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Protocol
Health consequences of the Urmia Lake crisis: the baseline study protocol
  1. Homayoun Sadeghi-Bazargani1,
  2. Mortaza Saadatkhah2,
  3. Mostafa Farahbakhsh3,
  4. Behrouz Sari Sarraf4,
  5. Ommolbanin Abbasnezhad1,
  6. Iraj Mohebbi5,
  7. Gholamhassan Mohammadi6,
  8. Rasoul EntezarMahdi5,
  9. Faramarz Pourasghar7
  1. 1 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
  2. 2 Tabriz University of Medical Sciences, Tabriz, East Azerbaijan, Iran
  3. 3 Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
  4. 4 Faculty of Planning and Environmental Sciences, University of Tabriz, Tabriz, Iran
  5. 5 Social Determinants of Health Research Center, Urmia University of Medical Sciences, Urmia, Iran
  6. 6 I. R. of Iranian Meteorological Organization, Tabriz, Iran
  7. 7 Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
  1. Correspondence to Mrs Ommolbanin Abbasnezhad; oa_1362{at}yahoo.com

Abstract

Introduction Climate change may affect human health due to various mechanisms including overexposure to environmental pollution or dispersed particles. Lake Urmia (LU) drying in recent years has turned into a crisis with particle distribution as its main manifest. It is told that this crisis may affect the health of neighbouring residents. In this paper, we elaborate on a research protocol developed to assess the potential health consequences of LU drying (LUD) by investigating the distribution of physical and mental health conditions/disorders among residents of LU’s surrounding provinces with different exposure levels to LUD outcomes.

Methods and analysis The target population of this study is the residents of the LU basin from East Azerbaijan and West Azerbaijan provinces of Iran. A total of 803 households and 2783 people are studied in 86 clusters. Cluster sampling is applied. The weighting of the samples is based on a satellite map of the density of suspended particles such that people living in areas with higher risk have a higher chance of selection. Various types of measurements are done in three major groups including self-reported health, clinical interview/examination and paraclinical assays.

Ethics and dissemination In this project, all procedures are in accordance with the ethical standards of the Ethics Committee of Tabriz University of Medical Sciences. Moreover, an informed consent letter is obtained from all participants included in the study. The results from this study will be disseminated in international journals and implemented in the primary care guidelines and national policy documents on managing the potential health consequences of LUD.

  • EPIDEMIOLOGY
  • Protocols & guidelines
  • Public health
  • Disasters
  • Climate change
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Strengths and limitations of this study

  • To the best of our knowledge, this is the only nationally approved comprehensive project study on the health consequences of Lake Urmia in Iran.

  • Previously validated data collection tools were used or the study tools were developed and validated through the standard methodology.

  • In this study, measurement of urinary sodium in addition to measuring salt consumption using salt diaries was conducted which is a concurrent validity approach.

  • Some diseases, such as eye cataracts, cannot be diagnosed by medical history and clinical examination alone and require further studies.

  • Due to cost constraints, not all tests have been performed, such as thyroid hormone tests.

Introduction

Over the past decade, the number of deaths and economic losses related to natural disasters has increased markedly.1 Big efforts have been made in recent years to evaluate and manage adverse effects of the natural disasters.2 3 Among the different disasters, lakes drying is one of the most important environmental changes that are less addressed and we have little information about it.4 These kinds of environmental changes and disasters have different health consequences.5

‘Urmia Lake’ is a lake in North-West Iran located between the two provinces of East and West Azerbaijan.6 Lake Urmia (LU) used to be the second great saline lake in the world and the largest lake in Iran.7 8 The area of LU in the summer of 2015 was about 6000 km2, which is the 25th largest lake in the world in terms of area. LU is home to 212 species of birds, 41 species of reptiles, 7 species of amphibians and 27 species of mammals, including the Iranian yellow deer. This ecosystem is internationally registered by UNESCO as a protected area. The Environmental Organization of Iran has identified most parts of the lake as a national park.6 An examination of satellite images shows that in 2015 the lake had lost 88% of its area.

According to the last national census in 2016, the two provinces of East Azerbaijan and West Azerbaijan had a population of 3909 652 and 3265 2119, respectively.9 Territorially, the LU basin includes the central, western and south-western parts of East Azerbaijan province (a relatively large part of the province, approximately 19 000 km2), as well as about half of the province of West Azerbaijan (southern half of the province, approximately 21 500 km2). It also covers the northern part of Kurdistan about 5000 km2 and includes a very small part of Zanjan province.10 The LU catchment has a population of about two million people. The lake’s basin encompasses a continental climate within its surrounding mountains. The lake is split into southern and northern parts by the Martyr Kalantari highway constructed across the lake for ease of transportation between the east (Tabriz District) and the west (Urmia District) of the lake.11

The lake began to dry in the mid-2001s. Although many authorities were concerned about the survival of the lake and considered it in danger of drying 4 years ago, the situation improved later in 2011, and hopes for the survival of LU are growing. Many environmental experts and officials believe that the drying of LU may lead to inevitable consequences not only for Iran but also for other countries in the region. Increased airborne salt and chemicals, changes in natural timing of the seasons, diminished agriculture and inevitable economic losses could be among the possible consequences of the drought due to LU drying (LUD).12 The lowered water level of LU will lead to a decrease in the number of tourists visiting the region and the economic income of the people living near the lake, encouraging some to emigrate. The incidence of various diseases among humans, animals and plants; reduced fertility of agricultural lands; disruption of quantitative and qualitative interaction of groundwater in the region; and inevitable economic losses could be other consequences of drought in LU. The movement of airborne salt particles to surrounding towns, villages and lands, the rapid decline in groundwater levels in the plains of the region, and the migration of people from villages and towns around the lake are other challenges of the current state of the lake. On the other hand, LUD may disseminate salt dust from the lake basin in Azerbaijan to other provinces of Iran as well as other countries in the region, just like the drying of Iraqi lakes and wetlands has created the phenomenon of fine dust over Iran and other countries.7 Respiratory diseases, increased cancers, high blood pressure, the spread of eye diseases, increased skin problems, psychological risks and abortion are just a small part of the potential risks hypothesised to occur due to LUD among the people of the region and other parts of the country.13–16

Low rainfall along with resource abuse (change in resource use management) are part of the causes of the onset of lake drying. Some reasons are stated by local authorities or researchers to be the potential causes of the crisis including climate change and drought through the recent decade; reduced water entry to the lake due to the construction of dams and improper use of water resources in the lake’s basin. However, more robust evidence on the causality of LUD may need to be added in the future to consolidate our current understanding of the causes of LUD and their share. Although some authorities have also considered the construction of a new highway over the lake as a potential cause, it seems the construction of the highway only disturbed the lake water circulation between the northern and southern parts, resulting in quality segregation of the lake water.17 Moreover, a new study by several researchers in North America shows that droughts only reduce rainfall by 5% in the lake’s basin, and human factors including ambitious economic water development projects may put the lake in crisis. By 2012, more than 200 dams on rivers in the lake’s basin were ready for operation or at the end of the design process.18 19

In recent years, although the causes of LUD are now nearly well understood and documented,20 the research has not been wide enough to depict all aspects of the drying crisis affecting health status. In practice, due to the lack of comprehensive precrisis data and sparse research in this regard limited to small-sized cross-sectional studies in the process of LUD,21–24 it is hard to robustly talk about causality. But it can generate very helpful information in this area and will, at least pessimistically, play a great role in hypothesis production.

Hence, it is necessary to measure the effects of LUD on the health of the residents around the lake. In this paper, we elaborate on a research protocol developed to assess the potential health consequences of LUD by investigating the distribution of physical and mental health conditions/disorders among residents of LU’s surrounding provinces with different exposure levels to LUD outcomes.

Material and methods

Study population and sampling

This study was conducted as part of national research projects on the effects of the LUD crisis on the health status of the residents of areas close to the lake in East and West Azerbaijan, Iran, with expected final data collection in 2023. The target population of this study is the residents of the LU basin from the two provinces of East Azerbaijan and West Azerbaijan. These residents are studied using cluster sampling by weighting according to the amount of particle exposure. Cluster sampling is the most commonly applied spatial sampling method in epidemiological surveys. The area under study is divided into units, and a selection is then randomly done in each unit. Subjects are ideally selected through simple random sampling. Without modifying the estimated parameter, cluster sampling is unbiased when the clusters are approximately the same size. In this condition, the parameter is computed by pooling all the chosen clusters. When the clusters have different sizes, there are several options: one possible solution is to use probability proportionate to size (PPS) sampling. In this sampling methodology, the probability of choosing a cluster is proportional to its size, such that a large cluster would benefit from a greater probability of selection than a cluster with a smaller size. The advantage of PPS cluster sampling is that when clusters are selected with PPS, the same number of interviews should be carried out in each sampled cluster and this will ensure an equal probability of selection for each sampled unit.25–27

A total of 803 households and 2783 people will be studied in 86 clusters. These people are residents of the urban and rural areas of the lake basin. A total of 81 villages and 19 towns are to be studied. The names of the study districts are Tabriz, Osko, Shabestar, Marand, Bonab, Maragheh, Bostan Abad, Hashtrood, Sarab, Azarshahr, Miyaneh, Malekan, Mahabad, Urmia, Salmas, Shahin Dej, Takab, Miandoab and Naqadeh. Figure 1 shows more details.

Figure 1

The geographical location of Lake Urmia as well as the studied residential areas.

Identifying risk areas and survey sampling methodology

Cluster sampling is applied in this protocol. To select the samples, first, the eastern and western areas of LU are divided into specific areas with different exposure risk levels (seven risk areas according to particle density information) including an area with a minimum or no risk of exposure to particles according to the methodology developed by the Faculty of Planning and Environmental Sciences of Tabriz University. PPS allocation for each area while applying predefined weights to areas at higher risk of exposure is used as the sampling technique in this protocol. Table 1 provides more information.

Table 1

Sampling details and study sampling weights for the residential areas surrounding Lake Urmia through the survey on health consequences of the Lake Urmia crisis.

The weighting of the samples is based on a satellite map of the density of suspended particles in such a way that areas with higher risk have a higher chance of selection. The methodology of this risk assessment is as follows:

To perform sampling, a series of geographical and meteorological information is used, including the distance from the saline bed of LU (dry bed of LU), the arrangement of the mountains towards the lake, and most importantly the zoning of the dominant routes of salt dust due to prevailing winds. The use of this information is as follows:

  1. Initially, it was necessary to identify the range of saline soils along the lake to determine the basic plan for the next steps. For this purpose, by receiving the Landsat 8 satellite image in September 2014 (at the lowest water level of the lake) with a spatial resolution of 30 m and implementing Salinity Index, saline soils were separated from other areas and the plan of saline soils in the environment of the geographical information system (GIS) was developed to be used in this survey.

  2. The areas that are at the shortest distance from the lake have a higher risk of spreading salt. To determine the effect of this factor, seven spatial distances from the shores of LU are determined and plotted as a buffer in a GIS environment.

  3. The elevation of LU is about 1270 m and Sahand Mountain is located west and Moro and Mishu Mountains are located east of the lake. Therefore, the areas located at a height close to the height of the lake and a short distance from the lake have the highest risk. The heights located 250 km from the lake are classified into seven categories, and the map is prepared in a GIS environment.

  4. The most important factor in determining the risk areas against the spread of salt is the prevailing winds that transport dust from the bed of LU. To consider this factor for determining the risk areas, moderate resolution imaging spectrometer satellite imagery and the Hybrid Single-Particle Lagrangian Integrated Trajectory (HYSPLIT) model are used.28 29 Initially, using the Aerosol Optical Depth Index on satellite images, 70 dust storms have been identified in the lake bed. The HYSPLIT model was then implemented for 24 hours for the identified storms. The trajectories were generated in GIS environment and Kernel density was implementated for raster convertion.30 The map is also classified into seven categories, which show the intensity of the impact of dust storms on LU.

  5. In the final step, the above three maps are overlapped using the classified weighted model in the GIS environment and model builder.31 The final map includes seven geographical areas on the shores of LU, which are classified based on the severity of the impact of the spread of salt on LU. To select rural and urban settlements for medical sampling, their location is placed on the final map, and finally, 66 villages are to be selected. Figures 2 and 3 illustrate more details.

Figure 2

Geographical location and topography of Urmia Lake basin.

Figure 3

Different aerosol optical depth classes (left) and distance from Urmia Lake salt marshes (right).

Measurements

General consideration

Various types of measurements are done in three major groups of self declaration, clinical interview, and examination and paraclinical assays. To prevent loss of data validity due to overexposing the participants to a large number of questionnaires and interviewer fatigue the following plan is applied: in each sampling cluster two separate packages are used, a red package and a yellow package, that include 11 common questionnaires in both packages as well as several different questionnaires specific for each package. The questionnaires in the red package are completed by 6 out of 10 households in each cluster and the yellow package is to be completed by 4 households in each cluster.

Details of specific measurements being conducted in this study are as follows:

Self-reported health and health-related issues

In this section, we will represent 26 scales filled out at the participant’s home by trained interviewers. Details of these are given as follows:

Background data and general measurements

Household and Socioeconomic Status (SES) questionnaires provide the required information in this section.

  • The household questionnaire includes questions about the age, sex, literacy, job and insurance situation of the family members. Questions about having a pregnant woman, having a child aged 6 years, having a traffic-injured person, length of stay in the city, use of lake salt, and the history of abortions, stillbirths, and preterm or post-term delivery are also included.

  • SES is used to assess socioeconomic status. It is a 14-item questionnaire and is completed by all households in every cluster and an ultra-short version is also available that could be used.32 33

Asthma and dermatitis

Three questionnaires investigate asthma, allergy, dermatitis and pulmonary risk factors in children aged 6–7 years and 13–14 years and adults over 17 years. The questionnaire for children aged 6–7 years includes four categories and 48 questions. The questionnaire for children aged 13–14 years includes four categories and 39 questions and the questionnaire for adults has 55 questions.

Ophthalmic disease

No separate questionnaire was used for ophthalmic diseases. The necessary information was collected during the clinical interview and examination, with some questions about ophthalmic diseases included in a questionnaire assessing adults over 17 years old.

Psychiatric assessment tools include the following:

  • Adult and child attention deficit hyperactivity disorder (ADHD) tools: The adult ADHD Questionnaire includes 12 questions which are completed by adults over 17 years old and the child ADHD Questionnaire includes 18 questions which is completed by children aged 7–12 years. The ADHD Questionnaires have been previously validated in Persian by Sadeghi-Bazargani et al. 34

  • Patient Health Questionnaire (PHQ): A validated questionnaire with 10 questions to screen depression.35

  • General Health Questionnaire (GHQ): A validated questionnaire with 28 questions. PHQ and GHQ questionnaires are completed by adults over 17 years old in four households in a cluster (yellow package).36

  • Resilience: A questionnaire with 25 questions completed by householders of all households of a cluster.

  • Pittsburgh Sleep Quality Index (PSQI): This questionnaire includes 18 questions that indicate the sleep status of adults over 17 years old in the red package that six households will complete. A short version of the sleep quality questionnaire with eight items is used in present study.37

  • Geriatric Depression Scale (GDS): This is a validated questionnaire for assessing depression and has 15 questions.38 GDS and quality of life questionnaires are completed by old people over 60 years of age in all households of a cluster.

Nutritional status

The frequency of the consumption of various food groups and salt intake are assessed using a valid and reliable tool.39

  • The food insecurity questionnaire includes 13 questions about having enough money for providing food and the amount of some food items purchased by the household.

  • The questionnaire on the use of salt includes 23 questions. The amount of salt used in the diet by a household and their interest in salt are assessed in this questionnaire.

Non-communicable diseases risk factors

A modified Persian version of the WHO STEPS Questionnaire is used. This questionnaire has four categories and 16 items. Fast food consumption, fruit and vegetable consumption, smoking, and leisure-time activities are explored using this instrument.40 This questionnaire will be completed by all adults over 17 years old living in each of the six households (households 1, 2, 3, 8, 9, 10) in every cluster.

Health services utilisation

Use of health system services, satisfaction and trust are three questionnaires in this section.

  • Use of health system services: This includes seven items about health services utilisation and quality of services provided in health centres. This questionnaire will be completed by one in each of the six households (households 1, 2, 3, 8, 9, 10) in every cluster.

  • Satisfaction: This questionnaire has 15 items about the satisfaction with services provided in health centres. This questionnaire will be completed by one in each of the six households in every cluster.

  • Trust: This is a modified questionnaire developed based on a previous tool for public trust in healthcare. The questionnaire includes 43 items on public trust in the government and officials' efforts to mitigate the impact of LU crisis on the health and well-being of the local residents. However, a dimension reduction may be applied through factor analysis. The questionnaire will be completed by a single randomly selected adult living in each of the households (4–7) per cluster.

Other assessments

Other than the tools included in any of the abovementioned categories, seven more questionnaires are also used to assess the health status among the participants as follows:

  • Health Questionnaire EuroQol 5-Dimensions 3-Levels (EQ-5D-3L): This questionnaire is a validated questionnaire and includes five questions. Adults over 17 years old complete this tool and describe their health status.41

  • The questionnaire of assessment of physical health status of the adults over 17 years of age: This questionnaire is completed in all households of a cluster. This questionnaire has four categories and 40 items. The categories include assessment of blood pressure, history of chronic diseases, prevalence of headache and eye problems.

  • The Chest Pain Questionnaire: This has eight questions and evaluates the participant’s chest pain. All adults over 17 years old in the red package will complete this questionnaire.

  • Maternity care: This questionnaire is built based on health ministry standards and has 21 questions about prenatal care, pregnancy situation (wanted or unwanted), history of past pregnancies, pregnancy risk factors, and taking supplements during the pregnancy. All pregnant women living in any of the 10 households in each cluster are enrolled and will complete this questionnaire.

  • Childcare: This questionnaire (based on health ministry standards) has 16 questions about childcare providers and child development monitoring.

  • Self-care: This questionnaire has been previously used in a health complex project in Iran and validated by researchers of the health complex project. The questionnaire will be completed by two adults (a man and a woman) living in each of the four households in the yellow package.

  • Community empowerment: This questionnaire has also been used in a health complex project and validated by researchers of health complex projects. Health system performance in community empowerment and public participation in healthcare are surveyed.

Details of the scales are given in table 2.

Table 2

Description of the scales/questionnaires used in the Lake Urmia Drying Survey on health consequences

Clinical interview and examination

The measurements in this area are through medical examination and interview by medical doctors with at least 2 years of experience in general medical practice at Iran’s health system who participate in a complementary training workshop by clinical specialists and researchers specifically for this project. The past medical history of participants is received through physician interviews and a review of available medical records. Physical examination is done by the physician using a standard tool repeatedly applied in previous national surveys minimally adopted for use in this project. The tool includes 55 items in two categories as followes: history of chronic diseases including 26 items about cardiovascular diseases; respiratory, nervous, gastroentric and urinary systems; as well as the history of diabetes, cancer, eye cataract and allergy. A whole body general examination is also done to be recorded over 26 items.

Paraclinical assessments

In this study, a variety of blood and urine tests are performed. These include complete blood count (CBC), ferritin, fasting blood sugar (FBS), Hemoglobin A1c (HbA1c), cholesterol, Alkaline Phosphatase (ALP), Serum Glutamic Oxaloacetic Transaminase (SGOT), Serum Glutamic Pyruvic Transaminase (SGPT), High-Density Lipoprotein (HDL), Low-Density Lipoprotein (LDL), triglycerides, Erythrocyte Sedimentation Rate (ESR), IgE, sodium and creatinine. The levels of serum Total Cholesterol (TC), Triglycerides (TG), HDL, LDL, ALP, SGOT, SGPT, HbA1c and FBS are measured by an automatic analyser (Mindray autoanalyser Bs 380). An automated counter (Celltac alpha MEK-6510 Nihon Kohden) is applied for measuring CBC. Serum ferritin levels are measured by an ELISA test kit (Unielyza human). ESR level is measured by an ESR analyser.

Urinary salt excretion: The first-morning spot urine sample is collected from the first voided morning urine. The sodium concentration and creatinine levels are measured by an automatic Caretium electrolyte analyser.

Health system data and diseases registry

Although our study measures cancer, its statistical power is low. In this case, we will use the registry system including cancer registry, low birth weight survey registry and death registry.

Patient and public involvement

None.

Discussion

This study is a baseline cross-sectional survey which has a given value in causality investigation. One of the important issues in causality is temporality, and the findings of this study can be compared with the changes in later studies. On the other hand, the dose-response relationship is another issue in the topic of causality that is more debatable in cross-sectional studies. In this case, in our study, we have considered different regions with different risks of exposure. Not only have we considered the distance from the lake but we have also considered other exposures such as the density of airborne particles. It is good to argue that, for example, in the case of mental health, the distance may solely explain the affected health, however, in the case of lung diseases, the role of particles may be more important than the distance. For example, one area may be close to the lake but not in the wind direction, but another area may be farther away from the lake but in the direction of seasonal winds. Other issues such as natural barriers and industrial pollution should also be considered in this regard.

In multidisciplinary areas of health where multiple body systems may be affected by a major catastrophic event such as the LU crisis, depicting a holistic view of health through comprehensive assessments is not only an asset but also a must. While previous similar studies may have not taken a comprehensive look at the issue, this present study has tried to gain its highest accuracy in assessments and a comprehensive view in the evaluation of the effectiveness of this project. Although this strategy has been time-consuming and cost-consuming, it has led to a major national project, and since it has national financial support we can have a more comprehensive view. The comprehensiveness of the study may give rise to some problems such as increasing the number of questionnaires that can reduce the quality of data if not addressed appropriately. Therefore, we categorised the clusters and did not fill all the questionnaires in all households while complying with general standards. Moreover, this has been done with enough time to repeat, if necessary, to minimise these problems.

In this study, we use three types of measurements: clinical examination, self-report and bioassay. The other challenge in this regard is to use validated tools for the setting and language, for assessing the outcomes of interest. Some of the scales used in the present study have been validated and repeatedly used in previous national studies. This makes our measurements reliable and comparable to other studies.

Despite all this, not everything is measurable because it is not cost-effective and is an expensive project for a middle-income country. In some areas, our measurements were complete, but in other areas, we were obliged to restrict the assessment to screening. For example, in assessing ophthalmological problems, the examinations will be done by a trained physician (general practitioner) and this helps to recognise and screen some diseases but there may be a need for complementary studies by clinical specialty physicians such as ophthalmologists or respiratory disease subspecialists.

In the present study, we investigate the effect of LUD on diseases of the cardiovascular, respiratory, nervous, gastroenteric and urinary systems as well as the history of diabetes, cancer, cataract and allergy. Previous studies have shown the effect of lakes’ drying on these diseases, but most of them were small in size or were performed at very old times when there were no current skills and the definitions of the diseases were also different.42–44 Regardless of the limitations of cross-sectional studies, there is one more limitation in studying the association of LUD with cancers. Because the incidence of cancer is much lower compared with other conditions such as respiratory diseases or mental disorders, and the long time between exposure and cancer diagnosis, it is assumed that enough cancer cases cannot be captured within the studied population to be adequate for applying classical statistical tests. Although the application of some statistically powerful methods such as Partial Least Squares (PLS) may be used in the analysis, this may not even be adequate and future or extended research may be needed.

In cases such as asthma, allergies and lung diseases, there may be a higher plausibility for a casual association. Nevertheless, in some areas, this is less likely and the researchers may be satisfied with producing a hypothesis for a casual association rather than determining such an association. Although when it comes to the drying of a big lake with high concentrations of salt the main risk exposure is generally considered to be airborne salt particles, it could be misleading if the role of other particles arising from the dried area is ignored. Particles including heavy metals could be an example of this which may cause diseases such as cancer. Saline dust storms differ from conventional dust storms in terms of the chemical structure and particle size distribution and transfer a dense mass of very fine dust particles containing adsorbed sulfate, chlorides, insecticides and some heavy metals such as manganese, arsenic, rubidium, lead, strontium and chromium.45 46

Ethical issues

The study protocol has been in the regional ethics committees of both East Azerbaijan and West Azerbaijan provinces. In this project, all procedures follow the ethical standards of the Ethics Committee of Tabriz University of Medical Sciences. This manuscript describes the research protocol. Informed consent will be taken from all participants when the protocol is put into action and collection of human data is started.

Dissemination

Results of the present study will be disseminated as follows:

  1. Articles will be published in peer-reviewed international and national journals.

  2. Results will be available as a monograph (in Persian) in limited copies to be used for national policy making.

  3. Results will be provided as a local briefing package for target groups including the general population, local authorities as well as municipal crises management bodies working on LUD.

Ethics statements

Patient consent for publication

Acknowledgments

The authors express their gratitude to the authorities in National Lake Restoration Programme, Tabriz University of Medical Sciences, and Urmia University of Medical Sciences for their collaboration during the project implementation phase. They also acknowledge the participation of individuals from the East Azerbaijan Governor’s office and health network officials.

References

Footnotes

  • Contributors HS-B is the principal investigator for this project. All authors contributed. HS-B, MS, MF, IM and BSS conceptualised the initial study design. OEA as the PhD candidate student wrote the first draft of the manuscript. All the authors including HS-B, MS, MF, IM, BSS, OEA, FP, GM and RE contributed to drafting the work or revising it critically for important intellectual content. BSS and GM contributed to geographical and meteorological planning for the sampling methodology. IM and RE contributed to research activity in West Azerbaijan.

  • Funding The budgeting for data collection is supported both by Tabriz University of Medical Sciences and the Urmia Lake Survival Commission.

  • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographical or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.