en Health Management and Economics Health Management and Economics Original Research Original Research <span style="font-size:13pt"><span style="text-justify:kashida"><span style="text-kashida:0%"><span style="text-autospace:none"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-style:italic"><b>&nbsp;&nbsp;</b><b><span style="font-size:9.0pt"><span style="font-style:normal">&nbsp; Background: </span></span></b><span style="font-size:9.0pt"><span style="font-style:normal">Despite extensive evidence regarding the significant impact of the COVID-19 pandemic on population health in Iran, its effects at the sub-national level and comparisons across different geographic regions have garnered less attention. This study aimed to estimate key disease burden indicators, including incidence rate, mortality rate, case fatality rate, and disability-adjusted life years, across Iranian provinces during 2020 and 2021.</span></span></span></span></span></span></span></span><br> <span style="font-size:13pt"><span style="text-justify:kashida"><span style="text-kashida:0%"><span style="text-autospace:none"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-style:italic"><span style="font-size:9.0pt"><span style="font-style:normal">&nbsp;&nbsp; <b>Methods:</b> We obtained and analyzed hospital billing records of beneficiaries from the Iran Health Insurance Organization (IHIO) who were admitted for COVID-19 across Iran from the onset of the pandemic until December 2021. We identified cases using the WHO-recommended ICD-10 codes U07.1 and U07.2. In addition to reporting provincial-level rates of incidence, mortality, and case fatality rates, we also assessed disease burden by aggregating Years of Life Lost and Years Lived with Disability. Data management and analysis were conducted using Microsoft Excel Office 19 (Microsoft Corporation).</span></span></span></span></span></span></span></span><br> <span style="font-size:13pt"><span style="text-justify:kashida"><span style="text-kashida:0%"><span style="text-autospace:none"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-style:italic"><span style="font-size:9.0pt"><span style="font-style:normal">&nbsp;&nbsp; <b>Results: </b>Substantial interprovincial disparities were observed. Semnan (3,331) and Yazd (3,171) recorded the highest incidence rates per 100,000 people, whereas Qom (224) and Alborz (212) reported the highest death rates. In 2020, the highest case fatality rate (18.59%) was recorded in Razavi Khorasan province, while in 2021, the peak rate (12.52%) was observed in Qom province, both rates exceeding the national average. The burden of disease peaked in Qom (4,287) and the central provinces, while the lowest burden was observed in Kohgiluyeh and Boyer-Ahmad (1,042).</span></span></span></span></span></span></span></span><br> <span style="font-size:13pt"><span style="text-justify:kashida"><span style="text-kashida:0%"><span style="text-autospace:none"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-style:italic"><span style="font-size:9.0pt"><span style="font-style:normal">&nbsp;&nbsp; <b>Conclusion:</b> This study indicates geographic, age, and sex-based disparities in the burden of COVID-19 in Iran. Therefore, future pandemic preparedness policies must account for regional differences and allocate resources equitably based on the needs of various population subgroups. Further research on health inequalities and comprehensive data on social determinants of health is essential.</span></span></span></span></span></span></span></span><br> <span style="font-size:13pt"><span style="text-justify:kashida"><span style="text-kashida:0%"><span style="text-autospace:none"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-style:italic"><span style="font-size:9.0pt"><span style="font-style:normal">This provides stronger evidence for policymakers to address disparities in COVID-19 case fatality and mortality rates.</span></span></span></span></span></span></span></span><br> &nbsp; COVID-19, Disability-Adjusted Life Years, Subnational Health Disparities, Iran, Epidemiology 470 480 http://mjiri.iums.ac.ir/browse.php?a_code=A-10-2982-2&slc_lang=en&sid=1 Soheila Damiri damiri.soheila@gmail.com 200319475328460098074 200319475328460098074 No National Center for Health Insurance Research, Tehran, Iran Behzad Raei raeibehzad@gmail.com 200319475328460098075 200319475328460098075 No Social Determinants of Health Research Center, Health and Metabolic Diseases Research Institute, Zanjan University of Medical Sciences, Zanjan, Iran Hossein Ranjbaran ho.ranjbaran@gmail.com 200319475328460098076 200319475328460098076 Yes Immunogenetics Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran Rajabali Daroudi rdaroudi@sina.tums.ac.ir 200319475328460098077 200319475328460098077 No Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Abolfazl Zendehdel A.zendedel@yahoo.com 200319475328460098078 200319475328460098078 No Internal Medicine Department, Ziaeian Hospital, Tehran University of Medical Sciences, Tehran, Iran Reza Bakhtiari Dastgerdi bakhtiaridastgerdireza@gmail.com 200319475328460098079 0009-0005-4492-6555 No Clinical Research Development Center, Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Zahra Shahali z.shahali3000@ihio.gov.ir 200319475328460098080 200319475328460098080 No Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran Roghayeh Esmaeili esmaeiliroqi@gmail.com 200319475328460098081 0009-0009-2627-9162 No Student Research Committee, Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran Mahbubeh Ghavidast Kuhpayeh m.ghavidast2015@gmail.com 200319475328460098082 200319475328460098082 No National Center for Health Insurance Research, Tehran, Iran