National burden of asthma in Iran in 2003

Abbass Entezari M.D Community & Preventive specialist

Shaheed Beheshti University of Medical sciences

Individual Health Promotion

Improve Outcomes For Patient (clinical benefits)

Health Promotion
Apropriate Decision Making

Community Health Promotion

Improve Use of Resources (economic Benefits)

Service

Knowledge

Research

education

Information

Clinical Data

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.

2.

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

USA

(Global Initiative for Asthma

IRAN

World Map of the Prevalence of Asthma

(Global Initiative for Asthma

An overview to burden of asthma

Region
AFRO AMRO EMRO EURO SEARO WPRO Global

population
(10.70( 13.70 8.05 25.47 25.47 27.79 100

Death
(10.62( 24000 7.96 7.96
17.70 38.50 17.26 100

DALY
14.94 17.31 8.68 9.09 27.80 22.17 100

655476000

2243000 2598000 1303000 1365000 4173000 3327000

838967000 493091000 874178000

18000 18000
40000 87000 39000

1559810000 1701689000

6123211000

226000

15010000

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 18000 Global asthmatic patient is 300/000/000

Needs for DALY calculation

1. 2. 3. 4. 5. 6. 7.

Prevalence of asthma Incidence of asthma Age of onset & Duration of asthma Mortality of asthma Remission rate of asthma Case fatality of asthma RR mortality plus
Total population of Iran Total Mortality of iran

problem
There

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

1. 2.

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

Methods
4.

5.

6. 7.

Checked internal consistency of all data by disease modeling and DISMOD software Creat all necessary index for DALY calculation by DISMOD Checked all DISMOD outputs in expert panel 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

Forest Plot of prevalence
1 2 3

Symbol Combined Individual

10

11

12

13

14

15

16

17

18

19

20

21

Combined

0.0

0.1

0.2

0.3

0.4

prevalence

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

Forest Plot prevalence
1 2 3

Symbol Combined Individual

10

11

12

13

14

15

16

17

18

Combined

0.0

0.1

0.2

0.2

0.3

prevalence

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

Forest Plot prevalence
1 2 3

Symbol Combined Individual

10

11

12

13

14

15

16

17

Combined

0.0

0.1

0.2

0.2

0.3

prevalence

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
18000 16000 14000 12000 10000 8000 6000 4000 2000 0 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
Age groups
(Males)

(Victoria BOD study (Australia Age groups Duration

(Females)

Duration
17.5 17.1 28.8 31.8 27.6 20.4 14.7 10.6 5.5

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 +75

17.2 16.3 27.1 30.3 26.1 18.9 13.1 9.1 4.9

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 +75

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;59:925929. doi: 10.1136/thx.2003.016246 Thorax 2004;59:925929. 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. 2. 3.

Prevalence of asthma Mortality of asthma 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

Results
DALYs in Male
Total +80 70-79 60-69 45-59 30-44 15-29 5-14 0-4 3,092 304 3,128 8,868 11,527 34,696 25,740 37,149 124,505

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Results
DALYs in Female
Total +80 70-79 60-69 45-59 30-44 15-29 5-14 0-4 2,896 342 3,246 9,112 12,419 35,604 25,744 35,510 124,874

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Results
Total DALYs
Total 80+ 70-79 60-69 45-59 30-44 15-29 5-14 0-4 5,989 50,000 100,000 150,000 200,000 250,000 300,000 646 6,374 17,980 23,946 70,300 51,485 72,659 249,379

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%