Elsevier

The Lancet

Volume 375, Issue 9727, 15–21 May 2010, Pages 1704-1720
The Lancet

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Worldwide mortality in men and women aged 15–59 years from 1970 to 2010: a systematic analysis

https://doi.org/10.1016/S0140-6736(10)60517-XGet rights and content

Summary

Background

Adult deaths are a crucial priority for global health. Causes of adult death are important components of Millennium Development Goals 5 and 6. However, adult mortality has received little policy attention, resources, or monitoring efforts. This study aimed to estimate worldwide mortality in men and women aged 15–59 years.

Methods

We compiled a database of 3889 measurements of adult mortality for 187 countries from 1970 to 2010 using vital registration data and census and survey data for deaths in the household corrected for completeness, and sibling history data from surveys corrected for survival bias. We used Gaussian process regression to generate yearly estimates of the probability of death between the ages of 15 years and 60 years (45q15) for men and women for every country with uncertainty intervals that indicate sampling and non-sampling error. We showed that these analytical methods have good predictive validity for countries with missing data.

Findings

Adult mortality varied substantially across countries and over time. In 2010, the countries with the lowest risk of mortality for men and women are Iceland and Cyprus, respectively. In Iceland, male 45q15 is 65 (uncertainty interval 61–69) per 1000; in Cyprus, female 45q15 is 38 (36–41) per 1000. Highest risk of mortality in 2010 is seen in Swaziland for men (45q15 of 765 [692–845] per 1000) and Zambia for women (606 [518–708] per 1000). Between 1970 and 2010, substantial increases in adult mortality occurred in sub-Saharan Africa because of the HIV epidemic and in countries in or related to the former Soviet Union. Other regional trends were also seen, such as stagnation in the decline of adult mortality for large countries in southeast Asia and a striking decline in female mortality in south Asia.

Interpretation

The prevention of premature adult death is just as important for global health policy as the improvement of child survival. Routine monitoring of adult mortality should be given much greater emphasis.

Funding

Bill & Melinda Gates Foundation.

Introduction

Public health efforts in the 1980s and 1990s had a substantial focus on improving mortality and morbidity in children.1, 2, 3 Both the numbers and rates of death in children under 5 years of age have been falling for several decades, although many countries are not on track to achieve Millennium Development Goal (MDG) 4, which calls for a two-thirds reduction in the mortality rate in children younger than 5 years between 1990 and 2015.1, 3, 4, 5, 6 Concomitant with decreases in under-5 mortality, global fertility has declined from a total fertility rate (TFR) of 5·0 in 1950 to 2·5 in 2009, leading to a substantial increase in the mean and median age of most populations.7 Declining under-5 mortality rates and ageing populations also mean that a larger proportion of deaths occur in adults.7, 8 Despite the increase in adult population and the related change in population health issues that follow this demographic shift, there has been much less global health focus on the health and survival of adults.

In 1992, Feachem and colleagues9 drew attention to deaths in adults aged 15–59 years. Deaths in individuals aged younger than 60 years can be considered premature by any standard.10, 11, 12 Deaths in the most economically and socially active groups can also have major effects on society.13, 14, 15 For these reasons, the World Bank and subsequently WHO have reported adult mortality risk, also referred to as 45q15.8, 16 For a given year, 45q15 represents the probability that an individual who has just turned 15 years will die before reaching the age of 60 years, on the assumption that the age-specific mortality conditions of the year are constant throughout this individual's life.

Interest in adult mortality has been intensified through the Millennium Declaration. MDG 5 on maternal health focuses on one of the important causes of death in women aged 15–49 years. Adult female mortality rates are an essential component of the measurement of the maternal mortality ratio.17 Two of the three diseases covered by MDG 6, tuberculosis and HIV, are largely killers of adults—95% and 85% of deaths from these diseases, respectively, occur in people older than 15 years.8 Although maternal mortality, HIV, and tuberculosis have received substantial policy attention and development assistance for health,18 the rising burden of non-communicable diseases in developing countries has received much less policy attention.19, 20, 21

Despite the attention on specific diseases that affect adults, policy traction towards improving overall adult health outcomes continues to be low.9 This disinterest has led to widespread neglect for building and maintaining data systems for measuring adult mortality.22, 23 Tracking change in this basic outcome of adult health is important for assessing progress, improving interventions, and driving further investment.24 However, challenges in measurement of adult mortality have been noted historically and continue to persist.2, 22, 23, 25, 26

Assessments every 2 years by the United Nations Population Division (UNPD) are undertaken to produce population estimates and projections for most countries for 5-year periods. These efforts also produce estimates of life expectancy, age-specific deaths, and 45q15, but for most developing countries, the estimates are based on models that assume a close correlation between adult and under-5 mortality.7 WHO also periodically produces estimates of 45q15; these often differ substantially from UNPD estimates. WHO does not produce a complete time series (only selected years) and, similar to UNPD, major limitations of WHO's approach are that the process is neither transparent nor replicable.27 Large-scale systematic assessments that cover all publicly available data sources over several decades have been completed for children but not for adults.1, 28, 29 In countries without complete vital registration systems, there has been disagreement about the best methods to analyse and interpret partial vital registration data, survey data for sibling histories, and survey or census recall of deaths.2 For some regions, important comparative analyses of available data have been undertaken but these efforts did not cover the entire developing and developed world.30 The absence of a systematic assessment of the evidence on trends in adult mortality, especially in developing countries, has resulted in a “scandal of ignorance”.2, 30, 31 Several developments in data availability and analytical methods now make a systematic assessment of trends in 45q15 feasible. Improved methods for analysis of incomplete vital registration or sample registration data are now available.32 Issues of survivor bias in the analysis of sibling histories widely available in sub-Saharan Africa have been addressed and practical implementation of this approach worked out.33, 34 More demographic surveillance system and sample registration data are available.35 Finally, techniques used to synthesise multiple data sources for children can be adapted for studying adult mortality (Rajaratnam J K, et al, unpublished data). In this study, we systematically analysed data for 187 countries from 1970 to 2010 to estimate 45q15 for men and women.

Section snippets

Data sources

Empirical measurements of adult mortality were drawn from four types of sources (table 1): (1) vital registration data, (2) sample registration systems (when available), and nationally representative survey or census data that enable direct estimation of age-specific adult mortality rates from questions about either (3) deaths in the household or (4) the survival of siblings of a respondent. In a few cases, an estimate of 45q15 from survey reports was used when other sources of microdata or

Results

The empirical measurements of 45q15 and the results of our data synthesis, including uncertainty intervals, are available for each country in webappendix pp 18–391; five examples of these data plots are shown in figure 1. Data for adult male mortality in Chile provide an example of a complete time series with complete vital registration data. In this case, our Gaussian process regression model produced estimates that were very close to the observed data and the uncertainty intervals represent

Discussion

Our analysis of all available empirical data for adult mortality from 1970 to 2010 for 187 countries shows that the rates of change for adult mortality are substantially more varied than are those for mortality in children under 5 years of age (Rajaratnam J K, et al, unpublished data). Risk of mortality is generally higher for men than for women; however in 2·5% of country-years, risk is higher for women than for men. There is also a widening gap between risks of male and female mortality.

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