Int J Public Health (2018) 63 (Suppl 1):S97–S108 https://doi.org/10.1007/s00038-017-1007-0 ORIGINAL ARTICLE Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and 2015: ﬁndings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Lower Respiratory Infections Collaborators Received: 1 May 2017 / Revised: 8 June 2017 / Accepted: 28 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Somalia and Lebanon, respectively. Undernutrition in Objectives We used data from the Global Burden of Dis- childhood and ambient particulate matter air pollution in ease 2015 study (GBD) to calculate the burden of lower the elderly were the main risk factors. respiratory infections (LRIs) in the 22 countries of the Conclusions Our ﬁndings call for public health strategies Eastern Mediterranean Region (EMR) from 1990 to 2015. to reduce the level of risk factors in each age group, Methods We conducted a systematic analysis of mortality especially vulnerable child and elderly populations. and morbidity data for LRI and its speciﬁc etiologic fac- tors, including pneumococcus, Haemophilus inﬂuenzae Keywords Lower respiratory infection Incidence type b, Respiratory syncytial virus, and inﬂuenza virus. We Mortality DALY Eastern Mediterranean Region used modeling methods to estimate incidence, deaths, and disability-adjusted life-years (DALYs). We calculated burden attributable to known risk factors for LRI. Introduction Results In 2015, LRIs were the fourth-leading cause of DALYs, causing 11,098,243 (95% UI Lower respiratory infections (LRIs) are one of the leading 9,857,095–12,396,566) DALYs and 191,114 (95% UI causes of death and disability-adjusted life-years (DALYs) 170,934–210,705) deaths. The LRI DALY rates were worldwide, especially among children under 5 (Kassebaum higher than global estimates in 2015. The highest and et al. 2016;Wangetal. 2016). Since 1990, LRI has been the lowest age-standardized rates of DALYs were observed in closest competitor of cardiovascular diseases as the top leading cause of DALYs in the Eastern Mediterranean Region (EMR) and the Arab world (Mokdad et al. 2014, 2016). This article is part of the supplement ‘‘The state of health in the Several factors, such as poverty, indoor and outdoor air pol- Eastern Mediterranean Region, 1990–2015’’. lution, malnutrition, smoking, chronic lung diseases, and The members of GBD (Global Burden of Disease) 2015 Eastern delayed and inappropriate case management contribute to the Mediterranean Region Lower Respiratory Infections Collaborators high burden of LRI (Hadi 2003). Population-based measures are listed at the end of the article. Ali H. Mokdad, on behalf of GBD of morbidity and mortality of LRI are scarce. Most of the 2015 Eastern Mediterranean Region Lower Respiratory Infections available data are limited to children and are based on Collaborators, is the corresponding author. modeling approaches. Even fewer data are available for Electronic supplementary material The online version of this causative agents of LRI (Kovacs et al. 2015). article (doi:10.1007/s00038-017-1007-0) contains supplementary Rudan et al. estimated an incidence of 0.22 episodes of material, which is available to authorized users. community-acquired pneumonia per child-year in children & GBD 2015 Eastern Mediterranean Region Lower Respiratory under 5 in low- and middle-income countries in 2010 Infections Collaborators (Rudan et al. 2013) The Child Health Epidemiology Ref- firstname.lastname@example.org erence Group (CHERG) estimated 0.26 episodes per child- year for the world and 0.28 for the World Health Organi- Institute for Health Metrics and Evaluation, 2301 5th Avenue, zation’s (WHO) Eastern Mediterranean Region (EMR). Suite 600, Seattle, WA 98121, USA 123 S98 GBD 2015 Eastern Mediterranean Region Lower Respiratory Infections Collaborators These estimates translate to about 20 million cases of P23.9, and Z25.1. The ICD-10 codes for etiologic cate- childhood pneumonia each year in the EMR, with gories of LRI included J09–J11.89 and Z25.1 for Inﬂuenza approximately 10% of cases requiring hospitalization virus, J12.1 for RSV, J13, J13.0, J15.3, J15.4, and J15.6 for (Rudan et al. 2008). More than 99% of all LRI deaths occur pneumococcus, J14 and J14.0 for Hib, and J12, J12.0, in low- and middle-income countries. Although about 62% J12.2–J12.9, J15–J15.9, J15.5, J15.7, J15.8, J16–J16.9, of children with severe LRI reach hospitals, more than 80% J20–J21.9, and P23-P23.9 for other LRI. We did not of all childhood LRI deaths take place outside the hospital include tuberculosis in this study; it has been classiﬁed as a setting (Nair et al. 2013;Tong 2013). Despite high levels of separate item in GBD. morbidity and mortality, the decreasing trend in LRI An analysis of available data on all-cause mortality for mortality rates has contributed to increasing life expec- all countries was undertaken (Wang et al. 2016). For tancy worldwide (Wang et al. 2016). Improvements in pathogen-speciﬁc mortality rates of LRI, we used a coun- nutritional status (less malnutrition through attention to terfactual approach based on the epidemiological concept childhood and maternal nutritional status), increased of attributable mortality. The change in LRI was estimated uptake of vaccines such as immunization against Strepto- assuming the condition that a speciﬁc pathogen was not coccus pneumoniae (pneumococcus) and Haemophilus present. We adopted different approaches to estimate inﬂuenzae type b (Hib) in children and high-risk popula- bacterial and viral causes based on the available data. For tions in EMRs, and improved access to antibiotics and pneumococcal and Hib LRI, we estimated the causal supportive care have decreased the incidence and fatality of fraction from vaccine efﬁcacy trials data. For RSV and LRI in many countries (Williams and Shah 2012; Tong inﬂuenza, we relied on observational studies that measured 2013). causal fractions among hospital admissions for LRI (Vos In this study, we report ﬁndings from the Global Burden of et al. 2016; Wang et al. 2016). We estimated the causal Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) fractions among cases by country, age, and sex. To account on LRI in the 22 countries of the EMR between 1990 and for the higher case-fatality rate of bacterial versus viral 2015. We describe the burden of LRI and a subset of speciﬁc LRI, we applied a relative case-fatality differential based etiologic pathogens, including pneumococcus, Hib, respi- on hospital data that included cases coded to the speciﬁc ratory syncytial virus (RSV), and inﬂuenza virus, based on pneumonia causes. Our mortality estimates were used to deaths, years of life lost (YLLs), years lived with disability calculate cause-speciﬁc YLLs for each age, sex, location, (YLDs), and disability-adjusted life-years (DALYs). and calendar year. To estimate LRI-related morbidity, a systematic review of studies on epidemiological indicators of LRI was done Methods as part of the GBD standard methodology. We used 197 sources of data from EMR countries (46 for non-fatal GBD 2015 covers 195 countries, 21 regions, and seven outcomes and others for cause of death) which contained super-regions from 1990 to 2015 for 315 diseases and data on LRI. A list of all data sources is available on the injuries and 79 risk factors. A counterfactual approach was Institute for Health Metrics and Evaluation’s website. used for estimating LRI etiologies, one of the method- (Institute for Health Metrics and Evaluation) A series of ological differences compared to GBD 2010. Detailed Bayesian meta-regression analyses through DisMod-MR descriptions of the methodological approach for GBD 2015 2.1 were used for disease modeling. Model-based epi- have been published elsewhere (Forouzanfar et al. 2016; demiological estimates in combination with disability Kassebaum et al. 2016; Vos et al. 2016; Wang et al. 2016). weights were used to calculate cause-speciﬁc YLDs for The EMR consists of 22 countries with different levels each age, sex, location, and calendar year. DALYs were of gross national income (GNI) per capita. The low-income calculated through summation of YLLs and YLDs countries (LICs) are Afghanistan, Djibouti, Somalia, and (Kassebaum et al. 2016; Vos et al. 2016). Yemen. The middle-income countries (MICs) are Egypt, We estimated burden of LRI attributable to childhood Iran, Iraq, Jordan, Lebanon, Libya, Morocco, Pakistan, malnutrition (underweight, wasting, and stunting), non- Palestine, Sudan, Syria, and Tunisia. The high-income exclusive breastfeeding, zinc deﬁciency, smoking, sec- countries (HICs) are Bahrain, Kuwait, Oman, Qatar, Saudi ondhand smoke exposure, household air pollution from Arabia, and the United Arab Emirates (UAE). solid fuels, and ambient air pollution as known LRI risk All types of LRI (bronchitis, bronchiolitis, and pneu- factors. Details on deﬁnitions and measures of age- and monia) were included in this study. We used the following sex-speciﬁc relative risks of LRI for each of the risk factors International Classiﬁcation of Diseases (ICD-10) codes (or are available elsewhere (Forouzanfar et al. 2016). their corresponding codes from earlier ICD versions) as We report 95% uncertainty intervals (UI) for each equivalent to LRI: J09–J15.8, J16–J16.9, J20–J21.9, P23- estimate—such as rates or numbers of deaths or DALYs. 123 Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and… S99 We estimated UIs by taking 1000 samples from the pos- (Iran, Lebanon, Libya, Morocco, Palestine, Syria, and terior distribution of each quantity and using the 25th- and Tunisia), the LRI death rates among older age groups were 975th-ordered draws of the uncertainty distribution. greater than the mortality rates among children under 5 years. Death rates were 31.5 per 100,000 (95% UI 27.3–35.4) in men compared to 27.4 per 100,000 in women (95% UI 23.9–31.2) in the region. The LRI death rate was Results not different in EMR countries in boys versus girls under 5 (2015). LRI deaths decreased by 30.2% from 273,714 (95% UI 239,890–306,648) in 1990 to 191,114 (95% UI Figure 1 shows the age-standardized death rates for LRI by EMR country in 2013. Somalia, Djibouti, and Afgha- 170,934–210,705) in 2015 in EMR countries. In spite of nistan had the highest death rates in the region. the decrease, LRI is still the third-leading cause of death for all ages in 2015. The death rate per 100,000 was 74.0 Among the etiologic causes, pneumococcus had the highest mortality rate (16.6 per 100,000, 95% UI (95% UI 64.8–82.9) in 1990 and decreased to 29.5 (95% UI 26.4–32.5) in 2015, a 60.1% reduction. The age-standard- 10.0–22.9), followed by respiratory syncytial virus (1.5 per 100,000, 95% UI 0.9–2.4), Haemophilus inﬂuenzae type b ized death rate for LRI was 65.4 (95% UI 58.6–73.4) in 1990 and declined by 38.5% to 40.2 (95% UI 36.0–45.2) in (1.1 per 100,000, 95% UI 0.0–2.3), and inﬂuenza virus (0.8 per 100,000, 95% UI 0.5–1.2). Figure 2 demonstrates the 2015. In 2015, 4.8% (95% UI 4.3–5.2) of all deaths and 13.0% (95% UI 11.5–14.7) of under-5 deaths were due to contribution of different etiologic causes to LRI deaths by age. LRI. The rate of YLLs per 100,000 population decreased by At the regional level, the highest death rates and num- 69.5% from 5579 (95% UI 4,831–6,320) in 1990–1702 bers of deaths were among children under 5 years old, (95% UI 1,510–1,902) in 2015. However, LRI was still the followed by those aged 65 years or older. However, there was considerable heterogeneity in the age pattern of LRI third-leading cause of YLLs in 2015. e-Table 1 shows age-standardized incidence rates of deaths between the countries of the EMR. In all high-in- come countries (Bahrain, Saudi Arabia, Kuwait, Oman, LRI in males and females of the EMR countries. The highest incidence rate was observed in Afghanistan and the Qatar, and UAE), and some of the middle-income countries Fig. 1 Age-standardized death rates of lower respiratory tract infections per 100,000 population in the countries of the Eastern Mediterranean Region, Global Burden of Disease study, 2015 123 S100 GBD 2015 Eastern Mediterranean Region Lower Respiratory Infections Collaborators Fig. 2 Number of lower respiratory tract infection deaths by etiologic causes in the Eastern Mediterranean Region, Global Burden of Disease study, 2015 lowest in Tunisia for both sexes. In all countries but Afghanistan, and Djibouti. LRI DALY rates did not differ Afghanistan, Bahrain, and Djibouti, the incidence rates signiﬁcantly between males and females. were higher among men than women, with the highest Figure 5 shows DALY rates for different etiologies of male-to-female ratio in Iran and Libya. LRI in EMR countries in 2015. The largest variation in The rate of YLDs per 100,000 decreased from 15.8 country-speciﬁc DALYs (highest to lowest ratio) was (95% UI 10.7–22.9) to 9.7 (95% UI 6.5–13.6) per 100,000 observed for Hib (2068.7) compared to 125.5 for pneu- during 1990–2015. mococcus, 109.4 for RSV, and 30.6 for inﬂuenza. The Total DALYs from LRI decreased by 40.6%, from DALY rate for Hib was less than one DALY per 100,000 in 20,746,747 (95% UI 17,954,899–23,444,142) in 1990 to UAE and Qatar, compared to 916.7 in Somalia and 458.5 in 11,098,243 (95% UI 9,857,095–12,396,566) in 2015. LRI, Afghanistan (Fig. 5). which was the leading cause of DALYs in 1990, was Figure 6 shows the LRI DALY rates attributable to ranked fourth in 2015, behind ischemic heart disease, different risk factors in 2015. Childhood undernutrition, neonatal preterm birth complications, and neonatal household air pollution from solid fuels, ambient particu- encephalopathy. LRI DALY rates were 5594 (95% UI late matter pollution, suboptimal breastfeeding, second- 4851–6334) and 1712 (95% UI 1520–1912) DALYs per hand smoke, no handwashing with soap, and zinc 100,000 population in 1990 and 2015, respectively, a deﬁciency were the most important risk factors for LRI in 69.4% reduction. About 4.9% (95% UI 4.3–5.5) of DALYs children under 5. Among those aged 70 years or older, in all ages and 12.2% (95% UI 10.8–13.8) of DALYs in ambient particulate matter pollution, household air pollu- children under 5 were due to LRI in 2015. tion from solid fuels, smoking, no handwashing with soap, Age-standardized DALY rates were 3411 per 100,000 secondhand smoke, and alcohol use were the main risk (95% UI 2,993–3,824) in 1990 compared to 1518 per factors. 100,000 (95% UI 1357–1673) in 2015 in the EMR. Global age-standardized DALY rates for LRI were lower than those in the EMR: 3310 (95% UI 3033–3551) in 1990, and Discussion 1428 (95% UI 1330–1511) in 2013. There was a 56.9% reduction in age-standardized DALY rates at the global Our study showed a substantial burden of LRI in the EMR. level, which was similar to the EMR (55.5% reduction) Despite a decline in the burden of LRI since 1990, LRI during 1990–2015. Figure 3 presents trends in age-stan- remained the fourth-leading cause of DALYs and third- dardized and all-ages LRI DALY rates between 1990 and leading cause of death in the region in 2015. The all-ages 2015 globally and for the EMR. burden of LRI in the EMR is considerably higher than Figure 4 shows age-standardized LRI DALY rates in the global rates, and even the age-standardized burden is EMR countries. The highest rates were seen in Somalia, slightly higher. Our ﬁndings call for intensiﬁed efforts to control and reduce the burden of LRI in the EMR, 123 Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and… S101 Fig. 3 Trends of age- standardized (AS) and all-age (AA) DALY rates of lower respiratory infections in the Eastern Mediterranean Region and the world, Global Burden of Disease study, 1990–2015 Fig. 4 Age-standardized disability-adjusted life-years (DALYs) rates of lower respiratory tract infections per 100,000 population in the countries of Eastern Mediterranean Region, Global Burden of Disease study, 2015 especially among low-income countries and low-resource diarrheal diseases, malnutrition, respiratory infections, settings. Moreover, since the current situation of health and measles (Guha-Sapir and Panhuis 2004). These are status and LRI varies widely between the EMR countries, due to different causes such as displacement of popula- suggested interventions to avert LRI deaths and disabilities tions, breakdown of health and social services, and should be speciﬁed at the national or even subnational level increased risk of disease transmission (Murray et al. (Akseer et al. 2015). 2008). Beyond improving social determinants that affect The unstable political situation and wars in many of the LRI, a combination of public health and clinical strategies EMR countries present a major challenge for controlling is required to control them (World Health Organization communicable diseases in the region (Haq et al. 2013). and UNICEF 1986). The ‘‘Protect, Prevent, and Treat’’ Countries with highest burden of LRI (Somalia, Afgha- framework provides a blueprint for such interventions nistan, and Djibouti) have beeninvolvedinarmed con- (Qazietal. 2015). The need for an integrated global ﬂicts and social unrest in recent decades. Conﬂict-affected action plan led to the launch of the Global Action Plan for children experience signiﬁcant increases in deaths due to the Prevention and Control of Pneumonia and Diarrhea 123 S102 GBD 2015 Eastern Mediterranean Region Lower Respiratory Infections Collaborators Fig. 5 Disability-adjusted life- years (DALYs) rates for different etiologies of lower respiratory tract infections in the countries of the Eastern Mediterranean Region, Global Burden of Disease study, 2015 Fig. 6 Disability-adjusted life-years (DALYs) attributable to risk factors of lower respiratory tract infections, Eastern Mediterranean Region, Global Burden of Disease study, 2015 (GAPPD), which can be used by EMR countries as well Immunization is one of the most effective public health (Qazietal. 2015). strategies to prevent and reduce the burden of LRI, such as immunization against pneumococcal infection, Hib, and 123 Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and… S103 seasonal inﬂuenza. Immunization is highly effective at Additionally, enhancing breastfeeding and encouraging reducing the burden of ill health from pneumococcal zinc supplementation can reduce the burden of childhood infection and Hib, but less so for inﬂuenza. The effec- LRI in the region (Roth et al. 2008, 2010; Shah et al. 2013). tiveness of inﬂuenza vaccination depends on the match Moreover, based on our data, reducing indoor air pollution between the antigenic strains included in the vaccine and (mainly due to household use of solid fuels) and outdoor air the circulating strains in the community, and this can vary pollution (especially ambient particulate matter) contribute substantially from year to year. EMR countries are at dif- to reducing the burden of disease in all age groups (Ren- ferent stages of adopting these vaccines. High-income zetti et al. 2009; Rehfuess et al. 2009). Unfortunately, EMR countries have introduced pneumococcal conjugate many countries of the region suffer from air pollution: vaccine (PCV) to their national immunization programs. while Afghanistan, Pakistan, Somalia, Sudan, and Yemen Moreover, all low-income countries in the region except have considerable issues with household air pollution, Somalia have introduced PCV thanks to support from Gavi, more countries are affected by outdoor air pollution the Vaccine Alliance. (Gavi 2017 the Vaccine Alliance) (Afghanistan, Egypt, Iran, Iraq, Lebanon, Libya, Pakistan, Somalia has issues with under-coverage of immunization, Saudi Arabia, Syria, and Tunisia) (Cohen et al. 2017; even for traditional vaccines such as DTP vaccine (diph- World Health Organization Eastern Mediterranean Region theria, tetanus, and pertussis). The majority of middle-in- 2017). Smoking and exposure to secondhand smoke are come countries in the region (Egypt, Iran, Iraq, Jordan, other factors that inﬂuence LRI (Oberg et al. 2011). Most Lebanon, Syria, and Tunisia), have yet to introduce PCV or of the countries of the region (all except Somalia and are in the early stages of planning (Moradi-Lakeh and Morocco) have ratiﬁed the Framework Convention on Esteghamati 2013; Sibak et al. 2015). Tobacco Control (FCTC), which provides a baseline for All EMR countries have introduced Hib vaccine to their tobacco control (Framework Convention Alliance Parties immunization programs, and coverage of Hib3 in the EMR to the WHO 2017). However, the anti-smoking activities has increased from 13% in 2005 to 72% in 2014. However, need to be boosted (Usmanova and Mokdad 2013) and coverage of Hib3 varies across EMR countries (World expanded to shisha use, which is very common in the Health Organization 2017). Hib3 coverage was 75% or less region (Moradi-Lakeh et al. 2015). in ﬁve countries in 2014: Somalia, Syria, Iraq, Pakistan, Access to adequate health care and appropriate case and Afghanistan (World Health Organization 2017). The management (rapid diagnosis, access to antibiotics and coverage rate in Syria dropped from 80% in 2010 to 43% supportive care) are important therapeutic interventions for due to the ongoing war in the country (World Health LRI control (Bhutta et al. 2013). Although in general health Organization 2017). Iran was the last country in the region care access has improved in EMR countries, there is still to introduce Hib vaccine in late 2014 and has not yet limited access to high-quality health care due to avail- published coverage data. Economic sanctions against Iran ability, accessibility, acceptability, and costs, especially for had an impact on health policies and slowed down imple- those who live in remote areas as well as disadvantaged mentation of immunization programs and policies groups (Kronfol 2012; Takian et al. 2013). The use of (Kheirandish et al. 2015; Massoumi and Koduri 2015). simple, standardized guidelines for diagnosis and treatment There are different immunization policies against sea- of LRI reduces complications and deaths. These guidelines sonal inﬂuenza virus in EMR countries. Although the should be made available to all care facilities including impact of the inﬂuenza vaccine on prevention of LRI is not community health facilities and mobile units (Kronfol as clear as that of conjugate vaccines against pneumococcal 2012; Takian et al. 2013). Unfortunately, many EMR infections and Hib, its effectiveness in protecting speciﬁc countries have not implemented such evidence-based high-risk groups against severe inﬂuenza-associated dis- guidelines. Although the required expertise and local data ease and death is generally accepted (Voordouw et al. for developing guidelines are not available in the majority 2003; Nichol et al. 2007). Indeed, the policies for inﬂuenza of EMR countries, adaptation of international guidelines vaccination are impacted by national capacities, resources, can be used as an alternative method to increase quality of and epidemiological status (World Health Organization care (Rashidian 2008). On the other hand, several countries 2012). In the countries that have already established vac- in the region (such as Libya, Syria, and Yemen, as the most cination programs, a number of strategies such as public recent examples) have experienced considerable setbacks education and reminders for parents and immunization in access to health care because of war, social unrest, and providers can increase immunization coverage (Williams mass displacement of populations (Dewachi et al. 2014; et al. 2011). Burki 2015). Shortages in the provision of acute care, Improving diet and nutritional status in the population inpatient and outpatient clinical services as well as primary groups that are most vulnerable to LRI, such as children care services, and access to essential medicines are among and elderly people, can help prevent infection. the most urgent issues in such unstable conditions. 123 S104 GBD 2015 Eastern Mediterranean Region Lower Respiratory Infections Collaborators Moreover, continuity of providing preventive and health Therefore, it is important for the international community promotion services is difﬁcult during war and instability; to work to improve political stability in the EMR, and to several reports have demonstrated the effect of war on strengthen support for low-income countries and disad- childhood malnutrition and the inability to maintain a cold vantaged groups, in order to reduce LRI morbidity and chain for vaccines during the wars in Afghanistan, Iraq, mortality in the region. and Yemen (Assefa et al. 2001; Levy and Sidel 2016; Burki GBD 2015 Eastern Mediterranean Region Lower Respiratory 2016). These are among the well-known LRI risk factors. Infections Collaborators Ali H. Mokdad, PhD (corresponding Surveillance systems are crucial for planning and author), Institute for Health Metrics and Evaluation, University of managing LRI and identifying emerging infections (Brei- Washington, Seattle, Washington, United States. Maziar Moradi- man et al. 2013). In 2015, several outbreaks of LRI Lakeh MD, Department of Community Medicine, Gastrointestinal and Liver Disease Research Center (GILDRC), Preventative Medi- occurred in the EMR, for instance inﬂuenza A(H1N1) cine and Public Health Research Center, Iran University of Medical pdm09 in Libya, Kuwait, and Jordan; avian inﬂuenza A Sciences, Tehran, Iran. Charbel El Bcheraoui, PhD, Institute for (H5N1) in Egypt; and Middle East respiratory syndrome Health Metrics and Evaluation, University of Washington, Seattle, coronavirus (MERS-CoV) in Saudi Arabia and Jordan Washington, United States. Raghid Charara, MD, American Univer- sity of Beirut, Beirut, Lebanon. Ibrahim Khalil, PhD, Institute for (WHO Regional Ofﬁce for the Eastern Mediterranean Health Metrics and Evaluation, University of Washington, Seattle, 2016). However, many EMR countries do not have ade- Washington, United States. Ashkan Afshin, MD, Institute for Health quate health information systems to monitor the situation Metrics and Evaluation, University of Washington, Seattle, Wash- of LRI. (World Health Organization and UNICEF 2013) ington, United States. Nicholas J. Kassebaum, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Therefore, it is important to assist countries to set up such Washington, United States; Department of Anesthesiology and Pain systems to identify and manage outbreaks, and monitor the Medicine, Seattle Children’s Hospital, Seattle, Washington, United trends and risk factors of LRI. It also helps to improve States. Michael Collison, BS, Institute for Health Metrics and Eval- accuracy of estimates for EMR in the next rounds of the uation, University of Washington, Seattle, Washington, United States. Farah Daoud, BA/BS, Institute for Health Metrics and Evaluation, GBD study. University of Washington, Seattle, Washington, United States. Our study has some limitations. First, there are not Adrienne Chew, Institute for Health Metrics and Evaluation, enough original data for all countries of the region. For University of Washington, Seattle, Washington, United States. instance, many countries did not have estimates on inci- Kristopher J. Krohn, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Danny dence or etiologic agents of LRI. However, we used Colombara, PhD, Institute for Health Metrics and Evaluation, modeling approaches to estimate the burden, even for University of Washington, Seattle, Washington, United States. countries with limited data. While we did not assess avian Rebecca Ehrenkranz, MPH, Institute for Health Metrics and Evalu- inﬂuenza, severe acute respiratory syndrome (SARS), and ation, University of Washington, Seattle, Washington, United States. Kyle J. Foreman, PhD, Institute for Health Metrics and Evaluation, MERS-CoV (Beaute et al. 2014; Milne-Price et al. 2014)as University of Washington, Seattle, Washington, United States; separate etiologic agents, all of them were included in total Imperial College London, London United Kingdom. Joseph Frostad, numbers of incidence, deaths, and DALYs. MPH, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. William W. God- win, BS, Institute for Health Metrics and Evaluation, University of Conclusion Washington, Seattle, Washington, United States. Michael Kutz, BS, Institute for Health Metrics and Evaluation, University of Washing- LRI is one of the leading causes of morbidity and mortality ton, Seattle, Washington, United States. Puja, C Rao, MPH, Institute in the EMR. Efforts are urgently needed to prevent and for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Robert Reiner, BA, Institute for Health control LRI in the region, especially in the low-income Metrics and Evaluation, University of Washington, Seattle, Wash- countries of the region. All countries should consider ington, United States. Christopher Troeger, MPH, Institute for Health adopting vaccines against pneumococcus, if they have not Metrics and Evaluation, University of Washington, Seattle, Wash- already, to reduce the burden. To adequately address the ington, United States. Haidong Wang, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Wash- LRI burden, a public health and health care systems ington, United States. Amanuel Alemu Abajobir, MPH, School of approach is needed. A comprehensive plan that includes Public Health, University of Queensland, Brisbane, QLD, Australia. addressing known risk factors such as poor diet, smoking, Kaja M. Abbas, PhD, Virginia Tech, Blacksburg, VA, United States. and exposure to secondhand smoke; health systems to Semaw Ferede Abera, MSc, School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia; Food Secu- improve prevention and treatment of cases; and community rity and Institute for Biological Chemistry and Nutrition, University programs to increase awareness and immunization uptake of Hohenheim, Stuttgart, Germany. Laith J. Abu-Raddad, PhD, are needed. A reliable surveillance system is required to Infectious Disease Epidemiology Group, Weill Cornell Medical monitor trends of disease burden and evaluate new College in Qatar, Doha, Qatar. Kelemework Adane, MS, Department of Medical Microbiology and Immunology, College of Health Sci- interventions. ences, Mekelle University, Mekelle, Ethiopia. Aliasghar Ahmad Unstable economies, political instability, and unrest in Kiadaliri, PhD, Department of Clinical Sciences Lund, Orthopedics, the region are major barriers to improving health. 123 Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and… S105 Clinical Epidemiology Unit, Lund University, Lund, Sweden. Alireza Institute for Health Policy, Massachusetts General Hospital, Boston, Ahmadi, PhD, Kermanshah University of Medical Sciences, Ker- MA, United States. Seyed-Mohammad Fereshtehnejad, PhD, manshah, Iran; Stockholm, Sweden. Muktar Beshir, MPH, College of Department of Neurobiology, Care Sciences and Society (NVS), Health Sciences, Department of Epidemiology, ICT and e-Learning Karolinska Institutet, Stockholm, Sweden. Florian Fischer, PhD, Coordinator, Jimma University, Jimma, Oromiya, Ethiopia. Ayman School of Public Health, Bielefeld University, Bielefeld, North Al-Eyadhy, MD, King Saud University, Riyadh, Saudi Arabia; Saudi Rhine-Westphalia, Germany; Alberto L. Garcia-Basteiro, MSc Epi- Arabia. Khurshid Alam, PhD, Murdoch Childrens Research Institute, demiology, Manhic¸a Health Research Center, Manhic¸a, Maputo, The University of Melbourne, Parkville, Victoria, Australia; The Mozambique, Barcelona Institute for Global Health, Barcelona, University of Melbourne, Melbourne, VIC, Australia; The University Barcelona, Spain. Kiros Tedla Gebrehiwot, MSc, Mekelle University, of Sydney, Sydney, NSW, Australia. Noore Alam, MAppEpid, Mekelle, Tigray, Ethiopia. Tsegaye Tewelde Gebrehiwot, MPH, Department of Health, Queensland, Brisbane, Queensland, Australia; Jimma University, Jimma, Oromia, Ethiopia. Gessessew Bugssa Nathan, Queensland, Australia. Deena Alasfoor, MSc, Ministry of Hailu, MSc, Mekelle University, Mekelle, Ethiopia, Kilte Awlaelo Health, Al Khuwair, Muscat, Oman. Reza Alizadeh-Navaei, PhD, Health and Demographic Surveillance System, Mekelle, Ethiopia. Gastrointestinal Cancer Research Center, Mazandaran University of Randah Ribhi Hamadeh, DPhil, Arabian Gulf University, Manama, Medical Sciences, Sari, Mazandaran, Iran. Fatma Al-Maskari, PhD, Bahrain. Mitiku Teshome Hambisa, MPH, College of Health and College of Medicine and Health Sciences, United Arab Emirates Medical Sciences, Haramaya University, Harar, Harari, Ethiopia. University, Al-Ain City, United Arab Emirates. Rajaa Al-Raddadi, Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, email@example.com, PhD, Joint Program of Family and Dubai, United Arab Emirates. 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Amany H University of Washington, Seattle, Washington, United States. Refaat, PhD, Walden University, Minneapolis, MN, United Sta- Mohsen Naghavi, PhD, Institute for Health Metrics and Evaluation, tesSuez Canal University, Ismailia, Ismailia, Egypt. Satar Rezaei, University of Washington, Seattle, Washington, United States. Simon PhD, School of Public Health, Kermanshah University of Medical I. Hay, DSc, Oxford Big Data Institute, Li Ka Shing Centre for Health Sciences, Kermanshah, Iran. Mohammad Sadegh Rezai, MD, Information and Discovery, University of Oxford, Oxford United Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Kingdom; Institute for Health Metrics and Evaluation, University of Hirbo Shore Roba, MPH, College of Health and Medical Sciences, Washington, Seattle, Washington, United States. Christopher J. Haramaya University, Harar, Ethiopia. Gholamreza Roshandel, PhD, L. Murray, DPhil, Institute for Health Metrics and Evaluation, Golestan Research Center of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, United States. Golestan University of Medical Sciences, Gorgan, Iran; Digestive The authors would like to acknowledge Adrienne Chew at the Diseases Research Institute, Tehran University of Medical Sciences, Institute for Health Metrics and Evaluation, Seattle, WA, for editing Tehran, Iran. Mahdi Safdarian, MD, Sina Trauma and Surgery this paper. This research was funded by the Bill and Melinda Gates Research Center, Tehran, Iran. Saeid Saﬁri, PhD, Managerial Epi- Foundation. demiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Compliance with ethical standards Maragheh, Iran. Mohammad Ali Sahraian, MD, MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, This manuscript reﬂects original work that has not previously been Tehran, Iran. Payman Salamati, MD, Sina Trauma and Surgery published in whole or in part and is not under consideration else- Research Center, Tehran University of Medical Sciences, Tehran, where. All authors have read the manuscript and have agreed that the Tehran, Iran. Abdallah M Samy, PhD, Ain Shams University, Cairo, work is ready for submission and accept responsibility for its con- Egypt; Lawrence, Kansas, United States. Benn Sartorius, PhD, Public tents. The authors of this paper have complied with all ethical stan- Health Medicine, School of Nursing and Public Health, University of dards and do not have any conﬂicts of interest to disclose at the time KwaZulu-Natal, Durban, South Africa; UKZN Gastrointestinal Can- of submission. The funding source played no role in the design of the cer Research Centre, South African Medical Research Council study, the analysis and interpretation of data, and the writing of the (SAMRC), Durban, South Africa. Sadaf G. Sepanlou, PhD, Digestive paper. Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Tehran, Iran. Masood Ali Shaikh, MD, Independent Con- Conﬂict of interest Dr. Carl Abelardo T. Antonio reports Grants and sultant, Karachi, Pakistan. Morteza Shamsizadeh, MPH, Department personal fees from Johnson and Johnson (Philippines), Inc. outside of Medical Surgical Nursing, School of Nursing and Midwifery, the submitted work. Dr. Jasvinder Singh serves as the principal Hamadan University of Medical Sciences, Hamadan, Iran. Mika investigator for an investigator-initiated study funded by Horizon Shigematsu, PhD, National Institute of Infectious Diseases, Tokyo, Pharmaceuticals through a grant to DINORA, Inc., a 501 (c)(3) entity. Japan, Sandia National Laboratories, Albuquerque, New Mexico, Dr. Singh is a member of the executive of OMERACT, an organi- United States. Jasvinder A. Singh, MD, University of Alabama at zation that develops outcome measures in rheumatology and receives Birmingham and Birmingham Veterans Affairs Medical Center, arms-length funding from 36 companies; a member of the American 123 Burden of lower respiratory infections in the Eastern Mediterranean Region between 1990 and… S107 College of Rheumatology’s (ACR) Annual Meeting Planning Com- Framework Convention Alliance Parties to the WHO FCTC mittee (AMPC); Chair of the ACR Meet-the-Professor, Workshop and (2017). http://www.fctc.org/about-fca/tobacco-control-treaty/ Study Group Subcommittee; and a member of the Veterans Affairs latest-ratiﬁcations/parties-ratiﬁcations-accessions. Accessed 6 Rheumatology Field Advisory Committee. Other authors have no Jun 2017 conﬂict of interest. 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