One health operational framework for action for the Eastern Mediterranean Region, focusing on zoonotic diseases

Human health is intrinsically linked to the health of animals and to the environment, and efforts by just one sector alone cannot prevent or adequately address the complex problems at the human–animal–environment interface. Countries of the World Health Organization Eastern Mediterranean Region, as any other region, face the threat of emerging and remerging zoonoses. However, the challenges in this Region are high given the lack of resources, poor health systems, and political factors. Hence, adopting the One Health approach becomes urgent to assist those countries. Subsequently, based on analysis of One Health capacities in the Region and in close consultation with representatives and subject matter experts from countries in the Region, a framework for action towards effectively implementing the One Health approach was developed. The framework capitalizes on current opportunities in the region and provide countries with a list of practical key activities towards optimal use of their resources and strengthening their capabilities to tackle concurrent and future health challenges at the interface. Strong governance structures and building on existing mechanisms are crucial for achieving effective disease surveillance and response. Additionally, using intersectoral approaches for risk assessment and risk mitigation for health issues at the human–animal–environment interface can improve efficiency and result in more successful outcomes.

Estimating the number of COVID-19-related infections, deaths and hospitalizations in Iran under different physical distancing and isolation scenarios: A compartmental mathematical modeling

BackgroundIran is one of the countries that has been overwhelmed with COVID-19. We aimed to estimate the total number of COVID-19 related infections, deaths, and hospitalizations in Iran under different physical distancing and isolation scenarios. MethodsWe developed a Susceptible-Exposed-Infected-Removed (SEIR) model, parameterized to the COVID-19 pandemic in Iran. We used the model to quantify the magnitude of the outbreak in Iran and assess the effectiveness of isolation and physical distancing under five different scenarios (A: 0% isolation, through E: 40% isolation of all infected cases). We used Monte-Carlo simulation to calculate the 95% uncertainty intervals (UI). FindingsUnder scenario A, we estimated 5,196,000 (UI 1,753,000 - 10,220,000) infections to happen till mid-June with 966,000 (UI 467,800 - 1,702,000) hospitalizations and 111,000 (UI 53,400 - 200,000) deaths. Successful implantation of scenario E would reduce the number of infections by 90% (i.e. 550,000) and change the epidemic peak from 66,000 on June 9th to 9,400 on March 1st. Scenario E also reduces the hospitalizations by 92% (i.e. 74,500), and deaths by 93% (i.e. 7,800). InterpretationWith no approved vaccination or therapy, we found physical distancing and isolation that includes public awareness and case-finding/isolation of 40% of infected people can reduce the burden of COVID-19 in Iran by 90% by mid-June. FundingWe received no funding for this work. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSIran has been heavily impacted by the COVID-19 outbreak, and the virus has now spread to all of its provinces. Iran has been implementing different levels of partial physical distancing and isolation policies in the past few months. We searched PubMed and preprint archives for articles published up to April 15, 2020 that included information about control measures against COVID-19 in Iran using the following terms: ("coronavirus" OR "2019-nCoV" OR "COVID-19") AND "Iran" AND ("intervention" OR "prevention" OR "physical distancing" OR "social distancing"). We found no studies that had quantified the impact of policies in Iran. Added value of this studyGiven the scarcity of evidence on the magnitude of the outbreak and the burden of COVID-19 in Iran, we used multiple sources of data to estimate the number of COVID-19 infections, hospitalizations, and deaths under different physical distancing and isolation scenarios until mid-June. We showed that implementing no control measures could lead to over five million infections in Iran; [~]19% of whom would be hospitalized, and [~]2% would die. However, under our most optimistic scenario, these estimates could be reduced by [~]90%. Implications of all the available evidenceWith no effective vaccination or treatment, advocating and enforcing physical distancing and isolation along with public education on prevention measures could significantly reduce the burden of COVID-19 in Iran. Nonetheless, even under the most optimistic scenario, the burden of COVID-19 would be substantial and well beyond the current capacity of the healthcare system in Iran.

Prevalence of latent tuberculosis infection among tuberculosis laboratory workers in Iran / 한국역학회지

OBJECTIVES: The risk of transmission of Mycobacterium tuberculosis from patients to health care workers (HCWs) is a neglected problem in many countries, including Iran. The aim of this study was to estimate the prevalence of latent tuberculosis (TB) infection (LTBI) among TB laboratory staff in Iran, and to elucidate the risk factors associated with LTBI.METHODS: All TB laboratory staff (689 individuals) employed in the TB laboratories of 50 Iranian universities of medical sciences and a random sample consisting of 317 low-risk HCWs were included in this cross-sectional study. Participants with tuberculin skin test indurations of 10 mm or more were considered to have an LTBI.RESULTS: The prevalence of LTBI among TB laboratory staff and low-risk HCWs was 24.83% (95% confidence interval [CI], 21.31 to 27.74%) and 14.82% (95% CI, 11.31 to 19.20%), respectively. No active TB cases were found in either group. After adjusting for potential confounders, TB laboratory staff were more likely to have an LTBI than low-risk HCWs (prevalence odds ratio, 2.06; 95% CI, 1.35 to 3.17).CONCLUSIONS: This study showed that LTBI are an occupational health problem among TB laboratory staff in Iran. This study reinforces the need to design and implement simple, effective, and affordable TB infection control programs in TB laboratories in Iran.

Prevalence of latent tuberculosis infection among tuberculosis laboratory workers in Iran / 한국역학회지

OBJECTIVES: The risk of transmission of Mycobacterium tuberculosis from patients to health care workers (HCWs) is a neglected problem in many countries, including Iran. The aim of this study was to estimate the prevalence of latent tuberculosis (TB) infection (LTBI) among TB laboratory staff in Iran, and to elucidate the risk factors associated with LTBI. METHODS: All TB laboratory staff (689 individuals) employed in the TB laboratories of 50 Iranian universities of medical sciences and a random sample consisting of 317 low-risk HCWs were included in this cross-sectional study. Participants with tuberculin skin test indurations of 10 mm or more were considered to have an LTBI. RESULTS: The prevalence of LTBI among TB laboratory staff and low-risk HCWs was 24.83% (95% confidence interval [CI], 21.31 to 27.74%) and 14.82% (95% CI, 11.31 to 19.20%), respectively. No active TB cases were found in either group. After adjusting for potential confounders, TB laboratory staff were more likely to have an LTBI than low-risk HCWs (prevalence odds ratio, 2.06; 95% CI, 1.35 to 3.17). CONCLUSIONS: This study showed that LTBI are an occupational health problem among TB laboratory staff in Iran. This study reinforces the need to design and implement simple, effective, and affordable TB infection control programs in TB laboratories in Iran.

Plague in Iran: its history and current status / 한국역학회지

OBJECTIVES: Plague remains a public health concern worldwide, particularly in old foci. Multiple epidemics of this disease have been recorded throughout the history of Iran. Despite the long-standing history of human plague in Iran, it remains difficult to obtain an accurate overview of the history and current status of plague in Iran. METHODS: In this review, available data and reports on cases and outbreaks of human plague in the past and present in Iran and in neighboring countries were collected, and information was compiled regarding when, where, and how many cases occurred. RESULTS: This paper considers the history of plague in Persia (the predecessor of today’s Iran) and has a brief review of plague in countries in the World Health Organization Eastern Mediterranean Region, including a range of countries in the Middle East and North Africa. CONCLUSIONS: Since Iran has experienced outbreaks of plague for several centuries, neighboring countries have reported the disease in recent years, the disease can be silent for decades, and the circulation of Yersinia pestis has been reported among rodents and dogs in western Iran, more attention should be paid to disease monitoring in areas with previously reported human cases and in high-risk regions with previous epizootic and enzootic activity.

Comparison of the tuberculin skin test and the QuantiFERON-TB Gold test in detecting latent tuberculosis in health care workers in Iran / 한국역학회지

OBJECTIVES: The tuberculin skin test (TST) and the QuantiFERON-TB Gold test (QFT) are used to identify latent tuberculosis infections (LTBIs). The aim of this study was to determine the agreement between these two tests among health care workers in Iran. METHODS: This cross-sectional study included 177 tuberculosis (TB) laboratory staff and 67 non-TB staff. TST indurations of 10 mm or more were considered positive. The Student's t-test and the chi-square test were used to compare the mean score and proportion of variables between the TB laboratory staff and the non-TB laboratory staff. Kappa statistics were used to evaluate the agreement between these tests, and logistic regression was used to assess the risk factors associated with positive results for each test. RESULTS: The prevalence of LTBIs according to both the QFT and the TST was 17% (95% confidence interval [CI], 12% to 21%) and 16% (95% CI, 11% to 21%), respectively. The agreement between the QFT and the TST was 77.46%, with a kappa of 0.19 (95% CI, 0.04 to 0.34). CONCLUSIONS: Although the prevalence of LTBI based on the QFT and the TST was not significantly different, the kappa statistic was low between these two tests for the detection of LTBIs.

Tularemia, a re-emerging infectious disease in Iran and neighboring countries / 한국역학회지

OBJECTIVES: Tularemia is a zoonotic disease transmitted by direct contact with infected animals and through arthropod bites, inhalation of contaminated aerosols, ingestion of contaminated meat or water, and skin contact with any infected material. It is widespread throughout the northern hemisphere, including Iran and its neighbors to the north, northeast, and northwest. METHODS: In this paper, the epidemiology of tularemia as a re-emerging infectious disease in the world with a focus on Iran and the neighboring countries is reviewed. RESULTS: In Iran, positive serological tests were first reported in 1973, in wildlife and domestic livestock in the northwestern and southeastern parts of the country. The first human case was reported in 1980 in the southwest of Iran, and recent studies conducted among at-risk populations in the western, southeastern, and southwestern parts of Iran revealed seroprevalences of 14.4, 6.52, and 6%, respectively. CONCLUSIONS: Several factors may explain the absence of reported tularemia cases in Iran since 1980. Tularemia may be underdiagnosed in Iran because Francisella tularensis subspecies holarctica is likely to be the major etiological agent and usually causes mild to moderately severe disease. Furthermore, tularemia is not a disease extensively studied in the medical educational system in Iran, and empirical therapy may be effective in many cases. Finally, it should be noted that laboratories capable of diagnosing tularemia have only been established in the last few years. Since both recent and older studies have consistently found tularemia antibodies in humans and animals, the surveillance of this disease should receive more attention. In particular, it would be worthwhile for clinical researchers to confirm tularemia cases more often by isolating F. tularensis from infected humans and animals.

Do the tuberculin skin test and the QuantiFERON-TB Gold in-tube test agree in detecting latent tuberculosis among high-risk contacts? A systematic review and meta-analysis / 한국역학회지

OBJECTIVES: The QuantiFERON-TB Gold in-tube test (QFT-GIT) and the tuberculin skin test (TST) are used to diagnose latent tuberculosis infection (LTBI). However, conclusive evidence regarding the agreement of these two tests among high risk contacts is lacking. This systematic review and meta-analysis aimed to estimate the agreement between the TST and the QFT-GIT using kappa statistics. METHODS: According to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, scientific databases including PubMed, Scopus, and Ovid were searched using a targeted search strategy to identify relevant studies published as of June 2015. Two researchers reviewed the eligibility of studies and extracted data from them. The pooled kappa estimate was determined using a random effect model. Subgroup analysis, Egger's test and sensitivity analysis were also performed. RESULTS: A total of 6,744 articles were retrieved in the initial search, of which 24 studies had data suitable for meta-analysis. The pooled kappa coefficient and prevalence-adjusted bias-adjusted kappa were 0.40 (95% confidence interval [CI], 0.34 to 0.45) and 0.45 (95% CI, 0.38 to 0.49), respectively. The results of the subgroup analysis found that age group, quality of the study, location, and the TST cutoff point affected heterogeneity for the kappa estimate. No publication bias was found (Begg's test, p=0.53; Egger's test, p=0.32). CONCLUSIONS: The agreement between the QFT-GIT and the TST in diagnosing LTBI among high-risk contacts was found to range from fair to moderate.

Tularemia and plague survey in rodents in an earthquake zone in southeastern Iran / 한국역학회지

OBJECTIVES: Earthquakes are one the most common natural disasters that lead to increased mortality and morbidity from transmissible diseases, partially because the rodents displaced by an earthquake can lead to an increased rate of disease transmission. The aim of this study was to evaluate the prevalence of plague and tularemia in rodents in the earthquake zones in southeastern Iran. METHODS: In April 2013, a research team was dispatched to explore the possible presence of diseases in rodents displaced by a recent earthquake magnitude 7.7 around the cities of Khash and Saravan in Sistan and Baluchestan Province. Rodents were trapped near and in the earthquake zone, in a location where an outbreak of tularemia was reported in 2007. Rodent serums were tested for a serological survey using an enzyme-linked immunosorbent assay. RESULTS: In the 13 areas that were studied, nine rodents were caught over a total of 200 trap-days. Forty-eight fleas and 10 ticks were obtained from the rodents. The ticks were from the Hyalomma genus and the fleas were from the Xenopsylla genus. All the trapped rodents were Tatera indica. Serological results were negative for plague, but the serum agglutination test was positive for tularemia in one of the rodents. Tatera indica has never been previously documented to be involved in the transmission of tularemia. CONCLUSIONS: No evidence of the plague cycle was found in the rodents of the area, but evidence was found of tularemia infection in rodents, as demonstrated by a positive serological test for tularemia in one rodent.

An epidemiological comparative study on diagnosis of rodent leptospirosis in Mazandaran Province, northern Iran / 한국역학회지

OBJECTIVES: Leptospirosis is a zoonosis caused by leptospires, in which transmission occurs through contact with contaminated biological fluids from infected animals. Rodents can act as a source of infection for humans and animals. The disease has a global distribution, mainly in humid, tropical and sub-tropical regions. The aim of this study was to compare culture assays, the microscopic agglutination test (MAT), polymerase chain reaction (PCR), and nested PCR (n-PCR), for the diagnosis of leptospirosis in rodents in Mazandaran Province, northern Iran. METHODS: One hundred fifty-one rodents were trapped alive at 10 locations, and their urine and kidney samples were collected and used for the isolation of live Leptospira. The infecting serovars were identified and the antibody titres were measured by MAT, using a panel of 20 strains of live Leptospira species as antigens. The presence of leptospiral DNA was evaluated in urine and kidney samples using PCR and n-PCR. RESULTS: No live leptospires were isolated from the kidney and urine samples of the rodents. Different detection rates of leptospirosis were observed with MAT (21.2%), PCR (11.3%), and n-PCR (3.3%). The dominant strain was Leptospira serjoehardjo (34.4%, p=0.28), although other serotypes were also found. The prevalence of positive leptospirosis tests in rodents was 15.9, 2.6, and 2.6% among Rattus norvegicus, R. rattus, and Apodemus sylvaticus, respectively. CONCLUSIONS: Leptospirosis was prevalent in rodents in Mazandaran Province, northern Iran. MAT was able to detect leptospires more frequently than culture or PCR. The kidney was a more suitable site for identifying leptospiral DNA by n-PCR than urine. Culture was not found to be an appropriate technique for clinical diagnosis.

Major infectious diseases affecting the Afghan immigrant population of Iran: a systematic review and meta-analysis / 한국역학회지

OBJECTIVES: As Afghans make up the largest group of foreign nationals in Iran, the aim of this study was to assess the proportion of Afghan immigrants among those afflicted by the most prevalent infectious diseases in Iran. METHODS: National and international online scientific databases were searched through November 2013. The reference lists of included studies were also searched. All descriptive studies concerning the most common infectious diseases in Iran, including tuberculosis, multiple-drug-resistant tuberculosis, malaria, cholera, Crimean-Congo hemorrhagic fever, leishmaniasis, and hepatitis B were retrieved. The nationality of patients was not considered. The selection of studies and data extraction was performed separately by two authors. Results were reported using a random effect model with a 95% confidence interval (CI). RESULTS: The overall proportion of Afghan immigrants with the aforementioned infectious diseases was 29% (95% CI, 21 to 37). According to a stratified analysis, the proportion of Afghan immigrants afflicted with tuberculosis was (29%), multiple-drug-resistant tuberculosis (56%), malaria (40%), cholera (8%), Crimean-Congo hemorrhagic fever (25%), leishmaniasis (7%), and hepatitis B (14%). CONCLUSIONS: It is highly recommended to monitor the health status of the Afghan immigrants when entering Iran, to reduce the spread of communicable diseases, which are viewed as serious in international health regulations.