Evaluating the hepatitis B vaccination impact in the Republic of Moldova: A nationwide representative serosurvey of children born in 2013

Objectives

The WHO European Region set targets for the control of hepatitis B through immunization, including prevalence of hepatitis B surface antigen (HBsAg) at ≤0.5% in vaccinated cohorts. The Republic of Moldova implemented universal hepatitis B vaccination since 1995. We conducted a nationwide representative serosurvey to estimate HBsAg seroprevalence in children born in 2013 to validate hepatitis B control targets.

Methods

We used probability-based sampling and a two-stage cluster design. All children born in 2013 and registered in primary healthcare facilities were eligible for participation. We tested blood samples of all participants for hepatitis B core antibody (anti-HBc), using Enzyme-Linked Immunosorbent Assay (ELISA). Anti-HBc-positive samples were tested for HBsAg and HBsAg-positive samples confirmed, using ELISA. We obtained information on hepatitis B vaccination from vaccination cards.

Results

Of 3352 sampled children, 3064 (91%) participated. Most participating children were 7 years old (n = 3030, 99%), 1426 (48%) were girls. The weighted, national seroprevalence estimate was 3.1% (95% confidence interval = 2.1-4.5) for anti-HBc and 0.21% (95% confidence interval = 0.08-0.53) for HBsAg.

Conclusion

The study demonstrated the impact of hepatitis B vaccination and allowed the Republic of Moldova to validate regional hepatitis B control targets. Other countries with high vaccination coverage could use hepatitis B serosurveys and apply for validation. Sustained efforts in the Republic of Moldova will be crucial on the path to hepatitis B elimination.

The Influence of HLA Polymorphisms on the Severity of COVID-19 in the Romanian Population

In this study, we aimed to investigate whether specific HLA alleles found in patients from Romania and the Republic of Moldova were associated with the severity of COVID-19 infection and its associated mortality. We analyzed the HLA alleles at the -A, -B, -C, -DRB1, and -DQB1 loci in a cohort of 130 individuals with severe and extremely severe forms of COVID-19, including 44 individuals who died. We compared these findings to a control group consisting of individuals who had either not been diagnosed with COVID-19 or had experienced mild forms of the disease. Using multivariate logistic regression models, we discovered that the B*27 and B*50 alleles were associated with an increased susceptibility to developing a severe form of COVID-19. The A*33 and C*15 alleles showed potential for offering protection against the disease. Furthermore, we identified two protective alleles (A*03 and DQB1*02) against the development of extremely severe forms of COVID-19. By utilizing score statistics, we established a statistically significant association between haplotypes and disease severity (p = 0.021). In summary, this study provides evidence that HLA genotype plays a role in influencing the clinical outcome of COVID-19 infection.

The impact of the COVID-19 pandemic on primary health care practices and patient management in the Republic of Moldova - results from the PRICOV-19 survey

BACKGROUND

The COVID-19 pandemic has had an enormous impact on health systems in Europe and has generated unprecedented challenges for tertiary care. Less is known about the effects on the activities of local family doctors (FDs), who have shifted tasks and adapted their practice to accommodate the new services brought by the pandemic. The PRICOV-19 study was a multi-country survey aiming to understand the challenges posed by the pandemic in primary health care (PHC) practices around Europe. Within the framework of this study, we assessed the impact of the pandemic on PHC facilities in urban, rural, and mixed urban/rural areas in the Republic of Moldova.

METHODS

We present the results from the PRICOV-19 questionnaire designed at Ghent University (Belgium) and distributed between January and March 2021 to PHC facilities from the 35 districts of the Republic of Moldova. This analysis presents descriptive data on limitations to service delivery, staff role changes, implementation and acceptance of COVID-19 guidelines, and incidents reported on staff and patient safety during the pandemic.

RESULTS

Results highlighted the differences between facilities located in urban, rural, and mixed areas in several dimensions of PHC. Nearly half of the surveyed facilities experienced limitations in the building or infrastructure when delivering services during the pandemic. 95% of respondents reported an increase in time spent giving information to patients by phone, and 88% reported an increase in responsibilities. Few practices reported errors in clinical assessments, though a slightly higher number of incidents were reported in urban areas. Half of the respondents reported difficulties delivering routine care to patients with chronic conditions and a delay in treatment-seeking.

CONCLUSIONS

During the pandemic, the workload of PHC staff saw a significant increase, and practices met important structural and organizational limitations. Consequently, these limitations may have also affected care delivery for vulnerable patients with chronic conditions. Adjustments and bottlenecks need to be addressed, considering the different needs of PHC facilities in urban, rural, and mixed areas.

Epidemiological Survey of the Main Tick-Borne Pathogens Infecting Dogs from the Republic of Moldova

Despite the significant burden of tick-borne diseases (TBDs), epidemiologic studies are missing, and TBD awareness is low in the Republic of Moldova. Our study is the first to assess the prevalence of the main tick-borne pathogens (TBPs) infecting dogs in this country and associated risk factors. In this cross-sectional, multi-centre study (June 2018-July 2019), blood samples were collected from dogs presenting in veterinary clinics (Chişinău: N = 30) and hosted in public dog shelters (Cahul: N = 42; Chişinău: N = 48). TBPs were assessed by molecular techniques and risk factors by the logistic regression model. Hepatozoon canis was the most prevalent TBP (15.8% [19/120]), followed by Babesia canis (11.7% [14/120]), Anaplasma phagocytophilum (5.8% [7/120]), and Bartonella spp. (0.8% [1/120]). Blood samples tested negative for Borrelia spp., Rickettsia spp., Francisella tularensis, Anaplasma platys, and Ehrlichia canis. Dogs originating from the veterinary clinics had a higher prevalence of A. phagocytophilum infection than those from the shelters (16.6% versus 2.2%, respectively, p = 0.0292; OR: 27.0 [95%CI: 1.4-521.9]). Dogs from Chișinău had a higher prevalence of Hepatozoon canis infection versus those from Cahul (19.2% versus 9.5%, respectively, p = 0.0295; OR: 3.9 [95%CI: 1.1-13.4]). We recommend routine use of acaricides and deworming of dogs to prevent or/and limit TBD spread. Further TBD surveillance studies are needed.

Food security of people with celiac disease in the Republic of Moldova through prism of public policies

Food security is an important lever for the implementation of rights-based legislation, policies, and programs, while being a public health and socio-economic priority. Foodborne illnesses have a major impact on public health, and nutritional interventions are essential therapeutic strategies to combat them. Gluten ingestion has been linked to several clinical disorders, collectively called gluten-related disorders. The most serious of these is celiac disease. The only way to treat celiac disease is to stick to a gluten-free diet for life. Following a strict diet is also the only way to prevent the long-term consequences of the disease. Public policies are essential to ensure the food security of people with gluten-related disorders. The aim of the research is to assess the level of care for people with celiac disease in the Republic of Moldova, in terms of public policies, to ensure a sustainable sector that effectively satisfies the food security of people with disorders associated with gluten consumption. To assess the level of care for people with gluten-related disorders, the working algorithm was taken, with reference to global public policies in support of people with celiac disease, developed and validated by Falcomer et al., Focused on 6 items. The results of the study showed that the Republic of Moldova does not have adequate policy support to ensure food security for people with gluten-related disorders, which poses major challenges and, as a result, may increase the complications of these problems.

The first record of the invasive mosquito species Aedes albopictus in Chişinӑu, Republic of Moldova, 2020

BACKGROUND

In Europe, Aedes albopictus is an important vector of chikungunya virus and Dirofilaria nematodes and has been involved in local autochthonous circulation of dengue and Zika viruses. Due to the ongoing spread, targeted field surveillance at potential points of entry of invasive Aedes mosquitoes was initiated by the Republic of Moldova in 2020 as part of the transboundary "Invasive Aedes Mosquitoes COST-Action project."

METHODS

In 2020, ovitraps were positioned at each of three locations: the border crossing to Romania in Leuşeni (Hancesti region), Chişinӑu International Airport and Chişinӑu Botanical Garden.

RESULTS

A total of 188 Aedes spp. eggs were collected at the Chişinӑu International Airport between August and September 2020. Twenty-three adults reared in the laboratory were identified morphologically as Ae. albopictus (Skuse, 1895), and 12 selected specimens were confirmed by molecular barcoding of the cytochrome oxidase subunit I gene region. In addition, one adult Ae. albopictus female at the same site was caught with a manual aspirator.

CONCLUSIONS

This is the first documented report of Ae. albopictus in the Republic of Moldova. The presence of immature and adult stages indicates the local reproduction of the species in the country. Therefore, it is crucial to extend and strengthen surveillance of the invasive Aedes mosquitoes to prevent Ae. albopictus and other exotic mosquito species from becoming established in the Republic of Moldova.

An epidemiological survey of Dirofilaria spp. and Acanthocheilonema spp. in dogs from the Republic of Moldova

Background

During the last decades, filarial infections caused by Dirofilaria spp. have spread rapidly within dog populations of several European countries. Increasing scientific interest in filariasis, and the availability of new diagnostic tools, has led to improved knowledge of the biology, morphology, and epidemiology of different species of filarial worms. However, data are still scarce for a number of countries, including the Republic of Moldova. Thus, we assessed the epidemiological status of canine filariasis in the Republic of Moldova to address part of this knowledge gap.

Methods

A total of 120 blood samples were collected between June 2018 and July 2019 from dogs originating from the cities of Cahul and Chişinău. The samples were examined microscopically, and multiplex polymerase chain reaction was performed to evaluate filarioid species diversity.

Results

Microscopic examination revealed that 12 dogs (10.0%) were positive for circulating microfilariae. The molecular test showed that one dog was positive for Acanthocheilonema reconditum (0.8%), one for Dirofilariaimmitis (0.8%), six for Dirofilariarepens (5.0%), and four (3.3%) harboured a co-infection with D. immitis and D. repens. Prevalence was significantly higher in dogs aged ≥ 2 years.

Conclusions

The epidemiological survey presented here for the Republic of Moldova confirmed the presence D. immitis, D. repens and A. reconditum in dogs that had not received any heartworm preventive.

Graphical abstract

Accumulation of Potentially Toxic Elements in Mosses Collected in the Republic of Moldova

For the second time, the moss biomonitoring technique was applied to evaluate the deposition of potentially toxic elements in the Republic of Moldova. The study was performed in the framework of the International Cooperative Program on Effects of Air Pollution on Natural Vegetation and Crops. Moss Hypnum cupressiforme Hedw. samples were collected in May 2020 from 41 sampling sites distributed over the entire territory of the country. The mass fractions of 35 elements (Na, Mg, Al, Cl, K, Ca, Sc, Ti, V, Cr, Mn, Fe, Co, Ni, Cu, Zn, As, Br, Se, Rb, Sr, Sb, Cs, Ba, Cd, La, Ce, Sm, Eu, Tb, Hf, Ta, Th, Pb, and U) were determined using neutron activation analysis and atomic absorption spectrometry. Comparing with 2015/2016 moss survey data, significant differences in the mass fractions of Cr, As, Se, Br, Sr, Sb, Cd, Pb, and Cu were found. Main air pollution sources (natural processes, transport, industry, agriculture, mining) were identified and characterized using factor and correlation analyses. GIS maps were built to point out the zones with the highest element mass fractions and to relate this to the known sources of contamination. Contamination factor, geo-accumulation index, pollution load index, and potential ecological risk index were calculated to assess the air pollution levels in the country. According to the calculated values, Moldova can be characterized as unpolluted to moderately polluted, with low potential ecological risk related to the degree of atmospheric deposition of potentially toxic elements. The cities of Chisinau and Balti were determined to experience particular environmental stress and are considered moderately polluted.

Sodium, Potassium and Iodine Intake, in A National Adult Population Sample of the Republic of Moldova

In the Republic of Moldova, more than half of all deaths due to noncommunicable diseases (NCDs) are caused by cardiovascular disease (CVD). Excess salt (sodium) and inadequate potassium intakes are associated with high CVD. Moreover, salt iodisation is the preferred policy to prevent iodine deficiency and associated disorders. However, there is no survey that has directly measured sodium, potassium and iodine consumption in adults in the Republic of Moldova. A national random sample of adults attended a screening including demographic, anthropometric and physical measurements. Sodium, potassium and iodine intakes were assessed by 24 h urinary sodium (UNa), potassium (UK) and iodine (UI) excretions. Knowledge, attidues and behaviours were collected by questionnaire. Eight-hundred and fifty-eight participants (326 men and 532 women, 18–69 years) were included in the analysis (response rate 66%). Mean age was 48.5 years (SD 13.8). Mean UNa was 172.7 (79.3) mmoL/day, equivalent to 10.8 g of salt/day and potassium excretion 72.7 (31.5) mmoL/day, equivalent to 3.26 g/day. Only 11.3% met the World Health Organization (WHO) recommended salt targets of 5 g/day and 39% met potassium targets (>90 mmoL/day). Whilst 81.7% declared limiting their consumption of processed food and over 70% not adding salt at the table, only 8.8% looked at sodium content of food, 31% still added salt when cooking and less than 1% took other measures to control salt consumption. Measures of awareness were significantly more common in urban compared to rural areas. Mean urinary iodine was 225 (SD: 152; median 196) mcg/24 h, with no difference between sexes. According to WHO criteria, 41.0% had adequate iodine intake. Iodine content of salt table was 21.0 (SD: 18.6) mg/kg, lower in rural than urban areas (16.7, SD = 18.6 vs. 28.1, SD = 16.5 mg/kg, p < 0.001). In most cases participants were not using iodised salt as their main source of salt, more so in rural areas. In the Republic of Moldova, salt consumption is unequivocally high, potassium consumption is lower than recommended, both in men and in women, whilst iodine intake is still inadequate in one in three people, although severe iodine deficiency is rare. Salt consumed is often not iodised.

First report of canine ocular thelaziosis in the Republic of Moldova

Background

Countries of eastern Europe are considered, due to several risk factors, more vulnerable to infections with newly (re)emerging pathogens. During the last decade, in several European countries, reports of autochthonous cases of ocular thelaziosis due to Thelazia callipaeda have been published, posing a great concern from both veterinary and public health perspective. However, in the Republic of Moldova only limited epidemiological data are available regarding zoonotic vector-borne pathogens and, until now, no data exist on the zoonotic nematode T. callipaeda.

Methods

In September 2018, an 11-year-old dog, mixed-breed, intact male was referred to a private veterinary clinic from Chișinău, Republic of Moldova, with a history of 2 weeks of an ocular condition affecting the right eye. The ophthalmological exam revealed the presence of nematode parasites in the conjunctival sac and under the third eyelid. The collected parasites were identified by morphological techniques and molecular analysis.

Results

A total of 7 nematodes were collected, and 5 females and 2 males of T. callipaeda were identified morphologically. The BLAST analysis confirmed the low genetic variability of this parasite in Europe. The travel history of the patient allowed us to confirm the autochthonous character of the case.

Conclusions

To the best of our knowledge, this is the first report of thelaziosis in dogs from the Republic of Moldova, which confirms the spreading trend of T. callipaeda and the existence of an autochthonous transmission cycle of this zoonotic parasite in the country.

Traumatic Dental Injuries among Adolescents In Republic of Moldova

Objectives: The aim of this investigation was to evaluate the epidemiological data on dental injuries in permanent teeth among seventh and tenth grade schoolchildren in the Republic of Moldova. Study design: The pathfinder study model was chosen to evaluate the prevalence of Traumatic Dental Injuries (TDI). Schoolchildren ages 12 and 15 years old were examined: In the capital city (four schools), in two other major cities-(two schools each city), and in four villages (one per each village) in accordance with the WHO's recommendations. Results: A total of 720 seventh and tenth grade schoolchildren were examined. The overall prevalence of TDI was found to be 16.4% (total of 118 children). The prevalence of TDI was greater in the older age cohort (p<0.05). Children from rural areas presented with greater prevalence of TDI compared to children who live in urban region (p<0.03). The maxillary central incisors were found to be the most common teeth affected by trauma constituting 57.1% of the evaluated TDI cases. Enamel fracture was the main type of TDI (83%). Conclusions: The TDI mainly involved enamel fractures. Urban schoolchildren show lower rates of TDI compared to rural schoolchildren.

The pathfinder study among schoolchildren in the Republic of Moldova: dental caries experience

OBJECTIVES

The aim of the present research was to evaluate the current caries experience of schoolchildren in the Republic of Moldova.

METHODS

A pathfinder study was planned and executed according to the World Health Organization (WHO) recommendations. Caries experience was recorded in three large cities (the capital city and two other large cities) and four villages throughout the country. Within each site and age group, school clusters were randomly chosen. Three different age groups (6, 12 and 15 years) of schoolchildren were assessed.

RESULTS

Overall, 1,100 children were examined: 724 from cities and 376 from the villages. Among the study population, 408 (37.1%) were female and 692 (62.9%) were male, 380 were 6 years of age, 365 were 12 years and 355 were 15 years. The prevalence of caries experience [decayed, missing and filled scores of > 1 for primary (dmft) and secondary (DMFT) teeth] was 87.4% (dmft score = 3.9 ± 3.0) for 6-year-old participants, 77.53% (DMFT score = 2.7 ± 2.3) for 12-year-old participants and 86.2% (DMFT score = 3.7 ± 2.9) for 15-year-old participants. For the 12-year group, a higher proportion of caries-free children were detected in urban areas than in rural areas (25.5% vs. 15.5%, P = 0.003). We found more caries-free participants among 12-year-olds than among 15-year-olds (22.5% vs. 13.8%, P = 0.004).

CONCLUSIONS

These WHO key index age groups may be inserted into the global oral health databank and provide a 'pathfinder' baseline for formulating and conducting future public oral health programmes in the Republic of Moldova, with an emphasis on children in rural locations.

Survey on patient safety culture in the Republic of Moldova: a baseline study in three healthcare settings

BACKGROUND AND AIMS

The Republic of Moldova is a small ex-soviet country in the Central Eastern European group of states, whose official language is Romanian. In countries with limited resources, quality improvement in healthcare and patient safety are very challenging. This study aims to identify which areas of the patient safety culture (PSC) need prompt intervention.

METHODS

A cross-sectional study was conducted in three Moldovan healthcare settings, using the Romanian translation of the US Hospital Survey on Patient Safety Culture HSOPSC. Descriptive statistics were carried out, based on the responses from n. 929 staff. Percentages of positive responses (PPRs) by item (41 items) and composite (12 PSC areas) were computed.

RESULTS

Most respondents were nurses (53%), followed by doctors (35%). The main work areas were: primary care (27%), medical specialties (20%), gynecology and obstetrics (16%), and general surgery (11%). The highest composite PPRs were for: teamwork within units (80%), feedback & communication about error, organizational learning-continuous improvement and supervisor/manager expectations & actions promoting patient safety (78%), and management support for patient safety (75%). The lowest composites were for: frequency of events reported (57%), non-punitive response to errors (53%), communication openness (51%) and staffing (37%).

CONCLUSION

Our results suggest that staffing issues should be tackled to provide safe care. Staff avoid to openly report adverse events and/or discuss errors, likely because a poor understanding of the potential of these events for learning and because of fear of blame or punitive actions. Future research should check psychometrics of the Romanian version of the HSOPSC applied to Moldovan staff.

Progress in increasing affordability of medicines for non-communicable diseases since the introduction of mandatory health insurance in the Republic of Moldova

BACKGROUND

To assess progress in improving affordability of medicines since the introduction of mandatory health insurance in the Republic of Moldova.

METHOD

Using data from national health insurance, we estimate affordability of partially reimbursed medicines for the treatment of non-communicable diseases, and analyse which factors contributed to changes in affordability.

RESULTS

Affordability of subsidized medicines improved over time. In 2013, it took a median of 0.84 days of income for the lowest income quintile (ranging from 0 to 3.32 days) to purchase 1 month of treatment for cardiovascular conditions in comparison to 1.85 days in 2006. This improvement however was mainly driven by higher incomes rather than deeper coverage through the reimbursement list.

CONCLUSION

If mandatory health insurance is to improve affordability of medicines for the Moldovan population, more funds need to be (re-)allocated to enable higher percentage coverage of essential medicines and efficiencies need to be generated within the health system. These should include a budget reallocation between secondary and primary care, strengthening primary care to manage chronic conditions and raise population awareness, implementation of evidence-based selection and quality use of medicines in both outpatient and inpatient settings, improving monitoring and regulation of prices and the supply chain; and alignment of national treatment guidelines and clinical practice with international best practices and evidence-based medicine.

An in-depth analysis of pharmaceutical regulation in the Republic of Moldova

OBJECTIVE

Regulation of the pharmaceutical system is a crucial, yet often neglected, component in ensuring access to safe and effective medicines. The aim of this study was to provide an in-depth analysis of the existing pharmaceutical regulation, including recent changes, in the Republic of Moldova.

METHODS

Data from field work conducted by the World Health Organization (WHO) together with a review of policy documents and quantitative secondary data analysis was used to achieve this aim.

RESULTS

This analysis identified several ways in which pharmaceutical regulation affects availability of quality medicines in the Republic of Moldova. These include lack of full implementation bioequivalence requirements for generics registration, incomplete implementation of good manufacturing practices and no implementation of good distribution practices, use of quality control instead of quality assurance as a method to ensure quality of medicines, frequent change of power within the Medicines and Medical Devices Agency (MMDA) leading to lack of long-term strategy and plans, conflict of interest between the different functions of the MMDA, the lack of sufficient funding for the MMDA to conduct its activities and to invest in continuous training of its staff (particularly inspectors) and very weak post-marketing control. Notably, several improvements have been recently introduced, including a roadmap for change for the MMDA, the introduction of good manufacturing practices and the drafting of a quality manual for the Agency.

CONCLUSION

Based on these findings the authors propose a set of priority actions to address existing gaps and draw lessons learned from other countries.