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Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study
  1. Spencer L James1,
  2. Chris D Castle1,
  3. Zachary V Dingels1,
  4. Jack T Fox1,
  5. Erin B Hamilton1,
  6. Zichen Liu1,
  7. Nicholas L S Roberts1,
  8. Dillon O Sylte1,
  9. Gregory J Bertolacci1,
  10. Matthew Cunningham1,
  11. Nathaniel J Henry1,
  12. Kate E LeGrand1,
  13. Ahmed Abdelalim2,
  14. Ibrahim Abdollahpour3,
  15. Rizwan Suliankatchi Abdulkader4,
  16. Aidin Abedi5,
  17. Kedir Hussein Abegaz6,7,
  18. Akine Eshete Abosetugn8,
  19. Abdelrahman I Abushouk9,
  20. Oladimeji M Adebayo10,
  21. Jose C Adsuar11,
  22. Shailesh M Advani12,13,
  23. Marcela Agudelo-Botero14,
  24. Tauseef Ahmad15,16,
  25. Muktar Beshir Ahmed17,
  26. Rushdia Ahmed18,19,
  27. Miloud Taki Eddine Aichour20,
  28. Fares Alahdab21,
  29. Fahad Mashhour Alanezi22,
  30. Niguse Meles Alema23,
  31. Biresaw Wassihun Alemu24,25,
  32. Suliman A Alghnam26,
  33. Beriwan Abdulqadir Ali27,
  34. Saqib Ali28,
  35. Cyrus Alinia29,
  36. Vahid Alipour30,31,
  37. Syed Mohamed Aljunid32,33,
  38. Amir Almasi-Hashiani34,
  39. Nihad A Almasri35,
  40. Khalid Altirkawi36,
  41. Yasser Sami Abdeldayem Amer37,38,
  42. Catalina Liliana Andrei39,
  43. Alireza Ansari-Moghaddam40,
  44. Carl Abelardo T Antonio41,42,
  45. Davood Anvari43,44,
  46. Seth Christopher Yaw Appiah45,46,
  47. Jalal Arabloo30,
  48. Morteza Arab-Zozani47,
  49. Zohreh Arefi48,
  50. Olatunde Aremu49,
  51. Filippo Ariani50,
  52. Amit Arora51,52,
  53. Malke Asaad53,
  54. Beatriz Paulina Ayala Quintanilla54,55,
  55. Getinet Ayano56,
  56. Martin Amogre Ayanore57,
  57. Ghasem Azarian58,
  58. Alaa Badawi59,60,
  59. Ashish D Badiye61,
  60. Atif Amin Baig62,63,
  61. Mohan Bairwa64,65,
  62. Ahad Bakhtiari66,
  63. Arun Balachandran67,68,
  64. Maciej Banach69,70,
  65. Srikanta K Banerjee71,
  66. Palash Chandra Banik72,
  67. Amrit Banstola73,
  68. Suzanne Lyn Barker-Collo74,
  69. Till Winfried Bärnighausen75,76,
  70. Akbar Barzegar77,
  71. Mohsen Bayati78,
  72. Shahrzad Bazargan-Hejazi79,80,
  73. Neeraj Bedi81,82,
  74. Masoud Behzadifar83,
  75. Habte Belete84,
  76. Derrick A Bennett85,
  77. Isabela M Bensenor86,
  78. Kidanemaryam Berhe87,
  79. Akshaya Srikanth Bhagavathula88,89,
  80. Pankaj Bhardwaj90,91,
  81. Anusha Ganapati Bhat92,
  82. Krittika Bhattacharyya93,94,
  83. Zulfiqar A Bhutta95,96,
  84. Sadia Bibi97,
  85. Ali Bijani98,
  86. Archith Boloor99,
  87. Guilherme Borges100,
  88. Rohan Borschmann101,102,
  89. Antonio Maria Borzì103,
  90. Soufiane Boufous104,
  91. Dejana Braithwaite105,
  92. Nikolay Ivanovich Briko106,
  93. Traolach Brugha107,
  94. Shyam S Budhathoki108,
  95. Josip Car109,110,
  96. Rosario Cárdenas111,
  97. Félix Carvalho112,
  98. João Mauricio Castaldelli-Maia113,
  99. Carlos A Castañeda-Orjuela114,115,
  100. Giulio Castelpietra116,117,
  101. Ferrán Catalá-López118,119,
  102. Ester Cerin120,121,
  103. Joht S Chandan122,
  104. Jens Robert Chapman123,
  105. Vijay Kumar Chattu124,
  106. Soosanna Kumary Chattu125,
  107. Irini Chatziralli126,127,
  108. Neha Chaudhary128,129,
  109. Daniel Youngwhan Cho130,
  110. Jee-Young J Choi131,
  111. Mohiuddin Ahsanul Kabir Chowdhury132,133,
  112. Devasahayam J Christopher134,
  113. Dinh-Toi Chu135,
  114. Flavia M Cicuttini136,
  115. João M Coelho137,
  116. Vera M Costa112,
  117. Saad M A Dahlawi138,
  118. Ahmad Daryani139,
  119. Claudio Alberto Dávila-Cervantes140,
  120. Diego De Leo141,
  121. Feleke Mekonnen Demeke142,
  122. Gebre Teklemariam Demoz143,144,
  123. Desalegn Getnet Demsie23,
  124. Kebede Deribe145,146,
  125. Rupak Desai147,
  126. Mostafa Dianati Nasab148,
  127. Diana Dias da Silva149,
  128. Zahra Sadat Dibaji Forooshani150,
  129. Hoa Thi Do151,
  130. Kerrie E Doyle152,
  131. Tim Robert Driscoll153,
  132. Eleonora Dubljanin154,
  133. Bereket Duko Adema155,156,
  134. Arielle Wilder Eagan157,158,
  135. Demelash Abewa Elemineh159,
  136. Shaimaa I El-Jaafary2,
  137. Ziad El-Khatib160,161,
  138. Christian Lycke Ellingsen162,163,
  139. Maysaa El Sayed Zaki164,
  140. Sharareh Eskandarieh165,
  141. Oghenowede Eyawo166,167,
  142. Pawan Sirwan Faris168,169,
  143. Andre Faro170,
  144. Farshad Farzadfar171,
  145. Seyed-Mohammad Fereshtehnejad172,173,
  146. Eduarda Fernandes174,
  147. Pietro Ferrara175,
  148. Florian Fischer176,
  149. Morenike Oluwatoyin Folayan177,
  150. Artem Alekseevich Fomenkov178,
  151. Masoud Foroutan179,
  152. Joel Msafiri Francis180,
  153. Richard Charles Franklin181,182,
  154. Takeshi Fukumoto183,184,
  155. Biniyam Sahiledengle Geberemariyam185,
  156. Hadush Gebremariam87,
  157. Ketema Bizuwork Gebremedhin186,
  158. Leake G Gebremeskel143,187,
  159. Gebreamlak Gebremedhn Gebremeskel188,189,
  160. Berhe Gebremichael190,
  161. Getnet Azeze Gedefaw191,192,
  162. Birhanu Geta193,
  163. Agegnehu Bante Getenet194,
  164. Mansour Ghafourifard195,
  165. Farhad Ghamari196,
  166. Reza Ghanei Gheshlagh197,
  167. Asadollah Gholamian198,199,
  168. Syed Amir Gilani200,201,
  169. Tiffany K Gill202,
  170. Amir Hossein Goudarzian203,
  171. Alessandra C Goulart204,205,
  172. Ayman Grada206,
  173. Michal Grivna207,
  174. Rafael Alves Guimarães208,
  175. Yuming Guo136,209,
  176. Gaurav Gupta210,
  177. Juanita A Haagsma211,
  178. Brian James Hall212,
  179. Randah R Hamadeh213,
  180. Samer Hamidi214,
  181. Demelash Woldeyohannes Handiso185,
  182. Josep Maria Haro215,216,
  183. Amir Hasanzadeh217,218,
  184. Shoaib Hassan219,
  185. Soheil Hassanipour220,221,
  186. Hadi Hassankhani222,223,
  187. Hamid Yimam Hassen224,225,
  188. Rasmus Havmoeller226,
  189. Delia Hendrie56,
  190. Fatemeh Heydarpour227,
  191. Martha Híjar228,229,
  192. Hung Chak Ho230,
  193. Chi Linh Hoang231,
  194. Michael K Hole232,
  195. Ramesh Holla233,
  196. Naznin Hossain234,235,
  197. Mehdi Hosseinzadeh236,237,
  198. Sorin Hostiuc238,239,
  199. Guoqing Hu240,
  200. Segun Emmanuel Ibitoye241,
  201. Olayinka Stephen Ilesanmi242,
  202. Leeberk Raja Inbaraj243,
  203. Seyed Sina Naghibi Irvani244,
  204. M Mofizul Islam245,
  205. Sheikh Mohammed Shariful Islam246,247,
  206. Rebecca Q Ivers248,
  207. Mohammad Ali Jahani249,
  208. Mihajlo Jakovljevic250,
  209. Farzad Jalilian251,
  210. Sudha Jayaraman252,
  211. Achala Upendra Jayatilleke253,254,
  212. Ravi Prakash Jha255,
  213. Yetunde O John-Akinola256,
  214. Jost B Jonas257,258,
  215. Kelly M Jones259,
  216. Nitin Joseph260,
  217. Farahnaz Joukar220,
  218. Jacek Jerzy Jozwiak261,
  219. Suresh Banayya Jungari262,
  220. Mikk Jürisson263,
  221. Ali Kabir264,
  222. Amaha Kahsay87,
  223. Leila R Kalankesh265,
  224. Rohollah Kalhor266,267,
  225. Teshome Abegaz Kamil268,
  226. Tanuj Kanchan269,
  227. Neeti Kapoor61,
  228. Manoochehr Karami270,
  229. Amir Kasaeian271,272,
  230. Hagazi Gebremedhin Kassaye23,
  231. Taras Kavetskyy273,274,
  232. Gbenga A Kayode275,276,
  233. Peter Njenga Keiyoro277,
  234. Abraham Getachew Kelbore278,
  235. Yousef Saleh Khader279,
  236. Morteza Abdullatif Khafaie280,
  237. Nauman Khalid281,
  238. Ibrahim A Khalil282,
  239. Rovshan Khalilov283,
  240. Maseer Khan284,
  241. Ejaz Ahmad Khan285,
  242. Junaid Khan286,
  243. Tripti Khanna287,288,
  244. Salman Khazaei270,
  245. Habibolah Khazaie289,
  246. Roba Khundkar290,
  247. Daniel N Kiirithio291,
  248. Young-Eun Kim292,
  249. Yun Jin Kim293,
  250. Daniel Kim294,
  251. Sezer Kisa295,
  252. Adnan Kisa296,
  253. Hamidreza Komaki297,298,
  254. Shivakumar K M Kondlahalli299,
  255. Ali Koolivand300,
  256. Vladimir Andreevich Korshunov106,
  257. Ai Koyanagi301,302,
  258. Moritz U G Kraemer303,304,
  259. Kewal Krishan305,
  260. Barthelemy Kuate Defo306,307,
  261. Burcu Kucuk Bicer308,309,
  262. Nuworza Kugbey310,311,
  263. Nithin Kumar312,
  264. Manasi Kumar313,314,
  265. Vivek Kumar315,
  266. Narinder Kumar316,
  267. Girikumar Kumaresh317,
  268. Faris Hasan Lami318,
  269. Van C Lansingh319,320,
  270. Savita Lasrado321,
  271. Arman Latifi322,
  272. Paolo Lauriola323,
  273. Carlo La Vecchia324,
  274. Janet L Leasher325,
  275. Shaun Wen Huey Lee326,327,
  276. Shanshan Li136,
  277. Xuefeng Liu328,
  278. Alan D Lopez1,102,329,
  279. Paulo A Lotufo330,
  280. Ronan A Lyons331,
  281. Daiane Borges Machado332,333,
  282. Mohammed Madadin334,
  283. Muhammed Magdy Abd El Razek335,
  284. Narayan Bahadur Mahotra336,
  285. Marek Majdan337,
  286. Azeem Majeed338,
  287. Venkatesh Maled339,340,
  288. Deborah Carvalho Malta341,
  289. Navid Manafi342,343,
  290. Amir Manafi344,
  291. Ana-Laura Manda345,
  292. Narayana Manjunatha346,
  293. Fariborz Mansour-Ghanaei220,
  294. Mohammad Ali Mansournia347,
  295. Joemer C Maravilla348,
  296. Amanda J Mason-Jones349,
  297. Seyedeh Zahra Masoumi350,
  298. Benjamin Ballard Massenburg130,
  299. Pallab K Maulik351,352,
  300. Man Mohan Mehndiratta353,354,
  301. Zeleke Aschalew Melketsedik194,
  302. Peter T N Memiah355,
  303. Walter Mendoza356,
  304. Ritesh G Menezes357,
  305. Melkamu Merid Mengesha358,
  306. Tuomo J Meretoja359,360,
  307. Atte Meretoja361,362,
  308. Hayimro Edemealem Merie363,
  309. Tomislav Mestrovic364,365,
  310. Bartosz Miazgowski366,367,
  311. Tomasz Miazgowski368,
  312. Ted R Miller56,369,
  313. G K Mini370,371,
  314. Andreea Mirica372,373,
  315. Erkin M Mirrakhimov374,375,
  316. Mehdi Mirzaei-Alavijeh251,
  317. Prasanna Mithra260,
  318. Babak Moazen376,377,
  319. Masoud Moghadaszadeh378,379,
  320. Efat Mohamadi380,
  321. Yousef Mohammad381,
  322. Aso Mohammad Darwesh382,
  323. Abdollah Mohammadian-Hafshejani383,
  324. Reza Mohammadpourhodki384,
  325. Shafiu Mohammed75,385,
  326. Jemal Abdu Mohammed386,
  327. Farnam Mohebi171,387,
  328. Mohammad A Mohseni Bandpei388,
  329. Mariam Molokhia389,
  330. Lorenzo Monasta390,
  331. Yoshan Moodley391,
  332. Masoud Moradi392,393,
  333. Ghobad Moradi394,395,
  334. Maziar Moradi-Lakeh396,
  335. Rahmatollah Moradzadeh34,
  336. Lidia Morawska397,
  337. Ilais Moreno Velásquez398,
  338. Shane Douglas Morrison130,
  339. Tilahun Belete Mossie399,
  340. Atalay Goshu Muluneh400,
  341. Kamarul Imran Musa401,
  342. Ghulam Mustafa402,403,
  343. Mehdi Naderi404,
  344. Ahamarshan Jayaraman Nagarajan405,406,
  345. Gurudatta Naik407,
  346. Mukhammad David Naimzada408,409,
  347. Farid Najafi410,
  348. Vinay Nangia411,
  349. Bruno Ramos Nascimento412,
  350. Morteza Naserbakht413,414,
  351. Vinod Nayak415,
  352. Javad Nazari416,417,
  353. Duduzile Edith Ndwandwe418,
  354. Ionut Negoi419,420,
  355. Josephine W Ngunjiri421,
  356. Trang Huyen Nguyen231,
  357. Cuong Tat Nguyen422,
  358. Diep Ngoc Nguyen423,424,
  359. Huong Lan Thi Nguyen422,
  360. Rajan Nikbakhsh425,426,
  361. Dina Nur Anggraini Ningrum427,428,
  362. Chukwudi A Nnaji418,429,
  363. Richard Ofori-Asenso430,431,
  364. Felix Akpojene Ogbo432,
  365. Onome Bright Oghenetega433,
  366. In-Hwan Oh434,
  367. Andrew T Olagunju435,436,
  368. Tinuke O Olagunju437,
  369. Ahmed Omar Bali438,
  370. Obinna E Onwujekwe439,
  371. Heather M Orpana440,441,
  372. Erika Ota442,
  373. Nikita Otstavnov408,443,
  374. Stanislav S Otstavnov408,444,
  375. Mahesh P A445,
  376. Jagadish Rao Padubidri446,
  377. Smita Pakhale447,
  378. Keyvan Pakshir448,
  379. Songhomitra Panda-Jonas449,
  380. Eun-Kee Park450,
  381. Sangram Kishor Patel451,452,
  382. Ashish Pathak453,454,
  383. Sanghamitra Pati455,
  384. Kebreab Paulos456,
  385. Amy E Peden182,457,
  386. Veincent Christian Filipino Pepito458,
  387. Jeevan Pereira459,
  388. Michael R Phillips460,461,
  389. Roman V Polibin462,
  390. Suzanne Polinder211,
  391. Farshad Pourmalek463,
  392. Akram Pourshams464,
  393. Hossein Poustchi464,
  394. Swayam Prakash465,
  395. Dimas Ria Angga Pribadi466,
  396. Parul Puri286,
  397. Zahiruddin Quazi Syed91,
  398. Navid Rabiee467,
  399. Mohammad Rabiee468,
  400. Amir Radfar469,470,
  401. Anwar Rafay471,
  402. Ata Rafiee472,
  403. Alireza Rafiei473,474,
  404. Fakher Rahim475,476,
  405. Siavash Rahimi477,
  406. Muhammad Aziz Rahman478,479,
  407. Ali Rajabpour-Sanati480,
  408. Fatemeh Rajati392,
  409. Ivo Rakovac481,
  410. Sowmya J Rao482,
  411. Vahid Rashedi483,
  412. Prateek Rastogi446,
  413. Priya Rathi233,
  414. Salman Rawaf338,484,
  415. Lal Rawal485,
  416. Reza Rawassizadeh486,
  417. Vishnu Renjith487,
  418. Serge Resnikoff488,489,
  419. Aziz Rezapour30,
  420. Ana Isabel Ribeiro490,
  421. Jennifer Rickard491,492,
  422. Carlos Miguel Rios González493,494,
  423. Leonardo Roever495,
  424. Luca Ronfani390,
  425. Gholamreza Roshandel464,496,
  426. Basema Saddik497,
  427. Hamid Safarpour498,
  428. Mahdi Safdarian499,500,
  429. S Mohammad Sajadi501,
  430. Payman Salamati500,
  431. Marwa R Rashad Salem502,
  432. Hosni Salem503,
  433. Inbal Salz504,
  434. Abdallah M Samy505,
  435. Juan Sanabria506,507,
  436. Lidia Sanchez Riera508,509,
  437. Milena M Santric Milicevic510,511,
  438. Abdur Razzaque Sarker512,
  439. Arash Sarveazad513,
  440. Brijesh Sathian514,515,
  441. Monika Sawhney516,
  442. Mehdi Sayyah517,
  443. David C Schwebel518,
  444. Soraya Seedat519,
  445. Subramanian Senthilkumaran520,
  446. Seyedmojtaba Seyedmousavi521,
  447. Feng Sha522,
  448. Faramarz Shaahmadi523,
  449. Saeed Shahabi524,
  450. Masood Ali Shaikh525,
  451. Mehran Shams-Beyranvand526,
  452. Aziz Sheikh527,528,
  453. Mika Shigematsu529,
  454. Jae Il Shin530,531,
  455. Rahman Shiri532,
  456. Soraya Siabani533,534,
  457. Inga Dora Sigfusdottir535,536,
  458. Jasvinder A Singh537,538,
  459. Pankaj Kumar Singh539,
  460. Dhirendra Narain Sinha540,541,
  461. Amin Soheili542,543,
  462. Joan B Soriano544,545,
  463. Muluken Bekele Sorrie546,
  464. Ireneous N Soyiri547,548,
  465. Mark A Stokes549,
  466. Mu'awiyyah Babale Sufiyan550,
  467. Bryan L Sykes551,
  468. Rafael Tabarés-Seisdedos552,553,
  469. Karen M Tabb554,
  470. Biruk Wogayehu Taddele555,
  471. Yonatal Mesfin Tefera556,557,
  472. Arash Tehrani-Banihashemi396,558,
  473. Gebretsadkan Hintsa Tekulu559,
  474. Ayenew Kassie Tesema Tesema560,
  475. Berhe Etsay Tesfay561,
  476. Rekha Thapar312,
  477. Mariya Vladimirovna Titova178,562,
  478. Kenean Getaneh Tlaye563,
  479. Hamid Reza Tohidinik347,564,
  480. Roman Topor-Madry565,566,
  481. Khanh Bao Tran567,568,
  482. Bach Xuan Tran569,
  483. Jaya Prasad Tripathy90,
  484. Alexander C Tsai570,571,
  485. Aristidis Tsatsakis572,
  486. Lorainne Tudor Car573,
  487. Irfan Ullah574,575,
  488. Saif Ullah97,
  489. Bhaskaran Unnikrishnan260,
  490. Era Upadhyay576,
  491. Olalekan A Uthman577,
  492. Pascual R Valdez578,579,
  493. Tommi Juhani Vasankari580,
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  495. Narayanaswamy Venketasubramanian582,583,
  496. Francesco S Violante584,585,
  497. Vasily Vlassov586,
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  499. Yuan-Pang Wang113,
  500. Taweewat Wiangkham588,
  501. Haileab Fekadu Wolde400,
  502. Dawit Habte Woldeyes589,
  503. Temesgen Gebeyehu Wondmeneh386,
  504. Adam Belay Wondmieneh186,590,
  505. Ai-Min Wu591,
  506. Grant M A Wyper592,
  507. Rajaram Yadav286,
  508. Ali Yadollahpour593,
  509. Yuichiro Yano594,
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  512. Pengpeng Ye598,
  513. Paul Yip599,600,
  514. Engida Yisma601,
  515. Naohiro Yonemoto602,
  516. Seok-Jun Yoon292,
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  518. Mustafa Z Younis604,605,
  519. Zabihollah Yousefi606,607,
  520. Chuanhua Yu608,609,
  521. Yong Yu610,
  522. Telma Zahirian Moghadam30,611,
  523. Zoubida Zaidi612,
  524. Sojib Bin Zaman132,613,
  525. Mohammad Zamani614,
  526. Hamed Zandian611,615,
  527. Fatemeh Zarei616,
  528. Zhi-Jiang Zhang617,
  529. Yunquan Zhang618,619,
  530. Arash Ziapour533,
  531. Sanjay Zodpey620,
  532. Rakhi Dandona1,329,621,
  533. Samath Dhamminda Dharmaratne1,329,622,
  534. Simon I Hay1,329,
  535. Ali H Mokdad1,329,
  536. David M Pigott1,329,
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  538. Theo Vos1,329
  1. 1 Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
  2. 2 Department of Neurology, Cairo University, Cairo, Egypt
  3. 3 Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
  4. 4 Department of Public Health, Ministry of Health, Riyadh, Saudi Arabia
  5. 5 Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
  6. 6 Biostatistics and Health Informatics, Madda Walabu University, Bale Robe, Ethiopia
  7. 7 Radiotherapy Center, Addis Ababa University, Addis Ababa, Ethiopia
  8. 8 Department of Public Health, Debre Berhan University, Debre Berhan, Ethiopia
  9. 9 Cardiovascular Medicine Department, Ain Shams University, Abbasia, Egypt
  10. 10 Department of Medicine, University College Hospital, Ibadan, Nigeria
  11. 11 Sport Science Department, University of Extremadura, Badajoz, Spain
  12. 12 Social Behavioral Research Branch, National Institute of Health, Bethesda, MD, USA
  13. 13 Cancer Prevention and Control, Georgetown University, Washington, DC, USA
  14. 14 School of Medicine, Center for Politics, Population and Health Research, National Autonomous University of Mexico, Mexico City, Mexico
  15. 15 Department of Epidemiology and Health Statistics, Southeast University Nanjing, Nanjing, China
  16. 16 Microbiology Department, Hazara University, Mansehra, Pakistan
  17. 17 Department of Epidemiology, Jimma University, Jimma, Ethiopia
  18. 18 James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
  19. 19 Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
  20. 20 Higher National School of Veterinary Medicine, Algiers, Algeria
  21. 21 Evidence Based Practice Center, Mayo Clinic Foundation for Medical Education and Research, Rochester, MN, USA
  22. 22 Department of Computer Sciences, Imam Abdulrehman Bin Faisal University, Dammam, Saudi Arabia
  23. 23 Department of Pharmacy, Adigrat University, Adigrat, Ethiopia
  24. 24 Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia
  25. 25 Midwifery Department, Arba Minch University, Injbara, Ethiopia
  26. 26 Department of Population Health Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
  27. 27 Medical Technical Institute, Erbil Polytechnic University, Erbil, Iraq
  28. 28 Department of Information Systems, College of Economics and Political Science, Sultan Qaboos University, Muscat, Oman
  29. 29 Department of Health Care Management and Economics, Urmia University of Medical Science, Urmia, Iran
  30. 30 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
  31. 31 Health Economics Department, Iran University of Medical Sciences, Tehran, Iran
  32. 32 Department of Health Policy and Management, Kuwait University, Safat, Kuwait
  33. 33 International Centre for Casemix and Clinical Coding, National University of Malaysia, Bandar Tun Razak, Malaysia
  34. 34 Department of Epidemiology, Arak University of Medical Sciences, Arak, Iran
  35. 35 Physiotherapy Department, The University of Jordan, Amman, Jordan
  36. 36 King Saud University, Riyadh, Saudi Arabia
  37. 37 Clinical Practice Guidelines Unit, King Saud University, Riyadh, Saudi Arabia
  38. 38 Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria, Egypt
  39. 39 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
  40. 40 Department of Epidemiology and Biostatistics, Health Promotion Research Center, Zahedan, Iran
  41. 41 Department of Health Policy and Administration, University of the Philippines Manila, Manila, Philippines
  42. 42 Department of Applied Social Sciences, Hong Kong Polytechnic University, Hong Kong, China
  43. 43 Department of Parasitology, Mazandaran University of Medical Sciences, Sari, Iran
  44. 44 Department of Microbiology and Immunology, Iranshahr University of Medical Sciences, Iranshahr, Iran
  45. 45 Department of Sociology and Social Work, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
  46. 46 Center for International Health, Ludwig Maximilians University, Munich, Germany
  47. 47 Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
  48. 48 Department of Health Promotion and Education, Tehran University of Medical Sciences, Tehran, Iran
  49. 49 School of Health Sciences, Birmingham City University, Birmingham, UK
  50. 50 Regional Centre for the Analysis of Data on Occupational and Work-related Injuries and Diseases, Local Health Unit Tuscany Centre, Florence, Italy
  51. 51 School of Science and Health, Western Sydney University, Sydney, New South Wales, Australia
  52. 52 Oral Health Services, Sydney Local Health District, Sydney, New South Wales, Australia
  53. 53 Plastic Surgery Department, University of Texas, Houston, TX, USA
  54. 54 The Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
  55. 55 General Office for Research and Technological Transfer, Peruvian National Institute of Health, Lima, Peru
  56. 56 School of Public Health, Curtin University, Perth, Western Australia, Australia
  57. 57 Department of Health Policy Planning and Management, University of Health and Allied Sciences, Ho, Ghana
  58. 58 Department of Environmental Health Engineering, Hamadan University of Medical Sciences, Hamadan, Iran
  59. 59 Public Health Risk Sciences Division, Public Health Agency of Canada, Toronto, Ontario, Canada
  60. 60 Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
  61. 61 Department of Forensic Science, Government Institute of Forensic Science, Nagpur, India
  62. 62 Biochemistry Unit, Universiti Sultan Zainal Abidin, Kuala Terengganu, Malaysia
  63. 63 School of Health Sciences, Univeristi Sultan Zainal Abidin, Kuala Terengganu, Malaysia
  64. 64 Institute of Health Management Research, Indian Institute of Health Management Research University, Jaipur, India
  65. 65 Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
  66. 66 Health Policy and Management Department, Tehran University of Medical Sciences, Tehran, Iran
  67. 67 Department of Demography, University of Groningen, Groningen, Netherlands
  68. 68 Population Research Centre, Institute for Social and Economic Change, Bengaluru, India
  69. 69 Department of Hypertension, Medical University of Lodz, Lodz, Poland
  70. 70 Polish Mothers’ Memorial Hospital Research Institute, Lodz, Poland
  71. 71 School of Health Sciences, Walden University, Minneapolis, MN, USA
  72. 72 Department of Noncommunicable Diseases, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh
  73. 73 Department of Research, Public Health Perspective Nepal, Pokhara-Lekhnath Metropolitan City, Nepal
  74. 74 School of Psychology, University of Auckland, Auckland, New Zealand
  75. 75 Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany
  76. 76 T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
  77. 77 Occupational Health Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
  78. 78 Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
  79. 79 Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
  80. 80 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
  81. 81 Department of Community Medicine, Gandhi Medical College Bhopal, Bhopal, India
  82. 82 Jazan University, Jazan, Saudi Arabia
  83. 83 Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
  84. 84 Psychiatry Department, Bahir Dar University, Bhair Dar, Ethiopia
  85. 85 Nuffield Department of Population Health, University of Oxford, Oxford, UK
  86. 86 Department of Internal Medicine, University of São Paulo, São Paulo, Brazil
  87. 87 Department of Nutrition and Dietetics, Mekelle University, Mekelle, Ethiopia
  88. 88 Department of Internal Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
  89. 89 Social and Clinical Pharmacy, Charles University, Hradec Kralova, Czech Republic
  90. 90 Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, India
  91. 91 Department of Community Medicine, Datta Meghe Institute of Medical Sciences, Wardha, India
  92. 92 Internal Medicine Department, University of Massachusetts Medical School, Springfield, MA, USA
  93. 93 Department of Statistical and Computational Genomics, National Institute of Biomedical Genomics, Kalyani, India
  94. 94 Department of Statistics, University of Calcutta, Kolkata, India
  95. 95 Centre for Global Child Health, University of Toronto, Toronto, Ontario, Canada
  96. 96 Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
  97. 97 Institute of Soil and Environmental Sciences, University of Agriculture, Faisalabad, Pakistan
  98. 98 Social Determinants of Health Research Center, Babol University of Medical Sciences, Babol, Iran
  99. 99 Department of Internal Medicine, Manipal Academy of Higher Education, Mangalore, India
  100. 100 Department of Epidemiology and Psychosocial Reseach, Ramón de la Fuente Muñiz National Institute of Psychiatry, Mexico City, Mexico
  101. 101 Centre for Adolescent Health, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
  102. 102 School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  103. 103 Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
  104. 104 Transport and Road Safety (TARS) Research Department, University of New South Wales, Sydney, New South Wales, Australia
  105. 105 Division of Hematology and Oncology, Georgetown University, Washington DC, USA
  106. 106 Department of Epidemiology and Evidence Based Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
  107. 107 Department of Health Sciences, University of Leicester, Leicester, UK
  108. 108 Research Department, Golden Community, Kathmandu, Nepal
  109. 109 Centre for Population Health Sciences, Nanyang Technological University, Singapore, Singapore
  110. 110 Global eHealth Unit, Imperial College London, London, UK
  111. 111 Department of Population and Health, Metropolitan Autonomous University, Mexico City, Mexico
  112. 112 Research Unit on Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal
  113. 113 Department of Psychiatry, University of São Paulo, São Paulo, Brazil
  114. 114 Colombian National Health Observatory, National Institute of Health, Bogota, Colombia
  115. 115 Epidemiology and Public Health Evaluation Group, National University of Colombia, Bogota, Colombia
  116. 116 Primary Care Services Area, Central Health Directorate, Region Friuli Venezia Giulia, Trieste, Italy
  117. 117 Department of Medicine (DAME), University of Udine, Udine, Italy
  118. 118 National School of Public Health, Carlos III Health Institute, Madrid, Spain
  119. 119 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  120. 120 Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
  121. 121 School of Public Health, University of Hong Kong, Hong Kong, China
  122. 122 Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  123. 123 Swedish Neuroscience Institute, Swedish Brain and Spine Specialists, Seattle, WA, USA
  124. 124 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  125. 125 Department of Public Health, Texila American University, Georgetown, Guyana
  126. 126 2nd Department of Ophthalmology, University of Athens, Haidari, Greece
  127. 127 Ophthalmology Independent Consultant, Athens, Greece
  128. 128 Pediatrics Department, Harvard University, Boston, MA, USA
  129. 129 Neonatology Department, Beth Israel Deaconess Medical Center, Boston, MA, USA
  130. 130 Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Washington, Seattle, WA, USA
  131. 131 Department of Biochemistry and Biomedical Science, Seoul National University Hospital, Seoul, South Korea
  132. 132 Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
  133. 133 Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
  134. 134 Department of Pulmonary Medicine, Christian Medical College and Hospital (CMC), Vellore, India
  135. 135 Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
  136. 136 School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  137. 137 Centro Hospitalar Universitário do Porto - Serviço de Oftalmologia, University of Porto, Porto, Portugal
  138. 138 Department of Environmental Health, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  139. 139 Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran
  140. 140 Population and Development, Facultad Latinoamericana de Ciencias Sociales Mexico, Mexico City, Mexico
  141. 141 Australian Institute for Suicide Research and Prevention, Griffith University, Mount Gravatt, Queensland, Australia
  142. 142 Department of Medical Laboratory Sciences, Bahir Dar University, Bahir Dar, Ethiopia
  143. 143 School of Pharmacy, Aksum University, Aksum, Ethiopia
  144. 144 Addis Ababa University, Addis Ababa, Ethiopia
  145. 145 Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
  146. 146 School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
  147. 147 Division of Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
  148. 148 Department of Epidemiology, Shiraz University of Medical Sciences, Shiraz, Iran
  149. 149 Faculty of Pharmacy, University of Porto, Porto, Portugal
  150. 150 Tehran University of Medical Sciences, Tehran, Iran
  151. 151 Center of Excellence in Public Health Nutrition, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
  152. 152 School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology University, Bundoora, Victoria, Australia
  153. 153 Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  154. 154 Faculty of Medicine, University of Belgrade, Belgrade, Serbia
  155. 155 Public Health Department, Hawassa University, Hawassa, Ethiopia
  156. 156 Curtin University, Perth, Western Australia, Australia
  157. 157 Department of Global Health and Social Medicine, Harvard University, Boston, MA, USA
  158. 158 Department of Social Services, Tufts Medical Center, Boston, MA, USA
  159. 159 Department of Statistics, Debre Markos University, Debre Markos, Ethiopia
  160. 160 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  161. 161 World Health Programme, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
  162. 162 Department of Pathology, Stavanger University Hospital, Stavanger, Norway
  163. 163 Norwegian Institute of Public Health, Oslo, Norway
  164. 164 Department of Clinical Pathology, Mansoura University, Mansoura, Egypt
  165. 165 Multiple Sclerosis Research Center, Tehran University of Medical Sciences, Tehran, Iran
  166. 166 Epidemiology and Population Health, York University, Vancouver, British Columbia, Canada
  167. 167 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  168. 168 Biology Department, Salahaddin University-Erbil, Erbil, Iraq
  169. 169 Department of Biology and Biotechnology “Lazzaro Spallanzani", University of Pavia, Pavia, Italy
  170. 170 Department of Psychology, Federal University of Sergipe, Sao Cristovao, Brazil
  171. 171 Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
  172. 172 Department of Neurobiology, Karolinska Institutet, Stockholm, Sweden
  173. 173 Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada
  174. 174 REQUIMTE/LAQV, University of Porto, Porto, Portugal
  175. 175 Research Centre on Public Health (CESP), University of Milan Bicocca, Monza, Italy
  176. 176 Department of Population Medicine and Health Services Research, Bielefeld University, Bielefeld, Germany
  177. 177 Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria
  178. 178 Timiryazev Institute of Plant Physiology, Russian Academy of Sciences, Moscow, Russia
  179. 179 Abadan School of Medical Sciences, Abadan University of Medical Sciences, Abadan, Iran
  180. 180 Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa
  181. 181 College of Public Health, Medical and Veterinary Science, James Cook University, Douglas, Queensland, Australia
  182. 182 Royal Life Saving Society, Sydney, New South Wales, Australia
  183. 183 Department of Dermatology, Kobe University, Kobe, Japan
  184. 184 Gene Expression & Regulation Program, The Wistar Institute, Philadelphia, PA, USA
  185. 185 Public Health Department, Madda Walabu University, Bale Robe, Ethiopia
  186. 186 Department of Nursing and Midwifery, Addis Ababa University, Addis Ababa, Ethiopia
  187. 187 Pharmacy Department, Mekelle University, Mekelle, Ethiopia
  188. 188 Department of Nursing, Aksum University, Aksum, Ethiopia
  189. 189 Department of Nursing, Mekelle University, Mekelle, Ethiopia
  190. 190 Public Health, Haramaya University, Harar, Ethiopia
  191. 191 Bahir Dar University, Bahir Dar, Ethiopia
  192. 192 Haramaya University, Dire Dawa, Ethiopia
  193. 193 Department of Pharmacy, Wollo University, Dessie, Ethiopia
  194. 194 Department of Nursing, Arba Minch University, Arba Minch, Ethiopia
  195. 195 Department of Medical Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
  196. 196 Occupational Health Department, Arak University of Medical Sciences, Arak, Iran
  197. 197 Department of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
  198. 198 Science and Research Branch, Islamic Azad University, Tehran, Iran
  199. 199 Young Researchers and Elite Club, Islamic Azad University, Rasht, Iran
  200. 200 Faculty of Allied Health Sciences, The University of Lahore, Lahore, Pakistan
  201. 201 Chairman BOG, Afro-Asian Institute, Lahore, Pakistan
  202. 202 Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
  203. 203 Nursing and Midwifery Department, Mazandaran University of Medical Sciences, Sari, Iran
  204. 204 Center for Clinical and Epidemiological Research, University of São Paulo, Sao Paulo, Brazil
  205. 205 Internal Medicine Department, University of São Paulo, Sao Paulo, Brazil
  206. 206 Department of Dermatology, Boston University, Boston, MA, USA
  207. 207 Institute of Public Health, United Arab Emirates University, Al Ain, United Arab Emirates
  208. 208 Instituto de Patologia Tropical e Saúde Pública, Federal University of Goias, Goiânia, Brazil
  209. 209 Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
  210. 210 Non-Communicable Diseases (NCD), World Health Organization (WHO), New Delhi, India
  211. 211 Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
  212. 212 Global and Community Mental Health Research Group, University of Macau, Macao, China
  213. 213 Department of Family and Community Medicine, Arabian Gulf University, Manama, Bahrain
  214. 214 School of Health and Environmental Studies, Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates
  215. 215 Biomedical Research Networking Center for Mental Health Network (CiberSAM), Madrid, Spain
  216. 216 Research and Development Unit, San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain
  217. 217 Department of Microbiology, Maragheh University of Medical Sciences, Maragheh, Iran
  218. 218 Department of Microbiology, Tehran University of Medical Sciences, Tehran, Iran
  219. 219 Centre for International Health and Section for Ethics and Health Economics, University of Bergen, Bergen, Norway
  220. 220 Gastrointestinal and Liver Disease Research Center, Guilan University of Medical Sciences, Rasht, Iran
  221. 221 Guilan University of Medical Sciences, Rasht, Iran
  222. 222 School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
  223. 223 Independent Consultant, Tabriz, Iran
  224. 224 Department of Public Health, Mizan-Tepi University, Tepi, Ethiopia
  225. 225 Unit of Epidemiology and Social Medicine, University Hospital Antwerp, Wilrijk, Belgium
  226. 226 Department of Clinical Sciences, Karolinska University Hospital, Stockholm, Sweden
  227. 227 Medical Biology Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
  228. 228 Research Coordination, AC Environments Foundation, Cuernavaca, Mexico
  229. 229 CISS, National Institute of Public Health, Cuernavaca. Mexico
  230. 230 Department of Urban Planning and Design, University of Hong Kong, Hong Kong, China
  231. 231 Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
  232. 232 Department of Pediatrics, Dell Medical School, University of Texas Austin, Austin, TX, USA
  233. 233 Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
  234. 234 Department of Pharmacology and Therapeutics, Dhaka Medical College, Dhaka, Bangladesh
  235. 235 Department of Pharmacology, Bangladesh Industrial Gases Limited, Tangail, Bangladesh
  236. 236 Department of Computer Engineering, Islamic Azad University, Tehran, Iran
  237. 237 Computer Science Department, University of Human Development, Sulaymaniyah, Iraq
  238. 238 Department of Legal Medicine and Bioethics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
  239. 239 Clinical Legal Medicine Department, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
  240. 240 Department of Epidemiology and Health Statistics, Central South University, Changsha, China
  241. 241 Department of Health Promotion and Education, University of Ibadan, Ibadan, Nigeria
  242. 242 Department of Community Medicine, University of Ibadan, Ibadan, Nigeria
  243. 243 Department of Family Medicine, Bangalore Baptist Hospital, Bangalore, India
  244. 244 Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  245. 245 School of Psychology and Public Health, La Trobe University, Bundoora, Melbourne, Victoria, Australia
  246. 246 Institute for Physical Activity and Nutrition, Deakin University, Burwood, Victoria, Australia
  247. 247 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
  248. 248 School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
  249. 249 Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
  250. 250 Department for Health Care and Public Health, Sechenov First Moscow State Medical University, Moscow, Russia
  251. 251 Social Development & Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
  252. 252 Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
  253. 253 Institute of Medicine, University of Colombo, Colombo, Sri Lanka
  254. 254 Faculty of Graduate Studies, University of Colombo, Colombo, Sri Lanka
  255. 255 Department of Community Medicine, Banaras Hindu University, Varanasi, India
  256. 256 Health Promotion and Education, University of Ibadan, Ibadan, Nigeria
  257. 257 Department of Ophthalmology, Heidelberg University, Mannheim, Germany
  258. 258 Beijing Ophthalmology & Visual Science Key Laboratory, Beijing Tongren Hospital, Beijing, China
  259. 259 Auckland University of Technology, Auckland, New Zealand
  260. 260 Community Medicine Department, Manipal Academy of Higher Education, Mangalore, India
  261. 261 Department of Family Medicine and Public Health, University of Opole, Opole, Poland
  262. 262 School of Health Sciences, Savitribai Phule Pune University, Pune, India
  263. 263 Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
  264. 264 Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
  265. 265 Department of Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
  266. 266 Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
  267. 267 Health Services Management Department, Qazvin University of Medical Sciences, Qazvin, Iran
  268. 268 School of Public Health, Department of Health informatics and Health Innovation, A.C.S. Medical College and Hospital, Mekelle, Ethiopia
  269. 269 Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, India
  270. 270 Department of Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran
  271. 271 Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
  272. 272 Pars Advanced and Minimally Invasive Medical Manners Research Center, Iran University of Medical Sciences, Tehran, Iran
  273. 273 Department of Applied Physics, The John Paul II Catholic University of Lublin, Lublin Voivodeship, Poland
  274. 274 Department of Biology and Chemistry, Drohobych Ivan Franko State Pedagogical University, Drohobych, Ukraine
  275. 275 International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
  276. 276 Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
  277. 277 Open, Distance and eLearning Campus, University of Nairobi, Nairobi, Kenya
  278. 278 Department of Dermatology, Wolaita Sodo University, Wolaita Sodo, Ethiopia
  279. 279 Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
  280. 280 Social Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  281. 281 School of Food and Agricultural Sciences, University of Management and Technology, Lahore, Pakistan
  282. 282 Department of Global Health, University of Washington, Seattle, WA, USA
  283. 283 Department of Physiology, Baku State University, Baku, Azerbaijan
  284. 284 Epidemiology, Faculty of Public Health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia
  285. 285 Epidemiology and Biostatistics Department, Health Services Academy, Islamabad, Pakistan
  286. 286 Department of Population Studies, International Institute for Population Sciences, Mumbai, India
  287. 287 Department of Health Research, Indian Council of Medical Research, New Delhi, India
  288. 288 Centre for Ethics, Jawahar Lal Nehru University, New Delhi, India
  289. 289 Department of Psychiatry, Kermanshah University of Medical Sciences, Kermanshah, Iran
  290. 290 Nuffield Department of Surgical Sciences, Oxford University Global Surgery Group, University of Oxford, Oxford, UK
  291. 291 Research and Data Solutions, Synotech Consultant, Nairobi, Kenya
  292. 292 Department of Preventive Medicine, Korea University, Seoul, South Korea
  293. 293 School of Medicine, Xiamen University Malaysia, Sepang, Malaysia
  294. 294 Department of Health Sciences, Northeastern University, Boston, MA, USA
  295. 295 Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
  296. 296 School of Health Sciences, Kristiania University College, Oslo, Norway
  297. 297 Neurophysiology Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
  298. 298 Brain Engineering Research Center, Institute for Research in Fundamental Sciences, Tehran, Iran
  299. 299 Public Health Dentistry Department, Krishna Institute of Medical Sciences Deemed to be University, Karad, India
  300. 300 Environmental Health Engineering, Arak University of Medical Sciences, Arak, Iran
  301. 301 CIBERSAM, San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain
  302. 302 Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
  303. 303 Department of Zoology, University of Oxford, Oxford, UK
  304. 304 Harvard Medical School, Harvard University, Boston, MA, USA
  305. 305 Department of Anthropology, Panjab University, Chandigarh, India
  306. 306 Department of Demography, University of Montreal, Montreal, Quebec, Canada
  307. 307 Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada
  308. 308 Department of Public Health, Yuksek Ihtisas University, Ankara, Turkey
  309. 309 Department of Public Health, Hacettepe University, Ankara, Turkey
  310. 310 Department of Family and Community Health, University of Health and Allied Sciences, Ho, Ghana
  311. 311 Department of Psychology and Health Promotion, University of KwaZulu-Natal, Durban, South Africa
  312. 312 Community Medicine Department, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, India
  313. 313 Department of Psychiatry, University of Nairobi, Nairobi, Kenya
  314. 314 Division of Psychology and Language Sciences, University College London, London, UK
  315. 315 Department of Medicine Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
  316. 316 Orthopaedics Department, Base Hospital Lucknow Cantt, Lucknow, India
  317. 317 Mechanical and Industrial Engineering, Indian Institute of Technology, Roorkee, India
  318. 318 Department of Community and Family Medicine, University of Baghdad, Baghdad, Iraq
  319. 319 HelpMeSee, New York, NY, USA
  320. 320 International Relations, Mexican Institute of Ophthalmology, Queretaro, Mexico
  321. 321 Department of Otorhinolaryngology (ENT), Father Muller Medical College, Mangalore, India
  322. 322 Department of Public Health, Maragheh University of Medical Sciences, Maragheh, Iran
  323. 323 Institute of Clinical Physiology, National Research Council, Pisa, Italy
  324. 324 Clinical Medicine and Community Health, University of Milan, Milano, Italy
  325. 325 College of Optometry, Nova Southeastern University, Fort Lauderdale, FL, USA
  326. 326 School of Pharmacy, Monash University, Bandar Sunway, Malaysia
  327. 327 School of Pharmacy, Taylor’s University Lakeside Campus, Subang Jaya, Malaysia
  328. 328 Department of Systems, Populations and Leadership, University of Michigan, Ann Arbor, MI, USA
  329. 329 Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
  330. 330 Department of Medicine, University of São Paulo, Sao Paulo, Brazil
  331. 331 Health Data Research UK, Swansea University, Swansea, UK
  332. 332 Center for Integration of Data and Health Knowledge, FIOCRUZ: Cidacs Center for Integration of Data and Health Knowledge, Salvador, Brazil
  333. 333 Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, England
  334. 334 Pathology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  335. 335 Ophthalmology Department, Aswan Faculty of Medicine, Aswan, Egypt
  336. 336 Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
  337. 337 Department of Public Health, Trnava University, Trnava, Slovakia
  338. 338 Department of Primary Care and Public Health, Imperial College London, London, UK
  339. 339 Health Education and Research Department, SDM College of Medical Sciences & Hospital, Dharwad, India
  340. 340 Health University, Rajiv Gandhi University of Health Sciences, Bangalore, India
  341. 341 Department of Maternal and Child Nursing and Public Health, Federal University of Minas Gerais, Belo Horizonte, Brazil
  342. 342 Ophthalmology Department, Iran University of Medical Sciences, Tehran, Iran
  343. 343 Ophthalmology Department, University of Manitoba, Winnipeg, Manitoba, Canada
  344. 344 Department of Surgery, University of Virginia, Charlottesville, VA, USA
  345. 345 Surgery Department, Emergency University Hospital Bucharest, Bucharest, Romania
  346. 346 Psychiatry Department, National Institute of Mental Health and Neurosciences, Bengaluru, India
  347. 347 Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
  348. 348 Institute for Social Science Research, The University of Queensland, Brisbane, Queensland, Australia
  349. 349 Department of Health Sciences, University of York, York, UK
  350. 350 Department of Midwifery-Reproductive Health, Hamadan University of Medical Sciences, Hamadan, Iran
  351. 351 Research Department, The George Institute for Global Health, New Delhi, India
  352. 352 School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
  353. 353 Neurology Department, Janakpuri Super Specialty Hospital Society, New Delhi, India
  354. 354 Department of Neurology, Govind Ballabh Institute of Medical Education and Research, New Delhi, India
  355. 355 Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland, Baltimore, MD, USA
  356. 356 Peru Country Office, United Nations Population Fund (UNFPA), Lima, Peru
  357. 357 Forensic Medicine Division, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
  358. 358 Department of Epidemiology and Biostatistics, Haramaya University, Harar, Ethiopia
  359. 359 Breast Surgery Unit, Helsinki University Hospital, Helsinki, Finland
  360. 360 University of Helsinki, Helsinki, Finland
  361. 361 Neurocenter, Helsinki University Hospital, Helsinki, Finland
  362. 362 School of Health Sciences, University of Melbourne, Parkville, Victoria, Australia
  363. 363 Statistics Department, Debre Markos University, Debre Markos, Ethiopia
  364. 364 Clinical Microbiology and Parasitology Unit, Zora Profozic Polyclinic, Zagreb, Croatia
  365. 365 University Centre Varazdin, University North, Varazdin, Croatia
  366. 366 Center for Innovation in Medical Education, Pomeranian Medical University, Szczecin, Poland
  367. 367 Pomeranian Medical University, Szczecin, Poland
  368. 368 Department of Propedeutics of Internal Diseases & Arterial Hypertension, Pomeranian Medical University, Szczecin, Poland
  369. 369 Pacific Institute for Research & Evaluation, Calverton, MD, USA
  370. 370 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
  371. 371 Global Institute of Public Health (GIPH), Ananthapuri Hospitals and Research Centre, Trivandrum, India
  372. 372 Department of Statistics and Econometrics, Bucharest University of Economic Studies, Bucharest, Romania
  373. 373 President’s Office, National Institute of Statistics, Bucharest, Romania
  374. 374 Faculty of Internal Medicine, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
  375. 375 Department of Atherosclerosis and Coronary Heart Disease, National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan
  376. 376 Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
  377. 377 Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt, Germany
  378. 378 Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
  379. 379 Molecular Medicine Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
  380. 380 Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
  381. 381 Internal Medicine Department, King Saud University, Riyadh, Saudi Arabia
  382. 382 Department of Information Technology, University of Human Development, Sulaymaniyah, Iraq
  383. 383 Department of Epidemiology and Biostatistics, Shahrekord University of Medical Sciences Shahrekord, Iran
  384. 384 Department of Nursing, Shahroud University of Medical Sciences, Shahroud, Iran
  385. 385 Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria
  386. 386 Department of Public Health, Samara University, Samara, Ethiopia
  387. 387 Iran National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
  388. 388 Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
  389. 389 Faculty of Life Sciences and Medicine, King’s College London, London, UK
  390. 390 Clinical Epidemiology and Public Health Research Unit, Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy
  391. 391 Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
  392. 392 Research Center for Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
  393. 393 Kermanshah University of Medical Sciences, Kermanshah, Iran
  394. 394 Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
  395. 395 Department of Epidemiology and Biostatistics, Kurdistan University of Medical Sciences, Sanandaj, Iran
  396. 396 Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
  397. 397 International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Queensland, Australia
  398. 398 Gorgas Memorial Institute for Health Studies, Panama City, Panama
  399. 399 Department of Psychiatry, Badhir Dar University, Ethiopia
  400. 400 Department of Epidemiology and Biostatistics, University of Gondar, Gondar, Ethiopia
  401. 401 School of Medical Sciences, Science University of Malaysia, Kubang Kerian, Malaysia
  402. 402 Department of Pediatric Medicine, Nishtar Medical University, Multan, Pakistan
  403. 403 Department of Pediatrics & Pediatric Pulmonology, Institute of Mother & Child Care, Multan, Pakistan
  404. 404 Clinical Research Development Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
  405. 405 Research and Analytics, Initiative for Financing Health and Human Development, Chennai, India
  406. 406 Research and Analytics, Bioinsilico Technologies, Chennai, India
  407. 407 Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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  410. 410 Department of Epidemiology & Biostatistics, Kermanshah University of Medical Sciences, Kermanshah, Iran
  411. 411 Suraj Eye Institute, Nagpur, India
  412. 412 Hospital of the Federal University of Minas Gerais, Federal University of Minas Gerais, Belo Horizonte, Brazil
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  414. 414 Preventive Medicine and Public Health Research Center, IUMS, Tehran, Iran
  415. 415 Department of Forensic Medicine and Toxicology, Manipal Academy of Higher Education, Manipal, India
  416. 416 Department of Pediatrics, Arak University of Medical Sciences, Arak, Iran
  417. 417 Iranian Ministry of Health and Medical Education, Tehran, Iran
  418. 418 Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
  419. 419 Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
  420. 420 Department of General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
  421. 421 Department of Biological Sciences, University of Embu, Embu, Kenya
  422. 422 Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam
  423. 423 Project of ADB, National Institute of Nutrition, Hanoi, Vietnam
  424. 424 Industrial Management Department, Hanoi University of Science and Technology, Hanoi, Vietnam
  425. 425 Department of Pharmacology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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  434. 434 Department of Preventive Medicine, Kyung Hee University, Dongdaemun-gu, South Korea
  435. 435 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
  436. 436 Department of Psychiatry, University of Lagos, Lagos, Nigeria
  437. 437 Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
  438. 438 Diplomacy and Public Relations Department, University of Human Development, Sulaimaniyah, Iraq
  439. 439 Department of Pharmacology and Therapeutics, University of Nigeria Nsukka, Enugu, Nigeria
  440. 440 Applied Research Division, Public Health Agency of Canada, Ottawa, Ontario, Canada
  441. 441 School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
  442. 442 Department of Global Health Nursing, St. Luke’s International University, Chuo-ku, Japan
  443. 443 Academic Department, Unium Ltd, Moscow, Russia
  444. 444 Department of Project Management, National Research University Higher School of Economics, Moscow, Russia
  445. 445 Department of Respiratory Medicine, Jagadguru Sri Shivarathreeswara Academy of Health Education and Research, Mysore, India
  446. 446 Department of Forensic Medicine, Manipal Academy of Higher Education, Manipal, India
  447. 447 Department of Medicine, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
  448. 448 Parasitology and Mycology Department, Shiraz University of Medical Sciences, Shiraz, Iran
  449. 449 Augenpraxis Jonas, Heidelberg University, Heidelberg, Germany
  450. 450 Department of Medical Humanities and Social Medicine, Kosin University, Busan, South Korea
  451. 451 Research and Evaluation Department, Population Council, New Delhi, India
  452. 452 Indian Institute of Health Management Research University, Jaipur, India
  453. 453 Department of Pediatircs, RD Gardi Medical College, Ujjain, India
  454. 454 Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  455. 455 Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar, India
  456. 456 Department of Midwifery, Wolaita Sodo University, Wolaita Sodo, Ethiopia
  457. 457 School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
  458. 458 Center for Research and Innovation, Ateneo De Manila University, Pasig City, Philippines
  459. 459 Department of Orthopedics, Yenepoya Medical College, Mangalore, India
  460. 460 Department of Psychiatry, Department of Epidemiology, Columbia University, New York, NY, USA
  461. 461 Shanghai Mental Health Center, Shanghai Jiao Tong University, Shanghai, China
  462. 462 Department of Epidemiology and Evidence-Based Medicine, Sechenon University, Moscow, Russia
  463. 463 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
  464. 464 Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
  465. 465 Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
  466. 466 Health Sciences Department, Muhammadiyah University of Surakarta, Sukoharjo, Indonesia
  467. 467 Department of Chemistry, Sharif University of Technology, Tehran, Iran
  468. 468 Biomedical Engineering Department, Amirkabir University of Technology, Tehran, Iran
  469. 469 College of Medicine, University of Central Florida, Orlando, FL, USA
  470. 470 College of Graduate Health Sciences, A.T. Still University, Mesa, AZ, USA
  471. 471 Department of Epidemiology & Biostatistics, Contech School of Public Health, Lahore, Pakistan
  472. 472 Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  473. 473 Department of Immunology, Mazandaran University of Medical Sciences, Sari, Iran
  474. 474 Molecular and Cell Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran
  475. 475 Thalassemia and Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  476. 476 Metabolomics and Genomics Research Center, Tehran University of Medical Sciences, Tehran, Iran
  477. 477 Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
  478. 478 School of Nursing and Healthcare Professions, Federation University Australia, Berwick, Victoria, Australia
  479. 479 School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
  480. 480 Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
  481. 481 European Office for the Prevention and Control of Noncommunicable Diseases, World Health Organization (WHO), Moscow, Russia
  482. 482 Department of Oral Pathology, Srinivas Institute of Dental Sciences, Mangalore, India
  483. 483 School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Tehran, Iran
  484. 484 Academic Public Health Department, Public Health England, London, UK
  485. 485 School of Health, Medical and Applied Sciences, CQ University, Sydney, New South Wales, Australia
  486. 486 Department of Computer Science, Metropolitan College, Boston University, Boston, USA
  487. 487 Neurology Department, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
  488. 488 Brien Holden Vision Institute, Sydney, New South Wales, Australia
  489. 489 Organization for the Prevention of Blindness, Paris, France
  490. 490 EPIUnit - Public Health Institute University Porto (ISPUP), University of Porto, Porto, Portugal
  491. 491 Surgery Department, University of Minnesota, Minneapolis, MN, USA
  492. 492 Surgery Department, University Teaching Hospital of Kigali, Kigali, Rwanda
  493. 493 Research Directorate, Nihon Gakko University, Fernando de la Mora, Paraguay
  494. 494 Research Direction, Universidad Nacional de Caaguazú, Coronel Oviedo, Paraguay
  495. 495 Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil
  496. 496 Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
  497. 497 College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
  498. 498 Department of Health in Disasters and Emergencies, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  499. 499 Department of Neuroscience, Iran University of Medical Sciences, Tehran, Iran
  500. 500 Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
  501. 501 Nanobiotechnology Center, Soran University, Soran, Iraq
  502. 502 Public Health and Community Medicine Department, Cairo University, Giza, Egypt
  503. 503 Urology Department, Cairo University, Giza, Egypt
  504. 504 Health and Disability Intelligence Group, Ministry of Health, Wellington, New Zealand
  505. 505 Department of Entomology, Ain Shams University, Cairo, Egypt
  506. 506 Department of Surgery, Marshall University, Huntington, WV, USA
  507. 507 Department of Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, OH, USA
  508. 508 Rheumatology Department, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  509. 509 Institute of Bone and Joint Research, University of Sydney, Syndey, New South Wales, Australia
  510. 510 Institute of Social Medicine, University of Belgrade, Belgrade, Serbia
  511. 511 Centre-School of Public Health and Health Management, University of Belgrade, Belgrade, Serbia
  512. 512 Health Economics, Bangladesh Institute of Development Studies (BIDS), Dhaka, Bangladesh
  513. 513 Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
  514. 514 Surgery Department, Hamad Medical Corporation, Doha, Qatar
  515. 515 Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
  516. 516 Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
  517. 517 Education Development Center, Faculty Member of Education Development Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  518. 518 Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
  519. 519 Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
  520. 520 Emergency Department, Manian Medical Centre, Erode, India
  521. 521 Microbiology Service, National Institutes of Health, Bethesda, MD, USA
  522. 522 Center for Biomedical Information Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
  523. 523 Department of Health Promotion and Education, Alborz University of Medical Sciences, Karaj, Iran
  524. 524 Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
  525. 525 Independent Consultant, Karachi, Pakistan
  526. 526 School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
  527. 527 Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
  528. 528 Division of General Internal Medicine, Harvard University, Boston, MA, USA
  529. 529 National Institute of Infectious Diseases, Tokyo, Japan
  530. 530 College of Medicine, Yonsei University, Seodaemun-gu, South Korea
  531. 531 Division of Cardiology, Emory University, Atlanta, GA, USA
  532. 532 Finnish Institute of Occupational Health, Helsinki, Finland
  533. 533 Department of Health Education & Promotion, Kermanshah University of Medical Sciences, Kermanshah, Iran
  534. 534 School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
  535. 535 Department of Psychology, Reykjavik University, Reykjavik, Iceland
  536. 536 Department of Health and Behavior Studies, Columbia University, New York, NY, USA
  537. 537 Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
  538. 538 Medicine Service, US Department of Veterans Affairs (VA), Birmingham, AL, USA
  539. 539 Department of Forensic Medicine, Kathmandu University, Dhulikhel, Nepal
  540. 540 Department of Epidemiology, School of Preventive Oncology, Patna, India
  541. 541 Department of Epidemiology, Healis Sekhsaria Institute for Public Health, Mumbai, India
  542. 542 Medical Surgical Nursing Department, Urmia University of Medical Science, Urmia, Iran
  543. 543 Emergency Nursing Department, Semnan University of Medical Sciences, Semnan, Iran
  544. 544 Hospital Universitario de la Princesa, Autonomous University of Madrid, Madrid, Spain
  545. 545 Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
  546. 546 Department of Public Health, Arba Minch University, Arba Minch, Ethiopia
  547. 547 Hull York Medical School, University of Hull, Hull City, UK
  548. 548 Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
  549. 549 Department of Psychology, Deakin University, Melbourne, Victoria, Australia
  550. 550 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
  551. 551 Department of Criminology, Law and Society, University of California Irvine, Irvine, CA, USA
  552. 552 Department of Medicine, University of Valencia, Valencia, Spain
  553. 553 Carlos III Health Institute, Biomedical Research Networking Center for Mental Health Network (CiberSAM), Madrid, Spain
  554. 554 School of Social Work, University of Illinois, Urbana, IL, USA
  555. 555 Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
  556. 556 School of Public Health, University of Adelaide, Adelaide, SA, Australia
  557. 557 Department of Environmental Health, Wollo University, Dessie, Ethiopia
  558. 558 Department of Community and Family Medicine, Iran University of Medical Sciences, Tehran, Iran
  559. 559 Department of Pharmacognosy, Mekelle University, Mekelle, Ethiopia
  560. 560 Institute of Public Health, University of Gondar, Gondar, Ethiopia
  561. 561 Department of Public Health, Adigrat University, Adigrat, Ethiopia
  562. 562 Biology Department, Moscow State University, Moscow, Russia
  563. 563 Department of Nursing, Woldia University, Woldia, Ethiopia
  564. 564 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Kerman University of Medical Sciences, Kerman, Iran
  565. 565 Institute of Public Health, Krakow, Poland
  566. 566 The Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
  567. 567 Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
  568. 568 Clinical Hematology and Toxicology, Military Medical University, Hanoi, Vietnam
  569. 569 Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam
  570. 570 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
  571. 571 Mbarara University of Science and Technology, Mbarara, Uganda
  572. 572 Department of Medicine, University of Crete, Heraklion, Greece
  573. 573 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
  574. 574 Gomal Center of Biochemistry and Biotechnology, Gomal University, Dera Ismail Khan, Pakistan
  575. 575 TB Culture Laboratory, Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Pakistan
  576. 576 Amity Institute of Biotechnology, Amity University Rajasthan, Jaipur, India
  577. 577 Division of Health Sciences, University of Warwick, Coventry, UK
  578. 578 Argentine Society of Medicine, Buenos Aires, Argentina
  579. 579 Velez Sarsfield Hospital, Buenos Aires, Argentina
  580. 580 UKK Institute, Tampere, Finland
  581. 581 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran
  582. 582 Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
  583. 583 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  584. 584 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
  585. 585 Occupational Health Unit, Sant’Orsola Malpighi Hospital, Bologna, Italy
  586. 586 Department of Health Care Administration and Economics, National Research University Higher School of Economics, Moscow, Russia
  587. 587 Foundation University Medical College, Foundation University, Islamabad, Pakistan
  588. 588 Department of Physical Therapy, Naresuan University, Meung District, Thailand
  589. 589 Department of Human Anatomy, Histology, and Embryology, Bahir Dar University, Bahir Dar, Ethiopia
  590. 590 Department of Nursing, Wollo University, Dessie, Ethiopia
  591. 591 Department of Orthopaedics, Wenzhou Medical University, Wenzhou, China
  592. 592 Public Health Science Directorate, NHS Health Scotland, Glasgow, Scotland
  593. 593 Medical Physics Department, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  594. 594 Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
  595. 595 School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
  596. 596 Health Services Management Research Center, Kerman University of Medical Sciences, Kerman, Iran
  597. 597 Department of Health Management, Policy and Economics, Kerman University of Medical Sciences, Kerman, Iran
  598. 598 Division of Injury Prevention and Mental Health Improvement, National Center for Chronic and Noncommunicable Disease Control, Chinese Center for Disease Control and Prevention, Beijing, China
  599. 599 Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China
  600. 600 Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China
  601. 601 School of Allied Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
  602. 602 Department of Psychopharmacology, National Center of Neurology and Psychiatry, Tokyo, Japan
  603. 603 Department of Sociology, Yonsei University, Seoul, South Korea
  604. 604 Department of Health Policy & Management, Jackson State University, Jackson, MS, USA
  605. 605 School of Medicine, Tsinghua University, Beijing, China
  606. 606 Department of Environmental Health, Mazandaran University of Medical Sciences, Sari, Iran
  607. 607 Environmental Health, Academy of Medical Science, Sari, Iran
  608. 608 Department of Epidemiology and Biostatistics, Wuhan University, Wuhan, China
  609. 609 Global Health Institute, Wuhan University, Wuhan, China
  610. 610 School of Public Health and Management, Hubei University of Medicine, Shiyan, China
  611. 611 Social Determinants of Health Research Center, Ardabil University of Medical Science, Ardabil, Iran
  612. 612 Department of Epidemiology, University Hospital of Setif, Setif, Algeria
  613. 613 Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
  614. 614 Student Research Committee, Babol University of Medical Sciences, Babol, Iran
  615. 615 Department of Community Medicine, Ardabil University of Medical Science, Ardabil, Iran
  616. 616 Faculty of Medical Sciences, Department of Health Education, Tarbiat Modares University, Tehran, Iran
  617. 617 Department of Preventive Medicine, Wuhan University, Wuhan, China
  618. 618 School of Public Health, Wuhan University of Science and Technology, Wuhan, China
  619. 619 Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan, China
  620. 620 Indian Institute of Public Health, Public Health Foundation of India, Gurugram, India
  621. 621 Public Health Foundation of India, Gurugram, India
  622. 622 Department of Community Medicine, University of Peradeniya, Peradeniya, Sri Lanka

Abstract

Background While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

Methods In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

Results GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

Conclusions GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

  • populations/contexts
  • methodology
  • descriptive epidemiology
  • statistical issues
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INTRODUCTION

The Global Burden of Disease (GBD) study is a comprehensive assessment of population health loss. GBD has expanded in scope since its original release in 1994 (GBD 1990) and was most recently updated in autumn 2018 (GBD 2017).1–7 Each update of the study has provided updated results through the most recent year of data availability as well as increasingly refined detail in terms of locations, age groups and causes. In addition, GBD incorporates new data as well as updated methods for each annual release that represent the expanding complexity of the study. Cumulatively, the increasing volume of data and increasingly sophisticated estimation methods have necessitated near-continual refinements in terms of data processing, statistical modelling, computational storage and processing as well as global collaboration with the over 4000 GBD collaborators in over 140 countries and territories.

Historically, injuries have formed one of the three broad cause groups in the GBD cause hierarchy alongside the other two main groups of health loss (communicable, maternal, neonatal and nutritional diseases; non-communicable diseases). Not surprisingly, there is considerable variation in how morbidity and mortality are estimated across different causes in the GBD hierarchy and study design. The methods for estimating morbidity and mortality from injuries have evolved over time through the most recent release of GBD 2017. Historically, there have been certain challenges in injuries burden estimation, some of which have been addressed and updated over time, and some of which remain as methodological challenges to address as population health measurement develops more sophisticated modelling strategies. For example, methodological challenges that have been identified over the past three decades in population health research have included obtaining data in data-sparse, burden-heavy areas of the world, developing adjustments for ill-defined causes of death, separately estimating cause of injury from the bodily harm that results from an injury event and adjusting for known biases in data, such as underestimation in sexual violence data.3 8 9 Cumulatively, the global injuries research community has developed a wide array of methodological innovations and advancements to overcome many of these challenges, although undoubtedly the science will continue to advance as higher-quality datasets become available, as modelling methods improve and as computational processing power becomes more accessible to population health research groups around the world.

Many studies have been published based on different releases of the GBD study, ranging from studies on intentional injuries in the eastern Mediterranean to detailed assessments of traumatic brain injury and spinal cord injury disability rates on a global scale.10 11 While this array of published GBD injury studies demonstrates a broad spectrum of expert knowledge on specific injuries or specific geographies or both, it is also critical to recognise that population health is a rapidly evolving, collaborative science that has benefited from near-continual improvements even through the current updates being implemented for GBD 2019. As a result, it should benefit the scientific enterprise to focus on publishing the most updated results with perspective on global, demographic and temporal patterns, and on sharing iterative updates on the current state of the science of GBD injuries burden estimation. The goal of this study is to comprehensively review and report methods used for GBD 2017 and associated publications that have gone through extensive collaborator-review and peer-review processes.

METHODS

GBD 2017 study

GBD is predicated on the principle that every case of death and disability in the population should be systematically identified and accounted for in the formulation of global disease and injury burden. On the side of mortality, every death that occurs in the population should have one underlying cause of death which can be assigned to a cause in a mutually exclusive, collectively exhaustive hierarchy of diseases and injuries that can cause death. These data can be used in a method described below to calculate cause-specific mortality rates and years of life lost. For morbidity, every non-fatal case of disease or injury should have an amount of disability assigned for some period of time. These data can be used in a process described below to estimate the incidence, prevalence and years lived with disability. Summing morbidity and mortality from some cause form the burden from that cause, expressed as disability-adjusted life-years (DALY). For causes with known risk factors, some portion of this burden may be explained by exposure to that risk factor. Across causes within some population, it is also a principle of GBD that the sum of all cause-specific deaths should equal all-cause mortality in the population, and that rates of incidence, prevalence, remission and cause-specific mortality can be reconciled with one another such that all death and disability in a population is internally consistent across causes and geographies. As examples, the sum of different types of road injury cases must sum up to overall road injuries, and the sum of deaths from different injuries in a given country must sum up to the estimate of all-injury deaths. The principle of internal consistency extends to populations used in GBD, where every birth, death and net migration must be accounted for in the population estimates which form the denominators of GBD results. While there is immense complexity in the process summarised above, it is important to begin with these core principles which govern the computation processes at the heart of GBD burden estimation. A summarised overview of key GBD 2017 methods is also provided in online supplementary appendix 1.

GBD study design and hierarchies

GBD study design, including cause-specific methods, is described in a high level of detail in associated publications.2–7 In addition to the injury-focused methods described in this paper, it is important to define hierarchies used in the GBD study design. In particular, GBD 2017 was built around a location hierarchy where different subnational locations (eg, US states, India states, China provinces) which form a composite of a national location (eg, the USA, India, China). National locations are aggregated to form GBD regions, which are then aggregated to form GBD super regions. These designations affect the modelling structure and utilisation of location random effects, processes which are described in more detail later. The country-level and regional-level GBD location hierarchy used in GBD 2017 is provided in online supplementary appendix table 1. In addition to locations, GBD processes are conducted to produce estimates for every one of 22 age groups, male and female sex and across 28 years from 1990 to 2017 (inclusive). Age-standardised, all-age and combined sex results are also computed for each GBD result. Exceptions exist to the rules above, for example, self-harm is not permitted to occur in the 0–6 days (early neonatal) age group in the GBD age hierarchy. There are no sex restrictions placed on any GBD injury causes, although these restrictions exist for other GBD causes, such as cancers like prostate, cervical and uterine being related to one sex.

GBD injury classification

In the GBD cause hierarchy, injuries are part of the first level of the GBD cause hierarchy, which consists of three broad groups: communicable, maternal, neonatal and nutritional diseases; non-communicable diseases and injuries. Additional levels of the GBD cause hierarchy provide additional detail. The hierarchy of injuries in GBD is provided in table 1. The organisation of the hierarchy has implications both in terms of how results are produced and in terms of analytical and processing steps which are discussed in more detail below. Case definitions including International Classification of Diseases (ICD) codes used to identify injury deaths and cases are provided in table 2.

Table 1

Global Burden of Disease cause-of-injury hierarchy

Table 2

Case definitions for cause of injury in GBD 2017

GBD separates the concept of cause of injury from nature of injury. Cause of injury (eg, road injuries, falls, drowning) have historically been used for assigning cause of death as opposed to the ‘nature’ of injury, which more directly specifies the pathology that resulted in death. For example, an individual who falls, fractures his or her hip, undergoes surgery and then develops hospital-acquired pneumonia and dies while hospitalised would still have a fall as the underlying cause of death, regardless of whether sepsis or some other disease process leads to death more proximally in the chain of events. In this individual, the ‘nature’ of injury would have been specified as a hip fracture, since it is the bodily injury that would dictate the disability this person experiences. Since it is evident that a hip fracture is more disabling than a mild skin abrasion, it is important for measuring non-fatal burden to consider both the cause and the nature in the formulation of complete injury burden. A full list of nature of injury is provided in table 3.

Table 3

GBD nature of injury

Cause-specific mortality and years of life lost

As described above, cause-specific mortality is measured for every cause of injury in the GBD cause hierarchy with the exception of foreign body in the ear and sexual violence, which undergo only non-fatal burden estimation (described in more detail below). GBD adheres to five general principles for measuring cause-specific mortality, which are described in more detail elsewhere but are summarised as follows.12 First, GBD 2017 identifies all available data. For injuries, this includes vital registration (VR), vital registration samples, verbal autopsy (VA), police records and mortuary/hospital data. VR is the preferred data source but is not available in every location in the GBD location hierarchy. Prior VA research has demonstrated that VA is more accurate for certain injury causes than it is for certain diseases.13 Police data undergo additional validity checks to ensure that systematic under-reporting does not occur in comparison to VR data, which is described in more detail in a related publication.6 The second general principle relevant to injury mortality estimation is maximising comparability and quality of the dataset. For the purposes of injury mortality estimation, this process is largely focused on (1) ensuring appropriate accounting for different ICD code versions used for cause of death data classification over time, (2) redistribution of ill-defined causes of death (described in more detail elsewhere) and (3) processing VA studies into usable data that map to the GBD cause hierarchy.8 9 12 The third general principle for injury cause of death models in GBD 2017 is to develop a diverse set of plausible models. This process is conducted via the Cause of Death Ensemble model (CODEm) framework, which is the standard, peer-reviewed cause of death estimation process used extensively in the GBD study. CODEm generates a large set of possible models based on covariates suggested by the modeller based on expert input and literature review (eg, alcohol for road injuries) and then runs every plausible model, which can range into the thousands per cause. These models can be conducted in both rate space and cause fraction space and use an assortment of combinations among the user-selected covariates (table 4). Fourth, the predictive validity of each one of these submodels is tested using test-train holdouts, whereby a specific model is trained on a portion of data and tested on a separate portion to determine out-of-sample predictive validity. Once the submodels are conducted and predictive validity is measured, then an ensemble model is developed out of the submodels. The submodels and the ensemble model are then subject to the fifth principle, which is to choose the best-performing models based on out-of-sample predictive validity. The chosen models may be a single cause model or an ensemble of models. Beyond these processes, which have become automated with expert review in the GBD processing architecture, there is also considerable time required by the analysts, modellers, collaborators and principal investigators who are involved in the GBD study. Such processes also come under expert scrutiny via the GBD Scientific Council and the peer-review process in the annual GBD capstone publications.2–7

Table 4

Covariates used in GBD cause of death models

Once submodels and ensemble models have been conducted for each cause in the GBD cause hierarchy, a process to correct for cause of death rates to ensure internal consistency is conducted. Specifically, each subcause within some overall cause is rescaled such that, for example, every subtype of road injuries sums to road injuries deaths overall, and then road injuries and other transport injuries sum to equal the overall transport injuries cause. As this cascades to the overall cause hierarchy and the overall all-cause mortality rates, cause-specific mortality across all causes ultimately equals the overall mortality in the population. An example of an injuries cause of death model with vital registration data (Colombia, females) is shown in figure 1. A similar model with relatively less data is shown in figure 2 (Honduras, females). While data are absent in more recent years in Honduras, the model is still able to follow temporal trends, age patterns and broader geographical patterns by harnessing signals from covariate-based fixed effects (eg, alcohol consumption per capita) and location-based random effects (eg, the regional trends in Central Latin America and patterns in neighbouring countries). All cause of death models from GBD 2017 are publicly available for review (https://vizhub.healthdata.org/cod/). Cause-specific deaths are converted to cause-specific mortality rates (CSMRs) using GBD populations. Once CSMRs are established, years of life lost (YLLs) are computed as the product of CSMRs and residual life expectancy at the age of death. The residual life expectancy is based on the lowest observed mortality rate for each age across all populations over 5 million. For example, if a death from road injuries occurs at age 25 and the residual life expectancy is 60 years, then there are 60 YLLs attributed to that death. If the death had occurred at age 50 with a residual life expectancy of 38 years, then 38 YLLs would be attributed. Life tables used for GBD 2017 are provided in related publications. 7

Figure 1

Cause of Death Ensemble model with data points for road injuries in Colombia for females.

Figure 2

Cause of Death Ensemble model with data points for road injuries in Honduras for females

Injury incidence, prevalence and years lived with disability

After cause-specific models for each cause of injury in the GBD cause hierarchy are conducted, the non-fatal estimation process is conducted. An overview of this process is depicted in figure 3. In the first stage, we estimate the incidence of injuries warranting medical care using DisMod-MR 2.1 (abbreviated DisMod). DisMod is a meta-regression tool for epidemiological estimation that uses a compartmental model structure whereby a healthy population may become diseased or injured, at which point the individual either remains a prevalent case, goes into remission or dies. DisMod essentially fits differential equations to reconcile the transitions between these different compartments, so that the final posterior estimate for each epidemiological parameter can be explained in the context of the other parameters. Similar to the principles described in CODEm, DisMod uses all available data, ranging from incidence data to cause-specific mortality rates from the corrected CODEm results, to produce estimates for every age, sex, year and location. For the purposes of injuries, we established our case definition for non-fatal injuries as injuries that require medical care. This is a necessary case definition as we do not want to consider minor stumbles and falls, for example, that led to no actual bodily harm as injuries for GBD, since they would not have any associated disability. These models are conducted only for injury causes as opposed to the nature of injuries references above. Each data input is designated based on type of data—specifically, inpatient data, outpatient data, surveillance data, survey data and literature studies that are population-representative. We model incidence rates for hospital admissions for injuries, so the non-inpatient data sources get adjusted according to their classification so that the model inputs are consistent as injuries that warranted or received inpatient medical care. The coefficients measured by DisMod that were used for adjustment are provided in table 5. Input data for injury cause incidence models included sources identified as part of systematic reviews conducted in past GBD cycles, new sources identified by the GBD collaborator network and new sources of clinical data and other injuries data obtained by the core injuries burden estimation team at the Institute for Health Metrics and Evaluation at the University of Washington. In addition, CSMRs from the corrected CODEm models described above are used in this stage of DisMod modelling. The list of non-fatal injury sources used in GBD 2017 is provided in online supplementary appendix table 2. The completed DisMod models for inpatient incidence for each cause of injury are publicly available at https://vizhub.healthdata.org/epi/.

Figure 3

Injuries non-fatal estimation flow chart.

Table 5

Covariates and coefficients used in Global Burden of Disease incidence cause models

Once an incidence cause model is constructed for each cause of injury, an extensive analytical ‘pipeline’ follows which converts injury cause incidence into years lived with disability. First, inpatient incidence is split into inpatient and outpatient incidence using coefficients empirically measured by DisMod. The outpatient coefficients for each injury cause are also included in table 5. Separate pipelines are then conducted for inpatient and outpatient injury incidence—each step below can be considered to have been run for both streams of data, for each cause of injury. After the coefficient is applied, incidence is adjusted by the excess mortality rate measured by DisMod to essentially remove injury cases that died after the injury occurred. Once these deaths are removed from the incidence pool, the resulting steps are applied to these surviving cases of injury. First, each new case of injury is considered to have 47 possible ‘natures’ of injury that can result. These are the types of bodily injury that are considered to be possible outcomes from a given injury cause. The proportion of new cases of injury that would have some nature of injury as the most disabling outcome is determined based on dual-coded clinical data sources where both the cause and nature of injury were included as ICD codes.10 Of note, one limitation of this process is that due to computational demands, it is currently only possible to apportion the most disabling nature of injury for each new case of injury. As such, the probability that each nature of injury is the most disabling nature of injury for some cause of injury is modelled in a Dirichlet regression such that the probabilities sum to 1. In other words, each nature of injury has some probability of being the most disabling injury suffered by the victim of some cause of injury, but if multiple natures of injury occurred, then the less disabling injuries are not captured as part of that injury cause’s disability. This limitation has been recognised as a limitation of GBD injury burden estimation in various peer-reviewed articles and will likely be addressed in future GBD updates as computational efficiency improves.3 10

The probability distributions of each cause-nature are computed separately for each age, sex, year and location. At this point, the analytical stage has the age-specific, sex-specific, year-specific, location-specific incidence of a cause-nature combination, for example, the incidence of road injuries that led to a cervical-level spinal cord injury in males aged 20–24 years in 2017 in Stockholm, Sweden. The next step converts these incidence estimates into short-term and long-term injury incidence estimates, where long-term disability is defined as having a lower functional status 1 year postinjury than at the time of injury. These probabilities were measured using long-term follow-up studies.14–20 For some natures of injury, such as lower extremity amputation, the probability of being a long-term injury is 1. The probabilities of short-term versus long-term injury for each cause-nature combination are used to split the incidence values into short-term and long-term pipelines. The long-term incidence is then converted to prevalence using the ordinary differential equation solver used in DisMod, which also uses as an input excess mortality estimated for certain natures of injury such as traumatic brain injury and spinal cord injury conducted in a previous systematic review and meta-analysis. The short-term incidence is converted to prevalence by multiplying incidence and duration of injury, where duration of injury was either computed directly from follow-up studies or, in the case of unavailable data, estimated by an expert clinical panel involved in previous iterations of the GBD study. Since access to medical treatment is assumed to affect duration of injury and disability, the GBD Healthcare Access and Quality Index is used to estimate the proportion with and without access to medical treatment on a location-specific basis.21 The average duration for short-term injury is therefore calculated as the percentage treated multiplied by treated duration added to the percentage untreated multiplied by the untreated duration. The output from this step is the short-term prevalence of each cause-nature combination. Short-term prevalence is subtracted from long-term prevalence at this stage to avoid double counting the same case of injury. Once short-term and long-term prevalence estimates for each cause-nature are computed, then disability weights as derived by the Salomon et al process are assigned to each injury nature.22 Short-term disability weights by injury nature are shown in table 6, which does not include amputations since we assume they cause only long-term disability. The full list of long-term disability weights by injury nature, location and year are provided in online supplementary appendix table 3, which does not include foreign body in respiratory system, foreign body in gastrointestinal and urogenital system, foreign body in ear and superficial injury of any part of body, since we assume these natures of injury do not cause long-term disability. After disability weights are assigned to each injury case, years lived with disability for each cause of injury are calculated as the prevalence of each health state multiplied by the corresponding disability weight and then summed across natures of injury for each cause to compute years lived with disability (YLDs) for each age, sex, year and location for that injury cause. YLDs then undergo comorbidity adjustment used across the GBD study whereby comorbid cases of disease and injury in the population are simulated and adjusted disability weights are computed. These processes are described in more detail in GBD literature.3 GBD 2017 provided an important methodological update whereby nature of injury results, regardless of cause of injury, could be reviewed in the results from this process; this has enabled more advanced GBD research such as measuring the burden of traumatic brain injury and spinal cord injury, measuring the burden of facial fractures and measuring the burden of hand and finger fractures.10

Table 6

Short-term disability weights for each nature of injury

Sexual violence

Sexual violence follows a different analytical pathway than the other causes of injury. This process is shown in figure 4. We used the same study framework as was developed for other injury rates in the GBD 2017 study to estimate the yearly proportion of the population that experienced at least one episode of sexual violence in the past year, using a case definition of any sexual assault including penetrative sexual violence (rape) and non-penetrative sexual violence (other forms of unwanted sexual touching). To inform the sexual violence estimates, we identified data in 93 countries that met the case definition above. This resulted in 263 site-years of data, which mainly were derived from surveys such as Demographic and Health Surveys and Reproductive Health Surveys. Similar to our other injury models, we used DisMod 2.1 to model prevalence. The sexual violence prevalence model used study-level covariates for each type of survey question, for example, we used a study-level covariate to identify surveys that identify penetrative sexual violence only to account for how the overall incidence of sexual violence is greater than this value. This model also used a covariate on alcohol use in litres per capita for each location to help fit the model in data-sparse locations. Once yearly prevalence was measured, sexual violence cases undergo a process by which short-term disability from the physical and psychological harm of sexual violence cases is assigned to each prevalent case; however, long-term sequelae of sexual violence are currently not captured in this process, which has been a known limitation of sexual violence estimation in the GBD framework.

Figure 4

Sexual violence estimation flow chart. HAQI, Healthcare Access and Quality Index.

Disability-adjusted life-years

After estimation of cause-specific mortality and YLLs as well as non-fatal health outcomes estimation including YLDs, DALYs are calculated as the sum of YLLs and YLDs for each cause of injury. YLDs are also calculated for each nature of injury category.

GATHER statement

GBD 2017 adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). GATHER is described in more detail in online supplementary appendix 2.

RESULTS

Results for all GBD 2017 injury estimates are available in associated publications as well as online. Specifically, results by age, sex, year, subnational location and nature of injury can be viewed and downloaded online via the GBD Results Tool (http://ghdx.healthdata.org/gbd-results-tool) and GBD Compare (https://vizhub.healthdata.org/gbd-compare/). These results are available in terms of incidence, prevalence, YLDs, cause-specific mortality, YLLs and DALYs, expressed in counts, rates, and percentages. Analytical code and input datasets are available at http://ghdx.healthdata.org.

CODEm models

Model performance metrics for each injury cause model in GBD 2017 are provided in table 7. Model performance metrics for CODEm models include root mean square error (RMSE) for in-sample tests and out-of-sample tests, percentage of data points that correctly predict the trend in-sample and out-of-sample and percentage of data points that are present within the 95% uncertainty intervals (UIs) of the model fit. RMSE in-sample is generally better than RMSE out-of-sample, which is an expected result that also demonstrates the importance of performing out-of-sample predictive validity tests. While the correct trend is predicted in approximately one in five models, this may also be related to more dynamic temporal trends in injury mortality patterns over time. In general, most data points exist within the 95% UI of the model fit (mean: 98.5% in-sample, 98.0% out-of-sample).

Table 7

Performance metrics for each cause-of-injury CODEm model

Incidence models

Model performance metrics for each injury cause model in GBD 2017 are provided in table 8. These model performance metrics include in-sample coverage and RMSE of estimated results for cause-specific mortality, excess mortality and incidence. There are no performance metrics for CSMR or excess mortality for foreign body in eyes since we do not estimate mortality from this cause of injury. For incidence, the in-sample coverage average was 55.3% across cause-of-injury models and ranged from a low of 26% in falls to a high of 88% in poisoning by carbon monoxide. Incidence RMSE ranged from a low of 1.04 in pedestrian road injuries to a high of 4.86 in foreign body in eye.

Table 8

Performance metrics for each cause-of-injury DisMod model

DISCUSSION

Many considerable advancements have been made in the measurement of global injury burden since early versions of the GBD Study. Novel datasets, sophisticated statistical modelling and global collaboration have all facilitated the advancement of injury burden measurement science. Many more advancements in future updates should be possible as larger datasets become available and as computational power allows for more detailed measurement processes. Continued global collaboration will be an integral component. Suggested priority items for the advancement of injury burden estimation are as follows:

First, while much of the global injury burden occurs in low-income and middle-income countries, these countries are frequently the most data-sparse. GBD has rigorously attempted to collect all available data, including police records and verbal autopsy studies and inpatient and outpatient records; however, it is likely that additional data sources in data-sparse countries exist. Parties who are aware of additional data sources that could be used in the GBD estimation framework should consider joining the GBD collaborator network to contribute new sources of data to be used in future estimation updates.

Second, computational and data limitations make it difficult to account for the full disability that might be experienced in the setting of multiple injuries. For example, if an individual sustains a below-neck spinal injury and an upper extremity amputation, the amputation is not directly accounted for in the prevalence or YLD estimate of the injury cause to which this disability is attributed. This problem quickly grows in complexity, as one can imagine an event like a road injury leading to multiple contusions and abrasions, several fractures in different anatomical sites, a mild traumatic brain injury and a spinal cord injury. There are over 3.6 million permutations of injury if one considers only 10 possible natures of injury, making it difficult to quantitatively measure these relationships by cause of injury and by age, sex, year and location. Future research to address this limitation may focus on simulation studies that model the probability of different comorbid injury combinations to better inform disability weight applications.

Third, more data could be used for nature of injury measurement. Traumatic brain injury and spinal cord injury registries, for example, are not currently directly compatible with the GBD injury estimation framework yet provide rich epidemiological information. Future updates to GBD should focus more attention on incorporating data that measure burden of nature of injury in terms of incidence, prevalence or excess mortality. Incorporating these types of data would require a method to be developed such that estimates were internally consistent across cause-nature distributions. While the methods and data required for this update would be complex, they would represent a large increase in the available data that could be used for GBD injuries estimation.

Fourth, measuring the total burden of sexual violence has proven to be a challenging area of estimation in the GBD framework. As noted in the ‘Methods’ section of this paper, one known limitation is how long-term sequelae and conditions may not be adequately accounted for in sexual violence burden estimation. In order to attribute burden from major depressive disorder, anxiety disorders, self-harm and substance use disorders, measuring the relative risk of developing these conditions for victims of sexual violence would allow for population attributable fractions to be calculated and DALYs from these conditions to be attributed to sexual violence. While the premise of this methodological update is relatively simple, currently there are relatively few studies to inform these relative risks, and conducting and adding such studies in the future would be recognised as a major achievement in GBD research as it would allow for more accurate estimation of lifetime disability caused by sexual violence. This effort would moreover represent an important contribution to research surrounding the Sustainable Development Goals related to sexual violence and women’s rights. 23 24

Fifth, non-fatal injuries from conflict and natural disaster are challenging to estimate because of data sparsity in areas that are afflicted by these events. Fatalities are estimated after such events, but there is still considerable injury burden among the population that survives. Since data collection systems and hospitals may also be destroyed in these events, it becomes difficult to collect adequate non-fatal injury data. Global collaboration should also focus on identifying sources of data on non-fatal and fatal injury cases in conflict and natural disaster events.

It will be important to monitor the effects of implementing these priorities as injury measurement science continues to evolve. Global collaborations including the GBD enterprise should monitor performance statistics and utilisation of results by research groups and ministries to track how improvements to injury measurement progress over time. Scientific dialogue and collaboration must be a major focus, and the GBD enterprise is a good forum to support this kind of data sharing. For example, a collaborative effort between researchers in Vietnam and the Institute for Health Metrics on Evaluation on developing a study on Vietnam injury burden following GBD 2017 led to identifying the use of the Vietnam National Injury Survey, which was then added for estimation in GBD 2019. Increasing data collection standardisation efforts should be emphasised as a priority in all countries, particularly countries where data coverage on injuries is sparse. Ongoing dialogue via scientific publications and international conferences should also continue to serve as a forum to discuss data and methodological updates that can continue to refine the science of injuries estimation in GBD.

CONCLUSION

Measuring injuries burden in GBD is a complex scientific endeavour that leverages large amounts of data, a complex analytical framework and a global research network. GBD 2017 included more comprehensive detail of injury burden than any other known efforts to date. GBD 2019 and future updates will continue to add detail and refine methods in the interest of providing injury burden estimates that are robust, accurate and timely. Expanded injury data collection efforts will be a critical component of future injury burden estimation.

What is already known on the subject

  • Global Burden of Disease (GBD) 2017 provided an extensive peer-reviewed assessment of death and disability.

  • GBD 2017 methods have been reviewed and updated iteratively as new methods and data become available.

  • Measuring injury burden in GBD 2017 is complex due to differences in measuring cause of injury versus nature of injury and the temporal difference between them.

What this study adds

  • This capstone study details key estimation methods that are used for measuring the global burden of injuries as described in related publications in this journal.

  • More detailed methods descriptions and model performance metrics from GBD 2017 are provided in this study than in related studies.

  • This study also includes suggested future directions for improving injury burden research.

Acknowledgments

Seyed Aljunid acknowledges 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. Alaa Badawi acknowledges support by the Public Health Agency of Canada. Till Bärnighausen acknowledges support by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. Traolach Brugha received support from NatCen Social Research (http://natcen.ac.uk/) via NHS Digital and Department of Health and Social Care London, for the Adult Psychiatric Morbidity Survey (APMS) programme. Felix Carvalho received support from UID/MULTI/04378/2019 with funding from FCT/MCTES through national funds. Vera M Costa acknowledges support from 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. Kebede Deribe is supported by a grant from the Wellcome Trust [grant number 201900] as part of his International Intermediate Fellowship. Tim Driscoll acknowledges that work on occupational risk factors was partially supported by funds from the World Health Organization. Eduarda Fernandes acknowledges support from UID/QUI/50006/2019 with funding from FCT/MCTES through national funds. Yuming Guo acknowledges support from Career Development Fellowships of the Australian National Health and Medical Research Council (numbers APP1107107 and APP1163693). Sheikh Mohammed Shariful Islam is funded by a Fellowship from National Heart Foundation of Australia and Institute for Physical Activity and Nutrition, Deakin University. Mihajlo Jakovljevic acknowledges support by the Ministry of Education Science and Technological Development of the Republic of Serbia through the Grant number OI175014; publication of results was not contingent upon Ministry's censorship or approval. Sudha Jayaraman acknowledges support from: NIH R21: 1R21TW010439-01A1 (PI); Rotary Foundation Global Grant #GG1749568 (PI); NIH P20: 1P20CA210284-01A1 (Co-PI) and DOD grant W81XWH-16-2-0040 (Co-I), during the period of this study. Yun Jin Kim acknowledges support from a grant from the Research Management Centre, Xiamen University Malaysia [grant number: XMUMRF/2018-C2/ITCM/0001]. Kewal Krishan is supported by UGC Centre of Advanced Study (CAS II) awarded to the Department of Anthropology, Panjab University, Chandigarh, India. Mansai Kumar acknowledges support from FIC/ NIH K43 1K43MH114320-01. Amanda Mason-Jones acknowledges support by the University of York. Mariam Molokhia is supported by the National Institute for Health Research Biomedical Research Center at Guy’s and St Thomas’s National Health Service Foundation Trust and King’s College London. Ilais Moreno Velasquez is supported by the Sistema Nacional de Investigación (SNI, Senacyt, Panama). Mukhammad David Naimzada acknowledges support from Government of the Russian Federation (Agreement No – 075-02-2019-967). Duduzile Ndwandwe acknowledges support from Cochrane South Africa, South African Medical Research Council. Stanislav S. Otstavnov acknowledges the support from the Government of the Russian Federation (Agreement No – 075-02-2019-967). Ashish Pathak acknowledges support from Indian Council of Medical Research (ICMR), New Delhi, India (Grant number 2013-1253). Michael R Phillips acknowledges support in part by a grant from the National Natural Science Foundation of China (No.81761128031). Abdallah M. Samy received a fellowship from the Egyptian Fulbright Mission Program. Milena Santric Milicevic acknowledges the support from the Ministry of Education, Science and Technological Development, Republic of Serbia (Contract No. 175087). Seyedmojtaba Seyedmousavi was supported by the Intramural Research Program of the National Institutes of Health, Clinical Center, Department of Laboratory Medicine, Bethesda, MD, USA. Rafael Tabarés-Seisdedos was supported in part by the national grant PI17/00719 from ISCIII-FEDER. Sojib Bin Zaman acknowledges support from an "Australian Government Research Training Program (RTP) Scholarship.”

References

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Footnotes

  • Funding This study was funded by The Bill and Melinda Gates Foundation. SLJ conducts research for a grant on influenza and RSV which is funded in part by Sanofi Pasteur.

  • Competing interests Dr. James reports grants from Sanofi Pasteur, outside the submitted work. Dr. Driscoll reports grants from World Health Organisation, during the conduct of the study. Dr Shariful Islam is funded by a Fellowship from National Heart Foundation of Australia and Institute for Physical Activity and Nutrition, Deakin University. Dr. Ivers reports grants from National Health and Medical Research Council of Australia, during the conduct of the study. Dr. Jozwiak reports personal fees from TEVA, personal fees from ALAB, personal fees from BOEHRINGER INGELHEIM, personal fees from SYNEXUS, non-financial support from SERVIER, non-financial support from MICROLIFE, non-financial support from MEDICOVER, outside the submitted work. Walter Mendoza is currently Program Analyst Population and Development at the Peru Country Office of the United Nations Population Fund-UNFPA, which does not necessarily endorses this study. Dr. Rakovac reports grants from World Health Organization, during the conduct of the study. Dr. Sheikh reports grants from Health Data Research UK, outside the submitted work. Dr. Singh reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, Practice Point communications, the National Institutes of Health and the American College of Rheumatology, personal fees from Speaker’s bureau of Simply Speaking. Dr. Singh owns stock options in Amarin pharmaceuticals and Viking pharmaceuticals. Dr. Singh serves on the steering committee of OMERACT, an international organization that develops measures for clinical trials and receives arms-length funding from 12 pharmaceutical companies. Dr. Singh serves on the FDA Arthritis Advisory Committee. Dr. Singh is a member of the Veterans Affairs Rheumatology Field Advisory Committee. Dr. Singh is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis, outside the submitted work. Dr. Stein reports personal fees from Lundbeck and Sun, outside the submitted work.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Availability of input data varies by source. Select data are available in a public, open-access repository. Select data are available on reasonable request. Select data may be obtained from a third party and are not publicly available. All results from the study are included in the article or uploaded as supplementary information or are available online.

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