Burden of disease attributable to risk factors in European countries: a scoping literature review.

OBJECTIVES: Within the framework of the burden of disease (BoD) approach, disease and injury burden estimates attributable to risk factors are a useful guide for policy formulation and priority setting in disease prevention. Considering the important differences in methods, and their impact on burden estimates, we conducted a scoping literature review to: (1) map the BoD assessments including risk factors performed across Europe; and (2) identify the methodological choices in comparative risk assessment (CRA) and risk assessment methods. METHODS: We searched multiple literature databases, including grey literature websites and targeted public health agencies websites. RESULTS: A total of 113 studies were included in the synthesis and further divided into independent BoD assessments (54 studies) and studies linked to the Global Burden of Disease (59 papers). Our results showed that the methods used to perform CRA varied substantially across independent European BoD studies. While there were some methodological choices that were more common than others, we did not observe patterns in terms of country, year or risk factor. Each methodological choice can affect the comparability of estimates between and within countries and/or risk factors, since they might significantly influence the quantification of the attributable burden. From our analysis we observed that the use of CRA was less common for some types of risk factors and outcomes. These included environmental and occupational risk factors, which are more likely to use bottom-up approaches for health outcomes where disease envelopes may not be available. CONCLUSIONS: Our review also highlighted misreporting, the lack of uncertainty analysis and the under-investigation of causal relationships in BoD studies. Development and use of guidelines for performing and reporting BoD studies will help understand differences, avoid misinterpretations thus improving comparability among estimates. REGISTRATION: The study protocol has been registered on PROSPERO, CRD42020177477 (available at: https://www.crd.york.ac.uk/PROSPERO/ ).

Burden of infectious disease studies in Europe and the United Kingdom: a review of methodological design choices.

This systematic literature review aimed to provide an overview of the characteristics and methods used in studies applying the disability-adjusted life years (DALY) concept for infectious diseases within European Union (EU)/European Economic Area (EEA)/European Free Trade Association (EFTA) countries and the United Kingdom. Electronic databases and grey literature were searched for articles reporting the assessment of DALY and its components. We considered studies in which researchers performed DALY calculations using primary epidemiological data input sources. We screened 3053 studies of which 2948 were excluded and 105 studies met our inclusion criteria. Of these studies, 22 were multi-country and 83 were single-country studies, of which 46 were from the Netherlands. Food- and water-borne diseases were the most frequently studied infectious diseases. Between 2015 and 2022, the number of burden of infectious disease studies was 1.6 times higher compared to that published between 2000 and 2014. Almost all studies (97%) estimated DALYs based on the incidence- and pathogen-based approach and without social weighting functions; however, there was less methodological consensus with regards to the disability weights and life tables that were applied. The number of burden of infectious disease studies undertaken across Europe has increased over time. Development and use of guidelines will promote performing burden of infectious disease studies and facilitate comparability of the results.

The increasing significance of disease severity in a burden of disease framework.

Recent estimates have reiterated that non-fatal causes of disease, such as low back pain, headaches and depressive disorders, are amongst the leading causes of disability-adjusted life years (DALYs). For these causes, the contribution of years lived with disability (YLD) - put simply, ill-health - is what drives DALYs, not mortality. Being able to monitor trends in YLD closely is particularly relevant for countries that sit high on the socio-demographic spectrum of development, as it contributes more than half of all DALYs. There is a paucity of data on how the population-level occurrence of disease is distributed according to severity, and as such, the majority of global and national efforts in monitoring YLD lack the ability to differentiate changes in severity across time and location. This raises uncertainties in interpreting these findings without triangulation with other relevant data sources. Our commentary aims to bring this issue to the forefront for users of burden of disease estimates, as its impact is often easily overlooked as part of the fundamental process of generating DALY estimates. Moreover, the wider health harms of the COVID-19 pandemic have underlined the likelihood of latent and delayed demand in accessing vital health and care services that will ultimately lead to exacerbated disease severity and health outcomes. This places increased importance on attempts to be able to differentiate by both the occurrence and severity of disease.

The Burden of Disease in Germany at the National and Regional Level.

BACKGROUND: .Summary measures such as disability-adjusted life years (DALY) are becoming increasingly important for the standardized assessment of the burden of disease due to death and disability. The BURDEN 2020 pilot project was designed as an independent burden-of-disease study for Germany, which was based on nationwide data, but which also yielded regional estimates. METHODS: DALY is defined as the sum of years of life lost due to death (YLL) and years lived with disability (YLD). YLL is the difference between the age at death due to disease and the remaining life expectancy at this age, while YLD quantifies the number of years individuals have spent with health impairments. Data are derived mainly from causes of death statistics, population health surveys, and claims data from health insurers. RESULTS: In 2017, there were approximately 12 million DALY in Germany, or 14 584 DALY per 100 000 inhabitants. Conditions which caused the greatest number of DALY were coronary heart disease (2321 DALY), low back pain (1735 DALY), and lung cancer (1197 DALY). Headache and dementia accounted for a greater disease burden in women than in men, while lung cancer and alcohol use disorders accounted for a greater disease burden in men than in women. Pain disorders and alcohol use disorders were the leading causes of DALY among young adults of both sexes. The disease burden rose with age for some diseases, including cardiovascular diseases, dementia, and diabetes mellitus. For some diseases and conditions, the disease burden varied by geographical region. CONCLUSION: The results indicate a need for age- and sex-specific prevention and for differing interventions according to geographic region. Burden of disease studies yield comprehensive population health surveillance data and are a useful aid to decision-making in health policy.

Burden of Disease Due to Ambient Particulate Matter in Germany-Explaining the Differences in the Available Estimates.

Ambient particulate matter (PM2.5) pollution is an important threat to human health. The aim of this study is to estimate the environmental burden of disease (EBD) for the German population associated with PM2.5 exposure in Germany for the years 2010 until 2018. The EBD method was used to quantify relevant indicators, e.g., disability-adjusted life years (DALYs), and the life table approach was used to estimate the reduction in life expectancy caused by long-term PM2.5 exposure. The impact of varying assumptions and input data was assessed. From 2010 to 2018 in Germany, the annual population-weighted PM2.5 concentration declined from 13.7 to 10.8 µg/m3. The estimates of annual PM2.5-attributable DALYs for all disease outcomes showed a downward trend. In 2018, the highest EBD was estimated for ischemic heart disease (101.776; 95% uncertainty interval (UI) 62,713-145,644), followed by lung cancer (60,843; 95% UI 43,380-79,379). The estimates for Germany differ from those provided by other institutions. This is mainly related to considerable differences in the input data, the use of a specific German national life expectancy and the selected relative risks. A transparent description of input data, computational steps, and assumptions is essential to explain differing results of EBD studies to improve methodological credibility and trust in the results. Furthermore, the different calculated indicators should be explained and interpreted with caution.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review.

BACKGROUND: Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies. METHODS: We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021. RESULTS: We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables. CONCLUSIONS: Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Correction: Tobollik et al. Burden of Disease Due to Traffic Noise in Germany. Int. J. Environ. Res. Public Health 2019, 16, 2304.

The authors wish to make the following corrections to this paper [...].

Estimating risk factor attributable burden - challenges and potential solutions when using the comparative risk assessment methodology.

BACKGROUND: Burden of disease analyses quantify population health and provide comprehensive overviews of the health status of countries or specific population groups. The comparative risk assessment (CRA) methodology is commonly used to estimate the share of the burden attributable to risk factors. The aim of this paper is to identify and address some selected important challenges associated with CRA, illustrated by examples, and to discuss ways to handle them. Further, the main challenges are addressed and finally, similarities and differences between CRA and health impact assessments (HIA) are discussed, as these concepts are sometimes referred to synonymously but have distinctly different applications. RESULTS: CRAs are very data demanding. One key element is the exposure-response relationship described e.g. by a mathematical function. Combining estimates to arrive at coherent functions is challenging due to the large variability in risk exposure definitions and data quality. Also, the uncertainty attached to this data is difficult to account for. Another key issue along the CRA-steps is to define a theoretical minimal risk exposure level for each risk factor. In some cases, this level is evident and self-explanatory (e.g., zero smoking), but often more difficult to define and justify (e.g., ideal consumption of whole grains). CRA combine all relevant information and allow to estimate population attributable fractions (PAFs) quantifying the proportion of disease burden attributable to exposure. Among many available formulae for PAFs, it is important to use the one that allows consistency between definitions, units of the exposure data, and the exposure response functions. When combined effects of different risk factors are of interest, the non-additive nature of PAFs and possible mediation effects need to be reflected. Further, as attributable burden is typically calculated based on current exposure and current health outcomes, the time dimensions of risk and outcomes may become inconsistent. Finally, the evidence of the association between exposure and outcome can be heterogeneous which needs to be considered when interpreting CRA results. CONCLUSIONS: The methodological challenges make transparent reporting of input and process data in CRA a necessary prerequisite. The evidence for causality between included risk-outcome pairs has to be well established to inform public health practice.

Burden of non-communicable disease studies in Europe: a systematic review of data sources and methodological choices.

BACKGROUND: Assessment of disability-adjusted life years (DALYs) resulting from non-communicable diseases (NCDs) requires specific calculation methods and input data. The aims of this study were to (i) identify existing NCD burden of disease (BoD) activities in Europe; (ii) collate information on data sources for mortality and morbidity; and (iii) provide an overview of NCD-specific methods for calculating NCD DALYs. METHODS: NCD BoD studies were systematically searched in international electronic literature databases and in grey literature. We included all BoD studies that used the DALY metric to quantify the health impact of one or more NCDs in countries belonging to the European Region. RESULTS: A total of 163 BoD studies were retained: 96 (59%) were single-country or sub-national studies and 67 (41%) considered more than one country. Of the single-country studies, 29 (30%) consisted of secondary analyses using existing Global Burden of Disease (GBD) results. Mortality data were mainly derived (49%) from vital statistics. Morbidity data were frequently (40%) drawn from routine administrative and survey datasets, including disease registries and hospital discharge databases. The majority (60%) of national BoD studies reported mortality corrections. Multimorbidity adjustments were performed in 18% of national BoD studies. CONCLUSION: The number of national NCD BoD assessments across Europe increased over time, driven by an increase in BoD studies that consisted of secondary data analysis of GBD study findings. Ambiguity in reporting the use of NCD-specific BoD methods underlines the need for reporting guidelines of BoD studies to enhance the transparency of NCD BoD estimates across Europe.

Risk factors and their contribution to population health in the European Union (EU-28) countries in 2007 and 2017.

BACKGROUND: The Global Burden of Disease (GBD) study has generated a wealth of data on death and disability outcomes in Europe. It is important to identify the disease burden that is attributable to risk factors and, therefore, amenable to interventions. This paper reports the burden attributable to risk factors, in deaths and disability-adjusted life years (DALYs), in the 28 European Union (EU) countries, comparing exposure to risks between them, from 2007 to 2017. METHODS: Retrospective descriptive study, using secondary data from the GBD 2017 Results Tool. For the EU-28 and each country, attributable (all-cause) age-standardized death and DALY rates, and summary exposure values are reported. RESULTS: In 2017, behavioural and metabolic risk factors showed a higher attributable burden compared with environmental risks, with tobacco, dietary risks and high systolic blood pressure standing out. While tobacco and air quality improved significantly between 2007 and 2017 in both exposure and attributable burden, others such as childhood maltreatment, drug use or alcohol use did not. Despite significant heterogeneity between EU countries, the EU-28 burden attributable to risk factors decreased in this period. CONCLUSION: Accompanying the improvement of population health in the EU-28, a comparable trend is visible for attributable burden due to risk factors. Besides opportunities for mutual learning across countries with different disease/risk factors patterns, good practices (i.e. tobacco control in Sweden, air pollution mitigation in Finland) might be followed. On the opposite side, some concerning cases must be highlighted (i.e. tobacco in Bulgaria, Latvia and Estonia or drug use in Czech Republic).

Years of Life Lost to Death­A Comprehensive Analysis of Mortality in Germany Conducted as Part of the BURDEN 2020 Project

BACKGROUND: Knowing which diseases and causes of death account for most of the years of life lost (YLL) can help to better target appropriate prevention and intervention measures. The YLL in Germany for specific causes of death were estimated as part of the BURDEN 2020 project at the Robert Koch Institute. METHODS: Data from cause-of-death statistics were used for the analysis. ICD codes were grouped into causes of death categories at different levels of disaggregation. The YLL were estimated by combining each cause of death with the remaining life expectancy at the age of death. Deaths and YLL were compared by sex, age category, and regional distribution. RESULTS: Approximately 11.6 million years were estimated to be lost in Germany in 2017, of which 42.8% were lost by women and 57.2% by men. The largest number of YLL were due to (malignant) neoplasms (35.2%), followed by cardiovascular diseases (27.6%), gastrointestinal diseases (5.8%), and neurological diseases (5.7%). Deaths at younger ages had a greater impact on population health if expressed in YLL: the death share of persons under age 65 was 14.7%, but the years of life lost in this age group amounted to 38.3% of all YLL. The most common causes of death in this group include accidents, self-injury and violence, malignant neoplasms, and alcohol-related diseases. CONCLUSION: A large proportion of YLL is borne by young and middle-aged persons. These findings emphasize the need to introduce preventive strategies early in life to reduce the YLL at younger ages, as well as to prevent risk factors for diseases in older ages.

The COVID-19 Disease Burden in Germany in 2020­Years of Life Lost to Death and Disease Over the Course of the Pandemic.

BACKGROUND: The SARS-CoV-2 pandemic presented major challenges to the health sector in 2020. The burden of disease arising from COVID-19 can be expressed as the number of years of life lost to disease or death. For example, death at age 40 involves a loss of far more years of life than death at age 80. METHODS: The disability-adjusted life years (DALY) lost to COVID-19 were calculated as the sum of the years of life lost through death (YLL) and the number of years lived with disability (YLD), on the basis of laboratory-confirmed notifiable cases of SARS-CoV-2 infection in Germany in 2020 (documented as of 18 January 2021). The methodology was based on that used in the Global Burden of Disease Study. Pre-existing diseases do not enter into the determination of YLL; rather, the residual life expectancy that is applied in this calculation corresponds to a mean age-specific level of morbidity. RESULTS: 305 641 years of life were lost to COVID-19 in Germany in 2020. The percentage of DALY lost by persons under 70 was 34.8% in men and 21.0% in women. 99.3% of the COVID-19 disease burden was accounted for by death (YLL). The daily average years of life lost due to death was lower for COVID-19 than for the major non-communicable diseases. Persons who died of COVID-19 lost a mean of 9.6 years of life; those who were under 70 when they died lost a mean of 25.2 years of life. Men lost more years of life than women (11.0 vs. 8.1 years). CONCLUSION: The effects of COVID-19 on public health can be expressed through the burden of disease indicators. This method yields additional information that should be put to use early in the course of future outbreaks.

Redistributing ill-defined causes of death - a case study from the BURDEN 2020-project in Germany.

BACKGROUND: The cause of death statistics in Germany include a relatively high share (26% in 2017) of ill-defined deaths (IDD). To make use of the cause of death statistics for Burden of Disease calculations we redistribute those IDD to valid causes of death. METHODS: The process of proportional redistribution is described in detail. It makes use of the distribution of the valid ICD-codes in the cause of death data. We use examples of stroke, diabetes, and heart failure to illustrate how IDD are reallocated. RESULTS: The largest increases in the number of deaths for both women and men were found for lower respiratory infections, diabetes mellitus, and stroke. The numbers of deaths for these causes more than doubled after redistribution. CONCLUSION: This is the first comprehensive redistribution of IDD using the German cause of death statistics. Performing a redistribution is necessary for burden of disease analyses, otherwise there would be an underreporting of certain causes of death or large numbers of deaths coded to residual or unspecific codes.

Population vulnerability to COVID-19 in Europe: a burden of disease analysis.

BACKGROUND: Evidence has emerged showing that elderly people and those with pre-existing chronic health conditions may be at higher risk of developing severe health consequences from COVID-19. In Europe, this is of particular relevance with ageing populations living with non-communicable diseases, multi-morbidity and frailty. Published estimates of Years Lived with Disability (YLD) from the Global Burden of Disease (GBD) study help to characterise the extent of these effects. Our aim was to identify the countries across Europe that have populations at highest risk from COVID-19 by using estimates of population age structure and YLD for health conditions linked to severe illness from COVID-19. METHODS: Population and YLD estimates from GBD 2017 were extracted for 45 countries in Europe. YLD was restricted to a list of specific health conditions associated with being at risk of developing severe consequences from COVID-19 based on guidance from the United Kingdom Government. This guidance also identified individuals aged 70 years and above as being at higher risk of developing severe health consequences. Study outcomes were defined as: (i) proportion of population aged 70 years and above; and (ii) rate of YLD for COVID-19 vulnerable health conditions across all ages. Bivariate groupings were established for each outcome and combined to establish overall population-level vulnerability. RESULTS: Countries with the highest proportions of elderly residents were Italy, Greece, Germany, Portugal and Finland. When assessments of population-level YLD rates for COVID-19 vulnerable health conditions were made, the highest rates were observed for Bulgaria, Czechia, Croatia, Hungary and Bosnia and Herzegovina. A bivariate analysis indicated that the countries at high-risk across both measures of vulnerability were: Bulgaria; Portugal; Latvia; Lithuania; Greece; Germany; Estonia; and Sweden. CONCLUSION: Routine estimates of population structures and non-fatal burden of disease measures can be usefully combined to create composite indicators of vulnerability for rapid assessments, in this case to severe health consequences from COVID-19. Countries with available results for sub-national regions within their country, or national burden of disease studies that also use sub-national levels for burden quantifications, should consider using non-fatal burden of disease estimates to estimate geographical vulnerability to COVID-19.

Correction to: Population vulnerability to COVID-19 in Europe: a burden of disease analysis.

[This corrects the article DOI: 10.1186/s13690-020-00433-y.].

[ICD coding of causes of death: challenges for calculating the burden of disease in Germany]. / ICD-Codierung von Todesursachen: Herausforderungen bei der Berechnung der Krankheitslast in Deutschland.

In the project BURDEN 2020 - "The burden of disease in Germany and its regions" - the years of life lost (YLL) due to premature mortality are calculated on the basis of official cause-of-death statistics. This requires the identification and redistribution of the so-called ill-defined ICD codes. "Ill-defined" means that an ICD code does not sufficiently reflect the cause of death, such that it is not informative for the calculation of the burden of disease.The first steps on the way to calculating cause-specific YLL are presented. Different frameworks of ill-defined codes are compared. The number of deaths with ill-defined codes that can be found in the German cause-of-death statistics in absolute and relative terms are analyzed, including how they are distributed by age, sex, and region.According to the WHO framework, 15.6% of the 925,200 deaths in Germany in 2015 can be identified as ill-defined. According to the framework of the Institute for Health Metrics and Evaluation (IHME) in the Global Burden of Disease Study (GBD), the proportion of ill-defined codes is 26.6%. The ICD-related distribution patterns hardly differ between WHO and IHME classifications. Considerable differences exist between the federal states, with shares of ill-defined codes between 16 and 35% (IHME framework).The cause-of-death statistics in Germany contain a considerable proportion of ill-defined codes. The differences between the federal states can only partially be explained by different electronic data processing. Due to further dissemination and improvement of electronic data collection, higher quality of cause-of-death statistics can be expected in the future.

Burden of Disease Due to Traffic Noise in Germany.

Traffic noise is nearly ubiquitous and thus can affect the health of many people. Using the German noise mapping data according to the Directive 2002/49/EC of 2017 and exposure-response functions for ischemic heart disease, noise annoyance and sleep disturbance assessed by the World Health Organization's Environmental Noise Guidelines for the European Region the burden of disease due to traffic noise is quantified. The burden of disease is expressed in disability-adjusted life years (DALYs) and its components. The highest burden was found for road traffic noise, with 75,896 DALYs when only considering moderate evidence. When including all available evidence, 176,888 DALYs can be attributable to road traffic noise. The burden due to aircraft and railway noise is lower because fewer people are exposed. Comparing the burden by health outcomes, the biggest share is due to ischemic heart disease (90%) in regard to aircraft noise, however, the lowest evidence was expressed for the association between traffic noise and ischemic heart disease. Therefore, the results should be interpreted with caution. Using alternative input parameters (e.g., exposure data) can lead to a much higher burden. Nevertheless, environmental noise is an important risk factor which leads to considerable loss of healthy life years.

Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011.

BACKGROUND: High-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level. METHODS: Data on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008-2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18-79 years nested in 162 municipalities. RESULTS: No statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model. CONCLUSIONS: Area-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

BURDEN 2020-Burden of disease in Germany at the national and regional level.

BACKGROUND: Evidence-based policy measures need non-interest-guided information about the health status of a population and the diseases that affect the population the most. In such cases, a national burden of disease study can provide reliable insights at the regional level. AIM: This article presents the potential of the BURDEN 2020 project and its expected outcome for Germany at the national and regional level. METHODS: The BURDEN 2020 project uses several indicators including years of life lost (YLL) to cover the impact of mortality and years lived with disability (YLD) to cover morbidity. The sum of both is the measure of population health called disability adjusted life years (DALY). RESULTS: The study ranks individual diseases and risk factors based on their impact on population health. The burden of disease approach is assumed to be sensitive to subnational differences and may generate immediate benefits for regional planning. The BURDEN 2020 study will pilot a national burden of disease study for Germany that will later be transformed into a continuous data processing and visualization tool. This is done by using, modifying and supplementing the methodology employed by the Global Burden of Disease (GBD) study to better fit the needs of health policy in Germany. This study is aimed at calculating the disease burden for up to 17 preselected diseases. Furthermore, the estimates of burden of disease are attributed to a selected set of risk factors. CONCLUSION: The Burden 2020 study will provide the results of a new, health-related data processing system to the public. This includes a noninterest-guided presentation of the burden of disease (DALY) in Germany at the national and regional level.

Erratum to: BURDEN 2020-Burden of disease in Germany at the national and regional level.

Erratum to:Bundesgesundheitsbl (2018) https://doi.org/10.1007/s00103-018-2793-0 The original publication of this article contained an error in the list of the authors, in which the contributing author Christian Schmidt was missing. The full list of authors has now been updated. The original article ….