Years of Life Lost due to Premature Mortality Following Sulfur Mustard Exposure: A Post-War National Burden of Disease Study (1988-2021)

Years of Life Lost due to Premature Mortality Following Sulfur Mustard Exposure: A Post-War National Burden of Disease Study (1988-2021) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Years of Life Lost due to Premature Mortality Following Sulfur Mustard Exposure: A Post-War National Burden of Disease Study (1988-2021) Sajad Shojaee, Rasoul Aliannejad, Fatemeh Nobakht, Alireza Akbarzadeh Baghban, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7847427/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Sulfur Mustard (SM), widely used during the Iran-Iraq war, has caused long-lasting health effects and reduced life expectancy among exposed individuals. This national study aimed to quantify Years of Life Lost (YLL) due to premature mortality among Iranian survivors exposed to SM during the post-war period (1988–2021). Methods Data were obtained from the Veterans and Martyr Affairs Foundation (VMAF). YLL was calculated using both the Iranian Nationwide Life Table and the Coale-Demeny Model Life Table West, incorporating discount rates (0%, 3%, and 6%) and age-weightings (0 and 1). Results A total of 8,956 deaths were recorded among individuals with a history of SM exposure, predominantly in males (98.3%). Depending on methodological assumptions, the total YLL ranged from 87,625.7 to 228,951.1. Using a 0% discount rate and no age-weighting based on the Iranian Nationwide Life Table, males accounted for the vast majority of YLL (188,234.4 years; 98.8%), with the highest burden in the 50–54 age group (38,072.9 years). Females experienced considerably lower YLL (2,342.4 years; 1.2%), with a peak in the 60–64 age group (339.1 years). Under the same assumption, the average YLL per deceased male was 21.4 years, compared to 15.0 years for females. Average YLL increased with the severity of lung injury (from mild to severe), rising from 20.5 to 21.4 years in men and from 15.3 to 34.7 years in women. Survivors with combined lung/skin or lung/eye complications showed the highest average YLL in males (21.4 and 21.2 years, respectively), whereas females with severe lung complications faced an elevated average of 34.7 years. Geographic disparities were observed across provinces, and a statistically significant upward trend in YLL over time was found for both sexes (p < 0.001 for each). Conclusions These findings highlight the critical need for sustained monitoring and targeted care for survivors with lung damages, especially those with multiple or severe pulmonary complications. The rising YLL over time underscore the importance of ongoing research to guide the effective prevention and intervention strategies. Further investigation into geographic disparities is needed to improve regional and population-specific care. Years of Life Lost Chemical Warfare Survivors Sulfur Mustard Exposure Involved Organs Severity of Complications Burden of Disease Figures Figure 1 Figure 2 Introduction Chemical weapons are considered one of the most horrific weapons of mass destruction due to their acute and chronic effects on the human health ( 1 , 2 ). Sulfur mustard (SM), a well-known chemical instrument, has been documented to cause devastating health consequences ( 3 ). It is a colorless, odorless gas that persists in the environment, rendering affected areas uninhabitable. Victims of SM exposure often experience temporary loss of vision within hours, a tactic that has been strategically employed in numerous military conflicts ( 4 – 6 ). As a potent alkylating agent, SM induces cellular necrosis and has mutagenic and carcinogenic properties ( 7 – 9 ). Injuries resulting from SM exposure are categorized into early and late-onset complications, with the latter primarily affecting the respiratory system, leading to chronic conditions such as bronchitis, bronchiectasis, and recurrent bronchopneumonia ( 2 ). The weaponization of SM dates back to 1917 when the German army deployed it against Canadian and French troops during World War I ( 10 ). Its use has persisted through various military conflicts, including the Iran-Iraq War. During the eight-year conflict, the Iraqi army chemically attacked the Iranians 387 times, using over 1,800 tons of sulfur mustard ( 4 , 11 , 12 ) and injuring around 100,000 people, many of whom still require long-term medical care due to persistent health complications ( 13 , 14 ). The most intense chemical attacks took place in the cities of Sardasht and Oshnaviyeh, resulting in catastrophic health outcomes ( 4 ). Despite extensive research on the long-term effects and complications associated with SM exposure, studies on mortality rates remain limited ( 15 – 17 ). One study estimated that each Iranian victim killed during the Iran-Iraq war lost an average of at most 61.3 years of his/her life, amounting to a total of 11.2 million years lost ( 18 ). To date, a comprehensive analysis of the years of life lost (YLL) due to premature mortality among Iranian chemical warfare survivors (CWS) has not been conducted. YLL is a critical public health measure that captures the impact of premature mortality by accounting for both the age at death and the expected lifespan. Evaluating YLL in the population exposed to SM reveals the hidden burden of premature mortality, informs evidence-based health planning, and emphasizes the lasting impact of chemical weapons for affected individuals. Therefore, this study aims to assess YLL among Iranian veterans and civilians exposed to SM as part of the overall burden of disease, using a long-term post-war follow-up period (1988–2021). The Disability-Adjusted Life Year (DALY) represents the sum of years of life lost (YLL) and years lived with disability (YLD), serving as a standardized measure of overall burden of disease. To our knowledge, this study provides the initial estimation of DALY attributable to sulfur mustard exposure among Iranian survivors of the Iran–Iraq War. Methods Study design and settings This study used a national Iranian database of individuals exposed to SM during the Iran–Iraq war (1980–1988). The data were obtained from the Veterans and Martyr Affairs Foundation (VMAF) database, encompassing records from the Medical Commission, the Center for the Care of Chemical Injuries, and the Information Technology database. All war-related injuries, including those caused by SM, are documented in the VMAF database. This agency provides free, comprehensive, long-term healthcare to injured war survivors and their families, upholding the highest standards of care. The complexities of acute and chronic SM exposure necessitated ongoing care for affected individuals. To manage this, an expert panel systematically reviewed each case, documenting all resulting complications within the VMAF database. Actually, medical experts reviewed documented lesions on the lungs, skin, and eyes to diagnose and grade the severity of SM injuries. SM exposure data were categorized into three groups: ( 1 ) confirmed exposure with evacuation/admission, ( 2 ) confirmed exposure without evacuation/admission, and ( 3 ) undocumented cases with late-onset symptoms indicative of exposure. This classification distinguished varying levels of documented SM exposure. Study population and inclusion/exclusion criteria The study population comprised individuals with documented exposure to SM gas between 1980 and 1988. This study covered 8,956 SM post-war death, including 8,800 males and 156 females. National database for Iranian veterans and civilians who exclusively exposed to SM during the period 1980–1988, and subsequently died between 1988 and 2021 were retrieved and considered as an inclusion criteria. Exposure to any other chemical warfare agents served as an exclusion criteria. Classification of injuries in organs due to SM exposure Classification of chemical warfare injuries in lung, eye, and skin due to exposure to SM was conducted. Lung. Lung lesions following SM exposure were classified based on spirometry results of forced expiratory volume in first second (FEV1) as follows. Subclinical or asymptomatic: FEV1 higher than 80%; mild: FEV1 greater than 70% but less than or equal to 80%; moderate: FEV1 greater than 50% but less than or equal to 70%; and severe: FEV1 less than or equal to 50% with normal arterial blood gas or severe tracheobronchomalacia ( 19 ). Skin. The presence of specific scars of SM in skin areas including pigmentation, vascular or trophic changes, as well as the appearance of cutaneous T-cell lymphoma or mycosis fungoid indicated clinical signs and symptoms of the exposure to SM in the skin ( 20 ). The mild category was defined as 1) the presence of an SM-specific scar in less than 5% of the body surface; 2) the presence of such a scar plus mild dermatitis and mild xerosis or mild-to-moderate autoimmune diseases; 3) and concurrent medical documents plus severe autoimmune diseases or any mild dermatitis. The moderate category was defined as 1) the presence of an SM-specific scar at least 5% and to at most 20% of the body surface; 2) presence of an SM-specific scar with significant nutritional changes in the genital area or anus; 3) the presence of an SM-specific scar of any size whether with or without concurrent medical documents plus severe dermatitis covering less than half of the body surface; 4) concurrent medical documents with severe dermatitis or xerosis covering less than half of the body surface; 5) and the presence of an SM-specific scar of any size whether with or without concurrent medical documents plus any severe autoimmune disease at more than half of the body surface. The severe category was defined as 1) the presence of an SM-specific scar more than 20% of the body surface; 2) the presence of an SM-specific scar of any size whether with or without concurrent medical documents with severe dermatitis or xerosis covering more than half of the body surface; 3) and concurrent medical documents with severe dermatitis or xerosis covering less than half of the body surface. Eye. The presence of conjunctival vascular changes, including: telangiectasia, segmentation, venous beading, tortuosity, and vascular dilatation, along with vascular ischemic complications of the limbus, were specific clinical signs and symptoms of SM in the eyes ( 21 ). The mild category was defined as itching, burning, tearing, redness, blurred vision, foreign body sensation, conjunctivitis, subconjunctival hemorrhage, photophobia, or conjunctival vascular changes in each or both eyes. The moderate category was defined as the same changes in the mild category plus conjunctival ischemia in the limbus area, as well as closure of unilateral or bilateral or punctum cauterization. The severe category was defined as similar observations in the moderate category plus symptoms of corneal involvement, keratopathy, pannus, epithelial and subepithelial opacity and anterior stroma in the cornea, hyperpigmentation around the nerve, iron deposition in the cornea and corneal vascularization, stenosis, and involvement of both eyes less than half unilaterally or bilaterally ( 21 ). Statistical Analysis This study analyzed the burden of disease due to SM exposure in Iran from 1988 to 2021. YLL, a component of DALY, was calculated as the number of cause-specific deaths multiplied by a loss function which specifies the years lost as a function of the age at which death occurs ( 22 ). We employed two approaches to estimate YLL. The first utilized life chart of the book of the Statistics Center of Iran (State Management and Planning Organization) based on sex and age at death ( 18 ). The second approach employed the Coale-Demeny Model Life Table West (Levels 25 and 26) for males and females ( 23 – 25 ). Both methods incorporated variations in discount rates (0%, 3%, and 6%) and age weightings (0 = none, 1 = applied) to reflect the age-dependent value of life. Crude expected years of life lost were initially calculated as the product of the number of deaths ( \(\:{\text{D}}_{\text{x}}\) ) and the standard life expectancy at the age of death ( \(\:{\text{e}}_{\text{x}}^{\text{s}}\) ): $$\:\text{Y}\text{L}\text{L}=\:{\text{D}}_{\text{x}}{\text{e}}_{\text{x}}^{\text{s}}$$ To further extend the basic formula and incorporate discounting and age weighting, necessitates several assumptions. The following formula was used to calculate the extended YLL: $$\:{\text{Y}}_{\text{x}}=\:{\text{d}}_{\text{x}}\left[\frac{\text{K}\text{C}{\text{e}}^{\text{r}}\left({\text{a}}_{\text{x}}\right)}{{\left(\text{r}+{\beta\:}\right)}^{2}}\left({\text{e}}^{\text{z}}\left[\text{z}-1\right]-{\text{e}}^{-\left(\text{r}+{\beta\:}\right){\text{a}}_{\text{x}}}\left[-\left(\text{r}+{\beta\:}\right){\text{a}}_{\text{x}}-1\right]\right)+\frac{1-\text{K}}{\text{r}}\left(1-{\text{e}}^{\text{r}\left({\text{e}}_{\text{x}}^{\text{s}}\right)}\right)\right]$$ However, when the discount rate equals zero, the equation requires simplification for practical use ( 26 ). Symbol definitions are listed below: 𝑎 = age at death 𝑟 = discount rate 𝛽 = age weighting constant (typically 0.04) 𝐾 = age-weighting modulation constant 𝐶 = adjustment constant for age-weights (typically 0.1658) 𝑒 = standard life expectancy at age of death 𝑑 = number of deaths The discount rate accounts for the reduced value of future mortality compared to present; therefore higher discount rates lessen the impact of future losses. Age weighting assigns greater value to years of life lost at younger ages. The constants C and β were derived from the 1990 Global Burden of Disease study ( 27 ). YLL calculations were stratified by sex and five-year age groups. These calculations were further broken down by affected organ system (lung, skin, and eye), and analyzed over time to assess trends from 1988 to 2021. Average YLL per deceased individual was determined by dividing total YLL by the total number of deaths. A Mann-Kendall test was also employed to determine the presence of trends in the data. All statistical analysis were conducted using R software, version 4.5.1 and ArcMap, version 10.8.2. Ethical consideration The research protocol was reviewed and approved by the Ethics Committee Board at the Janbazan Medical and Engineering Research Center in Tehran, Iran. To ensure ethical standards and protect individual rights, all personally identifiable information has been removed to maintain confidentiality. The authorization to access and utilization of the data was obtained by the Ethics Committee for this study. Results The VMAF database The VMAF database recorded 8,956 SM post-war deaths (1988–2021), overwhelmingly male (8,800, 98.3%) compared to female (156, 1.7%). The median age of exposure to war-related events was 27 (IQR: 21–39), while the median age at death was 55 (IQR: 48–66). Ages at exposure ranged from 1 to 84 years, and ages at death from 11 to 113 years. A noticeable proportion of male survivors (32.5%, n = 2,861) died aged 50–59, whereas a larger percentage of female survivors (41.0%, n = 64) died at age 75 or older. Lung complications were prevalent, affecting 50.4% of male survivors (n = 4,318) and 70.4% of female survivors (n = 107). Nearly half (49.4%) of deaths were attributed to lung damage, while smaller proportions involved skin (10.6%) or eye (12.8%) complications. Among survivors with a single affected organ, death due to lung complications were considerably more common (13.4%) compared to skin (0.7%), eye (0.3%), or combinations of these (lung and skin 0.6%, lung and eye 0.3%, skin and eye 0.0%, and all three 0.1%). YLL on different approaches The distribution of YLL is presented in Table 1 , incorporating variations in discount rates (0%, 3%, and 6%) and age weightings (0, 1), based on two model life tables. Without discounting and age weighting, total YLL was 190,576.8 (188,234.4 male, 2,342.4 female) using the Iranian Nationwide Life Table. Employing the Coale-Demeny Model Life Table West under the same conditions increased the total YLL to 228,951.1 (226,026.4 male, 2,924.8 female). Applying a 6% discount rate and applying age weighting yielded the lowest YLL estimates: 87,625.7 (86,635.1 male, 990.6 female) for the Iranian Nationwide Life Table and 92,296.5 (91,203.6 male, 1,093.0 female) for the Coale-Demeny Model Life Table West. Table 1 Years of Life Lost among Iranians Exposed to Sulfur Mustard: A Review of Approaches YLL (Discount rate, Age weighting) Iranian Nationwide Life Table Coale-Demeny Model Life Table West Male Female Total Male Female Total YLL (0%, 0) 188,234.4 2,342.4 190,576.8 226,026.4 2,924.8 228,951.1 YLL (0%, 1) 158,917.0 1,795.0 160,712.0 180,176.7 2,082.2 182,258.9 YLL (3%, 0) 132,278.4 1,677.2 133,955.6 149,213.2 2,010.6 151,223.8 YLL (3%, 1) 114,034.6 1,286.6 115,321.2 123,455.4 1,447.2 124,902.6 YLL (6%, 0) 98,724.6 1,292.3 100,017.0 107,020.6 1,508.9 108,529.5 YLL (6%, 1) 86,635.1 990.6 87,625.7 91,203.6 1,093.0 92,296.5 YLL decreases with higher discount rates and applied age weighting. It shows an elevated burden of premature mortality with the Coale-Demeny model West compared to the Iranian life table, particularly without adjustments. YLL at several age categories YLL stratified by age and sex were calculated using the Iranian Nationwide Life Table, applying a 0% discount rate and no age weighting (Table 2 ). A notable disparity was observed between sexes: males accounted for the vast majority of deaths (8,800; 98.3%) and YLL (188,234.4 years; 98.8%), with the highest YLL concentrated in the 45–54 age groups (30,822.7 and 38,072.9 years, respectively). In contrast, females experienced considerably fewer deaths (156; 1.7%) and lower YLL (2,342.4 years; 1.2%), with maximum YLL observed in the 60–64 age group (339.1 years). Table 2 Years of Life Lost by Age at Death using Iranian Reference (0%, 0) Age interval Iranian Nationwide Life Table (Discount Rate = 0%, Age Weighting = 0) Male Female Total YLL Death YLL Death YLL Death 10–14 56.3 1 0.0 0 56.3 1 15–19 248.6 5 0.0 0 248.6 5 20–24 1,485.5 32 0.0 0 1,485.5 32 25–29 4,091.0 95 298.4 6 4,389.5 101 30–34 10,438.9 263 84.9 2 10,523.8 265 35–39 17,416.0 485 122.0 3 17,538.0 488 40–44 22,433.8 699 150.6 4 22,584.4 703 45–49 30,822.7 1,084 190.5 6 31,013.2 1,090 50–54 38,072.9 1,545 159.0 6 38,231.9 1,551 55–59 27,071.1 1,316 296.3 13 27,367.3 1,329 60–64 14,846.4 894 339.1 18 15,185.5 912 65–69 9,398.5 717 190.5 13 9,589.0 730 70–74 5,473.3 542 237.0 21 5,710.4 563 75+ 6,379.3 1,122 274.0 64 6,653.3 1,186 The data highlight a pronounced male predominance in both mortality and premature mortality burden. YLL in severity of lung, skin and eye complications Analysis of Table 3 indicates a relationship between the severity of SM-related complications and YLL. Calculations were made using the Iranian Nationwide Life Table with a 0% discount rate and no age weighting. Table 3 Years of Life Lost by Injury Severity using Iranian Reference (0%, 0) Severity Type Iranian Nationwide Life Table (Discount Rate = 0%, Age Weighting = 0) Male Female YLL (N) YLL (%) Death (N) Death (%) YLL (Avg.) YLL (N) YLL (%) Death (N) Death (%) YLL (Avg.) Lung Subclinical 95,840.6 52.3 4,255 49.6 22.5 605.4 26.5 45 29.6 13.5 Mild 62,571.9 34.1 3,058 35.7 20.5 1,196.5 52.3 78 51.3 15.3 Moderate 20,912.4 11.4 1,073 12.5 19.5 345.2 15.1 25 16.4 13.8 Severe 3,994.1 2.2 187 2.2 21.4 138.9 6.1 4 2.6 34.7 Eye Subclinical 164,914.2 88.2 7,634 87.2 21.6 2,062.2 88.3 133 85.8 15.5 Mild 21,010.9 11.2 1,049 12.0 20.0 272.7 11.7 22 14.2 12.4 Moderate 600.3 0.3 33 0.4 18.2 0.0 0.0 0 0.0 - Severe 657.2 0.2 34 0.4 19.3 0.0 0.0 0 0.0 - Skin Subclinical 167,304.9 89.9 7,791 89.5 21.5 1,998.5 86.6 128 83.1 15.6 Mild 16,586.1 8.9 792 9.1 20.9 225.0 9.7 19 12.3 11.8 Moderate 1,919.6 1.0 101 1.2 19.0 84.5 3.7 7 4.5 12.1 Severe 344.0 0.2 20 0.2 17.2 0.0 0.0 0 0.0 - Average YLL increased with severity among males with lung injury and more markedly among females, particularly for severe lung involvement (34.7 years). In contrast, no consistent trend was observed for eye or skin injuries. Both mild-to-severe eye and skin injuries individually accounted for more than 10% of YLL in males and females. In comparison, mild-to-severe lung injury accounted for 47.7% (males) and 73.5% (females) of total YLL. Average YLL also increased with the severity of lung injury, rising from 20.5 in mild cases to 21.4 in severe cases among men, and from 15.3 to 34.7 among women. Additionally, severe lung injuries resulted in a much higher average YLL for females (34.7 years) compared to males (21.4 years). YLL in total severity and involved organs Total injury severity showed that males accounted for a total of 188,234.4 YLL, with the subclinical severity category contributing the highest proportion (87,777.0 years, 46.1%), followed by mild (73,980.0 years, 39.7%), moderate (21,835.0 years, 11.8%), and severe (4,642.4 years, 2.5%). Conversely, females experienced a total of 2,342.2 YLL, with a predominance of mild severity cases (1,301.4 years, 54.8%) and a notably average YLL of 34.7 years by severe cases. Simultaneously Involved Organs represented that The majority of YLL in males (161,757.1 years, 85.7%) was associated with subclinical/mild conditions, followed by lung involvement accounted for 12.6% of YLL, resulted in a significantly higher average YLL per case (19.7 years). In females, the total YLL was substantially lower with the highest proportion (1,791.8 years, 75.9%) linked to subclinical/mild cases, and of course, the highest average of 17.3 years was associated to lung involvement. All analysis was conducted using the Iranian Nationwide Life Table; a 0% discount rate and no age weighting were applied to the calculations (Table 4 ). Table 4 Years of Life Lost by Total Severity and Involved Organs using Iranian Reference (0%, 0) Variables Type Iranian Nationwide Life Table (Discount Rate = 0%, Age Weighting = 0) Male Female YLL (N) YLL (%) Death (N) Death (%) YLL (Avg.) YLL (N) YLL (%) Death (N) Death (%) YLL (Avg.) Total Severity Subclinical 87,777.0 46.1 3,863 43.9 22.7 490.4 21.1 38 24.4 12.9 Mild 73,980.0 39.7 3,585 40.7 20.6 1,301.4 54.8 84 53.8 15.5 Moderate 21,835.0 11.8 1,128 12.8 19.4 411.7 18.0 30 19.2 13.7 Severe 4,642.4 2.5 224 2.5 20.7 138.9 6.1 4 2.6 34.7 Involved Organs Subclinical/Mild 161,757.1 85.7 7,448 84.6 21.7 1,791.8 75.9 122 78.2 14.7 Lung 23,116.6 12.6 1,175 13.4 19.7 466.1 20.4 27 17.3 17.3 Skin 1,053.1 0.5 61 0.7 17.3 66.5 2.9 5 3.2 13.3 Eye 503.8 0.2 28 0.3 18.0 0.0 0.0 0 0.0 - Lung/Skin 1,050.1 0.6 49 0.6 21.4 18.0 0.8 2 1.3 9.0 Lung/Eye 593.3 0.3 28 0.3 21.2 0.0 0.0 0 0.0 - Skin/Eye 14.0 0.0 3 0.0 4.7 0.0 0.0 0 0.0 - Lung/Skin/Eye 146.5 0.1 8 0.1 18.3 0.0 0.0 0 0.0 - Severe injuries, though rare, showed elevated average YLL (20.3 years in males, 34.7 years in females). A synergistic effect on premature mortality was observed when lung injury co-occurred with skin (1,050.1 YLL) or eye involvement (593.3 YLL), resulting in an increased average YLL per death (rising from 21.2 to 21.4 years), compared to single-organ conditions. YLL and time trend analysis The analysis of the trend of YLL over the study period (1988–2021) provided in Fig. 1 , using a 0% discount rate and no age weighting by the Iranian Nationwide Life Table. During the first decade following the Iran-Iraq post-war, YLL remained relatively stable. However, subsequent years witnessed a marked increase in both YLL and mortality for both males and females. As shown in Fig. 1 , YLL in females exhibited greater fluctuation than in males. The highest YLL estimates (near 15,000 years) occurred in 2020 and 2021. Despite the ups and downs in different years, the Mann-Kendall trend test confirmed a statistically significant upward trend in both of males (p < 0.001, Fig. 1 a) and females (p < 0.001, Fig. 1 b). YLL across provinces of Iran YLL due to SM exposure according to the Iranian Nationwide Life Table, a 0% discount rate and no age weighting displayed substantial geographic variation across Iranian provinces. The highest YLL were observed on the provinces of Tehran (19,933.1), Khorasan Razavi (16,197.3), Isfahan (15,962.8), Fars (14,982.3), and Kerman (14,526.6), all belonging to the same cluster. Conversely, the lowest YLL were found in Hormozgan (878) and South Khorasan (966.3). The distribution of YLL represented a high dispersion and diversity across provinces of Iran (Fig. 2 ). Supplementary Analysis The analysis revealed that the highest YLL were found in the age group of 45–54 years, whereas the lowest YLL were observed in the 10–19 age category, despite differing estimation methodologies (see Supplementary Tables S1-S11). Among male survivors, the highest average YLL, excluding subclinical cases, were linked to severe lung injuries, with averages 21.4 years based on the Iranian Nationwide Life Table and 25.7 years according to the Coale-Demeny Model Life Table West. In contrast, female survivors exhibited the highest average YLL associated with severe lung lesions, recorded at 34.7 years per the Iranian Nationwide Life Table and 41.3 years according to the Coale-Demeny Model Life Table West (see Supplementary Tables S12-S22). For male survivors, the highest average YLL, excluding subclinical cases, were attributed to simultaneously lung/eye and lung/skin injuries, yielding averages of 21.2 and 21.4 years according to the Iranian reference, and 25.0 and 25.8 years using the West reference. In female survivors, the highest average YLL were noted for unique lung injuries, with averages of 17.3 years based on the Iranian reference and 21.5 years according to the West reference (see Supplementary Tables S23-S33). In recent years, the YLL figures have approached 15,000 according to Iranian references and exceeded 15,000 based on West references, displaying an upward trend over time (p < 0.001) despite some fluctuations (see Supplementary Figs. S1-S11). Finally, the YLL calculations depicted on the map of Iranian provinces illustrated a wide dispersion and variability in years lost, even when evaluated through different estimation models. Notably, Tehran recorded nearly 20,000 years lost using Iranian references and surpassing 20,000 under West references (see Supplementary Figs. S11-S22). Discussion In the aftermath of the Iran-Iraq war, the use of chemical weapons, specifically sulfur mustard, by the Iraqi army has had long-lasting and devastating effects. Despite over 34 years since the end of the war, the consequences of the chemical warfare attacks continue ( 2 , 28 ). According to the VMAF, since the ceasefire, a total of 8,956 Iranian CWS exposed to SM passed away from 1988 through 2021. The majority of these population were male with 8,800 deaths (98.3%), and 156 female (1.7%). About 62.8% of male and 25.6% of female died before elderly (before 60). The findings of the study showed that the average age of death for females (69.06 ± 17.43) was higher than that of males (56.75 ± 13.95). This study aimed to calculate the total YLL as a result of premature death caused by exposure to SM agent following the Iran-Iraq war (1988–2021). Following the 8 years of the Iran-Iraq war, survivors having lost at least 87,625.7 (Iranian reference; discount rate = 6%, age weighting = 1) and at most 228,951.1 (West reference; discount rate = 0%, age weighting = 0) years of their lives due to the effects of SM agent till to 2021 post-war. A 25-year perspective study conducted by Mousavi et al. using the same method in 2013 revealed that YLL from premature death among Iranian war casualties were estimated at 2.8–11.2 million years ( 18 ). In our study, by dividing the total YLL (190,576.8 years; 0% discount rate and no age weighting) to the total number of people losing their lives (8,956 death), it can be said that every SM exposed victims who survived the war has lost an average of 21.3 years of his/her life. Accordingly, Mousavi's study by the same method and 8.2 million YLL revealed that each Iranians victims lost an average of 44.7 years of his/her life due to the burden of war, which was over twice the impact of SM exposure. This is expected due to the significant number of young casualties during the war, with a mean age of 23 years among martyrs and approximately 144,000 children left orphaned ( 28 ). The results correspond to major conflicts and wars throughout human history ( 29 , 30 ). According to World Health Organization estimates for the year of 2000, armed conflict was responsible for approximately 0.7% of the global burden of disease, expressed in DALY (years of life lost plus years lived with disability) ( 31 ). Age-specific distribution of YLL was greatest among individuals aged 50–54 years (38,231.9 years), followed by those aged 45–49 (31,013.2 years) and 40–44 (22,584.4 years). Conversely, younger age groups ( 10 – 14 and 15 – 19 ) exhibited minimal YLL, reflecting their comparatively low mortality rates. As a consequence, YLL gradually increases from the 20–24 age group onward, peaking in middle-aged groups before declining in older ages. This age-related pattern, however, was less pronounced among females. Based on the results, the years of life lost due to premature death associated with skin damages accounted for 10.2% of the overall burden of disease, with 10.1% (18,849.7 years) attributed to males and 13.4% (309.5 years) to females. A comparable trend was observed for the YLL related to eye injuries, which constituted 11.8% of the total burden, with 11.7% (21,968.4 years) for males and 11.7% (2,72.7 years) for females. A study by Bullman and Kang ( 32 ), found that mortality among World War II Navy veterans exposed to low-dose sulfur mustard agent was enough to cause skin reactions such as blisters and ulcers, but this exposure did not increase the risk of mortality. Also, according to some studies, in less than 1% of patients exposed with sulfur mustard, a type of delayed ulcerative keratopathy may occur, which leads to late blindness ( 33 , 34 ). Also, in another study, corneal and conjunctival complications were the most common sites of eye involvement ( 35 ) and in another study, corneal findings include scarring or corneal opacity (89.5%), changes in the outer surface of the eye, including chronic blepharitis, tear meniscus reduction, limbus ischemia (81.3%) and conjunctival vascular disorders (50.0%) were complications caused by mustard in veterans with severe eye damage ( 36 ). This is while no fatal effects of dermal and ocular injuries were observed in these studies. The average YLL per individual for male survivors with mild skin damage was 20.9 years, 19.0 years for moderate damage, and 17.2 years for severe damage. Overall, the severity of dermal lesions did not have a direct impact on the average YLL. This was a confirmation of the non-fatality of this injury and suggests that there is no relationship between the severity of damage and YLL. The same pattern was also seen in the eye lesion. The YLL in survivors with lung injury accounted for nearly half of the share in male (87,478.4 years) and three quarters in female (1,680.6 years). In the study of Case and Lea ( 37 ), regarding the effect of exposure to sulfur mustard in the First World War (1914–1918) and the possibility of causing cancer, the number of deaths from lung cancer (SMR = 207, 0.001 < p < 0.01) was more than the general population significantly; while for people who died due to cancers other than lung cancer (SMR = 107, 0.01 < p < 0.05), this rate was almost similar to the general population. However, Case and Lea concluded that sulfur mustard does not have direct carcinogenic effects, but it probably causes chronic bronchitis and subsequently increases mortality ( 37 ). The average YLL per person for male survivors with mild lung injury was 20.5 years, 19.5 years for moderate, and 21.4 years for severe. The rise in the severity of lung disease has directly contributed to the increase in average YLL, highlighting the connection between severity of lesion and YLL. The highest average YLL was seen in female with severe lung injury (34.7 years). More than 95% of the YLL for both male and female was attributed to the subclinical & mild and lung injuries. The highest average YLL were observed in the pulmonary organs, either alone or in combination with other organs. One study indicated that pulmonary lesions caused by SM agent were more likely to result in fatality compared to skin and eye lesions. The results also suggested a possible link between the severity of lung damage and survival time ( 15 ). In planning for the health of any society, understanding the statistics and causes of death is crucial ( 38 , 39 ). In a study conducted in 2015, the top three causes of death among elderly Iranian male and female were cardiovascular disease, cancer, and respiratory disease, which accounted for the highest YLL per 1,000 individuals. These findings highlight the importance of addressing these health issues in order to improve the overall well-being of the population ( 40 ). A 39-years follow-up of another study on the mortality of CWS exposed to SM produced similar results. This study showed that death from the circulatory system was the most common cause of death, followed by cancers and death from the respiratory system. It is worth mentioning that many individuals have passed away from causes unrelated to the effects of chemical warfare agents ( 15 ). The findings indicated that the impact of the war persisted even after the ceasefire, leading to loss of life. The rising YLL trend in recent decades likely reflects the aging of the affected population, where the progressive nature of chronic complications following SM exposure tends to intensify over time, yielding to greater premature mortality. Furthermore, improvements in mortality registration and health surveillance systems have likely resulted in more accurate and comprehensive recording of SM-related deaths, which can appear as an upward trend in YLL ( 41 , 42 ). Throughout the war, individuals from all provinces in Iran, including both male and female, were involved in the conflict. While there is no set ranking among provinces in terms of the YLL; it was observed that individuals from heavily populated provinces tended to experience greater losses in years of life. The provinces of Kerman, Hamadan and Kohgiluyeh and Boyer-Ahmad recorded a relatively high YLL despite having smaller populations compared to other provinces in the same category. Kerman province lost 14,526.6 years in the first cluster, Hamedan lost 8,068.3 years in the second cluster and Kohgiluyeh and Boyer-Ahmad lost 5,189.5 years in the third cluster. Even though Hamadan province had a high rate of elderly population ( 43 ), the causes of death and other social health factors should be further examined to understand the reasons behind these high YLL rates. In the most extreme scenario based on the Iranian reference, survivors lost a total of 190,576.8 years of life due to the effects of SM gas. This corresponds to an average of 21.3 YLL per Iranian survivor who died in the post-war period following the Iraq–Iran conflict. While the average YLL for male survivors matched the overall average, female survivors experienced a lower average of 15.0 years. In comparison, under the most extreme scenario using the West reference, the total YLL amounted to 228,951.1, leading to an average of 25.6 YLL per killed Iranian survivor. In this case, the average YLL for male survivors aligned with the overall average, whereas the average for females was 18.8 years. The discrepancies observed across the different scenarios underscore the importance of transparently reporting the methodological choices used in such analyses. The impact of discounting and age weighting is evident across all scenarios or analyses, consistently reducing YLL estimates for both males and females under both models. The effect is more pronounced in the Iranian Nationwide Life Table estimates, reflecting the specific age structure of mortality within the Iranian population. Our findings call for a shift from reactive treatment to proactive in survivor healthcare, prioritizing pulmonary function monitoring, timely intervention in early-stage lung disease, and equitable distribution of medical resources across geographical areas. Health policy should prioritize sustained investment in specialized care services, not only for reducing avoidable deaths but also for optimizing quality of life and long-term health outcomes in this aging survivor population. One of the limitations of this study is that the specific types and doses of SM agent used in the war and the duration of exposure for those affected were unknown, making it difficult to accurately estimate their impact. Additionally, the high level of spirituality among Iranians meant that some damages from the war were not reported or documented. Another limitation of the study was the potential underestimation of the SM impact, which can be attributed to two main factors. Firstly, there was a larger population who have been exposed to SM, but due to lack of documentation, their data was not accessible for analysis. Secondly, the study focused on estimating post-war years of life lost, and did not include data on individuals who survived the initial exposure but passed away during the course of the war. Furthermore, the absence of similar studies posed a challenge in directly comparing the burden of disease identified in this study with that of others. The study's strength lies in being the first to estimate the burden of disease and having a long follow-up period until 2021 post-war. This uniqueness adds credibility to the results, which have been confirmed by the opinion of the specialized medical commissions of the Veterans and Martyrs Affairs Foundation on the research data. Medical professionals can provide valuable insights into the future health of survivors through regular examinations of patients. Conclusions Given the rising burden of premature mortality among Iranian chemical warfare survivors and the fact that the majority have now entered their sixth decade of life and are predominantly male, there is an urgent need for enhanced healthcare services, targeted intervention strategies, and sustained investment in long-term medical support. The study found that lung injury resulting from SM exposure have a higher likelihood of being fatal compared to skin or eye injuries, highlighting the necessity of ongoing monitoring and supportive care particularly for those with severe or multiple pulmonary lesions. The varying social, welfare, and climatic conditions across regions of Iran emphasize the importance of implementing tailored health policies at the provincial level. Data availability The datasets analyzed in this study are national in scope and cannot be conveniently disclosed; however, data can be made available upon reasonable request from the corresponding author. Abbreviations YLL Years of Life Lost SM Sulfur Mustard VMAF Veterans and Martyr Affairs Foundation CWS chemical warfare survivors DALY Disability-Adjusted Life Year Declarations Data availability The datasets analyzed in this study are national in scope and cannot be conveniently disclosed; however, data can be made available upon reasonable request from the corresponding author. Authors and affiliations Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran Sajad Shojaee Thoracic Research Center, Division of Pulmonary and Critical Care, Shariati Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Rasoul Aliannejad Chemical Injuries Research Center, System Biology and Poisonings Institute, Baqiyatallah University, Tehran, Iran. Fatemeh Nobakht Proteomics Research Center, Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Alireza Akbarzadeh Baghban Prevention Department, Janbazan Medical and Engineering Research Center, Tehran, Iran. Batool Mousavi Corresponding author Correspondence to Batool Mousavi Authors' Contributions S.S. designed the study, performed data analysis, made the tables and figures, developed the software, and wrote the manuscript. R.A. performed the investigation, conceptualized the trial, administrated the project, and wrote the manuscript. F.K. conducted the data curation, and wrote the manuscript. A.A.B interpreted the data, and performed statistical analysis. B.M. designed the study, administrated the project, and supervised the research. All authors contributed to the review and editing of the manuscript and approved the final version. Funding No funding was received for the study. Acknowledgments We would like to express our sincere gratitude to Dr. Alam-Beladi for their invaluable support and guidance throughout the preparation of this article. We also extend our heartfelt thanks to Ganj-Parvar, Minooiefar, Rahimpoor, Babaei, and Asgari for their contributions and insights, which have been instrumental in shaping our research. Their collaboration and encouragement have been crucial to our journey, and we are truly appreciative and grateful of their commitment to our team. Ethics declarations Ethics approval and consent to participate The research protocol received approval from the Ethics Committee Board at the Janbazan Medical and Engineering Research Center in Tehran, Iran (IR.ISAAR.REC.1402.009). This approval ensures that the study adheres to ethical standards and safeguards the rights and welfare of participants. Confidentiality of all personal data was maintained throughout the study. The data utilized were accessed from a secure database maintained by the Veterans and Martyr Affair Foundation (VMAF). The Ethics Committee provided legal authorization for data use and waived the requirement for informed consent, considering the non-identifiable nature of the data. The study was conducted in full compliance with ethical standards to maintain research integrity. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Devereaux A, Amundson DE, Parrish JS, Lazarus AA. Vesicants and nerve agents in chemical warfare: Decontamination and treatment strategies for a changed world. Postgrad Med. 2002;112(4):90–6. Khateri S, Ghanei M, Keshavarz S, Soroush M, Haines D. Incidence of lung, eye, and skin lesions as late complications in 34,000 Iranians with wartime exposure to mustard agent. J Occup Environ Med. 2003;45(11):1136–43. Hu H, Cook-Deegan R, Shukri A. 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1","display":"","copyAsset":false,"role":"figure","size":209661,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTemporal Trends in Years of Life Lost by Sex Using Iranian Reference (0%, 0). \u003c/strong\u003eThe analysis reveals a fluctuating but progressively increasing trend in YLL (1988–2021) for both males (a) and females (b), with a statistically significant upward trend (p \u0026lt; 0.001 for each). YLL peaked at 14,448 years in males (2021) and 248 years in females (2014), reflecting a growing burden of premature mortality over time.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7847427/v1/25b325c538c7e22b70a98b94.png"},{"id":95903848,"identity":"eb9dd994-1e49-441d-92ce-597ed3a4b1d1","added_by":"auto","created_at":"2025-11-14 08:58:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":308589,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGeographic Distribution of Years of Life Lost across Iranian Provinces using Iranian Reference (0%, 0). \u003c/strong\u003eThe highest burden was observed in Tehran (19,933.1 years), part of the highest-YLL class, while the lowest was recorded in Hormozgan (878.0 years), within the lowest-YLL class, highlighting substantial regional inequities in mortality and population impact.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7847427/v1/da119ffe10e56e5ca8e872cc.png"},{"id":96362917,"identity":"5efe9dbf-63aa-4fe3-84b6-ec85802561d6","added_by":"auto","created_at":"2025-11-20 10:02:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1830692,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7847427/v1/125cce3e-539b-4ab2-a4da-57aa6fe9c1e2.pdf"},{"id":95903860,"identity":"4dc71584-e805-48e8-8ff2-1ce91f7922ba","added_by":"auto","created_at":"2025-11-14 08:58:57","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":2979947,"visible":true,"origin":"","legend":"","description":"","filename":"SupplemantaryTables10.13.2025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7847427/v1/df9745a756713effc38dbcac.docx"},{"id":95903858,"identity":"0caf992b-8bd0-4c47-8ad2-349f88cff3c9","added_by":"auto","created_at":"2025-11-14 08:58:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":8939733,"visible":true,"origin":"","legend":"","description":"","filename":"SupplemantaryFigures10.13.2025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7847427/v1/774bfaae36841aaa83538a86.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Years of Life Lost due to Premature Mortality Following Sulfur Mustard Exposure: A Post-War National Burden of Disease Study (1988-2021)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChemical weapons are considered one of the most horrific weapons of mass destruction due to their acute and chronic effects on the human health (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Sulfur mustard (SM), a well-known chemical instrument, has been documented to cause devastating health consequences (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is a colorless, odorless gas that persists in the environment, rendering affected areas uninhabitable. Victims of SM exposure often experience temporary loss of vision within hours, a tactic that has been strategically employed in numerous military conflicts (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). As a potent alkylating agent, SM induces cellular necrosis and has mutagenic and carcinogenic properties (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Injuries resulting from SM exposure are categorized into early and late-onset complications, with the latter primarily affecting the respiratory system, leading to chronic conditions such as bronchitis, bronchiectasis, and recurrent bronchopneumonia (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe weaponization of SM dates back to 1917 when the German army deployed it against Canadian and French troops during World War I (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Its use has persisted through various military conflicts, including the Iran-Iraq War. During the eight-year conflict, the Iraqi army chemically attacked the Iranians 387 times, using over 1,800 tons of sulfur mustard (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and injuring around 100,000 people, many of whom still require long-term medical care due to persistent health complications (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The most intense chemical attacks took place in the cities of Sardasht and Oshnaviyeh, resulting in catastrophic health outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite extensive research on the long-term effects and complications associated with SM exposure, studies on mortality rates remain limited (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). One study estimated that each Iranian victim killed during the Iran-Iraq war lost an average of at most 61.3 years of his/her life, amounting to a total of 11.2\u0026nbsp;million years lost (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). To date, a comprehensive analysis of the years of life lost (YLL) due to premature mortality among Iranian chemical warfare survivors (CWS) has not been conducted. YLL is a critical public health measure that captures the impact of premature mortality by accounting for both the age at death and the expected lifespan. Evaluating YLL in the population exposed to SM reveals the hidden burden of premature mortality, informs evidence-based health planning, and emphasizes the lasting impact of chemical weapons for affected individuals. Therefore, this study aims to assess YLL among Iranian veterans and civilians exposed to SM as part of the overall burden of disease, using a long-term post-war follow-up period (1988\u0026ndash;2021). The Disability-Adjusted Life Year (DALY) represents the sum of years of life lost (YLL) and years lived with disability (YLD), serving as a standardized measure of overall burden of disease. To our knowledge, this study provides the initial estimation of DALY attributable to sulfur mustard exposure among Iranian survivors of the Iran\u0026ndash;Iraq War.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and settings\u003c/h2\u003e\u003cp\u003eThis study used a national Iranian database of individuals exposed to SM during the Iran\u0026ndash;Iraq war (1980\u0026ndash;1988). The data were obtained from the Veterans and Martyr Affairs Foundation (VMAF) database, encompassing records from the Medical Commission, the Center for the Care of Chemical Injuries, and the Information Technology database.\u003c/p\u003e\u003cp\u003eAll war-related injuries, including those caused by SM, are documented in the VMAF database. This agency provides free, comprehensive, long-term healthcare to injured war survivors and their families, upholding the highest standards of care. The complexities of acute and chronic SM exposure necessitated ongoing care for affected individuals. To manage this, an expert panel systematically reviewed each case, documenting all resulting complications within the VMAF database. Actually, medical experts reviewed documented lesions on the lungs, skin, and eyes to diagnose and grade the severity of SM injuries.\u003c/p\u003e\u003cp\u003eSM exposure data were categorized into three groups: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) confirmed exposure with evacuation/admission, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) confirmed exposure without evacuation/admission, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) undocumented cases with late-onset symptoms indicative of exposure. This classification distinguished varying levels of documented SM exposure.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population and inclusion/exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe study population comprised individuals with documented exposure to SM gas between 1980 and 1988. This study covered 8,956 SM post-war death, including 8,800 males and 156 females. National database for Iranian veterans and civilians who exclusively exposed to SM during the period 1980\u0026ndash;1988, and subsequently died between 1988 and 2021 were retrieved and considered as an inclusion criteria. Exposure to any other chemical warfare agents served as an exclusion criteria.\u003c/p\u003e\n\u003ch3\u003eClassification of injuries in organs due to SM exposure\u003c/h3\u003e\n\u003cp\u003eClassification of chemical warfare injuries in lung, eye, and skin due to exposure to SM was conducted. \u003cb\u003eLung.\u003c/b\u003e Lung lesions following SM exposure were classified based on spirometry results of forced expiratory volume in first second (FEV1) as follows. Subclinical or asymptomatic: FEV1 higher than 80%; mild: FEV1 greater than 70% but less than or equal to 80%; moderate: FEV1 greater than 50% but less than or equal to 70%; and severe: FEV1 less than or equal to 50% with normal arterial blood gas or severe tracheobronchomalacia (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). \u003cb\u003eSkin.\u003c/b\u003e The presence of specific scars of SM in skin areas including pigmentation, vascular or trophic changes, as well as the appearance of cutaneous T-cell lymphoma or mycosis fungoid indicated clinical signs and symptoms of the exposure to SM in the skin (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The mild category was defined as 1) the presence of an SM-specific scar in less than 5% of the body surface; 2) the presence of such a scar plus mild dermatitis and mild xerosis or mild-to-moderate autoimmune diseases; 3) and concurrent medical documents plus severe autoimmune diseases or any mild dermatitis. The moderate category was defined as 1) the presence of an SM-specific scar at least 5% and to at most 20% of the body surface; 2) presence of an SM-specific scar with significant nutritional changes in the genital area or anus; 3) the presence of an SM-specific scar of any size whether with or without concurrent medical documents plus severe dermatitis covering less than half of the body surface; 4) concurrent medical documents with severe dermatitis or xerosis covering less than half of the body surface; 5) and the presence of an SM-specific scar of any size whether with or without concurrent medical documents plus any severe autoimmune disease at more than half of the body surface. The severe category was defined as 1) the presence of an SM-specific scar more than 20% of the body surface; 2) the presence of an SM-specific scar of any size whether with or without concurrent medical documents with severe dermatitis or xerosis covering more than half of the body surface; 3) and concurrent medical documents with severe dermatitis or xerosis covering less than half of the body surface. \u003cb\u003eEye.\u003c/b\u003e The presence of conjunctival vascular changes, including: telangiectasia, segmentation, venous beading, tortuosity, and vascular dilatation, along with vascular ischemic complications of the limbus, were specific clinical signs and symptoms of SM in the eyes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The mild category was defined as itching, burning, tearing, redness, blurred vision, foreign body sensation, conjunctivitis, subconjunctival hemorrhage, photophobia, or conjunctival vascular changes in each or both eyes. The moderate category was defined as the same changes in the mild category plus conjunctival ischemia in the limbus area, as well as closure of unilateral or bilateral or punctum cauterization. The severe category was defined as similar observations in the moderate category plus symptoms of corneal involvement, keratopathy, pannus, epithelial and subepithelial opacity and anterior stroma in the cornea, hyperpigmentation around the nerve, iron deposition in the cornea and corneal vascularization, stenosis, and involvement of both eyes less than half unilaterally or bilaterally (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThis study analyzed the burden of disease due to SM exposure in Iran from 1988 to 2021. YLL, a component of DALY, was calculated as the number of cause-specific deaths multiplied by a loss function which specifies the years lost as a function of the age at which death occurs (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe employed two approaches to estimate YLL. The first utilized life chart of the book of the Statistics Center of Iran (State Management and Planning Organization) based on sex and age at death (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The second approach employed the Coale-Demeny Model Life Table West (Levels 25 and 26) for males and females (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Both methods incorporated variations in discount rates (0%, 3%, and 6%) and age weightings (0\u0026thinsp;=\u0026thinsp;none, 1\u0026thinsp;=\u0026thinsp;applied) to reflect the age-dependent value of life.\u003c/p\u003e\u003cp\u003eCrude expected years of life lost were initially calculated as the product of the number of deaths (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\text{D}}_{\\text{x}}\\)\u003c/span\u003e\u003c/span\u003e) and the standard life expectancy at the age of death (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\text{e}}_{\\text{x}}^{\\text{s}}\\)\u003c/span\u003e\u003c/span\u003e):\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\text{Y}\\text{L}\\text{L}=\\:{\\text{D}}_{\\text{x}}{\\text{e}}_{\\text{x}}^{\\text{s}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo further extend the basic formula and incorporate discounting and age weighting, necessitates several assumptions. The following formula was used to calculate the extended YLL:\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:{\\text{Y}}_{\\text{x}}=\\:{\\text{d}}_{\\text{x}}\\left[\\frac{\\text{K}\\text{C}{\\text{e}}^{\\text{r}}\\left({\\text{a}}_{\\text{x}}\\right)}{{\\left(\\text{r}+{\\beta\\:}\\right)}^{2}}\\left({\\text{e}}^{\\text{z}}\\left[\\text{z}-1\\right]-{\\text{e}}^{-\\left(\\text{r}+{\\beta\\:}\\right){\\text{a}}_{\\text{x}}}\\left[-\\left(\\text{r}+{\\beta\\:}\\right){\\text{a}}_{\\text{x}}-1\\right]\\right)+\\frac{1-\\text{K}}{\\text{r}}\\left(1-{\\text{e}}^{\\text{r}\\left({\\text{e}}_{\\text{x}}^{\\text{s}}\\right)}\\right)\\right]$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHowever, when the discount rate equals zero, the equation requires simplification for practical use (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Symbol definitions are listed below:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026#119886; = age at death\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#119903; = discount rate\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#120573; = age weighting constant (typically 0.04)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#119870; = age-weighting modulation constant\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#119862; = adjustment constant for age-weights (typically 0.1658)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#119890; = standard life expectancy at age of death\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026#119889; = number of deaths\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe discount rate accounts for the reduced value of future mortality compared to present; therefore higher discount rates lessen the impact of future losses. Age weighting assigns greater value to years of life lost at younger ages. The constants C and β were derived from the 1990 Global Burden of Disease study (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). YLL calculations were stratified by sex and five-year age groups. These calculations were further broken down by affected organ system (lung, skin, and eye), and analyzed over time to assess trends from 1988 to 2021. Average YLL per deceased individual was determined by dividing total YLL by the total number of deaths. A Mann-Kendall test was also employed to determine the presence of trends in the data. All statistical analysis were conducted using R software, version 4.5.1 and ArcMap, version 10.8.2.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003eThe research protocol was reviewed and approved by the Ethics Committee Board at the Janbazan Medical and Engineering Research Center in Tehran, Iran. To ensure ethical standards and protect individual rights, all personally identifiable information has been removed to maintain confidentiality. The authorization to access and utilization of the data was obtained by the Ethics Committee for this study.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eThe VMAF database\u003c/h2\u003e\u003cp\u003eThe VMAF database recorded 8,956 SM post-war deaths (1988\u0026ndash;2021), overwhelmingly male (8,800, 98.3%) compared to female (156, 1.7%). The median age of exposure to war-related events was 27 (IQR: 21\u0026ndash;39), while the median age at death was 55 (IQR: 48\u0026ndash;66). Ages at exposure ranged from 1 to 84 years, and ages at death from 11 to 113 years. A noticeable proportion of male survivors (32.5%, n\u0026thinsp;=\u0026thinsp;2,861) died aged 50\u0026ndash;59, whereas a larger percentage of female survivors (41.0%, n\u0026thinsp;=\u0026thinsp;64) died at age 75 or older. Lung complications were prevalent, affecting 50.4% of male survivors (n\u0026thinsp;=\u0026thinsp;4,318) and 70.4% of female survivors (n\u0026thinsp;=\u0026thinsp;107).\u003c/p\u003e\u003cp\u003eNearly half (49.4%) of deaths were attributed to lung damage, while smaller proportions involved skin (10.6%) or eye (12.8%) complications. Among survivors with a single affected organ, death due to lung complications were considerably more common (13.4%) compared to skin (0.7%), eye (0.3%), or combinations of these (lung and skin 0.6%, lung and eye 0.3%, skin and eye 0.0%, and all three 0.1%).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eYLL on different approaches\u003c/h3\u003e\n\u003cp\u003eThe distribution of YLL is presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, incorporating variations in discount rates (0%, 3%, and 6%) and age weightings (0, 1), based on two model life tables. Without discounting and age weighting, total YLL was 190,576.8 (188,234.4 male, 2,342.4 female) using the Iranian Nationwide Life Table. Employing the Coale-Demeny Model Life Table West under the same conditions increased the total YLL to 228,951.1 (226,026.4 male, 2,924.8 female). Applying a 6% discount rate and applying age weighting yielded the lowest YLL estimates: 87,625.7 (86,635.1 male, 990.6 female) for the Iranian Nationwide Life Table and 92,296.5 (91,203.6 male, 1,093.0 female) for the Coale-Demeny Model Life Table West.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eYears of Life Lost among Iranians Exposed to Sulfur Mustard: A Review of Approaches\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eYLL\u003c/p\u003e\u003cp\u003e(Discount rate, Age weighting)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eIranian Nationwide Life Table\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eCoale-Demeny Model Life Table West\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (0%, 0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e188,234.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,342.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e190,576.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e226,026.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2,924.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e228,951.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (0%, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e158,917.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,795.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e160,712.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e180,176.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2,082.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e182,258.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (3%, 0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e132,278.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,677.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e133,955.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e149,213.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2,010.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e151,223.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (3%, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e114,034.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,286.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e115,321.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e123,455.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1,447.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e124,902.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (6%, 0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e98,724.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,292.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100,017.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e107,020.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1,508.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e108,529.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYLL (6%, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e86,635.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e990.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87,625.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e91,203.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1,093.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e92,296.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eYLL decreases with higher discount rates and applied age weighting. It shows an elevated burden of premature mortality with the Coale-Demeny model West compared to the Iranian life table, particularly without adjustments.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eYLL at several age categories\u003c/h2\u003e\u003cp\u003eYLL stratified by age and sex were calculated using the Iranian Nationwide Life Table, applying a 0% discount rate and no age weighting (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A notable disparity was observed between sexes: males accounted for the vast majority of deaths (8,800; 98.3%) and YLL (188,234.4 years; 98.8%), with the highest YLL concentrated in the 45\u0026ndash;54 age groups (30,822.7 and 38,072.9 years, respectively). In contrast, females experienced considerably fewer deaths (156; 1.7%) and lower YLL (2,342.4 years; 1.2%), with maximum YLL observed in the 60\u0026ndash;64 age group (339.1 years).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eYears of Life Lost by Age at Death using Iranian Reference (0%, 0)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAge interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eIranian Nationwide Life Table\u003c/p\u003e\u003cp\u003e(Discount Rate\u0026thinsp;=\u0026thinsp;0%, Age Weighting\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e248.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e248.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,485.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1,485.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4,091.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e298.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4,389.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10,438.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10,523.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17,416.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e485\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e122.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17,538.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e488\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22,433.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e699\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e150.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22,584.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e703\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30,822.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,084\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e190.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e31,013.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1,090\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38,072.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e159.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e38,231.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1,551\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e55\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27,071.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,316\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e296.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e27,367.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1,329\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14,846.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e894\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e339.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15,185.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e912\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e65\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9,398.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e717\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e190.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9,589.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e730\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5,473.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e542\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e237.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5,710.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e563\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e75+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6,379.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e274.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6,653.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1,186\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eThe data highlight a pronounced male predominance in both mortality and premature mortality burden.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eYLL in severity of lung, skin and eye complications\u003c/h2\u003e\u003cp\u003eAnalysis of Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e indicates a relationship between the severity of SM-related complications and YLL. Calculations were made using the Iranian Nationwide Life Table with a 0% discount rate and no age weighting.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eYears of Life Lost by Injury Severity using Iranian Reference (0%, 0)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"14\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSeverity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eType\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c13\" namest=\"c3\"\u003e\u003cp\u003eIranian Nationwide Life Table\u003c/p\u003e\u003cp\u003e(Discount Rate\u0026thinsp;=\u0026thinsp;0%, Age Weighting\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c13\" namest=\"c9\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eYLL (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eDeath (N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eDeath (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eYLL (Avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e\u003cb\u003eYLL (N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003eYLL (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cb\u003eDeath (N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e\u003cb\u003eDeath (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e\u003cb\u003eYLL (Avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eLung\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubclinical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95,840.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4,255\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e605.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e26.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e29.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMild\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62,571.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3,058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e1,196.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e52.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e51.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e15.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20,912.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e345.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e16.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSevere\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3,994.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e138.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e34.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEye\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubclinical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164,914.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7,634\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e2,062.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e88.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e85.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMild\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21,010.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e272.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e11.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e14.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e12.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e600.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSevere\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e657.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSkin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubclinical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e167,304.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e89.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7,791\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e89.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e1,998.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e86.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e83.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e15.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMild\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16,586.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e792\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e225.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,919.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e84.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e12.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSevere\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e344.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"14\"\u003eAverage YLL increased with severity among males with lung injury and more markedly among females, particularly for severe lung involvement (34.7 years). In contrast, no consistent trend was observed for eye or skin injuries.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBoth mild-to-severe eye and skin injuries individually accounted for more than 10% of YLL in males and females. In comparison, mild-to-severe lung injury accounted for 47.7% (males) and 73.5% (females) of total YLL.\u003c/p\u003e\u003cp\u003eAverage YLL also increased with the severity of lung injury, rising from 20.5 in mild cases to 21.4 in severe cases among men, and from 15.3 to 34.7 among women. Additionally, severe lung injuries resulted in a much higher average YLL for females (34.7 years) compared to males (21.4 years).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eYLL in total severity and involved organs\u003c/h2\u003e\u003cp\u003eTotal injury severity showed that males accounted for a total of 188,234.4 YLL, with the subclinical severity category contributing the highest proportion (87,777.0 years, 46.1%), followed by mild (73,980.0 years, 39.7%), moderate (21,835.0 years, 11.8%), and severe (4,642.4 years, 2.5%). Conversely, females experienced a total of 2,342.2 YLL, with a predominance of mild severity cases (1,301.4 years, 54.8%) and a notably average YLL of 34.7 years by severe cases.\u003c/p\u003e\u003cp\u003eSimultaneously Involved Organs represented that The majority of YLL in males (161,757.1 years, 85.7%) was associated with subclinical/mild conditions, followed by lung involvement accounted for 12.6% of YLL, resulted in a significantly higher average YLL per case (19.7 years). In females, the total YLL was substantially lower with the highest proportion (1,791.8 years, 75.9%) linked to subclinical/mild cases, and of course, the highest average of 17.3 years was associated to lung involvement.\u003c/p\u003e\u003cp\u003eAll analysis was conducted using the Iranian Nationwide Life Table; a 0% discount rate and no age weighting were applied to the calculations (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eYears of Life Lost by Total Severity and Involved Organs using Iranian Reference (0%, 0)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"14\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eType\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c13\" namest=\"c3\"\u003e\u003cp\u003eIranian Nationwide Life Table\u003c/p\u003e\u003cp\u003e(Discount Rate\u0026thinsp;=\u0026thinsp;0%, Age Weighting\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c13\" namest=\"c9\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eYLL (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eDeath (N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eDeath (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eYLL (Avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e\u003cb\u003eYLL\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003eYLL (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cb\u003eDeath (N)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e\u003cb\u003eDeath (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e\u003cb\u003eYLL (Avg.)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eTotal Severity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubclinical\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87,777.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3,863\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e490.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e21.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e24.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e12.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMild\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73,980.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3,585\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e1,301.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e54.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e53.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21,835.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e411.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e19.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e13.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSevere\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4,642.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e138.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e34.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eInvolved Organs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubclinical/Mild\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e161,757.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7,448\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e1,791.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e75.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e78.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e14.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eLung\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23,116.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e466.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e20.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSkin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,053.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e66.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e13.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEye\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e503.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eLung/Skin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1,050.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eLung/Eye\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e593.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSkin/Eye\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eLung/Skin/Eye\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"14\"\u003eSevere injuries, though rare, showed elevated average YLL (20.3 years in males, 34.7 years in females). A synergistic effect on premature mortality was observed when lung injury co-occurred with skin (1,050.1 YLL) or eye involvement (593.3 YLL), resulting in an increased average YLL per death (rising from 21.2 to 21.4 years), compared to single-organ conditions.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eYLL and time trend analysis\u003c/h2\u003e\u003cp\u003eThe analysis of the trend of YLL over the study period (1988\u0026ndash;2021) provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, using a 0% discount rate and no age weighting by the Iranian Nationwide Life Table. During the first decade following the Iran-Iraq post-war, YLL remained relatively stable. However, subsequent years witnessed a marked increase in both YLL and mortality for both males and females. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, YLL in females exhibited greater fluctuation than in males. The highest YLL estimates (near 15,000 years) occurred in 2020 and 2021. Despite the ups and downs in different years, the Mann-Kendall trend test confirmed a statistically significant upward trend in both of males (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea) and females (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eYLL across provinces of Iran\u003c/h2\u003e\u003cp\u003eYLL due to SM exposure according to the Iranian Nationwide Life Table, a 0% discount rate and no age weighting displayed substantial geographic variation across Iranian provinces. The highest YLL were observed on the provinces of Tehran (19,933.1), Khorasan Razavi (16,197.3), Isfahan (15,962.8), Fars (14,982.3), and Kerman (14,526.6), all belonging to the same cluster. Conversely, the lowest YLL were found in Hormozgan (878) and South Khorasan (966.3). The distribution of YLL represented a high dispersion and diversity across provinces of Iran (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSupplementary Analysis\u003c/h2\u003e\u003cp\u003eThe analysis revealed that the highest YLL were found in the age group of 45\u0026ndash;54 years, whereas the lowest YLL were observed in the 10\u0026ndash;19 age category, despite differing estimation methodologies (see Supplementary Tables S1-S11). Among male survivors, the highest average YLL, excluding subclinical cases, were linked to severe lung injuries, with averages 21.4 years based on the Iranian Nationwide Life Table and 25.7 years according to the Coale-Demeny Model Life Table West. In contrast, female survivors exhibited the highest average YLL associated with severe lung lesions, recorded at 34.7 years per the Iranian Nationwide Life Table and 41.3 years according to the Coale-Demeny Model Life Table West (see Supplementary Tables S12-S22). For male survivors, the highest average YLL, excluding subclinical cases, were attributed to simultaneously lung/eye and lung/skin injuries, yielding averages of 21.2 and 21.4 years according to the Iranian reference, and 25.0 and 25.8 years using the West reference. In female survivors, the highest average YLL were noted for unique lung injuries, with averages of 17.3 years based on the Iranian reference and 21.5 years according to the West reference (see Supplementary Tables S23-S33). In recent years, the YLL figures have approached 15,000 according to Iranian references and exceeded 15,000 based on West references, displaying an upward trend over time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) despite some fluctuations (see Supplementary Figs. S1-S11). Finally, the YLL calculations depicted on the map of Iranian provinces illustrated a wide dispersion and variability in years lost, even when evaluated through different estimation models. Notably, Tehran recorded nearly 20,000 years lost using Iranian references and surpassing 20,000 under West references (see Supplementary Figs. S11-S22).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the aftermath of the Iran-Iraq war, the use of chemical weapons, specifically sulfur mustard, by the Iraqi army has had long-lasting and devastating effects. Despite over 34 years since the end of the war, the consequences of the chemical warfare attacks continue (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to the VMAF, since the ceasefire, a total of 8,956 Iranian CWS exposed to SM passed away from 1988 through 2021. The majority of these population were male with 8,800 deaths (98.3%), and 156 female (1.7%). About 62.8% of male and 25.6% of female died before elderly (before 60). The findings of the study showed that the average age of death for females (69.06\u0026thinsp;\u0026plusmn;\u0026thinsp;17.43) was higher than that of males (56.75\u0026thinsp;\u0026plusmn;\u0026thinsp;13.95). This study aimed to calculate the total YLL as a result of premature death caused by exposure to SM agent following the Iran-Iraq war (1988\u0026ndash;2021).\u003c/p\u003e\u003cp\u003eFollowing the 8 years of the Iran-Iraq war, survivors having lost at least 87,625.7 (Iranian reference; discount rate\u0026thinsp;=\u0026thinsp;6%, age weighting\u0026thinsp;=\u0026thinsp;1) and at most 228,951.1 (West reference; discount rate\u0026thinsp;=\u0026thinsp;0%, age weighting\u0026thinsp;=\u0026thinsp;0) years of their lives due to the effects of SM agent till to 2021 post-war. A 25-year perspective study conducted by Mousavi et al. using the same method in 2013 revealed that YLL from premature death among Iranian war casualties were estimated at 2.8\u0026ndash;11.2\u0026nbsp;million years (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In our study, by dividing the total YLL (190,576.8 years; 0% discount rate and no age weighting) to the total number of people losing their lives (8,956 death), it can be said that every SM exposed victims who survived the war has lost an average of 21.3 years of his/her life. Accordingly, Mousavi's study by the same method and 8.2\u0026nbsp;million YLL revealed that each Iranians victims lost an average of 44.7 years of his/her life due to the burden of war, which was over twice the impact of SM exposure. This is expected due to the significant number of young casualties during the war, with a mean age of 23 years among martyrs and approximately 144,000 children left orphaned (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The results correspond to major conflicts and wars throughout human history (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). According to World Health Organization estimates for the year of 2000, armed conflict was responsible for approximately 0.7% of the global burden of disease, expressed in DALY (years of life lost plus years lived with disability) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAge-specific distribution of YLL was greatest among individuals aged 50\u0026ndash;54 years (38,231.9 years), followed by those aged 45\u0026ndash;49 (31,013.2 years) and 40\u0026ndash;44 (22,584.4 years). Conversely, younger age groups (\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e and \u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) exhibited minimal YLL, reflecting their comparatively low mortality rates. As a consequence, YLL gradually increases from the 20\u0026ndash;24 age group onward, peaking in middle-aged groups before declining in older ages. This age-related pattern, however, was less pronounced among females.\u003c/p\u003e\u003cp\u003eBased on the results, the years of life lost due to premature death associated with skin damages accounted for 10.2% of the overall burden of disease, with 10.1% (18,849.7 years) attributed to males and 13.4% (309.5 years) to females. A comparable trend was observed for the YLL related to eye injuries, which constituted 11.8% of the total burden, with 11.7% (21,968.4 years) for males and 11.7% (2,72.7 years) for females. A study by Bullman and Kang (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), found that mortality among World War II Navy veterans exposed to low-dose sulfur mustard agent was enough to cause skin reactions such as blisters and ulcers, but this exposure did not increase the risk of mortality. Also, according to some studies, in less than 1% of patients exposed with sulfur mustard, a type of delayed ulcerative keratopathy may occur, which leads to late blindness (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Also, in another study, corneal and conjunctival complications were the most common sites of eye involvement (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and in another study, corneal findings include scarring or corneal opacity (89.5%), changes in the outer surface of the eye, including chronic blepharitis, tear meniscus reduction, limbus ischemia (81.3%) and conjunctival vascular disorders (50.0%) were complications caused by mustard in veterans with severe eye damage (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This is while no fatal effects of dermal and ocular injuries were observed in these studies. The average YLL per individual for male survivors with mild skin damage was 20.9 years, 19.0 years for moderate damage, and 17.2 years for severe damage. Overall, the severity of dermal lesions did not have a direct impact on the average YLL. This was a confirmation of the non-fatality of this injury and suggests that there is no relationship between the severity of damage and YLL. The same pattern was also seen in the eye lesion.\u003c/p\u003e\u003cp\u003eThe YLL in survivors with lung injury accounted for nearly half of the share in male (87,478.4 years) and three quarters in female (1,680.6 years). In the study of Case and Lea (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), regarding the effect of exposure to sulfur mustard in the First World War (1914\u0026ndash;1918) and the possibility of causing cancer, the number of deaths from lung cancer (SMR\u0026thinsp;=\u0026thinsp;207, 0.001\u0026thinsp;\u0026lt;\u0026thinsp;p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) was more than the general population significantly; while for people who died due to cancers other than lung cancer (SMR\u0026thinsp;=\u0026thinsp;107, 0.01\u0026thinsp;\u0026lt;\u0026thinsp;p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), this rate was almost similar to the general population. However, Case and Lea concluded that sulfur mustard does not have direct carcinogenic effects, but it probably causes chronic bronchitis and subsequently increases mortality (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The average YLL per person for male survivors with mild lung injury was 20.5 years, 19.5 years for moderate, and 21.4 years for severe. The rise in the severity of lung disease has directly contributed to the increase in average YLL, highlighting the connection between severity of lesion and YLL. The highest average YLL was seen in female with severe lung injury (34.7 years). More than 95% of the YLL for both male and female was attributed to the subclinical \u0026amp; mild and lung injuries. The highest average YLL were observed in the pulmonary organs, either alone or in combination with other organs. One study indicated that pulmonary lesions caused by SM agent were more likely to result in fatality compared to skin and eye lesions. The results also suggested a possible link between the severity of lung damage and survival time (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn planning for the health of any society, understanding the statistics and causes of death is crucial (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In a study conducted in 2015, the top three causes of death among elderly Iranian male and female were cardiovascular disease, cancer, and respiratory disease, which accounted for the highest YLL per 1,000 individuals. These findings highlight the importance of addressing these health issues in order to improve the overall well-being of the population (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). A 39-years follow-up of another study on the mortality of CWS exposed to SM produced similar results. This study showed that death from the circulatory system was the most common cause of death, followed by cancers and death from the respiratory system. It is worth mentioning that many individuals have passed away from causes unrelated to the effects of chemical warfare agents (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe findings indicated that the impact of the war persisted even after the ceasefire, leading to loss of life. The rising YLL trend in recent decades likely reflects the aging of the affected population, where the progressive nature of chronic complications following SM exposure tends to intensify over time, yielding to greater premature mortality. Furthermore, improvements in mortality registration and health surveillance systems have likely resulted in more accurate and comprehensive recording of SM-related deaths, which can appear as an upward trend in YLL (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThroughout the war, individuals from all provinces in Iran, including both male and female, were involved in the conflict. While there is no set ranking among provinces in terms of the YLL; it was observed that individuals from heavily populated provinces tended to experience greater losses in years of life. The provinces of Kerman, Hamadan and Kohgiluyeh and Boyer-Ahmad recorded a relatively high YLL despite having smaller populations compared to other provinces in the same category. Kerman province lost 14,526.6 years in the first cluster, Hamedan lost 8,068.3 years in the second cluster and Kohgiluyeh and Boyer-Ahmad lost 5,189.5 years in the third cluster. Even though Hamadan province had a high rate of elderly population (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), the causes of death and other social health factors should be further examined to understand the reasons behind these high YLL rates.\u003c/p\u003e\u003cp\u003eIn the most extreme scenario based on the Iranian reference, survivors lost a total of 190,576.8 years of life due to the effects of SM gas. This corresponds to an average of 21.3 YLL per Iranian survivor who died in the post-war period following the Iraq\u0026ndash;Iran conflict. While the average YLL for male survivors matched the overall average, female survivors experienced a lower average of 15.0 years. In comparison, under the most extreme scenario using the West reference, the total YLL amounted to 228,951.1, leading to an average of 25.6 YLL per killed Iranian survivor. In this case, the average YLL for male survivors aligned with the overall average, whereas the average for females was 18.8 years. The discrepancies observed across the different scenarios underscore the importance of transparently reporting the methodological choices used in such analyses. The impact of discounting and age weighting is evident across all scenarios or analyses, consistently reducing YLL estimates for both males and females under both models. The effect is more pronounced in the Iranian Nationwide Life Table estimates, reflecting the specific age structure of mortality within the Iranian population.\u003c/p\u003e\u003cp\u003eOur findings call for a shift from reactive treatment to proactive in survivor healthcare, prioritizing pulmonary function monitoring, timely intervention in early-stage lung disease, and equitable distribution of medical resources across geographical areas. Health policy should prioritize sustained investment in specialized care services, not only for reducing avoidable deaths but also for optimizing quality of life and long-term health outcomes in this aging survivor population.\u003c/p\u003e\u003cp\u003eOne of the limitations of this study is that the specific types and doses of SM agent used in the war and the duration of exposure for those affected were unknown, making it difficult to accurately estimate their impact. Additionally, the high level of spirituality among Iranians meant that some damages from the war were not reported or documented. Another limitation of the study was the potential underestimation of the SM impact, which can be attributed to two main factors. Firstly, there was a larger population who have been exposed to SM, but due to lack of documentation, their data was not accessible for analysis. Secondly, the study focused on estimating post-war years of life lost, and did not include data on individuals who survived the initial exposure but passed away during the course of the war. Furthermore, the absence of similar studies posed a challenge in directly comparing the burden of disease identified in this study with that of others. The study's strength lies in being the first to estimate the burden of disease and having a long follow-up period until 2021 post-war. This uniqueness adds credibility to the results, which have been confirmed by the opinion of the specialized medical commissions of the Veterans and Martyrs Affairs Foundation on the research data. Medical professionals can provide valuable insights into the future health of survivors through regular examinations of patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGiven the rising burden of premature mortality among Iranian chemical warfare survivors and the fact that the majority have now entered their sixth decade of life and are predominantly male, there is an urgent need for enhanced healthcare services, targeted intervention strategies, and sustained investment in long-term medical support. The study found that lung injury resulting from SM exposure have a higher likelihood of being fatal compared to skin or eye injuries, highlighting the necessity of ongoing monitoring and supportive care particularly for those with severe or multiple pulmonary lesions. The varying social, welfare, and climatic conditions across regions of Iran emphasize the importance of implementing tailored health policies at the provincial level.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eData availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed in this study are national in scope and cannot be conveniently disclosed; however, data can be made available upon reasonable request from the corresponding author.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eYLL Years of Life Lost\u003c/p\u003e\u003cp\u003eSM Sulfur Mustard\u003c/p\u003e\u003cp\u003eVMAF Veterans and Martyr Affairs Foundation\u003c/p\u003e\u003cp\u003eCWS chemical warfare survivors\u003c/p\u003e\u003cp\u003eDALY Disability-Adjusted Life Year\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed in this study are national in scope and cannot be conveniently disclosed; however, data can be made available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBasic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran\u003c/p\u003e\n\u003cp\u003eSajad Shojaee\u003c/p\u003e\n\u003cp\u003eThoracic Research Center, Division of Pulmonary and Critical Care, Shariati Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003eRasoul Aliannejad\u003c/p\u003e\n\u003cp\u003eChemical Injuries Research Center, System Biology and Poisonings Institute, Baqiyatallah University, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003eFatemeh Nobakht\u003c/p\u003e\n\u003cp\u003eProteomics Research Center, Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003eAlireza Akbarzadeh Baghban\u003c/p\u003e\n\u003cp\u003ePrevention Department, Janbazan Medical and Engineering Research Center, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003eBatool Mousavi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Batool Mousavi\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.S. designed the study, performed data analysis, made the tables and figures, developed the software, and wrote the manuscript. R.A. performed the investigation, conceptualized the trial, administrated the project, and wrote the manuscript. F.K. conducted the data curation, and wrote the manuscript. A.A.B interpreted the data, and performed statistical analysis. B.M. designed the study, administrated the project, and supervised the research. All authors contributed to the review and editing of the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to Dr. Alam-Beladi for their invaluable support and guidance throughout the preparation of this article. We also extend our heartfelt thanks to Ganj-Parvar, Minooiefar, Rahimpoor, Babaei, and Asgari for their contributions and insights, which have been instrumental in shaping our research. Their collaboration and encouragement have been crucial to our journey, and we are truly appreciative\u0026nbsp;and \u003cstrong\u003egrateful\u003c/strong\u003e of their commitment to our team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocol received approval from the Ethics Committee Board at the Janbazan Medical and Engineering Research Center in Tehran, Iran (IR.ISAAR.REC.1402.009). This approval ensures that the study adheres to ethical standards and safeguards the rights and welfare of participants. Confidentiality of all personal data was maintained throughout the study. The data utilized were accessed from a secure database maintained by the Veterans and Martyr Affair Foundation (VMAF). The Ethics Committee provided legal authorization for data use and waived the requirement for informed consent, considering the non-identifiable nature of the data. The study was conducted in full compliance with ethical standards to maintain research integrity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDevereaux A, Amundson DE, Parrish JS, Lazarus AA. Vesicants and nerve agents in chemical warfare: Decontamination and treatment strategies for a changed world. 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Armaghane Danesh. 2022;27(1):67\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJafari N, Kabir MJ, Motlagh ME. Death registration system in IR Iran. 2009.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKazemi E, Rezanejad-Asl P, Rabbani B, Khosravi A. Historical trends in completeness of death registration in Islamic Republic of Iran. East Mediterr Heal journal\u0026thinsp;=\u0026thinsp;La Rev sante la Mediterr Orient al-Majallah al-sihhiyah li-sharq al-mutawassit. 2025;31(6):371\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAfshar PF, Asgari P, Shiri M, Bahramnezhad F. A review of the Iran\u0026rsquo;s elderly status according to the census records. Galen Med J. 2016;5(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Years of Life Lost, Chemical Warfare Survivors, Sulfur Mustard Exposure, Involved Organs, Severity of Complications, Burden of Disease","lastPublishedDoi":"10.21203/rs.3.rs-7847427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7847427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSulfur Mustard (SM), widely used during the Iran-Iraq war, has caused long-lasting health effects and reduced life expectancy among exposed individuals. This national study aimed to quantify Years of Life Lost (YLL) due to premature mortality among Iranian survivors exposed to SM during the post-war period (1988\u0026ndash;2021).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData were obtained from the Veterans and Martyr Affairs Foundation (VMAF). YLL was calculated using both the Iranian Nationwide Life Table and the Coale-Demeny Model Life Table West, incorporating discount rates (0%, 3%, and 6%) and age-weightings (0 and 1).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 8,956 deaths were recorded among individuals with a history of SM exposure, predominantly in males (98.3%). Depending on methodological assumptions, the total YLL ranged from 87,625.7 to 228,951.1. Using a 0% discount rate and no age-weighting based on the Iranian Nationwide Life Table, males accounted for the vast majority of YLL (188,234.4 years; 98.8%), with the highest burden in the 50\u0026ndash;54 age group (38,072.9 years). Females experienced considerably lower YLL (2,342.4 years; 1.2%), with a peak in the 60\u0026ndash;64 age group (339.1 years). Under the same assumption, the average YLL per deceased male was 21.4 years, compared to 15.0 years for females. Average YLL increased with the severity of lung injury (from mild to severe), rising from 20.5 to 21.4 years in men and from 15.3 to 34.7 years in women. Survivors with combined lung/skin or lung/eye complications showed the highest average YLL in males (21.4 and 21.2 years, respectively), whereas females with severe lung complications faced an elevated average of 34.7 years. Geographic disparities were observed across provinces, and a statistically significant upward trend in YLL over time was found for both sexes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThese findings highlight the critical need for sustained monitoring and targeted care for survivors with lung damages, especially those with multiple or severe pulmonary complications. The rising YLL over time underscore the importance of ongoing research to guide the effective prevention and intervention strategies. Further investigation into geographic disparities is needed to improve regional and population-specific care.\u003c/p\u003e","manuscriptTitle":"Years of Life Lost due to Premature Mortality Following Sulfur Mustard Exposure: A Post-War National Burden of Disease Study (1988-2021)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-14 08:58:36","doi":"10.21203/rs.3.rs-7847427/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-28T20:33:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280774652070905057511081673839057421561","date":"2025-12-07T10:36:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T19:55:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113154248943986100782157014412418020450","date":"2025-11-06T17:41:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-04T17:26:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-30T10:51:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-21T04:30:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-20T16:08:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-20T16:05:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1dd530cd-6fd9-48c5-aae9-7c2ae65c8a79","owner":[],"postedDate":"November 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-14T08:58:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-14 08:58:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7847427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7847427","identity":"rs-7847427","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}