Temporal Trends and Sex Differences in Disability-Adjusted Life Years (DALYs), Years Lived With Disability (YLDs), and Years of Life Lost (YLLs) Attributable to Infectious Diseases in Afghanistan: Global Burden of Disease 2023 Estimates, 1999-2023.

This study examined 25 years (1999-2023) of Global Burden of Disease (GBD) 2023 data to understand how infectious disease burden has changed over time in Afghanistan and whether men and women are affected differently. The study analyzed disability‑adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) for 46 infectious etiologies, generating 2,300 disease-year-sex data points for DALYs and YLDs, and 2,292 for YLLs. Annual Wilcoxon signed-rank tests showed that men had higher DALY and YLL rates for many etiologies in most years, with particularly consistent male excess from 2016 onward, whereas women had higher YLD rates for many etiologies throughout the study period. When pooled across all 25 years, the overall Mann-Whitney U test found no significant sex difference in DALYs (p=0.158) or YLLs (p=0.161), but did find a significant female excess in YLDs (p=0.017). Generalized estimating equation models (GEE), which accounted for repeated annual observations within each etiology-by-sex series, showed significant declines in burden rates over time. DALY rates declined by 5.354 units per year (95% confidence interval (CI): -8.178 to -2.530), YLL rates declined by 5.301 units per year (95% CI: -8.105 to -2.498), and YLD rates declined by 0.043 units per year (95% CI: -0.066 to -0.020; all p<0.001). Sex-by-year interactions were not statistically significant for DALYs (p=0.938), YLLs (p=0.936), or YLDs (p=0.792). Severity-stratified heatmap analysis classified five etiologies (10.9%) as high burden, 32 etiologies (69.6%) as intermediate burden, and nine etiologies (19.6%) as low burden according to their cross-etiology mean DALY rates. Streptococcus pneumoniae, rotavirus, and Klebsiella pneumoniae were among the etiologies with the highest burden throughout the study period. These findings suggest that Afghanistan's infectious disease burden improved modestly over the 25-year study period. However, the improvements were unevenly distributed across etiologies. Annual comparisons identified sex differences in many years; however, GEE models found no evidence that male and female burden rates followed different linear trends over time. Targeted, sex-responsive, and etiology-focused public health strategies are still needed to decrease the burden of infectious disease in vulnerable populations.