The source of the Black Death in fourteenth-century central Eurasia.

The origin of the medieval Black Death pandemic (AD 1346-1353) has been a topic of continuous investigation because of the pandemic's extensive demographic impact and long-lasting consequences1,2. Until now, the most debated archaeological evidence potentially associated with the pandemic's initiation derives from cemeteries located near Lake Issyk-Kul of modern-day Kyrgyzstan1,3-9. These sites are thought to have housed victims of a fourteenth-century epidemic as tombstone inscriptions directly dated to 1338-1339 state 'pestilence' as the cause of death for the buried individuals9. Here we report ancient DNA data from seven individuals exhumed from two of these cemeteries, Kara-Djigach and Burana. Our synthesis of archaeological, historical and ancient genomic data shows a clear involvement of the plague bacterium Yersinia pestis in this epidemic event. Two reconstructed ancient Y. pestis genomes represent a single strain and are identified as the most recent common ancestor of a major diversification commonly associated with the pandemic's emergence, here dated to the first half of the fourteenth century. Comparisons with present-day diversity from Y. pestis reservoirs in the extended Tian Shan region support a local emergence of the recovered ancient strain. Through multiple lines of evidence, our data support an early fourteenth-century source of the second plague pandemic in central Eurasia.

Drug-Resistant Tuberculosis, Georgia, Kazakhstan, Kyrgyzstan, Moldova, and Ukraine, 2017-2022.

In 2021, the World Health Organization recommended new extensively drug-resistant (XDR) and pre-XDR tuberculosis (TB) definitions. In a recent cohort of TB patients in Eastern Europe, we show that XDR TB as currently defined is associated with exceptionally poor treatment outcomes, considerably worse than for the former definition (31% vs. 54% treatment success).

Financial Vulnerability and Its Association with HIV Transmission Risk Behaviors Among People Who Inject Drugs in Kyrgyzstan.

The Family Resource Scale (FRS) is a three-factor financial vulnerability (FV) measure. FV may impact HIV transmission risks. Cross-sectional data from 279 people who inject drugs (PWID) in Kyrgyzstan surveyed April-October 2021 was used to validate the FRS and estimate associations between FV on past 6-month injection and sexual HIV risk outcomes. The three-factor FRS reflected housing, essential needs, and fiscal independence, and had good internal reliability and structural validity. Greater cumulative, housing, and essential needs FRS scores were associated with increased relative risk on public injection (adjusted risk ratio [aRR], 95% confidence interval [95% CI]: 1.03 [1.01, 1.04]; aRR [95% CI]: 1.06 [1.02, 1.09]; aRR [95% CI]: 1.06 [1.03, 1.08], respectively, all p < 0.001) and preparing injections with unsafe water sources (aRR [95% CI]: 1.04 [1.02, 1.07]; aRR [95% CI]: 1.09 [1.04, 1.15]; aRR [95% CI]: 1.08 [1.03, 1.14], respectively, all p < 0.001). Results suggest that PWID housing- and essential needs-related FV may exacerbate injection HIV transmission risks. Reducing PWIDs' FV may enhance the HIV response in Kyrgyzstan.

RESUMEN: La Escala de Recursos Familiares (FRS, por sus siglas en inglés) es una medida de vulnerabilidad financiera (FV, por sus siglas en inglés) de tres factores. La FV puede afectar los riesgos de transmisión del VIH. Se utilizaron datos transversales de 279 personas que se inyectan drogas (PWID, por sus siglas en inglés) en Kirguistán encuestadas de abril a octubre de 2021 para validar la FRS y estimar las asociaciones entre la FV en la inyección y los resultados de riesgo sexual del VIH en los últimos seis meses. La FRS de tres factores reflejaba la vivienda, las necesidades esenciales y la independencia fiscal, y presentaba una buena confiabilidad interna y validez estructural. Mayores puntajes acumulativos de la FRS en vivienda y necesidades esenciales se asociaron con un mayor riesgo relativo en la inyección pública (Riesgo relativo ajustada [aRR], Intervalo de Confianza del 95% [IC95%]: 1.03 [1.01, 1.04]; aRR [IC95%]: 1.06 [1.02, 1.09]; aRR [IC95%]: 1.06 [1.03, 1.08], respectivamente, todos p < 0.001) y la preparación de inyección con fuentes de agua no seguras (aRR [IC95%]: 1.04 [1.02, 1.07]; aRR [IC95%]: 1.09 [1.04, 1.15]; aRR [IC95%]: 1.08 [1.03, 1.14], respectivamente, todos p < 0.001). Los resultados sugieren que la FV relacionada con la vivienda y las necesidades esenciales de las PWID puede exacerbar los riesgos de transmisión del VIH por la inyección. Reducir la FV de las PWID puede mejorar la respuesta al VIH en Kirguistán.

Environmental distribution of Echinococcus- and Taenia spp.-contaminated dog feces in Kyrgyzstan.

Recently, there have been epidemics of human cystic echinococcosis (CE) and alveolar echinococcosis (AE) in Kyrgyzstan. This study investigated 2 districts for the presence of Echinococcus granulosus s.l. and Echinococcus multilocularis eggs; species identity was confirmed by polymerase chain reaction in dog feces and the level of environmental contamination with parasite eggs in 2017­2018 was also investigated. In the Alay district 5 villages with a high reported annual incidence of AE of 162 cases per 100 000 and 5 villages in the Kochkor district which had a much lower incidence of 21 cases per 100 000 were investigated. However, the proportion of dog feces containing E. granulosus s.l. eggs was ~4.2 and ~3.5% in Alay and Kochkor respectively. For E. multilocularis, the corresponding proportions were 2.8 and 3.2%. Environmental contamination of Echinococcus spp. eggs was estimated using the McMaster technique for fecal egg counts, weight and density of canine feces. The level of environmental contamination with E. multilocularis eggs was similar at 4.4 and 5.0 eggs per m2 in Alay and Kochkor respectively. The corresponding values for E. granulosus s.l. were 8.3 and 7.5 eggs per m2. There was no association between village or district level incidence of human AE or CE and the proportion of dog feces containing eggs of Echinococcus spp. or the level of environmental contamination. Increased contamination of taeniid eggs occured in the autumn, after the return of farmers with dogs from summer mountain pastures.

History of organic pollution in montane lake Issyk-Kul, Kyrgyzstan, Central Asia, inferred from a sediment core.

In arid regions, montane lakes are valuable water sources and play important ecological roles. However, recent human-induced inputs of organic pollutants are threatening lake ecology in such regions and becoming a matter of great concern. To investigate pollutant histories and sources, we measured polycyclic aromatic hydrocarbons (PAHs) and n-alkanes in a dated sediment core that spans the last ∼350 years, from montane Lake Issyk-Kul (Kyrgyzstan, Central Asia). Results showed that organic pollutants were delivered to Lake Issyk-Kul in four stages and that their concentrations increased from Stage I (∼1670-1800 CE) to Stage IV (∼2000-2010 CE). Furthermore, we tracked the sources of sedimented PAHs using their ratios combined with n-alkanes data. Ratios of PAHs Ant/(Ant + Phe), Flt/(Flt + Pyr) and Bap/BghiP indicated that inputs during Stage II (∼1800-1970 CE) and Stage III (∼1970-2000 CE) came mainly from high-temperature combustion of coal and vehicle emissions. PAHs in Stage I and Stage IV, however, were mainly derived from low-temperature combustion and petrogenic sources. Diagnostic PAH ratios, combined with the natural n-alkane ratio (NAR＜0) and unresolved complex mixtures (UCM), showed that the sources of PAHs in Stage I were mainly from erosion of bedrock and partly influenced by forest wildfires, different from the source during Stage IV, which was mainly from refined petroleum caused by accidental spills. Our assessment of the contamination history of the lake indicates that toxicity risk to the waterbody from sediment PAHs is low, but recent discharges arising from traffic deserve attention.

Unmet need for contraception among married women in the Kyrgyz Republic using the datasets from the 2006, 2014 and 2018 Multiple Indicator Cluster Survey: a cross-sectional study.

BACKGROUND: Since the beginning of the family program in 1998, the proportion of married women who used contraception has fluctuated. An unmet need for contraception among women in Kyrgyzstan drastically increased from 2006 (1.1%) to 2014 (19.1%), and remained unchanged until 2018 (19.0%). This study aims to re-investigate the prevalence of an unmet need for contraception from 2006 to 2018 in a comprehensive manner, and examine the factors associated with an unmet need for contraception among married women over the course of 12 years in the Kyrgyz Republic. METHODS: This is a cross-sectional study using secondary data that derived from the Multiple Indicator Cluster Survey (MICS). The study employed three datasets from the MICS 2006, 2014, and 2018. The study included a total of 9,229 women aged 15-49 who were married and fecund, and whose status of the met/unmet need for contraception could be identified. Logistic regression was employed to estimate the relationship of an unmet need for contraception with independent factors. A P value < 0.05 was set as statistically significant. RESULTS: The prevalence of an unmet need for contraception was 19.9% in 2006, 20.4% in 2014, and 22.5% in 2018. Across 12 years, all reversible-contraceptive methods for women constantly declined. Although intrauterine devices were the prominent contraceptive method of usage among Kyrgyz women, the trend of usage drastically decreased over time. Factors associated with unmet need for contraception included women's age, area of residence, mother tongue of household head, age of husband, and number of children ever born. CONCLUSION: The unmet need for contraception among married Kyrgyz women slightly increased, and the trend of modern contraceptive usage declined from 2006 to 2018, particularly the use of pills, injections, and intra-uterine devices. Comprehensive sexual health education for young people and youth-friendly services should be promoted. An effective and reliable supply chain of contraceptive commodities should be prioritized and strengthened. Regular supportive supervision visits are essential to improve the knowledge and skills of healthcare providers to be able to provide intrauterine device service as a contraceptive choice for Kyrgyz women.

Associations between different forms of intimate partner violence and posttraumatic stress among women who use drugs and alcohol in Kyrgyzstan.

Survivors of intimate partner violence (IPV) have an increased risk of experiencing posttraumatic stress, and the subsequently associated symptoms can vary by form of IPV exposure (i.e., physical, sexual, or psychological IPV). Related research among socially marginalized populations, however, is limited, including among women who use and misuse substances. Drawing on baseline data from a pilot study conducted among 213 women in Kyrgyzstan who reported using drugs or engaging in hazardous alcohol use, we examined the associations between different forms of IPV and severe posttraumatic stress symptoms (PTSS). The vast majority of participants reported lifetime (93.9%, n = 200) and past 3-month (65.3%, n = 139) IPV, and two thirds of participants (65.3%, n = 139) reported experiencing PTSS in the prior month. Multivariable logistic regression analyses indicated statistically significant associations between only some forms of IPV and PTSS, including physical IPV, adjusted odds ratio (aOR) = 3.24, 95% confidence interval (CI) [1.15, 9.14], and injurious IPV, aOR = 2.71, 95% CI [1.10, 6.65]. Additionally, experiencing any form of IPV was associated with 4.95 higher odds of reporting PTSS, 95% CI [1.16, 21.15]; no other results were significant. These results not only underscore the need for future research on the mechanisms that might explain the unique associations between different forms of IPV and posttraumatic stress, but also highlight an urgent need for trauma-informed mental health and psychosocial support interventions for women who use drugs and alcohol.

Contact tracing in Austria, Georgia, Kyrgyzstan, Ukraine, and Kosovo† during the COVID-19 pandemic: response review and good practices.

BACKGROUND: During the COVID-19 pandemic, effective contact tracing was recognized as a crucial public health response to mitigate the spread of SARS-CoV-2 and reduce COVID-19-related morbidity and mortality, particularly before widespread vaccination. The World Health Organization (WHO) recommended implementing active surveillance strategies to trace and quarantine contacts of confirmed or suspected COVID-19 cases. METHODS: A detailed review and analysis of the COVID-19 contact tracing responses was conducted in five European countries and territories, between March 2021 and August 2022. The countries and territories were selected to ensure geographical representation across the WHO European Region and applied a mixed-methods approach of in-depth interviews with various stakeholders across different administrative levels to identify good practices in COVID-19 contact tracing. The interviews covered 12 themes, including methods and procedures for COVID-19 contact tracing, information technology, quality assurance and key performance indicators. RESULTS: The findings demonstrate that the policy approach, digitalization capabilities and implementation approach varied in the countries and territories and were dynamic throughout the pandemic. The analysis revealed that some practices were applicable across all countries and territories, while others were context-specific, catering to each country's and territory's unique needs. The study highlighted a need for all countries to institutionalize contact tracing as an essential function of existing health systems, to digitalize contact tracing practices and processes, and to build and retain contact tracing capacities for better pandemic preparedness. CONCLUSION: The lessons related to COVID-19 contact tracing should be utilized to strengthen future outbreak response operations as part of epidemic and pandemic preparedness.

A metagenomic survey of bacterial communities from kurut: The fermented cow milk in Kyrgyzstan.

Kurut is a traditional dry dairy product mostly consumed in Central Asia. In this study, the distribution of the dominant bacteria present in kurut samples (n=84) originated from seven (Chuy, Issyk-Kul, Talas, Naryn, Jalal-Abad, Osh, and Batken) regions in Kyrgyzstan were analyzed with Illumina iSeq100 platform. The dominant phylum detected was Firmicutes followed by Proteobacteria, Actinobacteria, Cyanobacteria/Chloroplast, and Tenericutes. The most abundant family detected was Lactobacillaceae followed by Streptococcaceae, Enterococcaceae, Chloroplast, and Leuconostocaceae. At the genus level, Lactobacillus was the predominant one in samples and Streptococcus, Enterococcus, Lactococcus, and Streptophyta followed this. Further comprehensive characterization analyses in kurut samples may have potential applications both in industrial starter culture developments and also future therapeutic approaches based on potential strains with probiotic properties.

Possibilities of Using the National Electronic Data Syetstem in Assessing the Control of Arterial Hypertension at The Primary Health Care Level in the Kyrgyz Republic Using the Example of a Single Family Medicine Center.

AIM: To determine the capabilities of the National Electronic System for collecting quantitative data necessary to assess the quality of management and effectiveness of arterial hypertension (AH) control at the primary health care (PHC) level and to develop indicators and possibilities of their use for a standardized report on the quality of AH management and control at the PHC level in the Kyrgyz Republic. MATERIAL AND METHODS: Data from electronic outpatient records were processed for all registered patients of a pilot family medicine center (FMC) that was selected randomly. The registered patient group consisted of 91,226 people older than 18 years, including 37,740 men and 53,486 women. The data obtained during contact with a patient was entered by the family doctor into the electronic outpatient record and automatically forwarded to the center that collected and aggregated the data. To monitor AH control, 11 indicators were developed and evaluated. The indicators were divided into 3 groups: indicators for identifying AH, indicators for the quality of AH patient management, and indicators for the effectiveness of AH control. RESULTS: In total, 26,206 patients (7,933 men and 18,273 women) visited the FMC during a year, and blood pressure (BP) was measured in 71.4% of them. In 2022, 5,072 patients (5.6% of the registered group) visited the FMC for AH, including 1,539 men and 3,533 women (4.1 and 6.6% of the registered patient group, respectively; p<0.001). The proportion of patients with AH who, according to the clinical protocol, had their BP measured 2 times a year or more, was 81.4% and was slightly higher for women than for men (82.3% and 79.1%, respectively; p<0.01). 38.7% of AH patients received antihypertensive drugs. Lipid-lowering therapy was prescribed to 23.5% of AH patients. The proportion of AH patients taking acetylsalicylic acid was higher, 36.3% for the whole group, including 34.1% for men and 37.2% for women (p<0.05). The efficacy of AH treatment was 62.8%. CONCLUSION: Any monitoring system has limitations for the amount of useful data that can be obtained ensuring their proper quality. Taking this into account, two major indicators are suggested to use for evaluating the effectiveness of AH control at the PHC level: 1) the number of AH patients who have achieved the BP goal; 2) the number of AH patients who visited a medical institution (health care facility) during a calendar year relative to the number of registered patients (AH detectability).

[The lost years of potential life under cancer of neck of uterus in the Kyrgyz Republic].

One of modern methods of estimating health losses under malignant neoplasms in economic terms, characterizing number of deaths and age of death are lost years of potential life. The cumulative losses from premature cancer mortality made up to 29 217.5 man-years in 2013 and 39 710 man-years in 2021. The number of years lost over 9 years increased by 10 492.5 man-years despite decreasing of mortality across all ages. The rate of lost years of potential life during this period increased from 5.3 to 6.2 years. The maximal contribution to lost years of potential life was made by population groups 45-59 years old. Total losses from premature mortality from cervical cancer were 2682.5 man-years and 2411 man-years in 2013 in 2021. The number of years lost decreased by 271.5 man-years. The rate of lost years of potential life during this period increased from 0.5 to 3.7 years. The greatest contribution to lost years of potential life was made by population groups 60-64 and 40-49 years old. The calculation demonstrated that there are significant reserves for reducing population mortality from malignant neoplasms in most vulnerable age population groups that is important for organization of oncological care and planning of target prevention programs.

[The appealability of patients with glaucoma in the Kyrgyz Republic].

According to world forecasting, the number of patients with glaucoma all over the world will reach 111.8 million up to 2040 . The percentage of primary open-angle glaucoma is 2.34% and primary closed-angle glaucoma is 0.73%. According to mathematical forecast, further increasing of common and primary morbidity is expected. The retrospective analysis of patient records of the Department of Eye Microsurgery № 2 of the National Hospital of the Ministry of Health of the Kyrgyz Republic was carried out. It is established that among total number of treated patients with glaucoma, no significant difference in rate of cases of closed-angle (53,7±1,7) and open-angle forms (46,3±1,7) was established. In most cases, open-angle glaucoma was diagnosed in age group of 60-79 years and closed-angle glaucoma in age group of 50-79 years. The women are reliably more often suffer of glaucoma. The majority of patients had stage III (42,3±2,5), stage II (31,8±2,4) and stage I (22,2±2,1). At all stages, women more often had glaucoma with the exception of stage III and IV that were diagnosed with same rate were diagnosed in patients of both sexes. Unfortunately, there were isolated cases of open-angle glaucoma at young age. The results of the study dictate importance of prevention, early diagnostic, treatment and rehabilitation of ophthalmologic patients.

Asia's glaciers are a regionally important buffer against drought.

The high mountains of Asia-encompassing the Himalayas, the Hindu Kush, Karakoram, Pamir Alai, Kunlun Shan, and Tian Shan mountains-have the highest concentration of glaciers globally, and 800 million people depend in part on meltwater from them. Water stress makes this region vulnerable economically and socially to drought, but glaciers are a uniquely drought-resilient source of water. Here I show that these glaciers provide summer meltwater to rivers and aquifers that is sufficient for the basic needs of 136 million people, or most of the annual municipal and industrial needs of Pakistan, Tajikistan, Turkmenistan, Uzbekistan and Kyrgyzstan. During drought summers, meltwater dominates water inputs to the upper Indus and Aral river basins. Uncertainties in mountain precipitation are poorly known, but, given the magnitude of this water supply, predicted glacier loss would add considerably to drought-related water stress. Such additional water stress increases the risk of social instability, conflict and sudden, uncontrolled population migrations triggered by water scarcity, which is already associated with the large and rapidly growing populations and hydro-economies of these basins.

A Triassic stem-salamander from Kyrgyzstan and the origin of salamanders.

The origin of extant amphibians remains largely obscure, with only a few early Mesozoic stem taxa known, as opposed to a much better fossil record from the mid-Jurassic on. In recent time, anurans have been traced back to Early Triassic forms and caecilians have been traced back to the Late Jurassic Eocaecilia, both of which exemplify the stepwise acquisition of apomorphies. Yet the most ancient stem-salamanders, known from mid-Jurassic rocks, shed little light on the origin of the clade. The gap between salamanders and other lissamphibians, as well as Paleozoic tetrapods, remains considerable. Here we report a new specimen of Triassurus sixtelae, a hitherto enigmatic tetrapod from the Middle/Late Triassic of Kyrgyzstan, which we identify as the geologically oldest stem-group salamander. This sheds light not only on the early evolution of the salamander body plan, but also on the origin of the group as a whole. The new, second specimen is derived from the same beds as the holotype, the Madygen Formation of southwestern Kyrgyzstan. It reveals a range of salamander characters in this taxon, pushing back the rock record of urodeles by at least 60 to 74 Ma (Carnian-Bathonian). In addition, this stem-salamander shares plesiomorphic characters with temnospondyls, especially branchiosaurids and amphibamiforms.

Exploring medical students' perceptions of family medicine in Kyrgyzstan: a mixed method study.

BACKGROUND: Despite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice. METHODS: This study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review. RESULTS: The interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student's perceptions and prevented students' ability to identify with the practice of family medicine. However, students' awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved. CONCLUSION: This study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools' institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Using Open Foris Collect Earth in Kyrgyzstan to support greenhouse gas inventory in the land use, land use change, and forestry sector.

The Kyrgyz Republic (Kyrgyzstan) is one of the countries most vulnerable to the adverse effects of climate change in Central Asia. The land use, land use change, and forestry (LULUCF) sector is critical in climate change mitigation in Kyrgyzstan and is integral to national greenhouse gas (GHG) inventories. However, consistent, complete, and updated activity data is required for the LULUCF sector to develop a transparent GHG inventory. Collect Earth (CE), developed by the Food and Agriculture Organization of the United Nations (FAO), is a free, user-friendly, and open-source tool for collecting activity data for the LULUCF sector. CE assists countries in developing GHG inventories by providing consistent and complete land representation. This article reports an estimate of land use and land-use change dynamics in Kyrgyzstan, based on analyzing 13,414 1-hectare (ha) sampling units through an augmented visual interpretation approach using satellite imagery at the very high spatial and temporal resolution available through the Google Earth platform. The results show that in 2019, forests covered 1.36 million ha or 6.83% of the total land with a 6.23% uncertainty. This estimate was 5 to 16% higher than previous estimates, detecting an additional 63,024 to 188,164 ha of forestland that had not been reported previously. The new estimates suggest an average increase of 10.4% in the current forestlands of Kyrgyzstan.

Building the competency of health professionals in the Kyrgyz Republic for the Baby-Friendly Hospital Initiative.

Health professional competency building is one of nine national responsibilities (to achieve universal coverage and sustainability) described in the 2018 World Health Organization/UNICEF implementation guidance for the Baby-Friendly Hospital Initiative (BFHI). Skilled breastfeeding support as a standard of newborn care is critical to the establishment of lactation and exclusive breastfeeding. This qualitative case study describes the Kyrgyz Republic's experience with health professional competency building related to breastfeeding counselling and support. We interviewed 38 key informants and reviewed national policies and international guidelines related to BFHI. The study found that although the country has a new policy reflecting BFHI global standards and guidance, the policy has not been disseminated nationally. Additionally, the policy lacks guidance on competency monitoring and verification and does not mention preservice training, even though preservice training on breastfeeding support exists. To achieve universal coverage for health professional competencies, the Kyrgyz Republic uses preservice, in-service and refresher training. However, the main limitations to aligning with the new guidance are a lack of preservice BFHI- and breastfeeding-specific curricula, experienced trainers and sufficient time and funding to dedicate to practical skill development. Conducted during the COVID-19 pandemic, this study confirmed disruptions to BFHI training and service delivery but also documents the Kyrgyz Republic's resilient strides to mitigate impacts on breastfeeding support through facility-level individual champions and adjustments to training such as going online. Opportunities exist for strengthening the competencies of service providers through strengthened preservice training, comprehensive and consistent in-service training, solutions for overworked service providers and clear and sufficiently funded monitoring guidance.

[Features of the state of health, including physical development, of adolescent girls living in the middle and high mountains of the Kyrgyz Republic].

Adolescent girls aged 15-18 are in an active process of growth and development, as evidenced by the dynamics of changes in height and weight indicators. Low values of average growth indicators were determined among girls in Batken, on average 2 cm less than the average indicators of girls in Bishkek, however, the statistical analysis performed did not confirm the reliability of these differences. In 84.3% of the surveyed adolescent girls living in Naryn, iron deficiency anemia was detected. Kidney and urinary tract diseases (31.4%) took the first place in the structure of diseases among girls in Batken. Diffuse enlargement of the thyroid gland was found in 13% of women living in highlands. Inflammatory diseases of the genitourinary system are two or more times more common among girls in the middle and high mountains than in Bishkek: vulvitis in 8.7-11.4% of cases against 4.1% of cases, urogenital diseases in 6.5-17.4 versus 3.9 respectively. This indicates the need to introduce specific preventive programs for girls living in the middle and high mountains.

Risk Factors for Severe Cutaneous Anthrax in a Retrospective Case Series and Use of a Clinical Algorithm to Identify Likely Meningitis and Evaluate Treatment Outcomes, Kyrgyz Republic, 2005-2012.

BACKGROUND: US Centers for Disease Control and Prevention guidelines currently recommend triple-therapy antimicrobial treatment for anthrax meningitis. In the Kyrgyz Republic, a country with endemic anthrax, cutaneous anthrax patients are routinely hospitalized and treated successfully with only monotherapy or dual therapy. Clinical algorithms have been developed to identify patients with likely anthrax meningitis based on signs and symptoms alone. We sought to retrospectively identify likely meningitis patients in the Kyrgyz Republic using a clinical algorithm and evaluate risk factors and their outcomes by type of treatment. METHODS: We conducted a retrospective chart review of cutaneous anthrax patients in the Kyrgyz Republic from 2005 through 2012. Using previous methods, we developed a highly specific algorithm to categorize patients by meningitis status. We then evaluated patient risk factors, treatments, and outcomes by disease severity and meningitis status. RESULTS: We categorized 37 of 230 cutaneous anthrax patients as likely having meningitis. All 37 likely meningitis patients survived, receiving only mono- or dual-therapy antimicrobials. We identified underlying medical conditions, such as obesity, hypertension, and chronic obstructive pulmonary disease, and tobacco and alcohol use, as potential risk factors for severe anthrax and anthrax meningitis. CONCLUSIONS: Based on our analyses, treatment of anthrax meningitis may not require 3 antimicrobials, which could impact future anthrax treatment recommendations. In addition, chronic comorbidities may increase risk for severe anthrax and anthrax meningitis. Future research should further investigate potential risk factors for severe anthrax and their impact on laboratory-confirmed meningitis and evaluate mono- and dual-therapy antimicrobial regimens for anthrax meningitis.

An observational prospective cohort study of naloxone use at witnessed overdoses, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine.

Objective: To determine whether participation in the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization's (WHO) Stop Overdose Safely (S-O-S) take-home naloxone training project in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine resulted in naloxone use at witnessed opioid overdoses. Methods: An observational prospective cohort study was performed by recruiting participants in the implementation of the S-O-S project, which was developed as part of the broader S-O-S initiative. Training included instruction on overdose responses and naloxone use. Study participants were followed for 6 months after completing training. The primary study outcome was participants' naloxone use at witnessed overdoses, reported at follow-up. Findings: Between 400 and 417 S-O-S project participants were recruited in each country. Overall, 84% (1388/1646) of participants were interviewed at 6-month follow-up. The percentage who reported witnessing an overdose between baseline and follow-up was 20% (71/356) in Tajikistan, 33% (113/349) in Kyrgyzstan, 37% (125/342) in Ukraine and 50% (170/341) in Kazakhstan. The percentage who reported using naloxone at their most recently witnessed overdose was 82% (103/125) in Ukraine, 89% (152/170) in Kazakhstan, 89% (101/113) in Kyrgyzstan and 100% (71/71) in Tajikistan. Conclusion: Implementation of the UNODC-WHO S-O-S training project in four low- to middle-income countries resulted in the reported use of take-home naloxone at around 90% of witnessed opioid overdoses. The percentage varied between countries but was generally higher than found in previous studies. Take-home naloxone is particularly important in countries where emergency medical responses to opioid overdoses may be limited.