World Health Organization Eastern Mediterranean Region Research Articles

Approaches for delivery of refractive and optical care services in community and primary care settings.

Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states. To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation. We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery. We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002. Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme. We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services. We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels. This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership. The protocol of this scoping review was published in the Open Source Framework.

National immunization technical advisory groups (NITAGs) in the WHO Eastern Mediterranean Region (EMR): A decade of shaping immunization policies, 2010–2021

In the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), little is known on National Immunization Technical Advisory Groups’ (NITAGs) outputs, including recommendations and their outcomes. We abstracted information from the WHO/UNICEF joint reporting forms and extracted implemented immunization policy decisions from the WHO immunization portal. We describe trends in establishments and functionality of NITAGs and immunization policies implemented in EMR from 2010 to 2021. In 2013, all 22 EMR countries had a NITAG, although only 20 remained active in 2021. The number of countries meeting six NITAG process indicators increased from 7 in 2010, to 14 in 2019, then reduced to 12 in 2021. In 2021, the proportion of countries with a functional NITAG decreased with income level, from 83% in high-income countries, to 55% in middle-income countries and 20% in low-income countries. From 2010 to 2021, there were 103 new vaccine introductions, 31 vaccine switches, and 28 schedule changes implemented across all 22 countries, irrespective of income groups. While NITAGs are established and making recommendations in countries, their functionality decreases with income level. Governments should continue to invest in NITAGs, including on strengthening processes and ensuring that recommendations made are based on evidence to decision frameworks.

The impact of the COVID-19 pandemic on service delivery for noncommunicable diseases in the Eastern Mediterranean Region.

The COVID-19 pandemic has adversely affected the delivery of noncommunicable diseases (NCDs) services globally as health systems are overwhelmed by the response to the pandemic. The World Health Organization (WHO) Regional Office for the Eastern Mediterranean conducted an assessment to evaluate the impact of COVID-19 on NCD-related services, programmes, funding and consideration of NCDs in COVID-19 response. Data were collected from countries of the WHO Eastern Mediterranean Region (EMR) in mid-2020 through a web-based questionnaire on NCD services-related infrastructure, policies and plans, staffing, funding, NCD services disruptions and their causes, disruption mitigation strategies, data collection on comorbidity, surveillance, and suggestions for WHO technical guidance. The data were exported into Microsoft Excel and summarized. Countries were grouped according to socioeconomic level. Nineteen of the 22 countries in the EMR responded: 95% had NCD staff reallocated to support their COVID-19 response. Lower-income countries were less likely to include NCDs in their pandemic response plans and more likely to report disruption of services. The most commonly disrupted services were hypertension management (10 countries 53%), dental care (10 countries 53%), rehabilitation (9 countries 47%), palliative care (9 countries 47%) and asthma management (9 countries 47%). The COVID-19 pandemic has disrupted the continuity of NCD-related services in EMR countries. The ability to mitigate service disruptions varied noticeably between countries. The mitigation measures implemented included triaging of patients, novel NCD medicines supply chains and dispensing interventions, and the use of digital health and telemedicine. Guidance and support for systems resilience, preparedness and response to crises are recommended.

Adult Vaccine Hesitancy Scale in Arabic and French: Protocol for Translation and Validation in the World Health Organization Eastern Mediterranean Region.

BackgroundThe world as we know it changed during the COVID-19 pandemic. Hope has emerged with the development of new vaccines against the disease. However, many factors hinder vaccine uptake and lead to vaccine hesitancy. Understanding the factors affecting vaccine hesitancy and how to assess its prevalence have become imperative amid the COVID-19 pandemic. The vaccine hesitancy scale (VHS), developed by the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization, has been modified to the adult VHS (aVHS) and validated in English and Chinese. To our knowledge, no available aVHS has been designed or validated in Arabic or French.ObjectiveThe aim of this research is to translate the aVHS from its original English language to Arabic and French and validate the translations in the WHO Eastern Mediterranean region.MethodsThe study will follow a cross-sectional design divided into 5 phases. In phase 1, the original aVHS will be forward-translated to Arabic and French, followed by backward translation to English. An expert committee will review and rate all versions of the translations. Expert agreement will then be measured using the Cohen kappa coefficient (k). In phase 2, the translated aVHS will be pilot-tested with 2 samples of participants (n=100): a group that speaks both Arabic and English and another that speaks French and English. Participants’ responses to the English version will also be collected. In phase 3, responses will then be compared. Descriptive statistics and paired t tests or one-way analyses of variance (ANOVA) and Pearson correlation coefficient will be used in the preliminary validation. In phase 4, prefinal versions (Arabic and French) will be tested with larger sample sizes of Arabic speakers (n=1000) and French speakers (n=1000). Sociodemographic information and vaccination status will be collected and used for further analysis. In phase 5, the scale's statistical reliability and internal consistency will be measured using Cronbach alpha. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) will be used to examine the model fit resulting from the EFA. ANOVA and regression models will be constructed to control for confounders. All data will be electronically collected.ResultsAs of January 2022, the scale had been translated to Arabic and French and was undergoing the process of back translation. All data collection tools have been prepared (ie, sociodemographics, vaccination status, and open-ended questions) and are ready to go into their electronic formats. We expect to reach the desired sample size in this phase by June 2022.ConclusionsThis study will provide researchers with a validated tool to assess adult vaccine hesitancy within populations that speak Arabic and/or French and provide a road map to scale translation and ensure cross-cultural adaptation.International Registered Report Identifier (IRRID)PRR1-10.2196/36928

The forgotten sub-regional COVID-19 response layer. The case of the WHO Eastern Mediterranean Region.

The response to the COVID-19 pandemic have been driven by epidemiology, health system characteristics and control measures in form of social/physical distancing. Guidance, information and best practices have been characterized by territorial thinking with concentration on national health system and social contexts. Information was to a large extent provided from global entities such as the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) and others. This bipolar response mechanism came to the detriment of regional and sub-regional levels. The development of the global pandemic was evaluated in terms of the performance of single countries without trying to reflect on possible regional or sub-regional results of similar characteristics in health system and social contexts. To have a clearer view of the issue of sub-regional similarities, we examined the WHO, Eastern Mediterranean Region. When examining the development of confirmed cases for countries in the region, we identified four different sub-groups similar in the development of the pandemic and the social distancing measure implemented. Despite the complicated situation, these groups gave space for thinking outside the box of traditional outbreaks or pandemic response. We think that this sub-regional approach could be very effective in addressing more characteristics and not geographically based analysis. Furthermore, this can be an area of additional conceptual approaches, modelling and concrete platforms for information and lessons learned exchange.

Measures implemented in the school setting to contain the COVID-19 pandemic: a scoping review.

In response to the spread of SARS-CoV-2 and the impact of COVID-19, national and subnational governments implemented a variety of measures in order to control the spread of the virus and the associated disease. While these measures were imposed with the intention of controlling the pandemic, they were also associated with severe psychosocial, societal, and economic implications on a societal level. One setting affected heavily by these measures is the school setting. By mid-April 2020, 192 countries had closed schools, affecting more than 90% of the world's student population. In consideration of the adverse consequences of school closures, many countries around the world reopened their schools in the months after the initial closures. To safely reopen schools and keep them open, governments implemented a broad range of measures. The evidence with regards to these measures, however, is heterogeneous, with a multitude of study designs, populations, settings, interventions and outcomes being assessed. To make sense of this heterogeneity, we conducted a rapid scoping review (8 October to 5 November 2020). This rapid scoping review is intended to serve as a precursor to a systematic review of effectiveness, which will inform guidelines issued by the World Health Organization (WHO). This review is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and was registered with the Open Science Framework. To identify and comprehensively map the evidence assessing the impacts of measures implemented in the school setting to reopen schools, or keep schools open, or both, during the SARS-CoV-2/COVID-19 pandemic, with particular focus on the types of measures implemented in different school settings, the outcomes used to measure their impacts and the study types used to assess these. We searched the Cochrane COVID-19 Study Register, MEDLINE, Embase, the CDC COVID-19 Research Articles Downloadable Database for preprints, and the WHO COVID-19 Global literature on coronavirus disease on 8 October 2020. We included studies that assessed the impact of measures implemented in the school setting. Eligible populations were populations at risk of becoming infected with SARS-CoV-2, or developing COVID-19 disease, or both, and included people both directly and indirectly impacted by interventions, including students, teachers, other school staff, and contacts of these groups, as well as the broader community. We considered all types of empirical studies, which quantitatively assessed impact including epidemiological studies, modelling studies, mixed-methods studies, and diagnostic studies that assessed the impact of relevant interventions beyond diagnostic test accuracy. Broad outcome categories of interest included infectious disease transmission-related outcomes, other harmful or beneficial health-related outcomes, and societal, economic, and ecological implications. We extracted data from included studies in a standardized manner, and mapped them to categories within our a priori logic model where possible. Where not possible, we inductively developed new categories. In line with standard expectations for scoping reviews, the review provides an overview of the existing evidence regardless of methodological quality or risk of bias, and was not designed to synthesize effectiveness data, assess risk of bias, or characterize strength of evidence (GRADE). We included 42 studies that assessed measures implemented in the school setting. The majority of studies used mathematical modelling designs (n = 31), while nine studies used observational designs, and two studies used experimental or quasi-experimental designs. Studies conducted in real-world contexts or using real data focused on the WHO European region (EUR; n = 20), the WHO region of the Americas (AMR; n = 13), the West Pacific region (WPR; n = 6), and the WHO Eastern Mediterranean Region (EMR; n = 1). One study conducted a global assessment and one did not report on data from, or that were applicable to, a specific country. Three broad intervention categories emerged from the included studies: organizational measures to reduce transmission of SARS-CoV-2 (n = 36), structural/environmental measures to reduce transmission of SARS-CoV-2 (n = 11), and surveillance and response measures to detect SARS-CoV-2 infections (n = 19). Most studies assessed SARS-CoV-2 transmission-related outcomes (n = 29), while others assessed healthcare utilization (n = 8), other health outcomes (n = 3), and societal, economic, and ecological outcomes (n = 5). Studies assessed both harmful and beneficial outcomes across all outcome categories. We identified a heterogeneous and complex evidence base of measures implemented in the school setting. This review is an important first step in understanding the available evidence and will inform the development of rapid reviews on this topic.

Community Participation and Empowerment in Healthy Cities Initiative: Experience from the Eastern Mediterranean Region

Background: The healthy city concept has been widely accepted globally and has been established in all six World Health Organization (WHO) Regions. Community involvement, empowerment, and leadership are embedded core principles in the Healthy Cities initiative and pillars to achieve the health and health-related sustainable development goals. This article aimed to present the findings of the recent evaluation of eleven healthy cities in the WHO Eastern Mediterranean Region (EMR).
 Methods: The descriptive comparative evaluation was based on the WHO/EMRO healthy city 80 indicators. It included eleven cities (Al-Dariyah, Jalajil, Al-Jamoum, Unaiza, Riyadh Alkhubra, Sharoura, Al-Madina, Al-Taif, and Al-Mundaq in Kingdom of Saudi Arabia; Al-Yarmouk in Kuwait, and Manama in Bahrain).
 Results: The findings revealed that eleven cities were peculiar in demonstrating community involvement, empowerment, and leadership in real terms. All had well mechanisms for communities to voice themselves and participate in decision-making, assessing the needs, setting priorities, planning better for their cities, and monitoring. The community engagement was based on voluntarism with a high sense of loyalty. It has been well demonstrated in community organizations like women and youth groups, health volunteers, community-based organizations, and others.
 Conclusion: Although community participation and empowerment remain at the heart of the healthy cities initiative, to be meaningful, the government-related sectors must foresee this as an integral part of long-term strategic development. Moreover, a paradigm shift towards a more integrated approach to promote health, well-being, accelerate the achievement of health-related sustainable development goals, and reduce health inequities in urban settings requires multi-stakeholder collaboration, including public, private, and community civil societies.

Health consequences of drought in the WHO Eastern Mediterranean Region: hotspot areas and needed actions

BackgroundOver the past four decades, drought episodes in the Eastern Mediterranean Region (EMR) of the of the World Health Organization (WHO) have gradually become more widespread, prolonged and frequent. We aimed to map hotspot countries and identified key strategic actions for health consequences.MethodsWe reviewed scientific literature and WHO EMR documentation on trends and patterns of the drought health consequences from 1990 through 2019. Extensive communication was also carried out with EMR WHO country offices to retrieve information on ongoing initiatives to face health consequences due to drought. An index score was developed to categorize countries according vulnerability factors towards drought.ResultsA series of complex health consequences are due to drought in EMR, including malnutrition, vector-borne diseases, and water-borne diseases. The index score indicated how Afghanistan, Yemen and Somalia are “hotspots” due to poor population health status and access to basic sanitation as well as other elements such as food insecurity, displacement and conflicts/political instability. WHO country offices effort is towards enhancing access to water and sanitation and essential healthcare services including immunization and psychological support, strengthening disease surveillance and response, and risk communication.ConclusionsDrought-related health effects in the WHO EMR represent a public health emergency. Strengthening mitigation activities and additional tailored efforts are urgently needed to overcome context-specific gaps and weaknesses, with specific focus on financing, accountability and enhanced data availability.

Evolution of insecticide resistance and its mechanisms in Anopheles stephensi in the WHO Eastern Mediterranean Region

BackgroundWhile Iran is on the path to eliminating malaria, the disease with 4.9 million estimated cases and 9300 estimated deaths in 2018 remains a serious health problem in the World Health Organization (WHO) Eastern Mediterranean Region. Anopheles stephensi is the main malaria vector in Iran and its range extends from Iraq to western China. Recently, the vector invaded new territories in Sri Lanka and countries in the Horn of Africa. Insecticide resistance in An. stephensi is a potential issue in controlling the spread of this vector.MethodsData were collated from national and international databases, including PubMed, Google Scholar, Scopus, ScienceDirect, SID, and IranMedex using appropriate search terms.ResultsIndoor residual spaying (IRS) with DDT was piloted in Iran in 1945 and subsequently used in the malaria eradication programme. Resistance to DDT in An. stephensi was detected in Iran, Iraq, Pakistan, and Saudi Arabia in the late 1960s. Malathion was used for malaria control in Iran in 1967, then propoxur in 1978, followed by pirimiphos-methyl from 1992 to 1994. The pyrethroid insecticide lambda-cyhalothrin was used from 1994 to 2003 followed by deltamethrin IRS and long-lasting insecticidal nets (LLINs). Some of these insecticides with the same sequence were used in other malaria-endemic countries of the region. Pyrethroid resistance was detected in An. stephensi in Afghanistan in 2010, in 2011 in India and in 2012 in Iran. The newly invaded population of An. stephensi in Ethiopia was resistant to insecticides of all four major insecticide classes. Different mechanisms of insecticide resistance, including metabolic and insecticide target site insensitivity, have been developed in An. stephensi. Resistance to DDT was initially glutathione S-transferase based. Target site knockdown resistance was later selected by pyrethroids. Esterases and altered acetylcholinesterase are the underlying cause of organophosphate resistance and cytochrome p450s were involved in pyrethroid metabolic resistance.ConclusionsAnopheles stephensi is a major malaria vector in Iran and many countries in the region and beyond. The species is leading in terms of development of insecticide resistance as well as developing a variety of resistance mechanisms. Knowledge of the evolution of insecticide resistance and their underlying mechanisms, in particular, are important to Iran, considering the final steps the country is taking towards malaria elimination, but also to other countries in the region for their battle against malaria. This systematic review may also be of value to countries and territories newly invaded by this species, especially in the Horn of Africa, where the malaria situation is already dire.

Developing health accounts following SHA 2011: a situational analysis of countries in WHO Eastern Mediterranean Region

National health accounts provide data for health-financing policy analysis, reforms and strategies to attain national health development goals and objectives such as universal health coverage. However, in the World Health Organization (WHO) Eastern Mediterranean Region there are many challenges, making it difficult for health accounts teams to provide timely reports and for policy-makers to use them to inform policy change. To undertake a situational analysis of health accounts in the Region and assess the health accounts production process. Additionally, the study looked at challenges facing health accounts teams in institutionalizing the health accounts process. The WHO Regional Office for the Eastern Mediterranean has been conducting country missions to its 22 countries to assist health accounts teams and assess the status of health accounts production and institutionalization. A survey administered at a regional training workshop in October 2018 examined the challenges and successes in health accounts production. Three countries in the Region produce annual health accounts but most take several years between reports. Only 55% of the countries use System of Health Accounts (SHA) 2011 methodology while 27% still use SHA 1.0. The main challenges facing countries include a high turnover of employees involved in health accounts production, and time lag of data. Notable successes include policy changes based on health accounts findings. Few countries in the Region produce annual health accounts and many still use SHA 1.0. The commitment of a country's top management is vital to ensure successful health accounts production.

A Systematic Review of the Current Hepatitis B Viral Infection and Hepatocellular Carcinoma Situation in Mediterranean Countries.

Viral hepatitis B is a global public health problem affecting nearly two billion subjects; 3.3% of whom are from the WHO (World Health Organization) Eastern Mediterranean Region (EMRO). It induces both acute and chronic hepatic disorders with subsequent liver cirrhosis and hepatocellular carcinoma (HCC) in a considerable percentage of patients based on the age of exposure. In this review, hepatitis B virus (HBV) and HCC prevalence, distribution and prevalence of different genotypes, and male/female infection frequencies in relation to the vaccination status in the Mediterranean countries were reported. Study Design. This systematic review describes the prevalence of hepatitis B infection, genotype distribution of hepatitis B virus, and prevalence and incidence of hepatocellular carcinoma in Mediterranean countries belonging to three different continents: Southern Europe (Spain, France, Italy, Croatia, and Greece), North Africa (Morocco, Algeria, Tunisia, Libya, and Egypt), and the Near East region (Syria, Lebanon, Turkey, Israel, and Palestine). We tried to collect new data from electronic databases: PubMed, ScienceDirect, ResearchGate, Google Scholar, and public health reports between 1980 and 2019. For each publication, we recorded reference, publication year, study characteristics (date, locations, sample size, and study population), and participant characteristics (population group, year, age, and sex). No language limitation was imposed, and articles or reports from non-peer-reviewed sources were not considered for this analysis. The main keywords were HBV prevalence, hepatitis B infection, HBV genotype, and HCC. Inclusion and Exclusion Criteria. Healthy population-based studies included the following sample populations: (i) voluntary blood donors, (ii) pregnant women, (iii) community studies, (iv) hemodialysis patients, (v) hospitalized patients, (vi) healthcare workers, (vii) sex workers, (viii) drug abusers, and (ix) prisoners. We excluded studies from the following special groups who were assumed to be at a special high risk: patients from sexually transmitted disease clinics and thalassemia clinics and professional or paid blood donors.

Recent Outbreaks of Dengue Fever in the WHO Eastern Mediterranean Region: A Narrative Mini-review

Dengue Fever (DF) is the most important, rapidly spreading, emerging/re-emerging, arboviral disease that threats a global human health and economic development. Dengue viral infection is transmitted to human by infected female Aedes mosquito vector, significantly Aedes aegypti. This article reviewed the recent status of dengue fever outbreaks indicated in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) in the last five years (2016-2020), based on reports of WHO, and other available data. Recent DF outbreaks were in Sudan (2017, 2019), Yemen (2016, 2018, 2019), Oman (2018), and Pakistan (2017, 2018, 2019, 2020). The two species, Aedes aegypti and Aedes albopictus were geographically distributed and mapped by country-level according to the published reports. There are several factors contributing to the emergence and rapid transmission of dengue in the region, include rapid prevalence of the main dengue vector, host vulnerability, favorable environmental conditions (temperatures, precipitation and humidity), and unplanned expanding urbanization. In addition to the movement of traveler’s people during an outbreak responsible for introducing DF to new locations. Early detection of diseases and effective mosquito vector control is an essential strategy for preventing the transmission of diseases outbreaks.

Influenza pandemic preparedness in the World Health Organization Eastern Mediterranean Region.

Preparedness is key to controlling influenza pandemics and epidemics. A comprehensive literature review was conducted to analyse the response and preparedness to influenza pandemics in the World Health Organization Eastern Mediterranean Region (WHO/EMR). Published and grey literatures were searched in PubMed, Scopus, and Google scholar, and the WHO/EMR online databases. International and national plans were searched via official websites of the relevant ministries of the countries. We found that the response from EMR countries was minimal and scientific papers published were limited. Moreover, most of those papers studied the preparedness plan partially by focusing on one or more elements such as infection control measures and vaccines, or were directed to certain populations such as health workers. Continuous active surveillance is ignored in most of the countries although it was the most important lesson learned from the pandemic. The national preparedness plans should be updated, taking guidance from the findings in the present report, to address any emerging pandemic virus as well as attending to surges of seasonal influenza cases.

Salt intake reduction strategies in the Eastern Mediterranean Region.

The high burden of noncommunicable diseases (NCDs), particularly cardiovascular diseases (CVDs), in countries of the Eastern Mediterranean Region requires an immediate public health attention. The World Health Organization (WHO) has recommended salt reduction as a "best buy", recognizing it as one of the most cost-effective approaches in preventing NCDs and reducing CVDs and medical costs. In the context of the global target to reduce salt intake by 30% by 2025, the objective of this review is to present an up-to-date overview of the current salt reduction initiatives in the Region by highlighting regional and national policies, strategies, and activities that aim at characterizing and/or reducing the intakes of dietary salt. This review details the WHO policies and strategies which address salt reduction in the WHO Eastern Mediterranean Region. The high intake levels of sodium in the countries of the Region are emphasized. The policies and strategies in place to address this situation are described, however, there is a need for more data on intake levels. There are a number of salt reduction initiatives currently being undertaken in the countries of the Region. The WHO should continue to play a key role in providing evidence-based tools for the planning, implementation, and surveillance of national salt reduction initiatives.

World Health Organization \u201cSchool Mental Health Manual\u201d-based training for school teachers in Urban Lahore, Pakistan: study protocol for a randomized controlled trial

BackgroundThe teacher’s role in school mental health initiatives cannot be overemphasized. Despite global evidence of educational interventions in improving teachers’ knowledge and attitudes regarding mental health, this area remains under researched in Pakistan. This paper presents a study protocol of a pilot randomized controlled trial to examine the effectiveness of a teacher training intervention for improving mental health literacy and self-efficacy among school teachers in urban Lahore, Pakistan.MethodsThe randomized controlled trial will follow the CONSORT guidelines. Participants will be allocated to the Intervention group (receiving the World Health Organization, Eastern Mediterranean Region (WHO-EMRO) School Mental Health Manual-based intervention in three 6-h, face-to-face sessions) or a waitlist control group (not receiving training during the study period). Participants will be teachers of private schools with similar broad demographic characteristics in an inner city area of Lahore. The primary outcome measures for the trial is teachers’ mental health literacy. It will be assessed by using the previously applied (during WHO training of Master Trainers) self-administered questionnaire in both groups pre and post training and at 3 months’ follow-up. Secondary outcomes include: for teachers: Teachers’ self-efficacy (assessed by the Teachers’ Sense of Self Efficacy Scale (TSES) short form.); for students (11–16 years): socio-emotional skills and psychological problems measured by the Strengths and Difficulties Questionnaire (assessed at baseline and 3 months post intervention); for schools: the WHO School Psychosocial Profile Questionnaire (baseline and 3 months post intervention).DiscussionGiven the high prevalence of child mental health problems, stigma and lack of services, it is important to consider alternate avenues for promoting positive mental health among youth. This pilot study should establish the effectiveness of the WHO-EMRO School Mental Health Manual-based Intervention improving teacher’s mental health literacy and helping them to learn practical steps that can be implemented at low cost in school settings. It will also provide information regarding intervention implementation and sustainability.Trial registrationClinicalTrials.gov, ID: NCT02937714. Registered on 18 October 2016.

Mycobacterium tuberculosis Complex Drug Resistance in a High Tuberculosis Incidence Area from the WHO Eastern Mediterranean Region

The incidence of tuberculosis (TB) in Golestan province of Iran has been ranked 10th among countries of World Health Organization (WHO) Eastern Mediterranean Region. The province is residence of ethnically heterogeneous groups. However, there are limited data on Mycobacterium tuberculosis drug resistance in this province. The main aim of this study was to determine the resistance profile of M. tuberculosis complex (MTBC) isolates to first-line anti-TB drugs. The clinical specimens were collected from 11807 cases diagnosed during this study. MTBC isolates were tested for susceptibility to first-line anti-TB drugs. A total of 176 new cases were diagnosed as culture positive for MTBC. There was one case that had multidrug-resistant (MDR) isolate and 18 (10.2%) had isolates that were resistant to at least one drug (any drug resistant). Resistance to streptomycin and isoniazid was noted in 15 (8.5%) and 5 isolates (2.8%), respectively. Also, a statistically significant association was observed between age groups and any drug resistance pattern (p = 0.022): 1-24 years vs. 25-45 years (p = 0.033), 25-45 years vs. >65 years (p = 0.010), 46-65 years vs. >65 years (p = 0.050). One third of any drug resistant isolates were obtained from TB patients of Persian ethnic group. Despite the high incidence of TB, the rate of MDR-TB in Golestan province was similar to those reported by WHO for Iranian new cases from other regions. One-tenth of the studied isolates showed any drug resistance pattern. This rate of any drug resistance implies the possibility of initial resistance of MTBC isolates circulating in this region.

Frequency of use of the International Classification of Diseases ICD-10 diagnostic categories for mental and behavioural disorders across world regions.

The study aimed to examine variations in the use of International Classification of Diseases, Tenth Edition (ICD-10) diagnostic categories for mental and behavioural disorders across countries, regions and income levels using data from the online World Psychiatric Association (WPA)-World Health Organization (WHO) Global Survey that examined the attitudes of psychiatrists towards the classification of mental disorders. A survey was sent to 46 psychiatric societies which are members of WPA. A total of 4887 psychiatrists participated in the survey, which asked about their use of classification, their preferred system and the categories that were used most frequently. The majority (70.1%) of participating psychiatrists (out of 4887 psychiatrists) reported using the ICD-10 the most and using at least one diagnostic category once a week. Nine out of 44 diagnostic categories were considerably variable in terms of frequency of use across countries. These were: emotionally unstable personality disorder, borderline type; dissociative (conversion) disorder; somatoform disorders; obsessive-compulsive disorder (OCD); mental and behavioural disorders due to the use of alcohol; adjustment disorder; mental and behavioural disorders due to the use of cannabinoids; dementia in Alzheimer's disease; and acute and transient psychotic disorder. The frequency of use for these nine categories was examined across WHO regions and income levels. The most striking differences across WHO regions were found for five out of these nine categories. For dissociative (conversion) disorder, use was highest for the WHO Eastern Mediterranean Region (EMRO) and non-existent for the WHO African Region. For mental and behavioural disorders due to the use of alcohol, use was lowest for EMRO. For mental and behavioural disorders due to the use of cannabinoids, use was lowest for the WHO European Region and the WHO Western Pacific Region. For OCD and somatoform disorders, use was lowest for EMRO and the WHO Southeast Asian Region. Differences in the frequency of use across income levels were statistically significant for all categories except for mental and behavioural disorders due to the use of alcohol. The most striking variations were found for acute and transient psychotic disorder, which was reported to be more commonly used among psychiatrists from countries with lower income levels. The differences in frequency of use reported in the current study show that cross-cultural variations in psychiatric practice exist. However, whether these differences are due to the variations in prevalence, treatment-seeking behaviour and other factors, such as psychiatrist and patient characteristics as a result of culture, cannot be determined based on the findings of the study. Further research is needed to examine whether these variations are culturally determined and how that would affect the cross-cultural applicability of ICD-10 diagnostic categories.

Distressed setting and profound challenges: Pandemic influenza preparedness plans in the Eastern Mediterranean Region.

Influenza pandemics are unpredictable and can have severe health and economic implications. Preparedness for pandemic influenza as advised by the World Health Organization (WHO) is key in minimizing the potential impacts. Pandemic Influenza Preparedness (PIP) Framework is a global public-private initiative to strengthen the preparedness. A total of 43 countries receive funds through Partnership Contribution (PC) component of PIP Framework to enhance preparedness; seven of these fall in the WHO's Eastern Mediterranean Region. We report findings of a desk review of preparedness plans of six such countries from the Region. The assessment was done using a standardized checklist containing five criteria and 68 indicators. The checklist was developed using the latest WHO guidelines, in consultation with influenza experts from the Region. The criteria included preparation, surveillance, prevention and containment, case investigation and treatment, and risk communication. Two evaluators independently examined and scored the plans. Pandemic preparedness plan of only one country scored above 70% on aggregate and above 50% on all individual criteria. Plans from rest of the countries scored below satisfactory on aggregate, as well as on individual preparedness criteria. Among the individual criteria, prevention and containment scored highest while case investigation and treatment, the lowest for majority of the countries. In general, surveillance also scored low while it was absent altogether, in one of the plans. This was a desk review of the plans and not the actual assessment of the influenza preparedness. Moreover, only plans of countries facilitated through funds provided under the PC implementation plan were included. The preparedness scores of majority of reviewed plans were not satisfactory. This warrants a larger study of a representative sample from the Region and also calls for immediate policy action to improve the pandemic influenza preparedness plans and thereby enhance pandemic preparedness in the Region.

Global Prevalence of Fetal Alcohol Spectrum Disorder Among Children and Youth

Prevalence estimates are essential to effectively prioritize, plan, and deliver health care to high-needs populations such as children and youth with fetal alcohol spectrum disorder (FASD). However, most countries do not have population-level prevalence data for FASD. To obtain prevalence estimates of FASD among children and youth in the general population by country, by World Health Organization (WHO) region, and globally. MEDLINE, MEDLINE in process, EMBASE, Education Resource Information Center, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsychINFO, and Scopus were systematically searched for studies published from November 1, 1973, through June 30, 2015, without geographic or language restrictions. Original quantitative studies that reported the prevalence of FASD among children and youth in the general population, used active case ascertainment or clinic-based methods, and specified the diagnostic guideline or case definition used were included. Individual study characteristics and prevalence of FASD were extracted. Country-specific random-effects meta-analyses were conducted. For countries with 1 or no empirical study on the prevalence of FASD, this indicator was estimated based on the proportion of women who consumed alcohol during pregnancy per 1 case of FASD. Finally, WHO regional and global mean prevalence of FASD weighted by the number of live births in each country was estimated. Prevalence of FASD. A total of 24 unique studies including 1416 unique children and youth diagnosed with FASD (age range, 0-16.4 years) were retained for data extraction. The global prevalence of FASD among children and youth in the general population was estimated to be 7.7 per 1000 population (95% CI, 4.9-11.7 per 1000 population). The WHO European Region had the highest prevalence (19.8 per 1000 population; 95% CI, 14.1-28.0 per 1000 population), and the WHO Eastern Mediterranean Region had the lowest (0.1 per 1000 population; 95% CI, 0.1-0.5 per 1000 population). Of 187 countries, South Africa was estimated to have the highest prevalence of FASD at 111.1 per 1000 population (95% CI, 71.1-158.4 per 1000 population), followed by Croatia at 53.3 per 1000 population (95% CI, 30.9-81.2 per 1000 population) and Ireland at 47.5 per 1000 population (95% CI, 28.0-73.6 per 1000 population). Globally, FASD is a prevalent alcohol-related developmental disability that is largely preventable. The findings highlight the need to establish a universal public health message about the potential harm of prenatal alcohol exposure and a routine screening protocol. Brief interventions should be provided, where appropriate.

Actual and predicted prevalence of alcohol consumption during pregnancy in the WHO African Region.

To estimate the prevalence of alcohol consumption and binge drinking during pregnancy among the general population in the World Health Organization (WHO) African Region, by country. First, a comprehensive systematic literature search was performed to identify all published and unpublished studies. Then, several meta-analyses, assuming a random-effects model, were conducted to estimate the prevalence of alcohol consumption and binge drinking during pregnancy among the general population for countries in the WHO African Region with two or more studies available. Lastly, for countries with less than two studies or no known data predictions were obtained using regression modelling. The estimated prevalence of alcohol consumption during pregnancy among the general population ranged from 2.2% (95% confidence interval [CI]: 1.6-2.8%; Equatorial Guinea) to 12.6% (95% CI: 9.9-15.4%; Cameroon) in Central Africa, 3.4% (95% CI: 2.6-4.3%; Seychelles) to 20.5% (95% CI: 16.4-24.7%; Uganda) in Eastern Africa, 5.7% (95% CI: 4.4-7.1%; Botswana) to 14.2% (95% CI: 11.1-17.3%; Namibia) in Southern Africa, 6.6% (95% CI: 5.0-8.3%; Mauritania) to 14.8% (95% CI: 11.6-17.9%; Sierra Leone) in Western Africa, and 4.3% (95% CI: 3.2-5.3%; Algeria) in Northern Africa. The high prevalence of alcohol consumption and binge drinking during pregnancy in some African countries calls for educational campaigns, screening and targeted interventions for women of childbearing age.