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

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. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4 (62.3 (55.1�70.8) million) to 6.4 (58.3 (47.6�70.7) million), but is predicted to remain above the World Health Organization�s Global Nutrition Target of <5 in over half of LMICs by 2025. Prevalence of overweight increased from 5.2 (30 (22.8�38.5) million) in 2000 to 6.0 (55.5 (44.8�67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic. © 2020, The Author(s)

Global burden of 87 risk factors in 204 countries and territories, 1990�2019: a systematic analysis for the Global Burden of Disease Study 2019

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. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Author Correction: Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017 (Nature Medicine, (2020), 26, 5, (750-759), 10.1038/s41591-020-0807-6)

An amendment to this paper has been published and can be accessed via a link at the top of the paper. © 2020, The Author(s)

Author Correction: Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017 (Nature Medicine, (2020), 26, 5, (750-759), 10.1038/s41591-020-0807-6)

An amendment to this paper has been published and can be accessed via a link at the top of the paper. © 2020, The Author(s)

Study of the transient voltage behaviour of the present ITER TF coil design for determination of the test voltages and procedures

Studie über das transiente elektrische Verhalten der aktuellen ITER Spulenkonstruktion zur Bestimmung von Testspannung und Testverfahren ITER ist ein experimenteller Tokamak Fusionsreaktor, in dem die kontrollierte Kernfusion gezündet und aufrechterhalten wird. Einschluß und Regelung des Plasmas erfolgen hierbei mit supraleitenden Magneten. Vom "ITER International Team" wird als wahrscheinlichste Ursache für einen Ausfall eines Großmagneten ein Isolationsfehler angesehen. Aufgrund der schwierigen Austauschbedingungen für Toroidalfeldspulen (TF) im ITER Magnetsystem und der verschiedenen Probleme, die sich während der Tests der ITER Modellspulen gezeigt hatten, sind für die ITER Magnete Verbesserungen in unterschiedlichen Bereichen der Hochspannungstechnik erforderlich. Besonders wichtig ist die Berücksichtigung des transienten elektrischen Verhaltens, da schnelle Spannungsänderungen (z. B. Blitz- und Schaltstoßspannungen) nichtlineare Spannungsverteilungen und Resonanzen in Spulen erzeugen können. Derartige Hochspannungsbeanspruchungen können örtliche Überlastungen und Zerstörungen am Isolationssystem verursachen. Dieser Bericht zeigt für die Schnellentladung und zwei Fehlerfälle die Berechnungen der Spannungen an den Spulenenden im ITER TF System sowie die Spannungsbelastungen der 3 Arten elektrischer Isolierung (Erd-, Radialplatten- und Leiterisolation) innerhalb einer ITER TF Einzelspule. Für eine ITER TF Einzelspule wird das elektrische Ersatzschaltbild erstellt. Hierzu werden die internen Induktivitäten und Kapazitäten sowie die Erdkapazitäten bestimmt. Mit FEM-Berechnungen werden Skin- und Proximity-Effekt sowie die von Wirbelströmen in den Radialplatten verursachten Dämpfungen ermittelt. Ein weiteres Netzwerkmodell wird für das aus 18 TF Einzelspulen und 9 Schnellentladeeinheiten bestehende ITER TF System erstellt. Das Ergebnis einer niedrigeren Resonanzfrequenz für die TF Spule als für die TF Modellspule kann auf die größeren Abmessungen der TF Spule zurückgeführt werden. Für die Schnellentladung ergibt sich für alle 3 Isolierungsarten eine nichtlineare Spannungsbelastung, die im Falle eines Erdschlusses verstärkt wird. Zur Sicherstellung eines zuverlässigen Betriebes für die vorgesehene Einsatzdauer von ITER muß die Festlegung der Testspannungen somit unter Berücksichtigung von Spannungsbelastungen erfolgen, die bei Schnellentladungen und realistischen Fehlerfällen auftreten können. Ausgehend von den berechneten Spannungsbelastungen und den Erfahrungen, die während dem ITER Modellspulentest gemacht wurden, werden Vorschläge für Testverfahren diskutiert und verschiedene Abnahmekriterien vorgeschlagen. Als Ergänzung werden Sicherheitsempfehlungen vorgestellt, die der Verhinderung unzulässiger Belastungen während der Tests dienen

Functional outcome in traumatic brain injury in Tunisia

IntroductionTraumatic brain injury (TBI) occurs mainly in young adults in full swing. The objective of this work is to specify the functional outcome of patients with TBI sequelae.MethodsWe included adult patients who were hospitalised between January 2009 and December 2013 for the management of TBI sequelae. We excluded patients with a history of neurological or psychiatric disorders before the TBI. We contacted these patients in an attempt to clarify their current functional status. For each patient we stated: the functional independence measurement (FIM), the severity of disability based on the Glasgow Outcome Scale (GOS). The motor part of the Canadian neurological scale was used to evaluate motor impairments.Results27 patients were included. 89.3% of our patients were male. The mean age was 34.6 (range: 19 to 66 years). The TBI was severe in 19 cases and moderate in 8 patients. The average duration of post-traumatic coma was 38.7 days. Initial FIM was 66.4/126. The overall assessment of disability by the GOS found two vegetative states; 9 patients had moderate disability and 16 patients had severe disability. A motor impairment was found in all these patients. Only one patient had resumed his previous occupation; 2 had resumed a professional activity with adaptation of the workplace; and 3 others were following appropriate training.ConclusionThe socio-professional reintegration remains a difficult goal to achieve, due to neuropsychological disorders in addition to orthopaedic sequelae which often causes neuro dependency and disability. However, it should optimise the residual functional capacity whenever the possibility of a life plan is offered to the patient

Contamination and Prevalence of Histamine in Canned Tuna from Iran: A Systematic Review, Meta-Analysis, and Health Risk Assessment

HIGHLIGHTS: Data from 11 articles and a total of 693 samples were used for a meta-analysis. Pooled mean histamine, 77.86 mg kg-1, was lower than the FDA limit (200 mg kg-1). Pooled mean histamine prevalence was 9.19 with considerable heterogeneity. THQ value <1 indicates that adult consumers are not at risk of histamine poisoning