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Chaabane S, Chaabna K, Khawaja S, Aboughanem J, Mittal D, Mamtani R, Cheema S. Sleep disorders and associated factors among medical students in the Middle East and North Africa: a systematic review and meta-analysis. Sci Rep 2024; 14:4656. [PMID: 38409132 PMCID: PMC10897338 DOI: 10.1038/s41598-024-53818-2] [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: 04/19/2023] [Accepted: 02/05/2024] [Indexed: 02/28/2024] Open
Abstract
Sleep disturbances like poor and insufficient sleep are common among medical students in the Middle East and North Africa (MENA) countries; however, the extent of medically defined sleep disorders (SDs) remains unclear. This meta-analysis determines SD prevalence and identifies associated factors among medical students in the MENA. PubMed, Web of Science, Google Scholar, and reference lists of included studies were searched (latest search: June 2022). Meta-analyses included 22 studies and were performed using random-effect models. Included studies used self-reported screening tools for assessing SDs and then estimated the proportion of participants at high risk of developing a SD. Central disorders of hypersomnolence were the most prevalent SD [prevalencepooled range: 30.9% (Jordan) to 62.5% (Saudi Arabia)], followed by insomnia disorders [prevalencepooled range: 30.4% (Jordan) to 59.1% (Morocco)], circadian rhythm sleep-wake disorders [prevalencepooled range: 13.5% (Jordan) to 22.4% (Saudi Arabia)], sleep-related breathing disorders [prevalencepooled range: 12.2% (Jordan) to 22.5% (Pakistan)], sleep-related movement disorders [prevalencepooled range: 5.9% (Egypt) to 30.6% (Saudi Arabia)], and parasomnias [prevalencepooled range: 5.6% (Jordan) to 17.4% (Saudi Arabia)]. Female sex, studying in the latter academic years, having anxiety, excessive internet use, and poor academic performance were significantly associated with SDs. SDs are prevalent among MENA medical students. Implementing student-centered interventions targeting high risk groups in medical schools should be considered to improve students' health and wellbeing.
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Affiliation(s)
- Sonia Chaabane
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar.
| | - Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
| | - Salina Khawaja
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
| | - Jasmine Aboughanem
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
| | - Dhruv Mittal
- Intern, Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
| | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine - Qatar, Education City, Qatar Foundation, P.O. Box. 24144, Doha, Qatar
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Alassad A, Al Rahwanji MJ, Yousfan A, Al Moualem S, Farhat A, Youssef LA. Seroprevalence and trends of hepatitis B virus, hepatitis C virus and human immunodeficiency virus in Syrian blood donors at Damascus University Blood Center between 2004 and 2021. Front Public Health 2023; 11:1174638. [PMID: 37325302 PMCID: PMC10267398 DOI: 10.3389/fpubh.2023.1174638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Seroprevalence of transfusion-transmitted viral infections (TTVIs) is a valuable indicator for assessing blood safety, population health and health system performance in the times of peace and conflicts. Only scarce information is available on the impact of the decade-long violent conflict on the prevalence of TTVIs in Syria. Moreover, hepatitis B vaccine was introduced to the national vaccination program in 1993; however, no data is available on the vaccine effectiveness. Methods In this retrospective cross-sectional study, we compiled the screening results for major TTVIs, namely hepatitis B virus (HBV), hepatitis C virus (HCV), and human immuno-deficiency virus (HIV), of volunteer donors at Damascus University Blood Center from May 2004 to October 2021. Prevalence was expressed in percentages for the entire study group and subgroups. Chi-square test and linear regression were used to examine the differences and describe trends in prevalence, respectively, based on demographic characteristics (i.e., age and gender) and time. P-value of <0.005 was considered statistically significant. Results Of the total 307,774 donors (82.27% males, median age 27 years), 5,929 (1.93%) had serological evidence of at least one TTVI, and 26 (0.0085%) had multiple infections. The lowest prevalence (1.09%) was detected in donors aged 18-25 years old, and a higher prevalence (2.05%) was evident in males in comparison with females (1.38%). The seroprevalence of HBV, HCV, and HIV was 1.18, 0.52, and 0.23%, respectively. Trend analyses revealed a significant regression in HBV and HIV prevalence from 2011 to 2021. HBV seropositivity depicted a temporal decline by ~80%, from 0.79% in 2011 to 0.16% in 2021 in those born in 1993 and thereafter. Discussion The seroprevalence of HBV, HIV, and to a lesser extent HCV dropped over the study 18-year period. Possible explanations may include implementation of the HBV vaccine, robust national health system, conservative sociocultural values, and isolation.
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Affiliation(s)
- Alia Alassad
- Damascus University Blood Center, Damascus University, Damascus, Syria
| | - Mhd Jawad Al Rahwanji
- Department of Artificial Intelligence, Faculty of Information Technology Engineering, Damascus University, Damascus, Syria
- Department of Computer Science, Saarland University, Saarbrücken, Germany
| | - Amal Yousfan
- Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
- Department of Pharmaceutics and Pharmaceutical Technology, Pharmacy College, Al Andalus University for Medical Sciences, Tartus, Syria
| | - Sally Al Moualem
- Department of Biochemistry and Microbiology, Faculty of Pharmacy, Damascus University, Damascus, Syria
| | - Arwa Farhat
- Department of Biochemistry and Microbiology, Faculty of Pharmacy, Damascus University, Damascus, Syria
| | - Lama A. Youssef
- Program of Clinical and Hospital Pharmacy, Department of Pharmaceutics & Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syria
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Athamneh RY, Abudalo R, Sallam M, Alqudah A, Alquran H, Amawi KF, Abu-Harirah HA. Sub-genotypes of hepatitis C virus in the Middle East and North Africa: Patterns of distribution and temporal changes. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 109:105412. [PMID: 36791585 DOI: 10.1016/j.meegid.2023.105412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/04/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Infection with the hepatitis C virus (HCV) remains a considerable public health concern in the Middle East and North Africa (MENA). The objectives of this study were to analyze the HCV genotype (GT) and sub-genotype (SGT) distribution in the MENA region and to assess the temporal change in the number of sequences within the MENA region. All HCV molecular sequences collected in the MENA region had been retrieved from GenBank as of 1 August 2022. The number of HCV sequences retrieved was 6740 representing sequences from a total of 17 MENA countries with a majority from Iran (n = 1969, 29.2%), Egypt (n = 1591, 23.6%), Tunisia (n = 1305, 19.4%) and Saudi Arabia (n = 1085, 16.1%). The determination of GT/SGT was based on the NCBI genotyping and Blast tool. Genotype 1 (GT1) dominated infections in the MENA (n = 2777, 41.2%), followed by GT4 (n = 2566, 39.0%). Additionally, SGT4a (1515/6393, 23.7%) was the most common SGT in the MENA, and SGT4a was dominant in Egypt and Saudi Arabia, followed by SGT1b (n = 1308, 20.5%), which was dominant in Morocco and Tunisia, while SGT1a (n = 1275, 19.9%) was common in Iran, Iraq and Palestine. Furthermore, significant temporal increase in the number of HCV MENA sequences was observed. On the SGT level, specific patterns of HCV genetic diversity were seen in the MENA region, with the most common SGT being 4a, in addition to increasing the availability of HCV sequences in the MENA region.
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Affiliation(s)
- Rabaa Y Athamneh
- Department of Medical Laboratories Sciences, Faculty of Allied Medical Sciences, Zarqa University, Zarqa, Jordan.
| | - Rawan Abudalo
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, Jordan
| | - Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman, Jordan; Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman, Jordan
| | - Abdelrahim Alqudah
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, Jordan
| | - Hasan Alquran
- Department of Medical Laboratories Sciences, Faculty of Allied Medical Sciences, Zarqa University, Zarqa, Jordan
| | - Kawther Faisal Amawi
- Department of Medical Laboratories Sciences, Faculty of Allied Medical Sciences, Zarqa University, Zarqa, Jordan
| | - Hashem A Abu-Harirah
- Department of Medical Laboratories Sciences, Faculty of Allied Medical Sciences, Zarqa University, Zarqa, Jordan
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Alsughayyir J, Almalki Y, Alburayk I, Alalshaik M, Aljoni I, Kandel M, Alfhili MA, Alabdullateef AA. Prevalence of transfusion-transmitted infections in Saudi Arabia blood donors: A nationwide, cross-sectional study. Saudi Med J 2022; 43:1363-1372. [PMID: 36517064 PMCID: PMC9994514 DOI: 10.15537/smj.2022.43.12.20220634] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/17/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To establish a nationwide epidemiological profile of transfusion-transmittable infection (TTI) markers among seemingly healthy blood donors to update policies required to ensure blood safety. METHODS A nationwide, cross-sectional study was designed to examine donor demographics and TTI prevalence during 2020 using data provided by the Ministry of Health, Saudi Arabia. RESULTS Collectively, a total of 375,218 whole blood units were donated, of which 32,758 (8.7%) were excluded due to TTI-related risk. The exclusion was based on a positive nucleic acid amplification test (NAT) or seroreactivity to hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), human T-cell lymphotropic virus (HTLV-I/II), syphilis, or malaria. Notably, the central (37.6%) and southern (33%) regions were the epicenters of TTI-reactive blood donors. Hepatitis B virus markers accounted for 85.7% and were the overall most prevalent of TTI-positive donations, followed by HCV at 5.9% and syphilis at 5.6%. In particular, anti-HBc and HBsAg were most prevalent in the south, while HBV NAT was highest in the center. CONCLUSION Hepatitis B virus, HCV, and syphilis carry the greatest risk of TTI in Saudi Arabia. Including HBsAg screening is a necessary precautious measure to maintain blood safety.
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Affiliation(s)
- Jawaher Alsughayyir
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Yasser Almalki
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Imtinan Alburayk
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Mohrah Alalshaik
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Ibrahim Aljoni
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Mona Kandel
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Mohammad A. Alfhili
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
| | - Abdulmajeed A. Alabdullateef
- From the Chair of Medical and Molecular Genetics Research (Alfhili), Department of Clinical Laboratory Sciences, and from the Department of Clinical Laboratory Sciences, (Alsughayyir, Alalshaik,), College of Applied Medical Sciences, King Saud University; from the Division of Hematology (Almalki), King Khalid University Hospital; from the Blood Transfusion Services Operation Centre (Aljoni, Kandel, Alabdullateef Ministry of Health, Riyadh; and from the Maternity and Children Hospital (Alburayk), Ministry of Health, Hail, Kingdom of Saudi Arabia.
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Athamneh RY, Arıkan A, Sayan M, Mahafzah A, Sallam M. Variable Proportions of Phylogenetic Clustering and Low Levels of Antiviral Drug Resistance among the Major HBV Sub-Genotypes in the Middle East and North Africa. Pathogens 2021; 10:1333. [PMID: 34684283 PMCID: PMC8540944 DOI: 10.3390/pathogens10101333] [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: 09/22/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/21/2022] Open
Abstract
Hepatitis B virus (HBV) infection remains a major public health threat in the Middle East and North Africa (MENA). Phylogenetic analysis of HBV can be helpful to study the putative transmission links and patterns of inter-country spread of the virus. The objectives of the current study were to analyze the HBV genotype/sub-genotype (SGT) distribution, reverse transcriptase (RT), and surface (S) gene mutations and to investigate the domestic transmission of HBV in the MENA. All HBV molecular sequences collected in the MENA were retrieved from GenBank as of 30 April 2021. Determination of genotypes/SGT, RT, and S mutations were based on the Geno2pheno (hbv) 2.0 online tool. For the most prevalent HBV SGTs, maximum likelihood phylogenetic analysis was conducted to identify the putative phylogenetic clusters, with approximate Shimodaira-Hasegawa-like likelihood ratio test values ≥ 0.90, and genetic distance cut-off values ≤ 0.025 substitutions/site as implemented in Cluster Picker. The total number of HBV sequences used for genotype/SGT determination was 4352 that represented a total of 20 MENA countries, with a majority from Iran (n = 2103, 48.3%), Saudi Arabia (n = 503, 11.6%), Tunisia (n = 395, 9.1%), and Turkey (n = 267, 6.1%). Genotype D dominated infections in the MENA (86.6%), followed by genotype A (4.1%), with SGT D1 as the most common in 14 MENA countries and SGT D7 dominance in the Maghreb. The highest prevalence of antiviral drug resistance was observed against lamivudine (4.5%) and telbivudine (4.3%). The proportion of domestic phylogenetic clustering was the highest for SGT D7 (61.9%), followed by SGT D2 (28.2%) and genotype E (25.7%). The largest fraction of domestic clusters with evidence of inter-country spread within the MENA was seen in SGT D7 (81.3%). Small networks (containing 3-14 sequences) dominated among domestic phylogenetic clusters. Specific patterns of HBV genetic diversity were seen in the MENA with SGT D1 dominance in the Levant, Iran, and Turkey; SGT D7 dominance in the Maghreb; and extensive diversity in Saudi Arabia and Egypt. A low prevalence of lamivudine, telbivudine, and entecavir drug resistance was observed in the region, with almost an absence of resistance to tenofovir and adefovir. Variable proportions of phylogenetic clustering indicated prominent domestic transmission of SGT D7 (particularly in the Maghreb) and relatively high levels of virus mobility in SGT D1.
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Affiliation(s)
- Rabaa Y. Athamneh
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia 99138, Cyprus; (R.Y.A.); (A.A.)
| | - Ayşe Arıkan
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia 99138, Cyprus; (R.Y.A.); (A.A.)
- DESAM, Near East University, Nicosia 99138, Cyprus;
| | - Murat Sayan
- DESAM, Near East University, Nicosia 99138, Cyprus;
- Clinical Laboratory, PCR Unit, Faculty of Medicine, Kocaeli University, İzmit 41380, Turkey
| | - Azmi Mahafzah
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Amman 11942, Jordan;
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
| | - Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Amman 11942, Jordan;
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
- Department of Translational Medicine, Faculty of Medicine, Lund University, 22184 Malmö, Sweden
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Worldwide prevalence, genotype distribution and management of hepatitis C. Acta Gastroenterol Belg 2021; 84:637-656. [PMID: 34965046 DOI: 10.51821/84.4.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Hepatitis C virus (HCV) is one of the leading causes of chronic liver disease, cirrhosis, and hepatocellular carcinoma, resulting in major global public health concerns. The HCV infection is unevenly distributed worldwide, with variations in prevalence across and within countries. The studies on molecular epidemiology conducted in several countries provide an essential supplement for a comprehensive knowledge of HCV epidemiology, genotypes, and subtypes, along with providing information on the impact of current and earlier migratory flows. HCV is phylogenetically classified into 8 major genotypes and 57 subtypes. HCV genotype and subtype distribution differ according to geographic origin and transmission risk category. Unless people with HCV infection are detected and treated appropriately, the number of deaths due to the disease will continue to increase. In 2015, 1.75 million new viral infections were mostly due to unsafe healthcare procedures and drug use injections. In the same year, access to direct-acting antivirals was challenging and varied in developing and developed countries, affecting HCV cure rates based on their availability. The World Health Assembly, in 2016, approved a global strategy to achieve the elimination of the HCV public health threat by 2030 (by reducing new infections by 90% and deaths by 65%). Globally, countries are implementing policies and measures to eliminate HCV risk based on their distribution of genotypes and prevalence.
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Chouikha A, Ghrabi A, Ghodbane A, Hammemi W, Khedhiri M, Sadraoui A, Touzi H, Hassine HB, Maatoug S, Bensaoud C, Abdelhak S, Bouarrouj S, Gdoura M, Chaouachi H, Triki H. Distribution of HCV Genotypes Among People Who Inject Drugs in Tunisia: New Evidence for Scaling Up Prevention and Treatment Toward National Elimination Goal. Front Microbiol 2021; 12:697859. [PMID: 34385988 PMCID: PMC8353188 DOI: 10.3389/fmicb.2021.697859] [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: 04/20/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Little is known about the distribution of hepatitis C virus (HCV) genotypes among people who inject drugs (PWID) in North African countries, including Tunisia. This study aims to describe HCV genotypes circulating among Tunisian PWID. A cross-sectional study was conducted, and 128 HCV-positive PWID were recruited between 2018 and 2019 from community-based harm reduction centers. After informed consent, sociodemographic characteristics and risk behavior data were obtained using an interviewer-administrated questionnaire. Blood samples were collected for further serological and molecular testing. Overall, five women and 123 men were included. The median age was 39.5 years. The majority of PWID (56.3%) had less than a secondary level of education, were single (57%), were unemployed (65.6%), were incarcerated at least once (93.0%), and had a history of residency in at least one foreign country (50.8%). During the previous 12 months, 82.0% reported having reused syringes at least once, 43.8% shared syringes at least once, while 56.2% had at least one unprotected sexual relation, and 28.1% had more than two different sexual partners. Tattooing was reported among 60.2%. All positive results for HCV-infection by rapid testing were confirmed by enzyme-linked immunosorbent assay (ELISA). HCV-RNA was detectable in 79.7%. Genotyping showed a predominance of genotype 1 (52%) followed by genotype 3 (34%) and genotype 4 (10%). Four patients (4%) had an intergenotype mixed infection. Subtyping showed the presence of six different HCV subtypes as follows: 1a (53.2%), 1b (6.4%), 3a (33.0%), 4a (3.2%), and 4d (4.3%). This is the first study describing circulating HCV genotypes among PWID in Tunisia. The distribution of HCV genotypes is distinct from the general population with a predominance of subtypes 1a and 3a. These findings can be used to guide national efforts aiming to optimize the access of PWID to relevant HCV prevention and treatment measures including pangenotypic regimens for patients infected with HCV genotype 3.
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Affiliation(s)
- Anissa Chouikha
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Amine Ghrabi
- Association Tunisienne d'Information et d'Orientation sur le SIDA et la Toxicomanie (Tunisian Association for Information and Orientation on HIV/AIDS and Toxicomania - ATIOST), Tunis, Tunisia
| | - Amira Ghodbane
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Walid Hammemi
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Marwa Khedhiri
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Amel Sadraoui
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Henda Touzi
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | | | - Sonia Maatoug
- Science Shop, Institut Pasteur de Tunis, Tunis, Tunisia
| | - Chaima Bensaoud
- Science Shop, Institut Pasteur de Tunis, Tunis, Tunisia.,Institute of Parasitology, Biology Centre, Czech Academy of Sciences, Ceske Budejovice, Czechia
| | | | - Samir Bouarrouj
- Association Tunisienne d'Information et d'Orientation sur le SIDA et la Toxicomanie (Tunisian Association for Information and Orientation on HIV/AIDS and Toxicomania - ATIOST), Tunis, Tunisia
| | - Mariem Gdoura
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Hedia Chaouachi
- Association Tunisienne d'Information et d'Orientation sur le SIDA et la Toxicomanie (Tunisian Association for Information and Orientation on HIV/AIDS and Toxicomania - ATIOST), Tunis, Tunisia
| | - Henda Triki
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, Tunis El Manar University, Tunis, Tunisia
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Doraiswamy S, Chaabna K, Jithesh A, Mamtani R, Cheema S. Physician burnout in the Eastern Mediterranean region: influence of gender and related factors - Systematic review and meta-analysis. J Glob Health 2021; 11:04043. [PMID: 34326993 PMCID: PMC8285757 DOI: 10.7189/jogh.11.04043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background While recent reviews highlight high burnout prevalence among physicians in the World Health Organization's (WHO) Eastern Mediterranean Region (EMR), there has been a limited exploration into the role of gender and related factors in this problem. Methods We conducted a systematic review and meta-analysis of studies on the prevalence of physician burnout and its relationship to gender, physician specialties, and age in the WHO's EMR based on the Cochrane Handbook for Systematic Reviews. We searched PubMed, Embase, PsycINFO, Google Scholar, and Al Manhal databases and synthesized the findings from the included studies. Results Among the 78 studies included, data was available from 16/22 (72.7%) countries and territories in the EMR covering a total of 16 016 physicians. The pooled prevalence of overall burnout among physicians in the region was estimated to be 24.5%. Among the sub-components of burnout, we estimated a high pooled prevalence of 44.26% for emotional exhaustion followed by 37.83% for depersonalization and 36.57% for low personal achievement. There was a statistically significant difference in the prevalence across the countries in the EMR and among the sub-categories of specialist medical practitioners. There was no statistically significant difference across the two genders at a regionally aggregated level. Conclusions The levels of physician burnout including the three sub-components in EMR are high by any standards. Based on our review of available studies, it is difficult to ascertain gender differences with certainty in burnout levels among physicians in the EMR nations. There is a need for better quality studies in this area.
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Affiliation(s)
| | - Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine - Qatar
| | - Anupama Jithesh
- Institute for Population Health, Weill Cornell Medicine - Qatar
| | | | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine - Qatar
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Khalsa JH, Mathur P. Hepatitis C Virus Infection in Persons Who Inject Drugs in the Middle East and North Africa: Intervention Strategies. Viruses 2021; 13:1363. [PMID: 34372569 PMCID: PMC8310161 DOI: 10.3390/v13071363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/04/2021] [Accepted: 07/11/2021] [Indexed: 12/12/2022] Open
Abstract
There is a high incidence and prevalence of hepatitis C viral infection in persons with or without substance use disorders (SUDs) in the Middle East and North Africa (MENA) region, but only a small number receive comprehensive care. Highly effective direct-acting antiviral (DAA) medications are available at substantially lower costs; however, complete elimination of the hepatitis C virus (HCV) can only be achieved if integrated care strategies target those at highest risk for HCV infection and transmission and improve access to care. Due to the high prevalence of SUD in the MENA region, strategies to eliminate HCV must focus on integrated healthcare across multiple subspecialties, including addiction medicine, psychiatry, infectious diseases, hepatology, and social work. In this invited manuscript, we review the epidemiology of HCV in the MENA region and highlight intervention strategies to attain the WHO's goal of HCV eradication by 2030.
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Affiliation(s)
- Jag H. Khalsa
- Medical Consequences of Drug Abuse and Infections Branch, Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Poonam Mathur
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
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Abraham A, Chaabna K, Doraiswamy S, Bhagat S, Sheikh J, Mamtani R, Cheema S. Depression among healthcare workers in the Eastern Mediterranean Region: a systematic review and meta-analysis. HUMAN RESOURCES FOR HEALTH 2021; 19:81. [PMID: 34246282 PMCID: PMC8271293 DOI: 10.1186/s12960-021-00628-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/05/2021] [Indexed: 05/07/2023]
Abstract
BACKGROUND Depression is a major population health challenge globally. This systematic review and meta-analysis aims to (i) determine depression prevalence and (ii) identify the risk and protective factors of depression among healthcare workers (HCWs) in the Eastern Mediterranean Region (EMR). METHODS The protocol was registered on Open Science Framework (registration ID: https://osf.io/rdv27 ). We searched five databases (PubMed, Embase, PsycINFO, Al Manhal, Google Scholar) till July 22, 2020 without language restrictions. We included studies from the EMR using a depression screening or diagnostic instrument to measure the depression prevalence among HCWs. Studies were assessed and data were pooled using random-effects meta-analysis based on the Cochrane handbook. RESULTS The systematic review identified 108 studies from 12 EMR countries with varying quality. Working long hours, poor sleep quality and being female were risk factors for depression in EMR HCWs. The meta-analysis comprised 77 studies providing 122 prevalence measures across 7 EMR countries. The pooled prevalence of depression among EMR HCWs was 33.03% (95% CI = 27.40-39.19%). Emergency HCWs had markedly higher rates of depression [53.14% (95% CI = 26.63-77.99%)] compared to HCWs of other specialties. Most studies had an appropriate sample size. CONCLUSIONS Depression among EMR HCWs is a major concern. Steps must be taken to prevent, identify, and manage depression among HCWs. Fostering a compassionate and empathetic environment is critically important to building a resilient healthcare system. Generating high-quality regional data from longitudinal studies on mental health will further contribute to a better understanding and management of depression among EMR HCWs.
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Affiliation(s)
- Amit Abraham
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar.
| | - Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
| | - Sathyanarayanan Doraiswamy
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
| | - Sapna Bhagat
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
| | - Javaid Sheikh
- Office of the Dean, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, P.O. Box 24144, Doha, Qatar
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Sultan S, El-Mowafy M, Elgaml A, El-Mesery M, El Shabrawi A, Elegezy M, Hammami R, Mottawea W. Alterations of the Treatment-Naive Gut Microbiome in Newly Diagnosed Hepatitis C Virus Infection. ACS Infect Dis 2021; 7:1059-1068. [PMID: 33119247 DOI: 10.1021/acsinfecdis.0c00432] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gut microbiota dysbiosis has been linked to many heath disorders including hepatitis C virus (HCV) infection. However, profiles of the gut microbiota alterations in HCV are inconsistent in the literature and are affected by the treatment regimens. Using samples collected prior to treatment from newly diagnosed patients, we characterized the gut microbiota structure in HCV patients as compared to healthy controls. Treatment-naive HCV microbiota showed increased diversity, an increased abundance of Prevotella, Succinivibrio, Catenibacterium, Megasphaera, and Ruminococcaceae, and a lower abundance of Bacteroides, Dialister, Bilophila, Streptococcus, parabacteroides, Enterobacteriaceae, Erysipelotrichaceae, Rikenellaceae, and Alistipes. Predicted community metagenomic functions showed a depletion of carbohydrate and lipid metabolism in HCV microbiota along with perturbations of amino acid metabolism. Receiver-operating characteristic analysis identified five disease-specific operational taxonomic units (OTUs) as potential biomarkers of HCV infections. Collectively, our findings reveal the alteration of gut microbiota in treatment naive HCV patients and suggest that gut microbiota may hold diagnostic promise in HCV infection.
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Affiliation(s)
- Salma Sultan
- Faculty of Health Sciences, School of Nutrition Sciences, University of Ottawa, Ottawa, Ontario K1H8M5, Canada
| | | | - Abdelaziz Elgaml
- Faculty of Pharmacy, Department of Microbiology and Immunology, Horus University, New Damietta 34518, Egypt
| | | | | | | | - Riadh Hammami
- Faculty of Health Sciences, School of Nutrition Sciences, University of Ottawa, Ottawa, Ontario K1H8M5, Canada
| | - Walid Mottawea
- Faculty of Health Sciences, School of Nutrition Sciences, University of Ottawa, Ottawa, Ontario K1H8M5, Canada
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Chaabane S, Chaabna K, Bhagat S, Abraham A, Doraiswamy S, Mamtani R, Cheema S. Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews. Syst Rev 2021; 10:136. [PMID: 33952346 PMCID: PMC8101235 DOI: 10.1186/s13643-021-01691-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In nursing students, high stress levels can lead to burnout, anxiety, and depression. Our objective is to characterize the epidemiology of perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa region. METHODS We conducted an overview of systematic reviews. We systematically searched PubMed, Embase, PsycInfo, and grey literature sources between January 2008 and June 2020 with no language restrictions. We included any systematic review reporting measurable stress-related outcomes including stress prevalence, stressors, and stress coping strategies in nursing students residing in any of the 20 Middle East and North Africa countries. We also included additional primary studies identified through a hand search of the reference lists of relevant primary studies and systematic reviews. RESULTS Seven systematic reviews and 42 primary studies with data from Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan were identified. Most studies included nursing students undergoing clinical training. The prevalence range of low, moderate, and high perceived stress among nursing students was 0.8-65%, 5.9-84.5%, and 6.7-99.2%, respectively. Differences related to gender, training period, or the type of tool used to measure stress remain unclear given the wide variability in the reported prevalence measures across all stress levels. Common clinical training stressors were assignments, workload, and patient care. Academic training-related stressors included lack of break/leisure time, low grades, exams, and course load. Nursing students utilized problem focused (dealing with the problem), emotion focused (regulating the emotion), and dysfunctional (venting the emotions) stress coping mechanisms to alleviate their stress. CONCLUSIONS Available data does not allow the exploration of links between stress levels, stressors, and coping strategies. Limited country-specific prevalence data prevents comparability between countries. Reducing the number or intensity of stressors through curriculum revision and improving students' coping response could contribute to the reduction of stress levels among students. Mentorship, counseling, and an environment conducive to clinical training are essential to minimize perceived stress, enhance learning, and productivity, and prevent burnout among nursing students.
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Affiliation(s)
- Sonia Chaabane
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar
| | - Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar
| | - Sapna Bhagat
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar
| | - Amit Abraham
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar
| | | | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine-Qatar, Ar-Rayyan, Qatar.
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Hedayati-Moghaddam MR, Soltanian H, Ahmadi-Ghezeldasht S. Occult hepatitis C virus infection in the Middle East and Eastern Mediterranean countries: A systematic review and meta-analysis. World J Hepatol 2021; 13:242-260. [PMID: 33708353 PMCID: PMC7934012 DOI: 10.4254/wjh.v13.i2.242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/25/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The presence of hepatitis C virus (HCV) RNA in liver tissue or peripheral blood mononuclear cells with no identified virus genome in the serum has been reported worldwide among patients with either normal or elevated serum liver enzymes. The characterization of occult HCV infection (OCI) epidemiology in the Middle East and Eastern Mediterranean (M and E) countries, a region with the highest incidence and prevalence rates of HCV infection in the world, would be effective for more appropriate control of the infection.
AIM To estimate the pooled prevalence of OCI in M and E countries using a systematic review and meta-analysis.
METHODS A systematic literature search was performed using international, regional and local electronic databases. Some conference proceedings and references from bibliographies were also reviewed manually. The search was carried out during May and June 2020. Original observational surveys were considered if they assessed the prevalence of OCI among the population of M and E countries by examination of HCV nucleic acid in peripheral blood mononuclear cells in at least 30 cases selected by random or non-random sampling methods. The meta-analysis was performed using Comprehensive Meta-analysis software based on heterogeneity assessed by Cochran’s Q test and I-square statistics. Data were considered statistically significant at a P value < 0.05.
RESULTS A total of 116 non-duplicated citations were found in electronic sources and grey literature. A total of 51 non-overlapping original surveys were appraised, of which 37 met the inclusion criteria and were included in the analysis. Data were available from 5 of 26 countries including Egypt, Iran, Pakistan, Saudi Arabia, and Turkey. The overall prevalence rate of OCI was estimated at 10.04% (95%CI: 7.66%-13.05%). The lowest OCI rate was observed among healthy subjects (4.79%, 95%CI: 2.86%-7.93%). The higher rates were estimated for patients suffering from chronic liver diseases (12.04%, 95%CI: 5.87%-23.10%), and multi-transfused patients (8.71%, 95%CI: 6.05%-12.39%). Subgroup analysis indicated that the OCI rates were probably not associated with the studied subpopulations, country, year of study, the detection method of HCV RNA, sample size, patients’ HCV serostatus, and sex (all P > 0.05). Meta-regression analyses showed no significant time trends in OCI rates among different groups.
CONCLUSION This review estimated high rates of OCI prevalence in M and E countries, especially among multi-transfused patients as well as patients with chronic liver diseases.
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Affiliation(s)
- Mohammad Reza Hedayati-Moghaddam
- Blood Borne Infections Research Center, Academic Center for Education, Culture and Research (ACECR), Razavi Khorasan Branch, Mashhad 91779-49367, Iran
| | - Hossein Soltanian
- Blood Borne Infections Research Center, Academic Center for Education, Culture and Research (ACECR), Razavi Khorasan Branch, Mashhad 91779-49367, Iran
| | - Sanaz Ahmadi-Ghezeldasht
- Blood Borne Infections Research Center, Academic Center for Education, Culture and Research (ACECR), Razavi Khorasan Branch, Mashhad 91779-49367, Iran
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Chaabna K, Cheema S, Abraham A, Maisonneuve P, Lowenfels AB, Mamtani R. The state of population health research performance in the Middle East and North Africa: a meta-research study. Syst Rev 2021; 10:1. [PMID: 33388080 PMCID: PMC7777412 DOI: 10.1186/s13643-020-01552-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 12/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Population health (PH) research capacity and performance are essential pillars of evidence-based practice to help address health inequalities. Best evidence is provided by systematic reviews (SRs). None of the published bibliometric analysis specifically assess the production of SRs on PH in the Middle East and North Africa (MENA). The aim of our study is to investigate publication patterns and time trends of SRs reporting PH in the MENA region to evaluate the state of PH research performance in the region. METHOD The study protocol was developed a priori (protocol registration number: CRD42017076736). PubMed was searched. Two independent reviewers screened 5747 identified articles. We investigated author affiliation and collaboration, yearly citations of the SRs and journal information. Joinpoint regression was used to explore these characteristics overtime. RESULTS Our meta-research included 387 SRs published between 2008 and 2016 which reported data on PH in 20 MENA countries. Publication of SRs increased over time in journals with impact factor < 4 and in the categories of yearly number of citations < 50 (p values ≤ 0.0024). Authors belonging to the region published increasingly (p value = 0.0001) over time. Thirty percent of the SRs were from authors solely from the region, while an additional 30% were from the region collaborating with Western country authors. Of these collaborative reviews, 79% were led by authors from the region. However, collaboration in the region (with the exclusion of collaboration with Western country authors) was rare (0.8%). These authors from the region published more in open-access journals while authors from Western countries collaborating or not with authors from the region published more in hybrid or non-open-access journals (p value < 0.0001). Collaboration between authors from MENA and Western countries led to published SRs in journals with impact factor ≥ 10. Systematic reviews with global coverage were published more by authors from Western countries, while SRs with country-level coverage were published by authors from the region (p value < 0.0001). CONCLUSION The incremental trend of PH SR publications on MENA likely reflects the ongoing improvement in research performance in the region. Authors from the region appear to be taking a lead role in conducting and disseminating MENA PH research. Open-access journals are a major contributor in facilitating MENA research dissemination. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42017076736.
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Affiliation(s)
- Karima Chaabna
- Institute for Population Health, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Amit Abraham
- Institute for Population Health, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Albert B Lowenfels
- Department of Surgery and Department of Family Medicine, New York Medical College, Valhalla, NY, USA
| | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell Medicine-Qatar, Doha, Qatar
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15
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Elzouki AN, Lubbad R, Elzouki I, Elhaddad A, Ibrahim A. Frequency of hepatitis B and C in health care providers at three referral hospitals in Libya. Pan Afr Med J 2020; 37:214. [PMID: 33520053 PMCID: PMC7821797 DOI: 10.11604/pamj.2020.37.214.23997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction the aim of the present study was to determine the frequency of HBsAg and anti-HCV antibodies in health care providers (HCPs) at three referral hospitals in Libya, and to correlate the HBsAg status with history of hepatitis B vaccination among HCPs. Methods one hundred eighty-two HCPs, with a mean age (±SD) of 32.9±8 years and age range from 20 to 59 years, were enrolled in this study. They were 50 doctors, 68 nurses, 42 laboratory technicians, 12 hospital cleaners, five anesthesia technicians and five midwives. They were tested, after obtained a written consent, for the presence of HBsAg and anti-HCV antibodies by enzyme linked immuno-sorbent assay (ELISA) techniques. A pre-test questionnaire was filled by each HCP to verify place of work, working period, type of work, status of HBV vaccination, and history of needle stick injury. Results four HCPs have anti-HCV antibodies positive (2.2%) and nine were HBsAg positive (4.9%). Only 52% (95/182) of the HCPs received full dose of hepatitis B vaccine, while the others either not completed the vaccination schedule or have not receive it. One hundred (54.9%) of the participants had exposed to blood via needle stick injury during their work, 6 (6%) of them were HBsAg positive and three (3%) were anti-HCV positive. Needle stick injury was considered as primary risk factor in 66.7% (6/9 HCPs) of HBsAg-positives and 75% (3/4 subjects) of anti-HCV-positives. Conclusion the present study showed a higher frequency of HBsAg than anti-HCV among HCPs in three major hospitals in Libya. This difference may be explained by the low hepatitis B vaccination rate and the high rate of needle stick injury among this high risk group for these infections.
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Affiliation(s)
- Abdel-Naser Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medical College, Doha, Qatar
| | - Rafat Lubbad
- Department of Medicine, Althora Hospital, Albaida, Libya
| | - Islam Elzouki
- Department of Medicine, Tripoli Central Hospital, Tripoli, Libya
| | - Ahmed Elhaddad
- Department of Medicine, Infectious Disease Unit, Benghazi Medical Center, Benghazi, Libya.,Faculty of Medicine, Benghazi University, Benghazi, Libya
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Namayandeh M, Jamalidoust M, Heydari Marandi N, Aliabadi N, Ziyaeyan A, Pouladfar G, Ziyaeyan M. Hepatitis C virus genotypes in patients with chronic hepatitis C infection in southern Iran from 2016 to 2019. Microbiol Immunol 2020; 64:762-767. [PMID: 32902892 DOI: 10.1111/1348-0421.12845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/15/2020] [Accepted: 09/06/2020] [Indexed: 12/15/2022]
Abstract
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). The treatment of HCV infection has become more complicated due to various genotypes and subtypes of HCV. The treatment of HCV has made significant advances with direct-acting antivirals. However, for the choice of medicine or the combination of drugs for hepatitis C, it is imperative to detect and discriminate the crucial HCV genotypes. The main objective of this study was to determine the pattern of circulating HCV genotypes in southern Iran, from 2016 until 2019. The other aim of the study was to determine possible associations of patients' risk factors with HCV genotypes. A total of 803 serum samples were collected in 4 years (2016-2019) from patients with HCV antibody positive results. A total of 728 serum samples were HCV-RNA positive. The prevalence of HCV genotypes was detected using the genotype-specific RT-PCR test for serum samples obtained from 615 patients. The HCV genotype 1 (G1) was the most prevalent (48.8%) genotype in the area, with G1a, G1b, and mixed G1a/b representing 38.4%, 10.1%, and 0.3%, respectively. Genotype 3a was the next most prevalent (47.2%). Mixed genotypes 1a/3a were detected in 22 (3.6%) and finally G4 was found in 3 (0.5%) patients. The other HCV genotypes were not detected in any patient. Genotype 1 (1a and 1b alone, 1a/1b and 1a/3a coinfections) is the most prevalent HCV genotype in southern Iran. HCV G1 shows a significantly higher rate in people under 40 years old.
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Affiliation(s)
- Mandana Namayandeh
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Marzieh Jamalidoust
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Nahid Heydari Marandi
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Nasrin Aliabadi
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Atoosa Ziyaeyan
- Institute of Biomaterials and Biomedical Engineering (IBBME), University of Toronto, Toronto, Ontario, Canada
| | - Gholamreza Pouladfar
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Mazyar Ziyaeyan
- Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
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Chaabna K, Cheema S, Abraham A, Mamtani R. Strengthening literature search strategies for systematic reviews reporting population health in the Middle East and North Africa: A meta-research study. J Evid Based Med 2020; 13:192-198. [PMID: 32449308 PMCID: PMC7497175 DOI: 10.1111/jebm.12394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE In the Middle East and North Africa (MENA), data are produced in languages other than English and available through gray literature sources. We assessed the comprehensiveness of literature search strategies of systematic reviews (SRs) reporting population health primary data on MENA. METHODS Utilizing the registered protocol (PROSPERO CRD42017076736), we conducted a meta-research analysis on a cohort of SRs (systematic PubMed search: from 2008 to 2016) and evaluated their search strategies following AMSTAR recommendations. RESULTS A total of 379 SRs were included. Few SRs (10.3%, n = 39) conducted a comprehensive literature search including at least two databases, reference lists of included primary studies, gray literature sources, and no language restriction. Nevertheless, 90.5% (n = 343) searched at least two databases and 67.0% (n = 254) searched gray literature sources. Authors from MENA searched statistically more for gray literature than authors from Western countries (P = 0.022). Reference lists of the included studies were searched in 40.4% (n = 153) of the SRs. Searching the reference lists was positively associated with searching for gray literature (P < 0.001). Only 38.8% (n = 147) of the SRs had no language restriction or searched in English and in at least one language relevant to MENA, whereas 27.2% (n = 103) did not report this information. CONCLUSIONS Literature searches for SRs reporting population health data on MENA were limited in reporting quality, language restrictions, and lack of reference list searches. This was probably due to lack of adherence to the reporting guidelines. To ensure compilation of optimum evidence, expanding literature searches to reference list search and for additional languages relevant to MENA are required.
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Affiliation(s)
- Karima Chaabna
- Institute for Population Health, Weill Cornell MedicineEducation City‐Qatar FoundationDohaQatar
| | - Sohaila Cheema
- Institute for Population Health, Weill Cornell MedicineEducation City‐Qatar FoundationDohaQatar
| | - Amit Abraham
- Institute for Population Health, Weill Cornell MedicineEducation City‐Qatar FoundationDohaQatar
| | - Ravinder Mamtani
- Institute for Population Health, Weill Cornell MedicineEducation City‐Qatar FoundationDohaQatar
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Perinatal Mental Illness in the Middle East and North Africa Region-A Systematic Overview. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155487. [PMID: 32751384 PMCID: PMC7432515 DOI: 10.3390/ijerph17155487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
Aims: Perinatal mental illness (PMI) is associated with a high risk of maternal and infant morbidity. Recently, several systematic reviews and primary studies have explored the prevalence and risk factors of PMI in the Middle East and North Africa (MENA) region. To our knowledge, there has been no critical analysis of the existing systematic reviews (SRs) on this topic in the MENA region. Our systematic overview primarily aimed to synthesize evidence from the published SRs on PMI in the MENA countries focusing on a) the prevalence of PMI and b) the risk factors associated with PMI. Methods: We conducted a systematic overview of the epidemiology of PMI in the Middle East and North Africa region by searching the PubMed, Embase, and PsycInfo databases for relevant publications between January 2008 and July 2019. In addition to searching the reference lists of the identified SRs for other relevant SRs and additional primary studies of relevance (those which primarily discussed the prevalence of PMI and/or risk and protective factors), between August and October 2019, we also searched Google Scholar for relevant studies. Results: After applying our inclusion and exclusion criteria, 15 systematic reviews (SRs) and 79 primary studies were included in our overview. Studies utilizing validated diagnostic tools report a PMI prevalence range from 5.6% in Morocco to 28% in Pakistan. On the other hand, studies utilizing screening tools to detect PMI report a prevalence range of 9.2% in Sudan to 85.6% in the United Arab Emirates. Wide variations were observed in studies reporting PMI risk factors. We regrouped the risk factors applying an evidence-based categorization scheme. Our study indicates that risk factors in the relational, psychological, and sociodemographic categories are the most studied in the region. Conversely, lifestyle-related risk factors were less studied. Conclusions: Our systematic overview identifies perinatal mental illness as an important public health issue in the region. Standardizing approaches for estimating, preventing, screening, and treating perinatal mental illness would be a step in the right direction for the region.
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Poortahmasebi V, Baghi HB. Living in the shadows of hepatitis. THE LANCET. INFECTIOUS DISEASES 2020; 19:1171-1172. [PMID: 31657779 DOI: 10.1016/s1473-3099(19)30534-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Vahdat Poortahmasebi
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Research Center for Clinical Virology, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran
| | - Hossein Bannazadeh Baghi
- Infectious and Tropical Diseases Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Immunology Research Center, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran; Department of Virology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz 5165665931, Iran.
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20
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Prevalence of Hepatitis C Virus in Iranian Prisoners: An Updated Systematic Review and Multilevel Meta-Analysis Study. HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.102004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Alkharsah KR, Alzahrani AJ, Obeid OE, Aljindan RY, Guella A, Al-Ali AK, Al-Turaifi HR, Sallam TA. Association between Hepatitis C Virus Viremia and the rs12979860, rs2228145 and rs1800795 SNP (CT/AC/GG) Genotype in Saudi Kidney Transplant Recipients. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:46-52. [PMID: 31929778 PMCID: PMC6945315 DOI: 10.4103/sjmms.sjmms_175_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/01/2018] [Accepted: 12/25/2018] [Indexed: 02/06/2023]
Abstract
Background: Hepatitis C virus (HCV) is a major health problem, particularly in high-risk groups such as kidney transplant recipients, where it can adversely affect graft survival and increase the relative risk for mortality. Recently, the role of genetic variation among HCV patients in determining the outcome of infections has been under investigation. Objective: To investigate the association of single-nucleotide polymorphisms (SNPs) rs12979860 (located within the interleukin-28B locus), rs2228145 (interleukin-6 receptor) and rs1800795 (interleukin-6 promoter) with HCV viremia in renal transplant patients. Materials and Methods: In this analytical cross-sectional study, 149 kidney transplant recipients, 82 males (median age: 41 years) and 67 females (median age: 45 years), were screened for HCV RNA in blood using real-time polymerase chain reaction and genotyped by sequencing (rs12979860) and restriction fragment length polymorphism (rs2228145 and rs1800795). Results: HCV RNA was detected in 17 (11.41%) of the 149 patients. There was no statistically significant association between the studied SNPs and HCV viremia. However, a combination of the CT/AC/GG genotype was significantly associated with HCV viremia (odds ratio: 5.4). The genotype AA of rs2228145 in the IL-6 receptor was associated with viremia levels of >105 copies/ml (odds ratio: 5.96). Conclusion: To the best of the authors' knowledge, this is the first study that has shown that the CT/AC/GG genotype has an impact on HCV viremia in kidney transplant patients. Therefore, such SNP genotypes may potentially be used to identify transplant patients at risk of HCV infection.
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Affiliation(s)
- Khaled R Alkharsah
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alhussain J Alzahrani
- Department of Clinical Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Obeid E Obeid
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Reem Y Aljindan
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Adnane Guella
- Prince Sultan Research Center, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
| | - Amein K Al-Ali
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hussain R Al-Turaifi
- Department of Laboratory and Blood Bank, King Fahad Hospital, Hofuf, Saudi Arabia
| | - Talal A Sallam
- Department of Medical Microbiology, Faculty of Medicine, Al-Baha University, Al-Bahah, Saudi Arabia
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Sallam M, Batarseh R, Natsheh A, Abbadi J, Al-Fraihat E, Yaseen A, Kaddomi D, Khamees N, Mahafzah A, Şahin GÖ. An update on hepatitis C virus genotype distribution in Jordan: a 12-year retrospective study from a tertiary care teaching hospital in Amman. BMC Infect Dis 2019; 20:3. [PMID: 31892307 PMCID: PMC6938611 DOI: 10.1186/s12879-019-4735-3] [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: 10/30/2019] [Accepted: 12/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background Nucleic acid hybridization (NAH) of hepatitis C virus (HCV) is a practical and reliable tool for virus genotyping. Genotype assignment is an important factor in the prediction of treatment success in chronic hepatitis C patients. The aim of this study was to determine the genotype distribution among HCV clinical isolates in Jordan between 2007 and 2018. Methods Electronic and paper-based clinical data registry records from 2007 to 2018 at the Jordan University Hospital (JUH) were retrospectively examined for individuals with HCV genotype, HCV viral load, and alanine aminotransferase (ALT) testing results. Genotype determination was based on NAH technique using the HCV 5′ untranslated region (5′ UTR) with 386 requests available from 342 unique individuals. Results A total of 263 out of 342 unique individuals (76.9%) had genotyping results available for final analysis with 259 individuals each having a single genotyping result. The most common HCV genotypes in the study were: genotype 4 (n = 142, 54.0%), genotype 1 (n = 87, 33.1%), genotype 3 (n = 16, 6.1%), genotype 2 (n = 9, 3.4%), other undetermined genotypes (n = 5, 1.9%) and mixed infections (n = 4, 1.5%). Sub-genotyping results were available for 46 individuals as follows: sub-genotype 4c/d (n = 13, 28.3%), sub-genotype 1a (n = 11, 23.9%), sub-genotype 1b (n = 10, 21.7%), sub-genotype 4a (n = 8, 17.4%), sub-genotype 3a (n = 2, 4.3%), sub-genotypes 2a/c and 4 h (n = 1, 2.2% for both). Individuals infected with genotype 1 showed higher viral load when compared to those infected with genotype 4 (p = 0.048, t-test). Younger HCV-infected individuals (< 52 years) had higher ALT levels compared to older individuals (p = 0.036, t-test). Self-reported risk factors for HCV acquisition included: history of previous surgery, invasive dental procedures, and blood transfusion, delivery at home, circumcision at home and wet cupping therapy (hijama). Conclusions High genetic diversity of HCV was found in Jordan, with genotypes 4 and 1 as the most prevalent genotypes co-circulating in the country. Potential impact of virus genotype on disease markers (viral load, ALT) was detected and needs further assessment. The study can be helpful to plan for future prevention and management of HCV infection in Jordan.
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Affiliation(s)
- Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan. .,Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan. .,Department of Translational Medicine, Faculty of Medicine, Lund University, 22100, Malmö, Sweden.
| | - Rawan Batarseh
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Anas Natsheh
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan.,Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Jumana Abbadi
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan.,Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Esraa Al-Fraihat
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan.,Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Alaa' Yaseen
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Doaa Kaddomi
- Gastroenterology and Liver Division, Department of Internal Medicine, Jordan University Hospital, Amman, 11942, Jordan
| | - Nadia Khamees
- Gastroenterology and Liver Division, Department of Internal Medicine, Jordan University Hospital, Amman, 11942, Jordan
| | - Azmi Mahafzah
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, the University of Jordan, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan.,Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Queen Rania Al-Abdullah Street-Aljubeiha, /P.O. Box: 13046, Amman, 11942, Jordan
| | - Gülşen Özkaya Şahin
- Department of Translational Medicine, Faculty of Medicine, Lund University, 22100, Malmö, Sweden.,Department of Clinical Microbiology, Laboratory Medicine, Skåne University Hospital, 22100, Lund, Sweden
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Li M, Zhuang H, Wei L. How would China achieve WHO's target of eliminating HCV by 2030? Expert Rev Anti Infect Ther 2019; 17:763-773. [PMID: 31578079 DOI: 10.1080/14787210.2019.1675509] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Hepatitis C virus (HCV) infection is a major global health concern on the rise, prompting unprecedented efforts by the World Health Organization (WHO) to eliminate this epidemic by 2030. Being the country with the largest HCV-infected population in the world, China has been faced with a general lack of awareness for HCV, low treatment uptake and subpar collaborations among healthcare providers and stakeholders. Areas covered: This review discusses the epidemiological situations of HCV infection and the challenges in HCV management in China. This review also explores micro-elimination strategies in China, identifying potential sub-populations for concerted efforts in eliminating HCV. As DAAs are increasingly recognized as a more effective alternative to traditional regimens, the cost-effectiveness and budget impacts of bringing more DAAs into the reimbursement lists are also addressed. Several small-scale targeted literature searches were conducted in PubMed for various topics covered in the article, and hand searching was performed to fill any data gaps. More recent data were used wherever possible. Expert opinion: Considering the unique socioeconomical landscape of China, micro-elimination strategies might be more effective and should be targeted at high-risk populations. Varying regional needs in HCV care across the country necessitate decentralized approaches in research and policy-making.
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Affiliation(s)
| | - Hui Zhuang
- China Liver Health , Beijing , China.,Department of Microbiology and Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center , Beijing , China
| | - Lai Wei
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University , Beijing , China
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Generic sofosbuvir/ledipasvir for the treatment of genotype 4 chronic hepatitis C in Egyptian children (9–12 years) and adolescents. Hepatol Int 2019; 13:706-714. [DOI: 10.1007/s12072-019-09985-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/22/2019] [Indexed: 12/15/2022]
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