The Lancet: One in eight deaths in 2019 linked to bacterial infections, the second leading cause of death globally

• First global estimates of mortality involving 33 bacterial pathogens and 11 types of infection suggest they were associated with 7.7 million deaths in 2019.
• Deaths associated with the 33 pathogens accounted for 13.6% of all global deaths, with five pathogens – S. aureus, E. coli, S. pneumoniae, K. pneumoniae, and P. aeruginosa – accounting for more than half of all bacteria-related deaths.
• The mortality rate associated with bacterial infections was highest in sub-Saharan Africa and lowest in high-income regions, including Western Europe and North America.
• The study can serve to guide strategies for reducing bacterial infections, including control measures, vaccine development, and increased availability of basic acute care services.

Common bacterial infections were the second-leading cause of death in 2019, and were linked to one in eight deaths globally, according to an analysis published in The Lancet.

There were 7.7 million deaths in 2019 associated with 33 common bacterial infections, with five bacteria alone connected to more than half of all deaths. The deadliest bacterial pathogens and types of infection varied by location and age.

Bacterial infections were second only to ischemic heart disease as the leading cause of death in 2019, and the analysis highlights reducing them as a global public health priority. Building stronger health systems with greater diagnostic laboratory capacity, implementing control measures, and optimizing antibiotic use is crucial to lessen the burden of disease caused by common bacterial infections.

“These new data for the first time reveal the full extent of the global public health challenge posed by bacterial infections,” said Dr. Christopher Murray, study co-author and Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine. “It is of utmost importance to put these results on the radar of global health initiatives so that a deeper dive into these deadly pathogens can be conducted and proper investments are made to slash the number of deaths and infections.”

While many estimates exist for pathogens such as tuberculosis, malaria, and HIV, until now, estimates of the disease burden of bacterial pathogens were limited to a handful of specific pathogens and types of infection, or focused only on specific populations. More deaths were linked to two of the deadliest pathogens – S. aureus and E. coli – than HIV/AIDS (864,000 deaths) in 2019, yet analysis shows HIV research was awarded $42 billion dollars, while E. coli research was awarded $800 million. The authors say such funding gaps might have arisen because there was, until now, a lack of data on the global burden of these infections.

The new study provides the first global estimates of mortality associated with 33 common bacterial pathogens and 11 major infection types – known as infectious syndromes – leading to death from sepsis. Estimates were produced for all ages and sexes across 204 countries and territories. Utilising data and methods from the Global Burden of Disease 2019 and Global Research on Antimicrobial Resistance (GRAM) studies [2], the authors used 343 million individual records and pathogen isolates to estimate deaths associated with each pathogen and the type of infection responsible.

Of the estimated 13.7 million infection-related deaths that occurred in 2019, 7.7 million were associated with the 33 bacterial pathogens studied. Deaths associated with these bacteria accounted for 13.6% of all global deaths, and more than half of all sepsis-related deaths, in 2019. More than 75% of the 7.7 million bacterial deaths occurred because of three syndromes: lower respiratory infections (LRI), bloodstream infections (BSI), and peritoneal and intra-abdominal infections (IAA).

Five pathogens – S. aureus, E. coli, S. pneumoniae, K. pneumoniae, and P. aeruginosa – were responsible for 54.2% of deaths among the bacteria studied. The pathogen associated with the most deaths globally was S. aureus, with 1.1 million deaths. Four other pathogens were each associated with more than 500,000 deaths: E. coli (950,000 deaths), S. pneumoniae (829,000), K. pneumoniae (790,000), and Pseudomonas aeruginosa (559,000). A similar number of female and male deaths were associated with the leading bacterial pathogens.

Age-standardized mortality rates varied by location, as did the deadliest pathogens. Sub-Saharan Africa recorded the highest mortality rate, with 230 deaths per 100,000 population. By comparison, the high-income super-region – which includes countries in Western Europe, North America, and Australasia – recorded the lowest mortality rate, with 52 deaths per 100,000 population. S. aureus was the leading bacterial cause of death in 135 countries, followed by E. coli (37 countries), S. pneumoniae (24 countries), and K. pneumoniae and Acinetobacter baumannii (four countries each). Country-level data is available in Appendix Table S2.

“Until now, country-level estimates for parts of the world where people are worst affected by bacterial infections have been noticeably absent,” said Authia Gray, study co-author and Post-Bachelor Fellow at IHME at the University of Washington’s School of Medicine. “These new data could act as a guide to help address the disproportionately high burden of bacterial infections in low- and middle-income countries and may ultimately help save lives and prevent people losing years of their lives to illness.”

The pathogens associated with the most deaths differed by age. With 940,000 deaths, S. aureus was associated with the most deaths in adults aged over 15 years. The most deaths in children aged 5 to 14 years were associated with Salmonella enterica serovar Typhi, with 49,000 deaths. In children older than newborns but under 5 years of age, S. pneumoniae was the deadliest pathogen, accounting for 225,000 deaths. The pathogen associated with the most neonatal deaths was K. pneumoniae, with 124,000 deaths.

The authors acknowledge some limitations to their study, many of which are due to a lack of data. Limited data is available for some parts of the world, particularly many low- and middle-income countries (LMICs), where the estimated burden of disease is greatest. This underscores the need to improve data collection capacity and surveillance systems in LMICs. Combining and standardising data from a wide variety of sources also introduces potential sources of bias, including misclassification of community- or hospital-acquired infections as well as data from passive surveillance systems that may overestimate the virulence or drug-resistance of pathogens.

NOTES TO EDITORS

This study was funded by Bill & Melinda Gates Foundation, Wellcome Trust, Department of Health and Social Care using UK aid funding managed by the Fleming Fund. It was conducted by the Global Burden of Disease & Antimicrobial Resistance Collaborators.

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[1] Quote direct from author and cannot be found in the text of the Article.

[2] GBD 2019: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext; GRAM: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext

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