Global burden, inequalities, frontier dynamics, and risk factors of sudden infant death syndrome, 1990–2021: a systematic analysis from the global burden of disease study 2021

Introduction

Sudden infant death syndrome (SIDS) is one of the most severe health threats during infancy, specifically referring to the sudden and unexpected death of an infant under one year of age during sleep that cannot be reasonably explained by known medical history or autopsy results (1). Statistics from 2020 indicate that approximately 38.4 infants per 100,000 live births die from SIDS (2). This syndrome not only inflicts profound psychological trauma on families but also poses a significant challenge to global public health systems.

With the increasing availability of global health statistics and deepening research on the burden of disease, our understanding of SIDS continues to evolve (3). Despite the implementation of various public health initiatives targeting high-risk populations to improve sleeping environments and techniques, the prevention and control of SIDS remain challenging due to its global distribution characteristics, influencing factors, and epidemiological trends exhibiting significant diversity and complexity (4,5). A prior Global Burden of Disease Study (GBD) 2019 study revealed SIDS-related mortality and disability-adjusted life years (DALYs) (5). This study, using the latest GBD 2021 data, employs advanced analysis, cross-country inequality, and risk factor assessments to deepen understanding of the global SIDS burden. The goal is to provide data and evidence for reducing SIDS, mitigating health inequalities, and informing public health policy. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-475/rc).

Methods

Data source and framework

This cross-sectional study analyzed the latest data obtained from the GBD 2021 project (https://vizhub.healthdata.org/gbd-results/), which provides the largest and most up-to-date comparative assessments of the burden of 371 diseases and injuries and 88 risk factor-related diseases across 21 regions and 204 countries and territories from 1990 to 2021, stratified by age, sex, location, and year (6,7). Relevant data from systematic reviews of the literature, censuses, household surveys, civil registration and vital statistics data, surveillance data, and other sources were collected and identified for use in the GBD estimation process. The definition, processing, correction, and modeling of the data have been described elsewhere (5,6,8). In the GBD study, SIDS is defined as “the sudden death of an infant under one year of age that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene, and review of the clinical history” (5). The GBD 2021 study case definition for SIDS includes deaths coded under International Classification of Diseases (ICD)-10 codes R95, as well as the corresponding ICD-9 code 798. We extracted annual mortality and DALYs data for SIDS from 1990 to 2021. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

The sociodemographic index (SDI), integrating income, education, and fertility metrics, classified countries into five tiers (low, low-middle, middle, high-middle, high) (9). To provide a view of the age distribution of the SIDS burden, deceased infants were categorized into three distinct age groups: <28 days, 1–5 months, and 6–11 months. Additionally, cross-country health inequality in SIDS was analyzed using the slope index of inequality and health inequality concentration index, which measured mortality and DALYs against income-related social position and income distribution, respectively (10). Frontier analysis explored the relationship between SIDS burden and socioeconomic development, introducing the concept of ‘effective difference’ to represent unfulfilled health improvements (11). Risk factor analysis for SIDS-related mortality, employing systematic reviews, meta-regressions, and Gaussian process regression to quantify their population-level impacts (7).

Statistical analyses

Within the GBD research framework, mortality and DALYs rates per 100,000 population were reported along with 95% uncertainty intervals (UIs) (12). Estimated annual percentage change (EAPC) via log-linear regression characterized trends. Specifically, the following linear regression model was used for calculation: y=α+βx+ε, where y represents the natural logarithm of the age-standardized rate, x represents the year, and ε is the error term. The EAPC value was derived using the formula: EAPC=100×(eβ−1), and its 95% confidence interval (CI) was determined within the regression analysis framework (12). Statistical significance was set at P<0.05, with analyses conducted in R 4.4.2.

Results

Global burden

Globally, SIDS deaths decreased by 59.6% from 1990 to 2021 (75,718.9 to 30,607.7), with mortality rates declining from 59.3 to 24.2 per 100,000 population (EAPC=−2.5; 95% CI: −2.7 to −2.4). Similarly, DALYs fell from 5,318.8 to 2,167.6 per 100,000 population, reflecting a 3.0% annual decrease (95% CI: −3.2 to −2.8) (Table 1).

Trends by sex and age

Globally and across all SDI regions in 2021, males exhibited higher SIDS mortality and DALY rates than females (Figure 1). While both sexes showed declining trends from 1990 to 2021, reductions were more pronounced among females (Table 1, Figure 2).

Figure 1 Gender differences in SIDS burden at the global, SDI-stratified and regional levels in 2021. (A) Death rate; (B) DALYs rate. DALYs, disability-adjusted life years; SDI, sociodemographic index; SIDS, sudden infant death syndrome.

Figure 2 Temporal trend analysis of SIDS burden by sex globally and across different SDI regions from 1990 to 2021. (A) Deaths rate; (B) DALYs rate. DALYs, disability-adjusted life years; SDI, sociodemographic index; SIDS, sudden infant death syndrome.

In 2021, over 90% of SIDS deaths occurred in infants under 6 months, with the highest mortality in those aged 1–5 months (51.9%), followed by neonates (<28 days, 40.0%) and infants aged 6–11 months (8.1%). The 1–5 month age group dominated mortality in most regions, particularly in high-SDI areas (61.2%) and high-income Asia Pacific (74.8%), while neonates accounted for the majority in seven regions, notably Southeast Asia (62.2%). From 1990 to 2021, all age groups and SDI regions exhibited significant declines in SIDS mortality and DALY rates (Figure S1).

Global trends by SDI

In 2021, among the five SDI regions, the low SDI region had the highest mortality (42.8 per 100,000 population; 95% UI: 22.3–62.7) and DALY rates (3,840.1 per 100,000 population; 95% UI: 1,998.8–5,622.3) of SIDS, followed by the low-middle SDI region. From 1990 to 2021, all five SDI regions showed significant downward trends in mortality and DALY rates, with the low SDI region experiencing the smallest decrease and the high SDI region showing the most pronounced decrease (Table 1, Figure 2).

The relationship between disease burden trends and SDI across 21 regions was more complex, with a significant negative correlation when SDI values were below 0.6, a positive correlation when SDI values were between 0.6 and 0.75, and a negative correlation again when SDI values were above approximately 0.75 (Figure S2A,S2B). Analysis of the relationship between disease burden indicators and SDI across different countries showed that mortality and DALY rates of SIDS exhibited a consistent pattern across different SDI levels, with an overall decreasing trend in mortality and DALY rates as SDI values increased. For SDI values below 0.7, this downward trend was relatively significant, but above 0.7, the trend stabilized, suggesting that countries with lower SDI tend to report higher disease burden (Figure S2C,S2D).

Regional trends

In 2021, Western Sub-Saharan Africa had the highest number of deaths (7,891.5, 95% UI: 3,861.7–11,892.6) and DALYs (707,895.7, 95% UI: 346,509.4–1,066,855.5), followed by South Asia and Eastern Sub-Saharan Africa. In terms of rates, Western Sub-Saharan Africa also exhibited the highest burden. From 1990 to 2021, all GBD regions showed decreasing trends in SIDS mortality, with Australasia experiencing the largest decrease. During this period, with the exception of Central Latin America, where the SIDS-related DALY rate slightly increased, all other regions showed a declining trend (Table 1).

National trends

In 2021, Nigeria recorded the highest number of deaths (4,786.3, 95% UI: 2,075.2–8,117.0), followed by India (4,250.7, 95% UI: 2,084.0–7,002.2). In terms of DALYs, Nigeria and India continued to bear the heaviest burden. Notably, South Sudan ranked first in both mortality and DALY rate (Table S1 and Figure 3). From 1990 to 2021, the mortality rate of SIDS increased in nearly nine countries globally, while it remained stable or declined in 195 countries. Georgia experienced the steepest increase, while Australia saw the fastest decline. Furthermore, the DALY rate increased in 12 countries and remained stable or declined in 192 countries. Georgia had the fastest increase in DALY rate, while Puerto Rico experienced the steepest decline (Table S1).

Figure 3 Global trends in the disease burden of SIDS in 204 countries and territories in 2021. (A) Death rate; (B) DALYs rate. DALYs, disability-adjusted life years; SIDS, sudden infant death syndrome.

Inequality analysis

Regarding the burden of SIDS, significant absolute and relative inequalities were observed, which were associated with the SDI. Countries and territories with lower SDI disproportionately bore a higher burden. As indicated by the slope index of inequality, the gap in mortality rate between the highest and lowest SDI countries and territories narrowed from -60.32 (95% CI: −70.46 to −50.18) per 100,000 population in 1990 to −23.90 (95% CI: −27.46 to −20.33) per 100,000 population in 2021. Similarly, the gap in DALYs rate between these countries decreased from −5,412.79 (95% CI: −6,322.78 to −4,502.81) per 100,000 population in 1990 to −2,143.74 (95% CI: −2,463.78 to −1,823.71) per 100,000 population in 2021. Both concentration indices were −0.32 (95% CI: −0.48 to −0.08) in 1990 but increased to −0.46 (95% CI: −0.57 to −0.31) in 2021 (Figure S3A,S3B).

Frontier analysis

Using data from 1990 to 2021 and based on mortality/DALY rates and SDI, frontier analysis was conducted to explore the potential improvement space for mortality and DALY rates, considering national and regional development levels. The results indicated that as socio-demographic conditions improved over time, SIDS-related mortality and DALYs declined in most countries, accompanied by a narrowing of health inequalities across regions. This indicates that countries or regions with lower SDI have greater potential for improving the SIDS burden. Notably, the 15 countries and territories with the largest potential for actual improvement include Nigeria, India, Pakistan, Ethiopia, the United States of America, Afghanistan, Bangladesh, Yemen, Sudan, the United Republic of Tanzania, Indonesia, Egypt, China, Niger, and Chad (Figure 4A,4B). However, this interpretation must be made with extreme caution. The ‘unfulfilled potential’ identified in many of these high-priority countries (e.g., Nigeria, India, Pakistan) may not solely reflect a higher preventable SIDS burden but could be significantly confounded by under-ascertainment of cases due to non-standardized death investigation protocols and the well-documented diagnostic shift away from the R95 code.

Figure 4 Frontier analysis of the SIDS burden in 204 countries and territories. (A) Death rate; (B) DALYs rate. DALYs, disability-adjusted life years; SIDS, sudden infant death syndrome.

Risk factors analysis

The GBD database identified four major risk factors for the burden of SIDS: low birth weight (LBW), short gestation, household air pollution (HAP) from solid fuels, and ambient particulate matter (APM). Globally and across the five SDI regions, LBW was the primary cause of SIDS-related deaths and DALYs, followed by short gestation. Notably, the attribution proportions of these four risk factors were significantly higher in lower SDI regions compared to higher SDI regions. In terms of particulate pollution, the attribution proportion of HAP was higher in lower SDI regions than APM, while the opposite was true in higher SDI regions, where APM had a higher attribution proportion (Figure 5A and Figure S4A).

Figure 5 The proportion of risk factors attributed to the death and DALYs rates of SIDS at the global and SDI-stratified levels in 2021. (A) Death; (B) DALYs. SDI, sociodemographic index; SIDS, sudden infant death syndrome.

Since 1990, there have been significant variations in the trends of attributable proportions of SIDS-related deaths and DALYs caused by various risk factors across global and SDI regions. Specifically, the burden of SIDS due to LBW and short gestation showed a slow declining trend globally and in Low and Low-middle SDI regions but increased in 2020 and 2021. In contrast, this burden increased overall in higher SDI regions. Additionally, the burden of SIDS caused by HAP declined slowly across all regions, while the burden caused by APM exhibited a slight upward trend (Figure 5B and Figure S4B).

Discussion

This study provides a comprehensive global, regional, and national assessment of SIDS mortality and DALYs rates from 1990 to 2021, revealing a 59.6% decline globally. Low-SDI regions like sub-Saharan Africa face the highest burden, while high-SDI regions like Australasia and Western Europe have made significant progress. Male infants and those aged 1–5 months are at highest risk. Although absolute inequalities have eased, relative inequalities are intensifying. Additionally, LBW has been identified as one of the primary causes of SIDS-related deaths and DALYs. This study underscores the impact of SIDS on global health and provides a scientific basis for the formulation of prevention and management strategies.

Notably, we observed that high-SDI regions had a notably high SIDS mortality rate (89.2 per 100,000) in 1990, which was even higher than some middle- and low-SDI regions at that time. This counterintuitive finding may be explained by several factors. First, high-SDI countries likely had more complete death registration systems and stricter autopsy standards in the early 1990s, leading to more comprehensive identification and reporting of SIDS cases; in contrast, middle- and low-SDI regions may have suffered from significant under-reporting and misclassification (e.g., attributing SIDS to other causes) (5). Second, prior to the 1990s, high-SDI countries exhibited a higher prevalence of established SIDS risk factors, notably prone sleeping positions and maternal smoking. These factors were often most common among socioeconomically disadvantaged and marginalized populations within these wealthy nations (13). Therefore, the elevated SIDS rate in high-SDI countries in 1990 likely reflects the interaction between more complete data collection systems and the prior lack of widespread preventive measures. However, with the subsequent implementation of a series of successful public health initiatives targeting these modifiable risk factors since the early 1990s, such as the “Back to Sleep” campaign that promoted supine sleeping, SIDS-related mortality and DALYs have demonstrated a marked decline over recent decades (14). This trend indicates significant advancements in global child health, attributable to widespread efforts to improve infant sleeping environments and enhance parental education on SIDS risk reduction (15).

The triple-risk model posits SIDS requires three concurrent factors: a biologically vulnerable infant, critical developmental stage (2–4 months), and external stressors (16). This aligns with SIDS’s distinct age pattern—90% occur before 6 months (peak 2–3 months)—when infants undergo rapid respiratory, autonomic, and cardiac system maturation. At this stage, combined internal/external stressors may trigger fatal respiratory failure (16,17). Further research has found that vulnerable infants often show covert neurological abnormalities, particularly in brainstem regions regulating cardiopulmonary function, which are critical in SIDS pathogenesis (18-20).

Despite the overall declining trend in the burden of SIDS, the burden among male infants remains high, and health services urgently need to increase their focus on male SIDS. Early studies indicated that the risk of sudden infant death is approximately 1.5 times higher in boys than in girls (21). Some studies have proposed possible explanations, including biological factors and socio-environmental factors. For example, boys and girls may differ in physiological structure, metabolic rate, susceptibility to infections, and immune system responses, which may affect their sensitivity to certain potential lethal factors (22). For instance, male infants aged 1–5 months exhibit significantly higher testosterone levels than females. Testosterone can enhance interferon-gamma-induced release of pro-inflammatory cytokines (such as IL-6 and TNF-α) while simultaneously suppressing the production of the anti-inflammatory cytokine IL-10, leading to a more dysregulated inflammatory response following infections (23). Furthermore, socio-environmental factors, such as family care practices and sleeping environments, may also differ by gender, further influencing the risk of sudden infant death (24). In summary, gender differences do play a role in SIDS, but the specific mechanisms require further in-depth research.

There are significant differences in the burden of SIDS among different countries and regions, influenced by multiple factors such as economic and social development levels, cultural backgrounds, and parenting practices. It is well-known that low socioeconomic status is an important risk factor for SIDS (25). This study shows that although the burden of SIDS in low- or low-middle SDI regions is declining, it remains significantly higher than that in high-SDI regions. Regions such as sub-Saharan Africa and South Asia have a heavy burden of SIDS, with countries like Nigeria and India experiencing particularly high burdens, consistent with previous findings (26,27). This may be related to the high prevalence of known SIDS risk factors in these regions. For example, preterm birth itself is a significant risk factor for SIDS, and the incidence of preterm birth remains high in these areas—over 60% of global cases occur in sub-Saharan Africa and South Asia. Preterm infants have immature immune and respiratory regulatory systems, resulting in reduced tolerance to infections (23). Meanwhile, higher rates of prone and side sleeping positions, as well as bed-sharing with adults, directly increase the risk of SIDS. Such sleeping positions are particularly likely to cause accumulation of respiratory secretions, promote bacterial colonization and toxin production, and further elevate the likelihood of infections (28,29). High infectious load, a core characteristic of low socioeconomic settings, is not only a risk factor for SIDS itself but also interacts synergistically with other factors such as preterm birth and non-supine sleep positions, collectively exacerbating the risk of SIDS. Therefore, in these regions, enhancing maternal and infant healthcare, promoting safe sleep knowledge (e.g., avoiding prone sleeping), and improving care for preterm infants would be effective and cost-effective measures to reduce SIDS mortality (8,30).

High-SDI regions including Australia and Western Europe have reduced SIDS-related burden by over 80% in three decades—a reduction surpassing global averages—as advancements in maternal and infant healthcare systems and national safe sleep promotion programs were implemented (31). For example, in Australia, only 17% of caregivers typically place infants in non-supine sleep positions, significantly lower than reported in other international studies, and national public health campaigns recommend keeping infants in smoke-free environments (32,33). Furthermore, Australia still considers infant mortality, especially sleep-related infant deaths associated with suboptimal infant care practices, a universal priority. It has identified “developing and evaluating new methods to make safe sleep campaigns more effective” as a top research priority, which could further reduce sleep-related infant mortality (32).

Furthermore, as a high-SDI nation, the United States demonstrates significant potential for SIDS prevention, yet progress has stalled since 2000—with SIDS now accounting for nearly half of post-perinatal deaths (3,400 annual cases) (14,34). This stagnation reflects persistent disparities: African American infants exhibit higher rates of non-supine sleeping compared to white and Hispanic counterparts (34,35), while non-Hispanic Black SIDS cases show elevated prevalence of serotonin transporter gene polymorphisms critical to respiratory regulation (24). These genetic and behavioral disparities, compounded by socioeconomic inequities, underscore the need for targeted interventions to address racial or ethnic gaps in SIDS outcomes.

This study demonstrates that LBW and short gestation are major risk factors contributing to SIDS-related deaths and DALYs globally. Especially in regions with lower SDI, the attributable proportions of these two factors are significantly higher than those in regions with higher SDI, which may be linked to relatively scarce medical resources and inadequate maternal and child health services in these areas. Studies indicate that infants born between 22–28 or 28–32 weeks of gestation have twice the risk of SIDS compared to full-term infants, and the risk of unexpected infant death decreases with increasing gestational age. This may be attributed to immature respiratory neural control mechanisms in preterm infants, as well as enhanced infection response capacity due to immune system maturation. For example, as gestational age increases, the development of immune organs such as the thymus and spleen becomes more complete, the ability to produce self-antibodies improves, the efficiency of pathogen clearance increases, and the regulation of inflammatory responses is enhanced, thereby avoiding excessive infection-induced inflammation that could damage the respiratory and circulatory systems (23,31). Notably, this study also found that the burden of SIDS due to LBW and short gestation has increased globally since 2019. Reports indicate that the incidence of SIDS in the United States increased by 15% from 2019 to 2020, rising from the fourth to the third leading cause of infant death (36). Potential causes may be related to the COVID-19 pandemic or changes in death certification practices. Additionally, the pandemic disrupted social networks and limited access to healthcare, such as early postpartum discharges and timely well-baby visits after birth hospitalization, particularly follow-up and education for premature infants and LBW infants discharged from neonatal intensive care units (NICUs) (37). After the relaxation of pandemic restrictions, the resurgence of respiratory infectious diseases such as respiratory syncytial virus and pertussis has emerged as new exogenous stressors, overlapping with infants’ immune vulnerability and further elevating the risk of SIDS (38,39). Vaccination is currently considered a potential issue related to SIDS. Studies such as those by Miller et al. have found a positive correlation between the number of vaccine doses and infant mortality rate in highly developed countries (40,41); however, other studies have reached different or even opposite conclusions (42). Therefore, future research should involve larger, well-designed studies that control for confounding factors, incorporating vaccine types, timing of administration, number of doses, and regional epidemiological backgrounds. Such efforts would enable a more comprehensive assessment of the relationship between vaccination and SIDS and provide a reliable basis for public health practices and optimization of immunization strategies.

The link between particulate pollution and SIDS morbidity/mortality is suggested by accumulating epidemiological evidence. For instance, a time-stratified case-crossover study focusing on Korean infants found that short-term exposure to PM₁₀ was associated with a 14% higher SIDS risk per 27.8 µg/m³ increment at lag 2 days, with this association being more pronounced in vulnerable subgroups such as LBW and preterm infants (43). This observation is further supported by a large cohort study covering approximately 8 million live births in England and Wales: after adjusting for key confounders including deprivation, birth weight, and maternal age, the study confirmed an association between PM₁₀ exposure and postneonatal mortality (a category that includes a substantial proportion of SIDS cases) (44). Consistent with these prior findings, our study extends this understanding by revealing global disparities in particulate pollution-related SIDS burden: globally, HAP contributes more significantly to SIDS than APM, especially in low-SDI regions where infants spend most time indoors. Indoor air quality, shaped by outdoor pollution infiltration, indoor sources (e.g., biomass combustion, secondhand smoke), housing conditions, and socioeconomic factors drives these regional disparities: the HAP-dominated SIDS burden in low-SDI areas reflects reliance on solid fuels and poor ventilation, while APM’s greater impact in high-SDI regions mirrors higher industrial and traffic emissions (45,46). Thus, policymakers should implement region-specific strategies targeting both indoor (e.g., expanding clean energy access in low-SDI regions) and outdoor (e.g., tightening emissions standards in high-SDI regions) pollution sources to mitigate SIDS risks.

This study is subject to several methodological constraints. First, and most critically, the very definition of SIDS requires a thorough post-mortem investigation and death scene review to exclude other causes. However, the adherence to such standardized autopsy protocols varies dramatically across and within the 204 countries and territories studied. This heterogeneity in diagnostic rigor means that a case coded as SIDS (ICD-10 R95) in one region may not be comparable to a case similarly coded in another, fundamentally challenging the comparability of the data (47). Second, and closely related, our analysis relies on the GBD’s operational definition of SIDS based on specific ICD codes (ICD-10 R95; ICD-9 798). Over time, many regions have transitioned to broader classification systems such as Sudden Unexpected Death in Infancy (SUDI) (48). This diagnostic shift can artificially inflate the apparent decrease in SIDS-specific mortality, as true sudden infant deaths are increasingly classified under alternative codes. Consequently, the dramatic declines observed in some high-SDI regions likely reflect a combination of genuine public health improvements and evolving certification practices. Third, notable concern related to data quality is the presence of ascertainment bias: in certain countries, incomplete death registration systems fail to capture the full spectrum of mortality events. This incompleteness not only reduces the overall sample representativeness but also introduces inaccuracies, as unrecorded deaths may disproportionately occur in settings with the highest risk of SIDS. Fourth, although the risk factor assessment integrated multiple etiological determinants, certain critical variables, such as racial demographics and genetic predispositions, were not comprehensively incorporated. This omission potentially limits the granularity of causal inference. Finally, the utilization of GBD data, which are predominantly derived from historical datasets, introduces an inherent temporal lag. This limitation may compromise the immediacy of the findings, especially given rapidly evolving public health dynamics.

Conclusions

In summary, SIDS remains a critical public health challenge, driven by gender, age, and sociodemographic inequities. Our analysis, constrained by the inherent limitations of using the R95 code for international comparisons over time, likely captures a shifting subset of all SUDI. Targeted interventions addressing perinatal health, environmental risks, and healthcare access are essential. Prioritizing high-burden regions and monitoring emerging trends are urgent to reduce disparities. Future global assessments would benefit from analyzing the broader category of SUDI to mitigate the effects of diagnostic shift.

Acknowledgments

We acknowledge the expertise of the Global Burden of Disease Study 2021 collaborators, whose work made this analysis possible.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-475/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-475/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-475/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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