Preamble

Big Data Analysis: Trends in Disease Burden of Hearing Loss Among Middle-Aged and Elderly People in China, 1990–2021

ZHANG Yongqing¹,², LI Na¹,², GAO Yili¹,², QIN Jiawen¹,², YU Haiping¹,², SHI Hui³*

¹School of Medicine, Tongji University, Shanghai 200331, China
²Shanghai East Hospital, Tongji University, Shanghai 200120, China
³Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China

Corresponding author: SHI Hui, Nurse Supervisor; E-mail: shi.hui@zs-hospital.sh.cn

【Abstract】

Background: Hearing loss is a prevalent health issue among middle-aged and older adults that adversely affects quality of life and social interaction while increasing the risk of cognitive decline. As China's population aging deepens and the proportion of middle-aged and elderly individuals grows, trends in the disease burden of hearing loss within this demographic from 1990 to 2021 remain unclear.

Objective: To analyze trends in the disease burden of hearing loss among middle-aged and older adults (≥55 years) in China from 1990 to 2021, providing evidence for formulating effective public health strategies and healthcare resource allocation.

Methods: Data on the disease burden of hearing loss for individuals aged ≥55 years in China were extracted from the Global Burden of Disease Study 2021 (GBD 2021) database, including prevalence counts, Disability-Adjusted Life Years (DALYs), prevalence rates, DALY rates, and their age-standardized rates. Joinpoint regression analysis was employed to identify temporal trends and inflection points, while an age-period-cohort model was used to estimate the age, period, and cohort effects on hearing loss prevalence.

Results: From 1990 to 2021, all metrics of hearing loss burden among Chinese individuals ≥55 years increased substantially: prevalent cases rose from 100.997 million to 286.859 million, prevalence rates from 70,372.2 per 100,000 to 75,697.3 per 100,000, DALYs from 2.814 million person-years to 8.712 million person-years, and DALY rates from 1,961.0 per 100,000 person-years to 2,298.9 per 100,000 person-years. Joinpoint regression revealed consistent upward trends for crude prevalence rate, crude DALY rate, age-standardized prevalence rate (ASPR), and age-standardized DALY rate (ASDR) during 1990–2021, with average annual percentage changes (AAPC) of 0.24%, 0.53%, 0.19%, and 0.28%, respectively (all P<0.05). The disease burden was slightly higher in males than females. Male ASPR increased most rapidly during 2000–2009 (APC=0.31%, P<0.05), while male ASDR increased most rapidly during 2001–2004 (APC=1.68%, P<0.05). Female ASPR and ASDR both increased most rapidly during 2015–2019 (APC=0.47% and 0.91%, respectively; P<0.05) but declined during 2019–2021 (APC=-0.07% and -0.23%, respectively; P<0.05). Age effects showed that prevalence risk initially increased then plateaued with advancing age, with relative risk (RR) ranging 0.74–1.08 across age groups. Period effects demonstrated a monotonic increase in prevalence risk over time (RR range: 0.96–1.05). Cohort effects indicated gradually decreasing prevalence risk with more recent birth cohorts (RR range: 0.96–1.06). No pronounced gender differences were observed in these effects.

Conclusion: The burden of hearing loss among middle-aged and older adults in China increased steadily from 1990 to 2021, with discernible gender disparities in trends.

【Key words】 Hearing loss; Disease burden; DALY; Prevalence rate; Age-period-cohort model

Chinese Library Classification: R 764.43
Document Code: A
DOI: 10.12114/j.issn.1007-9572.2025.0041

Citation: ZHANG Y Q, LI N, GAO Y L, et al. Analysis on the trend of disease burden of hearing loss in middle-aged and elderly people in China from 1990 to 2021[J]. Chinese General Practice, 2025. DOI: 10.12114/j.issn.1007-9572.2025.0041. [Epub ahead of print] [www.chinagp.net]

Hearing loss, also known as hearing impairment, refers to functional abnormalities in the sound conduction, sensation, or integration components of the auditory system, resulting in varying degrees of hearing decline. As the most widespread sensory organ disorder globally, hearing loss affected an estimated 407 million people in China in 2019, with an age-standardized prevalence rate of 21.11%—a growth rate exceeding the global average【1】. The health loss attributable to hearing loss worldwide is estimated at 43.4 million disability years【2】, ranking it as the third leading cause of years lived with disability after low back pain and migraine【3】. Middle-aged and elderly populations constitute the primary affected group, with 62.1% of hearing loss patients being over 50 years old【4】. Age-related degeneration of the auditory system and cumulative effects of long-term noise exposure significantly increase hearing loss risk among older adults, with prevalence reaching 37% in those ≥65 years【5】. Beyond reducing quality of life and imposing substantial social healthcare costs【6】, hearing loss is widely underestimated in its impact on elderly well-being【7】. Hearing-impaired older adults experience restricted verbal communication, reduced social participation, and heightened risk of social isolation【8】. Moreover, hearing loss is closely associated with anxiety and depression【9-10】, represents a major risk factor for cognitive decline【11-12】, and impairs balance, increasing fall risk【13-14】.

Accurately understanding trends in China's hearing loss disease burden is crucial for developing effective prevention and control strategies. The age-period-cohort model, grounded in epidemiological principles, can effectively disentangle age, period, and birth cohort effects, overcoming limitations of traditional analytical methods and providing deeper insights into disease trends. However, current research on hearing loss burden trends in China has rarely employed this model for in-depth analysis, focusing primarily on descriptive statistics for the entire population while lacking investigation into middle-aged and elderly subgroups and factor interactions. This study utilizes GBD 2021 data to dissect hearing loss burden trends among Chinese middle-aged and older adults, aiming to clarify the influence of various factors and provide scientific evidence for hearing health interventions.

1.1 Data Sources

All data were extracted from the GBD 2021 database published by the Institute for Health Metrics and Evaluation at the University of Washington【15】. This database systematically assesses disease burden from 389 diseases and injuries and 87 risk factors across 204 countries and regions using standardized disease metrics and burden assessment methods, providing critical evidence for global health policy. This study analyzed age-related and other hearing loss data for mainland China (excluding Taiwan) from the GBD 2021 database.

1.2 Disease Definition and Indicator Extraction

In GBD 2021, hearing loss is defined as an average pure-tone threshold ≥20 dB at four specific frequencies (0.5, 1.0, 2.0, and 4.0 kHz) in a quiet environment, measured relative to the better-hearing ear. Severity grades range from mild to profound. Given that hearing loss predominantly occurs in older populations, this study analyzed data for Chinese individuals ≥55 years from 1990–2021, quantifying disease burden using prevalence counts/rates, DALY counts/rates, and age-standardized rates across different years, sexes, and age groups. Prevalence counts directly reflect the scale of hearing loss impact, while prevalence rates link to specific populations to accurately reflect relative disease burden, facilitating multidimensional comparisons for prevention strategies. DALYs comprehensively capture premature mortality and disability losses, reflecting the full impact on health and quality of life. DALY rates eliminate demographic factors for objective burden evaluation. Age-standardized rates remove age structure differences, enabling precise comparisons across populations and years using a uniform age benchmark. This study divided individuals ≥55 years into nine 5-year age groups (55–59, 60–64, ..., ≥90 years). To avoid temporal overlap between adjacent birth cohorts, we used discrete time points (1994, 1999, ..., 2021) and calculated birth cohorts by subtracting age from the corresponding year.

1.3 Statistical Methods

Data were organized using Excel 2019. Disease burden was described using prevalence counts/rates, DALY counts/rates, age-standardized prevalence rate (ASPR), and age-standardized DALY rate (ASDR). Joinpoint Regression Program 4.9.1.0 was used to identify local trend changes, inflection points (joinpoints), and to calculate annual percent change (APC), estimated annual percent change (EAPC), and average annual percent change (AAPC). APC represents the percentage trend change within a specific period, with each segment in the Joinpoint model having its own APC. EAPC is the model-estimated APC for a given period. AAPC is the weighted average of all APCs across the entire study period, providing a comprehensive reflection of overall trends.

The age-period-cohort model was constructed using the intrinsic estimator method, which constrains the sum of coefficients for age, period, and cohort groups to zero to exclude confounding among the three factors. The model's primary parameters are relative risk (RR) values for age, period, and cohort, describing hearing loss risk levels in China. Average risk across age, period, and birth cohorts served as the reference (RR=1.0); RR>1 indicated increased risk, while RR<1 indicated decreased risk. Stata 14.0 was used to construct the age-period-cohort model, and R 4.2.3 with the "ggplot" package was used for visualization. A two-sided significance level of α=0.05 was applied.

2.1 Trends in Disease Burden of Hearing Loss Among Chinese Population Aged ≥55 Years

From 1990 to 2021, prevalent cases among Chinese individuals ≥55 years increased from 100.997 million to 286.859 million, with prevalence rates rising from 70,372.2 to 75,697.3 per 100,000. DALYs increased from 2.814 million to 8.712 million person-years, and DALY rates rose from 1,961.0 to 2,298.9 per 100,000 person-years. The EAPC for prevalence and DALY rates was 0.24% and 0.53%, respectively. Male cases increased from 50.173 million to 140.934 million, while female cases increased from 50.824 million to 145.924 million. The EAPC for male and female prevalence rates was 0.25% and 0.23%, respectively, and for DALY rates was 0.57% and 0.48%, respectively. All age groups showed significant increases in both prevalent cases and DALYs. The 55–59 age group showed cases increasing from 24.668 million to 65.797 million and DALYs from 522,000 to 1.445 million person-years. The 80–84 age group showed cases increasing from 4.555 million to 17.624 million and DALYs from 204,000 to 804,000 person-years. Notably, the DALY rate EAPC for the ≥90 age group showed negative growth (-0.01% to -0.06%) [TABLE:1].

2.2 Joinpoint Analysis of Disease Burden

Joinpoint regression revealed that the DALY rate for individuals ≥55 years increased most substantially during 2014–2018 (APC=1.77%, P<0.05), with prevalence also rising significantly (APC=0.93%, P<0.05). ASPR increased during 2015–2019 (APC=0.48%, P<0.05), and ASDR increased during 2014–2019 (APC=0.78%, P<0.05). After 2019, the growth rate of all indicators slowed or showed slight declines. Overall, during 1990–2021, prevalence rate, DALY rate, ASPR, and ASDR all showed upward trends, with AAPC values of 0.24%, 0.53%, 0.19%, and 0.28%, respectively (P<0.05) [FIGURE:1].

Male and female hearing loss prevalence rates, DALY rates, ASPR, and ASDR showed fluctuating upward trends. Specifically, male ASPR increased most rapidly during 2000–2009 (APC=0.31%, P<0.05), while male ASDR increased most rapidly during 2001–2004 (APC=1.68%, P<0.05). Female ASPR and ASDR both increased most rapidly during 2015–2019 (APC=0.47% and 0.91%, respectively; P<0.05) but declined during 2019–2021 (APC=-0.07% and -0.23%, respectively; P<0.05) [FIGURE:1].

2.3 Age-Period-Cohort Analysis of Hearing Loss Prevalence

The age-period-cohort model analysis revealed distinct effects on hearing loss prevalence among Chinese individuals ≥55 years. Age effects showed that prevalence risk increased with age, initially rising then stabilizing: RR=0.74 for the 55–59 age group and RR=1.07 for those ≥95 years. Period effects demonstrated a monotonic increase in prevalence risk over time, from RR=0.96 in 1990–1994 to RR=1.05 in 2020–2021. Cohort effects indicated that earlier birth cohorts (e.g., 1895–1899, RR=1.06) had higher risk, while later cohorts (e.g., 1965–1969, RR=0.96) had lower risk. Age, period, and cohort effects were similar between males and females, with no pronounced gender differences [FIGURE:2].

As China's population aging accelerates, hearing health among middle-aged and older adults has attracted increasing attention. This study, based on GBD 2021 data, analyzed hearing loss trends among Chinese individuals ≥55 years from 1990–2021. The results demonstrate a significantly increasing disease burden, with substantial rises in prevalent cases, prevalence rates, DALYs, and DALY rates. The EAPC values for prevalence and DALY rates reached 0.24% and 0.53%, respectively, affecting all age groups—a trend consistent with global patterns【4】. Joinpoint analysis indicated a slightly higher burden in males than females. Age-period-cohort analysis revealed that hearing loss risk increased then plateaued with age, increased monotonically over time, and decreased with more recent birth cohorts, with no significant gender differences in these effects. The changing burden of hearing loss among Chinese individuals ≥55 years is influenced by multiple factors, necessitating deeper investigation into underlying mechanisms to inform targeted prevention strategies.

Currently, population aging is the key factor driving the increasing hearing loss burden in China. The continuously rising proportion of older adults, who are at high risk for hearing loss, inevitably leads to higher overall prevalence and foreshadows a sustained heavy disease burden【4】. Previous studies showed that global hearing loss prevalent cases and DALYs increased from 750 million and 22.01 million person-years in 1990 to 1.46 billion and 40.24 million person-years in 2019, while ASPR and ASDR declined【16】. This suggests that increases in absolute numbers were primarily driven by population aging, and that actual age-adjusted prevalence and DALY rates are decreasing. In contrast, this study found slow growth in ASPR and ASDR in China, further indicating that China's population aging is more severe than the global average. Additionally, the proportion of hearing loss burden attributable to occupational noise has declined over the past 30 years【9】, while the impact of aging has become increasingly prominent. Due to aging, the burden of hearing loss will continue to increase, creating greater future demand for hearing healthcare services.

Gender disparities exist in China's middle-aged and elderly hearing loss burden, with males bearing a slightly heavier burden than females, consistent with previous findings【17】. Joinpoint analysis showed that male prevalence rates, DALY rates, ASPR, and ASDR were slightly higher than female rates. Hearing loss in middle-aged and older adults is a cumulative process, and gender differences may be attributed to: (1) Higher likelihood of male employment in high-noise occupations (e.g., manufacturing, construction) increasing hearing loss risk【17】. A cross-sectional survey of 2,280 Chinese workers exposed to industrial noise found male hearing loss prevalence (34.4%) significantly higher than female (13.8%)【18】. (2) Higher rates of smoking and alcohol consumption among males, factors closely associated with hearing loss【19-20】. (3) Greater health management awareness and medical compliance among females, potentially enabling earlier detection and intervention. Future hearing health prevention efforts in China should address these gender differences by strengthening occupational protection and health guidance for men to improve hearing health among middle-aged and older adults.

Age effects showed that hearing loss risk among Chinese middle-aged and older adults increased with age, a clear and significant trend. For example, individuals ≥95 years had 1.45 times the risk of the 55–59 age group. This trend reflects complex physiological and pathological mechanisms. Physiologically, aging causes degenerative changes in the auditory system, including reduced cochlear hair cells, atrophy of auditory nerve fibers, and ossicular chain stiffening, decreasing hearing sensitivity【21】. Concurrently, chronic diseases such as hypertension and diabetes, whose prevalence increases with age, further damage the auditory system through impaired inner ear circulation and metabolism, synergistically elevating hearing loss risk【5】. Environmental noise exposure and medication use in older adults may also compound age-related hearing damage. Notably, risk reached a "plateau" in the 70–74 age group, with risk remaining similar after age 75. This suggests that below age 75, risk remains relatively unstable and potentially modifiable, making intervention during this window more likely to positively impact hearing health.

Period effects revealed a concerning monotonic increase in hearing loss risk over time. Compared with 1990–1994, risk increased by 9.38% in 2020–2021. Multiple factors contribute to this trend: (1) Accelerated industrialization and urbanization have intensified environmental noise pollution from traffic, industry, and construction. Long-term exposure causes irreversible inner ear damage, increasing hearing loss risk. Studies show that exposure to road traffic noise exceeding 70 dB significantly elevates auditory system damage risk【22】. (2) The modern lifestyle's fast pace has normalized prolonged high-volume headphone use, subjecting the inner ear to sustained intense acoustic stimulation. Increased social and recreational activities among older adults in noisy environments further burden the auditory system. (3) Historically, hearing detection equipment lacked precision, making early or mild hearing loss difficult to diagnose accurately. Today, widespread availability of pure-tone audiometry and smartphone-based mobile hearing tests【23】 enables precise detection of subtle hearing changes, increasing diagnosed prevalence. Additionally, the impact of population aging cannot be ignored. Future prevention efforts must adopt multifaceted approaches: strengthen environmental noise control, promote healthy lifestyles, optimize diagnostic technologies, and improve elderly hearing healthcare service systems.

Cohort effects showed that hearing loss risk among Chinese middle-aged and older adults gradually decreased with more recent birth cohorts. The 1965–1969 birth cohort had 10.42% lower risk than the 1895–1899 cohort. Earlier-born populations faced higher risk due to historical environmental and healthcare constraints: inadequate occupational protection exposed workers to high-intensity noise, causing severe auditory damage; poor public health conditions made children vulnerable to infectious diseases like mumps and meningitis that cause ear complications; and scarce medical resources with lagging detection and treatment technologies hindered early intervention, allowing conditions to worsen. Later-born cohorts benefited from improved health awareness and early intervention. With societal development, hearing health knowledge has spread widely, and universal newborn hearing screening enables timely detection and intervention, reducing severity in adulthood【24】. Medical advances have also provided hearing aids and cochlear implants that improve clinical outcomes for middle-aged and older adults.

In summary, this study, based on GBD 2021 data, reveals a significantly increasing burden of hearing loss among Chinese individuals ≥55 years from 1990–2021, with gender disparities and pronounced age, period, and cohort effects. As China's aging accelerates, hearing loss among middle-aged and older adults has become increasingly prominent, carrying major implications for future public health and healthcare efforts. On one hand, widespread hearing screening and targeted education should be implemented for middle-aged and older adults, especially high-risk groups, with expanded chronic disease management【25】. On the other hand, community-based assessment and intervention service models should be established, addressing mental health in hearing-impaired older adults and building a continuous three-tier prevention and control system integrating prevention, screening, treatment, and rehabilitation to comprehensively improve hearing health among middle-aged and older adults.

Author Contributions: ZHANG Yongqing conceived the study, designed the protocol, collected and organized data, and drafted the manuscript; LI Na, GAO Yili, and QIN Jiawen revised the manuscript and were responsible for quality control and review; YU Haiping verified data and edited tables and figures; SHI Hui participated in conceptualization and design, revised the final version, and takes responsibility for the full manuscript.

Conflict of Interest: The authors declare no actual or potential conflicts of interest.

References

【1】LI Keyong, SONG Yuanhang, HUANG Hutao, et al. Analysis of global and Chinese hearing loss disease burden from 1990 to 2019[J]. Occupational Health and Emergency Rescue, 2023, 41(4): 414-420. DOI: 10.16369/j.oher.issn.1007-1326.2023.04.005.

【2】NOCINI R, HENRY B M, LIPPI G, et al. Estimating the worldwide burden of health loss due to hearing loss[J]. Eur J Public Health, 2023, 33(1): 146-148. DOI: 10.1093/eurpub/ckac171.

【3】ZHAO I Y, PARIAL L L, MONTAYRE J, et al. Social engagement and depressive symptoms mediate the relationship between age-related hearing loss and cognitive status[J]. Int J Geriatr Psychiatry, 2023, 38(8): e5982. DOI: 10.1002/gps.5982.

【4】COLLABORATORS G 2 H L. Hearing loss prevalence and years lived with disability, 1990-2019: findings from the Global Burden of Disease Study 2019[J]. Lancet, 2021, 397(10278): 996-1009. DOI: 10.1016/S0140-6736(21)00516-X.

【5】MCKEE M M, STRANSKY M L, REICHARD A. Hearing loss and associated medical conditions among individuals 65 years and older[J]. Disabil Health J, 2018, 11(1): 122-125. DOI: 10.1016/j.dhjo.2017.05.007.

【6】TAN B K J, MAN R E K, GAN A T L, et al. Is sensory loss an understudied risk factor for frailty? A systematic review and meta-analysis[J]. J Gerontol A Biol Sci Med Sci, 2020, 75(12): 2461-2470. DOI: 10.1093/gerona/glaa171.

【7】LIU Jing. Analysis of factors related to the occurrence and development of hearing impairment in the elderly and research on prevention and control policies in China[D]. Shanghai: Naval Medical University of the Chinese People's Liberation Army, 2023. DOI: 10.26998/d.cnki.gjuyu.2023.000328.

【8】MOTALA A, JOHNSRUDE I S, HERRMANN B. A longitudinal framework to describe the relation between age-related hearing loss and social isolation[J]. Trends Hear, 2024, 28: 23312165241236041. DOI: 10.1177/23312165241236041.

【9】ZHOU Y F, LU Y, LIU Y, et al. Sensory impairments and subjective well-being status in middle-aged and older Chinese population: Cross-sectional and longitudinal analyses of a nationally representative survey[J]. Front Public Health, 2023, 11: 1099754. DOI: 10.3389/fpubh.2023.1099754.

【10】HAN D, LI S S, WU Y Y, et al. The mediating role of depression in the association between hearing impairment and functional disability among middle-aged and older adults in China[J]. Innov Aging, 2023, 7(8): igad093. DOI: 10.1093/geroni/igad093.

【11】LIU C J, CHANG P S, GRIFFITH C F, et al. The nexus of sensory loss, cognitive impairment, and functional decline in older adults: a scoping review[J]. Gerontologist, 2022, 62(8): e457-e467. DOI: 10.1093/geront/gnab082.

【12】SHARMA A, RUTHERFORD B R, LIN F, et al. Age-related hearing loss as a risk factor for late life depression and cognitive decline[J]. Am J Geriatr Psychiatry, 2019, 27(3): S43-S44. DOI: 10.1016/j.jagp.2019.01.195.

【13】ZHOU Y F, HU Y P, LUO J F, et al. Association between sensory loss and falls among middle-aged and older Chinese population: cross-sectional and longitudinal analyses[J]. Front Med, 2022, 8: 810159. DOI: 10.3389/fmed.2021.810159.

【14】LIU Jiamin, DAI Fumin, ZHAO Yasha, et al. Research progress on falls in older adults with hearing loss[J]. Chinese General Practice, 2023, 26(13): 1661-1666, 1670. DOI: 10.12114/j.issn.1007-9572.2022.0860.

【15】GBD Results[EB/OL]. [2025-02-19]. https://vizhub.healthdata.org/gbd-results.

【16】LI W Z, ZHAO Z Y, LU Z X, et al. The prevalence and global burden of hearing loss in 204 countries and territories, 1990-2019[J]. Environ Sci Pollut Res Int, 2022, 29(8): 12009-12016. DOI: 10.1007/s11356-021-16582-8.

【17】REAVIS K M, BISGAARD N, CANLON B, et al. Sex-linked biology and gender-related research is essential to advancing hearing health[J]. Ear Hear, 2023, 44(1): 10-27. DOI: 10.1097/AUD.0000000000001291.

【18】WANG Q X, WANG X L, YANG L, et al. Sex differences in noise-induced hearing loss: a cross-sectional study in China[J]. Biol Sex Differ, 2021, 12(1): 24. DOI: 10.1186/s13293-021-00363-8.

【19】NAM D W, PARK M H, JEONG S J, et al. Sex differences in associated factors for age-related hearing loss[J]. PLoS One, 2024, 19(3): e0298048. DOI: 10.1371/journal.pone.0298048.

【20】WANG Jing, JIA Haiying. Research progress on the effect of smoking on hearing loss[J]. Chinese Journal of Otology, 2025, 23(1): 144-148. DOI: 10.3969/j.issn.1672-2922.2025.01.028.

【21】DUAN Jinyu, ZHANG Zhiqiang, HUANG He, et al. Research progress on age-related hearing loss in older adults[J]. China Medical Innovation, 2024, 21(23): 177-182. DOI: 10.3969/j.issn.1674-4985.2024.23.041.

【22】WANG T C, CHANG T Y, TYLER R S, et al. Association between exposure to road traffic noise and hearing impairment: a case-control study[J]. J Environ Health Sci Eng, 2021, 19(2): 1483-1489. DOI: 10.1007/s40201-021-00704-y.

【23】WANG K R, WEI W R, SHI J Y, et al. Diagnostic accuracy of mobile health-based audiometry for the screening of hearing loss in adults: a systematic review and meta-analysis[J]. Telemed J E Health, 2023, 29(10): 1433-1445. DOI: 10.1089/tmj.2022.0427.

【24】SONG Lianlian, TANG Huaxiao. Analysis of hearing screening results and related influencing factors in 16,545 newborns[J]. Maternal and Child Health Care of China, 2025, 40(3): 513-516. DOI: 10.19829/j.zgfybj.issn.1001-4411.2025.03.030.

【25】LI Yu, SHAO Shihan, QIU Shuting, et al. Research progress on health hazards and daily interventions for age-related hearing loss[J]. Acta Academiae Medicinae Sinicae, 2024, 46(5): 740-746. DOI: 10.3881/j.issn.1000-503X.15880.

Received: 2025-04-10
Revised: 2025-06-26
Editor: MAO Yamin