Elsevier

The Lancet

Volume 380, Issue 9859, 15 December 2012–4 January 2013, Pages 2197-2223
The Lancet

Articles
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

https://doi.org/10.1016/S0140-6736(12)61689-4Get rights and content

Summary

Background

Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.

Methods

We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.

Findings

Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.

Interpretation

Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.

Funding

Bill & Melinda Gates Foundation.

Introduction

Summary measures of population health combine information on mortality and non-fatal health outcomes to provide unique perspectives on levels of health and key contributing causes to loss of health.1 There are three related but distinct uses of summary measures of population health at the global, regional, national, or subnational levels. Summary measures can be used, first, to compare overall population health across communities and over time; for example, national estimates of healthy life expectancy (HALE) have been published for 191 countries.2 The second and more common use of summary measures is to provide a coherent overall picture as to which diseases, injuries, and risk factors contribute the most to health loss in a given population. The comparative view provided by summary measures helps decision-makers, researchers, and citizens understand what the most important problems are and whether they are getting better or worse. This information, along with information on the costs, intervention effectiveness, and equity implications of health interventions and policy options, lays the foundation for a debate on priorities for health policy action and research that is clearly informed by the best available evidence. Third, summary measures can help guide an assessment of where health information systems are strong or weak by identifying which data sources required for their calculation are missing, of low quality, or highly uncertain. Different users in different contexts will make use of summary measures for any of the three purposes.

The only comprehensive effort to date to estimate summary measures of population health for the world, by cause, is the ongoing Global Burden of Diseases, Injuries, and Risk Factors (GBD) enterprise. For a summary measure of population health, the GBD study uses disability-adjusted life years (DALYs), which are the sum of years of life lost due to premature mortality (YLL) and years lived with disability (YLD). While the term disability has taken on many different meanings in different settings,3, 4, 5, 6, 7 in the GBD lexicon it refers to any short-term or long-term health loss, other than death. The construct of health in the GBD study is defined in terms of functioning, which encompasses multiple domains of health such as mobility, pain, affect, and cognition.8 Final GBD results for 1990 were published in 1996 and 1997.9, 10, 11, 12, 13, 14 GBD estimates were produced for 1999, 2000, 2001, 2002, and 2004 by WHO.15, 16, 17, 18, 19 Although GBD results have been estimated by WHO for 1999–2004, and incorporated new approaches to mortality measurement,20 these updates undertook systematic analysis of the epidemiological data for only a subset of disease sequelae.21 DALY results have been referenced extensively in global health debates and decision-making. The first results from the GBD study for 1990 were published in the World Development Report 1993: Investing in Health.22 The study has led to many national burden of disease studies in developed and developing countries using similar methods.23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 Subnational studies have also been done in many countries.76, 77, 78, 79, 80, 81 Quantifying health loss in terms of DALYs has led to increased attention to mental health problems82 and injuries,83 non-fatal health effects of neglected tropical diseases,84 and more generally non-communicable diseases (NCDs).85

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010)86 has been implemented as a collaboration of seven institutions: the Institute for Health Metrics and Evaluation (IHME) as the coordinating centre providing academic leadership; the University of Queensland School of Population Health; WHO; the Johns Hopkins Bloomberg School of Public Health; the Harvard School of Public Health; Imperial College London; and the University of Tokyo. The GBD 2010 has been undertaken to apply comparable, systematic, and rigorous epidemiological assessment of all diseases and injuries. The number of disease and injury sequelae has expanded from 483 to 1160. The study also uses a much more detailed set of age groups, 20 instead of eight; and 21 regions instead of the 14 used in the GBD 2000 study.86

In the GBD 1990 study, results were computed with several variants of DALYs reflecting different social-value choices for discounting and age-weighting. The base case reported for DALYs used a 3% discount rate and age weights that placed the greatest emphasis on health outcomes in young adults. WHO has continued in its updates for 1999, 2000, 2001, 2002, and 2004 to use this base case set of social-value choices although other variants have been calculated. One publication for 2001 reported discounted DALYs without age-weighting.87 On the basis of broad consultation,86 the base case for DALYs in GBD 2010 has been simplified to omit both discounting and age-weighting. YLLs are calculated with reference to a new reference-standard life expectancy at each age; for example, a death at age 5 years counts as 81·4 YLLs and a death at age 60 counts as 27·8 YLLs.86 The reference standard has been computed on the basis of the lowest age-specific death rates recorded across countries in 2010. YLDs are based on the product of the prevalence of a sequela and its associated disability weight. Of note, the empirical basis for disability weights in the GBD 2010 derives from judgments of the general public about health severity, by contrast with the GBD 1990 study that relied on judgments of health-care professionals.3 A key tenet of the GBD analytical philosophy is not to allow advocates for the importance of specific diseases to choose the disability weights associated with specific disorders (panel).

The goal of the GBD 2010 has been to synthesise available data on the epidemiology of all major diseases and injuries to provide a comprehensive and comparable assessment of the magnitude of 291 diseases and injuries and their associated sequelae in 1990, 2005, and 2010. In this Article, we summarise the results of a large and complex study involving hundreds of researchers. The findings draw on millions of observations of epidemiological parameters over the past three decades. By the synthetic nature of the work, we provide a high-level overview of key findings. Because this study uses consistent definitions and improved methods to assess the GBD over two decades, the findings supersede all previously published GBD results.

Section snippets

Study design

The division of countries into 21 epidemiological regions, the choice of 20 age groups, and the primary methods for each of the 18 components of the study are described by Murray and colleagues.86 We provide only a brief description here. The GBD cause list has 291 diseases and injuries, which are organised in a hierarchy with up to four levels of disaggregation. For each cause, there are from one to 24 sequelae. In total, the study includes 1160 sequelae. The expansion of the cause list and

Results

In 2010, there were a total of 2·490 billion DALYs, or 361 DALYs per 1000 population. Globally, 31·2% of DALYs in 2010 were from YLDs and 68·8% from YLLs. YLDs make very little contribution to the burden in the neonatal age groups but increase to a peak in age group 10–14 years when mortality rates are generally the lowest (figure 1). In nearly all age groups, YLDs make up a larger share of DALYs in women than in men. Globally, YLDs in women caused 50% or more of DALYs up until age 45 years and

Discussion

The GBD 2010 estimates that the number of DALYs for the world in 1990 was 2·503 billion, having decreased by 0·5% in 2010. Relatively small changes in the number of DALYs have occurred because the increase in global population has been largely balanced by a decrease in age-sex-specific DALY rates. The differential effect of population growth, population ageing, and changes in age-sex-specific rates have led to striking changes in the profile of burden in every dimension. Over two decades, the

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