Introducing a new method of retinoscopy for refraction of infants and young children: The �Mirza� tele lens retinoscopy

Purpose: This study aimed to evaluate the refractive error of the uncooperative infants and children with the new method of retinoscopy called the tele-lens (�Mirza�) retinoscopy. Methods: In the �Mirza� tele-lens retinoscopy, the examiner placed the trial lenses in 1/3 distance between the tested eye person and peephole of the retinoscope (22.2 cm far from the spectacle plane). First, the optical calculations were done to find the correction factors for this new method of retinoscopy. Second, the dry standard and �Mirza� tele-lens retinoscopy were performed in 78 eyes from 39 children aged 7�12 years with good cooperation and next, the procedure was repeated using cyclopentolate drops and then the results of the two methods were compared, and at the end, the dry �Mirza� tele-lens retinoscopy was done in the 60 eyes of 31 uncooperative infants with a mean age of 21.85 ± 8.79 months for evaluating the feasibility of the �Mirza� tele-lens retinoscopy procedure. The intraclass correlation coefficient (ICC) and Bland�Altman plot for assessment of agreement between the findings of two retinoscopic methods in dry and cyclo conditions were used. Results: The comparison between the dry standard and �Mirza� tele-lens retinoscopic results with means of 1.39 ± 1.43 and1.36 ± 1.39, respectively were not statistically significant (p > 0.05). Besides, comparing the mean cycloplegic results of two methods (standard vs. �Mirza� tele-lens), the difference was not statistically significant (2.37 ± 1.44 vs. 2.41 ± 1.37) (p > 0.05). Moreover, Two-way repeated measures ANOVA revealed no significant retinoscopy method � use of drops interaction (P = 0.103) in comparing two methods of the standard and �Mirza� tele-lens retinoscopy. ICC results indicated high agreement between two methods in both dry (ICC = 0.993) and cyclo (ICC = 0.989) conditions. Conclusions: The �Mirza� tele-lens retinoscopy method can be performed with satisfactory results in infants and children who do not cooperate for the standard procedure of measuring the refractive errors. © 2020 Spanish General Council of Optometr

Campo ambiental midiatizado: a vigilância colaborativa da Amazônia

RESUMO A manifestação do complexo processo de midiatização potencializou-se nas últimas décadas. Nesse cenário, os campos sociais se apropriaram de mecanismos discursivos do campo midiático, o que possibilitou a emergência de um espaço para a reflexão, vigilância e monitoramento de questões globais como os problemas ambientais. O objetivo desse artigo é mostrar como ocorrem imbricações entre os campos midiático e ambiental a partir da intensificação do processo de midiatização através do qual distintos cidadãos constroem o InfoAmazonia, banco de dados sobre as problemáticas da Amazônia. Para tanto, o trabalho se assenta metodologicamente na perspectiva da análise semiológica para identificar o contrato de leitura (VERÓN, 2004) construído pela plataforma. A investigação aponta que este enunciador se caracteriza pela legitimação de um sujeito protagonista, cogestor na vigilância colaborativa da Amazônia. Palavras-chave: midiatização; campo ambiental; contrato de leitura   RESUMEN La manifestación del complejo proceso de mediatización se intensifica en las últimas décadas. En este escenario, los mecanismos discursivos del campo de los medios son apropiados por los campos sociales, lo que permitió el surgimento de un espacio de reflexión, vigilancia y rastreo de temas globales como los problemas ambientales. Lo objetivo deste artículo és mostrar cómo se producen solapamientos entre los campos mediático e ambiental gracias a intensificación del proceso de mediatizatión, además analizar y describir el contracto de lectura que emerge del proceso de construcción de InfoAmazonia, base de datos sobre los problemas de la Amazonía. Por lo tanto, el trabajo se basa metodológicamente en la perspectiva semiológica para identificar el contrato de lectura (VERÓN, 2004) de la plataforma. La investigación muestra que este enunciador se caracteriza por la legitimación de un actor protagonista, cogestor en la vigilancia de colaboración de la Amazonia.   Palabras clave: mediatización; campo ambiental; contracto de lectura   ABSTRACT The manifestation of the complex process of mediatization is leveraged in recent decades. Under this scenario, the social fields appropriated discursive mechanisms of the media field, which allowed the emergence of a space for reflection, surveillance and monitoring of global issues such as environmental problems. This research aims to show how they occur overlaps between the media and environmental fields with the intensification of mediatization, besides analyze and describe the reading agreement emerging from the construction process of InfoAmazonia, a database about the problems of the Amazon. Therefore, the work is methodologically based on semiological perspective to identify the platform reading contract (VERÓN, 2004). Research shows that this annunciator is characterized by the legitimation of a subject protagonist, who helps oversee the collaborative surveillance of the Amazon.   Keywords: mediatization; environmental field; reading agreement

The Spanish Mediterranean Fishing Guilds (Cofradias): An Example of Collaborative Management with a Key Role in Sustainable Fisheries

[EN] The management of Spanish coastal fisheries is based on a mixed model where the centralised action of the government is combined with the self-organisation of fishers in cofradias (guilds). These institutions have economic and political functions, intermediating between the State and the fishing sector and mediating in the conflicts that may occur. They also have welfare and mutualist tasks. This original and traditional co-management model is part of the social capital of traditional Spanish fishing. The aim of this article is to explore the possibilities of these Spanish fishers' organisations in order to improve the legitimacy of the fishery system and the sustainability of fisheries. Our hypothesis is that updating and adapting some aspects of the cofradias model could produce efficient forms of collaborative management and lead to improvements in the sustainability of fisheries. To validate this hypothesis the study analysed 69 face-to-face interviews in 21 Spanish-Mediterranean guilds. The analysis focused on three core aspects: the control of fishing resources; the integration of fishing knowledge in the management system; and, finally, the guilds contribution to the legitimacy of the system in the eyes of the fishers.This work was supported by National Plan for Scientific and Technological Research and Innovation (Spanish Economy and Competitiveness Ministry). Research Project CSO2016-76135-P. There is no conflict of interest declared in this article.Herrera-Racionero, P.; Lizcano, E.; Miret Pastor, LG.; Mascarell, Y. (2019). The Spanish Mediterranean Fishing Guilds (Cofradias): An Example of Collaborative Management with a Key Role in Sustainable Fisheries. Fisheries. 44(4):172-182. https://doi.org/10.1002/fsh.10224S172182444Alegret J. L.1999.Gestión comunitaria cogestión y mercado. La evolución histórica de la gestión de la pesca en el Mediterráneo español. Pages109–124inG.Allut andJ.Pascual editors. Antropología de la pesca/Santiago de Compostela: Asociación Galega de Antropoloxía.La pesca a la Mediterrània 2016 Universidad de Alicante Alicante J. L Alegret J. L. Sánchez Lizaso Les confraries de pescadors a Espanya 47 54Andalusian Decree 86/2004 of March 2 2004 about Fishers Guilds and their Institutions. Available:https://www.juntadeandalucia.es/boja/2004/52/3Ariza, E., Pons, F., & Breton, F. (2016). Is «socio-ecological culture» really being taken into account to manage conflicts in the coastal zone? Inputs from Spanish Mediterranean beaches. Ocean & Coastal Management, 134, 183-193. doi:10.1016/j.ocecoaman.2016.10.006Catalan Law 22/2002 of July 12 2002 of Fishers Guilds. «DOGC» n. 3684. Available:https://www.boe.es/buscar/pdf/2002/BOE-A-2002-15890-consolidado.pdfCochrane, K. L., & Garcia, S. M. (Eds.). (2009). A Fishery Manager’s Guidebook. doi:10.1002/9781444316315Corral-Quintana, S., Legna-de la Nuez, D., Legna Verna, C., Hernández, J. H., & Romero-Manrique de Lara, D. (2016). How to improve strategic decision-making in complex systems when only qualitative information is available. Land Use Policy, 50, 83-101. doi:10.1016/j.landusepol.2015.09.0045. European Comission.2013.Commission implementing regulation6. (EU) Nº 1419/2013. Availablehttp://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32013R1419&from=ES(May2017)European Commission.2014.Coastal zones: achieving sustainable management. Availablehttp://ec.europa.eu/environment/integration/research/newsalert/pdf/coastal_zones_sustainable_management_46si_en.pdf(May 2017).European Parliament.2012.Common position on the role of the RACS in the future Common Fisheries Policy Reform. Available:http://www.europarl.europa.eu/document/activities/cont/201203/20120322ATT41696/20120322ATT41696EN.pdf(May 2017).Frangoudes, K., Marugán-Pintos, B., & Pascual-Fernández, J. J. (2008). From open access to co-governance and conservation: The case of women shellfish collectors in Galicia (Spain). Marine Policy, 32(2), 223-232. doi:10.1016/j.marpol.2007.09.007Herrera-Racionero, P., Lizcano-Fernández, E., & Miret-Pastor, L. (2015). «Us» and «them». Fishermen from Gandía and the loss of institutional legitimacy. Marine Policy, 54, 130-136. doi:10.1016/j.marpol.2014.12.018Jentoft, S. (2000). Legitimacy and disappointment in fisheries management. Marine Policy, 24(2), 141-148. doi:10.1016/s0308-597x(99)00025-1Kosamu, I. B. M. (2015). Conditions for sustainability of small-scale fisheries in developing countries. Fisheries Research, 161, 365-373. doi:10.1016/j.fishres.2014.09.002Law 2/2007 of March 12 2007 of Marine Fishery and Aquaculture of Murcia region. Available inhttps://www.boe.es/boe/dias/2008/07/21/pdfs/A31793-31815.pdf(November 2018)Long, R. D., Charles, A., & Stephenson, R. L. (2015). Key principles of marine ecosystem-based management. Marine Policy, 57, 53-60. doi:10.1016/j.marpol.2015.01.013Mackinson, S., Wilson, D. C., Galiay, P., & Deas, B. (2011). Engaging stakeholders in fisheries and marine research. Marine Policy, 35(1), 18-24. doi:10.1016/j.marpol.2010.07.003MAGRAMA (Ministry of Agriculture Food and Environment).2015.Estadísticas pesqueras: Pesca marítima. Availablehttp://www.magrama.gob.es/es/estadistica/temas/estadisticas-pesqueras/pesca-maritima/(July 2017)Martínez-Novo, R., Lizcano, E., Herrera-Racionero, P., & Miret-Pastor, L. (2016). Innovation or ‘Inventions’? The conflict between latent assumptions in marine aquaculture and local fishery. Public Understanding of Science, 27(2), 214-228. doi:10.1177/0963662516651358Noy, C. (2008). Sampling Knowledge: The Hermeneutics of Snowball Sampling in Qualitative Research. International Journal of Social Research Methodology, 11(4), 327-344. doi:10.1080/13645570701401305Ostrom, E. (2009). A General Framework for Analyzing Sustainability of Social-Ecological Systems. Science, 325(5939), 419-422. doi:10.1126/science.1172133Pita, P., Fernández-Vidal, D., García-Galdo, J., & Muíño, R. (2016). The use of the traditional ecological knowledge of fishermen, cost-effective tools and participatory models in artisanal fisheries: Towards the co-management of common octopus in Galicia (NW Spain). Fisheries Research, 178, 4-12. doi:10.1016/j.fishres.2015.07.021Producer organisations are officially recognised bodies set up by fishery or aquaculture producers. They play an essential role in running the European Common Fisheries Policy.State Marine Fishery Law: Law 3/2001 of March 26 2001. BOE (State Official Gazette) number 75. Available:https://www.boe.es/buscar/doc.php?id=BOE-A-2001-600

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

Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background Accurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. Methods To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. Findings During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. Interpretation Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic. Methods The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic. Findings Global DALYs increased from 2·63 billion (95% UI 2·44–2·85) in 2010 to 2·88 billion (2·64–3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7–17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8–6·3) in 2020 and 7·2% (4·7–10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0–234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7–198·3]), neonatal disorders (186·3 million [162·3–214·9]), and stroke (160·4 million [148·0–171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3–51·7) and for diarrhoeal diseases decreased by 47·0% (39·9–52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54–1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5–9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0–19·8]), depressive disorders (16·4% [11·9–21·3]), and diabetes (14·0% [10·0–17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7–27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6–63·6) in 2010 to 62·2 years (59·4–64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6–2·9) between 2019 and 2021. Interpretation Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades

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