Lancet. 2018 Nov 10;392(10159):1736-1788. doi: 10.1016/S0140-6736(18)32203-7. Epub 2018 Nov 8.
BACKGROUND: Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. METHODS: The causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries-Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised. FINDINGS: At the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest fraction of deaths, contributing to 73·4% (95% uncertainty interval [UI] 72·5-74·1) of total deaths in 2017, while communicable, maternal, neonatal, and nutritional (CMNN) causes accounted for 18·6% (17·9-19·6), and injuries 8·0% (7·7-8·2). Total numbers of deaths from NCD causes increased from 2007 to 2017 by 22·7% (21·5-23·9), representing an additional 7·61 million (7·20-8·01) deaths estimated in 2017 versus 2007. The death rate from NCDs decreased globally by 7·9% (7·0-8·8). The number of deaths for CMNN causes decreased by 22·2% (20·0-24·0) and the death rate by 31·8% (30·1-33·3). Total deaths from injuries increased by 2·3% (0·5-4·0) between 2007 and 2017, and the death rate from injuries decreased by 13·7% (12·2-15·1) to 57·9 deaths (55·9-59·2) per 100 000 in 2017. Deaths from substance use disorders also increased, rising from 284 000 deaths (268 000-289 000) globally in 2007 to 352 000 (334 000-363 000) in 2017. Between 2007 and 2017, total deaths from conflict and terrorism increased by 118·0% (88·8-148·6). A greater reduction in total deaths and death rates was observed for some CMNN causes among children younger than 5 years than for older adults, such as a 36·4% (32·2-40·6) reduction in deaths from lower respiratory infections for children younger than 5 years compared with a 33·6% (31·2-36·1) increase in adults older than 70 years. Globally, the number of deaths was greater for men than for women at most ages in 2017, except at ages older than 85 years. Trends in global YLLs reflect an epidemiological transition, with decreases in total YLLs from enteric infections, respiratory infections and tuberculosis, and maternal and neonatal disorders between 1990 and 2017; these were generally greater in magnitude at the lowest levels of the Socio-demographic Index (SDI). At the same time, there were large increases in YLLs from neoplasms and cardiovascular diseases. YLL rates decreased across the five leading Level 2 causes in all SDI quintiles. The leading causes of YLLs in 1990-neonatal disorders, lower respiratory infections, and diarrhoeal diseases-were ranked second, fourth, and fifth, in 2017. Meanwhile, estimated YLLs increased for ischaemic heart disease (ranked first in 2017) and stroke (ranked third), even though YLL rates decreased. Population growth contributed to increased total deaths across the 20 leading Level 2 causes of mortality between 2007 and 2017. Decreases in the cause-specific mortality rate reduced the effect of population growth for all but three causes: substance use disorders, neurological disorders, and skin and subcutaneous diseases. INTERPRETATION: Improvements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health. For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups. Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade. FUNDING: Bill & Melinda Gates Foundation.
背景:全球发展目标越来越依赖于特定国家的基准数据来衡量国家的进展情况。为了满足这一需求,全球疾病、伤害和风险因素研究(GBD)2016 年估计了自 1980 年以来全球、地区、国家以及部分特定地点的特定死因死亡率。本文报告了该研究的更新内容,利用了新的可用数据和改进的方法。GBD 2017 提供了 195 个国家和地区 282 种死因的综合评估,涵盖了 1980 年至 2017 年的死亡率数据。 方法:死因数据库由死因登记处(VR)、死因推断(VA)、登记处、调查、警察和监测数据组成。GBD 2017 新增了 10 项 VA 研究、127 个国家/地区的 VR 数据、502 个癌症登记处国家/地区的年份数据,以及另外一个监测国家/地区的年份数据。GBD 死因分类系统的扩展导致 2017 年估计了 18 种额外的死因。5 个新的国家/地区(埃塞俄比亚、伊朗、新西兰、挪威和俄罗斯)也有了亚级别的估计数据。对归因于非特异性、不可信或中间原因的 ICD 编码死亡进行了重新分配,分配给潜在原因,并通过纳入不确定性估计的再分配算法进行了重新分配。我们使用 GBD 开发的统计建模工具,包括死因综合模型(CODEm),生成了每个地点、年份、年龄和性别的死因分数和特定死因死亡率。与之前的版本不同,GBD 2017 独立估计了所有地点的人口规模和生育率,而不是使用联合国的估计数据。然后计算每年损失的寿命年(YLL),即每个死亡乘以每个年龄的标准预期寿命的总和。这里报告的所有死亡率都是年龄标准化的。 结果:在最广泛的死因分组(一级)中,非传染性疾病(NCDs)占死亡人数的最大比例,2017 年占总死亡人数的 73.4%(95%置信区间[CI]72.5-74.1),而传染性疾病、孕产妇、新生儿和营养(CMNN)占 18.6%(17.9-19.6),伤害占 8.0%(7.7-8.2)。NCD 死因导致的死亡人数从 2007 年到 2017 年增加了 22.7%(21.5-23.9),这意味着 2017 年比 2007 年额外增加了 7.61 百万人(7.20-8.01)的死亡人数。NCD 导致的死亡率全球下降了 7.9%(7.0-8.8)。CMNN 导致的死亡人数减少了 22.2%(20.0-24.0),死亡率下降了 31.8%(30.1-33.3)。伤害导致的死亡人数从 2007 年到 2017 年增加了 2.3%(0.5-4.0),伤害导致的死亡率下降了 13.7%(12.2-15.1),至 2017 年每 10 万人中 57.9 人(55.9-59.2)。药物使用障碍导致的死亡人数也有所增加,从 2007 年的全球 28.4 万人(26.8 万-28.9 万)增加到 2017 年的 35.2 万人(33.4 万-36.3 万)。2007 年至 2017 年,冲突和恐怖主义导致的总死亡人数增加了 118.0%(88.8-148.6)。与老年人相比,儿童(5 岁以下)的一些 CMNN 病因的总死亡人数和死亡率的下降幅度更大,例如,5 岁以下儿童下呼吸道感染的死亡人数减少了 36.4%(32.2-40.6),而 70 岁以上成年人的死亡人数增加了 33.6%(31.2-36.1)。2017 年,全球大多数年龄组的男性死亡人数都高于女性,除了 85 岁以上的年龄组。全球 YLL 趋势反映了一种流行病学的转变,即 1990 年至 2017 年期间,肠道感染、呼吸道感染和结核病以及孕产妇和新生儿疾病的总 YLL 减少;在社会人口指数(SDI)最低的水平,这些疾病的幅度更大。与此同时,肿瘤和心血管疾病的 YLL 大量增加。在所有 SDI 五分位数中,五个主要的二级死因的 YLL 率都有所下降。1990 年排名第二、第四和第五的主要死因分别是新生儿疾病、下呼吸道感染和腹泻病,2017 年则排名第二、第四和第五。与此同时,缺血性心脏病(2017 年排名第一)和中风(排名第三)的 YLL 估计值增加了,尽管 YLL 率有所下降。人口增长导致 2017 年排名前 20 的死因导致的总死亡人数在 2007 年至 2017 年期间增加。除了三种死因(药物使用障碍、神经障碍和皮肤及皮下疾病)外,其他死因的特定死因死亡率下降降低了人口增长的影响。 结论:全球卫生的改善在人群中分布不均。伤害、药物使用障碍、武装冲突和恐怖主义、肿瘤和心血管疾病是对全球健康的新威胁。对于下呼吸道和肠道感染等疾病,儿童的死亡率比老年人的死亡率下降得更快,而且各年龄段的性别死亡率差异仍然存在。一些常见疾病的死亡率下降速度本身已经放缓或已经停止,主要是 NCD,而某些病因的死亡率在过去十年中有所增加。 资金来源:比尔和梅琳达·盖茨基金会。
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