Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region, 1990–2015

Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean... Int J Public Health (2018) 63 (Suppl 1):S11–S23 https://doi.org/10.1007/s00038-017-1017-y ORIGINAL ARTICLE Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region, 1990–2015 GBD 2015 Eastern Mediterranean Region Collaborators Received: 4 May 2017 / Revised: 30 June 2017 / Accepted: 7 July 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Conclusions Our study shows that the region is facing Objectives The Eastern Mediterranean Region faces sev- several health challenges and calls for global efforts to eral health challenges at a difficult time with wars, unrest, stabilise the region and to address the current and future and economic change. burden of disease. Methods We used the Global Burden of Disease 2015 study to present the burden of diseases, injuries, and risk Keywords Burden of disease  Eastern Mediterranean factors in the Eastern Mediterranean Region from 1990 to Region  Injuries  Risk factors  Disability-adjusted life 2015. years Results Ischemic heart disease was the leading cause of death in the region in 2015, followed by cerebrovascular disease. Changes in total deaths ranged from a reduction of Introduction 25% for diarrheal diseases to an increase of about 42% for diabetes and tracheal, bronchus, and lung cancer. Collec- The Eastern Mediterranean Region (EMR) is home to more tive violence and legal intervention increased by 850% than 500 million people, representing a diverse group of 22 during the time period. Diet was the leading risk factor for countries: Afghanistan, Arab Republic of Egypt, Bahrain, disability-adjusted life years (DALYs) for men compared Djibouti, Iraq, Islamic Republic of Iran, Jordan, Kingdom to maternal malnutrition for females. Childhood undernu- of Saudi Arabia (KSA), Kuwait, Lebanon, Libya, Morocco, trition was the leading risk factor for DALYs in 1990 and Oman, Pakistan, Palestine, Qatar, Republic of Yemen, 2005, but the second in 2015 after high blood pressure. Somalia, Sudan, Syrian Arab Republic (Syria), Tunisia, and the United Arab Emirates (UAE). These countries have different gross domestic products, socio-demographic profiles, health indicators, and health system capacities and This article is part of the supplement ‘‘The state of health in the Eastern Mediterranean Region, 1990–2015’’. coverage (WHO EMRO 2017; Mandil et al. 2013). About 12.2% of the population comprises children under 5 years The members of GBD (Global Burden of Disease) 2015 Eastern of age, and 20% are women of childbearing age (WHO Mediterranean Region Collaborators are listed at the end of the EMRO 2013). article. Ali H. Mokdad, on behalf of GBD 2015 Eastern The region also has wide variation in per capita gross Mediterranean Region Collaborators, is the corresponding author. national product (GNP), ranging from a high of $134,420 Electronic supplementary material The online version of this in Qatar to a low of $2000 in Afghanistan (The World article (doi:10.1007/s00038-017-1017-y) contains supplementary Bank GNI per capita 2017). While the Gulf States are some material, which is available to authorized users. of the richest countries globally, poverty rates remain high & GBD 2015 Eastern Mediterranean Region Collaborators in many other countries of the EMR. The proportion of the mokdaa@uw.edu population living below the national poverty line, accord- ing to World Bank data, is more than 20% in seven EMR Institute for Health Metrics and Evaluation, University of countries: Afghanistan (36%), Egypt (22%), Iraq (23%), Washington, Seattle, WA, USA 123 S12 GBD 2015 Eastern Mediterranean Region Collaborators Pakistan (22%), Palestine (22%), Sudan (47%), and Yemen incidence, prevalence, exposure to risks, and injuries; and (35%). In five of these countries, approximately one-third statistical models to pool data, adjust for bias, and incor- of the population is also food-insecure: Afghanistan (34%), porate covariates. It uses several metrics to report results Iraq (30%), Pakistan (30%), Sudan (33%), and Yemen for health loss related to specific diseases, injuries, and risk (36%) (The World Bank Databank 2017). factors: deaths and death rates, years of life lost due to This region faces several health challenges at a difficult premature mortality (YLLs), prevalence and prevalence time with wars, unrest, and economic changes (Mokdad rates for sequelae, years lived with disability (YLDs), and et al. 2014, 2016). These events will put a strain on limited disability-adjusted life years (DALYs). It provides a com- resources and impact the health gains achieved so far. In prehensive assessment of all-cause mortality and causes of addition, the EMR has a large, young population, and death estimates due to 249 causes in 195 countries and current events will shape the well-being of future territories from 1990 to 2015. generations. GBD estimates incidence and prevalence by age, sex, In this issue of the Journal, we report the burden of cause, year, and geography using a wide range of updated several diseases and risk factors in separate manuscripts: and standardised analytical procedures. GBD uses DisMod- intentional injuries, lower respiratory infections, maternal MR, a Bayesian meta-regression tool first developed for mortality, mental health, obesity, vision loss, road traffic GBD 2010 and GBD 2013 to determine prevalence and injuries, adolescent health, cancer, cardiovascular disease, incidence by cause and sequelae. child mortality, diabetes and chronic kidney disease, diar- GBD 2015 used the comparative risk assessment (CRA) rhoea, and HIV (GBD 2015 EMR Diabetes and Chronic framework developed for previous iterations of the GBD Kidney Disease Collaborators 2017e; GBD 2015 EMR study to estimate attributable deaths, DALYs, and trends in Child Mortality Collaborators 2017d; GBD 2015 EMR exposure by age group, sex, year, and geography for 79 HIV Collaborators 2017g; GBD 2015 EMR Diarrhea Dis- behavioural, environmental and occupational, and meta- ease Collaborators 2017f; GBD 2015 EMR Cancer Col- bolic risks or clusters of risks over the period 1990–2015. laborators 2017c; GBD 2015 EMR Intentional Injuries Risk-outcome pairs were included in the GBD 2015 study Collaborators 2017h; GBD 2015 EMR Cardiovascular if they met World Cancer Research Fund criteria for con- Disease Collaborators 2017b; GBD 2015 EMR Adolescent vincing or probable evidence. Relative risk estimates were Health Collaborators 2017a; GBD 2015 EMR Lower extracted from published and unpublished randomised Respiratory Infections Collaborators 2017i; GBD 2015 controlled trials, cohorts, and pooled cohorts. Risk expo- EMR Vision Loss Collaborators 2017n; GBD 2015 EMR sures were estimated based on published studies, household Maternal Mortality Collaborators 2017j; GBD 2015 EMR surveys, census data, satellite data, and other sources. Two Transportation Injuries Collaborators 2017m; GBD 2015 modelling approaches—a Bayesian meta-regression model EMR Obesity Collaborators 2017l; GBD 2015 EMR and a spatiotemporal Gaussian process regression model— Mental Disorders Collaborators 2017k). These topics were developed for the GBD study were used to pool data from selected based on the burden of disease in the region as different sources, adjust for bias in the data, and incorpo- well as the interest of the collaborators and the scientific rate potential covariates. GBD uses the counterfactual community. This manuscript provides the overall burden of scenario of theoretical minimum risk exposure level diseases, injuries, and risk factors in the Eastern Mediter- (TMREL) to attribute burden. TMREL is the level for a ranean Region from 1990 to 2015 and provides an update given risk exposure that could minimise risk at the popu- of our previous publications (Mokdad et al. 2014, 2016; lation level. A summary exposure value (SEV) was Khalil et al. 2016; Moradi-Lakeh et al. 2017a; Moradi- developed for GBD 2015 as the relative risk-weighted Lakeh et al. 2017b; Charara et al. 2017). prevalence of exposure. SEV ranges from zero when no excess risk exists in a population to one when the popu- lation is at the highest risk. Methods Socio-demographic Index and decomposition Overview of variance The Global Burden of Disease (GBD) 2015 methodology GBD 2015 created a Socio-demographic Index based on has been published elsewhere (Forouzanfar et al. 2016; lag-dependent income per capita, average educational Kassebaum et al. 2016a, b; Vos et al. 2016; Wang et al. attainment for ages 15 or older, and the total fertility rate. 2016a, b). GBD 2015 uses a comprehensive approach to To analyse the drivers of change, GBD 2015 decomposed report causes of death with garbage code redistribution; a trends in diseases and attributable burden into contributions systematic and simultaneous estimation of disease from population growth, change in population structure by 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S13 age and sex, risk exposure, and risk-deleted cause-specific rates. The spikes that appear at the left side of the fig- DALY rates. ure show the impact of conflict and war. Increases are seen GBD 2015 has four levels of causes that are mutually in YLLs from causes like war and injuries, as expected, but exclusive and exhaustive. Level 1 has three causes: com- also from other types of causes, underscoring the effects municable, maternal, neonatal, and nutritional disorders; these conflicts have on health systems when they occur. non-communicable diseases; and injuries. Level 2 has 21 Figure 5 shows the EMR DALYs attributable to Level 2 causes, while Levels 3 and 4 consist of disaggregated risk factors for men and women in 2015. Diet is the leading causes. GBD 2015 documented each step of the estimation risk factor for men, followed by high systolic blood pres- processes, as well as data sources, in accordance with sure. Most of the DALYs burden for men is due to car- Guidelines for Accurate and Transparent Health Estimates diovascular diseases and diabetes. Child and maternal Reporting (GATHER). malnutrition was the leading risk factor for DALYs for females, followed by diet. Child and maternal malnutrition impacted diarrhoea, lower respiratory infections, and Results nutritional deficiencies, while diet impacted CVD and diabetes. Our results showed a major shift in burden of disease in the Figure 6 shows the EMR DALYs attributable to Level 3 region and a wide variation by countries. Ischaemic heart risk factors and their changes from 1990 to 2005 and 2005 disease (IHD) was the leading cause of death in the region to 2015. Childhood undernutrition was the leading risk in 2015, followed by cerebrovascular disease (Fig. 1). factor for DALYs in 1990 and 2005, but the second-leading Among the leading 30 causes of deaths, there were varia- in 2015 after high blood pressure. The percent change in tions in the drivers of changes in mortality from population the age-standardised DALY rate from 1990 to 2005 was a growth, ageing, and changes to age-standardised rates of decline of 48%, compared to a decline of 43.4% from 2005 cause-specific mortality from 2005 to 2015. Changes in to 2015. Both obesity and high fasting plasma glucose total deaths ranged from a reduction of 25% for diarrheal increased from 1990 to 2005 and from 2005 to 2015, but diseases to an increase of about 42% for diabetes and tra- the rate of increase was slower from 2005 to 2015. cheal, bronchus, and lung cancer. Population growth e-Figure 1 shows the decomposition of changes for all- accounted for increases across all causes, while population cause DALYs to Level 3 risk factors from 1990 to 2015 for ageing led to increases in 18 causes. Declines the region. Overall changes in in all causes of DALYs attributable to changes in age-specific and cause-specific ranged from a decline of 75% to an increase of a little over mortality rates varied markedly. Collective violence and 200%. Population growth contributed to the increase in DALYs for all risk factors, while population ageing con- legal intervention increased by 850% during the time period. tributed to an increase for 33 causes. Drug use had the Figure 2 shows the leading causes of disease burden highest increase in risk exposure, followed by high body over time in the EMR. Ischemic heart disease was the mass index and high fasting plasma glucose. Changes in leading cause of DALYs followed by neonatal preterm the risk-deleted DALYs rate resulted in a decline in all but birth complications, neonatal encephalopathy, lower res- six causes. piratory infections, and war and legal intervention. Figure 3 shows the changes in the leading causes of DALYs from 2005 to 2015 by age. Violence and war Discussion increased from an early age to 55 years old. Diabetes increased among ages 40 and older. There were declines in Our study shows that the region is facing several health some infectious diseases among children under 5. IHD challenges in addition to the impact of the ongoing wars remained the leading cause of DALYs for ages 40 and and unrest. The region is dealing with an epidemiological older. shift in burden from infectious to chronic diseases. How- Figure 4 shows the expected relationship between age- ever, the recent events may lead to a resurgence of some standardised and crude YLL and YLD rates for the region communicable diseases that were declining before these from 1990 to 2015 for Level 2 causes. Expected age-s- events. Moreover, countries will have a strain on their tandardised YLL rates for infectious diseases declined with efforts to control and prevent non-communicable diseases. increased SDI. Cardiovascular disease (CVD) age-stan- Our findings call for global efforts to stabilise the region dardised YLL rates also declined with increased SDI. At and to address the current and future burden of disease. the same time, age-standardised YLD rates for the top In addition, but also linked to other effects of unrest, causes did not change much with SDI. At the higher SDI several risk factors affecting health are present. Efforts to levels, YLD rates were the same as or higher than YLL reduce and prevent these risk factors in the region should 123 S14 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 1 Eastern Mediterranean Region decomposition of changes in Collective violence and legal intervention, which increased by 847%, leading 30 causes of death due to population growth, population was truncated for display purposes (Global Burden of Disease 2015 ageing, and changes in age-specific mortality rates, 2005–2015. study, Eastern Mediterranean Region, 1990–2015) be a health priority. For example, poor diet is the leading risk. We have previously reported on the global rise in the cause of DALYs in the region. Many countries in the burden of air pollution (Cohen et al. 2017). region are suffering from malnutrition and at the same time Several countries in the region face a major environ- from poor diet that is leading to disease. Tobacco smoking mental challenge due to lack of water, rising temperatures, and systolic blood pressure are among the top causes of and sand storms. Our findings call for renewed efforts to DALYs. Some countries in the region need to enforce address the burden of ambient air pollution. Indeed, unlike regulations on tobacco to control and prevent smoking other risk factors or challenges faced by the region, envi- initiation. Blood pressure medication is now cheap and ronmental health requires strong governmental commit- affordable for many in the EMR, but this may not be true ments to implement the global environmental standards for some low-income countries in the region. However, and utilise the currently available technologies to reduce mechanisms for early detection and proper management of the burden. The wars in the region, especially in Yemen, Iraq, and high blood pressure should be adopted to reduce this bur- den. Viral hepatitis accounts for a large burden in the Syria, are taking a large toll on the health of the population. region, especially in Somalia, Pakistan, Djibouti, Afgha- The immediate impact of the wars has been very high, with nistan, and Egypt (Institute for Health Metrics and Evalu- increased mortality due to violence. Moreover, these events ation 2016). The burden of hepatitis requires efforts to will lead to increased health burden in the future as the next prevent the spread of the disease through minimising risk generation in many countries in the region is being raised factors and providing proper immunizations. Moreover, under the harsh conditions of malnutrition and lack of screening and treatment for hepatitis C should be preventive health services. encouraged. The wars and unrest have led to major migration and a The EMR has a large burden from ambient air pollution. large refugee population inside and outside the region. For Ambient air pollution is associated with increased mortal- many host countries, the existing health systems and ity and morbidity (WHO 2005). Our study showed that infrastructure do not support such a large additional pop- ambient particulate matters are the 5th leading DALYs ulation. In Lebanon, for example, public schools are 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S15 Fig. 2 Leading 30 level 3 Eastern Mediterranean Region causes of For the time period 1990–2005 and for 2005–2015, three measures of disability-adjusted life-years (DALYs) for both sexes combined, change are shown: percent change in the number of DALYs, percent 1990, 2005 and 2015. Causes are connected by arrows between time change in the all-age DALY rate and percent change in the age- periods. Communicable, maternal, neonatal and nutritional causes are standardised DALY rate (Global Burden of Disease 2015 study, shown in red, non-communicable causes in blue and injuries in green. Eastern Mediterranean Region, 1990–2015) providing education to Lebanese and Syrian children, but Despite the market failures, the private sector can still the public school infrastructure is not capable of dealing play an important role in regional health systems. Provid- with such a large number of students. This has resulted in a ing an amiable environment to foster competition between double shift in schools and put a large strain on the system. public and private providers will ensure better quality and The same applies to other services besides health, and in efficiency of services delivered. Better engagement of the other countries. private providers can reduce the burden of financing on the Countries in the region need to continue to strive to public sector. In this respect, movement from input-based achieve universal health coverage, strong screening and payment toward a performance-based payment system is prevention programs, and effective health delivery sys- urgently needed. Furthermore, considering the variety of tems. The countries in the region can also learn from the health challenges facing the region, it is vital for the systems put in place for the training and accreditation of countries to adopt concepts of health in all policies. This health professionals, priority-setting, and the implementa- can be achieved by developing a national body that focuses tion of evidence-based health care undertaken by some on setting up collaborative efforts among all sectors to other developed countries. Investment in health systems incorporate health issues into all policy areas aiming to can create jobs and improve economic growth, in addition promote, protect, preserve, and restore population health. to the direct benefits on health outcomes. It is also A critical component to improve current and future important to look at the wider determinants of health— health in the EMR is the ability to effectively and effi- such as poverty, housing, education, and employment; and ciently diagnose the challenges to health and well-being to empower women to have a dramatic effect on health faced by the region. The Global Burden of Disease offers outcomes. accurate and comprehensive information on the global burden of diseases, injuries, and risk factors, and develops 123 S16 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 3 Leading ten Level 3 causes of Eastern Mediterranean Region diseases. Other NN = other neonatal disorders. Intest inf = intestinal age-specific disability-adjusted life-years (DALYs) in 2015. Each infectious diseases. Violence = interpersonal violence. NN Hae- cause is coloured by the percentage change in age-specific DALY rate mol = haemolytic disease and other neonatal jaundice. Anxi- from 2005 to 2015. NN Preterm = neonatal preterm birth complica- ety = anxiety disorders. TB = tuberculosis. Lung C = lung, tions. NN Sepsis = neonatal sepsis and other neonatal infections. bronchial, and tracheal cancers. STD = sexually transmitted diseases LRI = lower respiratory infections. Iron = iron-deficiency anaemia. excluding HIV. Haemog = haemoglobinopathies and haemolytic HIV = HIV/AIDS. Back and neck = low back and neck pain. anaemias. CKD = chronic kidney disease. Other MSK = other IHD = ischaemic heart disease. NN Enceph = neonatal musculoskeletal disorders. Drugs = drug use disorders. HTN encephalopathy due to birth asphyxia and trauma. Diarrhoea = diar- HD = hypertensive heart disease. Whooping = whooping cough. rhoeal diseases. Skin = skin and subcutaneous diseases. Depres- Other UI = other unintentional injuries. War = collective violence sion = depressive disorders. Stroke = cerebrovascular disease. and legal intervention. Cirrhosis Hep C = Cirrhosis and other chronic Congenital = congenital anomalies. Diabetes = diabetes mellitus. liver diseases due to hepatitis C. Other Cardio = Other cardiovascu- COPD = chronic obstructive pulmonary disease. Alzheimer’- lar and circulatory diseases. GBD = Global Burden of Disease s = Alzheimer’s disease and other dementias. PEM = protein-energy (Global Burden of Disease 2015 study, Eastern Mediterranean malnutrition. Conduct = conduct disorder. Sense = sense organ Countries, 2005–2015) new analytic methods and data visualisation tools to sup- topical area of burden from peer-reviewed and grey liter- port the understanding of this information and to empower ature and include both successful and negative outcomes policymakers and health leaders to act. However, the (as much can be learned from failures as from successes), region still has a long way to go in terms of having ade- as well as potential unintended consequences of interven- quate and timely data to better inform decision-makers of tions. The plan should include a synthesis of the available the burden. Therefore, there is an urgent need to improve quantitative and qualitative evidence on interventions and vital statistics, data sources, and surveillance systems in the innovations to develop a summary of why specific work region to better serve their purpose. around a risk or disease succeeds or fails. This analysis will The region is in dire need of a comprehensive plan to develop a deeper understanding of the necessary ingredi- build on existing expertise and projects to address the ents for success (i.e., to identify underlying social, eco- health challenges that exist at the nexus of human health, nomic, legal, and public policy features). This will allow environmental resilience, and social and economic equity. health actors to design and conduct innovative research on The region does not have proper health translation and intervention effectiveness, implementation, scale-up, dis- implementation efforts to address its growing health chal- semination, and economic return in partnership with lenges. Unfortunately, many countries have focused on community, governments, foundations, and other collabo- curative rather than preventive systems. Indeed, this will rators. This work should draw on resources including, but limit the pace of progress needed to address many of the not limited to, the United Nations’ Sustainable Develop- emerging challenges such as non-communicable diseases ment Goals, the Disease Control Priorities publications, and the emergence of infectious diseases in countries with and the World Health Organization’s ‘‘Best Buys’’. wars and unrest. This lack of progress is evidenced by wide Health education and training are crucial to improve the health disparities between and within countries and exists burden of disease in the EMR. There is a dire need for despite the identified organisations and forums that offer opportunities and funding to offer training for public offi- recommendations for intervention, such as the World cials (e.g., health ministers, policymakers, and local health Health Organization and others. officers) and program leaders, provided both on-site and on This comprehensive plan needs to review and compile a regional scale at in-country sites in collaboration with information on prior health interventions for each targeted other countries. These trainings should provide participants 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S17 Fig. 4 a Expected relationship between age-standardised years of life lost (YLL) and years lived with disability (YLD) rates per 100,000 and Sociodemographic index (SDI) and b all-age YLL and YLD rates (per 100,000) and SDI for 21 GBD Level 2 causes. These stacked curves represent the average relationship between SDI and each cause observed across the 22 Eastern Mediterranean Region countries in 2015. In each figure, the y- axis goes from lowest SDI to highest SDI. The left side shows rates for YLLs and the right side shows rates for YLDs; higher rates are further from the midline. The difference between (a) and (b) is the effect of shifts in population age structure expected with SDI. GBD = Global Burden of Disease (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 1990–2015) with actual experience implementing the interventions that encourage adoption, successful implementation, and ulti- have been developed. Finally, there is a need to scale up mately, sustainability of population health. the public health workforce across the region, to ensure The future of health in the region is grim unless the wars that the right policies are developed, implemented, and and unrest stop. Regional health professionals are dealing enforced. with overwhelming challenges and can barely meet basic Health advocacy and effective program and policy dis- health needs. The best intervention for a better future is an semination must be at the forefront of all health activities. international plan to stabilise the region. All countries have The region needs a catalyst for change at both country and an equally important role to play in bringing an end to the regional levels by providing a platform on which local and unrest and starting to rebuild. global strategies and successes are collaboratively shared Our study has some limitations. The availability and among local communities and countries. This, in turn, will quality of data for some countries in the region pose sub- stantial challenges for cause of death analysis. Many 123 S18 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 5 Eastern Mediterranean Region disability-adjusted life- years (DALYs) attributable to Level 2 risk factors for (a) men and (b) women in 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 1990–2015) countries in the region do not have strong vital registration with data quality or lack of it. Finally, our study provides systems. Our GBD methodology makes extensive efforts to the national burden and hence masks large disparities reduce the effects of variable data quality, and we have within a country. used standardised methods for each cause that are the same for all countries. We also provide uncertainty intervals for Conclusion each of our estimates that take into account the data issues, and we provide all our data sources and show what is Our study shows a tremendous impact of war and violence available for every country on our website (Institute for on the health of the region. The results show that in recent Health Metrics and Evaluation 2017). Our web visualisa- years, many of the health gains for some countries have tions allow comparison of raw data to final estimates and slowed and several health conditions that were under show the impact of our models and methods of dealing control are re-emerging. These findings clearly indicate 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S19 Fig. 6 Leading 30 level 3 Eastern Mediterranean Region risk factors percent change in the number of DALYs, percent change in the all- for disability-adjusted life-years (DALYs) for both sexes combined, age DALY rate and percent change in the age-standardised DALY 1990, 2005, and 2015. Risks are connected by arrows between time rate. Statistically significant increases or decreases are shown in bold periods. Behavioural risk factors are shown in red, environmental (p \ 0.05) (Global Burden of Disease 2015 study, Eastern Mediter- risks in blue and metabolic risks in green. For the time period ranean Region, 1990–2015) 1990–2005 and for 2005–2015, three measures of change are shown: Washington. Stan Biryukov, BS, Institute for Health Metrics and that the future health of the region is in danger. Immediate Evaluation, University of Washington, Seattle, Washington, United efforts to stabilise the region and improve the health of the States. Daniel Casey, BA, Institute for Health Metrics and Evaluation, population are urgently needed. University of Washington, Seattle, Washington, United States. Kelly Cercy, BS, Institute for Health Metrics and Evaluation, University of GBD 2015 Eastern Mediterranean Region Collaborators Ali H. Washington, Seattle, Washington, United States. Fiona J. Charlson, Mokdad, PhD (corresponding author), Institute for Health Metrics and PhD, School of Public Health, University of Queensland, Brisbane, Evaluation, University of Washington, Seattle, Washington, United Queensland, Australia; Institute for Health Metrics and Evaluation, States. Charbel El Bcheraoui, PhD, Institute for Health Metrics and University of Washington, Seattle, United States; Queensland Centre Evaluation, University of Washington, Seattle, Washington, United for Mental Health Research, Brisbane, Queensland, Australia. Leslie States. Raghid Charara, MD, American University of Beirut, Beirut, Cornaby, BS, Institute for Health Metrics and Evaluation, University Lebanon. Ibrahim Khalil, PhD, Institute for Health Metrics and of Washington, Seattle, Washington, United States. Daniel Dicker, Evaluation, University of Washington, Seattle, Washington, United BS, Institute for Health Metrics and Evaluation, University of States. Maziar Moradi-Lakeh, MD, Department of Community Washington, Seattle, Washington, United States. Holly E. Erskine, Medicine, Gastrointestinal and Liver Disease Research Center PhD, Queensland Centre for Mental Health Research, Brisbane, QLD, (GILDRC), Preventative Medicine and Public Health Research Cen- Australia; School of Public Health, University of Queensland, Bris- ter, Iran University of Medical Sciences, Tehran, Iran. Ashkan bane, QLD, Australia; Institute for Health Metrics and Evaluation, Afshin, MD, Institute for Health Metrics and Evaluation, University University of Washington, Seattle, WA, United States. Alize J. Fer- of Washington, Seattle, Washington, United States. Michael Collison, rari, PhD, School of Public Health, University of Queensland, Bris- BS, Institute for Health Metrics and Evaluation, University of bane, Queensland, Australia; Queensland Centre for Mental Health Washington, Seattle, Washington, United States. Farah Daoud, BA/ Research, Brisbane, Queensland, Australia; Institute for Health Met- BS, Institute for Health Metrics and Evaluation, University of rics and Evaluation, University of Washington, Seattle, Washington, Washington, Seattle, Washington, United States. Kristopher J. Krohn, United States. Christina Fitzmaurice, MD, Institute for Health Metrics BA, Institute for Health Metrics and Evaluation, University of and Evaluation, University of Washington, Seattle, Washington, Washington, Seattle, Washington, United States. Adrienne Chew, United States. Kyle J. Foreman, PhD, Institute for Health Metrics and ND, Institute for Health Metrics and Evaluation, University of Evaluation, University of Washington, Seattle, Washington, United 123 S20 GBD 2015 Eastern Mediterranean Region Collaborators States; Imperial College London, London, United Kingdom. Maya Alizadeh-Navaei, PhD, Gastrointestinal Cancer Research Center, Fraser, BA, Institute for Health Metrics and Evaluation, University of Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Washington, Seattle, Washington, United States. Joseph Frostad, Rajaa Al-Raddadi, PhD, Joint Program of Family and Community MPH, Institute for Health Metrics and Evaluation, University of Medicine, Jeddah, Makkah, Saudi_Arabia. Khalid A. Altirkawi, MD, Washington, Seattle, Washington, United States. William W. God- King Saud University, Riyadh, Saudi_Arabia. Nahla Anber, PhD, win, BS, Institute for Health Metrics and Evaluation, University of Mansoura University, Mansoura, Egypt. Hossein Ansari, PhD, Health Washington, Seattle, Washington, United States. Max Griswold, MA, Promotion Research Center, Department of Epidemiology and Bio- Institute for Health Metrics and Evaluation, University of Washing- statistics, Zahedan University of Medical Sciences, Zahedan, Iran. ton, Seattle, Washington, United States. Nicholas J. Kassebaum, MD, Palwasha Anwari, MD, Self-employed, Kabul, Kabul, Afghanistan. Institute for Health Metrics and Evaluation, University of Washing- Hamid Asayesh, PhD, Department of Medical Emergency, School of ton, Seattle, Washington, United States; Department of Anesthesiol- Paramedic, Qom University of Medical Sciences, Qom, Iran. Solo- ogy & Pain Medicine, Seattle Children’s Hospital, Seattle, mon W. Asgedom, PhD, Mekelle University, Mekelle, Tigray, Washington, United States. Laura Kemmer, Institute for Health Ethiopia. Tesfay Mehari Atey, MS, Mekelle University, Mekelle, Metrics and Evaluation, University of Washington, Seattle, Wash- Tigray, Ethiopia. Umar Bacha, PhD, School of Health Sciences, ington, United States. Michael Kutz, BS, Institute for Health Metrics University of Management and Technology, Lahore, Punjab, Pak- and Evaluation, University of Washington, Seattle, Washington, istan. Shahrzad Bazargan-Hejazi, PhD, College of Medicine, Charles United States. Hmwe H. Kyu, PhD, Institute for Health Metrics and R. Drew University of Medicine and Science, Los Angeles, CA, Evaluation, University of Washington, Seattle, Washington, United United States; David Geffen School of Medicine, University of Cal- States. Janni Leung, PhD, School of Public Health, University of ifornia at Los Angeles, Los Angeles, CA, United States. Neeraj Bedi, Queensland, Brisbane, QLD, Australia; University of Washington, MD, College of Public Health and Tropical Medicine, Jazan, Seattle, WA, United States. Patrick Liu, BA, Institute for Health Saudi_Arabia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Metrics and Evaluation, University of Washington, Seattle, Wash- Women and Child Health, Aga Khan University, Karachi, Pakistan; ington, United States. Joseph Mikesell, BS, Institute for Health Centre for Global Child Health, The Hospital for Sick Children, Metrics and Evaluation, University of Washington, Seattle, Wash- Toronto, ON, Canada. Donal Bisanzio, PhD, Nuffield Department of ington, United States. Grant Nguyen, MPH, Institute for Health Medicine, University of Oxford, Oxford, United Kingdom. Zahid A. Metrics and Evaluation, University of Washington, Seattle, Wash- Butt, PhD, Al Shifa Trust Eye Hospital, Rawalpindi, Punjab, Pakistan. ington, United States. Helen E. Olsen, MA, Institute for Health Amare Deribew, PhD, Nuffield Department of Medicine, University Metrics and Evaluation, University of Washington, Seattle, Wash- of Oxford, Oxford, United Kingdom; KEMRI-Wellcome Trust ington, United States. Robert Reiner, BA, Institute for Health Metrics Research Programme, Kilifi, Kenya. Shirin Djalalinia, PhD, Under- and Evaluation, University of Washington, Seattle, Washington, secretary for Research & Technology, Ministry of Health & Medical United States. Marissa Reitsma, BS, Institute for Health Metrics and Education, Tehran, Tehran, Iran. Babak Eshrati, PhD, Ministry of Evaluation, University of Washington, Seattle, Washington, United Health and Medical Education, Tehran, Tehran, Iran; Arak University States. Gregory Roth, MD, Institute for Health Metrics and Evalua- of Medical Sciences, Arak, Iran. Alireza Esteghamati, MD, tion, University of Washington, Seattle, Washington, United States. Endocrinology and Metabolism Research Center, Tehran University Damian Santomauro, PhD, School of Public Health, University of of Medical Sciences, Tehran, Tehran, Iran. Maryam S. Farvid, PhD, Queensland, Brisbane, Queensland, Australia; Queensland Centre for Department of Nutrition, Harvard T. 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Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. United States. Rima Afifi, PhD, Department of Health Promotion and Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Community Health, Faculty of Health Sciences, American University Dubai, united_arab_emirates. Peter J. Hotez, PhD, College of Medi- of Beirut, Beirut, Lebanon. Aliasghar Ahmad Kiadaliri, PhD, cine, Baylor University, Houston, Texas, United States. Mohamed Department of Clinical Sciences Lund, Orthopedics, Clinical Epi- Hsairi, MD, Department of Epidemiology, Salah Azaiz Institute, demiology Unit, Lund University, Lund, Sweden. Alireza Ahmadi, Tunis, Tunis, Tunisia. Jost B. Jonas, MD, Department of Ophthal- PhD, Kermanshah University of Medical Sciences, Kermanshah, Iran, mology, Medical Faculty Mannheim, Ruprecht-Karls-University Stockholm, Sweden. Hamid Ahmadieh, MD, Ophthalmic Research Heidelberg, Mannheim, Germany, Germany. Amir Kasaeian, PhD, Center, Shahid Beheshti University of Medical Sciences, Tehran, Hematology-Oncology and Stem Cell Transplantation Research Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Tehran University of Medical Sciences, Tehran, Tehran, Iran; Center, Tehran, Tehran, Iran. Khurshid Alam, PhD, Murdoch Chil- Endocrinology and Metabolism Population Sciences Institute, Tehran drens Research Institute, The University of Melbourne, Parkville, University of Medical Sciences, Tehran, Tehran, Iran. Yousef S. Victoria, Australia; The University of Melbourne, Melbourne, VIC, Khader, ScD, Department of Community Medicine, Public Health Australia; The University of Sydney, Sydney, NSW, Australia. Noore and Family Medicine, Jordan University of Science and Technology, Alam, MAppEpid, Department of Health, Queensland, Brisbane, Irbid, Irbid, Jordan. Ejaz A. Khan, MD, Health Services Academy, Queensland, Australia; Nathan, Queensland, Australia. Raghib Ali, Islamabad, Punjab, Pakistan. Gulfaraz Khan, PhD, Department of FRCP, University of Oxford, Oxford, United Kingdom. Reza Microbiology and Immunology, College of Medicine & Health 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S21 Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, Abdallah M. Samy, PhD, Ain Shams University, Cairo, Egypt; united_arab_emirates. Abdullah T. A. Khoja, MD, Mohammed Ibn Lawrence, Kansas, United States. Benn Sartorius, PhD, Public Health Saudi University, Riyadh, Saudi Arabia, Saudi_Arabia; Baltimore, Medicine, School of Nursing and Public Health, University of Kwa- MD, United States. Tawfik A. M. Khoja, FRCP, Executive Board of Zulu-Natal, Durban, South_Africa; UKZN Gastrointestinal Cancer the Health Ministers’ Council for Cooperation Council States, Research Centre, South African Medical Research Council Riyadh, Al-Riyadh, Saudi_Arabia. Jagdish Khubchandani, PhD, (SAMRC), Durban, South_Africa. Sadaf G. Sepanlou, PhD, Digestive Department of Nutrition and Health Science, Ball State University, Diseases Research Institute, Tehran University of Medical Sciences, Muncie, Indiana, United States. Jacek A. Kopec, PhD, University of Tehran, Tehran, Iran. Masood A. Shaikh, MD, Independent Consul- British Columbia, Vancouver, BC, Canada. Heidi J. Larson, PhD, tant, Karachi, Pakistan. Morteza Shamsizadeh, MPH, Department of Department of Infectious Disease Epidemiology, London School of Medical Surgical Nursing, School of Nursing and Midwifery, Hygiene & Tropical Medicine, London, United Kingdom; Institute for Hamadan University of Medical Sciences, Hamadan, Iran. Badr H. Health Metrics and Evaluation, University of Washington, Seattle, A. Sobaih, MD, king Saud university, Riyadh, middle province, WA, United States. Raimundas Lunevicius, PhD, Aintree University Saudi_Arabia, Riyadh, Saudi Arabia. Rizwan Suliankatchi Abdulka- Hospital National Health Service Foundation Trust, Liverpool, United der, MD, Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Kingdom; School of Medicine, University of Liverpool, Liverpool, Saudi_Arabia. Arash Tehrani-Banihashemi, PhD, Preventive Medi- United Kingdom. Hassan Magdy Abd El Razek, MBBCH, Mansoura cine and Public Health Research Center, Iran University of Medical Faculty of Medicine, Mansoura, Egypt. Mohammed Magdy Abd El Sciences, Tehran, Tehran, Iran. Mohamad-Hani Temsah, MD, King Razek, MBBCh, Aswan University Hospital, Aswan Faculty of Saud University, Riyadh, Saudi_Arabia; King Faisal Specialist Medicine, Aswan, Egypt. Reza Majdzadeh, PhD, Knowledge Hospital and Research Center, Riyadh, Saudi_Arabia. Abdullah S. Utilization Research Center, Tehran University of Medical Sciences, Terkawi, MD, Department of Anesthesiology, University of Virginia, Tehran, Iran. 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Mohsen Yaghoubi, MA, University of Saskatchewan, Saska- Diseases Research Center, Alborz University of Medical Sciences, toon, Saskatchewan, Canada, Tehran, Tehran, Iran. Mehdi Yaseri, Karaj, Iran. Amir Radfar, MD, A T Still University, Kirksville, MO, PhD, Tehran University of Medical Sciences, Terhan, Tehran, Iran; United States. Anwar Rafay, MS, Contech International Health Ophthalmic Research Center, Shahid Beheshti University of Medical Consultants, Lahore, Punjab, Pakistan; Contech School of Public Sciences, Tehran, Tehran, Iran. Mustafa Z. Younis, DrPH, Jackson Health, Lahore, Punjab, Pakistan. Vafa Rahimi-Movaghar, MD, Sina State University, Jackson, MS, United States. Maysaa E. S. Zaki, Trauma and Surgery Research Center, Tehran University of Medical PhD, Faculty of Medicine, Mansoura University, Mansoura, Egypt. Sciences, Tehran, Tehran, Iran. Rajesh Kumar Rai, MPH, Society for Aisha O. Jumaan, PhD, Independent Consultant, Seattle, Washington, Health and Demographic Surveillance, Suri, West Bengal, India. United States. Theo Vos, PhD, Institute for Health Metrics and David L. Rawaf, MD, MBBS, WHO Collaborating Centre, Imperial Evaluation, University of Washington, Seattle, Washington, United College London, London, United Kingdom; North Hampshire States. Mohsen Naghavi, PhD, Institute for Health Metrics and Hospitals, Basingstroke, United Kingdom; University College Lon- Evaluation, University of Washington, Seattle, Washington, United don Hospitals, London, United Kingdom. Salman Rawaf, MD, States. Simon I. Hay, DSc, Oxford Big Data Institute, Li Ka Shing Imperial College London, London, United Kingdom. Amany H. Centre for Health Information and Discovery, University of Oxford, Refaat, PhD, Walden University, Minneapolis, MN, United States; Oxford, United Kingdom; Institute for Health Metrics and Evaluation, Suez Canal University, Ismailia, Ismailia, Egypt. Satar Rezaei, PhD, University of Washington, Seattle, Washington, United States. School of Public Health, Kermanshah University of Medical Sci- Christopher J. L. Murray, DPhil, Institute for Health Metrics and ences, Kermanshah, Iran. Gholamreza Roshandel, PhD, Golestan Evaluation, University of Washington, Seattle, Washington, United Research Center of Gastroenterology and Hepatology, Golestan States. University of Medical Sciences, Gorgan, Iran; Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Compliance with ethical standards Iran. Mahdi Safdarian, MD, Sina Trauma & Surgery Research Center, Tehran, Iran. Sare Safi, MS, Ophthalmic Epidemiology Research This manuscript reflects original work that has not previously been Center, Shahid Beheshti University of Medical Sciences, Tehran, published in whole or in part and is not under consideration else- Iran. Saeid Safiri, PhD, Managerial Epidemiology Research Center, where. All authors have read the manuscript and have agreed that the Department of Public Health, School of Nursing and Midwifery, work is ready for submission and accept responsibility for its con- Maragheh University of Medical Sciences, Maragheh, Iran. tents. The authors of this paper have complied with all ethical stan- Mohammad Ali Sahraian, MD, MS Research Center, Neuroscience dards and do not have any conflicts of interest to disclose at the time Institute, Tehran University of Medical Sciences, Tehran, Iran. Pay- of submission. The funding source played no role in the design of the man Salamati, MD, Sina Trauma and Surgery Research Center, study, the analysis and interpretation of data, and the writing of the Tehran University of Medical Sciences, Tehran, Tehran, Iran. 123 S22 GBD 2015 Eastern Mediterranean Region Collaborators paper. The study did not involve human participants and/or animals; GBD 2015 EMR Intentional Injuries Collaborators (2017h) Inten- therefore, no informed consent was needed. tional injuries in the eastern mediterranean region, 1990–2015: findings from the global burden of disease 2015 study. Int J Publ Funding This research was funded by the Bill & Melinda Gates Health. doi:10.1007/s00038-017-1005-2 Foundation. GBD 2015 EMR Lower Respiratory Infections Collaborators (2017i) Burden of lower respiratory infections in the eastern mediter- ranean region between 1990 and 2015: findings from the global Conflict of interest The authors declare that they have no conflicts of burden of disease 2015 study. Int J Publ Health. doi:10.1007/ interest at this time. s00038-017-1007-0 GBD 2015 EMR Maternal Mortality Collaborators (2017j) Maternal Open Access This article is distributed under the terms of the mortality and morbidity burden in the eastern mediterranean Creative Commons Attribution 4.0 International License (http://crea region: findings from the global burden of disease 2015 study. tivecommons.org/licenses/by/4.0/), which permits unrestricted use, Int J Publ Health. doi:10.1007/s00038-017-1004-3 distribution, and reproduction in any medium, provided you give GBD 2015 EMR Mental Disorders Collaborators (2017k) The burden appropriate credit to the original author(s) and the source, provide a of mental disorders in the eastern mediterranean region, link to the Creative Commons license, and indicate if changes were 1990–2015: findings from the global burden of disease 2015 made. study. 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Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region, 1990–2015

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Abstract

Int J Public Health (2018) 63 (Suppl 1):S11–S23 https://doi.org/10.1007/s00038-017-1017-y ORIGINAL ARTICLE Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region, 1990–2015 GBD 2015 Eastern Mediterranean Region Collaborators Received: 4 May 2017 / Revised: 30 June 2017 / Accepted: 7 July 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Conclusions Our study shows that the region is facing Objectives The Eastern Mediterranean Region faces sev- several health challenges and calls for global efforts to eral health challenges at a difficult time with wars, unrest, stabilise the region and to address the current and future and economic change. burden of disease. Methods We used the Global Burden of Disease 2015 study to present the burden of diseases, injuries, and risk Keywords Burden of disease  Eastern Mediterranean factors in the Eastern Mediterranean Region from 1990 to Region  Injuries  Risk factors  Disability-adjusted life 2015. years Results Ischemic heart disease was the leading cause of death in the region in 2015, followed by cerebrovascular disease. Changes in total deaths ranged from a reduction of Introduction 25% for diarrheal diseases to an increase of about 42% for diabetes and tracheal, bronchus, and lung cancer. Collec- The Eastern Mediterranean Region (EMR) is home to more tive violence and legal intervention increased by 850% than 500 million people, representing a diverse group of 22 during the time period. Diet was the leading risk factor for countries: Afghanistan, Arab Republic of Egypt, Bahrain, disability-adjusted life years (DALYs) for men compared Djibouti, Iraq, Islamic Republic of Iran, Jordan, Kingdom to maternal malnutrition for females. Childhood undernu- of Saudi Arabia (KSA), Kuwait, Lebanon, Libya, Morocco, trition was the leading risk factor for DALYs in 1990 and Oman, Pakistan, Palestine, Qatar, Republic of Yemen, 2005, but the second in 2015 after high blood pressure. Somalia, Sudan, Syrian Arab Republic (Syria), Tunisia, and the United Arab Emirates (UAE). These countries have different gross domestic products, socio-demographic profiles, health indicators, and health system capacities and This article is part of the supplement ‘‘The state of health in the Eastern Mediterranean Region, 1990–2015’’. coverage (WHO EMRO 2017; Mandil et al. 2013). About 12.2% of the population comprises children under 5 years The members of GBD (Global Burden of Disease) 2015 Eastern of age, and 20% are women of childbearing age (WHO Mediterranean Region Collaborators are listed at the end of the EMRO 2013). article. Ali H. Mokdad, on behalf of GBD 2015 Eastern The region also has wide variation in per capita gross Mediterranean Region Collaborators, is the corresponding author. national product (GNP), ranging from a high of $134,420 Electronic supplementary material The online version of this in Qatar to a low of $2000 in Afghanistan (The World article (doi:10.1007/s00038-017-1017-y) contains supplementary Bank GNI per capita 2017). While the Gulf States are some material, which is available to authorized users. of the richest countries globally, poverty rates remain high & GBD 2015 Eastern Mediterranean Region Collaborators in many other countries of the EMR. The proportion of the mokdaa@uw.edu population living below the national poverty line, accord- ing to World Bank data, is more than 20% in seven EMR Institute for Health Metrics and Evaluation, University of countries: Afghanistan (36%), Egypt (22%), Iraq (23%), Washington, Seattle, WA, USA 123 S12 GBD 2015 Eastern Mediterranean Region Collaborators Pakistan (22%), Palestine (22%), Sudan (47%), and Yemen incidence, prevalence, exposure to risks, and injuries; and (35%). In five of these countries, approximately one-third statistical models to pool data, adjust for bias, and incor- of the population is also food-insecure: Afghanistan (34%), porate covariates. It uses several metrics to report results Iraq (30%), Pakistan (30%), Sudan (33%), and Yemen for health loss related to specific diseases, injuries, and risk (36%) (The World Bank Databank 2017). factors: deaths and death rates, years of life lost due to This region faces several health challenges at a difficult premature mortality (YLLs), prevalence and prevalence time with wars, unrest, and economic changes (Mokdad rates for sequelae, years lived with disability (YLDs), and et al. 2014, 2016). These events will put a strain on limited disability-adjusted life years (DALYs). It provides a com- resources and impact the health gains achieved so far. In prehensive assessment of all-cause mortality and causes of addition, the EMR has a large, young population, and death estimates due to 249 causes in 195 countries and current events will shape the well-being of future territories from 1990 to 2015. generations. GBD estimates incidence and prevalence by age, sex, In this issue of the Journal, we report the burden of cause, year, and geography using a wide range of updated several diseases and risk factors in separate manuscripts: and standardised analytical procedures. GBD uses DisMod- intentional injuries, lower respiratory infections, maternal MR, a Bayesian meta-regression tool first developed for mortality, mental health, obesity, vision loss, road traffic GBD 2010 and GBD 2013 to determine prevalence and injuries, adolescent health, cancer, cardiovascular disease, incidence by cause and sequelae. child mortality, diabetes and chronic kidney disease, diar- GBD 2015 used the comparative risk assessment (CRA) rhoea, and HIV (GBD 2015 EMR Diabetes and Chronic framework developed for previous iterations of the GBD Kidney Disease Collaborators 2017e; GBD 2015 EMR study to estimate attributable deaths, DALYs, and trends in Child Mortality Collaborators 2017d; GBD 2015 EMR exposure by age group, sex, year, and geography for 79 HIV Collaborators 2017g; GBD 2015 EMR Diarrhea Dis- behavioural, environmental and occupational, and meta- ease Collaborators 2017f; GBD 2015 EMR Cancer Col- bolic risks or clusters of risks over the period 1990–2015. laborators 2017c; GBD 2015 EMR Intentional Injuries Risk-outcome pairs were included in the GBD 2015 study Collaborators 2017h; GBD 2015 EMR Cardiovascular if they met World Cancer Research Fund criteria for con- Disease Collaborators 2017b; GBD 2015 EMR Adolescent vincing or probable evidence. Relative risk estimates were Health Collaborators 2017a; GBD 2015 EMR Lower extracted from published and unpublished randomised Respiratory Infections Collaborators 2017i; GBD 2015 controlled trials, cohorts, and pooled cohorts. Risk expo- EMR Vision Loss Collaborators 2017n; GBD 2015 EMR sures were estimated based on published studies, household Maternal Mortality Collaborators 2017j; GBD 2015 EMR surveys, census data, satellite data, and other sources. Two Transportation Injuries Collaborators 2017m; GBD 2015 modelling approaches—a Bayesian meta-regression model EMR Obesity Collaborators 2017l; GBD 2015 EMR and a spatiotemporal Gaussian process regression model— Mental Disorders Collaborators 2017k). These topics were developed for the GBD study were used to pool data from selected based on the burden of disease in the region as different sources, adjust for bias in the data, and incorpo- well as the interest of the collaborators and the scientific rate potential covariates. GBD uses the counterfactual community. This manuscript provides the overall burden of scenario of theoretical minimum risk exposure level diseases, injuries, and risk factors in the Eastern Mediter- (TMREL) to attribute burden. TMREL is the level for a ranean Region from 1990 to 2015 and provides an update given risk exposure that could minimise risk at the popu- of our previous publications (Mokdad et al. 2014, 2016; lation level. A summary exposure value (SEV) was Khalil et al. 2016; Moradi-Lakeh et al. 2017a; Moradi- developed for GBD 2015 as the relative risk-weighted Lakeh et al. 2017b; Charara et al. 2017). prevalence of exposure. SEV ranges from zero when no excess risk exists in a population to one when the popu- lation is at the highest risk. Methods Socio-demographic Index and decomposition Overview of variance The Global Burden of Disease (GBD) 2015 methodology GBD 2015 created a Socio-demographic Index based on has been published elsewhere (Forouzanfar et al. 2016; lag-dependent income per capita, average educational Kassebaum et al. 2016a, b; Vos et al. 2016; Wang et al. attainment for ages 15 or older, and the total fertility rate. 2016a, b). GBD 2015 uses a comprehensive approach to To analyse the drivers of change, GBD 2015 decomposed report causes of death with garbage code redistribution; a trends in diseases and attributable burden into contributions systematic and simultaneous estimation of disease from population growth, change in population structure by 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S13 age and sex, risk exposure, and risk-deleted cause-specific rates. The spikes that appear at the left side of the fig- DALY rates. ure show the impact of conflict and war. Increases are seen GBD 2015 has four levels of causes that are mutually in YLLs from causes like war and injuries, as expected, but exclusive and exhaustive. Level 1 has three causes: com- also from other types of causes, underscoring the effects municable, maternal, neonatal, and nutritional disorders; these conflicts have on health systems when they occur. non-communicable diseases; and injuries. Level 2 has 21 Figure 5 shows the EMR DALYs attributable to Level 2 causes, while Levels 3 and 4 consist of disaggregated risk factors for men and women in 2015. Diet is the leading causes. GBD 2015 documented each step of the estimation risk factor for men, followed by high systolic blood pres- processes, as well as data sources, in accordance with sure. Most of the DALYs burden for men is due to car- Guidelines for Accurate and Transparent Health Estimates diovascular diseases and diabetes. Child and maternal Reporting (GATHER). malnutrition was the leading risk factor for DALYs for females, followed by diet. Child and maternal malnutrition impacted diarrhoea, lower respiratory infections, and Results nutritional deficiencies, while diet impacted CVD and diabetes. Our results showed a major shift in burden of disease in the Figure 6 shows the EMR DALYs attributable to Level 3 region and a wide variation by countries. Ischaemic heart risk factors and their changes from 1990 to 2005 and 2005 disease (IHD) was the leading cause of death in the region to 2015. Childhood undernutrition was the leading risk in 2015, followed by cerebrovascular disease (Fig. 1). factor for DALYs in 1990 and 2005, but the second-leading Among the leading 30 causes of deaths, there were varia- in 2015 after high blood pressure. The percent change in tions in the drivers of changes in mortality from population the age-standardised DALY rate from 1990 to 2005 was a growth, ageing, and changes to age-standardised rates of decline of 48%, compared to a decline of 43.4% from 2005 cause-specific mortality from 2005 to 2015. Changes in to 2015. Both obesity and high fasting plasma glucose total deaths ranged from a reduction of 25% for diarrheal increased from 1990 to 2005 and from 2005 to 2015, but diseases to an increase of about 42% for diabetes and tra- the rate of increase was slower from 2005 to 2015. cheal, bronchus, and lung cancer. Population growth e-Figure 1 shows the decomposition of changes for all- accounted for increases across all causes, while population cause DALYs to Level 3 risk factors from 1990 to 2015 for ageing led to increases in 18 causes. Declines the region. Overall changes in in all causes of DALYs attributable to changes in age-specific and cause-specific ranged from a decline of 75% to an increase of a little over mortality rates varied markedly. Collective violence and 200%. Population growth contributed to the increase in DALYs for all risk factors, while population ageing con- legal intervention increased by 850% during the time period. tributed to an increase for 33 causes. Drug use had the Figure 2 shows the leading causes of disease burden highest increase in risk exposure, followed by high body over time in the EMR. Ischemic heart disease was the mass index and high fasting plasma glucose. Changes in leading cause of DALYs followed by neonatal preterm the risk-deleted DALYs rate resulted in a decline in all but birth complications, neonatal encephalopathy, lower res- six causes. piratory infections, and war and legal intervention. Figure 3 shows the changes in the leading causes of DALYs from 2005 to 2015 by age. Violence and war Discussion increased from an early age to 55 years old. Diabetes increased among ages 40 and older. There were declines in Our study shows that the region is facing several health some infectious diseases among children under 5. IHD challenges in addition to the impact of the ongoing wars remained the leading cause of DALYs for ages 40 and and unrest. The region is dealing with an epidemiological older. shift in burden from infectious to chronic diseases. How- Figure 4 shows the expected relationship between age- ever, the recent events may lead to a resurgence of some standardised and crude YLL and YLD rates for the region communicable diseases that were declining before these from 1990 to 2015 for Level 2 causes. Expected age-s- events. Moreover, countries will have a strain on their tandardised YLL rates for infectious diseases declined with efforts to control and prevent non-communicable diseases. increased SDI. Cardiovascular disease (CVD) age-stan- Our findings call for global efforts to stabilise the region dardised YLL rates also declined with increased SDI. At and to address the current and future burden of disease. the same time, age-standardised YLD rates for the top In addition, but also linked to other effects of unrest, causes did not change much with SDI. At the higher SDI several risk factors affecting health are present. Efforts to levels, YLD rates were the same as or higher than YLL reduce and prevent these risk factors in the region should 123 S14 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 1 Eastern Mediterranean Region decomposition of changes in Collective violence and legal intervention, which increased by 847%, leading 30 causes of death due to population growth, population was truncated for display purposes (Global Burden of Disease 2015 ageing, and changes in age-specific mortality rates, 2005–2015. study, Eastern Mediterranean Region, 1990–2015) be a health priority. For example, poor diet is the leading risk. We have previously reported on the global rise in the cause of DALYs in the region. Many countries in the burden of air pollution (Cohen et al. 2017). region are suffering from malnutrition and at the same time Several countries in the region face a major environ- from poor diet that is leading to disease. Tobacco smoking mental challenge due to lack of water, rising temperatures, and systolic blood pressure are among the top causes of and sand storms. Our findings call for renewed efforts to DALYs. Some countries in the region need to enforce address the burden of ambient air pollution. Indeed, unlike regulations on tobacco to control and prevent smoking other risk factors or challenges faced by the region, envi- initiation. Blood pressure medication is now cheap and ronmental health requires strong governmental commit- affordable for many in the EMR, but this may not be true ments to implement the global environmental standards for some low-income countries in the region. However, and utilise the currently available technologies to reduce mechanisms for early detection and proper management of the burden. The wars in the region, especially in Yemen, Iraq, and high blood pressure should be adopted to reduce this bur- den. Viral hepatitis accounts for a large burden in the Syria, are taking a large toll on the health of the population. region, especially in Somalia, Pakistan, Djibouti, Afgha- The immediate impact of the wars has been very high, with nistan, and Egypt (Institute for Health Metrics and Evalu- increased mortality due to violence. Moreover, these events ation 2016). The burden of hepatitis requires efforts to will lead to increased health burden in the future as the next prevent the spread of the disease through minimising risk generation in many countries in the region is being raised factors and providing proper immunizations. Moreover, under the harsh conditions of malnutrition and lack of screening and treatment for hepatitis C should be preventive health services. encouraged. The wars and unrest have led to major migration and a The EMR has a large burden from ambient air pollution. large refugee population inside and outside the region. For Ambient air pollution is associated with increased mortal- many host countries, the existing health systems and ity and morbidity (WHO 2005). Our study showed that infrastructure do not support such a large additional pop- ambient particulate matters are the 5th leading DALYs ulation. In Lebanon, for example, public schools are 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S15 Fig. 2 Leading 30 level 3 Eastern Mediterranean Region causes of For the time period 1990–2005 and for 2005–2015, three measures of disability-adjusted life-years (DALYs) for both sexes combined, change are shown: percent change in the number of DALYs, percent 1990, 2005 and 2015. Causes are connected by arrows between time change in the all-age DALY rate and percent change in the age- periods. Communicable, maternal, neonatal and nutritional causes are standardised DALY rate (Global Burden of Disease 2015 study, shown in red, non-communicable causes in blue and injuries in green. Eastern Mediterranean Region, 1990–2015) providing education to Lebanese and Syrian children, but Despite the market failures, the private sector can still the public school infrastructure is not capable of dealing play an important role in regional health systems. Provid- with such a large number of students. This has resulted in a ing an amiable environment to foster competition between double shift in schools and put a large strain on the system. public and private providers will ensure better quality and The same applies to other services besides health, and in efficiency of services delivered. Better engagement of the other countries. private providers can reduce the burden of financing on the Countries in the region need to continue to strive to public sector. In this respect, movement from input-based achieve universal health coverage, strong screening and payment toward a performance-based payment system is prevention programs, and effective health delivery sys- urgently needed. Furthermore, considering the variety of tems. The countries in the region can also learn from the health challenges facing the region, it is vital for the systems put in place for the training and accreditation of countries to adopt concepts of health in all policies. This health professionals, priority-setting, and the implementa- can be achieved by developing a national body that focuses tion of evidence-based health care undertaken by some on setting up collaborative efforts among all sectors to other developed countries. Investment in health systems incorporate health issues into all policy areas aiming to can create jobs and improve economic growth, in addition promote, protect, preserve, and restore population health. to the direct benefits on health outcomes. It is also A critical component to improve current and future important to look at the wider determinants of health— health in the EMR is the ability to effectively and effi- such as poverty, housing, education, and employment; and ciently diagnose the challenges to health and well-being to empower women to have a dramatic effect on health faced by the region. The Global Burden of Disease offers outcomes. accurate and comprehensive information on the global burden of diseases, injuries, and risk factors, and develops 123 S16 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 3 Leading ten Level 3 causes of Eastern Mediterranean Region diseases. Other NN = other neonatal disorders. Intest inf = intestinal age-specific disability-adjusted life-years (DALYs) in 2015. Each infectious diseases. Violence = interpersonal violence. NN Hae- cause is coloured by the percentage change in age-specific DALY rate mol = haemolytic disease and other neonatal jaundice. Anxi- from 2005 to 2015. NN Preterm = neonatal preterm birth complica- ety = anxiety disorders. TB = tuberculosis. Lung C = lung, tions. NN Sepsis = neonatal sepsis and other neonatal infections. bronchial, and tracheal cancers. STD = sexually transmitted diseases LRI = lower respiratory infections. Iron = iron-deficiency anaemia. excluding HIV. Haemog = haemoglobinopathies and haemolytic HIV = HIV/AIDS. Back and neck = low back and neck pain. anaemias. CKD = chronic kidney disease. Other MSK = other IHD = ischaemic heart disease. NN Enceph = neonatal musculoskeletal disorders. Drugs = drug use disorders. HTN encephalopathy due to birth asphyxia and trauma. Diarrhoea = diar- HD = hypertensive heart disease. Whooping = whooping cough. rhoeal diseases. Skin = skin and subcutaneous diseases. Depres- Other UI = other unintentional injuries. War = collective violence sion = depressive disorders. Stroke = cerebrovascular disease. and legal intervention. Cirrhosis Hep C = Cirrhosis and other chronic Congenital = congenital anomalies. Diabetes = diabetes mellitus. liver diseases due to hepatitis C. Other Cardio = Other cardiovascu- COPD = chronic obstructive pulmonary disease. Alzheimer’- lar and circulatory diseases. GBD = Global Burden of Disease s = Alzheimer’s disease and other dementias. PEM = protein-energy (Global Burden of Disease 2015 study, Eastern Mediterranean malnutrition. Conduct = conduct disorder. Sense = sense organ Countries, 2005–2015) new analytic methods and data visualisation tools to sup- topical area of burden from peer-reviewed and grey liter- port the understanding of this information and to empower ature and include both successful and negative outcomes policymakers and health leaders to act. However, the (as much can be learned from failures as from successes), region still has a long way to go in terms of having ade- as well as potential unintended consequences of interven- quate and timely data to better inform decision-makers of tions. The plan should include a synthesis of the available the burden. Therefore, there is an urgent need to improve quantitative and qualitative evidence on interventions and vital statistics, data sources, and surveillance systems in the innovations to develop a summary of why specific work region to better serve their purpose. around a risk or disease succeeds or fails. This analysis will The region is in dire need of a comprehensive plan to develop a deeper understanding of the necessary ingredi- build on existing expertise and projects to address the ents for success (i.e., to identify underlying social, eco- health challenges that exist at the nexus of human health, nomic, legal, and public policy features). This will allow environmental resilience, and social and economic equity. health actors to design and conduct innovative research on The region does not have proper health translation and intervention effectiveness, implementation, scale-up, dis- implementation efforts to address its growing health chal- semination, and economic return in partnership with lenges. Unfortunately, many countries have focused on community, governments, foundations, and other collabo- curative rather than preventive systems. Indeed, this will rators. This work should draw on resources including, but limit the pace of progress needed to address many of the not limited to, the United Nations’ Sustainable Develop- emerging challenges such as non-communicable diseases ment Goals, the Disease Control Priorities publications, and the emergence of infectious diseases in countries with and the World Health Organization’s ‘‘Best Buys’’. wars and unrest. This lack of progress is evidenced by wide Health education and training are crucial to improve the health disparities between and within countries and exists burden of disease in the EMR. There is a dire need for despite the identified organisations and forums that offer opportunities and funding to offer training for public offi- recommendations for intervention, such as the World cials (e.g., health ministers, policymakers, and local health Health Organization and others. officers) and program leaders, provided both on-site and on This comprehensive plan needs to review and compile a regional scale at in-country sites in collaboration with information on prior health interventions for each targeted other countries. These trainings should provide participants 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S17 Fig. 4 a Expected relationship between age-standardised years of life lost (YLL) and years lived with disability (YLD) rates per 100,000 and Sociodemographic index (SDI) and b all-age YLL and YLD rates (per 100,000) and SDI for 21 GBD Level 2 causes. These stacked curves represent the average relationship between SDI and each cause observed across the 22 Eastern Mediterranean Region countries in 2015. In each figure, the y- axis goes from lowest SDI to highest SDI. The left side shows rates for YLLs and the right side shows rates for YLDs; higher rates are further from the midline. The difference between (a) and (b) is the effect of shifts in population age structure expected with SDI. GBD = Global Burden of Disease (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 1990–2015) with actual experience implementing the interventions that encourage adoption, successful implementation, and ulti- have been developed. Finally, there is a need to scale up mately, sustainability of population health. the public health workforce across the region, to ensure The future of health in the region is grim unless the wars that the right policies are developed, implemented, and and unrest stop. Regional health professionals are dealing enforced. with overwhelming challenges and can barely meet basic Health advocacy and effective program and policy dis- health needs. The best intervention for a better future is an semination must be at the forefront of all health activities. international plan to stabilise the region. All countries have The region needs a catalyst for change at both country and an equally important role to play in bringing an end to the regional levels by providing a platform on which local and unrest and starting to rebuild. global strategies and successes are collaboratively shared Our study has some limitations. The availability and among local communities and countries. This, in turn, will quality of data for some countries in the region pose sub- stantial challenges for cause of death analysis. Many 123 S18 GBD 2015 Eastern Mediterranean Region Collaborators Fig. 5 Eastern Mediterranean Region disability-adjusted life- years (DALYs) attributable to Level 2 risk factors for (a) men and (b) women in 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 1990–2015) countries in the region do not have strong vital registration with data quality or lack of it. Finally, our study provides systems. Our GBD methodology makes extensive efforts to the national burden and hence masks large disparities reduce the effects of variable data quality, and we have within a country. used standardised methods for each cause that are the same for all countries. We also provide uncertainty intervals for Conclusion each of our estimates that take into account the data issues, and we provide all our data sources and show what is Our study shows a tremendous impact of war and violence available for every country on our website (Institute for on the health of the region. The results show that in recent Health Metrics and Evaluation 2017). Our web visualisa- years, many of the health gains for some countries have tions allow comparison of raw data to final estimates and slowed and several health conditions that were under show the impact of our models and methods of dealing control are re-emerging. These findings clearly indicate 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S19 Fig. 6 Leading 30 level 3 Eastern Mediterranean Region risk factors percent change in the number of DALYs, percent change in the all- for disability-adjusted life-years (DALYs) for both sexes combined, age DALY rate and percent change in the age-standardised DALY 1990, 2005, and 2015. Risks are connected by arrows between time rate. Statistically significant increases or decreases are shown in bold periods. Behavioural risk factors are shown in red, environmental (p \ 0.05) (Global Burden of Disease 2015 study, Eastern Mediter- risks in blue and metabolic risks in green. For the time period ranean Region, 1990–2015) 1990–2005 and for 2005–2015, three measures of change are shown: Washington. Stan Biryukov, BS, Institute for Health Metrics and that the future health of the region is in danger. Immediate Evaluation, University of Washington, Seattle, Washington, United efforts to stabilise the region and improve the health of the States. Daniel Casey, BA, Institute for Health Metrics and Evaluation, population are urgently needed. University of Washington, Seattle, Washington, United States. Kelly Cercy, BS, Institute for Health Metrics and Evaluation, University of GBD 2015 Eastern Mediterranean Region Collaborators Ali H. Washington, Seattle, Washington, United States. Fiona J. Charlson, Mokdad, PhD (corresponding author), Institute for Health Metrics and PhD, School of Public Health, University of Queensland, Brisbane, Evaluation, University of Washington, Seattle, Washington, United Queensland, Australia; Institute for Health Metrics and Evaluation, States. Charbel El Bcheraoui, PhD, Institute for Health Metrics and University of Washington, Seattle, United States; Queensland Centre Evaluation, University of Washington, Seattle, Washington, United for Mental Health Research, Brisbane, Queensland, Australia. Leslie States. Raghid Charara, MD, American University of Beirut, Beirut, Cornaby, BS, Institute for Health Metrics and Evaluation, University Lebanon. Ibrahim Khalil, PhD, Institute for Health Metrics and of Washington, Seattle, Washington, United States. Daniel Dicker, Evaluation, University of Washington, Seattle, Washington, United BS, Institute for Health Metrics and Evaluation, University of States. Maziar Moradi-Lakeh, MD, Department of Community Washington, Seattle, Washington, United States. Holly E. Erskine, Medicine, Gastrointestinal and Liver Disease Research Center PhD, Queensland Centre for Mental Health Research, Brisbane, QLD, (GILDRC), Preventative Medicine and Public Health Research Cen- Australia; School of Public Health, University of Queensland, Bris- ter, Iran University of Medical Sciences, Tehran, Iran. Ashkan bane, QLD, Australia; Institute for Health Metrics and Evaluation, Afshin, MD, Institute for Health Metrics and Evaluation, University University of Washington, Seattle, WA, United States. Alize J. Fer- of Washington, Seattle, Washington, United States. Michael Collison, rari, PhD, School of Public Health, University of Queensland, Bris- BS, Institute for Health Metrics and Evaluation, University of bane, Queensland, Australia; Queensland Centre for Mental Health Washington, Seattle, Washington, United States. Farah Daoud, BA/ Research, Brisbane, Queensland, Australia; Institute for Health Met- BS, Institute for Health Metrics and Evaluation, University of rics and Evaluation, University of Washington, Seattle, Washington, Washington, Seattle, Washington, United States. Kristopher J. Krohn, United States. Christina Fitzmaurice, MD, Institute for Health Metrics BA, Institute for Health Metrics and Evaluation, University of and Evaluation, University of Washington, Seattle, Washington, Washington, Seattle, Washington, United States. Adrienne Chew, United States. Kyle J. Foreman, PhD, Institute for Health Metrics and ND, Institute for Health Metrics and Evaluation, University of Evaluation, University of Washington, Seattle, Washington, United 123 S20 GBD 2015 Eastern Mediterranean Region Collaborators States; Imperial College London, London, United Kingdom. Maya Alizadeh-Navaei, PhD, Gastrointestinal Cancer Research Center, Fraser, BA, Institute for Health Metrics and Evaluation, University of Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Washington, Seattle, Washington, United States. Joseph Frostad, Rajaa Al-Raddadi, PhD, Joint Program of Family and Community MPH, Institute for Health Metrics and Evaluation, University of Medicine, Jeddah, Makkah, Saudi_Arabia. Khalid A. Altirkawi, MD, Washington, Seattle, Washington, United States. William W. God- King Saud University, Riyadh, Saudi_Arabia. Nahla Anber, PhD, win, BS, Institute for Health Metrics and Evaluation, University of Mansoura University, Mansoura, Egypt. Hossein Ansari, PhD, Health Washington, Seattle, Washington, United States. Max Griswold, MA, Promotion Research Center, Department of Epidemiology and Bio- Institute for Health Metrics and Evaluation, University of Washing- statistics, Zahedan University of Medical Sciences, Zahedan, Iran. ton, Seattle, Washington, United States. Nicholas J. Kassebaum, MD, Palwasha Anwari, MD, Self-employed, Kabul, Kabul, Afghanistan. Institute for Health Metrics and Evaluation, University of Washing- Hamid Asayesh, PhD, Department of Medical Emergency, School of ton, Seattle, Washington, United States; Department of Anesthesiol- Paramedic, Qom University of Medical Sciences, Qom, Iran. Solo- ogy & Pain Medicine, Seattle Children’s Hospital, Seattle, mon W. Asgedom, PhD, Mekelle University, Mekelle, Tigray, Washington, United States. Laura Kemmer, Institute for Health Ethiopia. Tesfay Mehari Atey, MS, Mekelle University, Mekelle, Metrics and Evaluation, University of Washington, Seattle, Wash- Tigray, Ethiopia. Umar Bacha, PhD, School of Health Sciences, ington, United States. Michael Kutz, BS, Institute for Health Metrics University of Management and Technology, Lahore, Punjab, Pak- and Evaluation, University of Washington, Seattle, Washington, istan. Shahrzad Bazargan-Hejazi, PhD, College of Medicine, Charles United States. Hmwe H. Kyu, PhD, Institute for Health Metrics and R. Drew University of Medicine and Science, Los Angeles, CA, Evaluation, University of Washington, Seattle, Washington, United United States; David Geffen School of Medicine, University of Cal- States. Janni Leung, PhD, School of Public Health, University of ifornia at Los Angeles, Los Angeles, CA, United States. Neeraj Bedi, Queensland, Brisbane, QLD, Australia; University of Washington, MD, College of Public Health and Tropical Medicine, Jazan, Seattle, WA, United States. Patrick Liu, BA, Institute for Health Saudi_Arabia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Metrics and Evaluation, University of Washington, Seattle, Wash- Women and Child Health, Aga Khan University, Karachi, Pakistan; ington, United States. Joseph Mikesell, BS, Institute for Health Centre for Global Child Health, The Hospital for Sick Children, Metrics and Evaluation, University of Washington, Seattle, Wash- Toronto, ON, Canada. Donal Bisanzio, PhD, Nuffield Department of ington, United States. Grant Nguyen, MPH, Institute for Health Medicine, University of Oxford, Oxford, United Kingdom. Zahid A. Metrics and Evaluation, University of Washington, Seattle, Wash- Butt, PhD, Al Shifa Trust Eye Hospital, Rawalpindi, Punjab, Pakistan. ington, United States. Helen E. Olsen, MA, Institute for Health Amare Deribew, PhD, Nuffield Department of Medicine, University Metrics and Evaluation, University of Washington, Seattle, Wash- of Oxford, Oxford, United Kingdom; KEMRI-Wellcome Trust ington, United States. Robert Reiner, BA, Institute for Health Metrics Research Programme, Kilifi, Kenya. Shirin Djalalinia, PhD, Under- and Evaluation, University of Washington, Seattle, Washington, secretary for Research & Technology, Ministry of Health & Medical United States. Marissa Reitsma, BS, Institute for Health Metrics and Education, Tehran, Tehran, Iran. Babak Eshrati, PhD, Ministry of Evaluation, University of Washington, Seattle, Washington, United Health and Medical Education, Tehran, Tehran, Iran; Arak University States. Gregory Roth, MD, Institute for Health Metrics and Evalua- of Medical Sciences, Arak, Iran. Alireza Esteghamati, MD, tion, University of Washington, Seattle, Washington, United States. Endocrinology and Metabolism Research Center, Tehran University Damian Santomauro, PhD, School of Public Health, University of of Medical Sciences, Tehran, Tehran, Iran. Maryam S. Farvid, PhD, Queensland, Brisbane, Queensland, Australia; Queensland Centre for Department of Nutrition, Harvard T. H. Chan School of Public Mental Health Research, Brisbane, Queensland, Australia; Institute Health, Harvard University, Boston, MA, United States; Harvard/ for Health Metrics and Evaluation, University of Washington, Seattle, MGH Center on Genomics, Vulnerable Populations, and Health WA, United States. Alison Smith, BA, Institute for Health Metrics Disparities, Mongan Institute for Health Policy, Massachusetts Gen- and Evaluation, University of Washington, Seattle, Washington, eral Hospital, Boston, MA, United States. Farshad Farzadfar, MD, United States. Jeffrey D. Stanaway, PhD, Institute for Health Metrics Non-Communicable Diseases Research Center, Tehran University of and Evaluation, University of Washington, Seattle, Washington, Medical Sciences, Tehran, Tehran, Iran. Seyed-Mohammad United States. Patrick Sur, BA, Institute for Health Metrics and Fereshtehnejad, PhD, Department of Neurobiology, Care Sciences Evaluation, University of Washington, Seattle, Washington, United and Society (NVS), Karolinska Institutet, Stockholm, Sweden. Flo- States. Haidong Wang, PhD, Institute for Health Metrics and Evalu- rian Fischer, PhD, School of Public Health, Bielefeld University, ation, University of Washington, Seattle, Washington, United States. Bielefeld, North Rhine-Westphalia, Germany. Tsegaye T. Gebrehi- Harvey A. Whiteford, PhD, School of Public Health, University of wot, MPH, Jimma University, Jimma, Oromia, Ethiopia. Nima Queensland, Brisbane, Queensland, Australia; Queensland Centre for Hafezi-Nejad, MD, Endocrinology and Metabolism Research Center, Mental Health Research, Brisbane, Queensland, Australia; Institute Tehran University of Medical Sciences, Tehran, Tehran, Iran. Randah for Health Metrics and Evaluation, University of Washington, Seattle, R. Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. United States. Rima Afifi, PhD, Department of Health Promotion and Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Community Health, Faculty of Health Sciences, American University Dubai, united_arab_emirates. Peter J. Hotez, PhD, College of Medi- of Beirut, Beirut, Lebanon. Aliasghar Ahmad Kiadaliri, PhD, cine, Baylor University, Houston, Texas, United States. Mohamed Department of Clinical Sciences Lund, Orthopedics, Clinical Epi- Hsairi, MD, Department of Epidemiology, Salah Azaiz Institute, demiology Unit, Lund University, Lund, Sweden. Alireza Ahmadi, Tunis, Tunis, Tunisia. Jost B. Jonas, MD, Department of Ophthal- PhD, Kermanshah University of Medical Sciences, Kermanshah, Iran, mology, Medical Faculty Mannheim, Ruprecht-Karls-University Stockholm, Sweden. Hamid Ahmadieh, MD, Ophthalmic Research Heidelberg, Mannheim, Germany, Germany. Amir Kasaeian, PhD, Center, Shahid Beheshti University of Medical Sciences, Tehran, Hematology-Oncology and Stem Cell Transplantation Research Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Tehran University of Medical Sciences, Tehran, Tehran, Iran; Center, Tehran, Tehran, Iran. Khurshid Alam, PhD, Murdoch Chil- Endocrinology and Metabolism Population Sciences Institute, Tehran drens Research Institute, The University of Melbourne, Parkville, University of Medical Sciences, Tehran, Tehran, Iran. Yousef S. Victoria, Australia; The University of Melbourne, Melbourne, VIC, Khader, ScD, Department of Community Medicine, Public Health Australia; The University of Sydney, Sydney, NSW, Australia. Noore and Family Medicine, Jordan University of Science and Technology, Alam, MAppEpid, Department of Health, Queensland, Brisbane, Irbid, Irbid, Jordan. Ejaz A. Khan, MD, Health Services Academy, Queensland, Australia; Nathan, Queensland, Australia. Raghib Ali, Islamabad, Punjab, Pakistan. Gulfaraz Khan, PhD, Department of FRCP, University of Oxford, Oxford, United Kingdom. Reza Microbiology and Immunology, College of Medicine & Health 123 Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region,… S21 Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, Abdallah M. Samy, PhD, Ain Shams University, Cairo, Egypt; united_arab_emirates. Abdullah T. A. Khoja, MD, Mohammed Ibn Lawrence, Kansas, United States. Benn Sartorius, PhD, Public Health Saudi University, Riyadh, Saudi Arabia, Saudi_Arabia; Baltimore, Medicine, School of Nursing and Public Health, University of Kwa- MD, United States. Tawfik A. M. Khoja, FRCP, Executive Board of Zulu-Natal, Durban, South_Africa; UKZN Gastrointestinal Cancer the Health Ministers’ Council for Cooperation Council States, Research Centre, South African Medical Research Council Riyadh, Al-Riyadh, Saudi_Arabia. Jagdish Khubchandani, PhD, (SAMRC), Durban, South_Africa. Sadaf G. Sepanlou, PhD, Digestive Department of Nutrition and Health Science, Ball State University, Diseases Research Institute, Tehran University of Medical Sciences, Muncie, Indiana, United States. Jacek A. Kopec, PhD, University of Tehran, Tehran, Iran. Masood A. Shaikh, MD, Independent Consul- British Columbia, Vancouver, BC, Canada. Heidi J. Larson, PhD, tant, Karachi, Pakistan. Morteza Shamsizadeh, MPH, Department of Department of Infectious Disease Epidemiology, London School of Medical Surgical Nursing, School of Nursing and Midwifery, Hygiene & Tropical Medicine, London, United Kingdom; Institute for Hamadan University of Medical Sciences, Hamadan, Iran. Badr H. Health Metrics and Evaluation, University of Washington, Seattle, A. Sobaih, MD, king Saud university, Riyadh, middle province, WA, United States. Raimundas Lunevicius, PhD, Aintree University Saudi_Arabia, Riyadh, Saudi Arabia. Rizwan Suliankatchi Abdulka- Hospital National Health Service Foundation Trust, Liverpool, United der, MD, Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Kingdom; School of Medicine, University of Liverpool, Liverpool, Saudi_Arabia. Arash Tehrani-Banihashemi, PhD, Preventive Medi- United Kingdom. Hassan Magdy Abd El Razek, MBBCH, Mansoura cine and Public Health Research Center, Iran University of Medical Faculty of Medicine, Mansoura, Egypt. Mohammed Magdy Abd El Sciences, Tehran, Tehran, Iran. Mohamad-Hani Temsah, MD, King Razek, MBBCh, Aswan University Hospital, Aswan Faculty of Saud University, Riyadh, Saudi_Arabia; King Faisal Specialist Medicine, Aswan, Egypt. Reza Majdzadeh, PhD, Knowledge Hospital and Research Center, Riyadh, Saudi_Arabia. Abdullah S. Utilization Research Center, Tehran University of Medical Sciences, Terkawi, MD, Department of Anesthesiology, University of Virginia, Tehran, Iran. 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Jumaan, PhD, Independent Consultant, Seattle, Washington, Health and Demographic Surveillance, Suri, West Bengal, India. United States. Theo Vos, PhD, Institute for Health Metrics and David L. Rawaf, MD, MBBS, WHO Collaborating Centre, Imperial Evaluation, University of Washington, Seattle, Washington, United College London, London, United Kingdom; North Hampshire States. Mohsen Naghavi, PhD, Institute for Health Metrics and Hospitals, Basingstroke, United Kingdom; University College Lon- Evaluation, University of Washington, Seattle, Washington, United don Hospitals, London, United Kingdom. Salman Rawaf, MD, States. Simon I. Hay, DSc, Oxford Big Data Institute, Li Ka Shing Imperial College London, London, United Kingdom. Amany H. Centre for Health Information and Discovery, University of Oxford, Refaat, PhD, Walden University, Minneapolis, MN, United States; Oxford, United Kingdom; Institute for Health Metrics and Evaluation, Suez Canal University, Ismailia, Ismailia, Egypt. Satar Rezaei, PhD, University of Washington, Seattle, Washington, United States. School of Public Health, Kermanshah University of Medical Sci- Christopher J. L. Murray, DPhil, Institute for Health Metrics and ences, Kermanshah, Iran. Gholamreza Roshandel, PhD, Golestan Evaluation, University of Washington, Seattle, Washington, United Research Center of Gastroenterology and Hepatology, Golestan States. University of Medical Sciences, Gorgan, Iran; Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Compliance with ethical standards Iran. Mahdi Safdarian, MD, Sina Trauma & Surgery Research Center, Tehran, Iran. Sare Safi, MS, Ophthalmic Epidemiology Research This manuscript reflects original work that has not previously been Center, Shahid Beheshti University of Medical Sciences, Tehran, published in whole or in part and is not under consideration else- Iran. Saeid Safiri, PhD, Managerial Epidemiology Research Center, where. All authors have read the manuscript and have agreed that the Department of Public Health, School of Nursing and Midwifery, work is ready for submission and accept responsibility for its con- Maragheh University of Medical Sciences, Maragheh, Iran. tents. The authors of this paper have complied with all ethical stan- Mohammad Ali Sahraian, MD, MS Research Center, Neuroscience dards and do not have any conflicts of interest to disclose at the time Institute, Tehran University of Medical Sciences, Tehran, Iran. Pay- of submission. The funding source played no role in the design of the man Salamati, MD, Sina Trauma and Surgery Research Center, study, the analysis and interpretation of data, and the writing of the Tehran University of Medical Sciences, Tehran, Tehran, Iran. 123 S22 GBD 2015 Eastern Mediterranean Region Collaborators paper. The study did not involve human participants and/or animals; GBD 2015 EMR Intentional Injuries Collaborators (2017h) Inten- therefore, no informed consent was needed. tional injuries in the eastern mediterranean region, 1990–2015: findings from the global burden of disease 2015 study. Int J Publ Funding This research was funded by the Bill & Melinda Gates Health. doi:10.1007/s00038-017-1005-2 Foundation. GBD 2015 EMR Lower Respiratory Infections Collaborators (2017i) Burden of lower respiratory infections in the eastern mediter- ranean region between 1990 and 2015: findings from the global Conflict of interest The authors declare that they have no conflicts of burden of disease 2015 study. Int J Publ Health. doi:10.1007/ interest at this time. s00038-017-1007-0 GBD 2015 EMR Maternal Mortality Collaborators (2017j) Maternal Open Access This article is distributed under the terms of the mortality and morbidity burden in the eastern mediterranean Creative Commons Attribution 4.0 International License (http://crea region: findings from the global burden of disease 2015 study. tivecommons.org/licenses/by/4.0/), which permits unrestricted use, Int J Publ Health. doi:10.1007/s00038-017-1004-3 distribution, and reproduction in any medium, provided you give GBD 2015 EMR Mental Disorders Collaborators (2017k) The burden appropriate credit to the original author(s) and the source, provide a of mental disorders in the eastern mediterranean region, link to the Creative Commons license, and indicate if changes were 1990–2015: findings from the global burden of disease 2015 made. study. 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International Journal of Public HealthSpringer Journals

Published: Aug 3, 2017

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