Call to action: the need for an incident learning system in Eastern Mediterranean Region and Turkey (EMRO+T)

We aimed to calculate the Population Attributable Fraction (PAF) of cancers due to tobacco use in the Eastern Mediterranean Region (EMRO), where water-pipe smoking is prevalent but its effect was not considered in previous studies. We applied Levin's formula to estimate PAFs of cancers due to tobacco use (defined as all type tobacco including both cigarette and water-pipe). We also calculated PAF of water-pipe smoking separately. Exposure prevalence data were retrieved from representative national and subnational surveys. Data on cancer incidence and death were also and cancer cases were obtained GLOBOCAN 2020. We also obtained associated relative risks from published meta-analyses. Of the total 715 658 incident adult cancer cases that were reported in 2020 in EMRO, 14.6% (n = 104 800) was attributable to tobacco smoking (26.9% [n = 92 753]) in men versus 3.3% (n = 12 048) in women. Further, 1.0% of incident adult cancers were attributable to current water-pipe use (n = 6825) (1.7% [n = 5568]) in men versus 0.4% (n = 1257 in women). PAFs of cancers due to tobacco smoking in EMRO were higher in our study than previous reports. This could be due to the neglected role of water-pipe in previous studies that is a common tobacco smoking method in EMRO. The proportion of cancers attributable to water-pipe smoking in EMRO might be underestimated due to lack of research on the risk of cancers associated with water-pipe smoking and also less developed cancer registries in EMRO. In this study, we found higher PAFs for cancers due to tobacco smoking in the Eastern Mediterranean (EMR) region than previous reports. This difference could be due to ignoring the role of water-pipe smoking in previous studies. In 2020, 1% of incident cancers and 1.3% of cancer-related deaths in EMRO were attributable to water-pipe smoking. We also found a big difference in PAFs of cancers due to tobacco and water-pipe smoking across EMRO countries, with Tunisia, Lebanon, and Jordan having the highest, and Djibouti, Sudan, and Somalia having the lowest proportions of cancers attributable to tobacco and water-pipe smoking.

Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse. We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world. Data were sourced from Ovid Medline, Ovid Embase, Cochrane Library, African Journals Online, and Global Index Medicus. Hospital-based studies, including the total number of neonatal admissions with at least one clinical outcome marker of SNJ, defined as acute bilirubin encephalopathy (ABE), exchange blood transfusions (EBT), jaundice-related death, or abnormal brainstem audio-evoked response (aBAER), were independently reviewed for inclusion in this meta-analysis. Of 84 articles, 64 (76.19%) were from low- and lower-middle-income countries (LMICs), and 14.26% of the represented neonates with jaundice in these studies had SNJ. The prevelance of SNJ among all admitted neonates varied across WHO regions, ranging from 0.73 to 3.34%. Among all neonatal admissions, SNJ clinical outcome markers for EBT ranged from 0.74 to 3.81%, with the highest percentage observed in the African and South-East Asian regions; ABE ranged from 0.16 to 2.75%, with the highest percentages observed in the African and Eastern Mediterranean regions; and jaundice-related deaths ranged from 0 to 1.49%, with the highest percentage observed in the African and Eastern Mediterranean regions. Among the cohort of neonates with jaundice, the prevalence of SNJ ranged from 8.31 to 31.49%, with the highest percentage observed in the African region; EBT ranged from 9.76 to 28.97%, with the highest percentages reported for the African region; ABE was highest in the Eastern Mediterranean (22.73%) and African regions (14.51%). Jaundice-related deaths were 13.02%, 7.52%, 2.01% and 0.07%, respectively, in the Eastern Mediterranean, African, South-East Asian and European regions, with none reported in the Americas. aBAER numbers were too small, and the Western Pacific region was represented by only one study, limiting the ability to make regional comparisons. The global burden of SNJ in hospitalized neonates remains high, causing substantial, preventable morbidity and mortality especially in LMICs.

Methane (CH4) is a potent greenhouse gas but its sources remain poorly quantified in the Eastern Mediterranean and Middle East (EMME) region where major oil and gas production takes place. Light alkanes, such as ethane (C2H6), are co-emitted with CH4 by oil and gas activities and are promising tracers for quantifying the methane emissions from this sector. Cyprus is an ideal location for studying the composition of regional air masses and for characterizing different emission source signatures at a regional scale. A Picarro G2401 greenhouse gas analyzer and two field-based Gas Chromatography Flame Ionization Detectors (GC-FID) for Non-Methane Hydrocarbons (NMHC) measurements were deployed during two campaigns, one in “urban” (Nicosia) and one in “regional background” (Cape Greko) environment respectively. The campaign at the regional background site consisted in continuous methane and NMHCs (C2-C12) observations using a mobile laboratory that was deployed at the south-eastern edge of the island between December 2021 and February 2022. This location was chosen to capture airmasses of remote south and eastern origin, uninfluenced by local sources. We use these observations to 1) evaluate the significance of long-range transported versus local sources in Cyprus, 2) identify and document regional anthropogenic methane sources, and 3) assess the accuracy of the EDGAR sectoral emission inventory over EMME. Positive Matrix Factorization (PMF) analysis of the NMHC dataset resulted in the identification of four distinct sources namely tropospheric background, urban, heavy oil combustion, and transported from Middle East. The latest occurred during three distinct episodes and on average, had the highest NMHC concentrations. Generally, the different urban and regional signatures/sources displayed good and variable correlations between CH4 and C2 to C6-NMHCs. By investigating the PMF results together with CH4 concentrations and an atmospheric dispersion model (FLEXPART), we provide a comprehensive characterization of the pollution sources at regional scale over the Eastern Mediterranean region.

Seasonal influenza represents a huge health burden, resulting in significant mortality and morbidity. Following the 2009 H1N1 pandemic, focus has been directed on the burden of influenza globally. Country and regional disease burden estimates play important roles in helping inform decisions on national influenza intervention programmes. Despite improvements in influenza surveillance following the 2009 pandemic, many opportunities remain unexplored in the Eastern Mediterranean and North African (EMNA) region, which has a high prevalence of patients with chronic disease and thus a population at high risk of influenza complications. We conducted a systematic literature review of Embase, Medline, Scopus and the Cochrane Database of Systematic Reviews from 1 January 1998 to 31 January 2020 covering the EMNA region with the aim to describe the epidemiology of influenza in the region and assess the influenza epidemiological surveillance research landscape. Relevant data on study characteristics, population, clinical/virology characteristics and epidemiology were extracted and summarised descriptively. Of the 112 studies identified for inclusion, 90 were conducted in the Eastern Mediterranean region, 19 in North Africa and three across the EMNA region. Data were reported on 314,058 laboratory-confirmed influenza cases, 96 of which were derived from surveillance systems. Amongst the surveillance studies, the percentage of positive cases reported ranged from 1% to 100%. The predominantly identified influenza strain was strain A; H1N1 was the most prominent circulating subtype. Typing was performed in approximately 75% and subtyping in 50% of studies, respectively. Data on those considered most at risk for influenza complications were collected in 21% of studies, highlighting a regional gap for these data. Our review reveals existing gaps in regional estimates of influenza health and economic burden, hospitalisation rates and duration, and highlights the need for robust and high-quality epidemiology data to help inform public health interventions.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00534-3.

Global prevalence of WHO infant feeding practices in 57 LMICs in 2010-2018 and time trends since 2000 for 44 LMICs.

The complexity of the plate interactions and associated crustal deformation in the Eastern Mediterranean region is reflected in many destructive earthquakes that have occurred throughout its recorded history, many of which are well documented and intensively studied. The Eastern Mediterranean region, including the surrounding areas of western Turkey and Greece, is indeed one of the most seismically active and rapidly deforming regions within the continents (Fig. 1). Thus, the region provides a unique opportunity to improve our understanding of the complexities of continental tectonics in an actively collisional orogen. The major scientific observations from this natural laboratory have clearly been helping us to better understand the tectonic processes in active collision zones, the mode and nature of continental growth, and the causes and distribution of seismic, volcanic and geomorphological events (e.g. tsunamis) and their impact on societal life and civilization. The tectonic evolution of the Eastern Mediterranean region is dominated by the effects of subduction along the Hellenic (Aegean) arc and of continental collision in eastern Turkey (Anatolia) and the Caucasus. Northward subduction of the African plate beneath western Turkey and the Aegean region is causing extension of the continental crust and volcanism in the overlying Aegean extensional province. Eastern Turkey has been experiencing crustal shortening and thickening as a result of northward motion of the Arabian plate relative to Eurasia and the attendant postcollisional magmatism (Taymaz et al. 1990, 1991a, b; McClusky et al. 2000, 2003; Dilek & Pavlides 2006, and references therein; Fig. 2). The resulting combination of forces (the ‘pull’ from the subduction zone to the west and ‘push’ from the convergent zone to the east) is causing the Turkish plate to move southwestward, bounded by strike-slip fault zones: the North Anatolian Fault Zone (NAFZ) to the north and the East Anatolian Fault Zone (EAFZ) to the south. Interplay between dynamic effects of the relative motions of adjoining plates thus controls large-scale crustal deformation and the associated seismicity and volcanism in Anatolia and the Aegean region (Taymaz et al. 2004).

Estimated incidence, prevalence, mortality, and registration of childhood cancer (ages 0–14 years) in the WHO Eastern Mediterranean region: an analysis of GLOBOCAN 2020 data

Transport-related injuries (TIs) are a substantial public health concern for all regions of the world. The present study quantified the burden of TIs and deaths in the Eastern Mediterranean region (EMR) in 2017 by sex and age. TIs and deaths were estimated by age, sex, country, and year using Cause of Death Ensemble modelling (CODEm) and DisMod-MR 2.1. Disability-adjusted life years (DALYs), which quantify the total burden of years lost due to premature death or disability, were also estimated per 100000 population. All estimates were reported along with their corresponding 95% uncertainty intervals (UIs). In 2017, there were 5.5 million (UI 4.9-6.2) transport-related incident cases in the EMR - a substantial increase from 1990 (2.8 million; UI 2.5-3.1). The age-standardized incidence rate for the EMR in 2017 was 787 (UI 705.5-876.2) per 100000, which has not changed significantly since 1990 (-0.9%; UI -4.7 to 3). These rates differed remarkably between countries, such that Oman (1303.9; UI 1167.3-1441.5) and Palestine (486.5; UI 434.5-545.9) had the highest and lowest age-standardized incidence rates per 100000, respectively. In 2017, there were 185.3 thousand (UI 170.8-200.6) transport-related fatalities in the EMR - a substantial increase since 1990 (140.4 thousand; UI 118.7-156.9). The age-standardized death rate for the EMR in 2017 was 29.5 (UI 27.1-31.9) per 100000, which was 30.5% lower than that found in 1990 (42.5; UI 36.8-47.3). In 2017, Somalia (54; UI 30-77.4) and Lebanon (7.1; UI 4.8-8.6) had the highest and lowest age-standardized death rates per 100,000, respectively. The age-standardised DALY rate for the EMR in 2017 was 1,528.8 (UI 1412.5-1651.3) per 100000, which was 34.4% lower than that found in 1990 (2,331.3; UI 1,993.1-2,589.9). In 2017, the highest DALY rate was found in Pakistan (3454121; UI 2297890- 4342908) and the lowest was found in Bahrain (8616; UI 7670-9751). The present study shows that while road traffic has become relatively safer (measured by deaths and DALYs per 100000 population), the number of transport-related fatalities in the EMR is growing and needs to be addressed urgently.

Eastern Mediterranean (EM) region countries include countries from the Mediterranean region and North Africa representing regions with wide variations in their politics, economy, peaceful status, and healthcare infrastructure. Commonly known lip and oral cancer risk factors such as consumption of tobacco and alcohol are widely prevalent in the region. Globocan data suggests that age-standardized incidence rates and age-adjusted mortality rates are higher in the region compared to world averages whereas 1-, 2-, and 3-year prevalence proportions are lower. These statistical profiles are generally similar for men and women. Within the region, in general, incidence, mortality, and prevalence is greater in men than women. However, there are important differences in overall incidence, prevalence, and mortality; differences between genders in these statistics which vary between countries. This manuscript describes and compares oral cancer statistics of the countries in the EM region.

BackgroundHealth policy and systems research (HPSR) can strengthen health systems and improve population health outcomes. In the Eastern Mediterranean Region (EMR), there is limited recognition of the importance of HPSR and funding remains the main challenge. This study seeks to: (1) assess the reporting of funding in HPSR papers published between 2010 and 2022 in the EMR, (2) examine the source of funding in the published HPSR papers in the EMR and (3) explore variables influencing funding sources, including any difference in funding sources for coronavirus disease 2019 (COVID-19)-related articles.MethodsWe conducted a rapid scoping review of HPSR papers published between 2010 and 2022 (inclusively) in the EMR, addressing the following areas: reporting of funding in HPSR papers, source of funding in the published HPSR papers, authors’ affiliations and country of focus. We followed the Joanna Briggs Institute (JBI) guidelines for conducting scoping reviews.We also conducted univariate and bivariate analyses for all variables at 0.05 significance level.ResultsOf 10,797 articles screened, 3408 were included (of which 9.3% were COVID-19-related). More than half of the included articles originated from three EMR countries: Iran (n = 1018, 29.9%), the Kingdom of Saudi Arabia (n = 595, 17.5%) and Pakistan (n = 360, 10.6%). Approximately 30% of the included articles did not report any details on study funding. Among articles that reported funding (n = 1346, 39.5%), analysis of funding sources across all country income groups revealed that the most prominent source was national (55.4%), followed by international (41.7%) and lastly regional sources (3%). Among the national funding sources, universities accounted for 76.8%, while governments accounted for 14.9%. Further analysis of funding sources by country income group showed that, in low-income and lower-middle-income countries, all or the majority of funding came from international sources, while in high-income and upper-middle-income countries, national funding sources, mainly universities, were the primary sources of funding. The majority of funded articles’ first authors were affiliated with academia/university, while a minority were affiliated with government, healthcare organizations or intergovernmental organizations. We identified the following characteristics to be significantly associated with the funding source: country income level, the focus of HPSR articles (within the EMR only, or extending beyond the EMR as part of international research consortia), and the first author’s affiliation. Similar funding patterns were observed for COVID-19-related HPSR articles, with national funding sources (78.95%), mainly universities, comprising the main source of funding. In contrast, international funding sources decreased to 15.8%.ConclusionThis is the first study to address the reporting of funding and funding sources in published HPSR articles in the EMR. Approximately 30% of HPSR articles did not report on the funding source. Study findings revealed heavy reliance on universities and international funding sources with minimal role of national governments and regional entities in funding HPSR articles in the EMR. We provide implications for policy and practice to enhance the profile of HPSR in the region.

Trends in the burden and determinants of hypertensive heart disease in the Eastern Mediterranean region, 1990-2019: an analysis of the Global Burden of Disease Study 2019.

National cancer control plans across the Eastern Mediterranean region: challenges and opportunities to scale-up.

The popularity and acceptance of Traditional/Complementary and Alternative Medicine (TCAM) in the treatment of various ailments has persisted over the millennia. The formulations are so made as to minimize the untoward effects and enhance synergism, thereby increasing the efficacy of the preparation as a whole. The idea was perhaps based on the logic of humoral concept and study of temperaments and allied factors in the patient. The concept of constitution of human being is well recognized by the modern physician including the genetic variations and drug therapy. By focusing on the innate healing abilities of the human organism, TCAM represents a perspective that conventional medicine lost in the twentieth century in its enthusiasm for external, technological solutions to all health problems. Obviously, therefore, there is a need for a systematic investigation on the TCAM situation world wide. Incidentally, up to now, no effective and accepted tool has been available to monitor the global use of TCAM, and particularly in the Eastern Mediterranean Region (EMR) where the TCAM remains the major source of health care for majority of the population. It is already the people’s own health care system and is well accepted by them. It has certain advantages over imported systems of medicine in any setting because, as integral part of the people’s culture, it is particularly effective in solving certain cultural health problems. It is accessible and affordable in rural areas while the chemical drugs are not. In certain rural areas, the only available practioners are traditional healers as the conventional physicians are usually available in urban areas and big cities. It can and does freely contribute to scientific and universal medicine. Its recognition, promotion and development would serve due respect for people’s culture and heritage. In the present work, an effort has been made to collect the secondary data on practices and utilization of TCAM in the Eastern Mediterranean Region (EMR) in order to asses the present status of TCAM in this region. To achieve this goal, the Ministers of Health of the countries of the Region were requested to furnish the relevant informations. While some countries responded, others did not. However, based on the informations received from the respondents and also from the literature review, the present report has been prepared which gives an overview of TCAM in the EMR. Perusal of the information/data reveals great variations between the countries of the region. These variations/aspects will be presented and discussed. Although GDP, national health expenditure, physician: population ratio, and literacy rate are most important components of health, these are very low in some of the EMR countries. Yet, most of the countries are not taking due interest in the development and promotion of TCAM, which might contribute effectively to improve the health status of poverty stricken masses. Particularly because, the appropriate use TCAM of guaranteed quality and efficacy and safety in a cost-effective manner is a culturally accepted way of treating a range of diseases. Herbal Medicines are widely used in many countries of the EMR for treatment of variety of disorders and hence are of great importance as a mechanism to increase access to health care services. It is of particular importance in the rural areas where it is accessible and affordable, and the only available healers are traditional healers as the conventional healers are reluctant to work in these areas. Overall, herbal medicines are culturally accepted and widely used in many countries of the EMR for treatment of variety of disorders and hence are of great importance as a mechanism to increase access to health care services. However, only few countries have some form of policy/mechanism on TCAM. Other countries need to develop their policy on TCAM to provide a sound basis in defining the role of TCAM in national health care delivery, ensuring that necessary regulatory and legal mechanisms are created for promoting and maintaining good practices, that access is equitable, affordable and that authenticity, safety and efficacy of therapies are ensured.

Tackling COVID-19 in the Eastern Mediterranean Region

BackgroundSufficient and sustainable financing of the health system is essential for improving the health of the community. The health systems financing of the EMR countries is facing the challenge. Assessment and ranking of healthcare financing can help identify and resolve some challenges of health systems. So, the aim of this study is to evaluate and rank the condition of the health sector financing in the EMR countries.MethodsThis study was a cross-sectional study. The data was of secondary type, extracted from the official WHO and World Bank data. The six healthcare financing indicators in a 10-year interval (2005–2014) in 19 EMR countries analyzed using Grey Relation Analysis and Shannon Entropy.ResultsOn average, the countries in the EMR region spent 4.87% of their GDP on the health sector. Jordan and Qatar allocated the highest (8.313) and the lowest (2.293) percentages of their GDP to the health sector, respectively. The results showed That Qatar was in a better condition than other EMR countries during 2005–2014 in terms of the health system financing and earned the first rank. After that, the UAE and Kuwait were ranked second and third.ConclusionsThere is a lot of inequality among the EMR countries in terms of health financing. However, our findings confirmed that only increasing the total health expenditure in a country would not improve its financing status compared to other countries, but it also depends on financing methods.