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The Government of the Islamic Republic of Iran (Iran) has embarked on a challenging project aiming to demonstrate how to make road travel safer through speed management measures based on Safe System Approach (SSA) and Result Based Management (RBM). This follows from mounting concern in curbing a high death rate from motor vehicle crashes in recent years. However, despite the Government’s commitment to address this problem, there have been setbacks owing to the challenges of putting in place a strong collaborative framework involving all the agencies charged with responsibilities for road engineering, traffic law enforcement and public education. Iran has established a National Road Safety Commission (NRSC) to lead and coordinate actions. In implementing a demonstration project, specific partnership arrangements have been established at national and provincial levels, as well as pillar-based project teams in 3 provinces. This paper examines the governance structure and opportunities to strengthen the collaborative management of the project and how similar programs can be established and executed in other countries to improve road safety based on SSA and RBM.

The level of road trauma is high in the Eastern Mediterranean Region with the Islamic Republic of Iran having a particularly high fatality rate at 20.5 per 100,000 population. The Government, assisted by the World Health Organisation (WHO), committed to implementing demonstration projects in three provinces that will form the basis of road safety actions to be advanced by the WHO across the Region. In recognition that speed management is a pivotal factor in achieving a safer road and traffic system, and as a component of the project, a review was carried out in 2019 by a team of international experts in the field in collaboration with national consultants. This review was undertaken in consideration of the Safe System Approach and the Results-Based Management Approach. The findings of this review and their implications for future actions in Iran are discussed in this paper.

Road traffic crashes are among the leading causes of death and disability in the world, particularly in low and middle-income countries. This study aimed at to conduct a social marketing formative research to inform the development of a campaign to manage driving speed on the intercity roads of Iran.To carry out the social marketing formative research, a qualitative and quantitative study were conducted. Also, a literature review of the speed management strategies was carried out and an analysis of traffic accident data and speeding violations was performed in selected provinces during 2019 and 2020.Based on the findings of the qualitative study, perceived sense of lack of speed control, poor monitoring system, and law enforcement are the main reasons drivers exceed the speed limit. They mostly suggest using punitive levers and more stringent law enforcement practices for speed management. Literature reviews also confirm that to successfully develop an effective speed management plan a set of measures should be implemented together, including road safety engineering, raising awareness, social marketing strategies, and finally strict law enforcement. The overriding findings of the formative research revealed that to persuade Iranian drivers to respect the speed limit, the messages of the campaign should focus on strict law enforcement in the selected corridors.In the minds of the Iranian audience, strict law enforcement is of paramount importance for a speed management strategy to work; hence it should be taken into consideration when tailoring the campaign messages. From the findings of the present study, it can be concluded that to manage speed on intercity routes in Iran, a social marketing campaign is needed to encourage compliance with speed limits.

The United Nations launched the Sustainable Development Agenda 2030 and its 17 Sustainable Development Goals (SDGs) in 2015, as a more detailed and ambitious follow-up to the Millennium Developments Goals (MDGs). Health and wellbeing of all, at all ages, is addressed by the third SDG (SDG3) and health-related targets of other SDGs. However, progress to date on the health-related SDGs in the Eastern Mediterranean Region (EMR) is not on track. Although there was progress in over half of the 50 health-related SDG targets and indicators between 2015 and 2019, there is still a long way to go. Progress is required, among others, in reducing maternal, child and neonatal mortality; increasing vaccination coverage; reducing the number of cases of malaria and HIV; and in tackling the increase in mortality rates due to noncommunicable diseases. Much progress is needed in many health-related SDGs considered as important social, economic and environmental determinants of health.

Sustainable Development Goals (SDGs) provide a global inclusive indicator framework for improving the population’s health, adapted to each country’s socio-political context. This study aimed to propose a national indicator framework for Iran as a reference list toward SDGs realisation in health and health-related. SDGs and three additional complementary frameworks (WHO Core Health Indicators, Action on Social Determinants of Health Core Indicators and Iranian National Health Equity Indicators) were selected to provide the theoretical base for the National Indicator Framework and to identify, compare, and select the potential indicators based on the country’s contextual needs and capacities. WHO’s “result chain pattern for heath core indicators classification” was used as a conceptual basis to facilitate identifying indicators and to link those to underlying country data systems and data gathering methods. After identifying the initial list of 181 indicators, senior informants from the Ministry of Health and Medical Education-related departments and other health-related organisations were consulted to reduce and verify the initial list. A National Indicator Framework for health monitoring in Iran has been developed to contain 101 indicators (including 12 input/ process indicators, 13 output indicators, 44 outcome indicators, and 32 impact indicators) organised within four domains of “health status”, “risk factors”, “service coverage” and “the health system”. This framework addresses the health core indicators gap identified in paragraph No. 3 under article NO.7 of the Law on Permanent Provisions of Country Development Programs. It will be used to notify policies and programs to improve the health system and population health status at the national level.

This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate (DMPA) and norethisterone enantate was higher (27.7218.16 respectively) than the facility CYP (7.215.08 respectively) (p0.05) with no injection related complications. The CBD's mean CYP for all methods was also found to be four times higher (11.65) than that generated in health facilities (2.86) (p0.05). This suggests that the CBD of injectable contraceptives is feasible and effective, even in a setting like northern Nigeria that has sensitivities about FP.

Objectives: The objective was to assess improvement, or lack thereof, in the uptake of prevention of mother-to-child transmission (MTCT) services at selected sites supported sites by the Global HIV/AIDS Initiative Nigeria (GHAIN). Design: The study used aggregated monthly service statistics to evaluate service improvement efforts that were conducted before and after these were undertaken between July 2007-June 2008. Settings and subjects: The service improvement efforts took place in 60 public healthcare facilities. Outcome measures: The study measured changes in the number of pregnant women who attended antenatal clinics for the first time, the number of pregnant women tested for human immunodeficiency virus (HIV), the number of HIV-positive women receiving antiretroviral (ARV) prophylaxis, and the service ratio, an indicator of the relative uptake of ARV prophylaxis. An estimate of MTCT events that were averted through ARV prophylaxis taken by the pregnant women was also calculated. Results: One hundred and twenty thousand, five hundred and thirty-seven women attended an antenatal clinic (ANC) for the first time. There was an average of 167.4 monthly attendances per facility. ANC attendance increased per facility by 11.1 women monthly post-intervention (p-value < 0.01). The uptake of HIV testing was 87%, with a monthly average increase of 17.8 women tested per facility (p-value < 0.01). ARV prophylaxis uptake rose from 3.3-5.4 women per facility per month (p-value < 0.01). The service ratio per facility improved from 5.3 women receiving ARVs to 6.5 for every 10 women who tested positive for HIV (p-value < 0.01). Applying risk reduction estimates of different ARV regimens, it was estimated that between 88-169 MTCT events were averted pre-intervention, and 143-276 events, post-intervention. Conclusion: Service improvement intervention improved the utilisation of PMTCT services. It should be a key intervention that is used to close the PMTCT gap in Nigeria.Keywords: HIV, PMTCT, evaluation, Nigeria, service improvement, effectiveness

Author details Department of Operations Research, HIV/AIDS Program. Population Council, Nigeria. No. 16, Mafemi Crescent, Utako, Abuja, Nigeria. Department of Health Policy and Management, Diadem Consults Ltd, Abuja, Nigeria. Management Sciences for Health, Abuja, Nigeria. Howard University PACE Center, Washington, USA. Society for Family Health, Abuja, Nigeria. Family Health International 360, Pretoria, South Africa. UNDP Regional Center for Europe and Central Asia, Bratislavia, Slovakia.

Summary The lytic effect of complement activated through the alternative pathway (AP) was studied on pathogenic and nonpathogenic Entamoeba histolytica recently isolated from stool samples. Recent nonpathogenic isolates were nearly unaffected by exposure to AP whereas recent pathogenic stool isolates were highly susceptible to AP dependent complement-mediated lysis. Complement susceptible pathogenic stool isolates developed complement resistance in vivo during hamster liver passage and in vitro during cultivation in the presence of increasing concentrations of normal human serum (NHS). Since a clone of pathogenic HM-l.IMSS which initially was highly susceptible also acquired complement resistance during cultivation in the presence of NHS, it is concluded that complement resistance was caused by induction rather than by selection alone. Because cultivation in the presence of heat-inactivated NHS did not affect complement susceptibility of the cloned HM-l.IMSS, complement activation itself might induce complement resistance in pathogenic E. histolytica.

Objective To evaluate HIV and syphilis prevalence among men who have sex with men (MSM) in Nigeria, and assess their HIV-related risk behaviours and exposure to HIV prevention interventions. Methods Cross-sectional study using respondent-driven sampling conducted in Lagos, Kano and Cross River states, Nigeria, between July and September 2007. Results A total of 879 MSM participated, 293 from each state. Eight participants (1.1%, CI 0.1% to 2.2%) in Cross River, 27 (9.3%, CI 5.7% to 15.4%) in Kano and 74 (17.4%, CI 12.3% to 23.2%) in Lagos tested positive for HIV. No syphilis was detected. The median age was 22 years. MSM reported an average of 4.2 male anal sex partners in the past 6 months. Between 24.4% (Lagos) and 36.0% (Kano) of MSM reported selling sex to other men. Up to 49.7% of MSM reported sex with a girlfriend and ≤6.5% purchased sex from female sex workers. Consistent condom use in commercial sex with other men over the past 6 months ranged from 28.0% (Cross River) to 34.3% (Kano), in contrast to between 23.9% (Kano) and 45.8% (Lagos) for non-commercial sex. Associations with HIV positivity included age in the three states, having been the receptive partner in anal sex in the past 6 months in Lagos and in Lagos and Kano feeling at risk of HIV. Conclusion Large differentials in HIV prevalence between states together with high mobility, inconsistent condom use and behavioural links with female sex partners, have the potential for further HIV transmission within MSM networks, and between MSM and the general population.

The lack of integrated ME system makes it difficult to assess the effectiveness of HIV and family planning (FP) service integration. Since 2007, Nigeria integrated FP and HIV ME systems. A pre-post survey compared the availability and use of FP-HIV integration ME tools six months pre- and 12-months post-integration in 71 health facilities supported by the Global HIV/AIDS Initiative Nigeria (GHAIN). Pre-integration, four facilities (6%) had national FP registers, 32 (45%) had monthly aggregated FP data and 33 (46%) reported data up to national level. Post-integration, all (100%) facilities used national FP register with FP-HIV integration indicators, and reported data up to national level. Sixty six facilities (93%) had at least one monthly supervisory visit. Average number of FP clients per facility referred for HIV testing increased from five in the first month to 15 by month 12 post-integration. Leveraging resources of HIV programs improved significantly the monitoring of FP-HIV services integration.

Objective: To measure changes in service utilization of a model integrating family planning with HIV counselling and testing (HCT) antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in the Nigerian public health facilities. Design: It is a retrospective survey of attendance and family planning commodity uptake in 71 health facilities in Nigeria that analyzes the preintegration and postintegration periods between March 2007 and January 2009. Methods: A prepost retrospective comparison of mean attendance at family planning clinics and couple-years of protection (CYP) compared 6 months preintegration with 9 months postintegration period. An analysis of service ratios was conducted relating completed referrals at family planning clinics to service utilization at the referring HIV clinics. Results: Mean attendance at family planning clinics increased significantly from 67.6 in preintegration to 87.0 in postintegration. Themean CYP increased significantly from32.3 preintegration to 38.2 postintegration. Service ratio of referrals from each of the HIV clinics was low but increased in the postintegration period by 4 34 and 42 per 1000 clients from HCT ART and PMTCT clinics respectively. Service ratios were higher in primary healthcare settings than in secondary or tertiary hospitals. Attendance by men at family planning clinics was significantly higher among clients referred from HIV clinics. Conclusion: Family planning-HIV integration using the referral model improved family planning service utilization by clients accessing HIV services but further improvement is possible. Male utilization of family planning services also improved. The government of Nigeria should review the family planning user fee policy and scale up the integration in primary healthcare facilities.

Background. Human infections with the tissue nematode Onchocerca volvulus show strong interindividual variation in intensity, which cannot be explained by differences in exposure alone. Several lines of evidence suggest a relevant influence of human genetics. Methods. In a genome-wide search for genetic determinants of resistance, we studied 196 siblings from 51 families exposed to endemic O. volvulus transmission in the forest zone of Ghana, West Africa. The numbers of worm larvae in the skin (i.e., microfilariae), which are the established measure of O. volvulus infection intensity, were counted in 4 small skin biopsy specimens (i.e., skin snips), and the numbers of palpable subcutaneous worm nodules (i.e., onchocercomata) were assessed. Numbers were corrected for age and exposure and were analyzed for linkage to 377 autosomal microsatellite markers and additional markers in genomic regions of interest. Results. Linkage was detected between the numbers of microfilariae and chromosome 2p21-p14 (maximum multipoint log 10 of odds (LOD) score of 3.80 at marker position D2S2378; empirical P = 2.9 X 10 -5 ). Conclusions. This finding provides strong evidence that a human genetic factor influences the intensity of O. volvulus infection. The strength of the linkage signal may facilitate the identification of the decisive genetic variants.

Summary Background Of 18 million people world-wide who are infested with the tissue nematode Onchocerca volvulus, more than 30% are considered to have skin lesions, the pathomechanisms of which are poorly understood. Objectives To relate skin changes associated with onchocerciasis to parasitological findings and systemic cellular immune responses. Methods In the course of a genetic study, 691 members of 241 families exposed to hyperendemic O. volvulus transmission and free of other filarial or schistosomal infestations were studied clinically, by counting palpable Onchocerca nodules and skin microfilariae, by measuring peripheral blood cell (PBC) counts and total serum IgE, and by determining PBC in vitro proliferation and cytokine secretion in response to O. volvulus antigen. Results Of 691 individuals studied, 219 presented with onchocerciasis-associated skin changes. The groups of individuals with and without skin lesions neither differed in prevalences nor in average numbers of microfilariae. Compared with individuals without skin lesions, pronounced systemic T-helper (Th) 2-type responses were found with a trend of increasing intensity in the order of depigmentation, papular dermatitis, atrophy and lichenified dermatitis. Differences between the groups were most pronounced for serum IgE, less so for eosinophilia, and relatively weak for PBC proliferation and interleukin-5 secretion. Conclusions Skin lesions in onchocerciasis are associated with a spectrum of increasing generalized Th2-type responses ranging from low reactivities in cases of depigmentation alone to strong reactivities in cases of lichenification.

The cellular immune response to Onchocerca volvulus antigen (OvAg) was studied in 551 persons exposed to O. volvulus transmission in a hyperendemic area of Ghana, West Africa. A whole-blood assay showed that, in response to a soluble O. volvulus extract, cell proliferation, as well as interleukin (IL)-5 and IL-13 concentrations in the supernatants, were high in cultures of blood from microfilaria (mf)-negative persons and significantly decreased with increasing mf counts of the donors. Only background concentrations of interferon (IFN)-gamma were found, and these did not correlate with mf counts. In response to a mitogen, cells from all persons strongly reacted with proliferation and secretion of all 3 cytokines studied. These findings show that the response of human peripheral blood cells to OvAg does not include significant IFN-gamma production; that mf negativity is associated with IL-5 and IL-13 production but not, as previously suggested, with IFN-gamma production; and that IL-5 and IL-13 production decreases with increasing mf density.

Mutations of the connexin 26 gene (GJB2) were studied in 365 apparently unrelated individuals with profound nonsyndromic, sensorineural hearing impairment from Ghana, West Africa. Among 121 mutated chromosomes found, 110 carried the previously described R143W mutation. A total of 6 novel mutations: L79P, V178A, R184Q, A197S, I203K, and L214P, were identified, whereby I203K was based on a dinucleotide exchange and R184Q appeared to be dominant. The GJB2 variants found in Ghana tend to comprise less nonsense and frameshift mutations and more mutations located in the C-terminal half of the molecule than the variants found in other parts of the world. Hum Mutat 18:84-85, 2001. © 2001 Wiley-Liss, Inc.

Entamoeba histolytica is susceptible to complement attack in its lumen-dwelling state and develops complement resistance during pathogenic tissue invasion. As experimental evidence suggests that this change in phenotype is accompanied by a change in gene expression, we constructed a subtractive cDNA library to identify genes involved. Poly(A) + RNA from complement-sensitive trophozoites was subtracted from single stranded cDNA derived from complement-resistant ones. Transcripts enriched in the library were found to code for a putative polypeptide comprising all sequence elements characteristic for serine/threonine protein kinases. The gene contains an intron of 46 nucleotides and two polyadenylation sites. Northern-blot analyses confirmed that the gene is expressed in both tissue-derived and laboratory-grown forms of complement-resistant E. histolytica.

Pathogenic forms of the protozoan parasite Entamoeba histolytica were reported previously to resist the cytolytic effect of the alternative complement pathway (AP) only temporarily during exposure to complement. In contrast, nonpathogenic forms of E. histolytica had been found to show AP resistance as a stable property. We studied the mechanisms of AP resistance of the two forms. Upon exposure to AP activity, resistant pathogenic or nonpathogenic forms bound significantly less C3 products than complement-sensitive pathogenic amebae, indicating that the two resistant forms both inhibited AP amplification. Various enzymatic treatments and inhibition of membrane mobility by cytochalasin B and glutaraldehyde fixation showed that the mechanisms of AP inhibition differed between pathogenic and nonpathogenic forms; in contrast to nonpathogenic forms, pathogenic amebae required intact membrane mobility and a trypsin-sensitive surface component(s) to inhibit AP activation.

Summary The effect of nonimmune human serum on Entamoeba histolytica trophozoites was studied: (a) using whole serum in the presence of Ca and Mg ions allowing complement activation via both the alternative and classical pathways or in the presence of MgEGTA permitting alternative pathway activation only; (b) using different E. histolytica isolates; (c) varying serum and trophozoite concentrations and the time of incubation; and (d) using three different methods to quantify lysis, i.e., microscopic inspection, flow cytometry and 111In release. All three methods yielded similar results, with flow cytometry being most sensitive in identifying membrane damage and 111In release being most valid in determining cell death. Microscopic analysis was reliable only when a chamber was used to calculate the number of complement treated cells in relation to the initial cell count. E. histolytica isolates were classified into three groups according to their susceptibility to lysis by complement: (i) pathogenic isolates after long term cultivation in vitro were susceptible; (ii) pathogenic isolates after recent in vivo passage were less susceptible; and (iii) nonpathogenic isolates were nearly unaffected by exposure to the alternative pathway alone. The extent of lysis of the various isolates correlated with the degree of complement consumption in the serum samples, suggesting that unlysed isolates did not activate complement under the conditions employed. In general, lysis of susceptible trophozoites increased with the serum concentration and with the time of incubation. However, when the trophozoite concentration was 106/ml or higher, lysis no longer reflected complement susceptibility because of exhaustion of the complement supply.

Endosymbiotic bacteria living in plasmodia or worm parasites are required for the homoeostasis of their host and should be excellent targets for chemotherapy of certain parasitic diseases. We show that targeting of Wolbachia spp bacteria in Onchocerca volvulus filariae by doxycycline leads to sterility of adult worms to an extent not seen with drugs used against onchocerciasis, a leading cause of blindness in African countries.