Global Burden of

Disease
Presented By:
Santoshi Paudel
MPH 2023
SPH&CM
BPKIHS, Dharan, Nepal
 › History of GBD study
› GBD
PRESENTATION
OUTLINE › Uses of GBD
› Calculation of GBD
› GBD Report, 2019
› Burden of Disease- Nepal
› References
 History of GBD study (1)
› The World Bank commissioned the first Global Burden of
Disease (GBD) study for its World Development Report 1993
(World Bank, 1993) in a collaboration between the Harvard
School of Public Health and the World Health Organization.

› This first GBD study quantified the health effects of more than
100 diseases and injuries for eight regions of the world and
generated comprehensive and internally consistent estimates
of mortality and morbidity by age, sex and region.

› Also introduced a new metric – the disability-adjusted life

year (DALY) – as a single measure to quantify the burden of
diseases, injuries and risk factors.
 History of GBD study (2)
› WHO produced annually updated GBD estimates for years
2000 to 2002.

› The GBD cause list was expanded to 136 causes (giving a

total of 160 cause categories, including group totals). The
WHO GBD updates incrementally revised and updated
estimates of incidence, prevalence and years of healthy life
lost due to disability (YLDs) for non-fatal health outcomes.

› By the time of the GBD 2004 study, 97 of the 136 causes had
been updated, including all causes of public health
importance or with significant YLD contribution to DALYs.
 History of GBD study (3)

› GBD 2010 study, funded by Bill & Melinda Gates Foundation

developed new methods for assessing causes of death and
for synthesizing epidemiological data to produce estimates of
incidence and prevalence of conditions for 21 regions of the
world.

› To develop comprehensive global health statistics and to

provide estimates for all-cause mortality and priority diseases
and injuries, the World Health Organization including IHME,
updated Global Health Estimates (GHE) for mortality, causes
of death, and disease burden, are being progressively
released.
 History of GBD study (4)

› This commenced with the release in mid-2013 of updated

regional-level estimates of deaths by cause, age and sex for
years 2000-2011, followed by country-specific estimates for
the years 2000-2012, later updated

› WHO has now released updated estimates of deaths and

DALYs by cause, age, and sex for years 2000- 2019 as part of
it update of Global Health Estimates 2019.
 Global Burden of Disease

› For many years population health was evaluated using Mortality

Indicators only.
› Although Mortality Indicators are useful they do not provide all
the information necessary to assess the health of a population
or to compare the effectiveness of interventions to protect or
improve health.
› Burden of disease is a statistical techniques to measure the
impact on a population of disease, health conditions, injuries
and various risk factors.
› The Global Burden of Disease (GBD) provides acomprehensive
picture of mortality and disability across countries, time, age,
and sex.
 Global Burden of Disease
› It quantifies health loss from hundreds of diseases,
injuries, and risk factors, so that health systems can be
improved and disparities eliminated.
› One of several methods to summarize risk impact of
disease, injuries in the populations.
› Provides information and projections about disease
burden on global scale.
 Uses of GBD
› To compare population health across communities and over
time
› To provide a full picture of which diseases, injuries and risk
factors contribute the most poor health in a specific population,
including identification of the most important health problems
and whether they are getting better or worse over time
› To assess which information or source of information are
missing, uncertain, or of low quality.
› It provides a roadmap for policymakers showing where health
needs are greatest, with country-specific data on risk factors
and chronic disease burden.
 Measurement of Burden of Disease?
Health-Adjusted Life Years (HALYs)
The population health summary measures typically used in
estimates of the burden of disease. They measure the combined
effects of mortality and morbidity in populations, allowing for
comparisons across illnesses or interventions as well as
between populations.
Average number of years a citizens can expect to live in full
health.
Two common approaches to measuring HALYs are
1. Quality Adjusted Life Years (QALY)
2. Disability Adjusted Life Years (DALY)
 Quality Adjusted Life Years (QALY)
› Measure of disease burden, including both the quality and
quantity of life lived.
› It can measure both the effectiveness and Cost-
effectiveness of an intervention.
› The measure can give an idea of how many extra months
or year of life of quality of health a person might gain with
each intervention. So, it can be used to determine where
resources should be allocated.
› 1 QALY=1 year of life x 1 utility value
 Disability Adjusted Life Years (DALY)

› DALYs are currently the most common methods used for

estimating burden of disease and measure of overall disease
burden.
› Conceptually, one DALY is the equivalent of losing one year in
good health because of either premature death or disease or
disability.
› One DALY represents one lost year of healthy life.
› DALYs for a disease or health condition are the sum of
-years of life lost to due to premature mortality (YLLs) and
- the years lived with a disability (YLDs) due to prevalent
cases of the disease or health condition in a population.
DALY Contd..
DALY Contd..
DALYs = Years of life lost due to premature mortality
(YLL) + Years lived with disability (YLD)

› YLL = N (number of deaths at age x) x L (standard of life

expectancy at age x in years)

› YLD = I (number of incident cases) x DW (disability

weight) x L (average duration of the case until remission
or death in years)
GLOBAL BURDEN
OF DISEASE,
2019
 Global Burden of Disease Report, 2019
› The Global Burden of Diseases, Injuries, and Risk Factors
Study (GBD) provides a systematic scientific assessment
of published, publicly available, and contributed data on
incidence, prevalence, and mortality for a mutually
exclusive and collectively exhaustive list of diseases and
injuries.
› GBD 2019 provides an opportunity to incorporate newly
available datasets, enhance method performance and
standardization, and reflect changes in scientific
understanding.
Global distribution of the disease burden
 Top 10 causes of disease burden by DALY in 2019
› Neonatal disorders 7%
› Ischemic heart disease 7%
› Stroke 6%
› Lower respiratory infections 4%
› Diarrheal diseases 3%
› COPD 3%
› Road injuries 3%
› Diabetes 3%
› Low back pain 2%
TOP 10 GLOBAL CAUSES OF
DEATH IN 2019
1. Ischaemic heart disease
2. Stroke
3. Chronic obstructive pulmonary
disease
4. Lower respiratory infections
5. Neonatal conditions
6. Trachea, bronchus, lung cancers
7. Alzheimer disease and other
dementias
8. Diarrhoeal diseases
9. Diabetes mellitus
10. Kidney diseases
TOP 10 GLOBAL CAUSES OF
DISABILITY-ADJUSTED LIFE
YEARS (DALYS) IN 2019
1. Neonatal conditions
2. Ischaemic heart disease
3. Stroke
4. Lower respiratory infections
5. Diarrhoeal diseases
6. Road injury
7. Chronic obstructive pulmonary
disease
8. Diabetes mellitus
9. Tuberculosis
10. Congenital anomalie
 Top 5 risk factors that causes death- globally

FEMALES MALES

› High blood pressure -5.2 › Tobacco & smoking -6.5 million

million
› High blood pressure – 5.6 million
› Diet – 3.4 million
› Diet – 4.4 million
› High blood sugar – 3.0 million
› Air pollution – 3.7 million
› Air pollution – 2.9 million
› High blood sugar – 3.1 million
› High BMI – 2.5 million
Global Shift in burden of
disease
Trend in disease burden by cause (1990–2019)
Epidemiologists break the disease
burden down into three key
categories of disability or disease
i) Non-communicable diseases
(NCDs)
ii) Communicable, maternal,
neonatal and nutritional
diseases (CMNN) and
iii) Injuries.

In 1990 communicable diseases

held the highest share at 46
percent worldwide.
High-income nations in 2019 NCDs
account for more than 80%, CD <5
% and in low-income nations
communicable disease accounts
for more than 6% across many
countries.
 Trends in the number of DALYs across the different age groups
(1990 and 2019)

› The ten most important causes of increasing burden include six causes that affect older adults (ischaemic
heart disease, diabetes, stroke, chronic kidney disease, lung cancer, and age-related hearing loss),
› whereas the other four causes (HIV/AIDS, other musculoskeletal disorders, low back pain, and depressive
disorders) are common from teenage years into old age.
› Despite these ten conditions contributing the largest number of additional DALYs over the 30-year period,
only HIV/AIDS, other musculoskeletal disorders, and diabetes saw large increases in age-standardized
DALY rates, with an increase of 58·5 for HIV/AIDS, 30·7% for other musculoskeletal disorders, and 24·4%
for diabetes.
› The burden of HIV/AIDS, however, peaked in 2004 and has dropped substantially after the global scale-up of
antiretroviral treatment (ART).
› The changes in age-standardized rates for chronic kidney disease, age-related hearing loss, and depressive
Trend in disease burden by age (1990–2019)

• Decline in health burden in children

under 5 years from 41 in 1990 to more
than 50 percent decline in 2019.

• At a global level, collective rates

across all ages have been in steady
decline.

• The global health has improved

considerably over the course of the last
generation.
Trend in disease burden from NCD (1990–2019)

3 NCDs with highest disease

includes:
1. Cardiovascular diseases,
2. Cancer
3. Musculoskeletal disorders
Trend in disease burden from CMNN Disease

A significant reduction in global

burden from communicable,
neonatal, maternal and
nutritional diseases in recent
decades, falling from 1.2 billion
in 1990 to below 670 million in
2019 (around a 44 % reduction).
Trend in disease burden from Injuries (1990–2019)

• Road accidents are

particularly dominant
followed by falls,
interpersonal violence and
self-harm.

• Burden attributed to both

conflict & terrorism and
natural disasters are
highly volatile.
Trend in burden of disease from Injuries age-wise (1990–
2019)
1. Double down on catch-up development
2. The Millennium Development Goal health agenda has been working
3. Health systems need to be more agile to adapt to the rapid shift to NCDs and
disabilities
4. Public health is failing to address the increase in crucial global risk factors
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
Published Date: October 15, 2020

Reveals how well the world’s population were prepared in terms of underlying health for the
impact of the COVID-19 pandemic.

Global crisis of chronic diseases and failure of public health to stem the rise in highly
preventable risk factors have left populations vulnerable to acute health emergencies such as
COVID-19.

Urgent action is needed to address the global syndemic of chronic diseases, social inequalities,
and COVID-19 to ensure more robust health systems and healthier people, making countries
more resilient to future pandemic threats.
Nepal Burden
of Disease
Report, 2019
 Nepal Burden of Disease, 2019
› (MoHP) started the BoD exercise in Nepal, with technical
support from the Institute for Health Metrics and Evaluation
(IHME), by conducting a scoping exercise in 2014.
› In 2018, the UKaid Nepal Health Sector Programme 3
(NHSP3), signed an MoU with NHRC.
› Using the GBD 2017 study, the first comprehensive report
was published in 2019 which examines health outcomes in
Nepal, specifically looking at fatal and nonfatal outcomes,
and risk factors.
› In 2019 GBD estimates, a total of 281,577sources were used
including 402 data sources for Nepal.
Trend of Life expectancy from 1990 to 2019

› Life expectancy
increased by 12.7
years between 1990
to 2019.
› Nepal’s life
expectancy was 71.1
years in 2019. On an
average, females (73.0
years) were found to
live longer than males
(69.2 years).
› However, not all those
additional years
gained will be healthy
ones.
Trend of HALE from 1990 to 2019
› HALE, (the average
number of years a
Nepalese citizen can
expect to live in full
health) was 61.5
years, approximately
10 years lower than
life expectancy.
› HALE of females
(62.2 years) was
slightly higher than
that of males (60.9
years) in 2019.
› HALE increased by
11.1 years between
1990 to 2019.
Cause-Specific Mortality, 2019

› A total of 193,331 deaths

were estimated in Nepal for
the year 2019, of which 71.1
% of deaths were due to
NCDs, 21.1% of deaths were
due to CMNN diseases and
the remaining 7.8% of
deaths were due to injuries.
Trend in causes of death 1990 to 2019

› Between 1990 and 2019, the

age standardized mortality
rate declined by 8.3% for
cardiovascular diseases, by
15.3% for chronic respiratory
diseases by 68.5% in the
case of respiratory
infections and TB
› Whereas increased by 32.9%
in the case of digestive
diseases, and by 7.0% in
neoplasm.

› Compared to NCDs and

injuries, CMNN diseases
have a relatively steeper
decline in age standardised
mortality rates
Mortality due to Injuries (1990–2019)
• The proportion of deaths due
to injuries showed a
fluctuating trend.
• Injuries were responsible for
7.8% of total deaths in 2019
which is an increase from
6.2% of total deaths in 1990.

• The proportion of deaths due

to injuries peaked at 12.2% in
2015, which could possibly be
due to earthquake related
deaths in the year
Leading risk factors of deaths in 2019
› Number of deaths and DALYs due to
environmental/ occupational risk
factors and behavioral risk factors
have declined from 1990 to 2019.
› However metabolic risk factors have
been constantly increasing.
› Smoking, which was the second
leading cause of death in 1990 has
ascended to the first position in
2019. (age standardised mortality
rate due to smoking decreased by
28%)
› High systolic BP, which was the fourth
leading cause of death in 1990, has
ascended to second position in
2019.
 Conclusion of the BOD report
› Increasing life expectancy and HALE from 1990 to 2019.
› A changing nature of the burden of disease with NCDs being a more
common cause of death, YLLs, YLDs, and DALYs in 2019 compared to
1990.
› In the same period the number of deaths, YLLs, YLDs and DALYs for
most of CMNN diseases has decreased notably. Despite a notable
decline in the burden of CMNN diseases, they are still among the
leading causes of mortality and morbidity.
› The health system needs to carefully consider resource allocation to
deal with the increasing burden of NCDs while ensuring that CMNN
diseases are not under resourced.
› Prioritization of modifiable risk factors could reduce avoidable
mortality in the coming days.
1. There has been considerable increase in prevalence, mortality rate, and DALYs attributable to DM in
Nepal which could further posing a serious challenge to the health system in future.

2. Health systems need to prepare themselves to deal with the higher number of DM cases that require
chronic long-term care.

3. Prevention of DM requires collaborative efforts from multiple sectors and also accelerating the early
diagnosis and treatment of DM.

4. The current federal structure could be an opportunity for integrated, locally tailored public health and
clinical interventions for the prevention of the disease and its consequences.
References
› Mortality Visualization – https://vizhub.healthdata.org/mortality
› Causes of Death (COD) Visualization – https://vizhub.healthdata.org/cod
› Epi Visualization – https://vizhub.healthdata.org/epi
› GBD Compare – https://vizhub.healthdata.org/gbd-compare
› GBD Results Tool – http://ghdx.healthdata.org/gbd-results-tool
› Country profiles – http://www.healthdata.org/results/country-profiles
› https://
nhrc.gov.np/wp-content/uploads/2022/02/BoD-Report-Book-includ-Cover-mail-6_co
mpressed.pdf
› https://
www.healthdata.org/news-release/global-burden-disease-massive-shifts-reshape-healt
h-landscape-worldwide
› https://
www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext#gr3
› https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7116361/