Strengthening Primary Healthcare in Jordan for Achieving Universal Health Coverage: A Need for Family Health Team Approach

Achieving Universal Health Coverage (UHC) is a strategic objective of the Jordanian government and has been prioritized in its strategies and plans. However, there are several challenges affecting primary healthcare in Jordan and the health system in general that prevent Jordan from achieving UHC. This paper highlights the importance of team-based care in the form of Family Health Teams (FHTs) to realize Jordan's goal of achieving UHC. FHTs are a team-based approach that brings together diverse professionals to provide a comprehensive, efficient, patient-centered primary care system that meets the changing needs of Jordan's population and refugees. However, the implementation of FHT may encounter obstacles, including individual, organizational, institutional, and external barriers. To overcome such obstacles, several actions and processes need to be taken, including political commitment and leadership, implementing good governance and policy frameworks, allocating resources and funding, multisectoral collaboration, and engagement of communities and stakeholders. The successful implementation of FHTs requires participation from government officials, parliamentarians, civil society, and influential community, religious, and business leaders. A strategic policy framework, effective oversight, coalition building, regulation, attention to system design, and accountability are also essential. In conclusion, adopting the FHT approach in Jordan's Primary Healthcare system offers a promising path towards achieving UHC, improving healthcare access, quality, and efficiency while addressing the unique challenges faced by the country's healthcare system.

Barriers to the HPV vaccination program in the Eastern Mediterranean region: a narrative review

Objective

The human papillomavirus (HPV) vaccine is regarded as one of the most effective ways of preventing cervical cancer. Despite the massive burden of this disease, only two countries in the Eastern Mediterranean Region (EMR) have implemented a national HPV vaccination program. The aim of the present study was to assess the main barriers to the integration of HPV vaccination in the national vaccination programs of EMR countries.

Material and Methods

We performed a narrative review with no inclusion and exclusion criteria. The electronic databases we searched included Medline, Scopus, Embase, and Web of Science (last update; December 2021). The search was not subject to any limitation in terms of time or method. Studies that dealt with the obstacles or the needs of vaccination programs in EMR countries were included in the investigation.

Results

After a full-text screening, the report comprised of 31 studies from 15 EMR countries. All of the studies were descriptive. The most common barriers to HPV vaccination are the following: a) lack of knowledge and awareness, b) economic barriers in terms of the cost-effectiveness of the HPV vaccination program, c) social insecurity in conflict zones, d) cultural norms and religion.

Conclusion

EMR countries should focus on modifiable barriers to the vaccination program. Steps to improve HPV vaccination coverage in these countries should include enhancing social awareness and mobilization, ensuring the support of the Global Alliance for Vaccines and Immunization in eligible countries, using national resources in an optimal way, and addressing HPV vaccination in undergraduate medicine and paramedic curriculums.

Perception and satisfaction of nephrology education and training in Iraq

BACKGROUND

Interest in training in nephrology is declining around the world. This is a particularly worrisome issue for future nephrology practice with the aging population and the increasing number of patients with kidney disease. We wished to understand the perception and measure the satisfaction of Iraqi medical interns regarding nephrology and explore factors affecting career decisions towards becoming a specialist nephrologist.

METHODS

A web-based authors-constructed survey consisting of a Likert-type scale questionnaire to assess perception and satisfaction was used. It comprised multiple-choice yes/no/maybe questions and addressed the willingness to pursue a career in nephrology. Iraqi medical interns in their final 2 years of training, 2021-2022, were assessed.

RESULTS

One hundred and twenty internal medicine Iraqi fellows participated in the survey (response rate 84.2%). Sixty-eight fellows (74%) described nephrology as a complex science. Acid-base and electrolytes disorders and transplantation were the most challenging topics, followed by glomerular diseases. Twenty-one fellows (23%) were satisfied with the quality of training and nephrology education during their medical school, residency and internship. In addition, 14% stated that they would pursue a future career in nephrology. The most selected barrier (34%) against choosing nephrology was a fellow's perception of the patient's complexity and the potentially futile outcome.

CONCLUSION

The majority (76%) of Iraqi medical interns are currently not satisfied with nephrology training and education. One in seven would pursue a future career in nephrology. New targeted innovative approaches are urgently needed for the various grades of trainees to highlight the benefits of nephrology as a career.

Assessing knowledge, attitudes, and practices toward sexually transmitted infections among Baghdad undergraduate students for research-guided sexual health education

Background

Sexually transmitted infections are common and tend to cause a lot of public misconceptions. This study was conducted to identify knowledge gaps and negative attitudes toward sexually transmitted infections and infected individuals among undergraduate students and give recommendations accordingly for the development of more objective research-guided health campaigns and school sex education programs.

Method

A cross-sectional study was conducted between May 17, 2022 and June 2, 2022 using a self-administrated questionnaire containing 84 items related to sexually transmitted infections distributed online to Baghdad-based university students.

Result

The sample consisted of 823 respondents; 332 men and 491 women. Overall knowledge was moderate to high, with 628 individuals (76.3%) answering more than half the questions correctly. There was no difference according to gender or previous sexual experience, but knowledge increased by an average of 2.73 points (p < 0.001) when a participant knew a previously infected individual. Less than half identified systemic symptoms of STIs, and their knowledge of other HIV items was also poor. Most respondents (85.5%) agreed to the need for sex education during middle or high school and cited traditional barriers as the most critical barrier (64.8%); in comparison, those who did not agree on its need cited the sensitivity of the subject (40.3%) or religious barriers (20.2%) as more important.

Conclusion

Specific knowledge gaps exist for HIV and non-HIV sexually transmitted infections; these should be addressed during sex education, focusing on specific high-risk groups. Negative attitudes and stigmatizing behavior should be addressed as well by increasing focused STI knowledge.

Barriers to the HPV Vaccination Program in the Eastern Mediterranean Region: A Narrative Review

The human papillomavirus (HPV) vaccine is regarded as one of the most effective ways of preventing cervical cancer. Despite the massive burden of this disease, only two countries in the Eastern Mediterranean Region (EMR) have implemented the HPV vaccination program. The aim of the present study was to assess the main barriers to the integration of HPV vaccination in the national vaccination programs of EMR countries. We performed a narrative review with no inclusion and exclusion criteria. The electronic databases we searched included Medline (PubMed), Scopus, Embase, and Web of Science (last update December 2021). The search was not subject to any limitation in terms of time or method. Studies that dealt with the obstacles or the needs of vaccination programs in EMR countries were included in the investigation. After a full-text screening, the report comprised 31 studies from 15 EMR countries. All of the studies were descriptive. The most common barriers to the HPV vaccination are the following: a) lack of knowledge and awareness, b) economic barriers in terms of the cost-effectiveness of the HPV vaccination program, c) social insecurity in conflict zones, d) cultural norms and religion. EMR countries should focus on modifiable barriers to the vaccination program. Steps to improve HPV vaccination coverage in these countries should include enhancing social awareness and mobilization, ensuring the support of the GAVI Alliance (Global Alliance for Vaccines and Immunization) in eligible countries, using national resources in an optimal way, and addressing the HPV vaccination in undergraduate medicine and paramedic curriculums.

Costs of childhood vaccine delivery in Iraq: a cross-sectional study

OBJECTIVES

In recent years, Iraq has expanded and revised the childhood immunisation schedule, but estimates of the costs of the programme are unavailable. The objective of this study was to estimate the economic costs of delivering childhood vaccines in Iraq from a government perspective.

SETTING

Health facilities were sampled using multistage probabilistic sampling and stratifying the country into three regions: Central and South, North/Kurdistan Region, and Retaken Areas. Cost data were collected from 97 health facilities and 44 district and regional vaccine stores. Total national costs were extrapolated using sample weight calibration.

PARTICIPANTS

Administrators at each health facility and vaccine store were interviewed using a standardised survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total costs of vaccine delivery per year, costs per dose delivered and delivery costs per fully vaccinated child.

RESULTS

An estimated 15.3 million vaccine doses were delivered in 2018, costing US$99.35 million, excluding costs of vaccines and injection material. Nearly 90% of delivery costs were attributed to personnel salaries. Vaccine record-keeping and management (21%) and facility-based vaccine delivery (19%) were the largest cost contributors. Vaccine transport and storage, programme management, and outreach services represented 13%, 12% and 10%, respectively. All other activities represented less than 10% of the total cost. Average costs per dose delivered was US$6.48, ranging from US$9.13 in Retaken Areas to US$5.84 in the Central and South. Vaccine delivery costs per fully vaccinated child totalled US$149.

CONCLUSION

This study provides baseline evidence of the current programme costs and human resource uses which can be used for annual planning, identifying areas for improvement, and targeting strategies to increase programme efficiency.

Trends in the Incidence and Mortality of the Most Common Cancers in Iraq (Iraqi Cancer Registry 1999-2019)

Cancer is the second leading cause of death in Iraq following heart and cerebrovascular diseases. Assessment of incidence and mortality trends is essential for prioritizing cancer control in the national health policies and plans.

AIM

To determine the patterns and trends in the incidence and mortality of the leading types of cancers affecting the Iraqi population during the last two decades.

MATERIAL AND METHODS

This is a descriptive retrospective study based on the available data of the Iraqi Cancer Registry for the years (1999 - 2019). The analyzed information included the annual total number of new cancer cases and cancer deaths during the assigned period categorized by site, age, gender and morphology of each cancer. The data was coded according to Cancer Registry Program 4 (Can Reg4) and the International Classification of Diseases for Oncology (ICD-O). The estimated total annual number of Iraqi populations for the same period was retrieved from the Iraqi Ministry of Planning. The incidence and mortality rates were calculated per 100,000 Iraqi population and classified by ICD-O, site of the tumor, gender and age group.

RESULTS

The overall cancer incidence rate (IR) in 2019 was 91.66/100,000 population (78.14 and 105.46/100,000 in males and females, respectively). The age standardized rate (ASR) was 155.60/100,000. The top five cancers in terms of IR were those of the breast (18.17/100,000; ASR:29.93/100,000), lung (7.24/100,000; ASR:14.81 /100,000), colorectum (5.95/100,000; ASR:10.77 /100,000), brain/CNS (5.83/100,000, ASR:8.39/100,000) and leukemia (5.05/100,000; ASR:6.83/100,000). The peak IR was observed among patients of both genders in the eighth decade of life (1127.37/100,000). The trend of IR for all cancers has significantly increased from 43.95/100,000 in 1999 to 91.66/100,000 in 2019 (more than 100%, p < 0.0001). The highest increase was demonstrated in cancers of the colorectum (from 1.2 to 5.90, p< 0.001), breast (from 6.6 to 18.2, p< 0.001) and brain (from 2.0 to 5.80, p=0.032). On the other hand, the mortality rate (MR) was 28/100,000 population in 2019 (28.45 and 27.55/100,000 in males and females, respectively). The highest MR was observed in cancers of the lung (4.48/100,000), breast (3.16/100,000) and leukemia (2.42/100,000). Whereas a non-significant increase in the mortality trends of leukemia, colorectum, breast and lung cancers were noted, our data revealed a decline in the trend of brain/CNS cancer mortality (from 3.2 to 2.3/100,000).

CONCLUSIONS

The top leading cancers in Iraq are steadily increasing in upward trends though they remain lower than the global rates. The underestimated IRs and MRs are possibly attributed to suboptimum registration and missing data due to the lack of a national surveillance system. Efforts should be directed to prioritize the adoption of the national cancer control plan focusing on strengthening the population-based cancer registry.

KEY WORDS

Trends, incidence; mortality, Iraq; common cancers.

Evaluation of dedicated COVID-19 hospitals in the pandemic response in Iraq: pandemic preparation within a recovering healthcare infrastructure

The purpose of this study is to evaluate Iraq’s health facility preparedness for the surge of hospitalised cases associated with the ongoing COVID-19 pandemic. In this article, we review pandemic preparedness at both general and tertiary hospitals throughout all districts of Iraq. COVID-19 pandemic preparedness, for the purpose of this review, is defined as: (1) staff to patient ratio, (2) personal protective equipment (PPE) to staff ratio, (3) infection control measures training and compliance and (4) laboratory and surveillance capacity. Despite the designation of facilities as COVID-19 referral hospitals, we did not find any increased preparedness with regard to staffing and PPE allocation. COVID-19 designated hospital reported an increased mean number of respiratory therapists as well as sufficient intensive care unit staff, but this did not reach significant levels. Non-COVID-19 facilities tended to have higher mean numbers of registered nurses, cleaning staff and laboratory staff, whereas the COVID-19 facilities were allocated additional N-95 masks (554.54 vs 147.76), gowns (226.72 vs 104.14) and boot coverings (170.48 vs 86.8) per 10 staff, but none of these differences were statistically significant. Though COVID-19 facilities were able to make increased requisitions for PPE supplies, all facility types reported unfulfilled requisitions, which is more likely a reflection of global storage rather than Iraq’s preparedness for the pandemic. Incorporating future pandemic preparedness into health system strengthening efforts across facilities, including supplies, staffing and training acquisition, retention and training, are critical to Iraq’s future success in mitigating the ongoing impact of the ongoing COVID-19 pandemic.

Impact of COVID-19 on Affected Individuals in Iraq Focusing on Deceased Cancer Patients

Mortality because of COVID-19 infections is continuously increasing among the high-risk groups, namely, elderly patients and those with underlying comorbidities including cardiovascular diseases, diabetes, respiratory problems, and cancer. The study aimed to assess the impact of COVID-19 on affected individuals in Iraq, focusing on the characteristics of COVID-19 deceased cases, with special emphasis on cancer as the associated comorbidity.

About 70% of patients who died from COVID-19 infection in Iraq had associated comorbidities. Those with history of cancer were younger and spent significantly longer duration in the hospital.

Public health workers' knowledge, attitude and practice regarding COVID-19: the impact of Field Epidemiology Training Program in the Eastern Mediterranean Region

BACKGROUND

This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained).

METHODS

Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs.

RESULTS

Overall, 1337 PHWs participated, with 835 (62.4%) < 40 years of age, and 851 (63.6%) males. Of them, 423 (31.6%) had FETP, including that 189 (44.7%) had advanced level, 155 (36.6%) intermediate and 79 (18.7%) basic level training. Compared with non-FETP trained, FETP trained were older, having higher KAP scores. FETP participation was low in infection control, and PH laboratories. KAP mean scores for intermediate level attendees are comparable to advanced level.

CONCLUSIONS

FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

Mobility indicators and COVID-19 growth ratio in Iraq: a correlation study

BACKGROUND

There is no prior study of the effect of mobility-limiting measures on the occurrence of COVID-19 in Iraq.

OBJECTIVES

To determine the relationship between publicly available mobility index data and the growth ratio (GR) of COVID-19.

METHOD

We used Google COVID-19 Community Mobility Reports to extract Iraq's mobility data and the official Ministry of Health COVID-19 statements. We used the data to calculate the Pearson's correlation coefficient and fit a linear regression model to determine the relationship between percentage change from the baseline in the mobility indices and the GR of COVID-19 in Iraq.

RESULTS

There was a moderate positive correlation between each of the mobility indices except the residential index and COVID-19 GR in Iraq. The general linear model indicated that as each of the mobility indices increases by one unit, the GR of COVID19 increases by 0.002-0.003 except for the residential index. As the residential mobility index increases by one unit, the GR decreases by 0.009. All the findings were statistically significant (P-value < 0.0001).

CONCLUSION

Mobility-limiting measures may be able to reduce the growth rate of COVID-19 moderately. Accordingly, mobility-limiting measures should be combined with other public control measures particularly mass mask use.

Resilience of health systems in conflict affected governorates of Iraq, 2014-2018

Objectives

The objective of this study was to assess the resilience of health systems in four governorates affected by conflict from 2014 to 2018, and to convey recommendations.

Methods

Health managers from Al Anbar, Ninawa, Salah al-Din, and Kirkuk governorates discussed resilience factors of Primary Health Care services affected by the 2014–2017 ISIS insurgency in focus groups, and general discussions. Additional information was gathered from key informants and a UNICEF health facility survey. Three specific aspects were examined: (1) meeting health needs in the immediate crisis response, (2) adaptation of services, (3) restructuring and recovery measures. Data from a MoH/UNICEF national health facility survey in 2017 were analyzed for functionality.

Results

There were many common themes across the four governorates, with local variations. (1) Absorption The shock to the public sector health services by the ISIS invasion caught health services in the four governorates unprepared, with limited abilities to continue to provide services. Private pharmacies and private clinics in some places withstood the initial shock better than the public sector. (2) Adaptation After the initial shock, many health facilities adapted by focusing on urgent needs for injury and communicable disease care. In most locations, maternal, neonatal, and child health (MNCH) preventive and promotive PHC services stopped. Ill persons would sometimes consult health workers in their houses at night for security reasons. (3) Restructuring or transformative activities In most areas, health services recovery was continuing in 2020. Some heavily damaged facilities are still functioning, but below pre-crisis level. Rebuilding lost community trust in the public sector is proving difficult.

Conclusion

Health services generally had little preparation for and limited resilience to the ISIS influx. Governorates are still restructuring services after the liberation from ISIS in 2017. Disaster planning was identified by all participants as a missing component, as everyone anticipated future similar emergencies.

Iraq experience in handling the COVID-19 pandemic: implications of public health challenges and lessons learned for future epidemic preparedness planning

Background

Iraq has been exceptionally challenged by the COVID-19 pandemic due to the already exhausted healthcare system.

Objectives

To describe the epidemiological situation of COVID-19 in Iraq, the government’s response to the pandemic, and provide recommendations for further action.

Methods

A desk review of secondary data using the available reports on the epidemiological situation in Iraq as well as official governmental sources was conducted.

Results

The major surge in the number of COVID-19 cases occurred in the first week of June and continued to increase dramatically until mid-October when a significant decrease happened. With a few exceptions, the reproductive number R has been consistently above 1. Patients aged 30–39 years (25.6%) were the most affected, while those aged 60–69 years (26.7%) had the highest deaths rates. Iraq tried to contain the pandemic through several regulations: border control, enforcing curfew, mask-wearing, and social distancing, COVID-19 isolation centers, expanding lab capacity, contact tracing, as well as several supportive economic measures. However, the extent of implementing these regulations is questionable.

Conclusion

Additional administrative and scientific measures with special emphasis on handling mass gathering, coordination with media and better training of healthcare workers particularly on infection prevention and control.

Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean Region: a multi-country study

Background

Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors.

Methods

A multi-country cross-sectional study was conducted during July–August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21).

Results

A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants’ residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores.

Conclusions

Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: A Multicountry Retrospective Study

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region (EMR) necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of COVID-19 patients.

OBJECTIVE

This study aimed to assess the patterns of COVID-19 severity and mortality in seven countries and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multi-country study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study included data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (HT) (24.7%) and diabetes (22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirmed the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: Multicountry Retrospective Study (Preprint).. [DOI: 10.2196/preprints.32831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19.

OBJECTIVE

This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

Impact of Modifiable Risk Factors on the Occurrence of Cutaneous Leishmaniasis in Diyala, Iraq: Case-Control Study

BACKGROUND

In 2018, an outbreak of cutaneous leishmaniasis (CL) occurred in Diyala Province in Iraq. Several risk factors of CL were identified in a prior study; however, the impact of removing modifiable risk factors on the occurrence of the disease was not measured.

OBJECTIVE

The aim of this study is to measure the impact of removing modifiable risk factors of CL on the occurrence of the disease.

METHODS

We conducted a population-based unmatched case-control study in two conveniently selected districts in Diyala Province. All cases of CL were included. Controls were chosen preferentially according to the site where the cases occurred. A structured questionnaire was used to collect data. The unadjusted odds ratios (ORs) and 95% confidence intervals for each risk factor were calculated using binary logistic regression. We also calculated the attributable fractions and 95% confidence intervals of the modifiable risk factors. A P value <.05 was considered statistically significant.

RESULTS

Data from 844 persons (432 cases, 51.2%) were analyzed. Cases were more likely than controls to report a history of previous displacement (OR 5.18, 95% CI 3.84-6.98), electricity supply for less than 12 hours per day (OR 1.94, 95% CI 1.47-2.55), living in a rural area (OR 1.91, 95% CI 1.45-2.51), living in a clay house (OR 2.41, 95% CI 1.59-3.66), having an unpainted indoor living space (OR 2.14, 95% CI 1.51-3.02), having rodents inside the house (OR 5.15, 95% CI 3.56-7.47), having chickens, sheep, or both (OR 3.44, 95% CI 2.48-4.75), having a mixture of dogs and sheep or of dogs and chickens within a distance of less than 100 meters (OR 3.92, 95% CI 2.59-5.94), fogging (OR 2.11, 95% CI 1.40-3.19), bed net use (OR 1.72, 95% CI 1.08-2.72), and sleeping outside or a mixture of inside and outside (OR 4.01, 95% CI 1.32-12.19). The data show that the exposure of approximately 70% to 80% of cases was associated with displacement, the presence of rodents inside the house, the presence of animals within 100 meters of the house, the presence of animals (chickens/sheep/both or a mixture of dogs and sheep or of dogs and chickens), and sleeping outside. Approximately 40%-50% of the cases reported living in a clay house, living in a rural area, having an unpainted indoor space, having an electricity supply for less than 12 hours, and using a bed net.

CONCLUSIONS

Prevention and control of CL requires a multifaceted approach that relies on changing environmental conditions, housing conditions, and human behavior. Fogging and bed net use were not effective because the underlying housing characteristics and human behavior provided a good culture for the disease. We recommend conducting a study to identify the species, reservoirs, and vectors of CL in Iraq; studying vector behaviors before applying environmental control measures; and educating the public on how and when to use bed nets as well as how to accompany their use with behavioral changes.

Real-Time Surveillance of Infectious Diseases, Injuries, and Chronic Conditions During the 2018 Iraq Arba'een Mass Gathering

The Arba'een pilgrimage in Iraq is now the largest annual gathering in a single place worldwide. To monitor and address the health needs of pilgrims in field clinics near the pilgrimage route, a syndromic surveillance system was designed and implemented by Global Health Development/Eastern Mediterranean Public Health Network in collaboration with Iraq Ministry of Health. This study aimed to analyze the effectiveness of the surveillance system and the data it gathered in evaluating the burden of common acute and infectious conditions, chronic conditions, and trauma and injuries during the Arba'een pilgrimage in 2018. Data were collected at 152 field clinics located across 11 governorates in Iraq at strategic points along the Arba'een pilgrimage route from all governorates to Karbala between October 8 and November 3, 2018. A team of 24 surveillance supervisors trained, oversaw, and provided technical support for 304 data collectors. The data collectors recorded data from 338,399 patients (42.5% female and 57.5% male) in the span of 26 days. The vast majority of patients were from Iraq (n = 294,260, 87.6%) and Iran (n = 34,691, 10.3%). Of the 338,399 patients whose data were recorded by the surveillance system, 246,469 (72.8%) reported acute and infectious conditions, 202,032 (59.70%) reported chronic conditions, and 6,737 (2.0%) reported traumas and injuries. Many patients reported several conditions in multiple categories. The most prevalent acute condition treated was influenza-like illness, identified through patients exhibiting a combination of fever and cough symptoms. Findings from this study will help inform future planning efforts so healthcare workers can be better prepared for treating such cases at mass gatherings. With the latest challenges posed by the COVID-19 pandemic, preparations for a possible future outbreak of the novel coronavirus are also discussed. The information from this study serves as a foundation to inform and optimize future planning of wide-scale surveillance efforts and address challenges in health service delivery and health security.

Injuries Reported by Selected Health Facilities During the Arbaeenia Mass Gathering at Babel Governorate, Iraq, 2014: Retrospective Records Analysis

BACKGROUND

Arbaeenia is the largest religious mass gathering in Iraq. The conditions associated with mass gatherings result in high rates of injury. There have been no prior studies on injuries during the Arbaeenia mass gathering.

OBJECTIVE

This study describes the injuries observed during the Arbaeenia mass gathering in Babel Governorate in Iraq between November 24 and December 14, 2014.

METHODS

The study was conducted in Babel Governorate at the emergency departments of six public hospitals and two major temporary medical units that were located along the three roads connecting the Middle and Southern Iraqi governorates. We used the Iraq Injury Surveillance System modified form to collect information on injured patients treated in the selected facilities. Data on fatal injuries was obtained from the coroner's office. The following data were collected from the patients: demographics, outcome of injury, place and time of occurrence, mode of evacuation and medical care before arriving at the hospital, duration of travel from place of occurrence to hospital, disposition of non-fatal injury, cause and mode of injury, and whether the injury occurred in connection with the Arbaeenia mass gathering.

RESULTS

Information was collected on 1564 injury cases, of which 73 were fatal. About half of the reported nonfatal injuries, 687/1404 (48.9%), and a quarter of fatalities, 18/73 (25%) were related to the Arbaeenia mass gathering (P<.001). Most of the reported injuries were unintentional, 1341/1404 (95.51%), occurred on the street, 864/1323 (65.6%), occurred during the daytime 1103/1174 (93.95 %). Most of those injured were evacuated by means other than ambulance 1107/1206 (91.79%) and did not receive pre-hospital medical care 788/1163 (67.7%). Minor injuries 400/1546 (25.9%) and traffic accidents 394/1546 (25.5%) were the most common types of injuries, followed by falls 270/1546 (17.5%). Among fatal injuries, traffic accidents 38/73 (52%) and violence 18/73 (25%) were the leading causes of death. Mass gathering injuries were more likely to occur among individuals aged 21-40 years (odds ratio [OR] 3.5; 95% CI 2.7-4.5) and >41 years (OR 7.6; 95% CI 5.4-10.6) versus those <21 years; more likely to be unintentional than assault (OR 5.3; 95% CI 1.8-15.5); more likely to happen on the street versus at home (OR 37.7; 95% CI 22.4-63.6); less likely to happen at night than during the day (OR 0.2; 95% CI 0.1-0.4); and less likely to result in hospital admission (OR 0.5; 95% CI 0.3-0.7).

CONCLUSIONS

The study shows that most injuries were minor, unintentional, and nonfatal, and most people with injuries had limited access to ambulance transportation and did not require hospitalization.

A Collaborative Initiative to Strengthen Sustainable Public Health Capacity for Polio Eradication and Routine Immunization Activities in the Eastern Mediterranean Region

The many challenges in the Eastern Mediterranean region put the involved countries at risk of polio transmission and affect their ability to meet progress targets in eliminating vaccine-preventable diseases. The Global Health Development (GHD) and Eastern Mediterranean Public Health Network (EMPHNET) are working together on the project "Strengthening sustainable public health capacity in the Eastern Mediterranean region for polio eradication and routine immunization activities" with an overall goal of improving routine immunization, eradicating poliovirus, and controlling/eliminating or eradicating other vaccine-preventable diseases in the Eastern Mediterranean region. The aim of this manuscript is to describe the project and the achievements of GHD/EMPHNET over the last 3 years (2016-2018) to build effective surveillance and immunization systems in the Eastern Mediterranean region through the development of a sustainable and competent public health system to eradicate polio and control/eliminate vaccine-preventable diseases. This project assists the targeted Eastern Mediterranean region countries to build effective surveillance and immunization systems in an effort to expand their capacities to eradicate polio and control/eliminate other vaccine-preventable diseases. The project is streamlined with the Global Polio Eradication Initiative, the Centers for Disease Control and Prevention's Strategic Framework for Global Immunization 2016-2020, and the Polio Eradication and Endgame Strategic Plan 2013-2018. The project also supports the Global Health Security Agenda by focusing on efforts to accelerate progress toward a world safe and secure from infectious disease threats. Project activities were designed to respond to countries' needs and assist them in building their institutional and workforce capacity to effectively plan, implement, and evaluate activities to eradicate polio and strengthen routine immunization activities. The project activities covered a set of areas including surveillance of acute flaccid paralysis and other vaccine-preventable diseases, family and community engagement, workforce capacity building, improvement of data quality, management and use of information systems, use of polio assets to control/eliminate other vaccine-preventable diseases, support of countries to develop national strategies, piloting of innovative initiatives, program evaluation and accountability, and immunization strengthening. The project adopts the Global Polio Eradication Initiative strategies for assisting countries to strengthen routine immunization services, maintain highly sensitive acute flaccid paralysis surveillance, and sustain polio eradication functions.

Disease Burden on Health Facilities in Governorates South of Karbala During the Arbaeenia Mass Gathering in Iraq in 2014: Cross-Sectional Study

Background

Millions of Iraqi pilgrims travel annually from the southern governorates to Karbala and pass through Thiqar, Muthana, and Diwania Governorates to join the Arbaeenia mass gathering event. During this event, participants are at high risk for diseases and death and stifle local health care resources. In addition, the mass gathering causes considerable burden on health facilities in the hosting localities.

Objective

This study aims to estimate the disease burden on health facilities caused by the pilgrims passing through Thiqar, Muthana, and Diwania Governorates en route to Karbala in Iraq.

Methods

This cross-sectional study was conducted on all health facilities in three governorates (Thiqar, Muthana, and Diwania) situated along the southern way to Karbala from Basra. The study started on December 11, 2014, and ended on December 24, 2014. The morbidity and mortality were collected from surveillance logbooks and death registers. Drug purchase data were obtained from the personnel in charge of the pharmacies. The study period was divided into three phases on the basis of the timing of the mass gathering event: pre-event, the event, and postevent.

Results

There were 884,834 incidents reported during the study. The majority of incidents were reported during the event phase (95%) and were attended mostly at mobile clinics (77%). The average daily incidents during the pre-event, event, and postevent phases were 4300, 56,040, and 4548 incidents, respectively. Musculoskeletal disorders were the most common illness reported (55%). The average number of daily deaths was 43, 36, and 45 during the pre-event, event, and postevent, respectively, and these values did not differ significantly. Cardiovascular diseases (43.5%), injuries (29.8%), and respiratory illnesses (12%) were the leading causes of deaths. Approximately US $1.3 million was spent on drug purchases during this mass gathering in the three governorates.

Conclusions

The Arbaeenia mass gathering causes a tremendous disease and economic burden on governorates that pilgrims pass through to attend this mass gathering in Karbala. Although Iraq’s Ministry of Health is aware of the high burden of this mass gathering on the health facilities in these governorates, more work is needed to ensure quality services during the event.

Knowledge, Attitude, and Practices of Food Handlers on Food Safety and Personal Hygiene During Arbaeenia Mass Gathering, Baghdad, Iraq, 2014: Cross-Sectional Study

Background

Millions of pilgrims attend Arbaeenia mass gathering (MG) in Iraq each year. Thousands of individuals work voluntarily at temporary rest areas (locally called Mawakib), distributed in most of Iraq governorates, to provide food and other services to the MG attendees. The potential for improper handling of food at Mawakib increases the risk of waterborne and foodborne diseases.

Objective

This study was aimed to assess the knowledge, attitude, and practices (KAP) of food handlers in Mawakibs in Baghdad city during Arbaeenia MG.

Methods

A random sample of 100 Mawakibs was selected in Baghdad, 50 from the eastern side (Rusafa) and 50 from the western side (Kerkh), and five food handlers were randomly selected from each Mawakib. A questionnaire was used to collect demographic data and KAP for food safety and personal hygiene. The questionnaire included 25 questions addressing knowledge, 10 addressing attitudes, and 14 addressing practices of the food handlers with respect to food safety and personal hygiene. Questions on knowledge and attitudes were answered through direct interview with the food handlers, whereas the questions on practices were answered through direct observation while handling or serving the food. SPSS version 20 (IBM SPSS Statistics 20) was used for data analysis and describing proportions.

Results

There was a varied knowledge of food safety practices among the individuals interviewed. On a scale of 3, the overall average score for both the attitude and practices for food safety and personal hygiene was 2, which corresponds to fair attitude and practices. The attitudes varied significantly by location, age group, and education, whereas the practices varied by location, age groups, employment, and previous experiences.

Conclusions

The food handlers had unsatisfactory attitudes and practices toward food handling and personal hygiene. Their participation in food handling at Mawakib carries a potential risk of spreading foodborne and waterborne diseases. All individuals intending to serve in Mawakib as food handlers should be licensed from the Ministry of Health after completing a formal training in food safety and personal hygiene.

Syndromic Surveillance of Communicable Diseases in Mobile Clinics During the Arbaeenia Mass Gathering in Wassit Governorate, Iraq, in 2014: Cross-Sectional Study

Background

Arbaeenia is the largest religious mass gathering organized annually in Karbala city, Iraq, and is attended by 8-14 million people. Outbreaks of communicable diseases are a significant risk due to overcrowding and potential food and water contamination. Syndromic surveillance is often used for rapid detection and response to disease outbreaks.

Objective

This study was conducted to identify the main communicable diseases syndromes among pilgrims during the Arbaeenia mass gathering in Wassit governorate, Iraq, in 2014.

Methods

This cross-sectional study was conducted in the 40 mobile clinics established within Wassit governorates along the road to Karbala during the Arbaeenia mass gathering. Six communicable disease syndromes were selected: acute watery diarrhea, bloody diarrhea, fever and cough, vomiting with or without diarrhea, fever and bleeding tendency, and fever and rash. A simple questionnaire was used to directly gather basic demographics and the syndromic diagnosis from the attendees.

Results

A total of 87,865 patients attended the clinics during the 10-day period, with an average of 219 patients/clinic/day. Approximately 5% (3999) of the attendees had communicable diseases syndromes: of these, 1693 (42%) had fever and cough, 1144 (29%) had acute diarrhea, 1062 (27%) presented with vomiting with/without diarrhea, and 100 (2%) had bloody diarrhea. The distribution of the syndromes did not vary by age or gender. Stool specimen cultures for Vibrio cholerae performed for 120 patients with acute diarrhea were all negative.

Conclusions

Syndromic surveillance was useful in determining the main communicable diseases encountered during the mass gathering. Expansion of this surveillance to other governorates and the use of mobile technology can help in timely detection and response to communicable disease outbreaks.

Impact of Training of Primary Health Care Centers' Vaccinators on Immunization Session Practices in Wasit Governorate, Iraq: Interventional Study

BACKGROUND

Immunization averts more than 2.5 million deaths of children annually. The World Health Organization (WHO) and the United Nations Children's Fund estimates of immunization coverage in Iraq in 2015 revealed a 58% coverage for the third dose of the diphtheria-tetanus-pertussis vaccine and a 57% coverage for the measles vaccine. High-quality immunization session practices (ISPs) can ensure safer, more effective vaccination and higher coverage rates.

OBJECTIVE

The goal of this study was to assess the impact of training of primary health care centers' (PHCs) vaccinators on the quality of ISPs.

METHODS

This was an interventional study conducted on 10 (18%) PHCs in Wasit Governorate. Two PHCs were randomly selected from each health district. ISPs were assessed by direct on-job observation, using modified WHO immunization session checklists. Findings were grouped into seven domains: vaccine and diluent management, cold chain management, session equipment, registration, communication, vaccine preparation and administration, and waste management. The vaccinators were enrolled in a one-day training session using the WHO module, "Managing an Immunization Session", and one month later a second assessment was conducted using the same tools and techniques. We then calculated the median differences of the domains' scores.

RESULTS

A total of 42 vaccinators were trained, with 25 (60%) of them having graduated from technical health institutes, but only 15 (36%) having had previous training on standard ISPs. Following training, a significant improvement was noticed in three domains: vaccines and diluents management (P=.01), cold chain management (P=.01) and vaccine preparation and administration (P=.02).

CONCLUSIONS

The training of the PHCs' vaccinators for a single day was effective in improving some ISPs. We would recommend using this training module, or a more in-depth one, for other PHCs to improve utilization of immunization services.

Real-Time Surveillance of Infectious Diseases and Other Health Conditions During Iraq's Arbaeenia Mass Gathering: Cross-Sectional Study

Background

The most common religious mass gatherings in the Middle East are the Hajj at Mecca in Saudi Arabia, which occurs annually, and the Arbaeenia in Karbala. The importance of developing public health surveillance systems for mass gatherings has been previously emphasized in other reports.

Objective

This study aimed to describe the common illnesses and health conditions affecting people during the Arbaeenia mass gathering in Iraq in 2016.

Methods

A total of 60 data collectors took part in the field data collection over a period of 11 days, from November 12, 2016 to November 22, 2016. Data were collected from 20 health outlets along the major route from Najaf to Karbala (10 health facilities in each governorate). Two digital forms, the Health Facility Survey and the Case Survey, were used for data collection.

Results

A total of 41,689 patients (33.3% female and 66.7% male) visited the 20 health care facilities over a period of 11 days from November 12, 2016 to November 22, 2016. More than three quarters of patients (77.5%; n=32,309) were between 20-59 years of age, more than half of patients were mainly from Iraq (56.5%; n=23,554), and about 38.9% (n=16,217) were from Iran. Patients in this study visited these health care facilities and presented with one or more conditions. Of a total 41,689 patients, 58.5% (n=24,398) had acute or infectious conditions and symptoms, 33.1% (n=13,799) had chronic conditions, 23.9% (n=9974) had traumas or injuries, 28.2% (n=11,762) had joint pain related to walking long distances, and 0.3% (n=133) had chronic dermatologic conditions.

Conclusions

The Arbaeenia mass gathering in 2016 exerted a high burden on the Iraqi health care system. Therefore, efforts must be made both before and during the event to ensure preparedness, proper management, and control of different conditions.

Assessment of Temporary Community-Based Health Care Facilities During Arbaeenia Mass Gathering at Karbala, Iraq: Cross-Sectional Survey Study

Background

Arbaeenia mass gathering (MG) in Karbala, Iraq, is becoming one of the largest MGs in the world. The health care infrastructure in Iraq is inadequately prepared to serve the health needs of the millions of pilgrims.

Objective

This study aimed to describe the temporary health care facilities installed and run by the local community to provide health care services to Arbaeenia pilgrims in Karbala, Iraq.

Methods

A survey was conducted in all community-based health care facilities located along part of Najaf to Karbala road within Karbala governorate. A structured questionnaire was answered through an interview with the workers and direct observation. Data were collected on staff profile, type of services provided, use of basic infection control measures, medical equipment, drugs and supplies, and the most commonly encountered medical problems.

Results

The total number of health care facilities was 120, staffed by 659 workers. Only 18 (15.0%, 18/120) facilities were licensed, and 44.1% (53/120) of the workers were health professionals. The health care workers provided different services including dispensing drugs (370/1692, 21.87%), measuring blood pressure and blood sugar (350/1692, 20.69%), and caring for wounds and injuries (319/1692, 18.85%). Around 97% (116/120) health facilities provided services for musculoskeletal disorders and only 16.7% (20/120) provided services for injuries. The drugs available in the clinic were analgesics, drugs for gastrointestinal and respiratory diseases, and antibiotics, with an availability range of 13.3% to 100.0%. Infection control practices for individual protection, environmental sanitation, and medical waste disposal were available in a range of 18.1% to 100.0%.

Conclusions

Community-based health care facilities experienced a profound shortage of trained human resources and medical supplies. They can significantly contribute to health services if they are adequately equipped and follow standardized operation procedures.

P2599Echo color doppler evaluation of renal hemodynamic during acute heart failure

Background

Acute heart failure (AHF) is often accompanied by impairment in renal function. A profound derangement of normal abdominal haemodynamic is always present during this clinical phase.

Methods

14 patients (6 F – mean age 80 – mean EF 0.39) admitted for acute heart failure underwent cardiac and renal Echo Doppler examination at day 1-3-5 of Hospital stay. Parameters of arterial and venous flow within cortical right kidney were recorded. Venous Doppler Profile (VDP) was classified as: continuous (C), pulsatile (P), biphasic (B) or monophasic (M) according to the growing degree of derangement. Arterial resistive index (RI) >0.8 was considered elevated. Correlation between renal hemodynamic (and its changes) with biohumoral and echo parameters was sought.

Outcome

At day 1 VDP was M or B in 8 patients (57%) and in four (50%) of them dropped to C or P at day 5. RI was elevated in 8 patients at day 1 while only in 4 at day 5. VDP and RI were not related to EF or BNP values. One patient died before day 5, no other worsening heart failure episodes occurred. Two patients (14%) developed acute kidney injury but their VDP and RI were normal and did not change. Three patients (21%) did not improve their BNP (decrease >30%) but this was not associated with VDP or RI changes. Elevated derived pulmonary artery systolic pressure (>40 mmHg) was present in 6 out of 8 patients (75%) with M or B VDP and in all 4 patients with both elevated RI and M or B VDP.

Venous Pattern Day 1 Day 3 Day 5 Continous 2 8 5 Pulsatile 4 2 4 Biphasic 2 1 2 Monophasic 6 3 2 Arterial RI >0.8 8 6 4 BNP, pg/ml 1060±1180* 372±281* 424±213* Creatinine, mg/dl 1.4±0.6 1.5±0.6 1.3±0.6 Hb, g/dl 12.1±2.3 12.3±3.6 13.2±2.3 *p>0.05.

Conclusions

This is the first study exploring changes in renal hemodynamic by echo Doppler during AHF. With respect to previous studies among stable patients, our preliminary data shows a higher proportion of deranged renal venous and/or arterial pattern. After diuretic therapy a trend towards improvement in VDP was recorded. No clear association with other clinical and hemodynamic parameters seems evident.

Noncommunicable Disease Emergencies During Arbaeenia Mass Gathering at Public Hospitals in Karbala, Najaf, and Babel Governorates, Iraq, 2014: Cross-Sectional Study

Background

Arbaeenia is the largest religious mass gathering (MG) in Iraq where millions of people from Iraq and many other countries visit Karbala city, south Iraq. MGs are associated with high rates of morbidity and mortality from different noncommunicable diseases (NCDs) such as cardiovascular diseases, diabetes mellitus, and asthma. There is a scarcity of publications that address MGs in Iraq.

Objective

This study aimed to explore the NCD emergencies in public hospitals in Karbala, Najaf, and Babel governorates in Iraq, during the Arbaeenia MG and assess predisposing factors for NCD emergencies.

Methods

The study was conducted from November 27 to December 16, 2014. Data were collected in the pre-event and during MG event from 7 selected hospitals. The pre-event data were collected from emergency room (ER) registers and logbooks, and the data on the MG event were collected daily through direct interview with patients and treating physicians using a structured questionnaire.

Results

In total, 4425 NCD emergencies were recorded. Of these, 80.13% (3546/4425) were collected during the MG event. The NCD emergencies attended at ER hospitals during MG were severe hypertension (HT), diabetes (hyperglycemia), ischemic heart disease (IHD), asthma, and pulmonary edema. The load of NCD emergencies and the daily average emergencies increased 4-fold and 2-fold during the MG event, respectively. Most of the NCD emergencies were treated at ER departments, and a few were hospitalized. Intense physical activities and poor adherence to diet and medication were risk factors for IHD, severe HT, and hyperglycemic diabetes emergencies. Exposure to noxious gases or fumes and recent respiratory infections were risk factors for asthma emergencies.

Conclusions

As the pilgrims approached Karbala city during the Arbaeenia MG, the hospitals on the roads leading to the city experienced an increased load of patients because of different NCD emergencies. Although hospitals should be equipped with the necessary supplies, health education for pilgrims is mandatory, particularly on the factors that can exacerbate their diseases.

Assessment of Temporary Medical Clinics During the Arbaeenia Mass Gathering at Al-Karkh, Baghdad, Iraq, in 2014: Cross-Sectional Study

Background

During mass gatherings, public health services and other medical services should be planned to protect attendees and people living around the venue to minimize the risk of disease transmission. These services are essential components of adequate planning for mass gatherings. The Arbaeenia mass gathering signifies the remembrance of the death of Imam Hussain, celebrated by Shiite Muslims, and takes place in Karbala, which is a city in southern Iraq. This annual mass gathering is attended by millions of people from within and outside Iraq.

Objective

This study aimed to map the availability of medical supplies, equipment, and instruments and the health workforce at the temporary clinics located in Al-Karkh, Baghdad, Iraq, in 2014.

Methods

This assessment was conducted on the temporary clinics that served the masses walking from Baghdad to Karbala. These clinics were set up by governmental and nongovernmental organizations (NGOs) and some faith-based civil society organizations, locally known as mawakib. We developed a checklist to collect information on clinic location, affiliation, availability of safe water and electricity, health personnel, availability of basic medical equipment and instruments, drugs and other supplies, and average daily number of patients seen by the clinic.

Results

A total of 30 temporary clinics were assessed: 18 clinics were set up by the Ministry of Health of Iraq and 12 by other governmental organizations and NGOs. The clinics were staffed by a total of 44 health care workers. The health workers served 16,205 persons per day, an average of 540 persons per clinic, and 368 persons per health care worker per day. The majority of clinics (63% [19/30]-100% [30/30]) had basic medical diagnostic equipment. Almost all clinics had symptom relief medications (87% [26/30]-100% [30/30]). Drugs for diabetes and hypertension were available in almost half of the clinics. The majority of clinics had personal hygiene supplies and environmental sanitation detergents (78%-90%), and approximately half of the clinics had medical waste disposal supplies. Instruments for cleansing and dressing wounds and injuries were available in almost all clinics (97%), but only 4 clinics had surgical sterilization instruments.

Conclusions

Although temporary clinics were relatively equipped with basic medical supplies, equipment, and instruments for personal medical services, the health workforce was insufficient, given the number of individuals seeking care, and only limited public health service, personal infection control, and supplies were available at the clinics.

Innovative Approaches to Improve Public Health Practice in the Eastern Mediterranean Region: Findings From the Sixth Eastern Mediterranean Public Health Network Regional Conference

Public health professionals in the Eastern Mediterranean region (EMR) have limited access to continuing education, including workshops and conferences in public health. Held under the theme Innovative Approaches: Adapting to the Current EMR Context, the Eastern Mediterranean Public Health Network (EMPHNET) organized and conducted the Sixth EMPHNET Regional Conference from March 26 to 29, 2018. This paper summarizes the key activities including workshops, roundtable discussions, oral and poster presentations, keynote speeches, and side meetings. Before the opening, 5 preconference workshops were held: “Field Epidemiology Training Program (FETP) Accreditation,” “Innovative Public Health Surveillance,” “Human and Animal Brucellosis,” “Rapid Response Teams,” and “Polio Transition and Routine Immunization.” The conference hosted 6 roundtable discussions: “Consolidation of the FETP Network,” “One Health to Achieve Global Health Security,” “Polio Eradication Efforts and Transition Planning for Measles Elimination,” “Mobile Data Collection and Other Innovative Tools to Enhance Decision Making,” “Confronting Candida auris: An Emerging Multidrug-resistant Global Pathogen,” and “Functioning and Sustainable Country Public Health Emergency Response Operation Framework.” One of the conference’s key objectives was to provide a space for FETP residents, graduates, and public health professionals to showcase achievements. A total of 421 abstracts were submitted and after professional review, 34.9% (147/421) were accepted (111 for oral presentations and 36 for poster presentations) and published by Iproceeding. The conference met the primary objectives of showcasing the public health accomplishments and contributions of the EMR, encouraging the exchange of ideas and coordination among stakeholders, and engaging cross-sectoral workforce in producing recommendations for approaching regional and global health concerns. Moreover, the conference presented a unique opportunity for FETPs and other public health professionals from the Mediterranean region to present their significant scientific work and also facilitated networking among professionals. EMPHNET strives to continue to present similar exchange opportunities for public health professionals in the region.

Self-rated Health and Medical Conditions in Refugees and Immigrants from the Same Country of Origin

BACKGROUND

Research suggests that refugees are at an increased risk for poor health outcomes as compared to immigrants. However, prior studies have compared refugees and immigrants from different countries and have failed to isolate specific war-related factors.

OBJECTIVE

To compare health outcomes and their determinants in refugees and immigrants from the same country of origin.

METHODS

A cross-sectional study based on a convenient sample and on self-report participants were conducted at Southeast Michigan during the period September to December 2009. A validated survey was used to examine refugees (n = 75) and immigrants (n = 65) from Iraq. The survey covered socioeconomics, lifestyle, violence exposure, self-rated health, and number of medical conditions (high blood pressure, fatigue, and backache, shortness of breath, gastrointestinal disorders, skin problems, and musculoskeletal problems). Group differences and predictors of health outcomes were assessed.

RESULTS

Refugees reported significantly more violence exposure than immigrants (p < 0.001). There were no significant differences in self-rated health or medical disorders between groups; however, violence exposure was the main predictor of health outcomes in refugees, whereas age was the main predictor in immigrants. Other predictors also varied by migratory group.

CONCLUSION

Even though migration status did not directly influence health outcomes, results suggest that factors associated with migration status, e.g., violence exposure and age, do impact health. Future studies need to more carefully define and control for country-specific variables.

Interactions between commonly used left and right ventricular function indexes in stable patients

AIM

Aim of this study was to better understand interactions between left ventricular (LV) and right ventricular (RV) systolic and diastolic function echocardiographic indexes in stable cardiovascular diseased patients and in subjects with cardiovascular risk factors.

METHODS

The study enrolled 683 stable patients who were submitted to standard transthoracic echocardiography with evaluation of left ventricular ejection fraction (LVEF) (Simpson biplane method), LV and RV systolic peak on Doppler tissue imaging (LVSys and RVSys), tricuspid annulus plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), and multiparameter evaluation of LV and RV diastolic function utilizing E and A peak, their ratio, E peak deceleration time, E' and A' peak on Doppler tissue imaging, their ratio, and E/E' ratio.

RESULTS

Part of the considered indexes had interactions but only LVEF and TAPSE were related to all the others (LVEF P<0.001 with all the considered parameters; TAPSE P<0.001 with all parameters except with PASP=0.003). Unexpectedly TAPSE seems to have, such as LVEF, a pivotal position among LV and RV function.

CONCLUSION

The study demonstrates the existence of interactions between LV and RV function indexes; these results may be considered as a piece of evidence in favor of heart seen as a single structure.

The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors

BACKGROUND

The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010).

METHODS

We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010.

FINDINGS

Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases--especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis--increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place.

INTERPRETATION

Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world--although these disorders do still persist in LICs--whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed.

FUNDING

Bill & Melinda Gates Foundation.

Trichodina nobilis Chen, 1963 and Trichodina reticulata Hirschmann et Partsch, 1955 from ornamental freshwater fishes in Brazil

In the present work Trichodina reticulata and T. nobilis (Ciliophora: Trichodinidae) are morphologically characterised from ornamental freshwater fish culture in the State of Santa Catarina, Brazil. The prevalence of infection and a list of comparative measurements are discussed. We examined "southern platyfish" Xiphophorus maculatus (n = 35), "goldfish" Carassius auratus (n = 31), "guppy" Poecilia reticulata (n = 20), "sailfin molly" Poecilia latipinna (n = 6), "beta" Betta splendens (n = 2) and "spotted headstander" Chilodus punctatus (n = 1). After being anesthetised in a benzocaine solution, fishes were examined for parasitological evaluation. A total of 51.57% fishes were parasitised by Trichodina spp. Carassius auratus was the most parasitised species, followed by X. maculatus and P. reticulata. Beta splendens, C. punctatus and P. latipinna were not parasitised by any trichodinid species. Two species of Trichodina were collected from the skin of fish: T. nobilis was found in C. auratus, P. reticulata and X. maculatus and T. reticulata was only observed in C. auratus. The importance of adequate handling in ornamental fish culture are also discussed.

Ranitidine bismuth citrate plus clarithromycin 7-day regimen is effective in eradicating Helicobacter pylori in patients with duodenal ulcer

BACKGROUND

No clinical study has been performed to-date to evaluate the efficacy of the dual therapy of ranitidine bismuth citrate (RBC) plus clarithromycin (C) 500 mg b.d. given for 7 days for the eradication of H. pylori.

AIM

To assess the eradication rates achieved by treatment with RBC 400 mg b.d. for 28 days combined with clarithromycin 500 mg b.d. for 7 days in H. pylori-positive duodenal ulcer patients.

METHODS

One hundred and twelve H. pylori-positive patients with endoscopically proven active duodenal ulcer were included in a multicentre, open, randomized trial. H. pylori infection was initially detected by CLO-test and histology on antral and corpus biopsies, and by 13C-urea breath test (UBT). Patients were included if at least two of the tests were positive for H. pylori infection. Patients were randomized to receive RBC 400 mg b.d. for 4 weeks combined with clarithromycin 500 mg b.d. for the first 7 days (Group A) or 14 days (Group B). A second endoscopy was performed at least 28 days after the end of therapy for the assessment of ulcer healing and H. pylori infection. Eradication was assumed if all the tests (CLO-test, histology and UBT) were negative for H. pylori.

RESULTS

Fifty patients in Group A and 55 in Group B were assessed for H. pylori eradication and ulcer healing. The eradication rates according to intention-to-treat analysis were 75% in Group A and 80% in Group B. Considering only those patients with evaluable data at least 28 days after the end of therapy, H. pylori eradication was achieved in 84% and 82% in Group A and B, respectively. No statistically significant difference in eradication was found between the two groups by Mantel-Haenszel test. Only one patient, in Group A, was withdrawn because of adverse events (epigastric pain and pruritus).

[The oral strontium load test in the assessment of intestinal calcium absorption]

A close correlation between calcium and strontium intestinal absorption has been described. In this study, a test using Stable Strontium has been assessed in women without abnormal calcium or bone metabolism, with no history of drugs which might affect calcium or bone metabolism. Decreasing values of Strontium intestinal absorption, according to the length of the postmenopausal period, have been observed. Besides, the Stable Strontium Test has been given in postmenopausal women with osteoporotic femur fractures. In comparison with age matched healthy women, this latter group showed a significantly lower Strontium intestinal absorption. Analogous behaviour has been reported for Calcium intestinal absorption.

Heparin prevents stasis-induced thrombosis through protection of the venous endothelial cells: an electron microscopic study in rabbits

This study was performed to see whether or not protection of the endothelial cells contributes to the antithrombotic effects of heparin. New Zealand albino rabbits were subjected to jugular vein stasis by single caudal ligation for 2 h. Three treatments were given: saline (control group), heparin (0.2 mg/kg) 5 or 45 min before ligature of the vein. Groups of 6-8 animals were killed at 0, 5, 15, 30 and 120 min. The following parameters were determined: (1) involution and damage of the endothelial cells by scanning and transmission electron microscopy; (2) incidence and weight of thrombi in the lumens of the veins after 2 h stasis, and (3) effects of heparin on APTT and anti-Xa activity. In the control group, stasis caused a considerable involution of the endothelial cells in the first 30 min, followed by fibrin deposition and thrombus generation. Heparin strongly reduced the damage to the endothelial cells, with very evident protection of the cell membranes, and prevented thrombus generation: there were significant decreases in both incidence and weight of thrombi. These effects of heparin were evident both shortly after (maximal anticoagulant effect) and long after (no anticoagulant effect) pretreatment. We think that, under the experimental conditions we used, heparin prevented venous thrombosis at least partially by protection of the endothelial cells, through unknown mechanisms.

Lactose malabsorption in adult patients with Crohn's disease

In order to evaluate, in adult patients with Crohn's disease (CD), the prevalence of lactose malabsorption and intolerance, and the percentage who can tolerate a physiologic amount of milk in their diet, we tested 37 patients with CD (19 with intestinal resection, and 18 without) and 67 healthy controls (C) with the H2-breath test after they had ingested increasing loads of lactose as 10% solution (12.5 g, 25 g, and 50 g). Patients with malabsorption after the 12.5-g dose were tested further with 250 ml of milk. In the total group of patients and in the subgroup of those with resection, the prevalence of malabsorption was higher than in controls at all lactose loads; in patients who had not undergone resection, no significant difference was observed with the 12.5-g dose. Eleven of 18 patients who were malabsorbers with the 12.5-g dose had malabsorption also with 250 ml milk; however, only three of them (8% of the total group) experienced symptoms of intolerance. We conclude that, in adult patients with CD, 1) the prevalence of lactose malabsorption is increased, 2) in patients who have undergone intestinal resection, malabsorption occurs at a lower dose of the sugar than in patients who did not, and 3) since only 8% of patients experienced symptoms of intolerance after the ingestion of milk 250 ml, this amount can be empirically inserted in the daily diet of an adult with CD.

Efficacy of addition of exogenous lactase to milk in adult lactase deficiency

The efficacy of lactase by Kluyveromyces lactis in hydrolyzing milk lactose and reducing milk intolerance symptoms was tested in 52 proved lactose malabsorbers. The enzyme was added to milk administered to the patients, and H2 breath excretion (as an index of carbohydrate malabsorption), was determined by gas chromatograph technique, and milk intolerance symptoms were recorded. H2 mean excretion was 78.3 +/- 5.49 ppm after administration of intact whole milk 500 ml (test A), 43.5 +/- 4.99 ppm when lactase 2000 U was added to milk 500 ml immediately before administration (test B); 36.7 +/- 5.01 ppm when milk 500 ml was incubated for 12 h with lactase 1000 U (test C), and 29.7 +/- 4.35 ppm when the incubation was prolonged for 24 h (test D). Symptoms score was: test A = 5.85 +/- 0.56, test B = 3.71 +/- 0.45, test C = 2.77 +/- 0.63, test D = 1.7 +/- 0.68. A correlation index of r = 0.44 (p less than 0.01) was obtained between reduction in H2 mean excretion and reduction in symptoms score of a single individual. The addition of this lactase to milk seems to be effective in correcting lactose malabsorption, thus representing a convenient approach in milk intolerance.

Effect of chemically defined formula diets on pancreatic mass in the rat

To establish the effect of chemically defined formula diets on pancreatic mass, 58 male Wistar rats, weighing approximately 200 g, were fed orally one of the following diets for 20 days: standard diet; partially hydrolyzed diet; elemental diet. The diets were isocaloric and provided 73 cal/day per rat. At the end of the experiment, the rats were killed and pancreas removed to assess wet weight and DNA and RNA content. Compared to the controls, the elemental diet caused a reduction in pancreatic wet weight (p less than 0.005), pancreatic DNA (p less than 0.001), and RNA content (p less than 0.001). In the group fed partially hydrolyzed diet, only pancreatic DNA content showed an highly significant reduction when compared with the reference group (p less than 0.001), whereas the value of RNA failed to reach the statistical significance. We found an increase of the ratio mg RNA/mg DNA in the partially hydrolyzed and elemental diet groups. These results suggest that long-term nutrition with the partially hydrolyzed diet, and more strongly with the elemental diet, may induce pancreatic hypoplasia.

A single-specimen fecal chymotrypsin test in the diagnosis of pancreatic insufficiency: correlation with secretin-cholecystokinin and NBT-PABA tests

An investigation of fecal chymotrypsin activity on spot fecal specimens was carried out in three groups of subjects, divided as follows: 45 healthy controls (group C); 36 patients with gastroenterological diseases of extrapancreatic origin (group VP); and 42 patients with chronic pancreatitis (group CP). Nineteen patients of group CP underwent pancreozymin-secretin and NBT-PABA tests. The following results, expressed as mg of chymotrypsin/g of feces, were obtained: C = 0.610 +/- 0.203; CP = 0.291 +/- 0.154, p less than 0.001; VP = 0.560 +/- 0.234. FCT showed a sensitivity rate of 78.5% and a specificity rate of 71.6%. The fecal output of chymotrypsin correlated well with the pancreatic secretion of chymotrypsin (r = 0.59, p less than 0.01) and with the percentage of recovery of urinary PABA (r = 0.44, p less than 0.05). We conclude that chymotrypsin assay by the described method on spot stool specimens is a simple, reliable technique which may be considered a good screening test for pancreatic insufficiency. The test will not detect minimal pancreatic disease or minimal pancreatic dysfunction.

Intestinal morphological changes during oral refeeding in a patient previously treated with total parenteral nutrition for small bowel resection

This report describes a patient who, after a subtotal resection of small intestine for an embolic obstruction of the superior mesenteric artery, was maintained on total parenteral nutrition for 30 days and then refed. Cytoproliferative analysis of the intestinal mucosa, evaluated by peroral biopsies performed on days 1, 5, 14 and 30 after oral refeeding, demonstrated an increase in cell proliferation from 1 to 14 days after refeeding, followed by a return to starting values after 30 days. On days 1 and 5, we saw an intestinal hypoplasia that became a hyperplasia after 14 days of oral refeeding. Our data confirm the importance of oral nutrition for the small intestinal response after resection.