Table of Contents  

Mahboub, Shiraz, Hassan, Mohammad, Iqbal, Vats, Razak, Safareni, al Zaabi, and Al Sairi: Respiratory diseases burden in the United Arab Emirates

Introduction

Respiratory diseases affect millions of individuals worldwide and the United Arab Emirates (UAE) is no exception to this global phenomenon. The spectrum and the burden of respiratory diseases vary throughout the UAE. Asthma, respiratory infections, sleep disorders and chronic obstructive pulmonary disease (COPD), in decreasing order of prevalence, are all underdiagnosed but remain the most important respiratory problems.

In a recent study1 that investigated the prevalence of asthma and its determinants in the UAE [based on the European Community Respiratory Health Survey1 (ECRHS)], it was found that 15.4% of participants [95% confidence interval (CI) 13.5–17.5%] fulfilled the UAE screening criteria for asthma, while 12.1% of participants (95% CI 10.4–14.1%) fulfilled the ECRHS asthma definition criteria. Of these patients, 9.8% (95% CI 7.8–12.2%) overall (8.6% of male and 11.8% of female patients) were aged 20–44 years. Certain specific persistent environmental factors, along with non-adherence to the controller medicines, lead to uncontrolled asthma with consequential exacerbations, morbidity and increased healthcare costs in the UAE.2

In a large, randomized, age-stratified cohort study of adolescent school children and their caretakers, allergic rhinitis and asthma comorbidity was monitored and multinomial regression was used to determine independent risk factors.3 A total of 6543 subjects were included in the study [median age 30 years (range 8–93 years) 52% males]. The standardized prevalence of concomitant asthma and allergic rhinitis was 7.3%. Subjects with allergic rhinitis had a 3-fold increased risk of also suffering from asthma compared with subjects without allergic rhinitis (23.8% and 7.5%, respectively). Subjects who had immigrated to the UAE had a significantly lower prevalence of asthma and allergic rhinitis comorbidity [adjusted odds ratio (OR) 0.53; 95% CI 0.33–0.85] than UAE nationals whereas higher age was associated with a lower risk (adjusted OR 0.58; 95% CI 0.44–0.78).

A family history of both allergic rhinitis (adjusted OR 3.03; 95% CI 2.31–3.98) and asthma (adjusted OR 4.65; 95% CI 3.53–6.12) was strongly associated with the co-occurrence of these two conditions, whereas gender and education were not. Patients with both asthma and allergic rhinitis displayed more severe symptoms than patients with asthma alone: 65% of patients with both conditions complained of a dry cough at night as opposed to only 36% with asthma alone; beta-mimetics were used by 42% of patients with both conditions compared with 30% of asthma suffers; and steroids were used by 25% of patients with both conditions compared with 13% of patients with asthma only.

In another community-based face-to-face survey4 of asthma control carried out in 2009, 64% of 200 asthmatic subjects experienced sudden and severe asthma attacks in the course of a year. Day-time symptoms and night-time symptoms were reported by 57.5% and 35.5%, respectively, over a 1-week period. Overall, 52.8% of children missed school and 17.1% of adults missed work during 2009, 27.5% had visited the emergency room and 4% were hospitalized. Only 5.5% used inhaled corticosteroids during the year, and 47.5% had been prescribed short-acting β2-agonists. Only 17.8% had ever owned a peak flowmeter and only 30% had ever undergone a lung function test. Only 17% were given scheduled follow-up sessions and 66% of these patients were followed up by general practitioners.4 This survey shows that the level of asthma control in the UAE is far from optimal and it is therefore necessary to increase the awareness among patients and update doctors about asthma control guidelines, thus reducing the burden of the disease.

To estimate the prevalence of allergic rhinitis in Al-Ain city, a validated and self-administered questionnaire, modified from the International Study of Asthma and Allergies in Childhood study, was used to collect data from a two-stage randomly selected sample of 10 000 school children.5 Overall, 7550 subjects (all aged 13 years and above and the participants included siblings and parents) responded. The crude and standardized prevalence of allergic rhinitis over the previous 12 months was assessed, as was the independent relationship of allergic rhinitis with age, gender, education, nationality and family history, by means of logistic regression. The response rate was 76% and a total of 6543 subjects (with a median age of 30 years) were included in the final analysis. Allergic rhinitis (defined as having suffered symptoms in the past 12 months) was self-reported by 36% of subjects, while adjustments for gender and age yielded a prevalence of 32%. Regression analysis revealed that allergic rhinitis was independently associated with family history, Arab origin, younger age, being female and higher education. The relatively high prevalence of allergic rhinitis found in this study was attributed to modernization (e.g. adoption of a sterile, urban lifestyle and less exposure to infectious agents) and genetic factors.

The Asthma Insights and Reality in the Gulf and Near-East survey was carried out in five countries – Jordan, Kuwait, Lebanon, Oman and the UAE – involving a total of 1000 patients with asthma.6 The authors reported several striking findings; for example, 68% of respondents had experienced daytime asthma symptoms and 51% had been woken by asthma in the preceding 4 weeks. Use of health services in the previous 12 months was high, with 52% having attended the emergency department and 23% having been hospitalized. Overall, 52% of children and 30% of adults missed school or work because of asthma; the highest rate of school absence was observed in Jordan and Lebanon (both 69%), and the highest rate of absence from work among adults was also in Jordan (46%). The use of peak flowmeters was very low, with only 17% of participants owning a device. Overall, 66% of participants had never undergone a lung function test.

Another study determined a prevalence of self-reported asthma of 13% in the UAE.7 Direct standardization of this result with the UAE population as a reference yielded an asthma prevalence of 12% in the UAE. Logistic regression revealed the main risk factors for asthma to be a family history of the condition and UAE nationality (about 50% of UAE nationals were of Bedouin origin). In addition, a significant (P = 0.001) interaction was observed between gender and age: in the group aged 13–19 years, asthma prevalence was significantly higher in males than in females (17% and 14%, respectively; adjusted OR 1.45; 95% CI 1.10–1.90) whereas, among those > 19 years, prevalence was significantly lower in males than in females (11% and 13%, respectively; adjusted OR 0.77; 95% CI 0.60–0.95).

A recent study8 revealed COPD prevalence to be approximately 3.7% among 40- to 80-year-old Emirati nationals, which makes the UAE as a low-prevalence country for COPD; however, one of the limitations of the study was that it was carried out in an Emirati population only, who make up just 20% of the total UAE population of 6 million people. The prevalence of smoking in the UAE is approximately 24%,9 which will increase the prevalence of COPD in the future. If patients of all nationalities were to be included in the evaluation of COPD prevalence, then the values for smoking and COPD prevalence would be relatively high.

Smoking

A 2009 federal law on tobacco control in the UAE forbids smoking (including using a Midwakh and shisha) in public places; however, despite this, smoking continues to represent a significant health hazard to the UAE society in general, as there are a large number of active or passive smokers, which reflects the failure to properly implement the law. It is important to note that prevalence of tobacco smoking in the UAE is lower than in many other countries in the Middle East;10 however, it is common among young Emiratis, which will inevitably lead to an increase in smoking-related comorbidities in the decades to come. Smoking is still uncommon among Arab women,11 with only 1.72% of adult females smoking, compared with 18.7% of adult males in 2009 (according to the World Bank report published in 2010).12 According to the Dubai Household Health Survey (DHHS),13 which reported on a sample size of 5000 households, making this the largest and most comprehensive survey ever carried out on health and healthcare issues in the Emirate of Dubai, the prevalence of smoking among Dubai residents is 17.2%, and men are five times more likely to smoke than women. The survey also showed that one-third of the Dubai population is exposed to the risk of smoking, either directly or as passive smokers. The DHHS showed that people in the lowest income quintile and the lowest educational level are approximately twice as likely to smoke as people in the highest income quintile and the highest educational level.

Some men start to smoke as young as 10 years and women at the age of 13, with 13% of smokers in Dubai having started before they complete secondary school. Amongst Emirati men in Dubai who smoke, one in every five had started smoking by the time they completed secondary school. The prevalence of smoking in the 18–24 years age group is 16.2% although overall smoking prevalence among UAE nationals is only 8.6%, which is significantly lower than any other nationality.13

Most male smokers in Dubai smoke on a daily basis (18.1%), and only 3% smoke occasionally. Only 3% of female smokers in Dubai smoke on a daily basis and 1% smoke occasionally. Approximately 17% of non-smoking Dubai residents are exposed to passive smoking in their own homes and men are as twice as likely to be exposed (19.8%) as women (9.1%). Approximately 62% of non-smoking Dubai residents are exposed to passive smoking at work and men are reported to be three times more likely to be exposed to passive smoking than women.13

The Weqaya population-based screening programme in Abu Dhabi9 screened 170 430 UAE nationals between 2008 and 2010 and found that the prevalence of smoking was over 24% among males and only 1% among females. The prevalence varied considerably by age and was highest in males aged 20–29 years (27.4%) and 30–39 years (28.2%). This screening programme showed that cigarettes remain the preferred method of smoking: 78% of smokers use cigarettes while 15% use a Midwakh and 6.8% prefer to use a shisha, although shisha smoking has increased over the past 30 years.14 Furthermore, smoking a Midwakh is cheaper than cigarettes as a week's supply of Dokha for an average smoker costs US$3 compared with US$21 for the average cigarette tobacco. Although shops are required to check the buyer's age before selling cigarettes, this is not always practised for the sale of Dokha.15 Despite this, the prevalence of smoking in the UAE is still lower than in many other countries.10

A study conducted by the Health Authority Abu Dhabi (HAAD) in government and private schools suggested that 25% of students had tried smoking before the age of 10 years.16 The study concluded that the home environment, i.e. exposure to smoke and the smoking habits of their parental role models, contributes to youngsters taking up smoking early in life.16

Another study carried out by HAAD in 194 schools in 2005 and in 52 schools in 2010 revealed that 48.3% of smoking students were Emiratis and 51.7% were expatriates; 15.7% of the students started smoking before the age of 12 years and 67% between 13 and 15 years of age. Approximately 21% of the students had parents who smoked at home.16

Tuberculosis

Tuberculosis (TB) is another challenging public health concern and is the most prevalent infectious disease, with over one-third of the world's population infected with latent TB. According to WHO, the incidence of TB in the UAE was 3.1% per 100 000 people in 2010.17,18

Fortunately, the rates of TB in the UAE are low compared with other countries; however, the main challenge is to monitor the majority of workers coming from countries with a high prevalence of TB, such as in Asia and Africa. Health Authority Abu Dhabi statistics show that newcomers to the country have a 20-fold higher TB rate than UAE nationals, which is a huge risk to the resident and national population.

There has been a sharp increase in the number of would-be migrants who are suffering from TB. Studies conducted by HAAD16 suggested the increase was consistent with findings from WHO in which an increase in the number of drug-resistant TB cases in Asia was reported.

According to the Dubai Health Authority, and supported by findings form HAAD, a sharp increase in the prevalence of TB has been reported over the past 4 years among those applying for work and residency visas within the UAE. There were 122 cases of TB detected in 2008, which increased during 2009 and increased further during 2010 to 722 cases. During the initial 3 months of 2011, there were 606 reported TB cases.19

According to HAAD statistics,16,20 there were 450 cases of pulmonary TB and 175 cases of extrapulmonary TB registered in the Emirate of Abu Dhabi during 2010.

A study carried out in Al-Qasimi Hospital between 2004 and 2008 found a high level of resistance to anti-TB drugs, with 21% of patients being resistant to isoniazid and 14% to streptomycin.21 Another study on all pulmonary and extrapulmonary TB patients with positive culture results was conducted between January 2001 and December 2008 in Abu Dhabi and reported that resistance to anti-TB drugs, such as isoniazid and pyrazinamide, was as high as 27.7%.22

A 2010 study conducted by HAAD23 summarized the risk of TB among 948 504 Abu Dhabi residents: 14% of the 1558 people who had TB were found to have a positive interferon-gamma release assay result, indicating that they carry a latent form of TB that may reactivate at any time. In addition, 9% had a positive response to the tuberculin skin test. These results showed that there is a potential risk of activation of TB in some individuals, with consequent spread of TB to the community.

Pneumonia

Pneumonia is a health problem that mainly affects children under the age of 5 years and adults over 65 years. Figures from WHO show that 5% of deaths among children under the age of 5 years in the UAE are caused by pneumonia.

A study carried out at Sheikh Khalifa Medical City found that the prevalence of pneumococcal disease among children was far higher in the UAE than in the West before the introduction of a vaccine against seven strains of the pneumococcal bacteria in the UAE that can lead to pneumonia.24

The incidence of invasive pneumococcal disease and non-invasive pneumococcal disease is 13.6/100 000 per year (95% CI 6.5–24.9) and 172.5/100 000 per year (95% CI 143.8–205.2), respectively. The total incidence of pneumonia in the UAE is 186.0/100 000 per year (95% CI 156.2–219.9). For comparison, in North America, the reported annual incidence of pneumonia is 72 per 100 000 in southern California and 11.8–16.1 in Canada.25,26 In Europe, the annual incidence per 100 000 is 42.1 in Great Britain, 24.2 in Finland and 10.1 in Germany,2729 while the incidence in Australia is 12.7/100 000.30 In Saudi Arabia, the reported incidence of pneumonia is 3.4–53.5 per 100 000 per year.31

Obesity

Obesity is becoming a major medical concern in several parts of the world, with huge economic impacts on healthcare system, mainly as a result of the associate in increased cardiovascular risks. In addition, obesity leads to a number of sleep disorders and interrupted breathing patterns such as obstructive sleep apnoea and obesity hypoventilation syndrome, which leads to increased morbidity and, as a result, reduced quality of life.

A study carried out at Rashid Hospital, UAE, using the Berlin Questionnaire, found that 15% of the residents in Dubai experience sleep disorders, which is lower than the average number of residents in the USA and the UK where a quarter of the population typically experience such problems.32 In a country such as the UAE, where nearly two in five women, and more than a quarter of men, are obese, this is a major problem.

Conclusion

Respiratory diseases are a major health concern in the UAE. Demographic data suggest that social and cultural norms will play an important role in formulating strategies for patient education, creating appropriate country-wide health facilities and gaining governmental support in order to improve the health of UAE residents and decrease the future financial burden on healthcare organizations.

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