Rising Multiple Sclerosis Rates in Middle East

We know a great deal about the epidemiology of MS in the populations of the United States, Canada and Europe. However, we don’t hear much about what is going on with MS outside of these regions, especially in the Arab world.

When I noticed a session  at the 2015 meeting of the European Committee on Treatment and Research in Multiple Sclerosis, titled “Epidemiology of Multiple Sclerosis in the Middle East,” I eagerly attended to learn more.

In the first presentation, the authors reviewed all of the MS epidemiologic studies from the different countries of the Middle East. They found that:

  • Most Arab countries are in the “moderate” MS prevalence (“prevalence” means number of people living with the disease) zone, with rates far lower than the high rates of Northern Europe, yet only slightly lower than those of Southern Europe; and much higher than MS in sub-Saharan Africa. Rates in the Middle East average 50-60/100,000. For comparison, rates per 100,000 in Canada are 291, in the UK 164, in the northern part of the US about 125, and in the southern part of the US about 70.
  • The typical age of onset is between 23.5 to 32.5 years (in the US it is 34 years old).
  • Primary progressive course was diagnosed in 4% to 19% (in the US it is 10%).

In addition, the prevalence of MS in the Arab countries is steadily increasing. For instance:

  • In Kuwait in 1992, the prevalence was reported as 15 per 100,000 population; in 2005, it was 31; and in 2013, it was 85.
  • In Saudi Arabia in 1993, the prevalence of MS was reported as 4 per 100,000, and just 16 years later, it was 30.
  • In Jordan in 1995, prevalence of MS was reported as 20 per100,000, compared to 38 per100,000 in 2006.

Interestingly, this rise is primarily driven by an increase of relapsing-remitting MS (RRMS) among females. In other parts of the world, the ratio of females to males with RRMS was around 1.5 in the 1950s, now it is 2.5-3.5 women to every man – this is a similar situation to that in the Middle East.

Why is prevalence of MS rising so rapidly in the Middle East? Many theories have been put forward as explanations:

  • Longer survival times: With increased use of disease-modifying therapies and better health overall, people with MS are simply living longer. The more people that are living with MS for more years, the higher the prevalence.
  • Earlier diagnosis: Like living longer, the earlier that a person is known to have MS, the longer they “count” towards the prevalence.
  • MRI availability: This relates to earlier diagnosis. More MRI technology is becoming available in different regions of the Middle East, making it possible to confirm MS diagnosis for more people.
  • Urbanization: This is potentially a multifactorial contributor to higher MS prevalence. One part of it relates to the reasons that we mentioned above, such as better access to modern healthcare and earlier diagnosis with MS.
  • Less sun: With greater urbanization and industrialization, people in the Middle East are spending far less time in the sun than they used to, resulting in lower vitamin D levels than in earlier times. Low vitamin D levels have been shown to be a risk factor for developing MS.
  • High BMI and changing diet: It was mentioned more than once that people in the Middle East are embracing a “Western lifestyle.” That was a euphemism for a diet comprised of a high percentage of processed foods, as well as a rising level of obesity. Certainly in recent years, obesity has been implicated in increased risk for MS, especially in young females.
  • Improved hygiene: This is a reference to the “hygiene hypothesis.” Basically, the thought behind this theory is that when environments get “too clean” and people are not exposed to enough pathogens for their immune system to react to, the immune system may begin to attack itself, causing autoimmune disorders like MS. Sanitary conditions have dramatically improved in the Middle East over the past several years, which do lend credence to this theory.

Bottom Line: Although ethnic differences may play a role, it is interesting to see that MS rates in the Middle East are increasing as the lifestyles become more like that of the “high-prevalence countries.”

As a footnote, I would like to point out that all of the numbers that we have in the US are estimates. It’s been many years since there was a solid study that tells us how many people in the US have MS. There’s a proposed bill that would establish a registry that would give us new information on how many people have MS, and inform factors like environmental factors and geographic clusters of MS, changes in gender ratio and lots of other vital information. If you want your legislators to know this is important to you, click here.

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Julie Stachowiak, PhD

Julie is the author of the Multiple Sclerosis Manifesto, the winner of the 2009 ForeWord Book of the Year Award in the Health Category. She is an epidemiologist who is also a person living with MS, Julie has an in-depth understanding about current research and scientific developments around MS. She also has first-hand knowledge of the frustrations and anxiety surrounding the disease, as she had MS for at least 15 years before receiving a diagnosis in 2003 and has had several relapses since her diagnosis.