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Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.
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1
Articles
Global, regional, and national burden of stroke and its risk
factors, 1990–2019: a systematic analysis for the Global
Burden of Disease Study 2019
GBD 2019 Stroke Collaborators*
Summary
Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence,
mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning
and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a
standardised and comprehensive measurement of these metrics at global, regional, and national levels.
Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted
life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty
intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates
were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes
combined, and stratified by sex, age group, and World Bank country income level.
Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111)
prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from
stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the
third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the
absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0%
(83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0%
(22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0),
mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by
36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0)
and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was
3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and
the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the
high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]),
while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage
constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood
pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-
mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million
[19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or
20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]).
Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019,
despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest
age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-
growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of
eective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly
in low-income countries.
Funding Bill & Melinda Gates Foundation.
Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0
license.
Introduction
Disease and population distribution patterns, life
expectancy, mortality, causes of death, and socio-
demographic factors continue to change across the
world, including ageing of populations and changes in
the prevalence of risk factors for non-communicable
disorders. Timely estimates of the burden of stroke and
its pathological types, the burden attributable to risk
factors, and trends in the burden over time are necessary
at the global, regional, and national levels to guide
Lancet Neurol 2021
Published Online
September 3, 2021
https://doi.org/10.1016/
S1474-4422(21)00252-0
See Online/Comment
https://doi.org/10.1016/
S1474-4422(21)00287-8
*Collaborators are listed at the
end of the Article
Correspondence to:
Prof Valery L Feigin, National
Institute for Stroke and Applied
Neurosciences, Faculty of Health
and Environmental Sciences,
Auckland University of
Technology, Northcote,
Auckland 0627, New Zealand
valery.feigin@aut.ac.nz
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evidence-based health-care policy, planning, and resource
allocation for stroke.
The Global Burden of Diseases, Injuries, and Risk
Factors Study (GBD) 2017 showed that stroke was the
third-leading cause of death and disability combined (as
measured by disability-adjusted life-years [DALYs]) and the
second-leading cause of death in the world in 2017.1,2 A
GBD 2017 stroke analysis found that, although
age-standardised mortality rates for stroke decreased
sharply from 1990 to 2017,2 the decrease in age-standardised
incidence was much less steep, suggesting that prevention
eorts have been less successful than treatment eorts.
The results from GBD 20163 showed that 87·9% of
ischaemic stroke DALYs and 89·5% of haemorrhagic
stroke DALYs were due to potentially modifiable risk
factors measured in GBD, demonstrating the enormous
potential to reduce the burden of stroke through reductions
in risk factor exposure. According to WHO, eective stroke
prevention strategies include reducing the risk associated
with hypertension (high systolic blood pressure), elevated
lipids, diabetes (high fasting plasma glucose), smoking,
low physical activity, unhealthy diet, and abdominal obesity
(high body-mass index [BMI]),4 which is similar to the
findings from GBD 20163 and GBD 2017.5
In this study, we estimated the global, regional, and
national burden of overall stroke, ischaemic stroke,
intracerebral haemorrhage, and subarachnoid haem-
orrhage in terms of their incidence, prevalence, mortality,
and DALYs, as well as stroke-related DALYs associated
with 19 potentially modifiable behavioural, environmental
and occupational, and metabolic risk factors or groups of
risk factors. We present data for 204 countries and
territories, 21 GBD regions, and four World Bank income
level groups from 1990 to 2019, by age group and sex.
This manuscript was produced as part of the GBD
Collaborator Network and in accordance with the GBD
Protocol.
Methods
Overview and case definition
Details of the GBD 2019 eligibility criteria, the literature
search strategy, and data extraction are described in detail
elsewhere6,7 (appendix sections 1.1–4.3). In brief, stroke
was defined by WHO clinical criteria8 as rapidly
developing clinical signs of (usually focal) disturbance of
cerebral function lasting more than 24 h or leading to
death. Ischaemic stroke was defined as an episode of
neurological dysfunction due to focal cerebral, spinal,
Research in context
Evidence before this study
The Global Burden of Diseases, Injuries, and Risk Factors Study
(GBD) produces the most comprehensive estimates of the global,
regional, and country-specific burden of stroke. Population-level
estimates for stroke incidence or mortality have been published
by WHO and independent research groups, but those of GBD
include more extensive estimates by age, sex, location, and year.
To evaluate the availability of evidence, we did a structured
review of the published scientific literature in Medline, Scopus,
Google Scholar, and PubMed for relevant reports published in any
language up to June 30, 2021, using search terms that included
“stroke”, “cerebral infarction”, “isch(a)emic stroke”, “intracerebral
h(a)emorrage”, “h(a)emorrhagic stroke”, or “subarachnoid h(a)
emorrage”, AND “incidence”, “prevalence”, “mortality”, or
“epidemiology” or “population attributable fraction (PAF)”, “risk
factor(s)”, or “disability-adjusted life-year(s) (DALYs)”. GBD 2017
included stroke in its analysis, but the most recent paper by the
GBD Collaborator Network on the topic of stroke was from GBD
2016. The report concluded that because the decrease in global
age-standardised incidence rates from 1990 to 2016 was
minimal, the burden of stroke was likely to remain high well into
the future.
Added value of this study
As part of GBD 2019, this study provides updated estimates of
the burden of overall stroke, ischaemic stroke, intracerebral
haemorrhage, and subarachnoid haemorrhage for
204 countries and territories in 21 GBD regions from 1990
to 2019, by age, sex, and country income level (by the World
Bank classification). Stroke burden was measured by incidence,
prevalence, mortality, and DALYs as well as the PAF of
stroke-related DALYs associated with potentially modifiable
behavioural, environmental and occupational, and metabolic
risk factors or risk factor clusters. Until GBD 2017, intracerebral
haemorrhage and subarachnoid haemorrhage were not
estimated separately, so this is the first report by the GBD
Collaborator Network to present the global, regional, and
national burden of haemorrhagic strokes by intracerebral
haemorrhage and subarachnoid haemorrhage separately.
This study is also the first systematic analysis to determine the
effect of non-optimal temperature on stroke burden.
Implications of all the available evidence
The findings from this study can help guide evidence-based
health-care planning, prevention, and resource allocation for
stroke and its pathological types, including country-specific
prioritisation of these measures. By evaluating the
risk-attributable burden of different stroke types in different
geographical locations, this study can be used to develop
location-specific strategies for reducing the burden of stroke.
Based on the available evidence, public health and research
priorities should include: expanding evidence-based
prevention strategies that reduce exposure to stroke risk
factors; reducing the gaps in acute and chronic stroke
prevention, screening, and treatment services between
high-income and low-income to middle-income countries;
and further epidemiological research on stroke risk and
outcomes across different countries and populations.
See Online for appendix
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3
or retinal infarction. Intracerebral haemorrhage was
defined as stroke with a focal collection of blood in the
brain not due to trauma. Subarachnoid haemorrhage was
defined as non-traumatic stroke due to bleeding into the
subarachnoid space of the brain. The GBD methods for
assigning cause of death to stroke and stroke subtypes in
regions where neuroimaging was not available have been
previously described.9 GBD classifies causes into four
levels, from the broadest (Level 1; eg, non-communicable
diseases), to the most specific (Level 4; eg, intracerebral
haemorrhage). Stroke is a Level 3 cause, within the
Level 2 category of cardiovascular diseases, while its
subtypes are Level 4 causes.
Fatal disease modelling
We used vital registration and verbal autopsy data as
inputs into the Cause of Death Ensemble modelling
(CODEm) framework to estimate deaths due to overall
stroke and stroke subtypes. CODEm is a flexible
modelling tool that utilises geospatial relationships and
information from covariates to produce estimates of
death for all locations across the time series (1990–2019).
Deaths from vital registration systems coded to
impossible or intermediate causes of death or unspecified
stroke were reassigned by use of statistical methods
(appendix sections 1.4, 1.7, 1.8).10
Non-fatal disease modelling
Estimates of the incidence and prevalence of stroke were
generated with the DisMod-MR 2.1 (disease-model-
Bayesian meta-regression) modelling tool.3 DisMod-MR
is a Bayesian geospatial disease modelling software
that uses data on various disease parameters, the
epidemiological relationships between these parameters,
and geospatial relationships to produce estimates of
prevalence and incidence (appendix section 3). All
available high-quality data on incidence, prevalence, and
mortality were used to estimate non-fatal stroke burden.
We modelled first-ever ischaemic stroke, intracerebral
haemorrhage, and subarachnoid haemorrhage from the
day of incidence through 28 days and separately modelled
survival beyond 28 days.
Risk factor estimation
To analyse the attributable burden of stroke due to 19 risk
factors currently available for such analysis in GBD 2019,
we calculated population attributable fractions (PAFs) of
DALYs (appendix section 2).7 This work was done within
the comparative risk assessments framework of GBD by
use of four datasets: the burden estimates for stroke and
its three pathological types; the exposure level for each
risk factor; the relative risk of stroke as an outcome of
exposure to the risk factor; and the theoretical minimum
risk exposure level (TMREL), which is the level of
exposure that minimises risk for each individual in the
population.11 The relative risks included in this analysis
were generated from meta-analyses of epidemiological
studies reporting associations between the risk factors of
interest and stroke; these analyses are not stroke-type
specific. The PAF (estimated independently for each risk
factor) is the proportion of the cause that would be
decreased if the exposure to the risk factor in the past had
been reduced to the counterfactual level of the TMREL.
Risks included in the analysis were ambient particulate
matter pollution; household air pollution from solid fuels;
non-optimal temperature—ie, low temperature (daily
temperatures below the TMREL) and high temperature
(daily temperatures above the TMREL); lead exposure;
diet high in sodium; diet high in red meat; diet low in
fruits; diet low in vegetables; diet low in whole grains;
alcohol consumption (any dosage); low physical activity
(only for ischaemic stroke burden); smoking; secondhand
smoke; high BMI; high fasting plasma glucose; high
systolic blood pressure; high LDL cholesterol (only for
ischaemic stroke burden); and kidney dysfunction, as
measured by low glomerular filtration rate (GFR; not
assessed for subarachnoid haemorrhage burden). As
with causes, GBD organises risk factors into four levels,
from the broadest (Level 1) to the most specific (Level 4).
In addition to the specific risk factors above, we assessed
the Level 1 groups of risks: behavioural, environmental
and occupational, and metabolic. The PAFs of risk factor
groups took into account interactions between risk
factors included in the group, as explained elsewhere.12
Percentages and number of DALYs are not mutually
exclusive. The crude sum of the PAF of the risk factors
might exceed 100% because the eects of many of these
risk factors are mediated partly or wholly through
another risk factor or risk factors. Definitions of risk
factors and risk groups and further details of risk factors
are provided in the appendix (section 2.1).
Data sources and presentation
For GBD 2019, we used data from 3686 vital registration
sources, 147 verbal autopsy sources, 368 incidence sources,
117 prevalence sources, 229 excess mortality sources,
7753 risk factor exposure sources, and 2733 risk factor
relative risk sources. Further details of the data sources
used in this analysis are available on the Global Health
Data Exchange website.
Estimates in this Article are presented in absolute
numbers and as age-standardised rates per
100 000 pop ulation (with 95% uncertainty intervals [UIs])
and are stratified by age, sex, 21 GBD regions, seven GBD
super-regions (appendix figure 6.1), and four income
levels (as determined by the World Bank).13 Count data
are presented in tables to two decimal places (and
rounded to one decimal place in the text), and percentage
data (including percentage change) are presented to one
decimal place.
Role of the funding source
The funder had no role in study design, data collection,
data analysis, interpretation of the study results, writing
For more on the Global Health
Data Exchange see http://ghdx.
healthdata.org/
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of the report, or the decision to submit the manuscript
for publication.
Results
Overall stroke burden
In 2019, there were 12·2 million (95% UI 11·0–13·6)
incident strokes and 101 million (93·2–111) prevalent
strokes, 143 million (133–153) DALYs due to stroke, and
55 million (6·00–7·02) deaths from stroke (table 1).
Globally, stroke was the second-leading Level 3 cause of
death (11·6% [10·8–12·2] of total deaths) after ischaemic
heart disease (16·2% [15·0–16·9]). Stroke was also the
third-leading Level 3 cause of death and disability
combined in 2019 (5·7% [5·1–6·2] of total DALYs), after
neonatal disorders (7·3% [64·4–8·4]) and ischaemic
heart disease (7·2% [6·5–8·0]; appendix section 4.1 and
figure S2). In 2019, the World Bank low-income group of
countries had an age-standardised stroke-related
mortality rate 3·6 (3·5–3·8) times higher and an age-
standardised stroke-related DALY rate 3·7 (3·5–3·9)
times higher than those of high-income countries (see
appendix tables S1, S3, and S5 and figures S2–7 for more
detailed results by country and World Bank income
group). In 2019, 86·0% (85·9–86·9) of all stroke-related
deaths and 89·0% (88·9–89·3) of stroke-related DALYs
occurred in lower-income, lower-middle-income, and
upper-middle-income countries (appendix table S1).
There were substantial between-country variations
(figure 1A) in age-standardised stroke incidence rates
and regional variations (figure 2) in age-standardised
incidence, prevalence, mortality, and DALY rates. The
absolute number of incident strokes globally increased
by 70·0% (67·0–73·0) from 1990 to 2019, whereas
prevalent strokes increased by 85·0% (83·0–88·0),
deaths from stroke increased by 43·0% (31·0–55·0), and
DALYs due to stroke increased by 32·0% (22·0–42·0;
table 1, appendix figure S3). Although absolute numbers
increased over the study period, age-standardised rates
all decreased between 1990 and 2019: by 17·0%
(15·0–18·0) for incidence; by 6·0% (5·0–7·0) for
prevalence; by 36·0% (31·0–42·0) for mortality; and by
36·0% (31·0–42·0) for DALYs (table 1). However, among
those younger than 70 years, age-specific stroke
prevalence and incidence rates increased substantially
over the study period (22·0% [21·0–24·0] increase in
prevalence and 15·0% [12·0–18·0] increase in incidence;
incidence data are shown in appendix figure 7, prevalence
data are available on the Global Health Data Exchange).
Although the absolute number of DALYs due to stroke
in males (76·9 million [95% UI 70·2–83·5]) exceeded
that in females (66·4 million [60·5–72·3]) at the global
level in 2019, the point estimates of incident and
prevalent strokes were higher in females (6·44 million
[5·81–7·17] incident strokes and 56·4 million [52·0–61·5]
prevalent strokes) than in males (5·79 million [5·24–6·45]
incident strokes and 45·0 million [41·1–49·3] prevalent
Incidence (95% UI) Deaths (95% UI) Prevalence (95% UI) DALYs (95% UI)
2019 Percentage
change,
1990–2019
2019 Percentage
change,
1990–2019
2019 Percentage
change,
1990–2019
2019 Percentage
change,
1990–2019
Ischaemic stroke
Absolute number, millions 7·63
(6·57 to 8·96)
88·0%
(83·0 to 92·0)
3·29
(2·97 to 3·54)
61·0%
(46·0 to 75·0)
77·19
(68·86 to 86·46)
95·0%
(92·0 to 99·0)
63·48
(57·83 to 68·99)
57·0%
(43·0 to 68·0)
Age-standardised rate,
per 100 000 people
94·51
(81·9 to 110·76)
–10·0%
(–12·0 to –8·0)
43·50
(39·08 to 46·77)
–34·0%
(–39·0 to –28·0)
951·0
(849·2 to 1064·1)
–2·0%
(–3·0 to 0·0)
798·8
(727·5 to 866·9)
–29·0%
(–35·0 to –23·0)
Intracerebral haemorrhage
Absolute number, millions 3·41
(2·97 to 3·91)
43·0%
(41·0 to 45·0)
2·89
(2·64 to 3·10)
37·0%
(22·0 to 51·0)
20·66
(18·02 to 23·42)
58·0%
(56·0 to 60·0)
68·57
(63·27 to 73·68)
25·0%
(12·0 to 36·0)
Age-standardised rate,
per 100 000 people
41·81
(36·53 to 47·88)
–29·0%
(–30·0 to –28·0)
36·04
(32·98 to 38·67)
–36·0%
(–43·0 to –29·0)
248·8
(217·1 to 281·4)
–17·0%
(–18·0 to –15·0)
823·8
(769·2 to 894·7)
–37·0%
(–43·0 to –31·0)
Subarachnoid haemorrhage
Absolute number, millions 1·18
(1·01 to 1·39)
61·0% (56·0
to 65·0)
0·37
(0·33 to 0·42)
–12·0%
(–25·0 to 26·0)
8·40
(7·19 to 9·83)
65·0% (60·0
to 68·0)
11·18
(9·89 to 12·67)
–14%
(–26·0 to 17·0)
Age-standardised rate,
per 100 000 people
14·46
(12·33 to 16·94)
–17·0%
(–19·0 to –15·0)
4·66
(4·13 to 5·17)
–57·0%
(–64·0 to –39·0)
101·6
(87·1 to 118·5)
–37·0%
(–43·0 to –31·0)
136·5
(120·8 to 154·7)
–54·0%
(–61·0 to –37·0)
Total stroke
Absolute number, millions 12·22
(11·04 to 13·59)
70·0%
(67·0 to 73·0)
6·55
(6·00 to 7·02)
43·0% (31·0
to 55·0)
101·47
(93·21 to 110·53)
85·0%
(83·0 to 88·0)
143·23
(133·10 to 153·24)
32·0%
(22·0 to 42·0)
Age-standardised rate,
per 100 000 people
150·8
(136·5 to 167·5)
–17·0%
(–18·0 to –15·0)
84·2
(76·8 to 90·2)
–36·0%
(–42·0 to –31·0)
1240·3
(1139·7 to 1353·0)
–6·0%
(–7·0 to –5·0)
1768·1
(1640·7 to 1889·4)
–36·0%
(–42·0 to –31·0)
Absolute numbers in millions and age-standardised rates per 100 000 people are presented to two decimal places and percentage change is shown to one decimal place. UI=uncertainty interval. DALY=disability-
adjusted life-year.
Table 1: Absolute number and age-standardised rates per year of incident and prevalent strokes, deaths from stroke and DALYs due to stroke in 2019, and percentage change globally for
1990–2019, by pathological types of stroke
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5
(Figure 1 continues on next page)
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<64·0
64·0 to <85·5
85·5 to <100·5
100·5 to <124·3
124·3 to <141·7
141·7 to <158·0
158·0 to <175·8
175·8 to <196·2
196·2 to <218·3
≥218·3
Incidence rates per 100
000 people
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<41·3
41·3 to <50·9
50·9 to <60·1
60·1 to <70·5
70·5 to <81·7
81·7 to <93·2
93·2 to <108·6
108·6 to <131·0
131·0 to <151·5
≥151·5
Incidence rates per 100
000 people
AAll strokes
BIschaemic strokes
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Figure 1: Age-standardised stroke incidence rates per 100 000 people by stroke type and country, for both sexes, 2019
(A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage.
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<15·0
15·0 to <21·4
21·4 to <31·5
31·5 to <39·7
39·7 to <48·6
48·6 to <57·4
57·4 to <68·8
68·8 to <80·4
80·4 to <97·1
≥97·1
Incidence rates per 100
000 people
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<8·6
8·6 to <11·0
11·0 to <13·3
13·3 to <15·6
15·6 to <18·1
18·1 to <22·1
22·1 to <25·1
25·1 to <30·4
30·4 to <61·8
≥61·8
Incidence rates per 100
000 people
CIntracerebral haemorrhage
DSubarachnoid haemorrhage
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7
strokes), and there were no noticeable sex dierences in
the number of stroke-related deaths (appendix table S2).
Although age-standardised incidence rates did not
dier significantly between males and females, age-
standardised death rates were greater in males than in
females (96·4 [87·6–104·2] per 100 000 vs 73·5
[65·2–80·7] per 100 000) as were DALY rates (2024·3
[1852·4–2195·6] per 100 000 vs 1531·3 [1397·1–1667·6]
per 100 000; see appendix section 4.1 for details of
age-specific trends by country).
Burden of pathological types of stroke
Ischaemic stroke constituted 62·4% of all new strokes
in 2019 (7·63 million [95% UI 6·57–8·96] strokes),
intracerebral haemorrhage constituted 27·9%
(3·41 million [2·97–3·91]), and subarachnoid haemor-
rhage constituted 9·7% (1·18 million [1·01–1·39]; table 1).
Intracerebral haemorrhage and subarachnoid haem-
orrhage showed larger reductions in age-standardised
rates from 1990 to 2019 than ischaemic stroke (table 1;
appendix section 4·2, tables S3–5, and figure S8). There
were substantial between-country variations in the age-
standardised incidence (figures 1B–D), prevalence,
mortality, and DALY rates (appendix figures S8–11) of
these three pathological types of stroke by GBD regions,
country income level, and sex (appendix section 4.2),
with an almost two-fold greater proportion of
intracerebral haemorrhage in World Bank low-income to
upper-middle-income countries compared with high-
income countries (29·5% [28·4–30·3] vs 15·8%
[15·5–16·2]), but a lower proportion of subarachnoid
haemorrhage in low-income to upper-middle-income
countries compared with high-income countries (7·9%
[7·5–8·3] vs 19·7% [18·4–21·0]).
Stroke-related DALYs attributable to risk factors
GBD stroke estimates for 1990–2019 are available to
download from the GBD Results Tool. In 2019, 87·0%
(95% UI 84·2–89·8) of total stroke DALYs were
attributable to the 19 risk factors modelled in GBD 2019.
The PAF of DALYs attributable to all risk factors
combined was similar for ischaemic stroke (85·7%
[81·2–90·3]), intracerebral haemorrhage (88·7%
[85·2–91·0]), and subarachnoid haemorrhage (84·6%
[81·3–87·6]; appendix section 4.3 and tables S6–8). From
1990 to 2019, the total number of stroke-related DALYs due
to risk factors increased from 91·5 million (85·8–98·3) to
125 million (115–134), with a decrease in the high-income
group (from 16·4 million [15·4–17·4] in 1990 to 13·1million
[11·8–14·4] in 2019) and an increase in the low-income
to upper-middle-income groups (from 75·1 million
[68·5–82·3] DALYs in all three income groups combined
in 1990 to 111 million [100·3–122·5] DALYs in 2019). From
1990 to 2019, the largest increase in the age-standardised
stroke PAF globally was for high BMI, increasing from
15·4% (8·2–24·2) to 24·3% (15·7–33·2), a 57·8% increase.
In other words, if high BMI exposure were reduced to its
TMREL, there would be a 24·3% reduction in stroke in
2019, compared to just a 15·4% reduction in 1990. Other
risk factors with an increasing age-standardised stroke
PAF from 1990 to 2019 included high systolic blood
Figure 2: Age-standardised incidence, prevalence, mortality, and DALY rates (per 100 000 people per year) in
seven GBD super regions, 1990–2019, for both sexes and all ages
DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.
Incidence Prevalence
Mortality DALY
Year Year
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
2020
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
2020
0
1000
2000
3000
4000
0
50
100
150
200
0
500
1000
1500
0
50
100
150
200
250
Age-standardised rate per 100
000Age-standardised rate per 100
000
Central Europe, eastern Europe, and central Asia High income Latin America and Caribbean
North Africa and Middle East South Asia Southeast Asia, east Asia, and Oceania
Sub-Saharan Africa
For the GBD Results Tool see
http://ghdx.healthdata.org/gbd-
results-tool
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8
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pressure (from 52·0% [44·6–58·6] to 55·5% [48·2–62·0],
a 6·7% increase) and high fasting plasma glucose (from
14·4% [9·9–20·8] to 20·2% [13·8–29·1], a 40·3% increase).
By contrast, from 1990 to 2019, the stroke PAF of ambient
particulate matter with a diameter of <2.5 μm (known as
PM2·5) pollution decreased from 32·5% (29·6–35·6) to
20·1% (16·6–23·0; a 38·2% decrease), and that of dietary
risks decreased from 32·6% (24·7–41·5) to 30·6%
(22·6–39·8; a 6·1% decrease).
In 2019, there were moderate between-country
(1·3 times), regional (as measured by 21 GBD regions),
and country economic development level (as measured by
the World Bank income groups) variations in the
proportion of stroke-related DALYs and its DALYs related
to stroke pathological types that were attributable to risk
factors. Between-country variations were more
pronounced for subarachnoid haemorrhage (figure 3;
appendix tables S6–12 and figures S12–14), and the highest
Globally World Bank high-income
countries
World Bank upper-middle-
income countries
World Bank lower-middle-
income countries
World Bank low-income
countries
Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage
Environmental risks
Ambient PM2·5
pollution
28·70
(23·40–33·40)
20·1%
(16·6–23·0)
1·57
(1·20–1·95)
9·9%
(7·8–12·3)
16·10
(13·20–18·90)
23·9%
(20·5–26·7)
10·30
(8·04–12·60)
20·0%
(15·7–24·1)
0·75
(0·42–1·16)
8·7%
(5·0–13·4)
Household air
pollution from solid
fuels
14·70
(10·10–20·10)
10·3%
(7·1–14·0)
0·03
(0·01–0·07)
0·2%
(0·1–0·5)
3·64
(1·86–6·14)
5·4%
(2·8–9·0)
8·09
(5·59–10·90)
15·7%
(11·0–21·0)
2·96
(2·29–3·69)
34·4%
(28·5–40·2)
Low ambient
temperature
8·36
(6·19–10·80)
5·8%
(4·4–7·5)
1·28
(0·96–1·64)
8·2%
(6·1–10·5)
5·47
(4·07–7·29)
8·1%
(6·2–10·7)
1·26
(0·45–2·03)
2·4%
(0·9–3·9)
0·35
(0·22–0·50)
4·0%
(2·6–5·6)
High ambient
temperature
1·09
(0·11–2·38)
0·8%
(0·1–1·6)
0·03
(0·01–0·06)
0·2%
(0·1–0·4)
0·14
(0·00–0·39)
0·2%
(0·0–0·6)
0·82
(0·06–1·72)
1·6%
(0·1–3·4)
0·10
(0·02–0·28)
1·2%
(0·3–3·1)
Lead exposure 6·74
(3·91–9·82)
4·7%
(2·8–6·8)
0·25
(0·06–0·50)
1·6%
(0·4–3·2)
3·13
(1·80–4·60)
4·7%
(2·8–6·7)
2·94
(1·78–4·17)
5·7%
(3·5–8·0)
0·42
(0·23–0·64)
4·9%
(2·7–7·2)
Dietary risks
Diet high in sodium 17·70
(5·75–34·90)
12·3%
(4·1–24·3)
1·03
(0·15–2·59)
6·5%
(0·9–16·4)
11·60
(4·77–20·20)
17·3%
(7·3–29·6)
4·33
(0·56–10·50)
8·4%
(1·1–20·3)
0·69
(0·09–1·88)
8·0%
(1·0–21·6)
Diet high in red
meat
10·10
(6·37–13·50)
7·1%
(4·5–9·3)
1·45
(0·98–1·85)
9·2%
(6·2–11·5)
6·73
(4·46–8·84)
10·0%
(6·7–12·8)
1·63
(0·75–2·44)
3·2%
(1·5–4·7)
0·29
(0·10–0·47)
3·4%
(1·1–5·3)
Diet low in fruits 10·50
(6·24–16·00)
7·3%
(4·4–11·2)
0·81
(0·41–1·30)
5·1%
(2·6–8·2)
3·70
(1·92–5·97)
5·5%
(2·9–8·8)
5·17
(3·23–7·74)
10·0%
(6·2–14·9)
0·81
(0·47–1·27)
9·4%
(5·6–14·4)
Diet low in
vegetables
4·15
(1·54–6·84)
2·9%
(1·1–4·8)
0·30
(0·10–0·54)
1·9%
(0·6–3·4)
0·73
(0·31–1·19)
1·1%
(0·5–1·8)
2·52
(0·80–4·30)
4·9%
(1·5–8·2)
0·60
(0·24–0·95)
7·0%
(2·8–11·1)
Diet low in whole
grains
3·26
(0·98–4·76)
2·3%
(0·7–3·3)
0·42
(0·12–0·62)
2·7%
(0·8–3·9)
1·73
(0·48–2·57)
2·6%
(0·7–3·7)
0·96
(0·31–1·43)
1·9%
(0·6–2·8)
0·13
(0·04–0·20)
1·6%
(0·5–2·3)
Alcohol
consumption
8·54
(6·02–11·10)
6·0%
(4·3–7·6)
1·00
(0·67–1·34)
6·3%
(4·2–8·4)
4·99
(3·48–6·64)
7·4%
(5·3–9·5)
2·13
(1·46–2·82)
4·1%
(2·8–5·5)
0·42
(0·25–0·60)
4·9%
(3·1–6·7)
Physical activity
Low physical activity 2·41
(0·43–6·38)
1·7%
(0·3–4·5)
0·46
(0·07–1·26)
2·9%
(0·5–8·0)
1·23
(0·23–3·29)
1·8%
(0·4–4·9)
0·65
(0·12–1·78)
1·3%
(0·2–3·4)
0·07
(0·01–0·20)
0·8%
(0·1–2·3)
Tobacco smoking
Smoking 25·30
(22·60–28·20)
17·6%
(16·4–19·0)
2·68
(2·44–2·94)
17·0%
(15·8–18·3)
13·90
(11·90–16·10)
20·7%
(19·0–22·4)
7·81
(6·94–8·74)
15·1%
(13·9–16·4)
0·88
(0·72–1·06)
10·2%
(9·1–11·3)
Second-hand
smoking
5·09
(3·79–6·56)
3·5%
(2·7–4·5)
0·31
(0·24–0·39)
2·0%
(1·5–2·5)
2·62
(1·93–3·37)
3·9%
(2·9–4·9)
1·93
(1·41–2·56)
3·7%
(2·8–4·8)
0·22
(0·15–0·30)
2·6%
(1·9–3·4)
Physiological factors
High body-mass
index
34·90
(22·30–48·60)
24·3%
(15·7–33·2)
3·99
(2·73–5·36)
25·4%
(17·2–34·2)
15·70
(9·39–22·80)
23·4%
(14·1–33·0)
13·30
(8·65–18·30)
25·8%
(17·0–34·7)
1·87
(1·04–2·84)
21·8%
(12·9–31·6)
High fasting plasma
glucose
28·90
(19·80–41·50)
20·2%
(13·8–29·1)
3·88
(2·45–6·35)
24·7%
(15·7–40·4)
12·30
(8·28–18·30)
18·3%
(12·4–26·5)
11·30
(7·73–15·90)
21·9%
(15·2–30·6)
1·37
(0·92–1·96)
15·9%
(11·1–22·7)
High systolic blood
pressure
79·60
(67·70–90·80)
55·5%
(48·2–62·0)
7·71
(6·44–9·07)
48·9%
(41·3–56·5)
37·20
(31·10–43·40)
55·4%
(47·2–62·6)
30·00
(25·50–34·00)
58·1%
(50·4–64·4)
4·57
(3·60–5·56)
53·2%
(45·6–59·6)
High LDL cholesterol 13·70
(7·72–23·40)
9·6%
(5·5–16·4)
2·02
(0·87–3·91)
12·8%
(5·5–24·3)
7·34
(4·07–12·50)
10·9%
(6·2–18·9)
3·84
(2·37–6·23)
7·4%
(4·6–12·1)
0·50
(0·31–0·77)
5·8%
(3·7–9·0)
Kidney dysfunction 11·90
(9·75–14·10)
8·3%
(7·0–9·7)
1·07
(0·73–1·38)
6·8%
(4·7–8·7)
5·62
(4·48–6·65)
8·4%
(7·0–9·7)
4·70
(3·88–5·55)
9·1%
(7·6–10·6)
0·56
(0·44–0·69)
6·5%
(5·5–7·7)
(Table 2 continues on the next page)
Articles
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9
proportion of stroke-related DALYs was observed in the
World Bank low-income to upper-middle-income groups
(ranging from 85·9% [95% UI 83·2–88·6] in the World
bank low-income group to 87·3% [84·4–89·9] in the World
Bank upper-middle-income group). From 1990 to 2019,
there was an increase in the total number of stroke-related
DALYs due to high BMI, high fasting plasma glucose, high
LDL cholesterol, kidney dysfunction, a diet high in red
meat, alcohol consumption, and second-hand smoking,
but a decrease in DALYs due to smoking and a diet low in
fruits and vegetables (appendix figure S15). There were
also moderate variations in the ranking of risk factors by
pathological types of stroke (figure 4; appendix figures
S16–18). In 2019, the five leading specific risk factors
contributing to stroke death and disability combined
(DALYs) were high systolic blood pressure (79·6 million
[67·7–90·8] attributable DALYs; 55·5% [48·2–62·0] of all
stroke DALYs]), high BMI (34·9 million [22·3–48·6];
[24·3% [15·7–33·2]), high fasting plasma glucose (28·9
million [19·8–41·5]; 20·2% [13·8–29·1]), ambient
particulate matter pollution (28·7 million [23·4–33·4];
20·1% [16·6–23·0]), and smoking (25·3 million
[22·6–28·2]; 17·6% [16·4–19·0]; table2, figure 5). For risk
factors by pathological type of stroke and changes in risk
factor rankings from 1990 to 2019 by GBD regions, see the
appendix (section 4.3 and figures S19–26).
Discussion
In 2019, stroke remained the second-leading Level 3
cause of death and the third-leading Level 3 cause of
death and disability combined in the world, and its
burden (in terms of the absolute number of cases)
increased substantially from 1990 to 2019. Our findings
indicate that the bulk of the global stroke burden (86·0%
[95% UI 85·9–86·9] of deaths and 89·0% [88·9–89·3] of
DALYs) is in lower-income and lower-middle-income
countries. Globally, over the past three decades, the total
number of stroke-related DALYs due to risk factors
increased substantially (by 33·5 million, from 91·5 million
in 1990 to 125 million in 2019), with diverging trends in
World Bank high-income countries and low-income to
upper-middle-income countries: a relatively small decrease
in the high-income group and large increases in the
low-income to upper-middle income groups. The large
increase in the global burden of stroke was probably not
only due to population growth and ageing but also because
of the substantial increase in exposure to several important
risk factors such as high BMI, ambient particulate matter
pollution, high fasting plasma glucose, high systolic blood
pressure, alcohol consumption, low physical activity,
kidney dysfunction, and high temperature (appendix
figure S26).7,14 This study is also the first systematic analysis
to determine the eect of non-optimal temperature on
Globally World Bank high-income
countries
World Bank upper-middle-
income countries
World Bank lower-middle-
income countries
World Bank low-income
countries
Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage Absolute
number
(millions)
Percentage
(Continued from previous page)
Cluster of risk factors
Air pollution* 43·50
(38·40–48·70)
30·4%
(27·7–33·1)
1·60
(1·23–2·00)
10·2%
(8·0–12·6)
19·70
(16·70–22·80)
29·3%
(26·5–32·2)
18·40
(16·20–20·70)
35·7%
(32·7–38·8)
3·71
(3·08–4·38)
43·1%
(40·1–46·3)
Tobacco smoke† 29·50
(26·30–32·70)
20·6%
(19·2–22·0)
2·92
(2·65–3·20)
18·5%
(17·3–19·8)
16·00
(13·80–18·50)
23·8%
(22·1–25·6)
9·49
(8·44–10·60)
18·4%
(16·8–19·8)
1·07
(0·89–1·30)
12·5%
(11·2–13·8)
Dietary risks‡ 43·80
(32·10–58·10)
30·6%
(22·6–39·8)
4·01
(2·98–5·39)
25·5%
(18·9–33·6)
22·40
(15·90–29·70)
33·3%
(24·4–42·9)
15·00
(10·60–20·00)
29·0%
(20·7–38·5)
2·42
(1·61–3·46)
28·2%
(19·6–38·9)
Behavioural risks§ 67·90
(58·20–79·30)
47·4%
(41·3–54·4)
6·88
(5·90–7·99)
43·7%
(38·0–49·8)
34·90
(29·10–41·20)
51·9%
(45·3–58·6)
22·70
(19·00–27·00)
44·0%
(37·7–51·5)
3·42
(2·59–4·43)
39·8%
(32·8–48·8)
Environmental or
occupational risks¶
54·20
(48·20–60·00)
37·8%
(35·0–41·0)
2·98
(2·48–3·53)
18·9%
(16·0–22·4)
25·60
(22·00–29·10)
38·1%
(34·9–41·4)
21·40
(18·90–24·10)
41·5%
(38·4–44·9)
4·17
(3·48–4·87)
48·6%
(45·3–51·8)
Metabolic risks|| 102·00
(89·80–112·00)
71·0%
(64·6–77·1)
10·90
(9·36–12·50)
69·1%
(61·1–77·0)
47·50
(40·70–53·70)
70·7%
(64·0–77·0)
37·60
(33·00–41·50)
72·8%
(66·6–78·1)
5·63
(4·57–6·70)
65·5%
(58·6–71·2)
Combined risk factors
All factors 125·00
(115·00–134·00)
87·0%
(84·2–89·8)
13·10
(11·80–14·40)
83·2%
(78·6–88·2)
59·10
(53·00–65·10)
87·9%
(84·9–90·7)
45·20
(41·30–49·00)
87·6%
(85·2–89·9)
7·18
(6·08–8·41)
83·7%
(81·0–86·1)
Data in parentheses are 95% uncertainty intervals. Count data in millions are presented to two decimal places and percentage data are presented to one decimal place. Percentages and number of DALYs are not
mutually exclusive: the sum of percentages and number of DALYs in the columns exceeds the totals for all risk factors combined because of overlap between various risk factors. The crude sum of population
attributable fraction (PAF) of the risk factors might exceed 100% because the effects of many of these risk factors are mediated partly or wholly through another risk factor or risk factors. DALY=disability-
adjusted life-year. PM2·5=particulate matter with a diameter of <25 μm. *Air pollution cluster includes ambient PM2·5 pollution and household air pollution from solid fuels. †Tobacco smoke cluster includes
smoking and second-hand smoking. ‡Dietary risks cluster includes diet high in sodium, diet low in fruits, diet low in vegetables, diet high in red meat, and diet low in whole grains, and alcohol consumption.
§Behavioural risks cluster includes smoking (including second-hand smoking), dietary risks (diet high in sodium, diet low in fruits, diet low in vegetables, diet high in red meat, diet low in whole grains, and
alcohol consumption), and low physical activity. ¶Environmental risks cluster includes air pollution cluster, low ambient temperature, high ambient temperature, and lead exposure. ||Metabolic risks cluster
includes high body-mass index, high fasting plasma glucose, high LDL cholesterol, high systolic blood pressure, and kidney dysfunction.
Table 2: Stroke-related DALYs (absolute numbers and percentages) associated with risk factors and their clusters in 2019, for all ages and both sexes
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(Figure 3 continues on next page)
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<448·7
448·7 to <536·1
536·1 to <642·1
642·1 to <964·0
964·0 to <1221·1
1221·1 to <1587·4
1587·4 to <1915·6
1915·6 to <2221·4
2221·4 to <2710·4
≥2710·4
DALYs per 100
000 people
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<231·9
231·9 to <266·1
266·1 to <315·1
315·1 to <433·4
433·4 to <533·4
533·4 to <617·0
617·0 to <734·9
734·9 to <926·1
926·1 to <1390·0
≥1390·0
DALYs per 100
000 people
AAll stroke
BIschaemic stroke
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11
Figure 3: Age-standardised stroke-related DALYs attributable to all risk factors combined, for both sexes, 2019
(A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. DALY=disability-adjusted life-year.
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<136·8
136·8 to <170·5
170·5 to <223·2
223·2 to <347·5
347·5 to <533·3
533·3 to <692·1
692·1 to <959·9
959·9 to <1217·3
1217·3 to <1507·4
≥1507·4
DALYs per 100
000 people
Caribbean and central America Persian Gulf West Africa
Balkan Peninsula
Eastern
Mediterranean
Southeast Asia
Northern Europe
<48·8
48·8 to <65·6
65·6 to <79·2
79·2 to <91·2
91·2 to <103·2
103·2 to <118·5
118·5 to <139·7
139·7 to <162·6
162·6 to <202·9
≥202·9
DALYs per 100
000 people
CIntracerebral haemorrhage
DSubarachnoid haemorrhage
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stroke burden. The greater age-standardised burden of
stroke in World Bank low-income to upper-middle-
income countries than in the high-income countries
might also relate to poorer acute health care for stroke,15
poorer stroke awareness,16 and greater prevalence or
eect of some risk factors (eg, tobacco use, poor diet,
diabetes, hypertension, cardiovascular disease, rheumatic
heart disease, dyslipidaemia, and obesity) in low-income
countries than in upper-middle-income countries,17,18
which highlights the inadequacy of primary prevention
eorts in these settings.
For the first time, we have presented the global,
regional, and national burden of stroke and its risk factors
by its major pathological types. Although ischaemic
(Figure 4 continues on next page)
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Global
Central Asia
Central Europe
Eastern Europe
Australasia
High-income Asia Pacific
High-income North America
Southern Latin America
Western Europe
Andean Latin America
Caribbean
Central Latin America
Tropical Latin America
North Africa and Middle East
South Asia
East Asia
Oceania
Southeast Asia
Central sub-Saharan Africa
Eastern sub-Saharan Africa
Southern sub-Saharan Africa
Western sub-Saharan Africa
High temperature
Low physical activity
Diet low in whole grains
Diet low in vegetables
Second-hand smoke
Lead exposure
Alcohol use
Low temperature
Diet high in red meat
Diet low in fruits
Kidney dysfunction
High LDL cholesterol
Household air pollution from solid fuels
Diet high in sodium
Smoking
Ambient particulate matter pollution
High fasting plasma glucose
High body-mass index
High systolic blood pressure
All strokes
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Ischaemic stroke
High temperature
Diet low in vegetables
Alcohol use
Second-hand smoke
Low physical activity
Lead exposure
Diet low in fruits
Diet low in whole grains
Low temperature
Diet high in red meat
Household air pollution from solid fuels
Kidney dysfunction
Diet high in sodium
Smoking
High body-mass index
Ambient particulate matter pollution
High LDL cholesterol
High fasting plasma glucose
High systolic blood pressure
A
B
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13
stroke continues to constitute the largest proportion of
all new strokes (comprising 62·4% of all incident strokes
in 2019), followed by intracerebral haemor rhage (27·9%),
and subarachnoid haemor rhage (9·7%), the relative
proportions of each pathological type varied substantially
by income group. For example, a new stroke case was
nearly twice as likely to be intracerebral haemorrhage in
the World Bank low-income to upper-middle-income
groups combined than in the high-income group (29·5%
of all incident strokes in 2019 vs 15·8%), whereas a new
stroke case was more than twice as likely to be sub-
arachnoid haemorrhage in the World Bank high-income
group than in the low-income to upper-middle-income
groups combined (19·7% vs 7·9%). The increased risk of
intracerebral haemorrhage in low-income and upper-
middle-income countries might be related to the high
relative clinical significance and population-attributable
risk of hypertension in these countries.18 Our finding
that a greater proportion of incident strokes in
low-income to upper-middle-income countries are intra-
cerebral haemor rhages in males than in females
(appendix figure F6.9) are in line with previous
observations,19,20 and might be explained by lower levels
of awareness and control of hypertension in low-income
Figure 4: Age-standardised stroke-related DALYs attributable to risk factors by 21 GBD regions, for both sexes, 2019
(A) All strokes. (B) Ischaemic stroke. (C) Intracerebral haemorrhage. (D) Subarachnoid haemorrhage. Numbers show the ranking level (1=highest, 15=lowest) by the number of DALYs attributable to
the corresponding risk factors. Red shows 1st ranking; light brown, 2nd and 3rd ranking; very light yellow, 4–7 ranking; very light blue, 8–13 ranking; and dark blue, 14–15 ranking. Diet low in whole
grains, low physical activity, and high LDL cholesterol were not assessed for intracerebral haemorrhage. Diet low in whole grains, alcohol use, low physical activity, high LDL cholesterol, and kidney
dysfunction were not assessed for subarachnoid haemorrhage. DALY=disability-adjusted life-year. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.
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High temperature
Diet low in vegetables
Second-hand smoke
Lead exposure
Low temperature
Diet high in red meat
Kidney dysfunction
Diet low in fruits
Alcohol use
Household air pollution from solid fuels
Diet high in sodium
Smoking
High fasting plasma glucose
Ambient particulate matter pollution
High body-mass index
High systolic blood pressure
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High temperature
Second-hand smoke
Diet low in vegetables
Lead exposure
Low temperature
Diet high in red meat
Diet low in fruits
Household air pollution from solid fuels
Diet high in sodium
High fasting plasma glucose
Smoking
Ambient particulate matter pollution
High body-mass index
High systolic blood pressure
Global
Central Asia
Central Europe
Eastern Europe
Australasia
High-income Asia Pacific
High-income North America
Southern Latin America
Western Europe
Andean Latin America
Caribbean
Central Latin America
Tropical Latin America
North Africa and Middle East
South Asia
East Asia
Oceania
Southeast Asia
Central sub-Saharan Africa
Eastern sub-Saharan Africa
Southern sub-Saharan Africa
Western sub-Saharan Africa
Intracerebral haemorrhage
Subarachnoid haemorrhage
C
D
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to upper-middle-income countries than in high-income
countries,18,21 as well as increased exposure to risk factors
predisposing a higher proportion of males to intracerebral
haemorrhage compared with females.20,22 Our study also
adds to the body of research on the incidence of
subarachnoid haemorrhage; a previous systematic review
of population-based studies of subarachnoid haemor-
rhage incidence by Etminan and colleagues23 had similar
findings to ours, as the authors used many of the same
sources, but they only used crude incidence rates, which
is perhaps why we found smaller between-country
variations in the age-standardised incidence of sub-
arachnoid haemor rhage (approximately a tenfold
variation in our findings [appendix table s5] compared
with a >20-fold variation in the systematic review).23 The
size of between-country variations we observed in
age-standardised incidence, prevalence, and DALY rates
of other pathological types of stroke and stroke overall
were in line with previous observations.2,3,19,20,24
Despite the overall declines in age-standardised stroke
incidence, prevalence, death, and DALY rates, three
concerning trends have emerged. First, the greatest
share of the global burden of stroke continues to be
borne by low-income to upper-middle-income countries.
The proportion of DALYs attributable to GBD-modelled
risk factors was also particularly high in low-income to
upper-middle-income countries. Second, the pace of the
global decline in age-standardised stroke incidence,
death, and DALY rates was noticeably slower over the
past decade (2010–19) than in the previous decade
(2000–09), and global age-standardised prevalence
significantly increased from 2010 to 2019 (appendix
figure 6.8). There was a significant increase in stroke
prevalence and incidence rates in people younger than
70 years between 1990 and 2019 with even faster increases
from 2010 to 2019 (appendix figure 6.7). A trend towards
plateauing or increasing stroke incidence or mortality
rates, or both, in middle-aged people was recently
observed in the USA, European countries, Brazil, and
China.25–30 This trend might be a reflection of the
increased exposure to some risk factors for stroke, such
as elevated blood pressure, high BMI, and high fasting
plasma glucose, across most countries.31–33 In the USA, a
worrisome trend observed in recent years (2017–18) is
that awareness of hypertension in the population whose
blood pressure is controlled is declining.34 Third, most
countries have not achieved sucient declines in stroke
incidence rates to oset the demographic force of
Figure 5: Proportion of DALYs attributable to risk factors by pathological type of stroke for both sexes combined, 2019
Proportion of DALYs attributable to household air pollution from solid fuels are not shown in this figure. DALY=disability-adjusted life-year.
Ischaemic stroke
Intracerebral haemorrhage
Subarachnoid haemorrhage
High temperature
Low physical activity
Diet low in whole grains
Diet low in vegetables
Second-hand smoke
Lead exposure
Low temperature
Alcohol use
Diet high in red meat
Diet low in fruits
Kidney dysfunction
High LDL cholesterol
Diet high in sodium
Smoking
High fasting plasma glucose
High body-mass index
Particulate matter pollution
High systolic blood pressure
0·0 1·0 2·0 3·0
Proportion of total DALYs (%)
Articles
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15
population growth and ageing, resulting in overall
increases in the number of incident, prevalent, fatal, and
disabling strokes over time. A linear interpolation shows
that if current trends continue, by 2050 there will be
more than 200 million stroke survivors and almost
300 million DALYs, 25 million new strokes, and
13 million deaths from stroke annually.
This study was, to our knowledge, the first systematic
analysis to provide estimates of the burden of stroke and
its subtypes associated with non-optimal temperature
(daily temperatures below or above the TMREL).
Although previous studies have made ecological
observations of the eects of ambient temperature on the
risk of stroke, this study was the first to show the sizeable
global eect of non-optimal temperature (primarily low
temperature, at 8·36 million [95% UI 6·19–10·80] DALYs
or a PAF of 5·8% [4·4–7·5]) on the burden of stroke and
its pathological types (appendix tables T10b, T11b, and
T12b). These findings were in line with a recent
systematic review on ambient temperature and stroke
occurrence.35 Our estimates of geographical variations in
the burden of stroke and its pathological types associated
with non-optimal temperature and other risk factors
suggest that country-specific and stroke type-specific
priorities and strategies should be developed and
implemented for reducing the burden of stroke in
dierent geographical locations.
Our findings of the high proportion (87·0%) of
age-standardised stroke-related DALYs associated with
GBD risk factors are in line with previous observations17,36
and highlight the potential to greatly reduce the stroke
burden by addressing risk factor exposure. The increased
contribution of certain metabolic risk factors in 2019
compared with 1990 (eg, an increase in the proportional
contribution to stroke-related DALYs of 57·8% by high
BMI and 40·3% by high fasting plasma glucose) and a
decreasing contribution of certain environmental and
occupational and behavioural risk factors to the stroke-
related DALY burden over the same period (eg, a
38·2% decrease for household air pollution from solid
fuels and a 6·1% decrease for a diet low in vegetables)
might be related to a growing proportion of the global
population reaching the final stages of the epidemiological
transition, in which the risk burden has shifted towards
metabolic risk factors and an increased proportion of the
disease burden comes from stroke and other non-
communicable diseases.37 This observation also means
that guidance on reducing the risk of stroke by targeting
certain risk factors will need to change to reflect changes
in the risk-attributable profile.
Our estimates of the global, regional, and national
burden of stroke and its pathological types and risk
factors are important for evidence-based health-care
planning, priority setting, and resource allocation for
stroke care, primary prevention, and research. The high
and increasing stroke burden alongside stagnant or even
increasing mortality rates from cardiovascular disease in
some countries,14 and increasing rates of exposure to
many important stroke risk factors from 1990 to 2019,7,14
suggest that current primary stroke prevention strategies
and measures are not sucient, and that eorts to
implement population-wide primary prevention
strategies more widely must be reinforced worldwide.38
For every US$1 spent on prevention of stroke and
cardiovascular disease, there is an estimated $10·9
return on investment.39 Population-wide interventions
for primary prevention of stroke and cardiovascular
disease should include measures to reduce exposure to
metabolic risk factors (eg, screening for and proper
management of systolic blood pressure and weight),
behavioural risk factors (eg, smoking cessation
programmes and programmes to increase the
accessibility and aordability of nutrient-rich foods), and
environmental and occupational risk factors (eg,
measures to reduce air pollution and lead exposure). The
development and implementation of such population-
level interventions, alongside eorts to reduce poverty
and racial and socioeconomic inequities, through
legislation, taxation, and other measures at the
government level, must be the mainstream approach for
reducing the risk of stroke, cardiovascular disease, and
other non-communicable diseases, but the importance of
primary prevention measures at the individual level
should not be overlooked. In this respect, the emphasis
should be on strategies that are appropriate for most
people at risk of stroke and cardiovascular disease
regardless of their level of risk exposure,38 such as digital
health technologies for aordable identification of people
at increased risk of stroke and cardiovascular disease,
universal health coverage, cheap and eective multidrug
regimens (eg, polypills) for people at increased risk of
cardiovascular disease, and involvement of health-care
volunteers in primary prevention activities. For example,
the World Stroke Organization recommends that all
adults know their individual risk of having a stroke, their
personal risk factors for stroke, and how to control these
risk factors using the validated, internationally endorsed,
and free Stroke Riskometer app, which is currently
available in 19 languages for more than 70% of the global
population.40 A recent Cochrane systematic review
showed the feasibility and potential eectiveness of
several health promotion interventions targeting risk
factors to achieve behavioural changes for primary
prevention of cardiovascular disease in low-income to
upper-middle-income countries.41 Although knowledge
of personal risk and management of behavioural risk
factor activities is primarily the prerogative of
individuals, health professionals have a responsibility to
identify risk factors that require pharmacological and
non-pharma cological treatment to reduce the chance of
stroke occurrence (eg, elevated blood pressure, atrial
fibrillation, diabetes, dyslipidaemia, or symptomatic
carotid artery stenosis). Simple, inexpensive screening
for cardiovascular disease risks (eg, elevated blood
For more on the Stroke
Riskometer & PreventS app see
https://nisan.aut.ac.nz/Stroke-
Riskometer/
Articles
16
www.thelancet.com/neurology Published online September 3, 2021 https://doi.org/10.1016/S1474-4422(21)00252-0
pressure, smoking, and overweight) by health
professionals in low-income and middle-income settings
or more accurate screening for high cardiovascular
disease risks (including blood lipid tests) by health
professionals in higher-income locations can help to
identify people who might require prophylactic drug
therapy, in conjunction with behavioural interventions.40
However, health professionals often do not have enough
time to conduct detailed assessments of behavioural risk
factors or to develop individually tailored recom-
mendations for primary prevention of stroke and cardio-
vascular disease. To ameliorate this problem, data on
stroke risk and risk factors from individuals should be
integrated with the electronic patient management
systems of health service providers. A study in Finland
suggests that the quality of stroke prevention by primary
health-care professionals could be improved by developing
digital clinical decision-making tools and by implementing
inter-professional teamwork42 (eg, the PreventS web app
currently being developed in New Zealand). All of these
measures should be facilitated by ongoing, culturally
appropriate health education campaigns (including
coordinated activities of non-governmental organisations)
and inclusion of such health education information into
standardised educational curricula at all levels.
In addition to primary stroke prevention eorts,
appropriate secondary prevention eorts and adequate
acute treatment and rehabilitation are essential to improve
stroke outcomes. Our findings of large geographical
variations in stroke prevalence, mortality, and disability
are a reflection not only of geographical dierences in
stroke incidence but also of major inequities in acute
stroke care and rehabilitation across countries.43 Even in
European countries, only 7·3% of all patients with acute
ischaemic stroke receive intravenous thrombolysis and
only 1·9% receive endovascular treatment, with the
highest country-level rates being 20·6% for intravenous
thrombolysis (in the Netherlands) and 5·6% for
endovascular treatment (in Malta),44 and one in three
patients discontinues using one or more secondary stroke
prevention drugs about 1 year after stroke.45 Treatment
rates are even lower in many low-income and middle-
income countries.21,43 To reduce inequalities in stroke care,
a roadmap for delivering quality stroke care and various
action plans46,47 have been suggested, with emphasis on
the importance of applying culturally appropriate and
context-appropriate strategies. There is a pressing need to
implement evidence-based guidelines for stroke
management and to reduce the gap in stroke care between
high-income countries and low-income and middle-
income countries. Recent evidence suggests that
delivering an adequate level of stroke care48,49 and
preventive interventions49 in low-income and middle-
income countries are feasible. Attention should be paid to
developing the workforce for stroke care and setting up
aordable and accessible rehabilitation facilities.
Promising results50 suggest that self-management could
be used as an adjunct strategy for ongoing rehabilitation
at home or in other settings. The importance of country-
based ongoing stroke registries and stroke risk factors
surveys, which are profoundly lacking in low-income and
middle-income countries, should also be emphasised.
Although this study was, to our knowledge, the first
and most comprehensive review of the global, regional,
and national burden of stroke and its 19 specific risk
factors by all three pathological types, it was not free
from limitations common to all previous GBD estimates
of stroke risk and risk factors,2,3,11,36 particularly the
absence of original, good-quality stroke epidemiological
studies for most countries. We therefore were not able to
include some important potential risk factors (eg, atrial
fibrillation and substance abuse), or include dierent
patterns in risk factor exposure (eg, dierent doses and
types of alcohol consumption, pack-years of smoking)
and doses of exposure, analyse stroke burden by
ischaemic stroke subtypes, or do a decomposition
analysis to attribute changes in stroke burden to changes
in the population growth, ageing, and risk factors
separately. Additionally, evidence for the selection of
TMRELs for some risk factors was uncertain and based
on non-experimental studies, although all TMRELs were
discussed and approved by a team of risk epidemiologists
and stroke experts. Despite these limitations, our results
are broadly consistent with previous estimates from
population-based and analytical epidemiological studies,
thus supporting the validity of our results.
In summary, although strokes are largely preventable,
as indicated by declining incidence rates globally, stroke
remained the second-leading cause of death and third-
leading cause of death and disability combined worldwide
in 2019. Without wider implementation of population-
wide primary stroke and cardiovascular disease pre-
vention strategies, the burden of stroke is likely to
continue growing, disproportionally aecting low-
income and middle-income countries. As the 19 analysed
risk factors for stroke are common for other major non-
communicable diseases, appropriate control of these risk
factors will also reduce the burden of coronary heart
disease, vascular dementia, type 2 diabetes, and even
some types of cancer. Further research on the frequency,
outcomes, and determinants of stroke and its pathological
types in dierent locations and over time is warranted.
Such research could include identifying populations at
highest risk as well as further investigating dierences
in stroke pathological types and their geographical
patterns, all of which would be useful for more targeted
prevention and treatment eorts. Closing the gaps
between high-income countries and low-income and
middle-income countries in the adaptation and imple-
mentation of internationally recognised guidelines and
recom mendations for reducing stroke morbidity and
mortality, with an emphasis on primary prevention
strategies, is crucial to addressing the global stroke
burden.
Articles
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17
Contributors
Please see the appendix (pp 7–10) for more detailed information about
individual author contributions to the research, divided into the
following categories: managing the estimation or publication process;
writing the first draft of the manuscript; primary responsibility for
applying analytical methods to produce estimates; primary responsibility
for seeking, cataloguing, extracting, or cleaning data; designing or
coding figures and tables; providing data or critical feedback on data
sources; development of methods or computational machinery;
providing critical feedback on methods or results; drafting the
manuscript or revising it critically for important intellectual content;
extracting, cleaning, or cataloguing data; designing or coding figures and
tables; and managing the overall research enterprise. V L Feigin and
GARoth had access to and verified the data underlying this
study. All authors had full access to all the data in the study, and
VLFeigin had final responsibility for the decision to submit for
publication.
GBD 2019 Stroke Collaborators
Valery L Feigin, Benjamin A Stark, Catherine Owens Johnson,
Gregory A Roth, Catherine Bisignano, Gdiom Gebreheat Abady,
Mitra Abbasifard, Mohsen Abbasi-Kangevari, Foad Abd-Allah,
Vida Abedi, Ahmed Abualhasan, Niveen ME Abu-Rmeileh, Abdelrahman
I Abushouk, Oladimeji M Adebayo, Gina Agarwal, Pradyumna Agasthi,
Bright Opoku Ahinkorah, Sohail Ahmad, Sepideh Ahmadi,
Yusra Ahmed Salih, Budi Aji, Samaneh Akbarpour,
Rufus Olusola Akinyemi, Hanadi Al Hamad, Fares Alahdab,
Sheikh Mohammad Alif, Vahid Alipour, Syed Mohamed Aljunid,
Sami Almustanyir, Rajaa M Al-Raddadi, Rustam Al-Shahi Salman,
Nelson Alvis-Guzman, Robert Ancuceanu, Deanna Anderlini,
Jason A Anderson, Adnan Ansar, Ippazio Cosimo Antonazzo,
Jalal Arabloo, Johan Ärnlöv, Kurnia Dwi Artanti, Zahra Aryan,
Samaneh Asgari, Tahira Ashraf, Mohammad Athar, Alok Atreya,
Marcel Ausloos, Atif Amin Baig, Ovidiu Constantin Baltatu,
Maciej Banach, Miguel A Barboza, Suzanne Lyn Barker-Collo,
Till Winfried Bärnighausen, Mark Thomaz Ugliara Barone, Sanjay Basu,
Gholamreza Bazmandegan, Ettore Beghi, Mahya Beheshti,
Yannick Béjot, Arielle Wilder Bell, Derrick A Bennett,
Isabela M Bensenor, Woldesellassie Mequanint Bezabhe,
Yihienew Mequanint Bezabih, Akshaya Srikanth Bhagavathula,
Pankaj Bhardwaj, Krittika Bhattacharyya, Ali Bijani, Boris Bikbov,
Mulugeta M Birhanu, Archith Boloor, Aime Bonny, Michael Brauer,
Hermann Brenner, Dana Bryazka, Zahid A Butt,
Florentino Luciano Caetano dos Santos, Ismael R Campos-Nonato,
Carlos Cantu-Brito, Juan J Carrero, Carlos A Castañeda-Orjuela,
Alberico L Catapano, Promit Ananyo Chakraborty, Jaykaran Charan,
Sonali Gajanan Choudhari, Enayet Karim Chowdhury, Dinh-Toi Chu,
Sheng-Chia Chung, David Colozza, Vera Marisa Costa,
Simona Costanzo, Michael H Criqui, Omid Dadras, Baye Dagnew,
Xiaochen Dai, Koustuv Dalal, Albertino Antonio Moura Damasceno,
Emanuele D’Amico, Lalit Dandona, Rakhi Dandona,
Jiregna Darega Gela, Kairat Davletov, Vanessa De la Cruz-Góngora,
Rupak Desai, Deepak Dhamnetiya, Samath Dhamminda Dharmaratne,
Mandira Lamichhane Dhimal, Meghnath Dhimal, Daniel Diaz,
Martin Dichgans, Klara Dokova, Rajkumar Doshi, Abdel Douiri,
Bruce B Duncan, Sahar Eftekharzadeh, Michael Ekholuenetale,
Nevine El Nahas, Islam Y Elgendy, Muhammed Elhadi,
Shaimaa I El-Jaafary, Matthias Endres, Aman Yesuf Endries,
Daniel Asfaw Erku, Emerito Jose A Faraon, Umar Farooque,
Farshad Farzadfar, Abdullah Hamid Feroze, Irina Filip, Florian Fischer,
David Flood, Mohamed M Gad, Shilpa Gaidhane,
Reza Ghanei Gheshlagh, Ahmad Ghashghaee, Nermin Ghith,
Ghozali Ghozali, Sherief Ghozy, Alessandro Gialluisi,
Simona Giampaoli, Syed Amir Gilani, Paramjit Singh Gill,
Elena V Gnedovskaya, Mahaveer Golechha, Alessandra C Goulart,
Yuming Guo, Rajeev Gupta, Veer Bala Gupta, Vivek Kumar Gupta,
Pradip Gyanwali, Nima Hafezi-Nejad, Samer Hamidi, Asif Hanif,
Graeme J Hankey, Arief Hargono, Abdiwahab Hashi, Treska S Hassan,
Hamid Yimam Hassen, Rasmus J Havmoeller, Simon I Hay,
Khezar Hayat, Mohamed I Hegazy, Claudiu Herteliu, Ramesh Holla,
Sorin Hostiuc, Mowafa Househ, Junjie Huang, Ayesha Humayun,
Bing-Fang Hwang, Licia Iacoviello, Ivo Iavicoli,
Segun Emmanuel Ibitoye, Olayinka Stephen Ilesanmi, Irena M Ilic,
Milena D Ilic, Usman Iqbal, Seyed Sina Naghibi Irvani,
Sheikh Mohammed Shariful Islam, Nahlah Elkudssiah Ismail,
Hiroyasu Iso, Gaetano Isola, Masao Iwagami, Louis Jacob,
Vardhmaan Jain, Sung-In Jang, Sathish Kumar Jayapal, Shubha Jayaram,
Ranil Jayawardena, Panniyammakal Jeemon, Ravi Prakash Jha,
Walter D Johnson, Jost B Jonas, Nitin Joseph, Jacek Jerzy Jozwiak,
Mikk Jürisson, Rizwan Kalani, Rohollah Kalhor, Yogeshwar Kalkonde,
Ashwin Kamath, Zahra Kamiab, Tanuj Kanchan, Himal Kandel,
André Karch, Patrick D M C Katoto, Gbenga A Kayode,
Pedram Keshavarz, Yousef Saleh Khader, Ejaz Ahmad Khan,
Imteyaz A Khan, Maseer Khan, Moien A B Khan,
Mahalaqua Nazli Khatib, Jagdish Khubchandani, Gyu Ri Kim,
Min Seo Kim, Yun Jin Kim, Adnan Kisa, Sezer Kisa,
Mika Kivimäki, Dhaval Kolte, Ali Koolivand,
Sindhura Lakshmi Koulmane Laxminarayana, Ai Koyanagi,
Kewal Krishan, Vijay Krishnamoorthy, Rita V Krishnamurthi,
G Anil Kumar, Dian Kusuma, Carlo La Vecchia, Ben Lacey,
Hassan Mehmood Lak, Tea Lallukka, Savita Lasrado, Pablo M Lavados,
Matilde Leonardi, Bingyu Li, Shanshan Li, Hualiang Lin, Ro-Ting Lin,
Xuefeng Liu, Warren David Lo, Stefan Lorkowski, Giancarlo Lucchetti,
Ricardo Lutzky Saute, Hassan Magdy Abd El Razek,
Francesca Giulia Magnani, Preetam Bhalchandra Mahajan,
Azeem Majeed, Alaa Makki, Reza Malekzadeh, Ahmad Azam Malik,
Navid Manafi, Mohammad Ali Mansournia,
Lorenzo Giovanni Mantovani, Santi Martini, Giampiero Mazzaglia,
Man Mohan Mehndiratta, Ritesh G Menezes, Atte Meretoja,
Amanual Getnet Mersha, Junmei Miao Jonasson, Bartosz Miazgowski,
Tomasz Miazgowski, Irmina Maria Michalek, Erkin M Mirrakhimov,
Yousef Mohammad, Abdollah Mohammadian-Hafshejani,
Shafiu Mohammed, Ali H Mokdad, Yaser Mokhayeri, Mariam Molokhia,
Mohammad Ali Moni, Ahmed Al Montasir, Rahmatollah Moradzadeh,
Lidia Morawska, Jakub Morze, Walter Muruet, Kamarul Imran Musa,
Ahamarshan Jayaraman Nagarajan, Mohsen Naghavi,
Sreenivas Narasimha Swamy, Bruno Ramos Nascimento,
Ruxandra Irina Negoi, Sandhya Neupane Kandel, Trang Huyen Nguyen,
Bo Norrving, Jean Jacques Noubiap, Vincent Ebuka Nwatah,
Bogdan Oancea, Oluwakemi Ololade Odukoya, Andrew T Olagunju,
Hans Orru, Mayowa O Owolabi, Jagadish Rao Padubidri, Adrian Pana,
Tarang Parekh, Eun-Cheol Park, Fatemeh Pashazadeh Kan,
Mona Pathak, Mario F P Peres, Arokiasamy Perianayagam,
Truong-Minh Pham, Michael A Piradov, Vivek Podder, Suzanne Polinder,
Maarten J Postma, Akram Pourshams, Amir Radfar, Alireza Rafiei,
Alberto Raggi, Fakher Rahim, Vafa Rahimi-Movaghar, Mosiur Rahman,
Muhammad Aziz Rahman, Amir Masoud Rahmani, Nazanin Rajai,
Priyanga Ranasinghe, Chythra R Rao, Sowmya J Rao, Priya Rathi,
David Laith Rawaf, Salman Rawaf, Marissa B Reitsma,
Vishnu Renjith, Andre M N Renzaho, Aziz Rezapour,
Jeerson Antonio Buendia Rodriguez, Leonardo Roever,
Michele Romoli, Andrzej Rynkiewicz, Simona Sacco,
Masoumeh Sadeghi, Sahar Saeedi Moghaddam, Amirhossein Sahebkar,
KM Saif-Ur-Rahman, Rehab Salah, Mehrnoosh Samaei,
Abdallah M Samy, Itamar S Santos, Milena M Santric-Milicevic,
Nizal Sarrafzadegan, Brijesh Sathian, Davide Sattin, Silvia Schiavolin,
Markus P Schlaich, Maria Inês Schmidt, Aletta Elisabeth Schutte,
Sadaf G Sepanlou, Allen Seylani, Feng Sha, Saeed Shahabi,
Masood Ali Shaikh, Mohammed Shannawaz,
Md Shajedur Rahman Shawon, Aziz Sheikh, Sara Sheikhbahaei,
Kenji Shibuya, Soraya Siabani, Diego Augusto Santos Silva,
Jasvinder A Singh, Jitendra Kumar Singh, Valentin Yurievich Skryabin,
Anna Aleksandrovna Skryabina, Badr Hasan Sobaih, Stefan Stortecky,
Saverio Stranges, Eyayou Girma Tadesse, Ingan Ukur Tarigan,
Mohamad-Hani Temsah, Yvonne Teuschl, Amanda G Thrift,
Marcello Tonelli, Marcos Roberto Tovani-Palone, Bach Xuan Tran,
Manjari Tripathi, Gebiyaw Wudie Tsegaye, Anayat Ullah, Brigid Unim,
Bhaskaran Unnikrishnan, Alireza Vakilian, Sahel Valadan Tahbaz,
Tommi Juhani Vasankari, Narayanaswamy Venketasubramanian,
Dominique Vervoort, Bay Vo, Victor Volovici, Kia Vosoughi,
Giang Thu Vu, Linh Gia Vu, Hatem A Wafa, Yasir Waheed,
Yanzhong Wang, Tissa Wijeratne, Andrea Sylvia Winkler,
Charles D A Wolfe, Mark Woodward, Jason H Wu, Sarah Wulf Hanson,
Articles
18
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Xiaoyue Xu, Lalit Yadav, Ali Yadollahpour,
Seyed Hossein Yahyazadeh Jabbari, Kazumasa Yamagishi,
Hiroshi Yatsuya, Naohiro Yonemoto, Chuanhua Yu, Ismaeel Yunusa,
Muhammed Shahriar Zaman, Sojib Bin Zaman, Maryam Zamanian,
Ramin Zand, Alireza Zandifar, Mikhail Sergeevich Zastrozhin,
Anasthasia Zastrozhina, Yunquan Zhang, Zhi-Jiang Zhang,
Chenwen Zhong, Yves Miel H Zuniga, and Christopher J L Murray.
Affiliations
National Institute for Stroke and Applied Neurosciences
(Prof V L Feigin PhD, R V Krishnamurthi PhD), Auckland University of
Technology, Auckland, New Zealand; Institute for Health Metrics and
Evaluation (Prof V L Feigin PhD, B A Stark MA, C O Johnson PhD,
G A Roth MD, C Bisignano MPH, J A Anderson BS, Prof M Brauer DSc,
D Bryazka BA, X Dai PhD, Prof L Dandona MD, Prof R Dandona PhD,
Prof S D Dharmaratne MD, Prof S I Hay FMedSci,
Prof A H Mokdad PhD, Prof M Naghavi MD, M B Reitsma BS,
S Wulf Hanson PhD, Prof C J L Murray DPhil), Division of Cardiology
(G A Roth MD), Department of Health Metrics Sciences, School of
Medicine (G A Roth MD, Prof R Dandona PhD,
Prof S D Dharmaratne MD, Prof S I Hay FMedSci,
Prof A H Mokdad PhD, Prof M Naghavi MD, Prof C J L Murray DPhil),
Department of Neurological Surgery (A H Feroze MD), Department of
Neurology (R Kalani MD), Department of Anesthesiology & Pain
Medicine (V Krishnamoorthy MD), University of Washington, Seattle,
WA, USA; Third Department of Neurology (E V Gnedovskaya PhD),
Research Center of Neurology, Moscow, Russia (Prof V L Feigin PhD,
Prof M A Piradov DSc); Department of Nursing (G G Abady MSc),
Adigrat University, Adigrat, Ethiopia; Department of Internal Medicine
(M Abbasifard MD, G Bazmandegan PhD), Clinical Research
Development Unit (M Abbasifard MD, G Bazmandegan PhD,
Z Kamiab MD), Family Medicine Department (Z Kamiab MD),
Department of Neurology (A Vakilian MD), Non-communicable
Diseases Research Center (A Vakilian MD), Rafsanjan University of
Medical Sciences, Rafsanjan, Iran; Social Determinants of Health
Research Center (M Abbasi-Kangevari MD), School of Advanced
Technologies in Medicine (S Ahmadi PhD), Prevention of Metabolic
Disorders Research Center (S Asgari MSc), Shahid Beheshti University
of Medical Sciences, Tehran, Iran; Department of Neurology
(Prof F Abd-Allah MD, A Abualhasan MD, S I El-Jaafary MD,
M I Hegazy PhD), Cairo University, Cairo, Egypt; Department of
Molecular and Functional Genomics (V Abedi PhD), Department of
Neuroscience (R Zand MD), Geisinger Health System, Danville, PA,
USA; Biocomplexity Institute (V Abedi PhD), Virginia Tech, Blacksburg,
VA, USA; Institute of Community and Public Health
(Prof N M Abu-Rmeileh PhD), Birzeit University, Ramallah, Palestine;
Harvard Medical School (A I Abushouk MD), Brigham and Women’s
Hospital (Z Aryan MD), TH Chan School of Public Health
(Prof T W Bärnighausen MD, I Yunusa PhD), Center for Primary Care
(S Basu PhD), Department of Global Health and Social Medicine
(A W Bell MSW), Division of Cardiology (I Y Elgendy MD), Department
of Medicine (D Kolte MD), Department of Internal Medicine
(N Rajai MD), Division of General Internal Medicine
(Prof A Sheikh MD), Harvard University, Boston, MA, USA; Department
of Medicine (A I Abushouk MD), Neurology Department
(Prof N El Nahas MD), Department of Entomology (A M Samy PhD),
Ain Shams University, Cairo, Egypt; College of Medicine
(O M Adebayo MD), Department of Community Medicine
(O S Ilesanmi PhD), Department of Medicine (Prof M O Owolabi DrM),
University College Hospital, Ibadan, Ibadan, Nigeria; Department of
Family Medicine (Prof G Agarwal PhD), Department of Psychiatry and
Behavioural Neurosciences (A T Olagunju MD), McMaster University,
Hamilton, ON, Canada; Department of Cardiovascular Medicine
(P Agasthi MD), Mayo Clinic, Scottsdale, AZ, USA; The Australian
Centre for Public and Population Health Research (ACPPHR)
(B O Ahinkorah MPH), School of Health (S Siabani PhD), University of
Technology Sydney, Sydney, NSW, Australia; Faculty of Pharmacy
(S Ahmad MSc), MAHSA University, Kuala Langat, Malaysia; Database
Technology Department (Y Ahmed Salih PhD), College of Informatics
(YAhmedSalih PhD), Sulaimani Polytechnic University, Sulaymaniyah,
Iraq; Faculty of Medicine and Public Health (B Aji DrPH), Jenderal
Soedirman University, Purwokerto, Indonesia; Occupational Sleep
Research Center (S Akbarpour PhD), Non-communicable Diseases
Research Center (Z Aryan MD, Prof F Farzadfar DSc,
S Saeedi Moghaddam MSc), School of Medicine (N Hafezi-Nejad MD),
Digestive Diseases Research Institute (Prof R Malekzadeh MD,
Prof A Pourshams MD, S G Sepanlou MD), Department of
Epidemiology and Biostatistics (M Mansournia PhD), Metabolomics and
Genomics Research Center (F Rahim PhD), Sina Trauma and Surgery
Research Center (Prof V Rahimi-Movaghar MD), Tehran University of
Medical Sciences, Tehran, Iran; Institute for Advanced Medical Research
and Training (R O Akinyemi PhD), Department of Epidemiology and
Medical Statistics (M Ekholuenetale MSc), Faculty of Public Health
(M Ekholuenetale MSc), Department of Health Promotion and
Education (S E Ibitoye MPH), Department of Community Medicine
(O S Ilesanmi PhD), Department of Medicine (Prof M O Owolabi DrM),
University of Ibadan, Ibadan, Nigeria; Institute of Neuroscience
(R O Akinyemi PhD), Newcastle University, Newcastle upon Tyne, UK;
Geriatric and Long Term Care Department (H Al Hamad MD,
B Sathian PhD), Rumailah Hospital (H Al Hamad MD), Hamad Medical
Corporation, Doha, Qatar; Mayo Evidence-based Practice Center
(F Alahdab MSc), Mayo Clinic Foundation for Medical Education and
Research, Rochester, MN, USA; Epidemiology and Preventive Medicine
(S M Alif PhD), Department of Epidemiology and Preventative Medicine
(E K Chowdhury PhD), Department of Epidemiology and Preventive
Medicine (Prof Y Guo PhD), School of Public Health and Preventive
Medicine (S Li PhD), Department of Medicine (Prof A G Thrift PhD),
The School of Clinical Sciences at Monash Health (S Zaman MPH),
Monash University, Melbourne, VIC, Australia; Health Management and
Economics Research Center (V Alipour PhD, J Arabloo PhD,
A Ghashghaee BSc, A Rezapour PhD), Department of Health Economics
(V Alipour PhD), Student Research Committee (A Ghashghaee BSc),
School of Medicine (N Manafi MD), Preventive Medicine and Public
Health Research Center (K Vosoughi MD), Iran University of Medical
Sciences, Tehran, Iran (F Pashazadeh Kan BSN); Department of Health
Policy and Management (Prof S M Aljunid PhD), Kuwait University,
Safat, Kuwait; International Centre for Casemix and Clinical Coding
(Prof S M Aljunid PhD), National University of Malaysia, Bandar Tun
Razak, Malaysia; College of Medicine (S Almustanyir MD), Alfaisal
University, Riyadh, Saudi Arabia; Ministry of Health, Riyadh, Saudi
Arabia (S Almustanyir MD); Department of Community Medicine
(R M Al-Raddadi PhD), Rabigh Faculty of Medicine (A A Malik PhD),
King Abdulaziz University, Jeddah, Saudi Arabia; Centre for Clinical
Brain Sciences (Prof R Al-Shahi Salman PhD), Centre for Medical
Informatics (Prof A Sheikh MD), University of Edinburgh, Edinburgh,
UK; Research Group in Hospital Management and Health Policies
(Prof N Alvis-Guzman PhD), Universidad de la Costa (University of the
Coast), Barranquilla, Colombia; Research Group in Health Economics
(Prof N Alvis-Guzman PhD), University of Cartagena, Cartagena,
Colombia; Pharmacy Department (Prof R Ancuceanu PhD), Department
of Legal Medicine and Bioethics (S Hostiuc PhD), Department of
Anatomy and Embryology (R I Negoi PhD), Carol Davila University of
Medicine and Pharmacy, Bucharest, Romania; Centre for Sensorimotor
Performance (D Anderlini MD), The University of Queensland,
Brisbane, QLD, Australia; Neurology Department (D Anderlini MD),
Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia; School
of Nursing and Midwifery (A Ansar MPH, M Rahman PhD), La Trobe
University, Melbourne, VIC, Australia; Special Interest Group
International Health (A Ansar MPH), Public Health Association of
Australia, Canberra, ACT, Australia; Research Center on Public Health
(I Antonazzo PhD), School of Medicine and Surgery
(Prof L G Mantovani DSc), Department of Medicine (G Mazzaglia PhD),
University of Milan Bicocca, Monza, Italy; Department of Neurobiology,
Care Sciences and Society (Prof J Ärnlöv PhD), Department of Medical
Epidemiology and Biostatistics (Prof J J Carrero PhD), Department of
Medicine (T S Hassan PhD), Karolinska Institute, Stockholm, Sweden;
School of Health and Social Studies (Prof J Ärnlöv PhD), Dalarna
University, Falun, Sweden; Department of Epidemiology
(K D Artanti MSc, A Hargono Dr), Faculty of Public Health
(S Martini PhD), Universitas Airlangga (Airlangga University), Surabaya,
Indonesia; University Institute of Radiological Sciences and Medical
Imaging Technology (T Ashraf MS), Faculty of Allied Health Sciences
(Prof S Gilani PhD), University Institute of Public Health (A Hanif PhD,
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19
A A Malik PhD), The University of Lahore, Lahore, Pakistan;
Department of Medical Genetics (M Athar PhD), Science and
Technology Unit (M Athar PhD), Umm Al-Qura University, Makkah,
Saudi Arabia; Department of Forensic Medicine (A Atreya MD), Lumbini
Medical College, Palpa, Nepal; School of Business (Prof M Ausloos PhD),
University of Leicester, Leicester, UK; Department of Statistics and
Econometrics (Prof M Ausloos PhD, Prof C Herteliu PhD, A Pana MD),
Bucharest University of Economic Studies, Bucharest, Romania; Unit of
Biochemistry (A A Baig PhD), Universiti Sultan Zainal Abidin (Sultan
Zainal Abidin University), Kuala Terengganu, Malaysia; Department of
Pharmacology & Therapeutics (Prof O C Baltatu PhD), Khalifa
University, Abu Dhabi, United Arab Emirates; Center of Innovation,
Technology and Education (CITE) (Prof O C Baltatu PhD), Anhembi
Morumbi University, Sao Jose dos Campos, Brazil; Department of
Hypertension (Prof M Banach PhD), Medical University of Lodz, Lodz,
Poland; Polish Mothers’ Memorial Hospital Research Institute, Lodz,
Poland (Prof M Banach PhD); Department of Neurosciences
(Prof M A Barboza MD), Costa Rican Department of Social Security,
San Jose, Costa Rica; School of Medicine (Prof M A Barboza MD),
University of Costa Rica, San Pedro, Costa Rica; School of Psychology
(Prof S L Barker-Collo PhD), University of Auckland, Auckland,
New Zealand; Heidelberg Institute of Global Health (HIGH)
(Prof T W Bärnighausen MD), Department of Ophthalmology
(Prof J B Jonas MD), Heidelberg University, Heidelberg, Germany;
Programs, Partnerships, Research and Education (M T U Barone PhD),
International Diabetes Federation, São Paulo, Brazil; International
Diabetes Federation, Brussels, Belgium (M T U Barone PhD); School of
Public Health (S Basu PhD), Imperial College Business School
(D Kusuma DSc), Department of Primary Care and Public Health
(Prof A Majeed MD, Prof S Rawaf MD), WHO Collaborating Centre for
Public Health Education and Training (D L Rawaf MD), Imperial College
London, London, UK; Department of Neuroscience (E Beghi MD),
Mario Negri Institute for Pharmacological Research, Milan, Italy;
Department of Physical Medicine and Rehabilitation (M Beheshti MD),
New York University, New York, NY, USA; Department of Neurology
(Prof Y Béjot PhD), University Hospital of Dijon, Dijon, France; Dijon
Stroke Registry - UFR Sciences Santé (Prof Y Béjot PhD), University of
Burgundy, Dijon, France; Department of Social Services
(A W Bell MSW), Tufts Medical Center, Boston, MA, USA; Nueld
Department of Population Health (D A Bennett PhD, B Lacey PhD),
University of Oxford, Oxford, UK; Department of Internal Medicine
(I M Bensenor PhD, A C Goulart PhD, I S Santos PhD), Center for
Clinical and Epidemiological Research (A C Goulart PhD,
I S Santos PhD), Department of Psychiatry (Prof M F P Peres MD),
University of São Paulo, São Paulo, Brazil; University of Tasmania,
Tasmania, VIC, Australia (W M Bezabhe BSc); Department of Internal
Medicine (Y M Bezabih MD), College of Medicine and Health Sciences
(G W Tsegaye MPH), Bahir Dar University, Bahir Dar, Ethiopia
(W M Bezabhe BSc); One Health (Y M Bezabih MD), University of
Nantes, Nantes, France; Department of Social and Clinical Pharmacy
(A S Bhagavathula PharmD), Charles University, Hradec Kralova, Czech
Republic; Institute of Public Health (A S Bhagavathula PharmD), Family
Medicine Department (M A Khan MSc), United Arab Emirates
University, Al Ain, United Arab Emirates; Department of Community
Medicine and Family Medicine (P Bhardwaj MD), School of Public
Health (P Bhardwaj MD), Department of Pharmacology (J Charan MD),
Department of Forensic Medicine and Toxicology (T Kanchan MD),
All India Institute of Medical Sciences, Jodhpur, India; Department of
Statistical and Computational Genomics (K Bhattacharyya MSc),
National Institute of Biomedical Genomics, Kalyani, India; Department
of Statistics (K Bhattacharyya MSc), University of Calcutta, Kolkata,
India; Social Determinants of Health Research Center (A Bijani PhD),
Babol University of Medical Sciences, Babol, Iran; Mario Negri Institute
for Pharmacological Research, Ranica, Italy (B Bikbov MD); Stroke and
Ageing Research Group, Epidemiology and Prevention Division
(M M Birhanu MSc), Monash University, Clayton, Melbourne, Australia;
Department of Nursing (M M Birhanu MSc), St Paul’s Hospital
Millennium Medical College, Addis Ababa, Ethiopia; Department of
Internal Medicine (A Boloor MD), Department of Community Medicine
(N Joseph MD), Kasturba Medical College (Prof B Unnikrishnan MD),
Manipal Academy of Higher Education, Mangalore, India; Faculty of
Medicine and Pharmaceutical Sciences (A Bonny MD), University of
Douala, Douala, Cameroon; Department of Cardiology (A Bonny MD),
Centre Hospitalier Montfermeil (Montfermeil Hospital Center),
Montfermeil, France; School of Population and Public Health
(Prof M Brauer DSc, P A Chakraborty MPH, Prof N Sarrafzadegan MD),
University of British Columbia, Vancouver, BC, Canada; Division of
Clinical Epidemiology and Aging Research (Prof H Brenner MD),
German Cancer Research Center, Heidelberg, Germany; School of
Public Health and Health Systems (Z A Butt PhD), University of
Waterloo, Waterloo, ON, Canada; Al Shifa School of Public Health
(Z A Butt PhD), Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan;
Institute of Microengineering (F Caetano dos Santos PhD), Federal
Polytechnic School of Lausanne, Lausanne, Switzerland; Health and
Nutrition Research Center (I R Campos-Nonato PhD), Center for
Evaluation and Surveys Research (V De la Cruz-Góngora PhD), National
Institute of Public Health, Cuernavaca, Mexico; Department of
Neurology (Prof C Cantu-Brito PhD), Salvador Zubiran National
Institute of Medical Sciences and Nutrition, Mexico City, Mexico;
Colombian National Health Observatory (C A Castañeda-Orjuela MD),
National Institute of Health, Bogota, Colombia; Epidemiology and Public
Health Evaluation Group (C A Castañeda-Orjuela MD), National
University of Colombia, Bogota, Colombia; Department of
Pharmacological and Biomolecular Sciences (Prof A L Catapano PhD),
Department of Clinical Sciences and Community Health
(Prof C La Vecchia MD), University of Milan, Milan, Italy; MultiMedica
(Prof A L Catapano PhD), IRCCS, Sesto S. Giovanni, Italy; Department
of Community Medicine (Prof S G Choudhari MD), Department of
Medicine (S Gaidhane PhD), Global Evidence Synthesis Initiative
(Prof M Khatib PhD), Datta Meghe Institute of Medical Sciences,
Wardha, India; School of Public Health (E K Chowdhury PhD), Curtin
University, Perth, WA, Australia; Center for Biomedicine and
Community Health (D Chu PhD), VNU-International School, Hanoi,
Vietnam; Department of Health Informatics (S Chung PhD),
Department of Epidemiology and Public Health (Prof M Kivimäki PhD),
University College London, London, UK; Health Data Research UK,
London, UK (S Chung PhD); Department of Global Health and Social
Medicine (D Colozza PhD), School of Population Health and
Environmental Sciences (A Douiri PhD, W Muruet MSc,
H A Wafa MPH, Y Wang PhD, Prof C D A Wolfe MD), Faculty of Life
Sciences and Medicine (M Molokhia PhD), King’s College London,
London, UK; Oce of Climate Change, Biodiversity and Environment
(D Colozza PhD), Food and Agriculture Organization of the United
Nations, Rome, Italy; Research Unit on Applied Molecular Biosciences
(UCIBIO) (V M Costa PhD), University of Porto, Porto, Portugal;
Department of Epidemiology and Prevention (S Costanzo PhD,
A Gialluisi PhD, Prof L Iacoviello MD), IRCCS Neuromed, Pozzilli, Italy;
Department of Family Medicine and Public Health
(Prof M H Criqui MD), University of California San Diego, La Jolla, CA,
USA; School of Public Health (O Dadras DrPH), Walailak University,
Nakhon Si Thammarat, Thailand; Graduate School of Medicine
(O Dadras DrPH), Kyoto University, Kyoto, Japan; Department of
Human Physiology (B Dagnew MSc), School of Medicine
(A G Mersha MD), University of Gondar, Gondar, Ethiopia; Division of
Public Health Science (Prof K Dalal PhD), Mid Sweden University,
Sundsvall, Sweden; Higher School of Public Health (Prof K Dalal PhD),
Health Research Institute (K Davletov PhD), Al Farabi Kazakh National
University, Almaty, Kazakhstan; Faculty of Medicine
(Prof A A M Damasceno PhD), Eduardo Mondlane University, Maputo,
Mozambique; Department of Medical and Surgical Sciences and
Advanced Technologies (E D’Amico MD), Department of General
Surgery and Surgical-Medical Specialties (Prof G Isola PhD), University
of Catania, Catania, Italy; Public Health Foundation of India, Gurugram,
India (Prof L Dandona MD, Prof R Dandona PhD, G Kumar PhD);
Indian Council of Medical Research, New Delhi, India
(Prof L Dandona MD); Department of Public Health
(J Darega Gela MPH), Ambo University, Ambo, Ethiopia; Division of
Cardiology (R Desai MBBS), Atlanta Veterans Aairs Medical Center,
Decatur, GA, USA; Department of Community Medicine (D Dhamnetiya
MD, R P Jha MSc), Dr Baba Sahib Ambedkar Medical College and
Hospital, Delhi, India; Department of Community Medicine
(Prof S D Dharmaratne MD), University of Peradeniya, Peradeniya,
Articles
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Sri Lanka; Policy Research Institute, Kathmandu, Nepal
(M L Dhimal PhD); Global Institute for Interdisciplinary Studies,
Kathmandu, Nepal (M L Dhimal PhD); Health Research Section
(M Dhimal PhD), Nepal Health Research Council, Kathmandu, Nepal
(P Gyanwali MD); Center of Complexity Sciences (Prof D Diaz PhD),
National Autonomous University of Mexico, Mexico City, Mexico; Faculty
of Veterinary Medicine and Zootechnics (Prof D Diaz PhD),
Autonomous University of Sinaloa, Culiacán Rosales, Mexico; Institute
for Stroke and Dementia Research (Prof M Dichgans MD), Ludwig
Maximilians University, Munich, Germany; Department of Social
Medicine and Health Care Organisation (K Dokova PhD), Medical
University of Varna, Varna, Bulgaria; Department of Internal Medicine
(R Doshi MD), University of Nevada Reno, Reno, NV, USA; Postgraduate
Program in Epidemiology (Prof B B Duncan PhD,
Prof M I Schmidt PhD), Federal University of Rio Grande do Sul, Porto
Alegre, Brazil; Division of Urology (S Eftekharzadeh MD), Department
of Radiology (A Zandifar MD), Children’s Hospital of Philadelphia,
Philadelphia, PA, USA; Division of Cardiology (I Y Elgendy MD,
D Kolte MD), Massachusetts General Hospital, Boston, MA, USA;
Faculty of Medicine (M Elhadi MD), University of Tripoli, Tripoli, Libya;
Department of Neurology (Prof M Endres MD), Charité University
Medical Center Berlin, Berlin, Germany; Public Health Department
(A Y Endries MPH), St Paul’s Hospital Millennium Medical College,
Addis Ababa, Ethiopia; Centre for Applied Health Economics
(D A Erku PhD), Grith University, Gold Coast, QLD, Australia;
Department of Health Policy and Administration (E A Faraon MD),
University of the Philippines Manila, Manila, Philippines; Department
of Internal Medicine (U Farooque MD), Dow University of Health
Sciences, Karachi, Pakistan; Human Biology Division (A H Feroze MD),
Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Psychiatry
Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA; School
of Health Sciences (I Filip MD), AT Still University, Mesa, AZ, USA;
Institute of Gerontological Health Services and Nursing Research
(F Fischer PhD), Ravensburg-Weingarten University of Applied
Sciences, Weingarten, Germany; Center for Research in Indigenous
Health (D Flood MD), Maya Health Alliance, Tecpán, Guatemala;
Department of Internal Medicine (D Flood MD), University of Michigan,
Ann Arbor, MI, USA; Department of Cardiovascular Medicine
(M M Gad MD), Department of Internal Medicine (V Jain MD,
H Lak MD), Lerner Research Institute (X Liu PhD), Cleveland Clinic,
Cleveland, OH, USA; Gillings School of Global Public Health
(M M Gad MD), University of North Carolina Chapel Hill, Chapel Hill,
NC, USA; Faculty of Nursing and Midwifery (R Ghanei Gheshlagh PhD),
Kurdistan University of Medical Sciences, Sanandaj, Iran; Research
Group for Genomic Epidemiology (N Ghith PhD), Technical University
of Denmark, Copenhagen, Denmark; Department of Public Health
(G Ghozali PhD), University of Muhammadiyah Kalimantan Timur,
Samarinda, Indonesia; Neurosurgery Department (S Ghozy MD),
Mansoura University, Mansoura, Egypt; Department of Cardiovascular
Endocrine-metabolic Diseases and Aging (S Giampaoli MD), Istituto
Superiore di Sanità, Rome, Italy; Afro-Asian Institute, Lahore, Pakistan
(Prof S Gilani PhD); Medical School (Prof P S Gill DM), University of
Warwick, Coventry, UK; Health Systems and Policy Research
(M Golechha PhD), Indian Institute of Public Health, Gandhinagar,
India; Department of Epidemiology (Prof Y Guo PhD), Binzhou Medical
University, Yantai City, China; Department of Preventive Cardiology
(Prof R Gupta MD), Eternal Heart Care Centre & Research Institute,
Jaipur, India; Department of Medicine (Prof R Gupta MD), Mahatma
Gandhi University Medical Sciences, Jaipur, India; School of Medicine
(V Gupta PhD), Deakin University, Geelong, VIC, Australia; Department
of Clinical Medicine (Prof V K Gupta PhD), Macquarie University,
Sydney, NSW, Australia; Department of Clinical Pharmacology
(P Gyanwali MD), Tribhuvan University, Kathmandu, Nepal;
Department of Radiology and Radiological Science (N Hafezi-Nejad MD,
S Sheikhbahaei MD), Health Policy and Management (D Vervoort MD),
Division of Gastroenterology and Hepatology (K Vosoughi MD),
Johns Hopkins University, Baltimore, MD, USA; School of Health and
Environmental Studies (Prof S Hamidi DrPH), Hamdan Bin
Mohammed Smart University, Dubai, United Arab Emirates; Medical
School (Prof G J Hankey MD), Dobney Hypertension Centre
(Prof M P Schlaich MD), University of Western Australia, Perth, WA,
Australia; Department of Neurology (Prof G J Hankey MD), Sir Charles
Gairdner Hospital, Perth, WA, Australia; Department of Public Health
(A Hashi PhD), Jigjiga University, Jijiga, Ethiopia; Research Centre
(T S Hassan PhD), Salahaddin University, Erbil, Iraq; Department of
Primary and Interdisciplinary Care (H Y Hassen MPH), University
Hospital Antwerp, Antwerp, Belgium; Department of Public Health
(H Y Hassen MPH), Mizan-Tepi University, Mizan Teferi, Ethiopia;
Skaane University Hospital (R J Havmoeller PhD), Skaane County
Council, Malmoe, Sweden; Institute of Pharmaceutical Sciences
(K Hayat MS), University of Veterinary and Animal Sciences, Lahore,
Pakistan; Department of Pharmacy Administration and Clinical
Pharmacy (K Hayat MS), Xian Jiaotong University, Xian, China; School
of Business (Prof C Herteliu PhD), London South Bank University,
London, UK; Kasturba Medical College, Mangalore (R Holla MD,
A Kamath MD, J Padubidri MD, P Rathi MD), Department of
Community Medicine (C R Rao MD), Manipal Academy of Higher
Education, Manipal, India (A Kamath MD); Clinical Legal Medicine
Department (S Hostiuc PhD), National Institute of Legal Medicine Mina
Minovici, Bucharest, Romania; College of Science and Engineering
(Prof M Househ PhD), Hamad Bin Khalifa University, Doha, Qatar;
Jockey Club School of Public Health and Primary Care (J Huang MD,
C Zhong MD), The Chinese University of Hong Kong, Hong Kong,
China; Department of Public Health and Community Medicine
(Prof A Humayun PhD), Shaikh Khalifa Bin Zayed Al-Nahyan Medical
College, Lahore, Pakistan; Department of Occupational Safety and
Health (Prof B Hwang PhD), College of Public Health (R Lin PhD),
China Medical University, Taichung, Taiwan; Research Center in
Epidemiology and Preventive Medicine (EPIMED)
(Prof L Iacoviello MD), University of Insubria, Varese, Italy; Department
of Public Health (Prof I Iavicoli PhD), University of Naples Federico II,
Naples, Italy; Faculty of Medicine (I M Ilic PhD, Prof M M Santric-
Milicevic PhD), School of Public Health and Health Management
(Prof M M Santric-Milicevic PhD), University of Belgrade, Belgrade,
Serbia; Department of Epidemiology (Prof M D Ilic PhD), University of
Kragujevac, Kragujevac, Serbia; College of Public Health (U Iqbal PhD),
Taipei Medical University, Taipei, Taiwan; Independent Consultant,
Tabriz, Iran (S N Irvani MD); Institute for Physical Activity and Nutrition
(S Islam PhD), Deakin University, Burwood, VIC, Australia; Sydney
Medical School (S Islam PhD), Save Sight Institute (H Kandel PhD),
University of Sydney, Sydney, NSW, Australia; Department of Clinical
Pharmacy (Prof N Ismail PhD), MAHSA University, Bandar Saujana
Putra, Malaysia; Public Health Department of Social Medicine
(Prof H Iso MD), Graduate School of Medicine (Prof K Yamagishi MD),
Osaka University, Suita, Japan; Department of Health Services Research
(M Iwagami PhD), Research and Development Center for Health
Services (Prof K Yamagishi MD), University of Tsukuba, Tsukuba, Japan;
Department of Non-Communicable Disease Epidemiology
(M Iwagami PhD), London School of Hygiene & Tropical Medicine,
London, UK; Research and Development Unit (L Jacob MD), Biomedical
Research Networking Center for Mental Health Network (CiberSAM),
Sant Boi de Llobregat, Spain; Faculty of Medicine (L Jacob MD),
University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-
Bretonneux, France; Department of Preventive Medicine
(Prof S Jang PhD), Yonsei University, Seodaemun-gu, South Korea;
Centre of Studies and Research (S Jayapal PhD), Ministry of Health,
Muscat, Oman; Department of Biochemistry (Prof S Jayaram MD),
Government Medical College, Mysuru, India; Department of Physiology
(R Jayawardena PhD), Department of Pharmacology (P Ranasinghe
PhD), University of Colombo, Colombo, Sri Lanka; School of Exercise
and Nutrition Sciences (R Jayawardena PhD), International Laboratory
for Air Quality and Health (Prof L Morawska PhD), Queensland
University of Technology, Brisbane, QLD, Australia; Achutha Menon
Centre for Health Science Studies (P Jeemon PhD), Sree Chitra Tirunal
Institute for Medical Sciences and Technology, Trivandrum, India;
Department of Community Medicine (R P Jha MSc), Banaras Hindu
University, Varanasi, India; Center for Global Surgery
(Prof W D Johnson MD), Loma Linda University, Loma Linda, CA, USA;
Beijing Institute of Ophthalmology (Prof J B Jonas MD), Beijing
Tongren Hospital, Beijing, China; Department of Family Medicine and
Public Health (J J Jozwiak PhD), University of Opole, Opole, Poland;
Institute of Family Medicine and Public Health (M Jürisson PhD,
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21
H Orru PhD), University of Tartu, Tartu, Estonia; Institute for
Prevention of Non-communicable Diseases (R Kalhor PhD), Health
Services Management Department (R Kalhor PhD), Qazvin University of
Medical Sciences, Qazvin, Iran; Public Health Division
(Y Kalkonde MD), Society for Education, Action and Research in
Community Health, Gadchiroli, India; Sydney Eye Hospital
(H Kandel PhD), South Eastern Sydney Local Health District, Sydney,
NSW, Australia; Institute for Epidemiology and Social Medicine
(A Karch MD), University of Münster, Münster, Germany; Centre for
Tropical Diseases and Global Health (P D Katoto PhD), Catholic
University of Bukavu, Bukavu, Democratic Republic of the Congo;
Department of Global Health (P D Katoto PhD), Stellenbosch University,
Cape Town, South Africa; International Research Center of Excellence
(G A Kayode PhD), Institute of Human Virology Nigeria, Abuja, Nigeria;
Julius Centre for Health Sciences and Primary Care (G A Kayode PhD),
Utrecht University, Utrecht, Netherlands; Department of Diagnostic &
Interventional Radiology (P Keshavarz MD), New Hospitals LTD, Tbilisi,
Georgia; Medical Imaging Center (P Keshavarz MD), Shiraz University
of Medical Sciences, Iran; Department of Public Health
(Prof Y S Khader PhD), Jordan University of Science and Technology,
Irbid, Jordan; Department of Epidemiology and Biostatistics
(E A Khan MPH), Health Services Academy, Islamabad, Pakistan;
Department of Pediatrics (I A Khan MD), Rutgers University,
New Brunswick, NJ, USA; Epidemiology Department (M Khan MD),
Jazan University, Jazan, Saudi Arabia; Primary Care Department
(M A Khan MSc), NHS North West London, London, UK; Department of
Public Health (Prof J Khubchandani PhD), New Mexico State University,
Las Cruces, NM, USA; Department of Preventive Medicine (G Kim PhD,
Prof E Park PhD), Institute of Health Services Research
(Prof E Park PhD), Yonsei University, Seoul, South Korea; Department of
Genomics and Digital Health (M Kim MD), Samsung Advanced
Institute for Health Sciences & Technology (SAIHST), Seoul,
South Korea; Public Health Center (M Kim MD), Ministry of Health and
Welfare, Wando, South Korea; School of Traditional Chinese Medicine
(Y Kim PhD), Xiamen University Malaysia, Sepang, Malaysia; School of
Health Sciences (Prof A Kisa PhD), Kristiania University College, Oslo,
Norway; Department of Global Community Health and Behavioral
Sciences (Prof A Kisa PhD), Tulane University, New Orleans, LA, USA;
Department of Nursing and Health Promotion (S Kisa PhD), Oslo
Metropolitan University, Oslo, Norway; Department of Public Health
(Prof M Kivimäki PhD, Prof T Lallukka PhD), University of Helsinki,
Helsinki, Finland; Department of Environmental Health Engineering
(A Koolivand PhD), Department of Epidemiology (R Moradzadeh PhD,
M Zamanian PhD), Arak University of Medical Sciences, Arak, Iran;
Kasturba Medical College, Udupi, India (S Koulmane Laxminarayana
MD); Biomedical Research Networking Center for Mental Health
Network (CIBERSAM) (A Koyanagi MD), San Juan de Dios Sanitary
Park, Sant Boi de Llobregat, Spain; Catalan Institution for Research and
Advanced Studies (ICREA), Barcelona, Spain (A Koyanagi MD);
Department of Anthropology (K Krishan PhD), Panjab University,
Chandigarh, India; Department of Anesthesiology (V Krishnamoorthy
MD), Duke University, Durham, NC, USA; Faculty of Public Health
(D Kusuma DSc), University of Indonesia, Depok, Indonesia; National
Institute for Health Research (NIHR) Oxford Biomedical Research
Centre, Oxford, UK (B Lacey PhD); Department of Otorhinolaryngology
(S Lasrado MS), Father Muller Medical College, Mangalore, India;
Department of Neurology and Psychiatry (P M Lavados MD), German
Clinic of Santiago, Santiago, Chile; Faculty of Medicine
(P M Lavados MD), University of Development, Santiago, Chile; UO
Neurologia, Salute Pubblica e Disabilità (M Leonardi MD,
F G Magnani PhD, A Raggi PhD, D Sattin PsyD, S Schiavolin MSc),
Fondazione IRCCS Istituto Neurologico Carlo Besta (Neurology, Public
Health and Disability Unit, Carlo Besta Neurological Institute), Milan,
Italy; Department of Sociology (B Li PhD), Shenzhen University,
Shenzhen, China; School of Public Health (Prof H Lin PhD),
Zhengzhou University, Zhengzhou, China; Asbestos Diseases Research
Institute, Concord, NSW, Australia (R Lin PhD); Department of
Quantitative Health Science (X Liu PhD), Case Western Reserve
University, Cleveland, OH, USA; Department of Pediatrics
(W D Lo MD), Ohio State University, Columbus, OH, USA; Department
of Pediatric Neurology (W D Lo MD), Nationwide Children’s Hospital,
Columbus, OH, USA; Institute of Nutritional Sciences
(Prof S Lorkowski PhD), Friedrich Schiller University Jena, Jena,
Germany; Competence Cluster for Nutrition and Cardiovascular Health
(nutriCARD), Jena, Germany (Prof S Lorkowski PhD); School of
Medicine (Prof G Lucchetti PhD), Federal University of Juiz de Fora,
Juiz de Fora, Brazil; Department of Neurosciences and Behavioral
Sciences (R Lutzky Saute MD), Department of Pathology and Legal
Medicine (M R Tovani-Palone PhD), University of São Paulo, Ribeirão
Preto, Brazil; Radiology Department (H Magdy Abd El Razek MD), Egypt
Ministry of Health and Population, Mansoura, Egypt; Department of
Community Medicine (P B Mahajan MD), Jawaharlal Institute of
Postgraduate Medical Education and Research, Karaikal, India; Mass
Communication Department (A Makki PhD), University of Sharjah,
Sharjah, United Arab Emirates; Non-communicable Disease Research
Center (Prof R Malekzadeh MD, S G Sepanlou MD), Health Policy
Research Center (S Shahabi PhD), Shiraz University of Medical
Sciences, Shiraz, Iran; School of Medicine (N Manafi MD), University of
Manitoba, Winnipeg, MB, Canada; Value-Based Healthcare Unit
(Prof L G Mantovani DSc), IRCCS MultiMedica, Sesto San Giovanni,
Italy; Indonesian Public Health Association, Surabaya, Indonesia
(S Martini PhD); Neurology Department (Prof M Mehndiratta MD),
Janakpuri Super Specialty Hospital Society, New Delhi, India;
Department of Neurology (Prof M Mehndiratta MD), Govind Ballabh
Institute of Medical Education and Research, New Delhi, India; Forensic
Medicine Division (Prof R G Menezes MD), Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia; Neurology Unit
(A Meretoja MD), Helsinki University Hospital, Helsinki, Finland;
School of Health Sciences (A Meretoja MD), Department of Neurology
(Prof T Wijeratne MD), University of Melbourne, Melbourne, VIC,
Australia; School of Medicine and Public Health (A G Mersha MD),
University of Newcastle, Newcastle, NSW, Australia; School of Public
Health and Community Medicine (J Miao Jonasson PhD), University of
Gothenburg, Gothenburg, Sweden; Center for Innovation in Medical
Education (B Miazgowski MD), Department of Propedeutics of Internal
Diseases & Arterial Hypertension (Prof T Miazgowski MD), Pomeranian
Medical University, Szczecin, Poland (B Miazgowski MD); Woman-
Mother-Child Department (I Michalek PhD), Lausanne University
Hospital, Lausanne, Switzerland; Internal Medicine Programme
(Prof E M Mirrakhimov PhD), Kyrgyz State Medical Academy, Bishkek,
Kyrgyzstan; Department of Atherosclerosis and Coronary Heart Disease
(Prof E M Mirrakhimov PhD), National Center of Cardiology and
Internal Disease, Bishkek, Kyrgyzstan; Internal Medicine Department
(Y Mohammad MD), Department of Pediatrics (B H Sobaih MD),
Pediatric Intensive Care Unit (M Temsah MD), King Saud University,
Riyadh, Saudi Arabia; Department of Epidemiology and Biostatistics
(A Mohammadian-Hafshejani PhD), Shahrekord University of Medical
Sciences, Shahrekord, Iran; Health Systems and Policy Research Unit
(S Mohammed PhD), Ahmadu Bello University, Zaria, Nigeria;
Department of Health Care Management (S Mohammed PhD),
Technical University of Berlin, Berlin, Germany; Department of
Epidemiology and Biostatistics (Y Mokhayeri PhD), Lorestan University
of Medical Sciences, Khorramabad, Iran; Department of Computer
Science and Engineering (M A Moni PhD), Pabna University of Science
and Technology, Pabna, Bangladesh; Department of Medicine
(A A Montasir FMD), TMSS Medical College, Bogura, Bangladesh;
Department of Medicine (A A Montasir FMD), Sofia Ismail Memorial
Medical Centre, Bogura, Bangladesh; Department of Cardiology and
Cardiac Surgery (J Morze PhD), Univeristy of Warmia and Mazury,
Olsztyn, Poland; School of Medical Sciences (K Musa PhD), Science
University of Malaysia, Kubang Kerian, Malaysia; Research and Analytics
Department (A J Nagarajan MTech), Initiative for Financing Health and
Human Development, Chennai, India; Department of Research and
Analytics (A J Nagarajan MTech), Bioinsilico Technologies, Chennai,
India; Mysore Medical College and Research Institute
(Prof S Narasimha Swamy MD), Government Medical College, Mysore,
India; Department of Clinical Medicine (Prof B R Nascimento PhD),
Clinical Hospital (Prof B R Nascimento PhD), Federal University of
Minas Gerais, Belo Horizonte, Brazil; Cardio-Aid, Bucharest, Romania
(R I Negoi PhD); Bupa Clemton Park (S Neupane Kandel BSN), Bupa,
Sydney, NSW, Australia; Institute for Global Health Innovations
(T H Nguyen MSc, L G Vu MSc), Faculty of Medicine (T H Nguyen MSc,
Articles
22
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L G Vu MSc), Duy Tan University, Da Nang, Vietnam; Department of
Clinical Sciences (Prof B Norrving PhD), Lund University, Lund,
Sweden; Centre for Heart Rhythm Disorders (J Noubiap MD), School of
Public Health (V Podder HSC), Adelaide Medical School (L Yadav PhD),
University of Adelaide, Adelaide, SA, Australia; Department of Pediatrics
(V E Nwatah MD), National Hospital, Abuja, Nigeria; Department of
International Public Health (V E Nwatah MD), University of Liverpool,
Liverpool, UK; Administrative and Economic Sciences Department
(Prof B Oancea PhD), University of Bucharest, Bucharest, Romania;
Department of Community Health and Primary Care
(O O Odukoya MSc), University of Lagos, Idi Araba, Nigeria;
Department of Family and Preventive Medicine (O O Odukoya MSc),
University of Utah, Salt Lake City, UT, USA; Department of Psychiatry
(A T Olagunju MD), University of Lagos, Lagos, Nigeria; Section of
Sustainable Health (H Orru PhD), Umeå University, Umea, Sweden;
Department of Health Metrics (A Pana MD), Center for Health
Outcomes & Evaluation, Bucharest, Romania; Department of Health
Administration and Policy (T Parekh MSc), George Mason University,
Fairfax, VA, USA; Research & Development Department
(M Pathak PhD), Kalinga Institute of Medical Sciences, Bhubaneswar,
India; International Institute for Educational Planning (IIEP)
(Prof M F P Peres MD), Albert Einstein Hospital, São Paulo, Brazil;
Department of Development Studies (Prof A Perianayagam PhD),
International Institute for Population Sciences, Mumbai, India; Cancer
Control Alberta (T Pham MD), Alberta Health Services, Edmonton, AB,
Canada; Medical College (V Podder HSC), Tairunnessa Memorial
Medical College and Hospital, Gazipur, Bangladesh; Department of
Public health (S Polinder PhD), Department of Neurosurgery
(V Volovici PhD), Erasmus University Medical Center, Rotterdam,
Netherlands; University Medical Center Groningen
(Prof M J Postma PhD), School of Economics and Business
(Prof M J Postma PhD), University of Groningen, Groningen,
Netherlands; College of Medicine (A Radfar MD), University of Central
Florida, Orlando, FL, USA; Department of Immunology
(Prof A Rafiei PhD), Molecular and Cell Biology Research Center
(Prof A Rafiei PhD), Mazandaran University of Medical Sciences, Sari,
Iran; Thalassemia and Hemoglobinopathy Research Center
(F Rahim PhD), Ahvaz Jundishapur University of Medical Sciences,
Ahvaz, Iran; Department of Population Science and Human Resource
Development (M Rahman DrPH), University of Rajshahi, Rajshahi,
Bangladesh; School of Nursing and Healthcare Professions
(M Rahman PhD), Federation University Australia, Berwick, VIC,
Australia; Future Technology Research Center (A Rahmani PhD),
National Yunlin University of Science and Technology, Yunlin, Taiwan;
Department of Oral Pathology (S Rao MDS), Srinivas Institute of Dental
Sciences, Mangalore, India; University College London Hospitals,
London, UK (D L Rawaf MD); Academic Public Health England
(Prof S Rawaf MD), Public Health England, London, UK; School of
Nursing and Midwifery (V Renjith PhD), Royal College of Surgeons in
Ireland - Bahrain, Muharraq Governorate, Bahrain; School of Medicine
(Prof A M N Renzaho PhD), Translational Health Research Institute
(Prof A M N Renzaho PhD), Western Sydney University, Campbelltown,
NSW, Australia; Department of Pharmacology and Toxicology
(Prof J A B Rodriguez PhD), University of Antioquia, Medellin,
Colombia; Department of Clinical Research (L Roever PhD), Federal
University of Uberlândia, Uberlândia, Brazil; Department of
Neuroscience (M Romoli MD), University of Perugia, Perugia, Italy;
Department of Neurology (M Romoli MD), Infermi Hospital, Rimini,
Italy; Department of Cardiology and Internal Medicine
(Prof A Rynkiewicz PhD), University of Warmia and Mazury, Olsztyn,
Poland; Department of Neurology (Prof S Sacco MD), University of
L’Aquila, LAquila, Italy; Cardiac Rehabilitation Research Center
(Prof M Sadeghi MD), Isfahan Cardiovascular Research Institute
(Prof N Sarrafzadegan MD), Isfahan University of Medical Sciences,
Isfahan, Iran; Applied Biomedical Research Center (A Sahebkar PhD),
Biotechnology Research Center (A Sahebkar PhD), Mashhad University
of Medical Sciences, Mashhad, Iran; Health Systems and Population
Studies Division (K Saif-Ur-Rahman MPH), Maternal and Child Health
Division (S Zaman MPH), International Centre for Diarrhoeal Disease
Research, Bangladesh, Dhaka, Bangladesh; Department of Public Health
and Health Systems (K Saif-Ur-Rahman MPH, Prof H Yatsuya PhD),
Nagoya University, Nagoya, Japan; Cardiovascular Intensive Care Unit
(R Salah MD), Ministry of Health & Population, Cairo, Egypt; Division of
Infectious Diseases (R Salah MD), University of Louisville, Louisville,
KY, USA; Emergency Department (M Samaei MD), Brown University,
Providence, RI, USA; Faculty of Health & Social Sciences
(B Sathian PhD), Bournemouth University, Bournemouth, UK;
Hypertension and Kidney Disease Laboratory (Prof M P Schlaich MD),
Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; School
of Public Health and Community Medicine (Prof A E Schutte PhD),
Centre for Big Data Research in Health (M Shawon PhD), School of
Population Health (X Xu PhD), University of New South Wales, Sydney,
NSW, Australia; Cardiovascular Program (X Xu PhD), The George
Institute for Global Health, Sydney, NSW, Australia
(Prof A E Schutte PhD); National Heart, Lung, and Blood Institute
(A Seylani BS), National Institute of Health, Rockville, MD, USA; Center
for Biomedical Information Technology (F Sha PhD), Shenzhen
Institutes of Advanced Technology, Shenzhen, China; Independent
Consultant, Karachi, Pakistan (M A Shaikh MD); Department of
Community Medicine (M Shannawaz PhD), BLDE University, Vijayapur,
India; The University of Tokyo, Tokyo, Japan (Prof K Shibuya MD);
Department of Health Education and Health Promotion
(S Siabani PhD), Kermanshah University of Medical Sciences,
Kermanshah, Iran; Department of Physical Education
(Prof D A S Silva PhD), Federal University of Santa Catarina,
Florianópolis, Brazil; School of Medicine (Prof J A Singh MD),
University of Alabama at Birmingham, Birmingham, AL, USA;
Medicine Service (Prof J A Singh MD), US Department of Veterans
Aairs (VA), Birmingham, AL, USA; Department of Community
Medicine & Public Health (J Singh PhD), Tribhuvan University,
Janakpur, Nepal; Department No.16 (V Y Skryabin MD), Laboratory of
Genetics and Genomics (Prof M S Zastrozhin PhD), Moscow Research
and Practical Centre on Addictions, Moscow, Russia; Therapeutic
Department (A A Skryabina MD), Balashiha Central Hospital,
Balashikha, Russia; Department of Pediatrics (B H Sobaih MD),
King Khalid University Hospital, Riyadh, Saudi Arabia; Department of
Cardiology (S Stortecky MD), University of Bern, Bern, Switzerland;
Department of Epidemiology & Biostatistics (Prof S Stranges MD),
The University of Western Ontario, London, ON, Canada; Department of
Population Health (Prof S Stranges MD), Luxembourg Institute of
Health, Strassen, Luxembourg; Department of Biomedical Sciences
(E G Tadesse MSc), Arba Minch University, Arba Minch, Ethiopia;
Research and Development Center for Humanities and Health
Management (I U Tarigan PhD), National Institute of Health Research &
Development, Jakarta, Indonesia; Department for Clinical Neurosciences
and Preventive Medicine (Y Teuschl PhD), Danube University Krems,
Krems, Austria; Department of Medicine (Prof M Tonelli MD),
University of Calgary, Calgary, AB, Canada; Modestum LTD, London, UK
(M R Tovani-Palone PhD); Department of Health Economics
(B X Tran PhD), Hanoi Medical University, Hanoi, Vietnam; Department
of Neurology (Prof M Tripathi MD), All India Institute of Medical
Sciences, Delhi, India; Multidisciplinary Department (A Ullah MS),
National University of Medical Sciences (NUMS), Rawalpindi, Pakistan;
Department of Cardiovascular, Endocrine-metabolic Diseases and Aging
(B Unim PhD), National Institute of Health, Rome, Italy; Clinical Cancer
Research Center (S Valadan Tahbaz PhD, S Yahyazadeh Jabbari MD),
Milad General Hospital, Tehran, Iran; Department of Microbiology
(S Valadan Tahbaz PhD), Islamic Azad University, Tehran, Iran; UKK
Institute, Tampere, Finland (Prof T J Vasankari MD); Raes
Neuroscience Centre (Prof N Venketasubramanian MBBS), Raes
Hospital, Singapore, Singapore; Yong Loo Lin School of Medicine
(Prof N Venketasubramanian MBBS), National University of Singapore,
Singapore, Singapore; Faculty of Information Technology (B Vo PhD),
Ho Chi Minh City University of Technology (HUTECH), Ho Chi Minh
City, Vietnam; Center for Experimental Microsurgery (V Volovici PhD),
Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca,
Romania; Center of Excellence in Behavioral Medicine (G T Vu BA),
Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam; Foundation
University Medical College (Prof Y Waheed PhD), Foundation University
Islamabad, Islamabad, Pakistan; Department of Medicine
(Prof T Wijeratne MD), University of Rajarata, Saliyapura
Anuradhapuraya, Sri Lanka; Institute of Health and Society
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23
(Prof A S Winkler PhD), University of Oslo, Oslo, Norway; Department
of Neurology (Prof A S Winkler PhD), Technical University of Munich,
Munich, Germany; NIHR Biomedical Research Centre
(Prof C D A Wolfe MD), Guy’s and St Thomas’ Hospital and Kings
College London, London, UK; The George Institute for Global Health
(Prof M Woodward PhD), University of New South Wales, Camperdown,
NSW, Australia; The George Institute (Prof M Woodward PhD),
University of New South Wales, Kensington, NSW, Australia; The
George Institute for Global Health (J H Wu PhD), University of
New South Wales, Newtown, NSW, Australia; Research and
Development Division (L Yadav PhD), The George Institute for Global
Health, New Delhi, India; Psychology Department
(A Yadollahpour PhD), University of Sheeld, Sheeld, UK;
Department of Public Health (Prof H Yatsuya PhD), Fujita Health
University, Toyoake, Japan; Department of Neuropsychopharmacology
(N Yonemoto MPH), National Center of Neurology and Psychiatry,
Kodaira, Japan; Department of Public Health (N Yonemoto MPH),
Juntendo University, Tokyo, Japan; Department of Epidemiology and
Biostatistics (Prof C Yu PhD), School of Medicine (Z Zhang PhD),
Wuhan University, Wuhan, China; Department of Clinical Pharmacy
and Outcomes Sciences (I Yunusa PhD), University of South Carolina,
Columbia, SC, USA; School of Rehabilitation Therapy
(M S Zaman MSc), Queen’s University, Kingston, ON, Canada;
Department of Neurology (R Zand MD), University of Tennessee,
Memphis, TN, USA; Addictology Department
(Prof M S Zastrozhin PhD), Pediatrics Department (A Zastrozhina PhD),
Russian Medical Academy of Continuous Professional Education,
Moscow, Russia; School of Public Health (Y Zhang PhD), Hubei
Province Key Laboratory of Occupational Hazard Identification and
Control (Y Zhang PhD), Wuhan University of Science and Technology,
Wuhan, China; Health Technology Assessment Unit (Y H Zuniga BS),
Department of Health Philippines, Manila, Philippines;
#MentalHealthPH, Inc, Quezon City, Philippines (Y H Zuniga BS).
Declaration of interests
V Feigin reports support for the present manuscript from PreventS web
app and free Stroke Riskometer app, which are owned and copyrighted
by Auckland University of Technology, New Zealand. V Feigin reports
grants received from the Brain Research New Zealand Centre of
Research Excellence (16/STH/36), National Health & Medical Research
Council (NHMRC, Australia APP1182071) and World Stroke
Organization to their institution; leadership or fiduciary role in board,
society, committee or advocacy group, paid or unpaid with World Stroke
Organization as Executive Committee member, New Zealand Stroke
Education (charitable) Trust as CEO, Stroke Central New Zealand as
Honorary Medical Director, all of which are honorary unpaid roles; all
outside the submitted work. O Adebayo reports grants or contracts from
Merck Foundation; support for attending meetings and/or travel from
Novartis; all outside the submitted work. R Akinyemi reports grants or
contracts from NIH (U01HG010273), and GCRF (GCRFNGR6\1498),
all outside the submitted work. R Ancuceanu consulting fees from
AbbVie and AstraZeneca; payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from AbbVie, Sandoz, and B. Braun; support for attending
meetings and/or travel from AbbVie and AstraZeneca; all outside the
submitted work. J Ärnlöv reports payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from AstraZeneca and Novartis; participation on a Data Safety
Monitoring Board or Advisory Board with AstraZeneca and Boehringer
Ingelheim; all outside the submitted work. Z Aryan reports support for
the present manuscript from American Heart Association as funding to
their institution, and from Brigham and Women’s Hospital as an
employee. M Ausloos reports grants or contracts from [Romanian
National Authority for Scientific Research and Innovation, CNDS-
UEFISCDI project number PN-III-P4-ID-PCCF-2016-0084, research
grant (Oct 2018–Sept 2022), grant title “Understanding and modelling
time-space patterns of psychology-related inequalities and polarization”
outside the submitted work. T Bärnighausen reports grants or contracts
from Research grants from the European Union (Horizon 2020 and EIT
Health), German Research Foundation (DFG), US National Institutes of
Health, German Ministry of Education Research, Alexander von
Humboldt Foundation, Else-Kröner-Fresenius-Foundation, Wellcome
Trust, Bill & Melinda Gates Foundation, KfW, UNAIDS, and WHO;
consulting fees from KfW on the OSCAR initiative in Vietnam;
participation on a Data Safety Monitoring Board or Advisory Board with
the NIH-funded study “Healthy Options” (PIs: Smith Fawzi, Kaaya),
Chair of the Data Safety and Monitoring Board (DSMB), German
National Committee on the “Future of Public Health Research and
Education”, Chair of the scientific advisory board to the EDCTP
Evaluation, Member of the UNAIDS Evaluation Expert Advisory
Committee, National Institutes of Health Study Section Member on
Population and Public Health Approaches to HIV/AIDS (PPAH),
US National Academies of Sciences, Engineering, and Medicine’s
Committee for the “Evaluation of Human Resources for Health in the
Republic of Rwanda under the President’s Emergency Plan for AIDS
Relief (PEPFAR)”, and University of Pennsylvania (UPenn) Population
Aging Research Center (PARC) External Advisory Board Member;
leadership or fiduciary role in board, society, committee or advocacy
group, paid or unpaid as the co-chair of the Global Health Hub Germany
(which was initiated by the German Ministry of Health); all outside the
submitted work. E Beghi reports grants or contracts from Italian Health
Ministry, American ALS Association, and SOBI Pharmaceutical
Company made to their institution; payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from University of Rochester; support for attending meetings
and/or travel from ILAE; participation on a Data Safety Monitoring
Board or Advisory Board with Arvelle Therapeutics; all outside the
submitted work. Y Béjot reports payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from Medtronic, Boehringer-Ingelheim, Pfizer, BMS, Servier, and
Amgen; support for attending meetings and/or travel from Servier; all
outside the submitted work. A Catapano reports grants or contracts from
Sanofi, Eli Lilly, Mylan, Sanofi Regeneron, Menarini, and Amgen;
payment or honoraria for lectures, presentations, speakers bureaus,
manuscript writing or educational events from Akcea, Amgen,
AstraZeneca, Aegerion, Amryt, Daiichi, Sankyo, Esperion, Kowa, Ionis
Pharmaceuticals, Mylan, Merck, Menarini, Novartis, Recordati,
Regeneron, Sandoz, and Sanofi; all outside the submitted work.
S Costanzo reports grants or contracts from ERAB (the European
Foundation for Alcohol Research; id. EA1767; 2018–2020 and Italian
Ministry of Health (grant RF-2018-12367074, CoPI), both paid to their
institution; payment or honoraria for lectures, presentations, speakers
bureaus, manuscript writing or educational events from as a member of
the Organizing Committee and speaker for the 9th European Beer and
Health Symposium (Bruxelles 2019) and for given lecture at the
13th European Nutrition Conference FENS 2019 (Dublin), sponsored by
the Beer and Health Initiative (The Dutch Beer Institute foundation—
The Brewers of Europe); all outside the submitted work. M Endres
reports grants or contracts from Bayer as an unrestricted grant to
Charité for MonDAFIS study and Berlin AFib registry; consulting fees
from Bayer paid to their institution; payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from Bayer, Boehringer Ingelheim, Pfizer, Amgen, GSK, Sanofi,
and Novartis, all paid to their institution; participation on a Data Safety
Monitoring Board or Advisory Board with BMS as a Country PI for
Axiomatic-SSP, Bayer as Country PO for NAVIGATE-ESUS,
AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Amgen, Covidien,
with all fees paid to their institution; leadership or fiduciary role in
board, society, committee or advocacy group, paid or unpaid with EAN
as part of the Board of Directors, DGN, ISCBFM, AHA/ASA, ESO,
WSO, DZHK (German Centre of Cardiovascular Research) as a PI, all of
which are unpaid positions, and with DZNE (German Center of
Neurodegenerative Diseases) as a paid PI; receipt of PCSK9 inhibitors
for mouse studies from Amgen; all outside the submitted work. I Filip
reports payment or honoraria for lectures, presentations, speakers
bureaus, manuscript writing or educational events from Avicenna
Medical and Clinical Research Institute, outside the submitted work.
A Gialluisi reports grants or contracts from Italian Ministry of Economic
Development (PLATONE project, bando “Agenda Digitale” PON I&C
2014–2020; Prog. n. F/080032/01-03/X35) paid to their institution,
outside the submitted work. C Herteliu reports grants or contracts from
Romanian National Authority for Scientific Research and Innovation,
CNDS-UEFISCDI project number PN-III-P4-ID-PCCF-2016-0084
Articles
24
www.thelancet.com/neurology Published online September 3, 2021 https://doi.org/10.1016/S1474-4422(21)00252-0
research grant (Oct 2018–Sept 2022) “Understanding and modelling
time-space patterns of psychology-related inequalities and polarization,”
and project number PN-III-P2-2.1-SOL-2020-2-0351 research grant
(June–Oct, 2021) “Approaches within public health management in the
context of COVID-19 pandemic,” and from the Ministry of Labour and
Social Justice, Romania, project number 30/PSCD/2018 research grant
(Sept 2018–June 2019) “Agenda for skills Romania 2020–2025;” all
outside the submitted work. S Islam reports grants or contracts from
National Heart Foundation Vanguard grant, Postdoctoral Fellowship and
NHMRC Emerging Leadership Fellowship, outside the submitted work.
Y Kalkonde reports grants or contracts from DBT/Wellcome Trust India
Alliance as a DBT/Wellcome Trust India Alliance fellow in Public Health
(grant number IA/CPHI/14/1/501514). M Kivimäki reports support for
the present manuscript from The Wellcome Trust (221854/Z/20/Z) and
Medical Research Council (MR/S011676/1), as research grants paid to
their institute. K Krishnan reports non-financial support from UGC
Centre of Advanced Study, Phase II, Department of Anthropology,
Panjab University, Chandigarh, India, outside the submitted work.
P Lavados reports grants or contracts from Boehringer Ingelheim as
grant support to their institute for RECCA stroke registry, and from
ANID as personal grant support for ADDSPISE trial; payment or
honoraria for lectures, presentations, speakers bureaus, manuscript
writing or educational events from Boehringer Ingelheim as personal
honoraria for lectures; support for attending meetings and/or travel
from Boehringer Ingelheim as support for attending Global Stroke
Netowrk meeting in 2020; all outside the submitted work. W Lo reports
grants or contracts from 1U01NS106655-01A1 (MPI: S Ramey, Lo),
5U24NS1072050-02 (PI: Kolb), and 1P2CHD101912-01 (PD: S. Ramey),
all outside the submitted work. S Lorkowski reports grants or contracts
from Akcea Therapeutics Germany as payments made to their
institution; consulting fees from Danone, Swedish Orphan Biovitrum
(SOBI), and Upfield; payment or honoraria for lectures, presentations,
speakers bureaus, manuscript writing or educational events from Akcea
Therapeutics Germany, AMARIN Germany, Amedes Holding, AMGEN,
Berlin-Chemie, Boehringer Ingelheim Pharma, Daiichi Sankyo
Deutschland, Danone, Hubert Burda Media Holding, Lilly Deutschland,
Novo Nordisk Pharma, Roche Pharma, Sanofi-Aventis, and SYNLAB
Holding Deutschland & SYNLAB Akademie as personal payments;
support for attending meetings and/or travel from Amgen as personal
payments; participation on a Data Safety Monitoring Board or Advisory
Board with Akcea Therapeutics Germany, Amgen, Daiichi Sankyo
Deutschland, and Sanofi-Aventis as personal payments; all outside the
submitted work. N Manafi reports support for the present manuscript
from BMGF as funding to IHME for this project. B Norrving reports
consulting fees from AstraZeneca and Bayer as personal payments
outside the submitted work. O Odukoya reports grants or contracts from
the Fogarty International Center of the National Institutes of Health as
protected time towards the research reported in this publication was
supported under the Award Number K43TW010704. The content is solely
the responsibility of the authors and does not necessarily represent the
ocial views of the National Institutes of Health. A Pana reports grants
or contracts from Romanian National Authority for Scientific Research
and Innovation, CNDS-UEFISCDI project number PN-III-P4-ID-
PCCF-2016-0084 research grant (Oct 2018–Sept 2022) “Understanding
and modelling time-space patterns of psychology-related inequalities
and polarization,” and project number PN-III-P2-2·1-SOL-2020-2-0351
research grant (June–Oct 2021) “Approaches within public health
management in the context of COVID-19 pandemic,” all outside the
submitted work. M Postma reports leadership or fiduciary role in other
board, society, committee or advocacy group, paid or unpaid with the
UK’s JCVI as an unpaid member, outside the current manuscript.
A Radfar reports payment or honoraria for lectures, presentations,
speakers’ bureaus, manuscript writing or educational events from
Avicenna Medical and Clinical Research Institute. S Sacco reports grants
or contracts from Novartis and Allergan-AbbVie; consulting fees from
Allergan-AbbVie, Novartis, Eli Lilly, AstraZeneca, and Novo Nordisk;
payment or honoraria for lectures, presentations, speakers bureaus,
manuscript writing or educational events from Allergan-AbbVie,
Novartis, Eli Lilly, TEVA, Abbott, Medscape, and Olgology; support for
attending meetings and/or travel from Allergan, Eli Lilly, Abbott,
Novartis, and Teva; leadership or fiduciary role in other board, society,
committee or advocacy group, paid or unpaid with Guideline Board
European Stroke Organization as Co-chair, and with the European
Headache Federation as a board member; all outside the submitted
work. A Schutte reports payment or honoraria for lectures,
presentations, speaker’s bureaus, manuscript writing or educational
events from Sanofi, Takeda, Abbott, Servier, and Omron Healthcare as
honoraria for lectures during educational events; support for attending
meetings and/or travel from Takeda and Omron; all outside the
submitted work. J Singh reports consulting fees from Crealta/Horizon,
Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care options,
Clearview healthcare partners, Putnam associates, Focus forward,
Navigant consulting, Spherix, MedIQ, UBM LLC, Trio Health,
Medscape, WebMD, and Practice Point communications; and the
National Institutes of Health and the American College of
Rheumatology; payment or honoraria for lectures, presentations,
speakers bureaus, manuscript writing or educational events from Simply
Speaking; support for attending meetings and/or travel from
OMERACT, an international organization that develops measures for
clinical trials and receives arm’s length funding from 12 pharmaceutical
companies, when traveling to OMERACT meetings; participation on a
Data Safety Monitoring Board or Advisory Board as a member of the
FDA Arthritis Advisory Committee; leadership or fiduciary role in other
board, society, committee or advocacy group, paid or unpaid, with
OMERACT as a member of the steering committee, with the Veterans
Aairs Rheumatology Field Advisory Committee as a member, and with
the UAB Cochrane Musculoskeletal Group Satellite Center on Network
Meta-analysis as a director and editor; stock or stock options in TPT
Global Tech, Vaxart pharmaceuticals, Charlotte’s Web Holdings and
previously owned stock options in Amarin, Viking, and Moderna
pharmaceuticals; all outside the submitted work. S Stortecky reports
grants or contracts from Edwards Lifesciences, Medtronic, Abbott, and
Boston Scientific as grants made to their institution; consulting fees
from Boston Scientific/BTG Teleflex; payment or honoraria for lectures,
presentations, speakers bureaus, manuscript writing or educational
events from Boston Scientific; all outside the submitted work.
M Woodward reports consulting fees from Amgen as personal payment.
All other authors declare no competing interests.
Data sharing
All data presented in the manuscript can be found on the Institute for
Health Metrics and Evaluation GBD Compare and Viz Hub website at
https://vizhub.healthdata.org/gbd-compare/#.
Acknowledgments
Funding for this study was obtained from the Bill & Melinda Gates
Foundation. S Alif would like to acknowledge support from Monash
University. S Aljunid would like to acknowledge the Department of
Health Policy and Management, Faculty of Public Health, Kuwait
University and International Centre for Casemix and Clinical Coding,
Faculty of Medicine, National University of Malaysia, for the approval
and support to participate in this research project. T Barnighausen was
supported by the Alexander von Humboldt Foundation through the
Alexander von Humboldt Professor award, funded by the German
Federal Ministry of Education and Research. D Bennett was supported
by the National Institute of Health Research (NIHR) Oxford Biomedical
Research Centre. The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department of Health
and Social Care. V Costa acknowledges her grant (SFRH/
BHD/110001/2015), received by Portuguese national funds through
Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma
Transitória DL57/2016/CP1334/CT0006. A Douiri acknowledges support
from the National Institute for Health Research (NIHR) Applied
Research Collaboration (ARC) South London at King’s College Hospital
NHS Foundation Trust and the Royal College of Physicians, as well as
the support from the NIHR Biomedical Research Centre based at Guy’s
and St Thomas’ NHS Foundation Trust and King’s College London.
B Duncan and M Schmidt were supported in part by the Brazilian
National Council for Scientific and Technological Development (CNPq,
research fellowship) and the Institute for Health Technology Assessment
(IATS; 465518/2014-1). N Ghith acknowledges support from a grant from
Novo Nordisk Foundation (NNF16OC0021856). A Gialluisi was
supported by Fondazione Umberto Veronesi. P Gill is part funded by the
Articles
www.thelancet.com/neurology Published online September 3, 2021 https://doi.org/10.1016/S1474-4422(21)00252-0
25
NIHR Applied Research Collaboration West Midlands and is NIHR
Senior Investigator. The views expressed are those of the author and not
necessarily those of the NIHR or the Department of Health and Social
Care. V Gupta acknowledges funding support from National Health and
Medical Research Council (NHMRC), Australia. S Islam is funded by
NHMRC and National Heart Foundation of Australia Fellowships.
P Jeemon acknowledges the Wellcome Trust/DBT India Alliance Clinical
and Public Health Intermediate Fellowship [IA/CPHI/14/1/501497].
Y Kalkonde is a DBT/Wellcome Trust India Alliance fellow in Public
Health (grant number IA/CPHI/14/1/501514). Y Kim was supported by
the Research Management Centre, Xiamen University Malaysia (grant
number XMUMRF-C6/ITCM/0004). S Koulmane Laxminarayana
acknowledges support from Manipal Academy of Higher Education.
K Krishan is supported by the UGC Centre of Advanced Study
(Phase II), awarded to the Department of Anthropology, Panjab
University, Chandigarh, India. B Lacey acknowledges support from UK
Biobank, University of Oxford. T Lallukka is supported by the Academy
of Finland (grant number 330527). S Lorkowski acknowledges
institutional support from the Competence Cluster for Nutrition and
Cardiovascular Health (nutriCARD) Halle-Jena-Leipzig (Germany;
German Federal Ministry of Education and Research; grant agreement
number 01EA1808A). L Mantovani acknowledges support from the
Italian Ministry of Health Ricerca Corrente – IRCCS MultiMedica.
M Molokhia is supported by the National Institute for Health Research
Biomedical Research Center at Guy’s and St Thomas’ National Health
Service Foundation Trust and King’s College London. O Odukoya was
supported by the Fogarty International Center of the National Institutes
of Health under the Award Number K43TW010704. The content is solely
the responsibility of the authors and does not necessarily represent the
ocial views of the National Institutes of Health. M Owolabi is
supported by NIH grant SIREN U54 HG007479 under the H3Africa
initiative and SIBS Genomics R01NS107900; SIBS Gen Gen
R01NS107900-02S1; ARISES R01NS115944; H3Africa CVD Supplement
3U24HG009780-03S5 and CaNVAS 1R01NS114045. A Pana, M Ausloos
and C Herteliu are partially supported by a grant of the Romanian
National Authority for Scientific Research and Innovation,
CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084.
A Raggi, D Sattin and S Schiavolin are supported by a grant from the
Italian Ministry of Health (Ricerca Corrente, Fondazione Istituto
Neurologico C. Besta, Linea 4—Outcome Research: dagli Indicatori alle
Raccomandazioni Cliniche). A Samy acknowledges the support from the
Egyptian Fulbright Mission Program. F Sha was supported by the
Shenzhen Science and Technology Program (Grant No.
KQTD20190929172835662). A Sheikh acknowledges the support of
Health Data Research UK. M Tonelli acknowledges support from the
David Freeze Chair in Health Research (University of Calgary).
B Unnikrishnan acknowledges support from Kasturba Medical College,
Mangalore, Manipal Academy of Higher Education, Manipal.
T Wijeratne acknowledges support from the Department of Medicine,
University of Rajarata, Sri Lanka. X Xu is supported by the National
Heart Foundation of Australia post-doctoral fellowship. S Zaman
received a scholarship from the Australian Government research
training program (RTP) in support of his academic career. Y Zhang was
supported by the Science and Technology Research Project of Hubei
Provincial Department of Education (Q20201104) and Open Fund Project
of Hubei Province Key Laboratory of Occupational Hazard Identification
and Control (OHIC2020Y01).
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