The global burden and temporal trend in UCAs along with the differences in gender
In 2019, Urogenital congenital anomalies caused 10 200 all-ages deaths (95% UI 7550–13 400). The combined global incidence rate was 8.38 per 1000 (5·88–12·0) live births and 6.28 million (4.98–7.72) people were living with urogenital congenital anomalies in 2019, compared with 14 759 all-ages deaths (95% UI 8698–23388), and 5.40 million (4.26–6.66) people were living with urogenital congenital anomalies in 1990. The ASIR per 100 000 population increased slightly from 16.91 (95% UI 11.88–24.11) in 1990 to 17.52 (95% UI 12.28–25.05) in 2019, with the EAPC of ASIR 0.09 (95% CI 0.02–0.17)(Tables 1–2). However, when we focus on the change in deaths rates, the ASDR per 100 000 population decreased slightly from 0.23 (95% UI 0.14–0.36) in 1990 to 0.15 (95% UI 0.11–0.20) in 2019, with the EAPC of ASDR − 1.19 (95% UI-1.27-0.17). Meanwhile, there was 16.4 (95%UI 12.4–21.0) per 100 000 DALYs rate worldwide in 2019, showing a decrease of 13.6% since 2010[(27.58; 95%UI 17.20-41.88) per 100 000](Table 1–2, Supplementary Tables S1). From 1990 to 2019, among the DALYs composed of YLLs and YLDs, the percentage share of YLLs stably increased (Fig. S1).
Table 1
The number of cases, rate and age-stadardized rate per 100 000 people of DALYs for both sexes, and female and male urogenital congenital anomalies in 2010 and 2019. DALYs, disability adjusted life years.
|
2010
|
2019
|
Characteristics
|
DALYs
(millions)
|
Rate
(per 100 000)
|
ASR of
DALYs
(per 10 000)
|
DALYs
(millions)
|
Rate
(per 100 000)
|
ASR of
DALYs
(per 10 000)
|
Global-Both sex
|
1.475
(0.920–2.24)
|
27.58
(17.20-41.88)
|
22.94
(14.37–34.73)
|
1.094
(0.832–1.408)
|
14.14
(10.76–18.20)
|
16.41
(12.43–21.05)
|
Global-Female
|
0.592
(0.363–1.127)
|
22.27
(13.66–43.43)
|
10.03
(11.72–36.10)
|
0.438
(0.302–0.604)
|
11.35
(7.83–15.66)
|
13.48
(9.24–18.72)
|
Global-Male
|
0.884
(0.519–1.479)
|
32.81
(19.27–54.92)
|
26.61
(15.75–44.28)
|
0.657
(0.435–0.925)
|
16.92
(11.22–23.85)
|
19.16
(12.59–27.09)
|
Both sexes
|
|
|
|
|
|
|
High SDI
|
0.086
(0.070–0.107)
|
8.96
(7.31–11.22)
|
15.06
(12.36–19.20)
|
0.070
(0.055–0.092)
|
6.96
(5.40–9.05)
|
12.58
(9.74–16.50)
|
High-middle SDI
|
0.136
(0.103–0.164)
|
10.05
(7.06–12.06)
|
15.55
(11.59–18.63)
|
0.103
(0.077–0.130)
|
7.19
(5.37–9.09)
|
12.03
(8.86–15.14)
|
Middle SDI
|
0.329
(0.263–0.434)
|
14.93
(11.95–19.70)
|
17.53
(13.98–23.37)
|
0.257
(0.204–0.324)
|
10.71
(8.51–13.50)
|
13.88
(10.97–17.80)
|
Low-middle SDI
|
0.374
(0.251–0.542)
|
23.87
(16.02–34.57)
|
20.97
(14.11–30.32)
|
0.318
(0.231–0.425)
|
18.05
(13.07–24.08)
|
18.41
(13.32–24.55)
|
Low SDI
|
0.333
(0.181–0.542)
|
30.97
(20.04–60.13)
|
21.23
(11.82–33.95)
|
0.345
(0.216–0.525)
|
30.58
(19.11–46.52)
|
19.98
(12.67–29.92)
|
Female
|
|
|
|
|
|
|
High SDI
|
0.032
(0.023–0.043)
|
6.65
(4.88–8.96)
|
11.19
(8.09–15.45)
|
0.027
(0.020–0.056)
|
5.33
(3.90–7.23)
|
9.61
(6.91–13.33)
|
High-middle SDI
|
0.057
(0.039–0.073)
|
0.837
(5.66–10.70)
|
13.23
(8.71–17.14)
|
0.043
(0.030–0.057)
|
6.08
(4.22–7.96)
|
10.41
(7.03–13.69)
|
Middle SDI
|
0.131
(0.099–0.183)
|
11.97
(9.11–16.78)
|
14.37
(10.88–20.51)
|
0.104
(0.079–0.146)
|
8.79
(6.61–12.28)
|
11.64(8.76–16.33)
|
Low-middle SDI
|
0.148
(0.083–0.259)
|
19.11
(10.67–33.43)
|
17.16
(9.58-30.00)
|
0.127
(0.076–0.191)
|
14.46
(8.70–21.80)
|
15.09
(8.98–22.92)
|
Low SDI
|
0.131
(0.064–0.257)
|
29.48
(14.40-57.48)
|
17.38
(8.81–33.12)
|
0.135
(0.077–0.224)
|
24.05
(13.63–39.84)
|
16.15
(9.28–26.34)
|
Male
|
|
|
|
|
|
|
High SDI
|
0.053
(0.042–0.072)
|
11.30
(8.76–15.26)
|
18.73
(14.31–25.72)
|
0.044
(0.031–0.059)
|
8.61
(6.22–11.74)
|
15.40
(11.06–11.73)
|
High-middle SDI
|
0.079
(0.053–0.098)
|
11.75
(7.92–14.45)
|
17.66
(11.61–21.77)
|
0.059
(0.040–0.076)
|
8.31
(5.61–10.66)
|
13.52
(8.81–17.44)
|
Middle SDI
|
0.199
(0.151–0.282)
|
17.83
(13.52–25.33)
|
20.43
(25.42–29.19)
|
0.151
(0.114–0.202)
|
12.60
(9.47–16.74)
|
15.95
(11.97–21.17)
|
Low-middle SDI
|
0.226
(0.125–0.341)
|
28.53
(15.80-42.99)
|
24.53
(13.62–36.88)
|
0.192
(0.112–0.281)
|
21.61
(12.46–31.69)
|
21.52
(12.46–31.69)
|
Low SDI
|
0.201
(0.095–0.382)
|
44.36
(20.89-84.284)
|
24.90
(12.09–46.56)
|
0.210
(0.110–0.366)
|
37.07
(19.47–64.69)
|
21.51
(12.46–31.69)
|
Table 2
Incidence and age-standardized incidence rate per 100 000 people for urogenital congenital anomalies, in 1990 and 2019, and their estimated annual percentage change from 1990 to 2019. No., number; ASIR, age-standardized incidence rate; ASDR, age-standardized deaths rate; UI, uncertainty interval; EAPC, estimated annual percentage change; CI, confidence interval.s
|
1990
|
2019
|
1990–2019
|
Characteristics
|
Deaths cases
No. (95% UI)
|
ASDR
per 100 000
No. (95% UI)
|
ASIR
per 100 000
No. (95% UI)
|
Deaths cases
No. (95% UI)
|
ASDR
per 100 000
No. (95% UI)
|
ASIR
per 100 000
No. (95% UI)
|
EAPC in ASIR
No. (95% CI)
|
EAPC in ASDR
No. (95% CI)
|
Global
|
14758.92 (8697.64-23388.21)
|
0.23 (0.14–0.36)
|
16.91 (11.88–24.11)
|
10215.86 (7553-13440.77)
|
0.15 (0.11–0.2)
|
17.52 (12.28–25.05)
|
0.09 (0.02–0.17)
|
-1.19 (-1.27-0.17)
|
SDI region
|
|
|
|
|
|
|
|
|
High SDI
|
1281.82 (921.72-1891.99)
|
0.22 (0.16–0.32)
|
16.92 (12.42–22.86)
|
601.75 (454.47-837.29)
|
0.11 (0.08–0.16)
|
14.83 (10.9-19.91)
|
-0.66 (-0.78–0.53)
|
-2.21 (-2.28–0.53)
|
High-middle SDI
|
2236.63 (1465.45-3368.48)
|
0.22 (0.14–0.33)
|
16.05 (11.34–22.86)
|
889.96 (633.88-1123.54)
|
0.11 (0.07–0.14)
|
16.9 (11.93–23.83)
|
0.06 (-0.1-0.22)
|
-2.54 (-2.62-0.22)
|
Middle SDI
|
4546.09 (2905.14-6976.24)
|
0.22 (0.14–0.34)
|
15.56 (10.95–22.09)
|
2358.52 (1895.42-3069.68)
|
0.13 (0.1–0.17)
|
16.56 (11.57–23.27)
|
0.11 (0-0.22)
|
-1.69 (-1.85-0.22)
|
Low-middle SDI
|
4215.75 (2120.06-7764.77)
|
0.24 (0.12–0.44)
|
18.17 (12.56–26.26)
|
2978.96 (2033.94-4111.52)
|
0.17 (0.12–0.24)
|
18.98 (13.27–27.53)
|
0.21 (0.15–0.28)
|
-0.87 (-0.96-0.28)
|
Low SDI
|
2470.43 (890.24-4936.65)
|
0.23 (0.09–0.47)
|
18.12 (12.49–26.33)
|
3379.04 (1926.06-5463.74)
|
0.19 (0.11–0.31)
|
18.04 (12.54–26.18)
|
0.04 (-0.02-0.11)
|
-0.43 (-0.51-0.11)
|
Gender
|
|
|
|
|
|
|
|
|
Male
|
8975.96
(4873.10-15424.48)
|
0.27(0.15–0.46)
|
16.33(11.44–23.38)
|
6295.65
(3777.04-9061.04)
|
0.18(0.11–0.27)
|
17.19(12.08–24.87)
|
0.16 (0.09–0.24)
|
-1.07 (-1.16–0.97)
|
Female
|
5782.96
(3350.26-11968.79)
|
0.19(0.11–0.38)
|
17.53(12.18–24.69)
|
3920.21
(2417.03-5711.80)
|
0.12(0.07–0.18)
|
17.86(12.54–25.27)
|
0.02 (-0.06-0.1)
|
-1.38 (-1.44–1.32)
|
GBD region
|
|
|
|
|
|
|
|
|
Tropical Latin America
|
951.3 (397.50-1827.07)
|
0.56 (0.23–1.07)
|
12.34 (8.88–17.43)
|
450.39 (272.38–596.2)
|
0.28 (0.17–0.38)
|
10.12 (7.35–14.1)
|
-0.76 (-0.94–0.57)
|
-1.58 (-1.89–0.57)
|
High-income North America
|
523.08 (383.05-784.67)
|
0.23 (0.17–0.35)
|
12.43 (9.13–16.75)
|
318.72 (217.23-435.06)
|
0.15 (0.1–0.21)
|
11.46 (8.52–15.19)
|
-0.48 (-0.59–0.37)
|
-1.18 (-1.3–0.37)
|
Caribbean
|
99.27 (53.15–159.8)
|
0.23 (0.13–0.38)
|
12.55 (8.92–17.35)
|
78.56 (39.61-137.53)
|
0.2 (0.1–0.34)
|
12.65 (8.99–17.67)
|
-0.16 (-0.24–0.09)
|
-0.23 (-0.4–0.09)
|
High-income Asia Pacific
|
156.71 (97.08-191.77)
|
0.16 (0.09–0.19)
|
27.43 (19.41–39.02)
|
46.51 (31.94–62.18)
|
0.05 (0.03–0.08)
|
21.1 (15.07–29.08)
|
-1.21 (-1.41–1)
|
-3.76 (-3.93–1)
|
Southeast Asia
|
635.16 (327.72-1206.55)
|
0.11 (0.06–0.2)
|
12.81 (8.76–18.27)
|
416.57 (312.96-563.26)
|
0.08 (0.06–0.1)
|
12.71 (8.63–18.33)
|
-0.14 (-0.19–0.09)
|
-1.13 (-1.24–0.09)
|
East Asia
|
1557.5 (846.16-2293.52)
|
0.13 (0.07–0.19)
|
11 (7.64–15.3)
|
364.39 (293.25-441.13)
|
0.04 (0.03–0.05)
|
12.88 (8.93–18.02)
|
-0.17 (-0.74-0.41)
|
-4.97 (-5.24-0.41)
|
Andean Latin America
|
52 (32.5-106.91)
|
0.09 (0.06–0.19)
|
11.66 (8.3-16.51)
|
71.98 (43.43–109)
|
0.11 (0.07–0.17)
|
13.22 (9.62–18.64)
|
0.45 (0.37–0.53)
|
1.43 (1.03–0.53)
|
Oceania
|
18.99 (6.45–41.54)
|
0.19 (0.07–0.4)
|
13.73 (9.53–19.12)
|
37.87 (13.94–82.78)
|
0.2 (0.08–0.43)
|
14.22 (9.73–20.33)
|
0.26 (0.11–0.41)
|
0.53 (0.33–0.41)
|
Western Europe
|
462.39 (304.37-740.78)
|
0.2 (0.13–0.32)
|
15.14 (11.54–20.47)
|
179.11 (132.98-282.85)
|
0.08 (0.06–0.13)
|
14.97 (11.12–20.05)
|
0.05 (-0.05-0.15)
|
-3 (-3.15-0.15)
|
Central Europe
|
165.85 (90.61-255.98)
|
0.2 (0.11–0.31)
|
17.75 (12.35–26.04)
|
44.95 (27.03–60.87)
|
0.07 (0.04–0.1)
|
15.53 (10.84–22.9)
|
-0.46 (-0.68–0.24)
|
-3.03 (-3.19–0.24)
|
Southern Latin America
|
154.49 (94.9-275.04)
|
0.31 (0.19–0.55)
|
15.25 (11.25–21.62)
|
107.48 (51.93-152.38)
|
0.23 (0.11–0.32)
|
16.41 (11.77–23.24)
|
0.41 (0.34–0.47)
|
-0.34 (-0.61-0.47)
|
Australasia
|
28.24 (18.03–49.48)
|
0.18 (0.11–0.32)
|
19.85 (14.08–27.81)
|
15.11 (10.69–25.72)
|
0.08 (0.05–0.14)
|
16.71 (11.91–23.1)
|
-0.62 (-0.67–0.57)
|
-2.49 (-2.69–0.57)
|
Eastern Sub-Saharan Africa
|
746.46 (237.79-1711.56)
|
0.19 (0.06–0.43)
|
18.47 (12.65–26.66)
|
927.5 (522.38-1576.53)
|
0.14 (0.08–0.24)
|
17.07 (11.89–24.6)
|
-0.1 (-0.18–0.02)
|
-0.55 (-0.72–0.02)
|
Central Asia
|
60.62 (42.46–89.28)
|
0.07 (0.05–0.1)
|
16.74 (11.55–23.74)
|
56 (34.52–76.67)
|
0.06 (0.04–0.08)
|
17.32 (11.91–24.58)
|
-0.08 (-0.19-0.03)
|
-0.05 (-0.28-0.03)
|
Central Latin America
|
995.1 (436.99-2823.95)
|
0.43 (0.2–1.2)
|
17.94 (12.67–25.48)
|
642.73 (450.53-1239.46)
|
0.29 (0.2–0.58)
|
17.37 (12.1-24.56)
|
0.12 (-0.18-0.43)
|
-0.86 (-1.03-0.43)
|
Western Sub-Saharan Africa
|
854.91 (229.47-2014.86)
|
0.22 (0.06–0.5)
|
19.16 (13.3-27.25)
|
1624.25 (672.76-2915.25)
|
0.22 (0.09–0.38)
|
18.54 (12.86–26.54)
|
-0.05 (-0.12-0.02)
|
0.14 (0.07 − 0.02)
|
Southern Sub-Saharan Africa
|
41.67 (31.49–56.63)
|
0.06 (0.05–0.08)
|
17.37 (11.97–24.48)
|
57 (38.24–79.89)
|
0.07 (0.05–0.1)
|
18.64 (12.95–26.06)
|
0.48 (0.36–0.59)
|
0.92 (0.8 − 0.59)
|
North Africa and Middle East
|
2992.46 (1562.24-5542.2)
|
0.54 (0.29–1.01)
|
21.05 (14.71–31.27)
|
1665.45 (1009.37-2265.6)
|
0.28 (0.17–0.39)
|
19.12 (13.32–28.15)
|
-0.42 (-0.54–0.29)
|
-2.06 (-2.13–0.29)
|
Central Sub-Saharan Africa
|
247.43 (83.69-526.31)
|
0.21 (0.07–0.44)
|
19.24 (13.28–27.54)
|
324.08 (180.6-538.45)
|
0.16 (0.09–0.26)
|
19.36 (13.05–28.23)
|
-0.2 (-0.34–0.06)
|
-0.61 (-0.74–0.06)
|
Eastern Sub-Saharan Africa
|
3752.97 (1623.19-7044.87)
|
0.23 (0.1–0.42)
|
20.29 (13.91–29.64)
|
2676.32 (1779.33-3924.37)
|
0.16 (0.11–0.24)
|
21.77 (14.99–31.87)
|
0.33 (0.25–0.42)
|
-0.9 (-0.99-0.42)
|
Western Sub-Saharan Africa
|
262.32 (194.82-537.16)
|
0.17 (0.12–0.36)
|
23.64 (16.31–34.24)
|
110.91 (83.23-220.26)
|
0.08 (0.05–0.18)
|
23.09 (15.95–33.12)
|
-0.12 (-0.23–0.01)
|
-3.09 (-3.31–0.01)
|
In addition, we should pay attention to the apparent differences in gender level. In 2019, there were comparable incidence rates in female and male UCAs[14.48(95% UI 10.16–20.49) per 100 000, 14.84(95% UI 10.42–21.46) per 100 000], while the deaths rates due to MUCAs are much higher than those due to FUCAs [0.10(95% UI 0.06–0.15) per 100 000, 0.16(95% UI 0.10–0.23)per 100 000]. Similarly, there were 11.35 (95%UI 7.83–15.66) per 100 000 of DALYs rate worldwide attributable to FUCAs in 2019, compared with 16.92 (95%UI 11.22–23.85) per 100 000 attributable to MUCAs. Although the rates were adjusted based on age, this difference can still be found, even after three decades(Table 1–2, Supplementary Tables S1).
Variation In Uca Burden At Regional And National Levels Along With The Differences In Gender
Among the 21 GBD regions, high-income Asia Pacific, and Eastern Europe were the top 2 regions with the highest ASPR (age-standardized prevalence rate) of UCAs in 2019, from 162.11 to 150.99 per 100 000 population. However, Tropical Latin America and Andean Latin America were the top 2 regions with the lowest ASPRs, from 54.58 to 62.90 per 100 000 population. Alarmingly, Tropical Latin America not only showed the highest ASPR but also showed the lowest ASIR and second highest ASDR in 2019. It was shown that East Asia held the lowest ASDR in 2019 and presented the largest decrease in ASDR from 1990 to 2019(EAPC=-4.97;95%UI -5.24-0.41)(Table 2, Supplementary Table S2). The ASIR of UCAs varied more than 4 times across 204 countries and territories in 2019, ranging from Paraguay (6.3/100 000) to Iran (26.4/100 000). The UCA-related ASIR exceeded 20 per 100 000 in 20 countries, such as the Russian Federation, India, Singapore, Mexico, and Japan. Conversely, the ASIR in 2019 was less than 10 per 100 000 in the Democratic People's Republic of Korea, Greenland, Canada, and 4 other countries. The geographic distribution of ASDR for UCAs in 2019 was different from the distribution of ASIR. In additon, the countries with the largest populations, including India, China, Nigeria, Pakistan, the United States of America, and Mexico had the most incident cases, prevalent cases, deaths cases, and DALYs rates in 2019, and all four indicators for India were all in the first place(Fig. 1, Supplementary Table S3). From 1990 to 2019, China was estimated to have a large increase in the ASIR but with a large decrease in the ASDR (AAPC of ASIR = 0.55; AAPC of ASDR = -4.3). The AAPC of ASIRs exceeding 0 was found in nearly half of 204 countries and territories, such as El Salvador, Georgia, Ecuador, France, and Turkmenistan. Moreover, the AAPC of ASDR exceeding 0.1 was observed in 25 other countries and territories, such as Tajikistan, Ecuador, El Salvador, Georgia, and Turkmenistan (Fig. 1, supplementary table).
When we focus on the differences at the gender level, the distributions of ASPRs and ASDRs in different GBD regions were similar for female and male UCAs. For the highest ASIR of MUCAs in 2019, Central Sub-Saharan Africa, Australasia, and South Asia are the top 3 regions. However, regarding FUCAs, Eastern Europe, high-income Asia Pacific and Central Asia are the top3 regions, while East Asia still held the lowest ASDR both in FUCAs and MUCAs in 2019 (Supplementary Table S2). The geographic distribution of ASDR in 2019, the change in ASIR in 2019, and the change in death cases and incident cases from 1990 to 2019 for female UCAs were highly consistent with those for male UCA. For instance, the AAPC of ASDR below − 4 was observed in Denmark, United Arab Emirates, Israel, Portugal, Saudi Arabia, Montenegro, and China. Afghanistan and the Cook Islands held the highest and lowest ASIRs, respectively, for both female and male UCAs. Inaddition, the number of deaths in Denmark and the number of incident cases in Puerto Rico were both among the top 10 greatest decreases for both FUCAs and MUCAs. What is notable is that FUCAs and MUCAs have a large discrepancy in the ASIR and the change trends of ASIR when compared at the geographic distribution level. Only the ASIRs of Ecuador, Azerbaijan, and Turkmenistan decreased exceeding 0.5 for both female and male UCAs. Besides, the ASIR in 2019 in Taiwan (Province of China) decreased to 0.1 (95%UI -0.5-0.3 ) in FUCAs with an increase to 0.7(95%UI 0.2–1.1 ) in MUCAs; the ASIR in 2019 in the United States of America decreased 1.0 (95%UI -1.1–0.9) in FUCAs with an increase to 0.2(95%UI 0.2–0.3) in MUCAs. Strikingly, Taiwan (Province of China) ranked ninth among the highest ASIRs in 2019 for male UCAs and the top 3 in lowest ASIR in 2019 for female UCAs (Supplementary Fig. S2-3, supplementary table).
Variation in UCA burden by SDI region and age group along with the differences in Gender
In 2019, the ASRs of deaths and DALYs due to UCAs were both highest in low-SDI regions, followed by low-middle-SDI regions, and lowest in high-middle-SDI regions and high-SDI regions. Nevertheless, the ASRs of incidence and prevalence for UCAs were both highest in low-middle SDI regions and lowest in middle SDI regions and high SDI regions, respectively. The ASIR was lowest in high SDI regions (14.83; 95%UI 10.9-19.91), while ASIR decreased significantly only in high SDI regions from 1990 to 2019 (EAPC = -0.66, 95% CI -0.78–0.53), as it remained elevated in other SDI regions. Moreover, the ASR of DALYs and ASDR both decreased in all SDI regions (Table 2, Supplementary Tables S1). From 1990 to 2019, in all level SDI regions, the ASIRs and ASDRs for UCAs in men were higher than those in women. Identically,in 2019, the ASDRs and ASIRs for UCAs in men were nearly times higher than those in women. Notably, because the decreasing trend in ASIRs was pronounced among women with the increasing ASIRs among men in high and high-middle regions, the gap in ASIRs between FUCAs and MUCAs was greater (Table 1, Fig. 2). In addition, compared to the ASDRs for FUCAs in the high SDI region constantly holding the lowest, the ASDRs for MUCAs in the high SDI region significantly decreased from the highest in 1990 to nearly the lowest in 2019 over the past 30 years (Fig. 2). Regarding the ASPR, the high-middle SDI region was the highest in women and lowest in men (Supplementary Table S2).
When we focused on the change in UCA burden by different age groups in 1990 and 2019, a remarkable declining trend in ASRs of DALYs was observed (FigS7). From 1990 to 2019, globally, the DALYs rates due to UCAs showed an upward trend among the population aged 20 to 44 years old. In addition, this increase in DALY rates also occurred in men in the 70 to 80 age group. In the population aged older than 40 years old, the DALY rates for FUCAs were higher than those for MUCAs. However, compared to the YLD rates in 1990, the rates among people older than 25 showed an increasing change. When we focused on gender differences, this trend was strikingly found in men aged 70 to 80 and females older than 45 (Fig. 3, FigS. 7).
The Influential Factors For Asrs And Eapc
We analyzed the relationship between the initial burden of ASIR and ASDR in 1990 and EAPC values in 204 countries or territories. There was a slight negative association between the EAPC of ASIR and initial ASIR in 1990 at the national level (ρ =-0.42, p = 7.797e− 11), even in female and male cases(ρ =-0.33, p = 1.867e− 06;ρ =-0.32, p = 3.818e− 06). This negative correlation between the EAPC of ASDR and initial ASDR in 1990 at the national level can also be observed at the national level (ρ =-0.24, p < 0.001;female: ρ =-0.27, p = 7.821e− 05;male: ρ =-0.27, p = 9.815e− 05). Moreover, we found that the EAPCs in ASRs were negatively associated with the HDI (in 2016) (ρ = -0.20, p < 0.001; ρ = -0.518, p = 3.155e− 05) (Fig. 4). The ASR of UCA in 1990 reflects the disease reservoir at baseline and the HDI in 2016 can serve as a surrogate for the level and availability of health care in each country.Countries with higher HDIs underwent a more rapid increase in the ASR of UCAs from 1990 to 2016. However, this association was not found between EAPC in ASIR for female UCAs and HDI (Fig. 4).
The observed regional and national ASRs in relation to the SDI, versus the expected level for each location on the basis of the SDI, are shown in Fig. 5. A significant negative association was found between ASDRs or ASRs of DALYs and SDI, whether analyzed at the regional or the national level, and in female or male cases. From 1990 to 2019, the ASDR and ASR of DALYs in most GBD regions presented an obvious declining trend over time, but Central Asia remained relatively stable. What’s more, Andean Latin America and Oceania showed a remarkable increasing trend and then a decreasing trend. Similar changing trends of ASDR with SDI in 21 GBD regions were found in female and male cases.When we focus on the changing trends of ASDR with SDI in 204 countries or territories, even for FUCAs and MUCAs, the results seem to be the same(Fig. S5-6).
As shown in Fig. S7, the association detected between ASRs (in 2019) and SDI appears to be more complicated. The ASIR generally tends to decrease generally as the SDI rises, however, it tends to increase when the SDI rises to a point, especially in Europe, Central Latin America, the Caribbean, and East Asia. In contrast, for MUCAs at the national level, the association would be stronger(Fig. S5-6).