1 Global, regional, and national burdens of acne vulgaris in adolescents and young

2 adults aged 10-24 years from 1990 to 2021: a trend analysis

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4 Zhou Zhu,1,2,3* Xiaoying Zhong,3* Zhongyu Luo,4* Mingjuan Liu,1,2,3 Hanlin Zhang,1,2

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5 Heyi Zheng1,2 and Jun Li1,2

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7 1 Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy
8 of Medical Sciences & Peking Union Medical College, Beijing, China

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9 2 State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical
10 College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical

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11 College, Beijing, China
12 3 4+4 Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union
13 Medical College, Beijing, China
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14 4 Peking Union Medical College Hospital, Chinese Academy of Medical Sciences &
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15 Peking Union Medical College, Beijing, China

16 * These authors contributed equally to this work.
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18 Corresponding author: Dr Jun Li
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19 Email: [email protected]
20
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21 Acknowledgement: As unofficial GBD collaborators, we would like to thank the Institute

22 for Health Metrics and Evaluation and the countless individuals who contributed to the
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23 GBD Study 2021 in various capacities. This analysis fully complied with the data-use
24 conditions of the GBD database.
25 Funding sources: This research received no specific grant from any funding agency in the
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26 public, commercial, or not-for-profit sectors.

27 Conflicts of interest: None to declare.
© The Author(s) 2024. Published by Oxford University Press on behalf of British Association of
Dermatologists. All rights reserved. For commercial re-use, please contact [email protected] for
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 1 Data availability: The data underlying this article will be shared on reasonable request to
2 the corresponding author.
3 Ethics statement: Not applicable.
4 Patient consent: Not applicable.

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5

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6 What is already known about this topic?

7 •

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Acne vulgaris is a common chronic inflammatory skin disease, most prevalent and

8 impactful during adolescence and early adulthood.

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9 • However, there is a scarcity of high-quality evidence tracking and comparing the

10 burden of acne vulgaris in this age group across different regions and countries.

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11 What does this study add?

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Utilizing the Global Burden of Disease Study model, this study provides a
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13 comprehensive summary of trends in the burden of acne vulgaris among

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adolescents and young adults.

15 • The highest burden of acne vulgaris in this age group was observed in Western
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16 Europe, while North Africa and the Middle East experienced the largest increase.
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17 • The burden of acne vulgaris continued to rise in nearly all countries, with the

18 exception of New Zealand.

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19
20 Abstract
21 Background: Acne vulgaris is a common skin condition affecting adolescents and young
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22 adults worldwide, yet data on its burden and trends remain limited. We aimed to investigate
23 trends in the burden of acne vulgaris among adolescents and young adults aged 10-24 years
24 at global, regional, and national levels.
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25 Methods: We retrieved data from the Global Burden of Disease Study (GBD) 2021 for
26 individuals aged 10-24 years in 204 countries and territories from 1990 to 2021. We
27 analyzed the numbers, age-standardised rates, and average annual percentage changes
28 (AAPCs) of the prevalence, incidence, and disability-adjusted life-years (DALYs) for acne
29 vulgaris at the global, regional, and national levels. Additionally, we examined these global
30 trends by age, gender, and Socio-demographic Index (SDI).
31 Results: Globally, the age-standardised prevalence rate of acne vulgaris among adolescents
2
 1 and young adults increased from 8,563.4 per 100,000 population (95% UI 7,343.5-9,920.1)
2 in 1990 to 9,790.5 (95% UI 8,420.9-11,287.2) per 100,000 population in 2021, with an
3 AAPC of 0.43 (95% CI 0.41-0.46). The age-standardised incidence rate and age-
4 standardised DALY rate also showed a similar upward trend. Regionally, Western Europe
5 had the highest age-standardised prevalence, incidence, and DALY rates, while North

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6 Africa and the Middle East had the largest increase in these rates. By SDI quintile, the high

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7 SDI region had the highest age-standardised prevalence, incidence, and DALY rates from
8 1990 to 2021, whereas the low-middle SDI region had the lowest burden of acne vulgaris
9 but experienced the most significant increase in these rates. Globally, the age-standardised

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10 prevalence rate of acne vulgaris in 2021 was approximately 25% higher in females than in
11 males (10,911.8 per 100,000 population vs. 8,727.8 per 100,000 population). Among all

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12 age groups, adolescents aged 15-19 years had the highest age-specific prevalence rate,
13 while adolescents aged 10-14 years experienced the largest increase from 1990 to 2021
14 (AAPC = 0.50, 95% CI 0.48-0.52).

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15 Conclusions: The burden of acne vulgaris among adolescents and young adults has
16 continued to increase in nearly all countries since the 1990s. Managing this condition
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remains a significant challenge, necessitating more effective and targeted interventions to
control the acne burden.
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19
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20 Introduction
21 Acne vulgaris is a chronic, inflammatory disease of the pilosebaceous unit, characterised
22 by androgen-induced increased sebum production, altered keratinization, inflammation,
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23 and bacterial colonization of hair follicles by Propionibacterium acnes1,2 . This condition

24 primarily affects the face, neck, chest, and back, leading to a high prevalence among
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25 adolescents worldwide, although it can occur at any age 3 . Due to its visibility on the skin
26 and potential for lasting scars, acne significantly impacts the quality of life, making it one
27 of the most common reasons for dermatologic consultations globally 4–6 .
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29 Compared to all subcategories of skin and subcutaneous diseases, acne vulgaris was ranked
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the second most prevalent skin disease globally and the third-largest contributor to the total
31 disability-adjusted life years (DALYs) caused by skin disorders in 20217 . The acne vulgaris
32 burden gradually increased worldwide during the past three decades, particularly among
33 adolescents and young adults aged 10-24 years8,9 . The age range of 10-24 years is widely
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34 recognized as a high-risk period for the onset of acne vulgaris10 . While many studies
35 recognize this age group as particularly affected, there is a lack of high-quality evidence
36 that tracks and compares the burden of acne vulgaris across various regions and countries.
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38 The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 is an
39 extensive study of global health loss that provides up-to-date information on the

3
 1 distribution and burden of diseases across time, age, gender, location, and socio-
2 demographic groups7 . In this study, we extracted data from GBD 2021 to analyze trends in
3 the prevalence, incidence, and DALYs of acne vulgaris among adolescents and young
4 adults across global, regional, and national levels. Furthermore, we stratified these trends
5 by age groups, gender, and sociodemographic index (SDI).

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7 Methods
8 Study population and data collection
9 We obtained the data for this study from the publicly available GBD 2021 datasets, which

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10 can be accessed at https://vizhub.healthdata.org/gbd-results/. The GBD 2021 database
11 provides comprehensive data on 371 diseases and injuries, along with 88 risk factors,

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12 across 204 countries and territories from 1990 to 2021 7,11 . The original data sources and
13 fitting methods for the GBD Study 2021 have been thoroughly detailed in previous
14 studies7 . The analysis process and reproducible statistical codes for estimating acne

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15 vulgaris can be found on the GBD supporting website (http://ghdx.healthdata.org/gbd -
16 2021/code/nonfatal-1). In this study, we focus on the specific methods used to estimate the
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burden of acne vulgaris. All steps in our analysis adhere to the Guidelines for Accurate and
Transparent Health Estimates Reporting (GATHER), with a completed GATHER checklist
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19 provided in Supplementary Table S112 .
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21 In the GBD 2021 assessment, acne vulgaris was defined as a chronic inflammatory disease
22 of the pilosebaceous unit characterized by increased sebum secretion. It was identified
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23 using the International Classification of Diseases 10th edition (ICD-10) diagnostic criteria
24 for acne vulgaris (L70, excluding L70.4). The severity of acne vulgaris in the GBD Study
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25 2021 was categorized into three levels-mild, moderate, and severe-based on expert
26 consensus (Supplementary Table S2). Epidemiological data on acne vulgaris were gathered
27 through searches in PubMed and Google Scholar, supplemented by outpatient data from
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28 several countries. The inclusion criteria for acne vulgaris data in the GBD Study 2021 were
29 as follows: (I) sources published between 1980 and 2017, (II) studies providing incidence
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or prevalence data, (III) studies using samples representative of the general population
31 (excluding those from the experimental arms of clinical trials or dermatology clinics), (IV)
32 a sample size larger than 100, and (V) studies offering sufficient information on research
33 methods and sample characteristics to assess their quality. Based on these criteria, a total
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34 of 108 original data sources were identified for the assessment of acne vulgaris. A bayesian
35 meta-regression modelling tool, DisMod-MR 2.1, was utilized to estimate non-fatal
36 burdens of acne vulgaris based on age, gender, year, and country 7 .
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38 In this secondary analysis, data were collected on acne vulgaris for both genders, across
39 three age groups (10-14 years, 15-19 years, and 20-24 years), and within the 21 regional

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 1 groups of countries that are geographically close and epidemiologically similar, as defined
2 by the GBD project7 . The World Health Organization (WHO) defines adolescence as the
3 age range of 10-19 years. In this study, we defined adolescents as aged 10-19 years and
4 young adults as aged 20-24 years. To provide a more detailed understanding of adolescent
5 growth and the popular understanding of this life phase, we further categorized adolescents

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6 into subgroups: younger adolescents (aged 10-14 years) and older adolescents (aged 15-19

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7 years)13,14 . The numbers of prevalent cases, incident cases, prevalence, incidence, as well
8 as the numbers and rates for DALYs, were directly extracted from the GBD Study 2021.
9 DALYs are calculated as the sum of years lived with disability and years of life lost, with

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10 one DALY representing the loss of one year of full health due to either premature death or
11 disability. GBD 2021 also reported an SDI for each country or territory, which is a

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12 composite indicator of social and economic conditions that influence health outcomes. An
13 SDI value of 0 represents the fewest years of education, the lowest per capita income, and
14 the highest fertility rate. The SDI is divided into five quintiles: low, low-middle, middle,

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15 high-middle, and high8,11 .
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Statistical analysis N
To estimate the age-standardised prevalence, incidence, and DALY rates of acne vulgaris
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19 among adolescents and young adults, we applied age-standardisation by the direct method,
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20 which assumes that the rates are distributed as a weighted sum of independent Poisson
21 random variables15,16 . These standardised metrics were used to quantify differences in the
22 burden of acne vulgaris across various time periods, genders, and locations, thereby
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23 controlling for variations in the age composition of the populations. Our estimates are
24 presented per 100,000 population, calculated using the equation shown at the top of Figure
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25 1. All rates are reported per 100,000 population. The 95% uncertainty intervals (UIs) were
26 defined by the 25th and 975th values of the ordered 1,000 estimates based on the GBD’s
27 algorithm.
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29 Joinpoint regression analysis was used to analyze the temporal trends in age-standardised
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rates of acne vulgaris burden at global, regional, and national levels. This method identifies
31 points with significant changes in trends, divides the overall trend into multiple
32 subsegments based on the observed joinpoints, and assesses the epidemiological trend of
33 each subsegment by calculating the annual percentage change (APC) and 95% confidence
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34 interval (CI). Additionally, the average APC (AAPC) was calculated as a summary measure
35 of the trend over a specified fixed interval, serving as a weighted average of the APC across
36 the segmented intervals17 . The AAPC was calculated using the equation provided in the
37 lower section of Figure 1 and reflects the annual percentage change, indicating whether
38 there was an increase, decrease, or no change. For instance, an AAPC of 0.1 would suggest
39 an annual rate increase of 0.1%. An increasing trend was determined if both the AAPC

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 1 estimate and the lower boundary of the 95% CI were > 0. Conversely, a decreasing trend
2 was determined if both the AAPC estimate and the upper boundary of the 95% CI were <
3 0. If neither condition was met, the trend was considered stable over time. All statistical
4 analyses were conducted using the Joinpoint Regression Program (version 5.0.2) and R
5 (version 4.3.2) (https://www.r-project.org/). Two tailed probability value of P < 0.05 was

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6 considered statistically significant.

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7
8 Results
9 Global trends

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10 Globally, the number of prevalent cases of acne vulgaris among adolescents and young
11 adults increased by 39.2%, from 132.4 million (95% UI 117.2-151.6) in 1990 to 184.3

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12 million (95% UI 163.8-210.5) in 2021 (Table 1). Furthermore, the age-standardised
13 prevalence rate of acne vulgaris increased from 8,563.4 (95% UI 7,343.5-9,920.1) to
14 9,790.5 (95% UI 8,420.9-11,287.2) per 100,000 population between 1990 and 2021, with

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15 an AAPC of 0.43 (95% CI 0.41-0.46) (Supplementary Figure S1). Meanwhile, the number
16 of incident cases of acne vulgaris globally reached 95.8 million (95% UI 81.7-112.5) in
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2021, up from 67.2 million (95% UI 57.7-78.6) in 1990 (Supplementary Table S3). The
age-standardised incidence rate increased with an AAPC of 0.49 (95% CI 0.47-0.50), rising
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19 from 4,396.8 (95% UI 3,448.0-5,547.6) per 100,000 population in 1990 to 5,112.1 (95%
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20 UI 3,988.7-6,468.9) per 100,000 population in 2021 (Supplementary Figure S2).
21 Additionally, the number of DALYs attributable to acne vulgaris reached 3.96 million (95%
22 UI 2.46-6.25) in 2021, representing an approximately 40% increase from 2.84 million
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23 (95% UI 1.76-4.46) DALYs in 1990 (Supplementary Table S4). The age-standardised

24 DALY rate also exhibited an upward trend, increasing from 183.7 (95% UI 112.5-292.2)
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25 per 100,000 population in 1990 to 210.1 (95% UI 129.0-334.3) per 100,000 population in
26 2021 (AAPC = 0.44, 95% CI 0.42-0.46) (Supplementary Figure S3).
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28 Global trends by gender

29 The global burden of acne vulgaris among adolescents and young adults increased for both
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males and females from 1990 to 2021 (Figure 2A-C). In 2021, the age-standardised
31 prevalence rate of acne vulgaris was approximately 25% higher in women than in men
32 (10,911.8 per 100,000 population vs. 8,727.8 per 100,000 population). However, the
33 gender gap in these rates has slightly narrowed over the past 30 years, primarily due to a
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34 more pronounced increase among male patients, with an AAPC of 0.49 for males and 0.39
35 for females (Table 1). Similarly, the age-standardised incidence rate showed an upward
36 trend in both females (AAPC = 0.46, 95% CI 0.44-0.48) and males (AAPC = 0.53, 95%
37 CI 0.52-0.54) (Supplementary Table S3). The age-standardised DALY rates also rose for
38 both genders, with an AAPC of 0.39 (95% CI 0.37-0.41) for females and 0.50 (95% CI
39 0.49-0.51) for males (Supplementary Table S4).

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 1 Global trends by age groups
2 Globally, the age-specific incidence rate of acne vulgaris peaked in the 10-14-year age
3 group and decreased with age (Figure 2E). In 2021, individuals aged 10-14 years accounted
4 for 57.5 million (60.0%) of the 95.8 million incident cases of acne vulgaris among
5 adolescents. However, the age-specific prevalence and DALY rates of acne vulgaris were

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6 primarily concentrated in adolescents aged 15-19 years (Figure 2D, F). The most

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7 significant rise in age-specific prevalence rate between 1990 and 2021 occurred in
8 individuals aged 10-14 years at the global level (AAPC = 0.50, 95% CI 0.48-0.52).
9 Individuals aged 15-19 years also showed an increased prevalence rate during this period,

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10 with an AAPC of 0.44 (95% CI 0.40-0.48). Additionally, the 10-14-year age group
11 experienced the largest increase in age-specific incidence rate from 1990 to 2021, with an

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12 AAPC of 0.65 (95% CI 0.62-0.67). The age-specific DALY rate attributable to acne
13 vulgaris also rose among adolescents aged 10-19 years during this timeframe
14 (Supplementary Table S5).

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16 Global trends by SDI quintiles
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All SDI regions experienced increasing trends in the burden of acne vulgaris from 1990 to
2021. The high SDI region consistently had the highest age-standardised prevalence,
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19 incidence, and DALY rates for acne vulgaris from 1990 to 2021, while the low-middle SDI
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20 region had the lowest rates across these metrics (Figure 2G-I). Notably, despite having the
21 lowest burden of acne vulgaris, the low-middle SDI region experienced the most significant
22 increases in age-standardised prevalence, incidence, and DALY rates during this period (all
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23 AAPCs more than 0.60) (Table 1, Supplementary Table S1-2). Additionally, the low SDI
24 region consistently had the second highest age-standardised prevalence, incidence, and
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25 DALY rates from 1990 to 2021, and also showed the second largest increases in these age-
26 standardised rates (all AAPCs more than 0.50) (Table 1, Supplementary Table S3-4).
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28 Regional trends
29 The GBD regional classification system, covering 204 countries and territories divided into
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21 regions, highlighted significant disparities in the prevalence, incidence, and DALYs of

31 adolescent acne vulgaris across these regions (Figure 3, Supplementary Figure S4-5).
32 Notably, South Asia reported remarkably high numbers in 2021, with 39.6 million
33 prevalent cases, 20.4 million incident cases, and 0.85 million DALYs. At the regional level,
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34 Western Europe exhibited the highest age-standardized prevalence rate (14,584.0 per
35 100,000 population), incidence rate (7,806.1 per 100,000 population), and DALY rate
36 (312.3 per 100,000 population) compared with other regions. On the contrary, Central
37 Europe had the lowest age-standardized prevalence rate (5,264.5 per 100,000 population),
38 incidence rate (2,902.5 per 100,000 population), and DALY rate (113.2 per 100,000
39 population). All GBD regions showed increasing trends in age-standardised prevalence,

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 1 incidence, and DALY rates from 1990 to 2021. Specifically, North Africa and Middle East
2 experienced the most rapid increase in these age-standardised rates (all AAPCs more than
3 0.60). In contrast, the slowest growth in age-standardised prevalence, incidence, and DALY
4 rates (all AAPCs no more than 0.20) was observed in Andean Latin America (Table 1,
5 Supplementary Table S3-4).

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7 National trends
8 At the national level in 2021, India, China, Nigeria, Indonesia, and the USA had the highest
9 number of prevalent cases of acne vulgaris among adolescents and young adults, with India

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10 leading at 30.7 million cases and China following with 26.3 million. Germany recorded the
11 highest age-standardised prevalence rate at 15,979.3 per 100,000 population, with Portugal

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12 close behind (Figure 4A, Supplementary Table S6). Sudan experienced the most significant
13 increase in age-standardised prevalence rate from 1990 to 2021 (AAPC = 0.74), whereas
14 New Zealand was the only country to show a decrease (AAPC = -0.04) (Figure 4B). India

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15 and China also had the highest number of new cases of adolescent acne vulgaris in 2021,
16 with 15.7 million in India and 12.6 million in China. Germany again led in age-standardised
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incidence rate, reaching 8,269.0 per 100,000 population, followed by Norway and Portugal
(Supplementary Figure S6A, Table S6). Iraq had the largest increase in age-standardised
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19 incidence rate from 1990 to 2021 (AAPC = 0.75), while New Zealand showed a slight
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20 decreasing trend (AAPC = -0.01) (Supplementary Figure S6B). For DALYs in 2021, India
21 led with 0.66 million cases, followed by China with 0.57 million. Germany had the highest
22 age-standardised DALY rate at 342.2 per 100,000 population, with Portugal ranking second
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23 (Supplementary Figure S7A, Table S6). Equatorial Guinea saw the largest increase in
24 DALY rates from 1990 to 2021 (AAPC = 0.75), while New Zealand was the only country
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25 to experience a decline (AAPC = -0.04) (Supplementary Figure S7B).

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27 Discussion
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28 Acne vulgaris usually develops with the onset of puberty, when an increase in various
29 endogenous hormones stimulates sebaceous gland activity, leading to the occurrence of
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acne9,18,19. To our knowledge, this is the first study to detail the prevalence and rates of
31 change of acne vulgaris among adolescents and young adults aged 10-24 years across 204
32 countries from 1990 to 2021, at global, regional, and national levels. Based on the GBD
33 2021 study, this comprehensive analysis provides vital insights into the trends in the burden
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34 of acne vulgaris across different demographics and regions, underscoring the urgent need
35 for more effective and targeted interventions.
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37 Increasing Global Burden
38 Our findings reveal a notable increase in the age-standardised prevalence rate of acne
39 vulgaris from 1990 to 2021, rising from 8,563.4 to 9,790.5 per 100,000 population. This

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 1 upward trend reflects the growing impact of acne on the global population among
2 adolescents and young adults aged 10-24 years. The age-standardised incidence and DALY
3 rates mirrored this upward trend, reflecting the escalating health impact of acne vulgaris.
4 Various external and internal factors have been suggested to impact acne, including air
5 pollution, aggressive skincare products, medication, mechanical, hormonal, and genetic

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6 predispositions, as well as lifestyle and stress20 . The persistent rise in the burden of acne

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7 vulgaris calls for a deeper understanding of its underlying causes. It is essential to
8 investigate whether factors such as increased consumption of processed foods, higher stress
9 levels, and greater exposure to pollutants are contributing to the rising prevalence of acne.

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10 Additionally, the role of hormonal changes during adolescence and young adulthood,
11 which are known to exacerbate acne, should be further explored 18,19 .

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12
13 Regional Disparities
14 Our results indicate that acne vulgaris is a common skin disease with significant

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15 geographical variations among adolescents and young adults, aligning with existing
16 data21,22 . In the present study, Western Europe exhibited the highest age-standardised
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prevalence, incidence, and DALY rates, suggesting a significant burden of acne vulgaris in
this region. In contrast, North Africa and the Middle East experienced the largest increases
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19 in these rates, indicating a rapidly growing burden in these areas. These regional disparities
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20 may be attributed to differences in environmental factors, healthcare access, and cultural
21 practices23 .
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23 In Western Europe, the high prevalence of acne may be linked to dietary habits, particularly
24 the consumption of high-glycemic-index foods and dairy products, which have been
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25 associated with acne development24–26 . Additionally, the high levels of pollution in urban
26 areas might exacerbate skin conditions, including acne. Gu et al. suggests that the
27 pathogenesis of air pollution stimulation involves oxidative stress, skin barrier damage,
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28 microbiome dysbiosis, and skin inflammation 27 . In contrast, the significant increase in

29 burden of acne vulgaris in North Africa and the Middle East could be influenced by the
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rapid urbanization and lifestyle changes occurring in these regions. Increased access to
31 processed foods and a sedentary lifestyle may contribute to the rising prevalence of acne.
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33 Socio-Demographic Variations
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34 The study reveals a universal increase in the burden of acne vulgaris among adolescents
35 and young adults across all SDI regions over the three-decade period. The high SDI regions
36 consistently had the highest rates from 1990 to 2021, supporting the existing data showing
37 that acne vulgaris remains a significant public health concern in more developed
38 regions9,28 . High SDI regions are characterised by better access to healthcare and a higher
39 likelihood of reporting and diagnosing acne cases. Additionally, lifestyle factors such as

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 1 dietary habits, life and learning stress, and the prevalence of obesity in high-income
2 countries may contribute to the higher burden 23,24 .
3
4 Low SDI regions also face a significant burden of acne vulgaris, primarily due to limited
5 access to effective skincare products and medical treatments. In many low-income areas,

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6 underdeveloped healthcare infrastructure means that individuals often lack the resources

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7 for professional dermatological care. This can lead to a higher prevalence of untreated acne
8 and more severe cases, resulting in increased DALYs. Moreover, poor sanitation in low
9 SDI regions contribute to higher incidence of acne vulgaris, especially in adolescents and

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10 young adults29 . Overcrowding living conditions further complicates personal hygiene,
11 making it more difficult to manage. The stress associated with living in cramped and

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12 unsanitary environments may also trigger hormonal changes that contribute to acne
13 development. Additionally, a lack of health education in low SDI regions can lead to
14 inadequate skincare routines, improper use of skincare products, and poor hygiene

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15 practices, all of which can increase the burden of acne vulgaris. The widespread use of
16 unregulated or low-quality cosmetic products, often containing comedogenic substances,
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is also more common in these areas and may further increase acne incidence 30 .
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19 Interestingly, the low-middle SDI regions, despite having the lowest burden, showed the
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20 most significant increases. This surge could be due to urbanization and the accompanying
21 lifestyle changes, such as increased consumption of fast food and exposure to pollution. It
22 may also be linked to better diagnostic practices and evolving perceptions of skincare and
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23 beauty31 . Additionally, countries with a low burden of acne vulgaris and limited health
24 resources are unlikely to prioritize acne prevention and treatment in public health
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25 initiatives, particularly in regions with relatively low SDI9,32 .

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27 Age-Specific Trends
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28 Age-related trends for acne vulgaris also emerged from the data, indicating distinct patterns
29 of prevalence and impact across different age groups. Our study identified adolescents aged
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15-19 years as the group with the highest age-specific prevalence and DALY rates, while
31 those aged 10-14 years exhibited the highest age-specific incidence rate. These findings
32 highlight the critical period of adolescence as a time of heightened vulnerability to acne. A
33 cross-sectional online survey of adolescents and young adults aged 15-24 years across
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34 seven European countries reported that acne prevalence peaked at ages 15-17 and declined
35 with increasing age, consistent with the findings of the present study 33 . Hormonal changes
36 during puberty play a significant role in acne development, with increased sebum
37 production and changes in skin microbiota contributing to the condition 18,19,34 .
38
39 Adolescents aged 10-14 years exhibited the largest increase in age-specific prevalence,

10
 1 incidence, and DALY rates The significant increase in acne burden among younger
2 adolescents raises concerns about the early onset of acne and its potential long-term impact.
3 Early intervention is crucial to prevent the progression of acne and minimize its
4 psychosocial effects. The psychosocial burden of acne vulgaris, particularly among
5 adolescents, cannot be ignored35 . Acne can lead to significant emotional distress, affecting

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6 self-esteem, social interactions, and overall quality of life. The stigmatization and bullying

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7 associated with visible skin conditions can exacerbate psychological issues, leading to
8 anxiety, depression, and social withdrawal36,37 . Educational programs targeting
9 adolescents, parents, and educators can promote early recognition and appropriate

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10 management of acne38 . Encouraging healthy skincare practices and seeking timely medical
11 advice can help reduce the burden of acne in this age group.

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12
13 Gender Differences
14 The sex disparity in acne vulgaris prevalence reported in several epidemiological studies

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15 remains controversial, and data for adolescents and young adults aged 10-24 years are
16 particularly sparse22,33,39. However, our results found that the age-standardised prevalence
17
18
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rate of acne vulgaris among females was approximately 1.25 times higher than that of
males. This gender disparity could be attributed to various factors, including hormonal
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19 differences, cosmetic use, and differing skincare routines between genders. Hormonal
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20 fluctuations, particularly during puberty, menstruation, and pregnancy, can exacerbate acne
21 in females. Additionally, the use of certain cosmetics and skincare products may contribute
22 to acne prevalence40 .
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23
24 It is essential to consider the psychosocial impact of acne on different genders. Females
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25 may experience greater psychological distress due to societal beauty standards and the
26 emphasis on clear skin41,42 . Therefore, healthcare providers should adopt a holistic
27 approach to acne treatment, addressing both the physical and emotional aspects of the
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28 condition. Tailored interventions that consider gender-specific needs and concerns can
29 improve treatment outcomes and enhance the quality of life for individuals affected by
30
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acne.
31
32 Need for Effective Interventions
33 The increasing burden of acne vulgaris among adolescents and young adults highlights the
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34 urgent need for more effective and targeted interventions. Current treatment options, such
35 as topical retinoids, antibiotics, and hormonal therapies, may not be sufficient to address
36 the growing prevalence and severity of acne38 . There is a need for innovative approaches
37 that consider the multifactorial nature of acne, including genetic, hormonal, environmental,
38 and lifestyle factors. Developing personalized treatment plans based on individual patient
39 profiles can enhance treatment efficacy and minimize side effects 35,43 . Additionally,

11
 1 promoting healthy dietary practices, stress management, and skincare routines can
2 complement medical treatments and reduce the burden of acne. For high SDI regions,
3 advances in dermatological research, including the identification of novel biomarkers and
4 the development of targeted therapies, hold great promise for improving acne management.
5 Conversely, in low SDI regions, establishing pharmacist-led clinics can enhance access to

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6 skincare advice and treatments. Furthermore, utilizing telehealth services can bridge the

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7 gap in healthcare access, ensuring that more individuals receive the care they need.
8 Implementing community-based programs that educate and empower individuals about
9 effective skincare practices and the importance of early intervention can also be beneficial.

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10
11 Limitations

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12 The limitations of the GDB 2021 database should be considered when interpreting our
13 findings. Firstly, diagnosing acne vulgaris can be particularly challenging in locations with
14 difficult access to health services, leading to potential underdiagnosis or misdiagnosis,

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15 especially in economically deprived groups. Secondly, variability in data collection across
16 regions can cause inconsistencies; well-developed healthcare systems may report higher
17
18
N
acne incidence due to better surveillance, while remote or impoverished areas might
underreport due to limited resources. Thirdly, temporal bias is a concern, as advancements
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19 in diagnostics, healthcare access, and awareness over time can lead to higher reported
M
20 incidences in recent years, potentially skewing the analysis. Fourthly, the psychosocial
21 burden caused by acne vulgaris in adolescents cannot be overlooked. However, the GBD
22 database does not account for the specific impact of acne-related comorbidities in its
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23 evaluation of the overall burden. Future research should prioritize the comprehensive
24 assessment of acne’s impact, including mental health outcomes and the associated
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25 healthcare costs. Finally, the burden of acne vulgaris has continued to increase in almost
26 all countries from 1990 to 2021, but the underlying risk factors remain unclear. Therefore,
27 the findings of this study should be further validated through high-quality real-world
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28 analyses.
29
30
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Conclusion
31 In conclusion, the burden of acne vulgaris among adolescents and young adults has
32 continued to increase in nearly all countries since the 1990s, with significant variations
33 across regions, genders, and age groups. Managing this condition remains a significant
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34 challenge, necessitating more effective and targeted interventions to control the acne
35 burden. Addressing the regional, gender, and age-specific disparities in acne prevalence
36 requires a multifaceted approach that combines medical, psychosocial, and public health
37 strategies. Future research should focus on understanding the underlying risk factors and
38 developing innovative treatment options to address this pervasive and impactful skin
39 condition.

12
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Shen, Y. et al. Prevalence of acne vulgaris in Chinese adolescents and adults: a
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19 (2012).
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20 40. Barbieri, J. S., Shin, D. B., Wang, S., Margolis, D. J. & Takeshita, J. Association of
21 Race/Ethnicity and Sex With Differences in Health Care Use and Treatment for Acne.
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31 Figure legends
32 Figure 1. Equations for calculating age-standardised rates and average annual percentage
33 change (AAPC).
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34
35 Figure 2. Global trends by gender for age-standardised prevalence rate (A), incidence rate
36 (B) and disability-adjusted life-year (DALY) rate (C) of acne vulgaris in adolescents and
37 young adults aged 10-24 years from 1990 to 2021. Global trends by age groups for age-
38 standardised prevalence rate (D), incidence rate (E) and DALY rate (F) of acne vulgaris
39 from 1990 to 2021. Global trends by SDI quintiles for age-standardised prevalence rate

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 1 (G), incidence rate (H) and DALY rate (I) of acne vulgaris from 1990 to 2021.
2
3 Figure 3. The number of prevalent cases (A) and age-standardised prevalence rate (B) for
4 acne vulgaris among adolescents and young adults across 21 Global Burden of Disease
5 (GBD) regions from 1990 to 2021.

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6

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7 Figure 4. The global prevalence of acne vulgaris among adolescents and young adults aged
8 10-24 years in 204 countries and territories. (A) Age-standardised prevalence rate in 2021.
9 (B) Average annual percentage change (AAPC) in prevalence from 1990 to 2021.

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10 Table 1. Age-standardised prevalence and AAPC of acne vulgaris in adolescents and
11 young adults aged 10-24 years at global and regional level, 1990-2021
Prevalence (95% UI)

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Cases in 1990 Age-standardised rate Cases in 2021 Age-standardised rate AAPC (95%
(million) in 1990 (per 100 000) (million) in 2021 (per 100 000) CI)
Global 132.4 (117.2-151.6) 8563.4 (7343.5-9920.1) 184.3 (163.8-210.5) 9790.5 (8420.9-11287.2) 0.43 (0.41-0.46)
Gender:

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Male 58.9 (52.1-67.5) 7490.9 (6425.4-8678.7) 84.4 (74.7-96.4) 8727.8 (7494.4-10099.9) 0.49 (0.48-0.51)
Female 73.5 (65.0-84.1) 9674.4 (8274.9-11203.8) 100.0 (89.0-114.1) 10911.8 (9387.1-12555) 0.39 (0.37-0.41)
SDI level:
High 19.7 (17.6-22.2) 10148.2 (8727.0-11712.7)
N19.8 (18.0-22.1) 10864.9 (9513.1-12305.6) 0.23 (0.20-0.26)
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High-middle 24.7 (21.9-28.2) 8795.4 (7498.5-10263.4) 22.6 (20.0-25.8) 10146.5 (9001.6-11786.8) 0.47 (0.45-0.49)
Middle 46.9 (41.3-53.7) 8576.6 (7318.3-9979.9) 53.5 (47.3-61.6) 9746.0 (8620.9-11291.9) 0.41 (0.41-0.42)
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Low-middle 26.7 (23.5-30.8) 7300.8 (6204.3-8507.0) 48.6 (42.8-55.6) 8795.9 (8323.6-10218.1) 0.60 (0.57-0.63)
Low 14.3 (12.6-16.4) 8999.8 (7687.9-10480.2) 39.6 (35.0-45.4) 10518.0 (7472.3-12235.7) 0.50 (0.48-0.52)
GBD Region:
Andean Latin America 1.4 (1.3-1.6) 11313.6 (9676-13153.8) 2.0 (1.8-2.3) 12008.8 (10193.1-13964.8) 0.19 (0.17-0.21)
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Australasia 0.4 (0.4-0.5) 9225.0 (7706.9-10914.5) 0.6 (0.5-0.6) 9792.4 (8106.4-11707.2) 0.20 (0.16-0.24)
Caribbean 0.8 (0.7-1.0) 7673.1 (6376.1-9210.9) 0.9 (0.8-1.1) 8524.7 (7051.0-10187.7) 0.34 (0.32-0.36)
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Central Asia 1.1 (1.0-1.3) 5580.0 (4577.6-6717.7) 1.3 (1.1-1.5) 6095.6 (5007.4-7317.6) 0.28 (0.26-0.31)
Central Europe 1.4 (1.3-1.5) 4727.6 (4166.2-5317.8) 0.9 (0.9-1.0) 5264.5 (4740.9-5870.4) 0.35 (0.32-0.37)
Central Latin America 4.1 (3.6-4.8) 7511.3 (6317.2-8839.9) 5.4 (4.7-6.3) 8396.3 (7111.2-9868.1) 0.36 (0.35-0.37)
Central Sub-Saharan
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1.7 (1.5-2.0) 9750.6 (8013.6-11700) 5.1 (4.4-6.0) 11053.0 (9096.7-13271.2) 0.40 (0.39-0.42)
Africa
East Asia 34.5 (30.3-39.4) 9575.9 (8062.6-11192.6) 27.3 (23.9-31.2) 11274.4 (9495.4-13108.7) 0.53 (0.52-0.55)
Eastern Europe 2.7 (2.4-3.1) 5737.7 (4856.1-6712.8) 2.1 (1.8-2.4) 6264.1 (5309.8-7329.3) 0.28 (0.27-0.29)
Eastern Sub-Saharan
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7.5 (6.6-8.6) 11767.0 (10076.6-13617.4) 19.9 (17.7-22.7) 13430.6 (11562.7-15484.3) 0.43 (0.41-0.44)
Africa
High-income Asia
4.9 (4.3-5.6) 11420.5 (9729.4-13233.5) 3.1 (2.8-3.6) 12315.2 (10514.7-14259.0) 0.25 (0.18-0.32)
Pacific
High-income North
4.6 (4.2-5.1) 7516.8 (6613.5-8538.4) 5.9 (5.6-6.3) 8294.6 (7597.6-9034.2) 0.32 (0.27-0.36)
America
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North Africa and 9.4 (8.3-10.8) 8486.8 (7179.8-9921.1) 16.6 (14.6-19.1) 10257.8 (8646.7-12004.9) 0.62 (0.59-0.65)
Middle East
Oceania 0.2 (0.1-0.2) 7676.5 (6269.2-9305.1) 0.3 (0.3-0.4) 8401.7 (6861.7-10110.7) 0.29 (0.28-0.30)
South Asia 21.3 (18.9-24.6) 6359.5 (5412.4-7396.8) 39.6 (34.9-45.7) 7559.0 (6435.6-8811.6) 0.56 (0.55-0.57)
Southeast Asia 13.2 (11.5-15.2) 8821.9 (7402.9-10419.9) 17.0 (14.9-19.6) 10051.2 (8466.9-11855.8) 0.42 (0.40-0.44)
Southern Latin America 1.2 (1.0-1.4) 8875.4 (7276.0-10635.6) 1.5 (1.2-1.7) 9618.8 (7803.3-11586.1) 0.30 (0.21-0.38)
Southern Sub-Saharan 1.8 (1.6-2.1) 10397.8 (8774.6-12143.9) 2.6 (2.2-2.9) 11720.9 (9940.9-13681.4) 0.39 (0.37-0.41)
Africa
Tropical Latin America 3.4 (3.0-3.9) 7086.7 (6029.1-8226.1) 3.8 (3.4-4.4) 7870.1 (6699.4-9142.6) 0.34 (0.33-0.35)

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Western Europe 11.1 (9.8-12.5) 13641.9 (11594-15878.1) 10.4 (9.2-11.9) 14584.0 (12434.6-16943.8) 0.24 (0.15-0.33)
Western Sub-Saharan
5.7 (5.0-6.5) 9332.4 (7948.0-10912.0) 17.8 (15.6-20.4) 10790.7 (9205.6-12576.9) 0.46 (0.42-0.50)
Africa
1 Abbreviations: AAPC, average annual percentage change; CI, confidence interval; SDI,
2 sociodemographic index; UI, uncertainty interval.
3

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