Respiratory health and the Syrian conflict: a scoping literature review

Conflict adversely affects respiratory health in both direct and indirect ways among populations whose health is already compromised through the compounding effects of conflict. Our aim is to review academic and grey literature relevant to respiratory health in the Syrian conflict (now more than a decade in duration) to explore its impacts on populations across Syria. We performed a scoping literature review of academic and grey literature on respiratory health in Syria between March 2011 (taken as the start of the conflict for practicality) and December 2023. Of 11,472 papers screened, 34 met the inclusion criteria, of which 29 were peer reviewed. Key themes identified included the impact of conflict on asthma diagnosis and management; the burden of respiratory tract infections (RTIs) and COVID-19; the impact of chemical weapon use and the impact of destruction and interruptions to the health system(s) across Syria on respiratory health. This review highlights the need for more in-depth exploration of the impact of conflict on respiratory health in Syria with focus on social determinants, for example, shelter, public health interventions, smoking cessation, and supporting early diagnosis and treatment of respiratory conditions to counter the effects that conflict has had on respiratory health.

Respiratory health in Syria: an analysis of primary data from the Syrian American Medical Society

 

Despite a decade of conflict, there has been little exploration of respiratory health in Syria. We explore the burden and trends of respiratory consultations in Syrian American Medical Society (SAMS) facilities in northwest Syria using mixed methods. We performed i) a scoping review of available academic and grey literature on respiratory health in Syria between 2011 and 2020 (17 databases) and ii) a retrospective review of routinely collected data relating to respiratory presentations in SAMS' facilities between March 2017 and June 2020. We identified 23 papers (19 peer-reviewed); 7 analysed primary data. Key themes included the impact of conflict on asthma diagnosis and management, the burden of respiratory tract infections (RTIs), the impact of chemical weapons and those relating to the destruction of the health system. In our quantitative analysis, data were available for 5,058,864 consultations, of which 1,228,722 (24%) were respiratory presentations. 45% of respiratory presentations were from hospitals, 44% from primary healthcare clinics and 9% from mobile clinics. The median monthly number of respiratory cases was 30,279 (25,792-33,732) out of a median 128,923 total monthly consultations (112,917-140,189). 73% of respiratory consultations were for children. Key findings include: respiratory presentations accounted for up to 38% of consultations each month with seasonal variation. RTIs accounted for 91% of all respiratory presentations. A steep decrease in consultations occurred between the end of 2019 (160,000) and the first quarter of 2020 (90,000), correlating with an escalation of violence in Idlib governorate. This study presents the largest quantitative analysis of respiratory data collected during the Syrian conflict. Our findings support the need for improved measures to aid the prevention, diagnosis and management of respiratory conditions during conflict. Further work exploring such interventions is needed.

Key messages

We present the largest study of the burden of respiratory presentations during the Syrian conflict accounting for 1,228,722 (24%) of all consultations; of these 72% were for children. Despite the burden of respiratory disease in the Syrian conflict, optimisation of respiratory health is neglected. Public health measures which address the causes and consequences are needed.

Experiences of healthcare workers displaced by conflict: lessons from past conflicts and implications

Background

Conflicts cause mass displacement, including of healthcare workers (HCWs). Understanding experiences of HCWs over the displacement trajectory, from push factors out of conflict zones, to barriers and facilitators in transit and host countries, is key to developing support mechanisms and informing policy discussions regarding return and reintegration.

Methodology

We systematically reviewed 6 academic databases and grey literature using combined search terms for HCWs, displacement, conflict, and experiences to identify English-language literature documenting personal or professional experiences of HCWs displaced by conflict, published between 1945 to 2020. Open coding and thematic analysis were used to identify emerging themes. Quality appraisal was conducted.

Results

25 publications from academic journals, snowballed references, and grey literature from 10 geographical contexts and various types of HCW met inclusion criteria, many from conflicts in the Middle-East. 5 themes emerged: Conflict drives displacement: HCWs fled due to direct violence and deteriorating working conditions caused by increased workload, depleting resources, workforce attrition and attacks on healthcare. Giving back: Refugee HCWs were determined to continue working but had to do so informally or by working with humanitarian agencies. Personal and professional integration in host countries: refugee HCWs overcame barriers to relicense after which they reported disadvantage in job applications due to professional gaps and discrimination; many ended up working under-qualified jobs. Psychological toll on HCWs was pronounced. Prospects on return: HCWs desired to return to their home countries but feared political instability and violence.

Conclusions

Policies which support HCW retention during conflict, integration into host health systems, and encourage return post-conflict must be implemented. Further research is required to understand the individual and systemic support mechanisms required.

Key messages

Displaced HCWs experience many personal and professional challenges. Policies that support HCWs across the displacement trajectory and support return and post-conflict system rebuilding are required.

The benefits and challenges of cash transfer programmes in Greece, with a focus on protection

Introduction

This qualitative study evaluates cash transfer programmes (CTPs) in forcibly displaced populations, specifically in Greece. There is a focus on protection, encompassing health, gender, child protection and disability. The Greece Cash Alliance, run by the United Nations High Commissioner for Refugees (UNHCR), currently supports 63,853 individuals with cash via a pre-paid card. This study provides insight into challenges encountered by implementers of cash programmes in Greece, and the potential protection issues faced with the changing climate of the cash programme in Greece.

Methods

A literature review of academic and grey literature and semi-structured key informant interviews with stakeholders including Non-Governmental Organisation and United Nations agency staff were performed. Key informants were identified through purposive sampling. An inductive thematic approach was taken in analysis.

Results

Main emerging themes included the benefits and challenges of CTPs and their role in protection. Challenges included the mobile, heterogenous population and benefits included economic development in Greece and restored choice to beneficiaries. With regards to protection, informants reported a positive impact through allowing refugees to meet their basic needs and prioritise other needs and CTPs providing consistent access to refugees which could allow identification of protection risks. However, protection was not considered in the design of all CTPs.

Conclusions

Due to the multi-sectoral nature of the response, there is no standard integration of protection into cash programmes. Cash programming offers unique, regular contact with beneficiaries and chances to identify protection risks that are not always utilised due to minimal staff training in protection. Cash assistance in Greece allows people to meet their basic needs and gives people space and funds to prioritise other needs such as health and education, inherently improving their protection status.

Key messages

With cash assistance growing in popularity in humanitarian programming, consideration of protection is important as it can improve the health, safety and dignity of beneficiaries. In Greece the cash programme was only designed to meet basic needs but broader effects on protection were seen.

Syndromic infectious disease surveillance of refugees in Greece: a mixed methods analysis

Background

An estimated 1,174,140 refugees have migrated into Greece, a main entry point for refugees into Europe, since 2014. Their infectious disease profile is monitored by a national-level ad-hoc syndromic surveillance system in refugee-migrant reception centres. The utility of this system is explored to contribute evidence to and improve syndromic surveillance in European refugee responses.

Methods

Proportional morbidities, numbers of cases and signals, cases above expected numbers, of 14 syndromes are collated from weekly reports between 2016-2019, graphed and analysed in the context of the humanitarian response. Semi-structured key informant interviews are conducted and thematically analysed.

Results

Between 20.06.2016 and 17.02.2019, 36358 cases and 116 signals occurred. Public health responses resulted and there were no significant outbreaks. On average 5% of all consultations in centres were on infectious syndromes. Respiratory infections with fever (57%), gastroenteritis (22%), suspected scabies (13%) and rashes with fever (5%) were most commonly reported. Every week, between 68-100% of 25-58 participating centres completed reporting adequately. 6 informants reported on their syndromic system user experience. The system’s benefits, providing information and safeguarding refugees, outweighed harms. Data was timely and complete, but likely under-reported for common conditions. Poor living conditions and inter-agency coordination complicated reporting and public health responses.

Conclusions

Infectious burdens and trends were provided by the system and allowed for timely responses. Data quality was adequate. The system was valuable and feasible to informants. The set-up of the humanitarian response, inadequate ownership and poor coordination of authorities reduced the system’s utility.

Key messages

Syndromic surveillance is useful for monitoring refugee infectious health. Structural barriers need to be resolved to improve systems’ data and user experience.

Healthcare access for refugees in Greece: Challenges and opportunities

The arrival of more than one million refugees and migrants in Europe in 2015, most of whom transited through Greece, has placed significant strains on local health systems and demonstrated the need for preparedness to meet the immediate and longer-term health needs of arrivals in EU countries. Population movements will continue to occur and the need for cost effective, appropriate provision of both primary and secondary health services to meet these needs is key. The Global Compact on Migration was ratified in 2018 and forms an overarching, international agreement to address safe, orderly and regular migration which benefits refugees and migrants as well as host communities; however, it did not give due emphasis to health. In this manuscript, we explore the evolution of the health response for refugees in Greece over the last three years, the challenges faced at different times of the response and the efforts to integrate refugees into Greece's health system.

The direct and indirect effects of kisspeptin-54 on granulosa lutein cell function

STUDY QUESTION

What are the in vivo and in vitro actions of kisspeptin-54 on the expression of genes involved in ovarian reproductive function, steroidogenesis and ovarian hyperstimulation syndrome (OHSS) in granulosa lutein (GL) cells when compared with traditional triggers of oocyte maturation?

SUMMARY ANSWER

The use of kisspeptin-54 as an oocyte maturation trigger augmented expression of genes involved in ovarian steroidogenesis in human GL cells including, FSH receptor (FSHR), LH/hCG receptor (LHCGR), steroid acute regulatory protein (STAR), aromatase, estrogen receptors alpha and beta (ESR1, ESR2), 3-beta-hydroxysteroid dehydrogenase type 2 (3BHSD2) and inhibin A (INHBA), when compared to traditional maturation triggers, but did not alter markers of OHSS.

WHAT IS KNOWN ALREADY

hCG is the most widely used trigger of oocyte maturation, but is associated with an increased risk of OHSS. The use of GnRH agonists to trigger oocyte maturation is a safer alternative to hCG. More recently, kisspeptin-54 has emerged as a novel therapeutic option that safely triggers oocyte maturation even in women at high risk of OHSS. Kisspeptin indirectly stimulates gonadotropin secretion by acting on hypothalamic GnRH neurons. Kisspeptin and its receptor are also expressed in the human ovary, but there is limited data on the direct action of kisspeptin on the ovary.

STUDY DESIGN SIZE, DURATION

Forty-eight women undergoing IVF treatment for infertility consented to kisspeptin-54 triggering and/or granulosa cell collection and were included in the study. Twelve women received hCG, 12 received GnRH agonist and 24 received kisspeptin-54 to trigger oocyte maturation. In the kisspeptin-54 group, 12 received one injection of kisseptin-54 (9.6 nmol/kg) and 12 received two injections of kisspeptin-54 at a 10 h interval (9.6 nmol/kg × 2).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Follicular fluid was aspirated and pooled from follicles during the retrieval of oocytes for IVF/ICSI. GL cells were isolated and either RNA extracted immediately or cultured in vitro ± kisspeptin or hCG.

MAIN RESULTS AND THE ROLE OF CHANCE

GL cells from women who had received kisspeptin-54 had a 14-fold and 8-fold higher gene expression of FSHR and a 2-fold (ns) and 2.5-fold (P < 0.05) higher expression of LHCGR than GL cells from women who had received hCG or GnRH agonist, respectively. CYP19A1 expression was 3.6-fold (P < 0.05) and 4.5-fold (P < 0.05) higher, STAR expression was 3.4-fold (P < 0.01) and 1.8-fold (P < 0.05) higher, HSD3B2 expression was 7.5- (P < 0.01) and 2.5-fold higher (P < 0.05), INHBA was 2.5-fold (P < 0.01) and 2.5-fold (P < 0.01) higher in GL cells from women who had received kisspeptin-54 than hCG or GnRHa, respectively. ESR1 (P < 0.05) and ESR2 (P < 0.05) both showed 3-fold higher expression in cells from kisspeptin treated than GnRHa treated women. Markers of vascular permeability and oocyte growth factors were unchanged (VEGFA, SERPINF1, CDH5, amphiregulin, epiregulin). Gene expression of kisspeptin receptor was unchanged. Whereas treating GL cells in vitro with hCG induced steroidogenic gene expression, kisspeptin-54 had no significant direct effects on either OHSS genes or steroidogenic genes.

LIMITATIONS REASONS FOR CAUTION

Most women in the study had PCOS, which may limit applicability to other patient groups. For the analysis of the in vitro effects of kisspeptin-54, it is important to note that GL cells had already been exposed in vivo to an alternate maturation trigger.

WIDER IMPLICATIONS OF THE FINDINGS

The profile of serum gonadotropins seen with kisspeptin administration compared to other triggers more closely resemble that of the natural cycle as compared with hCG. Thus, kisspeptin could potentially permit an ovarian environment augmented for steroidogenesis, in particular progesterone synthesis, which is required for embryo implantation.

STUDY FUNDING/COMPETING INTEREST(S)

Dr Owens is supported by an Imperial College London PhD Scholarship. Dr Abbara is supported by an National Institute of Health Research Academic Clinical Lectureship. The authors do not have any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01667406.

Clinical parameters of ovarian hyperstimulation syndrome following different hormonal triggers of oocyte maturation in IVF treatment

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic condition, predominantly related to the hormone used to induce oocyte maturation during IVF treatment. Kisspeptin is a hypothalamic neuropeptide that has recently been demonstrated to safely trigger final oocyte maturation during IVF treatment even in women at high risk of OHSS. However, to date, the safety of kisspeptin has not been compared to current hormonal triggers of oocyte maturation.

DESIGN

We conducted a retrospective single-centre cohort study investigating symptoms and clinical parameters of early OHSS in women at high risk of OHSS (antral follicle count or total number of follicles on day of trigger ≥23) triggered with human chorionic gonadotrophin (hCG) (n = 40), GnRH agonist (GnRHa; n = 99) or kisspeptin (n = 122) at Hammersmith Hospital IVF unit, London, UK (2013-2016).

RESULTS

Clinical Parameters of OHSS: Median ovarian volume was larger following hCG (138 ml) than GnRHa (73 ml; P < .0001), and in turn kisspeptin (44 ml; P < .0001). Median ovarian volume remained enlarged 20-fold following hCG, 8-fold following GnRHa and 5-fold following kisspeptin compared to prestimulation ovarian volumes. Mean (±SD) ascitic volumes were lesser following GnRHa (9 ± 44 ml) and kisspeptin (5 ± 8 ml) than hCG (62 ± 84 ml; P < .0001). Symptoms of OHSS were most frequent following hCG and least frequent following kisspeptin. Diagnosis of OHSS: The odds ratio for OHSS diagnosis was 33.6 (CI 12.6-89.5) following hCG and 3.6 (CI 1.8-7.1) following GnRHa, when compared to kisspeptin.

CONCLUSION

Triggering oocyte maturation by inducing endogenous gonadotrophin release is preferable to the use of exogenous hCG in women at high risk of OHSS.

Direct comparison of the effects of intravenous kisspeptin-10, kisspeptin-54 and GnRH on gonadotrophin secretion in healthy men

STUDY QUESTION

How potently does the novel hypothalamic stimulator of reproduction, kisspeptin, increase gonadotrophin secretion when compared with GnRH in healthy men?

SUMMARY ANSWER

At the doses tested, intravenous administration of either of two major kisspeptin isoforms, kisspeptin-10 and -54, was associated with similar levels of gonadotrophin secretion in healthy men; however, GnRH was more potent when compared with either kisspeptin isoform.

WHAT IS KNOWN ALREADY

Kisspeptin-10 and -54 are naturally occurring hormones in the kisspeptin peptide family which potently stimulates endogenous GnRH secretion from the hypothalamus, so have the potential to treat patients with reproductive disorders. Rodent studies suggest that kisspeptin-54 is more potent when compared with kisspepitn-10; however, their effects have not previously been directly compared in humans, or compared with direct pituitary stimulation of gonadotrophin secretion using GnRH.

STUDY DESIGN, SIZE AND DURATION

A single-blinded placebo controlled physiological study was performed from January to December 2013. Local ethical approval was granted, and five participants were recruited to each dosing group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthy men were administered vehicle, kisspeptin-10, kisspeptin-54 and GnRH intravenously for 3 h on different study days. Each hormone was administered at 0.1, 0.3 and 1.0 nmol/kg/h doses (n = 5 subjects per group). Regular blood sampling was conducted throughout the study to measure LH and FSH. Study visits were conducted at least a week apart.

MAIN RESULTS AND THE ROLE OF CHANCE

Serum LH and FSH levels were ∼3-fold higher during GnRH infusion when compared with kisspeptin-10 and ∼2-fold higher when compared with kisspeptin-54 [mean area under the curve serum LH during infusion (in hours times international units per litre, h.IU/l): 10.81 ± 1.73, 1.0 nmol/kg/h kisspeptin-10; 14.43 ± 1.27, 1.0 nmol/kg/h kisspeptin-54; 34.06 ± 5.18, 1.0 nmol/kg/h GnRH, P < 0.001 versus kisspeptin-10, P < 0.01 versus kisspeptin-54].

LIMITATIONS, REASONS FOR CAUTION

This study had a small sample size.

WIDER IMPLICATIONS OF THE FINDINGS

Kisspeptin offers a novel means of stimulating the reproductive axis. Our data suggest that kisspeptin stimulates gonadotrophin secretion less potently when compared with GnRH; however, kisspeptin may stimulate gonadotrophins in a more physiological manner when compared with current therapies. Kisspeptin is emerging as a future therapeutic agent, so it is important to establish which kisspeptin hormones could be used to treat patients with infertility. Results of this study suggest that either isoform has similar effects on reproductive hormone secretion in healthy men when administered intravenously.

STUDY FUNDING/COMPETING INTERESTS

This work is funded by grants from the MRC and NIHR and is supported by the NIHR Imperial Biomedical Research Centre Funding Scheme. C.N.J. is supported by an NIHR Clinical Lectureship. A.A. is supported by Wellcome Trust Research Training Fellowships. A.N.C. is supported by Wellcome Trust Translational Medicine Training Fellowship. W.S.D. is supported by an NIHR Career Development Fellowship.

Reduced levels of plasma kisspeptin during the antenatal booking visit are associated with increased risk of miscarriage

CONTEXT

Kisspeptin is a recently identified hormone encoded by the KISS1 gene, playing a critical role in human reproduction. Plasma kisspeptin levels rise dramatically during normal pregnancy due to placental synthesis, which implicates it as a potential tool for assessing risks of pregnancy complications. No previous prospective study has investigated the association between plasma kisspeptin and risk of miscarriage.

OBJECTIVE

The objective of the study was to determine whether a single plasma kisspeptin or serum human chorionic gonadotropin (hCG) measurement in asymptomatic women attending their booking antenatal visit is associated with miscarriage.

DESIGN

This was a prospective cohort study.

SETTING

The study was conducted at a tertiary obstetric center.

PARTICIPANTS

A total of 993 asymptomatic pregnant women with a gestation of 6 weeks or longer attending routine antenatal booking visit were recruited between January 2010 and December 2012.

MAIN OUTCOME MEASURES

Plasma kisspeptin and serum hCG were measured during the antenatal booking visit. Pregnancy outcome was recorded prospectively.

RESULTS

Plasma kisspeptin correlated with gestation (r(2) = 0.57; P < .0001). Gestational age-corrected (multiples of median) plasma kisspeptin was 60.4% lower (P < .001), and multiples of median-hCG was 36.1% lower (P < .001) in women later diagnosed with miscarriage compared with women without miscarriage. Increased plasma kisspeptin was associated with reduced miscarriage risk, even after adjusting for age, body mass index, gestational age, smoking, and blood pressure [odds ratio 0.13 (95% confidence interval 0.08-0.22), P = .0001]. Kisspeptin had a higher diagnostic performance for miscarriage than hCG (receiver-operator characteristic-area under the curve 0.899 ± 0.025 plasma kisspeptin; 0.775 ± 0.040, serum hCG, P < .01 vs plasma kisspeptin).

CONCLUSION

Our data suggest for the first time that a single plasma kisspeptin measurement taken during the antenatal booking visit provides a potential novel marker for identifying asymptomatic pregnant women at a gestation of 6 weeks or greater at increased risk of miscarriage.

Twice-daily subcutaneous injection of kisspeptin-54 does not abolish menstrual cyclicity in healthy female volunteers

BACKGROUND

Kisspeptin is a critical hypothalamic regulator of reproductive function. Chronic kisspeptin administration causes profound tachyphylaxis in male monkeys and in women with functional hypothalamic amenorrhea. The pharmacological effects of chronic kisspeptin exposure in healthy women with normal menstrual cycles have not been studied previously.

AIM

Our aim was to determine the effects of follicular-phase kisspeptin-54 treatment on menstrual cyclicity in healthy women.

METHODS

We performed a prospective, single-blinded, 1-way crossover study. Healthy women received twice-daily sc injections of kisspeptin (6.4 nmol/kg) or 0.9% saline during menstrual days 7-14 (n = 5 per treatment arm). Serial assessments of basal reproductive hormones, ultrasound parameters, LH pulsatility, and acute sensitivity to GnRH and kisspeptin-54 injection were performed.

RESULTS

Menstrual cyclicity persisted in all women after follicular-phase kisspeptin-54 treatment. Chronic exposure to kisspeptin-54 did not abolish acute stimulation of LH after injection of kisspeptin-54 or GnRH. In addition, kisspeptin-54 treatment was associated with a shorter mean length of the menstrual cycle (mean length of menstrual cycle was 28.6 ± 1.4 days with saline vs 26.8 ± 3.1 days with kisspeptin, P < .01), earlier onset of highest recorded serum LH (mean menstrual day of highest LH was 15.2 ± 1.3 with saline vs 13.0 ± 1.9 with kisspeptin, P < .05), and earlier onset of the luteal phase (mean menstrual day of progesterone increase was 18.0 ± 2.1 with saline vs 15.8 ± 0.9 with kisspeptin, P < .05).

CONCLUSION

Our data suggest that 1 week of exogenous kisspeptin-54 does not abolish menstrual cyclicity in healthy women. Further work is needed to determine whether kisspeptin could be used to treat certain anovulatory disorders.

A single injection of kisspeptin-54 temporarily increases luteinizing hormone pulsatility in healthy women

BACKGROUND

Kisspeptin is a novel hypothalamic peptide which stimulates endogenous gonadotrophin releasing hormone (GnRH) secretion. A single subcutaneous bolus injection of kisspeptin-54 increases circulating luteinizing hormone (LH) levels in women, but its acute effects on LH pulsatility are not known.

AIMS

To investigate the effects of a single subcutaneous (sc) injection of kisspeptin-54 administration on LH pulsatility in healthy female volunteers.

METHODS

Six healthy female adult volunteers underwent 10-minute blood sampling for serum LH measurement for 8 h during the follicular phase of menstrual cycle. Sc bolus injection of saline or kisspeptin-54 (0·15, 0·30 or 0·60 nmol/kg) was administered 4 h after commencing the study. A previously described, blinded deconvolution method was used to detect LH pulses.

RESULTS

Mean number of LH pulses was increased significantly following 0·30 and 0·60 nmol/kg kisspeptin-54 when compared with saline (mean increase in number of LH pulses per 4 h, following injection: -0·17 ± 0·54, saline; +2·33 ± 0·56, 0·30 nmol/kg kisspeptin-54, P < 0·05 vs saline; +2·33 ± 0·80, 0·60 nmol/kg kisspeptin-54, P < 0·05 vs saline). LH pulse secretory mass increased following injection of 0·60 nmol/kg in five of six subjects, but the mean change in all subjects was non-significant when compared with saline (mean increase in pulse secretory mass in IU/l following injection: +0·35 ± 0·40, saline; +2·61 ± 1·17, 0·60 nmol/kg kisspeptin-54, P = 0·10 vs saline).

CONCLUSIONS

A single injection of kisspeptin-54 temporarily stimulates the number of LH pulses in healthy women. Further studies are required to investigate the therapeutic potential of kisspeptin-54 injection to restore LH pulsatility in patients with reproductive disorders caused by impaired GnRH secretion.