Pre-infection antibody levels of vaccinated healthcare workers with SARS-CoV-2 breakthrough infection: A nested case-control study.

AIM: To evaluate anti-RBD IgG antibody levels and neutralizing antibody titers between the health care workers (HCWs) with breakthrough SARS-CoV-2 infection and controls. METHODS: In this nested case-case control study, we followed 548 vaccinated HCWs with homologous (only with inactivated vaccine) or heterologous (both with inactivated and BNT162b2 vaccine) vaccination for 11 months, prospectively. We obtained blood samples from the participants for quantitative anti-RBD IgG and surrogate neutralization test. The participants with SARS-CoV-2 PCR positivity (at least 14 days after the last vaccination) were considered breakthrough infection. We chose 1:2 matched controls from the cohort, according to age, sex and vaccination status. We used R version 4.0.2 for the statistical analysis. RESULTS: Sixty-five cases and 130 controls were included in the study. The number of the breakthrough infections in HCWs were correlated with the pandemic waves in Türkiye and peaked during Omicron outbreak. The median age of the cases was 39 and 78.5% were female. The cases had more comorbidities than controls, significantly (p = 0.021). All cases experienced no or mild symptoms and recovered completely. Both pre-infection anti-RBD antibody and neutralizing antibody titers did not differ between cases and matched controls (p = 0.767, p = 0.628). CONCLUSION: In this study, we showed that there was no comparable difference in humoral response after homologous or heterologous vaccination between the cases of breakthrough infection and matched controls. Compliance with infection control measures should be ensured, in combination with vaccination.

Which Jobs are Unlucky against the Biologic and the Economic Risks Caused by the Covid-19 Pandemic?

Context: Beyond the biological impact of the pandemic in working life, socioeconomic consequences is also important for workers. This study aimed to investigate both biologic and economic impacts of the pandemic. Methods: In this cross-sectional study, a structured questionnaire were applied by telephone to 233 workers who were diagnosed with coronavirus disease-2019 (Covid-19) at hospital. A pretest was applied before the data collection. The outcomes of the study were work-related Covid-19 transmission (WRCT) and pandemic-related economic worsening (PREW). Descriptive statistics is presented. Chi-square test is used in comparison of proportions. Results: Of the 233 workers, 52% were male (n = 120) and the mean age was 37.7 (±9.2) years. WRCT was observed in 73% of health care workers. PREW was 6.7 times higher in private sector (95% confidence interval = 3.1-14.5), especially in self-employed and small business owners. Drivers and sales workers were the unluckiest. Because they were affected in terms of both the WRCT and PREW. Conclusions: Within the framework of occupational health, the economic destructive effects of the Covid-19 pandemic as well as the biological impacts should be considered with a holistic perspective. Protective policies should be developed especially for economically fragile groups against the pandemic such as self-employed, small business owners, and private sector workers.

Precarious Work as Risk Factor for 5-Year Increase in Depressive Symptoms.

OBJECTIVES: The aim was to investigate the longitudinal relationship between precarious work and depressive symptoms in a representative cohort of employees in Germany. METHODS: In the German Study on Mental Health at Work (S-MGA) (n = 2009), depressive symptoms were assessed by the Patient Health Questionnaire (PHQ-9). Precarious work was measured through baseline (2012) self-reported job insecurity, marginal part-time, fixed-term contract, hourly wage and-during follow-ups 2012-2017-unemployment. Among employees without depressive symptoms at baseline (2012), we ran logistic regression analyses stratified by gender with depressive symptoms at follow-up in 2017 as the dependent variable, adjusting for baseline (2012) age, gender, socioeconomic position and partner status. RESULTS: Among men, job insecurity (OR: 2.47; 95% 95% CI: 1.37-4.48) and low wage (3.79; 1.64-8.72) at baseline were significantly associated with depressive symptoms at follow-up. Among women, indicators of precarious work were not associated with depressive symptoms at follow-up. Among men, a cumulative exposure index of precarious work was significantly associated with the development of depressive symptoms (one indicator: 1.84; 0.94-3.60, ≥two indicators: 7.65; 3.30-17.73). This index was not associated with depressive symptoms among women. The population attributable fraction of precarious work due to depressive symptoms among men was approximately 30%. CONCLUSIONS: Among employees in Germany, precarious work seems to be a risk factor for the subsequent development of depressive symptoms among men, but not among women. Research on precarious employment in different countries is needed.

An analysis of antibody response following the second dose of CoronaVac and humoral response after booster dose with BNT162b2 or CoronaVac among healthcare workers in Turkey.

Limited data are available on the short- to midterm levels of antibodies to the CoronaVac vaccine and quantitative change in humoral response after homologous or heterologous booster doses. In this prospective cohort study, we evaluated the anti-receptor-binding domain (RBD) immunoglobulin G (IgG) levels after two doses of CoronaVac and heterologous/homologous booster administration among healthcare workers in a university hospital in Turkey. Quantitative anti-RBD IgG antibody levels were measured at first and fourth months in 560 healthcare workers who had completed two doses of CoronaVac vaccine, and within 2 months after the third dose of CoronaVac or BNT162b2. Participants were asked to complete a questionnaire during the first blood draw. The seropositivity rate was 98.9% and 89.1%, and the median antibody level was 469.2 AU/ml and 166.5 AU/ml at first and fourth month, respectively. In the fourth month, a mean reduction of 61.4% ± 20% in antibody levels was observed in 79.8% of the participants. The presence of chronic disease (odds ratio [OR]: 1.76, 95% confidence interval [CI]: 1.15-2.69) and being in the 36-50 age group (OR: 2.11, 95% CI: 1.39-3.19) were identified as independent predictors for low antibody response. The antibody level increased 104.8-fold (median: 17 609.4 vs. 168 AU/ml) and 8.7-fold (median: 1237.9 vs. 141.4 AU/ml) in the participants who received BNT162b2 and CoronaVac, respectively. During the follow-up, 25 healthcare workers (4.5%) were infected with severe acute respiratory syndrome coronavirus 2. Considering the waning immunity and circulating variants, a single booster dose of messenger RNA vaccine seems reasonable after the inactivated vaccine especially in risk groups.

Associations Between Bioavailable Vitamin D and Remnant Cholesterol in Patients With Type 2 Diabetes Mellitus.

Introduction In circulation, 99% vitamin D is transported by binding to vitamin D binding protein (VDBP) and albumin. Vitamin D at free form and vitamin D binding to albumin are defined as bioavailable vitamin D. Vitamin D deficiency is associated with atherogenic lipid profile and insulin resistance. Remnant cholesterol is defined as the cholesterol component of triglyceride-rich lipoproteins and contributes to the atherosclerotic burden. The aim of this study was to investigate the association between bioavailable vitamin D and remnant cholesterol in patients with type 2 diabetes mellitus (T2DM). Methods A total of 198 T2DM patients and 208 non-diabetic subjects underwent biochemical measurements of lipid profiles, 25(OH)D, VDBP, CRP and albumin levels. Their demographic characteristics (age, sex) were questioned. Subjects with thyroid, kidney and liver dysfunction and using lipid-lowering therapy were not included in the study. The diagnosis of T2DM was made according to the American Diabetes Association ADA 2016 criteria. Classification of vitamin D levels was done according to the Endocrine Society. Bioavailable vitamin D concentrations were calculated. Results High-density lipoprotein cholesterol (HDL), 25(OH)D, free vitamin D and bioavailable vitamin D levels were significantly lower in diabetic patients than in non-diabetic patients while triglyceride, remnant cholesterol and CRP levels were found to be significantly higher. VDBP was positively correlated with CRP and remnant cholesterol in diabetic patients, but not in non-diabetic patients. Cut-off values were determined from non-diabetics as 3.56 ng/mL for bioavailable vitamin D and 26.56 mg/dL for remnant cholesterol. Logistic regression analysis in the control group showed that the odds ratio for increasing remnant cholesterol above the cut-off value was determined as 2.01 for low bioavailable vitamin D and 1.1 for elevated CRP. However, in T2DM there was no significant relationship. In all subjects, low bioavailable vitamin D increased the remnant cholesterol above the cut-off by 2.18-fold independent of the presence of T2DM. However, there was no significant risk to increase remnant cholesterol, considering a total 25(OH) D deficiency in all groups. Conclusions Low bioavailable vitamin D was found to be a risk factor for elevated remnant cholesterol. This relationship was not detected in patients with T2DM. We believe that the inflammation observed in Diabetes Mellitus may increase the concentrations of VDBP and a decrease in bioavailable vitamin D levels. Therefore, measuring VDBP and calculating the bioavailable vitamin D may provide additional information about the actual vitamin D status.

The Effects of Multifaceted Ergonomic Interventions on Musculoskeletal Complaints in Intensive Care Units.

Working at intensive care units (ICUs) is considered a risk factor for developing musculoskeletal complaints (MSC). This study was conducted between January 2017 and June 2019 in two ICUs of a university hospital. It was designed as a pre- and post-assessment of the intervention group (IG) (N = 27) compared with a control group (CG) (N = 23) to determine the effects of a multifaceted ergonomics intervention program in reducing MSC. The IG (N: 35) received a multifaceted ergonomic intervention program, which was implemented by an ERGO team over an 18 month period. Four ergonomic interventions were planned as follows: individual level interventions such as training; stretching exercises and motivation meetings; administrative intervention such as a daily 10 min stretching exercises break; engineering interventions such as lifting and usage of auxiliary devices. The CG (N:29) did not receive any intervention. Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to assess MSC in both groups. At the start of the intervention, both groups were similar concerning the number of visits to doctors due to MSC, the number of sick leave days, and total CMDQ scores (p > 0.05 for all). Two factor repeated ANOVA measures were performed for between-groups and within-group analyses. The mean of the initial CMSDQ total scores in both groups increased significantly in the 18th month (p < 0.001). However, the interaction effect of group and time (between and within factors) was not significant (p = 0.992). Work-related MSC is a common occupational health problem among nurses. This study showed that individual-level interventions are not likely to succeed in eliminating manual patient lifting by nurses. Our results suggested that interventions without administrative measures might have limited success.

The development of a globally acceptable national model for occupational hygiene in Turkey: a modified Delphi study.

BACKGROUND: Although various organizations working in developed countries established the standards and approaches used in occupational hygiene, occupational hygiene professional interests and needs continue to develop in a global context. There is thus an urgent need for expanded occupational hygiene models. For successful field implementation, these models should be based on several sets of criteria, including those related to international standards, various national requirements, and multidisciplinary approaches. This is particularly important for countries in which no occupational hygiene model has been developed. This study thus examined the consensus on occupational hygiene standards among stakeholders in Turkey regarding the development of a national model. A modified Delphi study was conducted among key occupational health experts in Turkey who could aid in the relevant implementation, policy-making, and educational processes for such a model. Participants were selected from various governmental institutions, non-governmental organizations, trade unions, universities, and occupational health practices. RESULTS: The first-round findings were obtained from open-ended questions. The results revealed several requirements, including the adoption of an international hygiene definition, the official recognition of professional and practical areas in Turkish occupational hygiene, hygienist training methods, priorities, and competent institutions. Second-round findings indicated a consensus rate of over 80% regarding the need for implementation standards, training and education standards, requirements and priorities, and competent institutions for professionals working in the field of occupational hygiene. A third-round and SWOT analysis was also conducted among the group to confirm the consensus issues. CONCLUSIONS: The search for solutions and developmental expectations increases when awareness of internationalization and the need for common global standards increase. This developmental process may provide the basis for an appropriate model in developing countries.

A novel version of Copenhagen Psychosocial Questionnaire-3: Turkish validation study.

Purpose: The aim of the study was to adapt the Copenhagen Psychosocial Questionnaire Version-3 (COPSOQ-3) into the Turkish language.Methods: This is a methodologic study. The field study occurred in four workplaces (call center, hospital, plastic and metal industries). The Kaiser-Meyer-Olkin (KMO) Measure of Sampling Adequacy and Bartlett's Test of Sphericity were used to assess the suitability of the sample for factor analysis. The principal component analysis and varimax rotation methods were used to identify the factor structure.The internal consistency was assessed using the Cronbach's alpha coefficient.Results: In total, 1076 respondents' questionnaires were evaluated. Fifty-eight percent of the participants were men and the mean age was 31.1 ± 7.7. Sampling adequacy was considered adequate (KMO =0.929). The factor analysis of the Turkish COPSOQ (COPSOQ-TR) identified 19 factors with eigenvalues higher than one and explained 66.1% of the total variance. The Cronbach's alpha values of 23 dimensions were over 0.70. The Cronbach's alpha values of control over working time and predictability were 0.54 and 0.66, respectively. The model was an excellent fit (Chi-Square = 8514.5, x2/df = 2.48, RMSEA = 0.038, SRMR = 0.053, CFI = 0.98).Conclusions: Findings show that COPSOQ-TR is a reliable and valid instrument that can be a useful tool to measure psychosocial risks in the Turkish language.

Three-year' experience of a tertiary level occupational diseases clinic.

INTRODUCTION: We aimed to evaluate the diagnosis of patients who applied on the first three years of our clinic, in order to contribute to the state of occupational diseases (OD) in Turkey. MATERIALS AND METHODS: The study is a cross-sectional study, between November 2013 and December 2016, 862 subjects were accepted for the evaluation. Gender, age, application ways, the reason of referral, workplace, exposure time and possible risks for the patients were evaluated through a file examination. RESULT: Total of 708 (82.1%) was male and 154 (17.9%) were female. The mean age of the subjects was 38.3 ± 7.7 years; the mean term of employment was 126.6 ± 87.3 (1-420) months. The most common cause of referral was the suspicion of occupational pulmonary diseases (64.3%) with 554 workers. 435 workers (50,6%) were diagnosed to have an OD, 78 workers (9.0%) were diagnosed with work-related diseases. The most common diagnoses of OD; 169 (38.9%) pneumoconiosis, 71 (16.3%) occupational asthma, 38 (8.7%) cervical disc hernia, 24 (5.5%) lumbar disc hernia, 24 (5.5%) hearing loss, 19 (4.3%) cubital/carpal tunnel, and 15 (3.4%) workers have lead intoxication. CONCLUSIONS: Dust, chemicals, ergonomic risks and noise still remain as important occupational health risks in Turkey. It is seen that the existing occupational diseases monitoring system is inadequate to identify and manage the health problems of the workers. An effective and comprehensive occupational disease monitoring system should be established and legal regulations should be planned.

The Third Version of the Copenhagen Psychosocial Questionnaire.

INTRODUCTION: A new third version of the Copenhagen Psychosocial Questionnaire (COPSOQ III) has been developed in response to trends in working life, theoretical concepts, and international experience. A key component of the COPSOQ III is a defined set of mandatory core items to be included in national short, middle, and long versions of the questionnaire. The aim of the present article is to present and test the reliability of the new international middle version of the COPSOQ III. METHODS: The questionnaire was tested among 23,361 employees during 2016-2017 in Canada, Spain, France, Germany, Sweden, and Turkey. A total of 26 dimensions (measured through scales or single items) of the middle version and two from the long version were tested. Psychometric properties of the dimensions were assessed regarding reliability (Cronbach α), ceiling and floor effects (fractions with extreme answers), and distinctiveness (correlations with other dimensions). RESULTS: Most international middle dimensions had satisfactory reliability in most countries, though some ceiling and floor effects were present. Dimensions with missing values were rare. Most dimensions had low to medium intercorrelations. CONCLUSIONS: The COPSOQ III offers reliable and distinct measures of a wide range of psychosocial dimensions of modern working life in different countries; although a few measures could be improved. Future testing should focus on validation of the COPSOQ items and dimensions using both qualitative and quantitative approaches. Such investigations would enhance the basis for recommendations using the COPSOQ III.

Employment status changes of workers after referral to an occupational disease clinic.

OBJECTIVE: Occupational diseases (OD) are among the most significant issues of work life, with economic, medical, social, and ethical aspects. The majority of studies concerning OD focus on the causes or medical outcomes of OD. There are a limited number of studies investigating the social and economic impacts of being diagnosed with an OD. One of the important social aspects of OD is the employability of workers after an OD diagnosis. The aim of this study is to evaluate the changes in employment status after the OD diagnosis process. METHODS: This is a cross sectional study. There were 204 eligible cases, and 198 (97%) completed the study. The study data were obtained from patient files, including OD Committee reports and questionnaires applied via telephone interview. RESULTS: Among the 198 applicants, 170 (85.9%) were male and 146 (73.7%) were diagnosed with an OD. Of these workers, 106 (53.5%) had quit their current jobs. Of those workers, 89 out of 106 were in the OD group, and 17 were in the non-OD group. Diagnosis with OD (OR: 3.1 CI: 1.4-6.8) and non-union membership (OR: 11.1 CI: 5.2-23.5) increased the likelihood of quitting the job after an OD diagnosis. CONCLUSION: The short-term prognosis of OD was relatively poor. OD diagnosis or even referral to an outpatient clinic may cause quitting the job. Policies should account for the risk of unemployment after an OD diagnosis, and OD surveillance systems should obtain data on the employment status of workers following diagnosis.

Dental Technicians' Pneumoconiosis; Illness Behind a Healthy Smile - Case Series of a Reference Center in Turkey.

BACKGROUND: Dental laboratories include many hazards and risks. Dental technicians working in an unfavorable work environment in Turkey and other parts of the world may develop pneumoconiosis as a result of exposure to dust, depending on exposure time. In this study, we aimed to investigate the clinical and laboratory findings of dental technicians. MATERIALS AND METHODS: The study consists of a case series. Between 2013 and 2016, a total of 70 who were working as a dental technician and referred to our clinic with suspicion of occupational disease were evaluated. Comprehensive work-history, physical examination complaints, functional status, chest X-ray, and high-resolution computed lung tomography (HRCT) findings were evaluated. RESULTS: In all, 46 (65.7%) of the 70 dental technicians were diagnosed with pneumoconiosis. About 45 (97.8%) subjects were male and 1 (2.2%) was female. The mean age of starting to work was 15.89 ± 2.79 (11-23) years. The mix dust exposure time was 176.13 ± 73.97 (18-384) months. Small round opacities were most common finding. In 16 patients, high profusion being 2/3 and above were identified, and large opacity was detected in 11 patients. The radiological profusion had a weak negative correlation with FEV 1 and FVC (correlation coefficient - 0.18, P = 0.210 and - 0.058, P = 0704) and moderate negative correlation between radiological profusion and FEV1/FVC (correlation coefficient - 0.377, P = 0.010). In addition, no correlation was observed between the age at start of work and the duration of exposure. CONCLUSION: The presence of pneumoconiosis continues in dental technicians in Turkey, especially because there is an early childhood apprenticeship culture and almost all workers in this period have the history of sandblasting.

Skydiving and the risk of cervical disc herniation.

The skydiving/parachuting sport which has recently gained popularity is also known for its accidents and injuries. However, there are a few studies related to its occupational ergonomic risks and occupational musculoskeletal diseases. It has been reported that the sudden hyperextension of the neck during the parachute opening, so called opening shock results in neck pain. It has been found that the jumpers are subjected to an average deceleration of 3-5 times the earth's gravitational acceleration (3-5 G) during parachute opening shock. It is considered that the spinal cord is destabilized by the impact of this force. This study presents the occupational cervical disc herniation occurring in the case of a subject who has been working as a skydiving/parachuting instructor for 25 years, and the ergonomic risks specific to the sports of skydiving. There is a requirement for systematic and representative studies related to the administrative measures to be taken in order to prevent the occupational diseases that may occur in the case of skydivers, the personal protective equipment to be used, and the employee. Int J Occup Med Environ Health 2018;31(2):243-249.

Changes in Employment Status after Myocardial Infarction among Men.

BACKGROUND: According to the Turkey Burden of Disease Study, 10% of the national burden of disease is attributed to cardiovascular diseases. Although the standardized coronary heart disease (CHD) rate is falling in general, CHD prevalence among young people is rising. On the other hand, as a result of increased life expectancy and higher retirement ages, the CHD rate among workers is also increasing. Therefore, work ability and return to work after diagnosis are important for population health and well-being. Socioeconomic factors and working conditions may play a key role as well as clinical conditions described in the literature that affect returning to work. AIMS: The aims of this qualitative study are exploring the changes in employment and working conditions of the patients after acute myocardial infarction (AMI) and affecting factors such as socioeconomic, personal and environmental. STUDY DESIGN: Qualitative research. METHODS: The research population are fifty-three patients who are engaged in paid employment when the people have been diagnosed with myocardial infarction for the first time between 2011 and 2012 at a university hospital coronary care unit. We intended to reach the whole population. Twenty-seven patients were contacted whose phone numbers were accessible from the hospital records. Semi-structured in-depth interviews were conducted with twelve patients in a meeting room at the hospital. The interviews were tape-recorded accompanied by note-taking and the content analysis method were evaluated. RESULTS: While many of the participants continued to work at the same job by working less, one third of them said that they were thinking about getting an easier job if they have the opportunity. On the other hand, in most cases, there were neither assessments about their work ability, nor changes to their working conditions after AMI. They had to cope with their conditions, such as economic or psychosocial, without any support. CONCLUSIONS: While the patients have to return to work for economic and social reasons, they expressed uncertainty about working after a diagnosis of AMI and could not reach professional support to assess their work abilities. Therefore, specific algorithms and assessment tools to manage the return to work of AMI patients would be useful.

Emergency department visits caused by adverse drug reactions: results of aTurkish university hospital.

BACKGROUND/AIM: We aimed to evaluate adverse drug reaction (ADR)-related emergency department (ED) visits in the ED of the Dokuz Eylül University Hospital prospectively. MATERIALS AND METHODS: Patients who were admitted to the ED during 1-week periods of four different seasons between July 2010 and April 2011 were enrolled. Demographics of patients, previous ADR history, clinical progress, and outcomes were recorded. Causality assessment was done according to World Health Organization Uppsala Monitoring Centre categories. ADRs were categorized as certain, probable, or possible. RESULTS: Patients who were on medications (26.5%, n = 1838) were evaluated for ADR-related ED admissions. ADRs accounted for 5.9% of cases (n = 108). The most frequently affected systems were the gastrointestinal (35.2%, n = 38), dermatological (23.1%, n = 25), and hematological (10.2%, n = 11) systems (7.4%, n = 8). The most common causes of ADRs were antiinfectives (31.6%, n = 33). Amoxicillin, Coumadin, and paracetamol were the most common medications that caused ADRs. CONCLUSION: Nearly 6% of the admissions were ADR-related. ADRs should always be considered when patients who are on medication are admitted to the ED. Multicenter epidemiologic studies are required to know the real rates of ADR cases in EDs in Turkey.

Effects of participatory ergonomic intervention on the development of upper extremity musculoskeletal disorders and disability in office employees using a computer.

OBJECTIVE: To evaluate the participatory ergonomic method on the development of upper extremity musculoskeletal disorders and disability in office employees. METHODS: This study is a randomized controlled intervention study. It comprised 116 office workers using computers. Those in the intervention group were taught office ergonomics and the risk assessment method. Cox proportional hazards model and generalized estimating equations (GEEs) were used. RESULTS: In the 10-month postintervention follow-up, the possibility of developing symptoms was 50.9%. According to multivariate analysis results, the possibility of developing symptoms on the right side of the neck and in the right wrist and hand was significantly less in the intervention group than in the control group (p<0.05). Neck disability/symptom scores over time were significantly lower in the intervention group compared with the control group (p<0.05). CONCLUSION: The participatory ergonomic intervention decreases the possibility of musculoskeletal complaints and disability/symptom level in office workers.

Call centers and noise-induced hearing loss.

Noise is defined as unwelcome sound. It has been estimated that 16% of adult hearing loss in the world is due to noise exposure at the workplace. This report offers a case that diagnosed with hearing loss of whom working as a call center operator at home. Home agent operators should be explored.

Contrasting cardiovascular mortality trends in Eastern Mediterranean populations: Contributions from risk factor changes and treatments.

BACKGROUND: Middle income countries are facing an epidemic of non-communicable diseases, especially coronary heart disease (CHD). We used a validated CHD mortality model (IMPACT) to explain recent trends in Tunisia, Syria, the occupied Palestinian territory (oPt) and Turkey. METHODS: Data on populations, mortality, patient numbers, treatments and risk factor trends from national and local surveys in each country were collated over two time points (1995-97; 2006-09); integrated and analysed using the IMPACT model. RESULTS: Risk factor trends: Smoking prevalence was high in men, persisting in Syria but decreasing in Tunisia, oPt and Turkey. BMI rose by 1-2 kg/m(2) and diabetes prevalence increased by 40%-50%. Mean systolic blood pressure and cholesterol levels increased in Tunisia and Syria. Mortality trends: Age-standardised CHD mortality rates rose by 20% in Tunisia and 62% in Syria. Much of this increase (79% and 72% respectively) was attributed to adverse trends in major risk factors, occurring despite some improvements in treatment uptake. CHD mortality rates fell by 17% in oPt and by 25% in Turkey, with risk factor changes accounting for around 46% and 30% of this reduction respectively. Increased uptake of community treatments (drug treatments for chronic angina, heart failure, hypertension and secondary prevention after a cardiac event) accounted for most of the remainder. DISCUSSION: CHD death rates are rising in Tunisia and Syria, whilst oPt and Turkey demonstrate clear falls, reflecting improvements in major risk factors with contributions from medical treatments. However, smoking prevalence remains very high in men; obesity and diabetes levels are rising dramatically.