Infective Endocarditis in North Africa and the Middle East, 1990‒2019: Updates from the Global Burden of Disease Study 2019.

BACKGROUND: Infective endocarditis (IE), a severe and economically impactful condition, lacks substantial epidemiological data in the North Africa and Middle East (NAME) region. This study focused on analyzing the trends and burden of IE in NAME from 1990 to 2019, taking into account factors like age, gender, and socio-demographic index (SDI). METHODS: The Global Burden of Disease data from 1990 to 2019 was retrieved from the Institute for Health Metrics and Evaluation (IHME) website. RESULTS: Between 1990 and 2019, the age-standardized rates (ASR) for IE incidence increased by 59%, and prevalence and years lived with disability (YLDs) rose by 12% and 9%, respectively, while the ASRs for deaths, disability-adjusted life years (DALYs), and years of life lost (YLLs) saw reductions of 22%, 34%, and 34% in the NAME region. Death rates among children under five declined by 72%. Gender and the SDI did not significantly influence these changes. Saudi Arabia witnessed the most significant increase in ASR of IE incidence since 1990, while Turkey had the highest rates in 2019. The year 2019 also saw the highest death rate among those aged 70 and over, with over 91000 DALYs from IE. DALYs decreased by 71.5% for children under five from 1990 to 2019 but remained stable for individuals in their seventies. Jordan showed the most notable decrease in ASRs for deaths, DALYs, and YLLs among children under five. CONCLUSION: This study highlights the changing epidemiology of IE in the NAME region, recommending the establishment of multidisciplinary IE registries, antibiotic prophylaxis guidelines for healthcare-associated IE, and strategies to control antimicrobial resistance as key mitigation measures.

The prevalence of cardiovascular disease risk factors among adults living in extreme poverty.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries.

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Mortality and disability-adjusted life years in North Africa and Middle East attributed to kidney dysfunction: a systematic analysis for the Global Burden of Disease Study 2019.

Background: The study aimed to estimate the attributable burden to kidney dysfunction as a metabolic risk factor in the North Africa and Middle East (NAME) region and its 21 countries in 1990-2019. Methods: The data used in this study were obtained from the Global Burden of Diseases (GBD) 2019 study, which provided estimated measures of deaths, disability-adjusted life years (DALYs), and other epidemiological indicators of burden. To provide a better insight into the differences in the level of social, cultural, and economic factors, the Socio-Demographic Index (SDI) was used. Results: In the NAME region in 2019, the number of deaths attributed to kidney dysfunction was 296 632 (95% uncertainty interval: 249 965-343 962), which was about 2.5 times higher than in the year 1990. Afghanistan, Egypt, and Saudi Arabia had the highest, and Kuwait, Turkey, and Iran (Islamic Republic of) had the lowest age-standardized rate of DALYs attributed to kidney dysfunction in the region in 2019. Kidney dysfunction was accounted as a risk factor for ischemic heart disease, chronic kidney disease, stroke, and peripheral artery disease with 150 471, 111 812, 34 068, and 281 attributable deaths, respectively, in 2019 in the region. In 2019, both low-SDI and high-SDI countries in the region experienced higher burdens associated with kidney dysfunction compared to other countries. Conclusions: Kidney dysfunction increases the risk of cardiovascular diseases burden and accounted for more deaths attributable to cardiovascular diseases than chronic kidney disease in the region in 2019. Hence, policymakers in the NAME region should prioritize kidney disease prevention and control, recognizing that neglecting its impact on other diseases is a key limitation in its management.

Burden of Ischemic Heart Disease and Its Attributable Risk Factors in North Africa and the Middle East, 1990 to 2019: Results From the GBD Study 2019.

BACKGROUND: The North Africa and Middle East (NAME) region has one of the highest burdens of ischemic heart disease (IHD) worldwide. This study reports the contemporary epidemiology of IHD in NAME. METHODS AND RESULTS: We estimated the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs), and premature mortality of IHD, and its attributable risk factors in NAME from 1990 to 2019 using the results of the GBD (Global Burden of Disease study 2019). In 2019, 0.8 million lives and 18.0 million DALYs were lost due to IHD in NAME. From 1990 to 2019, the age-standardized DALY rate of IHD significantly decreased by 33.3%, mostly due to the reduction of years of life lost rather than years lived with disability. In 2019, the proportion of premature death attributable to IHD was higher in NAME compared with global measures: 26.8% versus 16.9% for women and 18.4% versus 14.8% for men, respectively. The age-standardized DALY rate of IHD attributed to metabolic risks, behavioral risks, and environmental/occupational risks significantly decreased by 28.7%, 37.8%, and 36.4%, respectively. Dietary risk factors, high systolic blood pressure, and high low-density lipoprotein cholesterol were the top 3 risks contributing to the IHD burden in most countries of NAME in 2019. CONCLUSIONS: In 2019, IHD was the leading cause of death and lost DALYs in NAME, where premature death due to IHD was greater than the global average. Despite the great reduction in the age-standardized DALYs of IHD in NAME from 1990 to 2019, this region still had the second-highest burden of IHD in 2019 globally.

National and Subnational Trend of Dental Caries of Permanent Teeth in Iran, 1990-2017.

OBJECTIVE: There are currently no integrated data on the trend of dental caries amongst distinct age groups in Iran. We aimed to assess the national and subnational trend of dental caries of permanent teeth in Iran from 1990 to 2017. METHODS: A literature search about dental caries and the decayed-missing-filled teeth index (DMFT) was performed in PubMed, Web of Science, Scopus, and 3 national databases (in Persian). All eligible national oral health surveys in these 28 years were included. We categorised and aggregated the DMFT values and their components based on age (5-year-based groups from 5 to 9 to 60+ years), sex, year, and province. The data for missing spots were estimated using the spatiotemporal Bayesian hierarchical model. We used the bootstrap method in multilevel models to predict the uncertainty interval (UI) of the modelled results. RESULTS: Nationally, the all-ages mean DMFT increased by nearly 58.0% (6.8 [95% UI, 4.1-10.5] in 1990 to 10.8 [95% UI, 7.5-14.5] in 2017). Decayed teeth (DT) and missing teeth (MT) rose by 84.5% and 31.6% during this period, respectively. Filled teeth (FT) showed almost a 2.6-fold increase in the same period from 0.6 (95% UI, 0.01-1.6) in 1990 to 1.7 (95% UI, 0.6-2.8) in 2017. The proportion of DT and FT continuously increased in both sexes. In 2017, the highest DT, MT, and FT were estimated in the 25-29 (4.9 [95% UI, 2.5-7.2]), 60+ (21.5 [95% UI, 17.5-25.4]), and 35-39 (2.6 [95% UI, 1.3-4.0]) year age groups. CONCLUSIONS: Caries of permanent dentition levies a growing burden on the Iranian population. Considering the continuous increase in caries during the 1990-2017 period, Iranian policymakers should pay heed to these findings and react more proactively to mitigate this perpetuating issue. Implementing nationwide interventions such as sugar consumption management should be encouraged to achieve sustainable outcomes in this regards.

Burden and quality of care index of chronic kidney disease: Global Burden of Disease analysis for 1990-2019.

BACKGROUND: Chronic kidney disease (CKD) imposes a heavy obscure burden on individuals and health systems. Besides its burden, the quality of care of CKD is less well investigated. In this study, we aimed to explore the global, regional and national trends of CKD burden and quality of care. METHODS: The Global Burden of Disease Study 2019 data were used. Trends of incidence, prevalence, deaths and disability-adjusted life years were studied for the 1990-2019 period in the global aspect. By generating four secondary indices to assess different aspects of quality of care the quality of care index (QCI) was developed to explore the care provided for CKD. Inequities and disparities between various geographic, socio-demographic and age stratifications, and sex were studied using the QCI values. RESULTS: In 2019, there were 18 986 903 (95% uncertainty interval 17 556 535 to 20 518 156) incident cases of CKD, globally. The overall global QCI score had increased slightly from 78.4 in 1990 to 81.6 in 2019, and it was marginally better in males (QCI score 83.5) than in females (80.3). The highest QCI score was observed in the European region with a score of 92.5, while the African region displayed the lowest QCI with 61.7. Among the age groups, the highest QCI was for children aged between 5 and 9 years old (92.0), and the lowest was in the age group of 20-24 year olds (65.5). CONCLUSIONS: This study revealed that significant disparities remain regarding the quality of care of CKD, and to reach better care for CKD, attention to and care of minorities should be reconsidered. The evidence presented in this study would benefit health policymakers toward better and more efficient control of CKD burden alongside improving the care of this condition.

The levels and trends of cancer incidence in the elderly population at national and sub-national scales in Iran from 1990 to 2016.

BACKGROUND: Cancer is most commonly associated with aging. It is necessary to gain a better understanding of cancer's trend and distribution among elderlies and provide comprehensive cancer care for this population. AIMS: The aim of the current study was to show the trends in cancer incidence focusing on the population aged 60+ from 1990 to 2016 in Iran. MATERIAL AND RESULTS: We used the dataset of the Iran Cancer Registry to estimate cancer incidences by sex, age, province, and year. In order to account for incomplete data we used a two-stage spatiotemporal model along with random intercept mixed effect models. We calculated annual age-standardized incidence rates (ASIRs) for age groups 60+ and 5-interval age groups. There was an increasing trend of 25.3% to 936.9% (95% uncertainty interval: 769.6-1141.8) in ASIR in the elderly in 2016. ASIR of all cancers were 889.7 (731.3-1083.6) in women and 988.1 (811.1-1205) in men in 2016, per 100 000 respectively, which had an increasing trend comparing 1990. Skin, breast, and stomach cancers in women and prostate, skin, and stomach cancers in men were the most common types in 2016. All the most incident cancer subtypes underwent an increasing trend in both sexes, except for the bladder, esophageal, and skin cancers which almost had a similar level in 1990 and 2016. Most provinces had an increasing trend in ASIR in all cancers combined from 1990 to 2016 except Zanjan with a decreasing trend. CONCLUSION: Regarding the persistent increasing trend of most elderly cancers' incidence, this is crucial for policymakers to establish preventive plans, determine proper resource allocation, and develop specific treatments for elderly cancer patients.

The national trend of the burden of Chronic Kidney Disease (CKD) in Iran from 1990 to 2019.

Purpose: Chronic Kidney Disease (CKD) has become the 8th leading cause of death in Iran in 2017, 5 steps up from 1990. This is important as hypertension, diabetes, and chronic glomerulonephritis along with exposure to toxins or heavy metals are the main risk factors for the disease. Despite its heavy burden, there are limited studies on the incidence and prevalence of the disease in the Iranian adult population. The present article studies the burden of CKD at the national level in 2019, and its trend over the past three decades. Methods: In 2019, the Global Burden of Disease (GBD) study provided an annual estimation of the burden of 369 diseases and injuries in 204 countries from 1990 until 2019. The data estimating CKD and related mortality in Iran were collected from the disease registry, survey, and scientific literature. All-ages and age-standardised indices of incidence, prevalence, deaths, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) were extracted for both sexes. Results: Since 1990, the age-standardized incidence (34.7% (95% uncertainty interval 30.8 - 38.8)) and prevalence (19.6% (17.7 - 21.8)) of CKD have risen, while a 21.5% (-28.8 - -15.4) and 18.0% (-35.4 - -10.8) decrease were noted in age-standardized DALYs and deaths rates, respectively. The lowest prevalence was reported in the eastern and western provinces. Conclusion: Current study provides comprehensive knowledge about the CKD burden, suggesting the Iranian healthcare system has been more effective in averting deaths rather than managing morbidities. Multi-sectoral action plans are needed to strengthen preventive and early detection programs in high-risk areas. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-023-01298-y.

The levels and trends of metabolic risk factors in the elderly population at the national and sub-national scale in Iran from 1990 to 2016.

Purpose: Describing the trends of metabolic risk factors (MRFs) in the elderly population. Methods: We used modeled data from previous comprehensive systematic reviews for MRFs among adults aged ≥ 60 years. Two stages of age-specific Spatio-temporal modeling and Gaussian process regression were used to estimate the mean of MRFs. We used crosswalk modeling to estimate the prevalence of elevated and raised Total cholesterol (TC), overweight/obesity and obesity, hypertension, and diabetes. Estimates were analyzed based on combinations of sex, age, year, and province from 1990 to 2016. Results: Comparing prevalence estimates from 2016 with those of 1990, in the elderly population, the age-standardized prevalence of overweight/obesity, obesity, diabetes, and hypertension increased, conversely, the prevalence of hypercholesteremia decreased. The prevalence of hypertension increased about 141.5% and 129.9% in men and women respectively. The age-standardized prevalence of diabetes increased about 109.5% in females, and 116.0% in males. Prevalence of elevated TC at the national level decreased to 67.4% (64.1-70.4) in women and to 51.1% (47.5-54.8) in men. These findings were almost shown across provinces. In general, the northern and western provinces had the highest prevalence of overweight/obesity in women in 2016. Conclusion: The rising prevalence of most MRFs, as well as the greater prevalence and mean of all MRFs in women, necessitate effective public health policies to reduce the burden of non-communicable diseases and run preventive programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-023-01297-z.

National and subnational burden of leukemia and its risk factors, 1990-2019: Results from the Global Burden of Disease study 2019.

BACKGROUND: Hematologic malignancies have a great essential role in cancer global burden. Leukemia which two major subtypes based on the onset, is one of the common subtypes of this malignancy. METHOD: For the GBD 2019 study, cancer registry data and vital registration system were used to estimate leukemia mortality. The Meta-Regression-Bayesian Regularized Trimmed (MR-BRT), Cause of Death Ensemble model (CODEm) and Spatiotemporal Gaussian Process Regression (ST-GPR) were used to model our data and estimate each quantity of interest. Mortality to incidence ratios (MIR) were used to generate incidence and survival from mortality rate. Prevalence and survival were used to generate years lived with disability (YLDs). Age-specific mortality and life expectancy at the same age were used to estimate years of life lost (YLLs). The sum of YLLs and YLDs generates DALYs. RESULTS: The total national incidence of leukemia increased from 6092 (UI 95%: 3803-8507) in 1990 to 6767 (4646-7890) new cases in 2019. However, leukemia age-standardized incidence ratio(ASIR) decreased from 11.6 (8-14.8) to 8.9 (6.2-10.3) new cases per 100,000 in this exact period. At the national level, deaths from leukemia increased 1.5-fold between 1990 and 2019, from 3287 (2284-4201) to 4424 (3137-5030), whereas the age-standardized death rate(ASDR) decreased from 8.3 (6.1-9.8) in 1990 to 6 (4.3-6.8) per 100,000 in 2019. In the study period, total leukemia DALYs decreased 12.2% and reached 162850 (110681-188806), in 2019. The age-standardized DALYs decreased 36.7% from 324.3 (224.8-413.4) in 1990 to 205.3 (140.3-237.8) in 2019. ASDR, DALYs, YLLs, and YLDs rate to high BMI was increasing while smoking and occupational exposure to benzene and formaldehyde were decreasing in the study period. CONCLUSION: This study provided a better understanding of leukemia burden and to reduce controversies of leukemia across Iran. The leukemia status alteration of the country, is trackable.

Sociodemographic differences in dietary trends among Iranian adults: findings from the 2005-2016 Iran-WHO STEPS survey.

OBJECTIVE: To examine trends in the intake of key food groups among Iranian adults between 2005 and 2016, overall, and according to sociodemographic characteristics. DESIGN: Repeat cross-sectional data from the Iran-STEPwise approach to risk factor surveillance (Iran-WHO STEPS) 2005-2016 were analysed. Regression analyses were used to evaluate trends in the frequency of fruits, vegetables and fish intake and type of oil used over time. Interactions by sex, age and area of residence were examined. SETTING: Iran. PARTICIPANTS: 225 221 Iranian adults. RESULTS: The frequency of vegetables (ß: -0·03; 95 % CI (-0·06, -0·00); P-trend = 0·030) and fish (ß: -0·09; 95 % CI (-0·10, -0·08); P-trend < 0·001) intake and use of solid fat (OR: 0·70; 95 % CI (0·70, 0·72); P-trend < 0·001) declined, whilst the frequency of fruit intake (ß-Coeff: 0·03, 95 % CI (0·01, 0·05); P-trend = 0·014) and liquid oil use (OR: 1·40; 95 % CI (1·3, 1·4); P-trend<0·001) rose. Rising trends in fruit intake were larger in mid-aged (40-60 years) and older (>60 years) adults (P-interaction < 0·001), whilst declines in vegetable (P-interaction < 0·001) and fish intake (P-interaction = 0·001) were larger in older adults. The declining use of solid fat was strongest in middle-aged and older adults (P-interaction = 0·035), while the increasing use of liquid oil was strongest in rural areas (P-interaction = 0·011). CONCLUSIONS: During the nutrition transition, liquid oil use and the frequency of fruit intake rose, while the frequency of vegetables and fish intake declined. Nonetheless, the fatty acid composition and cooking methods are important considerations. The changes observed are concerning from a public health perspective and demonstrate the need for interventions and possible targets for tailored strategies.

The burden of rheumatoid arthritis and low back pain in North Africa and Middle East from 1990 to 2019: Results from the Global Burden of Disease Study 2019.

BACKGROUND: Rheumatoid arthritis (RA) and low back pain (LBP) are among the most prevalent musculoskeletal disorders (MSDs). The need for investigation of regional and local patterns of these two MSDs seems inevitable for better policy-making. The current study presents updated results of the Global Burden of Disease (GBD) Study 2019 and reports the burden of RA and LBP in North Africa and Middle East (NAME) countries from 1990 to 2019. METHODS: Incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and risk factors, including high body mass index, occupational ergonomic factors, and smoking, were extracted based on the GBD 2019 data. RESULTS: The age-standardized prevalence and mortality of RA were 120.6 (95% uncertainty interval [95% UI] 107.0-135.7) and 0.1 (95% UI 0.1-0.2) per 100 000 population in 2019 with 28.3% (95% UI 25.5%-30.9%) increase and 7.5% (95% UI -37.5% to 32.5%) decrease since 1990, respectively. Turkey had the highest age-standardized incidence, prevalence, and DALYs of RA in 2019. All RA burden measures were higher for women; however, the incidence was almost the same at ages greater than 65 years. The age-standardized prevalence and DALYs of LBP were 7668.2 (95% UI 6798.0-8636.3) and 862 (95% UI 605.5-1153.3) in 2019, which had decreased by 5.8% (95% UI -7.4% to -4.3%) and 6.0% (95% UI -7.7% to -4.2%) since 1990, respectively. Moreover, although Turkey had the highest incidence and prevalence in 1990, Iran was at the top in 2019. The regional age-standardized DALY rates due to RA and LBP attributed to smoking were 1.7 (95% UI 0.5-3.2) and 139.4 (95% UI 87.3-198.8) in 2019, respectively, which had decreased 2.2% (95% UI -19.2% to 13.7%) and 15.4% (95% UI -19.4% to -10.5%) since 1990, respectively. CONCLUSION: RA still imposes a significant burden in the NAME region as the burden measures have increased from 1990 to 2019. On the other hand, regarding LBP, a decreasing pattern was observed. Differences among the countries and between ages and genders can have implications, and the results of this study may be helpful for policy-makers in the NAME countries.

A Global, Regional, and National Burden and Quality of Care Index for Schizophrenia: Global Burden of Disease Systematic Analysis 1990-2019.

BACKGROUND AND HYPOTHESIS: Schizophrenia is a mental disorder usually presented in adulthood that affects roughly 0.3 percent of the population. The disease contributes to more than 13 million years lived with disability the global burden of disease. The current study aimed to provide new insights into the quality of care in Schizophrenia via the implementation of the newly introduced quality of care index (QCI) into the existing data. STUDY DESIGN: The data from the global burden of disease database was used for schizophrenia. Two secondary indices were calculated from the available indices and used in a principal component analysis to develop a proxy of QCI for each country. The QCI was then compared between different sociodemographic index (SDI) and ages. To assess the disparity in QCI between the sexes, the gender disparity ratio (GDR) was also calculated and analyzed in different ages and SDIs. STUDY RESULTS: The global QCI proxy score has improved between 1990 and 2019 by roughly 13.5%. Concerning the gender disparity, along with a rise in overall GDR the number of countries having a GDR score of around one has decreased which indicates an increase in gender disparity regarding quality of care of schizophrenia. Bhutan and Singapore had 2 of the highest QCIs in 2019 while also showing GDR scores close to one. CONCLUSIONS: While the overall conditions in the quality of care have improved, significant disparities and differences still exist between different countries, genders, and ages in the quality of care regarding schizophrenia.

A Global, Regional, and National Survey on Burden and Quality of Care Index of Multiple Sclerosis: Global Burden of Disease Systematic Analysis 1990-2019.

BACKGROUND: Multiple sclerosis (MS) is a common neurologic autoimmune disorder. We have used a newly introduced measure, Quality of Care Index (QCI), which is associated with the efficacy of care given to patients suffering from MS. OBJECTIVES: The aims of the study were to report and compare the quality of care given to MS patients in different regions and country. METHODS: Primary measures were retrieved from Global Burden of Disease (GBD) from 1990 to 2019. Secondary measures (mortality-to-incidence ratio, DALY-to-prevalence ratio, prevalence-to-incidence ratio, and YLL-to-YLD ratio) were combined using principal component analysis, to form an essential component (QCI) (0-100 index with higher values representing better condition). RESULTS: In 2019, there were 59,345 (95% UI: 51,818-66,943) new MS incident cases globally. Global QCI of 88.4 was calculated for 2019. At national level, Qatar had the highest quality of care (100) followed by Kuwait (98.5) and Greenland (98.1). The lowest QCI was observed in Kiribati (13.5), Nauru (31.5), and Seychelles (36.3), respectively. Most countries have reached gender equity during the 30 years. Also, QCI was lowest in ages from 55 to 80 in global scale. CONCLUSION: MS QCI is better among those countries of higher socioeconomic status, possibly due to better healthcare access and early detection in these regions. Countries could benefit from adopting the introduced QCI to evaluate the quality of care given to MS patients at national and global level.

Efficacy and safety of an inactivated virus-particle vaccine for SARS-CoV-2, BIV1-CovIran: randomised, placebo controlled, double blind, multicentre, phase 3 clinical trial.

OBJECTIVE: To report the efficacy, safety, and exploratory immunogenicity findings of two 5 µg doses of the BIV1-CovIran vaccine. DESIGN: Randomised, placebo controlled, double blind, multicentre, phase 3 clinical trial. SETTING: In six cities of Iran, including Bushehr, Isfahan, Karaj, Mashhad, Shiraz, and Tehran. The first vaccine or placebo injection of the first participant was on 16 May 2021 in Tehran. The last vaccine or placebo injection of the last participant occurred on 15 July 2021 in Isfahan. PARTICIPANTS: 20 000 participants aged 18-75 years were randomly assigned to the intervention or placebo groups with a ratio of 2:1. INTERVENTION: 5 µg vaccine or placebo with the interval of 28 days. MAIN OUTCOME MEASURES: Vaccine efficacy for a 90 day follow-up period, safety and explanatory immunogenicity assessment, and variant detection during the trial. RESULTS: 20 000 participants were recruited and randomly assigned to receive BIV1-CovIran (n=13 335 (66.7%)) or placebo (n=6665 (33.3%)). Participants' mean age was 38.3 (standard deviation 11.2) years, and 6913 (34.6%) were female. Among vaccinated participants that had covid-19 reported during the follow-up (median 83 days), 758 (5.9%) had symptoms, 144 (1.1%) had severe infection, and seven (0.1%) were critical. Among participants who received placebo during the follow-up, 688 (10.7%) had symptoms, 221 (3.4%) had severe infection, and 19 (0.3%) were critical. Overall efficacy was 50.2% (95% confidence interval 44.7% to 55.0%) against symptomatic covid-19, 70.5% (63.7% to 76.1%) against severe disease, and 83.1% (61.2% to 93.5%) against critical cases. Two deaths were reported in the efficacy population in the placebo group, no deaths were from the intervention group. During follow-up, 41 922 adverse events were reported: 28 782 (68.7%) were adverse reactions, of which 19 363 (67.3%) were in the intervention group. Most adverse reactions were mild or moderate in severity (grade 1 or 2) and self-limiting. No serious adverse events were related to the injections. For variant investigation, of 119 participants positive for the SARS-CoV-2 variant, 106 (89.1%) were positive for the delta variant. CONCLUSIONS: A two dose regimen of the BIV1-CovIran vaccine conferred efficacy of 50.2% against symptomatic covid-19, 70.5% against severe disease, and 83.1% against critical disease. Vaccination was well tolerated, with no safety concerns raised. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, IRCT20201202049567N3. FUNDING: Shifa-Pharmed Industrial Group.

Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data.

BACKGROUND: The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs. METHODS: We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities. FINDINGS: The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education. INTERPRETATION: A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide. FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

Burden of breast cancer and attributable risk factors in the North Africa and Middle East region, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.

Background: Breast cancer (BC) is the most common cancer in women globally. The North Africa and Middle East (NAME) region is coping hard with the burden of BC. We aimed to present the latest epidemiology of BC and its risk factors in this region. Methods: We retrieved the data on BC burden and risk factors from the Global Burden of Disease Study 2019 to describe BC status in the 21 countries of the NAME region from 1990 to 2019. We explored BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to seven risk factors of female BC, namely, alcohol use, diet high in red meat, low physical activity, smoking, secondhand smoke, high body mass index, and high fasting plasma glucose. Decomposition analysis on BC incidence trend was done to find out the contributing factors to this cancer's growth. Results: In 2019, there were 835,576 (95% uncertainty interval: 741,968 to 944,851) female and 10,938 (9,030 to 13,256) male prevalent cases of BC in the NAME region. This number leads to 35,405 (30,676 to 40,571) deaths among female patients and 809 (654 to 1,002) deaths in male patients this year. BC was responsible for 1,222,835 (1,053,073 to 1,411,009) DALYs among female patients in 2019, with a greater proportion (94.9%) of burden in years of life lost (YLLs). The major contributor to female BC incidence increase in the past three decades was found to be increase in age-specific incidence rates of BC (227.5%), compared to population growth (73.8%) and aging (81.8%). The behavioral risk factors were responsible for majority of attributable female BC burden (DALYs: 106,026 [66,614 to 144,247]). High fasting plasma glucose was found to be the risk factor with the largest effect (DALYs: 84,912 [17,377 to 192,838]) on female BC burden. Conclusion: The increasing incidence and burden of BC in the NAME region is remarkable, especially when considering limited resources in the developing countries of this region. Proper policies like expanding screening programs and careful resource management are needed to effectively manage BC burden.

Risk of incident cardiovascular diseases at national and subnational levels in Iran from 2000 to 2016 and projection through 2030: Insights from Iran STEPS surveys.

BACKGROUND: Cardiovascular Disease (CVD) is the leading cause of death in developing countries. CVD risk stratification guides the health policy to make evidence-based decisions. AIM: To provide current picture and future trend of CVD risk in the adult Iranian population. METHODS: Nationally representative datasets of 2005, 2006, 2007, 2008, 2009, 2011, and 2016 STEPwise approach to non-communicable diseases risk factor surveillance (STEPS) studies were used to generate the 10-year and 30-year risks of CVD based on Framingham, Globorisk, and World Health Organization (WHO) risk estimation models. Trend of CVD risk was calculated from 2000 until 2016 and projected to 2030. RESULTS: In 2016, based on Framingham model, 14.0% of the Iranian, aged 30 to 74, were at great risk (≥20%) of CVD in the next 10 years (8.0% among females, 20.7% among males). Among those aged 25 to 59, 12.7% had ≥45% risk of CVD in the coming 30 years (9.2% among females, 16.6 among males). In 2016, CVD risk was higher among urban area inhabitants. Age-standardized Framingham 10-year CVD risk will increase 32.2% and 19%, from 2000 to 2030, in females and males, respectively. Eastern provinces had the lowest and northern provinces had the greatest risk. CONCLUSIONS: This study projected that CVD risk has increased from 2000 to 2016 in Iran. Without further risk factor modification, this trend will continue until 2030. We have identified populations at higher risks of CVD to guide future intervention.

Particulate Matter Pollution Remains a Threat for Cardiovascular Health: Findings From the Global Burden of Disease 2019.

Background Particulate matter (PM) pollution is a significant risk factor for cardiovascular diseases, causing substantial disease burden and deaths worldwide. This study aimed to investigate the global burden of cardiovascular diseases attributed to PM from 1990 to 2019. Methods and Results We used the GBD (Global Burden of Disease) study 2019 to investigate disability-adjusted life-years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), and deaths attributed to PM as well as its subgroups. It was shown that all burden measures' age-standardized rates for PM were in the same decreasing trend, with the highest decline recorded for deaths (-36.7%). However, the all-age DALYs increased by 31%, reaching 8.9 million in 2019, to which YLLs contributed the most (8.2 million [95% uncertainty interval, 7.3 million-9.2 million]). Men had higher deaths, DALYs, and YLLs despite lower years lived with disability in 2019 compared with women. There was an 8.1% increase in the age-standardized rate of DALYs for ambient PM; however, household air pollution from solid fuels decreased by 65.4% in the assessed period. Although higher in men, the low and high sociodemographic index regions had the highest and lowest attributed YLLs/YLDs ratio for PM pollution in 2019, respectively. Conclusions Although the total age-standardized rate of DALYs for PM-attributed cardiovascular diseases diminished from 1990 to 2019, the global burden of PM on cardiovascular diseases has increased. The differences between men and women and between regions have clinical and policy implications in global health planning toward more exact funding and resource allocation, in addition to addressing inequity in health care access.