Lancet Infect Dis. 2018 Nov;18(11):1191-1210. doi: 10.1016/S1473-3099(18)30310-4. Epub 2018 Sep 19.
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. FUNDING: Bill & Melinda Gates Foundation.
背景:下呼吸道感染是全世界发病率和死亡率的主要原因。全球疾病、伤害和危险因素研究 2016 年(GBD 2016)提供了最新的分析,研究了 195 个国家的下呼吸道感染负担。本研究评估了过去 26 年的病例、死亡和病因,并展示了下呼吸道感染在所有年龄段人群中的负担是如何变化的。
方法:我们在 GBD 2016 中使用了三种独立的下呼吸道感染建模策略:一个贝叶斯分层集成建模平台(死因集成模型),该模型使用人口登记、死因推断数据和监测系统数据来预测下呼吸道感染导致的死亡率;一个分类回归工具(DisMod-MR),该工具使用科学文献、代表性人口调查和医疗保健数据来预测发病率、患病率和死亡率;以及对肺炎链球菌、流感嗜血杆菌 b 型、流感和呼吸道合胞病毒导致的下呼吸道感染事件的人群归因分数的反事实估计的建模。我们为每个年龄、性别、年份和地点计算了每个模型的估计值。我们使用 DisMod-MR 和时空高斯过程回归来计算特定风险因素下的人群暴露水平,并评估了针对 5 岁以下儿童的每个风险因素的靶向干预措施的效果。我们还使用 2016 年 GBD 中与下呼吸道感染相关的风险因素对 2000-16 年下呼吸道感染死亡人数的变化进行了分解分析。
结果:2016 年,下呼吸道感染导致 5 岁以下儿童(<5 岁)死亡 652572 例(95%置信区间 [95%UI]:586475-720612),70 岁以上成年人死亡 1080958 例(943749-1170638),所有年龄组死亡 2377697 例(2145584-2512809),全球范围。肺炎链球菌是全球下呼吸道感染发病率和死亡率的主要原因,2016 年导致的死亡人数超过所有其他病因的总和(1189937 例,95%UI:690445-1770660)。儿童消瘦仍然是导致 5 岁以下儿童下呼吸道感染死亡的主要危险因素,占 2016 年下呼吸道感染死亡人数的 61.4%(95%UI:45.7-69.6)。改善消瘦、家庭空气污染、环境颗粒物污染和扩大抗生素使用范围等干预措施,可能会使每治疗 4000 名负担最重下呼吸道感染的国家中的儿童,就避免 1 名儿童死于下呼吸道感染。
解释:我们的研究结果表明,下呼吸道感染负担的减少取得了实质性进展,但这种进展在不同地区并不均衡,主要是由于几个主要危险因素的减少,而且在老年人群中可能需要付出更多的努力。通过突出负担最重的地区和人群,以及可能产生最大影响的风险因素,资助者、政策制定者和方案实施者可以更有效地减少世界上最易受感染人群的下呼吸道感染。
资金来源:比尔及梅琳达·盖茨基金会。
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