Prevalence of HIV in slums area: a systematic review and meta-analysis.

BACKGROUND: Human Immunodeficiency Virus (HIV) remains a significant global health burden, particularly affecting vulnerable populations residing in slum areas which is characterized by overcrowding, poverty, and limited access to healthcare services, create an environment conducive to the transmission and spread of HIV. Despite the recognition of this issue, there is a lack of comprehensive understanding regarding the prevalence of HIV in slums. The aim of this study was to systematically synthesize the existing global evidence on HIV prevalence in slum populations. METHODS: A rigorous systematic literature review was conducted by searching multiple electronic databases, including Medline via PubMed, Scopus, Embase, Web of Sciences, and Directory of Open Access Journals (DOAJ), covering the period from January 1, 1990, to March 31, 2023. The quality and risk of bias for each included study were assessed using the Newcastle-Ottawa Scale. The pooled prevalence with its corresponding 95% confidence interval (CI) was calculated using a random-effects model with the Freeman-Tukey double arcsine transformation. The degree of heterogeneity among the studies was evaluated using the I2 test. Publication bias was also assessed using Egger's test. Additionally, subgroup analysis was performed to explore potential factors contributing to the observed heterogeneity. RESULTS: A systematic examination of the relevant literature resulted in the inclusion of a total of 22 studies for the purpose of this meta-analysis. These studies collectively assessed a sizable cohort consisting of 52,802 participants. Utilizing a random-effects model, an estimation of the overall prevalence of HIV in the slum area was determined to be 10% (95% CI: 7-13%). Further delineation through subgroup analysis based on the gender revealed a higher prevalence of HIV among women, standing at 13% (95% CI: 8-19%, 18 studies: I2 = 98%), as opposed to men, where the prevalence was found to be 8% (95% CI: 6-12%, 16 studies: I2 = 95%). A geographical breakdown of the included studies revealed that Africa exhibited the highest prevalence, with a figure of 11% (95% CI: 9-13%, 18 studies: I2 = 98%). Subsequently, studies conducted in the American continent reported a prevalence of 9% (95% CI: 7-11%, 2 studies: I2 = 57%). The Asian continent, on the other hand, displayed the lowest prevalence of 1% (95% CI: 0-3%, 2 studies: I2 = 94%). Notably, studies employing rapid tests indicated a prevalence of 13% (95% CI: 9-17%, 6 studies: I2 = 94%), while those relying on self-reported data reported a lower prevalence of 8% (95% CI: 5-11%, 6 studies: I2 = 99%). Moreover, studies utilizing ELISA reported a prevalence of 9% (95% CI: 6-12%, 10 studies: I2 = 96%). Finally, it was determined that studies conducted in upper-middle-income countries reported a higher prevalence of 20% (95% CI: 16-24%, 5 studies: I2 = 45%), whereas studies conducted in lower- and middle-income countries reported a prevalence of 8% (95% CI: 6-10%, 12 studies: I2 = 98%). CONCLUSION: The current study elucidates the troublingly high prevalence of HIV infection within slums area. Also, this finding underscores the urgent necessity for targeted and tailored interventions specifically aimed at curtailing the spread of HIV within slums. Policymakers must take cognizance of these results and devote their efforts towards the implementation of effective strategies to mitigate gender disparities, address poverty alleviation, and empower the inhabitants of these marginalized areas.

Exploring the landscape of health technology assessment in Iran: perspectives from stakeholders on needs, demand and supply.

BACKGROUND: The evaluation of health technologies plays a crucial role in the allocation of resources and the promotion of equitable healthcare access, known as health technology assessment (HTA). This study focuses on Iran's efforts to integrate HTA and aims to gain insights into stakeholder perspectives regarding capacity needs, demand and implementation. METHODS: In this study, we employed the HTA introduction status analysis questionnaire developed by the International Decision Support Initiative (iDSI), which has been utilized in various countries. The questionnaire consisted of 12 questions divided into three sections: HTA need, demand and supply. To identify key informants, we conducted a literature review and consulted with the Ministry of Health and Medical Education (MOHME), as well we experts in policy-making, health service provision and HTA. We selected stakeholders who held decision-making positions in the healthcare domain. A modified Persian version of the questionnaire was administered online from September 2022 to January 2023 and was pretested for clarity. The analysis of the collected data involved quantitative methods for descriptive analysis and qualitative methods for thematic analysis. RESULTS: In this study, a total of 103 questionnaires were distributed, resulting in a favourable response rate of 61% from 63 participants, of whom 68% identified as male. The participants, when assessing the needs of HTA, rated allocative efficiency as the highest priority, with a mean rating of 8.53, thereby highlighting its crucial role in optimizing resource allocation. Furthermore, healthcare quality, with a mean rating of 8.17, and transparent decision-making, with a mean rating of 7.92, were highly valued for their impact on treatment outcomes and accountability. The importance of budget control (mean rating 7.58) and equity (mean rating 7.25) were also acknowledged, as they contribute to maintaining sustainability and promoting social justice. In terms of HTA demand, safety concerns were identified as the top priority, closely followed by effectiveness and cost-effectiveness, with an expanded perspective on the economy. However, limited access to local data was reported, which arose from various factors including data collection practices, system fragmentation and privacy concerns. The priorities of HTA users encompassed coverage, payment reform, benefits design, guidelines, service delivery and technology registration. Evidence generation involved the participation of medical universities, research centres and government bodies, albeit with ongoing challenges in research quality, data access and funding. The study highlights government support and medical education as notable strengths in this context. CONCLUSIONS: This study provides a comprehensive evaluation of Iran's HTA landscape, considering its capacity, demand and implementation aspects. It underlines the vital role of HTA in optimizing resources, improving healthcare quality and promoting equity. The study also sheds light on the strengths of evidence generation in the country, while simultaneously identifying challenges related to data access and system fragmentation. In terms of policy priorities, evidence-based decision-making emerges as crucial for enhancing healthcare access and integrating technology. The study stresses the need for evidence-based practices, a robust HTA infrastructure and collaboration among stakeholders to achieve better healthcare outcomes in Iran.

Cost-effectiveness of cardiovascular magnetic resonance imaging compared to common strategies in the diagnosis of coronary artery disease: a systematic review.

Cardiovascular magnetic resonance imaging (CMR) has established exceptional diagnostic utility and prognostic value in coronary artery disease (CAD). An assessment of the current evidence on the cost-effectiveness of CMR in patients referred for the investigation of CAD is essential for developing an economic model to evaluate the cost-effectiveness of CMR in CAD. We conducted a comprehensive search of multiple electronic databases, including PubMed, Scopus, Web of Science core collection, Embase, National Health Service Economic Evaluation Database (NHS EED), and health technology assessment, to identify relevant literature. After removing duplicates and screening the title/abstract, a total of 13 articles were deemed eligible for full-text assessment. We included studies that reported one or more of the following outcomes: incremental cost-effectiveness ratio (ICER), cost per quality-adjusted life year (QALYs), cost per life year gained, sensitivity and specificity rate as the primary outcome, and health utility measures or health-related quality of life as the secondary outcome. The quality of the included studies was assessed using the CHEERS 2022 guidelines. The findings of this study demonstrate that in patients undergoing urgent percutaneous coronary intervention, CMR over a one-year and lifetime horizon leads to higher quality-adjusted life years (QALYs) compared to current strategies in cases of multivessel disease. The systematic review indicates that the CMR-based strategy is more cost-effective when compared to standard methods such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), and coronary angiography (CA) (CMR = $19,273, SPECT = $19,578, CCTA = $19,886, and immediate CA = $20,929). The results also suggest that the CMR strategy can serve as a cost-effective gatekeeping tool for patients at risk of obstructive CAD. A CMR-based strategy for managing patients with suspected CAD is more cost-effective compared to both invasive and non-invasive strategies, particularly in real-world patient populations with a low to intermediate prevalence of the disease.

Implementation Challenges of Family Physician Program: A Systematic Review on Global Evidence.

Background: The family physician program, as one of the core arms of health care systems, has faced various implementation challenges around the world. Experiences in the implementation of family physician program can be helpful for nations that seek to apply for similar programs. The aim of this study is to systematically review the implementation challenges of family physician program across the world. Methods: A systematic search was conducted from January 2000 to February 2022 across scientific databases of Embase, MEDLINE, Web of Science, Scopus, CINAHL, EBSCO, and Google Scholar. The Framework approach was used to analyze the selected studies. The quality of the included studies was evaluated using the McMaster Critical Review Form for qualitative studies. Results: 35 studies upon the study inclusion criteria were included. Based on the Six Building Blocks frame, seven themes and 21 subthemes were developed as the implementation challenges of family physician program. 1) Governance: policy guidance, intelligence, coalition, regulation, system design, and accountability; 2) Financing: financing and payment system; 3) Health workforce: education, research, recruitment and motivation opportunities; 4) Service delivery: management of health services, service package, referral system, continuity of care; 5) Health information systems: production and evaluating the health information system; 6) Availability: provision basic health services, maintenance of facilities; and 7) Cultural considerations: behavior and social determinants of health. Conclusion: Scientific governance, financing, and payment mechanisms, workforce empowerment, designing a strong health information system, and providing access to services with cultural considerations can result in the successful implementation of the family physician program in communities.

Individual and institutional capacity-building for evidence-informed health policy-making in Iran: a mix of local and global evidence.

BACKGROUND: Providing valid evidence to policy-makers is a key factor in the development of evidence-informed policy-making (EIPM). This study aims to review interventions used to promote researchers' and knowledge-producing organizations' knowledge and skills in the production and translation of evidence to policy-making and explore the interventions at the individual and institutional level in the Iranian health system to strengthen EIPM. METHODS: The study was conducted in two main phases: a systematic review and a qualitative study. First, to conduct the systematic review, the PubMed and Scopus databases were searched. Quality appraisal was done using the Joanna Briggs Institute checklists. Second, semi-structured interviews and document review were used to collect local data. Purposive sampling was used and continued until data saturation. A qualitative content analysis approach was used for data analysis. RESULTS: From a total of 11,514 retrieved articles, 18 papers were eligible for the analysis. Based on the global evidence, face-to-face training workshops for researchers was the most widely used intervention for strengthening researchers' capacity regarding EIPM. Target audiences in almost all of the training programmes were researchers. Setting up joint training sessions that helped empower researchers in understanding the needs of health policy-makers had a considerable effect on strengthening EIPM. Based on the local collected evidence, the main interventions for individual and institutional capacity-building were educational and training programmes or courses related to the health system, policy-making and policy analysis, and research cycle management. To implement the individual and institutional interventions, health system planners and authorities and the community were found to have a key role as facilitating factors. CONCLUSION: The use of evidence-based interventions for strengthening research centres, such as training health researchers on knowledge translation and tackling institutional barriers that can prevent well-trained researchers from translating their knowledge, as well as the use of mechanisms and networks for effective interactions among policy-makers at the macro and meso (organizational) level and the research centre, will be constructive for individual and institutional capacity-building. The health system needs to strengthen its strategic capacity to facilitate an educational and training culture in order to motivate researchers in producing appropriate evidence for policy-makers.

Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016.

BACKGROUND: The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases. METHODS: We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate. RESULTS: The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation. CONCLUSIONS: In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe. (Funded by the Bill and Melinda Gates Foundation.).

Cost-effectiveness analysis of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation: a systematic review.

To assess the cost-effectiveness of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation and heart failure, a systematic literature search was conducted in various electronic databases to January 3, 2020. Eligibility criteria are the population (patients with mitral regurgitation (MR)), intervention (transcatheter mitral valve repair using the MitraClip), comparator (conventional medical treatment), outcomes, and designs (Model-based or trial-based full economic evaluations).The quality of included studies was assessed using the CHEERS checklist. Mortality and survival rate, quality-adjusted life year (QALY), life years gained (LYG), total cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of MitraClip System were considered as the key outcomes. Eight articles were eligible for full-text assessment. Ultimately, a total of seven studies were considered in the current systematic review. Results demonstrated that MitraClip reduces mortality rate and increases survival rate. The mortality rate at 1 year and 10 years was 16.7% versus 29.77% and 70.9% versus 98.8%, respectively. Total cost data based on 2019 USD show that the MitraClip has the highest cost in the USA ($121,390) and the lowest cost in Italy ($33,062). The results showed that in all selected countries, willingness-to-pay (WTP) thresholds are upper than the cost per QALY; also, the highest ICER for the MitraClip is in the USA ($55,600/QALY) and the lowest in Italy ($10,616/QALY). To conclude, evidence from this systematic review suggests that MitraClip Delivery System improved both life expectancy and QALY compared with medical treatment in patients at high surgical risk and it was also a cost-effective treatment option for patients with mitral regurgitation.

Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach.

BACKGROUND: High toll of traffic-related injuries, climate change, natural disasters, population aging, as well as chronic diseases have all made considerable demands on receiving physiotherapy services in Iran. Nevertheless, there is an assortment of complications facing utilization of such services, particularly poor insurance coverage. Therefore, the present study investigated and identified gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran. METHODS: This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the first phase, a qualitative study was completed to find policy recommendations. Such recommendations were then prioritized through the Analytical Hierarchy Process (AHP), in the second phase, based on effectiveness, acceptability, cost, fairness, feasibility, and time. RESULTS: Within the first phase, a total number of 30 semi-structured interviews with health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists were completed. Several policy recommendations were also proposed by the study participants. Following the second phase, prioritized recommendations were provided to promote stewardship (e.g., informing policy-makers about physiotherapy services), collection of funds (e.g., placing value-added taxes on luxury goods and services), pooling of funds (e.g., moving allocated resources towards insurance (viz. third-party) mechanism), purchasing (e.g., using strategic purchasing), and benefit package (e.g., considering preventive interventions) as the main components of insurance coverage. CONCLUSION: The study findings provided a favorable ground to improve insurance coverage for physiotherapy services in Iran. As well, decision- and policy-makers can place these recommendations on the agenda in the health sector to protect population health status, especially that of groups with disabilities.

Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams.

BACKGROUND: Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran. METHODS: An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams. RESULTS: The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream. CONCLUSION: The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.

The 'Health Transformation Plan' in Iran: A policy to achieve universal health coverage in slums and informal settlement areas.

Universal health coverage (UHC) is one of the strategies that health decision- and policy-makers worldwide are implementing to guarantee a good health status to everyone. Living in slums is characterized by several issues, including homelessness and malnutrition, environmental challenges, lack of sanitation and access to safe, healthy drinking water, waste disposal problems, widespread social disruptions, job insecurity, feelings of dissatisfaction and inadequacy. In Iran, the 'Health Transformation Plan' (HTP), despite its weaknesses, has had good effects on the health level of people living in slums, ensuring insurance coverage and reducing many economic, social and cultural problems, with a dramatic decline in out-of-pocket expenditures. Good governmental financial support and an adequate revision of the initial packages of health services and provisions have resulted in a higher access rate to healthcare. The HTP has been, indeed, a major step towards reaching UHC in Iran. If policy- and decision-makers can further improve the present situation and provide more and better-quality services to these people, it can be expected that health indicators in suburbs will be significantly improved. Researchers should monitor the impact of HTP and examine its effects on health indicators, specifically among particularly vulnerable groups such as children, women and the elderly.

The Impact of the Social Distancing Policy on COVID-19 Incidence Cases and Deaths in Iran from February 2020 to January 2021: Insights from an Interrupted Time Series Analysis.

Background: In December 2019, a viral outbreak occurred in China, and rapidly spread out worldwide. Due to the lack of immediately available vaccines and effective drugs, many policy- and decision-makers have focused on non-pharmacological methods, including social distancing. This study was aimed at assessing the effects of the implementation of this policy in Iran, one of the countries most affected by COVID-19. We conducted a quasi-experimental study, utilizing the interrupted time series analysis (ITSA) approach. Methods: We collected daily data between February 20, 2020 and January 29, 2021, through governmental websites from 954 public hospitals and healthcare settings. The Iranian government launched the social distancing policy on March 27, 2020. Statistical analyses, including ITSA, were carried out with R software Version 3.6.1 (London, UK). Results: During the study period, 1,398,835 confirmed incidence cases and 57,734 deaths occurred. We found a decrease of -179.93 (95% CI: -380.11 to -20.25, P-value=0.078) confirmed incidence cases following the implementation of the social distancing policy, corresponding to a daily decrease in the trend of -31.17 (95% CI: -46.95 to -15.40, P-value=0.08). Moreover, we found a decrease of -28.28 (95% CI: -43.55 to -13.01, P-value=0.05) deaths, corresponding to a daily decrease in the trend of -4.52 (95% CI: -5.25 to -3.78, P-value=0.003). Conclusion: The growth rate of confirmed incidence cases and deaths from COVID-19 in Iran has decreased from March 27, 2020 to January 29, 2021, after the implementation of social distancing. By implementing this policy in all countries, the burden of COVID-19 may be mitigated.

Financial Protection Indexes and the Iranian Health Transformation Plan: A Systematic Review.

Background: On May 5, 2014, the Iranian Ministry of Health and Medical Education launched the Health Transformation Plan (HTP) as a major healthcare reform to curb out-of-pocket (OOP) expenses and protect people from catastrophic health expenditures (CHEs). Therefore, in this study, we conducted a comprehensive literature search with the aim of systematically investigating the impacts of HTP on OOP and CHE after the implementation of the plan. Method: Web of Science, PubMed, Scopus, Embase, and Iranian bibliographic thesauri and repositories such as MagIran, Elmnet, and Scientific Information Database were searched. Studies published between May 2014 and December 2020 that reported the impact of HTP on the financial indicators under investigation in this study (OOP and CHEs) that were conducted in Iran. Estimated pooled change both for OOP and CHEs was calculated as effect size utilizing meta-analytical techniques. Also, heterogeneity among studies was assessed with the I2 statistics. Results: Seventeen studies were included, nine of which evaluated the OOP index, six studies assessed the CHEs index, and two studies examined both the OOP and CHEs indexes. The OOP was found to decrease after the implementation of the HTP (with an estimated decrease of 13.02% (95% CI: 9.09-16.94). Also, CHEs experienced a decrease of 5.80% (95% CI: 3.85-7.74). Conclusion: The findings show that the implementation of HTP has reduced health costs. In this regard and in order to keep reducing the costs that many people are unable to pay, the government and other organizations involved in the health system should provide sustainable financial resources in order to continue running HTP. However, there remain gaps and weaknesses that can be solved through discussion with all the actors involved.

Economic, Cultural, and Political Requirements for Medical Tourism Development in Iran: Insights from a Fuzzy Analytical Hierarchy Process Method.

Background: According to the World Bank, the medical tourism industry in 2016 generated more than $100 billion revenue turnover for the destination countries. This study aims to investigate the developmental requirements of medical tourism industry in Iran to identify sustainable development strategies within this sector. Methods: The present study was an applied-analytical study performed in a cross-sectional manner. A total of 25 experts, including policy experts, decision-makers, and managers with over 10 years of experience in the health system and familiar with the process of attracting medical tourists from foreign countries were asked to compare options for the development of the medical tourism. Expert opinions were analyzed using a fuzzy analytical hierarchy process using the open-source R Studio software. Results: Out of the 5 items included in the questionnaire, the criterion of "government policy making and related entities" was ranked the first in terms of importance and prioritization for medical tourism development (0.249) through attracting domestic and foreign investments followed by advertising and marketing (0.241). Also, the criteria of "destination characteristics" and "facilities and status of service capacities with 0.111 and 0.185 weights had the lowest weight among the 5 items, respectively. Conclusion: In general, governments play a key role in marketing and promoting the nascent medical tourism industry. Experts in the field believe that the role of government, policy and decision-makers in medical tourism can be an advantage for its prosperity and development.

Cost-effectiveness analysis of PCSK9 inhibitors in cardiovascular diseases: a systematic review.

AIMS: To assess the cost-effectiveness of pro-protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in cardiovascular disease. METHODS AND RESULTS: We performed a comprehensive search strategy in electronic databases from January 2015 to January 2019. Out of 475 articles, 16 were entered into the study. Quality-adjusted life year, life years gained (LYG), annual cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of PCSK9 inhibitors were considered as the key outcomes. The cost-effectiveness threshold varied from $45,000 in Spain to $150,000 in the USA. The annual cost of PCSK9 inhibitors for studies undertaken in the USA was in the range of $14,000 to $15,000, while it was about $7000 for other developed countries. The results showed that reduction in the price of PCSK9 inhibitors changed from 20 to 88%. The means of QALY were 0.65 and 0.67 in the Markov and Cardiovascular Disease Policy Modeling (CVDPM) models; also, the ICER means were $197,707 and $625,555 for the Markov and CVDPM model, respectively. CONCLUSION: According to the current study, the effectiveness of PCSK9 inhibitors is well documented, although all studies pointed out a higher cost of these inhibitors. TRIAL REGISTRATION: This study was registered within the International Prospective Register of Systematic Reviews (PROSPERO) database of the University of York (CRD42018088472).

Ensuring adequate health financing to prevent and control the COVID-19 in Iran.

On February 19th 2020, the Iranian Ministry of Health and Medical Education (MoHME) has announced the first 2 cases of SARS-CoV-2, a novel emerging coronavirus which causes an infection termed as COVID-19, in Qom city. As such, the Iranian government, through the establishment of the "National Headquarters for the management and control of the novel Coronavirus", has started implementing policies and programs for the prevention and control of the virus. These measures include schools and universities closure, reduced working hours, and increased production and delivery of equipment such as masks, gloves and hygienic materials for sterile environments. The government has also made efforts to divulge high-quality information concerning the COVID-19 and to provide laboratories and hospitals with diagnostic kits and adequate resources to treat patients. However, despite such efforts, the number of cases and deaths has progressively increased with rising trends in total confirmed cases and deaths, as well as in new daily cases and deaths associated with the COVID-19. Iran is a developing country and its economic infrastructure has been hit hardly by embargo and sanctions. While developed countries have allocated appropriate funding and are responding adequately to the COVID-19 pandemics, Iran has experienced a serious surge of cases and deaths and should strive to provide additional resources to the health system to make healthcare services more accessible and to increase the fairness of that access. All relevant actors and stakeholders should work together to fight this disease.

Zonisamide add-on therapy for focal epilepsy.

BACKGROUND: The majority of people with epilepsy have a good prognosis, and their seizures can be well controlled with the use of a single antiepileptic agent, but up to 30% develop dug-resistant epilepsy, especially those with focal seizures. In this review, we summarised the evidence from randomised controlled trials (RCT) of zonisamide, used as an add-on treatment for focal epilepsy uncontrolled by one or more concomitant antiepileptic drug. This is an updated version of the Cochrane review previously published in 2018. OBJECTIVES: To evaluate the efficacy and tolerability of zonisamide, when used as an add-on treatment for people with focal epilepsy uncontrolled by one or more concomitant antiepileptic drugs. SEARCH METHODS: For the latest update, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE Ovid (September 2019). In addition, we contacted Eisai Limited (makers and licensees of zonisamide) and experts in the field, to seek any ongoing or unpublished studies. SELECTION CRITERIA: Randomised controlled trials, in which add-on zonisamide was compared with placebo or another antiepileptic drug in people with focal epilepsy, uncontrolled by one or more concomitant antiepileptic drugs. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data, assessed for risk of bias using the Cochrane 'Risk of bias' tool, and assessed the certainty of the evidence, using the GRADE approach. The primary outcome was at least a 50% reduction in total seizure frequency; the secondary outcomes were (1) tolerability; and (2) adverse effects. We used an intention-to-treat approach for our primary analyses. We estimated summary risk ratios (RRs) for each outcome. We displayed a summary of the estimates of effects and certainty of the evidence for each outcome in a 'Summary of findings' table. MAIN RESULTS: We did not find any new studies since the last version of this review. We included eight studies (1636 participants) from previous versions of this review. The overall RR with 95% confidence interval (CI) for at least a 50% reduction in seizure frequency for 300 mg to 500 mg/day of zonisamide compared to placebo was 1.90 (95% CI 1.63 to 2.22; 7 trials, 1371 participants; moderate-certainty evidence). The RR for 50% reduction in seizure frequency compared to placebo for any dose of zonisamide (100 mg to 500 mg/day) was 1.86 (95% CI 1.60 to 2.17; 7 trials, 1429 participants; moderate-certainty evidence). The number needed to treat for an additional beneficial outcome was six (95% CI 4.1 to 6.8). Two trials provided evidence of a dose-response relationship for this outcome. The RR for treatment withdrawal for 300 mg to 500 mg/day of zonisamide compared to placebo was 1.59 (95% CI 1.18 to 2.13; 6 trials, 1099 participants; moderate-certainty evidence), and for 100 mg to 500 mg/day was 1.44 (95% CI 1.08 to 1.93; 6 trials, 1156 participants; moderate-certainty evidence). The number needed to treat for an additional harmful outcome was 15 (95% CI 9.3 to 36.7). The following adverse effects were more likely to be associated with zonisamide than with placebo: ataxia (RR 3.85, 99% CI 1.36 to 10.93; 4 trials, 734 participants; low-certainty evidence); somnolence (RR 1.52, 99% CI 1.00 to 2.31; 8 trials, 1636 participants; moderate-certainty evidence); agitation (RR 2.35, 99% CI 1.05 to 5.27; 4 trials, 598 participants; low-certainty evidence); and anorexia (RR 2.74, 99% CI 1.64 to 4.60; 6 trials, 1181 participants; low-certainty evidence). Across the eight studies, we rated risk of bias domains at low or unclear risk of bias, apart from two studies, which we rated at high risk of attrition bias. Five of the eight studies were sponsored by the drug companies that produced zonisamide. AUTHORS' CONCLUSIONS: When used as an add-on treatment in people with focal epilepsy, uncontrolled by one or more concomitant antiepileptic drugs, moderate-certainty evidence found that zonisamide was more successful than placebo at reducing the frequency of seizures by at least 50%. We were unable to identify minimum effective and maximum tolerated doses. The included trials evaluated a maximum stable-dose phase of 18 weeks, so results cannot be used to confirm longer periods of efficacy in seizure control. The results cannot be extrapolated to monotherapy, or to people with other seizure types or epilepsy syndromes.

Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.

BACKGROUND: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years. METHODS: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury. RESULTS: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change. CONCLUSIONS: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017.

BACKGROUND: The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates. METHODS: Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate. RESULTS: For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced. CONCLUSIONS: The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.

A systematic review and meta-analysis of the prevalence of hepatitis C virus infection in people who inject drugs in Iran.

BACKGROUND: Hepatitis C virus (HCV) infection is one of the major public health challenges generating a relevant burden. High-risk groups, including people who inject drugs (PWID), are at serious risk for developing HCV. In recent years, several investigations have been conducted in Iran to assess the prevalence e of HCV among PWID. The aim of the present study was to synthesize the literature performing a comprehensive search and meta-analysis. METHODS: A comprehensive literature search was carried out from January 2000 to September 2019. Several international databases, namely Scopus, PubMed/MEDLINE, Embase, ISI/Web of Science, PsycINFO, CINAHL, the Cochrane Library and the Directory of Open Access Journals (DOAJ), as well as Iranian databases (Barakathns, SID and MagIran), were consulted. Eligible studies were identified according to the following PECOS (population, exposure, comparison/comparator, outcome and study type) criteria: i) population: Iranian population; ii) exposure: injection drug users; iii) comparison/comparator: type of substance injected and level of substance use, iv) outcome: HCV prevalence; and v) study type: cross-sectional study. After finding potentially related studies, authors extracted relevant data and information based on an ad hoc Excel spreadsheet. Extracted data included the surname of the first author, the study journal, the year of publication, the number of participants examined, the type of diagnostic test performed, the number of positive HCV patients, the number of participants stratified by gender, the reported prevalence, the duration of drug injection practice and the history of using a shared syringe. RESULTS: Forty-two studies were included. 15,072 PWID were assessed for determining the prevalence of HCV. The overall prevalence of HCV among PWID in Iran was computed to be 47% (CI 95: 39-56). The prevalence ranged between 7 and 96%. Men and subjects using a common/shared syringe were 1.46 and 3.95 times more likely to be at risk, respectively. CONCLUSION: The findings of the present study showed that the prevalence of HCV among PWIDs in Iran is high. The support and implementation of ad hoc health-related policies and programs that reduce this should be put into action.

Current and former smokers among adolescents aged 12-17 years in Iran: a systematic review and meta-analysis.

BACKGROUND: Smoking, especially among adolescents, is considered a serious public health concern worldwide being associated with increased mortality. The present study was designed as the first systematic review and meta-analysis of the prevalence of current and former smoking behavior among adolescents in Iran. METHODS: Seven international scholarly databases, namely Scopus, Embase, Pubmed/Medline, ISI/Web of Science (WOS), the Cochrane Library, Psyc Info and Cinahl, were extensively searched from January 2000 to September 18, 2019. Google Scholar was also mined. Iranian databases were searched as well (namely, MagIran, Scientific Information Database (SID), and Barakatkns). The DerSimonian-Laird's approach, via the Freeman-Tukey double arcsine method, was used to synthesize the prevalence estimates. RESULTS: The prevalence of current smokers among Iranian adolescents was estimated to be 9% (95% CI: 7 to 10). Stratifying based on gender, the prevalence was 12% among boys (95% CI: 10 to 14) and 6% among girls (95% CI: 5 to 8). The prevalence of former smokers among Iranian adolescents using the random-effect model was computed to be 24% (95% CI: 21 to 27). CONCLUSION: The findings of this study showed that the prevalence of current and former smoking behavior among Iranian adolescents is a relevant public health concern. The country's young population should be given more attention by health policy- and decision-makers and implementation of ad hoc prevention and control policies should be on their agenda.