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Bigirinama RN, Makali SL, Mothupi MC, Chiribagula CZ, St Louis P, Mwene-Batu PL, Bisimwa GB, Mwembo AT, Porignon DG. Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo. BMC Health Serv Res 2023; 23:1362. [PMID: 38057862 DOI: 10.1186/s12913-023-10336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. METHODS A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. RESULTS The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. CONCLUSIONS Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.
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Affiliation(s)
- Rosine N Bigirinama
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo.
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo.
- Ecole de Santé Publique, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo.
| | - Samuel L Makali
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Mamothena C Mothupi
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Christian Z Chiribagula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Patricia St Louis
- Centre de Recherche Politiques, Systèmes de Santé, Santé Internationale (CR3), Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Pacifique L Mwene-Batu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- School of Medicine, Université de Kaziba, Bukavu, Democratic Republic of Congo
| | - Ghislain B Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- School of Medicine, Université Catholique de Bukavu, Avenue Michombero No. 02, Bukavu, Democratic Republic of Congo
- Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
| | - Albert T Mwembo
- Ecole de Santé Publique, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Denis G Porignon
- Département des Sciences de la Santé Publique, School of Medicine, Université de Liège, Liège, Belgium
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Mahmood NMA, Khadka S, Saleem M, Alkamel MAAM, Khudhiere MMSS, Prasad Panta P, Jabar Adnan MA, Yadav GK. Psychological effect of COVID-19 pandemic on healthcare professionals of Yemen and coping strategies. Libyan J Med 2023; 18:2184297. [PMID: 36855244 PMCID: PMC9979999 DOI: 10.1080/19932820.2023.2184297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
COVID-19 pandemic has triggered psychological stress such as anxiety and depression among people around the globe. Due to the nature of the job, healthcare professionals (HCPs) are at high risk of infection and are facing social stigma as well. This research was conducted with the objective to evaluate the psychological influence of the COVID-19 pandemic among HCPs in Yemen and the coping strategies adopted thereof. A web-based, as well as face-to-face cross-sectional study was carried out from July to December 2021 among HCPs of Yemen. The generalized anxiety disorder (GAD-7), patient health questionnaire (PHQ-9), and Brief-COPE scales were applied for the evaluation of anxiety, depression, and coping strategies. A total of 197 HCPs participated in the study where 28.4% and 43.1% had anxiety and depression respectively. The prevalence of both anxiety and depression in the majority were found of the minimal to none and mild categories (71.6% vs. 56.9% respectively). The respondents who had received training on COVID-19 had statistically significant lower GAD-7 scores than those who did not (6.32 vs. 8.02 respectively). A significant statistical difference was observed between physicians versus nurses regarding depression based on the working area (p < 0.05). The physician and pharmacist had a significant positive association with brief COPE scores at the 50th centile compared to other HCPs. The female respondents had statistically significant higher mean Brief COPE scores than male respondents (78.11 vs. 69.50 respectively). Our findings illustrate the requirement for efficient policies through administrative, clinical, and welfare perspectives from the regulatory body in preparedness and preventive measures towards such a pandemic that aids HCPs to provide service in a stress-free condition and assurance of a better healthcare system..
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Affiliation(s)
- Nagd Mohammed Ahmed Mahmood
- Department of Community Pharmacy, Palsm Pharmacy, Aden, Yemen,Department of Pharmacology, Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan,CONTACT Nagd Mohammed Ahmed Mahmood Punjab University College of Pharmacy, University of the Punjab, Lahore 54000, Pakistan
| | - Sitaram Khadka
- Department of Pharmacology, Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan,Department of Pharmacy, Shree Birendra Hospital, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Mohammad Saleem
- Department of Pharmacology, Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | | | - Maged Mohammed Salem Saeed Khudhiere
- Faculty of Dentistry, University of Aden, Aden, Yemen,Health and Nutrition Department, Health and Nutrition Foundation for Development (HAND), Aden, Yemen
| | - Prem Prasad Panta
- Department of Statistics, Karnali Academy of Health Sciences, Jumla, Nepal
| | | | - Gopal K Yadav
- Department of Internal Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
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Taher WT, Bawazir AA, Sallam TA, Alsurimi K. Seroprevalence and factors associated with SARS-CoV-2 infection among healthcare workers: cross-sectional study. BMC Infect Dis 2023; 23:761. [PMID: 37932664 PMCID: PMC10626741 DOI: 10.1186/s12879-023-08760-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Healthcare workers (HCWs) are at a higher risk of contracting COVID-19 due to their close contact with infected patients. However, the true burden of COVID-19 among HCWs in Yemen is unknown due to the inadequate availability of healthcare and the subclinical nature of the disease. This study aims to estimate the seroprevalence of SARS-CoV-2 infection among HCWs in two Yemeni governorates and identify associated factors using a cross-sectional design. METHOD A total of 404 HCWs were surveyed from June 2022 to September 2022 in Lahj and AL-Dhalea hospitals. A self-administered questionnaire collected demographic data, COVID-19 infection history, and vaccination status. A total of 404 human sera were tested using a specific electrochemiluminescence immunoassay assay. Association analysis was conducted to identify associations between antibody prevalence and demographic and vaccine-related variables. RESULT The median age of the HCWs was 31 (Range 20-64) years, with 65.0% being male and 35.0% female. Of all HCWs, 94% were SARS-CoV-2 seropositive and 77.0% had no confirmed test of COVID-19-related symptoms. There was no significant association between seropositivity and demographic factors such as age, gender, occupation, or COVID-19 vaccination (P > 0.05). CONCLUSION The seroprevalence of SARS-CoV-2 was high among HCWs in Yemen, primarily due to natural infection rather than vaccination. Compliance with infection prevention and control measures did not significantly affect seropositivity. This study highlights the need for improved healthcare systems and resources to reduce the burden of COVID-19 and promote infection prevention and control (IPC) measures among HCWs in Yemen.
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Affiliation(s)
- Watheq Thabet Taher
- Faculty of Medicine and Health Sciences, The University of Aden, Aden, Republic of Yemen
| | - Amen A Bawazir
- Faculty of Medicine and Health Sciences, The University of Aden, Aden, Republic of Yemen.
- College of Medicine, AlMaarefa University, Diriyah, Saudi Arabia.
| | - Talal A Sallam
- Faculty of Medicine, Al-Baha University, Al Bahah, Kingdom of Saudi Arabia
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Al-Ashwal FY, Sulaiman SAS, Sheikh Ghadzi SM, Kubas MA, Halboup A. Physicians and pharmacists' clinical knowledge of statin therapy and monitoring parameters, and the barriers to guideline implementation in clinical practice. PLoS One 2023; 18:e0280432. [PMID: 36662695 PMCID: PMC9858478 DOI: 10.1371/journal.pone.0280432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/01/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Millions of individuals worldwide use statins, and their significant impact on cardiovascular disease (CVD) has been well-established. However, a lack of knowledge about the up-to-date guideline recommendations regarding statin therapy is a common barrier to implementation in clinical practice. Therefore, the present study aimed to assess the current clinical knowledge about statin therapy and its monitoring parameters. Also, we evaluated the barriers to cholesterol management guideline implementation in Yemen. METHODS This observational cross-sectional study was conducted over four months, from June/2021 to September/2021, in Sana'a, Yemen. A validated questionnaire was distributed face-to-face to 650 participants (350 physicians and 300 pharmacists). Physicians and pharmacists from governmental and private hospitals and those working in private clinics or community pharmacies were included in the study. RESULTS A total of 496 participants filled out the survey, with 22 being excluded due to incomplete data. So, the study has an overall response rate of 72.9% (474). The majority of pharmacists (81.8%) and physicians (78.7%) could not identify the patient group that needed ASCVD risk assessment before statin therapy initiation. Although a significant proportion of respondents knew of the fact that high-intensity statins are recommended for patients with ASCVD (65.4%) and primary hypercholesterolemia (58.4%), the majority of physicians and pharmacists could not identify the high (61.6% and 66.7.3%, respectively) and moderate statin-intensity doses (72.2% and 68.6%, respectively). Only 21.9% of all respondents knew that atorvastatin and rosuvastatin can be administered at any time of the day. Similarly, a low overall rate of respondents (19.6%) knew that atorvastatin does not need dose adjustment in chronic kidney diseases, with a statistically significant difference in knowledge between physicians and pharmacists (12.5% vs. 25.6%, p <0.001, respectively). Notably, only 39.2% of participants were aware that statins are not safe to use during breastfeeding. Around half of respondents (52.3%) correctly identify the duration (4 to 12 weeks) at which LD-C measuring is recommended after therapy initiation or dose change. The lowest knowledge scores for respondents were related to statin-drug interactions. Age, experience, degree, and previous guideline exposure were all significantly associated with the knowledge scores (p <0.05). The four most perceived barriers to implementing cholesterol management guidelines were no audit on adherence to the guidelines in the workplace (73.4%), insufficient resources to adequately implement and follow up on the guideline's recommendations (73.6%), patient's financial status (75.7%), and lack of familiarity about the guideline's latest recommendations (63.3%). CONCLUSION Physicians and pharmacists had suboptimal clinical knowledge regarding statin therapy, dose intensities, drug-drug interaction, contraindications, and monitoring parameters. Therefore, physicians' and pharmacists' educational interventions regarding the up-to-date recommendation about statins are recommended.
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Affiliation(s)
- Fahmi Y. Al-Ashwal
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Science and Technology, Sana’a, Yemen
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - Mohammed Abdullah Kubas
- Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana’a, Yemen
- School of Pharmacy & Medical Sciences, Lebanese International University (LIU), Sana’a, Yemen
| | - Abdulsalam Halboup
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Science and Technology, Sana’a, Yemen
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Saleh EA, Haddadin RN, Saleh B, Elayeh E. Changes in drug demand when a pandemic coincides with other outbreaks in a war zone country: a cross-sectional pilot study. J Pharm Policy Pract 2022; 15:89. [PMID: 36419090 PMCID: PMC9682693 DOI: 10.1186/s40545-022-00487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/08/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Yemen's health system has severely deteriorated due to the ongoing civil war accompanied by the COVID-19 pandemic which coincided with other outbreaks of endemic infections. Many health institutions closed due to insufficient equipment and supplies. Consequently, pharmacists became the available healthcare provider on the frontlines. This study aimed to evaluate the pattern of demand for prescription and nonprescription drugs during the pandemic based on the pharmacist's perspective in Yemen, a conflict zone country. METHODS An online survey was developed, validated, and distributed among pharmacists. The questionnaire was composed of two sections: (1) demographic characteristics of the participants and (2) changes in the demand for different drug categories. Chi-square test and Fisher's exact test were used to find statistical associations. RESULTS Responses (330) were received from pharmacists working in 12 out of 22 governorates in Yemen. During the pandemic, there was an increase in the demand for prescription drugs such as antibiotics, antimalarials, and sedatives (95%, 90%, and 71%, respectively) and an increase in the demand for nonprescription drugs such as vitamins (93%) and paracetamol (> 90%). Some of these drugs could have serious side effects if taken without medical advice, and others could result in severe effects if taken concomitantly. In addition, there was an increase in the demand for prescription drugs without a prescription, which was reported by 50% of the participants. No statistical difference was seen between the frontline districts and major cities in terms of requesting these drugs without a prescription. On the other hand, most participants (75.2%) did not attend any training or workshop during the last 6 months of conducting this survey. CONCLUSION COVID-19 has increased the demand for many prescription and nonprescription drugs, where the irrational use of these drugs may lead to devastating health effects. In war zone areas hit by a pandemic, policymakers and public health organizations should focus on training and educating pharmacists as important health care and medicine providers for the public.
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Affiliation(s)
- Ebtesam A. Saleh
- grid.411125.20000 0001 2181 7851Department of Pharmacology & Toxicology, School of Pharmacy, University of Aden, Aden, Yemen
| | - Randa N. Haddadin
- grid.9670.80000 0001 2174 4509Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Bassam Saleh
- Medical and Health Unit, International Organization of Migration (IOM), Aden, Yemen
| | - Eman Elayeh
- grid.9670.80000 0001 2174 4509Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
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Clinical and Epidemiological Presentation of COVID-19 among Children in Conflict Setting. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111712. [PMID: 36360440 PMCID: PMC9688921 DOI: 10.3390/children9111712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
Abstract
Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020−February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children <5 years (11%) compared to other age groups (p < 0.001), for children from other nationalities (4%) compared to Yemeni children (p < 0.001) and for girls (21%) compared to boys (30%) (p < 0.031). Conclusion: Understanding and addressing the cause of these disparities and improving guidelines for COVID-19 screening among children will improve access to care and control of the COVID-19 pandemic.
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Rija A, Islam Z, Bilal W, Qamar K, Gangat SA, Abbas S, Mirha HT, Mohanan P, Rahmat ZS, Shaeen SK, Djedid SNK, Essar MY, Kashyap R. The impact of violence on healthcare workers' mental health in conflict based settings amidst COVID‐19 pandemic, and potential interventions: A narrative review. Health Sci Rep 2022; 5:e920. [PMCID: PMC9638051 DOI: 10.1002/hsr2.920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/27/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Aiman Rija
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Zarmina Islam
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Wajeeha Bilal
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Khulud Qamar
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Shazil Ahmed Gangat
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Samina Abbas
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Hania Tul Mirha
- Department of Medicine CMH Lahore Medical College Lahore Pakistan
| | | | - Zainab Syyeda Rahmat
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | - Sean Kaisser Shaeen
- Faculty of Medicine, Dow Medical College Dow University of Health Sciences Karachi Pakistan
| | | | | | - Rahul Kashyap
- Critical Care Medicine Mayo Clinic Rochester Minnesota USA
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Al-Ashwal FY, Sulaiman SAS, Sheikh Ghadzi SM, Kubas MA, Halboup A. Prevalence and predictors of clinically significant statin-drug interactions among Yemeni patients taking statins for primary and secondary prevention of cardiovascular disease. Curr Med Res Opin 2022; 38:889-899. [PMID: 35481428 DOI: 10.1080/03007995.2022.2072088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Statins are extensively used in clinical practice for the primary and secondary prevention of cardiovascular diseases. Statins are usually taken in combination with other medications. This may increase the risk of statin-drug interactions. The study aimed to evaluate the prevalence, patterns, and predictors of clinically significant statin-drug interactions among patients on statin therapy. MATERIAL AND METHODS A cross-sectional study was conducted at the cardiology, endocrine, and internal medicine outpatient clinics in four tertiary care hospitals in Sana'a, Yemen. Lexicomp Drug Interaction database was used to analyze the prescriptions for potential statin-drug interactions. Binary and multivariable logistic regression were utilized for analysis. RESULTS Of the total number of patients (634), 114 individuals (18%) had a total of 122 statin-drug interactions. According to Lexicomp risk classification, 102 (83.6%) DDIs were class C (monitor therapy), 19 (15.6%) were class D (therapy modification), and only one (0.8%) class X (avoid combination). Simvastatin use was significantly associated with the presence of category D and X DDIs (15.9% vs. 1.6%, p < .001). Polypharmacy (OR = 2.571, p < .001) and having ≥3 comorbidities (OR = 2.512, p < .001) were the only variables associated with the presence of statin-drug interactions (C, D, and/or X). CONCLUSION Patients with polypharmacy and those with three or more comorbidities had a higher risk for statin-drug interactions. Therefore, routine screening by physicians and pharmacists for potential interactions should occur before prescribing or dispensing any medication to avoid clinically significant statin-drug interactions.
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Affiliation(s)
- Fahmi Y Al-Ashwal
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana'a, Yemen
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - Mohammed Abdullah Kubas
- Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana'a, Yemen
| | - Abdulsalam Halboup
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Science and Technology, Sana'a, Yemen
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Al Amad M, Almoayed K. Influenza circulating viruses, positivity rate and risk factors for influenza associated severe acute respiratory infection during 2018/2019 winter season, Yemen. BMC Infect Dis 2022; 22:111. [PMID: 35105332 PMCID: PMC8804082 DOI: 10.1186/s12879-022-07090-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The burden of seasonal influenza in conflict counties is exacerbated due to limited resource and collapse of health system. During 2018 /2019 season, two-fold increase in the incidence of influenza was reported in Yemen with 22% case fatality of severe acute respiratory infection (SARI). The aims are to analyze the influenza circulating viruses, positivity rate and risk factors for hospitalizing influenza associated-SARI. METHODOLOGY We used a retrospective analytical study based on surveillance data. All reported patients during 2018/2019 season, fulfilling the WHO cases definition for SARI or influenza like illness (ILI), and had laboratory result from the National Laboratory were included. Influenza positivity rate was calculated, all SARI and ILI patients with positive influenza were included for further analysis by univariate and multivariate binary logistic regression. Crude and adjusted Odds ratio (AOR), 95% confidence interval and P-value < 0.05 were used for statistically significant. RESULTS Out of 2186 patients enrolled, 768 patients were tested for influenza viruses,: 19% were children < 15 years, 15% were ≥ 65 years, 69% males and 18% had co-morbidity with chronic diseases. Patients with SARI were 37% and 63% were ILI patients. Influenza viruses were detected in 411 (53.5%), 68% were influenza A subtype (H1N1)pdm09, 27% influenza B and 5% was influenza A not subtyped. The influenza positivity was significantly higher in SARI compared to ILI for patients < 15 years (95% vs, 66%, p < 0.001), and patients ≥ 65 years (83% vs. 56%, p < 0.002), respectively. The highest positivity for influenza type A and B reached 44% and 33% for patients ≥ 65 years and < 15 years, respectively. The risk factors for influenza-associated SARI in multivariate analysis included age < 5 [AOR 2.8] and ≥ 65 years old [AOR 3.1] compared to age 5- < 25 years, diabetes [AOR 4.7], heart diseases [AOR 3.1] and chronic respiratory diseases [AOR 5.0]. CONCLUSION The influenza positivity during 2018/2019 winter season was high in Yemen and varied by age distribution. Influenza subtype A (H1N1) pdm09 was the predominant and co circulated with influenza B. An influenza vaccination program for the risk group is necessary. Strengthening lab capacity to detect respiratory pathogens and further prospective study for more comprehensive picture are recommended.
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Al Serouri AA, Ghaleb YA, Al Aghbari LA, Al Amad MA, Alkohlani AS, Almoayed KA, Jumaan AO. Field Epidemiology Training Program Response to COVID-19 During a Conflict: Experience From Yemen. Front Public Health 2021; 9:688119. [PMID: 34881214 PMCID: PMC8646099 DOI: 10.3389/fpubh.2021.688119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022] Open
Abstract
COVID-19 pandemic has underscored the need for a well-trained public health workforce to save lives through timely outbreaks detection and response. In Yemen, a country that is entering its seventh year of a protracted war, the ongoing conflict severely limited the country's capacity to implement effective preparedness and response measures to outbreaks including COVID-19. There are growing concerns that the virus may be circulating within communities undetected and unmitigated especially as underreporting continues in some areas of the country due to a lack of testing facilities, delays in seeking treatment, stigma, difficulty accessing treatment centers, the perceived risks of seeking care or for political issues. The Yemen Field Epidemiology Training Program (FETP) was launched in 2011 to address the shortage of a skilled public health workforce, with the objective of strengthening capacity in field epidemiology. Thus, events of public health importance can be detected and investigated in a timely and effective manner. During the COVID-19 pandemic, the Yemen FETP's response has been instrumental through participating in country-level coordination, planning, monitoring, and developing guidelines/standard operating procedures and strengthening surveillance capacities, outbreak investigations, contact tracing, case management, infection prevention, and control, risk communication, and research. As the third wave is circulating with a steeper upward curve than the previous ones with possible new variants, the country will not be able to deal with a surge of cases as secondary care is extremely crippled. Since COVID-19 prevention and control are the only option available to reduce its grave impact on morbidity and mortality, health partners should support the Yemen FETP to strengthen the health system's response to future epidemics. One important lesson learned from the COVID-19 pandemic, especially in the Yemen context and applicable to developing and war-torn countries, is that access to outside experts becomes limited, therefore, it is crucial to invest in building national expertise to provide timely, cost-effective, and sustainable services that are culturally appropriate. It is also essential to build such expertise at the governorate and district levels, as they are normally the first respondents, and to provide them with the necessary tools for immediate response in order to overcome the disastrous delays.
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Affiliation(s)
| | - Yasser Ahmed Ghaleb
- Field Epidemiology Training Program, Ministry of Public Health and Population, Sana'a, Yemen
| | - Labiba Anam Al Aghbari
- Field Epidemiology Training Program, Ministry of Public Health and Population, Sana'a, Yemen
| | | | | | - Khaled Abdullah Almoayed
- General Directorate for Disease Surveillance and Control, Ministry of Public Health and Population, Sana'a, Yemen
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Bitar AN, Zawiah M, Al-Ashwal FY, Kubas M, Saeed RM, Abduljabbar R, Jaber AAS, Sulaiman SAS, Khan AH. Misinformation, perceptions towards COVID-19 and willingness to be vaccinated: A population-based survey in Yemen. PLoS One 2021; 16:e0248325. [PMID: 34714827 PMCID: PMC8555792 DOI: 10.1371/journal.pone.0248325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Since the beginning of the COVID-19 outbreak, many pharmaceutical companies have been racing to develop a safe and effective COVID-19 vaccine. Simultaneously, rumors and misinformation about COVID-19 are still widely spreading. Therefore, this study aimed to investigate the prevalence of COVID-19 misinformation among the Yemeni population and its association with vaccine acceptance and perceptions. METHODS A cross-sectional online survey was conducted in four major cities in Yemen. The constructed questionnaire consisted of four main sections (sociodemographic data, misinformation, perceptions (perceived susceptibility, severity, and worry), and vaccination acceptance evaluation). Subject recruitment and data collection were conducted online utilizing social websites and using the snowball sampling technique. Descriptive and inferential analyses were performed using SPSS version 27. RESULTS The total number of respondents was 484. Over 60% of them were males and had a university education. More than half had less than 100$ monthly income and were khat chewers, while only 18% were smokers. Misinformation prevalence ranged from 8.9% to 38.9%, depending on the statement being asked. Men, university education, higher income, employment, and living in urban areas were associated with a lower misinformation level (p <0.05). Statistically significant association (p <0.05) between university education, living in urban areas, and being employed with perceived susceptibility were observed. The acceptance rate was 61.2% for free vaccines, but it decreased to 43% if they had to purchase it. Females, respondents with lower monthly income, and those who believed that pharmaceutical companies made the virus for financial gains were more likely to reject the vaccination (p <0.05). CONCLUSION The study revealed that the acceptance rate to take a vaccine was suboptimal and significantly affected by gender, misinformation, cost, and income. Furthermore, being female, non-university educated, low-income, and living in rural areas were associated with higher susceptibility to misinformation about COVID-19. These findings show a clear link between misinformation susceptibility and willingness to vaccinate. Focused awareness campaigns to decrease misinformation and emphasize the vaccination's safety and efficacy might be fundamental before initiating any mass vaccination in Yemen.
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Affiliation(s)
- Ahmad Naoras Bitar
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Mohammed Zawiah
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Department of Pharmacy Practice, College of Clinical Pharmacy, University of Al Hodeida, Al Hodeida, Yemen
- * E-mail: (FYA); (MZ)
| | - Fahmi Y. Al-Ashwal
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Clinical Pharmacy Department, University of Science and Technology Hospital, Sana’a, Yemen
- * E-mail: (FYA); (MZ)
| | - Mohammed Kubas
- Clinical Pharmacy Department, University of Science and Technology Hospital, Sana’a, Yemen
- Pharmacy Practice Department, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Ramzi Mukred Saeed
- Department of Clinical Pharmacy and Pharmacy Practice, University of Science and Technology, Sana’a, Yemen
- Department of Pharmaceutical sciences, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Rami Abduljabbar
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, Dubai, United Arab Emirates
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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12
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Shoib S, Ullah I, Handuleh JIM, Arafat SMY, Ramalho R. Mental health crisis in Yemen. Asian J Psychiatr 2021; 64:102793. [PMID: 34325279 PMCID: PMC9760306 DOI: 10.1016/j.ajp.2021.102793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Jammu and Kashmir, India
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Jibril I M Handuleh
- Department of Psychiatry St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | - Rodrigo Ramalho
- Department of Social and Community Health, School of Population Health, The University of Auckland, Auckland, New Zealand.
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13
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Quiroz-Juárez MA, Torres-Gómez A, Hoyo-Ulloa I, León-Montiel RDJ, U’Ren AB. Identification of high-risk COVID-19 patients using machine learning. PLoS One 2021; 16:e0257234. [PMID: 34543294 PMCID: PMC8452016 DOI: 10.1371/journal.pone.0257234] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/26/2021] [Indexed: 12/21/2022] Open
Abstract
The current COVID-19 public health crisis, caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), has produced a devastating toll both in terms of human life loss and economic disruption. In this paper we present a machine-learning algorithm capable of identifying whether a given patient (actually infected or suspected to be infected) is more likely to survive than to die, or vice-versa. We train this algorithm with historical data, including medical history, demographic data, as well as COVID-19-related information. This is extracted from a database of confirmed and suspected COVID-19 infections in Mexico, constituting the official COVID-19 data compiled and made publicly available by the Mexican Federal Government. We demonstrate that the proposed method can detect high-risk patients with high accuracy, in each of four identified clinical stages, thus improving hospital capacity planning and timely treatment. Furthermore, we show that our method can be extended to provide optimal estimators for hypothesis-testing techniques commonly-used in biological and medical statistics. We believe that our work could be of use in the context of the current pandemic in assisting medical professionals with real-time assessments so as to determine health care priorities.
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Affiliation(s)
- Mario A. Quiroz-Juárez
- Departamento de Física, Universidad Autónoma Metropolitana Unidad Iztapalapa, Ciudad de México, México
- * E-mail:
| | | | | | | | - Alfred B. U’Ren
- Instituto de Ciencias Nucleares, Universidad Nacional Autónoma de México, Ciudad de México, México
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14
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Alhariri W, Mcnally A, Knuckey S. The Right to Mental Health in Yemen: A Distressed and Ignored Foundation for Peace. Health Hum Rights 2021; 23:43-53. [PMID: 34194200 PMCID: PMC8233030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Mental health issues are all too common consequences of conflict and atrocity crimes, often causing upwards of one-quarter of the postconflict, post-atrocity population to suffer from physical and mental sequelae that linger long after weapons have been silenced. After more than six years of ongoing conflict, Yemen's already weak health care system is on the brink of collapse, and population resilience has been severely stressed by indiscriminate attacks, airstrikes, torture, food insecurity, unemployment, cholera, and now the COVID-19 pandemic. This paper examines Yemen's responsibilities regarding the right to mental health and details the few actions the government has taken to date toward fulfilling this right. It also presents the current status of mental health care in Yemen, discussing some of the barriers to accessing the available care, as well as alternative models of mental health support being used by the population. In light of the pandemic presently facing the world, the paper also discusses COVID-19's impact on Yemen, detailing its further degrading effects on the country's health care system and people's mental health. Finally, the paper highlights the importance of addressing mental health in furtherance of the peace process.
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Affiliation(s)
- Waleed Alhariri
- Policy and Partnerships Director at the Sana’a Center for Strategic Studies.,Please address correspondence to Waleed Alhariri. E-mail: .
| | - Amanda Mcnally
- Research Fellow at the Sana’a Center for Strategic Studies
| | - Sarah Knuckey
- Clinical Professor of Law and Director of the Human Rights Clinic and Institute at Columbia Law School
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15
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Li L, Zeng M, Chen X, Cai S, Xu C, Xia W, Jiang L, Zou X, Chen P, Rong M. Optimizing Safe Dental Practice During the COVID-19 Pandemic: Recommendations Based on a Guide Developed for Dental Practices in China. Front Med (Lausanne) 2021; 8:619357. [PMID: 34124084 PMCID: PMC8187590 DOI: 10.3389/fmed.2021.619357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/09/2021] [Indexed: 12/18/2022] Open
Abstract
The current global coronavirus disease 2019 (COVID-19) outbreak is still exerting severe global implications, and its development in various regions is complex and variable. The high risk of cross-infection poses a great challenge to the dental practice environment; it is therefore urgent to develop a set of pandemic prevention measures to ensure dental practice safety during the COVID-19 outbreak. Therefore, we combined the epidemiological characteristics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), public emergency measures for COVID-19, characteristics of dental practice, and relevant literature reports to develop a set of dynamic practice measures for dental practices in high-, medium-, and low-risk areas affected by COVID-19. This will help dental practices to achieve standard prevention and ensure their safe and smooth operation during the pandemic. It is hoped that these measures will provide a reference basis for dental hospitals and dental clinics in their care and pandemic prevention work.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Pei Chen
- Department of Periodontology and Oral Implantology, Stomatological Hospital, Southern Medical University, Guangzhou, China
| | - Mingdeng Rong
- Department of Periodontology and Oral Implantology, Stomatological Hospital, Southern Medical University, Guangzhou, China
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16
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Koum Besson ES, Norris A, Bin Ghouth AS, Freemantle T, Alhaffar M, Vazquez Y, Reeve C, Curran PJ, Checchi F. Excess mortality during the COVID-19 pandemic: a geospatial and statistical analysis in Aden governorate, Yemen. BMJ Glob Health 2021; 6:bmjgh-2020-004564. [PMID: 33758012 PMCID: PMC7992372 DOI: 10.1136/bmjgh-2020-004564] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 01/15/2023] Open
Abstract
Background The burden of COVID-19 in low-income and conflict-affected countries remains unclear, largely reflecting low testing rates. In parts of Yemen, reports indicated a peak in hospital admissions and burials during May–June 2020. To estimate excess mortality during the epidemic period, we quantified activity across all identifiable cemeteries within Aden governorate (population approximately 1 million) by analysing very high-resolution satellite imagery and compared estimates to Civil Registry office records. Methods After identifying active cemeteries through remote and ground information, we applied geospatial analysis techniques to manually identify new grave plots and measure changes in burial surface area over a period from July 2016 to September 2020. After imputing missing grave counts using surface area data, we used alternative approaches, including simple interpolation and a generalised additive mixed growth model, to predict both actual and counterfactual (no epidemic) burial rates by cemetery and across the governorate during the most likely period of COVID-19 excess mortality (from 1 April 2020) and thereby compute excess burials. We also analysed death notifications to the Civil Registry office over the same period. Results We collected 78 observations from 11 cemeteries. In all but one, a peak in daily burial rates was evident from April to July 2020. Interpolation and mixed model methods estimated ≈1500 excess burials up to 6 July, and 2120 up to 19 September, corresponding to a peak weekly increase of 230% from the counterfactual. Satellite imagery estimates were generally lower than Civil Registry data, which indicated a peak 1823 deaths in May alone. However, both sources suggested the epidemic had waned by September 2020. Discussion To our knowledge, this is the first instance of satellite imagery being used for population mortality estimation. Findings suggest a substantial, under-ascertained impact of COVID-19 in this urban Yemeni governorate and are broadly in line with previous mathematical modelling predictions, though our method cannot distinguish direct from indirect virus deaths. Satellite imagery burial analysis appears a promising novel approach for monitoring epidemics and other crisis impacts, particularly where ground data are difficult to collect.
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Affiliation(s)
- Emilie S Koum Besson
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Andy Norris
- Earth observation, Satellite Applications Catapult, Didcot, UK
| | | | | | - Mervat Alhaffar
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Yolanda Vazquez
- Earth observation, Satellite Applications Catapult, Didcot, UK
| | - Chris Reeve
- Earth observation, Satellite Applications Catapult, Didcot, UK
| | - Patrick J Curran
- Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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17
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Al-Ashwal FY, Kubas M, Zawiah M, Bitar AN, Mukred Saeed R, Sulaiman SAS, Khan AH, Ghadzi SMS. Healthcare workers' knowledge, preparedness, counselling practices, and perceived barriers to confront COVID-19: A cross-sectional study from a war-torn country, Yemen. PLoS One 2020; 15:e0243962. [PMID: 33306750 PMCID: PMC7732096 DOI: 10.1371/journal.pone.0243962] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/02/2020] [Indexed: 12/23/2022] Open
Abstract
Background The coronavirus disease of 2019 (COVID-19) represents a difficult challenge and could have devastating consequences for the healthcare system and healthcare workers in war-torn countries with poor healthcare facilities such as Yemen. Our study aimed to evaluate the knowledge, preparedness, counselling practices of healthcare workers regarding COVID-19, and the perceived barriers to adequately prevent and control COVID-19 in Yemen. Methods Healthcare workers (HCWs) from major healthcare facilities participated in this cross-sectional study. A self-administered questionnaire comprising of five main domains (demographics, knowledge, self-preparedness, counselling practice, perceived barriers) was distributed among HCWs after obtaining informed consent. A convenient sampling technique was used. Descriptive and inferential analyses were applied using SPSS software. Results A total of 1000 participants were initially targeted to participate in the study with 514 (51.4%) responding, of which 55.3% were female. Physicians and nurses constituted the largest proportion of participants, with 39.5% and 33.3%, respectively. The median scores for knowledge, self-preparedness, and counselling practice were 8 (out of 9), 9 (out of 15), and 25 (out of 30), respectively. The physician group showed a statistically significant association with better knowledge compared to the nurse group only, P<0.001. Males had higher preparedness scores than females, p<0.001. Also, the intensive care unit (ICU) and emergency departments presented a statistically significant difference by which the participants from these departments were more prepared compared to the others (e.g. outpatients, paediatrics and surgery) with P < 0.0001. The lack of awareness among the general population about COVID-19 preventive measures was perceived as the most common barrier for the adequate prevention and control of COVID-19 in Yemen (89.1%). Conclusion The major highlight of this study is that HCWs have, overall, good knowledge, suboptimal preparedness, and adequate counselling practices prior to the outbreak of COVID-19 in Yemen, despite the high number of perceived barriers. However, urgent action and interventions are needed to improve the preparedness of HCWs to manage COVID-19. The perceived barriers also need to be fully addressed by the local healthcare authorities and international organisations working in Yemen for adequate prevention and control measures to be in place in managing COVID-19.
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Affiliation(s)
- Fahmi Y. Al-Ashwal
- Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana'a, Yemen
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Mohammed Kubas
- Clinical Pharmacy Department, University of Science and Technology Hospital (USTH), Sana'a, Yemen
- Pharmacy Practice Department, Kulliyyah of Pharmacy, International Islamic University Malaysia (IIUM), Kuantan, Pahang, Malaysia
| | - Mohammed Zawiah
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Department of Pharmacy Practice, College of Clinical Pharmacy, University of Al Hodeida, Al Hodeida, Yemen
- * E-mail:
| | - Ahmad Naoras Bitar
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Ramzi Mukred Saeed
- Department of Clinical Pharmacy and Pharmacy Practice, University of Science and Technology (UST), Sana'a, Yemen
- Department of Pharmaceutical sciences, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, Kepala Batas, Penang, Malaysia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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