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, 201 http://dx.doi.org/10.1016/ S144-4422(1)30415-0 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] 24 30 30 30 million) new cases of TBI and 0 3 million (0 1 16 million) new cases of SCI, with age-standardised incidence rates of 36 (331 412) per 100 000 population for TBI and 13 (11 16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55 50 million (53 40 5 62 million) and of SCI was 2 04 million (24 30 15 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 6 0 10 4 million) YLDs and SCI caused 5 million (6 12 4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (2 141) per 100 000 for TBI and 130 (0 10) per 100 000 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 www.thelancet.com/neurology Vol 1 January 201
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 2016. 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, 2016. 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 2016. 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 http://ghdx. 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. 6 12 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 www.thelancet.com/neurology Vol 1 January 201 5
Global 2 02 033 (24 302 01 to 30 2 10) High SDI 3 62 26 (3 112 645 to 4 34 060) High-middle SDI 5 550 132 (4 125 to 6 205 225) Middle SDI 2 05 (6 50 600 to 046 104) Low-middle SDI 04 1 ( 244 54 to 6 510) Low SDI 2 60 230 (2 21 622 to 2 64) High income 3 24 60 (2 36 20 to 3 5 32) High-income North America 1 221 44 (1 01 14 to 1 45 250) Canada 110 332 (2 166 to 133 51) Greenland 161 (133 to 1) USA 1 110 5 (2 14 to 1 340 515) Australasia 554 (65 10 to 3 41) Australia 66 020 (55 30 to 5) New Zealand 12 535 (10 560 to 14 4) High-income Asia Pacific 563 53 (41 6 to 61 62) Brunei 1535 (1306 to 11) Japan 32 54 (31 505 to 46 002) Singapore 11 13 (34 to 13 3) South Korea 16 56 (141 4 to 1 2) Western Europe 1 262 00 (1 042 41 to 1 546 0) Andorra 236 (14 to 22) Austria 2 255 (23 166 to 35 10) Belgium 41 126 (33 4 to 51 024) Cyprus 25 (2503 to 3516) Denmark 1 302 (14 20 to 21 444) 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) 55 45 64 (53 400 54 to 5 626 214) 463 13 ( 121 26 to 1 355) 13 45 443 (12 51 56 to 13 3 353) 16 45 1 (16 12 44 to 1 364 25) 13 524 22 (12 1 6 to 14 124 365) 3 506 60 (3 30 5 to 3 60 344) 330 041 ( 013 363 to 655 51) 2 603 351 (2 4 042 to 2 26 560) 253 144 (241 660 to 265 65) 21 (26 to 26) 2 34 01 (2 244 55 to 2 461 041) 1 663 (10 6 to 1 5) 150 213 (143 534 to 15 ) 2 450 (2 152 to 2 2) 1 256 353 (1 203 04 to 1 30 35) 20 (2564 to 25) 1 110 (54 60 to 2 03) 24 30 (23 165 to 25 421) 33 225 (323 46 to 352 3) 3 021 435 (2 0 245 to 3 154 51) 53 (554 to 611) 66 60 (63 606 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 www.thelancet.com/neurology Vol 1 January 201
(Continued from previous page) Finland 20 00 (16 226 to 25 40) France 20 6 (10 4 to 261 143) Germany 236 043 (12 62 to 25 65) Greece 33 04 (2 4 to 3 411) Iceland 26 (66 to 1120) Ireland 13 2 (10 56 to 16 111) Israel 22 03 (1 0 to 2 302) Italy 11 52 (15 5 to 231 54) Luxembourg 11 (1461 to 215) Malta 110 (65 to 1445) Netherlands 46 656 (3 2 to 56 15) Norway 15 56 (13 05 to 1 36) Portugal 2 0 (23 44 to 33 55) Spain 12 44 (10 05 to 155 54) Sweden 2 106 (22 0 to 34 1) Switzerland 25 123 (20 22 to 31 44) UK 16 5 (13 3 to 20 313) Southern Latin America 14 43 (124 0 to 1 016) Argentina 100 11 (4 40 to 120 244) Chile 3 6 (32 0 to 4 14) Uruguay 662 (243 to 10 453) Central Europe, eastern Europe, and central Asia 3 14 5 (2 13 645 to 3 622 4) Eastern Europe 1 6 6 (1 45 412 to 1 0 30) Belarus 5 26 (4 665 to 05) Estonia 43 (61 to 11 32) Latvia 15 511 (13 64 to 1 22) Lithuania 26 31 (23 106 to 30 541) 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) 44 056 (42 012 to 46 103) 466 01 (442 5 to 4 46) 52 23 (564 640 to 61 54) 2 (5 526 to 4 453) 2021 (125 to 2110) 2 3 (2 464 to 30 26) 45 34 (42 15 to 4 6) 41 141 (46 03 to 514 611) 30 (33 to 416) 20 (241 to 3000) 112 6 (10 3 to 11 00) 34 15 (33 251 to 36 5) 0 2 (6 2 to 4 142) 32 21 (312 4 to 343 13) 63 463 (60 1 to 66 262) 54 12 (52 351 to 5 06) 32 133 (364 51 to 3 04) 20 23 (25 242 to 21 56) 1 55 (12 21 to 1 26) 4 02 (1 04 to 306) 16 56 (15 to 1 20) 505 01 ( 13 54 to 2 426) 3 022 (3 6 64 to 4 15 331) 203 206 (12 52 to 213 64) 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) www.thelancet.com/neurology Vol 1 January 201 5
(Continued from previous page) Moldova 25 0 (22 243 to 2 62) Russia 1 202 502 (1 04 23 to 1 364 131) Ukraine 315 12 (2 5 to 360 233) Central Europe 1 055 30 (16 104 to 1 233 304) Albania 1 366 (1 024 to 22 10) Bosnia and Herzegovina 25 64 (22 525 to 2 4) Bulgaria 5 125 (4 635 to 66 125) Croatia 3 226 (33 26 to 46 01) Czech Republic 115 120 ( 5 to 135 30) Hungary 6 61 (2 02 to 115 43) Macedonia 14 5 (12 5 to 1 014) Montenegro 46 (436 to 560) Poland 30 01 (31 50 to 432 31) Romania 16 215 (146 35 to 16 1) Serbia 65 6 (5 63 to 5 4) Slovakia 51 215 (44 21 to 60 241) Slovenia 26 12 (22 0 to 31 03) Central Asia 43 1 (3 64 to 4 54) Armenia 14 32 (12 636 to 16 24) Azerbaijan 45 533 (40 30 to 51 0) Georgia 20 20 (1 4 to 22 4) Kazakhstan 10 4 (6 45 to 122 5) Kyrgyzstan 2 144 (24 6 to 31 5) Mongolia 1 3 (1 25 to 22 03) Tajikistan 35 1 (31 21 to 41 43) Turkmenistan 24 1 (22 055 to 2 455) Uzbekistan 141 21 (125 51 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 (55 632 to 62 363) 2 10 261 (2 6 210 to 2 3 02) 5 255 (45 321 to 24 6) 2 64 25 (2 512 45 to 2 2 424) 4 63 (46 22 to 51 6) 6 61 (1 24 to 2 10) 15 661 (14 402 to 165 50) 2 1 ( 4 to 6 55) 2 221 (21 50 to 314 241) 221 514 (20 001 to 234 10) 3 13 (35 00 to 3 44) 12 611 (11 30 to 13 31) 0 54 (60 062 to 60 24) 434 44 (411 34 to 45 01) 14 644 (164 3 to 14 515) 123 05 (11 261 to 130 31) 63 460 (60 04 to 6 002) 6 36 (23 61 to 16 ) 3 65 (36 01 to 45 144) 101 41 (5 66 to 10 26) 4 0 (46 31 to 51 143) 21 6 (206 52 to 22 023) 51 346 (4 550 to 54 313) 34 544 (32 03 to 36 466) 62 25 (5 266 to 66 604) 46 15 (44 152 to 4 61) 265 6 (251 46 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 www.thelancet.com/neurology Vol 1 January 201
(Continued from previous page) Latin America and Caribbean 1 45 5 (1 656 12 to 2 04 50) Central Latin America 16 600 (642 4 to 06 5) Colombia 13 2 (124 5 to 15 23) Costa Rica 15 03 (13 45 to 1 031) El Salvador 1 120 (16 to 21 613) Guatemala 45 33 (40 22 to 51 24) Honduras 20 23 (1 552 to 23 5) Mexico 341 66 (306 552 to 34 04) Nicaragua 15 254 (13 53 to 1 33) Panama 12 35 (11 042 to 13 15) Venezuela 10 03 (6 052 to 11 63) Andean Latin America 15 32 (15 046 to 15 33) Bolivia 31 106 (2 63 to 34 6) Ecuador 55 53 (4 25 to 63 120) Peru 513 ( 33 to 60) Caribbean 145 (130 066 to 163 62) 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 41 64 (36 46 to 4 35) Dominica 210 (1 to 236) Dominican Republic 32 20 (2 2 to 36 034) Grenada 333 (26 to 33) Guyana 22 (2055 to 252) Haiti 31 04 (2 52 to 36 334) 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) 3 21 363 (3 54 0 to 3 453) 1 412 146 (1 34 to 1 44 463) 300 52 (2 36 to 315 562) 33 61 (31 61 to 35 326) 3 24 (35 524 to 40 21) 3 30 (6 to 152) 3 56 (34 3 to 40 13) 65 215 (62 20 to 6 51) 2 22 (2 333 to 31 642) 25 33 (24 514 to 2 043) 215 60 (205 565 to 225 532) 33 065 (320 50 to 354 351) 55 5 (53 030 to 5 4) 101 553 (6 5 to 106 302) 10 63 (10 25 to 1 5) 322 21 (22 210 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 101 33) 45 (434 to 41) 65 016 (61 66 to 6 15) 643 (60 to 64) 416 (32 to 430) 1 46 (4 24 to 10 152) 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) www.thelancet.com/neurology Vol 1 January 201 61
(Continued from previous page) Jamaica 21 (65 to 611) Puerto Rico 13 213 (11 6 to 15 024) 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 6 433 (01 4 to 04) Paraguay 21 41 (1 4 to 24 600) Southeast Asia, east Asia, and Oceania 6 356 051 (5 36 33 to 010 413) East Asia 4 41 454 (4 033 1 to 4 4 33) China 4 33 654 (3 05 64 to 4 0 1) North Korea 1 12 (64 35 to 36) Taiwan (province of China) 0 0 (63 12 to 54) Southeast Asia 1 43 12 (1 66 45 to 2 03 4) Cambodia 41 142 (3 163 to 45 610) Indonesia 62 105 (606 26 to 43 145) Laos 1 5 (16 03 to 1 46) Malaysia 100 3 (0 36 to 111 622) Maldives 2 (6 to 5) Mauritius 335 (304 to 322) Myanmar 133 (120 2 to 14 ) Philippines 25 035 (256 11 to 31 16) Sri Lanka 63 643 (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) 16 25 (15 350 to 1 055) 31 24 (2 56 to 32 6) 11 (1141 to 125) 6 (661 to 31) 3444 (324 to 355) 1 (2 to 10 211) 34 (2 to 4) 1 64 60 (1 52 02 to 1 2 016) 1 60 456 (1 533 34 to 1 64 66) 40 404 (3 04 to 42 ) 16 424 025 (15 23 to 1 02 254) 12 301 02 (11 43 to 12 6 35) 11 31 4 (11 4 66 to 12 31 50) 163 3 (156 12 to 10 561) 205 1 (1 21 to 213 3) 4 00 463 (3 0 114 to 4 23 ) 0 21 (3 4 to 1 402) 1 453 365 (1 34 542 to 1 525 52) 2 003 (2 652 to 30 510) 21 05 (20 06 to 22 66) 163 (155 to 116) 10 (434 to 1) 30 036 (22 463 to 34 50) 525 214 (4 001 to 554 225) 12 62 (15 213 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 www.thelancet.com/neurology Vol 1 January 201
(Continued from previous page) Thailand 244 221 (21 41 to 21 1) Timor-Leste 26 (2426 to 20) Vietnam 25 305 (24 41 to 30 255) Oceania 31 414 (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 22 356 (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 2 434 103 (1 6 10 to 3 1 1) Afghanistan 20 43 (11 2 to 3 313) Algeria 124 2 (111 642 to 13 5) Bahrain 44 (42 to 5231) Egypt 262 264 (236 56 to 22 13) Iran 302 610 (22 13 to 335 3) Iraq 26 24 (165 0 to 466 10) Jordan 2 61 (22 4 to 3 6) Kuwait 14 02 (13 32 to 16 36) Lebanon 1 65 (16 061 to 22 52) Libya 26 136 (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) 652 5 (624 34 to 62 02) 552 (504 to 666) 605 6 (5 63 to 632 52) 52 40 (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 ) 35 154 (33 432 to 36 0) 44 ( to 6) 241 (2360 to 2611) 4 (4 to 523) 1206 (114 to 123) 3 66 24 (3 6 31 to 4 400 ) 21 (163 0 to 31 642) 25 35 (246 43 to 22 456) 10 1 (10 262 to 11 42) 44 35 (461 1 to 50 02) 01 53 (652 604 to 3 4) 314 31 (253 102 to 440 165) 40 5 (3 45 to 43 436) 33 516 (31 00 to 35 32) 63 264 (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) www.thelancet.com/neurology Vol 1 January 201 63
age-standardised (Continued from previous page) Morocco 5 064 (5 330 to 105 06) Oman 20 4 (1 25 to 22 1) Palestine 16 165 (14 415 to 1 200) Qatar 11 (10 504 to 13 13) Saudi Arabia 11 32 (10 1 to 132 05) Sudan 126 030 (10 0 to 146 6) Syria 262 602 (3 25 to 553 60) Tunisia 34 436 (30 0 to 3 256) Turkey 24 553 (222 612 to 2 22) United Arab Emirates 46 220 (41 326 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) 212 653 (203 045 to 224 043) 41 20 (3 21 to 43 61) 25 50 (22 0 to 30 11) 24 (23 43 to 26 1) 243 43 (233 302 to 255 66) 1 30 (1 41 to 215 246) 14 5 (10 414 to 21 53) 0 306 (6 20 to 4 356) 55 55 (531 362 to 54 50) 102 02 ( 64 to 10 666) 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 14 241 (130 6 to 32 ) South Asia 03 30 (6 22 303 to 12 364) Bangladesh 540 46 (45 23 to 5 5) Bhutan 3214 (22 to 35) India 5 641 6 (5 03 02 to 6 262 015) Nepal 10 610 (6 33 to 121 246) Pakistan 45 43 (66 513 to 30 22) Sub-Saharan Africa 2 56 0 (2 65 34 to 3 26 ) Southern sub-saharan Africa 251 5 (22 351 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 15 015 (16 062 to 205 56) Zimbabwe 3 66 (35 5 to 44 04) Western sub-saharan Africa 1 15 340 (1 040 15 to 1 23 25) 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 ) 14 165 (134 214 to 16 3) 12 366 12 (11 1 6 to 12 66 52) 0 1 (35 604 to 1 031 234) 54 (5233 to 556) 65 355 ( 55 41 to 10 35 5) 11 20 (13 44 to 11 20) 1 233 430 (1 14 231 to 1 21 24) 4 12 16 (3 03 to 4 35 220) 420 050 (401 203 to 441 11) 12 41 (12 262 to 13 600) 630 (6051 to 666) 00 (651 to 546) 11 413 (10 30 to 11 ) 32 53 (313 064 to 344 14) 52 663 (50 04 to 55 611) 1 614 512 (1 53 3 to 1 66 546) 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 www.thelancet.com/neurology Vol 1 January 201
(Continued from previous page) Benin 33 501 (30 12 to 3 2) Burkina Faso 53 214 (4 530 to 5 321) Cameroon 0 2 (63 to 440) Cape Verde 1654 (145 to 13) Chad 42 615 (3 1 to 4 636) Côte d Ivoire 1 655 (64 02 to 0 33) The Gambia 541 (4 to 6116) Ghana 4 24 (5 5 to 3 620) Guinea 35 050 (31 420 to 3 04) Guinea-Bissau 515 (5146 to 6362) Liberia 11 400 (10 21 to 12 62) Mali 4 132 (43 to 54 5) Mauritania 12 04 (10 36 to 13 462) Niger 52 541 (4 0 to 5 40) Nigeria 546 313 (4 3 to 60 60) São Tomé and Príncipe 60 (603 to 4) Senegal 44 145 (3 611 to 4 ) Sierra Leone 1 (16 024 to 1 2) Togo 20 024 (1 5 to 22 23) Eastern sub-saharan Africa 1 11 (1 055 453 to 1 31 16) Burundi 3 32 (33 413 to 41 2) Comoros 2436 (212 to 21) Djibouti 322 (24 to 361) Eritrea 16 6 (15 110 to 1 5) Ethiopia 314 622 (21 60 to 350 1) Kenya 14 50 (133 00 to 166 30) 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 ) 4 011 (44 631 to 4 362) 6 252 (65 64 to 2 04) 5 352 (0 2 to 100 5) 210 (263 to 244) 54 5 (51 4 to 5 150) 313 (3 6 to 104 562) 266 (6 to 63) 125 3 (11 141 to 131 52) 4 3 (46 352 to 51 16) 6 (400 to 13) 1 61 (16 43 to 20 466) 64 365 (61 06 to 6 253) 1 1 (1 26 to 20 120) 66 15 (63 2 to 0 34) 2 53 (31 53 to 14 54) 45 ( to 2) 61 131 (5 1 to 64 314) 25 65 (24 414 to 2 05) 2 6 (26 541 to 2 45) 1 64 534 (1 564 002 to 1 4 1) 51 646 (4 3 to 56 131) 346 (3554 to 340) 5163 (402 to 5411) 24 312 (22 0 to 26 223) 456 4 (430 26 to 45 6) 216 411 (206 413 to 226 ) 4 (3 3 to 104 236) 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) www.thelancet.com/neurology Vol 1 January 201 65
age-standardised (Continued from previous page) Malawi 45 111 (40 22 to 50 65) Mozambique 6 051 ( 161 to 5 3) Rwanda 33 114 (2 55 to 3 120) Somalia 3 1 (32 22 to 50 226) South Sudan 46 41 (41 340 to 52 564) Tanzania 166 23 (14 60 to 16 5) Uganda 116 06 (103 532 to 12 01) Zambia 55 61 (4 01 to 62 201) Central sub-saharan Africa 364 4 (32 646 to 405 6) Angola 553 (0 34 to 2) Central African Republic 14 436 (12 54 to 16 13) Congo (Brazzaville) 15 10 (14 211 to 1 546) Democratic Republic of the Congo 235 64 (211 454 to 262 31) 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 ) 56 44 (53 64 to 60 21) 116 (10 146 to 126 5) 63 (52 403 to 5 43) 45 2 (42 334 to 51 06) 63 0 (5 00 to 0 25) 225 251 (213 622 to 23 14) 14 404 (13 610 to 161 03) 6 654 (66 142 to 3 33) 4 04 (43 461 to 526 322) 123 421 (115 3 to 132 63) 1 1 (1 55 to 20 01) 23 6 (22 503 to 25 6) 316 53 (300 0 to 333 6) 514 (420 to 531) 10 02 (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 www.thelancet.com/neurology Vol 1 January 201
Global 34 51 (0 63 to 1 155 1) High SDI 26 30 (216 23 to 355 13) High-middle SDI 155 063 (12 5 to 14 025) Middle SDI 16 312 (14 4 to 20 614) Low-middle SDI 242 40 (1 305 to 340 46) Low SDI 536 (65 24 to 142 240) High income 2 206 (223 65 to 32 032) High-income North America 101 25 ( 044 to 12 22) Canada 654 (533 to 12 401) Greenland 15 (12 to 1) USA 1 556 (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 51 251 (40 22 to 65 4) Brunei 124 ( to 154) Japan 36 21 (2 255 to 46 43) Singapore 1000 (6 to 126) South Korea 13 0 (10 0 to 1 53) Western Europe 115 5 ( 45 to 151 615) 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 26 506) 2016 counts 2016 age-standardised rates (per 100 000) 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 ) 2 042 505 (24 6 60 to 30 14 230) 24 664 ( 524 04 to 53) 5 34 30 (4 4 153 to 6 042 15) 5 56 32 (5 244 3 to 5 41 25) 5 141 36 (4 51 0 to 6 34 00) 1 5 6 (1 32 16 to 2 61 01) 6 02 ( 46 042 to 10 41 324) 2 5 25 (2 25 26 to 3 165 6) 324 6 (2 545 to 34 52) 3 (35 to 416) 2 633 160 (2 42 10 to 2 1 1) 240 03 (220 533 to 25 20) 201 65 (15 041 to 21 1) 3 436 (35 415 to 41 61) 1 31 23 (1 66 204 to 1 6 5) 401 (3641 to 4463) 1 306 33 (1 202 40 to 1 424 15) 3 555 (36 21 to 43 5) 41 13 (440 64 to 52 12) 4 2 0 (3 65 06 to 4 06 2) 34 (63 to 15) 310 ( 64 to 10 61) 121 14 (110 2 to 133 10) 060 (244 to ) 5 60 (52 20 to 63 666) 64 35 (5 41 to 0 664) 643 61 (52 262 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) www.thelancet.com/neurology Vol 1 January 201 6
(Continued from previous page) Germany 22 04 (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 (13 033 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 11 33 (41 to 14 624) Sweden 21 (203 to 3556) Switzerland 23 (13 to 3115) UK 16 215 (12 431 to 21 12) Southern Latin America 12 125 (601 to 15 163) Argentina 06 (642 to 10 010) Chile 3362 (2662 to 426) Uruguay 6 (533 to 51) Central Europe, eastern Europe, and central Asia 2016 counts 2016 age-standardised rates (per 100 000) 52 (63 320 to 4 211) Eastern Europe 41 64 (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 (24 253 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) 111 122 (102 610 to 121 50) 313 (26 to 3465) 4 263 (43 550 to 53 544) 3 63 (63 1 to 4 545) 65 (602 165 to 25 620) 525 (5240 to 6266) 444 (40 to 420) 152 53 (141 164 to 164 05) 52 434 (4 00 to 5 063) 2 650 (5 56 to 100 266) 464 43 (42 50 to 50 351) 101 6 (2 140 to 113 32) 465 (3 5 to 5 6) 613 245 (561 10 to 6 232) 30 41 (343 020 to 3 05) 246 246 (22 to 265 40) 104 31 (6 1 to 112 51) 1 45 (1 265 to 21 341) 2 31 36 (2 210 605 to 2 553 00) 1 222 360 (1 141 216 to 1 306 6) 62 524 (5 133 to 66 05) 31 (4 to 006) 11 05 (11 114 to 12 653) 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 www.thelancet.com/neurology Vol 1 January 201
(Continued from previous page) Ukraine 45 (6532 to 53) Central Europe 24 512 (1 365 to 30 562) 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 11 666 (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 44 612 (36 1 to 53 003) Central Latin America 16 5 (14 04 to 20 23) 2016 counts 2016 age-standardised rates (per 100 000) 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) 251 34 (235 10 to 26 36) 12 242 (50 130 to 1 1) 1 030 (15 23 to 1 542) 33 351 (25 24 to 4 144) 4 216 (43 2 to 50 31) 2 54 (24 164 to 34 50) 1 60 (4 06 to 44) 64 31 (5 0 to 6 0) 12 11 (11 0 to 13 251) 352 (3633 to 4262) 26 15 (24 2 to 2 5) 12 4 (11 600 to 13 154) 60 445 (52 12 to 5 21) 3 606 (34 645 to 40 50) 1 63 (1 160 to 1 22) 33 334 (311 213 to 36 44) 1 21 (13 20 to 22 65) 41 13 (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) 12 043 (11 144 to 12 43) 31 335 (25 25 to 43 12) 1 2 (16 6 to 1 20) 104 24 ( 144 to 113 211) 1 25 30 (1 16 51 to 1 35 261) 41 04 (43 52 to 52 653) 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) www.thelancet.com/neurology Vol 1 January 201 6
(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 100 000) (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 ) 102 06 (3 11 to 113 136) 10 45 (631 to 11 355) 16 404 (11 6 to 2 532) 2 342 (24 201 to 36 40) 14 11 (12 2 to 16 ) 21 025 (202 252 to 234 02) 14 630 (10 612 to 23 65) 224 (5 to 2) 6 61 (62 42 to 3 6) 134 61 (124 0 to 14 122) 21 66 (1 34 to 23 636) 36 335 (33 4 to 3 41) 6 5 (0 42 to 4 1) 120 1 ( 20 to 156 635) 220 (203 to 23) 06 (42 to 2) 662 (616 to 0) 11 (65 to 0) 14 (161 to 16) 31 06 (2 03 to 33 423) 15 (145 to 10) 22 03 (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 www.thelancet.com/neurology Vol 1 January 201
(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 1 006 (15 54 to 22 05) Brazil 1 503 (15 141 to 22 303) Paraguay 503 (413 to 606) Southeast Asia, east Asia, and Oceania 2016 counts 2016 age-standardised rates (per 100 000) 14 6 (123 214 to 1 266) East Asia 101 644 (4 5 to 122 1) China 226 (1 6 to 11 651) North Korea 16 (1466 to 2124) Taiwan (province of China) 1650 (136 to 1) Southeast Asia 45 34 (3 40 to 54 20) Cambodia 1020 (60 to 1206) Indonesia 16 33 (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 10 612) 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) 521 040 (44 365 to 556 ) 50 5 (42 136 to 542 66) 13 452 (12 233 to 14 41) 5 355 50 (5 00 161 to 5 55 26) 3 51 5 (3 621 16 to 4 02 414) 3 3 610 (3 515 3 to 3 63 41) 4 16 (46 203 to 52 10) 62 (5 405 to 66 4) 1 46 6 (1 324 441 to 1 66 643) 4 3 (2 31 to 102 600) 525 421 (4 33 to 54 463) 10 06 (31 to 10 1) 0 211 (66 032 to 4 66) 632 (55 to 6) 266 (26 to 3052) 13 5 (10 122 to 13 3) 204 30 (1 6 to 256 102) 4 402 (61 40 to 10 102) 225 (211 to 240) 16 063 (15 0 to 1 225) 56 (2514 to 13 52) 16 504 (14 525 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) www.thelancet.com/neurology Vol 1 January 201 1
(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 114 545 (60 12 to 250 35) Afghanistan 14 304 (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 16 663 (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 100 000) ( 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) 146 1 (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 12 664) 344 (31 to 3) 56 (4 to 1) 15 (163 to 16) 406 (34 to 444) 2 41 341 (1 5 2 to 4 560 625) 313 21 (101 502 to 65 33) 106 241 (6 415 to 124 5) 4500 (416 to 42) 201 6 (14 4 to 225 6) 3 04 (25 to 23 2) 3 20 (14 340 to 1 02 60) 16 (15 6 to 1 34) 13 (12 640 to 16 10) 1 54 (33 043 to 252 34) 36 616 (1 3 to 25) 2 36 (6 645 to 66) 14 520 (13 56 to 15 636) 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 www.thelancet.com/neurology Vol 1 January 201
(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 13 02 (461 to 3 003) South Asia 10 120 (151 16 to 213 5) Bangladesh 14 525 (12 236 to 1 30) Bhutan 1 (6 to 6) India 143 43 (120 31 to 10 1) Nepal 20 (2421 to 330) Pakistan 1 02 (16 015 to 22 050) 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 33 433 (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 100 000) 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 1 265 1) 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 166 051) 15 4 (64 351 to 401 256) 31 16 (2 02 to 33 1) 231 112 (212 0 to 25 146) 35 43 (33 003 to 3 61) 5 00 (55 113 to 12 30) 4 12 35 (3 5 6 to 4 3 30) 36 2 (340 422 to 405 ) 2043 (113 to 212) 3 252 6 (3 04 402 to 3 44 115) 6 21 (62 55 to 2) 435 044 (402 203 to 42 53) 1 11 15 (1 53 01 to 2 405 23) 140 222 (130 205 to 151 6) 42 (4000 to 455) 163 (126 to 2104) 26 (254 to 25) 3 (36 to 422) 10 631 ( 61 to 11 234) 1 556 (1 025 to 21 00) 64 235 (5 26 to 23 553) 1 000 (15 34 to 1 325) 26 53 (24 44 to 2 52) 36 13 (33 240 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) www.thelancet.com/neurology Vol 1 January 201 3
(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 16 220 (13 543 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 100 000) ( 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 ) 25 52 (21 330 to 35 ) 36 366 (33 3 to 3 550) 301 (200 to 341) 46 645 (43 313 to 50 03) 1 154 (16 1 to 1 621) 26 (262 to 320) 12 25 (51 to 24 4) 2 2 (24 231 to 3 3) 511 (663 to 060) 25 26 (23 640 to 2 ) 311 002 (24 603 to 33 06) 363 (336 to 3) 23 03 (21 61 to 25 655) 13 60 (10 05 to 23 41) 10 662 (2 to 11 516) 04 6 (624 31 to 1 220 333) 2 356 (1 445 to 46 50) 134 (125 to 145) 10 (154 to 210) 13 0 (461 to 21 6) 223 360 (12 265 to 34 531) 3 265 ( 3 to 234) 36 61 (33 3 to 3 54) 21 452 (1 63 to 23 1) 60 152 (41 2 to 106 16) 5 43 (32 2 to 224 253) 2 54 (1 50 to 53 134) 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) 453 5 (106 2 to 1 244 1) 33 3 (6 to 1 ) (Table 2 continues on next page) 4 www.thelancet.com/neurology Vol 1 January 201
(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 10 034 (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 100 000) 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 ) 36 330 (23 5 to 66 34) 4 663 ( 11 to 1 04) 6 06 (5 55 to 123 332) 24 612 (22 13 to 26 463) 21 015 (1 254 to 313 214) 5 30 (44 235 to 5 5) 061 (6335 to 12 014) 11 542 (420 to 1 31) 133 41 (112 213 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 www.thelancet.com/neurology Vol 1 January 201 5
Age-standardised incidence (per 100 000) 200 2 300 3 400 4 500 5 600 6 00 00 00 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 100 000 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 0 110 (5% uncertainty interval [UI] 0 04 0 15) and 0 214 (0 141 0 2), respectively, 6 www.thelancet.com/neurology Vol 1 January 201
Age-standardised incidence (per 100 000) 5 10 14 15 1 20 24 25 2 30 34 35 3 40 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 100 000 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 http://healthdata. org For the online results tool see http://ghdx.healthdata.org/gbdresults-tool www.thelancet.com/neurology Vol 1 January 201