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Editorial

Ahmed Al Mandhari,¹ Rana Hajjeh,² Abdinasir Abubakar,³ Evans Buliva⁴ and Richard Brennan⁵

¹Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ²Director of Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ³Programme Area Manager, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Abdinasir Abubakar: This email address is being protected from spambots. You need JavaScript enabled to view it.). ⁴Technical Officer, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁵Regional Emergency Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Citation: Al Mandhari A; Hajjeh R; Abubakar A; Buliva E; Brennan R. Mitigating the resurgence of cholera in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):3–5. https://doi.org/10.26719/2023.29.1.3

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Countries in the WHO Eastern Mediterranean Region (EMR) are currently experiencing a resurgence of cholera. As of 31 December 2022, 8 of the 22 Member States in the region – Afghanistan, Islamic Republic of Iran, Iraq, Lebanon, Pakistan, Somalia, Syria, and Yemen – were grappling with outbreaks of cholera and acute watery diarrhoea (AWD). More than 1 000 000 suspected AWD/cholera cases, more than 7500 laboratory-confirmed cases, and 375 cholera-associated deaths were reported across the region in 2022 (1).

Cholera is an acute diarrhoeal disease caused by infection of the intestine with the bacterium Vibrio cholerae, either type O1 or type O139 (2). It is transmitted by ingestion of water or food that is contaminated with infected faecal matter, and remains an ever-present risk in many countries (2). The risk factors for cholera are inadequate or poor water and sanitation infrastructure, the impact of climate change, natural disasters, and the effects of humanitarian emergencies which precipitate population movements, overcrowding, and inadequate access to healthcare services, clean water, sanitation and hygiene (WASH) facilities (3).

People infected with cholera may experience mild to severe watery diarrhoea, vomiting, with resultant dehydration. Almost 20% of persons infected with V. cholerae develop acute watery diarrhoea and approximately 20% of these will develop severe dehydration. The case fatality ratio (CFR) for untreated patients may be 30–50%. However, the clinical management of cholera patients is straightforward – primarily oral rehydration and antibiotics for severe cases – and, if provided rapidly and appropriately, the CFR should remain below 1% (4,5).

Oral cholera vaccines (OCV) have increasingly become a vital addition to the cholera prevention and control toolkit, helping to reduce the burden of disease and complementing primary interventions such as safe water provision and the improvement of sanitation services. Studies have shown OCV to be effective and to have a good safety profile, substantially reducing the burden of disease and greatly contributing to long-term cholera control (6). The vaccines are safe for use among individuals ≥ 1 year of age, including pregnant and non-pregnant women, and immunocompromised individuals (6). The recommendation for OCV administration is 2 liquid doses given orally 14 days apart, however, a recent shortage in the global vaccine stockpile has made WHO to temporarily limit all reactive OCV campaigns to a single dose until vaccine supplies stabilize (7).

Globally, the number of cholera outbreaks has increased significantly from an average of 20 per year in 2017–2021 to 29 in 2022. In addition to previously active outbreaks, 13 new outbreaks were reported by different countries in 2022, and 5 of these outbreaks were in the EMR. This surge in cholera outbreaks worldwide has resulted in a shortage of cholera diagnostic and treatment kits as well as OCV (8).

Afghanistan, Pakistan, Somalia, and Yemen are endemic for cholera, with cholera cases associated with sustained local transmission documented consistently over the past 3 years. Iraq reported its last cholera outbreak in 2017 (9). The recent cholera outbreaks in Syria and Lebanon are alarming as these two countries have not been endemic for cholera (10,11); they last experienced cholera outbreaks 2 and 3 decades ago, respectively (10,11). The conflicts in Syria and the economic and political crises in Lebanon have resulted in mass population movements and deterioration of the WASH infrastructure, and the sanitation and waste management systems (10).

The WHO risk assessments have noted that the re-emergence of cholera in Syria and Lebanon is alarming as it increases the risk of cholera outbreaks in other countries in the EMR (7). Therefore, neighbouring countries, such as Jordan and occupied Palestinian territory, are taking active steps to strengthen preparedness for potential cross-border spread.

Severe flooding in Pakistan, earthquakes and drought in Afghanistan, and severe drought in Somalia have significantly increased the number of cholera cases in these countries (12,13). Given the large population movements across its borders, the cholera outbreak in the Islamic Republic of Iran is attributed to importation from the neighbouring cholera-reporting countries.

The current outbreaks in the region are disproportionately affecting children. More than half of suspected cholera cases in Afghanistan (55%) and Somalia (65%) are children under 5 years of age, and the proportion of under-5 children among the suspected cholera cases in Lebanon and Yemen are 26% and 24% respectively (7). This unusually large proportion of children affected by cholera indicates the urgent need for further investigation and intervention. WHO is strengthening laboratory capacities to identify and manage other causes of acute diarrhoeal diseases, especially among under-5 children, enhancing under-5 immunization activities, and strengthening the identification and management of children who may be coaffected by cholera and acute malnutrition.

In 2017, The Global Task Force on Cholera Control (GTFCC) launched the ‘Ending Cholera Road Map’ — a strategy that aims to reduce global cholera deaths by 90% and eliminate the disease in at least 20 countries by 2030 (14). The roadmap lists 9 EMR countries of Afghanistan, Djibouti, Islamic Republic of Iran, Iraq, Pakistan, Somalia, Sudan, Syria, and Yemen as having populations living in cholera hotspots. Response strategies must focus on improving access to clean water and appropriate sanitation along with hygiene, raising public awareness by engaging communities, and strengthening surveillance systems to early-detect and support timely and coordinated response, including quality clinical care (15). Progress is being made in the EMR to achieve the objectives of the strategy. WHO is supporting the ministries of health to strengthen their prevention and response strategies in the areas of coordination, risk assessment and response planning, epidemiological analysis to identify cholera hotspots, outbreak surveillance, laboratory confirmation, clinical case management, improving infection prevention and control (IPC) measures in health facilities, engaging with communities, deployment of oral cholera vaccines, and working closely with UNICEF and other partners to enhance WASH measures. WHO is also supporting countries in the region to develop national cholera plans and multisectoral advocacy for long-term prevention and control (7,16).

WHO is working closely with the 8 ministries of health in the affected countries to provide the needed technical guidance on surveillance and case detection, clinical management, IPC, enhancing laboratory testing capacities, promoting awareness among the populations, and continuing to monitor water quality in high-risk areas. Capacities for clinical management of cholera were lost in non-endemic countries due to decades of not experiencing cholera outbreaks, and this has had an impact on the outcome of patients. WHO has, therefore, recommended the need to conduct refresher training for primary care physicians in the region. WHO supported the deployment of OCV in Lebanon, Pakistan, Somalia, and Syria in 2022 and is closely working with other partners in a multisectoral approach to improve WASH and related interventions. WHO continues to advocate at global, regional and country levels and to engage and mobilize donors to invest in water and sanitation infrastructure in local communities. WHO’s cholera response in the EMR will contribute to the overall regional strategic priority of addressing health emergencies and the strategic objective of strengthening capacities to prevent and control epidemics and pandemics.

Key WHO recommendations for prevention and control of cholera in the EMR

Despite the challenges in eliminating cholera in the endemic EMR Member States, it is important to enhance cholera response to minimize the risk of future rebounds and spikes (17). It is critical for governments to advocate for and coordinate a multisectoral cholera prevention and control approach. Long-term investment by Member States and donors is essential to rebuild and improve WASH infrastructure. Cholera outbreaks have wider societal implications beyond the health sector and an impact on economies, trade, and tourism. It is therefore vital to prevent the recently affected countries, like Lebanon and Syria, from becoming endemic for cholera.

Effective implementation of the proposed WHO EMR cholera strategic framework, which emphasises real-time surveillance, outbreak detection and response, timely access to appropriate case management and cholera vaccines, enhancing WASH, and strengthening risk communication and community engagement, will significantly reduce cholera morbidity and mortality in countries.

In spite of these strategies, some challenges remain, including protracted conflict and emergencies, political instability, deteriorating economic situation, and climate change coupled with recurrent natural disasters (17). Many countries in the region have weak and underfunded health systems, with weak institutional capacities compounded with high turnover among skilled staff, especially in endemic cholera countries. Political interference, lack of transparency by governments, and non-adherence to the IHR-2005 obligations of reporting cholera and sharing data are areas that need urgent attention. National response measures are still not holistically robust, with insufficient implementation of multi-sectoral response (4).

Timely uptake of OCV as part of a comprehensive toolkit would significantly reduce case burden during outbreaks and prevent future occurrences at hotspots, noting that cholera vaccination is most important for short- to medium-term prevention and control while longer-term interventions for water and sanitation infrastructure systems are being established. Considering the increasing geographic spread of cholera and the global shortage of vaccines and other control tools, countries should invest more in WASH, surveillance, risk communication, and community engagement (8,10,15). Responding to cholera outbreaks is important, but greater investment in cholera prevention and preparedness, including WASH and health infrastructure, remains critical as we strive to ensure Health for All by All (8).

References

1. World Health Organization. Epidemic and pandemic-prone diseases. Cairo: WHO Regional Office for the Eastern Mediterranean, 2022. http://www.emro.who.int/pandemic-epidemic-diseases/outbreaks/index.html.
2. Deen J, Mengel MA, Clemens JD. Epidemiology of cholera. Vaccine. 2020;(38)Suppl 1:A31–40.
3. Federspiel F, Ali M. The cholera outbreak in Yemen: lessons learned and way forward. BMC Public Health. 2018;18(1):1338.
4. Al-Mandhari A, Musani A, Abubakar A, Malik M. Cholera in Yemen: concerns remain over recent spike but control efforts show promise (Editorial). East Mediterr Health J 2018;24(10):971–2.
5. Chen YT, Tang HJ, Chao CM, Lai CC. Clinical manifestations of non-O1 vibrio cholerae infections. PLOS ONE. 2015;10(1):e0116904.
6. World Health Organization. Cholera vaccine: WHO position paper, August 2017. Vaccine. 2018;36(24):3418–20.
7. World Health Organization. Cholera – global situation. Disease Outbreak News, 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426.
8. Taylor L. Cholera: WHO rations vaccines to preserve stocks amid rising outbreaks. BMJ. 2022;379:o2528.
9. Qamar K, Malik UU, Yousuf J, Essar MY, Muzzamil M, Hashim HT, et al. Rise of cholera in Iraq: A rising concern. Ann Med Surg 2012. 2022;81:104355.
10. Devi S. War driving cholera in Syria. Lancet Lond Engl. 2022;400(10357):986.
11. Lebanon is at risk to future cholera outbreaks. Oxford Analytica Daily Brief, 2022. https://dailybrief.oxan.com/Analysis/ES273859/Lebanon-is-at-risk-to-future-cholera-outbreaks.
12. Reda A, Sah R, Abdelaal A, Shrestha S, Rodriguez-Morales AJ. The emergence of cholera in multiple countries amidst current COVID-19 pandemic: Situation and implications for public health and travel medicine. Travel Med Infect Dis. 2022;49:102423.
13. Wang P, Asare E, Pitzer VE, Dubrow R, Chen K. Associations between long-term drought and diarrhea among children under five in low- and middle-income countries. Nat Commun. 2022;13(1):3661.
14. GTFCC. Ending Cholera: A Global Roadmap to 2030. Geneva: World Health Organization. https://www.who.int/cholera/publications/global-roadmap.pdf.
15. Enteric and diarrhoeal diseases surveillance, prevention and control in the Eastern Mediterranean Region. East Mediterr Health J. 2020;26(11):1430–1.
16. World Health Organization. WHO Regional Director’s statement on cholera outbreaks. Cairo: WHO Regional Office for the Eastern Mediterranean, 15 Jan 2022. http://www.emro.who.int/media/news/who-regional-director-for-the-eastern-mediterraneans-statement-on-cholera-outbreaks.html.
17. Brennan R, Hajjeh R, Al-Mandhari A. Responding to health emergencies in the Eastern Mediterranean region in times of conflict. Lancet Lond Engl. 2020;399(10332):e20–2.

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Shahrokh Izadi,¹ Mahdi Mohammadi,² Majid Sartipi,² Manoochehr Karami³ and Hossein Karimi⁴

¹Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran (correspondence to: Shahrokh Izadi: This email address is being protected from spambots. You need JavaScript enabled to view it.). ²Department of Epidemiology and Biostatistics; ⁴Health Promotion Research Centre, School of Public Health, Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran. ³Department of Epidemiology, Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Islamic Republic of Iran.

Abstract

Background: Since November 2014, the pentavalent (Diptheria+Tetanus+Pertussis and Hepatitis B and Hib or DTP-HB-Hib) vaccine has been integrated into the Iranian national vaccination programme.

Aims: We conducted a prospective study in Zahedan in the southeast of the Islamic Republic of Iran to determine the incidence of adverse events following immunization (AEFI) with the pentavalent vaccine in children aged under one year.

Methods: Using cluster sampling, 1119 children aged 2–10 months at 15 public health clinics were invited, through their parents, to participate in the study. The parents were trained to register and report any AEFIs in a questionnaire. They were instructed to return the child to the clinic for further examination by a physician if they observed any complications within 3 days of vaccination.

Results: The most commonly reported AEFIs were fever (50.94%), mild (41.46%) and severe (1.70%) injection site complications, persistent crying for 3 hours or more (1.88%), hypotonic hyporesponsive episode (0.36%), vomiting (1.88%), diarrhoea (2.95%), and sterile abscess (0.62%). There were no cases of convulsion, purulent abscess or rash. The work experience of vaccinators (OR = 1.85; 95% CI: 1.4–2.46) showed a significant statistical association with the incidence of mild local complications at the injection site. Those with a history of Bacillus Calmette–Guérin (BCG) lymphadenitis (OR = 3.89; 95% CI:1.04–14.49) had a higher risk of severe local complications at the injection site.

Conclusions: The observed incidence of serious AEFIs following pentavalent vaccine injection in the study population was within the expected range. However, some of the relationships observed in this study require further research.

Key words: DTP-HB-Hib, pentavalent vaccine, adverse event following immunization, Iran

Citation: Izadi S; Mohammadi M; Sartipi M; Karami M; Karimi H. Acute adverse events following immunization with DTP-HB-Hib pentavalent vaccine in the first year of life. East Mediterr Health J. 2023;29(1):6–14. https://doi.org/10.26719/emhj.23.002 Received: 22/10/20; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

No drug or vaccine is completely harmless. Adverse event following immunization (AEFI) has been defined as “any untoward medical occurrence which follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine” (1). There are 5 categories of AEFI: vaccine product-related reaction, vaccine quality defect-related reaction, immunization error-related reaction, immunization anxiety-related reaction and coincidental event (1,2).

Many countries, e.g. India, Indonesia, the Islamic Republic of Iran, Mexico and the United Kingdom, have combined the diphtheria–tetanus–pertussis (DTP) vaccine with the Haemophilus influenzae type b (Hib) vaccine and a fifth vaccine, usually hepatitis B or polio vaccine (or both), as part of a penta- or hexa-valent vaccine in their national immunization programmes. Most studies on these multivalent vaccines in these countries have focused on their efficacy and safety; fewer have looked at the AEFIs (3–6).

The pentavalent vaccine, which was integrated into the Iranian national vaccination programme in November 2014 in addition to the diphtheria, tetanus and pertussis vaccines, provides protection against hepatitis B and H. influenzae type b (Hib) (4). According to the national vaccination programme, each child must receive the pentavalent vaccine 3 times at intervals of 2 months. The first is usually at the end of the second month of life. Since the introduction of the pentavalent vaccine into the national immunization programme, only a few studies have been conducted on the frequency of AEFIs following administration. Since the vaccine is produced by different manufacturers in different countries, it has not been easy to determine the exact relationship between vaccine quality and vaccine production, and no detailed study has yet been conducted to determine this relationship.

In this study, we measured the frequency and investigated the possible causes of acute complications after the injection of the pentavalent vaccine within the first 72 hours after injection.

Methods

Zahedan is the capital of Sistan-va-Baluchestan province, located in the southeast of the Islamic Republic of Iran. According to the latest national census (2016), the population of Zahedan was about 600 000, with 18 000 children under one year old. In this short-term prospective study, the study population comprised all children aged under one year living in the urban areas of Zahedan who were healthy and eligible to receive the pentavalent vaccine.

In the Islamic Republic of Iran, health workers in charge of urban and rural health centres carry out local household visits at the beginning of each year to refresh information for the population under their coverage. For newborns who do not yet have a file, a vaccination card is issued and an electronic file is created in the health information system, the Integrated Comprehensive Health Information System (locally known as Samaneh SIB). If the parents do not bring their children for immunization on time, the clinic will contact them and may visit their homes if necessary.

The most important criterion for participating in the study was eligibility for the pentavalent vaccine injection. Children with major underlying diseases such as thalassaemia, diabetes or immunodeficiency virus infection were not invited to take part in the study. Other than that, there were no restrictions on children entering the study.

We used 2 questionnaires in this study. The first was the parents’ questionnaire, which had 6 questions about the symptoms of localized inflammation at the injection site, the child’s axillary temperature, vomiting, seizures, persistent crying attacks that last for 3 hours or more, severe watery diarrhoea and a hypotonic hyporesponsive episode, along with the time and date of each symptom.

In accordance with the national immunization schedule, every child must receive the pentavalent vaccine at least 3 times during the first year of life, preferably at the ages of 2, 4 and 6 months. So, in this short-term prospective cohort study, 3 groups of children were enrolled. One group (mostly about 2 months old) were those receiving their first dose of pentavalent vaccine, the second group (about 4 months old) were receiving their second dose and the third group (mostly around 6 months old) were receiving their third dose. The duration of follow-up for each child was at most 3 days from the time of the injection.

Parents who came with their children for vaccination between July and November 2019 were interviewed and informed about the importance of their participation in this study and asked for their consent for their child to participate in the study. After registering their consent, the training to complete the parents’ questionnaire was provided. For parents who were illiterates, consent was verified orally in the presence of a witness. There was no compulsion to participate in the study and routine vaccination services were provided to clients who did not wish to participate. Each of the participating children was followed up to evaluate the AEFI of only one dose of the vaccine that they were receiving for the first, second or third time.

Parents were asked in the parents’ questionnaire to record any side-effects they observed in their children within 3 days of their vaccination and to bring the child to the health centre if they noticed fever and/or any other complication so that caregivers could perform more comprehensive examinations and treatments. For parents who were illiterates, a literate relative was requested to help them complete the questionnaire. Parents were asked to submit the completed questionnaire to the vaccinator on the fourth day after vaccination. The vaccinator then completed the second questionnaire, which had more comprehensive questions, during a brief interview with the parents at the health centre. If they did not return the questionnaire for any reason, it was collected during a visit to their home and the second questionnaire was supposed to be completed there. During the 3 days that parents registered their children's complications in the questionnaire, if there was, for any reason, a need for further investigation, the physician in charge of the health clinic was required to examine the children more closely and comprehensively and order any necessary prescriptions and treatments. Primary health care, including the immunization programme and the services for diagnosing and treating AEFIs are free.

The second questionnaire contained 39 questions. The first 20 covered household demographic information, including the child’s birth date, their height and weight, sex, education level of parents, type of nutrition during the first 6 months of life, height and weight of the child at birth, nationality of the child, vaccination schedule, work experience of the health worker in charge of her/his vaccination (i.e. the vaccinator) and the serial number and manufacturer of the vaccine.

Unless explicitly stated, all definitions and cut-offs detailed in this study have been adapted from the reference book “Causality assessment of an adverse event following immunization (AEFI)”, which was the latest version at the time this study was conducted (1). In the questionnaires, the complications of vaccination (as outcome variables) were divided into 2 categories, topical and systemic complications. Topical complications were further divided into 2 categories, mild and severe. Swelling, redness of the skin and mild pain at the injection site, resolving within a maximum of 2 days, were considered as mild complications, while continuation of these symptoms for 3 days or more or the addition of joint pain and swelling to these symptoms or the need for hospitalization were classified as severe complications. The incidence of abscesses (sterile or infectious) within 3 days of vaccination was recorded separately as a severe complication.

Occurrence of any of the following signs and symptoms within 3 days of vaccination was considered a systemic complication: fever (body temperature 37.5 °C to 38.4 °C as mild; 38.5 °C and above as severe); continuous, persistent crying attack with restlessness for more than 3 hours, beginning at latest one hour after vaccination; hypersensitivity reactions; frequent vomiting within 3 days of vaccination; seizures; severe watery diarrhoea more than 3 times in 24 hours; and hypotonic hyporesponsive episode (sudden paleness with decreased response and decreased muscle tone, sagging and numbness of the hands and feet) (1).

All the injections were given intramuscularly in the anterolateral thigh muscle using 16mm syringes and standard methods and equipment.

To calculate the sample size, we considered the incidence rate of AEFI after a pentavalent injection to be 17% (7). With an accuracy of estimation (d) = 4%, type one error as large as 5%, and the design effect of the cluster sampling (health clinics as clusters) = 1.1, and given that the vaccine is administered 3 times during the first year of life, the sample size was multiplied by 3, so the final sample size was estimated at 1119.

There were 85 health clinics in Zahedan city. To distribute the sample in these centres, Zahedan was first divided into 5 equal zones in terms of population size, then 3 health clinics were selected from the list of centres located in each zone using a random numbers table, each clinic being considered as a cluster, with a total of 15 clusters. Subsequently, sampling was carried out at each facility in a consecutive manner and children under one year who were referred to health centres to receive their first, second or third pentavalent vaccine were invited to take part in the study. In each health clinic, care was taken to enrol an equal proportion of children who were to receive their first, second or third pentavalent vaccines. Most of the children invited were aged 2, 4 and 6 months.

Data collected were entered into a Microsoft Access database and analysed using STATA, version 11.2. Incidence rates along with their 95% confidence intervals (CIs) were calculated and reported. In monovariate analysis, the independent sample Student t-test, Fisher’s exact test, Chi-square test and odds ratios were used. In multivariate analysis, logistic regression was used to examine the relationships and eliminate the effect of confounders. The backward elimination procedure was used to select a model. To find confidence intervals for the model parameters, the asymptotic standard errors were used. In all instances, the 95% CIs were calculated and the cut-off for judging the relationship was P-value < 5%. Where applicable, the results have been reported as mean and standard deviation.

The ethics committee in medical research of Zahedan University of Medical Sciences reviewed and confirmed the protocol of the study (Ethics code: IR.ZAUMS.REC.1398.115).

Results

In total, the parents of 1119 children aged 2–10 months were invited to enrol their children in the study. One third of these children received the vaccine for the first time, one third for the second time and one third for the third time. Table 1 shows the characteristics of the participants in each group.

Fever was the most common complication after a pentavalent injection (the frequency of axillary temperature < 38.4° C = 42.81% and ≥ 38.5° C = 8.13%). The frequency of mild local complications at the injection site was 41.47% and that of severe local complications 1.70%. Table 2 shows the frequency of all reported AEFIs. Seizures occurred in only one case, 4 hours after the third injection of the pentavalent vaccine in a 6-month-old female child (age 188 days). The diagnosis of seizure in this child was based on the descriptions given by the parents, and the possibility of misdiagnosis could not be ruled out. There was no way for the doctor at the centre to confirm the occurrence of the seizure. In addition to the seizures, the child had a severe localized complication and a mild fever (37.5–38.4° C). According to the parents, she had no previous history of epilepsy or any similar condition.

Table 3 shows the results of crude and multivariate analyses (using logistic regression) of the relationship between AEFIs and participants’ characteristics. Two separate models were fitted for 2 different outcomes. Model Number 1 was fitted for mild local injection site complications vs none, therefore, 19 participants with severe local injection site complications were not included in this model. It was not possible to enter the 2 variables in the same model since, due to the high correlation between the level of education of mothers and fathers, the coefficient related to the level of education of the father was calculated and reported from a separate similar model. In this model, of the 3 vaccine manufacturers, the one showing the lowest incidence of the outcome (identified as No. 1) was considered the baseline. The chance of developing a complication for manufacturers Nos. 2 and 3 was more than 2–3 times that of manufacturer No. 1.

In Model Number 1, children without fever were considered as the baseline group. Birth weight and weight for age Z-score were the other 2 variables in this model that showed a statistically significant relationship with the chance of mild complications (P < 0.05).

Model Number 2 examined the relationship between this AEFI (severe vs mild and no local injection site complications) and other variables. Only 2 variables remained in this model, fever and history of BCG lymphadenitis. Fever over 38.4° C increased the chance of developing a severe injection site complication by more than 7 times (OR = 7.50; 95% CI: 2.23–25.22). Children with a history of BCG lymphadenitis were almost 4 times more likely to have a severe injection site complication (OR = 3.89; 95% CI: 1.04–14.49) (Table 3). Only 19 participants developed severe local injection site complications.

Discussion

In this short-term prospective study, we examined the incidence rate of acute complications associated with pentavalent vaccine in 1119 children aged 2–10 months. Fever was the most common complication after a pentavalent injection. The frequency of mild local complications at the injection site was 41.47% and that of severe local complications 1.70%. These findings were more or less similar to those of another study comparing the DTP vaccine with the pentavalent vaccine: fever was reported as the most common complication of the DTP vaccine (47.4%) and mild local complications at the injection site as the most common AEFI of the pentavalent vaccine (31.68%) (4). However, these results are slightly different from the findings of a similar study conducted in 2015 in Hamedan. In that study, the frequency of mild fever following injection of the pentavalent vaccine was reported as 12.6%, high fever as 0.1%, and swelling and redness at the injection site as 15.8% and 10.9% respectively (7). In a similar study on 173 infants aged 2–6 months in one of the northern provinces of the Islamic Republic of Iran, fever (54.0%) was the most common complication and the incidence of redness (5.7%) and swelling (6.9%) at the injection site were much lower (8).

In interpreting the statistical models in Table 3, it should be noted that the main purpose of including some variables, such as parents’ education level, birth weight and obesity index, was merely to control for their confounding effects. In most previous similar studies, these variables were not measured and no relationship was reported for them. Perhaps the main reason was that no specific etiological relationship between these variables and the occurrence of complications is conceivable. However, the effect of parent's education level on health literacy, and especially on immunization issues among their offspring, is indisputable, and has been repeatedly reported in other studies (9–11).

One of the most important factors showing a relationship with topical complications at the injection site was the vaccine manufacturer. In univariate analysis, the chances of a mild local complication varied from 3.0 to 3.9 times greater than baseline, depending on the manufacturer. In multivariate analysis, after eliminating the effects of confounding factors, the relationship of only one manufacturer with mild local complication remained statistically significant. This relationship between the vaccine manufacturer and complications may be attributed to one of the first 2 types of complications, i.e. vaccine product-related reaction or vaccine quality defect-related reaction (1,12). However, to substantiate this relationship and differentiate between relationships, more extensive, controlled studies with appropriate sample size in each group would be necessary. It should be noted that in this observational study, no intervention was carried out to balance the distribution of vaccines from different manufacturers between the participants with respect to their characteristics, and therefore the distribution observed in Table 1 is completely random. We did not find any other study examining such a relationship, and thus, whether this finding implies a causal relationship or is merely a result of chance and random variation remains to be determined in any future observations or studies. In the case of severe local complications, vaccine manufacturer did not show a statistically significant relationship. However, in interpreting and comparing these results, it should be noted that only 19 participants (1.70% of the total sample) had severe vaccine complications, i.e. presumably the sample size may not have been large enough to achieve a convincing conclusion.

There were no statistically significant differences between the children who received the pentavalent vaccine for the second or third time and the children who received the vaccine for the first time in regard to the frequency of any of the AEFIs (P > 0.05 for all). Considering the frequency distribution of the types of AEFI in Table 1, even without a statistical test, it is clear that there is no significant difference in this regard. In multivariate analysis, this variable (round of vaccination) did not remain in any of the models. None of the similar studies conducted in the Islamic Republic of Iran or other countries on the pentavalent vaccine, or similar vaccines, have considered this variable (3–5,7,8,11,13).

In Model Number 2, the factors associated with the occurrence of severe injection site complications were modelled. Only 2 variables remained, fever and history of lymphadenitis following congenital BCG vaccination at birth. Children with BCG lymphadenitis were almost 4 times more likely to have a severe injection site complication. Regional lymphadenitis is usually the most common feature of BCG-induced disease requiring medical attention; however, this relationship has not been reported in other studies, and whether our finding that it was about 4 times more likely was a chance result or a true relationship requires further study and observation (13,14). In Model Number 2, those children having a fever over 38.4° C had 7+ times greater chance of developing a severe injection site complication The association of these 2 complications with each other is probably a result of systemic inflammatory mechanisms.

Another interesting finding in this study was a higher chance of reporting a complication at the injection site among children whose vaccinators had more work experience (OR =1.87; 95% CI: 1.40–2.48, P-value < 0.001). The expectation would usually be the contrary. It is possible that those with more work experience need retraining, or perhaps those who are new are more cautious and follow the instructions more accurately. Whatever the reason, this is a finding that system administrators should take seriously and, on verification, seek to address the causes.

Mild fever (< 38.5° C) and mild local injection site complications were the most common complications observed in this study. Fever ≥ 38.5° C was observed in around 8% of children, and severe injection site complications in < 2%; the incidence of other complications was < 0.4–3.0%.

Comparing the findings of this study with similar studies in the Islamic Republic of Iran and other countries administering the pentavalent vaccine or other similar vaccines, this frequency of AEFIs may be considered to be as expected, and the use of this vaccine can be recommended. Using a pentavalent vaccine helps avoid the need to inject at least 3 types of vaccines differently. This is one of the important advantages of this vaccine.

Given that the follow-up period for children who participated in this study was not more than 3 days, based on our findings, it was not possible to comment on the long-term effects of this vaccine. Likewise, given that this study was not designed to compare vaccines produced by different manufacturers, it was not possible to comment definitively on the differences in the incidence of side-effects between the recipients of vaccines from different manufacturers. However, our results indicate that more detailed studies could provide more definitive information.

In reviewing the research literature, it appears that other studies have rarely addressed the details that have been considered in this study. While this makes the results of our study more interesting, it makes it difficult to find evidence to support them. On most of the issues raised by the study, confirmation or rejection of our findings are dependent on more detailed studies in the future, and many of the findings in this study should be considered as exploratory.

Acknowledgement

The authors and project executives would like to thank all the frontline health care providers, those to whom this work belongs.

Funding: This work was supported by Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran (grant number 9070).

Competing interests: None declared.

Manifestations postvaccinales indésirables aiguës liées au vaccin pentavalent DTC-HB-Hib au cours de la première année de vie

Résumé

Contexte : Depuis novembre 2014, le vaccin pentavalent (diphtérie, tétanos, coqueluche, hépatite B et Hib ou DTC-HB-Hib) est intégré au programme national de vaccination iranien.

Objectifs : Nous avons mené une étude prospective à Zahedan, dans le sud-est de la République islamique d'Iran, afin de déterminer l'incidence des manifestations postvaccinales indésirables (MAPI) liées au vaccin pentavalent chez les enfants âgés de moins d'un an.

Méthodes : Au moyen d'un sondage par grappe, 1119 enfants âgés de 2 à 10 mois fréquentant 15 centres de soins de santé publique ont été invités à participer à l'étude, par l'intermédiaire de leurs parents. Ces derniers ont été formés pour enregistrer et signaler toutes MAPI en répondant à un questionnaire. Ils ont reçu pour instruction de reconduire l'enfant au centre de soins de santé pour qu'il soit examiné de manière plus approfondie par un médecin s'ils observaient des complications dans les trois jours suivant la vaccination.

Résultats : Les MAPI les plus fréquemment signalées étaient les suivantes : fièvre (50,94 %), complications bénignes (41,46 %) et graves (1,70 %) au point d'injection, pleurs persistants pendant au moins trois heures (1,88 %), épisodes d'hypotonie-hyporéactivité (0,36 %), vomissements (1,88 %), diarrhée (2,95 %) et abcès stérile (0,62 %). Il n'y a pas eu de cas de convulsions, d'abcès purulent ou d'éruption cutanée. L'expérience professionnelle des agents de vaccination (OR = 1,85 ; IC à 95 % : 1,4-2,46) affichait une association statistique significative avec l'incidence des complications locales bénignes au point d'injection. Ceux qui avaient des antécédents de lymphadénite liée au vaccin Bacille Calmette-Guérin (BCG) (OR = 3,89 ; IC à 95 % : 1,04-14,49) présentaient un risque plus élevé de complications locales graves au point d'injection.

Conclusions : L'incidence des MAPI graves observée dans la population de l'étude après l'administration du vaccin pentavalent se situait dans la fourchette attendue. Toutefois, certaines des relations examinées dans la présente étude nécessitent des recherches plus approfondies.

الأحداث الضارة الشديدة بعد التطعيم باللقاح خماسي التكافؤ في السنة الأولى من العمر

شاهروخ إيزادي، مهدي محمدي، ماجد سرتبي، منوشهر كرامي، حسين كريمي

الخلاصة

الخلفية: أُدرِج اللقاح الخماسي التكافؤ (الدفيتريا + السعال الديكي (الشاهوق) + التيتانوس والتهاب الكبد B ولقاح المستدمية النزلية من النوع ب أو اللقاح الثلاثي HB-Hib) في برنامج التطعيم الوطني الإيراني منذ نوفمبر/ تشرين الثاني 2014.

الأهداف: هدفت هذه الدراسة الاستباقية التي أجريت في زاهدان، بجنوب شرق جمهورية إيران الإسلامية، الى تحديد معدل وقوع الأحداث الضارة بعد التطعيم باللقاح الخماسي في حالة الأطفال الذين تقل أعمارهم عن عام واحد.

طرق البحث: باستخدام الطريقة العنقودية لأخذ العينات، دُعي 1119 طفلًا، تتراوح أعمارهم بين شهرين و10 أشهر للمشاركة في هذه الدراسة في 15 عيادة صحية عامة، ووُجهت الدعوة إلى آبائهم. وجرى تدريب الآباء على تسجيل كل حدث ضار بعد التطعيم والإبلاغ عنه في استبيان. كذلك طُلب من الآباء التوجه بالطفل إلى العيادة ليُجري الطبيب المزيد من الفحوص، إذا لاحظوا مضاعفات خلال 3 أيام من تلقِّي اللقاح.

النتائج: كانت أكثر الأحداث الضارة بعد التطعيم شيوعًا: الحمى (50.94%)، والمضاعفات المتوسطة (41.46%)، والمضاعفات الشديدة (1.70%) في موضع الحَقْن، والبكاء المستمر 3 ساعات أو أكثر (1.88%)، ونوبات نقص استجابة الدم لنقص التوتر (0.36%)، والقيء (1.88%)، والإسهال (2.95%)، والخراج العقيم (0.62%). ولم تُسجل حالات تشنُّج أو خراج قيحي أو طفح جلدي. وأظهرت الخبرة العملية للقائمين على التطعيم (نسبة الأرجحية = 1.85؛ 95% فاصل الثقة: 1.4 – 2.46) ارتباطًا إحصائيًّا كبيرًا، مع حدوث مضاعفات موضعية خفيفة في موضع الحَقْن. وأولئك الذين سبق أن أُصيبوا بالتهاب الغدد الليمفاوية بعصيات كالميت جيران (BCG) أكثر عرضة للمضاعفات الموضعية الحادة في موضع الحقن (نسبة الأرجحية = 3.89؛ 95% فاصل الثقة: 1.04 – 14.49).

الاستنتاجات: إن معدل ملاحظة وقوع أحداث خطرة ضارة بعد التطعيم بتلقِّي حَقْن اللقاح الخماسي التكافؤ بين مجتمع الدراسة ضمن النطاق المتوقع. ورغم ذلك، فإن بعض العلاقات التي لوحظت في هذه الدراسة تستحق المزيد من البحث.

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Ali Ghaddar,^1,2,3 Sanaa Khandaqji,² Rawad Kansoun⁴ and Ali Ghassani⁵

¹Public Health Research Group, University of Alicante, Alicante, Spain (Correspondence to: A. Ghaddar: This email address is being protected from spambots. You need JavaScript enabled to view it.). ²Observatory of Public Policies and Health, Beirut, Lebanon. ³Department of Biomedical Sciences, Lebanese International University, Saida, Lebanon. ⁴Department of Communication Arts, Lebanese International University, Beirut, Lebanon. 5Amel Association, Beirut, Lebanon.

Abstract

Background: Polymerase chain reaction is a well-known method for testing COVID-19 infection, however, refugee populations often face difficulties in accessing testing. Several structural and cultural challenges have hindered access of Syrian refugees to COVID-19 testing in Lebanon, including financial barriers, stigma, and low perception of vulnerability.

Aims: To explore barriers to accessing COVID-19 testing by Syrian refugees in Lebanon. 

Methods: This qualitative study conducted 10 focus group discussions among Syrian refugees and 21 individual semi-structured interviews with healthcare workers. Ethical approval was obtained from the Institutional Review Board of the Lebanese International University, and the study followed the ethical principles of the Declaration of Helsinki.

Results: Syrian refugees in Lebanon did not consider COVID-19 testing to be important. Despite the availability of free testing services, psychological, cultural, environmental, and financial barriers hindered them from getting tested. Some of them relied on consultation with pharmacists, who were easy to access and provided symptomatic treatment without the need to test for COVID-19. Fear of stigma, deportation, and isolation were common cultural barriers. Testing was considered unnecessary because of the perception of low disease severity and an attitude of negligence towards preventive practices. The harsh economic and living conditions were of greater concern to the refugees.

Conclusion: Findings from this study add to existing literature regarding the social and cultural barriers to COVID-19 testing among Syrian refugees and should be considered when tailoring health promotion campaigns to halt the spread of the COVID-19 pandemic.

Keywords: COVID-19, laboratory test, refugees, stigma, Syria, Lebanon

Citation: Ghaddar A; Khandaqji S; Kansoun R; Ghassani A. Access of Syrian refugees to COVID-19 testing in Lebanon. East Mediterr Health J. 2023;29(1):15–23. https://doi.org/10.26719/emhj.23.001 Received: 16/06/22; accepted: 05/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Since January 2020, COVID-19 has affected over 220 countries, with > 263 million infections and > 5.2 million deaths globally (1). COVID-19 poses a major public health concern because of the high transmissibility of SARS-CoV-2, compared with other coronaviruses, through respiratory droplets and contact. Thus, testing remains a crucial preventive and diagnostic measure (2). Delays in detection and diagnosis can hamper national and international efforts to contain the pandemic (3).

Inequity in COVID-19 testing has been reported in various contexts and populations. Limited access to testing in rural and low socioeconomic status communities has been reported in the United States of America (USA), and was associated with confusion in understanding testing guidelines (4). In the United Kingdom of Great Britain and Northern Ireland, testing inequity has been reported among ethnic minorities and marginalized communities (5). In the USA, the cost of testing was a barrier, especially among minorities, including non-US citizens and immigrants (6). Poor awareness of symptoms and geographical access were other barriers to testing (7,8). In developing countries, limited geographical access and delay in reporting results were cited as barriers to testing (9). Cognitive and emotional barriers to testing included fear of pain and infection during testing (10). 

Refugee populations have been largely neglected in the COVID-19 response, and have suffered from a critical shortage of testing resources worldwide (11). The COVID-19 pandemic has highlighted existing disparities in accessing healthcare services globally, particularly among vulnerable groups such as refugees (12). According to the United Nations High Commissioner for Refugees (UNHCR), Lebanon hosts the largest number of refugees per capita, with ~1.5 million registered Syrian refugees since the beginning of the Syrian war in 2011 (13). The majority of Syrian refugees in Lebanon live in overcrowded camps or informal settlements with precarious living conditions, or in rented houses in low socioeconomic areas. This means that testing has become more important in preventing viral transmission, under conditions where physical distancing and isolation are not viable (14,15).

When the first case of COVID-19 in Lebanon was confirmed in February 2020, the Lebanese Ministry of Public Health offered free COVID-19 testing for symptomatic patients at government hospitals and through random community testing (16). Since then, the number of healthcare organizations offering COVID-19 polymerase chain reaction (PCR) testing has increased. However, logistic barriers to accessing such organizations, as well as the financial burden of testing at other approved testing facilities (80% of which are private hospitals and laboratories), have rendered COVID-19 testing inaccessible to most of the population, including Syrian refugees (17). The response strategy of the ministry to the pandemic failed to adequately address eligibility criteria for free COVID-19 testing, including for Syrian refugees, which is critical considering that > 90% were below the poverty line and facing affordability challenges (18). 

UNHCR cover the cost COVID-19 testing and treatment for Syrian refugees in Lebanon in coordination with the Lebanese Ministry of Public Health (19). Several nongovernmental organizations (NGOs), alongside UNHCR, have implemented various COVID-19 preventive measures, such as awareness sessions and distribution of hygiene kits. However, the temporary nature of activities implemented by NGOs due to limited resources and donor fatigue made the response to the pandemic in a refugee context challenging (20). Lebanon was in the midst of its worst economic crisis in decades, which posed additional challenges to an already overworked, underfunded national healthcare system (21,22).

Barriers to testing among Syrian refugees in Lebanon include lack of financial resources, as refugees who cannot afford the test (equivalent to US$10) isolate in their tents, unaware that UNHCR covers the cost of testing (23). Another barrier to testing is fear of stigma from the surrounding community. Reluctance to test is exacerbated by: the challenges of security checkpoints, which may induce fear because of refugees’ legal status and unavailability of registration papers; logistic barriers affecting accessibility of the nearest testing centres; and discrimination during testing from the surrounding community (24). The COVID-19 pandemic is largely perceived by Syrian refugees as propaganda, and many have conspiracy beliefs, and therefore do not believe in PCR testing (24). The dire economic situation has made the pandemic less of a priority for refugees than securing their daily livelihood, and fear of starvation exceeds that of COVID-19, which affects willingness to test (14). However, barriers to testing are not fully understood in the refugee context (15).

Accurate data on the prevalence and testing rate of COVID-19 among Syrian refugees are lacking, and there is a need to understand the different environmental, cultural, and social factors that affect COVID-19 testing. The aim of this study was to explore the barriers related to accessing COVID-19 PCR testing among Syrian refugees in Lebanon. 

Methods

Study design and population

This qualitative study was performed in September 2021 by conducting focus group discussions among Syrian refugees, and personal semistructured interviews with healthcare workers that provided healthcare services for Syrian refugees in Lebanon. 

Three of the 5 governorates in Lebanon were included in the study as they hosted the majority of the refugee population: Bekaa (350 560 refugees), Beirut (259 350 refugees), and South Lebanon (90 832 refugees) (25). The study population comprised both male and female Syrian refugees, married and unmarried, and aged > 18 years. We considered refugees living in camps and in rented houses in cities. After obtaining the list of refugee camps from UNHCR, we randomly selected 2 each from Bekaa and South Lebanon. In Beirut, most refugees lived in rented houses and were approached in the premises of the healthcare organizations that provided healthcare services to Syrian refugees. Two healthcare organizations were chosen randomly from 14 centres in Beirut run by a partner organization, Amel Association (NGO with primary healthcare centres in all Lebanese regions), which has been providing healthcare and social welfare services to Syrian refugees since 2016 (26).

The study population included healthcare workers with at least 1 year of experience in public or private organizations or NGOs providing health services to Syrian refugees in Lebanon. Twenty-one healthcare workers were randomly selected for individual interviews from healthcare centres run by NGOs and from private and governmental laboratories providing PCR testing in the selected study regions. 

Data collection

The study was approved by the Ethical Committee of the Lebanese International University (reference number: LIUIRB-210524-SK-040). Three researchers trained in qualitative techniques were recruited and trained in the framework of the study. Data collectors did not have any relationship with any of the interviewees. Data were collected during the first 3 weeks of September 2021.  

Focus group discussions with refugees living in camps were conducted in Bekaa and South Lebanon in coordination with Amel, which arranged the logistics, official permits, and appointments with refugees. Researchers approached the refugees in the backyards of the tents in the camps. Refugees living in rented houses in Beirut were approached at supermarkets and were invited to participate in the focus group discussions that were held at Amel Association centres. Healthcare workers were interviewed in the health centres in the 3 governorates visited by the refugees. None of the selected participants refused to be interviewed.

The researchers introduced the objectives of the study and obtained verbal informed consent (refugees were unfamiliar with the research modalities and were reluctant to sign). Participants were assured that information would be kept confidential and anonymous.

All semistructured interviews and focus group discussions were conducted in Arabic, and were recorded using a digital audio recorder. Field notes were taken after concluding the interviews. Interviews and discussions lasted approximately 25 and 50 minutes, respectively. The guidelines for focus group discussions with refugees included questions related to 3 main areas: attitudes toward COVID-19 (perceived severity and vulnerability); attitudes towards PCR testing (importance and availability); and use of testing services (facilitators and barriers to testing). Examples of questions included: (1) To what extent do you perceive that you and your family members are susceptible to COVID-19? (2) How serious is COVID-19 infection? (3) If you have experienced COVID-19-like symptoms, have you gone for a PCR test? The guidelines for interviews with healthcare workers included questions related to the prevalence of testing and barriers to testing. Examples of questions included: (1) Can you describe the barriers to conducting PCRs among refugees (financial, geographical, transportation, cultural, and environmental). (2) Can you describe the cultural factors that shape refugees’ decision to test? (3) Do you trust physicians and the healthcare service providers?

The required number of interviews was decided after attaining data saturation (27), when no new information was likely to be obtained in answering the study objectives, and sufficient information was gathered to replicate the findings (28). A total of 84 Syrian refugees (61 female and 23 male) participated in 10 focus group discussions (8–10 in each group). Five discussions were conducted in refugee camps (3 in Bekaa and 2 in South Lebanon) and 5 with refugees living in rented houses, interviewed at the Amel Association health centre in Beirut. Participants were aged 18–55 years and had resided in Lebanon for at least 1 year. We interviewed 21 healthcare workers, including physicians, laboratory directors and technicians, nurses, and social workers. The sociodemographic characteristics of the participants are shown in Table 1.

Data analysis

Data were transcribed into English and entered into Atlas Ti5 software for qualitative analysis. The analysis aimed to identify emergent themes extracted from the content of the interviews. Thematic analysis was applied to data to investigate their content and to provide an understanding of the barriers and facilitators to COVID-19 testing. Data were described after coding, categorizing, and assembling the themes. Phrases with similar meanings were identified, and coded and grouped by the first and second authors to form categories. Illustrative quotes were selected to support interpretation of the results.

Results

Table 2 provides the detailed themes, subthemes, and representative quotes retrieved from the interviews and focus group discussions.

COVID-19 test utilization

Healthcare workers at NGO clinics and private laboratories expressed concern about low COVID-19 testing rates, whereas those at public hospital laboratories did not perceive low testing rates: “I am not aware that there are barriers to testing among refugees; we conduct many tests daily” (Laboratory Director, Public Hospital, Beirut). Further analysis of the interviews clarified that many refugees did not use COVID-19 testing services or did not consider them to be important. Refugees only underwent testing when obliged to do so, such as for travel or hospital admission. One ethical violation emerged in the conduct of COVID-19 testing, with some laboratories accused of selling fake reports with negative results.

Availability and geographical accessibility to testing services

Healthcare workers indicated that free COVID-19 testing services were widely available to refugees. Several healthcare organizations offered testing services for free (UNHCR and other NGOs) or for a fee (private laboratories widespread in camp areas). Some healthcare workers expressed concern regarding free testing organized by NGOs, describing it as random and unsustainable. Participants in the focus group discussions confirmed the widespread presence of centres offering COVID-19 testing across all Lebanese governorates, and that geographical proximity was not an obstacle.

Barriers to testing

Despite the availability of free and geographically accessible COVID-19 testing services, testing was mostly done only when necessary. Several barriers to COVID-19 testing emerged, as illustrated by the psychological, social, and contextual challenges that shaped refugees’ decision to undergo testing.

Operational challenges to COVID-19 testing

Refugees expressed several challenges within the COVID-19 testing process. Many of them were unaware that testing was free at public hospitals, while others perceived the process as unclear. Refugees rarely tested and described the process as tedious, time consuming, and expensive. Most refugees stated that, upon experiencing COVID-19-like symptoms, they relied on pharmacies for provision of symptomatic treatment and medical advice because of proximity and easy access.

Psychological factors: perceived severity and vulnerability to COVID-19 

The focus group discussions and interviews with healthcare workers revealed that while refugees generally did not lack COVID-19 awareness, they usually had low risk perception, and thus did not comply with the preventive measures recommended by health authorities. A nurse in Beirut stated: “It is not an issue of awareness; enough campaigns were organized about COVID-19; still, they have reckless attitudes towards the virus”. Another nurse, in Bekaa stated: “They ignore their symptoms and treat it is as a flu”. Differences in COVID-19 risk perception were noted among refugees according to residence. When asked whether they considered themselves and their families to be vulnerable to infection, refugees residing in cities had a higher perceived risk of infection than those residing in camps. Healthcare workers attributed the different risk perceptions to the fact that refugees residing in houses in cities had higher socioeconomic status: “They mingle more with the local community, like when working in construction companies. They abide by recommendations, and wear masks in supermarkets and at work”. 

Beliefs and attitudes towards illness

Fear of stigma and discrimination was especially noted among refugees living in cities. In general, refugees had reckless attitudes towards infection. They believed in fate – an attitude enforced by their harsh living conditions. One woman living in a refugee camp stated: “If we finally die, it would not be worse than this life we are living”.

Financial barriers

The fear of testing positive and subsequently having to isolate and stop work was frequently mentioned by refugees. Unaffordability of testing was commonly mentioned by refugees in both camps and cities, and by healthcare workers. Some refugees affirmed that they would test if it were free of charge. Healthcare workers reported good participation of refugees in free COVID-19 testing campaigns. It was clear that refugees participated in free screening campaigns when organized by NGOs in order to “comply with programme components, thinking that if they did not participate, the NGO would not help them anymore” (physician, Bekaa). Another issue was that some refugees required an incentive to test: “They become used to receiving incentives from NGOs to participate; they always ask about gift bags” (physician, Bekaa). Healthcare workers disagreed that transportation costs were a barrier to testing: “Most refugees have motorcycles and they do not seem to have problems reaching the centres for services. Also, medical laboratories are widespread near the camps.” (Physician, South Lebanon). 

Political challenges: refugee status and fear of deportation

Refugees refused to test for COVID-19 for fear of deportation if they tested positive. Refugees usually did not inform UNHCR when experiencing COVID-19 symptoms, although free tests were available.

Discussion 

Many Syrian refugees in Lebanon did not believe in the importance of COVID-19 testing. Although testing services were geographically accessible to refugees throughout Lebanon, there were individual, cultural, environmental, and financial barriers to testing. Complications in the testing process and retrieving results, compared with the ease of access and lower financial burden of visiting pharmacies, made refugees rely on pharmacies (which did not provide testing services) when experiencing COVID-19 symptoms.

Previous studies have revealed that fear of starvation resulted in Syrian refugees giving screening a low priority (14). We identified additional, previously unexplored factors that created an attitude of carelessness towards COVID-19 infection, including harsh economic and living conditions, overcrowding in camps, and the myriad of worries that refugees face in daily life.

Our results agree with previous studies that identified financial barriers to testing among refugees (29–31). Other structural and contextual barriers to seeking health care have been described previously, including: low socioeconomic status, overcrowding, lack of access to clean water, stigma, high prevalence of noncommunicable diseases, and lack of awareness (32,33). Some studies have described lack of medical supplies, testing kits, and national surveillance as barriers to accessing COVID-19 testing (33,34), but these were not found in our study. 

We found that healthcare workers believed that COVID-19 prevalence among Syrian refugees in Lebanon was lower than expected. This may be attributed to under-reporting, or to slower transmission in refugee camps because of the younger demographics (50% of refugees globally are < 18 years of age) (32,34). However, this contradicts findings in other refugee contexts that have revealed high COVID-19 transmission and infection rates among refugees compared with the general population (33). 

Our study had some limitations. The results from the focus group discussions revealed barriers to acessing COVID-19 screening as perceived by refugees who were predominantly women, and all below university education level; thus, the perspectives of men or refugees with higher education levels were unexplored and may have differed.  The specific health system for refugees in Lebanon may differ from that in other countries, which limits the generalization of our results to refugees in other countries. However, our results provide important information for creating health policies for refugees in Lebanon and similar Middle Eastern countries.

The results of this study have several policy implications to take into consideration when implementing health promotion programmes for prevention of COVID-19 among refugees. Firstly, the fact that refugees rely mainly on and trust pharmacists highlights the importance of pharmacists as assets for the promotion of health services, and to explore the feasibility of implementing COVID-19 screening at the pharmacy level. Secondly, it is important to reflect on engaging policy-makers in appraising the ethical considerations of mandatory COVID-19 vaccination to mitigate the spread of the virus in overcrowded settings, such as refugee camps. Thirdly, it is important to consider evaluation and monitoring of healthcare programmes among refugees by an external agency to ensure accountability during service delivery. A laboratory director in Bekaa stated: “Some of these campaigns were just to report to the donor agency. In one campaign, 20–30 PCRs were performed. In another camp, the campaign performed only 5 PCRs”. Finally, this study demonstrates that policy-makers should not expect that refugees will use services, even if they are free. Therefore, when designing and implementing prevention programmes in refugee settings, it is crucial to address the indifference to preventive measures that arises from the harsh living conditions in refugee camps.

Funding: None

Competing interests: None declared.

Accès des réfugiés syriens au dépistage de la COVID-19 au Liban

Résumé

Contexte : L'amplification en chaîne par polymérase est une méthode bien connue de dépistage de la COVID-19, mais les populations de réfugiés rencontrent souvent des difficultés pour y accéder. Plusieurs problèmes structurels et culturels ont entravé l'accès des réfugiés syriens au dépistage de la COVID-19 au Liban, notamment des obstacles financiers, la stigmatisation et une faible perception de la vulnérabilité.

Objectifs : Examiner les obstacles qui entravent l'accès des réfugiés syriens au Liban aux tests de dépistage de la COVID-19. 

Méthodes : Dans le cadre de la présente étude qualitative, 10 groupes de discussion thématique réunissant des réfugiés syriens ont été organisés et 21 entretiens individuels semi-structurés ont été réalisés auprès d'agents de santé. L'approbation éthique du Comité d'examen institutionnel de l'Université internationale libanaise a été obtenue et l'étude a suivi les principes éthiques de la Déclaration d'Helsinki.

Résultats : Les réfugiés syriens au Liban ne considéraient pas que le dépistage de la COVID-19 était important. Malgré la disponibilité de services de dépistage gratuits, des obstacles psychologiques, culturels, environnementaux et financiers les ont empêchés de se faire dépister. Certains d'entre eux s'en remettaient à la consultation des pharmaciens, qui étaient faciles d'accès et fournissaient un traitement symptomatique sans qu'il soit nécessaire de procéder à un test de dépistage de la COVID-19. La peur de la stigmatisation, de l'expulsion et de l'isolement constituaient des barrières culturelles courantes. Les tests de dépistage ont été jugés inutiles en raison de la perception d'une faible gravité de la maladie et d'une attitude négligente à l'égard des pratiques préventives. Les conditions économiques et de vie difficiles préoccupaient davantage les réfugiés.

Conclusion : Les résultats de la présente étude s'ajoutent à la littérature existante concernant les obstacles sociaux et culturels qui entravent le dépistage de la COVID-19 chez les réfugiés syriens. Ces résultats devraient être pris en compte lors de la mise en place de campagnes de promotion de la santé visant à enrayer la propagation de la pandémie de COVID-19.

إمكانية وصول اللاجئين السوريين في لبنان إلى اختبارات كوفيد-19

علي غدار، سناء خندقجي، رواد كانسون، علي غساني

الخلاصة

الخلفية: تفاعل البوليميراز المتسَلسِل طريقة معروفة ومتبعة لاختبار حدوث عدوى كوفيد-19، ورغم ذلك، كثيرًا ما يواجه مجتمع اللاجئين صعوبات في الوصول إلى الاختبارات. فلقد عاقت عدةُ تحديات تنظيمية وثقافية وصولَ اللاجئين السوريين في لبنان إلى اختبارات كوفيد-19، ومنها مثلًا العقبات المالية والوصمة الاجتماعية وتدنِّي الوعي بالمخاطر.

الأهداف: هدفت هذه الدراسة الى تقصِّي العوائق التي تحول دون إجراء اختبار كوفيد-19 للَّاجئين السوريين في لبنان. 

طرق البحث: اشتملت هذه الدراسة النوعية على إجراء 10 مناقشات مع مجموعات بؤرية بين اللاجئين السوريين، و21 مقابلة فردية شبه منظمة مع العاملين في مجال الرعاية الصحية. وجرى الحصول على الموافقة الأخلاقية من لجنة المراجعة المؤسسية بالجامعة الدولية اللبنانية، واتبعت الدراسة المبادئ الأخلاقية لإعلان هلسنكي.

النتائج: لم ينظر اللاجئون السوريون في لبنان إلى اختبار كوفيد-19 على أنه أمر مهم. ورغم توفر خِدمات الاختبار مجانًا، فإنه ثمة عوائق نفسية وثقافية وبيئية ومالية حالت دون حصول اللاجئين السوريين على الاختبارات. واعتمد بعضهم على استشارة الصيادلة الذين كان يسهل الوصول إليهم، وكانوا يقدمون علاجًا للأعراض دون الحاجة إلى إجراء اختبار كوفيد-19. ومثَّل الخوف من الوصم والإبعاد والعزلة حواجز ثقافية شائعة. كما نُظر إلى الاختبار على أنه إجراء غير ضروري بسبب انخفاض الوعي بحدة المرض، وتشكَّل تيار عام من الإهمال تجاه الممارسات الوقائية. وبالمقابل، كانت الظروف الاقتصادية والأحوال المعيشية القاسية مصدر قلق أكبر لللاجئين.

الاستنتاجات: تُضيف نتائج هذه الدراسة إلى الأدبيات الحالية التي تتناول الحواجز الاجتماعية والثقافية التي تحول دون وصول اللاجئين السوريين إلى اختبار كوفيد-19، وينبغي مراعاتها عند تصميم حملات تعزيز الصحة الرامية لوقف انتشار جائحة كوفيد-19.

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Mehran Rostami,¹ Abdollah Jalilian,² Mohammad Reza Ghadirzadeh,³ Bashir Nazparvar,³ Ramin Rezaei-Zangeneh¹ and Mohammad Karamouzian^4,5,6*

¹Deputy of Health, Kermanshah University of Medical Sciences, Kermanshah, Islamic Republic of Iran. ²Department of Statistics, Faculty of Sciences, Razi University, Kermanshah, Islamic Republic of Iran. ³Legal Medicine Research Center, Legal Medicine Organization, Tehran, Islamic Republic of Iran. ⁴Centre on Drug Policy Evaluation, St. Michael’s Hospital, Toronto, Canada. 5Brown School of Public Health, Brown University, Providence, Rhode Island, United States of America (Correspondence to: M. Karamouzian: This email address is being protected from spambots. You need JavaScript enabled to view it.). ⁶HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Islamic Republic of Iran.

Abstract

Background: Drug use disorders are significant social and public health concerns in the Islamic Republic of Iran; however, little is known about drug-related mortality.

Aims: We quantified the spatial and age distribution of direct illicit-drug-related mortality in the Islamic Republic of Iran, to inform harm reduction policies and interventions.

Methods: We modelled and mapped registered illicit-drug-related deaths from March 2016 to March 2017. Data were obtained from the Iranian Forensic Medicine Organization. Besag–York–Mollie models were fitted using Bayesian spatial analysis to estimate the relative risk of illicit-drug-related mortality across different provinces and age groups.

Results: There were 2203 registered illicit-drug-related deaths during the study period, 1289 (58.5%) occurred in people aged 20–39 years and among men (n = 2013; 91.4%). The overall relative risk (95% credible interval) of illicit-drug-related mortality in the provinces of Hamadan (3.37; 2.88–3.91), Kermanshah (1.90; 1.55–2.28), Tehran (1.80; 1.67–1.94), Lorestan (1.71; 1.37–2.09), Isfahan (1.40; 1.21–1.60), and Razavi Khorasan (1.18; 1.04–1.33) was significantly higher than in the rest of the country.

Conclusion: We found evidence of age differences and spatial variations in illicit-drug-related mortality across different provinces in the Islamic Republic of Iran. Our findings highlight the urgent need to revisit existing drug-use treatment and harm reduction policies and ensure that overdose prevention programmes are adequately available for different age groups and settings.

Keywords: illicit drug use, disorders, mortality, Bayesian analysis, overdose, harm reduction, Iran

Citation: Rostami M; Jalilian A; Ghadirzadeh MR; Nazparvar B; Rezaei-Zangeneh R; Karamouzian M. Bayesian spatial analysis of age differences and geographical variations in illicit-drug-related mortality in the Islamic Republic of Iran. East Mediterr Health J. 2023;29(1):24–32. https://doi.org/10.26719/emhj.23.003

Received: 06/12/20; accepted: 05/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Data on drug-use-related mortality in the Eastern Mediterranean Region (EMR) are scarce because of the limited capacities in surveillance and data analysis (1,2). However, mental health and drug-use disorders are significant contributors to years lost due to disability in several countries in the EMR (2). In the Islamic Republic of Iran, where data on drug-use disorders are more available than in the rest of the region, mental health and drug-use disorders are among the leading contributors to disease burden (3). Drug-use disorders are associated with many adverse mental and physical health outcomes, such as mood and anxiety disorders (4), HIV infection and viral hepatitis (5), suicidal ideation and attempts (6), and fatal overdose (7).

The Iranian Mental Health Survey of 7841 adults in 2011 estimated the past 12-month prevalence of drug-use disorders to be 2.4%; defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (4). The pattern of illicit drug-use in the Islamic Republic of Iran has changed, and methamphetamine use has increased significantly in the past few years (8,9), although opium remains the most frequently used illicit drugs (10). The sociocultural acceptability of opium in the Islamic Republic of Iran could be attributed to the history of its production in the country before the Islamic Revolution, its proximity to Afghanistan (the country with the highest opium production in the world), and its location on the Balkan drug trafficking route (7,11,12). A population size estimation in 2013 found that ~2 million people used drugs illicitly and ~200 000 injected drugs in the Islamic Republic of Iran (13). Drug-use disorders are more common among specific demographic categories, such as men, divorced people, and those with low socioeconomic status (4).

There is a growing body of evidence on the epidemiology of illicit drug-use in the Islamic Republic of Iran, but data on illicit-drug-related mortality are scarce and incomplete (14). According to forensic evidence, the overall death rate from illicit drug-use in 2015 was 3.82 per 100 000 (15). However, for several reasons, Iranian illicit-drug-related mortality statistics are prone to under-registration and misclassification bias (7,16). For example, the data are collected by a few health organizations using various techniques. An integrated source of data collection across the country is still lacking, which complicates estimation and monitoring of illicit-drug-related mortality over time (17). The use of accurate statistics from the Iranian Forensic Medicine Organization to assess the national and provincial burdens of illicit-drug-related mortality provides valuable insight for health policy-makers and informs resource allocation, interventions, and evaluation efforts (3).

In this study, we aimed to provide an overall picture of direct illicit-drug-related mortality (i.e. deaths specific to drug toxicity and not including blood-borne diseases associated with drug use) across different age groups and Iranian provinces. Our findings provide an overview of illicit-drug-related mortality in the Islamic Republic of Iran and help inform drug use treatment and harm reduction interventions in the country.

Methods

Study population

The Islamic Republic of Iran is a Muslim majority country in the EMR and has 31 provinces. About 80 million people were living in the country in 2016; 74% of whom resided in urban areas, 31% were aged 60 years (18).

Data sources

Under Iranian laws and regulations, all deaths due to suspicious or unknown causes are referred to the Forensic Medicine Organization. Forensic physicians and pathologists examine the cases, determine the exact cause of death, and issue death certificates (15,16). These certificates are commonly issued in response to law enforcement requests; therefore, the direct cause of death is summarized as "death due to illicit drug abuse", accompanied by the corresponding International Classification of Diseases codes (F11–F19) (16). For this study, data on all available illicit-drug-related mortality were obtained from the Iranian Forensic Medicine Organization. Additional data were retrieved about nationality, age group, sex, and the primary province of residence (18). We included 2203 direct drug-related deaths registered from 21 March 2016 to 20 March 2017, including 2013 deaths in men and 190 in women. This study interval was chosen because the relevant data were only available for this period.

Data analysis

Illicit drugs included opium and other unregulated opioids, amphetamines and unregulated stimulants, hallucinogens, inhalants, cannabinoids, psychoactive drugs, and other unspecified drugs (e.g. synthetic drugs). Given the small number of women who died from illicit drug use, we did not build sex-based spatial models to avoid potential sparse data bias. We used the Iranian Population and Housing Census of 2016 to obtain data on the age distribution of the provincial population (18). Age groups were categorized into 0–19, 20–39, 40–59, and ≥ 60 years.

Model characteristics

Despite racial homogeneity in the Islamic Republic of Iran, ethnic heterogeneity is significant, and languages, religion, and socioeconomic status vary significantly across different regions of the country. Therefore, we expected to see heterogeneity and spatial correlation in the relative risk (RR) of illicit-drug-related mortality. A statistical model that accounted for possible spatial correlation and province-specific variations was a reasonable choice for modelling illicit-drug-related mortality in the Islamic Republic of Iran. Therefore, we used a Bayesian model (i.e. Besag–York–Mollie) and mapped registered deaths to estimate mortality risk across the country. Bayesian hierarchical models help explain sampling variabilities in spatial random effects (19). The Besag–York–Mollie model is suitable for addressing unobserved heterogeneity or spatial correlation and independent province-specific variations (20). A scaled version of the Besag–York–Mollie model accounts for the spatially structured component and provides an intuitive way to assign priors to the model parameters (19,21). R version 3.6.1 (R Foundation, Vienna, Austria) was used for all statistical analyses.

Ethical considerations

The study protocol was reviewed and approved by the Ethics Committee of Kerman University of Medical Sciences (reference number: IR.KMU.REC.1397.433). No informed consent was required for this study, given the anonymized and deidentified nature of the illicit-drug-related mortality data.

Results

The present study included 2203 illicit-drug-related deaths, registered from 21 March 2016 to 20 March 2017. The age distribution was: 0–19 years (4.8%, n = 106); 20–39 years (58.5%, n = 1289); 40–59 years (31.7%, n = 698); and ≥ 60 years (5.0%, n = 110). Most deaths occurred in men (n = 2013; 91.4%).

Compared with the rest of the country, the overall RR of illicit-drug-related mortality was significantly higher in Hamadan (RR: 3.37; 95% credible intervals [CrI]: 2.88–3.91), Kermanshah (RR: 1.90; 95% CrI: 1.55–2.28), Tehran (RR: 1.80; 95% CrI: 1.67–1.94), Lorestan (RR: 1.71; 95% CrI: 1.37–2.09), Isfahan (RR: 1.40; 95% CrI: 1.21–1.60), and Razavi Khorasan (RR: 1.18; 95% CrI: 1.04–1.33) (Figure 1). Table 1 presents a summary of the number of illicit-drug-related deaths, Yi,j, and the respective population, Pi,j, for each province (i) in different age groups (j). Table 1 also presents the expected number of illicit-drug-related deaths, Ei,j, and the posterior mean of the RR, θi,j, for each province and age group. The posterior mean, standard deviation, and 95% CrI for model parameters μj, τj, and ϕj are presented in Table 2. Except for the 0–19-years age group, the overall number of observed illicit-drug-related deaths was smaller than their expected values under the null model of homogeneous illicit-drug-related mortality rates for the whole country (Table 2).

Posterior means of ϕj parameters implied that the proportion of the variation in the spatial random effect bi,j explained by spatial correlation was 50% for age 0–19 years, 40% for 20–39 years, 44% for 40–59 years, and 24% for ≥ 60 years (Table 2). Therefore, the spatial correlation among provinces was relatively low, as at least half of the spatial variations among provinces were caused by random noise. The posterior means of RR (θi,j) are shown in Figure 2. Figure 2 and Table 1 indicate age differences and spatial variations in illicit-drug-related mortality across different provinces. The presented RRs were compared with the global (country-level) estimate. In the 0–19-years age group, the RRs of illicit-drug-related mortality in the provinces of Razavi Khorasan (RR: 1.97; 95% CrI: 1.15–2.78) and Isfahan (RR: 1.80; 95% CrI: 1.03–2.91) were significantly higher than in the rest of the country. In the 20–39-years age group, the RRs of illicit-drug-related mortality in Hamadan (RR: 3.29; 95% CrI: 2.65–3.98), Kermanshah (RR: 2.28; 95% CrI: 1.79–2.82), Tehran (RR: 1.62; 95% CrI: 1.45–1.79), Lorestan 1.58 (95% CrI: 1.16–2.05), and Isfahan (RR: 1.52; 95% CrI: 1.27–1.80) were significantly higher than in the rest of the country. In the 40–59-years age group, the RRs of illicit-drug-related mortality in Hamadan (RR: 3.14; 95% CrI: 2.34–4.04), Lorestan (RR: 2.0; 95% CrI: 1.37–2.75), and Tehran (RR: 1.88; 95% CrI: 1.65–2.12) were significantly higher than in the rest of the country. In the ≥ 60-years age group, the RRs of illicit-drug-related mortality in Hamadan (RR: 5.24; 95% CrI: 2.94–8.18) and Tehran (RR: 2.46; 95% CrI: 1.83–3.16) were significantly higher than in the rest of the country.

Discussion

We used a spatial Bayesian model to estimate the spatial risk of illicit-drug-related mortality in the Islamic Republic of Iran. We found age differences and spatial variations in illicit-drug-related mortality across different provinces. Most illicit-drug-related deaths occurred in the 20–39-years age group and in the western provinces, comparable with previous studies in the country (15,16).

We found spatial variations in illicit-drug-related mortality in the Islamic Republic of Iran. These findings are consistent with previous reports suggesting that western and south-eastern provinces had the highest drug-related mortality between 2005 and 2012 (16). The observed heterogeneity in drug-related mortality could be partly associated with historical opioid use in some provinces and their proximity to the primary drug trafficking routes from Afghanistan to Europe. It may also be attributed to the different socioeconomic status, literacy levels, unemployment rates, and access to addiction treatment services across different provinces (4,16). Iranian investment in expanding harm reduction services, methadone maintenance treatment in particular, is promising and considered progressive in the EMR (10). For example, as of March 2018, > 700 000 clients had received methadone maintenance services in 7225 outpatient centres (10). However, opioid agonist treatment coverage and accessibility varied greatly and were suboptimal in impoverished settings and border provinces (4,22). Our spatial estimates shed light on the existing geographic disparities in accessing harm reduction and drug use treatment and suggest that relevant interventions and resource allocations need to pay attention to areas with higher risk of drug-related mortality. More importantly, the existing disparities highlight the need to complement existing opioid agonist treatment services by scaling up nationwide, evidence-informed interventions for overdose prevention and management. This could include: increasing the availability and accessibility of naloxone for people likely to experience an opioid overdose; expanding overdose interventions delivered within emergency departments; educating frontline health workers and first responders about detection and treatment of people with overdose symptoms; and supporting community-based and peer-led opioid overdose prevention programmes and responses (23–27).

Our findings highlighted the limitations of current registry systems for illicit drug-use-related deaths and identified potential areas for improvement. In the Islamic Republic of Iran, diagnosis and official registration of deaths are carried out by two primary independent organizations (i.e. medical universities operating under the Ministry of Health and Medical Education, and the Forensic Medicine Organization operating under the supervision of the judiciary system). However, these two organizations do not sufficiently communicate to keep death records updated (28). Given the importance of illicit drug-use-related death data in drug-use surveillance and relevant public health decision-making in the Islamic Republic of Iran, there is a need to ensure that specific details about illicit drug-related deaths (e.g. type and class of drug, and mode of use) are recorded and reported (29). Inconsistent coding practices across clinical settings must be standardized using valid and specific International Classification of Diseases codes. This cannot be achieved without increasing awareness and training about accurate record keeping of illicit drug-use-related deaths for forensic physicians and other healthcare providers involved in recording the causes of death in such cases (30).

Our findings regarding the number of illicit-drug-related events among younger age groups are concerning. Our data cannot elucidate the underlying reasons behind these deaths, but this observation may be explained by a decrease in the age of drug-use initiation among children and adolescents, or because mortality in the 0–19-years age group could have included deaths from accidental drug poisoning (15,31,32). Regardless of the underlying cause of the notable death rate among children and young adults, these findings are alarming. They highlight the need for future overdose-related studies in this age group and improved public health education campaigns and interventions to increase awareness among young people about the overdose risks associated with illicit drugs and prescription opioids (33,34).

Our study had some limitations. First, the numbers of deaths reported by the Iranian Drug Control Headquarters and World Drug Report (2018) based on the estimates of the Ministry of Health and Medical Education were higher than those reported in our study. Our use of a selective administrative database such as the Forensic Medicine Organization may have underestimated the number of illicit-drug-related deaths because the organization does not cover all death registrations across the country. Some deaths in rural and remote areas are not referred to the Forensic Medicine Organization for further investigation. There is a time lag between the date of death and when the cause of death is updated in Forensic Medicine Organization records because of the time and resources required to complete an autopsy. Some of the initial clinical reports on drug-related deaths may be revoked after detailed investigation by the Forensic Medicine Organization. Second, our data did not include deaths associated with alcohol use, and we could not assess differential death rates by type of drug because the Forensic Medicine Organization database did not provide data on the type of drug detected during autopsy. Third, given the nature of the data available to us, we did not have any information on drug-specific cause of death, marital status, occupation, and educational levels, which could have been correlated with illicit-drug-related deaths (15,35). Our provincial data could not provide accurate data on homeless populations who may have died in a province other than their own. Fourth, we could not conduct a sex-specific analysis because of the small number of deaths recorded among women. We were unable to subdivide the 0–19-years age group because of the small sample size, which limited our ability to provide more details on specific groups of children or adolescents. Lastly, the data provided to us did not include detailed information on the manner of death (e.g. accidental or deliberate poisoning) and indirect deaths due to illicit drug use (e.g. road traffic injuries).

Conclusion

We examined data collected from the Iranian Forensic Medicine Organization and identified significant diversity in spatial risk of illicit-drug-related mortality across different age groups and provinces in the Islamic Republic of Iran. Our findings highlight the urgent need to revisit existing harm reduction and drug use treatment policies to ensure that preventive measures, such as overdose prevention and management programmes, are supported and scaled up.

Acknowledgement

The authors are thankful to Dr. Behzad Mahaki for his helpful feedback on the paper. Mohammad Karamouzian was supported by a Banting Postdoctoral Fellowship.

Funding: The study was funded by Kerman University of Medical Sciences.

Competing interests: None declared.

Analyse spatiale bayésienne des différences d'âge et des variations géographiques de la mortalité liée à la consommation de drogues illicites en République islamique d'Iran

Résumé

Contexte : Les troubles liés à la consommation de drogues constituent des préoccupations sociales et de santé publique importantes en République islamique d'Iran ; cependant, très peu d'informations sont disponibles sur la mortalité liée à la drogue.

Objectifs : Nous avons quantifié la distribution géographique et la répartition selon l'âge de la mortalité directement liée à la consommation de drogues illicites en République islamique d'Iran, afin de guider les politiques et les interventions en matière de réduction des effets nocifs.

Méthodes : Nous avons modélisé et recensé les décès liés à la consommation de drogues illicites enregistrés entre mars 2016 et mars 2017. Les données ont été obtenues auprès de l'Organisation de médecine légale iranienne. Les modèles de Besag, York et Mollié ont été ajustés à l'aide d'une analyse spatiale bayésienne pour estimer le risque relatif de mortalité liée à la consommation de drogues illicites dans les différentes provinces et les différents groupes d'âge.

Résultats : Durant la période de l'étude, 2203 décès liés à la consommation de drogues illicites ont été enregistrés, 1289 (58,5 %) sont survenus chez des personnes âgées de 20 à 39 ans et chez des hommes (n = 2013 ; 91,4 %). Le risque relatif global  (intervalle de crédibilité à 95 %) de mortalité liée aux drogues illicites dans les provinces de Hamadan (3,37 ; 2,88-3,91), Kermanshah (1,90 ; 1,55-2,28), Téhéran (1,80 ; 1,67-1,94), Lorestan (1,71 ; 1,37-2,09), d'Ispahan (1,40 ; 1,21-1,60) et de Razavi Khorasan (1,18 ; 1,04-1,33) était nettement plus élevé que dans le reste du pays.

Conclusion : Nous avons constaté des différences d'âge et des variations géographiques en matière de mortalité liée à la consommation de drogues illicites dans différentes provinces de la République islamique d'Iran. Nos résultats soulignent le besoin urgent de revoir les politiques existantes relatives à la prise en charge de la consommation de drogues et à la réduction des effets nocifs ainsi que de veiller à ce que les programmes de prévention des surdoses soient disponibles de manière adéquate pour les différents groupes d'âge et contextes.

تحليل مكاني بطريقة بايز للفروق العمرية والتباينات الجغرافية في الوفيات المرتبطة بالمخدرات غير المشروعة في جمهورية إيران الإسلامية

مهران رستمی، عبد الله جلیلیان، محمد رضا قدیرزاده، بشير ناز پرور، رامين رضایی زنگنه، محمد کارآموزیان

الخلاصة

الخلفية: إن اضطرابات تعاطي المخدرات في جمهورية إيران الإسلامية أحد الشواغل الرئيسية للصحة العامة والشواغل الاجتماعية ذات الشأن؛ ومع ذلك لا يُعرف الكثير عن الوفَيَات المرتبطة بتعاطي المواد المخدرة.

الأهداف: هدفت هذه الدراسة الى إجراء تقدير كمي لحجم التوزيع المكاني والعمري للوفيات المباشرة المرتبطة بالمخدرات غير المشروعة في جمهورية إيران الإسلامية، بالإضافة إلى تقديم المعلومات اللازمة للسياسات والتدخلات الرامية إلى الحد من الأضرار.

طرق البحث: صممنا ووضعنا خرائط للوفيات المرتبطة بالمواد المخدرة غير المشروعة المسجلة في الفترة من مارس/ آذار 2016 إلى مارس/ آذار 2017. وجرى الحصول على البيانات من مؤسسة الطب الشرعي بإيران. وجرى كذلك ضبط نماذج بيساج-يورك-مولي باستخدام التحليل المكاني بطريقة بايز لتقدير الخطر النسبي للوفيات المرتبطة بالمخدرات غير المشروعة في مختلف المحافظات والفئات العمرية.

النتائج: تبيَّن وجود 2203 حالة وفاة مسجلة بسبب المخدرات غير المشروعة خلال فترة الدراسة، وحدثت 1289 حالة وفاة (58.5%) بين أشخاص تتراوح أعمارهم بين 20 و39 سنة وبين الرجال (n = 2013؛ 91.4%). وكان الخطر النسبي العام (الفاصل الزمني الموثوق به بنسبة 95%) للوفيات الناجمة عن المخدرات غير المشروعة في محافظات همدان (3.37؛ 2.88-3.91)، وكرمانشاه (1.90؛ 1.55-2.28)، وطهران (1.80؛ 1.67-1.94)، ولورستان (1.71؛ 1.37-2.09)، إصفهان (1.40؛ 1.21-1.60)، رضوى خراسان (1.18؛ 1.04-1.33)، وذلك أعلى كثيرًا مما هو عليه في بقية البلاد.

الاستنتاجات: وقفنا على أدلة على الاختلافات العمرية والتباينات المكانية في الوفيات المرتبطة بالمواد المخدرة غير المشروعة في مختلف المحافظات في جمهورية إيران الإسلامية. وتبرز النتائج التي توصلنا إليها الحاجة الملحة إلى إعادة النظر في السياسات الحالية للعلاج من تعاطي المخدِّرات والحد من أضرارها، وضمان إتاحة برامج الوقاية من الجرعات المفرطة على نحو كافٍ لمختلف الفئات العمرية والبيئات.

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Nazia Mumtaz,¹ Ghulam Saqulain² and Muhammad Naveed Babur³

¹Department of Speech and Language Pathology, Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Lahore, Pakistan. ²Department of Otorhinolaryngology and Head and Neck Surgery, Capital Hospital PGMI, Islamabad, Pakistan (Correspondence to: G. Saqulain: This email address is being protected from spambots. You need JavaScript enabled to view it.). ³Faculty of Allied Health Sciences, Superior University Lahore, Pakistan

Abstract

Background: Hearing impairment and its consequences in children are often worsened by late identification in Pakistan. Deep-rooted cultural beliefs make some parents reluctant to seek clinical treatment, making adaptable solutions that traverse levels of socio-ecological model necessary.

Aims: To determine the impact of hearing impairment on children’s participation in social activities, and the financial burden on their parents.

Methods: This cross-sectional study included 377 parents of children with hearing impairment. The sample was recruited from special education schools and hospitals in Islamabad and Lahore, Pakistan, from November 2015 to April 2016. A 15-item structured questionnaire was used for data collection. SPSS version 21 was used for statistical analysis.

Results: Among children with hearing impairment, 47.5% faced moderate challenges in joining social activities, and 26.0% faced severe challenges. There was a significant positive correlation between the severity of hearing impairment, the person who suspected hearing impairment, age of detection of hearing impairment, and time of referral. Children with hearing impairment caused moderate financial strain on 39.0% of parents and mild strain on 26.8%.

Conclusion: Hearing impairment can significantly impact children's participation in social activities and cause financial burdens on their parents.

Keywords: hearing impairment, disability, children, parents, caregivers, hearing screening, social life, Pakistan

Citation: Mumtaz N; Saqulain G; Babur MN. Hearing impairment and its impact on children and parents in Pakistan. East Mediterr Health J. 2023;29(1):33–39. https://doi.org/10.26719/emhj.23.012 Received: 31/05/20; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

The World Health Organization (WHO) defines the inability to hear at a threshold of 20 dB as hearing impairment, and disabling hearing loss as loss of > 35 dB in the better ear (1). Hearing impairment is a major disability globally and is more frequent in developing countries. A study from 1 region of Pakistan reported a prevalence of 7.9% in school children (2). Late identification of hearing impairment among children is prevalent in developing countries, including Pakistan, because of the absence of neonatal hearing screening (3), and 26% of cases of mild hearing loss may even be missed in the presence of neonatal screening (4). Neonatal hearing screening in Pakistan is hindered by financial constraints and a dearth of research and reliable epidemiological data (5). Hearing impairment is an invisible disability, and missed or delayed diagnosis or lack of treatment results in delayed development of speech, language, and communication (5). This has a negative effect on educational progress, leading to unemployment or lower level of employment, isolation, loneliness, as well as social stigmatization. The global economic impact of untreated hearing impairment is around US$980 billion annually (1).

Although hearing impairment has detrimental consequences, deep-rooted cultural beliefs can predispose some parents or caregivers to refuse clinical treatment or rehabilitation (6). Hearing impairment is 1 of the 4 major disabilities recognized by WHO (7) and early hearing detection and intervention are required for speech and language development in children with this condition. Delays in identification of hearing impairment can result in speech and language, social, emotional, cognitive, educational, and occupational delays. Hence, hearing screening should be conducted by 1 month of age, diagnostic tests by 3 months, and appropriate intervention by 6 months. Transient evoked otoacoustic emissions and auditory brain response are commonly used for hearing screening (8), and brainstem evoked response audiometry and auditory steady state response are reserved for routine clinical testing (9).

Hearing is sometimes called the social sense because it has a fundamental role in interacting and relating with people and the social environment (10). Therefore, adaptable solutions are required for individuals with hearing impairment to improve hearing-related health and wellbeing (10). The extent of hearing impairment from moderate to profound has been highlighted in previous studies in which children were prone to make pragmatically inappropriate responses because they lacked the ability to comprehend environmentally available auditory cues and were victims of extreme literalness (11).

Diseases such as cancer, epilepsy, polio, hepatitis, AIDS, and drug abuse have been extensively studied and have received community support, accompanied by educational efforts, to improve knowledge and attitudes (6). However, there has been a lack of similar efforts towards the study of hearing impairment (10). There is a strong link between development of speech and language skills and activities such as those involving music in children with hearing impairment (12). There has also been an emphasis on the role of psychological models and need for cross-cultural research in addressing hearing impairment (6).

This study was conducted to determine the impact of suspicion, identification, and diagnosis of hearing impairment on the challenges faced by children with hearing impairment when participating in community activities (festive or religious), and the financial burden on their parents.

Methods

In this cross-sectional descriptive study, we used convenience sampling to recruit 377 parents of children with hearing impairment. The sample included parents of male and female children aged 4–15 years. Parents of children with any other disability were excluded. We recruited parents of children at special education schools and hospitals, including Special Children’s School, Bahria College, Al-Nafees Medical Hospital, and National Special Education Centre for Hearing Impaired Children in Islamabad; and Sheikh Zaid Hospital and Pearl Centre in Lahore, from 1 November 2015 to 30 April 2016. Data were collected using 10 items of a structured 15-item questionnaire developed by Mumtaz et al. (13) Ethical approval for the study was given by the Institutional Research Board of ISRA University (approval number 1402-PhD-011, dated 2 October 2015). Five hundred copies of the questionnaire were distributed to speech language pathologists and audiologists in the study settings, and 377 copies that were complete and met the selection criteria were included in the study.

SPSS version 21 was used for statistical analysis. Descriptive statistics, frequency and percentage of demographic and relevant questionnaire items were calculated. Pearson correlation was used to determine the linear relation between variables including severity, suspicion, identification, and diagnosis of hearing impairment in children. A -1 score represented total negative correlation, 0 no correlation, and +1 total positive correlation. The findings were then compared with national and international literature.

Results

The mean age of the children was 9.57 (4.21) years. Hearing impairment was profound in 207 (54.9%) children, severe in 106 (28.1%), moderate in 38 (10.1%), and mild in 26 (6.9%).

One hundred and thirty-two (35.0%) parents noticed hearing impairment before 6 months of age (Table 1). Hearing impairment was noticed first by parents in most cases (258, 68.4%), followed by grandparents (89, 23.6%). Professional advice was first sought at 19–24 months of age by 127 (33.7%) parents. The first professionals from whom advice was sought were audiologists in 166 (44.0 %) cases. One hundred and sixty children (42.4%) were referred immediately to another professional. Brainstem evoked response audiometry was the most commonly performed investigation (227, 71.8%), followed by auditory steady-state response (59, 18.7%). Late detection of hearing impairment at age 19–24 months was reported in 173 (45.9%) cases. Moderate challenges were reported for 179 (47.5%) children in joining community activities because of hearing impairment, and severe challenges for 98 (26.0%) children. One hundred and forty-eight (39.0%) children caused moderate financial strain on their parents.

Pearson’s correlation matrix showed that challenges in participating in community activities had a positive correlation with severity of hearing impairment (r = 0.19, P < 0.001); the person who suspected hearing impairment (r = 0.18, P < 0.001); age of detection of hearing impairment (r = 0.10, P = 0.035); and when the children were referred to a specialist (r = 0.12, P = 0.018). There was no correlation with the remaining variables. Financial strain on parents showed a positive correlation with severity of hearing impairment (r = 0.19, P < 0.001); first professional from whom advice was sought (r = 0.11, P = 0.037); when the child was referred to another professional (r = 0.13, P = 0.008); and challenges joining community activities (r = 0.37, P = 0.001). Financial strain showed a negative correlation with when hearing impairment was suspected (r = –0.13, P = 0.007); age of detection of hearing impairment (r = –0.12, P = 0.014); and age when professional advice was sought (r = –0.10, P = 0.0.036). There was no significant correlation with the remaining variables.

Discussion

This study shows that parents in Pakistan were late in noticing hearing impairment in their children, with only 35% reporting it before 6 months of age, 14.3% at 13–18 months, and the remainder even later. In contrast, in a 2017 study from the Khuzestan implant facility, Islamic Republic of Iran, age of suspicion of hearing impairment among 72 children was 9.05 (10.55) months for boys and 10.02 (10.46) months for girls, and in an older study in 2007, it was 12.6 (8.9) months (14,15). An Indian study in 2014 reported the age of suspicion as 16.5 months (16). A South African study in 2016 and an Indian study in 2010 reported an even higher median age of suspicion of 18 months (17,18). With no neonatal hearing screening in Pakistan, suspicion of hearing impairment before 6 months of age in this study is encouraging.

Hearing impairment is an imperceptible disability that is hidden and escapes early intervention, causing noticeable impediment in speech and language development (13,19). Parents, especially mothers, suspect hearing impairment when they realize that their child is not reacting to typical environmental sounds (18). Even children with negative results in neonatal hearing screening have been diagnosed with hearing impairment later in life because of parental apprehension and screening at school (20). In this study, hearing impairment was initially observed by parents (68.4%), followed by grandparents (23.6%) and teachers (6.1%). Professional advice was first sought at 19–24 months of age in 127 (33.7%) cases and < 6 months in 108 (28.6%) cases. One hundred and sixty (42.4%) children were referred immediately to another specialist. The first professionals from whom advice was sought were audiologists (44%), and speech and language pathologists were the least consulted (1.6%). In an Iranian study in 2005, on suspicion of hearing impairment, most parents visited physicians (57%), followed by audiologists (37.2%), speech and language pathologists (2.3%), or other specialists (3.5%) (15). Another study published in 2010 from West Bengal reported that the mean age of suspicion of hearing impairment was 1.5 years, mean age for consulting a specialist was 2.4 years, and 33.4% of children were referred for aural rehabilitation; however, the mean age of presenting to an audiologist was 9.3 years (18).

Interaction between speech and language pathologists and multidisciplinary teams creates a pool of clinical assessments for informal detection of hearing impairment as speech and language pathologists appraise a vast range of communication impairments (21). Research in rehabilitation sciences is difficult in a developing country like Pakistan with a fragile healthcare system (22). It is a continuous process for rehabilitation professionals to cope with emerging research trends to cater to the increasing demands at individual as well as community level (23).

In this study, hearing impairment was noticed fairly in time that is, before 6 months of age in 35% of cases and at 13–18 months in another 14.3%. The first professionals from whom assistance was sought were audiologists in 44% of cases followed by paediatricians in 27.1%. However, there was late detection of hearing impairment at 19–24 months in 45.9% of cases and at < 6 months in 25.2%. In a large South African study, although the median age of suspicion was 18 months and age of identification was 28 months, the earlier age of suspicion did not predict early identification (17). The median age of identification was 2.4 years in a study from West Bengal and 24.3 months in another study from India (16,18). The importance of early detection of hearing impairment in children has been constantly highlighted (24).

Socializing is a core component of human activity, and educating children with hearing impairment should also focus on this vital aspect of life. Hence, timely suspicion of hearing impairment, with prompt diagnosis and early intervention, positively affects socialization, including active involvement in festivities and religious activities. A 2002 review reported that children with hearing impairment are socially immature compared with children with normal hearing (25). Children with hearing impairment tend to interact more with other children that have hearing impairment rather than those with normal hearing. A South African study in 2011 revealed that children with hearing impairment who were engrossed in community and extracurricular activities had constructive social interactions (26).

In this study, 47.5% of children with hearing impairment experienced moderate challenges participating in community activities and 26% experienced severe challenges. Severity of hearing impairment, the person who suspected hearing impairment, age of detection, and when children were referred to another professional for further investigation, were all positively correlated with challenges to participating in community activities. At a global level, onset of hearing loss is projected to be the second major contributor to years lived with disability by 2050 (27).

In this study, 39% of children with hearing impairment caused moderate financial strain on their parents, and 26.8% caused mild strain. Severity of hearing impairment, first professional from whom advice was sought, when children were referred to another professional, and challenges joining community activities were positively correlated with financial strain on parents. Age of suspicion of hearing impairment, age of detection of hearing impairment, and when professional advice was sought were negatively correlated with financial strain on parents.

Professional failures can result in delayed diagnosis and fitting of amplification devices, in spite of suspecting hearing loss in the first 3 years of life (16). Lack of knowledge regarding the critical age of speech and language development and lack of rehabilitation facilities contribute to the delay in identification and rehabilitation of hearing impairment (18). Therefore, it is essential to improve awareness among mothers, as primary caregivers in Asian communities, of the importance of timely identification and intervention for hearing impairment (28).

Parents can be made to believe that their child does not have hearing impairment if the child has been subjected to a perfunctory testing regime that does not conform with internationally accepted norms of detection by neonatal hearing screening. For example, at age 2 days, some paediatricians resort to manual testing of children’s hearing by clapping or clicking their fingers. This can yield a false and misleading result, even for parents who suspect hearing impairment. Such children are deprived of the appropriate neonatal hearing screening, which invariably causes delay in rehabilitation and management of hearing impairment (5). Instead of the stepwise involvement of various professionals, the hearing impairment goes unnoticed. Subsequently, after the parents’ suspicion is heightened, the child is brought to the clinic or hospital and subjected to the requisite screening and hearing impairment testing. This sequence of events is common in the present healthcare system in Pakistan and emphasizes the lack of standardized neonatal hearing screening that needs to be addressed as a priority.

One limitation of our study was that the participants were not from all the provinces; therefore, the results cannot be generalized to the rest of Pakistan.

Conclusion

Suspicion and identification of hearing impairment had a significant impact on children's participation in community activities, and caused financial burden for their parents. The challenges faced while participating in community activities were positively correlated with severity of hearing impairment, the person who suspected hearing impairment, age of detection of hearing impairment, and when the child was referred to another professional. Financial burden on parents and caregivers was positively correlated with severity of hearing impairment, first professional from whom advice was sought, when the child was referred to another professional, and participation in community activities. Financial burden was negatively correlated with age of suspicion of hearing impairment, age of detection of hearing impairment, and when professional advice was sought.

Funding: None

Competing interests: None declared.

La déficience auditive et son impact sur les enfants et les parents au Pakistan

Résumé

Contexte : La déficience auditive et ses conséquences chez les enfants sont souvent aggravées par une identification tardive au Pakistan. Les croyances culturelles profondément ancrées suscitent chez certains parents une réticence à rechercher un traitement clinique, d'où la nécessité de trouver des solutions adaptables qui prennent en compte les différents niveaux du modèle socio-écologique.

Objectifs : Déterminer l'impact de la déficience auditive sur la participation des enfants aux activités sociales et le fardeau financier qui pèse sur leurs parents.

Méthodes : La présente étude transversale incluait 377 parents d'enfants qui souffrent de déficience auditive. L'échantillon a été recruté dans des écoles d'éducation spécialisée et des hôpitaux à Islamabad et à Lahore (Pakistan) de novembre 2015 à avril 2016. Un questionnaire structuré comprenant 15 items a été employé pour la collecte de données. La version 21 du logiciel SPSS a été utilisée pour l'analyse statistique.

Résultats : Parmi les enfants atteints de déficience auditive, 47,5 % ont rencontré des problèmes modérés concernant la participation aux activités sociales et 26,0 % ont été confrontés à des problèmes graves. Il y avait une corrélation positive significative avec la gravité de la déficience auditive, la personne qui a suspecté la déficience auditive, l'âge lors de la détection de cette dernière et la date de l'orientation médicale. Les enfants atteints de déficience auditive étaient une source de pression financière modérée pour 39,0 % des parents et faible pour 26,8 %.

Conclusion : La déficience auditive peut avoir un impact significatif sur la participation des enfants aux activités sociales et entraîner un fardeau financier pour leurs parents.

ضعف السمع وأثره على الأطفال والآباء في باكستان

ناظيا ممتاز، غلام صقولين، محمد بابور

الخلاصة

الخلفية: يتفاقم ضعف السمع وما يترتب عليه من عواقب وخيمة يعاني منها الأطفال في باكستان في كثير من الأحيان بسبب اكتشافه المتأخر. فالمعتقدات الثقافية الراسخة تدفع بعض الآباء إلى الإحجام عن التماس العلاج السريري، الأمر الذي يستلزم إيجاد حلول يمكن تطويعها بحيث تتجاوز كل مستويات النموذج الاجتماعي - الإيكولوجي السائد.

الأهداف: هدفت هذه الدراسة الى تحديد أثر الاشتباه في الإصابة بضعف السمع واكتشافه وتشخيصه على مشاركة الأطفال في الأنشطة المجتمعية، والعبء المالي الواقع على الآباء.

طرق البحث: شملت هذه الدراسة المقطعية 377 من آباء الأطفال الذين يعانون من ضعف السمع. واختيرت العينة من مدارس ومستشفيات التعليم الخاص في إسلام أباد ولاهور، باكستان، في الفترة من نوفمبر/ تشرين الثاني 2015 إلى أبريل/ نيسان 2016. واستُخدم استبيان منظَّم شمل 15 بندًا لجمع البيانات. واسْتُخدم كذلك الإصدار 21 من برمجية SPSS لإجراء التحليل الإحصائي.

النتائج: من بين الأطفال الذين يعانون من ضعف السمع، واجه 47.5% مشكلات متوسطة الشدة فيما يتعلق بالانضمام إلى الأنشطة المجتمعية، بينما واجه 26.0% مشكلات جسيمة. وتبيَّنَ أيضًا وجود علاقة ارتباطية إيجابية مهمة بين مدى وخامة ضعف السمع، والشخص المشتبه في الإصابة به، وسن الكشف عنه، وتوقيت الإحالة. ويتحمَّل 39.0% من الآباء عبئًا ماليًّا متوسط الشدة جرَّاء إصابة أطفالهم بضعف السمع، بينما يتحمَّل 26.8% منهم عبئًا ماليًّا خفيفًا.

الاستنتاجات: يترتَّب على الاشتباه في الإصابة بضعف السمع واكتشافه أثرٌ ملحوظ في التصدي للمشكلات التي يواجهها الأطفال أثناء انخراطهم في الأنشطة المجتمعية والعبء المالي الواقع على آبائهم.

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Council countries Karima Chaabna,¹ Heta Ladumor² and Sohaila Cheema ¹Institute for Population Health, Weill Cornell Medicine – Qatar, Doha, Qatar

Abstract

Background: Breast cancer incidence is increasing in the Gulf Cooperation Council (GCC) countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates.

Aims: This study analysed geographical patterns, time trends, and age distribution of female breast cancer incidence among nationals and non-nationals in GCC countries.

Methods: Available cancer registry data for 1979–2016 were retrieved for the GCC countries. Age-standardized rates (ASRs) per 100 000 women were calculated using the World standard population. Comparisons were made by calculating comparative incidence figures.

Results: From 1998 to 2012, incidence among nationals was highest in Bahrain (ASR 61.85), Kuwait (ASR 52.66), and Qatar (ASR 56.90) and lowest in Saudi Arabia (ASR 19.76), Oman (ASR 22.33), and United Arab Emirates (ASR 31.05). In the most recent period, data were available only in Qatar (2014–2016) and Saudi Arabia (2013–2015). Non-nationals and nationals in Qatar had higher incidence rates than in Saudi Arabia. Incidence among nationals in Qatar was at least twice that in Saudi Arabia (comparative incidence figure 2.32). Incidence among non-nationals in Qatar was 3 times higher than in Saudi Arabia. Among nationals in Kuwait, 10.8% of cases of breast cancer occurred in women aged < 40 years in 2008–2012, compared with 24.2% in non-nationals in Qatar in 2014–2016.

Conclusion: Breast cancer incidence has increased over time among women in most GCC countries, likely reflecting the improvements in healthcare access and screening programmes. Nationals and non-nationals developed breast cancer at a younger age than women in other high-income countries. Increased screening uptake is still required in the region. Evidence-based, locally-informed interventions should be implemented to address risk factors specific to the nationals and non-nationals in the GCC countries.

Keywords: breast cancer, cancer incidence, cancer screening, mammography, cancer prevention, Gulf Cooperation Council, nationals, non-nationals

Citation: Chaabna K; Ladumor H; Cheema S. Ecological study of breast cancer incidence among nationals and non-nationals in the Gulf Cooperation Council countries. East Mediterr Health J. 2023;29(1):40–48. https://doi.org/10.26719/emhj.23.005

Received: 19/10/21; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Breast cancer is the second most common cancer and the leading cause of cancer-related mortality in women worldwide (1). Although there has been an improvement in the overall survival rate of breast cancer, there are differences by country and region. Limited screening, diagnosis, and therapy are likely contributing factors (2).

The Gulf Cooperation Council (GCC) is an alliance of 6 countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE). These countries have rich endowments of natural resources, generous government-supported subsidies and welfare policies, large populations of expatriate workers, and common cultural, religious, and social heritage (3, 4). To support economic development in the past 2 decades, the GCC countries have experienced substantial population growth due to mass migration of temporary workers (4). Intense non-national population growth has reached > 80% of the population size in Qatar and UAE. Young healthy migrants have contributed mainly to the non-national population growth, which has skewed the age distribution towards the 15–49 years group (5). In parallel, there has been an increased adoption of westernized and sedentary lifestyles in the GCC countries (6) that has been linked to a variety of cancers including breast cancer (7). Breast cancer incidence is 3–5 times lower among nationals in GCC countries than in other high-income countries (8); however, incidence among GCC nationals increased by 40% between 1998 and 2009 (6). To the best of our knowledge, incidence has not been assessed separately for GCC nationals and non-nationals. As a result of the unique demographic profile of non-nationals in the region and the potential healthy migrant effect on trends (3,4), it is essential to analyse breast cancer incidence time trends, geographical patterns, and age distribution according to nationality.

This study aimed to characterize female breast cancer incidence in GCC countries. The study objectives were to: (1) analyse geographical patterns and time trends of female breast cancer incidence among GCC nationals and non-nationals separately; (2) explore incidence differences between nationals and non-nationals; and (3) assess breast cancer age distribution among nationals and non-nationals.

Methods

Study design

We used an ecological study design to evaluate breast cancer incidence among nationals and non-nationals in GCC countries.

Incidence data sources

We retrieved publicly available secondary cancer registry data from 4 sources (Table 1): International Agency for Research on Cancer (IARC); Gulf Centre for Cancer Control & Prevention (GCCCP); Qatar National Cancer Registry (QNCR); and Saudi National Cancer Registry (SNCR). IARC and GCCCP report cancer surveillance data collected by national cancer registries (Bahrain Cancer Registry, Kuwait Cancer Registry, Oman National Cancer Registry, QNCR, SNCR, and United Arab Emirates Cancer Registry). Cancer registry incidence data for Oman were also obtained from the report by Al-Lawati et al. (9). Data from GCCCP, QNCR, SNCR, and Al-Lawati et al. were primarily used to supplement missing information from IARC to allow for a comprehensive and up-to-date description of breast cancer incidence in GCC countries. No data estimated from modelling analysis (e.g. GLOBOCAN 2020) were used in our analysis, which used only real data.

GCCCP reported 15-year incidence data (1998–2012) for nationals of GCC countries (10). These data were used to analyse geographical patterns of incidence across the countries between 1998 and 2012. The IARC Cancer in Five Continents (CI5) database was searched for available data on breast cancer incidence for GCC nationals and non-nationals, without time restriction (Table 1). Data were not available in the IARC database for UAE and for non-nationals of Bahrain, Oman, Qatar, and Saudi Arabia. From the QNCR, we retrieved separate incidence data for nationals and non-nationals in Qatar for 2014–2016. From the SNCR, we retrieved separate incidence data for nationals and non-nationals in Saudi Arabia for 2013–2015. Al-Lawati et al. (9) reported 20-year incidence data (1996–2016) for nationals in Oman, which were used to supplement the minimal data available for Oman from IARC. The retrieved incidence data were used to further analyse geographical patterns, and to investigate time trends (1979–2016), age distribution, and national versus non-national incidence.

Statistical analysis

To conduct a valid comparison between populations with different age structures, we calculated the age-standardized rate (ASR), which is the weighted average of age-specific incidence rates using the direct standardization method with the World Standard Population (11). Incidence rates were standardized per 100 000 women. Age-specific incidence rate was calculated as number of new breast cancer cases per 100 000 women for a specific period, country, nationality, and narrow age range. The number of cases was extracted by sex, nationality, and 5-year-age groups (0 to > 75 or > 85 years). The comparative incidence figure (CIF) and its 95% confidence interval (CI) were calculated to assess ASR differences according to time period, country, and nationality (11). CIF was a ratio of the ASR in a specific period, country, and nationality compared with the ASR in another period, country, and nationality. We considered the difference to be significant if the value of 1.0 was not included within the 95% CI of CIF.

The population at risk for female breast cancer included all individuals susceptible to breast cancer. Person-years at risk by nationality and age group were retrieved from the same cancer incidence data source, except for the data from QNCR (2014–2016). Person-years at risk were calculated by the sum of population size in women by age group and nationality for all 3 years retrieved from the Labor Force Survey conducted by the Ministry of Development Planning and Statistics (https://www.psa.gov.qa/en/statistics1/Pages/default.aspx).

Results

Geographic patterns of breast cancer incidence in GCC countries

Over the period 1998–2012, breast cancer incidence in nationals was highest in Bahrain (ASR = 61.85), while it was 3 times lower in Saudi Arabia (ASR = 19.76; CIF = 3.13; 95% CI: 3.12932–3.12933) and 2 times lower in UAE (ASR = 31.05; CIF = 1.99; 95% CI: 1.9919–1.9920). Breast cancer incidence among nationals was 56.90, 52.66, and 22.33 per 100 000 in Qatar, Kuwait, and Oman, respectively.

The geographical pattern over shorter periods of time differed from that over the 15-year period

(Figure 1). Until 2003–2007, nationals in Bahrain had the highest ASRs when compared with the nationals of other GCC countries (except for UAE where data were not available) and compared with non-nationals in Kuwait. Thereafter, incidence among nationals in Bahrain declined in 2008–2012 and was lower than among nationals in Kuwait (CIF = 0.87; 95% CI: 0.86594–0.86595) and Qatar (CIF = 0.93; 95% CI: 0.93607–0.93608) but still higher than among nationals in Saudi Arabia (CIF = 2.1; 95% CI: 2.051829–2.051833) and among non-nationals in Kuwait (CIF = 1.22; 95% CI: 1.221258–1.221261). In the most recent period, data were available only in Qatar (2014–2016) and Saudi Arabia (2013–2015). Non-nationals and nationals in Qatar had higher incidence than non-nationals and nationals in Saudi Arabia. Breast cancer incidence among nationals in Qatar was at least twice that of nationals in Saudi Arabia in 2003–2007 (CIF = 2.17; 95% CI: 2.16753–2.16754), 2008–2012 (CIF = 2.19; 95%CI: 2.19194–2.19195), and 2013–2016 (CIF = 2.32; 95% CI: 2.32574–2.32575). Incidence among non-nationals in Qatar was 3 times higher than among non-nationals in Saudi Arabia.

Time trends of breast cancer incidence in GCC countries

Overall, breast cancer ASR increased in all GCC countries (Figure 1). However, a decline in the trends (among nationals in Qatar and Saudi Arabia) and even a decrease (among nationals in Bahrain and non-nationals in Kuwait) was observed in recent years. Breast cancer incidence among nationals in Bahrain increased between 1998–2002 and 2003–2007 (CIF = 1.2; 95% CI: 1.196026–1.196030) and decreased between 2003–2007 and 2008–2012 (CIF = 0.9; 95% CI: 0.899017–0.899019). Breast cancer incidence among nationals in Kuwait doubled between 1979–1982 and 1988–1993 (CIF = 2.01), remained the same until 1994–1997 (CIF =1.0; 95% CI: 1.00030–1.00031), and increased between 1994–1997 and 1998–2002 (CIF = 1.26; 95% CI: 1.257689–1.257693), 1998–2002 and 2003–2007 (CIF = 1.21; 95% CI: 1.211430–1.211433, and 2003–2007 and 2008–2012 (CIF = 1.16; 95% CI: 1.162534–1.162536). Breast cancer incidence among non-nationals in Kuwait increased between 1979–1982 and 1988–1993, remained the same until 1994–1997 (CIF = 1.0; 95% CI: 0.998832–0.998837), increased between 1994–1997 and 2003–2007 (CIF = 1.3; 95% CI: 1.302703–1.302708), and decreased in 2008–2012 (CIF = 0.92; 95% CI: 0.922989–0.922992). Breast cancer incidence among nationals in Oman increased between 1993–1997 and 1998–2001 (CIF = 1.15; 95% CI: 1.146130–1.146132). The ASR (22.33) estimated for 1996–2015 using data reported by Al-Lawati et al. (9) was similar to that in 1998–2012 (ASR = 20.75). Data for breast cancer incidence in Qatar were not available before 2003. The incidence among nationals increased between 2003–2007 and 2008–2012 (CIF = 1.18; 95% CI: 1.175398–1.175403) and between 2008–2012 and 2014–2016 (CIF = 1.04; 95% CI: 1.039074–1.039079). Data for breast cancer incidence in Saudi Arabia were not available prior to 2003. The incidence among nationals increased between 2003–2007 and 2008–2012 (CIF = 1.16; 95% CI: 1.162481–1.162483) and slightly decreased thereafter (2014-2016 CIF = 0.98).

Breast cancer incidence among nationals versus non-nationals

Breast cancer incidence in Kuwait was significantly lower among nationals than non-nationals and the gap between the 2 populations diminished until 1994–1997 (1988–1993: CIF = 0.96, 95% CI: 0.956013–0.956017; 1994–1997: CIF = 0.96, 95% CI: 0.957419–0.957424). Thereafter, breast cancer incidence was higher among nationals than non-nationals and the gap increased over time (CIF =1.06; 95% CI: 1.056254–1.056257, in 1998–2002 and CIF = 1.41; 95% CI: 1.410320–1.410323 in 2008–2012). Breast cancer incidence in Qatar was 50% lower among nationals than non-nationals during 2014–2016 (CIF = 0.50; 95% CI: 0.502528–0.502530; ASR = 55.89 and 111.23, respectively). Incidence in Saudi Arabia was lower among nationals than non-nationals during 2013–2015 (CIF = 0.69; 95% CI: 0.687872–0.687873; ASR = 24.0 and 34.9, respectively).

Breast cancer incidence by age group

Breast cancer incidence increased with age among nationals and non-nationals (Figure 2). No breast cancer was reported among nationals or non-nationals aged < 20 years, except among non-nationals in Qatar (age-specific incidence rate = 1.8). Among women aged < 40 years, breast cancer cases accounted for between 10.8% of all cases among nationals in Kuwait in 2008–2012, and 24.2% of all cases among non-nationals in Qatar in 2014–2016 (Figure 3).

Discussion

Breast cancer incidence was highest among nationals and non-nationals in Qatar, followed by nationals in Kuwait and Bahrain, nationals and non-nationals in Saudi Arabia, and nationals in Oman and UAE. In recent years, the incidence of breast cancer increased in all GCC countries but appeared to have decreased among nationals in Qatar and Saudi Arabia, and even reversing among nationals in Bahrain and non-nationals in Kuwait. Breast cancer incidence data for non-nationals were available only for Kuwait, Qatar, and Saudi Arabia. Non-nationals in Qatar and Saudi Arabia were more likely to have breast cancer than nationals, whereas in recent years, nationals in Kuwait were more likely than non-nationals to have breast cancer. Nationals and non-nationals in GCC countries appeared to develop breast cancer at a younger age than women in other high-income countries.

Several factors likely explain why breast cancer incidence in GCC countries was lower than in other high-income countries. Estimates of cancer incidence are closely dependent on levels of screening and detection. There is limited information on effectiveness of national-level breast cancer detection in GCC countries (14). In 2008–2009, the proportion of women aged 40–75 years who had undergone mammography within the previous 2 years was low among nationals and non-nationals (

Few studies have explored the barriers and enhancers of screening programmes in the region. Cultural, practical, and personal barriers have been reported (18–20). In GCC countries, participation in screening programmes may be low because of fear of treatment, doctors/examiners, hospitals, and consequences (18,21); embarrassment during breast examination (18,19); lack of awareness and knowledge about screening programmes (19,22) and doctor’s recommendations (18,19); and concerns over consulting a male or a non-Arabic-speaking doctor (19). Conversely, feelings of susceptibility and a supportive social environment were facilitators for screening in the region (20). Therefore, awareness campaigns aimed at enhancing knowledge and changing perceptions about breast cancer and the implementation of culturally sensitive screening programmes are necessary for tackling the breast cancer burden in the region.

Despite the likelihood that low screening rates may lead to underestimation of breast cancer incidence in GCC countries, the increase in incidence may reflect improved screening practices and better access to healthcare systems in recent years, compared with the period before the socioeconomic development in the region (23). Concomitantly, improvements in the healthcare system has resulted in more robust reporting of epidemiological statistics (24). Additional incidence data to assess the recent trends, and evaluation of screening programmes are required.

Time trends of the breast cancer stage may clarify whether the observed increase in breast cancer incidence over time was a true increase (observed at all stages) or the result of earlier diagnosis (increase mainly in early stages). Unfortunately, there were limited data about the specific stage of breast cancer diagnosed over time for GCC countries (25,26).

Breast cancer incidence was compared between nationals and non-nationals in Kuwait, Qatar, and Saudi Arabia. GCC country nationals have free access to all healthcare services (28), but employers must pay annual fees that enable non-national workers to access healthcare services at a reduced cost (29). The exception is in Oman, where non-nationals must pay to access public and private health services other than emergency services (29). In Qatar, despite similar access to the healthcare system for nationals and non-nationals, we observed a higher breast cancer incidence among non-nationals – similar to that observed in other high-income countries – probably because of greater awareness of breast cancer symptoms, more willingness to seek medical advice, and higher mammography screening uptake by non-nationals than nationals. This hypothesis needs to be investigated in future research.

Nationals and non-nationals in GCC countries seemed to have developed breast cancer at a younger age than women in other high-income countries. Breast cancer incidence was higher among women aged < 40 years in GCC countries than other high-income countries (31). Less variability among GCC countries and between nationals and non-nationals was observed in this age group. Cancer screening guidelines developed in the region are similar to international guidelines (32). Therefore, the higher incidence of breast cancer in women aged < 40 years was less likely because of early detection through screening. There is a need to investigate the higher proportion of national and non-national women diagnosed during the premenopausal period in GCC countries than in other high-income countries.

A study strength was the use of cancer registry data over a long period of 38 years. In comparison, previous studies evaluated patterns and trends over 5–10-year periods and did not analyse available data for non-nationals (6,8,35). Albeshan et al. (8) used the IARC modelled GLOBOCAN incidence estimation for 2008 and 2012 instead of cancer registry incidence data. This conflicts with the recommendation of IARC that GLOBOCAN incidence estimations in 2008 and 2012 should not be compared because of methodological differences in calculating these estimates (12).

Limitations included the lack of data on breast cancer incidence among non-nationals. While the data on non-nationals in Kuwait spanned 24 years, those on non-nationals in Qatar and Saudi Arabia were available only for 3 years, precluding in-depth exploration. Therefore, there is a need for long-term data from GCC countries to investigate incidence differences between nationals and non-nationals. The IARC CI5 database contained no data relating to nationals in UAE, either because of poor quality or lack of reporting to IARC. Hence, the analysis conducted on UAE may have been of lower precision than that in the other GCC countries.

The quality of cancer-related data was limited in GCC countries than other high-income countries. The proportion of breast cancer cases that were microscopically verified and histologically confirmed cases was >97% in the region (36). Despite suggesting good data validity, such a high proportion of microscopically verified breast cancer cases may be a sign of registry incompleteness because of a lack of use of other case-finding procedures (37), and that the GCC registries are over-reliant on pathology laboratories as the primary source of information (36). This seemed to be confirmed by the percentage of breast cancer cases identified during necropsy examination of women in whom breast cancer had not been diagnosed during their lifetime (< 1% in GCC countries). Consequently, cases detected by other procedures such as death certification were probably missing within the dataset (36). Comprehensive case-finding procedures including microscopic verification and death certificates is required for GCC cancer registries to improve their data quality (36).

Conclusion

Female breast cancer incidence has increased over time among most GCC countries, likely reflecting improvements in healthcare access and screening programmes. However, in contrast to other high-income countries, increased participation in screening continues to be critical for the region. GCC nationals and non-nationals appeared to have developed breast cancer at a younger age than women in other high-income countries. Risk factors specific to nationals and non-nationals in GCC countries should be further investigated. Evidence-based, locally informed interventions addressing these factors must be implemented. Educational interventions should be implemented to increase awareness about breast cancer and eliminate associated barriers. Data collection related to breast cancer among nationals and non-nationals must be enhanced in the region to fully understand its epidemiology and improve national guidelines.

Acknowledgement

We would like to thank QNCR, Ministry of Public Health – Qatar, and Qatar Cancer Information Center for providing us data on breast cancer in Qatar. We would also like to acknowledge Ms. Danielle Jones from the Writing Center and Dr. Ross MacDonald from the Library of Weill Cornell Medicine – Qatar, who helped with editing.

Funding: None.

Competing interests: None declared.

Étude écologique de l'incidence du cancer du sein chez les ressortissantes et les non-ressortissantes des pays membres du Conseil de coopération du Golfe

Résumé

Contexte : L'incidence du cancer du sein est en augmentation dans les pays membres du Conseil de coopération du Golfe (CCG) : Arabie saoudite, Bahreïn, Émirats arabes unis, Koweït, Oman et Qatar.

Objectifs : La présente étude a permis d'analyser les schémas géographiques, les tendances dans le temps et la répartition selon l'âge de l'incidence du cancer du sein chez les ressortissantes et les non-ressortissantes des pays membres du CCG.

Méthodes : Les données disponibles issues des registres du cancer pour la période 1979-2016 ont été extraites pour les pays membres du CCG. Les taux standardisés selon l'âge (TSA) pour 100 000 femmes ont été calculés sur la base de la population mondiale standard. Les comparaisons ont été faites en calculant les taux d'incidence comparatifs.

Résultats : Entre 1998 et 2012, l'incidence parmi les ressortissantes était la plus élevée à Bahreïn (TSA : 61,85), au Koweït (TSA : 52,66) et au Qatar (TSA : 56,90) et la plus faible en Arabie saoudite (TSA : 19,76), à Oman (TSA : 22,33) et aux Émirats arabes unis (TSA : 31,05). Au cours de la période la plus récente, seules des données concernant le Qatar (2014-2016) et l'Arabie saoudite (2013-2015) étaient disponibles. Les ressortissantes et les non-ressortissantes du Qatar présentaient des taux d'incidence plus élevés que celles de l'Arabie saoudite. L'incidence parmi les ressortissantes du Qatar était au moins deux fois plus élevée qu'en Arabie saoudite (voir la figure 2.32 sur l'incidence comparative), et celle parmi les non-ressortissantes était trois fois plus élevée qu'en Arabie saoudite. Parmi les ressortissantes du Koweït, 10,8 % des cas de cancer du sein sont survenus chez des femmes âgées de moins de 40 ans entre 2008 et 2012, tandis que ce taux était de 24,2 % chez les non-ressortissantes du Qatar pour la période 2014-2016.

Conclusion : L'incidence du cancer du sein a augmenté au fil du temps chez les femmes dans la plupart des pays membres du CCG, reflétant probablement les progrès réalisés en matière d'accès aux soins de santé et de programmes de dépistage. Les ressortissantes et les non-ressortissantes ont contracté le cancer du sein à un âge plus précoce que les femmes dans d'autres pays à revenu élevé. Une augmentation du taux de dépistage est encore nécessaire dans la Région. Des interventions fondées sur des données probantes et adaptées au contexte local devraient être mises en œuvre pour s’attaquer aux facteurs de risque spécifiques aux ressortissantes et aux non-ressortissantes des pays membres du CCG.

دراسة إيكولوجية لحالات الإصابة بسرطان الثدي بين المواطنات وغير المواطنات في دول مجلس التعاون الخليجي

كريمة شعبانة، هيتا لادمور، سهيلة شيما

الخلاصة

الخلفية: تتزايد حالات الإصابة بسرطان الثدي في دول مجلس التعاون الخليجي: البحرين، والكويت، وعُمان، وقطر، والمملكة العربية السعودية، والإمارات العربية المتحدة.

الأهداف: هدفت هذه الدراسة الى تحليل الأنماط الجغرافية والاتجاهات الزمنية والتوزيع العمري للإصابة بسرطان الثدي لدى الإناث بين المواطنات وغير المواطنات في دول مجلس التعاون الخليجي.

طرق البحث: جرى استخلاص بيانات سجل السرطان المتاحة عن المدة بين عامَي 1979-2016 لدول مجلس التعاون الخليجي. وحُسبت المعدلات المُوحَّدة حسب السن لكل 100000 امرأة باستخدام المعيار العالمي للسكان. وأُجريت مقارنات بحساب أرقام معدل الإصابة المقارنة.

النتائج: بالنسبة إلى الفترة الزمنية ما بين عامَي 1998-2012، تبيَّنَ أن أعلى معدل للإصابة بين المواطنات في دول مجلس التعاون الخليجي كان في كل من البحرين (معدل مُوحَّد حسب السن 61.85)، والكويت (معدل مُوحَّد حسب السن 52.66)، وقطر (معدل مُوحَّد حسب السن 56.90) وتبيَّنَ أن أدنى معدل للإصابة كان في المملكة العربية السعودية (معدل مُوحَّد حسب السن 19.76)، وعُمان (معدل مُوحَّد حسب السن 22.33)، والإمارات العربية المتحدة (معدل مُوحَّد حسب السن 31.05). ولكن في الفترة الأخيرة، لم تتوفر سوى البيانات الخاصة بقطر (2014-2016) والمملكة العربية السعودية (2013-2015). وسجلت المواطنات وغير المواطنات في قطر معدلات إصابة أعلى منها في المملكة العربية السعودية. وبلغ معدل الإصابة بين المواطنات في قطر ضعف مثيله على الأقل في المملكة العربية السعودية (الشكل 32.2 لمعدل الإصابة المقارنة). أما معدل الإصابة بين غير المواطنات في قطر، فجاء أعلى 3 مرات مقارنة بالمعدل في المملكة العربية السعودية. وحدثت 10.8% من حالات الإصابة بسرطان الثدي بين المواطنات في الكويت بين النساء اللاتي تقل أعمارهن عن 40 عامًا في المدة بين عامَي 2008-2012، مقارنة بنسبة 24.2% بين غير المواطنات في قطر في المدة بين عامَي 2014-2016.

الاستنتاجات: ازدادت معدلات الإصابة بسرطان الثدي مع مرور الوقت بين النساء في معظم دول مجلس التعاون الخليجي، الأمر الذي يعكس على الأرجح تحسُّنات في الوصول إلى الرعاية الصحية وبرامج الفحص. وتصاب المواطنات وغير المواطنات بسرطان الثدي في سن أصغر من سن النساء في البلدان الأخرى ذات الدخل المرتفع. ولا يزال من المطلوب زيادة الإقبال على الفحص في المنطقة. لذا، ينبغي تنفيذ تدخلات مُسندة بالبيِّنات ومستنيرة محليًّا للتصدي لعوامل الخطر الخاصة تحديدًا بالمواطنات وغير المواطنات في دول مجلس التعاون الخليجي.

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Mohammed Aljabari,¹ Mahmoud Elkhateeb,² Hamada Dorgham³ and Ahmed Alsufi⁴

¹European Gaza Hospital; ²Palestine College of Nursing; ³Public Health Emergency Operations Centre; ⁴International Cooperation Directorate, Gaza Strip, Palestine (Correspondence to: Mohammed Aljabari: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Abstract

Background: Hospital preparedness enables the healthcare delivery system to save lives during emergencies that surpass the day-to-day capacity of existing response systems. The COVID-19 pandemic negatively affected all aspects of life worldwide, and in the Gaza Strip particularly.

Aims: We assessed the preparedness of 2 hospitals in the Gaza Strip for response to COVID-19.

Methods: An observational, analytical, cross-sectional study was conducted among 160 nurses and physicians between July 2020 and October 2021 at the European Gaza Hospital and the Turkish-Palestinian Friendship Hospital, 2 hospitals dedicated to the reception and care of COVID-19 patients in the Gaza Strip. Data were collected using a structured, self-administered questionnaire and a checklist. The data were analysed using SPSS, version 23. Frequencies and descriptive data were used to assess the variables. Inferential statistics such as ANOVA and t-test were used to determine the significance and differences between the variables. Cronbach’s alpha was 0.903.

Results: The majority of the participants were nurses (77.5%) and they showed a high level of knowledge and training regarding the response to COVID-19 pandemic (73.4 %). Their perception of the preparedness of their hospitals in terms of work environment and availability of resources was average (63.6%). Around 70% perceived COVID-19 to have had a negative effect on their personal lives and work.

Conclusion: The preparedness level at the 2 hospitals was unsatisfactory (55.75%). Further research is recommended to assess the level of hospital preparedness from the viewpoint of other healthcare workers.

Keywords: COVID-19, preparedness, response, nurses, physicians, health emergencies, Gaza Strip

Citation: Aljabari M; Elkhateeb M; Dorgham H; Alsufi A. Assessment of preparedness for response to COVID-19 by two hospitals in the Gaza Strip. East Mediterr Health J. 2023;29(1):49–56. https://doi.org/10.26719/emhj.23.007
Received: 02/11/21; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Background

In December 2019, a new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused an outbreak that first emerged in Wuhan, Hubei Province, China (1).

The COVID-19 pandemic resulted in critical extra pressure on already weak healthcare systems, leading to impaired health status of affected populations, particularly those affected by recurrent humanitarian disasters. The virus spread to more than 182 countries and territories around the world (2). Countries ought to raise their capabilities for preparedness, alertness and response to the increasing number of new cases of COVID-19. There is no single perfect way to manage the crisis; all countries must, therefore, prepare their healthcare systems to respond effectively. Every country should conduct a precise assessment of the possible risks and carry out substantial, appropriate and timely actions to reduce COVID-19 transmission and its economic and social impacts (3).

The significant inadequacy of personal protective equipment (PPE) in most countries constitutes a major threat to the continuity of health care services for COVID-19 patients, therefore, it is essential for healthcare workers to have priority access to PPE so they can do their jobs safely and effectively (4).

The Israeli blockade, the internal Palestinian political divide, a chronic power deficit, and shortages of specialized staff, drugs and equipment are all factors affecting the ability of health systems in Gaza Strip to provide services during the pandemic (5).

Healthcare system in Palestine

The main parties providing health services in the Palestinian health system are the Ministry of Health, nongovernmental organizations, the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA), the military health services and the private sector. The total number of hospitals in Palestine is 83, of which 51 are in the West Bank, including East Jerusalem, and 32 in the Gaza Strip.

The Ministry of Health in the Gaza Strip has 13 hospitals, 16 belong to nongovernmental organizations, 2 to the Ministry of Interior and National Security, and 1 to the private sector. The total number of hospital beds in the Gaza Strip is 2943 (2240 belonging to the Ministry of Health, 526 to nongovernmental institutions and 177 to the Ministry of Interior and National Security). The Ministry of Health employs 3100 physicians, with 14.6 physicians per 10 000 population. There are 3682 nurses employed by the Ministry of Health, representing 25.1% of the total employees in the Ministry, with 21.2 nurses per 10 000 population. In 2018, 1 402 222 visits were made to emergency departments (6).

During the COVID-19 pandemic, the European Gaza Hospital and the Turkish-Palestinian Friendship Hospital were assigned to care for COVID-19 patients only.

Objectives

The main objective of this study was to assess hospital preparedness in response to the COVID-19 pandemic in the Gaza Strip. Specific objectives were to explore the status of hospitals' preparedness for COVID-19 in the Gaza Strip in terms of: hospital plans and their implementation processes; healthcare workers; equipment and materials; and the influence of COVID-19 on the personal lives and work of health care professionals. We aimed to make recommendations for policy-makers towards improving preparedness in the hospitals.

Methods

Study design

We used an observational, analytical, cross-sectional design to assess the preparedness of 2 hospitals in the Gaza Strip to respond to the COVID-19 pandemic..

Study setting

The study was conducted at the European Gaza Hospital and the Turkish-Palestinian Friendship Hospital, both of which were used for the reception and care of COVID-19 patients only. The Turkish-Palestinian Friendship Hospital was already in existence but was not in operation; it was first opened to deal with COVID-19 cases in November 2020 (7). Data collection was carried out during the period 1 November–31 December 2020. The study participants were nurses and physicians who worked in the 2 hospitals.

Sample size

The estimated sample size was 200 physicians and nurses. The study sample was estimated according to the following formula (8). Sample proportion (p) was assumed to be 0.5, which is conservative and gives the largest possible sample size.

where: N = population size = 412, e = margin of error = 0.05, z = z-score = 1.92, p = sample proportion = 0.5.

The participants were selected using convenience sampling. Physicians and nurses working in the two hospitals who were prepared to receive and care for COVID-19 patients were eligible to participate in the study. Exclusion criteria were: volunteers, students, interns and workers in other hospitals which were not prepared to receive and care for COVID-19 patients, and specialists such as radiologists, laboratory technicians, physiotherapists and pharmacists. The data collectors could not contact some of the targeted population who worked in the intensive care units (ICUs) because of the COVID-19 preventive measures imposed in those departments, therefore, the final sample was lower than the calculated size. In all, we had 160 participants out of 412: 36 physicians and 124 nurses (Table 1). There were more nurses because nurses constituted the majority of those providing services to COVID-19 patients. There were 14 partial respondents (2 physicians and 12 nurses, partial response rate 7%) and 26 nonrespondents (4 physicians and 22 nurses, nonresponse rate 13%).

Study instruments

The data were collected using 2 tools. The first was a self-administered questionnaire, structured on a 5-point-Likert-scale where 5 signified the highest agreement and 1 the least agreement. This tool was developed by the researchers in English after reviewing the available literature, then translated into Arabic. The second tool was an observational checklist in the English language, which was adapted from the “Comprehensive hospital preparedness checklist for COVID-19” (9). This tool assessed healthcare providers, key contact points, procurement and stock management, human capacity, facility and materials, training procedures, hand hygiene, PPE and waste management, triage, first contact and prioritization, patient placement and patient flow in the facilities.

Ethical considerations

Ethical codes of conduct were strictly adhered to at all stages of the study, and confidentiality was maintained. Ethical approval was obtained from the Ministry of Health and the Helsinki Committee. A letter of approval was obtained from the general directors of the 2 hospitals, and participants signed a consent form to confirm their agreement to participate in the study.

Coordination, monitoring and quality control

A pilot study (n = 30) was conducted to test the adequacy of the research questionnaire, determine the time needed to complete it and identify areas of ambiguity. The questionnaire was shared with a panel of experts to assess its clarity and relevance to the objectives of the study. All comments were taken into consideration. The pilot study results were included in the final study results. Reliability was tested using Cronbach’s alpha coefficient to determine the reliability and consistency of the survey. Cronbach’s alpha for the questionnaire was 0.903.

Data collection

Data on preparedness of the 2 hospitals in response to COVID-19 were collected using the 2 tools described above, a self-administered questionnaire filled out by the participants and a checklist filled out by the researchers. Three trained data collectors were selected from the workers in each hospital. Participants were asked to fill out the questionnaire, which was distributed during their working hours (day, evening and night shifts). Data were collected during the period 1 November–31 December 2020. Each data collector was assigned to collect data during a particular shift; their role was to distribute the questionnaires and answer any of the participants’ queries. Access to some areas in the hospitals was restricted, making data collection impossible in those areas.

Statistical analysis

The data were analysed using SPSS, version 23. The frequencies and descriptive data (mean, ranges, percentage, and standard deviations) were used to assess the research variables. Inferential statistics such as analysis of variance (ANOVA) and the t-test were used to determine significance and the differences between variables.

Results

Analysing the questionnaire

The distribution of the study participants from the 2 hospitals is shown in Table 1. Approximately two-thirds of the participants were less than 30 years old (Table 2). More than half of the health workers dealing with COVID-19 cases were young people. The majority of study participants (84.4%) were males – there were fewer females working in the hospitals – and 77.5% were nurses. A higher proportion of the participants (72.5%) were from the European Gaza Hospital. This hospital had a higher participation rate because it had been opened and accredited as an epidemiology hospital at the beginning of the COVID-19 pandemic, before the opening of the Turkish-Palestinian Friendship Hospital. It had a greater bed capacity and more ICU beds than the Turkish-Palestinian Friendship Hospital. Less than 50% of our participants had < 5 years experience, with about 26% having ≥ 10 years experience (Table 2).

The distribution of participants’ perceptions of the 2 hospitals’ preparedness is shown in Table 3. Independent t-test indicated there were statistically significant differences between workplace perception and the domain “Work environment and availability of resources” (P = 0.039) in favour of the European Gaza Hospital (the Turkish-Palestinian Friendship Hospital was unequipped before the COVID-19 outbreak, it was opened after the outbreak had started).

The total weighted mean for the “Knowledge and training” domain items was 74.3%, mean 3.71 [standard deviation (SD) 1.18] (Table 4). The highest rated item was “I am aware of the COVID-19 symptoms”, with a weighted mean of 81.1%; the fifth highest was “I have enough knowledge about COVID-19”, weighted mean 72.6%.

The total weighted mean for “Work environment and availability of resources” was 63.3 % (mean 3.17; SD 0.78) (Table 5). The highest rated item was “Supplies of alcohol-based hand sanitizers are available for staff and patients” at 73.3%, while “Instructions for correct hand hygiene procedures have been developed and distributed to hospital facilities” and “In my workplace, there is an infection control committee” were ranked fifth, both at 70.0%.

The total weighted mean for “Perceived effect on personal life and work” was 69.6% (mean 3.48; SD 0.54) (Table 6). The highest ranked item was “I am worried about my family in case of my absence” at 84.1%, while the 5th highest item was “I am afraid of falling ill with COVID-19” at 78.9%.

Analysing the checklist

Table 7 shows the completion of preparedness for COVID-19 in each hospital and the average completion rate for both hospitals. “Communicating information” was ranked first with an average completion rate of 78.85%, while “Knowledge and training” was ranked in seventh place with an average completion rate of 37.50%.

Discussion

The preparedness of health care facilities for the prevention of the transmission of SARS-CoV-2 is an immediate priority in providing COVID-19 care; protecting patients and health care workers; protecting high risk groups; maintaining essential health services to reduce the demand for specialized health care; and minimizing the spread of the pandemic to other health care facilities and the wider community (10). Thus, hospitals need to prepare in advance and develop an emergency plan; identify suppliers, PPE and equipment; and educate and train their staff in advance to prevent and treat large outbreaks of infectious diseases.

Almost two-thirds of the health workers dealing with COVID-19 cases in our study were young people, which may have some benefits in a pandemic situation as the level of effort in the isolation departments requires the strength and vitality of young people. They are generally able to endure the work stress which results from caring for large numbers of patients. Young people are in a position to receive and benefit from training and education programmes relevant to the circumstances.

Doctors and nurses are at high risk of being infected by patients if they do not have the essential knowledge and skills to deal with the disease or if they do not take adequate precautionary measures. In our study, the participants showed a high level of knowledge and training regarding the COVID-19 pandemic; this included symptoms of COVID-19 and its potential impact on public health, the basic principles of supportive clinical care for patients with COVID-19, and training on putting on and taking off PPE. This agrees with the findings of previous research, that participants were knowledgeable about the disease symptoms (11), and that majority of health care workers had sufficient knowledge of COVID-19 (12–16).

It was clear that the great majority of health care workers who participated in our study were worried about the risks to themselves and their families of working with people who had COVID-19 and about becoming infected because of their work. Their responses to the “Perceived effect on personal life and work” showed that they recognized that working with cases of COVID-19 affected their personal lives and their dealings with family members, especially the elderly. It affected how others related with them. Similar findings have been reported in other studies which showed that health care workers were anxious about their families becoming infected with COVID-19 because of their occupation, especially those who had young children and the elderly in their families (17–20).

Our findings indicated that the level of preparedness in the Turkish-Palestinian Friendship Hospital was unsatisfactory (completion rate 41.33%). This may be attributed to the fact that the hospital was newly opened, the majority of its employees were new, and the hospital was not sufficiently prepared to receive high patient loads in terms of devices, equipment, communication, etc. The European Gaza Hospital was better prepared and equipped for the treatment of COVID-19 patients (completion rate 70.16%). This may be because it was prepared and specialized in advance to be ready to receive and treat COVID-19 cases.

In general, the level of preparedness at the 2 hospitals was unsatisfactory (55.75%). This is in accord with previous research in similar conflict-affected areas, which likewise concluded that the health care facilities in Yemen were unprepared and lacked the most basic resources and capabilities to cope with or tackle COVID-19 (21). Similarly, a study from Nigeria noted that the preparedness and response to the COVID-19 pandemic were unsatisfactory (18).

In contrast, a study conducted in Vietnam found that the preparedness and response of the health system in Hanoi were satisfactory (22) and a study in India reported that a tertiary‑care teaching and research hospital in northern India obtained a score > 70% (good) (23).

The researchers recommend that the Ministry of Health should expedite the preparation of the Turkish-Palestinian Friendship Hospital to provide the best possible service to COVID-19 patients and reduce the burden on the European Gaza Hospital due to the high increase in the number of infected cases requiring medical care.

This study had some limitations. We used a convenience sampling method: this may be considered a source of selection bias. Only nurses and physicians were involved in the study, thus our sample did not represent all health care workers. However, nurses and physicians did comprise the greatest proportion of health care workers, had more contact with patients and were more affected by any change in the health system. Therefore, there is a need to assess the preparedness in these 2 hospitals from the perspective of other health care providers to get a clearer understanding of the situation. This may be considered sampling bias, which may undermine the external validity of the study (the ability of results to be generalized to all health care workers).

Data were collected using a self-administered questionnaire, which may be subjective and could reflect social desirability biases. To reduce this type of bias, the researchers used a checklist that was completed by themselves to assess preparedness in the 2 hospitals.

Conclusions

The participants showed a high level of knowledge and training regarding the COVID-19 pandemic (73.4 %). Overall, the level of the preparedness in the 2 hospitals was unsatisfactory. We recommend raising the level of preparedness in terms of equipment, resources and staff numbers (physicians and nurses).

Funding: This research was funded by the World Health Organization.

Competing interests: None declared.

Évaluation de la préparation à la riposte contre la COVID-19 dans deux hôpitaux de la bande de Gaza

Résumé

Contexte : La préparation des hôpitaux permet au système de prestation de soins de santé de sauver des vies lors de situations d'urgence qui dépassent la capacité quotidienne des systèmes de riposte existants. La pandémie de COVID-19 a eu des répercussions négatives sur tous les aspects de la vie à travers le monde, et en particulier dans la bande de Gaza.

Objectifs : Nous avons évalué l'état de préparation de deux hôpitaux dans la bande de Gaza pour la riposte à la COVID-19.

Méthodes : Une étude observationnelle, analytique et transversale a été menée auprès de 160 personnels infirmiers et médecins entre juillet 2020 et octobre 2021 à l'Hôpital européen de Gaza et à l'Hôpital de l'Amitié turco-palestinienne, deux hôpitaux dédiés à l'accueil et aux soins des patients atteints de la COVID-19 dans la bande de Gaza. Les données ont été recueillies au moyen d'auto-questionnaires structurés et d'une liste de contrôle. Elles ont été analysées à l'aide du logiciel SPSS, version 23. Les fréquences et les données descriptives ont été utilisées pour évaluer les variables. Des statistiques inférentielles telles que l'ANOVA et le test-t ont été employées pour déterminer la signification des variables et les différences entre elles. L'alpha de Cronbach était de 0,903.

Résultats : Les participants étaient majoritairement constitués de personnels infirmiers (77,5 %). Ces derniers ont fait preuve d'un niveau élevé de connaissances et de formation en matière de riposte à la pandémie de COVID-19 (73,4 %). Leur perception de l'état de préparation de leurs hôpitaux en termes d'environnement de travail et de disponibilité des ressources était moyenne (63,6 %). Ils étaient près de 70 % à considérer que la COVID-19 a eu un effet négatif sur leur vie personnelle et professionnelle.

Conclusion : Le niveau de préparation dans les deux hôpitaux n'était pas satisfaisant (55,75 %). Des recherches supplémentaires sont recommandées pour évaluer le niveau de préparation des hôpitaux du point de vue des autres agents de santé.

تقييم الجهوزية للاستجابة لمرض كوفيد-19 في مستشفيين اثنين في قطاع غزة

محمد الجعبري، محمود الخطيب، حمادة درغام، أحمد الصوفي

الخلاصة

الخلفية: إن تأهُّب المستشفيات يُمكِّن نظام تقديم الرعاية الصحية من إنقاذ الأرواح في حالات الطوارئ التي تتجاوز القدرات اليومية لنُظُم الاستجابة والتصدي الموجودة. ولقد كان لجائحة كوفيد-19 تأثير سلبي على جميع جوانب الحياة في جميع أنحاء العالم، وفي قطاع غزة خاصةً.

الأهداف: هدفت هذه الدراسة إلى تقييم مدى الجهوزية للاستجابة لكوفيد-19 في مستشفيين اثنين في قطاع غزة.

طرق البحث: أُجريَت دراسة رصدية وتحليلية مقطعية شملت 160 ممرضًا وطبيبًا في المدة من يوليو/ تموز 2020 إلى أكتوبر/ تشرين الأول 2021 في مستشفى غزة الأوروبي ومستشفى الصداقة التركي الفلسطيني، وهما مستشفيان مخصصان لاستقبال مرضى كوفيد-19 في قطاع غزة ورعايتهم. وجُمعت البيانات عبر استبيان منظَّم ذاتي يملؤه المستجيبون بأنفسهم وقائمة تحقُّق مرجعية. واستخدمنا SPSS، الإصدار 23، لتحليل البيانات. كذلك جرى استخدام التكرارات والبيانات الوصفية لتقييم المتغيرات. واستُخدمت إحصاءات استدلالية مثل تحليل التباين (ANOVA) واختبار t لتحديد الأهمية والاختلافات بين المتغيرات. وكان معامل ألفا كرونباخ يساوي 0.903.

النتائج: كان معظم المشاركين من من فئة التمريض (الممرضين والممرضات) (77.5%) الذين أظهروا مستوى عاليًا من المعرفة والتدريب بشأن الاستجابة لجائحة كوفيد-19 (73.4%). وتبين أن تصورهم لمدى جهوزية مستشفياتهم من حيث بيئة العمل وتوافر الموارد متوسط المستوى (63.6%). ورأى قُرابة 70% منهم أن مرض كوفيد-19 كان له تأثير سلبي على حياتهم الشخصية وعملهم.

الاستنتاجات: كان مستوى الجهوزية في المستشفيين الاثنين غير مُرضٍ (55.75%). ويُوصى بإجراء المزيد من البحوث لتقييم مستوى الجهوزية في المستشفيات حسب وجهة نظر العاملين الآخرين في مجال الرعاية الصحية.

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Short research communication

Mostafa Abdel-Kawi,¹ Khalid Taalab,² Nervana Hussien,³ Ahmed Ghandour,⁴ Amr Abdelazeem,⁵ Marwa Romeih¹ and Mohamed El-Kassas⁵

¹Radiodiagnosis Department, Faculty of Medicine, Helwan University, Cairo, Egypt. ²Nuclear Medicine Department, Military Medical Academy, Cairo, Egypt. ³Clinical Oncology Department, Faculty of Medicine, Helwan University, Cairo, Egypt. ⁴Community, Environmental and Occupational Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt. ⁵ Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt (Correspondence to: M. El-Kassas: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Abstract

Background: COVID-19 was first reported in Egypt on 14 February 2020 and continues to be a major threat to public health.

Aims: We studied the incidence of incidental positron emission tomography/computed tomography (PET/CT) signs of COVID-19 in asymptomatic cancer patients and compared this with the number of reported COVID-19 cases during the same period.

Methods: We included all cancer patients who underwent PET/CT at Misr Radiology Center, Cairo, between 2 May and 7 August 2020.

Results: There were 479 patients who underwent PET/CT primarily for follow-up, and 66 (13.78%) of them showed radiological signs of COVID-19, with the peak incidence in weeks 7–8 of the study. This coincided and strongly correlated with the peak incidence of COVID-19 in Egypt (Pearson’s correlation coefficient test = 0.943).

Conclusion: The incidence of incidental PET/CT signs of COVID-19 was in accordance with the officially reported incidence of COVID-19 in Egypt between 2 May and 7 August 2020. These results could be helpful for implementing and adjusting public health and social measures during the COVID-19 pandemic.

Keywords: COVID-19, cancer, positron emission tomography, computed tomography, Cairo, Egypt

Citation: Abdel-Kawi M; Taalab K; Hussien N; Ghandour A; Abdelazeem A; Romeih M; et al. Incidence of incidental positron emission tomography and computed tomography signs of COVID-19 in asymptomatic cancer patients in Egypt. East Mediterr Health J. 2023;29(1):57–62. https://doi.org/10.26719/emhj.23.006 Received: 04/06/21; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

In December 2019, cases of unexplained pneumonia were reported in Wuhan, China (1). The disease was caused by the novel SARS-CoV-2 and later named COVID-19 by the World Health Organization (2–4). In Egypt, the first case of COVID-19 was reported on 14 February 2020, followed by an increasing number of new cases and deaths that reached a peak in mid-June 2020, with approximately 1700 new cases and 90 deaths daily (2,5).

Many patients with COVID-19 are either in the subclinical phase or remain asymptomatic throughout the course of the disease. These patients present a challenge theoretically for epidemiological modelling of disease transmission, and practically for the protection of uninfected people and healthcare staff (6). The lungs are the site most affected by SARS-CoV-2 (7), and the most common symptoms, after fever, are severe respiratory manifestations (8). Radiological tools such as chest computed tomography (CT) are crucial for diagnosis of COVID-19 in patients with false-negative results for reverse transcription polymerase chain reaction (RT-PCR) (9). The chest CT findings of COVID-19 resemble those of viral pneumonia (10), with appearance of multifocal ground-glass opacity and consolidation, predominantly with a peripheral distribution (11,12), and a reported sensitivity of 98% (13,14).

18F-fluorodeoxyglucose (FDG) PET/CT is considered an essential tool in assessing solid and haematological malignancies (15). There are reports of incidental radiological findings of COVID-19 in 18F-FDG PET/CT for staging or follow-up of cancer patients who are asymptomatic or have mild symptoms of COVID-19 (16). Identification of these asymptomatic but potentially infective patients has attracted particular attention (6,17).

The objective of this study was to compare the incidence of incidental signs of COVID-19 in asymptomatic cancer patients undergoing PET/CT for staging or follow-up, with the number of cases of COVID-19 reported by the Egyptian Ministry of Health and Population between 2 May and 7 August 2020.

Methods

We performed a retrospective and prospective review of medical records and follow-up of cancer patients who underwent PET/CT staging or follow-up at a radiology referral centre in Cairo, Egypt, between 2 May and 7 August 2020. The study included 479 patients with breast, gastrointestinal, genitourinary, gynaecological, haematological, lung, or other cancers. The following data were collected for each group: demographic data, including age and gender; medical reason for the investigation; presence of any signs or symptoms of COVID-19 before or at the time of the study; and whether there were any incidental confirmed PET/CT signs of COVID-19. Records of patients with positive PCR for COVID-19 and patients with fever, cough, and shortness of breath were excluded.

All patients underwent dedicated PET/CT for staging or follow-up evaluation using an Ingenuity TF128 multislice PET/CT scanner (Philips, Eindhoven, Netherlands). This was followed by diagnostically enhanced CT. The CT characteristics of the lesions were identified according to internationally standard nomenclature (18). The typical CT findings for COVID-19 included ground glass opacity, patches of consolidation, and others (e.g. lymph node enlargement, and pleural effusion) (19). All patients with incidental radiological findings of COVID-19 by PET/CT were referred to a pulmonologist for further assessment. They were all confirmed to have COVID-19 based on the presence of mild symptoms (e.g. loss of taste and smell, headache, diarrhoea, sore throat, aches, and pains), together with typical CT findings and laboratory results. No PCR testing was performed in these patients because of the mild form of the disease. All appropriate safety measures and procedures were observed with these potentially infective patients.

All procedures were performed in accordance with the ethical standards of the institutional or national research committee, or both, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Research Ethics Committee for Human Research in the Faculty of Medicine, Helwan University, Cairo, Egypt.

Data were collected, coded, and analysed using SPSS version 21 (IBM, Armonk, NY, USA). Descriptive statistics included frequency, percentage, mean and standard deviation, and analysis of variance. The Chi-Square test was used to test the significance of the association between categorical variables. Pearson’s correlation coefficient test was used to determine the correlation between the number of cases of COVID-19 discovered in our study and the number reported by the Egyptian Ministry of Health and Population between 2 May and 7 August 2020. The accepted level of significance was P ≤ 0.05.

Results

The mean age of all 479 patients was 55.9 (14.23) years, with a significant difference among the different types of cancer (P < 0.001). The study included a wide range of adult and geriatric patients of both sexes (57% female and 43% male). Patients with genitourinary cancers had the highest mean age [62.67 (11.77) years] and those with other cancers had the lowest [43.58 (20.77) years]. Breast cancer was the most common primary cancer (25.1%). Significantly more patients (71.8%) sought PET/CT for follow-up of cancer than for staging (28.2%) (Table 1).

Sixty-six (13.78%) patients who underwent PET/CT showed positive signs of COVID-19 (Table 2). Table 2 shows the distribution of positive cases according to cancer type.

Incidentally discovered cases were tracked according to the week of examination. These cases were compared with the official number of positive COVID-19 cases reported by the Egyptian Ministry of Health and Population (Figure 1). The graphs revealed a gradual increase in cases from week 1, with none in our study and 2600 in the official records. Both graphs reached a peak in week 7, with 22 cases in our study and 10 900 in the official records. There was a gradual decline in the number of cases in week 8, with 11 cases in our study and 10 500 in the official records. There were no cases in weeks 12 and 14 in our study, and there 1100 cases in week 14 in the official records. Pearson’s correlation coefficient test = 0.9439 indicated a strong positive correlation.

Discussion

Our study showed that the incidence of incidental PET/CT signs of COVID-19 was in accordance with the officially reported incidence of COVID-19 in Egypt between 2 May and 7 August 2020. The age and sex of the studied patients, which included adult and geriatric patients of both sexes, showed significant differences among the different types of cancer.

Unlike other medical investigations, PET/CT for cancer patients cannot be postponed. The newly emerged COVID-19 resulted in a pandemic and a public health emergency that affected nearly every country around the world (20). Patients with cancer are considered vulnerable to infection because of their immune status, and were at higher risk of acquiring COVID-19 (21).

The coexistence of tumours and infectious diseases or noninfectious inflammatory diseases poses a serious medical challenge, especially in medical imaging. PET/CT is an unparalleled tool in detecting active infectious/inflammatory diseases and managing neoplasms (22,23). As a noninvasive imaging method, PET/CT plays an essential role in evaluating inflammatory and infectious pulmonary diseases, monitoring disease progression and treatment effects, and improving patient management. Qin and colleagues recently observed FDG uptake in patients with COVID-19 (24). Significant FDG uptake was observed in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection that progressed to pneumonia (25). Chefer et al. used PET/CT to observe rhesus macaques and simulate the host response to MERS-CoV infection (26).

The results of our study demonstrated the diagnostic accuracy of PET/CT in infectious and inflammatory diseases. A recent study confirmed high specificity of 93.8% and accuracy of 92.9% for using PET/CT in COVID-19 diagnosis (27). Despite all these findings, the contribution of PET/CT may be limited to clinical settings where infections are suspected, because of the cost and availability of examination. Studies using standardized diagnostic algorithms are needed to determine the utility of PET/CT in such situations and optimal timing of the examination, and to assess its impact on management decisions and patient-relevant outcomes.

Several reports have suggested higher number of COVID-19 cases in Egypt than that announced by the Egyptian authorities, raising suspicion regarding the actual number of COVID-19 cases in Egypt (5,28,29). In this study, we measured the incidence of incidental signs of COVID-19 in PET/CT examinations in asymptomatic patients and compared that with the number of positive COVID-19 cases in the official weekly reports. Our study showed an increasing trend in the incidental PET/CT findings, which was parallel to the trend in confirmed COVID-19 cases in Egypt. The number of incidentally diagnosed cases of COVID-19 reached a peak during weeks 7 and 8 (June 13–26 2020), followed by a decrease in cases, which was in accordance with the trend in the officially reported number of cases in Egypt during the same period. A clear correlation was noted throughout the study period between the incidental diagnosis of COVID-19 and the number of officially reported cases. Our study group consisted of patients with advanced cancer who required PET/CT examinations, and they were more susceptible than the general population to infection. This should be considered when assessing the results of this study as an indicator of COVID-19 infection in the community.

This study had some limitations. First, we were unable to obtain the results of RT-PCR testing for COVID-19 for most of the patients because of the difficulty in following up outpatient test results after PET/CT. Second, imaging interpretation was often not blinded to the clinical scenario, which may have influenced reporting of the PET/CT results. Differential verification and incorporation biases were likely to have caused overestimation of test performance; thus, the summary estimates should be interpreted with caution.

Conclusion

The incidence of incidental radiological signs of COVID-19 in asymptomatic cancer patients undergoing PET/CT for assessment of disease status was in accordance with the number of COVID-19 cases officially reported in Egypt between 2 May and 7 August 2020. These results could be helpful for implementing and adjusting public health and social measures during the COVID-19 pandemic.

Funding: None

Competing interests: None declared.

Incidence des signes fortuits de COVID-19 détectés au moyen de la tomographie par émission de positons et de la tomodensitométrie chez des patients asymptomatiques atteints de cancer en Égypte

Résumé

Contexte : La COVID-19 a été signalée pour la première fois en Égypte le 14 février 2020 et demeure une menace majeure pour la santé publique.

Objectifs : Nous avons étudié l'incidence des signes fortuits de COVID-19 détectés au moyen de la tomographie par émission de positons/de la tomodensitométrie (TEP/TDM) chez des patients asymptomatiques atteints de cancer. Puis, nous avons comparé cette incidence au nombre de cas de COVID-19 notifiés pendant la même période.

Méthodes : Nous avons inclus tous les patients atteints de cancer qui ont subi une TEP/TDM au Misr Radiology Center, au Caire, entre le 2 mai et le 7 août 2020.

Résultats : Au total, 479 patients ont subi une TEP/TDM principalement à des fins de suivi, et 66 (13,78 %) d'entre eux ont présenté des signes radiologiques de COVID-19, avec un pic d'incidence au cours des semaines sept et huit de l'étude. Cela a coïncidé et était fortement corrélé avec le pic d'incidence de la COVID-19 en Égypte (test du coefficient de corrélation de Pearson = 0,943).

Conclusion : L'incidence des signes fortuits de COVID-19 détectés par TEP/TDM était conforme à l'incidence officiellement notifiée de la COVID-19 en Égypte entre le 2 mai et le 7 août 2020. Ces résultats pourraient être utiles pour mettre en œuvre et ajuster les mesures sociales et de santé publique durant la pandémie de COVID-19.

حدوث علامات الإصابة بكوفيد19- عن طريق التصوير المقطعي المحوسب بين مرضى السرطان بدون أعراض في مصر

مصطفى عبد القوي، خالد طلب، نيرفانا حسين، أحمد غندور، عمرو عبد العظيم، مروة رومية، محمد القصاص

الخلاصة

الخلفية: جرى الإبلاغ عن كوفيد-19 لأول مرة في مصر في 14 فبراير/ شباط 2020، ولا تزال هذه الجائحة تمثل تهديدًا كبيرًا للصحة العامة.

الأهداف: هدفت هذه الدراسة الىى تقييم معدل حدوث علامات الإصابة بمرض كوفيد-19 بالتصوير المقطعي بالإصدار البوزيتروني العرضي/ التصوير المقطعي المحوسب (PET/CT) لدى مرضى السرطان العديمي الأعراض، وقارنَّا ذلك بعدد الحالات المبلَغ عنها بمرض كوفيد-19 خلال الفترة نفسها.

طرق البحث: شملت الدارسة جميع مرضى السرطان الذين خضعوا للتصوير المقطعي المحوسب بالأشعة في مركز مصر للأشعة، بالقاهرة، في المدة ما بين 2 مايو/ أيار و7 أغسطس/ آب 2020.

النتائج: خضع 479 مريضًا للأشعة المقطعية أو التصوير المقطعي المحوسب لغرض المتابعة في المقام الأول، وظهرت على 66 منهم (13.78%) علامات إشعاعية لمرض كوفيد-19، وبلغت معدلات الإصابة ذروتها في الأسبوعين 7-8 من عمر الدراسة. وتزامَن ذلك وارتبط ارتباطًا قويًّا مع ذروة الإصابة بمرض كوفيد-19 في مصر (اختبار معامل الارتباط لبيرسون = 0.943).

الاستنتاجات: يتوافق حدوث علامات التصوير المقطعي بالإصدار البوزيتروني/ التصوير المقطعي المُحوسَب العارضة لكوفيد-19 مع حدوث كوفيد-19 المبلَغ عنه رسميًّا في مصر في المدة ما بين 2 مايو/ أيار و7 أغسطس/ آب 2020. ويمكن أن تفيد هذه النتائج في تنفيذ تدابير الصحة العامة والتدابير الاجتماعية وتعديلها خلال جائحة كوفيد-19.

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Review

Zahra Hoseinipalangi,¹ Fatemeh Pashazadeh Kan,¹ Hossein Hosseinifard,² Maryam Doustmehraban,³ Maryam Masoumi,⁴ Sima Rafiei,³ Pooyan Barmayoon,⁵ Niloofar Ahmadi,¹ Afsaneh Dehnad,6 Hajar Eshtod,⁷ Mahsa Tohidi Asl,¹ Batool Sadat Hoseini,1 Mahmoud Nasiri,⁸ Moslem Arian,⁹ Sepideh Aghalou¹⁰ and Ahmad Ghashghaee³

¹School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. ²Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. ³Social Determinants of |Health Research Center, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran. ⁴Clinical Research and Development Center, Qom University of Medical Sciences, Qom, Islamic Republic of Iran. ⁵Department of Radiology Iran University of Medical Science, Tehran, Islamic Republic of Iran. ⁶Center for Educational Research in Medical Sciences (CERMS), Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. ⁷Department of Educational Sciences, Urmia Branch, Islamic Azad University, Urmia, Islamic Republic of Iran. ⁸Towards Evidence, Glasgow, United Kingdom. ⁹University of Social Welfare and Rehabilitation Sciences, Tehran, Islamic Republic of Iran. ¹⁰School of Medicine, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. (Correspondence to: Ahmad Ghashghaee: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Abstract

Background: Parkinson’s disease can adversely affect the quality-of-life.

Aims: We conducted a systematic review and meta-analysis of global literature on the quality-of-life of patients with Parkinson’s disease and examined the association between patient characteristics and quality-of-life.

Methods: We searched Embase, PubMed, Scopus and Web of Science from January 2000 to January 2020. We included articles published in English that used the Parkinson’s disease questionnaire to estimate the quality-of-life score and to identify the determinants of quality-of-life in patients with Parkinson’s disease.

Results: In total, 41 studies with data from 4060 patients who had Parkinson’s disease met our inclusion criteria. The overall quality-of-life score was 32.37 (95% confidence intervals (CI): 28.72–36.01). Age and duration of disease were inversely related to quality-of-life (P < 0.001). South America had the highest score on the questionnaire (39.73, 95% CI: 28.66–50.79, P < 0.001), indicating the lowest quality-of-life of patients with Parkinson’s disease. Of the 6 World Health Organization regions, the Eastern Mediterranean Region had the highest score (36.28, 95% CI: 23.44–49.13, P < 0.001).

Conclusion: Although the global score in patients with Parkinson’s disease indicated an acceptable quality-of-life, there is a possibility for improvements. The findings of this study can inform evidence-based strategies by health policymakers and clinicians to enhance the quality-of-life of patients with Parkinson’s disease.

Keywords: quality-of-life, Parkinson's disease, neurodegenerative disorder, systematic review, meta-analysis, global review.

Citation: Hoseinipalangi Z; Pashazadeh Kan F; Hosseinifard H; Doustmehraban M; Masoumi M; Rafiei S; et al. Systematic review and meta-analysis of the quality-of-life of patients with Parkinson’s disease. East Mediterr Health J. 2023;29(1):63–70. https://doi.org/10.26719/emhj.23.013
Received: 24/04/21; accepted: 19/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Parkinson's disease is one of the most common neurodegenerative disorders (1) and the second most common disease of the nervous system after Alzheimer disease. It affects more than 10 million people worldwide (2–5). It is a chronic and progressive disease that affects the dopaminergic neurons in a specific area of the brain, called the substantia nigra (6,7). The etiology of Parkinson's disease is still unknown, but genetic factors (in 10–15% of all patients with the disease) and environmental stimuli influence the development of the disease (8,9).

At the onset of the disease, the body appears to be physically damaged and most of the obvious symptoms are movement-related – difficulty in walking, speaking and even using the hands. In later stages, cognitive and behavioural problems may appear and sleep disorders may arise which negatively affect patients’ quality-of-life (QOL). Other conditions, including depression, severe fatigue, difficulty in mobility and speech, will exacerbate the patient’s medical condition (10,11). Decreased QOL not only affects the course of a patient’s treatment negatively, but it also lowers life expectancy among people with Parkinson's disease (10).

QOL has become an important issue in healthcare research, patient management policies and provision of effective medical interventions with sustainable effects. WHO defines health-related QOL as “an individual’s perception of the impact of health and disease on the physical, mental and social aspects of life” (12). Parkinson's disease can cause pain and limitations in daily activities (10,13), which have a substantial and long-lasting effect on the body. Factors such as self-image, satisfaction with life and interaction with other people are adversely affected in patients with Parkinson disease and result in decreased QOL (14,15).

As QOL is affected by complex multidimensional factors, it is crucial to identify its determinants (16–19) so as to improve QOL as much as possible for patients with Parkinson's disease. In fact, QOL is mainly dependent on physical health and self-efficacy (20,21). Many studies have examined the QOL of patients with Parkinson's disease (22,23), but most did not consider the contribution of factors such as age, sex, disease duration and disease severity. This lack of data makes it difficult to draw evidence-based conclusions about how demographic factors and patient characteristics contribute to QOL. Thus, in this study, we conducted a systematic review and meta-analysis of the literature on QOL of patients with Parkinson's disease to examine the association between patient characteristics and QOL in people with the disease.

Methods

This systematic review and meta-analysis was registered in PROSPERO database (registration code: CRD42020177015). The review is reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) (Figure 1) (24).

Databases searched and search terms

We undertook a systematic search of Embase, PubMed, Scopus and Web of Science from January 2000 to January 2020. We also searched Google Scholar using search terms: ((quality of life [Title/Abstract] OR health related quality of life [Title/Abstract] OR HRQOL [Title/Abstract]) AND (Parkinson [Title/Abstract] OR Parkinson’s disease [Title/Abstract] OR Idiopathic Parkinson’s disease [Title/Abstract] OR Lowy body Parkinson Disease [Title/Abstract])).

Inclusion and exclusion criteria

We included articles that used the PDQ-39 (25) to estimate the QOL score or identify the determinants of QOL among patients with Parkinson's Disease. The PDQ-39 is a self-report instrument widely used to understand disease-related health status and QOL. The 39-item PDQ evaluates the frequency of difficulties patients with Parkinson's disease experience in eight domains: daily activities, emotional well-being, stigmatization, social support, cognition, communication, and bodily discomfort. In this questionnaire, the score of each item is between 0 and 100, and the closer this score is to zero, the better the person’s QOL.

The other inclusion criteria were: original articles with full text available; observational prospective, descriptive, cross-sectional, case-study or cohort study design; published in English; and conducted between January 2000 and January 2020. Studies were excluded if they were not in English, and were published before January 2000 or after January 2020. Randomized controlled trials, editorials, commentaries, expert opinions, theses, reports, book chapters, case–control studies and case-series were excluded. Papers on evaluation of treatment effects, medication approaches and clinical decision-making were excluded.

Articles retrieved

From the search, 535 articles were identified. Our additional search in Google Scholar resulted in retrieval of 9 articles. After removing duplicates, 441 articles remained, of which 187 (42%) were retrieved from SCOPUS, 164 (37%) from PubMed, 55 (12%) from Embase and 35 (8%) from Web of Science. After screening the titles and abstracts of the records, 205 publications were excluded. The full texts of the remaining 236 articles were screened for eligibility based on the inclusion and exclusion criteria, of which 195 were excluded. Thus, 41 articles were included in the review.

Studies which incorporated quantitative data on QOL in patients with Parkinson's disease or determinants of QOL, such as demographic factors, disease duration and disease severity, were included in the review. References of articles and conference abstracts included were also searched to find any eligible data to be add to the review. After applying the inclusion and exclusion criteria, 41 studies were selected (Figure 1).

Data extraction

Two investigators extracted data independently and in case of disagreement, a third reviewer resolved the differences. We developed a data extraction form which included author’s name, publication date, research setting, study design, study findings (QOL determinants, total QOL score among patients with Parkinson disease, and level of anxiety and depression, emotional well-being, stigma, social support, cognition, communication, discomfort, and mobility .

Quality assessment

The quality of included articles was assessed using the Newcastle-Ottawa Scale, a standardized instrument for assessing the quality of observational studies (26). To reduce bias, two independent reviewers assessed the quality of the studies; in case of disagreement, a third investigator resolved the discrepancy. The Newcastle-Ottawa Scale examines the quality of articles based on the definition of cases, introduction of cases, selection of controls, definition of controls, comparability of cases and controls, and exposure and outcome. Reported and unreported items are scored 1 and 0, respectively. The sum of scores assigned to reported items was considered as the total quality score of each article. The highest and lowest scores on the Newcastle-Ottawa Scale for each article were 10 (best quality) and 0 (lowest quality). In our review, articles with scores < 4 were considered low quality.

Statistical analysis

We used random-effects analyses (Der Simonian and Laird) for the meta-analysis to estimate the mean effect size and variability across studies. The results are reported at a 95% confidence level, meta-regression analysis was determined on the basis of publication date and sample size. We carried out sensitivity analyses to confirm the stability of the results. We conducted subgroup analyses for all the items of PDQ-39, sex, publication date, study setting and sample size. Duration of illness, age and publication date were used for the cumulative meta-analysis. We used the Egger test to measure publication bias and analyzed the data using comprehensive Meta-Analysis and Stata version 14 software.

Results

Our findings are reported based on the PRISMA checklist. After extraction of the main data from the 41 articles, the total number of patients with Parkinson's disease was 4060 and their total QOL score was 32.37 (95% Cl: 28.72–36.01).

The total scores for each item of the PDQ-39 were: daily activities 39.97 (95% Cl: 35.23 to 44.71); cognition 32.00 (95% Cl: 28.57 to 35.43); communication 27.97 (95% Cl: 24.07 to 31.87); discomfort 38.86 (95% Cl: 34.60 to 43.11); emotional well-being 36.03 (95% Cl: 32.46 to 39.61); mobility 42.49 (95% Cl: 37.12 to 47.86); social support 20.22 (95% Cl: 16.26 to 24.18); and stigma: 30.31 (95% Cl: 26.76 to 33.86) (Table 1).

Analysis by sex

We found a significant relationship between sex and QOL in patients with Parkinson's disease indicating that the disease was more common in men (PDQ-39 summary index: 3.32; 95% Cl: 2.04 to 4.60) (Table 2). Items that had negative association with gender included daily activities: –1.48 (95% Cl: –2.98 to 0.03), cognition: –0.20 (95% Cl: –1.42 to 1.02), emotional well-being –5.32 (95% Cl: –6.58 to 4.06), mobility –2.75 (95% Cl: –4.34 to 1.17 , social support–3.24 (95% Cl: –4.29 to 2.18), and stigma – 3.84 (95% Cl: –5.26 to 2.42). On the other hand, items that had positive association included communication 0.99 (95% Cl: –0.34 to 2.31) and discomfort 0.87 (95% Cl: –0.54 to 2.27) which were more common in men (Table 2)

Analysis by age and disease duration

There was a significant direct correlation between QOL and age in patients with Parkinson's disease (P < 0.001): PDQ-39-summary index 0.62 (95% Cl: 0.54 to 0.70). Thus for a one-year increase in patient’s age, QOL score would decrease by 0.61 (Table 3).

There was a significant direct relationship between the duration of Parkinson's disease and QOL in patients (P < 0.001). Thus for a one-year increase in disease duration, the QOL score decreased by 0.13 (95% Cl: 0.12 to 0.14) (Table 3).

Analysis by location

The scores of all items of the PDQ-39 questionnaire were highest in South America (39.73; 95% Cl: 28.66 to 50.79) and lowest in Australia (20.9; 95% Cl: 1.89 to 39.91) (Table 4).

For the WHO regions, the Eastern Mediterranean Region had the highest score for the PDQ-39 summary index (36.28; 95% Cl: 23.44 to 49.13) and the Western Pacific Region had the lowest score (27.60; 95 % Cl: 20.71 to 34.49) (Table 4).

No studies were found for the WHO Africa Region.

Other sub-group analyses

Anxiety and depression affected the QOL of patients with Parkinson disease. The mean PDQ-39 scores in cases of anxiety and depression were 16.57 (95% CI: 7.60 to 25.53) and 5.87 (95% CI: 3.83 to 7.91) respectively.

Discussion

Our results based on the PDQ-39 showed that estimated QOL in patients with Parkinson's disease was 32.37. Based on the literature, there is no agreed range of scores to evaluate QOL by the PDQ-39. Thus, we categorized patient QOL into four levels based on information from the expert interviews, namely: 0–20 (good QOL); 21–40 (acceptable QOL); 41–60 (poor QOL) and more than 60 (very poor QOL). Our estimated QOL of 32.37 indicates that the QOL overall was in the acceptable range.

The total PDQ-39 score was highest in South America (39.73), which was close to the poor QOL range. Comparing the status of different countries in South America, the QOL in Brazil was estimated to be 45.00 (27), indicating a poor QOL. The scores on daily living, mobility and emotional well-being were high in South America resulting in poor QOL. In Asia, the QOL was estimated at 32.97 in the Philippines (20) and 16.80 in China (28) because most of the items used in this study had good scores. In Europe, the QOL score in the United Kingdom of Great Britain and Northern Ireland was 17.10 (29) also indicating a good QOL, while it was 45.83 in Serbia (30) showing a poor QOL. The good QOL in some countries, such as China and the United Kingdom, is probably due to their advanced healthcare systems that provide easy and sufficient access to high-quality healthcare services. In North and Central America, Mexico had a QOL score of 33.52 (31) and the United States a QOL score of 27.11 (32). Australia achieved a QOL score of 20.90, showing better QOL among people with Parkinson's disease than other continents (33).

We also evaluated the QOL scores in different regions of WHO: the Eastern Mediterranean Region had the highest score (36.28) and the Western Pacific Region had the lowest score (27.60), indicating better environments for people with Parkinson's disease in the Western Pacific and hence better QOL, probably due to this region’s economic development (34).

Our study showed a significant inverse association between patients’ age and QOL, meaning that increased age had a negative impact on an individual’s QOL. Another study reported that ageing had a negative effect on QOL and that younger patients had a higher QOL because of their active lifestyle and mobility (35). However, in another study, no significant association between PDQ-39 score and age was reported (31). Despite such discrepancies, it seems logical that ageing would negatively affect QOL because of the limitations it imposes on patients’ mobility and active daily life (36).

We found a significant inverse relationship between duration of disease and QOL, so that the longer the duration of Parkinson's disease, the lower the QOL score. A 2012 study reported this inverse relationship (37), and other studies reported no significant relationship between duration of Parkinson disease and QOL (31,38). Our results suggest that the duration of disease does not only affects QOL negatively, but also all the items of PDQ-39 questionnaire.

Regarding sex, men were more at risk of severe Parkinson's disease than women. Thus, women appeared to have a better QOL than men overall. However, we found different outcomes for the domains: men had poorer QOL for communication and discomfort, while women had more difficulties with daily activities, stigma, emotional well-being, mobility and cognition (39). Other studies found that QOL scores in female patients were higher than males indicating a lower QOL (40). A 2018 study concluded that men had higher scores (lower QOL) for mobility and discomfort, while women had higher scores for emotional well-being, stigma, cognition and communication (32).

We found that anxiety and depression influenced the QOL of patients with Parkinson's disease, with anxiety having the greater effect on patients' QOL. A study in Poland considered that depression was the most important factor influencing QOL and patients with untreated depression had poorer QOL (41). Another study mentioned depression as a determining factor for QOL, and anxiety as the second most common factor influencing QOL (27). A 2018 study also highlighted the important role of depression and anxiety in QOL among patients with Parkinson's disease (20).

A limitation of our study is that data from some countries were not available. Thus, studies in these countries were needed. Other limitations of the study were the lack of full text, lack of free access to, and low quality of some articles.

This study provides useful information about the effect of sex, age, duration of illness and psychological disorders, on the QOL of patients with Parkinson's disease. This information can be used by health policy-makers and clinicians for evidence-based strategies to improve the QOL of patients with Parkinson's disease who face problems with mobility, emotional well-being, daily living activities, stigma, social support, cognition, communication and discomfort.

Funding: None.

Competing interests: None declared.

Analyse systématique et méta-analyse de la qualité de vie des patients atteints de la maladie de Parkinson au niveau mondial

Résumé

Contexte : La maladie de Parkinson peut avoir un impact négatif sur la qualité de vie.

Objectifs : Nous avons réalisé une analyse systématique et une méta-analyse de la littérature mondiale sur la qualité de vie des patients atteints de la maladie de Parkinson et avons examiné l'association entre les caractéristiques des patients et la qualité de vie.

Méthodes : Nous avons effectué des recherches dans Embase, PubMed, Scopus et Web of Science sur la période allant de janvier 2000 à janvier 2020. Nous avons inclus des articles publiés en anglais qui ont eu recours au questionnaire sur la maladie de Parkinson pour estimer le score de qualité de vie et identifier les déterminants de la qualité de vie chez les patients atteints de cette maladie.

Résultats : Au total, 41 études comportant des données sur 4060 patients atteints de la maladie de Parkinson répondaient à nos critères d'inclusion. Le score global de qualité de vie était de 32,37 [intervalles de confiance (IC) à 95 % : 28,72-36,01]. L'âge et la durée de la maladie étaient inversement liés à la qualité de vie (p < 0,001). L'Amérique du Sud a obtenu le score le plus élevé au questionnaire (39,73, IC à 95 % : 28,66-50,79, p < 0,001), révélant ainsi la plus faible qualité de vie des patients atteints de la maladie de Parkinson. Parmi les six  Régions de l'Organisation mondiale de la Santé, la Région de la Méditerranée orientale a obtenu le score le plusb élevé (36,28, IC à 95 % : 23,44-49,13, p < 0,001).

Conclusion : Même si le score global des patients atteints de la maladie de Parkinson indiquait une qualité de vie acceptable, il est toujours possible de l'améliorer. Les résultats de la présente étude peuvent permettre aux responsables de l'élaboration des politiques en matière de santé et aux cliniciens de mettre en place des stratégies fondées sur des données probantes pour renforcer la qualité de vie des patients atteints de la maladie de Parkinson.

استعراض منهجي عالمي وتحليل تلوي لجودة حياة مرضى باركنسون (الشلل الرعَّاش)

زهراء بالانجي، فاطمة كان، حسين حسيني فارد، مريم دوستمهرابان، مريم معصومي، سيما الرافعي، بويان بارمايون، نيلوفر أحمدي، أفسانة ديهند، هاجر أشتود، ماشا أسل، بتول الحسيني، محمود الناصري، مسلم عريان، سيبيده أغالو، أحمد غاشجي

الخلاصة

الخلفية: يؤثر مرض باركنسون (الشلل الرعَّاش) سلبًا على نوعية الحياة.

الأهداف: هدفت هذه الدراسة الى إجراء مراجعة منهجية وتحليلًا تلويًّا للأدبيات عالميًّا بشأن جودة حياة مرضى باركنسون (الشلل الرعَّاش)، ودراسة العلاقة بين خصائص المريض وجودة الحياة.

طرق البحث: أجرينا بحثًا في قواعد البيانات في Embase وPubMed وScopus وWeb of Science طوال المدة من يناير 2000 إلى يناير 2020. وضمت الدراسة مقالات منشورة باللغة الإنجليزية استخدمت استبيان مرض باركنسون (الشلل الرعَّاش)، لتقدير درجة جودة الحياة والوقوف على محددات جودة الحياة للمرضى المصابين بمرض باركنسون (الشلل الرعَّاش).

النتائج: إجمالًا، استوفت 41 دراسة تحتوي على بيانات من 4060 مريضًا مصابًا بمرض باركنسون معايير الإدراج لدينا. وبلغت الدرجة الإجمالية لجودة الحياة 32.37 (فاصل الثقة 95%: 28.72–36.01). وكان عمر المريض ومدة الإصابة بالمرض مرتبطين ارتباطًا عكسيًّا بجودة الحياة ( القيمة الاحتمالية < 0.001). ونالت أمريكا الجنوبية أعلى درجة بالاستبيان (39.73، فاصل الثقة 95%: 28.66 - 50.79، القيمة الاحتمالية < 0.001)، الأمر الذي يشير إلى أدنى جودة لحياة المرضى المصابين بمرض باركنسون (الشلل الرعَّاش). ومن بين أقاليم منظمة الصحة العالمية الستة، نال إقليم شرق المتوسط أعلى درجة (36.28، فاصل الثقة 95%23.44–49.13؛ القيمة الاحتمالية < 0.001).

الاستنتاجات: رغم أن المعدل العالمي الذي حصل عليه المرضى المصابون بمرض باركنسون (الشلل الرعَّاش) يشير إلى جودة حياة مقبولة، فإنه ثمة إمكانية لتحسينها. ويمكن الاسترشاد بنتائج هذه الدراسة في صوغ الاستراتيجيات المسندة بالدلائل التي يضعها صناع السياسات الصحية والأطباء السريريون لتعزيز جودة حياة المرضى المصابين بمرض باركنسون (الشلل الرعَّاش).

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Letter to the editor

Rujittika Mungmunpuntipantip¹ and Viroj Wiwanitkit²

¹Private Academic Consultant, Bangkok, Thailand (Correspondence to: R. Mungmunpuntipantip: This email address is being protected from spambots. You need JavaScript enabled to view it.). ²Honorary Professor, Dr D Y Patil University, Pune, India

Citation: Mungmunpuntipantip R; Wiwanitkit V. COVID-19 financing strategies for refugees and migrants in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):71–72. https://doi.org/10.26719/emhj.23.004
Received: 13/02/22; accepted: 05/10/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Dear Editor,

We would like to share some thoughts on the paper “COVID-19 financing strategies for refugees and migrants in the Eastern Mediterranean Region” by Habersky and Damir (1). We agree that COVID-19 management is critical, and that everyone should be safeguarded. However, it is not unusual for poor populations, such as refugees and migrants, to face a shortage of suitable treatment and become high-risk groups for spreading COVID-19 (2). Currently, there are policies for dealing with the COVID-19 pandemic in different countries. Habersky and Damir are correct in emphasizing the importance of global economics. Vaccination coverage is uneven, and availability of vaccines varies according to the economic situation in a particular country (3). For example, in the poorer countries of Asia, healthcare funding and COVID-19 vaccination are limited. Vaccination of migrants is important because of the limited vaccination coverage of the local population. Perez-Brumer et al. examined COVID-19 vaccination policy in several developing countries and found that migrants continue to continue to face challenges and are often excluded or disadvantaged in vaccination policies, thus increasing the risks to their health and safety (4). Health officials should guarantee equal access to COVID-19 vaccines for local populations and migrants (5). A recent study showed that a significant majority of Ukrainian refugees had not received COVID-19 vaccination (6). There is a fundamental principle to provide free COVID-19 vaccination to people fleeing war; however, when there are many people leaving a conflict zone, finding sufficient vaccine becomes a challenge (6). The situation in host countries for Ukrainian refugees may be better than in other parts of the world that have similar conflict and refugee problems. It can be difficult to provide free COVID-19 vaccine to refugees in many situations where the local economy of the host nation is weak. During the planning of vaccination campaigns, giving priority to vulnerable populations like migrants and refugees is often politically impossible (7). When there is vaccine scarcity, it becomes challenging to provide vaccination to local residents and migrants. For instance, in Thailand, during the earlier days of the COVID-19 pandemic, the policy was to prioritize free vaccination to the local population. The local population received the first round of vaccination, followed by the migrant population at a later date. When there was a proposal to provide free COVID-19 vaccine to migrant groups, there were major discussions around the high cost of delivery and political and social acceptability, because the local population makes a significantly greater financial contribution to the economy (8,9). The strict immigration policies that are currently implemented in some European countries have been cited as additional obstacle hindering refugees from receiving free COVID-19 vaccination (10). When vaccine supply is insufficient for the local population, allocation to migrants may become an issue, resulting in social unrest. The policy for management of refugees and migrants is often used as a for societal debates on the rights of the native population. Developing countries are often unable to manage the increased burden of caring for refugees and migrants and external assistance is usually required. Collaboration between a country that hosts refugees and a third country is required to provide adequate financing and facilities to manage the healthcare needs of refugees (11). Global organizations like the United Nations and World Health Organization should ensure the provision of COVID-19 vaccination to migrants, refugees, and stateless communities because they may not be covered by local vaccination policies or priorities.

Funding: None

Competing interests: None declared.

References

1. Habersky E, Damir A. COVID-19 financing strategies for refugees and migrants in the Eastern Mediterranean Region. East Mediterr Health J. 2021 Dec 28;27(12):1229–38. https://doi.org/10.26719/emhj.21.061 PMID:35137391
2. Kluge HHP, Jakab Z, Bartovic J, D’Anna V, Severoni S. Refugee and migrant health in the COVID-19 response. Lancet. 2020 Apr 18;395(10232):1237–9. https://doi.org/10.1016/S0140-6736(20)30791-1 PMID:32243777
3. Hasan Q, Elfakki E, Fahmy K, Mere O, Ghoniem A, Langar H, et al. Inequities in the deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region, 2020-2021. BMJ Glob Health. 2022 Jun;7(Suppl 4):e008139. http://doi.org/10.1136/bmjgh-2021-008139s
4. Perez-Brumer A, Hill D, Andrade-Romo Z, Solari K, Adams E, Logie C, et al. Vaccines for all? A rapid scoping review of COVID-19 vaccine access for Venezuelan migrants in Latin America. J Migr Health. 2021;4:100072. https://doi.org/10.1016/j.jmh.2021.100072 PMID:34778855
5. Lin S. COVID-19 pandemic and im/migrants’ elevated health concerns in Canada: vaccine hesitancy, anticipated stigma, and risk perception of accessing care. J Immigr Minor Health. 2022 Aug;24(4):896–908. https://doi.org/10.1007/s10903-022-01337-5 PMID:35212825
6. Malchrzak W, Babicki M, Pokorna-Kałwak D, Doniec Z, Mastalerz-Migas A. COVID-19 vaccination and Ukrainian refugees in Poland during Russian–Ukrainian War – narrative review. Vaccines (Basel). 2022 Jun 16;10(6):955. https://doi.org/10.3390/vaccines10060955 PMID:35746562
7. Bellizzi S, Aidyralieva C, Alsawhala L, Al-Shaikh A, Santoro A, Profili MC. Vaccination for SARS-CoV-2 of migrants and refugees, Jordan. Bull World Health Organ. 2021 Sep 1;99(9):611. https://doi.org/10.2471/BLT.21.285591 PMID:34475595
8. Suphanchaimat R, Nittayasoot N, Thammawijaya P, Teekasap P, Ungchusak K. Predicted impact of vaccination and active case finding measures to control epidemic of coronavirus disease 2019 in a migrant-populated area in Thailand. Risk Manag Healthc Policy. 2021 Aug 3;14:3197–207. https://doi.org/10.2147/RMHP.S318012 PMID:34377040
9. Suphanchaimat R, Tuangratananon T, Rajatanavin N, Phaiyarom M, Jaruwanno W, Uansri S. Prioritization of the target population for coronavirus disease 2019 (COVID-19) vaccination program in Thailand. Int J Environ Res Public Health. 2021 Oct 14;18(20):10803. https://doi.org/10.3390/ijerph182010803 PMID:34682548
10. Deal A, Hayward SE, Huda M, Knights F, Crawshaw AF, Carter J, et al. Strategies and action points to ensure equitable uptake of COVID-19 vaccinations: a national qualitative interview study to explore the views of undocumented migrants, asylum seekers, and refugees. J Migr Health. 2021;4:100050. https://doi.org/10.1016/j.jmh.2021.100050 PMID:34075367
11. Bartovic J, Datta SS, Severoni S, D’Anna V. Ensuring equitable access to vaccines for refugees and migrants during the COVID-19 pandemic. Bull World Health Organ. 2021 Jan 1;99(1):3–3A. https://doi.org/10.2471/BLT.20.267690 PMID:33658728

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WHO event addressing public health priorities

Citation: World Health Organization. Summary report on the expert consultation on hospital resilience in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):73–74. https://doi.org/10.26719/2023.29.01.73

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Summary report on the Expert consultation on hospital resilience in the Eastern Mediterranean Region. https://applications.emro.who.int/docs/WHOEMHCM133E-eng.pdf.

Introduction

Lessons from the COVID-19 pandemic have highlighted the critical need to strengthen hospital and health systems to make them more resilient and better equipped to respond to health emergencies (1). The concept of hospital resilience is new and efforts have been made to conceptualize hospital resilience using different definitions (2).

Following the completion of a comprehensive regional mixed methods study (3), WHO/EMRO convened an expert consultation in May 2022 to obtain insights on hospital resilience, validate the draft framework on hospital resilience for the Eastern Mediterranean Region (EMR) and discuss interventions to operationalize and evaluate it (4). Present in the meeting were leading global and regional experts, including policymakers, hospital managers, academics, and representatives of WHO.

Summary of discussions

Findings on the conceptualization, operationalization and evaluation of hospital resilience were presented (3)

along with experiences of “resilience in action” and lessons in strengthening hospital resilience.

Conceptualization of hospital resilience

The proposed conceptual framework synthesizes existing evidence and highlights the starting point for discussion on strengthening hospital resilience (Figure 1). It defines hospital resilience using 6 components (6S), 4 capacities, and outcomes and impacts.

Strengthening hospital resilience requires hard and soft resilience, defined by 6 interdependent components: space, staff, stuff, strategies, systems, and services (3). Resilient hospitals must absorb, adapt, transform, and learn, using all these capacities, sometimes simultaneously, through prevention, preparedness, response, and recovery, within a risk-informed and all-hazard approach (3).

The primary outcome of resilient hospitals is the maintenance of hospital functions as they provide high-quality and continuous critical and essential services amidst crises, while leaving no one behind. Resilient hospitals help improve access and coverage, reduce vulnerabilities, and challenge inequalities, further contributing to the advancement of Universal Health Coverage, global health security, and health equity. Strengthening hospital resilience is embedded in and contributes to improving health systems and community resilience (Figure 1).

Participants found the framework to be comprehensive in capturing divergent concepts in the literature and recommended that it should be linked to a simple and practical operational guide to enable its application at the facility level. They suggested the linkage of components and capacities to interventions, monitoring and evaluation, and mechanisms to streamline and sustain continuous improvements, learning and innovation, and to reflect linkage to climate resilience and environmental sustainability.

Operationalization of hospital resilience

Operationalizing resilience is one of the greatest challenges in strengthening hospital resilience because of its newness and divergent concepts. There is limited contextualized and practical guidance for hospitals and hospital managers and a lack of integration of health system nuances and the dynamic nature of resilience into operationalization (3).

Participants highlighted the importance of embedding hospital resilience in the broader health systems strengthening initiatives and national incident management systems, and contextualising guidance on operationalization to accommodate the challenges of resource-restrained, fragile and conflict-affected settings. They proposed the development of an operational matrix to guide hospital managers before, during and after an emergency.

Participants noted the gaps and interventions on strengthening hospital resilience during the prevention, preparedness, response, and recovery stages (4). For example, they proposed risk assessment strategies to inform planning for service continuity and highlighted the need to update, re-align and strengthen facility and national preparedness and response plans based on prioritized risk profiles and hazard types. Participants proposed rapid health facility assessment to evaluate the safety of the hospital, available beds, staff, and resources and enable planning for an immediate and agile response and recovery. They highlighted the critical need for data, guidance for scale-down of response during recovery, and planning for mental health and psychosocial support of staff. They noted the need to compile an inventory of tools, document and share experiences, ensure sustainable and continuous improvements, and develop the capacities of hospital managers and their teams.

Evaluation of hospital resilience

A paucity of measurable and validated indices, lack of validated and standardized measurement tools, and limited linkages between theoretical frameworks and evaluation models remain challenges to evaluating hospital resilience (3). Participants agreed that hospital performance could be the primary indicator of resilience, while access, quality, cost-effectiveness, etc. could be intermediate measures (3-5).

Based on the conceptual framework, a guidance document with relevant tools has been developed, including interventions for each component across the prevention, preparedness, response, and recovery stages.

Conclusions

Participants in the expert panel encouraged EMR Member States to demonstrate political commitment and allocate resources to integrate hospital resilience within health systems and relevant national health security strategies. It is also advisable to pilot the hospital resilience operational guidance in collaboration with WHO/EMRO and evaluate the outcomes. WHO is encouraged to provide technical and capacity building support for piloting and implementation of the hospital resilience operational guidance. Developing a list of key indicators for qualitative and quantitative assessment of hospital resilience agenda at national level will also be beneficial. WHO and the countries should enhance efforts in conducting related operational research and documenting the outcomes for further use by the Member States.

References

1. World Health Organization. Regional Office for the Eastern Mediterranean. Strengthening hospital resilience in the Eastern Mediterranean Region: a policy paper on facility-level preparedness [Internet]. World Health Organization. Regional Office for the Eastern Mediterranean; 2022. Available from: https://apps.who.int/iris/handle/10665/352841.
2. Cristian B. Hospital resilience: a recent concept in disaster preparedness. J Crit Care Med (Targu Mures); 2018; 4(3):81-82. DOI: 10.2478/jccm-2018-0016.
3. Khalil M, Ravaghi H, Samhouri D, Abo J, Ali A, Sakr H and Camacho A. What is "hospital resilience"? A scoping review on conceptualization, operationalization, and evaluation. Front Public Health. 2022;14(10):1009400. DOI: 10.3389/fpubh.2022.
4. World Health Organization. Regional Office for the Eastern Mediterranean. Summary report on the Expert consultation on hospital resilience in the Eastern Mediterranean Region. World Health Organization. Regional Office for the Eastern Mediterranean; 2022. Available from https://applications.emro.who.int/docs/WHOEMHCM133E-eng.pdf.
5. World Health Organization. Health system performance assessment. 2022. Available from: https://www.who.int/publications-detail-redirect/9789240042476.
6. Citation: World Health Organization. Summary report on the expert consultation on hospital resilience in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):73–74. https://doi.org/10.26719/2023.29.01.73
7. Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Eastern Mediterranean Health Journal reviewers’ panel, 2022