Iranian Journal of

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Background and Objectives: Human Development Index (HDI) is an important indicator of a country’s development. On the other hand, mortality indicators are the most important indicators of the health of a society. This study aimed to examine the association between HDI and maternal, neonatal, infant, and under-five mortality rates in Iran between 2005 and 2016.
 
Methods: This longitudinal study was conducted using data collected from Iran Statistics Center, World Health Organization, and United Nations Development Program. SPSS software version 22 was used for data analysis. Pearson correlation test was applied to examine the correlation between HDI and mortality rates. Regression analysis was used to measure the effect of HDI on mortality rates.
 
Results: HDI increased from 0.690 in 2005 to 0.774 in 2016 (12% rise). Maternal, neonatal, infant, and under-five mortality rates decreased by 26, 41, 52, and 42% in 2016 compared to 2005, respectively. HDI had a significant indirect association with maternal (-0.973), neonatal (-0.983), infant (-0.739), and under-five mortality (-0.987). An increase of 0.01 in HDI reduced 1 maternal death per 100,000 births. An increase of 0.014, 0.009, and 0.008 in HDI decreased one neonatal, infant, and under-five death per 1000 births.
 
Conclusion: The results showed that increased HDI correlated with decreased mortality rates. Therefore, policy-makers should pay more attention to socio

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Background and Objectives: The purpose of this study was to predict the mortality rate of colorectal cancer in Iranian patients and determine the effective factors  on the mortality of patients with colorectal cancer using random forest and logistic regression methods.
 
Methods: Data from 304 patients with colorectal cancer registry from the Gastroenterology and Liver Research Center of Shahid Beheshti University of Medical Sciences during the years 2009 to 2014 were used as a retrospective study. Data analysis was performed using random forest and logistic regression methods. To analyze the data, R software version 3.4.3 was considered.
 
Results: Ten important variables related to colorectal cancer deaths were selected by random forest method. Several criteria such as the area under the characteristic curve (AUC) were used to compare the random forest method with logistic regression. According to both criteria, five important variables ranked by random forest were Cancer stage, age of diagnosis, patient's age, HLA, and degree of differentiation (tumor differentiation). In terms of different criteria, the random forest method had better performance than logistic regression (Area under the ROC curve for random forest and logistic regression methods was: 98%; 80% respectively).
 
Conclusion: Variables such as Cancer stage, age of diagnosis, patient's age, HLA, and degree of differentiation are considered as the most important factors affecting mortality in colorectal cancer, that the patients' longevity can be increased with the early diagnosis of cancer and screening programs.
 

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Background and Objectives: The Family Physician (FP) plan was implemented in rural areas and cities with a population of less than 20000 in 2005. The purpose of this study was to explain the challenges and obstacles of¬ the Rural Family Physician Program in Kurdistan Province from the perspective of stakeholders.
 
Methods: This qualitative study was conducted using 30 semi-structured interviews and 5 focused group discussions (FGD) with stakeholders of the FP plan from June 2017 to Jan 2018. The participants were selected through a purposive sampling method with maximum variation. The contents of the interviews and FGD were categorized by the content analysis method using MAXQDA10 software (V. 10).
 
Results: The challenges and obstacles of the FP plan were categorized into 16 subcategories and 5 main categories. The main categories were stewardship challenges, service delivery challenges, cultural and educational challenges, human resource challenges, and infrastructure challenges. The most important subcategories of these challenges included weaknesses in policy-making, formation of laws and regulations, weaknesses in insurance performance, weaknesses in intra-sector coordination, weaknesses in the referral system, weaknesses in communicating the plan to the community, low survival of physicians, inadequate motivational mechanisms, and weaknesses in the information system.
 
Conclusion: The rural FP plan faces many challenges that require multi-dimensional interventions. Identifying the challenges of the FP plan from the perspective of its stakeholders can help to gradually improve the plan.

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Background and Objectives: Highly pathogenic avian influenza (HPAI) viruses are particularly important due to huge economic consequences and public health concerns. During recent years, because of the severity of epidemics and failure in the control and eradication of HPAI, vaccination has been introduced into the National Prevention and Control Program of some countries, including Iran. This article discusses the role of vaccination in the control of HPAI, the characteristics and constraints of the vaccine, types of commercial vaccines, and previous experiences.
 
Methods: Scientific databases were searched to collect essential evidence on the role of vaccination in controlling HPAI in a variety of poultry and birds with no time and language restrictions. The articles related to the efficacy and effectiveness of the commercial vaccines on at a national level or population-based studies in some farms were included in present study.
 
Results: Because of the high pathogenicity and variability of the influenza virus as well as the shortcomings of some commercial vaccines in prevention of virus transmission, vaccination should only be taken into consideration when all other methods of disease control are ineffective. The consequences of the use of vaccines containing the seeds non-antigenically matched with the circulating strains have been reported frequently.
 
Conclusion: In the national vaccination program, informed policymaking requires evidence based vaccinology that can facilitate development of the national infrastructure with awareness of the limitations of commercial vaccines and the realistic expectations of logistic, financial, and human resources.

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Background and Objectives: Leishmaniasis control in each country, especially in countries where the disease is endemic, requires designing and implementing an organized national surveillance system. Iran has long been considered as an endemic country for leishmaniasis. The purpose of this study was to review the leishmaniasis surveillance system in Iran.
 
Methods: In this review study, the data were obtained from the surveillance system, reports and documents, published guidelines, reviews of the existing structures, and the views of the managers and experts of the Center for Communicable Diseases control in Iran in 2018.
 
Results: The surveillance system for two types of leishmaniasis, cutaneous leishmaniasis and visceral leishmaniasis (Kala-azar), is currently operational in the country, and new cases are reported monthly. For each identified case, in addition to the epidemiologic attributes, treatment and follow-up as well as follow-up of possible contacts are done as per to the guidelines for each of these diseases.
 
Conclusion: The current surveillance system for leishmaniasis has improved the process of reporting cases in recent years. However, the low rate of reporting of cases, especially for cutaneous leishmaniasis, and epidemiological complexities in the transmission of the infection indicate the need for reviewing and improving the current surveillance system.  Data from the surveillance system and the increasing number of leishmaniasis cases in Iran reveal the need for innovations to strengthen the control measures for this disease.

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Background and Objectives: Iran has long been considered to be one of the countries in the world with endemic brucellosis. The aim of this study was to review the surveillance system of brucellosis in Iran.
 
Methods: Data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, the review of records, documents, books and published articles and also interviews with process owners and experts of brucellosis surveillance in 2017-2019.
 
Results: In the current surveillance system in Iran, all patients with brucellosis will undergo standard treatment for at least 2 months. The patient identified at each site, private or public sector, reports to the health center of the city. After reporting cases to higher levels, city health center carried out required epidemiologic investigation in the place of reported case in collaboration with its environmental levels. Finally, the individual assessment form, epidemiologic investigation form, for reported case is completed and registered in national surveillance database.
 
Conclusion: Although integration of the brucellosis surveillance program into the health system of the country and reporting and treatment of human cases in accordance with the country's protocol in recent years is well executed, brucellosis control in Iran requires the one health approach. Accordingly, it can be concluded that despite the decrease in the number of brucellosis cases in recent years, the weakness in livestock surveillance has led to many fluctuations in the health system's success in providing surveillance for human cases of brucellosis.

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Background and Objectives: One of the causes of neonatal death and death in children under the age of five is premature birth of infants. The purpose of this study was to identify the risk factors associated with preterm infant birth in pregnant women.
 
Methods: This is a case-control study on mothers referring to comprehensive health centers in the provinces of the country. Descriptive analysis of variables was reported as percentage and frequency. In data analysis, logistic regression analysis was used at a significant level less than 0.05.
 
Results: In this study, 2463 pregnant women (668 cases as cases and 1795 as controls) were examined. There was a significant relationship between the place of residence (OR=0.702, P=0.002), level of maternal education (OR=1.920, P=0.027), degree of twin (OR=4.953, P=0.001), interval between pregnancies (OR=1.821, P=0.009), specific disease (OR=1.694, P=0.010), nutritional status of the mother (OR=1.420, P=0.024), physical activity (OR=1.591, P=0.001), Sleep patterns (OR=0.634, P=0.008) and history of stillbirth (OR=0.247, P=0.001) associated with the birth of premature infants.
 
Conclusion: Preterm infant birth is one of the main causes of neonatal death. Therefore, some of the birth defects of the premature baby can be prevented. It is possible to reduce the risk factors for the birth of a premature baby by improving the quality of pregnancy care and changing the lifestyle of the pregnant mother, and by raising awareness and creating a healthy and safe environment for the mother.

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Background and Objectives: Iran is one of the Middle Eastern countries that implemented the HIV / AIDS control and surveillance program many years ago. The purpose of this study was to review the HIV / AIDS surveillance system in Iran.
 
Methods: This was a review research to assess the processes, structures and achievements of the HIV/AIDS surveillance system in Iran. The information sources of this study included data from the surveillance system, reports and documentation, and published guidelines, reviewing existing structures and views of managers and practitioners of the HIV/AIDS surveillance system in Iran.
 
Results: In Iran, all cases with HIV / AIDS as well as people with high risk behaviors are referred to behavioral disease counseling centers in order to receive health care services. Harm reduction in people with risky behaviors in the form of counseling centers, drug addicts' centers, and women's counseling centers in collaboration with governmental and non-governmental organizations, and attention to the second generation of HIV/AIDS surveillance, particularly conducting behavioral studies, are other components of the HIV / AIDS surveillance system in Iran
 
Conclusion: Although the HIV / AIDS surveillance system in Iran has a large structure with many achievements in reducing new HIV cases, especially in some high-risk groups such as injecting drug users, as well as reducing HIV transmission from infected mothers to their children, strengthening this surveillance system, especially for sexual high-risk groups, is essential for controlling HIV/AIDS in the country.

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Background and Objectives: Iran, like most other countries in the world, is always threatened with global epidemics and pandemics of influenza. The purpose of this study was to review the influenza surveillance system in Iran.
 
Methods: Data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, the review of records, documents, books and published articles and also interviews with process owners and experts of influenza surveillance in 2017-2019.
 
Results: Influenza surveillance in Iran Currently, a combination of surveillance methods, including caring for patients, laboratory care, hospital care and surveillance of respiratory disease epidemics and also border surveillance. Reporting of human influenza outbreaks, as well as suspected avian flu as main notifiable diseases carried out through telephone. For each suspect case, in addition to taking and sending a sample to diagnose and also detect subtypes of the virus, medical treatment is immediately initiated and tracking of possible contacts is also done.
 
Conclusion: Although there is currently good coherence in the surveillance of influenza in Iran, but based on concerns about the emergence of influenza pandemics in the future, and considering the possible genetic variation of the flu viruses, the tracking of the flu virus circulation along with updating surveillance system especially emphasizing methods and formulas for rapid identification of disease outbreaks, as well as providing better health care and treatment is essential.

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Background and Objectives: Anthropometric indices, especially weight, provide useful information for the care and treatment of newborn infants and can be used to identify infants at risk. Therefore, this study was conducted to examine the mean weight, height and head circumference measurements of infants and some related factors.
 
Methods: This cross-sectional study was performed to investigate the anthropometric indices (weight, height and head circumference), demographic characteristics, and delivery data of 1484 newborns in 2016 using multi-stage sampling. Moreover, the predictors of these indices were analyzed using a linear regression model.
 
Results: The mean weight, height and head circumference of the newborn infants was 3185 ± 465 g, 49.92 ± 2.92 cm, and 34.58 ± 2.29 cm respectively, and 7% of newborns were low birth weight. The male newborns weighed 57.29 g more than females on average at birth (p <0.05). Besides, the height and head circumference of the male newborns were 0.15 and 0.10 cm larger than the female newborns respectively but the difference was not statistically significant. In addition to gender, gestational age at birth (week) and type of delivery correlated with all three anthropometric indices in multivariate analysis.
 
Conclusion: Identifying and controlling largely adjustable risk factors can make it possible to prevent low anthropometric parameters, particularly low birth weight.

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Background and Objectives: To provide an overview of the national program of Crimean-Congo hemorrhagic fever surveillance in Iran, its current achievements, and challenges.
 
Methods: In this mixed method study, the relevant reports, documents, and guidelines, as well as published literature and surveillance data were gathered and critically reviewed. The opinions of the key informants at local and governmental levels were assessed through structured interviews.
 
Results: The program was integrated into Iran’s primary healthcare (PHC) network in 1999. The involved organizations include CDC, medical universities, Pasteur Institute of Iran (PII), and Veterinary Organization. Case finding is based on standard definitions of suspected, probable, and confirmed cases. Laboratory confirmation is necessary for diagnosis and is provided within 48 hours after receipt of the specimen by the National Reference Laboratory of PII. CCHF treatment is primarily supportive. Antiviral therapy with ribavirin is also considered. Both therapeutic services are free. Education mainly focuses on high-risk groups and healthcare workers. Major achievements of the program include rapid diagnosis and treatment of cases, prevention of nosocomial transmission, identification of high-risk provinces and major transmission routes, improved outbreak preparedness, development of laboratory tests for detection of other arboviruses, and reduction of CCHF case fatality rate.
 
Conclusion: Program implementation has had a positive impact on early detection and proper control of annual outbreaks. However, some aspects of the program still need improvement, including promotion of the general and high-risk populations’ awareness and regional collaborations (especially among neighboring countries) for infection control in humans, livestock, and vectors.

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Background and Objectives: Iran started malaria elimination campaigns many years ago. The purpose of this study was to review the malaria surveillance system in Iran.
 
Methods: The data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, a review of records, documents, books and published articles, and also interviews with process owners and experts of malaria surveillance in 2017-2019.
 
Results: The surveillance system of malaria in Iran has a coherent structure, in which all identified cases are reported and monitored from the environmental levels to the center by telephone instantly. Considering that the main goals of the malaria program including disease elimination have been obtained, the surveillance system in Iran is currently aiming at strengthening the elimination phase. In this stage, all new cases are also epidemiologically investigated in addition to examination, treatment and follow-up for categorization of the cases in categories of relapse, indigenous, introduced, and induced.
 
Conclusion: The successful implementation of the surveillance system for malaria over time has caused indigenous cases of disease to be limited to three southeastern provinces of the country and there are fewer than 300 new cases a year. Despite success, since the goal of malaria surveillance in Iran is now disease elimination, continuous monitoring of  correct implementation of all processes and evaluation of the applied strategies are necessary.

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Background and Objectives: Over the past decades, the Iran’s anti-tuberculosis campaign has become highly structured and many achievements have been made. The purpose of this study was to describe the characteristics of the TB surveillance system and its components in the Islamic Republic of Iran.
 
Methods: The data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, a review of the records, documents, books and published articles, and also interviews with process owners and experts of TB surveillance during 2017-2019.
 
Results: Case finding and treatment and follow-up of TB patients and their household contacts are done In the TB surveillance system. The implementation of the DOTS, (DIRECTLY OBSERVED TREATMENT SHORT-Course) is a major component of the TB surveillance system. Patient registration is done in an online application, which allows extracting and reporting the important indicators of the program. In this surveillance system, there is a special sensitivity to the treatment of patients, so the incidence of multi drug-resistant TB in the country is lower than that of the neighbors. The presence of regional laboratories that cover the entire region of the country is one of the strengths of the TB surveillance program in Iran.
 
Conclusion: Despite budget problems, the anti-TB program in Iran has many achievements. However, new strategies need to be considered to reduce the incidence of TB.

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Background and Objectives: Rheumatoid arthritis is a chronic, progressive disease of the joints that presents with articular and systemic symptoms. The purpose of this study was to determine the quality of life in patients with rheumatoid arthritis and its relationship with body mass index.
 
Methods: This descriptive-analytical study was performed in 195 patients with rheumatoid arthritis in Tohid Hospital, Sanandaj, Iran. The data collection tool was a questionnaire including demographic and clinical characteristics. The SF-36 instrument was used to evaluate the quality of life.
 
Results: In the study, 40% of men and 58% of women had a disease severity higher than 2.6 according to the Disease Activity Score 28. There was a significant difference in all dimensions of quality of life including physical function, energy / fatigue and general health between men and women (P <0.05). All dimensions of quality of life were inversely correlated with BMI. There was a significant relationship between the disease severity and each of the dimensions of pain, general health and general changes (P <0.05).
 
Conclusion: Quality of life in patients with rheumatoid arthritis is correlated with body mass index and severity of rheumatoid arthritis; therefore, it seems that health policy makers or clinical practitioners need to pay more attention to these two factors to increase the patients’ quality of life.
 

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Background and Objectives: The purpose of this study was to present a summary of the rabies surveillance program in humans in the country, its achievements and its strengths and weaknesses.
 
Methods: This study was a review of the country's plan for surveillance and control of rabies in humans. The sources of information included the data, reports, documents, and published guidelines. The viewpoints of stakeholders and experts were also reviewed in this study.
 
Results: Since rabies is a zoonotic disease, its effective management requires a good collaboration between several organizations. Moreover, because Iran is located in an endemic region, there is a need for the development of regional and international cooperation for the success of disease prevention, control and management. Animal services for biting and rabies control are provided free of charge in more than 700 centers in the country. Major achievements of the program include timely preventive treatment for animal bite cases, knowledge of the geographical distribution of the disease, identification of high-risk provinces, and decreasing the percentage of human deaths.
 
Conclusion: The program has performed well for rabies secondary prevention. Some aspects of the program, however, still need to be improved, including improvement of educational programs targeting general population and high-risk groups, animal bite prevention, vaccination of domestic dogs, controlling the population of stray dogs, rabies control in wild animals, and proper waste collection and disposal.
 

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Background and Objectives: Elimination and eradication of measles requires designing and implementing an enhanced surveillance system. The purpose of this study was to review the measles surveillance system in Iran.
 
Methods: The data of this study were obtained from the surveillance system of the Center for Communicable Disease Control; a review of the records, documents, books, and published articles; and interviews with process owners and experts of measles surveillance in 2017-2019.
 
Results: Iran has a surveillance plan to eliminate the measles. The current design for suspected cases of measles in Iran is a case-based surveillance system, in which for each identified case with fever and maculopapular rashes, some activities such reporting, laboratory confirmation, clinical and epidemiological investigation and case registration in individual forms are done.
 
Conclusion: Complete surveillance of cases suspicious of measles and high coverage of vaccination in children less than 2 years in a cohesive surveillance system and rapid response to the outbreak have led to lack of occurrence of indigenous measles in Iran. Although the current status of the measles surveillance system in Iran seems to be favorable, since Iran is at the stage of measles elimination, it is essential to increase the sensitivity of the reporting system for suspected cases of measles and to maintain the status of vaccine coverage to save elimination status.
 

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Background and Objectives: : According to the global strategy for polio eradication, targeted surveillance of the disease is one of the main tasks of the health system. The purpose of this study was to review the status and surveillance of poliomyelitis/acute flaccid paralysis (AFP) in Iran.
 
Methods: The present study was a review on the processes, structures and achievements of the poliomyelitis/AFP surveillance system in Iran during 2017-2019. The data of this study were obtained from the surveillance system of the Center for Communicable Disease Control; a review of the records, documents, books and published articles; and interviews with process owners and experts of poliomyelitis/AFP surveillance.
 
Results: The polio eradication program in Iran is based on the action plan of the World Health Organization that was introduced initially in 1988. Currently, the surveillance system of AFP is active at three levels: country, university, and city. The number of poliomyelitis cases in the country decreased from 50 cases per year in 1985 to zero in 2001, and Iran has been a polio-free country since 2001. The final report on polio eradication in Iran was approved by the regional commission on polio detection in April 2006.
 
Conclusion: The surveillance system of AFP has had a proper effectiveness throughout the country. Maintaining this situation in the country requires an increase in the sensitivity of the surveillance system of the disease, regular monitoring of vaccine coverage, strict implementation of international health regulations, especially on the eastern borders of the country, and providing technical assistance to neighboring countries.

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Background and Objectives: On 12 November 2017, an earthquake with a magnitude of 7.3 on the Richter scale occurred in Kermanshah Province. Explaining the challenges and needs of the victims in such circumstances can be an important source of information for future planning and better management of such conditions. Thus, the purpose of this study was to explain the challenges and needs of the earthquake victims.
 
Methods: This study was a qualitative study. Twenty-nine semi-structured interviews were conducted with managers, policymakers, and health and emergency relief providers in earthquake areas, and 10 focused group discussions were held with earthquake victims from December to February 2016. The data were analyzed using conventional content analysis.
 
Results: The needs and challenges in Kermanshah earthquake were classified into three periods after the earthquake: 1. Challenges and needs in the first few days with three sub-categories including management, rescue services, and urgent care, 2- Challenges and needs in the first few weeks  after the earthquake with three sub-categories including housing and emergency assistance, public health services, and access to health care; and 3. Needs and challenges in several months after the earthquake with four sub-categories including economic, social, infrastructural and health service needs.
 
Conclusion: Lack of unity of command was the main challenge in this earthquake. Another point was the health needs of victim earthquakes over time. Therefore, dispatching of aid forces to the affected areas during natural disasters should be based on planning and needs.

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Background and Objectives: Randomized clinical trials are the gold standard for evaluating the effectiveness and safety of medical interventions. Some unpredictable challenges may affect the results of these studies. Therefore, the aim of this study was to identify the challenges of clinical trial studies in different stages including design, conduct, analysis, and reporting.
 
Methods: This study was a qualitative study using content analysis performed from 2017 to 2019. The study population included 13 clinical trial experts who were selected through purposeful sampling. Semi-structured interviews were conducted with all subjects. Data saturation was achieved after 13 interviews.
 
Results: Among the 4 steps of design, conduct, analysis, and reporting, the majority of the challenges were related to conducing randomized clinical trials. Lack of knowledge of researchers, subjects, sponsors and physicians and supervisory and ethical challenges were the main challenges related to performing these studies. Poor design and lack of clinical equipoise were considered as the main challenges in the design step. Inappropriate analytical methods due to the absence of statistician in these studies were considered as the most common challenge related to analysis. Finally, lack of familiarity with international guidelines was the most important challenge in reporting.
 
Conclusion: There are many challenges in different steps of clinical trial studies. Therefore, additional education sessions focusing on the related guidelines and standards as well as GCP workshops for researchers can be helpful.

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COVID-19 has now turned into a global crisis affecting all sections of economy and investment. Many interventions have been applied to control the COVID-19 epidemic. It seems that these measures and plans need to be assessed in the coming weeks and months to determine whether or not they have been effective. Each of these interventions started in their appropriate time during the epidemic; some of them are still in progress and some have been lifted. Nevertheless, improved public knowledge, attitude, and practice has played the most important role in controlling the COVID-19 epidemic. Future studies should take into account such interventions.