The maladies of water and war: addressing poor water quality in Iraq

Thirteen-year surveillance results of acute flaccid paralysis cases in Southeast Turkey and the effect of refugee movements on surveillance results

OBJECTIVE

Acute flaccid paralysis (AFP) is a major neurological problem. Turkey has accepted over 4 million refugees since 2011 due to the wars in neighbouring countries. In the long term, refugees can have adverse effects on the limited resources of health, sanitation, water supply, foodstuff, and shelter services of host countries, precipitating the transmission and spread of enteroviruses causing AFP. This study examines the 13-year surveillance and incidence of AFP cases in southeast Turkey, and questions possible impact of refugee movements on these parameters, comparing the periods before (2007-2010) and after (2011-2019) 2011, when the refugee movements emerged.

METHODS

The records of cases reported from southeast part of Turkey with suspected AFP between January 2007 and December 2019 were reviewed retrospectively.

RESULTS

Of the patients, 121 (58.5%) were male. Mean age was 80.36 ± 46.67 months. Eighty-five (41.1%) were aged 60 months or younger. The number of patients under 60 months increased significantly after 2011. Mean incidence was calculated as 0.88 cases/100,000 person years versus 1.58 cases/100,000 person years in the period before and after 2011, respectively. Guillain-Barré syndrome (GBS) was the most common cause of AFP in both periods. As of 2011, however, the incidence of acute transverse myelitis increased approximately 4 times and GBS decreased proportionally. Non-polio enteroviruses were the most frequent isolates, detected from 9.1% of stool samples.

CONCLUSION

Although refugee movements appear to may have adverse effects on AFP incidence and surveillance outcomes, larger studies involving the whole country, particularly at places where no refugees settled, are needed to achieve more conclusive evidence.

Waterborne Diseases and Wastewater Treatment in Iraq

Iraq is a desert country with access to large river resources and an extensive aquifer, but these have already been overdrawn for domestic, industry and agriculture use. The diminished flow of the Tigris and Euphrates rivers has allowed seawater intrusion from the Persian Gulf 110 km up as far as Basra, the county's third largest city. In addition, water distribution systems are overloaded and wastewater treatment plants (WWTPs) need upgrading, and fresh water sources polluted by lack of sanitation, agricultural runoff, household and industrial waste, and including the irrigation of vegetables with sewage water, have led to episodes of bacterial, viral and parasitic diseases. Also, there have been increases in many types of cancer since the early 1990s, and based on clinical and epidemiological data, these increases could be attributable to exposure to depleted uranium in the environment arising from conflict in Iraq and particularly during the Iraqi War started 20 years ago. The population affected would like government action to reduce their health concerns, and policies that have been proposed for improving water availability and quality, as well as but have not been followed up sufficiently to tackle these, including increasing the capacity and efficiency of WWTP; promoting the most efficient irrigation techniques for the local growing conditions; reducing the use of chemical fertilizers and pesticides that can decrease the water quality; reducing saline intrusion challenges; building compact desalination units; constructing water storage facilities to address water scarcity challenges; and establishing public education plans for consumers to reduce the water demand during the hot season. Whether the government rises to the task remains to be seen. Also, do those countries that used the DU have a responsibility to remove or otherwise dispose of the fragments that remain?

Rise of cholera in Iraq: A rising concern

With over seven pandemics and four million reported cases, Cholera remains of the most prevalent acute watery diarrheal diseases in the world to date. As in other developing countries, Iraq once again combats Cholera - and its past encounter in 2015, where the death toll reached 1500, highlights the importance of quickly addressing the current outbreak. The war-torn state of the nation, malnourished public, lack of sanitation and hygiene, mass displacement and global warming all contribute to the prevalence of Cholera in Iraq. Along with the current efforts, additional strategies are recommended for managing cholera cases, such as awareness campaigns, monitoring the safety of water bodies, and food inspection.

Determination of biochemical oxygen demand and dissolved oxygen for semi-arid river environment: application of soft computing models

Surface and ground water resources are highly sensitive aquatic systems to contaminants due to their accessibility to multiple-point and non-point sources of pollutions. Determination of water quality variables using mathematical models instead of laboratory experiments can have venerable significance in term of the environmental prospective. In this research, application of a new developed hybrid response surface method (HRSM) which is a modified model of the existing response surface model (RSM) is proposed for the first time to predict biochemical oxygen demand (BOD) and dissolved oxygen (DO) in Euphrates River, Iraq. The model was constructed using various physical and chemical variables including water temperature (T), turbidity, power of hydrogen (pH), electrical conductivity (EC), alkalinity, calcium (Ca), chemical oxygen demand (COD), sulfate (SO₄), total dissolved solids (TDS), and total suspended solids (TSS) as input attributes. The monthly water quality sampling data for the period 2004-2013 was considered for structuring the input-output pattern required for the development of the models. An advance analysis was conducted to comprehend the correlation between the predictors and predictand. The prediction performances of HRSM were compared with that of support vector regression (SVR) model which is one of the most predominate applied machine learning approaches of the state-of-the-art for water quality prediction. The results indicated a very optimistic modeling accuracy of the proposed HRSM model to predict BOD and DO. Furthermore, the results showed a robust alternative mathematical model for determining water quality particularly in a data scarce region like Iraq.

Portable platform for rapid in-field identification of human fecal pollution in water

Human fecal contamination of water is a public health risk. However, inadequate testing solutions frustrate timely, actionable monitoring. Bacterial culture-based methods are simple but typically cannot distinguish fecal host source. PCR assays can identify host sources but require expertise and infrastructure. To bridge this gap we have developed a field-ready nucleic acid diagnostic platform and rapid sample preparation methods that enable on-site identification of human fecal contamination within 80 min of sampling. Our platform relies on loop-mediated isothermal amplification (LAMP) of human-associated Bacteroides HF183 genetic markers from crude samples. Oligonucleotide strand exchange (OSD) probes reduce false positives by sequence specifically transducing LAMP amplicons into visible fluorescence that can be photographed by unmodified smartphones. Our assay can detect as few as 17 copies/ml of human-associated HF183 targets in sewage-contaminated water without cross-reaction with canine or feline feces. It performs robustly with a variety of environmental water sources and with raw sewage. We have also developed lyophilized assays and inexpensive 3D-printed devices to minimize cost and facilitate field application.

Poverty and health among CDC plantation labourers in Cameroon: Perceptions, challenges and coping strategies

Creating better access to good quality healthcare for the poor is a major challenge to development. In this study, we examined inter-linkages between poverty and disease, referred to as poverty-related diseases (PRDs), by investigating how Cameroon Development Corporation (CDC) camp dwellers respond to diseases that adversely affect their health and wellbeing. Living in plantation camps is associated with poverty, overcrowding, poor sanitation and the rapid spread of diseases. In a survey of 237 CDC camp dwellers in Cameroon, we used the health belief model to understand the drivers (perceived threats, benefits and cues for treatment seeking) of reported responses. Using logistic regression analysis, we looked for trends in people’s response to malaria. We calculated the odds ratio of factors shown to have an influence on people’s health, such as food, water, sanitation challenges and seeking formal healthcare for malaria. Malaria (40.3%), cholera (20.8%) and diarrhoea (17.7%) were the major PRDs perceived by camp dwellers. We found a strong link between what respondents perceived as PRDS and hygiene conditions. Poverty for our respondents was more about living in poor hygiene conditions than lack of money. Respondents perceived health challenges as stemming from their immediate living environment. Moreover, people employed self-medication and other informal health practices to seek healthcare. Interestingly, even though respondents reported using formal healthcare services as a general response to illness (84%), almost 90% stated that, in the case of malaria, they would use informal healthcare services. Our study recommends that efforts to curb the devastating effects of PRDs should have a strong focus on perceptions (i.e. include diseases that people living in conditions of poverty perceive as PRDs) and on hygiene practices, emphasising how they can be improved. By providing insights into the inter-linkages between poverty and disease, our study offers relevant guidance for potentially successful health promotion interventions.

Poverty is a condition that increases disease risks and presents severe health challenges. The negative impact of poverty on health is well understood, but much less is known about how people living in poor conditions themselves perceive health challenges and how they try to overcome these challenges. We studied a group of Cameroon Development Corporation (CDC) plantation workers, living in housing provided by the company, known as camps. Living conditions in plantation camps are characterised by small and very basic housing, shared toilet facilities and overall poor sanitation. In the camps, water sources were public taps found in strategic areas. During water cuts, camp dwellers used streams as their water sources. Water was treated at CDC management level. We questioned 237 labourers (or dependants) on matters related to their health. Malaria, cholera and diarrhoea were reported as the main diseases that they associated with poverty. Our results also show that the labourers associated poverty primarily with the poor state of their living conditions rather than with not having money. Even though CDC offered free healthcare, camp dwellers relied on self-treatment and unofficial medication, especially for malaria for which almost 90% of the workers did not use the free services. Therefore, for interventions to be successful, they should include people’s perceptions and focus on improving hygiene conditions.