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Xu H, Zou K, Dent J, Wiens KE, Malembaka EB, Bwire G, Okitayemba PW, Hampton LM, Azman AS, Lee EC. Enhanced cholera surveillance to improve vaccination campaign efficiency. Nat Med 2024; 30:1104-1110. [PMID: 38443690 PMCID: PMC11031394 DOI: 10.1038/s41591-024-02852-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
Systematic testing for Vibrio cholerae O1 is rare, which means that the world's limited supply of oral cholera vaccines (OCVs) may not be delivered to areas with the highest true cholera burden. Here we used a phenomenological model with subnational geographic targeting and fine-scale vaccine effects to model how expanding V. cholerae testing affected impact and cost-effectiveness for preventive vaccination campaigns across different bacteriological confirmation and vaccine targeting assumptions in 35 African countries. Systematic testing followed by OCV targeting based on confirmed cholera yielded higher efficiency and cost-effectiveness and slightly fewer averted cases than status quo scenarios targeting suspected cholera. Targeting vaccine to populations with an annual incidence rate greater than 10 per 10,000, the testing scenario averted 10.8 (95% prediction interval (PI) 9.4-12.6) cases per 1,000 fully vaccinated persons while the status quo scenario averted 6.9 (95% PI 6.0-7.8) cases per 1,000 fully vaccinated persons. In the testing scenario, testing costs increased by US$31 (95% PI 25-39) while vaccination costs reduced by US$248 (95% PI 176-326) per averted case compared to the status quo. Introduction of systematic testing into cholera surveillance could improve efficiency and reach of global OCV supply for preventive vaccination.
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Affiliation(s)
- Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juan Dent
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kirsten E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Placide Welo Okitayemba
- Programme National d'Elimination de Choléra et lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of the Congo
| | | | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Hegde ST, Khan AI, Perez-Saez J, Khan II, Hulse JD, Islam MT, Khan ZH, Ahmed S, Bertuna T, Rashid M, Rashid R, Hossain MZ, Shirin T, Wiens KE, Gurley ES, Bhuiyan TR, Qadri F, Azman AS. Clinical surveillance systems obscure the true cholera infection burden in an endemic region. Nat Med 2024; 30:888-895. [PMID: 38378884 PMCID: PMC10957480 DOI: 10.1038/s41591-024-02810-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/09/2024] [Indexed: 02/22/2024]
Abstract
Our understanding of cholera transmission and burden largely relies on clinic-based surveillance, which can obscure trends, bias burden estimates and limit the impact of targeted cholera-prevention measures. Serological surveillance provides a complementary approach to monitoring infections, although the link between serologically derived infections and medically attended disease incidence-shaped by immunological, behavioral and clinical factors-remains poorly understood. We unravel this cascade in a cholera-endemic Bangladeshi community by integrating clinic-based surveillance, healthcare-seeking and longitudinal serological data through statistical modeling. Combining the serological trajectories with a reconstructed incidence timeline of symptomatic cholera, we estimated an annual Vibrio cholerae O1 infection incidence rate of 535 per 1,000 population (95% credible interval 514-556), with incidence increasing by age group. Clinic-based surveillance alone underestimated the number of infections and reported cases were not consistently correlated with infection timing. Of the infections, 4 in 3,280 resulted in symptoms, only 1 of which was reported through the surveillance system. These results impart insights into cholera transmission dynamics and burden in the epicenter of the seventh cholera pandemic, where >50% of our study population had an annual V. cholerae O1 infection, and emphasize the potential for a biased view of disease burden and infection risk when depending solely on clinical surveillance data.
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Affiliation(s)
- Sonia T Hegde
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Ashraful Islam Khan
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Javier Perez-Saez
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
- Unit of Population Epidemiology, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Ishtiakul Islam Khan
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Juan Dent Hulse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Md Taufiqul Islam
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Zahid Hasan Khan
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Shakeel Ahmed
- Bangladesh Institute of Tropical and Infectious Diseases, Chattogram, Bangladesh
| | - Taner Bertuna
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Mamunur Rashid
- Bangladesh Institute of Tropical and Infectious Diseases, Chattogram, Bangladesh
| | - Rumana Rashid
- Bangladesh Institute of Tropical and Infectious Diseases, Chattogram, Bangladesh
| | - Md Zakir Hossain
- Bangladesh Institute of Tropical and Infectious Diseases, Chattogram, Bangladesh
| | - Tahmina Shirin
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Kirsten E Wiens
- Department of Epidemiology, Temple University, Philadelphia, PA, USA
| | - Emily S Gurley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Taufiqur Rahman Bhuiyan
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Firdausi Qadri
- Infectious Disease Division, icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh.
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland.
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland.
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Wiens KE, Xu H, Zou K, Mwaba J, Lessler J, Malembaka EB, Demby MN, Bwire G, Qadri F, Lee EC, Azman AS. Estimating the proportion of clinically suspected cholera cases that are true Vibrio cholerae infections: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004286. [PMID: 37708235 PMCID: PMC10538743 DOI: 10.1371/journal.pmed.1004286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 09/28/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Cholera surveillance relies on clinical diagnosis of acute watery diarrhea. Suspected cholera case definitions have high sensitivity but low specificity, challenging our ability to characterize cholera burden and epidemiology. Our objective was to estimate the proportion of clinically suspected cholera that are true Vibrio cholerae infections and identify factors that explain variation in positivity. METHODS AND FINDINGS We conducted a systematic review of studies that tested ≥10 suspected cholera cases for V. cholerae O1/O139 using culture, PCR, and/or a rapid diagnostic test. We searched PubMed, Embase, Scopus, and Google Scholar for studies that sampled at least one suspected case between January 1, 2000 and April 19, 2023, to reflect contemporary patterns in V. cholerae positivity. We estimated diagnostic test sensitivity and specificity using a latent class meta-analysis. We estimated V. cholerae positivity using a random-effects meta-analysis, adjusting for test performance. We included 119 studies from 30 countries. V. cholerae positivity was lower in studies with representative sampling and in studies that set minimum ages in suspected case definitions. After adjusting for test performance, on average, 52% (95% credible interval (CrI): 24%, 80%) of suspected cases represented true V. cholerae infections. After adjusting for test performance and study methodology, the odds of a suspected case having a true infection were 5.71 (odds ratio 95% CrI: 1.53, 15.43) times higher when surveillance was initiated in response to an outbreak than in non-outbreak settings. Variation across studies was high, and a limitation of our approach was that we were unable to explain all the heterogeneity with study-level attributes, including diagnostic test used, setting, and case definitions. CONCLUSIONS In this study, we found that burden estimates based on suspected cases alone may overestimate the incidence of medically attended cholera by 2-fold. However, accounting for cases missed by traditional clinical surveillance is key to unbiased cholera burden estimates. Given the substantial variability in positivity between settings, extrapolations from suspected to confirmed cases, which is necessary to estimate cholera incidence rates without exhaustive testing, should be based on local data.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Maya N. Demby
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth C. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
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Wiens KE, Iyer AS, Bhuiyan TR, Lu LL, Cizmeci D, Gorman MJ, Yuan D, Becker RL, Ryan ET, Calderwood SB, LaRocque RC, Chowdhury F, Khan AI, Levine MM, Chen WH, Charles RC, Azman AS, Qadri F, Alter G, Harris JB. Predicting Vibrio cholerae infection and symptomatic disease: a systems serology study. Lancet Microbe 2023; 4:e228-e235. [PMID: 36907197 PMCID: PMC10186354 DOI: 10.1016/s2666-5247(22)00391-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/18/2022] [Accepted: 12/09/2022] [Indexed: 03/11/2023]
Abstract
BACKGROUND Vibriocidal antibodies are currently the best characterised correlate of protection against cholera and are used to gauge immunogenicity in vaccine trials. Although other circulating antibody responses have been associated with a decreased risk of infection, the correlates of protection against cholera have not been comprehensively compared. We aimed to analyse antibody-mediated correlates of protection from both V cholerae infection and cholera-related diarrhoea. METHODS We conducted a systems serology study that analysed 58 serum antibody biomarkers as correlates of protection against V cholerae O1 infection or diarrhoea. We used serum samples from two cohorts: household contacts of people with confirmed cholera in Dhaka, Bangladesh, and cholera-naive volunteers who were recruited at three centres in the USA, vaccinated with a single dose of CVD 103-HgR live oral cholera vaccine, and then challenged with V cholerae O1 El Tor Inaba strain N16961. We measured antigen-specific immunoglobulin responses against antigens using a customised Luminex assay and used conditional random forest models to examine which baseline biomarkers were most important for classifying individuals who went on to develop infection versus those who remained uninfected or asymptomatic. V cholerae infection was defined as having a positive stool culture result on days 2-7 or day 30 after enrolment of the household's index cholera case and, in the vaccine challenge cohort, was the development of symptomatic diarrhoea (defined as two or more loose stools of ≥200 mL each, or a single loose stool of ≥300 mL over a 48-h period). FINDINGS In the household contact cohort (261 participants from 180 households), 20 (34%) of the 58 studied biomarkers were associated with protection against V cholerae infection. We identified serum antibody-dependent complement deposition targeting the O1 antigen as the most predictive correlate of protection from infection in the household contacts, whereas vibriocidal antibody titres ranked lower. A five-biomarker model predicted protection from V cholerae infection with a cross-validated area under the curve (cvAUC) of 79% (95% CI 73-85). This model also predicted protection against diarrhoea in unvaccinated volunteers challenged with V cholerae O1 after vaccination (n=67; area under the curve [AUC] 77%, 95% CI 64-90). Although a different five-biomarker model best predicted protection from the development of cholera diarrhoea in the challenged vaccinees (cvAUC 78%, 95% CI 66-91), this model did poorly at predicting protection against infection in the household contacts (AUC 60%, 52-67). INTERPRETATION Several biomarkers predict protection better than vibriocidal titres. A model based on protection against infection among household contacts was predictive of protection against both infection and diarrhoeal illness in challenged vaccinees, suggesting that models based on observed conditions in a cholera-endemic population might be more likely to identify broadly applicable correlates of protection than models trained on single experimental settings. FUNDING National Institute of Allergy and Infectious Diseases and National Institute of Child Health and Human Development, National Institutes of Health.
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Affiliation(s)
- Kirsten E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - Anita S Iyer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Taufiqur R Bhuiyan
- Infectious Diseases Division, International Centre for Diarrheoal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Lenette L Lu
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine and Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Parkland Health and Hospital System, Dallas, TX, USA
| | - Deniz Cizmeci
- Ragon Institute of MGH, Massachusetts Institute of Technology, and Harvard, Cambridge, MA, USA
| | - Matthew J Gorman
- Ragon Institute of MGH, Massachusetts Institute of Technology, and Harvard, Cambridge, MA, USA
| | - Dansu Yuan
- Ragon Institute of MGH, Massachusetts Institute of Technology, and Harvard, Cambridge, MA, USA
| | - Rachel L Becker
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Stephen B Calderwood
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Regina C LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Fahima Chowdhury
- Infectious Diseases Division, International Centre for Diarrheoal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ashraful I Khan
- Infectious Diseases Division, International Centre for Diarrheoal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Myron M Levine
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wilbur H Chen
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Richelle C Charles
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrheoal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Galit Alter
- Department of Medicine, Harvard Medical School, Boston, MA, USA; Ragon Institute of MGH, Massachusetts Institute of Technology, and Harvard, Cambridge, MA, USA
| | - Jason B Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Aiemjoy K, Rumunu J, Hassen JJ, Wiens KE, Garrett D, Kamenskaya P, Harris JB, Azman AS, Teunis P, Seidman JC, Wamala JF, Andrews JR, Charles RC. Seroincidence of Enteric Fever, Juba, South Sudan. Emerg Infect Dis 2022; 28. [PMID: 36286224 PMCID: PMC9622235 DOI: 10.3201/eid2811.220239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We applied a new serosurveillance tool to estimate typhoidal Salmonella burden using samples collected during 2020 from a population in Juba, South Sudan. By using dried blood spot testing, we found an enteric fever seroincidence rate of 30/100 person-years and cumulative incidence of 74% over a 4-year period.
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Frostad JJ, Nguyen QP, Baumann MM, Blacker BF, Marczak LB, Deshpande A, Wiens KE, LeGrand KE, Johnson KB, Abbasi-Kangevari M, Abdoli A, Abolhassani H, Abreu LG, Abrigo MRM, Abu-Rmeileh NME, Adekanmbi V, Agrawal A, Ahmed MB, Al-Aly Z, Alanezi FM, Alcalde-Rabanal JE, Alipour V, Altirkawi KA, Alvis-Guzman N, Alvis-Zakzuk NJ, Amegah AK, Amini S, Amiri F, Amugsi DA, Ancuceanu R, Andrei CL, Andrei T, Antriyandarti E, Anvari D, Arabloo J, Arab-Zozani M, Athari SS, Ausloos M, Ayano G, Aynalem YA, Azari S, Badiye AD, Baig AA, Balakrishnan K, Banach M, Basu S, Bedi N, Bell ML, Bennett DA, Bhattacharyya K, Bhutta ZA, Bibi S, Bohlouli S, Boufous S, Bragazzi NL, Braithwaite D, Burugina Nagaraja S, Butt ZA, Caetano dos Santos FL, Car J, Cárdenas R, Carvalho F, Castaldelli-Maia JM, Castañeda-Orjuela CA, Cerin E, Chattu SK, Chattu VK, Chaturvedi P, Chaturvedi S, Chen S, Chu DT, Chung SC, Dahlawi SMA, Damiani G, Dandona L, Dandona R, Darwesh AM, Das JK, Dash AP, Dávila-Cervantes CA, De Leo D, De Neve JW, Demissie GD, Denova-Gutiérrez E, Dey S, Dharmaratne SD, Dhimal M, Dhungana GP, Diaz D, Dipeolu IO, Dorostkar F, Doshmangir L, Duraes AR, Edinur HA, Efendi F, El Tantawi M, Eskandarieh S, Fadhil I, Fattahi N, Fauk NK, Fereshtehnejad SM, Folayan MO, Foroutan M, Fukumoto T, Gaidhane AM, Ghafourifard M, Ghashghaee A, Gilani SA, Gill TK, Goulart AC, Goulart BNG, Grada A, Gubari MIM, Guido D, Guo Y, Gupta RD, Gupta R, Gutiérrez RA, Hafezi-Nejad N, Hamadeh RR, Hasaballah AI, Hassanipour S, Hayat K, Heibati B, Heidari-Soureshjani R, Henry NJ, Herteliu C, Hosseinzadeh M, Hsairi M, Hu G, Ibitoye SE, Ilesanmi OS, Ilic IM, Ilic MD, Irvani SSN, Islam SMS, Iwu CCD, Jaafari J, Jakovljevic M, Javaheri T, Jha RP, Ji JS, Jonas JB, Kabir A, Kabir Z, Kalhor R, Kamyari N, Kanchan T, Kapil U, Kapoor N, Kayode GA, Keiyoro PN, Khader YS, Khalid N, Khan EA, Khan M, Khan MN, Khatab K, Khater MM, Khatib MN, Khayamzadeh M, Khubchandani J, Kim GR, Kim YJ, Kimokoti RW, Kisa A, Kisa S, Knibbs LD, Koul PA, Koyanagi A, Krishan K, Kumar GA, Kumar M, Kusuma D, La Vecchia C, Lacey B, Lami FH, Lan Q, Lasrado S, Lauriola P, Lee PH, Lewycka S, Li S, Machado DB, Mahasha PW, Maheri M, Majeed A, Maleki A, Malekzadeh R, Malta DC, Mansouri B, Mansournia MA, Martinez NM, Martini S, Martins-Melo FR, Mayala BK, Mehndiratta MM, Mendoza W, Menezes RG, Mengesha EW, Meretoja TJ, Mestrovic T, Michalek IM, Mirrakhimov EM, Mirzaei M, Mirzaei R, Moazen B, Mohammad Y, Mohammadian-Hafshejani A, Mohammed S, Mokdad AH, Monasta L, Moradi-Lakeh M, Moraga P, Morawska L, Mosapour A, Mouodi S, Mousavi Khaneghah A, Mukhopadhyay S, Munro SB, Murray CJL, Nagarajan AJ, Naghavi M, Nair S, Nangia V, Nascimento BR, Nazari J, Negoi I, Netsere HB, Ngunjiri JW, Nguyen HLT, Noubiap JJ, Oancea B, Ogbo FA, Oh IH, Olagunju AT, Olusanya BO, Olusanya JO, Omar Bali A, Onwujekwe OE, Otstavnov N, Otstavnov SS, Owolabi MO, P A M, Pandey A, Park EC, Park EK, Patel SK, Pham HQ, Pilgrim T, Pirsaheb M, Pokhrel KN, Postma MJ, Quazi Syed Z, Rabiee N, Radfar A, Rahim F, Rahman MHU, Rahman MA, Rahmani AM, Ranabhat CL, Rao SJ, Rasella D, Rastogi P, Rath GK, Rawaf DL, Rawaf S, Rawal L, Rawassizadeh R, Renzaho AMN, Reshmi B, Rezaei N, Rezaei N, Rezapour A, Rickard J, Roever L, Ronfani L, Rostamian M, Rubagotti E, Rwegerera GM, Saddik B, Sadeghi E, Saeedi Moghaddam S, Sagar R, Sahebkar A, Sahiledengle B, Salem MR, Samy AM, Santric-Milicevic MM, Saraswathy SYI, Sathian B, Sathish T, Schwebel DC, Sepanlou SG, Shahabi S, Shaheen AA, Shahid I, Shaikh MA, Shalash AS, Shams-Beyranvand M, Shannawaz M, Sharafi K, Sheikh A, Sheikhbahaei S, Shetty RS, Shiferaw WS, Shigematsu M, Shin JI, Shivakumar KM, Siabani S, Siddiqi TJ, Singh BB, Singh JA, Sintayehu Y, Sorrie MB, Soyiri IN, Spurlock EE, Sreeramareddy CT, Stockfelt L, Sufiyan MB, Suliankatchi Abdulkader R, Tabarés-Seisdedos R, Tabuchi T, Taherkhani A, Temsah MH, Thankappan KR, Tovani-Palone MR, Traini E, Ullah S, Unnikrishnan B, Upadhyay E, Valadan Tahbaz S, Varughese S, Violante FS, Vo B, Vu GT, Waheed Y, Wang YP, Welgan CA, Werdecker A, Yahyazadeh Jabbari SH, Yaya S, Yazdi-Feyzabadi V, Yilma MT, Yonemoto N, Younis MZ, Yousefinezhadi T, Yu C, Yu Y, Zaman SB, Zhang Y, Zhang ZJ, Brauer M, Hay SI, Reiner RC. Mapping development and health effects of cooking with solid fuels in low-income and middle-income countries, 2000-18: a geospatial modelling study. Lancet Glob Health 2022; 10:e1395-e1411. [PMID: 36113526 PMCID: PMC9638039 DOI: 10.1016/s2214-109x(22)00332-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/17/2022] [Accepted: 07/21/2022] [Indexed: 01/03/2023]
Abstract
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.
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Wiens KE, Smith CP, Badillo-Goicoechea E, Grantz KH, Grabowski MK, Azman AS, Stuart EA, Lessler J. In-person schooling and associated COVID-19 risk in the United States over spring semester 2021. Sci Adv 2022; 8:eabm9128. [PMID: 35442740 PMCID: PMC9020776 DOI: 10.1126/sciadv.abm9128] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Because of the importance of schools to childhood development, the relationship between in-person schooling and COVID-19 risk has been one of the most important questions of this pandemic. Previous work in the United States during winter 2020-2021 showed that in-person schooling carried some risk for household members and that mitigation measures reduced this risk. Schooling and the COVID-19 landscape changed radically over spring semester 2021. Here, we use data from a massive online survey to characterize changes in in-person schooling behavior and associated risks over that period. We find increases in in-person schooling and reductions in mitigations over time. In-person schooling is associated with increased reporting of COVID-19 outcomes even among vaccinated individuals (although the absolute risk among the vaccinated is greatly reduced). Vaccinated teachers working outside the home were less likely to report COVID-19-related outcomes than unvaccinated teachers working exclusively from home. Adequate mitigation measures appear to eliminate the excess risk associated with in-person schooling.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claire P. Smith
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elena Badillo-Goicoechea
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kyra H. Grantz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M. Kate Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Corresponding author.
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8
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Allorant A, Biswas S, Ahmed S, Wiens KE, LeGrand KE, Janko MM, Henry NJ, Dangel WJ, Watson A, Blacker BF, Kyu HH, Ross JM, Rahman MS, Hay SI, Reiner RC. Finding gaps in routine TB surveillance activities in Bangladesh. Int J Tuberc Lung Dis 2022; 26:356-362. [PMID: 35351241 PMCID: PMC8982646 DOI: 10.5588/ijtld.21.0624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND : TB was the leading cause of death from a single infectious pathogen globally between 2014 and 2019. Fine-scale estimates of TB prevalence and case notifications can be combined to guide priority-setting for strengthening routine surveillance activities in high-burden countries. We produce policy-relevant estimates of the TB epidemic at the second administrative unit in Bangladesh. METHODS : We used a Bayesian spatial framework and the cross-sectional National TB Prevalence Survey from 2015–2016 in Bangladesh to estimate prevalence by district. We used case notifications to calculate prevalence-to-notification ratio, a key metric of under-diagnosis and under-reporting. RESULTS : TB prevalence rates were highest in the north-eastern districts and ranged from 160 cases per 100,000 (95% uncertainty interval [UI] 80–310) in Jashore to 840 (UI 690–1020) in Sunamganj. Despite moderate prevalence rates, the Rajshahi and Dhaka Divisions presented the highest prevalence-to-notification ratios due to low case notifications. Resolving subnational disparities in case detection could lead to 26,500 additional TB cases (UI 8,500–79,400) notified every year. CONCLUSION : This study is the first to produce and map subnational estimates of TB prevalence and prevalence-to-notification ratios, which are essential to target prevention and treatment efforts in high-burden settings. Reaching TB cases currently missing from care will be key to ending the TB epidemic.
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Affiliation(s)
- A Allorant
- Department of Global Health, University of Washington, Seattle, WA, Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - S Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - S Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - K E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - K E LeGrand
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - M M Janko
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - N J Henry
- Institute for Health Metrics and Evaluation, Seattle, WA, USA, Big Data Institute, University of Oxford, Oxford, UK
| | - W J Dangel
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - A Watson
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - B F Blacker
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
| | - H H Kyu
- Institute for Health Metrics and Evaluation, Seattle, WA, USA, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - J M Ross
- Department of Global Health, University of Washington, Seattle, WA, Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - M S Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - S I Hay
- Institute for Health Metrics and Evaluation, Seattle, WA, USA, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - R C Reiner
- Institute for Health Metrics and Evaluation, Seattle, WA, USA, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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9
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Wiens KE, Mawien PN, Rumunu J, Slater D, Jones FK, Moheed S, Caflisch A, Bior BK, Jacob IA, Lako RL, Guyo AG, Olu OO, Maleghemi S, Baguma A, Hassen JJ, Baya SK, Deng L, Lessler J, Demby MN, Sanchez V, Mills R, Fraser C, Charles RC, Harris JB, Azman AS, Wamala JF. Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 IgG in Juba, South Sudan, 2020 1. Emerg Infect Dis 2021; 27:1598-1606. [PMID: 34013872 PMCID: PMC8153877 DOI: 10.3201/eid2706.210568] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Relatively few coronavirus disease cases and deaths have been reported from sub-Saharan Africa, although the extent of its spread remains unclear. During August 10-September 11, 2020, we recruited 2,214 participants for a representative household-based cross-sectional serosurvey in Juba, South Sudan. We found 22.3% of participants had severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor binding domain IgG titers above prepandemic levels. After accounting for waning antibody levels, age, and sex, we estimated that 38.3% (95% credible interval 31.8%-46.5%) of the population had been infected with SARS-CoV-2. At this rate, for each PCR-confirmed SARS-CoV-2 infection reported by the Ministry of Health, 103 (95% credible interval 86-126) infections would have been unreported, meaning SARS-CoV-2 has likely spread extensively within Juba. We also found differences in background reactivity in Juba compared with Boston, Massachusetts, USA, where the immunoassay was validated. Our findings underscore the need to validate serologic tests in sub-Saharan Africa populations.
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Affiliation(s)
- Kirsten E. Wiens
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Pinyi Nyimol Mawien
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - John Rumunu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Damien Slater
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Forrest K. Jones
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Serina Moheed
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Andrea Caflisch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Bior K. Bior
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Iboyi Amanya Jacob
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Richard Lino Lako
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Argata Guracha Guyo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Olushayo Oluseun Olu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Sylvester Maleghemi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Andrew Baguma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Juma John Hassen
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Sheila K. Baya
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Lul Deng
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Justin Lessler
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Maya N. Demby
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Vanessa Sanchez
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Rachel Mills
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
| | - Clare Fraser
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA (K.E. Wiens, F.K. Jones, J. Lessler, M.N. Demby, A.S. Azman)
- Republic of South Sudan Ministry of Health, Juba, South Sudan (P.N. Mawien, J. Rumunu, B.K. Bior, I.A. Jacob, R.L. Lako, L. Deng)
- Massachusetts General Hospital, Boston, Massachusetts, USA (D. Slater, S. Moheed, V. Sanchez, R. Mills, C. Fraser, R.C. Charles, J.B. Harris)
- International Organization for Migration, Juba (A. Caflisch)
- World Health Organization, Juba (A.G. Guyo, O.O. Olu, S. Maleghemi, A. Baguma, J.J. Hassen, S.K. Baya, J.F. Wamala)
- Kabale University School of Medicine, Kabale, Uganda (A. Baguma)
- Harvard Medical School, Boston (R.C. Charles, J.B. Harris)
- Médecins Sans Frontières, Geneva, Switzerland (A.S. Azman)
- Institute of Global Health, Geneva (A.S. Azman)
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10
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Wiens KE, Mawien PN, Rumunu J, Slater D, Jones FK, Moheed S, Caflish A, Bior BK, Jacob IA, Lako RLL, Guyo AG, Olu OO, Maleghemi S, Baguma A, Hassen JJ, Baya SK, Deng L, Lessler J, Demby MN, Sanchez V, Mills R, Fraser C, Charles RC, Harris JB, Azman AS, Wamala JF. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Juba, South Sudan: a population-based study. medRxiv 2021:2021.03.08.21253009. [PMID: 33758900 PMCID: PMC7987059 DOI: 10.1101/2021.03.08.21253009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Relatively few COVID-19 cases and deaths have been reported through much of sub-Saharan Africa, including South Sudan, although the extent of SARS-CoV-2 spread remains unclear due to weak surveillance systems and few population-representative serosurveys. METHODS We conducted a representative household-based cross-sectional serosurvey in Juba, South Sudan. We quantified IgG antibody responses to SARS-CoV-2 spike protein receptor-binding domain and estimated seroprevalence using a Bayesian regression model accounting for test performance. RESULTS We recruited 2,214 participants from August 10 to September 11, 2020 and 22.3% had anti-SARS-CoV-2 IgG titers above levels in pre-pandemic samples. After accounting for waning antibody levels, age, and sex, we estimated that 38.5% (32.1 - 46.8) of the population had been infected with SARS-CoV-2. For each RT-PCR confirmed COVID-19 case, 104 (87-126) infections were unreported. Background antibody reactivity was higher in pre-pandemic samples from Juba compared to Boston, where the serological test was validated. The estimated proportion of the population infected ranged from 30.1% to 60.6% depending on assumptions about test performance and prevalence of clinically severe infections. CONCLUSIONS SARS-CoV-2 has spread extensively within Juba. Validation of serological tests in sub-Saharan African populations is critical to improve our ability to use serosurveillance to understand and mitigate transmission.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - John Rumunu
- Republic of South Sudan Ministry of Health, Juba, South Sudan
| | - Damien Slater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Forrest K. Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Serina Moheed
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Andrea Caflish
- Displacement Tracking Matrix, International Organization for Migration, Juba, South Sudan
| | - Bior K. Bior
- Republic of South Sudan Ministry of Health, Juba, South Sudan
| | | | | | | | | | | | - Andrew Baguma
- World Health Organization, Juba, South Sudan
- Kabale University School of Medicine, Department of Microbiology and Immunology
| | | | | | - Lul Deng
- Republic of South Sudan Ministry of Health, Juba, South Sudan
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maya N. Demby
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vanessa Sanchez
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel Mills
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Clare Fraser
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Richelle C. Charles
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jason B. Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Médecins Sans Frontières, Geneva, Switzerland
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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11
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Wiens KE, Schaeffer LE, Sow SO, Ndoye B, Cain CJ, Baumann MM, Johnson KB, Lindstedt PA, Blacker BF, Bhutta ZA, Cormier NM, Daoud F, Earl L, Farag T, Khalil IA, Kinyoki DK, Larson HJ, LeGrand KE, Cook AJ, Malta DC, Månsson JC, Mayala BK, Mokdad AH, Ogbuanu IU, Sankoh O, Sartorius B, Topor-Madry R, Troeger CE, Welgan CA, Werdecker A, Hay SI, Reiner RC. Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy. BMC Med 2020; 18:405. [PMID: 33342436 PMCID: PMC7750121 DOI: 10.1186/s12916-020-01857-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes. METHODS We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access. RESULTS We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children. CONCLUSIONS Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.
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Affiliation(s)
- Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Samba O Sow
- Centre for Vaccine Development, Mali (CVD-Mali), Bamako, Mali
| | - Babacar Ndoye
- African Field Epidemiology Training Programme - Senegal, Ministry of Health, Dakar, Senegal
| | - Carrie Jo Cain
- World Hope International, Makeni, Sierra Leone
- Health Care Ministries, Wesleyan Church of Sierra Leone, Makeni, Sierra Leone
| | - Mathew M Baumann
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Kimberly B Johnson
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Paulina A Lindstedt
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Brigette F Blacker
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, University of Toronto, Toronto, ON, Canada
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Natalie M Cormier
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Farah Daoud
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Tamer Farag
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Ibrahim A Khalil
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Heidi J Larson
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kate E LeGrand
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Aubrey J Cook
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Deborah C Malta
- Department of Maternal and Child Nursing and Public Health, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Johan C Månsson
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Benjamin K Mayala
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- ICF International, DHS Program, Rockville, MD, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ikechukwu U Ogbuanu
- Expanded Programme on Immunization, World Health Organization, Geneva, Switzerland
| | - Osman Sankoh
- Statistics Sierra Leone, Tower Hill, Freetown, Sierra Leone
- Njala University, Njala, Bo, Freetown, Sierra Leone
| | - Benn Sartorius
- Department of Global Health, University of Washington, Seattle, WA, USA
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Roman Topor-Madry
- Institute of Public Health, Jagiellonian University Medical College, Kraków, Poland
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland
| | - Christopher E Troeger
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Catherine A Welgan
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Andrea Werdecker
- Demographic Change and Aging Research Area, Federal Institute for Population Research, Wiesbaden, Germany
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave. NE, Seattle, WA, 98195, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
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12
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Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, Abbasi-Kangevari M, Abbastabar H, Abd-Allah F, Abdelalim A, Abdollahi M, Abdollahpour I, Abolhassani H, Aboyans V, Abrams EM, Abreu LG, Abrigo MRM, Abu-Raddad LJ, Abushouk AI, Acebedo A, Ackerman IN, Adabi M, Adamu AA, Adebayo OM, Adekanmbi V, Adelson JD, Adetokunboh OO, Adham D, Afshari M, Afshin A, Agardh EE, Agarwal G, Agesa KM, Aghaali M, Aghamir SMK, Agrawal A, Ahmad T, Ahmadi A, Ahmadi M, Ahmadieh H, Ahmadpour E, Akalu TY, Akinyemi RO, Akinyemiju T, Akombi B, Al-Aly Z, Alam K, Alam N, Alam S, Alam T, Alanzi TM, Albertson SB, Alcalde-Rabanal JE, Alema NM, Ali M, Ali S, Alicandro G, Alijanzadeh M, Alinia C, Alipour V, Aljunid SM, Alla F, Allebeck P, Almasi-Hashiani A, Alonso J, Al-Raddadi RM, Altirkawi KA, Alvis-Guzman N, Alvis-Zakzuk NJ, Amini S, Amini-Rarani M, Aminorroaya A, Amiri F, Amit AML, Amugsi DA, Amul GGH, Anderlini D, Andrei CL, Andrei T, Anjomshoa M, Ansari F, Ansari I, Ansari-Moghaddam A, Antonio CAT, Antony CM, Antriyandarti E, Anvari D, Anwer R, Arabloo J, Arab-Zozani M, Aravkin AY, Ariani F, Ärnlöv J, Aryal KK, Arzani A, Asadi-Aliabadi M, Asadi-Pooya AA, Asghari B, Ashbaugh C, Atnafu DD, Atre SR, Ausloos F, Ausloos M, Ayala Quintanilla BP, Ayano G, Ayanore MA, Aynalem YA, Azari S, Azarian G, Azene ZN, Babaee E, Badawi A, Bagherzadeh M, Bakhshaei MH, Bakhtiari A, Balakrishnan S, Balalla S, Balassyano S, Banach M, Banik PC, Bannick MS, Bante AB, Baraki AG, Barboza MA, Barker-Collo SL, Barthelemy CM, Barua L, Barzegar A, Basu S, Baune BT, Bayati M, Bazmandegan G, Bedi N, Beghi E, Béjot Y, Bello AK, Bender RG, Bennett DA, Bennitt FB, Bensenor IM, Benziger CP, Berhe K, Bernabe E, Bertolacci GJ, Bhageerathy R, Bhala N, Bhandari D, Bhardwaj P, Bhattacharyya K, Bhutta ZA, Bibi S, Biehl MH, Bikbov B, Bin Sayeed MS, Biondi A, Birihane BM, Bisanzio D, Bisignano C, Biswas RK, Bohlouli S, Bohluli M, Bolla SRR, Boloor A, Boon-Dooley AS, Borges G, Borzì AM, Bourne R, Brady OJ, Brauer M, Brayne C, Breitborde NJK, Brenner H, Briant PS, Briggs AM, Briko NI, Britton GB, Bryazka D, Buchbinder R, Bumgarner BR, Busse R, Butt ZA, Caetano dos Santos FL, Cámera LLAA, Campos-Nonato IR, Car J, Cárdenas R, Carreras G, Carrero JJ, Carvalho F, Castaldelli-Maia JM, Castañeda-Orjuela CA, Castelpietra G, Castle CD, Castro F, Catalá-López F, Causey K, Cederroth CR, Cercy KM, Cerin E, Chandan JS, Chang AR, Charlson FJ, Chattu VK, Chaturvedi S, Chimed-Ochir O, Chin KL, Cho DY, Christensen H, Chu DT, Chung MT, Cicuttini FM, Ciobanu LG, Cirillo M, Collins EL, Compton K, Conti S, Cortesi PA, Costa VM, Cousin E, Cowden RG, Cowie BC, Cromwell EA, Cross DH, Crowe CS, Cruz JA, Cunningham M, Dahlawi SMA, Damiani G, Dandona L, Dandona R, Darwesh AM, Daryani A, Das JK, Das Gupta R, das Neves J, Dávila-Cervantes CA, Davletov K, De Leo D, Dean FE, DeCleene NK, Deen A, Degenhardt L, Dellavalle RP, Demeke FM, Demsie DG, Denova-Gutiérrez E, Dereje ND, Dervenis N, Desai R, Desalew A, Dessie GA, Dharmaratne SD, Dhungana GP, Dianatinasab M, Diaz D, Dibaji Forooshani ZS, Dingels ZV, Dirac MA, Djalalinia S, Do HT, Dokova K, Dorostkar F, Doshi CP, Doshmangir L, Douiri A, Doxey MC, Driscoll TR, Dunachie SJ, Duncan BB, Duraes AR, Eagan AW, Ebrahimi Kalan M, Edvardsson D, Ehrlich JR, El Nahas N, El Sayed I, El Tantawi M, Elbarazi I, Elgendy IY, Elhabashy HR, El-Jaafary SI, Elyazar IRF, Emamian MH, Emmons-Bell S, Erskine HE, Eshrati B, Eskandarieh S, Esmaeilnejad S, Esmaeilzadeh F, Esteghamati A, Estep K, Etemadi A, Etisso AE, Farahmand M, Faraj A, Fareed M, Faridnia R, Farinha CSES, Farioli A, Faro A, Faruque M, Farzadfar F, Fattahi N, Fazlzadeh M, Feigin VL, Feldman R, Fereshtehnejad SM, Fernandes E, Ferrari AJ, Ferreira ML, Filip I, Fischer F, Fisher JL, Fitzgerald R, Flohr C, Flor LS, Foigt NA, Folayan MO, Force LM, Fornari C, Foroutan M, Fox JT, Freitas M, Fu W, Fukumoto T, Furtado JM, Gad MM, Gakidou E, Galles NC, Gallus S, Gamkrelidze A, Garcia-Basteiro AL, Gardner WM, Geberemariyam BS, Gebrehiwot AM, Gebremedhin KB, Gebreslassie AAAA, Gershberg Hayoon A, Gething PW, Ghadimi M, Ghadiri K, Ghafourifard M, Ghajar A, Ghamari F, Ghashghaee A, Ghiasvand H, Ghith N, Gholamian A, Gilani SA, Gill PS, Gitimoghaddam M, Giussani G, Goli S, Gomez RS, Gopalani SV, Gorini G, Gorman TM, Gottlich HC, Goudarzi H, Goulart AC, Goulart BNG, Grada A, Grivna M, Grosso G, Gubari MIM, Gugnani HC, Guimaraes ALS, Guimarães RA, Guled RA, Guo G, Guo Y, Gupta R, Haagsma JA, Haddock B, Hafezi-Nejad N, Hafiz A, Hagins H, Haile LM, Hall BJ, Halvaei I, Hamadeh RR, Hamagharib Abdullah K, Hamilton EB, Han C, Han H, Hankey GJ, Haro JM, Harvey JD, Hasaballah AI, Hasanzadeh A, Hashemian M, Hassanipour S, Hassankhani H, Havmoeller RJ, Hay RJ, Hay SI, Hayat K, Heidari B, Heidari G, Heidari-Soureshjani R, Hendrie D, Henrikson HJ, Henry NJ, Herteliu C, Heydarpour F, Hird TR, Hoek HW, Hole MK, Holla R, Hoogar P, Hosgood HD, Hosseinzadeh M, Hostiuc M, Hostiuc S, Househ M, Hoy DG, Hsairi M, Hsieh VCR, Hu G, Huda TM, Hugo FN, Huynh CK, Hwang BF, Iannucci VC, Ibitoye SE, Ikuta KS, Ilesanmi OS, Ilic IM, Ilic MD, Inbaraj LR, Ippolito H, Irvani SSN, Islam MM, Islam M, Islam SMS, Islami F, Iso H, Ivers RQ, Iwu CCD, Iyamu IO, Jaafari J, Jacobsen KH, Jadidi-Niaragh F, Jafari H, Jafarinia M, Jahagirdar D, Jahani MA, Jahanmehr N, Jakovljevic M, Jalali A, Jalilian F, James SL, Janjani H, Janodia MD, Jayatilleke AU, Jeemon P, Jenabi E, Jha RP, Jha V, Ji JS, Jia P, John O, John-Akinola YO, Johnson CO, Johnson SC, Jonas JB, Joo T, Joshi A, Jozwiak JJ, Jürisson M, Kabir A, Kabir Z, Kalani H, Kalani R, Kalankesh LR, Kalhor R, Kamiab Z, Kanchan T, Karami Matin B, Karch A, Karim MA, Karimi SE, Kassa GM, Kassebaum NJ, Katikireddi SV, Kawakami N, Kayode GA, Keddie SH, Keller C, Kereselidze M, Khafaie MA, Khalid N, Khan M, Khatab K, Khater MM, Khatib MN, Khayamzadeh M, Khodayari MT, Khundkar R, Kianipour N, Kieling C, Kim D, Kim YE, Kim YJ, Kimokoti RW, Kisa A, Kisa S, Kissimova-Skarbek K, Kivimäki M, Kneib CJ, Knudsen AKS, Kocarnik JM, Kolola T, Kopec JA, Kosen S, Koul PA, Koyanagi A, Kravchenko MA, Krishan K, Krohn KJ, Kuate Defo B, Kucuk Bicer B, Kumar GA, Kumar M, Kumar P, Kumar V, Kumaresh G, Kurmi OP, Kusuma D, Kyu HH, La Vecchia C, Lacey B, Lal DK, Lalloo R, Lam JO, Lami FH, Landires I, Lang JJ, Lansingh VC, Larson SL, Larsson AO, Lasrado S, Lassi ZS, Lau KMM, Lavados PM, Lazarus JV, Ledesma JR, Lee PH, Lee SWH, LeGrand KE, Leigh J, Leonardi M, Lescinsky H, Leung J, Levi M, Lewington S, Li S, Lim LL, Lin C, Lin RT, Linehan C, Linn S, Liu HC, Liu S, Liu Z, Looker KJ, Lopez AD, Lopukhov PD, Lorkowski S, Lotufo PA, Lucas TCD, Lugo A, Lunevicius R, Lyons RA, Ma J, MacLachlan JH, Maddison ER, Maddison R, Madotto F, Mahasha PW, Mai HT, Majeed A, Maled V, Maleki S, Malekzadeh R, Malta DC, Mamun AA, Manafi A, Manafi N, Manguerra H, Mansouri B, Mansournia MA, Mantilla Herrera AM, Maravilla JC, Marks A, Martins-Melo FR, Martopullo I, Masoumi SZ, Massano J, Massenburg BB, Mathur MR, Maulik PK, McAlinden C, McGrath JJ, McKee M, Mehndiratta MM, Mehri F, Mehta KM, Meitei WB, Memiah PTN, Mendoza W, Menezes RG, Mengesha EW, Mengesha MB, Mereke A, Meretoja A, Meretoja TJ, Mestrovic T, Miazgowski B, Miazgowski T, Michalek IM, Mihretie KM, Miller TR, Mills EJ, Mirica A, Mirrakhimov EM, Mirzaei H, Mirzaei M, Mirzaei-Alavijeh M, Misganaw AT, Mithra P, Moazen B, Moghadaszadeh M, Mohamadi E, Mohammad DK, Mohammad Y, Mohammad Gholi Mezerji N, Mohammadian-Hafshejani A, Mohammadifard N, Mohammadpourhodki R, Mohammed S, Mokdad AH, Molokhia M, Momen NC, Monasta L, Mondello S, Mooney MD, Moosazadeh M, Moradi G, Moradi M, Moradi-Lakeh M, Moradzadeh R, Moraga P, Morales L, Morawska L, Moreno Velásquez I, Morgado-da-Costa J, Morrison SD, Mosser JF, Mouodi S, Mousavi SM, Mousavi Khaneghah A, Mueller UO, Munro SB, Muriithi MK, Musa KI, Muthupandian S, Naderi M, Nagarajan AJ, Nagel G, Naghshtabrizi B, Nair S, Nandi AK, Nangia V, Nansseu JR, Nayak VC, Nazari J, Negoi I, Negoi RI, Netsere HBN, 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Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396:1204-1222. [PMID: 33069326 PMCID: PMC7567026 DOI: 10.1016/s0140-6736(20)30925-9] [Citation(s) in RCA: 6299] [Impact Index Per Article: 1574.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/27/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. METHODS GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. FINDINGS Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. INTERPRETATION As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. FUNDING Bill & Melinda Gates Foundation.
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Prada SI, Prakash V, Pribadi DRA, Pupillo E, Quazi Syed Z, Rabiee M, Rabiee N, Radfar A, Rafiee A, Raggi A, Rahman MA, Rajabpour-Sanati A, Rajati F, Rakovac I, Ram P, Ramezanzadeh K, Ranabhat CL, Rao PC, Rao SJ, Rashedi V, Rathi P, Rawaf DL, Rawaf S, Rawal L, Rawassizadeh R, Rawat R, Razo C, Redford SB, Reiner RC, Reitsma MB, Remuzzi G, Renjith V, Renzaho AMN, Resnikoff S, Rezaei N, Rezaei N, Rezapour A, Rhinehart PA, Riahi SM, Ribeiro DC, Ribeiro D, Rickard J, Rivera JA, Roberts NLS, Rodríguez-Ramírez S, Roever L, Ronfani L, Room R, Roshandel G, Roth GA, Rothenbacher D, Rubagotti E, Rwegerera GM, Sabour S, Sachdev PS, Saddik B, Sadeghi E, Sadeghi M, Saeedi R, Saeedi Moghaddam S, Safari Y, Safi S, Safiri S, Sagar R, Sahebkar A, Sajadi SM, Salam N, Salamati P, Salem H, Salem MRR, Salimzadeh H, Salman OM, Salomon JA, Samad Z, Samadi Kafil H, Sambala EZ, Samy AM, Sanabria J, Sánchez-Pimienta TG, Santomauro DF, Santos IS, Santos JV, Santric-Milicevic MM, Saraswathy SYI, Sarmiento-Suárez R, Sarrafzadegan N, Sartorius B, Sarveazad A, Sathian B, Sathish T, Sattin D, Saxena S, Schaeffer LE, Schiavolin S, Schlaich MP, Schmidt MI, Schutte AE, Schwebel DC, Schwendicke F, Senbeta AM, Senthilkumaran S, Sepanlou SG, Serdar B, Serre ML, Shadid J, Shafaat O, Shahabi S, Shaheen AA, Shaikh MA, Shalash AS, Shams-Beyranvand M, Shamsizadeh M, Sharafi K, Sheikh A, Sheikhtaheri A, Shibuya K, Shield KD, Shigematsu M, Shin JI, Shin MJ, Shiri R, Shirkoohi R, Shuval K, Siabani S, Sierpinski R, Sigfusdottir ID, Sigurvinsdottir R, Silva JP, Simpson KE, Singh JA, Singh P, Skiadaresi E, Skou ST, Skryabin VY, Smith EUR, Soheili A, Soltani S, Soofi M, Sorensen RJD, Soriano JB, Sorrie MB, Soshnikov S, Soyiri IN, Spencer CN, Spotin A, Sreeramareddy CT, Srinivasan V, Stanaway JD, Stein C, Stein DJ, Steiner C, Stockfelt L, Stokes MA, Straif K, Stubbs JL, Sufiyan MB, Suleria HAR, Suliankatchi Abdulkader R, Sulo G, Sultan I, Szumowski Ł, Tabarés-Seisdedos R, Tabb KM, Tabuchi T, Taherkhani A, Tajdini M, Takahashi K, Takala JS, Tamiru AT, Taveira N, Tehrani-Banihashemi A, Temsah MH, Tesema GA, Tessema ZT, Thurston GD, Titova MV, Tohidinik HR, Tonelli M, Topor-Madry R, Topouzis F, Torre AE, Touvier M, Tovani-Palone MRR, Tran BX, Travillian R, Tsatsakis A, Tudor Car L, Tyrovolas S, Uddin R, Umeokonkwo CD, Unnikrishnan B, Upadhyay E, Vacante M, Valdez PR, van Donkelaar A, Vasankari TJ, Vasseghian Y, Veisani Y, Venketasubramanian N, Violante FS, Vlassov V, Vollset SE, Vos T, Vukovic R, Waheed Y, Wallin MT, Wang Y, Wang YP, Watson A, Wei J, Wei MYW, Weintraub RG, Weiss J, Werdecker A, West JJ, Westerman R, Whisnant JL, Whiteford HA, Wiens KE, Wolfe CDA, Wozniak SS, Wu AM, Wu J, Wulf Hanson S, Xu G, Xu R, Yadgir S, Yahyazadeh Jabbari SH, Yamagishi K, Yaminfirooz M, Yano Y, Yaya S, Yazdi-Feyzabadi V, Yeheyis TY, Yilgwan CS, Yilma MT, Yip P, Yonemoto N, Younis MZ, Younker TP, Yousefi B, Yousefi Z, Yousefinezhadi T, Yousuf AY, Yu C, Yusefzadeh H, Zahirian Moghadam T, Zamani M, Zamanian M, Zandian H, Zastrozhin MS, Zhang Y, Zhang ZJ, Zhao JT, Zhao XJG, Zhao Y, Zhou M, Ziapour A, Zimsen SRM, Brauer M, Afshin A, Lim SS. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396:1223-1249. [PMID: 33069327 PMCID: PMC7566194 DOI: 10.1016/s0140-6736(20)30752-2] [Citation(s) in RCA: 3234] [Impact Index Per Article: 808.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. METHODS GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. FINDINGS The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51-12·1) deaths (19·2% [16·9-21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12-9·31) deaths (15·4% [14·6-16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11·6% [10·3-13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older. INTERPRETATION Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. FUNDING Bill & Melinda Gates Foundation.
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Wang H, Abbas KM, Abbasifard M, Abbasi-Kangevari M, Abbastabar H, Abd-Allah F, Abdelalim A, Abolhassani H, Abreu LG, Abrigo MRM, Abushouk AI, Adabi M, Adair T, Adebayo OM, Adedeji IA, Adekanmbi V, Adeoye AM, Adetokunboh OO, Advani SM, Afshin A, Aghaali M, Agrawal A, Ahmadi K, Ahmadieh H, Ahmed MB, Al-Aly Z, Alam K, Alam T, Alanezi FM, Alanzi TM, Alcalde-Rabanal JE, Ali M, Alicandro G, Alijanzadeh M, Alinia C, Alipour V, Alizade H, Aljunid SM, Allebeck P, Almadi MAH, Almasi-Hashiani A, Al-Mekhlafi HM, Altirkawi KA, Alumran AK, Alvis-Guzman N, Amini-Rarani M, Aminorroaya A, Amit AML, Ancuceanu R, Andrei CL, Androudi S, Angus C, Anjomshoa M, Ansari F, Ansari I, Ansari-Moghaddam A, Antonio CAT, Antony CM, Anvari D, Appiah SCY, Arabloo J, Arab-Zozani M, Aravkin AY, Aremu O, Ärnlöv J, Aryal KK, Asadi-Pooya AA, Asgari S, Asghari Jafarabadi M, Atteraya MS, Ausloos M, Avila-Burgos L, Avokpaho EFGA, Ayala Quintanilla BP, Ayano G, Ayanore MA, Azarian G, Babaee E, Badiye AD, Bagli E, Bahrami MA, Bakhtiari A, Balassyano S, Banach M, Banik PC, Barker-Collo SL, Bärnighausen TW, Barzegar A, Basu S, Baune BT, Bayati M, Bazmandegan G, Bedi N, Bell ML, Bennett DA, Bensenor IM, Berhe K, Berman AE, Bertolacci GJ, Bhageerathy R, Bhala N, Bhattacharyya K, Bhutta ZA, Bijani A, Biondi A, Bisanzio D, Bisignano C, Biswas RK, Bjørge T, Bohlouli S, Bohluli M, Bolla SRR, Borzì AM, Borzouei S, Brady OJ, Braithwaite D, Brauer M, Briko AN, Briko NI, Bumgarner BR, Burugina Nagaraja S, Butt ZA, Caetano dos Santos FL, Cai T, Callender CSKH, Cámera LLAA, Campos-Nonato IR, Cárdenas R, Carreras G, Carrero JJ, Carvalho F, Castaldelli-Maia JM, Castelpietra G, Castro F, Catalá-López F, Cederroth CR, Cerin E, Chattu VK, Chin KL, Chu DT, Ciobanu LG, Cirillo M, Comfort H, Costa VM, Cowden RG, Cromwell EA, Croneberger AJ, Cunningham M, Dahlawi SMA, Damiani G, D'Amico E, Dandona L, Dandona R, Dargan PI, Darwesh AM, Daryani A, Das Gupta R, das Neves J, Davletov K, De Leo D, Denova-Gutiérrez E, Deribe K, Dervenis N, Desai R, Dhungana GP, Dias da Silva D, Diaz D, Dippenaar IN, Djalalinia S, Do HT, Dokova K, Doku DT, Dorostkar F, Doshi CP, Doshmangir L, Doyle KE, Dubljanin E, Duraes AR, Edvardsson D, Effiong A, El Sayed I, El Tantawi M, Elbarazi I, El-Jaafary SI, Emamian MH, Eskandarieh S, Esmaeilzadeh F, Estep K, Farahmand M, Faraj A, Fareed M, Faridnia R, Faro A, Farzadfar F, Fattahi N, Fazaeli AA, Fazlzadeh M, Feigin VL, Fereshtehnejad SM, Fernandes E, Ferreira ML, Filip I, Fischer F, Flohr C, Foigt NA, Folayan MO, Fomenkov AA, Freitas M, Fukumoto T, Fuller JE, Furtado JM, Gad MM, Gakidou E, Gallus S, Gebrehiwot AM, Gebremedhin KB, Gething PW, Ghamari F, Ghashghaee A, Gholamian A, Gilani SA, Gitimoghaddam M, Glushkova EV, Gnedovskaya EV, Gopalani SV, Goulart AC, Gugnani HC, Guo Y, Gupta R, Gupta SS, Haagsma JA, Haj-Mirzaian A, Haj-Mirzaian A, Halvaei I, Hamadeh RR, Hamagharib Abdullah K, Han C, Handiso DW, Hankey GJ, Haririan H, Haro JM, Hasaballah AI, Hassanipour S, Hassankhani H, Hay SI, Heibati B, Heidari-Soureshjani R, Henny K, Henry NJ, Herteliu C, Heydarpour F, Hole MK, Hoogar P, Hosgood HD, Hossain N, Hosseinzadeh M, Hostiuc M, Hostiuc S, Househ M, Hoy DG, Hu G, Huda TM, Ibitoye SE, Ikuta KS, Ilesanmi OS, Ilic IM, Ilic MD, Imani-Nasab MH, Islam M, Iso H, Iwu CJ, Jaafari J, Jacobsen KH, Jahagirdar D, Jahanmehr N, Jalali A, Jalilian F, James SL, Janjani H, Jenabi E, Jha RP, Jha V, Ji JS, Jonas JB, Joukar F, Jozwiak JJ, Jürisson M, Kabir Z, Kalani H, Kalankesh LR, Kamiab Z, Kanchan T, Kapoor N, Karch A, Karimi SE, Karimi SA, Kassebaum NJ, Katikireddi SV, Kawakami N, Kayode GA, Keiyoro PN, Keller C, Khader YS, Khalid N, Khan EA, Khan M, Khang YH, Khater AM, Khater MM, Khazaei S, Khazaie H, Khodayari MT, Khubchandani J, Kianipour N, Kim CI, Kim YE, Kim YJ, Kinfu Y, Kisa A, Kisa S, Kissimova-Skarbek K, Kivimäki M, Komaki H, Kopec JA, Kosen S, Koul PA, Koyanagi A, Kravchenko MA, Krishan K, Krohn KJ, Kuate Defo B, Kumar GA, Kumar M, Kumar P, Kumar V, Kusuma D, Kyu HH, La Vecchia C, Lacey B, Lal DK, Lalloo R, Lami FH, Lansky S, Larson SL, Larsson AO, Lasrado S, Lassi ZS, Lazarus JV, Lee PH, Lee SWH, Leever AT, LeGrand KE, Leonardi M, Li S, Lim LL, Lim SS, Linn S, Lodha R, Logroscino G, Lopez AD, Lopukhov PD, Lotufo PA, Lozano R, Lu A, Lunevicius R, Madadin M, Maddison ER, Magdy Abd El Razek H, Magdy Abd El Razek M, Mahasha PW, Mahdavi MM, Malekzadeh R, Mamun AA, Manafi N, Mansour-Ghanaei F, Mansouri B, Mansournia MA, Mapoma CC, Martini S, Martins-Melo FR, Masaka A, Mastrogiacomo CI, Mathur MR, May EA, McAlinden C, McGrath JJ, McKee M, Mehndiratta MM, Mehri F, Mehta KM, Meitei WB, Memiah PTN, Mendoza W, Menezes RG, Mengesha EW, Mensah GA, Meretoja A, Meretoja TJ, Mestrovic T, Michalek IM, Mihretie KM, Miller TR, Mills EJ, Milne GJ, Mirrakhimov EM, Mirzaei H, Mirzaei M, Mirzaei-Alavijeh M, Misganaw AT, Moazen B, Moghadaszadeh M, Mohamadi E, Mohammad DK, Mohammad Y, Mohammad Gholi Mezerji N, Mohammadbeigi A, Mohammadian-Hafshejani A, Mohammadpourhodki R, Mohammed H, Mohammed S, Mohebi F, Mohseni Bandpei MA, Mokari A, Mokdad AH, Momen NC, Monasta L, Mooney MD, Moradi G, Moradi M, Moradi-Joo M, Moradi-Lakeh M, Moradzadeh R, Moraga P, Moreno Velásquez I, Morgado-da-Costa J, Morrison SD, Mosser JF, Mouodi S, Mousavi SM, Mousavi Khaneghah A, Mueller UO, Musa KI, Muthupandian S, Nabavizadeh B, Naderi M, Nagarajan AJ, Naghavi M, Naghshtabrizi B, Naik G, Najafi F, Nangia V, Nansseu JR, Ndwandwe DE, Negoi I, Negoi RI, Ngunjiri JW, Nguyen HLT, Nguyen TH, Nigatu YT, Nikbakhsh R, Nikpoor AR, Nixon MR, Nnaji CA, Nomura S, Noubiap JJ, Nouraei Motlagh S, Nowak C, Oţoiu A, Odell CM, Oh IH, Oladnabi M, Olagunju AT, Olusanya BO, Olusanya JO, Omar Bali A, Ong KL, Onwujekwe OE, Ortiz A, Otstavnov N, Otstavnov SS, Øverland S, Owolabi MO, P A M, Padubidri JR, Pakshir K, Palladino R, Pana A, Panda-Jonas S, Park J, Pasupula DK, Patel JR, Patel SK, Patton GC, Paulson KR, Pazoki Toroudi H, Pease SA, Peden AE, Pepito VCF, Peprah EK, Pereira A, Pereira DM, Perico N, Pigott DM, Pilgrim T, Pilz TM, Piradov MA, Pirsaheb M, Pokhrel KN, Postma MJ, Pourjafar H, Pourmalek F, Pourshams A, Poznańska A, Prada SI, Prakash S, Preotescu L, Quazi Syed Z, Rabiee M, Rabiee N, Radfar A, Rafiei A, Raggi A, Rahman MA, Rajabpour-Sanati A, Ram P, Ranabhat CL, Rao SJ, Rasella D, Rashedi V, Rastogi P, Rathi P, Rawal L, Remuzzi G, Renjith V, Renzaho AMN, Resnikoff S, Rezaei N, Rezai MS, Rezapour A, Rickard J, Roever L, Ronfani L, Roshandel G, Rostamian M, Rubagotti E, Rwegerera GM, Sabour S, Saddik B, Sadeghi E, Sadeghi M, Saeedi Moghaddam S, Safari Y, Safi S, Safiri S, Sagar R, Sahebkar A, Sahraian MA, Sajadi SM, Salahshoor MR, Salama JS, Salamati P, Salem MRR, Salimi Y, Salomon JA, Salz I, Samad Z, Samy AM, Sanabria J, Santric-Milicevic MM, Saraswathy SYI, Sartorius B, Sarveazad A, Sathian B, Sathish T, Sattin D, Saylan M, Schaeffer LE, Schiavolin S, Schwebel DC, Schwendicke F, Sekerija M, Senbeta AM, Senthilkumaran S, Sepanlou SG, Serván-Mori E, Shabani M, Shahabi S, Shahbaz M, Shaheen AA, Shaikh MA, Shalash AS, Shams-Beyranvand M, Shamsi M, Shamsizadeh M, Shannawaz M, Sharafi K, Sharafi Z, Sharara F, Sharma R, Shaw DH, Sheikh A, Shin JI, Shiri R, Shrime MG, Shuval K, Siabani S, Sigfusdottir ID, Sigurvinsdottir R, Silva DAS, Simonetti B, Simpson KE, Singh JA, Skiadaresi E, Skryabin VY, Soheili A, Sokhan A, Sorensen RJD, Soriano JB, Sorrie MB, Soyiri IN, Spurlock EE, Sreeramareddy CT, Stockfelt L, Stokes MA, Stubbs JL, Sudaryanto A, Sufiyan MB, Suliankatchi Abdulkader R, Sykes BL, Tabarés-Seisdedos R, Tabb KM, Tadakamadla SK, Taherkhani A, Tang M, Taveira N, Taylor HJ, Teagle WL, Tehrani-Banihashemi A, Teklehaimanot BF, Tessema ZT, Thankappan KR, Thomas N, Thrift AG, Titova MV, Tohidinik HR, Tonelli M, Topor-Madry R, Topouzis F, Tovani-Palone MRR, Traini E, Tran BX, Travillian R, Trias-Llimós S, Truelsen TC, Tudor Car L, Unnikrishnan B, Upadhyay E, Vacante M, Vakilian A, Valdez PR, Valli A, Vardavas C, Vasankari TJ, Vasconcelos AMN, Vasseghian Y, Veisani Y, Venketasubramanian N, Vidale S, Violante FS, Vlassov V, Vollset SE, Vos T, Vujcic IS, Vukovic A, Vukovic R, Waheed Y, Wallin MT, Walters MK, Wang H, Wang YP, Watson S, Wei J, Weiss J, Weldesamuel GT, Werdecker A, Westerman R, Whiteford HA, Wiangkham T, Wiens KE, Wijeratne T, Wiysonge CS, Wojtyniak B, Wolfe CDA, Wondmieneh AB, Wool EE, Wu AM, Wu J, Xu G, Yamada T, Yamagishi K, Yano Y, Yaya S, Yazdi-Feyzabadi V, Yearwood JA, Yeheyis TY, Yilgwan CS, Yip P, Yonemoto N, Yoon SJ, Yoosefi Lebni J, York HW, Younis MZ, Younker TP, Yousefi Z, Yousefinezhadi T, Yousuf AY, Yusefzadeh H, Zahirian Moghadam T, Zakzuk J, Zaman SB, Zamani M, Zamanian M, Zandian H, Zhang ZJ, Zheng P, Zhou M, Ziapour A, Murray CJL. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396:1160-1203. [PMID: 33069325 PMCID: PMC7566045 DOI: 10.1016/s0140-6736(20)30977-6] [Citation(s) in RCA: 701] [Impact Index Per Article: 175.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/10/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. METHODS 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10-14 and 50-54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. FINDINGS The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66-2·79) in 2000 to 2·31 (2·17-2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5-137·8) in 2000 to a peak of 139·6 million (133·0-146·9) in 2016. Global livebirths then declined to 135·3 million (127·2-144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4-27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8-67·6) in 2000 to 73·5 years (72·8-74·3) in 2019. The total number of deaths increased from 50·7 million (49·5-51·9) in 2000 to 56·5 million (53·7-59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1-10·3) in 2000 to 5·0 million (4·3-6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0-6·3) in 2000 to 7·7 billion (7·5-8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1-60·8) in 2000 to 63·5 years (60·8-66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. INTERPRETATION Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. FUNDING Bill & Melinda Gates Foundation.
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Deshpande A, Miller-Petrie MK, Lindstedt PA, Baumann MM, Johnson KB, Blacker BF, Abbastabar H, Abd-Allah F, Abdelalim A, Abdollahpour I, Abegaz KH, Abejie AN, Abreu LG, Abrigo MR, Abualhasan A, Accrombessi MMK, Adamu AA, Adebayo OM, Adedeji IA, Adedoyin RA, Adekanmbi V, Adetokunboh OO, Adhikari TB, Afarideh M, Agudelo-Botero M, Ahmadi M, Ahmadi K, Ahmed MB, Ahmed AE, Akalu TY, Akanda AS, Alahdab F, Al-Aly Z, Alam S, Alam N, Alamene GM, Alanzi TM, Albright J, Albujeer A, Alcalde-Rabanal JE, Alebel A, Alemu ZA, Ali M, Alijanzadeh M, Alipour V, Aljunid SM, Almasi A, Almasi-Hashiani A, Al-Mekhlafi HM, Altirkawi KA, Alvis-Guzman N, Alvis-Zakzuk NJ, Amini S, Amit AML, Amul GGH, Andrei CL, Anjomshoa M, Ansariadi A, Antonio CAT, Antony B, Antriyandarti E, Arabloo J, Aref HMA, Aremu O, Armoon B, Arora A, Aryal KK, Arzani A, Asadi-Aliabadi M, Asmelash D, Atalay HT, Athari SM, Athari SS, Atre SR, Ausloos M, Awasthi S, Awoke N, Ayala Quintanilla BP, Ayano G, Ayanore MA, Aynalem YA, Azari S, Azman AS, Babaee E, Badawi A, Bagherzadeh M, Bakkannavar SM, Balakrishnan S, Banach M, Banoub JAM, Barac A, Barboza MA, Bärnighausen TW, Basu S, Bay VD, Bayati M, Bedi N, Beheshti M, Behzadifar M, Behzadifar M, Bejarano Ramirez DF, Bell ML, Bennett DA, Benzian H, Berbada DA, Bernstein RS, Bhat AG, Bhattacharyya K, Bhaumik S, Bhutta ZA, Bijani A, Bikbov B, Bin Sayeed MS, Biswas RK, Bohlouli S, Boufous S, Brady OJ, Briko AN, Briko NI, Britton GB, Brown A, Burugina Nagaraja S, Butt ZA, Cámera LA, Campos-Nonato IR, Campuzano Rincon JC, Cano J, Car J, Cárdenas R, Carvalho F, Castañeda-Orjuela CA, Castro F, Cerin E, Chalise B, Chattu VK, Chin KL, Christopher DJ, Chu DT, Cormier NM, Costa VM, Cromwell EA, Dadi AFF, Dahiru T, Dahlawi SMA, Dandona R, Dandona L, Dang AK, Daoud F, Darwesh AM, Darwish AH, Daryani A, Das JK, Das Gupta R, Dash AP, Dávila-Cervantes CA, Davis Weaver N, De la Hoz FP, De Neve JW, Demissie DB, Demoz GT, Denova-Gutiérrez E, Deribe K, Desalew A, Dharmaratne SD, Dhillon P, Dhimal M, Dhungana GP, Diaz D, Dipeolu IO, Do HT, Dolecek C, Doyle KE, Dubljanin E, Duraes AR, Edinur HA, Effiong A, Eftekhari A, El Nahas N, El Sayed Zaki M, El Tantawi M, Elhabashy HR, El-Jaafary SI, El-Khatib Z, Elkout H, Elsharkawy A, Enany S, Endalew DA, Eshrati B, Eskandarieh S, Etemadi A, Ezekannagha O, Faraon EJA, Fareed M, Faro A, Farzadfar F, Fasil AF, Fazlzadeh M, Feigin VL, Fekadu W, Fentahun N, Fereshtehnejad SM, Fernandes E, Filip I, Fischer F, Flohr C, Foigt NA, Folayan MO, Foroutan M, Franklin RC, Frostad JJ, Fukumoto T, Gad MM, Garcia GM, Gatotoh AM, Gayesa RT, Gebremedhin KB, Geramo YCD, Gesesew HA, Gezae KE, Ghashghaee A, Ghazi Sherbaf F, Gill TK, Gill PS, Ginindza TG, Girmay A, Gizaw Z, Goodridge A, Gopalani SV, Goulart BNG, Goulart AC, Grada A, Green MS, Gubari MIM, Gugnani HC, Guido D, Guimarães RA, Guo Y, Gupta R, Gupta R, Ha GH, Haagsma JA, Hafezi-Nejad N, Haile DH, Haile MT, Hall BJ, Hamidi S, Handiso DW, Haririan H, Hariyani N, Hasaballah AI, Hasan MM, Hasanzadeh A, Hassen HY, Hayelom DH, Hegazy MI, Heibati B, Heidari B, Hendrie D, Henok A, Herteliu C, Heydarpour F, Hidru HDD, Hird TR, Hoang CL, Hollerich GI, Hoogar P, Hossain N, Hosseinzadeh M, Househ M, Hu G, Humayun A, Hussain SA, Hussen MAA, Ibitoye SE, Ilesanmi OS, Ilic MD, Imani-Nasab MH, Iqbal U, Irvani SSN, Islam SMS, Ivers RQ, Iwu CJ, Jahanmehr N, Jakovljevic M, Jalali A, Jayatilleke AU, Jenabi E, Jha RP, Jha V, Ji JS, Jonas JB, Jozwiak JJ, Kabir A, Kabir Z, Kanchan T, Karch A, Karki S, Kasaeian A, Kasahun GG, Kasaye HK, Kassa GG, Kassa GM, Kayode GA, Kebede MM, Keiyoro PN, Ketema DB, Khader YS, Khafaie MA, Khalid N, Khalilov R, Khan EA, Khan J, Khan MN, Khatab K, Khater MM, Khater AM, Khayamzadeh M, Khazaei M, Khosravi MH, Khubchandani J, Kiadaliri A, Kim YJ, Kimokoti RW, Kisa S, Kisa A, Kochhar S, Kolola T, Komaki H, Kosen S, Koul PA, Koyanagi A, Krishan K, Kuate Defo B, Kugbey N, Kumar P, Kumar GA, Kumar M, Kusuma D, La Vecchia C, Lacey B, Lal A, Lal DK, Lam H, Lami FH, Lansingh VC, Lasrado S, Lebedev G, Lee PH, LeGrand KE, Leili M, Lenjebo TL, Leshargie CT, Levine AJ, Lewycka S, Li S, Linn S, Liu S, Lopez JCF, Lopukhov PD, Magdy Abd El Razek M, Mahadeshwara Prasad D, Mahasha PW, Mahotra NB, Majeed A, Malekzadeh R, Malta DC, Mamun AA, Manafi N, Mansournia MA, Mapoma CC, Martinez G, Martini S, Martins-Melo FR, Mathur MR, Mayala BK, Mazidi M, McAlinden C, Meharie BG, Mehndiratta MM, Mehrabi Nasab E, Mehta KM, Mekonnen T, Mekonnen TC, Meles GG, Meles HG, Memiah PTN, Memish ZA, Mendoza W, Menezes RG, Mereta ST, Meretoja TJ, Mestrovic T, Metekiya WM, Metekiya WM, Miazgowski B, Miller TR, Mini GK, Mirrakhimov EM, Moazen B, Mohajer B, Mohammad Y, Mohammad DK, Mohammad Gholi Mezerji N, Mohammadibakhsh R, Mohammed S, Mohammed JA, Mohammed H, Mohebi F, Mokdad AH, Moodley Y, Moradi M, Moradi G, Moradi-Joo M, Moraga P, Morales L, Mosapour A, Mosser JF, Mouodi S, Mousavi SM, Mozaffor M, Munro SB, Muriithi MK, Murray CJL, Musa KI, Mustafa G, Muthupandian S, Naderi M, Nagarajan AJ, Naghavi M, Naik G, Nangia V, Nascimento BR, Nazari J, Ndwandwe DE, Negoi I, Netsere HB, Ngunjiri JW, Nguyen CT, Nguyen HLT, Nguyen QP, Nigatu SG, Ningrum DNA, Nnaji CA, Nojomi M, Norheim OF, Noubiap JJ, Oancea B, Ogbo FA, Oh IH, Olagunju AT, Olusanya JO, Olusanya BO, Onwujekwe OE, Ortega-Altamirano DV, Osarenotor O, Osei FB, Owolabi MO, P A M, Padubidri JR, Pakhale S, Pana A, Park EK, Patel SK, Pathak A, Patle A, Paulos K, Pepito VCF, Perico N, Pervaiz A, Pescarini JM, Pesudovs K, Pham HQ, Pigott DM, Pilgrim T, Pirsaheb M, Poljak M, Pollock I, Postma MJ, Pourmalek F, Pourshams A, Prada SI, Preotescu L, Quintana H, Rabiee N, Rabiee M, Radfar A, Rafiei A, Rahim F, Rahimi S, Rahimi-Movaghar V, Rahman MA, Rahman MHU, Rajati F, Ranabhat CL, Rao PC, Rasella D, Rath GK, Rawaf S, Rawal L, Rawasia WF, Remuzzi G, Renjith V, Renzaho AM, Resnikoff S, Riahi SM, Ribeiro AI, Rickard J, Roever L, Ronfani L, Rubagotti E, Rubino S, Saad AM, Sabour S, Sadeghi E, Saeedi Moghaddam S, Safari Y, Sagar R, Sahraian MA, Sajadi SM, Salahshoor MR, Salam N, Saleem A, Salem H, Salem MR, Salimi Y, Salimzadeh H, Samy AM, Sanabria J, Santos IS, Santric-Milicevic MM, Sao Jose BP, Saraswathy SYI, Sarrafzadegan N, Sartorius B, Sathian B, Sathish T, Satpathy M, Sawhney M, Sayyah M, Sbarra AN, Schaeffer LE, Schwebel DC, Senbeta AM, Senthilkumaran S, Sepanlou SG, Serván-Mori E, Shafieesabet A, Shaheen AA, Shahid I, Shaikh MA, Shalash AS, Shams-Beyranvand M, Shamsi M, Shamsizadeh M, Shannawaz M, Sharafi K, Sharma R, Sheikh A, Shetty BSK, Shiferaw WS, Shigematsu M, Shin JI, Shiri R, Shirkoohi R, Shivakumar KM, Si S, Siabani S, Siddiqi TJ, Silva DAS, Singh V, Singh NP, Singh BBS, Singh JA, Singh A, Sinha DN, Sisay MM, Skiadaresi E, Smith DL, Soares Filho AM, Sobhiyeh MR, Sokhan A, Soriano JB, Sorrie MB, Soyiri IN, Spurlock EE, Sreeramareddy CT, Sudaryanto A, Sufiyan MB, Suleria HAR, Sykes BL, Tabarés-Seisdedos R, Tabuchi T, Tadesse DB, Tarigan IU, Taye B, Tefera YM, Tehrani-Banihashemi A, Tekelemedhin SW, Tekle MG, Temsah MH, Tesfay BE, Tesfay FH, Tessema ZT, Thankappan KR, ThekkePurakkal AS, Thomas N, Thompson RL, Thomson AJ, Topor-Madry R, Tovani-Palone MR, Traini E, Tran BX, Tran KB, Ullah I, Unnikrishnan B, Usman MS, Uthman OA, Uzochukwu BSC, Valdez PR, Varughese S, Veisani Y, Violante FS, Vollmer S, W/hawariat FG, Waheed Y, Wallin MT, Wang YP, Wang Y, Wangdi K, Weiss DJ, Weldesamuel GT, Werkneh AA, Westerman R, Wiangkham T, Wiens KE, Wijeratne T, Wiysonge CS, Wolde HF, Wondafrash DZ, Wonde TE, Worku GT, Yadollahpour A, Yahyazadeh Jabbari SH, Yamada T, Yaseri M, Yatsuya H, Yeshaneh A, Yilma MT, Yip P, Yisma E, Yonemoto N, Younis MZ, Yousof HASA, Yu C, Yusefzadeh H, Zadey S, Zahirian Moghadam T, Zaidi Z, Zaman SB, Zamani M, Zandian H, Zar HJ, Zerfu TA, Zhang Y, Ziapour A, Zodpey S, Zuniga YMH, Hay SI, Reiner RC. Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17. Lancet Glob Health 2020; 8:e1162-e1185. [PMID: 32827479 PMCID: PMC7443708 DOI: 10.1016/s2214-109x(20)30278-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/01/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities. METHODS We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs. FINDINGS Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017. INTERPRETATION Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation. FUNDING Bill & Melinda Gates Foundation.
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Reiner RC, Wiens KE, Deshpande A, Baumann MM, Lindstedt PA, Blacker BF, Troeger CE, Earl L, Munro SB, Abate D, Abbastabar H, Abd-Allah F, Abdelalim A, Abdollahpour I, Abdulkader RS, Abebe G, Abegaz KH, Abreu LG, Abrigo MRM, Accrombessi MMK, Acharya D, Adabi M, Adebayo OM, Adedoyin RA, Adekanmbi V, Adetokunboh OO, Adhena BM, Afarideh M, Ahmadi K, Ahmadi M, Ahmed AE, Ahmed MB, Ahmed R, Ajumobi O, Akal CG, Akalu TY, Akanda AS, Alamene GM, Alanzi TM, Albright JR, Alcalde Rabanal JE, Alemnew BT, Alemu ZA, Ali BA, Ali M, Alijanzadeh M, Alipour V, Aljunid SM, Almasi A, Almasi-Hashiani A, Al-Mekhlafi HM, Altirkawi K, Alvis-Guzman N, Alvis-Zakzuk NJ, Amare AT, Amini S, Amit AML, Andrei CL, Anegago MT, Anjomshoa M, Ansari F, Antonio CAT, Antriyandarti E, Appiah SCY, Arabloo J, Aremu O, Armoon B, Aryal KK, Arzani A, Asadi-Lari M, Ashagre AF, Atalay HT, Atique S, Atre SR, Ausloos M, Avila-Burgos L, Awasthi A, Awoke N, Ayala Quintanilla BP, Ayano G, Ayanore MA, Ayele AA, Aynalem YAA, Azari S, Babaee E, Badawi A, Bakkannavar SM, Balakrishnan S, Bali AG, Banach M, Barac A, Bärnighausen TW, Basaleem H, Bassat Q, Bayati M, Bedi N, Behzadifar M, Behzadifar M, Bekele YA, Bell ML, Bennett DA, Berbada DA, Beyranvand T, Bhat AG, Bhattacharyya K, Bhattarai S, Bhaumik S, Bijani A, Bikbov B, Biswas RK, Bogale KA, Bohlouli S, Brady OJ, Bragazzi NL, Briko NI, Briko AN, Burugina Nagaraja S, Butt ZA, Campos-Nonato IR, Campuzano Rincon JC, Cárdenas R, Carvalho F, Castro F, Chansa C, Chatterjee P, Chattu VK, Chauhan BG, Chin KL, Christopher DJ, Chu DT, Claro RM, Cormier NM, Costa VM, Damiani G, Daoud F, Dandona L, Dandona R, Darwish AH, Daryani A, Das JK, Das Gupta R, Dasa TT, Davila CA, Davis Weaver N, Davitoiu DV, De Neve JW, Demeke FM, Demis AB, Demoz GT, Denova-Gutiérrez E, Deribe K, Desalew A, Dessie GA, Dharmaratne SD, Dhillon P, Dhimal M, Dhungana GP, Diaz D, Ding EL, Diro HD, Djalalinia S, Do HP, Doku DT, Dolecek C, Dubey M, Dubljanin E, Duko Adema B, Dunachie SJ, Durães AR, Duraisamy S, Effiong A, Eftekhari A, El Sayed I, El Sayed Zaki M, El Tantawi M, Elemineh DA, El-Jaafary SI, Elkout H, Elsharkawy A, Enany S, Endalamfaw A, Endalew DA, Eskandarieh S, Esteghamati A, Etemadi A, Farag TH, Faraon EJA, Fareed M, Faridnia R, Farioli A, Faro A, Farzam H, Fazaeli AA, Fazlzadeh M, Fentahun N, Fereshtehnejad SM, Fernandes E, Filip I, Fischer F, Foroutan M, Francis JM, Franklin RC, Frostad JJ, Fukumoto T, Gayesa RT, Gebremariam KT, Gebremedhin KBB, Gebremeskel GG, Gedefaw GA, Geramo YCD, Geta B, Gezae KE, Ghashghaee A, Ghassemi F, Gill PS, Ginawi IA, Goli S, Gomes NGM, Gopalani SV, Goulart BNG, Grada A, Gugnani HC, Guido D, Guimares RA, Guo Y, Gupta R, Gupta R, Hafezi-Nejad N, Haile MT, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hall BJ, Handiso DW, Haririan H, Hariyani N, Hasaballah AI, Hasan MM, Hasanzadeh A, Hassankhani H, Hassen HY, Hayelom DH, Heidari B, Henry NJ, Herteliu C, Heydarpour F, Hidru HDD, Hoang CL, Hoogar P, Hoseini-Ghahfarokhi M, Hossain N, Hosseini M, Hosseinzadeh M, Househ M, Hu G, Humayun A, Hussain SA, Ibitoye SE, Ilesanmi OS, Ilic MD, Inbaraj LR, Irvani SSN, Islam SMS, Iwu CJ, Jaca A, Jafari Balalami N, Jahanmehr N, Jakovljevic M, Jalali A, Jayatilleke AU, Jenabi E, Jha RP, Jha V, Ji JS, Jia P, Johnson KB, Jonas JB, Jozwiak JJ, Kabir A, Kabir Z, Kahsay A, Kalani H, Kanchan T, Karami Matin B, Karch A, Karki S, Kasaeian A, Kasahun GG, Kayode GA, Kazemi Karyani A, Keiyoro PN, Ketema DB, Khader YS, Khafaie MA, Khalid N, Khalil AT, Khalil I, Khalilov R, Khan MN, Khan EA, Khan G, Khan J, Khatab K, Khater A, Khater MM, Khatony A, Khayamzadeh M, Khazaei M, Khazaei S, Khodamoradi E, Khosravi MH, Khubchandani J, Kiadaliri AA, Kim YJ, Kimokoti RW, Kisa S, Kisa A, Kissoon N, Kondlahalli SKMKMM, Kosek MN, Koyanagi A, Kraemer MUG, Krishan K, Kugbey N, Kumar GA, Kumar M, Kumar P, Kusuma D, La Vecchia C, Lacey B, Lal A, Lal DK, Lami FH, Lansingh VC, Lasrado S, Lee PH, Leili M, Lenjebo TTLL, Levine AJ, Lewycka S, Li S, Linn S, Lodha R, Longbottom J, Lopukhov PD, Magdeldin S, Mahasha PW, Mahotra NB, Malta DC, Mamun AA, Manafi N, Manafi F, Manda AL, Mansournia MA, Mapoma CC, Marami D, Marczak LB, Martins-Melo FR, März W, Masaka A, Mathur MR, Maulik PK, Mayala BK, McAlinden C, Mehndiratta MM, Mehrotra R, Mehta KM, Meles GG, Melese A, Memish ZA, Mena AT, Menezes RG, Mengesha MM, Mengistu DT, Mengistu G, Meretoja TJ, Miazgowski B, Mihretie KMM, Miller-Petrie MK, Mills EJ, Mir SM, Mirabi P, Mirrakhimov EM, Mohamadi-Bolbanabad A, Mohammad KA, Mohammad Y, Mohammad DK, Mohammad Darwesh A, Mohammad Gholi Mezerji N, Mohammadifard N, Mohammed AS, Mohammed S, Mohammed JA, Mohebi F, Mokdad AH, Monasta L, Moodley Y, Moradi M, Moradi G, Moradi-Joo M, Moradi-Lakeh M, Moraga P, Mosapour A, Mouodi S, Mousavi SM, Mozaffor MMM, Muluneh AG, Muriithi MK, Murray CJL, Murthy GVS, Musa KI, Mustafa G, Muthupandian S, Naderi M, Nagarajan AJ, Naghavi M, Najafi F, Nangia V, Nazari J, Ndwandwe DE, Negoi I, Ngunjiri JW, Nguyen QP, Nguyen TH, Nguyen CT, Nigatu D, Ningrum DNA, Nnaji CA, Nojomi M, Noubiap JJ, Oh IH, Okpala O, Olagunju AT, Omar Bali A, Onwujekwe OE, Ortega-Altamirano DDV, Osarenotor O, Osei FB, Owolabi MO, P A M, Padubidri JR, Pana A, Pashaei T, Pati S, Patle A, Patton GC, Paulos K, Pepito VCF, Pereira A, Perico N, Pesudovs K, Pigott DM, Piroozi B, Platts-Mills JA, Poljak M, Postma MJ, Pourjafar H, Pourmalek F, Pourshams A, Poustchi H, Prada SI, Preotescu L, Quintana H, Rabiee N, Rabiee M, Radfar A, Rafiei A, Rahim F, Rahimi-Movaghar V, Rahman MA, Rajati F, Ramezanzadeh K, Rana SM, Ranabhat CL, Rasella D, Rawaf S, Rawaf DL, Rawal L, Remuzzi G, Renjith V, Renzaho AMN, Reta MA, Rezaei S, Ribeiro AI, Rickard J, Rios González CM, Rios-Blancas MJ, Roever L, Ronfani L, Roro EM, Rostami A, Rothenbacher D, Rubagotti E, Rubino S, Saad AM, Sabour S, Sadeghi E, Safari S, Safdarian M, Sagar R, Sahraian MA, Sajadi SM, Salahshoor MR, Salam N, Salehi F, Salehi Zahabi S, Salem MRR, Salem H, Salimi Y, Salimzadeh H, Sambala EZ, Samy AM, Sanabria J, Santos IS, Saraswathy SYI, Sarker AR, Sartorius B, Sathian B, Satpathy M, Sbarra AN, Schaeffer LE, Schwebel DC, Senbeta AM, Senthilkumaran S, Shabaninejad H, Shaheen AA, Shaikh MA, Shalash AS, Shallo SA, Shams-Beyranvand M, Shamsi M, Shamsizadeh M, Sharif M, Shey MS, Shibuya K, Shiferaw WSS, Shigematsu M, Shil A, Shin JI, Shiri R, Shirkoohi R, Si S, Siabani S, Singh JA, Singh NP, Sinha DN, Sisay MM, Skiadaresi E, Smith DL, Sobhiyeh MR, Sokhan A, Soofi M, Soriano JB, Sorrie MB, Soyiri IN, Sreeramareddy CT, Sudaryanto A, Sufiyan MB, Suleria HAR, Sykes BL, Tamirat KS, Tassew AA, Taveira N, Taye B, Tehrani-Banihashemi A, Temsah MH, Tesfay BE, Tesfay FH, Tessema ZT, Thankappan KR, Thirunavukkarasu S, Thomas N, Tlaye KG, Tlou B, Tovani-Palone MR, Traini E, Tran KB, Trihandini I, Ullah I, Unnikrishnan B, Valadan Tahbaz S, Valdez PR, Varughese S, Veisani Y, Violante FS, Vollmer S, Vos T, Wada FW, Waheed Y, Wang Y, Wang YP, Weldesamuel GT, Welgan CA, Westerman R, Wiangkham T, Wijeratne T, Wiysonge CSS, Wolde HF, Wondafrash DZ, Wonde TE, Wu AM, Xu G, Yadollahpour A, Yahyazadeh Jabbari SH, Yamada T, Yaseri M, Yenesew MA, Yeshaneh A, Yilma MT, Yimer EM, Yip P, Yirsaw BD, Yisma E, Yonemoto N, Younis MZ, Yousof HASA, Yu C, Yusefzadeh H, Zamani M, Zambrana-Torrelio C, Zandian H, Zeleke AJ, Zepro NB, Zewale TA, Zhang D, Zhang Y, Zhao XJ, Ziapour A, Zodpey S, Hay SI. Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395:1779-1801. [PMID: 32513411 PMCID: PMC7314599 DOI: 10.1016/s0140-6736(20)30114-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/24/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. METHODS We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. FINDINGS The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. INTERPRETATION By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health. FUNDING Bill & Melinda Gates Foundation.
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17
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Troeger CE, Khalil IA, Blacker BF, Biehl MH, Albertson SB, Zimsen SRM, Rao PC, Abate D, Ahmadi A, Ahmed MLCB, Akal CG, Alahdab F, Alam N, Alene KA, Alipour V, Aljunid SM, Al-Raddadi RM, Alvis-Guzman N, Amini S, Anber NH, Anjomshoa M, Antonio CAT, Arabloo J, Aremu O, Atalay HT, Atique S, Avokpaho EFGA, Awad S, Awasthi A, Badawi A, Balakrishnan K, Banoub JAM, Barac A, Bassat Q, Bedi N, Bennett DA, Bhattacharyya K, Bhutta ZA, Bijani A, Car J, Carvalho F, Castañeda-Orjuela CA, Christopher DJ, Dandona L, Dandona R, Daryani A, Demeke FM, Deshpande A, Djalalinia S, Dubey M, Dubljanin E, Duken EE, El Sayed Zaki M, Endries AY, Fernandes E, Fischer F, Fullman N, Gardner WM, Geta B, Ghadiri K, Gorini G, Goulart AC, Guo Y, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hamidi S, Hassen HY, Hoang CL, Hostiuc M, Hussain Z, Irvani SSN, James SL, Jha RP, Jonas JB, Karch A, Kasaeian A, Kassa TD, Kassebaum NJ, Kefale AT, Khader YS, Khan EA, Khan MN, Khang YH, Khoja AT, Kimokoti RW, Kisa A, Kisa S, Kissoon N, Kochhar S, Kosen S, Koyanagi A, Kuate Defo B, Kumar GA, Lal DK, Leshargie CT, Li S, Lodha R, Macarayan ERK, Majdan M, Mamun AA, Manguerra H, Melese A, Memish ZA, Mengistu DT, Meretoja TJ, Mestrovic T, Miazgowski B, Mirrakhimov EM, Moazen B, Mohammad KA, Mohammed S, Monasta L, Moore CE, Mosser JF, Mousavi SM, Murthy S, Mustafa G, Nazari J, Nguyen CT, Nguyen LH, Nisar MI, Nixon MR, Ogbo FA, Okoro A, Olagunju AT, Olagunju TO, P A M, Pakhale S, Postma MJ, Qorbani M, Quansah R, Rafiei A, Rahim F, Rahimi-Movaghar V, Rai RK, Rezai MS, Rezapour A, Rios-Blancas MJ, Ronfani L, Rosettie K, Rothenbacher D, Safari S, Saleem Z, Sambala EZ, Samy AM, Santric Milicevic MM, Sartorius B, Sawhney M, Seyedmousavi S, Shaikh MA, Sheikh A, Shigematsu M, Smith DL, Soriano JB, Sreeramareddy CT, Stanaway JD, Sufiyan MB, Teklu TGE, Temsah MH, Tessema B, Tran BX, Tran KB, Ullah I, Updike RL, Vasankari TJ, Veisani Y, Wada FW, Waheed Y, Weaver M, Wiens KE, Wiysonge CS, Yimer EM, Yonemoto N, Zaidi Z, Zar HJ, Zarghi A, Lim SS, Vos T, Mokdad AH, Murray CJL, Kyu HH, Hay SI, Reiner RC. Quantifying risks and interventions that have affected the burden of diarrhoea among children younger than 5 years: an analysis of the Global Burden of Disease Study 2017. Lancet Infect Dis 2020; 20:37-59. [PMID: 31678029 PMCID: PMC7340495 DOI: 10.1016/s1473-3099(19)30401-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/13/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017. METHODS This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years. FINDINGS Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162-593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1-87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1-74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2-15·5), childhood wasting (9·9% decrease, 9·6-10·2), and low use of oral rehydration solution (6·9% decrease, 4·8-8·4). INTERPRETATION Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors-particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution-appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness. FUNDING Bill & Melinda Gates Foundation.
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18
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Hulland EN, Wiens KE, Shirude S, Morgan JD, Bertozzi-Villa A, Farag TH, Fullman N, Kraemer MUG, Miller-Petrie MK, Gupta V, Reiner RC, Rabinowitz P, Wasserheit JN, Bell BP, Hay SI, Weiss DJ, Pigott DM. Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response. BMC Med 2019; 17:232. [PMID: 31888667 PMCID: PMC6937971 DOI: 10.1186/s12916-019-1459-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Repeated outbreaks of emerging pathogens underscore the need for preparedness plans to prevent, detect, and respond. As countries develop and improve National Action Plans for Health Security, addressing subnational variation in preparedness is increasingly important. One facet of preparedness and mitigating disease transmission is health facility accessibility, linking infected persons with health systems and vice versa. Where potential patients can access care, local facilities must ensure they can appropriately diagnose, treat, and contain disease spread to prevent secondary transmission; where patients cannot readily access facilities, alternate plans must be developed. Here, we use travel time to link facilities and populations at risk of viral hemorrhagic fevers (VHFs) and identify spatial variation in these respective preparedness demands. METHODS AND FINDINGS We used geospatial resources of travel friction, pathogen environmental suitability, and health facilities to determine facility accessibility of any at-risk location within a country. We considered in-country and cross-border movements of exposed populations and highlighted vulnerable populations where current facilities are inaccessible and new infrastructure would reduce travel times. We developed profiles for 43 African countries. Resulting maps demonstrate gaps in health facility accessibility and highlight facilities closest to areas at risk for VHF spillover. For instance, in the Central African Republic, we identified travel times of over 24 h to access a health facility. Some countries had more uniformly short travel times, such as Nigeria, although regional disparities exist. For some populations, including many in Botswana, access to areas at risk for VHF nationally was low but proximity to suitable spillover areas in bordering countries was high. Additional analyses provide insights for considering future resource allocation. We provide a contemporary use case for these analyses for the ongoing Ebola outbreak. CONCLUSIONS These maps demonstrate the use of geospatial analytics for subnational preparedness, identifying facilities close to at-risk populations for prioritizing readiness to detect, treat, and respond to cases and highlighting where gaps in health facility accessibility exist. We identified cross-border threats for VHF exposure and demonstrate an opportunity to improve preparedness activities through the use of precision public health methods and data-driven insights for resource allocation as part of a country's preparedness plans.
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Affiliation(s)
- E N Hulland
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - K E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - S Shirude
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - J D Morgan
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - A Bertozzi-Villa
- Malaria Atlas Project, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Oxford, UK
- Institute for Disease Modeling, Bellevue, WA, 98005, USA
| | - T H Farag
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - N Fullman
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - M U G Kraemer
- Department of Zoology, University of Oxford, Oxford, UK
| | - M K Miller-Petrie
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - V Gupta
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - R C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, 98121, USA
| | - P Rabinowitz
- Department of Global Health, University of Washington, Seattle, WA, 98195, USA
| | - J N Wasserheit
- Department of Global Health, University of Washington, Seattle, WA, 98195, USA
| | - B P Bell
- Department of Global Health, University of Washington, Seattle, WA, 98195, USA
| | - S I Hay
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, 98121, USA
| | - D J Weiss
- Malaria Atlas Project, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Oxford, UK
| | - D M Pigott
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, 98121, USA.
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19
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Reiner RC, Welgan CA, Casey DC, Troeger CE, Baumann MM, Nguyen QP, Swartz SJ, Blacker BF, Deshpande A, Mosser JF, Osgood-Zimmerman AE, Earl L, Marczak LB, Munro SB, Miller-Petrie MK, Rodgers Kemp G, Frostad J, Wiens KE, Lindstedt PA, Pigott DM, Dwyer-Lindgren L, Ross JM, Burstein R, Graetz N, Rao PC, Khalil IA, Davis Weaver N, Ray SE, Davis I, Farag T, Brady OJ, Kraemer MUG, Smith DL, Bhatt S, Weiss DJ, Gething PW, Kassebaum NJ, Mokdad AH, Murray CJL, Hay SI. Identifying residual hotspots and mapping lower respiratory infection morbidity and mortality in African children from 2000 to 2017. Nat Microbiol 2019; 4:2310-2318. [PMID: 31570869 PMCID: PMC6877470 DOI: 10.1038/s41564-019-0562-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/15/2019] [Indexed: 12/13/2022]
Abstract
Lower respiratory infections (LRIs) are the leading cause of death in children under the age of 5, despite the existence of vaccines against many of their aetiologies. Furthermore, more than half of these deaths occur in Africa. Geospatial models can provide highly detailed estimates of trends subnationally, at the level where implementation of health policies has the greatest impact. We used Bayesian geostatistical modelling to estimate LRI incidence, prevalence and mortality in children under 5 subnationally in Africa for 2000–2017, using surveys covering 1.46 million children and 9,215,000 cases of LRI. Our model reveals large within-country variation in both health burden and its change over time. While reductions in childhood morbidity and mortality due to LRI were estimated for almost every country, we expose a cluster of residual high risk across seven countries, which averages 5.5 LRI deaths per 1,000 children per year. The preventable nature of the vast majority of LRI deaths mandates focused health system efforts in specific locations with the highest burden. Geospatial modelling shows an overall decline in morbidity and mortality due to lower respiratory infections in Africa from 2000 to 2017, but also identifies subnational areas with residual high risk.
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Affiliation(s)
- Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. .,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Catherine A Welgan
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Daniel C Casey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Christopher E Troeger
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Mathew M Baumann
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - QuynhAnh P Nguyen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Scott J Swartz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Brigette F Blacker
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Laurie B Marczak
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Sandra B Munro
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly K Miller-Petrie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Grant Rodgers Kemp
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Michigan State University, East Lansing, MI, USA
| | - Joseph Frostad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Paulina A Lindstedt
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David M Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer M Ross
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nicholas Graetz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Puja C Rao
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Ibrahim A Khalil
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Nicole Davis Weaver
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Sarah E Ray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Ian Davis
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tamer Farag
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Oliver J Brady
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Moritz U G Kraemer
- Department of Zoology, University of Oxford, Oxford, UK.,Harvard Medical School, University of Harvard, Boston, MA, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. .,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
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20
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Bhattacharjee NV, Schaeffer LE, Marczak LB, Ross JM, Swartz SJ, Albright J, Gardner WM, Shields C, Sligar A, Schipp MF, Pickering BV, Henry NJ, Johnson KB, Louie C, Cork MA, Steuben KM, Lazzar-Atwood A, Lu D, Kinyoki DK, Osgood-Zimmerman A, Earl L, Mosser JF, Deshpande A, Burstein R, Woyczynski LP, Wilson KF, VanderHeide JD, Wiens KE, Reiner RC, Piwoz EG, Rawat R, Sartorius B, Davis Weaver N, Nixon MR, Smith DL, Kassebaum NJ, Gakidou E, Lim SS, Mokdad AH, Murray CJL, Dwyer-Lindgren L, Hay SI. Mapping exclusive breastfeeding in Africa between 2000 and 2017. Nat Med 2019; 25:1205-1212. [PMID: 31332393 PMCID: PMC6749549 DOI: 10.1038/s41591-019-0525-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/17/2019] [Indexed: 11/30/2022]
Abstract
Exclusive breastfeeding (EBF)—giving infants only breast-milk (and medications, oral rehydration salts and vitamins as needed) with no additional food or drink for their first six months of life—is one of the most effective strategies for preventing child mortality1–4. Despite these advantages, only 37% of infants under 6 months of age in Africa were exclusively breastfed in 20175, and the practice of EBF varies by population. Here, we present a fine-scale geospatial analysis of EBF prevalence and trends in 49 African countries from 2000–2017, providing policy-relevant administrative- and national-level estimates. Previous national-level analyses found that most countries will not meet the World Health Organization’s Global Nutrition Target of 50% EBF prevalence by 20256. Our analyses show that even fewer will achieve this ambition in all subnational areas. Our estimates provide the ability to visualize subnational EBF variability and identify populations in need of additional breastfeeding support. Exclusive breastfeeding in Africa is highly varied within and between countries, with many countries unlikely to reach World Health Organization 2025 targets without urgent action.
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Affiliation(s)
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Laurie B Marczak
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jennifer M Ross
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Scott J Swartz
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - James Albright
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - William M Gardner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Chloe Shields
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Megan F Schipp
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Brandon V Pickering
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kimberly B Johnson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Celia Louie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael A Cork
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Krista M Steuben
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Alice Lazzar-Atwood
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Dan Lu
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Lauren P Woyczynski
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Katherine F Wilson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - John D VanderHeide
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | | | - Rahul Rawat
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Benn Sartorius
- Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicole Davis Weaver
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. .,Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
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21
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Dwyer-Lindgren L, Cork MA, Sligar A, Steuben KM, Wilson KF, Provost NR, Mayala BK, VanderHeide JD, Collison ML, Hall JB, Biehl MH, Carter A, Frank T, Douwes-Schultz D, Burstein R, Casey DC, Deshpande A, Earl L, El Bcheraoui C, Farag TH, Henry NJ, Kinyoki D, Marczak LB, Nixon MR, Osgood-Zimmerman A, Pigott D, Reiner RC, Ross JM, Schaeffer LE, Smith DL, Davis Weaver N, Wiens KE, Eaton JW, Justman JE, Opio A, Sartorius B, Tanser F, Wabiri N, Piot P, Murray CJL, Hay SI. Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017. Nature 2019; 570:189-193. [PMID: 31092927 PMCID: PMC6601349 DOI: 10.1038/s41586-019-1200-9] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 04/10/2019] [Indexed: 12/16/2022]
Abstract
HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15–49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa. Fine-scale estimates of the prevalence of HIV in adults across sub-Saharan Africa reveal substantial within-country variation and local differences in both the direction and rate of change in the prevalence of HIV between 2000 and 2017.
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Affiliation(s)
- Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael A Cork
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Krista M Steuben
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kate F Wilson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Naomi R Provost
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - John D VanderHeide
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael L Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jason B Hall
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly H Biehl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Austin Carter
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tahvi Frank
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Dirk Douwes-Schultz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Daniel C Casey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Charbel El Bcheraoui
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tamer H Farag
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Damaris Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Laurie B Marczak
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - David Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jennifer M Ross
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nicole Davis Weaver
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jeffrey W Eaton
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jessica E Justman
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Alex Opio
- Medireal Investment Uganda, Entebbe, Uganda
| | - Benn Sartorius
- Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,Research Department of Infection & Population Health, University College London, London, UK
| | - Njeri Wabiri
- HIV/AIDS, STIs & TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
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22
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Kyu HH, Maddison ER, Henry NJ, Ledesma JR, Wiens KE, Reiner R, Biehl MH, Shields C, Osgood-Zimmerman A, Ross JM, Carter A, Frank TD, Wang H, Srinivasan V, Agarwal SK, Alahdab F, Alene KA, Ali BA, Alvis-Guzman N, Andrews JR, Antonio CAT, Atique S, Atre SR, Awasthi A, Ayele HT, Badali H, Badawi A, Barac A, Bedi N, Behzadifar M, Behzadifar M, Bekele BB, Belay SA, Bensenor IM, Butt ZA, Carvalho F, Cercy K, Christopher DJ, Daba AK, Dandona L, Dandona R, Daryani A, Demeke FM, Deribe K, Dharmaratne SD, Doku DT, Dubey M, Edessa D, El-Khatib Z, Enany S, Fernandes E, Fischer F, Garcia-Basteiro AL, Gebre AK, Gebregergs GB, Gebremichael TG, Gelano TF, Geremew D, Gona PN, Goodridge A, Gupta R, Haghparast Bidgoli H, Hailu GB, Hassen HY, Hedayati MTT, Henok A, Hostiuc S, Hussen MA, Ilesanmi OS, Irvani SSN, Jacobsen KH, Johnson SC, Jonas JB, Kahsay A, Kant S, Kasaeian A, Kassa TD, Khader YS, Khafaie MA, Khalil I, Khan EA, Khang YH, Kim YJ, Kochhar S, Koyanagi A, Krohn KJ, Kumar GA, Lakew AM, Leshargie CT, Lodha R, Macarayan ERK, Majdzadeh R, Martins-Melo FR, Melese A, Memish ZA, Mendoza W, Mengistu DT, Mengistu G, Mestrovic T, Moazen B, Mohammad KA, Mohammed S, Mokdad AH, Moosazadeh M, Mousavi SM, Mustafa G, Nachega JB, Nguyen LH, Nguyen SH, Nguyen TH, Ningrum DNA, Nirayo YL, Nong VM, Ofori-Asenso R, Ogbo FA, Oh IH, Oladimeji O, Olagunju AT, Oren E, Pereira DM, Prakash S, Qorbani M, Rafay A, Rai RK, Ram U, Rubino S, Safiri S, Salomon JA, Samy AM, Sartorius B, Satpathy M, Seyedmousavi S, Sharif M, Silva JP, Silveira DGA, Singh JA, Sreeramareddy CT, Tran BX, Tsadik AG, Ukwaja KN, Ullah I, Uthman OA, Vlassov V, Vollset SE, Vu G, Weldegebreal F, Werdecker A, Yimer EM, Yonemoto N, Yotebieng M, Naghavi M, Vos T, Hay SI, Murray CJL. Global, regional, and national burden of tuberculosis, 1990-2016: results from the Global Burden of Diseases, Injuries, and Risk Factors 2016 Study. Lancet Infect Dis 2018; 18:1329-1349. [PMID: 30507459 PMCID: PMC6250050 DOI: 10.1016/s1473-3099(18)30625-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although a preventable and treatable disease, tuberculosis causes more than a million deaths each year. As countries work towards achieving the Sustainable Development Goal (SDG) target to end the tuberculosis epidemic by 2030, robust assessments of the levels and trends of the burden of tuberculosis are crucial to inform policy and programme decision making. We assessed the levels and trends in the fatal and non-fatal burden of tuberculosis by drug resistance and HIV status for 195 countries and territories from 1990 to 2016. METHODS We analysed 15 943 site-years of vital registration data, 1710 site-years of verbal autopsy data, 764 site-years of sample-based vital registration data, and 361 site-years of mortality surveillance data to estimate mortality due to tuberculosis using the Cause of Death Ensemble model. We analysed all available data sources, including annual case notifications, prevalence surveys, population-based tuberculin surveys, and estimated tuberculosis cause-specific mortality to generate internally consistent estimates of incidence, prevalence, and mortality using DisMod-MR 2.1, a Bayesian meta-regression tool. We assessed how the burden of tuberculosis differed from the burden predicted by the Socio-demographic Index (SDI), a composite indicator of income per capita, average years of schooling, and total fertility rate. FINDINGS Globally in 2016, among HIV-negative individuals, the number of incident cases of tuberculosis was 9·02 million (95% uncertainty interval [UI] 8·05-10·16) and the number of tuberculosis deaths was 1·21 million (1·16-1·27). Among HIV-positive individuals, the number of incident cases was 1·40 million (1·01-1·89) and the number of tuberculosis deaths was 0·24 million (0·16-0·31). Globally, among HIV-negative individuals the age-standardised incidence of tuberculosis decreased annually at a slower rate (-1·3% [-1·5 to -1·2]) than mortality did (-4·5% [-5·0 to -4·1]) from 2006 to 2016. Among HIV-positive individuals during the same period, the rate of change in annualised age-standardised incidence was -4·0% (-4·5 to -3·7) and mortality was -8·9% (-9·5 to -8·4). Several regions had higher rates of age-standardised incidence and mortality than expected on the basis of their SDI levels in 2016. For drug-susceptible tuberculosis, the highest observed-to-expected ratios were in southern sub-Saharan Africa (13·7 for incidence and 14·9 for mortality), and the lowest ratios were in high-income North America (0·4 for incidence) and Oceania (0·3 for mortality). For multidrug-resistant tuberculosis, eastern Europe had the highest observed-to-expected ratios (67·3 for incidence and 73·0 for mortality), and high-income North America had the lowest ratios (0·4 for incidence and 0·5 for mortality). INTERPRETATION If current trends in tuberculosis incidence continue, few countries are likely to meet the SDG target to end the tuberculosis epidemic by 2030. Progress needs to be accelerated by improving the quality of and access to tuberculosis diagnosis and care, by developing new tools, scaling up interventions to prevent risk factors for tuberculosis, and integrating control programmes for tuberculosis and HIV. FUNDING Bill & Melinda Gates Foundation.
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23
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Wiens KE, Woyczynski LP, Ledesma JR, Ross JM, Zenteno-Cuevas R, Goodridge A, Ullah I, Mathema B, Djoba Siawaya JF, Biehl MH, Ray SE, Bhattacharjee NV, Henry NJ, Reiner RC, Kyu HH, Murray CJL, Hay SI. Global variation in bacterial strains that cause tuberculosis disease: a systematic review and meta-analysis. BMC Med 2018; 16:196. [PMID: 30373589 PMCID: PMC6206891 DOI: 10.1186/s12916-018-1180-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/24/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The host, microbial, and environmental factors that contribute to variation in tuberculosis (TB) disease are incompletely understood. Accumulating evidence suggests that one driver of geographic variation in TB disease is the local ecology of mycobacterial genotypes or strains, and there is a need for a comprehensive and systematic synthesis of these data. The objectives of this study were to (1) map the global distribution of genotypes that cause TB disease and (2) examine whether any epidemiologically relevant clinical characteristics were associated with those genotypes. METHODS We performed a systematic review of PubMed and Scopus to create a comprehensive dataset of human TB molecular epidemiology studies that used representative sampling techniques. The methods were developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We extracted and synthesized data from studies that reported prevalence of bacterial genotypes and from studies that reported clinical characteristics associated with those genotypes. RESULTS The results of this study are twofold. First, we identified 206 studies for inclusion in the study, representing over 200,000 bacterial isolates collected over 27 years in 85 countries. We mapped the genotypes and found that, consistent with previously published maps, Euro-American lineage 4 and East Asian lineage 2 strains are widespread, and West African lineages 5 and 6 strains are geographically restricted. Second, 30 studies also reported transmission chains and 4 reported treatment failure associated with genotypes. We performed a meta-analysis and found substantial heterogeneity across studies. However, based on the data available, we found that lineage 2 strains may be associated with increased risk of transmission chains, while lineages 5 and 6 strains may be associated with reduced risk, compared with lineage 4 strains. CONCLUSIONS This study provides the most comprehensive systematic analysis of the evidence for diversity in bacterial strains that cause TB disease. The results show both geographic and epidemiological differences between strains, which could inform our understanding of the global burden of TB. Our findings also highlight the challenges of collecting the clinical data required to inform TB diagnosis and treatment. We urge future national TB programs and research efforts to prioritize and reinforce clinical data collection in study designs and results dissemination.
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Affiliation(s)
- Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Lauren P Woyczynski
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Jorge R Ledesma
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Jennifer M Ross
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
- Departments of Global Health and Medicine, University of Washington, Seattle, WA, USA
| | | | - Amador Goodridge
- Tuberculosis Biomarker Research Unit, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT-AIP), City of Knowledge, Panama, Panama
| | - Irfan Ullah
- Gomal Centre of Biochemistry and Biotechnology, Gomal University, Dera Ismail Khan, Khyber Pakhtunkhwa, Pakistan
- Programmatic Management of Drug-Resistant TB Unit, BSL-II TB Culture Laboratory, Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Khyber Pakhtunkhwa, Pakistan
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Joel Fleury Djoba Siawaya
- Unité de Recherche et de Diagnostics Spécialisés, Laboratoire National de Santé Publique, Libreville, Gabon
- Centre Hospitalier Universitaire Mère-Enfant Fondation Jeanne EBORI, Libreville, Gabon
| | - Molly H Biehl
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Sarah E Ray
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Natalia V Bhattacharjee
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Hmwe H Kyu
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
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24
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Ross JM, Henry NJ, Dwyer-Lindgren LA, de Paula Lobo A, Marinho de Souza F, Biehl MH, Ray SE, Reiner RC, Stubbs RW, Wiens KE, Earl L, Kutz MJ, Bhattacharjee NV, Kyu HH, Naghavi M, Hay SI. Progress toward eliminating TB and HIV deaths in Brazil, 2001-2015: a spatial assessment. BMC Med 2018; 16:144. [PMID: 30185204 PMCID: PMC6125942 DOI: 10.1186/s12916-018-1131-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/17/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Brazil has high burdens of tuberculosis (TB) and HIV, as previously estimated for the 26 states and the Federal District, as well as high levels of inequality in social and health indicators. We improved the geographic detail of burden estimation by modelling deaths due to TB and HIV and TB case fatality ratios for the more than 5400 municipalities in Brazil. METHODS This ecological study used vital registration data from the national mortality information system and TB case notifications from the national communicable disease notification system from 2001 to 2015. Mortality due to TB and HIV was modelled separately by cause and sex using a Bayesian spatially explicit mixed effects regression model. TB incidence was modelled using the same approach. Results were calibrated to the Global Burden of Disease Study 2016. Case fatality ratios were calculated for TB. RESULTS There was substantial inequality in TB and HIV mortality rates within the nation and within states. National-level TB mortality in people without HIV infection declined by nearly 50% during 2001 to 2015, but HIV mortality declined by just over 20% for males and 10% for females. TB and HIV mortality rates for municipalities in the 90th percentile nationally were more than three times rates in the 10th percentile, with nearly 70% of the worst-performing municipalities for male TB mortality and more than 75% for female mortality in 2001 also in the worst decile in 2015. The same municipality ranking metric for HIV was observed to be between 55% and 61%. Within states, the TB mortality rate ratios by sex for municipalities in the worst decile versus the best decile varied from 1.4 to 2.9, and HIV varied from 1.4 to 4.2. The World Health Organization target case fatality rate for TB of less than 10% was achieved in 9.6% of municipalities for males versus 38.4% for females in 2001 and improved to 38.4% and 56.6% of municipalities for males versus females, respectively, by 2014. CONCLUSIONS Mortality rates in municipalities within the same state exhibited nearly as much relative variation as within the nation as a whole. Monitoring the mortality burden at this level of geographic detail is critical for guiding precision public health responses.
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Affiliation(s)
- Jennifer M Ross
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA.,Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Laura A Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Andrea de Paula Lobo
- Department of Public Health, University of Brasilia, Distrito Federal, Brazil.,Department of Health Surveillance, Ministry of Health, Brasilia, Brazil
| | | | - Molly H Biehl
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Sarah E Ray
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Rebecca W Stubbs
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Michael J Kutz
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Natalia V Bhattacharjee
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Hmwe H Kyu
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave Suite 600, Seattle, WA, 98121, USA.
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25
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Osgood-Zimmerman A, Millear AI, Stubbs RW, Shields C, Pickering BV, Earl L, Graetz N, Kinyoki DK, Ray SE, Bhatt S, Browne AJ, Burstein R, Cameron E, Casey DC, Deshpande A, Fullman N, Gething PW, Gibson HS, Henry NJ, Herrero M, Krause LK, Letourneau ID, Levine AJ, Liu PY, Longbottom J, Mayala BK, Mosser JF, Noor AM, Pigott DM, Piwoz EG, Rao P, Rawat R, Reiner RC, Smith DL, Weiss DJ, Wiens KE, Mokdad AH, Lim SS, Murray CJL, Kassebaum NJ, Hay SI. Mapping child growth failure in Africa between 2000 and 2015. Nature 2018; 555:41-47. [PMID: 29493591 PMCID: PMC6346257 DOI: 10.1038/nature25760] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/17/2018] [Indexed: 12/28/2022]
Abstract
Insufficient growth during childhood is associated with poor health outcomes and an increased risk of death. Between 2000 and 2015, nearly all African countries demonstrated improvements for children under 5 years old for stunting, wasting, and underweight, the core components of child growth failure. Here we show that striking subnational heterogeneity in levels and trends of child growth remains. If current rates of progress are sustained, many areas of Africa will meet the World Health Organization Global Targets 2025 to improve maternal, infant and young child nutrition, but high levels of growth failure will persist across the Sahel. At these rates, much, if not all of the continent will fail to meet the Sustainable Development Goal target—to end malnutrition by 2030. Geospatial estimates of child growth failure provide a baseline for measuring progress as well as a precision public health platform to target interventions to those populations with the greatest need, in order to reduce health disparities and accelerate progress. Geospatial estimates of child growth failure in Africa provide a baseline for measuring progress and a precision public health platform to target interventions to those populations with the greatest need.
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Affiliation(s)
- Aaron Osgood-Zimmerman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Anoushka I Millear
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Rebecca W Stubbs
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Chloe Shields
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Brandon V Pickering
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Nicholas Graetz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Sarah E Ray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Samir Bhatt
- Department of Infectious Disease Epidemiology, Imperial College London, London SW7 2AZ, UK
| | - Annie J Browne
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Ewan Cameron
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Daniel C Casey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Peter W Gething
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Harry S Gibson
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Mario Herrero
- Commonwealth Scientific and Industrial Research Organisation, St Lucia, Queensland 4067, Australia
| | | | - Ian D Letourneau
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Aubrey J Levine
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Patrick Y Liu
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Joshua Longbottom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Benjamin K Mayala
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Abdisalan M Noor
- Kenya Medical Research Institute-Wellcome Trust Collaborative Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7FZ, USA
| | - David M Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Ellen G Piwoz
- Bill & Melinda Gates Foundation, Seattle, Washington 98109, USA
| | - Puja Rao
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Rahul Rawat
- Bill & Melinda Gates Foundation, Seattle, Washington 98109, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Daniel J Weiss
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
| | - Kirsten E Wiens
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA
| | - Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA.,Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington 98105, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington 98121, USA.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford OX3 7FZ, UK
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Wiens KE, Ernst JD. Type I Interferon is Pathogenic During Chronic Mycobacterium africanum Infection. J Infect Dis 2016; 214:1893-1896. [PMID: 27803172 DOI: 10.1093/infdis/jiw519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/20/2016] [Indexed: 11/13/2022] Open
Abstract
Type I interferons (IFNs, including IFN-αβ) contribute to the pathogenesis of Mycobacterium tuberculosis strains that induce high IFN-αβ levels. In the current study we examined the role of IFN-αβ during infection with a Mycobacterium africanum strain that induces low IFN-β levels. We infected wild-type and IFN-αβ receptor knockout mice with M. africanum and monitored bacterial growth, lung disease, and survival over 292 days. We found reduced lung bacterial burdens and less severe histopathological findings in the absence of IFN-αβ signaling. We conclude that IFN-αβ is pathogenic during chronic M. africanum infection and that the pathogenic effects may be mediated through poorer control of bacterial growth.
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Affiliation(s)
- Kirsten E Wiens
- Department of Pathology.,Department of Medicine, Division of Infectious Disease
| | - Joel D Ernst
- Department of Pathology.,Department of Medicine, Division of Infectious Disease.,Department of Microbiology, New York University School of Medicine, New York
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Wiens KE, Ernst JD. The Mechanism for Type I Interferon Induction by Mycobacterium tuberculosis is Bacterial Strain-Dependent. PLoS Pathog 2016; 12:e1005809. [PMID: 27500737 PMCID: PMC4976988 DOI: 10.1371/journal.ppat.1005809] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 07/13/2016] [Indexed: 12/30/2022] Open
Abstract
Type I interferons (including IFNαβ) are innate cytokines that may contribute to pathogenesis during Mycobacterium tuberculosis (Mtb) infection. To induce IFNβ, Mtb must gain access to the host cytosol and trigger stimulator of interferon genes (STING) signaling. A recently proposed model suggests that Mtb triggers STING signaling through bacterial DNA binding cyclic GMP-AMP synthase (cGAS) in the cytosol. The aim of this study was to test the generalizability of this model using phylogenetically distinct strains of the Mtb complex (MTBC). We infected bone marrow derived macrophages with strains from MTBC Lineages 2, 4 and 6. We found that the Lineage 6 strain induced less IFNβ, and that the Lineage 2 strain induced more IFNβ, than the Lineage 4 strain. The strains did not differ in their access to the host cytosol and IFNβ induction by each strain required both STING and cGAS. We also found that the three strains shed similar amounts of bacterial DNA. Interestingly, we found that the Lineage 6 strain was associated with less mitochondrial stress and less mitochondrial DNA (mtDNA) in the cytosol compared with the Lineage 4 strain. Treating macrophages with a mitochondria-specific antioxidant reduced cytosolic mtDNA and inhibited IFNβ induction by the Lineage 2 and 4 strains. We also found that the Lineage 2 strain did not induce more mitochondrial stress than the Lineage 4 strain, suggesting that additional pathways contribute to higher IFNβ induction. These results indicate that the mechanism for IFNβ by Mtb is more complex than the established model suggests. We show that mitochondrial dynamics and mtDNA contribute to IFNβ induction by Mtb. Moreover, we show that the contribution of mtDNA to the IFNβ response varies by MTBC strain and that additional mechanisms exist for Mtb to induce IFNβ.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
- Division of Infectious Disease, Department of Medicine, New York University School of Medicine, New York, New York, United States of America
| | - Joel D. Ernst
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
- Division of Infectious Disease, Department of Medicine, New York University School of Medicine, New York, New York, United States of America
- Department of Microbiology, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
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Leung JM, Davenport M, Wolff MJ, Wiens KE, Abidi WM, Poles MA, Cho I, Ullman T, Mayer L, Loke P. IL-22-producing CD4+ cells are depleted in actively inflamed colitis tissue. Mucosal Immunol 2014; 7:124-33. [PMID: 23695510 PMCID: PMC3870042 DOI: 10.1038/mi.2013.31] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 04/12/2013] [Indexed: 02/04/2023]
Abstract
T helper type (Th17) cytokines such as interleukin (IL)-17A and IL-22 are important in maintaining mucosal barrier function and may be important in the pathogenesis of inflammatory bowel diseases (IBDs). Here, we analyzed cells from the colon of IBD patients and show that Crohn's disease (CD) patients had significantly elevated numbers of IL-17+, CD4+ cells compared with healthy controls and ulcerative colitis (UC) patients, but these numbers did not vary based on the inflammatory status of the mucosa. By contrast, UC patients had significantly reduced numbers of IL-22+ cells in actively inflamed tissues compared with both normal tissue and healthy controls. There was a selective increase in mono-IL-17-producing cells from the mucosa of UC patients with active inflammation together with increased expression of transforming growth factor (TGF)-β and c-Maf. Increasing concentrations of TGF-β in lamina propria mononuclear cell cultures significantly depleted Th22 cells, whereas anti-TGF-β antibodies increased IL-22 production. When mucosal microbiota was examined, depletion of Th22 cells in actively inflamed tissue was associated with reduced populations of Clostridiales and increased populations of Proteobacteria. These results suggest that increased TGF-β during active inflammation in UC may lead to the loss of Th22 cells in the human intestinal mucosa.
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Affiliation(s)
- JM Leung
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
| | - M Davenport
- Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - MJ Wolff
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - KE Wiens
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
| | - WM Abidi
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
| | - MA Poles
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - I Cho
- Department of Medicine, New York University School of Medicine, New York, New York, USA
- VA New York Harbor Healthcare System, New York, New York, USA
| | - T Ullman
- Department of Medicine, Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
| | - L Mayer
- Immunology Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - P Loke
- Division of Parasitology, Department of Microbiology, New York University School of Medicine, New York, New York, USA
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29
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Wiens KE, Swaminathan H, Copin R, Lun DS, Ernst JD. Equivalent T cell epitope promiscuity in ecologically diverse human pathogens. PLoS One 2013; 8:e73124. [PMID: 23951341 PMCID: PMC3739752 DOI: 10.1371/journal.pone.0073124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/15/2013] [Indexed: 11/18/2022] Open
Abstract
Background The HLA (human leukocyte antigen) molecules that present pathogen-derived epitopes to T cells are highly diverse. Correspondingly, many pathogens such as HIV evolve epitope variants in order to evade immune recognition. In contrast, another persistent human pathogen, Mycobacterium tuberculosis, has highly conserved epitope sequences. This raises the question whether there is also a difference in the ability of these pathogens’ epitopes to bind diverse HLA alleles, referred to as an epitope’s binding promiscuity. To address this question, we compared the in silico HLA binding promiscuity of T cell epitopes from pathogens with distinct infection strategies and outcomes of human exposure. Methods We used computer algorithms to predict the binding affinity of experimentally-verified microbial epitope peptides to diverse HLA-DR, HLA-A and HLA-B alleles. We then analyzed binding promiscuity of epitopes derived from HIV and M. tuberculosis. We also analyzed promiscuity of epitopes from Streptococcus pyogenes, which is known to exhibit epitope diversity, and epitopes of Bacillus anthracis and Clostridium tetani toxins, as these bacteria do not depend on human hosts for their survival or replication, and their toxin antigens are highly immunogenic human vaccines. Results We found that B. anthracis and C. tetani epitopes were the most promiscuous of the group that we analyzed. However, there was no consistent difference or trend in promiscuity in epitopes contained in HIV, M. tuberculosis, and S. pyogenes. Conclusions Our results show that human pathogens with distinct immune evasion strategies and epitope diversities exhibit equivalent levels of T cell epitope promiscuity. These results indicate that differences in epitope promiscuity do not account for the observed differences in epitope variation and conservation.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
| | - Harish Swaminathan
- Department of Computer Science and Center for Computational and Integrative Biology, Rutgers University, Camden, New Jersey, United States of America
| | - Richard Copin
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
| | - Desmond S. Lun
- Department of Computer Science and Center for Computational and Integrative Biology, Rutgers University, Camden, New Jersey, United States of America
| | - Joel D. Ernst
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
- Department of Medicine, Division of Infectious Disease, New York University School of Medicine, New York, New York, United States of America
- Department of Microbiology, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
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30
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Broadhurst MJ, Ardeshir A, Kanwar B, Mirpuri J, Gundra UM, Leung JM, Wiens KE, Vujkovic-Cvijin I, Kim CC, Yarovinsky F, Lerche NW, McCune JM, Loke P. Therapeutic helminth infection of macaques with idiopathic chronic diarrhea alters the inflammatory signature and mucosal microbiota of the colon. PLoS Pathog 2012; 8:e1003000. [PMID: 23166490 PMCID: PMC3499566 DOI: 10.1371/journal.ppat.1003000] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 09/13/2012] [Indexed: 12/19/2022] Open
Abstract
Idiopathic chronic diarrhea (ICD) is a leading cause of morbidity amongst rhesus monkeys kept in captivity. Here, we show that exposure of affected animals to the whipworm Trichuris trichiura led to clinical improvement in fecal consistency, accompanied by weight gain, in four out of the five treated monkeys. By flow cytometry analysis of pinch biopsies collected during colonoscopies before and after treatment, we found an induction of a mucosal TH2 response following helminth treatment that was associated with a decrease in activated CD4+ Ki67+ cells. In parallel, expression profiling with oligonucleotide microarrays and real-time PCR analysis revealed reductions in TH1-type inflammatory gene expression and increased expression of genes associated with IgE signaling, mast cell activation, eosinophil recruitment, alternative activation of macrophages, and worm expulsion. By quantifying bacterial 16S rRNA in pinch biopsies using real-time PCR analysis, we found reduced bacterial attachment to the intestinal mucosa post-treatment. Finally, deep sequencing of bacterial 16S rRNA revealed changes to the composition of microbial communities attached to the intestinal mucosa following helminth treatment. Thus, the genus Streptophyta of the phylum Cyanobacteria was vastly increased in abundance in three out of five ICD monkeys relative to healthy controls, but was reduced to control levels post-treatment; by contrast, the phylum Tenericutes was expanded post-treatment. These findings suggest that helminth treatment in primates can ameliorate colitis by restoring mucosal barrier functions and reducing overall bacterial attachment, and also by altering the communities of attached bacteria. These results also define ICD in monkeys as a tractable preclinical model for ulcerative colitis in which these effects can be further investigated. Young macaques kept in captivity at Primate Research Centers often develop chronic diarrhea, which is difficult to treat because it is poorly understood. This disease shares many features with ulcerative colitis, which is an autoimmune disease affecting the intestinal tract of humans. Recently, parasitic worms have been used in clinical trials to treat inflammatory bowel diseases in humans with positive results, but very little is known about how worms can improve symptoms. We performed a trial where we treated macaques suffering from chronic diarrhea with human whipworms, collecting gut biopsies before and after treatment. We found that 4 out of the 5 treated macaques improved their symptoms and studied the changes in their gut immune responses, as they got better. We found that after treatment with worms, the monkeys had less bacteria attached to their intestinal wall and a reduced inflammatory response to the gut bacteria. Additionally, the composition of gut bacteria was altered in the sick macaques and was restored close to normal after treatment with whipworms. These results provide a potential mechanism by which parasitic worms may improve the symptoms of intestinal inflammation, by reducing the immune response against intestinal bacteria.
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Affiliation(s)
- Mara Jana Broadhurst
- Division of Experimental Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail: (MJB); (PL)
| | - Amir Ardeshir
- California National Primate Research Center, Davis, California, United States of America
| | - Bittoo Kanwar
- Division of Experimental Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Julie Mirpuri
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Uma Mahesh Gundra
- Department of Microbiology, New York University, New York, New York, United States of America
| | - Jacqueline M. Leung
- Department of Microbiology, New York University, New York, New York, United States of America
| | - Kirsten E. Wiens
- Department of Microbiology, New York University, New York, New York, United States of America
| | - Ivan Vujkovic-Cvijin
- Division of Experimental Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Charlie C. Kim
- Division of Experimental Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Felix Yarovinsky
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Nicholas W. Lerche
- California National Primate Research Center, Davis, California, United States of America
| | - Joseph M. McCune
- Division of Experimental Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - P'ng Loke
- Department of Microbiology, New York University, New York, New York, United States of America
- * E-mail: (MJB); (PL)
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