Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

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.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021

BACKGROUND

Unintentional carbon monoxide poisoning is a largely preventable cause of death that has received insufficient attention. We aimed to conduct a comprehensive global analysis of the demographic, temporal, and geographical patterns of fatal unintentional carbon monoxide poisoning from 2000 to 2021.

METHODS

As part of the latest Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), unintentional carbon monoxide poisoning mortality was quantified using the GBD cause of death ensemble modelling strategy. Vital registration data and covariates with an epidemiological link to unintentional carbon monoxide poisoning informed the estimates of death counts and mortality rates for all locations, sexes, ages, and years included in the GBD. Years of life lost (YLLs) were estimated by multiplying deaths by remaining standard life expectancy at age of death. Population attributable fractions (PAFs) for unintentional carbon monoxide poisoning deaths due to occupational injuries and high alcohol use were estimated.

FINDINGS

In 2021, the global mortality rate due to unintentional carbon monoxide poisoning was 0·366 per 100 000 (95% uncertainty interval 0·276-0·415), with 28 900 deaths (21 700-32 800) and 1·18 million YLLs (0·886-1·35) across all ages. Nearly 70% of deaths occurred in males (20 100 [15 800-24 000]), and the 50-54-year age group had the largest number of deaths (2210 [1660-2590]). The highest mortality rate was in those aged 85 years or older with 1·96 deaths (1·38-2·32) per 100 000. Eastern Europe had the highest age-standardised mortality rate at 2·12 deaths (1·98-2·30) per 100 000. Globally, there was a 53·5% (46·2-63·7) decrease in the age-standardised mortality rate from 2000 to 2021, although this decline was not uniform across regions. The overall PAFs for occupational injuries and high alcohol use were 13·6% (11·9-16·0) and 3·5% (1·4-6·2), respectively.

INTERPRETATION

Improvements in unintentional carbon monoxide poisoning mortality rates have been inconsistent across regions and over time since 2000. Given that unintentional carbon monoxide poisoning is almost entirely preventable, policy-level interventions that lower the risk of carbon monoxide poisoning events should be prioritised, such as those that increase access to improved heating and cooking devices, reduce carbon monoxide emissions from generators, and mandate use of carbon monoxide alarms.

FUNDING

Bill & Melinda Gates Foundation.

Non-interactive effects drive multiple stressor impacts on the taxonomic and functional diversity of atlantic stream macroinvertebrates

Freshwaters are considered among the most endangered ecosystems globally due to multiple stressors, which coincide in time and space. These local stressors typically result from land-use intensification or hydroclimatic alterations, among others. Despite recent advances on multiple stressor effects, current knowledge is still limited to manipulative approaches minimizing biological and abiotic variability. Thus, the assessment of multiple stressor effects in real-world ecosystems is required. Using an extensive survey of 50 stream reaches across North Portugal, we evaluated taxonomic and functional macroinvertebrate responses to multiple stressors, including marked gradients of nutrient enrichment, flow reduction, riparian vegetation structure, thermal stress and dissolved oxygen depletion. We analyzed multiple stressor effects on two taxonomic (taxon richness, Shannon-diversity) and two trait-based diversity indices (functional richness, functional dispersion), as well as changes in trait composition. We found that multiple stressors had additive effects on all diversity metrics, with nutrient enrichment identified as the most important stressor in three out of four metrics, followed by dissolved oxygen depletion and thermal stress. Taxon richness, Shannon-diversity and functional richness responded similarly, whereas functional dispersion was driven by changes in flow velocity and thermal stress. Functional trait composition changed along a major stress gradient determined by nutrient enrichment and oxygen depletion, which was positively correlated with organisms possessing fast-living strategies, aerial respiration, adult phases, and gathering-collector feeding habits. Overall, our results reinforce the need to consider complementary facets of biodiversity to better identify assembly processes in response to multiple stressors. Our data suggest that stressor interactions may be less frequent in real-word streams than predicted by manipulative experiments, which can facilitate mitigation strategies. By combining an extensive field survey with an integrative consideration of multiple biodiversity facets, our study provides new insights that can help to better assess and manage rivers in a global change context.

ESHRE PGT Consortium data collection XXI: PGT analyses in 2018

STUDY QUESTION

What are the trends and developments in preimplantation genetic testing (PGT) in 2018 as compared to previous years?

SUMMARY ANSWER

The main trends observed in this 21st dataset on PGT are that the implementation of trophectoderm biopsy with comprehensive whole-genome testing is most often applied for PGT-A and concurrent PGT-M/SR/A, while for PGT-M and PGT-SR, single-cell testing with PCR and FISH still prevail.

WHAT IS KNOWN ALREADY

Since it was established in 1997, the ESHRE PGT Consortium has been collecting and analysing data from mainly European PGT centres. To date, 20 datasets and an overview of the first 10 years of data collections have been published.

STUDY DESIGN SIZE DURATION

The data for PGT analyses performed between 1 January 2018 and 31 December 2018 with a 2-year follow-up after analysis were provided by participating centres on a voluntary basis. Data were collected using an online platform, which is based on genetic analysis and has been in use since 2016.

PARTICIPANTS/MATERIALS SETTING METHODS

Data on biopsy method, diagnostic technology, and clinical outcome were submitted by 44 centres. Records with analyses for more than one PGT for monogenic disorders (PGT-M) and/or PGT for chromosomal structural rearrangements (PGT-SR), or with inconsistent data regarding the PGT modality, were excluded. All transfers performed within 2 years after the analysis were included, enabling the calculation of cumulative pregnancy rates. Data analysis, calculations, and preparation of figures and tables were carried out by expert co-authors.

MAIN RESULTS AND THE ROLE OF CHANCE

The current data collection from 2018 covers a total of 1388 analyses for PGT-M, 462 analyses for PGT-SR, 3003 analyses for PGT for aneuploidies (PGT-A), and 338 analyses for concurrent PGT-M/SR with PGT-A.The application of blastocyst biopsy is gradually rising for PGT-M (from 19% in 2016-2017 to 33% in 2018), is status quo for PGT-SR (from 30% in 2016-2017 to 33% in 2018) and has become the most used biopsy stage for PGT-A (from 87% in 2016-2017 to 98% in 2018) and for concurrent PGT-M/SR with PGT-A (96%). The use of comprehensive, whole-genome amplification (WGA)-based diagnostic technology showed a small decrease for PGT-M (from 15% in 2016-2017 to 12% in 2018) and for PGT-SR (from 50% in 2016-2017 to 44% in 2018). Comprehensive testing was, however, the main technology for PGT-A (from 93% in 2016-2017 to 98% in 2018). WGA-based testing was also widely used for concurrent PGT-M/SR with PGT-A, as a standalone technique (74%) or in combination with PCR or FISH (24%). Trophectoderm biopsy and comprehensive testing strategies are linked with higher diagnostic efficiencies and improved clinical outcomes per embryo transfer.

LIMITATIONS REASONS FOR CAUTION

The findings apply to the data submitted by 44 participating centres and do not represent worldwide trends in PGT. Details on the health of babies born were not provided in this manuscript.

WIDER IMPLICATIONS OF THE FINDINGS

The Consortium datasets provide a valuable resource for following trends in PGT practice.

STUDY FUNDING/COMPETING INTERESTS

The study has no external funding, and all costs are covered by ESHRE. There are no competing interests declared.

TRIAL REGISTRATION NUMBER

N/A.

El uso terapéutico del cannabis y los cannabinoides

Los cannabinoides se dirigen principalmente al sistema endocannabinoide (ECS), que surge como un objetivo terapéutico potencialmente interesante debido a su importante papel en la modulación de procesos biológicos clave en todo el organismo. Como tal, los cannabinoides ya se han propuesto como, por ejemplo, antieméticos, agentes antiespásticos, estimulantes del apetito, antiepilépticos, analgésicos, depresores de la presión intraocular o como agentes para controlar los trastornos del movimiento en el síndrome de Tourette. Aquí revisamos las pruebas de investigación disponibles sobre el uso del cannabis y los cannabinoides para un conjunto de aplicaciones terapéuticas sugeridas, y abordamos algunos de los riesgos a corto y largo plazo que se han correlacionado con el uso de estas sustancias. Encontramos escasas pruebas científicas que apoyen el uso de productos basados en el cannabis para la mayoría de las aplicaciones sugeridas, así como ninguna necesidad médica no satisfecha que no esté ya abordada por los medicamentos existentes (algunos basados en cannabinoides) en el mercado. En este escenario, los riesgos potenciales asociados al uso crónico de estas sustancias pueden disuadir su uso médico.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000-2018

BACKGROUND

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA.

METHODS

We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units.

RESULTS

We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group.

CONCLUSIONS

As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

Mapping development and health effects of cooking with solid fuels in low-income and middle-income countries, 2000-18: a geospatial modelling study

BACKGROUND

More than 3 billion people do not have access to clean energy and primarily use solid fuels to cook. Use of solid fuels generates household air pollution, which was associated with more than 2 million deaths in 2019. Although local patterns in cooking vary systematically, subnational trends in use of solid fuels have yet to be comprehensively analysed. We estimated the prevalence of solid-fuel use with high spatial resolution to explore subnational inequalities, assess local progress, and assess the effects on health in low-income and middle-income countries (LMICs) without universal access to clean fuels.

METHODS

We did a geospatial modelling study to map the prevalence of solid-fuel use for cooking at a 5 km × 5 km resolution in 98 LMICs based on 2·1 million household observations of the primary cooking fuel used from 663 population-based household surveys over the years 2000 to 2018. We use observed temporal patterns to forecast household air pollution in 2030 and to assess the probability of attaining the Sustainable Development Goal (SDG) target indicator for clean cooking. We aligned our estimates of household air pollution to geospatial estimates of ambient air pollution to establish the risk transition occurring in LMICs. Finally, we quantified the effect of residual primary solid-fuel use for cooking on child health by doing a counterfactual risk assessment to estimate the proportion of deaths from lower respiratory tract infections in children younger than 5 years that could be associated with household air pollution.

FINDINGS

Although primary reliance on solid-fuel use for cooking has declined globally, it remains widespread. 593 million people live in districts where the prevalence of solid-fuel use for cooking exceeds 95%. 66% of people in LMICs live in districts that are not on track to meet the SDG target for universal access to clean energy by 2030. Household air pollution continues to be a major contributor to particulate exposure in LMICs, and rising ambient air pollution is undermining potential gains from reductions in the prevalence of solid-fuel use for cooking in many countries. We estimated that, in 2018, 205 000 (95% uncertainty interval 147 000-257 000) children younger than 5 years died from lower respiratory tract infections that could be attributed to household air pollution.

INTERPRETATION

Efforts to accelerate the adoption of clean cooking fuels need to be substantially increased and recalibrated to account for subnational inequalities, because there are substantial opportunities to improve air quality and avert child mortality associated with household air pollution.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of colorectal cancer and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths worldwide. Given the recent increasing trends in colorectal cancer incidence globally, up-to-date information on the colorectal cancer burden could guide screening, early detection, and treatment strategies, and help effectively allocate resources. We examined the temporal patterns of the global, regional, and national burden of colorectal cancer and its risk factors in 204 countries and territories across the past three decades.

METHODS

Estimates of incidence, mortality, and disability-adjusted life years (DALYs) for colorectal cancer were generated as a part of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 by age, sex, and geographical location for the period 1990-2019. Mortality estimates were produced using the cause of death ensemble model. We also calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer.

FINDINGS

Globally, between 1990 and 2019, colorectal cancer incident cases more than doubled, from 842 098 (95% uncertainty interval [UI] 810 408-868 574) to 2·17 million (2·00-2·34), and deaths increased from 518 126 (493 682-537 877) to 1·09 million (1·02-1·15). The global age-standardised incidence rate increased from 22·2 (95% UI 21·3-23·0) per 100 000 to 26·7 (24·6-28·9) per 100 000, whereas the age-standardised mortality rate decreased from 14·3 (13·5-14·9) per 100 000 to 13·7 (12·6-14·5) per 100 000 and the age-standardised DALY rate decreased from 308·5 (294·7-320·7) per 100 000 to 295·5 (275·2-313·0) per 100 000 from 1990 through 2019. Taiwan (province of China; 62·0 [48·9-80·0] per 100 000), Monaco (60·7 [48·5-73·6] per 100 000), and Andorra (56·6 [42·8-71·9] per 100 000) had the highest age-standardised incidence rates, while Greenland (31·4 [26·0-37·1] per 100 000), Brunei (30·3 [26·6-34·1] per 100 000), and Hungary (28·6 [23·6-34·0] per 100 000) had the highest age-standardised mortality rates. From 1990 through 2019, a substantial rise in incidence rates was observed in younger adults (age <50 years), particularly in high Socio-demographic Index (SDI) countries. Globally, a diet low in milk (15·6%), smoking (13·3%), a diet low in calcium (12·9%), and alcohol use (9·9%) were the main contributors to colorectal cancer DALYs in 2019.

INTERPRETATION

The increase in incidence rates in people younger than 50 years requires vigilance from researchers, clinicians, and policy makers and a possible reconsideration of screening guidelines. The fast-rising burden in low SDI and middle SDI countries in Asia and Africa calls for colorectal cancer prevention approaches, greater awareness, and cost-effective screening and therapeutic options in these regions.

FUNDING

Bill & Melinda Gates Foundation.

Estimates, trends, and drivers of the global burden of type 2 diabetes attributable to PM2·5 air pollution, 1990-2019: an analysis of data from the Global Burden of Disease Study 2019

BACKGROUND

Experimental and epidemiological studies indicate an association between exposure to particulate matter (PM) air pollution and increased risk of type 2 diabetes. In view of the high and increasing prevalence of diabetes, we aimed to quantify the burden of type 2 diabetes attributable to PM2·5 originating from ambient and household air pollution.

METHODS

We systematically compiled all relevant cohort and case-control studies assessing the effect of exposure to household and ambient fine particulate matter (PM2·5) air pollution on type 2 diabetes incidence and mortality. We derived an exposure-response curve from the extracted relative risk estimates using the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. The estimated curve was linked to ambient and household PM2·5 exposures from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, and estimates of the attributable burden (population attributable fractions and rates per 100 000 population of deaths and disability-adjusted life-years) for 204 countries from 1990 to 2019 were calculated. We also assessed the role of changes in exposure, population size, age, and type 2 diabetes incidence in the observed trend in PM2·5-attributable type 2 diabetes burden. All estimates are presented with 95% uncertainty intervals.

FINDINGS

In 2019, approximately a fifth of the global burden of type 2 diabetes was attributable to PM2·5 exposure, with an estimated 3·78 (95% uncertainty interval 2·68-4·83) deaths per 100 000 population and 167 (117-223) disability-adjusted life-years (DALYs) per 100 000 population. Approximately 13·4% (9·49-17·5) of deaths and 13·6% (9·73-17·9) of DALYs due to type 2 diabetes were contributed by ambient PM2·5, and 6·50% (4·22-9·53) of deaths and 5·92% (3·81-8·64) of DALYs by household air pollution. High burdens, in terms of numbers as well as rates, were estimated in Asia, sub-Saharan Africa, and South America. Since 1990, the attributable burden has increased by 50%, driven largely by population growth and ageing. Globally, the impact of reductions in household air pollution was largely offset by increased ambient PM2·5.

INTERPRETATION

Air pollution is a major risk factor for diabetes. We estimated that about a fifth of the global burden of type 2 diabetes is attributable PM2·5 pollution. Air pollution mitigation therefore might have an essential role in reducing the global disease burden resulting from type 2 diabetes.

FUNDING

Bill & Melinda Gates Foundation.

P-538 KATNAL1 polymorphisms confer susceptibility to severe phenotypes of male infertility in a large European cohort

Study question

What is the contribution of the common variation of KATNAL1 to the development of severe spermatogenic failure (SPGF) in a phenotypically well-characterized cohort?

Summary answer

An allelic combination of KATNAL1 single-nucleotide polymorphisms (SNPs) increases the risk to develop SPGF, likely by altering the expression and splicing pattern of the gene.

What is known already

Spermatogenesis is a process that requires an exhaustive control of gene expression, and subtle alterations of its molecular regulatory network can lead to male infertility. The aetiology of most SPGF cases remains unknown, and increasing evidence clearly suggests that the idiopathic form of SPGF represents a complex trait, in which genetic susceptibility is conferred by the accumulation of risk alleles in genetically predisposed men. In this regard, previous studies reported that rare genetic mutations and polymorphisms in the KATNAL1 locus lead to male infertility through the disruption of microtubule remodelling and premature germ cell exfoliation.

Study design, size, duration

We designed a case-control genetic association study including three SNPs (rs2077011, rs7338931, and rs2149971) in the 3' and 5' regulatory regions of KATNAL1, which tagged the common genetic variability in the region. The allele frequencies in the study population, composed of 715 infertile men diagnosed with idiopathic SPGF, were compared to those observed in a control group comprising 1058 fertile men from Spain and Portugal.

Participants/materials, setting, methods

The SPGF group comprised 210 men with severe oligospermia (SO) and 505 with non-obstructive azoospermia (NOA). The latter were phenotypically characterised according to the histological examination of testis biopsies and its outcome (Sertoli cell-only syndrome, SCO; maturation arrest, MA; hypospermatogenesis, HS; and testicular sperm extraction, TESE). After genotyping, case-control association analyses by logistic regression were conducted. In silico functional characterization of risk variants was also carried out using public multiomic databases and bioinformatic tools.

Main results and the role of chance

Significant genetic associations with different SPGF patterns and/or TESE outcome were observed even after correction for multiple testing when independent SNP models were tested. However, in all cases, the haplotype model including the three risk alleles (rs2077011*C | rs7338931*T | rs2149971*A) was the most informative. This haplotype was specifically over-represented in the SPGF group (P = 3.45E-02, OR = 2.33), which includes all infertile men, and in the NOA group (P = 8.22E-03, OR = 2.97). In addition, subtype-specific associations were observed with the most severe subgroups, namely MA (P = 2.44E-02, OR = 5.00), SCO (P = 4.03E-03, OR = 5.16), and unsuccessful TESE outcome (P = 2.22E-04, OR = 6.13), which indicates the relevant role of KATNAL1 in spermatogenesis development. We prioritized the most likely causal variant/s based on in silico analyses addressing the possible functional implication of the tagged variants. We observed that an alteration of the KATNAL1 splicing pattern, by favouring the overrepresentation of a short non-functional transcript isoform in the testis, might be the cause behind the observed genetic association. The analysis of the testis transcriptome at the single cell level showed that KATNAL1 transcripts were mostly presented in spermatocytes and early spermatids at puberty, which correlates with its effect of premature exfoliation and loss of the germ cells.

Limitations, reasons for caution

Although a previous low-powered study reported suggestive associations between KATNAL1 and SPGF, additional genetic association studies in independent populations should be conducted to confirm our findings. Moreover, the statistical power for the overall analysis was appropriate, but the subphenotype analyses were performed with reduced power due to smaller study groups.

Wider implications of the findings

Our results suggest a relevant role of the common genetic variation of KATNAL1 in the susceptibility to develop the most severe histological phenotypes of NOA (i.e., SCO and MA). Studies like the one presented here may definitively help to develop future non-invasive molecular markers of TESE success.

Trial registration number

Not Applicable

O-041 Data from the ESHRE PGT consortium – year 2020

Study question

Which are the trends shown in data collection XXII of the European Society of Human Reproduction and Embryology (ESHRE) PGT Consortium compared with previous years?

Summary answer

Data collection XXII, year 2020, represents valuable data on PGT activity in (mainly) Europe and reports on the main trends observed, being the further expansion of comprehensive testing technology in PGT-SR and PGT-A.

What is known already

The ESHRE PGT Consortium was set up in 1997 and from that time has been collecting data on PGT and PGT-A. The PGT database comprises the world’s largest collection of PGT / PGT-A data providing a valuable resource for data mining and for following trends in PGT practice. So far, up to the year 2015, data collections were carried out in a retrospective data way, from 2016 onwards a prospective cycle-by-cycle data collection was in place.

Study design, size, duration

As the nature of PGT/ PGT-A treatments has changed significantly over the last years and IVF cycle management and genetic analysis techniques are getting more complex, ESHRE uses an online data collection system in which data are collected prospectively from oocyte retrieval to analysis, embryo transfer and pregnancy / live birth. Data are collected cycle by cycle on a voluntary basis.

Participants/materials, settings, method

For the 2020 data, individual centres (37) from 20 countries directly entered the data into the PGT database through software developed by ESHRE. Data were analysed at ESHRE headquarters and include all aspects of PGT/PGT-A cycles.

Main results and the role of chance

The Consortium has analysed the PGT analyses (n = 2809) performed in 2020. The indications for PGT included inherited chromosomal abnormalities (n = 331 analyses), monogenic disorders (n = 987 analyses), aneuploidy testing for infertility (n = 1417 analyses) or combinations of the above (n = 74 analyses). In addition, 704 clinical pregnancies and 335 deliveries have been analysed in detail. The methods used for biopsy were polar body (2%), cleavage stage biopsy (20%) and blastocyst biopsy (78%), showing a further increase of blastocyst biopsy compared to 2019. The methodology used for diagnosis is what is evolving most over the last years, with data set XXII (2020) showing around 4% of FISH, 28% of PCR and 68% of WGA. Within WGA 95% of the analysis were done using NGS, in 4% of the cases SNP arrays were used and in 1% array-CGH was used. The overall clinical pregnancy rate is about 25% per analysis. The baby data show that it is difficult for most centres to have a detailed follow-up.

Limitations, reasons for caution

The findings apply to the 37 participating centres and may not represent worldwide trends in PGT. Data were collected prospectively, but details of the follow-up on PGT pregnancies and babies born were limited.

Wider implications of the findings

The ESHRE PGD Consortium continues its activities as an important forum for PGT practitioners to share data and exchange experiences. The information extracted from the data collections helps to monitor quality issues in PGT and survey the introduction and effectiveness of new PGT technologies and methods.

Trial registration number

Portuguese validation of the Self-Generated Stress Scale

Introduction

Self-Generated Stress might be defined as stress that is created by oneself by engaging in behavior or making decisions that ultimately add strain to pre-existing personal stress. The Self-Generated Stress Scale (SGSS; Flett et al. 2020) is a seven-item self-report measure built to assess this tendency to make one’s own life more stressful.

Objectives

To analyze the psychometric properties of the Portuguese Version of the SGSS.

Methods

Participants (127 medicine and dentistry students; 78.0% female) answered an online survey including the preliminary Portuguese version of the SGSS and other validated questionnaires: Maslach Burnout Inventory – Students Survey, Depression Anxiety and Stress Scales, HEXACO-60 and Big Three Perfectionism Scale.

Results

Confirmatory Factor Analysis showed that the unidimensional model presented good fit indexes (χ2/df=1.546; RMSEA=.0666, p<.001; CFI=.982 TLI=.972, GFI=.960). The Cronbach’s alfa was .868. Pearson correlations between SGSS and the other measures were significant (p<.01) and moderate/high: Burnout, .412; Stress/Anxiety/Depression, >.550; Perfectionism, .600; Emotionality, .315; Extroversion, -.411. After controlling for the effect of Emotionality and Extroversion, SGSS explained significant additional increments of 19.9% and 14.0% of the DASS and MBI variance; controlling for Perfectionism, the increments were respectively of 27.9% and 2.0%. SGSS mean score (22.96±5.90 was not significantly different by gender.

Conclusions

As observed with the original English-language scale, the Portuguese version of SGSS showed good validity (construct and convergent-divergent) and internal consistency. As such, the SGSS might be useful in further investigation, particularly to explore the different pathways between personality traits, emotional regulation processes and psychological distress.

Disclosure

No significant relationships.

Inventory of Sources of Stress During Medical Education - Further Validation

Introduction

The Inventory of Academic Sources of Stress in Medical Education (IASSME) evaluates the presence and intensity of the main sources of academic stress for Portuguese Medicine students in five dimensions: Course demands/CD, Human demands/HD, Lifestyle/LS, Academic competition/AC, and Academic adjustment/AA.

Objectives

To further validate the ISSME using Confirmatory Factor Analysis and to analyze[ATP1] the psychometric properties of a new version including additional sources of stress.

Methods

Participants were 666 Portuguese medicine (82.6%) and dentistry (17.4%) students (81.8% girls); they answered an online survey including the ISSME and other validated questionnaires: Maslach Burnout Inventory – Students Survey (MBI-SS) and Depression Anxiety and Stress Scales (DASS).

Results

Confirmatory Factor Analysis showed that the second order model composed of five factors (the original structure by Loureiro et al. 2008), but excluding item 11 (loading=.371), presented good fit indexes (χ²/df=3.274; RMSEA=.0581, p<.001; CFI=.917; TLI=.904, GFI=.919). The Cronbach’s alfas were α=.897 for the total and from α=.669 (F2-HD) to α=.859 (F1-CD) for the dimensions. The expanded version, including two additional items related to lack of interest in medicine/dentistry (F6, α=.543) and two additional COVID-19 stress-related-items (F7, α=.744) also showed acceptable fit indexes (χ²/df=3.513; RMSEA=.061, p<.001; CFI=.88.; TLI=.866, GFI=.892). This new version’s α was of .896. Pearson correlations between ISSME and the other measures were significant (p<.01) and high: >.55 with DASS and >.50 with MBI-SS. Girls presented significantly higher ISSME scores. F6 score was significantly higher in dentistry students.

Conclusions

This further validation study underlines that IASSME presents good validity (construct and convergent) and reliability.

Disclosure

No significant relationships.

COVID-19 Pandemic: Another Source of Stress for Medical Students

Introduction

The COVID-19 pandemic has completely changed the experience of higher education with potentially negative consequences for students’ wellbeing.

Objectives

To compare medicine/dentistry students’ depression/anxiety/stress levels before versus during the pandemic and to analyse the role of COVID-19-related stressors in their psychological distress.

Methods

Students from the Faculty of Medicine University of Coimbra answered socio-demographic and personality questionnaires and the Depression, Anxiety and Stress Scale/DASS before (academic years 2016-2017-2018-2019 - SAMPLE1; n=1000) and during (September-December 2020 and January-March 2021 - SAMPLE2; n=650) the COVID-19 pandemic. Mean age (21.12±3.75), personality traits scores, and gender proportions (»75% girls) did not significantly differ between samples. SAMPLE2 also filled in the Fear of COVID-19 Scale and a new version of the Inventory of Sources of Stress During Medical Education/ISSDME, containing a COVID-19 -related dimension (restrictions on training and on socializing with friends/colleagues).

Results

SAMPLE2 presented significantly higher mean scores of depression (3.89±3.55vs.3.33±3.34), anxiety (3.27±4.08vs.2.86±3.29), stress (7.07±5.72vs.6.18±4.59) and total DASS (12.28±10.55vs.13.65±11.13) than SAMPLE1 (all p<.05). Fear of COVID-19 was a significant predictor of DASS score (adjusted R2=2.9%, p<.001). COVID-19-related stressors continued explaining significant increments of DASS variance after controlling for each of the ISSDME dimensions: Course demands (R2 Change=1.8%), Human demands (2.5%), Lifestyle (2.3%), Academic competition (5.5%), and Academic adjustment (5.2%) (all p<.001).

Conclusions

This study adds to the evidence of the negative impact of COVID-19 on students and emphasizes its pernicious role on medical students’ psychological distress, which is already higher due to the individual and academic stressors to which they are more exposed.

Disclosure

No significant relationships.

Screening Accuracy of the Portuguese version of the Postpartum Depression Screening Scale-7 according to DSM-5 criteria

Introduction

The Portuguese shortest version of the Perinatal Depression Screening Scale/PDSS-7 proved to be valid and reliable, in Portugal and Brazil, but it is essential to analyze its operational characteristics before using it for screening purposes.

Objectives

To determine PDSS-7 cut-off points and associated conditional probabilities to screen for major depression, according to the DSM-5.

Methods

he pregnancy sample was composed of 259 women in the second trimester (Mean gestation weeks=17.83±4.750). The postpartum sample consisted of 241 women assessed between the 2^nd-6^thmonths postpartum(M=17.99±4.689 weeks postpartum). All women completed the PDSS-7 and were interviewed with the Diagnostic Interview for Psychological Distress(Pereira et al., 2017), a semi-structured clinical interview to assess the most prevalent psychiatric disorders in the perinatal period according to the DSM-5 criteria. MedCalc was used to perform ROC analysis.

Results

During pregnancy, the major depression prevalence was of 4.6%(n=12). The cut-off point that maximizes the Youden Index(J=.98, 95%CI: .97-.99; AUC=.99; se=.004; p<.001) was of 18(95%CI:17-19), which resulted in a sensitivity of 100%(71.5%-100%), a specificity of 97.98%(95.3%-99.3%), a positive predictive value/+PP of 68.8%(48.0%-84.0%) and a negative predictive value/-PP of 100%. In the postpartum, the major depression prevalence was of 10.4%(n=25). The cut-off point(J=.79, 95%CI: .63-.82; AUC=.89; se=.036; p<.001) was of 14(95%CI: 12-16), with a sensitivity of 85.0%(69.3%-93.2%), a specificity of 85.0%(69.3%-93.2%), a +PP of 56.5%(46.1%-67.3%) and a -PP of 97.5%(94.6%-98.8%).

Conclusions

The Portuguese version of PDSS-7 presents good combinations of sensitivity and specificity, being accurate and usable to screen for depression during pregnancy and in the postpartum both in research and primary health care.

Disclosure

No significant relationships.

Further Validation of the Short Form of the Self-Compassion Scale in a sample of Portuguese Medicine Students

Introduction

The Short Form of the Self-Compassion Scale (SCS-SF; Raes et al. 2011) is composed of 12 items that evaluate the same six dimensions (Self-Kindness/SK, Self-Judgement/SJ, Common Humanity/CH, Isolation, Mindfulness/M, Over-Identification/OI) as the long scale (26 items). The Portuguese version of the SCS-SF (Castilho et al. 2015) was validated in a vast sample from clinical and general populations, the latter being composed of students, other than from medicine courses.

Objectives

To analyze the psychometric properties of the Portuguese version of the SCS-SF in a sample of Medicine/Dentistry students.

Methods

Participants were 666 Portuguese medicine (82.6%) and dentistry (17.4%) students (81.8% girls); they answered an online survey including the SCS and other validated questionnaires from the OECD Study on Social and Emotional Skills/SSES: Stress resistance, Emotional control, Optimism and Persistence.

Results

Confirmatory Factor Analysis showed that the model composed of six factors, two second order factors (positive and negative) and one third order factor (total) presented good fit indexes (χ2/df=3.013; RMSEA=.0066, p<.001; CFI=.970; TLI=.948, GFI=.947). The Cronbach’s alfas were .892, .869 and .877 respectively for the total, self-compassion and self-criticism dimension. Pearson correlations of the SCS-SF total score, self-compassion and self-criticism dimensional scores were moderate to high with the SSES measures, from .272/-.236/.247 with Persistence to .709/-.634/.615 with Optimism.

Conclusions

Although reduced to less than half than the original SCS, the SCS–SF is a valid and useful alternative to measure general self-compassion and their positive and negative components in an ongoing longitudinal research with medicine/dentistry students.

Disclosure

No significant relationships.

Inventory of Sources of Stress During Medical Education - Further Validation

Introduction

The Inventory of Academic Sources of Stress in Medical Education (IASSME) evaluates the presence and intensity of the main sources of academic stress for Portuguese Medicine students in five dimensions: Course demands/CD, Human demands/HD, Lifestyle/LS, Academic competition/AC, and Academic adjustment/AA.

Objectives

To further validate the ISSME using Confirmatory Factor Analysis and to analyze the psychometric properties of a new version including additional sources of stress.

Methods

Participants were 666 Portuguese medicine (82.6%) and dentistry (17.4%) students (81.8% girls); they answered an online survey including the ISSME and other validated questionnaires: Maslach Burnout Inventory – Students Survey (MBI-SS) and Depression Anxiety and Stress Scales (DASS).

Results

Confirmatory Factor Analysis showed that the second order model composed of five factors (the original structure by Loureiro et al. 2008), but excluding item 11 (loading=.371), presented good fit indexes (χ2/df=3.274; RMSEA=.0581, p<.001; CFI=.917; TLI=.904, GFI=.919). The Cronbach’s alfas were α=.897 for the total and from α=.669 (F2-HD) to α=.859 (F1-CD) for the dimensions. The expanded version, including two additional items related to lack of interest in medicine/dentistry (F6, α=.543) and two additional COVID-19 stress-related-items (F7, α=.744) also showed acceptable fit indexes (χ2/df=3.513; RMSEA=.061, p<.001; CFI=.88.; TLI=.866, GFI=.892). This new version’s α was of .896. Pearson correlations between ISSME and the other measures were significant (p<.01) and high: >.55 with DASS and >.50 with MBI-SS. Girls presented significantly higher ISSME scores. F6 score was significantly higher in dentistry students.

Conclusions

This further validation study underlines that IASSME presents good validity (construct and convergent) and reliability.

Disclosure

No significant relationships.

Further validation of the European and Brazilian Portuguese short version of the Postpartum Depression Screening Scale-7

Introduction

We have recently validated the Portuguese shortest version of the Perinatal Depression Screening Scale-PDSS-7 (items selected from the PDSS-21; each one representing a dimension evaluated by the PDSS-35), for the assessment of depression severity in pregnancy, both in Portugal and Brazil.

Objectives

To analyze the validity and reliability of the PDSS-7 Portuguese version to evaluate postpartum women both from Portugal and Brazil.

Methods

The Portuguese sample was composed of 304 women between the 2nd-6th postpartum months (Mean=20.09±7.21 weeks postpartum). These participants were not the same who participated in the psychometric study that led to the selection of the seven items. The Brazilian sample was composed of 121 women (Mean=10.51±4.53 weeks postpartum). All the participants completed the European/Brazilian Portuguese versions of PDSS-21, which was composed of the same items and included the seven items of PDSS-7. Participants also filled in the validated versions of Perinatal Anxiety Screening Scale and Profile of Mood States.

Results

Confirmatory Factor Analysis revealed that the unidimensional model of PDSS-7 presented acceptable/good fit indexes in both samples (Portuguese/Brazilian: χ²/d.f.=2.6598/1.7897; RMSEA=.0740/.0807, CFI=.8289/.7934, TLI=.7901/.8434, GFI=.9298/.9496; p<.001). The PDSS-7 Cronbach’s alphas were of .841/.856 and all the items contributed to the internal consistency. Pearson correlations with postpartum anxiety (.646/.763) and negative affect (.666/.676) were significantly (p<.01) high. PDSS-7 mean scores were higher in the Brazilian sample (16.06±7.39 versus 11.37±4.37, p<.01).

Conclusions

PDSS-7 presented validity (construct and convergent), reliability and utility in clinical and research settings, including in transcultural studies, in Portugal and Brazil, namely in the postpartum.

Disclosure

No significant relationships.

Stigma towards mental illness in med students: you label me, I label you?

Introduction

Evidence suggests that besides having stigmatizing misconceptions towards people with mental illness, medical students and doctors often resist seeking help for their own mental issues. This is a vulnerable group for stress and other mental health problems, due not only to professional burden but also high perfectionism and low self-compassion.

Objectives

To analyse the relationship between mental health stigma (MHS) and other variables related to personality and emotional states in a sample of medical students.

Methods

634 medicine and dentistry students (mean age = 21.6±6.9;81.4% female) answered to a survey including sociodemographic data, self-perception of psychological health/SPPH and the Portuguese validated versions of: Link’s Perceived Discrimination and Devaluation (PDD) scale to assess MHS and its two dimensions - social stigma/SocS and self-stigma/SelS; Depression Anxiety Stress Scale (DASS-21); Neff’s Self-Compassion Scale (SCS); and Big Three Perfectionism Scale (BTPS). Correlations, t-student tests and linear regressions were performed with SPSS 27.0.

Results

Stigma correlated negatively to SPPH and positively to DASS, the negative poles of SCS (self-judgement, isolation and over-identification) and BTPS second-order factors (all from p<.05 to p<.01). No gender differences in MHS were observed. Participants with higher mean levels of total and SelS had significantly higher scores in all DASS dimensions and lower SPPH; participants with higher SocS also scored higher in DASS, but didn’t reveal lower SPPH. Isolation was a significant predictor of SocS (R2=2.8%;p<.05); isolation and narcissistic perfectionism were significant predictors of SelS (R2=11%;p<.01).

Conclusions

Our results highlight the importance of including MHS as a main need in the curricula of future doctors.

Disclosure

No significant relationships.

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019

Background

Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time.

Methods

Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated.

Findings

In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs.

Interpretation

Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people.

Funding

The Bill and Melinda Gates Foundation.

Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

Tuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019.

METHODS

We used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates.

FINDINGS

Globally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08-1·29) deaths due to tuberculosis and 8·50 million (7·45-9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000-279 000) deaths due to tuberculosis and 1·15 million (1·01-1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000-425 000) more deaths and 1·01 million (0·82-1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820-11 400) more deaths and 81 100 (63 300-100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69-5·02), 6·17 (5·48-7·02), and 1·17 (1·07-1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03-2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05-1·08) times greater among females than males.

INTERPRETATION

As countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones.

FUNDING

Bill & Melinda Gates Foundation.

Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019

BACKGROUND

Given the projected trends in population ageing and population growth, the number of people with dementia is expected to increase. In addition, strong evidence has emerged supporting the importance of potentially modifiable risk factors for dementia. Characterising the distribution and magnitude of anticipated growth is crucial for public health planning and resource prioritisation. This study aimed to improve on previous forecasts of dementia prevalence by producing country-level estimates and incorporating information on selected risk factors.

METHODS

We forecasted the prevalence of dementia attributable to the three dementia risk factors included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 (high body-mass index, high fasting plasma glucose, and smoking) from 2019 to 2050, using relative risks and forecasted risk factor prevalence to predict GBD risk-attributable prevalence in 2050 globally and by world region and country. Using linear regression models with education included as an additional predictor, we then forecasted the prevalence of dementia not attributable to GBD risks. To assess the relative contribution of future trends in GBD risk factors, education, population growth, and population ageing, we did a decomposition analysis.

FINDINGS

We estimated that the number of people with dementia would increase from 57·4 (95% uncertainty interval 50·4-65·1) million cases globally in 2019 to 152·8 (130·8-175·9) million cases in 2050. Despite large increases in the projected number of people living with dementia, age-standardised both-sex prevalence remained stable between 2019 and 2050 (global percentage change of 0·1% [-7·5 to 10·8]). We estimated that there were more women with dementia than men with dementia globally in 2019 (female-to-male ratio of 1·69 [1·64-1·73]), and we expect this pattern to continue to 2050 (female-to-male ratio of 1·67 [1·52-1·85]). There was geographical heterogeneity in the projected increases across countries and regions, with the smallest percentage changes in the number of projected dementia cases in high-income Asia Pacific (53% [41-67]) and western Europe (74% [58-90]), and the largest in north Africa and the Middle East (367% [329-403]) and eastern sub-Saharan Africa (357% [323-395]). Projected increases in cases could largely be attributed to population growth and population ageing, although their relative importance varied by world region, with population growth contributing most to the increases in sub-Saharan Africa and population ageing contributing most to the increases in east Asia.

INTERPRETATION

Growth in the number of individuals living with dementia underscores the need for public health planning efforts and policy to address the needs of this group. Country-level estimates can be used to inform national planning efforts and decisions. Multifaceted approaches, including scaling up interventions to address modifiable risk factors and investing in research on biological mechanisms, will be key in addressing the expected increases in the number of individuals affected by dementia.

FUNDING

Bill & Melinda Gates Foundation and Gates Ventures.

Filamentous fungi occurrence on Molossus molossus (Pallas, 1766) (Chiroptera: Molossidae) present in an Atlantic Forest remnant in Southern Brazil

The bats usually inhabit shelters with favorable conditions for fungal proliferation, including pathogenic and opportunistic species. The fungal diversity present on bats is little known and the studies are scarce in Brazil, which only a work has been performed in Cerrado and Pantanal biomes. Therefore, the objective of this study was evaluating the occurrence of filamentous fungi on the rostral region of Molossus molossus in an Atlantic Forest remnant of Brazil. The bats were captured with mist nets installed outside a shelter located in the municipality of Treviso, (28°29'23"S and 49°31'23"W), south region of state Santa Catarina. With a swab sterile moistened in saline solution, samples from the rostral region were obtained from all captured M. molossus individuals. The samples were taken to the laboratory for analysis and isolation in different culture media, followed of identification of fungal through the microculture technique. In total, 15 individuals were captured, which five fungal genus and 19 taxa were identified. Among the taxa registered, Aspergillioides sp.2, (47%), Penicillium sp.1 (33%), Chrysonilia sp. (33%), Cladosporium sp. (27%) were classified as little constant. In terms of abundance, Penicillium sp.1 (34%), Aspergillioides sp.2 (21%) and Aspergillus sp.2 (11%) were the most abundant in the samples. The results showed the occurrence of high diversity fungal in the rostral region of M. molossus in the Atlantic Forest, which is higher than observed in others Brazilian biomes. Some fungal genera found may harbor pathogenic and opportunistic species that need to be identified for preventing potential disease well as for bat conservation projects.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

BACKGROUND

Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.

METHODS

We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.

FINDINGS

Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.

INTERPRETATION

Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.

FUNDING

Bill & Melinda Gates Foundation.

The portuguese version of the big three perfectionism scale – further validation with adults from the general population

Introduction

Both original Big Three Perfectionism Scale (BTPS; Smith et al. 2016), and the Portuguese version validated with a sample of university students (Lino et al. 2018) evaluates three second-order factors (rigid, self-oriented and narcissistic perfectionism) and ten facets.

Objectives

To confirm the BTPS three-factors-ten-dimensions’ structure in a sample of Portuguese adults from the general population.

Methods

A sample of 467 adults (70.7% females; Mean age=38.44±12.27; range: 25-82) answered the BTPS Portuguese version and other validated perfectionism measures (Multidimensional Perfectionism Scales from Frost and Hewitt & Flett; Self-Presentation Perfectionism Scale). To study the temporal stability a sub-sample of 132 participants completed the BTPS again after approximately five weeks. SPSS and AMOS software was used.

Results

The second order model presented an acceptable fit (X²/df=3.115; TLI=.811; CFI=.825; RMSEA=.067). There was also evidence of a general factor comprising all the 45 items (X²/df=3.127; TLI=.809; CFI=.823; [JA1] RMSEA=.068). The Cronbach alphas of the three factors ranged from a=.88 to a=.92; and facets had a>.70 showing a total of a=.94. Total and dimensional scores showed significant positive and moderate to high correlations with the other perfectionism measures and their test-retest correlation coefficients were r=.85 (p<0.001).

Conclusions

This study confirms the validity and reliability of the Portuguese BTPS underlying three-factors structure. Additionally, we found, for the first time, that BTPS can also be validly and reliably used to measure a global perfectionism construct. It is our intention to develop a shorter version the Portuguese BTPS in the near future.

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1

BACKGROUND

Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time.

METHODS

For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development.

FINDINGS

By 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4-82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5-42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4-41·3] in 1980 to 83·6% [82·3-84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4-44·1) in 1980 to 79·8% (78·4-81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6-60·9) to 14·5 million (13·4-15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019.

INTERPRETATION

After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines.

FUNDING

Bill & Melinda Gates Foundation.

O-009 Data from the ESHRE PGT consortium – year 2019

Study question

Which are the trends shown in data collection XXI of the European Society of Human Reproduction and Embryology (ESHRE) PGT Consortium compared with previous years?

Summary answer

Data collection XXI, year 2019, represents valuable data on PGT activity in (mainly) Europe and reports on the main trends observed, being the further expansion of comprehensive testing technology in PGT-SR and PGT-A.

What is known already

The ESHRE PGT Consortium was set up in 1997 and from that time has been collecting data on PGT and PGT-A. The PGT database comprises the world’s largest collection of PGT / PGT-A data providing a valuable resource for data mining and for following trends in PGT practice. So far, up to the year 2015, data collections were carried out in a retrospective data way, from 2016 onwards a prospective data collection was in place.

Study design, size, duration

As the nature of PGT/ PGT-A treatments has changed significantly over the last years and IVF cycle management and genetic analysis techniques are getting more complex, ESHRE uses an online data collection system in which data are collected prospectively from oocyte retrieval to analysis, embryo transfer and pregnancy / live birth. Data are collected cycle by cycle on a voluntary basis.

Participants/materials, settings, method

For the 2019 data, individual centres (31) from 19 countries directly entered the data into the PGT database through software developed by ESHRE. Data were analysed at ESHRE headquarters and include all aspects of PGT/PGT-A cycles.

Main results and the role of chance

The Consortium has analysed the PGT analyses (n = 2735) performed in 2019. The indications for PGT included inherited chromosomal abnormalities (n = 253 analyses), monogenic disorders (n = 1105 analyses), aneuploidy testing for infertility (n = 1111 analyses) or combinations of the above (n = 266 analyses). In addition, 662 clinical pregnancies and 216 deliveries have been analysed in detail. The methods used for biopsy were polar body (2%), cleavage stage biopsy (35%) and blastocyst biopsy (61%; comparable with data from 2018). The methodology used for diagnosis is what is evolving most over the last years, with data set XXI (2019) showing around 7% of FISH, 37% of PCR and 55% of WGA. Within WGA 90.6% of the analysis were done using NGS, in 4.4% cases SNP arrays were used and in 2.4% array-CGH was used. The overall clinical pregnancy rate is about 24% per analysis. The baby data show that it is difficult for most centres to have a detailed follow-up.

Limitations, reasons for caution

The findings apply to the 31 participating centres and may not represent worldwide trends in PGT. Data were collected prospectively, but details of the follow-up on PGT pregnancies and babies born were limited.

Wider implications of the findings

The ESHRE PGD Consortium continues its activities as an important forum for PGT practitioners to share data and exchange experiences. The information extracted from the data collections helps to monitor quality issues in PGT and survey the introduction and effectiveness of new PGT technologies and methods.

ESHRE PGT Consortium data collection XIX-XX: PGT analyses from 2016 to 2017†

STUDY QUESTION

What are the trends and developments in pre-implantation genetic testing (PGT) in 2016–2017 as compared to previous years?

SUMMARY ANSWER

The main trends observed in this 19th and 20th data set on PGT are that trophectoderm biopsy has become the main biopsy stage for PGT for aneuploidies (PGT-A) and that the implementation of comprehensive testing technologies is the most advanced with PGT-A.

WHAT IS KNOWN ALREADY

Since it was established in 1997, the ESHRE PGT Consortium has been collecting and analysing data from mainly European PGT centres. To date, 18 data sets and an overview of the first 10 years of data collections have been published.

STUDY DESIGN, SIZE, DURATION

The data for PGT analyses performed between 1 January 2016 and 31 December 2017 with a 2-year follow-up after analysis were provided by participating centres on a voluntary basis. Data were collected using a new online platform, which is based on genetic analysis as opposed to the former cycle-based format.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on biopsy method, diagnostic technology and clinical outcome were submitted by 61 centres. Records with analyses for more than one PGT for monogenic/single gene defects (PGT-M) and/or PGT for chromosomal structural rearrangements (PGT-SR) indication or with inconsistent data regarding the PGT modality were excluded. All transfers performed within 2 years after the analysis were included enabling the calculation of cumulative pregnancy rates. Data analysis, calculations, figures and tables were made by expert co-authors.

MAIN RESULTS AND THE ROLE OF CHANCE

The current data collection from 2016 to 2017 covers a total of 3098 analyses for PGT-M, 1018 analyses for PGT-SR, 4033 analyses for PGT-A and 654 analyses for concurrent PGT-M/SR with PGT-A.

The application of blastocyst biopsy is gradually rising for PGT-M (from 8–12% in 2013–2015 to 19% in 2016–2017), is status quo for PGT-R (from 22–36% in 2013–2015 to 30% in 2016–2017) and has become the preferential biopsy stage for PGT-A (from 23–36% in 2013–2015 to 87% in 2016–2017). For concurrent PGT-M/SR with PGT-A, biopsy was primarily performed at the blastocyst stage (93%). The use of comprehensive diagnostic technology showed a similar trend with a small increased use for PGT-M (from 9–12% in 2013–2015 to 15% in 2016–2017) and a status quo for PGT-SR (from 36–58% in 2013–2015 to 50% in 2016–2017). Comprehensive testing was the main technology for PGT-A (from 66–75% in 2013–2015 to 93% in 2016–2017) and for concurrent PGT-M/SR with PGT-A (93%).

LIMITATIONS, REASONS FOR CAUTION

The findings apply to the data submitted by 61 participating centres and do not represent worldwide trends in PGT. Details on the health of babies born were not provided in this manuscript.

WIDER IMPLICATIONS OF THE FINDINGS

Being the largest data collection on PGT in Europe/worldwide, the data sets provide a valuable resource for following trends in PGT practice.

STUDY FUNDING/COMPETING INTEREST(S)

The study has no external funding and all costs are covered by ESHRE. There are no competing interests declared.

TRIAL REGISTRATION NUMBER

N/A.

Subnational mapping of HIV incidence and mortality among individuals aged 15-49 years in sub-Saharan Africa, 2000-18: a modelling study

BACKGROUND

High-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa.

METHODS

In this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15-49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000-18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit.

FINDINGS

The estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2·8 (95% uncertainty interval 2·1-3·8) in Mauritania to 1585·9 (1369·4-1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7-0·9) in Mauritania to 676·5 (513·6-888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8-8120·3]) cases per 100 000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0-1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81·1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020.

INTERPRETATION

Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas.

FUNDING

Bill & Melinda Gates Foundation.

The role of shame in the relationship between bullying and self-harm in portuguese adolescents

Introduction

Bullying consists in acts of intentional and repeated physical or psychological violence, completed by an individual or a group of individuals, provoking pain, distress and shame. Currently, it is considered a serious problem with health implications in adolescents. Shame is a self-conscious, multifaceted and socially focused emotion that relates to a negative self-assessment.

Objectives

The study aim was to investigate the mediating role of Shame in the relationship between Bullying and Self-harm and Suicide Ideation in Portuguese adolescents.

Methods

346 adolescents (58.4% girls), aged 15.32±1.193 from public and private schools (9^th to 12^th grades) in Coimbra, answered the validated Portuguese versions of the Bullying Questionnaire, the Other as Shame Scale for Adolescents and the Self-Harm and Suicidal Ideation Questionnaire. For data analysis the SPSS 26 and Macro Process (Hayes 2020) was used.

Results

Bullying Victimization had a prevalence of 18.78%. Girls and boys significantly differ in Bullying Victimisation, Self-Harm, Suicidal Ideation and Shame mean scores (all p<.05). In girls, Bullying Victimisation was correlated with Shame and Suicidal Ideation. The mediation analysis showed that, in girls, Shame partially mediated the relationship between Bullying and Suicidal Ideation (p<.001). We didn’t find these results in boys.

Conclusions

Bullying is a global problem that needs to be addressed. Adolescents of today are the adults of tomorrow. In a physical growth and mental maturation phase, it is urgent to avoid disruptors which lead to psychopathology. Our results corroborate that Shame can be a harmful factor in Bullying with deleterious consequences in adolescents.

Habits and quality of life in portuguese girl adolescents: Association with psychological disturbance distress

Introduction

Adolescence is a life period with considerable biological, psychological and social changes. Quality of life is a complex and multifactorial construct that necessarily encompasses the adolescent’s mental well-being. Some life habits like sleep, sport practice and screen time can be either risk factors or protective factors, influencing the quality of life and mental health.

Objectives

To investigate the role of sleep habits, sport practice and screen time in quality of life, and psychological distress in a Portuguese adolescent girl sample.

Methods

409 girls, mean aged 13.51±2.298, from public and private schools in Coimbra answered questions about sleep time, sport practice and screen time habits; the Portuguese versions of the Quality of Life Questionnaire (reduced version) and theAnxiety, Depression and Stress Scale. SPSS 26 was used.

Results

Girls mentioned to sleep 8,2 hours/night during the week and 9,4 hours/night at the weekend. They spend 1,5 hours/day during the week and 1,8 hours/day at the weekend with Screens. They spend 2,1 hours/ week in Sport Practice. Quality of Life was positive correlated with Sleep Time and negative correlated with Screen Time, Anxiety, Depression and Stress (all p<.05). Multiple regression analysis showed that Screen Time, Anxiety and Depression were all significant predictors of Quality of life in girls (p<0,05).

Conclusions

Our findings show that Screen Time is related with poor Quality of Life in girls. These results suggest the importance of addressing Screen Time and Psychological Distress in adolescent girls during adolescent health care consults.

Generalized problematic internet use and perfectionism in portuguese university students

Introduction

Although there are several empirical studies exploring the relationship between problematic Internet use and personality traits, few had considered perfectionism.

Objectives

To explore the association between generalized problematic Internet use and perfectionism.

Methods

A sample of 433 Portuguese university students (M_age = 20.15 years, SD = 1.77, range = 18-25 years) completed the Generalized Problematic Internet Use Scale 2/GPIU and the Multidimensional Perfectionism Composite Scale – short version.

Results

GPIU total score (rs=.16**), Mood Regulation (rs=.22**), and Deficient Self-Regulation (rs=.13**) were correlated with Positive Striving factor. GPIU total score (rs=.38**), Preference for Online Social Interaction (rs=.16**), Mood Regulation (rs=.28**), Deficient Self-Regulation (rs = .33**), and Negative Consequences (rs=.41**) were significantly correlated with Evaluative Concerns factor. A one-way between groups analysis of variance was conducted to explore the relation between GPIU and perfectionism. Subjects were divided into three groups according to their GPIU risk levels (Group1:low-risk; Group2:medium-risk; Group3:high-risk). There was a statistically difference at p >.05 level in Positive Striving scores for the three risk level groups: F (2,430)=4.39, p=.013, and in Evaluative Concerns scores, F (2,430)=28.83, p=<.001. Post-hoc comparisons using the Tukey USD test, for Positive Striving, indicated that the mean score for Group1 (M=39.21, SD=8.56) was significantly different from Group3 (M=43.69, SD=9.74). Considering Evaluative Concerns, the mean score for Group1 (M=39.86, SD=11.31) was significantly different from Group2 (M=46.91, SD=11.42) and from Group3 (M=51.75, SD=8.54).

Conclusions

GPIU is consistently related to maladaptive perfectionism. Future longitudinal studies are needed to clarify the bidirectional association between GPIU and perfectionism traits.

Association between appearance schemas and personality traits

Introduction

Personality traits play are related to many forms of psychological distress, such as body dissatisfaction.

Objectives

To explore the associations between appearance schemas and personality traits.

Methods

494 university students (80.2% females; 99.2% single), with a mean age of 20.17 years old (SD=1.77; range:18-20), filled in the Appearance Schemas Inventory-Revised, the NEO-Personality Inventory, and the Composite Multidimensional Perfectionism Scale.

Results

A significant difference was found in Self-evaluation Salience scores by sex [females (M=37.99,SD=7.82); males (M=35.36,SD=6.60);t(489)=-3.052,p=.002]. Having conducted correlations separately, by sex, Self-Evaluation Salience was correlated with Concern Over Mistakes (r=.27), Doubts about Actions (r=.35), and Socially-Prescribed Perfectionism (r=.23). For females, Self-evaluation Salience was correlated with Concern Over Mistakes (r=.34), Personal Standards (r=.25), Doubts about Actions (r=.33), Parental Expectations (r=.24), Parental Criticism (r=.24), Organization (r=.11), Socially-Prescribed Perfectionism (r=.31), Self-Oriented Perfectionism (r=.32), and Neuroticism (r=.33). Concerning Motivational Salience, in the total sample (not separately, by sex), this scale/dimension significantly correlated with Conscientiousness (r=. 18), Personal Standards (r=.23), Socially-Prescribed Perfectionism (r=. 10), and Self-Oriented Perfectionism (r=.29).

Conclusions

Females seem to value more their self-appearance and, in females, the salience of appearance in life seems to be associated with maladaptive-perfectionism, as well as with adaptive-perfectionism. In males, the salience of appearance was only related with adaptive perfectionism. Males seem more concerned with their own standards, while for females other´s standards are also relevant. In females the level of salience of appearance in life seems to relate to the experience of feelings, such as anxiety/depression (neuroticism). The motivation to improve appearance seemed to be particularly related, in both sex, to adaptive perfectionism.

Disclosure

No significant relationships.

Eating disorder examination-questionnaire – 7: Construct validity in a sample of portuguese overweight women

Introduction

Although the Eating Disorder Examination Questionnaire (EDEQ; Fairburn et al. 2008) is the most used instrument worldwide for the assessment of eating disorders symptoms, its factorial structure considerably varies, which limits its construct validity. Using exploratory factor analisys in data from a sample of overweight women, our group found a three-factors structure of the EDEQ Portuguese version (Peixoto et al. 2013), Although it was in accordance with other psychometric studies (eg. Peterson et al 2007), it was different from the original matrix. Further investigation regarding its factor structure has been conducted, with studies supporting a modified seven-item-three-factors structure (dietary restraint, shape/weight overvaluation, body dissatisfaction) with improved psychometric properties (Grilo et al. 2013, 2015), including with Portuguese samples (Machado et al. 2018; Santos et al. 2019).

Objectives

To analyze if the EDEQ version composed of seven items and three factors is replicated in a Portuguese sample of overweight women.

Methods

The EDEQ was administered to an outpatient sample of 276 women (Mean age= 43.85±11.89 years; Mean BMI=32.82±5.43 Kg/height²) attending a weight loss treatment consultation in a public hospital.

Results

Confirmatory factor analysis (CFA) revealed an adequate fit of the EDEQ-7 second order model with three dimensions (χ²/df=1.5497; RMSEA=.0452, CFI=.9955, TLI=.9914, GFI=.xxx; p<.001). The EDEQ7 Cronbach’s alphas for the total and its dimensions were α<.70.

Conclusions

Given its good psychometric properties, the overlap of the measurement model with those found with different samples and the reduced number of items, the EDEQ7 will be very useful both in research and clinical settings with/for overweight women.