Articles

Global, regional, and national incidence and mortality

burden of non-COVID-19 lower respiratory infections and
aetiologies, 1990–2021: a systematic analysis from the
Global Burden of Disease Study 2021
GBD 2021 Lower Respiratory Infections and Antimicrobial Resistance Collaborators*

Summary
Background Lower respiratory infections (LRIs) are a major global contributor to morbidity and mortality. In 2020–21, Lancet Infect Dis 2024
non-pharmaceutical interventions associated with the COVID-19 pandemic reduced not only the transmission of Published Online
SARS-CoV-2, but also the transmission of other LRI pathogens. Tracking LRI incidence and mortality, as well as the April 15, 2024
https://doi.org/10.1016/
pathogens responsible, can guide health-system responses and funding priorities to reduce future burden. We
S1473-3099(24)00176-2
present estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 of the burden of
See Online/Comment
non-COVID-19 LRIs and corresponding aetiologies from 1990 to 2021, inclusive of pandemic efects on the incidence https://doi.org/10.1016/
and mortality of select respiratory viruses, globally, regionally, and for 204 countries and territories. S1473-3099(24)00209-3
*Collaborators listed at the end
Methods We estimated mortality, incidence, and aetiology attribution for LRI, deined by the GBD as pneumonia or of the Article
bronchiolitis, not inclusive of COVID-19. We analysed 26 259 site-years of mortality data using the Cause of Death Correspondence to:
Ensemble model to estimate LRI mortality rates. We analysed all available age-speciic and sex-speciic data sources, Dr Hmwe H Kyu, Department of
Health Metrics Sciences, School
including published literature identiied by a systematic review, as well as household surveys, hospital admissions, of Medicine, Institute for Health
health insurance claims, and LRI mortality estimates, to generate internally consistent estimates of incidence and Metrics and Evaluation,
prevalence using DisMod-MR 2.1. For aetiology estimation, we analysed multiple causes of death, vital registration, University of Washington,
hospital discharge, microbial laboratory, and literature data using a network analysis model to produce the proportion Seattle, WA 98195, USA
[email protected]
of LRI deaths and episodes attributable to the following pathogens: Acinetobacter baumannii, Chlamydia spp,
Enterobacter spp, Escherichia coli, fungi, group B streptococcus, Haemophilus influenzae, inluenza viruses, Klebsiella
pneumoniae, Legionella spp, Mycoplasma spp, polymicrobial infections, Pseudomonas aeruginosa, respiratory syncytial
virus (RSV), Staphylococcus aureus, Streptococcus pneumoniae, and other viruses (ie, the aggregate of all viruses studied
except inluenza and RSV), as well as a residual category of other bacterial pathogens.

Findings Globally, in 2021, we estimated 344 million (95% uncertainty interval [UI] 325–364) incident episodes of LRI,
or 4350 episodes (4120–4610) per 100 000 population, and 2·18 million deaths (1·98–2·36), or 27·7 deaths (25·1–29·9)
per 100 000. 502 000 deaths (406 000–611 000) were in children younger than 5 years, among which 254 000 deaths
(197 000–320 000) occurred in countries with a low Socio-demographic Index. Of the 18 modelled pathogen categories
in 2021, S pneumoniae was responsible for the highest proportions of LRI episodes and deaths, with an estimated
97·9 million (92·1–104·0) episodes and 505 000 deaths (454 000–555 000) globally. The pathogens responsible for the
second and third highest episode counts globally were other viral aetiologies (46·4 million [43·6–49·3] episodes) and
Mycoplasma spp (25·3 million [23·5–27·2]), while those responsible for the second and third highest death counts
were S aureus (424 000 [380 000–459 000]) and K pneumoniae (176 000 [158 000–194 000]). From 1990 to 2019, the global
all-age non-COVID-19 LRI mortality rate declined by 41·7% (35·9–46·9), from 56·5 deaths (51·3–61·9) to 32·9 deaths
(29·9–35·4) per 100 000. From 2019 to 2021, during the COVID-19 pandemic and implementation of associated non-
pharmaceutical interventions, we estimated a 16·0% (13·1–18·6) decline in the global all-age non-COVID-19 LRI
mortality rate, largely accounted for by a 71·8% (63·8–78·9) decline in the number of inluenza deaths and a 66·7%
(56·6–75·3) decline in the number of RSV deaths.

Interpretation Substantial progress has been made in reducing LRI mortality, but the burden remains high, especially
in low-income and middle-income countries. During the COVID-19 pandemic, with its associated non-pharmaceutical
interventions, global incident LRI cases and mortality attributable to inluenza and RSV declined substantially.
Expanding access to health-care services and vaccines, including S pneumoniae, H influenzae type B, and novel RSV
vaccines, along with new low-cost interventions against S aureus, could mitigate the LRI burden and prevent
transmission of LRI-causing pathogens.

Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care (UK).

Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

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Research in context
Evidence before this study revise and improve estimates from previous years. Overall,
Lower respiratory infection (LRI) is a common and deadly these enhancements contribute to a more comprehensive and
infectious disease, particularly in children and older adults. up-to-date understanding of the global burden of LRI,
Previous iterations of the Global Burden of Diseases, Injuries, incorporating previously unaccounted for aetiologies and
and Risk Factors Study (GBD) and estimates from WHO and the considering the influence of the COVID-19 pandemic on
Maternal and Child Epidemiology Estimation Group have respiratory infections. This information is invaluable for health-
quantified the LRI burden for select aetiologies in the pre- care practitioners, policy makers, and researchers in effectively
COVID-19 era. In addition, many studies have estimated the developing targeted interventions to combat LRIs.
decrease in incidence or mortality due to LRI or select
Implications of all the available evidence
respiratory pathogens during the COVID-19 pandemic, but
With a comprehensive understanding of the aetiologies of LRI
these studies are generally limited to one or a few surveillance
and their impact, health-care authorities can design targeted
networks, countries, or clinical sites. We searched PubMed with
interventions to address specific pathogens responsible for
the search terms (“lower respiratory infection*”[Title/Abstract]
respiratory infections. These interventions might include
OR “LRI”[Title/Abstract]) AND (“mortality” OR “incidence”)
vaccination campaigns, improved infection control measures,
AND “global*” AND (“etiology” OR “pathogen”) with no
and early detection and treatment strategies. This study found
language restrictions, for articles published from Jan 1, 2021 to
S pneumoniae to be the most common cause of LRI deaths in
June 16, 2023. We did not identify any studies that evaluated
2021, followed by S aureus and K pneumoniae. During the
global levels and trends of LRI burden in all ages, attributable to
COVID-19 pandemic, following the implementation of non-
a comprehensive set of aetiologies, across all countries, and
pharmaceutical interventions such as facemask use and
inclusive of the COVID-19 pandemic’s effects to the year 2021.
mobility restrictions, we observed a decline in global influenza
Added value of this study and RSV infection incidence and mortality. Since 1990,
This study provides two key improvements on the past GBD incidence and mortality due to LRI have greatly decreased,
study: expanded aetiology estimation and evaluation of especially in children younger than 5 years, while mortality rates
COVID-19 pandemic impact. We produced estimates of non- in adults, especially those aged 70 years and older, have had a
COVID-19 LRI burden attributable to a comprehensive set of slower rate of decline. Our analysis particularly highlights the
18 different aetiologies (Acinetobacter baumannii, decrease in vaccine-preventable aetiologies, S pneumoniae and
Chlamydia spp, Enterobacter spp, Escherichia coli, fungi, group B H inluenzae, and the importance of maintaining and expanding
streptococcus, Haemophilus inluenzae, influenza, Klebsiella vaccine coverage against these bacteria. We also found high
pneumoniae, Legionella spp, Mycoplasma spp, polymicrobial mortality attributable to non-vaccine-preventable aetiologies,
infections, Pseudomonas aeruginosa, respiratory syncytial virus including S aureus; development of preventive therapies and
[RSV], Staphylococcus aureus, Streptococcus pneumoniae, and vaccines for these pathogens should receive further investment
other viruses, as well as a residual category of other bacterial and research. Furthermore, as the threat of antimicrobial
pathogens). 13 of these aetiologies are newly included in the resistance grows, robust pathogen surveillance, point-of-care
GBD study, significantly expanding our understanding of the pathogen identification, and implementation of strategies to
diverse causes of LRI. In addition, this research, which models reduce antibiotic overuse become essential. The LRI burden
through the year 2021, estimates the reduction in non- remains highly inequitable, with both deaths and cases highly
COVID-19 LRI incidence and mortality observed during the concentrated in low-income and middle-income countries;
COVID-19 pandemic period. In addition, we added many new thus, all interventions must be financially accessible and
data sources on LRI morbidity and mortality since GBD 2019, distributed to areas with a high burden of LRI.
which span widely across time and geography, enabling us to

Introduction aged 65 years and older, host-level risk factors can include
Lower respiratory infections (LRIs) were the leading frailty and presence of comorbid conditions such as
infectious cause of death globally in 2019.1,2 Gram-positive asthma.6,7 Vaccination against Streptococcus pneumoniae is
and Gram-negative bacteria, atypical bacteria, viruses, protective against pneumococcal pneumonia in both
and fungi can all cause LRI. Mortality rates are highest in infants and older adults.7,8
adults older than 70 years and in children younger than Among community-acquired bacterial LRIs,
5 years, and both incidence and mortality are generally S pneumoniae remains the most prevalent pathogen in
higher in males.3–5 Risk factors for LRI mortality in all age children and adults and across diferent income-level
groups include exposure to tobacco smoke, indoor and settings.9,10 Historically, Haemophilus influenzae was
outdoor particulate matter, and extreme temperatures.3 the second-leading cause of childhood pneumonia.11
In children younger than 5 years, wasting is estimated to However, with the widespread implementation of
be responsible for over half of LRI deaths.3 Among adults H influenzae type b (Hib) vaccination, the incidence of

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H influenzae pneumonia has declined substantially over to LRI by age and sex for 204 countries and territories
the past decade.8,12 Staphylococcus aureus, which is not between 1990 and 2021. The Global Burden of AMR
vaccine-preventable, is a noteworthy cause of complicated study produced estimates of aetiology-speciic fatal and
pneumonia, with substantially higher rates of poor non-fatal burdens of select infectious syndromes,
clinical outcomes, including sepsis and death, than including LRI.27 LRI is deined as acute pneumonia or
S pneumoniae.13,14 S aureus also has the ability to develop bronchiolitis, not inclusive of COVID-19. ICD codes
resistance to multiple antibiotics, posing further barriers mapped to LRI in GBD are provided in appendix 1 See Online for appendix 1
to care.15 In school-age children, the atypical bacterium (pp 17–18) for ICD-9 and ICD-10. The GBD case deinition
Mycoplasma pneumoniae is a leading cause of pneumonia, of LRI does not include tuberculosis, pertussis, or
with one review estimating that it is responsible for COVID-19; although the pathogens that cause these
4–39% of cases of paediatric community-acquired diseases can infect the lower respiratory tract, they are
pneumonia.16,17 modelled separately due to their individual public health
Viruses, including inluenza and respiratory syncytial signiicance and are not included in the GBD category
virus (RSV), are highly prevalent causes of LRIs, of LRI.
particularly in children.10,18 A 2021 global meta-analysis GBD uses a set of modelling tools, described in the
estimated that inluenza viruses were responsible for sections below, to extrapolate available data out to
14·1% of adult LRI hospitalisations, or more than produce results for the entire global population, by age,
5 million hospitalisations.19 Another global meta-analysis sex, and year. Modelling was done at the 1000 draw level,
estimated that RSV was responsible for 3·6 million where the point estimate was computed as the mean of
hospitalisations in 2019 among children younger than 1000 draws, and the 95% uncertainty intervals (UIs) were
5 years.20 In addition, viral infections increase patients’ computed as the 25th and 975th ranked values of
risk for superimposed bacterial infections, most 1000 draws. We used the GBD 2021 global population age
commonly by S pneumoniae and S aureus, causing standard to calculate age-standardised rates, which allow
substantial morbidity and mortality.21 for comparison of rates between locations or years with
Beginning in 2020, the COVID-19 pandemic promoted diferent age structures.29 In the following sections, we
the adoption of non-pharmaceutical interventions, summarise key methods from the GBD and Global
including stay-at-home orders, school and community Burden of AMR studies for the estimation of LRI and its
closures, and facemask requirements. These measures aetiologies. More details on these methods, including a
efectively curbed the incidence of respiratory infections lowchart, are provided in appendix 1 (pp 4–29). Full
in 2020 and 2021, for both COVID-19 and other descriptions of the GBD and Global Burden of AMR
respiratory viruses.22–25 RSV and inluenza infection studies have been published previously.2,27
incidence declined in response to these non- All metadata for input sources described below are
pharmaceutical interventions, although some locations available on the GBD Sources Tool, found on the Global For the GHDx GBD 2021 website
had outbreaks of these viruses in atypical seasons as non- Health Data Exchange (GHDx), which readers can use to see https://ghdx.healthdata.org/
record/ihme-data/global-
pharmaceutical interventions were relaxed.22–25 identify which sources were used for estimating an burden-disease-study-2021-
This study presents the results from the Global Burden outcome in any given location. GBD 2019 complies lower-respiratory-incidence-
of Diseases, Injuries, and Risk Factors Study (GBD) 2021, with the GATHER statement (appendix 1 pp 30–31).30 mortality-estimates-1990-2021
which estimates LRI incidence and mortality, combined Statistical code used for GBD estimation is publicly
with the indings of the Global Research on Antimicrobial available online on the GHDx.
Resistance (AMR) project, which estimates LRI pathogen
distribution. We aimed to describe the burden and trends Mortality estimation
of LRIs and the pathogens responsible across As inputs to the GBD LRI mortality-estimation model,
204 countries and territories from 1990 to 2021. Previous we used a total of 26 259 site-years of data: 23 062 site-
GBD studies included estimates of four aetiologies that years from vital registration, 825 site-years from sample
were not mutually exclusive or collectively exhaustive.2,26 vital registration, 1682 site-years from verbal autopsy,
In the current study, we provide estimates for a 681 site-years from surveillance sources, and 9 site-years
comprehensive set of 18 pathogen categories across all from minimally invasive tissue sampling. Data are
age groups.27,28 Additionally, the estimates for 2020 and processed using a set of standard algorithms accounting
2021 account for the reduction of LRIs seen during the for incompleteness, misclassiication of the underlying
COVID-19 pandemic and implementation of non- cause of death, garbage coding, and stochastic variability.2
pharmaceutical interventions. We estimated overall LRI mortality using the Cause of
Death Ensemble model (CODEm),31 which evaluates a
Methods wide array of potential models using various combinations
Overview of covariates and four model classes. Each model class
This Article was produced as part of the GBD Collaborator uses either cause fraction or death rate as the outcome
Network and in accordance with the GBD protocol. GBD variable, and either a mixed-efects linear model or a
2021 produced estimates of mortality and morbidity due spatiotemporal Gaussian process model as the regression

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method. Models included ixed efects on covariates and age group, location, and year. For data sources that only
age dummies. Random efects are applied at the levels of reported deaths, we used modelled case-fatality rates
super-region, region, and age in the spatiotemporal (CFRs) to retroactively estimate the number of cases.
model’s mixed-efects structure, and at the levels of super- These CFRs for each pathogen were modelled using a
region, region, country, and age in the mixed-efects Bayesian meta-regression tool, MR-BRT (meta-
linear models. In mixed-efects regression, the random regression—Bayesian, regularised, trimmed), as a function
efects are assumed to follow a normal distribution with a of age group, pathogen, and HAQ Index, with random
mean of zero and a variance–covariance matrix that is to efects on data source.27,33,34 For S pneumoniae, we used a
be estimated from the data. Models were evaluated using vaccine probe design as an additional input to the incidence
out-of-sample predictive validity and integrated into one proportion model, due to the documented challenge in the
ensemble model. A full list of covariates is provided in microbiological identiication of this pathogen.35 Modelled
appendix 1 (pp 8–9). Final LRI mortality estimates are CFRs were then used again to compute mortality
scaled by a procedure known as CoDCorrect to ensure proportions from case proportions. More details on
consistency between the sum of cause-speciic mortality aetiology estimation can be found in appendix 1 (pp 17–26).
and the total envelope of all-cause mortality.2 Ultimately, all estimated incident LRI cases were
distributed to an estimated aetiology, even those with no
Morbidity estimation aetiology detected, following the modelled aetiology
For LRI morbidity estimation, we used data from distribution patterns by age, location, and year.
published studies identiied via a systematic review
(appendix 1 p 10), surveillance data, LRI mortality COVID-19 impact adjustment
estimates (described above), health insurance claims We developed a multistep modelling process to estimate
data, and inpatient data.2 To correct for potential the reduction of incidence of inluenza and RSV in 2020
systematic bias among diferent categories of data and 2021. Our source data were reported cases of inluenza
sources, we used a standardised crosswalking technique by country, from notiications reported by countries to
to adjust the data to enhance comparability before WHO’s FluNet.36 First, we interpolated the number of
modelling (appendix 1 pp 10–13). We estimated LRI reported cases of inluenza in 2020 and 2021 by month
incidence and prevalence using DisMod-MR 2.1, a using the RegMod framework, a Poisson model that
compartmental Bayesian meta-regression model that estimates the underlying rate of infection in each month
enforces consistency among prevalence, incidence, as a function of a seasonal pattern and an underlying
remission, and mortality.2,32 More details on DisMod-MR, temporal trend.37 Second, we calculated an under-reporting
including information on priors and a full list of ratio in the pre-pandemic reference period, 2017–19, for
covariates, is provided in appendix 1 (pp 15–17). each location by dividing the interpolated number of
reported cases from RegMod by the GBD estimated
Aetiology estimation number of cases of LRI due to inluenza. Third, we
Data used for aetiology estimation originated from estimated the pandemic disruption-free counterfactual
multiple cause-of-death vital registration, hospital number of reported cases, meaning the number of
discharges, microbial laboratory data, and published reported cases we would have expected during 2020 and
studies from the literature.27 Mortality and morbidity are 2021 in the hypothetical pandemic-free scenario. We did
estimated for the following causes of LRI: Acinetobacter this by multiplying the under-reporting ratio by the
baumannii, Chlamydia spp, Enterobacter spp, Escherichia estimated number of cases of LRI due to inluenza, for
coli, fungi, group B streptococcus, H influenzae, inluenza 2020 and 2021, that GBD would have estimated in a
viruses, Klebsiella pneumoniae, Legionella spp, Mycoplasma pandemic-free scenario. Finally, we calculated a yearly
spp, polymicrobial infections, Pseudomonas aeruginosa, disruption inluenza scalar for each location for 2020 and
RSV, S aureus, S pneumoniae, and other viruses (ie, the 2021. This scalar was computed by dividing the
aggregate of all viruses except for inluenza and RSV), as interpolated number of reported cases from RegMod
well as a residual category of other bacterial pathogens. (result of irst step) by the counterfactual disruption-free
The ICD-9 and ICD-10 codes mapped to each cause are number of reported cases (result of third step).
listed in appendix 1 (pp 18–19). These inluenza disruption scalars (result of inal step)
Incidence proportions were estimated using multinomial were multiplied by counterfactual incident cases and
estimation as part of a network analysis model, which deaths for both inluenza and RSV (result of third step),
allows for the inclusion of data sources that are considered to estimate adjusted cases and deaths. More details on
to be partial observations—ie, which do not contain all the adjustments are provided in appendix 1 (pp 26–29).
pathogen groups modelled in the study.27 Proportions were
estimated as a function of age group, infection type, Hib Role of the funding source
and pneumococcal vaccination, and Healthcare Access The funders of the study had no role in study design,
and Quality (HAQ) Index. These covariates vary across data collection, data analysis, data interpretation, or
geography and time, creating unique predictions for each writing of the report.

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1990 2019 2020 2021 Incidence rate change, %

Episode count Incidence Episode count Incidence rate Episode count Incidence Episode count Incidence 1990–2019 2019–21
rate per per 100 000 rate per rate per
100 000 population 100 000 100 000
population population population
Global
All ages 314 000 000 5884·6 369 000 000 4766·4 342 000 000 4369·4 344 000 000 4354·2 –19·0% –8·6%
(294 000 000 to (5513·2 to (349 000 000 to (4507·5 to (324 000 000 to (4144·4 to (325 000 000 to (4121·1 to (–21·9 to (–10·4 to
333 000 000) 6249·0) 391 000 000) 5041·7) 360 000 000) 4608·3) 364 000 000) 4606·5) –16·0) –6·6)
<5 years 101 000 000 16 302·6 45 000 000 6639·0 39 800 000 5940·8 37 800 000 5747·5 –59·3% –13·4%
(89 800 000 to (14 489·0 to (40 000 000 to (5903·8 to (35 500 000 to (5296·9 to (33 500 000 to (5085·2 to (–60·1 to (–15·9 to
114 000 000) 18 341·7) 50 800 000) 7493·3) 45 000 000) 6720·0) 43 000 000) 6537·1) –58·3) –10·6)
5–14 years 43 600 000 3893·0 34 000 000 2560·4 32 500 000 2420·2 32 100 000 2369·3 –34·2% –7·5%
(35 500 000 to (3169·1 to (28 100 000 to (2117·1 to (26 800 000 to (1995·5 to (26 500 000 to (1954·0 to (–37·0 to (–9·3 to
52 800 000) 4719·6) 40 700 000) 3062·5) 38 900 000) 2900·1) 38 500 000) 2841·8) –31·2) –5·8)
15–49 years 66 700 000 2460·2 94 200 000 2415·0 87 700 000 2235·5 88 800 000 2249·6 –1·8% –6·8%
(60 400 000 to (2229·3 to (85 700 000 to (2197·9 to (79 800 000 to (2034·2 to (80 800 000 to (2046·5 to (–4·0 to (–8·6 to
73 300 000) 2703·7) 103 000 000) 2641·6) 95 900 000) 2444·1) 97 100 000) 2458·9) 0·6) –4·8)
50–69 years 56 800 000 8325·7 95 900 000 6965·5 89 500 000 6352·7 91 500 000 6366·3 –16·3% –8·6%
(51 400 000 to (7540·4 to (87 400 000 to (6349·8 to (81 500 000 to (5787·5 to (83 300 000 to (5802·0 to (–19·0 to (–10·3 to
62 100 000) 9112·5) 104 000 000) 7581·7) 97 100 000) 6890·2) 99 600 000) 6936·2) –13·7) –6·4)
≥70 years 45 800 000 22 654·9 100 000 000 21 560·2 92 300 000 19 279·4 93 400 000 18 897·7 –4·8% –12·3%
(41 100 000 to (20 326·7 to (90 900 000 to (19 575·2 to (83 800 000 to (17 503·3 to (84 300 000 to (17 055·2 to (–9·1 to (–14·2 to
50 700 000) 25 095·8) 112 000 000) 24 087·4) 102 000 000) 21 229·6) 104 000 000) 21 025·2) –0·4) –10·3)
High SDI
All ages 15 700 000 1783·6 17 900 000 1647·3 16 600 000 1519·6 14 800 000 1354·6 –7·6% –17·8%
(14 900 000 to (1689·8 to (17 000 000 to (1562·4 to (15 700 000 to (1439·4 to (14 100 000 to (1285·3 to (–10·1 to (–18·9 to
16 600 000) 1890·0) 18 900 000) 1738·8) 17 500 000) 1608·0) 15 700 000) 1433·2) –5·3) –16·5)
<5 years 1 920 000 3104·5 908 000 1623·3 750 000 1365·2 600 000 1114·0 –47·7% –31·4%
(1 660 000 to (2686·7 to (775 000 to (1386·1 to (638 000 to (1160·7 to (513 000 to (952·4 to (–50·6 to (–32·9 to
2 190 000) 3556·3) 1 060 000) 1900·3) 874 000) 1590·2) 702 000) 1302·9) –45·1) –29·4)
5–14 years 1 040 000 841·3 604 000 511·0 565 000 476·7 533 000 449·5 –39·3% –12·0%
(820 000to (660·5 to (476 000 to (402·9 to (447 000 to (376·7 to (420 000 to (354·2 to (–41·5 to (–13·5 to
1 340 000) 1080·0) 761 000) 643·8) 720 000) 607·5) 675 000) 569·0) –36·6) –10·7)
15–49 years 2 490 000 539·5 2 120 000 418·8 1 930 000 382·9 1 820 000 363·3 –22·4% –13·3%
(2 220 000 to (481·7 to (1 900 000 to (376·0 to (1 740 000 to (344·4 to (1 630 000 to (324·8 to (–24·3 to (–14·6 to
2 790 000) 604·4) 2 340 000) 462·7) 2 130 000) 422·8) 2 010 000) 400·7) –20·5) –11·8)
50–69 years 3 860 000 2354·7 4 520 000 1663·0 4 190 000 1532·8 3 860 000 1399·4 –29·4% –15·9%
(3 560 000 to (2173·2 to (4 180 000 to (1537·2 to (3 860 000 to (1412·3 to (3 560 000 to (1290·0 to (–30·9 to (–17·1 to
4 170 000) 2542·5) 4 880 000) 1796·6) 4 530 000) 1654·1) 4 160 000) 1509·6) –27·5) –14·3)
≥70 years 6 380 000 9244·5 9 760 000 7192·4 9 140 000 6534·2 8 000 000 5578·0 –22·2% –22·4%
(5 880 000 to (8509·4 to (9 050 000 to (6664·9 to (8 480 000 to (6059·1 to (7 420 000 to (5172·7 to (–24·4 to (–23·7 to
6 960 000) 10 077·5) 10 600 000) 7805·8) 9 840 000) 7036·3) 8 680 000) 6051·3) –20·1) –21·1)
High-middle SDI
All ages 37 200 000 3498·3 45 900 000 3535·0 42 400 000 3261·4 40 900 000 3138·7 1·1% –11·2%
(34 900 000 to (3279·9 to (43 000 000 to (3316·4 to (39 900 000 to (3065·9 to (38 500 000 to (2951·6 to (–4·2 to (–13·3 to
39 700 000) 3730·9) 48 900 000) 3772·9) 45 200 000) 3474·3) 43 500 000) 3339·3) 6·3) –9·2)
<5 years 11 300 000 12 155·7 3 220 000 4201·3 2 720 000 3682·0 2 240 000 3202·9 –65·4% –23·8%
(9 950 000 to (10 709·8 to (2 710 000 to (3537·7 to (2 290 000 to (3096·2 to (1 880 000 to (2686·7 to (–68·5 to (–26·1 to
12 900 000) 13 896·9) 3 790 000) 4940·8) 3 200 000) 4325·9) 2 620 000) 3735·4) –62·2) –21·2)
5–14 years 4 980 000 2756·3 3 730 000 2412·3 3 640 000 2304·1 3 640 000 2260·8 –12·5% –6·3%
(4 020 000 to (2224·9 to (2 940 000 to (1902·9 to (2 870 000 to (1819·7 to (2 870 000 to (1782·5 to (–19·4 to (–9·2 to
6 130 000) 3392·1) 4 640 000) 3001·3) 4 540 000) 2877·3) 4 540 000) 2824·0) –4·8) –3·5)
15–49 years 6 710 000 1188·4 8 620 000 1345·6 7 950 000 1252·6 7 620 000 1211·1 13·2% –10·0%
(6 030 000 to (1068·1 to (7 700 000 to (1202·4 to (7 120 000 to (1121·2 to (6 840 000 to (1085·7 to (9·7 to (–11·8 to
7 440 000) 1318·7) 9 620 000) 1502·0) 8 830 000) 1390·1) 8 460 000) 1343·0) 17·3) –8·1)
50–69 years 7 460 000 4284·7 12 100 000 3825·6 11 500 000 3581·3 11 100 000 3417·1 –10·7% –10·7%
(6 830 000 to (3925·4 to (11 000 000 to (3485·4 to (10 500 000 to (3281·3 to (10 100 000 to (3094·2 to (–13·8 to (–13·3 to
8 080 000) 4640·2) 13 200 000) 4174·3) 12 500 000) 3888·7) 12 100 000) 3705·9) –6·9) –7·7)
≥70 years 6 770 000 13 149·2 18 200 000 16 585·7 16 600 000 14 660·6 16 300 000 13 866·9 26·1% –16·4%
(6 140 000 to (11 923·5 to (16 300 000 to (14 816·6 to (14 900 000 to (13 102·3 to (14 600 000 to (12 398·2 to (19·2 to (–19·6 to
7 390 000) 14 362·2) 20 300 000) 18 516·2) 18 300 000) 16 151·7) 18 100 000) 15 377·7) 34·3) –13·1)
(Table 1 continues on next page)

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 Articles

1990 2019 2020 2021 Incidence rate change, %

Episode count Incidence Episode count Incidence rate Episode count Incidence Episode count Incidence 1990–2019 2019–21
rate per per 100 000 rate per rate per
100 000 population 100 000 100 000
population population population
(Continued from previous page)
Middle SDI
All ages 87 100 000 5054·4 96 700 000 4012·3 89 000 000 3662·1 89 500 000 3657·2 –20·6% –8·8%
(81 400 000 to (4726·3 to (91 100 000 to (3778·5 to (84 200 000 to (3461·7 to (84 700 000 to (3457·2 to (–24·1 to (–10·8 to
92 900 000) 5390·2) 102 000 000) 4251·6) 94 300 000) 3879·0) 95 300 000) 3892·0) –16·7) –6·7)
<5 years 29 700 000 14 797·3 8 680 000 4632·6 7 590 000 4148·5 6 850 000 3879·7 –68·7% –16·3%
(26 300 000 to (13 136·4 to (7 630 000 to (4071·5 to (6 680 000 to (3650·8 to (5 990 000 to (3392·6 to (–69·7 to (–18·8 to
33 500 000) 16 713·9) 9 890 000) 5274·5) 8 680 000) 4740·1) 7 890 000) 4469·1) –67·6) –13·2)
5–14 years 12 800 000 3402·6 7 370 000 1930·1 6 970 000 1803·1 6 830 000 1750·7 –43·3% –9·3%
(10 500 000 to (2778·2 to (5 990 000 to (1568·4 to (5 660 000 to (1465·3 to (5 560 000 to (1426·0 to (–46·4 to (–11·2 to
15 500 000) 4121·3) 8 910 000) 2332·2) 8 430 000) 2183·1) 8 280 000) 2122·5) –39·5) –7·4)
15–49 years 18 900 000 2074·9 24 600 000 1966·6 22 500 000 1799·4 22 600 000 1803·5 –5·2% –8·3%
(17 200 000 to (1885·7 to (22 300 000 to (1781·8 to (20 500 000 to (1634·5 to (20 500 000 to (1633·0 to (–8·0 to (–10·5 to
20 800 000) 2280·5) 27 000 000) 2159·1) 24 700 000) 1973·7) 24 900 000) 1986·2) –2·8) –6·1)
50–69 years 14 400 000 7609·8 27 800 000 6042·7 25 900 000 5468·6 26 600 000 5470·5 –20·6% –9·5%
(13 000 000 to (6853·4 to (25 200 000 to (5495·9 to (23 600 000 to (4987·2 to (24 200 000 to (4990·1 to (–23·4 to (–11·4 to
15 800 000) 8360·1) 30 500 000) 6633·2) 28 300 000) 5975·0) 29 000 000) 5976·3) –17·6) –7·1)
≥70 years 11 300 000 24 697·8 28 300 000 21 637·0 26 000 000 19 223·2 26 700 000 18 911·1 –12·4% –12·6%
(10 100 000 to (22 037·6 to (25 700 000 to (19 643·2 to (23 700 000 to (17 467·8 to (24 100 000 to (17 100·3 to (–16·4 to (–15·0 to
12 500 000) 27 426·9) 31 600 000) 24 127·6) 28 800 000) 21 269·0) 29 600 000) 21 016·6) –7·2) –10·1)
Low-middle SDI
All ages 119 000 000 10 254·0 137 000 000 7301·1 126 000 000 6638·3 130 000 000 6742·4 –28·8% –7·7%
(111 000 000 to (9596·2 to (129 000 000 to (6889·2 to (119 000 000 to (6282·2 to (122 000 000 to (6355·3 to (–31·5 to (–10·3 to
127 000 000) 10 941·0) 145 000 000) 7748·4) 133 000 000) 7006·3) 138 000 000) 7173·5) –26·0) –4·6)
<5 years 37 500 000 21 604·0 16 700 000 8530·6 14 500 000 7512·9 14 100 000 7343·5 –60·5% –13·9%
(33 300 000 to (19 187·8 to (14 900 000 to (7610·6 to (13 000 000 to (6704·2 to (12 400 000 to (6464·9 to (–61·5 to (–17·8 to
42 000 000) 24 200·3) 18 700 000) 9580·6) 16 600 000) 8555·4) 16 000 000) 8356·5) –59·4) –10·0)
5–14 years 17 000 000 5694·7 13 000 000 3353·2 12 100 000 3136·1 12 000 000 3099·9 –41·1% –7·6%
(13 900 000 to (4647·4 to (10 700 000 to (2768·0 to (10 100 000 to (2604·9 to (9 930 000 to (2556·6 to (–44·2 to (–10·6 to
20 800 000) 6948·8) 15 400 000) 3977·9) 14 500 000) 3745·9) 14 400 000) 3718·7) –38·0) –4·4)
15–49 years 26 800 000 4865·4 38 600 000 3908·7 35 800 000 3573·6 36 700 000 3613·3 –19·7% –7·6%
(24 200 000 to (4397·2 to (35 200 000 to (3562·9 to (32 500 000 to (3242·2 to (33 300 000 to (3279·4 to (–21·7 to (–10·5 to
29 600 000) 5362·7) 42 100 000) 4260·6) 39 100 000) 3907·2) 40 100 000) 3947·7) –17·1) –4·5)
50–69 years 22 000 000 19 664·4 36 300 000 14 999·1 33 600 000 13 488·6 35 000 000 13 744·2 –23·7% –8·4%
(19 800 000 to (17 647·7 to (33 000 000 to (13 644·8 to (30 500 000 to (12 241·0 to (31 800 000 to (12 491·8 to (–27·4 to (–11·4 to
24 400 000) 21 804·9) 39 700 000) 16 423·3) 36 500 000) 14 682·2) 38 200 000) 14 995·5) –19·9) –5·2)
≥70 years 15 800 000 60 146·0 32 600 000 48 877·1 30 100 000 43 991·0 31 700 000 45 178·2 –18·7% –7·6%
(13 900 000 to (52 905·4 to (29 400 000 to (44 089·3 to (27 000 000 to (39 501·2 to (28 200 000 to (40 213·6 to (–24·0 to (–11·3 to
17 800 000) 67 732·4) 36 900 000) 55 283·6) 33 700 000) 49 353·2) 35 900 000) 51 217·1) –13·3) –3·5)
Low SDI
All ages 54 600 000 10 899·1 71 500 000 6698·9 67 500 000 6176·0 68 600 000 6143·1 –38·5% –8·3%
(50 900 000 to (10 149·8 to (67 300 000 to (6308·8 to (63 600 000 to (5823·9 to (65 000 000 to (5812·8 to (–40·4 to (–10·2 to
58 200 000) 11 601·2) 75 400 000) 7070·2) 71 100 000) 6510·0) 72 600 000) 6500·9) –36·5) –6·3)
<5 years 20 600 000 22 738·9 15 500 000 9564·9 14 200 000 8642·5 14 000 000 8480·2 –57·9% –11·3%
(18 200 000 to (20 015·8 to (13 900 000 to (8563·1 to (12 600 000 to (7675·9 to (12 500 000 to (7543·0 to (–59·1 to (–14·0 to
23 400 000) 25 809·9) 17 400 000) 10 736·1) 15 900 000) 9724·6) 15 900 000) 9585·9) –56·7) –8·6)
5–14 years 7 700 000 5576·6 9 320 000 3263·0 9 130 000 3146·1 9 020 000 3061·6 –41·5% –6·2%
(6 290 000 to (4554·1 to (7 750 000 to (2713·8 to (7 650 000 to (2636·6 to (7 500 000 to (2543·7 to (–44·4 to (–8·3 to
9 290 000) 6725·8) 11 100 000) 3892·8) 10 900 000) 3757·0) 10 900 000) 3691·2) –38·1) –3·8)
15–49 years 11 800 000 5317·4 20 200 000 3951·9 19 500 000 3693·8 20 000 000 3686·4 –25·7% –6·7%
(10 600 000 to (4806·8 to (18 300 000 to (3580·5 to (17 700 000 to (3367·2 to (18 300 000 to (3364·9 to (–28·1 to (–8·7 to
12 900 000) 5850·9) 22 000 000) 4303·3) 21 100 000) 4009·8) 21 900 000) 4029·7) –22·8) –4·5)
50–69 years 9 010 000 21 438·0 15 200 000 17 480·9 14 300 000 15 844·2 14 800 000 15 955·7 –18·5% –8·7%
(8 030 000 to (19 102·1 to (13 800 000 to (15 878·6 to (13 100 000 to (14 473·5 to (13 500 000 to (14 491·9 to (–22·4 to (–11·6 to
9 980 000) 23 759·2) 16 700 000) 19 177·8) 15 600 000) 17 304·6) 16 200 000) 17 459·3) –14·2) –6·0)
≥70 years 5 530 000 59 241·9 11 200 000 53 575·8 10 400 000 48 762·8 10 800 000 49 111·1 –9·6% –8·3%
(4 900 000 to (52 529·8 to (10 000 000 to (47 915·3 to (9 300 000 to (43 489·0 to (9 600 000 to (43 765·6 to (–15·4 to (–11·6 to
6 210 000) 66 532·7) 12 700 000) 60 574·5) 11 700 000) 54 900·8) 12 200 000) 55 612·9) –2·0) –4·8)
(Table 1 continues on next page)

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 Articles

1990 2019 2020 2021 Incidence rate change, %

Episode count Incidence Episode count Incidence rate Episode count Incidence Episode count Incidence 1990–2019 2019–21
rate per per 100 000 rate per rate per
100 000 population 100 000 100 000
population population population
(Continued from previous page)
Central Europe, Eastern Europe, and Central Asia
All ages 10 800 000 2570·4 8 010 000 1913·5 7 860 000 1877·0 6 950 000 1664·0 –25·6% –13·0%
(10 200 000 to (2426·7 to (7 600 000 to (1816·4 to (7 490 000 to (1788·7 to (6 600 000 to (1580·1 to (–28·0 to (–14·1 to
11 400 000) 2718·0) 8 450 000) 2018·3) 8 240 000) 1969·3) 7 330 000) 1754·3) –23·0) –11·9)
<5 years 3 150 000 8779·0 874 000 3234·3 812 000 3078·0 607 000 2363·2 –63·2% –26·9%
(2 800 000 to (7807·7 to (783 000 to (2897·7 to (719 000 to (2726·4 to (542 000 to (2110·1 to (–65·2 to (–28·8 to
3 520 000) 9795·9) 980 000) 3628·1) 908 000) 3440·6) 689 000) 2679·0) –61·0) –24·9)
5–14 years 1 440 000 2055·0 669 000 1249·0 666 000 1223·6 609 000 1105·0 –39·2% –11·5%
(1 200 000 to (1708·4 to (557 000 to (1040·5 to (555 000 to (1018·6 to (504 000 to (914·2 to (–41·5 to (–13·9 to
1 750 000) 2500·7) 801 000) 1496·1) 806 000) 1479·8) 739 000) 1341·5) –37·0) –9·0)
15–49 years 1 730 000 843·2 1 670 000 836·5 1 660 000 834·4 1 490 000 754·8 –0·8% –9·8%
(1 600 000 to (775·8 to (1 550 000 to (775·5 to (1 550 000 to (777·3 to (1 390 000 to (701·2 to (–4·4 to (–11·4 to
1 880 000) 914·7) 1 800 000) 899·6) 1 790 000) 900·3) 1 610 000) 815·4) 3·0) –8·0)
50–69 years 2 560 000 3054·6 2 500 000 2499·2 2 470 000 2470·0 2 240 000 2244·8 –18·2% –10·2%
(2 370 000 to (2822·0 to (2 290 000 to (2292·1 to (2 290 000 to (2287·9 to (2 070 000 to (2073·3 to (–20·3 to (–11·7 to
2 770 000) 3303·6) 2 700 000) 2703·0) 2 650 000) 2655·1) 2 420 000) 2431·5) –16·3) –8·5)
≥70 years 1 930 000 7626·4 2 290 000 6037·4 2 250 000 5773·6 2 010 000 5062·9 –20·8% –16·1%
(1 760 000 to (6970·1 to (2 110 000 to (5559·7 to (2 060 000 to (5297·5 to (1 850 000 to (4662·7 to (–23·0 to (–17·6 to
2 120 000) 8376·3) 2 530 000) 6670·9) 2 470 000) 6327·9) 2 210 000) 5579·0) –18·7) –14·6)
High-income
All ages 14 300 000 1572·4 15 900 000 1465·3 14 600 000 1341·4 13 000 000 1188·6 –6·8% –18·9%
(13 500 000 to (1490·5 to (15 100 000 to (1388·2 to (13 900 000 to (1272·7 to (12 300 000 to (1125·1 to (–9·1 to (–20·0 to
15 100 000) 1665·2) 16 800 000) 1546·9) 15 500 000) 1418·8) 13 700 000) 1257·8) –4·7) –17·7)
<5 years 1 520 000 2464·9 777 000 1375·3 617 000 1114·0 510 000 939·6 –44·2% –31·7%
(1 320 000 to (2137·1 to (661 000 to (1170·6 to (521 000 to (940·6 to (436 000 to (803·2 to (–47·1 to (–33·5 to
1 730 000) 2814·1) 906 000) 1604·2) 726 000) 1310·9) 594 000) 1093·5) –41·7) –29·6)
5–14 years 726 000 576·7 453 000 369·6 414 000 338·4 392 000 320·7 –35·9% –13·2%
(566 000 to (449·6 to (358 000 to (292·5 to (328 000 to (268·2 to (310 000 to (254·1 to (–38·2 to (–14·6 to
925 000) 735·0) 570 000) 465·3) 521 000) 425·7) 491 000) 402·2) –33·1) –11·8)
15–49 years 2 200 000 467·4 1 660 000 340·4 1 490 000 306·8 1 420 000 292·8 –27·2% –14·0%
(1 960 000 to (417·2 to (1 490 000 to (306·2 to (1 340 000 to (276·3 to (1 270 000 to (261·8 to (–29·0 to (–15·2 to
2 470 000) 524·1) 1 830 000) 375·2) 1 640 000) 337·0) 1 560 000) 322·8) –25·0) –12·6)
50–69 years 3 540 000 2019·0 3 850 000 1406·3 3 530 000 1282·8 3 230 000 1164·2 –30·3% –17·2%
(3 270 000 to (1867·6 to (3 560 000 to (1302·5 to (3 270 000 to (1188·9 to (2 970 000 to (1070·6 to (–32·0 to (–18·5 to
3 820 000) 2179·5) 4 150 000) 1516·7) 3 790 000) 1376·1) 3 480 000) 1255·5) –28·4) –16·0)
≥70 years 6 310 000 8318·1 9 180 000 6284·8 8 560 000 5705·6 7 420 000 4846·6 –24·4% –22·9%
(5 820 000 to (7666·1 to (8 520 000 to (5830·6 to (7 980 000 to (5324·0 to (6 870 000 to (4486·3 to (–26·6 to (–24·2 to
6 870 000) 9051·3) 9 950 000) 6814·7) 9 210 000) 6143·0) 8 050 000) 5252·9) –22·4) –21·6)
Latin America and Caribbean
All ages 15 800 000 4052·0 15 000 000 2558·8 13 300 000 2256·3 12 900 000 2165·7 –36·9% –15·4%
(14 900 000 to (3806·2 to (14 200 000 to (2420·0 to (12 600 000 to (2131·9 to (12 100 000 to (2044·1 to (–39·4 to (–17·6 to
17 000 000) 4347·7) 15 800 000) 2702·8) 14 000 000) 2373·9) 13 700 000) 2300·0) –34·2) –12·6)
<5 years 5 940 000 11 992·5 2 390 000 4912·8 1 870 000 3891·1 1 680 000 3560·6 –59·0% –27·5%
(5 280 000 to (10 660·4 to (2 080 000 to (4271·4 to (1 620 000 to (3365·0 to (1 450 000 to (3072·6 to (–60·5 to (–30·9 to
6 740 000) 13 618·8) 2 740 000) 5627·1) 2 140 000) 4461·9) 1 930 000) 4087·7) –57·7) –23·0)
5–14 years 2 360 000 2491·9 1 160 000 1211·6 1 040 000 1086·2 1 000 000 1045·7 –51·4% –13·7%
(1 970 000 to (2074·2 to (943 000 to (983·5 to (854 000 to (890·3 to (819 000 to (853·1 to (–53·8 to (–15·8 to
2 850 000) 3010·9) 1 430 000) 1495·9) 1 270 000) 1326·2) 1 240 000) 1290·9) –48·8) –11·3)
15–49 years 2 860 000 1449·4 2 650 000 859·9 2 400 000 772·8 2 330 000 746·6 –40·7% –13·2%
(2 630 000 to (1332·4 to (2 450 000 to (794·1 to (2 210 000 to (713·0 to (2 150 000 to (688·9 to (–42·1 to (–15·3 to
3 110 000) 1578·4) 2 870 000) 930·7) 2 600 000) 837·7) 2 540 000) 814·1) –39·1) –10·8)
50–69 years 2 260 000 5947·3 3 630 000 3645·6 3 380 000 3302·0 3 320 000 3181·4 –38·7% –12·7%
(2 080 000 to (5462·6 to (3 330 000 to (3346·4 to (3 100 000 to (3035·8 to (3 060 000 to (2925·2 to (–40·0 to (–15·0 to
2 460 000) 6460·2) 3 910 000) 3922·1) 3 640 000) 3559·9) 3 600 000) 3449·4) –37·3) –10·1)
≥70 years 2 400 000 21 978·6 5 140 000 15 764·3 4 630 000 13 775·5 4 530 000 13 119·2 –28·3% –16·8%
(2 190 000 to (20 058·6 to (4 710 000 to (14 439·0 to (4 210 000 to (12 531·4 to (4 140 000 to (11 991·9 to (–30·1 to (–19·4 to
2 620 000) 24 044·7) 5 630 000) 17 253·9) 5 040 000) 14 985·4) 4 990 000) 14 468·1) –26·2) –14·0)
(Table 1 continues on next page)

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 Articles

1990 2019 2020 2021 Incidence rate change, %

Episode count Incidence Episode count Incidence rate Episode count Incidence Episode count Incidence 1990–2019 2019–21
rate per per 100 000 rate per rate per
100 000 population 100 000 100 000
population population population
(Continued from previous page)
North Africa and Middle East
All ages 11 200 000 3287·9 10 500 000 1731·5 10 000 000 1631·0 9 380 000 1505·4 –47·3% –13·1%
(10 200 000 to (3003·6 to (9 850 000 to (1625·1 to (9 370 000 to (1523·4 to (8 820 000 to (1415·1 to (–49·8 to (–15·4 to
12 200 000) 3598·4) 11 200 000) 1843·1) 10 800 000) 1757·7) 9 980 000) 1601·6) –44·1) –10·2)
<5 years 5 690 000 11 105·8 2 270 000 3558·6 1 940 000 3108·6 1 670 000 2725·0 –68·0% –23·4%
(4 890 000 to (9544·3 to (1 960 000 to (3073·1 to (1 640 000 to (2619·8 to (1 430 000 to (2334·8 to (–69·4 to (–27·5 to
6 590 000) 12 868·0) 2 640 000) 4150·2) 2 300 000) 3682·1) 1 960 000) 3202·1) –66·3) –18·2)
5–14 years 1 640 000 1840·2 1 290 000 1088·8 1 240 000 1032·4 1 190 000 970·5 –40·8% –10·9%
(1 310 000 to (1464·4 to (1 020 000 to (862·9 to (999 000 to (829·0 to (944 000 to (772·4 to (–43·9 to (–13·8 to
2 020 000) 2265·8) 1 600 000) 1346·5) 1 520 000) 1258·8) 1 460 000) 1195·0) –37·8) –7·3)
15–49 years 1 660 000 1035·9 2 600 000 797·0 2 510 000 761·6 2 410 000 722·0 –23·1% –9·4%
(1 500 000 to (934·6 to (2 350 000 to (720·6 to (2 280 000 to (690·0 to (2 190 000 to (655·6 to (–25·6 to (–11·8 to
1 840 000) 1150·3) 2 870 000) 880·3) 2 790 000) 845·4) 2 660 000) 795·1) –20·3) –6·3)
50–69 years 1 180 000 3772·2 2 210 000 2793·3 2 230 000 2712·6 2 150 000 2528·9 –26·0% –9·5%
(1 050 000 to (3378·9 to (2 010 000 to (2538·5 to (2 020 000 to (2456·1 to (1 960 000 to (2307·4 to (–29·7 to (–12·4 to
1 300 000) 4165·4) 2 410 000) 3049·8) 2 440 000) 2975·9) 2 340 000) 2757·0) –21·8) –6·0)
≥70 years 983 000 13 606·8 2 140 000 11 094·4 2 100 000 10 609·3 1 960 000 9653·6 –18·5% –13·0%
(870 000to (12 046·8 to (1 940 000 to (10 077·1 to (1 890 000 to (9538·0 to (1 790 000 to (8803·5 to (–23·7 to (–16·2 to
1 090 000) 15 107·9) 2 360 000) 12 259·5) 2 370 000) 11 978·7) 2 180 000) 10 726·7) –12·8) –9·2)
South Asia
All ages 143 000 000 13 099·4 180 000 000 9965·4 165 000 000 9021·6 172 000 000 9319·4 –23·9% –6·5%
(134 000 000 to (12 268·7 to (169 000 000 to (9363·5 to (156 000 000 to (8518·1 to (161 000 000 to (8733·8 to (–27·0 to (–9·8 to
153 000 000) 13 973·1) 192 000 000) 10 604·1) 174 000 000) 9543·7) 184 000 000) 9984·8) –20·8) –2·8)
<5 years 38 400 000 24 450·9 16 900 000 10 340·6 15 400 000 9575·9 15 300 000 9627·6 –57·7% –6·9%
(34 100 000 to (21 713·4 to (15 100 000 to (9243·4 to (13 600 000 to (8470·8 to (13 400 000 to (8435·1 to (–58·9 to (–12·7 to
42 900 000) 27 340·1) 18 800 000) 11 556·0) 17 500 000) 10 885·7) 17 700 000) 11 133·9) –56·3) –0·7)
5–14 years 20 600 000 7453·7 15 700 000 4461·8 14 600 000 4170·0 14 600 000 4197·6 –40·1% –5·9%
(16 800 000 to (6064·5 to (12 900 000 to (3668·6 to (12 000 000 to (3413·6 to (11 900 000 to (3426·9 to (–43·9 to (–9·5 to
25 200 000) 9107·7) 18 900 000) 5362·4) 17 700 000) 5042·5) 17 700 000) 5077·4) –36·3) –2·3)
15–49 years 35 700 000 6743·8 53 200 000 5436·5 48 500 000 4881·7 50 100 000 4974·0 –19·4% –8·5%
(32 100 000 to (6060·6 to (48 200 000 to (4925·2 to (43 900 000 to (4425·5 to (45 200 000 to (4491·6 to (–21·5 to (–11·6 to
39 300 000) 7427·6) 58 200 000) 5949·9) 53 300 000) 5366·7) 55 200 000) 5479·6) –17·0) –5·2)
50–69 years 29 000 000 26 980·0 50 700 000 20 611·3 46 300 000 18 270·9 48 900 000 18 843·4 –23·6% –8·6%
(25 900 000 to (24 062·2 to (46 000 000 to (18 699·2 to (42 000 000 to (16 562·3 to (44 400 000 to (17 118·0 to (–27·3 to (–11·6 to
32 200 000) 29 943·6) 55 700 000) 22 650·5) 50 600 000) 19 978·4) 53 700 000) 20 687·0) –19·8) –4·8)
≥70 years 19 600 000 83 238·5 43 700 000 63 388·1 40 200 000 56 615·1 43 200 000 59 004·4 –23·8% –6·9%
(17 200 000 to (73 340·4 to (39 100 000 to (56 714·2 to (35 800 000 to (50 503·2 to (38 200 000 to (52 213·3 to (–28·8 to (–11·2 to
22 100 000) 94 207·4) 49 700 000) 71 959·6) 45 200 000) 63 669·3) 49 200 000) 67 237·2) –18·3) –2·4)
Southeast Asia, East Asia, and Oceania
All ages 74 600 000 4418·3 75 400 000 3487·6 69 700 000 3204·6 67 300 000 3080·4 –21·1% –11·7%
(69 600 000 to (4117·6 to (71 000 000 to (3283·4 to (65 500 000 to (3012·0 to (63 400 000 to (2900·2 to (–25·7 to (–13·0 to
79 900 000) 4731·3) 80 400 000) 3716·3) 74 100 000) 3408·7) 71 400 000) 3268·2) –16·4) –10·1)
<5 years 28 900 000 16 514·4 6 830 000 4564·0 5 850 000 4023·1 4 880 000 3529·1 –72·4% –22·7%
(25 500 000 to (14 541·9 to (5 880 000 to (3928·0 to (5 010 000 to (3441·5 to (4 190 000 to (3032·2 to (–74·1 to (–24·4 to
32 900 000) 18 804·0) 7 850 000) 5243·7) 6 860 000) 4717·5) 5 680 000) 4105·8) –70·6) –20·8)
5–14 years 10 700 000 3253·2 6 240 000 2119·7 6 020 000 2002·8 5 940 000 1936·7 –34·8% –8·6%
(8 720 000 to (2656·2 to (4 970 000 to (1687·6 to (4 790 000 to (1593·2 to (4 710 000 to (1535·5 to (–40·2 to (–10·5 to
13 000 000) 3973·7) 7 810 000) 2649·8) 7 510 000) 2499·4) 7 370 000) 2402·1) –28·5) –6·7)
15–49 years 12 700 000 1364·0 13 500 000 1244·5 12 500 000 1160·4 11 900 000 1116·0 –8·8% –10·3%
(11 400 000 to (1226·0 to (12 100 000 to (1116·4 to (11 100 000 to (1034·9 to (10 600 000 to (995·9 to (–11·7 to (–11·8 to
14 100 000) 1514·3) 15 000 000) 1382·7) 13 800 000) 1282·4) 13 100 000) 1233·0) –5·6) –8·9)
50–69 years 11 900 000 5720·0 20 000 000 4053·7 19 000 000 3744·9 18 600 000 3571·8 –29·1% –11·9%
(10 700 000 to (5163·4 to (18 200 000 to (3682·9 to (17 400 000 to (3426·5 to (16 800 000 to (3236·8 to (–31·3 to (–13·6 to
13 000 000) 6283·5) 21 800 000) 4420·0) 20 700 000) 4080·0) 20 200 000) 3892·7) –26·2) –10·0)
≥70 years 10 500 000 21 063·0 28 800 000 20 500·9 26 300 000 17 997·9 26 000 000 16 906·4 –2·7% –17·5%
(9 370 000 to (18 768·0 to (25 900 000 to (18 415·1 to (23 600 000 to (16 137·1 to (23 400 000 to (15 228·1 to (–8·4 to (–19·5 to
11 600 000) 23 319·3) 32 000 000) 22 744·8) 29 000 000) 19 827·2) 28 700 000) 18 662·1) 4·2) –15·1)
(Table 1 continues on next page)

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1990 2019 2020 2021 Incidence rate change, %

Episode count Incidence Episode count Incidence rate Episode count Incidence Episode count Incidence 1990–2019 2019–21
rate per per 100 000 rate per rate per
100 000 population 100 000 100 000
population population population
(Continued from previous page)
Sub-Saharan Africa
All ages 43 900 000 8936·4 64 200 000 5952·8 61 400 000 5546·3 62 000 000 5474·6 –33·4% –8·0%
(41 000 000 to (8335·8 to (60 700 000 to (5620·3 to (58 000 000 to (5245·1 to (58 500 000 to (5165·0 to (–35·3 to (–9·6 to
46 800 000) 9525·6) 67 700 000) 6277·1) 64 600 000) 5840·1) 65 200 000) 5753·4) –31·3) –6·5)
<5 years 17 500 000 19 478·0 15 000 000 8863·0 13 300 000 7766·1 13 200 000 7642·8 –54·5% –13·8%
(15 400 000 to (17 143·7 to (13 400 000 to (7932·3 to (11 800 000 to (6918·0 to (11 800 000 to (6825·6 to (–55·8 to (–16·0 to
19 800 000) 22 080·6) 16 900 000) 9960·6) 15 000 000) 8749·9) 14 800 000) 8583·4) –53·1) –11·4)
5–14 years 6 130 000 4547·4 8 490 000 2915·6 8 470 000 2849·9 8 320 000 2743·5 –35·9% –5·9%
(5 060 000 to (3752·5 to (7 110 000 to (2442·3 to (7 130 000 to (2399·7 to (6 920 000 to (2282·0 to (–38·4 to (–8·0 to
7 350 000) 5452·7) 10 100 000) 3475·8) 10 000 000) 3372·7) 9 950 000) 3281·2) –32·6) –3·7)
15–49 years 9 890 000 4511·4 18 900 000 3673·6 18 700 000 3526·2 19 200 000 3509·4 –18·6% –4·5%
(8 990 000 to (4100·7 to (17 200 000 to (3345·0 to (17 100 000 to (3227·0 to (17 700 000 to (3230·1 to (–21·0 to (–6·0 to
10 800 000) 4925·8) 20 600 000) 3992·1) 20 300 000) 3824·5) 20 800 000) 3809·5) –15·6) –2·8)
50–69 years 6 350 000 16 502·6 13 000 000 15 344·8 12 600 000 14 331·7 13 000 000 14 391·6 –7·0% –6·2%
(5 730 000 to (14 891·8 to (11 800 000 to (13 882·5 to (11 500 000 to (13 087·7 to (11 900 000 to (13 110·3 to (–10·5 to (–7·8 to
6 990 000) 18 163·4) 14 200 000) 16 730·5) 13 800 000) 15 656·8) 14 200 000) 15 695·7) –3·8) –4·6)
≥70 years 4 070 000 44 066·2 8 810 000 46 676·0 8 290 000 43 028·9 8 280 000 42 264·9 5·9% –9·5%
(3 620 000 to (39 216·4 to (7 940 000 to (42 070·1 to (7 480 000 to (38 829·9 to (7 500 000 to (38 278·7 to (0·7 to (–11·2 to
4 560 000) 49 342·5) 9 880 000) 52 387·7) 9 300 000) 48 260·3) 9 260 000) 47 260·2) 12·1) –7·6)

Values in parentheses are 95% uncertainty intervals. Count data are presented to three significant figures. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. SDI=Socio-demographic Index.

Table 1: Lower respiratory infection incidence counts and rates for all-ages and selected age groups in 1990, 2019, 2020, and 2021, and incidence rate percentage change from
1990 to 2019 and from 2019 to 2021, globally and by SDI quintile and GBD super-region

Results children younger than 5 years, which decreased 59·3%

Incidence of LRIs (58·3–60·1), from 16 300 episodes (14 500–18 300) per
Globally, in 2019, before the reductions in incidence 100 000 in 1990 to 6640 episodes (5900–7490) per 100 000
observed during the COVID-19 pandemic, we estimated in 2019 (table 1). By contrast, the global incidence rate
369 million (95% UI 349–391) LRI episodes, for an all- among adults aged 70 years and older declined at a lower
age incidence rate of 4770 episodes (4510–5040) per rate from 1990 to 2019, with an overall decrease of 4·8%
100 000 population (table 1). (0·4–9·1; table 1).
In 2021, we estimated 344 million (325–364) incident
episodes of LRI globally, for an all-age incidence rate of Mortality of LRIs
4350 episodes (4120–4610) per 100 000 (table 1). Across Globally in 2019, before reductions in mortality observed
204 modelled locations, the all-age incidence rate in 2021 during the COVID-19 pandemic, we estimated
ranged from 463 episodes (428–500) per 100 000 in 2·55 million (95% UI 2·32–2·74) global LRI deaths and
Cyprus to 9980 episodes (9220–10 800) per 100 000 in an all-age mortality rate of 32·9 deaths (29·9–35·4) per
Nepal (igure 1; appendix 2 p 5). Adults aged 70 years and 100 000 population, representing a 41·7% decrease See Online for appendix 2
older had the highest global incidence rate at (35·9–46·9) in mortality rate since 1990 (table 2). Among
18 900 episodes (17 100–21 000) per 100 000, followed by children younger than 5 years, we estimated 693 000
adults aged 50–69 years at 6370 episodes (5800–6940) (580 000–822 000) deaths, for a mortality rate of 102·2
per 100 000 (table 1). Among children younger than deaths (85·5–121·3) per 100 000 in this age group in 2019
5 years, we estimated 37·8 million (33·5–43·0) incident (table 2).
episodes of LRI and an incidence rate of 5750 episodes In 2021, we estimated 2·18 million (1·98–2·36) deaths
(5090–6540) per 100 000 (table 1), ranging from globally due to LRI and an all-age mortality rate of
413 episodes (335–504) per 100 000 in the Netherlands to 27·7 deaths (25·1–29·9) per 100 000 (table 2). The all-age
12 190 episodes (10 600–13 900) per 100 000 in Pakistan mortality rate ranged from 2·3 deaths (1·8–2·9)
(appendix 2 p 5). per 100 000 in Qatar to 104·0 deaths (81·8–129·2)
Since 1990, the all-age global LRI incidence rate per 100 000 in Chad (igure 1; appendix 2 p 86). Among
decreased 19·0% (95% UI 16·0–21·9), from 5880 children younger than 5 years, we estimated
(5510–6250) episodes per 100 000 in 1990 to 4770 episodes 502 000 deaths (406 000–611 000) due to LRI globally, or
(4510–5040) per 100 000 in 2019 (table 1). This decline was 76·2 deaths (61·7–92·9) per 100 000 (table 2), ranging
primarily attributable to reductions in incidence among from 0·3 deaths (0·2–0·5) per 100 000 in Andorra to

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A LRI incidence rate

Episodes per 100 000 population

0 to <868 1990 to <2440
868 to <1120 2440 to <3180
1120 to <1360 3180 to <4680
1360 to <1660 4680 to <5720
1660 to <1990 ≥5720
Eastern
Caribbean and Central America Persian Gulf Balkan Peninsula Southeast Asia West Africa Mediterranean

Northern Europe

B LRI mortality rate

Deaths per 100 000 population

0 to <11·9 28·2 to <34·8
11·9 to <14·5 34·8 to <39·4
14·5 to <18·2 39·4 to <46·8
18·2 to <22·2 46·8 to <56·1
22·2 to <28·2 ≥56·1
Eastern
Caribbean and Central America Persian Gulf Balkan Peninsula Southeast Asia West Africa Mediterranean

Northern Europe

Figure 1: Global maps of LRI incidence and mortality rates across all ages, 2021
Maps show incidence rates (A) and mortality rates (B) per 100 000 population, with colours representing global deciles. LRI=lower respiratory infection.

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1990 2019 2020 2021 Mortality rate change, %

Death count Mortality rate Death count Mortality rate Death count Mortality rate Death count Mortality rate 1990–2019 2019–21
per 100 000 per 100 000 per 100 000 per 100 000
population population population population
Global
All ages 3 010 000 56·5 2 550 000 32·9 2 280 000 29·1 2 180 000 27·7 –41·7% –16·0%
(2 730 000 to (51·3 to (2 320 000 to (29·9 to (2 080 000 to (26·5 to (1 980 000 to (25·1 to (–46·9 to (–18·6 to
3 300 000) 61·9) 2 740 000) 35·4) 2 460 000) 31·4) 2 360 000) 29·9) –35·9) –13·1)
<5 years 1 940 000 313·7 693 000 102·2 557 000 83·1 502 000 76·2 –67·4% –25·4%
(1 690 000 to (272·4 to (580 000 to (85·5 to (455 000 to (67·9 to (406 000 to (61·7 to (–72·2 to (–30·0 to
2 230 000) 359·3) 822 000) 121·3) 665 000) 99·3) 611 000) 92·9) –61·3) –20·3)
5–14 years 89 000 7·9 51 900 3·9 46 100 3·4 43 700 3·2 –50·8% –17·4%
(74 200 to (6·6 to (45 300 to (3·4 to (40 100 to (3·0 to (37 600 to (2·8 to (–56·3 to (–21·2 to
99 900) 8·9) 58 500) 4·4) 51 900) 3·9) 49 400) 3·7) –42·5) –13·6)
15–49 years 141 000 5·2 174 000 4·5 162 000 4·1 160 000 4·1 –14·2% –9·0%
(130 000 to (4·8 to (161 000 to (4·1 to (150 000 to (3·8 to (147 000 to (3·7 to (–19·6 to (–12·1 to
150 000) 5·5) 189 000) 4·9) 176 000) 4·5) 175 000) 4·4) –7·3) –5·7)
50–69 years 243 000 35·6 394 000 28·6 373 000 26·5 367 000 25·5 –19·6% –10·9%
(224 000 to (32·8 to (367 000 to (26·7 to (345 000 to (24·5 to (335 000 to (23·3 to (–24·8 to (–14·2 to
261 000) 38·2) 421 000) 30·6) 400 000) 28·4) 394 000) 27·4) –13·2) –7·2)
≥70 years 596 000 295·0 1 240 000 266·3 1 140 000 238·5 1 110 000 224·6 –9·7% –15·7%
(542 000 to (268·1 to (1 100 000 to (236·5 to (1 020 000 to (212·1 to (978 000 to (197·8 to (–14·7 to (–18·2 to
642 000) 318·0) 1 330 000) 287·2) 1 230 000) 256·7) 1 200 000) 243·7) –4·5) –12·9)
High SDI
All ages 269 000 30·6 363 000 33·4 332 000 30·4 299 000 27·4 9·2% –18·0%
(244 000 to (27·7 to (308 000 to (28·4 to (284 000 to (26·0 to (252 000 to (23·0 to (2·0 to (–19·2 to
281 000) 32·0) 393 000) 36·1) 359 000) 32·9) 325 000) 29·7) 13·4) –17·0)
<5 years 8370 13·6 1750 3·1 1350 2·5 998 1·9 –76·9% –40·8%
(7650 to 9280) (12·4 to (1640 to (2·9 to (1220 to (2·2 to (898 to (1·7 to (–79·5 to (–45·0 to
15·0) 1870) 3·3) 1470) 2·7) 1080) 2·0) –74·9) –37·1)
5–14 years 1360 1·1 469 0·4 398 0·3 354 0·3 –63·9% –24·9%
(1270 to (1·0 to (448 to (0·4 to (374 to (0·3 to (333 to (0·3 to (–66·5 to (–27·2 to
1460) 1·2) 497) 0·4) 428) 0·4) 381) 0·3) –61·1) –22·8)
15–49 years 10 500 2·3 9230 1·8 8350 1·7 7330 1·5 –19·8% –20·1%
(10 200 to (2·2 to (8760 to (1·7 to (7840 to (1·6 to (6850 to (1·4 to (–24·3 to (–22·3 to
10 700) 2·3) 9810) 1·9) 8970) 1·8) 7910) 1·6) –14·8) –17·6)
50–69 years 31 000 18·9 37 500 13·8 34 300 12·5 31 100 11·3 –27·1% –18·3%
(30 200 to (18·5 to (36 200 to (13·3 to (33 100 to (12·1 to (29 900 to (10·8 to (–28·9 to (–19·8 to
31 600) 19·3) 38 500) 14·2) 35 400) 12·9) 32 200) 11·7) –25·3) –16·7)
≥70 years 218 000 315·2 314 000 231·4 288 000 205·7 260 000 180·9 –26·6% –21·8%
(192 000 to (278·4 to (260 000 to (191·6 to (239 000 to (171·2 to (213 000 to (148·2 to (–31·8 to (–22·9 to
230 000) 332·6) 343 000) 252·8) 313 000) 224·0) 284 000) 198·0) –23·6) –20·8)
High-middle SDI
All ages 248 000 23·3 275 000 21·2 252 000 19·3 242 000 18·5 –9·0% –12·7%
(231 000 to (21·7 to (249 000 to (19·2 to (226 000 to (17·4 to (216 000 to (16·6 to (–17·0 to (–17·4 to
268 000) 25·2) 296 000) 22·8) 272 000) 20·9) 266 000) 20·4) –0·9) –7·3)
<5 years 114 000 122·3 9000 11·8 7190 9·7 6000 8·6 –90·4% –27·0%
(101 000 to (108·3 to (7880 to (10·3 to (6200 to (8·4 to (5050 to (7·2 to (–92·2 to (–31·6 to
131 000) 140·9) 10 300) 13·4) 8300) 11·2) 7020) 10·0) –88·6) –22·7)
5–14 years 5900 3·3 1520 1·0 1280 0·8 1210 0·8 –69·9% –23·5%
(5370 to (3·0 to (1410 to (0·9 to (1180 to (0·7 to (1110 to (0·7 to (–72·9 to (–26·5 to
6460) 3·6) 1700) 1·1) 1440) 0·9) 1380) 0·9) –65·9) –20·8)
15–49 years 17 100 3·0 20 400 3·2 18 400 2·9 17 200 2·7 5·0% –14·0%
(16 000 to (2·8 to (19 600 to (3·1 to (17 600 to (2·8 to (16 200 to (2·6 to (–1·5 to (–19·7 to
18 100) 3·2) 21 300) 3·3) 19 400) 3·1) 18 400) 2·9) 12·6) –7·9)
50–69 years 29 700 17·1 48 000 15·2 44 700 13·9 42 300 13·0 –10·7% –14·8%
(27 800 to (16·0 to (45 700 to (14·5 to (42 300 to (13·2 to (39 600 to (12·1 to (–17·1 to (–19·9 to
31 700) 18·2) 50 500) 16·0) 47 400) 14·8) 45 300) 13·9) –3·7) –8·8)
≥70 years 81 700 158·7 197 000 178·9 180 000 158·7 175 000 149·1 12·7% –16·7%
(73 800 to (143·5 to (171 000 to (156·0 to (156 000 to (137·8 to (151 000 to (128·3 to (4·3 to (–21·6 to
88 600) 172·1) 216 000) 197·0) 198 000) 174·3) 196 000) 167·0) 21·4) –11·0)
(Table 2 continues on next page)

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1990 2019 2020 2021 Mortality rate change, %

Death count Mortality rate Death count Mortality rate Death count Mortality rate Death count Mortality rate 1990–2019 2019–21
per 100 000 per 100 000 per 100 000 per 100 000
population population population population
(Continued from previous page)
Middle SDI
All ages 777 000 45·1 605 000 25·1 548 000 22·5 543 000 22·2 –44·3% –11·7%
(715 000 to (41·5 to (555 000 to (23·0 to (502 000 to (20·6 to (494 000 to (20·2 to (–48·9 to (–16·1 to
840 000) 48·8) 647 000) 26·8) 588 000) 24·2) 589 000) 24·1) –39·2) –7·3)
<5 years 509 000 253·9 90 900 48·5 70 200 38·3 60 400 34·2 –80·9% –29·4%
(457 000 to (227·7 to (78 300 to (41·8 to (59 900 to (32·7 to (50 800 to (28·8 to (–83·8 to (–34·0 to
568 000) 283·2) 106 000) 56·4) 82 000) 44·8) 71 200) 40·3) –77·4) –24·6)
5–14 years 26 300 7·0 9510 2·5 8170 2·1 7660 2·0 –64·3% –21·2%
(22 100 to (5·9 to (8610 to (2·3 to (7440 to (1·9 to (6950 to (1·8 to (–68·2 to (–24·9 to
28 600) 7·6) 10 700) 2·8) 9070) 2·3) 8440) 2·2) –57·6) –17·3)
15–49 years 46 100 5·1 47 000 3·8 42 700 3·4 42 700 3·4 –25·7% –9·5%
(42 500 to (4·7 to (44 800 to (3·6 to (40 500 to (3·2 to (40 000 to (3·2 to (–30·5 to (–14·1 to
48 900) 5·4) 50 000) 4·0) 45 300) 3·6) 45 900) 3·7) –20·1) –4·9)
50–69 years 60 400 31·9 111 000 24·1 105 000 22·3 106 000 21·8 –24·5% –9·5%
(55 100 to (29·1 to (104 000 to (22·5 to (97 800 to (20·6 to (97 300 to (20·0 to (–30·5 to (–14·7 to
65 500) 34·6) 117 000) 25·4) 112 000) 23·7) 114 000) 23·4) –17·2) –4·5)
≥70 years 135 000 295·5 348 000 265·6 321 000 237·0 326 000 231·5 –10·1% –12·9%
(122 000 to (266·1 to (309 000 to (236·1 to (284 000 to (209·5 to (288 000 to (204·3 to (–17·4 to (–17·5 to
149 000) 326·0) 376 000) 287·7) 349 000) 258·0) 358 000) 254·2) –1·8) –7·8)
Low-middle SDI
All ages 954 000 82·1 712 000 37·9 619 000 32·6 594 000 30·9 –53·8% –18·5%
(850 000 to (73·2 to (641 000 to (34·2 to (558 000 to (29·4 to (528 000 to (27·5 to (–59·2 to (–22·8 to
1 070 000) 91·9) 777 000) 41·4) 680 000) 35·8) 657 000) 34·2) –47·8) –13·5)
<5 years 719 000 414·3 263 000 134·3 200 000 103·4 180 000 94·0 –67·6% –30·0%
(626 000 to (360·7 to (222 000 to (113·6 to (168 000 to (86·7 to (148 000 to (77·5 to (–73·0 to (–35·9 to
827 000) 476·8) 307 000) 156·9) 238 000) 122·8) 215 000) 112·4) –61·3) –23·2)
5–14 years 31 500 10·6 17 300 4·5 15 000 3·9 14 200 3·6 –57·6% –18·5%
(26 000 to (8·7 to (15 000 to (3·9 to (12 900 to (3·3 to (12 100 to (3·1 to (–63·5 to (–23·0 to
36 500) 12·2) 19 700) 5·1) 17 100) 4·4) 16 300) 4·2) –49·2) –13·9)
15–49 years 37 200 6·7 50 400 5·1 47 400 4·7 47 200 4·6 –24·4% –9·0%
(33 900 to (6·1 to (45 400 to (4·6 to (42 600 to (4·3 to (41 900 to (4·1 to (–31·0 to (–13·8 to
42 200) 7·7) 56 900) 5·8) 53 600) 5·4) 53 500) 5·3) –15·8) –4·1)
50–69 years 68 000 60·8 123 000 50·8 116 000 46·5 114 000 44·8 –16·5% –11·7%
(60 400 to (54·0 to (110 000 to (45·7 to (103 000 to (41·4 to (100 000 to (39·3 to (–25·4 to (–17·0 to
75 700) 67·6) 135 000) 56·0) 129 000) 51·8) 127 000) 50·0) –4·8) –5·5)
≥70 years 98 100 374·0 259 000 388·4 241 000 352·6 238 000 340·2 3·8% –12·4%
(85 900 to (327·5 to (232 000 to (348·6 to (215 000 to (314·0 to (209 000 to (298·2 to (–8·4 to (–17·3 to
114 000) 435·3) 286 000) 428·5) 268 000) 391·8) 268 000) 382·1) 17·7) –7·2)
Low SDI
All ages 763 000 152·2 591 000 55·4 527 000 48·3 503 000 45·0 –63·6% –18·9%
(644 000 to (128·5 to (512 000 to (48·0 to (452 000 to (41·4 to (430 000 to (38·5 to (–68·8 to (–22·5 to
891 000) 177·7) 681 000) 63·8) 611 000) 56·0) 582 000) 52·1) –57·2) –15·1)
<5 years 593 000 653·5 328 000 202·5 277 000 169·3 254 000 153·2 –69·0% –24·3%
(477 000 to (525·6 to (262 000 to (162·0 to (217 000 to (132·5 to (197 000 to (118·7 to (–74·4 to (–29·4 to
726 000) 800·1) 403 000) 249·0) 346 000) 211·1) 320 000) 193·4) –62·1) –19·3)
5–14 years 23 800 17·3 23 100 8·1 21 200 7·3 20 300 6·9 –53·2% –14·7%
(18 100 to (13·1 to (19 200 to (6·7 to (17 500 to (6·0 to (16 700 to (5·7 to (–60·5 to (–19·2 to
28 600) 20·7) 26 900) 9·4) 24 600) 8·5) 23 900) 8·1) –41·8) –9·7)
15–49 years 29 800 13·5 46 600 9·1 44 900 8·5 45 600 8·4 –32·4% –7·8%
(25 600 to (11·6 to (40 300 to (7·9 to (38 900 to (7·4 to (39 200 to (7·2 to (–40·1 to (–12·3 to
33 700) 15·2) 54 000) 10·6) 52 000) 9·9) 52 700) 9·7) –22·8) –3·3)
50–69 years 53 400 127·2 74 800 85·9 72 600 80·4 72 900 78·5 –32·5% –8·6%
(46 100 to (109·8 to (65 300 to (75·0 to (63 300 to (70·2 to (63 200 to (68·1 to (–39·9 to (–12·9 to
60 500) 144·1) 85 400) 98·1) 83 000) 92·0) 83 500) 90·0) –23·3) –4·4)
≥70 years 62 800 673·0 119 000 567·4 111 000 521·0 110 000 501·7 –15·7% –11·6%
(54 500 to (584·5 to (106 000 to (504·6 to (99 300 to (464·4 to (97 900 to (446·2 to (–24·7 to (–15·9 to
72 200) 773·7) 136 000) 647·7) 126 000) 590·1) 126 000) 572·5) –5·3) –7·4)
(Table 2 continues on next page)

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1990 2019 2020 2021 Mortality rate change, %

Death count Mortality rate Death count Mortality rate Death count Mortality rate Death count Mortality rate 1990–2019 2019–21
per 100 000 per 100 000 per 100 000 per 100 000
population population population population
(Continued from previous page)
Central Europe, Eastern Europe, and Central Asia
All ages 108 000 25·6 102 000 24·3 96 200 23·0 82 800 19·8 –5·3% –18·4%
(104 000 to (24·7 to (96 600 to (23·1 to (91 200 to (21·8 to (77 800 to (18·6 to (–9·8 to (–21·5 to
112 000) 26·7) 106 000) 25·3) 101 000) 24·1) 87 500) 21·0) –0·9) –15·2)
<5 years 63 600 177·0 16 200 59·9 14 500 55·1 11 000 43·0 –66·2% –28·3%
(60 000 to (167·0 to (13 700 to (50·8 to (12 300 to (46·7 to (9240 to (35·9 to (–71·1 to (–32·0 to
67 600) 188·2) 19 000) 70·2) 17 000) 64·5) 13 200) 51·3) –60·2) –24·5)
5–14 years 2640 3·8 1460 2·7 1370 2·5 1190 2·2 –27·5% –20·9%
(2520 to (3·6 to (1330 to (2·5 to (1240 to (2·3 to (1080 to (2·0 to (–33·9 to (–23·3 to
2740) 3·9) 1610) 3·0) 1500) 2·8) 1320) 2·4) –20·0) –18·2)
15–49 years 8800 4·3 14 600 7·3 13 600 6·9 12 200 6·2 70·7% –15·2%
(8620 to (4·2 to (14 100 to (7·0 to (13 000 to (6·6 to (11 300 to (5·7 to (64·2 to (–21·7 to
8980) 4·4) 15 200) 7·6) 14 300) 7·2) 13 300) 6·7) 78·3) –8·5)
50–69 years 13 800 16·5 26 200 26·1 24 700 24·7 21 900 22·0 58·9% –15·8%
(13 500 to (16·1 to (25 400 to (25·4 to (23 700 to (23·7 to (20 600 to (20·6 to (53·7 to (–21·0 to
14 100) 16·8) 27 000) 26·9) 25 700) 25·7) 23 500) 23·5) 64·3) –10·6)
≥70 years 19 200 75·7 43 200 113·8 42 000 107·9 36 400 91·9 50·4% –19·3%
(18 100 to (71·4 to (39 500 to (103·9 to (38 100 to (97·8 to (32 900 to (82·9 to (43·8 to (–21·9 to
19 900) 78·5) 45 300) 119·2) 44 700) 114·7) 38 600) 97·6) 56·0) –16·5)
High-income
All ages 280 000 30·8 400 000 36·8 361 000 33·1 321 000 29·4 19·6% –20·2%
(252 000 to (27·7 to (339 000 to (31·2 to (306 000 to (28·1 to (267 000 to (24·5 to (11·8 to (–21·2 to
293 000) 32·2) 432 000) 39·8) 390 000) 35·8) 348 000) 31·9) 24·2) –19·3)
<5 years 6180 10·0 1640 2·9 1180 2·1 855 1·6 –71·1% –45·8%
(5970 to (9·7 to (1570 to (2·8 to 3·0) (1070 to (1·9 to (760 to (1·4 to (–72·4 to (–51·1 to
6410) 10·4) 1720) 1270) 2·3) 943) 1·7) –69·5) –40·8)
5–14 years 1040 0·8 439 0·4 358 0·3 327 0·3 –56·6% –25·2%
(976 to (0·8 to (427 to (0·3 to (343 to (0·3 to (310 to (0·3 to (–59·2 to (–28·3 to
1100) 0·9) 451) 0·4) 375) 0·3) 343) 0·3) –53·6) –22·5)
15–49 years 9940 2·1 8020 1·6 6950 1·4 6040 1·2 –22·1% –24·3%
(9780 to (2·1 to (7850 to (1·6 to (6710 to (1·4 to (5860 to (1·2 to (–24·1 to (–25·7 to –
10 100) 2·1) 8210) 1·7) 7190) 1·5) 6220) 1·3) –20·1) 22·8)
50–69 years 31 300 17·8 37 200 13·6 33 700 12·2 30 300 10·9 –23·7% –19·8%
(30 500 to (17·4 to (36 000 to (13·2 to (32 600 to (11·8 to (29 200 to (10·5 to (–25·7 to (–20·9 to
31 800) 18·2) 38 200) 14·0) 34 700) 12·6) 31 300) 11·3) –21·7) –18·6)
≥70 years 231 000 304·4 352 000 241·2 318 000 212·3 283 000 184·9 –20·8% –23·4%
(204 000 to (268·8 to (292 000 to (199·9 to (264 000 to (176·1 to (231 000 to (150·5 to (–26·1 to (–24·3 to
244 000) 321·5) 384 000) 263·2) 347 000) 231·3) 310 000) 202·3) –17·7) –22·5)
Latin America and Caribbean
All ages 166 000 42·6 215 000 36·7 187 000 31·7 177 000 29·8 –13·9% –18·9%
(158 000 to (40·6 to (195 000 to (33·2 to (169 000 to (28·7 to (157 000 to (26·5 to (–21·0 to (–22·5 to
174 000) 44·7) 228 000) 39·0) 200 000) 33·9) 194 000) 32·6) –8·2) –14·8)
<5 years 89 000 179·7 20 100 41·2 14 400 30·0 12 200 25·7 –77·0% –37·6%
(82 600 to (166·8 to (16 400 to (33·8 to (11 700 to (24·5 to (9570 to (20·2 to (–81·2 to (–44·2 to
95 800) 193·6) 23 800) 48·8) 17 400) 36·1) 15 200) 32·1) –72·7) –30·5)
5–14 years 4890 5·2 2250 2·4 1820 1·9 1620 1·7 –54·4% –28·0%
(4640 to 5130) (4·9 to (2010 to (2·1 to (1630 to (1·7 to (1430 to (1·5 to (–59·2 to (–33·8 to
5·4) 2500) 2·6) 2030) 2·1) 1850) 1·9) –49·5) –22·1)
15–49 years 13 000 6·6 18 000 5·8 16 000 5·1 15 500 5·0 –11·7% –14·5%
(12 600 to (6·4 to (17 300 to (5·6 to (15 100 to (4·9 to (14 500 to (4·6 to (–15·6 to (–18·9 to
13 400) 6·8) 18 800) 6·1) 16 900) 5·4) 16 900) 5·4) –7·5) –9·8)
50–69 years 16 000 42·0 38 400 38·5 36 200 35·4 35 400 33·9 –8·2% –12·1%
(15 400 to (40·5 to (36 600 to (36·8 to (34 400 to (33·6 to (32 800 to (31·4 to (–12·4 to (–16·7 to
16 500) 43·5) 39 900) 40·1) 38 300) 37·4) 38 400) 36·7) –4·1) –7·1)
≥70 years 43 500 398·9 136 000 417·6 119 000 353·3 112 000 325·1 4·7% –22·1%
(40 100 to (367·7 to (119 000 to (363·7 to (103 000 to (306·4 to (96 000 to (278·3 to (–1·5 to (–25·8 to
45 600) 417·9) 146 000) 446·6) 128 000) 379·4) 123 000) 356·4) 9·3) –18·3)
(Table 2 continues on next page)

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1990 2019 2020 2021 Mortality rate change, %

Death count Mortality rate Death count Mortality rate Death count Mortality rate Death count Mortality rate 1990–2019 2019–21
per 100 000 per 100 000 per 100 000 per 100 000
population population population population
(Continued from previous page)
North Africa and Middle East
All ages 181 000 53·3 113 000 18·7 103 000 16·8 92 200 14·8 –64·9% –20·9%
(159 000 to (46·8 to (102 000 to (16·8 to (91 000 to (14·8 to (81 400 to (13·1 to (–70·7 to (–24·8 to
218 000) 64·2) 126 000) 20·7) 116 000) 18·9) 105 000) 16·8) –60·0) –16·5)
<5 years 138 000 270·2 32 700 51·4 25 900 41·4 20 200 33·1 –81·0% –35·6%
(118 000 to (230·0 to (26 900 to (42·2 to (21 000 to (33·6 to (16 600 to (27·1 to (–84·8 to (–41·6 to
176 000) 343·4) 39 900) 62·7) 31 300) 50·1) 24 600) 40·3) –77·0) –28·8)
5–14 years 7290 8·2 3610 3·0 3200 2·7 2880 2·4 –62·7% –22·8%
(6190 to (6·9 to (3010 to (2·5 to (2660 to (2·2 to (2350 to (1·9 to (–70·0 to (–27·8 to
8320) 9·3) 4380) 3·7) 3900) 3·2) 3550) 2·9) –55·2) –17·8)
15–49 years 7660 4·8 11 800 3·6 11 100 3·4 10 500 3·1 –24·4% –13·4%
(6870 to (4·3 to (10 400 to (3·2 to (9600 to (2·9 to (8980 to (2·7 to (–32·7 to (–18·2 to
8970) 5·6) 13 300) 4·1) 12 800) 3·9) 12 200) 3·6) –15·3) –8·6)
50–69 years 9840 31·5 18 700 23·6 18 300 22·3 17 600 20·7 –25·0% –12·5%
(8750 to (28·0 to (16 600 to (21·0 to (16 000 to (19·5 to (15 100 to (17·7 to (–34·0 to (–18·9 to
11 400) 36·6) 20 800) 26·4) 20 700) 25·3) 20 500) 24·1) –15·6) –6·1)
≥70 years 17 600 243·0 46 600 241·9 44 600 224·8 41 000 201·6 –0·5% –16·6%
(15 300 to (211·8 to (40 300 to (209·1 to (38 400 to (193·8 to (35 300 to (173·4 to (–15·0 to (–20·3 to
21 400) 296·3) 51 500) 267·6) 50 200) 253·1) 46 200) 227·0) 11·3) –12·6)
South Asia
All ages 802 000 73·3 609 000 33·7 522 000 28·5 516 000 27·9 –54·1% –17·1%
(696 000 to (63·7 to (548 000 to (30·3 to (465 000 to (25·4 to (451 000 to (24·4 to (–60·3 to (–24·2 to
902 000) 82·5) 674 000) 37·3) 582 000) 31·8) 584 000) 31·6) –46·5) –9·2)
<5 years 610 000 388·6 229 000 140·6 167 000 103·6 154 000 97·3 –63·8% –30·8%
(516 000 to (328·5 to (191 000 to (117·4 to (135 000 to (84·2 to (124 000 to (78·5 to (–70·8 to (–39·5 to
707 000) 450·2) 273 000) 167·3) 202 000) 125·9) 190 000) 119·7) –54·9) –20·1)
5–14 years 27 900 10·1 13 000 3·7 10 800 3·1 10 200 2·9 –63·4% –20·4%
(21 800 to (7·9 to (10 800 to (3·1 to (8890 to (2·5 to (8360 to (2·4 to (–69·9 to (–27·6 to
33 400) 12·1) 15 300) 4·4) 12 800) 3·6) 12 100) 3·5) –53·9) –12·6)
15–49 years 27 200 5·1 31 300 3·2 30 000 3·0 30 800 3·1 –37·7% –4·5%
(24 300 to (4·6 to (28 100 to (2·9 to (26 500 to (2·7 to (26 600 to (2·6 to (–44·2 to (–14·4 to
32 700) 6·2) 37 600) 3·8) 35 800) 3·6) 37 100) 3·7) –29·7) 6·2)
50–69 years 58 900 54·8 108 000 44·1 101 000 39·9 101 000 38·9 –19·6% –11·8%
(51 000 to (47·5 to (95 200 to (38·8 to (88 600 to (35·0 to (86 800 to (33·4 to (–29·5 to (–21·0 to
68 000) 63·3) 122 000) 49·7) 116 000) 45·9) 117 000) 45·2) –6·7) –1·5)
≥70 years 77 600 330·4 227 000 329·4 213 000 300·7 219 000 299·7 –0·3% –9·0%
(64 200 to (273·4 to (199 000 to (288·5 to (186 000 to (262·1 to (187 000 to (255·5 to (–14·1 to (–17·2 to
93 800) 399·3) 257 000) 372·3) 244 000) 344·2) 257 000) 350·5) 18·0) –0·4)
Southeast Asia, East Asia, and Oceania
All ages 734 000 43·5 455 000 21·1 424 000 19·5 431 000 19·7 –51·5% –6·2%
(666 000 to (39·4 to (410 000 to (19·0 to (378 000 to (17·4 to (384 000 to (17·6 to (–56·9 to (–13·6 to
809 000) 47·9) 499 000) 23·1) 469 000) 21·6) 482 000) 22·0) –45·6) 2·1)
<5 years 486 000 277·7 57 700 38·5 48 700 33·4 41 700 30·1 –86·1% –21·8%
(426 000 to (243·2 to (48 400 to (32·3 to (40 900 to (28·1 to (34 400 to (24·9 to (–88·5 to (–26·1 to
557 000) 318·4) 68 100) 45·5) 57 400) 39·5) 49 200) 35·6) –83·2) –17·0)
5–14 years 23 400 7·1 5790 2·0 5070 1·7 4810 1·6 –72·4% –20·3%
(19 000 to (5·8 to (5130 to (1·7 to (4530 to (1·5 to (4220 to (1·4 to (–76·3 to (–24·1 to
26 000) 7·9) 6860) 2·3) 5970) 2·0) 5640) 1·8) –64·5) –15·9)
15–49 years 36 000 3·9 26 200 2·4 23 900 2·2 23 500 2·2 –37·5% –9·1%
(31 700 to (3·4 to (24 100 to (2·2 to (21 700 to (2·0 to (21 000 to (2·0 to (–45·0 to (–17·0 to
39 600) 4·3) 29 300) 2·7) 26 800) 2·5) 26 200) 2·5) –28·8) –0·5)
50–69 years 55 200 26·6 72 600 14·7 69 500 13·7 69 800 13·4 –44·7% –8·6%
(48 400 to (23·3 to (65 700 to (13·3 to (62 700 to (12·3 to (62 000 to (11·9 to (–51·9 to (–17·3 to
61 800) 29·8) 79 600) 16·1) 76 500) 15·1) 77 700) 15·0) –36·3) 1·4)
≥70 years 134 000 267·5 293 000 208·4 276 000 188·9 292 000 189·5 –22·1% –9·1%
(116 000 to (232·5 to (257 000 to (182·3 to (239 000 to (163·6 to (252 000 to (163·6 to (–30·8 to (–17·0 to
150 000) 300·6) 327 000) 232·3) 309 000) 211·5) 331 000) 214·7) –12·0) 0·1)
(Table 2 continues on next page)

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1990 2019 2020 2021 Mortality rate change, %

Death count Mortality rate Death count Mortality rate Death count Mortality rate Death count Mortality rate 1990–2019 2019–21
per 100 000 per 100 000 per 100 000 per 100 000
population population population population
(Continued from previous page)
Sub-Saharan Africa
All ages 742 000 151·1 655 000 60·7 588 000 53·1 563 000 49·7 –59·8% –18·2%
(629 000 to (127·9 to (557 000 to (51·6 to (494 000 to (44·6 to (472 000 to (41·6 to (–65·1 to (–21·9 to
875 000) 178·0) 757 000) 70·1) 686 000) 62·0) 655 000) 57·8) –53·2) –14·1)
<5 years 551 000 614·5 335 000 197·9 285 000 166·6 261 000 151·2 –67·8% –23·6%
(443 000 to (494·0 to (261 000 to (153·7 to (217 000 to (126·7 to (197 000 to (113·9 to (–73·4 to (–28·6 to
683 000) 761·5) 418 000) 246·8) 361 000) 211·0) 334 000) 193·4) –60·8) –18·3)
5–14 years 21 900 16·2 25 400 8·7 23 500 7·9 22 700 7·5 –46·3% –14·2%
(17 000 to (12·6 to (20 700 to (7·1 to (18 900 to (6·4 to (18 100 to (6·0 to (–54·5 to (–19·0 to
26 300) 19·5) 30 100) 10·3) 27 800) 9·4) 27 100) 8·9) –33·2) –8·6)
15–49 years 38 100 17·4 63 800 12·4 60 400 11·4 61 500 11·3 –28·8% –9·2%
(33 000 to (15·0 to (55 200 to (10·7 to (52 000 to (9·8 to (53 200 to (9·7 to (–36·6 to (–13·9 to
42 300) 19·3) 73 300) 14·2) 69 700) 13·1) 71 000) 13·0) –18·8) –3·9)
50–69 years 57 700 150·0 92 600 109·2 89 600 102·1 90 600 100·1 –27·2% –8·4%
(50 100 to (130·3 to (81 100 to (95·7 to (78 200 to (89·1 to (78 900 to (87·2 to (–35·0 to (–12·6 to
65 400) 169·8) 105 000) 123·8) 102 000) 115·7) 103 000) 113·7) –16·6) –3·9)
≥70 years 73 300 793·6 138 000 732·9 129 000 668·2 127 000 646·4 –7·6% –11·8%
(64 500 to (698·0 to (124 000 to (656·0 to (115 000 to (595·9 to (113 000 to (576·2 to (–16·2 to (–15·7 to
83 000) 898·2) 155 000) 820·7) 143 000) 742·1) 141 000) 718·2) 2·8) –7·6)

Values in parentheses are 95% uncertainty intervals. Count data are presented to three significant figures. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. SDI=Socio-demographic Index.

Table 2: Lower respiratory infection mortality counts and rates for all-ages and selected age groups in 1990, 2019, 2020, and 2021, and mortality rate percentage change from
1990 to 2019 and from 2019 to 2021, globally and by SDI quintile and GBD super-region

357·9 deaths (271·4–456·4) per 100 000 in Chad (48·8–60·5) to 25·7 deaths (22·5–28·3) per 100 000
(appendix 2 p 86). Across the aggregated age groups, (igure 2). Analogous to incidence, the decline in mortality
adults aged 70 years and older had the highest global was largely attributable to reductions in deaths among
mortality rate (224·6 deaths [197·8–243·7] per 100 000), children; LRI mortality rate decreased by 75·6%
followed by children younger than 5 years (table 2). (70·7–79·8) in children younger than 5 years and 59·2%
LRI fatalities in 2021, especially among children, were (52·7–64·2) in children aged 5–14 years (igure 2). Adults
concentrated in countries with a low Socio-demographic aged 70 years and older had the smallest decrease in LRI
Index (SDI; appendix 2 p 5).38 Of 204 modelled countries mortality rate, with a 23·8% (18·7–28·7) decline (igure 2).
and territories, 57 had an LRI mortality rate greater More detailed results on LRI incidence and mortality for
than 60 per 100 000 among children younger than 5 years additional age groups by sex, country, and year are
in 2021 (appendix 2 p 86). In 2021, among children available online via the GBD Results Tool on the GHDx.
younger than 5 years, mortality rates per 100 000 population
were 153·2 deaths (118·7–193·4) in low SDI countries, Aetiologies of LRIs
94·0 (77·5–112·4) in low-middle SDI countries, 34·2 In 2021, the pathogen responsible for the largest
(28·8–40·3) in middle SDI countries, 8·6 (7·2–10·0) in proportion of LRI incident episodes globally was
high-middle SDI countries, and 1·9 (1·7–2·0) in high S pneumoniae, which caused an estimated 97·9 million
SDI countries (table 2). In total, 254 000 LRI deaths (95% UI 92·1–104·0) episodes (igures 3, 4; appendix 2
(197 000–320 000) in children younger than 5 years p 2104). This was followed by the categories of other
occurred in low SDI countries (table 2). However, viruses (ie, the aggregate of all viruses studied except
although the low SDI quintile had the highest burden in inluenza and RSV; 46·4 million [43·6–49·3] episodes)
2021, these countries also showed the greatest and Mycoplasma spp (25·3 million [23·5–27·2] episodes;
improvement in all-age mortality rates over time (table 2). igures 3, 4; appendix 2 p 2104). Key pathogens varied by
Globally, between 1990 and 2021, the all-age LRI age and geography. S pneumoniae was responsible for the
mortality rate decreased by 50·9% (95% UI 45·6–55·9), largest number of episodes in 165 of the 204 modelled
from 56·5 deaths (51·3–61·9) to 27·7 deaths (25·1–29·9) countries and territories in 2021, while the category of
per 100 000 population (igure 2). For males, it decreased other viruses was responsible for the largest number of
by 49·4% (44·0–54·4), from 58·6 deaths (53·0–64·6) to episodes in 39 countries (appendix 2 p 156). For all ive
29·6 deaths (27·2–32·1) per 100 000. For females, it studied age subdivisions, S pneumoniae caused the most
decreased by 52·7% (46·3–58·6), from 54·4 deaths episodes (igure 3; appendix 2 p 2104).

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<5 years 5–14 years 15–49 years 50–69 years ≥70 years All ages
400
Deaths per 100000 population

300

200

100
Male
Female
All
0

3000000

2000000
Death count

1000000

0
1990 2000 2010 2020 1990 2000 2010 2020 1990 2000 2010 2020 1990 2000 2010 2020 1990 2000 2010 2020 1990 2000 2010 2020
Year Year Year Year Year Year

Figure 2: LRI mortality rates and death counts by age and sex, 1990–2021
Upper graphs show mortality rates per 100 000 population. Lower graphs show death counts. Shaded areas represent 95% uncertainty intervals. LRI=lower respiratory infection.

Pathogen
Streptococcus pneumoniae Chlamydia spp Haemophilus influenzae Acinetobacter baumannii Respiratory syncytial virus
Other viruses* Klebsiella pneumoniae Mycoplasma spp Group B streptococcus Polymicrobial
Other bacterial pathogen Pseudomonas aeruginosa Escherichia coli Fungus
Staphylococcus aureus Influenza Legionella spp Enterobacter spp

≥70

50−69
Age group (years)

15–49

5–14

<5

0 25 000 000 50 000 000 75 000 000 0 300 000 600 000 900 000
Number of cases Number of deaths

Figure 3: Aetiology distribution of global LRI cases and deaths by age group, 2021
LRI=lower respiratory infection. *“Other viruses” represents the aggregate of all viruses studied except influenza and respiratory syncytial virus.

In 2019, before the COVID-19 pandemic and the was inluenza, responsible for 36·4 million (95% UI
decline in observed incidence of inluenza and RSV, 34·2–38·7) episodes globally (igure 4). S pneumoniae
the irst and second most common aetiologies were the was responsible for the most LRI episodes in all ive age
same as for 2021, but the third most common aetiology groups in 2019, and was followed by the category of

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A Cases
1990 2019 2020 2021

1 S pneumoniae 112 (104–120) 1 S pneumoniae 96·9 (91·3–103) 1 S pneumoniae 96·0 (90·8–101) 1 S pneumoniae 97·9 (92·1–104)

2 Other viruses* 38·4 (35·5–41·7) 2 Other viruses* 46·1 (43·6–49·0) 2 Other viruses* 45·8 (43·2–48·7) 2 Other viruses* 46·4 (43·6–49·3)

3 Influenza 21·0 (19·4–22·7) 3 Influenza 36·4 (34·2–38·7) 3 Mycoplasma spp 24·9 (23·1–26·6) 3 Mycoplasma spp 25·3 (23·5–27·2)

4 Chlamydia spp 20·2 (18·1–22·5) 4 Mycoplasma spp 25·1 (23·3–27·0) 4 S aureus 23·8 (22·3–25·3) 4 S aureus 24·3 (22·7–25·9)

5 Mycoplasma spp 20·1 (18·2–22·1) 5 S aureus 23·9 (22·3–25·5) 5 Other bacterial pathogen 23·0 (20·9–25·1) 5 Other bacterial pathogen 23·7 (21·5–26·0)

6 Other bacterial pathogen 17·2 (15·7–18·9) 6 Other bacterial pathogen 23·2 (21·2–25·4) 6 Chlamydia spp 18·9 (17·4–20·7) 6 Chlamydia spp 19·4 (17·7–21·2)

7 H influenzae 16·1 (14·4–18·0) 7 Chlamydia spp 19·1 (17·5–20·8) 7 Influenza 17·8 (14·8–21·1) 7 H influenzae 18·1 (16·7–19·6)

8 K pneumoniae 13·0 (11·9–14·2) 8 H influenzae 17·9 (16·4–19·3) 8 H influenzae 17·7 (16·4–19·1) 8 K pneumoniae 15·5 (14·4–16·8)

9 S aureus 11·8 (11·0–12·7) 9 K pneumoniae 15·3 (14·2–16·4) 9 K pneumoniae 15·2 (14·1–16·3) 9 Influenza 14·4 (9·81–19·4)

10 Respiratory syncytial virus 10·6 (9·55–11·9) 10 P aeruginosa 13·7 (12·7–14·7) 10 P aeruginosa 13·6 (12·7–14·5) 10 P aeruginosa 13·9 (12·9–14·9)

11 A baumannii 8·31 (7·14–9·66) 11 Respiratory syncytial virus 12·5 (11·5–13·7) 11 Legionella spp 8·76 (8·03–9·58) 11 Legionella spp 8·96 (8·18–9·79)

12 P aeruginosa 6·54 (5·98–7·17) 12 Legionella spp 8·82 (8·09–9·62) 12 A baumannii 7·63 (6·67–8·73) 12 A baumannii 7·88 (6·87–9·08)

13 E coli 4·93 (4·31–5·59) 13 A baumannii 7·71 (6·74–8·84) 13 E coli 7·57 (6·86–8·31) 13 E coli 7·76 (7·03–8·56)

14 Legionella spp 4·13 (3·64–4·71) 14 E coli 7·61 (6·91–8·41) 14 Respiratory syncytial virus 6·15 (5·18–7·19) 14 Group B streptococcus 6·08 (5·54–6·70)

15 Group B streptococcus 3·85 (3·39–4·39) 15 Group B streptococcus 5·98 (5·45–6·61) 15 Group B streptococcus 5·94 (5·44–6·55) 15 Fungus 5·62 (4·93–6·40)

16 Fungus 3·57 (3·01–4·20) 16 Fungus 5·51 (4·81–6·29) 16 Fungus 5·47 (4·80–6·22) 16 Respiratory syncytial virus 4·59 (3·32–6·02)

17 Enterobacter spp 1·25 (1·03–1·51) 17 Enterobacter spp 2·36 (2·05–2·72) 17 Enterobacter spp 2·35 (2·04–2·71) 17 Enterobacter spp 2·40 (2·08–2·78)

18 Polymicrobial 0·942 (0·704–1·27) 18 Polymicrobial 1·19 (0·833–1·70) 18 Polymicrobial 1·18 (0·833–1·69) 18 Polymicrobial 1·21 (0·849–1·73)

B Deaths
1990 2019 2020 2021
1 S pneumoniae 1·03 (0·924–1·16) 1 S pneumoniae 0·528 (0·478–0·574) 1 S pneumoniae 0·510 (0·459–0·559) 1 S pneumoniae 0·505 (0·454–0·555)

2 Influenza 0·274 (0·246–0·304) 2 S aureus 0·425 (0·385–0·457) 2 S aureus 0·421 (0·379–0·456) 2 S aureus 0·424 (0·380–0·459)

3 S aureus 0·253 (0·231–0·275) 3 Influenza 0·349 (0·318–0·377) 3 K pneumoniae 0·177 (0·160–0·195) 3 K pneumoniae 0·176 (0·158–0·194)

4 K pneumoniae 0·239 (0·213–0·268) 4 K pneumoniae 0·182 (0·165–0·199) 4 Influenza 0·174 (0·153–0·197) 4 Other bacterial pathogen 0·140 (0·123–0·156)

5 Other viruses* 0·181 (0·162–0·204) 5 Other bacterial pathogen 0·139 (0·122–0·154) 5 Other bacterial pathogen 0·139 (0·122–0·154) 5 P aeruginosa 0·124 (0·111–0·134)

6 Respiratory syncytial virus 0·140 (0·123–0·159) 6 Other viruses* 0·128 (0·116–0·140) 6 P aeruginosa 0·123 (0·112–0·134) 6 Other viruses* 0·121 (0·109–0·133)

7 H influenzae 0·133 (0·114–0·155) 7 P aeruginosa 0·125 (0·114–0·135) 7 Other viruses* 0·122 (0·110–0·135) 7 E coli 0·100 (0·0890–0·112)

8 Other bacterial pathogen 0·119 (0·106–0·133) 8 E coli 0·103 (0·0918–0·114) 8 E coli 0·101 (0·0897–0·112) 8 Influenza 0·0982 (0·0743–0·126)

9 A baumannii 0·104 (0·0849–0·130) 9 Respiratory syncytial virus 0·0949 (0·0822–0·109) 9 A baumannii 0·0760 (0·0651–0·0891) 9 A baumannii 0·0757 (0·0649–0·0883)

10 E coli 0·0959 (0·0829–0·110) 10 A baumannii 0·0766 (0·0659–0·0895) 10 Legionella spp 0·0673 (0·0597–0·0737) 10 Legionella spp 0·0682 (0·0604–0·0748)

11 Chlamydia spp 0·0912 (0·0797–0·103) 11 Legionella spp 0·0675 (0·0604–0·0735) 11 Mycoplasma spp 0·0592 (0·0525–0·0654) 11 Mycoplasma spp 0·0584 (0·0518–0·0649)

12 P aeruginosa 0·0891 (0·0809–0·0984) 12 Mycoplasma spp 0·0613 (0·0549–0·0676) 12 H influenzae 0·0576 (0·0509–0·0640) 12 H influenzae 0·0568 (0·0501–0·0634)

13 Mycoplasma spp 0·0743 (0·0654–0·0850) 13 H influenzae 0·0598 (0·0532–0·0662) 13 Group B streptococcus 0·0554 (0·0491–0·0619) 13 Group B streptococcus 0·0547 (0·0486–0·0611)

14 Group B streptococcus 0·0649 (0·0557–0·0748) 14 Group B streptococcus 0·0569 (0·0508–0·0634) 14 Chlamydia spp 0·0549 (0·0485–0·0614) 14 Chlamydia spp 0·0540 (0·0476–0·0605)

15 Legionella spp 0·0422 (0·0358–0·0505) 15 Chlamydia spp 0·0564 (0·0502–0·0627) 15 Respiratory syncytial virus 0·0464 (0·0382–0·0558) 15 Fungus 0·0456 (0·0397–0·0519)

16 Fungus 0·0304 (0·0253–0·0360) 16 Fungus 0·0452 (0·0395–0·0514) 16 Fungus 0·0452 (0·0394–0·0515) 16 Respiratory syncytial virus 0·0315 (0·0233–0·0416)

17 Polymicrobial 0·0292 (0·0191–0·0433) 17 Enterobacter spp 0·0301 (0·0258–0·0344) 17 Enterobacter spp 0·0296 (0·0253–0·0340) 17 Enterobacter spp 0·0296 (0·0251–0·0340)

18 Enterobacter spp 0·0238 (0·0184–0·0316) 18 Polymicrobial 0·0210 (0·0149–0·0291) 18 Polymicrobial 0·0203 (0·0143–0·0280) 18 Polymicrobial 0·0198 (0·0140–0·0275)

Figure 4: Ranked aetiologies by number of global cases and deaths across all ages, 1990, 2019, 2020, and 2021
Values are estimated millions of cases (A) or deaths (B) caused by each pathogen, with 95% uncertainty intervals in parentheses. Estimates are presented to three significant figures.
A baumannii=Acinetobacter baumannii. E coli=Escherichia coli. H influenzae=Haemophilus influenzae. K pneumoniae=Klebsiella pneumoniae. P aeruginosa=Pseudomonas aeruginosa. S aureus=Staphylococcus
aureus. S pneumoniae=Streptococcus pneumoniae. *“Other viruses” represents the aggregate of all viruses studied except influenza and respiratory syncytial virus.

other viruses in all age groups except 70 years and older, children younger than 5 years, Mycoplasma spp in
in which inluenza ranked second highest (appendix 2 children aged 5–14 years and people aged 15–49 years,
p 2104). The third most common aetiology was other and inluenza in people aged 50–69 years (appendix 2
viruses in people aged 70 years and older, RSV in p 1971).

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In 2021, the pathogen responsible for the largest Similarly, since 2019, we estimated that global RSV
proportion of all-age LRI deaths globally was also episodes declined by 63·2% (53·1–72·7) to reach
S pneumoniae, which led to an estimated 505 000 deaths 4·59 million (3·32–6·02) in 2021, with a similar decrease
(95% UI 454 000–555 000; igure 4; appendix 2 p 2107). in RSV deaths (66·7% [56·6–75·3]), to 31 500
This was followed by S aureus (424 000 deaths (23 300–41 600) in 2021 (igure 4; appendix 2 p 1951).
[380 000–459 000]) and K pneumoniae (176 000 deaths Overall, for non-COVID-19 LRIs from 2019 to 2021, we
[158 000–194 000]; igure 4; appendix 2 p 2104). In 2019, estimated an 8·6% (6·6–10·4) decline in the overall
before COVID-19 impacted the transmission of inluenza incidence rate, from 4770 episodes (4510–5040) to
and RSV, the irst and second most common aetiologies 4350 episodes (4120–4610) per 100 000 population (from
leading to LRI death were the same as in 2021, but the 369 million [349–391] to 344 million [325–364] total
third most common aetiology was inluenza, which led to episodes), and a 16·0% (13·1–18·6) decline in mortality
349 000 deaths (318 000–377 000) globally (igure 4). Across rate, from 32·9 deaths (29·9–35·4) to 27·7 deaths
age groups, in both 2019 and 2021, S pneumoniae was (25·1–29·9) per 100 000 (table 2).
responsible for the most LRI deaths in people younger
than 70 years, whereas S aureus caused the most deaths in Discussion
people aged 70 years and older (igure 3; appendix 2 This study provides comprehensive global, regional, and
p 2104). In 2019, the second largest number of deaths national estimates of LRI episodes and deaths attributable
came from S aureus in all age groups except children to 18 pathogen categories, by age group, from 1990 until
younger than 5 years, for whom the second-ranked 2021. These estimates are inclusive of the reduction in
aetiology was RSV, and people aged 70 years and older, for transmission of certain respiratory viruses observed
whom the second-ranked aetiology was S pneumoniae. during the COVID-19 pandemic and implementation
The third most common aetiology leading to death was of non-pharmaceutical interventions. We estimated
inluenza for all ive age groups (appendix 2 p 1971). In 344 million (95% UI 325–364) incident episodes of LRIs
2021, S pneumoniae was responsible for the highest and 2·18 million (1·98–2·36) deaths worldwide in 2021.
number of deaths in 103 of 204 modelled countries and S pneumoniae was responsible for the highest proportion
territories, whereas S aureus was responsible for the most of both incidence and mortality in all ages, followed by
deaths in the remaining 101 countries. These diferences the category of other viral aetiologies and Mycoplasma spp
were largely attributable to diferences in age structures for incidence, and S aureus and K pneumoniae for
across countries (appendix 2 p 156). mortality. Between 2019 and 2021, during the COVID-19
From 1990 to 2019, H influenzae had the largest pandemic, we estimated substantial declines in global
reduction in global mortality (a 54·8% decrease [95% UI inluenza incidence and RSV incidence.
48·8–60·6] to 59 800 deaths [53 200–66 200]), followed by Although LRIs are ubiquitous across the world, the
S pneumoniae (48·5% decrease [42·8–53·9]; appendix 2 burden disproportionately falls on people living in
p 1971). Most of this improvement for both pathogens was poverty.39 In 2013, WHO and UNICEF formulated the
in children younger than 5 years, with a 77·4% (72·9–81·2) Global Action Plan for the Prevention and Control of
decline in deaths due to H influenzae (from 102 000 Pneumonia and Diarrhea (GAPPD), with the ambitious
[83 800–123 000] to 23 000 [18 600–27 700]) and a 76·1% goal to end preventable childhood pneumonia and
(71·4–79·7) decline in deaths due to S pneumoniae (from diarrhoea deaths by 2025.40 A speciic target for 2025 is to
721 000 [621 000–843 000] to 172 000 [142 000–205 000]) reduce mortality from pneumonia in children younger
during this period (appendix 2 p 1971). than 5 years to fewer than 3 deaths per 1000 livebirths,
roughly equivalent to a mortality rate of less than
COVID-19 impact 60 deaths per 100 000 people per year among children
Following the onset of the COVID-19 pandemic, we younger than 5 years. As of 2021, we estimated a global
estimated that from 2019 to 2021, the number of LRI mortality rate of 76·2 deaths (61·7–92·9) per
inluenza episodes decreased by 60·3% (95% UI 100 000 children in this age group, and that 57 countries
47·1–72·9) to 14·4 million (9·81–19·4) episodes, and and territories, all but one of which were low-income and
deaths decreased by 71·8% (63·8–78·9) to 98 200 middle-income countries (LMICs), had a mortality rate
(74 300–126 000; appendix 2 p 1951). Across 18 modelled over the global benchmark of 60 deaths per 100 000. To
pathogen categories, inluenza fell from being the third reduce mortality, the action plan calls for promotion of
leading cause of both LRI episodes and deaths globally in exclusive breastfeeding in infants younger than
2019, to the ninth leading cause of episodes and the 6 months, reduction of indoor air pollution, expanded
eighth leading cause of deaths in 2021 (igure 4). The access to health care, and ongoing pneumonia case
high-income super-region saw the largest decrease in management in LMICs—approaches that have
inluenza episodes from 2019 to 2021 (91·5% historically driven progress towards reducing LRI child
[86·6–94·7]), and south Asia had the smallest decrease in mortality.41,42
inluenza episodes in that same time frame (44·0% The WHO and UNICEF GAPPD also calls for increased
[14·6–71·8]; appendix 2 p 1951). coverage of pneumococcal conjugate vaccines (PCVs)

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and Hib vaccines. From 1990 to 2019, H influenzae antibodies (mAbs) was a priority for WHO’s Vaccine
showed the largest decline in global deaths, followed by Product and Delivery Research Unit and an active area of
S pneumoniae, both largely attributable to vaccination. research.62,63 These eforts came to fruition in 2023, when
Between 2000 and 2015, use of the Hib vaccine prevented two vaccines for RSV were approved in the EU and the
an estimated 1·2 million deaths due to H influenzae USA.64–67 Both are for use in adults aged 60 years and
infection globally, and PCV prevented an estimated older, and one is also approved for pregnant women to
250 000 deaths due to pneumococcal infection.8 However, protect their infants. In addition, a new long-acting mAb
global coverage of these vaccines shows substantial room injection, nirsevimab, was approved in 2022 in the EU
for improvement. According to WHO–UNICEF and in 2023 in the USA to prevent RSV hospitalisation in
estimates of national immunisation coverage, global both healthy and high-risk infants.68,69 Generally, mAbs,
inal-dose coverage of PCV among 1-year-olds was 60% including the long-approved, short-acting, RSV-
and Hib coverage was 76% in 2022, both of which are preventive palivizumab, are too costly for use in most
above 2019 levels, suggesting recovery from pandemic LMICs.70 The afordability of long-acting mAbs for LMICs
immunisation disruptions.42–44 Although these global is not yet known; preliminary cost-efectiveness analyses
increases are promising, they can mask substantial suggest a beneit, but this cost-efectiveness will depend
inequities, and many vulnerable communities remain on multiple factors, including pricing.62,70–72 These long-
without access to vaccination.44–46 Strategies described by acting mAbs and RSV vaccines, available for the irst
the WHO Immunization Agenda 2030 to increase time, have the potential to avert unprecedented numbers
coverage—including focusing on children who have not of RSV cases and deaths in the 2023–24 respiratory
received any routine immunisations, building trust to infection season and beyond. A 2023 modelling study
avert vaccine hesitancy, and increasing vaccine access forecasts that with 60% vaccine coverage, in the USA
across the lifespan—can help reduce pneumonia alone, up to 2·0 million symptomatic RSV respiratory
mortality in areas with the highest burden.46–49 infections could be averted per year in adults older than
The age groups of children younger than 5 years and 60 years, plus another 690 000 infections in the non-
adults aged 70 years and older had the highest LRI vaccinated population through indirect efects.73
mortality rates in 1990. Time trends showed a steep However, these beneits will only reach locations where
decline in mortality in children younger than 5 years patients can access the vaccines. For the full global
between 1990 and 2021, whereas no substantial decrease beneit of these preventives to be realised, equitable
was observed in adults aged 70 years and older (igure 2). distribution is essential. It will be crucial for pharma-
This trend holds true for the more granular age groups of ceutical companies, non-governmental organisations,
70–74 years and 75–79 years (appendix 2 p 4). Decline in and governments to work together to reduce barriers to
immune function with ageing, called immuno- access in LMICs.74
senescence, promotes susceptibility to LRIs, as do age- We have quantiied the global burden of LRI
related organ system changes and the development of attributable to S aureus in all ages and, for the irst time
comorbid conditions.50,51 Inluenza and pneumococcal in a comprehensive global study, we have identiied the
vaccination remain efective tools to address LRIs in pathogen as the second-leading cause of LRI mortality
older adults.7 Pneumococcal immunisation of infant after S pneumoniae in 2021. Although S aureus is a less
populations provides some herd protection for older frequent cause of LRI cases than S pneumoniae, it has a
adults.52,53 In addition, pneumococcal vaccine higher incidence of complications and a higher CFR. In a
administration to adults aged 65 years and older has multisite US study, adult patients with S aureus LRI
been shown to be cost-efective54 with modest eicacy,55–57 (n=37) had worse outcomes than those with S pneumoniae
at least in high-income settings. Because immuno- (n=115), including higher rates of intensive care unit
senescence limits the eicacy of some vaccines in older (ICU) admission (62·2% vs 34·8%), mechanical
adults, improved vaccine eicacy has emerged as a ventilation (24·3% vs 12·2%), and inpatient mortality
priority.51 Strategies towards more efective vaccines for (10·8% vs 4·4%).13 Because of this poor prognosis,
older adults include higher doses of vaccines, repeated antistaphylococcal therapy is frequently included in
vaccinations, mucosal, subcutaneous, or intradermal empirical treatment for severe pneumonia.13,75 Finding
administration, and use of more potent adjuvants.58 In the causative pathogen in a patient with pneumonia can
LMICs, vaccine access for older adults is severely be challenging, and clinicians face the trade-of of
limited.59 More research is needed to assess the potential balancing suiciently broad empirical treatment with
beneits of adult vaccination, understand barriers and antibiotic stewardship.75,76 In a global meta-analysis of
challenges, and establish evidence-based guidelines in S aureus pneumonia, 51% of isolates were meticillin-
these settings.60,61 resistant S aureus (MRSA).77 The emergence of
RSV, the second-leading cause of LRI deaths in children vancomycin-intermediate and vancomycin-resistant
younger than 5 years in 2019, has historically not been S aureus represents an escalating concern, and multidrug-
vaccine preventable. The development of afordable RSV resistant S aureus is classiied as high-priority on the
vaccines and long-acting, afordable monoclonal WHO global priority antimicrobial resistance pathogen

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list.78,79 Antibiotic overuse, a key driver of resistance, RSV, rather than reduced transmissibility or serotype
remains an important concern across high-income selection of S pneumoniae itself.95 For the bacterial
countries and LMICs. Improved point-of-care diag- aetiologies that are predominantly health-care acquired,
nostics, including targeted PCR testing for MRSA, can evidence is mostly limited to single-site studies and
prevent antibiotic overuse.80–82 In addition, although mixed, with some studies showing a reduction,96,97 others
eforts to develop a vaccine against S aureus have so far showing an increase,91 and others showing no change.98
been unsuccessful, ongoing research might generate a In the post-pandemic period, studies suggest that several
new method for prevention or treatment.83,84 of the pathogens that decreased in 2020 rebounded,
Our overall estimates of LRI mortality among children including RSV, inluenza, and pneumococcus.99–102 Other
younger than 5 years are consistent with indings from a pathogens—namely, Mycoplasma spp—showed a decline
publication by WHO and the Maternal and Child that persisted for a longer duration after the COVID-19
Epidemiology Estimation Group, which estimated pandemic, with continued decreased detection observed
740 000 (95% UI 620 000–840 000) child LRI deaths in until the end of 2022, followed by a delayed re-emergence
2019.85 We estimated 693 000 (580 000–822 000) child LRI in some countries in mid-2023.103–105 Due to interruption
deaths in 2019. Our estimates of pathogen distribution of established data exchanges caused by the COVID-19
are also similar to other global reports. A 2016 study from pandemic, we were unable to estimate how bacterial
the Global Initiative for MRSA Pneumonia (GLIMP),77 pathogen distributions might have changed between
which included data across 54 countries, identiied 2019 and 2021. As data become available for more
S aureus in 188 (6%) of 3193 adults with community- locations, pathogens, and years, we can comprehensively
acquired pneumonia, in alignment with the current quantify the indirect efects of the pandemic on the
study. Likewise, a 2021 meta-analysis across eight incidence of LRI and its aetiologies in future rounds
countries estimated that 18% (95% CI 13–24) of of GBD.
community-acquired pneumonia cases in adults aged A second limitation is that, when estimating the efect
50 years and older were attributable to S pneumoniae.86 of the COVID-19 pandemic on inluenza and RSV
Our estimates for the 50–69 years and 70 years and older incidence, we relied exclusively on case notiication data
global age groups are within the 95% CI of this meta- from national and multinational surveillance networks.
analysis. Our method cannot separate the efects of a true decrease
In addition, we have estimated the COVID-19 in LRI incidence from the efects of a decrease in health-
pandemic-era reduction in inluenza and RSV mortality care-seeking behaviour; we also did not account for
and incidence by country, applied to a comprehensive set potential changes in reporting capability over time.
of global LRI estimates. From 2019 to 2021, we estimated Third, to calculate the reduction in RSV, we applied
a 71·8% (95% UI 63·8–78·9) decrease in inluenza modelled estimates of COVID-19 pandemic-associated
deaths and a 66·7% (56·6–75·3) decrease in RSV deaths inluenza reduction directly to RSV estimates. This
worldwide (appendix 2 p 1951). These reductions were decision was based on a meta-analysis of the ratio of the
observed following the implementation of non-pharma- percentage change in inluenza to the percentage change
ceutical interventions such as facemask use and mobility in RSV in 2020, relative to the pre-pandemic period,
restriction, which have been implicated in the reduction which showed no statistically signiicant diference in the
of transmission of respiratory viruses, including reduction of the two pathogens. However, empirical
inluenza and RSV, in 2020 and 2021.22,87–90 However, studies published since the pandemic have shown that
other respiratory viruses, such as rhinovirus, adenovirus, the resurgence patterns of RSV and inluenza have
and respiratory enteroviruses, quickly rebounded within difered.106–110 Fourth, limited data availability and quality
a few months and persisted despite non-pharmaceutical are constraints, particularly in low-income countries,
interventions, showing fewer luctuations in case counts where the LRI burden is highest. Our assessment of LRI
with changing policies compared with inluenza and mortality in countries lacking vital registration data relies
RSV.22 Overall, hospitals across the world have reported largely on verbal autopsy studies, which have modest
reductions in admissions for community-acquired sensitivity in accurately identifying deaths due to LRIs.111
pneumonia during the COVID-19 pandemic.91–93 Covariates and regional trends were leveraged to predict
This study has several limitations. First, we quantiied the burden of LRI and corresponding aetiologies for
the COVID-19 pandemic-attributable reduction in LRI locations with few or no data. In selecting these
for inluenza and RSV only. New evidence from a global covariates, some degree of model misspeciication is
surveillance network including 26 countries shows a possible due to potential omitted variables that are not
decline in incidence of invasive infections attributable to captured in the dataset, which could afect the accuracy
respiratory pathogens, including S pneumoniae and of our predictive model. Fifth, misclassiication might be
H influenzae, during the COVID-19 pandemic.94 The present in pathogen proportion data if certain pathogens
decline in pneumococcal disease incidence might be are more diicult to detect than others, or if some
primarily attributable to the decline in transmission of pathogens, such as viruses in the population of older
co-infecting respiratory viruses, including inluenza and adults, are irregularly tested in a laboratory or clinical

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setting. Sixth, although we used a crosswalking process Arkadiusz Marian Dziedzic, Tim Eckmanns, Abdelaziz Ed-Dra,
to adjust for systematic diferences in incidence data Ferry Efendi, Aziz Eftekharimehrabad, David William Eyre,
Ayesha Fahim, Alireza Feizkhah, Timothy William Felton,
source categories, this process might not fully account Nuno Ferreira, Luisa S Flor, Santosh Gaihre, Miglas W Gebregergis,
for all forms of bias. Finally, we directly applied LRI Mesin Gebrehiwot, Christine Gefers, Urge Gerema, Kazem Ghafari,
aetiology proportions from the Global Burden of AMR Mohamad Goldust, Pouya Goleij, Shi-Yang Guan,
study to GBD estimates of LRI cases and deaths, although Mesay Dechasa Gudeta, Cui Guo, Veer Bala Gupta, Ishita Gupta,
Farrokh Habibzadeh, Najah R Hadi, Emily Haeuser, Wase Benti Hailu,
the two studies use slightly diferent deinitions of LRI. Ramtin Hajibeygi, Arvin Haj-Mirzaian, Sebastian Haller,
In particular, the Global Burden of AMR study’s Mohammad Hamiduzzaman, Nasrin Hanii, Jan Hansel,
deinition of LRI deaths covers any event for which LRI Md Saquib Hasnain, Johannes Haubold, Nguyen Quoc Hoan,
was present in the causal chain, regardless of the Hong-Han Huynh, Kenneth Chukwuemeka Iregbu, Md Rabiul Islam,
Abdollah Jafarzadeh, Ammar Abdulrahman Jairoun, Mahsa Jalili,
underlying cause of death, whereas the GBD deinition Nabi Jomehzadeh, Charity Ehimwenma Joshua, Md Awal Kabir,
only includes instances in which LRI was the underlying Zul Kamal, Kehinde Kazeem Kanmodi, Rami S Kantar,
cause of death. Arman Karimi Behnagh, Navjot Kaur, Harkiran Kaur,
In summary, we have shown that, despite declines in Faham Khamesipour, M Nuruzzaman Khan,
Mahammed Ziauddin Khan Suheb, Vishnu Khanal, Khaled Khatab,
incidence during the COVID-19 pandemic, LRIs remain Mahalaqua Nazli Khatib, Grace Kim, Kwanghyun Kim,
a signiicant cause of morbidity and mortality worldwide. Aiggan Tamene Tamene Kitila, Somayeh Komaki, Kewal Krishan,
Increased access to existing vaccines, as well as rollout of Ralf Krumkamp, Md Abdul Kuddus, Maria Dyah Kurniasari,
novel vaccines and therapies, could reduce the burden of Chandrakant Lahariya, Kaveh Latiinaibin, Nhi Huu Hanh Le,
Thao Thi Thu Le, Trang Diep Thanh Le, Seung Won Lee, Alain Lepape,
LRIs. Supporting research for low-cost interventions Temesgen L Lerango, Ming-Chieh Li, Amir Ali Mahboobipour,
against S aureus could accelerate progress in reducing Kashish Malhotra, Tauqeer Hussain Mallhi, Anand Manoharan,
LRI-related mortality and incidence, especially in Bernardo Alfonso Martinez-Guerra, Alexander G Mathioudakis,
Rita Mattiello, Jürgen May, Barney McManigal, Steven M McPhail,
resource-constrained settings. In addition, the growing
Tesfahun Mekene Meto, Max Alberto Mendez Mendez-Lopez,
threat of antimicrobial resistance highlights the Sultan Ayoub Meo, Mohsen Merati, Tomislav Mestrovic,
importance of antibiotic stewardship and investment in Laurette Mhlanga, Le Huu Nhat Minh, Awoke Misganaw,
improved diagnostic technologies to improve the Vinaytosh Mishra, Arup Kumar Misra, Nouh Saad Mohamed,
Esmaeil Mohammadi, Mesud Mohammed, Mustapha Mohammed,
speciicity and accuracy of therapy. Finally, all these
Ali H Mokdad, Lorenzo Monasta, Catrin E Moore, Rohith Motappa,
interventions must come at an afordable cost, so that Vincent Mougin, Parsa Mousavi, Francesk Mulita,
they can reduce inequities seen in LRI mortality, rather Atsedemariam Andualem Mulu, Pirouz Naghavi, Ganesh R Naik,
than exacerbate them. Firzan Nainu, Tapas Sadasivan Nair, Shumaila Nargus,
Mohammad Negaresh, Hau Thi Hien Nguyen, Dang H Nguyen,
GBD 2021 Lower Respiratory Infections and Antimicrobial Resistance Van Thanh Nguyen, Taxiarchis Konstantinos Nikolouzakis,
Collaborators Efaq Ali Noman, Chisom Adaobi Nri-Ezedi, Ismail A Odetokun,
Rose Grace Bender*, Sarah Brooke Sirota, Lucien R Swetschinski, Patrick Godwin Okwute, Matifan Dereje Olana, Titilope O Olanipekun,
Regina-Mae Villanueva Dominguez, Amanda Novotney, Eve E Wool, Omotola O Olasupo, Antonio Olivas-Martinez, Michal Ordak,
Kevin S Ikuta, Avina Vongpradith, Emma Lynn Best Rogowski, Edgar Ortiz-Brizuela, Amel Ouyahia, Jagadish Rao Padubidri,
Matthew Doxey, Christopher E Troeger, Samuel B Albertson, Jianing Ma, Anton Pak, Anamika Pandey, Ioannis Pantazopoulos,
Jiawei He, Kelsey Lynn Maass, Eric A F Simões, Meriem Abdoun, Pragyan Paramita Parija, Romil R Parikh, Seoyeon Park,
Jeza Muhamad Abdul Aziz, Deldar Morad Abdulah, Ashwaghosha Parthasarathi, Ava Pashaei, Prince Peprah,
Samir Abu Rumeileh, Hasan Abualruz, Salahdein Aburuz, Hoang Tran Pham, Dimitri Poddighe, Andrew Pollard,
Abiola Victor Adepoju, Rishan Adha, Wirawan Adikusuma, Saryia Adra, Alfredo Ponce-De-Leon, Peralam Yegneswaran Prakash,
Ali Afraz, Shahin Aghamiri, Antonella Agodi, Elton Junio Sady Prates, Nguyen Khoi Quan, Pourya Raee,
Amir Mahmoud Ahmadzade, Haroon Ahmed, Ayman Ahmed, Fakher Rahim, Mosiur Rahman, Masoud Rahmati,
Karolina Akinosoglou, Tareq Mohammed Ali AL-Ahdal, Shakthi Kumaran Ramasamy, Shubham Ranjan,
Rasmieh Mustafa Al-amer, Mohammed Albashtawy, Indu Ramachandra Rao, Ahmed Mustafa Rashid, Sayaphet Rattanavong,
Mohammad T AlBataineh, Hediyeh Alemi, Adel Ali Saeed Al-Gheethi, Nakul Ravikumar, Murali Mohan Rama Krishna Reddy,
Abid Ali, Syed Shujait Shujait Ali, Jaber S Alqahtani, Elrashdy Moustafa Mohamed Redwan, Robert C Reiner Jr,
Mohammad AlQudah, Jafar A Al-Tawiq, Yaser Mohammed Al-Worai, Luis Felipe Reyes, Tamalee Roberts, Mónica Rodrigues,
Karem H Alzoubi, Reza Amani, Prince M Amegbor, Victor Daniel Rosenthal, Priyanka Roy, Tilleye Runghien, Umar Saeed,
Edward Kwabena Ameyaw, John H Amuasi, Abhishek Anil, Amene Saghazadeh, Narjes Saheb Sharif-Askari,
Philip Emeka Anyanwu, Mosab Arafat, Damelash Areda, Fatemeh Saheb Sharif-Askari, Soumya Swaroop Sahoo, Monalisha Sahu,
Reza Arefnezhad, Kendalem Asmare Atalell, Firayad Ayele, Joseph W Sakshaug, Afeez Abolarinwa Salami, Mohamed A Saleh,
Ahmed Y Azzam, Hassan Babamohamadi, François-Xavier Babin, Hossein Salehi omran, Malik Sallam, Sara Samadzadeh,
Yogesh Bahurupi, Stephen Baker, Biswajit Banik, Martina Barchitta, Yoseph Leonardo Samodra, Rama Krishna Sanjeev, Made Ary Sarasmita,
Hiba Jawdat Barqawi, Zarrin Basharat, Pritish Baskaran, Kavita Batra, Aswini Saravanan, Benn Sartorius, Jennifer Saulam,
Ravi Batra, Nebiyou Simegnew Bayileyegn, Apostolos Beloukas, Austin E Schumacher, Seyed Arsalan Seyedi, Mahan Shaie,
James A Berkley, Kebede A Beyene, Ashish Bhargava, Samiah Shahid, Sunder Sham, Muhammad Aaqib Shamim,
Priyadarshini Bhattacharjee, Julia A Bielicki, Mariah Malak Bilalaga, Mohammad Ali Shamshirgaran, Rajesh P Shastry,
Veera R Bitra, Colin Stewart Brown, Katrin Burkart, Yasser Bustanji, Samendra P Sherchan, Desalegn Shiferaw, Aminu Shittu,
Sinclair Carr, Yaacoub Chahine, Vijay Kumar Chattu, Fatemeh Chichagi, Emmanuel Edwar Siddig, Robert Sinto, Aayushi Sood,
Hitesh Chopra, Isaac Sunday Chukwu, Eunice Chung, Reed J D Sorensen, Andy Stergachis, Temenuga Zhekova Stoeva,
Sriharsha Dadana, Xiaochen Dai, Lalit Dandona, Rakhi Dandona, Chandan Kumar Swain, Lukasz Szarpak, Jacques Lukenze Tamuzi,
Isaac Darban, Nihar Ranjan Dash, Mohsen Dashti, Mohamad-Hani Temsah, Melkamu B Tessema Tessema,
Mohadese Dashtkoohi, Denise Myriam Dekker, Ivan Delgado-Enciso, Pugazhenthan Thangaraju, Nghia Minh Tran, Ngoc-Ha Tran,
Vinoth Gnana Chellaiyan Devanbu, Kuldeep Dhama, Nancy Diao, Munkhtuya Tumurkhuu, Sree Sudha Ty, Anieiok John Udoakang,
Thao Huynh Phuong Do, Klara Georgieva Dokova, Christiane Dolecek,

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Inam Ulhaq, Tungki Pratama Umar, Abdurezak Adem Umer, Kerman, Iran; Department of Biotechnology (S Aghamiri PhD), Obesity
Seyed Mohammad Vahabi, Asokan Govindaraj Vaithinathan, Research Center (A Haj-Mirzaian MD), Tracheal Diseases Research
Jef Van den Eynde, Judd L Walson, Muhammad Waqas, Yuhan Xing, Center (A Mahboobipour MD), Department of Biology and Anatomical
Mukesh Kumar Yadav, Galal Yahya, Dong Keon Yon, Sciences (P Raee PhD), Urology and Nephrology Research Center
Abed Zahedi Bialvaei, Fathiah Zakham, Abyalew Mamuye Zeleke, (H Salehi omran MD), Shahid Beheshti University of Medical Sciences,
Chunxia Zhai, Zhaofeng Zhang, Haijun Zhang, Tehran, Iran; Department of Medical and Surgical Sciences and
Magdalena Zielińska, Peng Zheng, Aleksandr Y Aravkin, Theo Vos, Advanced Technologies “GF Ingrassia” (Prof A Agodi PhD,
Simon I Hay, Jonathan F Mosser, Stephen S Lim, Mohsen Naghavi†, M Barchitta PhD), University of Catania, Catania, Italy; Department of
Christopher J L Murray†, Hmwe Hmwe Kyu†. *First author. †Co-senior Neuroscience (A Ahmadzade MD), Mashhad University of Medical
authors. Sciences, Mashhad, Iran; Department of Biosciences (H Ahmed PhD),
COMSATS Institute of Information Technology, Islamabad, Pakistan;
Affiliations
Institute of Endemic Diseases (A Ahmed MSc), Unit of Basic Medical
Institute for Health Metrics and Evaluation (R G Bender MSc,
Sciences (E E Siddig MD), University of Khartoum, Khartoum, Sudan;
S B Sirota MA, L R Swetschinski MSc, R-M V Dominguez BS,
Swiss Tropical and Public Health Institute (A Ahmed MSc), Department
A Novotney MPH, E E Wool MPH, K S Ikuta MD, A Vongpradith BA,
of Paediatric Infectious Diseases (J A Bielicki PhD), University of Basel,
E L B Rogowski MPH, C E Troeger MPH, S B Albertson BS, J He MSW,
Basel, Switzerland; Department of Internal Medicine
K L Maass PhD, K Burkart PhD, S Carr BSc, E Chung MSc, X Dai PhD,
(K Akinosoglou PhD), University of Patras, Patras, Greece; Department
Prof L Dandona MD, Prof R Dandona PhD, L S Flor MPH,
of Internal Medicine and Infectious Diseases (K Akinosoglou PhD),
E Haeuser PhD, T Mestrovic PhD, A H Mokdad PhD, V Mougin BA,
University General Hospital of Patras, Patras, Greece; Heidelberg
R C Reiner Jr PhD, A E Schumacher PhD, R J D Sorensen PhD,
Institute of Global Health (HIGH) (T M A AL-Ahdal MPH), Heidelberg
P Zheng PhD, A Y Aravkin PhD, Prof T Vos PhD, Prof S I Hay FMedSci,
University, Heidelberg, Germany; School of Nursing
J F Mosser MD, Prof S S Lim PhD, Prof M Naghavi PhD,
(R M Al-amer PhD), Yarmouk University, Irbid, Jordan; School of
Prof C J L Murray DPhil, H H Kyu PhD), Department of Health Metrics
Nursing and Midwifery (R M Al-amer PhD), Department of Engineering
Sciences, School of Medicine (K Burkart PhD, X Dai PhD,
(G R Naik PhD), Western Sydney University, Sydney, NSW, Australia;
L S Flor MPH, A Misganaw PhD, A H Mokdad PhD, R C Reiner Jr PhD,
Community and Mental Health Department (Prof M Albashtawy PhD),
Prof A Stergachis PhD, P Zheng PhD, Prof T Vos PhD,
Al al-Bayt University, Mafraq, Jordan; Department of Molecular Biology
Prof S I Hay FMedSci, Prof S S Lim PhD, Prof M Naghavi PhD,
and Genetics (Prof M T AlBataineh PhD), Khalifa University, Abu Dhabi,
Prof C J L Murray DPhil, H H Kyu PhD, Prof R Dandona PhD,
United Arab Emirates; Hematology, Oncology and Stem Cell
B Sartorius PhD, A Y Aravkin PhD), Department of Internal Medicine
Transplantation Research Center (H Alemi MD), Department of
(Y Chahine MD), Department of Cardiology (Y Chahine MD),
Scientiic Research (F Chichagi MD), Department of Obstetrics and
Department of Biostatistics (A Olivas-Martinez MD), Department of
Gynecology (M Dashtkoohi MD), Department of Radiology
Global Health (R J D Sorensen PhD, Prof J L Walson MD), Department
(R Hajibeygi MD), Center for Research and Training in Skin Diseases
of Pharmacy (Prof A Stergachis PhD), Department of Applied
and Leprosy (F Khamesipour PhD), School of Medicine (M Merati MD),
Mathematics (A Y Aravkin PhD), University of Washington, Seattle, WA,
Faculty of Medicine (E Mohammadi MD, S Vahabi MD), Non-
USA; School of Medicine (R G Bender MSc), Department of
communicable Diseases Research Center (P Mousavi MD), Research
Dermatology (M Goldust MD), Yale University, New Haven, CT, USA;
Center for Immunodeiciencies (A Saghazadeh MD), Endocrinology and
Division of Infectious Diseases (K S Ikuta MD), Veterans Afairs Greater
Metabolism Research Institute (S Seyedi MD), Department of Neurology
Los Angeles, Los Angeles, CA, USA; School of Medicine
(M Shaie MD), Tehran University of Medical Sciences, Tehran, Iran
(E L B Rogowski MPH), Emory University, Atlanta, GA, USA; Urban
(E Mohammadi MD); Global Centre for Environmental Remediation
Indian Health Institute (M Doxey MPH), Seattle Indian Health Board,
(A A S Al-Gheethi PhD), University of Newcastle, Newcastle, NSW,
Seattle, WA, USA; Center for Biostatistics (J Ma MS), Ohio State
Australia; Cooperative Research Centre for Contamination Assessment
University, Columbus, OH, USA; Center for Global Health
and Remediation of the Environment, Newcastle, NSW, Australia
(Prof E A F Simões MD), University of Colorado, Denver, CO, USA;
(A A S Al-Gheethi PhD); Department of Zoology (A Ali PhD), Abdul
Department of Medicine (Prof M Abdoun BMedSc), University of Setif
Wali Khan University Mardan, Mardan, Pakistan; Center for
Algeria, Sétif, Algeria; Department of Medical Laboratory of Science
Biotechnology and Microbiology (S S Ali PhD), University of Swat, Swat,
(J M Abdul Aziz MSc), University of Human Development,
Pakistan; Department of Respiratory Care (J S Alqahtani PhD), Prince
Sulaymaniyah, Iraq; Baxshin Hospital (J M Abdul Aziz MSc), Baxshin
Sultan Military College of Health Sciences, Dammam, Saudi Arabia;
Research Center, Sulaymaniyah, Iraq; Community and Maternity
Department of Pathology and Microbiology (M AlQudah MD),
Nursing Unit (D M Abdulah MPH), University of Duhok, Duhok, Iraq;
Department of Clinical Pharmacy (Prof K H Alzoubi PhD), Jordan
Department of Neurology (S Abu Rumeileh MD), Martin Luther
University of Science and Technology, Irbid, Jordan; Cell Therapy and
University Halle-Wittenberg, Halle, Germany; Department of Nursing
Applied Genomics Department (M AlQudah MD), King Hussein Cancer
(H Abualruz PhD), Al Zaytoonah University of Jordan, Amman, Jordan;
Center, Amman, Jordan; Department of Specialty Internal Medicine
Department of Therapeutics (Prof S Aburuz PhD), United Arab
(Prof J A Al-Tawiq MD), Johns Hopkins Aramco Healthcare, Dhahran,
Emirates University, Al Ain, United Arab Emirates; College of Pharmacy
Saudi Arabia; Medicine Department (Prof J A Al-Tawiq MD), Indiana
(Prof S Aburuz PhD) and Department of Biopharmaceutics and Clinical
University School of Medicine, Indianapolis, IN, USA; Department of
Pharmacy (Y Bustanji PhD), University of Jordan, Amman, Jordan; HIV
Medical Sciences (Prof Y M Al-Worai PhD), Azal University for Human
and Infectious Diseases Department (A V Adepoju MD), Jhpiego, Abuja,
Development, Sana’a, Yemen; Department of Clinical Sciences
Nigeria; Department of Adolescent Research and Care
(Prof Y M Al-Worai PhD), University of Science and Technology of
(A V Adepoju MD), Adolescent Friendly Research Initiative and Care,
Fujairah, Fujairah, United Arab Emirates; Interdisciplinary Graduate
Ado Ekiti, Nigeria; Department of Business Administration
Program in Human Toxicology (R Amani DVM), University of Iowa,
(R Adha PhD), Department of Pharmacy (W Adikusuma PhD),
Iowa City, IA, USA; Health Policy Research Center (R Amani DVM),
Muhammadiyah University of Mataram, Mataram, Indonesia; Clinical
Department of Anatomy (R Arefnezhad MSc), Shiraz University of
Sciences Department (S Adra MD, H J Barqawi MPhil, N R Dash MD,
Medical Sciences, Shiraz, Iran; School of Global Public Health
N Saheb Sharif-Askari PhD), Department of Pharmacy Practice and
(P M Amegbor PhD), New York University, New York, NY, USA; School
Pharmacotherapeutics (Prof K H Alzoubi PhD), Department of Clinical
of Graduate Studies (E K Ameyaw MPhil), Lingnan University, Hong
Sciences (M Bilalaga MBBS), Department of Basic Biomedical Sciences
Kong Special Administrative Region, China; Department of Global
(Y Bustanji PhD), Sharjah Institute of Medical Sciences
Health (J H Amuasi PhD), Kwame Nkrumah University of Science and
(F Saheb Sharif-Askari PhD), College of Medicine (M A Saleh PhD),
Technology, Kumasi, Ghana; Global Health and Infectious Diseases
University of Sharjah, Sharjah, United Arab Emirates; Department of
(J H Amuasi PhD), Kumasi Center for Collaborative Research in Tropical
Medical Information Sciences (A Afraz MSc), Department of
Medicine, Kumasi, Ghana; Department of Pharmacology (A Anil MD,
Immunology (Prof A Jafarzadeh PhD), Research Center for Hydatid
M Shamim MBBS), Department of Community Medicine and Family
Disease (F Khamesipour PhD), Kerman University of Medical Sciences,

22 www.thelancet.com/infection Published online April 15, 2024 https://doi.org/10.1016/S1473-3099(24)00176-2

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Medicine (P Baskaran MD), Department of Pharmacology and Research (I Delgado-Enciso DSc), University of Colima, Colima, Mexico;
(A Saravanan MD), All India Institute of Medical Sciences, Jodhpur, Department of Research (I Delgado-Enciso DSc), Colima State Health
India; All India Institute of Medical Sciences, Bhubaneswar, India Services, Colima, Mexico; Department of Community Medicine
(A Anil MD); Warwick Medical School (P E Anyanwu PhD), University (V G C Devanbu MD), Chettinad Academy of Research and Education,
of Warwick, Coventry, UK (J W Sakshaug PhD); College of Pharmacy Chennai, India; Division of Pathology (K Dhama PhD), ICAR-Indian
(M Arafat PhD), Al Ain University, Abu Dhabi, United Arab Emirates; Veterinary Research Institute, Bareilly, India; Department of
College of Art and Science (D Areda PhD), Ottawa University, Surprise, Environmental Health (N Diao DSc), Department of Pulmonary and
AZ, USA; School of Life Sciences (D Areda PhD), Arizona State Critical Care (T O Olanipekun MD), Harvard University, Boston, MA,
University, Tempe, AZ, USA; Department of Pediatrics and Child Health USA; Department of Medicine (T H Do MD), Can Tho University of
Nursing (K A Atalell MSc), University of Gondar, Gondar, Ethiopia; Medicine and Pharmacy, Can Tho, Viet Nam; Department of Social
School of Medical Laboratory Sciences (F Ayele MSc), Department of Medicine and Health Care Organisation (K G Dokova PhD), Medical
Clinical Pharmacy (M D Gudeta MSc), Haramaya University, Harar, University “Prof Dr Paraskev Stoyanov”, Varna, Bulgaria; Oxford Centre
Ethiopia; Department of Neurovascular Research (A Y Azzam MBBCh), for Global Health Research (C Dolecek PhD), Nuield Department of
Nested Knowledge, Saint Paul, MN, USA; Faculty of Medicine Population Health (Prof D W Eyre DPhil), Big Data Institute, Nuield
(A Y Azzam MBBCh), October 6 University, 6th of October City, Egypt; Department of Medicine (B McManigal PhD), Oxford Vaccine Group
Department of Nursing (H Babamohamadi PhD), Semnan University of (A Pollard FMedSci), Department of Pediatrics (A Pollard FMedSci),
Medical Sciences and Health Services, Semnan, Iran; Mérieux Nuield Department of Medicine (B Sartorius PhD), University of
Foundation, Lyon, France (F Babin PharmD); Department of Oxford, Oxford, UK; Mahidol Oxford Tropical Medicine Research Unit
Community Medicine and Family Medicine (Y Bahurupi MD), All India (C Dolecek PhD), Mahidol University, Bangkok, Thailand; Department
Institute of Medical Sciences, Rishikesh, India; Department of Medicine of Conservative Dentistry with Endodontics (A M Dziedzic DSc), Medical
(Prof S Baker PhD), Department of Clinical Medicine University of Silesia, Katowice, Poland; Department of Infectious
(P Bhattacharjee MD), University of Cambridge, Cambridge, UK; Disease Epidemiology (S Haller MD), Robert Koch Institute, Berlin,
Institute of Health and Wellbeing (IHW) (B Banik PhD), Federation Germany (T Eckmanns MD); Higher School of Technology
University Australia, Melbourne, VIC, Australia; Manna Institute (Prof A Ed-Dra PhD), Sultan Moulay Slimane University, Beni Mellal,
(B Banik PhD), University of New England, Armidale, NSW, Australia; Morocco; Advanced Nursing Department (F Efendi PhD), Universitas
Alpha Genomics, Islamabad, Pakistan (Z Basharat PhD); Department of Airlangga, Surabaya, Indonesia; Department of Biochemistry
Medical Education (K Batra PhD), School of Public Health (R Batra MS), (A Eftekharimehrabad PhD), Ege University, Izmir, Türkiye; Azerbaijan
University of Nevada Las Vegas, Las Vegas, NV, USA; IT Department State University of Economics (UNEC), Baku, Azerbaijan
(R Batra MS), Coforge, Georgia, GA, USA; Department of Surgery (A Eftekharimehrabad PhD); Department of Oral Biology
(N S Bayileyegn MD), Department of Public Health (U Gerema MSc), (A Fahim PhD), University Institute of Public Health (S Nargus PhD,
Department of Epidemiology (D Shiferaw MPH), Jimma University, S Nargus PhD), Institute of Molecular Biology and Biotechnology
Jimma, Ethiopia; Department of Biomedical Sciences (IMBB) (S Shahid PhD), Research Centre for Health Sciences (RCHS)
(Prof A Beloukas PhD), University of West Attica, Athens, Greece; (S Shahid PhD), The University of Lahore, Lahore, Pakistan; Department
Institute of Infection and Global Health (Prof A Beloukas PhD), of Social Medicine and Epidemiology (A Feizkhah MD), Guilan
University of Liverpool, Liverpool, UK; Clinical Research Department University of Medical Sciences, Rasht, Iran; Division of Immunology,
(Prof J A Berkley PhD), Kenya Medical Research Institute/Wellcome Immunity to Infection & Respiratory Medicine (T W Felton PhD,
Trust Research Programme, Kilii, Kenya; Centre for Tropical Medicine J Hansel MSc, A G Mathioudakis PhD), University of Manchester,
and Global Health (Prof J A Berkley PhD, T Roberts PhD) and Nuield Manchester, UK; Department of Social Sciences (Prof N Ferreira PhD),
Department of Medicine (T Runghien MSc), Oxford University, Oxford, University of Nicosia, Nicosia, Cyprus; Institute of Applied Health
UK; School of Pharmacy (K A Beyene PhD), University of Auckland, Sciences (S Gaihre PhD), University of Aberdeen, Aberdeen, UK;
Auckland, New Zealand; Department of Pharmaceutical and Department of Midwifery (M W Gebregergis MSc), Adigrat University,
Administrative Sciences (K A Beyene PhD), University of Health Adigrat, Ethiopia; Department of Environmental Health
Sciences and Pharmacy in St Louis, St Louis, MO, USA; Department of (M Gebrehiwot DSc), Wollo University, Dessie, Ethiopia; Institute for
Internal Medicine (A Bhargava MD), Wayne State University, Detroit, Hygiene and Environmental Medicine (Prof C Gefers PhD),
MI, USA; Department of Clinical Medicine (P Bhattacharjee MD), Department of Neurology (S Samadzadeh MD), Charité University
Cambridge University Hospitals NHS Foundation Trust, Cambridge, Medical Center Berlin, Berlin, Germany; Department of Laboratory
UK; Department of Infection and Immunity (J A Bielicki PhD), St Sciences (K Ghafari MSc), Khomein University of Medical Sciences,
George’s University of London, London, UK; Faculty of Health Sciences Khomein, Iran; Department of Genetics (P Goleij MSc), Sana Institute
(V R Bitra PhD), University of Botswana, Gaborone, Botswana; Faculty of Higher Education, Sari, Iran; Universal Scientiic Education and
of Medicine (Prof A Ouyahia PhD), University Ferhat Abbas of Setif, Research Network (USERN) (P Goleij MSc), Kermanshah University of
Setif, Algeria; HCAI, Fungal, AMR, AMU and Sepsis Division Medical Sciences, Kermanshah, Iran; Department of Epidemiology and
(C S Brown MD), United Kingdom Health Security Agency, London, Biostatistics (S Guan MD), Anhui Medicla University, Hefei, China;
UK; Department of Infection (C S Brown MD), Imperial College Department of Urban Planning and Design (C Guo PhD), University of
London, London, UK; Temerty Faculty of Medicine (V Chattu MD), Hong Kong, Hong Kong Special Administrative Region, China; School
University of Toronto, Toronto, ON, Canada; Department of Community of Medicine (V Gupta PhD), Deakin University, Geelong, VIC, Australia;
Medicine (V Chattu MD), Datta Meghe Institute of Medical Sciences, Department of Internal Medicine (I Gupta MD), Independent
Sawangi, India; Department of Biosciences (H Chopra PhD), Saveetha Consultant, Bharatpur, India; NGO (I Gupta MD), Independent
Institute of Medical and Technical Sciences, Chennai, India; Department Consultant, Delhi, India; Global Virus Network, Middle East Region,
of Paediatric Surgery (I S Chukwu BMedSc), Federal Medical Centre, Shiraz, Iran (F Habibzadeh MD); Department of Clinical Pharmacology
Umuahia, Nigeria; Department of Internal Medicine (S Dadana MD), and Medicine (Prof N R Hadi PhD), University of Kufa, Najaf, Iraq;
Cheyenne Regional Medical Center, Cheyenne, WY, USA; Public Health Department of Public Health (W B Hailu MPH), Wollega University,
Foundation of India (Prof L Dandona MD, Prof R Dandona PhD, Nekemte, Ethiopia; Department of Radiology (A Haj-Mirzaian MD),
A Pandey PhD), Gurugram, India; Indian Council of Medical Research Division of Cardiology (D H Nguyen BS), Massachusetts General
(Prof L Dandona MD), New Delhi, India; Department of Medical Hospital, Boston, MA, USA; Department of Public Health
Microbiology (I Darban BSc), University of Ghana, Accra, Ghana; (S Haller MD), Charité Institute of Public Health, Berlin, Germany;
Department of Radiology (M Dashti MD), Tabriz University of Medical Faculty of Health (M Hamiduzzaman PhD), Southern Cross University,
Sciences, Tabriz, Iran; Department of Gynecology and Obstetrics Bilinga, QLD, Australia; Department of Critical Care and Emergency
(M Dashtkoohi MD), Vali-E-Asr Reproductive Health Research Center, Nursing (N Hanii PhD), Zanjan University of Medical Sciences, Zanjan,
Family Health Research Institute, Tehran, Iran; Department Iran; Department of Pharmacy (Prof M S Hasnain PhD), Palamau
Implementation Research (D M Dekker PhD), Institute of Tropical Institute of Pharmacy, Daltonganj, India; Department of Diagnostic and
Medicine, Hamburg, Germany; School of Medicine Interventional Radiology and Neuroradiology (J Haubold MD), Institute

www.thelancet.com/infection Published online April 15, 2024 https://doi.org/10.1016/S1473-3099(24)00176-2 23

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of Artiicial Intelligence in Medicine (J Haubold MD), University and Strategy (Prof C Lahariya MD), Foundation for People-centric
Hospital Essen, Essen, Germany; School of Dentistry (N Q Hoan DDS), Health Systems, New Delhi, India; SD Gupta School of Public Health
Hanoi Medical University, Hanoi, Viet Nam; International Master (Prof C Lahariya MD), Indian Institute of Health Management Research
Program for Translational Science (H Huynh BS), Nursing School University, Jaipur, India; Faculty of Medicine (N Le MD), Department of
(M Kurniasari PhD), International Ph D Program in Medicine General Medicine (V T Nguyen MD), Department of Otolaryngology
(L Minh MD), Research Center for Artiicial Intelligence in Medicine (N Tran MSc), University of Medicine and Pharmacy at Ho Chi Minh
(L Minh MD), School of Public Health (Y L Samodra MPH, City, Ho Chi Minh City, Viet Nam (T T Le MD, T D T Le MD);
Y L Samodra MPH), Department of Clinical Pharmacy Cardiovascular Research Department (N Le MD), Methodist Hospital,
(M A Sarasmita PharmD), Taipei Medical University, Taipei, Taiwan; Merrillville, IN, USA; Independent Consultant, Ho Chi Minh City,
Department of Medical Microbiology (K C Iregbu MD), University of Viet Nam (T D T Le MD); Department of Precision Medicine
Abuja, Abuja, Nigeria; Department of Medical Microbiology (Prof S W Lee MD), Sungkyunkwan University, Suwon-si, South Korea;
(K C Iregbu MD), National Hospital, Abuja, Nigeria; Department of REA-REZO (A Lepape MD), Hospices Civils de Lyon, Lyon, France;
Pharmacy (M R Islam PhD), University of Asia Paciic, Dhaka, Public Health, Epidemiology and Evolutionary Ecology of Infectious
Bangladesh; Department of Immunology (Prof A Jafarzadeh PhD), Diseases (PHE3ID) (A Lepape MD), Centre International de Recherche
Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Health and en Infectiologie (CIRI), Lyon, France; Department of Public Health
Safety Department (A A Jairoun PhD), Dubai Municipality, Dubai, (T L Lerango MPH), Dilla University, Dilla, Ethiopia; Department of
United Arab Emirates; Department of Microbiology (M Jalili MSc), Health Promotion and Health Education (M Li PhD), National Taiwan
Hamadan University of Medical Sciences, Hamadan, Iran; Department Normal University, Taipei, Taiwan; Department of Internal Medicine
of Microbiology (N Jomehzadeh PhD), Abadan School of Medical (K Malhotra MBBS), Dayanand Medical College and Hospital, Ludhiana,
Sciences, Abadan, Iran; Department of Economics (C E Joshua BSc), India; Department of Clinical Pharmacy (T Mallhi PhD), Jouf University,
National Open University, Benin City, Nigeria; Department of Social Sakaka, Saudi Arabia; Molecular Laboratory (A Manoharan PhD), The
Work (M Kabir PhD), Pabna University of Science and Technology, CHILDS Trust Medical Research Foundation, Chennai, India;
Pabna, Bangladesh; Department of Pharmacy (Z Kamal PhD), Shaheed Department of Infectious Diseases (B A Martinez-Guerra MSc,
Benazir Bhutto University, Dir Upper, Pakistan; School of Pharmacy E Ortiz-Brizuela MSc, Prof A Ponce-De-Leon MD), Department of
(Z Kamal PhD), Shanghai Jiao Tong University, Shanghai, China; Medicine (A Olivas-Martinez MD), Instituto Nacional de Nutrición
Faculty of Dentistry (K K Kanmodi MPH), University of Puthisastra, Salvador Zubirán (Salvador Zubiran National Institute of Medical
Phnom Penh, Cambodia; Oice of the Executive Director Sciences and Nutrition), Mexico City, Mexico; North West Lung Centre
(K K Kanmodi MPH), Campaign for Health and Neck Cancer Education (A G Mathioudakis PhD), Manchester University NHS Foundation
(CHANCE) Programme (A A Salami BDS), Cephas Health Research Trust, Manchester, UK; Department of Social Medicine
Initiative, Ibadan, Nigeria; The Hansjörg Wyss Department of Plastic (R Mattiello PhD), Federal University of Rio Grande do Sul, Porto
and Reconstructive Surgery (R S Kantar MD), Nab’a Al-Hayat Alegre, Brazil; Department of Tropical Medicine (Prof J May MD),
Foundation for Medical Sciences and Health Care, New York, NY, USA; Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany;
Cleft Lip and Palate Surgery Division (R S Kantar MD), Global Smile Australian Centre for Health Services Innovation
Foundation, Norwood, MA, USA; Endocrine Research Center (Prof S M McPhail PhD), Queensland University of Technology, Kelvin
(A Karimi Behnagh MD), Department of Echocardiography Grove, QLD, Australia; Digital Health and Informatics Directorate
(A Karimi Behnagh MD), Department of Anesthesiology (Prof S M McPhail PhD), Queensland Health, Brisbane, QLD, Australia;
(K Latiinaibin MD), Microbial Biotechnology Research Center Department of Public Health (T Mekene Meto MPH), Arba Minch
(A Zahedi Bialvaei PhD), Iran University of Medical Sciences, Tehran, University, Arbaminch, Ethiopia; Department of Medical Oncology and
Iran; Department of ENT (N Kaur MS), Dr B R Ambedkar State Institute Hematology (M A M Mendez-Lopez PhD), Kantonsspital St Gallen,
of Medical Sciences (AIMS), Mohali, India; Public Health Foundation of St Gallen, Switzerland; Department of Physiology (Prof S A Meo PhD),
India, New Delhi, India (H Kaur MPH); Population Science Department Pediatric Intensive Care Unit (M Temsah MD), King Saud University,
(M Khan PhD), Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Riyadh, Saudi Arabia; University Centre Varazdin (T Mestrovic PhD),
Bangladesh; Department of Public Health (M Khan PhD), University of University North, Varazdin, Croatia; Department of Preventive Medicine
Sydney, Sydney, NSW, Australia; Department of Critical Care Medicine (L Mhlanga PhD), Northwestern University, Chicago, IL, USA; South
(M Z Khan Suheb MD), St Luke’s Aurora Medical Center, Milwaukee, African Centre for Epidemiological Modelling and Analysis (SACEMA)
WI, USA; Department of Health (V Khanal PhD), Nepal Development (L Mhlanga PhD), Department of Epidemiology (J L Tamuzi MSc),
Society, Chitwan, Nepal; Preventable Non Communicable Disease Stellenbosch University, Cape Town, South Africa; National Data
(V Khanal PhD), Menzies School of Health Research, Alice Springs, NT, Management Center for Health (A Misganaw PhD), Ethiopian Public
Australia; College of Health, Wellbeing and Life Sciences Health Institute, Addis Ababa, Ethiopia; College of Healthcare
(Prof K Khatab PhD), Sheield Hallam University, Sheield, UK; Management and Economics (V Mishra PhD), Gulf Medical University,
College of Arts and Sciences (Prof K Khatab PhD), Ohio University, Ajman, United Arab Emirates; Department of Research and
Zanesville, OH, USA; Global Consortium for Public Health Research Development (V Mishra PhD), Panacea Institute of Interdisciplinary
(Prof M Khatib PhD), Datta Meghe Institute of Higher Education and Research and Education, Varanasi, India, Varanasi, India; Department of
Research, Wardha, India; Department of Pediatrics (G Kim MD), Case Pharmacology (A K Misra MD), All India Institute of Medical Sciences,
Western Reserve University School of Medicine, Cleveland, OH, USA; Mangalagiri, India; Molecular Biology Unit (N S Mohamed MSc), Bio-
Division of Pediatric Hospital Medicine (G Kim MD), UH Rainbow Statistical and Molecular Biology Department (N S Mohamed MSc),
Babies and Children’s Hospital, Cleveland, OH, USA; Department of Sirius Training and Research Centre, Khartoum, Sudan; Department of
Preventive Medicine (K Kim MD), Yonsei University, Seoul, South Pharmacy (M Mohammed MSc), Madda Walabu University, Bale Robe,
Korea; Department of Public Health (A T Kitila MPH), Wachemo Ethiopia; QU Health (M Mohammed PhD), Qatar University, Doha,
University, Addis Ababa, Ethiopia; Department of Preventive and Social Qatar; Clinical Epidemiology and Public Health Research Unit
Medicine (A T Kitila MPH), University of Otago, Dunedin, New Zealand; (L Monasta DSc), Burlo Garofolo Institute for Maternal and Child
Department of Physiology (S Komaki MD), Hamedan University of Health, Trieste, Italy; Centre for Neonatal and Paediatric Infection
Medical Sciences, Hamedan, Iran; Department of Anthropology (C E Moore PhD), St George’s University of London, London, UK;
(Prof K Krishan PhD), Panjab University, Chandigarh, India; Department of Community Medicine (R Motappa MD), Department of
Department of Infectious Disease Epidemiology (R Krumkamp DrPH, Internal Medicine (M M R Reddy MD), Manipal Academy of Higher
Prof J May MD), Bernhard Nocht Institute for Tropical Medicine, Education, Mangalore, India; Department of Surgery (F Mulita PhD),
Hamburg, Germany; Department of Mathematics (M Kuddus PhD), General University Hospital of Patras, Patras, Greece; Faculty of
Department of Population Science and Human Resource Development Medicine (F Mulita PhD), Department of Emergency Medicine
(M Rahman DrPH), University of Rajshahi, Rajshahi, Bangladesh; (I Pantazopoulos PhD), University of Thessaly, Larissa, Greece;
Faculty of Medicine and Health Science (M Kurniasari PhD), Universitas Department of Nursing (A A Mulu MSc), Injibara University, Injibara,
Kristen Satya Wacana, Salatiga, Indonesia; Department of Health Policy Ethiopia; Department of Computer and Information Science and

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Engineering (P Naghavi MSc), University of Florida, Gainesville, FL, Institute of Technology Mandi, Mandi, India; Department of Medicine
USA; College of Medicine and Public Health (G R Naik PhD), Flinders (A M Rashid MD), Jinnah Sindh Medical University, Karachi, Pakistan;
University, Adelaide, SA, Australia; Faculty of Pharmacy (F Nainu PhD), Emergency Department (S Rattanavong MD), Savannakhet Provincial
Hasanuddin University, Makassar, Indonesia; Department of Hospital, Savannakhet, Laos; Section of Pulmonary and Critical Care
Community Medicine (T S Nair MD), MOSC Medical College, Medicine (N Ravikumar MD), University of Chicago, Chicago, IL, USA;
Kolenchery, India; Independent Consultant, Tehran, Iran Department Biological Sciences (Prof E M M Redwan PhD), King
(M Negaresh MD); Department of Internal Medicine (M Negaresh MD), Abdulaziz University, Jeddah, Egypt; Department of Protein Research
Ardabil University of Medical Science, Ardabil, Iran; Faculty of Medicine (Prof E M M Redwan PhD), Research and Academic Institution,
(H T H Nguyen MD), Institute for Research and Training in Medicine, Alexandria, Egypt; Unisabana Center for Translational Science
Biology and Pharmacy (H T H Nguyen MD), Duy Tan University, Da (L F Reyes PhD), Universidad de La Sabana (Savannah University), Chia,
Nang, Viet Nam; Department of Medical Engineering (D H Nguyen BS), Colombia; Critical Care Department (L F Reyes PhD), Clinica
University of South Florida, Tampa, FL, USA; Department of General Universidad De La Sabana (Savannah University Clinic), Chia,
Surgery (T K Nikolouzakis PhD), University Hospital of Heraklion, Colombia; Department of Microbiology (T Roberts PhD), Lao- Oxford-
Heraklion, Greece; Department of Laboratory of Toxicology Mahosot Hospital Wellcome Trust Research Unit, Vientiane, Laos;
(T K Nikolouzakis PhD), University of Crete, Heraklion, Greece; Department of Geography and Demography (M Rodrigues PhD),
Department of Applied Microbiology (E A Noman PhD), Taiz University, University of Coimbra, Coimbra, Portugal; Department of Public Health
Taiz, Yemen; Faculty of Applied Sciences and Technology Sciences (V D Rosenthal MD), University of Miami, Miami, FL, USA;
(E A Noman PhD), Universiti Tun Hussein Onn Malaysia, Johor, Department of Labour (P Roy PhD), Directorate of Factories,
Malaysia; Department of Paediatrics (C A Nri-Ezedi MD), Nnamdi Government of West Bengal, Kolkata, India; Institute for Health Metrics
Azikiwe University, Awka, Nigeria; Department of Veterinary Public and Evaluation (T Runghien MSc), University of Washington, Seattle,
Health and Preventive Medicine (I A Odetokun PhD), University of USA; Multidisciplinary Laboratory Foundation University School of
Ilorin, Ilorin, Nigeria; Department of Medical Physiology Health Sciences (FUSH) (Prof U Saeed PhD), Foundation University,
(P G Okwute MSc), Babcock University, Ilisan-Remo, Nigeria; Islamabad, Pakistan; International Center of Medical Sciences Research
Department of Medical Physiology (P G Okwute MSc), University of (ICMSR), Islamabad, Pakistan (Prof U Saeed PhD); Department of
Lagos, Lagos, Nigeria; Department of Microbiology, Immunology and Community Medicine and Family Medicine (S S Sahoo MD), All India
Parasitology (M D Olana PhD), Addis Ababa University, Addis Ababa, Institute of Medical Sciences, Bathinda, India; Department of Preventive
Ethiopia; Department of Medical Laboratory Sciences (M D Olana PhD), & Social Medicine (M Sahu MD), Independent Consultant, Kolkata,
Ambo University, Ambo, Ethiopia; Helath Information Research Unit India; Institute for Employment Research, Nuremberg, Germany
(O O Olasupo PhD), McMaster University, Hamilton, ON, Canada; (J W Sakshaug PhD); Department of Oral and Maxillofacial Surgery
Department of Pharmacotherapy and Pharmaceutical Care (A A Salami BDS), University College Hospital, Ibadan, Ibadan, Nigeria;
(M Ordak PhD), Department of Biochemistry and Pharmacogenomics Faculty of Pharmacy (M A Saleh PhD), Mansoura University, Mansoura,
(M Zielińska MPharm), Medical University of Warsaw, Warsaw, Poland; Egypt; Department of Pathology, Microbiology and Forensic Medicine
Department of Epidemiology, Biostatistics and Occupational Health (M Sallam PhD), Department of Clinical Laboratories and Forensic
(E Ortiz-Brizuela MSc), McGill University, Montreal, QC, Canada; Medicine (M Sallam PhD), Independent Consultant, Amman, Jordan;
Division of Infectious Diseases (Prof A Ouyahia PhD), University Department of Neurology (S Samadzadeh MD), University of Southern
Hospital of Setif, Setif, Algeria; Department of Forensic Medicine and Denmark, Odense, Denmark; Department of Pediatrics
Toxicology (J Padubidri MD), Kasturba Medical College, Mangalore, (R K Sanjeev MD), Pravara Institute of Medical Sciences, Loni, India;
Mangalore, India; Centre for the Business and Economics of Health Pharmacy Study Program (M A Sarasmita PharmD), Udayana
(A Pak PhD), Faculty of Medicine (B Sartorius PhD), The University of University, Badung, Indonesia; Indira Gandhi Medical College and
Queensland, Brisbane, QLD, Australia; Australian Institute of Tropical Research Institute, Puducherry, India (A Saravanan MD); Department of
Health and Medicine (A Pak PhD), James Cook University, Townsville, Medical Informatics (J Saulam MSc), Kagawa University, Miki-cho,
QLD, Australia; Department of Emergency Medicine Japan; Food Processing and Nutrition (J Saulam MSc), Karnataka State
(I Pantazopoulos PhD), University of Bern, Bern, Switzerland; Akkamahadevi Women’s University, Vijayapura, India; Department of
Department of Community Medicine (P P Parija MD), All India Institute Pathology and Laboratory Medicine (S Sham MD), Northwell Health,
of Medical Sciences, Jammu, India; Department of Epidemiology and New York, NY, USA; Department of Pathobiology
Community Health (R R Parikh MD), University of Minnesota School of (M Shamshirgaran PhD), Shahid Bahonar University of Kerman,
Public Health, Minneapolis, MN, USA; Department of Biomedical Data Kerman, Iran; Department of Microbiology (R P Shastry PhD), Yenepoya
Science (S Park MD), Department of Radiology (S Ramasamy MD), University, Mangalore, India; Department of Biology
Stanford University, Stanford, CA, USA; Center for (S P Sherchan PhD), Morgan State University, Baltimore, MD, USA;
Pharmacoepidemiology and Treatment Science (A Parthasarathi MD), Department of Environmental Health Sciences (S P Sherchan PhD),
Rutgers University, New Brunswick, NJ, USA; Research Center Tulane University, New Orleans, USA; Department of Public Health
(A Parthasarathi MD), Allergy Asthma and Chest Center, Mysore, India; (D Shiferaw MPH), Dambi Dollo University, Dembi Dollo, Ethiopia;
School of Nursing (A Pashaei MSc), University of British Columbia, Department of Veterinary Public Health and Preventive Medicine
Vancouver, BC, Canada; Centre for Primary Health Care and Equity (A Shittu MSc), Usmanu Danfodiyo University, Sokoto, Nigeria;
(P Peprah MSc), University of New South Wales, Kensington, Australia; Department of Medical Microbiology and Infectious Diseases
School of Medicine (H Pham MD), Pham Ngoc Thach University of (E E Siddig MD), Erasmus University, Rotterdam, Netherlands;
Medicine, Ho Chi Minh City, Viet Nam; Department of Medicine Department of Internal Medicine (R Sinto MD), University of Indonesia,
(Prof D Poddighe PhD), Nazarbayev University, Astana, Kazakhstan; Jakarta Pusat, Indonesia; Department of Internal Medicine
Clinical Academic Department of Pediatrics (Prof D Poddighe PhD), (R Sinto MD), Dr Cipto Mangunkusumo National Hospital, Jakarta
University Medical Center (UMC), Astana, Kazakhstan; Department of Pusat, Indonesia; Internal Medicine Department (A Sood MD), The
Microbiology (P Y Prakash PhD), Department of Nephrology Wright Center for Graduate Medical Education, Scranton, PA, USA;
(I Rao DM), Manipal Academy of Higher Education, Manipal, India; Department of Microbiology and Virology (Prof T Z Stoeva PhD),
Department of Maternal and Child Nursing and Public Health Medical University of Varna, Varna, Bulgaria; Microbiology Laboratory
(E J S Prates BS), Federal University of Minas Gerais, Belo Horizonte, (Prof T Z Stoeva PhD), University Hospital, Varna, Bulgaria; Department
Brazil; College of Health Sciences (N Quan MD), VinUniversity, Hanoi, of Analytical and Applied Economics (C K Swain MPhil), Utkal
Viet Nam; Department of Health Sciences (Prof F Rahim PhD), Cihan University, Bhubaneswar, India; Department of Clinical Outcomes
University-Sulaymaniyah, Sulaymaniyah, Iraq; Cihan University (Prof L Szarpak PhD), Maria Sklodowska-Curie Medical Academy,
Sulaimaniya Research Center (CUSRC), Sulaymaniyah, Iraq Warsaw, Poland; Department of Clinical Research and Development
(Prof F Rahim PhD); Department of Physical Education and Sport (Prof L Szarpak PhD), LUXMED Group, Warsaw, Poland; Department of
Sciences (Prof M Rahmati PhD), Lorestan University, Khoramabad, Iran; Medicine (J L Tamuzi MSc), Northlands Medical Group, Omuthiya,
School of Humanities and Social Sciences (S Ranjan MA), Indian Namibia; Department of Microbiology and Immunology

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(M B T Tessema PhD), University of Maryland, Baltimore, MD, USA; submitted work. M-C Li reports support for the present manuscript from
Department of Pharmacology (P Thangaraju MD), All India Institute of the National Science and Technology Council in Taiwan (112-2410-H-003-
Medical Sciences, Raipur, India; Department of Health (N M Tran MD), 031) and other inancial or non-inancial support as a Technical Editor of
Children’s Hospital 1, Ho Chi Minh City, Viet Nam; Department of the Journal of the American Heart Association, Review Editor of Frontiers in
Physiology (M Tumurkhuu PhD), East Carolina University, Greenville, Public Health, and Editorial Board Member of BMC Public Health, outside
NC, USA; Department of Pharmacology (S Ty MD), All India Institute of the submitted work. S A Meo reports grants or contracts from King Saud
Medical Sciences, Deoghar, India; Department of Biosciences and University (Riyadh, Saudi Arabia; RSP-2024 R47), outside the submitted
Biotechnology (A J Udoakang PhD), University of Medical Sciences, work. L Monasta reports support for the present manuscript from the
Ondo, Ondo, Nigeria; Health Department (I Ulhaq PhD), Ministry of Italian Ministry of Health (Ricerca Corrente 34/2017), with payments
Health, Peshawar, Pakistan; Health Department (I Ulhaq PhD), made to the Institute for Maternal and Child Health IRCCS Burlo
Directorate General of Health Services, Peshawar, Pakistan; Division of Garofolo. C Moore reports participation with Dr Gwen Knight as a
Surgery and Interventional Science (T Umar MD), University College member of the advisory board for MRC grants (no payments made), with
London, London, UK; Department of Public Health (A A Umer MPH), the WHO Advisory group, and with the REVIVE Advisory group as a
Dire Dawa University, Dire Dawa, Ethiopia; College of Health and Sport member of the steering group; and leadership or iduciary roles in board,
Sciences (A G Vaithinathan MSc), University of Bahrain, Salmanya, society, committee, or advocacy groups (unpaid) as the co-chair of the
Bahrain; Department of Cardiovascular Sciences (J Van den Eynde BSc), Impact and Inluence Group of the Microbiology Society, outside the
Katholieke Universiteit Leuven (University of Leuven), Leuven, Belgium; submitted work. A Pollard reports grants or contracts from the Bill &
Natural and Medical Sciences Research Center (M Waqas PhD), Melinda Gates Foundation, Wellcome Trust, Cepi, MRC, NIHR,
University of Nizwa, Nizwa, Oman; Department of Biotechnology and AstraZeneca, European Commission, and the Serum Institute of India;
Genetic Engineering (M Waqas PhD), Hazara University Mansehra, royalties or licenses from AstraZeneca; consulting fees from Shionogi;
Mansehra, Pakistan; Department of Paediatrics (Y Xing PhD), The leadership or iduciary roles in board, society, committee, or advocacy
Chinese University of Hong Kong, Hong Kong Special Administrative groups (unpaid) as the chair of the Department of Health and Social
Region, China; Department of Microbiology (M K Yadav PhD), Central Care’s Joint Committee on Vaccination and Immunisation and as a
University of Punjab, Bathinda, India; Department of Microbiology and member of the WHO Strategic Advisory Group of Experts on
Immunology (G Yahya PhD), Zagazig University, Zagazig, Egypt; Immunization until 2022; and receipt of equipment, materials, drugs,
Department of Cells and Tissues (G Yahya PhD), Molecular Biology medical writing, gifts, or other services from Moderna, outside the
Institute of Barcelona, Barcelona, Spain; Department of Pediatrics submitted work. L F Reyes reports grants or contracts from MSD and
(Prof D Yon MD), Kyung Hee University, Seoul, South Korea; Faculty of Pizer; consulting fees from GlaxoSmithKline, MSD, and Pizer; payment
Medicine and Health Sciences (F Zakham PhD), Hodeidah University, or honoraria for lectures, presentations, speakers bureaus, manuscript
Hodeidah, Yemen; Department of Virology (F Zakham PhD), University writing, or educational events from GlaxoSmithKline, MSD, and Pizer;
of Helsinki, Helsinki, Finland; School of Nursing (A M Zeleke MSc), payment for expert testimony from GlaxoSmithKline, MSD, and Pizer;
Hawassa University, Hawassa, Ethiopia; Department of Epidemiology and support for attending meetings or travel from GlaxoSmithKline and
and Biostatistics (C Zhai MD), Anhui Medical University, Hefei, China; Pizer, outside the submitted work. Y L Samodra reports grants or
Department of Nutrition and Food Hygiene (Z Zhang PhD), School of contracts from Taipei Medical University, and leadership or iduciary
Public Health (H Zhang MS), Peking University, Beijing, China; roles in board, society, committee, or advocacy groups (paid or unpaid) as
Department of International Health (H Zhang MS), Johns Hopkins the co-founder of Benang Merah Research Center, outside the submitted
University, Baltimore, MD, USA. work. E A F Simôes reports support for the present manuscript from the
Bill & Melinda Gates Foundation; grants or contracts from AstraZeneca,
Contributors
Merck & Co, Pizer, and Icosavax; consulting fees from Merck & Co,
Please see appendix 1 (pp 34–37) for more detailed information about
Pizer, GlaxoSmithKline, Sanoi Pasteur, Cidara Therapeutics, Adagio
individual author contributions to the research, divided into the
Therapeutics, Nuance Pharmaceuticals, Enanta, and Icosavax; payment
following categories: managing the overall research enterprise; writing
or honoraria for lectures, presentations, speakers bureaus, manuscript
the irst draft of the manuscript; primary responsibility for applying
writing, or educational events from Pizer and AstraZeneca; support for
analytical methods to produce estimates; primary responsibility for
attending meetings or travel from Pizer and AstraZeneca; and
seeking, cataloguing, extracting, or cleaning data; designing or coding
participation on a data safety monitoring board or advisory board with
igures and tables; providing data or critical feedback on data sources;
AbbVie, GlaxoSmithKline, the Bill & Melinda Gates Foundation, and
developing methods or computational machinery; providing critical
Moderna, outside the submitted work. M Zielińska reports other
feedback on methods or results; drafting the manuscript or revising it
inancial support as an AstraZeneca employee, outside the submitted
critically for important intellectual content; and managing the
work.
estimation or publications process. Members of the core research team
(R G Bender, S B Sirota, L R Swetschinski, R-M V Dominguez, Data sharing
For the GHDx GBD 2021 website A Novotney, E E Wool, K S Ikuta, A Vongpradith, E L B Rogowski, To download the data used in these analyses, please visit the GHDx GBD
see https://ghdx.healthdata.org/ S B Albertson, C J L Murray, M Naghavi, and H H Kyu) for this topic 2021 website.
record/ihme-data/global- area had full access to the underlying data used to generate the estimates
Acknowledgments
burden-disease-study-2021- presented in this Article. All other authors had access to and reviewed
This study was funded by the Bill & Melinda Gates Foundation,
lower-respiratory-incidence- the estimates as part of the research evaluation process, which included
Wellcome Trust, and Department of Health and Social Care using UK
mortality-estimates-1990-2021 additional formal stages of review. H H Kyu and M Naghavi accessed
aid funding managed by the Fleming Fund.
and veriied the underlying data reported in this study.
The corresponding author had inal responsibility for the decision to
Editorial note: The Lancet Group takes a neutral position with respect to
submit the manuscript for publication.
territorial claims in published maps and institutional ailiations.
Declaration of interests
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