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1. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

Author

Griswold, Max G, Fullman, Nancy, Hawley, Caitlin, Arian, Nicholas, Zimsen, Stephanie RM, Tymeson, Hayley D, Venkateswaran, Vidhya, Tapp, Austin Douglas, Forouzanfar, Mohammad H, Salama, Joseph S, Abate, Kalkidan Hassen, Abate, Degu, Abay, Solomon M, Abbafati, Cristiana, Abdulkader, Rizwan Suliankatchi, Abebe, Zegeye, Aboyans, Victor, Abrar, Mohammed Mehdi, Acharya, Pawan, Adetokunboh, Olatunji O, Adhikari, Tara Ballav, Adsuar, Jose C, Afarideh, Mohsen, Agardh, Emilie Elisabet, Agarwal, Gina, Aghayan, Sargis Aghasi, Agrawal, Sutapa, Ahmed, Muktar Beshir, Akibu, Mohammed, Akinyemiju, Tomi, Akseer, Nadia, Asfoor, Deena H Al, Al-Aly, Ziyad, Alahdab, Fares, Alam, Khurshid, Albujeer, Ammar, Alene, Kefyalew Addis, Ali, Raghib, Ali, Syed Danish, Alijanzadeh, Mehran, Aljunid, Syed Mohamed, Alkerwi, Ala'a, Allebeck, Peter, Alvis-Guzman, Nelson, Amare, Azmeraw T, Aminde, Leopold N, Ammar, Walid, Amoako, Yaw Ampem, Amul, Gianna Gayle Herrera, Andrei, Catalina Liliana, Angus, Colin, Ansha, Mustafa Geleto, Antonio, Carl Abelardo T, Aremu, Olatunde, Ärnlöv, Johan, Artaman, Al, Aryal, Krishna K, Assadi, Reza, Ausloos, Marcel, Avila-Burgos, Leticia, Avokpaho, Euripide F, Awasthi, Ashish, Ayele, Henok Tadesse, Ayer, Rakesh, Ayuk, Tambe B, Azzopardi, Peter S, Badali, Hamid, Badawi, Alaa, Banach, Maciej, Barker-Collo, Suzanne Lyn, Barrero, Lope H, Basaleem, Huda, Baye, Estifanos, Bazargan-Hejazi, Shahrzad, Bedi, Neeraj, Béjot, Yannick, Belachew, Abate Bekele, Belay, Saba Abraham, Bennett, Derrick A, Bensenor, Isabela M, Bernabe, Eduardo, Bernstein, Robert S, Beyene, Addisu Shunu, Beyranvand, Tina, Bhaumik, Soumyadeeep, Bhutta, Zulfiqar A, Biadgo, Belete, Bijani, Ali, Bililign, Nigus, Birlik, Sait Mentes, Birungi, Charles, Bizuneh, Hailemichael, Bjerregaard, Peter, Bjørge, Tone, Borges, Guilherme, Bosetti, Cristina, Boufous, Soufiane, Bragazzi, Nicola Luigi, Brenner, Hermann, and Butt, Zahid A

Subjects
Epidemiology, Public Health, Health Sciences, Women's Health, Alcoholism, Alcohol Use and Health, Substance Misuse, Prevention, Behavioral and Social Science, Aging, 2.4 Surveillance and distribution, Stroke, Cancer, Oral and gastrointestinal, Good Health and Well Being, Adolescent, Adult, Age Distribution, Aged, Aged, 80 and over, Alcohol Drinking, Cause of Death, Commerce, Female, Global Burden of Disease, Global Health, Humans, Male, Middle Aged, Observational Studies as Topic, Population Surveillance, Prevalence, Prospective Studies, Quality-Adjusted Life Years, Retrospective Studies, Risk Assessment, Risk Factors, Sex Distribution, Young Adult, GBD 2016 Alcohol Collaborators, Medical and Health Sciences, General & Internal Medicine, Biomedical and clinical sciences, Health sciences
Abstract

BackgroundAlcohol use is a leading risk factor for death and disability, but its overall association with health remains complex given the possible protective effects of moderate alcohol consumption on some conditions. With our comprehensive approach to health accounting within the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we generated improved estimates of alcohol use and alcohol-attributable deaths and disability-adjusted life-years (DALYs) for 195 locations from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older.MethodsUsing 694 data sources of individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use, we produced estimates of the prevalence of current drinking, abstention, the distribution of alcohol consumption among current drinkers in standard drinks daily (defined as 10 g of pure ethyl alcohol), and alcohol-attributable deaths and DALYs. We made several methodological improvements compared with previous estimates: first, we adjusted alcohol sales estimates to take into account tourist and unrecorded consumption; second, we did a new meta-analysis of relative risks for 23 health outcomes associated with alcohol use; and third, we developed a new method to quantify the level of alcohol consumption that minimises the overall risk to individual health.FindingsGlobally, alcohol use was the seventh leading risk factor for both deaths and DALYs in 2016, accounting for 2·2% (95% uncertainty interval [UI] 1·5-3·0) of age-standardised female deaths and 6·8% (5·8-8·0) of age-standardised male deaths. Among the population aged 15-49 years, alcohol use was the leading risk factor globally in 2016, with 3·8% (95% UI 3·2-4·3) of female deaths and 12·2% (10·8-13·6) of male deaths attributable to alcohol use. For the population aged 15-49 years, female attributable DALYs were 2·3% (95% UI 2·0-2·6) and male attributable DALYs were 8·9% (7·8-9·9). The three leading causes of attributable deaths in this age group were tuberculosis (1·4% [95% UI 1·0-1·7] of total deaths), road injuries (1·2% [0·7-1·9]), and self-harm (1·1% [0·6-1·5]). For populations aged 50 years and older, cancers accounted for a large proportion of total alcohol-attributable deaths in 2016, constituting 27·1% (95% UI 21·2-33·3) of total alcohol-attributable female deaths and 18·9% (15·3-22·6) of male deaths. The level of alcohol consumption that minimised harm across health outcomes was zero (95% UI 0·0-0·8) standard drinks per week.InterpretationAlcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption.FundingBill & Melinda Gates Foundation.

Published
2018

2. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

Author

Troeger, Christopher, Blacker, Brigette F, Khalil, Ibrahim A, Rao, Puja C, Cao, Shujin, Zimsen, Stephanie RM, Albertson, Samuel B, Stanaway, Jeffery D, Deshpande, Aniruddha, Abebe, Zegeye, Alvis-Guzman, Nelson, Amare, Azmeraw T, Asgedom, Solomon W, Anteneh, Zelalem Alamrew, Antonio, Carl Abelardo T, Aremu, Olatunde, Asfaw, Ephrem Tsegay, Atey, Tesfay Mehari, Atique, Suleman, Avokpaho, Euripide Frinel G Arthur, Awasthi, Ashish, Ayele, Henok Tadesse, Barac, Aleksandra, Barreto, Mauricio L, Bassat, Quique, Belay, Saba Abraham, Bensenor, Isabela M, Bhutta, Zulfiqar A, Bijani, Ali, Bizuneh, Hailemichael, Castañeda-Orjuela, Carlos A, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Do, Huyen Phuc, Dubey, Manisha, Dubljanin, Eleonora, Edessa, Dumessa, Endries, Aman Yesuf, Eshrati, Babak, Farag, Tamer, Feyissa, Garumma Tolu, Foreman, Kyle J, Forouzanfar, Mohammad H, Fullman, Nancy, Gething, Peter W, Gishu, Melkamu Dedefo, Godwin, William W, Gugnani, Harish Chander, Gupta, Rahul, Hailu, Gessessew Bugssa, Hassen, Hamid Yimam, Hibstu, Desalegn Tsegaw, Ilesanmi, Olayinka S, Jonas, Jost B, Kahsay, Amaha, Kang, Gagandeep, Kasaeian, Amir, Khader, Yousef Saleh, Khan, Ejaz Ahmad, Khan, Muhammad Ali, Khang, Young-Ho, Kissoon, Niranjan, Kochhar, Sonali, Kotloff, Karen L, Koyanagi, Ai, Kumar, G Anil, Magdy Abd El Razek, Hassan, Malekzadeh, Reza, Malta, Deborah Carvalho, Mehata, Suresh, Mendoza, Walter, Mengistu, Desalegn Tadese, Menota, Bereket Gebremichael, Mezgebe, Haftay Berhane, Mlashu, Fitsum Weldegebreal, Murthy, Srinivas, Naik, Gurudatta A, Nguyen, Cuong Tat, Nguyen, Trang Huyen, Ningrum, Dina Nur Anggraini, Ogbo, Felix Akpojene, Olagunju, Andrew Toyin, Paudel, Deepak, Platts-Mills, James A, Qorbani, Mostafa, Rafay, Anwar, Rai, Rajesh Kumar, Rana, Saleem M, Ranabhat, Chhabi Lal, Rasella, Davide, Ray, Sarah E, Reis, Cesar, Renzaho, Andre MN, Rezai, Mohammad Sadegh, Ruhago, George Mugambage, Safiri, Saeid, Salomon, Joshua A, Sanabria, Juan Ramon, Sartorius, Benn, Sawhney, Monika, Sepanlou, Sadaf G, Shigematsu, Mika, Sisay, Mekonnen, Somayaji, Ranjani, Sreeramareddy, Chandrashekhar T, Sykes, Bryan L, Taffere, Getachew Redae, Topor-Madry, Roman, Tran, Bach Xuan, Tuem, Kald Beshir, Ukwaja, Kingsley Nnanna, Vollset, Stein Emil, Walson, Judd L, Weaver, Marcia R, Weldegwergs, Kidu Gidey, Werdecker, Andrea, Workicho, Abdulhalik, Yenesew, Muluken, Yirsaw, Biruck Desalegn, Yonemoto, Naohiro, El Sayed Zaki, Maysaa, Vos, Theo, Lim, Stephen S, Naghavi, Mohsen, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, and Reiner, Robert C, Jr

Published
2018
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3. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

Author

Troeger, Christopher, Blacker, Brigette F, Khalil, Ibrahim A, Rao, Puja C, Cao, Shujin, Zimsen, Stephanie RM, Albertson, Samuel B, Stanaway, Jeffery D, Deshpande, Aniruddha, Abebe, Zegeye, Alvis-Guzman, Nelson, Amare, Azmeraw T, Asgedom, Solomon W, Anteneh, Zelalem Alamrew, Antonio, Carl Abelardo T, Aremu, Olatunde, Asfaw, Ephrem Tsegay, Atey, Tesfay Mehari, Atique, Suleman, Avokpaho, Euripide Frinel G Arthur, Awasthi, Ashish, Ayele, Henok Tadesse, Barac, Aleksandra, Barreto, Mauricio L, Bassat, Quique, Belay, Saba Abraham, Bensenor, Isabela M, Bhutta, Zulfiqar A, Bijani, Ali, Bizuneh, Hailemichael, Castañeda-Orjuela, Carlos A, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Do, Huyen Phuc, Dubey, Manisha, Dubljanin, Eleonora, Edessa, Dumessa, Endries, Aman Yesuf, Eshrati, Babak, Farag, Tamer, Feyissa, Garumma Tolu, Foreman, Kyle J, Forouzanfar, Mohammad H, Fullman, Nancy, Gething, Peter W, Gishu, Melkamu Dedefo, Godwin, William W, Gugnani, Harish Chander, Gupta, Rahul, Hailu, Gessessew Bugssa, Hassen, Hamid Yimam, Hibstu, Desalegn Tsegaw, Ilesanmi, Olayinka S, Jonas, Jost B, Kahsay, Amaha, Kang, Gagandeep, Kasaeian, Amir, Khader, Yousef Saleh, Khan, Ejaz Ahmad, Khan, Muhammad Ali, Khang, Young-Ho, Kissoon, Niranjan, Kochhar, Sonali, Kotloff, Karen L, Koyanagi, Ai, Kumar, G Anil, Magdy Abd El Razek, Hassan, Malekzadeh, Reza, Malta, Deborah Carvalho, Mehata, Suresh, Mendoza, Walter, Mengistu, Desalegn Tadese, Menota, Bereket Gebremichael, Mezgebe, Haftay Berhane, Mlashu, Fitsum Weldegebreal, Murthy, Srinivas, Naik, Gurudatta A, Nguyen, Cuong Tat, Nguyen, Trang Huyen, Ningrum, Dina Nur Anggraini, Ogbo, Felix Akpojene, Olagunju, Andrew Toyin, Paudel, Deepak, Platts-Mills, James A, Qorbani, Mostafa, Rafay, Anwar, Rai, Rajesh Kumar, Rana, Saleem M, Ranabhat, Chhabi Lal, Rasella, Davide, Ray, Sarah E, Reis, Cesar, Renzaho, Andre MN, Rezai, Mohammad Sadegh, Ruhago, George Mugambage, Safiri, Saeid, Salomon, Joshua A, Sanabria, Juan Ramon, Sartorius, Benn, Sawhney, Monika, Sepanlou, Sadaf G, Shigematsu, Mika, Sisay, Mekonnen, Somayaji, Ranjani, Sreeramareddy, Chandrashekhar T, Sykes, Bryan L, Taffere, Getachew Redae, Topor-Madry, Roman, Tran, Bach Xuan, Tuem, Kald Beshir, Ukwaja, Kingsley Nnanna, Vollset, Stein Emil, Walson, Judd L, Weaver, Marcia R, Weldegwergs, Kidu Gidey, Werdecker, Andrea, Workicho, Abdulhalik, Yenesew, Muluken, Yirsaw, Biruck Desalegn, Yonemoto, Naohiro, El Sayed Zaki, Maysaa, Vos, Theo, Lim, Stephen S, Naghavi, Mohsen, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, and Reiner, Robert C

Abstract

Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990–2016 and assesses how the burden of diarrhoea has changed in people of all ages Methods We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty. Findings In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073–2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894–504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138–155 133) and among all ages (228 047 deaths, 183 526–292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2–85·0), 72·1% (34·0–91·4), and 56·4% (49·3–62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521–2170) could avert one death from diarrhoea. Interpretation Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by decreases in several primary risk factors. However, this reduction has not been equal across locations, and burden among adults older than 70 years requires attention.

Published
2019

4. Mortality, morbidity, and hospitalisations due to influenza lower respiratory tract infections, 2017: an analysis for the Global Burden of Disease Study 2017

Author

Troeger, Christopher E, Blacker, Brigette F, Khalil, Ibrahim A, Zimsen, Stephanie RM, Albertson, Samuel B, Abate, Degu, Abdela, Jemal, Adhikari, Tara B, Aghayan, Sargis A, Agrawal, Sutapa, Ahmadi, Alireza, Aichour, Amani N, Aichour, Ibitihel, Aichour, Miloud TE, Al-Eyadhy, Ayman, Al-Raddadi, Rajaa M, Alahdab, Fares, Alene, Kefyalew A, Aljunid, Syed M, Alvis-Guzman, Nelson, Anber, Nahla H, Anjomshoa, Mina, Antonio, Carl AT, Aremu, Olatunde, Atalay, Hagos T, Atique, Suleman, Attia, Engi F, Avokpaho, Euripide FGA, Awasthi, Ashish, Babazadeh, Arefah, Badali, Hamid, Badawi, Alaa, Banoub, Joseph AM, Barac, Aleksandra, Bassat, Quique, Bedi, Neeraj, Belachew, Abate B, Bennett, Derrick A, Bhattacharyya, Krittika, Bhutta, Zulfiqar A, Bijani, Ali, Carvalho, Felix, Castaneda-Orjuela, Carlos A, Christopher, Devashahayam J, Dandona, Lalit, Dandona, Rakhi, Dang, Anh K, Daryani, Ahmad, Degefa, Meaza G, Demeke, Feleke M, Dhimal, Meghnath, Djalalinia, Shirin, Doku, David T, Dubey, Manisha, Dubljanin, Eleonora, Duken, Eyasu E, Edessa, Dumessa, Zaki, Maysaa ES, Fakhim, Hamed, Fernandes, Eduarda, Fischer, Florian, Flor, Luisa S, Foreman, Kyle J, Gebremichael, Teklu G, Geremew, Demeke, Ghadiri, Keyghobad, Goulart, Alessandra C, Guo, Jingwen, Ha, Giang H, Hailu, Gessessew B, Haj-Mirzaian, Arvin, Haj-Mirzaian, Arya, Hamidi, Samer, Hassen, Hamid Y, Hoang, Chi L, Horita, Nobuyuki, Hostiuc, Mihaela, Irvani, Seyed SN, Jha, Ravi P, Jonas, Jost B, Kahsay, Amaha, Karch, Andre, Kasaeian, Amir, Kassa, Tesfaye D, Kefale, Adane T, Khader, Yousef S, Khan, Ejaz A, Khan, Gulfaraz, Khan, Md Nuruzzaman, Khang, Young-Ho, Khoja, Abdullah T, Khubchandani, Jagdish, Kimokoti, Ruth W, Kisa, Adnan, Knibbs, Luke D, Kochhar, Sonali, Kosen, Soewarta, Koul, Parvaiz A, Koyanagi, Ai, Defo, Barthelemy K, Kumar, G Anil, Lal, Dharmesh K, Lamichhane, Prabhat, Leshargie, Cheru T, Levi, Miriam, Li, Shanshan, Macarayan, Erlyn RK, Majdan, Marek, Mehta, Varshil, Melese, Addisu, Memish, Ziad A, Mengistu, Desalegn T, Meretoja, Tuomo J, Mestrovic, Tomislav, Miazgowski, Bartosz, Milne, George J, Milosevic, Branko, Mirrakhimov, Erkin M, Moazen, Babak, Mohammad, Karzan A, Mohammed, Shafiu, Monasta, Lorenzo, Morawska, Lidia, Mousavi, Seyyed M, Muhammed, Oumer SS, Murthy, Srinivas, Mustafa, Ghulam, Naheed, Aliya, Huong, Lan Thi Nguyen, Nam, Ba Nguyen, Son, Hoang Nguyen, Trang, Huyen Nguyen, Nisar, Muhammad Imran, Nixon, Molly R, Ogbo, Felix Akpojene, Olagunju, Andrew T, Olagunju, Tinuke O, Oren, Eyal, Ortiz, Justin R, Mahesh, PA, Pakhale, Smita, Patel, Shanti, Paudel, Deepak, Pigott, David M, Postma, Maarten J, Qorbani, Mostafa, Rafay, Anwar, Rafiei, Alireza, Rahimi-Movaghar, Vafa, Rai, Rajesh K, Rezai, Mohammad S, Roberts, Nicholas LS, Ronfani, Luca, Rubino, Salvatore, Safari, Saeed, Safiri, Saeid, Saleem, Zikria, Sambala, Evanson Z, Samy, Abdallah M, Milicevic, Milena MS, Sartorius, Benn, Sarvi, Shahabeddin, Savic, Miloje, Sawhney, Monika, Saxena, Sonia, Seyedmousavi, Seyedmojtaba, Shaikh, Masood A, Sharif, Mehdi, Sheikh, Aziz, Shigematsu, Mika, Smith, David L, Somayaji, Ranjani, Soriano, Joan B, Sreeramareddy, Chandrashekhar T, Sufiyan, Mu'awiyyah B, Temsah, Mohamad-Hani, Tessema, Belay, Teweldemedhin, Mebrahtu, Tortajada-Girbes, Miguel, Tran, Bach X, Tran, Khanh B, Tsadik, Afewerki G, Ukwaja, Kingsley N, Ullah, Irfan, Vasankari, Tommi J, Vollset, Stein E, Vu, Giang T, Wada, Fiseha W, Waheed, Yasir, West, T Eoin, Wiysonge, Charles S, Yimer, Ebrahim M, Yonemoto, Naohiro, Zaidi, Zoubida, Vos, Theo, Lim, Stephen S, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, Reiner, Robert C, Troeger, Christopher E, Blacker, Brigette F, Khalil, Ibrahim A, Zimsen, Stephanie RM, Albertson, Samuel B, Abate, Degu, Abdela, Jemal, Adhikari, Tara B, Aghayan, Sargis A, Agrawal, Sutapa, Ahmadi, Alireza, Aichour, Amani N, Aichour, Ibitihel, Aichour, Miloud TE, Al-Eyadhy, Ayman, Al-Raddadi, Rajaa M, Alahdab, Fares, Alene, Kefyalew A, Aljunid, Syed M, Alvis-Guzman, Nelson, Anber, Nahla H, Anjomshoa, Mina, Antonio, Carl AT, Aremu, Olatunde, Atalay, Hagos T, Atique, Suleman, Attia, Engi F, Avokpaho, Euripide FGA, Awasthi, Ashish, Babazadeh, Arefah, Badali, Hamid, Badawi, Alaa, Banoub, Joseph AM, Barac, Aleksandra, Bassat, Quique, Bedi, Neeraj, Belachew, Abate B, Bennett, Derrick A, Bhattacharyya, Krittika, Bhutta, Zulfiqar A, Bijani, Ali, Carvalho, Felix, Castaneda-Orjuela, Carlos A, Christopher, Devashahayam J, Dandona, Lalit, Dandona, Rakhi, Dang, Anh K, Daryani, Ahmad, Degefa, Meaza G, Demeke, Feleke M, Dhimal, Meghnath, Djalalinia, Shirin, Doku, David T, Dubey, Manisha, Dubljanin, Eleonora, Duken, Eyasu E, Edessa, Dumessa, Zaki, Maysaa ES, Fakhim, Hamed, Fernandes, Eduarda, Fischer, Florian, Flor, Luisa S, Foreman, Kyle J, Gebremichael, Teklu G, Geremew, Demeke, Ghadiri, Keyghobad, Goulart, Alessandra C, Guo, Jingwen, Ha, Giang H, Hailu, Gessessew B, Haj-Mirzaian, Arvin, Haj-Mirzaian, Arya, Hamidi, Samer, Hassen, Hamid Y, Hoang, Chi L, Horita, Nobuyuki, Hostiuc, Mihaela, Irvani, Seyed SN, Jha, Ravi P, Jonas, Jost B, Kahsay, Amaha, Karch, Andre, Kasaeian, Amir, Kassa, Tesfaye D, Kefale, Adane T, Khader, Yousef S, Khan, Ejaz A, Khan, Gulfaraz, Khan, Md Nuruzzaman, Khang, Young-Ho, Khoja, Abdullah T, Khubchandani, Jagdish, Kimokoti, Ruth W, Kisa, Adnan, Knibbs, Luke D, Kochhar, Sonali, Kosen, Soewarta, Koul, Parvaiz A, Koyanagi, Ai, Defo, Barthelemy K, Kumar, G Anil, Lal, Dharmesh K, Lamichhane, Prabhat, Leshargie, Cheru T, Levi, Miriam, Li, Shanshan, Macarayan, Erlyn RK, Majdan, Marek, Mehta, Varshil, Melese, Addisu, Memish, Ziad A, Mengistu, Desalegn T, Meretoja, Tuomo J, Mestrovic, Tomislav, Miazgowski, Bartosz, Milne, George J, Milosevic, Branko, Mirrakhimov, Erkin M, Moazen, Babak, Mohammad, Karzan A, Mohammed, Shafiu, Monasta, Lorenzo, Morawska, Lidia, Mousavi, Seyyed M, Muhammed, Oumer SS, Murthy, Srinivas, Mustafa, Ghulam, Naheed, Aliya, Huong, Lan Thi Nguyen, Nam, Ba Nguyen, Son, Hoang Nguyen, Trang, Huyen Nguyen, Nisar, Muhammad Imran, Nixon, Molly R, Ogbo, Felix Akpojene, Olagunju, Andrew T, Olagunju, Tinuke O, Oren, Eyal, Ortiz, Justin R, Mahesh, PA, Pakhale, Smita, Patel, Shanti, Paudel, Deepak, Pigott, David M, Postma, Maarten J, Qorbani, Mostafa, Rafay, Anwar, Rafiei, Alireza, Rahimi-Movaghar, Vafa, Rai, Rajesh K, Rezai, Mohammad S, Roberts, Nicholas LS, Ronfani, Luca, Rubino, Salvatore, Safari, Saeed, Safiri, Saeid, Saleem, Zikria, Sambala, Evanson Z, Samy, Abdallah M, Milicevic, Milena MS, Sartorius, Benn, Sarvi, Shahabeddin, Savic, Miloje, Sawhney, Monika, Saxena, Sonia, Seyedmousavi, Seyedmojtaba, Shaikh, Masood A, Sharif, Mehdi, Sheikh, Aziz, Shigematsu, Mika, Smith, David L, Somayaji, Ranjani, Soriano, Joan B, Sreeramareddy, Chandrashekhar T, Sufiyan, Mu'awiyyah B, Temsah, Mohamad-Hani, Tessema, Belay, Teweldemedhin, Mebrahtu, Tortajada-Girbes, Miguel, Tran, Bach X, Tran, Khanh B, Tsadik, Afewerki G, Ukwaja, Kingsley N, Ullah, Irfan, Vasankari, Tommi J, Vollset, Stein E, Vu, Giang T, Wada, Fiseha W, Waheed, Yasir, West, T Eoin, Wiysonge, Charles S, Yimer, Ebrahim M, Yonemoto, Naohiro, Zaidi, Zoubida, Vos, Theo, Lim, Stephen S, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, and Reiner, Robert C

Published
2019

5. Estimaciones de la morbilidad, mortalidad y etiología de la diarrea a nivel mundial, regional y nacional en 195 países: un análisis sistemático para el estudio de la carga mundial de la enfermedad 2016

Author

Troeger, Christopher, Blacker, Brigette F, Khalil, Ibrahim A, Rao, Puja C, Cao, Shujin, Zimsen, Stephanie RM, Albertson, Samuel B, Stanaway, Jeffery D, Deshpande, Aniruddha, Abebe, Zegeye, and Alvis-Guzman, Nelson

Subjects
Análisis de la carga de la diarrea en 195 países, Analysis of the burden of the agenda in 195 countries, Estudio de la carga global de enfermedades, lesiones y factores de riesgo, 1990-2016, Study of the global burden of diseases, injuries and risk factors
Abstract

Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990–2016 and assesses how the burden of diarrhoea has changed in people of all ages Antecedentes El Estudio de la Carga Global de Enfermedades, Lesiones y Factores de Riesgo (GBD) de 2016 proporciona una información actualizada. Análisis de la carga de la diarrea en 195 países. Este estudio evalúa casos, muertes y etiologías en 1990-2016 y evalúa cómo ha cambiado la carga de la diarrea en personas de todas las edades

Published
2018

6. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

Author

米本, 直裕, Troeger, Christopher, Blacker, Brigette F, Khalil, Ibrahim A, Rao, Puja C, Cao, Shujin, Zimsen, Stephanie RM, Albertson, Samuel B, Stanaway, Jeffery D, Deshpande, Aniruddha, Abebe, Zegeye, Alvis-Guzman, Nelson, Amare, Azmeraw T, Asgedom, Solomon W, Anteneh, Zelalem Alamrew, Antonio, Carl Abelardo T, Aremu, Olatunde, Asfaw, Ephrem Tsegay, Atey, Tesfay Mehari, Atique, Suleman, Avokpaho, Euripide Frinel G Arthur, Awasthi, Ashish, Ayele, Henok Tadesse, Barac, Aleksandra, Barreto, Mauricio L, Bassat, Quique, Belay, Saba Abraham, Bensenor, Isabela M, Bhutta, Zulfiqar A, Bijani, Ali, Bizuneh, Hailemichael, Castañeda-Orjuela, Carlos A, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Do, Huyen Phuc, Dubey, Manisha, Dubljanin, Eleonora, Edessa, Dumessa, Endries, Aman Yesuf, Eshrati, Babak, Farag, Tamer, Feyissa, Garumma Tolu, Foreman, Kyle J, Forouzanfar, Mohammad H, Fullman, Nancy, Gething, Peter W, Gishu, Melkamu Dedefo, Godwin, William W, Gugnani, Harish Chander, Gupta, Rahul, Hailu, Gessessew Bugssa, Hassen, Hamid Yimam, Hibstu, Desalegn Tsegaw, Ilesanmi, Olayinka S, Jonas, Jost B, Kahsay, Amaha, Kang, Gagandeep, Kasaeian, Amir, Khader, Yousef Saleh, Khan, Ejaz Ahmad, Khan, Muhammad Ali, Khang, Young-Ho, Kissoon, Niranjan, Kochhar, Sonali, Kotloff, Karen L, Koyanagi, Ai, Kumar, G Anil, Magdy Abd El Razek, Hassan, Malekzadeh, Reza, Malta, Deborah Carvalho, Mehata, Suresh, Mendoza, Walter, Mengistu, Desalegn Tadese, Menota, Bereket Gebremichael, Mezgebe, Haftay Berhane, Mlashu, Fitsum Weldegebreal, Murthy, Srinivas, Naik, Gurudatta A, Nguyen, Cuong Tat, Nguyen, Trang Huyen, Ningrum, Dina Nur Anggraini, Ogbo, Felix Akpojene, Olagunju, Andrew Toyin, Paudel, Deepak, Platts-Mills, James A, Qorbani, Mostafa, Rafay, Anwar, Rai, Rajesh Kumar, Rana, Saleem M, Ranabhat, Chhabi Lal, Rasella, Davide, Ray, Sarah E, Reis, Cesar, Renzaho, Andre MN, Rezai, Mohammad Sadegh, Ruhago, George Mugambage, Safiri, Saeid, Salomon, Joshua A, Sanabria, Juan Ramon, Sartorius, Benn, Sawhney, Monika, Sepanlou, Sadaf G, Shigematsu, Mika, Sisay, Mekonnen, Somayaji, Ranjani, Sreeramareddy, Chandrashekhar T, Sykes, Bryan L, Taffere, Getachew Redae, Topor-Madry, Roman, Tran, Bach Xuan, Tuem, Kald Beshir, Ukwaja, Kingsley Nnanna, Vollset, Stein Emil, Walson, Judd L, Weaver, Marcia R, Weldegwergs, Kidu Gidey, Werdecker, Andrea, Workicho, Abdulhalik, Yenesew, Muluken, Yirsaw, Biruck Desalegn, Yonemoto, Naohiro, El Sayed Zaki, Maysaa, Vos, Theo, Lim, Stephen S, Naghavi, Mohsen, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, Reiner, Robert C, 米本, 直裕, Troeger, Christopher, Blacker, Brigette F, Khalil, Ibrahim A, Rao, Puja C, Cao, Shujin, Zimsen, Stephanie RM, Albertson, Samuel B, Stanaway, Jeffery D, Deshpande, Aniruddha, Abebe, Zegeye, Alvis-Guzman, Nelson, Amare, Azmeraw T, Asgedom, Solomon W, Anteneh, Zelalem Alamrew, Antonio, Carl Abelardo T, Aremu, Olatunde, Asfaw, Ephrem Tsegay, Atey, Tesfay Mehari, Atique, Suleman, Avokpaho, Euripide Frinel G Arthur, Awasthi, Ashish, Ayele, Henok Tadesse, Barac, Aleksandra, Barreto, Mauricio L, Bassat, Quique, Belay, Saba Abraham, Bensenor, Isabela M, Bhutta, Zulfiqar A, Bijani, Ali, Bizuneh, Hailemichael, Castañeda-Orjuela, Carlos A, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Do, Huyen Phuc, Dubey, Manisha, Dubljanin, Eleonora, Edessa, Dumessa, Endries, Aman Yesuf, Eshrati, Babak, Farag, Tamer, Feyissa, Garumma Tolu, Foreman, Kyle J, Forouzanfar, Mohammad H, Fullman, Nancy, Gething, Peter W, Gishu, Melkamu Dedefo, Godwin, William W, Gugnani, Harish Chander, Gupta, Rahul, Hailu, Gessessew Bugssa, Hassen, Hamid Yimam, Hibstu, Desalegn Tsegaw, Ilesanmi, Olayinka S, Jonas, Jost B, Kahsay, Amaha, Kang, Gagandeep, Kasaeian, Amir, Khader, Yousef Saleh, Khan, Ejaz Ahmad, Khan, Muhammad Ali, Khang, Young-Ho, Kissoon, Niranjan, Kochhar, Sonali, Kotloff, Karen L, Koyanagi, Ai, Kumar, G Anil, Magdy Abd El Razek, Hassan, Malekzadeh, Reza, Malta, Deborah Carvalho, Mehata, Suresh, Mendoza, Walter, Mengistu, Desalegn Tadese, Menota, Bereket Gebremichael, Mezgebe, Haftay Berhane, Mlashu, Fitsum Weldegebreal, Murthy, Srinivas, Naik, Gurudatta A, Nguyen, Cuong Tat, Nguyen, Trang Huyen, Ningrum, Dina Nur Anggraini, Ogbo, Felix Akpojene, Olagunju, Andrew Toyin, Paudel, Deepak, Platts-Mills, James A, Qorbani, Mostafa, Rafay, Anwar, Rai, Rajesh Kumar, Rana, Saleem M, Ranabhat, Chhabi Lal, Rasella, Davide, Ray, Sarah E, Reis, Cesar, Renzaho, Andre MN, Rezai, Mohammad Sadegh, Ruhago, George Mugambage, Safiri, Saeid, Salomon, Joshua A, Sanabria, Juan Ramon, Sartorius, Benn, Sawhney, Monika, Sepanlou, Sadaf G, Shigematsu, Mika, Sisay, Mekonnen, Somayaji, Ranjani, Sreeramareddy, Chandrashekhar T, Sykes, Bryan L, Taffere, Getachew Redae, Topor-Madry, Roman, Tran, Bach Xuan, Tuem, Kald Beshir, Ukwaja, Kingsley Nnanna, Vollset, Stein Emil, Walson, Judd L, Weaver, Marcia R, Weldegwergs, Kidu Gidey, Werdecker, Andrea, Workicho, Abdulhalik, Yenesew, Muluken, Yirsaw, Biruck Desalegn, Yonemoto, Naohiro, El Sayed Zaki, Maysaa, Vos, Theo, Lim, Stephen S, Naghavi, Mohsen, Murray, Christopher JL, Mokdad, Ali H, Hay, Simon I, and Reiner, Robert C

Abstract

[Background] The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990–2016 and assesses how the burden of diarrhoea has changed in people of all ages. [Methods] We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty. [Findings] In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073–2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894–504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138–155 133) and among all ages (228 047 deaths, 183 526–292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2–85·0), 72·1% (34·0–91·4), and 56·4% (49·3–62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521–2170) could avert one death from diarrhoea. [Interpretation] Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by

Published
2018

7. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

Author

Troeger, Christopher, Blacker, Brigette, Khalil, Ibrahim A., Rao, Puja C., Cao, Jackie, Zimsen, Stephanie Rm, Albertson, Samuel B., Deshpande, Aniruddha, Farag, Tamer, Abebe, Zegeye, Adetifa, Ifedayo Morayo O., Adhikari, Tara Ballav, Akibu, Mohammed, Al Lami, Faris Hasan, Al-Eyadhy, Ayman, Alvis-Guzman, Nelson, Amare, Azmeraw T., Amoako, Yaw Ampem, Antonio, Carl Abelardo T., Aremu, Olatunde, Asfaw, Ephrem Tsegay, Asgedom, Solomon Weldegebreal, Atey, Tesfay Mehari, Attia, Engi Farouk, Avokpaho, Euripide Frinel G. Arthur, Ayele, Henok Tadesse, Ayuk, Tambe Betrand, Balakrishnan, Kalpana, Barac, Aleksandra, Bassat, Quique, Behzadifar, Masoud, Behzadifar, Meysam, Bhaumik, Soumyadeep, Bhutta, Zulfiqar A., Bijani, Ali, Brauer, Michael, Brown, Alexandria, Camargos, Paulo Am, Castañeda-Orjuela, Carlos A., Colombara, Danny, Conti, Sara, Dadi, Abel Fekadu, Dandona, Lalit, Dandona, Rakhi, Do, Huyen Phuc, Dubljanin, Eleonora, Edessa, Dumessa, Elkout, Hajer, Endries, Aman Yesuf, Fijabi, Daniel Obadare, Foreman, Kyle J., Forouzanfar, Mohammad H., Fullman, Nancy, Garcia-Basteiro, Alberto L., Gessner, Bradford D., Gething, Peter W., Gupta, Rahul, Gupta, Tarun, Hailu, Gessessew Bugssa, Hassen, Hamid Yimam, Hedayati, Mohammad T., Heidari, Mohsen, Hibstu, Desalegn Tsegaw, Horita, Nobuyuki, Ilesanmi, Olayinka S., Jakovljevic, Mihajlo B., Jamal, Amr A., Amaha Kahsay, Kasaeian, Amir, Kassa, Dessalegn Haile, Khader, Yousef Saleh, Khan, Ejaz Ahmad, Khan, Md Nuruzzaman, Khang, Young-Ho, Kim, Yun Jin, Kissoon, Niranjan, Knibbs, Luke D., Kochhar, Sonali, Koul, Parvaiz A., Kumar, G. Anil, Lodha, Rakesh, Magdy Abd El Razek, Hassan, Malta, Deborah Carvalho, Mathew, Joseph L., Mengistu, Desalegn Tadese, Mezgebe, Haftay Berhane, Mohammad, Karzan Abdulmuhsin, Mohammed, Mohammed A., Momeniha, Fatemeh, Murthy, Srinivas, Nguyen, Cuong Tat, Nielsen, Katie R., Ningrum, Dina Nur Anggraini, Nirayo, Yirga Legesse, Oren, Eyal, Ortiz, Justin R., Pa, Mahesh, Postma, Maarten J., Qorbani, Mostafa, Quansah, Reginald, Rai, Rajesh Kumar, Rana, Saleem M., Ranabhat, Chhabi Lal, Ray, Sarah E., Rezai, Mohammad Sadegh, Ruhago, George Mugambage, Safiri, Saeid, Salomon, Joshua A., Sartorius, Benn, Savic, Miloje, Sawhney, Monika, She, Jun, Sheikh, Aziz, Shiferaw, Mekonnen Sisay, Shigematsu, Mika, Singh, Jasvinder A., Somayaji, Ranjani, Stanaway, Jeffrey D., Sufiyan, Muawiyyah Babale, Taffere, Getachew Redae, Temsah, Mohamad-Hani, Thompson, Matthew J., Tobe-Gai, Ruoyan, Topor-Madry, Roman, Tran, Bach Xuan, Tran, Tung Thanh, Tuem, Kald Beshir, Ukwaja, Kingsley Nnanna, Vollset, Stein Emil, Walson, Judd L., Weldegebreal, Fitsum, Werdecker, Andrea, West, T. Eoin, Yonemoto, Naohiro, Zaki, Maysaa El Sayed, Zhou, Lei, Zodpey, Sanjay, Vos, Theo, Naghavi, Mohsen, Lim, Stephen S., Mokdad, Ali H., Murray, Christopher Jl, Hay, Simon I., Reiner, Robert C., Troeger, C, Blacker, B, Khalil, I, Rao, P, Cao, J, Zimsen, S, Albertson, S, Deshpande, A, Farag, T, Abebe, Z, Adetifa, I, Adhikari, T, Akibu, M, Al Lami, F, Al-Eyadhy, A, Alvis-Guzman, N, Amare, A, Amoako, Y, Antonio, C, Aremu, O, Asfaw, E, Asgedom, S, Atey, T, Attia, E, Avokpaho, E, Ayele, H, Ayuk, T, Balakrishnan, K, Barac, A, Bassat, Q, Behzadifar, M, Bhaumik, S, Bhutta, Z, Bijani, A, Brauer, M, Brown, A, Camargos, P, Castañeda-Orjuela, C, Colombara, D, Conti, S, Dadi, A, Dandona, L, Dandona, R, Do, H, Dubljanin, E, Edessa, D, Elkout, H, Endries, A, Fijabi, D, Foreman, K, Forouzanfar, M, Fullman, N, Garcia-Basteiro, A, Gessner, B, Gething, P, Gupta, R, Gupta, T, Hailu, G, Hassen, H, Hedayati, M, Heidari, M, Hibstu, D, Horita, N, Ilesanmi, O, Jakovljevic, M, Jamal, A, Kahsay, A, Kasaeian, A, Kassa, D, Khader, Y, Khan, E, Khan, M, Khang, Y, Kim, Y, Kissoon, N, Knibbs, L, Kochhar, S, Koul, P, Kumar, G, Lodha, R, Magdy Abd El Razek, H, Malta, D, Mathew, J, Mengistu, D, Mezgebe, H, Mohammad, K, Mohammed, M, Momeniha, F, Murthy, S, Nguyen, C, Nielsen, K, Ningrum, D, Nirayo, Y, Oren, E, Ortiz, J, Pa, M, Postma, M, Qorbani, M, Quansah, R, Rai, R, Rana, S, Ranabhat, C, Ray, S, Rezai, M, Ruhago, G, Safiri, S, Salomon, J, Sartorius, B, Savic, M, Sawhney, M, She, J, Sheikh, A, Shiferaw, M, Shigematsu, M, Singh, J, Somayaji, R, Stanaway, J, Sufiyan, M, Taffere, G, Temsah, M, Thompson, M, Tobe-Gai, R, Topor-Madry, R, Tran, B, Tran, T, Tuem, K, Ukwaja, K, Vollset, S, Walson, J, Weldegebreal, F, Werdecker, A, West, T, Yonemoto, N, Zaki, M, Zhou, L, Zodpey, S, Vos, T, Naghavi, M, Lim, S, Mokdad, A, Murray, C, Hay, S, Reiner, R, and Public Health

Subjects
Adult, Male, Adolescent, Biostatistics, Global Health, Global Buren of Disease, Lower Respiratory Infections, Article, Global Burden of Disease, Young Adult, Cost of Illness, Risk Factors, Prevalence, Humans, Child, Respiratory Tract Infections, Aged, Aged, 80 and over, Incidence, Infant, Newborn, Infant, Bacterial Infections, Middle Aged, Survival Analysis, Virus Diseases, Child, Preschool, Female, Topography, Medical, Morbidity, Epidemiologic Methods
Abstract

[Background] Lower respiratory infections are a leading cause of morbidity and mortality around the world. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, provides an up-to-date analysis of the burden of lower respiratory infections in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 26 years and shows how the burden of lower respiratory infection has changed in people of all ages. [Methods] We used three separate modelling strategies for lower respiratory infections in GBD 2016: a Bayesian hierarchical ensemble modelling platform (Cause of Death Ensemble model), which uses vital registration, verbal autopsy data, and surveillance system data to predict mortality due to lower respiratory infections; a compartmental meta-regression tool (DisMod-MR), which uses scientific literature, population representative surveys, and health-care data to predict incidence, prevalence, and mortality; and modelling of counterfactual estimates of the population attributable fraction of lower respiratory infection episodes due to Streptococcus pneumoniae, Haemophilus influenzae type b, influenza, and respiratory syncytial virus. We calculated each modelled estimate for each age, sex, year, and location. We modelled the exposure level in a population for a given risk factor using DisMod-MR and a spatio-temporal Gaussian process regression, and assessed the effectiveness of targeted interventions for each risk factor in children younger than 5 years. We also did a decomposition analysis of the change in LRI deaths from 2000–16 using the risk factors associated with LRI in GBD 2016. [Findings] In 2016, lower respiratory infections caused 652 572 deaths (95% uncertainty interval [UI] 586 475–720 612) in children younger than 5 years (under-5s), 1 080 958 deaths (943 749–1 170 638) in adults older than 70 years, and 2 377 697 deaths (2 145 584–2 512 809) in people of all ages, worldwide. Streptococcus pneumoniae was the leading cause of lower respiratory infection morbidity and mortality globally, contributing to more deaths than all other aetiologies combined in 2016 (1 189 937 deaths, 95% UI 690 445–1 770 660). Childhood wasting remains the leading risk factor for lower respiratory infection mortality among children younger than 5 years, responsible for 61·4% of lower respiratory infection deaths in 2016 (95% UI 45·7–69·6). Interventions to improve wasting, household air pollution, ambient particulate matter pollution, and expanded antibiotic use could avert one under-5 death due to lower respiratory infection for every 4000 children treated in the countries with the highest lower respiratory infection burden. [Interpretation] Our findings show substantial progress in the reduction of lower respiratory infection burden, but this progress has not been equal across locations, has been driven by decreases in several primary risk factors, and might require more effort among elderly adults. By highlighting regions and populations with the highest burden, and the risk factors that could have the greatest effect, funders, policy makers, and programme implementers can more effectively reduce lower respiratory infections among the world's most susceptible populations. [Findings] Bill & Melinda Gates Foundation.

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