Equity and determinants in universal health coverage indicators in Iraq, 2000-2030: a national and subnational study.

BACKGROUND: Equity is one of three dimensions of universal health coverage (UHC). However, Iraq has had capital-focused health services and successive conflicts and political turmoil have hampered health services around the country. Iraq has embarked on a new reconstruction process since 2018 and it could be time to aim for equitable healthcare access to realise UHC. We aimed to examine inequality and determinants associated with Iraq's progress towards UHC targets. METHODS: We assessed the progress toward UHC in the context of equity using six nationally representative population-based household surveys in Iraq in 2000-2018. We included 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. Bayesian hierarchical regression model was used to estimate the trend, projection, and determinant analyses. Slope and relative index of inequality were used to assess wealth-based inequality. RESULTS: In the national-level health service indicators, inequality indices decreased substantially from 2000 to 2030. However, the wide inequalities are projected to remain in DTP3, measles, full immunisations, and antenatal care in 2030. The pro-rich inequality gap in catastrophic health expenditure increased significantly in all governorates except Sulaimaniya from 2007 to 2012. The higher increases in pro-rich inequality were found in Missan, Karbala, Erbil, and Diala. Mothers' higher education and more antenatal care visits were possible factors for increased coverage of health service indicators. The higher number of children and elderly population in the households were potential risk factors for an increased risk of catastrophic and impoverishing health payment in Iraq. CONCLUSIONS: To reduce inequality in Iraq, urgent health-system reform is needed, with consideration for vulnerable households having female-heads, less educated mothers, and more children and/or elderly people. Considering varying inequity between and within governorates in Iraq, reconstruction of primary healthcare across the country and cross-sectoral targeted interventions for women should be prioritised.

Accidents in Iraq during the period of conflict (2003-2016).

Background: Injuries are increasingly recognized as a major component of the global burden of disease, as they tend to affect mainly youth and are usually followed by premature death or severe disability. The longstanding conflict in Iraq has resulted in a situation of continuous violence and ongoing instability, which has in turn led to an increasing incidence of injuries and a crippled health system. Objective: To sketch a trend of non-military accidents in Iraq (road traffic accidents [RTA], falls, burns, firearm injuries, assaults by sharp objects and sexual assaults) among civilians during the last 14 years associated with the period of conflict (2003-2016). Methods: This descriptive study was conducted during the period from January 1st through to December 31st, 2017 using already available surveillance data from the Ministry of Health in Iraq. The methodology was based on measuring the incidence of each accident for the period from 2003 through 2016 and plotting it against time. Linear regression was computed to estimate the trends of the disease. Results: The rate of RTAs significantly increased between 2003 and 2016, from 1.85 to 2.9 per 1000 (p ≤ 0.01), as did accidental falls especially after 2008 (males more than females) (p ≤ 0.01). By contrast, after a peak in 2011, burns dropped significantly from 4.19 to 3.42/1000, along with firearm accidents, which fell from 2.2/1000 in 2007 to 0.39 in 2016 (p ≤ 0.01), mostly among males. Assaults with sharp objects also decreased with time to a rate of 0.47/1000 (p = 0.0001). Sexual assaults showed a significant downward sloping trend over time to p = 0.037. Conclusion: Accidents still add a burden on the already deteriorated Iraqi health system. Understanding the impact of this burden is essential to better prepare for future plans and interventions that may help improve the quality of health services.

TolC facilitates the intracellular survival and immunomodulation of Salmonella Typhi in human host cells.

Salmonella enterica serovar Typhi (S. Typhi) causes typhoid fever, a systemic infection that affects millions of people worldwide. S. Typhi can invade and survive within host cells, such as intestinal epithelial cells and macrophages, by modulating their immune responses. However, the immunomodulatory capability of S. Typhi in relation to TolC-facilitated efflux pump function remains unclear. The role of TolC, an outer membrane protein that facilitates efflux pump function, in the invasion and immunomodulation of S. Typhi, was studied in human intestinal epithelial cells and macrophages. The tolC deletion mutant of S. Typhi was compared with the wild-type and its complemented strain in terms of their ability to invade epithelial cells, survive and induce cytotoxicity in macrophages, and elicit proinflammatory cytokine production in macrophages. The tolC mutant, which has a defective outer membrane, was impaired in invading epithelial cells compared to the wild-type strain, but the intracellular presence of the tolC mutant exhibited greater cytotoxicity and induced higher levels of proinflammatory cytokines (IL-1ß and IL-8) in macrophages compared to the wild-type strain. These effects were reversed by complementing the tolC mutant with a functional tolC gene. Our results suggest that TolC plays a role in S. Typhi to efficiently invade epithelial cells and suppress host immune responses during infection. TolC may be a potential target for the development of novel therapeutics against typhoid fever.

Deletion of Salmonella enterica serovar Typhi tolC reduces bacterial adhesion and invasion toward host cells.

Background: S. Typhi is a Gram-negative bacterium that causes typhoid fever in humans. Its virulence depends on the TolC outer membrane pump, which expels toxic compounds and antibiotics. However, the role of TolC in the host cell adhesion and invasion by S. Typhi is unclear. Objective: We aimed to investigate how deleting the tolC affects the adhesion and invasion of HT-29 epithelial and THP-1 macrophage cells by S. Typhi in vitro. Methods: We compared the adhesion and invasion rates of the wild-type and the tolC mutant strains of S. Typhi using in vitro adhesion and invasion assays. We also measured the expression levels of SPI-1 genes (invF, sipA, sipC, and sipD) using quantitative PCR. Results: We found that the tolC mutant showed a significant reduction in adhesion and invasion compared to the wild-type strain in both cell types. We also observed that the expression of SPI-1 genes was downregulated in the tolC mutant. Discussion: Our results suggest that TolC modulates the expression of SPI-1 genes and facilitates the adhesion and invasion of host cells by S. Typhi. Our study provides new insights into the molecular mechanisms of S. Typhi pathogenesis and antibiotic resistance. However, our study is limited by the use of in vitro models and does not reflect the complex interactions between S. Typhi and host cells in vivo.

Cancer Trends in Iraq 2000-2016.

OBJECTIVES: Precise and quantitative assessment of the trend of cancer burden enables policymakers and health managers to prioritize diseases and allocate resources better. This infers what caused a decrease or increase in the rate of cancer occurrence, and if it denotes timing of implementation of a control measure, it presents the impact on the disease rate. This study's objective was to evaluate trends in child and adult cancer in Iraq from 2000 onwards. METHODS: We used the registries of the Iraqi Ministry of Health that were gathered from all governorates from 2000-2016. Data were presented as incidence rates to depict the trends of different types of cancers distributed by age, gender, and governorates. RESULTS: Breast cancer witnessed a significant increase with predominance in females. Lung cancer rate increased significantly from 4.08 to 5.60/100 000 (p = 0.038), affecting males more than females. The brain cancer trend showed a bimodal pattern (two peaks in 2004 and 2011) with no significant trend change (p = 0.788). Both genders were similarly affected. The trend of stomach and colorectal cancer showed an accelerated increase after 2007. CONCLUSIONS: Almost all cancers (particularly lung and gastrointestinal) showed constantly raising trends, especially after 2007. Only cervical and laryngeal cancer had a decreasing trend. Most cancers were predominant in males.

Trends and projections of universal health coverage indicators in Iraq, 2000-2030: A national and subnational study.

INTRODUCTION: Iraq has had limited access to healthcare services due to successive conflicts and political turmoil. Since 2018, Iraq has embarked on a new reconstruction process which includes a goal of 100% immunisation against certain diseases in 2030. We aimed to undertake a comprehensive assessment of Iraq's progress towards universal health coverage (UHC) targets that could contribute to Iraq's policy and strategies. METHODS: We estimated the coverage of UHC indicators from six nationally representative population-based household surveys in Iraq during 2000-2018. We employed 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. We used a Bayesian hierarchical regression model to estimate the trend and projection of health service indicators. RESULTS: Improved water sources, adequate sanitation, institutional delivery, skilled birth attendants, and BCG reached the 80% targets in 2018, and are projected to maintain their status in 2030 at national and subnational levels. Family planning needs satisfied, acute respiratory infection treatment for pneumonia, and oral rehydration therapy will be much less than 80% in 2030. 12% of Iraqi households incurred catastrophic health expenditures in 2012, which was a fourfold increase from 2007. Some governorates faced ten- to twentyfold increases in catastrophic health expenditures, for example, from 0.8% to 15.9% in Diala. Approximately 3% of non-poor households became poor due to out-of-pocket (OOP) payments in 2012. CONCLUSION: Without proactive strengthening of the healthcare systems, achieving UHC in Iraq by 2030 would be a challenge. Worsened trends were observed in both conflict-affected and underdeveloped areas in health service coverage and financial risk protection. Recovery of GDP spending on health and pre-pooled financing mechanisms should be introduced for OOP payment reduction. Prioritising nationwide primary healthcare services and regulating public-private role-allotment in the health sector are crucial in improving low coverage indicators and decreasing disparities among governorates.

Burden of non-communicable diseases in Iraq after the 2003 war.

OBJECTIVES: To figure out the burden of chronic non-communicable diseases in Iraq on the health system through measuring the incidence and trend of these diseases. Methods: This descriptive study that was conducted between January 2016 and 2017, involved treatment data of chronic non-communicable diseases (hypertension, diabetes mellitus, ischemic heart disease, stroke, asthma and epilepsy). The data was collected from the registry of the Department of Health and Vital Statistics in the Ministry of Health, Babylon, Iraq, between 2000 and 2016. Results: The prevalence of diabetes mellitus had significantly increased from 19.58/1000 in the year 2000 to 42.27 in 2015 (p=0.0002). The prevalence of hypertension also increased from 31.33 to 45.82 (p=0.003) in the same period. The prevalence of cerebrovascular accidents showed a significant increase especially after 2008 (p=0.007), while ischemic heart diseases increased from 6.3/1000 in the year 2000 to 8.2/1000 in 2014 with no significant change. Conclusion: Non-communicable diseases in Iraq continue to show as a new developing burden after the 2003 war. Hypertension and diabetes mellitus demonstrate rapidly rising trends which may, in turn, enhance the occurrence of ischemic heart diseases and cerebrovascular accidents.

Impact of an Educational Program on the Knowledge and Attitude About Pain Assessment and Management Among Critical Care Nurses.

BACKGROUND: Pain assessment and management are imperative parts of nursing care and considered as one of the most fundamental patient rights. The role of pain management education is well established in improving knowledge and attitude among nurses. OBJECTIVES: This study aims to evaluate the impact of pain management educational program on the knowledge and attitudes of intensive care unit (ICU) staff nurses toward pain assessment and management. The baseline score of pain assessment and management knowledge and attitude of ICU nurses has been identified in a previous research, and the result showed immense lack of knowledge and poor attitudes among ICU nurses toward pain assessment and management when dealing with ICU patients. METHODS: This is a pretest-posttest experimental study, utilizing a self-reporting questionnaire tool to obtain information about nurses' knowledge and attitudes toward pain assessment and management after implementation of new pain management educational program for critical care nurses. Data were collected using the Knowledge and Attitudes Survey Regarding Pain tool that measures knowledge with 22 question items and measures attitude with 17 question items. Paper-based questionnaire was distributed to nurses for data collection. RESULTS AND CONCLUSION: The results showed significant improvement in knowledge and attitudes about pain assessment and management among ICU nurses; it was evident after delivering pain management education program. At baseline, 204 ICU nurses gave consent and completed the questionnaire and thus included in baseline measurement before implementing the intervention. In the postintervention measurement, the questionnaire was distributed to the same participants included in the baseline phase from which 181 participants completed the questionnaire for the second time, with a response rate of 89%; the deficits and preconception in pain assessment and management can be improved through implementing pain management educational programs.

Trend of vaccine preventable diseases in Iraq in time of conflict.

INTRODUCTION: Iraq has passed through a series of successive conflicts, economic sanction and violence. The overall health sector in Iraq has been plunged and the services are facing a continuous shortage in vaccines, medicines and other supplies, and access of people to the basic health services being more impaired. The objective of this study was to portray the trend of vaccine preventable diseases in Iraq during the past 17 years to provide baseline information for disease burden estimation. METHODS: This study was built on collection and treatment of morbidity data related to vaccine preventable diseases (tuberculosis, poliomyelitis, measles, mumps, rubella, diphtheria, tetanus, pertussis, and hepatitis B) that were registered by the Department of Health Statistics during the years (2000-2016). The incidence rates were plotted on a timeline to define the trend of each disease. Data were also categorized by gender and age groups (less than five years, 5 to 15 years and 15 years and more). RESULTS: Diphtheria, rubella, and tuberculosis showed a slowly down going trend of incidence while mumps demonstrated a peak at 2016. Hepatitis B showed an up going trend of incidence while measles showed a secular trend every 4-5 years. CONCLUSION: Vaccine preventable diseases are still causing outbreaks; precipitated by fluctuation of vaccine coverage. Tuberculosis has been reemerged after a relatively long period of control.

Cadaveric Dissection a Thing of the Past? The Insight of Consultants, Fellows, and Residents.

Objective The objective of our study was to determine whether cadaveric dissection is a necessity in medical education. Another purpose of our study was to assess the attitude and perception of consultants, residents, and fellows about cadaveric dissection and whether it helped them in their medical practices. Method We performed an analytical cross-sectional study among consultants, fellows, and residents of different specialty areas practicing in Punjab. A self-constructed questionnaire compromising of 41 items was used to assess the perception of doctors about cadaveric dissection and other alternative anatomy teaching methods. Consultants, fellows, and residents who were in clinical practice for more than six months were included in the study. Results Out of the total sample size of 842, 44.7% were female medical doctors and 55.3 % were male medical doctors. Cadaveric dissection was thought to be the most effective method for teaching anatomy by 27.9% of the doctors. Mean cadaveric dissection, prosection and didactic teaching components were scored significantly higher by doctors in surgery and allied fields (p<0.001). Doctors in the surgical and allied field were 0.55 times less likely to think that cadaveric dissection was unethical as compared to doctors working in medicine and allied fields (p<0.001). Conclusion Dissection is still considered by several doctors as a valuable source of learning anatomy. However, the future of teaching anatomy does not depend on any single method. It is, in fact, the right combination of all available resources and using them in an interactive way that maximizes outcomes.

Evoked and event related potentials in chronic respiratory failure.

OBJECTIVE: To assess the value of brainstem auditory evoked potentials and event related evoked potential (3rd positive component of evoked related potentials with latency of 300 millisecond, in evaluating cognitive dysfunction in patients with chronic respiratory failure. METHODS: Thirty-two patients with chronic obstructive pulmonary disease and respiratory failure of mild to moderate severity, were assessed regarding their mental function, utilizing mini-mental state examination, arterial blood gases including PH, partial pressure of carbon dioxide, partial pressure of oxygen, and both brainstem auditory evoked potentials and event related evoked potential response. Twenty-five normal subjects, matched for age and sex, were also studied as a control group. The study was carried out during the year 1999 to 2000 in 3 hospitals; King Khalid University Hospital, King AbdulAziz University Hospital and Sahara Hospital, Riyadh, Kingdom of Saudi Arabia. RESULTS: There were significant delay of event related evoked potential response in patients compared with controls (P<0.05). No significant difference was noted for brainstem auditory evoked potentials and mini-mental state examination scores were within normal limits in 78% of patients. When event related evoked potential were analyzed in comparison with blood gases and mini-mental state examination, there was a clear moderate correlation with severity of hypoxemia (r = -0.697). Correlation was also noted, but to a lesser degree with partial pressure of carbon dioxide (r = 0.52) and PH (r = 0.53). There was no correlation with mini-mental state examination. CONCLUSION: The significant delay of event related evoked potential, which is considered the neuro-physiological correlate of cognition, points clearly to the presence of a certain degree of mental dysfunction in many of these patients, namely sub-clinical encephalopathy. These subtle changes commonly evade detection by conventional bed side test (mini-mental state examination), while detailed neuropsychological assessment is cumbersome and time consuming. So, event related evoked potential measurement may be an objective and practical test of subtle cognitive dysfunction in mild respiratory failure. Unfortunately, absolute event related evoked potential values may not be useful in individual patients, in view of its wide range. However, it is probably very helpful in the assessment of a group of subjects, such as trials of a new therapeutic modality. A follow-up study utilizing a larger group of patients, and formal neuropsychological mental assessment, will be expected to confirm and expand the present study`s conclusions.

Rosai-Dorfman disease with exclusive intra-abdominal lymphadenopathy masquerading as Wilkie's syndrome.

Rosai-Dorfman disease is a rare histiocytic proliferative disorder with a distinctive microscopic appearance. Patients usually present with nonspecific symptoms and massive cervical lymphadenopathy. Exclusive involvement of intra-abdominal lymph nodes is unusual and presentation mimicking Wilkie's syndrome due to compression of the third part of the duodenum by enlarged retroduodenal lymph nodes is rare. This entity should be included in the differential diagnosis with infectious, granulomatous and malignant causes of intra-abdominal lymphadenopathy. We highlight an uncommon presentation and discuss the challenges in the diagnosis and management of Rosai-Dorfman disease.