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GBD study

September 2023

September 2023

Authors:

Ahmadu Bello University Teaching Hospital

Background The causes for immune-mediated inflammatory diseases (IMIDs) are diverse and the incidence trends of IMIDs from specific causes are rarely studied. The study aims to investigate the pattern and trend of IMIDs from 1990 to 2019.

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Global, regional, and national incidence of six major

immune-mediated inﬂammatory diseases: ﬁndings from the

global burden of disease study 2019

GBD 2019 IMID Collaborators

Summary

Background The causes for immune-mediated inﬂammatory diseases (IMIDs) are diverse and the incidence trends of

IMIDs from speciﬁc causes are rarely studied. The study aims to investigate the pattern and trend of IMIDs from

1990 to 2019.

Methods We collected detailed information on six major causes of IMIDs, including asthma, inﬂammatory bowel

disease, multiple sclerosis, rheumatoid arthritis, psoriasis, and atopic dermatitis, between 1990 and 2019, derived

from the Global Burden of Disease study in 2019. The average annual percent change (AAPC) in number of incidents

and age standardized incidence rate (ASR) on IMIDs, by sex, age, region, and causes, were calculated to quantify the

temporal trends.

Findings In 2019, rheumatoid arthritis, atopic dermatitis, asthma, multiple sclerosis, psoriasis, inﬂammatory bowel

disease accounted 1.59%, 36.17%, 54.71%, 0.09%, 6.84%, 0.60% of overall new IMIDs cases, respectively. The ASR of

IMIDs showed substantial regional and global variation with the highest in High SDI region, High-income North

America, and United States of America. Throughout human lifespan, the age distribution of incident cases from

six IMIDs was quite different. Globally, incident cases of IMIDs increased with an AAPC of 0.68 and the ASR

decreased with an AAPC of −0.34 from 1990 to 2019. The incident cases increased across six IMIDs, the ASR of

rheumatoid arthritis increased (0.21, 95% CI 0.18, 0.25), while the ASR of asthma (AAPC = −0.41), inﬂammatory

bowel disease (AAPC = −0.72), multiple sclerosis (AAPC = −0.26), psoriasis (AAPC = −0.77), and atopic dermatitis

(AAPC = −0.15) decreased. The ASR of overall and six individual IMID increased with SDI at regional and global

level. Countries with higher ASR in 1990 experienced a more rapid decrease in ASR.

Interpretation The incidence patterns of IMIDs varied considerably across the world. Innovative prevention and

integrative management strategy are urgently needed to mitigate the increasing ASR of rheumatoid arthritis and

upsurging new cases of other ﬁve IMIDs, respectively.

Funding The Global Burden of Disease Study is funded by the Bill and Melinda Gates Foundation. The project funded

by Scientiﬁc Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital

(2022QN38).

(http://creativecommons.org/licenses/by/4.0/).

Keywords: Immune-mediated inﬂammatory disease; Incidence; Global burden of disease study; Trend

Introduction

Immune-mediated inﬂammatory diseases (IMIDs)

encompass a heterogeneous group of disorders affecting

various organs and tissues, including the skin (psoriasis

[PsO] and atopic dermatitis [AD]), and the joints (rheu-

matoid arthritis [RA] and psoriatic arthritis [PsA], in-

ternal lumen (inﬂammatory bowel disease [IBD] and

asthma) and white matter and gray matter (multiple

sclerosis [MS]).

Patients with IMID have a higher like-

lihood of developing another IMID and often present

with comorbidities, such as cardiovascular, psychiatric,

and peripheral artery disorders.

2–6

The evolving under-

standing of the shared underlying pathogenesis of these

clinically diverse diseases has led to a transition from

*Corresponding author. Department of Rheumatology and Immunology, Sichuan Provincial People’s Hospital, School of Medicine, University of

Electronic Science and Technology of China, Chengdu, China.

E-mail address: dongze_wu@163.com (D. Wu).

Collaborators are listed at the end of the Article.

eClinicalMedicine

2023;64: 102193

Published Online 9

September 2023

https://doi.org/10.

1016/j.eclinm.2023.

102193

www.thelancet.com Vol 64 October, 2023 1

Articles

organ-based to molecular-based classiﬁcation, which

was initiated by insights into associated key immune

and inﬂammatory pathways and the development of

cytokine targeted therapy, including monoclonal and

bispeciﬁc antibodies, small interfering RNA (siRNA)

therapeutics and chimeric antigen receptor (CAR)-T cell

therapy.

7–9

Over the past three decades, there has been a

remarkable increase in human life expectancy and

healthy life expectancy.

Higher life expectancy at age

70 has led to a greater proportion of years spent in ill

health at that age.

Healthcare access and quality

disparities persist worldwide, the Healthcare Access

and Quality Index increased globally from 1990 to

2019, low-SDI countries had a signiﬁcantly lower

overall index of 30.7 compared to high-SDI countries

with an index of 83.4.

In 2019, the median physician

density was ten times higher in high-SDI countries

compared to low-SDI countries.

Given that IMIDs

represent a signiﬁcant health concern, a reﬁned trend

analysis of IMIDs will aid in identifying and

addressing the underlying causes of disparities in the

diagnosis, treatment, and management of these

diseases.

The Global Burden of Diseases (GBD), Injuries, and

Risk Factors Study provided a systematic approach to

assess the burden of IMIDs in 204 countries and terri-

tories, offering a unique opportunity to understand the

underlying trends across the past three decades.

In this

study, we focused primarily on six major IMIDs, chosen

due to the emergence of novel drugs and treatment

strategies over the past few decades. Given the evolving

healthcare needs of patients with IMIDs over their

lifespan and medical advancements, this study aimed to

i) estimate the pattern and trend of IMIDs incidence

across the lifespan, ii) identify the global, regional, and

national trends in IMIDs incidence from 1990 to 2019,

and iii) determine the driving forces behind these

trends.

Methods

Data sources

The GBD 2019 study is the most comprehensive and up-

to-date source of epidemiological data, providing esti-

mates for 369 diseases and injuries across 204 countries

and territories from 1990 to 2019.

14,15

Using standard-

ized tools and a Bayesian framework, the study provides

a detailed estimation of the incidence of IMIDs across

all regions of the world. The accompanying GBD 2019

publications describe the data inputs, processing, syn-

thesis, and ﬁnal models used to estimate the disease

Research in context

Evidence before this study

We conducted a systematic search of the Medline and

EMBASE databases from their inception to January 9, 2023,

using the keywords “immune-mediated inﬂammatory

disease”,“incidence”,“trend”,“trend analysis”,“rheumatoid

arthritis”,“atopic dermatitis”,“asthma”,“multiple sclerosis”,

“inﬂammatory bowel disease”, and “psoriasis”. Although the

burden of immune-mediated inﬂammatory diseases (IMIDs) is

increasing globally, few studies have focused on the most up-

to-date incidence trends of IMIDs on a global scale. Most

studies have been limited to a single cause, country, or

population, or have considered the trend by a single factor. To

our knowledge, a comprehensive analysis of the pattern and

trends of IMID incidence has not been reported. Therefore,

this study aims to ﬁll this gap by providing a comprehensive

and up-to-date assessment of the global burden of six major

IMIDs, including asthma, inﬂammatory bowel disease,

multiple sclerosis, rheumatoid arthritis, psoriasis, and atopic

dermatitis, from 1990 to 2019.

Added value of this study

Our study presents a comprehensive analysis of the temporal

trends of IMIDs by gender, age, cause, region, and country,

and their association with the socio-demographic index (SDI)

across the world. Our ﬁndings reveal a wide variation in the

incidence of IMIDs, and the age-standardized rate (ASR) of

overall and six individual IMIDs increased with SDI across 21

Global Burden of Disease regions and 204 countries and

territories. Globally, the number of incident cases of IMIDs

increased, while the age-standardized rate decreased from

1990 to 2019. Throughout human lifespan, the age

distribution of incident cases from six IMIDs was quite

different. Among the six IMIDs studied, incident cases

increased, and the ASR of rheumatoid arthritis increased,

while the ASR of asthma, inﬂammatory bowel disease,

multiple sclerosis, psoriasis, and atopic dermatitis decreased.

We identiﬁed several at-risk populations for increasing trends

in patients with IMIDs, including those with rheumatoid

arthritis, people aged 60 years or older, and those from high-

income countries. Our study provides valuable insights into

the global burden of IMIDs and can inform future public

health policies aimed at reducing their impact.

Implications of all the available evidence

The magnitude of incident cases of IMIDs has increased

signiﬁcantly over the past few decades. As a result, there is an

urgent need for an integrative management strategy to

address the increasing ASR of rheumatoid arthritis and the

upsurge in new cases of the other ﬁve IMIDs studied.

Furthermore, future analyses of IMID trends should also

consider the potential impact of the COVID-19 pandemic on

incidence rates. One Health after the COVID-19 pandemic is

an opportunity to focus efforts and resources on IMIDs, which

can strengthen multisectoral coordination mechanisms.

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burden of IMIDs.

11,15

The GBD 2019 synthesizes a great

number of input sources to estimate the incidence of

IMIDs. The Data Input Sources Tool in Global Health

Data Exchange (http://ghdx.healthdata.org/gbd-2019/

data-input-sources) provides access to input sources

for speciﬁc GBD components, causes and risks, and

locations. The estimates and methods used in this study

are publicly available from the Institute for Health

Metrics and Evaluation website, including the GBD

Compare tool (https://vizhub.healthdata.org/gbd-

compare/) and the GBD Results Tool (http://ghdx.

healthdata.org/gbd-results-tool).

Data collection

Annual incident cases and age standardized incidences

of IMIDs from 1990 to 2019, by sex, region, country,

and cause (asthma, IBD, MS, RA, psoriasis, AD), were

collected from the Global Health Data Exchange

(GHDx) query tool (https://vizhub.healthdata.org/gbd-re

sults/). Data from a total of 204 countries and territories

were categorized into 5 regions in terms of socio-

demographic index (SDI), including low, low-middle,

middle, high-middle, and high and were separated

into 21 regions in terms of geography.

Socio-demographic index

The SDI is a composite index of socio-demographic

development status strongly correlated with health out-

comes, which is the geometric mean of 0–1 indices of

total fertility rate in those under 25 years old, mean

education for those age 15 years or older, and lag-

distributed income per capita.

Statistical analysis

The study aimed to analyze the patterns and trends of

major IMIDs using age-standardized incidence rate

(ASR) and incident cases. The temporal trend was eval-

uated using a join-point regression model, and the

average annual percent change (AAPC) was calculated for

the study period. An increasing trend was determined if

both the AAPC estimate and the lower boundary of its

95% conﬁdence interval (CI) were >0, while a decreasing

trend was established if both the AAPC estimate, and the

upper boundary of its 95% CI were <0. Otherwise, the

ASR was considered stable over time. The Join-point

analysis of entire range (1990–2019), and three segment

ranges (1990–1999, 2000–2009, 2010–2019) were used to

reﬂect the full and local trend of IMIDs. To investigate

the factors inﬂuencing AAPCs, the association between

AAPCs and ASRs (1990) and SDI (2019) was assessed at

the national level. All statistical analyses were conducted

using Join-point Regression Program (Version 4.8.0.1,

Statistical Methodology and Applications Branch, Sur-

veillance Research Program, National Cancer Institute).

Asigniﬁcance level of p < 0.05, at a two-tailed level, was

used to determine statistical signiﬁcance.

Ethics statement

This study was produced as part of the GBD Collabo-

rator Network and in accordance with the GBD Protocol

(IHME ID 4239-GBD2019-042,022). For GBD studies, a

waiver of informed consent was reviewed and approved

by the Institutional Review Board of the University of

Washington (https://www.healthdata.org/gbd/2019).

Role of the funding source

The funders of this study had no role in study design,

data collection, data analysis, data interpretation, and

writing of the manuscript.

Results

The age effect on incidence of overall immune-

mediated inﬂammatory disease

Throughout human lifespan, the age distribution of

incident cases from six IMIDs was quite different

(sTable S1,Fig. 1A and B). Most incident cases were

observed in individuals under the age of 25 for AD, in

the age group of 20–59 years for IBD, in individuals

aged 15–54 years for MS, among adults aged 30–69

years for RA, in individuals under the age of 69 for

psoriasis. MS and RA did not affect children under the

age of 5, while AD and asthma most frequently

affected children under the age of 5. The age-speciﬁc-

rate was highest among children under the age of 5,

decreased with age, but increased again for individuals

over the age of 80 for asthma and AD, increasing with

age and plateauing at 40–44 years for IBD, increased

rapidly, peaked at 25–29 years, and quickly turned to a

decrease for MS, slowly increased, peaked at 65–69

years, and quickly turned to a decrease for RA, slowly

increased, peaked at 55-55 years, and slowly turned to

a decrease for psoriasis (sTable S2,sFigure S1,

sFigure S2).

Throughout human lifespan, the AAPC of overall

IMIDs new cases decreased with age, the AAPC of

overall IMIDs incidence rate increased before 10 years,

decreased during 10–65 yeas, reached nadir at 65–69

years, then turned to increase (sTable S1,Fig. 1Cand

D). Speciﬁcally, the AAPC of incident cases attributable

to six individual IMIDs universally increased with age

(sFigure S3). In contrast, the AAPC of incidence rate

decreased with age, reached trough at 65–69 years, and

turn to increase for asthma; ﬂuctuant decrease with age

for inﬂammatory bowel disease; ﬂuctuant decrease

with age, reached trough at 50–54 years, then turned to

increase for MS; remained stale between 10 and 79

years, then turn to decrease for RA; slowly decrease,

reached trough at 40–44 years, then turned to increase

for psoriasis; ﬂuctuant increase with age, peaked at

50–54 years, slightly decrease, reached trough at 75–79

years, then turn to increase for AD (sTable S2,

sFigure S4).

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Global and regional incidence of overall immune-

mediated inﬂammatory disease

In 2019, the global incidence of overall IMIDs was

approximately 67,586,168 cases, with an ASR of 908.69

per 100,000 population. Throughout 5 SDI regions, 21

GBD region and 204 countries, the highest ASR was

found in the High SDI region, High-income North

America, United States of America, and the highest

incident cases were recorded in Middle SDI region,

South Asia, China, respectively (Table 1).

From 1990 to 2019, the global incident cases

increased with an AAPC of 0.68, but the ASRs decreased

with an AAPC of −0.34. The ASRs decreased in all ﬁve

SDI regions from 1990 to 2019, with the quickest decline

in the Low-middle SDI region (AAPC = −0.27). Across

the regional and national region, the most rapid increase

of ASR was observed in High-income North America

(AAPC = 0.21) and Oman (AAPC = 0.55), the most rapid

increases of incident cases were Western Sub-Saharan

Africa (AAPC = 2.59) and Qatar (AAPC = 5.83)

(Table 1,Fig. 2CandD,sFigure S5,sTable S3).

Incidence of six immune-mediated inﬂammatory

disease according to gender and proportion

Compared with males, females have more than twice

likelihood to develop RA, have modestly higher likeli-

hood to develop AD, have comparable possibility to

develop asthma, have more considerable likelihood to

develop MS, have similar possibility to develop psoria-

sis, has slight lower likelihood to IBD. (sFigure S6). In

1990 and 2019, RA, AD, asthma, MS, psoriasis, IBD

accounted for 1.02%, 34.32%, 57.53%, 0.07%, 6.53%,

0.53% and 1.59%, 36.17%, 54.71%, 0.09%, 6.84%,

0.60% of overall new IMIDs cases, respectively. In 2019,

this proportion exceeded 2.51% for RA in South Asia,

comprised as much as 0.27% for MS in certain high-

SDI regions, such as Western Europe, reached 1.70%

for IBD in Central Europe (Table 1,Fig. 3).

Incidence of six immune-mediated inﬂammatory

disease according to global, SDI and GBD region

From 1990 to 2019, the global ASR signiﬁcantly

increased for RA (AAPC = 0.21), albeit the ASRs

signiﬁcantly decreased for AD (AAPC = −0.15), asthma

(AAPC = −0.41), MS (AAPC = −0.26), psoriasis

(AAPC = −0.77), IBD (AAPC = −0.32). Among the six

IMIDs, the global new cases increased the fastest for RA

(AAPC = 2.22), followed by MS (AAPC = 1.21), IBD

(AAPC = 1.11), AD (AAPC = 0.84), psoriasis

(AAPC = 0.81), asthma (AAPC = 0.53) (Table 1).

The ASR increased across 5 SDI regions for RA,

decreased in four out of ﬁve SDI regions for AD except

for High-middle SDI, was only decreased in the High-

middle SDI region for MS, generally decreased across

the 5 SDI regions for asthma and psoriasis, increased

fastest in middle SDI regions for IBD. The incident

cases generally increased across the ﬁve SDI regions

for RA, AD, MS, psoriasis, IBD, increased in all ﬁve

regions except High-middle SDI for asthma

(sTable S4).

Fig. 1: Cross sectional and longitudinal trend of incidence attributable to overall immune-mediated inﬂammatory diseases throughout human

lifespan. The number of incident cases attributable to overall immune-mediated inﬂammatory diseases throughout human lifespan in 2019 (A),

The rate of incidence attributable to overall immune-mediated inﬂammatory diseases throughout human lifespan in 2019 (B), The average

annual percent change in number of indecent cases attributable to overall immune-mediated inﬂammatory diseases throughout human

lifespan, 1990–2019 (C), The average annual percent change in rate of incidence attributable to overall immune-mediated inﬂammatory

diseases throughout human lifespan, 1990–2019 (D).

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1990 2019 1990–1999 2000–2009 2010–2019 1990–2019

N (95%CI) N (95% CI) AAPC (95% CI) AAPC (95% CI) AAPC (95% CI) AAPC (95% CI)

Age standardized rate

Overall 1013.74 (888.58–1169.42) 908.69 (786.07–1057.33) −0.91 (−0.96, −0.87) −0.28 (−0.37, −0.19) 0.19 (−0.17, 0.54) −0.34 (−0.46, −0.22)

Male 936.49 (807.69–1098.63) 844.27 (717.13–1004.97) −0.90 (−0.96, −0.84) −0.13 (−0.33, 0.06) 0.11 (−0.26, 0.48) −0.29 (−0.43, −0.15)

Female 1092.27 (966.58–1243.79) 973.24 (851.86–1115.20) −0.93 (−0.97, −0.90) −0.39 (−0.50, −0.27) 0.20 (0.11, 0.29) −0.38 (−0.43, −0.33)

Cause

Asthma 580.09 (474.68–715.04) 504.28 (400.64–633.26) −1.47 (−1.55, −1.40) −0.32 (−0.58, −0.07) 0.54 (0.05, 1.02) −0.41 (−0.59, −0.23)

Inﬂammatory bowel disease 6.10 (5.35–6.96) 4.97 (4.43–5.59) −1.65 (−1.71, −1.59) −0.16 (−0.29, −0.03) −0.32 (−0.39, −0.26) −0.72 (−0.77, −0.67)

Multiple sclerosis 0.80 (0.70–0.90) 0.74 (0.65–0.83) −0.68 (−0.71, −0.65) −0.12 (−0.13, −0.11) 0.00 (−0.03, 0.03) −0.26 (−0.27, −0.24)

Rheumatoid arthritis 12.21 (11.13–13.38) 13.00 (11.83–14.27) 0.27 (0.23, 0.31) 0.41 (0.40, 0.42) −0.08 (−0.19, 0.02) 0.21 (0.18, 0.25)

Psoriasis 72.24 (69.70–74.72) 57.78 (55.76–59.71) −0.72 (−0.72, −0.71) −0.76 (−0.76, −0.75) −0.84 (−0.85,−0.83) −0.77 (−0.78, −0.76)

Atopic dermatitis 342.30 (327.04–358.42) 327.91 (312.76–343.67) −0.04 (−0.06, −0.03) −0.15 (−0.16, −0.14) −0.27 (−0.28, −0.27) −0.15 (−0.16, −0.14)

SDI region

High SDI 1505.32 (1289.94–1773.48) 1441.66 (1225.91–1685.83) −1.09 (−1.20, −0.98) 0.31 (0.20, 0.41) 0.24 (0.15, 0.33) −0.14 (−0.21, −0.08)

High−middle SDI 1013.46 (878.70–1180.79) 931.65 (794.68–1094.39) −0.61 (−0.84, −0.38) −0.60 (−0.74, −0.45) 0.61 (0.32, 0.89) −0.23 (−0.37, −0.09)

Middle SDI 965.01 (839.49–1123.07) 903.46 (775.97–1062.31) −0.69 (−0.74, −0.65) −0.38 (−0.43,−0.32) 0.40 (−0.05, 0.84) −0.23 (−0.37, −0.09)

Low−middle SDI 843.92 (744.71–963.28) 766.86 (672.61–884.99) −0.90 (−0.97, −0.84) 0.00 (−0.17, 0.17) 0.04 (−0.33, 0.42) −0.27 (−0.41, −0.14)

Low SDI 859.27 (741.80–999.00) 798.54 (682.39–936.25) −0.64 (−0.72, −0.56) −0.06 (−0.14, 0.02) 0.07 (−0.19, 0.34) −0.22 (−0.31, −0.13)

GBD region

East Asia 894.11 (774.31–1047.27) 843.98 (726.72–1002.12) −1.09 (−1.21, −0.98) −0.77 (−0.91, −0.62) 1.12 (−0.44, 2.71) −0.26 (−0.76, 0.24)

Southeast Asia 1137.98 (1007.04–1297.84) 1110.15 (974.02–1281.29) −0.30 (−0.33, −0.27) 0.01 (−0.04, 0.05) 0.04 (−0.03, 0.11) −0.10 (−0.13, −0.07)

Oceania 1312.62 (1158.42–1477.09) 1194.09 (1060.93–1340.98) −0.11 (−0.14, −0.08) −0.60 (−0.63, −0.57) −0.22 (−0.28, −0.16) −0.32 (−0.35, −0.29)

Central Asia 1116.28 (961.86–1299.42) 1077.72 (915.85–1273.98) −0.16 (−0.18,−0.13) −0.35 (−0.41,−0.30) 0.19 (0.14, 0.23) −0.11 (−0.14,−0.09)

Central Europe 1011.85 (871.77–1191.64) 895.63 (746.27–1085.60) −0.37 (−0.45, −0.30) −0.69 (−0.73, −0.65) −0.13 (−0.22, −0.03) −0.42 (−0.46, −0.37)

Eastern Europe 998.65 (841.63–1192.99) 803.47 (658.87–977.26) −0.68 (−0.80, −0.57) −1.54 (−1.66, −1.42) 0.16 (−0.04, 0.36) −0.73 (−0.82,−0.64)

High−income Asia Paciﬁc 1466.17 (1281.85–1695.46) 1168.98 (995.26–1378.25) −1.18 (−1.33, −1.03) −1.43 (−1.54, −1.32) 0.29 (0.18, 0.40) −0.84 (−0.91, −0.76)

Australasia 1338.01 (1138.99–1551.76) 1164.09 (984.84–1379.40) 0.24 (−0.01, 0.50) −1.70 (−1.84, −1.55) −0.07 (−0.19, 0.05) −0.49 (−0.60, −0.38)

Western Europe 1353.20 (1210.93–1519.95) 1229.29 (1072.90–1402.16) −0.70 (−0.97,−0.43) −0.24 (−0.28,−0.21) −0.09 (−0.29, 0.11) −0.34 (−0.44,−0.23)

Southern Latin America 1255.43 (1101.48–1453.59) 1263.50 (1076.81–1496.65) 0.12 (0.00, 0.23) 0.00 (−0.01, 0.01) 0.00 (−0.01, 0.01) 0.03 (−0.01, 0.06)

High−income North America 1826.13 (1487.93–2270.75) 1911.37 (1603.78–2271.19) −1.82 (−2.03, −1.61) 1.47 (1.32, 1.62) 0.69 (0.55, 0.82) 0.21 (0.10, 0.31)

Caribbean 1355.04 (1125.45–1626.43) 1283.19 (1060.07–1549.93) −0.29 (−0.31, −0.28) −0.29 (−0.31, −0.28) 0.12 (0.02, 0.22) −0.17 (−0.20, −0.13)

Andean Latin America 1293.82 (1042.51–1583.94) 1118.89 (903.69–1402.55) −0.68 (−0.73, −0.63) −1.09 (−1.13, −1.06) 0.37 (0.31, 0.43) −0.51 (−0.54, −0.48)

Central Latin America 982.24 (810.15–1192.05) 845.25 (673.58–1055.32) −1.05 (−1.19,−0.92) −0.66 (−0.78,−0.54) 0.25 (0.21, 0.28) −0.53 (−0.59,−0.47)

Tropical Latin America 1476.43 (1178.40–1839.26) 1341.33 (1049.19–1666.04) −0.48 (−0.66, −0.30) −0.94 (−1.02, −0.87) 0.55 (0.35, 0.75) −0.34 (−0.44, −0.25)

North Africa and Middle East 897.41 (768.64–1049.74) 851.41 (718.70–1007.79) −0.29 (−0.32,−0.26) −0.47 (−0.49,−0.45) 0.31 (0.22, 0.39) −0.18 (−0.21,−0.15)

South Asia 733.14 (649.63–827.25) 672.56 (596.87–760.22) −1.57 (−2.02,−1.13) 0.85 (0.19, 1.51) −0.28 (−0.57, 0.00) −0.34 (−0.61,−0.07)

Central Sub−Saharan Africa 816.85 (695.52–958.17) 741.82 (627.48–883.02) −0.34 (−0.35, −0.33) −0.49 (−0.57, −0.40) −0.14 (−0.19, −0.09) −0.33 (−0.36, −0.30)

Eastern Sub−Saharan Africa 943.32 (793.17–1131.35) 852.92 (708.08–1030.73) −0.57 (−0.64, −0.50) −0.48 (−0.50, −0.46) 0.06 (0.00, 0.13) −0.34 (−0.37,−0.31)

Southern Sub−Saharan Africa 779.75 (633.85–944.95) 709.23 (576.11–868.27) 0.35 (−0.07, 0.76) −3.54 (−4.77, −2.31) 3.28 (2.74, 3.83) −0.06 (−0.53, 0.41)

Western Sub−Saharan Africa 789.05 (666.42–944.59) 715.11 (599.63–870.18) −0.65 (−0.98, −0.32) −0.41 (−0.47, −0.35) 0.00 (−0.20, 0.20) −0.36 (−0.48, −0.23)

Number of incident cases

Overall 55,906,499 (48,383,433–65,460,874) 67,586,168 (58,788,402–77,980,783) 0.13 (0.09, 0.17) 0.75 (0.63, 0.88) 1.13 (0.90, 1.37) 0.68 (0.59, 0.77)

Male 26,180,219 (22,235,358–31,447,992) 31,442,524 (26,888,533–37,097,214) 0.05 (−0.01, 0.11) 0.85 (0.67, 1.03) 1.07 (0.74, 1.41) 0.68 (0.55, 0.80)

Female 29,726,280 (26,136,610–34,237,346) 36,143,644 (31,908,458–40,987,243) 0.17 (0.14, 0.20) 0.67 (0.64, 0.70) 1.23 (1.14, 1.32) 0.68 (0.65, 0.72)

(Table 1 continues on next page)

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1990 2019 1990–1999 2000–2009 2010–2019 1990–2019

N (95%CI) N (95% CI) AAPC (95% CI) AAPC (95% CI) AAPC (95% CI) AAPC (95% CI)

(Continued from previous page)

Cause

Asthma 32,163,213 (25,752,792–40,513,127) 36,979,267 (29,601,976–45,928,112) −0.52 (−0.60, −0.45) 0.61 (0.38, 0.84) 1.48 (1.04, 1.91) 0.53 (0.37, 0.70)

Inﬂammatory bowel disease 293,572 (257,425–336,651) 404,552 (360,521–456,478) 0.43 (0.30, 0.56) 1.67 (1.62, 1.71) 1.27 (1.21, 1.34) 1.11 (1.06, 1.16)

Multiple sclerosis 41,854 (36,306–47,445) 59,345 (51,818–66,943) 1.14 (1.10, 1.17) 1.36 (1.35, 1.37) 1.11 (1.08, 1.14) 1.21 (1.20, 1.23)

Rheumatoid arthritis 567,463 (519,417–621,415) 1,074,391 (975,502–1,179,332) 2.31 (2.28, 2.34) 2.47 (2.46, 2.48) 1.84 (1.75, 1.93) 2.22 (2.19, 2.25)

Psoriasis 3,653,236 (3,527,023–3,778,791) 4,622,594 (4,458,904–4,780,771) 0.98 (0.97, 1.00) 0.85 (0.84, 0.85) 0.61 (0.60, 0.63) 0.81 (0.80, 0.82)

Atopic dermatitis 19,187,161 (18,290,469–20,163,445) 24,446,018 (23,339,682–25,569,146) 0.93 (0.89, 0.97) 0.86 (0.86, 0.87) 0.72 (0.70, 0.74) 0.84 (0.82, 0.86)

SDI region

High SDI 11,308,057 (9,894,762–13,026,205) 12,088,206 (10,695,628–13,675,720) −0.87 (−0.96, −0.77) 0.79 (0.65, 0.93) 0.69 (0.60, 0.78) 0.25 (0.18, 0.32)

High−middle SDI 11,390,468 (9,919,040 –13,277,351) 11,576,149 (10,234,863–13,168,363) −0.38 (−0.61, −0.15) −0.29 (−0.39, −0.19) 1.03 (0.82, 1.24) 0.09 (−0.02, 0.21)

Middle SDI 17,217,439 (14,695,850–20,511,806) 20,163,835 (17,515,593–23,332,662) 0.22 (−0.01, 0.46) 0.30 (0.20, 0.41) 1.29 (1.07, 1.50) 0.59 (0.47, 0.70)

Low−middle SDI 10,430,368 (9,006,974–12,270,814) 13,307,082 (11,596,864–15,359,307) 0.47 (0.42, 0.52) 1.26 (1.10, 1.41) 0.87 (0.58, 1.16) 0.90 (0.79, 1.01)

Low SDI 5,522,262 (4,623,631–6,700,074) 10,402,167 (8,603,854–12,719,419) 2.01 (1.93, 2.10) 2.69 (2.57, 2.81) 2.04 (1.74, 2.33) 2.25 (2.15, 2.36)

GBD region

East Asia 10,690,192 (9,252,978–12,581,924) 11,270,729 (10,033,558–12,788,729) −0.26 (−0.85, 0.34) −0.58 (−0.84, −0.32) 1.83 (1.37, 2.29) 0.28 (0.00, 0.56)

Southeast Asia 5,520,353 (4,796,120–6,444,135) 7,160,601 (6,320,548–8,165,612) 0.91 (0.86, 0.95) 1.03 (0.96, 1.10) 0.74 (0.65, 0.83) 0.88 (0.84, 0.92)

Oceania 88,198 (75,687–102,467) 162,617 (142,217–186,085) 2.53 (2.48, 2.57) 1.72 (1.65, 1.78) 2.25 (2.09, 2.41) 2.15 (2.10, 2.21)

Central Asia 878,383 (742,184–1,047,408) 1,019,637 (864,469–1,210,312) −0.38 (−0.50, −0.26) 0.17 (−0.09, 0.43) 1.83 (1.78, 1.89) 0.53 (0.44, 0.63)

Central Europe 1,207,366 (1,049,354–1,402,317) 869,178 (755,103–1,000,998) −1.15 (−1.26,−1.05) −1.53 (−1.58,−1.49) −0.67 (−0.80, −0.53) −1.14 (−1.20, −1.09)

Eastern Europe 2,162,990 (1,846,212–2,545,314) 1,382,432 (1,179,409–1,627,520) −2.27 (−2.51, −2.04) −2.37 (−2.46, −2.29) 0.20 (−0.03, 0.43) −1.51 (−1.63,−1.39)

High−income Asia Paciﬁc 2,258,416 (1,988,004–2,583,898) 1,691,690 (1,513,016–1,891,154) −1.07 (−1.16, −0.97) −1.86 (−1.96, −1.75) 0.01 (−0.06, 0.08) −1.03 (−1.09, −0.98)

Australasia 243,038 (209,273–278,595) 286,422 (249,096–330,809) 1.00 (0.84, 1.16) −0.31 (−0.41, −0.20) 1.01 (0.95, 1.06) 0.57 (0.50, 0.64)

Western Europe 4,763,790 (4,308,445–5,272,713) 4,565,937 (4,109,690–5,053,466) −0.69 (−0.87, −0.51) 0.24 (0.13, 0.35) −0.03 (−0.11, 0.05) −0.19 (−0.26,−0.11)

Southern Latin America 633,000 (553,280–736,366) 775,180 (671,334–903,964) 0.79 (0.62, 0.95) 0.58 (0.51, 0.64) 0.82 (0.76, 0.87) 0.72 (0.66, 0.78)

High−income North America 4,662,400 (3,905,771–5,676,648) 5,910,905 (5,129,336–6,821,981) −1.17 (−1.45, −0.89) 2.25 (2.05, 2.44) 1.17 (1.00, 1.34) 0.85 (0.71, 0.99)

Caribbean 524,424 (432,880–632,393) 557,437 (464,673–667,717) 0.22 (0.18, 0.27) 0.01 (−0.03, 0.04) 0.36 (0.10, 0.62) 0.19 (0.11, 0.27)

Andean Latin America 627,462 (495,373–777,248) 711,504 (575,085–893,222) 0.23 (0.14, 0.31) −0.52 (−0.60, −0.45) 1.82 (1.75, 1.89) 0.44 (0.39, 0.49)

Central Latin America 1,926,142 (1,547,193–2,378,778) 1,998,679 (1,604,735–2,490,472) 0.14 (−0.10, 0.38) −0.13 (−0.22, −0.04) 0.45 (0.42, 0.48) 0.13 (0.05, 0.21)

Tropical Latin America 2,534,797 (1,993,882–3,218,798) 2,557,679 (2,044,355–3,124,198) −0.01 (−0.17, 0.14) −0.54 (−0.61, −0.48) 0.72 (0.56, 0.87) 0.01 (−0.07, 0.09)

North Africa and Middle East 3,496,870 (2,902,019–4,224,006) 5,108,802 (4,286,740–6,082,702) 1.39 (1.31, 1.46) 1.02 (0.99, 1.05) 1.59 (1.49, 1.69) 1.32 (1.28, 1.36)

South Asia 8,465,092 (7,460,147–9,802,521) 11,614,829 (10,330,682–13,169,438) −0.02 (−0.48, 0.43) 2.61 (1.95, 3.28) 0.65 (0.37, 0.93) 1.07 (0.79, 1.34)

Central Sub-Saharan Africa 574,128 (463,728–704,268) 1,163,850 (945,928–1,431,971) 2.50 (2.47, 2.52) 2.55 (2.52, 2.58) 2.36 (2.32, 2.41) 2.47 (2.45, 2.49)

Eastern Sub-Saharan Africa 2,337,638 (1,878,499–2,929,628) 4,284,839 (3,413,453–5,375,525) 1.98 (1.84, 2.13) 2.12 (2.07, 2.16) 2.28 (2.14, 2.41) 2.12 (2.05, 2.19)

Southern Sub-Saharan Africa 450,736 (356,336–561,184) 554,527 (447,968–685,629) 1.91 (1.42, 2.39) −3.15 (−4.52, −1.75) 4.57 (3.98, 5.17) 1.01 (0.48, 1.55)

Western Sub-Saharan Africa 1,861,085 (1,503,020–2,320,718) 3,938,693 (3,155,961–4,963,753) 2.39 (2.26, 2.52) 2.99 (2.87, 3.11) 2.49 (2.46, 2.53) 2.59 (2.52, 2.65)

Table 1: The incident cases and age-standardized rate of incidence attributable to immune-mediated inﬂammatory diseases according to gender, cause, socio-demographic index regions, global burden of disease

regions, and its temporal trends from 1990 to 2019.

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Of the 21 geographical regions, the most signiﬁcant

increase in ASR was observed in Andean Latin America

(AAPC = 1.36) for RA, in Eastern Europe (AAPC = 0.07)

for AD, in High-income North America (AAPC = 0.37)

for asthma, in Australasia (AAPC = 1.05) for MS, in East

Asia (AAPC = 2.48) for IBD. The ASR of psoriasis

unanimously decreased among the 21 regions, with the

highest decrement observed in North Africa and the

Middle East (AAPC = −0.90). The incident cases

increased across 21, 18, 12, 21, 19, 21 regions for RA,

AD, asthma, MS, psoriasis, IBD, with highest increase

in Andean Latin America (AAPC = 3.91), Western

Sub-Saharan Africa (AAPC = 2.82), Western Sub-

Saharan Africa (AAPC = 2.51), Western Sub-Saharan

Africa (AAPC = 3.61), Eastern Sub-Saharan Africa

(AAPC = 2.42), Central Sub-Saharan Africa

(AAPC = 3.90), respectively (sTable S5,sFigure S7,

sFigure S8).

Incidence of six immune-mediated inﬂammatory

disease according to countries and territories

At the national level, the highest ASR of RA, AD,

asthma, MS, psoriasis, IBD were observed in Ireland,

Mongolia, United States of America, Sweden, France,

Canada, while the highest incident cases were recorded

in India, China, India, United States of America, China,

United States of America for RA, AD, asthma, MS,

psoriasis, IBD, respectively. The fastest increasing trend

in ASR of RA, AD, asthma, MS, IBD were Peru

(AAPC = 1.43), Kenya (AAPC = 0.16), Oman

(AAPC = 0.93), Taiwan (Province of China)

(AAPC = 1.55), Taiwan (Province of China)

(AAPC = 3.20), respectively. The ASR of psoriasis

remained stable in Japan and Somalia but decreased in

other 202 countries and territories from 1990 to 2019.

The most signiﬁcant decline in ASR was observed in

Equatorial Guinea (AAPC = −1.66). The most signiﬁcant

increase of new cases across six IMIDs was observed in

Qatar (AAPC: RA = 8.32, AD = 5.85, asthma = 5.68,

MS = 8.82, psoriasis = 6.14, IBD = 8.24) (sTable S6,

sFigure S9–S12).

The association betweenASR,SDIandAAPC

In 2019, the ASR of overall IMIDs increased with the

SDI across 21 regions and 204 countries and territories

(Fig. 4A and B). This increasing trend was also observed

for six individual IMIDs at the regional and global levels

(sFigure S13,sFigure S14).

From 1990 to 2019, countries with higher ASR in

1990 showed a more rapid decrease in ASR of overall

IMIDs for an ASR below 1600 per 100,000 (Fig. 4-C).

The ASR of IMIDs in 1990 reﬂects the disease reservoir

at baseline, while the SDI in 2019 can serve as a sur-

rogate for the level and availability of healthcare in each

Fig. 2: The global map of incidence attributable to overall immune-mediated inﬂammatory diseases in 204 countries and territories for both

sexes combined. The global map in number of incident cases attributable to overall immune-mediated inﬂammatory diseases, 2019 (A). The

global map in age standardized rate of incidence attributable to overall immune-mediated inﬂammatory diseases, 2019 (B), The global map in

average annual percent change in number of incident cases attributable to overall immune-mediated inﬂammatory diseases, 1990–2019 (C).

The global map in average annual percent change in age standardized rate of incidence attributable to overall immune-mediated inﬂammatory

diseases, 1990–2019 (D).

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www.thelancet.com Vol 64 October, 2023 7

country. This decreasing trend was also found in four

IMIDs, with the most notable being RA. However, the

trend was reversed in psoriasis and MS (sFigure S15).

Throughout all regions and countries, those with

higher SDI have experienced a more rapid increase in

ASR of overall IMIDs from 1990 to 2019 (Fig. 4D). The

SDI in 2019 serves as a surrogate for the level and

availability of healthcare in each country. A similar

increasing trend was also found for IBD, MS, and pso-

riasis, while a reverse trend was observed for asthma,

RA, and AD at the global level (sFigure S16).

Discussion

This study provides a comprehensive estimation of the

incidence of IMIDs and investigates their temporal

trend by gender, age, SDI, and global-regional-national

levels for the ﬁrst time. The magnitude of incident

cases of IMIDs increased, probably driven by population

growth and ageing, societal development, interaction

between genetic and environmental factors. The global

population has risen from 5.3 billion in 1990 to 7.7

billion in 2019, the population aged 70–79 years

increased by 115.4%, aged 80–94 years increased by

164.7%, and ≥95 years increased by 363.7%,

respectively.

The ideal efforts to prevent the onset or redirect the

course of IMIDs should focus on modifying environ-

mental or behavioral factors.

The accumulation of

environmental exposures and lifestyle factors that can

trigger genetic predisposition underlying immune

response over time.

18–20

Exposure to environmental air

pollution above the threshold for human protection was

associated with a 10% higher risk of developing

IMIDs.

The hygiene hypothesis postulates that the

increase in the incidence of IMIDs was caused by the

reduced exposure to infectious agents, probably explains

the rising development of IMID’s in low-middle-SDI

countries, where there has been a steady decline in

microbes and parasites over the past thirty years.

For

example, exposure to agricultural farming and poultry is

associated with the asthma-protective effect in the rural

area.

Indeed, hygiene hypothesis cannot fully explain

autoimmunity, there is no strong evidence linking the

hygiene hypothesis to rheumatoid arthritis.

In addi-

tion, industrial PM2.5 associated with the risk of sys-

temic autoimmune rheumatic diseases and air pollution

may be a trigger factor for psoriasis ﬂare.

25,26

However,

the impact of lifestyle changes in preventing the devel-

opment of systemic autoimmunity in rheumatoid

arthritis, such as smoking cessation, dietary changes,

weight reduction, has been partially established.

Fig. 3: Contribution of incident cases from six individual to overall immune-mediated inﬂammatory diseases, both sexes, globally and by region,

1990 and 2019. Contribution of incident cases from six individual to overall immune-mediated inﬂammatory diseases, both sexes, globally and

by region, 1990 (A), Contribution of incident cases from six individual to overall immune-mediated inﬂammatory diseases, both sexes, globally

and by region, 2019 (B).

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8 www.thelancet.com Vol 64 October, 2023

Furthermore, the rise in overweigh and obesity has

paralleled the increase in the incidence of IMIDs, which

might be explained by the overstimulation of T lym-

phocytes by nutrient- and energy-sensing pathways and

loss of self-tolerance by metabolic overload.

Preventive strategy is urgently needed to address the

rising ASR of RA. Currently available treatment did not

shown to prevent the development of RA in individuals

at high risk, early treatment with rituximab and abata-

cept only delayed onset of full-blown RA.

Similarly, the

TREAT EARLIER study found that early intervention

with methotrexate and glucocorticoid treatment did not

prevent the development of clinical arthritis.

Ongoing

investigations into preventive interventions that

interfere with altered activation of the adaptive immune

system, such as ARIAA (EudraCT 2014-000555-93) and

APIPPRA (EudraCT 2013-003413-18), may provide

further insight into the feasibility of preventing RA in

the future.

31,32

A reoriented management strategy and more tar-

geted drugs are needed to control the disease burden

from the rapid increase in incident cases of IMIDs as

traditional therapeutic modalities, including biologic

and small-molecule therapies, is not a concern in pa-

tients with IMIDs. New methods are urgently needed to

choose tailored formulation and frequency of adminis-

tration with the highest probability of acceptance and to

limit unnecessary use of medication.

33–35

The Allergic

Fig. 4: The association between age standardized rate of incidence, socio-demographic index, average annual percent change across global

burden of disease regions and countries and territories. Age standardized rate of incidence attributable to overall immune-mediated inﬂam-

matory diseases per 100,000 persons for socio-demographic index by 21 global burden of diseaseregions, 2019 (A). Black line represents

expected values based on socio-demographic index and disease rates across 21 global burden of disease regions; each point shows observed age

standardized rate of incidence for speciﬁed global burden of diseaseregion in 2019. Age standardized rate of incidence attributable to overall

immune-mediated inﬂammatory diseases per 100,000 persons for socio-demographic index by 204 countries and territories, 2019(B). Black line

represents expected values based on socio-demographic index and disease across 204 countries and territories, each point shows observed age

standardized rate of incidence for speciﬁed country in 2019. The correlation between average annual percent change and age standardized rate

of incidence attributable to overall immune-mediated inﬂammatory in 1990 across 204 countries and territories (C). The size of circle is

increased with the incident cases of immune-mediated inﬂammatory diseases. The ρindices and p values were derived from Pearson correlation

analysis. The correlation between average annual percent change and socio-demographic index attributable to overall immune-mediated in-

ﬂammatory in 2019 across 204 countries and territories (D). The size of circle is increased with the incident cases of immune-mediated in-

ﬂammatory diseases. The ρindices and p values were derived from Pearson correlation analysis.

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www.thelancet.com Vol 64 October, 2023 9

March story tell us which subtype of AD are at risk

progresses to asthma, which might be enhanced when

allergic sensitization presents at early life,

36,37

long term

study was needed to investigate whether the new bi-

ologics that interact with classic type 2 inﬂammatory

process truly interrupt the atopic march.

The 2021

asthma recommendation from the Global Initiative for

Asthma (GINA) emphasizes the use of symptoms and

side-effect preventive modiﬁers instead of relying on

side-effect prone and regular use of relievers.

Whether

modern steroid-sparing anti-inﬂammatory treatments

are disease modiﬁers remain controversy as the thera-

peutic effect of allergen immunotherapy is modest and

therapeutic effects of biologics targeting IgE, IL-5, IL-4,

IL-13 are maintained in in adults with established

asthma.

40–42

Although biologic agents can be effective

add-on therapies for patients with type 2–high severe

asthma, no biologic drugs are currently available for type

2-low severe asthma.

However, the recent success of

tezepelumab, which targets the epithelial alarmin

thymic stromal lymphopoietin, is an encouraging

development.

Appropriate disease-modifying therapies should be

considered in patients with MS and comorbid autoim-

mune diseases due to the autoimmunity partially over-

lap with other autoimmune mediated disorders.

innovative therapies are needed to prevent neuro-

degeneration and reverse structural damage.

The

domain-driven treatment approach aims to address all

active domains of psoriatic disease and related condi-

tions.

Larger and longer trials are needed to assess the

comparative efﬁcacy and safety of tapinarof (1%) and

roﬂumilast cream (0.3%) in patients with skin psoria-

sis,.

48,49

While head-to-head trials have shown dual

blockade of IL-17A and IL-17F to be superior to biologic

targeting IL-17A, IL-12/23, TNF-αin patients with pso-

riasis, further data is required to conﬁrm whether this

ﬁnding replicated in patients with PsA.

50,51

Considering

the potential beneﬁts of small molecules over mono-

clonal antibodies, the next leap forward in treating

psoriasis and PsA might be small molecule modulators

targeting IL-17A/IL-17RA.

Exciting preliminary data

conﬁrms this leap, as deucravacitinib demonstrated

superiority over apremilast in patients with psoriasis,

and upadacitinib was superior to adalimumab in pa-

tients with PsA.

Although currently available thera-

peutic armamentarium resulting in somewhat durable

remission in patents with ulcerative colitis, the treat-

ment goal of corticosteroid-free clinical remission was

hardly achieved with biologic and small-molecule ther-

apies targeting TNF-α,4β7 integrin, JAK, S1P, TYK2,

etc.

Although the effect on small bowel lesions remain

unclear, risankizumab represents a promising and

favorable option for patients with Crohn’s disease who

still have unmet needs.

Emerging novel therapeutic modality opens a win-

dow on exit strategies of biologic therapy as both

patients and clinicians hope to avoid the undesirable

consequences of long-term biologic therapy. Effective

improvement in AD have been observed in mesen-

chymal stem cell (MSC) based therapy, although more

research is needed to determine optimal dosages, ideal

administration routes and standard methods.

A phase

1/2a single-arm study showed that intravenous in-

fusions of umbilical cord mesenchymal stem cells were

could partially be effective in treating psoriasis.

Autologous haemopoietic stem cell transplantation

(aHSCT), allogeneic neural stem-cell-based therapy, and

CAR-Tregs targeting myelin oligodendrocyte glycopro-

tein were effective for inducing remissions of active

relapsing remitting MS, although long follow-ups and

head-to-head comparisons with the most effective

disease-modifying treatments are necessary to under-

stand how to position them for the management of

patients with aggressive MS.

59–62

Novel vaccines that

prevent EBV infection or targeting EBV would be ex-

pected to prevent most new cases or represent a novel

treatment strategy for MS.

Although the failure of

Seres Therapeutics’microbiome-based candidate SER-

287 in ulcerative colitis casting a shadow over the

emerging ﬁeld,

more data on functional effects of in-

dividual and groups of microbes on the mucosal im-

mune system might lead to new microbiota-based

therapies.

65,66

Local treatment with adipose-derived

mesenchymal stem cells (Cx601) added on to estab-

lished treatments for Crohn’s disease represents a novel

and minimally invasive alternative for complex perianal

ﬁstulas.

67,68

The long-term efﬁcacy and time frame for

retreatment are currently being investigated in the

INSPIRE trial (EUPAS24267).

Future analyses of the IMIDs should prioritize

examining the direct and indirect effects of the COVID-

19 pandemic. While the pandemic threatens healthcare

access and quality gains achieved at all ages, it poses a

particularly grave risk to older individuals who account

for most COVID-19 deaths.

However, the pandemic

has also catalyzed innovation in the provision of health

care, including an expansion in the use of telemedi-

cine.

Recent data strongly suggest that patients with

IMID require a third SARS-CoV-2 vaccination, future

study should ascertain whether fourth and beyond doses

should be given as new boosters become available.

71,72

Immunocompromising therapies for IMIDs, such as

TNF-αinhibitors, are not associated with a signiﬁcantly

greater risk of SARS-CoV-2 or severe sequelae and may

even be associated with a lower risk of adverse COVID-

19 outcomes.

73,74

In addition to the impact of immune-

modulatory medications that were used in severe cases

of COVID-19, on the developing, recurring, or

improving the IMIDS, it is necessary to capture the

trends at different stages of the pandemic. For example,

there may be a surge in incidents as the post-COVID-19

era progresses and diagnoses return to normal levels.

The increased attention to One Health after the COVID-

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10 www.thelancet.com Vol 64 October, 2023

19 pandemic is an opportunity to focus efforts and re-

sources on IMIDs, which can strengthen multisectoral

coordination mechanisms at national, regional, and

global levels.

75,76

The previous analyses of the GBD study have high-

lighted its limitations.

11,15

The major limitation of the

analysis of the incidence of six IMIDs is the sources vary

substantially and out-of-sample modelling data where

primary data are not available. Although the data for the

modelling on the incidence of IMIDs comes from sci-

entiﬁc literature, national surveys, claims data, data were

excluded if they violated established regional trends and

age distributions, if they led to overestimation of sub-

national pseudo-random effects and poor model ﬁt. The

GBD study tried to include all available data to modeling

the global-regional-national incidence of IMIDs but part

data were marked as outliers and excluded if they were

implausibly high or low relative to global or regional

patterns, substantially conﬂicted with established age or

temporal patterns, signiﬁcantly conﬂicted with other

data sources conducted from the same locations or lo-

cations with similar socio-demographic index. Five

additional limitations have been identiﬁed. Firstly, the

current estimates of the incidence of IMIDs do not

reﬂect the impact of the COVID-19 pandemic. Secondly,

underreporting of IMID incidence in low- and middle-

income countries may occur due to inadequate report-

ing mechanisms and infrastructure in some regions.

However, the incidence rates of some countries may

have been overestimated as they were based on data

from major cities. Thirdly, the study does not include a

comprehensive list of IMIDs, such as systemic lupus

erythematosus, scleroderma, and primary Sjogren’s

syndrome, Muckle Wells syndrome. Fourthly, the

physician density, healthcare access, the quality of

medical training might inﬂuence the diagnosis of

different IMIDs, especially the incidence of IMIDs

might overestimate in developed countries and under-

estimate in developing countries. Fifthly, as inpatients

with IMIDs are severely affected patients, further anal-

ysis of inpatient data with IMIDs could reﬂect refractory

disease burden and difference of disease burden be-

tween inpatient and outpatient.

We recommend four areas of work that need priority

in future research. Firstly, it should incorporate how

intercept interventions impact the incidence of new

cases. Secondly, it should explore the reasons behind

these epidemiological transitions. Thirdly, it is vital to

train health care providers in the use of up-to-date

therapeutics. Finally, it should prioritize investments

and cost-effective healthcare to address the substantial

unmet healthcare needs.

Contributors

Dongze Wu, Yingzhao Jin, Cui Guo, and Lai-shan Tam had full access to

all the data in the study and directly accessed and veriﬁed the underlying

data reported in the manuscript. All authors had access to, reviewed

estimates, and agree to submit the manuscript. Please see appendix

(Authors’contributions) for more detailed information about individual

author contributions to the research, divided into the following cate-

gories: managing the overall research enterprise; writing the ﬁrst draft

of the manuscript; primary responsibility for applying analytical

methods to produce estimates; primary responsibility for seeking,

cataloguing, extracting, or cleaning data; designing or coding ﬁgures

and tables; providing data or critical feedback on data sources; devel-

oping methods or computational machinery; providing critical feedback

on methods or results; drafting the manuscript or revising it critically for

important intellectual content; and managing the estimation or publi-

cations process.

Data sharing statement

Data used for the analyses are publicly available from the Institute of

Health Metrics and Evaluation (http://www.healthdata.org/; http://

ghdx.healthdata.org/gbd-results-tool).

Declaration of interests

K Abuabara reports grants or contracts from Pﬁzer and Cosmetique

Internacional SNC to their institution, University of California San

Francisco; consulting fees from TARGET RWE; outside the submitted

work. S Bhaskar reports leadership or ﬁduciary role in other board,

society, committee or advocacy group, paid or unpaid, with the Rotary

Club or Sydney as Board Director and Chair of Youth, with Rotary

District 9675 as Chair of Diversity, Equity and Inclusion, and with

Global Hub Health Germany as Founding Member and Co-manager, all

outside the submitted work. R Buchbinder reports grants from

Australian National Health and Medical Research Council (NHMRC),

Arthritis Australia, Cabrini Foundation, HCF Foundation, Australian

Department of Health to their institution; royalties or licenses from

UptoDate as personal payments for a chapter on plantar fasciitis; all

outside the submitted work. A K Demetriades reports leadership or ﬁ-

duciary role in other board, society, committee or advocacy group, paid

or unpaid, with European Association of Neurosurgical Societies

(EANS) as President and with Global Neuro Foundation as Board

Member, all outside the submitted work. I Filip and A Radfar report

payment or honoraria for lectures, presentations, speakers bureaus,

manuscript writing or educational events from Avicenna Medical and

Clinical Research Institute. T Fukumoto reports payment or honoraria

for lectures, presentations, speakers bureaus, manuscript writing or

educational events from AbbVie, Eli Lilly, Sanoﬁ,Pﬁzer, Maruho,

Novartis, Taiho, Sun Pharma, UCB, and Janssen Pharma, all outside the

submitted work. C Herteliu reports a research grant from Romanian

Ministry of Research Innovation and Digitalization, MCID, for project

titled “Enhancing institutional performance through development of

infrastructure and transdisciplinary research ecosystem within socio-

economic domain–PERFECTIS,”project number ID-585-CTR-42-

PFE-2021, outside the submitted work. N Ismail reports leadership or

ﬁduciary role in other board, society, committee or advocacy group,

unpaid, with the Malaysian Academy of Pharmacy as council member

and bursar, outside the submitted work. K Krishan reports non-ﬁnancial

support from UGC Centre of Advanced Study, CAS II, Department of

Anthropology, Panjab University, Chandigarh, India, outside the sub-

mitted work. V Shivarov reports a pending Bulgarian patent for Possible

SARS-CoV-2 preimmune epitopes; stock or stock options in ICON PLC

through restricted stock units; other ﬁnancial interests from PRAHS/

ICON PLC through their salary; all outside the submitted work. C R

Simpson reports research grants from MBIE (NZ), HRC (NZ), Ministry

of Health (NZ), MRC (UK), HDRUK, and CSO (UK) to their institution,

all outside the submitted work. J A Singh reports consulting fees from

Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs Inc., Adept Field

Solutions, Clinical Care Options, Clearview Healthcare Partners, Put-

nam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ,

Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, Practice

Point Communications, the National Institutes of Health, and the

American College of Rheumatology all as personal payments; payment

or honoraria for speakers’bureaus from Simply Speaking; support for

attending meetings or travel from the steering committee of OMER-

ACT; unpaid participation on a Data Safety Monitoring Board or

Articles

www.thelancet.com Vol 64 October, 2023 11

Advisory Board with the US Food and Drug Administration Arthritis

Advisory Committee; leadership or ﬁduciary role in board, society,

committee or advocacy group, paid or unpaid, with OMERACT as a

steering committee member, with the Veterans Affairs Rheumatology

Field Advisory Committee as Chair (unpaid), and with the UAB

Cochrane Musculoskeletal Group Satellite Center on Network Meta-

analysis and editor and director (unpaid); stock or stock options in

Atai Life Sciences, Kintara Therapeutics, Intelligent Biosolutions,

Acumen Pharmaceutical, TPT Global Tech, Vaxart Pharmaceuticals,

Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris

Pharmaceuticals, Enzolytics Inc., Seres Therapeutics, Tonix Pharma-

ceuticals Holding Corp., and Charlotte’s Web Holdings, Inc., and pre-

viously owned stock options in Amarin, Viking, and Moderna

Pharmaceuticals; all outside the submitted work. M Zieli ´

nska reports

other ﬁnancial or non-ﬁnancial interests as an employee of AstraZeneca,

outside the submitted work. E Upadhyay reports a published patent for

A system and method of reusable ﬁlters for anti-pollution mask, A

system and method for electricity generation through crop stubble by

using microbial fuel cells, A system for disposed personal protection

equipment (PPE) into biofuel through pyrolysis and method, A novel

herbal pharmaceutical aid for formulation of gel and method thereof,

and reports leadship for Joint Secretary of Indian Meteorological Society,

Jaipur Chapter, India, Member Secretary-DSTPURSE Program.

Acknowledgements

DZ Wu acknowledges support from Scientiﬁc Research Fund of

Sichuan Academy of Medical Sciences & Sichuan Provincial People’s

Hospital (2022QN38). A Ahmad acknowledges support from Shaqra

University. A N Bhat acknowledges support from Kasturba Medical

College, Mangalore, Manipal Academy of Higher Education. V B Bitra

acknowledges support from the School of Pharmacy, University of

Botswana. K Bora acknowledges support from the Indian Council of

Medical Research (ICMR) under the research scheme titled ‘ICMR

Capacity Building for Disease Estimation and Projection’for the area

Non-communicable Diseases. R Buchbinder is supported by an

Australian National Health and Medical Research Council (NHMRC)

Investigator Fellowship. G Damiani acknowledges support from the

Italian Center of Precision Medicine and Chronic Inﬂammation in

Milan. A Fatehizadeh acknowledges support from the Department of

Environmental Health Engineering of Isfahan University of Medical

Sciences, Isfahan, Iran. V K Gupta acknowledges funding support from

National Health and Medical Research Council (NHMRC), Australia. S

Haque acknowledges support from Jazan University, Saudi Arabia for

providing the access of Saudi Digital Library for this study. J Haubold

acknowledges support from The Clinician Scientist Program of the

Clinician Scientist Academy (UMEA) of the University Hospital Essen.

N Ismail acknowledges support from AIMST University, Malaysia. N

Joseph acknowledges the Department of Community Medicine, Kas-

turba Medical College, Mangalore, Manipal Academy of Higher Edu-

cation, Manipal, India for their encouragement and support in this

research work. H Kandel is supported by a Kornhauser Research

Fellowship at The University of Sydney. J Lám acknowledges support

from the National Research, Development and Innovation Ofﬁce

Hungary. K Latief acknowledges support from Taipei Medical Univer-

sity for Doctoral Education during the conduct of this review. G Liu was

supported by CREATE Hope Scientiﬁc Fellowship from Lung Founda-

tion Australia. A G Mathioudakis was supported by the National Insti-

tute for Health and Care Research Manchester Biomedical Research

Centre and an NIHR Clinical Lectureship in Respiratory Medicine. J

Padubidri acknowledges Kasturba Medical College, Mangalore and

Manipal Academy of Higher Education, Manipal for their collaborative

support for the research. A R Pathan acknowledges Author Gate Pub-

lications for their support. I Qattea acknowledges support from the

Cleveland Clinic Foundation and Nassau University Medical center. A

Raggi is supported by the Italian Ministry of Health (RRC). E M M

Redwan acknowledges support from King Abdulaziz University (DSR),

Jeddah, and King Abdulaziz City for Science & Technology (KACSAT),

Saudi Arabia, Science & Technology Development Fund (STDF), and

US-Egypt Science & Technology joint Fund: The Academy of Scientiﬁc

Research and Technology (ASRT), Egypt. M Rodrigues was partially

supported by the Centre of Studies in Geography and Spatial Planning.

U Saeed would like to acknowledge the International Center of Medical

Sciences Research (ICMSR), Islamabad Pakistan. A M Samy acknowl-

edges the support from Ain Shams University and the Egyptian Ful-

bright Mission Program. A Schuermans was supported by the Belgian

American Educational Foundation. A Sheikh acknowledges support

from Health Data Research UK. R Tabarés-Seisdedos is supported by

the Spanish Ministry of Science and Innovation, Institute of Health

Carlos III, CIBERSAM, and INCLIVA. S Tabatabaei would like to

acknowledge the Clinical Research Development Unit, Imam Reza

Hospital, Mashhad University of Medical Sciences, for their assistance.

M Tabish would like to acknowledge Shaqra University for supporting

this work. M R Tovani-Palone acknowledges Saveetha Institute of

Medical and Technical Sciences and SRM Institute of Science and

Technology for supporting this study. Sai Ullah acknowledges support

by University of Agriculture, Faisalabad-Pakistan. Y Xing acknowledges

support from the Chinese University of Hong Kong Research Com-

mittee Postdoctoral Fellowship Scheme. G Yahya acknowledges the

institutional support of the Department of Microbiology and Immu-

nology, Faculty of Pharmacy, Zagazig University, Egypt. A Zumla ac-

knowledges support from the European (EU) and Developing Countries

Clinical Trials Partnership, the EU Horizon 2020 Framework Pro-

gramme, UK-National Institute for Health and Care Research, the

Mahathir Science Award Foundation and EU-EDCTP.

Collaborators

Dongze Wu

,¶

, Yingzhao Jin

#,¶

, Yuhan Xing

#,¶

, Melsew Dagne

Abate, Mohammadreza Abbasian, Mohsen Abbasi-Kangevari,

Zeinab Abbasi-Kangevari, Foad Abd-Allah, Michael Abdelmasseh,

Mohammad-Amin Abdollahifar, Deldar Morad Abdulah, Aidin Abedi,

Vida Abedi, Hassan Abidi, Richard Gyan Aboagye, Hassan Abolhassani,

Katrina Abuabara, Morteza Abyadeh, Isaac Yeboah Addo, Kayode

Nelson Adeniji, Abiola Victor Adepoju, Miracle Ayomikun Adesina,

Qorinah Estiningtyas Sakilah Adnani, Mohsen Afarideh, Shahin Agha-

miri, Antonella Agodi, Anurag Agrawal, Constanza Elizabeth Aguilera

Arriagada, Aqeel Ahmad, Danish Ahmad, Sajjad Ahmad, Sohail Ahmad,

Ali Ahmadi, Ali Ahmed, Ayman Ahmed, Janardhana P Aithala,

Abdullateef Abiodun Ajadi, Marjan Ajami, Mostafa Akbarzadeh-Khiavi,

Fares Alahdab, Mohammad T AlBataineh, Sharifullah Alemi, Adel Ali

Saeed Al-Gheethi, Liaqat Ali, Sheikh Mohammad Alif, Joseph Uy

Almazan, Sami Almustanyir, Jaber S Alqahtani, Ibrahim Alqasmi, Ihsan

Ullah Khan Altaf, Nelson Alvis-Guzman, Nelson J Alvis-Zakzuk, Yaser

Mohammed Al-Woraﬁ, Hany Aly, Reza Amani, Hubert Amu, Ganiyu

Adeniyi Amusa, Catalina Liliana Andrei, Adnan Ansar, Hossein

Ansariniya, Anayochukwu Edward Anyasodor, Jalal Arabloo, Reza Are-

fnezhad, Judie Arulappan, Mohammad Asghari-Jafarabadi, Tahira

Ashraf, Jamila Abdulhamid Atata, Seyyed Shamsadin Athari, Daniel

Atlaw, Maha Moh’d Wahbi Atout, Avinash Aujayeb, Asma Tahir Awan,

Haleh Ayatollahi, Sina Azadnajafabad, Ahmed Y Azzam, Alaa Badawi,

Ashish D Badiye, Sara Bagherieh, Atif Amin Baig, Berihun Bantie

Bantie, Martina Barchitta, Mainak Bardhan, Suzanne Lyn Barker-Collo,

Francesco Barone-Adesi, Kavita Batra, Nebiyou Simegnew Bayileyegn,

Amir Hossein Behnoush, Uzma Iqbal Belgaumi, Maryam Bemanali-

zadeh, Isabela M Bensenor, Kebede A Beyene, Akshaya Srikanth

Bhagavathula, Pankaj Bhardwaj, Sonu Bhaskar, Ajay Nagesh Bhat, Saeid

Bitaraf, Veera R Bitra, Archith Boloor, Kaustubh Bora, João Silva

Botelho, Rachelle Buchbinder, Daniela Calina, Luis Alberto Cámera,

Andre F Carvalho, Jeffrey Shi Kai Chan, Vijay Kumar Chattu, Endeshaw

Chekol Abebe, Fatemeh Chichagi, Sungchul Choi, Tzu-Chieh Chou,

Dinh-Toi Chu, Kaleb Coberly, Vera Marisa Costa, Rosa A S Couto,

Natália Cruz-Martins, Omid Dadras, Xiaochen Dai, Giovanni Damiani,

Ana Maria Dascalu, Mohsen Dashti, Sisay Abebe Debela, Robert Paul

Dellavalle, Andreas K Demetriades, Alemayehu Anley Demlash, Xinlei

Deng, Hardik Dineshbhai Desai, Rupak Desai, Syed Masudur Rahman

Dewan, Sourav Dey, Samath Dhamminda Dharmaratne, Daniel Diaz,

Mahmoud Dibas, Ricardo Jorge Dinis-Oliveira, Mengistie Diress, Thanh

Chi Do, Duy Khanh Doan, Masoud Dodangeh, Milad Dodangeh, Deepa

Dongarwar, John Dube, Arkadiusz Marian Dziedzic, Abdelaziz Ed-Dra,

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Hisham Atan Edinur, Negin Eissazade, Michael Ekholuenetale,

Temitope Cyrus Ekundayo, Noha Mousaad Elemam, Muhammed

Elhadi, Ahmed O Elmehrath, Omar Abdelsadek Abdou Elmeligy, Mehdi

Emamverdi, Theophilus I Emeto, Hawi Leul Esayas, Habitu Birhan

Eshetu, Farshid Etaee, Adeniyi Francis Fagbamigbe, Shahriar Faghani,

Ildar Ravisovich Fakhradiyev, Ali Fatehizadeh, Mobina Fathi, Alireza

Feizkhah, Ginenus Fekadu, Mohammad Fereidouni, Seyed-Mohammad

Fereshtehnejad, João C Fernandes, Pietro Ferrara, Getahun Fetensa,

Irina Filip, Florian Fischer, Behzad Foroutan, Masoud Foroutan,

Takeshi Fukumoto, Balasankar Ganesan, Belete Negese Belete Gemeda,

Seyyed-Hadi Ghamari, MohammadReza Ghasemi, Maryam Gholama-

lizadeh, Tiffany K Gill, Richard F Gillum, Mohamad Goldust, Mahaveer

Golechha, Pouya Goleij, Davide Golinelli, Houman Goudarzi, Shi-Yang

Guan, Yang Guo, Bhawna Gupta, Veer Bala Gupta, Vivek Kumar Gupta,

Rasool Haddadi, Najah R Hadi, Rabih Halwani, Shaﬁul Haque, Ikramul

Hasan, Reza Hashempour, Amr Hassan, Treska S Hassan,

Sara Hassanzadeh, Mohammed Bheser Hassen, Johannes Haubold,

Khezar Hayat, Golnaz Heidari, Mohammad Heidari, Reza Heidari-

Soureshjani, Claudiu Herteliu, Kamran Hessami, Kamal Hezam, Yuta

Hiraike, Ramesh Holla, Mohammad-Salar Hosseini, Hong-Han Huynh,

Bing-Fang Hwang, Segun Emmanuel Ibitoye, Irena M Ilic, Milena D

Ilic, Arad Iranmehr, Farideh Iravanpour, Nahlah Elkudssiah Ismail,

Masao Iwagami, Chidozie C D Iwu, Louis Jacob, Morteza Jafarinia,

Abdollah Jafarzadeh, Kasra Jahankhani, Haitham Jahrami, Mihajlo

Jakovljevic, Elham Jamshidi, Chinmay T Jani, Manthan Dilipkumar

Janodia, Sathish Kumar Jayapal, Shubha Jayaram, Jayakumar Jegana-

than, Jost B Jonas, Abel Joseph, Nitin Joseph, Charity Ehimwenma

Joshua, Vaishali K, Billingsley Kaambwa, Ali Kabir, Zubair Kabir, Vidya

Kadashetti, Feroze Kaliyadan, Fatemeh Kalroozi, Vineet Kumar Kamal,

Amit Kandel, Himal Kandel, Srikanta Kanungo, Jafar Karami, Ibraheem

M Karaye, Hanie Karimi, Hengameh Kasraei, Sina Kazemian, Sewnet

Adem Kebede, Leila Keikavoosi-Arani, Mohammad Keykhaei, Yousef

Saleh Khader, Himanshu Khajuria, Faham Khamesipour, Ejaz Ahmad

Khan, Imteyaz A Khan, Maseer Khan, Md Jobair Khan, Moien AB Khan,

Muhammad Arslan Khan, Haitham Khatatbeh, Moawiah Mohammad

Khatatbeh, Sorour Khateri, Hamid Reza Khayat Kashani, Min Seo Kim,

Adnan Kisa, Sezer Kisa, Hyun Yong Koh, Pavel Kolkhir, Oleksii Korzh,

Ashwin Laxmikant Kotnis, Parvaiz A Koul, Ai Koyanagi, Kewal Krishan,

Mohammed Kuddus, Vishnutheertha Vishnutheertha Kulkarni, Nar-

inder Kumar, Satyajit Kundu, Om P Kurmi, Carlo La Vecchia, Chan-

drakant Lahariya, Tri Laksono, Judit Lám, Kamaluddin Latief, Paolo

Lauriola, Basira Kankia Lawal, Thao Thi Thu Le, Trang Thi Bich Le,

Munjae Lee, Seung Won Lee, Wei-Chen Lee, Yo Han Lee, Jacopo Lenzi,

Miriam Levi, Wei Li, Virendra S Ligade, Stephen S Lim, Gang Liu,

Xuefeng Liu, Erand Llanaj, Chun-Han Lo, Vanessa Sintra Machado,

Azzam A Maghazachi, Mansour Adam Mahmoud, Tuan A Mai, Azeem

Majeed, Pantea Majma Sanaye, Omar Mohamed Makram, Elaheh

Malakan Rad, Kashish Malhotra, Ahmad Azam Malik, Iram Malik,

Tauqeer Hussain Mallhi, Deborah Carvalho Malta, Mohammad Ali

Mansournia, Lorenzo Giovanni Mantovani, Miquel Martorell, Sahar

Masoudi, Seyedeh Zahra Masoumi, Yasith Mathangasinghe, Elezebeth

Mathews, Alexander G Mathioudakis, Andrea Maugeri, Mahsa Mayeli,

John Robert Carabeo Medina, Gebrekiros Gebremichael Meles, José

João Mendes, Ritesh G Menezes, Tomislav Mestrovic, Irmina Maria

Michalek, Ana Carolina Micheletti Gomide Nogueira de Sá, Ephrem

Tesfaye Mihretie, Le Huu Nhat Minh, Reza Mirfakhraie, Erkin M

Mirrakhimov, Awoke Misganaw, Ashraf Mohamadkhani, Nouh Saad

Mohamed, Faezeh Mohammadi, Soheil Mohammadi, Salahuddin

Mohammed, Shaﬁu Mohammed, Syam Mohan, Anita Mohseni, Ali H

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Mustafa, Sathish Muthu, Firzan Nainu, Vinay Nangia, Sreenivas Nar-

asimha Swamy, Zuhair S Natto, Perumalsamy Navaraj, Biswa Prakash

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Nematollahi, Dang H Nguyen, Hau Thi Hien Nguyen, Hien Quang

Nguyen, Phat Tuan Nguyen, Van Thanh Nguyen, Robina Khan Niazi,

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Mamoona Noreen, Chimezie Igwegbe Nzoputam, Ogochukwu Janet

Nzoputam, Bogdan Oancea, In-Hwan Oh, Hassan Okati-Aliabad,

Osaretin Christabel Okonji, Patrick Godwin Okwute, Andrew T

Olagunju, Matthew Idowu Olatubi, Isaac Iyinoluwa Olufadewa, Michal

Ordak, Nikita Otstavnov, Mayowa O Owolabi, Mahesh P A, Jagadish Rao

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Ashwaghosha Parthasarathi, Ava Pashaei, Jay Patel, Aslam Ramjan

Pathan, Shankargouda Patil, Uttam Paudel, Shrikant Pawar, Paolo

Pedersini, Umberto Pensato, David M Pereira, Jeevan Pereira, Maria

Odete Pereira, Renato B Pereira, Mario F P Peres, Arokiasamy

Perianayagam, Simone Perna, Ionela-Roxana Petcu, Parmida Sadat

Pezeshki, Hoang Tran Pham, Anil K Philip, Michael A Piradov, Indra-

shis Podder, Vivek Podder, Dimitri Poddighe, Elton Junio Sady Prates,

Ibrahim Qattea, Amir Radfar, Pourya Raee, Alireza Raﬁei, Alberto

Raggi, Fakher Rahim, Mehran Rahimi, Mahban Rahimifard, Vafa

Rahimi-Movaghar, Md Obaidur Rahman, Mohammad Hifz Ur Rah-

man, Mosiur Rahman, Muhammad Aziz Rahman, Amir Masoud Rah-

mani, Mohamed Rahmani, Shayan Rahmani, Vahid Rahmanian,

Premkumar Ramasubramani, Nemanja Rancic, Indu Ramachandra

Rao, Sina Rashedi, Ahmed Mustafa Rashid, Nakul Ravikumar, Salman

Rawaf, Elrashdy Moustafa Mohamed Redwan, Nazila Rezaei, Negar

Rezaei, Nima Rezaei, Mohsen Rezaeian, Daniela Ribeiro, Mónica

Rodrigues, Jefferson Antonio Buendia Rodriguez, Leonardo Roever,

Esperanza Romero-Rodríguez, Aly M A Saad, Basema Saddik, Saeid

Sadeghian, Umar Saeed, Azam Safary, Mahdi Safdarian, Sher Zaman

Saﬁ, Amene Saghazadeh, Dominic Sagoe, Fatemeh Saheb Sharif-Askari,

Narjes Saheb Sharif-Askari, Amirhossein Sahebkar, Harihar Sahoo,

Mohammad Ali Sahraian, Mirza Rizwan Sajid, Sateesh Sakhamuri,

Joseph W Sakshaug, Mohamed A Saleh, Leili Salehi, Sana Salehi, Amir

Salek Farrokhi, Sara Samadzadeh, Saad Samargandy, Noosha Samiee-

far, Abdallah M Samy, Nima Sanadgol, Rama Krishna Sanjeev, Monika

Sawhney, Ganesh Kumar Saya, Art Schuermans, Subramanian Sen-

thilkumaran, Sadaf G Sepanlou, Yashendra Sethi, Mahan Shaﬁe,

Humaira Shah, Izza Shahid, Samiah Shahid, Masood Ali Shaikh, Sadaf

Sharfaei, Manoj Sharma, Maryam Shayan, Hatem Samir Shehata, Aziz

Sheikh, Jeevan K Shetty, Jae Il Shin, Reza Shirkoohi, Nebiyu Aniley

Shitaye, K M Shivakumar, Velizar Shivarov, Parnian Shobeiri, Soraya

Siabani, Migbar Mekonnen Sibhat, Emmanuel Edwar Siddig, Colin R

Simpson, Ehsan Sinaei, Harpreet Singh, Inderbir Singh, Jasvinder A

Singh, Paramdeep Singh, Surjit Singh, Md Shahjahan Siraj, Abdullah

Al Mamun Sohag, Ranjan Solanki, Solikhah Solikhah, Yonatan Solo-

mon, Mohammad Sadegh Soltani-Zangbar, Jing Sun, Mindy D Szeto,

Rafael Tabarés-Seisdedos, Seyyed Mohammad Tabatabaei, Mohammad

Tabish, Ensiyeh Taheri, Azin Tahvildari, Iman M Talaat, Jacques JL

Lukenze Tamuzi, Ker-Kan Tan, Nathan Y Tat, Razieh Tavakoli Oliaee,

Arian Tavasol, Mohamad-Hani Temsah, Pugazhenthan Thangaraju,

Samar Tharwat, Nigusie Selomon Tibebu, Jansje Henny Vera Ticoalu,

Tala Tillawi, Tenaw Yimer Tiruye, Amir Tiyuri, Marcos Roberto Tovani-

Palone, Manjari Tripathi, Guesh Mebrahtom Tsegay, Abdul Rohim

Tualeka, Sree Sudha Ty, Chukwudi S Ubah, Saif Ullah, Sana Ullah,

Muhammad Umair, Srikanth Umakanthan, Era Upadhyay, Seyed

Mohammad Vahabi, Asokan Govindaraj Vaithinathan, Sahel Valadan

Tahbaz, Rohollah Valizadeh, Shoban Babu Varthya, Tommi Juhani

Vasankari, Narayanaswamy Venketasubramanian, Georgios-Ioannis

Verras, Jorge Hugo Villafañe, Vasily Vlassov, Danh Cao Vo, Yasir

Waheed, Abdul Waris, Brhane Gebrehiwot Welegebrial, Ronny West-

erman, Dakshitha Praneeth Wickramasinghe, Nuwan Darshana Wick-

ramasinghe, Barbara Willekens, Beshada Zerfu Woldegeorgis, Melat

Woldemariam, Hong Xiao, Dereje Y Yada, Galal Yahya, Lin Yang,

Fereshteh Yazdanpanah, Dong Keon Yon, Naohiro Yonemoto, Yuyi

You, Mazyar Zahir, Syed Saoud Zaidi, Moein Zangiabadian, Iman Zare,

Mohammad A Zeineddine, Dawit T Zemedikun, Naod Gebrekrstos

Zeru, Chen Zhang, Hanqing Zhao, Chenwen Zhong, Magdalena Zie-

li ´

nska, Mohammad Zoladl, Alimuddin Zumla, Cui Guo*

,¶

, and Lai-

shan Tam*

,¶

Joint ﬁrst authors.

*Joint senior authors.

Writing authors.

Articles

www.thelancet.com Vol 64 October, 2023 13

Afﬁliations

Department of Rheumatology and Immunology (D Wu PhD), Sichuan

Provincial People’s Hospital, School of Medicine, University of Elec-

tronic Science and Technology of China; Department of Medicine &

Therapeutics (Y Jin PhD, Prof L Tam MD), Department of Paediatrics

(Y Xing PhD), School of Pharmacy (G Fekadu MSc), Jockey Club School

of Public Health and Primary Care (C Zhong MD), The Chinese Uni-

versity of Hong Kong, Hong Kong, China; Department of Nursing

(M D Abate MSc), Woldia University, Woldia, Ethiopia; Department of

Orthopedic Surgery (M Abbasian MD), Postgraduate Medical Education

(A O Elmehrath PGCert), Maternal Fetal Care Center (K Hessami MD),

Department of Health Policy and Oral Epidemiology (Z S Natto DrPH),

Division of General Internal Medicine (Prof A Sheikh MD), Harvard

University, Boston, MA, USA; Department of Orthopaedic Surgery

(M Abbasian MD), Social Determinants of Health Research Center

(Z Abbasi-Kangevari BSc, S Ghamari MD), Department of Biotech-

nology (S Aghamiri PhD), Department of Epidemiology (A Ahmadi

PhD), National Nutrition and Food Technology Research Institute

(M Ajami PhD), Department of Immunology (H Ansariniya PhD,

K Jahankhani MSc), Department of Neurology (M Fathi MD), Depart-

ment of Medical Genetics (M Ghasemi PhD), Center for Comprehen-

sive Genetic Services (M Ghasemi PhD), Cancer Research Center

(M Gholamalizadeh PhD), Department of Health Economics and Sta-

tistics (R Hashempour MSc), Functional Neurosurgery Research Center

(E Jamshidi PharmD), Department of Neurosurgery (H Khayat Kashani

MD), Department of Genetics (R Mirfakhraie PhD), Department of

Virology (A Mohseni BSc), Department of Biology and Anatomical

Sciences (P Raee PhD), School of Medicine (S Rahmani MD, N

Samieefar MD, M Zangiabadian MD), Ophthalmic Research Center

(ORC) (M Shayan MD), Department of Dermatology (A Tahvildari MD),

Faculty of Medicine (A Tavasol MD), Urology and Nephrology Research

Center (M Zahir MD), Shahid Beheshti University of Medical Sciences,

Tehran, Iran; Non-communicable Diseases Research Center (M Abbasi-

Kangevari MD, Z Abbasi-Kangevari BSc, S Azadnajafabad MD, S Gha-

mari MD, M Keykhaei MD, S Momtazmanesh MD, P Mousavi MD,

S Rahmani MD, N Rezaei MD, N Rezaei PhD), Research Center for

Immunodeﬁciencies (H Abolhassani PhD, Prof N Rezaei PhD,

A Saghazadeh MD), Endocrinology and Metabolism Research Center

(M Afarideh MD, N Rezaei PhD), School of Medicine (A Behnoush BS,

M Mayeli MD, S Mohammadi MD, S Momtazmanesh MD), Depart-

ment of Pediatric Neurology (M Bemanalizadeh MD), Department of

Scientiﬁc Research (F Chichagi MD), Interdisciplinary Neuroscience

Research Program (S Faghani MD), Department of Neurosurgery (A

Iranmehr MD), Immunology Department (J Karami PhD), Department

of Medicine (H Karimi MD), Cardiac Primary Prevention Research

Center (S Kazemian MD), Department of Cardiac Electrophysiology (S

Kazemian MD), Students Scientiﬁc Research Center (SSRC) (M Key-

khaei MD), Center for Research and Training in Skin Diseases and

Leprosy (F Khamesipour PhD), Department of Pediatric Cardiology

(Prof E Malakan Rad MD), Department of Epidemiology and Biostatis-

tics (M Mansournia PhD), Digestive Diseases Research Institute

(S Masoudi MSc, A Mohamadkhani PhD, S G Sepanlou MD), Depart-

ment of Internal Medicine (P Pezeshki BMedSc), Department of Public

Health (P Pezeshki BMedSc), Pharmaceutical Sciences Research Center

(PSRC) (M Rahimifard PhD), Sina Trauma and Surgery Research

Center (Prof V Rahimi-Movaghar MD), Department of Cardiology

(S Rashedi MD), Multiple Sclerosis Research Center (Prof M Sahraian

MD), Department of Neurology (M Shaﬁe MD), Cancer Research Center

(R Shirkoohi PhD), Cancer Biology Research Center (R Shirkoohi PhD),

Faculty of Medicine (P Shobeiri MD, S Vahabi MD), Department of

Pediatric Allergy and Immunology (F Yazdanpanah MD), Tehran Uni-

versity of Medical Sciences, Tehran, Iran (R Heidari-Soureshjani MSc);

Department of Neurology (Prof F Abd-Allah MD, A Hassan MD, Prof H

S Shehata MD), Faculty of Medicine (A O Elmehrath PGCert), Cairo

University, Cairo, Egypt; Department of Surgery (M Abdelmasseh MD),

Marshall University, Huntington, WV, USA; Department of Small An-

imal Clinical Sciences (M Abdollahifar PhD), University of Saskatch-

ewan, Saskatoon, SK, Canada; Community and Maternity Nursing Unit

(D M Abdulah MPH), University of Duhok, Duhok, Iraq; Department of

Neurosurgery (A Abedi MD), Keck School of Medicine (A Abedi MD),

Mark and Mary Stevens Neuroimaging and Informatics Institute

(S Salehi MD), University of Southern California, Los Angeles, CA,

USA; Department of Public Health Sciences (V Abedi PhD), Pennsyl-

vania State University, Hershey, PA, USA; Biocomplexity Institute (V

Abedi PhD), Virginia Tech, Blacksburg, VA, USA; Laboratory Technol-

ogy Sciences Department (H Abidi PhD), Department of Nursing (M

Zoladl PhD), Yasuj University of Medical Sciences, Yasuj, Iran;

Department of Family and Community Health (R G Aboagye MPH),

Department of Population and Behavioural Sciences (H Amu PhD),

University of Health and Allied Sciences, Ho, Ghana; Department of

Biosciences and Nutrition (H Abolhassani PhD), Karolinska University

Hospital, Huddinge, Sweden; Department of Dermatology (K Abuabara

MD), University of California San Francisco, San Francisco, CA, USA;

Virginia Commonwealth University, Richmond, VA, USA (M Abyadeh

PhD); Centre for Social Research in Health (I Y Addo PhD), University

of New South Wales, Sydney, NSW, Australia; Quality and Systems

Performance Unit (I Y Addo PhD), Cancer Institute NSW, Sydney,

NSW, Australia; Department of Geography Planning and Environment

(K N Adeniji MSc), Department of Public Health (C S Ubah MPH), East

Carolina University, Greenville, NC, USA; HIV and Infectious Diseases

Department (A V Adepoju MD), Jhpiego, Abuja, Nigeria; Adolescent

Research and Care (A V Adepoju MD), Adolescent Friendly Research

Initiative and Care, Ado Ekiti, Nigeria; Slum and Rural Health Initiative

Research Academy (M A Adesina BPT, I I Olufadewa MHS), Slum and

Rural Health Initiative, Ibadan, Nigeria; Department of Physiotherapy

(M A Adesina BPT), Department of Epidemiology and Medical Statistics

(M Ekholuenetale MSc, A F Fagbamigbe PhD), Faculty of Public Health

(M Ekholuenetale MSc, I I Olufadewa MHS), Department of Health

Promotion and Education (S E Ibitoye MPH), Department of Medicine

(Prof M O Owolabi DrM), University of Ibadan, Ibadan, Nigeria; Faculty

of Medicine (Q E S Adnani PhD), Universitas Padjadjaran, Bandung,

Indonesia; Department of Dermatology (M Afarideh MD), Mayo Clinic,

Rochester, MN, USA; Department of Medical and Surgical Sciences and

Advanced Technologies “GF Ingrassia”(Prof A Agodi PhD, M Barchitta

PhD, A Maugeri PhD), University of Catania, Catania, Italy; Trivedi

School of Biosciences (Prof A Agrawal PhD), Ashoka University, Soni-

pat, India; Section of General Internal Medicine (Prof A Agrawal PhD),

Baylor College of Medicine, Houston, TX, USA; Unidad de Emergencia

Adulto (C E Aguilera Arriagada MD), Complejo Asistencial Dr. Sótero

del Río, Santiago de Chile, Chile; Department of Medical Biochemistry

(A Ahmad PhD), Department of Pediatrics (Prof G Mustafa MD),

Department of Pharmacology (A R Pathan PhD, M Tabish MPharm),

Shaqra University, Shaqra, Saudi Arabia; Health Research Institute (D

Ahmad PhD), University of Canberra, Canberra, ACT, Australia; Public

Health Foundation of India, Gandhinagar, India (D Ahmad PhD);

Department of Health and Biological Sciences (S Ahmad PhD), Abasyn

University, Peshawar, Pakistan; Faculty of Pharmacy (S Ahmad MSc),

MAHSA University, Kuala Langat, Malaysia; Department of Epidemi-

ology and Biostatistics (A Ahmadi PhD), Community-oriented Nursing

Midwifery Research Center (M Heidari PhD), Shahrekord University of

Medical Sciences, Shahrekord, Iran; School of Pharmacy (A Ahmed

MPhil), Monash University, Bandar Sunway, Malaysia; Department of

Pharmacy (A Ahmed MPhil), Quaid I Azam University Islamabad,

Islamabad, Pakistan; Institute of Endemic Diseases (A Ahmed MSc),

Unit of Basic Medical Sciences (E E Siddig MD), University of Khar-

toum, Khartoum, Sudan; Swiss Tropical and Public Health Institute (A

Ahmed MSc), University of Basel, Basel, Switzerland; Department of

Orthopedics (Prof J P Aithala DNB, J Pereira MS), Yenepoya Medical

College, Mangalore, India; Department of Veterinary Pathology

(A A Ajadi MS), University of Ibadan, Ilorin, Nigeria; Veterinary Pa-

thology (A A Ajadi MS), Stockholm County Council Surveillance and

Analysis Centre for Epidemiology and Community Medicine, Ilorin,

Nigeria; Department of Food and Nutrition Policy and Planning

Research (M Ajami PhD), National Institute of Nutrition, Tehran, Iran;

Liver and Gastrointestinal Diseases Research Center (M Akbarzadeh-

Khiavi PhD), Department of Radiology (M Dashti MD), Research Cen-

ter for Evidence-Based Medicine (M Hosseini MD), Cardiovascular

Research Center (M Rahimi MD), Connective Tissue Diseases Research

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Center (A Safary PhD), Department of Immunology (M Soltani-Zangbar

MSc), Department of Pediatric Allergy and Immunology (F Yazdanpa-

nah MD), Tabriz University of Medical Sciences, Tabriz, Iran; Evidence-

Based Practice Center (F Alahdab MSc), Mayo Clinic Foundation for

Medical Education and Research, Rochester, MN, USA; Department of

Molecular Biology and Genetics (Prof M T AlBataineh PhD, Prof M

Rahmani PhD), Center for Biotechnology (Prof M Rahmani PhD),

Khalifa University, Abu Dhabi, United Arab Emirates; Global Health

Entrepreneurship (S Alemi PhD), Tokyo Medical and Dental University,

Tokyo, Japan; Micropollutant Research Centre (MPRC) (A A S Al-

Gheethi PhD), Tun Hussein Onn University of Malaysia (Universiti

Tun Hussein Onn Malaysia (UTHM)), Batu Pahat, Malaysia; Camborne

School of Mines (A A S Al-Gheethi PhD), University of Exeter, Penryn,

UK; Department of Biological Sciences (L Ali PhD), National University

of Medical Sciences, Rawalpindi, Pakistan; School of Public Health and

Preventive Medicine (S M Alif PhD), School of Public Health and Pre-

ventative Medicine (Prof M Asghari-Jafarabadi PhD), Department of

Epidemiology and Preventive Medicine (Prof R Buchbinder PhD),

Monash University, Melbourne, VIC, Australia; Department of Medi-

cine (J U Almazan PhD), School of Medicine (Prof D Poddighe PhD),

Nazarbayev University, Astana, Kazakhstan; College of Medicine (S

Almustanyir MD), Alfaisal University, Riyadh, Saudi Arabia; Ministry

of Health, Riyadh, Saudi Arabia (S Almustanyir MD); Department of

Respiratory Care (J S Alqahtani PhD), Prince Sultan Military College of

Health Sciences, Dammam, Saudi Arabia; Department of Public Health

(I Alqasmi PhD), Saudi Electronic University, Riyadh, Saudi Arabia;

Health Department (I Altaf MS), Directorate General of Health Services,

Peshawar, Pakistan; Research Group in Hospital Management and

Health Policies (Prof N Alvis-Guzman PhD), Universidad de la Costa

(University of the Coast), Barranquilla, Colombia; Research Group in

Health Economics (Prof N Alvis-Guzman PhD), University of Carta-

gena, Cartagena, Colombia; Department of Economic Sciences (N J

Alvis-Zakzuk MSc), University of the Coast, Barranquilla, Colombia;

National Health Observatory (N J Alvis-Zakzuk MSc), National Institute

of Health, Bogota, Colombia; Department of Medical Sciences (Prof Y M

Al-WoraﬁPhD), Azal University for Human Development, Sana’a,

Yemen; Department of Clinical Sciences (Prof Y M Al-WoraﬁPhD),

University of Science and Technology of Fujairah, Fujairah, United Arab

Emirates; Department of Pediatrics (Prof H Aly MD), Lerner Research

Institute (X Liu PhD), Cleveland Clinic, Cleveland, OH, USA; Depart-

ment of Veterinary Pathology (R Amani DVM), Islamic Azad University,

Babol, Iran; Health Policy Research Center (R Amani DVM, H Kasraei

MD), Department of Anatomy (R Arefnezhad MSc), Maternal Fetal

Medicine Research Center (K Hessami MD), Shiraz Neuroscience

Research Center (F Iravanpour PhD, M Jafarinia PhD), Non-

communicable Disease Research Center (S G Sepanlou MD), Depart-

ment of Physical Therapy (E Sinaei MSc), Department of Parasitology

and Mycology (R Tavakoli Oliaee PhD), Basic Sciences in Infectious

Diseases Research Center (R Tavakoli Oliaee PhD), Shiraz University of

Medical Sciences, Shiraz, Iran; Department of Medicine (G A Amusa

MD), University of Jos, Jos, Nigeria; Department of Internal Medicine

(G A Amusa MD), Jos University Teaching Hospital, Jos, Nigeria; Car-

diology Department (C Andrei PhD), Ophthalmology Department

(A Dascalu PhD), Carol Davila University of Medicine and Pharmacy,

Bucharest, Romania; School of Nursing and Midwifery (A Ansar PhD,

M Rahman PhD), La Trobe University, Melbourne, VIC, Australia;

Special Interest Group International Health (A Ansar PhD), Public

Health Association of Australia, Canberra, ACT, Australia; Reproductive

Immunology Research Center (H Ansariniya PhD), Shahid Sadoughi

University of Medical Sciences, Yazd, Iran; School of Dentistry and

Medical Sciences (A E Anyasodor PhD), Charles Sturt University, Or-

ange, NSW, Australia; Health Management and Economics Research

Center (J Arabloo PhD, H Ayatollahi PhD), Department of Health In-

formation Management (H Ayatollahi PhD), School of Medicine

(M Dodangeh MD, N Eissazade MD, F Mohammadi MD), Minimally

Invasive Surgery Research Center (A Kabir MD), Eye Research Center

(H Kasraei MD), Department of Epidemiology and Biostatistics

(A Tiyuri MSc), Iran University of Medical Sciences, Tehran, Iran;

Department of Maternal and Child Health (J Arulappan DSc), Sultan

Qaboos University, Muscat, Oman; Cabrini Research (Prof M Asghari-

Jafarabadi PhD), Cabrini Health, Melbourne, VIC, Australia; Univer-

sity Institute of Radiological Sciences and Medical Imaging Technology

(T Ashraf MS), University Institute of Public Health (A A Baig PhD, A A

Malik PhD), Biochemistry Department (S Shahid PhD), The University

of Lahore, Lahore, Pakistan; Department fo Veterinary Pathology (J A

Atata PhD), University of Ilorin, Nigeria, Kwara, Nigeria; Department of

Immunology (S Athari PhD), Department of Pharmacology (P Majma

Sanaye PharmD), Zanjan University of Medical Sciences, Zanjan, Iran;

Department of Biomedical Science (D Atlaw MSc), Madda Walabu

University, Bale Robe, Ethiopia; Faculty of Nursing (M M W Atout PhD),

Philadelphia University, Amman, Jordan; Northumbria HealthCare

NHS Foundation Trust, Newcastle upon Tyne, UK (A Aujayeb MBBS);

School of Nursing and Health Sciences (A T Awan DrPH), Capella

University, Minneapolis, MN, USA; Continuing Education Grant

Writing Academy (A T Awan DrPH), University of Nevada, Las Vegas,

NV, USA; Department of Neurovascular Research (A Y Azzam MD),

Nested Knowledge Inc, Saint Paul, MN, USA; Faculty of Medicine (A Y

Azzam MD), October 6 University, 6th of October City, Egypt; Public

Health Risk Sciences Division (A Badawi PhD), Public Health Agency of

Canada, Toronto, ON, Canada; Department of Nutritional Sciences

(A Badawi PhD), Temerty Faculty of Medicine (V Chattu MD), Uni-

versity of Toronto, Toronto, ON, Canada; Department of Forensic Sci-

ence (A D Badiye PhD), Government Institute of Forensic Science,

Nagpur, India; School of Medicine (S Bagherieh BSc, S Hassanzadeh

MD), Department of Pediatrics (M Bemanalizadeh MD), Department of

Environmental Health Engineering (A Fatehizadeh PhD, E Taheri PhD),

Isfahan University of Medical Sciences, Isfahan, Iran; Department of

Comprehensive Nursing (B B Bantie MSc), Department of Medical

Biochemistry (E Chekol Abebe MSc), Department of Pediatrics and

Child Health Nursing (N S Tibebu MSc), Debre Tabor University, Debre

Tabor, Ethiopia; Department of Molecular Microbiology and Bacteri-

ology (M Bardhan MD), National Institute of Cholera and Enteric Dis-

eases, Kolkata, India; Department of Molecular Microbiology

(M Bardhan MD), Department of Biostatistics (V K Kamal PhD), Indian

Council of Medical Research, New Delhi, India; School of Psychology

(Prof S L Barker-Collo PhD), University of Auckland, Auckland, New

Zealand; Department of Translational Medicine (F Barone-Adesi PhD),

University of Eastern Piedmont, Novara, Italy; Department of Medical

Education (K Batra PhD), Department of Social and Behavioral Health

(Prof M Sharma PhD), University of Nevada Las Vegas, Las Vegas, NV,

USA; Department of Surgery (N S Bayileyegn MD), Department of

Biostatistics (N G Zeru MSc), Jimma University, Jimma, Ethiopia; Non-

communicable Diseases Research Center, Tehran, Iran (A Behnoush

BS); Department of Oral Pathology and Microbiology (U I Belgaumi

MD), Department of Public Health Dentistry (Prof K M Shivakumar

PhD), Krishna Institute of Medical Sciences Deemed To Be University,

Karad, India; Department of Internal Medicine (I M Bensenor PhD),

Department of Psychiatry (Prof M F P Peres MD), University of São

Paulo, São Paulo, Brazil; School of Pharmacy (K A Beyene PhD), Uni-

versity of Auckland, AUCKLAND, New Zealand; Department of Phar-

maceutical and Administrative Sciences (K A Beyene PhD), University

of Health Sciences and Pharmacy in St. Louis, St louis, MI, USA;

Department of Health, Human Performance and Recreation (A S

Bhagavathula PhD), University of Arkansas, Fayetteville, AR, USA;

Department of Community Medicine and Family Medicine (P Bhardwaj

MD), School of Public Health (P Bhardwaj MD), Department of Phar-

macology (S Singh DM, S B Varthya MD), All India Institute of Medical

Sciences, Jodhpur, India; Global Health Neurology Lab (S Bhaskar

PhD), NSW Brain Clot Bank, Sydney, NSW, Australia; Department of

Neurology and Neurophysiology (S Bhaskar PhD), South West Sydney

Local Heath District and Liverpool Hospital, Sydney, NSW, Australia;

Department of General Medicine (A N Bhat MD, J Jeganathan MD),

Department of Internal Medicine (A Boloor MD), Department of

Community Medicine (N Joseph MD), Manipal Academy of Higher

Education, Mangalore, India; Department of Biostatistics and Epide-

miology (Prof S Bitaraf PhD), Ahvaz Jundishapur University of Medical

Sciences, Ahvaz, Iran; Faculty of Health Sciences (V R Bitra PhD),

University of Botswana, Gaborone, Botswana; Regional Medical

Articles

www.thelancet.com Vol 64 October, 2023 15

Research Centre North East Region (K Bora MD), Indian Council of

Medical Research, Dibrugarh, India; Clinical Research Unit (Prof J S

Botelho PhD), Centro de Investigação Interdisciplinar Egas Moniz,

Almada, Portugal; Monash Department of Clinical Epidemiology at

Cabrini Hospital (Prof R Buchbinder PhD), Cabrini Institute, Mel-

bourne, VIC, Australia; Department of Clinical Pharmacy (Prof D Calina

PhD), University of Medicine and Pharmacy of Craiova, Craiova,

Romania; Internal Medicine Department (Prof L A Cámera MD),

Hospital Italiano de Buenos Aires (Italian Hospital of Buenos Aires),

Buenos Aires, Argentina; Board of Directors (Prof L A Cámera MD),

Argentine Society of Medicine, Buenos Aires, Argentina; Institute for

Mental and Physical Health (A F Carvalho MD), School of Medicine

(V Gupta PhD), Deakin University, Geelong, VIC, Australia; Heart

Failure and Structural Heart Disease Unit (J Chan MBChB), Cardio-

vascular Analytics Group, Hong Kong, China; Saveetha Dental College

(V Chattu MD), Centre of Molecular Medicine and Diagnostics (COM-

ManD) (Prof S Patil PhD), Saveetha University, Chennai, India; College

of Medicine (S Choi BSc), Yonsei University, Seoul, South Korea;

Department of Public Health (Prof T Chou PhD), Department of

Occupational Safety and Health (Prof B Hwang PhD), China Medical

University, Taichung, Taiwan; Center for Biomedicine and Community

Health (D Chu PhD), VNU-International School, Hanoi, Viet Nam;

Institute for Health Metrics and Evaluation (K Coberly BS, X Dai PhD,

M Hassen BSc, Prof S S Lim PhD, T Mestrovic PhD, A H Mokdad PhD,

D Y Yada MSc), Department of Health Metrics Sciences, School of

Medicine (X Dai PhD, Prof S D Dharmaratne MD, Prof S S Lim PhD, A

Misganaw PhD, A H Mokdad PhD), University of Washington, Seattle,

WA, USA; Research Unit on Applied Molecular Biosciences (UCIBIO)

(V M Costa PhD), Department of Chemical Sciences (R A S Couto MD),

Institute for Research and Innovation in Health (Prof N Cruz-Martins

PhD), Faculty of Medicine (Prof R J Dinis-Oliveira PhD), Associated

Laboratory for Green Chemistry (LAQV) (Prof D M Pereira PhD, D

Ribeiro PhD), Department of Chemistry (R B Pereira PhD), University

of Porto, Porto, Portugal; Therapeutic and Diagnostic Technologies

Department (Prof N Cruz-Martins PhD), Cooperativa de Ensino Supe-

rior Politécnico e Universitário (Polytechnic and University Higher

Education Cooperative), Gandra, Portugal; Global Health and Rehabili-

tation Section (O Dadras DrPH), Western Norway University of Applied

Sciences, Bergen, Norway; Department of Global Public Health and

Primary Care (O Dadras DrPH), Department of Psychosocial Science (D

Sagoe PhD), University of Bergen, Bergen, Norway; IRCCS Istituto

Ortopedico Galeazzi (Galeazzi Orthopedic Institute IRCCS) (G Damiani

MD), Department of Clinical Sciences and Community Health (Prof C

La Vecchia MD), University of Milan, Milan, Italy; Department of

Dermatology (G Damiani MD), Department of Quantitative Health

Science (X Liu PhD), Department of Neonatology (I Qattea MD), Case

Western Reserve University, Cleveland, OH, USA; Ophthalmology

Department (A Dascalu PhD), Emergency University Hospital Buchar-

est, Bucuresti, Romania; School of Public Health (S Debela MPH),

Salale University, Fiche, Ethiopia; Department of Dermatology (Prof R P

Dellavalle MD), University of Colorado Denver, Aurora, CO, USA;

Dermatology Service (Prof R P Dellavalle MD), Department of Veterans

Affairs, Aurora, CO, USA; Department of Neurosurgery (A K Deme-

triades MD), Global Health Governance Programme (J Patel BSc),

Centre for Medical Informatics (Prof A Sheikh MD), Usher Institute

(Prof C R Simpson PhD), College of Medicine and Veterinary Medicine

(G Verras MD), University of Edinburgh, Edinburgh, UK; Department

of Neurosurgery (A K Demetriades MD), National Health Service (NHS)

Scotland, Edinburgh, UK; Department of Nursing (A A Demlash MSc),

Department of Midwifery (H L Esayas MSc), Department of Medical

Laboratory Science (M Woldemariam MSc), Arba Minch University,

Arba Minch, Ethiopia; Epidemiology Branch (X Deng PhD), National

Institute of Health, Durham, NC, USA; Department of Medicine (H D

Desai MD), Gujarat Adani Institute of Medical Sciences, Bhuj, India;

Division of Cardiology (R Desai MBBS), Atlanta Veterans Affairs Med-

ical Center, Decatur, GA, USA; Department of Pharmacy (S Dewan

PhD), University of Asia Paciﬁc, Dhaka, Bangladesh; Pharmacology

Department (S Dewan PhD), Center for Life Sciences Research

Bangladesh, Dhaka, Bangladesh; Department of Biostatistics and

Epidemiology (S Dey Mphil), Department of Development Studies (Prof

A Perianayagam PhD, H Sahoo PhD), International Institute for Pop-

ulation Sciences, Mumbai, India; Department of Community Medicine

(Prof S D Dharmaratne MD), University of Peradeniya, Peradeniya, Sri

Lanka; Institute for Health Metrics and Evaluation (Prof S D Dhar-

maratne MD), University of Washington, Seattle; WA (Prof S D Dhar-

maratne MD), USA, ; Center of Complexity Sciences (Prof D Diaz PhD),

National Autonomous University of Mexico, Mexico City, Mexico; Fac-

ulty of Veterinary Medicine and Zootechnics (Prof D Diaz PhD),

Autonomous University of Sinaloa, Culiacán Rosales, Mexico; Research

Unit (M Dibas MD), Sulaiman Al Rajhi University, Qassim, Saudi

Arabia; Sciences Department (Prof R J Dinis-Oliveira PhD), Advanced

Polytechnic and University Cooperative, Gandra, Portugal; Department

of Human Physiology (M Diress MSc), Department of Health Promo-

tion and Health Behavior (H B Eshetu MPH), University of Gondar,

Gondar, Ethiopia; Department of Medicine (T C Do MD), Medical

School (H Pham MD), Pham Ngoc Thach University of Medicine, Ho

Chi Minh City, Viet Nam; Department of Cardiothoracic Surgery (D K

Doan MD), Mayo Clinic, Jacksonville, FL, USA; Department of Biosta-

tistics (M Dodangeh MCom), Independent Consultant, Tehran, Iran;

Health Science Center (D Dongarwar MS), Department of Gastroin-

testinal Medical Oncology (M A Zeineddine MD), University of Texas,

Houston, TX, USA; Ofﬁce of Institutional Analysis (J Dube MA), Uni-

versity of Windsor, Windsor, ON, Canada; Department of Conservative

Dentistry with Endodontics (A M Dziedzic DSc), Medical University of

Silesia, Katowice, Poland; Higher School of Technology (Prof A Ed-Dra

PhD), Sultan Moulay Slimane University, Beni Mellal, Morocco; School

of Health Sciences (H A Edinur PhD), University of Science Malaysia

(Universiti Sains Malaysia), Kubang Kerian, Malaysia; Department of

Biological Sciences (T C Ekundayo PhD), University of Medical Sci-

ences, Ondo, Ondo, Nigeria; Sharjah Institute for Medical Research (N

M Elemam PhD, B Saddik PhD), Department of Clinical Sciences (Prof

R Halwani PhD, Prof A A Maghazachi PhD, N Saheb Sharif-Askari

PhD, Prof I M Talaat PhD), College of Medicine (Prof R Halwani

PhD, M A Saleh PhD), Sharjah Institute of Medical Sciences (F Saheb

Sharif-Askari PhD), University of Sharjah, Sharjah, United Arab Emir-

ates; Faculty of Medicine (M Elhadi MD), University of Tripoli, Tripoli,

Libya; Pediatric Dentistry Department (Prof O A A Elmeligy PhD),

Rabigh Faculty of Medicine (A A Malik PhD), Department of Dental

Public Health (Z S Natto DrPH), Department of Community Medicine

(S Samargandy PhD), King Abdulaziz University, Jeddah, Saudi Arabia;

Pediatric Dentistry and Dental Public Health Department (Prof O A A

Elmeligy PhD), Pathology Department (Prof I M Talaat PhD), Alexan-

dria University, Alexandria, Egypt; Doheny Eye Institute (M Emamverdi

MD), University of California Los Angeles, Los Angeles, CA, USA;

Department of Public Health and Tropical Medicine (T I Emeto PhD),

Australian Institute of Tropical Health and Medicine (A Pak PhD),

James Cook University, Townsville, QLD, Australia; Department of In-

ternal Medicine (F Etaee MD), Department of Dermatology (M Goldust

MD), Department of Psychiatry (W Li PhD), Department of Genetics (S

Pawar PhD), Yale University, New Haven, CT, USA; Institute of Applied

Health Sciences (A F Fagbamigbe PhD), University of Aberdeen,

Aberdeen, UK; Head of the Laboratory of Experimental Medicine (I R

Fakhradiyev PhD), Kazakh National Medical University, Almaty,

Kazakhstan; Department of Social Medicine and Epidemiology (A

Feizkhah MD), Guilan University of Medical Sciences, Rasht, Iran;

Department of Pharmacy (G Fekadu MSc), Department of Nursing (G

Fetensa MSc), Wollega University, Nekemte, Ethiopia; Department of

Molecular Medicine (M Fereidouni PhD), Cellular and Molecular

Research Center (M Fereidouni PhD), Department of Epidemiology and

Biostatistics (A Tiyuri MSc), Birjand University of Medical Sciences,

Birjand, Iran; Department of Neurobiology, Care Sciences, and Society

(S Fereshtehnejad PhD), Department of Medicine (T S Hassan PhD),

Karolinska Institute, Stockholm, Sweden; Division of Neurology (S

Fereshtehnejad PhD), University of Ottawa, Ottawa, ON, Canada;

Center for Biotechnology and Fine Chemistry (J C Fernandes PhD),

Catholic University of Portugal, Porto, Portugal; Research Center on

Public Health (P Ferrara MD), School of Medicine and Surgery (Prof L

G Mantovani DSc), University of Milan Bicocca, Monza, Italy; Psychiatry

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Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA;

School of Health Sciences (I Filip MD), A.T. Still University, Mesa, AZ,

USA; Institute of Public Health (F Fischer PhD), Institute for Aller-

gology (P Kolkhir MD), Charité Medical University Berlin (Charité

Universitätsmedizin Berlin), Berlin, Germany; Department of Pharma-

cology (Prof B Foroutan PhD), Iranshahr University of Medical Sci-

ences, Iranshahr, Iran; Department of Medical Parasitology

(M Foroutan PhD), Faculty of Medicine (M Foroutan PhD), Abadan

University of Medical Sciences, Abadan, Iran; Department of Derma-

tology (T Fukumoto PhD), Kobe University, Kobe, Japan; School of

Global Health (B Ganesan PhD), Institute of Health & Management,

Melbourne, VIC, Australia; Department of Occupational Therapy

(B Ganesan PhD), Mahatma Gandhi Occupational Therapy College,

Jaipur, India; Department of Nursing (B N B Gemeda MSc), Debre

Berhan University, Debre Birhan, Ethiopia; Adelaide Medical School

(T K Gill PhD), School of Public Health (V Podder HSC), University of

Adelaide, Adelaide, SA, Australia; Division of General Internal Medicine

(R F Gillum MD), Department of Community and Family Medicine

(R F Gillum MD), Howard University, Washington, DC, USA; Depart-

ment of Health Systems and Policy Research (M Golechha PhD), Indian

Institute of Public Health, Gandhinagar, India; Department of Genetics

(P Goleij MSc), Sana Institute of Higher Education, Sari, Iran; Depart-

ment of Biomedical and Neuromotor Sciences (D Golinelli MD, J Lenzi

PhD), University of Bologna, Bologna, Italy; Department of Respiratory

Medicine (H Goudarzi PhD), Center for Environmental and Health

Sciences (H Goudarzi PhD), Hokkaido University, Sapporo, Japan;

Department of Epidemiology and Biostatistics (S Guan MD), Anhui

Medicla University, Hefei, China; Peking University Shenzhen Hospital

(Y Guo PhD), Peking University, Shenzhen, China; Department of

Public Health (B Gupta PhD), Torrens University Australia, Melbourne,

VIC, Australia; Faculty of Medicine Health and Human Sciences (Prof V

K Gupta PhD), Macquarie Medical School (Y You PhD), Macquarie

University, Sydney, NSW, Australia; Department of Pharmacology and

Toxicology (R Haddadi PhD), Department of Midwifery (S Masoumi

PhD), Hamadan University of Medical Sciences, Hamadan, Iran;

Department of Clinical Pharmacology and Medicine (Prof N R Hadi

PhD), University of Kufa, Najaf, Iraq; Research & Scientiﬁc Studies Unit

(S Haque PhD), Epidemiology Department (M Khan MD), Substance

Abuse and Toxicology Research Center (S Mohan PhD), Jazan Univer-

sity, Jazan, Saudi Arabia; Department of Pharmaceutical Technology

(I Hasan MPharm), University of Dhaka, Dhaka, Bangladesh; Research

Centre (T S Hassan PhD), Salahaddin University, Erbil, Iraq; National

Data Management Center for Health (M Hassen BSc, A Misganaw

PhD), Ethiopian Public Health Institute, Addis Ababa, Ethiopia;

Department of Diagnostic and Interventional Radiology and Neurora-

diology (J Haubold MD), Institute of Artiﬁcial Intelligence in Medicine

(J Haubold MD), University Hospital Essen, Essen, Germany; Institute

of Pharmaceutical Sciences (K Hayat MS), University of Veterinary and

Animal Sciences, Lahore, Pakistan; Department of Pharmacy Admin-

istration and Clinical Pharmacy (K Hayat MS), Xian Jiaotong University,

Xian, China; Independent Consultant, Santa Clara, CA, USA (G Heidari

MD); Department of Statistics and Econometrics (Prof C Herteliu PhD,

I Petcu PhD), Bucharest University of Economic Studies, Bucharest,

Romania; School of Business (Prof C Herteliu PhD), London South

Bank University, London, UK; Department of Applied Microbiology

(K Hezam PhD), Taiz University, Taiz, Yemen; Department of Micro-

biology (K Hezam PhD), Nankai University, Tianjin, China; Division for

Health Service Promotion (Y Hiraike PhD), University of Tokyo, Tokyo,

Japan; Kasturba Medical College, Mangalore (R Holla MD), Manipal

College of Pharmaceutical Sciences (Prof M D Janodia PhD), Depart-

ment of Physiotherapy (Prof V K PhD), Department of Pharmacy

Management (V S Ligade PhD), Manipal TATA Medical College

(M Rahman PhD), Department of Nephrology (I Rao DM), Manipal

Academy of Higher Education, Manipal, India; School of Biotechnology

(H Huynh BS), Tan Tao University, Long An, Viet Nam; Department of

Occupational Therapy (Prof B Hwang PhD), Asia University, Taichung,

Taiwan; Faculty of Medicine (I M Ilic PhD), University of Belgrade,

Belgrade, Serbia; Department of Epidemiology (Prof M D Ilic PhD),

University of Kragujevac, Kragujevac, Serbia; Department of Clinical

Pharmacy & Pharmacy Practice (Prof N Ismail PhD), Asian Institute of

Medicine, Science and Technology, Kedah, Malaysia; Malaysian Acad-

emy of Pharmacy, Puchong, Malaysia (Prof N Ismail PhD); Department

of Health Services Research (M Iwagami PhD), University of Tsukuba,

Tsukuba, Japan; Department of Non-communicable Disease Epidemi-

ology (M Iwagami PhD), London School of Hygiene & Tropical Medi-

cine, London, UK; School of Health Systems and Public Health (C C D

Iwu MPH), University of Pretoria, Pretoria, South Africa; Research and

Development Unit (L Jacob MD), Biomedical Research Networking

Center for Mental Health Network (CiberSAM), Sant Boi de Llobregat,

Spain; Faculty of Medicine (L Jacob MD), University of Versailles Saint-

Quentin-en-Yvelines, Montigny-le-Bretonneux, France; Department of

Immunology (Prof A Jafarzadeh PhD), Department of Clinical

Biochemistry (M Nematollahi PhD), Kerman University of Medical

Sciences, Kerman, Iran; Department of Immunology (Prof A Jafarzadeh

PhD), Department of Epidemiology and Biostatistics (Prof M Rezaeian

PhD), Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Col-

lege of Medicine and Medical Sciences (H Jahrami PhD), Arabian Gulf

University, Manama, Bahrain; Ministry of Health, Manama, Bahrain (H

Jahrami PhD); Institute of Advanced Manufacturing Technologies (Prof

M Jakovljevic PhD), Peter the Great St. Petersburg Polytechnic Uni-

versity, St. Petersburg, Russia; Institute of Comparative Economic

Studies (Prof M Jakovljevic PhD), Hosei University, Tokyo, Japan; Di-

vision of Pulmonary Medicine (E Jamshidi PharmD), Lausanne Uni-

versity Hospital (CHUV), Lausanne, Switzerland; Department of

Internal Medicine (C T Jani MD), Harvard University, Cambridge, MA,

USA; Centre of Studies and Research (S Jayapal PhD), Ministry of

Health, Muscat, Oman; Department of Biochemistry (Prof S Jayaram

MD), Government Medical College, Mysuru, India; Institute of Molec-

ular and Clinical Ophthalmology Basel, Basel, Switzerland (Prof J B

Jonas MD); Department of Ophthalmology (Prof J B Jonas MD), Hei-

delberg University, Mannheim, Germany; Department of Gastroenter-

ology and Hepatology (A Joseph MD), Stanford University, Stanford,

CA, USA; Department of Economics (C E Joshua BSc), National Open

University, Benin City, Nigeria; Health Economics Unit (B Kaambwa

PhD), College of Medicine and Public Health (B Kaambwa PhD),

Flinders University, Adelaide, SA, Australia; School of Public Health (Z

Kabir PhD), University College Cork, Cork, Ireland; Department of Oral

and Maxillofacial Pathology (V Kadashetti MDS), Krishna institute of

Medical Sciences Deemed to be University, Karad, India; Dermatology

Department (F Kaliyadan MD), King Faisal University, Hofuf, Saudi

Arabia; department of pediatric nursing, department of research,

department of medical student research (F Kalroozi PhD), Aja Medical

University, tehran, Iran; Department of Pediatrics (F Kalroozi PhD),

Iran University of Medical Sciences, tehran, Iran; Division of Epide-

miology and Biostatistics (V K Kamal PhD), National Institute of

Epidemiology, Chennai, India; Department of Neurology (A Kandel

MD), University at Buffalo, Buffalo, NY, USA; Save Sight Institute (H

Kandel PhD, Y You PhD), University of Sydney, Sydney, NSW,

Australia; Sydney Eye Hospital (H Kandel PhD), South Eastern Sydney

Local Health District, Sydney, NSW, Australia; Regional Medical

Research Centre (S Kanungo MD), Indian Council of Medical Research,

Bhubaneswar, India; Laboratory Science Department (J Karami PhD),

Khomein University of Medical Sciences, Khomein, Iran; School of

Health Professions and Human Services (I M Karaye MD), Hofstra

University, Hempstead, NY, USA; Department of Epidemiology and

Biostatistics (S A Kebede MPH), University of Gondar, Gondar, Faroe

Islands; Department of Healthcare Services Management (L Keikavoosi-

Arani PhD), Research Center for Health, Safety and Environment (Prof

L Salehi PhD), Alborz University of Medical Sciences, Karaj, Iran;

Department of Public Health (Prof Y S Khader PhD), JordanUniversity of

Science and Technology, Irbid, Jordan; Amity Institute of Forensic Sci-

ences (H Khajuria PhD, B P Nayak PhD), Amity University, Noida, India;

Faculty of Veterinary Medicine (F Khamesipour PhD), Faculty of Veteri-

nary Medicine, Shahrekord Branch, Islamic Azad University, Shahrekord,

Iran; Department of Epidemiology and Biostatistics (E A Khan MPH),

Health Services Academy, Islamabad, Pakistan; Department of Pediatrics

(I A Khan MD), Center for Pharmacoepidemiology and Treatment Sci-

ence (A Parthasarathi MD), Rutgers University, New Brunswick, NJ,

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USA; Department of Rehabilitation Sciences (M Khan MPH), Hong Kong

Polytechnic University, Hong Kong, China; Family Medicine Department

(M A Khan MSc), United Arab Emirates University, Al Ain, United Arab

Emirates; Primary Care Department (M A Khan MSc), NHS North West

London, London, UK; Pharmacy Services (M Khan PharmD), The Indus

Hospital Health Network and Research Center, Lahore, Pakistan; Faculty

of Nursing (H Khatatbeh PhD), Jerash University, Jerash, Jordan;

Department of Basic Medical Sciences (M M Khatatbeh PhD), Yarmouk

University, Irbid, Jordan; School of Medicine (S Khateri MD), Kurdistan

University of Medical Sciences, Sanandaj, Iran; Cardiovascular Disease

Initiative (M Kim MD), Broad Institute of MIT and Harvard, Cam-

bridge, MA, USA; School of Health Sciences (Prof A Kisa PhD), Kris-

tiania University College, Oslo, Norway; Department of International

Health and Sustainable Development (Prof A Kisa PhD), Tulane Uni-

versity, New Orleans, LA, USA; Department of Nursing and Health

Promotion (S Kisa PhD), Oslo Metropolitan University, Oslo, Norway;

Department of Neurology (H Koh PhD), Boston Children’s Hospital,

Boston, MA, USA; Division of Immune-mediated Skin Diseases

(P Kolkhir MD), First Moscow State Medical University (Sechenov

University), Moscow, Russia; Department of General Practice Family

Medicine (Prof O Korzh DSc), Kharkiv National Medical University,

Kharkiv, Ukraine; Department of Biochemistry (A L Kotnis PhD), All

India Institute of Medical Sciences, Bhopal, India; Department of In-

ternal and Pulmonary Medicine (Prof P A Koul MD), Sheri Kashmir

Institute of Medical Sciences, Srinagar, India; San Juan de Dios Sanitary

Park, Barcelona, Spain (A Koyanagi MD); Department of Anthropology

(Prof K Krishan PhD), Panjab University, Chandigarh, India; Depart-

ment of Biochemistry (Prof M Kuddus PhD), University of Hail, Hail,

Saudi Arabia; Department of Medicine (V V Kulkarni MS), Queensland

Health, Brisbane, QLD, Australia; Department of Orthopaedics (Prof N

Kumar MS), Medanta Hospital, Lucknow, India; Global Health Institute

(S Kundu MPH), North South University, Dhaka, Bangladesh; Depart-

ment of Nutrition and Food Science (S Kundu MPH), Patuakhali Sci-

ence and Technology University, Patuakhali, Bangladesh; Faculty of

Health and Life Sciences (O P Kurmi PhD), Coventry University,

Coventry, UK; Department of Medicine (O P Kurmi PhD), Department

of Psychiatry and Behavioural Neurosciences (A T Olagunju MD),

McMaster University, Hamilton, ON, Canada; Department of Health

Policy and Strategy (Prof C Lahariya MD), Foundation for People-centric

Health Systems, New Delhi, India; SD Gupta School of Public Health

(Prof C Lahariya MD), Indian Institute of Health Management Research

University, Jaipur, India; Department of Physiotherapy (T Laksono MS),

Universitas Aisyiyah Yogyakarta, Yogyakarta, Indonesia; Institute of

Allied Health Sciences (T Laksono MS), National Cheng Kung Univer-

sity, Tainan, Taiwan; Health Services Management Training Centre (J

Lám PhD), Semmelweis University, Budapest, Hungary; NEVES Society

for Patient Safety (J Lám PhD), NEVES Society for Patient Safety,

Budapest, Hungary; Centre for Family Welfare (K Latief MSE), Uni-

versity of Indonesia, Depok, Indonesia; Department of Global Health

and Health Security (K Latief MSE), College of Medicine (L Minh MD),

Research Center for Artiﬁcial Intelligence in Medicine (L Minh MD),

Taipei Medical University, Taipei, Taiwan; International Society Doctors

for the Environment, Arezzo, Italy (P Lauriola MD); Clinical Pharmacy

and Pharmacy Management (B K Lawal PhD), Kaduna State University,

Kaduna, Nigeria; Department of Internal Medicine (T Le MD),

Department of General Medicine (V T Nguyen MD), Faculty of Medi-

cine (D C Vo MD), University of Medicine and Pharmacy at Ho Chi

Minh City, Ho Chi Minh City, Viet Nam (T T Le MD); Department of

Medical Humanities and Social Medicine (M Lee PhD), Ajou University

School of Medicine, Suwon, South Korea; Medial Research Collabo-

rating Center (M Lee PhD), Ajou University Medical Center, Suwon,

South Korea; Department of Precision Medicine (Prof S W Lee MD),

Sungkyunkwan University, Suwon-si, South Korea; Department of In-

ternal Medicine (W Lee PhD), University of Texas, Galveston, TX, USA;

Department of Preventive Medicine, College of Medicine (Prof Y Lee

PhD), Korea University, Seoul, South Korea; Department of Prevention

(M Levi PhD), USL Tuscany Center, Firenze, Italy; Department of

Health Sciences (M Levi PhD), University of Florence, Florence, Italy;

School of Life Sciences (G Liu PhD), University of Technology Sydney,

Ultimo, NSW, Australia; Centre for Inﬂammation (G Liu PhD), Cen-

tenary Institute, Camperdown, NSW, Australia; Department of Molec-

ular Epidemiology (E Llanaj PhD), German Institute of Human

Nutrition Potsdam-Rehbrücke, Potsdam, Germany; German Center for

Diabetes Research (DZD), München-Neuherberg, Germany (E Llanaj

PhD); Department of Internal Medicine (C Lo MD), Kirk Kerkorian

School of Medicine, Las Vegas, NV, USA; Clinical Research Unit (Prof V

S Machado PhD), Centro de Investigação Interdisciplinar Egas Moniz

(Egas Moniz Interdisciplinary Research Center), Monte da Caparica,

Portugal; Department of Clinical and Hospital Pharmacy (M A Mah-

moud PhD), Taibah University, Al-Madinah Al-Munawarrah, Saudi

Arabia; Cardiovascular Research department (T A Mai MSc), Cardio-

vascular Research Department (H Q Nguyen MD), Methodist Hospital,

Merrillville, IL, USA; Department of Primary Care and Public Health

(Prof A Majeed MD, R Palladino MD, Prof S Rawaf MD), Imperial

College London, London, UK; Center for Health & Nature (O M Mak-

ram MD), Houston Methodist Hospital, Houston, TX, USA; Depart-

ment of Cardiology (O M Makram MD), October 6 University, Cairo,

Egypt; Department of Internal Medicine (K Malhotra MBBS), Dayanand

Medical College and Hospital, Ludhiana, India; Material Science Pro-

gramme (I Malik PhD), Indian Institute of Technology Kanpur, Kanpur,

India; Department of Clinical Pharmacy (T Mallhi PhD), Jouf Univer-

sity, Sakaka, Saudi Arabia; Department of Maternal and Child Nursing

and Public Health (Prof D C Malta PhD, Prof A C Micheletti Gomide

Nogueira de Sá MSc, E J S Prates BS), Department of Applied Nursing

(Prof M O Pereira PhD), Federal University of Minas Gerais, Belo

Horizonte, Brazil; Laboratory of Public Health (Prof L G Mantovani

DSc), Instituto Auxologico Italiano IRCCS (Italian Auxological Institute),

Milan, Italy; Department of Nutrition and Dietetics (M Martorell PhD),

University of Concepcion, Concepción, Chile; Centre for Healthy Living

(M Martorell PhD), University of Concepción, Concepción, Chile;

Department of Anatomy, Genetics and Biomedical Informatics (Y

Mathangasinghe MD), University of Colombo, Colombo, Sri Lanka;

Australian Regenerative Medicine Institute (Y Mathangasinghe MD),

Monash University, Clayton, VIC, Australia; Department of Public

Health and Community Medicine (E Mathews PhD), Central University

of Kerala, Kasaragod, India; Division of Infection, Immunity and Res-

piratory Medicine (A G Mathioudakis PhD), University of Manchester,

Manchester, UK; North West Lung Centre (A G Mathioudakis PhD),

Manchester University NHS Foundation Trust, Manchester, UK;

Department of Epidemiology and Biostatistics (J C Medina MD), Uni-

versity of the Philippines Manila, Manila, Philippines; Department of

Global Health (J C Medina MD), University of the Ryukyus, Nishihara,

Japan; School of Public Health (G G Meles MPH), Department of Sta-

tistics (N G Zeru MSc), Mekelle University, Mekelle, Ethiopia; Clinical

Research Unit (Prof J Mendes PhD), Centro de Investigação Inter-

disciplinar Egas Moniz (Egas Moniz Interdisciplinary Research Center),

Monte de Caparica, Portugal; Forensic Medicine Division (Prof R G

Menezes MD), Imam Abdulrahman Bin Faisal University, Dammam,

Saudi Arabia; University Centre Varazdin (T Mestrovic PhD), University

North, Varazdin, Croatia; Department of Epidemiology (I Michalek

PhD), National Cancer Registry (I Michalek PhD), Maria Sklodowska-

Curie National Research Institute of Oncology, Warsaw, Poland;

Department of Medical Physiology (E T Mihretie MSc), Madda Walabu

University, Bale Goba, Ethiopia; Internal Medicine Programme (Prof E

M Mirrakhimov PhD), Kyrgyz State Medical Academy, Bishkek,

Kyrgyzstan; Department of Atherosclerosis and Coronary Heart Disease

(Prof E M Mirrakhimov PhD), National Center of Cardiology and In-

ternal Disease, Bishkek, Kyrgyzstan; Molecular Biology Unit (N S

Mohamed MSc), Bio-Statistical and Molecular Biology Department (N S

Mohamed MSc), Sirius Training and Research Centre, Khartoum,

Sudan; Department of Pharmaceutical Sciences (S Mohammed PhD),

Notre Dame of Maryland University, Baltimore, MD, USA; Department

of Pharmacy (S Mohammed PhD), Mizan-Tepi University, Mizan,

Ethiopia; Health Systems and Policy Research Unit (S Mohammed

PhD), Ahmadu Bello University, Zaria, Nigeria; Department of Health

Care Management (S Mohammed PhD), Technical University of Berlin,

Berlin, Germany; Center for Transdisciplinary Research (S Mohan

PhD), Saveetha Institute of Medical and Technical Science, Chennai,

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India; Clinical Epidemiology and Public Health Research Unit

(L Monasta DSc), Burlo Garofolo Institute for Maternal and Child

Health, Trieste, Italy; School of Health & Rehabilitation Sciences (M

Moni PhD), Mater Research Institute (M Moniruzzaman PhD), Centre

for the Business and Economics of Health (A Pak PhD), The University

of Queensland, Brisbane, QLD, Australia; Social Determinants of

Health Research Center (Y Moradi PhD), Kurdistan University of

Medical Sciences, Kurdistan, Iran; Clinical Research Development Unit

(N Morovatdar MD), Applied Biomedical Research Center (A Sahebkar

PhD), Biotechnology Research Center (A Sahebkar PhD), Department of

Medical Informatics (S Tabatabaei PhD), Clinial Research Development

Unit (S Tabatabaei PhD), Mashhad University of Medical Sciences,

Mashhad, Iran; Department of Medicine (E Mostafavi PhD), Stanford

Cardiovascular Institute (E Mostafavi PhD), Stanford University, Palo

Alto, CA, USA; Department of Surgery (G D Mukoro MD), Ahmadu

Bello University Teaching Hospital, Zaria, Nigeria; Department of

Medicine (A Mulita PhD), Democritus University of Thrace, Alexan-

droupolis, Greece; Department of Pediatrics and Child Health Nursing

(G B Mulu MSc), Debre Berhan University, Debre Berhan, Ethiopia;

Clinical Epidemiology Research Unit (E Murillo-Zamora PhD), Mexican

Institute of Social Security, Villa de Alvarez, Mexico; Postgraduate in

Medical Sciences (E Murillo-Zamora PhD), Universidad de Colima,

Colima, Mexico; Department of Pathobiology (F Musaigwa PhD), Uni-

versity of Pennsylvania, Philadelphia, PA, USA; Department of Pediat-

rics & Pediatric Pulmonology (Prof G Mustafa MD), Institute of Mother

& Child Care, Multan, Pakistan; Department of Orthopaedics (S Muthu

MS), Government Medical College, Dindigul, India; Quality Appraisal

Committee (S Muthu MS), Orthopaedic Research Group, Coimbatore,

India; Faculty of Pharmacy (F Nainu PhD), Hasanuddin University,

Makassar, Indonesia; Suraj Eye Institute, Nagpur, India (V Nangia MD);

Mysore Medical College and Research Institute (Prof S Narasimha

Swamy MD), Government Medical College, Mysore, India; Department

of Zoology (Prof N Perumalsamy PhD), Yadava College, Madurai, India;

Department of Zoology (Prof N Perumalsamy PhD), Annai Fathima

College, Madurai, India; Department of Health promotion (A Nazri-

Panjaki MSc), Health Promotion Research Center (H Okati-Aliabad

PhD), Zahedan University of Medical Sciences, Zahedan, Iran;

Department of Medical Laboratory Sciences (H Negash MSc), Depart-

ment of Pharmacy (B G Welegebrial MSc), Adigrat University, Adigrat,

Ethiopia; Division of Cardiology (D H Nguyen BS), Massachusetts

General Hospital, Boston, MA, USA; Department of Medical Engi-

neering (D H Nguyen BS), University of South Florida, Tampa, FL,

USA; Faculty of Medicine (H T H Nguyen MD), Institute for Research

and Training in Medicine, Biology and Pharmacy (H T H Nguyen MD),

Duy Tan University, Da Nang, Viet Nam; Department of Surgery (P T

Nguyen MD), Danang Family Hospital, Danang, Viet Nam; Interna-

tional Islamic University Islamabad, Islamabad, Pakistan (R K Niazi

PhD); Department of General Surgery (T K Nikolouzakis PhD), Uni-

versity Hospital of Heraklion, Heraklion, Greece; Laboratory of Toxi-

cology (T K Nikolouzakis PhD), University of Crete, Heraklion, Greece;

Center for Public Health (L A Nnyanzi PhD), Teesside University,

Middlesbrough, UK; Department of Microbiology and Molecular Ge-

netics (M Noreen PhD), The Women University Multan, Multan,

Pakistan; Center of Excellence in Reproductive Health Innovation

(CERHI) (C I Nzoputam MPH), University of Benin, Benin City,

Nigeria; Department of Physiology (O J Nzoputam PhD), University of

Benin, Edo, Nigeria; Department of Physiology (O J Nzoputam PhD),

Benson Idahosa University, Benin City, Nigeria; Department of Applied

Economics and Quantitative Analysis (Prof B Oancea PhD), University

of Bucharest, Bucharest, Romania; Department of Preventive Medicine

(I Oh PhD), Kyung Hee University, Dongdaemun-gu, South Korea;

School of Pharmacy (O C Okonji MSc), University of the Western Cape,

Cape Town, South Africa; Department of Medical Physiology (P G

Okwute MSc), Babcock University, Ilisan-Remo, Nigeria; Department of

Medical Physiology (P G Okwute MSc), Department of Psychiatry (A T

Olagunju MD), University of Lagos, Lagos, Nigeria; Department of

Nursing Science (M I Olatubi PhD), Bowen University, Iwo, Nigeria;

Department of Pharmacotherapy and Pharmaceutical Care (M Ordak

PhD), Department of Applied Pharmacy (M Zieli ´

nska PharmD),

Medical University of Warsaw, Warsaw, Poland; Laboratory of Public

Health Indicators Analysis and Health Digitalization (N Otstavnov BA),

Moscow Institute of Physics and Technology, Dolgoprudny, Russia;

Department of Medicine (Prof M O Owolabi DrM), University College

Hospital, Ibadan, Ibadan, Nigeria; Department of Respiratory Medicine

(Prof M P A DNB), Jagadguru Sri Shivarathreeswara Academy of Health

Education and Research, Mysore, India; Department of Forensic Med-

icine and Toxicology (J Padubidri MD), Kasturba Medical College,

Mangalore, India; Department of Epidemiology (R Pakzad PhD), Ilam

University of Medical Sciences, Ilam, Iran; Department of Public Health

(R Palladino MD), University of Naples Federico II, Naples, Italy;

Department of Public Health (A Pana PhD), Babes Bolyai University,

Cluj Napoca, Romania; Department of Health Metrics (A Pana PhD),

Center for Health Outcomes & Evaluation, Bucharest, Romania;

Department of Emergency Medicine (I Pantazopoulos PhD), University

of Thessaly, Larissa, Greece; Department of Emergency Medicine

(I Pantazopoulos PhD), University of Bern, Bern, Switzerland; Depart-

ment of Science and Mathematics (Prof P Papadopoulou PhD), Deree-

The American College of Greece, Athens, Greece; Department of

Biophysics (Prof P Papadopoulou PhD), University of Athens, Athens,

Greece; Vision and Eye Research Institute (Prof S Pardhan PhD), Anglia

Ruskin University, Cambridge, UK; Research Center (A Parthasarathi

MD), Allergy Asthma and Chest Center, Mysore, India; School of

Nursing (A Pashaei MSc), University of British Columbia, Vancouver,

BC, Canada; School of Dentistry (J Patel BSc), University of Leeds,

Leeds, UK; Research Consultancy (A R Pathan PhD), Author Gate

Publications, Malegaon, India; College of Dental Medicine (Prof S Patil

PhD), Roseman University of Health Sciences, South Jordan, UT, USA;

Research Section (U Paudel PhD), Nepal Health Research Council,

Kathmandu, Nepal; Faculty of Humanities and Social Sciences (U

Paudel PhD), Tribhuvan University, Kathmandu, Nepal; Clinical

Research Department (P Pedersini MSc, J H Villafañe PhD), IRCCS

Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Neurology

(U Pensato MD), IRCCS Humanitas Research Hospital, Milan, Italy;

International Institute for Educational Planning (IIEP) (Prof M F P

Peres MD), Albert Einstein Hospital, São Paulo, Brazil; Department of

Biology (Prof S Perna PhD), University of Bahrain, Sakir, Bahrain;

School of Pharmacy (A K Philip PhD), University of Nizwa, Nizwa,

Oman; Research Center of Neurology, Moscow, Russia (Prof M A

Piradov DSc); Department of Dermatology (I Podder MD), College of

Medicine and Sagore Dutta Hospital, Kolkata, India; Medical College (V

Podder HSC), Tairunnessa Memorial Medical College and Hospital,

Gazipur, Bangladesh; Clinical Academic Department of Pediatrics (Prof

D Poddighe PhD), University Medical Center (UMC), Astana,

Kazakhstan; College of Medicine (A Radfar MD), University of Central

Florida, Orlando, FL, USA; Department of Immunology (Prof A Raﬁei

PhD), Molecular and Cell Biology Research Center (Prof A Raﬁei PhD),

Mazandaran University of Medical Sciences, Sari, Iran; UO Neurologia,

Salute Pubblica e Disabilità (A Raggi PhD), Fondazione IRCCS Istituto

Neurologico Carlo Besta, Milan, Italy; Department of Anesthesia (F

Rahim PhD), Cihan University of Sulaimaniya, Sulaimaniya, Iraq; Na-

tional Institute of Infectious Diseases (M Rahman PhD), Center for

Surveillance, Immunization, and Epidemiologic Research, Tokyo,

Japan; Center for Evidence-Based Medicine and Clinical Research,

Dhaka, Bangladesh (M Rahman PhD); Department of Population Sci-

ence and Human Resource Development (M Rahman DrPH), Univer-

sity of Rajshahi, Rajshahi, Bangladesh; School of Nursing and

Healthcare Professions (M Rahman PhD), Federation University

Australia, Berwick, VIC, Australia; Future Technology Research Center

(A Rahmani PhD), National Yunlin University of Science and Tech-

nology, Yunlin, Taiwan; Department of Public Health (V Rahmanian

PhD), Torbat Jam Faculty of Medical Sciences, Torbat Jam, Iran;

Department of Community Medicine (P Ramasubramani MD),

Mahatma Gandhi Medical College and Research Institute, Puducherry,

India; Centre for Clinical Pharmacology (N Rancic PhD), University of

Defence in Belgrade, Belgrade, Serbia; Centre for Clinical Pharmacology

(N Rancic PhD), Medical College of Georgia at Augusta University,

Belgrade, Serbia; Department of Epidemiology (S Rashedi MD),

Department of International Studies (P Shobeiri MD), Non-

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Communicable Diseases Research Center (NCDRC), Tehran, Iran;

Department of Medicine (A M Rashid MD), Jinnah Sindh Medical

University, Karachi, Pakistan; Pulmonary Critical Care (N Ravikumar

MD), University of Chicago, Chicago, IL, USA; Academic Public Health

England (Prof S Rawaf MD), Public Health England, London, UK;

Department Biological Sciences (Prof E M M Redwan PhD), King

Abdulaziz University, Jeddah, Egypt; Department of Protein Research

(Prof E M M Redwan PhD), Research and Academic Institution, Alex-

andria, Egypt; Network of Immunity in Infection, Malignancy and

Autoimmunity (NIIMA) (Prof N Rezaei PhD), Network of Inter-

disciplinarity in Neonates and Infants (NINI) (N Samieefar MD), Uni-

versal Scientiﬁc Education and Research Network (USERN), Tehran,

Iran; Faculty of Agrarian Sciences and Environment (D Ribeiro PhD),

University of the Azores, Angra do Heroísmo, Portugal; Department of

Geography and Demography (M Rodrigues PhD), University of Coim-

bra, Coimbra, Portugal; Department of Pharmacology and Toxicology

(Prof J A B Rodriguez PhD), University of Antioquia, Medellin,

Colombia; Department of Clinical Research (L Roever PhD), Federal

University of Uberlândia, Uberlândia, Brazil; Clinical and Epidemio-

logical Research in Primary Care (GICEAP) (E Romero-Rodríguez PhD),

Maimonides Biomedical Research Institute of Cordoba (IMIBIC),

Cordoba, Spain; Cardiovascular Department (Prof A M A Saad MD),

Zagazig University, Zagazig, Egypt; Department of Pediatric Neurology

(S Sadeghian MD), Ahvaz Jundishapur University of Medical Sciences,

AHVAZ, Iran; Foundation University School of Health Sciences (Prof U

Saeed PhD), Foundation University, Islamabad, Pakistan; International

Center of Medical Sciences Research (ICMSR), Islamabad, Pakistan

(Prof U Saeed PhD); Department of Neurology (M Safdarian MD),

Christian-Doppler University Hospital, Salzburg, Austria; Spinal Cord

Injury and Tissue Regeneration Center Salzburg (SCI-TReCS) (M Saf-

darian MD), Paracelsus Medical University, Salzburg, Austria; Faculty of

Medicine, Bioscience and Nursing (S Z SaﬁPhD), MAHSA University,

Selangor, Malaysia; Interdisciplinary Research Centre in Biomedical

Materials (IRCBM) (S Z SaﬁPhD), COMSATS Institute of Information

Technology, Lahore, Pakistan; Department of Statistics (M R Sajid PhD),

University of Gujrat, Gujrat, Pakistan; Clinical Medical Sciences (S

Sakhamuri MD), University of the West Indies, St. Augustine, Trinidad

and Tobago; Thoracic Department (S Sakhamuri MD), North Central

Regional Health Authority, Champ Fleurs, Trinidad and Tobago; Insti-

tute for Employment Research (J W Sakshaug PhD), University of

Warwick, Coventry, UK; Department of Statistics (J W Sakshaug PhD),

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macy (M A Saleh PhD), Rheumatology and Immunology Unit (S

Tharwat MD), Mansoura University, Mansoura, Egypt; Department of

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Farrokhi PhD), Pasteur Institute of Iran, Tehran, Iran; Department of

Neurology (S Samadzadeh MD), Charité University Medical Center

Berlin, Berlin, Germany; Department of Neurology (S Samadzadeh

MD), University of Southern Denmark, Odense, Denmark; Department

of Entomology (A M Samy PhD), Medical Ain Shams Research Institute

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tute of Neuroanatomy (N Sanadgol PhD), Uniklinik Rhine-Westphalia

Technical University of Aachen, Aachen, Germany; Department of Pe-

diatrics (R K Sanjeev MD), Pravara Institute of Medical Sciences, Loni,

India; Department of Public Health Sciences (M Sawhney PhD), Uni-

versity of North Carolina at Charlotte, Charlotte, NC, USA; Department

of Preventive and Social Medicine (G Saya MD), Jawaharlal Institute of

Postgraduate Medical Education and Research, Puducherry, India;

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General Hospital, Cambridge, MA, USA; Department of Cardiovascular

Sciences (A Schuermans BSc), Katholieke Universiteit Leuven, Leuven,

Belgium; Emergency Department (S Senthilkumaran MD), Manian

Medical Centre, Erode, India; Department of Medicine and Surgery (Y

Sethi MBBS), Government Doon Medical College, Dehradun, India;

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MA, USA; Beth Israel Deaconess Medical Center (S Sharfaei MD),

Harvard University, Boston, USA; Schepens Eye Research Institute (M

Shayan MD), Harvard Medical School, Boston, MA, USA; Department

of Biochemistry (J K Shetty MD), Royal College of Surgeons in Ireland

Medical University of Bahrain, Busaiteen, Bahrain; Yonsei University

College of Medicine, Seoul, South Korea (Prof J Shin MD); Department

of Surgery (N A Shitaye MD), Bahir Dar University, Bahir Dar, Ethiopia;

Clinical Immunology and Hematology (V Shivarov PhD), Soﬁamed

University Hospital, Soﬁa, Bulgaria; Department of Genetics (V Shi-

varov PhD), Soﬁa University “St. Kliment Ohridiski”,Soﬁa, Bulgaria;

Department of Health Education and Health Promotion (S Siabani

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School of Health (S Siabani PhD), School of Computing Sciences (Prof J

Sun PhD), University of Technology Sydney, Sydney, NSW, Australia;

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Dilla University, Dilla, Ethiopia; Department of Medical Microbiology

and Infectious Diseases (E E Siddig MD), Erasmus University, Rotter-

dam, Netherlands; School of Health (Prof C R Simpson PhD), Victoria

University of Wellington, Wellington, New Zealand; Department of

Pulmonary and Critical Care Medicine (H Singh MD), Medical College

of Wisconsin, Milwaukee, WI, USA; Chitkara College of Pharmacy (Prof

I Singh PhD), Chitkara University, Punjab, India; School of Medicine

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mingham, AL, USA; Medicine Service (Prof J A Singh MD), US

Department of Veterans Affairs (VA), Birmingham, AL, USA; Depart-

ment of Radiodiagnosis (P Singh MD), All India Institute of Medical

Sciences, Bathinda, India; Maternal and Child Health Division (M Siraj

MSc), International Centre for Diarrhoeal Disease Research,

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ence (A Sohag MSc), Royal Melbourne Institute of Technology (RMIT)

University, Melbourne, VIC, Australia; Department of Pathology (R

Solanki MD), Ross University School of Medicine, Bridgetown,

Barbados; Department of Pathology (R Solanki MD), American Uni-

versity of the Caribbean School of Medicine, Cupecoy, Saint Martin;

Faculty of Public Health (S Solikhah DrPH), Universitas Ahmad Dah-

lan, Yogyakarta, Indonesia; Department of Nursing (Y Solomon MSc),

Dire Dawa University, Dire Dawa, Ethiopia; School of Medicine (Prof J

Sun PhD), Grifﬁth University, Gold Coast, QLD, Australia; Department

of Dermatology (M D Szeto BS), University of Colorado, Aurora, CO,

USA; Department of Medicine (Prof R Tabarés-Seisdedos PhD), Uni-

versity of Valencia, Valencia, Spain; Carlos III Health Institute (Prof R

Tabarés-Seisdedos PhD), Biomedical Research Networking Center for

Mental Health Network (CiberSAM), Madrid, Spain; Department of

Epidemiology (J J L Tamuzi MSc), Stellenbosch University, Cape Town,

South Africa; Department of Medicine (J J L Tamuzi MSc), Northlands

Medical Group, Omuthiya, Namibia; Department of Surgery (K Tan

PhD), Yong Loo Lin School of Medicine (Prof N Venketasubramanian

MBBS), National University of Singapore, Singapore, Singapore;

Department of Economics (N Y Tat MS), Rice University, Houston, TX,

USA; Research and Innovation Department (N Y Tat MS), Enventure

Medical Innovation, Houston, Texas, USA; Pediatric Intensive Care

Unit (M Temsah MD), King Saud University, Riyadh, Saudi Arabia;

Department of Pharmacology (P Thangaraju MD), All India Institute of

Medical Sciences, Raipur, India; Faculty of Public Health (J H V Ticoalu

MPH), Universitas Sam Ratulangi, Manado, Indonesia; Nufﬁeld

Department of Primary Care Health Sciences (T Tillawi MD), Oxford

University, Oxford, UK; Allied Health and Human Performance (T Y

Tiruye PhD), University of South Australia, Adelaide, SA, Australia;

Public Health Department (T Y Tiruye PhD), Debre Markos University,

Debre Markos, Ethiopia; Saveetha Dental College and Hospitals (M R

Tovani-Palone PhD), Saveetha Institute of Medical and Technical Sci-

ences, Chennai, India; SRM College of Pharmacy (M R Tovani-Palone

PhD), SRM Institute of Science and Technology (SRMIST), Chennai,

India; Department of Neurology (Prof M Tripathi MD), All India

Institute of Medical Sciences, Delhi, India; Department of Nursing (G

M Tsegay MSc), Aksum University, Aksum, Ethiopia; Department of

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Airlngga, Surabaya, Indonesia; Department of Pharmacology (S Ty MD),

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Public Health (C S Ubah MPH), Temple University, Philadelphia, PA,

USA; Institute of Soil and Environmental Sciences (S Ullah PhD),

University of Agriculture Faisalabad, Faisalabad, Pakistan; Department

of Zoology (S Ullah PhD), University of Education Lahore, Lahore,

Pakistan; Division of Science and Technology (S Ullah PhD), University

of Education, Lahore, Lahore, Pakistan; Medical Genomics Research

Department (M Umair PhD), King Abdullah International Medical

Research Center, Riyadh, Saudi Arabia; Department of Paraclinical

Sciences (S Umakanthan MD), The University of the West Indies, St.

Augustine, Trinidad and Tobago; Amity Institute of Biotechnology (E

Upadhyay PhD), Amity University, Jaipur, India; College of Health and

Sport Sciences (A G Vaithinathan MSc), University of Bahrain, Salma-

nya, Bahrain; Clinical Cancer Research Center (S Valadan Tahbaz PhD),

Milad General Hospital, Tehran, Iran; Department of Microbiology (S

Valadan Tahbaz PhD), Islamic Azad University, Tehran, Iran; Urmia

University of Medical Sciences, Urmia, Iran (R Valizadeh PhD); UKK

Institute, Tampere, Finland (Prof T J Vasankari MD); Faculty of Medi-

cine and Health Technology (Prof T J Vasankari MD), Tampere Uni-

versity, Tampere, Finland; Rafﬂes Neuroscience Centre (Prof N

Venketasubramanian MBBS), Rafﬂes Hospital, Singapore, Singapore;

Department of Surgery (G Verras MD), General University Hospital of

Patras, Patras, Greece; Department of Health Care Administration and

Economics (Prof V Vlassov MD), National Research University Higher

School of Economics, Moscow, Russia; Ofﬁce of Research, Innovation,

and Commercialization (Prof Y Waheed PhD), Shaheed Zulﬁqar Ali

Bhutto Medical University, Islamabad, Pakistan; Gilbert and Rose-Marie

Chagoury School of Medicine (Prof Y Waheed PhD), Lebanese Amer-

ican University, Byblos, Lebanon; Department of Biomedical Sciences

(A Waris MS), City University of Hong Kong, Hong Kong, China;

Competence Center of Mortality-Follow-Up of the German National

Cohort (R Westerman DSc), Federal Institute for Population Research,

Wiesbaden, Germany; Department of Surgery (D P Wickramasinghe

MD), University of Colombo, Colombo 08, Sri Lanka; Department of

Community Medicine (N D Wickramasinghe MD), Rajarata University

of Sri Lanka, Anuradhapura, Sri Lanka; Department of Neurology (B

Willekens PhD), Antwerp University Hospital, Antwerp (Edegem),

Belgium; Faculty of Medicine and Health Sciences (B Willekens PhD),

University of Antwerp, Antwerp, Belgium; Department of Internal

Medicine (B Z Woldegeorgis MD), Wolaita Sodo University, Sodo,

Ethiopia; School of Public Health (H Xiao PhD), Zhejiang University,

Zhejiang, China; Department of Public Health Science (H Xiao PhD),

Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Depart-

ment of Microbiology and Immunology (G Yahya PhD), Zagazig Uni-

versity, Al Sharkia, Egypt; Department of Cells and Tissues (G Yahya

PhD), Molecular Biology Institute of Barcelona, Spanish National

Research Council, Barcelona, Spain; Cancer Epidemiology and Preven-

tion Research (L Yang PhD), Alberta Health Services, Calgary, AB,

Canada; Department of Oncology (L Yang PhD), University of Calgary,

Calgary, AB, Canada; Department of Pediatrics (Prof D Yon MD), Kyung

Hee University, Seoul, South Korea; Department of Neuro-

psychopharmacology (N Yonemoto PhD), National Center of Neurology

and Psychiatry, Kodaira, Japan; Department of Public Health (N Yone-

moto PhD), Juntendo University, Tokyo, Japan; Department of Phar-

maceutics (S Zaidi PhD), Dow University of Health Sciences, Karachi,

Pakistan; Research and Development Department (I Zare BSc), Sina

Medical Biochemistry Technologies, Shiraz, Iran; School of Population

and Global Health (D T Zemedikun PhD), University of Western

Australia, Perth, WA, Australia; Institute of Applied Health Research (D

T Zemedikun PhD), University of Birmingham, Birmingham, UK;

Department of Neurology (C Zhang MD), National Center for Neuro-

logical Diseases (C Zhang MD), Capital Medical University, Beijing,

China; College of Traditional Chinese Medicine (H Zhao MD), Hebei

University, Baoding, China; Department of Infection (Prof A Zumla

PhD), University College London, London, UK; NIHR-Biomedical

Research Centre (Prof A Zumla PhD), University College London

Hospitals, London, UK; Department of Urban Planning and Design (C

Guo PhD), University of Hong Kong, Hong Kong Island, China.

Appendix A. Supplementary data

Supplementary data related to this article can be found at https://doi.

org/10.1016/j.eclinm.2023.102193.

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Articles

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Systemic autoimmune rheumatic diseases and multiple industrial air pollutant emissions: A large general population Canadian cohort analysis

Article

Full-text available

Apr 2023
ENVIRON INT

Background: Past investigations of air pollution and systemic autoimmune rheumatic diseases (SARDs) typically focused on individual (not mixed) and overall environmental emissions. We assessed mixtures of industrial emissions of fine particulate matter (PM2.5), nitrogen dioxide (NO2), and sulfur dioxide (SO2) and SARDs onset in Ontario, Canada. Methods: We assembled an open cohort of over 12 million adults (without SARD diagnoses at cohort entry) based on provincial health data for 2007-2020 and followed them until SARD onset, death, emigration, or end of study (December 2020). SARDs were identified using physician billing and hospitalization diagnostic codes for systemic lupus, scleroderma, myositis, undifferentiated connective tissue disease, and Sjogren's. Rheumatoid arthritis and vasculitis were not included. Average PM2.5, NO2, and SO2 industrial emissions from 2002 to one year before SARDs onset or end of study were assigned using residential postal codes. A quantile g-computation model for time to SARD onset was developed for the industrial emission mixture, adjusting for sex, age, income, rurality index, chronic obstructive pulmonary disease (as a proxy for smoking), background (environmental overall) PM2.5, and calendar year. We conducted stratified analyses across age, sex, and rurality. Results: We identified 43,931 new SARD diagnoses across 143,799,564 person-years. The adjusted hazard ratio for SARD onset for an increase in all emissions by one decile was 1.018 (95% confidence interval 1.013-1.022). Similar positive associations between SARDs and the mixed emissions were observed in most stratified analyses. Industrial PM2.5 contributed most to SARD risk. Conclusions: Industrial air pollution emissions were associated with SARDs risk.

Neural stem cell transplantation in patients with progressive multiple sclerosis: an open-label, phase 1 study

Article

Full-text available

Jan 2023
NAT MED

Innovative pro-regenerative treatment strategies for progressive multiple sclerosis (PMS), combining neuroprotection and immunomodulation, represent an unmet need. Neural precursor cells (NPCs) transplanted in animal models of multiple sclerosis have shown preclinical efficacy by promoting neuroprotection and remyelination by releasing molecules sustaining trophic support and neural plasticity. Here we present the results of STEMS, a prospective, therapeutic exploratory, non-randomized, open-label, single-dose-finding phase 1 clinical trial (NCT03269071, EudraCT 2016-002020-86), performed at San Raffaele Hospital in Milan, Italy, evaluating the feasibility, safety and tolerability of intrathecally transplanted human fetal NPCs (hfNPCs) in 12 patients with PMS (with evidence of disease progression, Expanded Disability Status Scale ≥6.5, age 18–55 years, disease duration 2–20 years, without any alternative approved therapy). The safety primary outcome was reached, with no severe adverse reactions related to hfNPCs at 2-year follow-up, clearly demonstrating that hfNPC therapy in PMS is feasible, safe and tolerable. Exploratory secondary analyses showed a lower rate of brain atrophy in patients receiving the highest dosage of hfNPCs and increased cerebrospinal fluid levels of anti-inflammatory and neuroprotective molecules. Although preliminary, these results support the rationale and value of future clinical studies with the highest dose of hfNPCs in a larger cohort of patients. Phase 1 trial results reveal that intrathecal transplantation of human fetal neural precursor cells in patients with progressive multiple sclerosis is feasible, safe and tolerable.

The link between obesity and autoimmunity

Article

Mar 2023
SCIENCE

Giuseppe Matarese

Overnutrition could lead to loss of self-tolerance by impinging on immune regulation.

Treatment of autoimmunity: The impact of disease-modifying therapies in multiple sclerosis and comorbid autoimmune disorders

Article

Mar 2023
AUTOIMMUN REV

More than 10 disease-modifying therapies (DMT) are approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) for the treatment of multiple sclerosis (MS) and new therapeutic options are on the horizon. Due to different underlying therapeutic mechanisms, a more individualized selection of DMTs in MS is possible, taking into account the patient's current situation. Therefore, concomitant treatment of various comorbid conditions, including autoimmune mediated disorders such as rheumatoid arthritis, should be considered in MS patients. Because the pathomechanisms of autoimmunity partially overlap, DMT could also treat concomitant inflammatory diseases and simplify the patient's treatment. In contrast, the exacerbation and even new occurrence of several autoimmune diseases have been reported as a result of immunomodulatory treatment of MS. To simplify treatment and avoid disease exacerbation, knowledge of the beneficial and adverse effects of DMT in other autoimmune disorders is critical. Therefore, we conducted a literature search and described the beneficial and adverse effects of approved and currently studied DMT in a large number of comorbid autoimmune diseases, including rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel diseases, cutaneous disorders including psoriasis, Sjögren´s syndrome, systemic lupus erythematosus, systemic vasculitis, autoimmune hepatitis, and ocular autoimmune disorders. Our review aims to facilitate the selection of an appropriate DMT in patients with MS and comorbid autoimmune diseases.

Epstein-Barr virus as a leading cause of multiple sclerosis: mechanisms and implications

Article

Feb 2023
NAT REV NEUROL

Epidemiological studies have provided compelling evidence that multiple sclerosis (MS) is a rare complication of infection with the Epstein-Barr virus (EBV), a herpesvirus that infects more than 90% of the global population. This link was long suspected because the risk of MS increases markedly after infectious mononucleosis (symptomatic primary EBV infection) and with high titres of antibodies to specific EBV antigens. However, it was not until 2022 that a longitudinal study demonstrated that MS risk is minimal in individuals who are not infected with EBV and that it increases over 30-fold following EBV infection. Over the past few years, a number of studies have provided clues on the underlying mechanisms, which might help us to develop more targeted treatments for MS. In this Review, we discuss the evidence linking EBV to the development of MS and the mechanisms by which the virus is thought to cause the disease. Furthermore, we discuss implications for the treatment and prevention of MS, including the use of antivirals and vaccines.

Advancing One human–animal–environment Health for global health security: what does the evidence say?

Article

Jan 2023
LANCET

In this Series paper, we review the contributions of One Health approaches (ie, at the human-animal-environment interface) to improve global health security across a range of health hazards and we summarise contemporary evidence of incremental benefits of a One Health approach. We assessed how One Health approaches were reported to the Food and Agricultural Organization of the UN, the World Organisation for Animal Health (WOAH, formerly OIE), and WHO, within the monitoring and assessment frameworks, including WHO International Health Regulations (2005) and WOAH Performance of Veterinary Services. We reviewed One Health theoretical foundations, methods, and case studies. Examples from joint health services and infrastructure, surveillance-response systems, surveillance of antimicrobial resistance, food safety and security, environmental hazards, water and sanitation, and zoonoses control clearly show incremental benefits of One Health approaches. One Health approaches appear to be most effective and sustainable in the prevention, preparedness, and early detection and investigation of evolving risks and hazards; the evidence base for their application is strongest in the control of endemic and neglected tropical diseases. For benefits to be maximised and extended, improved One Health operationalisation is needed by strengthening multisectoral coordination mechanisms at national, regional, and global levels.

A global analysis of One Health Networks and the proliferation of One Health collaborations

Article

Jan 2023
LANCET

There has been a renewed focus on threats to the human–animal–environment interface as a result of the COVID-19 pandemic, and investments in One Health collaborations are expected to increase. Efforts to monitor the development of One Health Networks (OHNs) are essential to avoid duplication or misalignment of investments. This Series paper shows the global distribution of existing OHNs and assesses their collective characteristics to identify potential deficits in the ways OHNs have formed and to help increase the effectiveness of investments. We searched PubMed, Google, Google Scholar, and relevant conference websites for potential OHNs and identified 184 worldwide for further analysis. We developed four case studies to show important findings from our research and exemplify best practices in One Health operationalisation. Our findings show that, although more OHNs were formed in the past 10 years than in the preceding decade, investment in OHNs has not been equitably distributed; more OHNs are formed and headquartered in Europe than in any other region, and emerging infections and novel pathogens were the priority focus area for most OHNs, with fewer OHNs focusing on other important hazards and pressing threats to health security. We found substantial deficits in the OHNs collaboration model regarding the diversity of stakeholder and sector representation, which we argue impedes effective and equitable OHN formation and contributes to other imbalances in OHN distribution and priorities. These findings are supported by previous evidence that shows the skewed investment in One Health thus far. The increased attention to One Health after the COVID-19 pandemic is an opportunity to focus efforts and resources to areas that need them most. Analyses, such as this Series paper, should be used to establish databases and repositories of OHNs worldwide. Increased attention should then be given to understanding existing resource allocation and distribution patterns, establish more egalitarian networks that encompass the breadth of One Health issues, and serve communities most affected by emerging, re-emerging, or endemic threats at the human–animal–environment interface.

Might biologics serve to interrupt the atopic march?

Article

Jan 2023
J ALLERGY CLIN IMMUN

The atopic march was described more than 20 years ago on the basis of initial observations, and it is now seen in prospective studies. The concept has evolved and is now considered to be the progression of atopic dermatitis to other atopic conditions, including asthma, allergic rhinitis, food allergy, and eosinophilic esophagitis in a nonlinear fashion. The progression can include some or all of the aforementioned atopic conditions. The pathogenesis is part of the classic type 2 inflammatory process involving IL-4, IL-5, and IL-13 preceded by induction of the alarmins (thymic stromal lymphopoietin, IL-33, and IL-25), leading to production of IgE in a genetically predisposed individual. The development of new biologics that interact with T2 pathway represent possible ways to prevent or modify the atopic march.

Recent advance in mesenchymal stem cells therapy for atopic dermatitis

Article

Dec 2022

Mesenchymal stem cells (MSCs) are multipotent cells found in a variety of tissues in the body, including but not limited to bone marrow, adipose tissue, umbilical cord, and umbilical cord blood. Given their immunomodulatory effect and ability to be readily isolated from several tissues, they have great potential to be used as a therapeutic agent in a variety of immune‐mediated disorders. Atopic dermatitis (AD) is a persistent and relapsing immune skin condition that has recently become more common in several species such as humans, canines, equines, and felines. The use of MSCs to treat AD has piqued the great interest of researchers in recent years. In this article, we review the recent understanding of AD pathology and advances in preclinical and clinical studies of MSCs, MSCs‐derived conditional media and exosomes as therapeutic tools to treat AD.

Long-term disease control in atopic dermatitis using biologics

Article