Tuberculosis in the Afghan Immigrant in Kerman Province of Iran

Changes in incidence and clinical features of tuberculosis with regard to the COVID-19 outbreak in Southern Iran

INTRODUCTION

Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a significant global health threat. It results in substantial mortality and may be underrecognized due to insufficient screening and diagnostic challenges. Furthermore, TB's impact is closely linked to complex socioeconomic and healthcare factors. The COVID-19 pandemic has exacerbated these challenges due to similarities in clinical presentation and transmission dynamics with TB. Socioeconomic factors such as limited access to healthcare services, resource constraints, and social stigma further complicate TB management. Historically, TB faced increased burdens during natural disasters, wars, and pandemics. This study analyzes TB incidence changes, emphasizing the crucial need for timely diagnosis within the context of COVID-19 measures.

METHOD

This cross-sectional study, conducted at Shiraz's TB referral center in Southern Iran, covered the period from January 1, 2018, to December 31, 2022. We analyzed patient data, including epidemiological and demographic factors, clinical and radiological features, and treatment outcomes. Data were compared between the pre-COVID-19 pandemic era and the COVID-19 pandemic era (from March 2020), using standard and regression analyses. A P-value of less than 0.05 was considered statistically significant.

RESULTS

We analyzed 388 TB patients with a mean age of 48.38 ± 20.53 years, including 264 pulmonary cases (68.0%). The highest incidence of TB was recorded in 2019, representing 27.6% of the cases. During the COVID-19 era, logistic regression analysis identified significant associations with higher education levels (P = 0.032; OR = 1.380; 95% CI: 1.028-1.851), a decrease in symptoms such as sputum production (P = 0.004; OR = 0.342; 95% CI: 0.166-0.705) and chills (P = 0.036; OR = 0.282; 95% CI: 0.087-0.919), and an increase in symptoms of fatigue (P = 0.006; OR = 2.856; 95% CI: 1.358-6.005).

CONCLUSION

The COVID-19 pandemic has had a prolonged impact on TB cases in our country, resulting in a reduction in reported cases due to challenges in quarantine and screening. However, it has also led to a shift in TB patterns and a potential increase in latent TB cases and future mortality rates. Addressing the repercussions requires enhanced control strategies, prioritized service delivery, and secured funding for intensified case finding, expanded contact-tracing, community engagement, digital health tools, and uninterrupted access to medications.

Spatio-temporal epidemiology of the tuberculosis incidence rate in Iran 2008 to 2018

BACKGROUND

Effective reduction of tuberculosis (TB) requires information on the distribution of TB incidence rate across time and location. This study aims to identify the spatio-temporal pattern of TB incidence rate in Iran between 2008 and 2018.

METHODS

This cross-sectional study was conducted on aggregated TB data (50,500 patients) at the provincial level provided by the Ministry of Health in Iran between 2008 and 2018. The Anselin Local Moran's I and Getis-Ord Gi* were performed to identify the spatial variations of the disease. Furthermore, spatial scan statistic was employed for purely temporal and spatio-temporal analyses. In all instances, the null hypothesis of no clusters was rejected at p ≤ 0.05.

RESULTS

The overall incidence rate of TB decreased from 13.46 per 100,000 (95% CI: 13.19-13.73) in 2008 to 10.88 per 100,000 (95% CI: 10.65-11.11) in 2018. The highest incidence rate of TB was observed in southeast and northeast of Iran for the whole study period. Additionally, spatial cluster analysis discovered Khuzestan Province, in the West of the country, having significantly higher rates than neighbouring provinces in terms of both total TB and smear-positive pulmonary TB (SPPTB). Purely temporal analysis showed that high-rate and low-rate clusters were predominantly distributed in the time periods 2010-2014 and 2017-2018. Spatio-temporal results showed that the statistically significant clusters were mainly distributed from centre to the east during the study period. Some high-trend TB and SPPTB statistically significant clusters were found.

CONCLUSION

The results provided an overview of the latest TB spatio-temporal status In Iran and identified decreasing trends of TB in the 2008-2018 period. Despite the decreasing incidence rate, there is still need for screening, and targeting of preventive interventions, especially in high-risk areas. Knowledge of the spatio-temporal pattern of TB can be useful for policy development as the information regarding the high-risk areas would contribute to the selection of areas needed to be targeted for the expansion of health facilities.

"It is good, but I can't afford it …" potential barriers to adequate prenatal care among Afghan women in Iran: a qualitative study in South Tehran

Background

An estimated 96% of registered refugees in Iran are Afghan. Almost half of them are young women at the reproductive age. The adequate maternity care is crucial for healthy pregnancy. There is limited knowledge regarding the access and adequacy of maternity care among Afghan women in Iran. The reports from ministry of health (MOH) implicate higher prevalence of perinatal complications in Afghan population. This mainly attributed to the inadequate prenatal care during pregnancy. Therefore, this paper explores the potential barriers to prenatal care among Afghan women in Iran.

Methods

Using convenience sampling, thirty pregnant Afghan women were recruited at three community health centers with the highest number of Afghan visitors in Tehran, the capital city of Iran. Data were collected through face-to-face interviews in Persian language using an interview guide. The interviewers were two bilingual Afghan graduate midwifery students. Each interview lasted for an hour. The questions regarding the concerns and experienced obstacles in seeking prenatal care were asked. The interviews were transcribed into original language (Persian) and analyzed using content analysis and further translated back into English. The main themes were extracted grouping the similar codes and categories after careful consideration and consensus between the researchers.

Results

The financial constraints and lack of affordable health insurance with adequate coverage of prenatal care services, particularly the diagnostic and screening tests, were the most frequent reported obstacles by Afghan women. In addition, personnel behavior, transportation issues, stigma and discrimination, cultural concerns, legal and immigration issues were also mentioned as the source of disappointment and inadequate utilization of such services.

Conclusions

The findings of present study emphasize the necessity of available and most importantly, affordable prenatal care for Afghan women in Iran. Providing an affordable health insurance with adequate coverage of prenatal and delivery services, could reduce the financial burden, facilitate the access, and ensure the maternal and child health in this vulnerable population. The issues of fear and concern of deportation must be removed for at least illegal Afghan mothers to ensure their access to maternity care and improve the health of both mother and offspring.

Toll-Like Receptor 4 as an Immune Receptor Against Mycobacterium tuberculosis: A Systematic Review

OBJECTIVE

To review the main Mycobacterium tuberculosis (Mtb) pathogen-associated molecular patterns (PAMPs) and the roles played by toll-like receptor (TLR)4 in determination of Mtb infection outcome.

METHODS

Several scientific databases, including Scopus, PubMed, and Google Scholar, were used for searching appropriate research articles from the literature for information on our topic.

RESULTS

TLR4 plays positive roles in induction of immune responses against Mtb and participates in eradication of the infection. Some limited investigations approved the roles of TLR4 in induction of apoptosis in macrophages during tuberculosis (TB) and attenuation of immune responses in some situations.

CONCLUSIONS

TB outcome appears to be dependent on TLR4/Mtb interaction and several factors, including bacterial load and immune or nonimmune cells, as hosts. Also, other TLR/Mtb interactions can affect TLR4 responses.

Health-Seeking Behavior of Afghan Women Immigrants: An Ethnographic Study

Background: Nowadays, in light of gender inequity, new concern has been raised for health-seeking behavior of women in clinical setting. The aim of this study was to investigate the perceptions and health-seeking behaviors of Afghan immigrant women residing in Mashhad, Iran. Method: An ethnographic design was used to examine the health-seeking behavior of Afghan women. This study took place in Tollab Tabarsi area of Mashhad, Iran, from March 2013 to July 2014. For gathering of data, participant observations, fieldwork, and formal interviews were included. Data were analyzed using thematic analysis. Results: Fourteen Afghan women immigrants and five health care professionals were interviewed. The overarching category derived from the data was gender inequity. The emergent three themes were cultural taboos, women position, and information gap. Discussions: The displaced Afghan women were found to be at significant risk of adverse health events, which affected both their physical health and mental health.

Genetic Lineages of Mycobacterium tuberculosis Isolates in Isfahan, Iran

In this study, we aimed to identify the genetic lineages of Mycobacterium tuberculosis isolates in Isfahan via the mycobacterial interspersed repetitive-unit-variable number tandem repeat typing method based on 15 loci. Forty-nine M. tuberculosis isolates were collected between 2013 and 2015 from Tuberculosis patients in Mollahadi Sabzevari Tuberculosis Center in Isfahan. All isolates were typed by 15-locus MIRU-VNTR typing. The highest percentage of isolates, 44.89 % (22/49), belonged to the Euro-American lineage, while the frequencies of the East-African-Indian, East-Asian, and Indo-Oceanic lineages were 28.57 % (14/49), 24.4 % (12/49), and 2.04 % (1/49), respectively. Among the 22 isolates of the Euro-American lineage, those belonging to the NEW-1 sub-lineage were most prevalent (24.4 %). Approximately, the same proportion of isolates belonging to the Delhi/CAS, Beijing, and NEW-1 sub-lineages were identified in Iranian and Afghan immigrant patients. The Delhi/CAS and Beijing sub-lineage isolates were prevalent among patients who had been previously treated for TB. Results showed that all of the 49 MIRU-VNTR patterns were unique and the clustering rate of the 15-locus MIRU-VNTR was 0.0 (minimum recent transmission). The results of this study show that the lineages of M. tuberculosis isolates in Isfahan are similar to those reported in the Eastern Mediterranean region (indicative of the epidemiological relationship between the countries in the region). The low clustering rate in our results reveals that transmission of tuberculosis in Isfahan is, in most cases, a reactivation of previous tuberculosis infection and the role of recently transmitted disease is minor.

Afghan refugees’ experience of Iran’s health service delivery

Purpose

– The purpose of this paper is to explore experiences of Afghan refugees from health service delivery in Mashhad, Iran.

Design/methodology/approach

– This is a descriptive study with contextual and qualitative design. Semi-structured interview conducted with 19 Afghan refugees and their caregivers and a focus group session were held with Afghan medical science students. Purposive sampling technique was used to select participants. Data were analysed by qualitative content analysis of Graneheim and Lundman. Lincoln and Guba’s criteria were implemented to ensure trustworthiness.

Findings

– The results with the core concept of “position of immigrants in the health system” were presented at four themes of “perceived discrimination”, “snowed with loneliness”, “feeling inferior”, and “gratitude”.

Research limitations/implications

– This study has some implications for researchers and practitioners. The present study is the first study that was done on the health of Afghan refugees in Iran, therefore it can be a ground for further research. In addition, it has valuable results regarding the Afghan immigrants’ experience of health care system of Iran.

Practical implications

– It can be useful for improving the condition of immigrants in Iran and for improving Iran’s health system. In order to improve the health system in Iran, authorities should pay much attention to transcultural caring and needs of minorities. Furthermore, health workers should be trained to appropriately take care of all patients, without prejudice.

Originality/value

– Overall the study revealed that there is inequity in access to health services among Afghan refugees in Iran. The findings, although not generalized, offer important insights into health care providers in Iran which should be delivering health service without prejudice. The authors recommended that policies of public medical insurance and assistance programme should be implemented for providing affordable health care services for Afghan refugees.

Tuberculosis in women from Pashtun region: an ecological study in Pakistan

SUMMARY In general, tuberculosis (TB) is more common in men than women. However, for reasons currently not understood, women are 1.5-2 times more likely to report TB compared to men in Pashtun region (Afghanistan, adjacent provinces Pakistan and Iran). We explored whether or not gender disparity in TB notifications in the Pashtun region of Pakistan can be explained by Pashtun ethnicity. Using an ecological linear regression design, we estimated the effect of Pashtun ethnicity on female-to-male ratio (FMR) in TB notifications after adjusting for other determinants of women's health, in Pakistan. Districts with a high proportion of women of Pashtun ethnicity had a 44% (95% confidence interval 27-61) increase in FMR of notified TB cases compared to those with low proportions, after controlling for confounders. Genetic predisposition and distinct socio-cultural determinants could be possible causative factors. However, these hypotheses need further evaluation through rigorous longitudinal studies.

Lessons from the profile of kidney diseases among Afghan refugees

BACKGROUND

Due to a paucity of research on the profile of kidney diseases among refugee populations, specifically Afghan refugees in Iran, this study aimed to illustrate the pattern of kidney disease among Afghan refugees in Iran and create a database for evaluating the performance of future health services.

MATERIAL AND METHODS

This was a retrospective cross sectional study, in which we collected the demographics and profile of kidney diseases among Afghan refugees between 2005 and 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran.

RESULTS

The total number of referrals in this group of diseases was 3193 out of 23 152 with 41.5% female and 58.5% male. Regarding age distribution, 10.5% were 0-14 years of age, 78% were 15-59, and 11.5% were ≥60. The most common health referral for females and males (0-14) was end-stage renal disease (ESRD), accounting for 34.6%. This was also the main reason of referrals for females and males aged 15-59, accounting for 73.5% and 66.6%, respectively, and in both sexes in the ≥60 age range it was 63.1%.

CONCLUSIONS

The pattern of our renal clinic referrals may gradually change to ESRD, which is associated with a huge economic burden. The need to provide health insurance to everyone or reform the health care system to provide coverage for more of the population can be justified and would improve cost effectiveness.

A retrospective study of demographic parameters and major health referrals among Afghan refugees in Iran

Introduction

For nearly three decades, the two neighboring countries of Iran and Pakistan hosted millions of Afghans. Today, Afghans still represent the largest group of refugees in the world. This feature has greatly influenced provision of health care for this population. Due to a paucity of research on the health status of Afghan refugees in Iran, this study aim to make a vista on the pattern of different common diseases among Afghan refugees in Iran and use it as an index for performance evaluation of future health services to them.

Methods

This is a retrospective cross sectional study, in which we collected the demographic and medical data between 2005 and 2010 from referrals to the United Nations High Commissioner for Refugees (UNHCR) offices in Iran. We also considered a comparative review of the burden of disease estimates by the World Health Organization (WHO) for Afghanistan and Iran.

Results

Total numbers of referrals were 23,152 with 52.6% Female and 47.66% male. 29% were 0–14 years of age, 54% were 15–59, and 17% were 60+. The most common health referral for females and males (0–14) was perinatal diseases (15.16%, 15.2%, respectively). In the females (15–59) it was ophthalmic diseases (13.65%), and for males it was nephropathies (21.4%), and in both sexes (60+) age range it was ophthalmic diseases (21.3%, 19.9%, respectively). The largest ethnic group of afghan refugees in this study was Hazara (55%) followed by Tajik (14%), Fars (12%), Sadat (9%), and 10% others. Ophthalmic diseases were the major cause of referrals by Hazara, Tajik, Fars, and Sadat groups with 26%, 20%, 26%, and 27% respectively. Referrals by pashtun group were mostly for neoplasms (17%), among Uzbek group it was nephropathies (26%), and in Baluch group Hematopoietic disorders (25%).

Conclusion

These data indicate higher referral rate for women 15–59 years of old and people in 60+ with ophthalmic diseases, neoplasms, and nephropathies. Even given certain intrinsic limitations of such a study, we believe these unique findings are worth further explanation. This implies the need for public health researchers to pursue prospective studies in these areas.