Highlights
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The incidence of eye injuries in children and adolescents decreased from 1990 to 2021.
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Regions with high Socio-Demographic Index exhibited the highest incidence of eye injuries.
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Boys had a higher incidence of eye injuries compared to girls.
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The incidence of eye injuries in children and adolescents increased with age.
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The primary causes of eye injuries in children and adolescents were foreign bodies, exposure to mechanical forces, and falls.
PURPOSE
Eye injuries are a leading cause of monocular vision impairment and disability in children and adolescents. Unlike adults, eye injuries in children exhibit significant age specificity, with worse visual outcomes due to immature vision, the risk of long-term damage, and amblyopia. However, research on the global distribution and trends of eye injury burdens in this population is limited.
DESIGN
Retrospective population-based trend study.
METHODS
This study analyzes the burden of eye injuries among children and adolescents aged 0 to 19 years globally, regionally, and nationally, using data from the 2021 Global Burden of Disease study. We evaluated the epidemiological characteristics of eye injuries by calculating incidence, years lived with disability (YLD), age-standardized incidence rates (ASIR), and age-standardized YLD rates (ASYR). Temporal trends in ASIR and ASYR from 1990 to 2021 were assessed using joinpoint regression analysis, expressed as average annual percentage changes. The analysis was further stratified by sex, age, and sociodemographic index (SDI) to explore trends in different subgroups.
RESULTS
In 2021, the global ASIR and ASYR for children and adolescents were 434.24 per 100,000 (95% confidence interval [CI], 305.17-603.22) and 3.19 per 100,000 (95% CI, 0.96-6.99), respectively, indicating a decline since 1990. Regions with high SDI showed the highest incidence of eye injuries. Australasia, Southern Latin America, and Western Europe had the highest ASIRs and ASYRs in both 1990 and 2021. From 1990 to 2021, Afghanistan, Yemen, Libya, the Central African Republic, and Chile experienced the most significant increases in pediatric eye injuries. Global data show that boys have an eye injury incidence rate approximately 1.8 times higher than that of girls. In 2021, the incidence of eye injuries among children and adolescents increased with age. The primary causes include foreign bodies, exposure to mechanical forces, and falls.
CONCLUSIONS
Despite observed declines in incidence and YLD, the burden of eye injuries in children and adolescents remains substantial. These findings underscore the urgent need for the development and implementation of targeted preventive education initiatives and ocular protection protocols on a global scale.
Introduction
E ye injury is the leading cause of monocular blindness and disability in children and adolescents, often resulting in permanent vision loss or lifelong impairment. It significantly affects quality of life and increases the demand for medical and vocational rehabilitation, imposing a substantial socio-economic burden. Unlike in adults, ocular trauma in children is distinctly age-specific. Due to visual immaturity, prolonged impairment, and the risk of amblyopia, children generally experience poorer visual outcomes than adults. Beyond diminished quality of life, they may face long-term educational, psychosocial, economic, and vocational challenges. From 2001 to 2014, approximately 940 thousand eye injury patients were hospitalized in the United States, including about 6 thousand infants, 52 thousand children, and 65 thousand adolescents, constituting 13.14% of all eye injury cases. With a hospitalization cost of $11 thousand per patient, this amounts to an annual expenditure of approximately $1.29 billion. Globally, an estimated 160 thousand to 280 thousand children under age 15 are hospitalized annually for severe eye injuries. Since 95% of eye injuries do not require hospitalization, the total number of injuries among children under 15 is estimated to be between 3.3 million and 5.7 million. Including serious eye injuries in individuals under 20, of which over 40% occur in those aged 15 to 19, the annual incidence likely exceeds 5 million.
Previous studies have analyzed data from the 2019 Global Burden of Disease (GBD) Study, encompassing 204 countries and territories, to examine spatial and temporal variations in the incidence and burden of eye injuries and their causes. In 2019, there were approximately 59,933 thousand cases of eye injuries globally, with an incidence rate of 773.45 per 100,000 people. Although the incidence trend has decreased, the number of individuals affected by eye injuries remained high in 2019, 1.25 times higher than in 1990. Notably, specific analyses for children and adolescents aged 0 to 19 years are lacking. The adverse effects of these injuries can be significantly mitigated or prevented through legislation, education, and personal eye protection, with prevention effectiveness estimated at up to 90%. , , Epidemiological studies contribute to the development of targeted interventions and prevention strategies for eye injuries in children and adolescents and provide a scientific basis for optimizing public health policies, thereby enhancing eye health globally.
Utilizing the GBD 2021 study, we examine the spatial and temporal trends in the prevalence of eye injuries among children and adolescents, the disease burden, and their leading causes, both globally and across 204 countries and territories from 1990 to 2021. This report aims to provide an overview of the global burden of eye injuries in children and adolescents, offering detailed prevalence trends and burden data for various regions. This information will assist public health decision-makers and policymakers in developing and implementing more effective prevention and intervention strategies, thus improving the eye health of children and adolescents worldwide and reducing the long-term social and economic impact of eye injuries.
METHODS
This retrospective population-based trend study conducted a secondary analysis of data from the GBD 2021 database. The GBD 2021 study provides updated global burden data on 371 diseases and injuries across 204 countries and territories from 1990 to 2021. The detailed study protocol and methodology have been described in previous research. The GBD 2021 update includes recent hospital and emergency records, adds granular age groups for children under five, and applies correction factors to avoid double-counting repeat visits for injuries. Additionally, a correction for limited access to healthcare facilities accounts for injuries not treated in hospitals. Repeated cross-sectional data on eye injuries in children and adolescents were obtained from the Global Health Data Exchange interactive data tool.
The GBD 2021 study adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting standards. Managed by the Institute for Health Metrics and Evaluation, the de-identified GBD data were provided to researchers in aggregated form. As the data were publicly available, the authors obtained a review waiver from the Ethics Committee of West China Hospital of Sichuan University. The study complied strictly with the ethical principles of the Declaration of Helsinki. Given its retrospective nature, informed consent was not required.
BURDEN DESCRIPTION
The methodology used by GBD 2021 to generate disease burden estimates aligns closely with GBD 2019. Disease Modeling-Meta Regression version 2.1 (DisMod-MR 2.1), a Bayesian meta-regression framework for epidemiological modeling, was employed to model the prevalence and incidence of eye injuries in children and adolescents. Data sources included hospital records, emergency room records, insurance claims, and population-representative surveys. The study encompassed data on eye injuries in individuals aged 0 to 19 years from 1990 to 2021. Results were categorized by age, sex, year, country or region (Supplemental Table S1), sociodemographic index (SDI), cause of trauma, and nature of injury, as defined in GBD 2021. Outcomes were presented in terms of incidence, years lived with disability (YLDs), age-standardized incidence rates (ASIR), age-standardized YLD rates (ASYR), and the average annual percentage change (AAPC) in incidence and YLD rates, all with 95% confidence intervals (CI).
Age subgroups were defined as preschoolers (0-4 years), older children (5-9 years), young adolescents (10-14 years), and older adolescents (15-19 years). The SDI, a composite indicator of socioeconomic development, categorizes countries into low, medium-low, medium, medium-high, and high SDI regions (Supplemental Table S2). The GBD 2021 study’s estimation process for nonfatal health outcomes from injuries included 29 causes, such as transport injuries, falls, drowning, self-harm, interpersonal violence, and animal contact (excluding sexual violence, detailed elsewhere). Injury incidence was defined using ICD-9 codes E000-E999 and ICD-10 chapters V to Y, while morbidity was estimated with ICD-10 chapters S and T and ICD-9 codes 800-999. Each injury cause can lead to various physical injury sequelae, referred to as the “nature of injury.” Initial models were based on the “cause of injury” level (e.g., drowning), but each cause was further divided into cause-nature pairs to capture the resulting disability. Incidence, prevalence, and YLDs due to injuries were reported at the cause-nature pair level. Eye injuries in children and adolescents were analyzed across 14 of these classifications.
STATISTICAL ANALYSIS
Joinpoint regression analysis is a common statistical method in epidemiology and public health research for analyzing temporal trends. We used the Joinpoint regression model (version 4.9.1.018, Surveillance Research Program, National Cancer Institute, USA) to examine changes in ASIR and ASYR over time in the GBD 2021 study. By calculating the AAPC and its 95% CI, we assessed trends in ASIR and ASYR stratified by age, sex, geographic location, and SDI from 1990 to 2021. An AAPC with a CI greater than 0 indicated an increasing trend; less than 0 indicated a decreasing trend; and close to 0 suggested stability. The larger the absolute value of the AAPC, the faster the rate of change. All statistical analyses and data visualizations were performed using R software (version 4.0.5, R Foundation, Vienna, Austria, https://www.r-project.org/ ). Two-tailed P values less than .05 were considered statistically significant.
RESULTS
GLOBAL LEVEL
Globally, the reported incidence of eye injuries in children and adolescents decreased from 12,522,046 cases in 1990 (95% CI, 8,898,127-17,358,806) to 11,547,996 cases in 2021 (95% CI, 8,096,231-16,072,199) ( Table 1 ). The global ASIR declined from 553.68 per 100,000 in 1990 (95% CI, 393.36-767.33) to 434.24 per 100,000 in 2021 (95% CI, 305.17-603.22), with an AAPC of −0.74 (95% CI, −0.86 to −0.62).
| Location | Incidence | YLDs | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Number (95% CI) | ASIR, per 100,000 (95% CI) | AAPC of ASIR (95% CI) | Number (95% CI) | ASYR, per 100,000 (95% CI) | AAPC of ASYR (95% CI) | |||||
| 1990 | 2021 | 1990 | 2021 | 1990 | 2021 | 1990 | 2021 | |||
| Global | 12522046.31 (8898127.34, 17358805.92) | 11547995.69 (8096231.27, 16072198.74) | 553.68 (393.36, 767.33) | 434.24 (305.17, 603.22) | -0.74 (-0.86, -0.62) | 91900.40 (27647.48, 201532.23) | 84789.61 (25429.97, 186141.85) | 4.06 (1.22, 8.91) | 3.19 (0.96, 6.99) | -0.74 (-0.86, -0.62) |
| Sex | ||||||||||
| Female | 4214396.48 (2961792.71, 5893112.03) | 3952599.31 (2715178.76, 5630466.99) | 382.53 (268.91, 534.67) | 308.17 (212.39, 437.66) | -0.72 (-0.84, -0.59) | 30954.25 (9207.81, 68770.32) | 29048.73 (8561.22, 64788.64) | 2.81 (0.84, 6.24) | 2.26 (0.67, 5.04) | -0.71 (-0.83, -0.59) |
| Male | 8307649.83 (5932551.70, 11462520.76) | 7595396.38 (5340251.49, 10540238.00) | 717.40 (512.15, 989.83) | 553.00 (389.70, 766.08) | -0.78 (-0.90, -0.66) | 60946.15 (18479.90, 132425.12) | 55740.88 (16715.09, 121603.42) | 5.26 (1.60, 11.44) | 4.06 (1.22, 8.84) | -0.78 (-0.90, -0.66) |
| Age Group | ||||||||||
| <5 years | 2837927.04 (2202128.73, 3619312.53) | 2271052.63 (1737118.71, 2935946.58) | 457.78 (355.22, 583.82) | 345.05 (263.93, 446.08) | -0.92 (-1.05, -0.78) | 20811.72 (6610.62, 42565.99) | 16663.16 (5274.16, 34763.31) | 3.36 (1.07, 6.87) | 2.53 (0.80, 5.28) | -0.92 (-1.05, -0.78) |
| 5 to 9 years | 2878289.51 (2038761.07, 4065661.19) | 2683098.85 (1873254.30, 3775735.87) | 493.25 (349.38, 696.73) | 390.52 (272.65, 549.55) | -0.78 (-0.95, -0.62) | 21157.88 (6315.83, 46675.27) | 19731.54 (5835.13, 42629.72) | 3.63 (1.08, 8.00) | 2.87 (0.85, 6.20) | -0.78 (-0.94, -0.62) |
| 10 to 14 years | 3067251.54 (2095423.44, 4193857.13) | 3061775.39 (2088883.80, 4208175.79) | 572.59 (391.17, 782.90) | 459.29 (313.35, 631.26) | -0.69 (-0.84, -0.53) | 22500.77 (6600.26, 50787.28) | 22466.60 (6575.58, 50962.50) | 4.20 (1.23, 9.48) | 3.37 (0.99, 7.64) | -0.70 (-0.77, -0.62) |
| 15 to 19 years | 3738578.22 (2561814.10, 5479975.08) | 3532068.82 (2396974.46, 5152340.50) | 719.76 (493.20, 1055.01) | 566.05 (384.14, 825.72) | -0.71 (-0.87, -0.55) | 27430.04 (8120.77, 61503.68) | 25928.31 (7745.10, 57786.32) | 5.28 (1.56, 11.84) | 4.16 (1.24, 9.26) | -0.71 (-0.87, -0.55) |
| SDI Region | ||||||||||
| High SDI | 2408452.19 (1730868.03, 3235320.18) | 1942465.16 (1345539.31, 2692854.11) | 946.66 (681.89, 1267.20) | 823.34 (573.05, 1136.02) | -0.44 (-0.55, -0.33) | 17695.53 (5241.65, 37750.69) | 14271.85 (4206.46, 31201.60) | 6.96 (2.06, 14.84) | 6.05 (1.79, 13.20) | -0.44 (-0.55, -0.32) |
| High-middle SDI | 2636330.76 (1847440.72, 3695226.61) | 1686241.17 (1176400.60, 2350031.73) | 700.26 (492.52, 978.12) | 547.92 (383.66, 761.25) | -0.78 (-0.91, -0.64) | 19348.40 (5711.58, 41946.79) | 12384.72 (3673.03, 27357.57) | 5.14 (1.52, 11.12) | 4.02 (1.20, 8.87) | -0.78 (-0.90, -0.65) |
| Middle SDI | 3548474.42 (2397740.80, 5176844.15) | 2810594.50 (1864712.84, 4159962.51) | 460.09 (311.89, 669.25) | 368.57 (245.66, 543.67) | -0.81 (-1.08, -0.54) | 26031.70 (7710.75, 57804.38) | 20635.58 (6065.82, 46806.98) | 3.318 (1.00, 7.49) | 2.71 (0.80, 6.12) | -0.79 (-1.09, -0.49) |
| Low-middle SDI | 2600760.87 (1834422.17, 3562909.43) | 2756464.98 (1904317.10, 3872390.06) | 444.81 (312.66, 611.38) | 356.84 (247.11, 499.85) | -0.77 (-0.98, -0.56) | 19085.72 (5809.31, 41706.20) | 20240.76 (6001.96, 44284.49) | 3.26 (0.99, 7.15) | 2.62 (0.78, 5.72) | -0.77 (-0.96, -0.57) |
| Low SDI | 1314755.46 (960991.36, 1752779.39) | 2342171.71 (1671258.73, 3177584.75) | 477.68 (346.42, 641.13) | 402.95 (287.01, 547.77) | -0.56 (-1.14, 0.02) | 9641.53 (2975.09, 20522.90) | 17182.80 (5293.14, 36675.45) | 3.50 (1.08, 7.48) | 2.96 (0.91, 6.32) | -0.56 (-1.13, 0.01) |
| Region | ||||||||||
| Andean Latin America | 122718.85 (91059.82, 163847.95) | 121323.22 (86116.40, 165328.38) | 648.14 (480.55, 866.00) | 511.05 (362.96, 695.78) | -0.85 (-0.97, -0.72) | 900.33 (276.35, 1877.80) | 891.17 (267.89, 1917.08) | 4.76 (1.46, 9.92) | 3.75 (1.13, 8.07) | -0.84 (-0.97, -0.72) |
| Australasia | 106002.74 (74189.68, 151069.15) | 112655.87 (78448.08, 158849.46) | 1687.81 (1179.35, 2405.45) | 1493.91 (1041.33, 2104.14) | -0.40 (-0.42, -0.37) | 778.53 (215.72, 1606.44) | 827.22 (228.99, 1715.60) | 12.39 (3.44, 25.55) | 10.97 (3.04, 22.72) | -0.40 (-0.42, -0.37) |
| Caribbean | 87645.47 (63413.92, 117590.48) | 91534.47 (66743.33, 122455.07) | 579.39 (419.06, 777.17) | 596.26 (435.11, 796.75) | 0.10 (-0.11, 0.32) | 643.98 (191.94, 1359.04) | 672.40 (201.32, 1412.90) | 4.26 (1.27, 8.99) | 4.38 (1.31, 9.20) | 0.12 (-0.12, 0.35) |
| Central Asia | 213615.31 (158140.91, 285680.54) | 194853.57 (141706.10, 262764.83) | 685.24 (506.27, 918.56) | 571.36 (415.34, 771.35) | -0.53 (-1.05, -0.01) | 1569.90 (457.84, 3249.55) | 1431.59 (417.47, 3006.35) | 5.04 (1.47, 10.44) | 4.20 (1.22, 8.81) | -0.53 (-1.05, -0.01) |
| Central Europe | 435044.19 (298609.57, 626484.48) | 206083.56 (138965.74, 301428.29) | 1095.15 (752.83, 1574.48) | 863.89 (583.15, 1261.63) | -0.82 (-1.00, -0.64) | 3196.73 (890.46, 6707.00) | 1515.08 (415.28, 3253.99) | 8.05 (2.25, 16.87) | 6.35 (1.74, 13.63) | -0.82 (-0.99, -0.64) |
| Central Latin America | 592769.01 (426882.65, 818936.96) | 466807.36 (325012.03, 654803.12) | 718.24 (517.00, 992.66) | 545.90 (380.18, 764.47) | -0.97 (-1.36, -0.59) | 4355.25 (1274.41, 9142.80) | 3430.97 (985.17, 7402.46) | 5.28 (1.54, 11.08) | 4.01 (1.15, 8.63) | -0.97 (-1.37, -0.58) |
| Central Sub-Saharan Africa | 131778.36 (95568.22, 177086.60) | 258000.90 (183400.49, 353470.20) | 425.33 (305.81, 576.10) | 352.81 (250.23, 485.14) | -0.44 (-2.30, 1.46) | 965.79 (302.57, 2044.47) | 1892.67 (572.12, 4098.59) | 3.12 (0.97, 6.64) | 2.59 (0.78, 5.62) | -0.42 (-2.36, 1.56) |
| East Asia | 1854002.02 (1048261.42, 3241264.20) | 1234625.59 (653990.43, 2278544.75) | 389.29 (224.32, 674.46) | 353.76 (188.33, 652.37) | -0.51 (-1.29, 0.28) | 13591.58 (3696.61, 32349.70) | 9053.62 (2424.52, 22365.12) | 2.85 (0.78, 6.77) | 2.59 (0.70, 6.39) | -0.24 (-0.77, 0.30) |
| Eastern Europe | 620664.72 (444848.55, 864456.10) | 280198.45 (202008.84, 380721.41) | 915.37 (656.48, 1274.33) | 594.67 (429.78, 805.86) | -1.42 (-1.55, -1.29) | 4560.91 (1288.97, 9345.58) | 2060.04 (583.95, 4300.64) | 6.73 (1.90, 13.78) | 4.37 (1.24, 9.11) | -1.42 (-1.55, -1.28) |
| Eastern Sub-Saharan Africa | 620056.63 (444108.26, 876742.58) | 894477.24 (631968.49, 1222700.72) | 571.56 (406.29, 814.75) | 394.21 (278.21, 539.60) | -1.23 (-2.07, -0.39) | 4542.73 (1386.54, 9644.58) | 6561.88 (1993.13, 14084.00) | 4.19 (1.28, 8.94) | 2.89 (0.88, 6.21) | -1.28 (-2.43, -0.11) |
| High-income Asia Pacific | 487415.22 (355279.28, 647317.02) | 256870.13 (183614.91, 344525.77) | 950.43 (696.36, 1251.82) | 822.23 (590.85, 1095.81) | -0.47 (-0.57, -0.37) | 3581.64 (1046.18, 7573.57) | 1887.87 (545.67, 4011.70) | 6.98 (2.05, 14.74) | 6.04 (1.76, 12.80) | -0.47 (-0.57, -0.37) |
| High-income North America | 741025.05 (515891.21, 1023991.33) | 657858.36 (426615.69, 969842.47) | 899.27 (626.15, 1241.81) | 717.16 (466.87, 1053.45) | -0.61 (-0.94, -0.28) | 5442.76 (1600.97, 11679.75) | 4830.43 (1400.96, 10665.68) | 6.61 (1.94, 14.18) | 5.27 (1.53, 11.58) | -0.62 (-0.98, -0.24) |
| North Africa and Middle East | 845989.52 (632304.15, 1105079.22) | 1032171.55 (752636.45, 1381392.23) | 483.19 (360.60, 632.19) | 434.73 (317.24, 581.40) | -0.39 (-0.72, -0.07) | 6210.73 (1888.32, 13247.76) | 7576.43 (2311.79, 16309.81) | 3.55 (1.08, 7.57) | 3.19 (0.97, 6.87) | -0.39 (-0.70, -0.09) |
| Oceania | 6493.96 (4625.60, 8887.50) | 12116.48 (8716.32, 16528.72) | 195.72 (139.02, 268.67) | 193.17 (138.61, 264.37) | -0.27 (-0.45, -0.08) | 47.75 (14.00, 104.82) | 89.12 (26.39, 195.49) | 1.44 (0.42, 3.16) | 1.42 (0.42, 3.12) | -0.31 (-0.55, -0.07) |
| South Asia | 2129817.42 (1490416.51, 2959585.62) | 2358543.06 (1546433.44, 3440102.00) | 397.33 (277.07, 554.72) | 336.91 (222.36, 488.13) | -0.60 (-0.81, -0.39) | 15643.33 (4717.82, 34266.73) | 17325.20 (5030.89, 38626.07) | 2.92 (0.88, 6.41) | 2.48 (0.72, 5.50) | -0.60 (-0.79, -0.41) |
| Southeast Asia | 625440.34 (463917.33, 832219.28) | 515598.05 (375454.28, 692316.64) | 284.29 (210.95, 378.12) | 221.64 (161.67, 297.04) | -0.86 (-1.57, -0.15) | 4593.54 (1370.64, 9743.52) | 3789.60 (1113.86, 8177.25) | 2.09 (0.62, 4.43) | 1.63 (0.48, 3.51) | -0.86 (-1.56, -0.15) |
| Southern Latin America | 259993.98 (189668.81, 353243.75) | 251124.42 (183928.54, 337796.77) | 1340.70 (978.30, 1821.14) | 1279.61 (938.96, 1718.27) | -0.22 (-0.39, -0.06) | 1909.06 (549.92, 3970.18) | 1844.34 (529.80, 3810.61) | 9.84 (2.84, 20.47) | 9.40 (2.71, 19.40) | -0.22 (-0.39, -0.05) |
| Southern Sub-Saharan Africa | 116726.44 (83433.09, 158468.89) | 116686.05 (80148.65, 162840.17) | 442.14 (315.66, 601.15) | 371.47 (255.62, 517.42) | -0.55 (-0.62, -0.48) | 856.41 (256.12, 1826.00) | 856.33 (252.96, 1853.30) | 3.24 (0.97, 6.92) | 2.73 (0.81, 5.89) | -0.55 (-0.62, -0.48) |
| Tropical Latin America | 740467.23 (399973.96, 1390647.34) | 388396.55 (238915.92, 655525.06) | 1058.27 (572.34, 1993.12) | 575.87 (354.03, 974.13) | -1.91 (-2.80, -1.01) | 5414.71 (1417.68, 13453.62) | 2848.16 (812.83, 6680.01) | 7.74 (2.03, 19.23) | 4.22 (1.21, 9.91) | -1.91 (-2.68, -1.13) |
| Western Europe | 1311335.94 (889780.44, 1885838.88) | 1044784.12 (722940.77, 1465688.58) | 1305.10 (892.54, 1863.57) | 1128.74 (785.43, 1574.82) | -0.48 (-0.51, -0.45) | 9625.18 (2886.75, 21370.37) | 7677.20 (2322.60, 16784.37) | 9.58 (2.88, 21.21) | 8.29 (2.51, 18.08) | -0.48 (-0.51, -0.44) |
| Western Sub-Saharan Africa | 473043.91 (341136.57, 637119.21) | 1053286.70 (745888.20, 1427369.87) | 439.45 (314.17, 597.90) | 394.21 (278.04, 537.07) | -0.32 (-0.39, -0.25) | 3469.57 (1055.96, 7409.12) | 7728.29 (2334.35, 16699.77) | 3.22 (0.98, 6.93) | 2.89 (0.87, 6.27) | -0.32 (-0.39, -0.25) |
In 2021, YLDs due to eye injuries among children and adolescents were estimated at 84,790 (95% CI, 25,430-186,142), a decrease from 1990. The global ASYR fell from 4.06 per 100,000 in 1990 (95% CI, 1.22-8.91) to 3.19 per 100,000 in 2021 (95% CI, 0.96-6.99), with an AAPC of −0.74 (95% CI, −0.86 to −0.62) ( Table 1 ).
REGIONAL LEVEL
In 2021, the High SDI regions had the highest ASIR at 823.34 cases per 100,000 people (95% CI, 573.05-1136.02), while the Low-middle SDI regions had the lowest at 356.84 cases per 100,000 people (95% CI, 247.11-499.85) ( Table 1 ). By region, Australasia had the highest ASIR at 1493.91 cases per 100,000 people (95% CI, 1041.33-2104.14), followed by Southern Latin America (1279.61 per 100,000; 95% CI, 938.96-1718.27) and Western Europe (1128.74 per 100,000; 95% CI, 785.43-1574.82). Oceania had the lowest ASIR at 193.17 per 100,000 people (95% CI, 138.61-264.37) ( Table 1 ). These regions also had the highest and lowest ASIR in 1990, though all have seen declines since then.
From 1990 to 2021, changes in ASIR varied across regions, but overall, there was a downward trend. The ASIR in High SDI regions decreased the slowest, with an AAPC of −0.44 (95% CI, −0.55 to −0.33), while the Middle SDI regions saw the fastest decline, with an AAPC of −0.81 (95% CI, −1.08 to −0.54) ( Table 1 ). The Caribbean was the only region to show an upward trend, with an AAPC of 0.10 (95% CI, −0.11 to 0.32), while all other regions showed a downward trend. The most significant declines were observed in Tropical Latin America (AAPC, −1.91; 95% CI, −2.80 to −1.01), Eastern Europe (AAPC, −1.42; 95% CI, −1.55 to −1.29), and Eastern Sub-Saharan Africa (AAPC, −1.23; 95% CI, −2.07 to −0.39) ( Table 1 ).
In 2021, High SDI regions had the highest ASYR at 6.05 per 100,000 (95% CI, 1.79-13.20). The Australasia region had the highest ASYR at 10.97 per 100,000 (95% CI, 3.04-22.72), followed by Southern Latin America (9.40 per 100,000; 95% CI, 2.71-19.40) and Western Europe (8.29 per 100,000; 95% CI, 2.51-18.08) ( Table 1 ). Oceania had the lowest ASYR at 1.42 per 100,000 (95% CI, 0.42-3.12). From 1990 to 2021, the global ASYR declined. Tropical Latin America saw the largest decline (AAPC, −1.91; 95% CI, −2.68 to −1.13), followed by Eastern Europe (AAPC, −1.42; 95% CI, −1.55 to −1.28) and Eastern Sub-Saharan Africa (AAPC, −1.28; 95% CI, −2.43 to −0.11). The Caribbean was the only region where the ASYR increased from 1990 to 2021 (AAPC, 0.12; 95% CI, −0.12 to 0.35).
NATIONAL LEVEL
In 2021, the countries with the highest ASIR globally were New Zealand (1768.97/100,000, 95% CI: 1271.03-2406.66), Italy (1744.58/100,000, 95% CI: 1178.10-2477.70), Finland (1637.66/100,000, 95% CI: 1102.44-2342.04), Australia (1436.61/100,000, 95% CI: 991.58-2047.45), Argentina (1323.70/100,000, 95% CI: 960.96-1785.23), and Belgium (1313.27/100,000, 95% CI: 885.07-1861.10) (Supplemental Table S3 and Figure 1 , A). The ASIR has decreased compared to 1990 (Supplemental Table S3). In 2021, the countries with the lowest ASIR were Kiribati (155.69/100,000, 95% CI: 105.07-223.69), Tonga (167.69/100,000, 95% CI: 115.18-240.34), Vanuatu (170.26/100,000, 95% CI: 117.28-242.54), Tuvalu (170.75/100,000, 95% CI: 118.05-242.60), Marshall Islands (173.82/100,000, 95% CI: 120.66-246.08), and Samoa (174.77/100,000, 95% CI: 120.37-248.54) (Supplemental Table S3 and Figure 1 , A).
