Review Article

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Medical Journal of the Islamic Republic of Iran (MJIRI)
Med J Islam Repub Iran. 2017(12 Feb);31.9. https://doi.org/10.18869/mjiri.31.9

Prevalence of asthma among Middle Eastern children:

A systematic review
Masoud Mirzaei1, Mehran Karimi2, Shima Beheshti3, Masoud Mohammadi*4

Received: 25 Oct 2015 Published: 02 Oct 2016

Abstract
Background: The prevalence of asthma and allergy has increased during the last decades, especially in children. However, little is
known about it in the Middle East region. This systematic review is aimed to estimate the prevalence of asthma among the Middle
Eastern children.
Methods: Local and international scientific databases including SID, Iranmedex, Medline and Science Direct were systematically
searched for relevant keywords including; asthma, prevalence, children, International Study of Asthma and Allergies in Childhood
(ISACC) and the names of Middle Eastern countries for the period of 1996-2011. Papers in Persian and English which met the defined
criteria were included into the study. Bibliographies of the extracted articles were also searched. After extraction of data, heterogeneity
between studies and publication bias were measured using Egger's-test. Effect size was pooled by the random-effect model. Since sig-
nificant heterogeneity was found between studies, univariate meta-regression analyses were done to assess the association of variables
with the overall results.
Results: Fifty studies in the Middle East examined the prevalence of asthma and allergy in children under the age of 18 years accord-
ing to the ISAAC criteria and were included. A total number of 289,717 children were examined in the included studies and the preva-
lence varied from 0.7 % in Isfahan to 22.3 % in Bagdad. The total prevalence of diagnosed asthma was calculated 7.53 % (95% Cl:
6.38-8.75). Prevalence of asthma in the 13-14 years age group was 7.57% (95% Cl: 5.78-9.29) and in 6-7 years age group was 7.43%
(95% Cl: 5.75-9.10). The prevalence of asthma among girls, based on random effect model, was 6.30% (95% Cl: 4.97-7.61) and
among boys, it was 8.91% (95% Cl: 6.80-11.04).
Conclusion: The prevalence of asthma in the Middle East is lower than most developed countries. However, there is not enough
longitudinal data to estimate the trend over time. In order to have more accurate estimates and to provide evidence for proper planning,
standard epidemiologic studies should be conducted in countries of the region.

Keywords: Asthma, Prevalence, Middle East, Children, Systematic review

Copyright© Iran University of Medical Sciences

Cite this article as: Mirzaei M, Karimi M, Beheshti Sh, Mohammadi M. Prevalence of asthma among Middle Eastern children: A systematic review.
Med J Islam Repub Iran. 2017(12 Feb);31:9. https://doi.org/10.18869/mjiri.31.9

Introduction
Worldwide, the prevalence of asthma has increased In some industrialized countries the prevalence of
during the last three decades (1,2). According to the asthma and allergy has reached to a warning level,
World Health Organization estimate in 2005, around and has affected more than one-third of the children
300 million people were affected by asthma. Accord- (4). It is not clear that this increase is due to a real
ing to the existing evidence, the prevalence of asth- increase in the prevalence of asthma and allergy (5),
ma and allergy in children is increasing around the or it is due to a higher level of awareness and diag-
world (3). It is estimated that this number will reach nosis. According to some studies, in developed coun-
400 millions by 2025. tries the prevalence of asthma has stopped to in-
_______________________________ ↑What is “already known” in this topic:
Corresponding author: Masoud Mohammadi, masoud.mohammadi1989@yahoo.com
Prevalence of asthma and allergy has reached to more than
1. Yazd Cardiovascular Research Centre, Shahid Sadoughi University of Medical Sci- one-third of the children in some developed countries. It seems
ences, Yazd, Iran. that factors like age, sex, economic status, genetics and expo-
2. Department of Pediatrics, Shahid Sadoughi University of Medical Sciences, Yazd,
sure to indoor and outdoor pollutions are related to the preva-
Iran.
3. Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
lence of asthma.
4. Department of Social Medicine, Faculty of Medicine, Kermanshah University of
→What this article adds:
Medical Sciences, Kermanshah, Iran.
The prevalence of asthma in the Middle Eastern countries is
lower than most developed countries. The prevalence studies of
asthma in the Middle East have to be repeated every 5 years
using criteria such as that of ISACC to reflect the trends of the
changes over time.
Prevalence of asthma in Middle Eastern children

crease or even started to decrease in the recent years “Citation pearl growing” technique (17) was used
(6- 8). It seems that factors like age, sex, economic to search the reference lists of the extracted papers.
status, genetics and exposure to indoor and outdoor This cross checking method continued up until no
pollutions are related to the prevalence of asthma other relevant article was found. In this study, all
(9,10). papers published from 1996-2011, in English or Per-
In a study by Smith Kline et al. in 2002, around sian languages, were searched, reviewed and includ-
one-third of those who were affected by asthma had ed if they met certain quality criteria. The results of
some limitations in doing their daily activities such this research were limited to cross- sectional descrip-
as physical exercise, social activities and sleeping tive studies. The research was conducted during Sep-
(11). tember to November 2012.
Overall, respiratory diseases cause 6.3 % of the to- Summaries of the extracted articles were reviewed
tal death around the world, and the share of asthma is first. Initial screening was done based on the subjects
0.4% (12). Based on the National Statistical Office and summaries of the articles. If the article was a
of Korea, the mortality rate, due to chronic respirato- peer reviewed epidemiologic study and the preva-
ry diseases (including asthma) increased during 1992 lence of asthma and the asthma symptoms were re-
to 2002 from 12.9 to 22.6 per 100,000 population. In ported in the article, then the article was considered
1992 chronic diseases of the lower respiratory sys- for quality check and inclusion. If some articles were
tem was the eighth cause of death in Korea, and it extracted from one study, the one with the most de-
reached to the fifth cause in 2002 (13). tails was selected. If the full text was not available,
Children’s asthma is a main clinical concern authors of the paper were contacted.
around the world that imposes a great burden on Selection criteria for the included papers were; a)
families and the society. The disease can impede the population-based studies which reported prevalence
academic development and social activities of the of asthma, b) age of the population groups less than
children. Children’s asthma is a burden on the health 18 years, c) random or census sampling of the study,
care system due to successive referral to practitioner d) using ISACC methods to diagnose asthma, and e)
and hospital which costs a lot (14,15). Due to the the article published either in English or Persian.
lack of a standard method for asthma diagnosis, ex- Studies which had the criteria to be entered into the
amining the prevalence of asthma over time (16) was study were coded in an information summary form,
difficult. The International Study of Asthma and Al- using FileMaker Pro V. 8.0 (FileMaker Inc., Santa
lergies in Children (ISAAC) was established in 1991 Clara, CA -USA). Some of the articles (10%) were
in order to provide reliable data on the prevalence of summarized and evaluated by two coders.
the disease, its symptoms and changes during the Coding form of the studies consisted of four sec-
time and in different countries. In the first phase tions including information related to the aim of the
children in the age group of 13-14 years in 56 coun- study, characteristics of the target population, sam-
tries, and in the age group of 6 to 7 years in 38 coun- pling method, information related to criteria for
tries were evaluated during 1994 to 1995. The sec- asthma diagnosis, epidemiologic information in or-
ond phase of ISAAC aimed to investigate risk factors der to extract the data reported in the article and in-
of the disease in 1998; only 22 countries formation related to the quality of the study.
participated, and no Middle Eastern countries were The quality of the studies was evaluated using a set
involved. Several Middle Eastern countries took part of defined criteria. The relevant checklist was de-
in various phases of ISAAC. However no systematic signed according to the critical evaluation guideline
review was published from these studies. This study of research papers on prevalence published by Loney
aims to systematically review the prevalence of et al. (18). The criteria are about the design including
asthma, according to ISAAC standard method, in the proper sampling framework, adequate sample size,
Middle Eastern children. appropriate evaluation of the result and the response
rate; interpretation included reporting the prevalence
Methods with confidence interval and adequate sub-group
Data analysis and applicability of the results including
Iranian scientific databases including Iranmedex explanation of the aims and detailed conditions.
and SID, as well as major international databases Quality grading of each study was made by two
including Medline and Science Direct were searched coders, and the results were compared to ensure in-
to find the relevant papers. The searched keywords ter-coder agreement. In cases of inconsistency be-
were "Asthma", "prevalence", "children", “ISACC” tween the coders, they discussed the issue until con-
and "Middle East" in English and the Persian equiva- sensus was reached.
lents.
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2 Med J Islam Repub Iran. 2017 (12 Feb); 31:9.
 M. Mirzaei, et al.

Fig. 1. Flowchart of the included studies

Data analysis the study, quality of the included studies, and also
The first step of data analysis was to estimate the language of the questionnaire, was analyzed to
overall pooled prevalence of asthma among all stud- see any relation with the prevalence of asthma.
ies. To assess heterogeneity, I2 Test was used in or- Due to the existing inconsistency in the studies, a
der to determine whether the difference between es- sensitivity analysis was conducted to determine the
timated prevalence in different studies is higher than influence of each included study on the total estima-
the randomly expected value. tion. There was no significant change observed by
A significant heterogeneity between the included excluding any particular paper.
studies was found. Univariate meta-regression analy- Effect of each variable including methodology, ge-
sis was done in order to evaluate the relationship be- ographic area of the study, urban and rural and popu-
tween methodological variables, age, and sex with lation mean age on the prevalence estimate were in-
the total estimate of the prevalence of asthma using vestigated by meta-regression analysis. This strategy
meta-regression analysis. This analytical strategy investigates which variable affects the final results.
tries to find which variable has affected the total re- The regressed variables include sample size, publica-
sult. Examined methodological variables were sam- tion year, and article's quality score. All statistical
ple size, year of publication, quality score of the arti- analysis was done using STATA SE (Ver.10).
cle, and also per capita income and air pollution of
the countries. Results
In this analysis the relationship between methodo- Out of 814 identified papers in the initial search,
logical variables like sample size, published year of after exclusion of repeated publications and critical

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Med J Islam Repub Iran. 2017 (12 Feb); 31.9. 3
Prevalence of asthma in Middle Eastern children

appraisal, 89 articles had the inclusion criteria. After More than half of the studies were done in urban
searching bibliography of the papers, 28 more papers populations, and the rest were done in the urban and
were identified, and the total number reached to 117 rural population at the same time. Only one study
(Fig. 1). was conducted among men, and the rest included
Out of the 117 articles, 67 articles excluded in the both men and women.
detailed review phase, either because they used non- Eighteen countries of the Middle East including
ISAAC protocol and questionnaire, or conducted in a Iran, Saudi Arabia, Oman, Lebanon, Palestine, Qatar,
specific age group (19-22), or had ISAAC question- Kuwait, Bahrain, Iraq, Morocco, Egypt, United Ar-
naire, but their reports were different from ISAAC ab Emirates, Syria, Israel and Yemen were included
protocol and thus excluded (23-27). The total num- in this systematic review. Twenty-six studies were
ber of subjects in the included studies (N=50) was from Iran (52%), eight studies were from other Per-
289,717. Five articles (10% of all articles), had a sian Gulf countries (26%), six studies (16%) were
population more than 10,000 (45.6% of the total sub- from other Arabic countries of the Middle East and
jects). The majority of the studies (88%) had the the rest were from North Africa (Table 2).
population between 1000 and 10000 (54% of all sub- The majority of studies (52 %) used Persian trans-
jects). Only one study had a population less than lation of the ISAAC questionnaire followed by Ara-
1000 (Table 1). bic translation (46%) and French translation (2%).

Table 1. Summary of the included studies on prevalence of asthma in children of the Middle East from 1996-2011
Author year The study area Country Type of Sample The age Sex Quality
area size range Score
El-Sharif N.A. et al (61) 2003 Ramallah & Qaza Palestine Urban / 14355 12 years Girl/Boy 13
rural
El-Sharif N.A. et al (53) 2002 Ramallah Palestine Urban / 3382 6 to 14 Girl/Boy 11
rural years
Bener A. et al (28) 2007 Qatar Qatar Urban / 31400 13 to 19 Girl/Boy 6
rural years
Janahi I.A. et al (62) 2006 Doha Qatar Urban / 3282 11 to 15 Girl/Boy 9
rural years
Nahhas M. et al (54) 2012 Medina Saudi Arabia Urban 5188 6 to 14 Girl/Boy 10
years
Al Ghobain M.O.et al (63) 2012 Riyadh Saudi Arabia Urban 3073 6 to 7 years Girl/Boy 10
Alshehri M.A. et al (64) 2000 Abha Saudi Arabia Urban 3274 13 to 14 Boy 10
years
Hijazi N. et al (65) 1999 Jeddah Saudi Arabia Urban / 1444 7 to 11 Girl/Boy 8
rural years
Mohammad Y. et al (66) 2010 Aleppo, Lattika, Tartous Syrian Arab Urban 10214 6 to 7 years Girl/Boy 12
Republic
Alsowaidi S. et al (20) 2010 Al-Ain United Arab Urban 2802 6 to 7 years Girl/Boy 9
Emirates
Georgy V. et al (67) 2006 EI Nozha area of Cairo Egypt Urban 2645 12 to 15 Girl/Boy 8
years
Zobeiri M. et al (68) 2011 Kermanshah Iran Urban / 6236 6 to 11 Girl/Boy 11
rural years
Rahimi Rad M.H.et al (69) 2008 Urmia Iran Urban 2999 6 to 12 Girl/Boy 11
years
Rahimi Rad M.H. et al (48) 2007 Urmia Iran Urban 3000 6 to 14 Girl/Boy 12
years
Kajbaf T.Z. et al (70) 2011 Ahvaz Iran Urban 903 13 to 14 Girl/Boy 6
years
Shakurnia A.H. et al (71) 2010 Ahvaz Iran Urban 2860 5 to 7 years Girl/Boy 11
Masjedi M.R. et al (72) 2004 Tehran Iran Urban 6140 13 to 14 Girl/Boy 10
years
Golshan M. et al (73) 2002 Isfahan Iran Urban 3924 5 to 12 Girl/Boy 10
years
Golshan M. et al (29) 2001 Isfahan Iran Urban 3858 13 to 14 Girl/Boy 10
years
AL-Thamiri D. et al (30) 2005 Baghdad Iraq Urban 2889 13 to 14 Girl/Boy 9
years
Abu-Ekteish F. et al (74) 2009 Amman, Al-Mafraq Jordan Urban / 9108 13 to 14 Girl/Boy 12
rural years
Owayed A et al (75) 2008 Kuwait City Kuwait Urban 2882 13 to 14 Girl/Boy 12
years
Abal A.T. et al (76) 2010 Kuwait City Kuwait Urban 2117 6 to 14 Girl/Boy 8
years
Musharrafieh U. et al (77) 2009 Beirut Lebanon Urban / 3115 13 to 14 Girl/Boy 10
rural years
Waked M.et al (20) 2008 Beka, Beirut, Mount, Naba- Lebanon Urban / 3907 13 to 14 Girl/Boy 9
tieh, North, South rural years
Waked M. et al (78) 2006 Beka, Beirut, Mount, Naba- Lebanon Urban / 1613 13 to 14 Girl/Boy 12
tieh, North, South rural years
Ait-Khaled N. et al (60) 2007 Wialya of Algeria,Khartoum Africa Urban / 66335 6 to 14 Girl/Boy 10
of Sudan, Grand Tunis & rural years
Sousse of Tunisia,...

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4 Med J Islam Repub Iran. 2017 (12 Feb); 31:9.
 M. Mirzaei, et al.

Table 1. Cntd
Bouyad Z.et al (79) 2006 Casabelanca, Marrakech, Morocco Urban 5665 6 to 14 Girl/Boy 11
BenSlimane, Boulmane years
Al-Rawas O.A. et al (58) 2008 Eight geographical regions of Oman Oman Urban / 7879 13 to 14 Girl/Boy 11
rural years
Al-Riyami B.M. et al (59) 2003 Sultanate Oman Urban 3893 13 to 14 Girl/Boy 12
years
Shohat T. et al (56) 2000 Nicosa, Limass Israel Urban / 10057 13 to 14 Girl/Boy 13
rural years
Golshan M.et al (73) 2002 Zarinshahr Iran Urban 1309 6 to 13 Girl/Boy 9
years
Habibi Khorasani A. et al 1998 Kermanshah Iran Urban 2217 6 to 12 Girl/Boy 9
(80) years
Bazzazi H. et al (81) 2006 Gorgan Iran Urban 2800 12 to 13 Girl/Boy 8
years
Mohammadzadeh I. et al (82) 2008 Babol Iran Urban 5933 6 to 14 Girl/Boy 12
years
Hasanzadeh J. et al (83) 1390 Shiraz Iran Urban 3000 13 to 14 Girl/Boy 11
years
Abbasi Ranjbar Z. (84) 2004 Rasht Iran Urban 6060 6 to 14 Girl/Boy 12
years
Karimi M. et al (42) 2006 Yazd Iran Urban 2740 6 to 7 years Girl/Boy 9
Sahebi L. et al (85) 2011 Tabriz Iran Urban 1508 13 to 16 Girl/Boy 6
years
Gharagozlou M. et al (86) 2006 Kashan Iran Urban 2533 13 to 14 Girl/Boy 11
years
Zohal M.A. et al (87) 2004 Qazvin Iran Urban 5068 6 to 14 Girl/Boy 12
years
Najafizadeh K. et al (88) 2008 Rasht Iran Urban 6074 6 to14years Girl/Boy 12
Gharagozlou M. et al (89) 2002 Kashan Iran Urban 3003 6 to 7 years Girl/Boy 10
Amra B. et al (90) 2005 Isfahan Iran Urban 2413 6 to14years Girl/Boy 8
Karimi M. et al (45) 2006 Yazd Iran Urban 3151 13 to 14 Girl/Boy 10
years
Hatami G. et al (91) 2001 Bushehr Iran Urban 2699 13 to 14 Girl/Boy 11
years
Golshan M. et al (92) 1998 Isfahan Iran Urban 3924 10 to 17 Girl/Boy 9
years
Al-Rawas O.A. et al (58) 2009 Muscat,Sharqiah Oman Urban 2441 10 years Girl/Boy 8
Golshan M.et al (29) 2001 Isfahan Iran Urban 3668 15 to 18 Girl/Boy 10
years
Hajavi et al (93) 2011 Gonabad Iran Urban / 1626 12 to 18 Girl/Boy 7
rural years

Table 2. Comparison of changes in the prevalence of asthma in the Middle East over the period of 1996-2011
Trend of The prevalence of asthma in The prevalence of asthma in Interval of 2 Age group Country / City
change the second study% the First study% reviews
Increase 11.2 4.5 2 Years 6 to 12 years Palestine / Ramallah
Constant 2.5 2.6 6 Years 13 to 14 years Iran / Tehran
Constant 10.6 10.5 6 Years 6 to7years Oman / Sultanat
Decrease 19.8 20.7 6 Years 13 to14years Oman/Sultanat
Increase 13.2 10.9 6 Years 13 to14years Iran
Increase 2 1.4 8 Years 13 to14years Iran / Tabriz
Increase 7.1 4.1 6 Years 6 to 7 years Iran / Rasht
Increase 4.5 2.7 6 Years 13 to 14 years Iran / Rasht
Decrease Girls:1.2 Girls:1.5 6 Years 6 to 7 years Iran / Tehran
Boys:1.0 Boys:1.9

The quality score of each paper was assessed, and group (23 studies) was 7.53% (95% Cl= 5.78-9.29)
the most common limitations of the studies were: 1) based on the random effect model. The prevalence of
not reporting the confidence interval of the preva- asthma in the 6 to 7 years old group, was 7.43%
lence, 2) including age groups not comply with (95% Cl= 5.75-9.1) based on the random effect
ISAAC protocol and 3) the reported prevalence was model. In 12 studies, the prevalence of asthma in the
not according to the defined age groups of ISAAC age group of 6 to 7 was 7.68% (95% Cl= 5.02-10.34)
(Fig. 2). was higher than the age group of 13 to 14; 6.1%
During the period of 1996-2011, the prevalence of (95% Cl= 4.41-6.91).
asthma in children of the Middle East was 7.57 %
(95% Cl=6.38-8.75). There was significant hetero- Discussion
geneity in the studies. (I2=99 %; p<0.001, df=45 and Prevalence of asthma in the Middle Eastern chil-
Q=9006.7) (Fig. 3). dren aged 13-14 years was 7.57% (95% Cl: 6.38-
The prevalence of asthma among girls, based on 8.75). The minimum prevalence rate of asthma
the random effect model, was 6.30% (95% Cl= 4.97- (0.7%) was observed in Isfahan in Iran (29), and the
7.61) and among boys, it was 8.91% (95% Cl= 6.80- highest 22.3% was reported from Bagdad in Iraq
11.04). Prevalence of asthma in the 13-14 years age
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Med J Islam Repub Iran. 2017 (12 Feb); 31.9. 5
Prevalence of asthma in Middle Eastern children

In Turkey, the prevalence of asthma in boys (19.4%)

is slightly higher than girls (16.2%) (34) similar to
Nigeria, South Korea, and India (36,39,40).
The prevalence of asthma in countries around the
world in the age group 6 to 7 years varies from 1.8%
in Lithuania to 27.4% in Costa Rica. In the age group
13 to 14 years the lowest prevalence rate reported
from Albania (2.6%) and the highest from Peru
(30.5%).
The prevalence of asthma is higher in older chil-
dren, e.g. in Indonesia the prevalence of asthma
among children 6-7 years is 5.3 % and among chil-
dren 13 -14 years is 7 %. This increase was reported
Fig. 2. Sensitivity analysis of the effect of excluded papers on the from Germany (4.3% vs. 7.5%) and Singapore (17%
final estimate of asthma prevalence in children of the Middle East vs. 23.7) too. However, in some countries like Costa
1996-2011
Rica the prevalence of asthma among children 6 to 7
(30). years old (27.4%) is slightly higher than the 13-14
Prevalence of asthma in the Middle East is lower years age group (20.8%), the reported difference in
than many developed countries such as the UK other countries is limited to 1% (41).
(25.9%) (31), Spain (12.8%) (32), Australia (31%) In a systematic review, Pearce et al. reported that
(33), and also Turkey (17.8%) (34). However, it is across 35 countries of the world, the prevalence of
higher than some developing countries like Tibet asthma in 21 countries (60%) is higher in the older
area in China (1.1%), (35) India (4.9%) (36) and age group and in nine countries (25.7%)is higher in
Taiwan (6%) (37). the younger age group. It was reported in 10 coun-
Studies in the Middle East also show that the tries (25.7%) that the difference was insignificant,
prevalence of asthma is higher among younger boys. and in only 5 countries the prevalence of asthma was
However, the difference decreases between the two higher in the 6 to 7 years age group including; Iran
sexes in early adolescence. In Japan prevalence of and Oman (41). Overall, in the Middle East, the
asthma was higher in boys (6%) than girls (4%) (38). prevalence of asthma is higher in the 13 -14 years

Fig. 3. Pool estimate of the prevalence of asthma in children of the Middle East 1996-2011

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6 Med J Islam Repub Iran. 2017 (12 Feb); 31:9.
 M. Mirzaei, et al.

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