Objectives Smoking is a major cause of preventable morbidity and mortality worldwide. Despite global tobacco control efforts, smoking prevalence remains high in many regions. This study aimed to determine the prevalence of smoking and its associated factors in the Kurdistan Region of Iraq. Methods A community-based, cross-sectional study was conducted in 2025, consisting of 1132 individuals aged ≥18 years selected through multistage random sampling from 12 districts of Duhok City. Data were collected using a structured questionnaire and anthropometric measurements. Descriptive statistics and logistic regression analyses were performed to identify factors associated with smoking. Results The mean age of participants was 37.5 ± 14.8 years. The overall prevalence of smoking was 33.6%, with a marked gender disparity (50.9% in men vs 5.7% in women). In univariate analysis, smoking was significantly associated with gender, education, marital status, employment status, physical activity, hypertension, waist circumference, and body mass index. Multivariate logistic regression showed that gender, education level, and employment status remained independently associated with smoking. Conclusions Smoking prevalence in the Kurdistan Region of Iraq is alarmingly high, particularly among men, individuals with lower education, and employed adults. These findings highlight the urgent need for strengthened tobacco control policies and targeted public health interventions in the region.

Medical education in Iraq is at a turning point, shaped by historic strength and contemporary systemic strains. Previously, the medical education in Iraq was known for its rigorous curricula and intense clinical training. Currently, the system faces escalating challenges that threaten its integrity and weaken the abilities to produce competent doctors. In this paper, key structural insufficiencies are discussed including students’ oversaturation. It also highlights the impact of non-traditionally trained staff, problematic academic policy and flexible standards and expansion without infrastructure on the education process. Finally, a road map for reform is proposed.

Introduction and Objectives: Cholera is an acute waterborne bacterial disease that remains a significant public health burden in developing countries. Recurrent outbreaks in Iraq highlight persistent infrastructural challenges and gaps in preventive measures. This study aims to assess knowledge, attitudes, and practices (KAP) regarding cholera among university students in Iraqi Kurdistan. Methods: This cross‑sectional study was conducted between January 10, 2025, and March 1, 2025. A total of 683 university students from the University of Zakho and University of Duhok, Iraqi Kurdistan were recruited. Data were collected through direct face‑to‑face interviews and electronically via Google Forms. The survey consisted of 31 items organized into four sections: demographic characteristics and KAP. Results: The mean age of the participants was 21.01 ± 1.6 standard deviation (SD) years, and about half (51.68%) were female. The mean overall KAP score among our students was 19.89 ± 3.09 SD out of 27, corresponding to a mean KAP percentage of (73.67%). Based on the KAP score classification, (34.26%) of the students were categorized as having good KAP levels. Higher KAP scores were observed among older students, females, and students from College of Medicine, with statistically significant differences (P = 0.017, P = 0.033, and P ≤ 0.0001), respectively. Conclusions: University students in the current study exhibited satisfactory levels of KAP regarding cholera, albeit still not optimal. Notable gaps in students’ KAP were identified. Therefore, educational campaigns and programs should be designed and conceptualized to address these gaps, enhance students’ awareness, and promote better practice.

Objective Cardiovascular diseases (CVD) remain the leading cause of global mortality, with dyslipidemia being a major modifiable risk factor. Dyslipidemia remains inadequately studied in developing countries like Iraq, so this study aims to assess the prevalence and determinants of dyslipidemia among residents of the Kurdistan Region of Iraq. This cross-sectional study was conducted between January and April 2025 and included 1132 participants aged ≥ 18 years. Dyslipidemia was defined based on prior confirmed diagnosis with documented laboratory, chronic disease registry identification card or specialist physician report. Results The overall prevalence of dyslipidemia was 13.5%, lower than neighboring regions, with higher prevalence in men (15.8%) compared to women (9.9%). Significant determinants of dyslipidemia in multivariable logistics regression included low education (OR 3.197, 95% CI: 2.257–4.527), obesity (4.039, 2.464–6.619), hypertension (6.301, 4.205–9.44), and ischemic heart disease (11.21, 6.16–20.43). These findings underscore the need for public health initiatives focused on promoting healthy lifestyles, particularly in at-risk populations, to reduce the burden of dyslipidemia and prevent cardiovascular events.

Tuberculosis (TB) is the leading global cause of death from a single infectious agent. Recent reductions in global health funding have threatened TB control, making comprehensive assessment of TB, HIV-related TB, and drug-resistant TB burdens before these disruptions essential for shaping effective responses. The WHO End TB Strategy sets targets of a 95% reduction in TB deaths and a 90% reduction in TB incidence between 2015 and 2035. Using results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, this study aims to assess the burden of TB and multidrug-resistant TB (MDR-TB) across 204 countries and territories, and to evaluate progress towards the WHO End TB incidence and mortality targets. Methods We quantified TB mortality using the Cause of Death Ensemble modelling platform with global vital registration, surveillance, verbal autopsy, and minimally invasive tissue sampling data. For TB morbidity estimation, we simultaneously modelled incidence, prevalence, and mortality by age and sex using DisMod-MR 2.1. A population attributable fraction (PAF) approach was applied to stratify morbidity and mortality estimates by HIV and drug-resistance status. We also calculated disability-adjusted life-years (DALYs) as the sum of years of life lost and years lived with disability. For the risk factor analysis, a comparative risk assessment framework was used and PAFs were derived for alcohol use, smoking, and high fasting plasma glucose to determine the proportion of TB burden associated with these risk factors. Findings In 2023, there were an estimated 9·11 million (95% uncertainty interval 8·04–10·3) incident cases of all-form TB, 1·22 million (0·98–1·49) deaths, and 54·6 million (43·8–65·5) DALYs globally. HIV-related TB comprised 781 000 (690 000–879 000) incident cases and 210 000 (142 000–279 000) deaths, contributing 11·0 million (7·56–14·3) DALYs. MDR-TB accounted for 466 000 (198 000–1 080 000) incident cases, 102 000 (31 700–238 000) deaths, and 3·96 million (1·31–9·01) DALYs. From 2015 to 2023, global all-form TB incidence rates declined by 19·2% (17·8–20·5) and deaths declined by 22·6% (4·7–35·7); declines were larger for drug-susceptible TB than for MDR-TB. Sub-Saharan Africa and south Asia had the highest mortality burdens in 2023; reductions in all-form TB incidence and mortality were uneven between 2000 and 2023, with limited progress in both measures in Latin America and the Caribbean. Removing smoking, alcohol use, and high fasting plasma glucose would reduce global TB deaths to 768 000 (592 000–970 000) and DALYs to 34·9 million (27·8–43·8) in 2023; MDR-TB deaths would decrease to 77 200 (23 400–183 000) and DALYs to 3·12 million (1·03–7·29).

Background and aims Diabetes mellitus is a chronic metabolic disorder and a major global health problem, predisposing patients to wound infections, with Pseudomonas aeruginosa being a frequent and resistant pathogen. This study aimed to identify P. aeruginosa, assess associated risk factors, and determine its antibiotic susceptibility pattern in diabetic wound infections in Duhok Province, Kurdistan Region, Iraq. Methods This cross-sectional study was conducted from June 2024 to July 2025 in Duhok Province, Kurdistan Region, Iraq. A total of 141 wound swab samples were collected from diabetic patients aged ≥18 years. P. aeruginosa was identified using biochemical tests, Vitek®2, and 16S rDNA PCR. Antimicrobial susceptibility testing was performed by the disc diffusion method on Mueller–Hinton agar, and data were analyzed using GraphPad Prism software. Results Out of 141 wound infection samples collected from diabetic patients, P. aeruginosa was isolated in 44.68% of cases. Overall, sociodemographic factors showed no significant association with PsA infection, except for occupational status in the multivariable analysis 0.12 [0.02–0.97, p = 0.046] and overweight 0.29 [0.10–0.82, p = 0.019]. Clinically, most variables including HbA1c, duration of diabetes, comorbidities, treatment type, and wound characteristics were not significantly associated with PsA infection. The only significant predictor was wound location, with leg-region infections showing a higher risk of PsA 3.94 [1.24–12.5, p = 0.02]. P. aeruginosa isolates showed high levels of multidrug resistance, especially to aztreonam, ceftazidime, cefepime, and tobramycin. Colistin showed the lowest resistance and highest sensitivity, followed by relatively better susceptibility to carbapenems. Conclusion P. aeruginosa is a common cause of wound infections in patients with diabetes mellitus, with its prevalence significantly associated with body mass index, occupational status and wound location, with leg-region wounds showing a higher risk. P. aeruginosa isolates demonstrated high multidrug resistance, although colistin and carbapenems retained relatively better activity. Early detection and appropriate antibiotic selection are essential to reduce complications and improve patient outcomes.

Background Enteric infectious diseases claim more than 1 million lives annually and are among the top ten causes of death in children younger than 5 years. Remarkable global investment has been dedicated to enteric infectious disease prevention and control; however, the shifting global health landscape is testing the continuance of progress. To evaluate the current status and guide future interventions, we present the latest epidemiological estimates of enteric infectious diseases from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 and assess progress towards the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) mortality target of fewer than 20 deaths per 100 000 children younger than 5 years by 2025. Methods We quantified the incidence, mortality, and disability-adjusted life-years (DALYs) of enteric infectious diseases by age, sex, and year across 204 countries and territories from 1990 to 2023. In GBD 2023, the following were considered under the category of enteric infectious diseases: diarrhoeal diseases, enteric fever (typhoid and paratyphoid), invasive non-typhoidal Salmonella spp (iNTS) infections, and other intestinal infectious diseases. We also examined 15 aetiologies contributing to diarrhoeal diseases. Incidence and prevalence were estimated with DisMod-MR (version 2.1), a Bayesian meta-regression tool, drawing on data from systematic reviews, population-based surveys, claims data, and hospital sources. Cause-specific mortality was modelled with Cause of Death Ensemble Modelling based on data from sources including vital registration, mortality surveillance, verbal autopsy, and minimally invasive tissue sampling. Years of life lost and years lived with disability were computed and combined to derive DALYs. For aetiology-specific estimation, population-attributable fractions (PAFs) for 15 pathogens were derived with a counterfactual framework. Point estimates and 95% uncertainty intervals (UIs) were generated from 250 draws from the posterior distribution. Findings In 2023, enteric infectious diseases resulted in an estimated 1·27 million (95% UI 0·963–1·68) deaths globally, declining from 3·69 million (3·04–4·56) in 1990. The global age-standardised mortality rate (ASMR) decreased from 74·1 (62·0–92·9) per 100 000 population to 16·4 (12·6–21·3) per 100 000 population during the same period. Diarrhoeal diseases accounted for most deaths in 2023 (1·11 million [0·811–1·54]), followed by enteric fever and iNTS. South Asia and sub-Saharan Africa remained the most affected regions in 2023, with 599 000 (441 000–882 000) and 501 000 (373 000–648 000) deaths due to enteric infectious diseases, respectively, predominantly from diarrhoeal disease. Rotavirus was the leading cause of all-age diarrhoeal disease deaths (PAF 16·3% [12·0–21·5]), followed by norovirus (10·2% [2·4–17·0]) and Shigella spp (9·3% [5·4–15·2]). Among children younger than 5 years, PAFs of deaths due to diarrhoeal diseases were 40·2% (32·5–48·5) for rotavirus, 24·0% (15·1–36·7) for Shigella spp, and 23·4% (13·7–34·3) for adenovirus. Across 204 countries and territories, 141 met the GAPPD mortality target in 2023. The driving aetiologies among countries that did not meet the target in 2023 varied slightly by GBD super-region, but the highest or second-highest number of deaths in children younger than 5 years were consistently attributed to rotavirus. Astrovirus and sapovirus, newly included in GBD 2023, were responsible for 24 600 (6290–49 000) and 18 800 (4650–44 400) deaths, respectively, in 2023, mainly in children younger than 5 years. Interpretation Our findings show that mortality and ASMRs of enteric infectious diseases declined substantially between 1990 and 2023. This decline is consistent with the expansion of public health measures and broader socioeconomic development. However, the burden in 2023 remains considerably high, with the highest mortality concentrated in sub-Saharan Africa and south Asia. Considering that more than a quarter of all countries had yet to meet the GAPPD mortality target in 2023, sustained efforts are needed to address the persistent burden in affected countries and to adapt to the changing global health landscape.

Objectives This study aimed to explores the knowledge, attitudes, and practices related to cardiovascular diseases (CVDs) risk factors among the Iraqi Kurdistan population to identify gaps and guide public health strategies for better cardiovascular health outcomes. Study design A population-based study. Methods This population-based study was conducted in Duhok Province and the Zakho Independent Administration within the Kurdistan Region of Iraq from April 20, 2024, to June 15, 2024. A total of 784 participants were enrolled in the study. Data collection was carried out through face-to-face interviews in various public settings using a questionnaire comprising 26 items divided into four sections: sociodemographic characteristics, knowledge, attitudes, and practices. Results The mean age of the study participants was 32.48 ± 13.63 years. Females made up (54 %) of the sample, and more than half had university or postgraduate education. While a majority recognized smoking (92.1 %), hypertension (81.5 %), and high cholesterol (86.2 %) as significant CVD risk factors, (31.7 %) were unaware that diabetes increases CVD risk. Despite high awareness, only (29.7 %) regularly exercised, and (34.6 %) consumed fast food regularly. The mean KAP score was 20.66 ± 2.63 out of 25, which manifests that participant had good KAP scores toward cardiovascular disease risk factors. The KAP scores were significantly higher among females, married individuals, healthcare workers, non-smokers, those with a family history of CVD, and individuals who obtained their knowledge from physicians. Conclusions This study reveals a gap between knowledge and practice regarding CVD risk factors in the Kurdistan Region. Awareness is high, but many, especially younger adults and those with lower education, fail to adopt healthy practices. The findings highlight the need for targeted interventions to promote behavioral changes.

Background. Migraine is a highly debilitating complex neurological disorder. Globally, migraine has been recognized as the second most common cause of disability. Objectives. This study aims to assess public knowledge, attitude, and practice (KAP) regarding migraine headaches and to identify factors influencing population KAP. Material and methods. This population-based study was conducted from October 20, 2024, and January 15, 2025, in the Zakho independent administration and Duhok Province, in the Kurdistan Region of Iraq. A total of 508 individuals were enrolled in this study. Data were collected in various public locations through direct interviews carried out by one of the authors. The questionnaire composed of 27 items divided into four sections: sociodemographic characteristics, knowledge, attitude, and practice. Results. The mean age of the study respondents was 34.89 ± 10.61 years. The male to female ratio was about equal, and 76.2% were university students or had graduated from university. Family and friends were the primary source of migraine knowledge for 47.05% of the participants. The mean KAP score was 12.31 ± 3.1 out of 18. About two-fifths (39.17% and 49.41%) were classified as having good and moderate KAP scores, respectively, and only 11.42% exhibited a poor KAP score. Females, those with higher educational level, and healthcare workers significantly demonstrated better KAP scores compared to their counterparts. Conclusions. Study participants demonstrated a moderate level of knowledge regarding migraine, while illustrating favorable attitudes and practices. The study results underscore the necessity for tailored public health initiatives and educational programs to improve migraine knowledge within our community. Key words: headache, migraine disorders, public health, preventive medicine, comprehension. S

Introduction and aims Helicobacter pylori (H. pylori) is a major contributor to gastrointestinal diseases and gastric cancer worldwide. Despite reports indicating a high seroprevalence of H. pylori in the Kurdistan Region of Iraq, data specific to Zakho City remain limited. This study aimed to determine the seroprevalence of H. pylori infection and to assess associated risk factors in a representative population sample from Zakho City. Methods A community-based cross-sectional study was conducted between 1 February and 1 March 2025. A total of 391 individuals were recruited using a multi-stage random sampling technique of households in the community. Data were collected using a structured self-administered questionnaire that assessed demographic characteristics, hygiene practices, gastrointestinal symptoms, and family history of H. pylori infection. Venous blood samples were obtained from all participants and analyzed for the presence of H. pylori IgG antibodies using standard serological methods. Results The overall seroprevalence of H. pylori was 52.9% (95% CI: 48%–58%). Multivariate logistic regression analysis demonstrated a significant association between age and H. pylori seropositivity (adjusted odds ratio = 1.028; p = 0.022), indicating a 2.8% increase in the odds of infection with each additional year of age. No significant associations were observed with gender, marital status, employment status, household size, source of drinking water, or sanitation practices. Conclusions H. pylori seroprevalence remains high in Zakho City, though at a lower rate than earlier national estimates. The age-related pattern, consistent with a cohort birth effect, highlights the importance of targeted screening and prevention strategies. It should be noted that IgG seropositivity reflects prior exposure and does not indicate the exact age at infection, and the association with age is based on cross-sectional data.

Introduction and Objectives Mpox is a re-emerging zoonotic viral infection that has recently caused widespread outbreaks in previously non-endemic regions, becoming an international public health concern. Medical students are future healthcare workers (HCWs); they play a critical role in public health initiatives and targeted preventive measures. Therefore, it’s necessary to assess and enhance their knowledge and attitude concerning new emerging infectious diseases like Mpox. Therefore, in this study, we aimed to fill the literature gap by assessing medical students’ knowledge and attitudes regarding Mpox infection in the Kurdistan Region of Iraq. Additionally, the study intends to demonstrate a correlation between knowledge and attitudes levels and demographic characteristics. Materials and Methods This cross-sectional study was carried out in Duhok Province, Kurdistan Region, Iraq, from January 30, 2024, to April 4, 2024, involving a total of 330 medical students. Data were collected using a structured self-administered questionnaire comprising 36 items categorized into three distinct sections: demographic characteristics, knowledge, and attitude. To maximize the response rate, both digital questionnaires distributed via Google Forms and traditional paper-based formats were employed. Results The participants’ mean age was 21.57 ± 1.69 years, with a slight female predominance (52.12%). Only (8.18%) of students had received Mpox training program. Social media was the primary information source for (36.97%) of students. The median [IQR] scores for knowledge and attitude were 20 [16 –23], and 42 [37 –45], respectively. About (40.91%) of respondents exhibited good knowledge, while (47.88%) demonstrated a positive attitude. A better knowledge score was significantly associated with age (p = 0.0067), and prior awareness of smallpox (p = 0.0011). In contrast, students who relied on friends as the main source of Mpox information demonstrated significantly lower knowledge levels (p = 0.015). Attitude was significantly linked to gender (p = 0.012), and a history of chickenpox (p = 0.0019). Conclusion Medical students in the present study demonstrated relatively insufficient knowledge about Mpox. However, their attitudes were more favorable, albeit still suboptimal. These findings highlight the urgent necessity for structured educational programs on emerging infectious diseases for health sciences students, with prioritization of students lacking knowledge of smallpox and chickenpox, and those who depended on non-formal information sources. Such programs are essential to equip students with the necessary knowledge and skills to enhance their ability to respond to and control infectious diseases outbreaks. Figures

Background and Objectives: Social Anxiety Disorder (SAD) is a common psychiatric condition characterized by excessive fear of social interaction. It significantly impairs academic and occupational functioning, with individuals frequently avoiding social situations or experiencing distress when exposed to them. Despite the burden of mental health disorders in the Kurdistan Region of Iraq, studies on SAD among medical students remain scarce. In light of this, the present study aimed to assess the prevalence of SAD among medical students in Zakho and Duhok medical colleges and to examine the extent of beta-blocker usage for symptom relief. Methods: This cross-sectional study was conducted from 10th October 2024 to 1st February 2025, among medical students in the Kurdistan Region of Iraq. A total of 769 medical students were included in the final analysis. A validated self-administered survey comprising 28 items, structured into four sections; demographic characteristics, academic details, beta blocker usage and Social Phobia Inventory (SPIN) scale, was delivered to students via a pen-and-paper method. Participants’ responses were rated using a five-point Likert scale. Results: The participants’ mean age was 20.61±1.9 SD. Among the participants, 394 (51.8%) were male. The prevalence of SAD was (31.86%), with 148 (19.25%) and 64 (8.32%) of the students reporting mild and moderate forms, respectively. Only 46 (6%) of the students used a beta-blocker and the main reason for their use was to reduce stress and anxiety (60.9%). Older students (OR = 0.662, 95% CI = [0.49-0.90]), those with a negative family history (OR = 0.57, 95% CI = [0.37–0.86]) and clinical stage students (OR = 0.43, 95% CI = [0.30-0.61]) had a lower probability of developing SAD (p-value <0.05). Conclusion: Social anxiety disorder was observed in about one-third of medical students, with most cases classified as mild. Beta-blocker usage was infrequent and primarily reported to reduce stress and anxiety. Furthermore, significant associations were found between the presence of SAD and age, stage and family history of SAD. Keywords Social Anxiety Disorder, Social Phobia Inventory Scale, Beta-Blocker, Psychiatric Disorders, Medical Students, Iraq INTRODUCTION

Background Maternal mortality has decreased globally in the past three decades; however, mortality remains high in some locations and progress has plateaued or reversed in others. Updated comprehensive assessments of maternal mortality for countries and territories, including subcauses of maternal mortality, are essential to understand progress toward meeting the Sustainable Development Goal (SDG) 3.1 target for maternal mortality ratio (MMR) of fewer than 70 deaths per 100 000 livebirths and to inform ongoing and future efforts to improve maternal health. Our study aim was to assess maternal mortality levels and trends globally and for regions, countries, and territories, to report progress toward meeting SDG 3.1, and to assess pandemic-year trends in maternal mortality. Methods In this systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2023, we used Cause of Death Ensemble modelling (CODEm) to estimate maternal mortality rates up to 1 year postpartum using data from vital registration, verbal autopsies, household surveys, censuses, surveillance systems, and maternal mortality audits. These estimates were combined with age-specific all-cause mortality, population, and fertility estimates to calculate maternal deaths, maternal cause fraction, and MMR (maternal deaths per 100 000 livebirths) from 1990 to 2023, by 5-year age groups from 10 years to 54 years, and for 204 countries and territories. We also estimated MMR for each of ten maternal subcauses. We assessed progress toward meeting the SDG 3.1 target by calculating MMR for women and girls aged 10–54 years, determining which countries and territories are currently meeting or close to meeting the target, assessing annualised rates of change in MMR, and identifying locations that have stagnated or reversed trends in MMR. Estimates for 2020 to 2023 capture the effects of the peak of the COVID-19 pandemic and subsequent recovery; however, pandemic effects are difficult to estimate in locations in which timely or high-quality data for pandemic years are scarce. We explored and separately reported three alternative (non-CODEm) methods of estimating COVID-19 effects for these locations: two population attributable fraction (PAF) approaches and an excess mortality approach. Findings In 2023, there were 240 000 (95% uncertainty interval [UI] 208 000–280 000) total maternal deaths globally, which equates to a global MMR of 190·5 (95% UI 165·1–222·5) maternal deaths per 100 000 livebirths. Maternal deaths account for 5·5% (95% UI 4·7–6·3) of all deaths among women and girls aged 10–54 years. Global MMR has decreased substantially from 1990 (321·0 [281·0–374·0]), but 104 of 204 countries and territories have yet to meet the SDG 3.1 target of MMR of less than 70. Of these 104 countries and territories, 15 had an MMR in the range of 70 to 100, 16 had an MMR between 100 and 140, and 73 had an MMR higher than 140. Most countries and territories (120 out of 204) had slower or reversed annualised rates of change in MMR during the early SDG period of 2015–23 compared with the Millennium Development Goals period of 2000–15. In some regions of the world, including the Caribbean, Latin America, high-income North America, central Asia, and central and eastern Europe, maternal deaths rose in 2020 and 2021, a departure appreciable using standard data collection and modelling methods. Using the experimental COVID-19 PAF, maternal PAF, and excess mortality approaches in locations lacking timely or high-quality data, we estimated approximately 1740 (95% UI –3380 to 8180), 23 100 (–14 900 to 90 800), and 22 900 (17 800 to 29 300) total additional maternal deaths due to the COVID-19 pandemic, respectively, for 2020 and 2021 combined. Interpretation Global progress on maternal mortality slowed during the early SDG period of 2015–23 and mortality remains high in many locations. We found that 104 of 204 countries and territories have yet to meet the SDG goal of fewer than 70 maternal deaths per 100 000 livebirths. The COVID-19 pandemic increased maternal mortality in the peak pandemic years of 2020 and 2021 in many locations with high COVID-19 mortality. High-quality and timely data are essential for monitoring progress toward meeting the SDG 3.1 target, and efforts should prioritise identifying data gaps and focusing data collection in areas where data are sparse or less timely. Efforts should also continue to focus on providing high-quality, accessible, and adaptable care to prevent and manage well known obstetric complications, while also assessing and responding to health threats such as COVID-19 in 2020 and 2021.

Background Meningitis remains the leading infectious cause of neurological disabilities globally, disproportionately affecting children younger than 5 years and populations in the African meningitis belt. Whereas previous global estimates focused on ten pathogen categories, this study presents the most comprehensive analysis to date, assessing the meningitis burden attributable to 17 causative pathogens based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework. Methods GBD is a systematic, scientific effort aimed at quantifying the comparative magnitude of health loss caused by diseases, injuries, and risk factors across age groups, sexes, and geographical locations over time. We estimated meningitis mortality using the Cause of Death Ensemble model (CODEm) and morbidity using DisMod-MR 2.1, incorporating data from vital registration, verbal autopsy, surveillance, hospital data, and systematic reviews. Aetiology-specific estimates were generated with pathogen-linked case-fatality ratios and splined binomial regression models. Risk factor attribution was based on established risk–outcome pairs and population attributable fractions. Findings In 2023, there were 259 000 (95% uncertainty interval 202 000–335 000) global deaths and 2·54 million (2·20–2·93) incident cases of meningitis. Children younger than 5 years accounted for more than a third of deaths (86 600 [53 300–149 000]). Streptococcus pneumoniae, Neisseria meningitidis, non-polio enteroviruses, and other viruses were the leading causes of death, while non-polio enteroviruses caused the most cases. The four WHO-defined preventable meningitis pathogens of interest (S pneumoniae, N meningitidis, Haemophilus influenzae, and Group B streptococcus) contributed to 98 700 deaths (77 000–127 000) and 594 000 cases (514 000–686 000). Low birthweight, short gestation, and household air pollution were the top risk factors for meningitis-related mortality. Interpretation Although mortality and incidence have declined significantly since 1990, progress is insufficient to meet WHO 2030 targets. Despite marked progress in reducing bacterial meningitis via global vaccination campaigns, a substantial meningitis burden persists, attributable both to common pathogens such as S pneumoniae and N meningitidis and to emerging non-bacterial pathogens such as Candida spp and drug-resistant fungi. Achieving WHO goals will require sustained investment in surveillance, vaccination, maternal screening, and health-system strengthening, especially in high-burden settings.

The Rhesus blood group system exhibits significant polymorphism, with diverse antigen distributions across populations. This study investigates the antigenic profile, haplotype frequencies, and genotype predictions in a cohort from Zakho, Kurdistan Region, Iraq, which is crucial for transfusion medicine and genetic studies. A prospective cross-sectional analysis was performed on 1,000 Kurdish individuals at Zakho Emergency Teaching Hospital. Blood samples were phenotyped for Rh (D, C, c, E, e) antigens. Haplotype assignments were made using Fisher-Race terminology, and probable genotypes were calculated based on allele frequencies and Wiener nomenclature. The most common Rhesus blood antigens are Rh(e) (95%), Rh(D) (91.9%), Rh(C) (76%), and Rh(c) (68%). Rh(E) is found in 25.8% of individuals, while only 8.1% are Rh(D) negative. Among the Rh(D) positive population, the most frequent phenotype/haplotype and presumed genotype was DCe (DCe/DCe, R1R1) at 31.4%, followed by DCce (DCe/dce, R1r) at 29.3%, and DCcEe (DCe/DcE, R1R1) at 13.8%. The dce phenotype (dce/dce, rr, in 7.2%) was the most common among Rh(D) negative individuals. No significant differences were observed between sexes. This study reveals that DCe, DCce, and DCcEe are prevalent phenotypes among Rh(D) positive individuals, whereas the dce haplotype predominates among Rh(D) negative individuals. The Rhesus phenotype/genotype aligns with Kurdish and Arab groups in Iraq and shows partial resemblance to Western European, Indian, and Iranian populations, but significantly differs from African-American populations, except for the dce phenotype (dce/dce, rr). These findings are crucial for blood transfusion strategies, donor selection, maternal and fetal health, the prevention of Rh incompatibilities, and genetic research in the region.

The first year of medical school builds a strong foundational knowledge among students required for medical education. However, many students struggle to pass this stage on their first attempt. A considerable higher percentage of medical students fail in first-year compared to subsequent academic years. This paper seeks to investigate factors contributing to the high first-year failure rate through an Iraqi college lens. It further aims to bridge this issue by providing recommendations to minimize this burden, including modifications in entry criteria, updating curriculum, and enhancing support for students’ mental well-being.

Background Lower respiratory infections (LRIs) remain the world's leading infectious cause of death. This analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides global, regional, and national estimates of LRI incidence, mortality, and disability-adjusted life-years (DALYs), with attribution to 26 pathogens, including 11 newly modelled pathogens, across 204 countries and territories from 1990 to 2023. With new data and revised modelling techniques, these estimates serve as an update and expansion to GBD 2021. Through these estimates, we also aimed to assess progress towards the 2025 Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) target for pneumonia mortality in children younger than 5 years. Methods Mortality from LRIs, defined as physician-diagnosed pneumonia or bronchiolitis, was estimated using the Cause of Death Ensemble model with data from vital registration, verbal autopsy, surveillance, and minimally invasive tissue sampling. The Bayesian meta-regression tool DisMod-MR 2.1 was used to model overall morbidity due to LRIs. DALYs were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs) for all locations, years, age groups, and sexes. We modelled pathogen-specific case-fatality ratios (CFRs) for each age group and location using splined binomial regression to create internally consistent estimates of incidence and mortality proportions attributable to viral, fungal, parasitic, and bacterial pathogens. Progress was assessed towards the GAPPD target of less than three deaths from pneumonia per 1000 livebirths, which is roughly equivalent to a mortality rate of less than 60 deaths per 100 000 children younger than 5 years. Findings In 2023, LRIs were responsible for 2·50 million (95% uncertainty interval [UI] 2·24–2·81) deaths and 98·7 million (87·7–112) DALYs, with children younger than 5 years and adults aged 70 years and older carrying the highest burden. LRI mortality in children younger than 5 years fell by 33·4% (10·4–47·4) since 2010, with a global mortality rate of 94·8 (75·6–116·4) per 100 000 person-years in 2023. Among adults aged 70 years and older, the burden remained substantial with only marginal declines since 2010. A mortality rate of less than 60 deaths per 100 000 for children younger than 5 years was met by 129 of the 204 modelled countries in 2023. At a super-regional level, sub-Saharan Africa had an aggregate mortality rate in children younger than 5 years (hereafter referred to as under-5 mortality rate) furthest from the GAPPD target. Streptococcus pneumoniae continued to account for the largest number of LRI deaths globally (634 000 [95% UI 565 000–721 000] deaths or 25·3% [24·5–26·1] of all LRI deaths), followed by Staphylococcus aureus (271 000 [243 000–298 000] deaths or 10·9% [10·3–11·3]), and Klebsiella pneumoniae (228 000 [204 000–261 000] deaths or 9·1% [8·8–9·5]). Among pathogens newly modelled in this study, non-tuberculous mycobacteria (responsible for 177 000 [95% UI 155 000–201 000] deaths) and Aspergillus spp (responsible for 67 800 [59 900–75 900] deaths) emerged as important contributors. Altogether, the 11 newly modelled pathogens accounted for approximately 22% of LRI deaths. Interpretation This comprehensive analysis underscores both the gains achieved through vaccination and the challenges that remain in controlling the LRI burden globally. Furthermore, it demonstrates persistent disparities in disease burden, with the highest mortality rates concentrated in countries in sub-Saharan Africa. Globally, as well as in these high-burden locations, the under-5 LRI mortality rate remains well above the GAPPD target. Progress towards this target requires equitable access to vaccines and preventive therapies—including newer interventions such as respiratory syncytial virus monoclonal antibodies—and health systems capable of early diagnosis and treatment. Expanding surveillance of emerging pathogens, strengthening adult immunisation programmes, and combating vaccine hesitancy are also crucial. As the global population ages, the dual challenge of sustaining gains in child survival while addressing the rising vulnerability in older adults will shape future pneumonia control strategies.

moking remains a significant public health issue globally, contributing to a wide range of preventable diseases and premature mortality. This study aims to assess the prevalence of smoking and its associated factors in Zakho, Kurdistan, Iraq. A cross-sectional study was conducted in January 2024, involving 537 adults aged 18 and older. Participants were randomly selected using a multistage sampling process, and data was collected using a structured questionnaire including clinical, behavioral, and sociodemographic information. Logistic regression was performed in IBM SPSS to identify factors associated with smoking. The mean age of participants was 35.73±13.95 standard deviation. The prevalence of smoking in Zakho was found to be 180 (33.5%), with significantly higher rates among men, 165 (47.8%) compared to women, 15 (7.8%). Factors such as gender, education, employment status, physical activity, and hypertension were significantly associated with smoking. The smoking prevalence in Zakho surpasses both the national and global averages. It is more common among men, the uneducated, and the employed. Targeted tobacco control measures such as public smoking bans, higher taxes, and education are needed. Healthcare professionals should promote cessation strategies to reduce the burden of smoking. Further longitudinal studies must explore long-term health effects.

Introduction. Diabetes and prediabetes are major global health concerns, with rising prevalence driven by aging, urbanization, obesity, and sedentary lifestyles. Early identification of at-risk individuals is essential to prevent progression and complications. Data on the epidemiology of diabetes and prediabetes in Duhok City, Iraq, remain scarce. This study aims to determine the prevalence of diabetes and prediabetes, as well as the associated risk factors, among adults in Duhok City, Iraq. Methods. A population-based cross-sectional study was conducted in March 2025 among 563 adults selected via multistage random sampling. Data on demographics, lifestyle, medical history, anthropometrics, and blood glucose were collected. Diabetes and prediabetes were diagnosed based on fasting blood glucose, random blood glucose, and glycated hemoglobin levels. Logistic regression was used to estimate odds ratios with 95% confidence intervals for factors associated with prediabetes and diabetes. Results. The overall prevalence of glycemic abnormalities was 18.1%, including 6.4% with prediabetes and 11.7% with diabetes; 13.6% of diabetes cases were previously undiagnosed. Factors associated with prediabetes were older age and a history of dyslipidemia, whereas factors associated with diabetes included older age, higher body mass index, a history of dyslipidemia, and a family history of diabetes. Conclusions. One in five adults in Duhok City has prediabetes or diabetes, with a substantial proportion undiagnosed. Older age, higher body mass index, a history of dyslipidemia, and a family history of diabetes are key determinants of diabetes. These findings emphasize the need for targeted screening and early interventions to prevent the progression of diabetes and its complications.

Abstract. Background and aim: Hepatitis A virus (HAV) is a major cause of acute hepatitis globally, with higher burden in low- and middle-income countries. Iraq is considered hyperendemic, yet limited regional data are available, particularly from Zakho city. This study aimed to evaluate the seroprevalence of HAV and identify associated risk factors in the general population of Zakho. Methods: A cross-sectional study was conducted in Zakho from February 1 to March 1, 2025. A multistage random sampling approach was used to select 391 participants. Information was collected through structured self-administered questionnaires, and blood samples were tested for HAV IgG. Results: The average age of participants was 33.53 ±13.34 years; 65% were male, and 93.9% lived in urban areas. The overall HAV seroprevalence was 34.5%, with the highest rates found in individuals aged 20–29. No significant associations were found concerning gender (p = 0.772), age (p = 0.095), or water source (p = 0.295). However, handwashing habits were significantly related to HAV status (p = 0.026). Conclusions: The lower HAV prevalence in Zakho compared to national statistics indicates improvements in sanitation and hygiene. Nevertheless, proper hand hygiene remains critical, underscoring the importance of targeted public health education.

Objectives This study aimed to explores the knowledge, attitudes, and practices related to cardiovascular diseases (CVDs) risk factors among the Iraqi Kurdistan population to identify gaps and guide public health strategies for better cardiovascular health outcomes. Study design A population-based study. Methods This population-based study was conducted in Duhok Province and the Zakho Independent Administration within the Kurdistan Region of Iraq from April 20, 2024, to June 15, 2024. A total of 784 participants were enrolled in the study. Data collection was carried out through face-to-face interviews in various public settings using a questionnaire comprising 26 items divided into four sections: sociodemographic characteristics, knowledge, attitudes, and practices. Results The mean age of the study participants was 32.48 ± 13.63 years. Females made up (54 %) of the sample, and more than half had university or postgraduate education. While a majority recognized smoking (92.1 %), hypertension (81.5 %), and high cholesterol (86.2 %) as significant CVD risk factors, (31.7 %) were unaware that diabetes increases CVD risk. Despite high awareness, only (29.7 %) regularly exercised, and (34.6 %) consumed fast food regularly. The mean KAP score was 20.66 ± 2.63 out of 25, which manifests that participant had good KAP scores toward cardiovascular disease risk factors. The KAP scores were significantly higher among females, married individuals, healthcare workers, non-smokers, those with a family history of CVD, and individuals who obtained their knowledge from physicians. Conclusions This study reveals a gap between knowledge and practice regarding CVD risk factors in the Kurdistan Region. Awareness is high, but many, especially younger adults and those with lower education, fail to adopt healthy practices. The findings highlight the need for targeted interventions to promote behavioral changes.

Background Comprehensive, comparable, and timely estimates of demographic metrics—including life expectancy and age-specific mortality—are essential for evaluating, understanding, and addressing trends in population health. The COVID-19 pandemic highlighted the importance of timely and all-cause mortality estimates for being able to respond to changing trends in health outcomes, showing a strong need for demographic analysis tools that can produce all-cause mortality estimates more rapidly with more readily available all-age vital registration (VR) data. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is an ongoing research effort that quantifies human health by estimating a range of epidemiological quantities of interest across time, age, sex, location, cause, and risk. This study—part of the latest GBD release, GBD 2023—aims to provide new and updated estimates of all-cause mortality and life expectancy for 1950 to 2023 using a novel statistical model that accounts for complex correlation structures in demographic data across age and time. Methods We used 24 025 data sources from VR, sample registration, surveys, censuses, and other sources to estimate all-cause mortality for males, females, and all sexes combined across 25 age groups in 204 countries and territories as well as 660 subnational units in 20 countries and territories, for the years 1950–2023. For the first time, we used complete birth history data for ages 5–14 years, age-specific sibling history data for ages 15–49 years, and age-specific mortality data from Health and Demographic Surveillance Systems. We developed a single statistical model that incorporates both parametric and non-parametric methods, referred to as OneMod, to produce estimates of all-cause mortality for each age-sex-location group. OneMod includes two main steps: a detailed regression analysis with a generalised linear modelling tool that accounts for age-specific covariate effects such as the Socio-demographic Index (SDI) and a population attributable fraction (PAF) for all risk factors combined; and a non-parametric analysis of residuals using a multivariate kernel regression model that smooths across age and time to adaptably follow trends in the data without overfitting. We calibrated asymptotic uncertainty estimates using Pearson residuals to produce 95% uncertainty intervals (UIs) and corresponding 1000 draws. Life expectancy was calculated from age-specific mortality rates with standard demographic methods. For each measure, 95% UIs were calculated with the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings In 2023, 60·1 million (95% UI 59·0–61·1) deaths occurred globally, of which 4·67 million (4·59–4·75) were in children younger than 5 years. Due to considerable population growth and ageing since 1950, the number of annual deaths globally increased by 35·2% (32·2–38·4) over the 1950–2023 study period, during which the global age-standardised all-cause mortality rate declined by 66·6% (65·8–67·3). Trends in age-specific mortality rates between 2011 and 2023 varied by age group and location, with the largest decline in under-5 mortality occurring in east Asia (67·7% decrease); the largest increases in mortality for those aged 5–14 years, 25–29 years, and 30–39 years occurring in high-income North America (11·5%, 31·7%, and 49·9%, respectively); and the largest increases in mortality for those aged 15–19 years and 20–24 years occurring in Eastern Europe (53·9% and 40·1%, respectively). We also identified higher than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 5–14 years (87·3% higher in GBD 2023 than GBD 2021 on average across countries and territories over the 1950–2021 period) and for females aged 15–29 years (61·2% higher), as well as lower than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 50 years and older (13·2% lower), reflecting advances in our modelling approach. Global life expectancy followed three distinct trends over the study period. First, between 1950 and 2019, there were considerable improvements, from 51·2 (50·6–51·7) years for females and 47·9 (47·4–48·4) years for males in 1950 to 76·3 (76·2–76·4) years for females and 71·4 (71·3–71·5) years for males in 2019. Second, this period was followed by a decrease in life expectancy during the COVID-19 pandemic, to 74·7 (74·6–74·8) years for females and 69·3 (69·2–69·4) years for males in 2021. Finally, the world experienced a period of post-pandemic recovery in 2022 and 2023, wherein life expectancy generally returned to pre-pandemic (2019) levels in 2023 (76·3 [76·0–76·6] years for females and 71·5 [71·2–71·8] years for males). 194 (95·1%) of 204 countries and territories experienced at least partial post-pandemic recovery in age-standardised mortality rates by 2023, with 61·8% (126 of 204) recovering to or falling below pre-pandemic levels. There were several mortality trajectories during and following the pandemic across countries and territories. Long-term mortality trends also varied considerably between age groups and locations, demonstrating the diverse landscape of health outcomes globally. Interpretation This analysis identified several key differences in mortality trends from previous estimates, including higher rates of adolescent mortality, higher rates of young adult mortality in females, and lower rates of mortality in older age groups in much of sub-Saharan Africa. The findings also highlight stark differences across countries and territories in the timing and scale of changes in all-cause mortality trends during and following the COVID-19 pandemic (2020–23). Our estimates of evolving trends in mortality and life expectancy across locations, ages, sexes, and SDI levels in recent years as well as over the entire 1950–2023 study period provide crucial information for governments, policy makers, and the public to ensure that health-care systems, economies, and societies are prepared to address the world's health needs, particularly in populations with higher rates of mortality than previously known. The estimates from this study provide a robust framework for GBD and a valuable foundation for policy development, implementation, and evaluation around the world.

Introduction and aims: Hypertension (HTN) is a chronic and common condition that causes health issues, such as stroke and heart failure, causing substantial disease burden and mortality. This study aimed to explore the prevalence of HTN and determine its risk factors in Zakho, Iraq. Methodology: This cross-sectional study occurred between 15 January 2024 and 18 March 2024. A multistage sampling method was utilized, with interviewers administering questionnaires to random households selected by a number generator. Results: A total of 537 participants were included, comprising 64.2% (n = 345) males and 35.8% (n = 192) females, with an average age of 35.75 (±13.89). The study showed that the prevalence of HTN was 9.5% (n = 51). A univariate analysis revealed that increasing age (p < 0.001), high waist circumference (p < 0.001), no education (p < 0.001), marriage (p = 0.001), unemployment (p = 0.04), non-smoking (p = 0.03), hyperlipidemia (p < 0.001), and ischemic heart disease (p = 0.003) were significantly associated with HTN. The multivariate logistic regression revealed that hyperlipidemia (adjusted odds ratio (aOR) = 3.729; 95% CI: 1.762-7.891), age (aOR = 1.056; 95% CI: 1.030-1.083), and non-smoking (aOR = 0.333; 95% CI: 0.142-0.781) were significant predictors of HTN, with p-values of 0.001, <0.001, and 0.011, respectively. Conclusions: A high prevalence of HTN was found among those having multiple comorbidities and was significantly associated with age and hyperlipidemia. Public awareness campaigns, targeted intervention for high-risk groups, and healthier lifestyles are crucial to combat HTN.

Background Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. Methods GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. Findings The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6–47·0) in 1990 to 63·4 years (63·1–63·7) in 2023. For males, mean age increased from 45·4 years (45·1–45·7) to 61·2 years (60·7–61·6), and for females it increased from 48·5 years (48·1–48·8) to 65·9 years (65·5–66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9–81·0) and for males 74·8 years (74·8–74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5–38·4) for females and 35·6 years (35·2–35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. Interpretation We examined global mortality patterns over the past three decades, highlighting—with enhanced estimation methods—the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales.

Background For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. Methods The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010–23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Findings Total numbers of global DALYs grew 6·1% (95% UI 4·0–8·1), from 2·64 billion (2·46–2·86) in 2010 to 2·80 billion (2·57–3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0–14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31–1·61) global DALYs in 2010, increasing to 1·80 billion (1·63–2·03) in 2023, alongside a concurrent 4·1% (1·9–6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176–209] DALYs), stroke (157 million [141–172]), and diabetes (90·2 million [75·2–107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0–107·5]), depressive disorders (26·3% [11·6–42·9]), and diabetes (14·9% [7·5–25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837–917) in 2010 to 681 million (642–736) in 2023, and a 25·8% (22·6–28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7–61·0) for diarrhoeal diseases, 42·9% (38·0–48·0) for HIV/AIDS, and 42·2% (23·6–56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6–22·0) and 24·8% (7·4–36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7–19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18–1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation—with high SBP accounting for 8·4% (6·9–10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories—behavioural, metabolic, and environmental and occupational—risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8–37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0–11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023—eg, declining by 54·4% (38·7–65·3) for unsafe sanitation, 50·5% (33·3–63·1) for unsafe water source, and 45·2% (25·6–72·0) for no access to handwashing facility, and by 44·9% (37·3–53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [–2·7 to 15·6]; non-significant). Interpretation Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors—eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG—including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic—the complex interaction of multiple health risks, social determinants, and systemic challenges—will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity.

Background: COVID-19 is a highly contagious viral respiratory disease that was declared a pandemic. Vaccination is considered one of the most effective methods of protection against this viral disease. The aim of this study was to determine the factors that contribute to the uptake or lack of uptake of the COVID-19 vaccine as well as identifying factors associated with post-vaccination regret that some healthcare providers may experience following being vaccinated in Duhok province in Kurdistan region of Iraq. Methods: This research was conducted as an observational cross-sectional study that took place from 1 January 2024 to 1 September 2024. A non-probability convenience sampling technique was employed to distribute questionnaires among healthcare workers within major hospitals in Duhok province. Results: Of the 502 participants, a total of 405 participants (76.05%) reported receiving the COVID-19 vaccine. Vaccination rates were higher among males (84.8%) than females (76.6%) (p = 0.02), and highest among clinicians (90.7%) compared to other occupations. Participants with more than 10 years of experience (92.4%) and those with comorbidities (91%) were more likely to be vaccinated. Regarding regret, 100 (24.7%) of vaccinated participants reported post-vaccination regret. Regret was more common among nurses (32.6%) and participants with secondary education (31.4%), while clinicians (11.1%) and PhD holders (16.7%) reported lower levels of regret. Years of experience was also significantly associated with regret, with the highest level among those with ≥10 years (30.4%). Conclusion: These findings emphasize the need for targeted strategies to address barriers to vaccine uptake and manage concerns about vaccination among healthcare providers, and gain a deeper understanding of the underlying causes of post-vaccination regret, ultimately enhancing public health efforts in the region.

For efficient undergraduate medical research education at the College of Medicine, University of Zakho, three research modules, known as "Student Selected Components" (SSCs), have been added to the college’s academic curriculum. These modules aim to enhance research skills and encourage problem-solving via community-based health projects. More than 50 peer-reviewed publications and around 30 national and international conference presentations were the result of this program, which was under the mentorship of college academics and external researchers. This project has substantially enhanced the university's academic reputation and approval. This paper investigates the transformational effect of SSCs in fostering students’ research orientation, development, and institutional reputation. Moreover, it represents a successful experience, serving as a model for other colleges in the country to follow.

Background: The rise in antimicrobial-resistant Escherichia coli (E. coli) strains pose a serious threat to global public health, necessitating coordinated efforts from government and the broader community to combat this growing challenge. This study aimed to analyze the antibiotic sensitivity of E. coli isolates from urine samples over a 10-Year Period collected from patients in Duhok, Kurdistan Region of Iraq. Methods: This cross-sectional study was conducted between December 2013 and January 2022. A total of 531 midstream urine samples were collected from patients with confirmed urinary tract infections. E. coli isolates were identified using standard culture methods and confirmed through biochemical testing. Antibiotic susceptibility testing was performed using the VITEK 2 system. Results: E. coli isolates exhibited the highest resistance rates in 2022, particularly against amoxicillin (84.2%). Overall, the most resistant antibiotics were amoxicillin (76.46%), ceftazidime (67.8%), and ceftriaxone (57.63%), while the highest sensitivity was observed for meropenem (95.86%) and imipenem (94.92%). Male patients exhibited higher resistance rates to several antibiotics, including ceftazidime, ceftriaxone, and ciprofloxacin (p ≤ 0.001), whereas no significant gender differences were observed for carbapenems or nitrofurantoin (p > 0.05). Conclusion: The findings indicate that E. coli isolates from urine samples demonstrated high resistance to amoxicillin, ceftazidime, and ceftriaxone, while maintaining high sensitivity to meropenem, imipenem, and amikacin. Gender-related differences in resistance were significant for several antibiotics, with higher resistance rates observed in male patients. Further multicenter studies across broader regions of Iraq are recommended to monitor and address the evolving resistance patterns of E. coli uropathogens.

Background and objectives Hepatitis B virus (HBV) infection remains a significant global health challenge, particularly in developing countries. Despite the availability of an effective vaccine, chronic HBV infection continues to cause substantial morbidity and mortality. This study aimed to determine the prevalence and associated risk factors of HBV infection in Zakho City, Kurdistan Region of Iraq. Methods A population-based cross-sectional study was conducted on 26 February 2025 in Zakho City, Kurdistan Region, Iraq, using a multistage random sampling method. Data were collected from 386 participants through structured face-to-face interviews and serological testing for hepatitis B surface antigen (HBsAg) and anti-hepatitis B core immunoglobulin G antibody (HBcAb) using enzyme-linked immunosorbent assay. Results The overall HBV positivity rate (HBcAb-positive) was 8%, with 7% indicating past infection (HBcAb-positive, HBsAg-negative) and 1% indicating chronic infection (HBcAb-positive and HBsAg-positive). In the multivariate analysis, HBV positivity was significantly associated with older age (P = 0.001) and male gender (P = 0.026). The highest prevalence (32.1%) was observed among participants aged ≥ 60 years. Conclusions The findings demonstrate a moderate prevalence of past HBV infection and a relatively low rate of chronic carriers in Zakho city. Older age and male gender were significant predictors of HBV positivity. These results underscore the importance of continued public health efforts in HBV screening, early detection, and vaccination, particularly targeting older and at-risk populations.

This study aimed to examine the association between breastfeeding practices and the risk reduction of childhood leukemia, and to identify the optimal breastfeeding duration for infant health. A case-control design was used, involving children aged 0–16 years diagnosed with leukemia and a matched control group without leukemia.MethodsData were collected on breastfeeding duration, type of feeding during the first six months, maternal characteristics (age, education, smoking during pregnancy, abortion history, birth control pill use), and child-related variables (sex, age at diagnosis, and birth order). Statistical analysis was conducted using SPSS Version 27. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and a p-value of12 months) was more frequent in controls (32%) than in cases (16%). Lower maternal education was significantly associated with leukemia cases (p = 0.001). Logistic regression showed exclusive breastfeeding (OR = 0.501, p < 0.001) and breastfeeding >12 months (OR = 0.721, p = 0.001) were protective.ConclusionExclusive and prolonged breastfeeding significantly reduce the risk of childhood leukemia. Maternal education is also an important factor, underscoring the need for public health initiatives to promote breastfeeding awareness

Background: Hepatitis C virus (HCV) infection continues to be a major public health concern. The advancement of directacting antivirals (DAAs) has transformed HCV therapy, making viral elimination possible. Nonetheless, experiencing a relapse following treatment continues to be a difficulty. Objectives: This research intended to evaluate the rate of HCV relapse 84 months after finishing DAA treatment. Methods: The study included 89 patients who had finished DAA therapy and achieved a sustained virologic response (SVR). These patients were monitored for as long as 84 months, with yearly follow-up appointments. Serological assessments for HIV and hepatitis B surface antigen (HBsAg) and HCV-RTPCR were performed. The average age of the participants was 23 years (±7 years). Results: Among the 89 patients, 41 (46.07%) exhibited genotype 1 (G1), 7 (7.87%) displayed genotype 3 (G3), and 41 (46.07%) represented genotype 4 (G4). The group was made up of 52 males (58.43%) and 37 females (41.57%). A co-morbid condition, thalassemia, was observed in 10 (11.24%). No patients showed positive results for HIV or hepatitis B. During the 84-month followup, no relapses or reinfections were noted. Conclusions: The research validates the effectiveness of DAAs in attaining a sustained virologic response and preventing HCV recurrence. Additional research involving larger groups and extended follow-up times is necessary to confirm these results.

Pseudomonas aeruginosa, a Gram-negative bacterium, causes a range of infections, including those affecting the skin and soft tissues, pneumonia, and sepsis. Its significance lies in its capacity to develop resistance to numerous antibiotic classes. In Iraq, infections caused by Pseudomonas are prevalent, especially within healthcare settings. Studies indicate a concerning level of antibiotic resistance in this microorganism. Information regarding the genetic basis of this resistance is limited in Iraq, with existing research typically involving small sample sizes. The growing resistance to β-lactams in Iraq is a serious concern, especially the extended-spectrum β-lactamases (ESBLs). Metallo-β-lactamases (MBLs) such as VIM and NDM are causing a rise in the resistance to carbapenems. The limited data about the resistance patterns to quinolones and aminoglycosides is another barrier. The high prevalence of Pseudomonas aeruginosa combined with limited data on its resistance pathways in Iraq highlights the need for continued surveillance, stronger infection control measures, and the development of more targeted treatment options to address this challenging pathogen.

Cholera remains a serious public health threat in Iraq. Since the start of the 21st century, the country has experienced multiple outbreaks, with the most recent epidemic occurring in 2022. In this paper, we examine cholera outbreaks in Iraq from 2020 to 2025, focusing on distribution patterns, public health challenges, and the impact of the COVID-19 pandemic on monitoring and control of cholera, with the aim of translating these findings into practical recommendations. Key contributing factors to recurring outbreaks are still prevalent in many areas of the country, including a shortage of access to safe drinking water, inadequate sewage infrastructure, conflicts, internal displacement, and low health literacy. Additionally, the COVID-19 pandemic has substantially impacted Iraq’s already exhausted health system and indirectly hindered cholera preparedness and response. In Iraq, cholera outbreaks tend to follow a geographical and seasonal pattern, with most outbreaks typically peaking between late summer and early winter. Despite predictable patterns, the government’s responses have remained exclusively reactive. A coordinated, forward-thinking approach is needed, with strengthening early alert systems, advancing local monitoring, and funding clean water and sewage facilities to achieve sustainable cholera control.

Background: The prevalence of Helicobacter pylori infection varies worldwide and is associated with gastrointestinal diseases. Helicobacter pylori prevalence varies globally and is linked to gastrointestinal diseases. This study examines the prevalence and histopathological features of H. pylori among outpatients undergoing upper endoscopy in Zakho, Iraq, from 2021 to 2023. Methods: This retrospective cross-sectional study was conducted between 2021 and 2023 in Zakho, Iraq. A total of 183 patients aged 16 to 75 years were diagnosed based on endoscopic biopsy and specimens obtained from the antrum and body of the stomach. A microscopic examination was performed following histopathological specimen preparation to detect H. pylori and analyze histopathological findings. Results: Among 183 patients who underwent endoscopy, H. pylori infection was found in 128 (69.94%). The most common symptoms were epigastric pain 55 (30.05%), burning sensation 41 (22.4%), and nausea 33 (18.03%), Only regurgitation showed a significant difference (p = 0.023). Common endoscopic findings included pangastritis 51 (27.87%, p = 0.01), erosive gastritis 40 (21.85%), gastric ulcers 31 (16.93%, p = 0.01), and duodenal ulcers 22 (12.02%, p = 0.003). Histopathologically, ulceration/erosion 127 (69.3%, p = 0.01) and lymphoepithelial lesions (20.76%, p = 0.001) were significantly more frequent in H. pylori-positive patients. Conclusion: This study revealed a high prevalence of H. pylori, strongly linked to ulceration, erosion, pangastritis, and erosive gastritis. The findings highlight the need for region-specific management guidelines to improve treatment and public health strategies in Zakho.

Introduction: This study aimed to determine the prevalence and associated factors of coronavirus disease 2019 (COVID-19) and long COVID-19 in children in Duhok province and Zakho city in the Kurdistan region. Methodology: The study was conducted as a cross-sectional study and included children aged 5–12 years in Duhok and Zakho, two major neighboring cities in the Bahdenan region of northern Iraq. A total of 330 participants were included and the study was conducted between October 2022 and April 2023. The children were tested for the presence of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) antibodies. A questionnaire was used to collect demographic and personal data, and symptoms of each participant to determine the prevalence of long COVID-19. Results: Out of 330 participants, 302 (91.5%) were positive for IgG, and 156 (51.7%) of them were male. Only 4 participants (1.3%) had pneumonia, and 282 (93.4%) were asymptomatic. Fourteen out of 302 (4.6%) participants had long COVID-19. There were significant associations between long COVID-19 and history of previous COVID-19 episodes (p = 0.001), presence of pneumonia (p = 0.001), and family history of COVID-19 (p = 0.005). Conclusions: There was a high prevalence of COVID-19 among children in Duhok province and Zakho city, and 4.6% of them experienced long COVID-19. Factors such as prior COVID-19, pneumonia, and family history of COVID-19 were associated with long COVID-19. Continued monitoring, education, vaccination, preventive measures, and supportive care are recommended to effectively address the impact of COVID-19 on the pediatric population.

We present this study to investigate various risk factors associated with hepatitis B in the Kurdistan region of Iraq. HBV Positivity. Among the 4091 study participants, 150 tested positive for HBsAg (3.67%). The prevalence of HBV positivity among females was 4.77% (136/2851). This was significantly higher than the prevalence of HBV positivity among males, which was 1.13% (14/1240) (p = 0.001). Risk factors for HBV infection. Various risk factors for HBV infection were considered, and the following factors were found to be statistically significantly associated with the HBV infection: gender, residence, marital status, receiving an injection, general operation, and history of tattoo (p = 0.001, 0.001, 0.0014, 0.001, 0.001 and 0.001 respectively). Multivariate analysis revealed that the association of surgical operation and history of tattoo to HBV infection is not statistically significant (multivariate p = 0.06325 and 0.0645, respectively). To conclude, 3.67% of the participants in this study were HBsAg positive; the predictive factors of infection were female gender, rural residency, and being married. Further population-based studies with larger sample sizes are needed to unify the results and be used to build a strong healthcare infrastructure to screen for hepatitis B.

Background Staphylococcus aureus is a gram-positive bacterium causing various infections, colonizing various human body sites, and leading to a wide spectrum of diseases. Antimicrobial resistance presents a growing and significant danger to worldwide public health, demanding urgent action from both governmental bodies and communities. Objectives This study aimed to analyze the antibiotic sensitivity of S. aureus for common antibiotics isolated from urine samples collected from participants at Azadi Teaching Hospital in Duhok, Iraq. Methods This study was conducted between January 2018 and February 2022. During this five-year period, a total of 396 samples were gathered from patients referring to Azadi Teaching Hospital, Duhok, Iraq. S. aureus strains were confirmed and tested in terms of susceptibility to various antibiotics using the VITEK 2 system (bioMérieux, Inc., Durham, NC). Results S. aureus isolates from urine samples from 2018 to 2022 showed the highest resistance rate in 2022. The highest resistance rate was reported for erythromycin (324, 81.82%) while the highest sensitivity rate was found for levofloxacin (275, 69.4%). Additionally, gender-based differences in antimicrobial susceptibility were negligible (p > 0.05), but generally, males had a slightly higher resistance rate compared to females. Conclusion According to the results, S. aureus isolated from urine samples varied in terms of the antibiotic susceptibility pattern with high resistance rates to erythromycin, penicillin, and oxacillin, while showing high sensitivity rates to levofloxacin, nitrofurantoin, and vancomycin. Further studies are needed with a broader geographical involvement to investigate the antibiotic sensitivity pattern in Iraq.

Objective This study aimed to study the prevalence of undiagnosed diabetes mellitus (DM) and its associated factors in adults aged over 18 in Zakho City, Kurdistan Region, Iraq. Methods A cross-sectional study was conducted recruiting 537 participants with a mean age of 35.43±13.88 years. Data on sociodemographic characteristics, health behaviors, clinical history, and anthropometric measurements, including body mass index (BMI) and waist circumference, were collected. Results The study sample comprised 345 (64.2%) men and 192 (35.8%) women, with 324 (60.3%) being married and 246 (45.8%) having a university-level education or higher. Regarding health behaviors, 218 (40.6%) participants engaged in physical activity, 180 (33.5%) were smokers, and 196 (36.5%) reported sleep disturbances, averaging 7.10±2.02 hours per night. Anthropometric assessments revealed that 209 (38.9%) were overweight, 131 (24.4%) were obese, and 273 (50.8%) had high waist circumference. The prevalence of abnormal glucose levels was 51 (9.5%) (95% CI: 7.02-11.98) including 14 (2.6%) (95% CI: 1.26-3.95) with undiagnosed DM and 37 (6.9%) (95% CI: 4.75-9.03) with prediabetes mellitus (pre-DM). Multivariate analysis showed significant associations between abnormal glucose levels and increased age (p<0.0001), high BMI (≥25 kg/m²) (p<0.0001), and high waist circumference (p<0.0001). Specifically, age was a significant predictor for pre-DM (adjusted odds ratio (aOR) 1.04; 95% CI: 1.01-1.07), while age and high waist circumference predicted undiagnosed DM (aOR 1.90; 95% CI: 1.03-1.16).

Background Hepatitis B (HBV) and Hepatitis C (HCV) are significant global health challenges, leading to severe complications such as liver cirrhosis and hepatocellular carcinoma. Despite available vaccines and treatments, these infections persist, particularly in regions like Iraq. Objectives and aims This study aimed to assess the prevalence of HBV and HCV among couples attending premarital screening programs in Zakho, Kurdistan Region of Iraq, and explore associated demographic risk factors. Materials and Methodology A retrospective cross-sectional study was conducted from 1st Oct 2019 to 31st Dec 2023, including 15,091 couples. Laboratory screening for HBV and HCV was performed using ELISA, followed by RNA quantification for HCV-positive cases. Results Out of the total of 15,091 couples, the overall prevalence of HBV was 0.92%, and HCV was 0.07%. Males, individuals aged 23-31, and urban residents had higher infection rates. Significant risk factors included being in the age group 23-31, male gender, and urban residency (p < 0.05). Conclusion The prevalence of HBV and HCV among couples in Zakho is consistent with regional data. Higher infection rates in males and urban areas suggest the need for targeted interventions, including public education and screening for high-risk populations.

Background and Objectives Hepatitis B virus (HBV) and hepatitis C virus (HCV) are significant global health challenges, leading to severe complications such as liver cirrhosis and hepatocellular carcinoma. Despite available vaccines and treatments, these infections persist, particularly, in regions such as Iraq. This study aimed to assess the prevalence of HBV and HCV among couples attending premarital screening programs in Zakho, Kurdistan Region of Iraq and explore the associated demographic risk factors. Methods A retrospective cross-sectional study was conducted from October 1, 2019 to December 31, 2023, including 15,091 couples. Laboratory screening for HBV and HCV was performed using enzyme-linked immunosorbent assay, followed by RNA quantification for HCV-positive cases. Results Of the total of 15,091 couples, the overall prevalence of HBV was 0.92% and HCV was 0.07%. Males, individuals aged 23-31 years, and urban residents had higher infection rates. Significant risk factors included age 23-31 years, male gender, and urban residency (P <0.05). Conclusions The prevalence of HBV and HCV among couples in Zakho is consistent with regional data. Higher infection rates in males and urban areas suggest the need for targeted interventions, including public education and screening for high-risk populations.

Background: Peptic ulcer disease (PUD) is a multifactorial disease whose global prevalence has reduced over the past years. Objectives: This study aimed to determine PUD's prevalence and risk factors and the associated risk factors behind this disease. Methods: A cross-sectional study was conducted in Duhok, Kurdistan, Iraq, between August 11 and December 17, 2022. A total of 218 patients (116 males and 102 females) who underwent upper gastrointestinal endoscopy by specialists at Azadi Teaching Hospital were interviewed face-to-face. The participants' ages ranged between 18 and 81. The upper GIT endoscopy was performed using a PENTAXI-scan 5000-type endoscopy. Results: The prevalence of peptic ulcers among the participants was 30 (13.8%), 27 (12.4%) duodenal ulcers and 3 (1.4%) gastric ulcers. Abdominal pain was the primary complaint, reported by (39%) of the participants, followed by heartburn (28.4%) and vomiting (6.9%). Regarding the risk factors for developing peptic ulcer among the studied cases, NSAID use was the highest risk factor (25.7%), followed by spicy food (21.6%), smoking (20.6%), family history (17%), and Helicobacter pylori infection (12.4%). A significant association was observed between H. pylori (P = 0.001) and gender (P = 0.001) with peptic ulcer. Additionally, (5%) of the participants reported melena as a complication, while only (2.3%) reported hematemesis. Conclusions: This study found that 13.8% of individuals undergoing upper gastrointestinal endoscopy exhibit peptic ulcers, with 12.4% manifesting duodenal ulcers and 1.4% exhibiting gastric ulcers. Identified risk factors for peptic ulcer disease include sex and H. pylori infection. Further research is crucial to thoroughly explore the impact of various factors on the development of PUD.

Background and aim The COVID-19 pandemic has globally impacted all sectors. Early vaccine development was crucial to curb the spread of the virus. However, concerns about vaccine safety and side effects have led to hesitancy. This study aims to examine and compare side effects associated with Pfizer/BioNTech, Oxford/AstraZeneca, and Sinopharm vaccines in Iraqi Kurdistan. Materials and methods A population-based study was conducted in the Kurdistan Region of Iraq from September 2022 to April 2023, involving 1,340 participants recruited through face-to-face interviews and online forms. The questionnaire collected demographic data and information on COVID-19 infection and vaccination status. Results Among the participants, 52.76% were females, with a mean age of 29.21 years (±13.09 SD). Of these, 67.84% received the Pfizer/BioNTech vaccine, and 60.9% had a prior COVID-19 infection. About 76.94% experienced post-vaccination side effects, lasting an average of 2.8 days (±1.92 SD). Notably, 60% reported no or mild side effects. Common side effects across all vaccines included injection site pain, fever, headache, and fatigue. Side effects were more frequent after the first dose and were highest with Oxford/AstraZeneca, followed by Pfizer/BioNTech and Sinopharm (p = 0.001). Higher rates of side effects were observed in participants aged 36-60, females, married individuals, those with chronic conditions, previously infected individuals, and those who contracted COVID-19 post-vaccination (p = 0.001). Conclusions This study reveals that most of the participants experienced either no side effects or only mild reactions following vaccination, with none of the side effects being serious. These findings are expected to boost public confidence and increase vaccine uptake, especially with booster doses now available.

Background and aim: The COVID-19 pandemic has profoundly impacted global health, necessitating the rapid development of vaccines to reduce its effects. However, concerns among healthcare workers regarding vaccine safety and side effects have led to increased hesitancy towards COVID-19 vaccination. Therefore, this study aims to assess the severity of adverse effects and associated factors of three COVID-19 vaccines among healthcare workers in Iraqi Kurdistan. Methods: A retrospective cross-sectional study was conducted among healthcare workers in Duhok province, Kurdistan Region, Iraq, with 625 participants aged 18 to 65 years (mean age 38.42±13.96) from August to December 2022. Data were collected through face-to-face interviews. The study questionnaire consisted of two parts: the first part collected demographic information about the participants, while the second part focused on their COVID-19 infection and vaccination status. Results: Of the total participants, 52.8% were female, with a mean age of 38.42 years (±13.96 SD). Approximately 67.5% received the Pfizer/BioNTech vaccine, and 60.9% had a prior history of COVID-19 infection. A significant proportion (82.24%) reported side effects, which were mostly mild or moderate, with 13.6% experiencing severe symptoms. The most commonly reported side effects across all three vaccines were pain at the injection site, fever, headache, and fatigue. Participants aged 36-50 reported significantly higher rates of severe side effects (87.88%, p = 0.047). Individuals with a history of allergies experienced significantly fewer adverse effects (48.93%) (p = 0.001). Those with prior COVID-19 infection also reported more severe symptoms post-vaccination (p = 0.001) and vaccine type-influenced side effects (p < 0.001), with Oxford/AstraZeneca recipients more likely to experience severe reactions compared to Pfizer recipients. Fatigue, chills, tremors, and myalgia were significantly more common in females than males (p < 0.005). Conclusion: This study identified the most common side effects of COVID-19 vaccines among healthcare workers in Kurdistan Region of Iraq. AstraZeneca vaccine was associated with a higher prevalence of systemic effects, including fever, fatigue, headache and myalgia. These findings provide valuable insights into the safety and side effect profile of COVID-19 vaccines in the region.

Sexually transmitted infections (STIs) are posing a challenge to public health, globally. The aim of this study was to determine the frequency of three STIs in married women, clinical characteristics, and their associated risk factors. A cross-sectional study was performed among married women who attended the Gynaecological Hospital in Zakho City, Iraq from October 2021 to April 2022. A total of 150 high vaginal swabs were collected from each subject aged between 18 and 48 years (32.64 years ±8.01 SD). DNA was extracted from swabs to determine STIs using Multiplex Real-Time PCR. The frequency of STIs was 26 out of 150 (17.33%). Chlamydia trachomatis accounted for 17 (11.33%), Trichomonas vaginalis 7 (4.66%), Neisseria gonorrhoeae 2 (1.33%). The highest rates of C. trachomatis, T. vaginalis, and N. gonorrhoeae were reported among young age groups. The level of education (p=0.043) and type of contraceptives (p=0.01) were identified as potential risk factors for T. vaginalis. The number of births (p=0.001) and using contraceptives (p=0.02) were reported as major risk factors for N. gonorrhoeae. Abnormal discharges (p=0.004), vaginal itching (p=0.03), painful intercourse (p=0.04), genital ulcers (p=0.03), and bleeding in the urine (p=0.001) were significantly associated with infections. The frequency of STIs was low in symptomatic patients but high among the reproductive age group. Education level, contraceptive usage, and number of births were identified as potential risk factors. Early detection of these factors is crucial for improving women’s health.

H. pylori is known to increase the risk of developing gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric lymphoma in adults, worldwide. This study aimed to determine the seroprevalence of H. pylori infection and risk factors associated with such infection among adult in Duhok province, Kurdistan Region, Iraq. This cross-sectional study was conducted among adult population in Duhok Province, Iraq. During the study period from 2018 to 2020, a total of 259 subjects aged more than 18 years who visited the general hospitals were included. H. pylori seropositivity rate was determined using un enzyme-linked immunosorbent assay (ELISA). A standardized questionnaire was administered to all study participants through face-to-face interview. The data obtained from H pylori IgG antibody were analyzed using the chi-square test. The prevalence of anti H. pylori IgG antibody positivity was present in 104 out259 (40.02%) of the adult. Among the studied variables, all the following risk factors were significantly associated with the presence of anti H. pylori IgG antibodies; male (p< 0.043), level of education (p<0.025), history of gastrointestinal diseases (p< 0.001), smoking status (p< 0.001) and a larger sibling number (p< 0.001). This study supports the hypothesis that H. pylori infection in adult is highly related to poor hygiene, smoking status, low level of education and crowded conditions. Therefore, it is crucial to implement effective strategies aimed at enhancing fundamental sanitary conditions, as well as improving educational level and socioeconomic status, in order to reduce the prevalence of H. pylori infection among adults in our region

Methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of infectious diseases among athletes, globally. There is very little data on the prevalence of these strains in Kurdistan region of Iraq, and none on the carriage among athletes. This study aimed to determine the prevalence and associated risk factors with MRSA and molecular detection of mecA gene among athletes. This study was conducted in Zakho City, Kurdistan Region, Iraq, nasal swabs were collected from 510 participants among various types of athletes following the completion of a questionnaire. Traditional bacteriological methods were used for the isolation of MRSA Staphylococcus aureus and oxacillin susceptibility test was performed as a preliminary step in MRSA identification. Then MRSA isolates were further analysed by PCR in order to detect the mecA gene. Out of 510 participating athletes, MRSA nasal carriage rate was 8.04% (41/510). The highest rate of infection was observed among football (10.71%) followed by gym (9.39%), but there was no significant difference between the various types of sports with MRSA (p=0.41). There was a significant relationship between gender and type of athletes (p=0.018). Nasal colonization of MRSA was significantly influenced by body mass index (p=0.006), previous use of antibiotics (p=0.02), previous surgical operation (p=0.002), duration of training/ day (p=0.025) and number of training sessions/week (p=0.047). mecA gene was then confirmed in 38/40 (95%) MRSA isolates. The MRSA infection rate in our study was higher compared to other studies conducted elsewhere and was significantly higher among male athletes; this was associated with personal hygiene and inappropriate use of antibiotics. More studies were recommended on molecular analysis of virulent genes associated with MRSA in athletes.

he severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic poses a danger to public health across the world. Specific and sensitive testing is vital to tracking and containing the infected individuals. This study examines the characteristics of 705 patients based on gender and age groups, with a focus on their CT (Cycle Threshold) values associated with E- and RdRp gene amplification. Among the patient cohort, 58.87% were male, while 41.13% were female. Notably, all males and females tested positive for the E gene, achieving a 100% detection rate, whereas the RdRp gene exhibited a slightly lower positive rate of 93.4% in males and 89.6% in females. Statistical analysis through the chi-square test revealed no significant disparities between target genes and gender. Additionally, a one-way ANOVA test demonstrated no significant distinctions between target genes and age groups. This study's findings suggest that gender and age do not significantly influence CT values for E and RdRp gene amplification, and there is no preferred gene for detection, providing valuable insights into the molecular characteristics of the studied cohort.

Anemia is a very important nutritional issue all over the world. It is most commonly present in preschool children with a prevalence of47.4%. Factors like low socio-economic status, large family size, ignorance and illiteracy are associated with anemia among children less than five years. Aim: To estimate the prevalence of anemia and identify the factors associated with it in children aged 2–5 years. Patients and Methods: A cross sectional study included 798 pre-school children (2–5 years of age) selected from those children who visited health care centres and Heevi Pediatric Teaching Hospital. Dietary, biochemical and anthropometrical, and information were collected through a questionnaire. Children with hemoglobin (Hb) values of <11.0 g/dl were considered anemic. Heights, weights and Body Mass Index [BMI] were measured. Children with [BMI] above 85th centile was considered as overweight and above 95th centile as obese. Data such as past breastfeeding practices, birth weights, time of starting weaning food, duration of breastfeeding, type of weaning food, time of starting infant formula, child’s chronic illness, child’s eating habits, mother’s age, occupation and education were collected. Results: The overall incidence of anemia is 29.8% (238/798). The male: female ratio 1.03:1 in the anemic children. The body weight of the anemic patients was most commonly between 5th and 85th centiles, 155 (65.12%). The most frequent birth weight of the anemic patients was between 2.5 and 4 Kg,191(80.25%). Most of anemic patients had history of breast feeding for equal to or more than six months ,113(47.47%). The weaning foods of most of the anemic patients were cereals, vegetables and fruit 146 (61.34%). About 139 (58.4%) of patients were eating regularly and 156 (65.54%) with the family. Chronic illnesses were present in 63 (26.47%) among anemic patients. About 135(56.72%) of anemic patients had less than three siblings. The age of the mothers was less than 30 years in 112(47.05%). Illiterate mothers were 63(26.47%) among anemic patients and only 18 (7.56%) were employed mothers. The significant association was with the age (p<0.038), the frequency of eating with family (p<0.01) and chronic illnesses (p<0.001). There was a strongly significant correlation between hemoglobin concentration and age group, weight and height. Female was 1.009 times more likely to be anemic. Conclusion: The overall incidence of anemia is 29.8%. The gender, the age of starting weaning foods, the type of weaning foods and the presence of chronic illnesses are significant factors associated with the risk of anemia in the children in Duhok.

H. pylori is known to increase the risk of developing gastritis, peptic ulcer disease, gastric adenocarcinoma, and gastric lymphoma in adults, worldwide. This study aimed to determine the seroprevalence of H. pylori infection and risk factors associated with such infection among adult in Duhok province, Kurdistan Region, Iraq. This cross-sectional study was conducted among adult population in Duhok Province, Iraq. During the study period from 2018 to 2020, a total of 259 subjects aged more than 18 years who visited the general hospitals were included. H. pylori seropositivity rate was determined using un enzyme-linked immunosorbent assay (ELISA). A standardized questionnaire was administered to all study participants through face-to-face interview. The data obtained from H pylori IgG antibody were analyzed using the chi-square test. The prevalence of anti H. pylori IgG antibody positivity was present in 104 out259 (40.02%) of the adult. Among the studied variables, all the following risk factors were significantly associated with the presence of anti H. pylori IgG antibodies; male (p< 0.043), level of education (p<0.025), history of gastrointestinal diseases (p< 0.001), smoking status (p< 0.001) and a larger sibling number (p< 0.001). This study supports the hypothesis that H. pylori infection in adult is highly related to poor hygiene, smoking status, low level of education and crowded conditions. Therefore, it is crucial to implement effective strategies aimed at enhancing fundamental sanitary conditions, as well as improving educational level and socioeconomic status, in order to reduce the prevalence of H. pylori infection among adults in our region

Background and aims Healthcare staff are at high risk of occupational exposure to Hepatitis B and other bloodborne diseases. Lack of education about the knowledge of Hepatitis B virus contributes to an increase in cases. This study aims to determine the knowledge of the Hepatitis B virus among the medical professionals in Duhok province, Kurdistan Region of Iraq, and to determine their knowledge of the importance of vaccination. Materials and methods This cross-sectional study was conducted in Duhok province, Kurdistan Region of Iraq, among medical science students from November 2022 to February 2023 and a total of 511 students participated in the study. A Self-administered questionnaire comprising 22 items categorized into five sections was distributed to the students either electronically or by paper and pen method. The survey utilized a Five-point Likert scale when assessing respondents’ opinions on knowledge, attitude, and practice (KAP). Microsoft Excel and GraphPad Prism 9 were used for statistical analysis. Results A total of 511 responses were collected from medical, dental, pharmacy, and laboratory students. The average age of the participants was 20.74 ±1.43 years. Among the respondents, only 96 (18.8%) were fully vaccinated against the Hepatitis B virus (received 3 or more doses of the vaccine), while 294 (57.5%) were not vaccinated. Lack of vaccination programs was the major reason for not receiving a vaccination (n = 182, 62%). About 286 (55.96%) of the participants had good knowledge, attitude, and practice on Hepatitis B, manifesting median scores of 26, 18, and 20, respectively. Conclusion In our study, half of the students were found to be unvaccinated, mainly due to the absence of vaccination programs. Vaccinated students exhibited better knowledge, attitude, and practice toward the infection than non-vaccinated students. Therefore, we recommend the implementation of a vaccination program as well as training on infection prevention guidelines to increase awareness and encourage vaccination.

Background and aims: Antiphospholipid antibodies are associated with miscarriage and abortion, and this association has been reported in different countries. The aim of this study is to assess the prevalence of antiphospholipid antibodies IgM and IgG among pregnant women with previous history of miscarriage in Zakho City, Kurdistan region, Iraq. Methods: This cross-sectional study was conducted in Zakho city among women who had history of miscarriages from 1 st April 2019 to 31st May 2021. A total of 460 women age ranged between 16-46 years (Average age 29.73± 5.93 STDEV) were recruited in the study. Enzyme-linked immunosorbent assay (ELISA) was used to measure antiphospholipid IgM and IgG antibodies. The relationship between age and level of antiphospholipid antibodies was performed using the Chi-Square test (Fisher Exact Test). Results: The overall rate of antiphospholipid antibodies was 31 (6.74%) for IgM, 16 (3.48%) for IgG and 9 (1.96%) was seropositive for both IgM and IgG antibodies. The study found that the highest IgM was 18 (11.25%) and IgG 10 (6.2%) seropositivity among age group 30 years old. There was a significant association between age groups and IgM seropositivity (P=0.02; OR=0.4; 95% CI 0.2-0.9) but statistically not significant between age groups and IgG seropositivity (P=0.79; OR=0.9; 95% CI 0.3-2). It was also found no significant differences between age groups and both IgM and IgG seropositivity (P=0.28; OR=0.4; 95% CI 0.1-1). Conclusion: The prevalence of antiphospholipid antibodies among aborted women was relatively low compared to other study. There was a positively association between IgM seropositivity and age group. Therefore, it is essential to conduct APA screening for women who have recurrent pregnancy loss and investigate the therapeutic effects of heparin and aspirin; this approach might improve fetal survival by starting anticoagulant treatment early.

The emergence of the SARS-CoV-2 Omicron variant has raised concerns due to its increased transmissibility and potential implications on clinical characteristics and outcomes in infected individuals. The aims of this report were to study the profile of SARS-CoV-2 infection with omicron variant, investigate the infection outcome, reinfection rates with associated factors, antibody levels, and explore the associations between biochemical markers and disease severity. This prospective cohort study was conducted in Duhok city in the Northern of Iraq. All volunteers with confirmed SARS-CoV-2 RT–PCR and confirmed Omicron infection who were older than 18 years old and agreed to participate were recruited for this study. The study was carried out from January to April 2022. There were 234 cases of confirmed SARS-CoV-2 RT–PCR Omicron infection. The mean age was 48.12±17.3 years, 43.2% were vaccinated, and 40.2% were male. Among the recruited patients, 99.1% recovered and did not need hospitalization. In this study,(38.9%) had a history of previously confirmed COVID-19 infection. Reinfection was significantly higher in females than males (p= 0.04; OR= 0.56). It was found that the IgG antibody levels were higher in patients who received Pfizer-BioNTech than in those who received other vaccines (p= 0.001). The levels of IgG were also significantly higher in patients with mild infection (p= 0.046), whereas the levels of D-dimer were significantly higher in patients with severe cases of the infection compared to those with mild or moderate cases (p= 0.001). Additionally, the levels of C-reactive protein (CRP) were observed to be higher in …

Background. Diabetes mellitus (DM) is a chronic, non-transmissible health condition distinguished by high blood glucose levels caused by faulty insulin secretion and impaired insulin activity. People play an essential role in preventing and managing their illnesses. Thus, the misconceptions may negatively influence the prevention and management of DM. The aim of this study was to gauge the extent of knowledge among the general population concerning DM, to determine the prevalence of misconceptions about DM in the community, and to find the factors influencing them. Methods. A population-based study was conducted in Duhok Province, the Kurdistan Region of Iraq. A total of 2,305 adults were enrolled in the study. The study data were collected by face-to-face interview. The survey questionnaire comprised two sections: the first section included basic demographic characteristics of participants, while the second section consisted of ten questions to identify common misconceptions about DM among participants. Results. Among the participants, there were 1,406 (61.0%) females. Participants’ age ranged from 18 to 90 years (the mean age: 54 ± 13.69 years). The most common misconceptions positively responded to were “Will I become addicted to insulin if I start taking it?”, followed by“ Does DM occur because of increased sugar intake?”. Male gender was associated with higher level of misconceptions. In addition, the misconceptions were more prevalent among diabetics as they might seek treatment from non-professionals. There was a significant association between education status and the prevalence of misconceptions. Healthcare workers were found to have a better knowledge about DM compared to the general population. Surprisingly, certain myths were prevalent even among healthcare workers. Conclusions. Certain myths and misconceptions have been pervasive in our society. Actions must be taken to dispel these misconceptions as they lead to an avoidable burden of disease. Therefore, people’s knowledge of DM needs to be enhanced through educational programs, social media, television, newspapers and campaigns.

Background: Candida vaginitis is a major fungal infection of the female genital tract ranging from mucosal to systemic infection. Candida species has remained a major public health issue affecting women globally. Objectives: The aim of this study was to evaluate the prevalence of Candida albicans and its associated risk factors among married women with signs and symptoms of vaginitis referring to Obstetrics and Gynecological Hospital at Zakho City, Iraq. Methods: Vaginal samples were collected from 150 symptomatic women aged 18-48 years from October 2021-to April 2022 using two sterile cotton swabs. Wet mount was initially performed from first swab for the presence of budding yeast cells, and pseudo-hyphae of Candida infection. The second collected swabs were cultured on Sabouraud dextrose agar and incubated at 35°C for 24-48 hrs. C. albicans was then detected using morphologic characteristics of the colony. Candida colonies were finally confirmed by germ tube test. Results: Overall, 58 (38.67%) C. albicans were diagnosed. The highest rate of infection was reported in the age group of 31-40 years (45%) and non-educated people (37%), but statistically not significant (p>0.05). C. albicans was also higher in women who used pills as a contraceptive (45.45%) than other types of contraceptives. Women who had low number of births were significantly associated with C. albicans (OR; 1.01, 95% CI; 0.94-1.26, p=028). C. albicans was also significantly associated among symptomatic patients with vaginal itching (67.19%) (OR; 9.69, 95% CI; 4.52-20.79, p=0.001) and vaginal pH level > 4.5 (OR; 0.39, 95% CI; 0.19-0.82, p=0.001). C. albicans was also significantly higher among participants who had whitish vaginal discharges (96.67%) (OR; 8.0, 95%CI, 3.8-16.85, p=0.001), and yellow-green vaginal discharges (58.62%) (OR; 0.12, 95% CI; 0.01-0.93, p=0.007). Conclusions: C. albicans is a relatively common gynaecological problem among married women in our region. C. albicans is significantly higher among child bearing age women who had vaginal discharges and itching in our study. These results call for preventive measures to protect women against Candidiasis. Therefore, public health education and campaign should be implemented.

Background and aims: Intestinal protozoan parasitic infections are considered one of the most frequent types of infection caused by these parasites and remain a major health problem for communities. This study aims to detect the frequency of intestinal protozoan infections infection among Zakho general population from October 2018 to June 2022. Methods: This study was performed as a cross-sectional study among 2118 patients referring to private medical diagnostic laboratories in Zakho City, Kurdistan Region, Iraq. Samples of faecal matter were collected and subjected to analysis using two different techniques: direct observation under the microscope (wet mount) and formalin-ether concentration methods. Morphological characteristics of trophozoites and cysts were used to identify E. histolytica using microscopical examination. Results: Out of 2118 recruited samples, 1155 (54.53%) were male and 963 (45.47%) were female. The mean age of participants was 20.41 (±19.12) with ages ranging from 1-63 years. The overall prevalence of protozoan infections was 395/2118 (18.65%). Out of these, Entamoeba histolytica was the predominant pathogenic protozoa infection 271 (68.61%), followed by Giardia lamblia 100 (25.31%). A significant association was seen between Entamoeba histolytica and age groups (p=0.003) and gender (p=0.004). The highest infection rate was reported among the age group <15 years (55.72%). We also found a higher rate of Giardia infection among age group <15 years (46%) with significant differences (p=0.002) and a higher rate of Giardia seen in females (55%) with significant association (p=0.014). Conclusion: The frequency of Giardia lamblia and E. histolytica infections in our study was higher than other studies reported in Iraq and other countries, and these infections continue to pose a difficult public health issue and necessitate the implementation of stronger and more effective preventative measures.

Background. After COVID-19 emergence, medical education witnessed a shift from face-to-face education to digital education, which inevitably affected medical students. Globally, due to the closure of schools and universities, medical education was shifted to electronic learning (E-learning). This paper aimed to assess the effects of the COVID-19 pandemic on medical education and determine medical students’ knowledge, attitude, and practices towards E-learning in the Kurdistan Region of Iraq. Materials and Methods. An online cross-sectional study was conducted among 500 undergraduate students of seven medical colleges in the Kurdistan Region, Iraq, in November 2021, to assess their state during the COVID-19 pandemic and how this affected their education. Results. There were 50.6% of males and 49.4% of females. The mean age was 20.6 ( ± 1.5 SD) years. Approximately 17% of participants mentioned having financial issues, while 19.2% of students experienced health-related problems. As many as 67% of participants reported that the Internet quality was good or very good, whereas 46.8% of students disagreed that E-learning was a possible substitute for traditional learning. About two-thirds of participants agreed or were neutral that downloadable content was better than live content; however, only 19.2% of students agreed that E-learning could be used in the clinical aspect. A total of 52.2% of participants disagreed that E-testing could replace traditional learning methods. Surprisingly, 86.4% of students stated that they regularly used the Internet in their study. Conclusions. E-learning was the main adjustment made in the educational system, including medical education. The study concluded with insights into how different circumstances could have different consequences on the efficacy of medical education. E-learning showed effective results in continuing learning untilthe educational system switched to a blended system. Training programs for medical education personnel are vital in effective E-learning opportunities

Objectives: The aim of this cross-sectional study is to evaluate the seroprevalence of total antibodies to SARS-CoV-2 and associated risk factors in Zakho City, Kurdistan Region of Iraq. Methods: This cross-sectional study was performed at Zako City, Northern, Iraq. Blood samples were collected from different districts of Zakho city between January and March 2021. Immunoassays were performed to detect the total antibodies against SARS-CoV-2, and the associations between several variables were investigated. Results: A total of 315 participants were agreed and enrolled in the study. The average age of the participants was 32.87±13.25 years. Among the participants, 214/315 (67.93%) were found to have antibodies against SARS-CoV-2. Among those who had positive antibodies, 169/214 (78.97%) were asymptomatic and 45/214 (21.03%) had a history of COVID-19 related symptoms. The most common symptom was fever (95.56%), followed by loss of smell (84.44%) and myalgia (80.0%). We found that antibody levels significantly associated with age (P=0.021). The presence of symptoms was significantly higher among subjects with a history of comorbidity diseases (P=0.038), and older people (P = 0.015). A significant association was found between antibody levels and the marital status (P=0.014), chronic diseases (P=0.001), presence (P=0.015) and duration of symptoms (P=0.028). Conclusion: A significant association between antibody levels to SARS-CoV-2 and age, chronic diseases, presence and duration of symptoms were found in this study. Seroprevalence studies of antibodies to SARS-CoV-2 among general population are of utmost importance to develop infection prevention programs in our society.

The aim of this letter is to discuss the pandemic management measures, including social distancing and community containment, taken in Duhok city in Northern Iraq, where a few patients were infected with COVID-19. During the first three months of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, 15 patients were diagnosed with SARS-CoV-2 in Duhok city. All the patients were asymptomatic and were discharged to their home within 10 ± 3.2 days after throat swabs indicated a negative SARS-CoV-2 Real Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test. The social distancing and lockdown measures taken by the city were implemented in three stages. In the first stage, all educational institutions including schools, colleges and universities were closed. In the second stage, all gatherings were banned. Finally, state-imposed community-wide containment was declared. The social distancing measures helped control infections in the city. Gradual reopening is recommended to avoid the spread of infection.

Objective This study aimed to investigate the breakthrough infection rate and safety profile of the AstraZeneca vaccine. Methods The breakthrough COVID-19 infection rate was defined as a positive polymerase chain reaction test 14 days after the vaccine dose. Safety was assessed as local reactions and systemic events that occurred within 14 days of receiving vaccine doses. Results The average age of the 265 participants was 43.85 years and 169 (63.77%) were male. . After the second dose, 18 (6.71%) participants contracted the infection. The SARS-CoV-2 delta variant was responsible for all infections but no participants required hospitalisation. We found significant correlations between post-vaccination IgG levels and post-vaccination infection (P = 0.001; odds ratio [OR] = 0.959; 95% Confidence interval [CI]: 0.944–0.974), and between a history of previous infection and post-vaccination infection rates (P = 0.005; OR = 0.1; 95%CI:0.009–0.6). IgG levels were significantly higher in women than in men (P = 0.006) and in patients who developed side effects after vaccination than in those without side effects (P = 0.04). A significant association was found between a history of COVID-19 infection prior to vaccination and IgG levels (P = 0.001). Conclusions The vaccine is effective in preventing severe disease, with few side effects.

Bacterial Vaginosis (BV) is a leading cause of reproductive tract problem affecting mostly of reproductive age group, worldwide. The aim of this study is to detect the infection rate of BV and then evaluate the risk factors associated with this bacterium among married women in Zakho city, Iraq. This cross-sectional study was performed among 150 reproductive age women group from October 2021 till April 2022. The administered and structured questionnaire was designed to measure demographic, risk factors and clinical characteristics. The vaginal swabs were collected from each subject and used for microscopical examination including wet mount, vaginal pH, germ tube and Gram stain methods to analyze the infection rate. The analysis of univariate regression analysis was applied to determine the relationships between BV and associated risk factors and clinical characteristics. The average age of participants was 32.64 years (±8.01 SD). The prevalence of BV was 41 (27.33%) among married women. About 12 (8%) and 1 (0.67%) of participants had mixed infections with Candida albicans and Trichomonas vaginalis, respectively. BV was found mostly among the age group less than 20 years (41.67) followed by age group of 40-50 years (37.93%). We found a higher infection rate among subjects from rural area (34.78%), but statistically not significant (p=0.17). Higher number of births was statistically associated to BV (OR 1.17, 1.006-1.37; p=0.003). BV was also highly associated among symptomatic patients with abnormal vaginal discharges (OR 4.18, 1.89-1.9.23; p=0.002), genital ulcer (OR 0.34, 0.13-0.84; p=0.01), and vaginal pH level more than 4.5 (OR 0.009, 0.002-0.043; p=0.001). BV is still prevalent among the married women in our region. The higher infection rate was significantly associated with higher births number, vaginal discharges, genital ulcer and higher vaginal pH. There is an urgent regular required screening for bacterial vaginosis among symptomatic women. Therefore, the early detection of risk factors associated with bacterial vaginal growth is critical to enhance the health condition of married women, in order to prevent the risk of BV.

Background Despite vaccine and antiviral treatment availability, hepatitis B virus (HBV) continues to circulate among pregnant women in Iraq. HBV spread is due to many factors. This study evaluated HBV prevalence among pregnant women and Syrian refugees residing in Zakho city, Iraq, and identified risk factors associated with infection. Materials and methods Demographic data were collected from 2,054 pregnant women via a questionnaire assessing risk factors associated with HBV infection. Blood samples were collected for hepatitis B surface antigen (HBsAg) and were screened using an enzyme-linked immunosorbent assay. Results Tests revealed that 1.1% of pregnant women in Zakho and 11.3% of Syrian refugees (p = 0.001) were positive for HBsAg. The average age of HBsAg-positive patients was 31.4286 ± 6.6746 years (p = 0.002). Average rates of parity and abortion in HBV-infected subjects were 3.5 ± 2.6874 and 0.1785 ± 0.5479, respectively (p = 0.044 and 0.012, respectively). The following were identified as associated risk factors for HBV infection: nationality, (Zakho versus the city centre), tattoos, and polygamy (p = 0.001, 0.03, 0.007, and 0.001, respectively). No significant associations between HBV prevalence and blood transfusion, prior injection history, dental procedures, or surgical procedures were found. Conclusion The prevalence of HBV infection among Syrian refugees was higher than that of indigenous participants. Several risk factors were significantly associated with HBV positivity, which may facilitate effective preventive program implementation and decrease mother-to-child transmission risk. This will likely reduce infant and childhood HBV chronicity, and mortality rates.

Background and aims: Staphylococcus aureus is a leading cause of infectious diseases and responsible for outbreaks among athletes’ team. This study aimed to analysis the prevalence rate of S. aureus among athletes, and evaluate the antibiotic resistance and associated risk factors. Materials and methods: This cross-sectional study was performed to evaluate the nasal carriage rate of S. aureus among athletes applying different sports. Nasal swabs were collected from 510 athletes aged between 14-55 years. Conventional bacteriological methods were used for the isolation and identification of the S. aureus. According to the Clinical and Laboratory Standards Institute (CLSI), the profile of antibiotic sensitivity test was performed. Results: Out of recruited samples, S. aureus carriage rate among athletes was 30.2% (154/510) The highest infection rate was reported among boxing athletes 33.33% (8/24) and gym 32.65% (80/245). S. aureus colonization was significantly higher among the athletes who had low body mass index (p=0.001), longer duration of training/day (p=0.001) and higher number of training session /week (p=0.012). S. aureus carriage was significantly higher among male athletes 77.27% (119/154) than female athletes 22.73% (35/154) (p=0.002). The oxacillin resistance rate was 26.61%. S. aureus isolates were highly susceptible to rifampicin (100%), gentamycin (98.05%) and fusidic acid (98.7%). Conclusion: The prevalence of nasal carriage of S. aureus is comparatively high and the highest prevalent reported among male athletes. It is suggested that the control prevention program to be applied to reduce nasal carriage rate of infection, and associated risk factors with S. aureus among athletes. More studies on carriage rate of S. aureus should be applied using molecular study

Background: Escherichia coli (E. coli) are known to be a major cause of uropathogen among women globally. Urinary tract infection in pregnant women continues to pose clinical problems, which is a big burden for physicians. The emergence of antibiotic resistance to E. coli is inevitable and one of the critical health-associated problems. The present study aimed to determine the E. coli isolates, risk factors, and antibiotic resistance profile of the UTI among pregnant women. Methods: We conducted this cross-sectional study on pregnant women who attended maternity hospital in Zakho City, Kurdistan Region, Iraq. From October 2020 to January 2021, 196 subjects were recruited in the present experiment. Uropathogenic E. coli were detected from mid-stream urine of the participants. Subsequently, we performed antibiotic sensitivity test using microbiological standard tests. Through the use of designed questionnaires, the required data were collected, processed, and analysed via the Fisher’s exact test and Chi-square. Results: Out of a total of 196 subjects, 34 (17.34%) were culture positive for E. coli infection among pregnant women. A high rate of infection was detected in the age group of between 25-34 years (21.6%). Additionally, the highest rate of E. coli belonged to illiterate people (19.4%), followed by those with higher education (18.9%). The assessment of the risk factors associated with E. coli indicated that diabetes (P=0.028), a history of UTI infection (P=0.049), and the presence of symptoms during infection (P=0.001) were statistically significantly different. The antibiotics sensitivity profile in urine samples of pregnant women showed that E. coli were extremely sensitive to Nitrofurantoin (82.4%), Meropenem (79.4%), and around 67.6% for both Amikacin and Ciprofloxacin. Conclusion: The prevalence rate of E. coli infection is quite lower among pregnant women compared to that in non-pregnant ones. The major risk factors associated with E. coli during pregnancy were diabetes mellitus, a history of UTI, and the presence of symptoms during infection. E. coli isolated from urine samples seem to be different concerning antibiotic sensitivity pattern. During their regular follow-up, pregnant women should also be examined for major risk factors and antibiotic susceptibility.

Objectives: The aims of this study were to determine the prevalence of HBV infection and investigate the HBV-related risk factors in the Kurdistan region of Iraq. Methods: Sera samples were collected from 3423 patients visiting three centers and tested for HBV positivity by enzyme-linked immunosorbent assay. A questionnaire was prepared and used by the volunteers who collected data, including age, marital status, and different HBV-related risk factors, through face-to-face interviews. Results: The mean age of the recruited participants was 28.94 ± 11.17 years. In addition, 873/3423 (25.47%) were males, and 3024/3423 (88.34%) were married. Furthermore, HBV infection had a prevalence of 1.37% (47/3243). Multivariate analysis was conducted to identify the predictive factors of HBV infection, which revealed that a history of tattoos and age were predictive factors (p<0.05). We then stratified our data according to sex. No association was found between the various factors and HBV positivity in males. On the other hand, in females, a significant association was found between the history of tattoos or age and HBV positivity (p<0.05). Conclusions: In conclusion, the prevalence of HBV infection was low. Our study showed that a history of tattooing and older age were predictive of HBV infection. Our results could be used as a basis for local elimination programs.

Objectives: Helicobacter pylori infection is predominantly acquired in early childhood and persists for decades before causing disease. This study aimed to detect the prevalence of H. pylori infection and identify potential factors associated with infection in Duhok province, Iraq. Methods: This cross-sectional study was conducted in Duhok Province, Kurdistan Region, Iraq. Over a four-year period from 2016 to 2020, a total of 381 children aged four to 18 years who attended the hospitals and were evaluated for specific IgG antibodies against H. pylori using serological tests were included. A questionnaire was completed at the start of the study. H. pylori serology data were analyzed using the chi-square test. Results: The seroprevalence of H. pylori IgG-specific antibodies among the study participants was 31%. The infection rate significantly increased with increasing age of the participants (p<0.001), from 19.8% among four to five-year-olds to 42.9% among 16 and 18-year-olds. The infection rate was significantly higher in girls (35.9%) than that in boys (26.5%) (p<0.047). Infections were also higher among university students (41%; p<0.001), children from the country-side population (41%; p<0.001), children from crowded households (67.3%; p<0.001), and children with a history of gastrointestinal pain (44.4%; p>0.001). Conclusion. The prevalence rate of H. pylori infection among children in Duhok province is quite similar to that reported in previous studies in the Kurdistan region, Iraq, and increases with age. University attendance, history of gastrointestinal pain, countryside population, and overcrowding were risk factors associated with H. pylori infection. Valuable approaches to improve sanitary purposes and educational and socioeconomic status should be emphasized and promoted to reduce the risk of H. pylori infection among children.

Since the discovery of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus disease (COVID-19) pandemic has become the most important health-care crisis globally, having spread to millions of people worldwide. Patients who recover from COVID-19 are still susceptible to reinfection. In this report, we present the case of a patient who had recovered from COVID-19. Recovery was defined as the resolution of symptoms accompanied by two consecutive SARS-CoV-2-negative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) test results. Two months after the first infection, the patient tested positive for anti-SARS-CoV-2 antibodies. Three months after this test, the patient presented with mild COVID-19 symptoms that was confirmed by RT-PCR. These findings indicate a possible reinfection case. If the occurrence of reinfections is demonstrated to be true, then it may change the strategy of community-based disease prevention. More research is needed to confirm the concept of reinfection.

Introduction: The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) causes severe respiratory infection. Gastrointestinal symptoms have been reported in up to 10% of patients. Case Presentation: We here report a case of COVID-19-associated acute mesenteric ischemia in a patient presenting with fever and abdominal pain, deteriorating over a four-day period. The diagnosis was initially missed due to a low suspicion level. COVID-19 infection was confirmed by chest CT scan and RT-PCR. Then the patient underwent an emergency laparotomy showing segmental small bowel ischemia of about 2 meters (between the lower jejunum and upper ileum). Resection of the ischemic segment was performed by end-to-end anastomosis. He was then discharged from the hospital after recovering from COVID-19. Conclusions: The present case report highlights the importance of being vigilant about mesenteric ischemia symptoms in the patients with COVID-19, presenting with progressive abdominal pain for timely ordering appropriate diagnostic and therapeutic procedures

Background: Hepatitis B and C virus (HBV and HCV) infections are major global health issues and the leading causes of liver cirrhosis and hepatocellular carcinoma. Objectives: The aim of this study was to investigate the prevalence of HBV and HCV infections in couples attending a premarital screening program in Zakho city, Kurdistan region, Iraq. Methods: This cross-sectional study was carried out in Zakho city, Kurdistan Region of Iraq, between January and October 2019. During this period, 2123 couples were screened for HBV and HCV as a part of premarital screening. The age of couples ranged from 18 to 63 years old. ELISA test was used to detect HBsAg, HBc IgG, and HCV Ab. Hepatitis C virus Ab positivity was then confirmed by HCV RT-PCR, and all HCV positive patients were then tested for genotyping. Results: Among the recruited subjects, 38/4246 (0.89%) patients were positive for HBsAg. Of these, 12/2123 (0.57%) were females, and 26/2123 (1.22%) were males. Hepatitis C virus RT-PCR confirmed HCV positivity for one female patient who was further confirmed to be infected with HCV genotype 4. Conclusions: To conclude, the present study showed a relatively low prevalence of HBV and HCV infections in the couples tested through the premarital screening program in Zakho city. The prevalence of HBV seropositivity was higher in males than females. Therefore special attention should be paid to males during prevention strategies.

Novel coronavirus disease (COVID-19) or SARS-CoV-2 infection was discovered in December 2019 in Wuhan City, China. The infection became a global pandemic over a period of few months. Post-infection immunity and susceptibility for reinfection is still under investigation. In this report, we present a case of a COVID-19 reinfection in patient who had recovered from an initial infection. Case Report: 41-year-old male, nurse working in emergency hospital, presented in August 2020 with two days history of fever, sore throat, myalgia, lower back pain, shortness of breath. Then, his oxygen saturation dropped to 80%. COVID-19 infection was proved by a positive RT-PCR for SARS-CoV-2 and CT scan of the chest demonstrated bilateral ground glass opacities. After clinical improvement, the patient was discharged from hospital. On 26th of October, he developed fever, and fatiguability. RT-PCR for SARS-CoV-2 resulted as positive twice. The infection was mild and no specific treatment was administered to the patient during the second infection. On 6th of November, the patient was asymptomatic. On 7-8 th of November, he consecutively tested negative for SARS-CoV-2 twice. Conclusions: Mild SARS-CoV-2 reinfection may occur rarely due to repeated exposed to the virus in hospital setting. If the occurrence of reinfections is demonstrated to be true, it may change the strategy of infection prevention. Further studies are needed to confirm the possibility of COVID-19 reinfection

Objective This population-based study aimed to evaluate the seroprevalence of antibodies to SARS-CoV-2 in Duhok City, Kurdistan Region of Iraq. Methods We analyzed the national COVID-19 database that contains data regarding COVID-19 testing, management, and clinical outcomes in Duhok. For this study, different subdistricts within each district of Duhok were considered distinct clusters. Blood samples were collected from and questionnaires were administered to eligible and consenting participants who were members of different families from the subdistricts. Immunoassays were conducted to detect antibodies against SARS-CoV-2, and the associations between certain variables were investigated. Results The average number cases of COVID-19 before November 2020 was 23141 ± 4364, which was significantly higher than the average number of cases between November 2020 and February 2021 (3737 ± 2634; P = 0.001). A total of 743 individuals agreed to participate and were enrolled in the study. Among the participants, 465/743 (62.58%) were found to have antibodies against severe acute respiratory syndrome coronavirus 2. Among the participants with antibodies, 262/465 (56.34%) denied having any history of COVID-19-related symptoms. The most common symptom was fever (81.77%), followed by myalgia (81.28%). We found that antibody levels increased steadily with age (Pearson correlation coefficient = 0.117; P = 0.012). A significant association was found between antibody levels and the presence of symptoms (P = 0.023; odds ratio = 1.0023; 95% confidence interval = 1.0002-1.0061). Conclusions A significant reduction in the number of COVID-19 cases was observed. This might be due to the high prevalence of SARS-CoV-2 antibodies in Duhok. However, infection-prevention measures should be followed as it remains unclear whether acquired immunity is protective against reinfection. It expected that the infection rates during the next wave will not be as high as the first wave due to the high infection rate in the society.

Abstract: Background/Objectives: Coronavirus disease (COVID-19) is an emerging viral respiratory disease that has currently reached pandemic status. This study aimed to assessCOVID-19 knowledge, attitudes, and practices among the Kurdish population in Iraq. Methods: This cross-sectional study was conducted from July 15 to September 15, 2020 among the Kurdish population in Iraq. A total of 885 subjects were interviewed. All subjects were aged 15–75 years. Knowledge scores, attitudes, and practices of subjects were analyzed according to demographic characteristics. Results: The study subjects were largely male, the average age was31.79 years, and 41.92% subjects were from Erbil province. Approximately 85.31% subjects had enhanced knowledge regarding disease prevention and control. The lowest subscale scores were related to clinical manifestations of the disease. Knowledge scores were significantly associated with age, place of current residence, and level of education. A large number of participants believed COVID-19 would be controlled and the fight against the pandemic would be won. Subjects’ attitudes toward success differed significantly by demographic characteristics, except marital status. Approximately 40.03% subjects reported that they had not visited a crowded place, and 60.22% of these subjects wore face masks when leaving home. Conclusions: This study found good knowledge, positive attitudes, and proper practices among the general population regarding the COVID-19 pandemic. However, community-based health campaigns in the region should encourage optimistic attitudes and appropriate practices regarding virus containment and dissemination. Our findings may be used as a baseline for planning health education campaigns in the region.

The salivary glands have an important role in the functions of digestion by making lubrication fluid, respiration, speech, and overall homeostasis, and they also contain antibodies. Generally, the salivary gland tumors might be categorized into non inflammatory, inflammatory, and neoplastic swellings such as calculi, benign tumors like Warthin tumor, oncocytoma, pleomorphic adenoma, malignant tumors involving undifferentiated carcinoma, adenoid cystic carcinoma, and adenocarcinoma. Methodology: This epidemiological study is carried out at the Department of histopathology, Zakho general hospital, thirty salivary glands cases are involved in this work in a period of 15-years. Results: There are 30 patients with major salivary gland tumors, while 26 patients (86.666) had parotid and 4 patients (13.333) had sub-mandibular major salivary gland tumors. In the presented work, 26 (86.666) cases from a total of 30 salivary tumor cases have been benign, while only 4 (13.333) are malignant, from a total of 26 patents of parotid tumors, overall of 20(76.923) cases have been identified in superficial lobe, whereas only 6(23.076) cases have been in deep lobe, from a total of 30 salivary gland tumors, overall of 26(86.666) cases are pleomorphic adenoma and just 3 (11.538%) cases are mucoepidermoid carcinoma and only single case (3.333%) has been acinic cell carcinoma. Conclusions: The parotid gland has been defined as the major site of origin which is related to benign as well as malignant tumors, also the pleomorphic adenoma is the major benign salivary gland tumor and mucoepidermoid carcinoma is the major common malignant tumor. The rest of the cases are autoimmune disease and minor salivary gland tumors.

Background and Aim: Infection with hepatitis C virus (HCV) is a public health threat worldwide. The World Health Organization aims to eliminate HCV. However, the coronavirus disease (COVID‑19) pandemic has led to a severe compromise in health services, and this has halted efforts to eliminate HCV. Herein, we report our experience with the initiative of HCV elimination in Duhok city, Kurdistan

Background and Aim: Infection with hepatitis C virus (HCV) is a public health threat worldwide. The World Health Organization aims to eliminate HCV. However, the coronavirus disease (COVID‑19) pandemic has led to a severe compromise in health services, and this has halted efforts to eliminate HCV. Herein, we report our experience with the initiative of HCV elimination in Duhok city, Kurdistan Region of Iraq, with a focus on the effect of the COVID‑19 pandemic on the HCV elimination plan. Materials and Methods: An anti‑HCV antibody test was used to screen subjects. All positive results were then confirmed by reverse‑transcription polymerase chain reaction (RT‑PCR) testing. All patients with current HCV infection were treated with direct‑acting antiviral regimens. Results: During the study period, 459,015 subjects were tested for anti‑HCV antibody positivity, with a monthly average of 9,562 tests for HCV. This number dropped to zero during the lockdown period between 1March and 31May 2020. Among the tested samples, 0.29% (1350/459015) tested positive for anti‑HCV antibodies. RT‑PCR testing of all positive samples revealed that 0.020% (93/459015) were positive. Of the 93 recruited subjects, 3 patients did not complete the treatment course due to the lockdown. All patients who finished the treatment course were cured as determined by sustained virologic response 12 (SVR12) weeks after finishing the treatment course. Conclusion: During the COVID‑19 pandemic, reductions in health facility utilisation led to a significant decrease in services offered for HCV screening and treatment. Such a decrease in services has had a negative impact on HCV elimination. An urgent plan is needed to resume the services, and strict follow‑up is needed for patients whose treatment was interrupted.

Background: The impact of COVID-19 on mental health outcomes of medical residency is an important concern. Currently, evidence regarding this issue is not sufficient. Objectives: The current study aimed to demonstrate the impact of the COVID-19 pandemic on residency training programs as well as its psychological consequences for both individuals and their families in the Kurdistan Region, Iraq. Methods: This online cross-sectional study was performed at the Kurdistan Region, Iraq, from 12 - 25 August 2020. In total, 275 residents participated. Data were collected online, and the items were sent through specific Facebook and Viber groups of residents. Data were analyzed using descriptive statistics (i.e., frequency and percentage). Besides, the Chi-square and Fisher's exact test were used to compare the participants based on their sociodemographic characteristics. Results: Of 275 participants, 50.9% were female and mostly older than 30 years (52.4%). Surgical (36.4%) was the most commonly cited specialty, followed by medical (22.2%). Around 40% of residents were forced to changes the hospital due to the COVID-19 pandemic. Also, 50% of them had close contact with COVID-19 patients, and only 12.7% had enough training for the proper use of personal protective equipment (PPE). Moreover, 90% of the residents felt anxious and concerned about the situation. Nearly 10% of residents were infected with COVID-19, and 24% of them had an infected family member. Approximately 92% reported a reduction in training activities due to the COVID-19 outbreak. Of those with surgical specialties, 83% reported a significant reduction in the number of surgeries since the onset of the pandemic (P < 0.024). Conclusions: The COVID-19 pandemic has caused high levels of psychological distress of medical residency. The combination of psychological disorders with high infection rates among students of residency in our region may cause a critical impact on the residency training program. Besides, the quality of programs may also be influenced. An urgent plan is required to reduce the psychological stress and protecting doctors against the infection.

Introduction: The COVID-19 pandemic is a major challenge to healthcare services in the world. It has negatively impacted surgical practice, and health workers. We aimed to assess the impact of the COVID-19 pandemic on surgical practice in the Kurdistan Region, Iraq. Methods: An online cross-sectional study using an online survey was performed between 13 April to 29April, 2020 in the Kurdistan Region, Iraq. An online cross-sectional study using an online survey was performed between 13 April to 29 April, 2020 in the Kurdistan Region, Iraq. A total of 241 surgeons, aged28e70 years (mean range 22.2±7.9 SD), were recruited to this study. The questionnaire was designed to evaluate the impact of the COVID-19 pandemic on surgeons' practices. Participants completed a self-developed online questionnaire. Results: The majority of participants (44.39%) were general surgeons, followed by urologists (17.01%).Approximately 82.57% of surgeons performed surgeries during the COVID-19 pandemic and 60.31%undertook emergency surgeries only. There was no significant difference between men and women(P¼0.41) and different age groups (P¼0.08). Only 28.22% of surgeons had access to full personal protective equipment (PPE), and 41.18% believed that wearing PPEs severely affected their skills. Results also found that surgeons aged between 28 and 34 years were more pledged to the use of PPEs, than other age groups (P¼0.001). The use of PPEs during surgeries was significantly higher in the Sulaymaniyah province (P¼0.001). The surgical services were also severely impacted in the Sulaymaniyah province than in the other provinces (p¼0.001).Conclusion: The COVID-19 pandemic severely affected surgical practice in the Kurdistan Region, particularly in the Sulaymaniyah province. Males, and young surgeons showed a higher commitment level for using PPE. Additional training and precautions are needed to increase awareness about COVID-19 among surgeons, and the importance of using PPE during surgery

Background: Urinary Tract Infections (UTIs) are one of the most common bacterial infections worldwide. The study of bacterial uropathogens in a local area and their susceptibility to antimicrobial agents is required to determine empirical therapy. Objectives: This study aimed to assess the profile and antibiotic resistance patterns of bacteria, causing urinary infections isolated from female patients in Duhok province, Iraq. Methods: A total of 530 urine samples were collected from females clinically suspected of UTIs over three years between January 2017 and February 2020. The samples were inoculated directly on MacConkey and Blood agar media and then incubated aerobically for 24 h at 37°C. Samples that gave up colony counts of ≥ 105 CFU/mL were considered as positive growth. Purified colonies were identified through standard bacteriological tests, and their susceptibility to different antibiotics was determined using the Vitek-2 system. Results: Out of 530 urine samples, 450 (84.9%) contained Gram-negative bacteria, while the other 80 (15.1%) harbored Gram-positive bacteria. Escherichia coli was the most common uropathogenic isolate (58.5%), followed by K. pneumoniae (14.3%), Staphylococcus spp. (8.9%), P. mirabilis (6.6%), E. faecalis (3.2%), and S. agalactiae (3.02%). The majority of Gram-negative uropathogens were resistant to ampicillin, aztreonam, ceftriaxone, and cefepime and around 95% were sensitive to ertapenem and imipenem. Most Gram-positive isolates showed high resistance to benzylpenicillin, oxacillin, gentamicin, and erythromycin, and high susceptibility to linezolid, tigecycline, and nitrofurantoin. Conclusions: It was concluded from this study that E. coli is the predominant pathogen causing UTIs in female patients in Duhok province, Iraq. There were increasing antibiotic resistance rates, particularly to ampicillin, aztreonam, ceftriaxone, benzylpenicillin, and erythromycin. Therefore, empirical antibiotic therapy should be based on local sensitivity patterns rather than international guidelines.

Background and Aim: The World Health Organization (WHO) declared the novel coronavirus infection COVID‑19 as a pandemic on March 11, 2020. Adherence to infection control measures is potentially influenced by people’s knowledge, attitudes, and practices (KAP) about the infection. This project was performed to assess the KAP toward COVID‑19 of university students in Kurdistan Region, Iraq. Materials and Methods: An online cross‑sectional study was performed in April 2020 to evaluate KAP about coronavirus infection among university students in Kurdistan Region, Iraq. A total of 1959 students were recruited in this study and ages ranged from 18 to 55 years old. Results: Among the respondents, 55.03% were female, 93.8% were from Duhok province, and the majority of participants (93.4%) were undergraduate students. The overall correct answer rate of the knowledge questions toward COVID‑19 was 75.8% with an average score of 9.1 ± 2.1 SD out of 12. Participants showed better knowledge of infection prevention with around 86.2% correct answers, while the lowermost subscale scores were (67.7%) for questions toward the mode of the transmission of the infection. We found a significant difference in knowledge scores across genders, marital status, program of study, and among different colleges/institutes (P < 0.001). The majority of participants agreed that the local authority will control the infection successfully (69.8%) and showed confidence that the battle against the virus will be won by Kurdistan Regional Government (86.7%). The majority of the recruited sample (93.0%) had not been in any area with crowd and 57.3% used facemasks when leaving out, recently. Conclusion: Students demonstrated good knowledge, appropriate practice, and positive attitude about the infection. These findings indicated that local health education plans to improve people’s knowledge about the infection are valuable in protecting the community. The results may be helpful in tailoring an educational program for better containment of the infection and halting the spread of the virus.

ABSTRACT: Background: Nasal colonization with Methicillin-resistant Staphylococcus aureus (MRSA) can predispose to subsequent infections in surgical and non-surgical patients, making the management challenging with increased rates of morbidity, mortality and cost burden. Objectives: The present study was carried out to evaluate the risk factors of MRSA nasal colonization in preoperative patients in Azadi Teaching Hospital in Duhok Province - Kurdistan Region-Iraq. Methods: Nasal swabs were obtained from 150 patients after completing a questionnaire. Conventional laboratory methods were carried out to identify Staphylococcus aureus (S. aureus) and antimicrobial susceptibility test was conducted for recognizing MRSA isolates. Results: A total of 41 (27.3%) of 150 patients were MRSA carriers. The mean age of participants MRSA carriers was 35.27±20.40 years old. The highest prevalence rate of nasal colonization with MRSA was in males (27.94%) than females (26.82%). In logistic regression analysis, no significant differences was detected between MRSA carriage and the associated risk factors including age [OR: 0.99 (95 % CI: 0.97- 1.01); P = 0.45], gender [OR: 1.05 (95 % CI: 0.51- 2.17); P = 0.87] and medical comorbidities [OR: 1.11 (95 % CI: 0.42- 2.92); P = 0.82]. Conclusions: Age, gender and medical comorbidities were not associated common risk factors for nasal colonization of MRSA in preoperative patients. This study should be considered preliminary and studies with larger sample sizes and with using advance molecular tools are needed in the future.

Background: Helicobacter pylori infection is associated with peptic ulcer diseases and gastric adenocarcinoma. Accordingly, the aim of this study was to assess the efficiency of tetracycline quadruple therapy versus levofloxacin-based regimen (LBR) for the eradication of H. pylori. Methods: To this end, 197 subjects with H. pylori infection were recruited in this randomized clinical study in Kurdistan region, Iraq between October 2018 and May 2019 and randomly divided into 2 groups. The LBR group received levofloxacin 500 mg one time per day, amoxicillin 1000 mg two times per day, and omeprazole 20 mg two times per day for two weeks. In addition, the tetracycline-metronidazole-bismuth (TMB) group received bismuth sub citrate 140 mg, metronidazole 125 mg, and tetracycline 125 mg plus omeprazole 20 mg twice per day for 10 days. Finally, 28 days after the completion of the treatment course, the eradication of H. pylori was evaluated by the 14C urease breath test. Results: The total eradication rate of H. pylori infection was 149/197 (75.6%). Although the success eradication rate in the LBR regimen was 70/112 (62.5%), the eradication success rate was 79/85 (92.9%) in the TMB regimen (P = 0.001, odds ratio = 7.9, confidence interval = 3.17-19.7). Finally, gender and age represented on the effect of the eradication rate. Conclusions: In general, the bismuth-based regimen could eradicate a high rate of H. pylori infection. Therefore, this regimen can be used to overcome treatment failure in areas with a high prevalence of antibiotics resistance. Keywords: Helicobacter pylori, Levofloxacin, Iraq, Bismuth, Ampicillin

Background: Hepatitis C virus (HCV) is a public health issue. Successful treatment of HCV infection results in sustained virologic response (SVR) in the majority of subjects. Subsequent recurrence of HCV, either from late relapse or reinfection, may occur. The aim of this study was to assess the recurrence rate of HCV in Iraqi patients. Methods: In this study, 113 patients who completed anti-HCV therapy successfully were recruited. While 23 patients received a classical regimen of peg-interferon plus ribavirin, 90 patients received direct-acting antiviral therapy. Those patients were followed up for three years. HCV recurrence rate was calculated using events/ person years of follow-up (PYFU). Results: Among the recruited patients, HCV RT-PCR was positive in 1 (0.88%) patient giving a recurrence rate of 2.95 per 1000 PYFU. When the data were stratified according to the treatment regimen, the recurrence rate was 14.49 per 1000 PYFU in patients who received the classical regimen of interferon and ribavirin. Conclusions: The overall recurrence rate was low in Iraq. No recurrence was recorded in patients received direct-acting antiviral therapy. Further studies are needed with a larger sample size and longer follow-up to determine the relapse rate in Iraq.

Background: Klebsiella pneumoniae is an important opportunistic enteric bacterial strain, which is a major cause of pneumonia and urinary tract infection. Antimicrobial resistance is an increasingly severe threat to the Global Public Health, requiring immediate action across governmental sectors and communities. Objectives: The present study aimed to determine the sensitivity pattern of K. pneumonia isolated from various clinical specimens for common antibiotics in Duhok City, Iraq. Methods: This study was conducted in Duhok City during January 2017-February 2019 on 130 clinical samples of urine, blood, sputum, wound swabs, central venous lines, and oral swabs. K. pneumoniae strains were confirmed and tested in terms of susceptibility to various antimicrobial drugs using the VITEK-2 compact system. Results: In total, 130 positive K. pneumoniae cultures from various clinical samples were examined. The isolates were more predominant in the females (n = 99; 76.2%) compared to males (n = 31; 23.8%). The antibiotic resistance rate of K. pneumoniae varied among different isolate clinical sample sources. Overall, high resistance rates were recorded for ampicillin (96.9%), ceftriaxone (65.8%), and cefepime (60.8%). However, ertapenem (93.8%) and imipenem (82.3%) showed the highest susceptibility rate against the isolates. Conclusions: According to the results, K. pneumoniae isolated from various clinical specimens varied in terms of the antibiotic susceptibility pattern with high resistance to common antibiotics, particularly ampicillin. Ertapenem and imipenem were the most effective antibiotics against the isolates. Our findings could help physicians and clinicians to select appropriate antimicrobial therapies in the region.

To the editor. Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an emerging infectious disease that was identified in December 2019 in Wuhan, China. In February 2020, the first cases of COVID-19 were recorded in Southern Iraq. With the appearance of these cases, strict control measures were implemented in the Kurdistan Region. These measures included the closure of schools and universities, the closing of borders and airports, cancellation of public and religious gatherings, and mandatory quarantine for persons returning from traveling abroad and contacts of confirmed cases. Despite these measures, the first case of COVID-19 was diagnosed in the region on March 1, 2020. All individuals diagnosed with SARS-CoV-2 infection were admitted to designated COVID centers regardless of symptoms and were treated according to the Ministry of Health guidelines. This report describes the first three months of the SARS-CoV-2epidemic in the Kurdistan Region of Iraq, including the case fatality rate and the recovery rate and factors related to COVID-19-related deaths.

Background and aims The coronavirus disease-2019 (COVID-19) pandemic impacted healthcare services for kidney disease patients. Lockdown and social distancing were mandated in Kurdistan, Iraq to combat the transmission of the infection. The report analyzed the impact of the COVID-19 pandemic on kidney disease patient care in Duhok City, Kurdistan Region of Iraq. Methods This study took place in the Duhok Kidney Disease and Transplant Center and compared data from February–April 2019 and 2020. Results The average number of patients visiting the consultation unit per week was reduced from 68.67 ± 13.6, to 33.42 ± 29.36 (P = 0.001) during the pandemic. In the dialysis unit, weekly hemodialysis sessions were reduced from 341.5 to 306.42 sessions (P = 0.002). The number of patients visiting the kidney transplant consultation unit was significantly reduced (135.7 ± 37.7 versus 102.5 ± 26.3; P = 0.005). The number of kidney transplant operations per week was reduced from 1.167 to 0.5 (P = 0.025). Conclusions The COVID-19 pandemic interrupted healthcare services and may continue to impart long-term negative consequences for kidney disease patients.

Recurrent abortion is a worldwide issue. Anticardiolipin antibodies (ACA) are found to be among the most important factors related to recurrent spontaneous early pregnancy loss. This study aimed to investigate the prevalence of anticardiolipin IgM and IgG antibodies in women with recurrent abortion in Kurdistan Region of Iraq. The present study was conducted in Duhok and Zakho cities for the period from April 2014 to May 2019. A total of 1230 women aged between 18 to 46 years old were included in this study. ELISA was used for the detection of anticardiolipin antibodies. Among the studied subjects, the prevalence of anticardiolipin antibodies was 74 (6.02%) for ACA IgM and 56 (4.6%) for ACA IgG. It was also observed that 16 (1.3%) subject were positive for both ACA IgM and IgG antibodies. Additionally, the highest anticardiolipin antibody positivity rates were recorded in patients older than 30 year old (p value <0.01). The IgM ACA positivity was higher in Zakho city 45 (7.2%) when compared to Duhok city 29 (4.6%) (P value < 0.04). In conclusion, anticardiolipin antibodies can have a positive association among women with recurrent abortion. Therefore, it is suggested that woman with recurrent abortion should be screened for anticardiolipin antibodies; this could increase fetal survival by initiating early anticoagulant therapy when other causes of abortion are excluded.

Background: Urinary tract infection (UTI) is one of the most common infectious diseases at the community level, worldwide. Objectives: This study aimed to assess the prevalence and antimicrobial susceptibility patterns of the main pathogens responsible for male UTI in the community. Methods: Urine samples were collected from 211 subjects with UTI between January 2017 and February 2020. The samples were inoculated directly on MacConkey and Blood agar and then incubated at 37°C for 24 h. Samples with a colony count of 105 CFU/mL bacteria were considered positive. Bacterial colonies were determined by standard culture and biochemical characteristics, and their susceptibility to different antibiotics was identified by the Vitek-2 compact equipment. Results: The vast majority of the bacteria were Gram-negative (170 [80.6%]), while 41 (19.4%) of them were Gram-positive. The highest infection was by Escherichia coli (52.6%), followed by Pseudomonas aeruginosa (14.2%). Staphylococcus spp. were the most common Gram-positive bacteria (13.8%). The highest susceptibility of Escherichia coli isolates was found to imipenem (96.4%), and the highest resistance rate was to ampicillin (96.4%). Pseudomonas aeruginosa was resistant to all commonly used antibiotics, and around 86% was susceptible to ertapenem (86.7%). It was also found that Staphylococcus strains were resistant to benzylpenicillin (100%) and sensitive to linezolid (100%), tigecycline (100%), and nitrofurantoin (100%). Conclusions: E. coli isolates were the most frequent pathogens causing UTI in males, followed by P. aeruginosa and Staphylococcus spp. The vast majority of isolates were resistant to commonly prescribed antibiotics such as ampicillin, ceftriaxone, cefepime, benzylpenicillin, oxacillin, and erythromycin. This is an alarming situation, and an urgent plan to control antibacterial resistance is required in the region.

With the appearance of first cases of Coronavirus disease (COVID-19), strict control measures were implemented in the Kurdistan Region of Iraq to combat the infection. These measures included the closure of schools and universities, the closure of borders and airports, cancellation of public and religious gatherings, and mandatory quarantine for persons returning from traveling abroad. Such measures have played a major role in the control of COVID-19 spread. However, due to social and economic pressures, the government relaxed the lockdown. After relaxing the measures, a sharp increase in the number of patients was noticed. Besides, there was a significant increase in the number of symptomatic patients and the case fatality rate was doubled. In addition, the outbreak and outbreak response led to the loss of trust and a breakdown in relations between the society and local authority. To minimize the consequences for population health, local authority should have a plan that balances between health imperatives and socioeconomic imperatives. Finally, to be successful in controlling the infection, the government must rebuild public trust in the handling of COVID-19 outbreak and compensate people for lost earnings.

Coronavirus Disease 2019 (COVID-19) was first diagnosed in Wuhan, China, in December 2019 (1). Since then, the infection has spread to all countries around the world. The World Health Organization declared the infection a pandemic on 11 March 2020. in the Kurdistan Region, educational institutes moved to new ways of teaching and assessing during the lockdown. The main challenges were the lack of required infrastructures, skills, availability of gadgets, the achievement of adequate practical training, and the format of examinations. Good preparedness is needed to overcome the obstacles in the next academic year if the COVID-19 pandemic continues.

Cutaneous leishmaniasis (CL) is endemic in Iraq. After the last war in Iraq against Islamic State in Iraq and Syria (ISIS), the number of CL cases has peaked particularly in children. International guidelines do not provide an insight on how to choose treatment regimen of CL in children. The aim of this paper was to study the efficacy of intralesional sodium stibogluconate (SSG) therapy for school age children with CL. In the period between June 2016 and June 2019, 288 internally displaced school age children (6‐12 years old) from Ninewa city were recruited in the study. All patients received intralesional SSG twice a week for a maximum of twelve sessions. All patients were followed up for 12 weeks after the last treatment session. The mean age of recruited patients was 8.6 ± 2 years and 164/288 (56.9%) were male. 202/288 (70.1%) of the patients presented with single lesion. The total number of lesions was 417 of which 141/417 (33.8%) lesion were nodular and the rest were ulcerative lesions. The treatment success rate was (282/288) 97.91%. No significant association was found between age, gender, number of lesions, or duration of lesions and the treatment outcome. Mild local pain, mild bleeding at the site of injection and itching at the site of injection were the most common side effects. Intralesional SSG infiltrate is effective and minimal side effects. Further studies including clinical trials are required to provide robust data on the efficacy and the safety.

Background: Escherichia coli (E. coli) is one of the most common causative agents of bacterial infections. The emergence of multidrug-resistant E. coli is a major public health threat worldwide. Objectives: This study aimed to determine the antibiotic susceptibility profile of clinical isolates of E. coli from different samples. Methods: A total number of 454 clinical samples, including urine, wound, cervical swab, blood, semen, ascetic, and cerebral spinal fluid samples were collected from patients between January 2017 and February 2020. Then, E. coli was confirmed and susceptibility to different antibiotics was determined using the Vitek-2 compact system. Results: Escherichia coli isolates were more frequent in females (70.7%) than in males (29.3%). In the case of urine samples, E. coli was found to be highly susceptible to ertapenem (97.6%) and imipenem (96.4%) but resistant to ampicillin (87.8%). For wound and cervical swabs, E. coli was 100% resistant to ampicillin and cefepime but 100% sensitive to ertapenem and imipenem. It was found that E. coli isolates from blood samples were 100% resistant to ampicillin, ceftriaxone, and cefoxitin, and around 75% of them were sensitive to ertapenem, ciprofloxacin, and levofloxacin. Finally, E. coli isolated from other clinical samples were highly sensitive to ertapenem, imipenem, levofloxacin, nitrofurantoin, and cefazolin. Conclusions: Escherichia coli isolated from various clinical specimens showed differences in antibiotic sensitivity patterns, with high resistance to commonly used antibiotics. The most effective antibiotics against E. coli isolates were ertapenem, imipenem, and nitrofurantoin. However, the clinical isolates of E. coli displayed high resistance rates to ampicillin, ceftriaxone, and cefepime. Therefore, it is proposed to perform antibiotic sensitivity testing by physicians to select the most effective antibiotics

Cutaneous Leishmaniasis (CL) is caused by protozoan parasites called Leishmania. CL is endemic in Iraq and caused by L. tropica and L. major species. Between August 2014 and September 2019, 104 patients with CL were recruited. Among those, ten patients were excluded because they did not follow the protocol of treatment, changed address before finishing treatment, or received treatment from more than one clinic and so they were excluded from further analysis. The mean age of patients was 13.6±2.7 months, and 47/94 (50%) were male.60/94 (63.8%) of the patients presented with a single lesion. The total number of lesions was 155, of which 51/155 (32.9%) lesion were nodular, and the rest were ulcerative lesions. Our findings showed that intralesional sodium stibogluconate resulted in a 100% cure rate. Intralesional sodium stibogluconate infiltration seems safe, effective, and well-tolerated with minimal adverse effects. Further studies, including clinical trials, are required to provide robust data on the efficacy and the safety of intralesional sodium stibogluconate leading to the development of clinical guidelines for the treatment of CL in this age group.

This study was carried out on seven flocks of ewes suffered from late abortion and neonatal death with prevalence rate of infection was 13.95%. Blood and tissue samples were taken from aborted ewes in several flocks of Duhok province, Kurdistan Region-Iraq. Serological analysis confirmed that all aborted ewes were positive agglutination reaction for T. gondii antibody. Gross finding of aborted feti were showed blood stained fluid in the thoracic and abdominal cavity and most of the aborted feti also revealed enlarged, congested and friable liver and lungs. The placenta was swollen, reddish and friable and its cotyledons were also spotted with whitish foci. T. gondii tachyzoites were also demonstrated from placental sections of some aborted ewes. Severe congestion, necrosis, and infiltration of multinucleated cells were the most predominant histopathological changes of aborted fetuses as well as presented tissue cysts, tachyzoites and bradyzoites in the liver, brain, heart and lung. There were also several clusters of dark purple banana-shape of T. gondii tachyzoites within the brain and heart tissue in most of examined aborted feti in different flocks. T.gondii Tachyzoites were also clearly detected from the peritoneal ascites of mice inoculated 12 days post infection experimentally. T. gondi tissue cysts were also detected from impression smears of mice brain after 32 days post infection. This result was concluded that the demonstration of T. gondii parasites in Giemsa stained impression smears associated with characteristic histopathological changes from different organs are of great fundamental method for diagnosis of T. gondii in aborted cases.

Social distancing is important to decrease the interactions between people in the society. As a set of measures, social distancing is taken to reduce infections transmitted by droplets. To achieve its aim, social distancing should include the cancellation of funerals and weddings, the closure of schools and universities, and the cancellation of mass gatherings (1). In a study conducted in China during the epidemic outbreak of coronavirus disease 2019 (COVID-19), the death rate was about 10% in the epicenter of the epidemic whereas the death rate was 1% in other areas. It was concluded that the high death rate was due to the breakdown of the healthcare system owing to the large number of patients. It was then recommended that social distancing may help in preventing the breakdown of healthcare system (2). In another study in China, it was concluded that social distancing can reduce the number of infections by 98% and the number of deaths by 99% (3). The first case of COVID-19 in Kurdistan region was diagnosed in beginning of March 2020, and from that time 324 confirmed cases have been recorded onwards. The region is divided into four cities: Duhok (15 COVID-19 cases), Erbil (168 cases), Sulaimani (120 cases), and Halabja (21 cases). The age range of COVID-19 patients was from 10 months to 70 years old. Amongst the 324 patients, 52% were female, 80% were asymptomatic and diagnosed while in the quarantine, and 0.9% passed away (4). The regional government in Kurdistan, northern Iraq imposed strict measures to stop the spread of the infection. These measures included the closure of educational institutions, workplaces, roads, and the cancellation of public gatherings including Friday prayers, church gatherings, funerals, and weddings. Besides, measures included mandatory quarantine of uninfected subjects with a history of travel or exposure to SARS-CoV-2. However, imposing these rules was challenging in the area. On March 23, 31 cases of COVID-19 were diagnosed in Erbil city which was the highest number of patients discovered in one day. Careful examination and tracing revealed that those patients had attended unpermitted funerals. Healthcare authority in the city launched a tracing operation to quarantine and test all the people attended the funeral. This resulted in the diagnosis of 98 funeral-related patients in the city. This also represented 129/168 (76.78%) of the patients diagnosed in Erbil. In another incidence in Sulaimani city, 15/120 (12.5%) patients were diagnosed after attending unpermitted funeral in the city. Totally, these patients comprised 44.4% of the patients diagnosed in the region. It appeared that breaching the lockdown and social distancing increased the number of patients sharply in the region and particularly in Erbil city. Therefore, it seems imposing social distancing must be accompanied with health education programs to educate the people about the consequences of cancellation of gatherings and importance of lockdown in preventing the transmission of the virus. To conclude, the strict social distancing measures helped in limiting the spread of infection. However, breaching the lockdown increased the number of patients sharply. Health education is required alongside in order to increase the awareness of the people and ensure better commitment.

Background and aim: Hepatitis B and C virus (HBV and HCV) infections are considered as major global public health concerns. Chronic infections may lead to liver cirrhosis, hepatic failure, and hepatocellular carcinoma. Therefore, the aim of this study was to investigate the prevalence of HBV and HCV infections in patients with end-stage kidney disease (ESKD) and on regular hemodialysis in Duhok located in the Kurdistan region of Iraq. Methods: A cross-sectional study was conducted in Duhok, Iraq between January 2019 and October 2019. During this period, a total of 143 patients within the age range of 9-72 years old with ESKD visited the Duhok dialysis center for regular hemodialysis. Enzyme-linked immunosorbent assay (ELISA) was conducted to test HBV and HCV positivity and then HBV viral load was tested by the real-time polymerase chain reaction (RTPCR). Finally, HCV positivity was confirmed by the Xpert HCV quantification assay. Results: Among the recruited samples, 5 out of 143 (3.49%) patients were positive for HBV while HBV viral load for those patients was undetected. On the other hand, 3/143 (2.1%) patients tested positive for HCV Ab. All these 3 patients were also confirmed positive by the RT-PCR. Conclusions: ESKD patients on regular analysis showed a low prevalence of HBV and HCV in the Duhok dialysis center. An effective infection control program, vaccination, and treatment of HCV make the elimination of HBV and HCV feasible in such a group.

Background: In pregnant women, primary infection with rubella and herpes virus may lead to serious complications, including abortion, stillbirth, and severe birth defect. The objective of the present study was to determine the prevalence of rubella and herpes IgG and IgM antibodies in pregnant women. Methods: A cross-sectional study was conducted in Zakho city, Kurdistan, Iraq. A total of 200 women aged 18-45 years with a history of miscarriage and stillbirth were recruited. Samples were collected from Private Clinical Health Centre at Zakho City between January 2015 and December 2018. All samples were then tested by Enzyme Linked Fluorescent Assay (ELFA) (VIDAS instrument) for detection of rubella and herpes specific IgG and IgM classes of antibodies. Results: Of the total study participants, 166 (83%) were seropositive for anti-rubella IgG antibodies while nine (4.5%) were positive for anti-rubella IgM antibodies. In addition, seroprevalence of IgG and IgM antibodies to Herpes simplex virus was observed in 154 (77%) and 10 (5%) subjects, respectively. As far as age is concerned, the highest seropositivity of specific IgG and IgM antibodies to Rubella and Herpes was found in participants younger than 30 years, but statistically not significant differences were found (P<0.45 and 0.73 for Rubella and P<0.86 and 0.19 for Herpes, respectively). Conclusion: This study provided pilot data on Rubella and Herpes virus infections among women in Zakho city, Kurdistan, Iraq. Data from the present study showed a high anti-Rubella and Herpes IgG and a low IgM positivity in the recruited subjects. Screening women with miscarriage or stillbirth might be conducive to specifying the causes of abortion or stillbirth.

Background: Toxoplasma gondii and Cytomegalovirus (CMV) can cause a range of diseases in pregnant women and may lead to adverse fetal outcomes. Therefore, the detection of these infections is necessary during pregnancy. Objectives: The aim of this study was to estimate the seroprevalence of Toxoplasma and Cytomegalovirus infections among the pregnant women with history of abortion in Zakho city, Iraq. Methods: Over a period of five years (2014-2018), blood samples were collected from 500 subjects aged 16-45 years old and tested to identify the presence of specific IgG and IgM to Toxoplasma and CMV infections by Enzyme Linked Fluorescent Assay (ELFA) method. Results: Of 500 pregnant women, 145 (29%) and 7 (1.8%) were seropositive for anti-Toxoplasma IgG and IgM, respectively. IgG seropositivityto T. gondii infection varied significantly between age groups (P=0.05). Additionally, the seroprevalence of IgG and IgM antibodies for CMV was 475 (95%) and 9 (1.8%), respectively. Estimation of age specific subgroups showed high CMV IgG seropositivity rates for all age groups with no significant difference between them. Altogether, 145 cases were verified seropositive for specific IgG antibody against both pathogens and only 2 cases were positive for specific IgM against both agents. Conclusion: Anti-Toxoplasma and CMV IgG and IgM antibodies positivity rates among pregnant women determined in the present study are quite similar as compared to other studies reported in Kurdistan Region, Iraq. Though, infection with those pathogens is not a major cause of abortion; it is useful to screen women with recurrent abortion for such infections in order to avoid undesirable fetal outcomes and other serious complications.

Background: Infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) are major global public health problems. Infection with such viruses is commonly associated with liver cirrhosis and hepatocellular carcinoma. Objectives: The aim of this study was to determine the prevalence rate of HBV and HCV in women in Zakho City, Kurdistan Region of Iraq. Methods: A cross sectional study was performed in Zakho City, Iraq between January 2019 and October 2019. A total of 2223 females aged between 18 to 52 years old were included in this study. ELISA test was used to determine HBsAg, HBc IgG, and HCV antibodies positivity. HCV positive samples were then confirmed by Xpert HCV quantification assay. Results: Among the studied subjects, 12/2223 (0.54%) samples were positive for HBs Ag. All these 12 patients showed also positivity for HBc IgG. Only 1/2223 (0.045%) sample was positive for HCV antibodies. The result of HCV-RT-PCR confirmed the positivity for this patient. Conclusions: The low prevalence rate of HBV and HCV infection among women in Zakho City was less than that reported in other studies. Population-based study is needed to estimate the prevalence of infection.

his study performed molecular detection and analysis of the heterogeneity of the 18S rRNA gene isolates obtained from equids such as horse, mule, donkey and pony from Erbil province, Kurdistan region of Iraq. Multiplex polymerase chain reaction (PCR) indicated that 76/136 (55.88%) of equine were infected with piroplasms, with Theileria equi (P=41.91%; CI=3.76-14.77%) more prevalent than Babesia caballi (P=8.82%; CI=1.00%), while mixed infection was less (P=5.15%; CI=0.21-1.46%) with a significant difference (P<0.001). There was a significant association between the prevalence of T. equi and recreation (p<0.03) or racing (p<0.02), and but neither the type of equids nor the gender and age groups was significantly associated with prevalence. The obtained sequences were utilized for characterizing the genotypes and phylogeny of both the protozoa. BLAST analysis indicated 98-100% similarity to species isolated in Turkey, Malaysia, Egypt, Sudan, Jordan, Iran, Brazil and South Africa. Four 18S rRNA genotype clades were observed for T. equi (A, B, C and D) and two for B. caballi (A and B). Genetic variation found among the equids in Erbil province is probably due to introduction of equines from other countries without quarantine measures. This study indicates that infection with T. equi is more prevalent than that of B. caballi in the studied area.

Background and Aims: Hepatitis C virus is a major global health problem that primarily affects the liver which lead to liver cirrhosis, liver failure and hepatocellular carcinoma. The aim of this report was to investigate the genotypes of HCV in patients on regular hemodialysis in Iraq. Materials and Methods: A cross sectional study was conducted to investigate the genotypes of HCV in patients on regular hemodialysis in 7 centers across Iraq. A total of 255 subjects with positive anti-HCV antibodies were recruited in this study. Results: To confirm the positivity, RT-PCR was performed. Amongst all samples, 31% (79/255) was positive by RT-PCR. Then, we genotyped all the RT-PCR positive samples, it was found that 39/79 (49.4 %) of our samples were typed as HCV genotype 1 including 26 samples (66.7%) as HCV 1a and 13 samples (33.3%) as HCV 1b. HCV genotype 4 was found in 34/79 (43%) of the samples while 6/79 (7.6%) of the samples typed as HCV 3 Conclusion: HCV genotype 1 was the most prevalent genotype followed by genotype 4. Further population-based study is required to investigate the prevalence of HCV genotypes.

Salmonella Enteritidis is an important cause of human salmonellosis and food-poisoning associated with consumption of contaminated chicken eggs and poultry products. Objective of the study was to develop a serological diagnostic testfor the recognition of different Salmonella serovars in chickens. Here, phage peptide libraries were screened against 9 IgY samples from chickens infected with S. Enteritidis and 9 IgY samples with S. Hadar and the individual peptide binders were then identified using NGS. Twenty-nine peptides were identifiedin silico assessmentas being enriched specifically against IgY from multiple chickens infected with S. Enteritidis compared to those infected with S. Hadar. Twenty Nine peptides identifiedin silico assessmentwere thentested by both training and test cohorts of chicken IgY samples in ELISAs. The training set of samples was made upof IgY from 9 chickens infected with S. Enteritidis and 9 infected with S. Hadar. Seventeen peptides were selected as the most recognized specific peptides against S. Enteritidis infection and were then used against IgY samples from10 birds infected with S. Enteritids and20 birds with S. Typhimurium as a test cohort. Overall, for both training and test cohorts the peptide ELISA assay sensitivity and specificity were 90 % for detecting infections. The most discriminatory peptides by ELISA test were AEGEFEPQSARPS and AEGEFFVNRALINQ. The data demonstrated that the NGPD method could identify peptides that represented serovar-specific epitopes/mimotopes, these peptide have potentially important applications for the development of peptide based immuno-diagnostic assays for the recognition of Salmonella Enteritidis in chickens.

Acute Anaplasma ovis infections can cause severe clinical symptoms and might lead to significant economic losses in small ruminant flocks. However, little information has been provided related the prevalence of anaplasmosis in Angora goats. The study was designed to investigate the prevalence of Anaplasma ovis serologically (cELISA) and microscopically (Giemsa stained blood smears) among Angora goats from Duhok districts of the northern part of Iraq. A total of 92 blood samples were randomly collected from three localities of Duhok city; Zakho, Batel and Sumil during the study period from April to October 2009. The infection rate of A. ovis was 38.04% by Giemsa stained blood smear and 66.3% by cELISA. The prevalence of A. ovis in female goats was higher than that in males, but statistically not significant difference (P>0.05) by using both methods. The prevalence was also significantly higher (P<0.05) in goats more than three years old than in younger ones. The highest prevalence of A. ovis was found in Zakho, whereas the lowest was reported in Sumail. Results of hematological parameters indicated microcytic hypochromic type of anemia.It is concluded that A. ovis can infected Angora goats in district Duhok, Kurdistan region, Iraq and this might be due to high distribution of the disease and its transmitters which were lead to substantial effect followed by high mortalities

Serological surveillance and vaccination are important strategies for controlling infectious diseases of food production animals. However, the compatibility of these strategies is limited by a lack of assays capable of differentiating infected from vaccinated animals (DIVA tests) for established killed or attenuated vaccines. Here, we used next generation phage-display (NGPD) and a 2-proportion Z score analysis to identify peptides that were preferentially bound by IgY from chickens infected with Salmonella Typhimurium or S. Enteritidis compared to IgY from vaccinates, for both an attenuated and an inactivated commercial vaccine. Peptides that were highly enriched against IgY from at least 4 out of 10 infected chickens were selected: 18 and 12 peptides for the killed and attenuated vaccines, respectively. The ten most discriminatory peptides for each vaccine were identified in an ELISA using a training set of IgY samples. These peptides were then used in multi-peptide assays that, when analysing a wider set of samples from infected and vaccinated animals, diagnosed infection with 100% sensitivity and specificity. The data describes a method for the development of DIVA assays for conventional attenuated and killed vaccines.

Mapping polyclonal antibody responses to infectious diseases to identify individual epitopes has the potential to underpin the development of novel serological assays and vaccines. Here, phage-peptide library panning coupled with screening using next generation sequencing was used to map antibody responses to bacterial infections. In the first instance, pigs experimentally infected with Salmonella enterica serovar Typhimurium was investigated. IgG samples from twelve infected pigs were probed in parallel and phage binding compared to that with equivalent IgG from pre-infected animals. Seventyseven peptide mimotopes were enriched specifically against sera from multiple infected animals. Twenty-seven of these peptides were tested in ELISA and twenty-two were highly discriminatory for sera taken from pigs post-infection (P < 0.05) indicating that these peptides are mimicking epitopes from the bacteria. In order to further test this methodology, it was applied to differentiate antibody responses in poultry to infections with distinct serovars of Salmonella enterica. Twenty-seven peptides were identified as being enriched specifically against IgY from multiple animals infected with S. Enteritidis compared to those infected with S. Hadar. Nine of fifteen peptides tested in ELISA were highly discriminatory for IgY following S. Enteritidis infection (p < 0.05) compared to infections with S. Hadar or S. Typhimurium.

Salmonellosis causes significant economic losses to the pig industry and contaminated pork products are an important source of Salmonella for humans. The EU ban on the use of antibiotic growth promoters in pig production, and the emergence of antibiotic resistance has meant there is a pressing need for alternative control strategies for pathogenic bacteria such as S. Typhimurium in pigs. Here, we determined the effects of prebiotic, probiotic and synbiotic diet regimes on antibody responses to oral Salmonella challenge of pigs. The data demonstrate that the inclusion of the probiotic Lactobacillus plantarum B2984 in the diet of piglets (∼1×1010 cfu/animal/day) enhanced serum IgM (P<0.001), IgG (P=0.001) and IgA (P=0.039) responses to S. Typhimurium infection including cross-reacting antibodies to S. Enteritidis. Similarly, inclusion of the prebiotic lactulose at 1% (w/w) of the feed on a daily basis in the diet enhanced serum IgM (P=0.010), IgG (P=0.004) and IgA (P=0.046) responses to S. Typhimurium infection and also cross-reacting antibodies to S. Enteritidis. Inclusion of both additives in the synbiotic diet also elicited an enhanced immune response with IgM (P=0.009) and IgG (P=0.046) levels being increased, however a significant interaction of the pre and probiotics was observed when considering the immune responses to S. Typhimurium (IgM P=0.004; IgG and IgA, P<0.001 for interaction). With respect to immune responses, the effects of pre or probiotic administration were the same or reduced in the synbiotic diet compared to when used in isolation. The data support the use of Lactobacillus plantarum B2984 or lactulose as strategies to contribute to the protection of weaned piglets from zoonotic bacterial pathogens, but caution must be taken when combining dietary supplements as combinations can interact.

An investigation into ectoparasites of sheep and goats was carried out in Duhok province North West region of Iraq, during six months of a year, from January to June 2010. One thousand and two hundred forty eight (1248) sheep and 954 goats in 110 flocks from 80 villages were examined. Among them overall animals (66.89%) were infested with one or more species of ectoparasites. Of 720 (57.7%) and of 753 (78.9%) sheep and goats, respectively were infested. Five different types of ectoparasites, ticks (46.7%, 34.9%), lice (3.8%, 33.8%), mites (7.1%, 0.1%), fleas (2.8%, 7.75%) and ked (1.2%, 4.5%) were identified sheep and goats, respectively. Five species of hard ticks (Ixodidae) were identified in both sheep and goats, namely Hyalomma anatolicum anatolicun (48.37%, 13.5%), H. marginatum (18.01%, 8.1%), Rhipicephalus sanguineous (21.09%, 39.93%), R. turanicus (16.8%, 49.54%) and Haemaphysalis ssp. (2.5%, 0.9%). Two species of lice were infested each one of animal these namely, Damalinia Ovis (75%) and Linognathus stenopsis (33.3%) on sheep, and D. caprae (80.74%) and L.stenopsis (19.2%) on goats. Sheep were highly infested with two species of mites, Sarcoptes scabiei (25.84%) and Psoroptes Ovis (74.15%) than the goats, which one goat was found (0.1%) infested with S. scabiei. Three species of fleas were found infested both sheep and goats. Out of 106 collected fleas (47.2%, 43.4%, 9.4%) were Ctenocephalides felis felis, Pulex irritans and Xenopsylla cheopis, respectively. However, the only one species of Ked Melophagus ovinus were infested (1.2%) of sheep and (4.5%) of goats.

The prevalence of Theileria hirci and Babesia motasi was studied in goats in the Duhok area of Iraq from April to September 2010. A total of 500 local black breed goats represent 35 flocks of different localities were clinically and then in laboratory examined for the presence of piroplasmosis in blood smears. The study revealed that 20.8% of the goats infected with T. hirci and 4% infected with Babesia motasi. Prevalence of piroplasms infection between male and female and between different age groups of goats was statistically significant. Hematological findings, showed a significant decrease in red blood cell, hemoglobin concentration, and packed cell volume beside the significant increase in the mean corpuscular volume. No changes in mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration values were noted. Macrocytic and normochromic type of anemia was found.

The objectives of the present work were done to investigate the prevalence of Anaplasma ovis infection in goats in Duhok area, Kurdistan Region, of Iraq from April to September 2009. A total of 460 local black breed goats represent (35 flocks) of different localities were examined for the presence of Anaplasma ovis by Giemsa stained blood smears and serologically by competitive inhibition enzyme-linked immunosorbent assay (cELISA) for antibodies against A. ovis. The results revealed that 257 (55.86%) and 346 (75.22%) of goats were infected with A. ovis by Giemsa stained and by (cELISA) respectively. Statistically significant difference was encountered between males and females and among the different age groups of goats, high infection rate was detected in goats more than 3 year old 146 (31.74 %) , where as goats 1-3 years old and those less than one year old of 84 (18.26%) and 27 (5.86%) respectively. The percentage of parasitemia ranged between 2.8-12.2% with mean of (7.12 %). The hematological parameters were estimated from positive cases of Giemsa stained. The mean values of erythrocyte count (5.9 ± 1.17) 106/μl, packed cell volume (19.5 ±2.68) % and hemoglobin concentration (6.3 ± 0.83) g/dl were statistically significant decrease (P 0.05). Also there was a statistical significant increased (P 0.05) in mean corpuscular volume (MCV) (33.9 ± 5.88) fl, while there was no statistical significant in mean corpuscular hemoglobin (MCH) (10.8 ± 1.76) pg and the mean corpuscular hemoglobin concentration (MCHC) (32.3 ± 2.19) g/dl. This indicated evidence of macrocytic normochromic type of anemia, whereas no significant differences were encountered in the differential count of leukocytes.