Fallahzadeh et al.

BMC Public Health (2023) 23:2404 BMC Public Health

https://doi.org/10.1186/s12889-023-17114-4

RESEARCH Open Access

Distribution incidence, mortality

of tuberculosis and human development
index in Iran: estimates from the global burden
of disease study 2019
Hossien Fallahzadeh1, Zaher Khazaei1, Moslem Lari Najafi2, Sajjad Rahimi Pordanjani3 and Elham Goodarzi4*

Abstract
Background Tuberculosis is one of the most serious challenges facing the global healthcare system. This study
aims to investigate the incidence and mortality of tuberculosis in Iran from 2010 to 2019 as well as its relationship
with the human development index (HDI).
Methods The present study is an ecological study aiming at investigating the incidence and mortality of tubercu-
losis in Iran during the years 2010 to 2019. The related data were extracted from the Global Burden of Disease (GBD)
website. The spatial pattern attributed to tuberculosis in the provinces of Iran was analyzed using ArcGIS software.
In this study, the two-variable correlation method was used to analyze the data extracted to study the correlation
between Tuberculosis and HDI.
Result Based on the results recorded in GBD, the incidence of tuberculosis in 2010, that is, 14.61 (12.72, 16.74),
declined compared to 2019, namely 12.29 (10.71, 14.09). The age-standardized mortality rate which was 1.63
(1.52, 1.73) in 2010, has decreased compared to 2019: 1.17 (1.07, 1.32). The incidence and mortality rates of tuber-
culosis in Iran in all age groups have decreased in 2019 compared to 2010. The highest incidence and mortality
among tuberculosis patients were recorded in Sistan and Baluchistan and Golestan provinces. The results indicated
that there was a negative and significant correlation between the mortality rate of tuberculosis and the human
development index in 2010 (r = -0.509, P-value = 0.003) and 2019 (r = -0.36, P-value = 0.001); however, this correlation
between incidence and human development index was not significant (p > 0.05).
Conclusion Since mortality is mostly observed in areas with low HDI, health system policymakers must pay more
attention to these areas in order to improve care and perform screenings to diagnose and treat patients thus reducing
the mortality rate of tuberculosis and preventing an increase in its incidence in Iran.
Keywords Death, Incidence, Tuberculosis, HDI, Iran

*Correspondence:
Elham Goodarzi
[email protected]
Full list of author information is available at the end of the article

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-
mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 2 of 12

Introduction of education or income, immigrants, and people with

Policymakers and researchers are paying more and more high-risk lifestyles [14–16]. Many social, environmental,
attention to the significance of infectious diseases for and biological risk factors of tuberculosis are prevalent
public health and the economic development of coun- among the poor versus the wealthier people [17]. These
tries in the last few decades [1, 2]. Despite its long history factors probably contribute to a complex network of
of about 3000 years, tuberculosis (TB) is still an acute risk factors based on the relationship between poverty
health problem in human societies [3]. This disease is a and tuberculosis [18, 19]. Human Development Index
global emergency leading to high morbidity and mortal- (HDI) is a three-dimensional measure including life
ity, especially in sub-Saharan African countries, and, after expectancy, education, and income. In addition, HDI is
acquired immunodeficiency syndrome (HIV/AIDS), it one of the most important indices indicating the level of
is considered the second leading fatal infectious disease development in each region [20]. The level of the human
[4, 5]. Recent estimates of the global burden of people development index is a strong predictor of the changes
infected with Mycobacterium tuberculosis indicate that in the incidence of tuberculosis over time in the coun-
about 1.7 billion people, i.e., 23% of the world’s popula- tries [21, 22]. This study aims to investigate the incidence
tion, have this infection. This large number of people and mortality of tuberculosis in Iran from 2010 to 2019
with latent tuberculosis is the bed of infectious tubercu- based on the global burden of disease data and its rela-
losis patients in the future, and despite BCG immuniza- tionship with the human development index in the prov-
tion, adult forms of tuberculosis continue to emerge, inces of the country.
indicating that the current vaccine has limited efficacy
against adult tuberculosis, hence the need for tubercu- Methods
losis vaccines with high protective efficiency [1, 4, 6]. It Data sources
is estimated that by 2030 and 2050, latent tuberculosis The Institute for Health Metrics and Evaluation (IHME)
patients will generate 16.3 and 8.3 active tuberculosis produces annual updates to the GBD study, including
patients per 100,000 population, respectively [7]. The temporal and geographic trends, since 1990. Updating
incidence of tuberculosis varies considerably among dif- new data and methodological advances to provide policy-
ferent countries and in different population groups and makers with the most up-to-date information for health
within countries [8, 9]. care planning and resource allocation. The 2019 GBD
The incidence rate of tuberculosis is about 365 cases study estimated incidence, prevalence, and mortality by
per 100,000 people in Africa; it is about 5 people per age, sex, year, and location for 354 diseases and injuries
100,000 people in London; it is about 21 people per and 3484 sequelae i.e., disabling consequences of these
100,000 people in Spain; it is 5 people per 100,000 peo- diseases and injuries [23].
ple in America; and globally, on average, it is 13 cases This ecological study in Iran was designed to investigate
per 100,000 people. In Iran, the incidence rate of tuber- the distribution of the incidence and mortality of tuber-
culosis reached 16 cases per 100,000 people in 2015 and culosis and its relationship with the human development
declined to 14 cases per 100,000 people in 2016 and index. All the data used in this research were made avail-
2017, and fell to 13 cases per 100,000 people in 2020, able to the public at http://​ghdx.​healt​hdata.​org/​gbd-​resul​
where 4% of cases of tuberculosis patients were under ts-​tool. Data were extracted using GBD results. These
14 years old [5, 10, 11]. data including mortality and incidence estimates for all
Iran’s wide borders with tuberculosis-affected coun- age and sex groups along with the 95% CI were acces-
tries such as Azerbaijan, Turkmenistan, Armenia, sible. For some indices, the percentage change between
Pakistan, Afghanistan, and Iraq lead to an increase in 1990 and 2019 was reported [24].
immigration and travel to Iran from neighboring coun- TB incidence (number of new cases of the disease in
tries, which seriously impedes tuberculosis control. the population per 100,000) and mortality (number of
Since the distribution of the disease is different in differ- deaths per 100,000) were collected by the GBD from vari-
ent regions of the country, effective screening programs ous data sources.
are needed to identify high-risk areas [12, 13]. Health The data relating to the human development index
disparities refer to differences in the incidence, preva- was extracted from the United Nations Development
lence, mortality, burden of disease, and other adverse Program.
health conditions experienced by certain population The Human Development Index (HDI) is a statistical
groups. A comprehensive literature review of other arti- tool used to measure a country’s overall achievements
cles indicated that in every country, there is a dispropor- in its social and economic dimensions. According to this
tionately higher prevalence of communicable diseases index, the social and economic dimensions of a country
among vulnerable groups, i.e., those with low levels are evaluated based on the health of people, their level
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 3 of 12

of education, and their standard of living. The United The results showed that in 2010, the incidence rate in
Nations measures the HDI index annually for the mem- women was higher than that in men, and during the fol-
ber countries of the United Nations in a report based on lowing years, this incidence in women decreased and
which different countries are ranked [25, 26]. became less than in men. Mortality decline has occurred
among men from 2010 to 2019, and in women, although
Data analysis the trend of mortality has been almost constant between
The analysis of the spatial pattern attributed to tuber- 2010 and 2014, since 2014, there has been a decreasing
culosis in the provinces of Iran was done using ArcGIS trend (Fig. 1).
software. Figure 2 compares the incidence rate of tuberculosis
In this study, the two-variable correlation method was in 2010 compared to 2019 based on age groups. It can
used to analyze the data extracted to study the correlation be observed that the incidence rate of tuberculosis has
between Tuberculosis and HDI. The significance level was declined in all age groups in 2019 compared to 2010, and
P < 0.05. The analyses were made using Stata software ver- the highest incidence rate of tuberculosis can be seen
sion 12 (Stata Corp, College Station, TX, USA). among age groups above 60 years and the lowest incidence
rate of tuberculosis is related to children under 5 years old.
Results Figure 3 compares the mortality rate of tuberculosis in
Based on the results recorded in GBD, the incidence of 2010 compared to 2019 based on age groups. As can be
tuberculosis in 2010, that is, 14.61 (12.72, 16.74), declined seen in all age groups, the mortality rate of tuberculosis
compared to 2019, namely 12.29 (10.71, 14.09). The age- has decreased in 2019 compared to 2010, and the high-
standardized mortality rate which was 1.63 (1.52, 1.73) in est incidence rate of Tuberculosis is seen among the age
2010, has decreased compared to 2019: 1.17 (1.07, 1.32). groups above 60 years old, and a sharp decline in the
The results showed that the age-standardized preva- mortality rate is observed in these age groups.
lence rate of tuberculosis in Iran was 27,251.1 (24,466.9, Figure 4 shows the incidence rate of tuberculosis in
30,263.7) in 2010 and 25,365.7 (22,803.1, 28,334.3) in different provinces of the country from 2009 to 2019.
2019. The results are presented by sex in Table 1. As can be seen, the provinces of Sistan and Baluchistan,

Table 1 Incidence, mortality, and prevalence rate in Iran (source: Global Burden of Disease)
Age-standardized Rate

Male Female Both

2010 2019 Change 2010 2019 Change 2010 2019 Change

2010–2019 2010–2019 2010–2019

Incidence 14.24 13.49 -0.05 15.01 11.07 -0.26 14.61 12.29 -0.15
(12.39, 16.4) (11.69, 15.5) (-0.09, -0.008) (12.97, 17.37) (9.57, 12.76) (-0.29, -0.23) (12.72, 16.74) (10.71, 14.09) (-0.18, -0.12)
Death 2.02 1.34 -0.33 1.23 0.99 -0.19 1.63 1.17 -0.28
(1.87, 2.15) (1.23, 1.45) (-0.38, -0.27) (1.11, 1.34) (0.87, 1.28) (-0.28, 0.11) (1.52, 1.73) (1.07, 1.32) (-0.33, -0.17)
Prevalence 26,687.9 24,618.09 -0.07 27,825.8 26,113.9 -0.06 27,251.1 25,364.7 -0.06
(23,917.4, 29,672.8) (22,096.8, 27,590.7) (-0.1, -0.04) (24,946.6, 30,910.2) (23,530.4, 29,059.3) (-0.08, -0.03) (24,466.9, (22,803.1, 28,334.3) (-0.09, -0.04)
30,263.7)

Fig. 1 The incidence and mortality trend of tuberculosis patients in Iran during 2010–2019 based on sex (source: Global Burden of Disease)
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 4 of 12

Fig. 2 Comparing the incidence rate of Tuberculosis in 2010 VS 2019 by age group in Iran (source: Global Burden of Disease)

Fig. 3 Comparing mortality rate of Tuberculosis in 2010 VS 2019 by age group in Iran (source: Global Burden of Disease)

Khorasan Razavi, Golestan, and Tehran had the high- Golestan provinces still had the highest incidence rate
est incidence rate in the country until 2015. In 2017 and of tuberculosis (Fig. 3).
2019, the incidence rate decreased in Tehran and Kho- Figure 5 shows the mortality rate of tuberculosis in dif-
rasan Razavi provinces, but Sistan and Baluchestan and ferent provinces of Iran from 2009 to 2019. As can be
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 5 of 12

Fig. 4 Distribution of Incidence Rate of Tuberculosis in Iran During 2009–2019 (source: Global Burden of Disease)

seen, the provinces of Sistan and Baluchistan, Khorasan Table 3 compares the death rate of tuberculosis by
Razavi, Golestan, and South Khorasan had the highest province in men and women in 2010 compared to 2019
mortality rate in the country until 2011. And in 2015 to and shows the changes from 2010 to 2019 in all prov-
2019, the highest mortality rate from tuberculosis was inces. It can be seen that the death rate in men and
seen in Golestan, and Sistan and Baluchistan provinces women shows negative changes in 2019 compared to
(Fig. 5). 2010 in all provinces, indicating a decrease in the death
Figure 6 shows the changes in incidence and death in rate in men and women (Table 3).
Iran by province. It can be seen that in all provinces of The results showed that there was a negative and signif-
the country (except Ardabil province), the changes in icant correlation between the death rate of tuberculosis
2010–2019 related to incidence and death were nega- and the human development index in the years 2010 and
tive, which indicates a decrease in the incidence rate and 2019. Considering the relationship between the incidence
death rate during these years. rate and the HDI index, the results showed that there was
Table 2 provides a comparison of the incidence rate a negative correlation between the incidence rate and the
of tuberculosis in women and men by the province in HDI index in the years 2010 and 2019, but this correla-
2010 compared to 2019 and it also compares the changes tion was not statistically significant (Fig. 7).
from 2010 to 2019 in the provinces. It can be seen that
the incidence rate in women shows a negative change in Discussion
all provinces in 2019 compared to the year 2010, which Tuberculosis cases occur in every part of the world. In
indicates a decline in the incidence rate in women. How- 2021, the largest number of new cases of TB was found in
ever, the rate of changes in incidence among men has Southeast Asia with 46% of new cases, followed by Africa
been positive in some provinces of the country, including with 23% of new cases, and the Western Pacific with 18%.
Alborz, Ardabil, West Azerbaijan, Fars, Gilan, Hormoz- Globally, the incidence of tuberculosis is falling, but not
gan, Mazandaran, Qom, Sistan and Baluchistan, Kerman, fast enough to reach the 2020 milestone of a 20% reduc-
Khuzestan, and Tehran, which indicates an increase in tion between 2015 and 2020 [27]. Glaziou et al. reported
incidence rate among men in these provinces (Table 2). a decreasing trend in the incidence, prevalence, and
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 6 of 12

Fig. 5 Distribution of death rate of Tuberculosis in Iran from 2009 to 2019 (source: Global Burden of Disease)

Fig. 6 Comparing the change in incidence and death in 2010–2019 in Iran (source: Global Burden of Disease)
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 7 of 12

Table 2 The incidence rate of Tuberculosis in 2010 VS 2019 by sex in Iran (All ages) (source: Global Burden of Disease)

mortality rate of tuberculosis in the world between 1990 to control tuberculosis, leading to some achievements.
and 2015. According to the United States CDC report, The present study showed that the incidence and death
the incidence rate of tuberculosis has been decreasing rates of tuberculosis in Iran in all age groups declined in
during 1993–2010 [28]. 2019 compared to 2010.
One of the key factors in healthcare planning in any Based on the Iranian Ministry of Health reports, the
society is determining the incidence of diseases. Knowing total incidence of tuberculosis in Iran decreased by 1.17%
about the pattern of changes in the incidence of diseases between 2005 and 2015, while it increased by approxi-
in a country can be of paramount importance for plan- mately 4% in Mazandaran province [27]. A study con-
ning strategies at the country level. Public health organi- ducted in the west of Iran (Kurdistan province) showed
zations argue that assessment or surveillance of disease that the incidence rate has been decreasing during the
incidence trends, mortality rate, and disease risk factors years 2000–2012 [30]. A study on Iran conducted dur-
might contribute to the occurrence of adverse health ing 1998–2009 showed a decreasing trend [31]. Another
events [29]. In Iran, important measures have been taken study in Iran pointed to a decreasing trend in the
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 8 of 12

Table 3 The death rate of Tuberculosis in 2010 VS 2019 by sex in Iran (All ages) (source: Global Burden of Disease)
Death Male Female
2010 2019 Change 2010–2019 2010 2019 Change 2010–2019

Alborz 0.858 0.824 -0.039 0.607 0.638 0.051

(0.72, 1) (0.64, 1.04) (-0.25, 0.23) (0.5, 0.7) (0.5, 0.82) (-0.2, 0.46)
Ardebil 0.796 0.769 -0.034 0.513 0.594 0.157
(0.69, 0.92) (0.64, 0.92) (-0.21, 0.19) (0.44, 0.58) (0.48, 0.78) (-0.07, 0.6)
Bushehr 1.05 0.739 -0.297 0.539 0.446 -0.171
(0.95, 1.15) (0.63, 0.85) (-0.4, -0.17) (0.47, 0.6) (0.37, 0.6) (-0.32, 0.15)
Chahar Mahaal and Bakhtiari 0.224 0.149 -0.331 0.123 0.084 -0.314
(0.18, 0.26) (0.12, 0.18) (-0.47, -0.05) (0.1, 0.14) (0.06, 0.12) (-0.5, 0.06)
East Azarbayejan 1.03 0.754 -0.267 0.571 0.535 -0.063
(0.18, 0.26) (0.61, 0.93) (-0.42, -0.05) (0.49, 0.66) (0.41, 0.78) (-0.29, 0.44)
Fars 0.756 0.589 -0.22 0.37 0.331 -0.103
(0.64, 0.87) (0.46, 0.73) (-0.39, -0.01) (0.31, 0.43) (0.26, 0.46) (-0.31, 0.28)
Gilan 1.39 1.22 -0.118 0.545 0.597 0.094
(1.21, 1.61) (0.99, 1.49) (-0.3, 0.1) (0.47, 0.62) (0.47, 0.79) (-0.15, 0.46)
Golestan 3.41 3.11 -0.085 1.56 1.75 0.12
(3.01, 3.81) (2.57, 3.74) (-0.26, 0.11) (1.37, 1.75) (1.41, 2.33) (-0.11, 0.53)
Hamadan 0.885 0.768 -0.132 0.459 0.493 0.074
(0.75, 1.03) (0.61, 0.93) (-0.31, 0.09) (0.39, 0.52) (0.39, 0.65) (-0.15, 0.52)
Hormozgan 1.93 1.27 -0.343 0.781 0.618 -0.209
(1.69, 2.2) (1.04, 1.51) (-0.46, -0.19) (0.68, 0.88) (0.49, 0.88) (-0.37, 0.18)
Ilam 0.674 0.572 -0.151 0.322 0.354 0.098
(0.45, 0.62) (0.48, 0.68) (-0.3, 0.02) (0.28, 0.36) (0.28, 0.48) (-0.12, 0.55)
Isfahan 0.536 0.488 -0.088(-0.29, 0.16) 0.359 0.395 0.099
(0.45, 0.62) (0.48, 0.68) (0.3, 0.42) (0.31, 0.53) (-0.16, 0.55)
Kerman 1.25 1.02 -0.18 0.731 0.739 0.011
(1.08, 1.42) (0.84, 1.23) (-0.32, 0.01) (0.63, 0.83) (0.59, 0.98) (-0.19, 0.36)
Kermanshah 1.68 1.25 -0.256 0.9 0.832 -0.075
(1.45, 1.94) (1.01, 1.51) (-0.41, -0.06) (0.77, 1.04) (0.66, 1.14) (-0.28, 0.34)
Khorasan-e-Razavi 2.53 1.82 -0.279 1.59 1.42 -0.106
(2.24, 2.84) (1.51, 2.17) (-0.41, -0.11) (1.37, 1.82) (1.12, 2) (-0.31, 0.34)
Khuzestan 1.94 1.53 -0.211(-0.37, -0.01) 0.835 0.826 -0.011
(1.7, 2.2) (1.25, 1.86) (0.72, 0.94) (0.64,1.17) (-0.24, 0.42)
Kohgiluyeh and Boyer-Ahmad 0.51 0.405 -0.206 0.195 0.164 -0.158
(0.41, 0.61) (0.31, 0.51) (-0.41, 0.07) (0.15, 0.23) (0.12, 0.23) (-0.39, 0.31)
Kurdistan 0.94 0.645 -0.313 0.70 0.60 -0.134
(0.81, 1.08) (0.52, 0.78) (-0.45, -0.14) (0.6, 0.81) (0.48, 0.84) (-0.33, 0.25)
Lorestan 1.39 0.953 -0.314 0.521 0.41 -0.213
(1.17, 1.64) (0.77, 1.17) (-0.45, -0.1) (0.44, 0.6) (0.3, 0.64) (-0.42, 0.23)
Markazi 1.7 1.24 -0.268 0.936 0.937 0.001
(1.47, 1.95) (1.02, 1.49) (-0.42, -0.08) (0.78, 1.08) (0.74, 1.25) (-0.23, 0.39)
Mazandaran 1.01 0.865 -0.144 0.38 0.435 0.144
(0.86, 1.17) (0.71, 1.05) (-0.32, 0.07) (0.32, 0.43) (0.34, 0.57) (-0.11, 0.55)
North Khorasan 1.15 1 -0.125 0.591 0.704 0.191
(1.01, 1.32) (0.83, 1.19) (-0.28, 0.06) (0.51, 0.67) (0.55, 0.96) (-0.06, 0.67)
Qazvin 0.67 0.542 -0.191 0.35 0.321 -0.090
(0.58, 0.75) (0.45, 0.64) (-0.33, -0.01) (0.3, 0.4) (0.25, 0.44) (-0.29, 0.31)
Qom 1.96 1.36 -0.302 1.50 1.14 -0.242
(1.71, 2.23) (1.12, 1.65) (-0.43, -0.14) (1.3, 1.72) (0.91, 1.56) (-0.4, 0.09)
Semnan 1.37 1.03 -0.244 0.916 0.766 -0.163
(1.2, 1.5) (0.86, 1.21) (-0.37, -0.08) (0.79, 1.05) (0.59, 1.07) (-0.34, 0.14)
Sistan and Baluchistan 3.99 3.02 -0.242 2.66 2.28 -0.141
(3.41, 4.64) (2.41, 3.75) (-0.41, -0.01) (2.21, 3.12) (1.78, 3.09) (-0.34, 0.28)
South Khorasan 2.79 1.95 -0.301 1.27 1.11 -0.13
(2.44, 3.18) (1.62, 2.32) (-0.42, -0.15) (1.1, 1.47) (0.89, 1.51) (-0.3, 0.23)
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 9 of 12

Table 3 (continued)
Death Male Female
2010 2019 Change 2010–2019 2010 2019 Change 2010–2019

Tehran 1.27 1.07 -0.162 1.14 1.02 -0.106

(1.06, 1.52) (0.85, 1.35) (-0.36, 0.01) (0.91, 1.38) (0.8, 1.31) (-0.32, 0.25)
West Azarbayejan 0.914 0.706 -0.227 0.45 0.469 0.0216
(0.8, 1.03) (0.58, 0.85) (-0.37, -0.06) (0.4, 0.52) (0.37, 0.67) (-021, 0.53)
Yazd 1.71 1.15 -0.325 0.98 0.811 -0.178
(1.45, 1.99) (0.93, 1.4) (-0.46, -0.15) (0.84, 1.15) (0.62, 1.16) (-0.37, 0.24)
Zanjan 1.03 0.734 -0.289 0.34 0.334 -0.025
(0.91, 1.16) (0.61, 0.86) (-0.4, -0.16) (0.29, 0.38) (0.26, 0.48) (-0.25, 0.43)

Fig. 7 Correlation between the Human Development Index, incidence and Death rates of Tuberculosis in Iran in 2010 and 2019

incidence of tuberculosis from 1995 to 2012 [32]. Noeske The risk of contracting tuberculosis is higher among the
et al., in a study in Cameroon, reported a decrease in elderly population in the world. According to the present
PTB + cases from 139 to 121 cases per 1000 people dur- study, the highest incidence and death rate of tuberculo-
ing 2006–2014 [33]. sis is seen in the age groups above 60 years and the lowest
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 10 of 12

rate is related to children under 5 years old, which may be The reasons behind the higher concentration of TB
the effect of reducing immunity in the lungs in the elderly incidence in less developed areas may be living in poor
and shows the significant success of the country in con- conditions such as food insecurity, inadequate housing,
trolling the disease in younger age groups. In the study and lack of access to proper health care [42]. Therefore,
by Khajedaluee et al. (2019), the mortality rate was higher in areas with lower HDI, a control program with a pub-
in the elderly group [34]. Hagiya et al. (2019) investigated lic health approach is needed. In fact, every effort should
the incidence of active tuberculosis and mortality among be made to improve social conditions, including reduc-
the elderly and showed that although decreasing steadily, ing the incidence and death of infectious diseases in these
the incidence and death rates are still high [35]. areas.
According to the present study, the incidence and death One of the limitations of this study was that since the
due to tuberculosis during the years 2010 to 2019 were current study was an ecological study, the most impor-
higher in men, and the decreasing trend of the disease in tant error in this study was an ecological fallacy, and the
women was more significant than in men. Based on the results of these studies should be interpreted with cau-
documents, men get lower health services than women tion. Furthermore, other limitations to be mentioned
[31, 36]. Male patients with tuberculosis usually postpone here are those reported in GBD studies and the lack of
health care more than female patients [30]. accurate and reliable data for the incidence and mortal-
Although all parts of Iran are under the surveillance ity rates in some provinces of Iran, especially in the more
of the comprehensive tuberculosis control program, the deprived areas.
incidence of tuberculosis is not the same in all regions
of the country. According to the prior studies, although
Golestan province is not bordering provinces with a high Conclusion
prevalence of tuberculosis, in 2005, it ranked second in Studying the trend of changes in the prevalence or inci-
terms of incidence and prevalence of tuberculosis with a dence rates provides valuable information for assessing
rate of 38.1 per 100,000. Sistan and Baluchistan ranked the needs, and designing and revising development plans
first in overall TB prevalence with a rate of 44.1 per and indices in a country. Evaluation of data related to
100,000 people. While Mazandaran province, Golestan one period can also help predict the frequency of future
province’s neighbor, with a similar ecosystem, has a incidents. To achieve the objectives of TB control, activi-
tuberculosis incidence of 9.6 per 100,000, which is much ties leading to timely detection and effective treatment of
lower [37]. patients in each country and province should be included
This study showed that Sistan and Baluchestan and in TB control strategies. On the other hand, based on the
Golestan provinces had the highest incidence and death results of mortality in 2010, mortality rates were higher
rates of tuberculosis. Due to its proximity to Afghanistan in areas with lower HDI, and this relationship and cor-
and Pakistan, the province of Sistan and Baluchistan had relation were also observed in 2019, showing that despite
a high prevalence of tuberculosis. The results of the study the passage of several years and a decrease in the inci-
conducted by Salek et al. in Golestan province showed dence and death rates of tuberculosis, in Areas with a
that the incidence rate of smear-positive pulmonary lower human development index, more deaths occur due
tuberculosis in Golestan and the national incidence rate to tuberculosis, which shows that these areas should be
in the same year were 22.1 and 7.8 per 100,000 people, included in the priorities and planning of the livelihood
respectively [37]. The high rate of tuberculosis in this policy so that they can be effective in reducing deaths
province can be due to being located on the border. resulting from this disease in the country.
The results of the present study showed that there was
a negative and significant correlation between the death Supplementary Information
rate of tuberculosis disease and the human development The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12889-​023-​17114-4.
index in 2010 and 2019. The results of Okhovat-Isfahani
et al. [17], Muniyandi et al. [38], and Rodríguez-Morales
Additional file 1.
et al. [39] showed a higher concentration of TB in coun-
tries with low HDI. Inequality in TB incidence has been
Acknowledgements
observed based on WHO regions. In most WHO regions, The authors would like to thank Global Burden of Disease and their staff for
tuberculosis and TB/HIV were concentrated in countries their willingness to provide the data required for this research.
with lower HDI [17]. According to some studies, poverty,
Authors’ contributions
income inequality and lack of social capital were impor- Design: E.G, Z.Kh, and Processing: E.G, H.F, Analysis or Interpretation: E.G, S.R,
tant predictors of an increase in tuberculosis incidence Z.Kh Literature Review: M.L.N, E.G All authors reviewed the manuscript.
[21, 40, 41].
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 11 of 12

Funding and treatment outcomes of patients with smear positive pulmonary

Not applicable. tuberculosis: a population-based study. J Mazandaran Univ Med Sci.
2012;21(1):9–18.
Availability of data and materials 12. Abbas J, Aman J, Nurunnabi M, Bano S. The impact of social media on
All the data used in this research were made available to the public at http://​ learning behavior for sustainable education: Evidence of students from
ghdx.​healt​hdata.​org/​gbd-​resul​ts-​tool selected universities in Pakistan. Sustainability. 2019;11(6):1683.
13. Asgharzadeh M. Use of DNA Fingerprinting in Identifying the Source Case
of Tuberculosis in East Azarbaijan Province of Iran" M. Asgharzadeh,“K.
Declarations Shahbabian," H. Samadi Kafil and" A. Raf J Med Sci. 2007;7(3):418–21.
14. Keppel K, Pamuk E, Lynch J, Carter-Pokras O, Kim I, Mays V, et al. Methodo-
Ethics approval and consent to participate logical issues in measuring health disparities. Vital and health statistics
The study was approved by the ethics committee of Yazd University of Medi- Series 2, Data evaluation and methods research. 2005(141):1.
cal Science, Iran. 15. Braveman P. What are health disparities and health equity? We need to be
clear. Public health rep. 2014;129(1_suppl2):5–8.
Consent for publication 16. Semenza JC, Giesecke J. Intervening to reduce inequalities in infections in
Not Applicable. Europe. Am J Public Health. 2008;98(5):787–92.
17. Okhovat-Isfahani B, Bitaraf S, Mansournia MA, Doosti-Irani A. Inequality
Competing interests in the global incidence and prevalence of tuberculosis (TB) and TB/HIV
The authors declare that there is no conflict of interests. according to the human development index. Med J Islam Repub Iran.
2019;33:45.
Author details 18. Harling G, Ehrlich R, Myer L. The social epidemiology of tuberculosis in
1
Center for Healthcare Data Modeling, Departments of Biostatistics and Epi- South Africa: a multilevel analysis. Soc Sci Med. 2008;66(2):492–505.
demiology, School of Public Health, Shahid Sadoughi University of Medi- 19. Hoa N, Tiemersma E, Sy D, Nhung N, Gebhard A, Borgdorff M, et al.
cal Sciences, Yazd, Iran. 2 Pharmaceutical Sciences and Cosmetic Products Household expenditure and tuberculosis prevalence in VietNam:
Research Center, Kerman University of Medical Sciences, Kerman, Iran. 3 Social prediction by a set of household indicators. Int J Tuberc Lung Dis.
Determinants of Health Research Center, Semnan University of Medical Sci- 2011;15(1):32–7.
ences, Semnan, Iran. 4 Social Determinants of Health Research Center, Lorestan 20. Goodarzi E, Sohrabivafa M, Darvishi I, Naemi H, Khazaei Z. Epidemiol-
University of Medical Sciences, Khorramabad, Iran. ogy of mortality induced by acute respiratory infections in infants and
children under the age of 5 years and its relationship with the Human
Received: 9 February 2023 Accepted: 31 October 2023 Development Index in Asia: an updated ecological study. J Public Health.
2021;29(5):1047–54.
21. Goodarzi E, Sohrabivafa M, Hassanpour Dehkordi A, Moayed L, Khazaei Z.
Effect of human development index on tuberculosis incidence in Asia: An
ecological study. Advances in Human Biology. 2019.
References 22. Khazaei S, Rezaeian S, Baigi V, Saatchi M, Molaeipoor L, Khazaei Z, et al.
1. Bütikofer A, Salvanes KG. Disease control and inequality reduction: Evi- Incidence and pattern of tuberculosis treatment success rates in different
dence from a tuberculosis testing and vaccination campaign. Rev Econ levels of the human development index: a global perspective. South Afr J
Stud. 2020;87(5):2087–125. Infect Dis. 2017;32(3):100–4.
2. Makki SSM, Ghorbani F, Najafizadeh K, Shafaghi S, Vishteh HRK. Assess- 23. Murray CJ, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari
ment of diagnostic value of different methods (culture, PCR and biopsy) M, et al. Global burden of 87 risk factors in 204 countries and territories,
for the diagnosis of tuberculosis in patients with bronchial anthracosis. 1990–2019: a systematic analysis for the Global Burden of Disease Study
Immunopathologia Persa. 2020;6(2):e24-e. 2019. The Lancet. 2020;396(10258):1223–49.
3. Salehi M, Vahabi N, Pirhoseini H, Zayeri F. Trend analysis and longitudinal 24. Collaborators G, Ärnlöv J. Global burden of 87 risk factors in 204 countries
clustering of tuberculosis mortality in Asian and North African countries: and territories, 1990–2019: a systematic analysis for the Global Burden of
Results from the global burden of disease 2017 study. Med J Islam Repub Disease Study 2019. The Lancet. 2020;396(10258):1223–49.
Iran. 2021;35:46. 25. Goodarzi E, Sohrabivafa M, Adineh H, Moayed L, Khazaei Z. Geographi-
4. Sekadde MP, Wobudeya E, Joloba ML, Ssengooba W, Kisembo H, Bakeera- cal distribution global incidence and mortality of lung cancer and its
Kitaka S, et al. Evaluation of the Xpert MTB/RIF test for the diagnosis of relationship with the Human Development Index (HDI); an ecology study
childhood pulmonary tuberculosis in Uganda: a cross-sectional diagnos- in 2018. World Cancer Res J. 2019;6:11.
tic study. BMC Infect Dis. 2013;13(1):1–8. 26. Khazaei Z, Namayandeh SM, Beiranvand R, Naemi H, Bechashk SM,
5. Movahedi Z, Mahmoudi S, Banar M, Pourakbari B, Aziz-Ahari A, Goodarzi E. Worldwide incidence and mortality of ovarian cancer and
Ramezani A, et al. Pediatric tuberculosis in Iran: a review of 10-years Human Development Index (HDI): GLOBOCAN sources and methods
study in an Iranian referral hospital. Acta Bio-medica: Atenei Parmensis. 2018. J Prev Med Hyg. 2021;62(1):E174.
2022;93(2):e2022035-e. 27. Marvi A, Asadi-Aliabadi M, Darabi M, Rostami-Maskopaee F, Siamian H,
6. Dirlikov E, Raviglione M, Scano F. Global tuberculosis control: toward the Abedi G. Silent changes of tuberculosis in Iran (2005–2015): A join-
2015 targets and beyond. Ann Intern Med. 2015;163(1):52–8. point regression analysis. Journal of family medicine and primary care.
7. Houben RM, Dodd PJ. The global burden of latent tuberculosis 2017;6(4):760.
infection: a re-estimation using mathematical modelling. PLoS Med. 28. Glaziou P, Sismanidis C, Floyd K, Raviglione M. Global epidemiology of
2016;13(10):e1002152. tuberculosis. Cold Spring Harb Perspect Med. 2015;5(2):a017798.
8. Glaziou P, Falzon D, Floyd K, Raviglione M, editors. Global epidemiology 29. Honarvar MR, Charkazi A, Mirkarimi K, Sheikhi M, Kamalinia HR, Arbabi ER.
of tuberculosis. Seminars in respiratory and critical care medicine; 2013: Eleven year epidemiological study of tuberculosis in Golestan Province,
Thieme Medical Publishers. 2013;2(5):136. Northern of Iran. Iranian J Public Health. 2020;49(3):563–9.
9. Kia NS, Zavareh MN, Sarkheil E, Ghods E. Prevalence of biologic, behavio- 30. Karimi M, Azadi N, Rahmani K. Trend of TB incidence rate and its treat-
ral and psychosocial determinant of tuberculosis in tuberculosis patients ment success in Kurdistan, Iran from 2000 to 2012. Scientific Journal of
of Semnan city; a five-year cross-sectional study. Journal of Preventive Kurdistan University of Medical Sciences. 2015;20(3):1–9.
Epidemiology. 2020;5(2):e24-e. 31. Kazemnejad A, Arsang Jang S, Amani F, Omidi A. Global epidemic trend
10. Bay V, Tabarsi P, Rezapour A, Marzban S, Zarei E. Cost of tuberculosis of tuberculosis during 1990–2010: using segmented regression model. J
treatment: evidence from Iran’s health system. Osong public health and res health sci. 2014;14(2):115–21.
research perspectives. 2017;8(5):351. 32. Khazaei S, Soheilyzad M, Molaeipoor L, Khazaei Z, Rezaeian S,
11. Nasehi MM, Moosazadeh M, Amiresmaeili MR, Parsaee MR, Nezam- Khazaei S. Trend of smear-positive pulmonary tuberculosis in Iran
mahalleh A. The epidemiology of factors associated with screening
Fallahzadeh et al. BMC Public Health (2023) 23:2404 Page 12 of 12

during 1995–2012: a segmented regression model. Int JPreventive

Med. 2016;7(11):125.
33. Noeske J, Nana Yakam A, Abena FJ. Epidemiology of tuberculosis in
Cameroon as mirrored in notification data, 2006–2014. Int J Tuberc Lung
Dis. 2016;20(11):1489–94.
34. Khajedaluee M, Nasehi M, Sharafii S, Dadgarmoghaddam M. The burden
of tuberculosis in Iran, A 12-year population-based study. Med J Islam
Repub Iran. 2021;35(1):99–103.
35. Hagiya H, Koyama T, Zamami Y, Minato Y, Tatebe Y, Mikami N, et al. Trends
in incidence and mortality of tuberculosis in Japan: a population-based
study, 1997–2016. Epidemiology & Infection. 2019;147.
36. Gebreegziabher SB, Yimer SA, Bjune GA. Tuberculosis case notification
and treatment outcomes in West Gojjam Zone, Northwest Ethiopia:
a five-year retrospective study. Journal of Tuberculosis Research.
2016;4(1):23–33.
37. Salek S, Emami H, Masjedi MR, Velayati AA. Epidemiologic status of tuber-
culosis in Golestan province. 2008.
38. Muniyandi M, Ramachandran R. Socioeconomic inequalities of tuberculo-
sis in India. Expert Opin Pharmacother. 2008;9(10):1623–8.
39. Rodríguez-Morales AJ, Castañeda-Hernández DM. Relationships between
morbidity and mortality from tuberculosis and the human development
index (HDI) in Venezuela, 1998–2008. Int J Infect Dis. 2012;16(9):e704–5.
40. Arenas NE, Quintero-Álvarez L, Rodríguez-Marín K, Gómez-Marín JE.
Sociodemographic and spatial transmission of tuberculosis in the city of
Armenia (Colombia). Infectio. 2012;16(3):154–60.
41. Holtgrave DR, Crosby RA. Social determinants of tuberculosis case rates in
the United States. Am J Prev Med. 2004;26(2):159–62.
42. Lönnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, et al.
Tuberculosis control and elimination 2010–50: cure, care, and social
development. The lancet. 2010;375(9728):1814–29.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions