This progress report is for the Injury Prevention Research Training in Egypt and the Middle East grant, funded by the U.S. National Institutes of Health’s Fogarty International Center, and covers the period from April 1, 2012 through March 31, 2013. This program, between University of Maryland School of Medicine in Baltimore Maryland and the Faculty of Medicine of Ain Shams University in Cairo, is designed to help Egyptian health professionals increase their knowledge and understanding of human trauma and injury prevention. It is also designed to help them apply this knowledge in public health and clinical practice in order to decrease the significant morbidity and mortality caused by injuries. Our three main objectives to further the success of this research training program are: 1) Continue to train our growing cadre of traumatologists and emergency physicians in the use of currently available methodologies in trauma resuscitation, injury research, and the collection of data about injuries; 2) In conjunction with our developing WHO Collaborating Center, further the development of our program to expand research and training opportunities for injury-related research in Egypt and the Middle East; and 3) Expand our select group of health professionals trained in our intensive summer injury research training courses, followed by in-country mentored research activities, to cement and expand our core group of injury researchers in Egypt and the Eastern Mediterranean Region and work with them to develop sustainable injury research programs. This report briefly discusses overall project accomplishments for the past year, reviews short course activities, and highlight the activities of selected long-term trainees
B. Overall Course Accomplishments And Current Challenges :
B. Overall Course Accomplishments And Current Challenges To date, approximately 800 trainees from countries in the Middle East, including Egypt, Iraq, Sudan, Palestine, Saudi Arabia, Syria, Yemen, Pakistan, Iran, Oman and Afghanistan have participated in one or more of the training courses initiated through this program developed with grant support from the U.S. National Institutes of Health’s Fogarty International Center. The majority of these individuals have been trained in one of our short course offerings, primarily our Sequential Trauma Educational Programs (STEPS) course to improve the clinical care of trauma patients. Importantly, during the first grant award, we trained 13 individuals in the long-term injury research training component of this program. An additional 5 individuals from Egypt were trained last year in the long-term injury research training component with support from this grant, as well as two individuals from Kenya with outside funding. The majority of these long-term trainees are currently completing research projects, advanced degrees or have accepted faculty/leadership positions at academic institutions or in governmental agencies in Egypt. This past year continued to present substantial challenges for individuals working in the Eastern Mediterranean Region and conducting research and research training, and particularly in Egypt due to the political instability resulting from the “Arab Spring” revolution and subsequent constitutional changes and elections. As noted in last year’s progress report, because of the political instability and lack of adequate security, our training activities were placed on hold during much of 2011. This, unfortunately, meant we were not able to select trainees during February and March of 2011 for our intensive summer injury epidemiology and research course and were not able to train a new cohort of young physician researchers in the summer of 2011. However, despite the continued political and societal turmoil in Egypt, this past year we successfully completed multiple training courses, including our intensive summer research training courses in the summer of 2012 and an in-country two week injury epidemiology courses in Cairo in January 2013. Additionally, we successfully conducted a regional conference on Occupational Injuries in the Arab Countries in collaboration with multiple universities, professional organizations and the World Health Organization’s Eastern Mediterranean Regional Office. These activities are discussed in more detail below. As a stated objective of this project, we have worked to create a World Health Organization (WHO) regional Collaborating Centre for Research and Training on Injury Prevention and Management at Ain Shams University in order to study the causes, dynamics, treatments, and outcomes of traumatic injury. Morbidity and mortality from injuries in the WHO’s Eastern Mediterranean Region (EMRO) made this a top priority for the health and development sectors. This collaborating center will serve as a focal point for determining opportunities for information, skills, infrastructure, and interactions and for developing regional plans for growth in the fields of trauma response, training, and injury control research. Our vision is to reduce the devastating impact of the thousands of traumatic injuries and deaths that occur in the region each year. The application for the Centre was submitted to the Eastern Mediterranean Regional Office (EMRO) of the WHO. Ain Shams University and our injury research prevention program are currently working with the new technical officer assigned to injury and violence prevention in the regional office to finalize the application and move it forward. Over the past year, the following articles have been published that are either directly related to this grant or were influenced by our work.
1) Health-related quality of life after serious occupational injury in Egyptian workers: a cross-sectional study. Salah Eldin W, Hirshon JM, Smith GS, Kamal AA, Abou-El-Fetouh A, El-Setouhy M. BMJ Open. 2012 Nov 27;2(6). doi:pii: e000413. 10.1136/bmjopen-2011-000413. Print 2012. PMID: 23187968 (free article online)
2) Health systems and services: the role of acute care. Hirshon JM, Risko N, Calvello EJB, de Ramirez SS, Narayan M, Theodosis C, O’Neill J. WHO Bulletin. Article ID: BLT.12.112664. Available at: http://www.who.int/bulletin/online_first/12-112664.pdf Of additional note, the first Occupational Injuries in Arab Countries conference was held in June 2012 with the support of a conference grant from National Institutes of Occupational Safety and Health. The conference went off well, considering the political issues swirling around Egypt at the time. The conference was schedule for Sunday (6/24) and Monday (6/25). The Supreme Council of the Armed Forces decided two weeks before the conference to announce the results of the presidential election on Sunday, June 24th. Depending on the results announced, there could have been riots or celebrations on the street. Several individuals committed to the conference, including at least one speaker, decided not to attend Sunday because they were concerned that they would not be able to get home once the election results were announced because of riots. After the announcement of the results of the presidential election, the situation calmed down. Despite this societal turbulence, we had approximately 75 individuals participate during both days of the conference. There was quite a lot of excitement about the topic of occupational injuries and keen interest in the discussions. A second conference is scheduled for June 2013.
C -Short Course Training
During the first grant funding cycle, as we initiated our work in Egypt in 2005 and 2006, it became clear that there was a critical need for a portable and flexible trauma response program for the emergency care of injured individuals throughout the world and especially in lower- and middle-income countries (LMICs) such as Egypt. In recognition of this problem, we developed a complete educational program titled Sequential Trauma Education ProgramS (STEPS). This training course covers a number of areas, including injury prevention, disaster preparedness, trauma airway management, shock, abdominal injuries, musculoskeletal injuries, thoracic injuries, triage, pediatric trauma, and special situations such as burn evaluation and management. Of the approximately 800 physicians trained through this grant, approximately 700 of them have completed our STEPS course. The STEPS course has become an independent didactic activity primarily organized and conducted by Egyptian physicians. Our STEPS course or its equivalent is now required for emergency medicine trainees by the Egyptian Board of Emergency Medicine, the curriculum of the Masters in Emergency Medicine being offered by Alexandria University and is recognized by the Egyptian Society of Intensive Care and Trauma. Official accreditation by the Egyptian Medical Syndicate, the highest physician organization within Egypt, is currently pending. We believe that we have made significant progress regarding capacity building related to the development of emergency care in the region and have been particularly successful in Egypt, based on the high quality of Egyptian trainers who are now available to teach physicians in trauma preparedness and response.
In recognition of the unstable political environment of Egypt and the Middle East, we developed a short (two-week) injury epidemiology course in July 2011. These courses have been primarily directed towards Egyptians interested in injury epidemiology and in emergency care, but through the EMRO-WHO we have invited colleagues from the Eastern Mediterranean region, which spreads from Morocco to Pakistan. Our most recent injury epidemiology course was held during January 2013 in Cairo, Egypt. During this course, we had participants from Egypt, Sudan, Saudi Arabia, Oman and Iran. Additional individuals from Palestine, Afghanistan and Djibouti were not able to attend because the course was full or because of issues with obtaining timely Egyptian visas. Thus, during the past two years, we have trained 53 individuals in injury epidemiology and research from around the region, including 34 from Egypt (including the WHO Injury Focal Point), 6 from Sudan (including the WHO Injury Focal Point), 3 from Oman (including the WHO Injury Focal Point), 3 from Iran (including the WHO Injury Focal Point), 3 from Saudi Arabia, 1 from Yemen, 1 from Iraq (through WHO-EMRO), 1 from Gaza (through WHO-EMRO), 1 from Pakistan (through WHO-EMRO). Through these courses, we are able to identify high quality candidates for our summer course. Additionally, we now have a growing Facebook page (Injury Epidemiology Group: http://www.facebook.com/groups/229280403781271/) focused on injury epidemiology and injury research in the Eastern Mediterranean Region.
D- Long-term Injury Research Training
For individuals with a strong interest in injury-related research, we determined that it was more effective to bring trainees to the U.S. for an intensive summer training program, frequently as part of their overall pursuit of advanced degrees in Egypt, rather than sponsoring students for a year or longer in the U.S to obtain a graduate degree. This approach allowed us to train a greater number of physicians while increasing the likelihood that they would return to Egypt to continue with their research activities and academic careers. Upon completion of the course, students return to their academic institutions in Egypt for continued training as they complete a mentored research project. During June and July, 2012 we conducted our intensive summer research training course. There were 7 participants in this course- 5 from Egypt sponsored through our grant supported program and 2 from Kenya supported with outside funding. The trainees, and their proposed projects, were:
1) Amir El Shahawy (Egypt), Project- Assessment of Risk Perception and Occupational Injuries among Cement Workers in Helwan Industrial Area, Cairo, Egypt;
2) Elsayed Zied (Egypt), Project- Assessment of Quality Indicators for Multi-Trauma Patients after conducting Short Course Trauma Training, Sequential Trauma Education Programs (STEPS) at Suez Canal University Hospital, Ismailia, Egypt;
3) Mohamed Seif El-Din (Egypt), Project- An Epidemiological Study of Injuries during The Arab Spring in Egypt, 2011;
4) Shereen N. Elboray (Egypt), Project- Knowledge, Attitude and Practice of Family Physicians and Nurses towards Childhood Unintentional Injuries Prevention in Cairo, Egypt;
5) Wafaa M. Bkheit (Egypt), Project- Causes, Outcomes and Direct Medical Cost of Injuries in Adult Patients Admitted to Intensive Care Units in Ain Shams University (ASU) Hospital
6) David Nyamu (Kenya), Project- A Randomized Controlled Trial to Study the Vascular Events on HIV+ Adult Patients Receiving Lopinavir/Ritonavir Regimens
7) Richard Ayah (Kenya), Project- Determination of Clinical Governance Factors that enhance Clinicians’ Practice in reducing early mortality and loss to follow up of patients initiated on ART in Nairobi, Kenya
Long-term Trainees Supported During Past Year:
Mohamed El Shinawi
Dr. El Shinawi is an Associate Professor of general surgery in the General surgery department-Faculty of Medicine -Ain Shams University and the Head of the Emergency Hospital in Ain Shams University and a key leader in the development of the new Ain Shams University Trauma Center. He is the Lead Trainer of the STEPS course in Egypt. Dr. El Shinawi is pursuing a career in trauma and emergency care as well as in breast surgery. He is a member of a number of local and international associations and societies. He has successfully completed the STEPS and the International Emergency Preparedness and Response program awarded by University of Maryland, School of Medicine, Baltimore. He has also successfully completed the Advanced Trauma Life Support course of the American College of Surgeons Committee on Trauma, as well as Basic Disaster Life Support Course taught at Maryland Fire Rescue Institute, and an Advanced Laparoscopic Suturing, Stapling and Gastrointestinal course under the supervision of the European Surgical Institute. He had several publications and is supervising a number of junior physicians in master’s and doctoral programs. He is directing breast cancer awareness programs at Ain Shams University and is an investigator on four projects regarding breast cancer in collaboration with different institutes and universities in the United States.
Waleed Salah Eldin
Dr. Salah Eldin (Assistant Professor of Occupational Medicine at Ain Shams University) attended the injury epidemiology course at University of Maryland in the summer of 2007, aimed at training epidemiologists, surgeons, and other medical specialties on how to conduct injury related research. Besides the training in scientific methods of conducting injury prevention research, he participated in a number of other valuable experiences, such as attending committee meetings on ethics, attending a doctoral thesis defense, and a visit to the World Bank. His proposal on research related to injury prevention, a requirement for completion of the course, was the basis for his doctoral thesis, which he has successfully defended. His dissertation was entitled “Assessment of Disability Adjusted Life Years due to Occupational Injuries and Health Related Quality of Life of Injured Workers in the Eastern Delta Region of Egypt”, a part of which has been submitted to an international journal. He has published one manuscript entitled “Methodology for the investigation of occupational injury burden in Egypt” in the Ain Shams Medical Journal and has another manuscript in preparation. He recently published a second manuscript entitled “Health-related quality of life after serious occupational injury in Egyptian workers: a cross-sectional study” in BMJ Open. He had an abstract based upon his research accepted at the Safety 2010 conference. Under the supervision of Drs. Hirshon and El-Setouhy, he is conducting research on occupational injuries among children who work in small shops and factories in Diametta, Egypt. This work is being conducted in conjunction with the Swiss based, non-governmental organization Terre des Hommes. Data collection for this project is completed and undergoing analysis and manuscript development.
Dr. Momen (Assistant Professor of Occupational Medicine at Ain Shams University) is currently a teaching and research associate in the Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, at Ain Shams University in Egypt. He successfully defended his MD thesis related to occupational health last year. His main responsibilities include teaching epidemiology and research methodology to 4th year medical students, and conducting research and surveys in collaboration with different institutes, such as the Egyptian Smoking Prevention Research Institute and Pasteur institute for Liver Disease. His main interests are in smoking, needle stick injuries among healthcare workers, and substance abuse. His training in the injury epidemiology program at the University of Maryland has allowed him to further develop his skills and broaden his knowledge about the systematic conduct of research. The training gave him the capability to develop a scientific hypothesis and to design a research project. In addition, he learned how to communicate and work within a team and within different social environments, as well as in a different language. After returning back to Cairo, under the supervision of Drs. Hirshon, El-Setouhy and El Shinawi, he has helped developed a research program to study the prevalence of substance abuse among injury patients admitted to Ain Shams University Hospitals. This research, deemed not human subjects research by the University of Maryland, Baltimore Institutional Review Board as it is only using information collected for clinical purposes and residual blood/urine specimens, was placed on hold because of the unstable political situation in Egypt. However, during the past year, this research moved forward. Data collection is now complete and the data is being entered into a unified data base and cleaned. Data analysis and manuscript development should occur in the near future. The completion of this research will assist in obtaining more descriptive and analytical information to inform policy development. He intends to publish his work in an international journal..
E- Lessons Learned
We have learned a number of important lessons throughout this project. First, working directly with the Ministry of Health has been difficult for several reasons, especially because our key contacts changed frequently and political considerations often delayed or deferred important steps. These delays retarded our initial efforts by 18 to 24 months. After refocusing our project, we have concentrated on our relationship with Ain Shams University, which has applied to be a WHO Collaborating Center for injuries and trauma in the Eastern Mediterranean Region, as defined by the WHO. This center will serve as a regional focal point to study the causes, dynamics, treatments, and outcomes of traumatic injury and to apply this knowledge to decrease the burden of injuries. As noted above, one of our key successes has been our STEPS educational program, which was initially developed to address the non-research needs of physicians in Egypt. This program has fostered the growth of key relationships with leaders in emergency medicine and trauma surgery, while allowing for important research into implementing practice-changing educational programs in a developing country, and improving our understanding of injury-related research needs. This program is available for dissemination and implementation in lower- and middle-income countries (LMICs), particularly in the Arab Middle East and sub-Saharan Africa. Additionally, our extremely successful new two week injury epidemiology course has allowed our program to develop important relationships with individuals from throughout the Middle East, expanding the group of academicians and public health professionals interested in injury prevention and injury research. This in-country short course allows for the development of new research projects and for improved identification of potential participants in the intensive summer research program.
F- Activities Planned for Next Grant YearThe specific activities planned for the next year are:
1) Short Term Training
A. STEPS Courses (4), to be conducted at various Universities in Egypt
B. Injury Epidemiology Course (2), to be conducted in fall/winter at Ain Shams University
2) Long Term Training
A. Conduct the intensive summer injury epidemiology and research course at University of Maryland, Baltimore in August and September of 2013 with 8 trainees. (The timing of the course has been adjusted to accommodate the Muslim holy month of Ramadan.)
B. Continue supporting selected prior long term trainees who are actively conducting injury related research.
A. As noted above, we conducted the first Occupational Injuries in Arab Countries conference in June 2012 with support from a National Institutes of Occupational Safety and Health conference grant. We are currently planning a second conference for June 2013 and are working in collaboration with the Egyptian Chapter of the American Society of Safety Engineers.
A. In cooperation with Terre des Hommes, continue with the survey among children working in furniture industry, as well as their families, in order to evaluate the prevalence of occupational diseases and injuries. Lead Trainee Researcher: Waldi Saleh El Din.
B. Continue with a prospective, cross-sectional study of all injured patients admitted overnight to the Surgical Emergency Hospital of Ain Shams University Hospital, Cairo, Egypt. This study, based upon de-identified data obtained from injury epidemiology data sheet as part of the hospital medical record for patients with acute injuries is combined with de-identified residual urine and blood samples from each subject and screened for alcohol, cannabis, opiates and tramadol. Lead Trainee Researcher: Mohamed Momen.
C. Continue with the support of the research of our current trainees. Of particular note, Dr. Shereen N. Elboray has already completed her project conducting a survey looking at the knowledge, attitude and practice of family physicians and nurses towards childhood unintentional injuries prevention in Cairo, Egypt. This will be used to complete her master’s thesis and is expected to be turned into a publication for an international journal.
5) WHO Collaborating Centre
A. Work with colleagues at Ain Shams University and WHO-EMRO to further our application to become a WHO Regional Collaborating Centre focused on injury prevention and injury research.