WHO+全球口腔卫生状况报告-Global oral health status report -Towards universal health coverage for oral health by 2030

Globaloralhealthstatusreport

Towardsuniversalhealthcoveragefororalhealthby2030

Globaloralhealthstatusreport:towardsuniversalhealthcoveragefororalhealthby2030

ISBN978-92-4-006148-4(electronicversion)

ISBN978-92-4-006149-1(printversion)

©WorldHealthOrganization2022

Somerightsreserved.ThisworkisavailableundertheCreativeCommonsAttribution-NonCommercial-ShareAlike3.0IGOlicence

(CCBY-NC-SA3.0IGO;

/licenses/by-nc-sa/3.0/igo

).

Underthetermsofthislicence,youmaycopy,redistributeandadapttheworkfornon-commercialpurposes,providedthework

isappropriatelycited,asindicatedbelow.Inanyuseofthiswork,thereshouldbenosuggestionthatWHOendorsesanyspecific

organization,productsorservices.TheuseoftheWHOlogoisnotpermitted.Ifyouadaptthework,thenyoumustlicenseyour

workunderthesameorequivalentCreativeCommonslicence.Ifyoucreateatranslationofthiswork,youshouldaddthefollowing

disclaimeralongwiththesuggestedcitation:“ThistranslationwasnotcreatedbytheWorldHealthOrganization(WHO).WHOisnot

responsibleforthecontentoraccuracyofthistranslation.TheoriginalEnglisheditionshallbethebindingandauthenticedition”.

AnymediationrelatingtodisputesarisingunderthelicenceshallbeconductedinaccordancewiththemediationrulesoftheWorld

IntellectualPropertyOrganization(

/amc/en/mediation/rules/

).

Suggestedcitation.Globaloralhealthstatusreport:towardsuniversalhealthcoveragefororalhealthby2030.Geneva:World

HealthOrganization;2022.Licence:

CCBY-NC-SA3.0IGO

.

Cataloguing-in-Publication(CIP)data.CIPdataareavailableat/iris.

Sales,rightsandlicensing.TopurchaseWHOpublications,see/bookorders.Tosubmitrequestsforcommercial

useandqueriesonrightsandlicensing,see/copyright.

Third-partymaterials.Ifyouwishtoreusematerialfromthisworkthatisattributedtoathirdparty,suchastables,figuresor

images,itisyourresponsibilitytodeterminewhetherpermissionisneededforthatreuseandtoobtainpermissionfromthecopyright

holder.Theriskofclaimsresultingfrominfringementofanythird-party-ownedcomponentintheworkrestssolelywiththeuser.

Generaldisclaimers.Thedesignationsemployedandthepresentationofthematerialinthispublicationdonotimplytheexpression

ofanyopinionwhatsoeveronthepartofWHOconcerningthelegalstatusofanycountry,territory,cityorareaorofitsauthorities,

orconcerningthedelimitationofitsfrontiersorboundaries.Dottedanddashedlinesonmapsrepresentapproximateborderlines

forwhichtheremaynotyetbefullagreement.

Thementionofspecificcompaniesorofcertainmanufacturers’productsdoesnotimplythattheyareendorsedorrecommended

byWHOinpreferencetoothersofasimilarnaturethatarenotmentioned.Errorsandomissionsexcepted,thenamesofproprietary

productsaredistinguishedbyinitialcapitalletters.

AllreasonableprecautionshavebeentakenbyWHOtoverifytheinformationcontainedinthispublication.However,thepublished

materialisbeingdistributedwithoutwarrantyofanykind,eitherexpressedorimplied.Theresponsibilityfortheinterpretation

anduseofthemateriallieswiththereader.InnoeventshallWHObeliablefordamagesarisingfromitsuse.

Designandlayout:JuliePudlowskiConsulting

Frontcoverphotograph:JuliePudlowski

Globaloralhealth

statusreport

Towardsuniversalhealthcoverage

fororalhealthby2030

©JuliePudlowski

iii

Contents

Forewordv

Acknowledgementsvii

Listofabbreviationsx

Introduction1

1.Oraldiseasesareglobalpublichealthproblems5

1.1Oraldiseases–anincreasingglobalburden7

1.2Oraldiseases–commondeterminantsandriskfactors15

1.3Oraldiseases–individualandpopulationimpactsalongthelifecourse19

1.4Oraldiseases–globalinequalitiesintheburden22

1.5Oraldiseases–inequalitiesinaccesstooralhealthservices23

1.6Oraldiseases–globalexpendituresandeconomicimpactoforaldiseases26

2.Theburdenofthemainoraldiseases29

2.1Dentalcaries30

2.2Severeperiodontaldisease37

2.3Edentulism41

2.4Oralcancer45

2.5Otheroralconditionsofpublichealthrelevance52

3.Challengesandopportunitiestowardsoralhealthforall59

3.1Healthserviceandmodelsoforalhealthcare60

3.2Globaloralhealthworkforce62

3.3Fluoridesfororalhealth66

3.4Oralhealthinformationandresearchchallenges70

3.5Issuesofpublichealthrelevanceinoralhealthcare73

3.6ReorientationonprimaryoralhealthcareandUHC79

4.AroadmaptowardsUHCfororalhealth83

5.References

87

©JuliePudlowski

v

Foreword

Oraldiseasesareamongthemostcommonnoncommunicablediseasesworldwide,affectinganestimated3.5billionpeople.Theburdenisincreasing,particularlyinlow-andmiddle-incomecountries.

Goodoralhealthisessentialforeating,breathingandspeaking,andcontributestooverallhealth,well-beingandconfidenceininteractingwithothers.Butoralhealthischallengedbyarangeofdiseasesandconditions,andstarkandpersistentinequalitiesintheburdenofdiseaseandaccesstooralhealthcare.Disadvantagedandmarginalizedpeoplearemorelikelytobeatriskoforaldiseasesandtheirnegativeconsequences.

Thegoodnewsisthatmanyoraldiseasescanbepreventedandtreated.Cost-effectivepreventiveandclinicalinterventionsareavailable,togetherwithapproachestotackleriskscommontoallnoncommunicablediseases,withthepotentialtobeeffectiveinarangeofcontexts,includinglow-andmiddle-incomecountries.

Oralhealthhaslongbeenneglectedintheglobalhealthagenda.Ourbiggestchallengenowisensuringthatallpeople,wherevertheyliveandwhatevertheirincome,havetheknowledgeandtoolsneededtolookaftertheirteethandmouths,andaccesstopreventionandcarewhentheyneedit.Forthistohappen,allcountriesneedsufficientstafftrainedinoralhealth,andoralhealthservicesmustbeincludedinnationalhealthcoveragepackages,eitherfreeofchargeoratapricethatpeoplecanafford.

TheadoptionbyWHOMemberStatesofahistoricresolutiononoralhealthattheWorldHealthAssemblyin2021wasanimportantstepforward.ThedevelopmentandadoptionofacomprehensiveGlobalStrategyonOralHealth,withaboldvisionforuniversalcoverageoforalhealthservicesby2030wasanothermilestone.TheGlobalOralHealthActionPlantobediscussedin2023willincludeamonitoringframework,withcleartargetstobeachievedby2030.Thesepolicieswillprovideuswithaclearpathtowardsensuringoralhealthforall.

ThisWHOGlobaloralhealthstatusreportprovidesacomprehensivepictureoftheoraldiseaseburden,theresourcesavailablefororalhealth,andthechallengesahead.

Thereportalsoincludescountryprofiles,andwillserveasabaselinefortrackingprogress.IntegratingoralhealthpromotionandcareintoprimaryhealthcareandUHCbenefitpackageswillbekeytosuccess.WHOiscommittedtoprovidingguidanceandsupporttocountriestohelpmakethishappen.

Iamconfidentthatthisreportwillcontributetocontinuedandincreasedeffortstoimproveoralhealthglobally,sothatnooneisleftbehindwithpreventableandtreatableoraldiseases.

DrTedrosAdhanomGhebreyesusDirector-General,WorldHealthOrganization

©WHO

vii

Acknowledgements

TheWorldHealthOrganization(WHO)isgratefulforthecontributionsthatmanyindividualsandorganizationshavemadeoverseveralyearstothedevelopmentofthisreport.

TheWHOGlobaloralhealthstatusreportwasproducedbytheDepartmentofNoncommunicableDiseases,UniversalHealthCoverage/CommunicableandNoncommunicableDiseases(UCN)divisionoftheWorldHealthOrganization(WHO),Geneva,Switzerland(WHOHQ),undertheinitialgeneralguidanceofDouglasBettcher,Director,PreventionofNoncommunicableDiseasesDepartment,andlaterofBenteMikkelsen,Director,DepartmentofNoncommunicableDiseasesandSlimSlama,UnitHead,NoncommunicableDiseasesManagement-Screening,DiagnosisandTreatment,DepartmentofNoncommunicableDiseases,andundertheleadofBenoitVarenne,DentalOfficer,OralHealthProgramme,DepartmentofNoncommunicableDiseases.

Steeringcommittee

FatenBenAbdelaziz(WHOHQ);HabibBenzian(WHOCollaboratingCentre,NewYorkUniversity,NewYorkCity,UnitedStatesofAmerica);DongboFu(WHOHQ);YurikoHarada(WHOHQ);JasonLigot(WHOHQ);StefanListl(RadboudUniversity,Nijmegen,theNetherlands);WagnerMarcenes(GlobalBurdenofDiseaseOralHealthCollaboratorsGroup,King’sCollege,London,UnitedKingdomofGreatBritainandNorthernIreland);YukaMakino(WHORegionalOfficeforAfrica,Brazzaville,Congo);PoulErikPetersen(WHOCollaboratingCentre,UniversityofCopenhagen,Denmark);NicoleRendell(WHOHQ);LeanneRiley(WHOHQ);BenoitVarenne(WHOHQ);AkihitoWatabe(WHOHQ);andRichardWatt(WHOCollaboratingCentre,UniversityCollege,London,UnitedKingdom).

Editorialcommittee

HabibBenzian(WHOCollaboratingCentre,NewYorkUniversity,NewYorkCity,UnitedStates);YukaMakino(WHORegionalOfficeforAfrica,Brazzaville,Congo);NicoleStauf(LondonSchoolofHygieneandTropicalMedicine,London,UnitedKingdom);BenoitVarenne(WHOHQ);andRichardWatt(London,UnitedKingdom).

Reportdevelopment

WHOisverygratefultoHabibBenzianandRichardWattfortheireditorialleadershipandtechnicalwritingskillsduringthedevelopmentofthereport.

WHOalsothanksthefollowingindividualswhosededicatedeffortsandexpertisecontributedtothedevelopmentofthereport:HudaAbdulGhaffar(WHORegionalOfficefortheEasternMediterranean);SamiraAsma(WHOHQ);PaulBrennan(IARC,Lyon,France);AlisonRuthBrunier,(WHOHQ);AndreCarvalho(IARC,Lyon,France)SomnathChatterji(WHOHQ);KhassoumDiallo,(WHOHQ);GampoDorji(WHORegionalOfficeforSouth-EastAsia);DianaEstevezFernandez(WHOHQ);JillLouiseFarrington(WHORegionalOfficeforEurope);Riitta-maijaHämälainen(WHORegionalOfficefortheWesternPacific);HayateeHasan(WHOHQ);

viii

CarolinaHommes(WHORegionalOfficefortheAmericas);AndreIlbawi(WHOHQ);RatnasabapathipillaiKesavan,(WHORegionalOfficeforSouth-EastAsia);TeenaKuniumen,(WHOHQ);BeatriceLauby-Secretan(IARC,Lyon,France)AmitPrasad(WHOHQ);VinayakPrasad(WHOHQ);FelipeRoitberg(WHOHQ);StefanSavin(WHOHQ);DeependraSingh(IARC,Lyon,France);SlimSlama(WHOHQ);YvesTurgeon(WHOHQ);MennoVanHilten(WHOHQ);CherianVarghese(WHOHQ);KhanWasiqMehmood(WHORegionalOfficefortheEasternMediterranean).

Externalreviewers

AluísioJDBarros(UniversidadeFederaldePelotas,Brazil);LoisK.Cohen(NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,WashingtonDC,UnitedStates);StefanListl(RadboudUniversity,Nijmegen,theNetherlands);WagnerMarcenes(GlobalBurdenofDiseaseOralHealthGroup,King’sCollege,London,UnitedKingdom);SudeshniNaidoo(WHOCollaboratingCentreforOralHealth,UniversityoftheWesternCape,Bellville,RepublicofSouthAfrica);RichardNiederman(WHOCollaboratingCentre,NewYorkUniversity,NewYorkCity,UnitedStates);SrinathReddy(PublicHealthFoundationofIndia,Gurugram,India);VirojTangcharoensathien(InternationalHealthPolicyProgram,Nonthaburi,Thailand);andStéphanieTubert-Jeannin(UniversitéClermontAuvergne,France).

Othercontributors

WHOisgratefultothefollowingWHOCollaboratingCentres,consultantsandexternalexpertswhocontributedtothedevelopmentofspecificsectionsofthereport,totheimplementationofWHO-ledglobalsurveysatdifferentstagesofthedevelopmentofthereport,and/ortoregionalconsultationsorganized:

JunAida(TohokuUniversity,Sendai,Japan);EduardoBernabé(GlobalBurdenofDiseaseOralHealthCollaboratorsGroup,King’sCollege,London,UnitedKingdom);PascalBovet(UniversityofLausanne,Switzerland);ChristianBradley(WesternNSWLocalHealthDistrict,Dubbo,Australia);PeterCarlsson(WHOCollaboratingCentre,MalmöUniversity,Malmö,Sweden);DavidConway(UniversityofGlasgow,UnitedKingdom);SarahCrummey(King’sCollege,London,UnitedKingdom);ElisabethDimba(UniversityofNairobi,Kenya);DuangthipDuangporn(UniversityofHongKong,China,HongKongSpecialAdministrativeRegion(HongKongSAR,China);RituDuggal(WHOCollaboratingCentre,AllIndiaInstituteofMedicalSciences,NewDelhi,India);MahaElTantawi(ImamAbdulrahmanBinFaisalUniversity,Dammam,SaudiArabia);DeniseFaulks(UniversitéClermontAuvergne,France);CarlosFeldens(UniversidadeLuteranadoBrasil,SãoJosé,Brazil);JennyGallagher(King’sCollege,London,UnitedKingdom);NicolasGiraudeau(UniversitédeMontpellier,France);AthanasiosGkekas(UniversityofYork,UnitedKingdom);MaireadHarding(UniversityCollege,Cork,Ireland);AnjaHeilmann(UniversityCollege,London,UnitedKingdom);MilicaJevdjevic(RadboudUniversity,Nijmegen,theNetherlands);NewellJohnson(GriffithUniversity,Brisbane,Australia);RaksananKarawekpanyawong(WHOCollaboratingCentre,NiigataUniversity,Niigata,Japan);CristinKearns(UniversityofCalifornia,SanFrancisco,UnitedStates);O.P.Kharbanda(WHOCollaborationCentre,AllIndiaInstituteofMedicalSciences,NewDelhi,India);YuKubota(WHOCollaboratingCentre,NiigataUniversity,Niigata,Japan);ÖzlemElmasLubino(Saint-Genis-Pouilly,France);LornaMacpherson(UniversityofGlasgow,UnitedKingdom);ManuRajMathur(PublicHealthFoundationofIndia,Gurugram,India);GrazielleMattosSavage(King’sCollege,London,UnitedKingdom);AfshanMirza(UniversityCollege,London,UnitedKingdom);PeterMossey(UniversityofDundee,UnitedKingdom);PaulaMoynihan(University

ix

ofAdelaide,Australia);MargaretNamusisi(MakerereUniversity,Kampala,Uganda);BelindaNicolau(McGillUniversity,Montreal,Canada);KanameNohno(WHOCollaboratingCentre,NiigataUniversity,Niigata,Japan);HiroshiOgawa(WHOCollaboratingCentre,NiigataUniversity,Niigata,Japan);EmmanuelOtho(RegionalCenterforOralHealthResearch,Jos,Nigeria);PrathipPhanthumvanit(AssociationofAsianChiefDentalOfficers,Thailand);AvePöld(InternationalAssociationofDentalStudents,Estonia);KoheiTamura(WHOCollaboratingCentre,NiigataUniversity,Niigata,Japan);JamesTaylor(SectionofChiefDentalOfficersandDentalPublicHealth,FDIWorldDentalFederation,andPublicHealthAgencyofCanada,Ottawa,Canada);GeorgeTsakos(UniversityCollegeLondon,UnitedKingdom);KasturiWarnakulasuriya(WHOCollaboratingCentre,King’sCollege,London,UnitedKingdom);TaoXu(WHOCollaboratingCentre,PekingUniversity,Beijing,China);ShanshanZhang(WHOCollaboratingCentre,PekingUniversity,Beijing,China);andShuguoZheng(WHOCollaboratingCentre,PekingUniversity,Beijing,China).

WHOisgratefultoSamiraAsma(WHOHQ)forfacilitatingcollaborationwiththeInstituteforHealthMetricsandEvaluation(IHME)attheUniversityofWashington,Seattle,UnitedStates,whoprovidedaccesstodataonoraldiseasesfromtheGlobalBurdenofDiseaseProject(2019).AttheIHME,WHOespeciallythanksKellyBienhoff,LisaForce,NickKassebaum,RafaelLozanoandMeghanMooney.

WHOthanksallthosementionedinthecasestudiesfortheircollaborationandforsharingtheirownexperiencesandpersonalinsights:SemiyuAdetunjiAdeniyi,VoramonAgrasuta,PhilippeAubert,MariaCorazonDumlao,ClaireJeantet,MulikatOkanlawon,VictorOluwalomola,MaryOtto,WarisaPanichkriangkrai,NormanTinanoff,NoelVallesteros,ShashankWani,RahulWankhede,SakujiYanadoriandPascalZoungrana.

WHOowesaveryspecialthankstoRicardoMartinezandLuceroLopezPerez,OctomaConsultantsTeam,Mexico,fortheirexpertdataanalysisandvisualizations.

WHOacknowledgeswithgratitudethefundsreceivedfromtheWHOvoluntarycontributionsoftheBorrowFoundation,UnitedKingdom,andHilfsaktionNomae.V.,Germany.

x

Listofabbreviations

AMRAntimicrobialresistance

CCS

CountryCapacitySurvey

CPI

CommunityPeriodontalIndex

DALY

disability-adjustedlifeyear

DATs

dentalassistantsandtherapists

DMFT

decayed,missingandfilledteeth

DPTs

dentalprosthetists/technicians

GBD

GlobalBurdenofDisease

GSHS

GlobalSchool-basedStudentHealthSurvey

HPV

humanpapillomavirus

HTA

healthtechnologyassessment

IARC

InternationalAgencyforResearchonCancer

IHME

InstituteofHealthMetricsandEvaluation

ILO

InternationalLabourOrganization

IPC

infectionpreventionandcontrol

ITU

InternationalTelecommunicationUnion

mHealth

mobilehealth

NCD

noncommunicabledisease

NGO

nongovernmentalorganization

NHWA

NationalHealthWorkforceAccount

OFC

orofacialclefts

PHC

primaryhealthcare

SDGs

SustainableDevelopmentGoals

SSB

sugar-sweetenedbeverage

UHC

universalhealthcoverage

UN

UnitedNations

UNICEF

UnitedNationsChildren’sFund

WB

WorldBank

WHO

WorldHealthOrganization

WHOEML/cWHOmodellistofessentialmedicinesforadultsandchildren

xi

Listoffigures

Fig.1

RankingofmostprevalentconditionsperWBcountryincomelevel

8 Fig.2

ComparisonofestimatedglobalcasenumbersforselectedNCDs

9

Fig.3

EstimatedcasenumbersandprevalenceofthemajororaldiseasescombinedperWB

9

countryincomegroup(excludinglip/oralcavitycancer)

Fig.4

Estimatedcasenumbersandprevalenceofthemajororaldiseasescombinedper

WHOregion(excludinglip/oralcavitycancer)

10

Fig.5

Estimatedcasenumbersofthemajororaldiseasescombinedbetween1990and2019

perWBcountryincomegroup(excludinglip/oralcavitycancer)

11

Fig.6

Estimatedpopulationchangebetween1990and2019byWBcountryincomegroup

12

Fig.7

ComparisonofestimatedglobalDALYsforselectedNCDs

13

Fig.8

Socialandcommercialdeterminantsoforaldiseases

15

Fig.9

CommonriskfactorsforNCDsandoralhealth

17

Fig.10

Prevalenceratesoffourmajororaldiseasesoverthelifecourse

19

Fig.11

Selectedimpactsoforaldiseases

21

Fig.12

Comparisonofedentulismbyeducationalattainmentindifferentpopulations

(inpercentageofedentulouspopulation)

23

Fig.13

PercapitadirectdentalexpenditureinUS$perWBcountryincomegroup(2019)

27

Fig.14

TotaldirectdentalexpenditureinUS$perWBcountryincomegroup(2019)

27

Fig.15

capitadentalexpendituresinUS$percountry(2019)

Per

28

Fig.16

Estimatedprevalenceofdentalcariesofdeciduousteethpercountry

31

Fig.17

EstimatedcasesandprevalenceofcariesofdeciduousteethperWBcountry

incomegroup

32

Fig.18

EstimatedcasesandprevalenceofcariesofdeciduousteethperWHOregion

33

Fig.19

EstimatedcasesandprevalenceofcariesofpermanentteethperWBincomegroup

34

xii

Fig.20

Estimatedprevalenceofcariesofpermanentteethpercountry

35

Fig.21

EstimatedcasesandprevalenceofcariesofpermanentteethperWHOregion

38

Fig.22

EstimatedcasesandprevalenceofsevereperiodontaldiseaseperWBcountry

38

incomegroup

Fig.23

Estimatedprevalenceofsevereperiodontaldiseasepercountry

39

Fig.24

EstimatedcasesandprevalenceofsevereperiodontaldiseaseperWHOregion

39

Fig.25

EstimatedcasesandprevalenceofedentulismperWBcountryincomegroup

42

Fig.26

EstimatedcasesandprevalenceofedentulismperWHOregion

43

Fig.27

Estimatedprevalenceofedentulism

44

Fig.28

IncidenceandmortalityratesoflipandoralcavitycancerperWBcountryincomegroup

46

Fig.29

IncidenceandmortalityratesoflipandoralcavitycancerperWHOregion

46

Fig.30

Estimatedincidenceratesoflipandoralcavitycancer

47

Fig.31

Estimatedmortalityratesoflipandoralcavitycancer

47

Fig.32

Estimatednumbersofnewcasesandpercentageshareoftotalcasesoflipandoral

cavitycancerperWBcountryincomegroup(2020)

51

Fig.33

Estimatednumbersofnewcasesandpercentageshareoftotalcasesoflipandoral

cavitycancerperWHOregion(2020)

51

Fig.34

EstimatedcasesandprevalenceofOFCsbyWBIncomegroup

52

Fig.35

EstimatedcasesandprevalenceofOFCsbyWHOregion

53

Fig.36

Workforcefororalhealth–dentistdensity

64

Fig.37

Usesoforalhealthinformation

71

Fig.38

Conceptualmodeloftheprimaryoralhealthcarepyramid

80

Fig.39

Theprimaryoralhealthcareoperationalframework

82

xiii

Listoftables

Percentagechangeinestimatedprevalence,casenumbersandDALYsofthemajororal

11

Table1.

diseases(exceptlipandoralcavitycancer)andchangeinpopulationbyWBcountry

incomegroup

Table2.

Estimatedprevalenceandcasesofcariesofdeciduousteethin2019andthepercentage

changefrom1990to2019perWBcountryincomegroup

31

Table3.

Estimatedprevalenceandcasenumbersofcariesofdeciduousteethin2019

andtheirpercentagechangefrom1990to2019perWHOregion

32

Table4.

Estimatedprevalenceandcasesofcariesofpermanentteethin2019

andthepercentagechangeofprevalence,casesandpopulationfrom1990to2019

perWBcountryincomegroup

34

Table5.

Estimatedprevalenceandcasesofcariesofpermanentteethin2019andthepercentage

changeofprevalence,casesandpopulationfrom1990to2019perWHOregion

35

Table6.

Estimatedprevalenceandcasesofsevereperiodontaldiseasein2019andthe

percentagechangeofprevalence,casesandpopulationfrom1990to2019perWB

countryincomegroup

38

Table7.

Estimatedprevalenceandcasesofsevereperiodontaldiseasein2019

andthepercentagechangeofprevalence,casesandpopulationfrom1990to2019

perWHOregion

40

Table8.

Estimatedprevalenceandcasesofedentulismin2019andthepercentagechangeof

prevalence,casesandpopulationfrom1990to2019perWBcountryincomegroup

42

Table9.

Estimatedprevalenceandcasenumbersofedentulismin2019andthepercentage

changeofprevalence,casesandpopulationfrom1990to2019perWHOregi