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1 Global, regional, and national burden of traumatic brain injury and spinal cord injury, : a systematic analysis for the Global Burden of Disease Study 2016 GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators* Lancet Neurol 201; 1: 56 Published Online November 26, S (1) See Comment page 24 *Collaborators listed at the end of the Article Correspondence to: Dr Spencer L James, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA 121, USA spencj@uw.edu or Dr Alice Theadom, National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, AUT North Campus, 0 Akoranga Drive, Northcote, Auckland 1142, New Zealand alice.theadom@aut.ac.nz Summary Background Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 10 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury. Methods We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used causespecific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility. Findings In 2016, there were 2 0 million (5% uncertainty interval [UI] million) new cases of TBI and 0 3 million ( million) new cases of SCI, with age-standardised incidence rates of 36 ( ) per population for TBI and 13 (11 16) per for SCI. In 2016, the number of prevalent cases of TBI was million ( million) and of SCI was 2 04 million ( million). From 10 to 2016, the agestandardised prevalence of TBI increased by 4% (5% UI to 2), whereas that of SCI did not change significantly ( 0 2% [ 2 1 to 2 ]). Age-standardised incidence rates increased by 3 6% (1 to 5 5) for TBI, but did not change significantly for SCI ( 3 6% [ 4 to 4 0]). TBI caused 1 million (5% UI million) YLDs and SCI caused 5 million ( million) YLDs in 2016, corresponding to age-standardised rates of 111 (2 141) per for TBI and 130 (0 10) per for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions. Interpretation TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments. Funding Bill & Melinda Gates Foundation. Copyright 201 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Introduction Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly considered to be important global health priorities. 1 These injuries not only cause health loss and disability for individ uals and their families, but also represent a burden to health-care systems and economies through lost pro ductivity and high health-care costs. 2 Given that the injuries that lead to TBI and SCI are frequently preventable, there is also value in measuring the extent to which different causes of injury lead to TBI or SCI to help to understand the effect that injuryprevention programmes could have. Many epidemiological studies have been limited by difficulties in comprehensively measuring the incidence of cross-injury sequelae such as TBI and SCI, and have instead focused on the incidence of the causes of injury, 56 Vol 1 January 201

2 Research in context Evidence before this study Previous epidemiological studies of the incidence and outcomes of traumatic brain injury (TBI) and spinal cord injury (SCI) have been limited by focusing on certain subpopulations, including only select injuries, or by providing estimates only for areas of the world with accessible data. Previous Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies have reported the burden of injury by cause of injury, such as self-harm, road injuries, and falls, but have not reported results by nature of injury sustained as a result of those causes, including TBI and SCI. To date, no studies have systematically measured the burden of TBI and SCI globally for all countries, ages, and sexes through recent years and from all causes of injury. To identify sources of injury data that could inform an assessment of non-fatal burden from TBI and SCI, we used results from the GBD 2016 injuries estimation process, which included systematic reviews of injury incidence data for all causes of injury that were initially done for GBD 2010 and updated as new data and literature studies became available in GBD 2013, GBD 2015, and GBD Inclusion criteria for the systematic reviews were representative, population-based surveys; reporting of injuries incidence; and clinical records from general hospitals, outpatient primary care facilities, and health insurance claims when such data were available with injury diagnosis codes. In this study, we updated a previous review of injuries data done for the World Bank that contributed to GBD 2010, GBD 2013, and GBD 2015 by searching the Global Health Data Exchange for surveys, hospital datasets, and literature studies in any language that were tagged as having injury-related data up to Dec 31, Added value of this study In this study, we used for the first time the GBD 2016 framework to report estimates of the global, regional, and national burden in terms of incidence, prevalence, and years of life lived with disability of TBI and SCI for 15 countries and territories. We have provided these estimates globally, by region, and by Socio-demographic Index quintiles in 2016, as well as the percentage change since 10. We also provide estimates of the proportions of TBI and SCI caused by different causes of injury for each geographical region in Although epidemiological assessments that focus on particular populations have been done, no other studies of TBI or SCI have provided estimates in this level of detail for all countries derived from a standardised, systematic approach. We were able to measure uncertainty in our estimates by using the uncertainty propogation methods used throughout the GBD study. Implications of all the available evidence Our estimates suggest that TBI and SCI are severely disabling injuries. The global burden of TBI increased significantly between 10 and 2016, whereas that of SCI has not changed significantly over time in terms of age-standardised incidence and prevalence. Age-standardised incidence and prevalence of TBI and SCI were high in central Europe, eastern Europe, and central Asia; the incidence and prevalence of SCI were high in North America and western Europe. Addressing the global burden of these conditions requires improved efforts to decrease the causes of SCI and TBI (eg, fall-prevention strategies, reducing alcohol overuse, and improving road safety, all of which could help to prevent injuries or decrease injury severity) and improved access to, and quality of, medical and social care (which could improve survival and reduce morbidity). People with TBI or SCI can have other medical conditions that require close supervision and might benefit from rehabilitation and medical care to reduce disability. Hence, although injury prevention efforts are key, health-care systems should also anticipate a growing burden from caring for people with TBI and SCI. These conditions could necessitate special focus within health-care systems, because they can be medically complex and burdensome for patients, clinicians, and families. In the future, development of improved methods for surveillance of TBI and SCI will be important, particularly in low-income settings, as will development of methods to identify patients with TBI who do not seek medical care. For the Global Health Data Exchange see healthdata.org such as falls, road injuries, and interpersonal violence. 3 As a result, few comprehensive epidemi ological assessments have been done across all sources of injury, despite increasing dialogue about the long-term neuropsychological consequences of con cussions in young people and professional athletes playing sports and about the risk of TBI from head trauma in bicycle crashes and other causes of injury. 4,5 Epidemiological studies that have focused specifically on TBI and SCI without estimation of all potential causes of injury have identified substantial burdens, but are often limited by relying on locations where incidence data were available without adopting modelling strategies for estimation of the burden in locations where data were sparse Epidemiological assessments have been done in low-income and lowmiddle-income countries but typically have been limited by poor availability of data.,12,13 Few studies have reported age-standardised incidence rates, which would enable comparison between countries with different popula tions, and the studies that have reported such data showed that the incidence rates of TBI and SCI vary substantially between countries.,12 These studies have not measured the relative disability caused by different injuries over time; such data are important because, whereas injuries such as fractures might be disabling only in the short term, conditions such as cognitive impairment from TBI or paraplegia from SCI can leave patients with lifelong health loss. In general, measurement of the burden of TBI and SCI in greater geographical and demographic detail and over time is of substantial value. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) study is the product of a global research Vol 1 January 201 5

3 Global ( to ) High SDI ( to ) High-middle SDI (4 125 to ) Middle SDI 2 05 ( to ) Low-middle SDI 04 1 ( to 6 510) Low SDI ( to 2 64) High income ( to ) High-income North America ( to ) Canada (2 166 to ) Greenland 161 (133 to 1) USA (2 14 to ) Australasia 554 (65 10 to 3 41) Australia (55 30 to 5) New Zealand ( to 14 4) High-income Asia Pacific (41 6 to 61 62) Brunei 1535 (1306 to 11) Japan ( to ) Singapore (34 to 13 3) South Korea (141 4 to 1 2) Western Europe ( to ) Andorra 236 (14 to 22) Austria ( to 35 10) Belgium (33 4 to ) Cyprus 25 (2503 to 3516) Denmark (14 20 to ) 36 (331 to 412) 343 (23 to 403) 46 (41 to 523) 31 (2 to 351) 3 (356 to 441) 366 (323 to 416) 2 (251 to 354) 32 (2 to 32) 302 (254 to 361) 321 (26 to 3) 333 (20 to 36) 26 (231 to 32) 25 (230 to 32) 2 (236 to 330) 26 (231 to 330) 34 (325 to 456) 263 (220 to 314) 25 (23 to 340) 316 (26 to 3) 22 (244 to 351) 300 (24 to 361) 322 (266 to 3) 344 (2 to 416) 323 (23 to 31) 301 (24 to 366) age-standardised 3 6 (1 to 5 5) 4 ( 12 2 to 6 2) 10 ( 13 3 to 4) 21 (1 to 24 ) 11 1 ( 6 to 16 5) 3 ( 14 to 6 0) 6 ( 13 0 to 6 1) 4 1 ( to 1 2) 10 4 ( 15 2 to 6 0) 1 0 ( 21 3 to 16 5) 3 3 ( 2 to 2 5) 13 0 ( 1 6 to 3) 12 1 ( 1 to 6 3) 1 1 ( 23 2 to 11 1) 16 ( 20 6 to 13 1) 20 ( 24 6 to 16 6) 15 5 ( 1 to 11 2) 4 4 ( 10 0 to 0 6) 1 4 ( 23 to 14 ) 13 4 ( 1 2 to ) 4 1 (0 to 5) 1 ( 24 5 to 14 ) 6 ( 13 6 to 0 6) 10 0 ( 14 2 to 5 6) 14 ( 1 to 10 0) ( to ) ( to 1 355) ( to ) ( to ) ( to ) ( to ) ( to ) ( to ) ( to ) 21 (26 to 26) ( to ) (10 6 to 1 5) ( to 15 ) (2 152 to 2 2) ( to ) 20 (2564 to 25) (54 60 to 2 03) ( to ) ( to 352 3) ( to ) 53 (554 to 611) ( to 6 564) 0 4 (6 26 to 4 63) 6605 (620 to 64) 3 56 (3 14 to 41 50) 5 (31 to ) 4 ( to 2) 64 (61 to 65) ( to 1) 1032 (3 to 1 04) 6 (64 to 25) 4 (1 to ) 66 (633 to 1) 544 (520 to 56) 600 (53 to 630) 55 (532 to 56) 525 (502 to 553) 605 (5 to 635) 52 (503 to 556) 52 (503 to 555) 534 (50 to 561) 4 (46 to 511) 63 (640 to 0) 44 (452 to 46) 516 (41 to 540) 535 (510 to 55) 546 (51 to 52) 565 (536 to 54) 5 (561 to 616) 621 (50 to 652) 61 (5 to 650) 556 (52 to 54) 5 4 ( 6 3 to 4 5) 32 4 (31 0 to 33 ) 1 (1 to 20 0) 3 3 (1 to 4 ) 10 2 ( 11 0 to 2) 6 3 ( to 4 6) 11 2 ( 12 to 2) 14 6 ( 15 to 13 2) 5 ( 5 to 3 ) 14 1 ( 15 6 to 12 2) 13 3 ( 14 to 11 3) 1 1 ( 20 3 to 16 1) 14 ( 16 1 to 13 5) 21 3 ( 22 to 1 ) 14 2 ( 15 to 12 4) 0 ( 3 0 to 1 5) 1 4 ( 20 1 to 1 0) 12 ( 13 to 11 ) 6 2 (4 to ) 1 ( 1 4 to 16 2) 10 1 ( 11 to 1) 0 ( 10 3 to 6) 12 5 ( 14 0 to 11 0) (Table 1 continues on next page) 5 Vol 1 January 201

4 (Continued from previous page) Finland ( to 25 40) France 20 6 (10 4 to ) Germany (12 62 to 25 65) Greece (2 4 to 3 411) Iceland 26 (66 to 1120) Ireland 13 2 (10 56 to ) Israel (1 0 to 2 302) Italy (15 5 to ) Luxembourg 11 (1461 to 215) Malta 110 (65 to 1445) Netherlands (3 2 to 56 15) Norway (13 05 to 1 36) Portugal 2 0 (23 44 to 33 55) Spain (10 05 to ) Sweden (22 0 to 34 1) Switzerland (20 22 to 31 44) UK 16 5 (13 3 to ) Southern Latin America (124 0 to 1 016) Argentina (4 40 to ) Chile 3 6 (32 0 to 4 14) Uruguay 662 (243 to ) Central Europe, eastern Europe, and central Asia ( to ) Eastern Europe ( to ) Belarus 5 26 (4 665 to 05) Estonia 43 (61 to 11 32) Latvia (13 64 to 1 22) Lithuania ( to ) 344 (24 to 420) 30 (255 to 32) 2 (23 to 346) 321 (21 to 32) 22 (233 to 33) 2 (246 to 356) 2 (232 to 332) 315 (263 to 3) 303 (252 to 36) 2 (240 to 352) 25 (233 to 32) 2 (246 to 363) 26 (226 to 316) 24 (23 to 33) 22 (233 to 342) 24 (233 to 343) 260 (215 to 316) 225 (10 to 21) 22 (12 to 23) 214 (1 to 25) 244 (205 to 24) 40 (65 to 44) 2 (6 to 6) 53 (4 to ) 22 (635 to 2) 43 (654 to 51) 45 (43 to 2) age-standardised 5 5 ( 10 4 to 0 ) 1 ( 24 6 to 15 3) 12 ( 1 4 to ) ( 14 to 4 ) 5 ( 11 to 2 ) 6 0 ( 11 1 to 0 6) 4 5 ( 11 5 to 1 3) 11 ( 15 to 3) 26 5 ( 31 5 to 21 ) ( 12 4 to 5 1) 0 0 ( 5 4 to 5 ) 5 5 ( 10 5 to 0 ) 2 3 ( 34 6 to 24 6) 16 4 ( 21 3 to 11 4) 4 6 ( 1 to 0 1) 2 1 ( 33 to 24 ) 5 ( to 2 0) 11 ( to 14 ) 14 0 ( to 1 2) 4 4 (1 1 to ) 13 ( 4 to 1 3) 4 2 ( 6 3 to 2 2) 2 4 ( 5 2 to 0 3) 15 (11 5 to 20 3) 20 2 ( 24 0 to 16 0) 22 6 ( 26 0 to 1 ) 5 5 ( 4 to 1 3) ( to ) (442 5 to 4 46) ( to 61 54) 2 (5 526 to 4 453) 2021 (125 to 2110) 2 3 (2 464 to 30 26) (42 15 to 4 6) (46 03 to ) 30 (33 to 416) 20 (241 to 3000) (10 3 to 11 00) ( to 36 5) 0 2 (6 2 to 4 142) (312 4 to ) (60 1 to ) ( to 5 06) ( to 3 04) ( to 21 56) 1 55 (12 21 to 1 26) 4 02 (1 04 to 306) (15 to 1 20) ( to 2 426) ( to ) (12 52 to ) 25 6 (24 3 to 2 131) 3 6 (3 015 to 40 ) 64 3 (61 51 to 6 064) 60 (5 to 63) 564 (535 to 53) 535 (50 to 562) 62 (54 to 660) 532 (506 to 55) 550 (523 to 5) 556 (521 to 605) 56 (566 to 626) 563 (535 to 51) 53 (514 to 566) 523 (4 to 54) 54 (51 to 54) 504 (40 to 52) 543 (515 to 56) 512 (4 to 536) 4 (46 to 520) 4 (454 to 4) 32 (36 to 40) 401 (34 to 41) 36 (352 to 34) 424 (406 to 443) 153 (1464 to 1614) 1546 (142 to 1623) 124 (1632 to 115) 152 (1445 to 1622) 151 (1436 to 1601) 10 (161 to 100) 4 5 ( 6 3 to 2 ) 1 ( 21 4 to 1 1) 12 6 ( 14 2 to 11 1) ( 2 to 6 4) 1 ( to 5 3) 6 5 ( 1 to 4 ) 4 0 (1 0 to 4) 10 2 ( 11 to ) 25 ( 2 1 to 24 3) 5 ( 1 to 4 4) 1 2 ( 0 to 3 1) 4 3 ( 5 to 2 5) 2 5 ( 30 3 to 26 6) 16 5 ( 1 0 to 14 6) 5 ( 6 to 4 2) 2 4 ( 30 to 2 ) 6 5 ( 5 to 5 3) 15 1 (13 to 16 5) 1 0 (16 4 to 1 ) 0 (6 3 to 5) 1 0 (15 2 to 1 0) 0 6 ( 1 5 to 0 6) 1 5 ( 3 0 to 0 2) 15 2 (12 to 1 ) 14 1 ( 16 2 to 11 ) 1 4 ( 20 2 to 16 6) 3 ( 5 to 1 ) (Table 1 continues on next page) Vol 1 January 201 5

5 (Continued from previous page) Moldova 25 0 ( to 2 62) Russia ( to ) Ukraine (2 5 to ) Central Europe ( to ) Albania (1 024 to 22 10) Bosnia and Herzegovina ( to 2 4) Bulgaria (4 635 to ) Croatia (33 26 to 46 01) Czech Republic ( 5 to ) Hungary 6 61 (2 02 to ) Macedonia 14 5 (12 5 to 1 014) Montenegro 46 (436 to 560) Poland (31 50 to ) Romania ( to 16 1) Serbia 65 6 (5 63 to 5 4) Slovakia (44 21 to ) Slovenia (22 0 to 31 03) Central Asia 43 1 (3 64 to 4 54) Armenia ( to 16 24) Azerbaijan (40 30 to 51 0) Georgia (1 4 to 22 4) Kazakhstan 10 4 (6 45 to 122 5) Kyrgyzstan (24 6 to 31 5) Mongolia 1 3 (1 25 to 22 03) Tajikistan 35 1 (31 21 to 41 43) Turkmenistan 24 1 ( to 2 455) Uzbekistan ( to 160 2) 60 (53 to 66) (15 to 05) 63 (605 to ) 5 (50 to ) 662 (53 to 61) 6 (5 to 3) 6 (63 to ) 01 (04 to 14) 1022 (5 to 111) 65 (44 to 101) 14 (621 to 21) 5 3 (2 to 103) 34 (2 to 66) 33 (642 to 40) (5 to 1031) 102 (3 to 124) 45 (43 to 563) 44 (41 to 53) 465 (410 to 530) 46 (440 to 563) 60 (541 to 6) 40 (41 to 532) 634 (563 to 23) 41 (364 to 42) 44 (3 to 512) 45 (405 to 521) age-standardised 1 6 ( 21 2 to 14 0) 1 5 ( 4 to 2 2) 6 5 ( 10 0 to 2 ) 3 0 ( 5 to 0 4) 10 1 (6 5 to 13 ) 42 4 (3 to 46 ) 5 3 ( 4 to 1 3) 3 1 ( 3 to 2 5) 5 3 ( to 0 3) 1 0 ( 23 5 to 14 ) 16 0 (11 to 20 0) 5 (5 3 to 11 ) 1 0 ( 3 6 to 5 2) ( 12 5 to 3 4) 13 4 (10 0 to 16 ) ( 13 3 to 6 0) 3 ( 3 to 3 1) 0 1 ( 2 3 to 2 4) 12 4 ( 16 1 to 6) 3 4 ( 6 to 0 1) 4 6 ( 2 to 1 3) (5 to 14 2) 13 1 ( 16 to 6) 51 3 (43 5 to 5 0) 13 3 ( 16 to ) 0 2 ( 3 to 3 6) 4 0 (0 1 to 5) 5 6 ( to ) ( to ) ( to 24 6) ( to ) 4 63 (46 22 to 51 6) 6 61 (1 24 to 2 10) ( to ) 2 1 ( 4 to 6 55) (21 50 to ) ( to ) 3 13 (35 00 to 3 44) (11 30 to 13 31) 0 54 ( to 60 24) ( to 45 01) (164 3 to ) ( to ) (60 04 to 6 002) 6 36 (23 61 to 16 ) 3 65 (36 01 to ) (5 66 to 10 26) 4 0 (46 31 to ) 21 6 ( to ) (4 550 to ) (32 03 to ) (5 266 to ) ( to 4 61) ( to 22 42) 1251 (111 to 132) 15 (1512 to 166) 130 (131 to 1464) 1 (16 to 15) 140 (1405 to 15) 1600 (143 to 114) 1663 (152 to 156) 162 (1553 to 103) 214 (2051 to 230) 10 (1606 to 110) 1526 (1434 to 1621) 112 (1615 to 110) 156 (153 to 164) 151 (1653 to 14) 1604 (1511 to 105) 131 (130 to 136) 2255 (2133 to 234) 1054 (1002 to 110) 111 (105 to 1325) 100 (54 to 1065) 1046 (4 to 1100) 1251 (11 to 1313) (40 to 1043) 125 (11 to 1325) 1 (61 to ) 45 (4 to ) 63 (13 to 101) 14 2 ( 16 4 to 12 0) 0 6 ( 2 5 to 1 6) 6 1 ( 1 to 4 1) 4 4 (3 3 to 5 5) 12 6 ( to 16 1) 53 (4 to 62 5) 1 ( 3 to 0 6) 0 1 ( 2 to 3 3) 1 (6 to 11 5) ( 11 2 to 6 4) 1 3 (15 2 to 21 3) 11 5 ( 3 to 13 ) 1 (6 to 11 3) 5 0 ( 6 to 3 1) 1 (14 to 21 6) 2 0 ( 3 to 0 4) 3 2 (1 3 to 5 5) 1 (0 to 3 2) 13 3 ( 1 4 to 4) 1 6 ( 0 to 4 5) 3 0 ( 5 6 to 0 1) 11 3 ( to 13 ) 6 ( 12 0 to 2) 52 1 (4 4 to 56 6) 6 ( 10 1 to 2 ) 3 6 (1 0 to 5 ) 5 4 (3 0 to ) (Table 1 continues on next page) 60 Vol 1 January 201

6 (Continued from previous page) Latin America and Caribbean ( to ) Central Latin America (642 4 to 06 5) Colombia 13 2 (124 5 to 15 23) Costa Rica (13 45 to 1 031) El Salvador (16 to ) Guatemala (40 22 to 51 24) Honduras (1 552 to 23 5) Mexico ( to 34 04) Nicaragua (13 53 to 1 33) Panama ( to 13 15) Venezuela (6 052 to 11 63) Andean Latin America ( to 15 33) Bolivia (2 63 to 34 6) Ecuador (4 25 to ) Peru 513 ( 33 to 60) Caribbean 145 ( to ) Antigua and Barbuda 263 (235 to 25) The Bahamas 1222 (10 to 136) Barbados 2 (6 to 5) Belize 114 (102 to 122) Bermuda 226 (201 to 253) Cuba (36 46 to 4 35) Dominica 210 (1 to 236) Dominican Republic (2 2 to ) Grenada 333 (26 to 33) Guyana 22 (2055 to 252) Haiti (2 52 to ) 330 (26 to 32) 23 (263 to 330) 24 (263 to 331) 316 (21 to 35) 31 (22 to 35) 301 (26 to 341) 2 (246 to 31) 2 (24 to 315) 263 (233 to 2) 315 (21 to 354) 34 (313 to 30) 303 (21 to 340) 24 (262 to 32) 350 (310 to 3) 22 (252 to 316) 320 (25 to 360) 21 (25 to 326) 314 (21 to 352) 25 (246 to 30) 321 (2 to 35) 322 (26 to 361) 33 (26 to 3) 24 (254 to 31) 30 (2 to 343) 31 (23 to 356) 30 (26 to 344) 2 (255 to 32) age-standardised 1 1 ( 0 to 3 3) 5 ( 11 6 to 6) ( 12 1 to 5 1) 1 3 (13 to 23 1) 1 0 ( 3 to 0) 14 2 (6 5 to 1 ) 30 4 (25 3 to 36 2) 1 ( 21 to 1 ) 4 (1 1 to ) 1 1 (15 2 to 23 4) 14 0 ( 4 to 1 ) (4 to 11 2) 4 0 ( 0 to 1 2) 16 5 ( 0 to 26 0) 6 (2 3 to 11 4) 21 1 (1 to 24 5) 15 4 (12 3 to 1 ) 6 3 (2 to ) 1 2 (16 2 to 22 5) 32 3 (26 4 to 3 1) 4 0 ( 5 to 0 2) 12 5 ( 0 to 1 ) 32 (2 1 to 36 5) 31 (2 to 36 2) 2 (26 2 to 33 5) 15 4 (11 to 1 3) 20 1 (12 3 to 31 0) ( to 3 453) (1 34 to ) (2 36 to ) (31 61 to ) 3 24 ( to 40 21) 3 30 (6 to 152) 3 56 (34 3 to 40 13) (62 20 to 6 51) 2 22 (2 333 to ) ( to 2 043) ( to ) ( to ) 55 5 ( to 5 4) (6 5 to ) (10 25 to 1 5) ( to 35 14) 56 (566 to 625) 220 (251 to 243) 15 (1 to 204) 16 (13 to 2056) 515 (40 to 53) 6 30 (1 245 to ) 45 (434 to 41) (61 66 to 6 15) 643 (60 to 64) 416 (32 to 430) 1 46 (4 24 to ) 61 (650 to 10) 60 (54 to 635) 632 (605 to 663) 6 (643 to 10) 660 (622 to 05) 53 (56 to 620) 56 (532 to 610) 565 (540 to 5) 564 (531 to 60) 63 (64 to 15) 42 (0 to 5) 640 (610 to 60) 60 (5 to 63) 66 (663 to 2) 622 (50 to 652) 06 (640 to ) 640 (60 to 61) 660 (62 to 60) 600 (56 to 62) 65 (62 to 65) 1 (64 to 52) 63 (646 to 1) 610 (5 to 641) 6 (645 to 0) 645 (612 to 64) 5 (561 to 616) 4 (530 to 10) 3 6 (2 2 to 4 ) 5 0 ( 5 to 3 ) 1 ( 4 0 to 0 3) 24 (21 5 to 2 3) 5 5 ( 0 5 to 6) 1 1 (15 0 to 22 4) 33 1 (26 4 to 42 1) 16 ( 1 0 to 15 6) 0 0 ( 5 3 to 4 5) 24 0 (20 to 2 1) 1 6 (16 to 22 5) 12 1 (10 2 to 14 0) 2 6 (0 2 to 5 1) 11 ( 3 to 14 3) 15 1 (11 to 1 3) 2 (20 2 to 44 6) 1 5 (15 6 to 21 4) 11 2 ( 6 to 14 5) 23 1 (1 to 26 3) 31 (2 6 to 35 3) 5 0 (2 4 to ) 10 6 ( 6 to 13 ) 35 5 (31 6 to 40 0) 34 1 (30 to 3 ) 31 5 (2 5 to 34 6) 1 1 (16 5 to 22 0) 6 6 (20 6 to 144 6) (Table 1 continues on next page) Vol 1 January

7 (Continued from previous page) Jamaica 21 (65 to 611) Puerto Rico (11 6 to ) Saint Lucia 526 (46 to 52) Saint Vincent and the Grenadines 342 (305 to 3) Suriname 164 (1511 to 15) Trinidad and Tobago 4111 (364 to 45) Virgin Islands 343 (306 to 3) Tropical Latin America 0 14 (20 0 to 13 66) Brazil (01 4 to 04) Paraguay (1 4 to ) Southeast Asia, east Asia, and Oceania ( to ) East Asia ( to ) China ( to 4 0 1) North Korea 1 12 (64 35 to 36) Taiwan (province of China) 0 0 (63 12 to 54) Southeast Asia ( to ) Cambodia (3 163 to ) Indonesia ( to ) Laos 1 5 (16 03 to 1 46) Malaysia (0 36 to ) Maldives 2 (6 to 5) Mauritius 335 (304 to 322) Myanmar 133 (120 2 to 14 ) Philippines ( to 31 16) Sri Lanka (5 1 to 0 0) Seychelles 306 (2 to 33) 26 (23 to 2) 346 (30 to 31) 21 (260 to 32) 312 (2 to 352) 313 (21 to 351) 312 (20 to 34) 30 (26 to 34) 32 (340 to 432) 33 (341 to 434) 330 (23 to 36) 302 (23 to 332) 312 (22 to 344) 313 (23 to 345) 26 (241 to 2) 26 (26 to 32) 23 (256 to 312) 263 (23 to 21) 264 (23 to 22) 241 (21 to 26) 324 (22 to 35) 211 (12 to 233) 26 (244 to 2) 250 (225 to 2) 25 (24 to 30) 30 (21 to 340) 312 (23 to 345) age-standardised 3 (35 5 to 42 ) 21 (1 1 to 2 0) 20 1 (16 to 23 4) 2 1 (25 3 to 32 ) 26 1 (22 2 to 30 2) 24 (1 to 2 ) 15 2 (11 6 to 1 ) 6 2 (3 0 to ) 5 6 (2 4 to 2) 36 (32 6 to 41 ) 31 1 (26 to 35 5) 33 3 (2 5 to 3 3) 33 1 (2 3 to 3 1) 56 4 (4 to 63 1) 26 2 (21 3 to 31 ) 2 1 (20 to 32 0) 25 3 (6 to 3 0) 25 2 (21 4 to 2 1) 1 ( to 35 4) 36 5 (32 2 to 41 5) 2 (3 6 to 10 5) 43 (3 1 to 4 6) 43 3 (3 4 to 4 5) 2 (21 0 to 3 3) 23 4 ( 4 2 to 0 2) 3 (33 4 to 42 4) ( to 1 055) (2 56 to 32 6) 11 (1141 to 125) 6 (661 to 31) 3444 (324 to 355) 1 (2 to ) 34 (2 to 4) ( to ) ( to ) (3 04 to 42 ) (15 23 to ) (11 43 to ) ( to ) ( to ) (1 21 to 213 3) ( to 4 23 ) 0 21 (3 4 to 1 402) ( to ) (2 652 to ) (20 06 to 22 66) 163 (155 to 116) 10 (434 to 1) ( to 34 50) (4 001 to ) ( to 15 2) 64 (665 to 23) 50 (54 to 60) 31 (60 to 66) 632 (602 to 663) 63 (606 to 66) 652 (623 to 60) 661 (62 to 61) 640 (60 to 62) 63 (2 to ) 64 (2 to 01) 62 (655 to 31) 14 (6 to 43) 3 (12 to 6) 42 (15 to 1) 50 (566 to 616) 0 (6 to 3) 64 (620 to 60) 615 (560 to 13) 55 (56 to 624) 523 (500 to 546) 46 (15 to 1) 505 (43 to 52) 61 (52 to 646) 5 (54 to 60) 5 (562 to 621) 4 (2 to ) 62 (663 to 20) 3 2 (33 to 42 4) 23 4 (1 to 2 1) 25 2 (21 to 2 ) 30 (2 2 to 34 ) 2 0 (23 5 to 30 3) 33 0 (2 5 to 36 5) 16 4 (13 to 1 ) 5 4 (3 0 to 5) 4 (2 4 to 0) 33 (2 4 to 3 3) 43 0 (41 0 to 45 4) 43 5 (41 4 to 45 ) 43 6 (41 4 to 45 ) 54 1 (50 3 to 5 6) 31 1 (2 2 to 34 1) 42 (40 1 to 46 0) 24 4 (5 0 to 41 4) 35 (32 6 to 3 5) 53 6 (4 to 5 0) 42 (40 1 to 45 4) 20 5 (1 3 to 23 3) 52 3 (4 to 55 6) 2 3 (60 5 to ) 42 4 (3 2 to 45 ) 3 5 (2 to 4 6) 45 6 (43 1 to 4 5) (Table 1 continues on next page) 62 Vol 1 January 201

8 (Continued from previous page) Thailand (21 41 to 21 1) Timor-Leste 26 (2426 to 20) Vietnam (24 41 to ) Oceania (2 426 to 34 33) American Samoa 22 (206 to 250) Federated States of Micronesia 23 (24 to 302) Fiji 211 (12 to 240) Guam 566 (514 to 624) Kiribati 23 (255 to 316) Marshall Islands 1 (1 to 21) Northern Mariana Islands 405 (365 to 451) Papua New Guinea (20 20 to 24 ) Samoa 51 (46 to 51) Solomon Islands 153 (1443 to 165) Tonga 2 (261 to 320) Vanuatu 25 (655 to 03) North Africa and Middle East ( to 3 1 1) Afghanistan (11 2 to 3 313) Algeria ( to 13 5) Bahrain 44 (42 to 5231) Egypt ( to 22 13) Iran (22 13 to 335 3) Iraq (165 0 to ) Jordan 2 61 (22 4 to 3 6) Kuwait (13 32 to 16 36) Lebanon 1 65 ( to 22 52) Libya (1 63 to 3 31) 352 (31 to 31) 235 (213 to 260) 21 (262 to 323) 22 (256 to 312) 20 (264 to 320) 26 (242 to 25) 256 (234 to 22) 326 (26 to 35) 243 (21 to 21) 263 (23 to 2) 30 (2 to 33) 2 (260 to 320) 261 (23 to 2) 26 (245 to 2) 26 (244 to 26) 25 (235 to 2) 412 (340 to 52) 564 (331 to 1 046) 310 (2 to 343) 33 (305 to 34) 21 (254 to 312) 32 (335 to 411) 633 (40 to 1 0) 343 (2 to 45) 36 (33 to 415) 32 (22 to 35) 420 (31 to 61) age-standardised 2 2 (23 to 32 ) 26 3 ( 56 to 5) 50 4 (46 0 to 55 0) 2 1 (24 1 to 33 ) 13 2 (10 1 to 16 6) 2 0 (24 2 to 32 1) 40 0 (35 to 44 4) 34 0 (2 6 to 3 6) 42 2 (3 0 to 46 ) 31 4 (2 2 to 35 ) 10 4 ( 4 to 13 6) 2 0 (21 0 to 32 2) 2 3 (23 to 31 1) 33 4 (2 3 to 3 6) 1 4 (14 2 to 22 ) 40 4 (35 to 45 1) 14 5 ( 1 1 to 43 0) 63 3 ( 0 4 to 166 ) 5 ( 10 0 to 4 ) 4 ( 11 6 to 5 1) 24 6 (21 1 to 2 6) 32 ( 4 to 12 2) 6 2 ( to 11 ) 4 3 ( 12 2 to 41 3) 32 3 ( 53 5 to 10 ) 44 6 ( 62 5 to 26 6) 2 1 (0 5 to 0 0) ( to 62 02) 552 (504 to 666) (5 63 to ) (4 0 to 55 14) 444 (422 to 466) 464 (442 to 4) 45 (4402 to 412) 123 (121 to 1330) 46 (444 to 41) 322 (30 to 33) 5 (20 to ) ( to 36 0) 44 ( to 6) 241 (2360 to 2611) 4 (4 to 523) 1206 (114 to 123) ( to ) 21 (163 0 to ) ( to ) 10 1 ( to 11 42) (461 1 to 50 02) ( to 3 4) ( to ) 40 5 (3 45 to ) (31 00 to 35 32) (4 11 to 2 56) 4 41 (41 3 to 5 143) 12 (6 to 4) 11 (53 to 30) 644 (616 to 62) 565 (540 to 51) 644 (616 to 64) 545 (521 to 51) 53 (516 to 562) 26 (65 to 5) 41 (45 to 503) 52 (505 to 552) 02 (63 to 34) 566 (540 to 52) 53 (55 to 612) 53 (515 to 563) 565 (542 to 5) 53 (514 to 566) 2 (30 to 64) 53 (60 to 1 45) 10 (6 to 43) 6 (5 to 35) 601 (54 to 62) 21 (5 to 1013) 1134 (0 to 151) 646 (616 to 6) 02 (61 to 43) 10 (4 to 1623) 14 (23 to 0) 35 6 (32 to 3 2) 3 3 (2 2 to 4 ) 5 2 (55 to 62 5) 3 (3 6 to 42 4) 1 6 (14 to 20 2) 31 4 (2 6 to 34 2) 43 5 (40 to 45 ) 34 (32 6 to 3 1) 4 2 (45 6 to 51 2) 31 1 (2 4 to 33 ) 11 ( to 13 ) 41 4 (3 6 to 44 3) 36 5 (33 2 to 40 5) 3 5 (36 2 to 41 0) 25 4 (23 1 to 2 ) 46 (43 5 to 4 ) 1 3 ( 0 to 3 ) 10 5 ( 22 to 11 3) 1 6 ( 3 6 to 0 ) 2 1 ( 4 to 0 ) 23 2 (20 3 to 26 4) ( 12 to 3 5) 4 2 ( 12 to 5 1) 11 4 ( 13 to 5) 6 4 ( to 4 0) 21 ( 30 4 to 12 0) 6 ( 3 4 to 25 2) (Table 1 continues on next page) Vol 1 January

9 age-standardised (Continued from previous page) Morocco (5 330 to ) Oman 20 4 (1 25 to 22 1) Palestine ( to 1 200) Qatar 11 ( to 13 13) Saudi Arabia (10 1 to ) Sudan (10 0 to 146 6) Syria (3 25 to ) Tunisia (30 0 to 3 256) Turkey ( to 2 22) United Arab Emirates ( to 51 43) 24 (255 to 316) 42 (33 to 45) 24 (256 to 31) 44 (436 to 535) 30 (341 to 41) 306 (26 to 352) 1322 (41 to 2 ) 314 (21 to 34) 316 (23 to 352) 464 (41 to 513) 0 5 ( 2 4 to 3 4) 5 5 ( 0 to 2 0) 2 ( 1 to 5) 2 3 ( 5 5 to 0 ) 13 5 ( 15 3 to 11 5) 6 ( 0 6 to 14 5) 424 (0 to 1 02 ) 4 4 (1 4 to 2) 15 ( 1 3 to 10 ) 6 ( 2 to 4 4) ( to ) (3 21 to 43 61) (22 0 to 30 11) 24 (23 43 to 26 1) ( to ) 1 30 (1 41 to ) 14 5 ( to 21 53) (6 20 to 4 356) ( to 54 50) ( 64 to ) 64 (61 to 60) 1 (45 to 1036) 14 (62 to 5) 1155 (1102 to 1210) 55 (21 to 2) 63 (605 to 66) 1 (66 to 12) 6 (664 to 34) 0 (66 to 42) 104 (102 to 1125) 5 (3 to 5) 1 1 ( 3 0 to 0 ) 1 2 ( 10 3 to ) 0 0 ( 2 2 to 1 ) 11 1 ( 12 5 to 10 0) 12 (10 4 to 15 ) 60 3 (26 to 11 ) 1 (4 2 to 10 ) 13 2 ( 16 3 to 10 2) 4 1 ( 6 3 to 2 1) Yemen (130 6 to 32 ) South Asia ( to ) Bangladesh (45 23 to 5 5) Bhutan 3214 (22 to 35) India ( to ) Nepal (6 33 to ) Pakistan ( to 30 22) Sub-Saharan Africa ( to 3 26 ) Southern sub-saharan Africa ( to 2 66) Botswana 64 (032 to 5) eswatini 435 (4232 to 5305) Lesotho 016 (6310 to 10) Namibia 400 (6646 to 200) South Africa ( to ) Zimbabwe 3 66 (35 5 to 44 04) Western sub-saharan Africa ( to ) 626 (42 to 1051) 43 (33 to 4) 343 (30 to 33) 426 (3 to 4) 455 (406 to 505) 32 (340 to 42) 401 (361 to 446) 326 (23 to 363) 332 (300 to 36) 351 (316 to 31) 365 (326 to 40) 336 (304 to 32) 26 (266 to 326) 352 (31 to 30) 21 (245 to 300) 316 (24 to 353) 0 (35 to 234 4) 4 4 (2 4 to 6 6) 12 ( 6 to 16 3) 2 1 ( 0 5 to 4 ) 2 3 (0 1 to 4 6) 3 (0 to 1) 1 (16 5 to 23 2) 11 ( 20 3 to 6 ) 14 4 ( 1 0 to 12 0) 1 1 (14 2 to 20 1) 1 0 (13 3 to 20 ) 25 (22 4 to 2 2) 0 2 ( 2 to 2 4) 1 ( 22 to 15 ) 2 (0 to 5 0) 2 6 ( 4 to 0 ) ( to 16 3) ( to ) 0 1 ( to ) 54 (5233 to 556) ( to ) (13 44 to 11 20) ( to ) (3 03 to ) ( to ) ( to ) 630 (6051 to 666) 00 (651 to 546) (10 30 to 11 ) ( to ) (50 04 to ) ( to ) 0 (65 to 3) 2 (4 to 60) 6 (666 to 32) 11 ( to 4) 46 (11 to ) 51 (1 to ) 03 (6 to 3) 621 (54 to 64) 640 (614 to 60) 65 (643 to 06) 646 (61 to 65) 52 (50 to 555) 5 (551 to 603) 60 (652 to 12) 41 (452 to 42) 5 (52 to 622) (3 0 to 15 6) 16 (15 to 1 ) 2 5 (26 4 to 33 2) 6 (5 2 to 10 0) 14 (13 to 15 ) 20 3 (1 3 to 23 ) 26 5 (23 to 30 0) 0 ( 0 3 to 1 ) 15 2 ( 16 2 to 14 3) 16 0 (14 2 to 1 0) 3 (6 5 to 10 2) 0 ( 0 to 11 2) 2 1 (0 to 3 6) 1 3 ( 20 3 to 1 3) 0 ( 1 1 to 2 5) 3 1 (1 to 4 4) (Table 1 continues on next page) 64 Vol 1 January 201

10 (Continued from previous page) Benin (30 12 to 3 2) Burkina Faso (4 530 to 5 321) Cameroon 0 2 (63 to 440) Cape Verde 1654 (145 to 13) Chad (3 1 to 4 636) Côte d Ivoire (64 02 to 0 33) The Gambia 541 (4 to 6116) Ghana 4 24 (5 5 to 3 620) Guinea ( to 3 04) Guinea-Bissau 515 (5146 to 6362) Liberia (10 21 to 12 62) Mali (43 to 54 5) Mauritania (10 36 to ) Niger (4 0 to 5 40) Nigeria (4 3 to 60 60) São Tomé and Príncipe 60 (603 to 4) Senegal (3 611 to 4 ) Sierra Leone 1 ( to 1 2) Togo (1 5 to 22 23) Eastern sub-saharan Africa 1 11 ( to ) Burundi 3 32 ( to 41 2) Comoros 2436 (212 to 21) Djibouti 322 (24 to 361) Eritrea 16 6 ( to 1 5) Ethiopia (21 60 to 350 1) Kenya ( to ) Madagascar 0 46 (63 03 to 0) 32 (23 to 364) 312 (2 to 34) 320 (26 to 35) 304 (25 to 33) 315 (22 to 351) 344 (30 to 35) 21 (261 to 325) 32 (25 to 36) 2 (26 to 331) 32 (25 to 365) 20 (242 to 302) 22 (263 to 325) 321 (2 to 35) 21 (253 to 314) 31 (26 to 35) 360 (324 to 402) 314 (20 to 350) 2 (26 to 334) 26 (265 to 330) 33 (302 to 3) 363 (324 to 40) 33 (304 to 3) 364 (326 to 40) 35 (31 to 400) 343 (30 to 32) 34 (313 to 31) 305 (22 to 342) age-standardised 4 6 (1 to 6) 0 6 ( 3 2 to 2 1) 3 0 (0 0 to 6 2) 12 2 ( to 14 ) 6 ( 22 to 2 ) 5 3 ( to 2 6) ( 11 to 0) 12 5 (10 0 to 15 1) 5 1 ( 2 to 2 ) ( 5 to 6 1) 61 6 ( 5 to 41 0) 5 0 ( 6 to 2 3) 11 3 ( 22 4 to 3 5) 11 2 ( 14 2 to ) 0 6 ( 3 3 to 2 6) 5 (3 0 to ) 0 4 ( 3 1 to 2 5) 5 1 ( 3 to 3 0) 1 ( 4 4 to 0 ) 1 1 ( 33 5 to 4) 3 0 (0 5 to 5 6) 22 2 ( 24 0 to 20 1) 1 ( 16 4 to 4 4) 1 4 ( 4 3 to 1 4) 43 4 ( 62 2 to 25 4) ( to ) 5 6 ( 3 to 2 ) ( to 4 362) (65 64 to 2 04) (0 2 to 100 5) 210 (263 to 244) 54 5 (51 4 to 5 150) 313 (3 6 to ) 266 (6 to 63) ( to ) 4 3 ( to 51 16) 6 (400 to 13) 1 61 (16 43 to ) (61 06 to 6 253) 1 1 (1 26 to ) (63 2 to 0 34) 2 53 (31 53 to 14 54) 45 ( to 2) (5 1 to ) ( to 2 05) 2 6 ( to 2 45) ( to 1 4 1) (4 3 to ) 346 (3554 to 340) 5163 (402 to 5411) (22 0 to ) ( to 45 6) ( to 226 ) 4 (3 3 to ) 613 (55 to 63) 56 (542 to 52) 52 (546 to 5) 626 (600 to 653) 55 (564 to 631) 61 (5 to 644) 552 (52 to 5) 614 (5 to 640) 53 (516 to 562) 56 (544 to 51) 55 (512 to 634) 55 (532 to 56) 642 (614 to 60) 521 (4 to 543) 61 (51 to 64) 05 (63 to 3) 56 (560 to 612) 53 (541 to 620) 536 (513 to 55) 640 (60 to 60) 6 (646 to 4) 661 (632 to 60) 0 (66 to 3) 6 (640 to 2) 65 (624 to 03) 66 (642 to 66) 56 (540 to 53) (5 2 to 10 1) 6 3 (4 3 to 6) 0 5 ( 1 4 to 2 ) 16 0 (13 5 to 1 6) 5 1 (2 0 to ) 3 0 ( 5 1 to 0 ) 4 ( 11 5 to 4) 15 (13 5 to 1 4) 4 ( 6 to 2 2) 4 ( 6 to 2 ) 4 3 ( 11 0 to 4 ) 6 6 (3 5 to 11 1) 5 (3 6 to ) 5 6 ( to 3 6) 3 (1 to 6 0) 6 3 (3 to ) 2 4 ( 0 1 to 4 6) 0 ( 3 5 to 5) 1 ( 3 to 0 4) 5 3 (3 4 to 0) 24 3 (1 to 34 5) 16 ( 1 6 to 14 ) 1 2 ( 3 1 to 1 0) 15 2 (10 5 to 22 6) 2 4 ( 2 to 6 0) 12 (12 1 to 13 ) 2 6 ( 4 to 0 3) (Table 1 continues on next page) Vol 1 January

11 age-standardised (Continued from previous page) Malawi (40 22 to 50 65) Mozambique ( 161 to 5 3) Rwanda (2 55 to 3 120) Somalia 3 1 (32 22 to ) South Sudan ( to ) Tanzania (14 60 to 16 5) Uganda ( to 12 01) Zambia (4 01 to ) Central sub-saharan Africa ( to 405 6) Angola 553 (0 34 to 2) Central African Republic (12 54 to 16 13) Congo (Brazzaville) ( to 1 546) Democratic Republic of the Congo ( to ) Equatorial Guinea 3144 (20 to 3501) Gabon 625 (5600 to 656) 23 (244 to 30) 333 (2 to 31) 2 (265 to 334) 402 (33 to 505) 33 (341 to 434) 332 (2 to 31) 316 (23 to 354) 31 (341 to 424) 331 (26 to 36) 3 (33 to 424) 2 (26 to 335) 356 (31 to 3) 315 (23 to 351) 402 (35 to 452) 30 (331 to 411) 13 1 ( 15 3 to 10 ) 1 5 ( 11 2 to 5) 35 1 ( 50 5 to 24 ) 11 6 ( 1 6 to 6 ) 2 0 ( 4 5 to 0) 3 1 ( 5 3 to 0 ) 0 3 ( 4 1 to 3 ) 1 (4 3 to 10 0) 4 ( 11 to 4 5) 12 ( 2 2 to 3 2) 5 (1 6 to 11 2) 2 4 ( 4 4 to 0 2) 6 6 ( 6 to 4 6) 16 1 (12 5 to 20 0) 12 0 ( 14 1 to ) (53 64 to 60 21) 116 ( to 126 5) 63 ( to 5 43) 45 2 ( to 51 06) 63 0 (5 00 to 0 25) ( to 23 14) ( to ) ( to 3 33) 4 04 ( to ) (115 3 to ) 1 1 (1 55 to 20 01) 23 6 ( to 25 6) (300 0 to 333 6) 514 (420 to 531) (50 to 10 42) 4 (455 to 502) 62 (54 to 6) 2 (633 to 1065) 645 (5 to 1) 23 (64 to ) 615 (5 to 643) 60 (56 to 64) 64 (61 to 65) 63 (60 to 63) 2 (26 to 41) 4 (464 to 513) 11 (66 to 6) 5 (51 to 62) (65 to 31) 32 (01 to 61) ( 12 3 to ) 4 2 ( 5 1 to 11 2) 2 0 (4 1 to 3 2) 1 2 ( 2 3 to 6 6) 1 1 ( 3 0 to 3) 1 ( 0 5 to 4 0) 2 ( 0 6 to 16 ) 4 6 (2 6 to 6 ) 2 5 (0 to 4 ) 6 4 (1 5 to 10 2) 5 (2 6 to ) 15 3 (10 3 to 24 3) 0 5 ( 3 1 to 3 0) 3 4 (36 4 to 42 4) 4 0 ( 5 to 2 4) 5% uncertainty intervals are in parentheses. SDI=Socio-demographic Index. Table 1: and prevalence of traumatic brain injury in 2016, and percentage change in age-standardised rates by location, See Online for appendix 1 collaboration that quantifies the effects of hundreds of diseases, injuries, and risk factors around the world, producing annual estimates of all-cause mortality, causes of death, non-fatal health outcomes, and risk factors. Within the GBD framework, estimates for TBI and SCI burden have not previously been available as reported results. Instead, these nature-of-injury codes were incorporated as part of the analytic process that computed disability and results were ultimately provided only by cause (eg, falls) rather than by nature of injury (eg, TBI). Here, we describe an approach for estimation of naturespecific non-fatal burden estimates for all injuries, and report the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI, as well as the proportion of TBI and SCI caused by different injuries by region. Methods Overview Our approach to measuring TBI and SCI was developed within the GBD 2016 study framework. In the GBD 2016 study, standardised analytic methods were used to estimate incidence, prevalence, and YLDs by age, sex, cause, year, and location. The study was an attempt to use all accessible information about disease and injury occurrence, clinical course, and severity that passed a set of inclusion criteria. The comparability of data was optimised by adjusting for different case definitions, enforcing consistency between data for prevalence, incidence, and cause of death estimates, and predicting estimates for locations with sparse data by borrowing information from other locations and covariates. These methods, data, and criteria are described in more detail in other GBD 2016 reports. 3,14 1 Detailed elements of the GBD methods for measurement of TBI and SCI (including case definitions and severity definitions), a flowchart for our TBI and SCI estimation, and overall GBD study methods are in appendix 1. The measurement of TBI and SCI burden had two key deviations from the standard GBD framework. First, the GBD cause hierarchy categorised both TBI and SCI as being a nature of injury as opposed to a cause of 66 Vol 1 January 201

12 Global (0 63 to ) High SDI ( to ) High-middle SDI (12 5 to ) Middle SDI (14 4 to ) Low-middle SDI (1 305 to ) Low SDI 536 (65 24 to ) High income ( to ) High-income North America ( 044 to 12 22) Canada 654 (533 to ) Greenland 15 (12 to 1) USA (1 406 to 11 4) Australasia 6612 (511 to 442) Australia 5556 (4366 to 00) New Zealand 105 (30 to 1351) High-income Asia Pacific (40 22 to 65 4) Brunei 124 ( to 154) Japan (2 255 to 46 43) Singapore 1000 (6 to 126) South Korea 13 0 (10 0 to 1 53) Western Europe ( 45 to ) Andorra 21 (16 to 2) Austria 2614 (12 to 345) Belgium 34 (263 to 50) Cyprus 23 (16 to 303) Denmark 152 (11 to 201) Finland 163 (146 to 263) France 1 1 (14 to ) 2016 counts 2016 age-standardised rates (per ) 13 (11 to 16) 25 (20 to 31) 13 (11 to 16) ( to ) 12 ( to 16) 12 ( to 1) 25 (20 to 32) 26 (20 to 33) 25 (20 to 31) 31 (24 to 3) 26 (20 to 33) 23 (1 to 2) 23 (1 to 2) 23 (1 to 2) 25 (20 to 32) 32 (25 to 40) 25 (20 to 31) 26 (21 to 33) 2 (21 to 34) 26 (20 to 33) 26 (20 to 33) 2 (22 to 3) 30 (23 to 3) 2 (21 to 34) 2 (21 to 35) 32 (25 to 42) 2 (21 to 35) Percentage change in age-standardised 3 6 ( 4 to 4 0) 3 6 ( 6 to 0 5) 13 ( 1 to 10 0) 5 ( 0 to 11 ) 1 (4 2 to 54 0) 20 0 ( 33 2 to 10 1) 4 3 ( to 1 1) 2 ( 3 2 to 0) 2 5 ( 3 to 1 ) 16 5 ( 1 0 to 14 0) 3 ( 2 to 10 5) 2 2 ( 0 to 2 ) 1 3 ( 1 to 4 1) 6 4 ( 12 3 to 0 ) 6 ( 13 6 to 5 ) 13 ( 1 to ) 5 1 ( 10 0 to 1 0) 2 0 ( 2 5 to 6 5) 1 2 ( 21 3 to 12 3) 6 ( 10 to 3 5) 4 0 (1 4 to 6 ) 14 ( 1 0 to 10 3) 3 ( 3 3 to 10 2) 2 4 ( 0 to 1 ) 10 ( 15 6 to 6 0) 0 5 ( 4 3 to 5 4) 12 4 ( 1 1 to ) ( to ) ( to 53) ( to ) ( to ) ( to ) ( to ) 6 02 ( to ) ( to ) (2 545 to 34 52) 3 (35 to 416) ( to 2 1 1) ( to 25 20) ( to 21 1) ( to 41 61) ( to 1 6 5) 401 (3641 to 4463) ( to ) (36 21 to 43 5) ( to 52 12) ( to ) 34 (63 to 15) 310 ( 64 to 10 61) (110 2 to ) 060 (244 to ) 5 60 (52 20 to ) (5 41 to 0 664) ( to 02 3) 36 (340 to 40) 60 (6 to 2) 420 (3 to 46) 231 (21 to 246) 260 (233 to 31) 304 (220 to 51) 6 (13 to 46) 0 (650 to 61) 52 (65 to 11) 04 (644 to 5) 04 (646 to 56) 45 (62 to 11) 42 (6 to 0) 5 (65 to 2) 21 (4 to 0) 22 (40 to 1021) 24 (4 to 13) 5 ( to 6) 11 (3 to 4) 54 (0 to 45) 6 (05 to 5) 3 (53 to 1051) 0 (2 to 100) (03 to 4) 6 (3 to ) (4 to 104) 55 (1 to 43) 0 2 ( 2 1 to 2 ) 1 5 ( 3 1 to 0 1) 4 ( 6 4 to 3 3) 25 6 (23 4 to 2 0) 22 6 (1 5 to 2 1) 14 2 ( 1 to 25 5) 2 0 ( 3 6 to 0 6) 6 5 ( to 2 6) 0 5 ( 2 to 3 ) 2 1 ( 5 5 to 1 5) 3 ( 11 1 to 3 0) 3 3 ( 0 3 to 6 ) 3 ( 0 1 to ) 0 3 ( 3 5 to 5 4) 1 1 ( 1 3 to 3 ) 6 ( to 3 ) 5 0 (2 1 to ) 15 6 (10 5 to 21 3) 1 ( 11 6 to 4 4) 0 3 ( 1 6 to 2 5) 0 (3 3 to 10 ) 5 ( to 1 3) 3 (0 0 to ) 5 0 (1 6 to ) 5 1 (0 6 to 2) 11 3 ( 5 to 15 ) 5 5 ( to 1 ) (Table 2 continues on next page) Vol 1 January 201 6

13 (Continued from previous page) Germany (16 2 to 2 01) Greece 262 (2036 to 331) Iceland 4 (65 to 10) Ireland 1250 (64 to 1625) Israel 16 (1532 to 2513) Italy 16 ( to 21 03) Luxembourg 15 (121 to 206) Malta 10 (4 to 141) Netherlands 401 (3104 to 516) Norway 14 (113 to 11) Portugal 2425 (1 to 313) Spain (41 to ) Sweden 21 (203 to 3556) Switzerland 23 (13 to 3115) UK ( to 21 12) Southern Latin America (601 to ) Argentina 06 (642 to ) Chile 3362 (2662 to 426) Uruguay 6 (533 to 51) Central Europe, eastern Europe, and central Asia 2016 counts 2016 age-standardised rates (per ) 52 ( to 4 211) Eastern Europe (34 03 to 50 16) Belarus 2111 (11 to 25) Estonia 24 (201 to 304) Latvia 33 (310 to 40) Lithuania 653 (52 to ) Moldova 652 (53 to 6) Russia 2 61 ( to 35 5) 26 (20 to 33) 25 (20 to 32) 25 (20 to 32) 2 (21 to 35) 24 (1 to 30) 2 (21 to 34) 2 (20 to 34) 26 (21 to 34) 23 (1 to 2) 2 (21 to 35) 22 (1 to 2) 24 (1 to 31) 26 (20 to 34) 25 (20 to 33) 25 (1 to 32) 1 (15 to 23) 1 (15 to 23) 1 (14 to 23) 1 (15 to 23) 1 (15 to 22) 1 (16 to 23) 22 (1 to 26) 1 (15 to 23) 1 (15 to 23) 21 (1 to 26) 16 (13 to 1) 20 (16 to 24) Percentage change in age-standardised 5 6 ( 10 to 0 ) ( 13 to 5 ) 1 2 ( 5 6 to 3 2) 5 4 ( 0 to 10 ) 0 2 ( to 6 3) 6 0 ( to 1 ) 21 0 ( 25 3 to 16 ) ( 11 0 to 4 5) 3 0 ( 2 5 to 1) 0 5 ( 4 to 4 2) 23 3 ( 2 1 to 1 ) 6 4 ( 11 to 1 0) 2 ( 1 to 0) 2 3 ( 34 0 to 23 3) 0 4 ( 4 5 to 2 ) 6 (6 1 to 12 6) 10 3 (5 5 to 14 5) 4 (1 5 to 1) 14 6 (11 1 to 1 3) 5 2 ( 3 to 3 1) 4 2 ( 1 to 1 4) 14 2 (10 3 to 1 3) 1 0 ( 22 1 to 13 6) 20 4 ( 24 1 to 16 4) 3 ( 6 to 0 4) 15 ( 1 2 to 11 ) 4 1 ( to 0 ) 3 65 (6 21 to 21 4) ( to ) 313 (26 to 3465) ( to ) 3 63 (63 1 to 4 545) 65 ( to ) 525 (5240 to 6266) 444 (40 to 420) ( to ) (4 00 to 5 063) (5 56 to ) (42 50 to ) (2 140 to ) 465 (3 5 to 5 6) ( to 6 232) ( to 3 05) (22 to ) (6 1 to ) 1 45 (1 265 to ) ( to ) ( to ) (5 133 to 66 05) 31 (4 to 006) ( to ) 1 42 (1 014 to 20 00) 20 3 (1 342 to 22 6) 4 ( 56 to 0 26) 42 (65 to 3) 60 ( to 4) 64 (6 to 5) 61 (62 to 103) 13 (2 to 11) 3 (10 to ) 54 ( to 41) 05 (20 to 1003) 64 (02 to 33) 6 (5 to 2) 30 (61 to ) 41 (6 to 31) 03 (11 to 101) 0 (1 to 4) 33 (54 to 2) 54 (50 to 51) 556 (514 to 600) 534 (43 to 55) 534 (42 to 5) 513 (4 to 554) 510 (44 to 54) 56 (52 to 60) 54 (50 to 52) 516 (40 to 552) 50 (526 to 614) 45 (422 to 4) 514 (4 to 552) 3 0 ( 1 0 to 3) 3 ( 0 to 0 5) 6 (3 3 to 12 4) 13 3 ( to 1 4) 1 (10 6 to 32 3) 0 ( 2 to 4 ) 13 6 ( 16 to 10 1) 0 1 ( 4 0 to 3 3) (4 1 to 13 ) (5 5 to 14 3) 1 2 ( 22 0 to 14 4) 1 0 ( 2 to 5 ) 2 (2 to 11 4) 23 ( 2 0 to 1 ) 2 5 (0 2 to 4 ) 1 3 (15 6 to 23 5) 20 5 (15 to 26 0) 15 2 (11 2 to 1 2) 20 (16 5 to 26 4) 2 5 ( 0 1 to 0) 1 0 ( 3 to 2 ) 13 (10 1 to 1 6) 4 0 ( 6 to 0 4) 5 ( 12 1 to 6 6) 1 ( 2 1 to 5 5) 5 0 ( 0 to 0 3) 1 3 ( 4 to 3 1) (Table 2 continues on next page) 6 Vol 1 January 201

14 (Continued from previous page) Ukraine 45 (6532 to 53) Central Europe (1 365 to ) Albania 463 (36 to 56) Bosnia and Herzegovina 621 (4 to 2) Bulgaria 1331 (1055 to 1664) Croatia 4 (6 to 1101) Czech Republic 261 (2131 to 334) Hungary 2256 (15 to 263) Macedonia 350 (26 to 430) Montenegro 11 (4 to 144) Poland 501 (633 to 10 62) Romania 32 (3142 to 442) Serbia 1542 (1220 to 116) Slovakia 11 (3 to 14) Slovenia 605 (465 to ) Central Asia (62 to 13 1) Armenia 31 (312 to 456) Azerbaijan 1233 (1023 to 140) Georgia 514 (422 to 615) Kazakhstan 2 (2306 to 323) Kyrgyzstan 51 (625 to 1) Mongolia 46 (410 to 52) Tajikistan 1012 (36 to 1206) Turkmenistan 61 (55 to 2) Uzbekistan 331 (313 to 453) Latin America and Caribbean (36 1 to ) Central Latin America 16 5 (14 04 to 20 23) 2016 counts 2016 age-standardised rates (per ) 1 (15 to 21) 20 (16 to 25) 16 (13 to 20) 1 (14 to 21) 1 (15 to 23) 1 (15 to 22) 24 (20 to 30) 21 (16 to 26) 1 (14 to 21) 1 (15 to 23) 21 (1 to 26) 20 (16 to 25) 1 (14 to 22) 21 (1 to 26) 26 (20 to 33) 13 (11 to 16) 13 (11 to 15) 13 (10 to 15) 13 (11 to 15) 15 (13 to 1) 12 (10 to 15) 16 (13 to 1) 11 ( to 14) 12 (10 to 14) 12 (10 to 15) (6 to ) Percentage change in age-standardised 6 3 ( to 2 ) 3 3 ( 6 4 to 0 6) 10 4 (5 3 to 15 3) 32 5 (2 6 to 3 0) 6 1 ( 10 4 to 1 ) 3 ( to 2 2) 4 5 ( 10 0 to 1 1) 1 4 ( 22 5 to 12 ) 1 5 (12 to 21 ) 0 (4 to 11 4) 0 ( 3 6 to 5 0) 10 3 ( 15 0 to 5 ) 13 (10 3 to 1 4) 4 ( 13 1 to 5 5) 0 ( 6 to 3) 0 ( 3 1 to 1 4) 12 5 ( 16 5 to 6) 3 0 ( 6 3 to 0 4) 5 6 ( 2 to 2 0) 5 (1 to 10 0) 14 3 ( 1 to 10 ) 34 1 (1 4 to 44 4) 11 5 ( 15 0 to 1) 0 2 ( 3 4 to 3 ) 3 (0 3 to 6 ) 4 4 ( 6 to 1 1) 14 ( 1 to 11 6) ( to 26 36) ( to 1 1) (15 23 to 1 542) (25 24 to 4 144) (43 2 to 50 31) 2 54 ( to 34 50) 1 60 (4 06 to 44) (5 0 to 6 0) (11 0 to ) 352 (3633 to 4262) (24 2 to 2 5) 12 4 ( to ) (52 12 to 5 21) ( to 40 50) 1 63 (1 160 to 1 22) ( to 36 44) 1 21 (13 20 to 22 65) (3 3 to 4 65) 1 3 (15 04 to 20 31) 4 42 (6 35 to 13) 1 31 (1 264 to 21 22) ( to 12 43) (25 25 to 43 12) 1 2 (16 6 to 1 20) ( 144 to ) ( to ) (43 52 to ) 44 (451 to 51) 5 (54 to 653) 53 (40 to 622) 3 (56 to 10) 553 (503 to 5) 545 (42 to 64) 2 (662 to 1) 554 (504 to 603) 51 (40 to 56) 564 (515 to 612) 5 (543 to 641) 51 (525 to 61) 604 (51 to 61) 5 (53 to 63) 32 (60 to 5) 31 (361 to 425) 51 (41 to 6) 40 (36 to 46) 35 (355 to 464) 41 (31 to 450) 354 (32 to 3) 405 (3 to 434) 416 (346 to 56) 344 (31 to 36) 355 (330 to 33) 222 (206 to 23) 1 (11 to 216) 2 6 ( 6 3 to 1 ) 12 1 ( to 1 ) 20 0 (11 to 36 ) 1 (50 to 14 2) 0 0 ( 3 to 3 5) 13 6 ( 0 4 to 46 6) 1 1 (14 6 to 24 6) 4 1 ( 0 6 to 5) 21 (16 to 2 2) 11 6 ( 2 to 15 ) 15 1 (11 2 to 1 5) 5 5 ( 3 to 2 0) 36 (20 to 2 ) 5 (2 1 to 4) 14 5 (10 3 to 1 ) 5 4 (1 to 12 0) 15 ( 23 6 to 2) 14 1 (5 to 30 ) 4 3 ( 4 5 to 22 4) 5 (4 5 to 10 ) 6 ( 11 4 to 2 0) 3 1 (34 1 to 44 5) 20 (2 2 to 63 ) 0 (4 to 11 4) 0 (5 2 to 11 0) 1 2 ( 1 1 to 4 3) 5 2 ( 4 to 2 ) (Table 2 continues on next page) Vol 1 January 201 6

15 (Continued from previous page) Colombia 3224 (2631 to 36) Costa Rica 34 (25 to 421) El Salvador 43 (35 to 52) Guatemala 1134 (3 to 1355) Honduras 511 (420 to 615) Mexico 221 (610 to 5) Nicaragua 34 (30 to 44) Panama 25 (234 to 345) Venezuela 2424 (15 to 22) Andean Latin America 400 (410 to 540) Bolivia 5 (1 to 1002) Ecuador 1553 (124 to 14) Peru 24 (205 to 213) Caribbean 34 (3111 to 444) Antigua and Barbuda (6 to ) The Bahamas 30 (25 to 36) Barbados 20 (16 to 23) Belize 2 (24 to 34) Bermuda 5 (4 to 6) Cuba 1054 (53 to 1310) Dominica 5 (4 to 6) Dominican Republic 0 (636 to 20) Grenada Guyana 5 (4 to 0) Haiti 3 (4 to 110) Jamaica 14 (161 to 230) Puerto Rico 31 (260 to 36) Saint Lucia 13 (11 to 15) 2016 counts 2016 age-standardised rates (per ) (6 to ) (6 to ) (6 to ) 6 (5 to ) ( to ) 10 ( to 12) ( to ) ( to ) (6 to ) ( to ) (6 to ) ( to 11) (6 to ) Percentage change in age-standardised 12 6 ( 1 0 to ) 16 2 (12 2 to 20 2) 22 1 ( 4 3 to 0 6) 3 5 ( 30 6 to 12 3) 2 (23 4 to 36 ) 23 ( 26 6 to 20 ) 0 ( 4 to 5 ) 14 (10 to 1 ) 11 0 (6 5 to 16 1) 2 1 ( 12 2 to 5 5) ( 12 to 6 6) 23 ( to 53 4) 11 5 ( 25 3 to 1 5) 22 1 (16 4 to 30 ) 11 6 ( 5 to 15 0) 6 6 (3 2 to 10 0) 16 (14 1 to 1 ) 1 2 ( 0 to 2 1) 2 5 ( 5 to 0 ) 15 2 ( 3 to 21 0) 2 6 (24 2 to 31 1) 26 2 (22 2 to 30 4) 24 6 (20 to 2 5) 5 (5 to 13 4) 31 2 (10 5 to 65 2) 31 0 (2 0 to 35 2) 22 4 (1 3 to 2 ) 16 6 (13 3 to 1 ) (3 11 to ) (631 to ) (11 6 to 2 532) ( to 36 40) (12 2 to 16 ) ( to ) ( to 23 65) 224 (5 to 2) 6 61 (62 42 to 3 6) (124 0 to ) (1 34 to ) (33 4 to 3 41) 6 5 (0 42 to 4 1) ( 20 to ) 220 (203 to 23) 06 (42 to 2) 662 (616 to 0) 11 (65 to 0) 14 (161 to 16) (2 03 to ) 15 (145 to 10) (20 42 to 23 53) 230 (212 to 24) 1433 (1336 to 152) 3 4 (1 to 2 460) 533 (530 to 614) 65 (034 to 10 34) 406 (3 to 436) 210 (12 to 230) 20 (12 to 226) 22 (202 to 41) 20 (1 to 2) 13 (16 to 22) 1 (165 to 10) 260 (10 to 421) 212 (16 to 22) 223 (20 to 242) 241 (224 to 262) 21 (202 to 236) 236 (220 to 255) 251 (231 to 2) 263 (216 to 341) 232 (215 to 250) 220 (204 to 236) 212 (1 to 22) 212 (1 to 22) 241 (223 to 25) 236 (21 to 255) 20 (12 to 224) 220 (204 to 236) 220 (204 to 23) 11 (1 to 203) 31 (1 to 1) 202 (1 to 216) 23 (222 to 256) 213 (1 to 22) 4 6 (0 4 to 10 4) 25 0 (21 to 2 1) 10 6 ( 22 4 to 4 ) 6 4 ( 6 to 1 6) 4 5 (33 4 to 3 ) 1 0 ( 1 5 to 14 2) 11 3 ( 23 4 to 3 2) 21 (1 5 to 24 ) 20 (16 5 to 2 3) 10 6 ( to 14 3) 6 5 (3 to 4) 11 6 ( 2 to 14 4) 11 3 ( 1 to 16 6) 4 (24 2 to 4 0) 15 6 (12 0 to 1 6) 15 (12 2 to 1 3) 20 4 (16 to 25 3) 23 6 (1 2 to 2 ) 15 (12 3 to 1 4) 1 (13 to 23 3) 31 1 (26 0 to 3 3) 33 (2 5 to 40 6) 24 (20 to 2 5) 16 6 (13 2 to 1 ) 1 3 (3 to 41 ) 30 1 (26 0 to 35 4) 2 (25 2 to 33 2) 24 3 (21 1 to 2 1) (Table 2 continues on next page) 0 Vol 1 January 201

16 (Continued from previous page) Saint Vincent and the Grenadines Suriname 41 (35 to 4) Trinidad and Tobago (1 to 11) Virgin Islands Tropical Latin America (15 54 to 22 05) Brazil ( to ) Paraguay 503 (413 to 606) Southeast Asia, east Asia, and Oceania 2016 counts 2016 age-standardised rates (per ) 14 6 ( to 1 266) East Asia (4 5 to 122 1) China 226 (1 6 to ) North Korea 16 (1466 to 2124) Taiwan (province of China) 1650 (136 to 1) Southeast Asia (3 40 to 54 20) Cambodia 1020 (60 to 1206) Indonesia (13 2 to 1 4) Laos 444 (3 to 52) Malaysia 2304 (120 to 2) Maldives 20 (1 to 23) Mauritius 1 (6 to 6) Myanmar 336 (24 to 316) Philippines 21 (6314 to ) Sri Lanka 153 (1350 to 15) Seychelles Thailand 550 (4550 to 644) Timor-Leste 6 (5 to 1) Vietnam 651 (5510 to 44) ( to ) ( to ) ( to 11) ( to 11) (5 to ) (6 to ) (6 to ) (6 to ) 6 (5 to ) 6 (5 to 6) (6 to ) 6 (5 to ) (6 to 10) ( to ) ( to ) 6 (5 to ) (6 to ) Percentage change in age-standardised 20 4 (15 to 25 1) 20 2 (16 6 to 24 3) 12 ( 1 to 21 ) 13 3 (10 2 to 16 ) 0 4 ( 4 0 to 5 0) 0 1 ( 4 6 to 4 5) 2 4 (24 0 to 33 4) ( 0 1 to 1 5) 10 0 (0 2 to 1 6) 3 ( 0 5 to 1 1) 44 4 (33 1 to 5 ) 21 6 (14 to 2 ) 6 4 ( 11 2 to 1 2) 13 ( 4 to 1 1) 14 1 ( to 1 3) 26 ( 60 to 11 5) 23 2 (1 0 to 2 5) 0 ( 4 6 to 3 1) 30 3 (25 0 to 36 4) 25 6 (14 to 34 3) 5 ( 10 6 to 24 ) 63 ( 4 1 to 23 6) 24 (20 1 to 31 0) 16 5 (11 1 to 22 3) 0 0 ( 0 to 25 0) 36 (30 to 43 2) 242 (224 to 25) 110 (102 to 123) 316 (263 to 3403) 254 (236 to 23) ( to 556 ) 50 5 ( to ) ( to 14 41) ( to ) ( to ) ( to ) 4 16 ( to 52 10) 62 (5 405 to 66 4) ( to ) 4 3 (2 31 to ) (4 33 to ) (31 to 10 1) ( to 4 66) 632 (55 to 6) 266 (26 to 3052) 13 5 ( to 13 3) (1 6 to ) (61 40 to ) 225 (211 to 240) (15 0 to 1 225) 56 (2514 to 13 52) ( to 20 22) 216 (201 to 231) 216 (201 to 233) 21 (203 to 234) 21 (200 to 233) 235 (21 to 251) 235 (21 to 252) 216 (1 to 235) 234 (21 to 251) 236 (222 to 250) 23 (223 to 251) 1 (16 to 10) 22 (213 to 242) 22 (204 to 21) 3 (212 to 20) 205 (1 to 22) 164 (153 to 1) 22 (216 to 243) 14 (11 to 16) 206 (14 to 220) 256 (203 to 343) 21 (10 to 2) 435 (26 to 3) 223 (20 to 23) 23 (226 to 254) 6 (20 to 165) 204 (12 to 21) 22 0 (1 6 to 2 ) 21 (15 to 26 5) 31 (2 2 to 3 ) 16 (13 3 to 20 ) 2 4 ( 4 to 0 0) 2 ( 5 3 to 0 4) 20 0 (15 6 to 24 0) 32 3 (2 6 to 36 2) 30 (2 4 to 34 0) 30 6 (2 3 to 33 ) 35 0 (31 to 3 6) 2 3 (25 6 to 33 ) 3 3 (26 to 4 ) 15 ( 2 5 to 1 0) 33 2 (21 5 to 44 5) 4 (42 to 53 3) 33 2 (30 6 to 35 ) 30 (2 0 to 35 4) 41 (3 to 46 3) 6 4 (31 5 to 124 ) 2 6 (12 3 to 3 ) 3 5 (4 to 161 0) 35 5 (2 2 to 40 3) 2 4 (26 3 to 33 2) 41 3 (21 3 to 65 ) 52 0 (4 1 to 55 ) (Table 2 continues on next page) Vol 1 January 201 1

17 (Continued from previous page) Oceania 3 (62 to 41) American Samoa 6 (5 to ) Federated States of Micronesia (6 to ) Fiji 56 (4 to 66) Guam 14 (12 to 1) Kiribati Marshall Islands 5 (4 to 6) Northern Mariana Islands 10 ( to 12) Papua New Guinea 562 (46 to 66) Samoa 14 (11 to 16) Solomon Islands 41 (34 to 4) Tonga Vanuatu 1 (16 to 22) North Africa and Middle East (60 12 to ) Afghanistan (4044 to 3 406) Algeria 324 (25 to 345) Bahrain 122 (104 to 145) Egypt 43 (626 to 12) Iran 332 (616 to 63) Iraq (5613 to 4 04) Jordan 1204 (663 to 2460) Kuwait 365 (30 to 42) Lebanon 66 (44 to 115) Libya 126 (55 to 3231) Morocco 2466 (204 to 26) Oman 461 (31 to 55) Palestine 504 (400 to 66) 2016 counts 2016 age-standardised rates (per ) ( to ) (6 to ) (6 to ) 6 (5 to ) (6 to ) (6 to ) (6 to ) (6 to ) (6 to ) 1 (10 to 40) 3 (11 to 101) ( to 11) ( to 11) 3 (13 to 105) 14 ( to 30) 10 ( to 11) 12 ( to 21) 20 (10 to 51) 10 ( to 12) ( to 11) Percentage change in age-standardised 12 5 ( 1 5 to 21 ) 6 2 (2 5 to 10 0) 1 2 (15 2 to 24 0) 2 3 (24 6 to 35 0) 24 (20 1 to 2 ) 32 5 (2 6 to 3 ) 21 3 (16 to 26 6) 6 (3 to 10 1) 1 ( 5 to 1 ) 1 4 (14 3 to 23 1) 22 3 (1 to 2 0) 14 1 ( to 1 ) 2 2 (22 1 to 33 1) 6 6 (1 2 to 21 0) 16 ( 1 1 to 410 1) 5 4 ( to 2 ) 3 ( 5 to 0 1) 24 4 (16 5 to 43 ) 56 2 ( 6 0 to 21 2) 236 (25 5 to 01 4) 6 3 ( 2 to 246 ) 64 1 ( 6 5 to 1 1) 6 ( 2 0 to 3 3) (1 to 512 5) 1 6 ( 0 to 1 ) 3 3 ( 0 to 0 1) 24 3 ( 53 6 to 5) 1 4 (16 22 to 1 6) 12 (15 to 16) 161 (150 to 12) 1533 (1431 to 1641) 40 (34 to 434) 160 (14 to 14) 10 (101 to 116) 2 (26 to 30) 11 1 (10 34 to ) 344 (31 to 3) 56 (4 to 1) 15 (163 to 16) 406 (34 to 444) (1 5 2 to ) ( to 65 33) (6 415 to 124 5) 4500 (416 to 42) (14 4 to 225 6) 3 04 (25 to 23 2) 3 20 ( to ) 16 (15 6 to 1 34) 13 ( to 16 10) 1 54 ( to ) (1 3 to 25) 2 36 (6 645 to 66) (13 56 to ) 21 (11 2 to 4 6) 12 (160 to 14) 22 (214 to 24) 10 (160 to 11) 14 (163 to 16) 233 (21 to 24) 152 (141 to 16) 160 (150 to 10) 23 (224 to 253) 16 (156 to 11) 1 (15 to 21) 164 (153 to 15) 14 (13 to 15) 166 (153 to 12) 44 (2 to 43) 136 (32 to 35) 26 (252 to 31) 30 (2 to 331) 234 (215 to 263) 42 (322 to 6) 1331 (4 to 351) 24 (230 to 265) 342 (314 to 36) 150 (56 to 4363) 51 (313 to 120) 242 (226 to 261) 312 (23 to 335) 613 (304 to 1432) 3 6 (35 0 to 46 2) 1 (14 to 2 4) 2 6 (23 6 to 32 ) 36 (34 1 to 3 5) 2 (23 to 33 0) 50 0 (43 to 63 0) 20 (1 0 to 23 3) 5 (6 1 to 11 ) 44 (3 to 54 0) 36 1 (30 0 to 45 ) 30 (2 to 34 0) 24 5 (22 0 to 2 1) 3 2 (34 0 to 43 ) 4 1 ( 3 2 to 13 1) 15 ( 26 0 to 35 3) 12 5 (5 3 to 2 ) 13 1 ( to 16 ) 24 0 (1 to 2 4) 1 4 ( 26 to 3 6) ( 1 3 to 14 3) 2 5 ( 6 0 to 2 6) 5 (2 0 to 13 5) 26 3 ( 31 to 13 0) (14 6 to 23 ) (5 to 13 2) 5 3 (2 6 to 2) 13 0 ( 22 5 to ) (Table 2 continues on next page) 2 Vol 1 January 201

18 (Continued from previous page) Qatar 265 (21 to 320) Saudi Arabia 24 (24 to 346) Sudan 424 (3005 to 65) Syria 2 62 (50 to 0 3) Tunisia 66 (0 to 113) Turkey 321 (531 to 464) United Arab Emirates 1051 (0 to 1261) Yemen (461 to 3 003) South Asia ( to 213 5) Bangladesh ( to 1 30) Bhutan 1 (6 to 6) India ( to 10 1) Nepal 20 (2421 to 330) Pakistan 1 02 ( to ) Sub-Saharan Africa 2 30 (0 0 to 12) Southern sub-saharan Africa 615 (514 to 421) Botswana 10 (15 to 22) eswatini 113 (4 to 135) Lesotho 11 (143 to 203) Namibia 15 (155 to 21) South Africa 4444 (302 to 536) Zimbabwe 104 (20 to 126) Western sub-saharan Africa (2 312 to 3 50) Benin 06 (6 to 106) Burkina Faso 1512 (125 to 1) Cameroon 205 (121 to 244) Cape Verde 45 (3 to 52) 2016 counts 2016 age-standardised rates (per ) 11 (10 to 14) ( to 11) 10 ( to 16) 136 (25 to 441) ( to 11) ( to 12) 11 ( to 13) 42 (15 to 111) 11 (10 to 13) ( to 11) 11 ( to 13) 12 (10 to 14) 10 ( to 12) 10 ( to 12) (6 to ) ( to 11) Percentage change in age-standardised 3 5 ( 6 1 to 0 ) 13 6 ( 16 2 to 10 ) 0 ( 13 6 to 31 ) 1 0 (264 0 to 64 ) 1 (2 4 to 25 4) 6 6 ( 16 3 to 15 1) 6 ( to 4 6) 40 (4 to ) 2 1 ( 5 to 1 5) 5 (1 6 to 10 5) 0 3 ( 2 4 to 3 0) 4 2 ( 4 to 0 4) 0 1 ( 3 0 to 3 6) 14 1 (10 3 to 1 3) 30 4 ( 52 to 12 0) 21 0 ( 36 3 to 12 2) 12 6 ( 2 to 16 6) 13 2 ( to 16 6) 1 4 (13 to 22 6) 0 4 ( 1 to 2 5) 26 5 ( 42 to 16 0) 2 ( 0 4 to 5 ) 6 ( 14 1 to 2 5) 1 ( 0 to 4 6) 2 6 ( 5 6 to 1 3) 6 1 (0 to 1 1) 4 (6 1 to 12 ) 5 (206 to 463) 05 (3 54 to 4 4) 103 ( 40 to ) 15 4 ( to ) (2 02 to 33 1) (212 0 to ) ( to 3 61) 5 00 ( to 12 30) (3 5 6 to ) 36 2 ( to 405 ) 2043 (113 to 212) ( to ) 6 21 (62 55 to 2) ( to 42 53) ( to ) ( to 151 6) 42 (4000 to 455) 163 (126 to 2104) 26 (254 to 25) 3 (36 to 422) ( 61 to ) (1 025 to 21 00) (5 26 to ) (15 34 to 1 325) (24 44 to 2 52) ( to 3 021) 110 (102 to 11) 35 (351 to 3) 21 (24 to 30) 2 (22 to 4) 3 (36 to 204) 26 (24 to 20) 2 (265 to 321) 33 (315 to 360) 314 (235 to 50) 256 (242 to 22) 244 (226 to 20) 26 (25 to 25) 25 (243 to 22) 260 (236 to 23) 255 (23 to 24) 232 (14 to 31) 11 (1 to 20) 15 (13 to 206) 163 (153 to 13) 132 (125 to 141) 15 (163 to 16) 206 (11 to 22) 140 (131 to 14) 202 (16 to 226) 1 (15 to 200) 1 (16 to 10) 1 (166 to 12) 225 (210 to 23) 3 3 (0 to 5 ) 2 ( 10 2 to 5 ) 2 4 (20 2 to 3 1) 22 (1 6 to 45 6) 13 (10 0 to 1 ) 1 ( 6 to 1) 3 1 ( 5 to 0 3) 20 1 ( 0 to 3 6) 20 3 (1 3 to 22 ) 35 (2 to 44 2) 26 6 (23 0 to 31 1) 1 5 (16 0 to 1 0) 3 (2 to 56 2) 30 0 (24 4 to 3 ) 12 6 (6 2 to 24 2) 13 5 ( 15 to 11 1) (6 to 10 ) 6 5 ( 3 to 4 6) 10 6 ( 12 to ) 5 5 (3 2 to 0) 16 4 ( 1 to 13 6) 0 4 ( 1 2 to 2 0) 10 1 (6 0 to 1 1) 5 4 (3 1 to 6) 11 1 ( 6 to 13 2) 1 5 ( 4 2 to 1 ) 16 6 (14 2 to 1 1) (Table 2 continues on next page) Vol 1 January 201 3

19 (Continued from previous page) Chad 122 (103 to 143) Côte d Ivoire 16 (166 to 22) The Gambia 15 (132 to 14) Ghana 2301 (153 to 260) Guinea 3 (22 to 1 133) Guinea-Bissau 15 (132 to 13) Liberia 324 (25 to 3) Mali 142 (1206 to 16) Mauritania 326 (25 to 32) Niger 1545 (130 to 125) Nigeria ( to 1 530) São Tomé and Príncipe 1 (15 to 21) Senegal 1215 (102 to 141) Sierra Leone 4 (421 to 52) Togo 555 (46 to 64) Eastern sub-saharan Africa 33 1 (2 1 to 3 3) Burundi 1045 ( to 1240) Comoros 63 (53 to 5) Djibouti (3 to 102) Eritrea 454 (33 to 532) Ethiopia 60 (2 to 10 13) Kenya 3 (3363 to 4640) Madagascar 143 (1630 to 220) Malawi 120 (100 to 1504) Mozambique 2341 (12 to 24) Rwanda 0 (61 to 106) Somalia 10 (5 to 343) 2016 counts 2016 age-standardised rates (per ) ( to 11) ( to ) ( to ) ( to ) ( to 11) ( to 11) ( to ) ( to 11) 10 ( to 11) ( to 11) ( to 11) ( to 11) ( to 11) ( to ) 16 (10 to 31) Percentage change in age-standardised 32 0 ( 61 0 to 2 6) 4 6 ( 1 to 1 ) 2 ( 10 1 to 6 3) 10 5 ( 0 to 13 0) 6 ( 1 to 4 4) 5 ( 10 4 to 6 ) 5 ( 4 6 to 5 ) 12 4 ( 23 3 to 5 ) 31 1 ( 5 6 to 6) 15 3 ( 24 to 5) 3 0 ( 2 to 16 5) 4 0 (1 4 to 6 5) 3 2 ( 5 to 0 4) 5 2 ( 4 to 2 ) 2 3 ( 4 to 0 2) 4 2 ( 1 0 to 20 4) 3 1 ( 0 6 to 10 1) 20 3 ( 22 5 to 1 1) 24 4 ( 4 3 to ) 3 4 ( 6 2 to 0 4) 5 0 ( to 44 2) 3 (5 to ) 5 0 ( to 2 0) 13 4 ( 15 to 10 ) 24 0 ( 53 to 0 4) 5 4 ( to 30 3) 21 3 ( 2 to 11 ) ( to 35 ) (33 3 to 3 550) 301 (200 to 341) ( to 50 03) (16 1 to 1 621) 26 (262 to 320) (51 to 24 4) 2 2 ( to 3 3) 511 (663 to 060) ( to 2 ) ( to 33 06) 363 (336 to 3) (21 61 to ) (10 05 to 23 41) (2 to ) 04 6 ( to ) (1 445 to 46 50) 134 (125 to 145) 10 (154 to 210) 13 0 (461 to 21 6) ( to ) ( 3 to 234) (33 3 to 3 54) (1 63 to 23 1) (41 2 to ) 5 43 (32 2 to ) 2 54 (1 50 to ) 24 (14 to 36) 16 (13 to 201) 16 (1 to 226) 16 (13 to 20) 10 (15 to 13) 1 (162 to 202) 33 (203 to 6) 211 (16 to 22) 220 (205 to 235) 16 (15 to 12) 210 (14 to 22) 231 (216 to 246) 11 (1 to 205) 263 (1 to 451) 10 (15 to 12) 24 (206 to 441) 311 (216 to 553) 212 (1 to 226) 230 (212 to 255) 301 (21 to 506) 2 (213 to 44) 215 (201 to 22) 1 (166 to 10) 146 (136 to 156) 30 (1 to 55) 31 (346 to 2464) 32 (20 to 63) 1 3 ( 5 to 2) 1 ( 1 2 to 6 ) 6 ( 11 to 3 2) 1 4 (15 to 23 3) 5 5 ( 5 to 1 0) 4 0 ( 2 2 to 1 3) 5 (15 to 1 6) 2 0 (10 1 to ) 14 2 (12 0 to 16 6) 2 5 ( 5 1 to 1 0) 11 0 ( 2 to 1 3) (5 4 to 10 1) 5 4 (2 3 to ) 51 0 ( 2 to 154 5) 1 6 ( 4 1 to 1 ) 20 4 (13 0 to 33 0) 10 2 (43 3 to 26 0) 10 ( to 14 ) 2 ( 1 to 12 1) 0 4 (2 to 1 0) 13 0 (6 0 to 1 5) 1 2 (15 4 to 1 ) 2 4 ( 0 3 to 5 5) 4 ( 5 to 1 ) 1 ( 2 to 0 3) (106 2 to ) 33 3 (6 to 1 ) (Table 2 continues on next page) 4 Vol 1 January 201

20 (Continued from previous page) South Sudan 1455 (115 to 135) Tanzania 454 (33 to 5363) Uganda 3215 (200 to 34) Zambia 14 (1252 to 14) Central sub-saharan Africa (43 to 11 1) Angola 2361 (1 to 25) Central African Republic 434 (34 to 551) Congo (Brazzaville) 426 (360 to 50) Democratic Republic of the Congo 2016 counts 2016 age-standardised rates (per ) 656 (5542 to ) Equatorial Guinea 1 (6 to 4) Gabon 163 (13 to 11) 5% uncertainty intervals are in parentheses. SDI=Socio-demographic Index. 11 ( to 14) 10 ( to 11) ( to 11) 10 ( to 11) ( to 11) ( to 11) 10 ( to 12) 10 ( to 11) Percentage change in age-standardised 5 4 ( 6 to 21 2) 4 2 ( 6 3 to 2 1) 11 ( 2 0 to 1 6) 2 5 ( 2 1 to 5 ) 14 3 ( 2 1 to 5 ) 3 2 ( 66 2 to ) 14 (3 2 to 42 3) 0 5 ( 3 to 5 ) 4 5 ( 3 to 0 3) 11 (6 6 to 16 5) 10 ( 12 to ) (23 5 to 66 34) ( 11 to 1 04) 6 06 (5 55 to ) (22 13 to ) (1 254 to ) 5 30 ( to 5 5) 061 (6335 to ) (420 to 1 31) ( to 11 0) 16 (154 to 105) 3464 (321 to 320) 35 (230 to 66) 12 (1 to 205) 22 (12 to 540) 10 (16 to 12) 243 (14 to 35) 33 (234 to 53) 11 (13 to 24) 302 (21 to 516) 216 (11 to 26) 234 (21 to 24) 225 (211 to 240) 35 6 (2 6 to 0) 6 (4 5 to 2) 5 ( 24 3 to 23 6) 2 (0 3 to 4 ) 22 1 (11 0 to 42 6) 5 2 ( 3 to 23 ) 32 ( 6 to 3 0) 1 (31 0 to 20 4) 2 6 ( 5 to 4 1) 53 4 (4 to 5 2) 3 6 (1 6 to 5 ) Table 2: and prevalence of spinal cord injury in 2016, and percentage change in age-standardised rates by location, injury ie, these conditions previously had been measured as consequences of causes of injury. For example, a cause, such as a fall, could lead to SCI. Historically falls have been measured and reported but the actual nature of injury (eg, TBI, ankle fracture) that occurred because of the fall has not been directly reported. This aspect of the GBD study design was consistent across other natures of injuries. Second, estimation of TBI and SCI deviated from the GBD study framework in terms of the measures that were reported for the conditions, because we do not estimate death from TBI or SCI. Although TBI and SCI can lead to death, they were not considered causes of death in the GBD 2016 framework. Instead, the cause of injury (eg, falls) that led to a nature of injury such as TBI was considered the cause of death. For example, an individual who had a fall, sustained a TBI, and then died while in hospital after the injury would be considered to have had a death caused by a fall and an incident TBI. In this study, we estimated the non-fatal burden and therefore report incidence, pre valence, and YLDs, but not cause-specific mortality or years of life lost. Cause-of-injury estimation The process for estimation of incidence, prevalence, and YLDs was as follows. First, the incidence of 2 dif - ferent causes of injury (appendix 1) were modelled with DisMod-MR 2.1, a meta-regression tool that was used extensively throughout the GBD study. 3 These cause-of-injury models measured the incidence of each cause of injury that required medical care, which included patients who were admitted or seen in an outpatient clinic and received a diagnosis code for a given cause of injury. Receiving an injury diagnosis code did not preclude the possibility of death in the hospital or after discharge. Each of these cause models used an array of data types, including surveillance studies, literature studies, hospital discharge records, and emergency de partment records. The details of these models have previously been described in more detail. 3 Although we do not estimate death from TBI or SCI in this study, our modelling strategy also included cause-specific mortality rates from the cause of death ensemble model to inform incidence estimates for causeof-injury models such as road injuries in data-sparse areas using estimates from data-rich areas. 1 The outputs from these models were estimates of inpatient (admitted) and outpatient incidence rates of causes of injury and were specific for location, sex, age, and year. The outpatient incidence of each cause was derived from the inpatient incidence on the basis of a regression coefficient for outpatient incidence that was extracted from DisMod-MR 2.1 incidence models in locations that had both inpatient and outpatient data. Nature-of-injury estimation Clinical record data that coded for both cause and nature of injury were used to estimate the proportion of each cause Vol 1 January 201 5

21 Age-standardised incidence (per ) ATG VCT Barbados Comoros West Africa Eastern Mediterranean Marshall Isl Solomon Isl Kiribati FSM Dominica Grenada Maldives Mauritius Malta Vanuatu Samoa Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga Figure 1: Age-standardised incidence of traumatic brain injury per population by location for both sexes, 2016 ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. Isl=Islands. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. that resulted in each nature of injury. If an injury cause resulted in more than one nature of injury, the most severe was chosen on the basis of a mixed-effects regression model that estimated the disability ex perienced by an injured individual adjusted for age, sex, and never-injured status, with country and individual random effects. Because SCI was associated with higher disability than TBI (appendix 1), SCI was chosen if both conditions occurred as a result of the same injury. We used this method after finding in a previous GBD study 1 that statistically assigning multiple injury categories to a single individual was difficult because of a sparsity of data. This process and the severity rankings are de scribed in more detail in appendix 1. These proportions were calculated for each external cause-of-injury nature-of-injury (cause nature) combination, such that the proportions of all natures of injury for a given cause of injury sum to 1 because of a Dirichlet regression. The output from this step was incidence for each cause nature combination. Derivation of incidence, prevalence, and YLDs From the incidence estimates for each cause nature combination, we separately modelled short-term and longterm estimates using proportions of individuals expected to experience short-term versus long-term disability (the cutoff for long-term disability was 1 year). The proportions estimated to experience permanent health loss generally increased with age and were different for TBI and SCI (appendix 1). The short-term prevalence estimates were then calculated on the basis of average duration of a shortterm case, whereas the long-term estimates were considered to be permanent and underwent comorbidity adjustment as described pre viously. 3 Cause nature incidence rates were converted to prevalence with the differential equation solver used in DisMod-MR 2.1. This solver reconciled the incidence rates from the previous steps with standardised mortality ratios derived from literature studies to estimate prevalence, because people with long-term disability due to TBI and SCI die at a higher rate than the background mortality in the population. 20 The final output from this step was prevalence of each cause nature combination for each location, year, age, and sex combination. YLDs were then calculated by multiplying the prevalence by the disability weight. Measurement has been described in more detail previously, but in summary, disability weights were measured through population and internet surveys on the basis of lay descriptions of disabling conditions. 21 For example, the disability weight for short-term mild TBI and for short-term moderate or severe TBI were (5% uncertainty interval [UI] ) and ( ), respectively, 6 Vol 1 January 201

22 Age-standardised incidence (per ) ATG VCT Barbados Comoros West Africa Eastern Mediterranean Marshall Isl Solomon Isl Kiribati FSM Dominica Grenada Maldives Mauritius Malta Vanuatu Samoa Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga Figure 2: Age-standardised incidence of spinal cord injury per population by location for both sexes, 2016 ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. Isl=Islands. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. meaning that the affected people experienced health losses of 11 0% and 21 4%, respectively, compared with a person in full health. All disability weights for different severities of TBI and SCI are provided in appendix 1. After estimation of YLDs, the prevalence, incidence, and YLDs for TBI and SCI were then summed across all causes to estimate the all-injury prevalence, incidence, and YLDs for TBI and SCI separately. Uncertainty was propagated throughout this process by maintaining distributions of 1000 draws for each estimation stage (including percentage change over time). We use the 25th and 5th sorted values in the draw distributions as the upper and lower UIs for mean estimates and for percentage change, whereby change was judged to be significant if the lower and upper UIs did not overlap zero. This process is consistent with management of uncertainty throughout the GBD study framework. 3 Statistical analysis We grouped countries into quintiles on the basis of their 2016 Socio-demographic Index (SDI) value, which is a composite measure of development derived from income per person, educational attainment, and total fertility rate. 1 Additionally, we measured the most common causes of TBI and SCI separately in terms of the original cause of injury that led to the disability. Finally, we measured the proportion of TBI that was mild versus the proportion that was moderate or severe and the proportion of SCI that occurred at the neck versus below the neck and present these values at the global level. Analyses were done in Python (version 2.), Stata (version 13.1), and R (version 3.3). Statistical code used for this study will be made available upon publication of this Article via the Institute for Health Metrics and Evaluation. This study complies with the Guidelines for Accurate and Transparent Health Estimates Report (GATHER) recommendations (appendix 1). Role of the funding source The funder of the study had no role in study design, data collection, data analysis, data interpretation, or the writing of the report. All authors had full access to the data in the study and had final responsibility for the decision to submit for publication. Results We used incidence data for every cause of injury and every GBD region. The number of sources by injury and by region are in appendix 1., prevalence, and YLD estimates for every cause of injury by age, sex, and location for are available through an online results tool. For the statistical code used for this study see org For the online results tool see Vol 1 January 201

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