Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological…

GBD 2013 DALYs and HALE Collaborators, Christopher J L Murray, Ryan M Barber, Kyle J Foreman, Ayse Abbasoglu Ozgoren, Foad Abd-Allah, Semaw F Abera, Victor Aboyans, Jerry P Abraham, Ibrahim Abubakar, Laith J Abu-Raddad, Niveen M Abu-Rmeileh, Tom Achoki, Ilana N Ackerman, Zanfina Ademi, Arsène K Adou, José C Adsuar, Ashkan Afshin, Emilie E Agardh, Sayed Saidul Alam, Deena Alasfoor, Mohammed I Albittar, Miguel A Alegretti, Zewdie A Alemu, Rafael Alfonso-Cristancho, Samia Alhabib, Raghib Ali, François Alla, Peter Allebeck, Mohammad A Almazroa, Ubai Alsharif, Elena Alvarez, Nelson Alvis-Guzman, Azmeraw T Amare, Emmanuel A Ameh, Heresh Amini, Walid Ammar, H Ross Anderson, Benjamin O Anderson, Carl Abelardo T Antonio, Palwasha Anwari, Johan Arnlöv, Valentina S Arsic Arsenijevic, Al Artaman, Rana J Asghar, Reza Assadi, Lydia S Atkins, Marco A Avila, Baffour Awuah, Victoria F Bachman, Alaa Badawi, Maria C Bahit, Kalpana Balakrishnan, Amitava Banerjee, Suzanne L Barker-Collo, Simon Barquera, Lars Barregard, Lope H Barrero, Arindam Basu, Sanjay Basu, Mohammed O Basulaiman, Justin Beardsley, Neeraj Bedi, Ettore Beghi, Tolesa Bekele, Michelle L Bell, Corina Benjet, Derrick A Bennett, Isabela M Bensenor, Habib Benzian, Eduardo Bernabé, Amelia Bertozzi-Villa, Tariku J Beyene, Neeraj Bhala, Ashish Bhalla, Zulfiqar A Bhutta, Kelly Bienhoff, Boris Bikbov, Stan Biryukov, Jed D Blore, Christopher D Blosser, Fiona M Blyth, Megan A Bohensky, Ian W Bolliger, Berrak Bora Başara, Natan M Bornstein, Dipan Bose, Soufiane Boufous, Rupert R A Bourne, Lindsay N Boyers, Michael Brainin, Carol E Brayne, Alexandra Brazinova, Nicholas J K Breitborde, Hermann Brenner, Adam D Briggs, Peter M Brooks, Jonathan C Brown, Traolach S Brugha, Rachelle Buchbinder, Geoffrey C Buckle, Christine M Budke, Anne Bulchis, Andrew G Bulloch, Ismael R Campos-Nonato, Hélène Carabin, Jonathan R Carapetis, Rosario Cárdenas, David O Carpenter, Valeria Caso, Carlos A Castañeda-Orjuela, Ruben E Castro, Ferrán Catalá-López, Fiorella Cavalleri, Alanur Çavlin, Vineet K Chadha, Jung-Chen Chang, Fiona J Charlson, Honglei Chen, Wanqing Chen, Peggy P Chiang, Odgerel Chimed-Ochir, Rajiv Chowdhury, Hanne Christensen, Costas A Christophi, Massimo Cirillo, Matthew M Coates, Luc E Coffeng, Megan S Coggeshall, Valentina Colistro, Samantha M Colquhoun, Graham S Cooke, Cyrus Cooper, Leslie T Cooper, Luis M Coppola, Monica Cortinovis, Michael H Criqui, John A Crump, Lucia Cuevas-Nasu, Hadi Danawi, Lalit Dandona, Rakhi Dandona, Emily Dansereau, Paul I Dargan, Gail Davey, Adrian Davis, Dragos V Davitoiu, Anand Dayama, Diego De Leo, Louisa Degenhardt, Borja Del Pozo-Cruz, Robert P Dellavalle, Kebede Deribe, Sarah Derrett, Don C Des Jarlais, Muluken Dessalegn, Samath D Dharmaratne, Mukesh K Dherani, Cesar Diaz-Torné, Daniel Dicker, Eric L Ding, Klara Dokova, E Ray Dorsey, Tim R Driscoll, Leilei Duan, Herbert C Duber, Beth E Ebel, Karen M Edmond, Yousef M Elshrek, Matthias Endres, Sergey P Ermakov, Holly E Erskine, Babak Eshrati, Alireza Esteghamati, Kara Estep, Emerito Jose A Faraon, Farshad Farzadfar, Derek F Fay, Valery L Feigin, David T Felson, Seyed-Mohammad Fereshtehnejad, Jefferson G Fernandes, Alize J Ferrari, Christina Fitzmaurice, Abraham D Flaxman, Thomas D Fleming, Nataliya Foigt, Mohammad H Forouzanfar, F Gerry R Fowkes, Urbano Fra. Paleo, Richard C Franklin, Thomas Fürst, Belinda Gabbe, Lynne Gaffikin, Fortuné G Gankpé, Johanna M Geleijnse, Bradford D Gessner, Peter Gething, Katherine B Gibney, Maurice Giroud, Giorgia Giussani, Hector Gomez Dantes, Philimon Gona, Diego González-Medina, Richard A Gosselin, Carolyn C Gotay, Atsushi Goto, Hebe N Gouda, Nicholas Graetz, Harish C Gugnani, Rahul Gupta, Rajeev Gupta, Reyna A Gutiérrez, Juanita Haagsma, Nima Hafezi-Nejad, Holly Hagan, Yara A Halasa, Randah R Hamadeh, Hannah Hamavid, Mouhanad Hammami, Jamie Hancock, Graeme J Hankey, Gillian M Hansen, Yuantao Hao, Hilda L Harb, Josep Maria Haro, Rasmus Havmoeller, Simon I Hay, Roderick J Hay, Ileana B Heredia-Pi, Kyle R Heuton, Pouria Heydarpour, Hideki Higashi, Martha Hijar, Hans W Hoek, Howard J Hoffman, H Dean Hosgood, Mazeda Hossain, Peter J Hotez, Damian G Hoy, Mohamed Hsairi, Guoqing Hu, Cheng Huang, John J Huang, Abdullatif Husseini, Chantal Huynh, Marissa L Iannarone, Kim M Iburg, Kaire Innos, Manami Inoue, Farhad Islami, Kathryn H Jacobsen, Deborah L Jarvis, Simerjot K Jassal, Sun Ha Jee, Panniyammakal Jeemon, Paul N Jensen, Vivekanand Jha, Guohong Jiang, Ying Jiang, Jost B Jonas, Knud Juel, Haidong Kan, André Karch, Corine K Karema, Chante Karimkhani, Ganesan Karthikeyan, Nicholas J Kassebaum, Anil Kaul, Norito Kawakami, Konstantin Kazanjan, Andrew H Kemp, Andre P Kengne, Andre Keren, Yousef S Khader, Shams Eldin A Khalifa, Ejaz A Khan, Gulfaraz Khan, Young-Ho Khang, Christian Kieling, Daniel Kim, Sungroul Kim, Yunjin Kim, Yohannes Kinfu, Jonas M Kinge, Miia Kivipelto, Luke D Knibbs, Ann Kristin Knudsen, Yoshihiro Kokubo, Soewarta Kosen, Sanjay Krishnaswami, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Chanda Kulkarni, Veena S Kulkarni, G Anil Kumar, Hmwe H Kyu, Taavi Lai, Ratilal Lalloo, Tea Lallukka, Hilton Lam, Qing Lan, Van C Lansingh, Anders Larsson, Alicia E B Lawrynowicz, Janet L Leasher, James Leigh, Ricky Leung, Carly E Levitz, Bin Li, Yichong Li, Yongmei Li, Stephen S Lim, Maggie Lind, Steven E Lipshultz, Shiwei Liu, Yang Liu, Belinda K Lloyd, Katherine T Lofgren, Giancarlo Logroscino, Katharine J Looker, Joannie Lortet-Tieulent, Paulo A Lotufo, Rafael Lozano, Robyn M Lucas, Raimundas Lunevicius, Ronan A Lyons, Stefan Ma, Michael F Macintyre, Mark T Mackay, Marek Majdan, Reza Malekzadeh, Wagner Marcenes, David J Margolis, Christopher Margono, Melvin B Marzan, Joseph R Masci, Mohammad T Mashal, Richard Matzopoulos, Bongani M Mayosi, Tasara T Mazorodze, Neil W Mcgill, John J Mcgrath, Martin Mckee, Abigail Mclain, Peter A Meaney, Catalina Medina, Man Mohan Mehndiratta, Wubegzier Mekonnen, Yohannes A Melaku, Michele Meltzer, Ziad A Memish, George A Mensah, Atte Meretoja, Francis A Mhimbira, Renata Micha, Ted R Miller, Edward J Mills, Philip B Mitchell, Charles N Mock, Norlinah Mohamed Ibrahim, Karzan A Mohammad, Ali H Mokdad, Glen L D Mola, Lorenzo Monasta, Julio C Montañez Hernandez, Marcella Montico, Thomas J Montine, Meghan D Mooney, Ami R Moore, Maziar Moradi-Lakeh, Andrew E Moran, Rintaro Mori, Joanna Moschandreas, Wilkister N Moturi, Madeline L Moyer, Dariush Mozaffarian, William T Msemburi, Ulrich O Mueller, Mitsuru Mukaigawara, Erin C Mullany, Michele E Murdoch, Joseph Murray, Kinnari S Murthy, Mohsen Naghavi, Aliya Naheed, Kovin S Naidoo, Luigi Naldi, Devina Nand, Vinay Nangia, K M Venkat Narayan, Chakib Nejjari, Sudan P Neupane, Charles R Newton, Marie Ng, Frida N Ngalesoni, Grant Nguyen, Muhammad I Nisar, Sandra Nolte, Ole F Norheim, Rosana E Norman, Bo Norrving, Luke Nyakarahuka, In-Hwan Oh, Takayoshi Ohkubo, Summer L Ohno, Bolajoko O Olusanya, John Nelson Opio, Katrina Ortblad, Alberto Ortiz, Amanda W Pain, Jeyaraj D Pandian, Carlo Irwin A Panelo, Christina Papachristou, Eun-Kee Park, Jae-Hyun Park, Scott B Patten, George C Patton, Vinod K Paul, Boris I Pavlin, Neil Pearce, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz, Norberto Perico, Aslam Pervaiz, Konrad Pesudovs, Carrie B Peterson, Max Petzold, Michael R Phillips, Bryan K Phillips, David E Phillips, Frédéric B Piel, Dietrich Plass, Dan Poenaru, Suzanne Polinder, Daniel Pope, Svetlana Popova, Richie G Poulton, Farshad Pourmalek, Dorairaj Prabhakaran, Noela M Prasad, Rachel L Pullan, Dima M Qato, D Alex Quistberg, Anwar Rafay, Kazem Rahimi, Sajjad U Rahman, Murugesan Raju, Saleem M Rana, Homie Razavi, K Srinath Reddy, Amany Refaat, Giuseppe Remuzzi, Serge Resnikoff, Antonio L Ribeiro, Lee Richardson, Jan Hendrik Richardus, D Allen Roberts, David Rojas-Rueda, Luca Ronfani, Gregory A Roth, Dietrich Rothenbacher, David H Rothstein, Jane T Rowley, Nobhojit Roy, George M Ruhago, Mohammad Y Saeedi, Sukanta Saha, Mohammad Ali Sahraian, Uchechukwu K A Sampson, Juan R Sanabria, Logan Sandar, Itamar S Santos, Maheswar Satpathy, Monika Sawhney, Peter Scarborough, Ione J Schneider, Ben Schöttker, Austin E Schumacher, David C Schwebel, James G Scott, Soraya Seedat, Sadaf G Sepanlou, Peter T Serina, Edson E Servan-Mori, Katya A Shackelford, Amira Shaheen, Saeid Shahraz, Teresa Shamah Levy, Siyi Shangguan, Jun She, Sara Sheikhbahaei, Peilin Shi, Kenji Shibuya, Yukito Shinohara, Rahman Shiri, Kawkab Shishani, Ivy Shiue, Mark G Shrime, Inga D Sigfusdottir, Donald H Silberberg, Edgar P Simard, Shireen Sindi, Abhishek Singh, Jasvinder A Singh, Lavanya Singh, Vegard Skirbekk, Erica Leigh Slepak, Karen Sliwa, Samir Soneji, Kjetil Søreide, Sergey Soshnikov, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Jeffrey D Stanaway, Vasiliki Stathopoulou, Dan J Stein, Murray B Stein, Caitlyn Steiner, Timothy J Steiner, Antony Stevens, Andrea Stewart, Lars J Stovner, Konstantinos Stroumpoulis, Bruno F Sunguya, Soumya Swaminathan, Mamta Swaroop, Bryan L Sykes, Karen M Tabb, Ken Takahashi, Nikhil Tandon, David Tanne, Marcel Tanner, Mohammad Tavakkoli, Hugh R Taylor, Braden J Te Ao, Fabrizio Tediosi, Awoke M Temesgen, Tara Templin, Margreet Ten Have, Eric Y Tenkorang, Abdullah S Terkawi, Blake Thomson, Andrew L Thorne-Lyman, Amanda G Thrift, George D Thurston, Taavi Tillmann, Marcello Tonelli, Fotis Topouzis, Hideaki Toyoshima, Jefferson Traebert, Bach X Tran, Matias Trillini, Thomas Truelsen, Miltiadis Tsilimbaris, Emin M Tuzcu, Uche S Uchendu, Kingsley N Ukwaja, Eduardo A Undurraga, Selen B Uzun, Wim H Van Brakel, Steven Van De Vijver, Coen H van Gool, Jim Van Os, Tommi J Vasankari, N Venketasubramanian, Francesco S Violante, Vasiliy V Vlassov, Stein Emil Vollset, Gregory R Wagner, Joseph Wagner, Stephen G Waller, Xia Wan, Haidong Wang, Jianli Wang, Linhong Wang, Tati S Warouw, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Wang Wenzhi, Andrea Werdecker, Ronny Westerman, Harvey A Whiteford, James D Wilkinson, Thomas N Williams, Charles D Wolfe, Timothy M Wolock, Anthony D Woolf, Sarah Wulf, Brittany Wurtz, Gelin Xu, Lijing L Yan, Yuichiro Yano, Pengpeng Ye, Gökalp K Yentür, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Chuanhua Yu, Maysaa E Zaki, Yong Zhao, Yingfeng Zheng, David Zonies, Xiaonong Zou, Joshua A Salomon, Alan D Lopez, Theo Vos

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition-in which increasing sociodemographic status brings structured change in disease burden-is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. Bill & Melinda Gates Foundation.