Trends in childhood leukemia in Basrah, Iraq, 1993-2007

Assessing innovative approaches for global health capacity building in fragile settings in the MENA region: development of the evaluation of capacity building (eCAP) program

Background

Given the magnitude and frequency of conflicts in the MENA region along with their devastating impact on health responses and outcomes, there exists a strong need to invest in contextualized, innovative, and accessible capacity building approaches to enhance leadership and skills in global health. The MENA region suffers from limited (1) continued educational and career progression opportunities, (2) gender balance, and (3) skill-mix among its health workforce, which require significant attention.

Main text

The Global Health Institute at the American University of Beirut incepted the Academy division to develop and implement various global health capacity building (GHCB) initiatives to address those challenges in fragile settings across low-and middle-income countries in the MENA region. These initiatives play a strategic role in this context, especially given their focus on being accessible through employing innovative learning modalities. However, there exists a dearth of evidence-based knowledge on best practices and recommendations to optimize the design, implementation, and evaluation of GHCB in fragile settings in the MENA region. The present paper describes the development of the evaluation of capacity building program (eCAP), implemented under the Academy division, to assess the effectiveness of its initiatives. eCAP is composed of 3 phases: (1) a situational assessment, followed by (2) production of multiple case studies, and finally (3) a meta-assessment leading to model development. The goal of eCAP is not only to inform the Academy’s operations, but also to synthesize produced knowledge into the formation of an evidence-based, scalable, and replicable model for GHCB in fragile settings.

Conclusion

eCAP is an important initiative for researchers, educators, and practitioners interested in GHCB in fragile settings. Several lessons can be learned from the outcomes it has yielded so far in its first two phases of implementation, ranging from the situational assessment to the production of evaluation case studies, which are expanded on in the manuscript along with pertinent challenges.

Weaponised uranium and adverse health outcomes in Iraq: a systematic review

Background

The US military first deployed depleted uranium (DU) weapons in Iraq during the Gulf War in 1990 and in the 2003 invasion of Iraq. Research into the health impacts of DU has been mired in debate and controversy. Research funded by the US government has denied the health risks posed by DU to the Iraqi population, while opponents have claimed that DU is responsible for increased rates of birth defects and cancers in Iraq. Others assert that the public health impacts of DU weapons remain uncertain. This systematic review identified, appraised and synthesised all human observational studies assessing adverse health outcomes associated with DU exposure among the Iraqi population. To our knowledge, no systematic review has been conducted on the topic previously.

Methods

We searched 11 electronic databases for human observational studies published between 1990 and 2020 that measured association between exposure to weaponised uranium and health outcomes (including cancer, birth defects, immune system function and mortality) among the Iraqi population. We assessed risk of bias using the Navigation Guide’s risk of bias tool and rated certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO: CRD42018108225).

Results

Our searches identified 2601 records, of which 28 met our inclusion criteria. We identified five additional eligible reports from other sources. Two articles reported the results of multiple relevant studies; our final set included 33 articles reporting on 36 eligible studies. Most studies (n=30, 83%) reported a positive association between uranium exposure and adverse health outcomes. However, we found that the reviewed body of evidence suffers from a high risk of bias.

Conclusion

The available evidence suggests possible associations between exposure to depleted uranium and adverse health outcomes among the Iraqi population. More primary research and the release of missing data are needed to design meaningful health and policy interventions in Iraq.

Childhood leukaemia incidence and trends in a Middle Eastern country during 1980-2014: a population-based study

BACKGROUND

This retrospective cohort study examines the trends in childhood leukaemia age-standardized incidence rates (ASIRs) (per million person-years) using cases which were diagnosed at age 0-19 years from 1980 to 2014 and recorded in the Kuwait Cancer Control Center (KCCC) registry.

METHODS

Childhood leukaemia age-specific incidence rates overall and by sub-cohorts defined by age (0-4, 5-9, 10-14, and 15-19 years), sex (male, female) and nationality (Kuwaiti, non-Kuwaiti) were computed and age-standardized. Joinpoint regression models were used to evaluate trends in childhood leukaemia ASIRs. Average annual percent change (AAPC) and its 95% confidence interval (CI) were used to interpret the observed trends.

RESULTS

During the study period, 1077 childhood leukaemia cases of 32.3 million person-years were diagnosed. From 1980 to 2014, the average annual childhood leukaemia ASIR was 53.1 (95% CI 20.9, 85.2). Overall childhood leukaemia ASIRs significantly decreased on average by 6.8% per year (AAPC =  -6.8; 95% CI -12.1, -1.1; p = 0.02) from 1980 to 1993, but a marginally significant increase in ASIRs from 1993 to 2014 was recorded (AAPC = 2.5; 95% CI -0.5, 5.5; p = 0.10). During the entire period, childhood leukaemia ASIRs trends significantly (p < 0.05) increased among 6 of 16 sub-cohorts, which was more pronounced among females and 10-14-year-old children.

CONCLUSIONS

Overall, ASIRs significantly increased from 1993 to 2014, which specifically seems to be driven by an increase in ASIRs among females and 10-14 -year-old children. These increasing trends underscore the potential involvement of a range of exposures. Future studies on unravelling such factors may help develop preventive measures to minimize childhood leukaemia risk in this and similar settings in the region.

Semen Uranium Concentrations in Depleted Uranium Exposed Gulf War Veterans: Correlations with Other Body Fluid Matrices

Environmental metal exposure, as well as dietary metals, may adversely affect semen quality even as others play an essential role in normal spermatogenesis and fertility. Measures of seminal fluid metals have therefore been of high interest in the last several decades but have shown inconsistent results in correlations with some semen quality parameters. As well, environmental metal measures across various body fluid matrices have not been consistently correlated contrary to what one might hypothesize based on a systemic body burden of metal. This may be due to the body fluid matrices assessed and to other differences in laboratory methods and sample preparation. Measures of uranium, a potentially toxic metal in humans, have not previously been reported in the semen of environmentally metal-exposed populations. We report here uranium seminal fluid results and the high correlation of uranium concentrations across several body fluid matrices in a cohort of military veterans exposed to depleted uranium in combat events during the Iraqi Gulf War. These results inform the risk communication conversation for exposed populations and broaden the public health assessments from various exposure scenarios.

Effects of armed conflict on child health and development: A systematic review

BACKGROUND

Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development.

METHODS

A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425.

FINDINGS

Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce.

INTERPRETATION

The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.

Early childhood leukemia incidence trends in Brazil

Incidence rates of childhood leukemia vary between different regions of the world. The objective of this study was to test possible trends in incidence rate of early childhood leukemia (children <5 years old at the diagnosis) in Brazil. Data from 18 population-based cancer registries (PBCRs) were analyzed (period 1999-2010). The analysis consisted of frequencies, age-adjusted incidence rates, and joinpoint regression results, including annual average percent change (AAPC) in incidence rates and 95% confidence intervals (CIs). The median age-adjusted incidence rate (AAIR) of overall early childhood leukemia was 61 per million. The AAIR for acute lymphoid leukemia (ALL) was 44 per million and nonlymphoid acute leukemia (NLAL) was 14 per million. The median ALL/NLAL ratio was 3.0, suggesting higher incidence rate of NLAL in these settings. The joinpoint analysis demonstrated increased leukemia incidence rate in João Pessoa (AAPC = 20; 95% CI: 3.5, 39.4) and Salvador (AAPC = 8.68; 95% CI: 1.0, 16.9), respectively, whereas incidence rate in São Paulo PBCR decreased (AAPC = -4.02%; 95% CI: -6.1%, -1.9%). Correlation between ALL AAIR and selected variables of socioeconomic (SES) factors was not observed. Increased AAIR regionally overtime was observed. However, the interpretation for such phenomenon should be cautious because it might reflect the access to health care, diagnosis procedures, and improvement of PBCR´s quality. The observed trend supports the necessity of further ecological studies.

Incidence of cancer in Basrah: results of a household survey

BACKGROUND

Cancer is a major health problem at global level. It is increasingly registered in Iraq and Basrah but the epidemiological situation, though becoming better documented, is still questionable regarding the adequacy of data.

OBJECTIVE

The study aimed to measure the incidence of cancer in Basrah.

MATERIALS AND METHODS

The results presented in this paper are part of a large household survey carried out in Basrah governorate-southern Iraq over a 12 month period (January to December 2013). It involved a detailed interview with adult respondents from each and every household enrolled in the study during a three-year recall period about the incidence of cancer. A total of 6,999 households were covered yielding 40,684 persons.

RESULTS

The total number of new cancer cases reported over the three- year recall period (2010-2012) was 112. The average annual incidence rate of all cancers was 91.8 per 100,000 population with a higher rate for females (109.7) compared to males (74.3) The overall age standardized rate was 150.7 per 100,000. The highest incidence rate was recorded for the Southern part of the governorate (Abul-Khasib and Fao ) at 138.8 per 100,000 and the lowest was for East of Basrah (Shatt-Arab District) at 78.0 per 100,000. With respect to cancer types, the main cancers were those of breast, lung, larynx-pharynx, leukaemia, colon-rectum and urinary bladder. These six cancers accounted for 51.5% of all reported cases. Other important cancers were those of brain, bones, pancreas and liver, accounting for a further 17.9%.

CONCLUSIONS

The pattern of cancer in Basrah is generally similar to the pattern at the national level in terms of age, sex and topography but the incidence rate according to the present household survey is higher than any previously reported figures. Household surveys for cancer seem feasible albeit difficult and costly.

The role of public health in the prevention of war: rationale and competencies

In 2009 the American Public Health Association approved the policy statement, "The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War." Despite the known health effects of war, the development of competencies to prevent war has received little attention. Public health's ethical principles of practice prioritize addressing the fundamental causes of disease and adverse health outcomes. A working group grew out of the American Public Health Association's Peace Caucus to build upon the 2009 policy by proposing competencies to understand and prevent the political, economic, social, and cultural determinants of war, particularly militarism. The working group recommends that schools of public health and public health organizations incorporate these competencies into professional preparation programs, research, and advocacy.

Comparing the cancer in Ninawa during three periods (1980-1990, 1991-2000, 2001-2010) using Poisson regression

BACKGROUND

Iraq fought three wars in three consecutive decades, Iran-Iraq war (1980-1988), Persian Gulf War in 1991, and the Iraq's war in 2003. In the nineties of the last century and up to the present time, there have been anecdotal reports of increase in cancer in Ninawa as in all provinces of Iraq, possibly as a result of exposure to depleted uranium used by American troops in the last two wars. This paper deals with cancer incidence in Ninawa, the most importance province in Iraq, where many of her sons were soldiers in the Iraqi army, and they have participated in the wars.

MATERIALS AND METHODS

The data was derived from the Directorate of Health in Ninawa. The data was divided into three sub periods: 1980-1990, 1991-2000, and 2001-2010. The analyses are performed using Poisson regressions. The response variable is the cancer incidence number. Cancer cases, age, sex, and years were considered as the explanatory variables. The logarithm of the population of Ninawa is used as an offset. The aim of this paper is to model the cancer incidence data and estimate the cancer incidence rate ratio (IRR) to illustrate the changes that have occurred of incidence cancer in Ninawa in these three periods.

RESULTS

There is evidence of a reduction in the cancer IRR in Ninawa in the third period as well as in the second period. Our analyses found that breast cancer remained the first common cancer; while the lung, trachea, and bronchus the second in spite of decreasing as dramatically. Modest increases in incidence of prostate, penis, and other male genitals for the duration of the study period and stability in incidence of colon in the second and third periods. Modest increases in incidence of placenta and metastatic tumors, while the highest increase was in leukemia in the third period relates to the second period but not to the first period. The cancer IRR in men was decreased from more than 33% than those of females in the first period, more than 39% in the second period, and regressed to 9.56% in the third period.

CONCLUSION

Our paper confirms the media reports that there are increases in the number of cancer cases, but when it analyzed statistically with population growth in the Ninawa province, there are decreases in incidence rates in most cancer types.

Health services in Iraq

After decades of war, sanctions, and occupation, Iraq's health services are struggling to regain lost momentum. Many skilled health workers have moved to other countries, and young graduates continue to leave. In spite of much rebuilding, health infrastructure is not fully restored. National development plans call for a realignment of the health system with primary health care as the basis. Yet the health-care system continues to be centralised and focused on hospitals. These development plans also call for the introduction of private health care as a major force in the health sector, but much needs to be done before policies to support this change are in place. New initiatives include an active programme to match access to health services with the location and needs of the population.

Time trends and geographical distribution of childhood leukaemia in basrah, iraq, from 2004 to 2009

OBJECTIVES

This study aimed to assess the incidence and trend of childhood leukaemia in Basrah.

METHODS

This was a hospital-based cancer registry study carried out at the Pediatric Oncology Ward, Maternity & Children's Hospital and other institutes in Basrah, Iraq. All children with leukaemia, aged 0 to 14 years diagnosed and registered in Basrah from January 2004 to December 2009 were included in the study. Their records were retrieved and studied. The pattern of childhood leukaemia by year of diagnosis, age at diagnosis, morphological subtypes, and geographical distribution was analysed. Rates of childhood leukaemia over time were calculated for six years using standard linear regression.

RESULTS

The total number of cases of childhood leukaemia was 181. The number of cases ranged from 21 in year 1, to 31 in the final year reaching a peak of 39 in 2006. Leukaemia rates did not change over the study period (test for trend was not significant, P = 0.81). The trend line shows a shift towards younger children (less than 5 years). The commonest types of leukaemia were acute lymphoblastic leukaemia (ALL), then acute myeloid leukaemia (AML) and finally chronic myeloid leukaemia (CML).

CONCLUSION

Annual rates of childhood leukaemia in Basrah were similar to those in other countries with a trend towards younger children. This raises the question about the effect of environmental catastrophes in the alteration of some specific rates of childhood leukaemia, rather than the overall incidence rate. There is a need for further epidemiological studies to understand the aetiology of childhood leukaemia in Basrah.

Cancer, infant mortality and birth sex-ratio in Fallujah, Iraq 2005-2009

There have been anecdotal reports of increases in birth defects and cancer in Fallujah, Iraq blamed on the use of novel weapons (possibly including depleted uranium) in heavy fighting which occurred in that town between US led forces and local elements in 2004. In Jan/Feb 2010 the authors organised a team of researchers who visited 711 houses in Fallujah, Iraq and obtained responses to a questionnaire in Arabic on cancer, birth defects and infant mortality. The total population in the resulting sample was 4,843 persons with and overall response rate was better than 60%. Relative Risks for cancer were age-standardised and compared to rates in the Middle East Cancer Registry (MECC, Garbiah Egypt) for 1999 and rates in Jordan 1996-2001. Between Jan 2005 and the survey end date there were 62 cases of cancer malignancy reported (RR = 4.22; CI: 2.8, 6.6; p < 0.00000001) including 16 cases of childhood cancer 0-14 (RR = 12.6; CI: 4.9, 32; p < 0.00000001). Highest risks were found in all-leukaemia in the age groups 0-34 (20 cases RR = 38.5; CI: 19.2, 77; p < 0.00000001), all lymphoma 0-34 (8 cases, RR = 9.24;CI: 4.12, 20.8; p < 0.00000001), female breast cancer 0-44 (12 cases RR = 9.7;CI: 3.6, 25.6; p < 0.00000001) and brain tumours all ages (4 cases, RR = 7.4;CI: 2.4, 23.1; P < 0.004). Infant mortality was based on the mean birth rate over the 4 year period 2006-2009 with 1/6th added for cases reported in January and February 2010. There were 34 deaths in the age group 0-1 in this period giving a rate of 80 deaths per 1,000 births. This may be compared with a rate of 19.8 in Egypt (RR = 4.2 p < 0.00001) 17 in Jordan in 2008 and 9.7 in Kuwait in 2008. The mean birth sex-ratio in the recent 5-year cohort was anomalous. Normally the sex ratio in human populations is a constant with 1,050 boys born to 1,000 girls. This is disturbed if there is a genetic damage stress. The ratio of boys to 1,000 girls in the 0-4, 5-9, 10-14 and 15-19 age cohorts in the Fallujah sample were 860, 1,182, 1,108 and 1,010 respectively suggesting genetic damage to the 0-4 group (p < 0.01). Whilst the results seem to qualitatively support the existence of serious mutation-related health effects in Fallujah, owing to the structural problems associated with surveys of this kind, care should be exercised in interpreting the findings quantitatively.