Endemic infectious diseases of Afghanistan

Prevalence of soil-transmitted helminths and associated risk factors among primary school children in Kandahar, Afghanistan: A cross-sectional analytical study

BACKGROUND

Soil-transmitted helminth (STH) infections are global health problem, especially in low-income countries. Main objectives of this study were to estimate the prevalence and intensity of STH and its risk factors among school children in Kandahar city of Afghanistan.

METHODOLOGY/PRINCIPAL FINDINGS

This was a school-based cross-sectional analytical study, with data collected during eight-month-period (May-December, 2022) from 6- and 12-years old school children in Kandahar city, Afghanistan. All the stool samples were examined by saline wet mount method and Kato-Katz technique. Data were analyzed by using descriptive statistics, Chi square test, and multivariate logistic regression. A total of 1275 children from eight schools of Kandahar city were included in this study. Mean age of these children was 8.3 years with 53.3% boys. The overall prevalence of any intestinal parasitic infection was 68.4%. The overall prevalence of STH infection was 39.1%, with Ascaris lumbricoides (29.4%) as the most prevalent STH species. Mean intensity of overall STH infection was 97.8. Multivariate logistic regression revealed playing barefoot (AOR 1.6, 95% CI 1.1-2.2), not washing hands after defecating and before eating (AOR 1.3, 95% CI 1.0-1.7), having untrimmed nails (AOR 1.4, 95% CI 1.1-1.8), and belonging to poor families (AOR 1.3, 95% CI 1.0-1.7) as the risk factors associated with the predisposition of school children for getting STH in Kandahar city of Afghanistan.

CONCLUSIONS/SIGNIFICANCE

There is high prevalence of STH among school children of Kandahar city in Afghanistan. Most of the risk factors are related to poverty, decreased sanitation, and improper hygiene. Improvement of socioeconomic status, sanitation, and health education to promote public awareness about health and hygiene together with periodic mass deworming programs are better strategies for the control of STH infections in Afghanistan.

Understanding injecting drug use in Afghanistan: A scoping review

Background

Several reports have described a growing prevalence of illicit drug use in Afghanistan, with recognition of a recent shift from traditional modes of consumption involving inhalation and oral ingestion to injecting drug use.

Objective

Conduct a comprehensive review of existing literature to map the injecting drug use situation in Afghanistan. The review intends to describe risk factors and impacts of injecting drug use, drug use characteristics and risk behaviours among people who inject drugs (PWID), and access to harm reduction and treatment.

Methods

We searched Embase, Global Health, Medline, PsycINFO, Web of Science, and grey literature to identify English language publications up to March 26^th, 2022. Studies were eligible for inclusion if they explicitly targeted PWID or injecting drug use in Afghanistan and provided information relevant to the review questions. Two reviewers independently screened titles and abstracts for inclusion and extracted information based on the review objectives.

Results

A total of 25 articles were identified representing 15 studies (11 quantitative, 2 qualitative, 2 mixed methods). All but one studies were cross-sectional. In majority of the studies, over 95% of the participants were male and most were conducted over a decade ago, in urban settings, mainly Kabul. Only one study examined risk factors of injecting drug use. Eleven studies described drug use characteristics and 9 reported risk behaviours among PWID. Health and social burden of injecting drug use were reported by 8 and 5 studies, respectively. Nine studies described access to harm reduction and treatment. Afghan PWID had high levels of injecting and sexual risk behaviours compared to global estimates. They reported high prevalence of incarceration and displacement. Access to harm reduction and treatment was very limited. This scoping review revealed important knowledge gaps including a gender gap in research with serious implications for drug policy and substance use care.

Conclusions

Development of a national public health-oriented drug policy and substance use care programme is warranted along with efforts to develop health research capacity to address the need for epidemiological data. The current humanitarian crisis necessitates continued access to evidence-based harm reduction and treatment in Afghanistan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00491-1.

Prevalence and associated risk factors of soil-transmitted helminth infections in Kandahar, Afghanistan

Background

Soil-transmitted helminth (STH) infections are still a major health problem, especially in resource-limited countries. The community-based prevalence of STH is unknown in Afghanistan. Main objectives of this study were to estimate the prevalence and associated factors of STH among children in Daman district of Kandahar province in Afghanistan.

Methods

This was a community-based cross-sectional study, with data collected during five months (June–October, 2020) from children living in five villages of Daman district in Kandahar, Afghanistan. All the stool samples were examined by saline wet mount method. Data were analyzed by using descriptive statistics, Chi square test, and multivariate logistic regression.

Results

A total of 1426 children were studied, with majority (61.8%) of males and the mean age of 6.3 years. The overall prevalence of any intestinal parasitic infection was 39.8%. The overall prevalence of STH infection was 22.7%, with Ascaris lumbricoides (18.7%) as the most prevalent STH species, followed by hookworm (7.5%) and Trichuris trichiura (1.4%). Single, double, and triple STH infections were present in 14.9%, 7.2%, and 0.6% of the children, respectively. Multivariate logistic regression revealed that not washing hands after defecating/before eating (AOR 7.0, 95% CI 3.4–14.0), living in mud house (AOR 3.5, 95% CI 1.6–7.4), walking barefoot (AOR 2.2, 95% CI 1.6–3.1), living in overcrowded house (AOR 1.6, 95% CI 1.1–2.3), and practicing open defecation (AOR 1.4, 95% CI 1.1–2.0) as the risk factors associated with the predisposition of rural children for getting STH in Daman district of Afghanistan.

Conclusions

Prevalence of STH is high among children of Daman district in Afghanistan. Most of the risk factors are related to poverty, decreased sanitation, and improper hygiene. Improvement of socioeconomic status, sanitation, and health education to promote public awareness about health and hygiene together with periodic mass deworming programs are better strategies for the control of STH infections in Afghanistan. Also, government and international donor agencies in Afghanistan should help in improving socio-economic status of the rural areas through provision of basic facilities such as piped water, electricity, good housing, and proper toilets.

Cohort profile: a migratory cohort study of US Marines who train in Australia

PURPOSE

In 2012, US Marines and Sailors began annual deployments to Australia to participate in joint training exercises with the Australian Defence Force and other partners in the region. During their training, US service members are exposed to a variety of infectious disease threats not normally encountered by American citizens. This paper describes a cohort of US Marines and Sailors enrolled during five rotations to Australia between 2016 and 2020.

PARTICIPANTS

Study participation is strictly voluntary. Group informational sessions are held prior to deployment to describe the study structure and goals, as well as the infectious disease threats that participants may encounter while in Australia. All participants provided written informed consent. Consented participants complete a pre-deployment questionnaire to collect data including basic demographic information, military occupational specialty, travel history, family history, basic health status and personal habits such as alcohol consumption. Blood is collected for serum, plasma and peripheral blood mononuclear cells (PBMC) processing. Data and specimen collection is repeated up to three times: before, during and after deployment.

FINDINGS TO DATE

From the five rotations that comprised the 2016-2020 Marine Rotational Force-Darwin, we enrolled 1289 volunteers. Enrolments during this period were overwhelmingly white male under the age of 24 years. Most of the enrollees were junior enlisted and non-commissioned officers, with a smaller number of staff non-commissioned officers and commissioned officers, and minimal warrant officers. Over half of the enrollees had occupational specialty designations for infantry.

FUTURE PLANS

In the future, we will screen samples for serological evidence of infection with Burkholderia pseudomallei, Coxiella burnetii, Ross River virus, SARS-CoV-2 and other operationally relevant pathogens endemic in Australia. Antigenic stimulation assays will be performed on PBMCs collected from seropositive individuals to characterise the immune response to these infections in this healthy American population.

Small Mammals as Reservoir for Zoonotic Agents in Afghanistan

INTRODUCTION

Rodents and other small mammals can serve as reservoirs for a large number of zoonotic pathogens. A higher risk of infection with rodent-borne pathogens exists for humans with direct contact to rodents and/or their excretions, e.g., soldiers in operation areas. To date, little is known about endemic human pathogenic disease agents that are naturally associated with small mammals in Afghanistan. The aim of this study was to screen abundant rodents and insectivores collected from 2009 to 2012 in four field camps of the German Federal Armed Forces (Bundeswehr) in Northern Afghanistan for the presence of different pathogens.

MATERIALS AND METHODS

Isolated nucleic acids from ear pinna were screened by real-time PCR for spotted fever group (SFG) rickettsiae and from liver samples for Francisella spp., Coxiella burnetii, Brucella spp., Yersinia pestis, and poxvirus. Chest cavity lavage (CCL) samples were tested for antibodies against SFG and typhus group (TG) rickettsiae, as well as against flaviviruses using an indirect immunofluorescence assay.

RESULTS

Rickettsial DNA was detected in 7/750 (1%) ear pinna samples with one being identified as Rickettsia conorii. Antibodies against SFG rickettsiae were detected in 15.3% (n = 67/439) of the small mammals; positive samples were only from house mice (Mus musculus). Antibodies against TG rickettsiae were found in 8.2% (n = 36/439) of the samples, with 35 from house mice and one from gray dwarf hamster (Cricetulus migratorius). Flavivirus-reactive antibodies were detected in 2.3% (n = 10/439) of the investigated CCL samples; again positive samples were exclusively identified in house mice. All 199 investigated liver-derived DNA preparations were negative in the Francisella spp., C. burnetii, Brucella spp., Y. pestis, and poxvirus-specific PCRs.

CONCLUSIONS

Further investigations will have to prove the potential value of rodents in army camps as sentinel animals.

Vector-borne diseases in Iran: epidemiology and key challenges

Vector-borne diseases have become a global health concern in recent decades as a result of global warming, globalization, growth in international trade and travel, use of insecticide and drug resistance. This review study addressed the key vector-borne diseases and their current status in Iran to emphasize the requirements for further research on vector-borne diseases. The dispersion patterns of these diseases differ in various regions. Some of them such as Crimean-Congo hemorrhagic fever, and Q fever are distributed all across Iran, whereas some others such as plague, leishmaniasis, tularemia, and malaria are restricted to specific areas. The high prevalence of vectors throughout the country necessitates enhancing the monitoring and surveillance of emerging and reemerging vector-borne diseases and their potential vectors.

Diarrhea Patterns and Climate: A Spatiotemporal Bayesian Hierarchical Analysis of Diarrheal Disease in Afghanistan

Subject to a high burden of diarrheal diseases, Afghanistan is also susceptible to climate change. This study investigated the spatiotemporal distribution of diarrheal disease in the country and how associated it is with climate variables. Using monthly aggregated new cases of acute diarrhea reported between 2010 and 2016 and monthly averaged climate data at the district level, we fitted a hierarchical Bayesian spatiotemporal statistical model. We found aridity and mean daily temperature were positively associated with diarrhea incidence; every 1°C increase in mean daily temperature and 0.01-unit change in the aridity index were associated with a 0.70% (CI: 0.67%, 0.73%) increase and a 4.79% (CI: 4.30%, 5.26%) increase in the risk of diarrhea, respectively. Average annual temperature, on the other hand, was negatively associated, with a 3.7% (CI: 3.74%, 3.68) decrease in risk for every degree Celsius increase in annual average temperature. Temporally, most districts exhibited similar seasonal trends, with incidence peaking in summer, except for the eastern region where differences in climate patterns and population density may be associated with high rates of diarrhea throughout the year. The results from this study highlight the significant role of climate in shaping diarrheal patterns in Afghanistan, allowing policymakers to account for potential impacts of climate change in their public health assessments.

Old World cutaneous leishmaniasis treatment response varies depending on parasite species, geographical location and development of secondary infection

BACKGROUND

In the Kingdom of Saudi Arabia (KSA), Leishmania major and L. tropica are the main causative agents of Old World cutaneous leishmaniasis (CL). The national CL treatment regimen consists of topical 1% clotrimazole/2% fusidic acid cream followed by 1-2 courses of intralesional sodium stibogluconate (SSG); however, treatment efficacy is highly variable and the reasons for this are not well understood. In this study, we present a complete epidemiological map of CL and determined the efficacy of the standard CL treatment regime in several endemic regions of KSA.

RESULTS

Overall, three quarters of patients in all CL-endemic areas studied responded satisfactorily to the current treatment regime, with the remaining requiring only an extra course of SSG. The majority of unresponsive cases were infected with L. tropica. Furthermore, the development of secondary infections (SI) around or within the CL lesion significantly favoured the treatment response of L. major patients but had no effect on L. tropica cases.

CONCLUSIONS

The response of CL patients to a national treatment protocol appears to depend on several factors, including Leishmania parasite species, geographical location and occurrences of SI. Our findings suggest there is a need to implement alternative CL treatment protocols based on these parameters.

Leptospira spp. in Rodents and Shrews from Afghanistan

Leptospirosis is an occupational risk for military personnel and many cases have been reported worldwide. Rodents are the most important maintenance hosts for Leptospira spp. and may infect both animals and humans. To determine the occurrence and identity of pathogenic Leptospira spp. in rodent and shrew populations in German military camps in Afghanistan, we examined 751 animals ( Mus musculus, Cricetulus migratorius, Meriones libycus, Rattus tanezumi, Crocidura cf. suaveolens, and Suncus etruscus) from four military camps in Northern Afghanistan from 2009-12. Leptospiral DNA was found in 1.1% of the animals and only in Mus musculus. Partial secY sequencing identified Leptospira borgpetersenii and Leptospira kirschneri as infecting genomospecies. Multilocus sequence typing was successful in the L. borgpetersenii samples, which were identified as sequence type 155. The low prevalence we observed suggested that the exposure risk of military personnel to infectious Leptospira spp. in the region is low.

First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan

OBJECTIVE

To report presence of Leishmania major in Khyber Pakhtunkhwa of Pakistan, where cutaneous leishmaniasis (CL) is endemic and was thought to be caused by Leishmania tropica only.

METHODS

Biopsy samples from 432 CL suspected patients were collected from 3 southern districts of Khyber Pakhtunkhwa during years 2011-2016. Microscopy on Giemsa stained slides were done followed by amplification of the ribosomal internal transcribed spacer 1 gene.

RESULTS

Leishmania amastigotes were detected by microscopy in 308 of 432 samples (71.3%) while 374 out of 432 samples (86.6%) were positive by ribosomal internal transcribed spacer 1 PCR. Subsequent restriction fragment length polymorphism confirmed L. tropica in 351 and L. major in 6 biopsy samples.

CONCLUSIONS

This study is the first molecular characterization of Leishmania species in southern Khyber Pakhtunkhwa. It confirmed the previous assumptions that anthroponotic CL is the major CL form present in Khyber Pakhtunkhwa province. Furthermore, this is the first report of L. major from a classical anthroponotic CL endemic focus identified in rural areas of Kohat district in southern Khyber Pakhtunkhwa.

First detection and genotyping of Giardia intestinalis in stool samples collected from children in Ghazni Province, eastern Afghanistan and evaluation of the PCR assay in formalin-fixed specimens

It is estimated that faecal-orally transmitted diseases are common in Afghanistan, as a consequence of poor hygienic standards of life and widespread contamination of water and food with both human and animal faeces. However, there is little information in the literature concerning infections caused by intestinal parasites in the Afghan population. In this study, we report the occurrence of Giardia intestinalis assemblages (A and B) in formalin-fixed stool samples collected from 245 Afghan schoolchildren living in Ghazni Province in eastern Afghanistan. Detection of the parasite’s DNA and genotyping was performed using real-time PCR, specific to the β-giardin gene of G. intestinalis. Positive results were recorded in 52 (21.2%) samples. Genotyping was successful in 39 faecal samples and showed the predominance of assemblage B of G. intestinalis in this population (15 assemblage A and 24 assemblage B). Co-infection with both genotypes A and B was detected in four samples. Additionally, we evaluated the effect of 10% buffered formalin fixative on the detection of G. intestinalis DNA using real-time PCR and nested PCR characterised by different lengths of PCR products (74 and 479 bp, respectively). The human faeces containing the Giardia cysts were tested for 16 weeks. Amplification of G. intestinalis DNA with real-time PCR was possible up to 6 weeks of preservation of stool sample in formalin, compared to only 2 weeks with nested PCR. This suggests that real-time PCR is a more suitable tool in cases where stool samples have to be kept in formalin for longer periods of time.

Trends of vaccine-preventable diseases in Afghanistan from the Disease Early Warning System, 2009-2015

BACKGROUND

Afghanistan's public health system was neglected during decades of military and civil conflict, and trends in infectious disease occurrence remain poorly characterized. This study examines cyclical and long-term trends of six vaccine-preventable diseases: pneumonia, diarrhea, meningitis, typhoid, measles, and acute viral hepatitis.

METHODS

Using weekly data collected between 2009 and 2015 through Afghanistan's Disease Early Warning System, we calculated monthly case counts, and fit a Poisson regression with a Fourier transformation for seasonal cycles and dummy variables for year.

RESULTS

We found the greatest incidence of diarrhea and typhoid in the summer, pneumonia in the winter, and measles in the late spring. Meningitis and acute viral hepatitis did not demonstrate substantial seasonality. Rates of pneumonia and diarrhea were constant across years whereas rates of meningitis, typhoid, and acute viral hepatitis decreased. Measles incidence increased in 2015.

CONCLUSIONS

Communicable disease reporting systems can guide public health operations-such as the implementation of new vaccines, and permit evaluation of health interventions. For example, measles supplementary immunization activities in Afghanistan have not slowed long-term transmission of the disease, but decreases in typhoid fever and acute viral hepatitis are probably tied to improvements in sanitation in the country.

Non-traumatic Pulmonary Emergencies in the Deployed Setting

PURPOSE OF REVIEW

Pulmonary disorders accounted for up to 8% of the over 70,000 medical evacuations conducted from Iraq and Afghanistan in the past 15 years. This review of non-traumatic pulmonary emergencies provides an overview of deployed military medical treatment capabilities and highlights pulmonary emergencies requiring aeromedical evacuation from theater.

RECENT FINDINGS

Recent studies have improved the epidemiologic evaluation of non-traumatic pulmonary disease, highlighted specific parenchymal diseases, and revealed infection pathologies unique to the deployed setting. Literature regarding possible chemical exposures in the current deployed environment remains limited.

SUMMARY

Respiratory disorders requiring medical evacuation represent a wide variety of diseases. Complications such as pulmonary emboli, infectious pathogens, and hazardous chemical exposures threaten the deployed warfighter. Adequate medical care requires an understanding of these potential environmental exposures. This review serves as a general overview of this topic; however, more research regarding epidemiologic and environmental exposures is required.

Seroconversions for Coxiella and Rickettsial Pathogens among US Marines Deployed to Afghanistan, 2001-2010

We assessed serum samples from 1,000 US Marines deployed to Afghanistan during 2001-2010 to find evidence of 4 rickettsial pathogens. Analysis of predeployment and postdeployment samples showed that 3.4% and 0.5% of the Marines seroconverted for the causative agents of Q fever and spotted fever group rickettsiosis, respectively.

Seroconversion for infectious pathogens among UK military personnel deployed to Afghanistan, 2008-2011

Military personnel are at high risk of contracting vector-borne and zoonotic infections, particularly during overseas deployments, when they may be exposed to endemic or emerging infections not prevalent in their native countries. We conducted seroprevalence testing of 467 UK military personnel deployed to Helmand Province, Afghanistan, during 2008-2011 and found that up to 3.1% showed seroconversion for infection with Rickettsia spp., Coxiella burnetii, sandfly fever virus, or hantavirus; none showed seroconversion for infection with Crimean-Congo hemorrhagic fever virus. Most seroconversions occurred in personnel who did not report illness, except for those with hantavirus (70% symptomatic). These results indicate that many exposures to infectious pathogens, and potentially infections resulting from those exposures, may go unreported. Our findings reinforce the need for continued surveillance of military personnel and for education of health care providers to help recognize and prevent illnesses and transmission of pathogens during and after overseas deployments.

Epidemiology of intestinal parasitic infections in school children in Ghazni Province, eastern Afghanistan

OBJECTIVE

To estimate the prevalence of intestinal parasites and their species in Afghan school children and to establish appropriate treatment methods for detected pathogens.

METHODS

Parasitological examination of stool samples collected from 1369 children aged 8-18, students of the Jahan Malika High School in Ghazni Province in eastern Afghanistan, was conducted in the period November 2013-April 2014. Three stool samples were collected from each patient every second day; the samples were fixed in 10% formalin and tested by light microscopy using the methods of direct smear in Lugol's solution, decantation in distilled water, and Fülleborn's flotation.

RESULTS

Of 535 examined children (39.1% of the study group) were infected with nematodes (n=324), cestodes (n=118), trematodes (n=12), and protozoa (n=228), 132 were diagnosed with co-infections (mainly ascariasis+giardiasis, ascariasis+hymenolepiasis) and received single or combined therapy.

CONCLUSIONS

The Afghan community is an example of population characterized by a high rate of parasitic infections. Owing to high prevalence of multiple infections among inhabitants of Afghanistan, it seems that a mass deworming campaign with a single-dose chemotherapy may prove ineffective in eradicating intestinal parasites in the local population.

Seroprevalence of Brucellosis, Leptospirosis, and Q Fever among Butchers and Slaughterhouse Workers in South-Eastern Iran

Zoonotic diseases can be occupational hazards to people who work in close contact with animals or their carcasses. In this cross-sectional study, 190 sera were collected from butchers and slaughterhouse workers in different regions of the Sistan va Baluchestan province, in Iran in 2011. A questionnaire was filled for each participant to document personal and behavioural information. The sera were tested for detection of specific IgG antibodies against brucellosis, leptospirosis, and Q fever (phase I and II) using commercial enzyme-linked immunosorbent assays (ELISA). The seroprevalence of brucellosis was 7.9%, leptospirosis 23.4%, and phase I and II of Q fever were 18.1% and 14.4%, respectively. The seroprevalence of Q fever and leptospirosis, but not brucellosis, varied among regions within the province (p = 0.01). Additionally, a significant relationship was found between seropositivity of Q fever and camel slaughtering (p = 0.04). Reduced seropositivity rate of brucellosis was associated with use of personal protective equipment (PPE) (p = 0.004). This study shows that brucellosis, leptospirosis and Q fever occur among butchers and slaughterhouse workers in this area.

A space-time analysis of the WikiLeaks Afghan War Diary: a resource for analyzing the conflict-health nexus

Background

Although it is widely acknowledged that areas of conflict are associated with a high health burden, from a geospatial perspective it is difficult to establish these patterns at fine scales because of a lack of data. The release of the “WikiLeaks” Afghan War Diary (AWD) provides an interesting opportunity to advance analysis and theory into this interrelationship.

Methods

This paper will apply two different space time analyses to identify patterns of improvised explosive devices (IED) detonations for the period of 2004 to 2009 in Afghanistan.

Results

There is considerable spatial and temporal heterogeneity in IED explosions, with concentrations often following transportation links. The results are framed in terms of a resource for subsequent analyses to other existing health research in Afghanistan. To facilitate this, in our discussion we present a Google Earth file of overlapping rates that can be distributed to any researcher interested in combining his/her fine scale health data with a similarly granular layer of violence.

Conclusion

The release of the AWD presents a previously unavailable opportunity to consider how spatially detailed data about violence can be incorporated into understanding, and predicting, health related spillover effects. The AWD can enrich previous research conducted on Afghanistan, and provide a justification for future “official” data sharing at appropriately fine scales.

Frequency of West Nile Virus Infection in Iranian Blood Donors

West Nile virus (WNV) can be transmitted by blood transfusions and organ transplants. This study was a retrospective study which was performed in Blood Transfusion Center to evaluate the WNV infection in blood donors in Iran. A total of 540 blood samples were taken from volunteer healthy donors who referred for blood donation to Chabahar Blood Center. The presence of WNV was studied by detecting immunoglobulin G (IgG) WNV by enzyme linked immune sorbent assay (ELISA). Demonstration of elevated WNV IgG confirmed by immunoflouorescence assay (IFA) Euroimmun kit. Out of the 540 samples 17.96 % (97 cases) were seropositive by ELISA and 1.48 % (8 cases) was seropositive by IFA. This means that 8.24 % of ELISA seropositive samples were confirmed by IFA. Special attention should be paid to criteria of donor selection, albeit positive results may be due to a previous infection in these donors.

Imaging of pediatric pathology during the Iraq and Afghanistan conflicts

United States Armed Forces radiologists deployed to Afghanistan and Iraq in modern military conflicts may encounter pediatric patients as a casualty of war or when providing humanitarian assistance to the indigenous population. Pediatric patients account for 4-7% of admissions at U.S. military hospitals during the Iraq and Afghanistan conflicts. It is pertinent for radiologists in the humanitarian care team to be familiar with imaging pediatric trauma patients, the pathology endemic to the local population, and delayed presentations of congenital and developmental disorders to adequately care for these patients. The radiological manifestations of various pediatric disorders seen in the setting of the Iraq and Afghanistan conflicts will be explored.

Major infectious diseases affecting the Afghan immigrant population of Iran: a systematic review and meta-analysis

OBJECTIVES

As Afghans make up the largest group of foreign nationals in Iran, the aim of this study was to assess the proportion of Afghan immigrants among those afflicted by the most prevalent infectious diseases in Iran.

METHODS

National and international online scientific databases were searched through November 2013. The reference lists of included studies were also searched. All descriptive studies concerning the most common infectious diseases in Iran, including tuberculosis, multiple-drug-resistant tuberculosis, malaria, cholera, Crimean-Congo hemorrhagic fever, leishmaniasis, and hepatitis B were retrieved. The nationality of patients was not considered. The selection of studies and data extraction was performed separately by two authors. Results were reported using a random effect model with a 95% confidence interval (CI).

RESULTS

The overall proportion of Afghan immigrants with the aforementioned infectious diseases was 29% (95% CI, 21 to 37). According to a stratified analysis, the proportion of Afghan immigrants afflicted with tuberculosis was (29%), multiple-drug-resistant tuberculosis (56%), malaria (40%), cholera (8%), Crimean-Congo hemorrhagic fever (25%), leishmaniasis (7%), and hepatitis B (14%).

CONCLUSIONS

It is highly recommended to monitor the health status of the Afghan immigrants when entering Iran, to reduce the spread of communicable diseases, which are viewed as serious in international health regulations.

The contribution of unimproved water and toilet facilities to pregnancy-related mortality in Afghanistan: analysis of the Afghan Mortality Survey

OBJECTIVE

To estimate the effect of unimproved household water and toilet facilities on pregnancy-related mortality in Afghanistan.

METHODS

The data source was a population-based cross-sectional study, the Afghan Mortality Survey 2010. Descriptive, univariate and multivariate logistic regression analyses were carried out, comparing 69 pregnancy-related deaths (cases) and 15386 surviving women (non-cases) who had a live birth or stillbirth between 2007 and 2010.

RESULTS

After adjusting for confounders, households with unimproved water access had 1.91 the odds of pregnancy-related mortality [95% confidence interval (CI) 1.11-3.30] compared to households with improved water access. We also found an association between unimproved toilet facilities and pregnancy-related mortality (OR = 2.25; 95% CI 0.71-7.19; P-value = 0.169), but it was not statistically significant.

CONCLUSIONS

Unimproved household water access was an important risk factor for pregnancy-related mortality in Afghanistan. However, we were unable to discern whether unimproved water source is a marker of unhygienic environments or socio-economic position. There was weak evidence for the association between unimproved toilet facilities and pregnancy-related mortality; this association requires confirmation from larger studies.

Immunological Testing Reveals Exposure to Malaria in the Hypoendemic Region of Iran

Background. South eastern parts of Iran remain endemic for malaria infection. There is some concern that malaria infection may spread into Bushehr, which is located in the south western part bordering the Persian Gulf and at the periphery of the declared endemic region Hormozgan province due to frequency of visitors from eastern endemic areas and from neighboring malaria endemic countries. We investigated malaria prevalence in Bushehr. Methods and Results. Attempts were made to identify malaria active infection in blood smears and malaria specific antibody and antigens in serum samples. Traditional blood smears prepared from 1955 blood specimens yielded no definitive malaria positive case by microscopic technique. A total of 270 (13.8%) serum samples were positive for malaria antibodies. Using specific ELISA kits, presence of histidine rich proteins and lactate dehydrogenase antigens were investigated in serum samples. No histidine rich proteins specific for P. falciparum were detected amongst 270 antibody positive samples. However, six samples representing 0.3% of total population, were found to be positive for plasmodium pan specific lactate dehydrogenase antigens. This suggested the possibility of low level exposure to malaria in Bushehr community. Conclusions. Out of a total of 1955 samples tested, 270 (13.8%) were positive for malaria antibodies and six (0.3%) of these were positive for plasmodium-specific lactate dehydrogenase antigen suggesting a low level exposure to malaria in a hypoendemic region based on immunological testing. Since none of the 270 antibody samples were positive for histidine rich protein antigens, there is scope for further testing of blood samples by molecular methods such as polymerase chain reactions to confirm the plasmodium species and provide information valuable for future investigations. Our testing strategy for hypoemdemic malaria can be used as a template for investing malaria in 32 eliminating countries for testing ongoing transmission. This approach may be useful as a method in epidemiological studies.

Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan

OBJECTIVE

To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting.

DESIGN

Patient randomised trial in primary level clinics.

SETTING

Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern region) and one with low transmission (northern region).

PARTICIPANTS

5794 patients of all ages with suspected malaria enrolled by 80 clinicians in 22 clinics.

INTERVENTIONS

Malaria rapid diagnostic tests were compared with clinical diagnosis where no parasite diagnostic test was available, longer established field microscopy, and recently introduced microscopy.

MAIN OUTCOME MEASURES

Proportion of patients appropriately treated with an antimalarial, defined as patients with P vivax who received chloroquine, patients with P falciparum who received artemisinin based combination therapy, and patients with no malaria parasites who did not receive an antimalarial. Secondary outcomes included diagnostic test accuracy and the proportion of patients negative for malaria who received antibiotics and antimalarials.

RESULTS

In the low transmission area, comparing rapid diagnostic tests with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile patients were appropriately treated for malaria (adjusted odds ratio 92.7, 95% confidence interval 12.4 to 694.1, P<0.001). The proportion of patients who were negative for malaria and received an antibiotic was 57% (185/325) in the rapid diagnostic test arm compared with 14% (46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the comparison of rapid diagnostic test with microscopy in the moderate transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of patients were appropriately treated for malaria (1.70, 1.30 to 2.23, P<0.001). A higher proportion of P falciparum cases received appropriate treatment with artemisinin based combination therapy when malaria was diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88 to 21.66, P<0.001).

CONCLUSIONS

In South and central Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.

Concurrent Brucellosis and Q Fever Infection: a Case Control Study in Bamyan Province, Afghanistan

BACKGROUND

More than 500,000 people are affected by brucellosis each year while the incidence of Q fever is poorly recorded. Consistent outbreaks of brucellosis have been reported in Afghanistan, affecting social and economic life. This study aimed to determine the means of propagation of brucellosis and Q-fever and establish appropriate control measures for both.

METHODS AND MATERIALS

An outbreak of 1,317 cases of brucellosis and Q fever was investigated from May 2011 to the end of 2012 in Bamyan province of Afghanistan. A total of 100 cases were selected by random sampling with equal number of neighbor controls. Data were collected through structured questionnaire.

RESULTS

The average age was 30 years ±14 years. Of those sampled, 62% were female, 38% were male, and resided in three districts: Punjab, Yakawlang and Waras. Using multivariate analysis, being a housewife (OR=7.36), being within proximity of kitchens to barns (OR= 2.98), drinking un-boiled milk (OR= 5.26), butchering (OR= 3.53) and purchasing new animals in the last six months (OR= 3.53) were significantly associated with contraction of brucellosis and Q fever.

CONCLUSION

Health educators should focus on families dealing with animals, especially on females. Pasturing, healthy milking, dunging, and slaughtering practices, along with use of safe dairy products should be the focus of preventive measures.

Risk assessment and prevention of malaria among Italian troops in Afghanistan, 2002 to 2011

BACKGROUND

Malaria prevention policy is different among coalition troops in Afghanistan, ranging from the combined use of suppressive and terminal chemoprophylaxis to the absence of any prophylactic regimen. The objective of this study was to assess the compliance with malaria prevention measures and the risk of malaria among Italian troops in Afghanistan.

METHODS

Target population was the cohort of 32,500 army soldiers deployed in Afghanistan, 2002 to 2011; eligible subjects were the 21,900 soldiers stationed in endemic areas, who were prescribed mefloquine chemoprophylaxis. Adherence to chemoprophylaxis was assessed by a cross-sectional study in a volunteer sample of 5,773 (26.4%) of eligible subjects. The risk of malaria was assessed by detecting malaria cases in the target population.

RESULTS

Mefloquine chemoprophylaxis was administered to 4,123 (71.4%) of the 5,773 enrolled soldiers and 3,575 (86.7%) of these took it regularly; however, compliance dropped from 80.9% (2,592/3,202) in 2002 to 2006 to 59.5% (1,531/2,571) in 2007 to 2011 (p < 0.01). Adverse events were reported by 875 (21.2%) of the 4,123 soldiers taking mefloquine, but caused irregularity or interruption of chemoprophylaxis only in 48 (1.2%) and 113 (2.7%) subjects, respectively. No serious adverse events were reported. No malaria cases occurred in Afghanistan, and one Plasmodium vivax case was reported in Italy, yielding an incidence rate of 3.24 cases per 10,000 person-months of exposure (1/3,091) during the transmission season of 2003.

CONCLUSIONS

In spite of the decreasing compliance with chemoprophylaxis, suggesting a low perception of the risk of malaria, this study confirmed the good tolerability of mefloquine in the military. The risk of malaria for Italian troops in Afghanistan was very low, and chemoprophylaxis was suspended in 2012. A similar policy may be adopted by the generality of International Security Assistance Force troops, and any chemoprophylaxis may be restricted to soldiers stationing in areas where the risk of malaria is substantial.

Population Movement and Virus Spreading: HEV Spreading in a Pilgrimage City, Mashhad in Northeast Iran; an Example

BACKGROUND

Hepatitis E Virus (HEV) infection is a significant public health concern and responsible for large outbreaks of acute hepatitis in poor sanitary and living conditions.

OBJECTIVES

To investigate the impact of population movements on virus spreading, a large-scale population-based survey was performed in a pilgrimage- tourism area, the great Mashhad, capital city of Khorasan province.

PATIENTS AND METHODS

A cross-sectional study was carried out among 1582 randomly selected individuals from general population of Mashhad, north east of Iran, between May to September 2009. Serum samples were tested for total anti-HEV antibody using a specific enzyme linked immunoassay (ELISA) kit.

RESULTS

The prevalence of HEV infection was 14.2% (225/1582) with a maximum of 25.5 % (14/55) in densely populated areas. The highest prevalence was observed in visitant areas (≥ 20%) near the holly shrine with crowded hotels and inns. The differences between these areas and other districts were statistically significant (P < 0.001). The findings indicated that 13.2% (95/718) of males and 15.0% (130/864) of females were HEV positive; this difference is not significant. Seroprevalence increases with age rising , from 12.8% in subjects less than five years to 28.6% in individuals with more than 65 years old. Although, there were no meaningful differences between HEV seropositivity and socio-economic status, Illiterate individuals were significantly at higher risk for infection than educated persons (P < 0.001).

CONCLUSIONS

These findings demonstrated that, high prevalence of HEV is related to populated district, which can reach to the highest rate in hotels and inns close to visitants. Traditional sanitation and water supplying systems are the second important factor for the virus transmission. Therefore, it can be concluded that such areas need efficient surveillance systems to prevent the spreading of infectious diseases.

Prevalence of hepatitis d in the eastern mediterranean region: systematic review and meta analysis

BACKGROUND

Hepatitis D Virus (HDV) causes the most threatening form of chronic viral hepatitis. To date, there is no overall estimation of HDV prevalence in the Eastern Mediterranean Region Office of WHO (EMRO) countries.

OBJECTIVES

To provide a clear estimation of HDV prevalence in the aforementioned region.

PATIENTS AND METHODS

In the current systematic review, databases such as PubMed, Embase, Web of sciences and Google scholar were searched Until December 2010. The summary estimate of HDV prevalence in the EMRO region was calculated as an average of the pooled infection prevalence of each country weighted by the ratio of the country's HBV population to the study's sample size in the survey data analysis.

RESULTS

We included 62 eligible studies. The weighted mean of HDV prevalence in the EMRO region was 14.74% (95% CI: 14.73 - 14.77), 27.8% (95% CI: 27.78 - 27.82), 36.57% (95% CI: 36.55 - 36.59) and 16.44%. (95% CI: 16.42 - 16.46) in asymptomatic HBsAg positive carriers, chronic hepatitis patients, cirrhosis/ hepatocellular carcinoma, and high risk group, respectively. Among the asymptomatic HBsAg positive group, HDV prevalence was increased by years in older patients in Saudi Arabia but its prevalence was decreased in Iran. No specific pattern was seen according to chronological analysis during years among the EMRO countries.

CONCLUSIONS

HDV infection is endemic in the EMRO countries and it is more common among patients with severe forms of hepatitis. Due to the high HDV infection rates in the EMRO countries, we recommend blood screening for HDV infection in this region.

Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study

OBJECTIVE

To assess the accuracy of malaria diagnosis and treatment at primary level clinics in Afghanistan.

DESIGN

Prospective observational study.

SETTING

22 clinics in two Afghan provinces, one in the north (adjoining Tajikistan) and one in the east (adjoining Pakistan); areas with seasonal transmission of Plasmodium vivax and Plasmodium falciparum.

PARTICIPANTS

2357 patients of all ages enrolled if clinicians suspected malaria.

INTERVENTIONS

Established (>5 years) microscopy (12 clinics in east Afghanistan), newly established microscopy (five clinics in north Afghanistan), and no laboratory (five clinics in north Afghanistan). All clinics used the national malaria treatment guidelines.

MAIN OUTCOME MEASURES

Proportion of patients positive and negative for malaria who received a malaria drug; sensitivity and specificity of clinic based diagnosis; prescriber's response to the result of the clinic slide; and proportion of patients positive and negative for malaria who were prescribed antibiotics. Outcomes were measured against a double read reference blood slide.

RESULTS

In health centres using clinical diagnosis, although 413 of 414 patients were negative by the reference slide, 412 (99%) received a malaria drug and 47 (11%) received an antibiotic. In clinics using new microscopy, 37% (75/202) of patients who were negative by the reference slide received a malaria drug and 60% (103/202) received an antibiotic. In clinics using established microscopy, 50.8% (645/1269) of patients who were negative by the reference slide received a malaria drug and 27.0% (342/1269) received an antibiotic. Among the patients who tested positive for malaria, 94% (443/472) correctly received a malaria drug but only 1 of 6 cases of falciparum malaria was detected and appropriately treated. The specificity of established and new microscopy was 72.9% and 79.9%, respectively. In response to negative clinic slide results, malaria drugs were prescribed to 270/905 (28.8%) and 32/154 (21%) and antibiotics to 347/930 (37.3%) and 99/154 (64%) patients in established and new microscopy arms, respectively. Nurses were less likely to misprescribe than doctors.

CONCLUSIONS

Despite a much lower incidence of malaria in Afghanistan than in Africa, fever was substantially misdiagnosed as malaria in this south Asian setting. Inaccuracy was attributable to false positive laboratory diagnoses of malaria and the clinicians' disregard of negative slide results. Rare but potentially fatal cases of falciparum malaria were not detected, emphasising the potential role of rapid diagnostic tests. Microscopy increased the proportion of patients treated with antibiotics producing a trade-off between overtreatment with malaria drugs and probable overtreatment with antibiotics.

Fleas on operations in Afghanistan--environmental health measures on the front line

Flea bites can cause irritating symptoms, secondary infections, and may potentiate the spread of vector-borne disease. Flea infestation and bites may also cause significant psychological distress, and can reduce the morale and fighting fitness of deployed military personnel. The problem of flea infestation was highlighted during Op HERRICK 12 in two 'front line' Check Points (CPs) where the entire population of soldiers suffered from multiple symptoms due to flea infestation and bites. Several attempts at infestation control initially succeeded but later lead to recurrence. Such failure was due to the incomplete killing of all stages of the flea life cycle, and due to constraints on education, training, communication, and resupply in the isolated and austere environment of the CPs. A dedicated operation (designated Op Insecticide) was put into action in order to eradicate the problem and return the affected troops back to full fighting fitness. Op Insecticide was thorough, systematic and sustainable, and lead to an eradication of the flea infestation problem at the affected CPs.

Prevalence of hepatitis B virus genotypes in HBsAg positive individuals of Afghanistan

Background

The structural and functional differences between hepatitis B virus (HBV) genotypes are the mainstay to severity, complications, treatment and possibly vaccination against the virus. This study was conducted to determine the HBV genotypes in HBsAg positive patients of Afghanistan as no such large scale data available previously.

Methods

Two hundred and fourteen HBsAg-positive patients were included in this study. All patients were anti-HCV and anti-HIV negative. All the samples were confirmed for HBV DNA with nested PCR while HBV DNA positive samples were subjected to type specific PCR for HBV genotyping (A-F).

Results

Of the total samples, 168 (78.5%) were males and 46 (21.49%) females, aged ranged between 18 to 71 years. This study demonstrated that genotype D (35.67%) is the predominant genotype circulating in Afghani's population. Genotype C was observed in 32.16% followed by genotype A (19.30%), and genotype B (7.02%) while 6.07% of the individuals were not typed.

Conclusion

This study has shown a heterogeneous distribution of HBV genotypes. Further more, extensive studies are required to investigate genetic and geographical divergence and characteristics of the virus in the country, as no such large sample sized study has been carried out so far in this country.

Share of Afghanistan populace in hepatitis B and hepatitis C infection's pool: is it worthwhile?

There is a notable dearth of data about Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) prevalence in Afghanistan. Awareness program and research capacity in the field of hepatitis are very limited in Afghanistan. Number of vulnerabilities and patterns of risk behaviors signal the need to take action now. Thirty one studies dating from October 2003 to 2011 were included, consisting the data of 132,981 individuals for HBV and 132,500 individuals for HCV. Percentage prevalence was 1.9% for HBV and 1.1% for HCV in all available Afghanistan population. Most at risk population to hepatitis include injecting drug users who share needles and female sex workers, while truck drivers, prisoners and homosexual men needs attention, as their statistical figure are missing. Data suggests that high incidence of intravenous drug use, sexual activities, unsafe blood transfusion procedures and mobility are major risk factors for hepatitis transmission. This review is based on analysis of the limited available data in Afghanistan. Although there are many underlying vulnerability factors, it appears that Afghanistan remains at an early epidemic phase. Further research is required to determine the seroprevalence and prevalent genotype(s) of HBV and HCV in all provinces in Afghanistan. This article provides some key insights into the potential and likely future transmission dynamics of hepatitis which will serve as a guide in the identification of priority areas in term of high risk groups and risk behaviours in the country and will assist to develop urgent strategic plans to combat the future burden of hepatitis in Afghanistan.

[Deployment of a mobile RT-PCR laboratory molecular biology to deal with the A(H1N1) challenge in Kaboul]

Since October 2009, the fear of swine flu spread in Afghanistan and severe cases were observed among NATO soldiers. Two patients were hospitalized in an Intensive Care Unit. To face this new challenge, the French Health Service decided the deployment of a mobile RT-PCR laboratory molecular biology in the Kabul International Military Hospital. We describe the implementation of the mobile RT-PCR laboratory for the diagnosis of A(H1N1). The analysis of the first nasopharyngeal samples confirmed the presence of this virus in Afghanistan. The peak of positive cases was observed in mid-November 2009, and some cluster cases were observed among units deployed on the field.

Outbreak of gastroenteritis caused by Yersinia pestis in Afghanistan

Plague, which is most often caused by the bite of Yersinia pestis-infected fleas, is a rapidly progressing, serious disease that can be fatal without prompt antibiotic treatment. In late December 2007, an outbreak of acute gastroenteritis occurred in Nimroz Province of southern Afghanistan. Of the 83 probable cases of illness, 17 died (case fatality 20·5%). Being a case was associated with consumption or handling of camel meat (adjusted odds ratio 4·4, 95% confidence interval 2·2-8·8, P<0·001). Molecular testing of patient clinical samples and of tissue from the camel using PCR/electrospray ionization-mass spectrometry revealed DNA signatures consistent with Yersinia pestis. Confirmatory testing using real-time PCR and immunological seroconversion of one of the patients confirmed that the outbreak was caused by plague, with a rare gastrointestinal presentation. The study highlights the challenges of identifying infectious agents in low-resource settings; it is the first reported occurrence of plague in Afghanistan.

Q fever in members of the United States armed forces returning from Iraq

Large numbers of armed forces personnel returning from southwest Asia may present with infections that are not endemic to the United States or that occur rarely and are underdiagnosed in the United States. We report 2 cases of acute Q fever in members of the US Military recently returned from Iraq. Because a number of recent reports suggest that the risk of Q fever may be higher than initially thought among US forces deployed to this region, clinicians need to have a high index of clinical suspicion, an understanding of the available diagnostic tests, and knowledge regarding the methodology and capabilities of the laboratory to which specimens are submitted.

The efficacy and tolerability of doxycycline and mefloquine in malaria prophylaxis of the ISAF troops in Afghanistan

OBJECTIVES

Afghanistan is one of the endemic regions of chloroquine resistant P. falciparum. Mefloquine and doxycycline are among the recommended prophylactic regimes. The aim of the study was to compare the efficacy and tolerability of the two regimes on the Turkish soldiers settled in Kabul, Afghanistan.

METHODS

A total number of 1400 soldiers were subjected to prophylactic regimes with either doxycycline 100 mg/day (n=986) or mefloquine 250 mg/week (n=414). Prophylaxis lasted about 12 weeks. The side effects and compliances were investigated by questionnaires. All soldiers were monitored up to 6 months after returning home.

RESULTS

No malaria case was observed and there was no severe side effect in either group. The total side effects in doxycycline group were significantly higher (P<0.001). The compliance of mefloquine takers was better than the doxycycline takers (P<0.05).

CONCLUSIONS

The tolerability of the mefloquine regime is better than the doxycycline regime in malaria prophylaxis.