Independent Advisory Committee meetings

3-4 June, 2024, Seattle, USA

The 22nd meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened at the offices of IHME in Seattle on June 3rd and 4th 2024. Meeting participants included the GBD IAC members, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation, and the members of the IAC Secretariat.

This was the first meeting with a refreshed GBD IAC membership. The meeting started with the IAC Chair welcoming the new IAC members who include; Moustapha Cisse, Founder and CEO of Kera Health Platforms; Professor of AI at African Institute of Mathematical Sciences and Founder of African Masters of Machine Intelligence & of AI Startup; Lothar Wieler, Chair for Digital Global Public Health, The Hasso Plattner Institute; ex-President Robert Koch Institute, Berlin; Syarifah Liza Munira, Director General from Health Policy Agency at the Ministry of Health, Indonesia; and Leesa Lin (GBD IAC junior member), Co-Director of the Vaccine Confidence Project, London/Hong Kong.

Recommendations:

The IAC once again commends the tremendous progress made at IHME since the last IAC meeting, noting that it has been another highly productive few months in terms of the pace, volume and quality of the work produced.
As recommended at previous meetings, the committee greatly appreciated IHME providing the IAC meeting materials before the meeting, giving more succinct presentations, and for bringing in a wide range of IHME presenters to the meeting. The Seattle meetings are a good opportunity for the IAC to interact with the IHME teams and meeting some of the next generation of IHME experts was highly valued by the IAC.
The IAC was pleased to see that IHME have taken on the IAC recommendations of the new regional groupings. However, it notes that the previously recommended grouping of the European Union and its immediate neighbourhood has not been adopted.
Following the previous IAC suggestion that each GBD paper could finish with a section on the data availability and gaps, the IAC was pleased to see that IHME have made this suggestion to the Nature family of journals and are planning to try to include this now in the 3rd and 4th rounds of submissions in the Burden of Proof series. While the IAC recognizes that it is not IHME’s responsibility to improve country-level data availability, it suggests that this approach may help draw attention to such issues.
The IAC applauded the extensive media and social media coverage of the key GBD capstone papers and commends IHME’s expanded media coverage tracking in multiple non-English languages. It was noted that there is an opportunity to expand the outreach further for the DALYs and HALE papers whilst recognising that work needs to be undertaken to better explain the more complex terminology in these papers.
The Committee welcomes the expansion in languages of the GBD infographic booklet (the 2-pager format for disseminating GBD results).
The IAC suggested that IHME engages with national public health and academic institutes of key countries who may be effective “multipliers” for getting the core messages out.
The IAC commends the great progress that has been made on the collaborator network especially with regards to the tiering of the collaborators and the collaborator term renewal requirements. The IAC suggested making the information about collaborators, including an index of collaborators and details about how to become a collaborator more prominent on the IHME website.
The IAC suggested that IHME may encourage and support a national network of collaborators in key countries and could explore investing in conferences for collaborators at the regional and national level.
The IAC commends the very exciting work that has been undertaken in the USA around the Human Development Index (HDI). The IAC cautions that the findings have potential for misuse and providing a clear narrative around the findings will be critically important. The IAC suggests that this analysis would be interesting to do in other countries and IHME should consider publishing the methodology.
The Committee welcomes the commencement of an extensive comparison exercise for validating the new DisMod-AT model (as previously recommended). The IAC notes the volume of updates and outputs foreseen for the calendar year of 2024 and urges IHME to again review the necessity of completing GBD annual updates.

OneMod Modelling

The IAC welcomed the updates on OneMod and suggests IHME adopts it as quickly as possible.
The IAC suggests that the components of OneMod may well be of interest to other groups outside of IHME. The IAC encourages IHME to publish on this work and promotes the dissemination of the components.

All-cause mortality estimation

The IAC appreciated the detailed presentation which highlighted the computational advantage of OneMod that enables direct estimation of mortality rates over the highly complex all-cause mortality estimation process currently used. There was a suggestion that the generalised linear model (GLM) be kept in for comparison purposes.
The Committee advises that the age category “terminal” be renamed.

Climate and food insecurity

The IAC suggests that IHME should consider factoring in dengue, endemic parasitic diseases and conflict as confounders, and exploring the use of longitudinal and non-traditional data sources, and training models with lower resolution data (e.g. night-time satellite imagery).
The IAC suggests that IHME could demonstrate the usefulness of satellite imaging by finding a geographic area or areas experiencing recent infrastructure changes (e.g., rapid construction, new roads, recent expansion of electricity, etc.) and examining how accurately and reliably this technology is able to accurately track these changes. This could then help determine and document whether and how well satellite imaging may then be used to provide early warning for future events.
The Committee recommends that IHME explores the impact of climate change and food insecurity on child mortality.

Clinical informatics data

The IAC was made aware that laws around personal data may become a key issue with using electronic health records (EHRs) to inform disease burden estimation.
The IAC urged IHME to pay attention to the way that physicians are paid or reimbursed in different settings as this might impact how they code patients’ electronic health records.
The IAC also suggests that IHME look into EHRs within the private sector.

Antimicrobial resistance (AMR)

The IAC recognizes the importance of nuance around AMR messaging. The IAC stresses the tremendous progress achieved in child mortality thanks to antibiotics and that the lack of access to genuine antibiotic products (as opposed falsified and substandard medicines) and misuse of antibiotics continues to cause substantial disease burden in many low-resource settings. At the same time, the Committee notes the rapid rise in sexual transmitted infections (STIs) including multi-resistant gonorrhoea in many regions.
The Committee notes the evolution of antibiotic prescription practice, such as dosage and mix of antibiotics, over time. It suggests that it may be important to link global trends in AMR to usage by region.
The IAC suggests a more detailed breakdown of age groups than the current single split at age 5 since much of the variations are masked in the current wide age groups.
The Committee notes that the pharmaceutical industry holds comprehensive sales data and suggests that IHME explores their use.

Forecasts

The IAC notes the impressive development in the future health scenario (FHS) work since the last meeting. It has the following suggestions:
1. Consider showing how much a risk factor is needed to change to achieve a certain level of impact.
2. Negative scenarios: consider demonstrating the cost of inaction which may be likely to get policy makers’ attention, as well as linking an action to the return on investment. The cost (i.e. both Burden of Disease and the financial cost to the Government Budget) of action versus inaction may present an impactful message to a policy maker
3. Splitting the US forecast by subgroups, for example, the ten ‘Americas’.
4. Consider allowing users to alter the level of changes in the risk factors in the visualization tool to create their own “what-if” scenarios;
5. In presentations of the FHS work IHME should attempt to communicate the inexact nature of forecasting. I.e forecasting tools may be considered a tool that enables making better informed, rather than perfect, decisions.
The IAC agreed that forecasts for smoking should be extended beyond 2050 to better demonstrate the long-lasting impact of smoking reduction.
The IAC notes that dependencies among risk factors are not currently accounted for in forecasting and warrants further deliberation.
The Committee would like a future discussion on approaches to scenarios in health and how to prioritise the demand for the FHS work. It further suggests that a deep dive workshop may be beneficial to its future development. The IAC will consult IHME and BMGF on the prospect of such a workshop.

TB and the TB deep dive

The IAC commends IHME’s adoption of two of the key TB deep dive recommendations; (1) enhancing documentation in TB publications by including key material rather than referencing other publications and (2) strengthening the dialogue between IHME and WHO by exploring the causes of differences in TB estimates.
While the IAC welcomes BMGF funding an IHME-WHO collaborative project in a high TB burden country (Nigeria), it encourages similar initiatives in other high TB burden countries as recommended in the deep dive report [PR’s suggestion]. The Committee suggests that the project provides a great opportunity for developing a general ‘toolbox’ or protocol for comparison of different disease estimates and with different countries for harmonizing data sources and methodological approaches.
The IAC notes that part of the underlying issues for differences in the estimates between IHME and WHO lies in the diagnostics and definitions for TB (as has also been the case for malaria). It suggests that awareness around these challenges should be raised. The IAC acknowledges that unless more investment is made in this area these issues will continue to recur.

The next IAC meeting is scheduled to take place in Mexico from November 4th to 6th 2024.

2-3 November 2023, Addis Ababa, Ethiopia

The 21st meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened in Addis Ababa, Ethiopia - a location originally foreseen for a 2020 meeting that was postponed due to the COVID-19 pandemic. Meeting participants included the GBD IAC members and junior members, an independent observer, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation, and the members of the IAC Secretariat.

Prior to the meeting, a group from the IAC attended the opening session of the Ethiopia Burden of Disease Collaborators Symposium organized by National Data Management and Analytics Center (NDMC) and the Ethiopian Public Health Institute (EPHI). This insightful symposium detailed the organisational structure of the growing Ethiopian collaborator GBD network and the NDMC; updated on the subnational burden of disease study; and outlined the future vision of the collaboration with IHME in advancing local capacity to meet national and local evidence demands for informing policy decision making.

The Committee also visited the new Africa CDC headquarters, meeting with senior officials from Africa CDC, the Ministry of Health and EPHI, to learn more about the partnership, the evolution of Africa CDC and its collaboration with the IHME, and their future priorities. The IAC expresses its gratitude to the warm receptions received at the EPHI and the Africa CDC.

Meeting summary and recommendations:

The IAC once again commends the excellent progress made at IHME since the last IAC meeting, noting the agility of the IHME teams to respond to new developments, whilst continuing to produce a tremendous volume of high-quality work.
The Committee particularly appreciated IHME providing the IAC meeting pre-reads, questions, and presentations well ahead of the meeting which ensured IAC members were well briefed for all the sessions.
The Committee commends the innovative and original ‘burden of proof’ work by the IHME that illustrates the strength of evidence between health risks and outcomes. The IAC is excited to learn that the Nature group is considering applying the burden of proof concept across all areas in its journal series. This programme of work was in part response to an earlier IAC recommendation on using a star rating system for strength of evidence of association of risk-outcome pairs.
The IAC commends the broadening of collaborations between IHME and country governments and institutions. Specific examples include: the training of researchers from India with the Public Health Foundation of India and the Indian Council of Medical Research (ICMR) as well as from South Korea with the Korea Health Promotion Institute; the small area estimation of dengue fever with Aga Khan University in Pakistan, and the MoU signed with the Office of the President of Mongolia.
The IAC recommends that IHME should discontinue the separate estimation of ‘shocks’, for example, HIV and Covid-19, once a pandemic or epidemic has lasted beyond a certain period. The Committee also advises the IHME to add conflict to their list of extreme events.
The Committee commends the use of linked data in Sweden for conducting survival analysis to inform global burden of disease estimation. It would like this work continued in other settings, including lower income countries, which will make the estimates more relevant. This serves as a good example of what can be achieved with country collaborations through the tailored “customization of the interaction”.
The IAC notes that the impact of extreme weather events and conflicts in IHME’s future health scenario (FHS) work is likely to generate great interest and as a result they should be ready with a communication strategy for the messaging of these outputs.

Disease Expenditure (DEX)

The IAC commends IHME’s continuing disease expenditure (DEX) work in the US including the great attempt to study health expenditures on a disease-by-disease basis. The Committee urges IHME to be mindful of the differences in patterns of disease expenditures both among high-income countries with different types of health systems and between high-income and low-income countries. The IAC would like to see how their methods might evolve for non-US countries.
The Committee recommends including specific cases and examples in future presentations.
The IAC advises that IHME conducts a landscaping exercise and connects with efforts that already exist elsewhere, including other health economics teams, and especially those who may take up and use this work. For example, relevant data exist in Brazil but collaboration with local experts who understand them is needed. Ghana was cited as another possible example to take forward.
The IAC suggests that the analysis should be hypothesis driven and go beyond descriptive epidemiology with a focus on the key policy questions for the countries from which the data originate. For example, what kind or level of health or cost-effectiveness is achieved from the investments? (It was also noted that the relationship between health spending and actual health outcomes is not the same as that of healthcare provision and health outcomes - since administrative/insurance costs are included in healthcare spending).
The IAC noted that the DEX work seems to be unintegrated into the rest of the GBD and suggested linking this area of work specifically to future health scenario (FHS) work. It would be interesting to get an update on this work in future meetings.

DisMod-AT

The Committee welcomes the continuing development and testing of the new DisMod-AT tool, anticipated to replace DisMod-MR. It notes its huge potential to be used in a decentralized way while lending itself to opportunities for broadening the understanding of GBD methodology to interested parties worldwide. The IAC re-iterates the recommendation from the last meeting of the need for a clear messaging strategy around any changes in GBD results from earlier rounds upon the adoption of the new tool.

GPT4 for validation

The Committee notes the new exciting area of work using GPT4 for the validation of verbal autopsy (VA). It congratulates IHME’s systematic approach with insightful experiments and nuanced analysis in their exploratory work. IAC would like an update on this in the next meeting. It encourages that IHME:
1. develops relationships with pathologists to create a two-way learning process; picks out specific examples where there is real scope for improvement (as evidenced by their stillbirth example), and to see whether this could challenge what has previously been referred to as the “gold standard” of autopsies.
2. works with the Child Health and Mortality Prevention Surveillance (CHAMPS) Determination of Cause of Death (DeCoDe) Panel,
3. considers which subgroup of the GBD this should be used for based on the nature of the diseases/burden.
4. explores how this approach could be applied in other data sparse areas in different geographical regions, such as those in the global south, to improve VA work, and where there could be economics of scale, and
5. evaluates accuracy in their exploratory work.
The IAC commends the excellent “GBD way forward” presentation which clearly communicated the anticipated changes ahead for the GBD. In relation to the delayed release of GBD 2021, the Committee advises that IHME should manage users’ expectation by “versioning “the forthcoming releases in anticipation of changes between them.
The IAC suggests that IHME considers reviewing the Harvard Atlas of Economic Complexity – a “self-help” tool for decision makers in a complex policy area. The Atlas is an example of how complex communication can be done well – it provides clear “hooks” to policy makers regarding economic growth. The IAC also encourages that IHME uses scenarios - the key interest of decision makers – and that it highlights their powerful visualisations more.

Ethiopia Partnership and Africa CDC Collaboration

The IAC was impressed by the evolution of the partnership and the successful institutionalization of the burden of disease project in Ethiopia reflecting a clear commitment and sustainability. The IAC suggested that the Ethiopia work could serve as an exemplar for other IHME country collaborations (whilst also noting that work was needed to improve the gender balance in the in-country collaborator network).
The IHME should anticipate changes in the evolving relationship with, for example, the NDMC getting more involved in the modelling of disease burden locally in future phases of the work. During the broad programme of work and strategy presented to the Committee, the IAC observed a seeming lack of emphasis on data quality improvement which the IAC suggests should be seen as a priority.
The Committee commends IHME’s on-going collaboration and progress made with Africa CDC. Among the numerous achievements the IAC was impressed by the National and Regional Health Atlases which serve as important media tools for communication.

Remote sensing/satellites work

The IAC acknowledges that the great potential of the remote sensing/satellites work. It suggests that IHME should think through the direction of this work, build on work that already exists, assess who the competitors might be, and consider the transferability of this work outside of IHME (for example, propriety data concern).
The Committee would be interested in incorporating climate migration, food security as well as changes in healthcare utilization into this stream of work as well as potentially including the supply side of health care services as it would be useful for planning. The Committee would like an update on this work in a future meeting.
The Committee strongly urges that IHME be judicious in creating meaningful geographical subdivisions in all of their GBD results and publications. More specifically, the Central Asia, Central Europe and Eastern Europe regional groupings don’t reflect political, economic, cultural and social realities, and we recommend that an entity is created including the European Union and immediate neighbourhood . Grouping results in this way should have a greater impact on policy uptake and relevancy of the results. The Committee would like an update in the next meeting.
The recommendations of the IAC’s Midterm Review work (replacing this year’s “deep dive”) were presented to the group. The recommendations and final report will be updated following the feedback received and the final report is due to be completed by the end of 2023.
The meeting in Ethiopia was the last meeting under the current grant by the BMGF. Under the new grant, the membership of the IAC will be refreshed, and the Committee would like to specifically increase its expertise in AI and statistical methods for disease burden estimation. It is anticipated that in next iteration of the GBD IAC, the Committee will continue with annual deep dives reviews on specific topics agreed by the Foundation and IHME. Future potential topics discussed include reviews on global communications, small area estimation, and mental health.
The next GBD IAC meeting will take place in June 2024 in Seattle.

30-31st March 2023, Seattle, USA

The 20th meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened at the offices of IHME in Seattle. Meeting participants included the GBD IAC members and junior members, independent observers, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation, and the members of the IAC Secretariat. Some participants also participated and presented via Zoom.

Meeting summary and recommendations:

The IAC once again commends the great progress made at IHME since the last IAC meeting, noting that it has been another incredibly productive few months in terms of the pace, volume and quality of the work produced.
As recommended at the last meeting, the committee particularly appreciated IHME providing the IAC meeting pre-reads, questions, and presentations well ahead of the meeting. The IAC strongly recommends continuing this practise for future meetings.
Whilst the Committee was pleased that a proposal with WHO was developed to jointly produce TB estimates with national counterparts in priority countries (as recommended in last year's IAC "deep dive”), it was disappointed to learn that the new programme of work with WHO, that examines some of the major differences in the TB estimates in key high-burden countries, has not been funded by the Bill & Melinda Gates Foundation. Given the importance of this work, the IAC recommends that the IHME continues to try to pursue this work, perhaps using core funding or approaching alternative funders if needed. The IAC would like to discuss progress on this at the next IAC meeting.
The presentation of the work on the impact of COVID on population health was very insightful for the Committee and the IAC recommends going for simplified but pragmatic methods such as predicting age-specific mortality directly.
In terms of future priorities for GBD, the IAC feels that moving to modelling the impact of specific interventions is the next phase of GBD that will be of most interest to decision makers and policy makers. (The incorporation of interventions into GBD studies was previously recommended by the IAC.)

Collaborator network and communications

The IAC was very pleased to learn about the solid progress in the developments around the GBD collaborator network, especially with regards to the clear systemisation that is now in place for both for individual and institutional collaborators. The IAC sees this as a solid baseline to develop further.
The IAC urged caution on some of the language used and suggested, for example, using the term “informing” rather than “influencing” policy making.
On the media and communications strategies, the IAC strongly recommends further outreach to non-English language media and audiences. Exploring new software available in this field may help in reaching wider non-English language networks.

New general modelling tools:

The work presented on the new DisMod-AT (Age/Time) modelling tool, which takes the cohort effect into account, was seen by the IAC as very impressive and highly promising, albeit with some challenges. It’s “portable” nature (i.e. not being tied to IHME’s cluster computing architecture) would allow for a more decentralised approach to burden estimation. The IAC acknowledges that previous GBD results from earlier GBD rounds may change should it be adopted to replace DisMod-MR. The Committee recommends that the IHME develops a clear communication strategy in anticipation of such changes.
The IAC also commends the planned publication to compare DisMod-MR and DisMod-AT.
Whilst it would require a lot of work, the IAC recommends that IHME takes on at least once major validation effort with the new model (e.g. re-estimating a previous GBD round using DisMod-AT or doing a future GBD round using the new model) in addition to the more specific validation exercises that were presented. The committee would like to revisit this topic in the future.
The IAC proposes that the IHME considers creating a “sandbox” environment or Datalab platform that provides a safe and controlled environment where GBD users can experiment with existing and new modelling tools without jeopardising the GBD results and production. The Committee suggests that the new DisMod-AT modelling tool be included in the platform to begin with.
The IAC also recommended drawing lessons from the genomic modelling and software space where they make highly complex tools available to end users in a Datalab type environment.

Scores for levels of global threats:

On the scores for levels of threats work, the IAC recommends connecting with existing systems in the public sector and beyond (e.g. the WEF Global Risk Report) to further develop this work. The IAC also suggests that the IHME provides the rationale for the choice of pathogens to focus on in this work.

Pathogen distribution by GBD underlying cause

The pathogen distribution work was seen by the IAC as a very important new body of work. The IAC felt that the “pathway to death” and the “underlying cause” perspectives are both useful and should both be continued. The IAC felt that the use and value of the two approaches will ultimately depend on the end user and what kind of decisions they need to make. (For example, pharmaceutical companies would likely find more utility in the pathway to death approach however a foundation with priorities for low resource settings will most likely be more interested in the attributable causes approach).
The IAC recommends writing the first pathogens paper using both approaches, and seek independent validation of the results, given the major potential implications for resource allocation.

Competency-based training

There was great interest from the IAC in the new competency-based learning work that was presented which is seen a very promising development and step forward in the GBD training. IAC members will be sending some specific comments directly to IHME colleagues.
The IAC welcomes the inclusion of health inequity and suggests that health financing and disease surveillance be considered as parts of the core competency modules.
The IAC noted that communication, negotiation, presentation, engagement and team and technical leadership skills were currently not included in the core competencies. The IAC believes these should be considered.
The IAC also recommended trialling the plans in a few countries to see if it meets their expectations. There could be some important nuances to capture in the subsequent feedback from countries.

Climate change forecasting

The IAC was very pleased to learn about the development of the forecasting performance work and applauds the way that IHME is learning from the fields of weather and economic forecasting. The IAC feels as though this is the beginning of very important movement and hopes that this work is picked up by others in field of public health.
On the climate change forecasting work, the IAC recommends that future presentations on this topic are more user friendly, include comparisons with similar efforts, are more embedded in country-level data and issues, and consider the policy implications.
It was recommended that IHME approaches Packard Foundation and Bloomberg Philanthropies as a possible source of funding for looking into the health effects.
The IAC noted that cold weather appeared to have worse impact on health than hot weather from the presentation. The committee cautioned any potential bias due to data availability from potentially higher-income countries where climate data may be more readily available.
The IAC would also like IHME to consider the indirect impact on health from climate change such as food insecurity. The committee would like to revisit this topic in the future.
The IAC also recommended that the IHME may also want to consider looking into opportunities with changes at World Bank where climate change will be a major future focus and may be a key user for this work, as well as connecting with other, similar efforts as the degrees of uncertainty can be large.
On adopting the concept of “skill” as a metric for evaluating model performance (including models for GBD and future health scenarios), the IAC cautions the use of substandard model as baseline which may inadvertently inflate the performance of a comparator model. (In brief, skill quantifies how much better than a base model a comparator is on a 0 to 1 scale.)

WHO-IHME collaboration

The IAC was pleased to learn of the real progress in the collaboration with WHO and in the development of the action plan. The IAC recommends that there should be more focus now on developing the relationship further with SEARO and AFRO. The Committee recognised and applauded the joint efforts in institutionalising the relationship between IHME and WHO. It encourages continued work in this area.

Midterm Review

An update on the IAC commissioned Midterm Review (replacing the annual IAC “deep dive”) was discussed, with the work to date focussing on IHME’s collaborations and partnerships. It is anticipated that this work will expand in scope and a draft report (with forward looking actionable recommendations for IHME) will be presented at the next IAC meeting in November 2023.

The next GBD IAC meeting will take place from November 1-3rd 2023 in Addis Ababa, Ethiopia.

Brussels, October 2022

The 19^th meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened in Brussels, Belgium from October 27-28^th 2022. The meeting took place after the Grand Challenges conference which was hosted in Brussels, with many IAC members attending. Meeting participants included the GBD IAC members and junior members, independent observers, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation, and members of the IAC Secretariat. Some participants also participated and presented via Zoom.

Meeting summary and recommendations:

The IAC again commends the great progress that has been made by IHME and the incredible quantity and quality of work that has been produced since the last meeting.
For the IAC to function effectively, the Committee requests that for future IAC meetings, the questions for the IAC and all of the meeting pre-reads are all sent in a timely manner (~2 weeks in advance of the meetings).
The IHME presentations at the meeting were excellent overall and there was a good mixture and balance of themes. However, at times the presentations were too technical and overly detailed. For future meetings the IAC requests that the presentations are more policy oriented and framed to match the Committee’s mandate. Pre-meetings with the IAC Secretariat in advance of full IAC meetings could be helpful in this regard.
The IAC was pleased to see the great progress that has been made on the burden of proof work and commends particularly the excellent outreach to media, especially to non-English media outlets and across social media.

Star rating system:

On the burden of proof work, the star rating system was seen by the Committee as an excellent tool for communicating the strength of the current knowledge base and very effective for highlighting where further research (and future research funding) is needed. There was a suggestion that each GBD paper could finish with a section on the data availability and gaps, if any, identified in the given piece of work. The work was seen as a great public service to the scientific community and something that the IAC would like to discuss further at the next meeting.
Recognizing that where there are 1 or 2 star ratings and we might expect the results to change in the future, the IAC suggested that working on careful communications and messaging around why we might expect future changes will be important for policy makers to understand and to anticipate for certain research areas (e.g. with the diet work).

Publications:

The IAC was pleased to see the publication balance that is emerging from IHME. The Nature articles and the “30 year reflection article” for example were all cited as really helpful articles that take stock of the work that is coming out of IHME. On the burden of proof work, the IAC also applauded the publication of the key GBD “infrastructure” papers published in Nature (which was something that had been recommended at past IAC meetings). Overall, the IAC is pleased to see IHME diversify its publication base in general.
The IAC was pleased to learn about the internal Deep Dives being undertaken at IHME and recommended making the data sources aspect of this work available publicly. Writing and publishing on the data availability could be very helpful as this type of discussion might also stimulate further data sharing. (The IAC cautioned against using the term “data gaps” but rather talking instead along of the lines of “data status updates” which might prove to be more encouraging for further data sharing).
On the Lancet Commission on the 21^st Health Threats work, it was recommended that representatives from the Sahel across the various working groups were really needed. It was also suggested that considering the “health effects of conflict” would be good to incorporate in this body work, as well as adding “manufacturing” to the innovation working group. Another key area that could be incorporated in this work is on “healthy longevity” which is missing generally from the global health agenda.
The IAC cautioned against using the category of “low and middle income countries” (LMIC) as there is so much diversity within this group and better categorization of the countries would be more informative.

Antimicrobial Resistance (AMR):

The AMR work presented was commended by the Committee and the IAC urges IHME to continue with this important and complex body of work, especially with respect to the collaborations with WHO regional offices.
For the AMR work, the IAC cautioned against the use of the category of “susceptible” that included people with and without access to antibiotics. This definition should be more clearly defined. The IAC approved of the “attributable cause versus associated cause” approach.
The IAC recommended that for the AMR work, the next step of the work useful from a policy perspective would be to move from producing the descriptive data to assessing at the country level the success over time of certain key policies and interventions in AMR containment and infection control (e.g. antibiotic stewardship etc.) and to see if these measures are making a difference.
The IAC was pleased to learn that there is a new stream of work emerging on “fake and substandard medicines” and the IAC recommends trying to incorporate this within future AMR analysis.

Collaborations in Africa:

On the recent collaboration with the Africa CDC, the IAC noted that IHME can use the political and convening power of ACDC to take core issues to the country level. Engaging with the regional centers of Africa CDC will also be very important to work with in the future.
The IAC also noted that there are other convening African institutions for the African sub regions (such as ECOWAS in West Africa) that also have power to spread ideas and convene and it is important to work with these as well. Furthermore, teaming up with other initiatives that are strengthening surveillance would also be a good next step for the work as improving sub-national data must remain a key goal.
The IAC suggests that IHME critically assess the idea of the national data management centers as it is important to avoid duplication and make sure that additional institutions aren’t created if they already exist as there are several countries where such centers have been created.
For the Africa training workshops the IAC recommended incorporating other country experiences and country representatives (e.g. from Brazil) for cross learning which would be highly informative and might encourage further South-South collaboration. The development of a GBD fellowship program with young professionals with built in exchanges between Africa CDC and IHME might also be very useful.
The IAC recommended that IHME needs to be highly conscious to avoid “top down” training model and ensure a more equitable approach to training and capacity building that allows for a two-way dialogues and mutual learning with partners and collaborators.
The IAC noted that a central goal for IHME in its work with all partner countries, should be to facilitate the transition from “users to producers”. Partner countries should be actively participating in producing the GBD results as well as using the outputs, and training programs will be key to supporting this. IHME might wish to explore collaborating with entities such as the World Bank in sub-Saharan Africa and connecting with existing data generation initiatives by countries such as Norway and institutions like Wellcome Trust.

Gender:

On the gender work, the IAC recognized that this area is a very important addition to GBD and something that the IAC has pushed for since the beginning (especially the inclusion of gender based and sexual violence into the GBD risk factors and impact of COVID on gender equality). It was acknowledged that this important work might need some further support.
The IAC recognised that the gender work can be a highly politically sensitive issue . (It was noted that the challenge in getting papers accepted and published for some of the findings on COVID outcomes for men could also indicate some bias in the review and publication process). The IAC recommends that IHME now concentrates on how they can expand access to different sources of data (especially data that are under reported or might be harder to get – for example with gender based violence or psychological violence).
As with other areas of work, on the gender theme, the IAC recommends that IHME needs to move from descriptive epidemiology to the next phase of “what works” (e.g. with interventions against sexual violence) which is the key interest to policy makers.

Injuries:

The IAC was pleased to learn more about the injuries work which is an important area of the GBD enterprise. The IAC cautioned that attention needs to be paid to the terminology used (e.g. the term “complication” has different clinical connotations and term usages like this should be redefined). The IAC recommends that IHME works specifically with injury epidemiologists and convenes an expert group who can advise on this area of work and also on data sources ( as was done with risk factor experts from previous years). The IAC noted possible uses for example in the US the “workman’s compensation” programs as well as insurance companies as data sources. The CDC is also a huge resource for this area of work that IHME should explore further. In road injuries the IAC noted that often only deaths from, not the causes of, accidents or injuries are reported by countries. Reporting the causes of such incidence may help enhance the credibility of injury-related disability burden estimates.

WHO:

On the WHO Collaboration, the IAC noted the great progress that has been made and endorsed the road map of the collaboration which is seen as an important global contribution. The work with WHO Collaborating Centres in SEARO, and the positioning of Haidong Wang (IHME staff member) now at WHO will likely be very useful for the relationship. The presentation and messaging around the collaboration needs to be carefully considered as well.
The IAC welcomed IHME and WHO’s consideration to jointly explore the differences in their TB estimates with an aim to align the two sets of estimates for countries with high TB burdens to begin with. This was one of the recommendations given by the IAC-commissioned TB deep dive in 2021.

Demography:

On the fertility work and the revised fertility model, the IAC agreed that this was excellent work that should continue. Communication and messaging is key for this work as it can attract a lot of media attention and can be politically sensitive and highly charged with unintended effects. The Committee appreciated the sensitivity analyses of different covariates used in the model. From a policy perspective it was suggested that it might be useful to include the impact of population growth (pro-natal) policies.
The IAC also recommends that IHME carefully considers the dates used in their projections. 2100 is a good date but to translate to have meaningful impact from a policy perspective, other timeframes (e.g. next 20/30 years) might be more helpful to consider, as well as the need to include subnational breakdowns for larger countries (e.g India). Scenarios with covariates like education and the issue of global population aging warrant further considerations. The Committee would like to revisit this topic regularly in future meetings.

Collaborator Network:

On the collaborator network, the IAC recognized the real progress that has been made. It was very useful to understand the systems and processes for the collaborator networks and the processes in place for conflict management. The IAC understands that this work on the collaborator network is a major effort and is a costly exercise. The IAC also welcomes that past recommendations from IAC in this area have been taken up.

Midterm Review:

The IAC agreed on the aims and terms of reference of the Midterm Review (replacing this years “deep dive”). The aims are to:
1. Describe models of current IHME collaborations with individuals, academic institutions, and governments;
2. Describe how GBD collaborates with in-country partners to produce subnational estimates;
3. Delineate the strengths and weaknesses of existing collaborative approaches;
4. Make recommendations for future collaborative models that will: enhance equitable partnerships; build in-country capacity in data collection, analysis and estimation and; promote local ownership of estimates to facilitate their use in formulating policy.
The group agreed that the output of the report will seek to promote substantive discussions with IHME. It will include recommendations on how to structure future GBD collaborations with in-country partners and include a prioritization of any changes (if so identified)

IAC Membership:

On the IAC future membership, a further expert on AI and machine learning has been suggested and will be invited to the next meeting. An expert from UNFPA and the World Bank will be identified as Observer members and invited to the next meeting. The IAC is also looking for a recommendation to replace Dr. John Nkengasong, former Director of the Africa CDC who has had to step down from the IAC due to his new PEPFAR appointment. The addition and contributions of the IAC junior members (2020) was widely appreciated by the IAC group

Communications:

A key challenge for IHME’s next phase of work is how to effectively communicate the huge volume of research that comes out of IHME for the research to better drive policy making at the regional and country level. How to make the GBD outputs easier and more useful for policy makers whilst still staying scientific and neutral is a core challenge. It was suggested that it may also be useful for IHME to consider take on an evaluation of the impact of some of its key policy briefs.
It was decided that at the next IAC meeting a further review of IHME’s communication and dissemination strategy would be useful.
The IAC acknowledged IHME’s adoption of its June 2021 recommendation by introducing its free of charge non-commercial agreement (https://www.healthdata.org/Data-tools-practices/data-practices/ihme-free-charge-non-commercial-user-agreement). The Committee previously recommended that users downloading GBD data for own use should be asked to sign an online agreement form.

The next IAC meeting will take place in Seattle at IHME on March 30-31, 2023.

May 19-20, 2022

The 18^th meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened in Seattle from the 19^th - 20^th May, 2022. It was the first face-to-face committee meeting since the Covid-19 pandemic began. The two-day meeting was held in the new offices of the Institute for Health Metrics and Evaluation (IHME) located in the Hans Rosling Center for Population Health at the University of Washington, Seattle. Meeting participants included the GBD IAC members and junior members, an independent observer, IHME senior staff and researchers, a representative from the Bill & Melinda Gates Foundation, and members of the IAC Secretariat. Some members participated via Zoom.

MEETING SUMMARY AND RECOMMENDATIONS

The Committee once again commends the highly impressive volume and quality of work from IHME since the last IAC meeting. Of particular note were the sub-national burden estimation papers including Ethiopia and Indonesia; the national disease burden assessment conducted as part of The Lancet Nigeria Commission; and the policy briefing on antimicrobial resistance requested by the G7 Ministers of Health and over 20 Ministers at the World Health Assembly. These are acknowledged as great contributions - in addition to the core GBD outputs - and have met a clear demand from the global health and policy community.
While the IAC appreciates the continuing growth of the GBD collaborator network, the Committee does not feel its engagement process has yet reached maturity and queried its geographical distribution. The Committee would welcome a clearer definition of ‘collaboration’ as well as terms such as ‘collaborators’ and ‘engagement’ and individual versus institutional collaborations. It was also unclear to the Committee what the rules or principles of collaboration were, especially ones that might engender equitable collaboration. The IAC would like to pay special attention to the GBD collaborator network in a future meeting.
Among the selected themes of the GBD 2020 study presented, the accelerated epidemiological transition from 2010 to 2020 with its enormous non-communicable disease (NCD) burden was very clear. The Committee noted that these are the last set of the GBD results before the Covid-19 pandemic. This therefore presents a good opportunity to make the case for the growing NCD burden before the narrative is taken over by Covid-19.
The Committee encourages the IHME to adopt non-GBD standard geographical groupings to highlight the high level of child mortality in the Sahel region, as well as for other key issues that do not fall into standard GBD geographical groupings.
The IAC commends IHME for rolling out the star rating system that reflects the evidence -based quality of GBD estimates (as a function of the evidence strengths of risk-outcome relationships). The extensive work that underpins this new evidence rating system was instigated as the result of an IAC recommendation from October 2014.
The Committee would like to see further development and an expanded outreach to non-English language media outlets in the IHME communications and social media strategy that strives for deeper interactions in multiple languages.
The IAC welcomes the continuing development of (lack of) education as a risk factor into the GBD results. Incorporation of distal risk factors was one of the Committee’s earlier recommendations from the June 2014 meeting. The Committee suggests that some aspects of this work could be improved by using quality-adjusted education scores. The overall work may need to be approached in a different way as education cannot be treated as a “regular” or biological risk factor given its complex risk-outcome relationships with other risk factors.

The Committee recommends the team to develop a conceptual model that will serve as the foundation to the development of this work. The IAC also suggests developing a composite indicator rather than using the number of years of education as an independent variable. Such an approach could also be applicable to other non-biological indicators in the GBD work.
The Committee welcomes IHME’s presentation on waning immunity against Covid-19 post natural infection. The IAC recognizes that this is unfinished work with more data and analysis needed on past-infection protection on more recent variants and from more diverse geographies.

The IAC cautions the IHME about wading into “culture war” territory. The IHME should be very mindful about the potential impact of their results which could be “weaponized”. The Committee would like to know if IHME is prepared for such potential backlash and recommends considering some specialized expertise and/or some strategy development in this area.
The IAC appreciates the ongoing partnership development with the WHO but notes the apparent lack of major advancement except with the WHO regional offices. The Committee asks IHME to be mindful of its use of language, especially using terms such as “gain access”. It was also surprised that regional offices of PAHO and EURO were not mentioned in the presentation.
The IAC welcomes the revamp of some of the existing modelling tools into ROVER – a tool for model space exploration including variable selection, model aggregation, and inference. Its modular design is endorsed by the IAC. While the Committee agreed that ROVER should be open-source, IHME should also be mindful of the resource implications. The IAC recommends that IHME publishes the methodology that underpins ROVER which will go some way to address the continuing “black-box” perception by some. The Committee highly appreciated the visualization of the results in the presentation.
The Committee commends the multiple partnership and collaborative US Health Disparities Project with the National Institutes of Health (NIH) and the multi-institute US Health Disparities Working Group and the impressive dataset derived from this work. This serves as a good model for generating global public goods in the US and possibly beyond. The IAC recommends that IHME replicates this work in Brazil as the country already has a well-developed GBD community. It will be a good area to develop expertise in as analyses in disparities are often a key interest to policy makers. The IAC would also welcome further exploration of the effects of race over time.
The IAC recognizes the complex but important study of the effects of race/ethnicity. It warns against the use of averages. If IHME were to expand this work beyond the US, it should be conscious that it might need to adapt to locally used definitions and nomenclature, and may have to move away from exclusively using “race” in the definition of the contrast to more nuanced definitions depending on the setting, for example, minorities, ethnicity, and disenfranchised populations.
The Committee strongly commends the IHME for developing a sensible approach to studying the impact of Covid-19 mandates. This was a direct response to the IAC’s recommendation in the June 2021 meeting. While infection is an important outcome, IHME is advised to focus on mortality and severe disease, and cumulative mortality. Here the Committee reiterates the need for careful “political communication” on highly sensitive issues that requires carefully crafted language for publication. Furthermore, the IAC notes the US-centric terminology of “mandate”, which is not used in many countries.
The IAC welcomed the impressive work on India in collaboration with PHFI. In the presentation on ‘policy scenarios for India’, the IAC suggests the IHME should also estimate the economic impact of the various health outcomes which may be of great interest to policy makers. It also suggests that IHME should consider modelling the effect of a modest minimal package of care (or services) for both highly prevalent NCDs and for maternal and child health. The Committee notes the lower life expectancy for women in the presentation and would like IHME to consider the factors underlying this observation.
Within the India policy work the IAC supports forecasting to year 2030 , in addition to the timeframe of the Independence anniversary, in order to align with the SDG timeframes and strongly recommends not to make the forecasting approach more complex. The addition of the impact of extreme heat in the next stages of the work was also recommended.
The IAC commends the excellent presentation on ‘data quality approaches and incentivizing access’. The IAC has discussed issues around data quality on many occasions. The IAC agreed that there was a need to think about how to reward the provision of data into the GBD work and develop incentivizing structures to encourage such efforts. The Committee would like to revisit this topic in the future.
The composition of the Committee was discussed and it was agreed that some expertise in artificial intelligence (AI) would be a valuable addition to the group. A number of AI experts were discussed as possible candidates. The Chair has asked the group to consider any final additions and recommendations and he will then present a candidate to the IHME Board with the expectation that this expert will be invited to attend the next IAC. The IAC notes the potential need for an expert in public communications to bolster IAC’s capacity to strategically advise on communicating sensitive GBD topics and results. Committee members are asked to make any suggestions to the Chair.
The IAC has agreed to work on a mid-term review of the IHME Global Public Goods grant over the next year focusing on the high-level strategy and future direction of the GBD work.
The next IAC meeting is anticipated to take place in person in Brussels on October 27-28^th 2022.

NOVEMBER 17-29, 2021

The 17th meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened from the 17^th-19^th November, 2021. Given the ongoing Covid-19 pandemic and continuing travel restrictions the meeting was held virtually. The meeting was held online over three days with three three-hour sessions. Days one and two comprised the main business of the IAC, with day three dedicated to this year’s Deep Dive Review into GBD Tuberculosis (TB) estimation. Meeting participants included the GBD IAC members and junior members, IAC observers, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation and members of the IAC secretariat. Additional attendees on day three included members of the TB Deep Dive Review panel and representatives from the TB teams at IHME and the Bill & Melinda Gates Foundation.

MEETING SUMMARY AND RECOMMENDATIONS

The Committee extends its appreciation for the activities undertaken by IHME since the last meeting. The volume, quality and innovation of IHME’s work is impressive, and much needed.
The IAC supports the new cause “other Covid-19 pandemic related outcomes” in GBD 2020 in order to account for increasing mortality that occurred during 2020 and which is not a direct result of Covid-19.
The IAC appreciate IHME’s efforts in providing EU-wide as well as country- and Europe-specific Covid briefings.
On antimicrobial resistance (AMR)
1. The IAC commends IHME’s efforts in developing a comprehensive approach to studying the burden of bacterial AMR. This may help bridge the gap between public health and clinical medicine in understanding the pathway of bacterial AMR.
2. The IAC is mindful of the important and challenging distinction between “associated” and “attributed” in the estimation of the total impact of bacterial AMR.
3. While the IAC appreciate IHME’s effort in providing estimates for geographies with incomprehensive data on bacterial AMR, the Committee is conscious of the potential limitation of this exploration in geographies that lack the type of data required for studying this complex cause of ill health.
4. The IAC recommends that the important message of antibiotic use in animals (as a key covariate in burden estimation) as a major contributor to the burden in bacterial AMR in humans be widely disseminated to raise awareness.
5. The IAC noted the potential of this work in contributing to the forthcoming WHO’s strategy in this area and identified it as a meaningful area for collaboration.
The IAC welcomes IHME’s future plan to release the CODEm modelling tool as a piece of open-source standalone software or as part of a suite of software.
1. The Committee is mindful of the potential resource implications of making software open-source and the technical support required for these efforts. The IAC asks the IHME to consider means of increasing capacity in this area, such as the SAS Institute and training courses.
2. The IAC would like to revisit this topic in a future meeting.
Non-fatal Covid
1. The IAC invites the IHME to consider non-fatal Covid along the lines of short, mid, and long-term non-fatal Covid, specifically in how they might have contributed to the years lived with disability (YLD).
2. The IAC suggests that patient groups may be another source of data while being mindful of potential bias, and highlights mental health issues as another important sequala to Covid infection.
3. The Committee recognizes that the work on non-fatal Covid could be a long-haul exercise. The IAC further comment that this approach could be applied to other infectious diseases with long-term effects, such as Lyme disease – when time and capacity allow.
Effects of the Covid-19 pandemic on gender equality
1. The IAC recognizes the major negative impact of the Covid pandemic on advancing gender equality in various domains. The example of impacts on girls’ education in some LMICs such as India, where more girls than boys are not returning to education as schools reopen, was cited. It will be useful to highlight this issue if the study findings back this observation.
Pandemic preparedness
1. There was a suggestion that the pandemic preparedness modeling tool could form a better index than the Global Health Security Index, which to date has not proven of significant relevance or accuracy during the Covid pandemic.
2. There was also a suggestion that the tool could serve as an advocacy instrument in engaging with countries as well as regional organization such as the African Union.
Waning immunity meta-analysis
1. In addition to the analysis of post-vaccination waning immunity presented to the IAC, the Committee would like to see similar analyses on waning immunity post natural infection among vaccinated or unvaccinated people. Any evidence from mix-and-match vaccination strategies would also be welcomed.
2. The IAC recognizes the potential of this work for future scenarios of the Covid pandemic as well as the uncertainty associated with seroprevalence studies in some countries.
3. The IAC note that a number of the Covid vaccines deployed in many LMICs – such as Sinopharm, Sinovac, Covaxin and Sputnik – had not been included in IHME’s Covid vaccine waning study.
4. The IAC caution against any extrapolation of waning effect beyond what has been observed. The IAC was shown data which extrapolated zero effectiveness for some vaccines. This seems to defy common understandings of immunology. The IAC strongly caution against IHME making these data public before engaging in further critical consultation and sense-checking with immunologists and other relevant experts.
5. The IAC supports a “risk reduction”, rather than binary, approach in the model for waning immunity.
Covid model evaluation
1. The IAC supports this work, which was one of the Committee’s recommendations from the May 2020 meeting.
2. The IAC notes that other Covid modelers may have preferred or chosen performance metrics other than those used in IHME’s evaluation, and it would be most informative to evaluate the various models using the performance measures other groups are using. The IAC encourage IHME to collaborate with other researchers and entities in the compilation of any commonly agreed performance metrics, noting that doing so would enhance their acceptability.
Global health threats concept
1. The IAC request further clarity on the primary aims, missions, and governance of the proposed global health threats preparedness entity, including on its leadership structure. Who would lead and fund this initiative, for example? The Committee would like to understand how such an entity could more effectively translate evidence into policy than what has been observed during the pandemic.
2. It was noted that there appears to be several entities of a similar nature emerging. The IAC would like to see a scoping exercise of other efforts in this space, so as to minimize duplication, maximize resources and enhance synergies, and capitalize on IHME’s core strengths.
3. It was suggested that a mission which is realistic and does not promise an end to all future pandemics would be a sensible way forward.
4. It was also noted that another global health effort led by entities from Seattle may not be perceived positively by the rest of the world. The IAC supports the idea of a consortium-based approach rather than a single entity situated and headquartered in a HIC. This work could present a valuable opportunity to decolonize global health by ‘decentralising’ global health efforts from high-income countries.
5. The IAC suggests that said consortium have strong links to local frontline efforts and the One Health agenda (involving other sectors such as agricultural and environmental). Scientific evidence alone has shown to be insufficient in controlling the pandemic. Local efforts involving a vast array of players have been crucial in mitigating the impact of Covid.
6. The IAC recognize IHME’s core strength in global health data science, as evidenced by studies of the global impact of antimicrobial resistance and climate change. The Committee note that this makes IHME uniquely placed in its capacity to generate evidence for this initiative.
7. It was considered important for IHME to think about how the quality and frequency of regular IHME outputs may be affected as a result of this potential new endeavor.
Future health scenarios update
1. The IAC support replacing the “better” and “worse” scenarios with scenarios of environmental and non-communicable disease (NCD) risk factor packages.
2. The IAC recommend that the IHME consults policy makers for the scenarios that they would like to see in order to gain buy-in for the FHS outputs. The IAC is mindful that policies are often very local and specific, and that general packages may be needed for rolling out the forecast for all countries.
It was also identified that an expert or experts on AI and machine learning would prove beneficial additions to the IAC.
In a number of IHME presentations – AMR, long-Covid, and Covid model evaluation – a lack of data completeness in LMICs emerged as an issue. There was a sense that those countries with the highest disease burden might not have been served by IHME’s work as a result. It was noted that in order for IHME’s messages to be universal, their analyses should incorporate all countries and that greater collaboration with regions and sub-regions was needed.
While the IAC commends the vast array of impressive work by the IHME presented, the Committee would like to see IHME emphasize more agenda-setting in terms of setting research priorities and identifying in which areas (geographic or disease specific) more primary research is needed.

TB DEEP DIVE REVIEW

SUMMARY AND RECOMMENDATIONS

The Chair introduced the background to the deep dive review on GBD tuberculosis (TB) estimation. This was followed by a presentation by the members of the review panel which summarized the findings of the deep dive review. The presentation focused on two key themes: (i) quality and (ii) utility of GBD TB estimates.
The review was conducted by a 5-member panel co-led by Prasada Rao (IAC member) and Richard White (LSHTM). The membership was comprised of Rao, White, Mike Klag (IAC member), Faith Nfii (IAC junior member) and Pete Dodd (Sheffield University). The panel was advised by a 11-member international TB expert group and supported by Finn McQuaid (LSHTM) and the Secretariat of the Committee, represented by Anna Carnegie and Edmond Ng (both LSHTM).
The IAC expressed great appreciation for the excellent work contributed by all members of the review panel, as well as the support graciously provided by IHME’s TB and engagement teams.
Key points and recommendations made during the post-presentation discussion are summarized as follows:
1. The IAC recognizes the usefulness of IHME’s GBD estimates alongside WHO estimates. Uncertainty intervals of their country estimates often overlapped.
2. The IAC recognizes the unique value of GBD estimates in that that they always sum up to the total mortality of a given time and geography. Whereas the sum of disease-specific estimates from different sources can sometimes add up to exceed the total mortality.
3. The IAC recognizes the independence of IHME’s GBD TB estimation from Members States, while noting that Member States’ involvement in WHO TB estimation was perceived to enhance their confidence in, and adoption of, the WHO estimates.
  1. The IAC recognizes the potential opportunity for the IHME to enhance countries’ consideration and adaption of their estimates by leveraging on WHO’s partnership with Member States. This could be further enhanced by collaborating with the WHO to regularly and clearly communicate the reasons for difference between the two estimates and to support countries in understanding the implications of this for programmatic decision making.
4. The Committee recognizes the principle of IHME GBD’s estimation by utilizing all data available for the estimation of the burdens attributed to the diseases and conditions of interest. A suggested way forward from the review was to prioritize those large countries with the largest discrepant TB estimates (among others) and work with the WHO, international agencies, national TB control programmes (NTPs), and other stakeholders to understand the causes of such discrepancies.
  1. The IAC is mindful of the high resource implications of such an exercise, particularly considering the potentially large number of parties involved and other disease areas with similar discrepancies.
5. The IAC recognizes that gaps in primary data collection remains a key source of discrepancy between TB estimates generated by the IHME and other agencies and research groups. The Committee noted that results of local TB prevalence surveys in sub-Saharan Africa, for example, funded by international agencies are not always made publicly available for data-sharing. This appears to be different from other diseases such as malaria and pneumonia.
  1. The Committee strongly recommends that the BMGF and WHO work closely with IHME to identify and prioritize such gaps so as to address the fundamental issue of data paucity, especially in LMICs.
6. The Committee also recognizes the gaps in research knowledge in disease burden estimation in regions and countries. The IAC recommends that IHME consider a long-term vision in empowering regions and countries to conduct their own robust disease burden estimations.
  1. Within this, it would be valuable to understand what countries identify as the highest priority gaps in TB burden.
7. The IAC supports the inclusion of more programmatic drivers in GBD Future Health Scenarios forecasting work.
8. The IAC recognizes and strongly recommends accessible science communication to explain the methods underpinning GBD TB estimation and the differences between these and WHO’s estimates. Clear descriptions of the key components in the estimation process were considered important in this regard. This was also recognized during the last deep dive review on the Local Burden of Disease project.
9. The IAC requests that IHME propose a plan for the implementation or adaption of the panel’s recommendations and provide the IAC with periodic updates on progress.
10. The planning of the third deep dive review is underway with discussion between the BMGF and the IAC.

JUNE 14-15, 2021

The 16th meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened virtually from the 14th to the 15th of June 2021. Given the ongoing COVID-19 pandemic and continuing travel restrictions the meeting was held virtually rather than at the offices of the Institute for Health Metrics and Evaluation (IHME) in Seattle, United States. Despite the enormous workload that IHME has been undertaking throughout the pandemic, the IAC meeting went ahead as planned and was held online over two days with two three hour sessions. Meeting participants included the GBD IAC members and junior members, IAC observers, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation and members of the IAC secretariat. The meeting was recorded for those who were unable to join live.

Meeting Summary and GBD IAC Recommendations

The meeting began with an update from the IHME Director on IHME’s uptake and actions on a number of IAC recommendations made by the Committee. These actions included:
1. GBD dissemination: The IHME has adopted the IAC’s recommendation from the last meeting to include a session on antimicrobial resistance (AMR) and use short videos to disseminate GBD results, e.g. COVID-19 estimation and tobacco results. They have also shortened their presentations to allow more time for discussion.
2. Widening outlets for GBD research output: The IHME noted that one of the key elements in keeping collaborators engaged with the GBD is publications in high-impact journals. The IHME has been cultivating working relationships with high-impact journals such as the families of Nature, The Lancet, and JAMA as well as other specialty journals to broaden their research outlets.
The IAC highly commends IHME’s major progress in implementing its recommendations and applauds IHME’s impressive work outlined during the GBD update session, as well as their major contributions to COVID-19 response efforts around the world in the past year.
The IAC welcomes the new sub-national burden estimation efforts in the Philippines and Italy.
The IAC acknowledges the potential reputational risks posed by non-GBD collaboration papers on disease burden estimation. The IHME reported examples in which a reader might think the publication was written by official GBD Collaborators or that the authors had generated the reported burden estimates when they were using estimates produced by the GBD Collaborators instead. The IAC recommends that users downloading GBD data for own use should be asked to sign an online agreement form. IHME should also consider providing a standard citation format for referencing GBD data and results. The IAC notes that similar issues are occurring with genetic sequence data internationally.
Whereas regular updates of COVID-19 estimates are crucial, the IAC does not believe a proposed second GBD release in the same year would add much value, and that timely releases may not be as critical to other diseases. Changes in estimates within the same year may also have detrimental effects on the trust in GBD.
The IAC commends the increasing level of collaboration between IHME and WHO, particularly with WHO regional offices, as well as other bilateral collaborations such as IHME/PAHO, IHME/EURO, and IHME/Africa CDC. The IAC welcomes IHME’s application to become a WHO Collaborating Centre which was recommended by the IAC in May 2019. The IAC recommends that IHME also develops collaborations with WHO SEARO and AFRO as priorities.
The IAC highly commends the new project on the burden of bacterial AMR and IHME’s innovative approach to model the burden of AMR. IHME’s approach is critical in considering the burden attributable to AMR rather than using no infection as a counterfactual to estimate AMR burden. The IAC recommends that the new methodology be published. While the GBD is on human health, a high proportion of global antibiotic use is in animals, the IAC is mindful of the connection with the One Health agenda and advises this be considered. The IAC also discussed the potential impact of AMR due to the overuse of antibiotics during the COVID-19 pandemic.
The IAC acknowledges and commends the significant progress made over the last few years in the evidence score framework and recognises it as an important part of the GBD's investment in methods infrastructure. The IAC was impressed by the framework which includes a novel and unique approach to conducting meta-analysis. In particular, the conversion of evidence scores to a star system will make it more accessible to a wider research and policy audience. The next critical step in socialising and gaining acceptance and bolstering transparency of this approach will require targeted communication and dissemination. The IAC strongly recommends its dissemination with three levels of audiences in mind. These include:
1. Methodologists - peer-reviewed publications in key statistical and methodological journals, such as the Journals of the Royal Statistical Society, the American Statistical Association, Annual Review of Statistics and its Application, the International Journal of Epidemiology, and others.
2. Applied public health practitioners and clinical researchers - peer-reviewed publications in key public health and clinical journals, such as the American Journal of Public Health, European Journal of Public Health, Public Health Reports, International Journal of Epidemiology, American Journal of Epidemiology, The Lancet, and the British Medical Journal.
3. Policy makers – accompanying guides to interpretation on the IHME website and a short summary included in presentations and other materials aimed at policy makers and, occasionally, general newspapers and other publications.
On COVID-19 estimation:
1. The IAC commends the IHME for the robustness and high media attention of their COVID-19 estimation during the pandemic. The IAC notes that IHME’s collaboration with WHO, Africa CDC, and other countries, is of great importance for future surveillance modelling forecasting efforts, and management of global public health emergencies.
2. On using neutralising antibody response as a predictor of cross variant immunity and vaccine efficacy:
  1. The IAC is mindful of the challenge that this work involves in recognition of the variable reported vaccine efficacies (including different outcome definitions, e.g., death, severe to mild symptomatic COVID-19 infection, and hospitalization among others), different lineages, and perhaps even the sequence of infection with different variants. These may also vary by vaccines and countries.
  2. The IAC recognises the potential of this framework for studying the impact of variants on vaccine efficacy which may help inform the debate in vaccinating children and booster vaccines. However, it also felt that there was much emphasis on the biology but less consideration about the real world effectiveness against severe disease, hospital admissions and mortality.
3. Modelling the effects of different mandates:
  1. While the work on the effects of mandates is important, the IAC noted that it requires more work. For example, it is critical to distinguish between the effect of mask use and the effectiveness of the mask mandate. The results presented to the Committee carried a high risk of being misinterpreted as masks not working rather than mask mandates not being effective. Any misunderstanding of the effectiveness of mask use could potentially undermine countries’ efforts in implementing life-saving measures in the continuing COVID-19 pandemic in many parts of the world.
  2. The IAC suggested to look at the effects of ‘clusters’ or collections of mandates by country.
  3. There was some discussion on the appropriateness of the statistical method behind this work. There was a suggestion that mask use is function of mask mandate and transmission intensity among other factors. As such it would appear to be appropriate to consider the use of simultaneous equation models to take into account the co-determination, that is, one’s dependent variable may act as an independent variable and, in some case, one’s independent variables are themselves dependent variables.
  4. The IAC urges IHME to exercise extreme caution in proceeding with this work and what they publish. The IAC would like to revisit this topic in a future meeting.
4. On scenario forecasting:
  1. The IAC recommends that no more than 6 scenarios should be considered, and if possible, less.
  2. The IAC recommends the adoption of a gamification approach by focusing policy makers to a small number of 6 to 7 variables that really matter and when they do matter.
The purpose of a proposed Policy Advisory Council in the GBD Collaborator Network Strategy presented to the Committee is unclear.
1. The IAC noted that the proposal requires further deliberation. The Committee suggests linkage with regional, rather than global, entities such as ASEAN, WAHO, ECSA-HC, WHO AFRO, the EU, and the AU may be more fruitful.
2. The IAC is mindful of the potential increased demand on IHME’s senior leadership to engage with another high-level council body in addition to the existing Science Council and the IAC.
3. The IAC requests further clarification of the purpose of this proposed body and to revisit this topic in a future meeting.
The IAC commends the continuing development of distal risk-outcome work as per one of the IAC recommendations from the fifth meeting in Gurgaon in 2015.
The IAC endorses the new typology of 3 scenarios for future health scenario (FHS) work, namely ‘past rates of change’, ‘explicit levels of drivers’ and ‘adoption of specific policies’. IAC emphasizes that they should be referred to as scenarios, not policy scenarios. The IAC suggests to add the word ‘effective’ to precede the scenario of ‘adoption of specific policies’ to alert users to the importance of effective policy adoption as compared with policy release.
The IAC did not receive any session-specific questions from the IHME for this meeting. The IAC requests that the IHME provides these questions in advance for future IAC meetings.
The Committee confirmed that the “deep dive” review on GBD tuberculosis estimation is underway. The deep dive panel will produce a short report for presentation at the next IAC meeting.

The next GBD IAC meeting will be held in October/November 2021. Exact dates will be circulated to the group shortly.

NOVEMBER 2-4, 2020

The fifteenth meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened from the 2^nd to the 4^th of November 2020. Given the ongoing COVID-19 pandemic and continuing travel restrictions the meeting was held virtually rather than at the offices of the Africa CDC in Addis Ababa, Ethiopia. Despite the enormous workload that IHME has been undertaking in the pandemic, the IAC meeting went ahead as planned and was held on-line over three days, with participants including the GBD IAC members and junior members, IAC observers, IHME senior staff and researchers, representatives from the Bill & Melinda Gates Foundation and members of the IAC secretariat.

GBD IAC Recommendations

Following discussions by the group, the IAC made the following comments and recommendations:

The IAC commends IHME on the enormous progress made since the last meeting and on the timely uptake of the past IAC recommendations, especially during an extremely demanding time with the pandemic.
The Committee applauded the major policy impact of IHME’s work in the past year during the pandemic, both in the USA and in many other locations.

IAC highly commends IHME’s development (especially the underlying scientific rigour that underpins the method) on their innovative systematic approach for assessing and rating risk-outcome evidence in the literature. The development of this work was motivated by a number of IAC recommendations since 2014.

The Committee welcomes the new GBD publication strategy and is highly supportive of the new 2-pager format for communicating GBD results. While the IAC recognizes the appeal of the new format to policy makers, their advisors as well to the general public, it is cognizant of the value of the critical peer review process in academic journals for reassurance of validity of the results presented.
Publication of methods: The IAC recommended that method papers should be considered as “infrastructure” papers that can be published in the same or other journals and this can be done as part of the wider GBD infrastructure investments. The methods papers do not have to cover every methodological element of a particular paper or model but should clearly set out what the given component(s) do in different parts of the estimation process. Having these components and the methods behind them published will allow them to be referred to in the capstone publications and may help with future peer review processes.
1. The Committee suggests in order to reduce reliance on The Lancet, they should consider other journals such as Gates Open Research and Welcome Open Research. Both of these journals invite ‘open’ peer review after publication. The identities of the reviewers are open to the public. This (together with the previous suggestion) may mitigate the review bottleneck.
2. There was also a suggestion to include “journalist type” of writer(s) in the GBD teams.
3. The IAC is mindful of the importance of striking a balance between the volume of publications and the dissemination of GBD output. Products should be accessible to a range of audience including authorities and citizens and a more diverse range of journals should be considered.
The IAC suggested using more short videos and documentaries to engage with politicians, policy makers as well as the public, in order to broaden the audience base of GBD results.
The Chair asked that the IHME 2-pagers be made more searchable and have future forecasts incorporated into them . It was also suggested that IHME tailors their outputs the new 2-pagers for specific geo-political regions or entities such as the European Union (in addition to the “Europe region”). This may help GBD results reach the relevant political leadership or decision makers more efficiently.
The Committee commends the deepening cooperation between the IHME and the WHO regional offices as well as the HQ, including their Covid responses. This includes IHME’s contribution to production of WHO’s Global Health Estimates and the mutual ambition to align the two sets of global health estimates.
On IHME’s COVID-19 work:
1. IAC commends the critical work on modelling excess mortality. The IAC noted the challenges for producing estimates for year 2020 due to reduced level of reporting of vital registration as well as all-cause mortality data due to Covid-related disruptions in many countries.
2. While the IAC noted the disruptive impact of IHME’s Covid work on the other regular GBD outputs as well as on IHME’s ability to follow up on some previous IAC recommendations. However it was agreed that such disruptions are completely legitimate as part of the urgent response to the pandemic.
3. The IAC commends the new evaluation framework for comparing Covid-19 models proposed by the IHME. This work was instigated as a response to a previous IAC’s recommendation to evaluate IHME’s Covid model against reality.
4. IAC applauds IHME’s effort on their latest IHME Covid model in terms of its openness and flexibility. IAC suggests IHME is mindful of the potentially changing interactions between the mandate variable with other covariates. For example, effective contact-tracing may make mobility (using data from mobile phone tracing as a proxy) less predictive in the model.
5. The Committee complimented IHME on the consideration of seasonality of their Covid models. The IAC would like to learn more about what is driving the effect of seasonality in their Covid model beyond temperature per se. (IHME noted that altitude has been considered in their model but has not been shown to be very predictive while acknowledging that the altitude data accessible to the IHME are not very refined).
6. The IAC recommends that IHME writes up and shares their experience and insights from handling the richness and diversity of the data that they used for their Covid work in the future.
7. The IAC suggested that IHME considers more long term scenarios for Covid. For example, the Committee noted the increasing interests by governments, global institutions and investors in the duration of the pandemic, the collective effect of “packages” of interventions (e.g. testing, contact-tracing, treatments, etc.) and the timing of implementing them, as well as the potential arrival of Covid vaccine(s) on Covid outcomes. Decision makers will really want to know what should be in the “ideal package” for each level of infection.
The IAC recommends a special session on AMR at a future meeting.
The Committee confirmed that the next “deep dive” review will be on the topic of TB, with a small panel led by IAC member Prasada Rao together with an external expert, Professor Richard White. The deep dive panel will produce a short report for the Foundation and IHME which will be presented at the next IAC meeting, with the option of also producing an academic publication based on the panel’s findings.
The IAC recommends shorter presentations in future IAC meetings to allow more time for discussions.

MAY 6-7, 2020

The fourteenth meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened virtually from the 6^th to the 7^th of May 2020. Plans for this meeting to be held in Seattle were moved to an online discussion due to the COVID-19 pandemic which prohibited international travel. Given the unprecedented circumstances, the meeting agenda was reduced to include two working sessions – one on IHME’s COVID-19 modelling work and one on the IAC’s first “deep dive” review which was focussed on IHME’s local burden of disease (LBD) work.

Meeting participants included GBD IAC members, IAC observers, the new IAC junior members, IHME senior staff and researchers, senior representatives from the Bill & Melinda Gates Foundation and members of the IAC secretariat (the full participants lists is annexed to this document). The meeting was recorded for those who were unable to join live.

Day 1: COVID-19

IHME presented on their COVID-19 work and their COVID-19 model, including; its policy use, data processing, the death projection model, the transmission and hospital utilization model, excess mortality estimates, the model engineering and future directions for their work. Following the presentations, the IAC group provided a number of comments, questions and some recommendations for IHME.
The IAC group strongly commends IHME on the impressive and important work that IHME has been conducting and the speed at which they have been able to turn around this COVID- 19 work.
The IAC supports IHME in adapting their models as needed including the possible incorporation of disease transmission dynamics in their planned model update. The Committee recognizes this could be an opportunity for methodological developments in infectious disease modelling generally. The original and unprecedented approach in data collection, modelling and forecasting could be applied to IHME’s work modelling all-cause mortality and could be used as on-going monitoring tool into the future
The group expressed a keen interest to expand the COVID-19 work to Africa and other LMICs. The IAC suggests working initially with a few countries in Africa as a starting point where the data are stronger and suggests collaborating with the Africa CDC.
The IAC recommends that IHME only uses 3 (or a limited small number) of scenarios in their modelling to be most useful for informing policy.
IHME could consider introducing the concept of mass gathering (e.g. pilgrimages) into the modelling work, noting that some countries/locations have greater propensities to have them and they can largely be predicted.
The Committee acknowledges the importance of COVID-19 projections that serve as part of the evidence base to inform countries’ decisions and policies to impose (and to subsequently lift) their respective control measures. The IAC stresses the urgent need to compare the effectiveness of different control measures by different countries.
A suggested area for IHME to explore is around the predictive validity of key indexes such as Healthcare Access and Quality Index and Global Health Security Index.
The IAC notes there will be real interest on the impact of COVID-19 on other health areas and health outcomes (e.g. the impact of the closure of vaccination services, reduced treatment for other chronic conditions, disruption to family planning services etc). The IAC recommends assessing these links and the wider health impact of COVID-19 as future phase of work.
The IAC notes that the collective behaviour change on the ground (e.g. on mask wearing) is still unknown. The example of Hong Kong was cited where citizens are going far beyond the official government policy. The IAC recommends that IHME explores ways to use data on observed, rather than expected, citizens’ behaviour to input in the models.
While acknowledging the methodological complexities associated with it, the IAC recommend that IHME monitors carefully the effect of “testing per capita” as a covariate in the models since this may change over the course of the pandemic and the current assumption built into the model might not hold.
A wider question the IAC asks IHME consider going forward, is how to include the potential of immunity in the model. The Committee also noted that the inclusion of temperature, as a driver of the spread of SARS-CoV-2, in any COVID-19 model as well as the way that the effect of temperature is modelled should be informed by evidence.
On timeframes. the Committee recommends forecasting up to the Fall which coincides with rapid increase in economic activities and will have most impact for public policy planning.
A wider question is the impact on the rest of IHME’s work now that so much effort is focussed on COVID-19 and also on the financial implications for IHME on taking on this work. This will be a topic to consider with the IAC at future meetings.
On communications, the IAC recognises the enormous global interest now in modelling as a good opportunity to promote use of modelling. This will rely on clearly explaining the difference between the models used by IHME and other research groups around the world.
The IAC also recommends that IHME should consider not having such high frequencies of releasing estimates and could instead consider imposing its own time frame for releasing estimates.
The IAC recommends that IHME evaluates their COVID-19 model against reality (e.g. observed deaths) and makes the evaluation publicly available. The Committee also recommends making the COVID-19 model updates more prominent in their communications to the public and the media. Both of these actions will help demonstrate IHME’s commitment to transparency.

Day 2: Local Burden of Disease

The Chair introduced the background of the deep dive review on the Local Burden of Diseases project. This was followed by a presentation by the lead member of the panel of the summary findings of the deep dive review. The presentation focused on three key themes: past/current/future state of LBD, current/potential LBD methodology, and integration/leadership of LBD in precision global health. Key points and recommendations made during the post-presentation discussion are summarized as follows.
In relation to LBD’s works in India, the IAC discussed the need to sensitize state-level leadership to health information at local levels. The IAC recommends that IHME brings these estimates directly to the attention of state-level leadership and administrators. This could be part of the goal of the second generation of LBD going forward.
The IAC commends the important contribution the LBD team has made in revealing the large variations in U5MR across states and districts within states in India and, in particular, the growing trend of geographical disparity over time.
The IAC suggests a future deep dive review topic could be on the specific policy impact of the LBD work.
The IAC recommends having a designated country-level partner to speak on behalf of the IAC to engage with governments at different levels in key countries. The Committee also discussed that feasibility of such an approach in smaller countries to help with local capacity building efforts.
The IAC recommends the BMGF and WHO to work closely with the IHME to identify and prioritize data gaps with a long-term goal to improve availability and quality of primary data especially in LMICs. The IAC acknowledged WHO’s continuing effort in strengthening civil registration and vital statistics (CRVS), survey and administrative data worldwide including through its investment in its Reference Group on Health Statistics.
The IAC agrees to hold a detailed follow up discussion on the LBD deep dive review and the on plans for the next deep dive. The Committee will identify a lead for the next deep dive review and the full panel membership including an external (to IAC) member.

SINGAPORE, OCTOBER 7-9, 2019

The thirteenth meeting of the Global Burden of Disease (GBD) Independent Advisory Committee (IAC) was convened from the 7^th to 9th October 2019 at the Saw Swee Hock School of Public Health of the National University of Singapore (NUS). For the first day of the meeting, the IAC group joined roundtable discussions with GBD collaborators from the Singapore Ministry of Health (SMoH) and the National University of Singapore (NUS). Meeting participants included GBD IAC members, IAC observers, IHME senior staff and researchers, senior representatives from the Bill & Melinda Gates Foundation and members of the IAC secretariat. Prof Yik Ying Teo (Dean of School of Public Health, NUS) joined as an observer to the IAC meeting. Dr. Soewarta Kosen (a Jakarta-based health systems specialist and GBD collaborator) joined for the first day of the meeting to give an overview of the subnational burden of disease work in Indonesia.

Meeting Summary

October 7^th: The Role of GBD in Singapore

The team from the Singapore Ministry of Health (SMoH) presented an overview of the collaboration between SMoH and the IHME, including showcasing two case studies that demonstrated the critical role that GBD plays in informing policy making and planning within the SMoH. The first case study covered population health segmentation using a disease burden approach while the other focussed on health target setting using a future burden of disease approach.

IAC members met with Mr. Peter Ho, former head of civil service of Singapore, at the Urban Redevelopment Authority (URA) Centre. Mr. Ho presented an insightful overview of the development of sovereign Singapore and the critical role that foresight studies play in strategic planning within the Singaporean government.

The team from the NUS presented on Singapore’s academic model of Overseas Development Aid, in public health and clinical healthcare, and on the Singapore clinical network on antimicrobial resistance in the Association of Southeast Asian Nations (ASEAN). The day ended with an open discussion on the roles that Singapore can play in ASEAN for GBD priorities.

October 8^th and 9^th: GBD IAC meeting

IHME presented on the key updates to the GBD, developments on social and behavioural risk factors, future health scenarios, quality assurance for GBD, and the strength of evidence analysis. An update on IHME’s collaboration with the UN system was also discussed with Dr. Samira Asma (official WHO observer of the IAC) joining the meeting via video link.

Following discussions by the group, the IAC made the following comments and recommendations:

The IAC commends the Singapore government on their use of data in informing policy making and planning. It wishes to endorse a number of actions made by the colleagues from SMoH:
1. Using GBD for age segmentation of population for identifying top causes and risk factors for each age segment – this helps to engage and empower individuals with more tailored health promotions and interventions
2. Using results of age segmentation, with Disability-Adjusted Life Years (DALYs) as the primary metric, for policy making and strategic planning for population health with specific key performance indicators (KPIs) and targets
3. Using comparative risk assessment (CRA) framework to set targets for risk factor exposure and preventable DALYs.
4. The exploration of linking cost to disease burden for a more comprehensive way to prioritize resources
The IAC recommends that colleagues from SMoH and NUS publish their experience and learnings from their application and local adaptations of GBD in Singapore. The IAC has also made similar recommendations to the Brazilian team of burden of disease collaborators in order to demonstrate to international researchers and policy makers the possibilities and the potential impact of adopting GBD at a country level.
The Committee wishes to highlight a comment made on GBDs’ critical role in precision public health during the Singapore-focused day of the meeting. While many think of precision public health as the application of public health measures to individuals, at the NUS School of Public Health precision public health is perceived to work at three levels: individual, community and health system as well as global. They see a critical role for GBD in the application of precision public health worldwide. The GBD serves as a valuable tool to guide global to national level priority settings. The Singaporean example shows how GBD is used to inform what its government and MoH should focus on. This priority setting can then be “trickled down” to health service providers such as hospitals, and then to individuals on how they should manage their own health through M- or E-health.
The IAC recognizes the critical value of qualitative insights in scenario forecasting as demonstrated by some of the examples shared by the Singaporean researchers. The IAC recommends that IHME considers further qualitative insights in their scenario forecasting work.
The IAC commends IHME on their timely uptake of the past IAC recommendations on a consistent basis.
The IAC fully supports the disaggregation by sex for the whole of GBD.
The Committee supports the different typologies proposed by the GBD team for different stages of demographic transition. However, the IAC would like to see more nuance in the nomenclature of country groupings and to include change over time.
The IAC strongly supports the proposed new format and layout of the GBD capstone papers (i.e. 2 pagers with visuals and tables).
The Committee recommends that IHME shares their valuable lessons learned from their progress and innovate use of data visualization and communications in outlets outside of academic journals in, for example, media reports, etc.
The IAC recognizes the need to clearly define and promote the GBD membership strategy including in the categorization and distinction around collaborators, members, and others. Attention should be given to quality assurance and how to manage demand for collaborations. An idea of developing IHME “certified GBD consultants” was discussed. The Committee would like to return to this topic as a matter of priority in the next IAC meeting.
The IAC recommends that the issue of version control within GBD be expanded more broadly to include data products. For example, developing a reference system that allows for the citation of each of the datasets used in producing GBD estimates. The IHME’s approach to data management can be models for others.
The Committee welcomes the updated IHME management organisation (which includes the division into the 25 manager-led teams).
The IAC commends the inclusion of gender-based and sexual violence in GBD’s list of risk factors.
The IAC recommends that the GBD team continues to focus on interventions and costs in their social and behavioural risk factors work.
The IAC welcomes the lessons learned from GBD’s tobacco interest group (with external experts) and notes the GBD has invested substantially on the methodology to estimate the effect of tobacco consumption as well as assembling comprehensive data on tobacco. A question was raised as to whether data from regions outside of USA and LMICs have been included so that the estimates are representative in all regions. The Committee also recommends the inclusion of vaping and smokeless tobacco in the future.
The Committee commends the progress made in exploring inequality in education and its impact on health, and the work on exploring links to human capital in future health scenarios.
IAC recommends investigating whether a social cohesion measure might be worth including as a risk factor since there may be links with mental health, disease outbreaks, and health systems resilience. The IAC suggests organising a future workshop with IHME and other external social scientists, to begin to brainstorm how this might be done.
The IAC commends the great progress made with the WHO-IHME collaboration and welcomes a forthcoming joint Lancet article by the two parties. The committee recommended a pragmatic approach to the collaboration, and that IHME should carefully monitor the resources it invests in the relationship with WHO, as well as concrete progress. Other specific areas of future activity include the review of lifetables and child mortality estimation methods.
The Committee welcomed Dr Kosen’s presentation on the history and current development of Indonesian sub-national burden of disease research. The IAC will consider hosting a GBD IAC meeting in Indonesia in 2021.
The IAC commends the progress and maturation of IHME’s scenario forecasting work. The Committee recognizes the key limiting factor for further developments is the computing power required for this work. There is a need to either decrease the need for or improve computing power, or simplify the models. Creative solutions may be required.
On the future health scenarios, the IAC recommends that focus and priority should be given to national level estimates over sub-national ones at this stage.
The IAC recognizes the major leaps made in data governance in relation to quality assurance in GBD. IHME demonstrated the steps involved in the integrated data quality assurance process, from new data intake, cataloguing, extraction of new data, to the modelling and the intensive collaborator reviews and resolution processes. The IAC recognizes that this is an area where GBD can be a thought leader among other data-led efforts in the world. The IAC also suggests that IHME considers adopting the Five Safes framework^[1] for the use of confidential or sensitive data.
The IAC commends the GBD Data Librarians for their critical role in curating and documenting input data. It is paramount to get the data right from the start in the GBD estimation process. The Committee encourages publishing the lessons learnt in this process for knowledge sharing and to help demonstrate transparency and build trust of the GBD.
The group reiterated the importance of strengthening country level capacity to improve country level data and data quality. The IAC recommends leveraging the strong network of country level collaborators around the world, who can be used to catalyse other efforts and train others as part of a wider knowledge exchange. The successful recent exchange between Ghana and Brazil was cited as an example to build from.
The IAC recommends that IHME should not hold off from rolling out the star rating system for the strength of evidence in GBD 2020 and that delays in some areas such as occupational exposures should not hold up the rest of the work.
The IAC formally approved the first deep dive review topic and scope of work which will focus on the Local Burden of Disease (LBD) work. The deep dive will review the assumptions, data sources, and methods used to produce the geo-located disease burden and other health-related measure estimates by the LBD team at IHME. This first review will be led by Lance Waller, with Irene Agyepong, Marie Lynn Miranda, Gary King (all GBD IAC members) and Peter Diggle (independent expert). The panel will be supported by the Secretariat of the Committee represented by Edmond Ng (Senior Statistical Analyst). The sub-group will present their findings at the next GBD IAC meeting in May 2020.
A number of suggestions for future deep dive topics, led by the IAC, were proposed during the meeting, including; nutrition and diet, a topic decided with the WHO Reference Group, maternal mortality and a review of lifetables. A session will be dedicated to reporting on the first deep dive review on ‘local burden of disease’ (LBD) at next IAC meeting in Seattle in May 2020.
A general recommendation was made to ensure that the GBD outputs increasingly focus on health promotion and prevention which is likely to be of most interest to policy makers.
Finally, IAC commends the very high quality and focused IHME’s presentations in this meeting.

[1] The Five Safes framework is a set of principles that helps make decisions on the use of confidential and sensitive data. It has been adopted by a number of agencies including the UK Data Archive and the Office for National Statistics UK. For further details, please see: https://en.wikipedia.org/wiki/Five_safes

SEATTLE, MAY 2-3, 2019

Meeting summary

The 12^th meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened from May 2^nd -3^rd, 2019 at IHME in Seattle, USA

Over the course of the 2-day meeting, IHME presented on updates to the GBD and on the latest developments with the WHO-IHME collaboration. Other items on the agenda included updates on the local burden of disease (LBD) work, the strength of evidence analysis, data “crosswalking”, the GBD calendar and dissemination options, future health scenarios as well as a discussion of the Committee’s forthcoming program of work.

Following presentations by IHME and discussions by the group, the IAC made the following comments and recommendations:

The IAC applauds the significant progress and productivity that IHME has shown on the GBD, geospatial and forecasting work and also on its internal management reorganization since the last meeting.
With regards to the GBD collaborator network, the Committee commends the progress on country-level engagement with Indonesia over their subnational burden estimation work which led to Indonesia’s decision to collect cause of death data. The Committee recognizes Brazil as a great model for capacity strengthening, engagement, and for piloting the LBD work. The IAC also recognises the increased diversity of the international GBD collaborators in terms of its social-demographic index (SDI) distribution.
The IAC endorses IHME’s “waterfall” approach to standardizing the workflow of GBD modellers to enhance transparency and stability of GBD estimates, and the validation of death distribution methods (DDMs). The GBD “waterfall” approach requires modellers to cascade through a number of compulsory data processing and modelling steps (including standardizing locations, causing mapping, “crosswalking” to reference case definition, and cause of death correction) sequentially to enhance reproducibility of GBD results.
The Committee welcomed IHME’s major response to a previous IAC recommendation on the inclusion of the (lack of) education as a risk factor by conducting a revision of its estimation of education attainment by age, sex and location. The IAC also commends the decision to develop a new 5-year partnership with the Centre for Global Health Inequalities Research (CHAIN) and Eramus MC to study the association between socioeconomic position and health outcomes.
The IAC also welcomed the upgrade of IHME’s high-performance computing facility (known as “Buster”).
The Committee welcomes the inclusion of antimicrobial resistance to the GBD. The IAC recommends the consideration of also including antimicrobial resistance in animals.
Local Burden of Disease:
- The Committee welcomes IHME’s validation of the LBD methodology using US data (with high geospatial coverage) which was a direct recommendation by the IAC from the last IAC meeting in November 2018.
- The Committee is cognizant of the technical challenge in estimating uncertainty of geospatial estimates with binomial models (for discrete outcomes whereby the variance is a function of the mean) and appreciates the LBD team’s effort in considering alternatives such as exploring the use of coefficient of variation instead, for example.
- The IAC notes the impressive growth in geolocated datapoints used in the LBD work and the convergence to the star-rating system to aid the representation of data quality in geospatial estimates.
- The Committee appreciates the efforts made by the LBD team to “ground-truth” the LBD methodology (including simulation and validation) which is the result of a specific IAC recommendation from a previous meeting.
- The IAC recommends that the LBD team focusses on more local collaborations with the aim of increasing adoption and use of LBD estimates by local policy makers in more countries.
The Committee supports the creation of a new technical advisory group to the LBD work but recommends that IHME considers the geographical diversity of its members and includes partners of local collaborations.
The Committee stresses that the governance of the LBD is part of the overall governance structure of the GBD as a whole. The IAC is not supportive of the LBD work having its own engagement committee but recognizes the importance of formulating the LBD’s own engagement strategy which should be part of the larger overall GBD engagement effort. Such a strategy should consider what is most meaningful and useful to local policy makers with an ultimate goal of mainstreaming LBD into the overall GBD.
The Committee recommends that the LBD team should engage the same constituents as the overall GBD enterprise and not just with stakeholders with interest in geographic information system (GIS), as well as with non-health actors, for example development and planning departments.
The IAC welcomes the new and innovative evidence score (used for causal associations for risk factors and interventions) which it feels could serve as a global public good. This again was a direct response to an earlier recommendation by the IAC – the Committee previously asked the GBD team to develop a detailed strength of evidence scoring system for risk-outcome pairs in 2016. While the Committee welcomes IHME’s plan to publish the research behind this new scoring system in a peer-viewed journal, the IAC recommends further testing of its robustness including its application for the assessment of well-known therapeutic interventions, for example.
With regards to new evidence score the IAC recommends the following:
- evaluating the change from the global distribution of exposure to the Theoretical Minimum Risk Exposure Level (TMREL) once the risk-exposure curve has been estimated using all available studies
- using a current two-step approach, not only a single criterion, in including risks-outcome pairs
- further exploration of the ‘permissiveness’ of the star ratings
- the use of the MR-BRT model to estimate risk-exposure curves for the evidence score
- the use of evidence based on direct observation, such as HIV due to unsafe sex, in the estimation of population attributes fraction (PAF)
The Committee recognizes the high quality and the uniqueness of the work that underpins the new and more standardized approach to “cross-walking”[i] different case definitions of risk factor exposure for a given outcome. The Committee does not know of any other systematic effort by any group to address this critical methodological challenge. The IAC recommends that IHME publishes this underlying methodology. The new approach has the potential to improve the consistency of GBD estimates that are based on input data with, at times, vastly different case definitions and comparisons of different combinations of exposure levels.
The IAC was interested in the possibility of IHME migrating its systems to the cloud. It was agreed that at this stage the migration was not a cost effective move for IHME but the IAC would like to revisit the question at future meetings.
The Committee notes WHO’s reorganization of its senior management structure and commends the great effort from both sides to develop the nascent WHO-IHME collaboration. The IAC recognizes the opportunity that this collaboration represents and encourages IHME to embrace the potential for improving national health statistics by addressing data gaps and better data collection in different countries. The Committee recommends the dissemination of the GBD results to countries followed by meaningful dialogues through regional workshops.
The IAC recommends that IHME becomes a WHO collaborating center.
To achieve a successful long-term collaboration the Committee suggests that attention should be focussed on developing concrete “success stories” in the collaboration in the next 12 months.
The Committee endorses IHME’s new publication strategy which presents as a more cost-effective and rational approach to publication. The IAC recommends that IHME publishes a non-technical annual report and suggests that specific skillsets and potentially new staff might need to be considered to engage with a policy audience.
The Committee was highly impressed with the work presented on the new future health scenarios and feels that it could have wide reaching impact with policy makers. The IAC recommends first publishing the methodology followed by a paper with results in a non technical writing style for greatest impact.
The IAC recommends exploring other covariates, particularly climate change, in the next iteration of the future health scenarios work. Careful consideration should also be given to the messaging and language in any communication around this work. The IAC highlighted the urgency for IHME to engage in dialogues around population forecasts with larger countries such as China, India, and Nigeria.
The IAC agreed that the first “deep dive” exercise to be led by the IAC will be on the LBD work and a panel of five to six members will be formed to take this work on.
It was agreed with the BMGF senior programme officer that the consultations on the WHO-IHME collaboration under the new grant will be put on hold until further discussion with the WHO.
For the next meeting in Singapore, it has been suggested that the Committee should have a free discussion on the “uniqueness of the problems” that IHME tries to solve. For example, GBD’s own population estimates as well as its own unique approach to crosswalking disease case definitions for estimating the effects of risk factors.

[i] GBD uses a wide variety of data sources for estimating disease burdens globally. Crosswalks are crucial for synthesizing evidence from disparate data sources for use in GBD analysis. Consider data for a given outcome (e.g. disease incidence), risk factor exposure may be defined using different case definitions, assays, instruments, recall periods as well as coding systems (e.g. different version of the ICD). Standard GBD practice is to use the statistical relationship between the reference or preferred method of measurement and alternative methods of measurement to crosswalk the alternative methods of measurement to the equivalent level to allow the estimation of the effect of the risk factor.

RIO DE JANEIRO, BRAZIL, NOVEMBER 1-2, 2018

Meeting summary

The 11th meeting of the Global Burden of Disease Independent Advisory Committee (GBD IAC) was convened on November 1st - 2nd, 2018, at the Sofitel Ipanema Hotel in Rio de Janeiro, Brazil. Meeting participants included 10 GBD IAC members (including the Chair), an observer from both the World Bank and the WHO, 5 IHME staff, 1 participant from the Bill & Melinda Gates Foundation and 2 members of the IAC secretariat. This was the last meeting of the IAC in its current form. Renewed funding from the Bill & Melinda Gates Foundation will enable the IAC to continue for a further 4 years from November 2018-November 2022 with an updated terms of reference and renewed membership.

On October 31st, IAC members were invited to attend the Second Scientific Meeting of GBD Brazil Project, organised by the Brazilian Burden of Disease (BoD) network. The network presented on the history, objectives, experience, and on-going BoD research across Brazil, supported by the Brazilian Ministry of Health. Members of the IAC were unanimous in their appreciation of the lessons shared by the highly organized network. The IAC were particularly impressed by the extensive research and investigation into the creation of a bespoke “garbage code” re-distribution algorithm for Brazil.

In the IAC meeting, the IHME delegation began with a presentation on the social media impact of a series of GBD papers as reported by Altmetric - a media tracking service now widely used by journals such as JAMA. In particular, the GBD 2016 papers on alcohol, firearms, cancer, healthcare access and quality, multiple myeloma, and Parkinson’s disease were reported to be in the 99th percentile of all papers tracked. This was followed by presentations on the Brazilian burden of disease network and project, future health scenarios, local burden of disease mapping with geospatial models, the decomposition of changes in GBD into production process, and the future of the IAC.

GBD IAC Comments and Recommendations

IHME was commended again for the major progress made since the last IAC meeting and on the speed of the uptake of the IAC’s past recommendations.
The IAC agreed that the work presented by the Brazilian BoD network demonstrates how GBD has become a real movement for population health. The IAC recommends that the Brazilian BoD network document the important lessons learnt from their experience, especially in its systematic approach to develop its own garbage code distribution algorithm, so that the learnings can be shared more widely. Such documentation could include how the quality of the data has changed, estimates improved and any subsequent policy changes as a result of this work.
The IAC recognizes the need to differentiate between IHME approved GBD publications and those prepared by independent researchers using IHME data without IHME affiliation or approval, which presents a potential reputational risk to the IHME GBD network. It was suggested that a “light touch” branding process such as a simple line noting where papers had been prepared by the IHME GBD network could be added to IHME affiliated papers.
On productivity and staff turnover at IHME, the IAC strongly supports IHME’s new change management systems and commends the introduction of the surge team and staff being able to reserve 10% of staff time for innovation. The IAC stresses the need for a dedicated senior personnel to further manage and drive the change management. This effort is considered by the Committee as key to address sustainability issues at IHME. Furthermore, the IAC note the improved gender balance in GBD leadership team but recommends that further improvement is needed in this area.
The IAC is supportive of the IHME-WHO collaboration and its progress to date. The Committee notes the need for resources to nurture this relationship and requests a regular update on the relationship.
As noted in the Spring 2018 GBD IAC meeting, the IAC recommends again having a rotation of IHME staff who could spend time working with WHO in Geneva or regional offices, with a reciprocal arrangement for WHO staff in Seattle. This could both facilitate the partnership and also serve as an incentive or professional development opportunity for staff in both institutions.
On the GBD evidence score, the IAC recommends keeping the star ratings but agrees that the underlying algorithms should be more objective.
On the Local Burden of Disease (LBD) work using geospatial methods, a number of LBD specific recommendations were made, led by Lance Waller. These include:
- The IAC agreed that the LBD team should endeavour to resolve the technical issue of the unexpected behaviour of the uncertainty intervals in the data processing before there is further methodological developments.
- The Committee stresses that any validation of the models should be performed against real data, not via simulations or against other models alone
- On the level of aggregation, the Committee recommends focusing LBD maps and estimates at the smaller (within-country) administrative levels.
- On country collaborations, the IAC recommends outlining a framework for country collaborations with LBD for consideration at the next IAC meeting
- On “ground-truthing”, the IAC recommends that the LBD team provides a benchmark for LBD performance, uses a data-rich example (or examples) to examine statistical and estimation performance (accuracy, stability, reliability, uncertainty interval (UI) coverage) in the presence of increasing levels of data sparsity.
- On model validation, the IAC recommends assessing model performance at the level of decision making. The value of LBD for decision making will rely on its performance at the level the decisions are made. This may vary from region to region. Depending on model performance, consideration should be given to developing a star rating system for maps which reflects the model performance at the level that the model results are presented.
- On the observed patterns of predicted counts seemingly mirroring background population density, the IAC recommends considering a paired map presentation, one showing predicted rates and the other predicted counts (from the same model so this should not require excessive additional calculations), preferably with differing colour schemes to avoid confusion. This could be prototyped with a specific example for the next IAC meeting.
- On incidence versus prevalence mapping, the IAC suggests highlighting the distinction between incidence and prevalence for different classes of outcomes.
- The IAC recommends considering simulations on subsets of data to provide benchmarks for model diagnostics. This approach can be very useful for the mean-variance association but also for other measures of model fit (e.g., information criteria, posterior predictive checks, etc.). These could build toward a toolbox of model performance criteria for future reports.
- The IAC recommends that IHME considers adding scientific/technical expertise to a LBD Scientific Advisory Committee or adding these expertise to the existing GBD Scientific Council.
- The IAC recommended that the LBD team should keep one central question in mind in order to drive the research outputs which is, what is of most relevance to policy and decision makers?
- The Committee notes that incorporation of resource allocation in geospatial maps was discussed in the Seattle 2018 meeting but was not addressed in Brazil. The IAC would like to revisit this topic in a future meeting.
- The Committee supports the “2-year rule” for new LBD themes/topics before formal publication of any results.
On the future health scenario work, the IAC supports the inclusion of the new risk factors of sea rise, access to water and temperature as well as new parameters for tobacco, obesity and taxation (elasticity).
The Committee stresses that IHME should prioritize the development of the core platform over any bespoke analysis and bespoke analysis should be put on hold unless it specifically serves wider purpose for IHME.
The IAC strongly supports the development of the innovative GBD ‘prognosticator’ whereby changes in GBD estimates from one iteration to the next are decomposed into constituent parts which helps address trust issues in the GBD work and enhance transparency, traceability and reproducibility. This also helps pinpoint the key drivers behind any changes, facilitates quality control and corrections when identified.
The IAC recommends that the GBD team document the pioneering experiences and learnings from the development of their highly sophisticated and established data visualization and accompanying tools.
It was agreed that under the new grant for the IAC, the IAC will continue to operate with biannual meetings. The composition of the IAC will change to reflect evolving work of IHME. Additional activities undertaken by the IAC secretariat will include; independent consultations with WHO and others to collate feedback; and conducting “deep-dives” into specific areas of GBD estimation

SEATTLE, APRIL 23-24, 2018

Meeting summary

The 10^th meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened from April 23-24^th, 2018 at IHME in Seattle.

IHME presented on updates on the GBD and on the increased collaboration with World Health Organisation and the impact that the new collaboration will have on the GBD production schedule. Other items on the agenda included updates on; the inclusion of tobacco, education and temperature in the GBD risk factors; developments on machine learning; the forecasting and scenario work and the local burden of disease work. The meeting also included a discussion with the IHME team and IAC members on the future of the IAC. Following discussions with the group, the IAC made the following comments and recommendations:

The IAC once again commends the major progress that IHME has made on the GBD, geospatial and forecasting work and on the swift follow-up to a number of issues that were raised at the last IAC meeting. It was specifically noted that there have been remarkable developments on the AI/machine learning components of the work, following a Committee member’s recommendation last year.
The IAC found the presentations highly informative but suggested that when presenting to external audiences, that the GBD team always fully explain any acronyms on the slides and do not pack the slides too heavily with data so that they are easy to comprehend.
On the collaboration with WHO and the new MoU agreement, the IAC was very supportive and commends the partnership whilst also noting that it represents a major change in the GBD enterprise. As the collaboration develops, the IAC agreed that it is vitally important that IHME maintains its independence.
The IAC suggested that IHME shares some updates on the WHO collaboration between now and the next IAC meeting, especially if any issues emerge that IHME need advice on. This could be in the form of an interim report or a conference call with the IAC Chair and available IAC members.
The IAC suggested having a rotation of IHME staff who could spend time working with WHO in Geneva (e.g. 3-6 months) which would both facilitate the partnership and would serve as an incentive or development opportunity for IHME staff. WHO staff could equally spend some time at IHME in Seattle.
The IAC recommended that under the new working relationship with WHO, there should be an agreed process or mechanism for endeavouring to resolve any disputes over the estimates, including an established timeframe for these to be resolved in, so that disputes do not impact the GBD production schedule. The IAC recognizes the spirit of a commitment to working together will be critical to the success of this collaboration. It also recognised that, at least for an interim period, there may be circumstances in which the two parties “agree to differ” in their estimates. However, in such situations it would be important to explain, as far as possible, the reasons for the differing estimates.
The IAC noted that close attention will need to be paid to the communication to countries about the WHO collaboration. The “how and why” of the new MOU will need to be explained carefully, especially during the transition period where there may be still be 2 sets of published data.
The IAC noted that during the transition period under the new collaboration with WHO, because of the need to align the timing of the release of estimates, there will be no GBD papers released in 2019 and this represents a major opportunity for IHME who can use the time to focus on some of the areas that are usually difficult to schedule such as key infrastructure upgrades.
The IAC commended the major progress on the geospatial/local burden of disease work since last meeting. The IAC recommends that IHME now invests time and effort into defining the problems and needs of the GBD end-users who will ultimately be using the maps. Going through a disciplined process of problem identification will help shape how the maps can be better tailored to decision makers’ needs.
The IAC noted that the maps produced in the local burden of disease work are a useful communication tool and can be highly valuable for advocacy. Whilst the 5x5km level is useful, the IAC recommends also aggregating the data to above the 5x5 level for example to the local administrative levels (which might vary between geographies) as this is likely to be more useful to decision makers.
The IAC urged IHME to use data from countries with high-level geospatial coverage, such as the USA, to demonstrate the performance and validity of the cross-validation process of their models.
The IAC recommends not to going down to the 1x1km level which is unlikely to be useful to policy makers because of the uncertainties in estimates at such a fine level.
The IAC noted that there is still a challenge on how to show uncertainty of the estimates on the maps which needs to be addressed.
The IAC recommends that at some stage it would be useful to also include resource allocation to the maps as this will be of considerable value and interest to policy makers.
The IAC acknowledged that there is still a data sparsity issue across GBD. The IAC recommended that maps can be a useful advocacy tool for IHME to illustrate the global data gaps and to help with efforts to retrieve more data where it exists and to promote the need for additional data collection at a local level.
For the local burden of disease work in high-income countries, the IAC suggests that IHME could charge those country clients amounts that could also subsidise some of the work for low and middle-income countries.
The IAC continues to be supportive of the efforts to include level of education into their risk factor work (this came from some of the IAC’s earlier recommendations). The IAC recognises that this work has raised a lot of issues, including data sparsity, such as the lack of published literature on cause-specific mortality by level of education. The IAC recommends that IHME continues with this work and recommends publishing the education paper separately to the main GBD papers for the time being.
The IAC also recommended that it also might be useful to begin by working specifically with one country which is education data rich and to feed those data into the model to understand better the issues around education before scaling up globally.
The IAC welcomed the new work on temperature and noted that messaging will be critical for this area of work. It will be vitally important to contextualise the results and be clear about what these models do and do not show. The IAC recommended that IHME also connect with other partners like the Intergovernmental Panel on Climate Change (IPCC) regarding the language, messaging and positioning of this work.
The IAC also suggested including mental health as a health outcome for the temperature work.
The IAC were very impressed with the new approach taken for the tobacco work but noted that their findings on the duration of risk following smoking cessation might be controversial and may provoke reaction. The IAC recommended engaging with relevant stakeholders and public health authorities before the tobacco specific paper is published.
The IAC was supportive of including smokeless tobacco in this work. When it comes to products like e-cigarettes, IHME should focus on the data and not label as harm reduction (as this is a policy issue).
The IAC commended the developments on the scenarios work. For policy makers, the IAC recommended changing the time frame on the models to 2030 to align with the UN goals.
The IAC recommended that IHME should be very explicit about their assumptions in the scenario work. They need to be clear in the language about the “scope for change” for policy makers (i.e what future scenarios outcomes are down to specific changes in policy vs general GDP improvements).
The IAC were very impressed with the developments on machine vision, initially as a quality control tool, and noted the huge potential for IHME in this work with major gains in efficiency with regards to the allocation of human resources as well as mediating attrition and keeping staff motivated by reducing some work burden. The IAC recommended that has this work develops, IHME will need to have multiple trainers and assessors.
Regarding country level engagement, particularly for the local burden of disease work in key GBD countries, the IAC recommended some staff rotations with staff at the country level spending time at IHME and IHME staff also spending time in country (following the Ethiopia example). This will encourage country level ownership of GBD.
The IAC acknowledged that the quality of data issue remains a highly complex issue and the IAC recommends a publication on this topic.
The IAC also suggested the inclusion of social capital or social cohesion as a new covariate in the model as there is a strong emerging literature in this area. The IAC would like to add a discussion on this to the agenda of the next meeting.
On the future of the IAC the Committee recommended that it should continue to serve as an independent forum for an exchange of feedback and constructive criticism. IAC members will review the IAC’s terms of reference and future milestones which will be presented at the next IAC meeting.

NEW DELHI, INDIA, NOVEMBER 15-16, 2017

Meeting summary

The ninth meeting of the Independent Advisory Meeting (IAC) of the Global Burden of Disease (GBD) was held in New Delhi, India from the 15th-16th November 2017.

The delegation from the IHME began by presenting a summary of the GBD 20^th anniversary event that was held in Seattle in September 2017. This was followed by updates on the planned GBD 2016 papers, the development in GBD methodology including changes in the cause list, risk factors, geospatial modelling and causation scores. Discussions also focused on the sub-national burden of disease estimation for India, GBD data quality and data gaps, as well as collaboration with the World Health Organization.

Prior to the IAC meeting, the IHME team and IAC members joined for the launch of the India State-level Disease Burden report on November 14^th which was hosted by the Public Health Foundation of India (PHFI) and the Indian Council of Medical Research (ICMR).

GBD IAC Comments and Recommendations

The IAC commends the consistent high quality of the work produced by the IHME including an impressive list of published and planned papers, and the launch of the India sub-national burden of disease estimation.
The IAC notes the growing demand for sub-national analyses and supports the criteria set by the IHME to prioritize such demands from different countries.
The IAC applauds the successful launch of the India State-level Disease Burden report. The Committee is mindful that continuing commitment by the Indian government and support by the IHME will be needed to continue this worthwhile effort.
On the topic of sub-national estimates, members of the Committee commented on the potential ‘fatigue’ by policy makers by annual releases of new sub-national estimates. A major release every 3 years supplemented by annual releases based on thematic local disease burden results was suggested as an alternative. Malnutrition and air pollution were suggested as potential themes.
The incorporation of ‘interventions’ into the GBD risk methodology was discussed again and discussions focussed on how this can be incorporated into GBD whether this should be looked at separately with its own analyses. The Committee agreed to revisit this topic in the next IAC meeting in spring 2018.
The IAC supports the implementation of the new DisMod AT tool (undergone a 3-year development) for a number of models for GBD 2017, trialling it before its full deployment for GBD 2018.
The IAC welcomes the development of separate GBD teams with specific areas of work which may help address a number of issues previously raised by the IAC. The issues include: streamlining workflow, staffing, and the separation of the methodological development and the production of GBD results.
The IAC recommends increasing investment in communications with an aim to bring about enhanced policy impact attributable to the use of GBD in general.
The IAC recognized that while the largest policy impact may result from the adoption of GBD, local burden of disease, scenario planning, and effective communications, the IHME should be mindful of the resource implications and the tension between generating burden estimates and aiding policy decision-making or advocacy.
The IAC strongly supports IHME’s assistance to monitor WHO’s Global Programme of Work (GPW) for 2019 to 2023 on request by the Director-General. This may include the monitoring of a new “3 billions” target: 1 billion increased Universal Health Care coverage, 1 billion safer, 1 billion with enhanced SDG intervention target achievement.
The IAC discussed some of the issues around managing the membership of the extensive GBD collaborator network and criteria of authorship of GBD papers. It was agreed that a statement could be added to the GBD protocol allowing IHME to remove collaborators in particular circumstances. There was also support for creating a new “student” category of collaborators.
The IAC strongly recommends that all parts of the GBD enterprise, including the geospatial analysis, use the same approach to collective authorship by all those involved. The geospatial analysis should be more fully integrated within the wider GBD and a communication strategy should be integral to this whole program of work.
The IAC welcomes the development of the GBD evidence grading system and supports the proposed strategy of its development. The evidence score is derived based on three components of conclusion of study, study design, and quality of study. The latter is a composite function of different aspects that affect the quality of a study.
The IAC welcomes the development of local burden of disease (BoD) studies using GBD geospatial analysis and mapping. The level of viewership of the newly developed visualization tools for these BoD studies was reportedly to be relatively low. The Committee suggested communication is the key to increase uptake. A communication strategy is needed to drive demand. One approach suggested is to pursue a “pull” rather than “push” strategy by engaging high-level local stakeholders to adopt maps and have them incorporated into their work at the outset. The importance of drawing on local reports and publications to increase uptake was also discussed.
A committee member suggested that one idea for further discussion is for IHME to develop standardized (and automated) map templates for the online format that allow an easy export of “branded” maps for regional and country-level reporting. That way the look and feel of local/regional outputs is standardized and the geospatial communication becomes a familiar and expected piece of reporting and may help with uptake and adoption.
The IAC commends IHME’s development of a GBD data quality assessment framework. The latest development of the framework was presented to the Committee. The Committee would like an update on this item in the agenda for the next IAC meeting.

SEATTLE, MAY 15-16, 2017

Meeting summary

The eighth meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) took place on May 15 and 16, at IHME in Seattle. On May 17, an additional one-day workshop on the development of reference and alternative scenarios was held at IHME with IAC members and external experts.

At the IAC meeting, the delegation from IHME presented on the latest updates to the GBD papers and outlined developments on areas including the subnational disease burden estimates, new risk factors and causation scores. There were also presentations and discussions on data quality and data gap measurement, scenarios and the inclusion of interventions as risks.

GBD IAC Comments and Recommendations

The IAC commends the great progress that IHME has made in the last six months, since the last IAC meeting.
The IAC strongly welcomes the fact that so many of the IAC’s past meeting recommendations have been addressed by IHME. This includes, but is not limited to, the work that has been done to refine the GBD risk factors, the development of the scenarios work, the addition of the new “star rating” system on data quality, the separation of the GBD production and development workflows and the improvements on data visualization tools. It will be very useful now for the IAC to record and track how the Committee’s recommendations have been taken on by IHME.
The Committee acknowledged that a major challenge moving forward is how to better ensure the use of GBD for policymaking, guiding investment and de-investments.
The Committee applauded the GBD team for the much-improved data visualization tools. The IAC acknowledges that further work might now need to be taken on with regard to development and branding of new versions of the tools for different types of users (e.g., academic audiences versus policymakers). At the next IAC meeting, it was agreed that it would be useful to review how to make best use of the data visualizations for policymakers. The IAC recommends again taking on a user-centred design approach for the development of these tools.
At a future meeting, the IAC would like to review the GBD collaborator network protocol again to better understand how IHME manages its collaborations and its wider community engagement.
The IAC commended the work that has been done on the new Healthcare Access and Quality Index, which brings additional precision to the frontier analysis using mortality amenable to individual healthcare relative to the use of Life Expectance (LE) or Healthy Life Expectancy (HALE) in the context of health(care) system performance and efficiency assessments.
There was great support by the IAC for the huge amount of work that IHME has done with on the subnational estimates. The IAC feels that the subnational work is likely to have the most relevance for policymakers. This work will be essential for continued user engagement with GBD and is likely to have the greatest impact.
With regard to the criteria for when to conduct subnational estimates, the IAC felt that in addition to objective criteria such as population size (for which they recommended lowering the threshold to 100 million), IHME should look at those locations that are most likely to use the results to guide decision-making (i.e., where the demand is). Other suggested criteria for deciding on subnational locations could be progress toward the SDGs, the level of decentralization, the diversity/heterogeneity within a national population, and the relative scale of the disease burden. Also consideration should be given to those locations with growing populations that are likely to have a population over the threshold criteria in the near future.
The IAC agreed that there is a need to consolidate the gains and evaluate the usefulness of the estimates for the policymakers before taking on subnational estimates for new countries.
The IAC suggested that IHME consider new techniques such as adversarial machine learning which may be useful for reducing the burden for some of the close-level human screening of the GBD results. As the number of subnational analyses grows, there is a major feasibility concern for IHME being able to keep up with the level of demand and adversarial machine learning techniques may help reduce the human burden of the workload.
On the LBW risk factor preliminary analyses, the IAC commended the work that has been done but suggested that the IHME team expand their data sources on this area. (The group suggested that some of the studies done on maternal supplementation in different geographies, for example, may prove useful).
On (low) education as a risk factor, the IAC was pleased to see this being incorporated into the GBD work as this was one of the IAC’s earlier recommendations. It was acknowledged that this is a very complex addition, which requires a different approach to the other universal risk factors. Despite the challenges, the IAC agreed that this is something that is very worthwhile to include in GBD.
The IAC noted that while education and income are major predictors for modeling, the level of social support structures in a country might also be useful to explore in the future as a possible covariate, since these have been shown to be very important in explaining mental health outcomes in particular.
The IAC acknowledged the real progress that has been made on the risk factors work and agreed that there will need to be a continuing dialogue on risk factors to further refine this work.
On the data quality, the IAC applauded the newly introduced four levels of garbage coding. The IAC also strongly endorsed the newly introduced “star rating” system, which is something that was also recommended by the IAC in earlier meetings. The IAC recommended a filtering system to be built into the data visualization tools so that users can filter their results based on the quality of the data. Different users will likely have different preferences on what levels they would like to include (i.e., precautionary principle type users versus those who would like to include only the top quality, 4*-5* data).
On the idea of establishing unique data identifiers for each data collection source as a global public good, the IAC are supportive of the idea and feel like it is worthy of exploring further. The Committee recommended looking into existing technologies such as Blockchain to support this initiative. On the question of where the data repository would be, the IAC recommended that this should not be hosted by IHME.
On the causation scores, there was wide support from the IAC but the Committee recommended that the same process should be applied to the data from both observational studies as well as randomized control trials (RCTs).
The IAC commended the major developments that have been done on the forward-looking, scenarios work. There has been great progress and this work is moving GBD into a very relevant policy space.
The IAC endorsed the current suggestion of developing three types of scenarios (i.e., reference scenarios, “best case,” and “worst case” scenarios). The IAC also affirmed the current scenario threshold levels used by IHME (i.e., 85^th percentile and 15^th percentile of observed rates of change in the recent past).
The IAC welcomes the shift in language and mindset from forecasts and predictions to reference scenarios.
The IAC was pleased to see the comparison work that was done to compare the GBD’s GDP estimates and those of the IMF. The IAC welcomes the publication of the paper detailing this work.
The IAC suggested that thought now needs to go into the global branding of the scenarios work. Lessons can be taken from the WEF Global Competitiveness report for example, where annually two to three key messages are drawn out of the analysis which can serve to create visibility and generate conversations. It was acknowledged that there is currently a gap in the landscape when it comes to global health futures, so there is a real opportunity for IHME to fill this space.
The IAC recommended reporting on the intermediary SDG 2020 targets as well as the final 2030 deadline in the GBD and scenarios work, for monitoring country-level progress on the SDGs.
On the interventions as risks work, the IAC commended the work done so far and recognized that this is still a work in progress. The Committee recommended taking on this work in a piecemeal approach as it would be impossible to include everything at once. Grouping interventions by disease cluster (e.g., HIV/malaria/TB) might be a useful start. The IAC also recommended keeping this part of the work separate from the other GBD risk factor work.
The IAC raised concerns regarding the security of data infrastructure, including the website, and suggested that a security audit maybe warranted in the near future.
There was very positive feedback from IHME on work of IAC and the high uptake of IAC recommendations was applauded by the Committee. IHME confirmed that they think that the IAC has a continued role to play on guiding the overall strategic direction of GBD. They would like the IAC to continue to advise on, for example, making the GBD outputs relevant for policymaking, advising on country updates, packaging GBD for different audiences, and promoting country ownership. It was agreed that moving forward, the IAC will continue to meet in person, twice annually.

CUERNAVACA, NOVEMBER 7-8, 2016

Meeting summary

The seventh meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened on November 7-8, 2016, at the Instituto Nacional de Salud Pública (INSP), in Cuernavaca, Mexico. Meeting participants included 13 GBD IAC members, the two IAC observers, five IHME staff, one participant from the Bill & Melinda Gates Foundation, and the members of the IAC Secretariat.

The delegation from IHME presented on updates to the GBD 2015 papers and outlined the major goals for improvement for the GBD 2016 cycle. There were also presentations and discussions on the Sustainable Development Goal (SDG) analysis, geospatial mapping, health futures work, and the latest GBD HIV/AIDS estimates.

Rafael Lozano and Héctor Lamadrid-Figueroa of INSP and Sebastian García-Saizo (General Director of Quality and Health Education, Secretaría de Salud) also presented on building local capacity for GBD in Mexico and on the use and uptake of GBD results in Mexico.

Following discussions with the group, the IAC made the following comments and recommendations:

GBD IAC comments and recommendations

The IAC strongly commends the recent work of IHME and the GBD team and were very impressed with the progress and the level of activity since the last meeting, particularly with regard to the new areas of analyses. The IHME team were commended for always exploiting the GBD data in new and interesting ways, which keeps the annual results exciting and relevant for users. The group agreed that a very constructive relationship has developed between IHME and the IAC. The meetings allow for a very useful and productive dialogue between the two groups.
It was agreed that the GBD subnational results remain highly relevant for policymakers and health program managers. The IAC recommends that subnational datasets, results, and launches should always be organized separately from the release of the global papers in order to achieve maximum impact at the country level.
The IAC recognized that there are still challenges with some technical inconsistencies in the GBD data that often get picked up at the national or subnational level. The IAC recommends that IHME develop a more systematic approach to dealing with users at the country level by developing a formal quality assurance policy or quality process which would outline how users can provide feedback on issues that they have identified in the GBD estimates. It was agreed that it would be useful for IHME to present on this process at the next meeting. It was suggested that before the official release of the results, previews or “sneak peaks” should be organized for priority countries, to ensure that there are no surprises and to help key countries to leverage the results. A community manager-type role was suggested for key countries to act as a specific focal point who could help to detect inconsistences in country-level data, field the feedback from country-level users, handle media relations, help facilitate the national launches, and assist in national outreach activities.
With regard to plans for GBD 2016 and the risk factor work, the IAC agreed that the inclusion of the lack/absence of interventions (e.g., vaccines), as previously recommended by the IAC, is a very encouraging and useful development. The group noted that including the coverage of interventions in GBD papers will be difficult to do but it is worth putting effort into.
The IAC commended the GBD on their recent management restructuring efforts at IHME, which is something that has been discussed in previous meetings. The IAC agreed that it would be useful to get an update at the next meeting on how this is going.
The IAC commended the work that was going on in Mexico with regard to investing in local capacity-building and the GBD training at the master's and PhD level which promotes the sustainability of GBD use. The IAC recommends that PhD students working on GBD theses should be seen as a valuable resource for GBD – they provide an additional (albeit informal) form of reviewing the methods and results, and PhD students can potentially help to put the results in the hands of users. The session on GBD use in Mexico was seen as being very useful to see how GBD data and results are used at the country level. Some questions still remain over how this use actually influences policy and brings about change. The IAC suggested it would be informative to try to document the process of how GBD is used at the national level. Such an exercise would not necessarily be conducted IHME but by a third-party organization like INSP.
With regard to the SDG work, the IAC recommends that IHME not develop its own targets where they have not been specified in the official SDGs. Rather, IHME should concentrate on measuring progress and identifying trends. On tracking progress on non-health SDG indicators, the IAC recommends that IHME just focus on those indicators that it is already measuring as part of the wider GBD work.
The IAC recognized that the geospatial mapping work has come on substantially and this area of work has really benefited from the expansion of its team. It was recommended that while the 5x5 km-pixel, granular detail is useful, the results should also be presented at administrative levels (e.g., districts or sub-districts) to impact policymakers. The IAC recommended that on the geospatial work that the team should consider a user-centered design (UCD) approach in its next phase of the work, working together with and listening to users in selected priority areas. An iterative UCD approach, working side by side with users through workshops and other means, could be used to refine the design and development of this work. This UCD approach can and should be taken on for the GBD outputs as a whole.
On the health futures/forecasting work, the IAC welcomed IHME’s response to past IAC suggestions with regard to the ensemble modeling and commended the recent developments with regard to the GDP models that have established baseline projections. This was regarded by the group as a major qualitative step forward. The IAC strongly recommends that for the health futures work that scenarios are developed and not just projections and extrapolations. This will require consulting with potential users to see what their expectations and needs are, as well as bringing in a wide range of external experts to think through all of the “what ifs.” The IAC encourages IHME to host a workshop or consultation exercise in the coming year (akin to the risk factors workshop), and IAC members would be keen to participate in this. A date of May 17, 2017, (directly after the next IAC meeting) has since been tentatively agreed for this.
On the HIV/AIDS work it was agreed by the IAC that there has been great progress in reassessing and triangulating the ART data. It was suggested that IHME could write a paper on where the key data gaps and discrepancies are.
On the extension of GBD and the inclusion of the concept of mortality amenable to health care, the IAC felt that this was a very useful and positive development but also warned that this area of work requires very careful and thoughtful presentation. It is likely to be very exciting for GBD users but it is also politically sensitive and IHME needs to ensure that this concept is communicated correctly so that users understand how to interpret the results.

SEATTLE, APRIL 21-22, 2016

Meeting summary

The sixth meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened on April 21-22, 2016, at the Institute for Health Metrics and Evaluation, Seattle, US. Meeting participants included 13 GBD IAC members, the two IAC observers, members of the IAC Secretariat, and a number of IHME staff.

Christopher Murray and the delegation from IHME presented updates to the IAC on GBD 2015 as well as updates on GBD scenario forecasting, risk factors, geospatial mapping work, subnational burden of disease work, and the collaborator network. A review of the GBD Data Access Plan and Implementation was also presented. Following discussions with the group, the IAC made the following comments and recommendations:

IAC comments and recommendations

The IAC praised IHME for being responsive to their comments, including in the areas of transparency and credibility, and welcome progress made and the considerable outputs.
Having built the whole GBD estimation platform and having successfully separated development and production, the IAC recognized that the GBD enterprise is entering into a new phase where the IAC considers strategy, use, and advocacy as rapidly becoming critical in GBD’s path of development. The IAC suggested that more attention should go on the policy implications of GBD results, beyond academic considerations.
The IAC welcomes discussions with IHME on GBD’s high-level strategy. The IAC requests IHME to present a structured strategy including areas such as production, development of new areas (forecasting and others), methodology, use, communications, and country engagement.
The IAC raised concern about the sustainability of annual GBD reporting in The Lancet. The IAC recognized the importance of keeping publication incentives for academics but at same time felt that innovations with new ways of presenting the data should be explored.
While commending the work on malaria, HIV, Ebola, and Zika, the IAC felt that it is important for the IHME team to think through the use of the geospatial approach to the long list of health outcomes currently proposed, e.g., TB and pneumonia, and to clarify the methodology. The IAC invites IHME to explore further the specific purpose and value of geospatial work and its link to services and delivery.
The IAC recognized the huge potential impact of the new health services research work including the work on the US and suggested that IHME should think how to apply such work to LMICs. The IAC suggests a cross-country comparative disease expenditure (DEX) analysis which may lead to impactful output. The IAC praised the significant progress in this area of work and particularly commended IHME for their attention to and quality of DEX graphics produced. The IAC also highlighted the need to clearly outline what is included in the IHME definition of health care spending and make explicit the assumption of randomness of missing information.
The IAC raised concern over the potential duplication of governance roles between the IAC, SOG, and IHME Board, and the burden on IHME staff for all of their respective meetings. The IAC suggests that IHME look into these issues and report back to the Committee.
The IAC recognizes a country’s support of GBD as well as local burden of disease initiatives may not be always sustained by local partners in the long term. IHME’s roles in training, capacity development, and ownership transfer should be carefully balanced with its core functions.
On “Health Futures” (or forecasting) the IAC recommends that IHME clearly define the aims of this area of work and then consult with stakeholders to ensure that they are fully aware of existing debates in this area.
The IAC strongly recommended that IHME clarify which creative commons license currently applies to their shared data and ensure most appropriate licensing is being used going forward.
There was support from IAC for the following methodological developments:
- age to be categorized to 100 years to avoid having to reinitiate this work again in the future
- GBD causation scoring system to improve transparency and help identify neglected topics/data gaps and to identify priority areas of research
- current GBD approach to widen uncertainty intervals of effects of risk exposure to reflect the state of knowledge of such effects, for example, those that are currently involved in scientific controversies.
Two potential papers or publications identified by the IAC include a piece explaining why IHME believes SDI to be a superior metric to HDI; and a paper on why joining up cause-specific and all-cause mortality seems to result in an underestimate of the decline in mortality.
The IAC requested IHME to circulate questions to the IAC ahead of IAC meetings in order to allow Committee members the time to reflect and respond at the meetings. Improvements to meeting room acoustics were also registered for future IAC meeting planning.

GURGAON, OCTOBER 13-14, 2015

Meeting summary

The fifth meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened on October 13-14, 2015, at the Public Health Foundation of India (PHFI) in Gurgaon, India.

Christopher Murray and a delegation from IHME presented updates to the committee on GBD 2015, scenario forecasting, risk factors, the Indian State-level Burden of Disease Initiative and the GBD collaborator network. Ongoing GBD sense-making and policy translation activities, initial geospatial mapping workplans and a comparison of MCEE/CHERG and GBD 2013 child death estimates were also reviewed. Additionally a discussion was held about potential opportunities to align GBD’s work with health-related SDGs.

IAC comments and recommendations

The IAC commends IHME for the growing maturity of the GBD endeavor and the successful delivery of the first GBD annual update. The IAC also appreciates IHME’s constructive engagement with the committee.
Following its earlier recommendation the committee commends the publication of the GBD methodology [Flaxman AD, Vos T, and Murray CJL. 2015. An Integrative Metaregression Framework for Descriptive Epidemiology. Seattle: University of Washington Press.] which serves to disseminate the GBD methodology more widely and helps further the scientific discourse in the rapidly evolving field of descriptive epidemiology.
The Committee notes the resource implications of the annual updates for IHME staffing and computational needs. As the GBD endeavor continues to grow, a clearer separation of production and methodological development remains a critical goal in terms of ensuring (organizational) sustainability. The IAC notes progress made in this area and recommends a review of IHME staffing with this goal in mind.
The IAC recommends that IHME develop a comprehensive risk management strategy incorporating quality control and other issues related to annual GBD production.
The IAC was pleased with the presentation of IHME’s top-level goals for GBD 2015 and recommends this be published more widely in the public domain.
In response to IHME’s observations about increased uncertainty leading to problems with calculation of incidence, the committee suggests that IHME prepare a technical paper on HIV incidence measurement, including a call for better (greater) data collection.
The IAC praises IHME for achieving good progress in GBD scenario work and recommends that IHME:
- Carry out a consultation on its scenario forecasting work to inform its direction;
- Produce scenario forecasts on HIV/AIDS to 2030 and;
- Develop a strong communications plan around scenarios.
The IAC recommends that IHME launch its GBD scenario work with an initial focus on the SDGs, producing initial baseline as well as future SDG scenarios.
The committee welcomes the inclusion of geospatial mapping into GBD and stresses the need to develop a strong communications plan and key messages in relation to geospatial mapping.
The IAC does not currently recommend that all GBD data be geo-located as the availability of sufficient data is not yet clear, nor whether demand for this exists and what benefits this would deliver. This will be reviewed in future when GBD geospatial mapping work matures.
The committee welcomes the inclusion of distal risk factors in GBD comparative risk factors work and recommends developing assessment criteria for risk factors.
The IAC recommends that IHME, as a major independent voice in global health metrics, actively monitor global progress against the SDGs.
The committee welcomes the increasingly constructive dialogue between IHME and MCEE/CHERG on child death estimates.
The committee welcomes the expanding GBD collaborator network and:
- Commends IHME for its increasingly systematic approach to managing the GBD collaborative network and resulting prioritization of collaborator engagement. A strategy for network engagement will become increasingly important as the size of the network continues to grow.
- Urges caution about resource implications associated with the expanding number of MoUs, and encourages IHME to manage expectations carefully.
- Recommends that IHME consider Nigeria for network expansion.
- Commends IHME, PHFI and ICMR on their breakthrough collaborations and the successful launch of the state-level burden of disease study in India. The IAC also notes the importance of continued engagement with various Indian stakeholders to ensure the long-term success of the initiative.
- Highlights the issue of the ongoing (financial) sustainability of subnational burden of disease studies and suggests active engagement with local funding partners, as is already the case in a number of countries such as the UK and Japan.
The IAC stresses the need to develop a robust GBD publication and dissemination strategy which addresses tensions between prioritization of publication in high-citation journals vs. policy impact. Non-English language versions are critical for policy impact in certain countries.
The recent work on sense-making and policy translation of GBD is critical for IHME’s mission and should be further expanded. The IAC recommends that a systematic approach to measuring impact be adopted.

SEATTLE, MAY 4-5, 2015

Meeting summary

The fourth meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened May 4-5, 2015, at the Institute for Health Metrics and Evaluation (IHME) in Seattle.

A delegation from IHME, led by Christopher Murray, presented updates on GBD 2013 and GBD 2015, risk factors, HIV estimate methodology for GBD 2013, the India subnational estimation, and scenario-based disease burden forecasting. Additionally, IHME funding sources, GBD production timeline and publication strategy, and GBD’s policy and impact conceptual framework were presented to the committee.

IAC comments and recommendations

The Committee welcomed IHME’s strong commitment to improving GBD methodology in response to IAC recommendations from previous meetings. Most notable were the convening of the risk factor consultation in January 2015, reintroduction of unsafe sexual practices as a risk factor, the new Data Representativeness Index, separation of development and production, and the revision of HIV/AIDS estimation for GBD 2013.
The IAC commended IHME’s ongoing expansion of collaborations, particularly collaborations with WHO, the World Bank, and the Russian Bureau of Statistics, which serve to improve the quality of global health estimates.
There was strong support for integrating geospatial disease mapping and surveillance into the core of GBD. The IAC urged IHME to ensure that sufficient consideration would be given to data confidentiality, ethics, and individuals’ privacy.
There was support for a release calendar of GBD results to help maximize potential impact and media coverage. The IAC encourages diversity of publication outlets.
In light of the planned expansion of work on risk factors, the IAC suggested putting out an open call inviting proposals for additional risk-outcome pairs to incorporate into GBD. Some suggestions were given by IAC members for screening proposals.
The IAC strongly recommends that IHME publish GBD methodology as well as the process of conducting burden of disease studies. Buy-in from the wider research community was recognized as crucial to the success of GBD.
There was strong support for the development of scenario-based forecasts. IHME should engage in stakeholder dialogue as early as possible in order to ensure that the forecasting tool is relevant to users and grounded in reality. Some concern was expressed about plans to forecast GBD’s own population growth and GDP. IHME was cautioned about the importance of using appropriate language in any messaging. Being clear with the purpose and sense-checking of the proposed scenarios and resultant forecasts will be key to the success of this endeavor. As such, the committee recommends that a new member with expertise in this area be invited to join the IAC.
IAC discussions also highlighted a need to identify key IHME communications audiences for research uptake purposes. Pursuing a targeted approach and feeding tailored and digestible information to groups or individuals (such as technical advisors to ministries) was likely to achieve greater impact/influence on policy.
There was support for improving collaborations with ministries and NGOs in existing partner countries. However, due primarily to the foreseeable difficulties associated with scaling up such efforts in multiple countries, increasing IHME’s presence in other countries was not supported.

Future agenda items

Agenda items for future meetings include the following:

Guidelines for access to and use of GBD data at different geographic levels (including data governance and protection)
Forecasting and scenario-building with special focuses on:
- Population growth modeling
- Difference between forecasting and evaluation
- Sense-making of any proposed scenarios and forecasts
Health expenditures and interventions update (into future GBD studies)
Risk factor estimation update
Sense-making/policy translation
Collaborations update

LONDON, OCTOBER 23-24, 2014

Meeting summary

The third meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) was convened October 23-24, 2014, at the Wellcome Trust in London.

A delegation from IHME, led by Christopher Murray, presented on GBD analysis, risk estimates, national burden of disease work, subnational estimation for China, and plans to incorporate health expenditures and interventions as well as forecasting into future GBD work. Other agenda items included a Brazilian national burden of disease case study, the SEED cross-pathogen surveillance network, and WHO’s latest health estimates.

IAC comments and recommendations

The Committee welcomed IHME’s new cause-level maps of data availability and agreed that this visualization tool will provide helpful context on overall data availability as well as being a very useful addition to the GBD work. The difficulties around the communication of uncertainty were highlighted, and it was recognized that this is a critical part of the planned forecasting work. Traffic light/star rating systems were suggested as a way of enhancing users’ understanding of the quality of the estimates. It was also suggested that IHME create a GBD application for smart phones/tablets.
The IAC was receptive to IHME’s improvements to the presentation of risk factors in GBD in three categories: behavioral, environmental, and metabolic. The new Venn diagram presentation is a valuable addition, but it was also noted that it is still important to retain the original comprehensive list of risk factors as in past GBD studies.
On the subject of identifying potential target audience for GBD outputs, the IAC suggested targeting policymakers’ staffers who are likely to be in charge of putting together policy briefs. They could also be targeted for future GBD trainings and apps.
There was strong support for IHME’s national Burden of Disease work, using Brazil as a case study. National burden of disease projects are recognized as being crucial for the sustainability of GBD, and this type of country-based approach strengthens the work of GBD as a whole.
The IAC commended IHME’s expansion of collaborations in relation to subnational estimation for China but highlighted the issue of the variable quality of Chinese provincial data on childhood mortality.
In response to the Foundation’s proposed SEED network, the IAC noted that there are already a huge number of surveillance sites in operation across Africa. The committee identified a critical need to engage with public health leaders in country to ensure the program’s fit within the existing environment. It will also be important to build links with policy/decision-makers in order for this surveillance program to have (the desired) impact.
There was strong support for the increased collaboration between IHME and WHO in recent years, particularly the draft MoU now under development. IAC members agreed that competition between WHO and IHME is healthy and, provided there is a forum for the discussion of differences between estimates, should lead to better-quality estimates.
The IAC commended IHME for preliminary work on incorporating health expenditures and interventions into future GBD studies. The enormous scope of this work was recognized, in particular the challenges of capturing indirect costs/expenditure for poor health and the duration of time it might take to set up this project framework.
The IAC noted that efforts at incorporating forecasting and scenario-building into future GBD work were in early stages but agreed that this could add great value to the GBD work and would be of great interest to policymakers and GBD users. The IAC recommended connecting with forecasting researchers in governmental or industry sectors who specialize in forecasting and scenario-building over long periods of time.

SEATTLE, JUNE 17-18, 2014

Meeting summary

The second meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) project was held June 17-18, 2014, at the Bill & Melinda Gates Foundation in Seattle. A delegation from the Institute for Health Metrics and Evaluation (IHME), led by GBD study principal investigator Christopher Murray, presented on the GBD 2013 updates, plans for future studies, GBD uptake and collaboration, and the GBD risk factor assessment. Other agenda items included the working methods of the IAC and the garbage code methodology. Eleven GBD IAC members joined the meeting, including two new members and two observers from the World Bank and WHO.

IAC comments and recommendations

1. The Committee commended IHME again on its impressive work in generating global health estimates, which have become genuine global public goods for which there is currently no alternative. The IAC noted that the GBD efforts expose the urgent and critical need for global improvements and investments in better primary health data.

2. The Committee welcomes the Bill & Melinda Gates Foundation’s planned investments in surveillance sites and networks. The IAC strongly recommends the inclusion of risk determinants in the surveillance sites and networks (in addition to disease estimates) as well as continued advocacy at the country level to ensure greater country buy-in on data collection improvements.

3. The challenges in conveying and communicating the extent of uncertainty in GBD estimates was raised as an issue that requires further exploration. One IAC recommendation was to develop a simple grading system for the presentation of GBD estimates.

4. The IAC stressed the need for IHME to invest more in sense-making and policy dialogue, in addition to the publication of its work.

5. The IAC recommends commissioning an independent report on the use of GBD.

6. GBD Work Plan. The IAC supports the proposed new schedule of work and annual publication plan presented by IHME, which specifically separates different work flows in the GBD process, such as the development and production phase of estimates. This more “staggered schedule” was seen as a better means of working within IHME’s current scope and resources.

7. The IAC prioritized the following special topics for future analysis, from a list proposed by IHME:

Forecasting and scenarios (often of most interest to policymakers)
Health/disease expenditure
Inequality
Generating subnational estimates
Specific health issues such as water and sanitation
Resolving discrepancies in major health issues such as maternal mortality

8. The IAC reviewed the current garbage code correction technique and recommended a change in the terminology (noting the sensitivity of the “garbage” term). There was also support for garbage-coding visualization tools and in making the code available.

9. The IAC welcomed the fact that IHME is revisiting its approach to estimates of risk determinants. The area of risk factor estimates had already been noted in the first GBD IAC meeting as a topic that needed improvements. The IAC recommended the following:

To incorporate three levels (physiological, behavioral/exposure, and distal) and recognized the complexities of trying to capture these effectively.
To adapt the evidence criteria for each layer of risk.
The focus for the global estimates should still be on the theoretical minimum risk.
Detailed case studies or pilot studies in data-rich settings could also look at the affordable minimum risk.
The IAC welcomes the risk factor consultation later in the year, which IAC members will join.

10. The IAC noted improvements in collaboration and consultation with the World Bank, WHO (particularly some regional offices), UNAIDS, and UNICEF, and encouraged IHME to continue the dialogue. The IAC agreed that there is value in differences between the estimates, and that as long as the data are poor there will continue to be uncertainty in all estimates.

11. The IAC will work in different sub-groups for the following particular areas of interest:

Reviewing the risk factor methodology
Data management issues for IHME
Sense-making/policy translation/policy engagement

12. The IAC will publish an article articulating the role of the IAC (stressing its independent nature), its terms of reference, and the meaning of health estimates. On the role of the IAC, it was agreed that the IAC has a role in raising concerns that other groups/external audiences have about GBD to IHME. The IAC also recommends commissioning an independent report on the use of GBD.

Future agenda items

Agenda items for future meetings include the following:

Risk estimates
Forecasting and scenario-building that IHME is keen to develop
Incorporating health expenditures and interventions into future GBD studies
Discrepancies on specific estimates
The long-term strategy for the GBD

BRUSSELS, NOVEMBER 15-16, 2013

Meeting summary

The first meeting of the Independent Advisory Committee (IAC) of the Global Burden of Disease (GBD) project was convened November 15-16, 2013, at the King Baudouin Foundation in Brussels. A delegation from the Institute for Health Metrics and Evaluation (IHME), led by the GBD study’s principal investigator, Christopher Murray, presented on their work to date and objectives for future GBD studies. The Bill & Melinda Gates Foundation (the project funders) had representatives present at the meeting, including the president of its Global Health Program, Trevor Mundel. Peter Piot (London School of Hygiene & Tropical Medicine) chaired the proceedings.

The two-day meeting was attended by 10 of the current committee members. Two further committee members are being sought to join the GBD-IAC for future meetings, and IAC members are asked to propose potential candidates to Peter Piot.

Over the course of the discussions, the IAC members noted the major improvements in the GBD estimates and models, the worldwide attention that the project has received, and the increasing use of the GBD by countries to improve their own disease estimates and inform health policy. Proposed new areas for future GBD studies, such as forecasting capabilities and the inclusion of health expenditure data, were very much welcomed by the Committee. Comments to IHME raised by the IAC members included suggestions to improve the project’s communications strategy to combat some of the criticisms over transparency; ensuring that the new plans for GBD work remain within the scope of the project and the IHME team; the need to address potential vulnerabilities with the organizational structure and the GBD business model; and the need for a methodological rethinking of the GBD risk factors.

For more information, please contact GBD-IAC Program Manager Sarah Curran.

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All-cause mortality estimation

Climate and food insecurity

Clinical informatics data

Antimicrobial resistance (AMR)

Forecasts

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Competency-based training

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Meeting summary and recommendations:

Star rating system:

Publications:

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Gender:

Injuries:

WHO:

Demography:

Collaborator Network:

Midterm Review:

IAC Membership:

Communications:

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