UNIVERSIDAD CATOLICA DE SANTA MARÍA

FACULTAD DE CIENCIAS E INGENIERAS FISICAS Y

FORMALES

ESCUELA PROFESIONAL DE INGENIERIA DE

SISTEMAS

MATEMATICA : CALCULO

TEMA: ARTICULO “GLOBAL AND REGIONAL

CAUSES OF DEATH”
INTEGRANTE:
 MAURICIO GABRIEL DELGADO GUILLEN
Published Online September 22, 2009

Global and regional causes of death

Colin D. Mathers*, Ties Boerma, and Doris Ma Fat

Department of Health Statistics and Informatics, World Health Organization, 20 Avenue Appia
1211, Geneva, Switzerland

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Background: Assessing the causes of death across all regions of the world
requires a framework for integrating, and analysing, the fragmentary
information that is available on numbers of deaths and their cause distributions.
This paper provides an overview of the met and methods used by the World
Health Organization to develop global-, regional- and country-level estimates of
mortality for a comprehensive set of causes, and provides an overview of global
and regional levels and patterns of causes of death for the year 2004. The paper
also examines some of the data gaps, uncertainties and limitations in the
resulting mortality estimates.
Sources of data: Deaths for 136 disease and injury causes were estimated from
available death registration data (111 countries), sample death registration data
(India and China), and for the remaining countries from census and survey
information, and cause-of-death models. Population-based epidemiological
studies and notifications systems also contributed to estimating mortality for 21
of these causes (representing 28% of deaths globally, 58% in Africa).
Areas of agreement: Ischaemic heart disease and cerebrovascular disease are the
leading causes of death, followed by lower respiratory infections, chronic
obstructive pulmonary disease and diarrhoeal diseases. AIDS and TB are the
sixth and seventh most common causes of death, respectively, lower than in
previous estimates. One-half of all child deaths are from four preventable
and treatable communicable diseases. Globally, around 6 in 10 deaths are from
non-communicable diseases, 3 from communicable diseases and 1 from injuries.
Injury mortality is highest in South-East Asia, Latin America and the Eastern
Mediterranean region. These results illustrate continuing huge disparities in risks
and causes of death across the world.

Accepted: July 10, 2009
*Correspondence to:
Dr Colin Mathers, World
Health Organization, 20
Avenue Appia, 1211
Geneva, Switzerland.
E-mail: mathersc@who.int
Areas of controversy: Global mortality analyses of the type reported here have
been criticized for making estimates of mortality for regions with limited,
incomplete and uncertain data. Estimates presented here use a range of
techniques depending on the type and quality of evidence. Better evidence on
levels of adult mortality is needed for African countries.
Growing points: Considerable gaps and deficiencies remain in the information
available on causes of death. Nine of 10 deaths in 2004 occurred in low- and
middle-income countries, reinforcing the fundamental importance of improving

British Medical Bulletin 2009; 92: 7–32 & The Author 2009. Published by Oxford University Press. All rights reserved.
DOI:10.1093/bmb/ldp028 For permissions, please e-mail: journals.permissions@oxfordjournals.org
C. D. Mathers et al.

mortality statistics as a measure of health status in the developing world.

Acknowledging the controversies around use of incomplete and uncertain data,
systematic assessments and synthesis of the available evidence will continue to
provide important inputs for global health planning.
Areas timely for developing research: Innovative methods involving sample
registration, and the use of verbal autopsy questionnaires in surveys, are needed
to address these gaps. Research on strategies to improve comparability of cause-
of-death certification and coding practices across countries is also a high priority.

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Keywords: mortality/causes of death/burden of disease

Introduction
An important input to national and international health decision-
making and planning processes is a consistent and comparative analysis
of the causes of death across different population groups. Assessing the
causes of death across all regions of the world requires a framework
for integrating, validating, analysing and disseminating the fragmen-
tary, and at times contradictory, information that is available on
numbers of deaths and their cause distributions. World Health
Organization (WHO) maintains a mortality database1 that includes
detailed annual tabulations of deaths from the death registration
systems of Member States, with causes classified in most cases accord-
ing to the 9th or 10th revision of the International Classification of
Diseases (ICD).2
Over the last decade, the WHO has intensified efforts to support the
collection of vital registration information and other mortality data in
developing countries. The number of countries reporting data on recent
death registrations to WHO annually has increased from around 65 in
1970, 90 in 1999, to over 110 in 2009 (Table 1). Regional coverage of
death registration varies from close to 100% in the European region to
around 50% in the Asia-Pacific region and less than 10% in Africa.
However, death registration is considered to be essentially 100% com-
plete in only 64 of the countries reporting data, and predominantly
these are the developed countries in Europe, the Americas and the
Pacific region (Table 1).
In terms of actual deaths recorded by registration systems, data are
provided to WHO annually for about 18.6 million deaths, representing
one-third of all deaths estimated to be occurring in the world. Taking
account of the representative data from multiple registration systems
for India and China (described in the following section), population-
level information on mortality and causes of death is available for
around 72% of the world’s population.3

8 British Medical Bulletin 2009;92

 Global and regional causes of death

Table 1 Availability of recent death registration data in 2008, by WHO region.

Data/method Number of countries

Africa The Eastern Europe South-East Western World

Americas Mediterranean Asia Pacific

Death registration 3 21 2 40 1 12 79
data with coverage of
85% or more
Death registration – 12 7 11 1 3 34
data with coverage of

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,85%
SRS* – – – – 1 1 2
No population level 43 2 12 2 8 11 78
death registration
data†
Total countries 46 35 21 52 11 27 193

*China and India both maintain systems in which deaths are recorded in a representative sample of
districts across the country. Cause of death for most deaths is attributed using data collected using the
VA methods (see text).
†
Some of these countries do collect data on deaths in hospitals or urban areas, but these data cannot
be considered to provide a representative picture of cause-of-death patterns at the population level.

During the last decade, a number of WHO programmes have made

substantial investments in the collection and analysis of data to esti-
mate the mortality for specific causes of policy interest, particularly for
HIV, tuberculosis (TB), major causes of maternal and child deaths, and
more recently, for malaria deaths.4 – 6 Additionally, the WHO has
invested substantial effort, along with other UN Agencies such as
UNICEF, in collecting and analysing information on total all-cause
mortality levels for children in developing countries drawing on popu-
lation surveys and censuses. Available information on adult mortality
from demographic surveillance systems, sample registration systems
(SRSs), surveys and censuses has also been used to improve estimates of
adult mortality—all cause, and cause specific.
WHO has recently released an updated assessment of global and
regional causes of death, drawing on extensive WHO databases and
information provided by Member States, as part of an update of the
Global Burden of Disease (GBD) study for the year 2004.7 This update
built on previous WHO analyses using methods documented in a book
published in 2006 by the Disease Control Priorities project,8 with some
revisions and new data as described below.
The purpose of this paper is to provide an overview of the data and
methods used by WHO to develop global-, regional- and country-level
estimates of mortality for a comprehensive set of causes, and to
provide an overview of global and regional levels and patterns of

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C. D. Mathers et al.

causes of death. The paper also examines some of the data gaps, uncer-
tainties and limitations in the resulting mortality estimates.
Results are presented here for high-income countries, treated as one
group, and for low- and middle-income countries grouped by WHO
regions. Results are available on the WHO website9 for other regional
groupings, including World Bank regions and the regions used for
monitoring progress to the Millennium Development Goals and for
192 countries. The 2004 estimates discussed here have also been used
to prepare updated projections of mortality by cause for all regions of

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the world to the year 2030; these results are also available on the
WHO website.

Improving and updating global estimates of deaths by cause

The original GBD study for 1990 was the first attempt to estimate
global and regional numbers of deaths due to a comprehensive set of
causes while ensuring consistency with death totals provided by death
registration and demographic methods.10 Estimates of numbers of
deaths carried out separately for individual causes and that are not
constrained to sum to a demographically derived total often result in
substantial overestimates of deaths due to each cause for regions
without complete death registration data.11 In part, this occurs because
in carrying out analysis for a single cause it is easy to be over-inclusive
in counting the deaths attributable to the cause of interest, even if there
is not an intention to maximize the size of the specific problem.
The first analytical step in estimating deaths by cause is thus to esti-
mate the age-specific total death rates, by sex. Life tables specifying
mortality rates by age and sex for 192 WHO Member States were
developed for 2004 from available death registration data (111
Member States), SRSs (India, China, described below) and data on
child and adult mortality from censuses and surveys. Surveys such as
the Demographic and Health Surveys and UNICEF’s Multiple
Indicator Cluster Surveys now provide information on levels of child
mortality for most developing countries.12 For 55 countries, 42 of
them in the Sub-Saharan Africa, no information was available on levels
of adult mortality in 2004. Based on the estimated level of child mor-
tality in 2004, the most likely level of adult mortality was estimated,
based on regression models of child versus adult mortality as observed
in a set of almost 2000 life tables judged to be of good quality, includ-
ing the data for a number of African and other countries with high
levels of child mortality.13,14 As almost all the life tables were for
populations without significant HIV mortality, HIV deaths were
excluded, and estimated HIV and conflict deaths (for countries with

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 Global and regional causes of death

Table 2 Methods used for cause-of-death estimation for 2004, by WHO region.

Data/method Per cent of total deaths within region

Africa The Eastern Europe South-East Western World

Americas Mediterranean Asia Pacific

Death registration data 7 63 0 88 3 12 26

with coverage of 85% or
more
Death registration data 0 30 20 10 1 3 7
with coverage of

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,85%—adjusted for bias
in cause-of-death
distribution
SRS 0 0 0 0 45 56 23
Cause-specific estimates* 58 6 38 2 32 23 28
CodMod, regional 36 1 42 0 19 5 16
pattern of causes of
death
Total deaths (millions) 11.2 6.2 4.3 9.5 15.3 12.2 58.8

*Epidemiological estimates obtained from studies, WHO technical programmes, CHERG and UNAIDS for
the following causes: AIDS, TB, diphtheria, measles, pertussis, poliomyelitis, tetanus, dengue, malaria,
schistosomiasis, trypanosomiasis, Japanese encephalitis, Chagas, maternal conditions (including
abortion), all major causes of death in the neonatal period and in children to age 5, drug use disorders,
rheumatoid arthritis and war.

war or civil conflict) were added to the predicted adult mortality to

obtain the total estimated adult deaths.
For countries with death registration data, demographic techniques
known as death distribution methods, which compare the number of
registered deaths in an intercensal period with changes in population
numbers, were used to assess the level of completeness of the recorded
mortality data for adults,15,16 where completeness was assessed as less
than 100%, death rates above age 5 were adjusted accordingly.
Completeness of child death registration was separately assessed, using
other available sources of information on child mortality.
We drew on four broad sources of mortality data for assessing causes
of death: death registration systems with medically certified
cause-of-death information, sample death registrations systems for
India and China, epidemiological assessments for specific causes and
cause-of-death models (CodMod). We summarize the approach used
for the 2004 estimates; more detail is provided elsewhere.7 Table 2
summarizes the proportions of deaths in each region and in the world
in 2004 for which the cause of death was estimated using each of these
four data sources or methods.
Death registration data with information on cause-of-death distri-
butions were available for 111 countries, the majority of these in the
high-income group, Latin America and the Caribbean, and Europe and

British Medical Bulletin 2009;92 11

C. D. Mathers et al.

Central Asia (Table 1). Deaths coded to the ICD codes for ‘symptoms,
signs and ill-defined conditions’ as well as certain ill-defined codes
within the cancer, cardiovascular disease and injury chapters of ICD
were re-distributed across defined causes.17 The percentage of deaths
coded to these ill-defined causes varied from 4% in New Zealand to
more than 30% in Sri Lanka and Thailand.3 Cause of death was esti-
mated for one-third of global deaths in 2004 using information from
the death registration data (Table 2).
China and India, two countries with large populations (20% and

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17% of the global population, respectively), do not have complete vital
registration but information on causes of death are available from
SRSs. From the mid-1990s until recently, death data for China has
been routinely available from a nationally representative system of 145
disease surveillance centres (DSP) covering 1% of the total Chinese
population.18 At each surveillance centre, a team including a physician
investigated each death using medical records and interviews with
family members to assign a cause of death. Periodic evaluations of the
DSP data by re-surveying households at random have suggested a level
of underreporting of deaths of about 15%.18 More recently, the DSP
sites were used as the sampling frame for the third National Mortality
Survey, which collected the cause of death for 868 000 deaths in
2004 –2005.19
Data on the age, sex and cause of more than 300 000 deaths are also
collected annually from the vital registration system operated by the
Chinese Ministry of Health, covering a population of 57 million,
(36 million in the urban areas and 21 million in the rural). While
the data are not representative of mortality conditions throughout
China, they are useful for suggesting trends in mortality, given the
number of deaths covered, and also provide valuable information on
cause-of-death patterns. A third source of data on mortality in China is
the decennial population census that asks about deaths in the house-
hold in the past 12 months.20 From these three data sources, it has
been possible to extrapolate to the national level and contribute to esti-
mates of global patterns and causes of death.
In India, the Medical Certificate of Cause of Death provides infor-
mation for deaths in the urban India. Additionally, an SRS has success-
fully collected data on rural mortality and fertility since 1965 through
continuous recording by resident enumerators as well as retrospective
half yearly population surveys. During the early years of the twenty-
first century, the methods used in the SRS in India were substantially
revised as part of the Million Deaths study (MDS). As of 2002, causes
of death have been ascertained using a verbal autopsy (VA) method
(see below), with re-sampling, double coding by physicians centrally
and other quality control efforts. The MDS is following the lives and

12 British Medical Bulletin 2009;92

 Global and regional causes of death

deaths of 1.1 million households throughout India until 2014.21,22

Data for a nationally representative sample of 62 553 deaths in 2001 –
2003 have now been released.23
Both the Chinese and the Indian SRSs use VA methods to assign
cause of death for deaths outside hospitals. A questionnaire is adminis-
tered to care-givers or family members of deceased persons to gather
information on signs and symptoms and their durations, and other per-
tinent information about the decedent in the period before death. Most
approaches to date have used panels of physicians to review the data

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collected and assign a probable cause of death. Such methods naturally
produce more uncertain attribution of cause of death than physician
diagnosis.24 Categorical assignment of cause of death is inherently dif-
ficult for diseases without distinctive symptoms, such as malaria in
children, or some forms of cardiovascular disease in older adults.
WHO is working to standardize VA instruments for use with children
and adult deaths.25 Cause of death was estimated for just under one-
quarter of global deaths in 2004 using the VA and vital registration
data for China and India (Table 2).
Population-based epidemiological studies, disease registers and notifi-
cations systems (in excess of 2700 data sets) also contributed to the
estimation of mortality due to 21 specific causes of death, including
HIV/AIDS (acquired immuno-deficiency syndrome), malaria, TB, child-
hood immunizable diseases, schistosomiasis, trypanosomiasis, Chagas
disease, cancers, drug dependence, war and natural disasters. Almost
one-third of these data sets was related to sub-Saharan Africa.
Particular attention was paid to the estimation of causes of child
death in ,5 years of age and in the infant and neonatal (under
28 days) periods. For countries without relatively complete death regis-
tration data, cause-specific and multi-cause models for child mortality,
developed by the WHO Child Health Epidemiology Reference Group
(CHERG) and the WHO Department of Immunization, Biologicals
and Vaccines, were used to estimate causes of child deaths ,5 years of
age (neonatal and postneonatal);7,26,27 the resulting cause-specific esti-
mates were adjusted country-by-country for consistency with estimated
total deaths for neonates, infants and children aged ,5 years.28,29
Cause of death was estimated using cause-specific information for just
under under 30% of global deaths in 2004; with proportions ranging
from 2% of deaths in Europe to 58% of deaths in the African region
(Table 2).
Although epidemiological studies, and other data sources described
above, allow estimation of deaths for certain causes in populations
without death registration data, they do not cover many important
causes of death in these populations, such as cardiovascular disease or
injuries. In order to address these information gaps, models for

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C. D. Mathers et al.

estimating broad cause-of-death patterns can serve as the starting

point for indirect methods of estimating attributable mortality for a
comprehensive list of detailed causes.
Indirect methods for estimating cause-of-death structure were first
developed by Preston,30 who modelled the relationship between total
mortality and cause-specific mortality for 12 broad groups of causes
using the historical vital registration data for industrialized countries
and a few developing countries. In the original GBD study for the
year 1990, Murray and Lopez31 used cause-of-death models to esti-

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mate the mortality for three major cause groups: I, II and III, as a
function of mortality from all causes, based on the regression analysis
of observations on recent mortality patterns from 67 countries.
Group I causes comprise communicable, maternal and perinatal
conditions and nutritional deficiencies, Group II includes non-
communicable diseases and Group III injuries. Group I causes are
conditions that occur largely in the poorer populations, and typically
decline at a faster pace than all-cause mortality during the epidemio-
logical transition (in which the pattern of mortality shifts from high
death rates from Group I causes at younger ages to Group II diseases
at older ages).
For WHO updates of global causes of death, the statistical model for
cause-of-death composition was estimated using a much larger data set
consisting of 1613 country-years of historical death registration data.32
Regional patterns for detailed cause distributions within the broad
cause groups were based on available death registration data within
each region. The regional patterns were updated for African countries
using a greater range of information on cause-of-death distributions
in Africa than previously. These included the South African 2004
vital registration data, the Zimbabwe National Burden of Disease
Study 1997,33 INDEPTH VA data from seven sites in Africa for 1999 –
2002,34 data from Antananarivo in Madagascar for 1976 –1995,34
and Mozambique Maputo Central Hospital Mortuary data for
1993 –2004.35 Cause of death was assigned using the CodMod for
around 40% of deaths, primarily non-communicable diseases and inju-
ries, in Africa and South-East Asia. At a global level, around 16% of
deaths were assigned cause using CodMod (Table 2).
For this updated global analysis of causes of death for 2004, a com-
plete analysis of the above sources of data was carried out at a country
level for 192 countries. Apart from the specific data sources for China
and India, this update also benefited from recent detailed analyses of
causes of death drawing on multiple data sources for Iran,36 Mexico,37
South Africa,38 Thailand39 and Turkey.40
Mortality estimates for HIV/AIDS were based on the most recent esti-
mates released by WHO and the Joint United Nations Programme on

14 British Medical Bulletin 2009;92

 Global and regional causes of death

HIV/AIDS (UNAIDS).4 Advances in methodology, applied to an

increased range of country data, resulted in a substantial reduction in
the estimated global deaths due to HIV/AIDS: these were revised down-
wards from 2.7 million to 2.0 million for 2004.
Updated estimates for vaccine-preventable childhood diseases were
prepared by the WHO Department of Immunization, Vaccines and
Biologicals using estimates for vaccine coverage in 2004 prepared by
WHO and UNICEF (United Nations Children’s Fund).
Revised mortality estimates for malaria were based on the estimates

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and analyses prepared by the Roll Back Malaria Partnership, CHERG
and the Malaria Epidemiology Reference Group (MERG), together with
the data from national case reports.6 Estimates for mortality for ages 5
years and above were revised using a transmission-intensity-based model,
resulting in an increased proportion of such deaths (21% globally in
2004, compared with 10% in previous estimates).7
Mortality estimates for tropical diseases, including dengue fever and
Japanese encephalitis, were revised to take into account the latest
WHO data on populations at risk, levels of endemicity, reported cases,
treatment coverage and case fatality. Site-specific cancer incidence and
mortality estimates were updated using revised estimates of site-specific
survival probabilities for 2004, together with the site-specific incidence
distributions from the Globocan 2002 database of the International
Agency for Research on Cancer.41 Country-specific estimates of war
and conflict deaths were updated to 2004 using information on conflict
intensity, time trends and mortality obtained from a variety of pub-
lished and unpublished war mortality databases.7 Population estimates
for 2004 were based on the latest revisions by the UN Population
Division.42

Sensitivity of methods and uncertainty of results

There remain substantial data gaps and deficiencies, particularly for
regions with limited death registration data. The results reported below
include estimates of cause-specific deaths even for regions with limited
death registration data, based on the best possible assessment of the
available evidence. While these estimates will have wider uncertainty
ranges than those for regions with more data, their exclusion would
result in a potentially biased picture of the patterns of global mortality.
2004 includes results for these regions, albeit with wider uncertainty
ranges. Uncertainty ranges for all-cause mortality rates for WHO
Member States were published in the World Health Report 2006.28
Uncertainty analysis for the 2004 cause-specific estimates has not
been carried out, but the ranges are likely to be similar to those

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C. D. Mathers et al.

assessed previously for 2001, with some reductions in uncertainty

for specific countries and causes where improved data have become
available.43
Ninety-five per cent uncertainty ranges for regional cause-specific
mortality estimates were calculated for 2001 using simulation methods
based on the estimated uncertainty ranges for input data.43 Uncertainty
in estimated all-cause mortality for 2001 ranged from +1% for high-
income countries to +15 –20% for sub-Saharan Africa, reflecting
differential data availability. Uncertainty ranges were generally larger

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for deaths from specific causes. For example, the relative uncertainty
for deaths from ischaemic heart disease (IHD) ranged from +12%
for high-income countries to +25– 35% for sub-Saharan Africa. There
is considerable uncertainty in estimates of cause-specific deaths
for chronic diseases such as IHD, cerebrovascular disease, diabetes,
chronic obstructive pulmonary disease and external causes of injury
for sub-Saharan Africa where these estimates depend heavily on
cause-of-death modelling.

Results
Life expectancy
Life expectancy at birth in 2004 ranged from 79 years in high-income
countries down to 50 years in sub-Saharan Africa. This is a 1.6-fold
difference in total life expectancy across major regions of the globe.
Overall, for the entire population of the world, average life expectancy
at birth in 2004 was 65.6 years, an increase of almost 9 years over the
last quarter century. Life expectancy increased during the 1990s for
most regions of the world, with the notable exception of Africa and
the former Soviet countries of Europe.44

Global deaths: where and at what ages?

We estimated that almost 59 million people died in 2004, 10.4 million
(or nearly 20%) of whom were children ,5 years of age. Of these
child deaths, 99% occurred in low- and middle-income countries. Just
over 70% of deaths in high-income countries occur beyond age 70,
compared with 32% in low- and middle-income countries (Fig. 1). A
key point is the comparatively high numbers of deaths in poor
countries at young adult ages (15 –59 years). Just over 30% of all
deaths in low- and middle-income countries occur at younger adult
ages (15– 59 years), compared with 15% in wealthy regions.

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 Global and regional causes of death

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Fig. 1 Per cent distribution of age at death by region, 2004. Note: High-income countries
have been excluded for each WHO region and are shown as a single group at the right.
Source: Ref. 7.

Broad patterns of cause of death

Among both men and women, most deaths are due to non-
communicable conditions (Group II), and they account for about 6 of
10 deaths globally. Communicable diseases, reproductive and nutri-
tional conditions are responsible for just under one-third of deaths in
both males and females. The largest difference between the sexes
occurs for Group III, with injuries accounting for almost 1 in 8 male
deaths and 1 in 14 female deaths.
Figure 2 shows the distribution of deaths at all ages for 12 major
cause groups. Cardiovascular diseases are the leading cause of death in
the world, particularly among women; such diseases caused almost
32% of all deaths in women and 27% in men in 2004. Infectious and
parasitic diseases are the next leading cause, followed by cancers, but
these groupings show much smaller overall sex differentials. The
largest differences between men and women are observed for inten-
tional injuries (twice as high among men) and unintentional injuries.
Maternal conditions account for 1.9% of all female deaths.

Leading causes of death

Table 3 shows the 20 most frequent causes of death, using cause cat-
egories at the next level below the broad cause groups shown in Fig. 2.
IHD and cerebrovascular disease are the leading causes of death,

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C. D. Mathers et al.

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Fig. 2 Distribution of deaths by leading cause groups, men and women, world, 2004.
Source: Ref. 7.

Table 3 Leading causes of death, all ages, 2004.

Disease or injury Deaths (millions) Per cent of total deaths

1 IHD 7.2 12.2

2 Cerebrovascular disease 5.7 9.7
3 Lower respiratory infections 4.2 7.1
4 COPD 3.0 5.1
5 Diarrhoeal diseases 2.2 3.7
6 HIV/AIDS 2.0 3.5
7 TB 1.5 2.5
8 Trachea, bronchus, lung cancers 1.3 2.3
9 Road traffic accidents 1.3 2.2
10 Prematurity and low birth weight 1.2 2.0
11 Neonatal infections* 1.1 1.9
12 Diabetes mellitus 1.1 1.9
13 Hypertensive heart disease 1.0 1.7
14 Malaria 0.9 1.5
15 Birth asphyxia and birth trauma 0.9 1.5
16 Self-inflicted injuries† 0.8 1.4
17 Stomach cancer 0.8 1.4
18 Cirrhosis of the liver 0.8 1.3
19 Nephritis and nephrosis 0.7 1.3
20 Colon and rectum cancers 0.6 1.1
All causes 58.8 100

COPD, chronic obstructive pulmonary disease; IHD, ischaemic heart disease; TB, tuberculosis.
*This category also includes other non-infectious causes arising in the perinatal period, apart from
prematurity, low birth weight, birth trauma and asphyxia. These non-infectious causes are responsible
for about 20% of deaths shown in this category.
†
Self-inflicted injuries resulting in death can also be referred to as suicides.

18 British Medical Bulletin 2009;92

 Global and regional causes of death

followed by lower respiratory infections (including pneumonia),

chronic obstructive pulmonary disease and diarrhoeal diseases. HIV/
AIDS and TB are the sixth and seventh most common causes of death,
respectively, and together caused 3.5 million deaths in 2004.
As may be expected from the very different distributions of deaths by
age and sex, there are major differences in the ranking of causes
between high- and low-income countries (Table 4). In low-income
countries, the dominant causes are infectious and parasitic diseases
(including malaria), and neonatal causes. In the high-income countries,

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9 of the 10 leading causes of death are non-communicable conditions,
including the four types of cancer. In the middle-income countries, the
10 leading causes of death are again dominated by non-communicable
conditions; they also include road traffic accidents as the sixth most
common cause.
IHD and cerebrovascular disease (stroke) were the leading causes of
death in both middle- and high-income countries in 2004, and also in
the top five causes for low-income countries. These two causes were
together responsible for 22% of all deaths worldwide. Only 1.3
million of the 7.2 million deaths from IHD were in high-income
countries. Of the 5.7 million stroke deaths, less than 0.8 million were
in high-income countries. Lung cancer was the third leading cause
of death in high-income countries, and the fifth leading cause in
middle-income countries.

Causes of death among children ,5 years of age

Six causes of death accounted for 73% of the 10.4 million deaths
among children ,5 years in 2004 (Fig. 3): acute respiratory infections,
mainly pneumonia (17%), diarrhoeal diseases (17%), prematurity and
low birth weight (11%), neonatal infections such as sepsis (9%), birth
asphyxia and trauma (8%) and malaria (7%) The four communicable
disease categories accounted for one-half (50%) of all child deaths.
Deaths in the neonatal period (0–28 days) account for more than
one-third of all deaths in children. Among neonatal deaths, three main
causes account for 80% of all neonatal deaths: prematurity and low
birth weight (31%), neonatal infections (mainly sepsis and pneumonia
and excluding diarrhoeal diseases) (26%) and birth asphyxia and birth
trauma (23%).
Forty-five per cent (4.7 million deaths) of all child deaths ,5 years
in 2004 occurred in the African region, and an additional 30% (3.1
million) in the South-East Asia region. The death rate per 1000 chil-
dren aged 0 –4 years in the African region is almost double that of the
region with the next highest rate, the Eastern Mediterranean, and more

British Medical Bulletin 2009;92 19

20

C. D. Mathers et al.
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Table 4 Leading causes of death by income group, 2004.

Disease or injury Deaths Per cent of Disease or injury Deaths Per cent of
(millions) total deaths (millions) total deaths

World Low-income countries *

1 IHD 7.2 12.2 1 Lower respiratory infections 2.9 11.2
2 Cerebrovascular disease 5.7 9.7 2 IHD 2.5 9.4
3 Lower respiratory infections 4.2 7.1 3 Diarrhoeal diseases 1.8 6.9
4 COPD 3.0 5.1 4 HIV/AIDS 1.5 5.7
5 Diarrhoeal diseases 2.2 3.7 5 Cerebrovascular disease 1.5 5.6
6 HIV/AIDS 2.0 3.5 6 COPD 0.9 3.6
7 TB 1.5 2.5 7 TB 0.9 3.5
8 Trachea, bronchus, lung cancers 1.3 2.3 8 Neonatal infections† 0.9 3.4
9 Road traffic accidents 1.3 2.2 9 Malaria 0.9 3.3
10 Prematurity and low birth weight 1.2 2.0 10 Prematurity and low birth weight 0.8 3.2
All causes 58.8 100 All causes 26.3 100
Middle-income countries High-income countries
1 Cerebrovascular disease 3.5 14.2 1 IHD 1.3 16.3
2 IHD 3.4 13.9 2 Cerebrovascular disease 0.8 9.3
3 COPD 1.8 7.4 3 Trachea, bronchus, lung cancers 0.5 5.9
4 Lower respiratory infections 0.9 3.8 4 Lower respiratory infections 0.3 3.8
5 Trachea, bronchus, lung cancers 0.7 2.9 5 COPD 0.3 3.5
6 Road traffic accidents 0.7 2.8 6 Alzheimer and other dementias 0.3 3.4
7 Hypertensive heart disease 0.6 2.5 7 Colon and rectum cancers 0.3 3.3
8 Stomach cancer 0.5 2.2 8 Diabetes mellitus 0.2 2.8
9 TB 0.5 2.2 9 Breast cancer 0.2 2.0
10 Diabetes mellitus 0.5 2.1 10 Stomach cancer 0.1 1.8
All causes 24.3 100 All causes 8.1 100
British Medical Bulletin 2009;92

COPD, chronic obstructive pulmonary disease; IHD, ischaemic heart disease; TB, tuberculosis.
*
Countries grouped by gross national income per capita—low income ($825 or less), high income ($10 066 or more).
†
This category also includes other non-infectious causes arising in the perinatal period, which are responsible for about 20% of deaths shown in this category.
 Global and regional causes of death

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Fig. 3 Distribution of causes of death among children aged ,5 years and within the neo-
natal period, 2004. aIncludes other non-communicable diseases (1%) and injuries (0.3%).
b
ICD-10 codes Q00-Q99. Another 1.2% of neonatal deaths are due to genetic conditions
classified elsewhere. cOther non-infectious causes arising in the perinatal period. dIncludes
all neonatal infections except diarrhoeal diseases and neonatal tetanus. Source: Ref. 7.

Fig. 4 Differences in causes of child death, 2004. Note: High-income countries have been
excluded for each WHO region and are shown as a single group at the top. Source: Ref. 7.

than double that of any other region (Fig. 4). The two leading commu-
nicable disease killers in all the regions are diarrhoeal diseases and res-
piratory infections. Deaths directly attributable to malaria occur almost
entirely in the African region, representing 16% of all under-five
deaths in that region.

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C. D. Mathers et al.

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Fig. 5 Adult mortality rates by major cause group and region, 2004. Note: Respiratory
infections are included in the category ‘Other infectious and parasitic diseases’, and are to
be distinguished from chronic respiratory diseases, included in the category ‘Other non-
communicable diseases’. Source: Ref. 7.

HIV/AIDS and measles are important causes of death summarized in

the ‘other’ category. Globally, estimates suggest that 2.5% of all child
deaths are associated with the HIV infection. In the African region,
however—where more than 9 of 10 of the total global number of child
deaths due to HIV/AIDS in 2004 occurred—5% of all child deaths are
associated with HIV. Measles mortality, which has declined consider-
ably in recent years, is estimated to be responsible for 4% of deaths
among children aged ,5 years worldwide and 5% of such deaths in
the African region.

Causes of death among adults aged 15–59 years

The ranking of regions by mortality rates among adults aged 15– 59
years differs markedly from the rankings by child mortality. The low-
and middle-income countries of the European region have the second
highest mortality level for adults aged 15 –59 years, lower than for the
African region but higher than that of the South-East Asia region
(Fig. 5).
The mortality rate due to non-communicable diseases is highest in
Europe, where nearly two-thirds of all deaths at ages 15 –59 years for
low- and middle-income countries are associated with cardiovascular
diseases, cancers and other non-communicable diseases. Mortality rates
due to non-communicable diseases are second highest in the African

22 British Medical Bulletin 2009;92

 Global and regional causes of death

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Fig. 6 Adult mortality rates among those aged 15– 59 years in the African region, by sex
and major cause group, 2004. Source: Ref. 7.

region, followed by the Eastern Mediterranean and South-East Asia

regions, and lowest in the high-income countries. Injury mortality
ranges from 0.5 (high-income countries) to 1.5 (European region) per
1000 adults aged 15– 59 years. The proportion of deaths in this age
group due to injuries ranges from 22% (high-income countries) to
29% (the Americas) of all deaths at ages 15– 59, except in Africa,
where it is 13%.
Group I causes of death—which include infectious and parasitic dis-
eases, and maternal and nutritional conditions—account for more than
one-fifth of all deaths in adults aged 15 –59 years in two regions:
South-East Asia (29%) and Africa (62%). This includes 35% of deaths
due to HIV/AIDS in Africa. In fact, the mortality rate among adults
due to HIV/AIDS alone in Africa is higher than mortality at 15– 59
years due to all causes in three other regions: high-income countries,
the Americas and the Western Pacific region.

Adult mortality in Africa

In the African region, mortality among men is slightly higher than
among women, entirely due to higher mortality through injuries
(Fig. 6). Women have higher mortality due to Group I causes. At ages
15 –59 years, women have much higher mortality than men for HIV/
AIDS, which causes more than half of all deaths in Group I and 40%
of all female deaths. Maternal causes were associated with 14% of all

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C. D. Mathers et al.

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Fig. 7 Adult mortality among those aged 15– 59 years in the European region (excluding
high-income countries) by sex and major cause grouping, 2004. Source: Ref. 7.

deaths. Maternal causes are causes associated specifically with preg-

nancy and childbirth and include deaths due to obstructed labour,
maternal haemorrhage, sepsis, maternal hypertension, and to unsafe
abortion.

Adult mortality in low- and middle-income countries of Europe

Figure 7 illustrates the high levels of mortality among men in the low-
and middle-income countries of the European region. The main reason
is the high mortality rates due to cardiovascular diseases and injuries,
each associated with a mortality rate exceeding 2.5 per 1000 adults
aged 15 –59 years, and together being responsible for almost two-thirds
of overall male mortality in this age group.

Adult mortality in Latin America and the Caribbean

The most striking data from the low- and middle-income countries of
the Americas relate to injury mortality, which is about 1.6 per 1000
men aged 15 –59 years, making it the leading cause group (Fig. 8).
Intentional injuries account for 57% of adult mortality due to injuries,
while motor vehicle accidents account for 25% of adult mortality due
to injuries. One-quarter of the 600 000 global homicides occur in Latin
America, 8.4% of the world’s population.

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 Global and regional causes of death

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Fig. 8 Adult mortality among those aged 15–59 years in the low- and middle-income
countries of the Americas by sex and major cause grouping, 2004. Source: Ref. 7.

Mortality in the Eastern Mediterranean region

Perhaps unsurprisingly given the conflicts in Iraq and Afghanistan, war
and violence are responsible for 40% of injury deaths in the Eastern
Mediterranean region. Almost 55% of estimated 184 000 global war
deaths occurred in this region in 2004. There is considerable uncertainty
with estimates of war deaths; the 56 000 estimated conflict deaths in
Iraq have an uncertainty range of approximately 45 000 –66 000.45

South-East Asia
One-third of the 527 000 global deaths due to pregnancy and child-
birth (maternal causes) occurred in South-East Asia in 2004.
Accidental fire deaths were high in this region and caused twice as
many deaths in women as in men. An extraordinary 80% of global
fire-related deaths among adult women occurred in South-East Asia.
Many fire deaths are probably related to cooking accidents but this is
not the only cause. In India, fire is implicated in an estimated 16% of
suicides in women and an unknown number of homicides.46

Western Pacific region

China, with 20% of the world’s population, dominates mortality for
the low- and middle-income countries of the Western Pacific region.

British Medical Bulletin 2009;92 25

C. D. Mathers et al.

Low- and middle-income countries of this region now have a lower

child mortality rate than the former Soviet countries of Europe (Fig. 4),
and adults aged 15 –59 years have the lowest mortality rate for any
regional grouping of low- and middle-income countries (Fig. 5), not far
behind the mortality rates for high-income countries.
Suicide, arguably the most extreme expression of mental illness, is
the sixth leading cause of death globally for adults aged 20 –59 years,
and the third leading cause of death in low- and middle-income
countries of the Western Pacific region. The suicide rate for women

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aged 15 –44 years in these countries is 60% times higher than that for
the rest of the world.

Discussion
The original GBD study, initial results of which appeared in the 1993
World Development Report,47 was the first attempt to provide
comprehensive regional and global estimates for mortality by cause for
a comprehensive set of more than 130 causes. Earlier attempts to
quantify global cause-of-death patterns were largely restricted to
broad cause-of-death groups (e.g. all infections and parasitic diseases
combined).48,49
In updating global cause-of-death estimates over the last decade, the
WHO has focused on individual countries as the unit of analysis, with
the systematic application of standardized approaches for countries in
each category for mortality data availability as well as drawing much
more extensively on the detailed analyses of cause-specific data carried
out in priority areas by WHO and other international agencies. This
has greatly improved the cross-population comparability of cause-
specific death estimates as well as increasing the usefulness of the
results for country-level health situation assessment and priority
setting. More attention has also been paid to assessing uncertainty in
both national and global assessments of cause-specific and all-cause
deaths. This uncertainty must be taken into account when making
cross-national comparisons, and needs to be carefully communicated
and interpreted by epidemiologists and policy-makers alike.

Global patterns of mortality in the early twenty-first century

Communicable diseases remain an important cause of death in low-
income countries. Seven of 10 deaths in children ,5 years still occur in
low-income countries and almost half are due to only four infectious
diseases: pneumonia, diarrhoeal diseases, malaria and measles. There

26 British Medical Bulletin 2009;92

 Global and regional causes of death

have been impressive reductions in diarrhoeal disease and measles

deaths, but malaria, malnutrition and safe water and sanitation systems
remain as substantial challenges. A recent study projected that global
under-five mortality will decline by 27% from 1990 to 2015, substan-
tially less than the target of Millennium Development Goal 4 of a 67%
decrease.50 Globally, we are not doing a better job of reducing child
mortality now than we were three decades ago.
These results incorporate recent revisions to HIV/AIDS mortality,
which have used improved methods, applied to an increased range of

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country data resulting in a significant reduction in estimated HIV
prevalence and HIV/AIDS mortality.4 However, HIV/AIDS remains the
leading cause of death in sub-Saharan Africa, causing an estimated 1.7
million deaths (or 15% of all deaths) in 2004.
Our results also confirm the growing importance of non-
communicable diseases in most low- and middle-income countries.
Population ageing is the most important driver of this trend, but
adverse risk factor trends for tobacco and overweight and obesity will
exacerbate it. Already more than half of the world’s population .65
years lives in low- and middle-income countries. The proportion of the
world’s population .65 years, currently 7%, will be more than double
(to 16%) in the next 50 years. In all regions in 2004, except for Africa,
non-communicable diseases were responsible for one-half or more of
all deaths in low- and middle-income countries. The dramatic reversal
in adult mortality decline in Eastern Europe during the 1990s is a stark
reminder that epidemiological transitions, and improvements, can be
very rapidly reversed.

Controversy
Previous global mortality analyses of the type reported here have
been criticized for making estimates of mortality for regions with
limited, incomplete and uncertain data, and have even been charac-
terized by some critics as having at best only tenuous links to empiri-
cal evidence.51 Murray et al. 52 have argued systematic assessments
and synthesis of the available evidence, which attempt to ensure con-
sistency and adjust for known biases, will almost always provide a
better basis for health planning than ideology or special interests.
The analytical approach used here has been strongly influenced by
demographic and economic traditions of making the best possible
estimates of quantities of interest for populations from the available
data, using a range of techniques depending on the type and quality
of evidence.

British Medical Bulletin 2009;92 27

C. D. Mathers et al.

Addressing the data limitations and gaps

Although morbidity and disability assessment is of growing significance
in all countries, mortality as a health status measure is still of great
importance in the poorer countries. Of the estimated 58.8 million
deaths worldwide in 2004, 9 of 10 occurred in low- and
middle-income countries, reinforcing the fundamental importance of
improving mortality statistics as a measure of health status in the devel-
oping world.

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While there have been noteworthy improvements in the coverage and
quality of death registration data, with Iran and South Africa being
two success stories in the last decade or so, only one-third of the
world’s population is covered by population-level death registration
data. China and India, the two most populous nations in the world,
have both been redeveloping their VA-based SRSs, and the new data
from these systems is now becoming available to improve our under-
standing of the causes of death in almost 40% of the world’s
population.
Apart from the as-yet unsolved problems in obtaining valid
cause-of-death information from VA instruments, less than 5% of the
African population is covered by functioning death registration
systems. There is very little national-level information available on the
causes of child mortality or even on levels of adult mortality for most
African countries.1
Assignment of cause of death is one of the areas that require
additional data and research. Mirroring the work on causes of death
among children,53 there is a need to better understand and characterize
the role of specific diseases in adult mortality in a consistent and com-
parable framework. Currently the ICD rules determine the assignment
of causes of death, but have shortcomings for diseases such as TB, dia-
betes and hepatitis B and C, which are both direct causes of death and
increase the risk of other diseases such as HIV/AIDS, cirrhosis of the
liver, renal failure and cardiovascular diseases.
There remain unresolved methodological and empirical challenges
for better global and national estimates of causes of death. Chief
among these are the following:

† Development of improved methods for ascertaining levels and causes of

mortality using survey and VA methods for populations where it is not yet
possible to establish functioning vital registration systems with medically
certified causes of death.25,54
† Increasing the coverage of the global population by death registration with
medically certified cause of death. WHO is working with other inter-
national agencies and partnerships to assist countries in implementing and
improving vital registration systems.1 There have been relatively few

28 British Medical Bulletin 2009;92

 Global and regional causes of death

success stories in the last three decades of countries implementing good

civil registration from scratch— considerable country-level political will is
necessary.
† Improving the quality of certification and coding of causes of death using
the ICD and its guidelines and rules.2 There are unacceptably large pro-
portions of deaths in some countries, which are coded to inappropriate or
invalid codes for underlying cause of death.3
Besides the international agencies, non-governmental organizations

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such as the Bill and Melinda Gates Foundation are funding research
and capacity building in this area. These networks and research groups
should provide valuable partners for global health agencies, such as
WHO, UNICEF and the World Bank, in improving the measurement
and policy use of information on population health.

Acknowledgements
The views expressed in this paper are entirely those of its authors and
do not necessarily represent the decisions or the stated policy of the
World Health Organization or its Member States. Valuable inputs
were provided by WHO staff from many departments and by experts
outside WHO. While it is not possible to name all those who contribu-
ted to this effort, we would like to particularly note the contributions
of Bob Black, Cynthia Boschi-Pinto, Somnath Chatterji, Richard
Cibulskis, Simon Cousens, Chris Dye, Mercedes de Onis, Majid Ezzati,
Marta Gacic Dobo, Peter Ghys, Kim Iburg, Mie Inoue, Eline
Korenremp, Joy Lawn, Steve Lim, Silvio Mariotti, Erin McLean,
Donatella Pascolini, Juergen Rehm, Serge Resnikoff, Lisa Rogers,
Alexander Rowe, Lale Say, Suzanne Scheele, Kenji Shibuya, Andrew
Smith, Karen Stanecki, Jose Suaya, Jos Vandelaer, Theo Vos and Lara
Wolfson.

Funding
This work was funded by the World Health Organization.

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32 British Medical Bulletin 2009;92

Comentarios:
Según el artículo publicado en el año 2009 las enfermedades transmisibles eran la causa
más importante de muerte en países de bajos ingresos esta se debía a enfermedades
infecciosas como la neumonía, el paludismo, enfermedades diarreicas, etc. sin embargo el
panorama cambio en el año 2019 según la OMS la mayor causa de defunción del mundo
hasta esa fecha era la cardiopatía isquémica, una enfermedad no trasmisible, pero las
infecciones de las vías respiratorias inferiores siguen siendo la enfermedad transmisible
más mortal del mundo y esto ha quedado demostrado con la pandemia ocasionada por el
Covid -19 ( enfermedad por coronavirus ) la que ha cobrado alrededor de 7 millones de
muertes en el mundo a la fecha .

Lo que el COVID-19 nos ha recordado es que vida es el bien más preciado y esta va de la
mano con el cuidado de la salud.

Apa:

Mathers. C.D, Boerma.T, & Fat, D.M.(2009). Global and regional causes of death .British Medical.
Bulletin 92, 7–32.https:// DOI:10.1093/bmb/ldp028