Infectious diseases in the era of refugees: Hepatitis A outbreak in Lebanon

Syrian Refugees Seeking Hospital Care in Beirut: A Cross-Sectional Study of Reasons for Hospital Admissions

INTRODUCTION

Lebanon has the highest Syrian refugee density worldwide. The influx of Syrian refugees has had various impacts on Lebanon, with one of the most significant effects observed in the already exhausted healthcare system. This study aimed to determine the reasons for hospitalization among registered Syrian refugees in Beirut who were admitted to Rafik Hariri University Hospital (RHUH) between December 2017 and June 2020.

METHODS

Data from 7,480 diagnosed cases were collected from the RHUH archives between December 2017 and June 2020 and were analyzed using SPSS (IBM Corp., Armonk, NY, USA). The collected data included information related to demographics, admission date, primary diagnosis, and other related medical problems. Variations and correlations were then tested.

RESULTS

Of the cases, 73.4% were females; the mean age was 28 ± 16.23 years. Fifty-seven percent of the admitted cases were solely due to pregnancy, childbirth, and puerperium reasons, and 91.14% of the deliveries were single deliveries by cesarean section. Common reasons for hospitalization were injuries (5.8%) and diseases of the digestive system (6.8%), circulatory system (4.7%), and respiratory system (4.4%). Non-communicable diseases (NCDs) constituted 61% of all hospital admissions, while only 6.6% belonged to communicable diseases. Reasons for hospitalization and the type of diagnosed diseases were associated with gender and age groups (p-values <0.001).

CONCLUSION

The major reasons for hospitalization among Syrian refugees were related to pregnancies and NCDs. The burden of the Syrian refugee influx on the Lebanese healthcare system can be alleviated by improving community health education, public health services, and conditions for refugees.

Socio-political and organizational influences on national infectious disease surveillance for refugees: A qualitative case study in Lebanon

Infectious disease surveillance provides actionable information on displaced populations and helps identify outbreaks. Though not a signatory to the 1951 Refugee Convention, Lebanon has experienced large refugee influxes (e.g. Palestinians in 1948, Syrians in 2011), yet information on socio-political and organizational influences shaping surveillance targeting refugees is limited. We thus aimed to examine how Lebanese socio-politics affected infectious disease surveillance for refugees in Lebanon. We conducted a qualitative multimethod single case study of government engagement with refugee infectious disease surveillance (2011-2018) drawing from document analysis, semi-structured observations, and semi-structured key informant interviews at four surveillance sites in Lebanon. We analysed data thematically, using deductive and inductive coding. National politics delayed government and thus its epidemiological surveillance program's (ESU) engagement with refugee disease surveillance, largely due to Lebanon not being a 1951 Refugee Convention signatory and internal policy disagreements. Thus, it was initially difficult for the ESU to lead surveillance activities, though it later became more active. The ESU was limited by unclear reporting mechanisms and resources and its reliance on aggregated surveillance data prevented provision of data-informed responses. Though the ESU led surveillance nationally, and we identified positive provincial level collaborations due to individual efforts, some partners still conducted parallel surveillance. We found no systematic approach to infectious disease surveillance for refugees. The ESU could improve surveillance for refugees by collaborative strategic planning with partners for preparedness, surveillance, reporting, and sustainable resource allocation during refugee crises. Further suggestions include collecting disaggregated data, and piloting potentially more efficient syndromic surveillance, based on symptom clusters, for refugee populations.

Hepatitis A virus outbreak in Lebanon: Is it a matter of concern?

Lebanon has been grappling with hepatitis A virus (HAV) outbreaks for 3 decades, to an extent that it has been now termed an endemic zone for HAV. However, the rise in cases above the annual average concerns a potential outbreak in the North, and the Bekaa governorates of Lebanon must be highlighted. Although the Lebanese health authorities have ordered a probe into the possible causes of the outbreak, it has been speculated that the immigration of Syrian refugees has overburdened public health services. Reduced seroprevalence of HAV immunoglobulin G has also led to an epidemiological shift from child to adult populations. The current economic crisis affecting Lebanese society is another significant problem that could have contributed to the rise in incidents. This article examines Lebanon's current HAV outbreak and epidemiological status, offering suggestions for the future. In the event of an outbreak, the infrastructure for water sanitation and sewage is known to allow HAV to spread via the faecal-oral pathway. Maintaining personal hygiene, early detection, and vaccination have all been recommended as significant regional and individual control measures.

Emerging and Re-emerging Infectious Diseases in the WHO Eastern Mediterranean Region, 2001-2018

BACKGROUND

Countries in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) are predisposed to highly contagious, severe and fatal, emerging infectious diseases (EIDs), and re-emerging infectious diseases (RIDs). This paper reviews the epidemiological situation of EIDs and RIDs of global concern in the EMR between 2001 and 2018.

METHODS

To do a narrative review, a complete list of studies in the field was we prepared following a systematic search approach. Studies that were purposively reviewed were identified to summarize the epidemiological situation of each targeted disease. A comprehensive search of all published studies on EIDs and RIDs between 2001 and 2018 was carried out through search engines including Medline, Web of Science, Scopus, Google Scholar, and ScienceDirect.

RESULTS

Leishmaniasis, hepatitis A virus (HAV) and hepatitis E virus (HEV) are reported from all countries in the region. Chikungunya, Crimean Congo hemorrhagic fever (CCHF), dengue fever, and H5N1 have been increasing in number, frequency, and expanding in their geographic distribution. Middle East respiratory syndrome (MERS), which was reported in this region in 2012 is still a public health concern. There are challenges to control cholera, diphtheria, leishmaniasis, measles, and poliomyelitis in some of the countries. Moreover, Alkhurma hemorrhagic fever (AHF), and Rift Valley fever (RVF) are limited to some countries in the region. Also, there is little information about the real situation of the plague, Q fever, and tularemia.

CONCLUSION

EIDs and RIDs are prevalent in most countries in the region and could further spread within the region. It is crucial to improve regional capacities and capabilities in preventing and responding to disease outbreaks with adequate resources and expertise.

Epidemiology and Incidence of Retinoblastoma in the Middle East: A Nationwide Study in Lebanon

Background: Retinoblastoma, although a rare pediatric cancer, can lead to disastrous outcomes if not managed early. This mishap often happens in developing countries. Conversely, early diagnosis and treatment of retinoblastoma in developed countries were associated with a surge in RB1 gene carriers.

Aim: The authors aimed to evaluate the incidence of retinoblastoma in the Lebanese population aged between 0 and 19 years according to age, sex, and other variables and compare the age-standardized incidence rates with regional and worldwide countries.

Methods: Data were retrieved from the National Cancer Registry (NCR) of the Ministry of Public Health (MOPH). Subsequently, incidence rates, age-standardized rates, and fictional incidence rates excluding the emigrant population were calculated. Retinoblastoma trends were found using the Joinpoint regression program software.

Results: From the 38 cases of retinoblastoma recorded in the nine years cohort, 29 cases occurred in the 0-4 age group, and age-standardized rates were 2.8 and 3.6 per million person-years for the 0-19 and 0-14 age groups, respectively. When the refugee population was excluded, the ASR 0-19 almost doubled from 2.8 per million person-years to 5.16 per million person-years. Joinpoint regression revealed that retinoblastoma trends were divided into two segments showing a decrease from 2005 until 2011 and a rising trend in 2011-2015. When compared to other countries in the region, Lebanon had low-intermediate 0-19 ASRs.

Conclusion: Retinoblastoma incidence in Lebanon is in the lower margin of the worldwide average and could be underestimated due to the underdiagnosis in the refugee population. Efforts are being deployed to overcome the financial barriers in the treatment of retinoblastoma by coordinating with neighboring Arab countries.

The Burden of Communicable Diseases in Lebanon: Trends in the Past Decade

The present study aims to review the main communicable diseases that experienced an upsurge in the past decade in Lebanon and to highlight the reasons behind this increase. Data of reported communicable diseases from 2010 till 2019 were obtained from the Lebanese Ministry of Public Health (LMOPH) epidemiological surveillance database. Tuberculosis, measles, mumps, leishmaniasis, and hepatitis A were the main communicable diseases that showed a sharp increase in the past 10 y. Measles outbreaks occurred in 2013 and 2018, leishmaniasis outbreak in 2013, and mumps and hepatitis A outbreaks in 2014. The highest percentages of reported diseases were from Beqaa and North governorates. The massive influx of Syrian refugees to Lebanon, together with the poor water management system, poor sanitation, deprived living conditions, and limited health-care access in rural areas might have contributed to the upsurge of communicable diseases. Although the LMOPH succeeded in containing the outbreaks, further efforts are needed to improve the identified gaps to avoid future outbreaks.

Factors influencing the occurrence of infectious disease outbreaks in Lebanon since the Syrian crisis

Since the beginning of the Syrian crisis in 2011, the region has witnessed a major population displacement. Lebanon, a country with a population of 4.2 million, has welcomed around one million refugees. A rise in the incidence of Measles, Hepatitis A and Leishmaniosis was noted. This paper aims to document the incidence of outbreaks along with the factors that contributed to their emergence in Lebanon. A comprehensive literature review was conducted using electronic databases and (non) governmental reports, including studies reporting the state of Syrian refugees in Lebanon and those reporting on infectious outbreaks in Lebanon and Syria. Primary outcomes were defined as incidence or prevalence of Measles, Hepatitis A, and Leishmaniosis in both populations. Secondary outcomes were set to be the risk factors for the outbreaks. As of February 2016, Lebanon registered a total of 1.067.785 refugees. Infectious outbreaks were reported in Lebanon just after initiation of Syrian migration, with 1760 new measles cases, 1551 hepatitis A cases, and 1033 Leishmania cases in 2013. Local factors probably contributing to the emergence and dissemination of the outbreaks include living conditions, water and sanitation, nutritional state, and immunization. The outbreaks were not only reported in regions with higher refugee concentration, but also within other Lebanese regions. This was attributed to deficiencies in immunization of measles, low socioeconomic status and poor living conditions. The Syrian crisis has led to considerable impact on the demographic, economic, and political systems in Lebanon, next to an important burden on the healthcare system.

First Nation-Wide Analysis of Food Safety and Acceptability Data in Lebanon

The challenges to food safety in Lebanon are numerous and have coalesced to pose a serious public health concern. This is evident in well-documented food poisoning outbreaks and adulteration cases. In response, the Lebanese government initiated an unprecedented food safety campaign (2015–2017) that aimed to test food samples that were randomly collected from foodservices and industries across the country. The data were made available publicly, but they were never analyzed to prioritize and determine high risk foods and most prevalent contaminants nationally or across governorates. To answer these questions, we performed an in-depth statistical analysis of the data, which included 11,625 individual food samples. Our analysis showed that water (55% of tested water samples), spices (49.3%), red meat (34.4%), poultry (30.9%) and dairy (28.3%) were the main foods associated with the highest rejection rates. The most common biological contaminants detected in rejected foods were sulfate-reducing bacteria (34.7%), Escherichia coli (32.1%), coliforms (19.6%), Staphylococcus aureus (12.8%), and Salmonella (11.6%). We conclude that Lebanon needs rigorous and sustainable programs to monitor the quality and safety of foods. Given the lack of resources, we recommend putting emphasis on extensive outreach programs that aim at enhancing food safety knowledge from farm to fork.

Social networks and health-promoting behaviors among North Korean refugees in South Korea

Poor health behaviors among North Korean refugees (NKRs) in South Korea are serious risk factors hindering their overall well-being. Despite their significance, little is known about the roles of social networks in promoting health behaviors of NKRs. Thus, we examined how social network characteristics were associated with health-promoting behaviors among 202 NKRs. We found that social networks featuring members of religious organizations were positively associated with overall health-promoting behaviors, health responsibility, exercise, and nutrition, whereas networks with South Korean friends were negatively associated with nutrition. Findings suggest that health interventions facilitating religion-based network ties may promote health behaviors among NKRs.

Effect of Leishmaniasis on the Performance of Elementary School Students: A Case Study among Syrian Refugees in Some Bekaa (Lebanon) Area Schools

Since the Syrian conflict started, Lebanon became a common destination receiving a huge number of Syrian refugees that are living in camps spread all over the country, with the largest concentration in the Bekaa Valley. Generous steps are being taken to increase the access to formal education, such as offering free public education and opening second shifts in the public schools in the afternoon. Yet barriers, such as child labor and health-related factors like the spreading of some communicable diseases, like Leishmania, are keeping children out of classroom. The present study was done with the aim of investigating the effect of leishmaniasis on the performance and the academic achievement of Syrian refugee children. The results showed varying degrees of knowledge and dealing with the case of leishmaniasis. The disease clearly had an effect on the students’ attendance in schools, and by proxy on their academic performance.

Hepatitis A: Epidemiology, Natural History, Unusual Clinical Manifestations, and Prevention

Hepatitis A virus (HAV) is a positive-strand RNA virus that is transmitted feco-orally through person-to-person contact. Outbreaks are often linked to poor sanitation, overcrowding, or food and water contamination. Infection is often asymptomatic in children, but adults present with jaundice, abdominal pain, hepatitis, and hyperbilirubinemia. Diagnosis is through detection of immunoglobulin M antibodies against HAV, and treatment is supportive. Vaccination is the mainstay of prevention and should be given before exposure whenever possible.

Epidemiology of hepatitis A in Greece in the last decade: management of reported cases and outbreaks and lessons learned

Hepatitis A is a mandatory notifiable disease in Greece. Here, we present the epidemiological data for 2009-2018 and the results of outbreak investigations performed, and discuss future public health priorities.Overall, 1193 cases were reported; 320 migrants/refugees, 240 Roma, 112 travellers and 521 from the general population. The median age of the affected general population (37 years) had an increasing trend (from 30.8 years in 2009 to 40.5 in 2018, P < 0.001) and was significantly higher than that among Roma and migrants (7 and 8 years, respectively, P < 0.001). Twenty-two cases (2.2%) were unvaccinated patients with a chronic liver disease. Fifty clusters with 2-12 cases each were recorded; 44 were attributed to person-to-person transmission and six to food consumption. Three outbreaks accounting for 32.3% of the total number of recorded cases were identified; in 2013 among Roma (112 cases), in 2016 among refugees (188 cases) and in 2017 among men having sex with men (96 cases; 33 of them (34.4%) HIV-positive). The epidemiological data depict that improving living conditions and vaccination coverage of deprived populations, and informing adults on the disease focusing at faecal-oral transmission during sexual intercourse and travel should be the future public health priorities.

Medical schools in times of war: Integrating conflict medicine in medical education

Amid the rise in conflict and war and their ensuing repercussions, traumatic injuries, psychological distress, and communicable diseases spread widely. Today, health-care providers in the Middle East are faced with new and unfamiliar cases resulting from the use of new and advanced types of weapons. In addition, there has not been enough emphasis on hands-on experiences in medical school, which can be imperative in times of war. Lack of academia is another inadequacy that limits the transmission of knowledge onto the newer generations. Here, we will shed light on the inadequacies in medical curricula in the Middle East when it comes to addressing patients of war. We also call for action to advance medical education in war-ridden areas by incorporating "conflict medicine" as an integral module in medical curricula.

Breast Cancer Epidemiology among Lebanese Women: An 11-Year Analysis

Background and Objectives: Breast cancer is the most prevalent cancer in women worldwide. Lebanon is a developing country in the Middle East with a prominent breast cancer incidence. The aim of our study was to explore the incidence rates of breast cancer in Lebanon from 2005 to 2015, and compare them to the rates of other countries. Materials and Methods: Breast cancer data for the years 2005-2015 was collected from the National Cancer Registry of Lebanon and stratified by gender and age group. Age-specific and age-standardized incidence rates were calculated and analyzed using joinpoint regression. Age-standardized incidence rates in the world population (ASR(w)) were obtained for other countries, from two online databases. Results: Breast cancer was found to be the most prevalent cancer in Lebanon, accounting for 20% of all cancer cases. The average ASR(w) was 96.5 per 100,000. Over the studied period, breast cancer ASR(w) in Lebanon showed a significantly increasing trend with an annual percent change (APC) of +4.6. Moreover, the APC of breast cancer age-specific rates significantly increased for the age groups 45-49 (p = 0.013), 50-54 (p < 0.001), 55-59 (p = 0.001), 60-64 (p = 0.002), 65-69 (p = 0.003), 70-74 (p < 0.001), and 75+ years (p < 0.001). Lebanon had the highest breast cancer ASR(w), when compared to other regional countries, and trailed only behind Denmark, when compared to selected countries from different parts of the world. Conclusions: Breast cancer incidence in Lebanon is among the highest in the world. Future studies should focus on exploring the genetic profile of the Lebanese population in an aim to extrapolate proper prevention guidelines.