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Lancet Infect Dis. 2018 Nov;18(11):1191-1210. doi: 10.1016/S1473-3099(18)30310-4. Epub 2018 Sep 19.

Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

Collaborators (144)

Troeger C, Blacker B, Khalil IA, Rao PC, Cao J, Zimsen SRM, Albertson SB, Deshpande A, Farag T, Abebe Z, Adetifa IMO, Adhikari TB, Akibu M, Al Lami FH, Al-Eyadhy A, Alvis-Guzman N, Amare AT, Amoako YA, Antonio CAT, Aremu O, Asfaw ET, Asgedom SW, Atey TM, Attia EF, Avokpaho EFGA, Ayele HT, Ayuk TB, Balakrishnan K, Barac A, Bassat Q, Behzadifar M, Behzadifar M, Bhaumik S, Bhutta ZA, Bijani A, Brauer M, Brown A, Camargos PAM, Castañeda-Orjuela CA, Colombara D, Conti S, Dadi AF, Dandona L, Dandona R, Do HP, Dubljanin E, Edessa D, Elkout H, Endries AY, Fijabi DO, Foreman KJ, Forouzanfar MH, Fullman N, Garcia-Basteiro AL, Gessner BD, Gething PW, Gupta R, Gupta T, Hailu GB, Hassen HY, Hedayati MT, Heidari M, Hibstu DT, Horita N, Ilesanmi OS, Jakovljevic MB, Jamal AA, Kahsay A, Kasaeian A, Kassa DH, Khader YS, Khan EA, Khan MN, Khang YH, Kim YJ, Kissoon N, Knibbs LD, Kochhar S, Koul PA, Kumar GA, Lodha R, Magdy Abd El Razek H, Malta DC, Mathew JL, Mengistu DT, Mezgebe HB, Mohammad KA, Mohammed MA, Momeniha F, Murthy S, Nguyen CT, Nielsen KR, Ningrum DNA, Nirayo YL, Oren E, Ortiz JR, Pa M, Postma MJ, Qorbani M, Quansah R, Rai RK, Rana SM, Ranabhat CL, Ray SE, Rezai MS, Ruhago GM, Safiri S, Salomon JA, Sartorius B, Savic M, Sawhney M, She J, Sheikh A, Shiferaw MS, Shigematsu M, Singh JA, Somayaji R, Stanaway JD, Sufiyan MB, Taffere GR, Temsah MH, Thompson MJ, Tobe-Gai R, Topor-Madry R, Tran BX, Tran TT, Tuem KB, Ukwaja KN, Vollset SE, Walson JL, Weldegebreal F, Werdecker A, West TE, Yonemoto N, Zaki MES, Zhou L, Zodpey S, Vos T, Naghavi M, Lim SS, Mokdad AH, Murray CJL, Hay SI, Reiner RC Jr.



Lower respiratory infections are a leading cause of morbidity and mortality around the world. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, provides an up-to-date analysis of the burden of lower respiratory infections in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 26 years and shows how the burden of lower respiratory infection has changed in people of all ages.


We used three separate modelling strategies for lower respiratory infections in GBD 2016: a Bayesian hierarchical ensemble modelling platform (Cause of Death Ensemble model), which uses vital registration, verbal autopsy data, and surveillance system data to predict mortality due to lower respiratory infections; a compartmental meta-regression tool (DisMod-MR), which uses scientific literature, population representative surveys, and health-care data to predict incidence, prevalence, and mortality; and modelling of counterfactual estimates of the population attributable fraction of lower respiratory infection episodes due to Streptococcus pneumoniae, Haemophilus influenzae type b, influenza, and respiratory syncytial virus. We calculated each modelled estimate for each age, sex, year, and location. We modelled the exposure level in a population for a given risk factor using DisMod-MR and a spatio-temporal Gaussian process regression, and assessed the effectiveness of targeted interventions for each risk factor in children younger than 5 years. We also did a decomposition analysis of the change in LRI deaths from 2000-16 using the risk factors associated with LRI in GBD 2016.


In 2016, lower respiratory infections caused 652 572 deaths (95% uncertainty interval [UI] 586 475-720 612) in children younger than 5 years (under-5s), 1 080 958 deaths (943 749-1 170 638) in adults older than 70 years, and 2 377 697 deaths (2 145 584-2 512 809) in people of all ages, worldwide. Streptococcus pneumoniae was the leading cause of lower respiratory infection morbidity and mortality globally, contributing to more deaths than all other aetiologies combined in 2016 (1 189 937 deaths, 95% UI 690 445-1 770 660). Childhood wasting remains the leading risk factor for lower respiratory infection mortality among children younger than 5 years, responsible for 61·4% of lower respiratory infection deaths in 2016 (95% UI 45·7-69·6). Interventions to improve wasting, household air pollution, ambient particulate matter pollution, and expanded antibiotic use could avert one under-5 death due to lower respiratory infection for every 4000 children treated in the countries with the highest lower respiratory infection burden.


Our findings show substantial progress in the reduction of lower respiratory infection burden, but this progress has not been equal across locations, has been driven by decreases in several primary risk factors, and might require more effort among elderly adults. By highlighting regions and populations with the highest burden, and the risk factors that could have the greatest effect, funders, policy makers, and programme implementers can more effectively reduce lower respiratory infections among the world's most susceptible populations.


Bill & Melinda Gates Foundation.

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