Abstract Background The Global Burden of Disease (GBD) Study provides detailed information about leading causes of premature mortality and disability to help policy makers assess health in their ...countries. GBD is also a massive and rigorous audit of country data collection systems. Globally, major challenges are posed by missing data on mortality and causes of death and disability, which creates substantial uncertainty in GBD estimates for numerous causes in many countries. This study aims to identify gaps in data sources that are important to fill to improve estimation of disease burden; gaps exist because data are either not collected or not being made available for research. Methods The data used in this study were derived from the GBD Study 2010 (GBD 2010), which compiled secondary data from literature reviews, internet searches, and correspondence and consultations with researchers, staff of national statistics institutes and ministries of health, and other experts. Frequently, literature reviews were not the primary source of data on causes of death and disability. Findings In general, data on mortality and causes of death were sparsest in countries with the fewest resources. Vital registration data with medical certification of causes of death were available from 130 countries. Regions with the greatest data gaps were sub-Saharan Africa and parts of Asia. Cause of death data from verbal autopsy were available only for 486 site-years from 66 countries, just 10% (47 site-years) of which were nationally representative. Gaps in sources of disability data were even more profound. Hospital discharge data coded in International Classification of Disease and Injuries (ICD) formats 9 and 10 were available for just 43 countries, and outpatient data were only available for the USA and Canada. Interpretation The GBD 2010 is a powerful starting point for evidence-based policy making. However, the accuracy of future GBD updates will be enhanced by improvements and expansion in data collection, which will strengthen future decision making and will be essential for monitoring progress toward the Millennium Development Goals and any health-related post-2015 goals. Gaps in mortality and cause of death data could be remedied through increased investment in vital registration and verbal autopsy data collection, particularly in low-resource settings. Training physicians in ICD coding and medical certification is crucial for strengthening the quality of vital registration data. Our findings about disability data scarcity highlight the importance of addressing these gaps, particularly in countries where GBD 2010 has documented the fastest epidemiological transitions. Funding Bill & Melinda Gates Foundation.
Abstract Background With the rising cost of health care and the population ageing, many governments, including that of Vietnam, are looking for effective strategies to prevent diseases. To inform ...preventive health policies, quantification of the contribution of major risk factors to the burden of disease and injury is essential. Methods Global comparative risk assessment methodology was applied to estimate the ten major risk factors attributed to the burden of disease in Vietnam in 2008, including high blood pressure, high blood cholesterol, high body-mass index, diabetes, physical inactivity, tobacco smoking, alcohol consumption, unsafe water and sanitation, air pollution, and low fruit and vegetable intake. The proportion of deaths and disease burden (measured by disability-adjusted life-years DALYs) was estimated by the population attributable fraction, which projects how much the disease burden would have been reduced if exposure to a risk factor in the population had been at the level of a theoretical minimum. Findings In Vietnam, the three leading risk factors for deaths and disease burden were high blood pressure (17·4% 94 314 of 541 228 of total deaths, 7·8% 958 512 of 12 268 460 of total DALYs), tobacco smoking (6·2% 33 695 of 541 228 of total deaths, 4·1% 499 396 of 12 268 460 of total DALYs), and low fruit and vegetable intake (6·3% 33 951 of 541 228 of total deaths, 4·2% 513 327 of 12 268 460 of total DALYs). Lifestyle risk factors—physical inactivity, tobacco smoking, alcohol consumption, and low fruit and vegetable intake—together accounted for 16·6% 90 064 of 541 228 of total deaths and 11·2% 1 378 115 of 12 268 460 of total DALYs, while two environmental risk factors—unsafe water and sanitation and air pollution—were responsible for 1·1% 5954 of 541 228 of total deaths and 0·7% 90 979 of 12 268 460 of total DALYs in Vietnam. Interpretation Vietnam is moving fast in the epidemiological transition whereby lifestyle risk factors play a significant role in non-communicable diseases. Our work provides the first empirical evidence of how risk factors contributed to disease burden in Vietnam, which can aid priority setting and preventive efforts. Funding The Atlantic Philanthropies.
Abstract Background Global Burden of Diseases, Injuries, and Risk Factors Study 2010 results show continued limitations of data quality and availability in most of the African region. Focused efforts ...in South Africa, however, have contributed to improved completeness and availability of mortality data, such that South Africa is currently undertaking a second National Burden of Disease Study. Mortality estimates have been developed nationally and for the nine provinces for 1997–2009. Methods Vital registration data obtained for 1997–2009 were adjusted for completeness using indirect demographic techniques. A regression approach was used to identify misclassified AIDS deaths, and garbage codes were proportionally redistributed by age, sex, and population group. Injury deaths were estimated from additional data sources. Age-standardised mortality rate (ASMR) trends for the nine provinces were calculated using ASSA 2008 population estimates and the WHO age standard. Findings All-cause mortality peaked in 2006 and thereafter started to decline. ASMRs showed a two-fold difference between the highest-affected and lowest-affected provinces for the 1997–2009 period. ASMR from HIV/AIDS increased threefold since 1997 with provincial variation, while mortality from non-HIV-related tuberculosis declined. Mortality rates from non-communicable diseases decreased over the period nationally but increased for some provinces and remained stable for others as a result of differing trends in hypertensive heart disease and respiratory diseases. Nationally, preliminary analyses for 2009 show that HIV/AIDS was responsible for the highest number of deaths (31·2%; n=194 322 of 622 300 deaths), followed by cerebrovascular disease (6·2%; n=38 666), tuberculosis (5·4%; n=33 375), lower respiratory infections (5·2%; n=32 568), and ischaemic heart disease (4·4%; n=27 688). However, tuberculosis and interpersonal violence ranked among the top five causes for males, while hypertensive heart disease and ischaemic heart disease featured for females. Interpretation The downward trend in HIV/AIDS mortality can be attributed to the extensive antiretroviral treatment rollout since 2005. Differential provincial mortality trends reflect the different stages of epidemiological transition and differential health services in the provinces, providing relevant information for policy makers to address inequalities. Funding South African Medical Research Council.
Summary Background China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. ...Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. Methods Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. Findings All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4·0 years in Hebei province to 14·2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0–14, 15–49, and 50–74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. Interpretation Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. Funding China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.
Summary Background The UK has had universal free health care and public health programmes for more than six decades. Several policy initiatives and structural reforms of the health system have been ...undertaken. Health expenditure has increased substantially since 1990, albeit from relatively low levels compared with other countries. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to examine the patterns of health loss in the UK, the leading preventable risks that explain some of these patterns, and how UK outcomes compare with a set of comparable countries in the European Union and elsewhere in 1990 and 2010. Methods We used results of GBD 2010 for 1990 and 2010 for the UK and 18 other comparator nations (the original 15 members of the European Union, Australia, Canada, Norway, and the USA; henceforth EU15+). We present analyses of trends and relative performance for mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 259 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to the UK. We assessed the UK's rank for age-standardised YLLs and DALYs for their leading causes compared with EU15+ in 1990 and 2010. We estimated 95% uncertainty intervals (UIs) for all measures. Findings For both mortality and disability, overall health has improved substantially in absolute terms in the UK from 1990 to 2010. Life expectancy in the UK increased by 4·2 years (95% UI 4·2–4·3) from 1990 to 2010. However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates, and life expectancy in 1990, and its relative position had worsened by 2010. Although in most age groups, there have been reductions in age-specific mortality, for men aged 30–34 years, mortality rates have hardly changed (reduction of 3·7%, 95% UI 2·7–4·9). In terms of premature mortality, worsening ranks are most notable for men and women aged 20–54 years. For all age groups, the contributions of Alzheimer's disease (increase of 137%, 16–277), cirrhosis (65%, −15 to 107), and drug use disorders (577%, 71–942) to premature mortality rose from 1990 to 2010. In 2010, compared with EU15+, the UK had significantly lower rates of age-standardised YLLs for road injury, diabetes, liver cancer, and chronic kidney disease, but significantly greater rates for ischaemic heart disease, chronic obstructive pulmonary disease, lower respiratory infections, breast cancer, other cardiovascular and circulatory disorders, oesophageal cancer, preterm birth complications, congenital anomalies, and aortic aneurysm. Because YLDs per person by age and sex have not changed substantially from 1990 to 2010 but age-specific mortality has been falling, the importance of chronic disability is rising. The major causes of YLDs in 2010 were mental and behavioural disorders (including substance abuse; 21·5% 95 UI 17·2–26·3 of YLDs), and musculoskeletal disorders (30·5% 25·5–35·7). The leading risk factor in the UK was tobacco (11·8% 10·5–13·3 of DALYs), followed by increased blood pressure (9·0 % 7·5–10·5), and high body-mass index (8·6% 7·4–9·8). Diet and physical inactivity accounted for 14·3% (95% UI 12·8–15·9) of UK DALYs in 2010. Interpretation The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action. Further progress in premature mortality from several major causes, such as cardiovascular diseases and cancers, will probably require improved public health, prevention, early intervention, and treatment activities. The growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response. Funding Bill & Melinda Gates Foundation.
Summary Background The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of ...death data for 1997–2012 and develop national, population group, and provincial estimates of the levels and causes of mortality. Method We used underlying cause of death data from death notifications for 1997–2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white European descent, and coloured of mixed ancestry according to the preceding categories). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison. Findings All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence. Interpretation This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data. Funding South African Medical Research Council's Flagships Awards Project.
Summary Background With recent improvements in vaccines and treatments against viral hepatitis, an improved understanding of the burden of viral hepatitis is needed to inform global intervention ...strategies. We used data from the Global Burden of Disease (GBD) Study to estimate morbidity and mortality for acute viral hepatitis, and for cirrhosis and liver cancer caused by viral hepatitis, by age, sex, and country from 1990 to 2013. Methods We estimated mortality using natural history models for acute hepatitis infections and GBD's cause-of-death ensemble model for cirrhosis and liver cancer. We used meta-regression to estimate total cirrhosis and total liver cancer prevalence, as well as the proportion of cirrhosis and liver cancer attributable to each cause. We then estimated cause-specific prevalence as the product of the total prevalence and the proportion attributable to a specific cause. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs). Findings Between 1990 and 2013, global viral hepatitis deaths increased from 0·89 million (95% uncertainty interval UI 0·86–0·94) to 1·45 million (1·38–1·54); YLLs from 31·0 million (29·6–32·6) to 41·6 million (39·1–44·7); YLDs from 0·65 million (0·45–0·89) to 0·87 million (0·61–1·18); and DALYs from 31·7 million (30·2–33·3) to 42·5 million (39·9–45·6). In 2013, viral hepatitis was the seventh (95% UI seventh to eighth) leading cause of death worldwide, compared with tenth (tenth to 12th) in 1990. Interpretation Viral hepatitis is a leading cause of death and disability worldwide. Unlike most communicable diseases, the absolute burden and relative rank of viral hepatitis increased between 1990 and 2013. The enormous health loss attributable to viral hepatitis, and the availability of effective vaccines and treatments, suggests an important opportunity to improve public health. Funding Bill & Melinda Gates Foundation.
Summary Background Young people's health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people's health have the potential to undermine future ...population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10–24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. Methods The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. Findings The leading causes of death in 2013 for young people aged 10–14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15–19 years (14·2%) and 20–24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20–24 years (17·1%) and the fourth highest for girls aged 15–19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15–19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20–24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20–24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20–24 years. Alcohol and drug use in those aged 10–24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. Interpretation Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people's health risk factors and their determinants in health information systems. Funding Bill & Melinda Gates Foundation.
Summary Background Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which ...decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time. Methods We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors. Findings From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1–3·8), from 72·1 years (71·8–72·3) to 75·5 years (75·3–75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9–14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6–23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013. Interpretation Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state. Funding Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.
Summary Background Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus. ...Methods We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked. Findings There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0·1–0·3 years for men and 0·1–0·4 years for women). For net harm to occur, 14–25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14–25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. Interpretation Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.
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