Spinal Cord Injury and TBI recognized as global health priorities - The Lancet

December 06, 2018, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators Open AccessPublished:November 26, 2018DOI:https://doi.org/10.1016/S1474-4422(18)30415-0

Note: this article can be read fully with all figures and charts here.


Summary

Background

Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury.

Methods

We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility.

Findings

In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30–30·30 million) new cases of TBI and 0·93 million (0·78–1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331–412) per 100 000 population for TBI and 13 (11–16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40–57·62 million) and of SCI was 27·04 million (24·98–30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (−0·2% [–2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (−3·6% [–7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0–10·4 million) YLDs and SCI caused 9·5 million (6·7–12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82–141) per 100 000 for TBI and 130 (90–170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions.

Interpretation

TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments.

Funding

Bill & Melinda Gates Foundation.

Introduction

Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly considered to be important global health priorities. These injuries not only cause health loss and disability for individuals and their families, but also represent a burden to health-care systems and economies through lost productivity and high health-care costs.  Given that the injuries that lead to TBI and SCI are frequently preventable, there is also value in measuring the extent to which different causes of injury lead to TBI or SCI to help to understand the effect that injury-prevention programmes could have. Many epidemiological studies have been limited by difficulties in comprehensively measuring the incidence of cross-injury sequelae such as TBI and SCI, and have instead focused on the incidence of the causes of injury, such as falls, road injuries, and interpersonal violence.  As a result, few comprehensive epidemiological assessments have been done across all sources of injury, despite increasing dialogue about the long-term neuropsychological consequences of concussions in young people and professional athletes playing sports and about the risk of TBI from head trauma in bicycle crashes and other causes of injury. Epidemiological studies that have focused specifically on TBI and SCI without estimation of all potential causes of injury have identified substantial burdens, but are often limited by relying on locations where incidence data were available without adopting modelling strategies for estimation of the burden in locations where data were sparse. Epidemiological assessments have been done in low-income and low-middle-income countries but typically have been limited by poor availability of data. Few studies have reported age-standardised incidence rates, which would enable comparison between countries with different populations, and the studies that have reported such data showed that the incidence rates of TBI and SCI vary substantially between countries. These studies have not measured the relative disability caused by different injuries over time; such data are important because, whereas injuries such as fractures might be disabling only in the short term, conditions such as cognitive impairment from TBI or paraplegia from SCI can leave patients with lifelong health loss. In general, measurement of the burden of TBI and SCI in greater geographical and demographic detail—and over time—is of substantial value.

Research in context

Evidence before this study

Previous epidemiological studies of the incidence and outcomes of traumatic brain injury (TBI) and spinal cord injury (SCI) have been limited by focusing on certain subpopulations, including only select injuries, or by providing estimates only for areas of the world with accessible data. Previous Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies have reported the burden of injury by cause of injury, such as self-harm, road injuries, and falls, but have not reported results by nature of injury sustained as a result of those causes, including TBI and SCI. To date, no studies have systematically measured the burden of TBI and SCI globally for all countries, ages, and sexes through recent years and from all causes of injury. To identify sources of injury data that could inform an assessment of non-fatal burden from TBI and SCI, we used results from the GBD 2016 injuries estimation process, which included systematic reviews of injury incidence data for all causes of injury that were initially done for GBD 2010 and updated as new data and literature studies became available in GBD 2013, GBD 2015, and GBD 2016. Inclusion criteria for the systematic reviews were representative, population-based surveys; reporting of injuries incidence; and clinical records from general hospitals, outpatient primary care facilities, and health insurance claims when such data were available with injury diagnosis codes. In this study, we updated a previous review of injuries data done for the World Bank that contributed to GBD 2010, GBD 2013, and GBD 2015 by searching the Global Health Data Exchange for surveys, hospital datasets, and literature studies in any language that were tagged as having injury-related data up to Dec 31, 2016.

Added value of this study

In this study, we used for the first time the GBD 2016 framework to report estimates of the global, regional, and national burden in terms of incidence, prevalence, and years of life lived with disability of TBI and SCI for 195 countries and territories. We have provided these estimates globally, by region, and by Socio-demographic Index quintiles in 2016, as well as the percentage change since 1990. We also provide estimates of the proportions of TBI and SCI caused by different causes of injury for each geographical region in 2016. Although epidemiological assessments that focus on particular populations have been done, no other studies of TBI or SCI have provided estimates in this level of detail for all countries derived from a standardised, systematic approach. We were able to measure uncertainty in our estimates by using the uncertainty propogation methods used throughout the GBD study.

Implications of all the available evidence

Our estimates suggest that TBI and SCI are severely disabling injuries. The global burden of TBI increased significantly between 1990 and 2016, whereas that of SCI has not changed significantly over time in terms of age-standardised incidence and prevalence. Age-standardised incidence and prevalence of TBI and SCI were high in central Europe, eastern Europe, and central Asia; the incidence and prevalence of SCI were high in North America and western Europe. Addressing the global burden of these conditions requires improved efforts to decrease the causes of SCI and TBI (eg, fall-prevention strategies, reducing alcohol overuse, and improving road safety, all of which could help to prevent injuries or decrease injury severity) and improved access to, and quality of, medical and social care (which could improve survival and reduce morbidity). People with TBI or SCI can have other medical conditions that require close supervision and might benefit from rehabilitation and medical care to reduce disability. Hence, although injury prevention efforts are key, health-care systems should also anticipate a growing burden from caring for people with TBI and SCI. These conditions could necessitate special focus within health-care systems, because they can be medically complex and burdensome for patients, clinicians, and families. In the future, development of improved methods for surveillance of TBI and SCI will be important, particularly in low-income settings, as will development of methods to identify patients with TBI who do not seek medical care.

The Global Burden of Diseases, Injuries, and Risk Factors (GBD) study is the product of a global research collaboration that quantifies the effects of hundreds of diseases, injuries, and risk factors around the world, producing annual estimates of all-cause mortality, causes of death, non-fatal health outcomes, and risk factors. Within the GBD framework, estimates for TBI and SCI burden have not previously been available as reported results. Instead, these nature-of-injury codes were incorporated as part of the analytic process that computed disability and results were ultimately provided only by cause (eg, falls) rather than by nature of injury (eg, TBI). Here, we describe an approach for estimation of nature-specific non-fatal burden estimates for all injuries, and report the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI, as well as the proportion of TBI and SCI caused by different injuries by region.

Methods

Overview

Our approach to measuring TBI and SCI was developed within the GBD 2016 study framework. In the GBD 2016 study, standardised analytic methods were used to estimate incidence, prevalence, and YLDs by age, sex, cause, year, and location. The study was an attempt to use all accessible information about disease and injury occurrence, clinical course, and severity that passed a set of inclusion criteria. The comparability of data was optimised by adjusting for different case definitions, enforcing consistency between data for prevalence, incidence, and cause of death estimates, and predicting estimates for locations with sparse data by borrowing information from other locations and covariates. These methods, data, and criteria are described in more detail in other GBD 2016 reports. Detailed elements of the GBD methods for measurement of TBI and SCI (including case definitions and severity definitions), a flowchart for our TBI and SCI estimation, and overall GBD study methods are in appendix 1. The measurement of TBI and SCI burden had two key deviations from the standard GBD framework. First, the GBD cause hierarchy categorised both TBI and SCI as being a nature of injury as opposed to a cause of injury—ie, these conditions previously had been measured as consequences of causes of injury. For example, a cause, such as a fall, could lead to SCI. Historically falls have been measured and reported but the actual nature of injury (eg, TBI, ankle fracture) that occurred because of the fall has not been directly reported. This aspect of the GBD study design was consistent across other natures of injuries. Second, estimation of TBI and SCI deviated from the GBD study framework in terms of the measures that were reported for the conditions, because we do not estimate death from TBI or SCI. Although TBI and SCI can lead to death, they were not considered causes of death in the GBD 2016 framework. Instead, the cause of injury (eg, falls) that led to a nature of injury such as TBI was considered the cause of death. For example, an individual who had a fall, sustained a TBI, and then died while in hospital after the injury would be considered to have had a death caused by a fall and an incident TBI. In this study, we estimated the non-fatal burden and therefore report incidence, prevalence, and YLDs, but not cause-specific mortality or years of life lost.

Cause-of-injury estimation

The process for estimation of incidence, prevalence, and YLDs was as follows. First, the incidence of 29 different causes of injury (appendix 1) were modelled with DisMod-MR 2.1, a meta-regression tool that was used extensively throughout the GBD study. These cause-of-injury models measured the incidence of each cause of injury that required medical care, which included patients who were admitted or seen in an outpatient clinic and received a diagnosis code for a given cause of injury. Receiving an injury diagnosis code did not preclude the possibility of death in the hospital or after discharge. Each of these cause models used an array of data types, including surveillance studies, literature studies, hospital discharge records, and emergency department records. The details of these models have previously been described in more detail.  Although we do not estimate death from TBI or SCI in this study, our modelling strategy also included cause-specific mortality rates from the cause of death ensemble model to inform incidence estimates for cause-of-injury models such as road injuries in data-sparse areas using estimates from data-rich areas. The outputs from these models were estimates of inpatient (admitted) and outpatient incidence rates of causes of injury and were specific for location, sex, age, and year. The outpatient incidence of each cause was derived from the inpatient incidence on the basis of a regression coefficient for outpatient incidence that was extracted from DisMod-MR 2.1 incidence models in locations that had both inpatient and outpatient data.

Nature-of-injury estimation

Clinical record data that coded for both cause and nature of injury were used to estimate the proportion of each cause that resulted in each nature of injury. If an injury cause resulted in more than one nature of injury, the most severe was chosen on the basis of a mixed-effects regression model that estimated the disability experienced by an injured individual adjusted for age, sex, and never-injured status, with country and individual random effects. Because SCI was associated with higher disability than TBI (appendix 1), SCI was chosen if both conditions occurred as a result of the same injury. We used this method after finding in a previous GBD study that statistically assigning multiple injury categories to a single individual was difficult because of a sparsity of data. This process and the severity rankings are described in more detail in appendix 1. These proportions were calculated for each external cause-of-injury–nature-of-injury (cause–nature) combination, such that the proportions of all natures of injury for a given cause of injury sum to 1 because of a Dirichlet regression. The output from this step was incidence for each cause–nature combination.

Derivation of incidence, prevalence, and YLDs

From the incidence estimates for each cause–nature combination, we separately modelled short-term and long-term estimates using proportions of individuals expected to experience short-term versus long-term disability (the cutoff for long-term disability was 1 year). The proportions estimated to experience permanent health loss generally increased with age and were different for TBI and SCI (appendix 1). The short-term prevalence estimates were then calculated on the basis of average duration of a short-term case, whereas the long-term estimates were considered to be permanent and underwent comorbidity adjustment as described previously. Cause–nature incidence rates were converted to prevalence with the differential equation solver used in DisMod-MR 2.1. This solver reconciled the incidence rates from the previous steps with standardised mortality ratios derived from literature studies to estimate prevalence, because people with long-term disability due to TBI and SCI die at a higher rate than the background mortality in the population. The final output from this step was prevalence of each cause–nature combination for each location, year, age, and sex combination.

YLDs were then calculated by multiplying the prevalence by the disability weight. Measurement has been described in more detail previously, but in summary, disability weights were measured through population and internet surveys on the basis of lay descriptions of disabling condition For example, the disability weight for short-term mild TBI and for short-term moderate or severe TBI were 0·110 (95% uncertainty interval [UI] 0·074–0·158) and 0·214 (0·141–0·297), respectively, meaning that the affected people experienced health losses of 11·0% and 21·4%, respectively, compared with a person in full health. All disability weights for different severities of TBI and SCI are provided in appendix 1.

After estimation of YLDs, the prevalence, incidence, and YLDs for TBI and SCI were then summed across all causes to estimate the all-injury prevalence, incidence, and YLDs for TBI and SCI separately. Uncertainty was propagated throughout this process by maintaining distributions of 1000 draws for each estimation stage (including percentage change over time). We use the 25th and 975th sorted values in the draw distributions as the upper and lower UIs for mean estimates and for percentage change, whereby change was judged to be significant if the lower and upper UIs did not overlap zero. This process is consistent with management of uncertainty throughout the GBD study framework.

Statistical analysis

We grouped countries into quintiles on the basis of their 2016 Socio-demographic Index (SDI) value, which is a composite measure of development derived from income per person, educational attainment, and total fertility rate. Additionally, we measured the most common causes of TBI and SCI separately in terms of the original cause of injury that led to the disability. Finally, we measured the proportion of TBI that was mild versus the proportion that was moderate or severe and the proportion of SCI that occurred at the neck versus below the neck and present these values at the global level. Analyses were done in Python (version 2.7), Stata (version 13.1), and R (version 3.3). Statistical code used for this study will be made available upon publication of this Article via the Institute for Health Metrics and Evaluation. This study complies with the Guidelines for Accurate and Transparent Health Estimates Report (GATHER) recommendations (appendix 1).

Role of the funding source

The funder of the study had no role in study design, data collection, data analysis, data interpretation, or the writing of the report. All authors had full access to the data in the study and had final responsibility for the decision to submit for publication.

Results

We used incidence data for every cause of injury and every GBD region. The number of sources by injury and by region are in appendix 1. Incidence, prevalence, and YLD estimates for every cause of injury by age, sex, and location for 1990–2016 are available through an online results tool.

Table 1 shows the incidence and prevalence of TBI in terms of all-age counts, age-standardised rates (per 100 000 population), and percentage change in age-standardised rates between 1990 and 2016. Table 2 shows the same information for SCI. YLDs from TBI and SCI in terms of all-age counts, age-standardised rates, and total percentage change are in appendix 2, which also includes these estimates by age and sex, and for 1990. Between 1990 and 2016, age-standardised incidence rates significantly increased by 3·6% (95% UI 1·8 to 5·5) for TBI and decreased non-significantly by −3·6% (−7·4 to 4·0) for SCI, leading to age-standardised incidence rates of 369 (331 to 412) per 100 000 for TBI and 13 (11 to 16) per 100 000 for SCI (Table 1Table 2).

 

To view the extensive tables please review the original article here. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30415-0/fulltext

In terms of individuals living with disability from these conditions in 2016, TBI had a global age-standardised prevalence of 759 (95% UI 731–788) per 100 000 (table 1), and SCI had a global age-standardised prevalence of 368 (340–409) per 100 000 (table 2). These estimates corresponded to 55 million (53–58) individuals with TBI and 27 million (25–30) with SCI (for unrounded estimates see table 1). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2; table 1), whereas that of SCI decreased non-significantly by −0·2% (−2·1 to 2·7; table 2). Age-standardised prevalence of TBI was high in the super-region of cental Europe, eastern Europe, and central Asia at 1539 (1464–1614) per 100 000, representing roughly 7·5 million prevalent cases (7·1–7·9). Age-standardised prevalence for SCI was highest in high SDI regions—specifically western Europe (854 [780–945 per 100 000) and high-income Asia Pacific (821 [747–907] per 100 000; table 2).

TBI and SCI caused 8·1 million (95% UI 6·0–10·4) and 9·5 million (6·7–12·4) YLDs, respectively, in 2016. The age-standardised YLD rates were 111 (82–141) per 100 000 for TBI and 130 (90–170) per 100 000 for SCI (appendix 2). The global age-standardised YLD rates per 100 000 population for TBI increased by 8·5% (7·6–9·3) from 1990 to 2016 and those for SCI decreased by 10·0% (7·0–13·3) from 1990 to 2016. At the country level, for TBI, the distribution of YLDs was similar to those of incidence and prevalence. Specifically, countries in central Europe, eastern Europe, and central Asia had the highest age-standardised YLD rates, with country-specific rates ranging from 135 (99–175) per 100 000 in Tajikistan to 335 (241–421) per 100 000 in Slovenia. For SCI, the high-income super-region had the highest age-standardised YLD rates (229 [159–303] per 100 000). Within these locations, Finland (287 [197–381] per 100 000), Ireland (283 [192–373] per 100 000), and Israel (282 [181–396] per 100 000) had the highest age-standardised YLD rates.

The proportion of causes leading to TBI and SCI by region are shown in figure 4. In general, falls were the main cause of TBI. In some regions, such as central Europe, more than 50% of the age-standardised incidence of TBI was caused by falls; in other regions, such as Oceania, falls were still the predominant cause but accounted for a smaller proportion of the age-standardised incidence (figure 4). In addition to having high age-standardised incidence, prevalence, and YLDs attributable to TBI, central and eastern Europe also had the highest incidence of TBI caused by falls. The second most common cause of TBI in most regions was motor vehicle road injuries (figure 4A). The main cause of SCI in most regions was also falls, which accounted for more than 50% of age-standardised incidence in nine different GBD regions (figure 4). Conflict and terrorism was the most common cause in North Africa and the Middle East in 2016 (figure 4B).

Discussion

This study, in which we used the GBD framework to estimate the non-fatal burden of TBI and SCI, is to our knowledge the first effort to quantify the burden of these conditions at global, regional, and national levels for all ages and sexes, and over time, from 1990 to 2016. Globally, these conditions cause non-fatal health loss that is distributed across various levels of income, geographies, and the lifespan, and represent a substantial proportion of global injury burden that could be averted through injury prevention and safety measures.

We identified an increase in global age-standardised incidence, prevalence, and YLDs of TBI between 1990 and 2016. This increase probably reflects the increasing rates of falls and road injuries over this period, which could in turn be due to increased use of motor vehicles, unsafe road conditions, and, in some areas, increased rates of alcohol consumption or unsafe infrastructure. By contrast, we noted no significant change in the age-standardised incidence or prevalence of SCI, although with global population growth, the absolute number of people living with the effects of SCI is expected to increase. The increasing global incidence of both TBI and SCI starting approximately at age 70 years also shows the importance of preventive measures for injuries through all years of life—particularly in the context of an ageing global population—and of adequate access to acute medical care resources such as emergency medical services and emergency department care.

Regional patterns differed between TBI and SCI. The highest incidence rates of TBI were in central Europe, eastern Europe, and central Asia, whereas the highest incidence rates of SCI were in high-income North America, western Europe, and high-income Asia Pacific. Conflict-affected countries in the Middle East—ie, Syria, Yemen, and Iraq—and Afghanistan had the highest country-specific incidence of SCI, and Syria also had the highest incidence of TBI. Rates of TBI and SCI were lower in some low SDI countries in regions such as sub-Saharan Africa, which generally corresponded with the geographical patterns of falls and road injuries in those regions as reported in GBD 2016. These variations in the underlying causes of TBI and SCI probably explain much of the geographical variation in the incidence of TBI and SCI. Access to health-care resources could also explain some geographical variation. For example, the higher prevalence of SCI in North America and western Europe could be related to survival bias in high SDI areas, whereby medical services have led to successful resuscitation in injury victims who otherwise would have died without receiving a TBI or SCI diagnosis code. The high rates of TBI in central Europe, eastern Europe, and central Asia generally correspond with the high all-injury rate estimated in those regions in GBD 2016.Our findings show that, globally, falls and road injuries were the most important cause of non-fatal cases of both TBI and SCI, reflecting the findings for all 328 diseases and injuries from GBD 2016, in which falls were the tenth leading cause of age-standardised YLDs from 1990 to 2016. This burden of falls was particularly evident in our study for central Europe, eastern Europe, and central Asia, where falls were the second most common cause of disability in 1990 and the third most common cause in 2016.Although the context in which a fall occurred could not be established in this study because of a lack of International Classification of Diseases (ICD) coding detail, falls can be preventable irrespective of where they occur. Falls leading to SCI have been associated with alcohol use in countries such as Estonia, so risk factor profiles across countries could explain some geographical patterns in this study. Road injuries were also important causes of these conditions, suggesting that achievement of Sustainable Development Goal 3.6 (“By 2020, halve the number of global deaths and injuries from road traffic accidents”) could reduce the burden of conditions such as TBI and SCI that can result from road injuries.

Our estimates for TBI incidence diverged from estimates in other published literature. Our study relied on cause-of-injury models that by design estimate the incidence of injuries requiring medical care. A limitation of this approach is that some people with TBI, particularly mild TBI, might not seek medical attention after injury and are thus not captured in the analysis, which could lead to underestimation of the global burden of TBI.

 In a study done in New Zealand, in which proactive screening methods were used to contact people after an accident to their upper body (including use of broad ICD-10 codes [S00–09] in addition to community-based case-ascertainment sources to identify individuals not seeking medical treatment), the incidence of TBI was 790 per 100 000 (substantially higher than that in our study), and approximately 30% of people with mild TBI did not seek medical attention soon after their TBI. However, this study was done in only one country, and the findings can probably not be generalised to the global population. However, the findings of that study emphasise the need for other international studies to use a comprehensive community-based approach for case ascertainment to increase the accuracy of GBD estimates.

In general, our study had similar limitations to other GBD studies, but with the added complexity and uncertainty of measuring TBI and SCI within other injury estimates, which has not been done previously in the GBD framework. In terms of TBI-specific and SCI-specific limitations, we used medical record data extensively in our modelling process, which might not be representative of the entire population. This point is pertinent because most of the dual-coded clinical data that was used in the derivation of cause–nature proportions was from high-income countries. Additionally, the derivation of the incidence coefficient that adjusts for injuries receiving outpatient care was based on limited data. These factors could have introduced selection bias, which was addressed to some extent by incorporation of income and health-care access in our modelling process. However, by relying on medical care records, we potentially did not include people with mild TBI who did not seek medical care, which therefore could be a source of detection bias leading to underestimation, although we addressed this issue by using cause-of-injury incidence models for all injuries requiring medical care, followed by a Dirichlet-based modelling approach of cause–nature combinations. An additional limitation stems from the studies examining how TBI and SCI can occur together.

 A proportion of people can experience an SCI from a traumatic event and also experience TBI, and because of the disability-ranking approach that we used in our cause–nature proportion analysis, these patients would be assigned SCI as their nature of injury. Experiencing both SCI and TBI can also complicate recovery, and presence of non-brain injuries in people with TBI can affect survival, although estimates of the cumulative effect are outside the scope of this analysis. The ICD codes used to identify SCI cases also include some injuries that do not necessarily lead to paraplegia or tetraplegia, and some such injuries, such as spinal cord contusions, can improve over time. Additionally, emerging evidence about long-term deficits such as dementia, stroke, and increased risk of engagement in antisocial behaviour linked to TBI were not included in our disability computation. The long-term neurological and psychological sequelae of TBI are poorly understood, and the epidemiological, neuropathological, and psychiatric analyses intended to understand the resultant disabilities will be important to incorporate in future assessments. Similarly, our analysis does not capture cohort effects over time, a limitation that can be addressed in future GBD studies. Overall, the long-term sequelae due to TBI and SCI suggest that further work in terms of measurement of long-term disability is needed to measure the effect of these conditions more accurately, and to ensure that the disability weights accurately reflect the health loss observed in clinical practice and experienced by individuals; such further work could influence future research into disability-weight measurement via health loss surveys. The limitations we describe also show how more research is needed, particularly in low-income areas of the world, to collect comprehensive injury data. Focusing of resources on injury epidemiology data could improve the accuracy of future epidemiological assessments of TBI and SCI.

In conclusion, the age-standardised incidence, prevalence, and YLD of TBI are increasing globally, whereas age-standardised rates of SCI have not changed (although the number of individuals with SCI is likely to be increasing globally). In view of the expense and complexity of managing patients with TBI and SCI, ministries of health, medical systems, and social support infrastructure should focus on development and improvement of injury-prevention strategies, although maintenance of short-term and long-term care pathways to mitigate health loss and improve outcomes among patients with TBI and SCI is also crucial. Finally, measurement of the burden of these conditions could be improved with the establishment of registry systems for patients with TBI and SCI worldwide, which could help to facilitate further research and intervention efforts and improve the accuracy of future epidemiological assessments of these important conditions.

GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators

Spencer L James, Alice Theadom, Richard G Ellenbogen, Marlena S Bannick, W Cliff Mountjoy-Venning, Lydia R Lucchesi, Nooshin Abbasi, Rizwan Abdulkader, Haftom Niguse Abraha, Jose C Adsuar, Mohsen Afarideh, Sutapa Agrawal, Alireza Ahmadi, Muktar Beshir Ahmed, Amani Nidhal Aichour, Ibtihel Aichour, Miloud Taki Eddine Aichour, Rufus Olusola Akinyemi, Nadia Akseer, Fares Alahdab, Animut Alebel, Suliman A Alghnam, Beriwan Abdulqadir Ali, Ubai Alsharif, Khalid Altirkawi, Catalina Liliana Andrei, Mina Anjomshoa, Hossein Ansari, Mustafa Geleto Ansha, Carl Abelardo T Antonio, Seth Christopher Yaw Appiah, Filippo Ariani, Nigus Gebremedhin Asefa, Solomon Weldegebreal Asgedom, Suleman Atique, Ashish Awasthi, Beatriz Paulina Ayala Quintanilla, Tambe B Ayuk, Peter S Azzopardi, Hamid Badali, Alaa Badawi, Shivanthi Balalla, Amrit Banstola, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Neeraj Bedi, Masoud Behzadifar, Meysam Behzadifar, Bayu Begashaw Bekele, Abate Bekele Belachew, Yihalem Abebe Belay, Derrick A Bennett, Isabela M Bensenor, Adugnaw Berhane, Mircea Beuran, Ashish Bhalla, Soumyadeeep Bhaumik, Zulfiqar A Bhutta, Belete Biadgo, Marco Biffino, Ali Bijani, Nigus Bililign, Charles Birungi, Soufiane Boufous, Alexandra Brazinova, Allen W Brown, Mate Car, Rosario Cárdenas, Juan J Carrero, Félix Carvalho, Carlos A Castañeda-Orjuela, Ferrán Catalá-López, Yazan Chaiah, Ana Paula Champs, Jung-Chen Chang, Jee-Young J Choi, Devasahayam J Christopher, Cyrus Cooper, Christopher Stephen Crowe, Lalit Dandona, Rakhi Dandona, Ahmad Daryani, Dragos Virgil Davitoiu, Meaza Girma Degefa, Gebre Teklemariam Demoz, Kebede Deribe, Shirin Djalalinia, Huyen Phuc Do, David Teye Doku, Thomas M Drake, Manisha Dubey, Eleonora Dubljanin, Ziad El-Khatib, Sharareh Eskandarieh, Alireza Esteghamati, Sadaf Esteghamati, Andre Faro, Farshad Farzadfar, Mohammad Hosein Farzaei, Seyed-Mohammad Fereshtehnejad, Eduarda Fernandes, Garumma Tolu Feyissa, Irina Filip, Florian Fischer, Takeshi Fukumoto, Morasaleh Ganji, Fortune Gbetoho Gankpe, Abadi Kahsu Gebre, Tsegaye Tewelde Gebrehiwot, Kebede Embaye Gezae, Gururaj Gopalkrishna, Alessandra C Goulart, Juanita A Haagsma, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Randah R Hamadeh, Samer Hamidi, Josep Maria Haro, Hadi Hassankhani, Hamid Yimam Hassen, Rasmus Havmoeller, Caitlin Hawley, Simon I Hay, Mohamed I Hegazy, Delia Hendrie, Andualem Henok, Desalegn Tsegaw Hibstu, Howard J Hoffman, Michael K Hole, Enayatollah Homaie Rad, Seyed Mostafa Hosseini, Sorin Hostiuc, Guoqing Hu, Mamusha Aman Hussen, Olayinka Stephen Ilesanmi, Seyed Naghibi Irvani, Mihajlo Jakovljevic, Sudha Jayaraman, Ravi Prakash Jha, Jost B Jonas, Kelly M Jones, Zahra Jorjoran Shushtari, Jacek Jerzy Jozwiak, Mikk Jürisson, Ali Kabir, Amaha Kahsay, Molla Kahssay, Rizwan Kalani, André Karch, Amir Kasaeian, Getachew Mullu Kassa, Tesfaye Dessale Kassa, Zemenu Yohannes Kassa, Andre Pascal Kengne, Yousef Saleh Khader, Morteza Abdullatif Khafaie, Nauman Khalid, Ibrahim Khalil, Ejaz Ahmad Khan, Muhammad Shahzeb Khan, Young-Ho Khang, Habibolah Khazaie, Abdullah T Khoja, Jagdish Khubchandani, Aliasghar A Kiadaliri, Daniel Kim, Young-Eun Kim, Adnan Kisa, Ai Koyanagi, Kristopher J Krohn, Barthelemy Kuate Defo, Burcu Kucuk Bicer, G Anil Kumar, Manasi Kumar, Ratilal Lalloo, Faris Hasan Lami, Van C Lansingh, Dennis Odai Laryea, Arman Latifi, Cheru Tesema Leshargie, Miriam Levi, Shanshan Li, Misgan Legesse Liben, Paulo A Lotufo, Raimundas Lunevicius, Narayan Bahadur Mahotra, Marek Majdan, Azeem Majeed, Reza Malekzadeh, Ana-Laura Manda, Mohammad Ali Mansournia, Benjamin Ballard Massenburg, Kedar K V Mate, Man Mohan Mehndiratta, Varshil Mehta, Hagazi Meles, Addisu Melese, Peter T N Memiah, Walter Mendoza, Getnet Mengistu, Atte Meretoja, Tuomo J Meretoja, Tomislav Mestrovic, Tomasz Miazgowski, Ted R Miller, G K Mini, Andreea Mirica, Erkin M Mirrakhimov, Babak Moazen, Moslem Mohammadi, Ali H Mokdad, Mariam Molokhia, Lorenzo Monasta, Stefania Mondello, Mahmood Moosazadeh, Ghobad Moradi, Mahmoudreza Moradi, Maziar Moradi-Lakeh, Mehdi Moradinazar, Shane Douglas Morrison, Marilita M Moschos, Seyyed Meysam Mousavi, Srinivas Murthy, Kamarul Imran Musa, Ghulam Mustafa, Mohsen Naghavi, Gurudatta Naik, Farid Najafi, Vinay Nangia, Bruno Ramos Nascimento, Ionut Negoi, Trang Huyen Nguyen, Emma Nichols, Dina Nur Anggraini Ningrum, Yirga Legesse Nirayo, Peter S Nyasulu, Richard Ofori-Asenso, Felix Akpojene Ogbo, In-Hwan Oh, Anselm Okoro, Andrew T Olagunju, Tinuke O Olagunju, Pedro R Olivares, Stanislav S Otstavnov, Mayowa Ojo Owolabi, Mahesh P A, Smita Pakhale, Achyut Raj Pandey, Konrad Pesudovs, Gabriel D Pinilla-Monsalve, Suzanne Polinder, Hossein Poustchi, Swayam Prakash, Mostafa Qorbani, Amir Radfar, Anwar Rafay, Alireza Rafiei, Afarin Rahimi-Movaghar, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Muhammad Aziz Rahman, Rajesh Kumar Rai, Fatemeh Rajati, Usha Ram, David Laith Rawaf, Salman Rawaf, Robert C Reiner, Cesar Reis, Andre M N Renzaho, Serge Resnikoff, Satar Rezaei, Shahab Rezaeian, Leonardo Roever, Luca Ronfani, Gholamreza Roshandel, Nobhojit Roy, George Mugambage Ruhago, Basema Saddik, Hosein Safari, Saeid Safiri, Mohammad Ali Sahraian, Payman Salamati, Raphael de Freitas Saldanha, Abdallah M Samy, Juan Sanabria, João Vasco Santos, Milena M M Santric Milicevic, Benn Sartorius, Maheswar Satpathy, Ione J C Schneider, David C Schwebel, Sadaf G Sepanlou, Hosein Shabaninejad, Masood A Ali Shaikh, Mehran Shams-Beyranvand, Mehdi Sharif, Mahdi Sharif-Alhoseini, Sheikh Mohammed Shariful Islam, Jun She, Aziz Sheikh, Jiabin Shen, Kevin N Sheth, Kenji Shibuya, Mekonnen Sisay Shiferaw, Mika Shigematsu, Rahman Shiri, Ivy Shiue, Haitham Shoman, Soraya Siabani, Tariq J Siddiqi, João Pedro Silva, Dayane Gabriele Alves Silveira, Dhirendra Narain Sinha, Mari Smith, Adauto Martins Soares Filho, Soheila Sobhani, Moslem Soofi, Joan B Soriano, Ireneous N Soyiri, Dan J Stein, Mark A Stokes, Mu'awiyyah Babale Sufiyan, Bruno F Sunguya, Jacob E Sunshine, Bryan L Sykes, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Braden James Te Ao, Arash Tehrani-Banihashemi, Merhawi Gebremedhin Tekle, Mohamad-Hani Temsah, Omar Temsah, Roman Topor-Madry, Miguel Tortajada-Girbés, Bach Xuan Tran, Khanh Bao Tran, Lorainne Tudor Car, Kingsley Nnanna Ukwaja, Irfan Ullah, Muhammad Shariq Usman, Olalekan A Uthman, Pascual R Valdez, Tommi Juhani Vasankari, Narayanaswamy Venketasubramanian, Francesco S Violante, Fasil Shiferaw Wagnew, Yasir Waheed, Yuan-Pang Wang, Kidu Gidey Weldegwergs, Andrea Werdecker, Tissa Wijeratne, Andrea Sylvia Winkler, Grant M A Wyper, Yuichiro Yano, Mehdi Yaseri, Yasin Jemal Yasin, Pengpeng Ye, Ebrahim M Yimer, Paul Yip, Engida Yisma, Naohiro Yonemoto, Seok-Jun Yoon, Michael G Yost, Mustafa Z Younis, Mahmoud Yousefifard, Chuanhua Yu, Zoubida Zaidi, Sojib Bin Zaman, Mohammad Zamani, Zerihun Menlkalew Zenebe, Sanjay Zodpey, Valery L Feigin, Theo Vos, Christopher J L Murray.

Affiliations

Institute for Health Metrics and Evaluation (S L James MD, M S Bannick BS, W C Montjoy-Venning BA, L R Lucchesi BA, Prof L Dandona MD, Prof R Dandona PhD, C Hawley MSPH, Prof S I Hay DSc, M Jakovljevic PhD, I Khalil PhD, K J Krohn MPH, Prof A H Mokdad PhD, Prof M Naghavi PhD, E Nichols BA, R C Reiner PhD, M Smith MPA, Prof V L Feigin PhD, Prof T Vos PhD, Prof C J L Murray DPhil), Department of Health Metrics Sciences (S I Hay, I Khalil, A H Mokdad, M Naghavi, R C Reiner, T Vos, C J L Murray), Department of Anesthesiology and Pain Medicine (J E Sunshine MD), Department of Environmental and Occupational Health Sciences (Prof M G Yost PhD), Department of Neurology (Prof R G Ellenbogen MD, R Kalani MD), Department of Surgery (S D Morrison MD), and Division of Plastic Surgery, Department of Surgery (C S Crowe MD, B B Massenburg MD), University of Washington, Seattle, WA, USA; National Institute for Stroke and Applied Neurosciences (A Theadom PhD, Prof V L Feigin, B J Te Ao PhD), and School of Public Health (S Balalla MPH), Auckland University of Technology, Auckland, New Zealand (K M Jones PhD); Centre of Cardiovascular Research and Education in Therapeutics (R Ofori-Asenso MSc) and School of Public Health and Preventive Medicine (S Li PhD), Monash University, Melbourne, VIC, Australia; Department of Anatomy (S Sobhani MD), Department of Epidemiology and Biostatistics (Prof S M Hosseini PhD, M A Mansournia PhD, M Yaseri PhD), Department of Health Management and Economics (M Anjomshoa PhD, S M Mousavi PhD), Department of Pharmacology (Arv Haj-Mirzaian MD, Ary Haj-Mirzaian MD), Digestive Diseases Research Institute (Prof R Malekzadeh MD, H Poustchi PhD, G Roshandel PhD, S G Sepanlou MD), Endocrinology and Metabolism Research Center (M Afarideh MD, Prof A Esteghamati MD, S Esteghamati MD, M Ganji MD), Hematologic Malignancies Research Center (A Kasaeian PhD), Hematology-Oncology and Stem Cell Transplantation Research Center (A Kasaeian), Iranian National Center for Addiction Studies (A Rahimi-Movaghar MD), MS Research Center (S Eskandarieh PhD, Prof M A Sahraian MD), Non-Communicable Diseases Research Center (M Shams-Beyranvand MS), Non-communicable Diseases Research Center (N Abbasi MD, F Farzadfar MD, S N Irvani MD), and Sina Trauma and Surgery Research Center (Prof V Rahimi-Movaghar MD, P Salamati MD, M Sharif-Alhoseini PhD), Tehran University of Medical Sciences, Tehran, Iran; Montreal Neuroimaging Center (N Abbasi), Montreal Neurological Institute (S-M Fereshtehnejad PhD), and School of Physical and Occupational Therapy (K K V Mate MSc), McGill University, Montreal, QC, Canada; Department of Statistics, Manonmaniam Sundaranar University, Tirunelveli, India (R Abdulkader MD); Clinical Pharmacy Unit (H N Abraha MSc, T D Kassa MS, Y L Nirayo MS, K G Weldegwergs MS), Department of Biostatistics (K E Gezae MS), Department of Midwifery (Z M Zenebe MS), Department of Nutrition and Dietetics (M G Degefa BSc, A Kahsay MPH), School of Pharmacy (S W Asgedom MS, A K Gebre MS, E M Yimer MS), and School of Public Health (A B Belachew MS), Mekelle University, Mekelle, Ethiopia (H Meles MPH); Sport Science Department, University of Extremadura, Badajoz, Spain (J C Adsuar PhD); Indian Institute of Public Health (Prof S Zodpey PhD), Public Health Foundation of India, Gurugram, India (S Agrawal PhD, A Awasthi PhD, Prof L Dandona, Prof R Dandona, G A Kumar PhD); Vital Strategies, Gurugram, India (S Agrawal); Department of Anesthesiology (A Ahmadi PhD), Department of Epidemiology and Biostatistics (Prof F Najafi PhD), Department of Health Education and Promotion (F Rajati PhD), Department of Psychiatry (H Khazaie MD), Department of Traditional and Complementary Medicine (M H Farzaei PhD), Department of Urology (Prof M Moradi MD), Environmental Determinants of Health Research Center (S Rezaei PhD, M Soofi PhD), Imam Ali Cardiovascular Research Center (S Siabani PhD), and Pharmaceutical Sciences Research Center (M H Farzaei), Kermanshah University of Medical Sciences, Kermanshah, Iran (S Rezaeian PhD); Department of Epidemiology (M B Ahmed MPH, T T Gebrehiwot MPH) and Department of Health Education and Behavioral Sciences (G T Feyissa MPH, M A Hussen MPH), Jimma University, Jimma, Ethiopia; University Ferhat Abbas of Setif, Setif, Algeria (A Aichour BMedSc, I Aichour BPharm); Higher National School of Veterinary Medicine, Algiers, Algeria (M T E Aichour MA); Institute for Advanced Medical Research and Training, University of Ibadan, Ibadan, Nigeria (R O Akinyemi PhD, Prof M O Owolabi DrM); Centre for Global Child Health, The Hospital for Sick Children (N Akseer PhD, Z A Bhutta PhD) and Department of Nutritional Sciences (A Badawi PhD), University of Toronto, Toronto, Ontario, Canada; Evidence-based Practice Center (F Alahdab MD), Mayo Clinic Foundation for Medical Education and Research, Rochester, MN, USA; Research Committee, Syrian American Medical Society, Washington, DC, USA (F Alahdab); College of Health Sciences (G M Kassa MS), Department of Nursing (A Alebel MS, F W S Wagnew MS), Department of Public Health (Y A Belay MPH, C T Leshargie MPH), Debre Markos University, Debre Markos, Ethiopia; Department of Population Health Research (S A Alghnam PhD), King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Medical Technical Institute, Erbil Polytechnic University, Erbil, Iraq (B A Ali PhD); Faculty of Pharmacy, Ishik University, Erbil, Iraq (B A Ali); Charité University Medical Center Berlin, Berlin, Germany (U Alsharif MD); Department of Pediatrics (M-H Temsah MD), King Saud University, Riyadh, Saudi Arabia (K Altirkawi MD); Department of General Surgery (D V Davitoiu PhD), Department of Legal Medicine and Bioethics (S Hostiuc PhD), and Emergency Hospital of Bucharest (M Beuran PhD, I Negoi PhD), Carol Davila University of Medicine and Pharmacy, Bucharest, Romania (C L Andrei PhD); Zahedan University of Medical Sciences, Zahedan, Iran (H Ansari PhD); Department of Public Health, Debre Berhan University, Debre Berhan, Ethiopia (M G Ansha MPH); Department of Health Policy and Administration, University of the Philippines Manila, Manila, Philippines (C A T Antonio MD); Department of Sociology and Social Work, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (S C Y Appiah MS); Center for International Health, Ludwig Maximilians University, Munich, Germany (S C Y Appiah); Regional Centre for the Analysis of Data on Occupational and Work-related Injuries and Diseases (M Levi PhD), Local Health Unit Tuscany Centre, Florence, Italy (F Ariani MSc, M Biffino MSc); University Medical Center Groningen, University of Groningen, Groningen, Netherlands (N G Asefa MPH); University Institute of Public Health, University of Lahore, Lahore, Pakistan (S Atique PhD); Public Health Department, University of Hail, Hail, Saudi Arabia (S Atique); Indian Institute of Public Health, Gandhinagar, India (A Awasthi); Austin Clinical School of Nursing (M A Rahman PhD), Department of Psychology (Prof T Wijeratne MD), and the Judith Lumley Centre (B P Ayala Quintanilla PhD), La Trobe University, Melbourne, VIC, Australia; General Office for Research and Technological Transfer, Peruvian National Institute of Health, Lima, Peru (B P Ayala Quintanilla); Centre for Food and Nutrition Research, Institute of Medical Research and Medicinal Plant studies, Yaounde, Cameroon (T B Ayuk PhD); Global Adolescent Health Group, Burnet Institute, Melbourne, VIC, Australia (P S Azzopardi PhD); Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, SA, Australia (P S Azzopardi); Department of Immunology (Prof A Rafiei PhD), Department of Medical Mycology (H Badali PhD), Department of Physiology and Pharmacology (M Mohammadi PhD), Health Sciences Research Center (M Moosazadeh PhD), Molecular and Cell Biology Research Center (Prof A Rafiei), and Toxoplasmosis Research Center (A Daryani PhD), Mazandaran University of Medical Sciences, Sari, Iran; Public Health Risk Sciences Division, Public Health Agency of Canada, Toronto, ON, Canada (A Badawi); Department of Research, Public Health Perspective Nepal, Pokhara-Lekhnath, Nepal (A Banstola MPH); Molecular Medicine and Pathology (K B Tran MD), School of Population Health, Faculty of Medical and Health Science (B J Te Ao), and School of Psychology (Prof S L Barker-Collo PhD), University of Auckland, Auckland, New Zealand; Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany (T W Bärnighausen MD); TH Chan School of Public Health, Harvard University, Boston, MA; (T W Bärnighausen); Department of Community Medicine, Gandhi Medical College Bhopal, Bhopal, India (N Bedi MD); Jazan University, Jazan, Saudi Arabia (N Bedi); Department of Community Medicine (A Tehrani-Banihashemi PhD), Department of Health Policy (H Shabaninejad PhD), Health Management and Economics Research Center (Ma Behzadifar PhD), Minimally Invasive Surgery Research Center (A Kabir MD), Physiology Research Center (M Yousefifard PhD), and Preventive Medicine and Public Health Research Center (A Tehrani-Banihashemi, M Moradi-Lakeh MD), Iran University of Medical Sciences, Tehran, Iran; Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran (Ma Behzadifar, Me Behzadifar MS); Public Health Department (B Bekele MPH, H Y Hassen MPH), Mizan-Tepi University, Teppi, Ethiopia (A Henok MPH); Department of Clinical Chemistry (B Biadgo MS) and Institute of Public Health (B Bekele), University of Gondar, Gondar, Ethiopia; Nuffield Department of Population Health, University of Oxford, Oxford, UK (D A Bennett PhD); Center for Clinical and Epidemiological Research (A C Goulart PhD), Department of Internal Medicine (I M Bensenor PhD), Department of Medicine (P A Lotufo DrPH), Department of Psychiatry (Y P Wang PhD), and Internal Medicine Department (A C Goulart), University of São Paulo, São Paulo, Brazil; School of Alaide Health Sciences (E Yisma MPH) and School of Public Health (A Berhane PhD, K Deribe PhD, Y J Yasin MPH), Addis Ababa University, Addis Ababa, Ethiopia (G T Demoz MS); Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India (Prof A Bhalla MD); The George Institute for Global Health, New Delhi, India (S Bhaumik MBBS); Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan (Z A Bhutta); Social Determinant of Health Research Center (A Bijani PhD) and Student Research Committee (M Zamani MD), Babol University of Medical Sciences, Babol, Iran; Woldia University, Woldia, Ethiopia (N Bililign BHlthSci); Department of Psychology (M Kumar PhD) and UCL Centre for Global Health Economics (C Birungi MSc), University College London, London, UK; Fast-Track Implementation Department, UNAIDS, Gaborone, Botswana (C Birungi); Transport and Road Safety Research, University of New South Wales, Sydney, NSW, Australia (S Boufous PhD); Institute of Epidemiology, Comenius University, Bratislava, Slovakia (A Brazinova MD); Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, MN, USA (A W Brown MD); Department of Primary Care and Public Health (M Car PhD, Prof A Majeed MD, S Rawaf PhD) and WHO Collaborating Centre for Public Health Education and Training (D L Rawaf MD, H Shoman MPH), Imperial College London, London, UK; Ministry of Health, Riyadh, Saudi Arabia (M Car); Department of Population and Health, Metropolitan Autonomous University, Mexico City, Mexico (Prof R Cárdenas DSc); Department of Medical Epidemiology and Biostatistics (J J Carrero PhD), Department of Neurobiology, Care Sciences and Society (S-M Fereshtehnejad), and Department of Public Health Sciences (Z El-Khatib PhD, N Roy PhD), Karolinska Institute, Stockholm, Sweden; Applied Molecular Biosciences Unit (F Carvalho PhD), Department of Community Medicine, Information and Health Decision Sciences, CINTESIS, Faculty of Medicine (J V Santos MD), Institute of Public Health (F Carvalho), REQUIMTE/LAQV (Prof E Fernandes PhD), and UCIBIO (J P Silva PhD), University of Porto, Porto, Portugal; Colombian National Health Observatory (C A Castañeda-Orjuela MS) and National Institute on Deafness and Other Communication Disorders (H J Hoffman MA), National Institute of Health, Bogota, Colombia; Epidemiology and Public Health Evaluation Group, National University of Colombia, Bogota, Colombia (C A Castañeda-Orjuela); Department of Health Planning and Economics, Institute of Health Carlos III, Madrid, Spain (F Catalá-López PhD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Y Chaiah, M-H Temsah, O Temsah); Independent Consultant, Minas Gerais, Brazil (Prof A P Champs PhD); College of Medicine, National Taiwan University, Taipei, Taiwan (J-C Chang PhD); Biochemistry, Biomedical Science, Seoul National University Hospital, Seoul, South Korea (J-Y J Choi PhD); Department of Pulmonary Medicine, Christian Medical College and Hospital, Vellore, India (D J Christopher MD); NIHR Oxford Biomedical Research Centre, University of Southampton, Southampton, UK (Prof C Cooper MEd); Department of Surgery, Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania (D V Davitoiu); Department of Clinical Pharmacy, Aksum University, Aksum, Ethiopia (G T Demoz); Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK (K Deribe); Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran (S Djalalinia PhD); Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam (H P Do PhD, T H Nguyen BMedSc); Department of Population and Health, University of Cape Coast, Cape Coast, Ghana (D T Doku PhD); Faculty of Social Sciences, University of Tampere, Tampere, Finland (D T Doku); Department of Clinical Surgery (T M Drake MD), and Usher Institute of Population Health Sciences and Informatics (Prof A Sheikh MSc, I N Soyiri PhD), University of Edinburgh, Edinburgh, Scotland, UK; UN World Food Programme, New Delhi, India (M Dubey PhD); Centre School of Public Health and Health Management (M M M Santric Milicevic PhD) and Faculty of Medicine (E Dubljanin PhD), University of Belgrade, Belgrade, Serbia; Department of Surgery, Seattle Childrens Hospital, Seattle, WA, USA (Prof R G Ellenbogen); Department of Psychology, Federal University of Sergipe, Sao Cristovao, Brazil (A Faro PhD); Psychiatry, Kaiser Permanente, Fontana, CA, USA (I Filip MD); Department of Health Sciences (I Filip), AT Still University, Mesa, AZ, USA (A Radfar MD); Department of Public Health Medicine, Bielefeld University, Bielefeld, Germany (F Fischer PhD); Gene Expression and Regulation Program, Cancer Institute, Philadelphia, PA, USA (T Fukumoto PhD); Department of Dermatology, Kobe University, Kobe, Japan (T Fukumoto); Faculty of Medicine and Pharmacy of Fez, University Sidi Mohammed Ben Abdellah, Fez, Morocco (F G Gankpe MD); Non Communicable Disease Department, Laboratory of Studies and Research—Action in Health, Porto-Novo, Benin (F G Gankpe); Department of Epidemiology, National Institute of Mental Health and Neurosciences, Bangalore, India (Prof G Gopalkrishna MD); Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands (J A Haagsma PhD, S Polinder MA); Ophthalmic Research Center (M Yaseri), and Research Institute for Endocrine Sciences (Arv Haj-Mirzaian, S N Irvani), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Health Policy and Management (A T Khoja MD), Department of Neurology and Neurosurgery (G D Pinilla-Monsalve MD), and Department of Radiology (Ary Haj-Mirzaian), Johns Hopkins University, Baltimore, MD, USA; Department of Family and Community Medicine, Arabian Gulf University, Manama, Bahrain (Prof R R Hamadeh DPhil); School of Health and Environmental Studies, Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates (Prof S Hamidi DrPH); Clinical Microbiology and Parasitology Unit, Research and Development Unit (Prof J M Haro MD), San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain (Prof J M Haro); Tabriz University of Medical Sciences, Tabriz, Iran (H Hassankhani PhD); Clinical Sciences, Karolinska University Hospital, Stockholm, Sweden (R Havmoeller PhD); Department of Neurology, Cairo University, Cairo, Egypt (M I Hegazy PhD); School of Public Health, Curtin University, Bentley, WA, Australia (D Hendrie PhD, T R Miller PhD); Department of Reproductive Health (D T Hibstu MPH) and School of Nursing and Midwifery (Z Y Kassa MSc), Hawassa University, Hawassa, Ethiopia; Division of Scientific Programs, National Institutes of Health, Bethesda, MD, USA (H J Hoffman); University of Texas, Austin, Austin, TX, USA (M K Hole MD); Guilan Road Trauma Research Center and School of, Guilan University of Medical Sciences, Rasht, Iran (E Homaie Rad PhD); Clinical Legal Medicine, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania (S Hostiuc); Department of Epidemiology and Health Statistics, Central South University, Changsha, China (Prof G Hu PhD); Department of Public Health and Community Medicine, University of Liberia, Monrovia, Liberia (O S Ilesanmi PhD); Medical Sciences Department, University of Kragujevac, Kragujevac, Serbia (M Jakovljevic); Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA (S Jayaraman MD); Department of Community Medicine, Banaras Hindu University, Varanasi, India (R P Jha MS); Department of Ophthalmology (J B Jonas MD) and Institute of Public Health (B Moazen MS), Heidelberg University, Mannheim, Germany; Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Beijing, China (J B Jonas); University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (Z Jorjoran Shushtari MS); Institution of Health and Nutrition Sciences, Czestochowa University of Technology, Czestochowa, Poland (J J Jozwiak PhD); Faculty of Medicine and Health Sciences, University of Opole, Opole, Poland (J J Jozwiak); Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia (M Jürisson PhD); Department of Public Health, Samara University, Samara, Ethiopia (M Kahssay MPH, M L Liben MPH); Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany (A Karch MD); Non-Communicable Diseases Research Unit, Medical Research Council South Africa, Cape Town, South Africa (Prof A P Kengne PhD); Department of Public Health and Community Medicine, Jordan University of Science and Technology, Ramtha, Jordan (Prof Y S Khader PhD); Department of Neurosurgery (H Safari MD) and Department of Public Health (M A Khafaie PhD), Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; School of Food and Agricultural Sciences, University of Management and Technology, Lahore, Pakistan (N Khalid PhD); Epidemiology and Biostatistics Department, Health Services Academy, Islamabad, Pakistan (E A Khan MPH); Department of Internal Medicine, John H Stroger, Jr Hospital of Cook County, Chicago, IL, USA (M S Khan MD); Department of Internal Medicine (M S Khan, M S Usman MBBS, T J Siddiqi), Dow University of Health Sciences, Karachi, Pakistan; Department of Health Policy and Management and Institute of Health Policy and Management, Seoul National University, Seoul, South Korea (Prof Y-H Khang MD); Department of Public Health, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia (A T Khoja); Department of Nutrition and Health Science, Ball State University, Muncie, IN, USA (J Khubchandani PhD); Clinical Epidemiology Unit, Lund University, Lund, Sweden (A A Kiadaliri PhD); Department of Health Sciences, Northeastern University, Boston, MA, USA (Prof D Kim DrPH); Department of Preventive Medicine, Korea University, Seoul, South Korea (Y-E Kim PhD, S-J Yoon PhD); Department of Health Management and Health Economics (A Kisa PhD) and Institute of Health and Society (A S Winkler PhD), University of Oslo, Oslo, Norway; Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA, USA (A Kisa); Research and Development Unit, San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain (A Koyanagi MD); Department of Demography and Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada (Prof B Kuate Defo PhD); Faculty of Medicine, Department of Public Health, Yuksek Ihtisas University, Ankara, Turkey (B Kucuk Bicer BEP); Department of Public Health, Hacettepe University, Ankara, Turkey (B Kucuk Bicer); University of Nairobi, Nairobi, Kenya (M Kumar); School of Dentistry, University of Queensland, Brisbane, QLD, Australia (R Lalloo PhD); Department of Epidemiology (M Moradinazar PhD) and Department of Community and Family Medicine (F H Lami PhD), Academy of Medical Science, Baghdad, Iraq; HelpMeSee, New York, NY, USA (V C Lansingh PhD); Relaciones Internacionales, Mexican Institute of Ophthalmology, Queretaro, Mexico (V C Lansingh); Disease Control Department, Ghana Health Service, Accra, Ghana (D O Laryea MD); Department of Public Health (A Latifi PhD) and Managerial Epidemiology Research Center (S Safiri PhD), Maragheh University of Medical Sciences, Maragheh, Iran; Department of Health Sciences, University of Florence, Florence (M Levi); General Surgery Department, Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK (R Lunevicius PhD); Surgery Department University of Liverpool, Liverpool, UK (R Lunevicius); Institute of Medicine, Tribhuvan University, Kathmandu, Nepal (N B Mahotra MD); Department of Public Health, Trnava University, Trnava, Slovakia (M Majdan PhD); Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran (Prof R Malekzadeh, S G Sepanlou); Surgery Department, Emergency University Hospital Bucharest, Bucharest, Romania (A-L Manda MD); Neurology Department, Janakpuri Super Specialty Hospital Society, New Delhi, India (M M Mehndiratta MD); Department of Internal Medicine, SevenHills Hospital, Mumbai, India (V Mehta MD); College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia (A Melese MS); Department of Public Health, University of West Florida, Pensacola, FL, USA (P T N Memiah DrPH); Peru Country Office, UNFPA, Lima, Peru (W Mendoza MD); School of Pharmacy (G Mengistu MS, M S Shiferaw MSc) and School of Public Health (M G Tekle MPH), Haramaya University, Harar, Ethiopia; Department of Pharmacy, Wollo University, Dessie, Ethiopia (G Mengistu); Breast Surgery Unit (T J Meretoja MD) and Neurocenter (A Meretoja MD), Helsinki University Hospital, Helsinki, Finland; Department of Medicine (Prof T Wijeratne) and School of Health Sciences (A Meretoja, Prof C E I Szoeke PhD), University of Melbourne, Parkville, VIC, Australia; University of Helsinki, Helsinki, Finland (T J Meretoja); Dr Zora Profozic Polyclinic, Zagreb, Croatia (T Mestrovich PhD); University Centre Varazdin, University North, Varazdin, Croatia (T Mestrovic); Department of Hypertension, Pomeranian Medical University, Szczecin, Poland (T Miazgowski MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller); Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India (G K Mini PhD); Department of Public Health, Amrita Institute of Medical Sciences, Kochi, India (G K Mini); Department of Statistics and Econometrics, Bucharest University of Economic Studies, Bucharest, Romania (A Mirica PhD); President's Office, National Institute of Statistics, Bucharest, Romania (A Mirica); Faculty of General Medicine, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan (E M Mirrakhimov MD); Department of Atherosclerosis and Coronary Heart Disease, National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan (E M Mirrakhimov); Institute of Addiction Research, Frankfurt University of Applied Sciences, Frankfurt, Germany (B Moazen); Faculty of Life Sciences and Medicine, King's College London, London, UK (M Molokhia PhD); Clinical Epidemiology and Public Health Research Unit, Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy (L Monasta DSc, L Ronfani PhD); Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy (S Mondello MD); Department of Neurology (S Mondello MD), Oasi Research Institute, Troina, Italy (S Mondello); Department of Epidemiology and Biostatistics and Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran (G Moradi PhD); First Department of Ophthalmology, General Hospital of Athens, University of Athens, Athens, Greece (M M Moschos PhD); Biomedical Research Foundation, Academy of Athens, Athens, Greece (M M Moschos); Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada (S Murthy MD); School of Medical Sciences, Science University of Malaysia, Kubang Kerian, Malaysia (K I Musa PhD); Pediatrics Department, Nishtar Medical University, Multan, Pakistan (Prof G Mustafa MD); Pediatrics and Pediatric Pulmonology, Institute of Mother and Child Care, Multan, Parkistan (Prof G Mustafa); Department of Epidemiology (G Naik MPH) and Department of Psychology (D C Schwebel PhD), University of Alabama at Birmingham, Birmingham, AL, USA; Ophthalmology, Suraj Eye Institute, Nagpur, India (V Nangia MD); Hospital of the Federal University of Minas Gerais, Federal University of Minas Gerais, Belo Horizonte, Brazil (B R Nascimento PhD); Public Health Science Department, State University of Semarang, Gunungpati, Indonesia (D N A Ningrum MPH); Graduate Institute of Biomedical Informatics, Taipei University, Taipei, Taiwan (D N A Ningrum); Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa (Prof P S Nyasulu PhD); Independent Consultant, Accra, Ghana (R Ofori-Asenso); School of Social Sciences and Psychology (Prof A M N Renzaho PhD) and Translation Health Research Institute (F A Ogbo PhD), Western Sydney University, Penrith, NSW, Australia; Department of Preventive Medicine, School of Medicine, Kyung Hee University, Dongdaemun-gu, South Korea (I-H Oh PhD); Research, Measurement, and Results, Society for Family Health, Nigeria, Abuja, Nigeria (A Okoro MPH); University of Adelaide, Adelaide, SA Australia, Australia (A T Olagunju MD); Department of Psychiatry, University of Lagos, Lagos, Nigeria (A T Olagunju); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada (T O Olagunju MD); Institute of Physical Activity and Health, Autonomous University of Chile, Talca, Chile (Prof P R Olivares PhD); Center for Healthcare Quality Assessment and Control, Ministry of Health of the Russian Federation, Moscow, Russia (S S Otstavnov PhD); Moscow Institute of Physics and Technology, Moscow State University, Dolgoprudny, Russia (S S Otstavnov); Department of TB and Respiratory Medicine, Jagadguru Sri Shivarathreeswara University, Mysore, India (Prof M P A DNB); Department of Medicine, University of Ottawa, Ottawa, ON, Canada (S Pakhale MD); Research Section, Nepal Health Research Council, Kathmandu, Nepal (A R Pandey MPH); Independent Consultant, Glenelg, SA, Australia (Prof K Pesudovs PhD); Cardiovascular Institute, International Hospital of Colombia, Floridablanca, Colombia (G D Pinilla-Monsalve); Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (S Prakash PhD); Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran (M Qorbani PhD); Medichem, Barcelona, Spain (A Radfar); Epidemiology and Biostatistics, Contech School of Public Health, Lahore, Pakistan (A Rafay MS); Research and Evaluation Divison, BRAC University, Dhaka, Bangladesh (M Rahman PhD); Department of Psychology (M A Stokes PhD), Institute for Physical Activity and Nutrition (S M Shariful Islam PhD), and School of Medicine (M A Rahman PhD), Deakin University, Waurn Ponds, VIC, Australia; Society for Health and Demographic Surveillance, Suri, India (R K Rai MPH); Department of Economics, University of Göttingen, Göttingen, (R K Rai); Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India (U Ram PhD); University College London Hospitals, London, UK (D L Rawaf); Public Health England, London, UK (S Rawaf); Department of Preventive Medicine and Occupational Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA (C Reis MD); Brien Holden Vision Institute, Sydney, NSW, Australia (S Resnikoff MD); Organization for the Prevention of Blindness, Paris, France (S Resnikoff); Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil (L Roever PhD); Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran (G Roshandel); Public Health Planning and Evidence Practice Area, National Health Systems Resource Centre, New Delhi, India (N Roy); Department of Community Health (B F Sunguya PhD) and School of Public Health (G M Ruhago PhD), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Medical Department, University of Sharjah, Sharjah, United Arab Emirates (B Saddik PhD); School of Health and Policy Management, York University, Toronto, ON, Canada (P Salamati); Institute of Scientific and Technological Communication and Information in Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil (R d F Saldanha MPH); Department of Entomology, Ain Shams University, Cairo, Egypt (A M Samy PhD); Department of Surgery, Marshall University, Huntington, WV, USA (J Sanabria MD); Department of Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, OH, USA (J Sanabria); Department of Public Health, Regional Health Administration Do Norte IP, Vila Nova de Gaia, Portungal (J V Santos); Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa (Prof B Sartorius PhD); UGC Centre of Advanced Study in Psychology, Utkal University, Bhubaneswar, India (M Satpathy PhD); Udyam-Global Association for Sustainable Development, Bhubaneswar, India (M Satpathy); School of Health Sciences, Federal University of Santa Catarina, Araranguá, Brazil (I J C Schneider PhD); Independent Consultant, Karachi, Pakistan (M A A Shaikh MD); School of Medicine, Dezful University of Medical Sciences, Dezful, Iran (M Shams-Beyranvand); Department of Basic Sciences, Islamic Azad University, Sari, Iran (Prof M Sharif PhD); Department of Pulmonary Medicine, Fudan University, Shanghai, China (J She MD); Center for Pediatric Trauma Research, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA (J Shen PhD); Department of Neurology, Yale University, New Haven, CT, USA (K N Sheth MD); Department of Global Health Policy, University of Tokyo, Bunkyo-ku, Japan (K Shibuya MD); National Institute of Infectious Diseases, Tokyo, Japan (M Shigematsu PhD); Finnish Institute of Occupational Health, Helsinki, Finland (R Shiri PhD); Institute of Medical Epidemiology, Martin Luther University Halle-Wittenberg, Halle, Germany (I Shiue PhD); School of Health, University of Technology Sydney, Sydney, NSW, Australia (S Siabani); Brasília University, Brasília, Brazil (Prof D A Silveira MS); Department of Diseases and Noncommunicable Diseases and Health Promotion (A M Soares Filho DSc) and Department of the Health Industrial Complex and Innovation in Health (Prof D A Silveira), Federal Ministry of Health, Brasília, Brazil; Epidemiology, School of Preventive Oncology, Patna, India (D N Sinha PhD); Service of Pulmonology, Health Research Institute of the University Hospital de la Princesa, Madrid, Spain (Prof J B Soriano MD); Department of Epidemiology, Healis Sekhsaria Institute for Public Health, Mumbai, India (D N Sinha); Pneumology Service, Autonomous University of Madrid, Madrid, Spain (Prof J B Soriano); Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa (Prof D J Stein MD); South African Medical Research Council, Cape Town, South Africa (Prof D J Stein); Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria (M B Sufiyan MD); Department of Criminology, Law and Society, University of California, Irvine, Irvine, CA, USA (Prof B L Sykes PhD); The Brain Institute, Australian Catholic University, Melbourne, VIC, Australia (Prof C E I Szoeke); Department of Medicine (R Tabarés-Seisdedos PhD) and Department of Pediatrics, Obstetricts and Gynecology (M Tortajada-Girbés PhD), University of Valencia, Valencia, Spain; Carlos III Health Institute, Biomedical Research Networking Center for Mental Health Network, Madrid, Spain (R Tabarés-Seisdedos); Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland (R Topor-Madry PhD); Pediatric Department, University Hospital Doctor Peset, Valencia, Spain (M Tortajada-Girbés); Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam (B X Tran PhD); Clinical Hematology and Toxicology, Military Medical University, Hanoi, Hanoi, Vietnam (K B Tran); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore (L Tudor Car PhD); Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria (K N Ukwaja MS); Gomal Center of Biochemistry and Biotechnology, Gomal University, Dera Ismail Khan, Pakistan (I Ullah PhD); TB Culture Laboratory, Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Pakistan (I Ullah); Division of Health Sciences, University of Warwick, Coventry, UK (O A Uthman PhD); Argentine Society of Medicine, Buenos Aires, Argentina (P R Valdez MEd); Intensive Care Unit Staff, Velez Sarsfield Hospital, Buenos Aires, Argentina (P R Valdez); UKK Institute, Tampere, Finland (T J Vasankari MD); Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore (Prof N Venketasubramanian MBBS); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (Prof N Venketasubramanian); Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Prof F S Violante MPH); Occupational Health Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy (Prof F S Violante); Foundation University Medical College, Foundation University, Rawalpindi, Pakistan (Y Waheed PhD); Demographic Change and Ageing Research Area, Federal Institute for Population Research, Wiesbaden, Germany (A Werdecker PhD); Independent Consultant, Staufenberg, Germany (A Werdecker); National Health Service Scotland, Edinburgh, Scotland, UK (G M A Wyper MSc); University of Strathclyde, Glasgow, Scotland, UK (G M A Wyper); Department of Preventive Medicine, Northwestern University, Chicago, IL, USA (Y Yano MD); Department of Earth Science, King Fahd University of Petroleum and Minerals, Dhahran, Saudi Arabia (Y J Yasin); Division of Injury Prevention and Mental Health Improvement, Chinese Center for Disease Control and Prevention, Beijing, China (P Ye MPH); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); Department of Biostatistics, Kyoto University, Kyoto, Japan (N Yonemoto MPH); Department of Health Policy and Management, Jackson State University, Jackson, MS, USA (Prof M Z Younis DrPH); Tsinghua University, Beijing, China (Prof M Z Younis); Department of Epidemiology and Biostatistics and Global Health Institute, Wuhan University, Wuhan, China (Prof C Yu PhD); University Hospital of Setif, Setif, Algeria (Prof Z Zaidi PhD); and Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (S B Zaman MPH).

Contributors

SLJ, AT, VLF, RGE, and TV prepared the first draft. MSB, WCM-V, and LRL analysed the data and edited the first draft and final versions of the Article. SLJ, AT, VLF, RGE, and TV finalised all drafts, and approved the final version of the Article. All other authors provided data, developed models, reviewed results, provided guidance on methods, or reviewed the Article, and approved the final version.

Declaration of interests

CATA reports personal fees from Johnson & Johnson (Philippines). CC reports personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GlaxoSmithKline, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda, and UCB. JJJ reports a grant from Valeant, personal fees from Valeant, ALAB Laboratoria, and Amgen, and non-financial support from Microlife and Servier. WM is the Program Analyst for Population and Development at the Peru Country Office of UNFPA, an institution which does not necessarily endorse this study. KS reports grants from the Japanese Ministry of Health, Labour and Welfare, Ministry of Education, Culture, Sports, Science and Technology, and National Center for Global Health and Medicine. CEIS reports grants from the Australian National Medical Health Research Council, Lundbeck, the Australian Alzheimer's Association, and the Royal Australasian College of Practitioners, and is the holder of a patent (PCT/AU2008/001556). JK has received research funds from Merck Neuroscience Research Laboratories. All other authors declare no competing interests.

Acknowledgments

We acknowledge the funding and support of the Bill & Melinda Gates Foundation. AK was supported by the Miguel Servet contract, which was financed by the CP13/00150 and PI15/00862 projects integrated into the National Research, Development, and Implementation, and funded by the Instituto de Salud Carlos III General Branch Evaluation and Promotion of Health Research and the European Regional Development Fund (ERDF-FEDER). AMS is supported by the Egyptian Fulbright Mission Program. AF acknowledges the Federal University of Sergipe (Sergipe, Brazil). AA received financial assistance from the Indian Department of Science and Technology (New Delhi, India) through the INSPIRE faculty programme. AS is supported by Health Data Research UK. DJS is supported by the South African Medical Research Council. AB is supported by the Public Health Agency of Canada. SMSI received a senior research fellowship from the Institute for Physical Activity and Nutrition, Deakin University (Waurn Ponds, VIC, Australia), and a career transition grant from the High Blood Pressure Research Council of Australia. FP and CF acknowledge support from the European Union (FEDER funds POCI/01/0145/FEDER/007728 and POCI/01/0145/FEDER/007265) and National Funds (FCT/MEC, Fundação para a Ciência e a Tecnologia, and Ministério da Educação e Ciência) under the Partnership Agreements PT2020 UID/MULTI/04378/2013 and PT2020 UID/QUI/50006/2013. TB acknowledges financial support from the Institute of Medical Research and Medicinal Plant Studies, Yaoundé, Cameroon. AM of Imperial College London is grateful for support from the Northwest London National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care and the Imperial NIHR Biomedical Research Centre. KD is funded by a Wellcome Trust Intermediate Fellowship in Public Health and Tropical Medicine (grant number 201900). PSA is supported by an Australian National Health and Medical Research Council Early Career Fellowship. RT-S was supported in part by grant number PROMETEOII/2015/021 from Generalitat Valenciana and the national grant PI17/00719 from ISCIII-FEDER. The Serbian part of this contribution (by MJ) has been co-financed with grant OI175014 from the Serbian Ministry of Education, Science and Technological Development; publication of results was not contingent upon the Ministry's approval. MMMSM acknowledges support from the Serbian Ministry of Education, Science and Technological Development (contract 175087). MM's research was supported by the NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust (London, UK) and King's College London. The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR, or the UK Department of Health. TWB was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt professor award, which was funded by the German Federal Ministry of Education and Research.

Publication History

Published: November 26, 2018

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DOI: 10.1016/S1474-4422(18)30415-0

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© 2018 The Author(s). Published by Elsevier Ltd.

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