Burden of disease and life expectancy decomposition in Brazil and its federated units, 1990-2023: an analysis based on the global burden of disease study 2023.

Background: Understanding mortality, morbidity, and life expectancy (LE) patterns in Brazil subsidies public health decisions. We analysed changes in the burden of disease from 1990 to 2023 and investigated the impact of the COVID-19 pandemic throughout Brazil and its federated units (FUs). Methods: We estimated all-cause and cause-specific mortality, morbidity, risk factors, and LE from 1990 to 2023, for Brazil and its 27 FUs. To compare estimates before (1990-2019), during (2019-2021), and after (2021-2023) the COVID-19 pandemic. Findings: All-cause age-standardised mortality and disability-adjusted life-year (DALY) rates reduced from 1990 to 2023 (-34.5% [95% uncertainty interval -35.3 to -33.8] and -29.5% [-32.3 to -26.9]), respectively. This reduction reversed between 2019 and 2021 with an increase in all-cause age-standardised mortality (27.6% [26.7, 28.6]) and DALY (18.3% [16.3, 20.5]) rates. The magnitude of changes in these rates varied largely within Brazil. During the pandemic, most of the FUs had an increase in mortality of over 20%. In 2023, total all-cause age-standardised mortality rates returned to the level observed before the pandemic. In 2019, the main underlying causes of death were ischaemic heart disease, stroke and lower respiratory infection. In 2021, the leading cause of deaths and DALY shifted to COVID-19. In 2023, the main causes returned to the 2019 ranking. LE increased 7.01 years from 1990 to 2019, but decreased 3.4 years in the pandemic period, resulting in 7.18 years of increment from 1990 to 2023. Interpretation: The pattern of LE increase and reductions in the leading causes of death from 1990 to 2019, was disrupted by the COVID-19 pandemic. The adverse effects of this health crisis on the burden of disease and LE were heterogeneous within the country. These findings reveal the strength and resilience of the public health system, but reinforces the need to focus on equity and preparedness for future health emergencies. Funding: Gates Foundation and the Brazilian Ministry of Health. TED 67/2023. Health and Environment Surveillance Secretariat, Ministry of Health, Brazil.