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Background: Identifying spatial variation in TB burden can help national TB programs effectively allocate resources to reach and treat all people with TB. However, data limitations pose challenges for subnational TB burden estimation., Methods: We developed a small-area modeling approach using geo-positioned prevalence survey data, case notifications, and geospatial covariates to simultaneously estimate spatial variation in TB incidence and case notification completeness across districts in Uganda from 2016-2019. TB incidence was estimated using 1) cluster-level data from the national 2014-2015 TB prevalence survey transformed to incidence, and 2) case notifications adjusted for geospatial covariates of health system access. The case notification completeness surface was fit jointly using observed case notifications and estimated incidence., Results: Estimated pulmonary TB incidence among adults varied >10-fold across Ugandan districts in 2019. Case detection increased nationwide from 2016 to 2019, and the number of districts with case detection rates >70% quadrupled. District-level estimates of TB incidence were five times more precise than a model using TB prevalence survey data alone., Conclusion: A joint spatial modeling approach provides useful insights for TB program operation, outlining areas where TB incidence estimates are highest and health programs should concentrate their efforts. This approach can be applied in many countries with high TB burden., (© 2024 The Authors.)

Background: The COVID-19 pandemic disrupted health systems in 2020, but it is unclear how financial hardship due to out-of-pocket (OOP) health-care costs was affected. We analysed catastrophic health expenditure (CHE) in 2020 in five countries with available household expenditure data: Belarus, Mexico, Peru, Russia, and Viet Nam. In Mexico and Peru, we also conducted an analysis of drivers of change in CHE in 2020 using publicly available data., Methods: In this time-series analysis, we defined CHE as when OOP health-care spending exceeds 10% of consumption expenditure. Data for 2004-20 were obtained from individual and household level survey microdata (available for Mexico and Peru only), and tabulated data from the National Statistical Committee of Belarus and the World Bank Health Equity and Financial Protection Indicator database (for Viet Nam and Russia). We compared 2020 CHE with the CHE predicted from historical trends using an ensemble model. This method was also used to assess drivers of CHE: insurance coverage, OOP expenditure, and consumption expenditure. Interrupted time-series analysis was used to investigate the role of stay-at-home orders in March, 2020 in changes in health-care use and sector (ie, private vs public)., Findings: In Mexico, CHE increased to 5·6% (95% uncertainty interval [UI] 5·1-6·2) in 2020, higher than predicted (3·2%, 2·5-4·0). In Belarus, CHE was 13·5% (11·8-15·2) in 2020, also higher than predicted (9·7%, 7·7-11·3). CHE was not different than predicted by past trends in Russia, Peru, and Viet Nam. Between March and April, 2020, health-care visits dropped by 4·6 (2·6-6·5) percentage points in Mexico and by 48·3 (40·6-56·0) percentage points in Peru, and the private share of health-care visits increased by 7·3 (4·3-10·3) percentage points in Mexico and by 20·7 (17·3-24·0) percentage points in Peru., Interpretation: In three of the five countries studied, health systems either did not protect people from the financial risks of health care or did not maintain health-care access in 2020, an indication of health systems failing to maintain basic functions. If the 2020 response to the COVID-19 pandemic accelerated shifts to private health-care use, policies to cover costs in that sector or motivate patients to return to the public sector are needed to maintain financial risk protection., Funding: The Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests JLD reports support for the present manuscript from the Bill & Melinda Gates Foundation. JLD reports grants or contracts from the Bill & Melinda Gates Foundation, Gates Ventures, and Peterson Center on Healthcare, all outside the submitted work. HJV reports a grant from his university from the Mexican Association of Pharmaceutical Research Industries and direct payment from Roche for attending two meetings of the Roche Mexico Academic Advisory Board regarding long running trends in the Mexican health system; all outside the submitted work. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Meeting the contraceptive needs of women of reproductive age is beneficial for the health of women and children, and the economic and social empowerment of women. Higher rates of contraceptive coverage have been linked to the availability of a more diverse range of contraceptive methods. We present estimates of the contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), demand satisfied, and the method of contraception used for both partnered and unpartnered women for 5-year age groups in 204 countries and territories between 1970 and 2019., Methods: We used 1162 population-based surveys capturing contraceptive use among women between 1970 and 2019, in which women of reproductive age (15-49 years) self-reported their, or their partner's, current use of contraception for family planning purposes. Spatiotemporal Gaussian process regression was used to generate estimates of the CPR, mCPR, demand satisfied, and method mix by age and marital status. We assessed how age-specific mCPR and demand satisfied changed with the Socio-demographic Index (SDI), a measure of social and economic development, using the meta-regression Bayesian, regularised, trimmed method from the Global Burden of Diseases, Injuries, and Risk Factors Study., Findings: In 2019, 162·9 million (95% uncertainty interval [UI] 155·6-170·2) women had unmet need for contraception, of whom 29·3% (27·9-30·6) resided in sub-Saharan Africa and 27·2% (24·4-30·3) resided in south Asia. Women aged 15-19 years (64·8% [62·9-66·7]) and 20-24 years (71·9% [68·9-74·2]) had the lowest rates of demand satisfied, with 43·2 million (95% UI 39·3-48·0) women aged 15-24 years with unmet need in 2019. The mCPR and demand satisfied among women aged 15-19 years were substantially lower than among women aged 20-49 years at SDI values below 60 (on a 0-100 scale), but began to equalise as SDI increased above 60. Between 1970 and 2019, the global mCPR increased by 20·1 percentage points (95% UI 18·7-21·6). During this time, traditional methods declined as a proportion of all contraceptive methods, whereas the use of implants, injections, female sterilisation, and condoms increased. Method mix differs substantially depending on age and geography, with the share of female sterilisation increasing with age and comprising more than 50% of methods in use in south Asia. In 28 countries, one method was used by more than 50% of users in 2019., Interpretation: The dominance of one contraceptive method in some locations raises the question of whether family planning policies should aim to expand method mix or invest in making existing methods more accessible. Lower rates of demand satisfied among women aged 15-24 years are also concerning because unintended pregnancies before age 25 years can forestall or eliminate education and employment opportunities that lead to social and economic empowerment. Policy makers should strive to tailor family planning programmes to the preferences of the groups with the most need, while maintaining the programmes used by existing users., Funding: Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests NF reports other funding support from WHO as a consultant from June to September 2019 and Gates Ventures since 2020, all outside the submitted work. NJH reports grants or contracts from the Bill & Melinda Gates Foundation, outside the submitted work. All other authors declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

BACKGROUND: TB was the leading cause of death from a single infectious pathogen globally between 2014 and 2019. Fine-scale estimates of TB prevalence and case notifications can be combined to guide priority-setting for strengthening routine surveillance activities in high-burden countries. We produce policy-relevant estimates of the TB epidemic at the second administrative unit in Bangladesh. METHODS: We used a Bayesian spatial framework and the cross-sectional National TB Prevalence Survey from 2015-2016 in Bangladesh to estimate prevalence by district. We used case notifications to calculate prevalence-to-notification ratio, a key metric of under-diagnosis and under-reporting. RESULTS: TB prevalence rates were highest in the north-eastern districts and ranged from 160 cases per 100,000 (95% uncertainty interval [UI] 80-310) in Jashore to 840 (UI 690-1020) in Sunamganj. Despite moderate prevalence rates, the Rajshahi and Dhaka Divisions presented the highest prevalence-to-notification ratios due to low case notifications. Resolving subnational disparities in case detection could lead to 26,500 additional TB cases (UI 8,500-79,400) notified every year. CONCLUSION: This study is the first to produce and map subnational estimates of TB prevalence and prevalence-to-notification ratios, which are essential to target prevention and treatment efforts in high-burden settings. Reaching TB cases currently missing from care will be key to ending the TB epidemic.

Although previous evidence suggests that the infection fatality rate from COVID-19 varies by age and sex, and that transmission intensity varies geographically within countries, no study has yet explored the age-sex-space distribution of excess mortality associated with the COVID pandemic. By applying the principles of small-area estimation to existing model formulations for excess mortality, this study develops a novel method for assessing excess mortality across small populations and assesses the pattern of COVID excess mortality by province, year, week, age group, and sex in Italy from March through May 2020. We estimate that 53,200 excess deaths occurred across Italy during this time period, compared to just 35,500 deaths where COVID-19 was registered as the underlying cause of death. Out of the total excess mortality burden, 97% of excess deaths occurred among adults over age 60, and 68% of excess deaths were concentrated among adults over age 80. The burden of excess mortality was unevenly distributed across the country, with just three of Italy's 107 provinces accounting for 32% of all excess mortality. This method for estimating excess mortality can be adapted to other countries where COVID-19 diagnostic capacity is still insufficient, and could be incorporated into public health rapid response systems., (© 2022. The Author(s).)

Pakistan's national tuberculosis control programme (NTP) is among the many programmes worldwide that value the importance of subnational tuberculosis (TB) burden estimates to support disease control efforts, but do not have reliable estimates. A hackathon was thus organised to solicit the development and comparison of several models for small area estimation of TB. The TB hackathon was launched in April 2019. Participating teams were requested to produce district-level estimates of bacteriologically positive TB prevalence among adults (over 15 years of age) for 2018. The NTP provided case-based data from their 2010-2011 TB prevalence survey, along with data relating to TB screening, testing and treatment for the period between 2010-2011 and 2018. Five teams submitted district-level TB prevalence estimates, methodological details and programming code. Although the geographical distribution of TB prevalence varied considerably across models, we identified several districts with consistently low notification-to-prevalence ratios. The hackathon highlighted the challenges of generating granular spatiotemporal TB prevalence forecasts based on a cross-sectional prevalence survey data and other data sources. Nevertheless, it provided a range of approaches to subnational disease modelling. The NTP's use and plans for these outputs shows that, limitations notwithstanding, they can be valuable for programme planning.

Background: Antimicrobial resistance (AMR) is a serious threat to global public health. WHO emphasises the need for countries to monitor antibiotic consumption to combat AMR. Many low-income and middle-income countries (LMICs) lack surveillance capacity; we aimed to use multiple data sources and statistical models to estimate global antibiotic consumption., Methods: In this spatial modelling study, we used individual-level data from household surveys to inform a Bayesian geostatistical model of antibiotic usage in children (aged <5 years) with lower respiratory tract infections in LMICs. Antibiotic consumption data were obtained from multiple sources, including IQVIA, WHO, and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). The estimates of the antibiotic usage model were used alongside sociodemographic and health covariates to inform a model of total antibiotic consumption in LMICs. This was combined with a single model of antibiotic consumption in high-income countries to produce estimates of antibiotic consumption covering 204 countries and 19 years., Findings: We analysed 209 surveys done between 2000 and 2018, covering 284 045 children with lower respiratory tract infections. We identified large national and subnational variations of antibiotic usage in LMICs, with the lowest levels estimated in sub-Saharan Africa and the highest in eastern Europe and central Asia. We estimated a global antibiotic consumption rate of 14·3 (95% uncertainty interval 13·2-15·6) defined daily doses (DDD) per 1000 population per day in 2018 (40·2 [37·2-43·7] billion DDD), an increase of 46% from 9·8 (9·2-10·5) DDD per 1000 per day in 2000. We identified large spatial disparities, with antibiotic consumption rates varying from 5·0 (4·8-5·3) DDD per 1000 per day in the Philippines to 45·9 DDD per 1000 per day in Greece in 2018. Additionally, we present trends in consumption of different classes of antibiotics for selected Global Burden of Disease study regions using the IQVIA, WHO, and ESAC-net input data. We identified large increases in the consumption of fluoroquinolones and third-generation cephalosporins in North Africa and Middle East, and south Asia., Interpretation: To our knowledge, this is the first study that incorporates antibiotic usage and consumption data and uses geostatistical modelling techniques to estimate antibiotic consumption for 204 countries from 2000 to 2018. Our analysis identifies both high rates of antibiotic consumption and a lack of access to antibiotics, providing a benchmark for future interventions., Funding: Fleming Fund, UK Department of Health and Social Care; Wellcome Trust; and Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests AS has been the recipient of research grants from the Bill & Melinda Gates Foundation. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls., Methods: Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records., Results: Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence was 5186 (4622-5849) per 100 000 in 2017, representing a decline of 6.5% (7.6 to 5.4) from 1990 to 2017. Age-standardised mortality rate was 9.2 (8.5-9.8) per 100 000 which equated to 695 771 (644 927-741 720) deaths in 2017. Globally, falls resulted in 16 688 088 (15 101 897-17 636 830) YLLs, 19 252 699 (13 725 429-26 140 433) YLDs and 35 940 787 (30 185 695-42 903 289) DALYs across all ages. The most common injury sustained by fall victims is fracture of patella, tibia or fibula, or ankle. Globally, age-specific YLD rates increased with age., Conclusions: This study shows that the burden of falls is substantial. Investing in further research, fall prevention strategies and access to care is critical., Competing Interests: Competing interests: SJ reports grants from Sanofi Pasteur outside the submitted work; AB reports personal fees from World Health Organization outside the submitted work; CC reports personal fees from Amgen, personal fees from Danone, personal fees from Eli Lilly, personal fees from GlaxoSmithKline, personal fees from Kyowa Kirin, personal fees from Medtronic, personal fees from Merck, personal fees from Nestle, personal fees from Novartis, personal fees from Pfizer, personal fees from Roche, personal fees from Servier, personal fees from Shire, personal fees from Takeda, and personal fees from UCB outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria., Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced., Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes., Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future., Competing Interests: Competing interests: Dr. James reports grants from Sanofi Pasteur, outside the submitted work. Dr. Driscoll reports grants from World Health Organisation, during the conduct of the study. Dr Shariful Islam is funded by a Fellowship from National Heart Foundation of Australia and Institute for Physical Activity and Nutrition, Deakin University. Dr. Ivers reports grants from National Health and Medical Research Council of Australia, during the conduct of the study. Dr. Jozwiak reports personal fees from TEVA, personal fees from ALAB, personal fees from BOEHRINGER INGELHEIM, personal fees from SYNEXUS, non-financial support from SERVIER, non-financial support from MICROLIFE, non-financial support from MEDICOVER, outside the submitted work. Walter Mendoza is currently Program Analyst Population and Development at the Peru Country Office of the United Nations Population Fund-UNFPA, which does not necessarily endorses this study. Dr. Rakovac reports grants from World Health Organization, during the conduct of the study. Dr. Sheikh reports grants from Health Data Research UK, outside the submitted work. Dr. Singh reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, Practice Point communications, the National Institutes of Health and the American College of Rheumatology, personal fees from Speaker’s bureau of Simply Speaking. Dr. Singh owns stock options in Amarin pharmaceuticals and Viking pharmaceuticals. Dr. Singh serves on the steering committee of OMERACT, an international organization that develops measures for clinical trials and receives arms-length funding from 12 pharmaceutical companies. Dr. Singh serves on the FDA Arthritis Advisory Committee. Dr. Singh is a member of the Veterans Affairs Rheumatology Field Advisory Committee. Dr. Singh is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis, outside the submitted work. Dr. Stein reports personal fees from Lundbeck and Sun, outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries., Methods: We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs)., Findings: In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505)., Interpretation: Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care., Competing Interests: Competing interests: Dr. James reports grants from Sanofi Pasteur, outside the submitted work. Dr. Driscoll reports grants from World Health Organization, during the conduct of the study. Dr. Ivers reports grants from National Health and Medical Research Council of Australia, during the conduct of the study. Dr. Jozwiak reports personal fees from TEVA, personal fees from ALAB, personal fees from BOEHRINGER INGELHEIM, personal fees from SYNEXUS, non-financial support from SERVIER, non-financial support from MICROLIFE, non-financial support from MEDICOVER, outside the submitted work. Dr. Rakovac reports grants from World Health Organization, during the conduct of the study. Dr Shariful Islam is funded by National Heart Foundation of Australia and Institute for Physical Activity and Nutrition, Deakin University. Dr. Sheikh reports grants from Health Data Research UK, outside the submitted work. Dr. Singh reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, Practice Point communications, the National Institutes of Health and the American College of Rheumatology, and Speaker’s bureau of Simply Speaking, owns stock options in Amarin pharmaceuticals and Viking pharmaceuticals, serves on the steering committee of OMERACT, an international organization that develops measures for clinical trials and receives arm’s length funding from 12 pharmaceutical companies, serves on the FDA Arthritis Advisory Committee, is a member of the Veterans Affairs Rheumatology Field Advisory Committee, and is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis, outside the submitted work. Dr. Stein reports personal fees from Lundbeck, personal fees from Sun, outside the submitted work. Dr. Degenhardt reports grants from Indivior, Seqirus, Reckitt Benckiser, outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Past research has shown how fires, heat and hot substances are important causes of health loss globally. Detailed estimates of the morbidity and mortality from these injuries could help drive preventative measures and improved access to care., Methods: We used the Global Burden of Disease 2017 framework to produce three main results. First, we produced results on incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years from 1990 to 2017 for 195 countries and territories. Second, we analysed these results to measure mortality-to-incidence ratios by location. Third, we reported the measures above in terms of the cause of fire, heat and hot substances and the types of bodily injuries that result., Results: Globally, there were 8 991 468 (7 481 218 to 10 740 897) new fire, heat and hot substance injuries in 2017 with 120 632 (101 630 to 129 383) deaths. At the global level, the age-standardised mortality caused by fire, heat and hot substances significantly declined from 1990 to 2017, but regionally there was variability in age-standardised incidence with some regions experiencing an increase (eg, Southern Latin America) and others experiencing a significant decrease (eg, High-income North America)., Conclusions: The incidence and mortality of injuries that result from fire, heat and hot substances affect every region of the world but are most concentrated in middle and lower income areas. More resources should be invested in measuring these injuries as well as in improving infrastructure, advancing safety measures and ensuring access to care., Competing Interests: Competing interests: Dr. Spencer James reports grants from Sanofi Pasteur, outside the submitted work. All other authors have nothing to disclose. Dr. Carl Abelardo T Antonio reports grants and personal fees from Johnson & Johnson (Philippines), Inc., outside the submitted work., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data., Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning., Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence., Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572 000 deaths and 15.2 million DALYs), and stomach cancer (542 000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819 000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601 000 deaths and 17.4 million DALYs), TBL cancer (596 000 deaths and 12.6 million DALYs), and colorectal cancer (414 000 deaths and 8.3 million DALYs)., Conclusions and Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Exclusive breastfeeding (EBF)-giving infants only breast-milk (and medications, oral rehydration salts and vitamins as needed) with no additional food or drink for their first six months of life-is one of the most effective strategies for preventing child mortality 1-4 . Despite these advantages, only 37% of infants under 6 months of age in Africa were exclusively breastfed in 2017 5 , and the practice of EBF varies by population. Here, we present a fine-scale geospatial analysis of EBF prevalence and trends in 49 African countries from 2000-2017, providing policy-relevant administrative- and national-level estimates. Previous national-level analyses found that most countries will not meet the World Health Organization's Global Nutrition Target of 50% EBF prevalence by 2025 6 . Our analyses show that even fewer will achieve this ambition in all subnational areas. Our estimates provide the ability to visualize subnational EBF variability and identify populations in need of additional breastfeeding support.

HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15-49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.

Background: The host, microbial, and environmental factors that contribute to variation in tuberculosis (TB) disease are incompletely understood. Accumulating evidence suggests that one driver of geographic variation in TB disease is the local ecology of mycobacterial genotypes or strains, and there is a need for a comprehensive and systematic synthesis of these data. The objectives of this study were to (1) map the global distribution of genotypes that cause TB disease and (2) examine whether any epidemiologically relevant clinical characteristics were associated with those genotypes., Methods: We performed a systematic review of PubMed and Scopus to create a comprehensive dataset of human TB molecular epidemiology studies that used representative sampling techniques. The methods were developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We extracted and synthesized data from studies that reported prevalence of bacterial genotypes and from studies that reported clinical characteristics associated with those genotypes., Results: The results of this study are twofold. First, we identified 206 studies for inclusion in the study, representing over 200,000 bacterial isolates collected over 27 years in 85 countries. We mapped the genotypes and found that, consistent with previously published maps, Euro-American lineage 4 and East Asian lineage 2 strains are widespread, and West African lineages 5 and 6 strains are geographically restricted. Second, 30 studies also reported transmission chains and 4 reported treatment failure associated with genotypes. We performed a meta-analysis and found substantial heterogeneity across studies. However, based on the data available, we found that lineage 2 strains may be associated with increased risk of transmission chains, while lineages 5 and 6 strains may be associated with reduced risk, compared with lineage 4 strains., Conclusions: This study provides the most comprehensive systematic analysis of the evidence for diversity in bacterial strains that cause TB disease. The results show both geographic and epidemiological differences between strains, which could inform our understanding of the global burden of TB. Our findings also highlight the challenges of collecting the clinical data required to inform TB diagnosis and treatment. We urge future national TB programs and research efforts to prioritize and reinforce clinical data collection in study designs and results dissemination.

Background: Brazil has high burdens of tuberculosis (TB) and HIV, as previously estimated for the 26 states and the Federal District, as well as high levels of inequality in social and health indicators. We improved the geographic detail of burden estimation by modelling deaths due to TB and HIV and TB case fatality ratios for the more than 5400 municipalities in Brazil., Methods: This ecological study used vital registration data from the national mortality information system and TB case notifications from the national communicable disease notification system from 2001 to 2015. Mortality due to TB and HIV was modelled separately by cause and sex using a Bayesian spatially explicit mixed effects regression model. TB incidence was modelled using the same approach. Results were calibrated to the Global Burden of Disease Study 2016. Case fatality ratios were calculated for TB., Results: There was substantial inequality in TB and HIV mortality rates within the nation and within states. National-level TB mortality in people without HIV infection declined by nearly 50% during 2001 to 2015, but HIV mortality declined by just over 20% for males and 10% for females. TB and HIV mortality rates for municipalities in the 90th percentile nationally were more than three times rates in the 10th percentile, with nearly 70% of the worst-performing municipalities for male TB mortality and more than 75% for female mortality in 2001 also in the worst decile in 2015. The same municipality ranking metric for HIV was observed to be between 55% and 61%. Within states, the TB mortality rate ratios by sex for municipalities in the worst decile versus the best decile varied from 1.4 to 2.9, and HIV varied from 1.4 to 4.2. The World Health Organization target case fatality rate for TB of less than 10% was achieved in 9.6% of municipalities for males versus 38.4% for females in 2001 and improved to 38.4% and 56.6% of municipalities for males versus females, respectively, by 2014., Conclusions: Mortality rates in municipalities within the same state exhibited nearly as much relative variation as within the nation as a whole. Monitoring the mortality burden at this level of geographic detail is critical for guiding precision public health responses.

Insufficient growth during childhood is associated with poor health outcomes and an increased risk of death. Between 2000 and 2015, nearly all African countries demonstrated improvements for children under 5 years old for stunting, wasting, and underweight, the core components of child growth failure. Here we show that striking subnational heterogeneity in levels and trends of child growth remains. If current rates of progress are sustained, many areas of Africa will meet the World Health Organization Global Targets 2025 to improve maternal, infant and young child nutrition, but high levels of growth failure will persist across the Sahel. At these rates, much, if not all of the continent will fail to meet the Sustainable Development Goal target-to end malnutrition by 2030. Geospatial estimates of child growth failure provide a baseline for measuring progress as well as a precision public health platform to target interventions to those populations with the greatest need, in order to reduce health disparities and accelerate progress.

The indirect association of marital quality with metabolic syndrome (MetS) through depressive symptoms was examined in 301 middle-aged and older couples. MetS components (i.e., waist circumference, blood pressure, blood draws to assess triglycerides, HDL cholesterol, and fasting glucose) were assessed following a 12-h fast, and were treated as a continuous latent variable for analyses. In structural equation modeling of this indirect effect, overall model fit was good, and husbands' and wives' marital quality was associated with MetS only through depressive symptoms. Joint tests of the parameters indicated that gender did not moderate this association. The best fitting, most parsimonious model, after nested model comparisons, was one in which husbands' and wives' indirect paths were equated. Overall, marital quality was related to MetS through its relationship to depressive symptoms for men and women. Associations of marital quality and depression with MetS may overlap, and couple-based approaches to psychosocial risk factors for cardiovascular disease may be useful in future research.

Objective: To examine behavioral observations of affiliation (ie, warmth versus hostility) and control (ie, dominance versus submissiveness) and prior divorce as predictors of coronary artery calcification (CAC) in older couples. In some but not all studies, marital disruption and low marital quality have been shown to confer risk of coronary artery disease (CAD). Inconsistencies might reflect limitations of self-reports of marital quality compared with behavioral observations. Also, aspects of marital quality related to CAD might differ for men and women., Methods: Couples underwent computed tomography scans for CAC and marital assessments, including observations of laboratory-based disagreement. Participants were 154 couples (mean age, 63.5 years; mean length of marriage, 36.4 years) free of prior diagnosis of CAD., Results: Controlling traditional risk factors, we found behavioral measures of affiliation (low warmth) accounted for 6.2% of variance in CAC for women, p < .01, but not for men. Controlling behavior (dominance) accounted for 6.0% of variance in CAC for men, p < .02, but not for women. Behavioral measures were related to self-reports of marital quality, but the latter were unrelated to CAC. History of divorce predicted CAC for men and women., Conclusions: History of divorce and behavioral--but not self-report--measures of marital quality were related to CAD, such that low warmth and high dominance conferred risk for women and men, respectively. Prior research might underestimate the role of marital quality in CAD by relying on global self-reports of this risk factor.

Prior theory and research regarding age differences in marital interaction suggest that older couples display and experience more positivity and less negativity than middle-aged couples. However, studies of overt behavior in older couples are relatively rare and have emphasized disagreement, neglecting other important contexts for older couples such as collaboration during everyday problem solving. Further, the affiliation or communion dimension of social interaction (i.e., warmth vs. hostility) is commonly assessed but not the control or agency dimension (e.g., dominance vs. submissiveness). The present study examined affect, cognitive appraisals, and overt behavior during disagreement (i.e., discussing a current conflict) and collaboration (i.e., planning errands) in 300 middle-aged and older married couples. Older couples reported less negative affect during disagreement and rated spouses as warmer than did middle-aged couples. However, these effects were eliminated when older couples' greater marital satisfaction was controlled. For observed behavior, older couples displayed little evidence of greater positivity and reduced negativity-especially women. During collaboration, older couples displayed a unique blend of warmth and control, suggesting a greater focus on emotional and social concerns during problem solving., ((c) 2009 APA, all rights reserved.)

Objective: Aspects of negative affect and social behavior studied as risk factors for coronary heart disease are usually examined separately and through self-reports. Using structural models of these personality domains, we tested associations of self-reports and spouse ratings of anxiety, depressive symptoms, anger, affiliation and dominance with coronary artery disease (CAD)., Design: In 154 healthy older couples, the authors tested cross-sectional associations with CAD of three facets of negative affectivity and two dimensions of the Interpersonal Circumplex, (IPC) using scales derived from the NEO-PI-R., Main Outcome Measures: CAD was quantified as Agatston scores from CT scans of coronary artery calcification (CAC)., Results: Self-reports were generally unrelated to CAC, whereas spouse ratings were consistently associated, largely independent of potential confounds. When considered simultaneously, anxiety and anger were related to CAC but depression was not. When considered together, both dominance and (low) affiliation were related to CAC., Conclusions: Structural models of negative affectivity and social behavior can facilitate integrative study of psychosocial risk factors. Further, self-report measures of these traits might under-estimate related CHD risk.

This study examined whether positive sentiment override (greater positive appraisal of spouse's affiliative behavior than is warranted by observed behavior) occurred more frequently in older compared with middle-aged married couples and whether age differences were mediated by older adults' greater marital satisfaction when controlling for optimism. Participants included 270 middle-aged (40-50 years old) and older (60-70 years old) couples who discussed a marital disagreement and completed an errand task. Couples provided appraisals of their spouse's affiliation, and the authors coded affiliative interactions using the structural analysis of social behavior. Hierarchical multivariate linear modeling indicated that older husbands and wives viewed their spouse's behavior as more positive during disagreement interactions than did independent observers; in the errand task, only older wives demonstrated positive sentiment override. Age differences in positive sentiment override were mediated by marital satisfaction, even when controlling for optimism. The results are consistent with theories of emotion regulation, such as socioemotional selectivity theory, that suggest that older adults are biased toward the positive aspects of close relationships., (PsycINFO Database Record (c) 2008 APA, all rights reserved.)

The study examined age differences in positive (e.g., warm) and negative (e.g., hostile) characteristics of marital interactions between middle-aged and older couples and whether these characteristics were differentially associated with marital satisfaction by age. Spouses' perception of partners' positive and negative behavior during marital interaction was assessed in general and following disagreement and collaborative tasks. Trained observers coded spouses' positive and negative behavior during interactions. Older individuals reported higher marital satisfaction and perceived their spouse's behavior as less negative in general and more positive across all contexts than middle-aged individuals. Spouses' perceptions of their partners' positive and negative behavior independently predicted marital satisfaction for both age groups across contexts. Perceptions of partners' negative behavior in general and of both positive and negative behavior in the disagreement task were more closely associated with marital satisfaction for older spouses than for middle-aged spouses. Results point to the importance of positive and negative characteristics in marital functioning across age cohorts and indicate that such characteristics may be context dependent. Findings suggest that, in some contexts, both positive and negative characteristics are more salient for older adults., ((PsycINFO Database Record (c) 2007 APA, all rights reserved).)

Collaborative problem solving may be used by older couples to optimize cognitive functioning, with some suggestion that older couples exhibit greater collaborative expertise. The study explored age differences in 2 aspects of collaborative expertise: spouses' knowledge of their own and their spouse's cognitive abilities and the ability to fit task control to these cognitive abilities. The participants were 300 middle-aged and older couples who completed a hypothetical errand task. The interactions were coded for control asserted by husbands and wives. Fluid intelligence was assessed, and spouses rated their own and their spouse's cognitive abilities. The results revealed no age differences in couple expertise, either in the ability to predict their own and their spouse's cognitive abilities or in the ability to fit task control to abilities. However, gender differences were found. Women fit task control to their own and their spouse's cognitive abilities; men only fit task control to their spouse's cognitive abilities. For women only, the fit between control and abilities was associated with better performance. The results indicate no age differences in couple expertise but point to gender as a factor in optimal collaboration., ((PsycINFO Database Record (c) 2007 APA, all rights reserved).)