Elsevier

The Lancet

Volume 385, Issue 9963, 10–16 January 2015, Pages 117-171
The Lancet

Articles
Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

https://doi.org/10.1016/S0140-6736(14)61682-2Get rights and content

Summary

Background

Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries.

Methods

We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions.

Findings

Global life expectancy for both sexes increased from 65·3 years (UI 65·0–65·6) in 1990, to 71·5 years (UI 71·0–71·9) in 2013, while the number of deaths increased from 47·5 million (UI 46·8–48·2) to 54·9 million (UI 53·6–56·3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25–39 years and older than 75 years and for men aged 20–49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10·7%, from 4·3 million deaths in 1990 to 4·8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100 000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions.

Interpretation

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade.

Funding

Bill & Melinda Gates Foundation.

Introduction

The Global Burden of Disease (GBD) study provides a unique comprehensive framework to systematically assess national trends in age-specific and sex-specific all-cause and cause-specific mortality. Up-to-date and comprehensive evidence for levels and trends for each country is critical for informed priority setting. Trends quantify progress against explicit health targets, whether local, national, or global, and help to evaluate where programmes are working or not. Quantification across populations and over time using comparable definitions and methods can also enable benchmarking. Regular comprehensive updates about causes of death will identify emerging public health challenges. The GBD 2013 study provides the first GBD study to use a continuously updated approach to global health surveillance.1

The GBD 2010 study, a collaboration of 488 investigators, showed important global and regional trends for all-cause and cause-specific mortality.2, 3, 4, 5, 6, 7, 8 The GBD 2010 reported substantial decreases in child mortality driven by reductions in diarrhoea, lower respiratory infections, and more recently, malaria. The lowest income regions had progressed in combating maternal mortality, HIV/AIDS, tuberculosis, and malaria. Nevertheless, much work remains to be done for these Millennium Development Goal-related diseases. Outside sub-Saharan Africa, 1990–2010 saw rapid shifts towards a larger share of death from non-communicable diseases and injuries and a rising mean age of death. Country analyses using the GBD 2010 database have been reported for China, Iran, Mexico, UK, and USA, taking advantage of the comparable methods and definitions of the GBD to benchmark these countries against their peers.9, 10, 11, 12, 13, 14, 15, 16

Much debate surrounds what should follow the Millennium Development Goals; objective, timely, and comprehensive evidence for the levels and trends in causes of death can be a useful input. Ambitious goals have been discussed,16 such as the elimination of preventable child and maternal mortality in a generation. Targets of zero disease have been formulated for HIV/AIDS, tuberculosis, and malaria by various groups.17, 18, 19, 20, 21, 22, 23 The Lancet Commission on Global health 2035: a world converging within a generation24 suggested that a grand convergence in health can be achieved between poor and rich countries by 2035. Advocates for non-communicable disease programmes argue25 that rapid epidemiological transitions in many regions of the world require broader health goals for the development community. Movements to focus on universal health coverage in the post-2015 health agenda emphasise the consequences of failure to meet basic health-care needs.24, 25, 26, 27

Broad interest in the GBD 2010 has led to the expansion of the GBD collaboration to include more than 1000 investigators in 106 countries. The GBD 2013 not only incorporates newly published or released datasets, particularly from the past 5 years, but also expands the analysis in other ways. We included subnational assessments for provinces of China, states of Mexico, and regions of the UK. These subnational assessments will help national decision makers to identify inequalities and local variation in leading diseases, injuries, and risk factors. The list of causes has been expanded and many new and more detailed data sources incorporated. We report the new findings for the first time at the country-level for 1990–2013.

Section snippets

Study design

The GBD approach to estimating all-cause mortality and cause-specific mortality has been previously described.2, 3 Here, we describe several refinements.28 Figure 1 shows the general analysis of all-cause mortality and cause-specific mortality and their interactions. GBD 2010 included 291 causes of death or disability, of which 235 were causes of death; we have expanded the list to include 306 causes of death or disability, of which 240 are causes of death. The extra causes were added on the

Global all-cause mortality

Global life expectancy at birth for both sexes increased from 65·3 years in 1990, to 71·5 years in 2013, an average increase of 0·27 years per calendar year. Life expectancy increased over this period by 6·6 years for females and 5·8 years for males. Figure 4 shows the yearly change in global life expectancy at birth, with a large drop in the 1990s as a result of the Rwanda genocide and famine in North Korea and the return to increases of about 0·3 years or more per year since 2003. If the

Main findings

The GBD 2013 incorporates many new datasets for cause of death, particularly from China, and new data for 155 other countries. Compared with the GBD 2010, it provides the most comprehensive and up-to-date assessment of causes of death. The results for the GBD 2013 are based on re-estimation of all causes from 1990 to 2013, and thus supersede all previously published GBD time series (panel). Publication of country-level results provides many opportunities for comparing a country's performance

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