Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Perceptions of Good Health and Impact of COVID-19 Among Adolescents in a Low-Income Urban Agglomerate in Delhi, India: A Qualitative Study

Adolescents constitute 16% of the global population and are susceptible to adverse health and illness from substance abuse, unhealthy diet, physical inactivity, and high-risk sexual behaviors. We conducted this study to assess the perceptions of good health, health-seeking behavior, and health service utilization among adolescents living in a low-income urban neighborhood after the second wave of the COVID-19 pandemic. A total of 23 adolescents, including 12 males and 11 females, were interviewed. Adolescents' perceived body image and size considerations apart from functioning at an optimum physical capacity as the principal attributes of good health, which was possible through the intake of a healthy diet and exercise. Adolescents were likely to be aware of the addiction potential and risk of cancer from using tobacco and alcohol, but attitudes towards eschewing their use were ambivalent. Adolescents perceived themselves as lacking access to reliable, adequate, and validated sources of sexual and reproductive health information. Knowledge and utilization of adolescent health services in this area were negligible, suggestive of the need to strengthen these services and improve the program outreach.

Seroprevalence of SARS-CoV-2 and Risk Assessment Among Healthcare Workers at a Dedicated Tertiary Care COVID-19 Hospital in Delhi, India: A Cohort Study

Background Healthcare workers (HCWs) have a substantially higher risk of Covid-19 infection but there is a paucity of information on the risk factors of disease transmission in high-burden real-world settings. The study objective was to determine the seroprevalence of SARS-CoV-2 among healthcare workers in a high-burden Covid-19 setting and to estimate the incidence and identify the risk factors of infection. Methods This was a prospective observational cohort study amongst doctors and nurses working at a dedicated Covid-19 tertiary care government hospital in Delhi, India. A baseline blood sample (2-3ml) was collected from all the participants to test for the presence of total SARS-CoV-2 antibodies. The HCWs that were seronegative (non-reactive) at baseline were followed-up for ≥21≤28 days with the collection of a second blood sample to assess for the incidence of SARS-CoV-2 infection. Results A total of 321 (51.3%, 95% C.I 47.4, 55.3) HCWs were detected with SARS-CoV-2 antibodies on baseline examination. The seroprevalence, when adjusted for assay characteristics, was 54.5% (95% C.I 50.3, 58.6). On bivariate analysis, SARS-CoV-2 antibody positivity lacked statistically significant association with either age, sex, occupation, cumulative duty duration, and smoking status. The incidence of seroconversion in the baseline seronegative cohort on follow-up after 21-28 days was observed in 35 (14.9%) HCWs (n=245). Furthermore, the self-reported adherence to infection prevention and control measures did not show a statistically significant association with antibody positivity in the HCWs, neither at baseline nor on follow-up. Conclusions  The high risk of SARS-CoV-2 transmission in HCWs may be substantially reduced by adherence to Infection Prevention Control (IPC) and protective measures.

Knowledge and practices related to the use of personal audio devices and associated health risks among medical students in Delhi

BACKGROUND

Over 1 billion young people globally are at risk of hearing loss and road traffic accidents due to unsafe listening practices while using personal audio devices (PADs). Rapid proliferation of mobile phones with built-in music playback facility has rendered nearly universal PAD access. The objective of this study was to ascertain the knowledge of risks and patterns of usage of PADs among medical undergraduate students in Delhi, India.

MATERIALS AND METHODS

A cross-sectional study was conducted among medical students] aged ≥18 years. Data were collected using a pretested self-administered questionnaire during December 2016-May 2017. Chi-square test was used to find an association between the categorical variables.

RESULTS

A total of 255 male and 133 female students were enrolled (n = 388). Male students used PADs with greater frequency and perceived lesser susceptibility to adverse health effects on prolonged PAD usage compared to female students. However, volume preference for PAD usage did not vary across gender. Self-reported history of hearing loss and tinnitus which persisted for at least 3 days in the previous 6 months was 10.6% and 6.4%, respectively. Nearly one in ten students agreed to the possibility of crossing the road while listening to music on their PADs.

DISCUSSION

Unsafe music-listening practices using PADs is potentially compromising the health and safety of young people in India. Strategic approaches supporting information education communication activities for promoting awareness of hearing and health risks related to prolonged PAD use at loud volumes and enactment of policies restricting undesirable PAD usage threatening road safety need consideration.

Health-Seeking Behaviour for Childhood Ailments in Caregivers of Under-Five Children in an Urban Resettlement Colony in Delhi, India

This explorative qualitative study assesses the health-seeking behaviour for childhood ailments in caregivers of under-five children in a low-income neighbourhood in Delhi, India during July-September 2021. A total of 17 caregivers (mothers) of eight male and nine female under-five children were enrolled, with the mother being the caregiver in most (94%) cases. Caregivers consulted on common childhood ailments from multiple sources, including family, neighbours, healthcare providers (both licensed and unlicensed), frontline workers, and local pharmacists. The internet was often used as a source of child health information due to its ease of access but often "confused" caregivers due to the presence of too much information. Health-seeking behaviour of caregivers for childhood ailments could range from self-medication, local pharmacist dispensing, and private and public healthcare providers. Factors that influenced preference for the healthcare facility or provider were accessibility issues (waiting time, queuing), perceived physician competence, and associated out-of-pocket expenses. Caregivers reported dissatisfaction with government health facilities because of shorter operational hours, overcrowding, suboptimal sanitation, queuing with limited seating arrangements, and occasionally discourteous health staff. Self-medication and over-the-counter use of antibiotics was high due to a lack of awareness of the challenges of antibiotic resistance or any perceived side effects. Preference for unlicensed practitioners for medical treatment was low and based on long-term familial beliefs and acceptance. However, traditional practitioners enjoyed a high level of trust in the community from shared cultural values, enjoining attenuation of the perceived non-biological agents of childhood illnesses through non-medical supernatural interventions.

Perceptions of Frontline Workers, Female Health Workers, and School Teachers in Menstrual Hygiene Promotion among Adolescent Girls of Delhi, India: A Qualitative Study

BACKGROUND

Government schemes for the promotion of Menstrual Hygiene Management (MHM) among adolescent girls in India are underpinned by crucial implementation efforts from the frontline health workers, community health workers, and school teachers.

AIM

The aim of the study is to identify the perspectives on menstrual health and hygiene management with regard to government schemes for sanitary pad distribution to adolescent girls among the frontline workers and the government school teachers located in urban resettlement colonies in Delhi.

METHODS

In-depth interviews were conducted with 30 accredited social health activisits, 30 Anganwadi Workers (AWW), and 30 auxiliary nurse midwives (ANMs) and five focus group discussions among 28 government school teachers from the middle, high, and secondary standard.

RESULTS

Most participants recognized the phenomenon of menstruation-related problems in adolescent girls and were aware of some of the common sociocultural, religious, and hygiene-related menstrual restrictions prevalent in their communities. All the participants believed that the pad distribution scheme was highly beneficial. However, in spite of inclusion of menstrual health promotion in the school curriculum, teachers often lacked self-efficacy in discussing challenges and health concerns related to MHM with their students.

CONCLUSIONS

Despite their potential as community resources for adolescent girls, FHWs, ANMs, and school teachers often fail to impart crucial menstrual hygiene information and skills-building needed toward achieving effective, safe, and optimal MHM.

Medication adherence and glycemic control among diabetes patients in developing countries

The potential interconnectedness of medication adherence, glycemic control, and clinical inertia in resource-constrained settings of the developing world needs further evaluation.

Abortion services and ethico-legal considerations in India: The case for transitioning from provider-centered to women-centered care

Nearly a million Indian women lack access to safe and dignified abortion services from public healthcare facilities and instead opt to induce abortions by themselves or with the help from unskilled and unauthorized practitioners. Unsafe abortions account for an estimated 9% of all maternal deaths in India despite the legalization of abortion on all grounds since 1971 via the MTP Act. However, the Act technically does not make any provision for abortion based on a woman's request alone, subjecting her decision to the approval of her healthcare provider, limiting reproductive autonomy. Moreover, the problem of female feticide through sex-selective abortions has also contributed to a conflicting public agenda that prioritizes preventing the former over allowing women access to abortion services for other reasons. Women who are socio-economically, culturally, and educationally vulnerable and minors may experience further abortion related stigmatization. These ethico-legal considerations highlight the need for transition from a provider-centered to a woman-centered abortion service model.

Media Reporting Relating to COVID-19 Vaccination as a Driver of Vaccine Hesitancy Prior to the Second Wave of the COVID-19 Pandemic in India: A Content Analysis of Newspaper and Digital Media Reports

Background Over 2,40,000 deaths were attributed to the SARS-CoV-2 Delta (B.1.617.2) variant in India during the second wave of the pandemic from April to June 2021 with most deaths occurring in the unvaccinated population. High levels of coronavirus disease 2019 (COVID-19) vaccine hesitancy contributed to significantly reduced vaccination coverage in the eligible population especially among healthcare workers, comorbid and older people. The existing global evidence suggests misinformation through social media to accentuate, while newspaper and mainstream media reporting to be protective against vaccine hesitancy during the COVID-19 pandemic. Content analysis of regular press coverage of COVID-19 vaccination in India during the period of initial deployment and until the onset of the second wave of the pandemic can provide useful learnings and strengthen preparedness for addressing potential vaccine hesitancy concerns during future pandemics. Therefore, we conducted this inductive content analysis of press coverage related to the COVID-19 vaccine hesitancy in India prior to the second (Delta) wave of the COVID-19 pandemic. Methods We examined news reports related to COVID-19 vaccination in India for the period from 1st January 2021 to 28 February 2021 from a high circulation English language daily (Hindustan Times), Hindi (vernacular) language daily (Dainik Jagran), and English language news reports from selected digital news portals. The inclusion criterion was any news report related to COVID-19 vaccination including editorials and guest opinion pieces that could potentially generate COVID-19-related vaccine hesitancy. The news items were classified depending on their potential to drive vaccine hesitancy by either avoiding reporting of positive information related to COVID-19 vaccines, or attributing directly or indirectly, negative or misleading commentary relating to vaccine safety or efficacy. Reports with possible risk of increasing vaccine hesitancy were further analyzed based on content, source of information, and the extent of fact-checking. Results Most of the published newspaper reports examined in this study echoed official news sources and views from government health agencies promoting COVID-19 vaccine acceptance and dispelling doubts on concerns regarding vaccine safety. There were eight unique newspaper reports after excluding duplicated bilingual entries and four news items from online digital Indian news sources that met our criterion of reports with possible contribution to vaccine hesitancy. The reports possibly contributed to vaccine hesitancy were grouped into two themes: (i) Doubts on the safety and efficacy of local manufactured vaccines: most of these reports focused on the granting of emergency use authorization for Covaxin (BBV152) in 'clinical trial mode' without the completion and publication of Phase-3 efficacy data (ii). Doubts on vaccine requirement considering high seroprevalence and reduced virus transmission.  Conclusions Concerns about the efficacy and safety of Covaxin (BBV152), safety of the Covishield vaccine, and questioning the necessity of immunizing all adults with COVID-19 vaccines were observed in multiple press reports with attempts at politicization of vaccination-related decisions. The press reporting with potential for contributing to significant COVID-19 vaccine hesitancy since launch and until the Delta wave of the pandemic in India has important lessons in future pandemic preparedness.

Hypertension care cascade and their determinants among older adolescents in India: evidence from a nationally representative cross-sectional survey

Adolescent hypertension in India is an emergent public health concern with lack of programmatic focus on regular screening amongst both individuals and healthcare providers. This study was conducted to assess the hypertension care cascade (prevalence, awareness, treatment and control status of hypertension) from nationally representative data. We used data from the demographic and health surveillance (DHS) comprising India's National Family Health Survey Fifth Round (2019-2021). The prevalence of hypertension among 204,054 older adolescents (15-19 years) was 5.08% (95% CI: 4.94-5.23%) wherein 42.26% (95% CI: 40.69-43.64%) were aware of their condition, 43.70% (95% CI: 41.73-45.70%) of those aware were receiving treatment, and 85.88% (95% CI: 83.83-87.71%) of those on treatment achieved blood pressure control. Overall, there were nearly 60% newly diagnosed hypertension cases detected on screening. Females had significantly lower odds, while those with diabetes and higher waist-hip ratio had significantly higher odds of having hypertension. The awareness of their hypertensive status was higher among females and rural residents, while it was lower among adolescents that were obese and tobacco smokers. Improved blood pressure control was associated with a lower waist-to-hip ratio. In conclusion, nearly five in every hundred older adolescents in India are clinically hypertensive with significantly higher odds linked with obesity and male gender. Awareness and utilization of antihypertensive treatment was lower than the classical rule of halves signifying deficiencies in hypertension screening and management strategies for older adolescents within the existing public health policy framework.

Forecasting the effects of smoking prevalence scenarios on years of life lost and life expectancy from 2022 to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Smoking is the leading behavioural risk factor for mortality globally, accounting for more than 175 million deaths and nearly 4·30 billion years of life lost (YLLs) from 1990 to 2021. The pace of decline in smoking prevalence has slowed in recent years for many countries, and although strategies have recently been proposed to achieve tobacco-free generations, none have been implemented to date. Assessing what could happen if current trends in smoking prevalence persist, and what could happen if additional smoking prevalence reductions occur, is important for communicating the effect of potential smoking policies.

METHODS

In this analysis, we use the Institute for Health Metrics and Evaluation's Future Health Scenarios platform to forecast the effects of three smoking prevalence scenarios on all-cause and cause-specific YLLs and life expectancy at birth until 2050. YLLs were computed for each scenario using the Global Burden of Disease Study 2021 reference life table and forecasts of cause-specific mortality under each scenario. The reference scenario forecasts what could occur if past smoking prevalence and other risk factor trends continue, the Tobacco Smoking Elimination as of 2023 (Elimination-2023) scenario quantifies the maximum potential future health benefits from assuming zero percent smoking prevalence from 2023 onwards, whereas the Tobacco Smoking Elimination by 2050 (Elimination-2050) scenario provides estimates for countries considering policies to steadily reduce smoking prevalence to 5%. Together, these scenarios underscore the magnitude of health benefits that could be reached by 2050 if countries take decisive action to eliminate smoking. The 95% uncertainty interval (UI) of estimates is based on the 2·5th and 97·5th percentile of draws that were carried through the multistage computational framework.

FINDINGS

Global age-standardised smoking prevalence was estimated to be 28·5% (95% UI 27·9-29·1) among males and 5·96% (5·76-6·21) among females in 2022. In the reference scenario, smoking prevalence declined by 25·9% (25·2-26·6) among males, and 30·0% (26·1-32·1) among females from 2022 to 2050. Under this scenario, we forecast a cumulative 29·3 billion (95% UI 26·8-32·4) overall YLLs among males and 22·2 billion (20·1-24·6) YLLs among females over this period. Life expectancy at birth under this scenario would increase from 73·6 years (95% UI 72·8-74·4) in 2022 to 78·3 years (75·9-80·3) in 2050. Under our Elimination-2023 scenario, we forecast 2·04 billion (95% UI 1·90-2·21) fewer cumulative YLLs by 2050 compared with the reference scenario, and life expectancy at birth would increase to 77·6 years (95% UI 75·1-79·6) among males and 81·0 years (78·5-83·1) among females. Under our Elimination-2050 scenario, we forecast 735 million (675-808) and 141 million (131-154) cumulative YLLs would be avoided among males and females, respectively. Life expectancy in 2050 would increase to 77·1 years (95% UI 74·6-79·0) among males and 80·8 years (78·3-82·9) among females.

INTERPRETATION

Existing tobacco policies must be maintained if smoking prevalence is to continue to decline as forecast by the reference scenario. In addition, substantial smoking-attributable burden can be avoided by accelerating the pace of smoking elimination. Implementation of new tobacco control policies are crucial in avoiding additional smoking-attributable burden in the coming decades and to ensure that the gains won over the past three decades are not lost.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Multi-dose vials versus single-dose vials for vaccination: perspectives from lower-middle income countries

The choice of the vaccine packaging type either as single- or multi-dose vial is a crucial determinant of vaccine coverage. The experience of vaccination strategies in lower-middle-income countries suggests that multi-dose vaccine vials translate into greater economic-logistic advantages due to lower packaging and storage costs with significant environmental benefits accrued from reduced medical waste generation. However, the use of multi-dose vials is associated with a theoretical risk of contamination particularly from human error. Moreover, the overall economic advantage of multi-dose vials is contingent on the reduction of the extent of vaccine wastage associated with their use. Robust data collection for monitoring of vaccine wastage rates and adverse effects following immunization is therefore needed to understand the extent of economic benefit and risks involved with multi-dose vial use.

Outpatient antibiotic prescribing behavior and their psychosocial predictors among early-career clinicians in Delhi, India

Introduction:

Psychosocial factors are significant drivers of inappropriate antibiotic prescription leading to antibiotic resistance. We ascertained the psychosocial predictors of outpatient antibiotic prescribing (OAP) behavior among early-career clinicians in India.

Materials and Methods:

We enrolled 200 early-career clinicians, including 100 medical interns and 100 junior residents (postgraduate student doctors) in six clinical departments, and collected data using a self-administered questionnaire. Response options were coded on five-item Likert scales.

Results:

Antimicrobial resistance was viewed as a significant public health problem by most (95%) participants. Presumptive antibiotic prescribing was reported by 84% of participants, although the participant attitude indicated a slight disinclination against the presumptive use of antibiotics (mean = 2.8, standard deviation = 0.72). The majority (52.5%) of the participant's perceived social pressure frequently influenced their decision to prescribe antibiotics to the outpatients. Furthermore, the maximum social pressure was perceived as driven by patient expectation for antibiotics and the existing antibiotic prescribing behavior of their peers and colleagues. The perception of increased social pressure stipulating antibiotic prescribing negatively correlated with the participant's intention to reduce antibiotic use in outpatients (r= −0.124, P < 0.001). Social pressure was reported to be higher when treating adult patients reporting diarrheal symptoms and children having cough.

Conclusions:

OAP practices among early-career clinicians working in the government health sector in India are mediated by considerable social pressure despite behavioral intention for reducing antibiotic use.

The following core competencies are addressed in this article:

Practice-based learning and improvement, Professionalism.

Utilization of Nutritional Supplementation Services and Their Predictors in Pregnant and Lactating Women Living in an Urban Resettlement Colony of Delhi, India: A Cross-Sectional Study

Introduction Maternal undernutrition during pregnancy and lactating has adverse health consequences for the mother and her child. The Integrated Child Development Services (ICDS) scheme by the Government of India provides supplementary nutrition services to all pregnant and lactating women but its utilization is suboptimal due to inefficient distribution through the health system and beneficiary concerns regarding its usefulness. This study was conducted with the objective of assessing the utilization of nutrition-related ICDS services by pregnant and lactating women in urban poor settlements of Delhi and the sociodemographic factors associated with non-utilization. Materials and methods This was a community-based cross-sectional survey in an urban resettlement colony and slum area located in the northeast district of Delhi. The data collection was conducted from January to May 2022. Eligible participants included pregnant women in their second or third trimester of pregnancy and lactating mothers in their first six months of the postpartum period who were residents of the study setting. Data were collected using face-to-face interviews using a pre-tested and self-designed questionnaire. The primary outcome was the proportion of women utilizing ICDS take-home rations (THR) in the previous month. Results A total of 365 participants were recruited in this study including 208 pregnant and 157 lactating women having a median (IQR) age of 25 (22-28) years. A total of 211 (57.8%) participants reported a history of utilization of ICDS supplementary nutrition services during their current pregnancy or postpartum with 154 (42.2%) having received THR in the previous month. Among the currently pregnant women, 84 (40.4%) had utilized ICDS THR while in the currently lactating women, 70 (44.6%) had utilized THR in the previous month. On adjusted analysis, multigravid women were less likely to have utilized ICDS compared to primigravida women. Reasons for non-utilization of the ICDS supplementary nutrition services by the mothers were temporary disruption due to cessation of ICDS services by protesting Anganwadi workers (over demand for increased honorarium), difficult access to Anganwadi center, the poor perceived taste of the food provided as THR, and perception by the mothers that they did not require THR. Most women reported sharing the THR with their family members. All pregnant and lactating women were found to be calorie and protein deficient in this study when applying the recommended intake values. No association was observed between the utilization of ICDS in the previous month and the presence of calorie deficiency in both pregnant (p=0.35) and lactating (p=0.24) women. Conclusions More than four in ten eligible pregnant and lactating women in an urban resettlement colony in Delhi did not utilize ICDS supplementary nutrition services with similar rates of utilization in both pregnant and lactating women. Women living in joint families and consequently larger households were less likely to utilize ICDS services. A majority of pregnant and lactating women were calorie and protein deficient even on applying non-pregnant cut-off requirements. The ICDS scheme needs to strengthen information, education, and communication (IEC) strategies and interventions to improve its acceptability and utilization by this vulnerable population.

Global, regional, and national prevalence of adult overweight and obesity, 1990-2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021

BACKGROUND

Overweight and obesity is a global epidemic. Forecasting future trajectories of the epidemic is crucial for providing an evidence base for policy change. In this study, we examine the historical trends of the global, regional, and national prevalence of adult overweight and obesity from 1990 to 2021 and forecast the future trajectories to 2050.

METHODS

Leveraging established methodology from the Global Burden of Diseases, Injuries, and Risk Factors Study, we estimated the prevalence of overweight and obesity among individuals aged 25 years and older by age and sex for 204 countries and territories from 1990 to 2050. Retrospective and current prevalence trends were derived based on both self-reported and measured anthropometric data extracted from 1350 unique sources, which include survey microdata and reports, as well as published literature. Specific adjustment was applied to correct for self-report bias. Spatiotemporal Gaussian process regression models were used to synthesise data, leveraging both spatial and temporal correlation in epidemiological trends, to optimise the comparability of results across time and geographies. To generate forecast estimates, we used forecasts of the Socio-demographic Index and temporal correlation patterns presented as annualised rate of change to inform future trajectories. We considered a reference scenario assuming the continuation of historical trends.

FINDINGS

Rates of overweight and obesity increased at the global and regional levels, and in all nations, between 1990 and 2021. In 2021, an estimated 1·00 billion (95% uncertainty interval [UI] 0·989-1·01) adult males and 1·11 billion (1·10-1·12) adult females had overweight and obesity. China had the largest population of adults with overweight and obesity (402 million [397-407] individuals), followed by India (180 million [167-194]) and the USA (172 million [169-174]). The highest age-standardised prevalence of overweight and obesity was observed in countries in Oceania and north Africa and the Middle East, with many of these countries reporting prevalence of more than 80% in adults. Compared with 1990, the global prevalence of obesity had increased by 155·1% (149·8-160·3) in males and 104·9% (95% UI 100·9-108·8) in females. The most rapid rise in obesity prevalence was observed in the north Africa and the Middle East super-region, where age-standardised prevalence rates in males more than tripled and in females more than doubled. Assuming the continuation of historical trends, by 2050, we forecast that the total number of adults living with overweight and obesity will reach 3·80 billion (95% UI 3·39-4·04), over half of the likely global adult population at that time. While China, India, and the USA will continue to constitute a large proportion of the global population with overweight and obesity, the number in the sub-Saharan Africa super-region is forecasted to increase by 254·8% (234·4-269·5). In Nigeria specifically, the number of adults with overweight and obesity is forecasted to rise to 141 million (121-162) by 2050, making it the country with the fourth-largest population with overweight and obesity.

INTERPRETATION

No country to date has successfully curbed the rising rates of adult overweight and obesity. Without immediate and effective intervention, overweight and obesity will continue to increase globally. Particularly in Asia and Africa, driven by growing populations, the number of individuals with overweight and obesity is forecast to rise substantially. These regions will face a considerable increase in obesity-related disease burden. Merely acknowledging obesity as a global health issue would be negligent on the part of global health and public health practitioners; more aggressive and targeted measures are required to address this crisis, as obesity is one of the foremost avertible risks to health now and in the future and poses an unparalleled threat of premature disease and death at local, national, and global levels.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of household air pollution, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Despite a substantial reduction in the use of solid fuels for cooking worldwide, exposure to household air pollution (HAP) remains a leading global risk factor, contributing considerably to the burden of disease. We present a comprehensive analysis of spatial patterns and temporal trends in exposure and attributable disease from 1990 to 2021, featuring substantial methodological updates compared with previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study, including improved exposure estimations accounting for specific fuel types.

METHODS

We estimated HAP exposure and trends and attributable burden for cataract, chronic obstructive pulmonary disease, ischaemic heart disease, lower respiratory infections, tracheal cancer, bronchus cancer, lung cancer, stroke, type 2 diabetes, and causes mediated via adverse reproductive outcomes for 204 countries and territories from 1990 to 2021. We first estimated the mean fuel type-specific concentrations (in μg/m3) of fine particulate matter (PM2·5) pollution to which individuals using solid fuels for cooking were exposed, categorised by fuel type, location, year, age, and sex. Using a systematic review of the epidemiological literature and a newly developed meta-regression tool (meta-regression: Bayesian, regularised, trimmed), we derived disease-specific, non-parametric exposure-response curves to estimate relative risk as a function of PM2·5 concentration. We combined our exposure estimates and relative risks to estimate population attributable fractions and attributable burden for each cause by sex, age, location, and year.

FINDINGS

In 2021, 2·67 billion (95% uncertainty interval [UI] 2·63-2·71) people, 33·8% (95% UI 33·2-34·3) of the global population, were exposed to HAP from all sources at a mean concentration of 84·2 μg/m3. Although these figures show a notable reduction in the percentage of the global population exposed in 1990 (56·7%, 56·4-57·1), in absolute terms, there has been only a decline of 0·35 billion (10%) from the 3·02 billion people exposed to HAP in 1990. In 2021, 111 million (95% UI 75·1-164) global disability-adjusted life-years (DALYs) were attributable to HAP, accounting for 3·9% (95% UI 2·6-5·7) of all DALYs. The rate of global, HAP-attributable DALYs in 2021 was 1500·3 (95% UI 1028·4-2195·6) age-standardised DALYs per 100 000 population, a decline of 63·8% since 1990, when HAP-attributable DALYs comprised 4147·7 (3101·4-5104·6) age-standardised DALYs per 100 000 population. HAP-attributable burden remained highest in sub-Saharan Africa and south Asia, with 4044·1 (3103·4-5219·7) and 3213·5 (2165·4-4409·4) age-standardised DALYs per 100 000 population, respectively. The rate of HAP-attributable DALYs was higher for males (1530·5, 1023·4-2263·6) than for females (1318·5, 866·1-1977·2). Approximately one-third of the HAP-attributable burden (518·1, 410·1-641·7) was mediated via short gestation and low birthweight. Decomposition of trends and drivers behind changes in the HAP-attributable burden highlighted that declines in exposures were counteracted by population growth in most regions of the world, especially sub-Saharan Africa.

INTERPRETATION

Although the burden attributable to HAP has decreased considerably, HAP remains a substantial risk factor, especially in sub-Saharan Africa and south Asia. Our comprehensive estimates of HAP exposure and attributable burden offer a robust and reliable resource for health policy makers and practitioners to precisely target and tailor health interventions. Given the persistent and substantial impact of HAP in many regions and countries, it is imperative to accelerate efforts to transition under-resourced communities to cleaner household energy sources. Such initiatives are crucial for mitigating health risks and promoting sustainable development, ultimately improving the quality of life and health outcomes for millions of people.

FUNDING

Bill & Melinda Gates Foundation.