Prevalence of Asthma among Children and Adolescents in WHO's Eastern Mediterranean Region: A Meta-Analysis of Over 0.5 Million Participants

doi:10.21203/rs.3.rs-4002410/v1

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Systematic Review

Prevalence of Asthma among Children and Adolescents in WHO's Eastern Mediterranean Region: A Meta-Analysis of Over 0.5 Million Participants

https://doi.org/10.21203/rs.3.rs-4002410/v1

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Objective: This study aims to evaluate the epidemiology of asthma among children and adolescents in the Eastern Mediterranean Region (EMRO).

Methods: Exhaustive searches were conducted across databases, including PubMed, Scopus, Web of Knowledge Core Collection, Embase, and Google Scholar. The selection criteria included studies in English and Persian languages reporting asthma prevalence in individuals aged 0 to 19 years, using validated questionnaires. Data were extracted and synthesized using the DerSimonian and Laird random effects model.

Results: The overall prevalence of asthma in Eastern Mediterranean Regional Office (EMRO) countries, among the 514,468 children and adolescents included in this meta-analysis, was 10.61%, synthesized from 95 studies. Among the countries studied, Qatar exhibited the highest prevalence at 16.69%, followed by Saudi Arabia at 16.57%, Iraq at 16.22%, Oman at 15.20%, and Afghanistan at 14.90%. Adolescents showed a slightly higher prevalence of asthma at 10.10% compared to children at 9.70%. Boys exhibited a higher prevalence at 11.48% compared to girls at 9.75%. Urban areas demonstrated a higher prevalence at 11.27% compared to rural areas at 8.29%.

Conclusion: Efforts to reduce asthma prevalence in Arab countries and address underdiagnosis in African nations within the EMRO are crucial. Targeted interventions should focus on addressing environmental triggers and improving access to healthcare. Enhanced diagnostic capabilities and healthcare infrastructure are necessary in African countries. Collaborative action is essential to alleviate the asthma burden and promote respiratory health across the EMRO region.

Epidemiology

Pediatrics

Asthma prevalence

Children

Adolescents

EMRO

In recent decades, the prevalence of asthma has increased significantly, becoming a major public health concern, especially among children and teenagers. Asthma, a complex respiratory disorder, is characterized by persistent inflammation of the airways, resulting in recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. These symptoms can significantly impair quality of life, limit physical activities, and impose a substantial financial burden on healthcare systems and families. While extensive research has explored the prevalence of asthma in different parts of the world, it is evident that several variables contribute significantly to its prevalence (1–4). Various factors, including age, sex, economic status, genetics, and exposure to pollutants, have been demonstrated to impact the occurrence and severity of asthma (5). First, age plays a vital role in determining asthma, as it influences the development and duration of the disease. Asthma usually occurs in childhood and the risk decreases as individuals enter adulthood. However, some asthma attacks may begin in old age or continue into later life, suggesting age-related differences in their prevalence (6). Gender is another factor affecting asthma. Many studies have shown that men and women have different rates of asthma. Boys have more asthma in childhood, but this trend often changes with more women in adolescence and adulthood (7). Economic conditions have also been shown to affect asthma. People from lower socioeconomic backgrounds often face challenges such as poor housing, lack of healthcare and environmental risks. These factors lead to higher rates of asthma in low-income communities (8). Exposure to air pollution is a well-known risk factor for asthma. Breathing in various environmental irritants and pollutants such as smoking, air pollution, allergies, and occupational exposure can cause and lead to asthma. People living in cities or near industrial areas may be particularly susceptible to asthma due to increased levels of air pollution (9).

The EMRO Locale, covering an endless range and comprising differing nations, presents a one-of-a-kind intersection of socio-economic, social, and natural variables that can impact the predominance and administration of asthma among children and teenagers. With nations extending from high-income countries with progressed healthcare frameworks to those hooking with financial challenges and restricted therapeutic assets, the EMRO Locale gives a complicated embroidered artwork for studying the prevalence of asthma (10–12).

The 2013 International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three revealed that the Eastern Mediterranean region had a comparatively lower incidence of asthma symptoms compared to other parts of the world. Specifically, in the 13–14 age group, boys exhibited a prevalence of 10.6%, while girls showed 7.9% for current asthma symptoms (13). However, despite this lower prevalence, the region still contends with a substantial burden due to the large number of children and adolescents. Previous studies have documented wide variations in asthma prevalence across different countries and areas in the region, ranging from 1.41% to over 20% (14, 15).

Interestingly, there are conflicting findings regarding asthma prevalence in rural areas. For instance, one study suggests a higher prevalence in rural settings than urban ones (20.5% vs. 7.5%), while another indicates lower rates in rural areas compared to urban settings (1.2% vs. 1.9%)(16, 17). This variation also extends to differences based on gender and location, highlighting a notable research gap.

To address these complexities, this study aims to contribute to our understanding of childhood asthma in the Eastern Mediterranean Region. Our goal is to conduct a thorough review of studies reporting asthma prevalence, providing updated regional and country-specific estimates.

This manuscript follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for clear reporting of the prevalence of asthma among children and adolescents in WHO's Eastern Mediterranean Region(18). Our study is registered in PROSPERO (CRD42023379776).

2.1. Search Strategy

Data were found using keywords such as asthma, prevalence, epidemiology, children, pediatrics, adolescent, name of the 21 countries located in emro including Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, Yemen. Also, the names of big cities of each country were included in the search strategy. We searched PubMed, Scopus, Web of Knowledge Core Collection, Embase, and Google Scholar from their inception until 1 April 2023. Additionally, the search was updated on 23 January to find relevant studies (Appendix A). Finally, citations of the included articles were searched to identify any additional relevant studies.

2.2. Inclusion Criteria

English and Persian studies that investigated the prevalence of asthma in children under the age of 19 were included in this systematic review. Studies used valid and reliable questionnaires to investigate the prevalence of asthma such as the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, were included. The participants were grouped based on their age, with children defined as those between the ages of 0 and 10, and adolescents classified as those aged 11 to 19. In this study, our aim was to encompass all types of observational studies suitable for assessing asthma prevalence, including cross-sectional, panel studies, and cohorts, while excluding review articles, letters to editors, case reports, case-control studies, and case series.

2.3. Exclusion Criteria

Exclusion criteria for this study included unrelated subjects, research conducted outside the EMRO region to assess asthma prevalence, usage of nonstandardized questionnaires, incomplete data, and studies that did not specify the age group. Additionally, review articles and case-control studies were also excluded.

2.4. Quality Assessment

For quality assessment, we used the Joanna Briggs Institute (JBI) Tool for Prevalence Studies, which contains 9 questions about the sampling frame, sampling method, validity and reliability of the outcome measurement, and statistical analysis of the study. In this checklist, scoring is shown by a scale of “No”, “Yes”, “unclear” and “Not Applicable”. Although there is no reference guide for scoring the checklist questions, we assigned a score of 1 to the "yes" answer, a score of 0.5 to the "unclear" answer, and a score of 0 to the "no" answer for each question. Finally, the Total JBI score was obtained by summing the score obtained from all the answers for a study divided by the total number of questions. Regarding the median JBI score among all studies (0.75) Studies with a total JBI score of 0.75 and higher were considered low-risk studies while studies with a JBI score of less than 0.75 were labeled as high-risk of bias studies. The quality assessment of included studies was conducted independently by two reviewers, with any discrepancies resolved through discussion and consensus with a third reviewer.

2.5. Data Extraction

The current study made use of the data obtained from included articles via a checklist designed for data extraction. This checklist comprises the author's name, study design, publication year, the score obtained from JBI quality assessment tool, country, city, sample size, overall age range, gender, asthma prevalence in total and also in the subgroups of gender, age and place of residence. Data extraction was performed by two reviewers independently, followed by a discussion and consensus with a third reviewer for solving discrepancies.

2.6. Statistical Analysis

The prevalence of asthma was determined by calculating a pooled estimate using DerSimonian and Laird random effects model (19). This model was selected due to its ability to accommodate significant heterogeneity arising from variations in assessment methods, demographics, and geographic factors among included studies, thereby providing a more conservative estimate of prevalence. Furthermore, the random effects model acknowledges that the prevalence of asthma in the Eastern Mediterranean Region (EMRO) follows a distribution, whereas a fixed effect assumes that there is only one true underlying effect size. The results were reported with a 95% confidence interval obtained through an exact method for calculating confidence intervals. To assess heterogeneity, the I2 threshold was applied. Additionally, a subgroup analysis was conducted to examine variations based on geographical areas, age, gender, year of publication, and place of residence. To identify potential reasons for heterogeneity, metaregression was employed by considering the sample size and publication years. Publication bias was evaluated using Egger's test and a Doiplot. Data analysis was performed using the Metaprop and Metan Stata packages.

3.1. Search Results

In the first stage, 2537 articles were found; 650 duplicate studies were removed and 1887 studies entered the title and abstract screening phase. Finally, 218 studies were selected to read the full text, 95 of which were eligible to be included in the study, and other studies were excluded for reasons such as inappropriate age range, a language other than English or Persian, conducting the study in countries located outside the EMRO region, inappropriate study design and lack of reporting required statistics (Fig. 1).

3.2. Characteristics of Included Studies

The publication year of the included studies was from 1990 to 2024. A total of 20 countries were included in this meta-analysis. The number of studies included from each country varies, with Iran having the highest number of studies (19), followed by Saudi Arabia (16), Egypt (12), United Arab Emirates(6), Jordan (6) and Pakistan(5). Some countries have only one study included in the analysis, such Bahrain and Afghanistan. No study was found from Djibouti and Somalia. One study reported the prevalence of Asthma in both Tunisia and morocco (20). Also one primary international study reporting the childhood asthma in entire EMRO was included in this meta-analysis (13). Most of the included studies used questionares to assess the self-report prevalence of asthma While only 6 studies evaluated the presence of asthma in participants through clinical examinations. Total number of responding participants of included studies varied from 309 to more than 92000 individuals. Among the included studies, the study that reported the lowest prevalence of asthma (1%) among children and adolescents was the study of Ahmadiafshar et al., which was conducted in Iran (Zanjan city). The highest asthma prevalence was reported by Alatawi et al, who reported an asthma prevalence of 31.8% in Saudi Arabian participants aged 5–19 years (Appendix, Table B1).

3.3. Risk of Bias Assessment

The mean JBI score of all included studies was 0.93 ± 0.10 with a minimum of 0.55 and a maximum score of 1 )Appendix, Table B2). The risk of bias was low in most of the included studies, so that 86 studies (90.53%) had a low risk of bias, and the risk of bias was high in the remaining 9 studies (9.47%).

3.4. The Overall Prevalence of Asthma In EMRO Countries

The overall prevalence of asthma in the EMRO countries among a total of 514468 children and adolescents included in this meta-analysis was 10.61% (95% CI: 9.51–11.71; I²: 99.6%; Fig. 2). The country with the highest asthma prevalence was Qatar at 16.69% (95% CI: 7.84–25.54%; I2 = 99.70%), followed closely by Saudi Arabia at 16.57% (95% CI: 14.29–18.86; I2 = 97.40%), and then United Arab Emirates at 12.95% (95% CI: 10.87–15.03; I2 = 94.30%). Iraq (16.22%), Oman (15.20%), and Yemen (14.40%) all fell within the range of 11–16% prevalence rates (Fig. 3). Similarly, Pakistan (13.07%), Kuwait (13.66%), and Libya (12.55%) also had prevalence rates within this range. Bahrain (11.02%), Egypt (8.85%), Jordan (8.24%), and Syria (8.78%) had prevalences ranging from 8–11%. Sudan (8.07%) and Morocco (7.76%) had prevalence rates at the lower end of this range. Lebanon (6.64%), Palestine (6.75%), and Tunisia (4.59%) had the lowest prevalence rates, ranging from 4.59–6.75%. Iran had one of the lowest prevalence rates at 5.28% (95% CI: 4.38–6.19; I2 = 97.80%).

Table 1

Results of subgroup meta-analyses of childhood asthma in EMRO
Variable	Subgroups	Pooled Prevalence	95 Confidence Interval	I2	Number of Studies (References)
Country	Iran	5.28	4.38–6.19	97.80%	19 (21–39)
	United Arab Emirates	12.95	10.87–15.03	94.30%	6 (40–45)
	Palestine	6.75	4.23–9.28	96.20%	3 (46–48)
	Qatar	16.69	7.84–25.54	99.70%	3 (49–51)
	Morocco	7.76	1.14–14.38	99.20%	2 (20, 52)
	Iraq	16.22	6.76–25.69	99.50%	4 (53–56)
	Pakistan	13.07	7.56–18.58	98.00%	5 (57–61)
	Jordan	8.24	4.25–12.23	99.40%	6 (62–67)
	Bahrain	11.02	9.66–12.49	.	1 (68)
	Saudi Arabia	16.57	14.29–18.86	97.40%	16 (16, 69–83)
	Egypt	8.85	6-11.69	99.00%	12 (14, 84–94)
	Kuwait	13.66	11.55–15.76	93.50%	3 (95–97)
	Oman	15.20	14.72–15.68	0.00%	2 (98, 99)
	Lebanon	6.64	4.74–8.53	91.80%	4 (100–103)
	Yemen	14.40	12.31–16.69	.	1 (104)
	Sudan	8.07	5.87–10.26	91.90%	2 (105, 106)
	Tunisia	4.59	2.47–6.71	90.50%	2 (20, 107)
	Afghanistan	14.90	13.64–16.23	.	1 (108)
	Libya	12.55	9.72–15.86	.	1 (109)
	Syria	8.78	0.9-16.66	99.20%	2 (110, 111)
Age Group	Children	9.70	8.29–11.10	99.07%	36
Age Group	Adolescents	10.10	8.82–11.38	98.93%	48
Gender	Girls	9.75	8.51–10.99	99.07%	56
Gender	Boys	11.48	10.18–12.78	98.47%	57
Place of Residence	Rural Area	8.29	6.91–9.68	96.62%	13
Place of Residence	Urban Area	11.27	9.32–13.22	98.76%	22
Publication Year	1990s	10.359	5.87–14.85	99.50%	4
	2000s	10.323	8.59–12.05	99.20%	30
	2010s	10.487	8.62–12.36	99.70%	40
	2020s	11.646	9.39–13.9	99.10%	21
Sample Size	0-4999	10.99	9.84–12.14	98.80%	76
	5000–10000	9.22	6.13–12.31	99.70%	11
	> 10000	9.549	5.29–13.8	99.90%	8
Assessment Method	Clinical Examination	15.813	7.78–23.85	100.00%	6
Assessment Method	Self-report	10.273	9.37–11.18	99.20%	89
Risk of Bias	High Risk	9.986	6.86–13.11	99.00%	9
Risk of Bias	Low Risk	10.751	9.57–11.94	99.60%	86

3.5. Overall Prevalence of Asthma According to Gender, Age and Place of Residence

The prevalence of asthma in girls was lower than that of boys under study, with the pooled prevalence of asthma among girls in EMRO countries estimated at 9.75% (95% CI: 8.51–10.99; I2: 99.07%), compared to 11.48% (95% CI: 10.18–12.78; I2: 98.47%) in boys (Appendix, Figure C1 & C2). Additionally, the prevalence of asthma differed among different age groups. The pooled prevalence of asthma in children under 10 years old was 9.70% (95% CI: 8.29–11.10; I2: 99.07%), whereas in adolescents aged between 10 and 19 years old, it was slightly higher at 10.10% (95% CI: 8.82–11.38; I2: 98.93%; Figure C3 & C4). Furthermore, the prevalence of asthma varied based on the place of residence. In 13 studies reporting the prevalence of asthma in rural areas, the overall prevalence was 8.29% (95% CI: 6.91–9.68; I2: 96.62%). Conversely, the overall prevalence of asthma in urban areas was estimated to be higher, with a pooled prevalence of 11.27% (95% CI: 9.32–13.22; I2: 98.76%; Figure C5 & C6).

3.6. Subgroup analysis based on ssessment method, risk of bias, publication year, and sample size

In studies which used clinical examinations to evaluate the prevalence of asthma, the pooled prevalence was found to be 15.81% (95% CI: 7.78–23.85; I2: 100.00%). Conversely, self-reporting resulted in a higher pooled prevalence of asthma, at 10.27% (95% CI: 9.37–11.18; I2: 99.20%). Asthma prevalence among studies with a high risk of bias was 9.986% (95% CI: 6.86–13.11; I2: 99.00%), while among studies with low risk of bias, it was slightly higher at 10.751% (95% CI: 9.57–11.94; I2: 99.60%).

In terms of publication year, the pooled prevalence of asthma in the 1990s was 10.359% (95% CI: 5.87–14.85; I2: 99.50%) across 4 studies. This prevalence decreased in the 2000s to 10.323% (95% CI: 8.59–12.05; I2: 99.20%) across 30 studies. However, in the 2010s, the prevalence slightly increased to 10.487% (95% CI: 8.62–12.36; I2: 99.70%) across 40 studies. Finally, in the 2020s, the prevalence further increased to 11.646% (95% CI: 9.39–13.9; I2: 99.10%) across 21 studies (Table 1).

Considering sample size, the pooled prevalence of asthma in studies with a sample size greater than 10,000 was 9.549% (95% CI: 5.29–13.8; I2: 99.90%) across 8 studies. For studies with a sample size between 5,000 and 10,000, the pooled prevalence was 9.22% (95% CI: 6.13–12.31; I2: 99.70%) across 11 studies. Finally, studies with a sample size less than 5,000 showed a pooled prevalence of 10.99% (95% CI: 9.84–12.14; I2: 98.80%) across 76 studies.

3.7. Meta-regression Results

A total of 94 studies were included in DerSimonian-Laird random effect meta-regression (Table 2). The overall model fit was moderate with an R-squared value of 53.42% indicating that 53.42% of heterogeneity is explained by the variables included in the model. The Wald chi-square test showed that the model as a whole was statistically significant (p < 0.001). In the meta-regression analysis, several variables were examined to assess their impact on the prevalence of asthma across different settings and time periods. Notably, the prevalence of asthma varied significantly across decades, with a substantial increase observed in the 2010s (coefficient: 3.06, p-value: 0.19) and 2020s (coefficient: 3.34, p-value: 0.16) compared to the reference period in the 1990s. Moreover, certain countries exhibited notably higher prevalence rates, particularly Qatar (coefficient: 11.56, p-value: 0.00), Iraq (coefficient: 11.05, p-value: 0.00), and Saudi Arabia (coefficient: 11.14, p-value: 0.00). Conversely, lower prevalence rates were observed in countries such as Iran, where the coefficient for asthma prevalence was not statistically significant compared to the reference. Additionally, the analysis considered the influence of sample size and risk of bias, although the associations were not statistically significant for these factors.

Table 2

Meta-regression Results for prevalence of childhood asthma in EMRO
Variable		Coefficient	Standard Error	P-value	Lower Limit	Upper Limit
Risk of Bias	High risk	Ref	-	-	-	-
Risk of Bias	Low Risk	1.37	1.58	0.39	-1.73	4.48
Decade	1990s	Ref	-	-	-	-
	2000s	1.33	2.35	0.57	-3.27	5.93
	2010s	3.06	2.34	0.19	-1.54	7.65
	2020s	3.34	2.39	0.16	-1.33	8.02
Sample Size	< 5000	Ref
	5000–10000	-1.41	1.49	0.35	-4.33	1.52
	> 10000	-1.71	1.89	0.37	-5.40	1.99
Country	Iran	Ref	-	-	-	-
	United Arab Emirates	8.21	1.96	0.00	4.37	12.05
	Palestine	2.84	2.71	0.29	-2.46	8.14
	Qatar	11.56	2.57	0.00	6.52	16.60
	Morocco	8.08	4.31	0.06	-0.36	16.52
	Iraq	11.05	2.28	0.00	6.59	15.52
	Pakistan	7.68	2.11	0.00	3.55	11.82
	Jordan	3.43	1.92	0.08	-0.34	7.20
	Bahrain	4.83	4.14	0.24	-3.28	12.94
	Saudi Arabia	11.14	1.40	0.00	8.40	13.87
	Egypt	2.85	1.52	0.06	-0.12	5.82
	Kuwait	10.74	2.76	0.00	5.33	16.16
	Oman	12.26	3.25	0.00	5.89	18.62
	Lebanon	2.10	2.35	0.37	-2.50	6.70
	Yemen	8.21	4.22	0.05	-0.07	16.48
	Sudan	2.74	2.98	0.36	-3.10	8.59
	Tunisia	0.17	3.07	0.96	-5.85	6.20
	Afghanistan	8.71	4.13	0.04	0.62	16.80
	Libya	6.07	4.43	0.17	-2.61	14.76
	Syria	3.28	3.12	0.29	-2.82	9.39
Constant		1.76	2.84	0.54	-3.81	7.33

3.8. Publication Bias

Egger's test results indicated that publication bias may exist in this study (p-value = 0.01), and these findings were consistent with Doi plot which had an asymmetric shape (Fig. 4). In the nonparametric trim-and-fill analysis of publication bias, 11 studies on the left side were imputed to address potential bias. The observed prevalence was 10.6%, while the adjusted prevalence, including imputed studies, was 9.05%.

The overall prevalence of asthma in the Eastern Mediterranean Regional Office (EMRO) countries, as determined by our meta-analysis, was found to be 10.61% (95% CI: 9.51–11.71; I2: 99.6%). This estimate was derived from a comprehensive analysis of data from a total of 514,468 children and adolescents included in the study. Interestingly, our findings reveal a slightly higher prevalence compared to the prevalence reported by Mallol et al. in 2013, which was 9.35%, contrasting with the 8% prevalence of asthma reported by the World Health Organization (WHO) for the EMRO (13, 112). This discrepancy may stem from variations in study methodologies, population demographics, or changes in asthma prevalence over time. On the other hand, in conjunction with the DOI plot and trim-and-fill analysis, it's important to acknowledge that our findings may still be influenced by publication bias, wherein studies reporting higher prevalence rates of asthma are more likely to be published, potentially leading to an overestimation of asthma prevalence in the Eastern Mediterranean Regional Office (EMRO) countries. One possible explanation for the higher prevalence in our study is that childhood asthma prevalence was relatively higher in the 2020s compared to previous decades, aligning with WHO projections of asthma deaths in the Eastern Mediterranean Region, estimated at 20,000 for 2015 and anticipated to reach 27,000 by 2030 (112).

This study highlights a significant disparity in asthma prevalence between Arab and African countries within the Eastern Mediterranean Regional Office (EMRO) region, suggesting potential discrepancies in reporting and diagnosis practices. The prevalence of asthma in Arab countries, including Qatar, Saudi Arabia, and the United Arab Emirates, exhibited notably higher rates ranging from 12.95–16.69%, compared to African countries such as Sudan and Morocco, where prevalence rates fell within the lower range of 7.76–8.07%. Some of this discrepancy may be attributed to underreporting and underdiagnosis of asthma in African countries, as indicated in previous studies, which is consistent with the weaker body of evidence identified in African countries revealed by the current meta-analysis (113, 114).

Urbanization is another factor that might cause a higher prevalence in Arab countries compared to African ones. In our study, we found a significantly higher prevalence of asthma in urban areas compared to rural ones, with rates of 11.27% and 8.29%, respectively. This difference can be attributed to several factors inherent to urban environments, including heightened levels of both indoor and outdoor air pollution, which introduce harmful substances like particulate matter, nitrogen dioxide (NO2), and ozone. Additionally, urban dwellings often face issues related to pest infestations and mold growth, particularly in substandard housing conditions, serving as potent triggers for asthma exacerbations. Moreover, the presence of endotoxins in urban environments, particularly in poorly maintained housing, further compounds the problem. Economic disparities and housing inadequacies prevalent in urban neighborhoods can exacerbate exposure to asthma triggers like pests, mold, and indoor pollutants. Furthermore, the prevalence of obesity and chronic stress, more common among urban children living in poverty, serves to worsen asthma outcomes, underscoring the multifaceted nature of the urban asthma burden (115–118).

The heterogeneity of asthma prevalence within populations, particularly in regions like the EMRO, may be influenced by a complex interplay of genetic and environmental factors. Genome-Wide Association Studies (GWAS) have unveiled a multitude of genes linked to asthma, shedding light on potential genetic predispositions. For instance, studies such as the GABRIEL study have pinpointed genes on various chromosomes, such as 2, 6, 9, 15, 17, and 22, associated with asthma development. Notably, the ORMDL3 gene on chromosome 17 has been implicated in childhood-onset asthma, while the HLA-DQ gene has been associated with later-onset asthma (119). These findings underscore the genetic component of asthma susceptibility. However, the manifestation of asthma is not solely dictated by genetic makeup; environmental influences also play a crucial role. Factors like air pollution and tobacco smoke exposure can exacerbate asthma symptoms, particularly in individuals with genetic susceptibilities (120). This interaction between genetic predispositions and environmental exposures adds complexity to the understanding of asthma heterogeneity, emphasizing the need for comprehensive approaches that consider both genetic and environmental factors in asthma research and healthcare interventions within the EMRO region and beyond.

It is essential to acknowledge the limitations of our study when interpreting the results. The included studies exhibited significant heterogeneity, which may affect the overall estimates. Additionally, relying on self-report questionnaires and clinical examinations to assess asthma prevalence may introduce measurement bias and misclassification, potentially affecting the accuracy of our estimates. There is also the possibility of publication bias, where studies with significant findings are more likely to be published, thus potentially skewing the overall prevalence estimates. Moreover, the EMRO region consists of countries with diverse socioeconomic, environmental, and healthcare contexts, which may influence prevalence estimates and limit the generalizability of our findings. Furthermore, data availability from some countries may be limited, impacting the representativeness of our analysis for certain regions. Our study was also restricted to publications in English and Persian languages, potentially excluding relevant studies published in other languages and introducing language bias. Finally, while we examined prevalence trends over different decades, we did not fully explore the potential impact of changes in diagnostic criteria, awareness, and reporting practices over time. Nevertheless, our systematic review and meta-analysis offer valuable insights into the prevalence of asthma among children and adolescents in the EMRO region. These findings contribute to the existing knowledge on this topic and highlight the necessity for further research to explore the complex factors that influence asthma prevalence in this specific area.

Efforts to reduce asthma prevalence in Arab countries and address underdiagnosis in African nations within the Eastern Mediterranean Regional Office (EMRO) are imperative. In Arab countries with higher asthma rates, interventions must target environmental triggers like air pollution and indoor allergens, alongside improving access to healthcare and raising awareness about asthma management. Concurrently, African countries require improved diagnostic capabilities and healthcare infrastructure to ensure accurate identification and treatment of asthma cases. This necessitates collaborative action among governments, healthcare providers, researchers, and community organizations. By implementing targeted measures, we can alleviate the burden of asthma, enhance respiratory health, and promote equitable access to asthma care across the EMRO region.

EMRO - Eastern Mediterranean Regional Office

ISAAC - International Study of Asthma and Allergies in Childhood

WHO - World Health Organization

GWAS - Genome-Wide Association Studies

NO2 - Nitrogen dioxide

JBI - Joanna Briggs Institute

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PROSPERO - International Prospective Register of Systematic Reviews

CI - Confidence Interval

Ethics approval and consent to participate:

Not applicable

Consent for publication:

Not applicable

Availability of Data and Materials:

Data will be made available on request.

Competing interests:

The authors declare that they have no competing interests.

Funding:

Not applicable

Authors' contributions:

MRT and AyH: conceptualization and investigation. AMJ and SSHN: supervision on data extraction, screening and quality assessment. MRT: formal analysis. SAA: project administration. FF, YS, PN and GJ: data extraction, screening and quality assessment. ArH, NA, SAA, and AR wrote the initial draft and all other authors edited the manuscript. All authors contributed to the article and approved the submitted version.

Acknowledgments:

This research was part of an internship program funded by the “Health Economics and Finance Research Group - University of Sharjah, Sharjah, United Arab Emirates” and implemented by the West Asian Organization for Cancer Prevention (APOCP's West Asia Chapter).

van den Wijngaart LS, Roukema J, Merkus PJ. The value of spirometry and exercise challenge test to diagnose and monitor children with asthma. Respirol Case Rep. 2015;3(1):25-8.
He Z, Feng J, Xia J, Wu Q, Yang H, Ma Q. Frequency of Signs and Symptoms in Persons With Asthma. Respir Care. 2020;65(2):252-64.
Inniss LJ. Independent prescribing for a child with a first diagnosis of asthma: a case study. Emerg Nurse. 2022.
Holmes J, O'Neill V, McGarvey LP, Heaney LG. Adverse perception of cough in patients with severe asthma: a discrete choice experiment. ERJ Open Res. 2023;9(1).
Rahimian N, Aghajanpour M, Jouybari L, Ataee P, Fathollahpour A, Lamuch-Deli N, et al. The Prevalence of Asthma among Iranian Children and Adolescent: A Systematic Review and Meta-Analysis. Oxid Med Cell Longev. 2021;2021:6671870.
Trivedi M, Denton E. Asthma in Children and Adults-What Are the Differences and What Can They Tell us About Asthma? Front Pediatr. 2019;7:256.
Shah R, Newcomb DC. Sex Bias in Asthma Prevalence and Pathogenesis. Front Immunol. 2018;9:2997.
Perez MF, Coutinho MT. An Overview of Health Disparities in Asthma. Yale J Biol Med. 2021;94(3):497-507.
Tiotiu AI, Novakova P, Nedeva D, Chong-Neto HJ, Novakova S, Steiropoulos P, et al. Impact of Air Pollution on Asthma Outcomes. Int J Environ Res Public Health. 2020;17(17).
Crowl AA, Visger CJ, Mansion G, Hand R, Wu HH, Kamari G, et al. Evolution and biogeography of the endemic Roucela complex (Campanulaceae: Campanula) in the Eastern Mediterranean. Ecol Evol. 2015;5(22):5329-43.
Beca-Carretero P, Teichberg M, Winters G, Procaccini G, Reuter H. Projected Rapid Habitat Expansion of Tropical Seagrass Species in the Mediterranean Sea as Climate Change Progresses. Front Plant Sci. 2020;11:555376.
Song P, Adeloye D, Salim H, Dos Santos JP, Campbell H, Sheikh A, et al. Global, regional, and national prevalence of asthma in 2019: a systematic analysis and modelling study. J Glob Health. 2022;12:04052.
Mallol J, Crane J, von Mutius E, Odhiambo J, Keil U, Stewart A, et al. The International Study of Asthma and Allergies in Childhood (ISAAC) phase three: a global synthesis. Allergologia et immunopathologia. 2013;41(2):73-85.
Abd Elmoneim A, Hassan I, Abd Elnaby A, Abou Elmagd A. Epidemiology and outcome of childhood asthma: a clinical study in an Egyptian university medical centre. East Mediterr Health J. 2013;19(6):520-6.
Al-Kubaisy W, Ali SH, Al-Thamiri D. Risk factors for asthma among primary school children in Baghdad, Iraq. Saudi medical journal. 2005;26(3):460-6.
Gohal G, Yassin A, Darraj H, Darraj A, Maghrabi R, Abutalib Y, et al. Prevalence and Risk Factors of Childhood Asthma in Jazan Region, Saudi Arabia. Journal of Asthma and Allergy. 2024;17:33 - 43.
Vlaski E, Lawson J. Urban–rural differences in asthma prevalence among young adolescents: The role of behavioural and environmental factors. Allergologia et Immunopathologia. 2015;43(2):131-41.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. International journal of surgery. 2021;88:105906.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-88.
El Ftouh M, Yassine N, Benkheder A, Bouacha H, Nafti S, Taright S, et al. Paediatric asthma in North Africa: the Asthma Insights and Reality in the Maghreb (AIRMAG) study. Respir Med. 2009;103 Suppl 2:S21-9.
Habibi-Khorasani SAR, Janghorbani M, Gozashti MH, Samareh fekri M. Prevalence of asthma in elementary school children in Kerman in 1999. Journal of Kerman University of Medical Sciences. 2002;9(4):184-93.
Bazazi H, Gharagozlou M, Kassai M, Zahmatkesh H, Parsikia A. The prevalence of asthma and allergic disorders among school children in Gorgan. 2007.
Rahimi Rad M, Hejazi M, Behrouzian R. Asthma and other allergic diseases in 13-14-year-old schoolchildren in Urmia: an ISAAC study. EMHJ-Eastern Mediterranean Health Journal, 13 (5), 1005-1016, 2007. 2007.
Najafizadeh K, FADAEIZADEH L, Salek S. Prevalence and severity of asthmatic symptoms in rasht students: A report from ISAAC study. 2008.
Shakurnia A, Assar S, Afra M, Latifi M. Prevalence of asthma among schoolchildren in Ahvaz, Islamic Republic of Iran. EMHJ-Eastern Mediterranean Health Journal, 16 (6), 651-656, 2010. 2010.
Zobeiri M. Prevalence, risk factors and severity of asthma symptoms in children of Kermanshah, IRAN: ISAAC phase I, II. 2011.
Ghaffari J, Mohammadzadeh I, Khalilian A, Rafatpanah H, Mohammadjafari H, Davoudi A. Prevalence of asthma, allergic rhinitis and eczema in elementary schools in Sari (Iran). Caspian journal of internal medicine. 2012;3(1):372.
Kiadeh SSNH, Fereidouni M, Khozeime AH. Asthma diagnosis and treatment–1025. Prevalence of childhood asthma in small city of Iran: an ISAAC study. World Allergy Organization Journal. 2013;6:P24-P.
Farrokhi S, Gheybi MK, Movahhed A, Dehdari R, Gooya M, Keshvari S, et al. Prevalence and risk factors of asthma and allergic diseases in primary schoolchildren living in Bushehr, Iran: phase I, III ISAAC protocol. Iranian Journal of Allergy, Asthma and Immunology. 2014:348-55?
Mortazavi Moghaddam G, Akbari H, Saadatjoo A. Asthma in Iranian schoolchildren: Comparison of ISAAC video and written questionnaires. Iranian Journal of Medical Sciences. 2015;30(3):110-4.
Kalmarzi RN, Shekari AH, Tajik M, Ataee P, Homagostar G, Roshani D, et al. The Prevalence of Asthma Symptoms in Elementary and Middle School Students in Kurdistan Province, the West of Iran. International Journal of Pediatrics. 2016;4:1323-30.
Mehravar F, Rafiee S, Bazrafshan B, Khodadost M. Prevalence of asthma symptoms in Golestan schoolchildren aged 6–7 and 13–14 years in Northeast Iran. Frontiers of Medicine. 2016;10:345-50.
Ghozikali MG, Ansarin K, Naddafi K, Nodehi RN, Yaghmaeian K, Hassanvand MS, et al. Prevalence of asthma and associated factors among male late adolescents in Tabriz, Iran. Environmental Science and Pollution Research. 2017;25:2184-93.
Fazlollahi MR, Najmi M, Fallahnezhad M, Sabetkish N, Kazemnejad A, Bidad K, et al. Paediatric asthma prevalence: The first national population‐based survey in Iran. The clinical respiratory journal. 2019;13(1):14-22.
Ahmadiafshar A, Nourollahi S, Arminpour A, Faghihzadeh S. The Prevalence and Risk Factors of Asthma, Allergic Rhinitis, and Eczema in Primary School Children, Zanjan, Iran. Journal of Advances in Medical and Biomedical Research. 2020;28(130):230-6.
Tavakol M, Abhari SMF, Moosaie F, Rasmi M, Bakhtiyari M, Keikavoosi-Arani L, et al. Prevalence of Asthma Symptoms in 13-14-year-old Adolescents in Karaj. Iranian Journal of Allergy, Asthma and Immunology. 2020.
Behniafard N, Nafei Z, Mirzaei M, Karimi M, Vakili M. Prevalence and Severity of Adolescent Asthma in Yazd, Iran: Based on the 2020 Global Asthma Network (GAN) Survey Adolescents Asthma Prevalence in Central Iran. Iranian Journal of Allergy, Asthma and Immunology. 2021;20(1):24.
Sabeti Z, Ansarin K, Seyedrezazadeh E, Asghari Jafarabadi M, Zafari V, Dastgiri S, et al. A comparison of asthma prevalence in adolescents living in urban and semi-urban areas in northwestern Iran. Human and Ecological Risk Assessment: An International Journal. 2021;27(8):2051-68.
Dastoorpoor M, Khodadadi N, Madadizadeh F, Raji H, Shahidizadeh E, Idani E, et al. Assessing the prevalence and severity of asthma, rhinitis, and eczema among schoolchildren (6–7 and 13–14 years old) in Khuzestan, Iran: a cross-sectional survey. BMC pediatrics. 2022;22(1):1-10.
Bener A, Abdulrazzaq Y, Debuse P, Al-Mutawwa J. Prevalence of asthma among Emirates school children. European journal of epidemiology. 1994;10:271-8.
Al-Maskari F, Bener A, Al-Kaabi A, Al-Suwaidi NA, Norman N, Brebner J. Asthma and respiratory symptoms among school children in United Arab Emirates. Allergie et immunologie. 2000;32 4:159-63.
Alsowaidi S, Abdulle A, Bernsen R. Prevalence and risk factors of asthma among adolescents and their parents in Al-Ain (United Arab Emirates). Respiration. 2009;79(2):105-11.
AlBehandy N, Hussein H, Al Faisal W, El Sawaf E, Wasfy A, Alshareef N, et al. Prevalence of Bronchial Asthma and Its Association with Obesity and Overweight Among Adolescents in Dubai, UAE. 2015.
Ibrahim NM, Almarzouqi FI, Al Melaih FA, Farouk H, Alsayed M, AlJassim FM. Prevalence of asthma and allergies among children in the United Arab Emirates: A cross-sectional study. World Allergy Organization Journal. 2021;14(10):100588.
Jamil M, Al Janabi MSY, Francis N, Ali S, Alfalahi A, Ibrahim M. Prevalence of Asthma among High School Students in Ajman, Uae: A Cross-Sectional Study. Annals of the Romanian Society for Cell Biology. 2021;25(6):10843-9.
Hasan MM, Gofin R, Bar-Yishay E. Urbanization and the risk of asthma among schoolchildren in the Palestinian Authority. Journal of Asthma. 2000;37(4):353-60.
El-Sharif N, Abdeen Z, Qasrawi R, Moens G, Nemery B. Asthma prevalence in children living in villages, cities and refugee camps in Palestine. European respiratory journal. 2002;19(6):1026-34.
El-Sharif NA, Nemery B, Barghuthy F, Mortaja S, Qasrawi R, Abdeen Z. Geographical variations of asthma and asthma symptoms among schoolchildren aged 5 to 8 years and 12 to 15 years in Palestine: the International Study of Asthma and Allergies in Childhood (ISAAC). Annals of allergy, asthma & immunology. 2003;90(1):63-71.
Janahi IA, Bener A, Bush A. Prevalence of asthma among Qatari schoolchildren: international study of asthma and allergies in childhood, Qatar. Pediatric pulmonology. 2006;41(1):80-6.
Veettil ST, Alnuaimi ASA. Epidemiology and utilization of primary health care services in Qatar by asthmatic children 5–12 years old: secondary data analysis 2016–2017. Asthma research and practice. 2019;5:1-8.
Hammoudeh S, Hani Y, Alfaki M, Omar N, El Dimassi D, Nowir K, et al. The prevalence of asthma, allergic rhinitis, and eczema among school‐aged children in Qatar: A Global Asthma Network Study. Pediatric pulmonology. 2022;57(6):1440-6.
Bouayad Z, Aichane A, Afif A, Benouhoud N, Trombati N, Chan-Yeung M, et al. Prevalence and trend of self-reported asthma and other allergic disease symptoms in Morocco: ISAAC phase I and III. The International Journal of Tuberculosis and Lung Disease. 2006;10(4):371-7.
Al Thamiri D, Al Kubaisy W, Ali S. Asthma prevalence and severity among primary-school children in Baghdad. EMHJ-Eastern Mediterranean Health Journal, 11 (1-2), 79-86, 2005. 2005.
Alsamarai AM, Salih MA, Alobaidy AH, Alwan AM, Abdulaziz ZH. Risk factors for asthma in Iraqi children. J Rural Trop Public Health. 2009;8:45-52.
Al-Kubaisy W, Al–Thamiri D. Pediatric asthma and its relation to socio-demographic factors in Baghdad. Asian Journal of Environment-Behaviour Studies. 2017;2(4):1-10.
Alsaadi IM, Al-Tawil NG. PREVALENCE OF, AND FACTORS ASSOCIATED WITH ASTHMA AMONG TEENAGER STUDENTS IN ERBIL CITY. Journal of Pharmaceutical Negative Results. 2022:2577-86.
Mustafa G, Khan PA, Iqbal I. Nocturnal asthma in school children of south Punjab Pakistan. J Ayub Med Coll Abbottabad. 2008;20(3):36-9.
Hasnain SM, Khan M, Saleem A, Waqar MA. Prevalence of asthma and allergic rhinitis among school children of Karachi, Pakistan, 2007. Journal of Asthma. 2009;46(1):86-90.
Khan AA, Tanzil S, Jamali T, Shahid A, Naeem S, Sahito A, et al. Burden of asthma among children in a developing megacity: childhood asthma study, Pakistan. Journal of Asthma. 2014;51(9):891-9.
Zahid W, Rozi S, Khan FR, Zahid N, Kadir M. Association between Asthma and Dental Caries amongst 12 - 15 Years Old Children: A School-Based Cross-Sectional Study in Karachi, Pakistan. Open Journal of Epidemiology. 2019.
Samoo UG, Ehsan S. Prevalence of asthma and allergic disorders in school children of Karachi. International Journal of Contemporary Pediatrics. 2021.
Abuekteish F, Alwash R, Hassan M, Daoud A. Prevalence of asthma and wheeze in primary school children in northern Jordan. Annals of tropical paediatrics. 1996;16(3):227-31.
Abu-Ekteish F, Otoom S, Shehabi I, editors. Prevalence of asthma in Jordan: comparison between Bedouins and urban schoolchildren using the International Study of Asthma and Allergies in Childhood phase III protocol. Allergy & Asthma Proceedings; 2009.
Al-Sheyab N, Alomari MA, Shah S, Gallagher P, Gallagher R. Prevalence, patterns and correlates of cigarette smoking in male adolescents in northern Jordan, and the influence of waterpipe use and asthma diagnosis: a descriptive cross-sectional study. International journal of environmental research and public health. 2014;11(9):9008-23.
Al-Motlaq MA, Al-Sheyab NA. Childhood asthma prevalence and severity in Zarqa city, Jordan. Jordan Medical Journal. 2019;53(3):139-46.
Al-Sheyab NA, Alomari MA. Prevalence, associated factors, and control level of asthma symptoms among adolescents in Northern Jordan. International Journal of Adolescent Medicine and Health. 2020;32(3).
Nour A, Alsayed AR, Basheti I, editors. Prevalence of asthma amongst schoolchildren in Jordan and staff readiness to help. Healthcare; 2023: MDPI.
Al-Sindi H, Al-Mulla M, Bu-Saibaa A, Al-Sharaf B, Jawad JS, Karim OA. Prevalence of asthma and allergic diseases in children aged 6-7 in the Kingdom of Bahrain. J Bahrain Med Soc. 2014;25(2):71.
Hijazi N, Abalkhail B, Seaton A. Asthma and respiratory symptoms in urban and rural Saudi Arabia. Eur Respir J. 1998;12(1):41-4.
Al-Dawood KM. Epidemiology of bronchial asthma among school boys in Al-Khobar city, Saudi Arabia. Saudi medical journal. 2000;22(1):61-6.
Alshehri MA, Abolfotouh MA, Sadeg A, Najjar Y, Asindi AA, Harthi A, et al. Screening for asthma and associated risk factors among urban school boys in Abha city. Saudi medical journal. 2000;21(11):1048-53.
Al Frayh A, Shakoor Z, ElRab MG, Hasnain S. Increased prevalence of asthma in Saudi Arabia. Annals of Allergy, Asthma & Immunology. 2001;86(3):292-6.
Al Frayh A. A 17 year trend for the prevalence of asthma and allergic diseases among children in Saudi Arabia. Journal of Allergy and Clinical Immunology. 2005;115(2):S232.
Al Ghobain MO, Al-Hajjaj MS, Al Moamary MS. Asthma prevalence among 16-to 18-year-old adolescents in Saudi Arabia using the ISAAC questionnaire. BMC public health. 2012;12(1):1-5.
Nahhas MA, Bhopal R, Anandan C, Elton R, Sheikh A. Prevalence of Allergic Disorders among Primary School-Aged Children in Madinah, Saudi Arabia: Two-Stage Cross-Sectional Survey. PLoS ONE. 2012;7.
Alqahtani JM. Asthma and other allergic diseases among Saudi schoolchildren in Najran: the need for a comprehensive intervention program. Annals of Saudi Medicine. 2016;36(6):379-85.
Khawaji AF, Basudan A, Moafa A, Faqihi M, Alhazmi M, Mahnashi TA, et al. Epidemiology of bronchial asthma among children in Jazan Region, Saudi Arabia. Indian Journal of Allergy, Asthma and Immunology. 2017;31(2):69.
al-Mutairi AM, Qassim, Almutairi SM, editors. EPIDEMIOLOGY OF BRONCHIAL ASTHMA AMONG PRIMARY SCHOOL CHILDREN IN BURAYDAH2018.
Alruwaili MF, Elwan A. Prevalence of asthma among male 16 to 18-year-old adolescents in the Northern Borders Region of Saudi Arabia. Electronic Physician. 2018;10:6920 - 6.
Fareed M, Meshal MMA, Balood MSA, Halim K. Prevalence of Asthma and Allergic Symptoms among General Population in Riyadh Region of Saudi Arabia. International Journal of Medical Research and Health Sciences. 2018;7:121-6.
Alomary SA, Althagafi WA, Al Madani AJ, Adam IF, Elsherif OE, Al-Abdullaah AA, et al. The burden of asthma among children and adolescents in Saudi Arabia: A national cross-sectional survey. Journal of Allergy and Clinical Immunology: Global. 2022;1(4):241-7.
Alshammrie FF, Albarrak SKA, Alhuthaili AA, Alakash SA, Al Mansour MH, Gammash MR. Prevalence and Influencing Risk Factors of Eczema Among Preschool Children in Hail City. Cureus. 2022;14.
Alatawi AM, Alanazi A, Almutairi ABS, Albalawi R, Alhakami AAM, Alnuaman AAS, et al. Prevalence and Risk Factors of Allergic Diseases Among School Students in Tabuk: A Cross-Sectional Study. Cureus. 2023;15.
Zedan M, Settin A, Farag M, Ezz-Elregal M, Osman E, Fouda A. Prevalence of bronchial asthma among Egyptian school children. Egypt J Bronchol. 2009;3(2):124-30.
Abdallah AM, Sanusy KA, Said WS, Mahran DG, Mohamed-Hussein AA. Epidemiology of bronchial asthma among preparatory school children in Assiut district. Egyptian Journal of Pediatric Allergy and Immunology (The). 2012;10(2).
Mansour AE, Yasein YA, Ghandour AA, Zaidan O, El-Abaas MMA, editors. Prevalence of bronchial asthma and its impact on the cognitive functions and academic achievement among preparatory school children in Damietta Governorate, Egypt2014.
Abdel Hafez A, El-Mashad G, Mahmoud A. The prevalence of bronchial asthma among primary school children in Menoufiya Governorate (El-Bagour Center). Menoufia Medical Journal. 2016;29(1).
El Sherbini M, Ata AB, El- Sayed S. Prevalence of asthma and other atopies among school children in Qalyubia Governorate, Egypt. Medical Research Journal. 2016;15:27–33.
Eldin E, El G, Ahmed R, Kamel AS, Amin SA, Hashem AE, editors. Epidemiology of Childhood Asthma in Fayoum City (District) Egypt2016.
Meatty EM, El-Desoky T, El-Domyaty H, El-Gilany A, Nasef N. Prevalence of childhood bronchial asthma and its associated factors: a community based study in Egypt. Progress Med Sci. 2018;2(2):14-20.
Boshra M, Ahmed MM, Raafat D. Prevalence of bronchial asthma in primary school students in Assiut. Journal of Current Medical Research and Practice. 2019;4:77 - 82.
Abdelmotaleb GS, Aldosoky RS, Abdelaaty RI, Abd AL-Hakam HA. Prevalence of childhood bronchial asthma and its risk factors in Kom Hamada district, Beheira Governorate, Egypt. International Journal of Psychosocial Rehabilitation. 2020;24(10).
Mohammed M, ABDELAKHER AR, SHOKRY DM, SAFAA AE. Prevalence of bronchial asthma among school aged children in Elmaraghah Center in Sohag Governorate. The Medical Journal of Cairo University. 2020;88(June):1097-101.
Sobieh A, Shahin A, Ali M. Prevalence of Childhood Asthma in Preschool Children in Qalyubiya Governorate. Benha Journal of Applied Sciences. 2020;5(5 part (1)):159-64.
Strannegard IL, Strannegård Ö. Childhood bronchial asthma in a desert country. Allergy. 1990;45(5):327-33.
Behbehani NA, Abal A, Syabbalo N, Abd Azeem A, Shareef E, Al-Momen J. Prevalence of asthma, allergic rhinitis, and eczema in 13-to 14-year-old children in Kuwait: an ISAAC study. Annals of Allergy, Asthma & Immunology. 2000;85(1):58-63.
Owayed A, Behbehani N, Al-Momen J. Changing prevalence of asthma and allergic diseases among Kuwaiti children: an ISAAC study (phase III). Medical Principles and Practice. 2008;17(4):284-9.
AL‐RIYAMI BM, AL‐RAWAS OA, AL‐RIYAMI AA, Jasim LG, Mohammed AJ. A relatively high prevalence and severity of asthma, allergic rhinitis and atopic eczema in schoolchildren in the Sultanate of Oman. Respirology. 2003;8(1):69-76.
Al-Rawas OA, Al-Riyami BM, Al-Kindy H, Al-Maniri AA, Al-Riyami AA. Regional variation in the prevalence of asthma symptoms among Omani school children: Comparisons from two nationwide cross-sectional surveys six years apart. Sultan Qaboos University medical journal. 2008;8(2):157.
Waked M, Salameh P. Asthma, allergic rhinitis and eczema in 13-14-year-old schoolchildren across Lebanon. J Med Liban. 2006;54(4):181-90.
Waked M, Salameh P. Asthma, allergic rhinitis and eczema in 5–12-year-old school children across Lebanon. Public health. 2008;122(9):965-73.
Musharrafieh U, Al-Sahab B, Zaitoun F, El-Hajj MA, Ramadan F, Tamim H. Prevalence of asthma, allergic rhinitis and eczema among Lebanese adolescents. J Asthma. 2009;46(4):382-7.
Hallit S, Sacre H, Kheir N, Hallit R, Waked M, Salameh P. Prevalence of asthma, its correlates, and validation of the Pre-School Asthma Risk Factors Scale (PS-ARFS) among preschool children in Lebanon. Allergologia et Immunopathologia. 2021;49(1):40-9.
Bahaj S, Moharem A, Kaid A. Prevalence of asthma and allergic diseases among high school students in urban and rural communities, Yemen. The Egyptian Journal of Medical Microbiology. 2012;38:1-5.
Hussein SE, Ahmed MA. Prevalence and risk factors of Asthma among Wad Medani basic school children, Gezira State, Sudan. Journal of family & community medicine. 2005;12(3):145.
Halay S, Balla SA, Elsheikh TAE, Awadalla H, Burbr AA, Hamid EK, et al. Prevalence of Wheezes and Asthma among Preschool Children (1-6 Years) in Rural Sudan 2016. International Journal of TROPICAL DISEASE & Health. 2018;32(1):1-8.
Sonia T, Meriem M, Yacine O, Nozha BS, Nadia M, Bechir L, et al. Prevalence of asthma and rhinitis in a Tunisian population. Clin Respir J. 2018;12(2):608-15.
Bemanin M, Fallahpour M, Arshi S, Nabavi M, Yousofi T, Shariatifar A. First report of asthma prevalence in Afghanistan using international standardized methods. EMHJ-Eastern Mediterranean Health Journal. 2015;21(3):194-8.
Ali M, Abduljawad N, Saad Abdalla Al-Zawi A. THE PREVALENCE OF ASTHMA AND ALLERGIC DISEASES IN SCHOOL AGE CHILDREN IN ALBAYDA-LIBYA. EUROPEAN JOURNAL OF PHARMACEUTICAL AND MEDICAL RESEARCH. 2021;8:194-6.
Mohammad Y, Tabbah K, Mohammad S, Yassine F, Clayton T, Hassan M. International study of asthma and allergies in childhood: phase 3 in the Syrian Arab Republic. EMHJ-Eastern Mediterranean Health Journal, 16 (7), 710-716, 2010. 2010.
Mohammad Y, Rafea S, Latifeh Y, Haydar T, Jamal H, Alkhayer G, et al. Global Asthma Network Phase I Syria asthma surveillance and the impact of the war. J Thorac Dis. 2023;15(5):2873-81.
Organization WH. Asthma [Available from: https://www.emro.who.int/health-topics/asthma/index.html.
Adeloye D, Chan KY, Rudan I, Campbell H. An estimate of asthma prevalence in Africa: a systematic analysis. Croat Med J. 2013;54(6):519-31.
Ehrlich R, Jordaan E, Du Toit D, Volmink J, Weinberg E, Zwarenstein M. Underrecognition and undertreatment of asthma in Cape Town primary school children. South African Medical Journal. 1998;88(8):986-94.
Anenberg SC, Mohegh A, Goldberg DL, Kerr GH, Brauer M, Burkart K, et al. Long-term trends in urban NO2 concentrations and associated paediatric asthma incidence: estimates from global datasets. The Lancet Planetary Health. 2022;6(1):e49-e58.
Balmes JR. The role of ozone exposure in the epidemiology of asthma. Environ Health Perspect. 1993;101 Suppl 4(Suppl 4):219-24.
Gern JE. The Urban Environment and Childhood Asthma study. J Allergy Clin Immunol. 2010;125(3):545-9.
Grant TL, Wood RA. The influence of urban exposures and residence on childhood asthma. Pediatr Allergy Immunol. 2022;33(5):e13784.
Moffatt MF, Gut IG, Demenais F, Strachan DP, Bouzigon E, Heath S, et al. A large-scale, consortium-based genomewide association study of asthma. New England Journal of Medicine. 2010;363(13):1211-21.
Ranjbar M, Whetstone CE, Omer H, Power L, Cusack RP, Gauvreau GM. The Genetic Factors of the Airway Epithelium Associated with the Pathology of Asthma. Genes (Basel). 2022;13(10).

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Prevalence of Asthma among Children and Adolescents in WHO's Eastern Mediterranean Region: A Meta-Analysis of Over 0.5 Million Participants

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Abstract

Figures

1. Introduction

2. Methods and materials

2.1. Search Strategy

2.2. Inclusion Criteria

2.3. Exclusion Criteria

2.4. Quality Assessment

2.5. Data Extraction

2.6. Statistical Analysis

3. Results

3.1. Search Results

3.2. Characteristics of Included Studies

3.3. Risk of Bias Assessment

3.4. The Overall Prevalence of Asthma In EMRO Countries

3.5. Overall Prevalence of Asthma According to Gender, Age and Place of Residence

3.6. Subgroup analysis based on ssessment method, risk of bias, publication year, and sample size

3.7. Meta-regression Results

3.8. Publication Bias

4. Discussion

5. Conclusion

Abbreviations

Declarations

References

Appendix

Additional Declarations

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