Int J Public Health (2018) 63 (Suppl 1):S63–S77 https://doi.org/10.1007/s00038-017-0998-x O R I G IN AL ARTI CL E Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean region: ﬁndings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators Received: 1 May 2017 / Revised: 15 June 2017 / Accepted: 21 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Conclusions Our ﬁndings call for accelerated action to Objectives Although substantial reductions in under-5 decrease child morbidity and mortality in the EMR. mortality have been observed during the past 35 years, Governments and organizations should coordinate efforts progress in the Eastern Mediterranean Region (EMR) has to address this burden. Political commitment is needed to been uneven. This paper provides an overview of child ensure that child health receives the resources needed to mortality and morbidity in the EMR based on the Global end preventable deaths. Burden of Disease (GBD) study. Methods We used GBD 2015 study results to explore Keywords Child mortality Burden of disease Infant under-5 mortality and morbidity in EMR countries. mortality Neonatal mortality Eastern Mediterranean Results In 2015, 755,844 (95% uncertainty interval (UI) Region 712,064–801,565) children under 5 died in the EMR. In the early neonatal category, deaths in the EMR decreased by 22.4%, compared to 42.4% globally. The rate of years of Introduction life lost per 100,000 population under 5 decreased 54.38% from 177,537 (173,812–181,463) in 1990 to 80,985 Creating evidence-based estimates and understanding the (76,308–85,876) in 2015; the rate of years lived with dis- causes of child mortality are essential for tracking progress ability decreased by 0.57% in the EMR compared to 9.97% toward child survival goals and for planning health globally. strategies, policies, and interventions on child health. Substantial reductions have been observed in under-5 mortality worldwide during the past 35 years, with every This article is part of the supplement ‘‘The state of health in the region in the world recording sizeable improvements in Eastern Mediterranean Region, 1990–2015’’. child survival (Rajaratnam et al. 2010; Lozano et al. 2011; Wang et al. 2014; Liu et al. 2015; You et al. 2015). The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality The Global Burden of Disease (GBD) study provides an Collaborators are listed at the end of the article. Ali H. Mokdad, on assessment of global child morbidity and mortality, docu- behalf of GBD 2015 Eastern Mediterranean Region Neonatal, Infant, menting child health achievements during the Millennium and under-5 Mortality Collaborators, is the corresponding author. Development Goal era and providing estimates of child Electronic supplementary material The online version of this mortality by age (neonatal, post-neonatal, 1–4 years, and article (doi:10.1007/s00038-017-0998-x) contains supplementary under-5), sex, and cause over time (GBD 2015 Mortality material, which is available to authorized users. and Causes of Death Collaborators 2016). In this manu- & GBD 2015 Eastern Mediterranean Region Neonatal, Infant, script, we used data from the GBD study to report child and under-5 Mortality Collaborators morbidity and mortality by age (neonatal, post-neonatal, email@example.com 1–4 years, and under-5), sex, and cause over time in the EMR from 1990 to 2015. Institute for Health Metrics and Evaluation, Seattle, WA, USA 123 S64 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators This study provides the most comprehensive assessment of $2000 in Afghanistan (The World Bank GNI per capita so far of levels and trends of child morbidity and mortality 2017a). in the EMR. Through a series of decomposition analyses, While the Gulf States are some of the richest countries we identify which groups of causes contribute most to globally, poverty rates remain high in many other countries reductions in under-5 mortality across regions and the of the EMR. The proportion of the population living below development spectrum. Comparisons of recorded levels the national poverty line, according to World Bank data, is and cause composition for child mortality by country offer more than 20% in seven EMR countries: Afghanistan an in-depth, nuanced picture of where countries might need (36%), Egypt (22%), Iraq (23%), Pakistan (22%), Palestine to refocus policies and resource allocation to accelerate (22%), Sudan (47%), and Yemen (35%). In ﬁve of these improvements in child survival in the future. countries, approximately one-third of the population is also Millennium Development Goal 4 (MDG 4), ‘‘Reduce food-insecure: Afghanistan (34%), Iraq (30%), Pakistan child mortality,’’ called for the reduction of the under-5 (30%), Sudan (33%), and Yemen (36%) (The World Bank mortality rate by two-thirds between 1990 and 2015 Databank 2017b). Such wide variation has a major inﬂu- (United Nations 2000). The new Sustainable Development ence on overall health spending and results in substantial Goals (SDGs) call for an end to preventable deaths of health inequities both within and across countries. newborns and children by 2030, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as Methods 25 per 1000 live births (United Nations Sustainable Development Goals 2017). Globally, the number of under- The methods used to generate estimates of under-5 mor- 5 deaths has declined by 52% (from 12.7 to 5.8 million tality and age-speciﬁc death rates (neonatal, post-neonatal, from 1990 to 2015) (GBD 2015 Child Mortality Collabo- ages 1–4 years, and under-5), contribute to broader GBD rators 2016), while progress across the EMR for child 2015 analyses and results on all-cause mortality and cause survival remains uneven. Nine countries (Bahrain, Egypt, of death. Substantial detail on data inputs, processing, and Iran, Lebanon, Morocco, Oman, Saudi Arabia, Tunisia, and estimation methods can be found elsewhere (GBD 2015 United Arab Emirates) met MDG 4 for annual reduction in Mortality and Causes of Death Collaborators 2016). Here, child mortality of at least 4.4% between 1990 and 2015 in we provide a brief summary of our under-5 mortality the EMR (GBD 2015 Child Mortality Collaborators 2016). estimation approach and accompanying analyses, including Neonatal deaths are the one of the largest causes of child an assessment of mortality trends by Socio-demographic mortality in the region, and are clearly linked to low levels Index (SDI), and changes in under-5 mortality of maternal health among the poorest segments of the attributable to leading causes of death. population (Liu et al. 2012). The World Health Organiza- Our GBD 2015 analyses follow the recently proposed tion (WHO) and UNICEF reported that less than 50% of Guidelines for Accurate and Transparent Health Estimates deliveries were attended by skilled health personnel in four Reporting (GATHER) (Stevens et al. 2016), which include countries—Afghanistan, Pakistan, Somalia, and Yemen— the documentation of data sources and inputs, processing in the year 2010. Across the region, only 31% of married and estimation steps, and overarching methods used women use modern contraceptives, and 35% of newborns throughout the GBD study. are delivered without a skilled birth attendant present (UNICEF and WHO 2012). Beyond the neonatal period, Data four disorders—diarrhea, pneumonia, malaria, and measles—are the major causes of post-neonatal death Data sources and types used for estimating child mortality (Walker et al. 2013). are described extensively elsewhere (GBD 2015 Mortality The Eastern Mediterranean Region (EMR) is home to and Causes of Death Collaborators 2016), but in sum, vital more than 500 million people, representing a diverse group registration (VR) systems, censuses, and household surveys of 22 countries, including Arab states in North Africa, Gulf with complete or summary birth histories served as primary nations, and countries in West Asia; 12.2% of the popu- inputs for our analyses. Other sources, including sample lation are children under 5 years of age, and 20% are registration systems and disease surveillance systems, also women of childbearing age (WHO EMRO 2013). contributed as input data. In total we applied formal EMR countries have diverse historical backgrounds, demographic techniques to 8169 input data sources of political and social contexts, and ﬁscal and cultural inﬂu- under-5 mortality from 1950 to 2015. Overall data avail- ences that impact maternal and child health. The region ability and availability by source data type varied by also has wide variation in per capita gross national product country. (GNP), ranging from a high of $134,420 in Qatar to a low 123 Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean… S65 All-cause under-5 mortality and age-speciﬁc Disability-adjusted life years (DALYs) were calculated by mortality adding YLLs and YLDs. Detailed methods on YLLs, YLDs, and DALYs are published elsewhere (GBD 2015 We estimated all-cause under-5 mortality and death rates Disease and Injury Incidence and Prevalence Collaborators by age group: neonatal (0–28 days), post-neonatal 2016; Kassebaum et al. 2016). (29–364 days), and ages 1–4 years. Details on data bias adjustments for under-5 mortality, using spatiotemporal Socio-demographic Index Gaussian process regression to generate a complete time series of under-5 mortality for EMR countries and the age– We studied patterns in child mortality as they related to sex model to produce estimates of mortality for neonatal, measures of socioeconomic status and development. post-neonatal, and ages 1–4 years, have been extensively Drawing on methods used to construct the Human Devel- discussed previously (Wang et al. 2014). opment Index (HDI) (UNDP 2016), we created a com- To estimate mortality by age group and sex within the posite indicator, the Socio-demographic Index (SDI), based under-5 categorization, we used a two-stage modeling on equally weighted estimates of lagged distributed income process that has been described in detail elsewhere (GBD (LDI) per person, average years of education among indi- 2015 Mortality and Causes of Death Collaborators 2016). viduals older than 15 years, and total fertility rate. SDI was For this analysis, we report on early neonatal and late constructed as the geometric mean of these three values. To neonatal mortality results in aggregate as neonatal capture the average relationships for each age–sex group, mortality. we applied a simple least squares spline regression of mortality rate on SDI. SDI values were scaled to a range of Under-5 causes of death 0–1, with 0 equaling measures of the lowest educational attainment, lowest income, and highest fertility rate The methods developed and used in GBD 2015, including between 1980 and 2015, and 1 equaling measures of the the systematic approach to collating causes of death from highest educational attainment, highest income, and lowest different countries; mapping across different revisions; fertility rate during this time. Additional information can redistributing deaths assigned to so-called garbage codes; be found elsewhere (GBD 2015 Mortality and Causes of and the overall and disease-speciﬁc cause of death mod- Death Collaborators 2016). eling approaches, are described in other publications (Foreman et al. 2012; GBD 2015 Mortality and Causes of Decomposing change in under-5 mortality rate Death Collaborators 2016). by causes of death For GBD 2015, we assessed 249 causes of death across age groups. Because of cause-speciﬁc age restrictions (e.g., Based on the age-speciﬁc, sex-speciﬁc, and cause-speciﬁc no child deaths due to Alzheimer’s disease and other mortality results from GBD 2015 (GBD 2015 Mortality dementias), not all causes of death were applicable for and Causes of Death Collaborators 2016), we attributed children younger than 5 years (GBD 2015 Mortality and changes in under-5 mortality rate between 1990 and 2015 Causes of Death Collaborators 2016). to changes in leading causes of death in children younger than 5 years in the EMR during the same period. To do YLLs, YLDs, and DALYs this, we applied the decomposition method developed by Beltran-Sanchez and colleagues (Beltran-Sanchez et al. We calculated years of life lost (YLLs) by multiplying 2008), which has also been used for other GBD analyses deaths by the remaining life expectancy at the age of death (GBD 2015 Mortality and Causes of Death Collaborators from a standard life table chosen as the norm for estimating 2016). premature mortality in GBD. We consider the standard life expectancy as a composite of the best case mortality sce- Uncertainty analysis nario for every year, age, and sex. The metric therefore highlights premature deaths by applying a larger weight to We propagated known measures of uncertainty through key deaths that occur at younger ages. Years lived with dis- steps of the mortality estimation processes, including ability (YLDs) were calculated by multiplying the number uncertainty associated with varying sample sizes of data, of prevalent cases of a certain health outcome by the dis- source-speciﬁc adjustments to data used for all-cause ability weight assigned to this health outcome. A disability mortality, model speciﬁcations for spatiotemporal Gaus- weight reﬂects the magnitude of the health loss associated sian process regression (ST-GPR) and cause-speciﬁc model with an outcome and has a value that is anchored between speciﬁcations, and estimation procedures. Uncertainty 0, equivalent to full health, and 1, equivalent to death. estimates were derived from 1000 draws for under-5 123 S66 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators mortality, age-speciﬁc mortality, and cause-speciﬁc mor- ninth between 2000 and 2015, and measles dropped from tality by sex, year, and geography from the posterior dis- sixth to 17th. tribution of each step of the estimation process. These In Afghanistan, mortality rates from nine top-10 causes draws allowed us to quantify, and then propagate, uncer- were greater than the EMR average, with mortality from tainty for all mortality metrics. Percent changes and neonatal encephalopathy as the only exception (Table 2). annualized rates of change were calculated between mean Likewise, all countries except Pakistan fell beneath the estimates, while the uncertainty intervals associated with average regional rate for neonatal encephalopathy, with a the percent changes were derived from the 1000 draws. rate of 423.6 (318.5–528.3) per 100,000 population under 5 compared to the regional rate of 154.4 (121.7–187.9). Bahrain, Kuwait, Lebanon, Palestine, Qatar, Saudi Arabia, Results Tunisia, and United Arab Emirates were below the average regional rates in all top-10 causes. Somalia, Afghanistan, Mortality and Pakistan had the highest mortality rates for the top 10 sub-causes of under-5 morality in 2015, while United Arab All-cause mortality rates for under-5 age groups in the Emirates, Bahrain, and Kuwait had the lowest (Fig. 3). EMR decreased from 1990 to 2015, closely following global patterns of decline of around 54% (Institute for Observed mortality versus expected mortality based Health Metrics and Evaluation 2017). In 2015, there were on SDI alone 755,843 under-5 deaths in the EMR, which constitute about 18.8% of total deaths in the region for all ages. The largest Observed mortality rates in the EMR have been consis- difference in under-5 deaths was in the early neonatal tently lower than expected mortality rates based on SDI category, where deaths in the EMR decreased by 22.4%, in alone for the under-5 age group (e-Fig. 1). Kuwait had the comparison to 42.4% globally (Institute for Health Metrics highest observed-to-expected ratio at 1.61, followed by and Evaluation 2017). Total deaths for all under-5 age United Arab Emirates at 1.15 (e-Table 2). Kuwait and groups decreased in the EMR at a slower rate than globally United Arab Emirates have the highest SDIs in the region, (e-Table 1). at 0.86 and 0.88, respectively. Djibouti, Pakistan, and Qatar In 2015, neonatal mortality was the largest contributing also had observed-to-expected ratios greater than 1. Mor- group to under-5 mortality in most EMR countries occo and Palestine had the lowest ratios at 0.42 and 0.44, (Table 1). The exceptions to this were Afghanistan, Dji- respectively, with SDIs at 0.5 and 0.57. Somalia, with the bouti, and Syria, with roughly equal mortality rates for lowest SDI in the region, had a ratio of 0.58. neonatal, post-neonatal, and child (1–4 years) age groups, and Somalia with a child mortality rate of 44.6 (95% UI: YLLs 32.4–58.8) deaths per 1000 live births compared to a neonatal mortality rate of 31.3 (27.2–35.9) (Table 1). The decrease in YLL rate per 100,000 population under 5 Somalia also had the highest under-5 mortality rate of from 1990 to 2015 was similar globally and for the EMR, 112.2 (97.5–130.4) deaths per 1000 live births. The United with percent decreases of about 54% (Table 3). From 1990 Arab Emirates had the lowest under-5 mortality rate, 5.5 to 2015, YLLs decreased in all countries (Table 3). The (3.2–9.1) deaths per 1000 live births. Under-5 mortality largest decrease was in Iran, where the YLL rate decreased rate declined annually from 1990 to 2015 in all countries, 81% from 132,265 (116,751–150,030) to 25,276 ranging from Somalia with the smallest rate of change 2.1 (18,585–33,780) per 100,000 population under 5. The (1.4–2.7) to Iran with the largest 6.5 (5.2–7.9). smallest decrease was in Kuwait, where the YLL rate Figure 1 shows the top cause of under-5 mortality for decreased 42% from 25,451 (22,873–28,223) to 14,665 individual countries in 2015. The top ﬁve causes of under-5 (11,594–18,408) per 100,000 population under 5. Simi- mortality—preterm birth complications, neonatal larly, Somalia’s YLL rate decreased 43% from 380,035 encephalopathy, lower respiratory infections, congenital (359,276–402,133) to 217,737 (188,533–253,963) per defects, and diarrheal disease—were the same in the EMR 100,000 population under 5. and globally, with congenital defects and diarrheal diseases ranked fourth and ﬁfth in the EMR, but ﬁfth and fourth YLDs globally (Institute for Health Metrics and Evaluation 2017). War ranked ninth in the EMR and 25th globally (Fig. 2). YLDs in the EMR did not track the global trend from 1990 From 1990 to 2015, the top ﬁve causes of under-5 mortality to 2015. The under-5 YLD rate decreased by 0.6% in the in the EMR remained the same. War moved from 43rd to EMR compared to 10.0% globally (Table 3). Five coun- tries in the EMR had increased YLD rates (Table 3). Syria 123 Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean… S67 Table 1 Mortality rates, deaths and annual rate of decline in mortality by country in 2015 Country Deaths per 1000 livebirths Total under-5 deaths Annualized rate of decline for under-5 mortality (thousands) Neonatal Post-neonatal Child Under-5 1990–2000 2000–2015 1990–2015 (0–27 days) (28 days–12 months) (12–59 months) Global 12.2 (11.0–13.6) 12.2 (10.9–13.6) 11.2 (9.8–12.8) 41.4 (37.9–45.5) 5820.9 (5673.3–5965.1) 2.0 (1.7–2.4) 3.6 (3.0–4.2) 3.0 (2.6–3.3) EMR 22.5 (21.1–24.0) 12.4 (11.4–13.4) 9.3 (8.1–10.5) 44.2 (41.6–46.9) 755.8 (712.1–801.6) – – – Afghanistan 28.6 (24.7–33.0) 30.5 (24.0–38.2) 25.9 (17.3–36.3) 82.6 (69.5–98.0) 89.3 (75.5–105.6) 5.1 (4.1–6.2) 4.3 (3.2–5.6) 2.7 (1.9–3.5) Bahrain 3.8 (3.2–4.5) 2.0 (1.6–2.3) 0.9 (0.6–1.2) 6.6 (5.6–7.8) 0.1 (0.1–0.2) 1.0 (0.2–1.8) 3.0 (2.0–3.9) 4.7 (4.0–5.3) Djibouti 23.4 (20.3–27.0) 23.2 (18.1–29.1) 20.4 (14.0–28.7) 65.5 (55.4–78.7) 1.4 (1.2–1.7) 6.4 (5.5–7.4) 4.7 (2.8–6.6) 2.2 (1.4–2.9) Egypt 12.1 (8.9–15.4) 6.0 (4.3–8.6) 3.6 (2.6–5.1) 21.5 (16.3–28.3) 53.3 (40.1–70.1) 6.5 (4.2–8.9) 6.5 (4.1–8.9) 5.4 (4.2–6.5) Iran 8.1 (5.6–11.4) 4.0 (2.9–5.3) 2.7 (1.7–3.9) 14.7 (10.8–19.5) 19.9 (14.7–26.5) 2.4 (1.7–3.0) 2.9 (1.7–4.1) 6.5 (5.2–7.9) Iraq 15.5 (13.4–18.0) 7.1 (5.6–9.1) 5.0 (3.3–7.2) 27.3 (23.2–32.6) 33.5 (28.9–39.2) 2.9 (2.4–3.5) 3.3 (2.3–4.2) 2.7 (2.0–3.4) Jordan 7.7 (6.4–9.2) 3.5 (2.9–4.2) 3.6 (2.6–4.6) 14.8 (12.9–17.2) 2.9 (2.6–3.4) 2.5 (1.2–3.8) 2.9 (1.3–4.5) 3.1 (2.6–3.7) Kuwait 4.4 (3.4–5.4) 2.4 (1.8–3.2) 1.4 (1.0–2.0) 8.2 (6.5–10.2) 0.6 (0.5–0.8) 4.8 (2.3–7.5) 6.6 (4.0–9.0) 2.7 (1.7–3.8) Lebanon 4.4 (3.2–6.0) 2.2 (1.6–3.2) 1.5 (1.0–2.3) 8.1 (5.9–11.3) 0.7 (0.5–0.9) 3.9 (2.5–5.4) 3.2 (1.6–4.7) 5.9 (4.5–7.3) Libya 8.1 (5.7–11.1) 4.7 (3.5–6.3) 4.8 (3.23–6.9) 17.5 (13.2–22.6) 2.3 (1.8–3.0) 4.7 (3.8–5.5) 4.5 (3.2–5.8) 3.5 (2.3–4.6) Morocco 12.7 (10.0–15.5) 5.8 (4.3–7.8) 4.1 (3.0–5.6) 22.4 (18.0–27.9) 15.7 (12.6–19.5) 10.2 (8.6–11.0) 3.3 (2.0–4.6) 4.6 (3.7–5.5) Oman 4.7 (4.1–5.3) 2.6 (2.1–3.2) 2.1 (1.6–2.8) 9.4 (8.1–10.8) 0.8 (0.7–0.9) 2.0 (1.6–2.4) 2.4 (1.8–3.1) 6.0 (5.2–6.9) Pakistan 37.9 (34.8–41.3) 15.9 (13.6–18.5) 10.4 (7.3–13.8) 63.0 (57.4–69.4) 341.7 (311.3–376.0) 4.2 (2.7–5.8) 2.7 (1.0–4.5) 2.3 (1.9–2.7) Palestine 9.9 (7.3–12.7) 4.6 (3.7–6.0) 2.9 (2.0–4.0) 17.3 (13.5–21.8) 2.6 (2.0–3.3) 3.0 (1.2–7.0) 4.2 (1.1–7.1) 3.3 (2.3–4.4) Qatar 4.7 (3.2–6.6) 2.4 (1.6–3.5) 1.6 (1.0–2.4) 8.6 (6.0–12.1) 0.2 (0.2–0.3) 6.7 (5.0–8.3) 4.9 (3.1–6.6) 3.7 (2.0–5.7) Saudi Arabia 6.1 (4.4–9.2) 3.2 (2.2–4.4) 2.2 (1.4–3.2) 11.5 (8.3–16.3) 7.1 (6.3–8.1) 1.7 (1.0–2.3) 2.3 (1.4–3.2) 5.6 (4.2–6.9) Somalia 31.3 (27.2–35.9) 40.8 (32.8–49.6) 44.6 (32.4–58.8) 112.2 (97.5–130.4) 51.7 (44.7–60.3) 3.2 (2.0–4.3) 3.7 (1.8–5.5) 2.1 (1.4–2.7) Sudan 24.1 (19.9–29.4) 17.2 (12.4–23.4) 15.8 (10.4–23.8) 56.0 (43.3–73.7) 73.2 (56.7–96.3) 7.0 (6.1–7.9) 0.4 (2.4–1.8) 3.5 (2.4–4.6) Syria 7.1 (6.0–8.5) 5.8 (4.3–7.5) 9.7 (4.9–15.5) 22.4 (16.2–29.3) 10.1 (7.3–12.9) 6.0 (5.2–7.0) 4.5 (3.3–5.7) 2.6 (1.4–3.9) Tunisia 7.4 (5.9–9.2) 3.5 (2.9–4.2) 3.0 (2.1–3.9) 13.8 (11.5–16.5) 2.8 (2.3–3.3) 6.8 (0.1–13.0) 5.4 (0.5–9.9) 5.1 (4.3–5.8) United Arab 2.9 (1.5–5.0) 1.5 (1.0–2.5) 1.1 (0.6–1.7) 5.5 (3.2–9.1) 0.5 (0.3–0.9) 5.1 (4.1–6.2) 4.3 (3.2–5.6) 6.0 (2.9–8.7) Emirates Yemen 20.9 (19.1–23.2) 18.0 (14.9–21.9) 15.7 (10.3–22.6) 53.6 (45.9–63.2) 45.5 (40.2–51.3) 1.0 (0.2–1.8) 3.0 (2.0–3.9) 2.7 (1.9–3.5) 95% uncertainty intervals are provided in parentheses. Annualized rate of decline not available for the Eastern Mediterranean Region in aggregate. (Global Burden of Disease 2015 Study, Global, Eastern Mediterranean Countries, 1990–2015) S68 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators Fig. 1 Top cause of under-5 deaths in the Eastern Mediterranean Region by country, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 2015) Fig. 2 Changes in number of deaths and mortality rates in top 25 healthdata.org/gbd-compare. (Global Burden of Disease 2015 study, causes of under-5 mortality in the Eastern Mediterranean Region, Eastern Mediterranean Region, 1990–2015) 1990–2000 and 2000–2015. Data available at https://vizhub. 123 Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean… S69 Table 2 Mortality rates for 10 major causes of under-5 mortality by country in 2015 Country Neonatal Neonatal Lower Congenital Diarrheal Other Neonatal Meningitis War and legal Road preterm birth encephalopathy respiratory defects diseases neonatal sepsis intervention injuries infection Global 120.0 110.3 104.82 74.0 74.3 32.8 52.37 25.8 3.5 (2.2–4.8) 7.4 (6.4–8.5) (109.6–133.8) (99.4–123.5) (97.0–113.6) (66.2–82.6) (66.6–83.0) (25.0–41.2) (37.11–68.37) (20.4–34.1) Eastern 163.6 154.4 122.7 102.7 81.8 43.5 36.4 31.9 26.1 (16.4–36.4) 11.8 Mediterranean (136.0–195.6) (121.7–187.9) (106.9–140.8) (86.4–128.2) (66.8–99.0) (27.2–64.5) (19.1–57.9) (22.4–46.9) (8.9–15.8) Region Afghanistan 209.6 103.4 380.0 198.5 122.0 93.1 45.9 104.6 72.6 23.4 (137.9–301.0) (59.1–161.9) (254.4–518.7) (100.2–433.4) (71.7–188.5) (31.2–180.2) (17.6–91.3) (53.4–191.1) (25.6–119.9) (9.4–49.1) Bahrain 25.5 6.2 (4.4–8.3) 8.6 (6.0–11.2) 54.2 3.0 (1.9–4.1) 6.2 (4.3–8.5) 5.4 (3.0–7.9) 0.8 (0.5–1.2) – 2.5 (1.5–3.8) (19.7–32.3) (41.2–71.2) Djibouti 130.2 98.8 215.8 134.0 122.9 60.6 90.0 47.0 – 9.8 (79.1–189.4) (50.1–162.1) (134.6–301.9) (85.9–187.4) (59.1–193.1) (23.0–117.5) (44.8–165.5) (20.7–89.8) (3.0–23.5) Egypt 72.4 6.8 (4.0–11.4) 83.0 (59.7–113.5) 130.3 34.2 22.0 12.5 (5.4–20.4) 2.4 (1.7–3.6) 1.7 (0.6–2.8) 6.3 (4.2–9.2) (51.2–96.8) (91.0–177.3) (23.0–52.1) (13.8–32.4) Iran 73.1 13.5 (6.7–24.1) 17.1 (11.1–25.6) 87.1 3.5 (1.9–6.1) 29.9 6.1 (2.3–12.3) 2.4 (1.2–4.2) – 14.8 (45.0–109.6) (56.0–125.2) (15.1–51.7) (7.9–24.1) Iraq 127.7 27.9 (14.8–46.5) 47.1 (32.7–63.7) 121.5 21.7 23.4 81.6 11.4 39.2 (13.8–64.7) 9.0 (85.9–168.5) (78.8–209.8) (12.7–33.4) (9.6–46.6) (32.2–137.8) (5.2–22.0) (3.7–20.0) Jordan 65.9 19.8 (12.2–29.8) 28.2 (21.8–36.4) 95.3 2.5 (1.6–3.9) 9.0 (4.6–16.5) 23.9 2.9 (1.6–5.0) – 13.8 (48.6–85.8) (78.4–115.6) (12.9–41.4) (7.8–20.8) Kuwait 42.4 4.7 (3.4–6.4) 10.1 (7.6–13.7) 76.8 1.1 (0.8–1.6) 2.6 (1.8–3.6) 2.4 (1.4–4.6) 1.2 (0.9–1.6) 0.3 (0.1–.6) 4.6 (3.2–6.4) (32.0–54.4) (59.1–99.2) Lebanon 40.3 11.4 (5.6–19.8) 6.8 (3.9–11.1) 74.4 1.8 (0.8–3.5) 8.4 (3.1–17.6) 8.9 (3.7–17.2) 1.4 (0.5–3.4) 1.1 (0.4–1.8) 2.4 (0.9–5.8) (25.0–59.4) (45.8–108.9) Libya 77.7 15.0 (7.6–25.8) 15.1 (10.0–22.0) 95.9 4.9 (2.5–8.2) 12.6 10.7 (4.4–21.5) 2.8 (1.2–4.9) 25.5 (9.0–42.0) 9.5 (50.7–113.7) (70.7–128.3) (4.9–25.6) (4.6–17.1) Morocco 124.8 50.3 (31.2–75.7) 29.0 (19.8–41.5) 75.9 8.6 (5.2–13.6) 10.7 46.7 7.9 (4.5–13.5) – 12.5 (83.2–169.8) (45.5–141.8) (4.8–20.4) (26.0–75.9) (6.8–20.8) Oman 36.0 10.1 (5.9–15.6) 9.6 (6.9–13.1) 57.1 1.0 (0.6–1.6) 26.5 2.4 (0.5–6.1) 1.4 (0.8–2.8) – 14.2 (25.4–47.4) (44.0–74.4) (15.5–38.8) (8.4–21.7) Pakistan 221.7 423.6 157.7 56.3 135.3 68.4 50.6 60.4 1.4 (0.7–2.1) 6.5 (140.1–309.8) (318.5–528.3) (118.9–200.8) (39.5–72.9) (92.6–185.8) (27.9–126.4) (20.8–107.9) (35.5–102.5) (2.4–14.9) Palestine 126.2 28.5 (18.1–43.4) 14.2 (9.6–20.4) 84.8 2.3 (1.5–3.5) 14.3 31.6 (5.1–56.7) 2.4 (1.3–3.8) – 9.4 (91.3–165.7) (56.8–140.0) (7.2–25.9) (4.8–15.6) Qatar 53.3 8.5 (4.5–14.8) 3.9 (2.3–6.3) 73.5 0.8 (0.4–1.4) 10.0 1.2 (0.5–2.4) 1.6 (0.8–2.9) – 7.9 (35.1–79.9) (47.7–107.0) (4.9–17.4) (3.9–13.5) Saudi Arabia 58.1 12.8 (8.8–16.5) 4.3 (3.5–5.3) 84.9 3.4 (2.6–4.3) 8.6 (5.0–12.2) 27.6 0.8 (0.5–1.2) 0.1 (0.0–0.4) 5.9 (4.4–8.1) (40.4–71.7) (70.1–109.4) (20.7–40.7) Somalia 158.0 106.5 546.8 114.2 449.6 78.0 91.2 82.1 21.2 (.0–54.4) 11.6 (95.8–235.9) (54.0–176.6) (404.5–716.4) (81.9–155.5) (296.7–630.6) (26.1–165.6) (40.6–168.5) (43.2–144.7) (4.7–26.3) S70 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators had the largest increase, 99%, followed by Yemen with a 59% increase. This increase was driven primarily by war in both countries, where it accounted for 52.4% of total YLDs in Syria and 36.9% in Yemen. The largest decrease in YLD rate was in Lebanon, a 43% decrease from 6804 (4457–10,960) to 3878 (2676–5307) per 100,000 popula- tion under 5. DALYs In 2015, there were 69,297,241 under-5 DALYs in the EMR, which constituted 30.2% of total DALYs in the region for all ages. From 1990 to 2015, the under-5 DALY rate in the EMR decreased by 52.8%, the same as the decrease in the global rate (Table 3). For all countries, this decrease in the DALY rate was driven primarily by a decrease in the YLL rate (Table 3). Iran had the largest decrease in DALY rate, 79%, from 137,881 (122,316–155,406) in 1990 to 29,140 (22,262–37,880) per 100,000 population under 5 in 2015. The smallest decrea- ses were in Kuwait (40%) and Somalia (42%). Discussion Our study shows that progress across the region for child survival remains uneven, and total deaths for children under 5 decreased in the EMR at a slower rate than glob- ally. Our study showed large variation in the burden by countries of the region, with about 80% of under-5 deaths occurring in six countries of the region (Afghanistan, Pakistan, Somalia, South Sudan, Sudan, and Yemen), and three countries (Sudan, Afghanistan, and Pakistan) among the 10 countries with the highest child mortality in the world (GBD 2015 Mortality and Causes of Death Collab- orators 2016). Although the top ﬁve causes of under-5 mortality— namely neonatal preterm birth complications, neonatal encephalopathy, lower respiratory tract infections (LRI), congenital defects, and diarrheal diseases—were the same globally and in the EMR, the early neonatal mortality burden still poses a huge problem in the region. The decrease in the EMR countries has been the smallest com- pared to other regions in the world between 1990 and 2015. War and legal intervention ranked as the ninth cause of death in children under 5 years of age in the EMR, com- pared to 25th globally in 2015. This ﬁnding highlights the consequences of recent conﬂicts and political unrest in the region, and the wars that followed (Institute for Health Metrics and Evaluation 2017). The EMR also now carries the largest burden of displaced populations globally. Out of a total of 50 million refugees and internally displaced persons (IDPs) worldwide, more than 29 million (9 million Table 2 continued Country Neonatal Neonatal Lower respiratory Congenital Diarrheal Other neonatal Neonatal sepsis Meningitis War and legal Road injuries preterm birth encephalopathy infection defects diseases intervention Sudan 330.1 45.9 (23.7–79.9) 142.2 178.0 124.8 42.2 24.6 24.8 2.0 (0.0–5.5) 35.8 (249.5–419.0) (89.8–218.9) (104.6–323.2) (70.0–205.2) (17.1–87.2) (10.8–52.9) (10.3–45.6) (12.1–73.7) Syria 30.9 27.5 (14.5–45.0) 32.5 (22.8–42.4) 73.6 2.2 (1.3–3.5) 15.4 12.9 (6.3–23.8) 6.2 (3.2–10.7) 180.0 5.0 (2.3–9.2) (20.1–44.1) (52.6–89.8) (5.6–28.7) (63.6–297.1) Tunisia 76.9 25.9 (16.1–38.7) 11.3 (8.1–15.2) 70.4 3.8 (2.3–5.7) 11.9 25.5 4.0 (2.3–6.8) 0.7 (0.2–1.2) 6.7 (55.3–105.1) (52.9–97.8) (5.8–21.5) (14.4–40.9) (3.6–11.5) United Arab 21.0 6.8 (2.6–14.2) 2.1 (1.1–3.9) 42.1 0.5 (0.2–1.0) 6.1 (2.2–13.7) 7.2 (2.8–14.9) 1.4 (0.6–3.0) – 4.5 (1.9–8.9) Emirates (10.5–38.6) (22.1–72.5) Yemen 281.4 38.4 (19.2–66.3) 100.2 152.0 74.3 38.4 18.2 (7.1–37.7) 12.1 239.5 20.4 (204.2–352.9) (69.1–138.9) (94.5–249.3) (37.8–120.0) (13.1–83.8) (4.5–22.4) (148.0–331.0) (8.5–39.1) All rates are per 100,000 population under-5. 95% uncertainty intervals are provided in parentheses. War and legal intervention was left empty where values were not estimated. (Global Burden of Disease 2015 Study, Global, Eastern Mediterranean Countries, 1990–2015) Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean… S71 Fig. 3 Mortality rates for top 10 causes of under-5 mortality in the Eastern Mediterranean Region by country, 2015 (Global Burden of Disease 2015 study, Eastern Mediterranean Countries, 2015) refugees and 20 million IDPs) came from the region before the age of 18 years in 15 countries in the region (Mokdad et al. 2016). The impact of these emergencies on (The World Bank). In four countries, Afghanistan, Soma- public health is profound and affects both the displaced lia, Sudan, and Yemen, the rate is estimated to be as high as populations and host communities and usually results in 50% (The World Bank). In addition, illiteracy, especially food insecurity, lack of access to sanitation and health care among young females, is a common problem in the EMR. facilities, and inadequate care. Conﬂicts also disrupt fam- The literacy rate among females older than 15 years is ily, which further exacerbates child morbidity and mor- approximately 80% in the EMR on average, but it is esti- tality burden due to unhealthy environments, spread of mated to be around 67% for Morocco, 66% for Yemen, disease, and decreased quantity and quality of food intake 61% for Sudan, 55% for Pakistan, and 32% for Afghanistan (WHO EMRO 2015). (The World Bank). Conﬂict also deteriorates child health by increasing the Our ﬁndings showed that while YLLs and DALYs fol- incidence of sexual violence against women and children. lowed the global trend of decrease from 1990 to 2015, Higher rates of rape, sexually transmitted diseases, YLDs in the EMR did not decrease during this period, unwanted pregnancies, and unsafe abortions have been which demonstrates the lack of improvement in socioeco- documented in previous conﬂicts (Akseer et al. 2015). nomic conditions, in addition to the lack of improvement in Poverty and economic inequity are also important treatments and health care facilities. determinants of child health in the EMR. A meta-analysis Worldwide, successes in decreasing child mortality have examined the association of poverty with infant mortality been attributed to rising levels of income per person (Jahan in the EMR countries and suggested that there is a signif- 2008; O’Hare et al. 2013); higher education, especially in icantly increased mortality risk in infants born in poor women of reproductive age (Preston 1975; Gakidou et al. households. The results suggest that policies aimed at 2010); lower fertility rates; and strengthened public health poverty alleviation and female literacy will substantially programs. contribute to a decrease in infant mortality in the EMR In the EMR, action must be taken immediately to save (Cottingham et al. 2008). children’s lives by expanding effective preventive and Child marriage is highly prevalent in the EMR. A report curative interventions. The health interventions needed to showed that approximately 25% of all girls were married address the major causes of neonatal death generally differ 123 S72 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators Table 3 YLLs, YLDs, and DALYs per 100,000 under-5 population and percent change by country, 1990–2015 Country SDI Under-5 YLL rate per 100,000 Under-5 YLD rate per 100,000 Under-5 daly rate per 100,000 (2015) 1990 2015 % 1990 2015 % 1990 2015 % change change change Global 0.64 162,811 74,441 -54 5512 4962 -10 168,324 79,403 -53 (161,334–164,422) (72,554–76,285) (3868–7521) (3499.8–6746) (166,143–170,828) (76,806–81,838) Eastern 0.55 177,537 80,985 -54 5388 5357 -1 182,925 86,342 -53 Mediterranean (173,812–181,463) (76,308–85,876) (3866–7271) (3750–7290) (178,760–186,979) (81,261–91,567) Region Afghanistan 0.29 326,350 152,191 -53 6598 5530 -16 332,948 157,721 -53 (303,452–351,586) (128,892–180,117) (4553–9151) (3849–7565) (310,338–358,029) (134,351–185,824) Bahrain 0.78 37,616 11,413 -70 4006 3374 -16 41,622 14,787 -64 (35,223–40,144) (9697–13,368) (2826–5397) (2378–4606) (38,741–44,523) (12,824–17,208) Djibouti 0.46 226,135 118,367 -48 6492 6743 4 232,627 125,110 -46 (210,850–241,280) (99,999–142,052) (4552–8834) (4588–9207) (217,252–247,793) (106,641–148,413) Egypt 0.62 151,318 39,029 -74 4960 4496 -9 156,278 43,525 -72 (142,553–159,885) (29,380–51,379) (3516–6837) (3053–6390) (147,486–164,909) (34,043–56,032) Iran 0.72 132,265 25,276 -81 5616 3864 -31 137,881 29,140 -79 (116,751–150,030) (18,585–33,780) (4016–7677) (2709–5313) (122,316–155,406) (22,262–37,880) Iraq 0.58 101,180 50,346 -50 4818 4596 -5 105,997 54,941 -48 (96,461–105,998) (43,459–59,054) (3435–6478) (3167–6566) (100,973–110,991) (47,877–63,758) Jordan 0.7 60,426 26,220 -57 3923 3466 -12 64,349 29,686 -54 (58,011–62,916) (22,899–30,491) (2755–5337) (2427–4732) (61,841–67,152) (26,108–33,991) Kuwait 0.86 25,451 14,665 -42 3924 3010 -23 29,374 17,675 -40 (22,873–28,223) (11,594–18,408) (2724–5617) (2103–4102) (26,334–32,511) (14,368–21,513) Lebanon 0.75 61,129 15,562 -75 6804 3878 -43 67,933 19,440 -71 (52,841–70,642) (11,368–21,614) (4457–10,960) (2676–5307) (59,255–77,662) (15,114–25,648) Libya 0.64 72,412 29,599 -59 3940 4229 7 76,352 33,828 -56 (65,190–79,811) (22,636–38,322) (2767–5607) (2828–6079) (69,519–83,925) (26,576–42,261) Morocco 0.5 126,475 39,544 -69 4975 4207 -15 131,450 43,751 -67 (121,222–131,669) (31,692–49,221) (3456–6725) (2936–5730) (126,095–137,032) (35,664–53,401) Oman 0.73 75,607 17,135 -77 5879 4868 -17 81,486 22,002 -73 (63,659–90,351) (14,831–19,666) (4039–8106) (3326–6827) (69,237–96,665) (19,103–24,919) Pakistan 0.47 217,582 118,554 -46 5597 5849 4 223,179 124,403 -44 (211,203–224,200) (107,976–130,484) (3914–7706) (3977–8048) (216,642–229,864) (113,390–136,107) Palestine 0.57 75,846 31,431 -59 3586 3266 -9 79,433 34,697 -56 (68,219–83,975) (24,502–39,774) (2544–4831) (2255–4538) (71,341–87,766) (27,702–43,034) Qatar 0.8 38,386 16,144 -58 3989 3441 -14 42,376 19,585 -54 (28,814–50,253) (11,147–22,773) (2782–5439) (2440–4733) (32,600–54,473) (14,459–26,356) Saudi Arabia 0.76 85,559 20,090 -77 3258 2864 -12 88,817 22,953 -74 (77,918–93,903) (17,725–22,742) (2324–4357) (2028–3813) (81,094–97,189) (20,425–25,781) Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean… S73 from those needed to address other under-5 deaths, and are closely linked to maternal health. Antenatal care, delivery in a health facility attended by a skilled birth attendant, and newborn care are all essential public health measures that need to be strengthened in the EMR. In addition, global policy changes, like prevention of war and peaceful reso- lutions of conﬂicts to improve the well-being of children. More than half of under-5 child deaths are due to dis- eases that are preventable and treatable through good nutrition and simple, affordable interventions. For some of the most deadly childhood diseases, such as measles, polio, diphtheria, tetanus, pertussis, pneumonia due to Hae- mophilus inﬂuenza type B and Streptococcus pneumoniae, and diarrhea due to rotavirus, vaccines are available and can protect children from illness and death (Fuchs et al. 2010). Strengthening health systems with a focus on delivery strategies and mechanisms for scaling up coverage to provide such interventions to all children is crucial to accelerate progress in improving child health in the EMR. Health education programs, including providing infor- mation and confronting cultural and religious barriers toward utilization of family planning services, are crucial to decrease child mortality rates in the EMR. Birth spacing, decreasing the rate of high-risk pregnancies, and delaying the age of marriage, in addition to literacy, have been found to be associated with child health and survival (UNICEF 2005; Grown et al. 2005; Jain and Kurz 2007; Bhutta et al. 2013, 2014; Nasrullah et al. 2014). In addition, special care and protection should be given to vulnerable populations in war times, as well as secure shelter, food, and access to health care to prevent the devastating effects of these emergencies on child health. Study Limitations: While our paper reports important information using the GBD methodology, this information has wide uncertainty due to absence of data or data with poor quality, and possible bias from modeling. Despite such shortcoming in the estimates produced, it provides estimates to EMR countries that could be a baseline to gauge progress of interventions. The methodology used makes the estimates comparable across countries. The EMR is going through chronic and acute turmoil that makes it difﬁcult to observe any improvement in the future. Conclusion In spite of the global achievements in improving child survival across geographies, the pace of progress was slow and uneven in the EMR. Our ﬁndings reinforce the imperative need for intensive and accelerated action to decrease the burden of child morbidity and mortality in the EMR. Ministries of health, non-governmental organiza- tions, and civic society in the region need to rise to the Table 3 continued Country SDI Under-5 YLL rate per 100,000 Under-5 YLD rate per 100,000 Under-5 daly rate per 100,000 (2015) 1990 2015 % 1990 2015 % 1990 2015 % change change change Somalia 0.15 380,035 217,737 -43 6804 6786 0 386,839 224,523 -42 (359,276–402,133) (188,533–253,963) (4570–9591) (4565–9724) (366,551–408,916) (195,558–260,559) Sudan 0.43 270,463 102,900 -62 7221 6213 -14 277,684 109,112 -61 (252,550–290,131) (79,559–135,299) (4932–9990) (4235–8569) (259,409–297,220) (85,741–141,261) Syria 0.58 76,228 37,424 -51 4229 8398 99 80,457 45,823 -43 (69,751–83,006) (27,052–47,636) (2959–5715) (4695–14,357) (73,755–87,715) (35,144–57,195) Tunisia 0.65 86,176 24,401 -72 4185 3352 -20 90,362 27,753 -69 (81,431–91,325) (20,379–29,206) (2932–5763) (2358–4636) (85,673–95,668) (23,536–32,514) United Arab 0.88 44,587 9635 (5545–15,958) -78 4707 3885 -17 49,294 13,520 -73 Emirates (25,858–70,617) (3207–6428) (2685–5325) (30,621–75,379) (9078–19,664) Yemen 0.41 262,432 97,450 -63 5938 9469 59 268,369 106,919 -60 (252,686–272,966) (86,201–109,915) (4095–8071) (5970–15,234) (258,479–278,816) (94,845–120,445) 95% uncertainty intervals are provided in parentheses YLDs years lived with disability, YLLs years of life lost, DALYS disability-adjusted life-years. (Global Burden of Disease 2015 Study, Global, Eastern Mediterranean Countries, 1990–2015) S74 GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators Washington, United States. Alison Smith, BA, Institute for Health challenge and accelerate the pace of progress toward Metrics and Evaluation, University of Washington, Seattle, Wash- decreasing the unacceptably high mortality numbers ington, United States. Jeffrey D. Stanaway, PhD, Institute for Health among children under 5 years of age in the region. Political Metrics and Evaluation, University of Washington, Seattle, Wash- awareness, commitment, and leadership are needed to ington, United States. Johan Arnlo ¨ v, PhD, Department of Neurobi- ology, Care Sciences and Society, Division of Family Medicine and ensure that child health receives the attention and resources Primary Care, Karolinska Institutet, Stockholm, Sweden; School of needed to end preventable child deaths. Health and Social Studies, Dalarna University, Falun, Sweden. Kalkidan Hassen Abate, MS, Jimma University, Jimma, Ethiopia. GBD 2015 Eastern Mediterranean Region Neonatal, Infant, and Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Sciences Under-5 Mortality Collaborators: Ali H. Mokdad, PhD (corre- Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, sponding author), Institute for Health Metrics and Evaluation, Lund, Sweden. Khurshid Alam, PhD, Murdoch Childrens Research University of Washington, Seattle, Washington, United States. Ibra- Institute, The University of Melbourne, Parkville, Victoria, Australia; him Khalil, MD, Institute for Health Metrics and Evaluation, The University of Melbourne, Melbourne, VIC, Australia; The University of Washington, Seattle, Washington, United States. University of Sydney, Sydney, NSW, Australia. Deena Alasfoor, Michael Collison, BS, Institute for Health Metrics and Evaluation, MSc, Ministry of Health, Al Khuwair, Muscat, Oman. Raghib Ali, University of Washington, Seattle, Washington, United States. MSc, University of Oxford, Oxford, United Kingdom. Reza Alizadeh- Charbel El Bcheraoui, PhD, Institute for Health Metrics and Evalu- Navaei, PhD, Gastrointestinal Cancer Research Center, Mazandaran ation, University of Washington, Seattle, Washington, United States. University of Medical Sciences, Sari, Mazandaran, Iran. Rajaa Al- Raghid Charara, MD, American University of Beirut, Beirut, Leba- Raddadi, PhD, Joint Program of Family and Community Medicine, non. Maziar Moradi-Lakeh, MD, Department of Community Medi- Jeddah, Saudi Arabia. Khalid A. Altirkawi, MD, King Saud Univer- cine, Preventive Medicine and Public Health Research sity, Riyadh, Saudi Arabia. Nelson Alvis-Guzman, PhD, Universidad Center, Gastrointestinal and Liver Disease Research Center de Cartagena, Cartagena de Indias, Colombia. Nahla Anber, PhD, (GILDRC), Iran University of Medical Sciences, Tehran, Iran. 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Amira Shaheen, PhD, Department of Public Health, An- Christopher J. L. Murray, DPhil, Institute for Health Metrics and Najah National University, Nablus, Palestine. Masood Ali Shaikh, Evaluation, University of Washington, Seattle, Washington, United MD, Independent Consultant, Karachi, Pakistan. Morteza Sham- States. sizadeh, MPH, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Compliance with ethical standards Hamadan, Iran. Rahman Shiri, PhD, Finnish Institute of Occupational Health, Work Organizations, Work Disability Program, Department This manuscript reﬂects original work that has not previously been of Public Health, Faculty of Medicine, University of Helsinki, Hel- published in whole or in part and is not under consideration else- sinki, Finland. Vegard Skirbekk, PhD, Norwegian Institute of Public where. All authors have read the manuscript and have agreed that the Health, Oslo, Norway; Columbia University, New York, United work is ready for submission and accept responsibility for its con- States. Badr H. A. Sobaih, MD, King Saud University, Riyadh, Saudi tents.The authors of this paper have complied with all ethical stan- Arabia. Chandrashekhar T. Sreeramareddy, MD, Department of dards and do not have any conﬂicts of interest to disclose at the time Community Medicine, International Medical University, Kuala of submission. The funding source played no role in the design of the Lumpur, Malaysia. Vasiliki Stathopoulou, PhD, Attikon University study, the analysis and interpretation of data, and the writing of the Hospital, Athens, Greece. Rizwan Suliankatchi Abdulkader, MD, paper. The study did not involve human participants and/or animals; Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia. therefore, no informed consent was needed. Arash Tehrani-Banihashemi, PhD, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Funding This research was funded by the Bill & Melinda Gates Iran. Mohamad-Hani Temsah, MD, King Saud University, Riyadh, Foundation. Saudi Arabia. J. S. Thakur, MD, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, Conﬂict of interest The authors declare that they have no conﬂicts of India. Alan J Thomson, PhD, Adaptive Knowledge Management, interest at this time. Victoria, BC, Canada. Bach Xuan Tran, PhD, Johns Hopkins University, Baltimore, Maryland, United States; Hanoi Medical Open Access This article is distributed under the terms of the University, Hanoi, Vietnam. Thomas Truelsen, DMSc, Department of Creative Commons Attribution 4.0 International License (http://crea Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, tivecommons.org/licenses/by/4.0/), which permits unrestricted use, Denmark. Kingsley Nnanna Ukwaja, MD, Department of Internal distribution, and reproduction in any medium, provided you give Medicine, Federal Teaching Hospital, Abakaliki, Nigeria. Olalekan appropriate credit to the original author(s) and the source, provide a A. Uthman, PhD, Warwick Medical School, University of Warwick, link to the Creative Commons license, and indicate if changes were Coventry, United Kingdom. Tommi Vasankari, PhD, UKK Institute made. for Health Promotion Research, Tampere, Finland. Vasiliy Vic- torovich Vlassov, MD, National Research University Higher School of Economics, Moscow, Russia. 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International Journal of Public Health – Springer Journals
Published: Aug 3, 2017
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