Biomarkers of Secondhand Smoke Exposure in Waterpipe Tobacco Venue Employees in Istanbul, Moscow, and Cairo.

Background: Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees. Methods: We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul, Moscow, and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO), hair nicotine, saliva cotinine, urine cotinine, urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures. Results: There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers, the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2, 40.9) µg/g creatinine urine cotinine, 5.5 (2, 15) ng/mL saliva cotinine, 0.95 (0.36, 5.02) ng/mg hair nicotine, 1.48 (0.98, 3.97) pg/mg creatinine urine NNAL, 0.54 (0.25, 0.97) pmol/mg creatinine urine 1-OHPG, and 1.67 (1.33, 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68, 95% CI: 1.20, 2.37) and hair nicotine (GMR: 1.22, 95% CI: 1.05, 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83, 95% CI: 1.05, 7.62). Conclusions: Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS, including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs). Implications: Smoke-free regulation should be extended to waterpipe venues to protect nonsmoking employees and patrons from the adverse health effects of SHS.

Secondhand smoke in waterpipe tobacco venues in Istanbul, Moscow, and Cairo.

OBJECTIVE: The prevalence of waterpipe tobacco smoking has risen in recent decades. Controlled studies suggest that waterpipe secondhand smoke (SHS) contains similar or greater quantities of toxicants than cigarette SHS, which causes significant morbidity and mortality. Few studies have examined SHS from waterpipe tobacco in real-world settings. The purpose of this study was to quantify SHS exposure levels and describe the characteristics of waterpipe tobacco venues. METHODS: In 2012-2014, we conducted cross-sectional surveys of 46 waterpipe tobacco venues (9 in Istanbul, 17 in Moscow, and 20 in Cairo). We administered venue questionnaires, conducted venue observations, and sampled indoor air particulate matter (PM2.5) (N=35), carbon monoxide (CO) (N=23), particle-bound polycyclic aromatic hydrocarbons (p-PAHs) (N=31), 4-methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (N=43), and air nicotine (N=46). RESULTS: Venue characteristics and SHS concentrations were highly variable within and between cities. Overall, we observed a mean (standard deviation (SD)) of 5 (5) waterpipe smokers and 5 (3) cigarette smokers per venue. The overall median (25th percentile, 75th percentile) of venue mean air concentrations was 136 (82, 213) µg/m(3) for PM2.5, 3.9 (1.7, 22) ppm for CO, 68 (33, 121) ng/m(3) for p-PAHs, 1.0 (0.5, 1.9) ng/m(3) for NNK, and 5.3 (0.7, 14) µg/m(3) for nicotine. PM2.5, CO, and p-PAHs concentrations were generally higher in venues with more waterpipe smokers and cigarette smokers, although associations were not statistically significant. CONCLUSION: High concentrations of SHS constituents known to cause health effects indicate that indoor air quality in waterpipe tobacco venues may adversely affect the health of employees and customers.

Published Research on COVID-19 in the Eastern Mediterranean Region: Bibliometric Analysis.

BACKGROUND: The challenges presented by the COVID-19 pandemic have led to unprecedented global research activity. The Eastern Mediterranean Region (EMR) continues to contribute to COVID-19 research driven by the unique challenges of the region, including the protracted conflicts, already stressed health systems, and serious health and social inequalities. OBJECTIVE: This study aims to provide an overview of the publication activities and trends in COVID-19 research in the EMR from the onset of the disease to early 2022 using bibliometric methods. METHODS: A literature search using Scopus was conducted from December 1, 2019, to January 31, 2022, using keywords relevant to COVID-19 and the World Health Organization (WHO) EMR country list. Data were exported and analyzed using Microsoft Excel and the Citation Overview function on Scopus. The quality of journals was determined using SCImago Journal Rank and CiteScore. VOSviewer software was used to visualize the relationships between authors, countries, and key terms used in the retrieved documents. RESULTS: A total of 6880 documents were retrieved, of which 1805 (26.24%) were from the Kingdom of Saudi Arabia (KSA) and 1782 (25.90%) from Iran, followed by Pakistan, Egypt, and Jordan. Most published documents were affiliated with EMR universities, primarily the Tehran University of Medical Sciences in Iran and King Saud University in KSA (396/6880, 5.76%, and 370/6880, 5.4%, respectively), while only 407 (5.92%) of 6880 documents were associated with universities outside the EMR. For most of the identified publications (5020/6880, 72.97%), no funding source was reported, while King Saud University contributed the largest share (282/1860, 15.16%) of funded publications. Retrieved documents were cited 53,516 times, with an average of 7.78 (SD 34.30). Iran was the EMR country with the most links to other countries (77 links and total link strength of 1279). The 5 authors with the most publications were from KSA, Qatar, and Jordan. There were 290 high-frequency keywords that occurred ≥10 times and were linked in 7 different clusters. The cluster with the most linked keywords was related to epidemiology and mortality. Recent topics included vaccines, vaccination, machine learning, and online learning. CONCLUSIONS: This is the first study to show trends in and project future developments of COVID-19 research activity in the EMR. Authors and institutions who led research on COVID-19 in the region were from Iran and KSA. There were multiple regional collaborative efforts; however, international collaboration was limited. Recently, interest has been shifting toward topics related to vaccination, machine learning, and online learning. Understanding the current state of research is instrumental to future research production, and our study will inform regional research initiatives on emerging concepts, as well as opportunities for collaboration and funding.

Funding for health policy and systems research in the Eastern Mediterranean region: amount, source and key determinants.

OBJECTIVES: To provide an overview of the current state of funding for health policy and systems research (HPSR) on a national level across the Eastern Mediterranean region (EMR), and to examine the key factors influencing funding for HPSR in the region. METHODS: A multistep approach was employed, involving a documentation review, secondary data analysis and key informant interviews with 30 stakeholders from five countries in the EMR. Findings are presented narratively (and where applicable as percentages). RESULTS: National funding for research and development (R&D) in general, and for health research in particular, has been low in comparative terms and lagging behind at the global scale, while funding for HPSR has been lacking on a national level. None of the 22 EMR countries studied had explicit national funding or a budget line for HPSR. Analysis of funding sources of 1821 published HPSR articles in the EMR (2010-2019) showed that the most notable source was external/international grants (45.6%), followed by university/academia (35.1%), and government (9.5%). Although HPSR publications have been increasing over time, this still falls short of the scale needed for strengthening health systems and informing current transformations in the region. Findings from the interviews identified several factors influencing investment in or funding for HPSR in the EMR. CONCLUSIONS: Many of the EMR's policy priorities are related to health systems, however our research finds that overall investment in health research and HPSR is still low, with limited recognition of the importance of HPSR in the EMR.

Integration of sexual and reproductive health services in the provision of primary health care in the Arab States: status and a way forward.

Different approaches are used for integration of sexual and reproductive health (SRH) services at the primary health care (PHC) level, aiming at providing comprehensive services leaving no one behind. This paper aims to assess gaps in the delivery of SRH in PHC services, identifying challenges and proposing action towards universal health coverage in Arab countries. The United Nations Population Fund, Arab States Regional Office (UNFPA/ASRO), in partnership with Middle East and North Africa Health Policy Forum (HPF), launched an assessment of integration of SRH into PHC in 11 Arab countries in 2017-2018. Desk reviews were conducted, using published program reports and national statistics. Data from country reports were compiled to present a regional assessment, challenges and recommendations. SRH services are partially integrated in PHC. Family planning is part of PHC in all countries except Libya, where only counselling is provided. Only Morocco, Tunisia and Oman provide comprehensive HIV services at PHC level. Jordan, Libya and Saudi Arabia rely mainly on referral to other facilities, while most of the integrated family planning or HIV services in Sudan, Morocco and Oman are provided within the same facilities. Action is required at the policy, organisational and operational levels. Prioritisation of services can guide the development of essential packages of SRH care. Developing the skills of the PHC workforce in SRH services and the adoption of the family medicine/general practice model can ensure proper allocation of resources. A presented regional integration framework needs further efforts for addressing the actions entailed.

Implementation of Health Technology Assessment in the Middle East and North Africa: Comparison Between the Current and Preferred Status.

INTRODUCTION: Implementation of health technology assessment (HTA) is still in an early stage with some heterogeneity in the Middle East and North Africa (MENA). Our objective was to assess the current and future status of HTA implementation in the MENA region by focusing on regional commonalities. METHODS: Preparatory discussions for the first ISPOR conference in the MENA region indicated some potentially generalizable trends of HTA roadmaps. To widen the perspective, a policy survey was conducted among conference participants by applying an HTA implementation scorecard. Discussion group members helped to validate key conclusions during and after the conference. RESULTS: Health policy experts in MENA countries would like to facilitate HTA implementation and expect significant changes with some generalizable directions in 10 years compared to the current status according. HTA capacity building has to be strengthened by more graduate and postgraduate programs. Increased public budget and enhanced institutionalization are necessary success factors of HTA implementation. The scope of HTA has to be extended from pharmaceuticals to non-pharmaceutical technologies and to revision of previous policy decisions. Although cost-effectiveness with explicit threshold remains the most preferred HTA criterion, several other criteria have to be considered, maybe even by applying an explicit MCDA framework. The role of local evidence and data has to be strengthened in MENA countries, which translates to the extended use of local patient registries and payers' databases. Duplication of efforts can be reduced if international collaboration is integrated into national HTA implementation. DISCUSSION: Our results should be viewed as an initial step in a multi-stakeholder dialogue on HTA implementation. Each MENA country should develop its context-specific HTA roadmap, as such roadmaps are not transferable without taking into account country size, economic status, public health priorities and adopted systems of health care financing.