Elsevier

The Lancet

Volume 386, Issue 9995, 22–28 August 2015, Pages 743-800
The Lancet

Articles
Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

https://doi.org/10.1016/S0140-6736(15)60692-4Get rights and content

Summary

Background

Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013.

Methods

Estimates were calculated for disease and injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refinements. Results for incidence of acute disorders and prevalence of chronic disorders are new additions to the analysis. Key improvements include expansion to the cause and sequelae list, updated systematic reviews, use of detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of severity splits for various causes. An index of data representativeness, showing data availability, was calculated for each cause and impairment during three periods globally and at the country level for 2013. In total, 35 620 distinct sources of data were used and documented to calculated estimates for 301 diseases and injuries and 2337 sequelae. The comorbidity simulation provides estimates for the number of sequelae, concurrently, by individuals by country, year, age, and sex. Disability weights were updated with the addition of new population-based survey data from four countries.

Findings

Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae. Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely, leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence estimates for asymptomatic permanent caries and tension-type headache of 2·4 billion and 1·6 billion, respectively. The distribution of the number of sequelae in populations varied widely across regions, with an expected relation between age and disease prevalence. YLDs for both sexes increased from 537·6 million in 1990 to 764·8 million in 2013 due to population growth and ageing, whereas the age-standardised rate decreased little from 114·87 per 1000 people to 110·31 per 1000 people between 1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years due to YLDs increased globally from 21·1% in 1990 to 31·2% in 2013.

Interpretation

Ageing of the world's population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems. The transition to non-fatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guide future health initiatives through examination of epidemiological trends and a better understanding of variation across countries.

Funding

Bill & Melinda Gates Foundation.

Introduction

The Global Burden of Disease Study 2013 (GBD 2013) is the first of a series of yearly updates for the GBD studies that began with estimates for 1990 and were most recently updated to 2010. The 2010 update (GBD 2010) systematically quantified prevalence of 1160 sequelae of 289 diseases and injuries across 21 regions.1 National estimates for 187 countries were also derived on the basis of global and regional statistical analyses.1 The metrics of years lived with disability (YLDs), equal to the sum of prevalence multiplied by the general public's assessment of the severity of health loss, was used to explore patterns over time, age, sex, and geography.1 Results for specific diseases and impairments have been extensively reported.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 These results drew attention to the importance of disability from musculoskeletal disorders, mental and substance use disorders, and various other non-communicable diseases.1 In developing countries, disorders such as anaemia and neglected tropical diseases remained important contributors to health loss.18, 43, 47 More generally, the analysis showed the global transition towards a rapid increase in YLDs due to global population growth and ageing, combined with little progress in reduction of age-specific YLD rates.

In view of the ambitious goal of the GBD 2010, to synthesise the global evidence for the country–age–sex–year prevalence of all major disorders, several specific estimates were critiqued. Specific data sources, modelling assumptions, and aspects of the general approach were challenged and there was widespread recognition that more and higher quality data could improve the estimates.48, 49, 50, 51, 52 Disability weights that were used to calculate YLDs were based on surveys of the general public in five countries (Bangladesh, Indonesia, Peru, Tanzania, and the USA) and an open internet survey. The validity of disability weights was questioned for selected states including hearing loss, vision loss, drug use, spinal cord lesion, intellectual disability, and musculoskeletal disorders.53, 54 Some investigators questioned whether disability weights should be used to measure health or the loss of wellbeing associated with health states.53, 55 Additionally, the YLD uncertainty intervals were large for several disorders because of scarce data, hence there was a need to statistically adjust for different case definitions, measurement methods, and wide uncertainty intervals for disability weights. Wide uncertainty intervals reduced the number of significant differences for some disorders reported across time and countries. Broad interest and crucial discourse about GBD also drew attention to many unpublished data sources in specific countries that could be used to strengthen the analysis.

With the prominent role attached to quantification of disease burden for health research and policy nationally and globally, up-to-date estimates based on the latest evidence for descriptive epidemiology constituted an essential global public good.22, 23, 24, 25, 26, 27, 32, 56, 57, 58, 59, 60 The GBD 2013 provides an opportunity to incorporate constructive criticism about GBD 2010 data sources, model development, methods, and interpretation. Additionally, the GBD 2013 shows methodological advances and includes new data for disability weights, capturing many new published or unpublished data sources for the disorders included in the GBD. Here, we report data, methods, and results from the analysis of 188 countries for 1990 to 2013 for 301 diseases and injuries and their 2337 sequelae. We report incidence for acute sequelae, prevalence for chronic sequelae, total prevalence by cause, in addition to YLDs for all causes. Because prevalence and YLDs for the entire period from 1990 to 2013 were reanalysed using consistent data and methods, these results supersede any previous publications about GBD.

Section snippets

Overview

Our general approach was similar to that for GBD 2010. The analysis of incidence and prevalence for HIV/AIDS, tuberculosis, and malaria for GBD 2013 have already been reported in detail.61 Key changes from GBD 2010 were the inclusion of new data through updated systematic reviews and the contribution of unpublished data sources from many collaborators; elaboration of the sequelae list to include asymptomatic states, such as Plasmodium falciparum parasitaemia (without symptoms); use of more

Results

Figure 2A–C shows the population pyramid for developed countries, developing countries excluding sub-Saharan Africa, and sub-Saharan Africa in 1990 and 2013 broken down by the number of sequelae, ranging from none to more than ten sequelae. Most of the world's population had at least one of the GBD sequelae and most people had several. As expected, in view of the strong relation between age and disease prevalence for most non-communicable diseases and injuries, the number of individuals with

Discussion

We analysed more than 35 620 epidemiological sources from 188 countries spanning the past three decades to provide the most up-to-date empirical assessment of the leading causes of acute disease incidence, chronic disease prevalence, and YLDs for 6 years (1990, 1995, 2000, 2005, 2010, and 2013) for 188 countries using consistent and comparable methods. Importantly, our study provides the first comprehensive assessment of the extent, pattern, and trend of non-fatal health loss in countries, with

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