Global burden and trends of age-related and other hearing loss: A 32-year analysis and future projections based on the GBD 2021

Jiao Zhu; Min Yang; Cuiying Zhou; Houyong Kang; Deping Wang

doi:10.1371/journal.pone.0330690

Peer Review History

Original SubmissionApril 7, 2025
16 Jun 2025 Decision Letter - Gauri Mankekar, Editor Dear Dr. Wang, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: Please see the comments of the reviewers and revise the manuscript. ============================== Please submit your revised manuscript by Jul 31 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No ****** Reviewer #1: Observations The study was done through a systematic literature analysis based on Global Burden of Disease (GBD) 2021 database. The study aimed at providing a comprehensive analysis of the global, regional, and national burden of Age Related and other Hearing Loss (ARoHL). The study involved the GBD 2021 database which integrates multidimensional epidemiological data from 204 countries and regions worldwide, covering 371 diseases and health issues, as well as 88 risk factors, spanning the years 1990 to 2021. Overall, it is a well-thought out and executed research manuscript capable of contributing to the body of knowledge regarding the impact of ARoHL. However, I have the following observations, 1. Methods: The study utilized a variety of instruments such as the health inequality analysis. Based on the populations of countries like China and India, their contribution which had the largest impact on Slope index of Inequality, might have been due this factor. Hence comparism with smaller countries may not truly give realistic values. Hence might tend to have inherent sampling bias. 2. References: The referencing style appears generally fine. However, it appears the reference cited (references 9) due to its publication date, 1978 might not be reflective of current trends due to being slightly outdated. 3. The phrasing of the language used in the entire document could benefit from a more professional grammatical input. 4. I found the title, study design, statistics, figures and tables quite satisfactory. Reviewer #2: Comments on Strengths. a) Good graphs/figures with appropriate labels and annotations. Best figures are 1, 2, 4. b) Compréhensive, quantitative analyses. Good use of techniques for decomposition analysis, cross-country inequality analysis, frontier analysis, and predictive analysis. c) Attempt to provide a quantitative perspective for global, regional, and national prevalence of ARoHL that would be helpful for developing health-care plans appropriate for a given region/nation. Issues, Items, and Questions to be Addressed. General: 1) Provide a table with definitions for all acronyms used throughout the manuscript. 2) When giving numbers, show only the significant digits and use exponential notation when spanning several orders of magnitude. Do this throughout the text and also for Table 1 (which is difficult to read as it is). 3) Throughout the text, as a “standard”, state and use and discuss all variables in terms of normalized (for population size; i.e., per 100,000). When stating/discussion “raw”, un-normalized values, then clearly state that (and distinguish from normalized values). Specific: 1) The reference list is difficult to read. Re-format. For example, for a given reference indent all lines after the first. In addition, double space between references. 2) Table 1 is difficult to read. Re-format per above. Consider putting this into supplementary material (and relying on the figures). 3) Abstract a. Emphasize prevalence and YLDs that are normalized for population size (e.g., cases per fixed number of people within a given population). b. Emphasize trends, disparities, and differences between using normalized values (for population size) for prevalence an YLDs. 4) Add more detail, emphasis, and discussion about normalizing the prevalence, YLDs, and distribution of ARoHL with respect to the population size at each time point being analyzed. In other words, prevalence per fixed number of people within a given population. The normalized variables are more meaningful in terms of explaining possible effects of the various “driving” factors (compared to the effect of increases/decreases in the total population size on the raw, absolute numbers). 5) Provide some examples of possible actions that could be taken and strategies that could be proposed, in view of the projections for future trends. 6) Decomposition Analysis a. Discuss possible other/confounding factors, including the following: noise-induced hearing loss (outside environment and home/work conditions), side-effects of medical treatments (medications/drugs, surgery, radiation), family history and genetic pre-dispositions. b. Line 134: Provide a table listing all the factors “behind changes in the disease burden of ARoHL” and their percent contributions. Emphasize the percent contributions for changes in a normalized (for population size) prevalence of ARoHL. c. Line 140: Discuss “the accelerated aging process”. d. Line 147: Explain and discuss the meaning of “for a comprehensive understanding of the epidemiological evolution of middle ear disease”, within the context of ARoHL. Why refer to “middle ear disease”? 7) Results a. Emphasize ASPR per 100,000 people within a given population (i.e., normalized for population size). b. Lines 216 - 218: State that these numbers for prevalence are a raw number of cases in the population. State that the ASPR is per 100,000 (i.e., normalized for population size. It is especially meaningful to emphasize changes in a normalized prevalence (cases per fixed number of people within a population) over the 21-year time period. Thereafter, one can consider possible factors involved (other than population increase or decrease). c. Lines 218 – 219: In regard to “age-standardized prevalence rate (ASPR)”, provide a literature reference/citation that details/describes comparing across populations with different age structures (using weights based on the age distribution of a standard population). d. Table 1 legend: State the EAPC is based on the normalized ASPRs (per 100,000 people). e. Figure 1 legend: State normalized ASPR and normalized YLDs are shown in the figure. 8) Conclusions a. Lines 448 – 452: Expand. Besides “raw”, un-normalized total numbers, emphasize changes in numbers that are normalized for population size. Summarize the percent changes (for normalized data). This way one can meaningfully consider changes in prevalence related to all factors (other than population growth) which might be important for considering intervention strategies. Finally, suggest (speculate) possible intervention strategies. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Stephen O Adebola Reviewer #2: Yes: John H Anderson, MD, PhD ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0330690.r001
Revision 1
3 Jul 2025 Author Response We have uploaded our detailed responses to the reviewers' comments as a separate document titled 'Response to Reviewers.' The specific contents are as follows: Reviewer #1: 1. Methods: The study utilized a variety of instruments such as the health inequality analysis. Based on the populations of countries like China and India, their contribution which had the largest impact on Slope index of Inequality, might have been due this factor. Hence comparism with smaller countries may not truly give realistic values. Hence might tend to have inherent sampling bias. Response: We acknowledge the limitation regarding the influence of large-population countries on the Slope Index of Inequality. Unfortunately, there is no universally accepted method to fully address this issue 2. References: The referencing style appears generally fine. However, it appears the reference cited (references 9) due to its publication date, 1978 might not be reflective of current trends due to being slightly outdated. Response: We have replaced the outdated reference (Reference 10) with a more recent and relevant source to better reflect current trends. 3. The phrasing of the language used in the entire document could benefit from a more professional grammatical input. Response: Taking your suggestions into consideration, we have had the language of the entire document polished by AJE. 4. I found the title, study design, statistics, figures and tables quite satisfactory. Response: We appreciate the reviewer's positive feedback on the title, study design, statistics, figures, and tables. However, after revising and polishing the entire manuscript, we have made minor adjustments to these sections to ensure overall consistency. Reviewer #2: General: 1) Provide a table with definitions for all acronyms used throughout the manuscript. Response: In response to your suggestion, a “List of Abbreviations” has been added immediately following the Conclusion section. This table provides definitions for all acronyms and abbreviations used throughout the manuscript to enhance clarity. 2) When giving numbers, show only the significant digits and use exponential notation when spanning several orders of magnitude. Do this throughout the text and also for Table 1 (which is difficult to read as it is). Response: We have revised the numerical data presentation throughout the text to show only significant digits and used exponential notation where appropriate. Additionally, Table 1 has been revised and moved to the Supporting Information as S1 Table. We have also applied the same formatting changes to S2 Table. 3) Throughout the text, as a “standard”, state and use and discuss all variables in terms of normalized (for population size; i.e., per 100,000). When stating/discussion “raw”, un-normalized values, then clearly state that (and distinguish from normalized values). Response: We have standardized the presentation of all variables throughout the manuscript using normalized values (per 100,000) according to this suggestion. For ASPR and ASYR, we have explicitly noted that these are expressed per 100,000. Additionally, we have clearly distinguished raw, un-normalized values by specifying them as “number of cases” or “number of YLDs” whenever they appear. This ensures consistency and clarity in our data presentation. Specific: 1) The reference list is difficult to read. Re-format. For example, for a given reference indent all lines after the first. In addition, double space between references. Response: We have reformatted the references in accordance with your request. 2) Table 1 is difficult to read. Re-format per above. Consider putting this into supplementary material (and relying on the figures). Response: We have re-formatted Table 1 as requested and renamed it as S1 Table, placing it in the Supporting Information. 3) Abstract a. Emphasize prevalence and YLDs that are normalized for population size (e.g., cases per fixed number of people within a given population). Response: In the abstract, we have explicitly noted that ASPR and ASYR are expressed per 100,000, emphasizing the use of normalized values as requested. b. Emphasize trends, disparities, and differences between using normalized values (for population size) for prevalence an YLDs. Response: We have revised the abstract to emphasize the trends, disparities, and differences in prevalence and YLDs when using normalized values (per 100,000). 4) Add more detail, emphasis, and discussion about normalizing the prevalence, YLDs, and distribution of ARoHL with respect to the population size at each time point being analyzed. In other words, prevalence per fixed number of people within a given population. The normalized variables are more meaningful in terms of explaining possible effects of the various “driving” factors (compared to the effect of increases/decreases in the total population size on the raw, absolute numbers). Response: We have revised the manuscript to emphasize and discuss the normalization of prevalence, YLDs, and ARoHL distribution with respect to population size at each time point, focusing primarily on the normalized variables as requested. 5) Provide some examples of possible actions that could be taken and strategies that could be proposed, in view of the projections for future trends. Response: We have incorporated examples of possible actions and strategies that could be proposed based on the projections for future trends, as requested. 6) Decomposition Analysis a. Discuss possible other/confounding factors, including the following: noise-induced hearing loss (outside environment and home/work conditions), side-effects of medical treatments (medications/drugs, surgery, radiation), family history and genetic pre-dispositions. Response: We have added a discussion of additional potential confounding factors, including noise-induced hearing loss, medical treatment side effects, and genetic predispositions, in the discussion section. b. Line 134: Provide a table listing all the factors “behind changes in the disease burden of ARoHL” and their percent contributions. Emphasize the percent contributions for changes in a normalized (for population size) prevalence of ARoHL. Response: We have detailed the drivers of absolute changes in ARoHL burden in Supplementary Table S5, quantifying contributions from population growth, aging, and epidemiological shifts. For normalized prevalence (ASPR), given its design to remove population size effects, we currently believe that attributing specific drivers would be methodologically unsound. Instead, we have analyzed the relationships between ASPR and factors such as age, gender, and SDI throughout the text. c. Line 140: Discuss “the accelerated aging process”. Response: We apologize for the oversight in our manuscript where we inadvertently used the term “the accelerated aging process” instead of “population aging.” We have now corrected this error. While we acknowledge the importance of discussing population aging, we did not elaborate further on this topic in our discussion, as population aging is difficult to change in the short term, as mentioned in our discussion section. d. Line 147: Explain and discuss the meaning of “for a comprehensive understanding of the epidemiological evolution of middle ear disease”, within the context of ARoHL. Why refer to “middle ear disease”? Response: We appreciate the reviewer’s attention to this point. The reference to “middle ear disease” was indeed an oversight, and we intended to discuss ARoHL. We were concurrently working on a study related to middle ear disease, which likely contributed to the confusion. We have now corrected this error and have thoroughly reviewed the entire manuscript to ensure consistency and accuracy, minimizing the possibility of similar mistakes. 7) Results a. Emphasize ASPR per 100,000 people within a given population (i.e., normalized for population size). Response: We have made the revision as requested. b. Lines 216 - 218: State that these numbers for prevalence are a raw number of cases in the population. State that the ASPR is per 100,000 (i.e., normalized for population size. It is especially meaningful to emphasize changes in a normalized prevalence (cases per fixed number of people within a population) over the 21-year time period. Thereafter, one can consider possible factors involved (other than population increase or decrease). Response: We have made the revision as requested. c. Lines 218 – 219: In regard to “age-standardized prevalence rate (ASPR)”, provide a literature reference/citation that details/describes comparing across populations with different age structures (using weights based on the age distribution of a standard population). Response: We have addressed this point by providing a literature reference and detailed explanation regarding the calculation of the age-standardized prevalence rate (ASPR) and age-standardized YLDs rate (ASYR) in the “Estimation of disease burden” section of the Materials & Methods. d. Table 1 legend: State the EAPC is based on the normalized ASPRs (per 100,000 people). Response: We have made the revision as requested. e. Figure 1 legend: State normalized ASPR and normalized YLDs are shown in the figure. Response: We have made the revision as requested. 8) Conclusions a. Lines 448 – 452: Expand. Besides “raw”, un-normalized total numbers, emphasize changes in numbers that are normalized for population size. Summarize the percent changes (for normalized data). This way one can meaningfully consider changes in prevalence related to all factors (other than population growth) which might be important for considering intervention strategies. Finally, suggest (speculate) possible intervention strategies. Response: We have made the revision as requested. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0330690.r002
5 Aug 2025 Decision Letter - Gauri Mankekar, Editor Global burden and trends of age-related and other hearing loss: A 32-year analysis and future projections based on the GBD 2021 PONE-D-25-18205R1 Dear Dr. Wang, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Gauri Mankekar, MD,PhD,FACS Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: (No Response) Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Observations The study was done through a systematic literature analysis based on the Global Burden of Disease (GBD) 2021 database. The study aimed at providing a comprehensive analysis of the global, regional, and national burden of Age Related and other Hearing Loss (ARoHL). The study involved the GBD 2021 database which integrates multidimensional epidemiological data from 204 countries and regions worldwide, covering 371 diseases and health issues, as well as 88 risk factors, spanning the years 1990 to 2021. Overall, it is a well-thought out and executed research manuscript capable of contributing to the body of knowledge regarding the impact of ARoHL. However, I have the following observations, 1. Methods: Study design appeared a bit skewed, but acceptable in current version 2. References: Improved upon based on updated revised copy 3. The phrasing of the language reads more grammatically based on professional input. I found the title, study design, statistics, figures and tables quite satisfactory Reviewer #2: The reviewers' requests were fully addressed. The clarity, specificity, and context for the results have been significantly improved. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Stephen Adebola Reviewer #2: Yes: John H Anderson ******** https://doi.org/10.1371/journal.pone.0330690.r003
Formally Accepted
Acceptance Letter - Gauri Mankekar, Editor PONE-D-25-18205R1 PLOS ONE Dear Dr. Wang, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Gauri Mankekar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0330690.r004

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