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Lancet. 2019 Sep 3. pii: S0140-6736(19)32007-0. doi: 10.1016/S0140-6736(19)32007-0. [Epub ahead of print]

Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study.

Author information

Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada.
Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada.
Department of Medicine, Universidad de La Frontera, Temuco, Chile.
Medical School, Fundación Oftalmológica de Santander, Universidad de Santander, Bucaramanga, Colombia.
Eternal Heart Care Centre and Research Institute, Jaipur, India; Department of Medicine, Rajasthan University of Health Sciences, Jaipur, India.
Estudios Clinicos Latinoamérica, Rosario, Argentina.
Department of Medicine, Hospital Alemão Oswaldo Cruz, Universidade de Santo Amaro, São Paulo, Brazil.
Dante Pazzanese Institute of Cardiology, São Paulo, Brazil.
Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
St John's Research Institute, St John's Medical College, Bangalore, India.
Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Department of Cardiology, Faculty of Medicine, Saglik Bilimleri University, Ankara, Turkey.
Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
Pamoja Tunaweza Women's Centre, Moshi, Tanzania; Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada.
Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Research Institute, Advocate Health Care, Chicago, IL, USA.
Independent University, Dhaka, Bangladesh.
Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland.
Department of Medicine, Aga Khan University, Karachi, Pakistan.
National Centre for Cardiovascular Diseases, Cardiovascular Institute, Beijing, China; Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China.
Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
Health Action by People, Trivandrum, India; Amrita Institute of Medical Sciences, Kochi, India.
School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India.
Department of Medicine, Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates.
Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address:

Erratum in



To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.


The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.


This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.


Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.


Full funding sources are listed at the end of the paper (see Acknowledgments).

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