Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023

Abstract

Background Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential forshaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, andRisk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of lifelost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death byquantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This studyenables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causesaffect global populations.Methods GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countriesand territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developedfor GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. Wecomputed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard lifeexpectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific ageperiod, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each agegroup for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a givencause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean ageacross causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death forindividuals within a population, based on global mortality rates and the population’s age structure. Comparatively, theobserved mean age represents the actual mean age at death, influenced by all factors unique to a location-specificpopulation, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generatedusing the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as countsand age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include acorrection for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19,and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registrationand verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, amongothers. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years ofsurveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added tothose used in previous GBD rounds.Findings The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes ofglobal deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classificationhierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning therankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke).While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing theirage-standardised mortality rates globally. Four other leading causes have also shown large declines in global agestandardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles.Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism insome locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this,neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in manyvaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this studyquantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation bysex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6–47·0) in 1990to 63·4 years (63·1–63·7) in 2023. For males, mean age increased from 45·4 years (45·1–45·7) to 61·2 years (60·7–61·6),and for females it increased from 48·5 years (48·1–48·8) to 65·9 years (65·5–66·3), from 1990 to 2023. The highestall-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9–81·0) and for males 74·8 years (74·8–74·9). By comparison, the lowest all-cause mean ageat death occurred in sub-Saharan Africa, where it was 38·0 years (37·5–38·4) for females and 35·6 years (35·2–35·9)for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and regionfrom 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increasedfrom drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included druguse disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicablediseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death forthis super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income superregion, which also had an observed mean age at death lower than the expected value.Interpretation We examined global mortality patterns over the past three decades, highlighting—with enhancedestimation methods—the impacts of major events such as the COVID-19 pandemic, in addition to broader trendssuch as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition.This study also delves into premature mortality patterns, exploring the interplay between age and causes of death anddeepening our understanding of where targeted resources could be applied to further reduce preventable sources ofmortality. We provide essential insights into global and regional health disparities, identifying locations in need oftargeted interventions to address both communicable and non-communicable diseases. There is an ever-present needfor strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease,particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death areincreasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need forglobal collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease areaffecting all nations, albeit at different paces and scales.Funding Gates Foundation.

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Identifiers

ORCID for Samuele Cortese: orcid.org/0000-0001-5877-8075

ORCID for Miguel Garcia-Argibay: orcid.org/0000-0002-4811-2330

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