Ka imi, Hanie e al.
A icle — Published Ve sion
Un eiling he lead exposu e a ibu ed bu den in I an
om 1990 o 2019 h ough he lens o he Global Bu den
o Disease s udy 2019
Scien i ic Repo s
P o ided in Coope a ion wi h:
Kiel Ins i u e o he Wo ld Economy – Leibniz Cen e o Resea ch on Global Economic Challenges
Sugges ed Ci a ion: Ka imi, Hanie e al. (2024) : Un eiling he lead exposu e a ibu ed bu den in I an
om 1990 o 2019 h ough he lens o he Global Bu den o Disease s udy 2019, Scien i ic Repo s,
ISSN 2045-2322, Sp inge Science and Business Media LLC, Be lin, Vol. 14, Iss. 1, pp. 1-12,
h ps://doi.o g/10.1038/s41598-024-58823-z
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Un eiling he lead exposu e
a ibu ed bu den in I an
om 1990 o 2019 h ough he lens
o he Global Bu den o Disease
s udy 2019
Hanie Ka imi
1,2, Sa a Mahda i
1,3, Saha Saeedi Moghaddam
1,4, Mohsen Abbasi‑Kange a i
1,
Zah a Soleimani
1, Zah a Es ahani
1,5, Masoud Masinaei
1,6, Saha Mohammadi Fa eh
1,
Ali Goles ani
1, A ezou Dilmaghani‑Ma and
1, Fa zad Kompani
7, Nega Rezaei
1,
E an Ghasemi
1, Baghe La ijani
8 & Fa shad Fa zad a
1,9*
This s udy aimed o in es iga e he es ima ed bu den a ibu ed o lead exposu e (LE), a he na ional
and subna ional le els om 1990 o 2019 in I an. The bu den a ibu ed o LE was de e mined h ough
he es ima ion o dea hs, disabili y‑adjus ed li e yea s (DALYs), yea s o li e los (YLLs) and yea s li ed
wi h disabili y (YLDs) using he compa a i e isk assessmen me hod o Global Bu den o Disease
(GBD) s udy p esen ing as age‑s anda dized pe 100,000 pe son yea (PY) wi h 95% unce ain y
in e als (95% UI). Fu he mo e, he bu den o each disease we e eco ded independen ly. E en ually,
he age‑s anda dized YLLs, DALYs, dea hs and YLDs a es a ibu ed o LE demons a ed a dec ease
o 50.7%, 48.9%, 38.0%, and 36.4%, espec i ely, om 1990 o 2019. The mos impo an causes o
LE bu den a e di ided in o wo acu e and ch onic ca ego ies: acu e, mainly causes men al diso de s
(DALYs a e o 36.0 in 2019), and ch onic, esul s in ca dio ascula diseases (CVDs) (DALYs a e o
391.8) and ch onic kidney diseases (CKDs) (DALYs a e o 26.6), wi h CVDs bea ing he mos signi ican
bu den. A he sub‑na ional le el, a dec ease in bu den was e iden in mos p o inces; mo eo e , low
and low‑middle SDI p o inces bo n he highes bu den. The bu den inc eased mainly by ageing and
was highe in males han emales. I was concluded ha al hough he o e all dec ease in he bu den;
s ill i is high, especially in low and low‑middle SDI p o inces, in ad anced ages and in males. Among
IDID, CKDs and CVDs ha a e he mos impo an causes o LE‑a ibu ed bu den in I an; CVDs bea
he highes bu den.
Keywo ds En i onmen al pollu an s, Ca dio ascula diseases, Dea h, Disabili y-adjus ed li e yea s, Global
bu den o disease, Lead
GBD 2019 has inco po a ed a ious en i onmen al isk ac o s including ou g oups o unsa e wa e and sani a-
ion, ai pollu ion, non-op imal empe a u e, and o he en i onmen al isk ac o s. Residen ial adon and lead
exposu e (LE) belong o he ou h g oup1.
OPEN
1Non-Communicable Diseases Resea ch Cen e , Endoc inology and Me abolism Popula ion Sciences Ins i u e,
Teh an Uni e si y o Medical Sciences, Teh an, I an. 2School o Medicine, Teh an Uni e si y o Medical Sciences,
Teh an, I an. 3School o Medicine, Albo z Uni e si y o Medical Sciences, Albo z, I an. 4Kiel Ins i u e o he Wo ld
Economy, Kiel, Ge many. 5Depa men o Bios a is ics, Uni e si y o Social Wel a e and Rehabili a ion Sciences,
Teh an, I an. 6Depa men o Epidemiology and Bios a is ics, Teh an Uni e si y o Medical Sciences, Teh an,
I an. 7Di ision o Hema ology and Oncology, Child en’s Medical Cen e , Pedia ics Cen e o Excellence, Teh an
Uni e si y o Medical Sciences, Teh an, I an. 8Endoc inology and Me abolism Resea ch Cen e , Endoc inology
and Me abolism Clinical Sciences Ins i u e, Teh an Uni e si y o Medical Sciences, Teh an, I an. 9Endoc inology
and Me abolism Resea ch Ins i u e, Teh an Uni e si y o Medical Sciences, Teh an, I an. *email: - a zad a @
ums.ac.i
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Lead (Pb) is a haza dous hea y me al en i onmen al oxin wi h many ha m ul heal h e ec s. While lead is
a oxic me al, i s cha ac e is ics ha e made i widely used in a ious indus ies, leading o en i onmen al con-
amina ion and a ious long- e m impac s on human heal h2. Two main sou ces o lead encompassing na u al
and syn he ic sou ces a e known exis . Lead is mainly ound in he ai , soil, wa e and di e en ood p oduc s,
as well as a ious syn he ic sou ces3.
His o ically, lead has been ex ensi ely used in indus y and a ious p oduc s, such as pe oleum, ba e ies,
pain s, and pipes4. Inhala ion and gas oin es inal en y a e he mos p e alen ou es o lead en y in o he body.
In adul s, lead abso p ion om inhala ion is es ima ed o ange be ween 20 and 60%. Al hough gas oin es inal
abso p ion a e is lowe in adul s, a ound 10%, he a io could be as high as 50% in child en5. Lead exposu e
poses a se e e isk o human heal h due o i s cumula i e e ec and non-biodeg adable na u e6. The abso bed
lead can be s o ed in so issues, such as he kidney, cen al ne ous sys em (CNS), and bones7. LE is a isk ac o
o non-communicable diseases (NCDs), such as ca dio ascula diseases (CVDs) and ch onic kidney diseases
(CKDs), and de elopmen al cogni i e damage like idiopa hic de elopmen al in ellec ual disabili y (IDID)) a
younge ages, e en in small doses8–11; which could ha e a signi ican bu den on public heal h in e ms o disabili y
o mo ali y12. Ne e heless, no sa e le el o LE has been es ablished ye 13. Mo eo e , NCDs ha e become a sig-
ni ican public heal h issue in de eloped and de eloping coun ies14. LE esul ed in 900,000 dea hs and 21,700,000
DALYs in 2019, assigning a subs an ial disease bu den2. The exposu e o lead in I an can occu h ough leaded
gasoline, al hough p ohibi ed, and indus ial LE wi h he po en ial o con amina ing ai , wa e and soil. Besides,
se e al oods o igina ing om he con amina ed en i onmen , such as ish, ice, ea, ege ables, aw ood, milk,
and b ead migh also be a ec ed. I is epo ed ha he plan ood lead con amina ion is highe han allowable
limi s in mos s udies conduc ed in I an which can esul in se e al heal h p oblems15,16.
Fu he mo e, he p e alence o lead in se e al d ugs, pa icula ly he bal ones, opium, child en’s oys and
cosme ics, has inc eased i s exposu e16. His o ically, LE has been used in a ious indus ial se ings and p od-
uc s, such as cosme ics, pain s, pe oleum, and pipes, and is one o he ea lies known causes o occupa ional
disease17,18. Al hough e idence was p esen ega ding he pa hological aspec s o con ac wi h LE, i was no
un il he la e wen ie h cen u y ha legisla ion and egula ions we e implemen ed o educe LE, which caused a
educ ion in associa ed diseases18. Occupa ional and en i onmen al legisla ion aimed a dec easing LE has also
been passed in I an16. Due o he egula ions made o educe he LE in I an and all o e he wo ld, om 1990 o
2019, he amoun o LE has dec eased by abou 1% pe yea globally12. Ne e heless, he exposu e emains high,
as hal o he 2,000,000 li es los o chemical exposu e in 2019 we e a ibu ed o LE2.
Thus, he p og ess owa ds educing he bu den a ibu able o LE needs o be in es iga ed o help de e mine
whe he p e ious e o s ha e been adequa e and assis policymake s in de eloping be e egula o y ules and
making e idence-based decisions.
The cu en s udy aims o discuss he bu den a ibu ed o LE and compa e a ibu able dea h, yea s o li e
los (YLLs), yea s li ed wi h disabili y (YLDs) and disabili y-adjus ed li e yea s (DALYs) o di e en diseases
induced by LE acco ding o he esul s o GBD 2019, among 31 p o inces o I an om 1990 o 2019.
Ma e ial and me hods
O e iew and da a esou ces
The da a was ob ained om he GBD 2019, a ailable a he Ins i u e o Heal h Me ics and E alua ion (IHME)
websi e (h p:// ghdx. heal hda a. o g/ gbd- esul s- ool), in which o de e mine isk exposu e o each isk ac o ,
published s udies and sys ema ic e iews, su eys, censuses, epo s, c oss-sec ional s udies, g ound moni o
da a, and adminis a i e da a in I an ha e been e alua ed om 1990 o 2019.
Compa a i e isk assessmen me hod
Since GBD 2002, he a ibu able bu den o each isk ac o has been based on compa a i e isk assessmen
(CRA). The ollowing analy ical s eps a e included in he CRA: (1) isk-ou come pai selec ion, (2) ela i e isk
es ima ion as an exposu e unc ion acco ding o sys ema ic e iews o a leas wo coho s udies and unning a
me a-analysis o he ela i e isks ( o new isk-ou come pai s, a e excluding po en ial bias and con ounding,
in he condi ion o P- alue < 0.05 he associa ion is p o en o be s a is ically signi ican ). (3) Es ima ion o he
le el o exposu e in each age-sex-loca ion-yea by spa io empo al Gaussian p ocess eg ession (ST-GPR) o
DisMod-MR 2.1 (Bayesian s a is ical models) (4) de e mina ion o he coun e ac ual le el o exposu e called
heo e ical minimum isk exposu e le el (TMREL) (5) compu a ion o popula ion a ibu able ac ion (PAF)
and calcula ing a ibu able dea h, YLLs, YLDs and DALYs by mul iplying PAF by he a es in each age–sex–loca-
ion–yea g oups. (6) Es ima ion o PAF and a ibu able bu den o isk ac o combina ions12.
Lead exposu e‑ ela ed diseases
Acco ding o he GBD 2019 s udy, LE- ela ed diseases a e classi ied in o h ee ypes: CVDs, CKDs and men al
diso de s. CVDs ela ed o LE include endoca di is, pe iphe al a e y disease, ao ic aneu ysm, a ial ib illa ion
and lu e , ca diomyopa hy and myoca di is, non- heuma ic al ula hea disease, hype ensi e hea disease,
s oke (suba achnoid hemo hage, in ace eb al hemo hage and ischemic s oke), ischemic hea disease (IHD),
heuma ic hea disease (RHD) and o he ca dio ascula and ci cula o y diseases. As a CVDs sub ype, s oke
has h ee sub ypes: suba achnoid hemo hage, in ace eb al hemo hage, and ischemic s oke. Subclasses o
diseases in CKDs ha ha e been su eyed include ch onic kidney disease due o he ollowing causes: diabe es
melli us ype 1, diabe es melli us ype 2, hype ension, glome uloneph i is, and ch onic kidney disease due o
o he and unspeci ied causes. Men al diso de s ha e one sub ype ela ed o LE: IDID.
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A ibu ed bu den indices
The a ibu ed bu den o acu e and ch onic LE in I an is demons a ed wi h YLLs, YLDs, DALYs ( he sum o
YLLs and YLDs) and dea h in wo ypes o all ages and age-s anda dized a e pe 100,000 popula ion in bo h
sexes a na ional and subna ional le els wi h 95% unce ain y in e als (95% UI)12.
Socio‑demog aphic index
The socio-demog aphic index (SDI) is used in GBD s udies o measu e sociodemog aphic de elopmen based on
pe capi a income, educa ional income, and o al e ili y a e. I is classi ied in o i e quin iles: high, high middle,
middle, low middle and low. The cu en s udy compa es he bu den a ibu ed o LE in di e en SDI quin iles.
S a is ical analysis
Da a on he LE was ga he ed om published li e a u e and su eys conduc ed in I an, which was ex ac ed om
he global heal h da a exchange sys em (GHDx)1. Blood lead le el (BLL) and bone lead le els we e ex ac ed
om s udies ha ake and analyze blood samples. By li e ime es ima ed blood lead, cumula i e blood lead index
can be ob ained o es ima ing bone lead le els.
Blood lead exposu es a e epo ed in a i hme ic mean, geome ic mean o median o ms. As in GBD 2019,
MR-BRT adjus men a iables a e u ilized o modi y all blood LE le els in he a i hme ic mean o m ( e e ence
o m) o make compa isons easie . The Bayesian s a is ical model in his s udy is he ST-GPR, which is used o
exposu e modelling, e.g., showing he blood LE dis ibu ion as a cu e o each yea o he li e ime and using he
a ea unde his cu e (cumula i e blood lead index) o de e mine bone lead; o , when he e is insu icien da a
abou a place o a ime, co a ia es ela ed o ha ime o place can be used by ST-GPR modelling. In conclusion,
he ST-GPR is an es ima ing ool o p edic ing BLL means and s anda d de ia ions in all GBD loca ions, all
ages, and sexes du ing any gi en pe iod.
A ailable e idence decla es ha BLL, used o acu e LE, is ela ed o he IDID; he ela i e isks o his asso-
cia ion in di e en BLLs a e adap ed om a 2013 pape 19; and bone lead le el, used o ch onic LE, is ela ed o
a ise in sys olic blood p essu e and e en ually o i s ca dio ascula and enal ou comes. The ela i e isks o
bone LE and ela ed diseases a e adap ed om a 2008 me a-analysis20.
In he cu en s udy, he cu -o alue o LE is based on he TMREL o lead, adap ed om GBD 2019, which
is conside ed 2.0 μg/dL; howe e , in some egions, i migh be much highe o lowe (e.g., he USA which has
had a TMREL o 1.2 μg/dL o BLL since 2009–201021).
Finally, YLLs, YLDs, DALYs and dea hs we e used o calcula e he bu den o diseases a na ional and sub-
na ional le els. Da a we e p esen ed as age-s anda dized pe 100,000 pe son yea (PY) wi h 95% unce ain y
in e als (95% UI). Besides, he calcula ion o pe cen change was based on he beginning (1990) and ending
(2019) yea s o he men ioned s udy pe iod. Mo eo e , he a ibu ed bu den was compa ed in di e en age
g oups, o bo h sexes and in a ious SDI quin iles. The isualiza ion and analysis o he da a and depic ion o
Figu es we e pe o med by STATA .13.1 and RS udio 1.4.1106.
Resul s
The all-cause and cause-speci ic bu dens a ibu ed o LE measu ed wi h dea hs, DALYs, YLLs and YLDs a e
desc ibed in he ollowing sec ions a he na ional and subna ional le els in I an. The LE cause-speci ic bu dens
a e di ided in o wo acu e and ch onic causes and hei subca ego ies’ bu den a e discussed u he ly.
All‑cause bu den
F om 1990 o 2019, a nea ly declining end in all-cause dea hs, DALYs, YLLs, and YLDs a es a ibu ed o LE
was seen o bo h sexes (Fig.1). The e was a di e gence be ween p o inces o dea hs, DALYs, YLLs and YLDs
a ibu ed o LE in 1990, which go mo e con e gen in 2019 (Fig.2).
The age-s anda dized dea hs a e (ASDR) pe 100,000 dec eased by 38.0% (95% UI 45.5–31.5) om 38.7
(27.3–52.1) in 1990 o 24.0 (16.5–32.7) in 2019. Simila ly, he changes o DALYs, YLLs and YLDs in he same ime
in e al showed a declining end as he ollowing: he age-s anda dized DALYs a e eached 454.4 (323.2–597.6)
pe 100,000 in 2019, indica ing a − 48.9% (− 54.6 o − 44.3) dec ease. The highes a e change was ela ed o YLLs
wi h a − 50.7% (− 56.9 o − 45.7) change; howe e , age-s anda dized YLDs a e had he lowes change in he
men ioned ime in e al (− 36.4% (− 41.6 o − 31.0)).
The ASDR a ibu ed o LE among 31 p o inces o I an a ied om 6.1 (3.3–9.4) in Teh an o 41.8 (30.5–55.6)
in Sis an and Baluchis an; Ho mozgan wi h he highes dea h a e in 1990, eached 34.5 in 2019, which was
nea ly hal o 1990. The age-s anda dized DALYs a e anged om 127.8 (71.8–192.2) pe 100,000 o 901.4
(673.8–1167.2) in 2019, wi h he same pa e n o dea hs: he highes and lowes p o inces almos hal ed in 2019
compa ed o 1990. In e ms o he age-s anda dized YLLs, in 2019, i anged om as low as 90.5 (45.5–143) pe
100,000 o as high as 793.9 (574.2–148.9), wi h a 50% dec ease in he lowes and highes a es o 1990. Acco ding
o he age-s anda dized YLDs a e in 2019, he lowes and highes we e 37.3 (20.1–60.7) pe 100,000 and 107.5
(68.2–156.6). Teh an and Sis an and Baluchis an we e he wo p o inces wi h he lowes and he highes a es,
espec i ely o all men ioned a es.
CVDs bu den
CVDs a ibu ed o LE accoun ed o an ASDR o 22.6 (15.4–31.1) in 2019, indica ing a dec ease (− 39.2% (− 46.6
o − 32.5)) since 1990. Simila ly, he age-s anda dized DALYs, YLLs and YLDs e ealed dec easing ends a he
same pe iod as ollows; a − 50.3% (− 56.6 o − 45.3), − 51.6% (− 57.9 o − 46.5) and − 23.5% (− 30.4 o − 18.1)
educ ion o 391.8 (270.8–528.6), 365.5 (253.8–494.5) and 26.3 (16.1–40.0) in 2019 was epo ed o he changes
o DALYs, YLLs and YLDs, espec i ely.
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Among subna ional p o inces, he ASDR a ied om 9.5 (14.9–15.9) in Teh an o 58.5 (39.6–79.8) in Ho -
mozgan and 5.6 (2.9–8.8) in Teh an o 37.7 (27–51.1) in A debil in 1990 and 2019, espec i ely, showing a
dec easing end o e ime. This end coincided, e en o he DALYs, YLLs, and YLDs. Thei educed 2019 a es
a e as ollows: DALYs spanned om 95 (47.3–149.7) o 755.6 (548.6–1000.2), YLLs om 83 (41.3–132) o 712.4
(511.6–950.4) and he YLDs om 12.0 (5.5–20.5) o 43.2 (28.6–61.9); Wi h Teh an being he p o ince wi h he
lowes a e and Sis an and Baluchis an wi h he highes a e o all. (Supplemen a y Fig.1).
Top h ee CVD sub ypes wi h he highes na ional bu den, based on DALYs a e, in 2019 a e u he dis-
cussed in he ollowing ( om highes o lowes ) a na ional le el, he da a ega ding hei subna ional bu den is
demons a ed in Supplemen a y File.
Ischemic hea disease
IHD bea s he highes bu den among CVDs sub ypes. The mos signi ican changes we e o YLLs and DALYs
wi h − 55.4% (− 61.8 o − 50.0) and − 54.8% (− 61.1 o − 49.4) down u n o 211.9 (146.5–290.4) and 217.9
(150.7–298.4) in 2019, espec i ely. A e ha , he ASDR showed a change o − 43.4% (− 50.8 o − 36.6) o e his
pe iod o 12.9 (8.6–18.1); and YLDs eached 6.0 (3.5–9.6) a he end o his ime in e al indica ing a − 10.6%
(− 18.6 o − 4.0) diminu ion.
500 1000
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
YLLs
50 100 150
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
YLDs
10 20 30 40 50 60
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
Bo h Female Male
Dea hs
500 1000 1500
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
DALY s
All causes
Figu e1. Time end o age-s anda dized a ibu ed bu den a e o lead exposu e by sex in I an, 1990–2019.
5001000
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
YLLs
40 80 120 160
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017
2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
YLDs
20 40 60
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
Albo z
A debil
Busheh
Chaha Mahaal and Bakh ia i
Eas Aza bayejan
Fa s
Gilan
Goles an
Hamadan
Ho mozgan
Ilam
I an (Islamic Republic o )
Is ahan
Ke man
Ke manshah
Kho asan−e−Raza i
Khuzes an
Kohgiluyeh and Boye −Ahmad
Ku dis an
Lo es an
Ma kazi
Mazanda an
No h Kho asan
Qaz in
Qom
Semnan
Sis an and Baluchis an
Sou h Kho asan
Teh an
Wes Aza bayejan
Yazd
Zanjan
Dea hs
500 1000
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017
2019
Yea
A ibu ed Age−s anda dized a e (pe 100,000)
DALY s
All causes
Figu e2. Time end o age-s anda dized a ibu ed bu den a e o lead exposu e a na ional and p o incial,
1990–2019.
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S oke
The second sub ype wi h he highes bu den a e IHD is s oke. The pa e n o s oke a es a he na ional le el
was declining as well. The dea h a e dec eased o 4.6 (3.0–6.4) in 2019, which showed a − 45.8% (− 54.0 o − 35.7)
educ ion compa ed wi h 1990. Besides, DALYs a e dec eased by − 53.2% (− 60.6 o − 45.7) om 1990 o 87.5
(57.8–117.9) in 2019; YLLs a e showed a educ ion almos simila o DALYs wi h − 55.5% (− 62.8 o − 47.6)
change om 1990 o 75.4 (50.1–101.3) in 2019. The leas change was o YLDs, which demons a ed a − 31.0%
(− 38.8 o − 24.8) educ ion o e 30 yea s o 12.0 (7.0–18.3) in 2019.
The bu den a ibu ed o 3 s oke sub ypes, including he suba achnoid hemo hage, in ace eb al hemo -
hage and ischemic s oke is u he desc ibed in he Supplemen a y File.
Hype ensi e hea disease
All bu den measu e a es had a declining pa e n a he na ional le el du ing he ime in e al om 1990 o 2019.
Dea hs a e wi h − 13.9% (− 40.4 o 10.3), DALYs a e wi h − 28.0% (− 48.9 o − 8.9), YLLs wi h − 28.8% (− 50.4
o − 8.7) and YLDs wi h − 12.3% (− 26.9 o − 2.0) educ ion eached o he ollowing a es in 2019, espec i ely:
4.3 (1.4–9.4), 68.8 (28.5–137.5), 64.4 (26.4–129.1) and 4.4 (1.7–9.3).
CKDs bu den
In es iga ing he bu den a ibu ed o diabe ics and CKDs due o LE o e 30yea s demons a ed a simila
downwa d end: dec eased age-s anda dized dea hs, DALYs, YLLs, and YLDs a es. The ASDR, wi h a change o
− 11.1% (− 28.2 o − 0.95) eached 1.4 (1.0–1.8) in 2019. The DALYs a e changed om − 23.3% (− 32.7 o − 0.16)
o 26.6 (18.3–35.9) in 2019. Meanwhile, he YLLs a e demons a ed a simila end and eached 21.2 (14.9–28.2)
(wi h a pe cen change o − 27.1% (− 37.7 o − 19.1)), and YLDs change was sligh ly in angible compa ed o o h-
e s: − 4.1% (− 14.3 o − 0.7) o 5.4 (3.2–8.4) in 2019.
Analysis o he bu den a he subna ional le el e ealed he ollowing ou comes: he lowes and highes ASDR
in 2019 was 0.6 (0.3–0.8) (Teh an) and 4.6 (3.3–6.1) (Sis an and Baluchis an), espec i ely; unlike o he ends,
he ASDR due o CKDs showed an inc easing end in some p o inces like op ou p o inces wi h he highes
ASDR in 2019: 1. Sis an and Baluchis an (4.1–4.6) 2. Ilam ( om 2.5 o 3.1) 3. A debil ( om 2.1 o 2.6) 4. Eas
Aze baijan ( om 2.3 o 2.5) (Supplemen a y Fig.2). This inc easing end in some p o inces was also e iden
ega ding he age-s anda dized DALYs, YLLs and YLDs due o CKDs. DALYs a e spanned om 10.0 (5.2–15.7)
o 92.5 (66.3–121.2) in 2019. Rega ding he YLLs a e, he ange was om 7.5 (3.9–11.7) o 81.5 (58.1–107.7).
Fu he mo e, he YLDs a e e ealed he lowes and he highes a es o 2.6 (1.2–4.6) and 11 (6.9–16.3) in 2019;
No ing ha Teh an was he p o ince wi h he lowes a e and Sis an and Baluchis an was he a ea wi h he high-
es a e o DALYs, YLLS and YLDs.
IDID bu den
Acu e LE causes men al diso de s a an ea ly age, and he only ype in ol ed in LE is IDID. Na ional, he DALYs
a e dec eased by − 45.8% (− 54.2 o − 40.3) o 36.0 (15.3–65.3) in 2019. Among subna ional p o inces o I an,
he lowes o highes DALYs a e eached 22.8 (8.3–43.3) (Teh an) o 53.3 (24.5–93) (Sis an and Baluchis an) in
2019. In e ms o YLDs in 2019, he o al ange was om 22.8 (8.3–43.3) (Teh an) o 53.3 (24.5–93) (Sis an and
Baluchis an), ep esen ing a signi ican dec ease since 2019 (Supplemen a y Fig.3).
A ibu ed bu den by SDI egions
A he SDI le el, he gene al end was as ollows: low and low-middle p o inces ep esen ed he highes a es
o age-s anda dized dea hs, DALYs, YLLs and YLDs a es due o all causes in bo h 1990 and 2019. On he o he
hand, p o inces in he high SDI quin ile acqui ed he lowes a es in bo h yea s. A close look a he a es e ealed
ha he highes dea h a es we e o low-middle and low SDI egions in 1990 and 2019. In con as , high SDI
p o inces e ealed he lowes dea h a es in bo h yea s. Rega ding he DALYs a e, he highes a e was seen in
low and low-middle SDI egions in 1990 and he low SDI egion in 2019, while he lowes a e was epo ed in
a high SDI p o ince in bo h yea s. YLDs a e had he same pa e n as DALYs; YLLs a e’s lowes a e was he
same as o he s in high SDI egions in bo h yea s. Conce ning he highes YLLs a es, low-middle and low-SDI
p o inces demons a ed his ea u e in 1990 and 2019, espec i ely. The c i ical poin compa ing 1990 and 2019
is he educ ion o almos all a es om 1990 o 2019 in all SDI quin iles (Fig.3). Ano he no ewo hy poin is
he imp o emen o SDI om 1990 o 2019, accompanying a educ ion in all causes bu den a ibu ed o LE
(Supplemen a y Figs.4–7).
CVDs caused by LE e ealed a ela i ely simila pa e n o all-cause bu den in e ms o SDI; howe e , some
sub ypes, including pe iphe al a e y disease and a ial ib illa ion and lu e , e ealed an inc easing pa e n
among hei dea hs, YLLs and YLDs (in pe iphe al a e y disease) a es om 1990 o 2019 (Fig.4, Supplemen-
a y Figs.8 and 9). Mo eo e , some o he sub ypes demons a ed di e en ela ions be ween he minimum and
maximum a es and SDI as ollows: some middle SDI p o inces had he highes bu den o ca diomyopa hy and
myoca di is and suba achnoid hemo hage; o non- heuma ic al ula hea disease had he highes bu den in
high-middle SDI p o inces, especially in 1990 and he lowes a e o YLDs in a low SDI p o ince in 2019, unlike
he gene al end. Addi ionally, ischemic s oke is ano he example ha had he highes a es o YLLs, YLDs and
DALYs in high SDI p o inces in 1990. Besides, RHD e ealed he lowes a e o YLDs in middle and high-middle
SDI p o inces (Supplemen a y Figs.10–14).
CKDs had an almos iden ical pa e n o dea hs, DALYs, YLLs and YLDs a es o all causes bu den by SDI
le el a he same pe iod (Fig.5).
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A ibu ed bu den by age and sex dis ibu ion
The ASDR, DALYs and YLLs a es a ibu ed o LE had simila age pa e ns, all a es inc eased wi h aging, and
he a es in 2019 we e lowe compa ed o he same age g oup in 1990; mo eo e , compa ing he a es be ween
males and emales in each age g oup, we ound ha males had signi ican ly highe a es han emales, illus a -
ing a dispa i y in ca e among sexes. Rega ding he YLDs a e, he e was an inc easing end by aging; howe e ,
in he age g oup be ween 5 and 39 yea s, he a e was almos cons an in 1990 and 2019. Fu he mo e, in all age
g oups, he YLDs a es we e highe in 1990 compa ed o 2019 in bo h sexes, bu in he age g oup o 70 plus, he
a es we e highe in 2019 han in 1990 in males, and his pa e n was e iden in emales 75 yea s and olde . The
pa e n o highe a es in males han emales was ob ious in he YLDs a es as well (Fig.6).
Rega ding he CVDs bu den, all a es inc eased by aging in bo h gende s in bo h yea s (1990 and 2019), and
i was always highe in males compa ed o emales; mo eo e , he a es o each age g oup in 1990 was signi i-
can ly highe han he same age g oup in 2019 o bo h gende s. YLDs a e ollowed a sligh ly dis inc pa e n; i
2010 2019
1990 2000
Albo z
A debil
Busheh
Chaha Mahaal and Bakh ia i
Eas Aza bayejan
Fa s
Gilan
Goles an
Hamadan
Ho mozgan
Ilam
Is ahan
Ke man
Ke manshah
Kho asan−e−Raza i
Khuzes an
Kohgiluyeh and Boye −Ahmad
Ku dis an
Lo es an
Ma kazi
Mazanda an
No h Kho asan
Qaz in
Qom
Semnan
Sis an and Baluchis an
Sou h Kho asan
Teh an
Wes Aza bayejan
Yazd
Zanjan
Albo z
A debil
Busheh
Chaha Mahaal and Bakh ia i
Eas Aza bayejan
Fa s
Gilan
Goles an
Hamadan
Ho mozgan
Ilam
Is ahan
Ke man
Ke manshah
Kho asan−e−Raza i
Khuzes an
Kohgiluyeh and Boye −Ahmad
Ku dis an
Lo es an
Ma kazi
Mazanda an
No h Kho asan
Qaz in
Qom
Semnan
Sis an and Baluchis an
Sou h Kho asan
Teh an
Wes Aza bayejan
Yazd
Zanjan
0 500 1000 15000 5001000 1500
A ibu ed Age−s anda dized a e (pe 100,000)
0.30.4 0.50.6 0.7
SDI
All causes
YLLs
Figu e3. P o incial age-s anda dized a ibu ed YLLs a e o lead exposu e by SDI in 1990, 2000, 2010 and
2019. YLLs: Yea s o Li e Los ; SDI: Socio-Demog aphic Index.
GI
AR
BS
KD
ZA
KZ
TE
KD
KE
ES
FA
KJ
MK
FA
HD
KJ
QZ
IL
EA
GO
CM
MN
HD
QM
YA
BK
KB
GO
MN
ES
LO
WA
KS
SM IL
SB
HG
QZ
KV
AL
GI
BK
ZA
AL
KV
QM
EA
WA
KZ
LO
KE
SM
CM
SB
KB
BS
MK
AR
TE
YA
HG
KS
1990 2019
Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI
250 500 750 1000 1250
A ibu ed Age−s anda dized a e (pe 100,000)
YLLs
GI
KS SM
ZA
KZ IL
KE
HG
QZ
FA
KV
KJ
KV
QZ
WA
EA
CM
KZ
MN
LO
QM
SM
CM
SB
KB
BS
MK
ES
YA
HG
KS
WA
AR
BS
KD
TE
KD
SB
ES
MK
AL
FA
HD
GI
KJ
BK
ZA
AL
QM
EA
IL
GO
HD
KE
YA
BK
KB
GO
MN
AR
TE
LO
1990 2019
Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI
20 30 40 50
A ibu ed Age−s anda dized a e (pe 100,000)
YLDs
SM
BS
KD
KZ
TE
IL
ES
KV
KJ
FA
HD
GI
KJ
BK
ZA
AL
EA
QZ
IL
WA
EA
GO
CM
LO
QM
YA
SB
KB
AR
LO
HG
GI
WA
KS
AR
ZA
KD
SB
KE
HG
QZ
FA
MK
AL
KV
QM
KZ
MN
HD KE
SM
BK
CM
KB
GO
BS
MK
MN
ES
TE
YA
KS
1990 2019
Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI
20 40 60
SDI quin ile
A ibu ed Age−s anda dized a e (pe 100,000)
Albo z
(AL)
A debil
(AR)
Busheh
(BS)
Chaha Mahaal and Bakh ia i
(CM)
Eas Aza bayejan
(EA)
Fa s
(FA)
Gilan
(GI)
Goles an
(GO)
Hamadan
(HD)
Ho mozgan
(HG)
Ilam
(IL)
Is ahan
(ES)
Ke man
(KE)
Ke manshah
(BK)
Kho asan−e−Raza i
(KV)
Khuzes an
(KZ)
Kohgiluyeh and Boye −Ahmad
(KB)
Ku dis an
(KD)
Lo es an
(LO)
Ma kazi
(MK)
Mazanda an
(MN)
No h Kho asan
(KS)
Qaz in
(QZ)
Qom
(QM)
Semnan
(SM)
Sis an and Baluchis an
(SB)
Sou h Kho asan
(KJ)
Teh an
(TE)
Wes Aza bayejan
(WA)
Yazd
(YA)
Zanjan
(ZA)
Dea hs
WA
KS
KZ
TE
KD
SB
KE
ES
HG
FA
KJ
AL
HD
GI
ZA
KV
QZ
IL
EA
QM
SM YA
BK
CM
KB
GO
BS MK
MN
AR LO
GI
SM
AR
BS
KD
ZA
IL
QZ
KV
MK FA
KJ
BK
AL
QM
EA
WA
GO
CM
KZ
MN
HD
LO
KE
SB
KB
ES
TE
YA
HG
KS
1990 2019
Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDIHigh−middle SDIHigh SDI
250 500 750 1000 1250
SDI quin ile
A ibu ed Age−s anda dized a e (pe 100,000)
DALY s
Ca dio ascula diseases
Figu e4. Dis ibu ion o p o incial age-s anda dized bu den a e due o ca dio ascula diseases a ibu ed o
lead exposu e by SDI quin iles, 1990 and 2019. SDI: Socio-Demog aphic Index.
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inc eased wi h aging in bo h gende s; howe e , in 1990, he a e o he 80 plus age g oup was lowe han 70–74
and 75–79 age g oups o males and bo h gende s, espec i ely. And i was highe in males han emales in bo h
yea s. Compa ing 1990 and 2019 ega ding YLDs a es showed highe a es in 1990 un il he age o 69 yea s
o males, and om 70 yea s and mo e, i was he o he way a ound; howe e , o emales, he YLDs a es we e
highe in 1990 un il he age o 79 yea s and he pa e n changed a e he 80 yea s (Fig.7).
The bu den o CKDs inc eased wi h aging o bo h gende s, which was consis en ly highe in males han
emales. Mo eo e , he a es in each age g oup we e highe in 1990 han in 2019 o bo h gende s excep o he
80-plus age g oup, demons a ing an in e ed pa e n. YLDs a e had an inc easing end wi h aging; i s a es in
males we e always highe o equal o emales excep o 35–39 and 75 plus age g oups. Fu he mo e, he a es o
YLDs in he 65-plus age g oup in 2019 we e highe han in 1990 in he same age g oup o bo h sexes, bu o he
ages had an in e ed pa e n (Fig.8).
IL
ZA
HD
KJ
AR
SM
GI
ES
TE
AL
KE
KS
BK
IL
GO
KB
KS
HD
BS
KJ
LO
EA
BS
KZ
ZA
KV
QM
WA
SB
BK
KD
KV
AL
MN
MN
CM
HG
AR
TE
HG
KE
YA
QZ
KZ
EA
QZ
KD
WA
YA
KB
MK
FA
CM
SM
GO
GI
FA
QM
ES
SB
LO
MK
1990 2019
Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI
20 40 60 80
A ibu ed Age−s anda dized a e (pe 100,000)
YLLs
KV
ZA
AL
HD
MN
MN
GI
ES
TE
KS
AR
IL
GO
KE KB
YA
KS
BS
KJ
KZ
EA
YA
KB
CM ZA
KV
SM GO
GI
QM SB IL
KJ
AR
SM
CM
AL
HG
KE
TE
BK
HG
HD
QZ
QZ
KD
LO
WA
EA
MK
FA
BS
KZ
QM
FA
WA
ES
SB
BK
KD
LO
MK
1990 2019
Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI
46810
A ibu ed Age−s anda dized a e (pe 100,000)
YLDs
ZA
HD
MN
GI
TE
HG
KE
KS
AR
BK
KE
YA
QZ
KJ
KZ
LO
YA
EA
KB
MK KZ
CM
ZA
GO
GI
WA
ES
SB
SB
KD
MK
IL
KV
AL
KJ
AR
MN
SM
CM
ES AL
TE
IL
GO
HG
KB
KS
HD BS
EA
QZ
KD
WA
FA
BS
KV
QM
SM
FA
QM
BK
LO
1990 2019
Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI
1234
SDI quin ile
A ibu ed Age−s anda dized a e (pe 100,000)
Albo z
(AL)
A debil
(AR)
Busheh
(BS)
Chaha Mahaal and Bakh ia i
(CM)
Eas Aza bayejan
(EA)
Fa s
(FA)
Gilan
(GI)
Goles an
(GO)
Hamadan
(HD)
Ho mozgan
(HG)
Ilam
(IL)
Is ahan
(ES)
Ke man
(KE)
Ke manshah
(BK)
Kho asan−e−Raza i
(KV)
Khuzes an
(KZ)
Kohgiluyeh and Boye −Ahmad
(KB)
Ku dis an
(KD)
Lo es an
(LO)
Ma kazi
(MK)
Mazanda an
(MN)
No h Kho asan
(KS)
Qaz in
(QZ)
Qom
(QM)
Semnan
(SM)
Sis an and Baluchis an
(SB)
Sou h Kho asan
(KJ)
Teh an
(TE)
Wes Aza bayejan
(WA)
Yazd
(YA)
Zanjan
(ZA)
Dea hs
IL
KV
HD
MN
CM
GI
ES
TE
AL
HG
KS
AR
BK
KE
QZ
KJ
LO
WA
YA
EA
KB
MK
BS
KZ
ZA
SM
GO
FA
QM
SB
KD
ZA
AL
KJ
MN
AR
SM
KE
TE
IL
GO
HG
KB YA
KS
HD
BS
KZ
EA
QZ
KD
FA
CM
KV
QM
GI
WA
ES
SB
BK LO MK
1990 2019
Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI Low SDILow−middle SDIMiddle SDI High−middle SDIHigh SDI
25 50 75
SDI quin ile
A ibu ed Age−s anda dized a e (pe 100,000)
DALY s
Ch onic kidney diseases
Figu e5. Dis ibu ion o p o incial age-s anda dized bu den a e due o ch onic kidney diseases a ibu ed o
lead exposu e by SDI quin iles, 1990 and 2019. SDI: Socio-Demog aphic Index.
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
6410 4807.5 3205 1602.501602.532054807.5 6410
A ibu ed Ra e (pe 100,000)
Age g oup
YLLs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
360270 18090090 180270 360
A ibu ed Ra e (pe 100,000)
Age g oup
YLDs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
700525 350 1750175350 525700
A ibu ed Ra e (pe 100,000)
Age g oup
Sex
Female Male
Dea hs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
6671 5003.2 3335.5 1667.801667.8 3335.55003.2 6671
A ibu ed Ra e (pe 100,000)
Age g oup
DALYs
1990 2019
All causes
Figu e6. A ibu ed bu den a e o lead exposu e by age g oups and sex in I an, 1990 s 2019.
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IDID’s DALYs a e inc eased un il he age o 10–14 o males and 5–9 o emales in 1990 and hen dec eased
wi h aging; in 2019, i app oxima ely inc eased un il he age 20–24 and hen dec eased by aging. The a e was
consis en ly highe in males han emales excep o he 80-plus age g oup in bo h yea s, which was oughly
equal in bo h gende s. Mo eo e , he a es demons a ed highe alues in 1990 han in 2019 o bo h gende s
un il he age o 69, while o he 70-plus age g oup, i was ice e sa (Fig.9).
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
6092 4569 3046 152301523 3046 4569 6092
A ibu ed Ra e (pe 100,000)
Age g oup
YLLs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
265 198.8 132.5 66.2066.2132.5198.8 265
A ibu ed Ra e (pe 100,000)
Age g oup
YLDs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
665498.8 332.5 166.20166.2 332.5498.8 665
A ibu ed Ra e (pe 100,000)
Age g oup
Sex
Female Male
Dea hs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
6302 4726.53151 1575.501575.5 31514726.5 6302
A ibu ed Ra e (pe 100,000)
Age g oup
DALYs
1990 2019
Ca dio ascula diseases
Figu e7. Bu den a e due o ca dio ascula diseases a ibu ed o lead exposu e by age g oups and sex in I an,
1990 s 2019.
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
351263.2 175.5 87.8 087.8 175.5263.2 351
A ibu ed Ra e (pe 100,000)
Age g oup
YLLs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
79 59.239.5 19.8 0 19.839.5 59.2 79
A ibu ed Ra e (pe 100,000)
Age g oup
YLDs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
38 28.5 19 9.5 0 9.5 19 28.5 38
A ibu ed Ra e (pe 100,000)
Age g oup
Sex
Female Male
Dea hs
1990 2019
Ea ly Neona al
La e Neona al
Pos Neona al
1 o 4
5 o 9
10 o 14
15 o 19
20 o 24
25 o 29
30 o 34
35 o 39
40 o 44
45 o 49
50 o 54
55 o 59
60 o 64
65 o 69
70 o 74
75 o 79
80 plus
430 322.5215 107.50107.5215 322.
54
30
A ibu ed Ra e (pe 100,000)
Age g oup
DALYs
1990 2019
Ch onic kidney diseases
Figu e8. Bu den a e due o ch onic kidney diseases a ibu ed o lead exposu e by age g oups and sex in I an,
1990 s 2019.
