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

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Promotion and strategies of menstrual cup use among healthcare providers: A primer towards a sustainable solution for menstrual health and hygiene management in India

Menstrual cups are considered a sustainable solution for menstrual health and hygiene management, as they are cost-effective, environment-friendly, reusable and offer health benefits over traditional menstrual hygiene products such as pads and tampons. However, in lower middle income countries (LMICs), menstrual cup use is limited. Recently, India's current menstrual hygiene program has included menstrual cups as an option for menstrual health and hygiene management. However, the menstrual cup has not been promoted widely in the Indian context. Even if the use of menstrual cups among female healthcare providers in India is minimal, the manuscript identified the crucial challenges in menstrual health and hygiene management, the role of menstrual cups as a solution and the essential strategies to increase menstrual cup use. Programmatic success requires endorsement from healthcare providers as they are trusted sources of information related to healthcare. Good experiences and leading examples from healthcare providers about using menstrual cups is a welcoming step in the path of the dream of a "pad-free country" for India

Plant-based diet: A solution to the sustainability of life and environment

The entirety of food and drink that an individual continually expends is called a diet. Proper nutrition – a sufficient, all-around offset diet with regular physical activity, frames the establishment for good health. The majority of the currently prevalent dietary recommendations are based on the health benefits of different individual food products. With the rising concern regarding climate change and evidence highlighting the influence of our nutritional practices on the environment, the time has come to redefine the dietary guidelines and recommendations considering the environmental impact of diet along with the health benefits. Studies have been reliably consistent with demonstrating that an equicaloric diet rich in plant-based products and lower in animal products is beneficial to health and put a lesser burden on the earth. There are five Sustainable Developmental Goals that can be linked with our dietary practices (no poverty, no hunger, good health and well-being, responsible consumption and production, and climate change). A plant-based diet is a suitable solution to the current crisis of noncommunicable diseases and climate change. Moving on to such a dietary practice would require immense changes in the currently prevalent food system with an emphasis on better production and waste management strategies along with improvement in food delivery and consumption practices worldwide. This article brings insight regarding the benefits of a plant-based diet and the need to address the ecological impact of animal-based foods

The top 100 cited articles in menstrual health among adolescent girls: a citation analysis

Abstract Background Menstrual health is an important public health concern where it is still considered a taboo, and adolescent girls often lack knowledge about menstrual health, face limited access to sanitation facilities, and struggle with the affordability of sanitary materials. Every year numerous articles are published; however, only a few of them would be influential in the evolution of a particular field. The number of citations received by an article serves as a quality factor for the impact of the article in a particular field. Citation analysis analyses the relationship between citations received by articles. From the literature search, no citation analysis was conducted on menstrual health. Hence the objective of the study was to identify the articles which received hundred or more citations and also to identify the leading countries, journals, study designs, and departments conducting research on menstrual health. Methods Citation analysis was done with search terms pertaining to adolescent and menstrual health using Google Scholar as a database in Publish or Perish software. The articles retrieved were exported to Microsoft Excel. Articles that received a hundred or more citations were screened for the type of article, department, and country where the study was conducted. A descriptive analysis of the hundred or more cited articles was done in Microsoft Excel. Results A total of 982 articles pertaining to menstrual health among adolescent girls were retrieved. There were hundred articles with hundred and more citations pertaining to the menstrual health of adolescent girls. Cross-sectional study design, Obstetrics and Gynaecology department, India and USA countries, and PLOS ONE journal had the most citations in research on menstrual health among adolescent girls. The top ten articles were on menorrhagia, menstrual hygiene practices, Water, Sanitation and hygiene (WASH), stigma on menstruation, and education on menstrual health. Conclusion The hundred cited articles on menstrual health among adolescent girls were mainly from high-income countries and were of more observational in nature than interventional. Thus, highlighting the need to strengthen experimental studies on the menstrual health of adolescent girls in Lower-middle-income countries

Development of new method and protocol for cryopreservation related to embryo and oocytes freezing in terms of fertilization rate: A comparative study including review of literature

Background: Cryopreservation is basically related to meritorious thin samples or small clumps of cells that are cooled quickly without loss. Our main objective is to establish and formulate an innovative method and protocol development for cryopreservation as a gold standard for clinical uses in laboratory practice and treatment. The knowledge regarding usefulness of cryopreservation in clinical practice is essential to carry forward the clinical practice and research. Materials and Methods: We are trying to compare different methods of cryopreservation (in two dozen of cells) at the same time we compare the embryo and oocyte freezing interms of fertilization rate according to the International standard protocol. Results: The combination of cryoprotectants and regimes of rapid cooling and rinsing during warming often allows successful cryopreservation of biological materials, particularly cell suspensions or thin tissue samples. Examples include semen, blood, tissue samples like tumors, histological cross-sections, human eggs and human embryos. Although presently many studies have reported that the children born from frozen embryos or "frosties, "show consistently positive results with no increase in birth defects or development abnormalities is quite good enough and similar to our study (50-85%). Conclusions: We ensure that cryopreservation technology provided useful cell survivability, tissue and organ preservation in a proper way. Although it varies according to different laboratory conditions, it is certainly beneficial for patient′s treatment and research. Further studies are needed for standardization and development of new protocol

Adapting the stepped care approach for providing comprehensive mental health services in rural India: Tapping the untapped potential

Recent National Mental Health Survey (2015-16) reported a prevalence of 13.7% for any mental disorders excluding tobacco use disorders in India. Translating it into real numbers, nearly 150 million people need active mental health interventions, disproportionately more in rural areas. Major challenges in delivering comprehensive mental health services in rural India are: a) lack of a well-defined strategy; and b) lack of trained mental health manpower. To fill this gap, the global mental health community has increasingly realized the importance of Community Health Workers (CHWs) and role of stepped care approach in mental health service delivery. We propose a model of stepped care approach to fulfil the need of rural India, utilizing the existing health system components for improving mental health knowledge, reducing social stigma for mental disorders, screening for priority mental disorders at community level, ensuring compliance to treatment, timely follow-up, and community-based rehabilitation by mobilising community support for diagnosed cases. This stepped care approach will integrate mental health into Ayushman Bharat’s Health and Wellness Centres (HWCs) for the provision of comprehensive primary health care. Integration of new age technologies such as telepsychiatry, e-health, and mHealth into the proposed model will make it feasible and cost-efficient for inaccessible parts of the country

Challenges of objective structured clinical examination as a tool in medical assessment

Medical education is witnessing changes across the globe to produce more competent and responsive medical graduates to meet patients' growing needs. Medical educators are aspiring for more objective and relevant assessment methods for the evaluation of medical graduates. Objective structured clinical examination (OSCE) introduced in the year 1975 for clinical evaluation has gone through many changes over the past 45 years and matured over time. The article describes the challenges of OSCE as a tool in medical assessment from students' and organizers' perspectives. We have also suggested a feasible solution to address the challenges while conducting OSCE to assess medical students