Relevance of the COVID-19 rapid response system to public health policymaking in Islamic Republic of Iran

BACKGROUND

The COVID-19 pandemic has increased awareness of the need for high-quality and timely evidence to support policy- and decision-making in emergency situations.

AIMS

To describe the experiences of the National Institute of Health Research (NIHR), Islamic Republic of Iran, in adopting evidence-informed policymaking during the COVID-19 pandemic.

METHODS

During the COVID-19 pandemic, NIHR institutionalized a rapid response system that was backed up by evidence-informed policy- and decision-making. Activities included establishment of a preparedness and response management committee, gathering and providing timely pandemic information to policymakers, establishing a timeline of actions and activities, and a feedback system for policy responses and queries.

RESULTS

The COVID-19 rapid response committee addressed the questions of 40 policymakers by synthesizing and analysing evidence and making it available to relevant stakeholders. It developed and disseminated knowledge products to provide relevant information. We identified the need for more timely data and more reliable research evidence for pandemic management.

CONCLUSION

National institutions responding to health emergencies need to take responsibility for establishing and managing a robust rapid response systems that can provide valid and timely evidence to policymakers. Over time, their capacity should be monitored, evaluated and strengthened to adapt and respond appropriately to pandemics, outbreaks and epidemics.

Mapping of national population-based surveys for better reporting of health-related indicators in the Eastern Mediterranean Region

BACKGROUND

Population-based surveys are the main data source to generate health-related indicators required to monitor progress toward national, regional and global goals effectively. Although the Eastern Mediterranean Region of World Health Organization (WHO) member states conduct many population-based surveys, they are not led regularly and fail to provide relevant indicators appropriately. Therefore, this study aims two-fold: to map out population-based surveys to be conducted data for the health-related indicators in the Region and propose a timetable for conducting national population-based surveys in the Region.

METHODS

The study was conducted in six phases: 1) Selecting survey-based indicators; 2) Extracting and comparing relevant survey modules; 3) Identifying sources of data for the indicators; 4) Assessing countries' status in reporting on core health indicators; 5) Review and confirmation of the results by the experts.

RESULTS

Population-based surveys are the sources of data for 44 (65%) out of 68 regional core health indicators and two (18%) out of 11 health-related Sustainable Development Goals (SDG) 3 indicators. The Health Examination Survey (HES) could cover 65% of the survey-based indicators. A total of 91% of survey-based indicators are obtained by a combination of HES, Demographic and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS) and Global School-based Student Health Survey (GSHS).

CONCLUSION

In order to effectively report health-related indicators, HES, DHS/MICS and GSHS are considered essential in national survey timetables. Each country needs to devise and implement a plan for population-based surveys by considering factors such as national health priorities, financial and human capacities, and previous experiences.

Primary Health Care Model for Non-Communicable Diseases Management during COVID-19 Pandemic in the Islamic Republic of Iran

Background

Given the importance of appropriate response to prevent and manage Non-Communicable Diseases (NCDs), this study aimed to analyze the state of NCDs services at the level of the PHC system during the COVID-19 pandemic and to determine the main strategies.

Methods

In this qualitative study, first, the circulars and guides in Iran's PHC system from the beginning of the pandemic to the end of September 2020 were retrieved manually and by searching the internal websites of the Ministry of Health. All documents about decision-making or governance and coordination mechanisms for the provision of NCDs services were enrolled and analyzed. In the second phase, the status of service delivery for major NCDs was presented in a model, and finally, SWOT analysis was used to analyze the situation and determine the main strategies.

Results

25 out of 199 circulars and guides were eligible and analyzed. In the crisis phase, most risk assessment, screening, and diagnosis services for NCDs have been suspended, and follow-up and care of patients with major NCDs were done by telephone. In the reopening phase, the general strategies and strategies to increase capacity and provide delayed care were adopted, and the PHC model of the provision of essential services for the major NCDs was developed in low-risk, intermediate and high-risk pandemic conditions. Finally, 16 main strategies were determined with the approach of integrating and focusing on essential services, considering vulnerable groups and the use of E-health technologies.

Conclusion

The results indicate on interruption of NCDs services in the crisis phase while adopting strategies for responding to the pandemic. Revision of the COVID-19 guides with a particular focus on NCDs is recommended.

Prevalence of tobacco use in adults; 2016 nationally representative household survey in Iran

Background:

Tobacco use is an established preventable risk factor for many noncommunicable diseases and is considered as an important indicator for monitoring progress towards Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs). This study aimed to determine the situation of tobacco use among Iranian adults using 2016 household survey.

Methods:

This is a secondary analysis of the data from 2016 nationally representative STEPwise approach to Surveillance (STEPs) survey with a sample size of 31,050. The data on tobacco consumption was gathered using questions incorporated in the survey questionnaire.

Results:

The prevalence of current tobacco use in Iran was 25.2 % (24.4-25.9) in men versus 4% (3.7-4.3) in women. The prevalence was higher in rural areas and among second wealth group. The prevalence of current daily cigarette smoking was 20.1% (19.4-20.7) in men versus 0.9% (0.8-1.1) in women). Average number of cigarettes per day among current cigarette smokers was 14.5% (14.1-14.9), mean age at start smoking among daily cigarette smokers was 21.6% (21.1-22), and 95.2% (94.4-96) of daily current daily cigarette smokers attempted for cessation during past 12 months. Prevalences of exposure to secondhand cigarette smoke among nonsmokers at homes and workplaces were 23.21% (22.65-23.76) and 18.04% (17.2-18.87), respectively.

Conclusions:

There was a large difference between the prevalence of tobacco use between men and women (25.2% vs. 4%). Higher prevalences of tobacco use in rural areas and among lower wealth quintiles require more equity-based approaches in tobacco combatting actions.

The Effect of the COVID-19 Pandemic on Non-Communicable Disease Prevention and Management Services in the Primary Health Care System of Iran

Background: The COVID-19 pandemic has caused significant disruptions in the provision of non-communicable disease (NCDs) prevention and control services in many countries, and there is a concern that it would lead to long-term complications of the diseases. The aim of this study is to assess the changes in the provisions of selected NCD services before and after the COVID-19 epidemic in Iran's primary healthcare system. Methods: In this descriptive-analytical retrospective study, the number of eight NCD services provided during the first 10 months of the COVID-19 pandemic from Feb 2020 to Dec 2020 were compared with the same period in the previous year using the data from the Iranian integrated electronic health record system (SIB) and also the association between the number of deaths due to COVID-19 and a sample of NCD services were assessed using cross-correlation analysis. The statistical analysis was performed in Stata Software v.14. Results: The NCD services have decreased by an average of 18.89% compared to the same period in the previous year; this decline was much more severe at the beginning of the epidemic period (up to 75% in some services) and was greater in physician-provided services than in non-physician services. Also, examining the course of the selected services during this period, a gradual compensation was evident after the initial reduction. Conclusion: The general trend of the selected services of prevention and control of NCDs in the PHC system of Iran within 10 months after the onset of COVID-19 showed a sharp decline and subsequent gradual compensation. Although the process of compensation in some services may be considered somewhat reassuring, in the case of some essential services, more effort and attention to the implementation of programs or compensatory policies seem necessary.

Evaluating the Women Health Volunteers Program in Iran- a Quarter Century Experience (1992-2016)

BACKGROUND

Running for more than 25 years, the Women Health Volunteers (WHV) program in Iran has made many great achievements. Considering the new expectations from the health system, this national program needs to be revised and undergo fundamental changes. Although many studies have been conducted to evaluate this program, there still is a lack of a comprehensive nationwide assessment containing policy recommendations.

METHODS

This study was conducted in a qualitative approach. The data were obtained from 3 sources: national documentations, semi-structured questionnaires by 49 key informants, and focused group discussions. The program was assessed in 4 domains including the program, goals, achievements, improved opportunities (weaknesses), and strategies for improvements.

RESULTS

The collected data were categorized into 4 main themes including goals and objectives, achievements, weaknesses, and recommendations. Main achievements of the WHV program are: increasing people's participation especially women, increasing health literacy, and increasing coverage and utilization of health services. The most important weaknesses of the program include: lack of a national roadmap and policy plan for the WHV program, lack of true belief in people's participation in policymakers, weakness in comprehensive system monitoring and evaluation, and inadequate funding.

CONCLUSION

Like many other health system programs in the country, the WHV program suffers from the lack of a binding strategic plan and goal so that by changes in management, sustainability of the program becomes hampered. An appropriate solution would be to operate the WHV program like a non-government organization (NGO) under the supervision of the Ministry of Health and Medical Education (MoHME).

Transition of Mental Health to a More Responsible Service in Iran

Objective: This study proposed a model for provision of an effective universal coverage for mental health services based on global and national experiences, available resources and the nature of primary health care system of Iran to reduce the burden of mental health conditions. Method: A framework with prioritized mental and social health services was devised through a review of literature and policy documents. It was then adapted using inputs from the stakeholders and experts. Results: The new model included 2 basic and specialized service strata: a PHC-based infrastructure and essential requirements needed to establish the service. Our proposed socio-mental health approach is based on a WHO recommendation. Conclusion: The key features of the model, which is going to be tested in a pilot study in 2015, are setting up a system for organized referrals to specialized mental facilities and compatibility with the existing primary health care system. Moreover, to achieve this goal, socio-mental health technicians should be employed.

How to integrate social care services into primary health care? An experience from Iran

BACKGROUND

Social issues have prominent effects on the peoples' physical and mental health and on the health risk factors. In Iran, many organizations provide social care services to their target population. This study aimed to explore the roles and functions of Primary Health Care (PHC) system in providing social care services in Iran.

METHODS

This was a qualitative study, for which data were collected via three sources: A review of the literature, in-depth interviews and focus group discussions with experts and stakeholders. The main objective was to find a way to integrate social care into the Iranian PHC system. A conventional content analysis was performed to explore the data.

RESULTS

Overall, 20 experts were interviewed and the acquired data were classified into four major categories including priorities, implementation, requirements and stewardship. The main challenges were the existing controversies in the definition of social care, social service unit disintegration, multiple stewards for social care services, weaknesses of rules and regulations and low financing of the public budget. Social care services can be divided into two categories: Basic and advanced. Urban and rural health centers, as the first level of PHC, could potentially provide basic social care services for their defined population and catchment areas such as detecting social harms in high risk individuals and families and providing counseling for people in need. They can also refer the individuals to receive advanced services.

CONCLUSION

Iran has a successful history of establishing the PHC System especially in rural areas. This network has an invaluable capacity to provide social health services. Establishing these services needs some prerequisites such as a reform PHC structure, macro support and technical intersectoral collaboration. They should also be piloted and evaluated before they could be implemented in the whole country.

Expression analysis of BECN1 in acute myeloid leukemia: association with distinct cytogenetic and molecular abnormalities

INTRODUCTION

In acute myeloid leukemia (AML), it has been shown that AML-derived cells often remain sensitive to autophagy-inducing stimuli, leading to the idea that harnessing the autophagy can be pertinent to AML cytotoxic therapy. Despite this promising notion, to date, there is no comprehensive study addressing autophagy-related genes expression status in AML. As a critical mediator, BECN1 influences the onset and advance of autophagy and several studies have pointed to the BECN1 recurrent allelic deletion and expression variation in a broad range of tumors. To explore this caveat, we chose this alteration-prone gene to investigate in our study.

METHODS

We have analyzed the expression status of BECN1 in a series of 128 de novo AML patients using real-time quantitative polymerase chain reaction (qRT-PCR).

RESULTS

In our favorable subgroup, BECN1 expression did not alter (P = 0.301), but in intermediate and unfavorable patients, we have had BECN1 low expression compared to the normal controls (P = 0.008 and P < 0.001, respectively). We found evidence for the association of reduced expression of BECN1 with FLT3-ITD mutation (19 of 27 patients), monosomal karyotype (all of 11 patients), higher age, and WBC count.

CONCLUSION

Overall, remarkable association of reduced expression of BECN1 with FLT3-ITD mutation and monosomal karyotype and their functional relationship is interesting which should be addressed and verified in future studies.

A mutational and expressional analysis of DNMT3A in acute myeloid leukemia cytogenetic subgroups

OBJECTIVES

Despite numerous studies in order to determine the allele frequency and clinical impact of DNA methyltransferase 3 A (DNMT3A) gene mutations in acute myeloid leukemia (AML), reports about the expression analysis of this gene are rare and between the available, differences are evident.

METHODS

In this study, we decided to investigate DNMT3A possible expression changes with regard to their mutation and cytogenetic status in a series of 96 AML patients.

RESULTS

Mutations were founded in 17 of the 96 patients (17.7%) and associated with higher age and white blood cell count (P < 0.001). Our mutants have had shorter overall survival (OS) (P < 0.001) and relapse-free survival (RFS) (P = 0.011) than those without. Multivariate analysis showed that DNMT3A mutation is an independent prognostic indicator for OS and RFS (P < 0.001). In relation to expression results, we had over and under expression for our favorable and unfavorable cytogenetic subgroups, respectively (P = 0.005 and P < 0.001, respectively). In intermediate subgroup, total DNMT3A expression did not alter (P = 0.575). Interestingly, we noticed similar expression results for DNMT3A transcript 2, to that of the total.

DISCUSSION AND CONCLUSION

In relation to DNMT3A expression, from the perspective of diagnostic application and its biological significance, it is difficult to accept its primacy over cytogenetic value in favorable and unfavorable subgroups and if so, we did not address this issue in our study due to sample size limitation. In intermediate subgroup, particularly in normal karyotype-AML, given the lack of convincing results, it seems unlikely that DNMT3A expression analysis could attract attention in diagnostic workup and risk prediction of AML.

Intact expression status of RASSF1A in acute myeloid leukemia

As a typical tumor suppressor gene, transcriptional silencing of ras-association domain family 1, isoform A (RASSF1A) is caused by biallelic methylation or the condition that one allele is methylated and then the other allele lost by allelic loss, as second hit. RASSF1A is inactivated epigenetically and thus down-regulated in many solid tumors. In summary, for the first time, we analyzed the expression status of RASSF1A in a cohort of 56 de novo acute myeloid leukemia (AML) patients using quantitative real-time polymerase chain reaction. Results of our study indicate that patients with AML exhibited no differences in the RASSF1A gene expression comparing to normal controls. In conclusion, expression status of RASSF1A remained intact in our target samples, indicating that RASSF1A expression variation does not participate in the pathogenesis and the progression of AML.