Background

To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.

Methods

The PURE study is a prospective, population-based cohort study of individuals aged 35–70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.

Findings

This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5–10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs ( vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.

Interpretation

Among adults aged 35–70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.

Funding

Full funding sources are listed at the end of the paper (see Acknowledgments).

中文翻译：

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来自五大洲（PURE）的21个国家/地区的中年成年人常见疾病，住院和死亡的变化：一项前瞻性队列研究

背景

据我们所知，以前的研究均未采用标准化方法前瞻性地记录了高收入国家（HIC），中等收入国家（MIC）和低收入国家（LIC）的常见疾病发病率和相关死亡率。此类信息对于制定全球性和针对特定环境的卫生策略至关重要。在对前瞻性城市农村流行病学（PURE）研究的分析中，我们旨在评估来自五个地区的21个HIC，MIC和LIC的当代大型成年人群中常见疾病发生率，相关医院入院率和相关死亡率的差异。大洲使用标准化方法。

方法

PURE研究是一项前瞻性，基于人群的队列研究，其研究对象是来自五大洲21个国家的35-70岁的个体。关键结果是致命和非致命性心血管疾病，癌症，伤害，呼吸系统疾病和住院治疗的发生率，我们计算了每千人年这些事件的年龄标准化和性别标准化的发生率。

发现

该分析评估了在2005年1月6日至2016年12月4日期间参与PURE核心研究的前两个阶段的162534名参与者的事件发生率，这些参与者的中位数为9·5年（ IQR 8·5-10·9）。在随访过程中，有11307名（7·0％）参与者死亡，9329名（5·7％）参与者患有心血管疾病，5151名（3·2％）参与者患有癌症，4386名（2·7％）参与者受伤了需要入院的患者中，有2911名（1·8％）的参与者患有肺炎，而1830名（1·1％）的参与者患有慢性阻塞性肺疾病（COPD）。与低收入国家（每1000人年4·3例）相比，低收入国家（每1000人年7·1例）和中等收入国家（每1000人年6·8例）发生的心血管疾病的发生率更高。但是，发生的癌症，伤害，COPD和肺炎在HIC中最常见，而在LIC中则最不常见。LIC的总死亡率（每千人年13·3例死亡）是中等收入国家（每千人年6·9例死亡）的两倍，是HIC（每1000人年3·4例死亡）的四倍。 。对于除癌症以外的所有死亡原因，均观察到LIC最高死亡率和HIC最低死亡率的格局，癌症在各个国家的收入水平上均相似。心血管疾病是整体上最常见的死亡原因（占40％），但仅占HIC死亡人数的23％（各个国家收入水平的死亡率相似。心血管疾病是整体上最常见的死亡原因（占40％），但仅占HIC死亡人数的23％（各个国家收入水平的死亡率相似。心血管疾病是整体上最常见的死亡原因（占40％），但仅占HIC死亡人数的23％（VS中的MIC 41％和在低收入国家43％），尽管在阀组多种心血管疾病的危险因素（如由判断INTERHEART风险分数），并在低收入国家最少这样的危险因素。在HIC中，心血管疾病与癌症的死亡率之比为0·4，在MIC中为1·3，在LIC中为3·0，四个较高的MIC（阿根廷，智利，土耳其和波兰）的比率与HIC。LIC中首次入院率和心血管疾病用药率最低，而HIC中最高。

解释

在35-70岁的成年人中，心血管疾病是全球死亡的主要原因。然而，在HIC和某些上等中等收入国家中，与心血管疾病相比，癌症死亡现在更为普遍，这表明中年死亡的主要原因已经发生了转变。随着许多国家心血管疾病的减少，癌症死亡率可能会成为主要的死亡原因。较贫穷国家的高死亡率与危险因素无关，但可能与较难获得医疗保健有关。

资金

本文的末尾列出了全部资金来源（请参阅致谢）。