Molecular characterization of a large cohort of mucopolysaccharidosis patients: Iran Mucopolysaccharidosis RE-diagnosis study (IMPRESsion).

Mucopolysaccharidoses (MPSs) are rare, heterogeneous inborn errors of metabolism (IEM) diagnosed through a combination of clinical, biochemical, and genetic investigations. The aim of this study was molecular characterization of the largest cohort of Iranian MPS patients (302 patients from 289 unrelated families), along with tracking their ethnicity and geographical origins. 185/289 patients were studied using an IEM-targeted NGS panel followed by complementary Sanger sequencing, which led to the diagnosis of 154 MPS patients and 5 non-MPS IEMs (diagnostic yield: 85.9%). Furthermore, 106/289 patients who were referred with positive findings went through reanalysis and confirmatory tests which confirmed MPS diagnosis in 104. Among the total of 258 MPS patients, 225 were homozygous, 90 harbored novel variants, and 9 had copy number variations. MPS IV was the most common type (34.8%) followed by MPS I (22.7%) and MPS VI (22.5%). Geographical origin analysis unveiled a pattern of distribution for frequent variants in ARSB (c.430G>A, c.962T>C [p.Leu321Pro], c.281C>A [p.Ser94*]), GALNS (c.319G>A [p.Ala107Thr], c.860C>T [p.Ser287Leu], c.1042A>G [p.Thr348Ala]), and IDUA (c.1A>C [p.Met1Leu], c.1598C>G [p.Pro533Arg], c.1562_1563insC [p.Gly522Argfs*50]). Our extensive patient cohort reveals the genetic and geographic landscape of MPS in Iran, which provides insight into genetic epidemiology of MPS and can facilitate a more cost-effective, time-efficient diagnostic approach based on the region-specific variants.

Evaluation Frequency of Human Papillomavirus and Its Related Genotypes in Women of the General Population Living in 11 Provinces of Iran.

Introduction: Persistent infection with one of the most high-risk genotypes of human papillomavirus causes all cases of cervical cancer and a significant proportion of other genital cancers. The HPV virus, unlike any other infection that leads to cancer, is transmitted only through sexual intercourse and is less affected by the general changes and development in lifestyle and medical standards, so only vaccination and screening can prevent the HPV virus and cancers caused by it. Therefore, determining the prevalence and distribution of HPV genotypes are of utmost importance in screening strategies regarding cervical cancer and vaccination decisions against HPV that vary based on the geographical and cultural characteristics of the study area. As a result, this study aimed to determine the frequency of human papillomavirus and the distribution of this virus's genotypes in the general population of women living in 11 provinces of Iran. Materials and Methods: This study is a community-based survey study. Sampling was done by the cluster sampling method. Women aged 15-59 years old from the general population living in 11 provinces of Iran were included in the study after considering the inclusion and exclusion criteria. Data were collected using a questionnaire and vaginal examination. The study was performed on 2562 vaginal specimens that were referred to the laboratory of the present study. HPV genome was detected by the nested MY-GP method and papillomavirus genotyping was performed using the PCR multiplex method to identify 19 papillomavirus genotypes. Results: The general prevalence of HPV in the 11 provinces was obtained at 2.4% (108 out of 2562 people). The highest prevalence of the virus was in the age group of 25-34 years. The prevalence of HPV was statistically significant among different provinces. Hormozgan province with 22 cases (5.9%) had the highest and Isfahan province with 6 cases (2.2%) had the lowest incidence of HPV. The prevalence of high-risk HPV and medium-risk HPV is 3%, and the prevalence of low-risk HPV was estimated to be 2.1% of the total female population. Also, the highest prevalence was related to genotype 16. Conclusion: According to the high prevalence of the HPV virus in young age groups in Iran, it is necessary to pay attention to screening programs to reduce the incidence of cervical cancer.

Nationwide population-based surveys of Iranian COVID-19 Serological Surveillance (ICS) program: The surveys protocol.

Background: Serological surveillance of COVID-19 through conducting repetitive population-based surveys can be useful in estimating and monitoring changes in the prevalence of infection across the country. This paper presents the protocol of nationwide population-based surveys of the Iranian COVID-19 Serological Surveillance (ICS) program. Methods: The target population of the surveys is all individuals ≥6 years in Iran. Stratified random sampling will be used to select participants from those registered in the primary health care electronic record systems in Iran. The strata are the 31 provinces of the country, in which sampling will be done through simple random sampling. The sample size is estimated 858 individuals for each province (except for Tehran province, which is 2574) at the first survey. It will be recalculated for the next surveys based on the findings of the first survey. The participants will be invited by the community health workers to the safe blood sampling centers at the district level. After obtaining written informed consent, 10 mL of venous blood will be taken from the participants. The blood samples will be transferred to selected reference laboratories in order to test IgG and IgM antibodies against COVID-19 using an Iranian SARS-CoV-2 ELISA Kit (Pishtaz Teb). A serologically positive test is defined as a positive IgG, IgM, or both. After adjusting for the measurement error of the laboratory test, nonresponse bias, and sampling design, the prevalence of COVID-19 will be estimated at the provincial and national levels. Also, the approximate incidence rate of infection will be calculated based on the data of both consecutive surveys. Conclusion: The implementation of these surveys will provide a comprehensive and clear picture of the magnitude of COVID-19 infection and its trend over time for health policymakers at the national and subnational levels.

Measuring the net profit of laboratory services: A case study in Iran.

Background: Clinical laboratories need to manage resources properly and scientifically to survive in today's highly competitive environment. In this context, scientific-economic principles should be considered to determine the profitability or loss of laboratories. Thus, in this study, the net profit of laboratory services was measured based on scientific-economic principles. Methods: This was an applied research with descriptive-retrospective approach. A laboratory was selected from 61 laboratories of Kerman, Iran, which performed the highest number of tests among the laboratories of this city. In addition, due to easy access, it was the most visited laboratory by patients. The present study had 2 main phases: (1) measuring the price of services and (2) calculating the net profit of the studied laboratory. Data analysis was performed using activity- based costing (ABC) as an econometric model and Excel software. Results: The highest charges were related to direct costs (78.28%); consumable goods (47.26%) and professional and logistic human resources (46.31%) had the highest share of these costs. In the test groups, the most expensive tests belonged to the hormones (23.03%) and clinical chemistry (20.84%). Total cost, revenue, and the net profit of the studied laboratory were 641 645, 1 390 942, and 749 297 USD, respectively. After doing sensitivity analysis (50% increase in the frequency of tests), the following values were obtained: 987 071, 2 086 413, and 1 099 342, respectively. Conclusion: Some test groups in the studied laboratory were not profitable, and this was due to the high cost of these tests and illogical tariffs. One way to overcome this problem is to increase the frequency of laboratory tests.

Comparison of In-House Multiplex Real Time PCR, Diagcor GenoFlow HPV Array Test and INNO-LiPA HPV Genotyping Extra Assays with LCD- Array Kit for Human Papillomavirus Genotyping in Cervical Liquid Based Cytology Specimens and Genital Lesions in Tehran, Iran.

BACKGROUND: Human papillomavirus is a major etiologic agent for some human common cancers. Cervical precancer and cancer is the most prevalent dysplasia by HPV genotypes. Various rapid and sensitive methods have been developed into readily HPV genotyping. METHODS: In the present study, we compared the performance of Real Time PCR, GenoFlow HPV Array, and INNO-LiPA HPV Genotyping Extra Assays with LCD- Array. RESULTS: From 108 cervical samples, HPV was detected in 33 women (30.55%). Among detected HPV genotypes, HPV 6 and 11 were dominant genotypes. Comparing these methods revealed that for Real Time PCR, Genoflow, and INNO-LiPA in comparison with LCD Array, sensitivity and specificity were 94.2%, 93%; 76.7%, 93%; 64%, 96.5%, respectively. Overall, accuracy and precision of these methods were more than 80% and 90%, respectively. CONCLUSIONS: It seems that these methods are reliable and suitable for detection and genotyping of HPVs in cervical disorders and other dysplasia associated with human papillomaviruses.

Monitoring human cytomegalovirus infection in pediatric hematopoietic stem cell transplant recipients: using an affordable in-house qPCR assay for management of HCMV infection under limited resources.

Quantitative real-time PCR (qPCR) assay is accepted as the method of choice for monitoring human cytomegalovirus (HCMV) infection in hematopoietic stem cell transplant recipients, but the high cost of commercial kits has hampered its use in many developing countries. In this study, an affordable in-house qPCR was used to manage HCMV infection in pediatric patients and the diagnostic value of this method was compared with the conventional pp65 antigenemia assay. A total number of 1179 samples from 82 recipients were used in this study, and the effect of some potential risk factors on HCMV reactivation was evaluated. The qPCR was able to detect HCMV reactivation earlier and with higher sensitivity than antigenemia assay. Forty-six episodes of reactivation were detected in 39 patients, of which all were detected by the qPCR assay, while only 21 episodes were diagnosed by antigenemia. The DNAemia level of 1284 IU/ml plasma was defined as the optimal cutoff value for starting pre-emptive therapy. It was shown that the acute GVHD severity and the relationship of donor and recipient are the most significant risk factors for HCMV reactivation. The data suggest that the antigenemia method for monitoring HCMV reactivation could be substituted by the qPCR assay.

Strategic Framework for Strengthening Health Laboratory Services in the COVID-19 Pandemic in Iran.

Background & Objective: Providing equitable access to good quality, timely, and affordable laboratory testing has always been a top priority for the Ministry of Health and Medical Education (MoH-ME) and the Reference Health Laboratory (RHL). Considering the significant role of medical laboratories in disease surveillance, RHL developed a strategic plan to manage laboratory services during the COVID-19 pandemic based on the "Strategic Framework for strengthening health laboratory services, 2016-2020" proposed by the World Health Organization (WHO). This article describes the steps taken to establish the strategic framework in Iran. Methods: Firstly, a National Laboratory Committee was formed in MoH-ME and a situation analysis was conducted to explore the strengths, weaknesses, opportunities, and threats in different components of our laboratory system. Gaps and resources needed to address those gaps were determined; then, RHL outlined operational processes and mechanisms for monitoring the activities. Results: The WHO strategic roadmap and its six strategic goals concerning leadership, quality, human resources, safety and security, laboratory networking, and rational use of laboratory testing, helped us to promote national laboratory services in accordance with health system requirements in the COVID-19 pandemic. Conclusion: The establishment of a national molecular laboratory network with more than 500 laboratories from different sectors may result in timely access to countrywide laboratory services and would be beneficial for future COVID-19 and/or other viral outbreaks. Continual evaluation of the COVID-19 laboratories' performance, production of PCR test kits by the local manufacturers, and development of a platform for virtual training would be other accomplishments that Iran achieved in coping with the recent pandemic.

Development of a robust, low cost stem-loop real-time quantification PCR technique for miRNA expression analysis.

Development of a rapid and accurate quantification method for the detection of microRNAs (miRNAs) has been desired, in particular, when they are differently expressed in normal and pathological conditions. However, various methods for the quantification of small non-coding RNAs as well as miRNAs have been described. These methods mainly include hybridization-based approaches such as primer extension, northern blotting, microarray profiling, and reverse transcription (RT) PCR. Here, we developed a simple and rapid method based on stem-loop primer-based real-time PCR assay for sensitive and accurate detection of mature miRNAs. Initially, a miRNA-specific stem-loop RT primer is used for RT, which is followed by TaqMan real-time PCR assay using specific forward primer in combination with universal reverse primer and TaqMan probe. The assay has shown high sensitivity (≤50 copies/reaction) for miRNA detection in two breast cancer cell lines, MCF-7 and MDA-MB-231. This assay might be implicated as a rapid and cost effective method for the detection of small non-coding RNAs.

Occurrence of methicillin resistant Staphylococcus aureus (MRSA) among clinical samples in tehran-iran and its correlation with polymorphism of specific accessory gene regulator (AGR) groups.

Methicillin-Resistant Staphylococcus aureus (MRSA) is responsible for an increasing number of serious hospital and community acquired infections. Virulence gene expression in Staphylococcus aureus is orchestrated by regulators such as the accessory gene regulator (agr). Staphylococcal strains are divided into four major agr groups (agrI-IV) on the basis of agrD and agrC polymorphisms. The purpose of this study was to define the prevalence of MRSA strains in appointed Tehran's hospitals and then to define and compare the proportion of agr I, II, III, IV polymorphisms between MRSA and Methicillin Sensitive Staphylococcus aureus (MSSA) strains. A total of 235 isolates were evaluated by conventional antibiotic susceptibility tests and PCR for agr and mecA genes. 112 strains were MRSA (47.5%) and the most prevalent agr specific group was agr I followed by agr III, agr II and agr IV, respectively. The prevalence of agr groups amongst MRSA and MSSA strains was not statistically significant (P≥0.05). This study suggests that agr I is not only the most prevalent agr type in MRSAs but also the most common one in Methicillin Sensitive Staphylococcus aureus (MSSA) strains in Iran.

Design and Development of a Multiplex Real-Time PCR Assay for Detection of HIV-1 and HCV Using Molecular Beacons.

At least 10 million individuals worldwide are co-infected with immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV). These two viruses are transmitted most primarily by exposure to infected blood or blood products. Various nucleic acid assays have been developed for diagnostics and therapeutic monitoring of infections. In the present study, a multiplex real-time PCR assay for simultaneous detection of HCV and HIV-1 using molecular beacons were designed and validated. A well-conserved region in the HIV-1 pol gene and 5'NCR of HCV genome were used for primers and molecular beacon design. The analysis of scalar concentrations of the samples indicated that this multiplex procedure detects at least 1,000 copies/ml of HIV-1 and 100 copies/ml of HCV with linear reference curve (R (2) > 0.94). The results demonstrate that a specificity of 100 % and sensitivity of 96 % can be achieved. The analytical sensitivity study with BLAST software demonstrated that the primers do not attach to any other sequences except for that of HIV-1 or HCV. The primers and molecular beacon probes only detected HIV-1 and all major variants of HCV. This assay may represent an alternative rapid and relatively inexpensive screening method for detection of HIV-1/HCV co-infection especially in blood screening.

Association between being metabolically healthy/unhealthy and metabolic syndrome in Iranian adults.

INTRODUCTION: The prevalence of metabolically healthy obesity (MHO) varies based on different criteria. We assessed the prevalence of MHO and metabolic unhealthiness based on body mass index (BMI) and their association with metabolic syndrome (MetS) in a nation-wide study. METHODS: Data were taken from the STEPs 2016 study, from 18,459 Iranians aged ≥25 years. Demographic, metabolic, and anthropometric data were collected. Subjects were stratified by BMI, metabolic unhealthiness, and having MetS. The latter was defined based on National Cholesterol Education Program Adult Treatment Panel III 2004 (NCEP ATP III), was then assessed. RESULTS: The prevalence of MHO and metabolic unhealthiness in obese subjects was 7.5% (about 3.6 million) and 18.3% (about 8.9 million), respectively. Most of the metabolic unhealthy individuals were female (53.5%) or urban residents (72.9%). Low physical activity was significantly and positively associated (Odds Ratio: 1.18, 95% CI: 1.04-1.35) with metabolic unhealthiness, while being a rural residence (0.83, 0.74-0.93), and having higher education (0.47, 0.39-0.58) significantly but negatively affected it. Dyslipidemia was the most frequent MetS component with a prevalence rate of 46.6% (42.1-51.1), 62.2% (60.8-63.6), 76.3% (75.1-77.5), and 83.4% (82.1-84.6) among underweight, normal weight, overweight and obese phenotypes, respectively. CONCLUSION: BMI aside, an additional set of criteria such as metabolic markers should be taken into account to identify normal weight but metabolically unhealthy individuals. Given the highest prevalence of dyslipidemia among obese subjects, further interventions are required to raise public awareness, promote healthy lifestyles and establish lipid clinics.

Prevalence of COVID-19 in Iran: results of the first survey of the Iranian COVID-19 Serological Surveillance programme.

OBJECTIVES: This study aims to estimate the prevalence of coronavirus disease 2019 (COVID-19) in the general population of Iran. METHODS: The target population was all Iranian people aged 6 years and older in the country. A stratified random sampling design was used to select 28 314 people from among the individuals registered in the electronic health record systems used in primary health care in Iran. Venous blood was taken from each participant and tested for the IgG antibody against COVID-19. The prevalence of COVID-19 was estimated at provincial and national levels after adjusting for the measurement error of the laboratory test, non-response bias and sampling design. RESULTS: Of the 28 314 Iranians selected, 11 256 (39.75%) participated in the study. Of these, 5406 (48.0%) were male and 6851 (60.9%) lived in urban areas. The mean (standard deviation) participant age was 35.89 (18.61) years. The adjusted prevalence of COVID-19 until 20 August 2020 was estimated as 14.2% (95% uncertainty interval 13.3%-15.2%), which was equal to 11 958 346 (95% CI 11 211 011-12 746 776) individuals. The adjusted prevalences of infection were 14.6%, 13.8%, 16.6%, 11.7% and 19.4% among men, women, urban population, rural population and individuals aged 60 years or more, respectively. Ardabil, Golestan and Khuzestan provinces had the highest prevalence and Alborz, Hormozgan and Kerman provinces had the lowest. CONCLUSIONS: Based on the study results, a large proportion of the Iranian population had not yet been infected by COVID-19. The observance of hygienic principles and social restrictions should therefore continue until the majority of the population has been vaccinated.

How Iran responded to expanding need for laboratory services for COVID-19?

After the emergence of SARS-CoV-2 in early 2020 in Iran, the rapid response team of Pasteur Institute of Iran was the first lab starting detection and report of suspected human samples. This article is a short summery of all actions from the preparedness for detecting the first cases of COVID-19, expanding the nationwide laboratory service, choosing the suitable laboratory tests and other challenges in laboratory detection during SARS-CoV-2 pandemic in Iran.

Development of a low-cost real-time reverse transcriptase-polymerase chain reaction technique for the detection and quantification of hepatitis C viral load.

BACKGROUND: It is necessary to develop a highly specific and sensitive assay to quantify the exact amount of hepatitis C virus (HCV) RNA in blood of patients with hepatitis C. For this reason, a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay for quantification of HCV RNA in human plasma was developed. METHODS: A pair of primers as well as hybridization probes were selected. A real-time RT-PCR was set up and optimized. To establish the sensitivity of the assay, a serial dilution of HCV standards and reference sera, including the six major HCV genotypes, was used. The performance of the assay was evaluated with 191 known HCV-RNA positive and 100 negative samples. RESULTS: The real-time assay had a sensitivity of 50 IU/mL, with a dynamic range of detection between 10(3) and 10(6) IU/mL. The coefficients of variation of threshold cycle values in intra- and inter-day-runs were <1.77% and 3.40%, respectively. Measurement of HCV-RNA positive samples yielded reproducible data with 100% specificity. CONCLUSIONS: The high sensitivity, simplicity, reproducibility, wide dynamic range, and low cost of this real-time HCV RNA quantification makes this method especially suitable for monitoring viral load during therapy and tailoring of treatment schedules accordingly.

A Real-Time RT-PCR Assay for Genotyping of Rotavirus

Background: Human rotavirus (HRV) is the causative agent of severe gastroenteritis in children and responsible for two million hospitalizations and more than a half-million deaths annually. Sequence characteristics of the gene segments encoding the VP7 and VP4 proteins are used for the genotype classification of rotavirus. A wide variety of molecular methods are available, mainly based on reverse transcription PCR for rapid, specific and sensitive genotyping of rotaviruses. This study describes an alternative real-time PCR assay for genotyping of rotavirus. Methods: The samples of stools studied in this research have been collected from patients referred to Children's Medical Centers, Tehran, Iran. Rotavirus detection and genotyping were performed using the RT-PCR and semi-nested RT-PCR, respectively. Samples were then genotyped with a new real-time PCR. Results: The real-time PCR was able to genotype all positive samples with a mean Ct of 28.2. Besides, a concordance rate of 100% was detected between real-time PCR and semi-nested RT-PCR. Conclusion: In this study, the genotyping of rotavirus with real-time PCR showed that this method can provide several favorable features, including high sensitivity and specificity, and a wide dynamic range for rotavirus genotyping.

The Utility of rRT-PCR in Diagnosis and Assessment of Case-fatality rates of COVID-19 In the Iranian Population. Positive Test Results are a Marker for Illness Severity.

The utility of PCR-based testing in characterizing patients with COVID-19 and the severity of their disease remains unknown. We performed an observational study among patients presenting to hospitals in Iran who were tested for 2019-nCoV viral RNA by rRT-PCR between the fourth week of February 2020 to the fourth week of March 2020. Frequency of symptoms, comorbidities, intubation, and mortality rates were compared between COVID-19 positive vs. negative patients. 96103 patients were tested from 879 hospitals. 18754 (19.5%) tested positive for COVID-19. Positive testing was more frequent in those 50 years or older. The prevalence of cough (54.5% vs. 49.7%), fever (49.5% vs. 44.7%), and respiratory distress (43.0% vs. 39.0%) but not hypoxia (46.9% vs. 56.7%) was higher in COVID-19 positive vs. negative patients (p<0.001 for all). More patients had cardiovascular diseases (10.6% vs. 9.5%, p<0.001) and type 2 diabetes mellitus (10.8% vs. 8.7%, p<0.001) among COVID-19 positive vs. negative patients. There were fewer patients with cancer (1.1%, vs. 1.4%, p<0.001), asthma (1.9% vs. 2.5%, p<0.001), or pregnant (0.4% vs. 0.6%, =0.001) in COVID-19 positive vs. negative groups. COVID-19 positive vs. negative patients required more intubation (7.7% vs. 5.2%, p<0.001) and had higher mortality (14.6% vs. 6.3%, p<0.001). Odds ratios for death of positive vs negative patients range from 2.01 to 3.10 across all age groups. In conclusion, COVID-19 test-positive vs. test-negative patients had more severe symptoms and comorbidities, required higher intubation, and had higher mortality. rRT-PCR positive result provided diagnosis and a marker of disease severity in Iranians.

Shiga toxin-producing bacteria as emerging enteric pathogens associated with outbreaks of foodborne illness in the Islamic Republic of Iran.

BACKGROUND: Detection of the cause of diarrhoeal diseases is important for the management of the outbreaks. AIMS: This study investigated the prevalence of Shiga toxin-producing bacteria in stool samples of patients with diarrhoea associated with outbreaks of foodborne illness in the Islamic Republic of Iran. METHODS: A total of 532 stool and rectal swab samples from 70 sporadic outbreaks during May 2014 to August 2015 were examined for infection with Shiga toxin-producing bacteria. The isolates were examined for carriage of the virulence genes stx1 and stx2 in all isolates and eae/ehxA in Escherichia coli. RESULTS: E. coli, Shigella spp., Citrobacter spp., Enterobacter spp., Klebsiella spp. and other enteric bacteria were detected in 77.7% (376/484), 5.0% (24/484), 3.9% (19/484), 0.4% (2/484), 3.7% (18/484) and 9.3% (45/484) of the samples respectively. Of the 196 sorbitol-negative E. coli strains, 3 (1.5%) carried the stx1 gene as did 2 of the 19 (10.5%) Citrobacter strains. CONCLUSION: Shiga toxin-producing Citrobacter spp. strains should be considered as a newly emerging foodborne pathogen in outbreaks.

Comparison of a new in-house HIV-1 TaqMan real-time PCR and three commercial HIV-1 RNA quantitative assays.

OBJECTIVES: The aim of this study was to compare the analytical performance of an In-House HIV-1 viral load determination technique with three commercial kits including COBAS® AmpliPrep, RealStar®, and RTA® HIV-1 Real-Time PCR. RESULTS: A total of 100 HIV-1 suspicious plasma samples were tested by the In-House TaqMan® Real-Time PCR assay along with the above-mentioned kits. Comparative analysis between In-House and reference method (COBAS® AmpliPrep/COBAS® TaqMan® HIV-1 Test version 2.0) showed high concordance with a mean difference of 0.08 log10 copies/ml. All samples results were within -0.16-0.31 log10 copies/ml. A suitable correlation was obtained with a coefficient (R2) of 0.82 between the In-House assay and RTA® Kit, however, two positive samples were not detected. The lowest agreement was detected with RealStar® HIV Kit 1.0 (R2 = 0.49, r = 0.7). CONCLUSIONS: The newly developed method has suitable sensitivity, accuracy, and precision. In addition, it is cost-effective and can be an alternative in all laboratories.

The Challenges and Barriers to the Integration of Laboratory Services in Iran from Laboratory Experts' Point of View.

BACKGROUND: Laboratory services fragmentation creates problems such as non-accountability for costs and quality, not being patient-centered and unsustainability of services in long run. Therefore, health systems consider laboratory services integration an inevitable way. This study aimed to investigate the challenges and barriers to the integration of laboratory services in Iran. METHODS: This qualitative case study was conducted in 2016. Using purposive sampling, semi-structured interviews were conducted with 34 informed participants. Each interview lasted between 30 to 60 min. Acceptability, transferability, reliability, and verifiability were used to assess the validity, accuracy and reliability of qualitative data. Framework approach was used to analyze data. RESULTS: Lack of economy of scale, unfair access, lack of grading, low quality, development of national strategies to create an integrated network of laboratories, criteria of the laboratories establishment, creation of necessary infrastructure, empowering the private sector and standardization of indicators were considered the most important problems of laboratory services integration in Iran; they were classified into two main themes. CONCLUSION: Identified issues are challenges which adversely impact the integration of laboratory services. Therefore, providing infrastructures with increased cooperation between various organizations to increase access to laboratory services in the form of an integrated network is essential.

Salt intake among Iranian population: the first national report on salt intake in Iran.

OBJECTIVE: In Iran, there has been no national report on salt intake based on laboratory measurements so far. Therefore, this study was conducted to measure salt intake among Iranian population at the national level. METHODS: In stepwise approach to conduct a surveillance survey 2016, 18 624 Iranian adults (25 years old and above), as a representative sample of Iranian adult population at national and subnational levels, underwent urine sodium measurement and were included in this study. The participants were recruited through a systematic random sampling from 30 provinces of Iran. For each individual, through a computer-assisted interview, a questionnaire on lifestyle risk factors was completed, all anthropometric indices were measured, and data on sodium of spot urine sample for all individuals and 24-h urine sample for a subsample were collected. To estimate the 24-h salt intake, common equations were used. RESULTS: In total, 97.66% of the population consumed at least 5 g of salt per day. In addition, in 41.20% of the population, the level of salt intake was at least two times higher than the level recommended by the WHO for adults. The mean of salt intake among Iranian population was 9.52 g/day (95% confidence interval: 9.48-9.56). CONCLUSION: The study showed that the consumption of salt among the Iranian population is higher than the level recommended by WHO. To reduce salt intake, it is necessary to adopt a combination of nationwide policies such as food reformulation and food labelling.