National burden of asthma in Iran in 2003

Abbass Entezari M.D Community & Preventive specialist

Shaheed Beheshti University of Medical sciences

Clinical Data

Information

Knowledge

Apropriate Decision Making

Improve Outcomes For Patient

(clinical benefits)

Improve Use of Resources

(economic Benefits)

Community Health Promotion

Individual Health Promotion

HealthPromotion

Service

Research

education

Necesity of priority setting

When resources are scarce “and they always are” we need methods to define what is most important.

Two public health questions:

1. What is the total impact of disease and injury in the population?

2. How do we compare the impacts of different diseases, risk factors, and interventions that affect different populations?

Ultimate Measure of Ill-health?

Death is most common Easy to determine Commonly tabulated

Deaths + Illness = ?

Disability Adjusted Life Year (DALY)

DALY = YLL + YLD Years of Lost Life (due to mortality) Years Lost to Disability (due to injury & illness)

The only differences in the rating of a death or disability should be due to age and sex, not to income, culture, location, social class.

Everyone in the world has right to best life expectancy in world

Burden of disease study

The purpose of the burden-of-disease concept is to provide a comprehensive assessment of health

challenges to inform public debate on the priorities for health action.

Asthma Asthma is the most common

chronic disease with immense social impact. The prevalence of asthma is rising in many parts of the world.

(harrison 2005)

Prevalnce of asthma in the world (Global Initiative for Asthma)

IRAN

USA

World Map of the Prevalence of Asthma (Global Initiative for Asthma)

An overview to burden of asthma

RegionpopulationDeathDALYAFRO655476000) 10.70)24000) 10.62)2243000 14.94

AMRO838967000 13.7018000 7.962598000 17.31

EMRO493091000 8.0518000 7.961303000 8.68

EURO874178000 25.4740000 17.701365000 9.09

SEARO1559810000 25.4787000 38.504173000 27.80

WPRO1701689000 27.7939000 17.263327000 22.17

Global6123211000 100226000 10015010000 100

An overview to burden of asthma

Global Burden of Asthma in 2002 is estimated near 15010000 DALYs

Burden of asthma in EMRO in 2002 is 1303000 DALYs

Global Asthma death in 2002 is estimated near 226000

Asthma death in EMRO is 18000Global asthmatic patient is 300/000/000

Needs for DALY calculation

1. Prevalence of asthma2. Incidence of asthma3. Age of onset & Duration of asthma4. Mortality of asthma5. Remission rate of asthma6. Case fatality of asthma7. RR mortality plus

Total population of IranTotal Mortality of iran

problemThere are no complete and

consistent data

WHO recommendation

Use of Disease Modeling concept and DISMOD software for production of consistent data

Methods

1. Collection of all published & unpublished epidemiologic data of asthma

• all universities• national & international articles

2. Review of all data in expert panel 3. Define the best estimation by expert opinion

Methods

4. Checked internal consistency of all data by disease modeling and DISMOD software

5. Creat all necessary index for DALY calculation by DISMOD

6. Checked all DISMOD outputs in expert panel7. DALY Calculation

Prevalence of mild asthma in Iran

Based on Meta-Analysis on 19 community based standard research on 61076 iranian children prevelence of asthma in general under 18 years age population prevalence of asthma in iran is 13.14% (95% CI 9.97% - 16.30%).

This is higher than international reports and estimations about Iran ( 10%)

Forest plot of all child data

0.0 0.1 0.2 0.3 0.4

Forest Plot of prevalence

prevalence

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Combined

Symbol Combined Individual

Prevalence of asthma( outlier free)

After deletion outliers prevalence of asthma in all parts is 9.56% (95% CI 6.93% to 12.19%)

This is equal tointernational reports and estimations about Iran ( 10%)

Forest plot of outler free data

0.0 0.1 0.2 0.2 0.3

Forest Plot prevalence

prevalence

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Combined

Symbol Combined Individual

Prevalence of astham (without Tehran)

After deletion Tehran data prevalence of asthma in all other parts of parts is 11.07% (95% CI 7.94% to 14.19%)

This is higher than international reports and estimations about Iran ( 10%)

Forest plot of all without tahran

0.0 0.1 0.2 0.2 0.3

Forest Plot prevalence

prevalence

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Combined

Symbol Combined Individual

Prevalence of astham in Tehran

Based on meta analysis on 3 study on 8738 children prevalence of asthma in tehran is 24.41% (95% CI 11.19% to 37.64%)

This is more than 2 folds of other regions of Iran

Publication Bias

Based on funnel plot of all data there is unavailable data or unpublished study in Iran

020004000600080001000012000140001600018000

0 5 10 15 20 25 30 35 40

Prevalence of mild asthma in adults

There are only two community base research on prevalence of asthma in Iranian adults on 6706 person.

Isfahan (rural areea): 6.1% Mashad (urban area): 2.8%

prevalence of asthma in Iranian general population in adult age groups is equal to 3.35%

Prevalence of sever asthma

Based on 2 study in Iran that reports mild and sever asthma prevalence of sever asthma is equal to 1/7 mild asthma

Prevalence of sever asthma in children is assumed 1.97% In adults 0.47%

Mortality of Asthma in Iran

Based on death registration on 23 provinces of iran 2625 is occurred in 48326451 Iranian Population .

Garbage code is 17%

Mortality of Asthma in Iran

After correction of garbage codes total number of death in Iran is estimated 4326.

Problem (mortality of asthma in Tehran is higher than other regions in iran and there is no valid data on mortality of asthma in tehran)

After correction of Tehran mortality (2 times than other parts) total number of death in Iran from asthma is estimated 4814.

Duration of asthma)Incident case(

Unfortunatly there is no evidence or study on this item in iran

For calculation of duration and remission of asthma we have need a cohort study (at least 15 year follow up)

But international reports is availabe.

Duration of asthma Victoria BOD study (Australia)

Age groups(Males)Duration

Age groups (Females)Duration

0-4 17.2 0-4 17.5

5-1416.3 5-1417.1

15-2427.1 15-2428.8

25-3430.3 25-3431.8

35-4426.1 35-4427.6

45-5418.9 45-5420.4

55-6413.1 55-6414.7

65-749.1 65-7410.6

75+4.9 75+5.5

Remission of asthma

A cohort of 119 allergic asthmatic children was examined three times with a mean follow up of 30 years.

Based on this study in Netherland complete remission of asthma after 30 years is 22.09% and clinicaly remission is 29.7%

Thorax 2004;59:925–929. doi: 10.1136/thx.2003.016246Thorax 2004;59:925–929. doi: 10.1136/thx.2003.016246

Remission of asthma in Iran

Unfortunatley there is no any follow up study on asthmatic patients in Iran.

Case fatality of asthma

Based on Death registartion data in 23 provinces and Prevalence studies in iran We estimated 4852416 asthmatic patients in Iran (by DISMOD)

(based on international report near 3000000 asthmatic patients lived in Iran) total number of death in Iran from asthma is estimated 4814. Case fatality in all age groups is equal to 0.001

But this is an estimation Unfortunatly there is no any study on Case fatality of

asthma in Iran

Disability weights of asthma

Based on Dutch disability weights DW of mild asthma is 0.03

(History of wheeze in the last 12 months) (ISAAC)

DW of sever asthma is 0.23 (History of wheeze in the last 12 months plus a positive airways

hyperresponsiveness test) (ISAAC)

Final inputs for DISMOD

After expert panel discussion we used below items

1. Prevalence of asthma2. Mortality of asthma3. Duration of asthma

DISMOD outputs

Internal consistency of outputs is checked by expert panel

Outputs are entered to BOD-InfoMan (an excel based DALY templete) and DALY calculate

ResultsDALYs in Male

3,092

37,149

25,740

34,696

11,527

8,868

3,128

304

124,505

20,000 40,000 60,000 80,000 100,000 120,000 140,000

0-4

5-14

15-29

30-44

45-59

60-69

70-79

80+

Total

ResultsDALYs in Female

2,896

35,510

25,744

35,604

12,419

9,112

3,246

342

124,874

20,000 40,000 60,000 80,000 100,000 120,000 140,000

0-4

5-14

15-29

30-44

45-59

60-69

70-79

80+

Total

ResultsTotal DALYs

5,98972,659

51,48570,300

23,94617,980

6,374646

249,379

- 50,000 100,000 150,000 200,000 250,000 300,000

0-4

5-14

15-29

30-44

45-59

60-69

70-79

80+

Total

Discussion

Based on the present study national burden of asthma is higher than international reports about Iran.

Burden of asthma in Iran is higher than mean of global burden of asthma.

Prevalence of asthma in Iran is increasing 0.17% annualy )world 0.06%(