Interpreting epidemiologic distribution of total and specific IgE levels for food allergy in Southern China from 2004 to 2023: understanding the mechanisms and focusing on prevention

Abstract

Background

The burgeoning prevalence of food allergy-related diseases is closely associated with geographical allergen distribution and societal lifestyle paradigms. This study aims to shed light on the distribution patterns of specific IgE (sIgE) and total IgE (tIgE) reactivity to common food allergens in the Southern Chinese populace.

Methods

Employing an analytical technique spanning two decades, we conducted specific IgE and total IgE on serum samples harvested from patients with food allergy-related pathologies at First Affiliated Hospital of Guangzhou Medical University from 2004 to 2023. This comprehensive examination of eight prototypical food allergens: egg white, milk, wheat, sesame, peanut, soybean, shrimp, and crab.

Results

Our analysis showed a 100% positivity rate for sIgE and an 86.54% positivity rate for tIgE. Milk had the highest positive response rate, followed by egg white and shrimp. Age-stratified data indicated that milk sensitization peaked in children aged 2 years or younger, while egg white sensitization peaked between 3 and 5 years of age. Sensitization rates for the remaining six allergens increased with age. Additionally, co-sensitization was observed between milk, egg white, crab, and shrimp with other allergens.

Conclusion

In common allergens of Southern China, egg white, milk, and shrimp ascend as the dominant subjects, underlining their imperative role in food allergy pathogenesis. This landscape-wide allergenic profiling, segregated across age clusters and enhanced by co-sensitization data, augments our power for early diagnosis and strategic intervention in food allergy diseases.

Introduction

Allergic diseases are recognized as a global health priority by the World Health Organization (WHO) [1, 2], with prevalence rates exceeding one-quarter of the population in developed countries and an increasing impact on developing nations [3, 4]. Food allergies, in particular, are driven by factors such as high-fat diets, obesity, genetics, and lifestyle changes, and affect approximately 5% of adults and 8% of children [5]. These conditions impose a significant burden on public health, reducing quality of life for affected individuals.

Egg white, milk, nuts, and shellfish are among the most common food allergens. Accurate identification of allergens [6] and strategic avoidance [7] are crucial for both prevention and treatment. The ImmunoCAP Phadia 1000 Immunoassay Analyzer has become the global standard for measuring total and specific IgE (tIgE and sIgE), making it essential tool in both clinical diagnosis and research.

Southern China, home to 55% of China’s population, defines itself as the region situated south of Qinling and Huaihe (103°E–123°E, 22°N–34°N) [8], presents unique environmental and dietary factors influencing allergen distribution [1, 9]. However, there is a notable scarcity of long-term studies examining food allergens in this region, particularly across different age groups [10], and explore the co-sensitization of multiple allergens with a lens of precision and care [11]. Our study, conducted at The First Affiliated Hospital of Guangzhou Medical University, investigates sIgE and tIgE responses to major food allergens over two decades, offering valuable insights into sensitization patterns. This research serves as a foundation for understanding allergen prevalence in Southern China and provides a framework for allergy prevention and management in similar regions globally.

Methods

Study design and population

20,504 serum specimens and associated demographic data were collected from the clinical laboratory of First Affiliated Hospital of Guangzhou Medical University. The selected serum samples were collected from individuals diagnosed with food allergic disorders who sought medical consultation in our respiratory, pediatric, and ENT (ear, nose, and throat) divisions between 2004 and 2023. A total of 12,321 patients underwent serum allergen-IgE testing, demonstrating reactivity to at least one food allergen. The diagnosis of food allergy in this study was based on a combination of clinical history, physician-diagnosed symptoms, and sIgE positivity using the ImmunoCAP system. Patients exhibited a range of allergic symptoms, including cutaneous reactions (e.g., rashes, eczema, urticaria), respiratory issues (e.g., rhinorrhea, sneezing, dyspnea), and gastrointestinal symptoms (e.g., vomiting, diarrhea). Self-reported symptoms were confirmed through clinical evaluation by physicians, and in cases where further validation was needed, specific IgE (sIgE) testing was used to corroborate sensitization. The exclusion criteria were carefully selected to omit 8,183 patients who had received allergen immunotherapy or had a medical history of conditions such as parasitic infections, autoimmune disorders, or lung malignancy. These exclusions were applied to ensure the integrity of the study, as these conditions or treatments may influence the immune system and potentially alter sIgE levels, leading to confounding results. By excluding these patients, we aimed to avoid any unintended bias in the analysis of allergen-specific IgE responses. The comprehensive procedural flow of the study is visually delineated in Fig. 1.

Fig. 1.

Study flow chart (a) Laboratory analysis process. Peripheral blood samples were drawn from patients diagnosed with food allergic diseases, exhibiting respiratory distress (e.g., nasal congestion), skin manifestations (e.g., rash), or gastrointestinal discomfort (e.g., diarrhea) following exposure to food allergens to test for serum concentrations of tIgE and sIgE employing ImmunoCAP 1000 system in Department of Allergy and Clinical Immunology. (b) Study framework diagram. The results of the remaining 12,321 enrolled patients were statistically analyzed after the initial screening of patients with allergic diseases were eliminated by exclusion criteria

Sample collection, processing, and storage

Upon obtaining informed consent from each qualifying participant, venous blood samples of 5 ml were collected into tubes pre-filled with separation gel. These samples were then centrifuged at a consistent speed of 3000 rpm for 10 min in a temperature-controlled centrifuge. Following this process, the supernatant serum was carefully aspirated using a pipette gun promptly aliquoted into labeled frozen storage tubes, and preserved at -80 °C to safeguard against multiple freeze-thaw cycles. Ensuring utmost integrity, all serum samples were dispatched to the Department of Allergy and Clinical Immunology using cold-chain logistics.

Allergen IgE detection and analysis

A fully automated in vitro allergen detector (Immuno-CAP 1000 system, Thermo Fisher Scientific Inc., California, USA) was used to precisely detect allergen-specific IgE and total IgE in sera. Assays were executed in strict adherence to both the manufacturer’s guidelines for instrumentation and reagents, as well as established standard operating procedures by operators who have undergone the Immuno-CAP Application Engineer training.

This study delved into the age distribution patterns of sIgE and tIgE for eight key food allergens (including egg white, milk, wheat, sesame, peanut, soybean, shrimp, and crab) and explored the significant correlations between sIgE and tIgE, aiming to enhance the diagnostic foundation of food allergic diseases. Assays for both sIgE and tIgE were quantified and determined based on their respective concentrations, expressed in IU/mL. A sIgE level of ≥ 0.35 kU/L (or Class 1 and above) was defined as positive reactivity. To provide a nuanced understanding, reactivity was further delineated into six distinct classes: Class 1, ≥ 0.35 kUA/L to < 0.70 kUA/L; Class 2, ≥ 0.70 kUA/L to < 3.50 kUA/L; Class 3, ≥ 3.50 kUA/L to < 17.50 kUA/L; Class 4, ≥ 17.50 kUA/L to < 50.00 kUA/L; Class 5, ≥ 50.00 kUA/L to < 100.00 kUA/L; and Class 6, ≥ 100.00 kUA/L. While for tIgE positivity, diagnostic criteria were set based on age: < 3 years old, tIgE ≥ 20 IU/mL; 3–6 years old, tIgE ≥ 35 IU/mL; 6–20 years old, tIgE ≥ 50 IU/mL; ≥ 20 years old, tIgE ≥ 100 IU/mL; ≥ 20 years old, tIgE ≥ 100 IU/mL. These criteria and classifications are pivotal in guiding accurate and informed diagnoses [12].

Ethical compliance and participant consent

This study received the esteemed endorsement of the Institutional Review Board of the First Affiliated Hospital at Guangzhou Medical University granted approval for this investigation (Approval number: GYFYY-2021-K25). Each participant in the research furnished written informed consent, demonstrating an understanding of the research objectives and procedures. All or part of the subjects and data involved in this research have not been published. None of the participants or the data from this research have been previously disclosed in full or in part. All procedures, from laboratory tests to research execution, adhered to the guidelines set by the Committee on Publication Ethics (COPE), the principles of the Declaration of Helsinki, and the Chinese regulatory framework for utilizing human biological specimens in studies.

Statistical analysis

Excel 2022 and IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp, Armonk, USA) were used for data processing and analysis. Quantitative datasets demonstrating a normal distribution were articulated as mean ± standard deviation. Conversely, datasets not conforming to a normal distribution were presented as median, complemented by interquartile ranges. To discern the differential sIgE positivity across diverse groups, the chi-square test was judiciously utilized. A statistical threshold was set, deeming P-values less than 0.05 as indicative of significance.

Results

Demographic characteristics

Between 2004 and 2023, 12,321 patients with allergic diseases were included in this study, across multiple departments such as Respiratory Medicine, Pediatrics, and Otolaryngology at the First Affiliated Hospital of Guangzhou Medical University. The gender distribution was 65.3% male (8,049 individuals) and 34.7% female (4,272 individuals). The median age was 11 years (interquartile range: 10.7–11.4 years). The most prevalent allergic condition was asthma, accounting for 41.1% of cases, followed by allergic rhinitis at 16.7%, urticaria at 2.1%, atopic dermatitis at 1.0%, eczema at 0.9%, and allergic diarrhea at 0.6%. The diagnoses for each of these allergic conditions were based on physician assessments, guided by clinical symptoms and confirmed through patient history and, where appropriate, diagnostic tests such as serum sIgE measurements. An additional 37.6% of patients were categorized as ‘Others’, which includes conditions like conjunctivitis, and less common forms of allergic reactions that did not fall into the predefined categories. (refer to Table 1 for details).

Table 1.

Characterization of the study population

Variable	Total (n = 12321)
Age (years), median (IQR)	11 (0–29)
Gender, n (%)
Male	8049 (65.3)
Female	4272 (34.7)
Disease, n (%)
Asthma	5061 (41.1)
Allergic rhinitis	2063 (16.7)
Atopic dermatitis Urticaria	263 (2.1) 126 (1.0)
Eczema	108 (0.9)
Allergic diarrhea	71 (0.6)
Others	4629 (37.6)

Assessment of sIgE and tIgE responses to eight prevalent food allergens

It was observed that the interaction with one or more of these allergens led to a striking 100% positivity rate in sIgE levels. Concurrently, tIgE responses manifested an impressive positivity rate of 86.54%, elucidating a substantial demographic that evinces sensitization to these alimentary antigens (Table 2). Significant statistical divergence was found between the positivity rates of sIgE and tIgE, substantiated by a Chi-square value of 64.97 and a highly significant p-value of less than 0.001. As we delved into individual allergenic profiles, milk, egg white, and shrimp emerged as the paramount culprits, evincing the highest positive rates. A noteworthy revelation was that approximately 90% of the observed allergic responses were confined predominantly within Classes 1–2 of the IgE concentration scale, indicating lower levels of IgE reactivity. For the remaining five food allergens, we discerned an ascending trend in the positive rate for wheat allergy. Intriguingly, sesame was the only allergen that did not record any occurrences of severe (Class 5–6) allergic responses. Meanwhile, despite crab registering a comparatively lower overall positive rate, it displayed a conspicuously elevated proportion of patients classified within severe allergic response categories (Class 5–6), as captured in Fig. 2.

Table 2.

Analysis of sIgE and tIgE positivity and allergy severity classification of eight food allergens (%)

Allergen	Positivity rate	IgE level classification
		Class 1–2	Class 3–4	Class 5–6
Egg white	47.26	92.27	7.35	0.38
Milk	63.82	87.70	12.05	0.24
Wheat	13.36	92.95	6.74	0.30
Sesame	1.17	87.50	12.50	0.00
Peanut	3.21	83.84	14.90	1.26
Soybeans	3.53	87.82	11.72	0.46
Crabs	7.83	78.76	19.17	2.07
Shrimp	26.81	81.57	16.92	1.51
tIgE	86.54

Fig. 2.

Distribution of the positive rates and allergy severity categorizations for sIgE and tIgE across eight prevalent food allergens

Age-Specific Exploration into the Positivity Rates of predominant food allergens

Using an age-stratified methodology to gauge tIgE positivity, we scrutinized the susceptibility to eight salient food allergens across a comprehensive spectrum of age demographics with triennial intervals—spanning from nascent life to the golden years of adulthood, in accordance with established criteria (Table 3; Fig. 3). Our study unearths conspicuous divergences in allergenic reactivity within disparate age strata. For instance, the allergenicity of egg white and milk manifested most potently among children and adolescents. Particularly, milk allergies reached an apogee at the tender age of two, with a startling positivity rate of 90.26%. Egg white-induced allergic responses, on the other hand, found their zenith between the ages of 3–5, registering at 66.32%. The receding trends observed in egg white-related reactivity with age may reflect the natural history of food allergy, where increased tolerance develops over time. This results in lower positivity rates among adults, as the immune system gradually adapts. While excepting egg white and milk, the remaining sextet of allergens showcased an upward trajectory of positivity as age ascended. Most notably, both crustaceans—crab and shrimp—flaunted exacerbated sensitization levels in adults and their sensitization apexed at an astonishing 32.58% and 79.57%, respectively. Sesame, however, maintained its positivity rates meandering consistently beneath the 10% threshold across all age groupings. Spanning the age continuum, tIgE positivity was pervasive, exceeding 70% in all evaluated age brackets. It reached its most accentuated levels within the 6–11 year age cluster, followed by a discernible decline as the population aged.

Table 3.

Age-stratified examination of food allergen positivity rates (%)

Allergens	0–2 years	3–5 years	6–8 years	9–11 years	12–14 years	15–17 years	≥ 18 years	χ2	P
	(n = 3890)	(n = 4264)	(n = 1220)	(n = 517)	(n = 220)	(n = 95)	(n = 2115)
Egg white	50.39	66.32	55.25	35.59	22.73	7.37	5.63	2281	< 0.001
Milk	90.26	76.55	59.18	39.26	29.09	9.47	4.26	5109	< 0.001
Wheat	8.15	11.75	17.30	19.15	16.36	23.16	21.75	270.3	< 0.001
Sesame	0.44	0.40	0.25	1.16	3.18	2.11	4.35	242.7	< 0.001
Peanut	1.21	1.38	2.21	3.29	4.55	6.32	10.87	503.4	< 0.001
Soybeans	0.77	0.56	0.90	1.55	3.64	16.84	15.98	1240	< 0.001
Crabs	0.39	2.11	5.25	9.09	17.27	23.16	32.58	2357	< 0.001
Shrimp	3.24	14.21	32.95	52.61	64.55	76.84	79.57	4926	< 0.001
tIgE	89.46	87.08	92.30	93.23	87.73	83.16	75.18	319.8	< 0.001

Note: Row × column list chi-square test was used to compare the differences between groups, and P < 0.05 considered the differences statistically significant

Fig. 3.

Age-integrated representation of sIgE and tIgE positivity rates across eight pivotal food allergens

Singular allergen sensitization and multiple allergen responsiveness in sIgE dynamics

In Fig. 4, we evaluated sIgE responses against an octet of allergens and delved into the relationships these exhibited with seven additional allergens in patients already manifesting sensitization to a singular allergen. Employing the visual radar chart, our data crystallized intriguing patterns of co-sensitization, revealing that individuals with heightened sIgE responses to milk, egg white, crabs, and shrimp maintained a remarkably consistent sensitization matrix with the other seven allergens under scrutiny. The proximity of points to the polygon’s periphery is emblematic of an elevated likelihood for the indicated allergen to serve as a sensitizing harbinger for other allergens. Inversely, points nestled closer to the geometric heart of the polygon signify a more subdued potential for co-sensitization in patients manifesting a positive allergic response to that particular allergen.

Fig. 4.

Radial Graphical Delineation of Single-Allergen Sensitization into Multi-Allergen Susceptibility in sIgE levels

In the subset of patients sensitized to the less conventional allergens of sesame, peanuts, and soy, we observed a striking co-sensitization propensity with wheat, manifesting rates of 70.8%, 59.8% and 79.3% respectively. The concomitant median sIgE levels registered were 1.08 kU/L, 1.02 kU/L, and 0.79 kU/L. Patients sensitized to milk and wheat revealed a preponderance for co-sensitization with egg white, evident in 54.7% and 57.1% of cases, each accompanied by median sIgE levels of 1.23 kU/L and 0.79 kU/L, respectively. Among those sensitized to egg white and wheat, milk emerged as the primary co-sensitizer, with respective rates of 73.9% and 54.7%, and median sIgE levels of 0.89 kU/L and 0.59 kU/L. When it comes to patients sensitized to sesame, we noted a fascinating proclivity for co-sensitization to peanuts, soybeans, and shrimp, with respective rates of 76.6%, 58.3%, and 54.2%. The median sIgE levels delineating these relationships were 0.81 kU/L, 0.86 kU/L, and 2.17 kU/L. Perhaps most captivating was the revelation that a staggering 82.6% of patients sensitized to crab exhibited co-sensitization to shrimp. In a contrasting dialectic, a mere 24.1% of shrimp-sensitized patients reciprocated with a co-sensitization to crab.

Discussion

In recent years, the fabric of our diets and lifestyles has been dramatically rewoven [13, 14], heralding an unprecedented surge in the incidence of food allergies. This surge spares no demographic, manifesting across the lifespan from infancy to adulthood [15]. Understanding the regional distribution of patients with these allergies can pave the way for improved prevention and control measures and also offer valuable data for localized allergen diagnosis. Our study, representing an expansive cohort of 12,321 individuals from southern China, provides insights into the geographic prevalent landscape of food-allergic diseases within this populous region. During our analysis of eight prevalent food allergens in southern China, we discovered that milk, egg white, shrimp, and crab reign supreme. Importantly, milk and egg white are not democratically distributed but are concentrated primarily among infants and young children. These food allergies are frequent protagonists in a wider cast of conditions, including asthma and gastrointestinal disorders, the underlying pathophysiology of which is elucidated in Fig. 5. The mechanism of food allergies [16] shares fundamental similarities with allergic reactions triggered by other allergens and can be divided into two key stages: sensitization and effector stages. During the initial exposure to food allergens, antigen-presenting cells like dendritic cells introduce the food allergens to Th2 cells, thus instigating the B-cell proliferation and culminating in the synthesis of IgE antibodies. These antibodies subsequently sensitize mast cells and basophils, thereby laying the groundwork for potent effector responses. Re-exposure to the offending allergens activates these sensitized cells, triggering the release of mediators like histamines and cytokines, which circulate through the bloodstream and elicit a broad spectrum of allergic responses—from localized irritations such as allergic rhinitis, urticaria, and allergic diarrhea to systemic emergencies like anaphylactic shock.

Fig. 5.

Mechanism of IgE-mediated food allergy

Our data unravels that milk sensitization peaks in children below three years, while egg white sensitization attains its zenith between ages three and five. Interestingly, the prevalence of these sensitivities diminishes with age, echoing the Shek et al. report that suggests an increased likelihood of tolerance development during early childhood. In addition, this study even proposed that by refining prognostic models that elucidate the decay rates of food-specific IgE levels, clinicians can tailor more precise, temporally optimized therapeutic strategies, including the timing of food challenges [17]. Given that milk and egg white allergies tend to introduce themselves early in life, vigilant monitoring during infancy and early childhood becomes critically imperative. While averting exposure to these allergens has both preventive and therapeutic virtues, monitoring serum IgE concentrations could further refine the prognosis of allergic severity and manifestations. Future research may explore statistical algorithms like latent classification analysis to establish correlations between sensitization profiles and clinical outcomes, as observed in the Hou et al. study [18]. Contrastingly, our study reveals that sensitization to allergens, notably grains like wheat and seafood like shrimp and crab, escalates in older populations, peaking post-adolescence. Strikingly, our findings on shrimp sensitization counter those from a study by Zeng et al. [19], which held that a decreasing trend with age in their research, highlighting the need for further scrutiny, potentially around sample size variance.

Previous studies have hinted that tIgE is less specific in its diagnostic utility, primarily indicating type I hypersensitivity reactions. Nonetheless, elevated tIgE levels can serve as harbingers for potential allergic ailments, as shown by Sabine et al. [20], who found that tIgE can be used as a marker of chronic spontaneous urticaria. Especially noteworthy is tIgE heightened sensitivity in tests combining multiple allergens [12]. Across the allergen pantheon of southern China, egg white, milk, shrimp, and crab comprise an overwhelming majority, with tIgE positivity rates exceeding 85%. Thus, a meticulous analysis of allergen traits across a range of allergy severities and age demographics can furnish invaluable vantage points for timely diagnostic procedures and interventional protocols. For instance, during the formative years of early childhood, milk and egg white prevail as the quintessential allergens. With advancing age and immunological maturation, a dynamic transformation occurs. A significant subset of individuals outgrow their sensitivity to milk and egg white, thereby pivoting towards a heightened susceptibility to seafood allergens like shrimp and crab. This intriguing metamorphosis could be modulated by both the cumulative allergen exposure and the unique sensitization trajectory of each individual’s allergy profile.

In view of such, leveraging radar charts, provides a comprehensive analysis of sensitization trends among various allergen categories: protein, grain, and seafood. In a striking parallel to previous findings that high egg white sensitization rates ranging from 41 to 67% among children allergic to milk [21], egg white and milk are conspicuously paired, revealing a considerable propensity for Co-sensitization within patients allergic to one or the other, at rates of 73.9% and 54.7% respectively. This mutual affinity becomes even more poignant against the backdrop of burgeoning rates of asthma and food allergies among pediatric populations. In infants, the presence of an egg white allergy serves as a sentinel marker, elevating the risk for subsequent development of allergic asthma [22]. Consequently, the imperative for precision in both clinical and phenotypic profiling of this vulnerable demographic becomes paramount. Implementing aggressive therapeutic interventions, encompassing low-dose allergen oral immunotherapy [23] coupled with other desensitization therapies and dietary management strategies [24], might substantially mitigate associated morbidity and mortality [25]. Additionally, wheat emerged as a significant co-allergen among those allergic to sesame, peanuts, and soy, with prevalence rates of 70.8%, 59.8%, and 79.3%, respectively. This intriguing pattern of multi-allergen sensitization may be attributed to either epitopic cross-reactivity or the phenomenon of co-exposure to dissimilar allergens. Indeed, prior studies have emphasized the potential for anaphylactic triggers through IgE antibodies that cross-react with allergens from diverse sources, such as grass pollen and wheat [26].

One of the focal points of our study is the identification of tropomyosin as a pivotal allergen, mainly found in shellfish and responsible for extensive cross-reactivity [9]. Our data resonate harmoniously with Nugraha et al. study, demonstrating that a staggering 82.6% of patients allergic to crabs were also allergic to shrimp. Moreover, a modest 24.1% of shrimp-allergic patients exhibited sensitization to crab [27]. This observed discrepancy may be attributed to regional dietary idiosyncrasies and seasonal variability in crab consumption. In southern China’s dietary patterns, crabs are often consumed alongside shrimps and tend to be more seasonally driven, potentially explaining the divergence in co-sensitization rates. Furthermore, the seafood allergens co-sensitization extends beyond food, interfacing with airborne particles like house dust mites and contact allergens such as cockroaches. Rosenfield et al. pinpointed that the principal allergen in shellfish allergies, protomyosin, is also prevalent in house dust mites and cockroaches [28]. The protomyosin from house dust mites closely resembles its counterpart in shellfish, facilitating cross-reactivity. Further, cockroaches have been identified as major cross-reactive allergen sources for shrimp-allergic patients [29]. This interconnectivity between alimentary and respiratory allergic manifestations is particularly salient, as activated T-lymphocytes in the gastrointestinal mucosa can reciprocally influence bronchial mucosa, potentially exacerbating asthmatic conditions. Emerging research even implicates the gut microflora as a pivotal factor in this complex immunological mechanism [30, 31].

While our study stands as a robust contribution to the mechanism of food allergens and their sensitization, it is imperative to acknowledge its inherent limitations. Our findings stem from a retrospective cross-sectional design confined to a specific temporal window, albeit one that is enriched by an expansive two-decade dataset and a substantial sample size. Additionally, despite the depth of our analysis, the absence of skin prick tests and exhaustive clinical evaluations introduces an element of diagnostic circumspection. Further, the range of allergens evaluated herein warrants expansion in subsequent studies, especially given the constraints imposed by the unavailability of commercial reagents for intricate Co-sensitization studies like shrimp and crab.

Conclusion

Our study illumines egg white, milk, and shrimp as the cardinal allergens shaping the landscape of food allergy afflictions in southern China from 2004 to 2023. Through investigation of allergenic profiles across diverse age cohorts and evaluating examination of co-sensitization propensities among distinct allergens, our work can pave the way for more precocious diagnostic endeavors and enable timelier, more targeted interventions in southern China even domestically, promising a new horizon in the fight against the insidious impact of food allergies on human health at home and abroad.

Abbreviations

sIgE

specific IgE

tIgE

total IgE

Author contributions

MTL, LL, and WTQ conceived and designed the study and drafted and revised this paper. XHZ and JXC contributed to the clinical and laboratory work of the study. JNY, YFL, JHL, XYL and XYH were responsible for the data collection and analytical insights. HMH and LL then lent their expertise in data interpretation. ZKJ.C and BQS provided sincere supervision of this study. All authors offered collective comments on the manuscript and approved the final version.

Funding

Our study is privileged to have received funding from Guangdong Zhong Nanshan Medical Foundation (ZNSXS-20220011), Natural Science Foundation of Guangdong Province (2021B1515230008), and Guangdong Key Areas R&D Program (2022B0202030002). We express our deepest gratitude for this magnanimous support, which has been instrumental in making this research endeavor a possibility.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical clearance for this study was granted by the Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University under approval number GYFYY-2021-K25. Also, our study did indeed involve minor participants under the age of 16. Consequently, we have ensured that informed consent was appropriately obtained from their parents or legal guardians. This procedure was adhered to and is now accurately documented in the Ethical Approval and Consent to Participate section of our manuscript. We affirm that all aspects of our research, particularly those involving minors, have been conducted in strict compliance with the ethical standards laid out in the 1964 Helsinki declaration, its subsequent amendments, and relevant local regulations. The ethical committee has reviewed and approved these consent procedures.

Consent for publication

All authors agree for the last version to be published.

Competing interests

The authors declare no competing interests.