22 research outputs found
Undernutrition and associated factors among adults with mental and neurological disorders in public health hospitals, Eastern Ethiopia, 2019: a cross-sectional study
No full textAbstract Background Poor nutritional status can be consequence of impaired mental health that may lead to involuntary weight gain, weight loss, or deficiency of essential nutrients. However, little has been documented about the nutritional status of adults with mental disorders and the contributing factors in low-income countries like Ethiopia. The aim of this study was to assess the magnitude of undernutrition and associated factors among adults with mental disorders in public hospitals of Eastern Ethiopia. Methods Institution-based, cross-sectional study was conducted among 507 adults with mental disorders from March 1, 2019 to April 1, 2019. Interviewer administered pretested structured questionnaire was used to collect data. Anthropometric data were collected using calibrated weighing scale and height measuring board. Descriptive statistics was computed to describe the data. Bivariable and multivariable logistic regression analyses were applied to identify factors associated with the undernutrition. Odds ratio alongside 95% confidence interval (CI) were estimated to measure the strength of the association. Level of statistical significance was declared at p-value less than 0.05. Results Undernutrition affected 62.7%; 95% CI: (58.3%, 67.7%) of the patients. Undernutrition was associated with meal frequency < 3 per day (adjusted odds ratio [(AOR = 2.07, 95% CI: (1.18, 3.63)], use of multiple medication (adjusted odds ratio [(AOR = 3.02, 95% CI: (1.88, 4.84)], being non-smoker [(AOR = 0.50, 95%CI: (0.25, 0.91)], and use of prescribed diet [(AOR = 0.45, 95%CI: (0.26, 0.78)]. Conclusions The magnitude of undernutrition was high among the study participants. Multiple medication, cigarette smoking, frequency of meal and taking prescribed diet were significantly associated with undernutrition. Nutrition education for patients with mental disorders and their caregivers about the impact of taking multiple medication and substance use needs to be emphasized alongside nutritional screening and support to improve their nutritional status
Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021
No full textBackground: accurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. Methods: to estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. Findings: during the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. Interpretation: fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world. Funding: Bill & Melinda Gates Foundation.</p
Global Fertility in 204 Countries and Territories, 1950–2021, with Forecasts to 2100: A Comprehensive Demographic Analysis for the Global Burden of Disease Study 2021
No full textBackground
Accurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.
Methods
To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.
Findings
During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world\u27s livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. Interpretation: Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.
Funding
Bill & Melinda Gates Foundation
Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021
No full textBackground: Accurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. Methods: To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. Findings: During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. Interpretation: Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world. Funding: Bill & Melinda Gates Foundation
Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
No full textBackground: Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. Methods: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. Findings: The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. Interpretation: Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. Funding: Bill & Melinda Gates Foundation
Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
No full textBackground: Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.
Methods: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.
Findings: The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.
Interpretation: Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.publishedVersio
Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021
No full textBackground
Accurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.
Methods
To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.
Findings
During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.
Interpretation
Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.publishedVersio
Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100 : a comprehensive demographic analysis for the Global Burden of Disease Study 2021
No full textNatalia V Bhattacharjee, Austin E Schumacher, Amirali Aali, Yohannes Habtegiorgis Abate, Rouzbeh Abbasgholizadeh, Mohammadreza Abbasian, Mohsen Abbasi-Kangevari, Hedayat Abbastabar, Samar Abd ElHafeez, Sherief Abd-Elsalam, Mohammad Abdollahi, Mohammad-Amin Abdollahifar, Meriem Abdoun, Auwal Abdullahi, Mesfin Abebe, Samrawit Shawel Abebe, Olumide Abiodun, Hassan Abolhassani, Meysam Abolmaali, Mohamed Abouzid, Girma Beressa Aboye, Lucas Guimarães Abreu, Woldu Aberhe Abrha, Michael R M Abrigo, Dariush Abtahi, Hasan Abualruz, Bilyaminu Abubakar, Eman Abu-Gharbieh, Niveen ME Abu-Rmeileh, Tadele Girum Girum Adal, Mesafint Molla Adane, Oluwafemi Atanda Adeagbo Adeagbo, Rufus Adesoji Adedoyin, Victor Adekanmbi, Bashir Aden, Abiola Victor Adepoju, Olatunji O Adetokunboh, Juliana Bunmi Adetunji, Daniel Adedayo Adeyinka, Olorunsola Israel Adeyomoye, Qorinah Estiningtyas Sakilah Adnani, Saryia Adra, Rotimi Felix Afolabi, Shadi Afyouni, Muhammad Sohail Afzal, Saira Afzal, Shahin Aghamiri, Antonella Agodi, Williams Agyemang-Duah, Bright Opoku Ahinkorah, Austin J Ahlstrom, Aqeel Ahmad, Danish Ahmad, Firdos Ahmad, Muayyad M Ahmad, Sajjad Ahmad, Tauseef Ahmad, Ali Ahmed, Ayman Ahmed, Haroon Ahmed, Luai A Ahmed, Meqdad Saleh Ahmed, Syed Anees Ahmed, Marjan Ajami, Budi Aji, Gizachew Taddesse Akalu, Hossein Akbarialiabad, Rufus Olusola Akinyemi, Mohammed Ahmed Akkaif, Sreelatha Akkala, Hanadi Al Hamad, Syed Mahfuz Al Hasan, Mohammad Al Qadire, Tareq Mohammed Ali AL-Ahdal, Samer O Alalalmeh, Tariq A Alalwan, Ziyad Al-Aly, Khurshid Alam, Rasmieh Mustafa Al-amer, Fahad Mashhour Alanezi, Turki M Alanzi, Almaza Albakri, Mohammed Albashtawy, Mohammad T AlBataineh, Hediyeh Alemi, Sharifullah Alemi, Yihun Mulugeta Alemu, Ayman Al-Eyadhy, Adel Ali Saeed Al-Gheethi, Khalid F Alhabib, Noora Alhajri, Fadwa Alhalaiqa Naji Alhalaiqa, Robert Kaba Alhassan, Abid Ali, Beriwan Abdulqadir Ali, Liaqat Ali, Mohammed Usman Ali, Rafat Ali, Syed Shujait Shujait Ali, Sheikh Mohammad Alif, 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Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
No full textRegular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.Research reported in this publication was supported by the Bill & Melinda Gates Foundation; Queensland Department of Health, Australia; UK Department of Health and Social Care; the Norwegian Institute of Public Health; St Jude Children’s Research Hospital; and the New Zealand Ministry of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. The Palestinian Central Bureau of Statistics granted the researchers access to relevant data in accordance with license number SLN2014-3-170, after subjecting data to processing aiming to preserve the confidentiality of individual data in accordance with the General Statistics Law–2000. The researchers are solely responsible for the conclusions and inferences drawn upon available data. Collection of these data was made possible by USAID under the terms of cooperative agreement GPO-A-00-08-000_D3-00.Peer ReviewedArticle signat per 2000 autors/es: Mohsen Naghavi , Kanyin Liane Ong , Amirali Aali , Hazim S Ababneh , Yohannes Habtegiorgis Abate , Cristiana Abbafati , Rouzbeh Abbasgholizadeh , Mohammadreza Abbasian , Mohsen Abbasi-Kangevari , Hedayat Abbastabar , Samar Abd ElHafeez , Michael Abdelmasseh , Sherief Abd-Elsalam , Ahmed Abdelwahab , Mohammad Abdollahi , Mohammad-Amin Abdollahifar , Meriem Abdoun , Deldar Morad Abdulah , Auwal Abdullahi , Mesfin Abebe , Samrawit Shawel Abebe , Aidin Abedi , Kedir Hussein Abegaz , E S Abhilash , Hassan Abidi , Olumide Abiodun , Richard Gyan Aboagye , Hassan Abolhassani , Meysam Abolmaali , Mohamed Abouzid , Girma Beressa Aboye , Lucas Guimarães Abreu , Woldu Aberhe Abrha , Dariush Abtahi , Samir Abu Rumeileh , Hasan Abualruz , Bilyaminu Abubakar , Eman Abu-Gharbieh , Niveen ME Abu-Rmeileh , Salahdein Aburuz , Ahmed Abu-Zaid , Manfred Mario Kokou Accrombessi , Tadele Girum Adal , Abdu A Adamu , Isaac Yeboah Addo , Giovanni Addolorato , Akindele Olupelumi Adebiyi , Victor Adekanmbi , Abiola Victor Adepoju , Charles Oluwaseun Adetunji , Juliana Bunmi Adetunji , Temitayo Esther Adeyeoluwa , Daniel Adedayo Adeyinka , Olorunsola Israel Adeyomoye , Biruk Adie Adie Admass , Qorinah Estiningtyas Sakilah Adnani , Saryia Adra , Aanuoluwapo Adeyimika Afolabi , Muhammad Sohail Afzal , Saira Afzal , Suneth Buddhika Agampodi , Pradyumna Agasthi , Manik Aggarwal , Shahin Aghamiri , Feleke Doyore Agide , Antonella Agodi , Anurag Agrawal , Williams Agyemang-Duah , Bright Opoku Ahinkorah , Aqeel Ahmad , Danish Ahmad , Firdos Ahmad , Muayyad M Ahmad , Sajjad Ahmad , Shahzaib Ahmad , Tauseef Ahmad , Keivan Ahmadi , Amir Mahmoud Ahmadzade , Ali Ahmed , Ayman Ahmed , Haroon Ahmed , Luai A Ahmed , Mehrunnisha Sharif Ahmed , Meqdad Saleh Ahmed , Muktar Beshir Ahmed , Syed Anees Ahmed , Marjan Ajami , Budi Aji , Essona Matatom Akara , Hossein Akbarialiabad , Karolina Akinosoglou , Tomi Akinyemiju , Mohammed Ahmed Akkaif , Samuel Akyirem , Hanadi Al Hamad , Syed Mahfuz Al Hasan , Fares Alahdab , Samer O Alalalmeh , Tariq A Alalwan , Ziyad Al-Aly , Khurshid Alam , Manjurul Alam , Noore Alam , Rasmieh Mustafa Al-amer , Fahad Mashhour Alanezi , Turki M Alanzi , Sayer Al-Azzam , Almaza Albakri , Mohammed Albashtawy , Mohammad T AlBataineh , Jacqueline Elizabeth Alcalde-Rabanal , Khalifah A Aldawsari , Wafa A Aldhaleei , Robert W Aldridge , Haileselasie Berhane Alema , Mulubirhan Assefa Alemayohu , Sharifullah Alemi , Yihun Mulugeta Alemu , Adel Ali Saeed Al-Gheethi , Khalid F Alhabib , Fadwa Alhalaiqa Naji Alhalaiqa , Mohammed Khaled Al-Hanawi , Abid Ali , Amjad Ali , Liaqat Ali , Mohammed Usman Ali , Rafat Ali , Shahid Ali , Syed Shujait Shujait Ali , Gianfranco Alicandro , Sheikh Mohammad Alif , Reyhaneh Alikhani , Yousef Alimohamadi , Ahmednur Adem Aliyi , Mohammad A M Aljasir , Syed Mohamed Aljunid , François Alla , Peter Allebeck , Sabah Al-Marwani , Sadeq Ali Ali Al-Maweri , Joseph Uy Almazan , Hesham M Al-Mekhlafi , Louay Almidani , Omar Almidani , Mahmoud A Alomari , Basem Al-Omari , Jordi Alonso , Jaber S Alqahtani , Shehabaldin Alqalyoobi , Ahmed Yaseen Alqutaibi , Salman Khalifah Al-Sabah , Zaid Altaany , Awais Altaf , Jaffar A Al-Tawfiq , Khalid A Altirkawi , Deborah Oyine Aluh , Nelson Alvis-Guzman , Hassan Alwafi , Yaser Mohammed Al-Worafi , Hany Aly , Safwat Aly , Karem H Alzoubi , Reza Amani , Azmeraw T Amare , Prince M Amegbor , Edward Kwabena Ameyaw , Tarek Tawfik Amin , Alireza Amindarolzarbi , Sohrab Amiri , Mohammad Hosein Amirzade-Iranaq , Hubert Amu , Dickson A Amugsi , Ganiyu Adeniyi Amusa , Robert Ancuceanu , Deanna Anderlini , David B Anderson , Pedro Prata Andrade , Catalina Liliana Andrei , Tudorel Andrei , Colin Angus , Abhishek Anil , Sneha Anil , Amir Anoushiravani , Hossein Ansari , Ansariadi Ansariadi , Alireza Ansari-Moghaddam , Catherine M Antony , Ernoiz Antriyandarti , Davood Anvari , Saeid Anvari , Saleha Anwar , Sumadi Lukman Anwar , Razique Anwer , Anayochukwu Edward Anyasodor , Muhammad Aqeel , Juan Pablo Arab , Jalal Arabloo , Mosab Arafat , Aleksandr Y Aravkin , Demelash Areda , Abdulfatai Aremu , Olatunde Aremu , Hany Ariffin , Mesay Arkew , Benedetta Armocida , Michael Benjamin Arndt , Johan Ärnlöv , Mahwish Arooj , Anton A Artamonov , Judie Arulappan , Raphael Taiwo Aruleba , Ashokan Arumugam , Malke Asaad , Mohsen Asadi-Lari , Akeza Awealom Asgedom , Mona Asghariahmadabad , Mohammad Asghari-Jafarabadi , Muhammad Ashraf , Armin Aslani , Thomas Astell-Burt , Mohammad Athar , Seyyed Shamsadin Athari , Bantalem Tilaye Tilaye Atinafu , Habtamu Wondmagegn Atlaw , Prince Atorkey , Maha Moh'd Wahbi Atout , Alok Atreya , Avinash Aujayeb , Marcel Ausloos , Abolfazl Avan , Atalel Fentahun Awedew , Amlaku Mulat Aweke , Beatriz Paulina Ayala Quintanilla , Haleh Ayatollahi , Jose L Ayuso-Mateos , Seyed Mohammad Ayyoubzadeh , Sina Azadnajafabad , Rui M S Azevedo , Ahmed Y Azzam , Darshan B B , Abraham Samuel Babu , Muhammad Badar , Ashish D Badiye , Soroush Baghdadi , Nasser Bagheri , Sara Bagherieh , Sulaiman Bah , Saeed Bahadorikhalili , Najmeh Bahmanziari , Ruhai Bai , Atif Amin Baig , Jennifer L Baker , Abdulaziz T Bako , Ravleen Kaur Bakshi , Senthilkumar Balakrishnan , Madhan Balasubramanian , Ovidiu Constantin Baltatu , Kiran Bam , Maciej Banach , Soham Bandyopadhyay , Palash Chandra Banik , Hansi Bansal , Kannu Bansal , Franca Barbic , Martina Barchitta , Mainak Bardhan , Erfan Bardideh , Suzanne Lyn Barker-Collo , Till Winfried Bärnighausen , Francesco Barone-Adesi , Hiba Jawdat Barqawi , Lope H Barrero , Amadou Barrow , Sandra Barteit , Lingkan Barua , Zarrin Basharat , Azadeh Bashiri , Afisu Basiru , Pritish Baskaran , Buddha Basnyat , Quique Bassat , João Diogo Basso , Ann V L Basting , Sanjay Basu , Kavita Batra , Bernhard T Baune , Mohsen Bayati , Nebiyou Simegnew Bayileyegn , Thomas Beaney , Neeraj Bedi , Massimiliano Beghi , Emad Behboudi , Priyamadhaba Behera , Amir Hossein Behnoush , Masoud Behzadifar , Maryam Beiranvand , Diana Fernanda Bejarano Ramirez , Yannick Béjot , Sefealem Assefa Belay , Chalie Mulu Belete , Michelle L Bell , Muhammad Bashir Bello , Olorunjuwon Omolaja Bello , Luis Belo , Apostolos Beloukas , Rose Grace Bender , Isabela M Bensenor , Azizullah Beran , Zombor Berezvai , Alemshet Yirga Berhie , Betyna N Berice , Robert S Bernstein , Gregory J Bertolacci , Paulo J G Bettencourt , Kebede A Beyene , Devidas S Bhagat , Akshaya Srikanth Bhagavathula , Neeraj Bhala , Ashish Bhalla , Dinesh Bhandari , Kayleigh Bhangdia , Nikha Bhardwaj , Pankaj Bhardwaj , Prarthna V Bhardwaj , Ashish Bhargava , Sonu Bhaskar , Vivek Bhat , Gurjit Kaur Bhatti , Jasvinder Singh Bhatti , Manpreet S Bhatti , Rajbir Bhatti , Zulfiqar A Bhutta , Boris Bikbov , Jessica Devin Bishai , Catherine Bisignano , Francesca Bisulli , Atanu Biswas , Bijit Biswas , Saeid Bitaraf , Bikes Destaw Bitew , Veera R Bitra , Tone Bjørge , Micheal Kofi Boachie , Mary Sefa Boampong , Anca Vasilica Bobirca , Virginia Bodolica , Aadam Olalekan Bodunrin , Eyob Ketema Bogale , Kassawmar Angaw Bogale , Somayeh Bohlouli , Obasanjo Afolabi Bolarinwa , Archith Boloor , Milad Bonakdar Hashemi , Aime Bonny , Kaustubh Bora , Berrak Bora Basara , Hamed Borhany , Arturo Borzutzky , Souad Bouaoud , Antoine Boustany , Christopher Boxe , Edward J Boyko , Oliver J Brady , Dejana Braithwaite , Luisa C Brant , Michael Brauer , Alexandra Brazinova , Javier Brazo-Sayavera , Nicholas J K Breitborde , Susanne Breitner , Hermann Brenner , Andrey Nikolaevich Briko , Nikolay Ivanovich Briko , Gabrielle Britton , Julie Brown , Traolach Brugha , Norma B Bulamu , Lemma N Bulto , Danilo Buonsenso , Richard A Burns , Reinhard Busse , Yasser Bustanji , Nadeem Shafique Butt , Zahid A Butt , Florentino Luciano Caetano dos Santos , Daniela Calina , Luis Alberto Cámera , Luciana Aparecida Campos , Ismael R Campos-Nonato , Chao Cao , Yin Cao , Angelo Capodici , Rosario Cárdenas , Sinclair Carr , Giulia Carreras , Juan J Carrero , Andrea Carugno , Cristina G Carvalheiro , Felix Carvalho , Márcia Carvalho , Joao Mauricio Castaldelli-Maia , Carlos A Castañeda-Orjuela , Giulio Castelpietra , Ferrán Catalá-López , Alberico L Catapano , Maria Sofia Cattaruzza , Christopher R Cederroth , Luca Cegolon , Francieli Cembranel , Muthia Cenderadewi , Kelly M Cercy , Ester Cerin , Muge Cevik , Joshua Chadwick , Yaacoub Chahine , Chiranjib Chakraborty , Promit Ananyo Chakraborty , Jeffrey Shi Kai Chan , Raymond N C Chan , Rama Mohan Chandika , Eeshwar K Chandrasekar , Chin-Kuo Chang , Jung-Chen Chang , Gashaw Sisay Chanie , Periklis Charalampous , Vijay Kumar Chattu , Pankaj Chaturvedi , Victoria Chatzimavridou-Grigoriadou , Akhilanand Chaurasia , Angela W Chen , An-Tian Chen , Catherine S Chen , Haowei Chen , Meng Xuan Chen , Simiao Chen , Ching-Yu Cheng , Esther T W Cheng , Nicolas Cherbuin , Wondimye Ashenafi Cheru , Ju-Huei Chien , Odgerel Chimed-Ochir , Ritesh Chimoriya , Patrick R Ching , Jesus Lorenzo Chirinos-Caceres , Abdulaal Chitheer , William C S Cho , Bryan Chong , Hitesh Chopra , Sonali Gajanan Choudhari , Rajiv Chowdhury , Devasahayam J Christopher , Isaac Sunday Chukwu , Eric Chung , Erin Chung , Eunice Chung , Sheng-Chia Chung , Muhammad Chutiyami , Zinhle Cindi , Iolanda Cioffi , Mareli M Claassens , Rafael M Claro , Kaleb Coberly , Rebecca M Cogen , Alyssa Columbus , Haley Comfort , Joao Conde , Samuele Cortese , Paolo Angelo Cortesi , Vera Marisa Costa , Simona Costanzo , Ewerton Cousin , Rosa A S Couto , Richard G Cowden , Kenneth Michael Cramer , Michael H Criqui , Natália Cruz-Martins , Silvia Magali Cuadra-Hernández , Garland T Culbreth , Patricia Cullen , Matthew Cunningham , Maria paula Curado , Sriharsha Dadana , Omid Dadras , Siyu Dai , Xiaochen Dai , Zhaoli Dai , Lachlan L Dalli , Giovanni Damiani , Jiregna Darega Gela , Jai K Das , Saswati Das , Subasish Das , Ana Maria Dascalu , Nihar Ranjan Dash , Mohsen Dashti , Anna Dastiridou , Gail Davey , Claudio Alberto Dávila-Cervantes , Nicole Davis Weaver , Kairat Davletov , Diego De Leo , Katie de Luca , Aklilu Tamire Debele , Shayom Debopadhaya , Louisa Degenhardt , Azizallah Dehghan , Lee Deitesfeld , Cristian Del Bo' , Ivan Delgado-Enciso , Berecha Hundessa Demessa , Andreas K Demetriades , Ke Deng , Xinlei Deng , Edgar Denova-Gutiérrez , Niloofar Deravi , Nebiyu Dereje , Nikolaos Dervenis , Emina Dervišević , Don C Des Jarlais , Hardik Dineshbhai Desai , Rupak Desai , Vinoth Gnana Chellaiyan Devanbu , Syed Masudur Rahman Dewan , Arkadeep Dhali , Kuldeep Dhama , Meghnath Dhimal , Sameer Dhingra , Vishal R Dhulipala , Diana Dias da Silva , Daniel Diaz , Michael J Diaz , Adriana Dima , Delaney D Ding , Huanghe Ding , Ricardo Jorge Dinis-Oliveira , M Ashworth Dirac , Shirin Djalalinia , Thao Huynh Phuong Do , Camila Bruneli do Prado , Saeid Doaei , Masoud Dodangeh , Milad Dodangeh , Sushil Dohare , Klara Georgieva Dokova , Christiane Dolecek , Regina-Mae Villanueva Dominguez , Wanyue Dong , Deepa Dongarwar , Mario D'Oria , Fariba Dorostkar , E Ray Dorsey , Wendel Mombaque dos Santos , Rajkumar Doshi , Leila Doshmangir , Robert Kokou Dowou , Tim Robert Driscoll , Haneil Larson Dsouza , Viola Dsouza , Mi Du , John Dube , Bruce B Duncan , Andre Rodrigues Duraes , Senbagam Duraisamy , Oyewole Christopher Durojaiye , Laura Dwyer-Lindgren , Paulina Agnieszka Dzianach , Arkadiusz Marian Dziedzic , Abdel Rahman E'mar , Ejemai Eboreime , Alireza Ebrahimi , Chidiebere Peter Echieh , Hisham Atan Edinur , David Edvardsson , Kristina Edvardsson , Defi Efendi , Ferry Efendi , Diyan Ermawan Effendi , Terje Andreas Eikemo , Ebrahim Eini , Michael Ekholuenetale , Temitope Cyrus Ekundayo , Iman El Sayed , Iffat Elbarazi , Teshome Bekele Elema , Noha Mousaad Elemam , Frank J Elgar , Islam Y Elgendy , Ghada Metwally Tawfik ElGohary , Hala Rashad Elhabashy , Muhammed Elhadi , Waseem El-Huneidi , Legesse Tesfaye Elilo , Omar Abdelsadek Abdou Elmeligy , Mohamed A Elmonem , Mohammed Elshaer , Ibrahim Elsohaby , Theophilus I Emeto , Luchuo Engelbert Bain , Ryenchindorj Erkhembayar , Christopher Imokhuede Esezobor , Babak Eshrati , Sharareh Eskandarieh , Juan Espinosa-Montero , Habtamu Esubalew , Farshid Etaee , Natalia Fabin , Adewale Oluwaseun Fadaka , Adeniyi Francis Fagbamigbe , Ayesha Fahim , Saman Fahimi , Aliasghar Fakhri-Demeshghieh , Luca Falzone , Mohammad Fareed , Carla Sofia e Sá Farinha , MoezAlIslam Ezzat Mahmoud Faris , Pawan Sirwan Faris , Andre Faro , Abidemi Omolara Fasanmi , Ali Fatehizadeh , Hamed Fattahi , Nelsensius Klau Fauk , Pooria Fazeli , Valery L Feigin , Alireza Feizkhah , Ginenus Fekadu , Xiaoru Feng , Seyed-Mohammad Fereshtehnejad , Abdullah Hamid Feroze , Daniela Ferrante , Alize J Ferrari , Nuno Ferreira , Getahun Fetensa , Bikila Regassa Feyisa , Irina Filip , Florian Fischer , Joanne Flavel , David Flood , Bobirca Teodor Florin , Nataliya A Foigt , Morenike Oluwatoyin Folayan , Artem Alekseevich Fomenkov , Behzad Foroutan , Masoud Foroutan , Ingeborg Forthun , Daniela Fortuna , Matteo Foschi , Kayode Raphael Fowobaje , Kate Louise Francis , Richard Charles Franklin , Alberto Freitas , Joseph Friedman , Sara D Friedman , Takeshi Fukumoto , John E Fuller , Blima Fux , Peter Andras Gaal , Muktar A Gadanya , Abhay Motiramji Gaidhane , Santosh Gaihre , Emmanuela Gakidou , Yaseen Galali , Natalie C Galles , Silvano Gallus , Mandukhai Ganbat , Aravind P Gandhi , Balasankar Ganesan , Mohammad Arfat Ganiyani , MA Garcia-Gordillo , William M Gardner , Jalaj Garg , Naval Garg , Rupesh K Gautam , Semiu Olatunde Gbadamosi , Tilaye Gebru Gebi , Miglas W Gebregergis , Mesfin Gebrehiwot , Teferi Gebru Gebremeskel , Simona Roxana Georgescu , Tamirat Getachew , Peter W Gething , Molla Getie , Keyghobad Ghadiri , Sulmaz Ghahramani , Khalid Yaser Ghailan , Mohammad-Reza Ghasemi , Ghazal Ghasempour Dabaghi , Afsaneh Ghasemzadeh , Ahmad Ghashghaee , Fariba Ghassemi , Ramy Mohamed Ghazy , Ajnish Ghimire , Sama Ghoba , Maryam Gholamalizadeh , Asadollah Gholamian , Ali Gholamrezanezhad , Nasim Gholizadeh , Mahsa Ghorbani , Pooyan Ghorbani Vajargah , Aloke Gopal Ghoshal , Paramjit Singh Gill , Tiffany K Gill , Richard F Gillum , Themba G Ginindza , Alem Girmay , James C Glasbey , Elena V Gnedovskaya , Laszlo Göbölös , Myron Anthony Godinho , Amit Goel , Ali Golchin , Mohamad Goldust , Mahaveer Golechha , Pouya Goleij , Nelson G M Gomes , Philimon N Gona , Sameer Vali Gopalani , Giuseppe Gorini , Houman Goudarzi , Alessandra C Goulart , Bárbara Niegia Garcia Goulart , Anmol Goyal , Ayman Grada , Simon Matthew Graham , Michal Grivna , Giuseppe Grosso , Shi-Yang Guan , Giovanni Guarducci , Mohammed Ibrahim Mohialdeen Gubari , Mesay Dechasa Gudeta , Avirup Guha , Stefano Guicciardi , Rafael Alves Guimarães , Snigdha Gulati , Damitha Asanga Gunawardane , Sasidhar Gunturu , Cui Guo , Anish Kumar Gupta , Bhawna Gupta , Manoj Kumar Gupta , Mohak Gupta , Rajat Das Gupta , Rajeev Gupta , Sapna Gupta , Veer Bala Gupta , Vijai Kumar Gupta , Vivek Kumar Gupta , Lami Gurmessa , Reyna Alma Gutiérrez , Farrokh Habibzadeh , Parham Habibzadeh , Rasool Haddadi , Mostafa Hadei , Najah R Hadi , Nils Haep , Nima Hafezi-Nejad , Alemayehu Hailu , Arvin Haj-Mirzaian , Esam S Halboub , Brian J Hall , Sebastian Haller , Rabih Halwani , Randah R Hamadeh , Sajid Hameed , Samer Hamidi , Erin B Hamilton , Chieh Han , Qiuxia Han , Asif Hanif , Nasrin Hanifi , Graeme J Hankey , Fahad Hanna , Md Abdul Hannan , Md Nuruzzaman Haque , Harapan Harapan , Arief Hargono , Josep Maria Haro , Ahmed I Hasaballah , Ikramul Hasan , M Tasdik Hasan , Hamidreza Hasani , Mohammad Hasanian , Abdiwahab Hashi , Md Saquib Hasnain , Ikrama Hassan , Soheil Hassanipour , Hadi Hassankhani , Johannes Haubold , Rasmus J Havmoeller , Simon I Hay , Jiawei He , Jeffrey J Hebert , Omar E Hegazi , Golnaz Heidari , Mohammad Heidari , Mahsa Heidari-Foroozan , Bartosz Helfer , Delia Hendrie , Brenda Yuliana Herrera-Serna , Claudiu Herteliu , Hamed Hesami , Kamal Hezam , Catherine L Hill , Yuta Hiraike , Ramesh Holla , Nobuyuki Horita , Md Mahbub Hossain , Sahadat Hossain , Mohammad-Salar Hosseini , Hassan Hosseinzadeh , Mehdi Hosseinzadeh , Ahmad Hosseinzadeh Adli , Mihaela Hostiuc , Sorin Hostiuc , Mohamed Hsairi , Vivian Chia-rong Hsieh , Rebecca L Hsu , Chengxi Hu , Junjie Huang , Michael Hultström , Ayesha Humayun , Tsegaye Gebreyes Hundie , Javid Hussain , M Azhar Hussain , Nawfal R Hussein , Foziya Mohammed Hussien , Hong-Han Huynh , Bing-Fang Hwang , Segun Emmanuel Ibitoye , Khalid S Ibrahim , Pulwasha Maria Iftikhar , Desta Ijo , Adalia I Ikiroma , Kevin S Ikuta , Paul Chukwudi Ikwegbue , Olayinka Stephen Ilesanmi , Irena M Ilic , Milena D Ilic , Mohammad Tarique Imam , Mustapha Immurana , Sumant Inamdar , Endang Indriasih , Muhammad Iqhrammullah , Arnaud Iradukunda , Kenneth Chukwuemeka Iregbu , Md Rabiul Islam , Sheikh Mohammed Shariful Islam , Farhad Islami , Faisal Ismail , Nahlah Elkudssiah Ismail , Hiroyasu Iso , Gaetano Isola , Masao Iwagami , Chidozie C D Iwu , Ihoghosa Osamuyi Iyamu , Mahalaxmi Iyer , Linda Merin J , Jalil Jaafari , Louis Jacob , Kathryn H Jacobsen , Farhad Jadidi-Niaragh , Morteza Jafarinia , Abdollah Jafarzadeh , Khushleen Jaggi , Kasra Jahankhani , Nader Jahanmehr , Haitham Jahrami , Nityanand Jain , Ammar Abdulrahman Jairoun , Abhishek Jaiswal , Elham Jamshidi , Mark M Janko , Abubakar Ibrahim Jatau , Sabzali Javadov , Tahereh Javaheri , Sathish Kumar Jayapal , Shubha Jayaram , Rime Jebai , Sun Ha Jee , Jayakumar Jeganathan , Anil K Jha , Ravi Prakash Jha , Heng Jiang , Yingzhao Jin , Olatunji Johnson , Mohammad Jokar , Jost B Jonas , Tamas Joo , Abel Joseph , Nitin Joseph , Charity Ehimwenma Joshua , Grace Joshy , Jacek Jerzy Jozwiak , Mikk Jürisson , Vaishali K , Billingsley Kaambwa , Ali Kabir , Zubair Kabir , Vidya Kadashetti , Dler Hussein Kadir , Rizwan Kalani , Laleh R Kalankesh , Leila R Kalankesh , Feroze Kaliyadan , Sanjay Kalra , Vineet Kumar Kamal , Sivesh Kathir Kamarajah , Rajesh Kamath , Zahra Kamiab , Naser Kamyari , Thanigaivelan Kanagasabai , Tanuj Kanchan , Himal Kandel , Arun R Kanmanthareddy , Edmund Wedam Kanmiki , Kehinde Kazeem Kanmodi , Suthanthira Kannan S , Sushil Kumar Kansal , Rami S Kantar , Neeti Kapoor , Mehrdad Karajizadeh , Shama D Karanth , Reema A Karasneh , Ibraheem M Karaye , André Karch , Asima Karim , Salah Eddin Karimi , Arman Karimi Behnagh , Faizan Zaffar Kashoo , Qalandar Hussein Abdulkarim Kasnazani , Hengameh Kasraei , Nicholas J Kassebaum , Molly B Kassel , Joonas H Kauppila , Navjot Kaur , Norito Kawakami , Gbenga A Kayode , Foad Kazemi , Sina Kazemian , Tahseen Haider Kazmi , Getu Mosisa Kebebew , Adera Debella Kebede , Fassikaw Kebede , Tibebeselassie S Keflie , Peter Njenga Keiyoro , Cathleen Keller , Jaimon Terence Kelly , John H Kempen , Jessica A Kerr , Emmanuelle Kesse-Guyot , Himanshu Khajuria , Amirmohammad Khalaji , Nauman Khalid , Anees Ahmed Khalil , Alireza Khalilian , Faham Khamesipour , Ajmal Khan , Asaduzzaman Khan , Gulfaraz Khan , Ikramullah Khan , Imteyaz A Khan , M Nuruzzaman Khan , Maseer Khan , Mohammad Jobair Khan , Moien AB Khan , Zeeshan Ali Khan , Mahammed Ziauddin Khan suheb , Shaghayegh Khanmohammadi , Khaled Khatab , Fatemeh Khatami , Haitham Khatatbeh , Moawiah Mohammad Khatatbeh , Armin Khavandegar , Hamid Reza Khayat Kashani , Feriha Fatima Khidri , Elaheh Khodadoust , Mohammad Khorgamphar , Moein Khormali , Zahra Khorrami , Ahmad Khosravi , Mohammad Ali Khosravi , Zemene Demelash Kifle , Grace Kim , Jihee Kim , Kwanghyun Kim , Min Seo Kim , Yun Jin Kim , Ruth W Kimokoti , Kasey E Kinzel , Adnan Kisa , Sezer Kisa , Desmond Klu , Ann Kristin Skrindo Knudsen , Jonathan M Kocarnik , Sonali Kochhar , Timea Kocsis , David S Q Koh , Ali-Asghar Kolahi , Kairi Kolves , Farzad Kompani , Gerbrand Koren , Soewarta Kosen , Karel Kostev , Parvaiz A Koul , Sindhura Lakshmi Koulmane Laxminarayana , Kewal Krishan , Hare Krishna , Varun Krishna , Vijay Krishnamoorthy , Yuvaraj Krishnamoorthy , Kris J Krohn , Barthelemy Kuate Defo , Burcu Kucuk Bicer , Md Abdul Kuddus , Mohammed Kuddus , Ilari Kuitunen , Mukhtar Kulimbet , Vishnutheertha Kulkarni , Akshay Kumar , Ashish Kumar , Harish Kumar , Manasi Kumar , Rakesh Kumar , Madhulata Kumari , Fantahun Tarekegn Kumie , Satyajit Kundu , Om P Kurmi , Asep Kusnali , Dian
a systematic analysis for the Global Burden of Disease Study 2021
No full textPublisher Copyright: © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. Methods: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. Findings: The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. Interpretation: Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. Funding: Bill & Melinda Gates Foundation.publishersversionpublishe
