Elsevier

The Lancet

Volume 380, Issue 9859, 15 December 2012–4 January 2013, Pages 2095-2128
The Lancet

Articles
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010

https://doi.org/10.1016/S0140-6736(12)61728-0Get rights and content

Summary

Background

Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

Methods

We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

Findings

In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45–54% since 1990; ischaemic heart disease and stroke YLLs increased by 17–28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

Interpretation

Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

Funding

Bill & Melinda Gates Foundation.

Introduction

Cause-specific mortality is arguably one of the most fundamental metrics of population health. The rates and numbers of people who die, where, at what age, and from what, is a crucial input into policy debates, planning interventions, and prioritising research for new health technologies. Trends in causes of death provide an important geographical summary of whether society is or is not making progress in reducing the burden of premature (and especially avoidable) mortality and where renewed efforts are needed. If a health information system is not providing timely and accurate information on causes of death by age and sex, major reforms are required to provide health planners with this essential health intelligence.

Despite the importance of tracking causes of death and the tradition since 1893 of standardisation of definitions and coding for causes of death in the International Classification of Diseases and Injuries (ICD), global assessments of causes of death are a major analytical challenge. Vital registration systems that include medical certification of the cause of death captured about 18·8 million deaths of an estimated annual total of 51·7 million deaths in 2005, which is the latest year for which the largest number of countries (100) reported deaths from a vital registration system. Even for these deaths, the comparability of findings on the leading causes of death is affected by variation in certification skills among physicians, the diagnostic and pathological data available at the time of completing a death certificate, variations in medical culture in choosing the underlying cause, and legal and institutional frameworks for governing mortality reporting.1, 2, 3, 4, 5 For the remaining deaths that are not medically certified, many different data sources and diagnostic approaches must be used from surveillance systems, demographic research sites, surveys, censuses, disease registries, and police records to construct a consolidated picture of causes of death in various populations. Because of the variety of data sources and their associated biases, cause of death assessments are inherently uncertain and subject to vigorous debate.6, 7, 8

Efforts to develop global assessments for selected causes began in the 1980s.9, 10, 11 These efforts were motivated partly because the sum of various disease-specific estimates substantially exceeded the estimated number of deaths in the world, particularly for children.12 Lopez and Hull11 attempted to develop a set of estimates of mortality in children younger than 5 years (under-5 mortality) by cause consistent with all-cause mortality data in 1983. The Global Burden of Disease study 1990 (GBD 1990) was the first comprehensive attempt to do so, and included 134 causes covering all age groups. The GBD 1990 cause of death approach was applied with some refinements to yield estimates of causes of death for 1999, 2000, 2001, 2002, 2004, and 2008.13, 14, 15, 16, 17 Over this period, special attention was paid to priority diseases such as malaria, HIV/AIDS, and tuberculosis. The Child Health Epidemiology Reference Group (CHERG) also produced estimates of under-5 mortality from 16 causes that summed to estimates of deaths in children younger than 5 years for 2000–03, 2008, and 2010,18, 19, 20 partly using the GBD 1990 approach combined with other methods, and putting special emphasis on the use of verbal autopsy as a source of data in low-income settings. Additionally to these comprehensive approaches, the tradition of disease-specific analyses that began in the 1980s with global cancer mortality has continued and intensified. In the past 5 years, for example, articles and reports have been published on global mortality from maternal causes,21, 22, 23, 24 malaria,25, 26 tuberculosis,27, 28 HIV/AIDS,29 road traffic accidents,30 site-specific cancers,31, 32 and diabetes,33 among others.34, 35 These assessments of individual causes are based on diverse epidemiological approaches of varying scientific rigour, and, moreover, are not constrained to sum to estimates of all-cause mortality from demographic sources.

Global cause of death assessments can be characterised in four dimensions: the universe of raw data identified and examined, efforts to evaluate and enhance quality and comparability of data, the statistical modelling strategy, and whether causes of death are constrained to sum to all-cause mortality. First, in terms of the universe of data, the various iterations of the GBD and CHERG analysis of deaths in children younger than 5 years have made substantial use of data on causes of death from systems that attempt to capture the event of death. Other single-cause analyses, such as the annual UNAIDS efforts to estimate HIV-related deaths, measles estimates,34 the World Malaria Report,26 the WHO Global TB Control Report,28 and many others have used data on disease incidence or prevalence and on case-fatality rates combined in a model of natural history progression. Second, perhaps the area of greatest variation in the published studies is the efforts to assess and enhance the quality and comparability of available data. These efforts often include very specific steps undertaken for different data sources and are frequently poorly documented. Third, in the past two decades, efforts to develop statistical models for causes of death have become more sophisticated. Compositional models that estimate cause fractions for several causes at once were first applied to global health by Salomon and Murray36 and have been used extensively by CHERG but only for a subset of causes. GBD revisions for 1999, 2000, 2001, 2002, 2004, and 2008 have used these compositional models to allocate deaths according to three broad cause groups: communicable, maternal, neonatal, and nutritional causes; non-communicable diseases; and injuries. More recently, the array of modelling strategies used for causes of death has been broadened to include spatial-temporal Gaussian process regression,22, 37 mixed effects hierarchical models, and ensemble models.38 Given the profusion of statistical modelling options, an important innovation has been the reporting of out-of-sample predictive validity to document the performance of complex models.22, 38

Finally, in view of the developments in the field of mortality and cause of death estimation, for the GBD 2010 we completely re-evaluated all aspects of the GBD analytical strategy, including demographic estimation of all-cause mortality.39, 40 Because of the huge increase in published verbal autopsy studies and the availability in the public domain of cause of death data from government vital registration sources (130 countries), the universe of data has expanded substantially. Assessing and enhancing the quality and comparability of data can now take into account time trends in cause of death data from 1980 to 2010 that provide important insights into changes in certification and coding. Borrowing from other scientific fields, we have changed our analytical approach (see below) to an ensemble modelling strategy to generate more realistic uncertainty intervals (UIs) and more accurate predictions.38 These innovations have been used in estimating mortality for an expanded GBD 2010 cause list of 291 causes compared with 134 in the GBD 1990 Study; of the 291 causes, 235 are causes of mortality, whereas the remaining causes account for years lived with disability (YLDs) but not deaths. We use a unified framework for all causes such that the sum of cause-specific estimates equals the number of deaths from all causes in each country or region, period, age group, and sex. This creates a link between the systematic analysis of data on all-cause mortality reported by Wang and colleagues40 and results by cause presented here. In this Article, we provide a summary overview of the vast array of data and methods that have gone into this revision of the GBD, as well as what we believe are the key global and regional findings of importance for health priority debates.

Section snippets

Methods

Some general aspects of the analytical framework such as the creation of the 21 GBD regions and the full hierarchical cause list including the mapping of the ICD to the GBD 2010 cause list are reported elsewhere.39 Although results are reported in this Article at the regional level for 1990 and 2010, the cause of death analysis has been undertaken at the country level for 187 countries from 1980 to 2010. Use of longer time series improves the performance of many types of estimation models; data

Results

The GBD 2010 cause list divides causes into three broad groups. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes account for 13·2 million (24·9%) of 52·8 million total deaths at all ages in 2010. Non-communicable causes account for 34·5 million or 65·5%. The third category, injuries, accounts for 5·1 million or 9·6%. The continued decrease in deaths from communicable, maternal, neonatal, and nutritional disorders is striking, if not surprising. The number of

Discussion

The GBD 2010 is the most comprehensive and systematic analysis of causes of death undertaken to date. The addition of time trends over 1980–2010 and quantification of uncertainty increases both the utility and the methodological rigour of the results. The global health community can now draw on annual estimates of mortality, by age and sex, for 21 regions of the world, for each year from 1980 to 2010, for 235 separate causes, each with 95% UIs to aid interpretation. These estimates of cause of

References (112)

  • MH Forouzanfar et al.

    Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis

    Lancet

    (2011)
  • E Simons et al.

    Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data

    Lancet

    (2012)
  • JK Rajaratnam et al.

    Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4

    Lancet

    (2010)
  • CJL Murray et al.

    The Global Burden of Disease Study 2010: design, definitions, and metrics

    Lancet

    (2012)
  • H Wang et al.

    Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010

    Lancet

    (2012)
  • T Vos et al.

    Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

    Lancet

    (2012)
  • M Bates et al.

    New global estimates of malaria deaths

    Lancet

    (2012)
  • M Lynch et al.

    New global estimates of malaria deaths

    Lancet

    (2012)
  • NK Shah et al.

    New global estimates of malaria deaths

    Lancet

    (2012)
  • NJ White et al.

    New global estimates of malaria deaths

    Lancet

    (2012)
  • H Nair et al.

    Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis

    Lancet

    (2010)
  • JP Watt et al.

    Burden of disease caused by Haemophilus influenza type b in children younger than 5 years: global estimates

    Lancet

    (2009)
  • J Almirall et al.

    Differences in the etiology of community-acquired pneumonia according to site of care: a population-based study

    Respir Med

    (2007)
  • A Díaz et al.

    Etiology of community-acquired pneumonia in hospitalized patients in chile: the increasing prevalence of respiratory viruses among classic pathogens

    Chest

    (2007)
  • T Maruyama et al.

    A prospective comparison of nursing home-acquired pneumonia with hospital-acquired pneumonia in non-intubated elderly

    Respir Med

    (2008)
  • T Maruyama et al.

    Community-acquired pneumonia and nursing home-acquired pneumonia in the very elderly patients

    Respir Med

    (2010)
  • GYK Ganyaglo et al.

    A 6-year (2004–2009) review of maternal mortality at the Eastern Regional Hospital, Koforidua, Ghana

    Semin Perinatol

    (2012)
  • MQ Almerie et al.

    A 20-year (1989–2008) audit of maternal mortality in Damascus, Syria

    Int J Gynaecol Obstet

    (2011)
  • KS Khan et al.

    WHO analysis of causes of maternal death: a systematic review

    Lancet

    (2006)
  • J Waage et al.

    The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015 Lancet and London International Development Centre Commission

    Lancet

    (2010)
  • R Beaglehole et al.

    Priority actions for the non-communicable disease crisis

    Lancet

    (2011)
  • R Beaglehole et al.

    Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults

    Lancet

    (2003)
  • RA Nugent et al.

    Non-communicable diseases and the Paris Declaration

    Lancet

    (2009)
  • R Geneau et al.

    Raising the priority of preventing chronic diseases: a political process

    Lancet

    (2010)
  • SS Lim et al.

    A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

    Lancet

    (2012)
  • CJL Murray et al.

    Understanding the coronary heart disease versus total cardiovascular mortality paradox: a method to enhance the comparability of cardiovascular death statistics in the United States

    Circulation

    (2006)
  • LT Ruzicka et al.

    The use of cause-of-death statistics for health situation assessment: national and international experiences

    World Health Stat Q

    (1990)
  • AD Lopez

    Causes of death in the industrialized and developing countries: estimates for 1985–1990

  • CD Mathers et al.

    Counting the dead and what they died from: an assessment of the global status of cause of death data

    Bull World Health Organ

    (2005)
  • NC Grassly et al.

    Uncertainty in estimates of HIV/AIDS: the estimation and application of plausibility bounds

    Sex Transm Infect

    (2004)
  • T Hakulinen et al.

    Global and regional mortality patterns by cause of death in 1980

    Int J Epidemiol

    (1986)
  • RA Bulatao et al.

    Global estimates and projections of mortality by cause, 1970–2015

    (1992)
  • AD Lopez et al.

    A note on estimating the cause of death structure in high mortality populations

    Popul Bull UN

    (1982)
  • CJL Murray et al.

    Evidence-based health policy—lessons from the Global Burden of Disease Study

    Science

    (1996)
  • The world health report 2000—Health systems: improving performance

    (2000)
  • The world health report 2001—Mental health: new understanding, new hope

    (2001)
  • The world health report 2002—Reducing risks, promoting healthy life

    (2002)
  • C Mathers et al.

    The Global Burden of Disease: 2004 Update

    (2008)
  • Disease and injury regional estimates. Cause-specific mortality: regional estimates for 2008. World Health Organization

  • Trends in Maternal Mortality: 1990 to 2010

    (2012)
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