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RESEARCH
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Open Access
BMC Gastroenterology
The global, regional, andnational
burden ofappendicitis in204 countries
andterritories, 1990–2019: asystematic analysis
fromtheGlobal Burden ofDisease Study 2019
Linjing Guan1†, Zhen Liu2†, Guangdong Pan2, Bulin Zhang1, Yongrong Wu2, Tao Gan3*† and Guoqing Ouyang3*†
Abstract
Background Appendicitis is the most common abdominal surgical emergency worldwide, and its burden has been
changing. We report the level and trends of appendicitis prevalence, and incidence; and years lived with disability
(YLD) in 204 countries and territories from 1990 to 2019, based on data from the Global Burden of Diseases, Injuries,
and Risk Factors Study (GBD) 2019.
Methods The numbers and age-standardized prevalence, incidence, and YLD rates per 100,000 population of appen-
dicitis were estimated across regions and countries by age, sex, and sociodemographic index (SDI). All the estimates
were reported with 95% uncertainty intervals (UIs).
Results Globally, the age-standardized prevalence and incidence rates of appendicitis in 2019 were 8.7 (95% UI 6.9
to 11.0) and 229.9 (95% UI 180.9 to 291.0) per 100,000 population, with increases of 20.8% (95% UI 18.9 to 23.0%) and
20.5% (95% UI 18.7 to 22.8%) from 1990 to 2019, respectively. Additionally, the age-standardized YLDs rate was 2.7
(95% UI 1.8 to 3.9) in 2019, with an increase of 20.4% (95% UI 16.2 to 25.1%) from 1990 to 2019. In 2019, the age-
standardized prevalence, incidence, and YLD rates peaked in the 15-to-19-year age groups in both male and female
individuals. However, no statistically significant differences were observed between the male and female individuals in
all groups. Ethiopia, India, and Nigeria showed the largest increases in the age-standardized prevalence rate between
1990 and 2019. Generally, positive associations were found between the age-standardized YLD rates and SDI at the
regional and national levels.
Conclusions Appendicitis remains a major public health challenge globally. Increasing awareness of appendicitis
and its risk factors and the importance of early diagnosis and treatment is warranted to reduce its the burden.
Keywords Appendicitis, Global Burden of Disease, Prevalence, Incidence, Years lived with disability
†Linjing Guan and Zhen Liu contributed equally as the first authors
†Tao Gan and Guoqing Ouyang contributed equally as co-authors
*Correspondence:
Tao Gan
gantao11@sina.com
Guoqing Ouyang
Ouyangguoqing@stu.gxmu.edu.cn
1 Department of Abdominal Ultrasound, Liuzhou People’s Hospital
Affiliated to Guangxi Medical University, Liuzhou, Guangxi, China
2 Department of Hepatobiliary Surgery, Liuzhou People’s Hospital
Affiliated to Guangxi Medical University, Liuzhou, Guangxi, China
3 Department of General Surgery, Liuzhou People’s Hospital Affiliated
to Guangxi Medical University, Liuzhou 545006, Guangxi, China
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Page 2 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
Background
Appendicitis is the most common abdominal surgi-
cal emergency worldwide, and it can lead to serious
complications, such as ileus, peritonitis, abscess, and
even death, as well as significant costs to the health-
care system [1, 2]. The incidence of appendicitis is
approximately 233 per 100,000 population per year,
with a lifetime incidence risk ranging from 6.7 to 8.6%
[3, 4]. Although Western countries have reported a
decrease in its incidence in the mid-twentieth century,
newly industrialized countries have shown an increas-
ing trend in the twenty-first century [4–6]. With the
increasing accuracy of acute appendicitis, ultrasound
and computed tomography (CT) were the most com-
mon modalities and promote the use of antibiotics.For
patients without high-risk CT findings, management
of antibiotics first is suggested, and surgery can be rec-
ommended if antibiotic treatment fails [7].
In 2018, World Health Organization (WHO) dis-
closed estimates of the cause-specific years of life lost
(YLL), years lived with disability (YLD), and disability-
adjusted life years (DALYs) for appendicitis stratified
by cause, age, and sex at the global, regional, and coun-
try levels from 2000 to 2016 [8]. However, no study
addressing these data has been published. Recently, a
systematic review reported the global incidence using
data from population-based studies, but only some
regional and country-level data were presented, and
the burden in most countries around the world was
unavailable [9]. The latest study reported the global
incidence and mortality from appendicitis using data
from the (Global Burden of Disease Study) [GBD], but
the 21 GBD regions and 204 countries were not ana-
lyzed in this study; in addition, prevalence and YLDs
were unavailable from this study [10]. Some national
and regional studies have evaluated the incidence,
prevalence, mortality, years of life lost (YLL), and
DALY, however, there is no comprehensive, detailed
data for all countries [4, 9, 11–14]. To date, the inci-
dence, prevalence, and YLD and association with the
sociodemographic index (SDI) in all countries have
not been analyzed. Therefore, a comprehensive, com-
parable analysis of the appendicitis burden is war-
ranted to aid policy makers and healthcare providers
in developing successful strategies to reduce the bur-
den of appendicitis.
In the present study, we report the prevalence, inci-
dence, and YLD of appendicitis in the general popu-
lation in 204 countries and territories at the global,
regional, and national levels in terms of the number
and age-standardized rates stratified by age, sex, and
SDI from 1990 to 2019.
Methods
Overview
e Institute of Health Metrics and Evaluation (IHME)
conducted the Global Burden of Disease Study (GBD)
2019, which involved 204 countries, seven super-regions
and 21 regions from 1990 to 2019 [15]. e GBD 2019
systematically analyzed 369 diseases and injuries, 286
causes of death and 87 risk factors in 2019. e general
methodology of the GBD 2019 conducted by the IHME
and its main modifications compared with previous years
have been described previously [15, 16]. Additional infor-
mation on non-fatal estimates was available at https://
vizhub. healt hdata. org/ gbd- compa re/ and http:// ghdx.
healt hdata. org/ gbd- resul ts- tool. GBD 2019 complied
with the Guidelines for Accurate and Transparent Health
Estimate Reporting (GATHER) statement [17].
Case denitions anddata sources
GBD 2019 defined appendicitis as inflammation of the
appendix causing nausea, vomiting, and sharp pain in
the right lower abdomen. e gold-standard treatment
for appendicitis is surgery. Furthermore, appendicitis
can lead to septic shock and other severe complications,
including sepsis and even death [15]. Vital registration
and verbal autopsy data from the cause of death (COD)
database were used to estimate mortality from appendi-
citis. In GBD 2019, the appendicitis data were obtained
from claims and hospital inpatient data, including Poland
claims data and additional years of data from USA claims
(years 2015–2016) and hospital discharges in Mexico,
India, New Zealand, Sweden, Georgia, Ecuador, Bot-
swana and southern sub-Saharan Africa (Additional
file1: TableS1). Garbage code redistribution and noise
reduction data, combined with small sample sizes, result-
ing in unreasonable cause fractions were excluded in the
estimation. Details on the data adjustment are shown in
Additional file1: Section1 and TableS2 [15].
e incidence of appendicitis was estimated by GBD
research based on 1412 site years. Notably, a site year, the
unique combination of a calendar year and location, was
defined as a country or other subnational geographical
unit contributing data each year. Only 48 of 204 countries
representing 16 of 21 GBD regions provided data to esti-
mate the incidence of appendicitis [15]. e data sources
used in estimating the burden of appendicitis in different
countries can be found using the GBD 2019 data input
source tool (http:// ghdx. healt hdata. org/ gbd- 2019/ datai
nput- sourc es).
Data processing anddisease model
e IHME used DisMod-MR 2.1, a Bayesian meta-
regression tool, to estimate the appendicitis incidence
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Page 3 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
and prevalence by pooling the age, sex, region and year.
e DisMod-MR 2.1 analytical process is shown in Addi-
tional file1: Figure S1. DisMod-MR 2.1 can conduct age-
integration; however, its performance decreased while
integrating across wide age groups (e.g., all ages). In the
DisMod-MR 2.1 model, the data were disaggregated by
age to calculate a country’s age-pattern and then the cal-
culated age pattern was applied to split aggregated all the
age data (Additional file1: Section2) [15].
For appendicitis, the reference incidence data were
adjusted using claims and hospital inpatient data. In the
IHME’s prior setting in the DisMod model, remission
was bounded from 25 to 27 (approximately 2weeks) for
all the age groups and excess mortality was capped at
0.31. Study covariates were used to adjust the incidence
date derived from USA claims data for 2000 to better
align with other incidence data points, which were more
representative of the general population [15].
Additionally, the function in DisMod-MR 2.1 was uti-
lized to calculate cause-specific mortality rates (CSMRs)
resulting from our CODEm and CODcorrect analy-
ses, and the CSMRs were matched with prevalence data
points for the same geography [15]. e excess mortal-
ity rate was calculated to estimate priors by dividing
the CSMR by the prevalence. Moreover, a country-level
fiber (g per day) covariate was applied to the incidence,
forcing a positive relationship with a lower bound of 0.
e excess mortality, log-transformed and forced nega-
tive with an upper bound of 0 and a lower bound of −1
was applied with a lag-distributed income (LDI) covari-
ate. Similarly, the Healthcare Access and Quality Index
(HAQI) covariate also forced a negative (−2, 0) excess
mortality value. In GBD 2019, the minimum coefficient
of variation at the regional, super-regional, and global-
levels was changed from 0.4 to 0.8 to improve the model
fit against input data. Betas and exponentiated values
(which can be interpreted as odds ratios) of predictive
covariates are shown in the Additional file1: Tables S3
and S4 [15].
Severity andYLDs
International Classification of Diseases version 10 (ICD-
10) codes were applied to identify appendicitis (K35-
K38). e lay descriptions of sequelae highlighting major
functional consequences and symptoms are the basis
for the GBD disability weights (DWs). Only one disease
sequela (severity level) in the data of GBD was evaluated
for appendicitis, and the DW was 0.324 (95% CI 0.219
to 0.442). e DW is recognized as a factor that reveals
the severity of a disease or condition on a scale from 0
(no disease) to 1 (death). Patients with severe appen-
dicitis had severe pain in the stomach, felt nauseated
and anxious and could not perform daily activities. e
sequela-specific prevalence was multiplied by the sever-
ity-specific DWs to estimate the YLDs [15, 18, 19].
Compilation ofresults
YLLs were calculated by multiplying the difference
between the standard life expectancy for a given age and
sum of deaths in each age group [20]. DALYs were cal-
culated by summing the YLL and YLD [21, 22]. Uncer-
tainty was estimated from multiple sources, such as the
input data, measurement error corrections, and residual
non-sampling error estimates. Uncertainty intervals
(UIs) were defined as the 2.5 and 97.5 percentiles of the
ordered draws. e flowcharts of estimation for appendi-
citis are shown in Additional file1: Figure S2 [15].
Smoothing spline models were employed to determine
the shape of the correlation curve between the appendi-
citis burden in terms of YLD and SDI for 21 regions and
204 countries and territories [23, 24]. e SDI is a value
ranging from 0 (worst) to 1.0 (best) and was calculated
from the total fertility rate among those aged younger
than 25years, with a mean education level for the popu-
lation greater than 15years, and lag-distributed income
per capita (LDI) [25]. All the estimates of prevalence,
incidence, and YLD was generated using by R software
version 3.6.3 [26]. e differences between sexes were
compared with unpaired t test. A P value < 0.05 was con-
sidered statistically significant.
Patient andpublic involvement statement
is study used the data freely available from the GBD
at http:// ghdx. healt hdata. org/ gbd- resul ts- tool. e
data analyzed during this study could refer to Table 1
and Additional file1: Tables S5-S7. In addition, data are
available from the corresponding author on reasonable
request. Patients were not involved in the design, recruit-
ment or conduct of the study. Results of this study will be
made publicly available through publication.
Results
Global level
Globally, there were 672,203 (95% UI 536,225 to 847,977)
prevalent cases of appendicitis, with an age-standardized
prevalence rate of 8.7 (95% UI 6.9 to 11.0) per 100,000
population in 2019. e age-standardized prevalence
rate was 7.2 (95% UI 5.7 to 9.1) per 100,000 population
in 1990, and increased by 20.8% (95% UI 18.9 to 23.0%)
from 1990 to 2019. Additionally, there were 17,698,765
(5% UI 14,101,114 to 22,324,572) incident appendicitis
cases, with an age-standardized incidence rate of 229.9
(95% UI 180.9 to 291.0) per 100,000 populations in 2019.
e age-standardized incidence rate was 190.7 (95% UI
149.6 to 240.6) per 100,000 population in 1990, with a
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Page 4 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
Table 1 Prevalent cases, incident cases, years lived with disability (YLD), and years of life lost (YLL) for appendicitis in 2019 for both
sexes and percentage change of age-standardized rates (ASR) per 100,000 populations from 1990 to 2019 by Global Burden of Disease
regions
Prevalence (95% uncertainty interval) Incidence (95% uncertainty interval) YLDs (95% uncertainty interval)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
Global 672,203
(536,225 to
847,977)
8.7
(6.9 to 11) 20.8
(23 to 18.9) 17,698,765
(14,101,114
to
22,324,572)
229.9
(180.9 to
291)
20.5
(22.8 to 18.7) 211,113
(137,041 to
303,366)
2.7
(1.8 to 3.9) 20.4
(25.1 to 16.2)
Andean Latin
America 21,347
(17,402 to
26,573)
32.5
(26.6 to 40.2)
− 30.7
(− 36.6
to − 22.2)
558,662
(456,610 to
696,711)
852.4
(697.7 to
1059.4)
− 30.5
(− 36.6
to − 22)
6569
(4287 to
9596)
10
(6.5 to 14.5)
− 30.7
(− 41.2
to − 17.9)
Australasia 2850
(2247 to
3629)
10.8
(8.4 to 14) 2.4
(− 2.1 to 6.4) 74,147
(58,363 to
94,560)
283.9
(220.1 to
369.3)
2.4
(− 2.1 to 6.4) 882
(546 to 1332) 3.4
(2 to 5.2) 2.4
(− 22.8 to 35.2)
Caribbean 5046
(3913 to
6473)
10.8
(8.3 to 13.9) 28.8
(25.3 to 32) 132,078
(102,639 to
169,890)
282.9
(219.4 to
361.9)
28.6
(25.1 to 31.8) 1574
(1023 to
2353)
3.4
(2.2 to 5) 28.3
(9.7 to 50.4)
Central Asia 8907
(6690 to
11,734)
9.4
(7 to 12.3) 1.5
(− 2 to 5.4) 233,029
(175,238 to
306,969)
245.3
(184.6 to
323.5)
1.5
(− 2.1 to 5.4) 2799
(1767 to
4212)
2.9
(1.8 to 4.4) 1.3
(− 13.5 to 17)
Central
Europe 7814
(6451 to
9388)
8.4
(6.7 to 10.4) 7.6
(0.6 to 15.8) 203,543
(167,437 to
245,338)
220.3
(175.2 to
271.3)
7.5
(0.6 to 15.7) 2486
(1625 to
3576)
2.7
(1.7 to 3.9) 7.4
(− 3.7 to 20.2)
Central Latin
America 34,366
(26,234 to
44,412)
13.6
(10.3 to 17.6) 16.1
(12.3 to 20.1) 900,312
(686,867 to
1,159,909)
358.2
(271.1 to
460.1)
15.4
(11.8 to 19.4) 10,795
(6781 to
16,177)
4.3
(2.7 to 6.4) 16.3
(6.1 to 27.3)
Central
Sub-Saharan
Africa
15,752
(11,998 to
20,404)
10.8
(8.5 to 13.8) 36.1
(30.6 to 42.4) 416,895
(315,480 to
538,242)
284.3
(224.9 to
361.7)
35.8
(30.3 to 42.2) 4900
(3015 to
7598)
3.4
(2.1 to 5.1) 36
(8 to 72.8)
East Asia 98,212
(77,893 to
120,704)
6.7
(5.3 to 8.3) 8.4
(2.7 to 14.7) 2,565,267
(2,034,140 to
3,149,307)
176.2
(138.5 to
220)
7.4
(1.8 to 13.6) 31,567
(20,685 to
45,211)
2.2
(1.4 to 3.1) 9.1
(1.5 to 18.2)
Eastern
Europe 18,435
(14,229 to
23,497)
10.4
(7.8 to 13.6) 19.9
(17.3 to 22.8) 480,413
(370,619 to
612,175)
273.2
(202.6 to
354.6)
19.7
(17.1 to 22.5) 5795
(3710 to
8441)
3.3
(2.1 to 4.9) 19.7
(9.4 to 31.6)
Eastern
Sub-Saharan
Africa
22,041
(16,104 to
29,956)
4.7
(3.6 to 6.3) 46.5
(42.9 to 49.9) 591,822
(432,475 to
797,031)
127
(96.7 to
166.9)
45.7
(42.2 to 49) 6956
(4286 to
10,506)
1.5
(0.9 to 2.2) 45.5
(31.2 to 61.2)
High-income
Asia Pacific 22,677
(17,978 to
28,337)
17.2
(13.1 to 22.1)
− 2.6
(− 7.2 to 2.3) 586,290
(463,318 to
730,184)
448.1
(339.7 to
572.3)
− 2.6
(− 7.2 to 2.5) 7111
(4538 to
10,230)
5.4
(3.4 to 7.9)
− 2.2
(− 11.7 to 8.9)
High-income
North
America
21,877
(19,671 to
24,295)
6.2
(5.5 to 6.9)
− 10.4
(− 21.8 to 4) 571,783
(514,543 to
636,513)
162.6
(144.9 to
182.1)
− 10.3
(− 21.7 to
4.1)
7057
(4756 to
9721)
2
(1.3 to 2.8)
− 8.9
(− 21.9 to 6.8)
North Africa
and Middle
East
66,665
(50,979 to
87,066)
10.4
(8 to 13.5) 48.2
(44.1 to 52.5) 1,745,503
(1,329,173 to
2,271,525)
271.6
(206.1 to
350.9)
48
(43.9 to 52.2) 20,714
(12,951 to
30,887)
3.2
(2 to 4.8) 46.5
(32.5 to 63)
Oceania 577
(444 to 755) 4.1
(3.2 to 5.4) 16.2
(12.2 to 21.1) 15,219
(11,665 to
19,748)
109.2
(85 to 140.3) 16.1
(12.1 to 21) 187
(118 to 279) 1.3
(0.9 to 2) 16.2
(12.2 to 21.1)
South Asia 196,227
(154,672 to
249,562)
10
(8 to 12.6) 53.5
(45.9 to 61) 5,214,009
(4,114,157 to
6,620,999)
266.7
(212.7 to
334.9)
51.8
(44.3 to 59.1) 60,854
(38,899 to
89,567)
3.1
(2 to 4.5) 52.5
(36.3 to 70.7)
Southeast
Asia 43,365
(33,776 to
56,231)
6.3
(4.9 to 8.1) 34.2
(30.6 to 37.7) 1,146,656
(892,434 to
1,477,241)
166.5
(129.2 to
216.3)
33.9
(30.4 to 37.4) 13,780
(8689 to
20,227)
2
(1.3 to 2.9) 34.5
(20.4 to 51.4)
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Page 5 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
20.5% (95% UI 18.7 to 22.8%) increase from 1990 to 2019
(Table1).
e global age-standardized YLD rate showed a steady
trend from 1990 to 1997, and then increased from 1998
to 2019. Globally, in 2019, appendicitis accounted for
211,113 (95% UI 137,041 to 303,366) YLD, with an age-
standardized YLD rate of 2.7 (95% UI 1.8 to 3.9) per
100,000 population. e age-standardized YLD rate was
2.3 (95% UI 1.5 to 3.2) per 100,000 population in 1990,
with an increase of 20.4% (95% UI 16.2 to 25.1%) from
1990 to 2019 (Table1).
Regional level
At the regional level, Andean Latin America (32.5 [95%
UI 26.6 to 40.2]), High-income Asia Pacific (17.2 [95% UI
13.1 to 22.1]), and Central Latin America (13.6 [95% UI
10.3 to 17.6]) demonstrated the highest age-standardized
prevalence rates of appendicitis per 100,000 population
in 2019. By contrast, the lowest age-standardized preva-
lence rate was found in Oceania (4.1 [95% UI 3.2 to 5.4]),
Western Sub-Saharan Africa (4.5 [95% UI 3.4 to 6.0]), and
Eastern Sub-Saharan Africa (4.7 [95% UI 3.6 to 6.3]) in
2019 (Table1, Fig.1A).
e age-standardized incidence rates of appendici-
tis per 100,000 population were also found to be high-
est in Andean Latin America (852.4 [95% UI 697.7 to
1059.4]), High-income Asia Pacific (448.1 [95% UI 339.7
to 572.3]), and Central Latin America (358.2 [95% UI
271.1 to 460.1]), whereas Oceania (109.2 [95% UI 85.0 to
140.3]), Western Sub-Saharan Africa (120.1 [95% UI 89.7
to 158.9]) and Eastern Sub-Saharan Africa (127.0 [95% UI
96.7 to 166.9]) had the lowest age-standardized incidence
rates (Table1, Fig.1B).
Andean Latin America (10.0 [95% UI 6.5 to 14.5]),
High-income Asia Pacific (5.4 [95% UI 3.4 to 7.9]) and
Central Latin America (4.3 [95% UI 2.7 to 6.4]) had the
highest age-standardized YLD rates from appendicitis
per 100,000 population in 2019, whereas Oceania (1.3
[95% UI 0.9 to 2.0]), Western Sub-Saharan Africa (1.4
[95% UI 0.9 to 2.2]) and Eastern Sub-Saharan Africa (1.5
[95% UI 0.9 to 2.2]) had the lowest age-standardized YLD
rates among the GBD 2019 regions (Table1, Additional
file2: Fig. S3).
e percentage change in the age-standardized preva-
lence rates varied across the 21 GBD regions from 1990
to 2019. South Asia (53.5% [95% UI 45.9 to 61.0%]),
Southern Latin America (49.8% [95% UI 42.0 to 57.6%]),
and Western Sub-Saharan Africa (48.7% [95% UI 43.6
to 54.0%]) showed the largest increasing trends, while
Andean Latin America (− 30.7% [95% UI − 36.6 to
−22.2%]), High-income North America (−10.4% [95%
UI − 21.8 to − 4.0%]) and High-income Asia Pacific
(−2.6% [95% UI − 7.2 to −2.3%]) showed the largest
decreasing trends (Additional file2: Fig. S4). e percent-
age change in the age-standardized incidence rates varied
across the 21 GBD regions from 1990 to 2019. South Asia
(51.8% [95% UI 44.3 to 59.1%]), Southern Latin America
(49.6% [95% UI 41.8 to 57.5%]), and North Africa and
Middle East (48.0% [95% UI 43.9 to 52.2%]) showed the
largest increasing trends, while Andean Latin America
Table 1 (continued)
Prevalence (95% uncertainty interval) Incidence (95% uncertainty interval) YLDs (95% uncertainty interval)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
Counts ASR per
100,000
population
(95% UI)
Percentage
change in
ASRs per
100,000
population
(95% UI)
South-
ern Latin
America
7736
(6046 to
9784)
11.7
(9 to 14.9) 49.8
(42 to 57.6) 201,955
(157,808 to
254,876)
305.5
(236.3 to
389.3)
49.6
(41.8 to 57.5) 2394
(1497 to
3585)
3.6
(2.2 to 5.4) 46.6
(14.1 to 86.4)
Southern
Sub-Saharan
Africa
5855
(4394 to
7749)
6.9
(5.2 to 9.1) 26.2
(22.4 to 30.6) 154,821
(116,584 to
203,979)
183
(138.5 to
241)
25.9
(22.1 to 30.2) 1837
(1152 to
2840)
2.2
(1.4 to 3.3) 25.1
(10 to 43.7)
Tropical Latin
America 11,326
(9235 to
14,000)
5.1
(4.1 to 6.3) 28.9
(23.6 to 35.5) 298,011
(243,250 to
366,750)
135.6
(109.7 to
167.8)
27.8
(22.6 to 34.3) 3616
(2379 to
5269)
1.6
(1.1 to 2.4) 27.8
(17.7 to 39.9)
Western
Europe 38,356
(31,229 to
47,142)
10.6
(8.5 to 13.6) 12.1
(6.6 to 18.3) 997,135
(806,633 to
1,229,567)
278.5
(220.2 to
352.8)
12.1
(6.6 to 18.3) 11,990
(7743 to
17,155)
3.3
(2.1 to 4.8) 12
(0.6 to 25.9)
Western
Sub-Saharan
Africa
22,773
(16,551 to
30,697)
4.5
(3.4 to 6) 48.7
(43.6 to 54) 611,213
(445,004 to
824,269)
120.1
(89.7 to
158.9)
47.6
(42.4 to 52.8) 7249
(4465 to
11,015)
1.4
(0.9 to 2.2) 47.9
(37 to 58.6)
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Page 6 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
(− 30.5% [95% UI − 36.6 to − 22.0%]), High-income
North America (− 10.3% [95% UI − 21.7 to − 4.1%])
and High-income Asia Pacific (−2.6% [95% UI −7.2 to
− 2.5%]) showed the largest decreasing trends (Addi-
tional file2: Fig. S5).
e top three statistically significant increases in age-
standardized YLD rates were observed in South Asia
(52.5% [95% UI 36.3 to 70.7%]), Western Sub-Saharan
Africa (47.9% [95% UI 37.0 to 58.6%]), and Southern
Latin America (46.6% [95% UI 14.1 to 86.4%]), whereas
the top three statistically significant decreasing trends
were observed in Andean Latin America (−30.7% [95%
UI − 41.2 to − 17.9%]), High-income North America
(−8.9% [95% UI −21.9 to 6.8%]), and High-income Asia
Pacific (− 2.2% [95% UI − 11.7 to 8.9%]) (Additional
file2: Fig. S6).
e number of prevalent cases was increased by 1.6
times from 1990 409,125 (95% UI: 318,852 to 520,824)
to 2019 672,203 (95% UI 536,225 to 847,977), but the
regions contributing to the increase in 2019 varied (Addi-
tional file2: Fig. S7). e number of incident cases was
also increased by 1.6 times from 10,821,656 (95% UI:
8,420,122 to 13,838,792) in 1990 to 17,698,765 (95% UI:
14,101,114 to 22,324,572) in 2019, with differing contri-
butions from GBD 2019 regions (Additional file2: Fig.
S8).
National level
At the national level, the age-standardized prevalence
rate of appendicitis varied from 1.9 to 51.5 cases per
100,000 population. Bangladesh (51.5 [95% UI 41.3 to
64.1]), Bhutan (44.8 [95% UI 35.8 to 56.0]), and Peru (33.6
[95% UI 26.4 to 43.2]) had the three highest age-stand-
ardized prevalence rates in 2019, whereas Ethiopia (1.9
[95% UI 1.3 to 2.6]), Kenya (2.3 [95% UI 1.7 to 3.2]) and
Indonesia (3.4 [95% UI 2.5 to 4.5]) showed the lowest age-
standardized rates (Additional file1: TableS5, Fig.2A).
e age-standardized incidence rates of appendicitis
varied from 53.8 to 1349.8 cases per 100,000 population.
In 2019, Bangladesh (1349.8 [95% UI 1092.2 to 1673.1]),
Bhutan (1174.4 [95% UI 942.1 to 1459.6]), and Peru
(879.7 [95% UI 688.0 to 1137.6]) had the highest age-
standardized incidence rates. By contrast, Ethiopia (53.8
[95% UI 38.8 to 73.3]), Kenya (65.4 [95% UI 47.4 to 88.7])
and Indonesia (92.5 [95% UI 68.7 to 121.8]) had the low-
est age-standardization rates (Additional file1: TableS6,
Fig.2B).
Additionally, the age-standardized YLD rate of appen-
dicitis in 2019 ranged from 0.6 to 15.7 cases per 100,000
population. e highest rates were found in Bangladesh
(15.7 [95% UI 10.1 to 23.5]), Bhutan (13.6 [95% UI 8.8 to
20.4]), and Peru (10.4 [95% UI 6.6 to 15.6]), and the low-
est rates were also found in Ethiopia (0.6 [95% UI 0.4 to
0.9]), Kenya (0.8 [95% UI 0.5 to 1.1]) and Indonesia (1.1
[95% UI 0.7 to 1.6]) (Additional file1: TableS7, Addi-
tional file2: Fig. S9).
e percent changes in the age-standardized preva-
lence rates per 100,000 population from 1990 to 2019
differed substantially among 204 countries and territo-
ries. Ethiopia (207.6% [95% UI 178.6 to 243.7%]), India
(105.6% [95% UI 98.5 to 113.5%]), and Nigeria (101.4%
[95% UI 94.7 to 109.7%]) had the largest increasing
Fig. 1 The age-standardized prevalence (A) and incidence (B) rate of appendicitis in 2019 for 21 GBD region, by sex
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Page 7 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
trends over the 30years. By contrast, Peru (− 44.3%
[95% UI −51.5 to −33.8%]), Mongolia (−39.7% [95%
UI −46.1 to −30.6%]) and Guatemala (−33.6% [95%
UI − 42.8 to − 22.8%]) had the largest decreasing
trends from 1990 to 2019 (Additional file1: TableS5,
Additional file2: Fig. S10).
e percent changes in the age-standardized inci-
dence rates between 1990 and 2019 also differed across
all countries and territories. e largest increases were
Fig. 2 The global age-standardized prevalence (A) and incidence (B) rate of appendicitis per 100,000 population in 2019, by country and territory
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Page 8 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
observed in Ethiopia (176.1% [95% UI 150.9 to 207.1%]),
India (98.4% [95% UI 91.2 to 106.2%]) and Nigeria (96.3%
[95% UI 90.2 to 104.1%]). e largest decreases dur-
ing this period were found in Peru (− 44.2% [95% UI
−51.5 to −33.6%]), Mongolia (−39.8% [95% UI −46.1
to −30.7%]) and Guatemala (−33.6% [95% UI −42.9 to
−22.9%]) (Additional file1: TableS6, Additional file2:
Fig. S11).
e largest increases in age-standardized YLD due
to appendicitis per 100,000 population between 1990
and 2019 were in Ethiopia (207.4% [95% UI 178.6 to
243.7%]), India (101.4% [95% UI 88.2 to 113.6%]), and
Nigeria (101.1% [95% UI 93.9 to 109.8%]). By contrast,
Peru (−44.3% [95% UI − 56.6 to −29.0%]), Mongolia
(−39.8% [95% UI −55.4 to −18.6%]), and Guatemala
(−32.6% [95% UI −50.5 to −10.9%]) showed the largest
decreases from 1990 to 2019 (Additional file1: TableS7,
Additional file2: Fig. S12).
Sex andage patterns
Globally, no statistically significant differences were
observed in the prevalence between women and men in
any age group. e number of prevalent cases increased
with age and peaked in the 15-to 19-year age group for
both males and female individuals, after this age, the
overall trend declined. Additionally, the prevalence rate
reached its peak in the 15- to 19-year age group and then
decreased with age in both males and female individuals
in 2019 (Fig.3). No visible difference was noted between
the incidence in males and female individuals in all age
groups. e number of incident cases reached its highest
level in the 15- to 19-year age group in both males and
females individuals, after which a declining trend with
increasing age was observed. In 2019, the incidence rate
also peaked in the 15- to 19-year age group. After this
age, the incidence rate then decreased with age in both
males and female individuals (Additional file2: Fig. S13).
e pattern of YLDs by sex and age group was relatively
similar to those of prevalence and incidence (Additional
file2: Fig. S14).
Burden ofappendicitis bySDI
At the regional level, a generally positive association was
observed between the age-standardized YLD rate and
SDI from 1990 to 2019. e lowest age-standardized YLD
rate was observed when the SDI was approximately 0.23,
showing an overall increasing trend with the SDI value.
From 1990 to 2019, the observed burden was higher than
the expected level in Andean Latin America, Central
Sub-Saharan Africa, Central Latin America, and High-
income Asia Pacific. By contrast, High-income North
America, Western Sub-Saharan Africa, Southeast Asia,
Tropical Latin America, East Asia, and global were below
the expected level based on the SDI in all years (Fig.4).
e national-level analysis revealed a generally positive
association between the age-standardized YLD rates and
Fig. 3 Global number and rates of prevalence for appendicitis per 100,000 population by age and sex, 2019. Shading indicates the 95% UIs for the
prevalent rate
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Page 9 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
SDI. e observed levels in Bangladesh, Bhutan, Peru,
Nepal, Ecuador, and many other countries were much
higher than the expected levels. However, in higher SDI
countries and territories, such as Ethiopia, Guam, Kiri-
bati, and many other countries, the observed levels were
much lower than the expected levels based on the SDI
(Fig.5).
Discussion
In the present study, we present the prevalence, inci-
dence, and YLD and age-standardized rates for appendi-
citis in 204 countries and territories from 1990 to 2019.
In 2019, there were 672,203 prevalent cases, 17,698,765
incident cases, and 211,113 YLD cases globally. e age-
standardized prevalence, incidence, and YLDs rates were
all increased from 1990 to 2019. To our best knowledge,
the present study is the first to estimate the associa-
tions of age-standardized rates with the SDI in 21 GBD
regions and 204 countries. e YLD rate of appendici-
tis increased with increasing SDI in terms of region and
country.
Acute appendicitis is an acute condition, and it can
lead to serious complications1,2, and some complications
can lead to live in disability perpetually. erefore, timely
treatment can prevent serious complications. If hospital
intraduct policies of prevent acute appendicitis, it can get
faster treatment.
Appendicitis is one of the most common causes of
abdominal pain in children and young adults, and occurs
when the lumen of the vermiform appendix becomes
inflamed, typically because of an obstruction. e condi-
tion can lead to death as well as significant costs to the
healthcare system [27]. In the United States, the cost of
hospitalization related to appendicitis may be as high as
$3 billion a year [28]. e incidence of appendicitis is
7.8% [29] and a 2017 study showed it has increased in
western countries in 1900 and declined until the mid-
dle of the 20th [4, 30]. However, the latest data show that
the incidence of appendicitis has been on the rise and
no complete and comprehensive study addressing these
data has been published. erefore, a comprehensive and
comparable analysis of the burden of appendicitis must
be performed to help decision makers and healthcare
providers develop successful strategies to reduce the bur-
den of appendicitis. In the present study, we report the
prevalence, incidence, and YLDs of appendicitis in the
Fig. 4 Age-standardized YLDs rates of appendicitis in 21 GBD regions by SDI, 1990–2019. Expected values based on Socio-demographic Index and
disease rates in all locations are shown as the black line. YLDs, years lived with disability. GBD, Global Burden of Diseases, Injuries, and Risk Factors
Study. SDI, Sociodemographic Index
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Guanetal. BMC Gastroenterology (2023) 23:44
general population in 204 countries and territories at the
global, regional, and national levels in terms of the num-
ber and age-standardized rates stratified by age, sex, and
SDI from 1990 to 2019.
GBD 2013 reported that the number of incident cases
of appendicitis was 16 million in 2013 [31] and increased
to 19 million in 2017 [32], whereas the number of inci-
dent cases was 17.7 million in 2019. e age-standard-
ized incidence rate was 225.2 per 100,000 population in
2013 and 251.72 per 100,100 population in 2017, with a
decrease of 14.58% from 1990 to 2013 and an increase of
1.8% from 1990 to 2017 [31, 32]. In GBD 2019, the age-
standardized incidence rate increased from 190.7 per
100,000 population in 1990 to 229.9 per 100,000 popu-
lation in 2019, and the age-standardized incidence rate
showed an increase of 20.5%. Similar to the incidence,
the age-standardized prevalence and YLDs rates also
showed decreasing and increasing trends from 1990 to
2013 and from 1990 to 2017, respectively [31, 32]. Com-
pared with GBD study, both the age-standardized preva-
lence and YLD rates showed an approximately tenfold
increase from 1990 to 2019. is suggests that the bur-
den of appendicitis increased over time, particularly from
2013 to 2019. However, number of incident cases in GBD
2019 was lower than that in GBD 2017. e results of
these two studies could not be directly compared with
our results, though, because of the different data sources
and methodologies applied. For instance, GBD 2013
employed DisMod-MR 2.0, but GBD 2017 and GBD 2019
used DisMod-MR 2.1, to pool the available data. Moreo-
ver, compared with GBD 2017, GBD 2019 added subna-
tional location data, such as Italy and Poland, and added
estimates for the new locations (Monaco, San Marino,
Cook Islands, and Saint Kitts and Nevis) [15].
Most appendicitis studies focused on only specific
regions or countries. Few have comprehensively inves-
tigated appendicitis at the regional and national levels
globally. Although a previous publication reviewed the
evolution of the global incidence of appendicitis dur-
ing the twentieth century, data from most countries are
unavailable [9]. In the present study, we found that the
highest age-standardized rates were more common in
less-developed regions, such as Andean Latin America,
Central Latin America, and Central Sub-Saharan Africa.
is result was somewhat consistent with a previous
review, which reported that the incidence in Asia, South
America, and the Middle East was much higher than that
in Western countries, and the incidence had increased
in newly industrialized countries in the Middle East,
South America, Asia, and Africa [4, 5, 9, 11, 12]. At the
country level, the present study found less-developed
and developing countries, namely Bangladesh, Bhutan,
and Peru, had the highest age-standardized incidence,
prevalence, and YLD rates, were further confirmed the
above findings. e above results suggest that the burden
of appendicitis in less-developed and developing coun-
tries, particularly in newly industrialized countries, is
higher than that in developed countries. e differences
Fig. 5 Age-standardized YLDs rates of appendicitis by 204 countries and territories and SDI, 2019. Expected values based on Socio-demographic
Index and disease rates in all locations are shown as the black line. YLDs, years lived with disability. SDI, Sociodemographic Index
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
between regions and countries may be due to differences
in healthcare systems, socioeconomic statuses of the
population, race, eating habits, and environmental expo-
sures [4, 5, 9, 11, 12]. erefore, prevention measures,
management strategies and policies to reduce the burden
of appendicitis should be given priority in these areas by
policy makers.
Notably, the data in GBD 2019 were estimated using
DisMod-MR 2.1 because only a few countries or territo-
ries provide actual population-based national data on the
burden of appendicitis. erefore, these national-level
estimates should be interpreted with caution. If possible,
additional attention should be given to health data col-
lection to acquire representative data from every coun-
try. Additional resources are recommended to reduce
the burden of appendicitis in low- and middle-income
countries; thus, increased global cooperation might be
necessary. ese resources will contribute to more accu-
rate predictions of the global burden of appendicitis and
provide a basis for policy making.
As shown in previous studies [5, 12], although the
burden was slightly higher in female individuals in our
study, no statistically significant difference was found in
the prevalence and incidence rates between male and
female individuals. Hence, both female and male indi-
viduals should be given equal priority in prevention and
treatment policies. However, some studies showed that
the incidence of appendicitis was higher in male than in
female individuals, likely because of geographic varia-
tions [4, 9, 12]. In 2019, the age-standardized prevalence,
incidence, and YLD rates peaked in the 15- to 19-year age
groups in both male and female individuals. ese results
were similar to those of a previous study that reported
that the highest incidence was in the 15- to 19-year age
group in female individuals and the 10- to 14-year age
group in male individuals. Other studies confirmed this
result and agreed that adolescents aged between 10 and
19years had the highest burden of appendicitis [4, 9, 12,
33].
To our best knowledge, the associations of the burden
of appendicitis with the development levels of regions
and countries have not been compared in previous stud-
ies.e present study found that the SDI was an impor-
tant factor in the appendicitis burden, and a generally
positive association was observed between the regional-
and national-level SDI and YLD because of appendicitis
from 1990 to 2019.us, the burden of appendicitis was
generally lower in countries with higher socioeconomic
development levels; however, the burden of appendi-
citis was not limited to either more-developed or less-
developed regions or countries, because low burdens of
appendicitis were observed in regions and countries with
different SDI.is phenomenon could be attributed to an
early accurate diagnosis and effective interventions, such
as appendectomy and antibiotics. Countries with high
socioeconomic development levels have better diagnostic
tools and treatment facilities than those with low socio-
economic development levels [11, 12]. e burdens of
appendicitis were higher than the expected levels in some
regions, such as Andean Latin America, Central Sub-
Saharan Africa, Central Latin America, and High-income
Asia Pacific, and other countries such as Andean Latin
America, the Caribbean, and South Asia. When consid-
ering prevention policies, the observed burden should be
combined with the expected burden based on the SDI in
each region and country/territory.
Detecting and controlling risk factors are important
approaches in prevention strategies. e risk factors for
appendicitis include geographic and socioeconomic fac-
tors, race, seasonal patterns (the risk is highest in the
summer), air pollution, dietary fiber, luminal obstruction,
gastrointestinal infection, and genetic factors [9, 33–38].
High temperatures in the summer, an important risk fac-
tor, must be considered in the development of regional-
and national-level prevention programs, as well as global
warming. In GBD 2019, risk factors for appendicitis such
low fruit consumption, low vegetable consumption, edu-
cation level and LDI were also evaluated in appendicitis
mortality estimation [15]. us, policymakers should
consider those risk factors in their policy making.
Some limitations should be noted. First, the data
included in the present study were secondary data from
GBD 2019. e accuracy and robustness of GBD 2019
mainly depend on the quality and quantity of the input
data used in the DisMod-MR 2.1 model. Second, the
effects of different diagnosis, prevention strategies, and
management policies in different regions and countries
were not assessed, and substantial variations may exist,
even in different regions and countries with the same
SDI. Finally, because of the lack of relevant data, the bur-
den of appendicitis stratified by histology was not evalu-
ated in the present study.
Conclusion
In summary, appendicitis remains a major public health
challenge globally. Globally, the age-standardized prev-
alence, incidence, and YLD rates increased from 1990
to 2019. e highest burden of appendicitis was in ado-
lescents, and no statistically significant difference was
found between male and female individuals. Increasing
awareness of appendicitis and its risk factors and the
importance of early diagnosis and treatment are war-
ranted to reduce the burden of appendicitis. Improv-
ing appendicitis health data in all regions and countries
and monitoring the burden and treatment of appendi-
citis should be given more attention. Our study may be
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Page 12 of 13
Guanetal. BMC Gastroenterology (2023) 23:44
useful for policymakers to efficiently allocate resources
to improve the diagnosis and treatment of appendicitis
and reduce its modifiable risk factors.
Abbreviations
YLD Years lived with disability
GBD The Global Burden of Diseases, Injuries, and Risk Factors Study
SDI Sociodemographic index
UIs Uncertainty intervals
WHO World Health Organization
YLL Years of life lost
DALYs Disability-adjusted life years
IHME The Institute of Health Metrics and Evaluation
GATHER Guidelines for Accurate and Transparent Health Estimate
Reporting
COD Cause of death
CSMRs Calculate cause-specific mortality rates
LDI Lag-distributed income
HAQI The Healthcare Access and Quality Index
DWs Disability weights
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12876- 023- 02678-7.
Additional le1. The data sources, estimation and data table of appen-
dicitis in 204 countries and territories, 1990–2019: a systematic analysis for
the Global Burden of Disease Study 2019.
Additional le2. The figures of appendicitis burden in 204 countries and
territories, 1990–2019: a systematic analysis from the Global Burden of
Disease Study 2019.
Acknowledgements
We appreciate the works by the Global Burden of Disease study 2019 col-
laborators. We would like to thank American Journal Experts (https:// www.
aje. com) for editing this manuscript. We appreciate the support by Liuzhou
Hepatobiliary and Pancreatic Diseases Precision Diagnosis Research Center of
Engineering Technology.
Author contributions
GQOY, LJG and ZL conceived, designed and refined the study protocol. LJG,
ZL, GDP, BLZ, YRW were involved in the data collection. LJG, ZL, TG ana-
lyzed the data. GQOY and LJG drafted the manuscript. All authors read and
approved the final manuscript.
Funding
This work was supported by the Hubei Chen Xiaoping Technology Develop-
ment Fund (No: CXPJJH1190000-2019321).
Availability of data and materials
The datasets generated for this study can be found in the GBD at http:// ghdx.
healt hdata. org/ gbd- resul ts- tool. The data analyzed during this study could
refer to Table 1 and Additional file 1: Tables S5–S7. In addition, data are avail-
able from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study did not require ethical approval.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 13 November 2022 Accepted: 14 February 2023
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