Publications by authors named "Rana Asghar"

20 Publications

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Outbreak investigation of at a tertiary care hospital in Karachi, Pakistan.

J Infect Prev 2020 Sep 30;21(5):189-195. Epub 2020 Jun 30.

Global Health Strategists & Implementers (GHSI), Islamabad, Pakistan.

Background: From September 2014, a tertiary care hospital in Karachi, Pakistan, started diagnosing 3-5 cases/month of a yeast locally identified as spp. resistant to fluconazole. US Centers for Disease Control and Prevention identified the isolates as . The Pakistan Field Epidemiology and Laboratory Training Program (FELTP) and the hospital investigated the outbreak from April 2015 to January 2016.

Objective: The aim of the outbreak investigation was to determine the risk factors and to inform measures to limit the spread of the organism in the hospital.

Methods: Medical records, nursing schedules and infection control practices were reviewed. Sixty-two age- and sex-matched hospital controls from the same wards were identified.

Results: Thirty cases (17 males) were identified (mean age = 51.6 years, age range = 2-91 years), case fatality was 53%. Multivariate logistic regression showed that a history of surgery within 90 days of diagnosis, admission to the emergency department and history of chronic kidney disease were significantly associated with infection.

Discussion: This is the report of the outbreak investigation that triggered a global exploration of as a newly identified multidrug-resistant nosocomial organism, spreading within the hospital, especially among patients with invasive procedures. Unfortunately, we could not identify any specific source of the outbreak nor stop the transmission of the organism.
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http://dx.doi.org/10.1177/1757177420935639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607399PMC
September 2020

Why is polio still here? A perspective from Pakistan.

Lancet Glob Health 2020 02;8(2):e177-e178

Global Health Strategists and Implementers, Emirates Tower, Islamabad 44210, Pakistan; University of Nebraska Medical Center, Omaha, NE, USA. Electronic address:

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http://dx.doi.org/10.1016/S2214-109X(19)30524-8DOI Listing
February 2020

Global Health Security: Rethinking Joint External Evaluations to Ensure Readiness?

Health Secur 2019 Nov/Dec;17(6):504-506. Epub 2019 Nov 26.

Ali S. Khan, MD, is Dean, College of Public Health, University of Nebraska Medical Center, Omaha, NE.

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http://dx.doi.org/10.1089/hs.2019.0104DOI Listing
May 2020

Seroprevalence of Transplacentally acquired Measles antibodies in unvaccinated infants at nine months of age and its relation to the feeding practices.

BMC Infect Dis 2019 Jul 5;19(1):587. Epub 2019 Jul 5.

Field Epidemiology and Lab. Training Program, Islamabad, Pakistan.

Background: In recent years Pakistan has faced frequent measles outbreaks killing hundreds of children despite the availability of vaccine for decades. This study was undertaken to determine the persistence of maternal transferred measles antibody levels in infants before measles vaccination with relation to their feeding practices.

Methods: A cross sectional study was conducted at district Islamabad over 1 year between 1st October 2013 to 30th Sept. 2016. Any infant less than 9 months of age, not suffering from an acute or debilitating illness and not vaccinated was enrolled in the study. After taking written informed consent from parents / guardians, information was collected on a pretested questionnaire. About 3 cc venous blood was taken to quantify any measles IgG antibodies. Data was analyzed by using Epi Info 7.2 version.

Results: Three hundred eighty-four infants were enrolled and were divided into three age groups, 1-90, 91-180 and 181-270 days age groups. Mean age of infants was 4.4 months ±3.2 SD. Male to female ratio was 1.2:1. A level of maternal measles IgG antibodies ≥12 U/ml was taken as protective. Of total 384 infants, 91(24%) had protective measles antibody titters (> 12 U/ml). and 65 (73%) of them were on breast milk. Highest antibody levels were found in 1-90 days age group. Analysis showed that 181-270 days aged infants had 3.1875 more odds of having unprotected/ low levels of antibodies against measles than children aged less than 180 days. Age group < 180 days found to be statistically significant with protective IgG levels (OR: 3.1875, P value: < 0.000063).

Conclusion: Measles protective antibodies were found in infants < 180 days age group. Breast feeding provides early protection against measles. Levels drop down to low levels immediately after birth and then after 06 months. It is, therefore, recommended that measles vaccination should be considered for administration at 6 months or even earlier if measles immunity is desired.
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http://dx.doi.org/10.1186/s12879-019-4167-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6612169PMC
July 2019

Comparative efficiency of wheat straw and sugarcane bagasse biochar reduces the cadmium bioavailability to spinach and enhances the microbial activity in contaminated soil.

Int J Phytoremediation 2019 27;21(11):1098-1103. Epub 2019 Jun 27.

College of Natural Resource and Environment, North West Forestry and Agricultural University , Xianyang , China.

Biochar is considered a novel soil amendment for cadmium (Cd) stabilization in contaminated soils. A pot experiment was conducted to examine the efficiency of wheat straw and sugarcane bagasse induced biochar on Cd mobility in soil and its bioavailability to spinach in contaminated soil. Soil pH, Cd contents in plant tissues and microbial biomass were examined. Results showed that Cd was significantly decreased by 30.95% and 20.83% with wheat straw and sugarcane bagasse biochar at 2% application rate respectively, relative to the control. Similarly, Cd contents were decreased in plants shoots by 15.41 and 14.33%, while in roots by 48.3 and 35.54%, when wheat straw and sugarcane biochar were added at 2% application rate respectively. Moreover, soil microbial biomass was significantly increased with the application of all biochar types and their applications rates. Finally, wheat straw biochar at 2% application rate can be considered as an effective approach for Cd stabilization in contaminated soils.
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http://dx.doi.org/10.1080/15226514.2019.1606781DOI Listing
September 2019

Fractional-Dose Inactivated Poliovirus Vaccine Campaign - Sindh Province, Pakistan, 2016.

MMWR Morb Mortal Wkly Rep 2017 Dec 1;66(47):1295-1299. Epub 2017 Dec 1.

Following the declaration of eradication of wild poliovirus (WPV) type 2 in September 2015, trivalent oral poliovirus vaccine (tOPV) was withdrawn globally to reduce the risk for type 2 vaccine-derived poliovirus (VDPV2) transmission; all countries implemented a synchronized switch to bivalent OPV (type 1 and 3) in April 2016 (1,2). Any isolation of VDPV2 after the switch is to be treated as a potential public health emergency and might indicate the need for supplementary immunization activities (3,4). On August 9, 2016, VDPV2 was isolated from a sewage sample taken from an environmental surveillance site in Hyderabad, Sindh province, Pakistan. Possible vaccination activities in response to VDPV2 isolation include the use of injectable inactivated polio vaccine (IPV), which poses no risk for vaccine-derived poliovirus transmission. Fractional-dose, intradermal IPV (fIPV), one fifth of the standard intramuscular dose, has been developed to more efficiently manage limited IPV supplies. fIPV has been shown in some studies to be noninferior to full-dose IPV (5,6) and was used successfully in response to a similar detection of a single VDPV2 isolate from sewage in India (7). Injectable fIPV was used for response activities in Hyderabad and three neighboring districts. This report describes the findings of an assessment of preparatory activities and subsequent implementation of the fIPV campaign. Despite achieving high coverage (>80%), several operational challenges were noted. The lessons learned from this campaign could help to guide the planning and implementation of future fIPV vaccination activities.
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http://dx.doi.org/10.15585/mmwr.mm6647a4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708687PMC
December 2017

In vivo antiviral potential of Glycyrrhiza glabra extract against Newcastle disease virus.

Pak J Pharm Sci 2017 Mar;30(2(Suppl.)):567-572

Department of Eastern Medicine, Directorate of Medical Sciences, Government College University, Faisalabad, Pakistan.

Newcastle disease is highly infectious viral disease causing huge economic losses worldwide. These losses can be prevented by control of viral diseases. Medicinal plants have been traditionally used for treatment of different diseases since long. In this study the effect of extracts from Glycyrrhiza glabra leaves are investigated against Newcastle disease virus (NDV) by an in-vivo assay. Seven groups of nine-day-old embryonated chicken eggs were inoculated with various treatments of different plant extracts. All the groups except uninoculated negative control group were inoculated with velogenic NDV strain; five groups received different concentrations of the three extracts. Daily observe the rate of embryo survival. Allantoic fluid from treated eggs was collected for hem agglutination test. Results showed that embryo survival rate was higher 300µg/mL treated group as all the extracts showed antiviral activity. Similarly, the plant extracts effectively control virus as no viruses were identified in the allantoic fluids of all groups treated with low doses of plant. The current results have clearly verified that all the extracts especially that of methanol 300µg/mL from leaves of Glycyrrhiza glabra have strong antiviral activity against NDV in vivo.
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March 2017

The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013.

PLoS One 2017 17;12(1):e0169575. Epub 2017 Jan 17.

Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America.

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost-YLLs) and nonfatal outcomes (years lived with disability-YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169575PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240956PMC
August 2017

Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses.

Clin Infect Dis 2017 Jan 20;64(2):134-140. Epub 2016 Oct 20.

Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Candida auris, a multidrug-resistant yeast that causes invasive infections, was first described in 2009 in Japan and has since been reported from several countries.

Methods: To understand the global emergence and epidemiology of C. auris, we obtained isolates from 54 patients with C. auris infection from Pakistan, India, South Africa, and Venezuela during 2012-2015 and the type specimen from Japan. Patient information was available for 41 of the isolates. We conducted antifungal susceptibility testing and whole-genome sequencing (WGS).

Results: Available clinical information revealed that 41% of patients had diabetes mellitus, 51% had undergone recent surgery, 73% had a central venous catheter, and 41% were receiving systemic antifungal therapy when C. auris was isolated. The median time from admission to infection was 19 days (interquartile range, 9-36 days), 61% of patients had bloodstream infection, and 59% died. Using stringent break points, 93% of isolates were resistant to fluconazole, 35% to amphotericin B, and 7% to echinocandins; 41% were resistant to 2 antifungal classes and 4% were resistant to 3 classes. WGS demonstrated that isolates were grouped into unique clades by geographic region. Clades were separated by thousands of single-nucleotide polymorphisms, but within each clade isolates were clonal. Different mutations in ERG11 were associated with azole resistance in each geographic clade.

Conclusions: C. auris is an emerging healthcare-associated pathogen associated with high mortality. Treatment options are limited, due to antifungal resistance. WGS analysis suggests nearly simultaneous, and recent, independent emergence of different clonal populations on 3 continents. Risk factors and transmission mechanisms need to be elucidated to guide control measures.
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http://dx.doi.org/10.1093/cid/ciw691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215215PMC
January 2017

Burden of Diarrhea in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013.

Authors:
Ibrahim Khalil Danny V Colombara Mohammad Hossein Forouzanfar Christopher Troeger Farah Daoud Maziar Moradi-Lakeh Charbel El Bcheraoui Puja C Rao Ashkan Afshin Raghid Charara Kalkidan Hassen Abate Mohammed Magdy Abd El Razek Foad Abd-Allah Remon Abu-Elyazeed Aliasghar Ahmad Kiadaliri Ali Shafqat Akanda Nadia Akseer Khurshid Alam Deena Alasfoor Raghib Ali Mohammad A AlMazroa Mahmoud A Alomari Rajaa Mohammad Salem Al-Raddadi Ubai Alsharif Shirina Alsowaidi Khalid A Altirkawi Nelson Alvis-Guzman Walid Ammar Carl Abelardo T Antonio Hamid Asayesh Rana Jawad Asghar Suleman Atique Ashish Awasthi Umar Bacha Alaa Badawi Aleksandra Barac Neeraj Bedi Tolesa Bekele Isabela M Bensenor Balem Demtsu Betsu Zulfiqar Bhutta Aref A Bin Abdulhak Zahid A Butt Hadi Danawi Manisha Dubey Aman Yesuf Endries Imad D A Faghmous Talha Farid Maryam S Farvid Farshad Farzadfar Seyed-Mohammad Fereshtehnejad Florian Fischer Joseph Robert Anderson Fitchett Katherine B Gibney Ibrahim Abdelmageem Mohamed Ginawi Melkamu Dedefo Gishu Harish Chander Gugnani Rahul Gupta Gessessew Bugssa Hailu Randah Ribhi Hamadeh Samer Hamidi Hilda L Harb Mohammad T Hedayati Mohamed Hsairi Abdullatif Husseini Nader Jahanmehr Mehdi Javanbakht Tariku Jibat Jost B Jonas Amir Kasaeian Yousef Saleh Khader Abdur Rahman Khan Ejaz Ahmad Khan Gulfaraz Khan Tawfik Ahmed Muthafer Khoja Yohannes Kinfu Niranjan Kissoon Ai Koyanagi Aparna Lal Asma Abdul Abdul Latif Raimundas Lunevicius Hassan Magdy Abd El Razek Azeem Majeed Reza Malekzadeh Alem Mehari Alemayehu B Mekonnen Yohannes Adama Melaku Ziad A Memish Walter Mendoza Awoke Misganaw Layla Abdalla Ibrahim Mohamed Jean B Nachega Quyen Le Nguyen Muhammad Imran Nisar Emmanuel Kwame Peprah James A Platts-Mills Farshad Pourmalek Mostafa Qorbani Anwar Rafay Vafa Rahimi-Movaghar Sajjad Ur Rahman Rajesh Kumar Rai Saleem M Rana Chhabi L Ranabhat Sowmya R Rao Amany H Refaat Mark Riddle Gholamreza Roshandel George Mugambage Ruhago Muhammad Muhammad Saleh Juan R Sanabria Monika Sawhney Sadaf G Sepanlou Tesfaye Setegn Karen Sliwa Chandrashekhar T Sreeramareddy Bryan L Sykes Mohammad Tavakkoli Bemnet Amare Tedla Abdullah S Terkawi Kingsley Ukwaja Olalekan A Uthman Ronny Westerman Mamo Wubshet Muluken A Yenesew Naohiro Yonemoto Mustafa Z Younis Zoubida Zaidi Maysaa El Sayed Zaki Abdullah A Al Rabeeah Haidong Wang Mohsen Naghavi Theo Vos Alan D Lopez Christopher J L Murray Ali H Mokdad

Am J Trop Med Hyg 2016 Dec 10;95(6):1319-1329. Epub 2016 Oct 10.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington.

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.
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http://dx.doi.org/10.4269/ajtmh.16-0339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154365PMC
December 2016

Health in times of uncertainty in the eastern Mediterranean region, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Authors:
Ali H Mokdad Mohammad Hossein Forouzanfar Farah Daoud Charbel El Bcheraoui Maziar Moradi-Lakeh Ibrahim Khalil Ashkan Afshin Marwa Tuffaha Raghid Charara Ryan M Barber Joseph Wagner Kelly Cercy Hannah Kravitz Matthew M Coates Margaret Robinson Kara Estep Caitlyn Steiner Sara Jaber Ali A Mokdad Kevin F O'Rourke Adrienne Chew Pauline Kim Mohamed Magdy Abd El Razek Safa Abdalla Foad Abd-Allah Jerry P Abraham Laith J Abu-Raddad Niveen M E Abu-Rmeileh Abdulwahab A Al-Nehmi Ali S Akanda Hanan Al Ahmadi Mazin J Al Khabouri Faris H Al Lami Zulfa A Al Rayess Deena Alasfoor Fadia S AlBuhairan Saleh F Aldhahri Suliman Alghnam Samia Alhabib Nawal Al-Hamad Raghib Ali Syed Danish Ali Mohammad Alkhateeb Mohammad A AlMazroa Mahmoud A Alomari Rajaa Al-Raddadi Ubai Alsharif Nihaya Al-Sheyab Shirina Alsowaidi Mohamed Al-Thani Khalid A Altirkawi Azmeraw T Amare Heresh Amini Walid Ammar Palwasha Anwari Hamid Asayesh Rana Asghar Ali M Assabri Reza Assadi Umar Bacha Alaa Badawi Talal Bakfalouni Mohammed O Basulaiman Shahrzad Bazargan-Hejazi Neeraj Bedi Amit R Bhakta Zulfiqar A Bhutta Aref A Bin Abdulhak Soufiane Boufous Rupert R A Bourne Hadi Danawi Jai Das Amare Deribew Eric L Ding Adnan M Durrani Yousef Elshrek Mohamed E Ibrahim Babak Eshrati Alireza Esteghamati Imad A D Faghmous Farshad Farzadfar Andrea B Feigl Seyed-Mohammad Fereshtehnejad Irina Filip Florian Fischer Fortuné G Gankpé Ibrahim Ginawi Melkamu Dedefo Gishu Rahul Gupta Rami M Habash Nima Hafezi-Nejad Randah R Hamadeh Hayet Hamdouni Samer Hamidi Hilda L Harb Mohammad Sadegh Hassanvand Mohammad T Hedayati Pouria Heydarpour Mohamed Hsairi Abdullatif Husseini Nader Jahanmehr Vivekanand Jha Jost B Jonas Nadim E Karam Amir Kasaeian Nega Assefa Kassa Anil Kaul Yousef Khader Shams Eldin A Khalifa Ejaz A Khan Gulfaraz Khan Tawfik Khoja Ardeshir Khosravi Yohannes Kinfu Barthelemy Kuate Defo Arjun Lakshmana Balaji Raimundas Lunevicius Carla Makhlouf Obermeyer Reza Malekzadeh Morteza Mansourian Wagner Marcenes Habibolah Masoudi Farid Alem Mehari Abla Mehio-Sibai Ziad A Memish George A Mensah Karzan A Mohammad Ziad Nahas Jamal T Nasher Haseeb Nawaz Chakib Nejjari Muhammad Imran Nisar Saad B Omer Mahboubeh Parsaeian Emmanuel K Peprah Aslam Pervaiz Farshad Pourmalek Dima M Qato Mostafa Qorbani Amir Radfar Anwar Rafay Kazem Rahimi Vafa Rahimi-Movaghar Sajjad Ur Rahman Rajesh K Rai Saleem M Rana Sowmya R Rao Amany H Refaat Serge Resnikoff Gholamreza Roshandel Georges Saade Mohammad Y Saeedi Mohammad Ali Sahraian Shadi Saleh Lidia Sanchez-Riera Maheswar Satpathy Sadaf G Sepanlou Tesfaye Setegn Amira Shaheen Saeid Shahraz Sara Sheikhbahaei Kawkab Shishani Karen Sliwa Mohammad Tavakkoli Abdullah S Terkawi Olalekan A Uthman Ronny Westerman Mustafa Z Younis Maysaa El Sayed Zaki Faiez Zannad Gregory A Roth Haidong Wang Mohsen Naghavi Theo Vos Abdullah A Al Rabeeah Alan D Lopez Christopher J L Murray

Lancet Glob Health 2016 10 25;4(10):e704-13. Epub 2016 Aug 25.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.

Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.

Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.

Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S2214-109X(16)30168-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660972PMC
October 2016

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Authors:
Mohammad H Forouzanfar Lily Alexander H Ross Anderson Victoria F Bachman Stan Biryukov Michael Brauer Richard Burnett Daniel Casey Matthew M Coates Aaron Cohen Kristen Delwiche Kara Estep Joseph J Frostad K C Astha Hmwe H Kyu Maziar Moradi-Lakeh Marie Ng Erica Leigh Slepak Bernadette A Thomas Joseph Wagner Gunn Marit Aasvang Cristiana Abbafati Ayse Abbasoglu Ozgoren Foad Abd-Allah Semaw F Abera Victor Aboyans Biju Abraham Jerry Puthenpurakal Abraham Ibrahim Abubakar Niveen M E Abu-Rmeileh Tania C Aburto Tom Achoki Ademola Adelekan Koranteng Adofo Arsène K Adou José C Adsuar Ashkan Afshin Emilie E Agardh Mazin J Al Khabouri Faris H Al Lami Sayed Saidul Alam Deena Alasfoor Mohammed I Albittar Miguel A Alegretti Alicia V Aleman Zewdie A Alemu Rafael Alfonso-Cristancho Samia Alhabib Raghib Ali Mohammed K Ali François Alla Peter Allebeck Peter J Allen Ubai Alsharif Elena Alvarez Nelson Alvis-Guzman Adansi A Amankwaa Azmeraw T Amare Emmanuel A Ameh Omid Ameli Heresh Amini Walid Ammar Benjamin O Anderson Carl Abelardo T Antonio Palwasha Anwari Solveig Argeseanu Cunningham Johan Arnlöv Valentina S Arsic Arsenijevic Al Artaman Rana J Asghar Reza Assadi Lydia S Atkins Charles Atkinson Marco A Avila Baffour Awuah Alaa Badawi Maria C Bahit Talal Bakfalouni Kalpana Balakrishnan Shivanthi Balalla Ravi Kumar Balu Amitava Banerjee Ryan M Barber Suzanne L Barker-Collo Simon Barquera Lars Barregard Lope H Barrero Tonatiuh Barrientos-Gutierrez Ana C Basto-Abreu Arindam Basu Sanjay Basu Mohammed O Basulaiman Carolina Batis Ruvalcaba Justin Beardsley Neeraj Bedi Tolesa Bekele Michelle L Bell Corina Benjet Derrick A Bennett Habib Benzian Eduardo Bernabé Tariku J Beyene Neeraj Bhala Ashish Bhalla Zulfiqar A Bhutta Boris Bikbov Aref A Bin Abdulhak Jed D Blore Fiona M Blyth Megan A Bohensky Berrak Bora Başara Guilherme Borges Natan M Bornstein Dipan Bose Soufiane Boufous Rupert R Bourne Michael Brainin Alexandra Brazinova Nicholas J Breitborde Hermann Brenner Adam D M Briggs David M Broday Peter M Brooks Nigel G Bruce Traolach S Brugha Bert Brunekreef Rachelle Buchbinder Linh N Bui Gene Bukhman Andrew G Bulloch Michael Burch Peter G J Burney Ismael R Campos-Nonato Julio C Campuzano Alejandra J Cantoral Jack Caravanos Rosario Cárdenas Elisabeth Cardis David O Carpenter Valeria Caso Carlos A Castañeda-Orjuela Ruben E Castro Ferrán Catalá-López Fiorella Cavalleri Alanur Çavlin Vineet K Chadha Jung-Chen Chang Fiona J Charlson Honglei Chen Wanqing Chen Zhengming Chen Peggy P Chiang Odgerel Chimed-Ochir Rajiv Chowdhury Costas A Christophi Ting-Wu Chuang Sumeet S Chugh Massimo Cirillo Thomas K D Claßen Valentina Colistro Mercedes Colomar Samantha M Colquhoun Alejandra G Contreras Cyrus Cooper Kimberly Cooperrider Leslie T Cooper Josef Coresh Karen J Courville Michael H Criqui Lucia Cuevas-Nasu James Damsere-Derry Hadi Danawi Lalit Dandona Rakhi Dandona Paul I Dargan Adrian Davis Dragos V Davitoiu Anand Dayama E Filipa de Castro Vanessa De la Cruz-Góngora Diego De Leo Graça de Lima Louisa Degenhardt Borja del Pozo-Cruz Robert P Dellavalle Kebede Deribe Sarah Derrett Don C Des Jarlais Muluken Dessalegn Gabrielle A deVeber Karen M Devries Samath D Dharmaratne Mukesh K Dherani Daniel Dicker Eric L Ding Klara Dokova E Ray Dorsey Tim R Driscoll Leilei Duan Adnan M Durrani Beth E Ebel Richard G Ellenbogen Yousef M Elshrek Matthias Endres Sergey P Ermakov Holly E Erskine Babak Eshrati Alireza Esteghamati Saman Fahimi Emerito Jose A Faraon Farshad Farzadfar Derek F J Fay Valery L Feigin Andrea B Feigl Seyed-Mohammad Fereshtehnejad Alize J Ferrari Cleusa P Ferri Abraham D Flaxman Thomas D Fleming Nataliya Foigt Kyle J Foreman Urbano Fra Paleo Richard C Franklin Belinda Gabbe Lynne Gaffikin Emmanuela Gakidou Amiran Gamkrelidze Fortuné G Gankpé Ron T Gansevoort Francisco A García-Guerra Evariste Gasana Johanna M Geleijnse Bradford D Gessner Pete Gething Katherine B Gibney Richard F Gillum Ibrahim A M Ginawi Maurice Giroud Giorgia Giussani Shifalika Goenka Ketevan Goginashvili Hector Gomez Dantes Philimon Gona Teresita Gonzalez de Cosio Dinorah González-Castell Carolyn C Gotay Atsushi Goto Hebe N Gouda Richard L Guerrant Harish C Gugnani Francis Guillemin David Gunnell Rahul Gupta Rajeev Gupta Reyna A Gutiérrez Nima Hafezi-Nejad Holly Hagan Maria Hagstromer Yara A Halasa Randah R Hamadeh Mouhanad Hammami Graeme J Hankey Yuantao Hao Hilda L Harb Tilahun Nigatu Haregu Josep Maria Haro Rasmus Havmoeller Simon I Hay Mohammad T Hedayati Ileana B Heredia-Pi Lucia Hernandez Kyle R Heuton Pouria Heydarpour Martha Hijar Hans W Hoek Howard J Hoffman John C Hornberger H Dean Hosgood Damian G Hoy Mohamed Hsairi Guoqing Hu Howard Hu Cheng Huang John J Huang Bryan J Hubbell Laetitia Huiart Abdullatif Husseini Marissa L Iannarone Kim M Iburg Bulat T Idrisov Nayu Ikeda Kaire Innos Manami Inoue Farhad Islami Samaya Ismayilova Kathryn H Jacobsen Henrica A Jansen Deborah L Jarvis Simerjot K Jassal Alejandra Jauregui Sudha Jayaraman Panniyammakal Jeemon Paul N Jensen Vivekanand Jha Fan Jiang Guohong Jiang Ying Jiang Jost B Jonas Knud Juel Haidong Kan Sidibe S Kany Roseline Nadim E Karam André Karch Corine K Karema Ganesan Karthikeyan Anil Kaul Norito Kawakami Dhruv S Kazi Andrew H Kemp Andre P Kengne Andre Keren Yousef S Khader Shams Eldin Ali Hassan Khalifa Ejaz A Khan Young-Ho Khang Shahab Khatibzadeh Irma Khonelidze Christian Kieling Daniel Kim Sungroul Kim Yunjin Kim Ruth W Kimokoti Yohannes Kinfu Jonas M Kinge Brett M Kissela Miia Kivipelto Luke D Knibbs Ann Kristin Knudsen Yoshihiro Kokubo M Rifat Kose Soewarta Kosen Alexander Kraemer Michael Kravchenko Sanjay Krishnaswami Hans Kromhout Tiffany Ku Barthelemy Kuate Defo Burcu Kucuk Bicer Ernst J Kuipers Chanda Kulkarni Veena S Kulkarni G Anil Kumar Gene F Kwan Taavi Lai Arjun Lakshmana Balaji Ratilal Lalloo Tea Lallukka Hilton Lam Qing Lan Van C Lansingh Heidi J Larson Anders Larsson Dennis O Laryea Pablo M Lavados Alicia E Lawrynowicz Janet L Leasher Jong-Tae Lee James Leigh Ricky Leung Miriam Levi Yichong Li Yongmei Li Juan Liang Xiaofeng Liang Stephen S Lim M Patrice Lindsay Steven E Lipshultz Shiwei Liu Yang Liu Belinda K Lloyd Giancarlo Logroscino Stephanie J London Nancy Lopez Joannie Lortet-Tieulent Paulo A Lotufo Rafael Lozano Raimundas Lunevicius Jixiang Ma Stefan Ma Vasco M P Machado Michael F MacIntyre Carlos Magis-Rodriguez Abbas A Mahdi Marek Majdan Reza Malekzadeh Srikanth Mangalam Christopher C Mapoma Marape Marape Wagner Marcenes David J Margolis Christopher Margono Guy B Marks Randall V Martin Melvin B Marzan Mohammad T Mashal Felix Masiye Amanda J Mason-Jones Kunihiro Matsushita Richard Matzopoulos Bongani M Mayosi Tasara T Mazorodze Abigail C McKay Martin McKee Abigail McLain Peter A Meaney Catalina Medina Man Mohan Mehndiratta Fabiola Mejia-Rodriguez Wubegzier Mekonnen Yohannes A Melaku Michele Meltzer Ziad A Memish Walter Mendoza George A Mensah Atte Meretoja Francis Apolinary Mhimbira Renata Micha Ted R Miller Edward J Mills Awoke Misganaw Santosh Mishra Norlinah Mohamed Ibrahim Karzan A Mohammad Ali H Mokdad Glen L Mola Lorenzo Monasta Julio C Montañez Hernandez Marcella Montico Ami R Moore Lidia Morawska Rintaro Mori Joanna Moschandreas Wilkister N Moturi Dariush Mozaffarian Ulrich O Mueller Mitsuru Mukaigawara Erin C Mullany Kinnari S Murthy Mohsen Naghavi Ziad Nahas Aliya Naheed Kovin S Naidoo Luigi Naldi Devina Nand Vinay Nangia K M Venkat Narayan Denis Nash Bruce Neal Chakib Nejjari Sudan P Neupane Charles R Newton Frida N Ngalesoni Jean de Dieu Ngirabega Grant Nguyen Nhung T Nguyen Mark J Nieuwenhuijsen Muhammad I Nisar José R Nogueira Joan M Nolla Sandra Nolte Ole F Norheim Rosana E Norman Bo Norrving Luke Nyakarahuka In-Hwan Oh Takayoshi Ohkubo Bolajoko O Olusanya Saad B Omer John Nelson Opio Ricardo Orozco Rodolfo S Pagcatipunan Amanda W Pain Jeyaraj D Pandian Carlo Irwin A Panelo Christina Papachristou Eun-Kee Park Charles D Parry Angel J Paternina Caicedo Scott B Patten Vinod K Paul Boris I Pavlin Neil Pearce Lilia S Pedraza Andrea Pedroza Ljiljana Pejin Stokic Ayfer Pekericli David M Pereira Rogelio Perez-Padilla Fernando Perez-Ruiz Norberto Perico Samuel A L Perry Aslam Pervaiz Konrad Pesudovs Carrie B Peterson Max Petzold Michael R Phillips Hwee Pin Phua Dietrich Plass Dan Poenaru Guilherme V Polanczyk Suzanne Polinder Constance D Pond C Arden Pope Daniel Pope Svetlana Popova Farshad Pourmalek John Powles Dorairaj Prabhakaran Noela M Prasad Dima M Qato Amado D Quezada D Alex A Quistberg Lionel Racapé Anwar Rafay Kazem Rahimi Vafa Rahimi-Movaghar Sajjad Ur Rahman Murugesan Raju Ivo Rakovac Saleem M Rana Mayuree Rao Homie Razavi K Srinath Reddy Amany H Refaat Jürgen Rehm Giuseppe Remuzzi Antonio L Ribeiro Patricia M Riccio Lee Richardson Anne Riederer Margaret Robinson Anna Roca Alina Rodriguez David Rojas-Rueda Isabelle Romieu Luca Ronfani Robin Room Nobhojit Roy George M Ruhago Lesley Rushton Nsanzimana Sabin Ralph L Sacco Sukanta Saha Ramesh Sahathevan Mohammad Ali Sahraian Joshua A Salomon Deborah Salvo Uchechukwu K Sampson Juan R Sanabria Luz Maria Sanchez Tania G Sánchez-Pimienta Lidia Sanchez-Riera Logan Sandar Itamar S Santos Amir Sapkota Maheswar Satpathy James E Saunders Monika Sawhney Mete I Saylan Peter Scarborough Jürgen C Schmidt Ione J C Schneider Ben Schöttker David C Schwebel James G Scott Soraya Seedat Sadaf G Sepanlou Berrin Serdar Edson E Servan-Mori Gavin Shaddick Saeid Shahraz Teresa Shamah Levy Siyi Shangguan Jun She Sara Sheikhbahaei Kenji Shibuya Hwashin H Shin Yukito Shinohara Rahman Shiri Kawkab Shishani Ivy Shiue Inga D Sigfusdottir Donald H Silberberg Edgar P Simard Shireen Sindi Abhishek Singh Gitanjali M Singh Jasvinder A Singh Vegard Skirbekk Karen Sliwa Michael Soljak Samir Soneji Kjetil Søreide Sergey Soshnikov Luciano A Sposato Chandrashekhar T Sreeramareddy Nicolas J C Stapelberg Vasiliki Stathopoulou Nadine Steckling Dan J Stein Murray B Stein Natalie Stephens Heidi Stöckl Kurt Straif Konstantinos Stroumpoulis Lela Sturua Bruno F Sunguya Soumya Swaminathan Mamta Swaroop Bryan L Sykes Karen M Tabb Ken Takahashi Roberto T Talongwa Nikhil Tandon David Tanne Marcel Tanner Mohammad Tavakkoli Braden J Te Ao Carolina M Teixeira Martha M Téllez Rojo Abdullah S Terkawi José Luis Texcalac-Sangrador Sarah V Thackway Blake Thomson Andrew L Thorne-Lyman Amanda G Thrift George D Thurston Taavi Tillmann Myriam Tobollik Marcello Tonelli Fotis Topouzis Jeffrey A Towbin Hideaki Toyoshima Jefferson Traebert Bach X Tran Leonardo Trasande Matias Trillini Ulises Trujillo Zacharie Tsala Dimbuene Miltiadis Tsilimbaris Emin Murat Tuzcu Uche S Uchendu Kingsley N Ukwaja Selen B Uzun Steven van de Vijver Rita Van Dingenen Coen H van Gool Jim van Os Yuri Y Varakin Tommi J Vasankari Ana Maria N Vasconcelos Monica S Vavilala Lennert J Veerman Gustavo Velasquez-Melendez N Venketasubramanian Lakshmi Vijayakumar Salvador Villalpando Francesco S Violante Vasiliy Victorovich Vlassov Stein Emil Vollset Gregory R Wagner Stephen G Waller Mitchell T Wallin Xia Wan Haidong Wang JianLi Wang Linhong Wang Wenzhi Wang Yanping Wang Tati S Warouw Charlotte H Watts Scott Weichenthal Elisabete Weiderpass Robert G Weintraub Andrea Werdecker K Ryan Wessells Ronny Westerman Harvey A Whiteford James D Wilkinson Hywel C Williams Thomas N Williams Solomon M Woldeyohannes Charles D A Wolfe John Q Wong Anthony D Woolf Jonathan L Wright Brittany Wurtz Gelin Xu Lijing L Yan Gonghuan Yang Yuichiro Yano Pengpeng Ye Muluken Yenesew Gökalp K Yentür Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Z Younis Zourkaleini Younoussi Chuanhua Yu Maysaa E Zaki Yong Zhao Yingfeng Zheng Maigeng Zhou Jun Zhu Shankuan Zhu Xiaonong Zou Joseph R Zunt Alan D Lopez Theo Vos Christopher J Murray

Lancet 2015 Dec 11;386(10010):2287-323. Epub 2015 Sep 11.

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(15)00128-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685753PMC
December 2015

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition.

Authors:
Christopher J L Murray Ryan M Barber Kyle J Foreman Ayse Abbasoglu Ozgoren Foad Abd-Allah Semaw F Abera Victor Aboyans Jerry P Abraham Ibrahim Abubakar Laith J Abu-Raddad Niveen M Abu-Rmeileh Tom Achoki Ilana N Ackerman Zanfina Ademi Arsène K Adou José C Adsuar Ashkan Afshin Emilie E Agardh Sayed Saidul Alam Deena Alasfoor Mohammed I Albittar Miguel A Alegretti Zewdie A Alemu Rafael Alfonso-Cristancho Samia Alhabib Raghib Ali François Alla Peter Allebeck Mohammad A Almazroa Ubai Alsharif Elena Alvarez Nelson Alvis-Guzman Azmeraw T Amare Emmanuel A Ameh Heresh Amini Walid Ammar H Ross Anderson Benjamin O Anderson Carl Abelardo T Antonio Palwasha Anwari Johan Arnlöv Valentina S Arsic Arsenijevic Al Artaman Rana J Asghar Reza Assadi Lydia S Atkins Marco A Avila Baffour Awuah Victoria F Bachman Alaa Badawi Maria C Bahit Kalpana Balakrishnan Amitava Banerjee Suzanne L Barker-Collo Simon Barquera Lars Barregard Lope H Barrero Arindam Basu Sanjay Basu Mohammed O Basulaiman Justin Beardsley Neeraj Bedi Ettore Beghi Tolesa Bekele Michelle L Bell Corina Benjet Derrick A Bennett Isabela M Bensenor Habib Benzian Eduardo Bernabé Amelia Bertozzi-Villa Tariku J Beyene Neeraj Bhala Ashish Bhalla Zulfiqar A Bhutta Kelly Bienhoff Boris Bikbov Stan Biryukov Jed D Blore Christopher D Blosser Fiona M Blyth Megan A Bohensky Ian W Bolliger Berrak Bora Başara Natan M Bornstein Dipan Bose Soufiane Boufous Rupert R A Bourne Lindsay N Boyers Michael Brainin Carol E Brayne Alexandra Brazinova Nicholas J K Breitborde Hermann Brenner Adam D Briggs Peter M Brooks Jonathan C Brown Traolach S Brugha Rachelle Buchbinder Geoffrey C Buckle Christine M Budke Anne Bulchis Andrew G Bulloch Ismael R Campos-Nonato Hélène Carabin Jonathan R Carapetis Rosario Cárdenas David O Carpenter Valeria Caso Carlos A Castañeda-Orjuela Ruben E Castro Ferrán Catalá-López Fiorella Cavalleri Alanur Çavlin Vineet K Chadha Jung-Chen Chang Fiona J Charlson Honglei Chen Wanqing Chen Peggy P Chiang Odgerel Chimed-Ochir Rajiv Chowdhury Hanne Christensen Costas A Christophi Massimo Cirillo Matthew M Coates Luc E Coffeng Megan S Coggeshall Valentina Colistro Samantha M Colquhoun Graham S Cooke Cyrus Cooper Leslie T Cooper Luis M Coppola Monica Cortinovis Michael H Criqui John A Crump Lucia Cuevas-Nasu Hadi Danawi Lalit Dandona Rakhi Dandona Emily Dansereau Paul I Dargan Gail Davey Adrian Davis Dragos V Davitoiu Anand Dayama Diego De Leo Louisa Degenhardt Borja Del Pozo-Cruz Robert P Dellavalle Kebede Deribe Sarah Derrett Don C Des Jarlais Muluken Dessalegn Samath D Dharmaratne Mukesh K Dherani Cesar Diaz-Torné Daniel Dicker Eric L Ding Klara Dokova E Ray Dorsey Tim R Driscoll Leilei Duan Herbert C Duber Beth E Ebel Karen M Edmond Yousef M Elshrek Matthias Endres Sergey P Ermakov Holly E Erskine Babak Eshrati Alireza Esteghamati Kara Estep Emerito Jose A Faraon Farshad Farzadfar Derek F Fay Valery L Feigin David T Felson Seyed-Mohammad Fereshtehnejad Jefferson G Fernandes Alize J Ferrari Christina Fitzmaurice Abraham D Flaxman Thomas D Fleming Nataliya Foigt Mohammad H Forouzanfar F Gerry R Fowkes Urbano Fra Paleo Richard C Franklin Thomas Fürst Belinda Gabbe Lynne Gaffikin Fortuné G Gankpé Johanna M Geleijnse Bradford D Gessner Peter Gething Katherine B Gibney Maurice Giroud Giorgia Giussani Hector Gomez Dantes Philimon Gona Diego González-Medina Richard A Gosselin Carolyn C Gotay Atsushi Goto Hebe N Gouda Nicholas Graetz Harish C Gugnani Rahul Gupta Rajeev Gupta Reyna A Gutiérrez Juanita Haagsma Nima Hafezi-Nejad Holly Hagan Yara A Halasa Randah R Hamadeh Hannah Hamavid Mouhanad Hammami Jamie Hancock Graeme J Hankey Gillian M Hansen Yuantao Hao Hilda L Harb Josep Maria Haro Rasmus Havmoeller Simon I Hay Roderick J Hay Ileana B Heredia-Pi Kyle R Heuton Pouria Heydarpour Hideki Higashi Martha Hijar Hans W Hoek Howard J Hoffman H Dean Hosgood Mazeda Hossain Peter J Hotez Damian G Hoy Mohamed Hsairi Guoqing Hu Cheng Huang John J Huang Abdullatif Husseini Chantal Huynh Marissa L Iannarone Kim M Iburg Kaire Innos Manami Inoue Farhad Islami Kathryn H Jacobsen Deborah L Jarvis Simerjot K Jassal Sun Ha Jee Panniyammakal Jeemon Paul N Jensen Vivekanand Jha Guohong Jiang Ying Jiang Jost B Jonas Knud Juel Haidong Kan André Karch Corine K Karema Chante Karimkhani Ganesan Karthikeyan Nicholas J Kassebaum Anil Kaul Norito Kawakami Konstantin Kazanjan Andrew H Kemp Andre P Kengne Andre Keren Yousef S Khader Shams Eldin A Khalifa Ejaz A Khan Gulfaraz Khan Young-Ho Khang Christian Kieling Daniel Kim Sungroul Kim Yunjin Kim Yohannes Kinfu Jonas M Kinge Miia Kivipelto Luke D Knibbs Ann Kristin Knudsen Yoshihiro Kokubo Soewarta Kosen Sanjay Krishnaswami Barthelemy Kuate Defo Burcu Kucuk Bicer Ernst J Kuipers Chanda Kulkarni Veena S Kulkarni G Anil Kumar Hmwe H Kyu Taavi Lai Ratilal Lalloo Tea Lallukka Hilton Lam Qing Lan Van C Lansingh Anders Larsson Alicia E B Lawrynowicz Janet L Leasher James Leigh Ricky Leung Carly E Levitz Bin Li Yichong Li Yongmei Li Stephen S Lim Maggie Lind Steven E Lipshultz Shiwei Liu Yang Liu Belinda K Lloyd Katherine T Lofgren Giancarlo Logroscino Katharine J Looker Joannie Lortet-Tieulent Paulo A Lotufo Rafael Lozano Robyn M Lucas Raimundas Lunevicius Ronan A Lyons Stefan Ma Michael F Macintyre Mark T Mackay Marek Majdan Reza Malekzadeh Wagner Marcenes David J Margolis Christopher Margono Melvin B Marzan Joseph R Masci Mohammad T Mashal Richard Matzopoulos Bongani M Mayosi Tasara T Mazorodze Neil W Mcgill John J Mcgrath Martin Mckee Abigail Mclain Peter A Meaney Catalina Medina Man Mohan Mehndiratta Wubegzier Mekonnen Yohannes A Melaku Michele Meltzer Ziad A Memish George A Mensah Atte Meretoja Francis A Mhimbira Renata Micha Ted R Miller Edward J Mills Philip B Mitchell Charles N Mock Norlinah Mohamed Ibrahim Karzan A Mohammad Ali H Mokdad Glen L D Mola Lorenzo Monasta Julio C Montañez Hernandez Marcella Montico Thomas J Montine Meghan D Mooney Ami R Moore Maziar Moradi-Lakeh Andrew E Moran Rintaro Mori Joanna Moschandreas Wilkister N Moturi Madeline L Moyer Dariush Mozaffarian William T Msemburi Ulrich O Mueller Mitsuru Mukaigawara Erin C Mullany Michele E Murdoch Joseph Murray Kinnari S Murthy Mohsen Naghavi Aliya Naheed Kovin S Naidoo Luigi Naldi Devina Nand Vinay Nangia K M Venkat Narayan Chakib Nejjari Sudan P Neupane Charles R Newton Marie Ng Frida N Ngalesoni Grant Nguyen Muhammad I Nisar Sandra Nolte Ole F Norheim Rosana E Norman Bo Norrving Luke Nyakarahuka In-Hwan Oh Takayoshi Ohkubo Summer L Ohno Bolajoko O Olusanya John Nelson Opio Katrina Ortblad Alberto Ortiz Amanda W Pain Jeyaraj D Pandian Carlo Irwin A Panelo Christina Papachristou Eun-Kee Park Jae-Hyun Park Scott B Patten George C Patton Vinod K Paul Boris I Pavlin Neil Pearce David M Pereira Rogelio Perez-Padilla Fernando Perez-Ruiz Norberto Perico Aslam Pervaiz Konrad Pesudovs Carrie B Peterson Max Petzold Michael R Phillips Bryan K Phillips David E Phillips Frédéric B Piel Dietrich Plass Dan Poenaru Suzanne Polinder Daniel Pope Svetlana Popova Richie G Poulton Farshad Pourmalek Dorairaj Prabhakaran Noela M Prasad Rachel L Pullan Dima M Qato D Alex Quistberg Anwar Rafay Kazem Rahimi Sajjad U Rahman Murugesan Raju Saleem M Rana Homie Razavi K Srinath Reddy Amany Refaat Giuseppe Remuzzi Serge Resnikoff Antonio L Ribeiro Lee Richardson Jan Hendrik Richardus D Allen Roberts David Rojas-Rueda Luca Ronfani Gregory A Roth Dietrich Rothenbacher David H Rothstein Jane T Rowley Nobhojit Roy George M Ruhago Mohammad Y Saeedi Sukanta Saha Mohammad Ali Sahraian Uchechukwu K A Sampson Juan R Sanabria Logan Sandar Itamar S Santos Maheswar Satpathy Monika Sawhney Peter Scarborough Ione J Schneider Ben Schöttker Austin E Schumacher David C Schwebel James G Scott Soraya Seedat Sadaf G Sepanlou Peter T Serina Edson E Servan-Mori Katya A Shackelford Amira Shaheen Saeid Shahraz Teresa Shamah Levy Siyi Shangguan Jun She Sara Sheikhbahaei Peilin Shi Kenji Shibuya Yukito Shinohara Rahman Shiri Kawkab Shishani Ivy Shiue Mark G Shrime Inga D Sigfusdottir Donald H Silberberg Edgar P Simard Shireen Sindi Abhishek Singh Jasvinder A Singh Lavanya Singh Vegard Skirbekk Erica Leigh Slepak Karen Sliwa Samir Soneji Kjetil Søreide Sergey Soshnikov Luciano A Sposato Chandrashekhar T Sreeramareddy Jeffrey D Stanaway Vasiliki Stathopoulou Dan J Stein Murray B Stein Caitlyn Steiner Timothy J Steiner Antony Stevens Andrea Stewart Lars J Stovner Konstantinos Stroumpoulis Bruno F Sunguya Soumya Swaminathan Mamta Swaroop Bryan L Sykes Karen M Tabb Ken Takahashi Nikhil Tandon David Tanne Marcel Tanner Mohammad Tavakkoli Hugh R Taylor Braden J Te Ao Fabrizio Tediosi Awoke M Temesgen Tara Templin Margreet Ten Have Eric Y Tenkorang Abdullah S Terkawi Blake Thomson Andrew L Thorne-Lyman Amanda G Thrift George D Thurston Taavi Tillmann Marcello Tonelli Fotis Topouzis Hideaki Toyoshima Jefferson Traebert Bach X Tran Matias Trillini Thomas Truelsen Miltiadis Tsilimbaris Emin M Tuzcu Uche S Uchendu Kingsley N Ukwaja Eduardo A Undurraga Selen B Uzun Wim H Van Brakel Steven Van De Vijver Coen H van Gool Jim Van Os Tommi J Vasankari N Venketasubramanian Francesco S Violante Vasiliy V Vlassov Stein Emil Vollset Gregory R Wagner Joseph Wagner Stephen G Waller Xia Wan Haidong Wang Jianli Wang Linhong Wang Tati S Warouw Scott Weichenthal Elisabete Weiderpass Robert G Weintraub Wang Wenzhi Andrea Werdecker Ronny Westerman Harvey A Whiteford James D Wilkinson Thomas N Williams Charles D Wolfe Timothy M Wolock Anthony D Woolf Sarah Wulf Brittany Wurtz Gelin Xu Lijing L Yan Yuichiro Yano Pengpeng Ye Gökalp K Yentür Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Z Younis Chuanhua Yu Maysaa E Zaki Yong Zhao Yingfeng Zheng David Zonies Xiaonong Zou Joshua A Salomon Alan D Lopez Theo Vos

Lancet 2015 Nov 28;386(10009):2145-91. Epub 2015 Aug 28.

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

Methods: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

Findings: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

Interpretation: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(15)61340-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673910PMC
November 2015

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Authors:
Christopher J L Murray Katrina F Ortblad Caterina Guinovart Stephen S Lim Timothy M Wolock D Allen Roberts Emily A Dansereau Nicholas Graetz Ryan M Barber Jonathan C Brown Haidong Wang Herbert C Duber Mohsen Naghavi Daniel Dicker Lalit Dandona Joshua A Salomon Kyle R Heuton Kyle Foreman David E Phillips Thomas D Fleming Abraham D Flaxman Bryan K Phillips Elizabeth K Johnson Megan S Coggeshall Foad Abd-Allah Semaw Ferede Abera Jerry P Abraham Ibrahim Abubakar Laith J Abu-Raddad Niveen Me Abu-Rmeileh Tom Achoki Austine Olufemi Adeyemo Arsène Kouablan Adou José C Adsuar Emilie Elisabet Agardh Dickens Akena Mazin J Al Kahbouri Deena Alasfoor Mohammed I Albittar Gabriel Alcalá-Cerra Miguel Angel Alegretti Zewdie Aderaw Alemu Rafael Alfonso-Cristancho Samia Alhabib Raghib Ali Francois Alla Peter J Allen Ubai Alsharif Elena Alvarez Nelson Alvis-Guzman Adansi A Amankwaa Azmeraw T Amare Hassan Amini Walid Ammar Benjamin O Anderson Carl Abelardo T Antonio Palwasha Anwari Johan Arnlöv Valentina S Arsic Arsenijevic Ali Artaman Rana J Asghar Reza Assadi Lydia S Atkins Alaa Badawi Kalpana Balakrishnan Amitava Banerjee Sanjay Basu Justin Beardsley Tolesa Bekele Michelle L Bell Eduardo Bernabe Tariku Jibat Beyene Neeraj Bhala Ashish Bhalla Zulfiqar A Bhutta Aref Bin Abdulhak Agnes Binagwaho Jed D Blore Berrak Bora Basara Dipan Bose Michael Brainin Nicholas Breitborde Carlos A Castañeda-Orjuela Ferrán Catalá-López Vineet K Chadha Jung-Chen Chang Peggy Pei-Chia Chiang Ting-Wu Chuang Mercedes Colomar Leslie Trumbull Cooper Cyrus Cooper Karen J Courville Benjamin C Cowie Michael H Criqui Rakhi Dandona Anand Dayama Diego De Leo Louisa Degenhardt Borja Del Pozo-Cruz Kebede Deribe Don C Des Jarlais Muluken Dessalegn Samath D Dharmaratne Uğur Dilmen Eric L Ding Tim R Driscoll Adnan M Durrani Richard G Ellenbogen Sergey Petrovich Ermakov Alireza Esteghamati Emerito Jose A Faraon Farshad Farzadfar Seyed-Mohammad Fereshtehnejad Daniel Obadare Fijabi Mohammad H Forouzanfar Urbano Fra Paleo Lynne Gaffikin Amiran Gamkrelidze Fortuné Gbètoho Gankpé Johanna M Geleijnse Bradford D Gessner Katherine B Gibney Ibrahim Abdelmageem Mohamed Ginawi Elizabeth L Glaser Philimon Gona Atsushi Goto Hebe N Gouda Harish Chander Gugnani Rajeev Gupta Rahul Gupta Nima Hafezi-Nejad Randah Ribhi Hamadeh Mouhanad Hammami Graeme J Hankey Hilda L Harb Josep Maria Haro Rasmus Havmoeller Simon I Hay Mohammad T Hedayati Ileana B Heredia Pi Hans W Hoek John C Hornberger H Dean Hosgood Peter J Hotez Damian G Hoy John J Huang Kim M Iburg Bulat T Idrisov Kaire Innos Kathryn H Jacobsen Panniyammakal Jeemon Paul N Jensen Vivekanand Jha Guohong Jiang Jost B Jonas Knud Juel Haidong Kan Ida Kankindi Nadim E Karam André Karch Corine Kakizi Karema Anil Kaul Norito Kawakami Dhruv S Kazi Andrew H Kemp Andre Pascal Kengne Andre Keren Maia Kereselidze Yousef Saleh Khader Shams Eldin Ali Hassan Khalifa Ejaz Ahmed Khan Young-Ho Khang Irma Khonelidze Yohannes Kinfu Jonas M Kinge Luke Knibbs Yoshihiro Kokubo S Kosen Barthelemy Kuate Defo Veena S Kulkarni Chanda Kulkarni Kaushalendra Kumar Ravi B Kumar G Anil Kumar Gene F Kwan Taavi Lai Arjun Lakshmana Balaji Hilton Lam Qing Lan Van C Lansingh Heidi J Larson Anders Larsson Jong-Tae Lee James Leigh Mall Leinsalu Ricky Leung Yichong Li Yongmei Li Graça Maria Ferreira De Lima Hsien-Ho Lin Steven E Lipshultz Shiwei Liu Yang Liu Belinda K Lloyd Paulo A Lotufo Vasco Manuel Pedro Machado Jennifer H Maclachlan Carlos Magis-Rodriguez Marek Majdan Christopher Chabila Mapoma Wagner Marcenes Melvin Barrientos Marzan Joseph R Masci Mohammad Taufiq Mashal Amanda J Mason-Jones Bongani M Mayosi Tasara T Mazorodze Abigail Cecilia Mckay Peter A Meaney Man Mohan Mehndiratta Fabiola Mejia-Rodriguez Yohannes Adama Melaku Ziad A Memish Walter Mendoza Ted R Miller Edward J Mills Karzan Abdulmuhsin Mohammad Ali H Mokdad Glen Liddell Mola Lorenzo Monasta Marcella Montico Ami R Moore Rintaro Mori Wilkister Nyaora Moturi Mitsuru Mukaigawara Kinnari S Murthy Aliya Naheed Kovin S Naidoo Luigi Naldi Vinay Nangia K M Venkat Narayan Denis Nash Chakib Nejjari Robert G Nelson Sudan Prasad Neupane Charles R Newton Marie Ng Muhammad Imran Nisar Sandra Nolte Ole F Norheim Vincent Nowaseb Luke Nyakarahuka In-Hwan Oh Takayoshi Ohkubo Bolajoko O Olusanya Saad B Omer John Nelson Opio Orish Ebere Orisakwe Jeyaraj D Pandian Christina Papachristou Angel J Paternina Caicedo Scott B Patten Vinod K Paul Boris Igor Pavlin Neil Pearce David M Pereira Aslam Pervaiz Konrad Pesudovs Max Petzold Farshad Pourmalek Dima Qato Amado D Quezada D Alex Quistberg Anwar Rafay Kazem Rahimi Vafa Rahimi-Movaghar Sajjad Ur Rahman Murugesan Raju Saleem M Rana Homie Razavi Robert Quentin Reilly Giuseppe Remuzzi Jan Hendrik Richardus Luca Ronfani Nobhojit Roy Nsanzimana Sabin Mohammad Yahya Saeedi Mohammad Ali Sahraian Genesis May J Samonte Monika Sawhney Ione J C Schneider David C Schwebel Soraya Seedat Sadaf G Sepanlou Edson E Servan-Mori Sara Sheikhbahaei Kenji Shibuya Hwashin Hyun Shin Ivy Shiue Rupak Shivakoti Inga Dora Sigfusdottir Donald H Silberberg Andrea P Silva Edgar P Simard Jasvinder A Singh Vegard Skirbekk Karen Sliwa Samir Soneji Sergey S Soshnikov Chandrashekhar T Sreeramareddy Vasiliki Kalliopi Stathopoulou Konstantinos Stroumpoulis Soumya Swaminathan Bryan L Sykes Karen M Tabb Roberto Tchio Talongwa Eric Yeboah Tenkorang Abdullah Sulieman Terkawi Alan J Thomson Andrew L Thorne-Lyman Jeffrey A Towbin Jefferson Traebert Bach X Tran Zacharie Tsala Dimbuene Miltiadis Tsilimbaris Uche S Uchendu Kingsley N Ukwaja Selen Begüm Uzun Andrew J Vallely Tommi J Vasankari N Venketasubramanian Francesco S Violante Vasiliy Victorovich Vlassov Stein Emil Vollset Stephen Waller Mitchell T Wallin Linhong Wang XiaoRong Wang Yanping Wang Scott Weichenthal Elisabete Weiderpass Robert G Weintraub Ronny Westerman Richard A White James D Wilkinson Thomas Neil Williams Solomon Meseret Woldeyohannes John Q Wong Gelin Xu Yang C Yang Yuichiro Yano Gokalp Kadri Yentur Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Younis Chuanhua Yu Kim Yun Jin Maysaa El Sayed Zaki Yong Zhao Yingfeng Zheng Maigeng Zhou Jun Zhu Xiao Nong Zou Alan D Lopez Theo Vos

Lancet 2014 Sep 22;384(9947):1005-70. Epub 2014 Jul 22.

Institute for Health Metrics and Evaluation, Seattle, WA, USA.

Background: The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.

Methods: To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

Findings: Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

Interpretation: Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(14)60844-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202387PMC
September 2014

Hepatitis A and E: not to be forgotten.

Authors:
Rana J Asghar

East Mediterr Health J 2014 Apr 3;20(3):212-3. Epub 2014 Apr 3.

South Asian Public Health Forum.

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April 2014

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Authors:
Nicholas J Kassebaum Amelia Bertozzi-Villa Megan S Coggeshall Katya A Shackelford Caitlyn Steiner Kyle R Heuton Diego Gonzalez-Medina Ryan Barber Chantal Huynh Daniel Dicker Tara Templin Timothy M Wolock Ayse Abbasoglu Ozgoren Foad Abd-Allah Semaw Ferede Abera Ibrahim Abubakar Tom Achoki Ademola Adelekan Zanfina Ademi Arsène Kouablan Adou José C Adsuar Emilie E Agardh Dickens Akena Deena Alasfoor Zewdie Aderaw Alemu Rafael Alfonso-Cristancho Samia Alhabib Raghib Ali Mazin J Al Kahbouri François Alla Peter J Allen Mohammad A AlMazroa Ubai Alsharif Elena Alvarez Nelson Alvis-Guzmán Adansi A Amankwaa Azmeraw T Amare Hassan Amini Walid Ammar Carl A T Antonio Palwasha Anwari Johan Arnlöv Valentina S Arsic Arsenijevic Ali Artaman Majed Masoud Asad Rana J Asghar Reza Assadi Lydia S Atkins Alaa Badawi Kalpana Balakrishnan Arindam Basu Sanjay Basu Justin Beardsley Neeraj Bedi Tolesa Bekele Michelle L Bell Eduardo Bernabe Tariku J Beyene Zulfiqar Bhutta Aref Bin Abdulhak Jed D Blore Berrak Bora Basara Dipan Bose Nicholas Breitborde Rosario Cárdenas Carlos A Castañeda-Orjuela Ruben Estanislao Castro Ferrán Catalá-López Alanur Cavlin Jung-Chen Chang Xuan Che Costas A Christophi Sumeet S Chugh Massimo Cirillo Samantha M Colquhoun Leslie Trumbull Cooper Cyrus Cooper Iuri da Costa Leite Lalit Dandona Rakhi Dandona Adrian Davis Anand Dayama Louisa Degenhardt Diego De Leo Borja del Pozo-Cruz Kebede Deribe Muluken Dessalegn Gabrielle A deVeber Samath D Dharmaratne Uğur Dilmen Eric L Ding Rob E Dorrington Tim R Driscoll Sergei Petrovich Ermakov Alireza Esteghamati Emerito Jose A Faraon Farshad Farzadfar Manuela Mendonca Felicio Seyed-Mohammad Fereshtehnejad Graça Maria Ferreira de Lima Mohammad H Forouzanfar Elisabeth B França Lynne Gaffikin Ketevan Gambashidze Fortuné Gbètoho Gankpé Ana C Garcia Johanna M Geleijnse Katherine B Gibney Maurice Giroud Elizabeth L Glaser Ketevan Goginashvili Philimon Gona Dinorah González-Castell Atsushi Goto Hebe N Gouda Harish Chander Gugnani Rahul Gupta Rajeev Gupta Nima Hafezi-Nejad Randah Ribhi Hamadeh Mouhanad Hammami Graeme J Hankey Hilda L Harb Rasmus Havmoeller Simon I Hay Ileana B Heredia Pi Hans W Hoek H Dean Hosgood Damian G Hoy Abdullatif Husseini Bulat T Idrisov Kaire Innos Manami Inoue Kathryn H Jacobsen Eiman Jahangir Sun Ha Jee Paul N Jensen Vivekanand Jha Guohong Jiang Jost B Jonas Knud Juel Edmond Kato Kabagambe Haidong Kan Nadim E Karam André Karch Corine Kakizi Karema Anil Kaul Norito Kawakami Konstantin Kazanjan Dhruv S Kazi Andrew H Kemp Andre Pascal Kengne Maia Kereselidze Yousef Saleh Khader Shams Eldin Ali Hassan Khalifa Ejaz Ahmed Khan Young-Ho Khang Luke Knibbs Yoshihiro Kokubo Soewarta Kosen Barthelemy Kuate Defo Chanda Kulkarni Veena S Kulkarni G Anil Kumar Kaushalendra Kumar Ravi B Kumar Gene Kwan Taavi Lai Ratilal Lalloo Hilton Lam Van C Lansingh Anders Larsson Jong-Tae Lee James Leigh Mall Leinsalu Ricky Leung Xiaohong Li Yichong Li Yongmei Li Juan Liang Xiaofeng Liang Stephen S Lim Hsien-Ho Lin Steven E Lipshultz Shiwei Liu Yang Liu Belinda K Lloyd Stephanie J London Paulo A Lotufo Jixiang Ma Stefan Ma Vasco Manuel Pedro Machado Nana Kwaku Mainoo Marek Majdan Christopher Chabila Mapoma Wagner Marcenes Melvin Barrientos Marzan Amanda J Mason-Jones Man Mohan Mehndiratta Fabiola Mejia-Rodriguez Ziad A Memish Walter Mendoza Ted R Miller Edward J Mills Ali H Mokdad Glen Liddell Mola Lorenzo Monasta Jonathan de la Cruz Monis Julio Cesar Montañez Hernandez Ami R Moore Maziar Moradi-Lakeh Rintaro Mori Ulrich O Mueller Mitsuru Mukaigawara Aliya Naheed Kovin S Naidoo Devina Nand Vinay Nangia Denis Nash Chakib Nejjari Robert G Nelson Sudan Prasad Neupane Charles R Newton Marie Ng Mark J Nieuwenhuijsen Muhammad Imran Nisar Sandra Nolte Ole F Norheim Luke Nyakarahuka In-Hwan Oh Takayoshi Ohkubo Bolajoko O Olusanya Saad B Omer John Nelson Opio Orish Ebere Orisakwe Jeyaraj D Pandian Christina Papachristou Jae-Hyun Park Angel J Paternina Caicedo Scott B Patten Vinod K Paul Boris Igor Pavlin Neil Pearce David M Pereira Konrad Pesudovs Max Petzold Dan Poenaru Guilherme V Polanczyk Suzanne Polinder Dan Pope Farshad Pourmalek Dima Qato D Alex Quistberg Anwar Rafay Kazem Rahimi Vafa Rahimi-Movaghar Sajjad ur Rahman Murugesan Raju Saleem M Rana Amany Refaat Luca Ronfani Nobhojit Roy Tania Georgina Sánchez Pimienta Mohammad Ali Sahraian Joshua A Salomon Uchechukwu Sampson Itamar S Santos Monika Sawhney Felix Sayinzoga Ione J C Schneider Austin Schumacher David C Schwebel Soraya Seedat Sadaf G Sepanlou Edson E Servan-Mori Marina Shakh-Nazarova Sara Sheikhbahaei Kenji Shibuya Hwashin Hyun Shin Ivy Shiue Inga Dora Sigfusdottir Donald H Silberberg Andrea P Silva Jasvinder A Singh Vegard Skirbekk Karen Sliwa Sergey S Soshnikov Luciano A Sposato Chandrashekhar T Sreeramareddy Konstantinos Stroumpoulis Lela Sturua Bryan L Sykes Karen M Tabb Roberto Tchio Talongwa Feng Tan Carolina Maria Teixeira Eric Yeboah Tenkorang Abdullah Sulieman Terkawi Andrew L Thorne-Lyman David L Tirschwell Jeffrey A Towbin Bach X Tran Miltiadis Tsilimbaris Uche S Uchendu Kingsley N Ukwaja Eduardo A Undurraga Selen Begüm Uzun Andrew J Vallely Coen H van Gool Tommi J Vasankari Monica S Vavilala N Venketasubramanian Salvador Villalpando Francesco S Violante Vasiliy Victorovich Vlassov Theo Vos Stephen Waller Haidong Wang Linhong Wang XiaoRong Wang Yanping Wang Scott Weichenthal Elisabete Weiderpass Robert G Weintraub Ronny Westerman James D Wilkinson Solomon Meseret Woldeyohannes John Q Wong Muluemebet Abera Wordofa Gelin Xu Yang C Yang Yuichiro Yano Gokalp Kadri Yentur Paul Yip Naohiro Yonemoto Seok-Jun Yoon Mustafa Z Younis Chuanhua Yu Kim Yun Jin Maysaa El Sayed Zaki Yong Zhao Yingfeng Zheng Maigeng Zhou Jun Zhu Xiao Nong Zou Alan D Lopez Mohsen Naghavi Christopher J L Murray Rafael Lozano

Lancet 2014 Sep 2;384(9947):980-1004. Epub 2014 May 2.

Institute for Health Metrics and Evaluation, Seattle, WA, USA; National Institute of Public Health, Cuernavaca, Mexico.

Background: The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

Methods: We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

Findings: 292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

Interpretation: Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(14)60696-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255481PMC
September 2014

HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan.

J Epidemiol Glob Health 2013 Dec 8;3(4):261-8. Epub 2013 Jul 8.

Field Epidemiology and Laboratory Training Programme, NIH, Pakistan.

Background: In June-July 2008 a non-governmental organization (NGO) in Jalalpur Jattan (JPJ), Gujrat, Pakistan arranged two voluntary HIV screening camps after numerous HIV-infected persons reported to their treatment center in Lahore; 88 (35.8%) of 246 persons screened in those camps were positive by rapid test. Intense media coverage made the residents of JPJ hostile to further inquiries. The Pakistan Field Epidemiology Training and Laboratory Training Program (FELTP) was requested by the Provincial AIDS Control Program to carry out an epidemiological investigation.

Methods: HIV-positive persons or family members of patients who died of AIDS and consented to be interviewed during the period 15 December 2008 to 2 January 2009 were investigated. Enhanced contact tracing was done to identify additional cases. A structured questionnaire was used to collect data regarding clinical history, risk factors, and HIV knowledge and practices. The national HIV/STI Referral Laboratory collected blood samples for HIV serology and molecular studies independently following pre- and post-counseling.

Results: A total of 53 HIV-infected persons were investigated. Out of these, 47 (88.7%) were alive at the time of investigation and 27 (50.9%) of the cases were female with 6 children aged 10years or less. Median age was 35years (mean 34.7, range 3-70). Most frequent symptoms were unexplained fever 42 (79.2%), diarrhea 34 (64.15%) and skin infections 27 (50.9%); 13 (24.5%) had co-infection with tuberculosis (TB) and 10 (18.9%) with hepatitis (B or C). Use of injections 51 (96.2%), dental procedures 21 (40%) and barber shop visits among males 18 (72%) were common risk factors. Extramarital sex was reported by 4 (9.4%). Only 19 (35.8%) were aware that HIV can be sexually transmitted and 18 (34%) were aware of HIV transmission by blood transfusion. Phylogenetic analysis revealed HIV infection in this group was HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather than an outbreak.

Conclusion: The investigation indicates high rates of HIV infection in JPJ. Unlike other studies from Pakistan, a high proportion of cases in females and children less than 10years of age were observed. Socio-cultural norms and stigmatization limited in-depth investigation of sexual and behavioral practices and history of drug abuse. A shift of HIV infection from high-risk groups to the general population was seen and requires vigilant surveillance besides targeted health education, clinical management, lab facilities for diagnosis and monitoring, and voluntary counseling and testing services to limit disease spread.
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http://dx.doi.org/10.1016/j.jegh.2013.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320408PMC
December 2013

Limited utility of name-based tuberculosis contact investigations among persons using illicit drugs: results of an outbreak investigation.

J Urban Health 2009 Sep 16;86(5):776-80. Epub 2009 Jun 16.

Epidemic Intelligence Service, Office of Workforce and Career Development and Division of Global Public Health Capacity Development, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Persons named by a patient with tuberculosis (TB) are the focus of traditional TB contact investigations. However, patients who use illicit drugs are often reluctant to name contacts. Between January 2004 and May 2005, 18 isoniazid-resistant TB cases with matching Mycobacterium tuberculosis genotypes (spoligotypes) were reported in Miami; most patients frequented crack houses and did not name potentially infected contacts. We reviewed medical records and re-interviewed patients about contacts and locations frequented to describe transmission patterns and make recommendations to control TB in this population. Observed contacts were not named but were encountered at the same crack houses as the patients. Contacts were evaluated for latent TB infection with a tuberculosis skin test (TST). All 18 patients had pulmonary TB. Twelve (67%) reported crack use and 14 (78%) any illicit drug use. Of the 187 contacts evaluated, 91 (49%) were named, 16 (8%) attended a church reported by a patient, 61 (33%) used a dialysis center reported by a patient, and 19 (10%) were observed contacts at local crack houses. Compared to named contacts, observed contacts were eight times as likely to have positive TST results (relative risk = 7.8; 95% confidence interval = 3.8-16.1). Dialysis center and church contacts had no elevated risk of a positive TST result. Testing observed contacts may provide a higher yield than traditional name-based contact investigations for tuberculosis patients who use illicit drugs or frequent venues characterized by illicit drug use.
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http://dx.doi.org/10.1007/s11524-009-9378-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729866PMC
September 2009

Tuberculosis in South Asians living in the United States, 1993-2004.

Arch Intern Med 2008 May;168(9):936-42

Division of Tuberculosis Elimination, Coordinating Office for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

Background: Patients with tuberculosis (TB) in the United States are often described in 2 broad categories, US-born and foreign-born, which may mask differences among different immigrant groups. We determined characteristics of patients born in South Asia and diagnosed as having TB in the United States.

Methods: All 224,101 TB cases reported to the US National Tuberculosis Surveillance System from the 50 states and the District of Columbia from 1993 to 2004 were included. We used descriptive analysis and logistic regression to explore differences among patients born in South Asia, other foreign-born, and US-born TB patients.

Results: Half of the South Asian TB patients (50.5%) in our study were in the 25- to 44-year-old age group, compared with 40.1% of other foreign-born TB patients and 31.8% of US-born TB patients. Compared with other foreign-born TB patients, South Asians were more likely to have extrapulmonary disease (odds ratio [OR], 1.7), more likely to be uninfected with human immunodeficiency virus (HIV) (OR, 5.8) but also more likely not to be offered HIV testing (OR, 9.4) or not to accept an HIV test if offered (OR, 11.8), and more likely not to be homeless (OR, 2.9) or not to use drugs or excess alcohol (OR, 2.7).

Conclusions: South Asian TB patients in the United States are younger and more commonly develop extrapulmonary TB than other foreign-born patients. New TB control strategies that target younger patients and that encourage HIV testing and inform physicians about high extrapulmonary TB in the absence of common risk factors in South Asians are needed.
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http://dx.doi.org/10.1001/archinte.168.9.936DOI Listing
May 2008

Promoting regional health cooperation: the South Asian Public Health Forum.

PLoS Med 2006 May 9;3(5):e108. Epub 2006 May 9.

Centers for Disease Control and Prevention, Atlanta, Georgia, United States.

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http://dx.doi.org/10.1371/journal.pmed.0030108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1457006PMC
May 2006