Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

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Abstract

BACKGROUND: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period. METHODS: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. FINDINGS: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. INTERPRETATION: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic. FUNDING: Bill & Melinda Gates Foundation.

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The record

Venue

The Lancet

Topic

COVID-19 epidemiological studies

Field

Mathematics

Canadian institutions

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Funders

Division of Mathematical SciencesNational Institute of Allergy and Infectious DiseasesNational Institute of Mental HealthNational Institute on AgingJeffrey Cheah School of Medicine and Health Sciences, Monash University MalaysiaFaculty of Medicine and Health, University of SydneyDipartimento di Medicina e Chirurgia, Università degli Studi di Milano-BicoccaNemzeti Kutatási, Fejlesztési és Innovaciós AlapFundamental Research Funds for the Central UniversitiesFuwai Hospital, Chinese Academy of Medical SciencesErasmus Universitair Medisch Centrum RotterdamCenter for International HealthYonsei University College of MedicineNational Drug and Alcohol Research CentreGastrointestinal and Liver Diseases Research CenterNational Research, Development and Innovation OfficeQueensland Brain InstituteInstituto de Salud Carlos IIIRussian Academy of SciencesJapan Society for the Promotion of ScienceNational Health and Medical Research CouncilMedical Research CouncilMusculoskeletal Research Center, Washington University in St. LouisHealth Equity Research Center, Washington State UniversitySchool of Medicine, Indiana UniversityUniversity of Texas Health Science Center at San AntonioLoyola University Chicago Stritch School of MedicineCollege of Engineering, Michigan State UniversityUniversity of Illinois at Urbana-ChampaignDefense Threat Reduction AgencyDirectorate for Computer and Information Science and EngineeringFoundation for Cardiovascular ResearchNational Institutes of HealthUniversidad de Ciencias Aplicadas y AmbientalesUniversidade Federal do Espírito SantoGeorge Institute for Global HealthNational Science and Technology CouncilNational Institute of Pharmaceutical Education and Research, RaebareliHumanitas Research HospitalUniversitas Sam RatulangiLaboratório Associado para a Química VerdeWestern Sydney UniversityAlfaisal UniversityAXA Research FundIstituto Superiore di SanitàHubei UniversityUniversidad Autónoma de SinaloaDuke Kunshan UniversityJahrom University of Medical SciencesUniversidad ICESIShahid Sadoughi University of Medical SciencesUniversitat Politècnica de CatalunyaHubei University of MedicineMenzies Institute for Medical ResearchH. Lundbeck A/SDebre Markos UniversityUniversität KasselUniversity of GujratUniversidad Santiago de CaliSouthern University of Science and TechnologyMinistry of Science and Higher Education of the Russian FederationFundació Institut de Recerca Hospital Universitari Vall d’HebronHealth CanadaChettinad Academy of Research and EducationRajarata University of Sri LankaPublic Health EnglandYonsei UniversityNorthumbria UniversityAmgenHawassa UniversityJawaharlal Institute Of Postgraduate Medical Education and ResearchNational Center of Neurology and PsychiatryUniversity of RochesterDebreceni EgyetemZanjan University of Medical SciencesUniversity of ZanjanEberhard Karls Universität TübingenUniversity of HailUniversidade Federal do Rio de JaneiroNational Heart, Lung, and Blood InstituteDire Dawa UniversityDezful University of Medical SciencesUniversità degli Studi di UdineKurdistan University Of Medical SciencesUniversidade de PernambucoEmory UniversityNanjing UniversityHebei UniversityHacettepe ÜniversitesiShahid Bahonar University of KermanUniversitas Sebelas MaretUniversitat Rovira i VirgiliAllerganInternational Medical UniversityUniversidade Federal de Minas GeraisChongqing Medical UniversityUrmia UniversityKhulna UniversityUniversity of Cape TownUniversity of IsfahanServierPublic Health Agency of CanadaWuhan UniversitySungkyunkwan UniversityTrakya ÜniversitesiUniversidade do PortoUniversity of JohannesburgCleveland ClinicGeneralitat de CatalunyaUniversity of Social Welfare and Rehabilitation SciencesCapital Medical UniversityNational Cheng Kung UniversityFundação Oswaldo CruzNational Taiwan UniversityUniversité de GenèveUniversity of GondarSanofiUniversity of ThessalyUnited Arab Emirates UniversityIndian Institute of Technology MandiBangladesh University of Health SciencesBahir Dar UniversityUniversity of Health and Allied SciencesUniversidade de LisboaGöteborgs UniversitetNational Research University Higher School of EconomicsBahauddin Zakariya UniversityUniversidad Nacional Autónoma de MéxicoUniversity of Florida HealthUniversity of JordanUniversity of California, IrvineBournemouth UniversityPirogov Russian National Research Medical UniversityUniwersytet ŁódzkiTarbiat Modares UniversityGolestan University of Medical SciencesUniversitatea de Medicină şi Farmacie "Carol Davila" BucureştiMinistry of Trade, Industry and EnergyMittuniversitetetUniversidad de AntioquiaSydäntutkimussäätiöWuhan University of Science and TechnologyNanjing University of Science and TechnologyNovo NordiskIntas PharmaceuticalsNational and Kapodistrian University of AthensChinese Academy of Medical SciencesUniversitair Medisch Centrum GroningenUniversidade Federal de Santa CatarinaShiraz UniversityWachemo UniversityAmerican Heart AssociationSüleyman Demirel ÜniversitesiCurtin University of TechnologyZahedan University of Medical SciencesUniversiteit van die VrystaatTeva Pharmaceutical IndustriesUniversidade de MacauPublic Health AgencyInyuvesi Yakwazulu-NataliUniversità degli Studi di GenovaAl-Farabi Kazakh National UniversityUniversity of WaterlooChinese Center for Disease Control and PreventionVrije Universiteit BrusselXiangya Hospital, Central South UniversityRajiv Gandhi University of Health SciencesQuaid-i-Azam UniversityUniversitas Gadjah MadaUniversidad Autónoma MetropolitanaWarszawski Uniwersytet MedycznyAmerican Association for the Study of Liver DiseasesKarolinska InstitutetSemnan UniversityKU LeuvenUniversidade Federal do Rio Grande do SulHouston Methodist HospitalSabzevar University of Medical SciencesPatuakhali Science and Technology UniversityUniversity of St AndrewsIsfahan University of Medical SciencesUniversität RegensburgHaramaya UniversityDeutsche ForschungsgemeinschaftMinistry of Health and Medical EducationLinköpings UniversitetJames Madison UniversityLiverpool University Hospitals NHS Foundation TrustHjärt-LungfondenMinistry of Health, New ZealandNational Research Foundation of KoreaU.S. Department of Veterans AffairsBundesministerium für GesundheitUniversitätsklinikum HeidelbergFlorida International UniversityUniversity of MinnesotaAnhui Medical UniversityKwame Nkrumah University of Science and TechnologyChulalongkorn UniversityWellcome TrustKorea UniversitySeoul National UniversityGachon UniversityTaibah UniversityUniversity of HullUniversidade Federal de Juiz de ForaUnited States Agency for International DevelopmentJimma UniversityBirzeit UniversityYale UniversityChinese Academy of SciencesUniversity of CreteRobarts Research InstituteFarhangian UniversityZhejiang UniversityUniversity of TwenteQueensland University of TechnologyUniversity of Central PunjabJames Cook UniversityHallym UniversityGriffith UniversityPan American Health OrganizationInstitut National de la Santé et de la Recherche MédicaleUniversity of LeicesterFlinders UniversityEli Lilly and CompanyCharles Sturt UniversityTemple UniversityVictoria University of WellingtonAmity UniversityMahidol UniversityIndian Council of Medical ResearchRice UniversityUniversity of the West of EnglandRoyal Australian College of General PractitionersTamilnadu State Council For Science And TechnologyMacquarie UniversityUrmia University of Medical SciencesKing Abdullah University of Science and TechnologyAugusta UniversityUniversity of EmbuFrankfurt University of Applied SciencesUniversità degli Studi di Napoli Federico IILa Trobe UniversityDilla UniversityCentre for Heart Rhythm Disorders, University of AdelaideEnvironmental Defense FundAustralian Catholic UniversityArmy Medical UniversityTehran Heart CenterUniversitas MataramNational Research FoundationCardiff UniversityUniversity of NottinghamKing's College LondonUniversity of OttawaGuru Angad Dev Veterinary and Animal Sciences UniversityMichigan State UniversityMonash University MalaysiaJackson State UniversityUniwersytet WarszawskiUniversity of SouthamptonUniversity of Arkansas for Medical SciencesPeking Union Medical CollegeJohns Hopkins UniversityKyung Hee UniversityInternational Association for the Study of PainUniversity of ExeterNational Institute for Health and Care ResearchAsian Institute of Medicine, Science and TechnologyAdamas UniversityUniversity of New South WalesHouston Methodist Research InstituteVanderbilt UniversityLebanese American UniversityInstitut für Arbeitsmarkt- und BerufsforschungGovernment of Jiangsu ProvinceMinistero della SaluteCentral South UniversityRede de Química e TecnologiaNeyshabur University of Medical SciencesCorporación colombiana de investigación agropecuariaAfrican Population and Health Research CenterTechnische Universität BerlinAjou UniversityUniversity of Central FloridaPhilipps-Universität MarburgSaveetha Dental CollegeKasturba Medical College, ManipalLunds UniversitetUniversity of CanberraCairo UniversityBrien Holden Vision InstituteVistagen TherapeuticsUniversidad Peruana Cayetano HerediaUniversitat Pompeu FabraCurtin University, MalaysiaChalmers Tekniska HögskolaDuke-NUS Medical SchoolCharotar University of Science and TechnologyIstituto di Ricerche Farmacologiche Mario Negri - IRCCSKeele UniversityNew Zealand GovernmentFlorida Department of HealthUniversity of Agriculture, PeshawarAlbert-Ludwigs-Universität FreiburgUniversidad de Buenos AiresUniversità di PisaLegal Aid New South WalesFederation University AustraliaBiogenCase Western Reserve UniversityRadboud UniversiteitAksum UniversityChina Academy of Chinese Medical SciencesUniversidad de ColimaVanderbilt University Medical CenterEuropean CommissionAhmadu Bello UniversityAkademiska SjukhusetCedars-Sinai Medical CenterUniversity of Wisconsin-MadisonUniversity of Texas Health Science Center at HoustonAteneo de Manila UniversityBoston Scientific CorporationKing Abdulaziz UniversityScottish GovernmentUppsala UniversitetGulf Medical UniversityNHS Health ScotlandUniversitatea din BucureștiNorthwell HealthPomorski Uniwersytet Medyczny W SzczecinieXuzhou Medical UniversityMassachusetts Eye and EarQueensland HealthFondation BotnarUniversity of New EnglandAmerican Diabetes AssociationLingnan UniversityGonabad University of Medical SciencesTomsk Polytechnic UniversityAristotle University of ThessalonikiIslamic Azad UniversityBirjand University of Medical SciencesState Key Laboratory of Numerical Modeling for Atmospheric Sciences and Geophysical Fluid DynamicsConselho Nacional de Desenvolvimento Científico e TecnológicoAnglia Ruskin UniversityUniversity of EssexMcMaster UniversityDirectorate for Biological SciencesDelhi Technological UniversityEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentUniversity of BernMinistry of EducationSveučilište u ZagrebuUniversity of South FloridaUniversity of KarachiBurnet InstituteHarvard UniversityDeutsches KrebsforschungszentrumFlorida Agricultural and Mechanical UniversityAstraZenecaEdwards LifesciencesUniversità degli Studi di PadovaIndian Council of Agricultural ResearchKorean Diabetes AssociationUniwersytet Medyczny im. Karola Marcinkowskiego w PoznaniuTehran University of Medical Sciences and Health ServicesU.S. Department of DefenseIndiviorMoscow Institute of Physics and TechnologyUniversity of California, San DiegoUniversità di CataniaInternational Parkinson and Movement Disorder SocietyUniversità degli Studi di MilanoBayerUniversity of OtagoCentre International de Recherche sur le CancerBritish Columbia Centre for Disease ControlChildren's Hospital of PhiladelphiaNational Institute for Research in TuberculosisSyddansk UniversitetMassachusetts General HospitalUniversity of MontanaAarhus UniversitetBeni-Suef UniversityRafsanjan University of Medical SciencesBaqiyatallah University of Medical SciencesUK Research and InnovationUnited Nations Population FundAl-Azhar UniversityUniversitas UdayanaUniversity Of Nigeria NsukkaConquer Cancer FoundationUniversity of Nevada, Las VegasNational Taiwan Normal UniversityUniversity of PennsylvaniaUniversity of South AfricaMekelle UniversityItä-Suomen YliopistoUniversiti Putra MalaysiaShiraz University of Medical SciencesU.S. Environmental Protection AgencyUmm Al-Qura UniversityVictoria UniversityClemson UniversityRijksuniversiteit GroningenAlberta Health ServicesXiamen UniversityLondon School of Economics and Political ScienceOttawa Hospital Research InstituteNorwegian Institute of Public HealthUniversity of TasmaniaDepartment of Health and Social CareGilead SciencesBill and Melinda Gates FoundationKuopion Yliopistollinen SairaalaUniversity of Southern CaliforniaUniversity College LondonNational Institute of Mental Health and NeurosciencesStudent Research Committee, Tabriz University of Medical SciencesUniversidad Nacional de ColombiaNorthwestern UniversityIndian Institute of Technology MadrasIran University of Medical SciencesHáskólinn í ReykjavíkPfizerLoyola University ChicagoICAR-Indian Veterinary Research InstituteUniversità degli Studi del Piemonte OrientaleMonash UniversityGazi ÜniversitesiPacific Institute for Research and EvaluationKeio UniversityLovely Professional UniversitySt. Baldrick's FoundationBirmingham City UniversityUniversity of Nebraska Medical CenterUniversity of TorontoUniversidade Federal de PernambucoFudan UniversityUniversidade da Beira Interior

Keywords

Life expectancyPandemicCoronavirus disease 2019 (COVID-19)Demography2019-20 coronavirus outbreakSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2)PopulationLongevityGeographyMedicineGerontologyVirologyOutbreakSociologyDisease

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