1,132 stillbirths were identified; 686 (62.2%) were boys, 327 (29.7%) were firstborn, and 760 (68.9%) were delivered at a health facility. Of all the stillbirths, 54.5% were estimated to be antepartum. Only 6,161 (55.9%) of the women reported at least 1 antenatal care visit, and 33% of the women reported not consuming the iron folic acid tablets during pregnancy. Significant differences were seen in delivery-related variables and associated maternal conditions based on the place of delivery and type of stillbirth. Only 6.1% of the women reported having undergone a test to rule out syphilis. For 34.2% of the stillbirths, the possible risk factor for stillbirth was unexplained. For the remaining 65.8% of the women who reported at least 1 complication during the last 3 months of pregnancy, maternal conditions including anaemia, fever during labour, and hypertension accounted for most of the complications. Of importance to note is that the maternal conditions overlapped quite significantly with the other possible underlying risk factors for stillbirth. Obstetrics complications and excessive bleeding during delivery contributed to nearly 30% of the cases as a possible risk factor for stillbirth, highlighting the need for better skilled care during delivery. Of the 5 major themes identified in open narratives, 3 were related to healthcare providers-lack of timely attention, poor skills (knowledge or implementation), and reluctance to deliver a dead baby. The case studies document the circumstances that highlight breakdowns in clinical care around the delivery or missed opportunities that can be used for improving the provision of quality skilled care. The main limitation of these data is that stillbirth is defined based on the gestation period and not based on birth weight; however, this is done in several studies from developing country settings in which birthweight is either not available or accurate. CONCLUSIONS: To our knowledge, this study is among the few large, population-based assessments of stillbirths using verbal autopsy at the state level in India. These findings provide detailed insight into investigating the possible risk factors for stillbirths, as well as insight into the ground-level changes that are needed within the health system to design and implement effective preventive and intervention policies to reduce the burden of stillbirths. As most of the stillbirths are preventable with high-quality, evidence-based interventions delivered before and during pregnancy and during labour and childbirth, it is imperative that with INAP in place, India aspires to document stillbirths in a systematic and standardised manner to bridge the knowledge gap for appropriate actions to reduce stillbirths. We have made several recommendations based on our study that could further strengthen the INAP approach to improve the quality and quantity of stillbirth data to avoid this needless loss of lives.

Mapping of health research funding in India.

BACKGROUND.: We aimed to estimate the total annual funding available for health research in India. We also examined the trends of funding for health research since 2001 by major national and international agencies. METHODS.: We did a retrospective survey of 1150 health research institutions in India to estimate the quantum of funding over 5 years. We explored the Prowess database for industry spending on health research and development and gathered data from key funding agencies. All amounts were converted to 2015 constant US$. RESULTS.: The total health research funding available in India in 2011-12 was US$ 1.42 billion, 0.09% of the gross domestic product (GDP) including only 0.02% from public sources. The average annual increase of funding over the previous 5 years (2007-08 to 2011-12) was 8.8%. 95% of this funding was from Indian sources, including 79% by the Indian pharmaceutical industry. Of the total funding, only 3.2% was available for public health research. From 2006-10 to 2011-15 the funding for health research in India by the three major international agencies cumulatively decreased by 40.8%. The non-industry funding for non-communicable diseases doubled from 2007-08 to 2011-12, but the funding for some of the leading causes of disease burden, including neonatal disorders, cardiovascular disease, chronic respiratory disease, mental health, musculoskeletal disorders and injuries was substantially lower than their contribution to the disease burden. CONCLUSION.: The total funding available for health research in India is lower than previous estimates, and only a miniscule proportion is available for public health research. The non industry funding for health research in India, which is predominantly from public resources, is extremely small, and had considerable mismatches with the major causes of disease burden. The magnitude of public funding for health research and its appropriate allocation should be addressed at the highest policy level.

A review of national health surveys in India.

Several rounds of national health surveys have generated a vast amount of data in India since 1992. We describe and compare the key health information gathered, assess the availability of health data in the public domain, and review publications resulting from the National Family Health Survey (NFHS), the District Level Household Survey (DLHS) and the Annual Health Survey (AHS). We highlight issues that need attention to improve the usefulness of the surveys in monitoring changing trends in India's disease burden: (i) inadequate coverage of noncommunicable diseases, injuries and some major communicable diseases; (ii) modest comparability between surveys on the key themes of child and maternal mortality and immunization to understand trends over time; (iii) short time intervals between the most recent survey rounds; and (iv) delays in making individual-level data available for analysis in the public domain. We identified 337 publications using NFHS data, in contrast only 48 and three publications were using data from the DLHS and AHS respectively. As national surveys are resource-intensive, it would be prudent to maximize their benefits. We suggest that India plan for a single major national health survey at five-year intervals in consultation with key stakeholders. This could cover additional major causes of the disease burden and their risk factors, as well as causes of death and adult mortality rate estimation. If done in a standardized manner, such a survey would provide useable and timely data to inform health interventions and facilitate assessment of their impact on population health.

Survival outcomes for first-line antiretroviral therapy in India's ART program.

BACKGROUND: Little is known about survival outcomes of HIV patients on first-line antiretroviral therapy (ART) on a large-scale in India, or facility level factors that influence patient survival to guide further improvements in the ART program in India. We examined factors at the facility level in addition to patient factors that influence survival of adult HIV patients on ART in the publicly-funded ART program in a high- and a low-HIV prevalence state. METHODS: Retrospective chart review in public sector ART facilities in the combined states of Andhra Pradesh and Telangana (APT) before these were split in 2014 and in Rajasthan (RAJ), the high- and a low-HIV prevalence states, respectively. Records of adults initiating ART between 2007-12 and 2008-13 in APT and RAJ, respectively, were reviewed and facility-level information collected at all ART centres and a sample of link ART centres. Survival probability was estimated using Kaplan-Meier method, and determinants of mortality explored with facility and patient-level factors using Cox proportional hazard model. RESULTS: Based on data from 6581 patients, the survival probability of ART at 60 months was 76.3 % (95 % CI 73.0-79.2) in APT and 78.3 % (74.4-81.7) in RAJ. The facilities with cumulative ART patient load above the state average had lower mortality in APT (Hazard ratio [HR] 0.74, 0.57-0.95) but higher in RAJ (HR 1.37, 1.01-1.87). Facilities with higher proportion of lost to follow-up patients in APT had higher mortality (HR 1.47, 1.06-2.05), as did those with higher ART to pre-ART patient ratio in RAJ (HR 1.62, 1.14-2.29). In both states, there was higher hazard for mortality in patients with CD4 count 100 cells/mm3 or less at ART initiation, males, and in patients with TB co-infection. CONCLUSIONS: These data from the majority of facilities in a high- and a low-HIV burden state of India over 5 years reveal reasonable and similar survival outcomes in the two states. The facilities with higher ART load in the longer established ART program in APT had better survival, but facilities with a higher ART load and a higher ratio of ART to pre-ART patients in the less experienced ART program in RAJ had poorer survival. These findings have important implications for India's ART program planning as it expands further.