Global, Regional, and National Epidemiology of Thalassemia in Childhood from 1990 to 2021 ()
1. Introduction
Thalassemia is a group of inherited blood disorders that primarily affect the production of hemoglobin [1] [2], leading to chronic anemia and other serious health issues. This condition not only causes patients to feel fatigued and weak but can also trigger a range of other severe health problems, such as heart disease, liver complications, and skeletal deformities [3]-[6]. Although the global burden of thalassemia has been somewhat alleviated, it remains a significant public health challenge in many regions. Pediatric thalassemia not only impacts the quality of life of patients but also imposes a heavy economic burden on families and society.
Early research focused mainly on the genetic basis and clinical manifestations of thalassemia. Studies found that thalassemia is caused by mutations in the hemoglobin genes, leading to insufficient or structurally abnormal hemoglobin production. With the advancement of molecular biology techniques, scientists have gained deeper insights into the mechanisms of these genetic mutations, thereby promoting progress in the diagnosis and treatment of thalassemia.
Additionally, significant advancements have been made in the research on treatments for thalassemia. Traditional treatment methods primarily include regular blood transfusions and iron chelation therapy to alleviate anemia and prevent complications caused by iron overload. In recent years, emerging technologies such as gene therapy and stem cell transplantation have offered hope for a cure for thalassemia. However, the high costs and complexity of these new technologies present challenges to their widespread adoption and application.
The Global Burden of Disease (GBD) study provides a comprehensive database for assessing the disease burden across different regions and countries [7]. By analyzing data from the GBD database, we can better understand the epidemiological characteristics of thalassemia at global, regional, and national levels. This is crucial for formulating effective public health policies and resource allocation strategies.
This study aims to analyze the trends in prevalence, mortality, and disability-adjusted life years (DALYs) of pediatric thalassemia from 1990 to 2021. By conducting a stratified analysis of data across different regions, countries, ages, genders, and SDI areas, we hope to uncover the epidemiological dynamics of thalassemia and provide scientific evidence for future prevention and control measures.
2. Methods
2.1 Overview and Data Collection
Using the Global Health Data Exchange query tool created by GBD collaborators, we collected available data, standardized disease definitions, and prevalence information for children aged 0 to 14 years with thalassemia. The 2021 GBD study assessed the incidence, mortality, and DALYs of 371 diseases and injuries across 204 countries and regions from 1990 to 2021, with corresponding rates and uncertainty intervals, an increase from 369 in the 2019 edition. To summarize the age distribution of the burden of pediatric thalassemia, we categorized patients into three groups: under 5 years, 5 to 9 years, and 10 to 14 years. In this study, we collected data on the number of thalassemia cases and prevalence, thalassemia-related mortality, and the number of disability-adjusted life years related to pediatric thalassemia, along with their corresponding rates at global, regional, and national levels. Data on the race and ethnicity of participants were not listed in the GBD database, which does not allocate data collection by race and ethnicity.
2.2. Sociodemographic Index
The Socio-demographic Index (SDI) is a measure of the development level of a country or region, based on data such as fertility rates, education levels, and per capita income [8]. The SDI ranges from 0 to 1, with higher levels indicating greater socio-economic development. It has been reported that SDI is associated with disease prevalence and mortality. This study categorizes countries and geographic regions into five SDI areas (low, lower-middle, middle, upper-middle, and high) to explore the relationship between the burden of pediatric thalassemia and socio-economic development.
2.3. Statistical Analysis
Incidence, mortality, DALYs, and their corresponding rates are the main indicators describing the burden of pediatric diabetes. These rates are reported per 100,000 people [9]. All calculations were performed using R4.4.1. By calculating the Estimated Annual Percentage Change (EAPCs), the dynamics of pediatric diabetes were analyzed to determine the time trends of the disease burden. This is of great significance for the formulation of public health policies and resource allocation.
3. Results
3.1. Global Trends in Childhood Thalassemia
Prevalence: In 2021, there were 869327.39 (708407.06 to 1065116.80) cases of thalassemia in children worldwide. Between 1990 and 2021, the global number of cases decreased by 6.41% (−5.37% to 7.22%). The corresponding prevalence decreased from 53.41 (44.59 to 64.11) in 1990 to 43.21 (35.21 to 52.94) in 2021. The prevalence of all children decreased with age (Figure 1).
Deaths: In 2021, the global number of thalassemia-related deaths in children was 5897.44 (3884.59, 7892.94), compared to 12017.59 (8270.41, 16293.83) in 1990, a decrease of 50.92% (−76.15%, −4.56%). The highest number of deaths in 1990 and 2021 were among children under 5 years of age, 9226.19 (5721.01 to 13107.82) and 4236.48 (2868.08 to 5928.82) respectively (Figure 1).
Disability-Adjusted Life Years (DALYs): Between 1990 and 2021, the number of thalassaemia-related disability-adjusted life years (DALYs) in children declined globally by about 50.08% (−74.60%, −4.29%). For both boys and girls, the older the age, the lower the incidence of DALYS (Figure 1).
(a)
(b)
(c)
Figure 1. Trends in prevalence, mortality, and disability-adjusted life rate (DALYs) among children by age and sex.
3.2. Trends in SDI Regions for Pediatric Thalassemia
Prevalence: In 2021, the region with moderate SDI will have the highest number of cases of thalassemia in children, 388827.55 (314835.60 to 477709.51). The prevalence of High-middle SDI increased the most, to 463.67% (370.94 to 556.40). The prevalence of Middle SDI decreased the most, to −24.92% (−31.25 to 18.59). The largest decline was in the medium SDI region, with an EAPC of −0.86 (−1.17 to −0.56) (Table 1).
Table 1. Prevalence of thalassemia in children at global and regional levels, 1990-2021.
|
1990 |
2021 |
1990-2021 |
location_name |
Prevalence number |
Prevalence rate |
Prevalence number |
Prevalence rate |
number change |
EAPC |
Global |
928874.73 (775519.52 to 1115004.79) |
53.41 (44.59 to 64.11) |
869327.39 (708407.06 to 1065116.80) |
43.21 (35.21 to 52.94) |
−6.41%
(−8.17 to −4.65) |
−0.68%
(−0.92 to −0.44) |
High-middle SDI |
20140.52 (108818.94 to 167381.63) |
49.20
(39.77 to 61.17) |
113563.87 (91269.60 to 139980.37) |
49.19 (39.53 to 60.63) |
463.67% (370.94 to 556.40) |
0.00%
(0.00 to 0.00) |
High SDI |
20140.52 (16361.35 to 24144.83) |
10.84
(8.81 to 12.99) |
17695.77
(14588.18 to 21300.00) |
10.25
(8.46 to 12.35) |
−12.12%
(−15.42 to −8.82) |
−0.18%
(−0.24 to −0.12) |
Low-middle SDI |
201655.35 (171767.32 to 239310.81) |
42.71
(36.38 to 50.69) |
234702.62
(186206.80 to 300237.05) |
40.48
(32.11 to 51.78) |
16.38%
(13.29 to 19.47) |
−0.17%
(−0.23 to −0.11) |
Low SDI |
53858.82 (43132.75 to 68150.26) |
23.53 (18.84 to 29.77) |
113951.82
(90646.69 to 146121.46) |
24.76
(19.70 to 31.75) |
111.52%
(90.91 to 132.13) |
0.16%
(0.11 to 0.22) |
Middle SDI |
518055.36 (424965.42 to 625614.89) |
89.75
(73.62 to 108.39) |
388827.55
(314835.60 to 477709.52) |
68.60
(55.54 to 84.27) |
−24.92%
(−31.25 to −18.59) |
−0.86%
(−1.17 to −0.56) |
Southeast Asia |
190359.50 (166548.21 to 220681.45) |
111.49 (97.54 to 129.24) |
177089.80
(143399.16 to 219882.52) |
102.57
(83.06 to 127.35) |
−6.97%
(−8.88 to −5.06) |
−0.27%
(−0.36 to −0.17) |
East Asia |
456514.89 (353394.66 to 579115.05) |
138.41 (107.14 to 175.58) |
331293.01
(255461.11 to 423058.03) |
123.92
(95.55 to 158.24) |
−27.45%
(−34.97 to −19.93) |
−0.36%
(−0.48 to −0.23) |
Oceania |
1276.58 (995.82 to 1603.62) |
47.64 (37.16 to 59.84) |
2585.18
(2008.21 to 3218.58) |
50.88 (39.52 to 63.35) |
102.48%
(83.98 to 120.98) |
0.21%
(0.14 to 0.29) |
Central Europe |
4341.71 (3356.07 to 5457.51) |
14.73 (11.38 to 18.51) |
2638.82
(2018.72 to 3359.18) |
14.91
(11.40 to 18.98) |
−39.23%
(−49.98 to −28.48) |
0.04%
(0.03 to 0.05) |
Eastern Europe |
9102.90 (6850.61 to 11908.01) |
17.69 (13.31 to 23.14) |
6424.33
(4858.40 to 8339.46) |
18.13
(13.71 to 23.53) |
−29.42%
(−37.47 to −21.37) |
0.08% (0.05 to 0.11) |
Western Europe |
8064.41 (6602.65 to 9523.50) |
11.36 (9.30 to 13.41) |
7195.03
(5936.52 to 8560.55) |
10.56
(8.72 to 12.57) |
−10.79%
(−13.73 to −7.85) |
−0.23%
(−0.32 to −0.15) |
Central Asia |
5102.88 (4078.67 to 6311.21) |
20.42 (16.32 to 25.25) |
5674.85
(4513.41 to 7167.42) |
20.50
(16.31 to 25.90) |
11.21%
(9.19 to 13.23) |
0.01%
(0.01 to 0.02) |
Australasia |
609.77 (462.22 to 785.51) |
13.30 (10.08 to 17.13) |
778.93
(583.91 to 1004.17) |
13.59
(10.19 to 17.52) |
27.74%
(22.74 to 32.74) |
0.07%
(0.05 to 0.10) |
Caribbean |
2017.54 (1505.33 to 2599.75) |
17.68 (13.19 to 22.78) |
2390.71
(1793.70 to 3127.87) |
20.78
(15.59 to 27.19) |
18.51%
(15.17 to 21.85) |
0.52%
(0.34 to 0.71) |
Andean Latin
America |
2575.94 (1929.34 to 3429.03) |
17.34 (12.99 to 23.09) |
3518.80
(2600.92 to 4743.69) |
19.45
(14.37 to 26.22) |
36.61%
(30.00 to 43.22) |
0.37% (0.24 to 0.50) |
High-income North America |
2687.33 (2058.67 to 3464.33) |
4.36 (3.34 to 5.62) |
2014.03
(1692.45 to 2372.32) |
3.07
(2.58 to 3.62) |
−25.06%
(−31.31 to −18.81) |
−1.12%
(−1.52 to −0.73) |
High-income Asia Pacific |
2814.38 (2255.24 to 3478.74) |
8.00 (6.41 to 9.88) |
1709.23
(1354.79 to 2131.59) |
7.62
(6.04 to 9.51) |
−39.27% (−49.99 to −28.55) |
−0.15%
(−0.21 to −0.10) |
North Africa and Middle East |
48583.99 (39771.09 to 58789.84) |
34.58 (28.31 to 41.85) |
60086.87
(47730.51 to 74729.12) |
32.78
(26.04 to 40.76) |
23.68%
(19.39 to 27.97) |
−0.17%
(−0.23 to −0.11) |
Southern Latin America |
724.67 (569.13 to 923.52) |
4.85 (3.81 to 6.19) |
684.42 (526.32 to 863.13) |
4.72
(3.63 to 5.95) |
−5.56% (−7.08 to −4.04) |
−0.09%
(−0.12 to −0.06) |
Tropical Latin America |
8868.05 (6592.75 to 11553.21) |
16.54 (12.30 to 21.55) |
9774.18
(7289.84 to 12845.02) |
19.47
(14.52 to 25.59) |
10.20%
(8.36 to 12.04) |
0.53%
(0.34 to 0.71) |
Central Sub-Saharan Africa |
5335.19 (3951.53 to 7209.70) |
21.09 (15.62 to 28.50) |
12565.46
(9195.91 to 16950.67) |
21.41
(15.67 to 28.89) |
135.51%
(111.89 to 159.13) |
0.05%
(0.03 to 0.07) |
Central Latin
America |
11744.93 (8735.45 to 15487.14) |
18.24 (13.57 to 24.06) |
13009.81
(9664.34 to 17083.80) |
20.49
(15.22 to 26.91) |
10.78%
(8.83 to 12.73) |
0.38%
(0.24 to 0.51) |
South Asia |
119088.20 (101957.24 to 138808.71) |
27.48 (23.53 to 32.03) |
124230.98
(98494.68 to 158105.50) |
24.50
(19.43 to 31.18) |
4.32%
(3.54 to 5.10) |
−0.37%
(−0.50 to −0.24) |
Western
Sub-Saharan Africa |
21182.72 (16490.45 to 27184.96) |
24.10 (18.76 to 30.93) |
53050.43
(41321.14 to 68603.71) |
24.70
(19.24 to 31.94) |
150.45% (124.12 to 176.78) |
0.08%
(0.05 to 0.11) |
Southern Sub-Saharan Africa |
5162.17 (3963.81 to 6797.87) |
24.95 (19.16 to 32.86) |
6322.60
(4883.98 to 8309.34) |
26.27
(20.29 to 34.53) |
22.47%
(18.54 to 26.40) |
0.17%
(0.11 to 0.23) |
Eastern Sub-Saharan Africa |
22716.99 (17780.24 to 29585.02) |
25.08 (19.63 to 32.67) |
46289.92
(36087.34 to 60079.53) |
25.94
(20.22 to 33.67) |
103.77%
(85.00 to 122.54) |
0.11%
(0.07 to 0.15) |
Deaths: Mortality rates decreased in all five SDI regions. The greatest reduction in mortality was seen in the medium-high SDI region, at 85.17% (85.11% to 85.24%). In 2021, the regions with the highest SDI had the lowest number of deaths, at 17695.77 (14588.18 to 21300.00). The number of deaths decreased with increasing SDI, and the mortality rate decreased with increasing SDI (Figure 2).
Disability-Adjusted Life Years (DALYs): In 2021, the number of DALYS will decrease with the increase of SDI, and the number of DALYS in low-SDI areas will be the highest, 220119.35 (146491.10 to 328060.66) (Figure 2).
(a) (d)
(b) (e)
(c) (f)
Figure 2. Prevalence, mortality, and disability-adjusted life rate (DALYs) in the five SDI regions in 2021.
3.3. Regional Trends in Pediatric Thalassemia
Prevalence: In 2021, East Asia will have the largest number of thalassemia cases in children with 331293.01 (255461.11 to 423058.03), followed by Southeast Asia and South Asia. The lowest number of cases was recorded in Southern Latin America, at 778.93 (583.91 to 1004.17). The highest prevalence was also found in East Asia, at 123.92 (95.55 to 158.24), followed by Southeast Asia, at 102.57 (83.05 to 127.35) (Figure 3). The largest downward trend in prevalence was in South Asia, with an EAPC of −0.37% (−0.50 to −0.24), and the largest upward trend was in Tropical Latin America, with an EAPC of 0.53% (0.34 to 0.71) (Table 1).
Deaths: West sub-Saharan Africa will have the highest number of deaths in 2021, at 1634.70 (982.98 to 2572.78). Western sub-Saharan Africa has the highest mortality rate of 0.76 (0.46 to 1.20) and high-income North America has the lowest mortality rate of 0.006 (0.004 to 0.006) (Figure 3). The largest decline in mortality was in East Asia, with an EAPC of −6.40 (−8.65 to −4.15) (Table 1).
Disability-Adjusted Life Years (DALYs): In 2021, children in western sub-Saharan Africa will have the highest number of thalassemia-related disability-adjusted life years (DALYs) of 147743.57 (89487.17 to 231580.15), while children in western sub-Saharan Africa will also have the highest DALYS rate. For 68.79 (41.67 to 107.83) (Figure 3). The decrease trend of DALYS rate was greatest in East Asia, with EAPC of −6.06 (−8.19 to −3.93) (Table 1).
(a)
(b)
Figure 3. Comparison of prevalence, mortality rates, and disability-adjusted life year rates (DALYs) by region in 2021.
3.4. National Trends in Pediatric Thalassemia
Prevalence: The country with the highest prevalence of thalassemia in children in 2021 is Cambodia, at 418.00 (312.89 to 543.84). The country with the highest number of cases is China, with 327888.97 (252513.83 to 419321.84). Brazil had the largest increase in Mediterranean cases in children, with an EAPC of 0.54 (0.72 to 0.35) (Table 2). The largest decline was in the United States of America, with an EAPC of −1.29 (−1.74 to −0.84) (Table 2).
Deaths: The highest number of thalassemia-related deaths in children in 2021 was in Pakistan, with 1360.96 (684.21 to 2175.62). The highest mortality rate was recorded in Guinea-Bissau, at 1.77 (0.36 to 9.34). The country with the largest increase in mortality was Tokelau, with an EAPC of 3.04 (1.97 to 4.11) (Table 2). The largest reduction in mortality was seen in Grenada, with an EAPC of −15.97 (−21.59 to −10.35) (Table 2).
Disability-Adjusted Life Years (DALYs): The highest number of DALYs in children with thalassemia in 2021 was in Pakistan, 116987.40 (59694.77 to 185535.93), and the highest DALYs rate was in Guinea-Bissau, 155.55 (32.67 to 816.01). Tokelau saw the largest increase in DALYs, with an EAPC of 2.76 (1.79 to 3.74) (Table 2), and Saudi Arabia saw the largest decrease in DALYs, with an EAPC of −6.53 (−8.83 to −4.23) (Table 2).
Table 2. Estimated annual percentage change (EAPC) of prevalence, deaths, and disability-adjusted life years (DALYs) in 204 countries from 1990 to 2021.
|
Prevalence |
Deaths |
Disability-Adjusted Life Years (DALYs) |
location_name |
EAPC |
CI_lower |
CI_upper |
EAPC |
CI_lower |
CI_upper |
EAPC |
CI_lower |
CI_upper |
Afghanistan |
0.170218 |
0.110297 |
0.23014 |
−2.55291 |
−1.65422 |
−3.4516 |
−2.52507 |
−1.63618 |
−3.41396 |
Albania |
−0.51335 |
−0.33264 |
−0.69406 |
−4.27884 |
−2.77257 |
−5.7851 |
−4.17647 |
−2.70624 |
−5.6467 |
Algeria |
0.031286 |
0.020272 |
0.042299 |
−4.08565 |
−2.64739 |
−5.52391 |
−3.98942 |
−2.58504 |
−5.39381 |
American Samoa |
−0.26952 |
−0.17464 |
−0.3644 |
−0.87094 |
−0.56435 |
−1.17754 |
−0.92591 |
−0.59997 |
−1.25186 |
Andorra |
−0.10572 |
−0.0685 |
−0.14293 |
−5.85894 |
−3.79644 |
−7.92144 |
−5.09504 |
−3.30145 |
−6.88862 |
Angola |
0.089335 |
0.057887 |
0.120784 |
−3.47077 |
−2.24897 |
−4.69257 |
−3.3601 |
−2.17726 |
−4.54295 |
Antigua and Barbuda |
0.344536 |
0.22325 |
0.465822 |
−6.31432 |
−4.09152 |
−8.53713 |
−2.75138 |
−1.78282 |
−3.71994 |
Argentina |
−0.10323 |
−0.06689 |
−0.13957 |
−4.7893 |
−3.10334 |
−6.47526 |
−4.53667 |
−2.93964 |
−6.13369 |
Armenia |
−0.11213 |
−0.07266 |
−0.1516 |
−3.16591 |
−2.05143 |
−4.28039 |
−2.80697 |
−1.81884 |
−3.79509 |
Australia |
0.061217 |
0.039667 |
0.082767 |
−4.02898 |
−2.61067 |
−5.44728 |
−3.43595 |
−2.2264 |
−4.64549 |
Austria |
−0.07389 |
−0.04788 |
−0.09991 |
−4.38459 |
−2.8411 |
−5.92808 |
−2.95896 |
−1.91733 |
−4.00059 |
Azerbaijan |
−0.48156 |
−0.31204 |
−0.65108 |
−3.44045 |
−2.22932 |
−4.65158 |
−3.43945 |
−2.22867 |
−4.65023 |
Bahamas |
0.330827 |
0.214367 |
0.447287 |
−5.68682 |
−3.68491 |
−7.68873 |
−0.57873 |
−0.375 |
−0.78246 |
Bahrain |
−0.26867 |
−0.17409 |
−0.36324 |
−4.12362 |
−2.672 |
−5.57524 |
−4.04265 |
−2.61953 |
−5.46578 |
Bangladesh |
0.036825 |
0.023862 |
0.049789 |
−4.0026 |
−2.59358 |
−5.41161 |
−3.55812 |
−2.30557 |
−4.81067 |
Barbados |
0.370646 |
0.240169 |
0.501123 |
−5.45277 |
−3.53325 |
−7.37229 |
−2.98505 |
−1.93423 |
−4.03587 |
Belarus |
0.161614 |
0.104722 |
0.218506 |
−0.29197 |
−0.18919 |
−0.39475 |
−0.5479 |
−0.35502 |
−0.74077 |
Belgium |
−0.11968 |
−0.07755 |
−0.16181 |
−3.93662 |
−2.55083 |
−5.32242 |
−3.27254 |
−2.12052 |
−4.42456 |
Belize |
0.305624 |
0.198036 |
0.413211 |
−2.80999 |
−1.8208 |
−3.79918 |
−1.96426 |
−1.27279 |
−2.65573 |
Cenin |
0.162752 |
0.105459 |
0.220045 |
−3.07721 |
−1.99395 |
−4.16047 |
−3.03781 |
−1.96842 |
−4.10719 |
Bermuda |
0.359475 |
0.23293 |
0.48602 |
−0.69151 |
−0.44808 |
−0.93493 |
−0.46359 |
−0.30039 |
−0.62678 |
Bhutan |
−0.15709 |
−0.10179 |
−0.21239 |
−3.02005 |
−1.95691 |
−4.08319 |
−2.87932 |
−1.86572 |
−3.89292 |
Bolivia (Plurinational State of) |
0.270249 |
0.175114 |
0.365383 |
−4.07089 |
−2.63783 |
−5.50396 |
−3.96439 |
−2.56882 |
−5.35996 |
Bosnia and Herzegovina |
−0.07009 |
−0.04542 |
−0.09477 |
−4.35461 |
−2.82167 |
−5.88754 |
−3.70594 |
−2.40135 |
−5.01053 |
Botswana |
0.159813 |
0.103555 |
0.216072 |
−0.23516 |
−0.15238 |
−0.31795 |
−0.22931 |
−0.14859 |
−0.31003 |
Brazil |
0.535117 |
0.346742 |
0.723492 |
−3.34395 |
−2.16679 |
−4.52111 |
−1.72355 |
−1.11682 |
−2.33029 |
Brunei Darussalam |
−0.24114 |
−0.15625 |
−0.32602 |
−2.25985 |
−1.46432 |
−3.05537 |
−2.15081 |
−1.39367 |
−2.90795 |
Bulgaria |
0.125999 |
0.081644 |
0.170354 |
−2.70934 |
−1.75558 |
−3.66309 |
−2.29153 |
−1.48485 |
−3.09821 |
Burkina Faso |
0.203144 |
0.131632 |
0.274657 |
−1.80102 |
−1.16702 |
−2.43503 |
−1.76441 |
−1.14329 |
−2.38553 |
Burundi |
0.183328 |
0.118792 |
0.247864 |
−2.81994 |
−1.82724 |
−3.81263 |
−2.77485 |
−1.79803 |
−3.75168 |
Cabo Verde |
0.088426 |
0.057297 |
0.119554 |
−3.72457 |
−2.41342 |
−5.03572 |
−3.66231 |
−2.37308 |
−4.95153 |
Cambodia |
0.244668 |
0.158538 |
0.330797 |
−3.03595 |
−1.96721 |
−4.10468 |
−2.55188 |
−1.65355 |
−3.45021 |
Cameroon |
0.058857 |
0.038138 |
0.079577 |
−1.63004 |
−1.05623 |
−2.20386 |
−1.62161 |
−1.05076 |
−2.19246 |
Canada |
−0.29016 |
−0.18802 |
−0.3923 |
−3.41945 |
−2.21571 |
−4.62318 |
−3.03546 |
−1.9669 |
−4.10403 |
Central African
Republic |
0.038935 |
0.025229 |
0.052642 |
−1.72244 |
−1.1161 |
−2.32879 |
−1.69786 |
−1.10017 |
−2.29556 |
Chad |
0.162012 |
0.104979 |
0.219044 |
−1.12882 |
−0.73145 |
−1.5262 |
−1.12625 |
−0.72978 |
−1.52271 |
Chile |
−0.09239 |
−0.05987 |
−0.12492 |
−4.57128 |
−2.96207 |
−6.18049 |
−3.63557 |
−2.35575 |
−4.91539 |
China |
−0.37524 |
−0.24315 |
−0.50734 |
−6.49132 |
−4.2062 |
−8.77643 |
−6.14163 |
−3.97962 |
−8.30365 |
Colombia |
0.382675 |
0.247964 |
0.517387 |
−2.15914 |
−1.39906 |
−2.91921 |
−1.19543 |
−0.77461 |
−1.61625 |
Comoros |
0.260092 |
0.168533 |
0.351652 |
−1.93084 |
−1.25113 |
−2.61054 |
−1.92548 |
−1.24766 |
−2.60329 |
Congo |
0.069769 |
0.045208 |
0.094329 |
−3.07016 |
−1.98938 |
−4.15093 |
−3.01212 |
−1.95178 |
−4.07247 |
Cook Islands |
−0.14772 |
−0.09572 |
−0.19972 |
−3.07814 |
−1.99455 |
−4.16172 |
−2.73506 |
−1.77225 |
−3.69788 |
Costa Rica |
0.355697 |
0.230482 |
0.480912 |
−3.68081 |
−2.38507 |
−4.97655 |
−1.78482 |
−1.15652 |
−2.41312 |
Croatia |
0.196236 |
0.127156 |
0.265317 |
−2.88127 |
−1.86699 |
−3.89555 |
−1.28657 |
−0.83366 |
−1.73947 |
Cuba |
0.326069 |
0.211284 |
0.440854 |
−6.36912 |
−4.12702 |
−8.61122 |
−2.41624 |
−1.56566 |
−3.26682 |
Cyprus |
−0.46801 |
−0.30326 |
−0.63276 |
−5.31048 |
−3.44105 |
−7.17991 |
−4.60229 |
−2.98216 |
−6.22242 |
Czechia |
0.291336 |
0.188778 |
0.393893 |
−2.92673 |
−1.89644 |
−3.95702 |
−1.18238 |
−0.76615 |
−1.59861 |
Côte d’Ivoire |
0.021971 |
0.014237 |
0.029706 |
−1.83047 |
−1.1861 |
−2.47485 |
−1.79856 |
−1.16542 |
−2.4317 |
Democratic People’s
Republic of Korea |
−0.17227 |
−0.11163 |
−0.23291 |
−3.05248 |
−1.97793 |
−4.12704 |
−2.99281 |
−1.93926 |
−4.04636 |
Democratic Republic of the Congo |
0.040429 |
0.026197 |
0.054661 |
−2.51556 |
−1.63002 |
−3.40111 |
−2.47334 |
−1.60266 |
−3.34403 |
Denmark |
0.000503 |
0.000326 |
0.000679 |
−3.45851 |
−2.24102 |
−4.67599 |
−2.56248 |
−1.66042 |
−3.46454 |
Djibouti |
0.247051 |
0.160082 |
0.334019 |
−2.32935 |
−1.50936 |
−3.14935 |
−2.27817 |
−1.47619 |
−3.08014 |
Dominica |
0.255508 |
0.165563 |
0.345454 |
0.282006 |
0.182732 |
0.381279 |
0.243374 |
0.1577 |
0.329048 |
Dominican Republic |
0.383351 |
0.248401 |
0.5183 |
−2.50206 |
−1.62127 |
−3.38285 |
−2.41598 |
−1.56549 |
−3.26646 |
Ecuador |
0.337007 |
0.218372 |
0.455643 |
−5.85323 |
−3.79274 |
−7.91372 |
−0.30902 |
−0.20024 |
−0.4178 |
Egypt |
0.049325 |
0.031961 |
0.066688 |
−2.94725 |
−1.90974 |
−3.98476 |
−2.84916 |
−1.84618 |
−3.85214 |
El Salvador |
0.407579 |
0.264101 |
0.551058 |
−3.95048 |
−2.5598 |
−5.34115 |
−3.89837 |
−2.52604 |
−5.27069 |
Equatorial Guinea |
−0.10676 |
−0.06918 |
−0.14434 |
−3.98247 |
−2.58054 |
−5.38441 |
−3.73219 |
−2.41836 |
−5.04602 |
Eritrea |
0.242748 |
0.157294 |
0.328201 |
−1.19277 |
−0.77289 |
−1.61266 |
−1.17089 |
−0.7587 |
−1.58307 |
Estonia |
0.130941 |
0.084846 |
0.177035 |
−3.63243 |
−2.35372 |
−4.91114 |
−1.05044 |
−0.68066 |
−1.42022 |
Eswatini |
0.13911 |
0.090139 |
0.18808 |
−0.71634 |
−0.46417 |
−0.9685 |
−0.70981 |
−0.45994 |
−0.95968 |
Ethiopia |
0.156291 |
0.101273 |
0.21131 |
−3.27518 |
−2.12223 |
−4.42813 |
−3.21296 |
−2.08191 |
−4.344 |
Fiji |
−0.03636 |
−0.02356 |
−0.04915 |
−0.14878 |
−0.0964 |
−0.20115 |
−0.15912 |
−0.1031 |
−0.21513 |
Finland |
−0.11288 |
−0.07315 |
−0.15262 |
−2.64416 |
−1.71334 |
−3.57497 |
−1.42202 |
−0.92143 |
−1.9226 |
France |
−0.13961 |
−0.09047 |
−0.18876 |
−3.79923 |
−2.4618 |
−5.13666 |
−3.00974 |
−1.95023 |
−4.06925 |
Gabon |
0.039713 |
0.025733 |
0.053693 |
−2.21053 |
−1.43237 |
−2.9887 |
−2.15485 |
−1.39628 |
−2.91341 |
Gambia |
0.11011 |
0.071348 |
0.148872 |
−2.04251 |
−1.32349 |
−2.76153 |
−2.02418 |
−1.31161 |
−2.73674 |
Georgia |
0.458016 |
0.296782 |
0.619249 |
−0.12358 |
−0.08008 |
−0.16708 |
−0.05934 |
−0.03845 |
−0.08022 |
Germany |
0.285636 |
0.185084 |
0.386187 |
−3.13866 |
−2.03377 |
−4.24355 |
−2.71519 |
−1.75937 |
−3.67101 |
Ghana |
0.112561 |
0.072937 |
0.152186 |
−2.43627 |
−1.57864 |
−3.2939 |
−2.41455 |
−1.56457 |
−3.26454 |
Greece |
−0.19738 |
−0.1279 |
−0.26686 |
−4.64633 |
−3.0107 |
−6.28197 |
−4.18552 |
−2.71211 |
−5.65893 |
Greenland |
−0.00625 |
−0.00405 |
−0.00845 |
−2.51848 |
−1.63191 |
−3.40505 |
−2.2523 |
−1.45943 |
−3.04517 |
Grenada |
0.298026 |
0.193113 |
0.402939 |
−15.9666 |
−10.346 |
−21.5873 |
−5.4256 |
−3.51565 |
−7.33556 |
Guam |
−0.11995 |
−0.07772 |
−0.16217 |
−4.45737 |
−2.88826 |
−6.02649 |
−3.19685 |
−2.07148 |
−4.32223 |
Guatemala |
0.280187 |
0.181554 |
0.37882 |
−2.86716 |
−1.85785 |
−3.87648 |
−1.20982 |
−0.78393 |
−1.63571 |
Guinea |
0.039306 |
0.025469 |
0.053143 |
−2.13575 |
−1.38391 |
−2.88759 |
−2.1127 |
−1.36897 |
−2.85643 |
Guinea-Bissau |
0.244126 |
0.158187 |
0.330065 |
−2.96593 |
−1.92184 |
−4.01001 |
−2.96386 |
−1.9205 |
−4.00722 |
Guyana |
0.18539 |
0.120128 |
0.250652 |
−7.20253 |
−4.66705 |
−9.73801 |
−5.52435 |
−3.57964 |
−7.46907 |
Haiti |
0.35156 |
0.227802 |
0.475319 |
−1.35936 |
−0.88083 |
−1.83788 |
−1.34337 |
−0.87047 |
−1.81627 |
Honduras |
0.462596 |
0.29975 |
0.625441 |
−4.20443 |
−2.72436 |
−5.6845 |
−4.15599 |
−2.69297 |
−5.61901 |
Hungary |
0.263448 |
0.170708 |
0.356189 |
−2.47497 |
−1.60372 |
−3.34623 |
−1.316 |
−0.85273 |
−1.77926 |
Iceland |
−0.06933 |
−0.04493 |
−0.09374 |
−2.63397 |
−1.70675 |
−3.5612 |
−0.56753 |
−0.36775 |
−0.76732 |
India |
−0.25221 |
−0.16342 |
−0.34099 |
−3.74366 |
−2.42579 |
−5.06153 |
−3.41545 |
−2.21312 |
−4.61777 |
Indonesia |
0.356334 |
0.230895 |
0.481773 |
−2.40675 |
−1.55951 |
−3.254 |
−2.35198 |
−1.52402 |
−3.17994 |
Iran
(Islamic Republic of) |
−0.16318 |
−0.10574 |
−0.22063 |
−6.08388 |
−3.94219 |
−8.22557 |
−5.87132 |
−3.80446 |
−7.93818 |
Iraq |
−0.19895 |
−0.12892 |
−0.26899 |
−4.25355 |
−2.75619 |
−5.75091 |
−4.08231 |
−2.64523 |
−5.51939 |
Ireland |
−0.0355 |
−0.023 |
−0.04799 |
−4.7873 |
−3.10205 |
−6.47256 |
−2.98131 |
−1.93181 |
−4.0308 |
Israel |
−0.18687 |
−0.12108 |
−0.25265 |
−4.9029 |
−3.17695 |
−6.62885 |
−4.53006 |
−2.93536 |
−6.12476 |
Italy |
0.099508 |
0.064478 |
0.134537 |
−5.02816 |
−3.25811 |
−6.7982 |
−4.25203 |
−2.7552 |
−5.74886 |
Jamaica |
0.344643 |
0.22332 |
0.465967 |
−4.88671 |
−3.16646 |
−6.60695 |
−0.82323 |
−0.53343 |
−1.11303 |
Japan |
−0.07542 |
−0.04887 |
−0.10196 |
−5.58619 |
−3.61971 |
−7.55268 |
−4.55898 |
−2.9541 |
−6.16387 |
Jordan |
−0.37765 |
−0.24471 |
−0.51059 |
−3.72181 |
−2.41163 |
−5.03198 |
−3.60248 |
−2.33431 |
−4.87064 |
Kazakhstan |
0.21118 |
0.136839 |
0.285521 |
1.675702 |
1.08581 |
2.265593 |
0.880589 |
0.570598 |
1.190579 |
Kenya |
0.015631 |
0.010129 |
0.021134 |
−1.45025 |
−0.93973 |
−1.96078 |
−1.38057 |
−0.89457 |
−1.86656 |
Kiribati |
−0.18651 |
−0.12085 |
−0.25216 |
−2.13484 |
−1.38332 |
−2.88636 |
−2.14768 |
−1.39164 |
−2.90372 |
Kuwait |
0.122793 |
0.079567 |
0.166019 |
−1.53316 |
−0.99344 |
−2.07287 |
−1.40504 |
−0.91043 |
−1.89966 |
Kyrgyzstan |
0.062663 |
0.040604 |
0.084722 |
−1.73343 |
−1.12322 |
−2.34364 |
−1.25914 |
−0.81589 |
−1.7024 |
Lao People’s
Democratic Republic |
0.368667 |
0.238887 |
0.498448 |
−2.86792 |
−1.85833 |
−3.8775 |
−2.50646 |
−1.62412 |
−3.3888 |
Latvia |
0.133543 |
0.086532 |
0.180553 |
−3.81046 |
−2.46908 |
−5.15184 |
−0.94058 |
−0.60947 |
−1.27169 |
Lebanon |
−0.31344 |
−0.2031 |
−0.42378 |
−4.076 |
−2.64114 |
−5.51085 |
−3.8712 |
−2.50844 |
−5.23396 |
Lesotho |
0.076365 |
0.049483 |
0.103248 |
0.24538 |
0.159 |
0.33176 |
0.202346 |
0.131115 |
0.273577 |
Liberia |
−0.12625 |
−0.08181 |
−0.1707 |
−3.62826 |
−2.35102 |
−4.9055 |
−3.58231 |
−2.32124 |
−4.84338 |
Libya |
−0.23095 |
−0.14965 |
−0.31224 |
−2.8158 |
−1.82457 |
−3.80704 |
−2.5745 |
−1.66821 |
−3.48079 |
Lithuania |
0.154333 |
0.100004 |
0.208663 |
−2.54075 |
−1.64634 |
−3.43516 |
−0.99802 |
−0.64669 |
−1.34935 |
Luxembourg |
0.026007 |
0.016852 |
0.035163 |
−5.67825 |
−3.67936 |
−7.67715 |
−3.94855 |
−2.55856 |
−5.33854 |
Madagascar |
0.05389 |
0.034919 |
0.072861 |
−2.4182 |
−1.56693 |
−3.26947 |
−2.37262 |
−1.5374 |
−3.20785 |
Malawi |
−0.02782 |
−0.01803 |
−0.03762 |
−3.61149 |
−2.34015 |
−4.88283 |
−3.57779 |
−2.31831 |
−4.83727 |
Malaysia |
−0.24434 |
−0.15833 |
−0.33035 |
−3.7788 |
−2.44856 |
−5.10904 |
−3.48574 |
−2.25867 |
−4.71282 |
Maldives |
−0.38681 |
−0.25064 |
−0.52298 |
−4.41996 |
−2.86402 |
−5.97591 |
−4.00258 |
−2.59357 |
−5.4116 |
Mali |
0.11595 |
0.075133 |
0.156768 |
−2.46085 |
−1.59457 |
−3.32714 |
−2.43373 |
−1.57699 |
−3.29047 |
Malta |
0.258578 |
0.167552 |
0.349604 |
−1.36291 |
−0.88313 |
−1.84269 |
−1.34154 |
−0.86928 |
−1.8138 |
Marshall Islands |
−0.10118 |
−0.06556 |
−0.13679 |
−1.11272 |
−0.72101 |
−1.50443 |
−1.04566 |
−0.67756 |
−1.41377 |
Mauritania |
0.063963 |
0.041446 |
0.086479 |
−2.73198 |
−1.77025 |
−3.69371 |
−2.69669 |
−1.74739 |
−3.646 |
Mauritius |
0.083588 |
0.054163 |
0.113013 |
−0.8354 |
−0.54131 |
−1.12948 |
−0.7504 |
−0.48624 |
−1.01457 |
Mexico |
0.353346 |
0.228959 |
0.477733 |
−1.95493 |
−1.26674 |
−2.64311 |
−0.96373 |
−0.62447 |
−1.30299 |
Micronesia
(Federated States of) |
−0.11412 |
−0.07395 |
−0.15429 |
−3.07444 |
−1.99216 |
−4.15672 |
−2.7936 |
−1.81018 |
−3.77702 |
Monaco |
−0.15681 |
−0.10161 |
−0.21201 |
−3.06168 |
−1.98388 |
−4.13947 |
−2.71358 |
−1.75833 |
−3.66883 |
Mongolia |
0.221198 |
0.143331 |
0.299066 |
−3.75487 |
−2.43306 |
−5.07668 |
−3.66229 |
−2.37307 |
−4.95151 |
Montenegro |
0.196391 |
0.127256 |
0.265526 |
−3.90018 |
−2.52722 |
−5.27315 |
−3.32877 |
−2.15696 |
−4.50059 |
Morocco |
−0.1356 |
−0.08786 |
−0.18333 |
−4.24457 |
−2.75037 |
−5.73877 |
−4.15213 |
−2.69047 |
−5.61379 |
Mozambique |
0.269815 |
0.174833 |
0.364797 |
−2.64133 |
−1.71151 |
−3.57115 |
−2.6107 |
−1.69166 |
−3.52973 |
Myanmar |
0.451772 |
0.292736 |
0.610808 |
−2.59999 |
−1.68473 |
−3.51526 |
−2.36328 |
−1.53134 |
−3.19522 |
Namibia |
0.148105 |
0.095968 |
0.200242 |
−0.82498 |
−0.53457 |
−1.1154 |
−0.81994 |
−0.5313 |
−1.10857 |
Nauru |
−0.1269 |
−0.08223 |
−0.17157 |
−1.50752 |
−0.97683 |
−2.0382 |
−1.42567 |
−0.9238 |
−1.92754 |
Nepal |
−0.05534 |
−0.03586 |
−0.07482 |
−4.47118 |
−2.89721 |
−6.04516 |
−4.28733 |
−2.77807 |
−5.79658 |
Netherlands |
−0.02075 |
−0.01345 |
−0.02805 |
−4.64474 |
−3.00967 |
−6.27981 |
−3.96624 |
−2.57002 |
−5.36246 |
New Zealand |
0.117875 |
0.07638 |
0.15937 |
−5.22238 |
−3.38396 |
−7.06079 |
−3.52951 |
−2.28703 |
−4.77199 |
Nicaragua |
0.401501 |
0.260162 |
0.54284 |
−4.87199 |
−3.15692 |
−6.58705 |
−4.79715 |
−3.10843 |
−6.48588 |
Niger |
0.159297 |
0.10322 |
0.215374 |
−3.48219 |
−2.25637 |
−4.70802 |
−3.39825 |
−2.20198 |
−4.59453 |
Nigeria |
0.120131 |
0.077841 |
0.16242 |
−0.96904 |
−0.62792 |
−1.31017 |
−0.9601 |
−0.62212 |
−1.29808 |
Niue |
−0.1519 |
−0.09843 |
−0.20537 |
2.680798 |
1.737087 |
3.62451 |
2.430342 |
1.574797 |
3.285887 |
North Macedonia |
0.054668 |
0.035424 |
0.073913 |
−6.06841 |
−3.93217 |
−8.20465 |
−5.5231 |
−3.57882 |
−7.46738 |
Northern Mariana
Islands |
−0.19437 |
−0.12595 |
−0.26279 |
−4.14285 |
−2.68446 |
−5.60125 |
−2.86039 |
−1.85346 |
−3.86732 |
Norway |
−0.17824 |
−0.11549 |
−0.24098 |
−6.21472 |
−4.02697 |
−8.40246 |
−2.79766 |
−1.81281 |
−3.78251 |
Oman |
−0.11004 |
−0.0713 |
−0.14878 |
−4.15492 |
−2.69228 |
−5.61756 |
−3.97191 |
−2.57369 |
−5.37013 |
Pakistan |
−0.71218 |
−0.46148 |
−0.96289 |
−0.83077 |
−0.53832 |
−1.12322 |
−0.85213 |
−0.55216 |
−1.15211 |
Palau |
−0.13323 |
−0.08633 |
−0.18013 |
−2.93337 |
−1.90075 |
−3.966 |
−2.60676 |
−1.68911 |
−3.52441 |
Palestine |
−0.2321 |
−0.15039 |
−0.3138 |
−3.90237 |
−2.52863 |
−5.27611 |
−3.78636 |
−2.45346 |
−5.11925 |
Panama |
0.423043 |
0.274121 |
0.571966 |
−2.11983 |
−1.3736 |
−2.86607 |
−1.52202 |
−0.98623 |
−2.05781 |
Papua New Guinea |
0.113215 |
0.07336 |
0.153069 |
−1.20233 |
−0.77908 |
−1.62559 |
−1.10972 |
−0.71907 |
−1.50037 |
Paraguay |
0.358985 |
0.232613 |
0.485357 |
−1.51917 |
−0.98438 |
−2.05395 |
−1.48263 |
−0.96071 |
−2.00456 |
Peru |
0.410729 |
0.266142 |
0.555317 |
−4.66966 |
−3.02582 |
−6.3135 |
−4.49158 |
−2.91043 |
−6.07274 |
Philippines |
0.062479 |
0.040485 |
0.084473 |
−2.59659 |
−1.68252 |
−3.51066 |
−2.5658 |
−1.66257 |
−3.46903 |
Poland |
−0.06242 |
−0.04044 |
−0.08439 |
−6.38559 |
−4.1377 |
−8.63349 |
−2.51257 |
−1.62808 |
−3.39705 |
Portugal |
−0.10047 |
−0.0651 |
−0.13584 |
−5.7661 |
−3.73628 |
−7.79592 |
−5.07526 |
−3.28863 |
−6.86188 |
Puerto Rico |
0.344741 |
0.223383 |
0.466099 |
−6.33121 |
−4.10245 |
−8.55996 |
−0.45034 |
−0.29181 |
−0.60887 |
Qatar |
−0.1634 |
−0.10588 |
−0.22093 |
−5.19144 |
−3.36392 |
−7.01896 |
−4.62996 |
−3.00009 |
−6.25983 |
Republic of Korea |
−0.13587 |
−0.08804 |
−0.18371 |
−6.38072 |
−4.13454 |
−8.62691 |
−5.93062 |
−3.84289 |
−8.01836 |
Republic of Moldova |
0.098613 |
0.063899 |
0.133328 |
−1.96621 |
−1.27405 |
−2.65836 |
−1.55547 |
−1.00791 |
−2.10304 |
Romania |
0.209643 |
0.135843 |
0.283443 |
−4.60025 |
−2.98084 |
−6.21965 |
−3.48517 |
−2.2583 |
−4.71205 |
Russian Federation |
0.068319 |
0.044269 |
0.09237 |
−2.08746 |
−1.35262 |
−2.8223 |
−1.50768 |
−0.97694 |
−2.03842 |
Rwanda |
0.199902 |
0.129531 |
0.270272 |
−3.13351 |
−2.03043 |
−4.23658 |
−3.09365 |
−2.0046 |
−4.18269 |
Saint Kitts and Nevis |
0.381153 |
0.246977 |
0.515329 |
−1.55503 |
−1.00762 |
−2.10244 |
−0.82187 |
−0.53255 |
−1.1112 |
Saint Lucia |
0.35708 |
0.231379 |
0.482782 |
0.822003 |
0.532636 |
1.11137 |
−0.21515 |
−0.13941 |
−0.29089 |
Saint Vincent and the Grenadines |
0.396145 |
0.256692 |
0.535599 |
−5.30559 |
−3.43788 |
−7.17329 |
−1.387 |
−0.89874 |
−1.87526 |
Samoa |
−0.03592 |
−0.02327 |
−0.04856 |
−2.68799 |
−1.74175 |
−3.63424 |
−2.40809 |
−1.56038 |
−3.25581 |
San Marino |
0.203516 |
0.131873 |
0.275159 |
−5.17 |
−3.35002 |
−6.98997 |
−4.02948 |
−2.611 |
−5.44796 |
Sao Tome and Principe |
0.096626 |
0.062611 |
0.130641 |
−4.4681 |
−2.89521 |
−6.04099 |
−4.36644 |
−2.82934 |
−5.90355 |
Saudi Arabia |
−0.13337 |
−0.08642 |
−0.18032 |
−6.92187 |
−4.48519 |
−9.35855 |
−6.53282 |
−4.23309 |
−8.83254 |
Senegal |
0.118371 |
0.076701 |
0.160041 |
−2.67114 |
−1.73083 |
−3.61145 |
−2.63775 |
−1.7092 |
−3.56631 |
Serbia |
0.091993 |
0.059609 |
0.124378 |
−6.45049 |
−4.17975 |
−8.72124 |
−5.67919 |
−3.67997 |
−7.67842 |
Seychelles |
−0.01591 |
−0.01031 |
−0.0215 |
−2.8354 |
−1.83726 |
−3.83354 |
−2.59127 |
−1.67908 |
−3.50347 |
Sierra Leone |
0.015863 |
0.010279 |
0.021447 |
−2.06853 |
−1.34035 |
−2.79671 |
−2.03977 |
−1.32172 |
−2.75782 |
Singapore |
−0.3149 |
−0.20405 |
−0.42576 |
−6.79255 |
−4.40139 |
−9.1837 |
−6.26825 |
−4.06166 |
−8.47484 |
Slovakia |
0.134213 |
0.086966 |
0.181459 |
−3.65713 |
−2.36972 |
−4.94453 |
−3.03051 |
−1.96369 |
−4.09733 |
Slovenia |
0.211908 |
0.137311 |
0.286505 |
−3.23689 |
−2.09742 |
−4.37636 |
−1.19727 |
−0.7758 |
−1.61874 |
Solomon Islands |
−0.11087 |
−0.07184 |
−0.1499 |
−2.06569 |
−1.33851 |
−2.79286 |
−1.88798 |
−1.22336 |
−2.5526 |
Somalia |
0.375828 |
0.243526 |
0.508129 |
−1.55438 |
−1.0072 |
−2.10157 |
−1.51961 |
−0.98467 |
−2.05456 |
South Africa |
0.134444 |
0.087116 |
0.181772 |
−1.37917 |
−0.89367 |
−1.86468 |
−1.32342 |
−0.85754 |
−1.7893 |
South Sudan |
0.14857 |
0.096269 |
0.200871 |
−0.72489 |
−0.46971 |
−0.98007 |
−0.74011 |
−0.47957 |
−1.00065 |
Spain |
0.079167 |
0.051298 |
0.107036 |
−3.91345 |
−2.53581 |
−5.29109 |
−3.40917 |
−2.20905 |
−4.60929 |
Sri Lanka |
0.139718 |
0.090533 |
0.188902 |
−5.16692 |
−3.34803 |
−6.98581 |
−4.86851 |
−3.15466 |
−6.58235 |
Sudan |
−0.12625 |
−0.08181 |
−0.17069 |
−4.11449 |
−2.66608 |
−5.5629 |
−4.03723 |
−2.61602 |
−5.45845 |
Suriname |
0.398284 |
0.258077 |
0.53849 |
−1.77719 |
−1.15157 |
−2.40281 |
−1.71442 |
−1.1109 |
−2.31794 |
Sweden |
−0.03025 |
−0.0196 |
−0.0409 |
−3.99796 |
−2.59057 |
−5.40534 |
−2.77601 |
−1.79878 |
−3.75324 |
Switzerland |
0.007796 |
0.005052 |
0.010541 |
−3.86175 |
−2.50231 |
−5.22119 |
−3.25456 |
−2.10887 |
−4.40026 |
Syrian Arab Republic |
−0.48379 |
−0.31348 |
−0.6541 |
−3.99448 |
−2.58832 |
−5.40064 |
−3.98334 |
−2.5811 |
−5.38558 |
Taiwan
(Province of China) |
0.506712 |
0.328336 |
0.685087 |
1.75767 |
1.138924 |
2.376416 |
1.566251 |
1.014889 |
2.117613 |
Tajikistan |
−0.29219 |
−0.18933 |
−0.39505 |
−2.37294 |
−1.5376 |
−3.20828 |
−2.31801 |
−1.50201 |
−3.13401 |
Thailand |
−0.1348 |
−0.08735 |
−0.18226 |
−6.54808 |
−4.24299 |
−8.85318 |
−5.11143 |
−3.31207 |
−6.91078 |
Timor-Leste |
−0.13564 |
−0.08789 |
−0.18339 |
−2.82754 |
−1.83217 |
−3.82291 |
−2.77763 |
−1.79983 |
−3.75543 |
Togo |
0.149509 |
0.096878 |
0.20214 |
−2.31728 |
−1.50154 |
−3.13302 |
−2.28878 |
−1.48307 |
−3.0945 |
Tokelau |
−0.19051 |
−0.12344 |
−0.25757 |
3.040014 |
1.969849 |
4.110179 |
2.762699 |
1.790156 |
3.735242 |
Tonga |
−0.04111 |
−0.02664 |
−0.05558 |
−1.9049 |
−1.23433 |
−2.57548 |
−1.67722 |
−1.0868 |
−2.26765 |
Trinidad and Tobago |
0.278181 |
0.180254 |
0.376108 |
−3.46309 |
−2.24399 |
−4.68219 |
−3.05107 |
−1.97701 |
−4.12512 |
Tunisia |
−0.32138 |
−0.20825 |
−0.43452 |
−4.9349 |
−3.19768 |
−6.67211 |
−4.72614 |
−3.06241 |
−6.38987 |
Turkey |
0.010793 |
0.006994 |
0.014592 |
−5.63985 |
−3.65447 |
−7.62522 |
−5.515 |
−3.57357 |
−7.45642 |
Turkmenistan |
0.113876 |
0.073789 |
0.153964 |
1.217122 |
0.788663 |
1.645581 |
0.900771 |
0.583676 |
1.217867 |
Tuvalu |
−0.25877 |
−0.16768 |
−0.34987 |
−4.18363 |
−2.71088 |
−5.65638 |
−3.93227 |
−2.54801 |
−5.31653 |
Uganda |
0.035603 |
0.02307 |
0.048136 |
−1.80192 |
−1.16759 |
−2.43624 |
−1.79574 |
−1.16359 |
−2.42789 |
Ukraine |
−0.00764 |
−0.00495 |
−0.01033 |
−2.81711 |
−1.82542 |
−3.80881 |
−2.41827 |
−1.56698 |
−3.26957 |
United Arab Emirates |
−0.50211 |
−0.32535 |
−0.67887 |
−5.24413 |
−3.39806 |
−7.09021 |
−4.81269 |
−3.11849 |
−6.50688 |
United Kingdom |
−0.07014 |
−0.04545 |
−0.09483 |
−0.03996 |
−0.02589 |
−0.05402 |
−0.07336 |
−0.04754 |
−0.09919 |
United Republic of
Tanzania |
0.084599 |
0.054818 |
0.11438 |
−1.60547 |
−1.0403 |
−2.17064 |
−1.6095 |
−1.04291 |
−2.17608 |
United States of
America |
−1.28956 |
−0.8356 |
−1.74352 |
−3.82361 |
−2.4776 |
−5.16962 |
−3.63334 |
−2.35431 |
−4.91237 |
United States Virgin
Islands |
0.419905 |
0.272087 |
0.567722 |
−4.2334 |
−2.74313 |
−5.72367 |
−3.56291 |
−2.30867 |
−4.81715 |
Uruguay |
−0.13219 |
−0.08566 |
−0.17873 |
−4.67974 |
−3.03235 |
−6.32713 |
−4.358 |
−2.82387 |
−5.89213 |
Uzbekistan |
−0.02777 |
−0.01799 |
−0.03754 |
0.083683 |
0.054225 |
0.113142 |
−0.01858 |
−0.01204 |
−0.02512 |
Vanuatu |
−0.11695 |
−0.07578 |
−0.15811 |
−1.79795 |
−1.16502 |
−2.43087 |
−1.60628 |
−1.04083 |
−2.17174 |
Venezuela
(Bolivarian Republic of) |
0.428484 |
0.277646 |
0.579322 |
−1.3434 |
−0.87049 |
−1.81631 |
−0.7677 |
−0.49745 |
−1.03795 |
Viet Nam |
−0.14905 |
−0.09658 |
−0.20152 |
−2.89369 |
−1.87504 |
−3.91235 |
−2.69885 |
−1.74879 |
−3.64892 |
Yemen |
−0.16477 |
−0.10677 |
−0.22278 |
−2.95746 |
−1.91636 |
−3.99856 |
−2.88005 |
−1.86619 |
−3.8939 |
Zambia |
0.060942 |
0.039489 |
0.082395 |
−3.3312 |
−2.15853 |
−4.50386 |
−3.2075 |
−2.07838 |
−4.33663 |
Zimbabwe |
0.279197 |
0.180912 |
0.377481 |
0.862734 |
0.559029 |
1.166439 |
0.811967 |
0.526133 |
1.0978 |
4. Discussion
Over the past 30 years, the global prevalence of pediatric thalassemia has decreased. However, due to increasing medical and social costs, pediatric thalassemia remains a significant public health issue. This study investigated the prevalence, thalassemia-related mortality, and thalassemia-related DALYs among children aged 0 to 14 years in all GBD regions and countries from 1990 to 2021. Our findings provide insights into the burden of pediatric thalassemia in regions and countries with different levels of development over the past 30 years.
From 1990 to 2021, both the number of thalassemia-related deaths and the number of thalassemia-related disability-adjusted life years (DALYs) in children decreased. However, the prevalence increased in low and lower-middle SDI regions, indicating that these areas still face significant challenges in disease control. This may be related to the lack of medical resources, weak public health infrastructure, and insufficient health education in these regions. Additionally, we found a significant negative correlation between SDI and the prevalence, thalassemia-related mortality, and thalassemia-related DALYs. The largest decrease in thalassemia-related mortality in children was observed in high SDI regions, which may be associated with better medical services in these areas, leading to early diagnosis and better treatment of pediatric thalassemia.
Thalassemia is a complex, multifactorial disease influenced by various genetic, metabolic, and environmental factors [10] [11]. The exact role of each factor in pediatric thalassemia is not yet clear and requires further exploration, which may vary by geographic location. These differences in potential factors are related to regional variations in the prevalence and mortality of pediatric thalassemia. Changes in modern dietary patterns have led to a rapid increase in global obesity rates, and obesity is considered a major risk factor for thalassemia and its complications [12]-[14]. Therefore, proactive obesity prevention and dietary management can help slow the progression of pediatric thalassemia.
In children with thalassemia, signs and symptoms are sometimes nonspecific [15]-[17]; delays in diagnosis can have devastating effects on the child’s health. Children with thalassemia typically initially present with fatigue, weakness, or symptoms of anemia [18]-[20]. Notably, symptoms of anemia are the primary cause of death in thalassemia patients. Therefore, failure to identify high-risk patients and provide timely treatment can lead to adverse outcomes and high mortality rates, especially in low-income countries. This failure may partially explain why pediatric thalassemia-related mortality is lower in higher SDI regions compared to lower SDI regions. Additionally, cardiovascular diseases can also contribute to the mortality of children with thalassemia [21] [22]. For example, chronic anemia can lead to early and progressive atherosclerosis [23].
Based on the survey results, we propose more specific and actionable policy recommendations, including promoting thalassemia screening programs and public awareness activities in low SDI regions, increasing investment in healthcare resources and improving infrastructure, providing training for healthcare professionals, establishing economic support policies, promoting genetic counseling services, and enhancing international cooperation and aid. These measures aim to improve early detection rates and public awareness of thalassemia, thereby effectively reducing the disease burden in low SDI regions.
5. Limitations
This study has certain limitations. Although the GBD database provides extensive data, it relies on the reporting and data collection quality of individual countries. Data from some regions may be incomplete or inaccurate, affecting the reliability of the results. Secondly, this study uses a cross-sectional design, which cannot establish causality. While trends can be observed, the specific reasons for these trends cannot be determined.
6. Conclusions
This study reveals the trends and burden of pediatric thalassemia by analyzing epidemiological data at global, regional, and national levels from 1990 to 2021. Although the prevalence, mortality, and disability-adjusted life years (DALYs) of pediatric thalassemia have decreased globally, significant differences remain between regions and countries with different Socio-demographic Index (SDI) levels.
The burden of pediatric thalassemia has significantly decreased in high SDI regions, indicating substantial progress in disease prevention and control in these areas. However, the prevalence and disease burden have increased in low and lower-middle SDI regions, suggesting that these areas still need to strengthen medical resources, public health infrastructure, and health education.
This study emphasizes the importance of enhancing the understanding of the epidemiology of pediatric thalassemia globally. Future research should further explore the specific needs of low SDI regions and develop effective interventions to reduce the disease burden. Additionally, policymakers and public health workers should focus on regional differences and formulate targeted public health policies and resource allocation strategies to better prevent and control pediatric thalassemia.
In conclusion, this study provides important reference data on the epidemiology of pediatric thalassemia at global, regional, and national levels. These data are crucial for the formulation of public health policies and resource allocation, helping to better prevent and control pediatric thalassemia worldwide.
Credit Authorship Contribution Statement
Yongle Li: Writing—review & editing, Writing—original draft, Methodology, Formal analysis, Data curation, Conceptualization. Wanshuo Wei, Yuan Gan, Xiaomei Xie, Pengtao Qin, Liangsen Teng: Writing—review & editing, Writing—original draft, Validation, Methodology, Conceptualization. Lihe Jiang: Conceptualization, Funed this research, Writing—review & editing, Writing—original draft, Formal analysis.
Funding
This study was supported by the Grant of research project on high-level talents of Youjiang Medical College for Nationalities (Grant No. YY2021SK02); Key Laboratory of Pollution Exposure and Health Intervention of Zhejiang Province (Grant No. 202300011).
Acknowledgements
We are grateful to the Global Burden of Disease (GBD) Study team for providing access to the comprehensive database used in this analysis.