The Global Governance of Antibiotic Stewardship: A One Health Scoping Review and the Integrated Polycentric Glocal Governance Framework (IPGF)

Pharmacists critical to managing antimicrobials, developing infection control procedures

BackgroundMore than 5.5 million Syrian refugees have fled violence and settled in mostly urban environments in neighboring countries. The Middle East and North Africa (MENA) region accounts for 6% of the global population but 25% of the population are ‘of concern’ to the UN Refugee Agency. In addition to large amounts of forced migration, the region is also undergoing an epidemiologic transition towards a heavier burden of noncommunicable diseases (NCDs), which in 2018 accounted for 74% of all deaths in the region. To address NCD needs globally, a myriad of policies and interventions have been implemented in low-income stable country settings. However, little is known about which policies and interventions are currently being implemented or are best suited for refugee hosting countries across the Middle East and North Africa.MethodsA scoping review of peer-reviewed literature was conducted to identify policies and interventions implemented in the Middle East and North Africa to address the needs of urban refugees with noncommunicable diseases.ResultsThis scoping review identified 11 studies from Jordan, Lebanon, Iran, West Bank, Gaza and Syria. These studies addressed three foci of extant work, (1) innovative financing for expensive treatments, (2) improvements to access and quality of treatment and, (3) efforts to prevent new diagnoses and secondary complications. All interventions targeted refugee populations including Palestinians, Sudanese, Syrians, Afghans and Iraqis.DiscussionThe scoping review highlighted five key findings. First, very few studies focused on the prevention of noncommunicable diseases among displaced populations. Second, several interventions made use of health information technologies, including electronic medical records and mHealth applications for patients. Third, the vast majority of publications were solely focused on tackling NCDs through primary care efforts. Fourth, the literature was very sparse in regard to national policy development, and instead favored interventions by NGOs and UN agencies. Last, the perspectives of refugees were notably absent.ConclusionOpportunities exist to prioritize prevention efforts, scale up eHealth interventions, expand access to secondary and tertiary services, address the scarcity of research on national policy, and incorporate the perspectives of affected persons in the broader discourse.

BackgroundCancer is one of the leading causes of death in children and adolescents, with a significant concentration in low and middle-income countries. Previous research has identified disparities in cancer incidence and mortality based on a country’s level of development. The Middle East and North Africa (MENA) region comprises of countries with heterogeneous income and development levels. This study aims to investigate whether discrepancies in cancer incidence and mortality among children and adolescents exist in countries within the MENA region.Materials and methodsData on cancer incidence and mortality were drawn from the Global Burden of Disease Study (GBD) 2019 for all malignant neoplasms (including non-melanoma skin cancers). The analysis was restricted to children and adolescents aged less than 20 years. Mortality- to-Incidence ratios (MIR) were calculated as a proxy measure of survival for each cancer type and country and Spearman’s correlation coefficient measured the association between socio-demographic index (SDI), incidence rates, mortality rates, and MIR.ResultsIn 2019, cancer incidence in the MENA region was 4.82/100,000 population, while mortality rate was 11.65/100,000 population. Cancer incidence and mortality was higher among males compared to females. A marked difference was observed in cancer-related mortality rates between low-income and high-income countries. MIR was higher in low-income countries, particularly for males and specific cancer types such as liver, colon and rectum, brain and central nervous system (CNS) cancers, and non-Hodgkin lymphoma among others. A negative correlation was observed between a country’s SDI and MIR (-0.797) and SDI and mortality rates (-0.547) indicating that higher SDI corresponds to lower MIR and lower mortality rates.ConclusionThese findings highlight the need for evidence-based interventions to reduce cancer-related mortality and disease burden among children and adolescents, particularly in low-income countries within the region and for cancer types with the highest mortality rates. Additionally, efforts should focus on establishing registries to provide up-to-date national data on cancer incidence and mortality in countries within the region.

Epidemiology and microbiology of catheter-associated urinary tract infections: A 14-year surveillance study at a tertiary care center in Lebanon

Two decades after the fall of the shah, Iran is still going through a long and frequently interrupted post-revolutionary transition, which has a significant impact on the country's politics and its external relations. This paper discusses the implications of Iran's foreign policy on security in the Middle East and North Africa (MENA) region with a specific focus on the national security of Egypt. The study was carried out in Egypt and North Africa, and it studied a sample of 50 adult male and female professors who specialize in Iranian affairs, politics, and diplomats. The purpose of this study is to assess the impact of Iran's foreign policy in the MENA region. The specific objectives of the study were: 1) to examine the current situation of Iran's foreign policy on security in the Middle East and North Africa (MENA); 2) to assess how Iran's foreign policy on security in the Middle East and North Africa (MENA) impact’s on Egypt's stability and; 3) to investigate strategies being used by Egypt to navigate security challenges and improve relations with Iran. The study is based on the shock theory. Data gathered from interviews and questionnaires using both qualitative and quantitative research methods have been used in the research. After gathering the data, they were analyzed using both qualitative and quantitative techniques. The findings of the study indicate that security challenges in the Middle East and North Africa (MENA) region are highly complex and are influenced by various factors such as politics, history, economics, and religion. The insights contained herein form the basis for understanding how Iran's foreign policy affects regional security and geopolitical stability, thereby necessitating context-dependent measures to address contemporary security threats in the MENA region.

PurposeThis article explores the current trends in civic engagement in the Middle East and North Africa (MENA) region after a decade of social media growth in the region.Design/methodology/approachThe methodology is based on a case studies approach. In these case studies, the authors use an exploratory approach to case study research. The authors employ a mixed-method approach to exploring the development of civic engagement in the MENA region.FindingsThe study’s finding shows that the MENA region's social media growth has enabled digital natives to play a vital role in enriching and empowering their communities and their lives.Research limitations/implicationsThe paper could have explored more examples from around the MENA region.Practical implicationsThe paper's practical significance is the understanding that the ground is shifting around Internet access and how digital natives in the MENA region are employing it for their civic engagement initiative. It is an important indication that the MENA region's next innovation could be in the civic engagement arena. Unlike their parents, who are digital immigrants, these young and energetic digital natives are out to shape all aspects of their lives. Paving the way for more innovative and creative ways of civic engagement in the MENA region.Originality/valueThe paper explores civic engagement development in the MENA region, shedding light on the issues concerning MENA region youth such as cleaning the environment, waste and food recycling, combating extremism, developing education curricula and even promoting peace. The paper's value is that it gives an update on civic engagement in the MENA region.

While the right to housing is a fundamental right per article 25 of the 1948 Universal Declaration of Human Rights, ‘homelessness’ is still generally a Western concept and not comprehensively recognized or addressed as a social issue in many countries, including many within the Middle East and North Africa. This paper looked at the literature on homelessness in the Middle East and North Africa (MENA) region to document the meaning and scope of homelessness within this region. After identifying and screening the relevant articles, 103 eligible articles were included in the final data synthesis stage. What we have learned from the review is organized in three categories: 1) conceptualizations of homelessness, 2) proposed responses to homelessness, and 3) research gaps. Studies addressing homelessness experienced by women, elderly, and family were underrepresented or did not exist. Homelessness among children dominates the literature in this review with 62% studies investigated the issue of homelessness in childhood. In a way, children are prioritized yet their adult relatives are often left invisible. Responding to the issue of homelessness on a global scale first involves having effective definitions that both properly enumerate and contextualize the issue. Without establishing a comprehensive definition of homelessness, efforts to address housing precarity can be ineffective.

The main purpose of this study is to measure the technical efficiency of twenty health systems in the Middle East and North Africa (MENA) region to inform evidence-based health policy decisions. In addition, the effects of alternative stochastic frontier model specification on the empirical results are examined. We conducted a stochastic frontier analysis to estimate the country-level technical efficiencies using secondary panel data for 20 MENA countries for the period of 1995-2012 from the World Bank database. We also tested the effect of alternative frontier model specification using three random-effects approaches: a time-invariant model where efficiency effects are assumed to be static with regard to time, and a time-varying efficiency model where efficiency effects have temporal variation, and one model to account for heterogeneity. The average estimated technical inefficiency of health systems in the MENA region was 6.9% with a range of 5.7-7.9% across the three models. Among the top performers, Lebanon, Qatar, and Morocco are ranked consistently high according to the three different inefficiency model specifications. On the opposite side, Sudan, Yemen and Djibouti ranked among the worst performers. On average, the two most technically efficient countries were Qatar and Lebanon. We found that the estimated technical efficiency scores vary substantially across alternative parametric models. Based on the findings reported in this study, most MENA countries appear to be operating, on average, with a reasonably high degree of technical efficiency compared with other countries in the region. However, there is evidence to suggest that there are considerable efficiency gains yet to be made by some MENA countries. Additional empirical research is needed to inform future health policies aimed at improving both the efficiency and sustainability of the health systems in the MENA region.

BackgroundThe epidemiology of Neisseria gonorrhoeae (NG) infection in the Middle East and North Africa (MENA) region remains poorly understood, despite the global recognition of its disease burden and the growing concern regarding antimicrobial resistance. This study aimed to systematically review the evidence on NG prevalence in MENA, estimate the pooled mean prevalence across different populations, and explore population-level associations with prevalence as well as sources of between-study heterogeneity.MethodsThe study conducted a systematic review, risk of bias assessment, meta-analyses, and meta-regressions, utilizing both published and unpublished evidence sourced from international, regional, and national databases, in adherence to PRISMA guidelines. Random-effects meta-analyses and meta-regressions were employed to analyze the data.ResultsThe study identified 341 NG prevalence measures from 21 countries in MENA. The pooled mean prevalence of current urogenital infection was 1.9% (95% confidence interval (CI) 1.1–2.8%) in the general population, with a higher pooled prevalence in studies with sample sizes < 200 (3.1%; 95% CI 1.5–5.0%) compared to those with sample sizes ≥ 200 (1.1%; 95% CI 0.5–1.9%). Among specific populations, the pooled prevalence was 6.5% (95% CI 4.4–9.0%) in female sex workers, 7.5% (95% CI 2.8–14.0%) in attendees of infertility clinics, 3.0% (95% CI 0.4–7.0%) in women with miscarriage or ectopic pregnancy, 3.9% (95% CI 2.7–5.3%) in symptomatic women, and 41.4% (95% CI 34.9–48.1%) in symptomatic men. For male sex workers and men who have sex with men, the pooled prevalence of current urogenital infection was 1.6% (95% CI 0.4–3.4%), while the prevalence of current anorectal infection was 10.4% (95% CI 4.6–18.0%). Through multivariable meta-regressions, 64% of the prevalence variation was explained, revealing a hierarchical pattern in prevalence by population type and sex, and a prevalence decline at a rate of 1% per year.ConclusionsNG prevalence in MENA is comparable to the global prevalence, underscoring a neglected and underrecognized disease burden, with social and economic consequences. Persistent transmission of NG among key populations and other populations at risk increases the potential for the emergence of new drug-resistant strains. MENA is far from achieving the World Health Organization’s target of reducing NG incidence by 90% by 2030.

Several Sustainable Development Goals of the United Nation are directly or indirectly related to nutrition, including SDG1 (no poverty) and SDG2 (zero hunger). Many parts of the Middle East and North Africa (MENA) region are experiencing poverty or suffering from micronutrient (Calcium, Iron, and Vitamin D) deficiencies, which has contributed to a high mortality rate among children and pregnant women. Teff, an old and well-known grain in MENA and a “Super Grain” in developed countries, has a strong potential to be utilized in food product development activities in MENA. These new products can be produced by local scientists and be sold domestically or internationally. The aim of this short communication is to review the limitations and opportunities that exist in the process of food product development with Teff. Several Sustainable Development Goals of the United Nation are directly or indirectly related to nutrition, including SDG1 (no poverty) and SDG2 (zero hunger). Many parts of the Middle East and North Africa (MENA) region are experiencing poverty or suffering from micronutrient (Calcium, Iron, and Vitamin D) deficiencies, which has contributed to a high mortality rate among children and pregnant women. Teff, an old and well-known grain in MENA and a “Super Grain” in developed countries, has a strong potential to be utilized in food product development activities in MENA. These new products can be produced by local scientists and be sold domestically or internationally. The aim of this short communication is to review the limitations and opportunities that exist in the process of food product development with Teff.

e13567 Background: Similar to other regions of the world, cancer incidence in Middle East and North Africa (MENA) is rising, which has been attributed to increased life expectancy and adoption of western lifestyle habits. Conducting clinical trials in the region is important to assess efficacy and safety of oncology medications in the specific population (response to drugs can be impacted by genetics, demographics and lifestyle factors). Although the MENA comprises around 5% of the global population, the region only participates in approximately 3% of clinical trials worldwide. It is important to understand the challenges in conducting trials in MENA and identify strategies to overcome these in order to facilitate advances in clinical research in the region. Methods: A literature review was conducted (via e.g. PubMed and ClinicalTrials.gov) to understand the current oncology clinical research landscape in MENA (from Jan 2015-Dec 2020), with the aim of identifying key challenges and potential strategies to overcome these. Results: Conduct of oncology clinical trials (phases 1-4) has risen in recent years in MENA, from 47 trials in 2015 to 53 trials in 2020. Despite the presence of various research-favourable factors in MENA (large patient pool, high demand for medication, lower clinical trial operational costs, compliance with ICH-GCP standards), the region still falls behind other countries in clinical research. Key factors identified as challenges in conducting clinical trials in MENA include the research infrastructure and patient awareness/understanding of research. We propose the following strategies to support the advancement of clinical research in the region: (1) Enhance research infrastructure through bolstering national clinical research networks and supporting collaboration between healthcare institutes, academia and the pharma industry; (2) Diversify methods of patient engagement (e.g. patient advisory groups and social media networks) and provide education on pros/cons of participating in research to raise awareness and improve trial participation rates; and (3) Improve availability of comprehensive oncology registries to enhance understanding of disease burden and support clinical research. Conclusions: The conduct of oncology clinical trials in MENA is increasing, yet the region is still under-represented in the global clinical trial market, despite its significant potential. The advancement of clinical research in the region will require a multi-level approach, involving collaboration between multiple stakeholders including the pharma industry, regulators, government, and healthcare professionals.

Psychometric evaluation of the COPD assessment test: Data from the BREATHE study in the Middle East and North Africa region

IntroductionConflict, fragility and political violence, that are taking place in many countries in the Middle East and North Africa (MENA) region have devastating effects on health. Digital health technologies can contribute to enhancing the quality, accessibility and availability of health care services in fragile and conflict-affected states of the MENA region. To inform future research, investments and policy processes, this scoping review aims to map out the evidence on digital health in fragile states in the MENA region.MethodWe conducted a scoping review following the Joanna Briggs Institute (JBI) guidelines. We conducted descriptive analysis of the general characteristics of the included papers and thematic analysis of the key findings of included studies categorized by targeted primary users of different digital health intervention.ResultsOut of the 10,724 articles identified, we included 93 studies. The included studies mainly focused on digital health interventions targeting healthcare providers, clients and data services, while few studies focused on health systems or organizations managers. Most of the included studies were observational studies (49%). We identified no systematic reviews. Most of the studies were conducted in Lebanon (32%) followed by Afghanistan (13%) and Palestine (12%). The first authors were mainly affiliated with institutions from countries outside the MENA region (57%), mainly United Kingdom and United States. Digital health interventions provided a platform for training, supervision, and consultation for health care providers, continuing education for medical students, and disease self-management. The review also highlighted some implementation considerations for the adoption of digital health such as computer literacy, weak technological infrastructure, and privacy concerns.ConclusionThis review showed that digital health technologies can provide promising solutions in addressing health needs in fragile and conflict-affected states. However, rigorous evaluation of digital technologies in fragile settings and humanitarian crises are needed to inform their design and deployment.

Regional Environmental Cooperation on Transboundary Air Pollution in the Middle East and North Africa Inkyoung Kim (bio) Introduction1 Since the United Nations Conference on the Human Environment in 1972, international communities have endeavored to clarify the right and responsibility of states regarding transboundary pollution. Principle 21 of the 1972 Declaration at this Conference stated that countries have "the responsibility to ensure that activities within their jurisdiction or control do not cause damage to the environment of other States or of areas beyond the limits of national jurisdiction."2 Europe has been successful in tackling transboundary air pollution through the Convention on Long-range Transboundary Air Pollution in 1979. Furthermore, the Agenda 21 of the 1992 Declaration of the United Nations Conference on Environment and Development urged European countries to share their successful experiences with other regional communities to help them solve transboundary pollution issues. Have European experiences on transboundary air pollution been shared [End Page 1] with the Middle East and North Africa (MENA) region? What are the main sources of transboundary air pollution in MENA? To address those issues, what kinds of cooperative mechanisms have been created in this region? While many studies have attempted to tease out the motivations, success, and limitations of European regional environmental cooperation, regional environmental cooperation in MENA has been understudied. This study aims to investigate regional environmental cooperation in MENA, focusing on transboundary air pollution. Transboundary Pollution Most pollution problems are caused by local or regional sources, but pollution does not stay within and stop at national borders. It can travel by air or water thousands of miles. Transboundary flows of pollutants occur among countries in the same region as well as between continents. The United Nations (UN) defines transboundary pollution as "pollution that originates in one country but, by crossing the border through pathways of water or air, is able to cause damage to the environment in another country."3 More specifically, the United Nations Economic Commission for Europe (UNECE) defines transboundary air pollution as "air pollution whose physical origin is situated wholly or in part within the area under the national jurisdiction of one State and which as adverse effects in the area under the jurisdiction of another State at such a distance that it is not generally possible to distinguish the contribution of individual emission sources or groups of sources" in Article 1 of the 1979 Convention on Long-range Transboundary Air Pollution.4 It is known that some air pollutants circulate even globally and deposit on land and water bodies far from their original sources.5 Acid rain problems in Europe have led 51 countries to adopt the Convention on the Long-range Transboundary Air Pollution and various numbers of countries to ratify eight protocols on the reduction of sulfur, nitrogen oxides, volatile organic compounds, persistent organic pollutants, and ozone emissions since 1979.6 East Asia has also addressed acid rain [End Page 2] and dust sandstorms since the 1990s. As the Sahara Desert in North Africa and the whole region of the Middle East are the two hot spots of primary dust storms around the world, it is important to understand what the main sources of dust storms are and if MENA has developed any significant cooperative mechanisms to tackle transboundary impact of dust storms originated in this region. MENA Different entities identify the MENA region differently. For example, the World Bank identifies MENA as one of six regions of the world.7 It classifies the 19 countries or territories as part of the Middle East and North Africa, including Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, West Bank and Gaza, and Yemen.8 The OECD does not include Iran but does include Mauritania and Palestinian Authority instead of West Bank and Gaza. The UN does not identify MENA as one of its five regional groups.9 Its agencies and programs define the MENA region differently and sometimes contradictorily. For instance, United Nations Environment Programme has six regional offices including Africa, Asia Pacific, Europe, Latin American and the Caribbean, North America, and West Asia. The regional office for Africa covers the entire African continent...

Human immunodeficiency virus (HIV) in the Middle East and North Africa (MENA) region is severely understudied despite the region’s increase in new HIV infections since 2010. A key population that is particularly affected, due to the lack of adequate knowledge and proper interventional implementation, includes people who inject drugs (PWID). Furthermore, the paucity of HIV data (prevalence and trends) worsens an already critical situation in this region. A scoping review was conducted to address the scarcity of information and to synthesize the available data on HIV prevalence rates within the key population of PWID throughout the MENA region. Information was sourced from major public health databases and world health reports. Of the 1864 articles screened, 40 studies discussed the various factors contributing to the under-reporting of HIV data in the MENA region among PWID. High and overlapping risk behaviors were cited as the most prevalent reason why HIV trends were incomprehensible and hard to characterize among PWID, followed by lack of service utilization, lack of intervention-based programs, cultural norms, lack of advanced HIV surveillance systems, and protracted humanitarian emergencies. Overall, the lack of reported information limits any adequate response to the growing and unknown HIV trends throughout the region.