Spatiotemporal Gaussian Process Regression Research Articles

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.

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.

National and subnational burden of leukemia and its risk factors, 1990-2019: Results from the Global Burden of Disease study 2019.

Hematologic malignancies have a great essential role in cancer global burden. Leukemia which two major subtypes based on the onset, is one of the common subtypes of this malignancy. For the GBD 2019 study, cancer registry data and vital registration system were used to estimate leukemia mortality. The Meta-Regression-Bayesian Regularized Trimmed (MR-BRT), Cause of Death Ensemble model (CODEm) and Spatiotemporal Gaussian Process Regression (ST-GPR) were used to model our data and estimate each quantity of interest. Mortality to incidence ratios (MIR) were used to generate incidence and survival from mortality rate. Prevalence and survival were used to generate years lived with disability (YLDs). Age-specific mortality and life expectancy at the same age were used to estimate years of life lost (YLLs). The sum of YLLs and YLDs generates DALYs. The total national incidence of leukemia increased from 6092 (UI 95%: 3803-8507) in 1990 to 6767 (4646-7890) new cases in 2019. However, leukemia age-standardized incidence ratio(ASIR) decreased from 11.6 (8-14.8) to 8.9 (6.2-10.3) new cases per 100,000 in this exact period. At the national level, deaths from leukemia increased 1.5-fold between 1990 and 2019, from 3287 (2284-4201) to 4424 (3137-5030), whereas the age-standardized death rate(ASDR) decreased from 8.3 (6.1-9.8) in 1990 to 6 (4.3-6.8) per 100,000 in 2019. In the study period, total leukemia DALYs decreased 12.2% and reached 162850 (110681-188806), in 2019. The age-standardized DALYs decreased 36.7% from 324.3 (224.8-413.4) in 1990 to 205.3 (140.3-237.8) in 2019. ASDR, DALYs, YLLs, and YLDs rate to high BMI was increasing while smoking and occupational exposure to benzene and formaldehyde were decreasing in the study period. This study provided a better understanding of leukemia burden and to reduce controversies of leukemia across Iran. The leukemia status alteration of the country, is trackable.

Burden of diseases attributable to excess body weight in the Middle East and North Africa region, 1990–2019

High body mass index (BMI), or excess body weight (EBW), represents a significant risk factor for a range of diseases, including cardiovascular diseases and cancers. The study sought to determine the burden of diseases attributable to EBW in the Middle East and North Africa (MENA) region from 1990 and 2019. The analysis also included an exploration of this burden by age, sex, underlying cause, and sociodemographic index (SDI). We utilized publicly available data from the Global Burden of Disease (GBD) study 2019 to identify the deaths and disability-adjusted life-years (DALYs) of diseases associated with EBW in MENA, spanning the period from 1990 to 2019. The GBD estimated the mean BMI and the prevalence of EBW using hierarchical mixed-effects regression, followed by spatiotemporal Gaussian process regression to determine the most accurate BMI distribution through comparison with actual data. In 2019, there were an estimated 538.4 thousand deaths (95% UI 369.9–712.3) and 17.9 million DALYs (12.9–23.1) attributable to EBW in the region. The DALYs attributable to EBW were higher in men (9.3 million [6.5–12.4]) than in women (8.5 million [6.4–10.8]). The age-standardized death and DALY rates for the diseases associated with EBW increased by 5.1% (− 9.0–25.9) and 8.3% (− 6.5–28.8), respectively, during the study period which was not significant. Egypt had the highest age-standardized mortality rate due to EBW (217.7 [140.0, 307.8]), while Yemen (88.6 [45.9, 143.5]) had the lowest. In 2019, the highest number of DALYs occurred among individuals aged 60 to 64 years old. Furthermore, we found a positive association between a nation's SDI and the age-standardized DALY rate linked to EBW. Cardiovascular disease emerged as the leading contributor to the EBW burden in MENA. The disease burden attributable to EBW showed a non-significant increase in MENA from 1990 to 2019.

The burden of disease attributable to indoor air pollutants in China from 2000 to 2017

High-level exposure to indoor air pollutants (IAPs) and their corresponding adverse health effects have become a public concern in China in the past 10 years. However, neither national nor provincial level burden of disease attributable to multiple IAPs has been reported for China. This is the first study to estimate and rank the annual burden of disease and the financial costs attributable to targeted residential IAPs at the national and provincial level in China from 2000 to 2017. We first did a systematic review and meta-analysis of 117 articles from 37 231 articles identified in major databases, and obtained exposure-response relationships for the candidate IAPs. The exposure levels to these IAPs were then collected by another systematic review of 1864 articles selected from 52 351 articles. After the systematic review, ten IAPs with significant and robust exposure-response relationships and sufficient exposure data were finally targeted: PM2·5, nitrogen dioxide, sulphur dioxide, ozone, carbon monoxide, radon, formaldehyde, benzene, toluene, and p-dichlorobenzene. The annual exposure levels in residences were then evaluated in all 31 provinces in mainland China continuously from 2000 to 2017, using the spatiotemporal Gaussian process regression model to analyse indoor originating IAPs, and the infiltration factor method to analyse outdoor originating IAPs. The disability-adjusted life-years (DALYs) attributable to the targeted IAPs were estimated at both national and provincial levels in China, using the population attributable fraction method. Financial costs were estimated by an adapted human capital approach. From 2000 to 2017, annual DALYs attributable to the ten IAPs in mainland China decreased from 4620 (95% CI 4070-5040) to 3700 (3210-4090) per 100 000. Nevertheless, in 2017, IAPs still ranked third among all risk factors, and their DALYs and financial costs accounted for 14·1% (95% CI 12·3-15·6) of total DALYs and 3·45% (3·01-3·82) of the gross domestic product. Specifically, the rank of ten targeted IAPs in order of their contribution to DALYs in 2017 was PM2·5, carbon monoxide, radon, benzene, nitrogen dioxide, ozone, sulphur dioxide, formaldehyde, toluene, and p-dichlorobenzene. The DALYs attributable to IAPs were 9·50% higher than those attributable to outdoor air pollution in 2017. For the leading IAP, PM2·5, the DALYs attributable to indoor origins are 18·3% higher than those of outdoor origins. DALYs attributed to IAPs in China have decreased by 20·0% over the past two decades. Even so, they are still much higher than those in the USA and European countries. This study can provide a basis for determining which IAPs to target in various indoor air quality standards and for estimating the health and economic benefits of various indoor air quality control approaches, which will help to reduce the adverse health effects of IAPs in China. The National Key Research and Development Program of China and the National Natural Science Foundation of China.

Global inpatient utilization from 1990 to 2020: effects of the COVID-19 pandemic

Abstract Background Inpatient service utilization rate is a key indicator for estimating the performance of health care systems on global, regional, and national levels. Methods We collected 1378 source-years of data, including administrative sources, nationally representative surveys, and government reports covering 130 countries overall, 29 of which are in the European region from 1990 to 2020. Inpatient admission was defined as an overnight stay at a formal healthcare facility for any cause. The data underwent age- and sex-splitting as per the available level of detail; survey sources were crosswalked to the gold-standard administrative data. The resulting data set was analyzed using Spatiotemporal Gaussian Process Regression (ST-GPR), a Bayesian meta-regression tool, to model the inpatient admission rate per capita across all countries, age groups, and sexes from 1990 to 2020. Admission rates were age- and sex-standardized to compute global proportions of hospitalized persons. Results In 2019, the global age-standardized inpatient utilization rate was 0.12 (95% uncertainty interval [UI] 0.09-0.15) admissions per capita. Globally, 0.93 billion (0.72-1.18) inpatient admissions were provided in 2019 compared to 0.68 billion (0.53-0.87) in 1990. In 2020, the global age-standardized inpatient utilization rate dropped to 0.057 (0.055-0.059) with a global proportion of hospitalized patients of 0.45 billion (0.43-0.46). Conclusions The increase in inpatient utilization from 1990 to 2019 may be attributable to population growth and increased capacity of health systems across most WHO regions. Health care utilization was highly variable between regions that was partly explainable by the variation in the socio-demographic index (SDI). The pandemic-mitigating measures limiting transportation and healthcare access were associated with the reduction in utilization in 2020. Key messages • The inpatient utilization rates were rising globally with large variation across regions, while decreasing in 2020 due the COVID-19 pandemic-related mitigating measures. • Health systems may use the inpatient utilization estimates to assess the effectiveness of health care reforms, plan for future capacity, and to allocate financial and human resources appropriately.

Burden of disease due to amphetamines, cannabis, cocaine, and opioid use disorders in South America, 1990–2019: a systematic analysis of the Global Burden of Disease Study 2019

South America's substance use profile, poverty, income inequality, and cocaine-supplier role make it a unique place for substance use research. This study investigated the burden of disease attributable to amphetamine use disorder, cannabis use disorder (CAD), cocaine use disorder, and opioid use disorder (OUD) in South America from 1990 to 2019, on the basis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. GBD 2019 estimated the incidence, prevalence, mortality, years of life lost (YLL), years of life lived with disability (YLD), and disability-adjusted life-years (DALYs) due to substance use disorders in each of the 12 South American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela). Data were modelled using standardised tools (ie, the Cause of Death Ensemble model, spatio-temporal Gaussian process regression, and disease modelling meta-regression) to generate estimates of each quantity of interest by sex, location, and year. The analysis included comparisons by sex and country, and against regional and global estimates. In 2019, the highest amphetamine use disorder burden per 100 000 population in South America was in Peru (66 DALYs). CAD DALY rates per 100 000 in South America were stable between 1990 and 2019, except in Chile and Colombia, which had the highest rates in 2019 (19 DALYs for Chile and 18 DALYs for Colombia). OUD DALYs per 100 000 increased during the period in Brazil and Peru, which in 2019 had the highest rates in South America (82 DALYs for Brazil and 70 DALYs for Peru). In 2019, Brazil had the highest cocaine use disorder DALYs per 100 000 (45 DALYs), nearly double its rate in 1990. DALY rates were higher in males than females for each substance use disorder, except in Paraguay. The overall burden of substance use disorders was higher in males than in females, mainly because of cocaine use disorder and CAD, whereas for amphetamine use disorder, the difference between sexes was minimal, and for OUD there was no difference. For males and females, the highest rate of substance use disorders DALYs per 100 000 was for OUD except in Argentina (in males, 58 DALYs for cocaine use disorder vs 52 DALYs for OUD) and in Paraguay (in females, 77 for amphetamine use disorder vs 50 for OUD). CAD DALY rates were generally the lowest among the substance use disorders for males and females. Amphetamine use disorder YLD rates were reasonably stable throughout the period and were highest in Peru, Paraguay, and Uruguay (>40 YLD per 100 000). For CAD, YLD rates were stable in all countries except Chile and Colombia. Cocaine use disorder YLD rates per 100 000 for the top four countries (Argentina, Uruguay, Chile, and Brazil) increased from 1990 to 2010 (eg, from 19 to 33 in Brazil), but decreased between 2010 and 2019 (eg, from 36 to 31 in Chile). For OUD, YLD rates showed a slight increase in most countries apart from Brazil, which increased from 52 in 1990 to 80 in 2019 and was top among the countries. Amphetamine use disorder YLL rates per 100 000 were highest in Suriname and Peru during the period, although in Suriname it increased from 2·7 in 2010 to 3·2 in 2019, whereas in Peru it decreased from 2·1 to 1·7. The highest YLL rate for cocaine use disorder was in Brazil, which increased from 3·7 in 1990 to 18·1 in 2019. Between 2000 and 2019, Chile and Uruguay showed the highest OUD YLL rates (11·6 for Chile and 10·9 for Uruguay). A high incidence of CAD was found in Chile, Colombia, Guyana, and Suriname. There were high incidences of amphetamine use disorder in Paraguay, cocaine use disorder in Argentina, and OUD in Ecuador. A decrease in annual prevalence for substance use disorders during the period was observed in Venezuela (amphetamine use disorder, CAD, and OUD), Brazil (CAD and amphetamine use disorder), Colombia (amphetamine use disorder and cocaine use disorder), Peru (amphetamine use disorder and cocaine use disorder), Chile and Suriname (amphetamine use disorder), Uruguay (CAD), and Bolivia (OUD). Overall, the cocaine use disorder burden stabilised then decreased. OUD was less prevalent than other substance use disorders but its burden was the highest. The decrease in the burden of cocaine use disorder probably reflects the success of national standardised treatment programmes. Programmes for amphetamine use disorder, CAD, and OUD management should be improved. We did not find an increase in CAD burden in Uruguay, the country with the highest degree of cannabis decriminalisation in the region. Countries in South America should improve monitoring of substance use disorders, including regular surveys to provide more accurate data on which to base policy decisions. The Bill & Melinda Gates Foundation.

Meningococcal A conjugate vaccine coverage in the meningitis belt of Africa from 2010 to 2021: a modelling study

As of the end of 2021, twenty-four countries in the African meningitis belt have rolled out mass campaigns of MenAfriVac®, a meningococcal A conjugate vaccine (MACV) first introduced in 2010. Twelve have completed introduction of MACV into routine immunisation (RI) schedules. Although select post-campaign coverage data are published, no study currently comprehensively estimates MACV coverage from both routine and campaign sources in the meningitis belt across age, country, and time. In this modelling study, we assembled campaign data from the twenty-four countries that had introduced any immunisation activity during or before the year 2021 (Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Eritrea, the Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Mali, Mauritania, Niger, Nigeria, Senegal, South Sudan, Sudan, Togo and Uganda) via WHO reports and RI data via systematic review. Next, we modelled RI coverage using Spatiotemporal Gaussian Process Regression. Then, we synthesized these estimates with campaign data into a cohort model, tracking coverage for each age cohort from age 1 to 29 years over time for each country. Coverage in high-risk locations amongst children aged 1-4 in 2021 was estimated to be highest in Togo with 96.0% (95% uncertainty interval [UI] 92.0-99.0), followed by Niger with 87.2% (95% UI 85.3-89.0) and Burkina Faso, with 86.4% (95% UI 85.1-87.6). These countries had high coverage values driven by an initial successful mass immunisation campaign, followed by a catch-up campaign, followed by introduction of RI. Due to the influence of older mass vaccination campaigns, coverage proportions skewed higher in the 1-29 age group than the 1-4 group, with a median coverage of 82.9% in 2021 in the broader age group compared to 45.6% in the narrower age group. These estimates highlight where gaps in immunisation remain and emphasise the need for broader efforts to strengthen RI systems. This methodological framework can be applied to estimate coverage for any vaccine that has been delivered in both routine and supplemental immunisation activities. Bill and Melinda Gates Foundation.

Measuring contraceptive method mix, prevalence, and demand satisfied by age and marital status in 204 countries and territories, 1970–2019: a systematic analysis for the Global Burden of Disease Study 2019

SummaryBackgroundMeeting the contraceptive needs of women of reproductive age is beneficial for the health of women and children, and the economic and social empowerment of women. Higher rates of contraceptive coverage have been linked to the availability of a more diverse range of contraceptive methods. We present estimates of the contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), demand satisfied, and the method of contraception used for both partnered and unpartnered women for 5-year age groups in 204 countries and territories between 1970 and 2019.MethodsWe used 1162 population-based surveys capturing contraceptive use among women between 1970 and 2019, in which women of reproductive age (15–49 years) self-reported their, or their partner's, current use of contraception for family planning purposes. Spatiotemporal Gaussian process regression was used to generate estimates of the CPR, mCPR, demand satisfied, and method mix by age and marital status. We assessed how age-specific mCPR and demand satisfied changed with the Socio-demographic Index (SDI), a measure of social and economic development, using the meta-regression Bayesian, regularised, trimmed method from the Global Burden of Diseases, Injuries, and Risk Factors Study.FindingsIn 2019, 162·9 million (95% uncertainty interval [UI] 155·6–170·2) women had unmet need for contraception, of whom 29·3% (27·9–30·6) resided in sub-Saharan Africa and 27·2% (24·4–30·3) resided in south Asia. Women aged 15–19 years (64·8% [62·9–66·7]) and 20–24 years (71·9% [68·9–74·2]) had the lowest rates of demand satisfied, with 43·2 million (95% UI 39·3–48·0) women aged 15–24 years with unmet need in 2019. The mCPR and demand satisfied among women aged 15–19 years were substantially lower than among women aged 20–49 years at SDI values below 60 (on a 0–100 scale), but began to equalise as SDI increased above 60. Between 1970 and 2019, the global mCPR increased by 20·1 percentage points (95% UI 18·7–21·6). During this time, traditional methods declined as a proportion of all contraceptive methods, whereas the use of implants, injections, female sterilisation, and condoms increased. Method mix differs substantially depending on age and geography, with the share of female sterilisation increasing with age and comprising more than 50% of methods in use in south Asia. In 28 countries, one method was used by more than 50% of users in 2019.InterpretationThe dominance of one contraceptive method in some locations raises the question of whether family planning policies should aim to expand method mix or invest in making existing methods more accessible. Lower rates of demand satisfied among women aged 15–24 years are also concerning because unintended pregnancies before age 25 years can forestall or eliminate education and employment opportunities that lead to social and economic empowerment. Policy makers should strive to tailor family planning programmes to the preferences of the groups with the most need, while maintaining the programmes used by existing users.FundingBill & Melinda Gates Foundation.

Global, regional, and national burden of hepatitis B, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

SummaryBackgroundCombating viral hepatitis is part of the UN Sustainable Development Goals (SDGs), and WHO has put forth hepatitis B elimination targets in its Global Health Sector Strategy on Viral Hepatitis (WHO-GHSS) and Interim Guidance for Country Validation of Viral Hepatitis Elimination (WHO Interim Guidance). We estimated the global, regional, and national prevalence of hepatitis B virus (HBV), as well as mortality and disability-adjusted life-years (DALYs) due to HBV, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. This included estimates for 194 WHO member states, for which we compared our estimates to WHO elimination targets.MethodsThe primary data sources were population-based serosurveys, claims and hospital discharges, cancer registries, vital registration systems, and published case series. We estimated chronic HBV infection and the burden of HBV-related diseases, defined as an aggregate of cirrhosis due to hepatitis B, liver cancer due to hepatitis B, and acute hepatitis B. We used DisMod-MR 2.1, a Bayesian mixed-effects meta-regression tool, to estimate the prevalence of chronic HBV infection, cirrhosis, and aetiological proportions of cirrhosis. We used mortality-to-incidence ratios modelled with spatiotemporal Gaussian process regression to estimate the incidence of liver cancer. We used the Cause of Death Ensemble modelling (CODEm) model, a tool that selects models and covariates on the basis of out-of-sample performance, to estimate mortality due to cirrhosis, liver cancer, and acute hepatitis B.FindingsIn 2019, the estimated global, all-age prevalence of chronic HBV infection was 4·1% (95% uncertainty interval [UI] 3·7 to 4·5), corresponding to 316 million (284 to 351) infected people. There was a 31·3% (29·0 to 33·9) decline in all-age prevalence between 1990 and 2019, with a more marked decline of 76·8% (76·2 to 77·5) in prevalence in children younger than 5 years. HBV-related diseases resulted in 555 000 global deaths (487 000 to 630 000) in 2019. The number of HBV-related deaths increased between 1990 and 2019 (by 5·9% [–5·6 to 19·2]) and between 2015 and 2019 (by 2·9% [–5·9 to 11·3]). By contrast, all-age and age-standardised death rates due to HBV-related diseases decreased during these periods. We compared estimates for 2019 in 194 WHO locations to WHO-GHSS 2020 targets, and found that four countries achieved a 10% reduction in deaths, 15 countries achieved a 30% reduction in new cases, and 147 countries achieved a 1% prevalence in children younger than 5 years. As of 2019, 68 of 194 countries had already achieved the 2030 target proposed in WHO Interim Guidance of an all-age HBV-related death rate of four per 100 000.InterpretationThe prevalence of chronic HBV infection declined over time, particularly in children younger than 5 years, since the introduction of hepatitis B vaccination. HBV-related death rates also decreased, but HBV-related death counts increased as a result of population growth, ageing, and cohort effects. By 2019, many countries had met the interim seroprevalence target for children younger than 5 years, but few countries had met the WHO-GHSS interim targets for deaths and new cases. Progress according to all indicators must be accelerated to meet 2030 targets, and there are marked disparities in burden and progress across the world. HBV interventions, such as vaccination, testing, and treatment, must be strategically supported and scaled up to achieve elimination.FundingBill & Melinda Gates Foundation.

Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

SummaryBackgroundHuman resources for health (HRH) include a range of occupations that aim to promote or improve human health. The UN Sustainable Development Goals (SDGs) and the WHO Health Workforce 2030 strategy have drawn attention to the importance of HRH for achieving policy priorities such as universal health coverage (UHC). Although previous research has found substantial global disparities in HRH, the absence of comparable cross-national estimates of existing workforces has hindered efforts to quantify workforce requirements to meet health system goals. We aimed to use comparable and standardised data sources to estimate HRH densities globally, and to examine the relationship between a subset of HRH cadres and UHC effective coverage performance.MethodsThrough the International Labour Organization and Global Health Data Exchange databases, we identified 1404 country-years of data from labour force surveys and 69 country-years of census data, with detailed microdata on health-related employment. From the WHO National Health Workforce Accounts, we identified 2950 country-years of data. We mapped data from all occupational coding systems to the International Standard Classification of Occupations 1988 (ISCO-88), allowing for standardised estimation of densities for 16 categories of health workers across the full time series. Using data from 1990 to 2019 for 196 of 204 countries and territories, covering seven Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) super-regions and 21 regions, we applied spatiotemporal Gaussian process regression (ST-GPR) to model HRH densities from 1990 to 2019 for all countries and territories. We used stochastic frontier meta-regression to model the relationship between the UHC effective coverage index and densities for the four categories of health workers enumerated in SDG indicator 3.c.1 pertaining to HRH: physicians, nurses and midwives, dentistry personnel, and pharmaceutical personnel. We identified minimum workforce density thresholds required to meet a specified target of 80 out of 100 on the UHC effective coverage index, and quantified national shortages with respect to those minimum thresholds.FindingsWe estimated that, in 2019, the world had 104·0 million (95% uncertainty interval 83·5–128·0) health workers, including 12·8 million (9·7–16·6) physicians, 29·8 million (23·3–37·7) nurses and midwives, 4·6 million (3·6–6·0) dentistry personnel, and 5·2 million (4·0–6·7) pharmaceutical personnel. We calculated a global physician density of 16·7 (12·6–21·6) per 10 000 population, and a nurse and midwife density of 38·6 (30·1–48·8) per 10 000 population. We found the GBD super-regions of sub-Saharan Africa, south Asia, and north Africa and the Middle East had the lowest HRH densities. To reach 80 out of 100 on the UHC effective coverage index, we estimated that, per 10 000 population, at least 20·7 physicians, 70·6 nurses and midwives, 8·2 dentistry personnel, and 9·4 pharmaceutical personnel would be needed. In total, the 2019 national health workforces fell short of these minimum thresholds by 6·4 million physicians, 30·6 million nurses and midwives, 3·3 million dentistry personnel, and 2·9 million pharmaceutical personnel.InterpretationConsiderable expansion of the world's health workforce is needed to achieve high levels of UHC effective coverage. The largest shortages are in low-income settings, highlighting the need for increased financing and coordination to train, employ, and retain human resources in the health sector. Actual HRH shortages might be larger than estimated because minimum thresholds for each cadre of health workers are benchmarked on health systems that most efficiently translate human resources into UHC attainment.FundingBill & Melinda Gates Foundation.

Global magnitude of encephalitis burden and its evolving pattern over the past 30 years

We aimed to estimate the spatiotemporal patterns of the encephalitis burden along with its attributable risk factors at the national, regional, and global levels, which may be helpful in guiding targeted prevention and treatment programs. Based on available data sources, the incidence, mortality, and disability-adjusted life years (DALYs) of encephalitis in 204 countries and regions from 1990 to 2019 were reconstructed by the Global Burden of Disease Study 2019 using the Cause of Death Ensemble model, spatiotemporal Gaussian process regression, and DisMod-MR 2.1. We conducted a systematic analysis on the epidemiological characteristics of encephalitis in detail by gender, region, and age over the past three decades. Globally, 1,444,720 incident cases, 89,900 deaths, and 4.80 million DALYs related to encephalitis were estimated in 2019. The age-standardized incidence rate and age-standardized mortality rate (ASMR) decreased from 23.17 and 2.18 to 19.33 and 1.19 per 100,000 person-years over the past 30 years, respectively. However, beginning in 2011-2013, the burden of encephalitis has shown an inflection point, with a further decline of the ASRs ceasing. Lower socio-demographic index (SDI) regions in South Asia, Western and Eastern Sub-Saharan Africa had the highest burden of encephalitis in 2019. During the past three decades, most countries of South Asia achieved significant control of the burden. In contrast, developed countries with a higher SDI have shown a notable increase in ASMR and age-standardized DALYs rate. Children and older adults have always been high-risk groups for encephalitis. Although the global burden of encephalitis has decreased in the past 30 years, a further decline stopped from 2011 to 2013. The diverse burden in different regions calls for differentiated management, and the persistent high burden in some low-SDI regions and the increased burden in developed countries with higher SDIs deserve more attention.

Progress in health among regions of Ethiopia, 1990–2019: a subnational country analysis for the Global Burden of Disease Study 2019

SummaryBackgroundPrevious Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) studies have reported national health estimates for Ethiopia. Substantial regional variations in socioeconomic status, population, demography, and access to health care within Ethiopia require comparable estimates at the subnational level. The GBD 2019 Ethiopia subnational analysis aimed to measure the progress and disparities in health across nine regions and two chartered cities.MethodsWe gathered 1057 distinct data sources for Ethiopia and all regions and cities that included census, demographic surveillance, household surveys, disease registry, health service use, disease notifications, and other data for this analysis. Using all available data sources, we estimated the Socio-demographic Index (SDI), total fertility rate (TFR), life expectancy, years of life lost, years lived with disability, disability-adjusted life-years, and risk-factor-attributable health loss with 95% uncertainty intervals (UIs) for Ethiopia's nine regions and two chartered cities from 1990 to 2019. Spatiotemporal Gaussian process regression, cause of death ensemble model, Bayesian meta-regression tool, DisMod-MR 2.1, and other models were used to generate fertility, mortality, cause of death, and disability rates. The risk factor attribution estimations followed the general framework established for comparative risk assessment.FindingsThe SDI steadily improved in all regions and cities from 1990 to 2019, yet the disparity between the highest and lowest SDI increased by 54% during that period. The TFR declined from 6·91 (95% UI 6·59–7·20) in 1990 to 4·43 (4·01–4·92) in 2019, but the magnitude of decline also varied substantially among regions and cities. In 2019, TFR ranged from 6·41 (5·96–6·86) in Somali to 1·50 (1·26–1·80) in Addis Ababa. Life expectancy improved in Ethiopia by 21·93 years (21·79–22·07), from 46·91 years (45·71–48·11) in 1990 to 68·84 years (67·51–70·18) in 2019. Addis Ababa had the highest life expectancy at 70·86 years (68·91–72·65) in 2019; Afar and Benishangul-Gumuz had the lowest at 63·74 years (61·53–66·01) for Afar and 64.28 (61.99-66.63) for Benishangul-Gumuz. The overall increases in life expectancy were driven by declines in under-5 mortality and mortality from common infectious diseases, nutritional deficiency, and war and conflict. In 2019, the age-standardised all-cause death rate was the highest in Afar at 1353·38 per 100 000 population (1195·69–1526·19). The leading causes of premature mortality for all sexes in Ethiopia in 2019 were neonatal disorders, diarrhoeal diseases, lower respiratory infections, tuberculosis, stroke, HIV/AIDS, ischaemic heart disease, cirrhosis, congenital defects, and diabetes. With high SDIs and life expectancy for all sexes, Addis Ababa, Dire Dawa, and Harari had low rates of premature mortality from the five leading causes, whereas regions with low SDIs and life expectancy for all sexes (Afar and Somali) had high rates of premature mortality from the leading causes. In 2019, child and maternal malnutrition; unsafe water, sanitation, and handwashing; air pollution; high systolic blood pressure; alcohol use; and high fasting plasma glucose were the leading risk factors for health loss across regions and cities.InterpretationThere were substantial improvements in health over the past three decades across regions and chartered cities in Ethiopia. However, the progress, measured in SDI, life expectancy, TFR, premature mortality, disability, and risk factors, was not uniform. Federal and regional health policy makers should match strategies, resources, and interventions to disease burden and risk factors across regions and cities to achieve national and regional plans, Sustainable Development Goals, and universal health coverage targets.FundingBill & Melinda Gates Foundation.

Global and regional spending on dementia care from 2000-2019 and expected future health spending scenarios from 2020-2050: An economic modelling exercise.

SummaryBackgroundThe global burden of dementia is increasing. As diagnosis and treatment rates increase and populations grow and age, additional diagnosed cases will present a challenge to healthcare systems globally. Even modelled estimates of the current and future healthcare spending attributable to dementia are valuable for decision makers and advocates to prepare for growing demand.MethodsWe modelled healthcare spending attributable to dementia from 2000 to 2019 and expected estimated future spending from 2020 to 2050 under multiple scenarios. Data were from the Global Burden of Diseases 2019 study and from two systematic literature reviews. We used meta-regression to estimate the fraction of dementia spending that is attributable to dementia for those receiving nursing home-based care and for those receiving community-based care. We used spatiotemporal Gaussian process regression to account for data missingness and model diagnosis and treatment rates, nursing home-based care and community-based care rates, and unit costs for the many countries without their own underlying estimates. Projections of future spending estimate a baseline scenario from 2020 to 2050 based on ongoing growth. Alternative scenarios assessed faster growth rates for dementia diagnosis and treatment rates, nursing home-based care, and healthcare costs. All spending is reported in 2019 United States dollars or 2019 purchasing-power parity-adjusted dollars.FindingsBased on observed and modelled inputs, we estimated that global spending on dementia increased by 4.5% (95% uncertainty interval: 3.4–5.4%) annually from 2000 to 2019, reaching $263 billion (95% uncertainty interval [UI] $199– $333) attributable to dementia in 2019. We estimated total healthcare spending on patients with dementia was $594 billion (95% UI $457–$843). Under the baseline scenario, we estimated that attributable dementia spending will reach $1.6 trillion (95% UI $0.9–$2.6) by 2050. We project it will represent 11% (95% UI 6–18%) of all expected health spending, although it could be as high as 17% (95% UI 10–26%) under alternative scenarios.InterpretationHealth systems will experience increases in the burden of dementia in the near future. These modelled direct cost estimates, built from a relatively small set of data and linear time trends, highlight the magnitude of health system resources expected to be used to provide care and ensure sufficient and adequate resources for aging populations and their caretakers. More data are needed to corroborate these important trends.

Abstract MP20: Global Burden Of Elevated Low-density Lipoprotein Cholesterol, 1990-2020: Findings From The Global Burden Of Disease Study 2020

We evaluated low-density lipoprotein (LDL) cholesterol patterns at the population level and quantified associated cardiovascular disease (CVD) morbidity and mortality for the Global Burden of Disease (GBD) 2020 study. Using all available high-quality data, we estimated the CVD burden attributable to elevated LDL (relative to the theoretical minimum risk exposure level of 1.3-1.7 mmol/L) by age, sex, country, and year among adults >25 years from 1990 - 2020. We used a spatiotemporal Gaussian process regression to estimate LDL mean and microdata to estimate standard deviation (SD) and characterize the global LDL distribution. In a meta-regression, we pooled data from 52 randomized control trials to estimate the relative risks for ischemic heart disease (IHD) and ischemic stroke. These were then used to calculate the population attributable fraction and the burden attributable to elevated LDL. We report SD and 95% uncertainty intervals (UI) in brackets. From 1990 to 2020, LDL levels measured in mmol/L increased globally from 1.4 [0.4] to 1.7 [0.4] in males, and from 1.5 [0.4] to 1.8 [0.5] in females. The highest LDL levels over the 30-year period were observed in high-income countries and Central and Eastern Europe and Central Asia. Sub-Saharan Africa had the lowest LDL levels. In 2020, a third (2.9 million [95% UI: 1.2-4.5 million]) and a fifth (1.5 million [919,750-2.1 million]) of deaths due to IHD and ischemic stroke, respectively, were attributable to elevated LDL. The estimated number of deaths and disability-adjusted life-years (DALYs) attributable to high LDL increased since 1990 reaching 4.5 million [2.6 - 6.2] deaths and 91.8 million [53.6 - 127] DALYs in 2020. More DALYs from elevated LDL were experienced by men than women (52.8 [29.7 - 73.4] vs 39 [23.9 - 53.5] million). Over the study period, the global all-age rates for deaths and DALYs per 100,000, remained unchanged at 58 [34-80] and 1,177 [688-1,629], respectively. Age-standardized deaths and DALYs due to high LDL levels decreased from 90 [55-123] to 57 [34-79] deaths per 100,000 and from 1,657 [981-2,251] to 1,610 [650-1,532] DALYs per 100,000. Age-standardized DALYs attributable to high LDL cholesterol were highest in Eastern Europe, Central Asia and North Africa and the Middle East. The lowest levels were observed in high-income Asia Pacific and Andean Latin America. The CVD burden attributable to LDL is increasing globally. In 2020, a fifth of CVD deaths and DALYs were associated with LDL. Differences between the trends of all-ages and age-standardized rates suggest that the LDL burden has been driven partially by population growth and aging. Measurement and estimation error must be considered when interpreting these trends. In addition to safe and cost-effective pharmacological and behavioral interventions, novel population level strategies are needed to reduce the LDL burden.

Global magnitude and temporal trend of infective endocarditis, 1990-2019: results from the Global Burden of Disease Study.

To estimate the spatiotemporal patterns in infective endocarditis (IE) burden along with its attributable risk factors at the national, regional, and global levels, which is essential to optimize the targeted prevention, clinical practice, and research. Based on all available data sources, the incidence, mortality, and disability-adjusted life years (DALYs) of IE in 204 countries and regions from 1990 to 2019 were reconstructed by Global Burden of Disease Study 2019 using the Cause of Death Ensemble model, spatiotemporal Gaussian process regression, and DisMod-MR 2.1. We depicted the epidemiological characteristics of IE in detail by gender, region, and age. Globally, 1 090 527 incident cases, 66 322 deaths, and 1 723 594 DALYs of IE were estimated in 2019. The age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) increased from 9.91 and 0.73 to 13.80 and 0.87 per 100 000 person-years over the past 30 years, respectively. ASIR were consistently more pronounced in higher socio-demographic index (SDI) regions. The leading ASMR in 2019 appeared in the High SDI region, with the largest increase in the past three decades. The age-specific burden rate of IE among people over 25 years old usually increased with age, and the annual increasing trend was more obvious for people over 60 years of age, especially in higher SDI regions. The incidence and mortality of IE have continued to rise in the past 30 years, especially in higher SDI regions. The patient population was gradually shifting from the young to the elderly.

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980–2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1

SummaryBackgroundMeasuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time.MethodsFor this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development.FindingsBy 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4–82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5–42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4–41·3] in 1980 to 83·6% [82·3–84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4–44·1) in 1980 to 79·8% (78·4–81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6–60·9) to 14·5 million (13·4–15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019.InterpretationAfter achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines.FundingBill & Melinda Gates Foundation.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990–2019

SummaryBackgroundUniversally, smoking cessation rates among established smokers are poor. Preventing young people from starting use of and becoming addicted to tobacco products remains a key strategy to end the tobacco epidemic. Previous country-specific studies have found that initiation of smoking tobacco use occurs predominantly among young people and have found mixed progress in reducing the prevalence of smoking tobacco use among young people. Current and comparable estimates for all countries are needed to inform targeted interventions and policies.MethodsWe modelled two indicators: prevalence of current smoking tobacco use among young adults aged 15–24 years, and the age at which current smokers aged 20–54 years in 2019 began smoking regularly. We synthesised data from 3625 nationally representative surveys on prevalence of smoking and 254 on age at initiation. We used spatiotemporal Gaussian process regression to produce estimates of the prevalence of smoking and age of initiation by sex, for 204 countries and territories for each year between 1990 and 2019.FindingsGlobally in 2019, an estimated 155 million (95% uncertainty interval 150–160) individuals aged 15–24 years were tobacco smokers, with a prevalence of 20·1% (19·4–20·8) among males and 4·95% (4·64–5·29) among females. We estimated that 82·6% (82·1–83·1) of current smokers initiated between ages 14 and 25 years, and that 18·5% (17·7–19·3) of smokers began smoking regularly by age 15 years. Although some countries have made substantial progress in reducing the prevalence of smoking tobacco use among young people, prevalence in 2019 still exceeds 20% among males aged 15–24 years in 120 countries and among females aged 15–24 years in 43 countries.InterpretationThe fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking.FundingBloomberg Philanthropies.

Abstract 062: Global Patterns Of Mean Systolic Blood Pressure Over Three Decades: Results From The Global Burden Of Disease 2019 Study

Background: Atherosclerotic cardiovascular disease and its risk factors are increasing globally. We estimated global and regional mean levels of systolic blood pressure (SBP) for the Global Burden of Disease (GBD) 2019 study. Methods: Mean SBP in mm Hg was estimated by age (adults >25 years), sex, location and year using all available population-based health surveys and studies that systematically measured brachial blood pressure. Estimates were produced using a Bayesian statistical model, spatiotemporal Gaussian process regression, which produces a smoothed time series from 1990 to 2019, borrowing strength over space and time, then aggregates to GBD regions. Each point in the figure represents age- and sex-specific mean SBP for one of 21 GBD regions, color coded by the 7 GBD super regions; black triangles denote global mean SBP. We report 95% uncertainty intervals in brackets. Results: Globally, mean SBP increased with age, peaking at 75-84 years, followed by a plateau and slight decline amongst oldest adults. In adults >60 in 1990 and >70 in 2019, females had higher SBP than males globally; this difference declined over time. In 1990, mean SBP was highest among females in Central Europe aged 60-64 (150 [147- 154]) and High-income Asia Pacific aged 80-84 (150 [147 - 152]), and in males aged 80-84 in Western Europe (150 [147-152]) and High-income Asia Pacific (148 [146 - 150]). By 2019, mean SBP was highest among adults aged 80-84 in Western and Southern Sub-Saharan Africa for both females (150 [136 - 164]; 149 [142 - 156], respectively), and males (145 [140 - 150]; 144 [136 - 153], respectively). Conclusions: SBP increased globally with age and was higher in older women than men. The 5-year age group with highest estimated SBP shifted over time from parts of Europe and High-income Asia Pacific to parts of Sub-Saharan Africa. Elevated SBP remains a major health risk for the world’s population, suggesting a need for increased investments in understanding its etiologies and how to treat and eventually prevent it as a cause of disease.

Spatio-temporal Gaussian process regression for room impulse response interpolation with acoustically informed priors

The reconstruction of sound fields in a room from a limited set of measurements is a central problem in acoustics, with relevant applications in e.g. acoustic analysis, audio, or sound field control. Conventional approaches rely on measuring the room impulse response (RIR) at several locations in the room, and fitting a wave model that enables to estimate the field at other locations—via solving an inverse problem. Previous studies have shown that the reconstruction of RIRs strongly depends on the regularization method used to solve the problem, and that enforcing sparsity is beneficial for the reconstruction of the early part of the RIR. This work studies Gaussian processes with time-dependent regularization in order to exploit the temporal properties of RIRs. The inverse problem is solved in the time domain, where hierarchical Bayes is applied in order to explicitly promote solutions where waves are more likely to propagate as time evolves. The model aims at reconstructing both the early part, and the late part of the RIRs. The performance of the proposed model is studied with experimental measurements, and compared to classical reconstruction methods with l1 and l2-norm regularization schemes

Subnational estimates of factors associated with under-five mortality in Kenya: a spatio-temporal analysis, 1993–2014

BackgroundTo improve child survival, it is necessary to describe and understand the spatial and temporal variation of factors associated with child survival beyond national aggregates, anchored at decentralised health planning...