Age–sex differences in the global burden of lower respiratory infections and risk factors, 1990–2019 : results from the Global Burden of Disease Study 2019

GBD 2019 LRI Collaborators, Edward Kwabena AMEYAW

Research output: Journal PublicationsJournal Article (refereed)peer-review

9 Citations (SciVal)


Background: The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across all age groups by sex, for 204 countries and territories. 

Methods: In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used clinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466–469, 470.0, 480–482.8, 483.0–483.9, 484.1–484.2, 484.6–484.7, and 487–489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4–B97.6, J09–J15.8, J16–J16.9, J20–J21.9, J91.0, P23.0–P23.4, and U04–U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23 109 site-years of vital registration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian meta-regression tool, to analyse age–sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and claims and inpatient data. Additionally, we estimated age–sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors. 

Findings: Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240–275) LRI incident episodes in males and 232 million (217–248) in females. In the same year, LRIs accounted for 1·30 million (95% UI 1·18–1·42) male deaths and 1·20 million (1·07–1·33) female deaths. Age-standardised incidence and mortality rates were 1·17 times (95% UI 1·16–1·18) and 1·31 times (95% UI 1·23–1·41) greater in males than in females in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126·0% [95% UI 121·4–131·1]) and deaths (100·0% [83·4–115·9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest decline was observed for LRI deaths in males younger than 5 years (–70·7% [–77·2 to –61·8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53·0% [95% UI 37·7–61·8] in males and 56·4% [40·7–65·1] in females), and more than a quarter of LRI deaths among those aged 5–14 years were attributable to household air pollution (PAF 26·0% [95% UI 16·6–35·5] for males and PAF 25·8% [16·3–35·4] for females). PAFs of male LRI deaths attributed to smoking were 20·4% (95% UI 15·4–25·2) in those aged 15–49 years, 30·5% (24·1–36·9) in those aged 50–69 years, and 21·9% (16·8–27·3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21·1% (95% UI 14·5–27·9) in those aged 15–49 years and 18·2% (12·5–24·5) in those aged 50–69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11·7% (95% UI 8·2–15·8) of LRI deaths. 

Interpretation: The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children younger than 5 years was clearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, including promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities. 

Funding: Bill & Melinda Gates Foundation.

Original languageEnglish
Pages (from-to)1626-1647
Number of pages22
JournalThe Lancet Infectious Diseases
Issue number11
Early online date11 Aug 2022
Publication statusE-pub ahead of print - 11 Aug 2022
Externally publishedYes

Bibliographical note

Funding Information:
V Abedi reports grants or contracts from Genentech/ROCHE Biotech company and the National Institutes of Health (NIH) (2R56HL116832-04) ending in 2021, outside the submitted work. S Afzal reports leadership or fiduciary roles in board, society, committee, or advocacy groups, paid or unpaid, as a member of the Corona Expert Advisory Group, a member of the Medical Microbiology and Infectious Diseases Society of Pakistan, and as secretary of the task force for integrated management of childhood illnesses, all outside the submitted work. E F Atia report grants or contracts from the NIH and National Heart, Lung, and Blood Institute (K23 HL129888) and participation on a data safety monitoring board for effectiveness of low-dose theophyline for biomass-associated chronic obstructive pulmonary disease study, all outside the submitted work. D Bryazka reports grants or contracts from Bloomberg outside the submitted work. B D Gessner is an employee of Pfizer Vaccines and holds stock options in Pfizer. J Jozwiak reports personal fees for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Teva, Amgen, Synexus, Boehringer Ingelheim, Zentiva, and Sanofi, all outside the submitted work. K Krishan reports non-financial support from the UGC Centre of Advanced Study, CAS II, Department of Anthropology, Panjab University, Chandigarh, India, all outside the submitted work. J A Loureiro reports support for the present manuscript from Scientific Employment Stimulus (CEECINST/00049/2018). A-F A Mentis reports grants or contracts from MilkSafe: a novel pipeline to enrich formula milk using omics technologies, a research co-financed by the European Regional Development Fund of the European Union and Greek national funds through the operational programme competitiveness, entrepreneurship and innovation, under the call research, create, innovate (T2EDK-02222), as well as from ELIDEK (Hellenic Foundation for Research and Innovation, MIMS-860); stock or stock options in a family winery; support from BGI Group as a scientific officer. L Monasta and L Ronfani report support for the present manuscript from the Italian Ministry of Health on project Ricerca Corrente 34/2017 and payments made to Institute for Maternal and Child Health IRCCS Burlo Garofolo. O Odukoya reports support from the present manuscript from the Fogarty International Center of the National Institutes of Health (K43TW020704) for protected time. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. M Postma reports stock or stock options from Pharmacoeconomics Advice Groningen and Health-Ecore, outside the submitted work. M Raad reports consulting fees from Fondation Mérieux, support for attending meetings from Fondation Mérieux, and is the CEO of an antibiotic prescription assistance company SMARTBIOTIC, all outside the submitted work. K E Rudd reports grants or contracts from the NIH National Institute of General Medical Sciences (1K23GM141463), outside the submitted work. C R Simpson reports grants or contracts from New Zealand Ministry of Business, Innovation and Employment, Health Research Council of New Zealand, UK Medical Research Council, and UK Chief Scientist Office, as research grants paid to their institution, outside the submitted work. J A Singh reports consulting fees from Crealta Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, and Practice Point Communications, the National Institutes of Health, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events from Simply Speaking; support for attending meetings or travel from the steering committee of OMERACT; participation on a data safety monitoring board or advisory board with the US Food and Drug Administration Arthritis Advisory Committee; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid, with OMERACT as a steering committee member, with the Veterans Affairs Rheumatology Field Advisory Committee as Chair (unpaid), and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis and editor and director (unpaid); stock or stock options in TPT Global Tech, Vaxart Pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals and Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna Pharmaceuticals; all outside the submitted work. E Upadhyay reports patents published for a system and method of reusable filters for anti-pollution mask and a system and method for electricity generation through crop stubble by using microbial fuel cells and filed for a system for disposed personal protection equipment (PPE) into biofuel through pyrolysis and method and a novel herbal pharmaceutical aid for formulation of gel and method thereof and a leadership or fiduciary role as part of the Joint Secretary of Indian Meteorological Society, Jaipur Chapter (India). A Zumla reports grants or contracts from Pan-African Network on Emerging and Re-Emerging Infections ( funded by the European and developing countries clinical trials partnership the EU horizon 2020 framework programme. Acknowledge support from EDCTP-Central Africa and East African Clinical Research Networks (CANTAM-3, EACCR-3) and unpaid membership of the Scientific Advisory Committee of the EC-EDCTP-3 global health programme, Brussels with effect from March, 2022, all outside the submitted work. All other authors declare no competing interests.

Publisher Copyright:
© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license


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