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National cancer control planning is crucial for countries in the WHO Eastern Mediterranean region. This region is challenged with an increase in cancer incidence leading to substantial disease burden, premature deaths, and increasing health-care costs in most countries. Huge inequity in cancer control planning and implementation exists between and within the countries. Over half of the countries (12 [55%] of 22) have standalone comprehensive National Cancer Control Plans and six (27%) have non-communicable disease plans that include cancer. The implementation of cancer plans has common challenges related to weak governance structure, few coordination mechanisms within countries, and inadequate human and financial resources. In most countries, the plan is not costed. Yet, the majority of countries (20 [91%]) reported having fully or partially funded plans. Additionally, political instability and conflicts affecting over half of the countries in the Eastern Mediterranean region have enormously affected cancer planning and implementation, both among the affected countries and those that host large numbers of refugees. In this Policy Review, we used the WHO regional framework for action on cancer to systematically analyse the status of cancer control planning and implementation across the six domains of cancer control, from prevention to palliation. We highlight the gaps, and the opportunities for bridging these gaps, to achieve scale-up on implementation of cancer control programmes in the Eastern Mediterranean region.

Although the role played by phylogeny in the assembly of plant communities remains as a priority to complete the theory of species coexistence, experimental evidence is lacking. It is still unclear to what extent phylogenetic diversity is a driver or a consequence of species assembly processes. We experimentally explored how phylogenetic diversity can drive the community level responses to drought conditions in annual plant communities. We manipulated the initial phylogenetic diversity of the assemblages and the water availability in a common garden experiment with two irrigation treatments: average natural rainfall and drought, formed with annual plant species of gypsum ecosystems of Central Spain. We recorded plant survival and the numbers of flowering and fruiting plants per species in each assemblage. GLMMs were performed for the proportion of surviving, flowering, fruiting plants per species and for total proportion of surviving species and plants per pot. In water limited conditions, high phylogenetic diversity favored species coexistence over time with higher plant survival and more flowering and fruiting plants per species and more species and plants surviving per pot. Our results agree with the existence of niche complementarity and the convergence of water economy strategies as major mechanisms for promoting species coexistence in plant assemblages in semiarid Mediterranean habitats. Our findings point to high phylogenetic diversity among neighboring plants as a plausible feature underpinning the coexistence of species, because the success of each species in terms of surviving and producing offspring in drought conditions was greater when the initial phylogenetic diversity was higher. Our study is a step forward to understand how phylogenetic relatedness is connected to the mechanisms determining the maintenance of biodiversity.

Nearly two-thirds of migrants residing in camps in Europe are women and children. Many of these children, being born on the way without essential newborns screening, are at some point admitted to pediatric wards in asylum countries. With hospitals overwhelmed with COVID-19 cases, taking appropriate care of newborns becomes a considerable burden. In this frame, prevention, in the form of adequate newborn screening, emerges as a better and more feasible strategy than healing.

We here analysed the populations’ genetic structure ofCoscinasterias tenuispina,an Atlantic-Mediterranean fissiparous starfish,focusing on the western Mediterranean,to investigate: the distribution and prevalence of genetic variants, the relative importance of asexual reproduction, connectivity across the Atlantic-Mediterranean transition, and the potential recent colonisation of the Mediterranean Sea. Individuals from 11 Atlantic-Mediterranean populations of a previous study added to 172 new samples from five new W Mediterranean sites. Individuals were genotyped at 12 microsatellite loci and their gonads histologically analysed for sex determination. Additionally, four populations were genotyped at two-time points. Results demonstrated genetic homogeneity and low clonal richness within the W Mediterranean, due to the dominance of asuperclone, but large genetic divergence with adjacent areas. The lack of new genotypes recruitment over time, and the absence of females, confirmed that W Mediterranean populations were exclusively maintained by fission and reinforced the idea of its recent colonization. The existence of different environmental conditions among basins and/or density-depend processes could explain this lack of recruitment from distant areas. The positive correlation between clonal richness and heterozygote excess suggests that most genetic diversity is retained within individuals in the form of heterozygosity in clonal populations, which might increase their resilience.

Background Single-center clinical series provide important information on genetic distribution that can guide genetic testing. However, there are few such studies on pediatric populations with inherited peripheral neuropathies (IPNs). Methods Thorough genetic testing was performed on IPN patients under 20 years of age from a geographically well-defined Mediterranean area (Valencian Community, Spain), annually assessed with the Charcot-Marie-Tooth disease Pediatric Scale (CMTPedS). Results From 86 families with IPNs, 99 patients (59 males) were identified, 85 with sensorimotor neuropathy or CMT (2/3 demyelinating form) and 14 with distal hereditary motor neuropathy (dHMN). Genetic diagnosis was achieved in 79.5% families, with a similar mutation detection rate in the demyelinating (88.7%) and axonal (89.5%) forms, significantly higher than in the dHMN families (27.3%). CMT1A was the most common subtype, followed by those carrying heterozygous mutations in either the GDAP1 or GJB1 genes. Mutations in 15 other genes were identified, including a new pathogenic variant in the ATP1A gene. The CMTPedS detected significant disease progression in all genetic subtypes of CMT, at a rate of 1.84 (+/- 3.7) over 1 year (p < 0.0005, n = 62) and a 2-year rate of 3.6 (+/- 4.4: p < 0.0005, n = 45). Significant disease worsening was also detected for CMT1A over 1 (1.7 +/- 3.6, p < 0.05) and 2 years (4.2 +/- 4.3, p < 0.0005). Conclusions This study highlights the unique spectrum of IPN gene frequencies among pediatric patients in this specific geographic region, identifying the CMTPedS as a sensitive tool to detect significant disease worsening over 1 year that could help optimize the design of clinical trials.

Carbapenem resistance in Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa is increasing worldwide, which has led the World Health Organization (WHO) to list these bacteria in the critical priority pathogens group. Infections by such pathogens pose a serious threat to hospitalised patients and are associated with clinical and economic consequences. What worsens the case is the weak pipeline of available antimicrobial agents to treat such infections and the absence of new drugs. The aim of this review was to shed light on all studies tackling carbapenem resistance in Enterobacteriaceae, A. baumannii and P. aeruginosa in the Eastern Mediterranean region, with indication for each country, description of studies timeline, prevalence of carbapenem resistance, and carbapenem resistance-encoding genes detected in these countries.

Thalassemia is a common genetic disorder. We aimed to present thalassemia mutation data that covers a period of 7 years from the Mediterranean region of Turkey by comparing with hemoglobin indices and to contribute to prenatal diagnosis and genetic counseling studies which should be decided very quickly. In this study, in which a retrospective archive was scanned, the cases were first grouped as α and β thalassemia, and then β thalassemia mutations were examined in a total of 5 groups as UTR-Pro, Codon, IVS, β0, and β+. We have reached the family of the proband that analyzed their Hb indices and genetic mutation. All mutations were statistically compared with Hb indices, HbF, and HbA2. We have identified two new β thalassemia mutations that have the feature of not being defined previously [HBB:C*62 A>G. (3'UTR+1536 A>G) and HBB:C*1 G>A (3'UTR+1475 G>A)]. The most commonly encountered 23 mutations account for 74.7% of all mutations which is unlike the literature. In the β thalassemia group, 73 different mutations were detected. The most common β thalassemia mutation was HBB: c.93-21 G>A (IVS I-110 G>A) with a frequency of 19.72%. A statistically significant difference was found when comparing the mutation groups with Hb indices. We think that it may be useful to evaluate the mutations we have newly identified too together with the Hb indices especially in evaluating the carriers of thalassemia and it will contribute to prenatal diagnosis and genetic counseling studies which should be decided very quickly.

Departamento de Reproducción animal, Flea infestations of wild rabbits were examined monthly in central Spain in a meso-Mediterranean area for 5 yr. A total of 1,180 wild rabbits were trapped and 7,022 fleas were collected from them. Overall, the prevalence was 74.1% with a mean flea index of 5.95 fleas per rabbit. Four flea species were identified: Spilopsyllus cuniculi (Dale, 1878) was the most abundant species (accounting for 74.3% of fleas collected) followed by Xenopsylla cunicularis (Smit, 1957), Odontopsyllus quirosi (Gil Collado, 1934), and Nosopsyllus fasciatus (Bosc, 1800) (18.9, 6.7, and 0.1%, respectively). The highest prevalence was observed in S. cuniculi (48.6%) followed by X. cunicularis, O. quirosi, and N. fasciatus (34.3, 20.0, and 0.6%, respectively). Odontopsyllus quirosi and S. cuniculi were mainly collected from autumn to spring with the peak of infestation in winter, while X. cunicularis was mainly found from spring to autumn with maximum levels of infestation during the summer months. The relevance of these findings is discussed.

BackgroundSelf-care interventions offer a solution to support the achievement of three goals of the World Health Organization (WHO): to improve universal health coverage, reach people in humanitarian situations, and improve health and well-being. In light of implementing WHO consolidated guidelines on self-care interventions to strengthen sexual and reproductive health (SRH) in the Eastern Mediterranean Region (EMR), especially during the COVID-19 pandemic, pharmacists from four different EMR countries discussed the current SRH situation, inequality gaps, barriers to SRH service access and the pharmacist’s crucial role as a first-line responder to patients before, during and after COVID-19.Case presentationSelf-care interventions for SRH allow health care providers to serve a greater number of patients, improve progress toward universal health coverage, and reach people in humanitarian crises. In fact, these interventions can be significantly enhanced by utilizing community pharmacists as first-line health care providers. This review highlights the important role of community pharmacists in promoting self-care interventions and empowering individuals, families and communities. As a result, well-informed individuals will be authoritative in their health decisions. Exploring self-care interventions in the EMR was done through reviewing selected SRH services delivery through community pharmacists before and during the COVID-19 pandemic in Egypt, Jordan, Lebanon and Somalia. Before the COVID-19 pandemic, community pharmacists were found to be excluded from both governmental and nongovernmental SRH programmes. During the pandemic, community pharmacists managed to support patients with self-care interventions, whether voluntarily or through their pharmacy associations. This highlights the need for the health care decision-makers to involve and support community pharmacists in influencing policies and promoting self-care interventions.ConclusionSelf-care interventions can increase individuals’ choice and autonomy over SRH. Supporting community pharmacists will definitely strengthen SRH in the EMR and may help make the health system more efficient and more targeted.

Highlights • The outbreak detection function was undermined by inclusion of non-epidemic diseases. • Adoption of electronic platforms expanded coverage of hard-to-reach areas. • Conflict emergencies limited coverage, despite progress due to electronic solutions. • The EWARN is being retained far longer than expected in protracted emergencies., Introduction The Eastern Mediterranean Region (EMR) has experienced several protracted humanitarian crises. The affected population are served by eight Early Warning Alert and Response Network (EWARN) systems for outbreak detection and response. This study aimed to compare structure, function and performance of the systems’ adherence to current guidance, and noted emerging lessons. Methods This study included a review of published and unpublished literature, a structured survey and interviews. Results Findings showed that all systems adhered to basic EWARN structure. Four of eight systems had electronic platforms, while one was implementing one. Regarding key EWARN function of outbreak detection: of the 35 health conditions, 26 were communicable diseases and nine were non-communicable; two systems focused on epidemic-prone diseases. Half the systems achieved ≥60% population coverage, five achieved ≥80% reporting timeliness, six achieved ≥80% reporting completeness, and seven achieved verification of ≥80% of alerts of suspected outbreaks. Conclusion The findings showed that the systems followed the EWARN structure, while increasing adoption of electronic platforms. Performance, including timeliness and completeness of reporting, and timely verification of alerts were optimal for most of the systems. However, population coverage was low for most of the systems, and the EWARN’s primary focus of outbreak detection was undermined by the increasing number of non-epidemic diseases.

Increases in the levels of environmental contaminants are reflected in wild animals, which are early indicators of pollution. Hatay is an ecologically important region with a high intensity of industrial and agricultural activities. This study aimed to investigate the contamination levels of metals and organochlorine pesticides associated with environmental pollution in tissues of wild boars from Turkey. The highest mean levels (mg kg−1) of metals were 0.05 for As, 0.51 for Cd, 6.30 for Cu, 0.07 for Hg, 0.54 for Ni, and 0.57 for Pb in kidney tissues and 0.22 for Cr, 353.38 for Fe, 2.86 for Mn, and 46.76 for Zn in liver tissues. The Cd and Pb levels exceeded the maximum residue limits (MRLs) in some tissues. Among the studied pesticides, only p,p′-DDE contamination was quantified, and the mean levels were 3.6, 0.1, and 0.5 µg kg−1 in liver, kidney, and muscle tissues respectively. In conclusion, Hatay Province requires monitoring in terms of environmentally important contaminants, mainly Cd, Pb, and DDT isomers.

Lymphatic filariasis (LF), a neglected tropical disease, is targeted for global elimination as a public health problem. This article reviews the history of LF control and elimination activities in the countries of the World Health Organization's (WHO) Eastern Mediterranean Region (EMR) over the last 2 decades. In 2000, the estimated at-risk population in EMR countries was 12.6 million people, accounting for approximately 1% of the global disease burden. Of the 22 EMR countries, 3 countries (Egypt, Sudan and Yemen) were LF endemic and the disease was suspected in 4 other countries (Djibouti, Oman, Somalia and Saudi Arabia). After almost 2 decades of implementing sustained control and prevention measures, Egypt and Yemen were successfully validated by the WHO as having achieved the elimination criteria in 2017 and 2019, respectively. In 2018, Sudan completed mapping of LF, reaching 26.2% geographical coverage where mass drug administration (MDA) is required and is scaling-up MDA. Extensive epidemiological assessment indicated the absence of LF transmission in the four suspected countries and no MDA required. Challenges faced during the elimination and post-elimination phases are described and discussed.

Background: Food protein‐induced enterocolitis syndrome (FPIES) is a rare non-IgE mediated food allergy. Objective: To delineate the differences in the spectrum of culprit foods, remission patterns, and predictors among varying cultures. Methods: We reviewed demographics, culprit foods, outcomes, and predictors in 81 children with a diagnosis of FPIES who were followed up between 2015 and 2020. Results: Eighty-one patients (55.6% boys) were enrolled, including 72 with acute FPIES and 9 with chronic FPIES. Hen’s egg was the most common culprit food (36.6%), followed by fish (26.9%), and cow’s milk (21.5%). Interestingly, cow’s milk was significantly prevalent in chronic FPIES cases (p = 0.006). The most common clinical symptoms were vomiting (100%), pallor (63.4%), and lethargy (55.9%). Emergency department visits were noted in 39 patients (41.9%), of whom 37 (39.8%) were treated with intravenous (IV) fluid. The subjects were followed up for a median (interquartile range) of 19.4 months (12.3‐41.2 months), and 26 subjects (32.1%) achieved tolerance. The median (interquartile range) age at tolerance was 2.5 years (2.1‐3.2 years). With regard to the culprit foods, hen’s egg was observed more frequently in the subjects with resolved FPIES cases (p = 0.008), whereas fish FPIES cases were high in the persistent group (p = 0.001). IgE sensitization of the culprit food was found to be an independent risk factor for the persistence of FPIES (odds ratio 4.855 [95% confidence interval, 1.131‐20.844]; p = 0.034). Conclusion: In our cohort, unlike other published series, hen’s egg and fish were the two most common culprit foods. Fish differed from other culprit foods, with significantly delayed onset and persistence, and may create a model that allows for the understanding of the disease.

Several studies have stablished discriminant formulas (DF) from red blood cell (RBC) data as simple, low time-consuming and inexpensive tools to differentiate β-thalassemia trait (β-TT) from iron deficiency anaemia (IDA). The aim of this work is to introduce new formulas and evaluate them in the differentiation of microcytic anaemia (MA) into either β-TT or IDA in the Mediterranean region of Tarragona. A total of 200 anonymized haematological determinations with MA were collected, 100 diagnosed of β-TT and 100 diagnosed of IDA. The cut-off values of new formulas were designed to differentiate β-TT from IDA groups and their diagnostic performance were compared with other published indices. Specifically, Martin-Sanchez index (MSI-I) = (%Micro-R/MCV) * MCHC * Hb and MSI-II = Hb * (MCHC + %Micro-R)/10. In addition, a new score: MSI-score = MCHC + MSI-I + MSI-II was proposed and evaluated in a transversal study with 200 patients. In our region, MSI-II index and MSI-score have demonstrated the best AUC and Youden’s index (YI) (AUC = 0.956, YI = 81%; AUC = 0.971, YI = 87%, respectively) to discriminate β-TT from IDA groups. In summary, the new MSI-score with the highest AUC, the highest YI and the best percentage (93.5%) of correctly identified patients could be used as an efficient and robust tool in microcytic anaemia mass-screening programs in this region.

Viral hepatitis B is a global public health problem affecting nearly two billion subjects; 3.3% of whom are from the WHO (World Health Organization) Eastern Mediterranean Region (EMRO). It induces both acute and chronic hepatic disorders with subsequent liver cirrhosis and hepatocellular carcinoma (HCC) in a considerable percentage of patients based on the age of exposure. In this review, hepatitis B virus (HBV) and HCC prevalence, distribution and prevalence of different genotypes, and male/female infection frequencies in relation to the vaccination status in the Mediterranean countries were reported. Study Design. This systematic review describes the prevalence of hepatitis B infection, genotype distribution of hepatitis B virus, and prevalence and incidence of hepatocellular carcinoma in Mediterranean countries belonging to three different continents: Southern Europe (Spain, France, Italy, Croatia, and Greece), North Africa (Morocco, Algeria, Tunisia, Libya, and Egypt), and the Near East region (Syria, Lebanon, Turkey, Israel, and Palestine). We tried to collect new data from electronic databases: PubMed, ScienceDirect, ResearchGate, Google Scholar, and public health reports between 1980 and 2019. For each publication, we recorded reference, publication year, study characteristics (date, locations, sample size, and study population), and participant characteristics (population group, year, age, and sex). No language limitation was imposed, and articles or reports from non-peer-reviewed sources were not considered for this analysis. The main keywords were HBV prevalence, hepatitis B infection, HBV genotype, and HCC. Inclusion and Exclusion Criteria. Healthy population-based studies included the following sample populations: (i) voluntary blood donors, (ii) pregnant women, (iii) community studies, (iv) hemodialysis patients, (v) hospitalized patients, (vi) healthcare workers, (vii) sex workers, (viii) drug abusers, and (ix) prisoners. We excluded studies from the following special groups who were assumed to be at a special high risk: patients from sexually transmitted disease clinics and thalassemia clinics and professional or paid blood donors.

BackgroundChild and adolescent injury is one of the leading causes of child death globally with a large proportion occurring in Low- and Middle-Income Countries (LMICs). Similarly, the Eastern Mediterranean Region (EMR) countries borne a heavy burden that largely impact child and adolescent safety and health in the region. We aim to assess child and adolescent injury morbidity and mortality and estimate its burden in the Eastern Mediterranean Region based on findings from the Global Burden of Disease (GBD), Injuries and Risk Factors study 2017.MethodsData from the Global Burden of Disease GBD 2017 were used to estimate injury mortality for children aged 0–19, Years of Life Lost (YLLs), Years lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs) by age and sex from 1990 to 2017.ResultsIn 2017, an estimated 133,117 (95% UI 122,587-143,361) children died in EMR compared to 707,755 (95% UI 674401.6–738,166.6) globally. The highest rate of injury deaths was reported in Syria at 183.7 (95% UI 181.8–185.7) per 100,000 population. The leading cause of injury deaths was self-harm and interpersonal violence followed by transport injury. The primary cause of injury DALYs in EMR in 2017 was self-harm and interpersonal violence with a rate of 1272.95 (95% UI 1228.9 – 1319.2) almost 3-times the global rate.ConclusionAlmost 19% of global child injury related deaths occur in the EMR. Concerted efforts should be integrated to inform policies and adopt injury preventive strategies to reduce injury burden and promote child and adolescent health and well-being in EMR countries.

Background The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. Methods MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20, 2019. Results Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4–30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. Conclusions Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

Background Rates of non-communicable diseases (NCDs) are rapidly rising in the Eastern Mediterranean Region (EMR). Systematic reviews satisfy the demand from practitioners and policy makers for prompt comprehensive evidence. The aim of this study is to review trends in NCD systematic reviews research output and quality by time and place, describe design and focus, and examine gaps in knowledge produced. Methods Using the Montori et al. systematic reviews filter, MeSH and keywords were applied to search Medline Ovid, Cochrane Central and Epistemonikos for publications from 1996 until 2015 in the 22 countries of the EMR. The ‘Measurement Tool to Assess Systematic Reviews’, AMSTAR, was used to assess the methodological quality of the papers. Results Our search yielded 2439 papers for abstract and title screening, and 89 papers for full text screening. A total of 39 (43.8%) studies included meta-analysis. Most of the papers were judged as being of low AMSTAR quality (83.2%), and only one paper was judged as being of high AMSTAR quality. Whilst annual number of papers increased over the years, the growth was mainly attributed to an increase in low-quality publications approaching in 2015 over four times the number of medium-quality publications. Reviews were significantly more likely to be characterized by higher AMSTAR scores (±SD) when meta-analysis was performed compared to when meta-analysis was not performed (3.4 ± 1.5 vs 2.6 ± 2.0; p-value = 0.034); and when critical appraisal of the included studies was conducted (4.3 ± 2.3 vs 2.5 ± 1.5; p-value = 0.004). Most of the reviews focused on cancer and diabetes as an outcome (25.8% and 24.7%, respectively), and on smoking, dietary habits and physical activity as exposures (15.7%, 12.4%, 9.0%, respectively). There was a blatant deficit in reviews examining associations between behaviors and physiologic factors, notably metabolic conditions. Conclusions Systematic reviews research in the EMR region are overwhelmingly of low quality, with gaps in the literature for studies on cardiovascular disease and on associations between behavioral factors and intermediary physiologic parameters. This study raises awareness of the need for high-quality evidence guided by locally driven research agenda responsive to emerging needs in countries of the EMR.

Background: Influenza surveillance systems in the Eastern Mediterranean Region have been strengthened in the past few years and 16 of the 19 countries in the Region with functional influenza surveillance systems report their influenza data to the EMFLU Network. This study aimed to investigate the epidemiology of circulating influenza viruses, causing SARI, and reported to the EMFLU during July 2016 to June 2018. Methods: Data included in this study were collected by 15 countries of the Region from 110 SARI sentinel surveillance sites over two influenza seasons. Results: A total of 40,917 cases of SARI were included in the study. Most cases [20,551 (50.2%)] were less than 5 years of age. Influenza virus was detected in 3995 patients, 2849 (11.8%) were influenza A and 1146 (4.8%) were influenza B. Influenza A(H1N1)pdm09 was the predominant circulating subtype with 1666 cases (58.5%). Other than influenza, respiratory syncytial virus was the most common respiratory infection circulating, with 277 cases (35.9%). Conclusion: Influenza viruses cause a high number of severe respiratory infections in EMR. It is crucial for the countries to continue improving their influenza surveillance capacity in order detect any unusual influenza activity or new strain that may cause a pandemic. Keywords: Influenza, Human, Severe acute respiratory infections, Sentinel surveillance, EMFLU Network, Eastern Mediterranean Region

Influenza causes significant morbidity and mortality worldwide. Owing to its ability to rapidly evolve and spread, the influenza virus is of global public health importance. Information on the burden, seasonality and risk factors of influenza in countries of the World Health Organization Eastern Mediterranean Region is emerging because of collaborative efforts between countries, WHO and its partners over the past 10 years. The fourth meeting of the Eastern Mediterranean Acute Respiratory Infection Surveillance network was held in Amman, Jordan on 11–14 December 2017. The meeting reviewed the progress and achievements reported by the countries in the areas of surveillance of and response to seasonal, zoonotic and pandemic influenza. The first scientific conference on acute respiratory infection in the Eastern Mediterranean Region was held at the same time and 38 abstracts from young researchers across the Region were presented on epidemiological and virological surveillance, outbreak detection and response, influenza at the animal-human interface, use and efficacy of new vaccines to control respiratory diseases and pandemic influenza threats. The meeting identified a number of challenges and ways to improve the quality of the surveillance system for influenza, sustain the system so as to address pandemic threats and use the data generated from the surveillance system to inform decision-making, policies and practices to reduce the burden of influenza-associated illnesses in the Region. Keywords: EMARIS, Influenza, Eastern Mediterranean Region, WHO

α-Thalassemia (α-thal) is the most common autosomal recessive hemoglobinopathy. There is a vast diversity and geographical variability in underlying genotypes in Hb H (β4) patients. Herein, we describe the genotypes found in the largest report of Omani Hb H patients. Moreover, we reviewed and summarized the literature published from the Eastern Mediterranean region. A retrospective review of all genetically confirmed Hb H disease patients diagnosed between 2007 and 2017 at Sultan Qaboos University Hospital, Muscat, Oman, was performed. Hematological parameters and clinical presentations were assessed. Both α-globin genes were screened for deletional and nondeletional mutations using a stepwise diagnostic strategy as described before. A total of 52 patients (27 females and 25 males) with a mean age of 20.6 years (range 0.23-80.0) were molecularly confirmed to carry Hb H disease. The patients had a hemoglobin (Hb) level of 9.3 g/dL (range 5.7-13.0) and mean corpuscular volume (MCV) of 58.4 fL (range 48.2-82.1). A total of eight genotype combinations were identified, with α2 polyadenylation signal mutation (polyA1) (AATAA

Several countries have started to introduce the HPV vaccine into their national immunisation programme, with the majority of these countries being high or upper-middle income countries. Currently, 91 countries have introduced the HPV vaccine globally. One of the regions lagging behind in the introduction of the HPV vaccine is the Eastern Mediterranean Region, with currently only Libya and the United Arab Emirates having introduced the HPV vaccine. In order to support countries in the Eastern Mediterranean Region with their decision-making process for HPV vaccine introduction, a regional workshop was organised to explore the current status of HPV vaccine introduction plans in the Eastern Mediterranean countries, gaps in information about HPV disease burden in the region and the need for quality HPV data to make an informed decision to introduce the HPV vaccine, socio-cultural and religious challenges with HPV vaccine introduction, and the role of NITAGs in formulating recommendations for HPV vaccine introduction. Participating countries reflected on their respective status of decision making process about HPV vaccine introduction; they discussed any needs for operational research to support the decision-making process; and highlighed technical and financial support that might be required from partners to assist with HPV vaccine introduction. Recommendations were made on how to advance the decision-making process for HPV vaccine introduction. The workshop increased the awareness of the need of data on burden of disease and the associated benefits of HPV vaccination in Eastern Mediterranean countries. The importance of collaboration between different programmes including: immunisation, adolescent health, school health, sexual and reproductive health and cancer control programmes was clearly emphasized. (C) 2019 Elsevier Ltd. All rights reserved.

Background: Higher Dietary Inflammatory Index (DII®) scores are associated with increased morbidity and mortality. However, little is known about the effects of DII on mortality in Mediterranean countries. Therefore, in the present study, we aimed to investigate the potential association between DII scores and overall, cancer and cardiovascular disease (CVD) mortality in people living in a Mediterranean area. Methods: DII scores were calculated using a validated food-frequency questionnaire. DII scores were then categorised into tertiles. Mortality was ascertained via death certificates. The association between DII scores with overall and cause-specific mortality was assessed via a multivariable Cox's regression analysis and reported as hazard ratios (HRs) with their 95% confidence intervals (CIs). Results: The study included 1565 participants (mean age65.5years; females44.7%). After a median follow-up of 12years (2005–2017), 366 (23.4%) participants died. After adjusting for 17 potential confounders, people with higher DII scores had an increased risk of death compared to those in the lowest (most anti-inflammatory) tertile (HR=1.38; 95% CI=1.04–1.82 for the second tertile; HR=1.38; 95% CI=1.03–1.86 for the third tertile). Each 1 SD increase in DII score increased the risk of death by 13%. No association was found between DII scores and cancer or CVD death when considered separately. Conclusions: Higher DII scores were associated with a significantly higher mortality risk, whereas the association with cause-specific mortality was less clear. These findings highlight the potential importance of diet in modulating inflammation and preventing death. © 2019 The British Dietetic Association Ltd.

The WHO Eastern Mediterranean Region is endowed with deep intellectual tradition, interesting cultural diversity, and a strong societal fabric; components of a vibrant platform for promoting health and wellbeing. Health has a central place in the Sustainable Development Goals (SDGs) for at least three reasons: Firstly, health is shaped by factors outside of the health sector. Secondly, health can be singled out among several SDGs as it provides a clear lens for examining the progress of the entire development process. Thirdly, in addition to being an outcome, health is also a contributor to achieving sustainable development. Realizing this central role of health in SDGs and the significance of collaboration among diverse sectors, the WHO is taking action. In its most recent General Program of Work 2019–2023 (GPW 13), the WHO has set a target of promoting the health of one billion more people by addressing social and other determinants of health through multi-sectoral collaboration. The WHO Regional Office for the Eastern Mediterranean Region, through Vision 2023, aims at addressing these determinants by adopting an equity-driven, leaving no one behind approach. Advocating for Health in All Policies, multi-sectoral action, community engagement, and strategic partnerships are the cornerstone for this approach. The focus areas include addressing the social and economic determinants of health across the life course, especially maternal and child health, communicable diseases, non-communicable diseases, and injuries. The aspirations are noteworthy – however, recent work in progress in countries has also highlighted some areas for improvement. Joint work among different ministries and departments at country level is essential to achieve the agenda of sustainable development. For collaboration, not only the ministries and departments need to be engaged, but the partnerships with other stakeholders such as civil society and private sector are a necessity and not a choice to effectively pursue achievement of SDGs.

Patient: Female, 23 Final Diagnosis: Desmoplastic small round cell tumor Symptoms: Nausea • vomiting • severe abdominal pain of two weeks • weight loss Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology Objective: Rare disease Background: Desmoplastic small round cell tumor (DSRCT) is a rare soft tissue sarcoma that usually arises in the abdomen or pelvis in young boys and adolescents. Presenting symptoms include abdominal pain and ascites. However, DSRCT is often disseminated throughout the peritoneal cavity at diagnosis, and the prognosis is poor. This report is of a case of DSRCT in a 23-year-old Jordanian woman who presented with abdominal pain. Case Report: An unmarried 23-year-old woman presented with abdominal pain. On examination, she was found to have ascites. A computed tomography (CT) scan of the abdomen and pelvis showed a complex cystic mass in the left ovary, multiple peritoneal deposits, a large amount of ascitic fluid, two hypodense lesions in the liver, and multiple enlarged lymph nodes. Diagnostic laparoscopy was performed, and multiple tumor biopsies were obtained. Histopathology showed a cellular tumor composed nests of small round cells embedded in desmoplastic stroma. Immunohistochemistry showed positive staining of the tumor cells for pan-cytokeratin, desmin, Wilms tumor 1 (WT1) antigen, epithelial membrane antigen (EMA), and CD56, which supported the diagnosis of DSRCT. After the second cycle of the P6 Protocol, which included seven courses of chemotherapy, the patient developed a severe and fatal infection. Conclusions: It is important to consider the diagnosis of DSRCT that may present atypically, particularly in patients who present with abdominal and pelvic masses. DSRCT has a rapid and aggressive course that requires early and definitive diagnosis with prompt treatment that includes systemic chemotherapy.

Immortelle (Helichrysum italicum (Roth) G. Don; Asteraceae) is a perennial plant species native to the Mediterranean region, known for many properties with wide application mainly in perfume and cosmetic industry. A total of 18 wild H. italicum populations systematically sampled along the eastern Adriatic environmental gradient were studied using AFLP markers to determine genetic diversity and structure and to identify loci potentially responsible for adaptive divergence. Results showed higher levels of intrapopulation diversity than interpopulation diversity. Genetic differentiation among populations was significant but low, indicating extensive gene flow between populations. Bayesian analysis of population structure revealed the existence of two genetic clusters. Combining the results of FST - outlier analysis (Mcheza and BayeScan) and genome-environment association analysis (Samβada, LFMM) four AFLP loci strongly associated with the bioclimatic variables Bio03 Isothermality, Bio08 Mean temperature of the wettest quarter, Bio15 Precipitation seasonality, and Bio17 Precipitation of driest quarter were found to be the main variables driving potential adaptive genetic variation in H. italicum along the eastern Adriatic environmental gradient. Redundancy analysis revealed that the partitioning of genetic variation was mainly associated with the adaptation to temperature oscillations. The results of the research may contribute to a clearer understanding of the importance of local adaptations for the genetic differentiation of Mediterranean plants and allow the planning of appropriate conservation strategies. However, considering that the identified outlier loci may be linked to genes under selection rather than being the target of natural selection, future studies must aim at their additional analysis.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

[EN] The temporal evolution of the electrical signal generated by Pinus halepensis was measured in a sample of 15 trees. Weekly experiments were carried out during a long-term campaign lasting over a year, while trials with a high frequency of measurements were also performed during several days. In the latter case, day-night oscillations of the electrical magnitudes were observed. Additionally, punctual meteorological events such as rainfall and electrical storms affect the electrical signal as well. The measured electrical intensity grows exponentially with the voltage. In fact, no electrical intensity that exceeds the threshold of 0.01 ¿A is gathered when voltage values are lower than 0.6 V. In general, higher electrical signals were gathered during the rainy seasons with moderate temperatures; while very low signals, including few measures of zero intensity, were obtained during the most stressful periods over the year, mainly by mid-summer. There is a strong correlation between the rainfall and the electrical signal. The rain-intensity correlation, together with sustained intensity values during the reproductive period in spring, suggests that this electrical magnitude could be an indicator of the physiological state of the tree and thus used for in situ and minimally invasive forest monitoring.

Recent results indicate that dysregulation of vitamin D-binding protein (VDBP) could be involved in the development of hypovitaminosis D, and it comprises a risk factor for adverse fetal, maternal and neonatal outcomes. Until recently, there was a paucity of results regarding the effect of maternal and neonatal VDBP polymorphisms on vitamin D status during pregnancy in the Mediterranean region, with a high prevalence of hypovitaminosis D. We aimed to evaluate the combined effect of maternal and neonatal VDBP polymorphisms and different maternal and neonatal 25-hydroxyvitamin D (25(OH)D) cut-offs on maternal and neonatal vitamin D profile. Blood samples were obtained from a cohort of 66 mother–child pairs at birth. Our results revealed that: (i) Maternal VDBP polymorphisms do not affect neonatal vitamin D status at birth, in any given internationally adopted maternal or neonatal cut-off for 25(OH)D concentrations, (ii) neonatal VDBP polymorphisms are not implicated in the regulation of neonatal vitamin D status at birth, (iii) comparing the distributions of maternal VDBP polymorphisms and maternal 25(OH)D concentrations, with cut-offs at birth, revealed that mothers with a CC genotype for rs2298850 and a CC genotype for rs4588 tended to demonstrate higher 25(OH)D (≥75 nmol/L) during delivery (p = 0.05 and p = 0.04, respectively), after adjustments for biofactors that affect vitamin D equilibrium, including UVB, BMI and weeks of gestation. In conclusion, this study from Southern Europe indicates that maternal and neonatal VDBP polymorphisms do not affect neonatal vitamin D status at birth, whereas mothers with CC genotype for rs2298850 and CC genotype for rs4588 demonstrate higher 25(OH)D concentrations. Future larger studies are required to establish a causative effect of these specific polymorphisms in the attainment of an adequate (≥75 nmol/L) maternal vitamin D status during pregnancy.

The atmosphere represents an underexplored temporary habitat for airborne microbial communities such as eukaryotes, whose taxonomic structure changes across different locations and/or regions as a function of both survival conditions and sources. A preliminary dataset on the seasonal dependence of the airborne eukaryotic community biodiversity, detected in PM10 samples collected from July 2018 to June 2019 at a coastal site representative of the Central Mediterranean, is provided in this study. Viridiplantae and Fungi were the most abundant eukaryotic kingdoms. Streptophyta was the prevailing Viridiplantae phylum, whilst Ascomycota and Basidiomycota were the prevailing Fungi phyla. Brassica and Panicum were the most abundant Streptophyta genera in winter and summer, respectively, whereas Olea was the most abundant genus in spring and autumn. With regards to Fungi, Botrytis and Colletotrichum were the most abundant Ascomycota genera, reaching the highest abundance in spring and summer, respectively, while Cryptococcus and Ustilago were the most abundant Basidiomycota genera, and reached the highest abundance in winter and spring, respectively. The genus community structure in the PM10 samples varied day-by-day, and mainly along with the seasons. The impact of long-range transported air masses on the same structure was also proven. Nevertheless, rather few genera were significantly correlated with meteorological parameters and PM10 mass concentrations. The PCoA plots and non-parametric Spearman’s rank-order correlation coefficients showed that the strongest correlations generally occurred between parameters reaching high abundances/values in the same season or PM10 sample. Moreover, the screening of potential pathogenic fungi allowed us to detect seven potential pathogenic genera in our PM10 samples. We also found that, with the exception of Panicum and Physcomitrella, all of the most abundant and pervasive identified Streptophyta genera could serve as potential sources of aeroallergens in the studied area.

Altres ajuts: AstraZeneca/ESR-16-12628 ; Applied Research Collaboration East Midlands (ARC EM) ; National Institute for Health Research (NIHR) ; Imperial Biomedical Research Centre (NIHR) The aims of our study was compare adherence measured by the medical possession ratio (MPR), time until discontinuation and describe adverse events after adding a DPP-4i, SGLT-2i, or sulfonylureas (SU) to metformin in a primary care population with insufficient glycemic control. We used routinely-collected health data from the SIDIAP database. The included subjects were matched by propensity score. The follow-up period was up to 24 months or premature discontinuation. The primary outcomes were the percentage of subjects with good adherence, treatment discontinuation and adverse events among treatment groups. The proportion of patients with good adherence (MPR> 0.8) after the addition of DPP-4i, SGLT-2i or SU was 53.6%, 68.7%, and 43.0%, respectively. SGLT-2i users were 1.7 times more likely to achieve good adherence compared with DPP-4i users (odds ratio [OR]:1.72, 98% confidence interval [CI]:1.51, 1.96), and 2.8 times more likely compared with SU users (OR: 0.35, 98% CI: 0.07, 0.29). The discontinuation hazard ratios were 1.43 (98%CI: 1.26; 1.62) and 1.60 (98%CI: 1.42; 1.81) times higher among SGLT-2i and SU users than DPP-4i users during the follow-up period. No differences were observed for adverse events among the treatment groups. In conclusion, in our real-world setting, the combination of SGLT-2i with metformin was associated with better adherence. The mean time until discontinuation was longer in the SGLT-2i group in comparison with the DPP-4i or SU groups.

Background While recent reviews highlight high burnout prevalence among physicians in the World Health Organization's (WHO) Eastern Mediterranean Region (EMR), there has been a limited exploration into the role of gender and related factors in this problem. Methods We conducted a systematic review and meta-analysis of studies on the prevalence of physician burnout and its relationship to gender, physician specialties, and age in the WHO's EMR based on the Cochrane Handbook for Systematic Reviews. We searched PubMed, Embase, PsycINFO, Google Scholar, and Al Manhal databases and synthesized the findings from the included studies. Results Among the 78 studies included, data was available from 16/22 (72.7%) countries and territories in the EMR covering a total of 16 016 physicians. The pooled prevalence of overall burnout among physicians in the region was estimated to be 24.5%. Among the sub-components of burnout, we estimated a high pooled prevalence of 44.26% for emotional exhaustion followed by 37.83% for depersonalization and 36.57% for low personal achievement. There was a statistically significant difference in the prevalence across the countries in the EMR and among the sub-categories of specialist medical practitioners. There was no statistically significant difference across the two genders at a regionally aggregated level. Conclusions The levels of physician burnout including the three sub-components in EMR are high by any standards. Based on our review of available studies, it is difficult to ascertain gender differences with certainty in burnout levels among physicians in the EMR nations. There is a need for better quality studies in this area.

Mediterranean regions are the most impacted by fire in Europe. The effects of fire on soil greatly vary according to several factors such as vegetation cover type, but they are scarcely studied. Therefore, this research aimed at evaluating the combined impacts of fire and vegetation on single soil characteristics and on the overall soil quality and functionality through two soil quality indices, simple additive (SQI) and a weighted function (SQIFUNCT). In order to reach the aims, burnt and unburnt soils were collected under different vegetation cover types (herbs and shrubs, black locust, pine and holm oak) within the Vesuvius National Park. The soils were analyzed for the main abiotic (water and organic matter content, total C, N, Ca, K, Cu and Pb concentrations, C/N ratio) and biotic (microbial and fungal biomasses, basal respiration, β-glucosidase activity) characteristics. On the basis of the investigated soil characteristics, several soil functions (water retention, nutrient supply, contamination content, microorganism habitat and activities), and the soil quality indices were calculated. The results showed that the impact of fire on soil quality and functionality was mediated by the vegetation cover type. In fact, fire occurrence led to a decrease in water and C/N ratio under herbs, a decrease in C concentration under holm oak and a decrease in Cu and Pb concentrations under pine. Although the soil characteristics showed significant changes according to vegetation cover types and fire occurrence, both the additive and weighted function soil quality indices did not significantly vary according to both fire occurrence and the vegetation cover type. Among the different vegetation cover types, pine was the most impacted one.

Mediterranean pastures are experiencing strong changes in management, involving shifts from sheep to cattle-based livestock systems. The impacts of such shifts on biodiversity are still poorly understood. Here, we sought to contrast the grazing regime, vegetation structure, bird species richness and abundance, between sheep and cattle grazed parcels, to understand the mechanisms through which management decisions impact farmland birds. During spring 2019, we characterized livestock management, bird populations and sward structure in 23 cattle and 27 sheep grazed parcels. We used a Structural Equation Model to infer the direct and indirect effects of sheep and cattle grazing on birds. Although no effects were found on overall species richness, there were species-specific responses to sheep and cattle grazed systems. Grazing pressure (variable integrating stocking rate and the number of days in the parcel) had negative impacts on the prevalence/abundance of Zitting Cisticola, Corn Bunting and Little Bustard, either directly or indirectly, through the effects of grazing pressure on vegetation height. Animal density and vegetation cover had direct positive effects in Galerida spp. and Common Quail, respectively. Zitting Cisticola and Little Bustard also showed a direct response to livestock type. Our study emphasizes the importance of grazing pressure as a driver of negative impacts for bird populations in Mediterranean grasslands. Since the ongoing transition from sheep to cattle-based systems involves increases in stocking rate, and therefore potentially higher grazing pressure, we propose a policy change to cap the maximum allowed grazing pressure. At the landscape scale, a mix of sheep and cattle grazed fields would be beneficial for maintaining bird diversity.

The Eastern Mediterranean Region (EMR) is facing extraordinary social and health challenges, aggravated by epidemiologic variations, high morbidity and mortality burden (communicable, noncommunicable, injuries), consequences of emergencies (including current COVID-19 pandemic), conflicts and massive migrant population movements. Research for health is essential for generating necessary evidence, which contributes to sustainable development, economic growth and sound health policy-making. Moreover, research for health that addresses national public health priorities is essential for developing required evidence for explanations that contribute towards health improvement and can assist in best utilization of available resources towards issues that maximize the research impact on population health.

Techniques of remote sensing are being used to develop phenological studies. Our goal is to study the correlation among the Normalized Difference Vegetation Index (NDVI) related with oak trees included in three set data polygons (15, 25 and 50 km to aerobiological sampling point as NDVI-15, 25 and 50), and oak (Quercus) daily average pollen counts from 1994 to 2013. The study was developed in the SW Mediterranean region with continuous pollen recording within the mean pollen season of each studied year. These pollen concentrations were compared with NDVI values in the locations containing the vegetation under a study based on two cartographic sources: the Extremadura Forest Map (MFEx) of Spain and the Fifth National Forest Inventory (IFN5) from Portugal. The importance of this work is to propose the relationship among data related in space and time by Spearman and Granger causality tests. 9 out of 20 studied years have shown significant results with the Granger causality test between NDVI and pollen concentration, and in 12 years, significant values were obtained by Spearman test. The distances of influence on the contribution of Quercus pollen to the sampler showed statistically significant results depending on the year. Moreover, a predictive model by using Artificial Neural Network (ANN) was applied with better results in NDVI25 than for NDVI15 or NDVI50. The addition of NDVI25 with the lag of 5 days and some weather parameters in the model was applied with a RMSE of 4.26 (Spearman coefficient r = 0.77) between observed and predicted values. Based on these results, NDVI seems to be a useful parameter to predict airborne pollen.

Background: Surgical site infections (SSIs) are the most common and costly type of hospital-acquired infections (HAIs) worldwide. Despite individual studies, there is also no clear statistics on th...

Introduction: This study aimed to assess the adherence to guidelines by practitioners working in the Mediterranean region and to identify the reasons for non-compliance., Methods: A opportunistic self-administered questionnaire was circulated among members of the Mediterranean Group for the Study of Diabetes (MGSD) and regional diabetic associations. The study was limited to the Mediterranean region; 2841 medical practitioners participated in the study. Intervention involved a self-administered questionnaire enabling demographic and personal details to be correlated to relevant information related to practice and continuing health professional education (CHPE) attitudes, perceptions related to diabetes and healthcare systems in the community, and physicians’ attitudes to healthcare practices and target goals relevant to type 2 diabetes mellitus (T2DM). The main outcome measure was adherence to evidence-based guidelines., Results: While the majority of respondents (69.9%) reported being confident in managing these patients, and 79.2% reported being aware of the availability of local guidelines; only a fifth opted to manage patients by strictly targeting an HbA1c value below 6.5%, while 3.3% were happy to maintain an HbA1c value of up to 8.0%. These goals appeared to be tempered by fear of eliciting hypoglycaemia in the belief that patients and their families do not have the skills to manage the complication. Endocrinologists/internists preferred more rigid control., Conclusion: It is clear that the promulgation of evidence-based guidelines cannot assume automatic adoption in clinical practice since adoption is tempered by on-the-ground practice circumstances that make the practitioner reluctant to fully endorse and adopt the targets defined by the guidelines. The evidence-based guidelines need to be modified for local or regional circumstances., This study and the Rapid Service Fee were supported by a financial grant from the Mediterranean Group for the Study of Diabetes which is supported by an unrestricted educational grant from Servier., peer-reviewed

The epidemiology of viral infections transmitted by arthropods is changing due to a variety of parameters related to the virus, the host and the environment. The Mediterranean region is highly affected by changes in the intensity and extension of global-scale climate patterns, and, due to its location, it provides a vulnerable environment for emergence of arboviral diseases. The main arboviruses that pose currently a public health threat in the Mediterranean region are West Nile virus and Crimean-Congo hemorrhagic fever virus and, in less extend, tick-borne encephalitis virus. Usutu virus that affects mainly birds, can infect also humans, while Dengue and Chikungunya viruses showed that they are capable to cause sporadic autochthonous cases, and even outbreaks in the Mediterranean region. Sandly-transmitted viruses continue to have a public health impact, and novel ones have been identified. The presence of competent vectors (mainly mosquitoes), combined by arbovirus introduction through viremic travelers returning from endemic regions, prompt for increased surveillance to mitigate the risk for local transmission. In order to tackle efficiently and effectively the emerging arboviral diseases, an integrated "One Health initiative" is required to be maintained, involving public health, animal health and environmental authorities. Awareness of medical and veterinary staff and laboratory capacity are crucial for the early detection of pathogens, while reporting the unusual and enhance surveillance are important.

Context: Preterm and low-birth weight are of the most common causes of mortality and critical disabilities in newborns. Although advances in neonatal care improved survival and quality of life in the developed countries, mortality and morbidity due to prematurity are still high in the developing and underdeveloped countries such countries in Eastern Mediterranean Region (EMR). Objective: The study aimed at evaluating mortality and morbidity among Very Low Birth Weight (VLBW) and Very Preterm (VP) neonates in EMR. Data Sources: A systematic search was conducted in CINAHL, Cochrane Library, Current Contents, Database of Abstracts of Reviews of Effects (DARE), Google Scholar, PubMed, PsycINFO, Thomson Reuters, Scientific Information Database (SID), and Medical Library (MedLib) as well as regional WHO database to detect relevant studies published from 1996 to 2016. Study Selection: English Language Literature From EMR countries, which reporting outcomes of VLBW and VP were considered. Finally, 32 full text articles were included. Data Extraction: Data on VLBW and VP outcomes including mortality, and short- and long-term morbidities were extracted. Results: Meta-analysis results of prevalence of mortality among VLBW newborns was obtained as 32.0%, which was different from Asian and African countries (23% vs. 55%). Pooled odds ratio of mortality among VLBW newborns was estimated as 2.41. The most prevalent comorbidity in VLBW and VP newborns were allocated to septicemia and Neurodevelopmental Delay (NDD), and the rarest belonged to Periventricular Leukomalacia (PVL) and Necrotizing Enterocolitis (NEC). The main limitation of the current study was lack of relevant studies and adequate sample size. Conclusions: It seems that indicators in EMR should be evaluated independently in Asian and African countries. Septicemia, as relatively curable cause of morbidity, is the most prevalent comorbidity among VLBW infants.