Global, regional, and national burden and trends of traumatic brain injury in China and worldwide from 1990 to 2021: insights from the Global Burden of Disease Study 2021

Global, regional, and national burden and trends of traumatic brain injury in China and worldwide from 1990 to 2021: insights from the Global Burden of Disease Study 2021 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Global, regional, and national burden and trends of traumatic brain injury in China and worldwide from 1990 to 2021: insights from the Global Burden of Disease Study 2021 changbin hu, Chenye Qiao, Anda Xiu, chuhan Liu, fanglei li, Boyang Wei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6970495/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives This study aimed to describe the temporal trends in age- and gender-specific burdens of traumatic brain injury (TBI) in China from 1990 to 2021, including incidence, prevalence, and years lived with disability (YLDs), and to compare these trends with the global burden of the disease. Methods Using publicly available data from the Global Burden of Disease (GBD) database (1990–2021), this study analyzed the characteristics of TBI burden in China and globally, focusing on changes in incidence, prevalence, and YLDs. Joinpoint regression analysis was conducted to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect trends in TBI burden. A comprehensive comparative analysis of TBI burden differences between China and the world was performed across multiple dimensions, including age, gender, and time periods. Results Between 1990 and 2021, the age-standardized incidence rate (ASIR) of TBI in China increased from 258.53/100,000 to 265.59/100,000, while the global ASIR decreased from 324.43/100,000 to 259.02/100,000. The age-standardized prevalence rate (ASPR) in China rose slightly from 473.63/100,000 to 481.66/100,000, whereas the global ASPR decreased from 536.72/100,000 to 448.04/100,000. The age-standardized YLDs rate (ASYR) in China increased marginally from 70.83/100,000 to 71.53/100,000, while the global ASYR declined from 77.27/100,000 to 64.76/100,000. The AAPCs of ASIR, ASPR, and ASYR in China were 0.08%, 0.05%, and 0.03%, respectively, in contrast to -0.80%, -0.58%, and -0.57% globally.Men demonstrated higher incidence and prevalence rates of TBI than women across most age groups, whereas women exhibited a greater burden in older age groups. Conclusion From 1990 to 2021, the ASIR, ASPR, and ASYR of TBI in China showed slight increases, indicating a growing burden of TBI. The burden of TBI is closely associated with age, with middle-aged adults exhibiting higher prevalence rates, while older populations face a greater burden of non-fatal disabilities. Men are more susceptible to TBI, bearing a higher burden in younger age groups, whereas women experience a notable increase in the burden among elderly populations. Given the substantial and rapidly aging population in China, this remains a significant challenge,underscoring the urgent need for targeted prevention and intervention strategies. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Traumatic brain injury (TBI), although often considered preventable, poses heavy burdens on the healthcare system and the economy due to its high prevalence, chronic disability propensity, and compromised quality of life[1, 2]. To effectively reduce the incidence of TBI and its social burden, it is imperative for affected countries to systematically implement evidence-based prevention measures[3, 4]. TBI is an acquired brain condition commonly seen in various age groups, resulting from external mechanical forces[5]. Latest findings in neurology indicate that TBI impacts a significant number of individuals each year. In 2019, there were an estimated 27.16 million (95% UI 23.36 to 31.42) new cases, 48.99 million (95% UI 46.84 to 51.32) prevalent cases, and 7.08 million (95% UI 5.00 to 9.59) years lived with disability (YLDs) attributed to TBI globally[6]. It is noteworthy that TBI, while initially presenting as an acute injury, is increasingly being recognized for its chronic sequelae potential, such as an elevated risk of developing late-onset neurodegenerative diseases[7]. Under these circumstances, it is essential to systematically analyse the burden of disease by year, age and sex and to summarize its patterns. These analyses provide an evidence-based foundation for deeper understanding of TBI etiologies and for predicting potential changes in the disease burden in the future[8]. The Latest Global Burden of Disease (GBD) report on TBI places a major emphasis on the epidemiological and economic impacts on a global and regional scale from 1990 to 2019[6]. While existing research has provided a detailed global perspective on TBI, it is still necessary to explore country-specific differences in depth. Such an expansion could more accurately discern the heterogeneity that exists across countries and regions, leading to a more detailed understanding of the burden of disease and its impacts. Our study provides a comprehensive analysis and comparison of the TBI burden in China and worldwide from 1990 to 2019, based on the latest GBD data. Employing Joinpoint regression analyses, we explored the temporal dynamics of TBI and elucidated changes in burden across three decades in terms of age and gender. We aim to provide pivotal insights for decision-makers to assess the overarching burden of TBI in China, thereby supporting the development of targeted preventive measures and equitable distribution of public health resources. Methods Data source Similar to the GBD study 2019, the data collection, processing, and overall analysis methods of the GBD study (2021) have been reported in detail previously[9–11].We collected the data on TBI-related burden from the Institute for Health Metrics and Evaluation (IHME, https://vizhub.healthdata.org/gbd-results/ ). We obtained the data on TBI-related burden about the numbers, rates (per 100,000 population), and age-standardized rates (per 100,000 population) of incidence, prevalence, and YLDs by age, sex, and state from 1990 to 2021. In the GBD study (2021), the TBI were defined based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or the International Classification of Diseases (ICD-10) diagnostic criteria. The ICD-10 codes for traumatic brain injury (TBI) are further classified into various categories[12]. For example, S02.0 represents fracture of vault of skull, S02.8 and S02.91 refer to fracture of other specified skull and facial bones and unspecified fracture respectively, S04.02, S04.03, S04.04 are related to injury of optic chiasm, injury of optic tract and pathways, and injuries of visual cortex, S06 indicates intracranial injury, and S07.1 stands for crushing injury of skull. Additionally, T74.4 is for shaken infant syndrome.These TBI can be classified by severity as well[13]. Mild TBI is often defined as concussion, while severe TBI includes conditions such as skull fracture, edema, brain injury, or bleeding. TBI can result from different causes, like an open head injury, a closed head injury, deceleration injuries, hypoxia, tumors, infections, stroke, or exposure to chemicals or toxins. The institutional ethics committee granted an exemption for this study, as it did not require approval, given that the data from the 2021 GBD are publicly available. This study adhered to the guidelines for accurate and transparent health assessment reporting. Statistical analysis We screened the incidence, prevalence, and YLDs, and corresponding age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized YLD rate (ASYR), and crude incidence rate (CIR), crude prevalence rate (CPR), and crude YLD rate (CYR) for each age group of TBI in China and worldwide from the GBD database. The average annual percentage change (AAPC) and corresponding 95% confidence interval (95% CI) were calculated using Joinpoint software (National Cancer Institute, Rockville, MD, USA) to determine the burden trend of the disease[14].The logarithmic age-standardized indicators can be fitted into a regression model, i.e., ln(y)=α + βx + ε, where y represents the respective age-standardized indicator and x represents the calendar year. The AAPC was calculated as 100 × (exp(β) − 1), and the 95% CI can also be calculated from the model. If the 95% CI of the corresponding AAPC estimate is > 0, the age-standardized indicator shows an increasing trend; if < 0, it shows a decreasing trend; if it includes 0, it shows a stable trend. The statistical analysis and visualization of the data in this study were performed using R statistical software program (version 4.1.3) and Joinpoint software program (version 4.9.1.0). A P value < 0.05 was considered to be statistically significant. Results Description of the burden of TBI in China and worldwide Incidence of TBI in China and worldwide The number of TBI cases in China decreased from 2,955,574 (95% CI: 2,563,349–3,423,630) in 1990 to 4,208,587 (95% CI: 3,574,631–4,884,216) in 2021, representing a cumulative change. The calculation of the cumulative change rate would be 42.39%.However, globally, the incidence decreased from 17,001,269 (95% CI: 14,859,015–19,464,639) in 1990 to 20,837,466 (95% CI: 18,128,307 − 23,839,394) in 2021.The ASIR globally decreased from 324.431 (95% CI: 283.291–370.12) per 100,000 population in 1990 to 259.022 (95% CI: 225.504–296.196) per 100,000 population in 2021. In China, the ASIR increased from 258.531 (95% CI: 224.46–295.086) per 100,000 population in 1990 to 265.594 (95% CI: 226.842–308.75) per 100,000 population in 2021. Meanwhile, the AAPC of the incidence rate in China was 0.0802 (95% CI: -0.4704, 0.6338) from 1990 to 2021, while it was − 0.7999 (95% CI: -0.8551, -0.7446) globally (Table 1 ). Table 1 All-age cases and age-standardized incidence, prevalence, YLDs rates and corresponding AAPC of TBI in China and globally in 1990 and 2019 Location Measure 1990 2021 1990–2021 AAPC All-age cases Age-standardlized rates per 100,000 people All-age cases Age-standardlized rates per 100,000 people N(95%CI) N(95%CI) N(95%CI) N(95%CI) N(95%CI) China Incidence 2955574 (2563349–3423630) 258.531 (224.46-295.086) 4208587 (3574631–4884216) 265.594 (226.842–308.75) 0.0802(-0.4704,0.6338) Prevalence 4978622 (4778745–5227317) 473.632 (454.526-497.376) 9282890 (8842361–9789406) 481.658 (460.206-505.733) 0.0537(-0.1235,0.2313) YLDs 750769 (524411–1023101) 70.833 (49.48-96.565) 1373267 (962256–1872386) 71.534 (49.826–97.4) 0.0318(-0.1468,0.2107) Global Incidence 17001269 (14859015–19464639) 324.431 (283.291–370.12) 20837466 (18128307–23839394) 259.022 (225.504-296.196) -0.7999(-0.8551,-0.7446) Prevalence 24745606 (23861550–25847393) 536.72 (517.441-560.461) 37928494 (36333777–39771327) 448.037 (429.328-469.745) -0.5809(-0.6377,-0.5241) YLDs 3590358 (2532780–4830321) 77.267 (54.515-103.667) 5480354 (3870216–7331092) 64.759 (45.749–86.688) -0.5678(-0.6278,-0.5077) Prevalence of TBI in China and worldwide In China, the prevalence of TBI cases increased from 4,978,622 (95% CI: 4,778,745–5,227,317) in 1990 to 9,282,890 (95% CI: 8,842,361–9,789,406) in 2021. The ASPR globally decreased from 536.72 (95% CI: 517.441–560.461) per 100,000 population in 1990 to 448.037 (95% CI: 429.328–469.745) per 100,000 population in 2021. In China, the ASPR increased from 473.632 (95% CI: 454.526–497.376) per 100,000 population in 1990 to 481.658 (95% CI: 460.206–505.733) per 100,000 population in 2021. Meanwhile, the AAPC of the prevalence in China was 0.0537 (95% CI: -0.1235, 0.2313) from 1990 to 2021, while it was − 0.5809 (95% CI: -0.6377, -0.5241) globally (Table 1 ). YLDs of TBI in China and worldwide In China, the number of YLDs due to TBI increased from 750,769 (95% CI: 524,411–1023,101) in 1990 to 1,373,267 (95% CI: 962,256–1872,386) in 2021. The ASYR globally decreased from 77.267 (95% CI: 54.515–103.667) per 100,000 population in 1990 to 64.759 (95% CI: 45.749–86.688) per 100,000 population in 2021. In China, the ASYR increased from 70.833 (95% CI: 49.48–96.565) per 100,000 population in 1990 to 71.534 (95% CI: 49.826–97.4) per 100,000 population in 2021. Meanwhile, the AAPC of the YLDs in China was 0.0318 (95% CI: -0.1468, 0.2107) from 1990 to 2021, while it was − 0.5678 (95% CI: -0.6278, -0.5077) globally (Table 1 ). Joinpoint regression analysis of the burden of TBI in China and worldwide The Joinpoint regression analysis of ASIR, ASPR, and ASYR for TBI in China from 1990 to 2019 is depicted in Figs. 1 . For ASIR, from 1990 to 2001, the Annual Percentage Change (APC) is 0.29, showing a slight upward trend. From 2001 to 2005, the APC is 3.69, indicating a significant upward trend, and from 2005 to 2021, the APC is 0.90, representing a slow upward trend.For ASPR, from 1990 to 1995, the APC is 0.25 with a slight upward trend. From 1995 to 2000, the APC is 1.38, showing a noticeable upward trend. From 2000 to 2005, the APC is 2.48, signifying a significant upward trend. From 2005 to 2010, the APC is 0.06, indicating relatively stable data. From 2010 to 2021, the APC is 0.76, representing a slow upward trend.For ASYR, from 1990 to 1995, the APC is 0.23 with a slight upward trend. From 1995 to 2000, the APC is 1.36, showing a noticeable upward trend. From 2000 to 2005, the APC is 2.47, signifying a significant upward trend. From 2005 to 2010, the APC is 0.05, indicating relatively stable data. From 2010 to 2021, the APC is 0.70, representing a slow upward trend.Overall, the trends among the three metrics vary from 1990 to 2000. ASIR has a significant increase from 2001 to 2005, while ASPR and ASYR have significant rises from 2000 to 2005. After 2005, all three metrics exhibit slow upward trends. The Joinpoint regression analysis of ASIR, ASPR, and ASYR for TBI in world from 1990 to 2019 is depicted in Figs. 2 .For ASIR, from 1990 to 2021, the Annual Percentage Change (APC) is − 0.80, showing a slow downward trend.For ASPR, from 1990 to 1995, the APC is − 0.52 with a slow downward trend. From 1995 to 2000, the APC is − 0.02, indicating relatively stable data. From 2000 to 2005, the APC is − 1.34, signifying a noticeable downward trend. From 2005 to 2010, the APC is − 0.43, showing a slow downward trend. From 2010 to 2017, the APC is − 1.01, indicating a noticeable downward trend. From 2017 to 2021, the APC is 0.16, representing a slight upward trend.For ASYR, from 1990 to 1995, the APC is 0.50 with a slight upward trend. From 1995 to 2000, the APC is 0.00, indicating relatively stable data. From 2000 to 2005, the APC is − 1.32, signifying a noticeable downward trend. From 2005 to 2010, the APC is 0.40, showing a slight upward trend. From 2010 to 2017, the APC is − 0.99, indicating a noticeable downward trend. From 2017 to 2021, the APC is 0.12, representing a slight upward trend.Overall, the trends among the three metrics vary from 1990 to 2021. ASIR shows a slow downward trend throughout the period. ASPR has a mix of downward and upward trends, with a noticeable downward trend from 2000 to 2017, followed by a slight upward trend from 2017 to 2021. ASYR also has a fluctuating trend with upward and downward changes, showing some stability and some significant changes in different sub - periods. Trends in the burden of TBI in China and worldwide From 1990 to 2021, the trends of traumatic brain injury in China and globally showed distinct patterns across ASPR, ASIR, and ASYR. In China, the ASPR exhibited an overall rise, followed by a decline and gradual rebound, increasing from 473.63 in 1990 to a peak of 495.53 in 2000, then dropping and stabilizing at 481.66 in 2021. The ASIR in China showed a decline until 2005, reaching its lowest point at 229.58, and then steadily increased to 267.87 in 2020, slightly decreasing to 265.59 in 2021. Meanwhile, the ASYR experienced a fluctuating upward trend, starting at 70.83 in 1990, dropping to 69.30 in 2003, and gradually rising to 72.01 in 2020 before a minor decline to 71.53 in 2021.Globally, the ASPR exhibited a steady decline, dropping from 536.72 in 1990 to 444.80 in 2019, with a slight increase to 448.84 in 2020 and stabilizing at 448.04 in 2021. The ASIR also showed a gradual decline, decreasing from 324.43 in 1990 to 259.02 in 2021, with minor fluctuations. The ASYR showed a consistent downward trend, declining from 77.27 in 1990 to 64.76 in 2021. Burden of TBI in different age groups in China in 1990 and 2021 Between 1990 and 2021, the burden of TBI in China and globally exhibited both parallels and distinct differences.For instance, global trends showed a similar aging-related pattern, with incidence rates for the 95 + age group increasing from 583.23 per 100,000 in 1990 to 945.20 per 100,000 in 2021. In contrast, China experienced a more dramatic rise, with incidence rates in the same group reaching 2,095.84 per 100,000 in 2021. Both globally and in China, the burden of TBI among younger populations (0–14 years) declined, with China showing a more pronounced decrease: incidence rates fell from 193.83 to 121.46 per 100,000, compared to the global reduction from 234.02 to 145.71 per 100,000(Fig. 4 a, Supplementary Fig. 1a).In terms of prevalence, the global prevalence rate for the 85–89 age group rose from 1,520.86 per 100,000 in 1990 to 1,797.66 per 100,000 in 2021, while China saw a sharper rise for the same age group, with rates increasing from 958.57 to 2,071.98 per 100,000 during the same period(Fig. 4 b, Supplementary Fig. 1b).YLDs trends also highlighted the increasing burden among older populations. Globally, the YLDs rate for the 85–89 age group rose from 188.19 per 100,000 in 1990 to 231.06 per 100,000 in 2021, while in China, the same group experienced a sharper increase, rising from 127.71 to 281.45 per 100,000. This suggests a relatively greater non-fatal health impact of TBI among China’s elderly population compared to the global average.(Fig. 4 c, Supplementary Fig. 1c). Overall, these trends demonstrate that while both China and the global population face an aging-driven increase in TBI burden, the rates of increase in China, especially among the elderly, are steeper. This underscores the urgent need for targeted interventions in China. At the same time, the significant decline in TBI burden among younger populations in China highlights the success of preventive measures, which could serve as a model for global health strategies. However, the rising burden among middle-aged and elderly populations in both China and globally calls for focused efforts in prevention, early detection, and rehabilitation, tailored to the needs of aging populations. Gender disparities in the burden of TBI in different age groups in China Figures 5 and 6 illustrate the incidence, prevalence, mortality, and YLDs of TBI in different age groups of males and females in China in 1990 and 2021.In 1990, the incidence rate for males aged 30–34 was 178,518, while the incidence rate for males aged 25–29 was 212,878, with other high-incidence age groups including the 0–14 age group (380,092), the 35–39 age group (194,109), and the 40–44 age group (140,345). For females in the same year, the incidence rate for the 30–34 age group was 70,396, significantly lower than that of males, with other high-incidence age groups being the 35–39 age group (79,258) and the 40–44 age group (57,974). By 2021, the incidence rate for males aged 30–34 reached 249,933, marking the highest peak, and middle-aged and older males (30 years and above) showed an increased incidence compared to 1990,the trend is consistent with the global one(Supplementary Fig. 2). Females in 2021 also exhibited a similar trend, with incidence rates for those aged 40 years and above showing significant increases compared to 1990. Overall, in both 1990 and 2021, males consistently exhibited higher incidence rates than females across almost all age groups(Fig. 5 a and 6 a).The prevalence data of TBI in China from 1990 to 2021 shows the number of prevalence cases has increased significantly in all age groups for both males and females. In terms of gender, in 1990, the number of males with TBI prevalence was higher than that of females in most age groups. For example, in the 30–34 age group, the number of males with TBI prevalence was about 268,512, while that of females was about 113,552. Only in the high - age group (such as 95 + years old), the number of females (261) was slightly higher than that of males (66). In 2021, the number of males with TBI prevalence was still higher than that of females in almost all age groups. For example, in the 30–34 age group, the number of males with TBI prevalence was about 326,530 and that of females was about 127,189.In terms of age - group characteristics, in 1990, the number of males with TBI prevalence reached a relatively high peak at the age of 35–39, about 354,032, and the number of females at this age group was also relatively high, about 151,257(Fig. 5 b and 6 b).In 2021, DLYs in most age groups were significantly higher than in 1990, particularly among middle-aged and older populations (50 years and above). For example, DLYs for males aged 55–59 increased from 47,342 in 1990 to 121,982 in 2021, a growth of approximately 2.6 times; for females in the same age group, DLYs increased from 21,259 to 51,774, a growth of approximately 2.4 times.The burden of DLYs in the elderly population (65 years and above) also increased significantly, with both males and females showing substantial growth.In both years, males had higher DLYs than females, especially in the middle-aged and young adult groups (30–49 years). For instance, in 1990, DLYs for males aged 30–34 were 41,814, compared to 17,362 for females. By 2021, DLYs for males in this age group rose to 50,808, while females reached 19,400.However, the increase in DLYs among elderly females was more pronounced in 2021, particularly in the age groups of 70 years and above(Fig. 5 c and 6 c). Figure 7 displayed a comparison of the disease burden and age-standardized rates of TBI in males and females of all ages in China from 1990 to 2021. Figure 7 a shows the ASIR remained stable from 1990 to 2000,, followed by a gradual decline until a sharp increase in 2008. From 2009 to 2020, the ASIR showed a consistent upward trend.The total number of cases and the ASIR for males were consistently higher than those for females, with a larger growth magnitude observed in males(Fig. 7 a).From 1990 to 2021, the total prevalence number for both males and females increased significantly, with males showing a more pronounced increase, reaching over 6 million in 2021, compared to over 3 million for females.From 1990 to 1997, the ASPR remained stable, followed by a slight increase from 1997 to 2000, and then a decline until a sharp spike in 2008. From 2009 to 2020, the ASPR showed a steady upward trend, consistent with the pattern observed in the ASIR, males consistently bore a higher prevalence burden than females, with a more notable growth rate(Fig. 7 b).By 2021, the total YLDs for males approached 1 million, while for females it reached approximately 500,000. From 1990 to 2000, the ASYR remained stable, followed by a decline between 2000 and 2005, and then remained steady until 2021(Fig. 7 c).Although the number of incidence, prevalence, and YLDs have steadily increased over the years in global, the ASIR, ASPR, and ASYR have shown a gradual decline, which is not consistent with the trend observed in China(Supplementary Fig. 3) Discussion In this study, we comprehensively evaluated the incidence, prevalence, and DLYs of TBI in China and worldwide over the past 30 years, based on the GBD 2021 database. We compared the differences in disease burden of TBI in China by age and gender. The results showed that although the absolute burden of TBI (incidence, prevalence, and total YLDs) has increased globally over the years, the age-standardized indicators (ASIR, ASPR, and ASYR) have shown a declining trend, which aligns with findings from previous studies[6]. This trend can likely be attributed to improvements in healthcare systems, enhanced preventive measures, and demographic transitions worldwide[15]. However, the trends in China differ notably, with ASIR and ASPR exhibiting a fluctuating upward trend, while ASYR remained relatively stable or showed a slight increase. Compared to the global trend, China's ASIR increased from 258.53 in 1990 to 265.59 in 2021, whereas the global ASIR decreased from 324.43 to 259.02 during the same period.This divergence may be attributed to several factors. First, China's rapid urbanization and industrialization have significantly increased exposure to high-risk factors, such as traffic accidents and occupational injuries[16]. Second, the accelerated aging of China's population has led to a growing proportion of elderly individuals, resulting in a significant shift in the age distribution of TBI burden, particularly among older age groups. Finally, Feigin et al. indicated that the incidence of traumatic brain injury is six times higher than the officially reported figures[17],the continuous improvement of China's healthcare system in recent years may have enhanced the diagnosis and reporting of TBI, thereby bringing the reported cases closer to actual levels. Gender disparities were prominently observed in this study, with males consistently bearing a significantly higher burden of TBI across all years in terms of ASIR, ASPR, and ASYR, aligning with findings from previous studies[18]. From 1990 to 2021, the growth in TBI burden was particularly pronounced in males; for instance, the total YLDs for males in 2021 approached 1 million, compared to approximately 500,000 for females. This disparity may be attributed to higher levels of occupational exposure, road traffic accidents, and participation in high-risk behaviors among males. Moreover, males engaged in high-risk professions, such as heavy industry and construction, face a significantly increased likelihood of sustaining head injuries[19].However, the TBI burden in females showed a more significant increase in elderly populations (aged 70 years and above), which may be linked to higher risks of osteoporosis, falls, and longer life expectancy among elderly women[20–22].This study revealed a significant shift in the burden of TBI from younger to older populations. In China, the incidence rate of TBI among individuals aged 85 years and older increased from 958.57 per 100,000 in 1990 to 2,071.98 per 100,000 in 2021, a growth rate far exceeding the global trend during the same period. Population aging in China has played a critical role in driving the TBI burden, which aligns with global trends[23].In contrast, the TBI burden in younger populations (0–14 years) has significantly declined both in China and globally. Among the Chinese population aged 0–14 years, the incidence rate of TBI dropped from 193.83 per 100,000 in 1990 to 121.46 per 100,000 in 2021, a decrease greater than that observed globally during the same period. This trend can be attributed to the implementation of road safety regulations in China, such as the mandatory use of helmets and child booster seat, as well as the strengthening of school-based safety education and the effectiveness of child injury prevention measures[24, 25]. We conducted a comprehensive analysis of the current status of the TBI burden in China and globally, focusing on incidence, prevalence, and YLDs from 1990 to 2021. Additionally, the study explored variations in age- and gender-specific burdens of TBI in China. The findings provide valuable insights for health authorities worldwide and could contribute to efforts aimed at reducing the global burden of TBI.However, this study has several limitations that should be acknowledged. Firstly, the data obtained from the GBD relies heavily on statistical modeling, as GBD collaborators employ various modeling techniques, particularly in regions where primary data is scarce or unavailable. Secondly, the diagnosis and detection methods for TBI may have evolved over time, and inconsistencies in data collection and measurement tools across different periods could introduce biases into the analysis. Lastly, while this study presents global TBI data to describe the overall burden, the levels of disease burden can vary significantly across countries and regions due to factors such as socio-economic development, geographic and environmental conditions, genetic and ethnic differences, as well as variations in healthcare resources and accessibility. Consequently, these global estimates may not serve as precise reference points for the disease burden in specific countries or regions. Further in-depth analyses based on localized data are essential to better understand and address the TBI burden in individual settings. Conclusions This study showed the trends and current status of TBI burden in China and global from 1990 to 2021. While global ASIR, ASPR, and ASYR have shown declines, these indicators exhibited slight increases in China, highlighting unique public health challenges.The increasing TBI burden in China is driven by factors such as rapid urbanization, industrialization, and an aging population. Males consistently showed higher burdens in younger and middle-aged groups, while females experienced significant increases among the elderly. Population aging has notably shaped the TBI landscape, while reductions in younger populations reflect the effectiveness of preventive measures.These findings emphasize the urgent need for targeted, age- and gender-specific interventions, alongside enhanced data collection systems, to address the public health impact of TBI. Developing tailored strategies that account for socio-economic and healthcare disparities is critical to reducing the TBI burden in China and worldwide. Declarations Ethical approval Not applicable. No involvement of human subjects. Anonymized publicly accessible population level estimate data used for analysis. Source of funding No funding sources Conflicts of interest disclosure No potential conflicts of interest relevant to this article were reported. Data Statement The datasets generated and/or analyzed during the current study are available at http:// ghdx.healthdata.org/gbd-results-tool. Provenance and peer review Not commissioned, externally peer-reviewed. 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Guan, B., et al., Global, regional and national burden of traumatic brain injury and spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. BMJ Open, 2023. 13(10): p. e075049. Wilson, L., et al., The chronic and evolving neurological consequences of traumatic brain injury. Lancet Neurol, 2017. 16(10): p. 813-825. Sveen, U., et al., Rehabilitation interventions after traumatic brain injury: a scoping review. Disabil Rehabil, 2022. 44(4): p. 653-660. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2133-2161. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2162-2203. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2100-2132. Chen, A.Y. and A. Colantonio, Defining neurotrauma in administrative data using the International Classification of Diseases Tenth Revision. Emerg Themes Epidemiol, 2011. 8(1): p. 4. Mckee, A.C. and D.H. Daneshvar, The neuropathology of traumatic brain injury. Handb Clin Neurol, 2015. 127: p. 45-66. Kim, H.J., et al., Permutation tests for joinpoint regression with applications to cancer rates. Stat Med, 2000. 19(3): p. 335-51. Fatuki, T.A., V. Zvonarev and A.W. Rodas, Prevention of Traumatic Brain Injury in the United States: Significance, New Findings, and Practical Applications. Cureus, 2020. 12(10): p. e11225. Gong, P., et al., Urbanisation and health in China. Lancet, 2012. 379(9818): p. 843-52. Feigin, V.L., et al., Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol, 2013. 12(1): p. 53-64. Teterina, A., et al., Gender versus sex in predicting outcomes of traumatic brain injury: a cohort study utilizing large administrative databases. Sci Rep, 2023. 13(1): p. 18453. Brolin, K., D. Lanner and P. Halldin, Work-related traumatic brain injury in the construction industry in Sweden and Germany. Safety Science, 2021. 136: p. 105147. Salari, N., et al., Global prevalence of osteoporosis among the world older adults: a comprehensive systematic review and meta-analysis. J Orthop Surg Res, 2021. 16(1): p. 669. Johansson, J., A. Nordstrom and P. Nordstrom, Greater Fall Risk in Elderly Women Than in Men Is Associated With Increased Gait Variability During Multitasking. J Am Med Dir Assoc, 2016. 17(6): p. 535-40. Gao, J., et al., Life expectancy among older adults with or without frailty in China: multistate modelling of a national longitudinal cohort study. BMC Med, 2023. 21(1): p. 101. Ma, Z., et al., Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res Rev, 2024. 99: p. 102376. Asbridge, M., et al., The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness. Accid Anal Prev, 2018. 119: p. 50-57. Sone, J.Y., et al., Helmet efficacy against concussion and traumatic brain injury: a review. J Neurosurg, 2017. 126(3): p. 768-781. Supplementary Figures Supplementary Figures 1-3 are not available with this version. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6970495","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491581998,"identity":"fcb9c8d3-b11f-4ab3-a05e-425b880c186d","order_by":0,"name":"changbin hu","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"changbin","middleName":"","lastName":"hu","suffix":""},{"id":491581999,"identity":"6f8848ea-fba7-4421-aa40-f5e33239a07f","order_by":1,"name":"Chenye Qiao","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chenye","middleName":"","lastName":"Qiao","suffix":""},{"id":491582000,"identity":"715256f8-3576-4016-ab53-e0de3d232092","order_by":2,"name":"Anda Xiu","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Anda","middleName":"","lastName":"Xiu","suffix":""},{"id":491582001,"identity":"b56d678f-52d4-4119-a7c6-19c94848cd66","order_by":3,"name":"chuhan Liu","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"chuhan","middleName":"","lastName":"Liu","suffix":""},{"id":491582002,"identity":"95f6d305-2c5c-417e-bb35-da5fb7b0343d","order_by":4,"name":"fanglei li","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"fanglei","middleName":"","lastName":"li","suffix":""},{"id":491582003,"identity":"66307e1d-612f-4e9e-af65-4e19da9a2b9d","order_by":5,"name":"Boyang Wei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBACNv72gw8+/LCR42fv//ggoaKGsBY+iTPJhjN70owlew4YGzw4c4ywFjmGBDNhHrZDiRtuOJhJPmxhJsJhDAfSGGfwHDCWnMGQVpHYwMbA396dgF8Lc+OxBx8s7sjxSzccu5G4Q4ZB4szZDYRsSTecwfPMWHLOwbYbiWfYGAwkcglpSTCT5mE7DPRLMltBYhszSVrS2BiI04II5DPMEglnjvEQ9It8Pzwqexg//qiokeNv78WvBQPwkKZ8FIyCUTAKRgFWAADv008+gvisOAAAAABJRU5ErkJggg==","orcid":"","institution":"Traditional Chinese Medicine Hospital of Huangyan,Taizhou","correspondingAuthor":true,"prefix":"","firstName":"Boyang","middleName":"","lastName":"Wei","suffix":""}],"badges":[],"createdAt":"2025-06-25 04:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6970495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6970495/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87844762,"identity":"6f7a1ad7-34c0-4b97-ad8e-568727af9db8","added_by":"auto","created_at":"2025-07-29 14:51:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49715,"visible":true,"origin":"","legend":"\u003cp\u003eThe APC of ASIR, ASPR, and ASYR of TBI in China from 1990 to 2021 (* means p-values\u0026lt;0.05 and significant results). (a) ASIR; (b) ASPR; (c) ASYR\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/a14139d2950089962b13dc43.png"},{"id":87844763,"identity":"eb5e1c1e-3f7f-4259-a687-d4a7c80e30b3","added_by":"auto","created_at":"2025-07-29 14:51:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41093,"visible":true,"origin":"","legend":"\u003cp\u003eThe APC of ASIR, ASPR, and ASYR of TBI in Global from 1990 to 2021 (* means p-values\u0026lt;0.05 and significant results). (a) ASIR; (b) ASPR; (c) ASYR\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/ef5bce1ac1b2d56b8563932c.png"},{"id":87844764,"identity":"1eb08094-b3da-4217-a8f2-b3a692e27bb2","added_by":"auto","created_at":"2025-07-29 14:51:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":61300,"visible":true,"origin":"","legend":"\u003cp\u003eTrend comparison of ASIR, ASPR,, and ASYR of TBI in China and worldwide from 1990 to 2021\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/b20c3a74a6a4c98b1995057c.png"},{"id":87844765,"identity":"144dc951-5060-4b8e-831f-02cbc7ebf891","added_by":"auto","created_at":"2025-07-29 14:51:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":89045,"visible":true,"origin":"","legend":"\u003cp\u003eComparative of the incidence, prevalence, and YLDs counts, along with their crude rates, by age group in China from 1990 and 2021.(a) Incident cases and CIR; (b) Prevalent cases and CPR; (c) YLDs counts and CYR; Bar charts represent counts; lines represent crude rates\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/91dc35fe6bbd2882ed5bbb24.png"},{"id":87845661,"identity":"271443f6-6ea6-44db-b3c4-4262ccb33ad8","added_by":"auto","created_at":"2025-07-29 14:59:58","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":92142,"visible":true,"origin":"","legend":"\u003cp\u003eomparison of the number of incidence, prevalence, mortality, and DALYs of RHD in males and females of different age groups in China in 1990.(a) Incidence; (b) Prevalence; (c) YLDs\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/615675627cfbced21b1c4883.png"},{"id":87845658,"identity":"c4aebc7a-104f-4794-9608-fc3e1d7d01fd","added_by":"auto","created_at":"2025-07-29 14:59:58","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":87844,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of of the number incidence, prevalence, and YLDs of TBI in males and females of different age groups in China in 2021.(a) Incidence; (b) Prevalence; (c) YLDs\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/95caa9b6a5da646e08f947d1.png"},{"id":87844776,"identity":"59da00a7-4911-4780-9c14-2308e8298b24","added_by":"auto","created_at":"2025-07-29 14:51:58","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":128852,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of full-age cases and age-standardized rates of incidence, prevalence, and YLDs among men and women in China from 1990 to 2021. (a) Incident cases and ASIR; (b) Prevalent cases and ASPR; (c) YLDs counts and CYR.Bar charts represent counts; lines represent age-standardized rates\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/fee3593b9b433bb6c5db9a82.png"},{"id":100563420,"identity":"30904284-63e5-4126-aa28-a2a1912de104","added_by":"auto","created_at":"2026-01-19 08:46:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1189684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6970495/v1/80926c62-4380-4b80-b517-2e799825043d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Global, regional, and national burden and trends of traumatic brain injury in China and worldwide from 1990 to 2021: insights from the Global Burden of Disease Study 2021","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraumatic brain injury (TBI), although often considered preventable, poses heavy burdens on the healthcare system and the economy due to its high prevalence, chronic disability propensity, and compromised quality of life[1, 2]. To effectively reduce the incidence of TBI and its social burden, it is imperative for affected countries to systematically implement evidence-based prevention measures[3, 4].\u003c/p\u003e\u003cp\u003eTBI is an acquired brain condition commonly seen in various age groups, resulting from external mechanical forces[5]. Latest findings in neurology indicate that TBI impacts a significant number of individuals each year. In 2019, there were an estimated 27.16\u0026nbsp;million (95% UI 23.36 to 31.42) new cases, 48.99\u0026nbsp;million (95% UI 46.84 to 51.32) prevalent cases, and 7.08\u0026nbsp;million (95% UI 5.00 to 9.59) years lived with disability (YLDs) attributed to TBI globally[6]. It is noteworthy that TBI, while initially presenting as an acute injury, is increasingly being recognized for its chronic sequelae potential, such as an elevated risk of developing late-onset neurodegenerative diseases[7]. Under these circumstances, it is essential to systematically analyse the burden of disease by year, age and sex and to summarize its patterns. These analyses provide an evidence-based foundation for deeper understanding of TBI etiologies and for predicting potential changes in the disease burden in the future[8].\u003c/p\u003e\u003cp\u003eThe Latest Global Burden of Disease (GBD) report on TBI places a major emphasis on the epidemiological and economic impacts on a global and regional scale from 1990 to 2019[6]. While existing research has provided a detailed global perspective on TBI, it is still necessary to explore country-specific differences in depth. Such an expansion could more accurately discern the heterogeneity that exists across countries and regions, leading to a more detailed understanding of the burden of disease and its impacts. Our study provides a comprehensive analysis and comparison of the TBI burden in China and worldwide from 1990 to 2019, based on the latest GBD data. Employing Joinpoint regression analyses, we explored the temporal dynamics of TBI and elucidated changes in burden across three decades in terms of age and gender. We aim to provide pivotal insights for decision-makers to assess the overarching burden of TBI in China, thereby supporting the development of targeted preventive measures and equitable distribution of public health resources.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData source\u003c/h2\u003e\u003cp\u003eSimilar to the GBD study 2019, the data collection, processing, and overall analysis methods of the GBD study (2021) have been reported in detail previously[9\u0026ndash;11].We collected the data on TBI-related burden from the Institute for Health Metrics and Evaluation (IHME, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://vizhub.healthdata.org/gbd-results/\u003c/span\u003e\u003cspan address=\"https://vizhub.healthdata.org/gbd-results/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). We obtained the data on TBI-related burden about the numbers, rates (per 100,000 population), and age-standardized rates (per 100,000 population) of incidence, prevalence, and YLDs by age, sex, and state from 1990 to 2021.\u003c/p\u003e\u003cp\u003eIn the GBD study (2021), the TBI were defined based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or the International Classification of Diseases (ICD-10) diagnostic criteria. The ICD-10 codes for traumatic brain injury (TBI) are further classified into various categories[12]. For example, S02.0 represents fracture of vault of skull, S02.8 and S02.91 refer to fracture of other specified skull and facial bones and unspecified fracture respectively, S04.02, S04.03, S04.04 are related to injury of optic chiasm, injury of optic tract and pathways, and injuries of visual cortex, S06 indicates intracranial injury, and S07.1 stands for crushing injury of skull. Additionally, T74.4 is for shaken infant syndrome.These TBI can be classified by severity as well[13]. Mild TBI is often defined as concussion, while severe TBI includes conditions such as skull fracture, edema, brain injury, or bleeding. TBI can result from different causes, like an open head injury, a closed head injury, deceleration injuries, hypoxia, tumors, infections, stroke, or exposure to chemicals or toxins. The institutional ethics committee granted an exemption for this study, as it did not require approval, given that the data from the 2021 GBD are publicly available. This study adhered to the guidelines for accurate and transparent health assessment reporting.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eWe screened the incidence, prevalence, and YLDs, and corresponding age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized YLD rate (ASYR), and crude incidence rate (CIR), crude prevalence rate (CPR), and crude YLD rate (CYR) for each age group of TBI in China and worldwide from the GBD database. The average annual percentage change (AAPC) and corresponding 95% confidence interval (95% CI) were calculated using Joinpoint software (National Cancer Institute, Rockville, MD, USA) to determine the burden trend of the disease[14].The logarithmic age-standardized indicators can be fitted into a regression model, i.e., ln(y)=α\u0026thinsp;+\u0026thinsp;βx\u0026thinsp;+\u0026thinsp;ε, where y represents the respective age-standardized indicator and x represents the calendar year. The AAPC was calculated as 100 \u0026times; (exp(β)\u0026thinsp;\u0026minus;\u0026thinsp;1), and the 95% CI can also be calculated from the model. If the 95% CI of the corresponding AAPC estimate is \u0026gt;\u0026thinsp;0, the age-standardized indicator shows an increasing trend; if\u0026thinsp;\u0026lt;\u0026thinsp;0, it shows a decreasing trend; if it includes 0, it shows a stable trend.\u003c/p\u003e\u003cp\u003eThe statistical analysis and visualization of the data in this study were performed using R statistical software program (version 4.1.3) and Joinpoint software program (version 4.9.1.0). A P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDescription of the burden of TBI in China and worldwide Incidence of TBI in China and worldwide\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe number of TBI cases in China decreased from 2,955,574 (95% CI: 2,563,349\u0026ndash;3,423,630) in 1990 to 4,208,587 (95% CI: 3,574,631\u0026ndash;4,884,216) in 2021, representing a cumulative change. The calculation of the cumulative change rate would be 42.39%.However, globally, the incidence decreased from 17,001,269 (95% CI: 14,859,015\u0026ndash;19,464,639) in 1990 to 20,837,466 (95% CI: 18,128,307\u0026thinsp;\u0026minus;\u0026thinsp;23,839,394) in 2021.The ASIR globally decreased from 324.431 (95% CI: 283.291\u0026ndash;370.12) per 100,000 population in 1990 to 259.022 (95% CI: 225.504\u0026ndash;296.196) per 100,000 population in 2021. In China, the ASIR increased from 258.531 (95% CI: 224.46\u0026ndash;295.086) per 100,000 population in 1990 to 265.594 (95% CI: 226.842\u0026ndash;308.75) per 100,000 population in 2021. Meanwhile, the AAPC of the incidence rate in China was 0.0802 (95% CI: -0.4704, 0.6338) from 1990 to 2021, while it was \u0026minus;\u0026thinsp;0.7999 (95% CI: -0.8551, -0.7446) globally (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAll-age cases and age-standardized incidence, prevalence, YLDs rates and corresponding AAPC of TBI in China and globally in 1990 and 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMeasure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1990\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1990\u0026ndash;2021 AAPC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll-age cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge-standardlized rates per 100,000 people\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAll-age cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAge-standardlized rates per 100,000 people\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN(95%CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2955574 (2563349\u0026ndash;3423630)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e258.531 (224.46-295.086)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4208587 (3574631\u0026ndash;4884216)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e265.594 (226.842\u0026ndash;308.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e0.0802(-0.4704,0.6338)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4978622 (4778745\u0026ndash;5227317)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e473.632 (454.526-497.376)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9282890 (8842361\u0026ndash;9789406)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e481.658 (460.206-505.733)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e0.0537(-0.1235,0.2313)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYLDs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e750769 (524411\u0026ndash;1023101)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.833 (49.48-96.565)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1373267 (962256\u0026ndash;1872386)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e71.534 (49.826\u0026ndash;97.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e0.0318(-0.1468,0.2107)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlobal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17001269 (14859015\u0026ndash;19464639)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e324.431 (283.291\u0026ndash;370.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20837466 (18128307\u0026ndash;23839394)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e259.022 (225.504-296.196)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e-0.7999(-0.8551,-0.7446)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrevalence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24745606 (23861550\u0026ndash;25847393)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e536.72 (517.441-560.461)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37928494 (36333777\u0026ndash;39771327)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e448.037 (429.328-469.745)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e-0.5809(-0.6377,-0.5241)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYLDs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3590358 (2532780\u0026ndash;4830321)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.267 (54.515-103.667)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5480354 (3870216\u0026ndash;7331092)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e64.759 (45.749\u0026ndash;86.688)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c7\"\u003e\u003cp\u003e-0.5678(-0.6278,-0.5077)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePrevalence of TBI in China and worldwide\u003c/h3\u003e\n\u003cp\u003eIn China, the prevalence of TBI cases increased from 4,978,622 (95% CI: 4,778,745\u0026ndash;5,227,317) in 1990 to 9,282,890 (95% CI: 8,842,361\u0026ndash;9,789,406) in 2021. The ASPR globally decreased from 536.72 (95% CI: 517.441\u0026ndash;560.461) per 100,000 population in 1990 to 448.037 (95% CI: 429.328\u0026ndash;469.745) per 100,000 population in 2021. In China, the ASPR increased from 473.632 (95% CI: 454.526\u0026ndash;497.376) per 100,000 population in 1990 to 481.658 (95% CI: 460.206\u0026ndash;505.733) per 100,000 population in 2021. Meanwhile, the AAPC of the prevalence in China was 0.0537 (95% CI: -0.1235, 0.2313) from 1990 to 2021, while it was \u0026minus;\u0026thinsp;0.5809 (95% CI: -0.6377, -0.5241) globally (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eYLDs of TBI in China and worldwide\u003c/h3\u003e\n\u003cp\u003eIn China, the number of YLDs due to TBI increased from 750,769 (95% CI: 524,411\u0026ndash;1023,101) in 1990 to 1,373,267 (95% CI: 962,256\u0026ndash;1872,386) in 2021. The ASYR globally decreased from 77.267 (95% CI: 54.515\u0026ndash;103.667) per 100,000 population in 1990 to 64.759 (95% CI: 45.749\u0026ndash;86.688) per 100,000 population in 2021. In China, the ASYR increased from 70.833 (95% CI: 49.48\u0026ndash;96.565) per 100,000 population in 1990 to 71.534 (95% CI: 49.826\u0026ndash;97.4) per 100,000 population in 2021. Meanwhile, the AAPC of the YLDs in China was 0.0318 (95% CI: -0.1468, 0.2107) from 1990 to 2021, while it was \u0026minus;\u0026thinsp;0.5678 (95% CI: -0.6278, -0.5077) globally (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eJoinpoint regression analysis of the burden of TBI in China and worldwide\u003c/h2\u003e\u003cp\u003eThe Joinpoint regression analysis of ASIR, ASPR, and ASYR for TBI in China from 1990 to 2019 is depicted in Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. For ASIR, from 1990 to 2001, the Annual Percentage Change (APC) is 0.29, showing a slight upward trend. From 2001 to 2005, the APC is 3.69, indicating a significant upward trend, and from 2005 to 2021, the APC is 0.90, representing a slow upward trend.For ASPR, from 1990 to 1995, the APC is 0.25 with a slight upward trend. From 1995 to 2000, the APC is 1.38, showing a noticeable upward trend. From 2000 to 2005, the APC is 2.48, signifying a significant upward trend. From 2005 to 2010, the APC is 0.06, indicating relatively stable data. From 2010 to 2021, the APC is 0.76, representing a slow upward trend.For ASYR, from 1990 to 1995, the APC is 0.23 with a slight upward trend. From 1995 to 2000, the APC is 1.36, showing a noticeable upward trend. From 2000 to 2005, the APC is 2.47, signifying a significant upward trend. From 2005 to 2010, the APC is 0.05, indicating relatively stable data. From 2010 to 2021, the APC is 0.70, representing a slow upward trend.Overall, the trends among the three metrics vary from 1990 to 2000. ASIR has a significant increase from 2001 to 2005, while ASPR and ASYR have significant rises from 2000 to 2005. After 2005, all three metrics exhibit slow upward trends.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe Joinpoint regression analysis of ASIR, ASPR, and ASYR for TBI in world from 1990 to 2019 is depicted in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.For ASIR, from 1990 to 2021, the Annual Percentage Change (APC) is \u0026minus;\u0026thinsp;0.80, showing a slow downward trend.For ASPR, from 1990 to 1995, the APC is \u0026minus;\u0026thinsp;0.52 with a slow downward trend. From 1995 to 2000, the APC is \u0026minus;\u0026thinsp;0.02, indicating relatively stable data. From 2000 to 2005, the APC is \u0026minus;\u0026thinsp;1.34, signifying a noticeable downward trend. From 2005 to 2010, the APC is \u0026minus;\u0026thinsp;0.43, showing a slow downward trend. From 2010 to 2017, the APC is \u0026minus;\u0026thinsp;1.01, indicating a noticeable downward trend. From 2017 to 2021, the APC is 0.16, representing a slight upward trend.For ASYR, from 1990 to 1995, the APC is 0.50 with a slight upward trend. From 1995 to 2000, the APC is 0.00, indicating relatively stable data. From 2000 to 2005, the APC is \u0026minus;\u0026thinsp;1.32, signifying a noticeable downward trend. From 2005 to 2010, the APC is 0.40, showing a slight upward trend. From 2010 to 2017, the APC is \u0026minus;\u0026thinsp;0.99, indicating a noticeable downward trend. From 2017 to 2021, the APC is 0.12, representing a slight upward trend.Overall, the trends among the three metrics vary from 1990 to 2021. ASIR shows a slow downward trend throughout the period. ASPR has a mix of downward and upward trends, with a noticeable downward trend from 2000 to 2017, followed by a slight upward trend from 2017 to 2021. ASYR also has a fluctuating trend with upward and downward changes, showing some stability and some significant changes in different sub - periods.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTrends in the burden of TBI in China and worldwide\u003c/h3\u003e\n\u003cp\u003eFrom 1990 to 2021, the trends of traumatic brain injury in China and globally showed distinct patterns across ASPR, ASIR, and ASYR. In China, the ASPR exhibited an overall rise, followed by a decline and gradual rebound, increasing from 473.63 in 1990 to a peak of 495.53 in 2000, then dropping and stabilizing at 481.66 in 2021. The ASIR in China showed a decline until 2005, reaching its lowest point at 229.58, and then steadily increased to 267.87 in 2020, slightly decreasing to 265.59 in 2021. Meanwhile, the ASYR experienced a fluctuating upward trend, starting at 70.83 in 1990, dropping to 69.30 in 2003, and gradually rising to 72.01 in 2020 before a minor decline to 71.53 in 2021.Globally, the ASPR exhibited a steady decline, dropping from 536.72 in 1990 to 444.80 in 2019, with a slight increase to 448.84 in 2020 and stabilizing at 448.04 in 2021. The ASIR also showed a gradual decline, decreasing from 324.43 in 1990 to 259.02 in 2021, with minor fluctuations. The ASYR showed a consistent downward trend, declining from 77.27 in 1990 to 64.76 in 2021.\u003c/p\u003e\n\u003ch3\u003eBurden of TBI in different age groups in China in 1990 and 2021\u003c/h3\u003e\n\u003cp\u003eBetween 1990 and 2021, the burden of TBI in China and globally exhibited both parallels and distinct differences.For instance, global trends showed a similar aging-related pattern, with incidence rates for the 95\u0026thinsp;+\u0026thinsp;age group increasing from 583.23 per 100,000 in 1990 to 945.20 per 100,000 in 2021. In contrast, China experienced a more dramatic rise, with incidence rates in the same group reaching 2,095.84 per 100,000 in 2021. Both globally and in China, the burden of TBI among younger populations (0\u0026ndash;14 years) declined, with China showing a more pronounced decrease: incidence rates fell from 193.83 to 121.46 per 100,000, compared to the global reduction from 234.02 to 145.71 per 100,000(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea, Supplementary Fig.\u0026nbsp;1a).In terms of prevalence, the global prevalence rate for the 85\u0026ndash;89 age group rose from 1,520.86 per 100,000 in 1990 to 1,797.66 per 100,000 in 2021, while China saw a sharper rise for the same age group, with rates increasing from 958.57 to 2,071.98 per 100,000 during the same period(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb, Supplementary Fig.\u0026nbsp;1b).YLDs trends also highlighted the increasing burden among older populations. Globally, the YLDs rate for the 85\u0026ndash;89 age group rose from 188.19 per 100,000 in 1990 to 231.06 per 100,000 in 2021, while in China, the same group experienced a sharper increase, rising from 127.71 to 281.45 per 100,000. This suggests a relatively greater non-fatal health impact of TBI among China\u0026rsquo;s elderly population compared to the global average.(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ec, Supplementary Fig.\u0026nbsp;1c).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOverall, these trends demonstrate that while both China and the global population face an aging-driven increase in TBI burden, the rates of increase in China, especially among the elderly, are steeper. This underscores the urgent need for targeted interventions in China. At the same time, the significant decline in TBI burden among younger populations in China highlights the success of preventive measures, which could serve as a model for global health strategies. However, the rising burden among middle-aged and elderly populations in both China and globally calls for focused efforts in prevention, early detection, and rehabilitation, tailored to the needs of aging populations.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eGender disparities in the burden of TBI in different age groups in China\u003c/h2\u003e\u003cp\u003eFigures \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e illustrate the incidence, prevalence, mortality, and YLDs of TBI in different age groups of males and females in China in 1990 and 2021.In 1990, the incidence rate for males aged 30\u0026ndash;34 was 178,518, while the incidence rate for males aged 25\u0026ndash;29 was 212,878, with other high-incidence age groups including the 0\u0026ndash;14 age group (380,092), the 35\u0026ndash;39 age group (194,109), and the 40\u0026ndash;44 age group (140,345). For females in the same year, the incidence rate for the 30\u0026ndash;34 age group was 70,396, significantly lower than that of males, with other high-incidence age groups being the 35\u0026ndash;39 age group (79,258) and the 40\u0026ndash;44 age group (57,974). By 2021, the incidence rate for males aged 30\u0026ndash;34 reached 249,933, marking the highest peak, and middle-aged and older males (30 years and above) showed an increased incidence compared to 1990,the trend is consistent with the global one(Supplementary Fig.\u0026nbsp;2). Females in 2021 also exhibited a similar trend, with incidence rates for those aged 40 years and above showing significant increases compared to 1990. Overall, in both 1990 and 2021, males consistently exhibited higher incidence rates than females across almost all age groups(Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ea and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ea).The prevalence data of TBI in China from 1990 to 2021 shows the number of prevalence cases has increased significantly in all age groups for both males and females. In terms of gender, in 1990, the number of males with TBI prevalence was higher than that of females in most age groups. For example, in the 30\u0026ndash;34 age group, the number of males with TBI prevalence was about 268,512, while that of females was about 113,552. Only in the high - age group (such as 95\u0026thinsp;+\u0026thinsp;years old), the number of females (261) was slightly higher than that of males (66). In 2021, the number of males with TBI prevalence was still higher than that of females in almost all age groups. For example, in the 30\u0026ndash;34 age group, the number of males with TBI prevalence was about 326,530 and that of females was about 127,189.In terms of age - group characteristics, in 1990, the number of males with TBI prevalence reached a relatively high peak at the age of 35\u0026ndash;39, about 354,032, and the number of females at this age group was also relatively high, about 151,257(Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eb and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eb).In 2021, DLYs in most age groups were significantly higher than in 1990, particularly among middle-aged and older populations (50 years and above). For example, DLYs for males aged 55\u0026ndash;59 increased from 47,342 in 1990 to 121,982 in 2021, a growth of approximately 2.6 times; for females in the same age group, DLYs increased from 21,259 to 51,774, a growth of approximately 2.4 times.The burden of DLYs in the elderly population (65 years and above) also increased significantly, with both males and females showing substantial growth.In both years, males had higher DLYs than females, especially in the middle-aged and young adult groups (30\u0026ndash;49 years). For instance, in 1990, DLYs for males aged 30\u0026ndash;34 were 41,814, compared to 17,362 for females. By 2021, DLYs for males in this age group rose to 50,808, while females reached 19,400.However, the increase in DLYs among elderly females was more pronounced in 2021, particularly in the age groups of 70 years and above(Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ec and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ec).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e displayed a comparison of the disease burden and age-standardized rates of TBI in males and females of all ages in China from 1990 to 2021. Figure\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003ea shows the ASIR remained stable from 1990 to 2000,, followed by a gradual decline until a sharp increase in 2008. From 2009 to 2020, the ASIR showed a consistent upward trend.The total number of cases and the ASIR for males were consistently higher than those for females, with a larger growth magnitude observed in males(Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003ea).From 1990 to 2021, the total prevalence number for both males and females increased significantly, with males showing a more pronounced increase, reaching over 6\u0026nbsp;million in 2021, compared to over 3\u0026nbsp;million for females.From 1990 to 1997, the ASPR remained stable, followed by a slight increase from 1997 to 2000, and then a decline until a sharp spike in 2008. From 2009 to 2020, the ASPR showed a steady upward trend, consistent with the pattern observed in the ASIR, males consistently bore a higher prevalence burden than females, with a more notable growth rate(Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eb).By 2021, the total YLDs for males approached 1\u0026nbsp;million, while for females it reached approximately 500,000. From 1990 to 2000, the ASYR remained stable, followed by a decline between 2000 and 2005, and then remained steady until 2021(Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003ec).Although the number of incidence, prevalence, and YLDs have steadily increased over the years in global, the ASIR, ASPR, and ASYR have shown a gradual decline, which is not consistent with the trend observed in China(Supplementary Fig.\u0026nbsp;3)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we comprehensively evaluated the incidence, prevalence, and DLYs of TBI in China and worldwide over the past 30 years, based on the GBD 2021 database. We compared the differences in disease burden of TBI in China by age and gender. The results showed that although the absolute burden of TBI (incidence, prevalence, and total YLDs) has increased globally over the years, the age-standardized indicators (ASIR, ASPR, and ASYR) have shown a declining trend, which aligns with findings from previous studies[6]. This trend can likely be attributed to improvements in healthcare systems, enhanced preventive measures, and demographic transitions worldwide[15]. However, the trends in China differ notably, with ASIR and ASPR exhibiting a fluctuating upward trend, while ASYR remained relatively stable or showed a slight increase. Compared to the global trend, China's ASIR increased from 258.53 in 1990 to 265.59 in 2021, whereas the global ASIR decreased from 324.43 to 259.02 during the same period.This divergence may be attributed to several factors. First, China's rapid urbanization and industrialization have significantly increased exposure to high-risk factors, such as traffic accidents and occupational injuries[16]. Second, the accelerated aging of China's population has led to a growing proportion of elderly individuals, resulting in a significant shift in the age distribution of TBI burden, particularly among older age groups. Finally, Feigin et al. indicated that the incidence of traumatic brain injury is six times higher than the officially reported figures[17],the continuous improvement of China's healthcare system in recent years may have enhanced the diagnosis and reporting of TBI, thereby bringing the reported cases closer to actual levels.\u003c/p\u003e\u003cp\u003eGender disparities were prominently observed in this study, with males consistently bearing a significantly higher burden of TBI across all years in terms of ASIR, ASPR, and ASYR, aligning with findings from previous studies[18]. From 1990 to 2021, the growth in TBI burden was particularly pronounced in males; for instance, the total YLDs for males in 2021 approached 1\u0026nbsp;million, compared to approximately 500,000 for females. This disparity may be attributed to higher levels of occupational exposure, road traffic accidents, and participation in high-risk behaviors among males. Moreover, males engaged in high-risk professions, such as heavy industry and construction, face a significantly increased likelihood of sustaining head injuries[19].However, the TBI burden in females showed a more significant increase in elderly populations (aged 70 years and above), which may be linked to higher risks of osteoporosis, falls, and longer life expectancy among elderly women[20\u0026ndash;22].This study revealed a significant shift in the burden of TBI from younger to older populations. In China, the incidence rate of TBI among individuals aged 85 years and older increased from 958.57 per 100,000 in 1990 to 2,071.98 per 100,000 in 2021, a growth rate far exceeding the global trend during the same period. Population aging in China has played a critical role in driving the TBI burden, which aligns with global trends[23].In contrast, the TBI burden in younger populations (0\u0026ndash;14 years) has significantly declined both in China and globally. Among the Chinese population aged 0\u0026ndash;14 years, the incidence rate of TBI dropped from 193.83 per 100,000 in 1990 to 121.46 per 100,000 in 2021, a decrease greater than that observed globally during the same period. This trend can be attributed to the implementation of road safety regulations in China, such as the mandatory use of helmets and child booster seat, as well as the strengthening of school-based safety education and the effectiveness of child injury prevention measures[24, 25].\u003c/p\u003e\u003cp\u003eWe conducted a comprehensive analysis of the current status of the TBI burden in China and globally, focusing on incidence, prevalence, and YLDs from 1990 to 2021. Additionally, the study explored variations in age- and gender-specific burdens of TBI in China. The findings provide valuable insights for health authorities worldwide and could contribute to efforts aimed at reducing the global burden of TBI.However, this study has several limitations that should be acknowledged. Firstly, the data obtained from the GBD relies heavily on statistical modeling, as GBD collaborators employ various modeling techniques, particularly in regions where primary data is scarce or unavailable. Secondly, the diagnosis and detection methods for TBI may have evolved over time, and inconsistencies in data collection and measurement tools across different periods could introduce biases into the analysis. Lastly, while this study presents global TBI data to describe the overall burden, the levels of disease burden can vary significantly across countries and regions due to factors such as socio-economic development, geographic and environmental conditions, genetic and ethnic differences, as well as variations in healthcare resources and accessibility. Consequently, these global estimates may not serve as precise reference points for the disease burden in specific countries or regions. Further in-depth analyses based on localized data are essential to better understand and address the TBI burden in individual settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study showed the trends and current status of TBI burden in China and global from 1990 to 2021. While global ASIR, ASPR, and ASYR have shown declines, these indicators exhibited slight increases in China, highlighting unique public health challenges.The increasing TBI burden in China is driven by factors such as rapid urbanization, industrialization, and an aging population. Males consistently showed higher burdens in younger and middle-aged groups, while females experienced significant increases among the elderly. Population aging has notably shaped the TBI landscape, while reductions in younger populations reflect the effectiveness of preventive measures.These findings emphasize the urgent need for targeted, age- and gender-specific interventions, alongside enhanced data collection systems, to address the public health impact of TBI. Developing tailored strategies that account for socio-economic and healthcare disparities is critical to reducing the TBI burden in China and worldwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No involvement of human subjects. Anonymized publicly accessible population level estimate data used for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding sources\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflicts of interest relevant to this article were reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available at http://\u003c/p\u003e\n\u003cp\u003eghdx.healthdata.org/gbd-results-tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot commissioned, externally peer-reviewed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eValentim, W., R. Bertani and S. Brasil, A Narrative Review on Financial Challenges and Health Care Costs Associated with Traumatic Brain Injury in the United States. World Neurosurg, 2024. 187: p. 82-92.\u003c/li\u003e\n \u003cli\u003eMartinez, B.I., et al., Uncovering temporospatial sensitive TBI targeting strategies via in vivo phage display. Sci Adv, 2022. 8(29): p. eabo5047.\u003c/li\u003e\n \u003cli\u003eKim, H.K., et al., Decreasing Incidence and Mortality in Traumatic Brain Injury in Korea, 2008-2017: A Population-Based Longitudinal Study. Int J Environ Res Public Health, 2020. 17(17).\u003c/li\u003e\n \u003cli\u003eTaylor, C.A., et al., Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. MMWR Surveill Summ, 2017. 66(9): p. 1-16.\u003c/li\u003e\n \u003cli\u003eMaas, A., et al., Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol, 2022. 21(11): p. 1004-1060.\u003c/li\u003e\n \u003cli\u003eGuan, B., et al., Global, regional and national burden of traumatic brain injury and spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. BMJ Open, 2023. 13(10): p. e075049.\u003c/li\u003e\n \u003cli\u003eWilson, L., et al., The chronic and evolving neurological consequences of traumatic brain injury. Lancet Neurol, 2017. 16(10): p. 813-825.\u003c/li\u003e\n \u003cli\u003eSveen, U., et al., Rehabilitation interventions after traumatic brain injury: a scoping review. Disabil Rehabil, 2022. 44(4): p. 653-660.\u003c/li\u003e\n \u003cli\u003eGlobal incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2133-2161.\u003c/li\u003e\n \u003cli\u003eGlobal burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2162-2203.\u003c/li\u003e\n \u003cli\u003eGlobal burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024. 403(10440): p. 2100-2132.\u003c/li\u003e\n \u003cli\u003eChen, A.Y. and A. Colantonio, Defining neurotrauma in administrative data using the International Classification of Diseases Tenth Revision. Emerg Themes Epidemiol, 2011. 8(1): p. 4.\u003c/li\u003e\n \u003cli\u003eMckee, A.C. and D.H. Daneshvar, The neuropathology of traumatic brain injury. Handb Clin Neurol, 2015. 127: p. 45-66.\u003c/li\u003e\n \u003cli\u003eKim, H.J., et al., Permutation tests for joinpoint regression with applications to cancer rates. Stat Med, 2000. 19(3): p. 335-51.\u003c/li\u003e\n \u003cli\u003eFatuki, T.A., V. Zvonarev and A.W. Rodas, Prevention of Traumatic Brain Injury in the United States: Significance, New Findings, and Practical Applications. Cureus, 2020. 12(10): p. e11225.\u003c/li\u003e\n \u003cli\u003eGong, P., et al., Urbanisation and health in China. Lancet, 2012. 379(9818): p. 843-52.\u003c/li\u003e\n \u003cli\u003eFeigin, V.L., et al., Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol, 2013. 12(1): p. 53-64.\u003c/li\u003e\n \u003cli\u003eTeterina, A., et al., Gender versus sex in predicting outcomes of traumatic brain injury: a cohort study utilizing large administrative databases. Sci Rep, 2023. 13(1): p. 18453.\u003c/li\u003e\n \u003cli\u003eBrolin, K., D. Lanner and P. Halldin, Work-related traumatic brain injury in the construction industry in Sweden and Germany. Safety Science, 2021. 136: p. 105147.\u003c/li\u003e\n \u003cli\u003eSalari, N., et al., Global prevalence of osteoporosis among the world older adults: a comprehensive systematic review and meta-analysis. J Orthop Surg Res, 2021. 16(1): p. 669.\u003c/li\u003e\n \u003cli\u003eJohansson, J., A. Nordstrom and P. Nordstrom, Greater Fall Risk in Elderly Women Than in Men Is Associated With Increased Gait Variability During Multitasking. J Am Med Dir Assoc, 2016. 17(6): p. 535-40.\u003c/li\u003e\n \u003cli\u003eGao, J., et al., Life expectancy among older adults with or without frailty in China: multistate modelling of a national longitudinal cohort study. BMC Med, 2023. 21(1): p. 101.\u003c/li\u003e\n \u003cli\u003eMa, Z., et al., Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res Rev, 2024. 99: p. 102376.\u003c/li\u003e\n \u003cli\u003eAsbridge, M., et al., The impact of booster seat use on child injury and mortality: Systematic review and meta-analysis of observational studies of booster seat effectiveness. Accid Anal Prev, 2018. 119: p. 50-57.\u003c/li\u003e\n \u003cli\u003eSone, J.Y., et al., Helmet efficacy against concussion and traumatic brain injury: a review. J Neurosurg, 2017. 126(3): p. 768-781.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplementary Figures","content":"\u003cp\u003eSupplementary Figures 1-3 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6970495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6970495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e This study aimed to describe the temporal trends in age- and gender-specific burdens of traumatic brain injury (TBI) in China from 1990 to 2021, including incidence, prevalence, and years lived with disability (YLDs), and to compare these trends with the global burden of the disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eUsing publicly available data from the Global Burden of Disease (GBD) database (1990–2021), this study analyzed the characteristics of TBI burden in China and globally, focusing on changes in incidence, prevalence, and YLDs. Joinpoint regression analysis was conducted to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect trends in TBI burden. A comprehensive comparative analysis of TBI burden differences between China and the world was performed across multiple dimensions, including age, gender, and time periods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Between 1990 and 2021, the age-standardized incidence rate (ASIR) of TBI in China increased from 258.53/100,000 to 265.59/100,000, while the global ASIR decreased from 324.43/100,000 to 259.02/100,000. The age-standardized prevalence rate (ASPR) in China rose slightly from 473.63/100,000 to 481.66/100,000, whereas the global ASPR decreased from 536.72/100,000 to 448.04/100,000. The age-standardized YLDs rate (ASYR) in China increased marginally from 70.83/100,000 to 71.53/100,000, while the global ASYR declined from 77.27/100,000 to 64.76/100,000. The AAPCs of ASIR, ASPR, and ASYR in China were 0.08%, 0.05%, and 0.03%, respectively, in contrast to -0.80%, -0.58%, and -0.57% globally.Men demonstrated higher incidence and prevalence rates of TBI than women across most age groups, whereas women exhibited a greater burden in older age groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e From 1990 to 2021, the ASIR, ASPR, and ASYR of TBI in China showed slight increases, indicating a growing burden of TBI. The burden of TBI is closely associated with age, with middle-aged adults exhibiting higher prevalence rates, while older populations face a greater burden of non-fatal disabilities. Men are more susceptible to TBI, bearing a higher burden in younger age groups, whereas women experience a notable increase in the burden among elderly populations. Given the substantial and rapidly aging population in China, this remains a significant challenge,underscoring the urgent need for targeted prevention and intervention strategies.\u003c/p\u003e","manuscriptTitle":"Global, regional, and national burden and trends of traumatic brain injury in China and worldwide from 1990 to 2021: insights from the Global Burden of Disease Study 2021","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 14:51:53","doi":"10.21203/rs.3.rs-6970495/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b729cce-73df-45ec-b383-5868fc80f20f","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T08:43:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 14:51:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6970495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6970495","identity":"rs-6970495","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}