Promoting rational antibiotic use in Turkey and among Turkish migrants in Europe - implications of a qualitative study in four countries

Background

Antimicrobial resistance is considered one of the major threats to global health. The emergence of resistant microorganisms is a consequence of irrational use of antibiotics. In Turkey, the consumption of antibiotics is relatively high and antibiotics are among the most commonly used drugs. However, Turkey has adopted new, more restrictive policies and regulations on antibiotics. In addition, Turkish migrants to EU countries, such as Germany, the Netherlands and Sweden, may encounter health systems that promote a more restrictive and rational antibiotic use.

The objective of this paper was to explore the variation in implemented policies related to rational antibiotic use that citizens in Turkey and Turkish migrants in Germany, the Netherlands and Sweden are subjected to and to discuss the implications for the promotion of rational antibiotic use.

Data were collected through focus groups and individual interviews with citizens, physicians and pharmacists in the four countries. In total, 130 respondents were interviewed. Content analysis was used.

Results

Three relevant themes were identified: Implementation of regulations and recommendations, Access to antibiotics and Need for health communication. Irrational use of antibiotics was reported mainly in Turkey. While it had become less likely to get antibiotics without a prescription, non-prescribed antibiotics remained a problem in Turkey. In the three EU countries, there were also alternative ways of getting antibiotics. Low levels of knowledge about the rational antibiotic use were reported in Turkey, while there were several sources of information on this in the EU countries. Communication with and trust in physicians were considered to be important. There were also system barriers, such as lacking opportunities for physicians to manage care in accordance with current evidence in Turkey and factors limiting access to care in EU countries.

Conclusions

Several fields of importance for promoting rational antibiotic use were identified. There is a need for harmonisation of health-related regulations and policy programmes. Antibiotics should only be available with a prescription. Programmes for rational antibiotic use should be implemented on a broad scale, in medical care, at pharmacies and in the population. Methods for health communication and patient-centred care should be further developed and implemented in this field.

Management of chronic diseases and healthcare use among the elderly in Turkey and Turkish migrants

Background

Turkish migrants are one of the largest groups of migrants in Germany, the Netherlands and Sweden. Particularly older migrants face different barriers in the health system that may limit their access to and quality of health care. The aim of this study was to examine how elderly people in Turkey and Turkish migrants in Germany, the Netherlands and Sweden manage chronic conditions, including how they utilize the respective healthcare systems.

Methods

A qualitative study design was used. A total of 20 in-depth interviews with individuals in Turkey and 10 semi-structured in-depth interviews each with Turkish migrants in Germany, the Netherlands and Sweden were conducted during 07/2018 and 05/2019. The interviews were based on a topic guide and were analyzed using qualitative content analysis.

Results

Participants from all groups experienced barriers in accessing health services and described difficulties in managing chronic conditions in their daily life. Pathways to care and patterns of utilization strongly depended on the structure of the respective health systems and differed between all groups. Circular migrants to Turkey relied on health professionals from their respective host countries to treat their chronic diseases, consulting professionals in Turkey mostly for emergencies or acute illness.

Conclusions

Turkish migrants and elderly adults in Turkey experience similar barriers and challenges in managing chronic diseases. How they access and utilize health services is dependent on the respective health system structures. Circular migrants use the Turkish health system differently than health systems in their host countries and elderly adults from Turkey. These results can contribute to the development of diversity-sensitive health care strategies.

Key messages

Turkish migrants and adults in Turkey experience similar challenges in managing chronic diseases. How Turkish migrants and adults in Turkey access healthcare depends on the respective systems.

Application of multiplex PCR for the simultaneous detection of Taenia spp. from domestic dogs in the north of Iran

The family Taeniidae is of great importance in the medical and veterinary fields, particularly in the tropics and subtropics. Identification of eggs of different Taenia spp. in the final host by morphological examination is difficult owing to their similarity. Therefore, a multiplex polymerase chain reaction (PCR) targeting a mitochondrial gene was applied to identify morphologically indistinguishable eggs. Fecal samples from 100 domestic dogs, from the Mazandaran province in Iran, were examined using the flotation/sieving method followed by multiplex PCR. Taeniid eggs were observed in 24 % samples, of which 12 %, 10 %, and 2 % were infected with Echinococcus granulosus, Taenia spp., and both E. granulosus and Taenia spp., respectively. E. multilocularis was absent in these samples. The prevalence of E. granulosus in the examined domestic dogs as definitive hosts in north of Iran was high (14 %). Therefore, people living in this region of Iran are in danger of acquiring hydatid cyst, which is a serious public health problem.

Molecular Characterization of Echinococcus granulosus from Hydatid Cysts Isolated from Human and Animals in Golestan Province, North of Iran

BACKGROUND

The aim of the present study was to determine the molecular characteristics of Echinococcus granulosus from paraffin-embedded tissues of hydatid cysts isolated from human and protoscoleces of hydatid cysts from sheep, cattle and camel isolates using PCR- RFLP of ITS1- rDNA analysis in Golestan Province, northern Iran.

METHODS

E. granulosus isolates from human patients infected with hydatid cyst and protoscoleces from hydatid cysts of sheep, cattle and camel isolates were collected from different hospitals and the abattoir throughout the Golestan Province. In all, 60 E. granulosus genomic DNA were extracted and examined by PCR - ITS1 of rDNA and amplified using BD1 / 4S and EGF1 / EGR2 primers, followed by RFLP using Alu1, Msp1 and TaqI restriction enzymes.

RESULTS

The PCR-ITS1 products obtained from sheep, cattle and human isolates were similar to sheep strain (1000 bp and 391 bp). Majority of the camel samples yielded 295 bp DNA bands. RFLP -ITS1 of E. granulosus with Taq1 in human, sheep and cattle isolates showed similar patterns in the number and size of DNA. RFLP methods in camel isolates showed a different genotype, using Taq1, whereas no DNA bands were observed using Alu1 in camel and human isolates. Therefore, two clearly distinguishable banding patterns of E. granulosus were obtained with the three enzymes, which separating human, sheep and cattle isolates from the camel origin.

CONCLUSION

The results indicate the possible of transmission of the G1 and G6 genotypes of E. granulosus between livestock animals and human in Golestan Province.

A seroepidemiological survey for toxoplasmosis among schoolchildren of Sari, Northern Iran

A seroepidemiological survey for toxoplasmosis among schoolchildren of public schools of the urban areas of the Sari, Mazandaran province, Iran, was carried out from September 2006 to March 2007. A total of 1209 serum samples (686 males, 523 females) were examined for IgG antibodies by ELISA. Questionnaires were completed for all participants. In regard to criteria>10 IU/mL as positive, the infection coefficient (IC) was 266 (22%), of which 161 were males (IC=23.5) and 105 females (IC=20.1) (P=0.15). No age-antibody association was detected, although an increase in positivity with increasing age was observed, reaching 23.1% in the oldest group (P=0.84). A significant association was observed with the presence of cat, contact with soil, washing hands before meals and eating raw or undercooked meat. An improvement in personal hygienic conditions and behavioral characteristics such as eating cooked meat is important in reducing the rate of Toxoplasma infection.

A faunistic survey of cercariae isolated from lymnaeid snails in central areas of Mazandaran, Iran

The aim of this study was to elucidate the species diversity of larva trematodes in the Mazandaran Province, Northern Iran. In this cross-sectional study, a total of 3,266 lymnaeid snails from 3 species were collected from different parts of streams, swamps, rice fields and rivers in the central areas of Mazandaran Province (Sari, Neka, Qaemshahr and Savad-Koh cities), during April to September, 2008. The samples were tested by crushing and emerging methods. From the total of examined snails, 119 (3.6%) were found to be infected with the lymnaeid snails. Lymnaea gedrosiana were found to be infected with the Furcocercariae of Diplostomidae, Clinostomidae, Echinostomatidae and also cercariae of the Plagiorchiidae. The latest infection was found to be in L. palustris. The Mazandaran Province with its temperate climate is a suitable place for living of snails, particularly lymnaeidae, that could have a significant role as an intermediate host of diseases.

Prevalence of intestinal parasites and profile of CD4+ counts in HIV+/AIDS people in north of Iran, 2007-2008

In this study 142 stool samples (64 HIV+/AIDS patients and 78 non-HIV infected individuals) collected from Mazandaran province and screened for intestinal parasites, using direct wet mont, formalin-ether sedimentation concentration, modified Ziehl Neelsen and modified trichrome techniques. Each person in this study was examined for CD4+ counts. Intestinal parasites were found in 11/64 (17.2%) of patients in HIV+/AIDS group and in 14/78 (17.9%) of controls. Prevalence of parasites detected in HIV+/AIDS individuals was as follow: Cryptosporidium sp. 9.4%, Giardia lamblia 3.1%, Entamoeba coli 1.6%, E. histolytica 1.6% and Chilomastix mesnili 1.6%. Prevalence of parasites in controls was as follow: Trichostrongylus sp. 6.4%, G. lamblia 3.8%, Cryptosporidium sp. 2.5%, E. coli 2.5%, E. histolytica 1.2%, Hookworms 1.2%. The mean of CD4+ counts in HIV-positive group (430 cells microL(-1)) was remarkedly less than controls (871 cells microL(-1)) (p = 0.001). As patients usually belong to poor socio-economic backgrounds and they can hardly afford treatment, therefore, it is suggested screening and free treatment of intestinal parasites in these individuals should be taken by health centers to prevent the occurrence of these diseases in HIV+/AIDS patients, as often the disease may take a fulminant form.

Effect of Giardia infection on nutritional status in primary schoolchildren, in northwest Iran

In order to determine the association between Giardia infection and nutritional status, a cross-sectional study was performed on twenty randomly selected primary schools from two regions of Ardabil province in 2005. Anthropometric factors including height, weight and midarm muscle circumference (MAC) were measured for 813 children (413 males, 400 females). The food intake was estimated for energy and other nutrients by 24 h recall method for three days in week. Determination of Giardia infection was done by using direct wet mount and formalin-ether sedimentation concentration. 10.9% of boys and 17.2% of girls were infected with Giardia infection. Weight and MAC in none infected girls and boys (only 7 and 11 years old) were higher than in infected groups. The average values for weight, height and MAC for both genders were lower than those of NCHS values. Vitamin E and phosphorous intake in non infected boys (in 7-10 years old) were less than infected boys. Calorie, protein, vitamins (B3, B5, B6, E and folacin) and minerals (copper, magnesium, phosphorous, potassium and selenium) intake of infected girls were less than non infected girls in 11-12 years old category. Based on the results found in this study, we conclude that Giardia infection may affect on some of anthropometric factors as well as the calorie and other nutrients intake in some of age groups.

Seroprevalence of toxocariasis in schoolchildren in Northern Iran

This cross-sectional study was carried out on 1210 randomly selected schoolchildren, attending sixteen primary and secondary schools, during the period between November 2005 and June 2006. Parents who accepted to include their children were requested to be present at sampling time and to fill in a simple questionnaire with personal and epidemiological data. Three milliliter of venous blood were taken by vein puncture under sterile conditions from each subject for detection and titration of antibodies to T. canis and eosinophil counts. Total IgG anti-Toxocara antibodies was evaluated by T. canis IgG ELISA kit. According to the manufacture recommendations, an index positivity >11 U was considered positive. Of the 1210 serum specimens tested, an overall seroprevalence for Toxocara antibodies of 25% was obtained. There was no association between positive seroprevalence and age (p = 0.34). Boys and girls differed significantly with regard to Toxocra titre (p = 0.003). Eosinophilia in peripheral blood (> or = 5%) was detected in 24.5% (297/1210) of the population studied, 97/297 (32.8%) of whom were seropositive for toxocariasis. The findings of this study confirmed that infection with Toxocara is quite high and widespread in children in Northern Iran. Therefore, health promotion efforts must be directed at increasing the awareness of the population about the potential zoonotic hazards associated with the disease and how to minimize them.

Prevalence of Toxocara canis in stray dogs, northern Iran

Toxocara canis is one of the most common parasites living in the intestine of domestic and stray dogs. A dog eliminates thousands of eggs into the environment that are potential etiological factor for human toxocariasis. The present study was undertaken to determine the prevalence of T. canis in stray dogs in Mazandaran, Iran. In this cross-sectional study, during the period from April to September 2007, 50 young and adult stray dogs were collected by shooting from urban areas of Sari city, Northern Iran. They were necropsied and the gastrointestinal tract was opened. Recovered parasites were fixed in alcohol and stained in carmine. Faecal specimens were also examined by the formalin ether concentration method. A total of 27 adult and 23 young dogs were examined with 11 adults (40.7%) and 19 youngs (82.6%) being infected with T. canis with an overall prevalence of 60%. There were significant differences in the prevalence of infection between adult and young dogs (p = 0.003). There were no significant differences in the prevalence of infection between male and female dogs (p > 0.05). Considering the high prevalence of this zoonotic parasite and its hygienic significance in causing human toxocariasis, particularly in children, plus the lack of control of stray dog populations, there is a need to improve personal and food hygiene as well controlling stray dogs in these urban

Seroprevalence of Toxoplasma gondii in cattle, sheep and goats slaughtered for food in Mazandaran province, Iran, during 2005

Serum samples from 290 cattle, 400 goats and 588 sheep slaughtered for food in various areas of the Mazandaran province, Iran were tested for antibodies to Toxoplasma gondii by the indirect immunofluorescence antibody test (IFAT), from December 2004 to April 2005. Antibodies to T. gondii were found in 30% (120/400) goats and 35% (206/588) sheep and 0% (0/290) cattle, at a dilution of 1:16 or more for goats and sheep and 1:128 or more for cattle. The highest titres observed in cattle, goats and sheep were 1:64 (0.7%), 1:128 (1%), 1:64 (2%), respectively. These results indicate that T. gondii antibodies are widespread in the animal populations and suggest that toxoplasmosis is a widely spread zoonotic infection in northern Iran.

Seroepidemiological study of toxoplasmosis in intellectual disability children in rehabilitation centers of northern Iran

Serological studies revealed that toxoplasmosis has world wide distribution. Although the infection by Toxoplasma gondii is widely prevalent in humans and animals, the disease is uncommon and most of the acquired infections are asymptomatic. The important aspect of this parasitic infection is the probable danger of congenital transmission and its severe effects on the fetus. There have been many reports about the prevalence of anti-T. gondii antibody among different groups of people in Iran; however the epidemiological data in intellectual disability (ID) persons are rare. This study was performed to evaluate the seroprevalence of toxoplasmosis among the inhabitants of rehabilitation centers of northern Iran. A total of 336 serum samples (161 males, 175 females) were examined for the IgG antibodies by indirect immunofluorescense technique. First of all, 1:50 titer dilution was tested, in the cases of positive result, further dilutions (1:100, 1:200, 1:400, 1:800, 1:1600, and 1:3200) were prepared and the last dilution was recorded. Among 336 sera, 77.4% showed seropositivity by IFAT. The positive rates of males and females were 77.6% (125/161) and 80% (140/175), respectively. However, there were no significant differences between sexes. Comparing the age groups, the highest seropositive rate showed in 19 or higher, and their rates had a tendency to increase with age. Prevalence of the infection in 10 rehabilitation centers was not significant either. Nevertheless, our data (77.4%) in rehabilitation centers in northern Iran suggest that infection is the same as in many other reports in normal population in this area, therefore toxoplasmosis is not a major problem in rehabilitation centers of this geographical area.

Toxocara catiinfections in stray cats in northern Iran

A cross-sectional survey was undertaken to study the prevalence and intensity of infection withToxocara catiin 100 stray cats, from April to October 2004 in urban areas of Sari, northern Iran. A total of 44 cats (44%) were found to be infected withT. cati. There was a significant difference in the prevalence of infection relative to host age and weight (P = 0.000). There was also a significant difference in the intensity of infection relative to body weight and urban sites (P < 0.05). No significant difference was found between the prevalence of infection relative to host gender, urban sites and season (P>0.05), nor in the intensity of infection between host gender, age and season (P>0.05). The intensity of infection ranged from 1 to 32 worms per cat, with a mean of 7.30 ± 6.82.

The prevalence, intensity and viability of hydatid cysts in slaughtered animals in the Ardabil province of Northwest Iran

In a cross-sectional study, a total of 5381 slaughtered animals, namely 928 cattle, 243 buffaloes, 3765 sheep and 445 goats were inspected macroscopically for hydatid cysts in northwest Iran, with prevalence values of 38.3%, 11.9%, 74.4% and 20%, respectively, being recorded. Prevalences were higher in females compared with males, but a significant difference (P < 0.001) was only found in sheep and cattle. Most cases which were condemned were seen in the lungs of sheep (13.4%) indicating that sheep are the most important intermediate hosts for Echinococcus granulosus in this area.