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Background: This paper describes the access to care for mental health problems in Afghanistan, according to the nature of the mental health problems and the service provider. Following the Andersen model, it evaluates the respective roles in access to care of “predisposing,” “needs,” “enabling” factors, and other “environmental” factors such as exposure to traumatic events and level of danger of the place of residence. Methods: Trans-sectional probability survey in general population by multistage sampling in 16 provinces, nationally representative: N=4445 (15 years or older), participation rate of 81%. Face to face interviews using standardized measures of mental health (CIDI, Composite International Diagnostic Interview). Different logistic regression models are presented. Results: The 12-month rate of mental health help-seeking was 6.56% with substantial regional variation (2.35% to 12.65%). Providers were mainly from the health sector; the non-health sector (religious and healers) was also prevalent. Most consultations were held in private clinics (non-governmental organisation, NGO). The severity of mental health disorders as well as the perceived impairment due to mental health were independently very important: odds ratio (OR) = 6.04 for severe disorder, OR=3.79 for perceived impairment. Living in a dangerous area decreased access to care: for high level of danger and for very high level: OR=0.22. Gender, education and ethnicity were not associated with mental health help-seeking after controlling for exposure to trauma. Conclusion: Access to care for mental health problems depended mainly on the needs as defined as disorder severity level and impairment, and on environmental factors such as exposure to traumatic events. The system seems equitable; however, this is counterbalanced by a very challenging environment. This survey is a testimony to the hardship experienced by the Afghan population and by health professionals, and to the efforts to deliver organized mental healthcare in a challenging situation. This research may inform and support policy-makers and NGOs in other countries undergoing similar challenges. [ABSTRACT FROM AUTHOR]

‘Honour killing’, the murder of women to preserve family reputation, is well recognised but infrequently systematically researched. This paper has three hypotheses. First, in families where women report an ‘honour killing’ there is more violence against women and girls, second these women are more likely to report more patriarchal gender attitudes than others, and third these families are exposed to higher levels of poverty. We asked (n = 1461) women enrolled in a trial in Afghanistan, and (n = 535) in a population-based sample in the occupied Palestinian Territories (oPT) if there had ever been an ‘honour killing’ in their family. In Afghanistan, 2.3% (n = 33), and the oPT 7.7% (n = 41), reported this. We built separate multivariable logistic regression models for each country, and for married and unmarried women in each country. Among Afghan married women, ‘honour killing’ was associated with borrowing because of hunger (adjusted odds ratio [aOR]8.71, 95%CI 2.27–33.40), easier access to money in emergency (aOR11.39, 95%CI 3.05–42.50), and violence within the family; intimate partner violence (IPV) (aOR3.73, 95%CI 1.12–12.36), and IPV and mother-in-law violence (aOR10.52, 2.60–42.56). For unmarried women in Afghanistan, ‘honour killing’ was associated with easier access money in an emergency (aOR4.06, 95%CI 0.85–19.37), household violence (hit by parent or sibling, or parent and sibling [aOR5.47, 95%CI 0.82–36.70; aOR7.37, 95%CI 1.24–43.86, respectively]); more childhood traumas (aOR1.24, 1.11–1.38), and more patriarchal personal gender attitudes (aOR1.24, 1.00–1.54). In the oPT experiencing IPV (aOR3.07, 1.02–9.23) and borrowing and experiencing IPV (aOR5.89, 1.84–18.79) were risks for married women. For unmarried women borrowing because of hunger was associated with higher risk (aOR2.33, 95%CI 1.18–4.85). Despite limitations–specifically the potential women were reporting the same ‘honour killing’—our analysis suggests ‘honour killings’ are associated with violence, patriarchy, and poverty. Research is needed for the prevention of ‘honour killing’, which must address the root causes. Trial Registration: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

Background: Four decades of conflict has indelibly impacted the lives of Afghans, exposing many to different forms of trauma. The aim of this paper investigate a hypothesis that (mostly war related) trauma is a key driver of partner violence in Afghanistan. Methods: 1,463 women aged 18–48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 8 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses multivariable logistic regression and structural equation modelling (SEM) to describe relationships between measures. Results: 57.4% of women reported exposure to one of four types of trauma: 23.3% an armed attack, 39.4% had felt close to death, 10.6% witnessed a friend or family member being killed and 21.4% witnessed the death of a stranger or someone unknown. Trauma exposure was associated with being older, Pashtan, madrassa educated, and food insecure. Women who were trauma exposed were more likely to have ever experienced IPV, have hit their children in the last 4 weeks, and be hit by a sibling or relative of their husband or their mother-in-law in the last year. They held less patriarchal personal gender attitudes and perceived the community to be more patriarchal. The SEM showed that all pathways between trauma exposure and IPV were ultimately mediated by either (mostly mental) ill-health or quarrelling, but not both of these. There were multiple paths through which trauma exposure impacted women’s past year experience of physical IPV. One was mediated by childhood trauma exposure and a latent variable for ill health. Other paths were mediated by women’s education and personal gender attitudes and ill-health, or else by quarrelling. Trauma exposure was related to lower educational levels. Another path was mediated by less patriarchal personal gender attitudes and ill health. Community gender attitudes was a mediating variable on a path which was also mediated by ill health and another mediated by quarrelling. It was also a mediator on a path which included personal gender attitudes and ill-health. Food insecurity mediated another path with ill health. It was also connected to childhood trauma, community gender attitudes and educational level. Conclusion: Trauma exposure due to conflict will persist until the conflict ends but the impact on women can be ameliorated. This analysis suggests interventions to reduce women’s exposure to IPV should focus on reducing poverty, changing social norms on gender, providing relationship skills to help reduce quarrelling and supporting women’s mental health. [ABSTRACT FROM AUTHOR]

Summary: Spatial statistical analyses are often used to study the link between environmental factors and the incidence of diseases. In modelling spatial data, the existence of spatial correlation between observations must be considered. However, in many situations, the exact form of the spatial correlation is unknown. This paper studies environmental factors that might influence the incidence of malaria in Afghanistan. We assume that spatial correlation may be induced by multiple latent sources. Our method is based on a generalized estimating equation of the marginal mean of disease incidence, as a function of the geographical factors and the spatial correlation. Instead of using one set of generalized estimating equations, we embed a series of generalized estimating equations, each reflecting a particular source of spatial correlation, into a larger system of estimating equations. To estimate the spatial correlation parameters, we set up a supplementary set of estimating equations based on the correlation structures that are induced from the various sources. Simultaneous estimation of the mean and correlation parameters is performed by alternating between the two systems of equations. [ABSTRACT FROM AUTHOR]

The paper by Noor et al. in this issue provides important and interesting data on the incidence and outcomes of patients with acute myeloid leukaemia in Afghanistan. The age of patients is much lower than we are used to seeing in the West, reflecting in part the particular demographics of the country; these data provide an important first step to identifying areas for improvement. Commentary on: Noor et al. Demographic and clinical characteristics of acute myeloid leukaemia diagnosed and treated at tertiary level in Afghanistan. Br J Haematol 2023;203:404–410. [ABSTRACT FROM AUTHOR]

• First autochthonous DENV cases were detected by the surveillance system in 2019. • Sustained and strengthened surveillance is required for early detection of DENV. • Afghanistan needs to develop preparedness and a response plan for DENV. • The cross-border spread of DENV has been reported between Afghanistan and Pakistan. • Enhanced cross-border collaboration is needed for active response and preventing the spread. This paper aims to describe the epidemiological characteristics and clinical manifestations of the first 15 dengue fever cases reported in Afghanistan. A retrospective descriptive analysis of the data on confirmed dengue cases detected by the national disease surveillance system was conducted. Epidemiological, socio-demographic, clinical, laboratory and outcome data from the cases were analyzed. Between May and December 2019, 62 samples were tested for DENV, among which 15 (24.2%) were positive. Seven of the cases were probable autochthonous with no travel history, the other seven cases had a travel history to dengue-endemic countries (five Pakistan, two India) and the travel history for one of the cases was not known. The 15 confirmed cases were reported from six provinces, seven cases (46.7%) were reported from Nangarhar Province, two (13%) from Paktya, and one (6.7%) from Paktika province, bordering with Pakistan, three (20%) were reported from Kabul, and one each (each 6.7%) from Faryab and Laghman provinces. All of the cases manifested fever, headache, myalgia, and arthralgia. Other clinical features were low platelet count (50%), pain behind eyes (36%), rash, and nausea/vomiting (each 21%). For the first time, the surveillance system detected and reported locally acquired DENV cases in Afghanistan, mostly in provinces bordering with Pakistan. Population movements between Afghanistan and Pakistan facilitate the cross-border spread of DENV between two countries. [ABSTRACT FROM AUTHOR]

• Crimean-Congo Hemorrhagic Fever (CCHF) has significantly increased in Afghanistan during recent years. • Those who are exposed to the vector (Hyalomma ticks), infected animals, the blood and tissues of freshly slaughtered livestock are most at risk. • The cases reach to its peak during Eid-al-Adha when people are sacrificing animals. • Information on CCHF pathogen genotypes and lineage, strain movement and sequence diversity of the CCHF in Afghanistan is not known yet. This study aims to provide descriptive epidemiology of human CCHF cases in Afghanistan by demographic, geographical, and seasonal characteristics. This paper's findings are based on the retrospective analysis of the National Surveillance System's collected data from 2016 to 2018. Weekly cases exceeding the 90th percentile of the expected number of cases were considered to be exceptional and above normal. The National Surveillance System detected 1,284 CCHF cases from 2007 to 2018, of which 163 cases were in 2016, 245 cases in 2017 and 483 cases in 2018. A total of 891 suspected and confirmed cases were reported between 2016 and 2018, 293 (33%) of these cases were confirmed by detecting IgM antibody using ELISA and RT-PCR. Among confirmed cases, the three-year case fatality ratio (CFR) was 43.3%. Among the reported cases, 68.5% were males and 31.5% females. The frequent reported occupational groups were housewives (15%), health staff (13%), shepherds (11%), butchers (6%), students (6%), animal dealers and farmers (both 2%) respectively, 19% were unemployed, and occupation was not recorded for 26% of cases. Recently, CCHF has significantly increased in Afghanistan. Despite the increased frequency of cases, the laboratory capacity to test specimens and overall knowledge of CCHF management remains limited. [ABSTRACT FROM AUTHOR]

Background: Anorexia nervosa (AN) is a complex and heritable psychiatric disorder, which imposes significant mortality and morbidity on sufferers globally. We aimed to report the prevalence, incidence and disability-adjusted life-years (DALYs) attributable to AN in the Middle East and North Africa (MENA) region by age, sex and socio-demographic index (SDI), between 1990 and 2019. Methods: The disease burden attributable to AN was obtained for the 21 countries located in the MENA region between 1990 and 2019 using publicly available data from the Global Burden of Disease (GBD) 2019 study. All estimates were provided as counts and age-standardized rates per 100,000 population, along with 95% uncertainty intervals (UIs). Results: In 2019, the estimated age-standardised point prevalence and incidence rate of AN (per 100,000) in MENA were 49.3 (95% UI: 34.6–70.4) and 16.0 (11.3–22.0), which were 11.4% (7.3–15.4) and 5.9% (2.6–9.1) higher than in 1990, respectively. Furthermore, the regional age-standardised DALY rate was 10.6 (6.3–17.0) per 100,000 in 2019, which was 11.8% (5.2–19.1) higher than in 1990. In 2019, Kuwait [17.3 (10.3-27.9)] and Afghanistan [6.3 (3.7-10.3)] had the highest and lowest age-standardised DALY rates, respectively. In addition, Iran showed the largest increases in the age-standardised point prevalence [30.0% (24.1–36.2)], incidence [24.6% (18.6–30.4)] and DALY [30.5% (22.6–38.9)] rates between 1990 and 2019. In 2019, the number of prevalent cases and prevalence estimates peaked in the 15–19 age group for males and the 20–24 age group for females, with females having a higher number of cases and prevalence in all age groups. In 2019, the age-standardised DALY rates in MENA were higher than the global rates among males aged 10–34 years, but were lower than the global estimates among females in almost all age groups. In addition, the burden of AN was positively associated with the level of socio-economic development during the measurement period. Conclusions: The burden of AN in the MENA region increased between 1990 and 2019, which indicates that it is likely to become a more serious public health issue in the future. Up-to-date information about the epidemiological trends in the region would allow health policymakers to make informed and appropriate decisions to help address this issue. Plain English summary: The findings of the present study showed that the point prevalence and incidence rate of anorexia nervosa have increased in the Middle East and North Africa region between 1990 and 2019. The highest burden in 2019 was found in Kuwait, while Afghanistan had the lowest attributable burden. In addition, between 1990 and 2019 Iran had the largest increase in the point prevalence of anorexia nervosa. Also in 2019, anorexia nervosa was more prevalent in females and peaked in the 15–19 age group for males and the 20–24 age group for females. Furthermore, as the level of socioeconomic development increased, so did the burden attributable to anorexia nervosa. [ABSTRACT FROM AUTHOR]

Background: Foot and mouth disease (FMD) is endemic in Afghanistan with serotypes O, A and Asia 1 being prevalent. A retrospective study of data collected through passive surveillance of outbreaks of FMD in Afghanistan from 1995 to 2016 was undertaken to determine the temporal and spatial distribution of FMD in the country. Results: A total of 4171 outbreaks were reported between 1995 and 2008 with a strong correlation between the number of outbreaks and the number of provinces (r = 0.85, s = 68.2, p < 0.001); and between the number of outbreaks and the number of districts containing infected animals (r = 0.68, s = 147.8, p = 0.008). Of 7558 samples collected from livestock originating from 34 provinces in 2009, 2011 and 2013–2015, 54.1% were test positive (FMDV 3ABC-trapping ELISA) and the prevalence varied significantly between years (χ2 = 263.98, df = 4, P < 0.001). Clinically suspected cases were reported in 2016 with a substantial positive correlation (r = 0.70, P < 0.001) between the number of districts with cases and the number of reported cases. Serotype O was the predominant serotype detected during the study period, although serotypes A and Asia1 were also detected. Cattle were involved in all outbreaks in the study period and infections were detected in all years of the study in Hirat province in the north-west (bordering Iran), Nangarhar province in the east (bordering Pakistan) and Kabul province in the centre of the country. Conclusions: The current paper was the first analysis of existing data focusing on the spatiotemporal distribution of FMD in Afghanistan. The findings from this study provide valuable direction for further research to understand the epidemiology of FMD and its control in Afghanistan. [ABSTRACT FROM AUTHOR]

Military personnel deployed to Southwest Asia and Afghanistan were exposed to high levels of ambient particulate matter (PM). However, quantitative ambient exposure data for conducting health studies are limited due to a lack of PM monitoring stations. Since visual range (VR) is proportional to particle light extinction, VR can serve as a surrogate for PM2.5 (particulate matter with an aerodynamic diameter =2.5 µm) concentrations. We used data on VR, relative humidity (RH), and PM2.5 ground measurements collected in Kuwait from years 2004-2005 to establish the relationship between PM2.5 and VR. Model validation obtained by regressing trimester average PM2.5 predictions against PM2.5 measurements in Kuwait produced an r2 value of 0.84. Cross validation of urban and rural sites in Kuwait also revealed good model fit. We applied this relationship to location-specific visibility data at 104 regional sites between years 2000-2012 to estimate monthly average PM2.5 concentrations. Monthly averages at sites in Iraq, Afghanistan, United Arab Emirates, Kuwait, Djibouti, and Qatar ranged from 10 to 365 µg/m3 during this period, while site averages ranged from 22 to 80 µg/m3, indicating considerable spatial and temporal heterogeneity in ambient PM2.5 across these regions. These data support the use of historical visibility data to estimate location-specific PM2.5 concentrations for application in epidemiological studies. Implications: This study demonstrates the ability to use airport visibility to estimate PM2.5 concentrations in Southwest Asian and Afghanistan. This supports the use of historical and ongoing visibility data to estimate PM2.5 exposure in this region of the world, where PM exposure information is otherwise scarce. This is of high utility to epidemiologists investigating the relationship between chronic exposure to PM2.5 and respiratory diseases among deployed military personnel stationed at various military bases throughout the region. Such information will enable the drafting of improved policies relating to military health. [ABSTRACT FROM AUTHOR]

Background. The prevalence rates of food- and waterborne parasitic infections in Afghanistan are unknown. Cases of invasive diseases found in Afghans are rarely laboratory-confirmed. Objectives. The aim of the study was to present the current status of intestinal parasitic infections in Afghan inhabitants on the example of patients hospitalized in two healthcare facilities in eastern Afghanistan. Material and methods. Fecal samples were collected from 548 patients (children aged 1-17 years and adults) with internal complaints, treated in Ghazni Provincial Hospital (Afghan civilian medical center, Ghazni province, 180 south-west of Kabul) and in Bagram Korean Hospital (Korean military medical center for Afghan patients, Parwan province, 60 km north of Kabul) between 2013 and 2014. One to three stool specimens from Afghan patients were fixed in 10% formalin, transported to the Military Institute of Medicine in Poland and tested by light microscopy using three diagnostic methods (direct smear in Lugol's solution, decantation in distilled water and Ful- leborn's flotation). Results. Intestinal parasites were found in 144/386 of tested patients from the Ghazni province (37.3% infected, mainly with Ascaris lumbricoides, Giardia intestinalis, Hymenolepis nana) and in 49/162 patients from the Parwan province (30.2% infected, mainly with G. intestinalis, A. lumbricoides, H. nana). Conclusions. The rates of intestinal parasitic infections among Afghans are high. The wide range of the detected parasites (protozoa, nematodes, cestodes) should result in the introduction of general screening to be conducted regularly among inhabitants of Afghanistan and the application of targeted antiparasitic chemotherapy aiming to eliminate intestinal helminths and protozoa from the local community. [ABSTRACT FROM AUTHOR]

Background: Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones. Methods: Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years). Results: Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6–12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1–3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates. Conclusions: Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts. [ABSTRACT FROM AUTHOR]

Background: Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients' care. Methods: We reviewed the records of all patients admitted at the Lashkargah "Emergency" hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death. Results: We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries. Conclusions: Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome. [ABSTRACT FROM AUTHOR]

Background. This article reviews the epidemiology of polio, acute flaccid paralysis (AFP) surveillance, and the implementation of supplemental immunization activities (SIAs) in Afghanistan from 1997 thru 2013.Methods. Published reports and unpublished national data on polio cases, AFP surveillance, and SIAs were analyzed. Recommendations from independent advisory groups and Afghan government informed the conclusions.Results. From 1997 thru 2013, the annual number of confirmed polio cases fluctuated from a low of 4 in 2004 to a high of 80 in 2011. Wild poliovirus types 2 and 3 were last reported in 1997 and 2010, respectively. Circulating vaccine-derived poliovirus type 2 emerged in 2009. AFP surveillance quality in children aged <15 years improved over time, achieving rates >8 per 100 000 population. Since 2001, at least 6 SIAs have been conducted annually.Conclusions. Afghanistan has made progress moving closer to eliminating polio. The program struggles to reach all children because of management and accountability problems in the field, inaccessible populations, and inadequate social mobilization. Consequently, too many children are missed during SIAs. Afghanistan adopted a national emergency action plan in 2012 to address these issues, but national elimination will require consistent and complete implementation of proven strategies. [ABSTRACT FROM PUBLISHER]