Control of antimicrobial resistance in Iran: the role of international factors

Economic barriers to prevent the smuggling of health goods in Iran

INTRODUCTION

In recent years, smuggling of health goods has apparently increased in the country. Despite the preventive and regulatory measures taken to combat this problem, the outcomes seem to be undesirable. This study thus aims to identify and elucidate the role of economic barriers in the prevention of smuggling health goods in Iran.

METHOD

We conducted semistructured interviews with 29 purposefully identified key informants in the detection, prevention and control of health goods smuggling in different organisations, between May 2021-January 2022. An inductive data-driven thematic analysis approach was further adopted to identify patterns of meaning, using MAXQDA 2020 software to facilitate data management.

RESULTS

We identified four main themes representing the economic barriers to prevent the smuggling of health goods in Iran; Monetary and financial policy, which includes subthemes of financial rules and procedures, market regulation, economic incentives and imbalanced development; Behavioural patterns, consisting of consumer behaviour, the opportunism of smugglers, the behaviour of statesmen and politicians; Economic diplomacy, categorised into international relations and interactions, relations and interactions in the national arena, interaction with non-governmental organisations and Health economic monitoring and evaluation including transparency of statistics and economic information and supervision.

CONCLUSION

Smuggling health goods has become a concerning challenge in the health sector. It is, therefore, imperative to develop and implement appropriate policies and operations towards security and international cooperation, lobbying and coalition-building. Demonopolisation, creating competitive and dynamic markets, removal of rent-seeking layers at all levels, and the use of commercial diplomacy to reduce the burden of smuggling in the health sector of Iran, and perhaps beyond might be of sizeable use to combat such challenge.

Explaining the barriers faced by veterinarians against preventing antimicrobial resistance: an innovative interdisciplinary qualitative study

BACKGROUND

Considering the significance of increased antimicrobial resistance (AMR) and its adverse effects on individual and social health and the important and effective role that veterinarians play in controlling this growing issue worldwide, it is essential to have effective preventive control programs. To this aim, the first step is to identify the factors behind the prevalence of AMR in Iran and the barriers veterinarians face to controlling this problem. Thus, the present study was conducted to explain the barriers veterinarians faced in the prevention of AMR from an Iranian veterinarian's perspective.

METHODS

The present research was done in three cities in Iran in 2021. The data were collected through in-depth interviews with 18 veterinarians selected through purposive and snowball sampling and analyzed using conventional qualitative content analysis.

RESULTS

The data analysis results were classified into 4 main categories and 44 subcategories. The former included: educational factors, administrative/legal factors, client-related factors, and veterinarian-related factors.

CONCLUSIONS

The increased AMR can be approached from multiple aspects. Considering the different factors that affect the increased AMR, it is necessary to consider them all through effective planning and policy-making at multi-level and multidisciplinary dimensions. There is special attention needed to scientific and practical interventions at the individual, interpersonal, social, and even political levels. At the same time, measures should be taken to rehabilitate and maintain the health of society to strengthen supervision and attract the full participation of interested organizations.

Economic sanctions and spread of infectious diseases

Economic sanctions can induce economic crises and compromise the determinants of health. In the literature, economic crises have been found to increase the risk of infectious disease outbreaks. Presumably, sanctions can increase the risk of infectious disease spreads, indirectly. However, non-economic factors can fuel the adverse impact of sanctions, including political consequences of sanctions and civil war. We performed a systematic literature review of articles in Embase, MEDLINE, Scopus, Web of Science, Cochrane Library, and the grey literature to assess empirically the impact of economic sanctions on the spread of infectious diseases within and beyond the borders of sanctioned countries. Our review did not identify any study meeting our inclusion criteria. Most of the studies did not control for major socio-political events, particularly armed conflicts in the sanctioned countries. This discovery underscores a notable gap in the examination of the impact of economic sanctions on the propagation of infectious diseases, presenting a threat to global health. Using the social-ecological model, we hypothesize how the economic crisis resulting from economic sanctions affects determinants of health, increases the risk of the spread of infectious diseases and hinders the response capacity of health systems.

Detection of Antimicrobial Resistance and Biofilm Production Among Staphylococcus pseudintermedius from Canine Skin Lesions

Aims: Staphylococcus pseudintermedius is an opportunistic pathogen also indicated as one of the major causes of skin infections in dogs. This study aimed to identify S. pseudintermedius isolated from canine skin lesions, evaluate their antibiotic resistance profile and biofilm production ability. Methodology: Lesions from 50 rural dogs with different skin lesions were sampled after pyoderma diagnosis by private practices. Bacterial species determination was investigated and susceptibility to nine antimicrobials were determined by means of Kirby-Bauer assay. Then seven antibiotic resistance genes, including mecA, blaZ, tetK, tetM, blaSHV, blaOXA-1, and blaTEM were screened by PCR. Moreover, biofilm formation ability of the strains was determined using the microtiter plate assay along with the presence of icaADBC genes. Results: A total of 37 (74%) isolates were identified as S. pseudintermedius. All S. pseudintermedius isolates were resistant to multiple drugs. Resistance to penicillin, amoxicillin-clavulanic acid, and cefazolin were higher than other antimicrobials. All the beta-lactam-resistant isolates carried blaZ, whereas mecA was found in 6 (16.21%) of them. Among tetracycline-resistant strains, the frequency of tetK and tetM determinants were 19 (90.47%) and 21 (100%), respectively. Finally, most cefazolin-resistant strains 31 (91.89%) were positive for blaTEM gene. The rate of biofilm production ability among S. pseudintermedius isolates was 35 (94.59%). Furthermore, the presence of icaA/D genes was detected in 35 (100%) and 29 (82.85%) of S. pseudintermedius strains, respectively. Conclusion: The high rates of antimicrobial resistance and biofilm production ability among S. pseudintermedius isolates, emphasize the urgent need to use more effective infection control policies and guidelines for antimicrobial use.

The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis

INTRODUCTION

Economic sanctions restrict customary commercial and financial ties between states to induce change in political constitution or conduct of the targeted country. Although the stated goals of sanctions often include humanitarian objectives, prospective procedures for health risk assessment are not regularly incorporated in their implementation. Moreover, past experience suggests that the burden of economic isolation may fall on the civilian population. We present key findings from a WHO-sponsored evidence review on the impact of economic sanctions on health and health systems in low-income and middle-income countries, aiming at comprehensive coverage and explicit consideration of issues of causality and mechanisms.

METHODS

Broad searches of PubMed and Google Scholar (1970-2021) were designed to retrieve published and grey English-language literature expected to cut across disciplines, terminology and research methods. Studies providing an impact estimate were rated by a structured assessment based on ROBINS-I risk of bias domains, synthesised via vote counting and contextualised into the broader literature through a thematic synthesis.

RESULTS

Included studies (185) were mostly peer-reviewed, mostly single-country, largely coming from medicine and public health, and chiefly concerned with three important target countries-Iraq, Haiti and Iran. Among studies providing impact estimates (31), most raised multiple risk-of-bias concerns. Excluding those with data integrity issues, a significant proportion (21/27) reported consistently adverse effects of sanctions across examined outcomes, with no apparent association to assessed quality, focus on early episodes or publication period. The thematic synthesis highlights the complexity of sanctions, their multidimensionality and the possible mechanisms of impact.

CONCLUSION

Future research should draw on qualitative knowledge to collect domain-relevant data, combining it with better estimation techniques and study design. However, only the adoption of a risk assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected.

Health system to response to economic sanctions: global evidence and lesson learned from Iran

BACKGROUND

Sanctions have direct and indirect impacts on people's lives. Therefore, the health systems of countries targeted by sanctions must respond effectively. This study proposes a set of mitigating measures and response strategies to improve the health systems of countries under sanctions.

METHODS

This three-stage study was conducted in Iran within the 2020-2021 period, in which a rapid review of evidence was carried out to identify the measures implemented or proposed to make the health system resilient in confronting sanctions. A qualitative approach was then adopted to determine how the health system could be improved to response to sanctions from the perspectives of 10 key experts. Semi-structured interviews and document analysis were conducted for data collection. Finally, a two-round Delphi technique was employed to help eleven experts reach a consensus on a set of mitigating measures, which were then prioritized.

RESULTS

In this research, 62 proposed or implemented mitigating measures were extracted from 13 eligible studies to improve the health system performance in confronting sanctions. Moreover, 18 measures were identified in interviews for a better health system response to sanctions. They were then classified as five categories: sustained financing, good governance, integrated and updated health information systems, qualified workforce, and efficient and equitable service delivery. In the first Delphi round, 28 mitigating measures were discovered. Nine measures were identified as more effective and feasible in both short and long runs. They were introduced as below: conducting proactive inventory control, developing the nationally essential list of medicines, providing additional clarification that oil revenues can be freely used for medicines procurement, defining tailored health service packages for vulnerable populations, establishing and enhancing an efficient surveillance system, reducing prices of imported medicines, developing dual policies of equity and priority for vulnerable groups, institutionalizing fair and effective resource allocations, and providing clinical guidelines.

CONCLUSIONS

According to the findings, the most critical areas for the resilience of a health system in confronting sanctions include strengthening particular components of governance, improving efficiency, and caring for vulnerable populations. The experts collectively emphasized investment in domestic capacities, public participation, and health diplomacy. Despite the proposed measures, it is unclear how effective these are and, especially whether they can significantly affect the harsh impacts of sanctions on health. Moreover, intensive and long-term sanctions have significant irreversible outcomes that cannot be reversed easily or quickly.

The Violence of Non-Violence: A Systematic Mixed-Studies Review on the Health Effects of Sanctions

The use of sanctions as a policy tool to affect change in the political behavior of target states has increased over the past 30 years, along with a concern about their impact on civilian health. Some researchers have proposed that targeting sanctions can avoid their moral costs, yet others have challenged this claim. This systematic mixed-studies review explored the debate about targeted sanctions by appraising their health effects as reported in the medical and public health literature, with a global focus and through the COVID-19 era.We searched three electronic databases without temporal or geographical restrictions and identified 50 studies spanning three decades (1992-2021) meeting our inclusion criteria. Using a piloted form, we extracted quotations addressing our research questions and identified themes that we grouped according to the effects of sanctions on health or its determinants, generating frequency distributions to assess the strength of support for each theme. While no study posited a causal relationship between sanctions and health, or engaged the morality of sanctions, most implied that when sanctions were present, health was inevitably impacted, even for sanctions ostensibly targeted to minimize civilian harm. Our findings suggest that given the integrated nature of the global economy, it is all but impossible to design sanctions that will achieve their stated goals without inflicting significant harm on civilians. We conclude that the use of sanctions as a policy tool threatens global health and human rights, especially in times of crises.

Understanding the Implementation of Antimicrobial Policies: Lessons from the Hong Kong Strategy and Action Plan

In 2017, the Hong Kong Strategy and Action Plan on Antimicrobial Resistance 2017–2022 (HKSAP) was announced with the aim of tackling the growing threat of antimicrobial resistance (AMR) in Hong Kong. However, little is known about how the planned activities have been implemented. In this study, we examine the status of implementation of the HKSAP using the Smith Policy Implementation Process Model. Semi-structured interviews with 17 informants found that important achievements have been made, including launching educational and training activities targeting the public, farmers, and healthcare professionals; upgrading the AMR surveillance system; and strengthening AMR stewardship and infection control. Nevertheless, participants also identified barriers to greater implementation, such as tensions across sectors, ongoing inappropriate drug use and prescription habits, insufficient human and technical resources, as well as a weak accountability framework. Environmental factors such as the COVID-19 pandemic also affected the implementation of HKSAP. Our study indicated that expanding engagement with the public and professionals, creating a collaborative environment for policy implementation, and building a well-functioning monitoring and evaluation system should be areas to focus on in future AMR policies.

Worldwide Traceability of Antibiotic Residues from Livestock in Wastewater and Soil: A Systematic Review

The use of antibiotics in animal production are widely used for disease treatment, health protection, and as growth promoters. Common antibiotics used in veterinary medicine are excreted and eliminated through the sewage system, contaminating water and soil with negative effects on agricultural activities. This systematic review focuses on the trend of research works on antibiotic residues, evaluating antibiotics used in livestock production and their excretion in animal products and in environmental matrices such as water and soil. Our database was composed of 165 articles, reporting the concentration of antibiotic residues found in the environment, livestock (cow, sheep, pig, horse, chicken, rabbit, goat), aquatic and terrestrial animal tissues, animal products (milk and eggs), wastewater, and soil. The documents were obtained from Asia, Africa, North America, South America, Europe, and Oceania. A descriptive analysis of antibiotic residues found worldwide was analyzed according to each of the variables used such as antibiotic family, name, concentration (% and mg/kg or ppm), and country and continent where the residue was found. The descriptive analysis was carried out using the "describe" function of psych package and pirate plots were drawn. According to our study, the main antibiotics used worldwide in animal production are sulfonamides, tetracyclines, quinolones, penicillin, and cephalosporins. At present, despite the trends of increased regulations on the use of antibiotics worldwide, antibiotics are still utilized in food animal production, and are present in water and soil, then, there is still the misuse of antibiotics in many countries. We need to become aware that antibiotic contamination is a global problem, and we are challenged to reduce and improve their use.

Compliance of imipenem and meropenem administration with the national antimicrobial stewardship program in a referral teaching hospital in Iran

INTRODUCTION

Considering the great significance of antimicrobial resistance, implementation of antimicrobial stewardship programs (ASPs) in healthcare facilities is of particular importance. This study aimed to evaluate the compliance of imipenem and meropenem administration with the ASP guidelines in a referral teaching hospital in Iran.

METHODS

In this retrospective cross-sectional study, the medical records of patients, who received either imipenem or meropenem at xx Hospital in Semnan, Iran, from March 21, 2017 until March 20, 2019, were reviewed using the developed ASP, according to the instructions issued by the Ministry of Health of Iran. The obtained findings were recorded in a checklist consisted of six items. If the action taken for the patient complied with the item requirement specified in the ASP, it would receive a score of one; otherwise, a score of zero. The sum of scores (range: 0-6) was reported and analyzed. Data were analyzed in SPSS version 23, using Chi-square, ANOVA, and independent t-test, and P <0.05 was considered as significant.

RESULTS

The mean duration of imipenem/meropenem administration was 9.2±8.0 days. A total of 6,032 imipenem/meropenem vials (1 g/vial) were prescribed during the study (meropenem for 210 patients and imipenem for 87 patients). In 64.2% of the patients, there was no indication, and the mean score of the subjects was 1.55±1.2. The obtained score was three in 53 (17.8%) records and four in 18 (6.1%) records. The mean score of ASP in the intensive care units was higher, while it was lower in the surgical ward as compared to the other wards (P=0.002).

DISCUSSION

Antibiotic prescription was inappropriate in our center, and compliance with the ASP guidelines was very low, especially in the surgical wards. It seems necessary to take effective steps for planning continuing education programs on rational antibiotic prescription and supervision of prescription patterns.