Medical education in Mongolia: Challenges and opportunities.

In the early twentieth century, Mongolia saw the establishment of Western medicine and educational system, supplementing its pre-existing history of eastern medicine. As a lower-middle-income country with vast landmass and low population density, Mongolia's medical education landscape has evolved significantly. The inception of the Mongolian National University of Medical Sciences in 1942 marked a pivotal moment, initiating the modern era of medical sciences and specialized training programs in the country. Initially shaped by Soviet Union-styled medical curriculum, the system has undergone substantial reform since the constitutional shift to a market economy in the 1990s. This transformation aligned the curriculum with international standards and modern educational approach, focusing on producing skilled medical professionals. Presently, over 10 public and private institutions of higher education in Mongolia provide comprehensive undergraduate, graduate and post-graduate training for medical training. These institutions vary in student enrollment, teaching staff, learning environments, and program models, contributing to the diverse landscape of medical education in the country.

Molecular epidemiology of SARS-CoV-2 in Mongolia, first experience with nanopore sequencing in lower- and middle-income countries setting.

BACKGROUND: Coronavirus disease (COVID-19) has had a significant impact globally, and extensive genomic research has been conducted on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lineage patterns and its variants. Mongolia's effective response resulted in low prevalence until vaccinations became available. However, due to the lack of systematically collected data and absence of whole genome sequencing capabilities, we conducted a two-stepped, nationally representative molecular epidemiologic study of SARS-CoV-2 in Mongolia for 2020 and 2021. METHODS: We used retrospective analysis of stored biological samples from November 2020 to October 2021 and a variant-specific real-time reverse transcription polymerase chain reaction (RT-PCR) test to detect SARS-CoV-2 variants, followed by whole genome sequencing by Nanopore technology. Samples were retrieved from different sites and stored at -70°C deep freezer, and tests were performed on samples with cycle threshold <30. RESULTS: Out of 4879 nucleic acid tests, 799 whole genome sequencing had been carried out. Among the stored samples of earlier local transmission, we found the 20B (B.1.1.46) variant predominated in the earlier local transmission period. A slower introduction and circulation of alpha and delta variants were observed compared to global dynamics in 2020 and 2021. Beta or Gamma variants were not detected between November 2020 and September 2021 in Mongolia. CONCLUSIONS: SARS-CoV-2 variants of concerns including alpha and delta were delayed in circulation potentially due to public health stringencies in Mongolia. We are sharing our initial experience with whole genome sequencing of SARS-CoV-2 from Mongolia, where sequencing data is sparse.

Prevalence of Type 2 Diabetes in Mongolia: Results from Population-Based Survey Compared with 1999 Study.

Purpose: The burden of diabetes in Mongolia has risen tremendously over the last three decades, and an individually tracked, national registry of diabetes is lacking. Therefore, we aim to investigate diabetes prevalence in Mongolia and analyze some associated factors. Materials and Methods: A cross-sectional, nationally representative, population-based survey was carried out in Mongolia. We recruited participants from randomly selected six different clusters for the required 3113 ± 311 sample size. We collected detailed demographics, diabetes condition and medications, anthropometric measurements, body composition, and glucose profiles. Oral glucose tolerance tests were used to diagnose diabetes using the International Diabetes Federation algorithm. Chi-square and multinomial logistic regression tests were used to determine associated factors. Age-standardized prevalence rates were estimated. Results: We recruited 3272 participants in the study between June and October 2019. Crude prevalence rates for prediabetes and diabetes were 10.8% (95% CI; 9.8-11.9) and 11.2% (95% CI; 10.1-12.3), respectively. Sixty-one adults were newly diagnosed with diabetes. Age-standardized prediabetes and diabetes prevalence rates were 9.8% (95% CI; 8.5-11.1) and 10.0% (95% CI; 8.7-11.3) among adults 30 or older. Higher BMI, central obesity, diabetes inheritance, sedentary habitus, and hypertension are significantly associated with diabetes in adjusted analysis for sex and age group. Conclusion: The prevalence of diabetes has increased at least threefold since 1999 in Mongolia. In addition, numerous modifiable risk factors were associated with diabetes. Therefore, future investigations and programs should focus on combating obesity and sedentary lifestyles and propose dietary recommendations in the context of expanding diabetes in Mongolia.

SARS-CoV-2 seroepidemiology in Mongolia, 2020-2021: a longitudinal national study.

Background: The COVID-19 pandemic has global impacts but is relatively understudied in developing countries. Mongolia, a lower-middle-income country, instituted strict control measures in early 2020 and avoided widespread transmission until vaccines became available in February, 2021. Mongolia achieved its 60% vaccination coverage goal by July 2021. We investigated the distribution and determinants of SARS-CoV-2 seroprevalence in Mongolia over 2020 and 2021. Methods: We performed a longitudinal seroepidemiologic study aligned with WHO's Unity Studies protocols. We collected data from a panel of 5000 individuals in four rounds between October 2020 and December 2021. We selected participants through local health centres across Mongolia by age-stratified multi-stage cluster sampling. We tested serum for the presence of total antibodies against SARS-CoV-2 receptor-binding domain, and levels of anti-SARS-CoV-2 spike IgG and neutralising antibodies. We linked participant data with national mortality, COVID-19 case, and vaccination registries. We estimated population seroprevalence and vaccine uptake, as well as unvaccinated population prior-infection prevalence. Findings: At the final round in late 2021, 82% (n = 4088) of participants completed follow-up. Estimated seroprevalence increased from 1.5% (95% CI: 1.2-2.0), to 82.3% (95% CI: 79.5-84.8) between late-2020 and late-2021. At the final round an estimated 62.4% (95% CI: 60.2-64.5) of the population were vaccinated, and of the unvaccinated population 64.5% (95% CI: 59.7-69.0) had been infected. Cumulative case ascertainment in the unvaccinated was 22.8% (95% CI: 19.1%-26.9%) and the overall infection-fatality ratio was 0.100% (95% CI: 0.088-0.124). Health workers had higher odds for being COVID-19 confirmed cases at all rounds. Males (1.72 (95% CI: 1.33-2.22)) and adults aged 20 and above (12.70 (95% CI: 8.14-20.26)) had higher odds for seroconverting by mid-2021. Among the seropositive, 87.1% (95% CI: 82.3%-90.8%) had SARS-CoV-2 neutralising antibodies by late 2021. Interpretation: Our study enabled tracking of SARS-CoV-2 serological markers in the Mongolian population over one year. We found low SARS-CoV-2 seroprevalence in 2020 and early 2021, with seropositivity increasing over a 3-month interval in 2021 due to vaccine roll out and rapid infection of most of the unvaccinated population. Despite high seroprevalence in Mongolia amongst both vaccinated and unvaccinated individuals by end-2021, the SARS-CoV-2 Omicron immune escape variant caused a substantial epidemic. Funding: World Health Organization, WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development. The Ministry of Health, Mongolia partially funded this study.

Anti-Inflammatory Effects of the 35kDa Hyaluronic Acid Fragment (B-HA/HA35).

Background: Hyaluronic acid (HA) and HA fragments interact with a variety of human body receptors and are involved in the regulation of various physiological functions and leukocyte trafficking in the body. Accordingly, the development of an injectable HA fragment with good tissue permeability, the identification of its indications, and molecular mechanisms are of great significance for its clinical application. The previous studies showed that the clinical effects of injectable 35kDa B-HA result from B-HA binding to multiple receptors in different cells, tissues, and organs. This study lays the foundation for further studies on the comprehensive clinical effects of injectable B-HA. Methods: We elaborated on the production process, bioactivity assay, efficacy analyses, and safety evaluation of an injectable novel HA fragment with an average molecular weight of 35 kDa (35 kDa B-HA), produced by recombinant human hyaluronidase PH20 digestion. Results: The results showed that 35 kDa B-HA induced human erythrocyte aggregation (rouleaux formation) and accelerated erythrocyte sedimentation rates through the CD44 receptor. B-HA application and injection treatment significantly promoted the removal of mononuclear cells from the site of inflammation and into the lymphatic circulation. At a low concentration, 35 kDa B-HA inhibited production of reactive oxygen species and tumor necrosis factor by neutrophils; at a higher concentration, 35 kDa B-HA promoted the migration of monocytes. Furthermore, 35 kDa B-HA significantly inhibited the migration of neutrophils with or without lipopolysaccharide treatment, suggesting that in local tissues, higher concentrations of 35 kDa B-HA have antiinflammatory effects. After 99mTc radiolabeled 35 kDa B-HA was intravenously injected into mice, it quickly entered into the spleen, liver, lungs, kidneys and other organs through the blood circulation. Conclusion: This study demonstrated that the HA fragment B-HA has good tissue permeability and antiinflammatory effects, laying a theoretical foundation for further clinical studies.

Mongolia health situation: based on the Global Burden of Disease Study 2019.

BACKGROUND: Over the past few decades, economic, political, and social changes have directly and indirectly affected the health of the Mongolian population. To date, no comprehensive analysis has been conducted on the burden of diseases in this country. Thus, we aimed to describe the leading causes of death and disabling conditions and their trends between 1990 and 2019 in the Mongolian population. METHODS: We used the data from the Global Burden of Disease (GBD) 2019 study. In the current study, we examined life expectancy at birth, healthy life expectancy, the 20 leading causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted-life-years (DALYs), and the contribution of major risk factors to DALYs in Mongolia. FINDINGS: The life expectancy at birth in Mongolia has gradually increased since 1995 and reached 63.8 years for men and 72.7 for women in 2019. The highest increase in the age-standardised death rate between 1990 and 2019 occurred in alcohol use disorders (628.6%; 95% UI 10.0-1109.6) among men, and in liver cancer (129.1%; UI 65.3-222.4) among women. Ischaemic heart disease and stroke showed the highest rates of death, YLLs, and DALYs among both men and women. In 2019, the highest age-standardised rates of DALYs were attributable to high systolic blood pressure and dietary risks. INTERPRETATION: Although Mongolia saw substantial improvements across many communicable diseases, maternal and neonatal disorders, and under-5 mortality between 1990 and 2019, non-communicable diseases remained leading causes of mortality. The mortality from the most preventable causes such as injury, alcohol use, and dietary risks remain substantially high, suggesting that individual and social efforts are needed to tackle these diseases. Our analyses will support the development of policy priorities and action plans in multiple sectors to improve the overall health of the Mongolian population. FUNDING: Bill & Melinda Gates Foundation.

SARS-CoV-2 seroprevalence in Mongolia: Results from a national population survey.

BACKGROUND: With the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early 2020, Mongolia implemented rapid emergency measures and did not report local transmission until November 2020. We conducted a national seroprevalence survey to monitor the burden of SARS-CoV-2 in Mongolia in the months surrounding the first local transmission. METHODS: During October-December 2020, participants were randomly selected using age stratification and invited for interviews and blood samples at local primary health centres. We screened for total SARS-CoV-2 antibodies, followed by two-step quantitative SARS-CoV-2 IgG serology tests for positive samples. Weighted and test-adjusted seroprevalences were estimated. We used chi-square, Fisher's exact and other tests to identify variables associated with seropositivity. FINDINGS: A total of 5000 subjects were enrolled. We detected SARS-CoV-2 IgG antibodies in 72 samples. Crude seroprevalence of SARS-CoV-2 antibodies was 1·44% (95%CI,1·21-1·67). Population weighted and test-adjusted seroprevalences were 1·36% (95%CI,1·11-1·63) and 1·45% (95%CI,1·11-1·63), respectively. Age, sex, geographical, and occupational factors were not associated with seropositivity (p>0·05). Symptoms and signs within past 3 months and seropositivity were not associated at the time of the survey (p>0·05). INTERPRETATION: SARS-CoV-2 seroprevalence in Mongolia was low in the first year of the pandemic potentially due to strong public health measures, including border restrictions, educational facilities closure, earlier adoption of mask-wearing and others. Our findings suggest large-scale community transmission could not have occurred up to November 2020 in Mongolia. Additional serosurveys are needed to monitor the local pandemic dynamic and estimate how far from herd immunity Mongolia will be following-up with vaccination programme in 2021 and 2022. FUNDING: World Health Organisation, WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development. TRANSLATION: Cyrillic and Traditional Mongolian translation of abstract is available on appendix section.

Father Presence, Father Engagement, and Specific Health and Developmental Outcomes of Mongolian Pre-School Children.

This study explored father involvement as a social determinant of child health within the context of macro-environmental changes in Mongolia. Using data for children aged 3-4 from UNICEF's Multiple Indicator Cluster Surveys, this cross-sectional analysis examined the association between father presence and engagement with child health and educational outcomes. Multivariate regression modeling was employed to identify associations between father presence, engagement, and child outcomes including fever, respiratory illness, diarrhea and preschool attendance. In unadjusted analyses, father engagement was associated with higher odds of preschool attendance (Odds Ratio (OR) = 1.12; 95% Confidence Interval (CI) 1.04-1.20) but not with child illness (OR = 1.04; 95% CI 0.95-1.14). Father engagement was no longer associated with preschool attendance after controlling for potentially confounding variables (ORadj = 0.95; 95% CI 0.88-1.03). Unadjusted and adjusted analyses showed that father presence was not associated with acute illness or preschool attendance. Results also suggest that a larger proportion of children were engaged in activities by their mother compared to their father or other adults. Data indicate that father presence and engagement were not associated with child illness or preschool attendance. Factors such as maternal education, household wealth, and region of residence are stronger predictors of preschool attendance and should continue to be considered for promoting child health and development in Mongolia.

Estimation of the unvaccinated among those aged less than 25 years according to aimag and its association with incidence of measles outbreak 2015-2016 in Mongolia.

Mongolia had an epidemic of measles in 2015-2016, even though more than 90% of the population have been vaccinated since 1997. This study aimed to examine the associations between unvaccinated proportion and measles incidence according to aimag. Mongolia has 21 provinces (aimag) with Ulaanbaatar as the capital city. Vaccination coverage between 1991 and 2014 and measles incidence according to aimag were obtained from the National Center for Communicable Diseases of Mongolia database. Accumulated unvaccinated proportion (AUP) among those aged 1 to 24 years in 2015 was estimated from the unvaccinated at the 1st dose of 1991 to 2014. From 1991 to 2014, unvaccinated proportion among those aged 1 to 24 years in the whole country has been reducing from 28.0% in 1991 to 1.8% in 2014. The AUP in 2015 varied from 2.7% (Selenge) to 21.8% (Govisumber). The incidence was remarkably higher in only two aimags with a large density of the unvaccinated aged 1 to 24 years (Ulaanbaatar and Darkhan-Uul) than in the other aimags. The incidence had no significant correlation with the AUP, although the correlation between the incidence and the density of unvaccinated aged 1 to 24 years was significant when the two aimags were included. In conclusion, the AUP between 2.7% and 21.8% had no correlation with the incidence according to aimags in Mongolia measles epidemic 2015-2016.

Early policy actions and emergency response to the COVID-19 pandemic in Mongolia: experiences and challenges.

Country-led control measures to contain the spread of the novel coronavirus, COVID-19, have been diverse. Originating in Wuhan, China, in December, 2019, the COVID-19 outbreak was declared a pandemic by WHO on March 11, 2020. In recognition of the severity of the outbreak, and having the longest shared border with China, the Government of Mongolia activated the State Emergency Committee in January, 2020, on the basis of the 2017 Disaster Protection Law. As a result, various public health measures have been taken that led to delaying the first confirmed case of COVID-19 until March 10, 2020, and with no intensive care admissions or deaths until July 6, 2020. These measures included promoting universal personal protection and preventions, such as the use of face masks and handwashing, restricting international travel, suspending all training and educational activities from kindergartens to universities, and banning major public gatherings such as the celebration of the national New Year holiday. These measures have been accompanied by active infection surveillance and self-isolation recommendations. The Mongolian case shows that with robust preventive systems, an effective response to a pandemic can be mounted in a low-income or middle-income country. We hereby examine the emergency preparedness experience, effectiveness, and challenges of the early outbreak policies on COVID-19 prevention in Mongolia, as well as any unintended consequences.