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The impact of pneumococcal conjugate vaccines (PCVs) on the burden of invasive pneumococcal disease (IPD) and serotype distribution was examined across age groups from data collected by the Lebanese Inter-Hospital Pneumococcal Surveillance Program. Between 2005 and 2020, 593 invasive Streptococcus pneumoniae isolates were collected from 79 hospitals throughout Lebanon. Serotypes and antimicrobial resistance (AMR) profiles were identified, and trends compared over 3 eras: PCV7, post-PCV7/ pre-PCV13, and PCV13 eras. The prevalence of PCV7 serotypes decreased significantly from 43.6% in the PCV7 era to 17.8% during the PCV13 era (p

Background Forced displacement and war trauma cause high rates of post-traumatic stress, anxiety disorders and depression in refugee populations. We investigated the impact of forced displacement on mental health status, gender, presentation of type 2 diabetes (T2D) and associated inflammatory markers among Syrian refugees in Lebanon. Methods Mental health status was assessed using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25). Additional metabolic and inflammatory markers were analyzed. Results Although symptomatic stress scores were observed in both men and women, women consistently displayed higher symptomatic anxiety/depression scores with the HSCL-25 (2.13 ± 0.58 versus 1.95 ± 0.63). With the HTQ, however, only women aged 35–55 years displayed symptomatic post-traumatic stress disorder (PTSD) scores (2.18 ± 0.43). Furthermore, a significantly higher prevalence of obesity, prediabetes and undiagnosed T2D were observed in women participants (23.43, 14.91 and 15.18%, respectively). Significantly high levels of the inflammatory marker serum amyloid A were observed in women (11.90 ± 11.27 versus 9.28 ± 6.93, P = 0.036). Conclusions Symptomatic PTSD, anxiety/depression coupled with higher levels of inflammatory marker and T2D were found in refugee women aged between 35 and 55 years favoring the strong need for psychosocial therapeutic interventions in moderating stress-related immune dysfunction and development of diabetes in this subset of female Syrian refugees.

BackgroundPatient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these do not capture all the information available through patient engagement. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study was aimed to identify and explore patient perspectives on hospital care in Lebanon, and to describe how they relate to the national pay-for-performance initiative.MethodsWe conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.ResultsFive overall themes supported by 17 categories were identified, capturing the meaning of the informants’ perspectives: health is everything; being turned into second class citizens; money and ‘wasta’ (personal connections) make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with one’s doctor.ConclusionsPatient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

To review our national cervical cancer screening program using existing Ministry of Public Health primary healthcare centers (PHCs) and report the impact of women's knowledge, attitude, behavior, and practices on screening uptake and outcome.A cross-sectional study on cervical cancer screening offered to sexually active Lebanese women aged 21 years and above visiting PHCs. Exclusions were history of complete hysterectomy, gynecologic cancers, and current pregnancy. Data were collected through a questionnaire and conventional cervical smear performed by trained healthcare providers and sent to one centralized cytopathology laboratory.Of 12 273 eligible women, 1.7% had an abnormal cervical smear test including 161 atypical squamous cells (ASC) of undetermined significance, 6 atypical glandular cells of undetermined significance, 16 low-grade squamous intraepithelial lesion (SIL), 17 ASC-cannot rule out high-grade SIL, 11 high-grade SIL, and one invasive carcinoma. Knowledge and attitudes significantly affected participation in screening; women lacking awareness had rarely undergone a cervical smear.In Lebanon, cytology-based cervical cancer screening is feasible within the PHCs. Positive screen incidence was low. Despite previous campaigns, a low level of knowledge persists, and affects women's com with the screening guidelines. Advocacy and awareness activities by key healthcare providers may help to improve participation.

Osteoporosis is more common than most feared non-communicable diseases in the Middle East. This justifies the need to place osteoporosis as a health priority in the region. Osteoporosis is a common disease associated with severe debilitating consequences. The objective of this study is To evaluate and compare disease burden from osteoporosis and other non-communicable diseases (NCDs) in Lebanon. We assessed the prevalence of osteoporosis and other NCDs, such as obesity, diabetes, hypertension, dyslipidemia, and cardiovascular diseases, based on a published population-based study of Lebanese ≥ 65 years. We compared incidence rates of hip fractures and major osteoporotic fractures (MOF) (spine, hip, humerus, and forearm) to the five commonest cancers in women ≥ 50 years. Rates were based on the national hip fracture and cancer registry data, provided by the Lebanese Ministry of Public Health. MOF incidence rates were derived from national hip fracture incidence rates and MOF/hip fractures incidence rate ratios from the literature. Over 70% of elderly Lebanese had osteoporosis defined by densitometric criteria or prevalent morphometric vertebral fractures. This by far exceeded the prevalence of other NCDs, such as hypertension (53%), diabetes (21%), dyslipidemia (31%), and cardiovascular diseases (30%). Morphometric vertebral fractures (grades 2 and 3) were present in 19% of women and 12% of men. The incidence rates for MOF were 1.6 times greater than those for breast cancer, and 7.4–9.9 folds higher than those for the next commonest cancers of the lungs, colon, and ovaries. Hip fracture incidence rates were lower than those of breast cancer but were 2.1–2.8 folds higher than those of the above-mentioned cancers. This first of its kind study in the Middle East demonstrates that osteoporosis is a common disease, more common than most feared NCDs. Our findings are comparable to those in western populations and justify placing osteoporosis on the top of NCDs’ priority list in our country and possibly the region.

People who inject drugs (PWIDs) are prone to a number of blood-borne viral infections. Hepatitis B virus (HBV) and hepatitis C virus (HCV) constitute an important public health concern in this high risk group.We aimed to determine the prevalence of HBV and HCV antibody among PWIDs in Lebanon.We conducted a prospective cross-sectional study between June 2015 and June 2016 on PWIDs recruited through Lebanese nongovernmental organizations in collaboration with the Lebanese Ministry of Public Health. The participants were tested for HBs antigen and HCV antibody using rapid test kits. The prevalence of each virus was then calculated. The correlation between both infections and other possible risk factors was also analysed.A total of 250 people were included in our study, of whom 98% were males. Mean age was 31.9 (standard deviation 8.7) years. The prevalence of HBsAg and anti-HCV among PWIDs was 1.2% and 15.6%, respectively. Older age, longer duration of drug use and lack of awareness were significantly correlated with a higher rate of HCV infection (P0.01). The high rate of needle sharing among our PWIDs significantly affected the prevalence of anti-HCVAb.PWIDs remain the subpopulation most affected with chronic HCV in Lebanon.معدل انتشار فيروس التهاب الكبد B وفيروس التهاب الكبد C في صفوف الأفراد الذين يتعاطون المخدرات حقنا في الفئات السكانية في لبنان.أنطوان أبو راشد، ماري نخول، كارين ريكا، عفيف جريج، بيير أبي حنا، وليد عمار.إن الأشخاص الذين يتعاطون المخدرات حقنا معرضون للإصابة بعدد من العداوى الفيروسية المنقولة عن طريق الدم. ويشكل فيروس التهاب الكبد B وفيروس التهاب الكبد C مصدرا للقلق البالغ على مستوى الصحة العامة ضمن هذه الفئة المعرضة لخطر مرتفع.هدفنا إلى تحديد معدل انتشار فيروس التهاب الكبد B وفيروس التهاب الكبد C في صفوف الأشخاص الذين يتعاطون المخدرات حقنا في لبنان.أجرينا دراسة استباقية مقطعية بين يونيو/حزيران 2015 و يونيو/حزيران 2016 على الأشخاص الذين يتعاطون المخدرات حقنا، والذين حشدتهم المنظمات غير الحكومية اللبنانية بالتعاون مع وزارة الصحة العامة في لبنان. وخضع المشاركون في اختبار لمستضدات التهاب الكبد B وأضداد فيروس التهاب الكبد C باستخدام عتائد الاختبار السريع. ثم تم احتساب معدل انتشار كل فيروس على حدة. كما جرى تحليل العلاقة الارتباطية بين كلا النوعين من العدوى وعوامل خطر أخرى محتملة.ضمت الدراسة عددا إجماليا بلغ 250 شخصا، %98 منهم من الذكور. وكان متوسط العمر 31.9 سنة (بانحراف معياري 8.7). وبلغ معدل انتشار مستضدات التهاب الكبد B وأضداد فيروس التهاب الكبد C في صفوف الأشخاص الذين يتعاطون المخدرات حقنا %1.2 و %15.6 على التوالي. وظهر ارتباط قوي بين كل من تقدم العمر، واستطالة مدة تعاطي المخدرات، ونقص الوعي بارتفاع معدل الإصابة بعدوى فيروس التهاب الكبد C(0.01P). وأدى ارتفاع معدل التشارك في استخدام الإبر في صفوف الأشخاص الذين يتعاطون المخدرات حقنا في لبنان إلى التأثير بصورة يُعتدُّ بها على معدل انتشار أضداد فيروس التهاب الكبد C.يظل الأشخاص الذين يتعاطون المخدرات حقنا هم الفئة الفرعية من السكان الأشد تأثرا بالتهاب الكبد C المزمن في لبنان.Prévalence des virus de l’hépatite B et de l’hépatite C chez les consommateurs de drogues injectables dans la population libanaise.Les consommateurs de drogues injectables sont exposés à un certain nombre d’infections virales transmises par le sang. Les virus de l’hépatite B (HBV) et de l’hépatite C (HCV) constituent une préoccupation de santé publique majeure dans ce groupe à risque élevé.La présente étude avait pour objectif de déterminer la prévalence du HBV et du HCV chez les consommateurs de drogues injectables au Liban.Entre juin 2015 et juin 2016, nous avons mené une étude transversale prospective sur des consommateurs de drogues injectables recrutés par l’intermédiaire d’organisations non gouvernementales libanaises, en collaboration avec le ministère de la Santé publique libanais. Les participants ont été soumis à des tests de dépistage des antigènes de surface de l’hépatite B et des anticorps anti-HCV à l’aide de kits de dépistage rapide. La prévalence de chaque virus a ensuite été calculée. La corrélation entre les deux infections et d’autres facteurs de risque possibles a également été examinée.Au total, 250 personnes ont été incluses dans l’étude, dont 98 % d’hommes. L’âge moyen était de 31,9 ans (écart type 8,7). La prévalence des antigènes de surface du virus de l’hépatite B et des anticorps anti-HCV, parmi les consommateurs de drogues injectables, était respectivement de 1,2 % et de 15,6 %. On a observé une corrélation significative entre l’âge, une durée plus longue de consommation de drogue, le manque de sensibilisation et le taux plus élevé d’infection à HCV (p0,01). Le taux élevé de partage de seringues chez les consommateurs de drogues injectables avait une incidence significative sur la prévalence des anticorps anti-HCV.Les consommateurs de drogues injectables restent la sous-population la plus touchée par l’hépatite C chronique au Liban.

PURPOSE Chronic myeloid leukemia (CML) ranks second in terms of disease-related health care expenditures at the Lebanese Ministry of Public Health (MoPH) after breast cancer. With the introduction of tyrosine kinase inhibitors (TKIs), survival of patients with CML has dramatically improved and approached that of the normal population. In recent years, several studies demonstrated that patients who achieve a deep molecular response while receiving TKI therapy could safely attempt treatment-free remission (TFR), the new treatment goal in patients with CML. The objective is to estimate the budget impact of TFR at the MoPH. METHODS Analyses were done on 162 patients with CML receiving imatinib, nilotinib, or dasatinib, as first-line or second-line therapy, over a 4-year time horizon using MoPH drug pricing. The model assumed that patients could attempt TFR after 36 months of TKI therapy, where the last 24 months were at stable molecular response as per MoPH and National Comprehensive Cancer Network guidelines. Duration of TFR was based on European Stop Kinase Inhibitor treatment-free survival curve. RESULTS Out of the 162 patients, 83 were eligible to attempt TFR, 36 patients were not eligible, 32 patients were lost to follow-up, two patients died as a result of CML progression, and five died as a result of other causes. The total cost of CML treatment with TFR from the time of analysis and over 4 years can be reduced by more than 7 million US dollars (57%). CONCLUSION The model can be used to inform health care decision makers on the importance of TFR and the potential savings.

Background Arterial stiffness is strongly linked to the pathogenesis of heart failure (HF), and development of acute decompensation of patients with stable chronic HF. Purpose To compare the arterial stiffness indices in patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization with acute decompensated state, and then three months later after discharge during the compensated state. Methods One hundred patients with acute decompensated HFrEF (NYHA class III and IV) and left ventricular ejection fraction (LVEF) ≤35% were included in the study. Fifty-six patients (56%) had ischemic cardiomyopathy (ICM) and the rest had dilated cardiomyopathy (DCM). During the initial and follow up visits, all patients were subjected to full medical history taking, clinical examination, electrocardiography (ECG), transthoracic echocardiography (TTE), routine labs and non-invasive pulse wave analysis (PWA) by the Mobil-O-Graph 24h PWA device for measurement of arterial stiffness parameters. Results The mean age was 51.6±6.1 years and 80% were males. There was a significant reduction of the central arterial stiffness indices in patients with HFrEF during the compensated state as compared to their decompensated state values, table (1). During the decompensated state, patients with ICM showed a significantly higher PWV as compared to patients with DCM (9.2±1.1 vs 8.6±1.4 m/sec, P=0.042), patients presented with NYHA FC IV (n=64) showed higher AI (24.5±10.0 vs 16.8±8.6, p Conclusion Central arterial stiffness indices derived from the non-invasive Mobil-O-Graph 24h PWA device in patients with HFrEF were significantly lower in the compensated state as compared to the decompensated state. Patients with ICM, NYHA FC IV and females showed higher stiffness indices in their decompensated state of heart failure. Funding Acknowledgement Type of funding sources: None.

Lebanon invested in the prevention of maternal mortality after the civil war, which left a deficient vital registration system leading to unreliable estimates of maternal mortality ratio (MMR). Starting in 2004, the Ministry of Public Health integrated reproductive health into primary health care and established a national notification system of maternal and neonatal deaths. From 1990 to 2013, Lebanon achieved an annual change in MMR of -7.5%, which was the highest rate of reduction in the region and met the requirements of Millennium Development Goal 5. For the period 2010-2018, data collected through the national notification system indicate an MMR of 14.9, which is below the officially reported MMR of 23. Since the influx of Syrian refugees, Lebanon has experienced a rise in the number of live births with a slightly increasing trend in MMR, especially in regions with the highest concentration of refugees. Causes of maternal mortality in Lebanon align with the three-delays model, pointing to deficiencies in the quality of maternity care. More efforts are needed toward strengthening the national notification system to include cases that occur outside hospitals, identifying near-miss cases, reinforcing the emergency response system, and engaging with all stakeholders to improve quality of care.

Background: Foodborne diseases are still a major health issue in Lebanon, although some steps have been taken forward in food safety. To this purpose, PulseNet Lebanon, a foodborne diseases tracking network, was established in 2009, through the collaboration between the Ministry of Public Health (MoPH) and the American University of Beirut (AUB). Materials and Methods: Three papers published regarding the PulseNet project were summarized. Initially, clinical and food samples, collected within the surveillance network scope, were identified by using the respective API for Salmonella and Listeria spp. Salmonella spp. were further serotyped by using the Kauffman and White method. Campylobacter spp. were determined by the 16 S rRNA sequencing method. Antimicrobial susceptibility to a number of antibiotics was determined by using the disk diffusion method for Samonella and Campylobacter spp. Genomic diversity was determined by using pulsed field gel electrophoresis (PFGE) and random amplified polymorphic DNA (RAPD). Results: Results indicated that 290 clinical and 49 food isolates were identified as Salmonella. Serotyping revealed the prevalence of ten and seven serotypes in the clinical and food samples, respectively. Fifty-one isolates from chicken ceca and carcass were identified to be Campylobacter spp. Fifty-nine samples were identified to be Listeria monocytogenes. Antimicrobial susceptibility testing revealed a wide range of resistance among the different samples. PFGE showed a variation in pulsotypes among the Salmonella serotypes. PFGE also linked certain outbreaks to their food sources. This method also demonstrated 13 subtypes with 100% similarity among the L. monocytogenes isolates. Finally, the Camplyobcater spp. were grouped into nine clusters with a minimum similarity of 43.5% using RAPD. Conclusion: This summary of results shows the importance of implementing a “farm-to-fork” approach in the surveillance of foodborne disease outbreaks in Lebanon, allowing the detection of pathogens causing foodborne disease outbreaks in a timely fashion.

Globally the nephrology community is witnessing an increased use of high-flux membranes and ultrapure water in haemodialysis (HD) units, and in low-and middle-income countries, data are lacking regarding HD water quality. In Lebanon the Ministry of Public Health released a decree calling for a progressive change in the HD water treatment system in order to implement ultrapure water in all dialysis facilities. This article reports on the problems previously encountered regarding water quality in Lebanon. It exposes the recent changes in standards as recommended by the government, especially the mandatory three sessions per week and ultrapure water. In addition, it analyses the cost-effectiveness of ultrapure water implementation in a low/middle-income country and demonstrates that the cost is lower than in high-income countries. Finally, this article summarizes the obstacles met and suggests a practical approach to maintain this high level of water treatment quality.

Background Following the Syrian crisis, a substantial influx of Syrian refugees into Lebanon posed new challenges to optimal vaccination coverage for all children residing in the country. In 2016, the district-based immunization coverage evaluation survey (CES) assessed routine immunization coverage at the district level in Lebanon among children aged 12–59 months. Methods A cross-sectional multistage cluster survey was conducted in all of Lebanon (with the exception of the Nabatieh district) using the World Health Organization (WHO) recommended Expanded Programme on Immunization (EPI) methodology adapted to the local context. A survey questionnaire consisting of closed and open-ended questions concerning demographic information and the child’s immunization status was administered to collect immunization status information. Results Among surveyed children aged 12–59 months, irrespective of nationality, vaccination coverage at the national level for any recommended last dose was below the targeted 95%. Generally, vaccination coverage levels increased with age and were higher among Lebanese than Syrian children. However, large variations were revealed when coverage rates were analyzed at the district level. Vaccination was significantly associated with nationality, age, mother’s educational status and the place of vaccination. Common reasons for undervaccination included the child’s illness at the time of vaccine administration, vaccination fees, lack of awareness or a doctor’s advice not to vaccinate during campaigns. Conclusions Substantial variability exists in vaccination coverage among children aged 12–59 months residing in different districts in Lebanon. Immunization coverage reached 90% or above only for the first doses of polio and pentavalent vaccines. A considerable dropout rate from the first dose of any vaccine is observed. Efforts to optimize coverage levels should include increased vaccination initiatives targeting both refugee children and children from vulnerable host communities, increased cooperation between public and private vaccine providers, improved training for vaccine providers to adhere to complete vaccine administration recommendations, and increased awareness among caregivers. Electronic supplementary material The online version of this article (10.1186/s12889-019-6418-9) contains supplementary material, which is available to authorized users.

Purpose This study aims to evaluate trends in the increasing costs of oncology drugs procured by the Lebanese Ministry of Public Health (MOPH) between 2014 and 2016 and to assess the impact of the introduction in mid-2015 of new immunotherapy drugs for the treatment of lung cancer on the overall and specific costs of that treatment. Methods A secondary analysis of data from the MOPH Cancer Drug Scientific Committee data base was conducted using a total of 18,133 cancer files between 2014 and 2016. Results Over the 3-year period, about $140 million (USD) was spent on cancer drugs by the MOPH free cancer drug dispensing program. The expenditures increased by 27% after immunotherapy was phased in. The average cost of drugs per patient per year measured across all cancer types increased from $7,000 in 2014 to $8,400 in 2016. Trastuzumab, approved for treating human epidermal growth factor receptor 2–positive breast cancer ranked first in total expenditures for 2014-2015. By 2016, two new immunotherapy drugs had topped the list: pembrolizumab ranked first and nivolumab ranked third, representing 64% of the total cost of lung cancer treatment and approximately 19% of the total yearly budget; beneficiaries represented only 3% of all patients. Conclusion This update documents the increasing financial impact of newer cancer drugs on the procurement process in the middle-income country of Lebanon. The trend is aligned with the financial burden of cancer drugs worldwide, which calls for a collaborative global response to this crisis.

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Background Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called ‘eSahha’. Methods The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed. Results About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001). Conclusion While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed. Keywords e-health, refugees

Background Given the sparse information on the burden of influenza in Lebanon, the Ministry of Public Health established a sentinel surveillance for severe acute respiratory infections (SARI) to identify the attribution of influenza to reported cases. We aim to highlight the proportion of influenza‐associated SARI from September 1st, 2015 to August 31st, 2016 in 2 Lebanese hospitals. Methods The study was conducted in 2 sentinel sites located in Beirut suburbs and southern province of Lebanon. WHO's 2011 standardized SARI case definition was used. Data from September 1, 2015 to August 31, 2016 were reviewed, and all‐cause hospital admission numbers were obtained. Nasopharyngeal swabs were collected and tested by RT‐PCR. Descriptive and bivariate analyses were conducted using STATA 13. Results The 2 sentinel sites reported 746 SARI cases during the studied time frame: 467 from the southern province site and 279 from the Beirut suburbs site. SARI reports peaked between January and March 2016. All, except 4, cases were sampled, and a co‐dominance of influenza B (43%) and influenza A (H1N1) (41%) was evident. A high proportion of cases was reported in children

This community-based, cross-sectional survey was conducted to determine the prevalence of anemia and iron deficiency anemia (IDA) and their association with nutritional behavior and other determinants. Arabic-speaking women, aged 15–49 years old, residing in Lebanon’s rural areas were included. Demographic and behavioral characteristics, obstetrical and gynecological history, personal and family medical history, and dietary intake data were collected. Predictors of anemia and IDA were determined using logistic regression. A total of 578 women were included (Lebanese: 55.2%; Syrian: 43.3%) in which 35.5% had anemia and 23.2% had IDA. The mean number of pregnancies was 3.1 ± 3.0 (number of children: 2.5 ± 2.5). In total, 30% had a personal history of anemia or IDA, 29% a family history of anemia, and 20% a family history of IDA. Iron-rich products were consumed by > 90% of the women, whereby > 66.7% mentioned eating liver, tuna, dates and nuts. Syrian nationality (OR = 2.21; CI 95%: 1.38–3.54), age (OR = 1.03, CI 95%: 1.00–1.06), personal history of anemia (OR = 1.97; CI 95%: 1.31–2.95), consumption of dates (OR = 2.07, CI 95%: 1.29–3.31), molasses (OR = 1.61; CI 95%: 1.03–2.51), and soft drinks > 5 times/week (OR = 1.66; CI 95%: 1.09–2.53) were predictors of anemia. Syrian nationality (OR = 1.73, CI 95%: 1.14–2.62), number of pregnancies (OR = 1.08; CI 95%: 1.01–1.15), period > 8 days (OR = 2.01, CI 95%: 1.07–3.80), consumption of eggs (OR = 0.48; CI 95%: 0.25–0.90), dates (OR = 2.58, CI 95%: 1.49–4.46), and coffee or tea (OR = 1.59, CI 95%: 1.03–2.45) were predictors of IDA. Anemia and IDA are prevalent in women of childbearing age in rural Lebanon. Intervention programs for raising the population’s awareness about IDA’s risk factors and proper nutrition must be implemented.

Waterpipe smoking is a rising global public health epidemic perceived by many users to be less harmful, though its toxicity overlaps or even exceeds that of cigarette smoking. Short-term cardiovascular changes due to waterpipe smoking are well established, but longer-term health impacts are still not fully elucidated.We aim to investigate the association of waterpipe smoking with myocardial infarction among patients undergoing cardiac catheterization.The study was performed on Lebanese patients referred for cardiac catheterization. Patient's blood was collected for metabolic measures and questionnaires were filled out to include socio-demographic, behavioral and pertinent medical characteristics of the study subjects.Myocardial infarction is significantly and independently associated with waterpipe smoking, with odds ratio (OR) of 1.329 (95% CI: [1.04-1.68]; p = .021), which is lower than that for cigarette smoking (OR = 1.87, 95% CI: [1.63-2.15]; p .001). Only diabetes showed significant association with waterpipe smoking among MI enrollees (OR = 1.66, 95%CI: [1.04-2.63]; p = .032).The study provides yet another evidence for the adverse cardiovascular effects of waterpipe smoking on a clinical level. The harmful effects of waterpipe smoking should be underscored by health care professionals.

Low job satisfaction is linked to higher staff turnover and intensified shortages in healthcare providers (HCP). This study investigates the level of, and factors associated with, HCP job satisfaction in the national primary healthcare (PHC) network in Lebanon. The study adopts a cross-sectional design to survey HCP at 99 PHC centres distributed across the country between October 2013 and May 2014. The study questionnaire consisted of four sections: socio-demographics/professional background, employment characteristics, level of job satisfaction (Measure of Job Satisfaction scale) and level of professional burnout (Maslach Burnout Inventory-HSS scale). A total of 1,000 providers completed the questionnaire (75.8% response rate). Bivariate and multivariate regression analyses were used to identify factors significantly associated with job satisfaction. Findings of the study highlight an overall mean job satisfaction score of 3.59 (SD 0.54) indicating that HCP are partially satisfied. Upon further examination, HCP were least satisfied with pay, training and job prospects. Gender, age, career plans, salary, exposure to violence, and level of burnout were significantly associated with the overall level of job satisfaction which was also associated with increased likelihood to quit. Overall, the study highlights how compensation, development and protection of PHC HCP can influence their job satisfaction. Recommendations include the necessity of developing a nationally representative committee, led by the Ministry of Public Health, to examine the policies and remuneration scales within the PHC sector and suggest mechanisms to bridge the pay differential with other sectors. The effective engagement of key stakeholders with the development, organisation and evaluation of professional development programmes offered to HCP in the PHC sector remains crucial. Concerned stakeholders should assess and formulate initiatives and programmes that enrich the physical, psychological and professional well-being of their HCP. The aforementioned suggestions are necessary to strengthen and sustain PHC HCP and support the provision of universal health coverage to the Lebanese population.

Background and study aims The prevalence of hepatitis C in Lebanon is low. It is estimated at 0.2% of the total population. The aim of our study is to evaluate the exact prevalence of each genotype on a large scale population and in each potential source of infection. Patients and methods We reviewed all the data in the Ministry of Public Health related to patients who have submitted their file for treatment during a period of 9 years ranging from January 2005 till December 2013. Results The genotype distribution in 1031 Lebanese patients was as following: Genotype 1 was the most predominant representing 47% followed by genotype 4 representing 34% then genotype 3 representing14%. Concerning sex distribution and routes of infection, there was a male predominance in intravenous drug users (IVDU), whereas approximately equal distribution was noted in haemodialysis and transfusion groups. A female predominance was noted in the “unknown” mode of infection. Concerning age distribution and routes of infection, a mean age of 27 was noted in the IVDU group, whereas mean age of 60 in the transfusion group and 50 in the haemodialysis group. In patients who acquired the infection post transfusion or during haemodialysis, genotype 1 was the most predominant, whereas in IVDU, genotype 3 was the most predominant. Concerning sub-genotyping: subtype 1b was the most predominant (84%) in genotype 1. in genotype 2 subtype b with 75%, all genotype 3 were subtype a, in genotype 4 subtype a represents 50% of genotype followed by subtype e in 30%. Conclusion Our data concerning Lebanese population demonstrate that genotype 1 is the most prevalent genotype followed by genotype 4. In IVU, we noted genotype-3 and -1 being the most prevalent in relation to clustering in this high risk group. This distribution differs from most surrounding countries and all other Arab countries.

Aims Worsening of renal function (WRF) is a common complication in patients with acute decompensated heart failure (ADHF). We aimed to evaluate the role of intrarenal Doppler ultrasound (IRD) in the early prediction of WRF in this patient group. Methods and results Among 90 patients (age: 57.5 ± 11.1 years; 62% male) hospitalized with ADHF, resistivity index (RI), acceleration time (AT), and pulsatility index (PI) were measured on admission and at 24 and 72 h. WRF was defined as increased serum creatinine ≥0.3 mg/dL from baseline. Adverse clinical outcomes were defined as the composite of death, use of vasopressors, and need for ultrafiltration for refractory oedema. WRF developed in 40% of patients. Mean values of renal AT, RI, and PI on admission were 59.7 ± 15, 0.717 ± 0.08, and 1.5 ± 0.48 ms, respectively. At 24 h, there was significant decrease in AT (to 56.7 ± 10 ms, P = 0.02) and renal RI (to 0.732 ± 0.07; P

—Since 2009, the Ministry of Public Health (MoPH) in Lebanon has been going through a major reform initiative to improve its contracting system with private and public hospitals. The private sector is the main provider of hospital care in the country and the main contractor to the MoPH for the provision of curative care. As an “insurer of last resort,” the MoPH plays an important role in providing hospital coverage to 53% of the population who lack coverage by private or public insurance schemes, through contractual arrangements with the private sector. Historically, the MoPH used hospital accreditation as the basis for contracting and for determining the reimbursement rate. However, recent studies by the MoPH showed that reimbursing hospitals solely on accreditation results was not appropriate and led to an unfair and inefficient reimbursement system. The reform program included the development of several components, in particular, an automated billing system, a utilization review function, standardized admission criteria, and a hospital case mix index that accounts for case complexity. In 2014, the MoPH started implementing a new mixed-model contracting system with private and public hospitals. Preliminary evaluation of the new model suggests that the system incentivized hospitals to admit fewer inappropriate cases and more cases that are more complex/serious. This article shares one experience of how to introduce a merit-based system to face the common practice of political clientelism and confessional/religious-based favoritism in Lebanon. It highlights the importance of stakeholder engagement in a framework of networking and participatory governance that proved to be a key element behind the resilience of a diversified health system.

Background In the international agenda, it has become common to assert that the assessment of health system governance using a practical tool is crucial. This approach can help us better understand how health systems are being steered as well as to identify gaps in the decision-making process and their causes. The authors developed a new assessment tool, the Health Policymaking Governance Guidance Tool (HP-GGT), that was designed to be conceptually sound and practical. This tool enables policy-makers and stakeholders to systematically review and assess health system governance at policy-making level. This article presents first use of the HP-GGT in Lebanon, together with generated results, recommendations, and discusses how these results improve governance practices when initiating new health policy formulation processes. Methods The HP-GGT, which is a multidimensional structured tool, was used retrospectively to assess and review the process used to develop a new mental health strategy; this process was compared against consensus-based good governance principles, focusing on participation, transparency, accountability, information and responsiveness. The assessment was conducted through face-to-face interviews with 11 key informants who were involved in the development of the strategy. Results The HP-GGT enabled policy-makers to reflect on their governance practices when developing a mental health strategy and was able to identify key areas of strengths and weaknesses using good governance practice checklists given by the questions. The insights generated from the assessment equipped the national policy-makers with a better understanding of the practice and meaning of policy-making governance. Identifying weaknesses to be addressed in future attempts to develop other national health policies helped in this regard. Using the tool also increased awareness of alternative good practices among policy-makers and stakeholders. Conclusions Assessing a health policy formulation process from a governance perspective is essential for improved policy-making. The HP-GGT was able to provide a general overview and an in-depth assessment of a policy formulation process related to governance issues according to international good practices that should be applied while formulating health policies in any field. The HP-GGT was found to be a practical tool that was useful for policy-makers when used in Lebanon and awaits applications in other low- and middle-income countries to further show its validity and utility.

Country-specific hip fracture incidence rates (IRs) and longevity allow the Fracture Risk Assessment Tool (FRAX) to be adapted to individual countries. Secular trends can affect tool calibration. Data on hip fracture IRs in the Middle East is scarce, and long-term secular trend studies are nonexistent. Using the Ministry of Public Health hip fracture registry, we calculated age- and sex-specific hip fracture IRs in Lebanon, from 2006 to 2017, among individuals aged ≥50 years. We used Kendall's tau-b (τb) test to determine the correlation between time and hip fracture IRs, and calculated both the annual % change in IRs and the % change in IR compared to the baseline period (2006 to 2008). The registry recorded 6985 hip fractures, 74% at the femoral neck, 23% intertrochanteric, and 3% subtrochanteric. Men constituted 32% of the population, and were significantly younger than women (76.5 ± 11.0 years versus 77.7 ± 10.3 years; p < 0.001). Annual overall IRs, per 100,000, ranged from 126.6 in 2014 to 213.2 in 2017 in women, and 61.4 in 2015 to 111.7 in 2017 in men. The average women to men IR ratio was 1.8 (range, 1.5 to 2.1). IRs steadily increased with age, and IR ratios increased in parallel in both sexes, with a steeper and earlier rise (by 5 years) in women. Data showed a consistent decline in hip fracture IRs starting in 2006 in women, and in 2009 in men. There was a significant negative correlation between time (2006 to 2014) and hip fracture IRs in women (τb = -0.611, p = 0.022) but not in men (τb = -0.444, p = 0.095). The steady decrease in IRs reversed after 2015 in both sexes. This long-term data on secular trends in the Middle East is novel and consistent with worldwide changes in hip fracture rates. The impact of such changes on national FRAX-derived estimates is unclear, should be assessed, and may necessitate an update in the FRAX Lebanon calculator. © 2019 American Society for Bone and Mineral Research.

Published Erratum. Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050. Lancet. 2021 Sep 11;398(10304):956. doi: 10.1016/S0140-6736(21)01806-7. PMID: 34509230. BACKGROUND: Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. METHODS: We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. FINDINGS: Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. INTERPRETATION: Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. FUNDING: Bill & Melinda Gates Foundation. Bill & Melinda Gates Foundation Sí

Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. The Lancet Publishing Group