Diaz Orihuela, Maria Magdalena

Nombre preferido

Afiliación principal

Facultad de Ciencias de la Salud

Correo electrónico

magi@upeu.edu.pe

ORCID

0000-0002-7779-4852

ID de autor de Scopus

58288979700

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Lineage-specific <i>tprK</i> diversification and <i>Treponema pallidum</i> transmission dynamics in Buenos Aires, Argentina
(2026-01-30)
Nicole A.P. Lieberman
;
Luciana García
;
Shah A.K. Mohamed Bakhash
;
Jeffrey C. Furlong
;
B. Ethan Nunley
Abstract Background Syphilis rates are rising globally, with increases in congenital syphilis in South America particularly concerning. The characterization of contemporary South American Treponema pallidum (Tp) strains is crucial to syphilis vaccine development, yet few genomic epidemiology studies have focused on this region. Here, we performed whole genome sequencing (WGS) of Tp from Buenos Aires, Argentina, as well as deep sequencing of the hypervariable tprK locus, which is critical to Tp immune evasion. Methods People with primary, secondary, or congenital syphilis were enrolled at two clinics in Buenos Aires between October 2018 and January 2023, including individuals associated with intra-household transmission. Hybrid capture WGS was performed and a core genome phylogeny generated. K-mer-based methods using full-length tprK PacBio long reads were used to uncover differences in diversity and detect Tp transmission. Findings Tp genomes were recovered from 70 individuals in Buenos Aires and primarily belonged to globally dominant SS14 sublineage-1 and Nichols sublineage-8, as did Tp from Brazil (n=8). Peruvian samples (n=3) all belonged to sublineage-1. Two individuals from Argentina had co-infections with Nichols- and SS14-lineage strains. Macrolide resistance via A2058G occurred in 27/70 (38.6%) samples. Across 56 samples, tprK allelic diversity was significantly increased in secondary syphilis, oral lesions, and SS14-lineage strains compared to primary syphilis, anogenital lesions, and Nichols-lineage strains, respectively. Increased diversity in SS14-lineage strains is driven by an enhanced repertoire of V7-specific donor sequences. tprK sequences from intra-household transmissions were more similar than unrelated samples with identical core genomes. Interpretation Tp circulating in South America is closely related to dominant global sublineages. Increased tprK diversity in the SS14 lineage may influence Tp’s ability to escape host immunity. tprK profiling is a promising tool to elucidate syphilis transmission networks. This study underscores the utility of genomics to yield insights into Tp pathogenesis. Research in context Evidence before this study Although whole genome sequencing (WGS) and genomic epidemiology have contributed to an understanding of the global diversity of Treponema pallidum ( Tp ), very few strains from South America have been sequenced to date. On January 6 th , 2026, we performed a PubMed search including terms “syphilis genomic epidemiology”, “South America”, “ Treponema pallidum ”, and “Argentina”. We excluded studies of ancient Tp samples found in South American archeological sites. A single Tp sample from Argentina was originally sequenced in 2016 and included in subsequent analyses of global diversity. Nine Peruvian samples were previously sequenced in a study of global diversity on six continents. Thirty-three samples from Cali, Colombia were predominantly SS14-lineage and genotypic macrolide resistance was found in half of strains. Additionally, studies of Tp in Buenos Aires using a multi-locus sequence typing approach have shown circulation of strains belonging to both Nichols and SS14 lineages, with an increasing rate of macrolide resistance over time. Five previous studies have examined tprK in clinical specimens and consistently shown increased tprK diversity in specimens associated with secondary syphilis compared to primary syphilis lesions. One study has shown that loss of tprK donor cassettes is associated with reduced tprK diversity, consistent with results from in vitro experiments. A single study has shown that tprK sequence content is more similar in samples with a suspected epidemiologic link, though no prior studies have looked at tprK diversity in the context of known syphilis transmission events. Added value of this study This study is the first to use WGS to comprehensively examine Tp transmission in a large South American city, yielding 96 samples from 70 individuals. We also add the first contemporary Tp genomes from Brazil. In contrast to findings from England, Australia, and other high-income countries, no Tp sublineages are associated with demographic groups or sexual networks in Buenos Aires. Two of seventy patients were co-infected with both Nichols- and SS14-lineage strains, showing the previously unappreciated frequency of conditions that permit inter-strain recombination-driven diversification of Tp . This study also reveals novel aspects of Tp pathogenesis, including lineage-specific differences in tprK diversity. We also develop methods for the analysis of tprK relatedness between samples and demonstrate that tprK sequences are more similar in samples from individuals within intra-household syphilis transmission chains compared to those from epidemiologically unrelated individuals. Implications of all the available evidence Tp strains circulating in Buenos Aires are genetically similar to those circulating worldwide and in Brazil and Peru but are noteworthy for the low (but rising) rate of macrolide resistance. Lineage-specific patterns of tprK antigenic variation could result in differences between Nichols- and SS14-lineage strains’ interactions with the host immune system. Finally, we show that tprK profiling holds promise to identify samples from within a syphilis transmission chain and could play an important role in public health.
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Global, regional, and national burden of HIV/AIDS, 1990–2021, and forecasts to 2050, for 204 countries and territories: the Global Burden of Disease Study 2021
(2024-11-25)
Austin Carter
;
Meixin Zhang
;
Khai Hoan Tram
;
Magdalene K Walters
;
Deepa Jahagirdar
BACKGROUND: As set out in Sustainable Development Goal 3.3, the target date for ending the HIV epidemic as a public health threat is 2030. Therefore, there is a crucial need to evaluate current epidemiological trends and monitor global progress towards HIV incidence and mortality reduction goals. In this analysis, we assess the current burden of HIV in 204 countries and territories and forecast HIV incidence, prevalence, and mortality up to 2050 to allow countries to plan for a sustained response with an increasing number of people living with HIV globally. METHODS: We used the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 analytical framework to compute age-sex-specific HIV mortality, incidence, and prevalence estimates for 204 countries and territories (1990-2021). We aimed to analyse all available data sources, including data on the provision of HIV programmes reported to UNAIDS, published literature on mortality among people on antiretroviral therapy (ART) identified by a systematic review, household surveys, sentinel surveillance antenatal care clinic data, vital registration data, and country-level case report data. We calibrated a mechanistic simulation of HIV infection and natural history to available data to estimate HIV burden from 1990 to 2021 and generated forecasts to 2050 through projection of all simulation inputs into the future. Historical outcomes (1990-2021) were simulated at the 1000-draw level to support propagation of uncertainty and reporting of uncertainty intervals (UIs). Our approach to forecasting utilised the transmission rate as the basis for projection, along with new rate-of-change projections of ART coverage. Additionally, we introduced two new metrics to our reporting: prevalence of unsuppressed viraemia (PUV), which represents the proportion of the population without a suppressed level of HIV (viral load <1000 copies per mL), and period lifetime probability of HIV acquisition, which quantifies the hypothetical probability of acquiring HIV for a synthetic cohort, a simulated population that is aged from birth to death through the set of age-specific incidence rates of a given time period. FINDINGS: Global new HIV infections decreased by 21·9% (95% UI 13·1-28·8) between 2010 and 2021, from 2·11 million (2·02-2·25) in 2010 to 1·65 million (1·48-1·82) in 2021. HIV-related deaths decreased by 39·7% (33·7-44·5), from 1·19 million (1·07-1·37) in 2010 to 718 000 (669 000-785 000) in 2021. The largest declines in both HIV incidence and mortality were in sub-Saharan Africa and south Asia. However, super-regions including central Europe, eastern Europe, and central Asia, and north Africa and the Middle East experienced increasing HIV incidence and mortality rates. The number of people living with HIV reached 40·0 million (38·0-42·4) in 2021, an increase from 29·5 million (28·1-31·0) in 2010. The lifetime probability of HIV acquisition remains highest in the sub-Saharan Africa super-region, where it declined from its 1995 peak of 21·8% (20·1-24·2) to 8·7% (7·5-10·7) in 2021. Four of the seven GBD super-regions had a lifetime probability of less than 1% in 2021. In 2021, sub-Saharan Africa had the highest PUV of 999·9 (857·4-1154·2) per 100 000 population, but this was a 64·5% (58·8-69·4) reduction in PUV from 2003 to 2021. In the same period, PUV increased in central Europe, eastern Europe, and central Asia by 116·1% (8·0-218·2). Our forecasts predict a continued global decline in HIV incidence and mortality, with the number of people living with HIV peaking at 44·4 million (40·7-49·8) by 2039, followed by a gradual decrease. In 2025, we projected 1·43 million (1·29-1·59) new HIV infections and 615 000 (567 000-680 000) HIV-related deaths, suggesting that the interim 2025 targets for reducing these figures are unlikely to be achieved. Furthermore, our forecasted results indicate that few countries will meet the 2030 target for reducing HIV incidence and HIV-related deaths by 90% from 2010 levels. INTERPRETATION: Our forecasts indicate that continuation of current levels of HIV control are not likely to attain ambitious incidence and mortality reduction targets by 2030, and more than 40 million people globally will continue to require lifelong ART for decades into the future. The global community will need to show sustained and substantive efforts to make the progress needed to reach and sustain the end of AIDS as a public threat. FUNDING: The Bill & Melinda Gates Foundation and the National Institute of Allergy and Infectious Diseases.
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Utility of Individual Neurocognitive Domains of the Rowland Universal Dementia Assessment Scale to Detect Cognitive Impairment in an Urban Illiterate Population
(2025-07-02)
Nilton Custodio
;
Marco Málaga
;
Diego Chambergo‐Michilot
;
Rosa Montesinos
;
Diego Bustamante‐Paytan
INTRODUCTION: Brief cognitive tests like the RUDAS are useful for early detection of neurodegenerative diseases, especially in low-literacy populations in low- and middle-income countries. This study assesses the diagnostic performance of the RUDAS by subdomains to detect MCI and dementia in illiterate individuals in Lima, Peru. METHODS: We performed a secondary analysis of a cohort of randomly selected illiterate individuals, recruited for validation of RUDAS in Lima, Peru. We compared the RUDAS domain and total scores to a battery of neuropsychological tests (FDS, BDS, ROCF, MINT and Craft 21) using a Spearman correlation coefficient. For diagnostic performance, we calculated the area under the curve (AUC) for each RUDAS domain. RESULTS: We included 187 patients (64 controls, 60 MCI, and 63 dementia patients). Average RUDAS score was 23.87 ± 0.93, 20.43 ± 1.39, and 14.97 ± 2.21, respectively. Differences were statistically significant between groups for all domains, except for ideomotor praxis and visuo-spatial praxis. For convergent validity, most significant correlations from the bivariate analysis remained in the age-adjusted regression, particularly for praxis, memory, and judgment. The total RUDAS score had an AUC of 98% (95% CI: 96-100%) for both MCI and dementia, by domains, judgment, verbal fluency, and memory AUC ranging from 0.7 to 0.8. CONCLUSIONS: Our study showed the RUDAS domains of visuo-spatial orientation and memory had an excellent diagnostic performance for the detection of dementia. However, further research is needed to validate the use of individual RUDAS items for assessing specific cognitive domains.
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The burden of cardiovascular events according to cardiovascular risk profile in adults from high-income, middle-income, and low-income countries (PURE): a cohort study
(2025-07-22)
Darryl P. Leong
;
Rita Yusuf
;
Romaina Iqbal
;
Álvaro Avezum
;
Afzalhussein Yusufali
BACKGROUND: Current strategies to prevent adverse cardiovascular outcomes focus primary prevention in high-risk groups and secondary prevention in people with known cardiovascular disease. We aimed to determine the proportion of events occurring in lower-risk groups globally. METHODS: We included people aged 40 years to younger than 75 years who were enrolled in the Prospective Urban Rural Epidemiology (PURE) study, which is an ongoing, international, prospective, population-based cohort study that started recruiting adults from households selected to be broadly representative of the sociodemographic composition of their communities. We prospectively documented fatal or non-fatal myocardial infarction, stroke, heart failure, or any other fatal cardiovascular event stratified by history of cardiovascular disease and by the 10-year predicted disease risk scores based on WHO 2019 laboratory risk tables (<10% [low], 10% to <20% [intermediate], and ≥20% [high]) in people without previous cardiovascular disease from 26 high-income, middle-income, and low-income countries. Outcome event rates were standardised for the cohort's age and sex distribution. FINDINGS: Between July 11, 2000, and May 6, 2019, 128 973 participants were included from 26 countries (mean age 53·6 years [SD 8·2]; 75 858 [58·8%] were female and 53 115 [41·2%] were male). We observed 11 483 outcome events affecting 8·9% of the cohort during a median follow-up of 12·3 years (IQR 9·8-14·6). Among participants, 89 508 (69·4%) had a low cardiovascular disease risk, 22 363 (17·3%) had an intermediate cardiovascular disease risk, and 5529 (4·3%) had a high cardiovascular disease risk, while 11 573 (9·0%) had known cardiovascular disease. The age-standardised and sex-standardised cardiovascular disease incidence rates per 1000 person-years was 4·1 (95% CI 4·0-4·2) in the low-risk group, 17·7 (15·2-20·2) in the intermediate-risk group, and 40·8 (25·1-56·4) in the high-risk group. Overall, 41% of outcome events occurred in cardiovascular disease-naive participants at low risk. The proportion of adverse cardiovascular outcomes occurring in this low-risk group was inversely related to country income level (32% in high-income, 38% in middle-income, and 54% in low-income countries) and was higher in women (51%) than in men (32%). INTERPRETATION: To achieve a substantial population-level reduction in cardiovascular disease, a fundamental change is needed, so that preventive strategies for cardiovascular disease extend beyond those at high or even intermediate predicted risk to include those at considered to be at low risk. FUNDING: The funding bodies are listed in the appendix (p 29).
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Neurocognitive disorders, depression, and associated factors in younger and older adults from an urban‐marginalized area of Peru
(2025-10-01)
Monica M. Diaz
;
Eder Herrera‐Pérez
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Rosa Montesinos
;
Chhitij Tiwari
;
Nilton Custodio
INTRODUCTION: In urban-marginalized areas of low-to-middle-income countries (LMICs), neurocognitive disorders (NCDs) and depression present significant public health issues, exacerbated by socioeconomic disparities. METHODS: This study explores the prevalence and risk factors of NCDs and depression among 1064 community-dwelling adults in an urban-marginalized district of Lima, Peru. Structured questionnaires collected demographic, health, and socioeconomic data; neurocognitive assessments and depression screening were conducted. RESULTS: Mean age was 50.5 years, with 71% female, and a mean of 9.1 years of education. Among older adults, 32% had mild NCD and 4.2% had major NCD; 21.1% of younger adults had any NCD. Nearly 40% of the cohort was depressed. Risk factors for MCI and NCD included lower education, hypertension, and non-Spanish native language, while depression was associated with female sex, lower education, overcrowding, and chronic diseases. DISCUSSION: The study emphasizes the need for targeted interventions to address NCDs and mental health in urban-marginalized areas of LMICs. HIGHLIGHTS: Among older adults, 32% had mild neurocognitive disorder (NCD) and 4.2% had major NCD; 21.1% of younger adults had any NCD. Nearly 40% of the cohort was depressed. Risk factors for mild cognitive impairment (MCI) and NCD included lower education, hypertension, and non-Spanish native language, while depression was associated with female sex, lower education, overcrowding, and chronic diseases.
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Rainfall events and daily mortality across 645 global locations: two stage time series analysis
(2024-10-09)
Cheng He
;
Susanne Breitner-Busch
;
Veronika Huber
;
Kai Chen
;
Siqi Zhang
OBJECTIVE: To examine the associations between characteristics of daily rainfall (intensity, duration, and frequency) and all cause, cardiovascular, and respiratory mortality. DESIGN: Two stage time series analysis. SETTING: 645 locations across 34 countries or regions. POPULATION: Daily mortality data, comprising a total of 109 954 744 all cause, 31 164 161 cardiovascular, and 11 817 278 respiratory deaths from 1980 to 2020. MAIN OUTCOME MEASURE: Association between daily mortality and rainfall events with return periods (the expected average time between occurrences of an extreme event of a certain magnitude) of one year, two years, and five years, with a 14 day lag period. A continuous relative intensity index was used to generate intensity-response curves to estimate mortality risks at a global scale. RESULTS: During the study period, a total of 50 913 rainfall events with a one year return period, 8362 events with a two year return period, and 3301 events with a five year return period were identified. A day of extreme rainfall with a five year return period was significantly associated with increased daily all cause, cardiovascular, and respiratory mortality, with cumulative relative risks across 0-14 lag days of 1.08 (95% confidence interval 1.05 to 1.11), 1.05 (1.02 to 1.08), and 1.29 (1.19 to 1.39), respectively. Rainfall events with a two year return period were associated with respiratory mortality only, whereas no significant associations were found for events with a one year return period. Non-linear analysis revealed protective effects (relative risk <1) with moderate-heavy rainfall events, shifting to adverse effects (relative risk >1) with extreme intensities. Additionally, mortality risks from extreme rainfall events appeared to be modified by climate type, baseline variability in rainfall, and vegetation coverage, whereas the moderating effects of population density and income level were not significant. Locations with lower variability of baseline rainfall or scarce vegetation coverage showed higher risks. CONCLUSION: Daily rainfall intensity is associated with varying health effects, with extreme events linked to an increasing relative risk for all cause, cardiovascular, and respiratory mortality. The observed associations varied with local climate and urban infrastructure.
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Mental health impact of the COVID‐19 pandemic on patients with neurodegenerative diseases and perceived family caregiver burden in Lima, Peru
(2024-01-01)
Monica M. Diaz
;
Maisie Bailey
;
Bettsie Garcia
;
Ximena Aguilar
;
Danilo Coronel Sanchez
BACKGROUND: Neurodegenerative diseases lead to difficulties with functional activities. In Peru, most caregivers are family members. Little is known about the COVID-19 pandemic's effect on caregivers in Peru. METHODS: This was a cross-sectional, prospective study of family caregivers of dependent patients with dementia or Parkinson's Disease in Lima, Peru. A caregiver burden and mental health questionnaire was administered to the caregiver. RESULTS: We enrolled 48 caregivers (65% females, mean ± SD age 49.0 ± 12.3 years); 70% of patients had dementia. Nearly 40% of caregivers reported having full-time jobs, and 82% felt overwhelmed with almost 75% dedicating more time to caregiving during the pandemic. Caregivers perceived patients felt lonelier (52%), had an increase in hallucinations (50%), or forgetfulness (71%) compared to pre-pandemic. CONCLUSIONS: Our study highlights that perceived caregiver burden and patient behavioral symptoms may have been exacerbated during the pandemic. In countries such as Peru, more caregiving resources and interventions are needed.
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Nivel de conocimiento sobre el Proceso de Atención de Enfermería (PAE) en el cuidado de la salud espiritual de los profesionales de Enfermería que laboran en las unidades críticas del Hospital Nacional Hipólito Unanue, Lima 2010
(2019-08-01)
María Magdalena Díaz Orihuela
;
Nira Cutipa Gonzáles
;
Rosa Matos Salgado
Objetivo: Determinar el nivel de conocimiento sobre el Proceso de Atención de Enfermería (PAE) en el cuidado de la salud espiritual que posee el profesional de enfermería que labora en las unidades críticas: Cirugía, Emergencia y UCI del Hospital Hipólito Unanue”, Lima, 2010. Material y métodos: El estudio fue de diseño no experimental, de enfoque cuantitativo, de tipo descriptivo transversal. La muestra estuvo conformada por 40 enfermeras que laboran en las unidades críticas del Hospital Hipólito Unanue, determinada mediante un muestreo probabilístico aleatorio. Para la recolección de datos se utilizó como instrumento el cuestionario para medir el nivel de conocimiento de los enfermeros sobre el PAE del cuidado de la salud espiritual, el cual fue elaborado por las investigadoras. El instrumento fue sometido a juicio de expertos y a la prueba de confiabilidad de Alpha de Cronbach (0.73). El análisis e interpretación de los mismos se realizó utilizando el paquete estadístico SPSS v. 15. Resultados: Los resultados obtenidos, en cuanto al nivel de conocimiento sobre el PAE del cuidado de la salud espiritual fueron: un 57.5% muestra un nivel de conocimiento deficiente, un 27.5% un nivel regular, un 12.5% un nivel bueno y solo un 2.5% un nivel excelente, esto indica que la mayoría de enfermeras encuestadas tiene un nivel conocimiento deficiente sobre el PAE en el cuidado espiritual. Conclusión: La mayoría de los enfermeros desconoce el fundamento científico del PAE sobre el cuidado de la salud espiritual, siendo esto una limitante para brindar los cuidados de Enfermería de forma integral.
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Short-term association between hot nights and mortality: a multicountry analysis in 178 locations considering hourly ambient temperature
(2025-08-22)
Dominic Royé
;
Francesco Sera
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Aurelio Tobı́as
;
Masahiro Hashizume
;
Yasushi Honda
BACKGROUND: The rise in hot nights over recent decades and projections of further increases due to climate change underscores the critical need to understand their impact. This knowledge is essential for shaping public health strategies and guiding adaptation efforts. Despite their significance, research on the implications of hot nights remains limited. OBJECTIVE: This study estimated the association between hot-night excess (the sum of excess heat during the nighttime above a threshold) and duration (the percent of nighttime with a positive excess) based on hourly ambient temperatures and daily mortality in the warm season over multiple locations worldwide. METHODS: We fitted time series regression models to mortality in 178 locations across 44 countries using a distributed lag non-linear model over lags of 0-3 days, controlling for daily maximum temperature and daily mean absolute humidity. Next, we used a multivariate meta-regression model to pool results and estimated attributable burdens. RESULTS: We found a positive, increasing mortality risk with hot-night excess and duration. Assuming 0 as a reference, the pooled relative risks of death associated with extreme excess and duration, defined as the 90th percentile in each index, were both similar at 1.026 (95 % CI, 1.017; 1.036) and 1.026 (95 % CI, 1.013; 1.040). The overall estimated attributable fractions were also observed to be closely similar at 0.60 % (95 % CI, 0.09; 1.10 %) and 0.62 % (95 % CI, 0.00; 1.23 %), respectively. DISCUSSION: This study provides new evidence that hot nights have a specific contribution to heat-related mortality risk. Modeling thermal characteristics' sub-hourly impact on mortality during the night could improve decision-making for long-term adaptions and preventive public health strategies.
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Global, regional, and national burden of stroke and its risk factors, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021
(2024-09-19)
Masayuki Teramoto
;
Melsew Dagne Abate
;
Yohannes Abate
;
Samar Abd ElHafeez
;
Foad Abd-Allah
BACKGROUND: Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990-2021. METHODS: We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. FINDINGS: In 2021, stroke was the third most common GBD level 3 cause of death (7·3 million [95% UI 6·6-7·8] deaths; 10·7% [9·8-11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8-171·6] DALYs; 5·6% [5·0-6·1] of all DALYs). In 2021, there were 93·8 million (89·0-99·3) prevalent and 11·9 million (10·7-13·2) incident strokes. We found disparities in stroke burden and risk factors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015 onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, east Asia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted 65·3% (62·4-67·7), intracerebral haemorrhage constituted 28·8% (28·3-28·8), and subarachnoid haemorrhage constituted 5·8% (5·7-6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI (88·2% [53·4-117·7]), high ambient temperature (72·4% [51·1 to 179·5]), high fasting plasma glucose (32·1% [26·7-38·1]), diet high in sugar-sweetened beverages (23·4% [12·7-35·7]), low physical activity (11·3% [1·8-34·9]), high systolic blood pressure (6·7% [2·5-11·6]), lead exposure (6·5% [4·5-11·2]), and diet low in omega-6 polyunsaturated fatty acids (5·3% [0·5-10·5]). INTERPRETATION: Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden. FUNDING: Bill & Melinda Gates Foundation.
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Diaz Orihuela, Maria Magdalena

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