Eastern
Mediterranean
Health Journal
Vol. 15 No. 1 January/Janvier
February/Fevrier
La Revue de SantИ
de la MИditerranИe
orientale
2009
?МДгМя?/? ъгДФД гАкгМД?║1 ? гАзоо?║?гЦАлАо гнАгЦс зят?
?щяхгМя?/?тхгь?
Contents
Letter from the Editor. ....................................................................................................................................................4
Research articles
Research in action: mammography utilization following breast cancer awareness campaigns in
Lebanon 2002√05
S.M. Adib, M.A. Sabbah, S. Hlais and P. Hanna...........................................................................................................6
Correction. Knowledge of and attitudes towards HIV/AIDS in Mashhad, Islamic Republic of Iran. ..........18
Cancer patients▓ desire for information: a study in a teaching hospital in Saudi Arabia
A.M. Al-Amri...............................................................................................................................................................19
Environmental exposure to asbestos and the exposure√response relationship with mesothelioma
M.T. Madkour, M.S. El Bokhary, H.I. Awad Allah, A.A. Awad and H.F. Mahmoud....................................................25
Infant exposure to environmental tobacco smoke: Jordan University hospital-based study
E. Badran, A.S. Salhab and M. Al-Jaghbir.................................................................................................................39
Evaluation of an educational intervention for farming families to protect their children from
pesticide exposure
T.M. Farahat, F.M. Farahat and A.A. Michael...........................................................................................................47
Injury epidemiology in Kermanshah: the National Trauma Project in Islamic Republic of Iran
M. Karbakhsh, N.S. Zandi, M. Roozrokh and M.R. Zarei...........................................................................................57
National Survey of Prevalence of Mental Disorders in Egypt: preliminary survey
M. Ghanem, M. Gadallah, F.A. Meky, S. Mourad and G. El-Kholy...........................................................................65
Direct estimation of life expectancy in the Islamic Republic of Iran in 2003
F. Pourmalek, F. Abolhassani, M. Naghavi, K. Mohammad, R. Majdzadeh, K.Holakouie Naeini and A. Fotouhi...76
Could the MMR vaccine replace the measles vaccine at one year of age in Egypt?
A.A. Abbassy, S.S. Barakat, M.M. Abd El Fattah, Z.N. Said and H.A. El Metwally...................................................85
Distinguishing between primary infection and reinfection with rubella vaccine virus by IgG avidity
assay in pregnant women
R. Hamkar, S. Jalilvand, M.H. Abdolbaghi, K.N. Jelyani, A. Esteghamati, A. Hagh-goo, T. Mohktari-Azad and
R. Nategh....................................................................................................................................................................94
Hygiene practices and sexual activity associated with urinary tract infection in pregnant women
F.N. Amiri, M.H. Rooshan, M.H. Ahmady and M.J. Soliamani................................................................................104
Training on the Practical Approach to Lung Health: effect on drug prescribing in PHC settings
in Jordan
K. Abu Rumman, S. Ottmani, N. Abu Sabra, S. Baghdadi, A. Seita and L. Blanc.................................................... 111
Antimalarial prescribing and dispensing practices in health centres of Khartoum state,
Sudan, 2003√04
A.A. Mannan, E.M. Malik and K.M. Ali...................................................................................................................122
Seroprevalence of Helicobacter pylori in Nahavand: a population based study
A.H.M. Alizadeh, S. Ansari, M. Ranjbar, H.M. Shalmani, M. Habibi, M. Firouzi and M.R. Zali............................129
Seroepidemiology of hepatitis E virus infection in 2√25-year-olds in Sari district, Islamic
Republic of Iran
M.J. Saffar, R. Farhadi, A. Ajami, A.R. Khalilian, F. Babamahmodi and H. Saffar.................................................136
Neurobrucellosis: report of a rare disease in 20 Iranian patients referred to a tertiary hospital
M. Ranjbar, A.A. Rezaiee, S.H. Hashemi and S. Mehdipour....................................................................................143
Characterization of Bacillus anthracis spores isolates from soil by biochemical and multiplex
PCR analysis
F. Vahedi, Gh. Moazeni Jula, M. Kianizadeh and M. Mahmoudi . ..........................................................................149
Prevalence of coronary heart disease among Tehran adults: Tehran Lipid and Glucose Study
F. Hadaegh, H. Harati, A. Ghanbarian and F. Azizi.................................................................................................157
PrИvalence de la rhinite allergique en milieu rural Ю Settat (Maroc)
S. El Kettani, B. Lotfi et A. Aichane..........................................................................................................................167
Significant caries index values and related factors in 5√6-year-old children in Istanbul, Turkey
N. Namal, A.A. YЭceokur and G. Can.......................................................................................................................178
Self-reported needle-stick injuries among dentists in north Jordan
Y. Khader, S. Burgan and Z. Amarin.........................................................................................................................185
Job satisfaction and burnout among Palestinian nurses
L. Abushaikha and H. Saca-Hazboun.......................................................................................................................190
?Дыяи Дгчои ЦАчяягй гААши гАзяхМи ъемоЛ ЦьАФхгй гАйзАМЦ гАзгМА Мщ ъАМгй гАзАФЦ гАумМи хлгЦзи глАрМяи?
? зЦя гАсМо гАьМх гАзхгс?║? сЦяМи мгЦо зхо гАяЦмД?║?цЦмо зхо гЕАА мЦЦогМД?.......................................................................198
Report
Epidemiological transition of some diseases in Oman: a situational analysis
S.S. Ganguly, M.A. Al-Shafaee, J.A. Al-Lawati, P.K. Dutta and K.K. Duttagupta....................................................209
Short communications
Microbial contamination in the operating theatre: a study in a hospital in Baghdad
S. Ensayef, S. Al-Shalchi and M. Sabbar..................................................................................................................219
Study of aerobic granulocyte functional activity in the presence of a radiosensitizer (metronidazole)
E.A.A. Al-Krawi and A.H.M. Al-Hashimi.................................................................................................................224
Case reports
Diffuse myelitis in a 9-month-old infant: case report and review of the literature
O. HЭdaoglu, U. Yis, S. Kurul, H. ?akmakГi, M. Saygi and E. Dirik.......................................................................230
Oral contraceptive pills and inherited thrombophilia in a young woman with deep venous thrombosis
R.A.R. Mahfouz, Z.K. Otrock, M.A. Ghasham, A.S. Sabbagh, A.T. Taher and A. Bazarbachi..................................235
Obituary.........................................................................................................................................................................239
Eastern Mediterranean health journal reviewers▓ panel, 2008. .........................................................................241
Guidelines for authors.................................................................................................................................................245
WHO sales and discount policy................................................................................................................................251
Eastern Mediterranean Health Journal
M. Haytham Khayat MD, FRSH, Editor-in-chief
Mohammad Afzal MSc, MPhil, PhD, Executive Editor
Editorial Board
Ibrahim M. Abdel Rahim MBBS, MPH&TM, MRCP
Houssain Abouzaid MS (Chem Eng), MS (Sanit Eng), DrS
Zuhair Hallaj MD, DPH, DrPH
Mohamed Hussein M. Khalil MD, MPH, PhD (Biostat)
Haifa Madi MD, MPH
Belgacem Sabri MD, MPA, MA (Econ)
Abdel Aziz Saleh Dip (Hosp Pharm), Dip (Indus Pharm), PhD
Kassem Sara MD, MAM
Anna Verster MBBS, Dip Nutr
M. Helmy Wahdan MD, DPH, PhD
International Advisory Panel
Dr S. Aboulazm. Professor of Orthodontics. Egypt
Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary
FRCM, Ireland, Honorary Dr. Law, Korea, Honorary
FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait
Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain
Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of
Medicine and Consultant Cardiologist. Saudi Arabia
Dr Ala▓din Alwan MD, FRCP, FFPHM. Iraq
Dr F. Azizi. Professor of Internal Medicine and
Endocrinology. Islamic Republic of Iran
Dr K. Bagchi BSc, MD, PhD. India
Professor K. Dawson BA, MD, PhD, FRCP, FRACP,
FRCPCH, DObst, RCOG. New Zealand
Professor Kaussay Dellagi MD. Tunisia
Dr R. Dybkaer MD. Denmark
Dr M. Aziz El-Matri. Professor of Medicine. Tunisia
Professor F. El-Sabban BSc, MS, PhD. United States of
America
Dr A.H. El-Shaarawi MSc (Stat), PhD?(Stat). Canada
Professor N. Fikri-Benbrahim PhD (Pub health)
(SocSci). Morocco
Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC,
FRPharmS, FRSE. United Kingdom
Professor Cheherezade M.K. Ghazi BS (Nursing), MS
(Nursing), DPH, MPA. Egypt
Professor M.A. Ghoneim MD, MD (Hons). Egypt
Dr J.A. Hashmi DTM&H, FRCP. Pakistan
Professor J. Jervell MD, PhD. Norway
Professor G.J. Johnson MA, MD, BChir, FRCS (C),
FRCOphth, DCEH. United Kingdom
Dr M. Kassas. Emeritus Professor of Plant Ecology.
Egypt
Professor M.M. Legnain MBBS, MRCOG, FRCOG.
Libyan Arab Jamahiriya
Professor El-Sheikh Mahgoub DipBact, PhD, MD,
FRCPath. Sudan
Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH.
Egypt
Professor A.B. Miller MB, FRCP. Canada
Professor S.S. Najjar MD. Lebanon
Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can),
FRCP FRCPath (UK). Republic of Yemen
Professor O.S.E. Rasslan MD, PhD. Egypt
Professor W.A. ReinkИ MBA, PhD. United States of
America
Professor I.A. Sallam, MD, Dip High Surgery Cairo,
Honorary FRCS, PhD (Glasgow), LRCP, MRCS,
FRCS (London), ECFMG. Egypt
Dr C.Th.S. Sibinga FRCP (Edin), FRCPath.
The?Netherlands
Mr Taoufik Zeribi Eng BSc, MSc. Tunisia
Editorial: Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet
4
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009
Letter from the Editor
It is with regret that we say farewell to Dr Ahmed Ezzat Abdou who has retired
as Executive Editor of EMHJ, a position he has held since 2003. Under Dr Abdou▓s tenure the journal has prospered. The long-standing delay in timeliness was
overcome in 2006, and the Journal returned to publishing 6 single issues per year.
In addition, EMHJ also witnessed a large increase in the number of submissions,
from around 300 in 2003 to over 700 in 2008, indicating its rising popularity. We
would like to express our sincere gratitude to Dr Abdou for his valuable contribution to the EMHJ and to extend to him our very best wishes.
It is with great pleasure that we welcome Dr Mohammad Afzal from Pakistan
as Executive Editor, who brings a wealth of knowledge and experience in the field
of scientific research and publication. We look forward to the further success of
EMHJ in the very capable hands of Dr Afzal.
February 4 marks the occasion of World Cancer Day when the World Health
Organization (WHO) joins with the International Union Against Cancer to raise
awareness of the burden of cancer and promote activities to prevent cancer, improve diagnosis and treatment, and enhance the quality of life of those suffering
from the disease.
Cancer is a leading cause of death around the world and unsurprisingly a diagnosis of cancer instills great fear universally. However, it is estimated that over
40% of all cancer is preventable and with early diagnosis and treatment a number
of the commonest cancers are curable.
According to WHO mortality estimates, cancer ranks fourth as a cause of death
in the Eastern Mediterranean Region (EMR) and is responsible for 272 000 deaths
each year. Of more concern is the estimate that EMR will have a 100% to 180%
increase in cancer incidence in the next 15 years, the largest of any of the WHO
regions. As part of its efforts to assist Member States address this critical issue, in
December 2008 the WHO Regional Office for the Eastern Mediterranean launched
the Regional Cancer Control Strategy at a meeting jointly organized by WHO, the
International Network for Cancer Treatment and Research and the Lalla Salma
Association Against Cancer.
Included in this issue of EMHJ are four papers that examine several important
aspects of cancer: mammography screening for breast cancer in Lebanon; the
opinion of Saudi Arabian cancer patients about how much they wish to know
about their condition; the prevalence of mesothelioma due to occupational and
environmental exposure to asbestos in Egypt; and the prevalence of environmental
exposure of Jordanian infants to tobacco smoke. These papers provide valuable
information on the current situation in these countries, and also highlight the need
for further research and intensified effort to tackle cancer throughout the Region.
As usual in the first issue of the year, the names of our esteemed reviewers for
2008 are included at the end of the issue. We would like to extend to them our deepest
thanks for their invaluable help in evaluating manuscripts submitted to the Journal.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
??Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009??
??5??
?ясгАи ЦД гЦАмяя?
?гЦАмяя гАйДщМпМ ААЦлАи гАумМи?
?Мзр зАМДг йФоМз гАоъйФя цЦмо зрй гАпМ бкя цД Мйчгзо ЦД ЦДух?
?ъЦ УЬ?
?Ь?
?Аятч гЦАйФсь? ║?ФЕФ гЦАДух гАпМ йч ЬАоЕ ЦДп згЦ ? .2003?ФЦДп пАъ гАФчй тЕой гЦАлАи гроЕгягП?
?ЦАмФы Пг? .?щйЦ Мщ згЦ ? 2006?гАйш УЬАх зЛА Цг зЕоДгЕ ЦД УЬ?
?йцня Мщ йФчМй геАуогя? ║?Фгсйзгой гЦАлАи сгхч?
?зЕоЕг хДят сйи еуогягй щяоМи сДФМ Пг? .?ъгЦ тЕой гЦАлАи гАумМи Аятч гЦАйФсь рМгои ъхяМи Мщ зоо?
?гцАФягч гАхмкМи гЦАчоСЬ Ци АйрМо ЦД ? 300?Фячи Мщ згЦ ? 2003?еЛА Цг МяхФ зЛА ? 700?Фячи Мщ згЦ ? ║2008?ЦЦг МтяМ?
?гАчМЦи Мщ?
?еЛА рМгои тзхМйЕг? .?ФМсзоДг цД ДйчоСЬ Ц хнгАу гАтъя ФгАйчоМя ААоъйФя зрй зЛА есЕгЦгйЕ Ь?
?гЦАлАи ЦйЦ ЬДДМ АЕ ъА гАйФщМч?.??
?ъгЦ МьМх АДг цД Дямх гАМФЦ хгАоъйФя мЦЦо цщжА? ║?ЦД хгъсйгД? ║?гАпМ нАщ гАоъйФя зрй Мщ?
?ЦДух гЦАмяя гАйДщМпМ? .?ФгАоъйФя цщжА нМйрД Мщ цзгЦчЕ щМж Пг ЦД ъДФр гЦАзящи ФгнАяхи гАФгсзи Мщ лЦгА?
?гАхмк гАзАЦМ ФгАДят? .?ФеДДг Дйь СЬАз еЛА емягр гЦАлАи гАумМи Аятч гЦАйФсь гЦАрМо ЦД гАДлгм зЛА цМоМ?
?гАоъйФя цщжА?.??
?ДмйщА МФЦ ? 4?тхгь?/?щяхгМя ЦД ъА згЦ хгАМФЦ гАзгЦАМ ЦАъгщми гАясьгД? ║?ФгАпМ МтЕо Епг гАзгЦ?
?йзгФД ЦДыЦи гАуми гАзгЦАМи Цз ггАмйго гАоФМА ЦАъгщми гАясьгД УхшЗ СМи епъга гАФзМ хзха гАясьгД?║??
?ФйзрМр цДтьи гАФчгМи ЦДЕ? ║?ФмйсДМ Ус УхА гАйтнМу ФгЦАзглАи? ║?ФйзрМр мМги ЦД МзгДФД ЦД Епг гАога?
?гАФхМА?.??
?щгАясьгД ЦД гцАсхгх гАяфМсМи гЦАщжМи еЛА гАФщги Мщ ъА цДмга гАзгЦА? ║?щгА шяФ цД Мхзк йтнМу?
?гАясьгД нЦгФщ тоМои зЛА ЦсйФЛ гАзгЦА? .?ФеД ъгД Цг МяхФ зЛА ? %40?ЦД ЦлМз мггАй гАясьгД МЦъД?
?йФ ЬчМЕг? ║?хА МЦъД гАтщга ЦД зоо ЦД цъкя цДФгз гАясьгД тМФз Пг хщжА гАйтнМу ФгЦАзглАи гЦАхъяи?.??
?ФФщч Пг АйчоМягй ЦДыЦи гАуми гАзгЦАМи ААФщМгй? ║?МцМй гАясьгД Мщ гЦАяйхи гАягхзи ЦД цсхгх гАФщМгй?
?Мщ ечАМЦ ятч гЦАйФсь? ║?ФЕФ гЦАсдФА зД ФчФз ? 272 000?Фщги сДФМ Пг? .?ФЦЦг МозФ ААЦрМо ЦД гАчАч цД?
?ечАМЦ ятч гЦАйФсь тЕо цъях рМгои хДМ цчгАМЦ гЦАДыЦи Мщ мггАй ФчФз гАясьгД Айэяйщз ЦД ? %100?еЛА?
?? %180?Мщ шжФД гАсДФгй гнАЦс зяти гАчгоЦи? .?ФМщ еьгя лЕФоЕ гЦАхпФАи ЦАсгзои гАоФА гцАзжга зЛА?
?гАйзгьМ Цз ЕпЕ гАчжМи гАхгАши гцАЦЕМи? ║?ФйзрМр чояЕйг зЛА гАйуоЬ М ЦАяж гАясьгД? ║?чгЦ Цъйх ЦДыЦи?
?гАуми гАзгЦАМи геАчАМЦМ Аятч гЦАйФсь хеьгАч ггАсйэягйМлМи геАчАМЦМи ЦАъгщми гАясьгД ФпАъ нгАА?
?ггАлйгЦз гЦАтйэяъ гАпМ зчойЕ ЦДыЦи гАуми гАзгЦАМи? ║?хгАйзгФД Цз гАтхъи гАоФАМи АхмФк ФЦзглАи?
?гАясьгД? ║?ФЦлзМи АгА сАЦЛ ЦАмгяхи гАясьгД?.??
?ФМйжЦД Епг гАзоо ЦД гЦАлАи гАумМи Аятч гЦАйФсь цяхз Фячгй йэйДгФА гАзоМо ЦД глАФгДх гЦАЕЦи?
?СЬ?
?ААясьгД? :?йуФМя гАкоМ гАтзгзМ мАггАй ясьгД гАкоМ Мщ АхДгД╨ Фбяга ЦяЛж гАясьгД гАсзФоМэДМ?
?мФА ъЦМи гЦАзАФЦгй гАйМ МяшхФД Мщ ЦзящйЕг зД мгАйЕЦ╨ ФЦзоСЬ А гДйтгя ФяЦ гЦАйФсьи гАДглЦ зД?
?гАйзяж гАхМфМ цАьщгА гцАяоД АонгД гАйхш?.??
?гАйзяж гЦАЕДМ ФгАхМфМ АгАсхсй Мщ Цяу ФЦзоСЬ А гДйтгя УЬ?
?УЬ?
?ФйчоЖЬ Ц ЕпЕ гАФячгй гАхмкМи ЦзАФЦгй ЬчМЦи зД гАФжз гАягЕД Мщ ЕпЕ гАхАогД? ║?ъгЦ ЖЬ?
?йФжм гмАгли еЛА?
?еляга гЦАрМо ЦД гАхмФк ФйъкМщ глАЕФо ЦАъгщми гАясьгД Мщ ъА цДмга геАчАМЦ?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
6
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Research in action: mammography
utilization following breast cancer
awareness campaigns in Lebanon
2002√05
S.M. Adib,1 M.A. Sabbah,1 S. Hlais1 and P. Hanna2
? хмк ЦМогМД?:2005 √ 2002 ?гсйногЦ йуФМя гАкоМ гАтзгзМ зчх ЦмгАй гАйФзМи мФА ясьгД гАкоМ Мщ АхДгД?
? хгшМ мДг?║? сДМ мАМс?║? мЦЦо ухСЬгм?║?сАМЦ цоМх?
? еЦяци Мщ сМгч гмАЦгАй гАФьДМи ААйФзМи?1200 ?Сй Мщ АхДгД цяхзи ЦсФмгй Цйзгчхи тЦА ъА ЦДЕг?
З ? цляМ?:?гнАгАуэи?
? ФпАъ АчМгс ЦзоСЬ А гДйтгя гсйногЦ гАйуФМя гАтзгзМ ААкоМ?║2005 ? еЛА?2002 ?мФА ясьгД гАкоМ Мщ гцАзФгЦ?
? Фчо ъгД гсйногЦ?.? ФеААчга гАжФа зЛА ггАнйгАщгй гАоМЦФшягщМи ФгеАчАМЦМи?║?ФААйзяУЬ щ зЛА цкя ЕпЕ гмАЦгАй?
%11 ?йуФМя гАкоМ ЦДнщж Пг Мщ гАтЕФя геАкДМ зяти гАсгхчи кЦ грого рМгои ьщМщи щчь зЛА ЦоЛ гАсДФгй гцАяхз (ЦД?
? ъгЦ ФуА?║?) ФЕФ Жжзщг Цг ЕФ зАМЕ Мщ гЦАДгьч гАяМщМи?%25( ? цухм Мщ хяМФй гАъяхЛ?2005 ? ФМщ ЦмАи згЦ?.)%18 ?еЛА?
?) цФ цъях?%12( ? хгЦАчгяДи Цз гАДсга гААФгМй ЕДЬ цушя сД Пг?% 21 ? згЦ Пг еЛА?49? Ф?40 ?АоЛ гАДсга гААФгМй ййэягФм цзгЦяЕД хДМ?
.? ФМщ ъА ЦФли Мухм йъягя гАйуФМя гАтзгзМ ААкоМ цчА тМФз Пг ЦЦг ъгД зАМЕ Мщ гАймяЬ М ААЦяи гцАФЛА?.)%11( ?сД Пг?
ABSTRACT Four consecutive annual surveys of 1200 women each were conducted in Lebanon in connection with the National Breast Cancer Awareness campaigns (2002√05) to measure the prevalence of
mammography utilization and the impact of these campaigns, and to highlight regional and demographic
differences. The utilization of mammography in the previous 12 months was low and increased only slightly over 4 years (from 11% to 18%). In the 2005 campaign, it was twice as high (25%) in greater Beirut than
in mostly rural areas, and among women aged 40√59 years (about 21%) compared with younger (12%) or
older (11%) women. In each wave, repeat mammograms were less common than first time screening.
Utilisation de la mammographie suite aux campagnes d▓information sur le cancer du sein au Liban
en 2002√2005 : la recherche en marche
R?SUM? Quatre enquЙtes annuelles consИcutives ont ИtИ rИalisИes auprХs de 1 200 femmes chacune,
au Liban, dans le cadre des campagnes nationales d▓information sur le cancer du sein (2002√2005)
afin de mesurer la prИvalence de l▓utilisation de la mammographie et l▓impact de ces campagnes, et
de mettre en lumiХre les diffИrences rИgionales et dИmographiques. L▓utilisation de la mammographie
au cours des 12 mois prИcИdents Иtait faible et n▓a augmentИ que lИgХrement pendant les quatre
annИes (de 11 % Ю 18 %). Pendant la campagne de 2005, elle Иtait deux fois plus ИlevИe (25 %) dans
l▓agglomИration de Beyrouth que dans les zones Ю dominante rurale, et chez les femmes БgИes de
40 Ю 59 ans (environ 21 %) que chez les femmes plus jeunes (12 %) ou plus БgИes (11 %). ? chaque
vague de campagne, les mammographies de contrТle Иtaient moins frИquentes que les premiХres
mammographies de dИpistage.
Family Medicine Program, Faculty of Medicine, UniversitИ Saint-Joseph, Beirut, Lebanon (Correspondence to
S.M. Adib: salim.adib@usj.edu.lb).
2
Ministry of Public Health, Beirut, Lebanon.
Received: 03/01/08; accepted: 27/03/08.
1
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Breast cancer is the most common non-skin
malignancy among women in Lebanon, as it
is in the whole world. For the past 50 years,
it has topped the list of cancers among
women [1√3]. About 1 in every 4 cancers in
Lebanon is breast cancer: age-adjusted incidence is currently estimated at 76 new cases
per 100═000 [4]. Because of concern about
the importance of improving prognosis by
diagnosing breast cancer in earlier stages,
many community campaigns have emerged
throughout the world with the aim of increasing uptake of screening by mammography. National levels of mammography
utilization for breast cancer screening in the
Lebanese population are unavailable.
In 2002, the Ministry of Public Health
(MOPH) in Lebanon started organizing
annual breast cancer awareness campaigns
around the time of the International Breast
Cancer Month in October. MOPH has
involved the private sector and various
health and academic centres in planning,
implementing and evaluating these awareness campaigns, which rely heavily on the
media. The 2003√05 campaigns included
a component to assess their impact. In
this study, data obtained from these crosssectional surveys are analysed and discussed.
These are the 1st multi-regional findings on
breast cancer screening ever published in
Lebanon. They mark a turning point in
public health in the recent years to tackle
the issue of cancer prevention seriously and
openly, and to evaluate all public health
interventions to optimize their effects.
The main objectives of this action research were: to measure the prevalence of
mammography utilization among women in
Lebanon; to assess the impact of campaigns
in prompting women to obtain a mammography; and to highlight regional and
demographic differences requiring specific
approaches in future campaigns.
7
Background to the study: the
campaigns
The central message of the breast cancer
awareness campaigns was the promotion of
annual mammography screenings among
asymptomatic women aged 40 years or older in order to detect incident cancers at the
earliest possible stage and thus to improve
the prognosis. All public communications
stressed that for breast cancer detected early
there was a greater than 90% chance of full
recovery.
Screening mammographies are rarely
reimbursed by third-party payers in Lebanon, forcing physicians to declare the
test for diagnostic purposes. In order to
facilitate women in obtaining a mammography, MOPH negotiated a discount price
of 40═000 Lebanese pounds (about US$
27) or less during the campaign month
with about 160 centres: hospitals, primary
care centres and private laboratories. Participating centres were listed by region on
pamphlets widely distributed in locations
such as pharmacies, waiting rooms, salons
and supermarkets. These pamphlets also
included frequently asked questions and
answers on breast cancer risk factors, signs,
detection and prognosis.
An educational compact disk with a
standard presentation was also prepared
which health care providers could use for
lectures and presentations in community
centres and social clubs. The campaigns
also included street signs, billboards and
pink ribbons, television and radio advertisements and television talk shows. Starting
with the 2005 campaign, cell-phone companies sent out brief advertisements free-ofcharge via messages to mobile telephones,
and campaign banners were included on the
homepages of the major Lebanese Internet
service providers. The 2006 campaign could
not be implemented as a result of the Israel√
Lebanon war during the summer of 2006.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
8
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
The 2003√05 campaigns included impact
assessment components. In September 2003
a pre-campaign survey (S1) was conducted
in 5 mostly rural areas outside greater Beirut, which included the city of Beirut and its
suburbs, to assess any possible long-term
effect from the October 2002 campaign. A
post-2003 campaign survey was conducted
in the same areas in January 2004 (S2). Two
other surveys were conducted in January
2005 and 2006 (S3 and S4) to evaluate
the previous year▓s campaigns. Since the
activities of the campaigns were inevitably
highly concentrated in the greater Beirut
area, organizers were initially most interested in assessing the impact in relatively
distant regions. Consequently, the 2002 and
2003 surveys did not include samples from
greater Beirut. Later, data from the greater
Beirut area were deemed equally important,
if only for comparison. Thus the 2004 and
2005 surveys added samples of women
from Beirut city and suburbs to those from
5 other rural districts.
Methods
Study design and target population
Cross-sectional sample surveys were conducted between 2003 and 2005 targeting
adult women selected in small towns and
villages in 5 mostly rural districts (cazas) in
Lebanon. These rural cazas were selected
for their particular sociocultural characteristics: Akkar and Batroun in north Lebanon,
Chouf in the central Mount Lebanon area,
Sour (Tyre) in south Lebanon and Zahleh in
the eastern inner Bekaa valley.
Sampling procedures
The selection of participants was performed
using a cluster sampling technique. Blocks
were randomly selected from detailed maps,
and buildings selected from within those
blocks. Interviewers then went to those
buildings (⌠cluster units■) and canvassed
women door-to-door. Questionnaires were
completed with consenting women who
fitted the inclusion criteria: age 40+ years
(in surveys S1 and S2) or age 35+ years (in
surveys S3√S5) and residing permanently in
the area for more than 1 year.
Selected clusters were canvassed consecutively until the target number of respondents was obtained. These procedures
were systematically applied in all waves,
and in all locations, including Beirut and
suburbs after 2004.
Instruments
A structured questionnaire was developed
and tested. It included several sociodemographic questions in addition to questions
regarding women▓s perceptions about breast
cancer, the advantages of and obstacles to
obtaining a mammography, and reactions
to various components of the campaign. A
preliminary survey using this questionnaire
was conducted for survey S1, prior to the
campaign of 2003, among 1200 women
selected in the same areas and in the same
manner described above. Experience acquired in that preliminary survey was used
as a pilot test to improve the flow and clarity
of the questionnaire.
At the time of the visit, the aim of the
survey was explained to the eligible woman,
and her free verbal consent to participate
was obtained. When a woman refused to
participate, interviewers moved on to her
neighbours in the next household within
the same cluster unit. The questionnaire
was completed in a face-to-face interview
conducted with the woman at home, in the
mornings and afternoons. Slight changes
were introduced in later waves in light of
experience acquired in the field and evolving action research questions.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Statistical analysis
In this descriptive analysis, all categorical
variables were tabulated as frequencies and
percentages and continuous variables as
means, standard deviations (SD) and ranges. Prevalence rates were presented with
their 95% confidence intervals (CI) :
The total prevalence was not weighted
in proportion to the regional components,
to avoid the impression that this may be a
⌠national■ prevalence figure. Indeed, this
could have been possible had the sampling
extended to the entire national territory.
However, for the purpose of this action
research evaluation analysis, an expertdetermined sampling of specific areas was
judged sufficient. Nevertheless, in view of
the large proportion of the population which
actually lives in the sampled areas, it is very
likely that total prevalence rates found here
are good estimates of the national figure.
On the other hand, the validity of findings
within each region is much more solid, as
sampling within areas was conducted using
a strict cluster random technique.
Comparisons of specific outcomes
such as mammography utilization were
performed by region and age group. These
were tested using the Student t-test and its
derivatives, chi-squared, Fisher exact test or
z-test, depending on the situation. Comparisons with P-value ? 0.05 were considered
statistically significant. All analyses were
conducted using SPSS-PC, complemented
when needed by the Stat-Calc function of
Epi-Info, version 6.
Results
Sociodemographic characteristics
The first 2 surveys were conducted with
1200 women drawn from 5 rural areas not
contiguous with greater Beirut. Starting
with S3, the same total sample was selected
9
from those districts as well as from Beirut
city and suburbs. In S1, the mean age of the
group was 50 (SD 11) years, range 40√87
years (Table 1). The mean age at menarche
was 13.1 (SD 1.5) years. The mean age at
marriage was 20 (SD 5) years, range 9√49
years. The mean number of children was 4.1
(SD 2.8), range 0√22. The mean crowding
index, an indicator of socioeconomic status
(SES) [5], was 1.9 (SD 1.4) persons/room
in the family household, range 0.17√13.
A level of crowding of 1 person/room is
generally considered as indicating middle
class SES; higher levels are associated with
lower SES. The skewed distribution of the
crowding index prompted us to consider
using the median instead of the mean in all
later considerations of this variable. When
medians are considered, the selected groups
at each wave and in each region tended
towards the middle-class level of 1 person/
room. Of surveyed women, only 20% had
employment outside the home.
The 1200 women participating in the
second survey (S2) did not differ on most
sociodemographic variables from those
surveyed in S1. The proportion of working
women rose to 26%, which may have improved the median crowding index, which
fell to 1.2, indicating better SES. The mean
age of participants, age at menarche, age
at first marriage and number of children
did not vary in a significant way in any
subsequent wave. The inclusion of women
from greater Beirut resulted in an increase
in the proportion of working women, with
a concomitant lowering of the crowding
index.
Mammography utilization
The proportion of women who had obtained a mammography in the previous 12
months varied between areas, and between
years (Table 2). Few consistent trends were
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
160
160
S3
S4
200
160
160
S2
S3
S4
160
160
S3
S4
399
160
160
S2
S3
S4
200
200
160
160
S1
S2
S3
S4
Sour
398
S1
Zahleh
199
200
S1
S2
Chouf
200
S1
Batroun
200
200
S1
n
51.0 (11.2)
45.4 (10.0)
50.1 (10.2)
50.0 (10.0)
50.0 (11.2)
44.9 (9.9)
48.9 (9.7)
48.4 (10.4)
50.0 (11.4)
48.9 (12.4)
51.5 (11.0)
53.2 (11.8)
52.2 (11.6)
50.6 (12.2)
52.2 (12.0)
49.5 (10.4)
47.0 (11.5)
46.3 (12.0)
51.3 (11.0)
51.0 (12.0)
Mean (SD)
Age (years)
S2
Akkar
Area/survey
160
160
196
199
160
159
396
384
159
158
199
200
159
160
199
199
160
160
198
193
n
13.0 (1.3)
13.2 (1.3)
13.3 (1.6)
12.9 (1.5)
13.0 (1.3)
12.6 (1.1)
13.4 (1.5)
13.5 (1.5)
13.0 (1.3)
13.4 (1.5)
13.2 (1.4)
13.3 (1.5)
13.2 (1.7)
13.4 (1.7)
13.1 (1.9)
12.9 (1.6)
13.0 (1.7)
13.3 (1.7)
13.3 (1.4)
12.8 (1.3)
Mean (SD)
Age at menarche
(years)
146
144
189
16
132
129
370
354
133
143
184
179
136
142
184
173
132
140
180
192
n
18.9 (4.4)
19.7 (5.2)
19.8 (5.4)
20.8 (5.7)
20.4 (4.5)
19.5 (3.7)
19.9 (6.4)
19.3 (4.5)
20.5 (5.3)
20.6 (5.0)
20.7 (4.6)
20.4 (4.8)
22.1 (5.2)
22.4 (5.0)
21.1 (5.0)
21.0 (5.3)
20.5 (4.5)
20.3 (4.9)
19.2 (3.9)
19.0 (4.6)
Mean (SD)
Age at first
marriage (years)
Table 1 Personal characteristics of women in 4 consecutive surveys (2003√06)
146
144
190
185
132
129
367
383
133
143
188
197
136
142
181
179
132
140
179
197
n
5.1 (2.6)
4.7 (2.4)
4.9 (3.0)
3.6 (2.6)
4.2 (2.4)
3.8 (2.0)
4.7 (2.7)
4.7 (3.2)
3.7 (2.6)
3.5 (2.1)
3.8 (2.3)
3.2 (2.2)
3.8 (1.9)
3.5 (2.2)
3.7 (1.8)
3.4 (2.0)
4.4 (2.6)
5.0 (3.4)
4.9 (2.7)
5.0 (2.8)
Mean (SD)
No. of children
150
160
200
192
157
160
398
390
160
160
200
199
159
160
197
193
160
156
199
196
No.
0.8
1.2
1.2
1.0
1.0
1.0
1.2
1.5
1.0
1.0
1.0
2.0
1.0
1.0
1.2
1.2
1.3
0.9
1.4
2.0
Mediana
Crowding index
(no. of persons/
room)
34
38
55
51
35
40
56
43
56
72
64
43
51
84
79
59
53
31
62
39
No.
21.4
23.8
27.5
26.0
22.0
25.0
14.2
11.1
35.2
45.0
32.2
21.5
32.1
52.5
39.5
32.0
33.1
19.4
31.5
20.0
%
Ever worked
outside the
house
10
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Figures for the median have been substituted to those of means for this particular variable because of the presence of a few outliers skewing the overall
distribution.
S1 = September 2003 survey; S2 = January 2004 survey; S3 = January 2005 survey; S4 = January 2006 survey.
n = number of women sampled; n/a = no sample taken.
39.5
32.5
a
65
79
1.0
1.0
200
200
3.5 (2.1)
4.0 (2.1)
177
177
21.2 (5.2)
20.7 (4.5)
177
12.7 (1.6)
200
200
S3
S4
12.7 (1.5)
198
199
51.9 (12.0)
53.2 (10.7)
177
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Administrative
Beirut
S1
S2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
%
No.
Mediana
n
Mean (SD)
n
Mean (SD)
n
Mean (SD)
n
n
Mean (SD)
No. of children
Age at first
marriage (years)
Age at menarche
(years)
Age (years)
Area/survey
Table 1 Personal characteristics of women in 4 consecutive surveys (2002√06) (concluded)
Crowding index
(no. of persons/
room)
Ever worked
outside the
house
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
11
detected. Overall, the prevalence of utilization increased between surveys S1 and S4,
but such a trend may be largely attributable
to the inclusion of subgroups from Beirut
city and suburbs. Detailed comparisons in
surveys S3 and S4 indicated that the rate
of mammography use among women in
greater Beirut was almost twice as high as
among women from outside. In most cases,
utilization results fluctuated, except for the
Chouf area where they remained relatively
low (about 10%) across all 4 waves. In
survey S2, utilization was the lowest in the
Zahleh, Sour and Chouf districts (9% to
10%). It was 22% in the Batroun area, and
was the highest (29%) in Akkar. In contrast, in survey S4, utilization was lowest in
Akkar (6%). It was 12% in Chouf, 16% in
Zahleh and Sour and 20% in Batroun. The
highest levels were noted in Beirut city and
suburbs (25%).
At all waves, among women who had
done a mammography in the previous 12
months, a large proportion had obtained it
for the first time in their life (Table 2). The
proportions ranged from a low of 43.6%
(survey S3) to a high of 66.7% (survey S4).
No data were obtained from survey S1.
Increasing trends for first-ever utilization
could be found over time in almost all areas
surveyed. The proportion of first-time users
was consistently higher among women in
the regions compared to those from Beirut
city and suburbs (Table 2).
Mammography utilization by age
At any single wave, utilization was low, but
less so among women aged 40√59 years than
among younger or older ones. In particular,
in survey S4, significantly lower rates of utilization were found among women aged < 35
years (12.4%) or 60+ years (11.4%), while
significantly higher proportions were found
among women aged 40√49 years (21.8%)
and 50√59 years (21.5%). No other trends
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 2 Utilization of mammography in the previous 12 months in 4 consecutive surveys and
first ever utilization in 3 consecutive surveys among Lebanese women
Area/survey
Outside Beirut
Akkar
S1
S2
S3
S4
Batroun
S1
S2
S3
S4
Chouf
S1
S2
S3
S4
Zahleh
S1
S2
S3
S4
Sour
S1
S2
S3
S4
Total
S1
S2
S3
S4
Greater Beirut
Beirut city
S1
S2
S3
S4
Utilization of mammography in
previous 12 months
n/N
% (95% CI)a
P-valueb
First ever utilization of
mammography
n/N
% (95% CI)a
P-valueb
21/200
58/200
22/160
10/160
10.5 (6.3√14.7)
0.655
29.0 (22.7√35.3) < 0.001
13.8 (8.4√19.1)
0.12
6.3 (2.5√10.0)
< 0.001
n/a
34/56
13/22
8/10
n/a
60.7 (47.9√73.5)
59.1 (38.5√79.6)
80.0 (55.2√100)
√
0.363
0.122
0.316
26/200
44/200
23/160
32/160
13.0 (8.3√17.7)
22.0 (16.3√27.7)
14.4 (8.9√19.8)
20.0 (13.8√26.2)
n/a
20/44
15/23
22/32
n/a
45.5 (30.7√60.2)
65.2 (45.7√84.7)
68.8 (52.7√84.8)
√
0.112
0.027
0.882
20/200
20/200
17/160
19/160
10.0 (5.8√14.2)
10.0 (5.8√14.2)
10.6 (5.8√15.4)
11.9 (6.9√16.9)
n/a
11/20
8/17
12/19
n/a
55.0 (33.2-76.8)
47.1 (23.3√70.8)
63.2 (41.5√84.8)
√
0.894
0.763
0.663
31/400
37/400
30/160
26/160
7.8 (5.1√10.3)
9.3 (6.4√12.1)
18.8 (12.7√24.8)
16.3 (10.5√22.0)
0.005
< 0.001
0.279
0.594
n/a
22/37
9/30
21/26
n/a
59.5 (43.6√75.3)
30.0 (13.6√46.4)
80.8 (65.6√95.9)
√
0.608
0.106
0.126
38/200
18/200
19/160
26/160
19.0 (13.6√24.4)
9.0 (5.0√13.0)
11.9 (6.9√16.9)
16.3 (10.5√22.0)
< 0.001
0.012
0.027
0.594
n/a
10/17
13/19
20/25
n/a
58.8 (35.4√82.2)
68.4 (47.5√89.3)
80.0 (64.3√95.7)
√
0.788
0.022
0.159
136/1200
177/1200
111/1200
113/1200
11.3 (9.5√13.1)
14.8 (12.7√16.8)
13.9 (11.5√16.3)
14.1 (11.7√16.5)
√
√
< 0.001
< 0.001
n/a
97/174
58/111
83/112
n/a
55.7 (48.4√63.1)
62.3 (43.0√61.5)
74.1 (66.0√82.2)
√
√
0.009
0.032
√
√
< 0.003
0.002
n/a
n/a
17/51
24/50
n/a
n/a
33.3 (20.4√46.3)
48.0 (34.1√61.8)
√
√
0.092
< 0.001
n/a
n/a
51/200
51/200
n/a
n/a
25.5 (19.5√31.5)
25.5 (19.5√31.5)
0.44
0.001
0.181
< 0.424
0.49
0.038
0.008
0.0367
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
13
Table 2 Utilization of mammography in the previous 12 months in 4 consecutive surveys and
first ever utilization in 3 consecutive surveys among Lebanese women (concluded)
Area/survey
Beirut suburbs
S1
S2
S3
S4
Total
S1
S2
S3
S4
All areas
S1
S2
S3
S4
Utilization of mammography in
previous 12 months
n/N
% (95% CI)a
P-valueb
n/a
n/a
56/200
49/200
n/a
n/a
107/400
100/400
First ever utilization of
mammography
n/N
% (95% CI)a
P-valueb
n/a
n/a
28.0 (21.8√34.2)
24.5 (18.5√30.5)
√
√
< 0.001
0.006
n/a
n/a
20/56
35/48
n/a
n/a
35.7 (23.2√48.3)
72.9 (60.3√85.5)
√
√
0.169
0.372
n/a
n/a
26.8 (22.4√31.1)
25.0 (20.8√29.2)
√
√
< 0.001
< 0.001
n/a
n/a
37/107
59/98
n/a
n/a
34.6 (25.6√43.6)
60.2 (50.5√69.9)
√
√
0.009
0.032
n/a
97/174
95/218
142/210
n/a
55.7 (47.6√62.4)
43.6 (37.0√50.2)
67.6 (61.3√73.9)
√
√
√
√
136/1200 11.3 (9.5√13.1)
177/1200 14.8 (12.7√16.8)
218/1200 18.2 (16.0√20.3)
213/1200 17.8 (15.6√19.9)
√
√
√
√
Percentage of women who had a mammography in the previous year, with corresponding 95% confidence
interval.
Obtained from a z-test or Fisher exact test comparing the prevalence in 1 group to the prevalence in all others
combined, or the prevalence outside Beirut compared to the prevalence in Greater Beirut.
S1 = September 2003 survey; S2 = January 2004 survey; S3 = January 2005 survey; S4 = January 2006 survey.
n/N = no. of women /total no. of women sampled; n/a = no samples taken.
a
b
existed across waves (Table 3). As expected,
the proportion of first-time users among
women who obtained a mammography in
the past 12 months decreased with older age
groups. This trend was consistent across the
3 waves in which this variable was assessed
(Table 3).
Overall impact of breast cancer
awareness campaigns
The overall impact of the campaigns has
been measured since survey S3 (Table 4).
Overall, more than 50% of participants
mentioned that they had heard about the
ongoing campaign at each given time. In
all areas, the proportion of women who
had heard of the breast cancer awareness
campaigns increased consistently between
surveys S3 and S4, except in Akkar. The
impact was highest in Beirut city and suburbs. In the suburbs, the proportion in survey S3 was already relatively high (69%)
and thus could improve by only a small
fraction to 70%.
Given that they had heard about the
campaign, the proportion of women who
were actually prompted to action was relatively low. While increasing in total from
surveys S3 to S4 (9.7% and 14.3% respectively), those figures did not increase in
Beirut city and suburbs (Table 4). In fact
between surveys S3 and S4, the proportion
of women prompted to action in Beirut city
decreased from 22% to 19%, and in the
suburbs from about 14% to 12%. Further
analysis in surveys S3 and S4 confirmed the
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14
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 3 Utilization of mammography in the previous 12 months in 4 consecutive surveys and
first ever utilization in 3 consecutive surveys among Lebanese women according to age
Age group/
survey
< 40 years
S1
S2
S3
S4
40√49 years
S1
S2
S3
S4
50√59 years
S1
S2
S3
S4
? 60 years
S1
S2
S3
S4
All ages
S1
S2
S3
S4
Utilization of mammography in
previous 12 months
n/N
% (95% CI)a
P-valueb
First ever utilization of
mammography
n/N
% (95% CI)a
P-valueb
n/a
n/a
33/329
25/202
n/a
n/a
10.0 (6.8√13.3)
12.5 (7.6√17.3)
n/a
n/a
< 0.001
0.028
n/a
n/a
22/33
21/25
n/a
n/a
66.7 (50.6√82.8)
84.0 (69.6√98.4)
√
n/a
0.018
0.062
77/713
99/663
85/420
96/441
10.8 (8.5√13.1)
14.9 (12.2√17.6)
20.2 (16.4√24.1)
21.8 (17.9√25.6)
0.394
0.885
0.172
0.005
n/a
58/96
37/85
69/93
n/a
60.4 (50.6√70.2)
43.5 (33.0√54.1)
74.2 (65.3√83.1)
√
0.198
0.991
0.069
31/208
46/283
51/210
61/284
14.9 (10.1√19.7)
16.2 (12.0√20.5)
24.3 (18.5√30.1)
21.5 (16.7√26.2)
0.085
0.418
0.011
0.06
n/a
24/45
21/51
35/61
n/a
53.3 (38.8√67.9)
41.2 (27.7√54.7)
57.4 (45.0√69.8)
√
0.705
0.693
0.042
29/276
32/250
49/241
31/273
10.5 (6.9√14.1)
12.8 (8.7√16.9)
20.3 (15.2√25.4)
11.3 (7.6√15.1)
0.577
0.325
0.329
0.002
n/a
15/32
15/49
17/31
n/a
46.9 (29.6√64.2)
30.6 (17.7√43.5)
54.8 (37.3√72.4)
√
0.263
0.038
0.099
137/1197
177/1196
218/1200
213/1200
11.4 (9.6√13.2)
14.8 (12.8√16.8)
18.2 (16.0√20.3)
17.8 (15.6√19.9)
n/a
97/173
95/218
142/210
n/a
56.1 (48.7√63.5)
43.6 (37.0√50.2)
67.6 (61.3√74.0)
√
√
√
√
√
√
√
√
Percentage of women who had a mammography in the previous year, with corresponding 95% confidence
interval (95% CI)
Obtained from a z-test or Fisher exact test, depending on the situation, comparing the prevalence in 1 group to
the prevalence in all others combined.
S1 = September 2003 survey; S2 = January 2004 survey; S3 = January 2005 survey; S4 = January 2006 survey.
n/a = no sample taken.
a
b
impression that the proportion of women
who had heard of the campaigns was significantly higher in greater Beirut than in
other regions. Changes have been found
regarding the effect of those campaigns in
prompting action. The difference between
greater Beirut and other regions vastly decreased between surveys S3 and S4.
Discussion
Annual national campaigns in Lebanon,
usually held in October, have been promoting the utilization of mammography to
screen for breast cancer among women aged
40+ years. There are no readily available
data concerning mammography utilization
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
15
Table 4 Overall impact of breast cancer awareness campaigns among Lebanese women in 2
consecutives surveys
═Area/survey
Outside Beirut
Akkar
S3
S4
Batroun
S3
S4
Chouf
S3
S4
Zahleh
S3
S4
Sour
S3
S4
Total
S3
S4
Greater Beirut
Beirut city
S3
S4
Beirut suburbs
S3
S4
Total
S3
S4
All areas
S3
S4
Heard about last breast
cancer campaign
P-valuea
Heard about last breast cancer
campaign and had a
mammography as a result
n/N
%
P-valuea
n/N
%
87/160
70/160
54.4
43.8
0.347
< 0.001
6/87
10/64
6.9
15.6
0.347
0.705
77/160
105/160
48.1
65.6
0.448
0.275
2/77
10/105
2.6
9.5
0.025
0.319
74/160
84/160
46.3
52.5
0.205
0.01
3/74
11/83
4.1
13.3
0.082
0.824
61/160
97/160
38.1
60.6
< 0.001
0.76
3/61
15/96
4.9
15.6
0.081
0.635
61/160
84/160
38.1
52.5
< 0.001
0.01
1/61
11/81
1.6
13.6
0.025
0.896
360/800
440/800
45.0
55.0
<0.001
<0.001
15/360
57/429
4.2
13.3
< 0.001
0.356
113/200
159/199
56.5
79.9
0.084
< 0.001
25/113
30/159
22.1
18.9
< 0.001
0.049
138/200
141/200
69.0
70.1
< 0.001
0.005
19/138
17/140
13.8
12.1
0.063
0.47
251/400
300/399
62.8
75.2
< 0.001
< 0.001
44/251
47/299
17.5
15.7
< 0.001
0.356
611/1200
740/1199
51.0
61.7
59/611
104/740
9.7
14.3
√
√
√
√
Obtained from a z-test or Fisher exact test, depending on the situation, comparing the prevalence in 1 group to
the prevalence in all others combined.
S3 = January 2005 survey; S4 = January 2006 survey.
n/N = no. of women/total no. of women sampled.
a
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
in Lebanon and the Arab world. A key indicator for success of such campaigns is the
percentage of those who underwent a mammogram within an interval recommended
by professional organizations. Data collected from 1200 women with a mean age
of 50 years, across various regions of Lebanon, from 4 consecutive surveys assessing
the awareness campaigns between 2003
and 2005, indicated that the proportion of
⌠proper■ utilization within the previous 12
months was low and increased only slightly
over time (11% to 18%).
Prior to our study, only 1 report could
be located in Lebanon [unpublished report,
Hariri Foundation, 2001]. It involved 315
women of the same average age, surveyed
in Beirut and Saida in 2001. That report
found an even lower proportion of mammography utilization (7%) within the previous 12 months. These figures may indicate
that progress in awareness and utilization
may be occurring in Lebanon, even if at a
very slow pace, and with regional and age
differences. This progress can be largely attributed to the national October campaigns
which remain the only concerted effort
conducted in Lebanon on the issue of breast
cancer. The campaigns are actually acting
as triggers for activities implemented by
various nongovernmental organizations
throughout the year to promote mammography and facilitate obtaining it in various
subpopulations of women in Lebanon.
The rate of recent mammography utilization is definitely higher in more developed
nations, around 70% in the United States
[6,7] and France [8,9]. On the other hand,
Lebanese rates are nearer to those in developing nations. In Istanbul, Turkey, a country
socioeconomically and sociologically comparable to Lebanon, the rate of undergoing a
recommended mammography in 2003 was
12.6% [10]. As prevention and awareness
efforts are repeated and improved, and ob-
stacles defined and removed, we can hope
that utilization rates will improve to equal
those of more developed nations.
It is most important that women in the
age group 40√60 years abide by recommendations for an annual breast mammography.
This is the age group likely to benefit the
most from screening, and in whom mammography is systematically recommended
in Lebanon and elsewhere. Studies have
shown that screening mammography in
women in this age group decreased mortality by about 20%√35% [11]. It was reassuring to find that, in all waves, mammography
utilization in women aged 40√60 years was
almost twice as high as in both younger
and older women. Nevertheless, messages
should be clearly sent to women with a
family history of breast cancer to start having a mammogm as early as 35 years [12].
With increasing life expectancy in Lebanon,
as elsewhere, more women will be reaching the 60+ years age group. They will be
expected to live a healthy life and cannot
be neglected as potential beneficiaries of
breast cancer screening [13].
Repeat mammography is also an important indicator for the greatest populationlevel benefits on breast cancer morbidity
and mortality [14]. In the first survey (S1)
only 2.2% of women said they had had
more than 1 mammogram in the past. This
rate is negligible compared with the rate of
25% in Turkey [15] and 40% in the Umited
States of America in the same period [16].
The existence of fluctuations in repeat
mammography across all years and within
regions may be attributed to a false sense
of security acquired from a first ⌠normal■
mammogram, which then acts as a disincentive to obtaining another one in the absence
of any perceived breast changes. Therefore,
campaigns should clearly indicate the need
for repeating the test even if the results were
negative in the previous year. Starting with
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
the 2007 campaign, advertisements have
emphasized this point consistently.
Overall, the campaigns were less effective in the regions outside greater Beirut and
their prompting effect was lower. Rates of
adequate utilization were also lower. However, not all regions were equally affected.
Those with larger rural populations such
as Chouf and Akkar had worse indicators
than areas with some urban centres such as
Zahleh and Sour. This seems to indicate that
obtaining a mammography in some areas
may be hampered by logistic obstacles such
as availability, affordability and access.
Other negative factors may be related to
values, expectations and beliefs of women
in various regions of Lebanon. Those issues
are currently under investigation using data
collected in the same surveys.
In conclusion, the breast cancer campaigns focusing on the importance of annual
screening mammography are having a small
17
yet measurable impact on women▓s practice
in Lebanon. While progress is expected to
remain slow for several years, it has to be
sustained until a critical mass of women has
acquired the regular habit and annual mammography has become the norm in Lebanon.
It is hoped that publishing such data may
prompt similar efforts to initiate screening
campaigns in other parts of the Arab world
where breast cancer is on the rise.
Acknowledgements
The activities of the National Breast Cancer
Awareness Campaigns are conducted under the umbrella of the Ministry of Public
Health in Lebanon, and largely funded
through grants from Roche International.
The survey data collection and entry was
conducted by Statistics Lebanon, a private
survey company in Beirut.
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Guilbert P, Baudier F, Gautier A. BaromХtre SantИ 2000. Volume 2. RИsultats
[Health barometer 2000. Volume 2.
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d▓Education pour la SantИ, 2001.
9.
Duport N, Ancelle-Park R. Do sociodemographic factors influence mammography use of French women? Analysis of
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a French cross-sectional survey. European journal of cancer prevention, 2006,
15(3):219√24.
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screening behaviors among women. Proceedings of the 2nd International and 9th
National Nursing Congress, 7√11 September 2003. Antalya, Turkey, 2003.
11. Elmore JG et al. Screening for breast
cancer. Journal of the American Medical
Association, 2005, 293(10):1245√56.
12. Johnson ET. Breast cancer racial differences before age 40≈implications for
screening. Journal of the National Medical Association, 2002, 94(3):149√56.
13. Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical
cancer in the elderly: a review of the
evidence. American journal of medicine,
2005, 118(10):1078√86.
14. Smith RA et al. American Cancer Society
guidelines for breast cancer screening:
update 2003. CA: a cancer journal for
clinicians, 2003, 53(3):141√69.
15. Secginli S, Nahcivan NO. Factors associated with breast cancer screening behaviours in a sample of Turkish women: a
questionnaire survey. International journal
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16. Glass AG et al. Breast cancer incidence
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Correction
Knowledge of and attitudes towards HIV/AIDS in Mashhad, Islamic Republic of Iran by M.R. HedayatiMoghaddam. Eastern Mediterranean Health Journal, 2008, 14(6):1321√32. The affiliation should read: Research Centre
for HIV/AIDS & Viral Hepatitis, Iranian Academic Centre for Education, Culture & Research (ACECR), Mashhad
Branch, Ferdowsi University Campus, Mashhad, Islamic Republic of Iran. On page 1324, Results section, paragraph 1,
last line, the correct phrase is: almost half (49.9%) (not 49.5%) had high school education.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
19
Cancer patients▓ desire for
information: a study in a teaching
hospital in Saudi Arabia
A.M. Al-Amri1
? оягси Мщ ЦсйтщЛ йзАМЦМ Мщ гЦАЦАъи гАзяхМи гАсзФоМи?:?яшхи ЦяЛж гАясьгД Мщ гЦАзящи?
?зЛА мЦЦо угАм гАзЦяМ?
? МЦМА цчяхга ЦяЛж гАясьгД еЛА ггАзйчго хцД еьЗ гАз ЦяжгЕЦ зЛА мчМчи еугхйЕЦ хгЦАяж МЦъД цД?:?гнАгАуи?
? Фчо чМСЬЦ гАхгмк Мщ ЕпЕ гАоягси ЦФгчщ ЦяЛж гАясьгД Мщ гЦАЦАъи гАзяхМи гАсзФоМи?.?МдоМ еЛА гАяжя ФгЦАзгДги?
? Фчо цляЛ гАхгмк?.? ФзД щФгфо гАзгАл ФбкгяЕ гАжгфяи?║?ЦД геАщугм зД гАйтнМу ФгеАДпгя [гЦАбА] ААЦяМж?
? мйЛ?2002 ?МДгМя?/?Цсм Пг гсйхМгДМ Пг ААЦяЛж гЦАяглзДМ нАоЦгй гцАЦягж гАясьгДМи нгАА гАщйэяи ЦД ъгДФД гАкгМД?
? ЦйДСЬЛ ЦлМз?║? ЦяМж Пг ляй ЦчгхАйЕЦ?114 ? ФЦД хДМ?.? чхА цД МзящФг гАйтнМу АоЕМЦ?2005 ?оМсЦях?/?ъгДФД гцАФА?
)%100( ?) цД МзящФг ЦлМз гЦАзАФЦгй зД ЦяжЕЦ Мщ мДМ ящж глАЦМз?%99 ?гЦАяЛж хгсйкДга ЦяМж Фгмо (цМ?
?) Мщ цД йзящ цясЕЦ йтнМу ЦяжЕЦ Мщ мДМ ЦА?%77( ? Фяшх цшАх гЦАяЛж?.?млх ЕпЕ гЦАзАФЦгй зДЕЦ?
?) гАйзящ зЛА ЦргМг гАзгАл?%98( ? Фцяго ЦлМз гЦАяЛж йчяМх Пг?.)%17( ?йяшх Мщ еьЗ гАз гцАуочга егА щфи чАМАи ЦДЕЦ?
.? Фяшх ЦлМз гЦАяЛж цД МйзящФг зЛА еДпгя [ЦбА] гЦАяж АоЕМЦ?.?) гАйзящ зЛА бкгяЕ гАжгфяи?%99(?Ф?
ABSTRACT Relatives of cancer patients in Saudi Arabia tend to believe that telling the truth to the
patient could lead to harm and suffering. This study assessed the attitudes of Saudi Arabian cancer
patients towards disclosure of cancer diagnosis and prognosis, and benefits and adverse effects of
therapy. A questionnaire survey was administered to patients attending the oncology service between
January 2002 and December 2005 before they knew their diagnosis. Of 114 patients interviewed, all
except 1 (99%) wished to know all the information about their disease and 100% rejected withholding
information. Most of the patients (77%) wanted their family to know the diagnosis but few (17%) wanted
their friends to be informed. Almost all patients wanted to know the benefits and adverse effects of therapy (98% and 99% respectively). All patients wanted to know about the prognosis of their disease.
VolontИ de savoir chez les patients atteints de cancer : Иtude dans un hТpital universitaire
d▓Arabie saoudite
R?SUM? Les proches des patients cancИreux en Arabie saoudite ont tendance Ю penser que le fait
de dire la vИritИ au patient peut lui faire du mal et le faire souffrir. Cette Иtude a ИvaluИ l▓attitude des
patients cancИreux saoudiens vis-Ю-vis de l▓annonce du diagnostic de cancer et de son pronostic, ainsi
que de l▓intИrЙt et des effets indИsirables du traitement. Une enquЙte par questionnaire a ИtИ rИalisИe
auprХs des patients frИquentant le service d▓oncologie entre janvier 2002 et dИcembre 2005 avant qu▓ils
n▓apprennent le diagnostic de leur maladie. Sur 114 patients interrogИs, tous sauf 1 (99 %) souhaitaient
tout savoir sur leur maladie et 100 % refusaient qu▓on leur cache des informations. La plupart d▓entre
eux (77 %) souhaitaient que leur famille soit informИe du diagnostic mais peu (17 %) que leurs amis en
soient informИs. Presque tous les patients souhaitaient connaНtre l▓intИrЙt et les effets indИsirables du
traitement (respectivement 98 % et 99 %). Tous voulaient connaНtre le pronostic de leur maladie.
Department of Internal Medicine and Medical Oncology, King Fahd Hospital of the University, King Faisal
University, Al-Khobar, Saudi Arabia (Correspondence to A.M. Al-Amri: aliamri49@hotmail.com).
Received: 01/06/06; accepted: 27/08/06
1
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20
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Introduction
Cancer is a major life-threatening disease
that can evoke deep-rooted fear of death
and sense of loss of hope. Even the word,
cancer, has powerful connotations of anxiety, pain and suffering.
Studies from many countries show that,
despite fear of cancer, a majority of both
healthy adults and cancer patients prefer to
know their diagnosis, prognosis, options for
treatment and the likely success of therapy
[1√5]. However, in the past there was a
convention among physicians of not giving
full information to cancer patients. Novack
et al. reported that in a questionnaire in 1961,
90% of American physicians preferred not
to tell a cancer patient his/her diagnosis. By
1977, this had reversed, with 97% preferring
to tell a cancer patient the diagnosis [4].
Nowadays, in many developed countries,
the attitudes of physicians towards informing
cancer patients about their diagnosis have
changed to truth-telling and disclosure of all
important facts related to the disease [4√9].
In Saudi Arabia, despite religious and
social taboos about lying and the risk of
loss of trust, the relatives of cancer patients
often defend the right of the patient not to
know about his/her diagnosis and prognosis
and insist on treating the patient without
telling him/her or requesting signed consent
for treatment. This study was conducted to
explore the opinion of Saudi Arabian cancer
patients about how much information they
would like to know about their diagnosis,
prognosis, treatment benefits and the adverse effect of therapy.
Methods
All of the study patients were Saudi Arabian
nationals who were suspected of malignant disease and referred for diagnosis to
King Fahd Hospital of the University at
Al-Khobar from January 2002 to December
2005. Both male and female patients were
included in this study and all patients were
over 18 years old.
The patients were given a structured
interview to gauge their opinion about how
much information they wished to know
about their diagnosis, prognosis, treatment
benefits and side-effects if their disease
proved to be cancer. The interviews were
carried out after the diagnosis of cancer had
been made at the hospital but before the
patients knew their diagnosis. After taking
verbal consent for participation, the author
interviewed each patient. The attitudes of
relatives of cancer patients in our community as well as the purpose of the study were
explained to the patients. Each question
was explained and the patients were asked
to respond according to their own point of
view after the questions were translated into
their local language if needed. Patients were
allowed to answer the questions without
help or guidance.
The questionnaire had 9 items, modified
from those used by Meredith et al. [10], Fallowfield et al. [11] and Jawaid et al. [12]:
∙ Do you want to know all the information
about your illness?
∙ Do you want to know only partial information?
∙ Should we withhold all the information?
∙ Should we tell your family?
∙ Should we tell your friends?
∙ Should we treat you without telling you
about the effect of the treatment?
∙ Should we treat you without telling you
about your disease if it proves to be cancer?
∙ Do you want to know all side-effect of
the treatment?
∙ Do you want to know about the prognosis of the disease?
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Results
A total of 114 consecutive Saudi cancer patients (67 females and 47 males) were interviewed before the result of histopathology
and confirmation of their malignant disease.
All of them were Muslims from different regions of Saudi Arabia. The majority
(61%) were from the Eastern Province and
just over half were illiterate (52%) (Table
1). More than half of the patients had breast
carcinoma or lymphoma.
Table 2 lists the answers to the questionnaire. In response to the first 3 questions,
only 1 patient wanted to know partial information and 113 (99%) of the patients
wished to know the information in detail.
None of the patients wanted information to
be hidden from them. In response to questions about informing friends and family, 88
(77%) patients wanted their family to know
about their diagnosis but only 19 (17%)
wanted their friends to know.
All of the patients rejected the idea of
treatment without knowing their diagnosis
and had a strong desire to know about the
treatment 113 (99%). Only 1 patient did not
want to know the adverse effects of treatment. All patients wanted to know about the
prognosis of their malignant disease.
There were no major differences in the
patients▓ attitude toward disclosure of information about their disease and its treatment
with respect to educational level and sex of
the patients (Table 3).
Discussion
Surveys of cancer patients in developed
countries indicate that the majority of
patients prefer to know their diagnosis,
options of treatment, adverse effects of
therapy and prognosis of their malignant
disease [1,5,6,10]. A survey of 1251 Ameri-
21
cans showed that 96% of patients wished to
be told if they were suffering from cancer
and 85% wished to know how long they
were going to survive [13]. European patients had a similar attitude. Meredith et al.
studied 250 patients attending an oncology
centre in Scotland and showed that 96%
wanted to know if their illness was cancer
[10]. In the present study, almost all of the
patients wanted to know their diagnosis;
100% would not like to be treated without
knowing the diagnosis and 99% wanted to Table 1 Demographic characteristics of the
study patients (n = 114)
Variable
Age (years)
18√85
Sex
Male
Female
Province
Eastern
Central
Western
Southern
North
Religion
Muslim
Level of education
Illiterate
Read and write
Primary school
Intermediate school
Secondary school
University
Type of cancer
Lymphoma
Breast cancer
Lung cancer
Other
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
No.
%
114
100
47
67
41
59
70
9
5
24
6
61
8
4
21
5
114
100
59
4
12
12
11
16
52
4
10
10
10
14
35
31
10
38
31
27
9
33
22
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 2 Responses of Saudi Arabian cancer patients (n = 114) to questionnaire about
information giving
Question
Yes
Do you want to know all information about your illness?
Do you want to know only partial information?
Should we withhold all information?
Should we tell your family?
Should we tell a friend?
Should we treat without telling you the effects of treatment?
Should we treat without telling you about your disease?
Do you want to know about the treatment side-effects?
Do you want to know about the prognosis?
know the benefits and adverse effects of
therapy.
Cultural and social factors in Saudi Arabia play a major role in giving bad news and
truth-telling about cancer diagnosis, treatment and prognosis. From the author▓s per-
No
No.
113
1
0
88
19
%
99
1
0
77
17
No.
1
113
114
26
95
%
1
99
100
23
83
2
0
113
114
2
0
99
100
112
114
1
0
98
100
1
0
sonal experience, relatives of Saudi patients
believe that telling the truth to the patient
could lead to harm and suffering and some
believe that patients are not sufficiently well
educated to understand medical terminology. Almost all of the family caregivers
Table 3 Responses of Saudi Arabian cancer patients to questionnaire about information giving
by level of literacy and sex
Question
Do you want to know all information about your illness?
Do you want to know only partial information?
Should we withhold all information?
Should we tell your family?
Should we tell a friend?
Should we treat you without telling you the effects of treatment?
Should we treat you without telling you about your disease?
Do you want to know about the treatment side-effects?
Do you want to know about the prognosis?
Literate
(n = 55)
Yes
No.
%
Illiterate
(n = 59)
Yes
No.
%
Females
(n = 67)
Yes
No.
%
Males
(n = 47)
Yes
No.
%
51
93
59
100
66
99
47
100
1
0
35
9
2
0
64
16
0
0
53
10
0
0
90
17
1
0
56
10
2
0
84
15
47
47
35
9
100
100
75
19
2
4
0
0
1
2
1
2
0
0
0
0
0
0
0
0
1
2
59
100
67
100
46
98
52
95
59
100
67
100
47
100
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
request a written medical report with full
medical information so that they can seek a
second opinion or treatment abroad.
The results of this study indicate that
the Saudi cancer patients who were interviewed at our hospital prefer to know the
truth about their illness, the prognosis and
the treatment available. All the patients
were of Saudi Arabian nationality and from
different regions of the country. The study
was designed to explore whether cancer
patients in Saudi Arabia might have different attitudes compared with patients in
developed countries, where there is a more
individualistic philosophy and where most
cancer patients want detailed information
about their cancer [10,14√19]. However,
we found that Saudi cancer patients were
not different from those in other parts of
the world.
In Saudi Arabia, there are 5 sociocultural
factors that may play a role in decisions
about how much information to give cancer
patients: (1) the family are key participants
in medical-related decision-making; (2)
patients are not financially autonomous;
(3) medical oncologists are trained in the
European and American medical traditions;
(4) lying to patients is not a valid option
for a physician; and (5) there is a lack of
institutional policies regarding the disclosure of diagnoses. These factors may lead
to doctor√patient conflict when discussing
cancer diagnosis, treatment advantages and
23
side-effects and prognosis, especially in
cultures where there is not full acceptance
of the principles of informed consent and
patient autonomy [20√22].
The present study had several limitations. First, the sample size was small.
Secondly, since the study was done at a
single institution and by a single researcher,
there could be a bias towards a positive
outcome. Thirdly, the participants were
predominantly from the Eastern Province
and may not be representative of all Saudi
cancer patients; however, the Eastern Province has a diverse population and there were
participants from the other regions of Saudi
Arabia. A multicentre study with a larger
sample size would allow for more definite
conclusions about the attitude of cancer
patients in the country as a whole.
In summary, contrary to what many
people in Saudi Arabia believe, these findings demonstrate that cancer patients do
want to know the truth about the diagnosis,
benefits and adverse effects of therapy and
prognosis of their malignant disease.
Acknowledgements
I would like to extend my sincere gratitude
to Professors Hassan Bella and Sadat Ali
for their valuable contribution in revising
the manuscript and for their suggestions and
comments in preparing this paper.
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Jenkins V, Fallowfield L, Saul J. Information needs for cancer patients: result from
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16. Hagerty RG et al. Cancer patient preferences for communication of prognosis in
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17. Mystakidou K et al. Disclosure of diagnostic information to cancer patients
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18. Kaplowitz SA, Campo S, Chui WT. Cancer patients desire for communication of
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19. Lamont EB, Christakis NA. Prognostic
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20. Goldberg RJ. Disclosure of information
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21. Annas G. Informed consent, cancer, and
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
25
Environmental exposure to asbestos
and the exposure√response
relationship with mesothelioma
M.T. Madkour,1 M.S. El Bokhary,2 H.I. Awad Allah,2 A.A. Awad3 and H.F. Mahmoud4
?гАйзяж ФггАсйлгхи ФхДМ ФяЦ гЦАйФсьи?
ЬУ ?гАйзяж гАхМфМ АцАсхсйФс ФгАзгАчи хДМ?
ЬУ
? мсДМ щймМ мЦЦФо?║? зхо гмАЦМо зФж?║? ЕгАЕ ехягЕМЦ зФж гЕАА?║? мЦЦФо ясМ гАхнгяМ?║?нЦйгя ьЕ ЦоъФя?
? мФА гАзгАчи хДМ?║? цляЛ гАхгмкФД оягси ФхгфМи ФхМфМи Мщ ЦДьчи тяхг гнАМЦи хЦоМДи гАчгЕяи гАъяхЛ?:?гнАгАуи?
? Фчо цляЛ гАхгмкФД йДыяМ Пг?.?гАэл ЗД СхФМ гнАхМк?
С ?гАйзяж ФггАсйлгхи АцАсхсйФс (гцАЦМгДй) ФхДМ ФяЦ гЦАйФсьи?
ЬУ
П
?ЦъФДи ЦД?
ЬС ? ФлЦЦФзи тгЕои?║?ЦзяжДМ хМфМг АЕ?
ЬС ? тну Пг?2913? Ф?║?ЦзяжДМ ЦЕДМ Пг АцАсхсйФс?
ЬС ? тну Пг?487 ?тзгзМ Пг Аэ?
? ФмооФг йяъМр?║? ъгЦ цнп гАхгмкФД нрзгй Сл ЗД СхФ СЬМи ЦД гмАггАй гЦАт Сй СхЕ Ехг?.?йзяж?
ЬУ ? тну Пг АМс ЕАЦ сФгхч?979
ЬС
? ЦДЕг ъгДй жЦД?87 ║? мгАи ЦД ФяЦ гЦАйФсьи?88 ?ФтнуФг?
.?цАМгщ гцАсхсйФс гЦАДчФАи хгЕАФга Мщ ЦлМз гЦАДгьч?
?гЦАзяжи хМфМ Пг цзЛА ЦД гЦАлЦФзйДМ?
ЬС ? ФйхДМ ААхгмкДМ цД гнйьгя ФяЦ гЦАйФсьи АоЛ гЦАлЦФзи?.?гЦАзяжи?
ЬС ?гЦАлЦФзи?
?гАйзяж?
ЬУ ? Фгрого гДйтгя ФяЦ гЦАйФсьи Цз гроМго?.? ъгЦ цД ггАнйьгя цзЛА АоЛ геАДгк ЦДЕ АоЛ гАпъФя?║?гцАняМДМ?
.?гАйэягъЦМ АцАсхсйФс?
ABSTRACT An epidemiological and environmental study was carried out in Shubra El-Kheima city,
greater Cairo, of the exposure√response relationship between asbestos and malignant pleural mesothelioma. Radiological screening was done for 487 people occupationally exposed to asbestos, 2913
environmentally exposed to asbestos and a control group of 979 with no history of exposure. Pleural biopsy was done for suspicious cases. The airborne asbestos fibre concentrations were determined in all
areas. There were 88 cases of mesothelioma diagnosed, 87 in the exposed group. The risk of mesothelioma was higher in the environmentally exposed group than other groups, and higher in females than
males. The prevalence of mesothelioma increased with increased cumulative exposure to asbestos.
Exposition environnementale Ю l▓amiante et relation exposition-rИponse avec le mИsothИliome
R?SUM? Une Иtude ИpidИmiologique et environnementale a ИtИ rИalisИe Ю Shubra El-Kheima, dans
la banlieue du Caire, sur la relation exposition-rИponse entre l▓amiante et le mИsothИliome pleural malin.
Un dИpistage radiologique a ИtИ effectuИ sur 487 personnes exposИes Ю l▓amiante dans le milieu
professionnel, 2 913 personnes exposИes Ю l▓amiante dans l▓environnement et un groupe tИmoin de
979 personnes n▓ayant jamais ИtИ exposИes. Une biopsie pleurale a ИtИ rИalisИe sur les cas suspects.
Les concentrations de fibre d▓amiante dans l▓air ont ИtИ Иtablies dans toutes les zones. Quatre-vingt-huit cas
de mИsothИliome ont ИtИ diagnostiquИs, dont 87 dans le groupe exposИ. Le risque de mИsothИliome
Иtait plus ИlevИ dans le groupe soumis Ю une exposition environnementale que dans les autres groupes,
et plus ИlevИ chez les femmes que chez les hommes. La prИvalence du mИsothИliome augmentait en
mЙme temps que l▓exposition cumulИe Ю l▓amiante.
Department of Chest Diseases, Faculty of Medicine; 2Department of Medical Sciences, Institute of
Environmental Studies and Research, Ain Shams University, Cairo, Egypt (Correspondence to M.T. Madkour:
ashraf_madkour@yahoo.com).
3
Department of Air Pollution, National Research Centre, Cairo, Egypt.
4
Abbassia Chest Hospital, Cairo, Egypt.
Received: 02/07/06; accepted: 04/12/06
1
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
26
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Introduction
Malignant pleural mesothelioma (MPM)
is associated with environmental and occupational exposure to asbestos [1]. During
the last 4 decades, numerous studies on
MPM have been conducted [2,3]. However,
the natural history of this tumour remains
ill-defined or scarcely known. Particular
topics that deserve further investigation
include the proportion of cases attributable
to asbestos, the spectrum of the population
at risk, the length of the latency period, the
impact of mild exposure to asbestos and the
role of cofactors in the development of the
tumour [4].
Epidemiological studies have linked
occupational exposure to asbestos with
mesothelioma [5√10]. Cohort studies have
found increased incidence of and mortality
from mesothelioma among asbestos workers
employed in mining [5], textile manufacturing [6], insulation [7] and asbestos cement
factories [8]. Exposure has been assessed by
a variety of methods, but all studies reach
the conclusion that the rate of mesothelioma
increases as the level of exposure increases
[10]. Non-occupational or environmental
exposure to asbestos is also associated with
an increased risk of mesothelioma [11].
Exposure is experienced by individuals
living with asbestos workers [12] and those
living near asbestos mines and mills [13] or
factories manufacturing asbestos products
[14]. The development of the disease has a
long latency, with cases arising more than
10 years after first exposure, and numbers
continue to rise exponentially with time
since first exposure [15].
Since other factors such as level of exposure also determine the risk of mesothelioma [16], it is important to analyse all these
factors to disentangle their separate effects.
The prevalence of mesothelioma has been
increasing throughout the industrialized
world [17]. The incidence is predicted to
peak around 2020 [18]. This reflects industrial exposure to asbestos, which was
common up to the 1980s, combined with a
latent period between exposure to asbestos
and development of mesothelioma averaging 30√40 years [17].
Data obtained from the information
network of the General Organization for
Industrialization in Egypt, showed that 14
asbestos factories were present in Egypt
in the year 2004 [19]. These factories affect an area of approximately 5√7 km in
radius, which explains the high incidence
of mesothelioma in the neighbourhood of
these factories. Workers employed since
1948 by the Egyptian asbestos company
Sigwart at the mills in greater Cairo (El
Maasara and Shubra El-Kheima) had an increased risk of mesothelioma, as did former
residents of Shubra El-Kheima who were
not directly employed in the milling of
asbestos. In 2002, a high prevalence of
pleuropulmonary disorders due to environmental asbestos exposure was reported in
the immediate vicinity, 0.5√1.5 km, from an
asbestos plant in south Cairo [20]. In Egypt,
the ministerial council decided to ban asbestos imports in 2004 and the Sigwart plants
were closed in November 2004. Therefore,
the predicted incidence of mesothelioma
in Egypt will reach its peak around 2040.
However, no previous Egyptian study of
environmental exposure to asbestos and
the risk of mesothelioma has been able to
utilize exposure levels to derive quantitative
exposure√response relationships.
The aims of this study were: to evaluate
the prevalence of MPM due to occupational
and environmental (non-occupational)
exposure to asbestos among persons who had
worked in the asbestos manufacturing plant
and in persons living in an area nearby the
plant with potentially significant population
exposure and to estimate the exposure√
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
response relationship between environmental
exposure to asbestos and MPM.
Methods
Location
This epidemiological and environmental
study was carried out in Shubra El-Kheima
city, greater Cairo, to evaluate the prevalence of MPM. Shubra El-Kheima is an
industrial city at the northern boundary of
Cairo, just upwind from downtown Cairo.
It has an area of about 30 km2. This city was
considered the focal point of the highest
environmental exposure to ambient asbestos fibres due to the operation of a large
asbestos manufacturing plant (the Sigwart
Company plant) (Figure 1). The Sigwart
plant is an asbestos manufacturing plant using chrysotile asbestos. It was constructed
in 1948 and its main products were asbestos
cement pipes and reinforced concrete products. The study included 6 areas in the near
vicinity of Sigwart plant, and these areas
were mapped according to the distance from
the asbestos plant and the airborne asbestos
fibre concentrations.
27
the 2000 census population data were obtained from the Egyptian Central Agency
for Public Mobilization and Statistics. All
sampling sites were located within 2 km of
the asbestos plant. El-Wehda El-Arabia area
2.5 km
Sample
The people working in the plant were designated the occupationally exposed group and
the population living in the 6 areas near the
plant were defined as the environmentally
exposed group. Sampling areas of airborne
asbestos fibres and the wind direction and
speed are shown in Figure 1.
Environmentally exposed group
The 6 areas which were defined in the near
vicinity of Sigwart plant included El-Wehda
El-Arabia, Manshiyat El-Gadida, Manshiyat
El-Horriya, Ezbet Osman, Manshiyat Abdel
Moneim Riad and Ezbet Rostom. For the
purpose of calculating population statistics,
Figure 1 Map of Shubra El-Kheima city
with superimposed direction and speed of
wind. Sampling areas: (1) Asbestos plant
(Sigwart store); (2) El-Wehda El-Arabia; (3)
Manshiyat El-Horriya; (4) Ezbet Rostom; (5)
Ezbet Osman; (6) Manshiyat El-Gadida; (7)
Manshiyat Abdel Moneim Riad
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28
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
includes 56═228 people and lies about 100 m
walking distance of the asbestos plant. Manshiyat El-Gadida includes 20═000 people,
Manshiyat El-Horriya includes 67═832 people, Ezbet Osman includes 25═000 people,
Manshiyat Abdel Moneim Riad includes
128═215 people, finally, Ezbet Rostom includes 24═834 people. A total of 322═109
people are still living in these areas and are
still exposed to asbestos.
Permission was taken from the health
centres in these areas to do the study and in
turn, the health visitors informed the population living in those areas to attend the centres
to do a mass miniature radiography (MMR)
scan. Considerable efforts were made to
convince people of the importance of doing
the MMR. Verbal consent was taken from
all individuals included in the study.
The sample size was calculated as 3059
subjects using the Epi-Info program. Those
who agreed to participate in the study were
2913 subjects who were chosen by cluster
sampling, with a response rate of 95%.
Details about occupation were taken, and
subjects who were working in the plant
or retired from the plant or had any history suggestive of occupational exposure
to asbestos were excluded from the environmentally exposed group to avoid double
registration.
Occupationally exposed group
Efforts were made to gain permission to do
the study inside the asbestos plant and to
convince the staff of the plant about the importance of having the MMR scan. The total
number of staff working in the plant was
about 543 people: 35 refused to participate
in the study, 21 were lost during the study
and the remaining 487 agreed to undergo
the MMR. This group included workers
dealing with asbestos manufacture in different processing sites (milling, manufacturing
and cutting) and those working in the store,
industrial shops, administration, asbestos
waste site and the gate of the plant. The
study was done during working hours in
the presence of the whole workforce of the
plant. All the staff inside the asbestos plant
were exposed to the hazards of asbestos as
there were contiguous rooms for all staff
inside the different sections of the plant and
clerks delivered circulars from the administration staff to the workers at their duty sites
and there was supervision of work performance by administration staff.
Control group
An agricultural area at Banha city about
40═km from the plant was included in the
study as a control area. The sample size of
the population included in the study in that
area was calculated as 1041 subjects using
the Epi-Info program. Those who agreed to
be included in the study were 979 people
chosen by cluster sampling, a response rate
of 94%. Verbal consent was taken before
doing the MMR. None of these individuals
had a history of occupational or environmental exposure to asbestos.
Data collection: clinical
Full history taking
All participants were interviewed. Occupational history was taken in full detail. The
place of birth and residence were recorded
in chronological order. The duration of
environmental exposure to asbestos was
determined. Full details were taken from the
environmentally exposed group regarding
their place of residence and period of residence in Shubra El-Kheima city. Care was
also taken to exclude those with a history of
occupational exposure to asbestos or retired
people who were working in an asbestos
plant. No history of migration was recorded
because levels of mobility from one area to
another in Egypt are very low and so the period from first residence in the area until the
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
time of study was considered as the duration
of environmental exposure.
Clinical examination
A thorough clinical examination was carried out for all subjects, with special emphasis on the respiratory system.
Mass miniature radiography
MMR was done for all studied groups.
All the films were read by 2 qualified and
experienced readers for diffuse parenchymatous disease and pleural diseases. We
used MMR for the initial screening for the
purpose of time and cost savings because
of the large number of subjects in the study
and also to avoid the health hazards of radiation to the community. This procedure is
usually adopted by the Egyptian Ministry of
Health surveys to detect cases with abnormal shadows and followed up with standard
chest radiographs for confirmation.
Standard chest radiographs
Suspected cases with MMR abnormalities
immediately underwent standard chest radiographs to confirm the presence of the
abnormality.
High-resolution computerized scans
A high-resolution computerized scan (HRCT)
of the chest was done for those persons with
abnormal chest radiographs for better assessment and localization of the lesion.
Admission to Abbassia Chest Hospital
Subjects with abnormal MMR and abnormal HRCT were admitted to Abbassia Chest
Hospital where pleural biopsy was done using thoracoscopy, limited thoracotomy or
CT-guided biopsy.
Data collection: estimation of
airborne asbestos fibres
The study was done in the period January
2003 to March 2004 inside the asbestos
29
plant when it was functioning at full capacity and after the plant was closed in November 2004. So the screening of workers and
other aspects of the study were done before
closure of the plant.
Air sampling and analytical methods
Each air sample was collected on a membrane filter (Millipore AA, 25 mm diameter) mounted on an open filter holder. The
air sampling was carried out for 8 hours
at a flow rate of 10 L/min. All the samples were prepared by the method of the
Occupational Safety and Health Agency
(OSHA7400).
Filters were placed onto the surface of
clean glass slides and were cleared using
acetone triacetin reagent. A clean cover
slip was gently lowered on the wedge at
a slight angle to reduce bubble formation.
The filter segment was outlined with a
glass marking pen to aid in microscopic
evaluation.
Measurements were carried out using
light microscopy, phase contrast with a blue
filter, adjustable field iris, 10 в eyepiece and
40 в phase objective (total magnification
400 в). Walton Beckett graticule type with
100 ?m diameter was used to count asbestos
fibres (field area of Walton Beckett graticule
is 0.00785 mm2). The slide was centred on
the stage of the calibrated microscope under
the objective lens, and the plane of the filter
was focused on the microscope.
Fibres longer than 5 ?m which lay entirely within the Walton Beckett graticule
were counted. Counting started from the
top of the filter wedge and progressed along
a radial line of the outer edge, shifted up√
down on the filter and continued in the
reverse direction. The graticule field was
chosen randomly. During 6 unit continuous
scans a range of focal planes was examined
by moving the 5 focus knobs to detect very
fine fibres which may be embedded in the
filter.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Calculations
Average count was calculated by dividing the total fibre count by the number of
fields observed. Fibre density (E) (fibres/
mm2) was defined as the average count
(fibres/ field) divided by the field graticule
area (AF) (0.00785 mm2):
Where F/nf = average fibre count/graticule
field, B/nb = mean field blank count/graticule field.
The concentration (C) (fibres/cm3) of
fibres in the air volume (V) (L) using the
effective collection area of the filter (AC)
(385 mm2) was calculated as follows:
Methods of estimation of individual
exposure levels
Intensity of exposure was calculated according to airborne asbestos fibre concentration (f/mL). Duration of exposure was
determined for all subjects. Duration of
exposure was then combined with intensity
of exposure to give a measure of cumulative exposure for each person in fibres per
millilitre years (f/mL-years). Latency was
estimated from the year of first exposure
until the onset of symptoms.
Statistical methods
Data were analysed using SPSS, version 9.
Statistical analysis was carried out using
Student t-test, Mann√Whitney test, chisquared test and Fisher test. Relative risks
(RR) and 95% confidence intervals (95%
CI) were calculated to determine the risk of
MPM in exposed subjects.
V = L/min в times = 3.1 в 30 = 93 L.
Sampling sites
Inside the asbestos plant: 45 air samples
were taken from all department, the milling
site (8 samples), the manufacturing machine
(7 samples), the cutting site (6 samples),
asbestos waste site (5 samples), industrial
shops (5 samples), the gate (4 samples), the
administration office (5 samples), and the
store (5 samples). The samples were collected in the working environment dealing
with the manufacture of the asbestos pipes
during different processes. The air samples
were collected at a height of 1.5 m (breathing zone) above the ground level between
09:00 and 17:00 hours.
Outside the asbestos plant: air samples
were collected at 6 different areas (5 samples each) in Shubra El-Kheima city around
the plant in a radius of 2.5 km.
Agricultural area: air samples were collected from an agricultural area at Banha
city, about 40 km from the plant.
Results
The demographic and exposure characteristics of asbestos-exposed subjects are shown
in Table 1. There was a highly statistically
significant difference between the environmentally and occupationally exposed
groups as regards age, sex, duration of
exposure (i.e. length of time resident in the
area or employed in the factory) and prevalence of MPM cases (P < 0.001).
The classification of pleuropulmonary
disorders in all study groups is shown in
Table 2. There were 88 cases of MPM
diagnosed, 87 in the exposed groups and 1
in the control group. MPM was more prevalent in the environmentally exposed group
(83/2913, 2.8%) than the occupationally
exposed group (4/487, 0.8%) and control
group (1/979, 0.1%) (Table 3).
The mean age of patients with MPM was
51.3 [standard deviation (SD) 8.08] years;
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
31
Table 1 Characteristics of groups occupationally and environmentally exposed to asbestos
Characteristic
Occupationally
Environmentally
exposed (n = 487) exposed (n = 2913)
57.5 (8.9)
No.
%
1616
55.5
1297
45.5
Test
P-value
t = 740.07
< 0.001
?2 = 350.56
< 0.001
Mean (SD) age (years)
Sex
Male
Female
Mean (SD) intensity of exposure
to asbestos (f/mL)
46.5 (3.9)
No.
%
487
100.0
0
0.0
Duration of residence in area or
employment in factory (years)
0√10
11√20
21√30
31√40
> 40
Malignant pleural
mesothelioma
+ve
√ve
No.
%
No.
%
47
107
88
47
98
10.0
22.0
18.0
30.0
20.0
307
616
837
618
535
10.5
21.2
28.7
21.2
18.4
?2 = 33.50
< 0.001
4
483
0.8
99.2
83
2830
2.8
97.2
?2 = 6.88
< 0.001
0.59 (0.76)
0.38 (0.87)
Mann√Whitney
test = 1.56
< 0.001
n = total number of people examined.
54.1 (SD 8.45) years (range 39√70 years)
for males and 49.5 (SD 7.39) years (range
35√60 years) for females.
The exposure characteristics of subjects
positive and negative for MPM are shown
in Table 4. Exposure to asbestos was significantly higher among patients with MPM
compared to non-MPM subjects.
The prevalence of MPM among the
environmentally exposed group in differ-
Table 2 Classification of pleuropulmonary disorders in groups occupationally and
environmentally exposed to asbestos
Disorder
Malignant pleural mesothelioma
Pleural plaques
Diffuse pleural thickening
Benign pleural effusion
Idiopathic pulmonary fibrosis
Pericardial calcification
Total
Occupationally
exposed (n = 487)
No.
%
4
0.8
7
1.4
29
5.9
1
0.2
4
0.8
1
0.2
46
9.4
Environmentally
exposed (n = 2913)
No.
%
83
2.8
46
1.5
39
1.3
36
1.2
29
0.9
11
0.3
244
8.3
Non-exposed
(n = 979)
No.
%
1
0.1
0
√
1
0.1
0
√
2
0.2
0
√
4
0.4
n = total number of people examined.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 3 Prevalence of malignant pleural
mesothelioma (MPM) cases in the asbestosexposed and non-exposed groups
Group
No.
examined
Occupationally exposed
Environmentally exposed
Non-exposed
MPM cases
No.
%
487
4
0.8
2913
979
83
1
2.8
0.1
ent areas is shown in Table 5. There was a
statistically significantly higher prevalence
of MPM cases in El-Wehda El-Arabia area
(4.5%) compared to Ezbet Rostom area
which had the lowest prevalence (1.2%) (?2
= 12.75, P = 0.03).
The risk of developing MPM was 26
times greater among the occupationally and
environmentally exposed groups compared
to the non-exposed group (Table 6).
The duration of exposure to asbestos
in cases of MPM in all studied groups is
shown in Table 7. There was a significantly
number of MPM cases in patients with
environmental asbestos exposure of more
than 40 years when compared to those with
a shorter duration of exposure (P < 0.001).
Figure 2 shows that the percentage of MPM
cases increased with longer duration of
exposure to asbestos fibres.
Fibre concentrations in the different
sites inside the asbestos plant are shown
in Table 8. There was a highly significant
difference between fibre concentrations at
the asbestos waste site versus other sites and
versus the control area (P < 0.001). Also
there was a highly significant difference
between fibre concentrations at asbestos
manufacturing sites (milling, cutting and
industrial shops) versus the control area (P
< 0.001). Airborne asbestos fibre concentrations in the surrounding areas outside the
Table 4 Characteristics of people with and without malignant pleural mesothelioma (MPM)
Characteristic
MPM
+ve (n = 88)
√ve (n = 4291)
No.
%
No.
%
Duration of residence in area or
employment in factory (years)
0√10
11√20
21√30
31√40
> 40
Age (years)
20√40
41√50
51√60
> 60
Sex
Male
Female
?2 and P values
0
5
14
16
53
0.0
5.7
15.9
18.2
60.2
406
785
992
831
1277
9.5
18.3
23.1
19.4
29.7
?2 = 44.30; P < 0.001
11
23
47
7
12.5
26.1
53.4
7.9
669
2086
1234
302
15.6
48.6
28.8
7.0
?2 = 27.59; P < 0.001
34
54
38.6
61.4
2606
1685
60.7
39.3
?2 = 17.58; P = 0.0021
n = total number of people examined.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
33
Table 5 Prevalence of malignant pleural mesothelioma (MPM) in the group environmentally
exposed to asbestos in different areas
Area (distance from the asbestos plant)
El-Wehda El-Arabia (100 m)
Manshiyat El-Gadida (800 m)
Manshiyat El-Horriya (1 km)
Ezbet Osman (1 km)
Manshiyat Abdel Moneim Riad (2 km)
Ezbet Rostom (2.5 km)
Table 6 Risk of malignant pleural
mesothelioma (MPM) in the asbestosexposed and non-exposed groups
MPM
+ve
√ve
Exposed
(n = 3400)
No.
%
87
2.6
3313
97.4
Non-exposed
(n = 979)
No.
%
1
0.1
978 99.9
Relative risk = 25.68.
n = total number of people examined.
asbestos plant and number of MPM cases are
shown in Table 9. The overall mean asbestos
fibre concentration in the exposure areas was
0.38 (SD 0.87) f/mL. The number of cases
of MPM was higher in El-Wehda El-Arabia
area (39 cases), where the concentration of
airborne asbestos fibres was higher (2.16
f/mL) compared with other areas (P < 0.01).
The distribution of various indices of
estimated exposure for MPM and nonMPM cases is shown in Table 10. Nearly
50% of patients with MPM had cumulative
exposure > 20 f/mL-years.
Discussion
In this study 88 cases of MPM were diagnosed, all except 1 in the asbestos-exposed
groups. The finding of 1 mesothelioma case
in the non-exposed group can be explained
by Hillerdal in 1999 who discussed the
No. exposed
No. examined
56═228
20═000
67═832
25═000
128═215
24═834
873
644
335
412
318
331
MPM cases
No.
%
39
4.5
17
2.6
8
2.4
9
2.2
6
1.9
4
1.2
evidence that the tumour can occur even
in the complete absence of asbestos, i.e. a
spontaneously occurring tumour [2].
The mean age of MPM cases was 54.1
years. These results are in agreement with
a study which reported that malignant
mesotheliomas of the pleura may occur
over a wide age range, but are most commonly observed in adults over the age
of═50═years═[21].
Our study showed a significant difference in age in all exposed groups including
MPM cases between the occupationally exposed and environmentally exposed groups.
This might be because workers inside the
asbestos plant were exposed to higher
concentrations of asbestos fibres than the
environmentally exposed group, so the mesothelioma might occur at an earlier age
than the environmentally exposed group or
there might be retirement at an earlier age
in addition to death from MPM at an earlier
age in the workers.
The female predominance of MPM
cases (61.4% versus 38.6%) in our study
is in agreement with another study which
found that out of 27 cases with malignant
pleural mesothelioma, 18 cases were females (66.7%) and 9 cases were males
(33.3%) [10].
In Egypt, one study found that the dust
concentration in the environment of Sigwart
factory was 3√20 f/mL [22]. Our results
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
302
Percentage of MPM cases
0
302
49
28
0
0
49
28
35
29
No.
1.4
1.2
1
0.8
0.6
11-20 years
394
33
53
0.2
0.1
21-30 years
31-40 years
41-50 years
Duration of exposure
Non exposed
1
Occupationally exposed
There were no females occupationally exposed.
351
17
368
97
1
98
> 40
?2 = 43.7, P < 0.001.
593
34
559
395
Figure 2 Prevalence of malignant pleural mesothelioma
according to the duration of exposure to asbestos
fibres
a
0
0
33
53
135
301
10
7
142
311
178
450
7
3
181
457
88
144
3
0
88
147
0√10
11√20
0.44
0.17
Environmentally exposed
31√40
17
38
261
349
No.
0.6
0.48
0.4
0
21√30
MPM
√ve
17
38
MPM
√ve
122
126
No.
Males
MPM
+ve
0
0
Non-exposed
(n = 979)
Environmentally exposed
(n = 2913)
Males
Females
MPM MPM
No.
MPM
+ve
√ve
+ve
0
261
122
0
2
347
129
3
1.75
1.6
0.2
Occupationally exposeda
(n = 487)
Males
No.
MPM
MPM
+ve
√ve
47
0
47
107
0
107
Duration
(years)
Table 7 Duration of exposure to asbestos in cases of malignant pleural mesothelioma (MPM) in all study groups
Females
MPM MPM
+ve
√ve
0
35
0
29
2
1.8
showed a much lower mean concentration of 0.59 f/
mL, presumably due to improvements in the technology of asbestos manufacturing and the use of
closed systems along with the application of filters,
frequent cleaning, suction systems and protective
masks for the workers which led to a decrease in the
concentration of the airborne asbestos fibres.
Environmental assessment of airborne asbestos
fibre concentrations showed that the highest mean
concentration (2.16 f/mL) was in the El-Wehda ElArabia area which lies within 100 m of the asbestos
plant and where the wind direction is towards that
area. Fibre concentrations start to decrease further
away from the plant. The overall mean asbestos
fibre concentration in the exposure areas was 0.38
f/mL. This was in contrast with the findings of
another study reporting a concentration of 7√13
f/mL in an area 0.5√1.5 km from the asbestos plant
[20]. Therefore, it seems that exposure to asbestos
fibres is not only limited to workers in factories but
to those living in areas with environmental pollution
from asbestos fibres.
In a study from Turkey the authors measured
the airborne fibre concentration in a village environmentally exposed to asbestos, where they found
that the mean concentration was 0.012 f/mL [23],
a figure lower than ours. Their study and others
[10,24] showed a higher rate of MPM cases among
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
35
Table 8 Asbestos fibre concentrations in the asbestos processing plant
in greater Cairo and malignant pleural mesothelioma (MPM) cases by
factory operation
Site
no.
1
2
3
4
5
6
7
8
Total
Control
Operation
No.
No. of MPM
examined
cases
Milling
Manufacturing
Cutting
Store
Asbestos waste
Office
Industrial shops
Gate
43
89
78
23
45
61
123
25
487
979
1
0
0
0
3
0
0
0
4
1
Fibre concentrations
(f/mL-years)
Mean
SD
0.764
0.73
0.250
0.11
0.239
0.15
0.183
0.21
2.330
1.30
0.126
0.16
0.920
0.70
0.007
0.007
0.590
0.76
0.0021
0.013
F = 160; P < 0.001.
SD = standard deviation.
Table 9 Airborne asbestos fibre concentration in the surrounding areas outside the asbestos
plant and number of malignant pleural mesothelioma (MPM) cases
Area (distance from the asbestos plant)
No. of MPM cases
El-Wehda El-Arabia (100 m)
El Manshiya El Gadida (800 m)
Manshiyet El Horriya (1 km)
Ezbet Osman (1 km)
Manshiyet Abd El Moneem Riyad (2 km)
Ezbet Rostom (2.5 km)
Total
Control
39
17
8
9
6
4
83
1
Fibre concentration (f/mL)
Mean
SD
2.16*
0.16
0.04
0.01
0.021
0.0005
0.021
0.002
0.025
0.004
0.021
0.003
0.38
0.87
0.0021
0.013
F = 47.01; *P < 0.01.
SD = standard deviation.
those with higher intensity and cumulative
exposure to asbestos. This was also confirmed in our study which showed a positive
correlation between the asbestos fibre concentration and the number of MPM cases in
all studied areas. It should be stressed that
the high number of women detected with
mesothelioma is due to the long duration of
residency near the asbestos plant with high
permissible concentrations of asbestos.
The current study showed that MPM was
more prevalent in the environmentally exposed group (2.8%) than in the occupationally
exposed group (0.8%) reflecting the impact
of environmental air pollution with asbestos
on the prevalence of mesothelioma. This is in
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 10 Distribution of various indices of estimated exposure of people with and without
malignant pleural mesothelioma (MPM)
Measure of exposure
P-value
MPM
+ve (n = 88)
No.
%
√ve (n = 4291)
No.
%
Estimated intensity of
exposure (f/mL)
< 0.5
0.51√0.75
> 0.75
45
0
43
51.1
0.0
48.8
3350
0
941
78.1
0.0
21.9
Estimated cumulative
exposure (f/mL-years)
< 7.00
7.01√20
> 20
45
0
43
51.1
0.0
48.8
3130
139
1022
73.0
3.2
23.8
?2 = 32.4; P < 0.01
n = total number of people examined.
agreement with a South African report which
showed that one-third of the mesothelioma
cases were exposed as residents living near
asbestos mines and mills [25].
Comparing the prevalence of MPM
among the environmentally exposed group
in the different areas, our study showed
that MPM was more prevalent in El Wehda
El Arabia (4.5%), the nearest area near to
the asbestos plant, than other areas further
away. This agrees with the results of other
studies which detected excess cases in the
immediate neighbourhood of factories that
processed asbestos, mainly from the same
South African mines [26√28].
As regards monitoring of airborne asbestos fibre concentration, our study showed
that the mean occupational airborne asbestos concentrations (0.59 f/mL) were
significantly higher than the environmental
concentrations (0.38 f/ mL). Similar results
have been shown in previous reports on
airborne asbestos concentrations in Europe
and the United States of America [29].
Conclusion
This study provides additional quantitative
information on the relative risks of pleural
mesothelioma in subjects environmentally
exposed to asbestos. Of special interest is
the 26-fold excess risk of pleural mesothelioma due to environmental exposure. The
central role of latency and of cumulative
exposure in determining the risk of mesothelioma is of special importance. The
present study has an important message.
The mesothelioma epidemic will affect
areas without major industrial exposure to
asbestos. Though the importation of raw
asbestos into Egypt was banned at the end
of 2004, the threat of developing mesothelioma will remain for a considerable period
of time due to the latency period. Therefore,
a high index of suspicion is needed for early
detection of mesothelioma in persons with
environmental exposure to asbestos.
Successful interventions have already
been made by the government of Egypt
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
to prevent further exposure to asbestos by
placing a ban on its use. The focus now
shifts to small informal workshops which
use asbestos with a high risk of environmental exposure. Despite technical difficulties, the process of replacing asbestos with
safer materials, especially in small informal
workshops, is essential to prevent further
37
release of asbestos into the environment.
Industries with harmful environmental and
health impacts are heavily regulated in the
developed countries and these industries are
migrating to the developing world. Therefore great caution is needed, especially in
the construction industry with the growing
use of asbestos-based cement products.
References
1.
Selcuk ZT et al. Malignant pleural mesothelioma due to environmental mineral
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September 28√29, 2006. Krakow, Faculty
of Materials Science and Ceramics, AGH
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Egyptian journal of chest diseases and
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of asbestos-related diseases among
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
39
Infant exposure to environmental
tobacco smoke: Jordan University
hospital-based study
E. Badran,1 A.S. Salhab2 and M. Al-Jaghbir3
? оягси ЦсйДои зЛА ЦсйтщЛ лгЦзи гцАяоД?:?гАяжз АонгД гАйхш гАхМфМ?
ЬС ?йзяУЬ ж?
? ЦгМж глАшхяМ?║? зхо гАзыМЦ сАЕх?║?еМгЦД хоягД?
? яжМз Пг цмяжФг еЛА?220 ? ояс гАхгмкФД гАйзяУЬ ж АонгД гАйхш гАхМфМ нгАА гАсДи гцАФЛА ЦД гАзЦя АоЛ?:?гнАгАуэи?
? Фчо гсйФщй гцАЦЕгй гсйгЦяи?.?гАзМгои гнАгялМи Аьх гцАьщгА Мщ лгЦзи гцАяоД Мщ рМгягй яФйМДМи Цз цЦЕгЕйЦ?
? Фчо цхАш?.?гАяжз АймАМА ЦсйФМгй гАъФйМДДМ?
ЬС ? Фцнпй зМДгй ЦД хФА?║?мФА згогй гАйонДМ хДМ цщяго гцАяси?
? ЦД гАяжз ААйонДМ гАчясМ Мщ гЦАДрА ФзД ФлФо ЦсйФМгй МЦъД ътщЕг ЦД гАъФйМДДМ Мщ гАхФА?%60 ?зД йзяУЬ ж?
? еД ФлФо ЦсйФМгй чгхАи ААътщ ЦД?.)?ЦА?/? Дш?41? Ф?0.27 ?ЦА ФгЦАлгА?/? Дш?7.1 ? ЦД гАяжз (гАФсьМ?%36.4 ?АоЛ?
?МоА зЛА?
ЬУ )?гАъФйМДДМ Мщ Азгх кгЦМД цЦЕгй ЦД хДМ зятМД цЦ Пг ЦД цЦЬЕгй гАФАогД (Мщ гАМФЦ гцАФА цФ гАкгМД ЦД гАзЦя?
.? Фчо цФЛу гАхгмкФД хмгЦМи гАсъгД гАэЦУ яЗ ЕС щДМ ЦД гАйзяУЬ ж АонгД гАйхш?.?гАйзяУЬ ж огнА гАямЦ?
ABSTRACT To study exposure to environmental tobacco smoke during the first year of life, 220 infants
attending the outpatient paediatric clinic of the University of Jordan for routine visits with their mothers
were recruited to the study. Mothers completed a questionnaire about smoking habits of household
members, and urine samples were obtained from infants for analysis of cotinine levels. A total of 60.0%
of infants were reported to be exposed to passive smoking at home and 36.4% had detectable levels of
urine cotinine (mean 7.1 ng/mL, range 0.27√41 ng/mL). Detectable saliva cotinine levels in 8/20 mothers of neonates (1√2 days old) suggested in utero exposure. Recommendations are made to protect
this vulnerable population from tobacco smoke exposure.
Exposition des nourrissons Ю la fumИe de tabac ambiante : Иtude en milieu hospitalier
Ю l▓UniversitИ de Jordanie
R?SUM? Afin d▓Иtudier l▓exposition Ю la fumИe de tabac ambiante au cours de la premiХre annИe
de vie, nous avons recrutИ 220 nourrissons, accompagnИs de leur mХre, qui se rendaient pour des
visites de routine dans le service de consultations externes de pИdiatrie de l▓UniversitИ de Jordanie.
Les mХres ont rempli un questionnaire sur les habitudes tabagiques des membres du mИnage, et des
Иchantillons d▓urine ont ИtИ prИlevИs sur les nourrissons en vue d▓une analyse des niveaux de cotinine.
Au total, il s▓est avИrИ que 60,0 % des nourrissons Иtaient exposИs au tabagisme passif Ю domicile
et que 36,4 % prИsentaient des niveaux dИtectables de cotinine urinaire (moyenne 7,1 ng/ml, avec des
extrЙmes allant de 0,27 Ю 41 ng/ml). Les niveaux de cotinine salivaire dИtectables chez 8 mХres de
nouveau-nИs (de 1 Ю 2 jours) sur 20 semblaient indiquer une exposition in utero. Des recommandations
sont formulИes afin de protИger cette population vulnИrable de l▓exposition Ю la fumИe de tabac.
Department of Paediatrics; 2Department of Pharmacology; 3Department of Family and Community
Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan (Correspondence to A.S. Salhab:
assalhab@ju.edu.jo).
Received: 04/01/05; accepted: 09/08/06
1
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Introduction
Infant and early childhood exposure to environmental tobacco smoke is well recognized
as a health hazard [1]. Compared to adults,
infants are more susceptible to the damaging effects of environmental tobacco smoke.
The consequences of prolonged exposure in
close proximity to parental smoking are
exacerbated by infants▓ immature immune
and pulmonary systems [2], small body size
and higher rates of ventilation [3].
Community studies in Europe, United
States, Australia and elsewhere in the world
have suggested that smoking by mothers
and other household members results in increased risk of chronic childhood otitis media, coughs, wheezing, bronchitis, asthma
and sudden infant death syndrome (SIDS)
[1,4√6]. In the United States of America,
studies using biochemically validated data
suggest that up to 77% of infants less than 12
months of age are exposed to environmental
tobacco smoke [5,7]. In neighbouring Arab
countries such as the Syrian Arab Republic,
Lebanon, Saudi Arabia and Egypt, infant
exposure to environmental tobacco smoke
has also been reported [8√12].
For accurate estimation of infant exposure, measurement of urinary levels of cotinine, the proximate metabolite of nicotine,
is considered the most accurate indicator of
exposure to environmental tobacco smoke
[7,13]. Parents▓ reporting of household
smoking offers a further means of assessing
infant exposure and provides additional
information concerning the circumstances
of exposure [14,15].
There have been several investigations
of smoking habits in Jordan. The first in
1982 revealed that 71% and 44% of Jordanian adult men and women respectively
were active smokers [16]. Ten years later
Zmeili et al. reported that 72% of male patients and 21% of female patients admitted
to the department of medicine wards at the
University of Jordan hospital over a 1-year
period were active smokers, while 25%
of males and 70% of female patients were
passive smokers [17].
Given the lack of data in Jordan about
infant exposure to environmental tobacco
smoke, the present study aimed to assess
the prevalence of infant exposure to environmental tobacco smoke and to measure
the cotinine levels in infant urine. In additon, we assessed the extent of exposure by
infants to tobacco smoke through information collected by a detailed questionnaire
completed by the mothers.
Methods
Infants were recruited from 2 different settings of the University of Jordan hospital.
The first was the outpatient paediatric clinic
where infants were taken by their mothers
for routine check-ups, immunizations or
other medical care. A total of 200 infants
aged up to 12 months were recruited from
the clinic during the study period, August
2004 to May 2005. The other setting was the
neonatal intensive care unit, which was chosen to assess in utero exposure of neonates
to tobacco smoke. Here, a total of 20 infants
aged 1 to 2 days were recruited during the
same study period.
Urine and saliva collections
Mothers of all the infants were approached
by a trained research assistant for their
consent to complete a questionnaire and to
allow a urine sample to be obtained from
their infants. To collect the urine sample,
a cotton wool pad was placed in the nappy
of each infant [14]. The pad was removed
at the conclusion of the questionnaire, duration 10 to 15 minutes. The urine was
extracted by compression in a syringe [7].
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Urine samples were kept frozen at √20 ╟C
until analysis.
In addition, 20 saliva samples were collected from the mothers of the neonates
only. The collected saliva samples were
kept frozen at √20 ╟C until analysis.
Cotinine extraction
Cotinine from urine or saliva samples
was extracted according to the procedure
developed by Salhab et al. [18]. Briefly, 1.0 mL urine, 1.0 mL NaOH (5 N)
and 3 mL methylene chloride were mixed.
The mixture was vortexed for 2 min then
centrifuged at 1000 rpm for 5 min. The
organic layer was pipetted out and the aqueous layer was extracted once more with
3 mL methylene chloride; then the mixture
was centrifuged again. The combined methylene chloride layer was evaporated under
a nitrogen stream until dry. The residue
was dissolved in 50 ╣L acetone containing
100 pg/╣L lignocaine as external standard,
then 1 or 2 ╣L of this solution were injected into a gas√liquid chromatograph. The
recovery of cotinine under the described
conditions was 97% with a coefficient of
variation of═7%.
Cotinine chromatography
Cotinine extracted from urine or saliva
samples was analysed using capillary gas
chromatography [19]. Briefly, the analysis
was performed with the GC-2010 gas chromatograph (Shimadzu), fitted with fused
silica capillary SP-1000 column (15 m в
0.3 mm i.d.), film thickness 1.0 ?m (Rhom
and Hass). Cotinine was detected with
nitrogen√phosphorous detector. The gas
flow rates were: air 175 mL/min, hydrogen
4.5 mL/min and helium (carrier + makeup)
30 mL/min. The temperature of the oven
was programmed as follows: initial temperature was 150 ╟C for 2 min, then raised
41
to 230 ╟C at a rate of 20 ╟C per min (kept
at 230 ╟C for 7 min), then raised again at
250?╟C at rate 50═╟C per min (kept 1 min).
The temperatures of the injector and the
detector were 250═╟C and 300═╟C respectively. The retention times for lignocaine,
cotinine and nicotine were 6.0, 5.5 and 2.2
min respectively. Under these conditions,
the detection limits of nicotine and cotinine
were 5 pg and 10 pg respectively.
Environmental tobacco exposure
questionnaire
In addition to obtaining demographic data
about the infants and neonates, the questionnaire sought information about the
following: parents▓ occupations, mother▓s
level of education, family income, number
of people in the household, infant▓s current
health status (e.g. otitis media, wheezing,
etc.), current smoking status of the mother
and number of people in the household,
including the number of cigarettes smoked
per day.
As a follow-up, a telephone interview
was carried out 6 months after the initiation of the study in order to ask about the
health status of the infants. The telephone
interviews were conducted by the research
assistant under the direction of the paediatrician (E.B.). Only 181 (82.3%) of
the mothers responded; the remaining 39
(17.7%) could not be reached because
they had no telephone at home or they had
changed address or were absent at the time
of the call.
Statistical analysis
Data are presented as mean and standard error of the mean (SE). The smoking
prevalence was calculated and comparisons
between data were performed using 2-tailed
Student t-test. A P-value < 0.05 was considered statistically significant.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
2.6 (2.9)
0.03√12
(40.0%). The overall prevalence of tobacco
exposure in both groups was 36.4%. The
mean level of cotinine in the urine of the
neonates was significantly higher than in
the infants (t-test, P < 0.05). The cotinine
levels in the saliva samples of mothers were
1.5-fold higher than the cotinine levels of
the neonate urine. Cotinine was detected in
the urine samples of 7 neonates of 8 mothers whose saliva samples were cotininepositive. This is evidence of neonatal exposure in utero.
Table 3 summarizes the education level
of the infants▓ mothers. More than 90% of
the mothers were high-school graduates and
among these 35% were university graduates. Mothers of infants passively exposed
to tobacco smoke had a similar level of
education to mothers of nonexposed infants.
The annual income of families was not significantly different between the 2 groups.
Table 4 summarizes the health status of
181 infants as reported by mothers in the
follow-up interviews about selected ear,
nose and throat complaints. About one-third
of smoke-exposed infants had complaints
of recurrent cough, wheezing and otitis
media (infants may have had more than 1
ailment). The proportion of infants whose
mothers reported no complaints was higher
in the group not exposed to smoking than
the smoking-exposed group.
4.8 (2.0)
0.8√10.7
Discussion
Results
Table 1 summarizes the demographic characteristics of the 220 infants and neonates
who participated in this study; 56.4% were
male and 43.6% were female. The range of
body weight was 0.8√10.7 kg. Most infants
(89.5%) were breastfed by their mothers.
According to mothers▓ reports 132
(60.0%) of the infants were exposed to
environmental tobacco smoke, mostly by
household members such as fathers, brothers or sisters and between 1 and 3 smokers
were sharing the infant▓s home. Only 40.0%
of infants were living in a house without any
smokers (Table 1). There were 8 mothers
who admitted that they smoked.
Table 2 summarizes the extent of exposure to tobacco smoke of the 2 groups
of infants. Cotinine was detected in the
urine of 72 infants (36.0%) and 8 neonates
Table 1 Demographic data and household
smoking patterns for the study group of
infants and neonates
Variable
No. of infants and neoneates
No. of males/females
Age of infants(months)
Mean (SE)
Range
Body weight of infants(kg)
Mean (SE)
Range
Feeding of infants
No. breastfed
Smokers in the householda
No. of mothers smoking
No. of other family members
smoking
No. of households without a
smoker
Value
220
124/96
Some households had more than 1 smoker.
SE = standard error.
a
197
8
138
88
Infants less than 12 months of age are perhaps the group most vulnerable to the toxic
effects of tobacco smoke. Our finding that
36.4% of infants had detectable levels of
cotinine in their urine is therefore of concern. It suggests that existing community
education strategies about environmental
tobacco smoke exposure at home, especially the environment surrounding infants, are
failing to protect this vulnerable group of
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
43
Table 2 Tobacco smoke exposure in infant and neonate groups as detected
by the presence of urine and saliva cotinine in mothers
Variable
Total no. in study
Age range
Infants
200
Neonates
20
0.23√12 months
1√2 days
7
1
No. of mothers smoking
Urine cotinine (infants)
No. with cotinine
72
8
Mean (SE) cotinine level (ng/mL)
7.1 (0.8)
12.5 (2.6)*
Range (ng/mL)
0.27√41
1.97√21.5
Saliva cotinine (mothers)
No. with cotinine
0
8
Mean (SE) cotinine level (ng/mL)
√
18.7 (4.3)
Range (ng/mL)
√
5.8√42.2
*P < 0.05.
Table 3 Mother▓s educational level and annual family income for infants exposed and not
exposed to environmental tobacco smoke
Variable
Mother▓s level of education [No. (%)]
University
Diploma
High school
Less than high school
Annual income of the family
(Jordanian dinar)
Smokingexposed
(n = 80)
Not smokingexposed
(n = 140)
Total
(n = 220)
32 (40.0)
22 (27.5)
23 (28.8)
3 (3.8)
45 (32.0)
35 (25.0)
45 (32.1)
15 (10.7)
77 (35.0)
57 (25.9)
68 (30.9)
18 (8.2)
2284
2738
√
n = total no. of infants.
Table 4 Mothers▓ reports of ear, nose and throat complaints in infants exposed and not exposed
to tobacco smoke (n = 181)
Complaint
Recurrent cough
Wheezing
Otitis media
No complaint
Smoking-exposed
(n = 65)
No.
%
23
35.4
23
35.4
16
24.6
23
35.4
Not smoking-exposed
(n = 116)
No.
%
40
34.5
39
33.6
29
25.0
54
46.6
n = total no. of infants.
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Total
(n = 181)
No.
63
62
45
77
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
the population. Furthermore, the finding of
tobacco smoke exposure in 8 out of 20 neonates who were less than 48 hours of age is
alarming. This is strong evidence that those
neonates were exposed to tobacco smoke
by mothers during pregnancy. Again, this
suggests that physicians are failing to educate pregnant women not to smoke at least
during pregnancy. This finding warrants
further investigation in the future.
In our study, the prevalence of raised
cotinine levels was 36.4% among infants up
to 12 months, which is in agreement with
the reported prevalence among passivesmoking infants in Australia [20]. Furthermore, similar results have been reported
by neighbouring countries such as Egypt,
Syrian Arab Republic, Lebanon and Saudi
Arabia [8√12]. In contrast, the prevalence
of exposure in this study is lower than that
reported previously in the United States
of America using the biomarker cotinine,
which suggested that up to 77% of infants
less than 12 months of age were exposed to
environmental tobacco smoke [5,6].
The mothers▓ reports revealed that 60.0%
of infants were living with household smokers. This finding is in agreement with our
earlier report [17] and the results of other researchers in different countries. Smoking in
the presence of infants by mothers, fathers,
sisters and brothers and other visitors to the
family needs to be modified. Many of the
mothers in our study were university graduates and more than 90% of mothers had
graduated from high school. This good level
of education should facilitate educational
efforts to tackle the problem of smoking in
families in order to protect infants, children
and others from tobacco smoke.
The results of this study failed to correlate the extent of tobacco smoke exposure
with certain infant diseases. This may be
due to the small sample size of this study
(220 infants). However, in the literature,
it is documented that exposure to parental
smoking after birth exacerbates asthma,
pneumonia, lower respiratory tract infections, wheezing, meningitis, SIDS, and eye
and ear problems [21]. Further, it is estimated that more than 20═000 children are
hospitalized annually for respiratory illness
caused by parental smoking and over 1000
infants die from such health complications
[22]. Also, the correlation of environmental
tobacco smoke and health diseases such as
asthma, cough, wheezing and otitis media,
has been reported by several researchers in
the Eastern Mediterranean Region [9,10].
The role of paediatricians in reducing
tobacco exposure in children is important
since adverse health effects are often observed in very young children, including
diseases primarily caused by environmental
tobacco smoke exposure such as attenuated lung growth, shortness of breath, exacerbation of asthma, respiratory distress,
increased incidence of ear infection, and
SIDS. Paediatricians may play a leadership
role in protecting young people from such
ailments because they are the first physician
to deal with childhood diseases [23].
A number of issues need to be considered when interpreting the results of
this study. First, given the use of convenience sampling from one hospital setting,
care should be taken when generalizing to
other populations. Secondly, it is difficult
to compare the results of tobacco exposure
in utero by mothers in neonates (less than
2 days old) with other infants exposed to
environmental tobacco smoke. Thirdly,
the detection of cotinine in 8 out 20 saliva
samples from mothers puts the credibility
of mother▓s reports of smoking in doubt and
suggests that it may be necessary to obtain
biological samples from mothers in order to
evaluate infant tobacco smoke exposure.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Recommendations
Based on the results of our study, the following actions are recommended to reduce
the level of infant exposure to smoking in
Jordan:
∙ Increase women▓s awareness about the
dangers of smoking during pregnancy.
∙ Increase parental knowledge about how
to reduce infant exposure to environmental tobacco smoke.
∙ Change parents▓ pattern of smoking behaviour around infants.
45
∙ Establish community education strategies, e.g. smoke-free policies on public
transport and in child-care centres.
Acknowledgements
This research was funded by the deanship
of research through grant number 856/2004.
The authors gratefully acknowledge Mrs
Feryal Mubarak and Mrs Suha Al-Rahma
for their skilful technical help and Mrs Wafa
Al-Shaer for her excellent secretarial work.
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findings and discussion. Tobacco control,
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Release of the Arabic edition of MPOWER
The Arabic edition of the MPOWER report was published in October
2008. The report presents the first comprehensive data on global tobacco use and control efforts. It shows that currently most countries in
the world do not have adequate information or policies about tobacco
use and trends, and 6 new policies are recommended for immediate
adoption by countries. These policies will support the full implementation of WHO FCTC. In other countries where FCTC is not yet officially
adopted they will pave the way for its adoption. More information about
this publication is available at: http://www.emro.who.int/tfi/tfi.htm
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
47
Evaluation of an educational intervention for farming families to protect
their children from pesticide exposure
T.M. Farahat,1 F.M. Farahat1and A.A. Michael1
?йчММЦ гАйонгАй гАйкчМщМи мАгЦМи гцАьщгА ЦД гАйзяУЬ ж ЦАхМогй гЕАФг ЬЦ Мщ гАзгфгАй гАчгьДи Мщ гЦАДгьч гАргязМи?
? згьщ зФж ЦМнгфМА?║? щМуА ЦуьщЛ щямгй?║?йшяМо мЦЦо щямгй?
║? цзоСЬ гАхгмкФД ЦогнАи йкчМщМи ЦДгсхи АйкчМщ гАзгфгАй гАчгьДи Мщ гЦАДгьч гАрягзМи Мщ мЦгщыи гЦАДФщМи хЦяу?:?гнАгАуи?
? щчо ФрСЬ зФг гбАхга ФгцАЦЕгй?.?ЦД цлА мйсДМ ЦзгящЕЦ ФЦЦгясгЕйЦ гЦАйзАЬчи хмгЦМи гцАьщгА ЦД гАйзяУЬ ж ЦАхМогй гЕАФгЦ?
? кЦ чМСЬЦ гАхгмкФД?.? Фгмои зД ьяМч гЦАмгяжи ФгцАняЛ зД ьяМч ЦтгЕои щАЦ щМоМФМ?║?зтФгфМ Пг зЛА лЦЦФзС й ЗСМ йояМх?
? ФгАкгДМи?║? гцАФЛА чхА гАйояМх?:? ФпАъ Мщ кгАк лАсгй?║?чояи йпъЬ я гЦАзАФЦгй ФмйсЬ Д гЦАгЦясгй АоЛ гбАхга ФгцАЦЕгй?
? ФФлоФг цД гАДчгь гЦАмяри хгАДсхи ААЦзгящ ФгЦАгЦясгй ъгДй?.? ФгАкгАки хзо тЕя ЦД гДчжга гАйояМх?║?хзо цсхФзДМ?
.П?хзо гАйояМх цзЛА АоЛ гАтхгх ФгАщфгй гцАъкя йзАМ ПгЦ ЦД гЦАтгяъДМ зДЕг АоЛ цФАфъ гАпМД ЕЦ цъях сД Пг ФцчА йзАМгЦ?
?ъгЦ йхМДЬ ЕАЦ цД цога гЦАзящи ФгЦАгЦяси цщжА АоЛ гЦАлЦФзи гАйМ тгЕой гАщАЦ гАщМоМФМ ЦД гЦАлЦФзи гАйМ мяжй?
?мйсД гЦАзящи хзо гАйояМх АоЛ ъАйг гЦАлЦФзйДМ ъгДй цзЛА хтъА МУзЗ йоУЬ хЕ емугфМ Пг?
ЬУ ? ФцД гАДчгь гЦАмяС рС и Мщ?║?гЦАмгяжи?
.?ЦД гАДчгь гЦАмяС рС и Мщ гЦАгЦяси?
ABSTRACT A culturally appropriate educational intervention was developed and directed towards farming
families in Menoufia governorate, Egypt, to improve their knowledge and practices in protecting their children from exposure to pesticides. Parents were randomly assigned to either a lecture or video╜tape training
group. Ability to recall information or improve practices among parents was evaluated in 3 sessions: pretraining and 2 weeks and 1 month after training. Knowledge and practice scores after training of younger
and more educated participants were significantly higher than older, less educated participants. Knowledge
and practice performance of the videotape group was better than the lecture group and in both groups the
improvement of knowledge scores after training was significantly higher than that of practice scores.
?valuation d▓une intervention Иducative visant Ю aider les familles d'agriculteurs Ю protИger leurs
enfants contre l▓exposition aux pesticides
R?SUM? Une intervention Иducative culturellement adaptИe a ИtИ mise au point Ю l▓intention des
familles d'agriculteurs du gouvernorat de Menoufia (?gypte) afin de leur permettre d▓amИliorer leurs
connaissances et leurs pratiques en ce qui concerne la protection de leurs enfants contre l▓exposition
aux pesticides. Les parents ont ИtИ rИpartis de faГon alИatoire dans deux groupes de formation, dont
l▓un a assistИ Ю des cours magistraux et l▓autre a visionnИ des vidИos. La capacitИ des parents Ю se
souvenir des informations ou Ю amИliorer leurs pratiques a ИtИ ИvaluИe lors de trois sessions : avant
la formation, deux semaines aprХs, et un mois aprХs. Les scores obtenus aprХs la formation en
matiХre de connaissances et de pratiques par les participants les plus jeunes et les plus instruits
Иtaient significativement plus ИlevИs que ceux obtenus par les participants plus БgИs et moins instruits.
Les rИsultats atteints en matiХre de connaissances et de pratiques par le groupe qui avait suivi la vidИoformation Иtaient supИrieurs Ю ceux atteints par l▓autre groupe, et dans les deux groupes, l▓amИlioration des
scores relatifs aux connaissances aprХs la formation Иtait significativement plus importante que celle des
scores relatifs aux pratiques.
Department of Community Medicine and Environmental Health, Faculty of Medicine, University of Menoufia,
Egypt (Correspondence to F.M. Farahat: fmfayssal@yahoo.com).
Received: 26/12/05; accepted: 28/08/06
1
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Introduction
In recent years there has been heightened
concern over the potential impact of environmental exposure to chemicals on the health
of children [1]. Pesticides represent one particular group of environmental contaminants
to which children in agricultural communities
are inequitably exposed [2].
Pesticides persist in dust when they are
used around homes, and those used outdoors
end up in soil and are brought into the house
on shoes and pets. Pesticides in soil and dust
in indoor environments persist longer than
they do outside, where exposure to sun and
rain helps to break down pesticide residues
[3]. Children and infants can be particularly affected by pesticides because of their
physiological immaturity and greater risk of
exposure to pesticides. The difference in risk
relates more to different levels of exposure
than to toxicological vulnerability by age [4].
The work and living environments in agricultural communities in developing countries
provide numerous sources of pesticide exposure. Keifer et al. categorized these sources as
avoidable (e.g. diluting and mixing pesticides,
applying pesticides, being sprayed), unavoidable (e.g. drifts, contact with residues) and
unknown (e.g. contaminated water, contaminated fruits and vegetables) [5]. This pattern
of exposure differs from those reported in
other studies due to the relatively high level
of exposure, lack of protective measures and
lack of awareness by the population about
the hazards and long-term effects of many
pesticides used [6]. Farmers▓ housing can
be a major source of contamination through
proximity to sprayed fields and exposure
to drifts during and following application
of pesticides [7]. Farmers themselves may
contaminate their homes by inadvertently carrying pesticides from work on their clothes,
skin, hair, tools and vehicles [2].
Pesticides are widely used in agriculture
in Egypt. Approximately 10═000 to 60═000
tons of pesticides are used annually in agriculture or for public health reasons [8]. Safety
measures are generally poorly applied and the
general population lacks proper knowledge
about safe handling and hazards of these
chemicals [9].
This study in Menoufia governorate in
Egypt aimed to evaluate the effectiveness of
culturally appropriate educational interventions directed towards farming families to
protect their children from the hazards of
pesticide exposure.
Methods
Location and sample
The study was conducted in 2 Egyptian villages (Ganzoor and Monsh▓at Sultan, village 1 and village 2 respectively) located in
Menoufia governorate, where agriculture is
the main occupation. They were randomly
selected from Menoufia villages that have
family health centres. The family health centre ensures that every family in the village has
a file to allow follow-up of the health of all
family members. This study was conducted
at the family health centre of each village.
Each centre has a well-equipped training unit
that includes 1 big room for health education,
4 small rooms for interview and a waiting
hall and playground used for accompanying
children.
A sample of 100 families registered at
the family health centre from each village
was randomly selected to participate in the
study. Inclusion criteria were: living in homes
among agricultural fields, having at least 1
preschool child (aged 4√6 years) and the family▓s main occupation being farming.
Questionnaire design
A questionnaire was designed and validated
to assess the pesticide-related knowledge
and practice of farmers. A pilot study was
conducted to test the reliability of the ques-
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
49
tionnaire. Irrelevant and difficult items were
omitted or modified to be easily understood by
participants with limited years of education.
The questionnaire included personal
and family data, previous history of pesticide poisoning for any family member,
attendance at any previous health education
session on pesticide hazards, parents▓ perceived needs for future relevant education
and parents▓ preferences for the education
method.
Knowledge questions included items
about different kinds of pesticides, routes
of exposure, short- and long-term effects of
pesticides on human health, vulnerability of
children, methods of protecting themselves
and their families from exposure (e.g. hand
washing, separating work clothes, timing of
entry after application), alternative methods
to combat pests in the field and at home
(e.g. keeping house clean, rapid disposal
of waste, keeping food and drinks covered,
using window screens).
Practice questions focused on frequency
of pesticide use at home and on the farm,
possible actions that could be taken by parents to reduce their children▓s exposure to
pesticides whether at the home or farm (e.g.
using minimal amount of pesticides and as
needed only, keeping pesticides away from
children, never allowing children to use
pesticides, avoiding use of pesticides on
children▓s bodies, keeping clothes and toys
of children and food or drink away during
pesticides application, teaching children to
wash their hands before eating and after
playing, washing all vegetables and fruits
before eating, never using empty pesticide
containers for any other purpose).
A total of 15 health education intervention
sessions were implemented in each village,
with about 10 participants per session.
The 2 villages were randomly assigned
to either lecture (village 1) or video (village
2) training sessions. A lecture and a video╜
tape on the hazards and safe use of pesticides were developed by the investigators
specifically for the purpose of this study.
Both parents were required to complete 3
consecutive educational sessions, 2 weeks
and 1 month apart. Child care was provided
for the accompanying children during the
training of parents.
During the 1st session demographic
and pre-training knowledge and practice
questionnaires were administered individually through an interview to assist less welleducated participants. After completion of
the questionnaires either a lecture or video╜
tape session, according to the village, was
provided to parents (about 10 participants
per session). The lecture and videotape
included the same information that was
asked about in the pre-training questionnaire. They lasted for 30 minutes followed
by 10 minutes discussion. All lectures and
discussions were administered by the same
investigator.
In the 2nd and 3rd sessions, participants
were tested for their ability to recall information or change in practice after attending
the lecture or watching the videotape. To
measure change in knowledge and/or practice, an identical pre- and post-training questionnaire was used. Knowledge and practice
scores were calculated for each participant.
The maximum total knowledge score was 23
and total practice score was 15.
Intervention
The study was conducted on Thursdays
(between 12.00 and 16.00 hours). It was
carried out in 2 phases: village 1 (March√
June 2004); village 2 (July√October 2004).
Statistical analysis
Statistical analysis was done using SPSS,
version 11.00. Student t-test was used to
compare the means of the 2 groups. ANOVA test was used to compare knowledge
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and practice scores in the consecutive sessions, followed by Student Newman√Keuls
post hoc test for multiple comparisons.
Chi-squared test with Yates continuity correction or Fisher exact test were used when
appropriate. Level of significance was determined at P-value ? 0.05.
The reliability of questionnaire items
was tested by entering data from the pilot
study and obtaining Cronbach alpha coefficients for knowledge and practice items.
Cronbach alpha coefficients were 0.723 and
0.897 respectively.
Results
Demographic characteristics
Table 1 shows the demographic characteristics
of the participating families. There were 100
mothers and 65 fathers from village 1 compared with 88 mothers and 44 fathers from village 2 who completed all 3 training sessions.
In both villages, the number of rooms in
the houses of participating families ranged
from 1√5 rooms with a mean of 2.8 (standard deviation 0.8). Water supply was either
through wells (48%), taps (40%) or both
(14%). Only 10% of the houses had floors
made of tiles, 40.5% were cement and 49.6%
were mud. Most houses (94.0%) had a room
for domestic animals (e.g. cows, buffaloes,
goats, sheep), either inside (50.5%) or outside
the home (43.5%). Window screens were reported to be present in 55.5% of the houses.
All participating families were living in
houses among agricultural fields and 78%
of the houses were near uncovered water
channels.
Parents▓ preference for the
educational method
None of the parents had received any previous education about pesticide exposure. Most
of them (81.6%) agreed that pesticide-related
training programmes should be implemented
Table 1 Demographic characteristics of
participating families
Variable
Lecture
group
Village 1
(n = 165)
Participating
individuals [No, (%)]
Mothers
100 (60.6)
Fathers
65 (39.4)
Mean (SD) family
size (No.)
4.42 (1.1)
Mean (SD) age of
parents (years)
29.3 (5.1)
Parent▓s education
[No, (%)]
Illiterate or read and write
74 (44.9)
Secondary school or higher
91 (55.2)
Videotape
group
Village 2
(n = 132)
88 (66.7)
44 (33.3)
4.93 (0.9)
30.9 (7.5)
53 (40.2)
79 (59.9)
n = total number of participants.
each year (i.e. before the season for pesticide
application to the cotton crop). Videotape
was the preferred method of training for
63.5% of participants compared with 30.5%
who preferred a lecture, while no preference
was expressed by 6.0% of the participants.
Pesticide application inside and
outside homes
All participating families were using pesticides at home and in the fields. Inside the
home, most of the families (80.5%) frequently applied pesticides (4√7 days/week)
as compared to 19.5% with infrequent application (1√3 days/week). All families
were using flying insect killers (main ingredients include tetramethrin, sumithrin,
pyrethrin, piperonyl butoxide) in different
forms, mainly mats (94.6%) and aerosols
(55.5%); 28% were applying crawling insect killer powder (main ingredients include
tetramethrin and malathion); 26% were
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
applying malathion on the hair of their children to protect them against hair lice; while
19% were occasionally using rodenticides
for rats (Table 2).
In the fields, 37% of families were applying pesticides themselves and 63% hired
workers to apply pesticides to their crops.
Pesticides applied in the fields were organo╜
phosphates (59.0%), carbamates (40.5%)
and pyrethroids (28.5%) (Table 2). Pesticides
were usually applied in the form of liquid
sprayed using special back-held machines.
Assessment of knowledge and
practice among parents
Knowledge and practice questions as well
as the percentage of participants▓ responses are presented in Tables 3√5 for the 1st
session (pre-training) and the 2nd and 3rd
sessions (2 weeks and 1 month later). In
both groups, the knowledge scores of par-
51
ticipants improved significantly in the 2nd
and 3rd sessions, as compared to the pretraining session. Although the practice scores
of both groups improved in subsequent sessions, the changes were not significant (Table 6). On the other hand, knowledge and
practice scores did not show any significant
differences between lecture and videotape
groups in any of the sessions (Table 6). However, knowledge and practice performance
of the videotape group was better in the 2nd
and 3rd sessions as compared to the lecture
group. At the same time, in the lecture
and videotape groups, the improvement of
knowledge scores was significantly higher
than that of practice scores.
The parents with high school or university degree showed significantly greater
improvements in knowledge and practice
than parents who were illiterate or only able
to read and write (Table 7).
Table 2 Use of pesticides at home and on the farm by participating families by method of
intervention
Variable
Frequency of pesticides use at home
Frequent (4√7 days/week)
Infrequent (1√3 days/week)
Pesticides used at home
Flying insect killers
Mats
Aerosols
Crawling insect killers powder
Rodenticides (for rats)
Head lice killers
Pesticides used at farm
Organophosphate
Carbamates
Pyrethroids
Lecture group
(n = 165)
No.
%
Videotape group
(n = 132)
No.
%
Both groups
(n = 297)
No.
%
130
35
78.8
21.2
109
23
82.6
17.4
239
58
80.5
19.5
165
94
50
36
47
100.0
57.0
30.3
21.8
28.5
116
71
32
20
29
87.9
53.8
24.2
15.2
22.0
281
165
82
56
76
94.6
55.5
27.5
19.0
25.5
92
78
55
55.8
47.3
33.3
83
42
30
62.9
31.8
23.0
175
120
85
59.0
40.5
28.5
n = total number of participants.
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Table 3 Comparison of knowledge of lecture and videotape groups regarding children▓s
exposure to pesticides, pre-training, and 2 weeks and 1 month after the training
Knowledge
Pre-training
Lecture
Video
(n = 65)
(n = 32)
%
%
Different types of pesticides
Know 4√6 types
Know 2√3 types
Know 1 type
Route of exposure to pesticides
Inhalation
Ingestion
Dermal
Children are more vulnerable to
pesticides toxicity:
Agree
Disagree
Health effects of pesticides on
children include:
Chest allergy
Skin allergy
Hepatotoxicity
Cancer
Nephrotoxicity
Decrease child attention
Decrease child memory
Decrease child intelligence
Alternate methods to minimize
use of pesticides at home
Keep house clean
Rapid disposal of wastes
Keep food and drinks covered
Use of window screen
Alternate methods to minimize
use of pesticides at farm
Continuous cleaning of plants
Proper disposal of wastes
Use of natural methods
Consult the agricultural authorities
2 weeks after
Lecture
Video
(n = 65)
(n = 32)
%
%
1 month after
Lecture
Video
(n = 65)
(n = 32)
%
%
54.0
23.0
23.0
58.0
21.0
21.0
83.0
14.0
3.0
91.0
7.0
2.0
78.0
19.0
3.0
85.0
14.0
1.0
64.0
74.0
49.0
68.0
71.0
51.0
91.0
93.0
89.0
94.0
98.0
92.0
89.0
92.0
85.0
93.0
99.0
91.0
74.0
26.0
78.0
22.0
100.0
0.0
100.0
0.0
100.0
0.0
100.0
0.0
76.0
73.0
58.0
56.0
50.0
44.0
36.0
40.0
76.0
74.0
55.0
60.0
55.0
41.0
38.0
42.0
90.0
88.0
87.0
83.0
86.0
79.0
75.0
85.0
92.0
92.0
96.0
94.0
91.0
83.0
83.0
82.0
89.0
90.0
85.0
82.0
86.0
74.0
73.0
81.0
92.0
90.0
91.0
90.0
88.0
80.0
80.0
79.0
75.0
56.0
69.0
58.0
77.0
53.0
66.0
61.0
100.0
90.0
89.0
95.0
100.0
95.0
100.0
100.0
100.0
86.0
90.0
95.0
100.0
93.0
100.0
100.0
64.0
45.0
38.0
62.0
47.0
42.0
76.0
79.0
68.0
82.0
87.0
89.0
74.0
75.0
65.0
80.0
87.0
85.0
26.0
24.0
65.0
83.0
61.0
79.0
n = total number of participants.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
53
Table 4 Comparison of practices of lecture and videotape groups to reduce exposure of their
children to pesticides at home, pre-training, and 2 weeks and 1 month after the training
Practice
Apply pesticides as needed only
Pre-training
Lecture
Video
2 weeks after
Lecture
Video
1 month after
Lecture
Video
(n = 165) (n = 132) (n = 165) (n = 132) (n = 165) (n = 132)
%
%
%
%
%
%
41.0
43.0
81.0
88.0
79.0
92.0
Avoid use of pesticides on children▓s bodies
83.0
82.0
99.0
97.0
99.0
97.0
Never allow children to use pesticides
61.0
63.0
92.0
95.0
91.0
96.0
Keep children▓s clothes and toys away during pesticide application
43.0
40.0
92.0
94.0
90.0
93.0
Keep food and drinks away during pesticide application
76.0
78.0
94.0
94.0
93.0
95.0
Teach children to wash hands before eating and after playing
58.0
56.0
87.0
92.0
85.0
90.0
Wash vegetables and fruits before eating
89.0
88.0
99.0
99.0
100.0
100.0
69.0
54.0
71.0
64.0
89.0
90.0
96.0
92.0
85.0
88.0
95.0
89.0
Never use empty pesticide containers in other purposes
Keep pesticides away from children
n = total number of participants.
Following training, about 60% of the
participants reported that they could completely stop the use of pesticides inside
the home in comparison with 30% before
the educational programme. However,
none thought that they could completely
stop the use of pesticides in the fields. Of
participating mothers, 5% and 8% (in the
lecture and videotape groups respectively)
mentioned that they had already stopped
the application of pesticides inside their
homes completely after the education intervention.
Discussion
The main objective of health education
programmes is to change knowledge and
consequently practices [10]. Researchers
usually assess only the immediate change
in knowledge after implementation of educational interventions. The current study
was conducted to measure the immediate
change as well as the sustainability of information gained after implementation of
2 different and commonly used educational interventions (lecture and videotape).
Both knowledge and practice of agricultural families were assessed and followed
up for 2 consecutive sessions, 2 weeks and
1 month apart. Most participants lacked
sound knowledge and proper practice about
handling of pesticides, whether at home
or at the farm. This may be attributed to
the absence or deficiency of health education programmes directed towards those
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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Table 5 Comparison of practices of lecture and videotape groups to reduce exposure of their
children to pesticides at the farm, pre-training, and 2 weeks and 1 month after the training
Practice
Pre-training
2 weeks after
1 month after
Lecture
Video
Lecture
Video
Lecture
Video
(n = 165) (n = 132) (n = 165) (n = 132) (n = 165) (n = 132)
%
%
%
%
%
%
Close house windows and doors during application in nearby farm
44.0
42.0
80.0
86.0
76.0
82.0
Never allow children in the field during spraying
38.0
42.0
98.0
98.0
95.0
96.0
Never allow household utensils to be used in diluting, mixing or application of pesticides
66.0
77.0
100.0
100.0
100.0
100.0
Father▓s contaminated clothes kept away from house
34.0
41.0
91.0
95.0
88.0
95.0
Father showers after use of pesticides in the farm
57.0
51.0
71.0
72.0
74.0
71.0
Dispose of empty containers in a safe place
74.0
77.0
89.0
91.0
91.0
92.0
n = total number of participants.
Table 6 Mean knowledge score of the lecture and videotape groups, pre-training, and 2 weeks
and 1 month after the training
Performance
Knowledge
Pre-training
2 weeks after
1 month after
P-valuea
Practice
Pre-training
2 weeks after
1 month after
P-valuea
Lecture group (n = 165)
Mean (SD) score
Videotape group (n = 132)
Mean (SD) score
P-value
14.20 (4.17)
21.10 (4.30)b
20.18 (4.90)b
< 0.001
14.04 (2.78)
22.60 (4.20)b
21.30 (4.80)b
< 0.001
> 0.05
> 0.05
> 0.05
9.32 (4.22)
10.82 (3.96)
10.52 (3.45)
> 0.05
9.05 (4.05)
11.20 (3.25)
11.01 (3.47)
> 0.05
> 0.05
> 0.05
> 0.05
a
b
ANOVA test.
Significant compared to pre-training (P < 0.05).
n = total number of participants; SD = standard deviation.
high-risk groups in Egypt or because these
programmes are improperly presented. Amr
stated that the adverse effects of pesticide
exposure in Egypt are due to lack of proper
knowledge of safe handling of pesticides
and that safety measures are generally
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
55
Table 7 Mean knowledge and practice scores of the lecture and videotape groups according to
level of education, pre-training, and 2 weeks and 1 month after the training
Performance
Knowledge
Pre-training
2 weeks after
1 month after
Practice
Pre-training
2 weeks after
1 month after
Lecture group
Videotape group
Illiterate/read High school/ P-value Illiterate/read High school/ P-value
university
and write
university
and write
(n = 79)
(n = 53)
(n = 91)
(n = 74)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
score
score
score
score
13.90 (1.50)
20.00 (1.90)
19.10 (1.70)
14.50 (2.90)
23.10 (2.26)
22.00 (2.88)
> 0.05
< 0.001
< 0.001
13.65 (1.63)
20.25 (1.84)
19.36 (1.87)
14.31 (2.84)
23.31 (2.74)
22.53 (2.81)
> 0.05
< 0.001
< 0.001
8.99 (1.30)
9.88 (2.10)
9.37 (2.30)
9.67 (3.24)
11.76 (1.88)
11.67 (1.50)
> 0.05
< 0.001
< 0.001
8.77 (1.61)
9.91 (2.32)
9.74 (2.21)
9.65 (3.70)
11.93 (2.30)
11.84 (2.20)
> 0.05
< 0.001
< 0.001
n = total number of participants; SD = standard deviation.
poorly applied by both the general public
and pesticide workers [9].
Changing behaviour is usually more
difficult although it may be more sustainable
than knowledge [11]. Using non-traditional
appropriately designed programmes that
depend more on visual memory is more
likely to ensure sustainability of the
knowledge gained as well as changes in
practice [12]. Visual memory is rapidly
acquired and longer-standing than auditory
memory═[13].
In the current study, after implementation of educational intervention programmes (lecture and videotape), there was
an immediate and sustained improvement
in the knowledge and practice of families.
However, knowledge showed a significantly greater improvement than practice.
There are many factors that could affect
knowledge gain and behaviour modification. The most important are age, educational level and cultural appropriateness
of the educational intervention [10]. In the
current study, the lecture and videotape
were prepared to include information from
the same environment where participants
were living. However, the videotape was
more culturally appropriate as it included
pictures and movies that showed the right
and wrong practices and was designed and
prepared inside homes and in the fields of
the participants.
Moreover, about 43% of participants
were illiterate or only able to read and
write, so videotapes with pictures and movies would ensure sustainability of gained
knowledge. At the same, well-educated
parents were better able to acquire information and change their behaviour than less
educated parents.
The mean age of the participants was
around 30 years, which may be an appropriate age for knowledge gain but is not the most
appropriate age for behaviour modification.
This raises the issue of implementing pesticide educational intervention programmes
as early as possible because younger people
are more likely to retain the knowledge and
change their practices [14,15].
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Conclusion
Pesticides represent a major environmental
hazard. The toxic effects of pesticides are
a concern among high-risk groups, especially children. Development of culturally
appropriate educational intervention programmes is essential to protect the children
of farming families from the hazards of
pesticide exposure. Video training is better
than lectures in assuring knowledge gain
and probably enhancing retention. Knowledge is easier to change than practice, which
requires continuous education and a supportive environment.
Acknowledgements
This article was supported in part by grant
EMRO/RPC/ TSA 03/102 from the Research and Policy Cooperation, World
Health Organization Regional Office for
the Eastern Mediterranean.
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Ecobichon DJ. Occupational hazards of
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Farahat TM et al. Neurobehavioural effects
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Simcox NJ et al. Pesticides in household dust and soil: exposure pathways
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Amr MM. Pesticide monitoring and its health
problems in Egypt, a third world country.
Toxicology letters, 1999, 107:1√13.
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education in primary health care. Geneva,
World Health Organization, 1988:22√3.
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Healthy environments for children. Initiating
an alliance for action. Geneva, World Health
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Keifer M et al. Symptoms and cholinesterase activity among rural residents living
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Rosenstock L et al. Chronic central nervous system effects of acute organophosphate pesticide intoxication. The Pesticide
Health Effects Study Group. Lancet, 1991,
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McCauley L. Reducing pesticide exposure
in minority families. Research Triangle Park,
North Carolina, United States Environmental Protection Agency, 2001.
11. Spreen O, Strauss E. A compendium of
neuropsychological tests: administration,
norms, and commentary, 2nd ed. Oxford,
Oxford University Press, 1998.
12. Coults LC, Hardy LK. Teaching for health,
1st ed. London, Churchill Livingstone, 1985.
13. Lezak MD. Neuropsychological assessment, 3rd ed. Oxford, Oxford University
Press, 1995:335√44.
14. Caldwell JC. Maternal education as a factor
in child mortality. World health forum, 1981,
2(1):75√8.
15. Steen W, Bond A, Mage D. Agricultural
health study-exposure pilot study report.
Research Triangle Park, North Carolina,
United States Environmental Protection
Agency, 1997.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
57
Injury epidemiology in Kermanshah:
the National Trauma Project in
Islamic Republic of Iran
M. Karbakhsh,1 N.S. Zandi,1 M. Rouzrokh2 and M.R. Zarei1
? гЦАятФз гАФьДМ ААяжФм Мщ ЦлЕФяМи еМягД геАсгАЦМи?:?ФхгфМгй геАугхгй Мщ ъяЦДтгЕ?
? мЦЦо яжг ргязМ?║? мЦсД яФрян?║? Дъгя угмАМгД рДоМ?║?лЦчгД ъгяхнт огФяМ?
? Мщ оягси Цсйзяжи тЦАй ЦлМз ЦяЛж гАяжФм гАпМД зФлАФг ЦАои цяхз ФзятМД сгзи зЛА гцАчА?:?гнАгАуи?
? Фчо хАш зооЕЦ?║? ФЕФ Цяър геАмгАи гАйзАМЦМ гАФмМо Мщ ЦоМДи ъяЦДтгЕ?║? Мщ ЦсйтщЛ ьгАчгМД?║?нгАА цяхзи цтЕя?
.? ФъгД цшАх гЦАяЛж ЦД гАпъФя гАзгьАДМ шяМ гЦАйзАЬЦДМ?.)19.9( ? сДи?34.7 ? ФъгД ФсьМ цзгЦяЕЦ?.П? ЦяМжг?779
? ФъгД гЦАтги?.? ФгАзДщ хДМ гцАщяго?║? ФгАсчФь?║?ФйхДМ цД цъкя Цсххгй геАугхгй тМФз Пг ЕМ гмАФгок зЛА гАьяч?
? ДлЦй?║%7.8 ? ФхАшй Дсхи гАФщМгй геАЦлгАМи?.?ЕЦ гцАъкя зяжи АеАугхгй ЦД хДМ жмгМг гмАФгок зЛА гАьУ яУ ч?
? Фчо оАЬй Дйгфл гАхмк цМж Пг зЛА цЦЕМи яжФм гАяцс хФущЕг гЦАФчз?.?) зД еугхгй Мщ гАяцс?%78.7( ?цшАхМйЕг?
.?гАйятмММ гАяфММс АеАугхгй?
ABSTRACT In a cross-sectional study, all trauma patients hospitalized for 24 hours or more over a
4-month period in Taleghani hospital, the only referral teaching centre in Kermanshah city, were studied
(n = 779). Mean age was 34.7 (standard deviation 19.9) years. Male, unemployed and illiterate patients
predominated. Road traffic accidents, falls and interpersonal violence were the most common mechanisms of injury. Among road traffic accident victims, pedestrians were the most vulnerable group. A total
of 7.8% of patients died, mostly due to head injuries (78.7%). Our findings also showed the importance
of head trauma as the main anatomical site of injury.
?pidИmiologie des traumatismes Ю Kermanshah : le projet national sur les traumatismes en
RИpublique islamique d▓Iran
R?SUM? Une Иtude transversale a ИtИ menИe sur tous les patients atteints de traumatismes et
hospitalisИs pendant 24 heures au minimum sur une pИriode de quatre mois Ю l▓hТpital de Taleghani,seul
centre spИcialisИ universitaire de Kermanshah (n = 779). La moyenne d▓Бge Иtait de 34,7 ans
(Иcart type 19,9). Les patients de sexe masculin, sans travail et analphabХtes Иtaient les plus
nombreux. Les accidents de la circulation, les chutes et la violence interpersonnelle Иtaient les
mИcanismes de blessure les plus courants. Parmi les victimes d▓accidents de la circulation, les piИtons
reprИsentaient le groupe le plus vulnИrable. Au total, 7,8 % des patients sont dИcИdИs, la plupart de
traumatismes crБniens (78,7 %). Nos rИsultats ont Иgalement montrИ l▓importance de la tЙte en tant que
principale zone anatomique touchИe par les blessures.
Sina Trauma Research Centre, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
(Correspondence to M. Karbakhsh: mkarbakh@sina.tums.ac.ir).
2
Department of Paediatric Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Islamic
Republic of Iran.
Received: 12/06/06; accepted: 06/08/06
1
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Introduction
Injuries account for about 12% of the world▓s
burden of disease [1]. Injuries, irrespective
of their intent or cause, have a major impact
on the health system which provides care
and support for victims [2]. Young people
between the ages of 15 and 44 years≈the
most economically productive members of
the population≈account for almost 50% of
the world▓s injury-related mortality [3].
In many developing countries, particularly in Asia, documentation of health statistics is limited and as a result the effect
of trauma is poorly understood [4]. There
are several articles describing different
aspects of trauma in the Islamic Republic
of Iran, e.g. road traffic accidents (RTA),
paediatric trauma, burns, prehospital care,
but comprehensive studies which give a
broader view on patterns of trauma in the
country are limited [4,5]. In this regard,
Sina Trauma and Surgery Research Centre,
the first registered trauma research centre in
the Islamic Republic of Iran, carried out the
National Trauma Project in 8 major cities
of the country to provide a national profile
of trauma, the circumstances in which it
occurs and the characteristics of victims.
The aim of this study was to demonstrate
the characteristics of trauma patients and
the pattern of trauma in one of these major
cities, Kermanshah.
Methods
In this cross-sectional study, all consecutive patients admitted to Taleghani hospital
for 24 hours or more over a 4-month period
(from October to February 2004) were included (n = 779). Taleghani hospital is the
only referral teaching hospital in Kermanshah, a city located in the western part of the
Islamic Republic of Iran, with a population
of about 822═921 in 2005. This hospital is
recognized by the public as the only trauma
centre admitting injured patients around
the clock. Patients admitted to hospital for
at least 1 day comprised about one-third of
all trauma patients admitted; the remainder
were discharged within 24 hours and were
not included in our data.
Data collection for this study was
performed around the clock by 5 general
practitioners who had undergone a special
training course to familiarize them with the
questionnaires. Each patient was admitted
to the emergency room, the clinical ward or
intensive care unit, and was followed until
discharge; the questionnaire was completed
during the course of the stay. The variables
included were: demographic characteristics
of the patient, injury characteristics (time,
place, intent, mechanism and situation of
trauma), transportation to the hospital, level
of consciousness on arrival according to
the Glasgow coma score, anatomic site
of injury, severity of injury and outcome.
Severity was assessed by the injury severity
score (ISS), defined as mild (score < 7),
moderate (score 7√12) and severe (score
12+) [6]. These variables were collected in
interviews with the patients and their relatives and the attending physicians.
An expert in medical records administration who was familiar with International
classification of diseases (ICD) coding,
coded the anatomical and external causes of
injuries according to ICD-10 (S00√S99 and
V01√Y98). Two other medical practitioners checked all the filled questionnaires
and evaluated and corrected them if necessary. Another physician supervised and
coordinated the whole team as the project
manager.
Descriptive (absolute and relative frequencies) and analytic (chi-squared) tests
were performed using SPSS, version 11.5.
P < 0.05 was considered as the level of
significance.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Results
From a total of 779 patients, 78.6% were
male (n = 612). The male to female ratio
was 3.66. Mean age was 34.7 (standard
deviation 19.9) years with a median of 28
years. About 31.4% of patients were illiterate (n = 224) and 20.5% had only primary
education (n = 160). Only 2.6% of patients
had university education (n = 20). The rate
of illiteracy in the study patients was greater
than that in the Islamic Republic of Iran
overall (P < 0.001) [7].
Regarding the occupation of the patients, the largest group (16.3%, n = 127)
were unemployed, 16.0% were housewives
(n = 125), 14.3% were manual workers (n
= 112) and 13.6% were students (n = 106).
The proportion of unemployed people in
our study was also higher than that in the
Kermanshah general population [8].
About 17.5% of patients referred to hospital on holidays (n = 136), which was more
than expected according to the number of
holidays and workdays during the study
period (P = 0.004). Injuries were more common between 24:00 and 06:00 hours (81.9%,
n = 638). Roads were the most common
place of trauma (61.9%, n = 482), followed
by the home 27.1% (211), workplace (4.9%,
n = 38) and other (6.2%, n = 48).
The mechanisms of injuries are shown
in Table 1. Victims of RTA (53.5%) and
falls (28.8%) were the highest proportion of
cases, followed by interpersonal violence
(10.1%). Pedestrians were 44.1% of RTA
victims and 23.6% of all cases. Only 3.2%
of car occupants had used seat belts and
14.0% of motorcyclists had used a helmet. The majority of cases sustaining stab
wounds in violent interactions had been
injured with a knife (90.9%).
A total of 482 patients arrived at hospital
directly from the scene of the accident
(i.e. were not referred), of whom 4.6%
59
Table 1 Mechanisms of injury in the studied
patients
Mechanism of injury
No. of
patients
%
Unintentional injury
Road traffic accident
Pedestrian
Car occupant
Motorcyclist
Other
Unknown
Fall
From a height < 4 m
From a height ? 4 m
Stumbling/slipping
Unknown
Laceration
692
417
184
124
100
3
6
224
150
11
58
5
23
88.8
53.5
23.6
15.9
12.8
0.4
0.8
28.8
19.3
1.4
7.4
0.6
3.0
Striking with blunt object
Other
Intentional injury
Interpersonal violence
Stabbing
Striking with blunt object
Gunshot
Other
Attempted suicide
Total
12
16
87
79
44
18
15
2
8
779
1.5
2.1
11.2
10.1
5.6
2.3
1.9
0.3
1.0
100.0
were transferred by ambulance (n = 22).
Of the cases referred from another hospital/
health centre, 75.4% were transported by
ambulance (n = 224). Thus overall, 31.6%
of patients were transferred to the hospital
by ambulance (n = 246). The mean time to
travel to the hospital was 2 h 42 min (standard deviation 6 h 32 min) with a median of
1 h 10 min.
In 81.4% of patients the Glasgow coma
score was 13√15 (n = 634), in 11.3% it was
9√< 13 and in 7.3% it was ? 8.
About 64.2% of patients had more than 1
injury (n = 500). Figure 1 shows the distribution of patients according to the number
of injuries they suffered.
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40
35.8
35
% of patients
30
27.3
25
19.8
20
15
10.3
10
4
5
1.8
0
1
2
3
4
5
6
0.5
0.5
7
8
No. of injuries suffered by each patient
Figure 1 Frequency distribution of the number of injuries
among the studied patients (n = 779)
The anatomic site of injuries is shown in
Table 2 as a proportion of the number of patients (1 injury was categorized as the main
reason for hospitalization for each patient)
and as proportion of all 1786 injuries recorded. Head injuries were the most common
injuries and also the most frequent among
the lesions leading to hospitalization.
The injury severity score was < 7 in
48.3% of the patients (n = 376), 7√12 in
33.6% (n = 262) and 12+ in 18.1% (n =
141).
A total of 7.8% of patients died (n =
61). The injury severity score was 12+ in
90.2% of patients dying (n = 55). The main
anatomic site of injury in these cases was
Table 2 Anatomic site of injuries
Anatomic site
No. of patientsa
%
No. of injuriesb
%
Head
215
27.6
602
33.7
Knee and lower leg
110
14.1
248
13.9
139
132
17.8
16.9
206
193
11.5
10.8
Elbow and forearm
39
5.0
119
6.7
Thorax
43
5.5
113
6.3
Wrist and hand
29
3.7
96
5.4
Shoulder and upper arm
33
4.2
94
5.3
Neck
23
0.3
61
3.4
Ankle and foot
15
1.9
54
3.0
779
100.0
1786
100.0
Abdomen, lower back, lumbar spine and pelvis
Hip and thigh
Total
One injury assigned as the main cause of hospitalization.
All injuries.
a
b
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
the head in 78.7% (n = 48), followed by the
neck in 8.2% (n = 5), thorax in 8.2% (n = 5),
hip and thigh in 3.3% (n = 2) and abdomen,
lower back, lumbar spine and pelvis in 1.6%
(n = 1). The mortality according to mechanism was: 13.3% striking with blunt objects
(3 unintentional, 1 intentional), 10.1% RTA
(n = 42), 6.3% gunshot (n = 1), 5.3 % falls
(n = 12) and 2.7 % cutting (n = 2) (laceration 1, stabbing 1) (P = 0.065).
Death was more commonly seen in patients with head injuries (22.3%, n = 48)
than other injuries (P < 0.001).
Discussion
In this 4-month study, 779 trauma patients
were recorded. The male to female ratio
was more than 3. Considering the sex ratio
in the general population of our country [9],
it might be concluded that men are more
commonly victims of trauma. The majority
of trauma cases were among young people. Previous studies have also indicated
that young men are at the highest risk for
trauma [4,10]. Several possible reasons
for this have been proposed including the
greater number of vehicles driven by males,
more participation in high-risk sports and
a greater tendency by males to acquire and
use weapons [11].
Illiterate people were over-represented
among trauma cases, which is in agreement with other studies [4,12√16]. The low
education level of trauma patients suggests
that poor education might increase the risk
for trauma.
Trauma was also more common in
unemployed people. To our knowledge
few studies have evaluated the role of unemployment as a risk factor in injuries
[12,14]. Unemployment has been used as
an indicator of material deprivation because
it reflects lack of income and insecurity
61
[12]. The choice of mode of transport in
developing countries is often influenced by
socioeconomic factors, especially income.
For people with low incomes the affordable
means of transport are walking, travelling
by bus or cycling, all of which expose them
to high risk of RTA [17].
Injuries were more common on holidays, which was also consistent with other
reports [18,19]. This could be the result of
more high-risk behaviour on holidays. For
instance, in one report from Australia, twothirds of RTAs occurred during the Friday/
Saturday/Sunday leisure period, and were
concluded to be a consequence of leisure
travel [18].
RTA, falls and interpersonal violence
were the 3 most common mechanisms of
trauma. The magnitude of RTA injury varies according to geographical region, with
the highest burden in developing countries
[20]. In these countries the impact of RTA
is less well understood [21], but according
to the hospital-based data, transport-related
injuries are among the leading causes of
more severe injuries, especially in urban
environments [21,22]. Even in some rural
areas, RTA has been the major mechanism
of injury [23]. Our findings indicated that
the most vulnerable road users were pedestrians, which is in agreement with other
studies [4,21].
The use of safety belts and helmets was
only 3.2% among car occupants and 14.0%
in motorcyclists. Since safety belts were
introduced in cars, a number of studies have
been published describing their effectiveness [24]. The use of helmets was rather low
compared with one American report, which
stated that helmet use was nearly 100% after a law requiring all motorcyclists to wear
helmets was implemented. Before the law,
only about 28%√40% of motorcyclists wore
helmets [25]. The efficiency of helmets
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as a means of protection from injuries is
universally attested [24].
Falls were the second most common
mechanism of trauma in our study. We
should take account of the fact that our
study was hospital-based and did not include minor injuries (e.g. due to falls). This
might explain why falls ranked second
in the mechanism of trauma in our study.
Some other studies have documented falls
as first or second rank among all mechanisms of injury [1,22,23].
Interpersonal violence was the third most
common mechanism of trauma. While other
assault-related studies have documented the
higher frequency of blunt instrument injuries [26], we recorded most assault-related
cases as the result of stabbing with knives.
This is likely to be due to the lack of laws
against carrying sharp weapons in public in
the Islamic Republic of Iran and, in addition,
the unavailability of firearms due to strict
legislation over ownership of weapons. The
high rate of fatal acts of violence with firearms is apparently due to easy public access
to them. In some countries, e.g. Denmark,
ownership and access to firearms are only
granted for hunting, police and military
purposes, and knives are not to be carried in
public without a permit [26].
Less than one-third of patients were
transferred to hospital by the emergency
medical services. Even when ambulances
were used, they served to transport patients
from hospital to hospital and rarely if ever
collected the injured from the scene of
injury (about 5%).
In most patients the Glasgow coma score
was 13√15. About half of patients had mild
injury (ISS < 7), which is less than the
proportion of mild injuries in a similar study
conducted in Tehran (92%) [4]. This disparity might be due to the difference in major
mechanism of trauma between the 2 studies.
While RTA was the main mechanism of
injury in our setting, striking by objects
was the major one in the other survey. We
also found that many of our patients had
multiple injuries, which is compatible with
other studies and indicates that special attention should be paid to RTA because they
are the dominant mechanism in multiple
traumas [4].
About 7.8% patients died, mostly due
to head injury and with high severity of
injuries. The 2 most common mechanisms
of injury with highest mortality were striking with blunt objects (13.3%) and RTA
(10.1%).
The mortality observed in our study was
considerable in comparison with another
epidemiologic study from our country [4]
and 2 other studies from Africa [22,23].
While treatment in the first hour after injury
is considered crucial in reducing mortality
[23], our findings showed that the emergency medical services did not provide good
prehospital transportation of patients and the
mean time for presentation to hospital was
noticeably high (2 h 42 min). This has also
been documented in another study from the
Islamic Republic of Iran [27]. Many other
factors such as the predominance of road
traffic injuries, inadequacy of public health
infrastructure [4,17] and poor enforcement
of traffic safety regulations [17] can count
towards the high mortality.
There are some limitations to our study.
It was performed over 4 months and thus
it could not demonstrate possible seasonal
variations in trauma admissions; our dataset
was hospital-based and did not include
patients with minor injuries treated in outpatient settings or admitted for less than
24 hours; and cases of very severe injuries
dying at the scene of trauma were also not
included. Furthermore, there may have been
injury-related deaths from various mechanisms that were referred directly to the
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
medicolegal centre and were not counted in
the mortality rate.
Young men of low socioeconomic status
were the most vulnerable group. Unintentional injuries due to RTA were the major
cause of trauma, and pedestrians comprised
a high proportion of the victims of RTA.
Our finding also showed the importance of
head trauma on the main anatomical site of
injury. These findings stress the necessity
of strict preventive strategies focusing on
different aspects of RTA.
63
Acknowledgements
This research was funded in Sina Trauma Research Centre, Tehran University of Medical
Sciences. The authors wish to thank Professor Moosa Zargar the head of Sina Trauma
Research Centre, Ali Khaji the investigator
of Sina Trauma Research Centre and all the
personnel at the emergency department of
Taleghani hospital, Kermanshah.
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13. Jha N, Agrawal CS. Epidemiological study
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
65
National Survey of Prevalence
of Mental Disorders in Egypt:
preliminary survey
M. Ghanem,1 M. Gadallah,2 F.A. Meky,2 S. Mourad3 and G. El-Kholy1
? Цсм цФМА?:?гЦАсм гАФьДМ ЦАзоСЬ гАй гДйтгя ггАжьягхгй гАДщсМи Мщ Цяу?
? шгои гнАФМА?║? сФсД Цяго?║? щгьЦи зхо гАсгАЦ ЦъМ?║? мЦсД лго гЕАА?║?мЦЦо шгДЦ?
? Фчо цляЛ?.? йзйях ЕпЕ гАоягси ньФи ЦхофМи ААЦсм гАФьДМ гАДйтгя ггАжьягхгй гАДщсМи Мщ Цяу?:?гнАгАуи?
? сДи ФпАъ Мщ Цнс ЦДгьч Мщ?64-18 ? хгАш Пг Мщ гЦАямАи гАзЦяМи?14640 ?гАхгмкФД Цсм Пг АцАяс ЦД огя Аогя жЦ?
? ФхАш?.?■ гАйтнМуМи?MINI-Plus ? хАСс?- ? Фчо гсйноЦФг Мщ йтнМу ггАжьягхгй гАДщсМи ЦчгхАи ⌠ЦМДМ?.?Цяу?
? ФЦйкСЬАй гЦАтгъА гАяфМсМи Мщ?.%16.93 ?ЦзоСЬ А ггАДйтгя геАЦлгМА гАйчоМяМ хДМ ЦлМз гАхгАшДМ гЦАоялДМ Мщ гАоягси?
? Фйягхьй ггАжьягхгй?.%4.72 ? ФггАжьягхгй гЦАйзоои?║%4.75 ? Фгжьягхгй гАчАч?║%6.43 ?гжьягхгй гЦАргл?
? Цяж?:? ФгАьгАч) ФзАА хоДМи (ЦД чСхМА?║? ФгАхьгАи?║? гцАДФки?:?гАДщсМи Цз зФгЦА глйгЦзМи оМЦФшягщМи (ЦД чСхМА?
.)? Фщяь жшь гАоЦ?║? ФЦяж гАъУ ЗАМСи?║?гАчАх?
ABSTRACT This study is an initial step for the National Survey of Prevalence of Mental Disorders in
Egypt. We conducted a door-to-door household survey of 14═640 adults aged 18√64 years in 5 regions
in Egypt. Mental disorders were diagnosed using the MINI-Plus diagnostic interview. Overall prevalence
was estimated at 16.93% of the studied adult population. The main problems were mood disorders,
6.43%, anxiety disorders, 4.75%, and multiple disorders, 4.72%. Mental disorders were associated with
sociodemographic factors (e.g. being female, being unemployed, being divorced) and physical illness
(e.g. heart disease, kidney disease, hypertension).
EnquЙte nationale sur la prИvalence des troubles mentaux en ?gypte : Иtude prИliminaire
R?SUM? Cette Иtude constitue une premiХre Иtape de l▓enquЙte nationale sur la prИvalence des
troubles mentaux en ?gypte. Nous avons rИalisИ une enquЙte auprХs des mИnages par porte Ю porte
dans cinq rИgions d▓?gypte et avons interrogИ 14 640 adultes БgИs de 18 Ю 64 ans. Les troubles
mentaux ont ИtИ diagnostiquИs sur la base de l▓interrogatoire MINI-Plus. La prИvalence globale a ИtИ
estimИe Ю 16,93 % de la population adulte ИtudiИe. Les principaux problХmes Иtaient des troubles de
l▓humeur (6,43 %), des troubles anxieux (4,75 %) et des troubles multiples (4,72 %). Les troubles
mentaux Иtaient associИs Ю des facteurs sociodИmographiques (par exemple le fait d▓Йtre une femme,
de ne pas avoir de travail et d▓Йtre divorcИ) et Ю des maladies physiques (par exemple une cardiopathie,
une maladie rИnale ou une hypertension).
Department of Neuro-Psychiatry; 2Department of Community, Environment and Occupational Medicine, Ain
Shams University, Cairo, Egypt (Correspondence to F.A. Meky: fammeky@yahoo.co.uk).
3
Abbassia Mental Hospital, Ministry of Health, Cairo, Egypt.
Received: 24/01/06; accepted: 27/06/06
1
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Introduction
The world is suffering from an increasing
burden of mental disorders and a widening
treatment gap: about 450 million people suffer from a mental or behavioural disorder,
yet only a small minority receives even the
most basic treatment. Mental disorder cases
are likely to increase due to ageing of the
population and deterioration in infrastructure and public health services [1]. Mental
disorders are known to have a greater negative effect on role functioning than many
serious chronic physical illnesses [2]. In the
original global estimates drawn up for 1990,
mental and neurological disorders accounted for 10.5% (projected to increase to 15%
in the year 2020 [3]) of the total disabilityadjusted life years (DALYs) lost due to all
diseases and injuries. It ranked in the top 20
leading causes of DALYs for all ages and in
the top 6 in the age group 15√44 years.
Although surveys of mental disorders
have been carried out since the end of
World War II, little is known about the
extent or severity of untreated mental disorders, especially in developing countries
like Egypt. Health care delivery in Egypt
still faces many problems. Both facilities
and staff tend to be unevenly distributed,
clustering mainly in urban areas, such as
Cairo and Alexandria. The total number
of available beds for psychiatric cases is
inadequate: less than 10═000 beds, around
13 per 100═000 population. The number of
professionals specialized in mental health
is far below international standards. The
main obstacle facing the services, however,
is that they are hospital-based rather than
community-based [4].
Lack of information about mental health
statistics is one of the most prominent problems in Arab countries. A community study
in Dubai estimated the prevalence of mental
disorders to be 18.9% in 2001 [5]. In a 1988
survey of a community sample from an
urban and rural population in Egypt, prevalence of depression was 15.3% [6].
In Egypt, there is a scarcity of community surveys in the field of psychiatry.
We need such information as a base for
future mental health planning, development, training and incorporation of mental
health in primary health care. This study
aimed to provide an accurate estimate of the
prevalence of common mental disorders in
5 different regions in Egypt, and to investigate sociodemographic factors associated
with these disorders as part of a national
survey. This project aims to shed light on
the true epidemiological status of psychiatric disorders in the country. The second
phase will be to cover governorates which
have different socioeconomic conditions,
notably those in Upper Egypt.
Methods
According to the population census of 2003,
for each selected region, a proportionate
sample was determined as follows: Alexandria 3750, Giza 3500, Qaliubia 3250,
Fayoum 3000 and Ismailia 1500. From each
region, 10 sites were selected to represent
different socioeconomic levels taking into
account cultural and geographic factors.
Each site was classified into 4 areas (North,
South, East, and West). In each area, the
health field team decided on a landmark as
the starting point; house selection started
at the first house beside the landmark and
then moved in a clockwise direction until
the required sample size from that area was
achieved. The representative sample comprised all adult residents aged 18√64 years
in selected households in 5 regions in Egypt.
We selected only those who had lived for
?═6 months in the house. We excluded people who were not normally resident such
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
as military personnel, prisoners and those
receiving long-term inpatient care.
In preparation for the survey, a World
Health Organization expert visited the General Secretariat of Mental Health for 10 days
in October 2002 to carry out the situational
analysis of mental health disorders and their
determinants and to design the survey. The
leaders of the research team held several
meetings in each governorate to explain
the aim of study, choose the research staff,
facilitate the implementation of work, and
to discuss the preparation of the training
programmes implemented before the fieldwork started. Before starting the fieldwork
all interviewers and supervisors attended a
standard training programme conducted by
Egyptian university consultants over 3 full
days. The curriculum included interviewing techniques, explanation of the aims
of the study, procedures, consent forms,
administration of tools and data entry as
well as practical training on a sample of a
few cases.
A pilot study was carried out on 150
people in Alexandria and Fayoum after the
training programme to test the application
of the instruments and logistics with the
interviewers and to identify any problems.
Patient compliance was also ascertained. A
monthly meeting was also held and individualized training was given to fieldworkers
on how to increase patient compliance.
The field study was done during the
period mid-August√end of November 2003.
Recruitment took place under the supervision of the local health district. Participants
were contacted either by telephone or via a
home visit by a primary health care nurse,
after which a fieldworker visited the house.
If nobody was present, the next house was
selected. On initial contact, the fieldworker
introduced him/herself to the participants
and explained the purpose of the survey. All
eligible residents in the selected household
67
were approached and asked to participate.
If anyone was absent at the time of the first
visit, the house was revisited at an arranged
time when he/she was available. Participants had the opportunity to ask questions,
and were asked to give their consent.
Instruments
Trained nurses visited the homes of participants and completed a sociodemographic questionnaire designed to assess
the risk factors for mental disorder. The
questionnaire included data about age, sex,
education, crowding index, employment,
residence, smoking, alcohol intake, religion
and present or past history of chronic physical illness. A fieldworker administered the
Arabic version of the MINI-Plus instrument
for diagnosing mental disorders [7]. This
was designed as a brief structured interview
for the major Axis I psychiatric disorders
in DSM-IV and ICD-10. Validation and
reliability studies have been done comparing the MINI-Plus to the SCID-P and the
CIDI, the 2 most widely used instruments.
The MINI-Plus has acceptably high validation and reliability scores, but can be administered in a short period of time [mean
18.7 (standard deviation 11.6) minutes]
compared to the 1√2 hours required for the
other 2 instruments [8]. All sections of the
MINI-Plus were used except those relating
to eating disorders, attention-deficit/hyperactivity disorder, major depressive episode
with melancholic features, suicide and antisocial personality disorder.
Within 2 weeks, 5% of all those we
interviewed were revisited to check for accuracy of diagnosis as a form of quality control assessment. This was carried out by 60
trained primary health care doctors working
3 days per week interviewing 4 people/day.
The interviewers made the diagnosis of
mental disorders. Local and central supervisors reviewed all questionnaires before data
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entry; missing data were checked with the
corresponding field supervisor. Data entry
and analysis were done by trained personnel
under the supervision of the senior epidemiologist of the programme.
Statistical analysis
We used SPSS for bivariate analysis. Epicalc
2000 was used to calculate the confidence
interval (CI) of the prevalence of different
types of mental disorder. Logistic regression analyses were used for estimation of
the association of each socioeconomic factor or chronic illness with mental disorder,
after adjustment for age. Similar analyses
were repeated after stratification of subjects
by sex. Age-adjusted odds ratios (ORs) with
95% CI were reported. We estimated the
association of each chronic disease with the
outcome, adjusting for all socioeconomic
variables identified in the previous step.
Results
The study sample included 15═000 participants: 360 were excluded from the analyses
as they were not within the predetermined
age range, had an unidentified diagnosis or
there were errors in data entry.
The overall prevalence of mental disorders in the surveyed sample was 16.93%
(95% CI: 16.35%√17.57%). As group
entities, the 3 most common disorders in
the surveyed sample were mood disorders
(6.43%), anxiety disorders (4.75%) and
multiple disorders (4.72%) (Table 1). The
most common disorders detected in the
sample were major depressive disorder
(2.70%) and premenstrual dysphoric disorder (2.52%). The least common were
alcohol dependence/abuse (only 5 cases)
and adjustment disorder (only 4 cases).
Women had a significantly higher odds
of having a mental disorder (OR =═2.24;
P <═0.001). Odds were also significantly
higher among those living in Ismailia, Giza
and Fayoum compared to those living in
Alexandria (Table 2). Other significant risk
factors for mental disorder included occupation (housewife, unemployed), marital
status (widowed, divorced). Odds of mental
disorder did not differ by residence, but was
significantly lower among those having
secondary or higher education. In addition,
having ?═3 children and being a current
smoker were protective factors.
Crowding index >═3 was the only significant socioeconomic factor associated with
mental disorder (OR = 1.26; CI: 1.13√1.41;
P═<═0.001). Other factors such as having
a car or living in a home connected to the
water and sewerage systems were not associated with having a mental disorder.
Table 3 shows the association of sociodemographic risk factors with mental disorders in general stratified by sex. Among
men, not being professional significantly
increased the OR. In addition, the odds
ratio of having a mental disorder was significantly dependent on marital status: the
ORs were 4.79, 3.25, and 1.32 for divorced,
widowed and single respectively compared
to married men. Having smoked cigarettes
(current or ex-smoker) increased the risk for
mental disorders 54% to 58% compared to
non-smokers. Economic variables such as
crowding index were significantly associated with increased risk of mental disorders.
However, having education (secondary
education or university degree) and having
children were protective.
Similarly, among women marital status
(divorced, widowed compared to married)
was a significant risk factor and having a
university degree was protective. Contrary
to men, occupation, having children, having
smoked cigarettes and economic variables
such as crowding index <═3 were not associated with mental disorders.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
69
Table 1 Prevalence of mental disorders in Egypt (n = 14═640)
Type of disorder
Mood
Major depressive disorder
Dysthymia
Hypomanic episode
Premenstrual dysphoric disorder
Anxiety
Panic
Agoraphobia
Social phobia
Specific phobia
Obsessive√compulsive
Post traumatic stress
Generalized anxiety
Mixed anxiety depressive
Somatoform
Somatization
Hypochondriasis
Body dysmorphic
Pain
Psychotic
Alcohol dependence/abuse
Drug dependence/abuse
Adjustment
Multiple
Frequency
942
395
151
27
369
694
100
73
33
197
99
16
133
43
97
20
45
21
11
28
5
19
4
691
Rate (%)
6.43
2.70
1.03
0.18
2.52
4.75
0.68
0.50
0.23
1.35
0.68
0.11
0.91
0.29
0.67
0.14
0.31
0.14
0.08
0.19
0.03
0.13
0.03
4.72
95% CI
6.04√6.84
2.45√2.98
0.88√1.21
0.12√0.27
2.77√2.79
4.40√5.10
0.56√0.83
0.39√0.63
0.16√0.33
1.17√1.55
0.56√0.83
0.07√0.18
0.77√1.08
0.21√0.40
0.54√0.81
0.09√0.22
0.23√0.42
0.09√0.22
0.04√0.15
0.13√0.28
0.01√0.08
0.08√0.21
0.01√0.08
4.38√5.08
CI = confidence interval.
The association of sociodemographic
risk factors with the most prevalent mental
disorders such mood disorders and anxiety
disorders stratified by sex was computed
(data not shown): only occupation (skilled,
retired or unemployed compared to professional) was associated with increased odds
of mood disorder (OR =═2.07, 2.02 and 5.09
respectively).
The risk for mental disorder was significantly higher in those having hypertension
(OR =═1.66), heart disease (OR =═2.06),
diabetes mellitus (OR =═1.25) and kidney
disease (OR =═1.95) (Table 2). Using logistic regression analysis, the association be-
tween chronic disease and mental disorders
remained significant even after adjustment
for sociodemographic variables such as sex,
education and marital status.
Discussion
The strengths of this study were using a
valid, reliable and brief structured psychiatry interview questionnaire (MINI-Plus) administered to a large representative sample,
covering a wide age range and including
both urban and rural residents in different
regions in Egypt. Trained physicians, and
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Table 2 Association of sociodemographic characteristics and chronic disease with
mental disorder in a sample of 14═640 participants from 5 areas in Egypt, 2003
Variablea
Total
No.
Sex
Male
Female
Governorate
Alexandria
Ismailia
Qualiobia
Giza
Fayoum
Residence
Urban
Rural
Education
Below secondary
Secondary
University
Occupation
Professional
Housewife
Skilled
Unskilled
Retired
Unemployed
Marital status
Married
Divorced
Widowed
Single
No. of childrenb
None
1√3
>═3
Smoking
Non-smoker
Current smoker
Ex-smoker
Having hypertension
No
Yes
Having mental disorder
No.
%
Age adjusted OR
(95% CI)
5═781
8═849
613
1═866
10.6
21.1
1
2.24 (2.03√2.47)***
3═700
1═479
3═411
3═151
2═899
408
193
795
363
721
11.0
13.0
23.3
11.5
24.9
1
1.21 (1.01√1.45)*
1.05 (0.90√1.22)
2.44 (2.14√2.78)***
2.66 (2.32√3.03)***
7═671
6═969
1═268
1═212
16.5
17.4
1
1.02 (0.99√1.11)
8═339
4═297
1═879
1═561
665
237
18.7
15.5
12.6
1
0.74 (0.67√0.82)***
0.59 (0.51√0.68)***
2═502
6═738
2═397
432
878
1═120
288
1═432
298
55
187
131
11.5
21.3
12.4
12.7
21.3
11.7
1
2.07 (1.80√2.37)***
1.07 (0.90√1.27)
1.02 (0.82√1.27)
1.21 (0.88√1.67)
1.10 (1.62√2.45)***
10═943
163
687
2═642
1═833
56
157
411
16.8
34.4
22.9
15.6
1
2.59 (1.87√3.60)***
1.75 (1.44√2.13)***
0.76 (0.67√0.87)***
700
6═444
7═496
141
1═031
1═308
20.1
16.0
17.4
1
0.79 (0.65√0.97)*
0.73 (0.73√1.09)
11═459
2═512
289
2═071
322
39
18.1
12.8
13.5
1
0.68 (0.60√0.77)***
0.73 (0.52√1.02)
11═455
919
2═247
262
19.6
28.5
1
1.66 (1.43√1.95)***
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
71
Table 2 Association of sociodemographic characteristics and chronic disease with
mental disorder in a sample of 14═640 participants from 5 areas in Egypt, 2003
(concluded)
Variablea
Having diabetes mellitus
No
Yes
Having liver disease
No
Yes
Having heart disease
No
Yes
Having cancer
No
Yes
Having kidney disease
No
Yes
Having schistosomiasis
No
Yes
Total
No.
Having mental disorder
No.
%
Age adjusted OR
(95% CI)
11═708
664
2═355
155
20.1
23.3
1
1.25 (1.06√1.55)**
12═161
211
2═457
50
20.2
23.7
1
1.25 (0.91√1.70)***
12═163
207
2═431
79
19.9
38.2
1
2.06 (1.61√2.74)
12═352
17
2═503
7
20.3
41.2
1
2.14 (0.89√5.17)
12═175
195
2═436
73
20.4
37.4
1
1.95 (1.46√2.53)**
12═249
122
2═483
27
20.3
22.1
1
1.10 (0.72√1.67)
Totals may vary owing to missing data.
Question only asked of married, widowed or divorced participants.
*P <═0.05; **P <═0.01; ***P <═0.001.
OR = odds ratio; CI = confidence interval.
a
b
primary health care nurses, closely supervised by psychiatrists, conducted the study.
Nevertheless, this was a cross-sectional
study which did not involve children under
18 years, those over 64 years, the homeless,
hospitalized/institutionalized persons or
prisoners. It would, therefore, be imprudent to generalize our results to the whole
country.
Overall, the prevalence of mental disorders varies widely among different countries; the rate has been found to be lowest
in China and highest in the United States
of America (USA) [9]. In the present study,
the overall prevalence (16.95%) was similar
to that in other Arab countries such as Dubai
(18.9%) [5] and Lebanon (16.9%) [9]. It
was also comparable to some European
countries such as France (18.4%) and the
Netherlands (14.9%) [9].
Mood and anxiety disorders were the
commonest disorders reported in this study.
Studies from areas such as the USA, Europe, Lebanon and Japan revealed the same
findings [9]. Alcohol and drug dependence/
abuse were the least prevalent in this study,
but these results could be inaccurate: they
may reflect the non-reliability of substance
abuse questions or perhaps the lack of privacy during the interview forced participants to conceal this information, especially
in the presence of family members.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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Table 3 Association of sociodemographic factors with mood disorder, anxiety
disorder and somatoform disorder in men and women in Egypt
Variable
%
Residence
Urban
Rural
Education
Below secondary
Secondary
University
Occupation
Professional
Housewife
Skilled
Unskilled
Retired
Unemployed
Marital status
Married
Divorced
Widowed
Single
No. of children
None
1√3
>═3
Smoking
Non-smoker
Current smoker
Ex-smoker
Men (n═=═5781)
OR (95% CI)
%
Women (n═=═8849)
OR (95% CI)
10.5
10.7
1
1.02 (0.87√1.21)
20.7
21.5
1
1.03 (0.93√1.15)
12.7
8.9
8.2
1
0.66 (0.54√0.81)***
0.61 (0.74√0.78)***
21.7
20.9
18.0
1
0.89 (0.78√1.01)
0.75 (0.62√0.90)**
7.9
√
10.9
10.5
12.6
16.9
1
√
1.46 (1.16√1.83)**
1.37 (1.05√1.79)*
1.52 (1.06√2.20)***
2.49 (1.81√3.43)*
19.9
21.3
19.2
20.6
16.7
25.2
1
1.09 (0.90√1.31)
0.90 (0.67√1.22)
1.05 (0.67√1.65)
0.88 (0.25√3.09)
1.30 (0.67√1.65)
10.1
34.5
28.6
11.4
1
4.79 (2.21√10.38)***
3.25 (1.54√6.68)**
1.32 (1.03√1.69)*
20.8
34.1
22.5
21.1
1
1.10 (1.39√2.88)***
1.29 (1.04√1.58)*
0.90 (0.76√1.06)
18.0
8.9
11.0
1
0.40 (0.29√0.55)***
0.37 (0.37√0.69)***
22.5
20.1
21.9
1
0.92 (0.70√1.20)
1.06 (0.81√1.39)
8.6
12.7
12.9
1
1.54 (1.29√1.84) ***
1.58 (1.08√2.30)*
21.4
18.3
30.0
1
0.85 (0.46√1.35)
1.60 (0.41√6.20)
*P <═0.05; **P <═0.01; ***P <═0.001.
OR = age adjusted odds ratio; CI = confidence interval.
In our study, point prevalence rate was
4.72% for multiple mental disorders, a rate
similar to that in Mexico (5.4%) and Turkey
(4.4%), but lower than in the USA (27.4%)
and Canada (16.3%) [9]. Psychotic disorders represent only 0.19% in our study,
which is less than what has been reported
from Dubai (0.7%) [5]. The low figure may
be the result of cultural denial of psychosis
because of the stigma related to that disorder. There are also probably psychotics
among those not included in our study, such
as homeless people, prisoners and those in
mental hospitals.
The risk of mental disorder among
women was over 2 times higher than among
men, consistent with many reports from
both developing and developed countries
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
[10√13]. Apart from the possible biological
factors which may explain the differences in
all societies, in many developing countries
women bear the brunt of the adversities associated with poverty: less access to education, physical abuse from husbands, forced
marriages, fewer job opportunities and, in
some societies, limitation of participation in
activities outside the house [14].
The increased risk of mental disorders
in Fayoum and Ismailia compared to Alexandria may be a result of the poorer health
services, which may be reflected in the
greater numbers of undiscovered and/or untreated cases in these regions. Differences
in lifestyle and ability to tolerate stress
may also result in increased risk of mental
disorders in some regions. Despite living in
a big city, Giza residents may have a higher
risk for mental disorders for a number of
reasons, such as wider geographical distribution, relatively fewer mental health
specialists and the absence of tertiary care
services, which are provided in Alexandria
at Mamoora hospital.
In developing countries, the relationship between urban/rural residence and the
prevalence of mental disorders is inconsistent. An epidemiological study in Pakistan
found higher prevalence rates of mental
disorders in the rural populations [15]. Also,
an early study in Egypt showed that depressive disorders were more prevalent in rural
residents [6]. In contrast, in Latin America
lower rates have been found in rural villages
than in urban areas [16]. However, in our
study and in a similar study in the Islamic
Republic of Iran [17], no differences were
found between urban and rural areas. In our
country, many rural residents migrate to
urban areas and this may create 2 matching
communities with the same socioeconomic
standards; as a consequence the urban√rural
differences found by others may be masked.
Both rural and urban residents have specific
73
problems, however, and this may also contribute towards masking the differences.
For instance, in urban areas, overcrowding,
polluted environment and high levels of
violence may affect the rates of mental
disorder. Rural residents may face problems
such as lack of proper infrastructure and
low socioeconomic standards.
Most studies from both developed and
developing countries have found that socially disadvantaged groups (illiterate, unemployed) and those who had previously
been married had a much higher prevalence
of common mental disorders [1,18,19].
Similarly in our study, marital status (divorced or widowed), poor education and
unemployment all played a significant role.
We suggest further analysis of these risk
factors will contribute towards primary
prevention of mental illness in our culture.
Risk factors for mental disorders were
similar for both men and women with the
exception of occupation and smoking: these
increased the risk of mental disorder in men.
Our failure to find an association between
mental disorder and occupation may have
been because the majority of the women in
this study were housewives. Although the
prevalence of mental disorders was higher
in non-smokers than smokers, most of the
non-smokers were females, in whom the
prevalence of mental disorder was greater.
In support of this, analysis of the association
of smoking with mental disorder by sex
strata showed that among males, smoking
(current or previous smokers) increased the
risk of mental disorder. We did not find the
same relationship among females. Other
studies have shown that depression, and
anxiety were strongly positively associated
with smoking [20,21].
Among women, sociodemographic factors such as education and marital status
played a role in increasing the risk of mental
disorders.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Chronic illness and poor physical health
have been shown to increase the risk of
mental disorder [22]. Hypertension, heart
disease, diabetes mellitus and kidney disease were all associated with an increased
risk of mental disorder in our study. Prevalence rates of diabetes, liver diseases, lower
back pain and pulmonary conditions were
higher in patients with bipolar disorder than
in a national cohort [23]. Moreover, mortality was higher in patients with co-morbidity
of depression and chronic kidney disease
compared with those with depression and
no, or less severe, disease [24]. Sokal et al.
reported that persons with serious mental
illness who are in care were more likely to
have co-morbid medical conditions than
persons in the general population, and the
odds of diabetes, lung disease, and liver
problems were particularly elevated [25].
The co-morbidity of anxiety and physical
illness such as cardiac disorders, hypertension, gastrointestinal problems, genitourinary difficulties and migraine has been
reported in prior studies [26].
From this study, it is clear that mental disorders are highly prevalent in our
country, with noticeable discrepancies between governorates. We recommend further
studies to investigate the reasons for these
discrepancies.
Acknowledgements
The World Health Organization in collaboration with the General Secretariat of
Mental Health sponsors the National Survey of Mental Health in Egypt. Administrative support was received from the foreign
health relations sector of the Ministry of
Health and Population, and the undersecretary of health of the selected governorates.
We would like to thank the following
people for their valuable contributions during this survey: David Sheehan, Ahmed
Mohit, Srinivasa Murthy and Richard Gater.
Many thanks go to participants, fieldworkers, staff and everyone who took part in this
work.
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Direct estimation of life expectancy in
the Islamic Republic of Iran in 2003
F. Pourmalek,1 F. Abolhassani,2 M. Naghavi,3 K. Mohammad,1 R. Majdzadeh,1 K. Holakouie
Naeini 1 and A. Fotouhi 1
2003 ?гАйчоМя гЦАхгят ЦАцЦФА гмАМги Мщ ЦлЕФяМи еМягД геАсгАЦМи Мщ згЦ?
? цъях щйФмМ?║? чФят ЕгАъФМЛ ДгМэМДМ?║? яжг лЦо ргоЕ?║? ъгыЦ мЦЦо?║? мЦсД ДчФМ?║? щяМо цхФ гмАсДМ?║?щятго хФя ЦгАъ?
? хгсйногЦ гАхМгДгй?║? ФгАМи Мщ ЦлЕФяМи еМягД геАсгАЦМи?23 ? Мщ?2003 ? чоЬ я гАхгмкФД ЦцЦФА гмАМги Мщ згЦ?:?гнАгАуи?
? ФцляФг йумМм Пг АйзФМж Дчу гАйхАМш?║?гАсъгДМи ФхМгДгй гАФщМгй гАугояи зД Фргяи гАуми ФгАйзАМЦ гАьхМ?
? Фгщйэяж гАхгмкФД цД?.?зД гАФщМгй Мщ гцАзгЦя гАйМ йрМо зЛА цяхз сДФгй хгсйногЦ ьяМчи (хягс) АйФгрД гАДЦФ?
?йФрМз гАсъгД ФгАФщМгй ФЦД кЦ ЦцЦФА гмАМги Мщ гАФгАМгй гАкгАк ФгАзятМД Цъгщфи АДыяМгЕйг Мщ ЦлМз гАФгАМгй?
? сДи (щйэяи?71.56 ? ФзЛА Епг щчо чоЬ я гАхгмкФД ЦцЦФА гмАМги зДо гАФгАои еАЦлгМА гАсъгД хэ?║?гАкгЦМД ФгАзятМД Мщ еМягД?
? сДи (щйэяи гАгА йМ ЬчД?70.09 ?сДи)╨ ФЦцЦФА гмАМги ААпъФя?
?гАгА йМ ЬчД?
? ФъгДй йчоМягй гАхгмкДМ?║)?сДи?
? сДи (щйэяи гАгА йМ ЬчД?73.17 ? ФЦцЦФА гмАМги АеАДгк?║)?сДи?
? ДйМли гАнйгАщ?║? ФгАхДъ гАоФМА?║? ФФъггАй гцАЦЦ гЦАймои?║?цзЛА ЦД гАйчоМягй гАДЦФплМи ЦАяър геАмуга Мщ еМягД?
.?ьяч гАйчоМя гЦАсйноЦи?
ABSTRACT We estimated the life expectancy for 2003 for 23 provinces in the Islamic Republic of Iran
using population and mortality data from the Ministry of Health and Medical Education. The underreporting of deaths above 4 years was corrected using the Brass Growth Balance method. We assumed
that the distributions of population, deaths, and hence life expectancy in the 23 provinces were equal to
those for all 28 provinces of the country. Thus we estimated life expectancy at birth to be 71.56 years for the
total population [95% uncertainty interval (UI): 71.52√71.62]; 70.09 (95% UI: 70.02√70.16) years for males,
and 73.17 (95% UI: 73.10√73.24) years for females. Our estimates were higher than the model-based estimates of the Statistical Centre of Iran, United Nations agencies and the World Bank, due to differences in
the estimation methods used.
Estimation directe de l▓espИrance de vie en RИpublique islamique d▓Iran en 2003
R?SUM? Nous avons estimИ l▓espИrance de vie pour 2003 dans 23 provinces de RИpublique islamique
d▓Iran Ю partir des donnИes dИmographiques et des donnИes sur la mortalitИ provenant du ministХre de la
SantИ et de l▓Enseignement mИdical. La sous-notification des dИcХs au-delЮ de quatre ans a ИtИ corrigИe
Ю l▓aide de la mИthode d▓Иquilibre de l▓accroissement de Brass. Nous sommes partis du principe que la
rИpartition de la population, de la mortalitИ et par consИquent de l▓espИrance de vie dans les 23 provinces
Иtait la mЙme que dans les 28 provinces du pays. Nous avons ainsi estimИ l▓espИrance de vie Ю la naissance Ю 71,56 ans pour l▓ensemble de la population [intervalle d▓incertitude (II) Ю 95 % : 71,52√71,62] ;
70,09 (II 95 % : 70,02√70,16) pour les hommes, et 73,17 (II 95 % : 73,10√73,24) ans pour les femmes.
Nos estimations Иtaient plus ИlevИes que les estimations fondИes sur des modХles du Centre des statistiques d▓Iran, des agences des Nations Unies et de la Banque mondiale, en raison des diffИrences entre
les mИthodes d▓estimation utilisИes.
1
Epidemiology and Biostatistics Department, School of Public Health; 2Internal Diseases Department, School of
Medicine, Tehran University of Medical Sciences, Islamic Republic of Iran (Correspondence to F. Pourmalek:
pourmalek_farshad@yahoo.com).
3
Center for Health Network Development, Ministry of Health and Medical Education, Tehran, Islamic Republic
of Iran.
Received: 06/01/06; accepted: 18/01/07
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Life expectancy is a summary measure of
health expectancy that abstracts the nonfatal outcomes of diseases and injuries in
the form of a single number, i.e. life expectancy at birth, and for all age and sex groups
of the population as a life table [1]. Construction of life tables and calculation of
life expectancy can be done by direct and
indirect methods. In the direct method, the
population and mortality data measured
through census and death registration systems or cross-sectional surveys are used for
estimation of age- and sex-specific mortality rates and construction of life tables. With
indirect methods, where directly measured
population and mortality data are not used,
statistical models are used instead for the
estimation of specific mortality rates and
the construction of life tables. The statistical
model used by the World Health Organization (WHO) is the modified Brass Logit
model [1]. Examples of indirect methods
include global studies for estimation of life
expectancy for every country of the world
(by United Nations agencies) or for forecasting life expectancy in a country for
future years (like the study of the Statistical Centre of Iran on life expectancy till the
year 2021) [2].
Estimation of life expectancy for the
population of the Islamic Republic of Iran
has been done in the past in both national
and international studies. For example, life
expectancy at birth [LE(0)] was estimated
by direct method as 55.1 years for males
and 56.3 years for females in 1973 in a sample survey by the School of Public Health
of Tehran University [3]. In the third evaluation of Health For All√2000 in the country,
the Ministry of Health and Medical Education (MOH) estimated LE(0) as 68 years
for males and 70 years for females in 1996
[4]. Values of LE(0) estimated by Unit-
77
ed Nations agencies, the World Bank and
the Statistical Centre of Iran for the years
2002√2004 are shown in Table 1.
The aim of our study was to estimate the
life expectancy with a direct method using
the national population and death data. At
the time of performing this study, the mortality data for 23 provinces of the Islamic
Republic of Iran by age group and sex for
2003 were completely available, but the
coverage of the MOH death registration
system did not include all 28 provinces of
the country. Therefore 2003 was the most
recent year for which the estimation of life
expectancy was feasible based on data from
the death registration system of MOH, and
this was selected as the reference year for
our calculations.
Methods
For calculation of an abridged period life
table of 23 provinces of the Islamic Republic of Iran in 2003, the number of deaths
registered by MOH in these 23 provinces
were used [14]. Under-reporting of deaths
in under 5-year-olds was estimated and
corrected with the Brass Growth Balance
method═[15]. For mortality rates of children
under 1 year and 1√4 years, rates from the
Demographic and Health Survey (DHS)
2000 with live births as the denominator
were substituted═[19]. For the total population of the 23 provinces, data were obtained
from MOH═[14]. The distribution of the
population was assumed to be similar to that
from DHS 2000 results, and also as result of
graduation of the whole country population
from 1996 census to 2003. Life expectancy
was estimated by age and sex for the obtained population and corrected deaths.
Calculations were made according to the
methods given in the WHO national burden
of disease manual with categorization into
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 1 Estimates of life expectancy at birth for the Iranian population for 2002√2004 from
various sources
Year
2002
2003
2004
00√05
Life expectancy at birth (years)
Total
Males
Females
PE (UI)
PE (UI)
PE (UI)
70.32
68.06
72.69
71.7 (70.5√72.8)
Source
SCI, 2005 [2]
68.9
66.5 (65.4√67.8)
NP
69.0
71.0
ESCAP, 2005 [6]
70.1
68.8
71.7
UNDP, 2004 [7]
WHO, 2004 [5]
70.25
68.83
71.74
World Bank, 2006 [8]
70.77
68.50
73.16
SCI, 2005 [2]
69 (69√70)
67 (66√68)
72 (71√73)
NP
68.0
WHO, 2005 [9]
70.0
ESCAP, 2005 [6]
70.4
69.0
71.9
UNDP, 2005 [10]
70.54
69.08
72.08
World Bank, 2006 [8]
71.22
68.94
73.62
SCI, 2005 [2]
70 (69√71)
68 (66√69)
72 (71√73)
NP
69.0
72.0
70.84
69.33
72.42
World Bank, 2006 [8]
70.2
68.8
71.7
United Nations, 2005 [13]
WHO, 2006 [11]
ESCAP, 2004 [12]
PE = point estimate; UI = uncertainty interval; NP = not published.
SCI = Statistical Centre of Iran; WHO = World Health Organization; ESCAP = United Nations Economic and
Social Commission for Asia and the Pacific; UNDP = United Nations Development Programme.
19 age groups, the oldest being 85 years and
above═[15]. It was assumed that the distributions of the population and deaths in the
23 provinces were similar to those of the 28
provinces of the Islamic Republic of Iran in
2003 and hence the estimated life expectancy for the 23 provinces would be the same
for all 28 provinces of the country.
To assess the sensitivity of the life
expectancy estimation if applied to a population distribution similar to the DHS 2000
results, life expectancy was also estimated with the population distribution of the
1996 census as an alternative after graduation of the population. Graduation in 1-year
age groups from the 1996 census to 2003
was done using the number of births by
sex and year (from the Civil Registration
Organization, with correction for delayed
registration) and the number of deaths by
sex, age group and year (from the vital horoscope of MOH for the main villages in the
country).
For estimation of uncertainty limits, the
Monte Carlo method with 1000 simulations
for Poisson distribution of registered deaths
in each of the age and sex groups was used.
The 2.5 and 97.5 percentiles from obtained
distributions of life expectancy in each of
the age groups were identified as the 95%
uncertainty interval (UI) [16]. All calculations were performed by directly writing
the formulas of life table functions in Excel
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
spread sheets. Add-ins for Excel [17] were
used for estimation of uncertainty intervals.
79
year and 1√4 years were 28.61 and 1.87 per
1000 live births respectively [19]. For the total
population, the average partial death rate for
the 6 age groups between 5 and 34 years (X1)
was 0.0066 and the average partial birth rate
of these groups (Y1) was 0.0361. The average
partial death rate for the 6 age groups between
40 and 69═years (X2) was 0.0264 and average
partial birth rate for these groups (Y2) was
0.0592. Therefore the K correction coefficient
for deaths registered for the total population
in the 23 provinces was 1.17, and the registration completeness proportion was 0.85. With
K═correction coefficients of 1.11 and 1.25 for
males and females respectively, the registration completeness proportions were 0.90 and
0.79. Table 2 shows the correction for the
under-reporting of deaths in the over 4 years
age group for the 23 provinces of the coun-
Results
The population of the 23 provinces of the Islamic Republic of Iran in 2003 was 48═379 502
persons [14]. The same population estimated
by the Statistical Center of Iran was 48.32 million [18]; the latter being about 0.12% lower
than the former. The population of the 23 provinces in 2003 was 73% of the total population
of the country in the same year (66.5 million).
The crude mortality rate for the 23 provinces
was 441 per 100 000 total population, 516 for
males, 363 for females═[14]. The uncorrected
number of deaths registered in the 23 provinces was 213 000 (127 000 for males, 86═000 for
females). Mortality rates for children under 1
0.12
0.10
Partial birth rate
0.08
0.06
0.04
0.02
0.00
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
Partial death rate
Figure 1 Plot of partial birth rates against partial death rates for the population of the 23
provinces in 2003 using Brass Growth Balance [15] for correction for under-reporting of
above-4 mortality.
The 6 points in the smaller oval show partial rates of the first group (5√34 years) and 6 points
in larger oval show partial rates of the second group (40√64 years). White points show the
group means. Source of population data: Ministry of Health and Population [14]; source of
death data: National Death Registration System [14].
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
30 359
24 234
18 124
195 028
75
80
85
5+
44 489 382
145 560
176 692
516 288
803 525
1 019 608
1 154 921
1 184 407
1 508 025
2 057 453
2 579 119
2 919 651
3 385 884
3 958 579
4 786 413
6 624 651
√
√
√
√
182 313
217 453
233 933
269 243
356 548
463 657
549 877
630 553
734 446
874 499
1 141 106
1 318 223
1 166 861
900 018
Population
at exact
age x
N(x)
Source of population data: Ministry of Health [14].
Source of death data: National Death Registration System [14].
17 689
25 375
65
70
8 469
11 595
55
60
7 217
8 645
50
6 187
40
45
5 448
6 463
25
5 147
8 139
20
30
6 578
35
2 793
15
6 557 580
5 111 028
2 564
5
10
Population
5Nx
Registered
deaths
5Dx
x
Exact age
(years)
√
√
√
√
1 642 065
2 661 672
3 816 593
5 001 000
6 509 025
8 566 478
11 145 597
14 065 248
17 451 131
21 409 710
26 196 123
32 820 774
39 378 354
44 489 382
Population at
exact age x
and above
N(x+)
√
√
√
√
98 092
115 781
127 376
135 846
144 491
151 708
157 895
163 042
168 490
174 953
183 092
189 670
192 463
195 028
Deaths at
exact age x
and above
D(x+)
√
√
√
√
0.0597
0.0435
0.0334
0.0272
0.0222
0.0177
0.0142
0.0116
0.0097
0.0082
0.0070
0.0058
0.0049
0.0044
D(x+)/
N(x+)
Partial
death rate
√
√
√
√
0.1110
0.0817
0.0613
0.0538
0.0548
0.0541
0.0493
0.0448
0.0421
0.0408
0.0436
0.0402
0.0296
0.0202
N(x)/N(x+)
Partial birth
rate
228 515
21 236
28 395
35 572
29 732
20 726
13 586
9 924
10 130
8 456
7 249
6 031
6 384
7 573
9 536
7 707
3 273
3 005
Corrected
number of
deaths
Adj. 5Dx
Table 2 Correction for the under-reporting of deaths of above 4 years age group for 23 provinces of the Islamic Republic of Iran in
2003 with Brass Growth-Balance method
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
try in 2003 using the Brass Growth Balance
method [15]. The plot for partial birth rates
against partial death rates for the population
of the 23 provinces in 2003 using the Brass
Growth Balance method [15] is shown in Figure 1.
Table 3 shows the point estimates and
95% uncertainty intervals (UI) of life expectancy for the Islamic Republic of Iran
in 2003 by age and sex. Life expectancy at
birth was 71.56 years for the total population (95%═UI: 71.52√71.62), 70.09 years
81
for males (95% UI: 70.02√70.16), and
73.17═years for females (95% UI: 73.10√
73.24). Life expectancy at birth for the total
population based on the population distribution graduated from the 1996 census was
71.26 years, which is 0.3 years or 0.4% lower than the main finding of 71.56 years.
Discussion
The main finding of this study was the estimate of 71.56 years life expectancy at
Table 3 Direct point estimate and 95% uncertainty intervals of life expectancy in the Islamic
Republic of Iran for 2003, by age group and sex
Age group
(years)
0
Total population
PE
LUL
UUL
71.56
71.52 71.62
PE
70.09
Males
LUL
70.02
UUL
70.16
PE
73.17
Females
LUL
73.10
UUL
73.24
1√4
72.62
72.57
72.66
71.39
71.33
71.45
73.96
73.88
74.02
5√9
69.15
69.10
69.19
67.71
67.65
67.77
70.71
70.64
70.77
10√14
15√19
20√24
25√29
30√34
35√39
40√44
45√49
50√54
55√59
60√64
65√69
70√74
75√79
80√84
85+
64.34
59.50
54.83
50.36
45.82
41.23
36.63
32.11
27.73
23.59
19.49
15.52
11.92
8.84
6.49
6.85
64.30
59.45
54.79
50.31
45.77
41.19
36.59
32.07
27.69
23.55
19.46
15.49
11.88
8.80
6.44
6.77
64.39
59.54
54.87
50.40
45.86
41.27
36.67
32.15
27.77
23.63
19.53
15.56
11.96
8.88
6.54
6.93
62.92
58.08
53.51
49.25
44.87
40.44
35.97
31.61
27.38
23.46
19.45
15.46
11.83
8.66
6.04
5.43
62.86
58.02
53.45
49.19
44.82
40.39
35.92
31.56
27.33
23.42
19.40
15.41
11.78
8.61
5.98
5.33
62.98
58.14
53.57
49.31
44.93
40.50
36.03
31.66
27.43
23.51
19.50
15.50
11.88
8.71
6.10
5.52
65.89
61.03
56.25
51.53
46.78
42.00
37.25
32.55
27.97
23.61
19.41
15.45
11.85
8.84
6.71
7.97
65.82
60.96
56.18
51.46
46.71
41.93
37.18
32.49
27.91
23.55
19.35
15.39
11.79
8.77
6.64
7.85
65.95
61.09
56.31
51.59
46.84
42.06
37.31
32.61
28.03
23.67
19.47
15.51
11.90
8.91
6.80
8.09
Mortality data were corrected with Brass Growth Balance method [15]; under-5 mortality was corrected with DHS
2000 results [19].
Source of population data: Ministry of Health [14]; Source of death data: National Death Registration System [14].
PE = point estimate; LUL = lower 95% uncertainty interval; UUL = upper 95% uncertainty interval.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
birth for the total population of the Islamic Republic of Iran in 2003,═70.09═years
for═males,═and 73.17 years for females. The
accuracy of the results depends on the degree to which the following 4 assumptions
hold true.
Assumptions about the population:
i) Population distribution taken from the
DHS 2000 study is reliable for the 23
provinces in the year 2003.
ii) Population information from MOH for
the 23 provinces in the year 2003 has adequate accuracy.
Assumptions about mortality:
iii)Death registration from MOH for the 23
provinces in the year 2003 has adequate
coverage.
iv)Age and sex specific mortality rates in
the 23 provinces in the year 2003 are
generalizable to the total country in the
same year.
Regarding the first assumption, the
DHS 2000 study population distribution
was based on direct sampling and therefore should be more accurate than similar
model-based estimates as alternatives. Analysis of the sensitivity of the main finding to
the use of the DHS 2000 study population
distribution shows that if the population
distribution graduated from the 1996 census
is used as an alternative, life expectancy at
birth would drop by only 0.5%. Therefore
the main results are negligibly sensitive to
this assumption.
Regarding the second assumption,
comparison of the population size for the
23 provinces from MOH information and
the estimate of this population size by the
Statistical Centre of Iran shows that the
difference is about 0.1% and indicates that
the accuracy of the population information
from MOH is adequate.
Regarding the third assumption, the
results of the Brass Growth Balance method
show that the death registry has acceptable
completeness [15]. Regarding the fourth assumption, it should be noted that among the
23 provinces, mortality rates of the 5 provinces which have the highest rates are not
very different from those in the 5 provinces
which have the lowest rates. Therefore it is
expected that the mortality rates of the other
5 provinces (not fully covered by the death
registry in 2003) should not be much different from those of the 23 provinces. Moreover, these 5 provinces have a mixture of
higher, medium and lower relative development levels and their overall mortality rates
(and also death registration completeness)
can be comparable with mortality rates for
the 23 provinces and the total country.
Increase in life expectancy from its
at-birth value to year-one value is seen
when the ratio of under-1 mortality to 1√4
years mortality is relatively high. Such an
increase was also seen in the life table estimated by the School of Public Health of
Tehran University in 1973 [3], and by WHO
for the years 1999 [20], 2000 and 2001 [21].
Greater life expectancy for females than for
males is also an expected result [1,22].
Our estimates are greater than similar
estimates by United Nations agencies and
other international institutions, which were
performed with indirect modelling methods. For the total population, the greatest
difference is with WHO▓s estimate (2.5
years), and the least difference is with the
World Bank▓s estimate (1 year). The estimates of these agencies and institutions
differ from each other with a range of more
than 1.5═years. Our estimate is only about
0.8 years lower than the estimate of the
Statistical Centre of Iran, which was performed using the logistic model. Whereas
population and mortality data were used
for direct estimation of mortality rates and
construction of a life table in our study, the
UN agencies, international institutions and
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
the Statistical Centre of Iran used indirect
methods based on statistical modelling.
Even using the various indirect methods, results are not always equal. Despite the most
vigorous efforts to utilize the best input data
and methods, because of differences in data
and methods used by national and international organizations, all the results for the
same estimations cannot be identical. It is
also worth noting that in the third evaluation of Health For All 2000 in the Islamic
Republic Iran, MOH estimated the life expectancy at birth as 68 years for males and
70 years for females in the year 1996 [4],
which is 1.2 years higher than the estimate
by the United Nations Economic and Social
Commission for Asia and the Pacific for
the same year [6], and even 1.7 years higher than the WHO estimate for 1999 [23].
Hence a similar difference between the results of direct and indirect methods was
also observed for 1996 [3]. A similar difference also exists for the 1973 estimates.
A small part of these differences is due to
a 2.63═month (0.22 year) difference in the
Gregorian and Iranian calendars.
In the present study, the uncertainty interval was much smaller than that from
studies that used indirect methods. In the
direct estimation method, the only major
source of variance of life expectancy is
83
the variance of death numbers in each age
group, which results in low variance of life
expectancy in different ages. This is because
the number of deaths is relatively high and,
whether with Poisson distribution or normal
distribution, this results in low variances. In
model-based methods, however, there are
more sources for random error of estimation. In our study the uncertainty interval
was greater in older age groups (especially in the last 2 age groups), and it was also
greater for each sex separately as compared
with the total population (both sexes), due
to fewer number of deaths, which thus resulted in greater variance.
Our direct estimate of life expectancy for the Islamic Republic of Iran in
the year 2003 is 0.8 years more than the
model-based estimate by the Statistical
Centre of Iran and 1 to 2.5 years more than
a similar estimate by United Nations agencies; this is due to differences in methods
used for estimation of age and sex specific mortality rates. Direct estimates of life
expectancy by the Ministry of Health for
1996 and by the School of Public Health
of Tehran University for 1973 had a similar difference with estimates by Statistical
Centre of Iran and United Nations agencies
for the same reason.
References
1. Murray CJL, Evans DB. Health systems
performance
assessment:
debates,
methods and empiricism. Geneva, World
Health Organization, 2003.
growth, life table.] Tehran, School of Public Health and School of Public Health of
Tehran University, 1978:186 (Serial No.
1992) [in Farsi].
2. Statistical Centre of Iran. 2005. [Child mortality trends and indicators in Iran in years
1335√1400 (1956√2021)]. (http://amar.sci.
org.ir/index_e.aspx, accessed 7 August
2008) [in Farsi].
4. Mohammad K, Malekafzali H, Nehapetian
V. [Statistical methods and health indices,
9th ed.]. Tehran, Mohammad K, Malekafzali H, Nehapetian V, 1998:283 [in Farsi].
3. Nehapetian V, Khazaneh H. [Life indicators of Iran: mortality, fertility, population
5. World health report 2004 √ changing history. Geneva, World Health Organization,
2004:114√5.
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6. Statistical Yearbook for Asia and the Pacific, 2004. Bangkok, United Nations
Economic and Social Commission for Asia
and the Pacific, 2005:184.
7.
Human Development Report 2004: cultural liberty in today▓s diverse world. New
York, United Nations Development Programme, 2004:141 & 219.
8. World Bank. World Development Indicators Database (http://devdata.worldbank.
org/query/, accessed 7 August 2008).
9. World health report 2005: make every
mother and child count. Geneva, World
Health Organization, 2005:176√7.
10. Human Development Report 2005: a better investment climate for everyone. New
York, United Nations Development Programme, 2005:220.
11. World Health Report 2006: working together for health. Geneva. World Health
Organization, 2006:170√1.
12. United Nations Economic and Social Commission for Asia and the Pacific. Statistical
indicators for Asia and the Pacific: 2006
(http://www.unescap.org/stat/data/statind/
index.asp, http://www.unescap.org/stat/,
accessed 7 August 2008).
13. United Nations. World population prospects, 2005 (http://esa.un.org/unpp accessed 7 August 2008).
14. Naghavi M. [Profile of death in 23 provinces of Iran in year 1382 (2003)]. Tehran,
Center for Health Network Expansion and
Health Promotion, Health Deputy, Ministry
of Health and Medical Education, 2005 [in
Farsi].
15. National burden of disease studies: a
practical guide. Geneva, World Health
Organization, Global Programme on Evidence for Health Policy, 2001:26.
16. Salomon JA et al. Methods for life expectancy and healthy life expectancy
uncertainty analysis. Geneva, World
Health Organization, Global Programme
on Evidence for Health Policy, 2001 (Working Paper No. 10).
17. @ Risk version 4.5.3. Newfield, Palisade
Corporation, 2004 (Standard edition. Trial
version).
18. [Reconstruction and estimation of urban
population of Iran based on year 1380
(2001) limits]. Tehran, Statistical Center of
Iran, 2004 [in Farsi].
19. Population and health in the Islamic Republic of Iran: Iran Demographic and
Health Survey (DHS) 2000. Tehran, Ministry of Health and Medical Education,
2000.
20. Lopez AD et al. Life tables for 191 countries: Data, methods and results. Geneva,
World Health Organization, 2002 (GPE
Discussion Paper Series No. 9).
21. World Health Organization Statistical Information System (WHOSIS). Life Table
of the Islamic Republic of Iran in2000
and 2001 (http://www3.who.int/whosis/life/
life_tables/download/life_Iran_(Islamic_
Republic_of)_2000.csv, accessed June
2005).
22. Murray CJL, Lopez AD. The global burden
of disease: a comprehensive assessment
of mortality and disability from diseases, injuries, and risk factors in 1990 and
projected to 2020. Cambridge, Harvard
School of Public Health on behalf of the
World Health Organization and the World
Bank, 1996.
23. World Health Report 2000. Health systems: improving performance. Geneva,
World Health Organization, 2000:159.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
85
Could the MMR vaccine replace the
measles vaccine at one year of age in
Egypt?
A.A. Abbassy,1 S.S. Barakat,1 M.M. Abd El Fattah,1 Z.N. Said2 and H.A. El Metwally3
?ЕА хгеАЦъгД ггАсйзгжи зД гнАьи гмАгАМи ААйАчМм жо гмАухи ФгмАухи гцАЦАгДМи ФгАДъгщ хлязи ФмМои ЦД гААчгм?
?гЦАтйэяъ хДЕгМи гАзгЦ гцАФА©?
? ЕгАи зхо гАядФщ гЦАйФМА?║? рМДх ДхМА сзМо?║? мЦЦо мЦЦо зхо гАщйгм?║? тЕяМи угАм гАоМД хяъгй?║?цЦмо зЦяФ зхгМс?
? ААйзящ зЛА еЦъгДМи?║? йчоЖЬ Ц ЕпЕ гАоягси гЦАсйзяжи йчММ ПгЦ ААмгАи гЦАДгзМи АоЛ цьщгА цумга шяМ ЦА СЬчмДМ?:?гнАгАуэи?
?АчгмМДЗ цмоЦЕг ЕФ гЦАжго ААмухи гАпМ МзьЛ Мщ гАтЕя гАйгсз ФгАкгМД ЕФ гЦАжго ААмухи ФгмАухи?
С ?ггАсйзгжи зД?
? хлязи ФмМои ЦД гААчгм гЦАжго ААмухи ФгмАухи гцАЦАгДМи?║?гцАЦАгДМи ФгАДъгщ гАпМ МзьЛ Мщ гАтЕя гАкгЦД зят?
П ? ьщ?566 ? Фчо цыЕяй зМДгй гЦАуА гЦАцнФпи ЦД?.?ФгАДъгщ Мщ гАтЕя гАкгМД зят?
ЬУ?гА ЦД геАсъДояМи Мщ Цяу Дчу Пг УМ ЗзйСо?
? яшЦ гроМго УМ ЗзйСоУЬ хЕ емугфМ Пг Мщ?║?хЕ емугфМ Пг Мщ ЦзоСЬ А геАлМгхМи гЦАуАМи АцАЦягж гАщяМФсМи гАкгАки Цз йчоУЬ Ц гАзЦя?
? ФАцАьщгА гАпМД ФАоФг Мщ?║?ЦзоСЬ А геАлМгхМи гЦАуАМи хДМ гцАьщгА гАпМД мМйАФД Цяйхи гАьщА гцАФА цФ гАкгМД Мщ гцАяси?
? ФМФМу гАхгмкФД хезьга глАязи гцАФЛА?.? цФ ЦД цЦЕгй АМс АоЕМД сФгхч гяйщгз жшь гАоЦ цкДга гмАЦА?║?ЦйгЦ гмАЦА?
? кЦ езьга лязи ЦзрЖЬ ри ЦДЕ Мщ гАсДи?║?ЦД Ачгм гмАухи ФгмАухи гцАЦАгДМи ФгАДъгщ хДМ гАтЕя гАйгсз ФгАтЕя гАкгМД зят?
.?гАягхзи ЦД гАзЦя?
ABSTRACT This cross-sectional study evaluated the immune status of non-vaccinated healthy infants to
determine if it is possible to replace both measles vaccine (at 9 months) and measles, mumps and rubella
(MMR) vaccine (at 18 months) with a single dose of MMR at 12 months. Serum samples from 566 children
in Alexandria, Egypt showed a significant decrease in the seropositive rate to the 3 viral diseases with
increasing age, but a significant increase in the seropositive rate among infants who were ranked 1st or
2nd in their family, full-term or born to mothers with no history of hypertension during pregnancy. We recommend administration of the first dose of MMR vaccine between 9 and 12 months of age, and a booster
dose of MMR vaccine at 4 years of age.
Le calendrier vaccinal actuel (rougeole Ю 9 mois et ROR Ю 18 mois) peut-il Йtre remplacИ par une
dose de ROR Ю 1 an en ?gypte ?
R?SUM? Cette Иtude transversale a ИvaluИ le statut immunitaire de nourrissons en bonne santИ non
vaccinИs afin de dИterminer la possibilitИ de remplacer le calendrier vaccinal actuel, qui prИvoit un vaccin
antirougeoleux Ю 9 mois et un vaccin antirougeoleux-antiourlien-antirubИoleux (ROR) Ю 18 mois, par une
dose unique de vaccin ROR Ю 12 mois. Les Иchantillons de sИrum prИlevИs sur 566 enfants d▓Alexandrie
(?gypte) ont montrИ une baisse significative du taux de sИropositivitИ aux trois maladies virales Ю mesure
que l▓Бge augmentait, mais une augmentation significative de ce taux chez les nourrissons qui Иtaient le
premier ou le deuxiХme enfant de la famille, nИs Ю terme ou de mХres n▓ayant pas d▓antИcИdents d▓hypertension pendant la grossesse. Nous recommandons l▓administration de la premiХre dose de vaccin ROR
entre 9 et 12 mois et une dose de rappel Ю l▓Бge de 4 ans.
Department of Paediatrics; 3Department of Microbiology, Faculty of Medicine, University of Alexandria,
Alexandria, Egypt (Correspondence to S.S. Barakat: shahirabarakat@yahoo.com).
2
Department of Microbiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt.
Received: 15/08/06; accepted: 04/02/07
1
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Introduction
The measles, mumps and rubella (MMR)
viruses contribute to a significant degree
of mortality and morbidity in developing
countries [1]. Though MMR vaccine has
been part of the immunization schedule
in developed countries for some time, it
has been included in the Egyptian national
immunization schedule only since 2000.
The MMR vaccine has been very effective
in the elimination of disease and has high
biosafety [2,3]. Furthermore, the vaccine
can be safely administered to children with
allergy to eggs, even those with severe hypersensitivity [4].
The Advisory Committee on Immunization Practices has recommended 2 doses of
MMR vaccine for all children and certain
high-risk groups of adolescents and adults,
including international travellers, people
attending colleges and other higher educational institutions and people who work at
health care facilities. The first dose of MMR
vaccine should be administered to all children beginning at or after age 12 months,
and the second dose routinely at age 4 to 6
years [5]. More than 30% of measles cases
occur before the age of 1 year in developing
countries, a time at which that majority of
children have lost their maternally-acquired
antibodies [6]. The World Health Organization (WHO) recommended the vaccination
schedule in Egypt as follow: measles vaccine at age 9 months and a single dose of
MMR vaccine at 18 months.
Serological studies show that measles
vaccine efficacy increases in children immunized at age 12 months or later [7,8].
This is due to the effect of persistent maternal antibodies that interfere with immunization [9,10]. Maternal antibody levels
to measles show progressive reduction with
increasing age from 7 months to 15 months
[11]. This also applies to maternal mumps-
specific IgG antibodies [12]. Gestational
age also has an important influence on the
placental transfer of maternal IgG antibodies to the fetus. The premature infant has
proportionally lower IgG concentration at
birth, and values reached their lowest level
at 3 months [13]. However, seroconversion
following vaccination is more common in
premature than in term infants because of
earlier disappearance of maternally-derived
antibody in premature infants who start
with a lower level of antibodies [14]. The
immune status of mothers against the MMR
viruses also has an important influence on
the timing of immunization of children.
It has been suggested that the children of
women who have received measles vaccine
might be successfully immunized at an
earlier age than the children of women who
have had measles. Antibody titres are lower
after immunization than after measles, and
therefore wane over a shorter period of time
[14].
The aim of our study was to determine
the immune status of non-vaccinated healthy
infants in Egypt to ascertain if it is possible
to replace the current vaccination schedule
regarding measles (at 9 months) and MMR
(at 18 months) by a single dose of MMR
given at 12 months.
Methods
This cross-sectional study was carried out at
the outpatient department of a tertiary care
hospital in Egypt, Alexandria University
Children▓s Hospital, over a 1-year period
from 1 March 2005 to 28 February 2006. A
total of 566 normal children aged from 0√12
months, attending the hospital for regular
follow-up, were enrolled in the study. Neonates less than 7 days were recruited from
the delivery room. None of them had been
previously vaccinated with MMR vaccine,
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
had any history of measles, mumps or rubella infection or was taking immunosuppressive agents. Additionally, children with
chronic illnesses such as malignancies,
severe malnutrition, tuberculosis, liver cirrhosis or renal failure were not included in
the study.
Written parental consent was obtained
for each participant, and the study was approved by the ethics committee of the University of Alexandria. All studied infants
were subjected to careful history taking
(age, sex, birth order, gestational age, history of vaccination against any of the 3 viral
diseases, maternal history of hypertension
during pregnancy and maternal history of
vaccination, infection or exposure to any
of the 3 viral diseases) and full clinical
examination.
A 3mL blood sample was withdrawn
from each infant by venepuncture and
sera were separated, divided in 3 aliquots
and kept frozen at √70 ?C until tested for
qualitative and quantitative measurement
of serum levels of measles-, mumps- and
rubella-specific IgG antibodies. Commercially available enzyme-linked immunosorbent assay kits were used for measles
(BAG-Masern-EIA-G, BAG Healthcare,
Lich, Germany), mumps (BAG-MumpsEIA-G, BAG Healthcare) and rubella (Biotec Laboratories Limited, United Kingdom)
[15]. Each test was performed following
the manufacturer▓s instructions. IgG levels
were expressed as IU/mL.
Statistical analysis
The data were analysed using SPSS, version
5. Quantitative variables were presented as
mean and standard deviation (SD). Analysis
of variance (ANOVA) was used to compare
the mean values of various quantitative
variables between multiple groups. The chisquared test was used to compare the proportion of quantitative variables between
87
them. For all tests, a P value of < 0.05 was
considered significant.
Results
The study included 566 healthy infants,
aged between 0√12 months. They were
299 (52.8%) males. The studied subjects
were categorized according to their ages
into 5 groups: 0 day√< 2 months (193 infants, 34.1%); > 2√< 4 months (110 infants, 19.4%); > 4√< 6 months (102 infants,
18.0%); > 6√< 9 months (103 infants,
18.2%); and > 9√< 12 months (58 infants,
10.2%)
Seropositive rates
The overall seropositive rate of the study
infants to the 3 viral diseases was 68.0% for
measles (385 infants), 79.5% for mumps (450
infants) and 57.6% for rubella (326 infants).
Changes in the seropositive rate of the
studied infants to the 3 viral diseases in the
different age groups are shown in Figure 1.
The measles seropositive rate of the studied
infants showed a significant decrease from
74.6% in the age group 0√< 2 months to
56.9% in the age group > 9√< 12 months (P
< 0.05). However, the mumps and rubella
seropositive rates showed a different trend,
as the decrease in the percentage seropositive until the age > 4√< 6 months was followed by slight increase at the age group >
6√< 9 months. However, the difference was
statistically insignificant (P > 0.05).
Factors affecting seropositivity
Factors affecting the seropositive rate of the
studied infants to the 3 viral diseases were
as follows.
Gestational age
The median level of maternal-specific IgG
antibodies to measles, mumps and rubella
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100.0
86.0
90.0
85.5
81.0
80.0
77.7
75.5
74.6
68.0
70.0
64.7 64.7
61.0
60.0
57.3
% of infants
60.0
56.9
55.0
48.0
50.0
40.0
30.0
20.0
10.0
0.0
0?2
2?4
4?6
6?9
9?12
Age (months)
Figure 1 Seropositive rate of the studied infants to measles, mumps and rubella viruses in
relation to age group
viruses was significantly higher in full-term
compared to preterm infants (1.7, 113.5 and
23.1 IU/mL versus 0.0, 24.0 and 2.3 IU/
mL respectively) (Table 1). Furthermore,
the seropositive rate of the studied infants
to measles, mumps and rubella was significantly higher in full-term compared to
preterm infants (70.0%, 82.0% and 59.2%
versus 0%, 0% and 5.9% respectively) (P <
0.001) (Table 1).
Birth order of the studied infants
A higher seropositive rate to all the MMR
viruses was shown among infants of 1st
or 2nd birth order in their family, with a
significant decrease in the percentage seropositive for infants ranked higher in the
family birth order (P < 0.001) (Figure 2).
Maternal history of hypertension during
pregnancy
We studied the effect of maternal hypertension during pregnancy on the median levels
of maternal-specific IgG antibodies to MMR
viruses and the corresponding seropositive
rate among the studied infants. Infants born
to mothers with hypertension during pregnancy showed a significant decrease in seropositivity to measles, mumps and rubella
than those born to mothers with normal
blood pressure during pregnancy (52.7%,
62.6% and 51.1% versus 72.6%, 84.6% and
59.5% respectively) (P < 0.001). However,
although the median levels of maternalspecific IgG antibodies to the MMR viruses
among infants born to mothers with hypertension were lower than the median levels
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
89
Table 1 Median levels of maternal-specific IgG antibodies and seropositive rate against
measles, mumps, and rubella among infants in relation to gestational age (n = 566)
Virus
Median maternal-specific IgG level
(IU/mL)
Preterm
Full-term
P-value
infants
infants
0.0
1.7
< 0.001
24.0
113.5
0.002
2.3
23.1
0.003
Measles
Mumps
Rubella
among infants born to mothers with normal
blood pressure, the difference was═statistically insignificant═(P═>═0.05)═(Table═2).
Maternal history of exposure,
infection or vaccination against the
3 viral diseases
We evaluated changes in the median levels
of the maternal IgG antibodies to the MMR
% of infants seropositive
Preterm
infants
0.0
0.0
5.9
Full-term
infants
70.0
82.0
59.2
P-value
< 0.001
< 0.001
< 0.001
viruses among the studied infants in relation
to maternal history of exposure, infection,
vaccination or no history of infection with
any of the 3 viral diseases. It was shown
that the median levels of maternal IgG antibodies to measles, mumps and rubella were
significantly higher among infants born to
mothers with a history of previous infection
to the corresponding virus (3.9, 233.2 and
100.0
91.9
90.0
87.4
76.9
80.0
78.2
80.8
77.6
70.0
60.1
58.8
% of infants
60.0
50.0
43.9
39.8
40.0
35.8
32.4
29.4
30.0
19.1
17.1
20.0
10.0
0.0
1st
2nd
3rd
4th
5th
Birth order
Figure 2 Seropositive rate of the studied infants to measles, mumps and rubella viruses in
relation to birth order in family
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Table 2 Median levels of maternal-specific IgG antibodies and seropositive rate against
measles, mumps, and rubella among infants born to mothers having a history of hypertension
during pregnancy and those born to healthy mothers (n = 566)
Virus
Measles
Mumps
Rubella
a
Median maternal-specific IgG level in
infants (IU/mL)
% of infants seropositive
Born to
mothers with
hypertension
in pregnancy
Born to
healthy
mothers
P-value
Born to
mothers with
hypertension
in pregnancy
Born to
healthy
mothers
P-value
3.5
165.1
157.8
5.2
270.8
374.8
> 0.05
> 0.05
> 0.05
52.7
62.6
51.1
72.6
84.6
59.5
< 0.001
< 0.001
< 0.001
In pregnancy
406.7 IU/mL respectively) (Table 3). The
highest seropositive rate to measles, mumps
and rubella was found among infants born
to mothers infected with the corresponding
virus (49.1%, 42.6% and 31.9% respectively, not shown on Table 3).
Discussion
IgG antibodies are actively transported
across the human placenta into the fetal
circulation, supplying the infant with a full
complement of its mother▓s IgG antibodies. Such antibodies, which degrade over
the first few months of life as the immune
system of the infant matures, may protect
against many infectious diseases but might
interfere with the effectiveness of infant
vaccination [16,17]. In this study we tried
to evaluate the immune status of healthy,
non-vaccinated Egyptian infants aged 0 day
to 12 months to MMR viruses to assess if it
is possible to change the current vaccination
schedule regarding measles and MMR and
replace it with a single dose of MMR given
at 12 months.
The present study showed a decrease in
the seropositive rate of the studied infants
to the MMR viruses with increasing age.
At the age of 9√12 months, about 50% of
the studied infants still had the protective
maternal antibodies, but also that at this age
50% of infants are susceptible to measles
and rubella.
Variation in the prevalence of maternal
antibodies to the MMR viruses between
infant populations across countries and sociodemographic strata is poorly understood
[9]. Some studies showed a persistence
Table 3 Median levels of maternal-specific IgG antibodies to measles, mumps and rubella
among infants in relation to mothers▓ history of vaccination, infection, exposure and no history
of any of the 3 viral diseases (n = 566)
Virus
Measles
Mumps
Rubella
Median maternal-specific IgG level (IU/mL) in infants
Born to mothers
Born to
Born to
Born to mothers
mothers with with no history of
mothers with
with exposure to
infection
vaccination
infection
infection
3.3
3.9
3.8
2.0
200.7
233.2
212.9
89.4
207.2
406.7
262.3
134.1
P-value
0.003
< 0.001
< 0.001
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
of maternal specific antibodies to measles
in infants up to 15 months of age [11,18].
On the other hand, other studies showed
early decay of maternal specific antibodies
at age 6 months [10,19]. Several studies
conducted at the University of Alexandria,
Egypt showed a persistence of maternally
transmitted antibodies to measles in only
30% of infants aged between 9√11 months,
and to mumps in 86% of infants in the same
age group [20√22]. Greater understanding
of the determinants of the prevalence of maternal-specific antibodies will help national
policy-makers to determine the appropriate
age for infant vaccination for MMR [7].
The transfer of IgG from the mother to her
fetus starts about the 6th month of gestation
and increases sharply, so that fetal levels
of IgG reach maternal levels during the 8th
month of gestation. At term, the fetal level
even exceeds the maternal level [17]. This
implies that gestational age is an important
determinant of transfer of IgG from the
mother to the fetus [23]. The present study
showed that significantly more full-term
than preterm infants were antibody-positive
to the MMR viruses. Also, the median
levels of maternal-specific antibodies were
significantly higher in full-term compared
to preterm infants. These results agree with
the work done by Okoko et al. [13] and
Doroudchi et al. [24].
The birth order of the studied infants had
an important impact on the seropositive rate
to the MMR viruses, as infants ordered the
1st or 2nd had the highest percentage seropositivity compared with those ordered 4th
or 5th. In Egypt, the poor nutritional state
of multiparous mothers may affect their
immune status, with a subsequent diminution of antibodies passively transferred to
the fetus. A similar finding was observed in
other studies [12,18].
Maternal diseases during pregnancy
have an important impact on the rate of
91
transmission of IgG antibodies across the
placenta. The present study showed that the
median levels of IgG titres and the proportion of infants who were antibody positive
to the MMR viruses was higher among
infants born to mothers who did not have
a history of hypertension during pregnancy
compared with those born to mothers with
hypertension during pregnancy. This is
might be attributed to ischaemic changes in
the placenta that accompany hypertension
and interfere with the normal transfer of
maternal antibodies. Similarly, Sethi et al.
found that IgG levels of low-birth-weight
newborns (weighing less than 2 standard
deviations below the expected weight for
gestational age due to maternal illness during pregnancy) were lower than the antibody levels of normal weight infants of
healthy mothers [25]. It is obvious that the
decrease in serum IgG levels in infants born
to mothers with antenatal illness is mainly
due to the effects of maternal malnutrition
and may possibly be related to the placental
pathology commonly observed in these
pregnancies [26].
Consideration has been given to the
effects of maternal antibodies on the seropositive rate of the studied infants to the
MMR viruses. The highest seropositive rate
was found among infants born to mothers
with a history of infection with any of the 3
viruses. Although our study did not include
measuring maternal antibodies to the 3 diseases in the mothers of the studied infants,
it is assumed to be highest among mothers
with a history of infection. A study conducted in both developing and developed
countries that measured maternal-specific
antibodies to measles found that mothers
who contracted measles had significantly
higher levels of antibodies and higher seroprevalence rates among their infants than
mothers who were vaccinated [26]. It has
been suggested that the children of women
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
who have received measles vaccine might
be successfully immunized at an earlier age
than the children of women who have had
measles [14].
In conclusion, we recommend administration of the first dose of MMR vaccine
between 9 and 12 months of age plus a
booster dose of MMR at 4 years of age,
according to the recommendations of the
American Academy of Pediatrics [27].
Acknowledgements
This work received a grant from the Ministry
of Health and Population. We acknowledge
with thanks Professor Mohamed Ibrahim
Kamel who did the statistical analysis of
this manuscript.
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21. Aref GH et al. A study of antibody titer against mumps in non-vaccinated
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Egypt, University of Alexandria, 1986.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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Distinguishing between primary
infection and reinfection with rubella
vaccine virus by IgG avidity assay in
pregnant women
R. Hamkar,1 S. Jalilvand,1 M.H. Abdolbaghi,2 K.N. Jelyani,1 A. Esteghamati,3
A. Hagh-goo,4 T. Mohktari-Azad1 and R. Nategh1
?гАйЦММр хДМ гАзоФЛ гцАФАМи ФхДМ лйоУЬ о гАзоФЛ хщяМФс Ачгм гмАухи гцАЦАгДМи зД ьяМч мйАМА яшгхи гАшАФхФАДМ гЦАДгзМ?
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?гЦАФсзи ААйАчМм жо гмАухи ФгмАухи гцАЦАгДМи?
У
ЬС ? цкДга гмАЦАи?:?гнАгАуи?
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?йъД?
Ь
Ь
.?жо гмАухи гцАЦАгДМи Ф УМз СйхяС Д ЦД мггАй лйоЬ о гАзоФЛ?
ABSTRACT During the mass measles/rubella vaccination campaign in 2003 in Iran, many pregnant women
were vaccinated mistakenly or became pregnant within 1 month of vaccination. To distinguish pregnant
women who were affected by rubella vaccine as primary infection from those who had rubella reinfection from
the vaccine, serum samples were collected 1√3 months after the campaign from 812 pregnant women. IgG
avidity assay showed that 0.3% of the women had no rubella-specific IgG response; 14.4% had low-avidity
anti-rubella IgG and were therefore not immune to rubella before vaccination; 85.3% had high-avidity antirubella IgG and were regarded as cases of reinfection.
Distinction entre la primo-infection et la rИinfection par le virus du vaccin contre la rubИole grБce au
test d▓aviditИ des IgG chez les femmes enceintes
R?SUM? Lors de la campagne de vaccination de masse contre la rougeole et la rubИole rИalisИe en
2003 en Iran, de nombreuses femmes enceintes ont ИtИ vaccinИes par erreur ou se sont trouvИes
enceintes un mois aprХs la vaccination. Afin de distinguer les cas de primo-infection par le vaccin contre la
rubИole des cas de rИinfection par ce vaccin, des Иchantillons de sИrum ont ИtИ prИlevИs sur 812 femmes
enceintes pendant une pИriode comprise entre un et trois mois aprХs la campagne. La mesure de l▓aviditИ
des IgG rubИoliques a montrИ que 0,3 % des femmes n▓avaient pas de rИponse ; 14,4 % avaient des IgG
antirubИoliques de faible aviditИ et n▓Иtaient donc pas immunisИes avant la vaccination ; et 85,3 % avaient
des IgG antirubИoliques de forte aviditИ et pouvaient donc Йtre considИrИes comme des cas de rИinfection.
School of Public Health; 2Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Islamic
Republic of Iran (Correspondence to R. Hamkar: rhamkar@sina.tums.ac.ir). 3Disease Management Centre,
Ministry of Health and Medical Education, Tehran, Iran. 4Rasool Akram Hospital, Iran University of Medical
Sciences, Tehran, Iran.
Received: 24/05/06; accepted: 27/07/06
1
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Rubella, if acquired during the first trimester of pregnancy, carries a 90% risk
of congenital malformations for the fetus,
called congenital rubella syndrome (CRS)
[1]. Prevention of CRS is the main goal of
rubella vaccination and 2 approaches are
recommended [2]: prevention of CRS only
through vaccination of adolescent girls and/
or women of childbearing age, and elimination of both rubella and CRS through universal vaccination of infants with/without
mass campaigns, surveillance and ensuring
immunity in women of childbearing age
[3].
There is a significant burden of disease
globally as a result of CRS, and the World
Health Organization (WHO) recommends
that countries incorporate rubella vaccine
into their vaccination programmes if possible [4√8].
Rubella vaccination in pregnancy caries
a theoretical risk of CRS if the vaccine is
administered during or just before pregnancy [3,9]. This is because the rubella
vaccine is a live attenuated virus that is able
to replicate in vaccinees and can cross the
placenta to infect the fetus in about 2% of
susceptible mothers. However, there is no
evidence that fetal infection with the vaccine virus is harmful [9,10]. Prospective
registries in several countries have identified no infants with CRS born to known
seronegative women who received rubella
vaccine within 3 months of conception;
thus, the observed risk is zero [3]. Based
on data from these registries, and using the
upper 95% confidence limit of the binomial
distribution, the maximum estimated risk
is 0.6% among women vaccinated within 3
months of conception with the Cendehill or
RA27/3 rubella strains, and the maximum
estimated risk is 2.5% among susceptible
women vaccinated within the first 2 months
95
of pregnancy with the RA27/3 strain. These
maximum theoretical risks remain lower
than the 3% risk of a major congenital
malformation in the general population. It
has been suggested that there will always be
an upper maximum theoretical risk greater
than zero, no matter how large a study is
carried out. It is believed, therefore, that
vaccination in pregnancy can never be positively recommended [9,10].
During the mass campaign of measles/
rubella (MR) vaccination in December
2003 in the Islamic Republic of Iran, a large
number of pregnant women received MR
vaccine mistakenly or became pregnant
soon after vaccination. Based on existing
data about the epidemiological features
of rubella in the Islamic Republic of Iran,
around 80%√90% of the above-mentioned
women may have been immune against
rubella before vaccination [11√13]. Therefore, they may have experienced a rubella
reinfection by the vaccine strain, and a relatively small proportion of them (10%√20%)
may have developed primary rubella infection from the vaccine strain. Although cases
of CRS due to rubella reinfection, even by
wild-type rubella virus, are very rare [14],
it was seen as necessary to distinguish between pregnant women who were affected
by rubella vaccine as primary infection and
those who had rubella reinfection from the
vaccine. Evidence of reinfection would be
accepted if a patient who had pre-existing
rubella antibodies showed a significant rise
of IgG antibody titre or a rubella-specific
IgM response, or both [1]. The IgM response is typically weak, but may sometimes be strong.
In this study, we used IgG avidity assay
to determine the immune response among
pregnant women receiving rubella vaccine
in the mass vaccination campaign in the
Islamic Republic of Iran in order to separate
reinfection cases with high-avidity IgG
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
antibodies from primary infections with
low-avidity response. Despite the lack of
any reports of CRS due to rubella vaccine,
there is a theoretical risk of CRS. Therefore,
susceptible women who experience primary
infection from rubella vaccine should be
followed up.
Methods
Background to the study
Prior to the mass vaccination programme
extensive information about the contraindications to vaccination during pregnancy
were released by the media and married
women were advised at the time of vaccination about the risks of becoming pregnant
for up to 1 month after vaccination. While
108═000 pregnant women did not participate
in vaccination during the mass campaign,
many pregnant women did receive the MR
vaccine. Most were in the early days of
pregnancy at the time of vaccination and
therefore did not know about their pregnancy, while some women, against advice,
became pregnant soon after vaccination.
Following the mass campaign, 2 major
hospitals in Tehran, Imam Khomeini and
Rasool Akram hospitals, and our laboratory
were prepared to advise pregnant women
who had been inadvertently vaccinated. A
total of 812 pregnant women were referred
to the above centres and participated in
the═study.
Sample
The study sample was 812 pregnant women
aged 15√25 years old [mean 21.9 (standard
deviation 2.4) years] who had received MR
vaccine mistakenly or became pregnant
after vaccination. The MR vaccine contained measles Edmonston Zagreb strain
and rubella RA27/3 strain (Serum Institute
of India Ltd, Hadepsar, Pune, India). Serum
samples were collected 1√3 months after the
MR mass campaign in December 2003, and
stored at √80 ╟C.
Commercial enzyme immunoassays
Serum samples were tested by both rubellaspecific IgM and IgG enzyme-linked immunoassay (EIA). The differential assay of
rubella high-avidity and low-avidity IgG
antibodies can be used as a potent assay to
distinguish between primary and secondary
immune response. This assay is gaining
popularity as a diagnostic method for the
assessment of the time of infection [15√17].
However, the rubella IgM assay may not
be an appropriate test to distinguish between the primary and secondary immune
responses, because detection of rubellaspecific IgM alone cannot be considered
absolute proof of a recent primary infection.
IgM response after primary infection may
be prolonged, lasting up to several years.
Furthermore, in some reinfections, rubella
IgM is detectable═[15].
The commercial kits used were the Enzygnost anti-rubella virus IgM and Enzygnost anti-rubella virus IgG (Dade Behring,
Marburg, Germany). All assay protocols,
cut-offs and interpretation of results were
carried out according to the manufacturer▓s
instructions.
For the anti-rubella IgM assay 2 local
(in-house) preparations of weak and strong
positive IgM standards were included as
external controls in every EIA run.
The avidity of IgG for rubella virus
was measured by a protein-denaturing EIA
where the antibodies were first allowed to
bind to the rubella virus antigen, followed
by elution by buffer with and without 35
mM diethylamine [15,18,19]. Each sample
was tested at 2 replicates and a single serum
dilution (1:200) was applied to each replicate. After incubation for 1 hour, test plates
were washed 4 times, and then 1 replicate
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
was soaked for 5 min in washing buffer
and the other replicate for 5 min in washing
buffer containing 35 mM diethylamine.
Fresh buffers were applied and this step was
carried out 2 more times. The plates were
then washed 4 times with washing buffer.
Then the test was continued according to
the kit procedure. The remaining specific
antibody was then detected using optical
density (OD), and an avidity index (AI) was
calculated as follows:
AI (%) =
ODwells soaked with 35 mM DEA
ODwells soaked with wash buffer
в 100
Four serum sample controls were used at
each testing: strong high-avidity anti-rubella
IgG antibody; moderate-avidity anti-rubella
IgG antibody; low-avidity anti-rubella IgG
antibody; and an anti-rubella IgG-negative
serum sample.
The rubella IgG avidity cut-off point was
53% of that calculated previously in another
study using well-defined panels of sera as
primary and secondary immune response
to rubella vaccine in order to determine
low- and high-avidity rubella-specific IgG
responses [15].
Statistical analysis
The parameters calculated included sensitivity, specificity and positive and negative
predictive values along with corresponding
95% confidence intervals (CI) in the differential diagnosis of rubella primary and
97
secondary immune responses for both
rubella IgM EIA and rubella IgG avidity
assay. The chi-squared test was used to determine the statistical difference between
the parameters of the 2 measurements. The
laboratory findings and personal data from
study groups were also compared using the
chi-squared test. The non-parametric Jonckheere√Terpstra statistical method [20]
was employed to test for trend of avidity
index values at the 1st, 2nd, 3rd and 4th
months after vaccination. P-value < 0.05
was considered statistically significant.
Results
Rubella IgG avidity assay results
A total of 117 cases (14.4%) had lowavidity anti-rubella IgG and 2 cases (0.3%)
did not have any rubella-specific IgG, while
693 cases (85.3%) had high-avidity antirubella IgG (Table 1).
The rate of low-avidity response was
significantly related to age (Table 2)
(P <═0.001). Low-avidity response was detected in 21.4% of women aged ? 20 years
and high-avidity rubella IgG in 78.6%,
while low-avidity response was detected in
only 12.0% of women aged >═20 years, and
88.0% exhibited high-avidity response to
rubella vaccine.
Rubella IgM-EIA results
Rubella-specific IgM was detected in 90
cases (76.9%) of primary infection (low-
Table 1 Distribution of rubella IgG avidity assay results by rubella IgM positivity for
pregnant women accidentally immunized with rubella
Rubella
IgM
Positive
Negative
Total
Low-avidity
rubella IgG
No.
%
90
97.8
27
3.7
117
14.4
High-avidity
rubella IgG
No.
%
2
2.2
691
96.0
693
85.3
Rubella IgG
negative
No.
%
0
0.0
2
0.3
2
0.3
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Total
92
720
812
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 2 Distribution of rubella IgG avidity assay results by age for pregnant women
accidentally immunized with rubella
Age
(years)
? 20
> 20
Low-avidity anti-rubella IgG
No.
%
46
21.4
71
12.0
Total
117
High-avidity anti-rubella IgG
No.
%
169
78.6
524
88.0
14.4
693
avidity anti-rubella IgG), and not detected
in 27 cases (23.1%) (Table 1). In the immune group, with high-avidity anti-rubella
IgG, anti-rubella IgM was not detected in
691 cases (99.7%).
Comparison of rubella IgM-EIA with
avidity assay
The rubella IgM-EIA was compared with
the rubella IgG avidity assay. The sensitivity and specificity were determined using low-avidity anti-rubella IgG response
(primary infection) and high-avidity antirubella IgG response (reinfection) cases
(Tables 1 and 3).
Effect of time of sample collection
on rubella IgG avidity maturation
In the low-avidity IgG group, IgG avidity
gradually increased over time; the mean
avidity index was 6.12% in the 1st month,
then increased to 20.82%, 27.16% and
38.03% in the 2nd, 3rd and 4th months
respectively (Table 4 and Figure 1). This
trend was highly significant in the lowavidity sera group (P < 0.001). However,
our results showed no significant trend
among avidity indices in the 1st, 2nd, 3rd
85.6
Total
215
595
810
and 4th months among the high-avidity sera
group (P═=═0.617).
Discussion
Rubella vaccination should be avoided in
pregnancy because of the theoretical (but
never demonstrated) teratogenic risk [10].
Data were available from the United States
of America, the United Kingdom, Sweden
and Germany on 680 live births to susceptible women who were vaccinated inadvertently 3 months before or during pregnancy
with HPV-77, Cendehill or RA27/3 vaccines. None of the infants was born with
CRS. However, a small theoretical risk of
0.5% (upper 95% CI = 0.5%) cannot be
ruled out. Limiting the analysis to the 293
infants born to susceptible mothers vaccinated 1√2 weeks before conception or
4√6 weeks after conception, the maximum
theoretical risk is 1.3% [9]. Although it
is reassuring that no child was born with
symptoms attributable to CRS, it is not appropriate to suggest that rubella vaccine is
safe in early pregnancy [21].
Table 3 Sensitivity, specificity and predictive values of rubella IgM enzyme immunoassay (EIA)
compare to rubella IgG avidity assay
Test
Rubella IgM-EIA
Sensitivity
Specificity
% (95% CI)
76.9 (69.3√84.5)
% (95% CI)
99.7 (99.3√100.0)
Positive
predictive value
% (95% CI)
97.8 (96.6√98.6)
Negative
predictive value
% (95% CI)
96.2 (95.1√97.7)
CI = confidence interval.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
P < 0 001 based on Jonckheere-Terpstra statistical test in favour of trend alternatives: 1st month ? 2nd month ? 3rd month ? 4th month.
SD = standard deviation
1st
2nd
3rd
4th
Total
a
High-avidity index (%)
Mean (SD)
Median
74.71 (9.75)
75.50
74.29 (9.08)
74.49
73.95 (9.49)
73.35
74.72 (9.60)
76.13
74.26 (9.26)
74.35
No.
58
414
177
44
693
Range
0.08√29.51
7.03√49.84
15.13√50.89
21.51√52.35
0.08√52.35
Low-avidity index (%)
Median
Mean (SD)a
6.12 (6.74)
4.80
20.82 (12.44)
15.82
27.16 (10.54)
23.27
38.03 (12.67)
37.97
22.39 (13.82)
18.82
No.
15
57
34
11
117
Month of
sampling
Table 4 Rubella IgG avidity maturation and time of sample collection in low and high-avidity groups
Range
54.19√100.0
54.18√100.0
54.73√100.0
55.14√100.0
54.18√100.0
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
99
According to existing data, about 80%√90% of fertileage women are immune to rubella before vaccination
[11√13]. Therefore, a relatively small proportion of inadvertently vaccinated pregnant women (10%√20%) may
develop primary rubella infection from the vaccine strain.
As documented reports of CRS by rubella reinfection, even
by wild-type rubella virus, are very rare [14], distinction
between primary infection and reinfection by the vaccine
is necessary.
In the present study, IgG avidity assay was used to
determine the immune response against rubella vaccine
among pregnant women. The most critical part of this
assay is the precise calculation of the cut-off point for
differentiating low-avidity IgG from high-avidity IgG. A
cut-off point equal to 53% of that previously calculated
was applied to separate rubella low-avidity IgG from highavidity IgG [15].
The laboratory findings indicated 14.7% of the women
were not immune against rubella virus before vaccination,
and 14.4% of them experienced a primary infection with
the rubella vaccine strain. However, 85.3% of cases had
high-avidity anti-rubella IgG, suggesting they were immune before vaccination and their response to rubella vaccine should be regarded as a secondary immune response.
These results demonstrate that most women are immune at
childbearing age. The findings also confirm previous reports of rubella immunity status in the Islamic Republic of
Iran. The rate of immunity against rubella infection in our
country was reported to range from 83% to 94.6% [11√13].
Thus around 5.4%√17% of Iranian women of childbearing
age are susceptible to rubella infection, which means that
there is a considerable risk of rubella infection during pregnancy, which could lead to CRS. According to these results,
rubella vaccination was deemed necessary for elimination
of CRS in the Islamic Republic of Iran. Mass vaccination
in December 2003 provided appropriate immune coverage
among women of childbearing age; only 0.3% of women
failed to take up the vaccine. It is essential that vaccination
against rubella enter into the policy of vaccination and
that all of infants should be vaccinated against rubella for
maintenance of this coverage.
Based on our results, the difference between primary infection and reinfection was statistically significant between
the 2 age groups. Among the age group ?═20 years old,
21.4% experienced primary infection and 78.6% showed
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Mean avidity index (%)
80
60
Avidity cut-off point = 53%
40
20
0
1st
2nd
3rd
4th
Time of sample collection (months)
Low-avidity group
High-avidity group
Figure 1 Rubella IgG avidity maturation by time of sample collection in low- and
high-avidity groups
reinfection following rubella vaccination.
However, among the >═20 years age group,
11.8% had primary infection and 88.2%
experienced reinfection or no immune response from the rubella vaccine strain. This
difference suggests that immunity against
rubella infection increases with age.
Our sampling continued up to 4 months
after vaccination and indicated that the
avidity index values of the low-avidity
group had an increasing trend by the time of
sample collection, but were lower than the
avidity cut-off point, even up to 4 months.
In contrast, for the high-avidity group sera,
the avidity index values were not affected
by the timing of sampling: mean avidity
indices were constant over the period of
sample collection. So, according to these results, measurement of rubella-specific IgG
avidity can distinguish primary infection
from reinfection up to 4 months after vaccination. In one study it was observed that all
samples had an avidity index < 30% up to 3
months and a considerable increase was ob-
served in avidity after 4 months [22]. That
result demonstrated that primary infection
can be differentiated from reinfection for
up to 4 months. In another study, the time
course of maturation of rubella IgG avidity
after acute infection was demonstrated [23].
Well-characterized serial samples from 15
patients with acute rubella were tested and
followed up for 5 months after the onset of
rash. A high-avidity index (> 60%) was not
observed until 13 weeks after infection.
In our study, rubella-specific IgM
antibody was detected in 76.9% of sera
containing low-avidity IgG, but 23.1% of
sera tested by IgM-EIA provided negative
results. While the sensitivity of IgM-EIA
for diagnosing primary rubella infection
was 76.9%, IgM-EIA did not have the appropriate sensitivity to distinguish between
primary and secondary infections. However, IgM-EIA has appropriate specificity
(99.7%) for determining negative cases and
it can detect non-primary rubella cases,
which again confirms previously reported
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
findings [15]. Previously, the sensitivity
and specificity of 7 commercial rubellaspecific IgM kits were assessed, and it was
shown that the sensitivity of most kits was
within the range of 66.4%√78.9% (median 73.9%). The specificity of these kits
was estimated to be 85.6%√96.1% (median
92.6%). The sensitivity and specificity of
IgM-EIA for detection of rubella infection was shown by Behring▓s indirect EIA
kit to be 75.9% and 98.7%, respectively
[5]. In another study it was shown that the
percentage of rubella-specific IgM-positive
sera decreased from 100% at 15√28 days
after the onset of infection through 71%,
28% and 9% at 1√2, 2√3 and 3√4 months,
respectively. After 4 months, all sera were
negative for rubella specific IgM antibody.
However, low-avidity specific IgG was
detected in all of the sera taken at 3 months.
At 3√4 months 91% and at 5√7 months 21%
of sera still showed low-avidity [24].
Our study shows that the positive predictive value and negative predictive value
of IgM-EIA were 97.6% and 96.4% respectively. When the prevalence of rubella is
low, such as in countries with high rubella
vaccination coverage, the positive predic-
101
tive value of IgM testing decreases such that
there is a significant risk of false positive
results, and additional confirmation tests are
therefore required [5,15,25]. The measurement of rubella-specific IgG avidity is a
specific and sensitive method for the serological diagnosis of recent primary infection, and provides the distinction between
primary infection and possible reinfection
[15,18].
It is essential that a correct diagnosis
of primary rubella can be achieved for the
management of pregnant women with a
recent rash or contact with a rubelliform
rash illness [26]. With the introduction
and widespread use of the rubella vaccine,
it is likely that, with time, relatively few
cases of rubella infection during pregnancy
will be primary infection and more will
be rubella reinfection [14,27]. Therefore,
detection of IgM alone cannot differentiate
primary infection from reinfection. For
these cases, the measurement of IgG avidity
is very useful, since, in the case of recent
primary infection, IgG is low-avidity and in
the case of reinfection, IgG is high-avidity
[15,18,24,28,29].
References
1.
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3.
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Tipples G et al. Evaluation of rubella IgM
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13. Kabiri M, Moattari A. The rubella immunosurveillance of Iranian females: an indication of the emergence of rubella outbreak
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14. Aboudy Y et al. Subclinical rubella reinfection during pregnancy followed by
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15. Hamkar R et al. Assessment of IgM enzyme immunoassay and IgG avidity assay
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16. BodИus M, Feyder S, Goubau P. Avidity of
IgG antibodies distinguishes primary from
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19. Thomas HI, Morgan-Capner P. Rubellaspecific IgG1 avidity: a comparison
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20. Hollander M, Wolfe DA. Nonparametric
statistical methods. Chapter 6. London,
John Wiley, 1999:202√12.
21. Tookey P. Pregnancy is a contraindication to rubella vaccination still [letter]. British medical journal, 2001, 322:1489.
22. Hedman K et al. Maturation of immuno╜
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23. Bottiger B, Jensen PI. Maturation of rubella IgG avidity over time after acute rubella
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IgM and low-avidity specific IgG1 following primary rubella. Journal of virological
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25. Best JM et al. Interpretation of rubella serology in pregnancy≈pitfalls and
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325:147√8.
26. Inouye S et al. Changes in antibody avidity after virus infections: detection by an
immunosorbent assay in which a mild
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
protein-denaturing agent is employed.
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27. Thomas HIJ, Charlett A, Cubie HA. Specific IgG1 avidity maturation after rubella
vaccination: A comparison with avidity
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28. Enders G, Knotek F. Rubella IgG total
antibody avidity and IgG subclass-specific
Measles and rubella laboratory network
The global measles and rubella laboratory network was developed
based on the successful model of the global polio laboratory network.
As of 2008, 679 laboratories have been established in 164 countries.
Many of these laboratories are also responsible for laboratory-based
surveillance of other vaccine preventable diseases in their countries.
Rubella surveillance is often integrated with measles surveillance as
the WHO measles case definition also captures rubella cases. Many
countries administering rubella vaccine also take advantage of the
combination vaccine presentation of measles and/or mumps. The
confirmation of rubella cases is very similar to measles. The standard
procedure recommends use of an IgM ELISA assay performed on
a single serum sample. Most countries follow a procedure of testing measles negative samples for rubella. Rubella virus detection is
more challenging than for measles, but when successful, sequence
information can be utilized for the same molecular epidemiological
purposes as for measles.
Further information about the Measles and rubella laboratory network
can be found at: http://www.who.int/immunization_monitoring/laboratory_measles/en/index.html
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Hygiene practices and sexual
activity associated with urinary tract
infection in pregnant women
F.N. Amiri,1 M.H. Rooshan,2 M.H. Ahmady3 and M.J. Soliamani4
?ЦЦгясгй гАДыгщи гАтнуМи ФгАДтгь глАДМс гЦАугмхи АзоФЛ гЦАсгАъ гАхФАМи Мщ гмАФгЦА?
? мЦЦо лзщя сАМгЦМД?║? мЦЦФо мглМ цЦмоМ?║? мЦЦо мсДлгД яФтД?║?щгьЦи ДуФяМ цЦяММ?
?ААйзящ зЛА Сй Сяг Ущч зоФЛ гЦАсгАъ гАхФАМи Цз ЦЦгясгй?
?цляЛ гАхгмкФД оягси ААмггАй ФгАтФгЕо?
С :?гнАгАуэи?
ЬУ
║? ФЦз гАДтгь глАДМс Мщ гмАФгЦА гАгАМй МяглзД зМгогй гмАФгЦА Мщ хгхФА?║?гАДыгщи гАтнуМи АцАзжга гАйДгсАМи?
?зМДи йжЦ Цфи мгЦА АоЕМД Цргяз елМгхМи ААхФА (хгзйхгяЕД?
Ь ? Фчо чгяД гАхгмкФД?.?хлЦЕФяМи еМягД геАсгАЦМи?
?МгЦкАДЕД ЦД мМк гАзЦя ФгмАгАи ггАлйгЦзМи ФггАчйугоМи ФгАкчгщМи?
?мггАй) Цз Цфи ФЦнсДМ ЦД гмАФгЦА гААФгМй?
ЬС
.? ЦД гмАггАй?%83 ?гЦАсхх ААзоФЛ Мщ?
Ь ?ФгАрФглМи (хгзйхгяЕД тФгЕо) Фчо ъгДй геАМятМъМгй гАчФАФДМи ЕМ гАзгЦА?
?цЦг гАзФгЦА гЦАягщчи гАнйьгя геАугхи хзоФЛ гЦАсгАъ гАхФАМи щйтЦА глАгЦз цъкя ЦД кгАк Цягй цсхФзМ Пг (Дсхи?
? ФзоЦ шсА гцАзжга гАйДгсАМи?║)3.27 ? ФФлФо зоФЛ моМки Мщ гЦАсгАъ гАхФАМи (Дсхи гцАялмМи?║)5.62 ?гцАялмМи?
? ФзоЦ гАйхФА хзо?║)2.89 ? ФзоЦ шсАЕг хзо глАгЦз (Дсхи гцАялмМи?║)2.16 ?гАыгЕяи чхА глАгЦз (Дсхи гцАялмМи?
.)2.96 ?) ФшсА гцАзжга гАйДгсАМи ЦД гнААщ еЛА гцАЦгЦ (Дсхи гцАялмМи?8.62 ?глАгЦз (Дсхи гцАялмМи?
ABSTRACT A case√control study determined the association of urinary tract infection (UTI) with genital
hygiene practices and sexual activity in pregnant women attending prenatal clinics in Babol, Islamic
Republic of Iran. A sample of 100 pregnant women with positive urine cultures (cases) were compared
with 150 healthy pregnant women matched for age, social, economic and education status and parity
(controls). Escherichia coli was the infecting organism in 83% of cases. Factors associated with UTI included sexual intercourse ? 3 times per week (OR = 5.62), recent UTI (OR = 3.27), not washing genitals
precoitus (OR = 2.16), not washing genitals postcoitus (OR = 2.89), not voiding urine postcoitus (OR =
8.62) and washing genitals from back to front (OR = 2.96)
Pratiques d▓hygiХne et activitИ sexuelle associИes Ю l▓infection urinaire chez les femmes enceintes
R?SUM? Une Иtude cas-tИmoins a ИvaluИ l▓association entre l▓infection urinaire, d▓une part, et
les pratiques d▓hygiХne intime et l▓activitИ sexuelle, d▓une autre part, chez les femmes enceintes
frИquentant les services de consultations prИnatales de Babol (RИpublique islamique d▓Iran).
Un Иchantillon de 100 femmes enceintes ayant des cultures urinaires positives (les cas) a ИtИ comparИ
Ю 150 femmes enceintes en bonne santИ appariИes sur l▓Бge, la situation sociale et Иconomique, le
niveau d▓instruction et le nombre d▓enfants (les tИmoins). L▓organisme infectieux Иtait Escherichia coli
dans 83 % des cas. Les facteurs associИs Ю l'infection urinaire Иtaient les rapports sexuels trois fois par
semaine ou plus (OR = 5,62), une rИcente infection urinaire (OR = 3,27), l▓absence de toilette intime avant le
coОt (OR = 2,16), l▓absence de toilette intime aprХs le coОt (OR = 2,89), l▓absence de miction aprХs le
coОt (OR = 8,62) et un lavage intime d▓arriХre en avant (OR = 2,96).
Department of Midwifery; 2Department of Infectious Diseases; 3Department of Social Medicine;
Department of Laboratory Medicine, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
(Correspondence to F.N. Amiri: nasiri_fa@yahoo.com).
Received: 26/04/06; accepted: 27/07/06
1
4
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Urinary tract infection (UTI) is a bacterial
infection commonly occurring during pregnancy [1]. The incidence of UTI in pregnant
women depends on parity, race and socioeconomic status and can be as high as 8%.
Beginning in week 6 and peaking during
weeks 22√24 of pregnancy, approximately
90% of pregnant women develop urethral
dilatation, which will remain until delivery.
Increased bladder volume and decreased
bladder tone, along with decreased urethral
tone, contribute to increased urinary stasis
and ureterovesical reflux. Additionally, up
to 70% of pregnant women develop glycosuria, which encourages bacterial growth in
the urine [2]. The prevalence of bacteriuria
also rises with higher parity, older age and
lower socioeconomic status, and in women
with diabetes mellitus, sickle-cell trait or a
past history of UTI. For example in lowincome populations, the prevalence of bacteriuria is about 2% in primiparas younger
than 21 years compared with 8%√10% in
grandmultiparas older than 35 years [3]. Although UTIs are common in young women,
the associated risk factors have not been
defined [4].
The organisms that cause UTI during
pregnancy are the same as those found in
non-pregnant patients. Escherichia coli
accounts for 80%√90% of infections [2].
Scholes et al. reported on 231 patients
and showed that E. coli was the causative
uropathogen for 85% of infections. Other
causative organisms were Staphylococcus
saprophyticus, Klebsiella spp., Enterobacter spp. and Proteus mirabilis [5].
UTIs in pregnancy may have serious
consequences for both the mother and the
child. These conditions may be related to
pyelonephritis, low birth weight, premature
labour, preterm birth, hypertension, preeclampsia, maternal anaemia, amnionitis
105
and increased incidence of perinatal death
[6]. Thus the prevention, early detection and
prompt treatment of UTI in pregnancy have
become essential components of prenatal
care [7]. Other studies have reported the
high prevalence of UTI in pregnant women
in developing countries in the Eastern
Mediterranean Region [8,9]. Since the risk
factors of symptomatic and asymptomatic
UTI in pregnant women in this Region have
not been fully described, the purpose of
this study was to determine the association
of UTI with genital hygiene practices and
sexual activity in pregnant women in Babol,
Islamic Republic of Iran.
Methods
This case√control study was performed
on 100 women with positive urine culture
(cases) and 150 healthy pregnant women
(controls), matched for age, gestational age,
parity, occupation and socioeconomic and
education status. The women were selected
consecutively from those attending 5 public clinics at Babol University of Medical
Sciences for prenatal care from 1 January
2002 to 20 February 2004. The exclusion
criteria were a history of >═2 episodes of
UTI per year, urinary stones or urinary tract
anomaly, chronic disease (diabetes mellitus, sickle-cell anaemia), consumption of
any antibiotic or immune system inhibitory
drugs in the previous 3 months, or the presence of any abnormal vaginal discharge.
Data on the women▓s genital hygiene
and sexual practices were collected by questionnaire completed by the midwives in
the clinics. The questionnaire asked about
demographic variables, frequency of coitus
(per week in the previous 30 days), genital
hygiene practices, e.g. whether they usually
urinated after coitus (> 15 minutes/< 15
minutes after), washing of genitals pre-
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coitus and postcoitus by the woman and
her husband (yes/no/sometimes) and other
health/hygiene practices, e.g. direction of
washing genitals (front to back/back to
front), frequency of changing underwear
(number of times per week), frequency of
baths (number of times per week), drying after voiding urine (yes/no), voluntary
delay in voiding urine (yes/no), how much
liquid (> 2/1√2/< 1 L) drunk per day. The
questionnaire also asked about urological
symptoms from the beginning of pregnancy
until the interview; frequency was defined
as total number of daily voids > 8 [10].
The women were instructed how to
give a clean-catch midstream urine specimen. The samples were sent to Babol Razi
laboratory and the fresh urine was tested
immediately. Urinalyses and urine cultures
were used for the detection of UTI. A UTI
was defined as the presence of significant
bacteriuria > 100═000 colony-forming units
per mL of urine. Several studies show the
specificity of urine culture to be high (97%
and 98%) [11,12].
This study was approved by the review
board of research on humans at the University of Babol.
Statistical analysis
Descriptive statistics and the chi-squared,
Fisher exact and t-tests were used to compare the 2 groups. P < 0.05 was considered
as significant. A risk profile for UTI was
expressed in the form of odd ratios (OR)
with 95% confidence intervals (CI) for the
250 women.
Results
There was no statistically significant difference between the case and control groups
with regard to attendance for regular prenatal care.
The clinical characteristics and urological symptoms of the case and control
women are shown in Table 1. The most
frequently reported symptoms among case
patients were frequency and urgency (77%
and 70% respectively); 96% of case patients
reported 1 or both of these symptoms.
A history of UTI was significantly associated with UTI. In case patients, 46% had
a previous history of UTI but in the control
group only 20% had a previous UTI (P
<═0.0001) (OR = 3.27; 95% CI: 1.87√5.70).
In the 100 cases with urinary isolates
analysed, E. coli was the causative uropathogen for 83% of infections. Other causative
organisms were S. saprophyticus (10%), Enterococci spp. (4%) and P. mirabilis═(3%).
Factors associated with UTI
A number of genital hygiene practices were
associated with UTI in univariate analyses.
Not voiding urine after coitus was the most
strongly associated variable (OR = 8.62;
95% CI: 6.66√16.66). Other genital hygiene practices were associated with UTI,
including: not washing genitals postcoitus
(OR = 2.89; 95% CI: 1.53√9.80), not washing genitals precoitus (OR = 2.16; 95%
CI: 1.29√3.63), and husband not washing
genitals precoitus (OR = 2.53; 95% CI:
1.48√ 4.32) (Table 2). Other practices associated with UTI included voluntary delay
of evacuating the bladder which had a more
than 4-fold likelihood of UTI (OR = 4.33;
95% CI: 2.51√7.47) (Table 2).
Mean frequency of sexual intercourse
was also associated with UTI (Table 3).
Mean frequency of sexual intercourse (per
week in the previous 30 days) in case and
control groups respectively were 2.63 (SD
1.01) and 1.81 (SD 0.94) (P < 0.05). Sexual
intercourse ? 3 times per week was associated with greater UTI risk (OR = 5.62; 95%
CI: 3.10√10.10).
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
107
Table 1 Clinical characteristic of women suffering from urinary tract infection (n = 100) and
matched controls (n = 150)
Clinical symptom
Frequency
Urgency
Lower abdominal pain
Dysuria
Change in odour of urine
Costal vertebral angle tenderness
Change in colour of urine
Fever
Chills
Cases
Yes
No
No.
%
No.
%
77
77.0 23
23.0
70
70.0 30
30.0
66
66.0 34
34.0
62
62.6 37
37.4
62
62.0 38
38.0
45
45.0 55
55.0
Controls
Yes
No
No. %
No. %
73
43.5
77 51.7
52
34.9
97 65.1
42
28.0 108 72.0
20
13.5 128 86.5
25
16.8 124 83.2
34
22.8 115 77.2
33
28
22
13
7
7
33.0 67
28.0 72
22.0 78
67.0
72.0
78.0
8.7 136 91.3
4.7 142 95.3
4.7 142 95.3
OR (95% CI)
3.45 (2.03√6.31)
4.35 (2.50√7.50)
4.99 (2.89√8.62)
10.72 (5.75√20.00)
8.93 (4.48√14.59)
2.77 (1.60√4.79)
5.15 (2.54√10.43)
7.81 (3.29√18.93)
5.72 (2.34√13.99)
Data missing for some variables.
OR = odds ratio; CI =confidence interval.
Women with UTI took baths less often
and replaced their underwear significantly
less often than control women (P < 0.05 and
P < 0.0001 respectively) (Table 3).
Discussion
E. coli was the predominant infecting organism in women suffering from UTI (83%), a
similar proportion to that previously reported for cystitis [5,13√16].
Most risk factors we identified for UTIs
were similar to those identified in previous
studies of young adult women with acute
and recurrent cystitis and asymptomatic
bacteriuria [13,14].
Sexual intercourse ? 3 times per week
was associated with greater frequency of
UTI. This association has been reported for
sporadic and recurrent cystitis [13,14,16√
19]. The mechanical action of sexual intercourse may facilitate entry of E. coli strains
into the urethra and bladder, because sexual
intercourse alters the normal lactobacillusdominant vaginal flora and facilitate E.
coli colonization of the vagina [20,21].
Uropathogenic E. coli strains may in some
cases be acquired by sexual transmission
[22]. These exposures, by facilitating entry
of E. coli into the bladder, may initiate
events leading to UTIs.
A history of UTI, any and recent, has
been a consistently reported risk factor for
subsequent cystitis in both young adult and
postmenopausal women [11,12,14,23,24].
Our study confirmed that a previous UTI
may predispose to subsequent UTI through
behavioural, microbiological or genetic
factors. These findings are consistent with
other studies [4,5,25].
Low intake of fluids and voluntary urinary retention were associated with UTI
in women in our study, which agrees with
other studies [5,7,26]. In our study, genital
hygiene practices such as frequency of coitus, urinating after coitus, washing genitals
precoitus, husband washing genitals precoitus, washing genitals postcoitus, taking
baths, frequent replacing of underwear and
washing genitals from front to back were associated with a reduced frequency of UTIs,
as found in other studies [27,28]. Women
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Table 2 Association of health and sexual hygiene practices with urinary tract infection for
cases (n = 100) and matched controls (n = 150)
Practice
Not washing genitals precoitus
Husband not washing genitals precoitus
Not washing genitals postcoitus
Washing genitals from back to front
Not voiding urine postcoitus
Delay in voiding urine (voluntary)
Not drying after voiding
Not drinking plenty of liquids
Cases
Yes
No
No.
%
No.
%
Controls
Yes
No
No.
%
No. %
OR (95% CI)
47
47.0
53
53.0
98
65.8
51
34.2
2.16 (1.29√3.63)
52
52.0
48
48.0
110
73.3
40
26.7
2.53 (1.48√4.32)
84
84.0
16
16.0
143
95.3
7
4.7
2.89 (1.53√9.80)
60
60.0
40
40.0
120
81.6
27
18.4
2.96 (1.66√5.28)
51
51.0
49
49.0
135
90.0
15
10.0
8.62 (6.66√16.66)
69
39
69.7
39.0
30
61
30.3
61.0
52
104
34.7
69.3
98
46
65.8
30.7
4.33 (2.51√7.47)
3.53 (1.61√6.21)
32
32.0
68
68.0
78
54.2
66
45.8
2.51 (1.45√4.24)
Data missing for some variables.
OR = odds ratio; CI =confidence interval.
who usually urinated within 15 minutes
of intercourse had a lower likelihood of
developing a UTI than women who did not
urinate afterwards. This contrasts with the
report of Beisel et al. which did not show
a statistically significant difference [29].
This may be due to the small sample size
in both studies and the study design; a randomized controlled trial of a larger sample
would be able to provide better evidence
that postcoital voiding is an effective means
of prevention of UTI.
In summary, our investigation found
that UTI in our sample of women were
primarily caused by bacteria from the stool
(E. coli) and that hygiene habits and sexual
behaviour may play a role in UTI in pregnant women.
Table 3 Personal hygiene and sexual habits of women suffering from
urinary tract infection (n = 100) and matched controls (n = 150)
Personal habit
Taking a bath (No. of times/week)
Replacing underwear (No. of times/week)
Coitus (No. of times/ week in last 30 days)
Cases
Mean (SD)
Controls
Mean (SD)
P-value
3.11 (0.99)
3.41 (1.53)
< 0.05
4.14 (1.80)
5.08 (2.02)
< 0.0001
2.63 (1.01)
1.81 (0.94)
< 0.0001
SD = standard deviation.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
109
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
111
Training on the Practical Approach to
Lung Health: effect on drug prescribing
in PHC settings in Jordan
K. Abu Rumman,1 S. Ottmani,2 N. Abu Sabra,1 S. Baghdadi,3 A. Seita3 and L. Blanc2
? цкя Фущ гАоФга Мщ ЦФгчз гАязгМи гАумМи гцАФАМи Мщ гцАяоД?:?гАйояМх зЛА гцАсАФх гАзЦМА Ауми гАяфи?
? АМФ хФА хгАД?║? цъМЕяФ сМйг?║? сЦМми хшогоМ?║? ДгоМи цхФ уяхг?║? угАм гАоМД зкгЦМД?║?нгАо цхФ яЦгД?
? СЬчМЦ гАхгмкФД Мщ ЕпЕ гАоягси цкя йояМх гцАьхга зЛА гцАсАФх гАзЦМА Ауми гАяфи Мщ гмАо ЦД Фущ?:?гнАгАуи?
? Фчо чФяДй гАхМгДгй чхА?.?гАоФга ФйъгАМщ гцАоФМи гЦАФуФщи АцАЦягж гАйДщсМи Мщ СЦ Сягщч гАязгМи гАумМи гцАФАМи?
.?Фхзо йояМх гЦАгЦясДМ гАзг ЖЬЦДМ зЛА гАогАфА геАятгоМи гЦАзМгяМи ЦАзглАи гмАггАй гЦАяжМи гАйДщсМи Мщ гАязгМи гцАФАМи?
║? мЦгщыи Мщ гцАяоД?12 ? Цяър Пг умМ Пг Мщ кгАк мЦгщыгй ЦД еЦлгМА?25 ? ЦЦгяс Пг згЦ Пг МзЦАФД Мщ?56 ?Фчо тЦАй гАоягси?
2709 ? ЦяМж Пг ФЦсм цкя гАйояМх гАпМ гтйЦА зЛА?6260 ?ЦЦД тгяъФг Мщ ъА ЦД гЦАсм гцАсгМс гАпМ гтйЦА зЛА?
? чо СЬцоЛ еЛА йчАМА зоо гцАоФМи гЦАФуФщи ААЦяЛж хДсхи?║? ФйхМДСЬ цД гАйояМх зЛА гцАсАФх гАзЦМА Ауми гАяфи?.?ЦяМж Пг?
.% 8.7 ? еЛА йчАМу ФсьМ йъАщи гцАоФМи гЦАФуФщи ААЦяЛж хДсхи?║? ФеЛА рМгои гцАоФМи гЦАцнФпи хггАсйДтгч?║% 12.2
ABSTRACT This study assessed whether training physicians on the Practical Approach to Lung Health
(PAL) reduces drug prescribing and the cost of drugs prescribed to respiratory patients in the primary
health care setting. Data were compared before and after training general practitioners on standard guidelines for case management of respiratory conditions in primary care. A total of 56 general practitioners
practising in 25 health centres in 3 out of 12 governorates of Jordan participated in both the baseline survey (n = 6260 respiratory patients) and the impact survey (n = 2709 patients). Training in PAL decreased
by 12.2% the number of drugs prescribed per patient, increased the prescription of inhaled medications
and reduced the mean cost of a drug prescription per patient by 8.7%.
Formation Ю l▓approche pratique de la santИ respiratoire : les effets sur la prescription de mИdicaments
dans les structures de soins de santИ primaires en Jordanie
R?SUM? Cette Иtude visait Ю dИterminer si le fait de former les mИdecins Ю l▓approche pratique de la
santИ respiratoire (APSR) entraНnait une rИduction de la prescription de mИdicaments et diminuait le
coШt des mИdicaments prescrits aux patients souffrant d▓affections respiratoires dans les structures de
soins de santИ primaires. Les donnИes ont ИtИ comparИes avant et aprХs que les mИdecins gИnИralistes
aient reГu une formation sur les recommandations standard concernant la prise en charge des affections
respiratoires dans le cadre des soins de santИ primaires. Au total, 56 mИdecins gИnИralistes exerГant
dans 25 centres de santИ situИs dans 3 des 12 gouvernorats de Jordanie ont participИ Ю l▓Иtude
de rИfИrence (n = 6 260 patients souffrant d▓affections respiratoires) et Ю l▓Иtude d▓impact
(n = 2 709 patients). La formation Ю l▓APSR a entraНnИ une diminution de 12,2 % du nombre de
mИdicaments prescrits par patient, une augmentation de la prescription de mИdicaments inhalИs et une
rИduction de 8,7 % du coШt moyen des prescriptions de mИdicaments par patient.
National Tuberculosis Control Programme, Ministry of Health, Amman, Jordan.
Stop TB Department, World Health Organization, Geneva, Switzerland (Correspondence to S. Ottmani:
ottmanis@who.int).
3
Stop TB Unit, Department of Communicable Diseases, World Health Organization Regional Office for the
Eastern Mediterranean, Cairo, Egypt.
Received: 02/03/08; accepted: 27/05/08
1
2
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Introduction
Among patients aged 5 years and over who
attend primary health care (PHC) facilities
for any reason, 20% and more seek care for
respiratory conditions in low- and middleincome countries [1,2]. Ten surveys carried out by the World Health Organization
(WHO) in 76 PHC facilities in 9 developing
countries showed that more than 95% of
respiratory patients were prescribed at least
1 drug, and more than 75% of them may
receive an antibiotic prescription [1]. The
Practical Approach to Lung Health (PAL) is
a patient-centred approach to diagnosis and
treatment of common respiratory illnesses
in PHC settings that has been developed
by WHO within the framework of the Stop
TB Strategy in order to contribute to health
system strengthening [3]. To this end, PAL
aims at improving the quality of respiratory
case management as well as the efficiency
of care delivery services for respiratory illnesses [4,5]. The PAL approach seeks to
standardize service delivery through the
development and implementation of clinical
guidelines. It is also intended to coordinate
not only among the different levels of health
care but also among the national health
programmes, including the TB control programme, and general health services [6,7].
Since 2001, many countries have introduced some form of PAL activities [7].
In March 2003, the national tuberculosis control programme (NTP) of Jordan
initiated the process of PAL development in
close collaboration with WHO. A national
working group on PAL was established under the leadership of the NTP and included
representatives from various departments
of the Ministry of Health, academic institutions and the private medical sector. The
national working group developed clinical
guidelines that take into account the health
context of Jordan [8] and training materials
[9]. The implementation of PAL was field
tested using a study protocol developed by
WHO [6].
One of the main objectives of this field
testing was to assess whether the implementation of PAL reduces drug prescribing and
its inherent costs in patients seeking care
for respiratory symptoms in PHC facilities.
This article reports the short-term impact of
training physicians about PAL guidelines
on drug prescribing observed during the
field testing of PAL.
Methods
To assess the feasibility and short-term
impact of training about PAL guidelines,
the results of 2 surveys were compared. The
first, or baseline, survey was undertaken
before any training of general practitioners
(GPs) and the second, or impact, survey
after training GPS on PAL guidelines. To
meet the requirements established in the
WHO study protocol [6], both surveys were
carried out in the same season and in the
same PHC facilities and involved the same
GPs. The same protocol was used in the
process of data collection in the 2 surveys.
The feasibility test was carried out in line
with ethical standards of the NTP and the
Ministry of Health of Jordan.
Selection of the survey sites and
GPs
The surveys took place in the governorates
of Amman, Balqa and Zarqa, which were
selected based on the availability of qualified human resources and ease of access to
facilitate supervision of the study. Out of
the 75 public sector PHC centres in the 3
governorates, 25 were selected. The selection of these health facilities was based on 3
factors: the extent of primary care services
that they provided to the local community;
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
the availability of resources that would facilitate the collection of data of satisfactory
quality; and patient access to the first level
of referral above PHC. Out of the 63 GPs
who were practising in these 25 centres,
7 could not participate in all of the phases
required to carry out a feasibility test of
PAL (baseline survey, training on PAL and
impact survey). Therefore, 56 of the 63 GPs
(89%) participated in both surveys.
Eligibility of the participants and
case definitions
Any patient aged 5+ years who sought
care for at least 1 respiratory symptom in
any of the selected PHC centres during the
study period was eligible to be enrolled in
the surveys. The complaint of respiratory
symptom(s) should originate spontaneously
from the patient and not be suggested to her/
him at the time of the visit. A respiratory
symptom was any clinical manifestation
generated from the upper respiratory tract
(e.g. ear pain, ear discharge, ear pruritis,
nasal obstruction, nasal discharge, nasal
pruritis, postnasal drip, sneezing, epistaxis,
dysphonia, sore throat, painful swallowing,
cervical tumour, etc.) or from or the lower
respiratory tract (e.g. cough, short breathing, expectoration, wheezing, haemoptysis,
chest pain, etc.). The respiratory symptoms
could be isolated or accompanied by other
symptoms such as fever, fatigue, weight
loss, cyanosis, dyspepsia, etc.
Suspected cases of TB were identified
using the definition of the NTP (i.e. cough
and expectoration for more than 14 days).
The other respiratory conditions were labelled according to disease categories proposed in the study protocol.
Data collection
The GPs involved in the study registered
specific information on every enrolled patient in a registry form. This information
113
included survey identification number, age,
sex, clinical symptoms, probable diagnosis
and management decision (prescription for
treatment and/or referral to higher level
of health care). The diagnosis was strictly
reported in line with the categories listed in
the study protocol.
For each patient enrolled in the study,
the survey identification number specified
in the registry form was systematically
registered in the clinical record, drug prescription form, treatment card and any patient health documents. When a patient was
prescribed drugs, a copy of that prescription
was kept on the data collection site. The cost
of the drug prescription was established on
the basis of the prices used in private pharmacies. This cost was specified for every
study participant who was prescribed drugs
as if she/he had purchased the prescribed
drugs in a private pharmacy.
Baseline survey
One week before the baseline survey, 56
GPs were trained for 1 day about using the
study register and forms in order to collect
the data needed in a standardized manner.
Nine coordinators ensured the supervision
and monitoring of the implementation of the
survey and the process of data collection. To
carry out the baseline survey, the eligibility
criteria of the study participants, the definitions and the process of data collection were
used as described above. The recruitment
of the respiratory patients for the baseline
survey took place in the 25 PHC facilities
from 12 to 16 December 2004.
Training on PAL guidelines
After the baseline survey was completed,
the 56 participating GPs were trained on the
use of the national PAL guidelines from 23
to 27 January 2005. The GPs were divided
into 3 groups of 23, 21 and 12 GPs who
were trained during the same week but sep-
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
arately. Each group was trained over 4 days
by facilitators, including 2√3 of the 9 coordinators and at least 1 senior staff from the
NTP and 1 senior chest specialist. The same
training materials and procedures were used
for the 3 groups. The training included: plenary sessions on the basic elements of PAL;
respiratory care and the health management information system; case studies with
simulation exercises that covered the whole
content of the guidelines; a practical session
on the use of the peak-flow meter and inhalation chamber; a session with role play;
and practical demonstrations of respiratory
case management using PAL guidelines in
PHC facilities.
Impact survey
After training on PAL guidelines, the impact
survey was carried out from 6 to 10 February 2005 in the same 25 PHC facilities. As
in the baseline survey, the 56 GPs used the
same eligibility criteria to enrol study participants, as well as the same definitions and
the same procedures to collect information.
However, the respiratory patients who were
enrolled in the impact survey were managed
as specified in the PAL guidelines. This was
the key difference from the baseline survey.
Statistical analysis
A data entry programme was adapted specifically for these surveys, using Epi-Info,
version 6.04b. The data analysis involved
studying the distribution of the variables
registered in each survey and the drugs prescribed to respiratory patients, particularly
antibiotics, bronchodilators, corticosteroids
and adjuvant drugs; the cost of drug prescriptions was assessed in each survey.
The findings were compared between the
baseline and impact surveys. The Student ttest was used in the comparison of 2 means,
and the chi-squared test for comparison of
proportions. The Fisher exact test was used
when the expected number was below 5 in
any 2 в 2 contingency table. The Mann√
Whitney test was used in the comparison
of 2 non-normal distributions of continuous
variables. A statistical difference was considered significant when the P-value was
below 5%.
Results
Characteristics of respiratory
patients
In the baseline survey, 6260 respiratory
patients were enrolled and in the impact survey there were 2709. The sex distribution
of the study participants was not significantly different between the 2 surveys (P
>═0.05). However, the mean age of respiratory patients for both sexes was lower in the
baseline survey (Table 1). The duration of
symptoms, from their onset to the patient▓s
visit to the PHC facility, was significantly
different between the baseline survey [mean
4.0 (SD 12.0) days; median 2.0 days; mode
2.0 days] and the impact survey [mean 4.8
(SD 13.5) days; median 3.0 days; mode 2
days] (Mann√Whitney test: P═< 0.001).
The proportion of patients with at least
1 concomitant condition or disease, and the
proportion who visited a health facility for
respiratory symptoms at least once within
the previous month was significantly different between the 2 surveys. Cough, fever,
nasal discharge, sore throat and expectoration were the most frequently reported
symptoms in both surveys (Table═2).
Patients with acute respiratory infection
(ARI) accounted for a very high proportion
in both surveys (90% or more); almost twothirds of the patients in each of the 2 surveys
had an acute upper respiratory infection.
The proportion with chronic respiratory
disease (CRD) was significantly higher in
the impact survey (Table 3).
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
115
Table 1 Sex distribution and mean age of respiratory patients aged ? 5 years enrolled in the
baseline and impact surveys of training physicians on the Practical Approach to Lung Health
Variable
Patients with respiratory
symptoms
Female
Male
Total
Age of respiratory
patients (years)
Female
Male
Total
Baseline survey
No
%
.
Impact survey
No.
%
3340
2920
6260
1427
1282
2709
53.4
46.6
100.0
Mean (SD)
Statistical tests
52.7
47.3
100.0
?╡ = 0.35; P = 0.554
Mean (SD)
31.5 (18.3)b
29.4 (18.8)b
30.5 (18.5)
26.5 (17.8)a
22.4 (17.8)a
24.6 (17.9)
t = 8.75; P < 0.001
t = 11.46; P < 0.001
t = 14.11; P < 0.001
Comparison of mean age of females and males in the baseline study (t = 9.17; P < 0.001).
Comparison of mean age of females and males in the impact study (t = 3.00; P < 0.01).
SD = standard deviation.
a
b
Table 2 Health profile of respiratory patients enrolled in the baseline and impact surveys
Variable
Prior visits to any health facility
within last month
Concomitant health condition or
disease
Sign/symptom
Cough
Fever
Nasal discharge
Sore throat
Expectoration
Short breathing and/or wheezing
Chest pain
Wheezing
Ear pain
Painful swallowing
Dysphonia
Cervical lymph node
Haemoptysis
Ear discharge
Other symptoms
Baseline survey
(n = 6260)
No.
%
Impact survey
(n = 2709)
No.
%
P-value
645
10.3
181
6.7
< 0.001
991
15.8
559
20.6
< 0.001
4671
3842
2041
1360
1061
391
371
268
217
156
78
50
38
37
1582
74.6
61.4
32.6
21.7
16.9
6.2
5.9
4.3
3.5
2.5
1.2
0.8
0.6
0.6
25.3
1805
1571
678
778
522
210
174
217
155
23
38
17
11
30
653
66.6
58.0
25.0
28.7
19.3
7.8
6.4
8.0
5.7
0.8
1.4
0.6
0.4
1.1
24.1
< 0.001
< 0.01
< 0.001
< 0.001
< 0.01
< 0.01
0.366
< 0.001
< 0.001
< 0.001
0.550
0.390
0.236
< 0.01
0.241
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Table 3 Distribution of respiratory conditions diagnosed among respiratory patients enrolled in
the baseline and impact surveys
Respiratory
condition
ARI
AURI
ALRI
CRD
High suspicion of TB
Other condition
Baseline survey (n = 6260)
No.
%
5835
93.2
4003
63.9
1832
29.3
378
6.0
29
0.5
18
0.3
Impact survey (n = 2709)
No.
%
2419
89.3
1741
64.2
678
25.0
263
9.7
20
0.7
7
0.3
P-value
< 0.001
0.771
< 0.001
< 0.001
0.105
0.810
ARI = acute respiratory infection; AURI = acute upper respiratory infection; ALRI = acute lower respiratory infection;
CRD = chronic respiratory disease; TB = tuberculosis.
Changes in drug prescribing
In both surveys, 97% of the respiratory
patients were prescribed drugs. The number
of drugs prescribed per patient decreased
by 12.2% between the baseline and impact
surveys. Among the patients who received a
drug prescription, the proportion who were
prescribed antibiotics decreased by 15.9%
in the impact survey. This decrease was observed in ARI and CRD patients (Table 4).
The prescription of bronchodilator drugs
was <═10% among patients who were prescribed drugs in both surveys. However,
the prescription of bronchodilator drugs increased significantly for inhaled ?-agonists
and decreased for the other forms of bronchodilators in the impact survey (Table 4).
The prescription of corticosteroids increased significantly, with an increase in
prescription for inhalation use; the prescription of injectable corticosteroids decreased
but not statistically significantly (Table 4).
In the impact survey, the proportion of
patients who were prescribed antihistamine
drugs, non-steroidal anti-inflammatory
drugs, expectorants or bronchial fluidifiers and vitamins significantly decreased,
while that of patients who were prescribed
paracetamol and nasal decongestants significantly increased (Table 4).
Changes in cost of prescriptions
The mean cost of the prescription of any
drug per patient was reduced by 8.7%
between the 2 surveys (P < 0.05). This
was particularly significant for antibiotics
and adjuvant drugs. However, the mean
cost of antibiotic prescriptions per patient
who was prescribed antibiotics did not
change between the 2 surveys, whereas the
mean cost of adjuvant drug prescriptions
decreased significantly among patients
who received adjuvant drug prescriptions
(Table 5).
Among patients who were prescribed
bronchodilators, the mean cost of bronchodilators was significantly higher in the
impact survey.
Furthermore, among patients prescribed
corticosteroids, the mean cost of cortico╜
steroids decreased in the impact survey,
but not statistically significantly (Table 5).
However, among the 43 and 51 respiratory patients who were prescribed inhaled
corticosteroids in the baseline and impact
surveys respectively, the mean cost per
patient of the prescription of this inhaled
medication decreased by 21.5%, from 3.8
Jordanian dinars (SD 2.3) in the baseline
survey to 3.0 Jordanian dinars (SD 1.7) in
the impact survey (P═<═0.05).
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
117
Table 4 Drugs prescribed for respiratory patients in the baseline and impact surveys
Drug prescription
No. of drugs per patient
prescribed drugs
No. of antibiotics prescribed
per patient prescribed drugs
No. of patients prescribed
drugs/total no. of patients
No. of patients prescribed
antibiotics/no. prescribed
drugs
No. of patients prescribed
antibiotics/no. prescribed
drugs for:
AURI
ALRI
CRD
High suspicion of TB
Other
No. of patients prescribed
a specific medication/no.
prescribed drugs (n = 6077):
Any bronchodilator
+ inhaled ?-agonist
+ other form of ?-agonist
+ theophylline
Any corticosteroid
+ bronchial inhalation
+ nasal inhalation
+ tablet
+ injection
Paracetamol
Nasal decongestant
Antihistamine
NSAID
Expectorant/fluidifier
Vitamins
Baseline survey
(n = 6260)
Mean (SD)
Impact survey
(n = 2709)
Mean (SD)
%
changea
P-value
2.55 (0.77)
2.24 (0.76)
√12.2
< 0.001
0.90 (0.15)
No.
%
0.77 (0.24)
No.
%
√15.0
< 0.001
6077/6260
97.1
2630/2709
97.1
0.0
0.985
5304/6077
87.3
1931/2630
73.4
√15.9
< 0.001
3399/3905
1635/1788
259/363
4/7
7/14
87.0
91.4
71.3
57.1
50.0
1299/1722
529/658
101/245
0/1
2/4
75.4
80.4
41.2
0.0
50.0
√13.3
√12.0
√42.2
√100.0
0.0
< 0.001
< 0.001
< 0.001
1.0b
1.0b
261
109
146
12
73
36
12
12
18
4795
170
2570
845
504
24
4.3
1.8
2.4
0.2
1.2
0.6
0.2
0.2
0.3
78.9
2.8
42.3
13.9
8.3
0.4
163
121
42
2
71
42
13
18
5
1986
129
608
213
137
5
6.2
4.6
1.6
0.1
2.7
1.6
0.5
0.7
0.2
75.5
4.9
23.1
8.1
5.2
0.2
+44.2
+155.0
√33.3
√62.0
+125.0
+166.7
+150.0
+250.0
√33.3
+4.3
+75.0
√45.4
√41.7
√37.3
√50.0
< 0.001
< 0.001
< 0.05
0.253b
< 0.001
< 0.001
< 0.05
< 0.001
0.670
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.05
Between baseline and impact surveys.
Fisher exact test.
SD = standard deviation.
AURI = acute upper respiratory infections; ALRI = acute lower respiratory infections; CRD = chronic respiratory
disease; TB = tuberculosis; NSAID = non-steroidal anti-inflammatory drug.
a
b
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Table 5 Mean cost of drug prescriptions per patient in the baseline and impact surveys
Variable
Mean cost of prescription/patient (JD) % changea P-value
Baseline survey
Impact survey
(n = 6260)
(n = 2709)
For patients prescribed drugs
AURI patients
ALRI patients
CDR patients
All patients
Antibiotics for patients
prescribed drugs
AURI patients
ALRI patients
CDR patients
All patients
Antibiotics for patients
prescribed antibiotics
AURI patients
ALRI patients
CDR patients
All patients
Bronchodilators for patients
prescribed bronchodilators
Corticosteroids for patients
prescribed corticosteroids
Adjuvant drugs for patients
prescribed:
Any drug
Any adjuvant drug
0.80
0.95
1.50
0.90
0.70
0.78
1.60
0.80
√12.3
√17.0
+6.3
√8.7
< 0.05
< 0.01
0.584
< 0.05
0.39
0.42
0.33
0.40
0.35
0.36
0.18
0.30
√10.6
√14.5
√44.2
√15.1
< 0.001
< 0.001
< 0.001
< 0.001
0.45
0.45
0.46
0.45
0.46
0.44
0.44
0.45
+2.2
√2.2
√3.3
0.0
0.115
0.559
0.612
0.510
0.98
1.18
+20.5
2.60
2.20
√15.0
0.42
0.43
0.34
0.36
√20.0
√16.3
< 0.01b
0.599b
< 0.01
< 0.001
Between baseline and impact surveys.
Mann√Whitney test for non-normal distribution.
JD = Jordanian dinar; AURI = acute upper respiratory infection; ALRI = acute lower respiratory infection; CRD =
chronic respiratory disease;
a
b
Discussion
To meet the requirements established by
WHO for PAL feasibility testing [6], the
same study protocol was used in the baseline and impact surveys. Also, both surveys
took place in the same season, within a
7-week interval in winter, in the same PHC
facilities and with the same GPs, in order
to ensure comparability between the data
sets of the 2 surveys. As the 56 GPs were
the same in both surveys, it is expected that
their practice in case management of respiratory patients would be influenced only by
the training on PAL guidelines.
However, the number of respiratory
patients enrolled in the baseline survey
was considerably higher than in the impact
survey. This important difference in patient
recruitment was due to the occurrence of
a snowstorm in the 3 study governorates
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
during the week of the impact survey. As a
result, many economic and social activities
decreased in that week, including disruptions to transportation as well as decreased
attendance at PHC facilities by patients. On
average, clusters of 112 and 48 respiratory
patients were managed by every GP in the
baseline and impact surveys respectively.
Patients included in the same cluster were
likely to be managed in a similar manner
by the GP, resulting in a clustering effect
that may have influenced the results in both
surveys. However, given that the average
number of study participants included in a
cluster was 2.3 times higher in the baseline
survey than in the impact survey, the clustering effect is likely to be stronger in the
first survey than in the second. Because of
this, some degree of distortion was probably
introduced in the comparability between
the data sets of the 2 surveys. It is not clear
how this may have influenced the findings
of this study.
The sex distribution was not significantly different between the 2 surveys, but the
patients enrolled in the impact survey were
older and tended to have more concomitant
diseases. The distribution of respiratory
illnesses was fairly similar between the 2
surveys. However, in comparison with the
baseline study, the proportion of patients
with CRDs was higher in the impact survey,
while the proportion of those with acute
lower respiratory infections was lower. It is
not clear whether this shift in the distribution was associated with the training on PAL
guidelines or the higher proportion of study
participants with a concomitant disease in
the impact survey. It is not known either
to what extent the limitations in the comparability between the participants of the 2
surveys may have influenced this═shift.
The comparison of the findings between
the baseline and impact surveys suggests
that training on PAL guidelines had an im-
119
pact in decreasing drug prescription through
a reduction in prescriptions for antibiotics
and adjuvant drugs. There was also a reduction in the mean cost of drug prescriptions
per patient after training on PAL. The cost
reduction in the impact survey seemed to be
related not only to the decrease in the prescriptions of antibiotics and adjuvant drugs
but also to a decrease in the cost of adjuvant
drug prescriptions in patients who were
prescribed such medications. Similar results
were reported in other countries where PAL
methods have been initiated. For instance,
the average cost of drug prescriptions per
patient was reduced by 13.6% in Algeria (N.
Zidouni, personal communication), 32.2%
in Bolivia [2], 32.4% in Kyrgyzstan [4],
18.1% in Morocco [4], 26.2% in the Syrian Arab Republic (F. Maamri, personal
communication), 19.3% in Tunisia (A. Ben
Kheder, personal communication) and by
2.5 rupees in Nepal═[10].
Our study indicates that training on
PAL is likely to increase the prescription
of inhaled bronchodilators and inhaled
corticosteroids and tends to decrease the
prescription of the other formulations of
these 2 categories of drugs. Similar findings
were reported for both types of medication
in Kyrgyzstan (N. Brimkulov, personal
communication), the Syrian Arab Republic
(F. Maamri, personal communication) and
Tunisia (A. Ben Kheder, personal communication); for inhaled beta-agonists in
Morocco (N. Bencheikh, personal communication); and for inhaled corticosteroids in
South Africa [11].
The mean cost of corticosteroid prescriptions per patient who was prescribed
this medication tended to decrease after GPs
were trained on PAL methods; moreover,
this decrease was significant in patients who
were prescribed inhaled corticosteroids.
Jordan has a well-functioning Essential
Drugs Programme implemented in PHC;
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
a wide range of antiasthmatic drugs and
brands of corticosteroids for inhalation use
are included in this programme. Inhaled
beclomethasone is the corticosteroid for
inhalation use that is specified in the PAL
guidelines developed in Jordan, and is included in a generic version in the Essential
Drugs Programme. Inhaled beclomethasone
in the generic version is usually one of the
cheapest inhaled corticosteroids. Therefore,
training physicians on PAL not only increased the prescription of corticosteroids
for inhalation use but also promoted their
cheapest formulation; this suggests that the
PAL approach can facilitate making inhaled
corticosteroids available for a wider range
of respiratory patients in PHC. Findings
from Kyrgyzstan (N. Brimkulov, personal
communication), the Syrian Arab Republic
(F. Maamri, personal communication) and
Tunisia (A. Ben Kheder, personal communication) showed that training physicians on
PAL increased the average cost of corticosteroids per patient because of the high price
of these drugs in their inhaled presentation.
Inhaled corticosteroids are still not accessible for many patients because of their
non-availability and/or prohibitive pricing
in many developing countries [12,13].
Despite the limitations of this study, the
findings suggest that implementation of the
PAL approach in the PHC setting is likely to
reduce drug prescribing for antibiotics and
adjuvant drugs in respiratory patients, to
increase the use of inhalation medications,
which is highly recommended in the management of asthma and chronic obstructive
pulmonary disease [14,15], and to decrease
the cost of drugs prescribed to respiratory
patients in PHC. These results are in line
with the findings of studies on PAL carried
out in other country settings. However,
the experience of PAL implementation
in many countries has not been fully reported. More documentation is needed on
the effects, particularly its impact on cost√
effectiveness of respiratory care services,
TB case detection and strengthening the
health system.
Acknowledgements
The study was supported by a grant from the
World Health Organization.
The authors are indebted to the local survey medical coordinators for their collaboration and help: Dr Ezzat Abu Hashem, Dr
Miassar Zenddah, Dr Sae▓b Khashman, and
Dr Khaleel Hanash in Amman Governorate;
Dr Jamal El-Dabbas and Dr Emad Husaini
in Balqa Governorate; Dr Hesham Sae▓di,
Dr Seyam Te▓meh and Dr Derar Al-Rawsh
in Zarqa governorate.
The authors gratefully acknowledge the
valuable input and collaboration of Mrs
Tejan Ali Elayan and Mrs Rasha Ali Oudeh
from the Central Unit of the National TB
Programme of Jordan.
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Global Initiative for Chronic Obstructive
Lung Disease [website] (http://www.goldcopd.org, accessed 6 July 2008).
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Antimalarial prescribing and
dispensing practices in health
centres of Khartoum state, 2003√04
A.A. Mannan,1 E.M. Malik 2 and K.M. Ali 3
?ЦЦгясгй Фущ Фяущ гцАоФМи гЦАжг СЬои ААЦгАяМг АоЛ ЦчоЖЬ ЦМ гАязгМи гАумМи Мщ гЦАягър гАумМи хФгАМи гнАяьФЦ?
2004-2003 ?Мщ гАсФогД нгАА згЦМ?
? ъгЦА ЦяМшДМ зМА?║? гАщгйм мЦЦо ЦгАъ?║?зхяМ цхФ рМо зьг гЦАДгД?
?гЦАжгои ААЦгАяМг ФяущЕг ЦД?
? СЬчМЦ гАхгмкФД Мщ ЕпЕ гАоягси гЦАя Сй Жъри зЛА гЦАдятгй ЦЦгясгй Фущ гцАоФМи?:?гнАгАуи?
ЬС
.? ФчгяДФЕг хгАогАфА геАятгоМи гАФьДМи ЦАзглАи гЦАгАяМг?║?Жч СхА ЦчоЖЬ ЦМ гАязгМи гАумМи Мщ гЦАягър гАумМи хФгАМи гнАяьФЦ?
? Фчо гАйрЦ ъгйхФ гАФущгй?.? Цяър Пг умМ Пг?24 ? ЦяМж Пг ФгАФущгй гАьхМи гнАгуи ЕхЦ Мщ?720 ?Фчо тЦАй гАоягси?
? ФЦз цД глАЦМз чо?.?) щчь ЦД еЦлгМА гЦАяЛж?% 38.6( ? ЦяМж Пг?278 ?гАьхМи хгАогАфА геАятгоМи гАФьДМи ААЦзглАи АоЛ?
? ЦДЕЦ щчь ЦмЛ?% 64.6 ? ФъгД АоЛ?║?ЦмЛ цФ сФгхч еугхи хгмАЦЛ?
Ь ? ЦДЕЦ щчь ъгД АоЕМЦ?% 77.6 ? щеД?║?зФлАФг ЦД гЦАгАяМг?
? Мщ?║]?гАэлДМси [шяМ мЦоСЬ ои гЦААъМи?
С ? Фчо УФущй гцАоФМи гЦАжгои ААЦгАяМг хцсгЦфЕг?.?ЦумФхи хелМгхМи гцАщгАЦ гАоЦФМи?
.? ЦД гАФущгй щмсх?% 23.5 ?Сх хтъА умМм егА Мщ?
З ? ФАъД глАязгй гАоФгфМи ЦА йУъй?║? ЦД гАФущгй?% 90 ?цъкя ЦД?
.? ФъгД Дущ гЦАяЛж щчь зЛА оягМи ъгщМи хЦзглАйЕЦ?.?ФъгД ЦзоСЬ А Фущ Цжгогй гЦАгАяМг хгмАчЗД Цяйщз Пг?
ABSTRACT This indicator-based study assessed the antimalarial drug prescribing and dispensing practices of health care providers in health centres of Khartoum state, and compared these with national
guidelines for malaria treatment. A total of 720 patients and their prescriptions in 24 health centres were
included. Prescribers adhered to national treatment guidelines for only 278 (38.6%) of patients. Although
all were treated for malaria, only 77.6% patients had fever or history of fever and only 64.6% had fever
and positive blood films. More than 90% of prescriptions prescribed antimalarial drugs by generic names
but dosage forms were correctly written in only 23.5%. There was a high rate of prescribing antimalarial
injections. Only half the patients had adequate knowledge of their treatment.
Pratiques en matiХre de prescription et d▓administration d▓antipaludИens dans les centres de
santИ de l▓?tat de Khartoum, 2003√2004
R?SUM? Cette Иtude fondИe sur des indicateurs a ИvaluИ les pratiques en matiХre de prescription et
d▓administration d▓antipaludИens chez les soignants exerГant dans les centres de santИ de l▓?tat de Khartoum,
et les a comparИes aux recommandations nationales relatives au traitement du paludisme. Au total,
l▓Иtude a portИ sur 720 patients de 24 centres de santИ et sur les prescriptions qui leur avaient ИtИ faites.
Les prescripteurs suivaient les recommandations nationales pour seulement 278 (38,6 %) patients. MЙme
si tous Иtaient traitИs contre le paludisme, seuls 77,6 % d▓entre eux avaient de la fiХvre ou des antИcИdents
de fiХvre et 64,6 % avaient de la fiХvre et des Иtalements sanguins positifs. Sur plus de 90 % des
ordonnances, les antipaludИens Иtaient dИsignИs par leur nom gИnИrique, mais la forme galИnique Иtait
correctement indiquИe sur seulement 23,5 %. Le taux de prescription d▓antipaludИens par infection Иtait
trХs ИlevИ. La moitiИ des patients seulement comprenaient bien Ю quoi correspondait leur traitement.
National Malaria Control Programme; 2Roll Back Malaria Programme, Federal Ministry of Health, Khartoum,
Sudan (Correspondence to A.A. Mannan: abeeratta@hotmail.com).
3
Department of Community Medicine, University of Khartoum, Khartoum, Sudan.
Received: 02/10/05; accepted: 17/08/06
1
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Malaria is the major public health problem
in Sudan. The whole country is considered
endemic, ranging from holoendemic in the
south to hypoendemic in the north. Plasmodium falciparum infection is overwhelmingly predominant (90%) and Anopheles
arabiensis is the main vector. About 40%
of outpatient attendance is due to malaria,
with a current estimated rate of 7√8 million
cases, and 35 000√40 000 deaths per year
due to malaria [1].
In many developing countries, including Sudan, inappropriate, ineffective and
inefficient use of drugs commonly occurs at
health facilities [2√4]. Lack of medicines,
absence of updated guidelines and laboratory facilities and inadequate training combine to influence prescribing practices [5].
It is necessary to define prescribing patterns
and to identify irrational prescribing habits
in order to plan educational messages to
prescribers [6].
Little is known about the determinants
of poor use of antimalarial drugs. A recent
review identified a scarcity of published
literature on the subject [7]. Lack of reliable
baseline data on antimalarial drug use in the
health facilities in Sudan was one reason
behind this study. The main objective of
the study was to assess the antimalarial
drug prescribing and dispensing practices
of health care providers in health centres
of Khartoum state, and to compare these
practices with the national guidelines for
malaria treatment.
Methods
Setting
Khartoum state includes the national capital
of Sudan. Its population is 4═568═177 (estimated from the 1993 census), increasing by
4.04% per year. The population is a mixture
123
of all Sudanese tribes and ethnic groups.
Almost 68% of the population live in urban
areas, 21% in rural areas and 11% are displaced people. The main health problems
are tropical diseases: malaria is top of the
list and is the major cause of death in children under the age of 5 years.
Study design
This was a facility-based, cross-sectional,
descriptive, analytical study following
World Health Organization (WHO) guidelines [8]. The sample size was calculated
to be 720 patients using the standard crosssectional survey formula. Two-stage cluster
sampling was used. The first stage was the
selection of health centres using probability
proportional to size and the second stage
was the selection of patients. Accordingly
the calculated sample was taken from 24
health centres (30 patients in each cluster).
Data collection
In each health centre, patients were selected
as they emerged from the pharmacy after
collecting their prescribed medicines. Four
trained data collectors positioned themselves
in the pharmacy and waited for patients. After interviewing patients, the information
was recorded on a standard form (patient
care form), then their prescriptions were
collected and the data extracted were recorded on another form (prescribing indicator
form). After the required number of patients
had been interviewed, information on the
types of antimalarial drugs available in stock
and the presence of the national protocol
poster in the health centre were recorded on
a third form (facility summary form).
Data management
The information on each indicator was recorded and calculated for individual health
centres. Data were entered, processed and
analysed using SPSS, version 9.05.
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Results
The study sample comprised 720 patients
who had been diagnosed as having uncomplicated malaria and had been prescribed
antimalarial treatment by the health care
providers in 24 health centres. However,
161 (22.4%) patients had neither presented
with fever nor reported an attack of fever
within a few days prior to presentation.
Moreover, only 378 patients (52.5%) were
physically examined. Thus the number correctly diagnosed as having malaria, i.e.
patients who had both a history of fever and
positive blood films for malaria, was only
465 (64.6%). Examination of the prescriptions showed that less than 40% of patients
were managed according to the recommended national treatment guidelines, i.e.
had a history of fever, had positive blood
films for malaria and were prescribed recommended antimalarial drugs. Prescriptions with the dosage form correctly written
were found for only 169 patients (23.5%)
(Table 1).
Table 2 shows the pattern of prescribing indicators. Almost all the prescriptions
(99.6%) contained only 1 antimalarial drug
and 659 (91.5%) were prescribed in the ge-
Table 1 Complementary antimalarial drug use
indicators in health facilities of Khartoum
state (n = 720 prescriptions/patients)
Indicator
Patients physically examined
Patients correctly diagnoseda
Prescriptions with dosage forms correctly written
Patients managed according to national treatment guidelinesb
No.
378
465
%
52.5
64.6
169
23.5
278
38.6
History of fever + positive blood films for malaria.
b
History of fever + positive blood films for malaria +
prescribed a recommended antimalarial drug.
a
Table 2 Antimalarial drug prescribing
indicators in health facilities of Khartoum
state (n = 720 prescriptions)
Prescribing indicator
Only 1 antimalarial drug
Antimalarial drug prescribed by generic name
Antimalarial + antibiotic
Antimalarial + analgesic
Antimalarial injection
No.
717
%
99.6
659
320
374
253
91.5
44.4
51.5
35.1
neric form. Antibiotics were combined with
antimalarials in 320 prescriptions (44.4%)
and analgesics in 374 prescriptions (51.5%).
Antimalarial drugs were prescribed in injection form for 253 patients (35.1%); 18.2%
of those who were prescribed injections
(6.4% of the total) actually had negative
blood films for malaria.
The patient care indicators showed that
for 718 prescriptions (99.7%) the prescribed
antimalarial drugs were actually dispensed
(Table 3). Chloroquine was prescribed in the
great majority of prescriptions. Adequately
labelled antimalarials, i.e. the label contained
at least the patient name, the drug name and
when the drug should be taken, were found
in only 80 (11.1%) prescriptions.
When asked to state the dosage schedules of the antimalarial treatment they had
received, only 357 patients (49.6%) had
adequate knowledge of their prescribed
treatment, i.e. the drug name, when it was to
be taken and in what quantity.
At the time of the study, all the key
antimalarial drugs (chloroquine in all formulations, sulfadoxine√pyremethamine
tablets, quinine tablets and injections) were
found in stock in 7 of the 24 visited health
centres. Treatment guidelines in the form
of poster information were found in 17
(70.8%) health centres (Table 4).
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Table 3 Patient care indicators in health
facilities of Khartoum state (n = 720
prescriptions/patients)
Patient care indicator
Prescriptions where antimalarial actually dispensed
Prescriptions where antimalarial adequately labelleda
Patients with adequate knowledge of prescribed doseb
No.
%
718
99.7
80
11.1
357
49.6
Label shows at least patient name + drug name +
when the drug should be taken.
b
Knowledge of drug name + when to be taken + in
what quantity.
a
Discussion
Prompt and accurate diagnosis of malaria
is the key to effective disease management,
and reducing the unnecessary use of antimalarial drugs [9]. Health care workers should
make a proper assessment for appropriate
management. This not only requires clinical skills but also sufficient consultation
time [10]. Many patients in this study were
not physically examined, reflecting a deviation from the standard way of managing
patients. Heavy patient loads in some health
centres, poor knowledge and poor clinical
skills or disinterest of the prescriber may
be associated with such practices. Lack of
close supervision and lack of proper training may also contribute. This could have
Table 4 Health facility indicators in Khartoum
state (n = 24 health centres)
Health facility indicator
Facilities with all key antimalarial drugs in stocka
Facilities with treatment guidelines poster available
No.
%
7
29.2
17
70.8
Availability was assessed against a predetermined list
of 6 forms of key antimalarial drugs recommended by
the national treatment guidelines.
a
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a negative impact on patients▓ satisfaction
with the care provided in health centres, and
may enhance self-medication, as many patients may skip doctor▓s consultations and
go straight to pharmacies to get their medicines [11]. However, when cases of malaria
are treated on the basis of clinical diagnosis
this leads to overdiagnosis of malaria and
overuse of antimalarial drugs [10]. Efforts
have been made to develop guidelines, such
as the integrated management of childhood
illnesses (IMCI), to assist health workers in
such settings.
In areas of intense malaria transmission,
where the burden of malaria is greatest
and where severe disease and mortality are
largely confined to children under 5 years of
age, malaria treatment is often dispensed on
the basis of ⌠fever■ rather than on the basis
of a parasitologically confirmed diagnosis.
However, with high malaria transmission
and high levels of immunity, a significant
proportion of the infections are asymptomatic, and detecting parasites in the blood
does not always help to distinguish malaria
from other causes of fever. Moreover, in
most of these areas microscopy and rapid
diagnostic tests (RDTs) are not generally
available at the periphery of the health services or at the community level, where most
cases of malaria are managed. In 2004, a
WHO technical consultation recommended
microscopy and RDTs for parasitological
confirmation of malaria. In all settings,
laboratory services that provide malaria
microscopy should be strengthened. Where
microscopy is not possible, RDTs should be
introduced [9]. Some patients in this study
were prescribed antimalarial drugs even
though parasites were not detected in their
peripheral blood films. Higher figures were
shown in a study from Tanzania; more than
60% of those diagnosed with malaria were
negative for malaria parasites [10].
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Factors related to both patients and prescribers may be responsible for prescribing antimalarial drugs for malaria-negative
patients. Some prescribers tend to rely on
their limited experience as they do not
trust laboratory results and prefer treating
malaria cases on the basis of clinical criteria. This attitude may be based on fear of
losing patients▓ confidence. Another reason
may be that in many developing countries
such as Sudan, microscopy is not reliable
because microscopists are insufficiently
trained and supervised or are overworked,
the microscopes and reagents are of poor
quality and often the supply of electricity is
unreliable [12]. On the other hand, patient
demand may be another factor: some patients may not be willing to put up with even
minor physical discomfort, and are difficult
to convince that they do not have malaria
and do not need any treatment [11].
To produce the desired effect, antimalarial drugs need to be given in adequate dosages. However, in our study, the dosage was
written in a correct and informative manner
in only 60.0% of prescriptions. This alarming figure indicates a major problem regarding antimalarial dosages, and ultimately
would have serious health consequences for
the population as under-dosage, together
with noncompliance, is one of the reasons
for the persistent presence of P. falciparum
malaria in the population [13].
Our study also showed a high rate of
prescribing antibiotics with antimalarial
drugs. More than half of malaria-negative
patients were prescribed antibiotics with
antimalarials. In some situations the misuse
of antibiotics is often due to uncertainty
about the diagnosis, as the clinical picture is
not clear or may even be misleading. Physicians tend to overestimate the severity of
illness to justify antibiotic prescribing. They
are also under pressure from patients seeking rapid amelioration of symptoms [14].
Prescribing analgesics with antimalarial
drugs is also a widespread practice. The
patient▓s temperature could be lowered by
mechanical antipyresis, e.g. fanning and
sponging down with tepid water. These
methods are particularly important for
young children, and can help in bringing
down the temperature even without giving
an antipyretic. Routine antipyretic therapy
in children with malaria has long been a
source of controversy. However, the usefulness of this practice has not been proven.
In a randomized clinical trial conducted in
Gabon, it was found that paracetamol had
no antipyretic benefits over mechanical
antipyresis alone in P. falciparum malaria.
Moreover, it was found that paracetamol
prolonged parasite clearance time, possibly
by decreasing production of tumour necrosis factor and oxygen radicals [15].
Another common type of irrational antimalarial use is overprescribing of injections. Injections are an important, powerful
and useful formulation when prescribed and
used properly, but potentially harmful and
dangerous when prescribed carelessly [16].
Furthermore, injections are more expensive
than oral forms of drugs. In many countries,
as in Sudan, some prescribers and patients
believe that injections have a stronger effect
and work faster than oral antimalarial drugs.
In our study, the highest rate of injection
prescriptions was among adult patients, and
18.2% of those who were prescribed injections actually had negative blood films for
malaria. The overprescribing of injections,
as explained by other authors, is mainly
due to lack of appropriate training of health
workers, lack of public education and patients▓ demands and beliefs [16].
Dispensing is an important step in ensuring antimalarial drug accessibility, affordability, safety and rational use. Almost all
prescribed antimalarial drugs in the study
were actually dispensed. High rates of dis-
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
pensing at the health centres can contribute
to patient trust and cooperation with the
health system and personnel [14]. However,
it was evident that the key antimalarial drugs
were not always in stock. Chloroquine was
available in all formulations in all health centres, with the exception of 1 health centre in
which chloroquine tablets were out of stock.
In that health centre the rate of prescription
of injections increased, reaching more than
70%. One way to promote rational use is by
ensuring that all essential antimalarial drugs
are available on a regular basis.
The results also showed poor patient
knowledge about the treatment they were
prescribed. This raises the question whether
the information about prescribed antimalarial drugs was offered voluntarily by health
providers or whether they expected patients
to ask questions. Improving the physical
layout of health centres (examination and
dispensing areas) to facilitate patient√
provider communication may help improve patients▓ understanding of prescribed
antimalarial drugs [8]. Antimalarial drug
labelling is one way to improve patient▓s
adherence to treatment. It reinforces the
information given by the prescriber and
dispenser, and it should be in clear and
simple language. Our results showed poor
labelling practices in many health centres.
In many cases the patient's name was missing and dosage schedules were incomplete
or sometimes incorrect. Lack of knowledge
about labelling on the part of the dispensers
may have accounted for this finding.
In Sudan, the national treatment guidelines are considered very useful in providing guidance to health professionals. It was
evident that the level of knowledge about
paediatric doses of antimalarials among prescribers and dispensers was average. Calculating paediatric doses is a genuine problem.
It is not always easy for a prescriber with
127
limited skills to calculate the dose in milligrams, and then to change it into millilitres
in order to write down the prescription in a
correct, simple and understandable form.
It is the responsibility of the prescriber to
ensure that the dose is accurately calculated,
and this responsibility should not be shifted
to the dispenser. Poor knowledge will in
turn result in poor prescribing practices and
ineffective treatment. However, only 23.8%
of prescribers and 44.4% of dispensers were
knowledgeable about the guidelines, i.e.
knew the correct malaria case definition
and knew different lines of treatment for
uncomplicated malaria. Some claimed that
the guidelines were not suitable for treating
all cases of uncomplicated malaria. Some
suggested an increase in the number of
tablets. Others thought that 2 injections per
day caused hypotension, and suggested that
the injectable dose be reduced. On the other
hand, some suggested that new antimalarial
drugs be added. Considering that effective
treatment is the main national control strategy for malaria in Sudan, there is a need to
determine the extent to which health care
providers follow guidelines. It was found
that only 38.6% of the total number of patients were actually managed according to
guidelines. Extensive and continuous training is needed to improve health providers▓
knowledge and hence promote adherence to
national treatment guidelines.
In conclusion, this study showed inappropriate prescribing practices and consequently inappropriate use of drugs for malaria.
Similar results have been shown in other
developing countries [2,3,17]. As Sudan has
recently changed the national antimalaria
treatment from monotherapy (chloroquine)
to artemisinin-based combination therapy,
the results of this study should be taken into
consideration for improving prescribing and
dispensing practices.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
129
Seroprevalence of Helicobacter
pylori in Nahavand: a populationbased study
A.H.M. Alizadeh,1 S. Ansari,1 M. Ranjbar,2 H.M. Shalmani,1 I. Habibi,1 M. Firouzi1 and
M.R. Zali1
Ь ? оягси?:?ААЦАФ СЬМи гАхФгхМи Мщ ЕДгФДо?
?съгДМи гЦАя Сй Сър?
С ?ЦзоСЬ А ггАДйтгя гЦАуМА?
║? ЦЕоМ щяМФрМ?║? зщй мхМхМ?║? ЦмМо мЦчч тАгЦМД?║? ЦМяйг яДлях?║? тгЕДМ цДугяМ?║?цЦяМ ЕФтДъ мЦЦо зМА ргоЕ?
?мЦЦо яжг ргМА?
?гАэЦАФ СЬМи гАхФгхМи ФгАзФгЦА гЦАйз ЬАчи хгДйчгЕАг?
С ? цляЛ гАхгмкФД оягси Цсйзяжи АйчМэМЦ ЦзоСЬ гАй гДйтгя?:?гнАгАуэи?
? Фчо?.? тну Пг йрМо цзгЦяЕЦ зЛА сй сДФгй ЦД хДМ съгД ЕДгФДо Мщ шях ЦлЕФяМи еМягД геАсгАЦМи?1518 ?АоЛ?
? Фцнпй зМДгй гАоЦ ЦД?.?гЦАйшМэягй ггАлйгЦзМи ФгАоМЦФшягщМи ЦД нгАА гЦАчгхгАй?
?гсйъЦАй ггАсйхМгДгй мФА?
Ь
ЬР
?хгАэЦАФ СЬМи гАхФгхМи хгсйногЦ гЦАчгМси гЦАДгзМи?
С ? гнАгу?IgG ?АймяМ гАшАФхФАДМ гЦАДгзМ?
ЬЖ ? Фгнйяхй гцАЦугА?║?ъА ЦДЕЦ?
П
П
? (хщгуАи?%71.0 ?ААэЦАФ СЬМи гАхФгхМи Цяйщзг еп хАш?
С ? Фчо ъгД ЦзоСЬ А ггАДйтгя гЦАуМА геАЦлгМА?.?геАДрМЦМи гЦАйФгщяи лйгяМг?
? ФгсйДго Пг еЛА гАйумМм гЦАйзоо?.?) ФАФмы гроМго йоялММ Цз гАзЦя?73? Ф?69 ? ФйягФм ЦзоСЬ А ггАДйтгя хДМ?%95 ?кчи?
.?гЦАйшяМгй щеД гцАДФки ФгАзЦя щчь ЦЕг гА ЬАпгД МЦъД гзйхгяЦЕг ЦД зФгЦА ггАнйьгя?
ABSTRACT In this cross-sectional study, we evaluated H. pylori seroprevalence and the relevant factors
in 1518 people aged ? 6 years from the general population of Nahavand, western Islamic Republic of
Iran. Questionnaires covering sociodemographic variables were completed by interview. Blood samples were taken from each individual. Sera were tested for anti-H. pylori IgG using commercial enzyme
immunoassay. Overall, seroprevalence of H. pylori was high, 71.0% (95% CI: 69.0%√73.0%). There
was a gradual increase with age. Based on multivariate adjustment, only female sex and age could be
considered risk factors.
SИroprИvalence de Helicobacter pylori Ю Nahavand : Иtude en population
R?SUM? Dans cette Иtude transversale, nous avons ИvaluИ les taux de sИroprИvalence de H. pylori
et les facteurs pertinents chez 1 518 personnes БgИes de 6 ans et plus choisies parmi la population
gИnИrale de Nahavand, dans l▓ouest de la RИpublique islamique d▓Iran. Des questionnaires sur les
variables sociodИmographiques ont ИtИ complИtИs dans le cadre d▓entretiens. Des prИlХvements
sanguins ont ИtИ effectuИs sur chaque sujet. La prИsence d▓anticorps anti-H. pylori de type IgG a
ИtИ recherchИe dans les sИrums grБce Ю un test immunoenzymatique disponible dans le commerce.
Globalement, la sИroprИvalence de H. pylori Иtait ИlevИe, Ю 71,0 % (IC 95 % : 69,0√73,0), et elle
augmentait progressivement avec l▓Бge. AprХs ajustement multivariИ, seuls l▓appartenance au sexe
fИminin et l▓Бge pouvaient Йtre considИrИs comme des facteurs de risque.
Research Centre for Gastroenterology and Liver Diseases, Shaheed Beheshti University of Medical
Sciences, Tehran, Islamic Republic of Iran (Correspondence to A.H.M. Alizadeh: article@rcgld.org;
ahmaliver@yahoo.com).
2
Iran University of Medical Sciences, Tehran, Islamic Republic of Iran.
Received: 25/05/05; accepted: 13/09/05
1
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Introduction
The incidental discovery in 1983 of a bacterium that infects one-half or more of
the world population [1] proved to have
profound public health implications [2].
Infection with Helicobacter pylori occurs
worldwide, but prevalence varies greatly
between countries and between population groups within the same country [3].
The prevalence among middle-aged adults
is >═80% in many developing countries,
compared with 20%√50% in industrialized
countries [3,4]. The infection in adults is
usually chronic and will not heal without
specific therapy; on the other hand, spontaneous elimination of the bacterium in
childhood is probably relatively common,
aided by the administration of antibiotics
for other reasons [5]. We now know that H.
pylori causes chronic gastritis, peptic ulcer
and probably gastric cancer as well. [6]. The
clinical course of infection is highly variable and is influenced by both microbial and
host factors [7].
The overall prevalence of H. pylori
infection is strongly correlated with socioeconomic conditions. It seems likely that in
industrialized countries direct transmission
from person to person by vomitus, saliva or
faeces predominates; additional transmission routes, such as water, may be important
in developing countries [8].
According to previous studies, the
prevalence of H. pylori in the Islamic Republic of Iran is high (30.6%√79.4%), but
unfortunately all studies involved volunteers, blood donors or attendants at health
clinics whereas population-based studies
would be needed to give a precise estimate
of the burden of H. pylori infection and the
relevant factors [9√11].
Thus, the objective of this study was to
evaluate the seroprevalence of H. pylori
infection and the relevant factors among a
large number of people from the general
population of Nahavand, western Islamic
Republic of Iran.
Methods
This cross-sectional study was conducted
during a 2-month period, February√March
2003, on people aged 6 years and over in
the city of Nahavand, population 72═000, in
the western part of the Islamic Republic of
Iran. It was approved by the ethics committee at the Reserch Centre for Gastroenterology and Liver Diseases, Shaheed Beheshti
University of Medical Sciences.
Of the 6 urban regions in Nahavand, 5
(total population >═61═000) were selected
for the study and 1518 participants were
recruited through systematic random sampling (304 in each region). All participants
signed a form giving informed consent
prior to entry into the study. Refusals to
participate were replaced by the nearest
neighbour. Questionnaires were completed
by face-to-face interview; questions covered
age, sex, education level, number of family
members in the household, hand washing
prior to meals, hand washing after using the
lavatory and hygienic disposal of sewage/
excreta (both indoors and outdoors).
Blood samples were taken from each
individual by trained health care workers.
Sera were transported to the laboratory of
the Research Centre for Gastroenterology
and Liver Diseases and stored at √20═╟C.
They were tested for anti-H. pylori IgG
using a commercial enzyme immunoassay
kit (H. pylori EIA, Genesis Biotechnology,
England) following the manufacturer▓s instructions. Cut-off was defined with positive
and negative control sera that were included
in each assay, according to the manufacturer▓s instructions. Samples were considered
positive if the optical density was >═6.25.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
All positive samples were verified with a
second assay using the same test.
Statistical analyses were performed using
Stata, version 8. The bivariate and multivariate associations of seropositivity (as binary
dependent variable) with other independent
variables were examined using a logistic regression model and crude and adjusted odds
ratios were estimated. Age was entered into
the models as a continuous variable. Also,
chi-squared was used to test the potential
statistical association of H. pylori seropositivity with demographic and hygiene factors.
Fisher exact test was used if the assumptions
of chi-squared were not met.
Results
Of the 1518 participants, 653 (43.0%) were
men and 865 (57.0%) were women. Mean
age was 36.4 years [standard deviation (SD)
19.8], median 34═years.
Overall seroprevalence of H. pylori was
70.6% (95% CI: 69.0%√73.0%). Seropositive subjects had a mean age 39.9 (SD 19.3)
years, median 37 years.
131
Table 1 shows the age-specific prevalence of H. pylori (?2 for trend = 106.3,
df═=═1, P <═0.001).
Table 2 shows the frequency of H. pylori
seropositivity by some sociodemographic
characteristics. Based on multivariate adjustment, only female sex, adjusted odds
ratio 0.72 (95% CI: 0.57√0.91), and age, adjusted odds ratio 1.04 (95% CI: 1.03√1.05),
could be considered risk factors.
Mean number of family members per
household was 4.54 (SD 2.06) in the H.
pylori positive group and 4.69 (SD 1.70)
in the negative group. The difference was
not statistically significant. We considered
families with >═5 members per household
as having a high crowding index. Neither
crowding index nor hygiene practices of the
participants had a statistically significant effect on seropositivity of H. pylori (Table 2).
Discussion
Overall, 70.6% of the study population was
infected with H. pylori. This corresponds
very closely to figures from other develop-
Table 1 Seroprevalence of Helicobacter pylori among 1518 people aged 6 years and over in
Nahavand, Islamic Republic of Iran by age group and sex
Age group (years)
6√10
11√20
21√30
31√40
41√50
51√60
61√70
>═70
?
?
?
a 2
for trend
b 2
for trend
c 2
for trend
Femalesa
No.
%
17/31
54.8
79/172
45.9
124/169
73.4
134/165
81.2
104/122
85.2
70/81
86.4
60/71
84.5
48/54
88.9
H. pylori positive
Malesb
No.
%
11/30
36.7
96/179
53.6
55/100
55.0
80/102
78.4
63/75
84.0
47/58
81.0
39/51
76.5
45/58
77.6
Totalc
No.
28/61
175/351
179/269
214/267
167/197
117/139
99/122
93/112
= 68.95; df = 1, P <═0.001.
= 38.49; df = 1, P <═0.001.
= 106.3; df = 1, P <═0.001.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
%
45.9
49.9
66.5
80.1
84.8
84.2
81.1
83.0
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 2 Seroprevalence of Helicobacter pylori infection and crude and adjusted odds ratios
(OR) for infection in Nahavand, Islamic Republic of Iran, by sociodemographic characteristics
and other risk factors
Variable
Sex
Female
Male
Education level
Illiterate
Elementary school
Middle school
High school
University
Family members in
household
?5
>═5
Hand washing
before meals
Missing data
Never
Sometimes
Often
Always
Hand washing after
using lavatory
Missing data
Never
Sometimes
Often
Always
Hygienic sewage
disposal
Yes
No
No.
positive/
no. tested
%
Crude OR
95% CI
Adjusted
OR
95% CI
637/865
435/653
73.4
66.6
0.72
1.04
0.58√0.90
1.03√1.05
0.72
1.04
0.57√0.91
1.03√1.05
286/341
247/361
130/202
315/480
94/134
83.9
68.4
64.4
65.6
70.1
1.86
1.09
1.30
1.23
0a
0.28√0.72
0.70√1.67
0.81√2.08
0.81√1.86
0.99
0.99
0.99
1.00
0.99
0.99√1.00
0.99√1.00
0.98√1.01
0.99√1.01
0.98√1.01
746/1060
326/458
73.6
66.6
1.01
0.97
0.94√1.09
0.82√1.15
1.00
1.00
0.99√1.00
0.99√1.01
17/20
41/60
289/397
63/91
662/950
85.0
68.3
72.8
69.2
69.7
√
2.63
2.12
2.52
2.47
√
0.69√10.05
0.61√7.37
0.68√9.29
0.72√8.48
√
0.99
1.00
1.00
0.99
√
0.97√1.02
0.99√1.01
0.99√1.02
0.99√1.00
26/31
27/40
188/247
56/73
775/1127
83.9
67.5
76.1
75.3
68.4
√
2.50
1.63
1.58
2.36
√
0.78√8.02
0.60√4.44
√0.53√4.74
0.90√6.20
√
1.00
1.00
0.98
1.00
√
0.98√1.03
0.99√1.01
0.95√1.01
0.99√1.00
241/349
831/1169
69.1
71.1
1.08
0.98
0.88√1.31
0.92√1.04
1.00
0.99
0.99√1.01
0.99√1.00
This parameter is set to zero because it is redundant.
CI = confidence interval.
a
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
ing countries, e.g. 79% for Pakistan and
63% at age 11√12 years in Turkey [12,13].
Our result is lower than in previous studies
in our country: 75.3% in Tehran and 79.4%
in Kerman [10√11]. This may be due to the
fact that those studies were not populationbased, only volunteers or referrals to clinics
had been examined.
Many studies have shown no sex difference in the seroprevalence of H. pylori
[14√16]. In a study on healthy persons aged
10√25 years in Tehran, H. pylori seroprevalence was equal for men and women [12]. In
a meta-analysis of seroprevalence studies,
seroprevalence was higher in males [17].
Relative immunodeficiency in males may
be an explanation for higher incidences of
other infections in male children. In our survey, seroprevalence was higher in females.
Most females in the Islamic Republic of
Iran, a developing country, are housewives
and are in close contact with children. In
the report of the Iranian Ministry of Health
and Medical Education, in 2000, 89.1% of
females over age 20 years in this region
were housewives, i.e. did not work outside
the home [18].
Cross-sectional serological studies in
industrialized countries such as the United
States of America show a gradual agerelated increase in H. pylori prevalence
[14,19]. A similar trend has been observed
in developing countries, since the acquisition of H. pylori is known to occur mostly
during childhood [10√16,20]. In the present
study, also, there was an increase in the
prevalence of infection with age, which is
considered by some investigators to be due
to an annual increase in rate of infection [21]
but others consider it to be due to a cohort
effect [22]. According to the cohort hypothesis, the infection is acquired in childhood,
the children harbour the microorganism all
their life and the prevalence curves drawn
from cross-sectional population studies
133
reflect the level of infection of each group
in its youth.
In this survey, educated participants (as
surrogate markers for higher socioeconomic
status) had a lower frequency of H. pylori infection compared with those who were illiterate. This finding is in agreement with reports
by others who have indicated that individuals
of higher socioeconomic status are often less
likely to be infected [22]. To date, almost
all epidemiological studies have shown an
inverse relationship between H. pylori infection and socioeconomic status═[23].
In our study, the number of family members in the household did not play a significant role in H. pylori seropositivity. This is
comparable with study from Greenland in
which antibody status did not differ with
respect to the number of persons per household [24]. Large family size is, however,
generally accepted as being a risk factor for
the aquisition of H. pylori infection [25] and
declining family size reduces the opportunity for transmission and increases the age
of acquisition [23]. In both the United States
of America and Bangladesh, crowding in
the home was significantly associated with
H. pylori infection [26,27]. Also, in a study
among people referred to health centres in
Kerman, Islamic Republic of Iran, large
family size was associated with increased
prevalence of H. pylori [13].
We did not find any association between
H. pylori seropositivity and hand washing
before meals or after using the lavatory.
In a study of a rural population in China,
elevated risk was associated with infrequent
hand washing before meals [28]. A study in
rural Guatemala found evidence of H. pylori DNA under the fingernails of infected
individuals, suggesting that the hand may
play a role in transmission [29]. If we consider that not all answers to the question in
our study were truthful (there is a tendency
to conceal one▓s unsanitary habits), more
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
reliable studies need to be carried out to
document the true effect of hand washing in
H. pylori seropositivity.
In conclusion, the high seroprevalence
of anti-H. pylori IgG is an indicator of a
high prevalence of infection in a popula-
tion from a developing country. Based on
multivariate adjustment, female sex and age
were significant risk factors. Infection with
H. pylori should, therefore, be considered
in the evaluation of upper gastrointestinal
complaints in developing═countries.
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Seroepidemiology of hepatitis E
virus infection in 2√25-year-olds in
Sari district, Islamic Republic of Iran
M.J. Saffar,1 R. Farhadi,1 A. Ajami,2 A.R. Khalilian,3 F. Babamahmodi4 and H. Saffar1
? Мщ Цчгьзи?25? Ф?2 ?гАФхгфМгй гАсяМФАФлМи ААзоФЛ хщяМФс гАйЕгх гАъхоМ ⌠фМ■ Мщ ЦД ййэягФм цзгЦяЕЦ хДМ?
?сгяМ Мщ ЦлЕФяМи еМягД геАсгАЦМи?
? ЕМФг ущгя?║? щяЕДъ хгхг мЦЦФоМ?║? зАяМжг нАМАМгД?║? цхФ гАчгсЦ злЦМ?║? яФМг щяЕгоМ?║?мЦЦо лзщя ущгя?
? хДМ гцАьщгА Фушгя?E ■? ояс гАхгмкФД ЦзоСЬ А ггАДйтгя гАсяМФАФлМ АщяМФс гАйЕгх гАъхо ⌠фМ?:?гнАгАуэи?
? Фчо цнпй зМДгй гЦАуА?.? Мщ Цсм лЦйЦзМ гЦАяйър Мщ емоЛ гЦАДгьч тгЦА ЦлЕФяМи еМягД геАсгАЦМи?║?гАхгАшДМ?
? ФййэягФм цзгЦяЕЦ хДМ сДйДМ ФЦнс?║? ЦЦД йыЕя зАМЕЦ згАЦгй гАуми?║? тну йЦ гнйМгяЕЦ зтФгфМ Пг?1080 ?ЦД?
? Фчо УФлой цжого гАшАФхФАДМ гЦАДгзМ гЦАжго?.?ФзятМД сДи ЦД ЦДгьч мяжМи ФцняЛ яМщМи ЦД Цчгьзи сгяМ?
? ФъгД ггАДйтгя гЦАуМА Мрого хтъА ЦАмФы?║)% 2.3( ? АоЛ Цнс ФзятМД тну Пг?E ■?АщяМФс гАйЕгх гАъхо ⌠фМ?
?) щМЦД?% 7.3( 110 ? ЦД цуА?18 ?) Мщ гцАьщгА оФД сД гАзгяти еЛА?% 1.2( 255 ? ЦД цуА?3 ?Цз йчоУЬ Ц гАзЦя ЦД?
.? хДМ глАДсДМ?E ■? ФЦА йгАмы цМи щяФч Мщ Фжз щяМФс гАйЕгх гАъхо ⌠фМ?.? згЦ Пг?25? Ф?20 ?ййэягФм цзгЦяЕЦ хДМ?
.?МйзяжФД ААзоФЛ Мщ сД цушя ФхЦзоСЬ А цзЛА ЦД съгД гЦАДгьч гмАяжМи?
Ь ?ФАФмы цД съгД гЦАДгьч гАяМщМи?
ABSTRACT The seroprevalence of hepatitis E virus infection (HEV) in children and young adults was
determined in a community-based survey in an area of northern Islamic Republic of Iran. Serum samples were taken from 1080 randomly selected apparently healthy 2√25-year-olds from urban and rural
regions of Sari district. Anti-HEV IgG antibodies were detected in 25 individuals (2.3%). Seroprevalence
increased significantly with age from 3/255 (1.2%) in children < 10 years to 8/110 (7.3%) in those aged
20√25 years. No differences in HEV status were noted between the sexes. Earlier age at exposure to
infection and a higher infection rate were found in people residing in rural areas than in urban areas.
SИroИpidИmiologie de l▓infection par le virus de l▓hИpatite E chez les enfants et les jeunes
de 2 Ю 25 ans dans le district de Sari (RИpublique islamique d▓Iran)
R?SUM? La sИroprИvalence de l▓infection par le virus de l▓hИpatite E (VHE) chez les enfants et les
jeunes adultes a ИtИ dИterminИe grБce Ю une enquЙte communautaire rИalisИe dans une rИgion du
nord de la RИpublique islamique d▓Iran. Des Иchantillons de sИrum ont ИtИ prИlevИs sur 1 080 enfants
et jeunes БgИs de 2 Ю 25 ans sИlectionnИs au hasard, apparemment en bonne santИ, qui venaient de
rИgions urbaines et rurales du district de Sari. Des anticorps anti-VHE de type IgG ont ИtИ dИtectИs
chez 25 sujets (2,3 %). La sИroprИvalence augmentait significativement avec l▓Бge, de 3 sur 255 (1,2 %)
chez les enfants de moins de 10 ans Ю 8 sur 110 (7,3 %) chez les jeunes БgИs de 20 Ю 25 ans. Aucune
diffИrence n▓a ИtИ observИe entre les deux sexes quant Ю la sИrologie VHE. L▓enquЙte a montrИ que
les personnes vivant en zone rurale Иtaient exposИes plus jeunes Ю l▓infection et connaissaient un taux
d▓infection plus ИlevИ que celles vivant en zone urbaine.
Department of Paediatrics; 2Department of Immunology; 3Department of Biostatistics; 4Department
of Infectious Diseases, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
(Correspondence to M.J. Saffar: saffar@softhome.net).
Received: 13/04/06; accepted: 27/07/06
1
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Introduction
Hepatitis E virus (HEV) infection, also
called enterically-transmitted non-A non-B
hepatitis, is a major cause of epidemic and
acute sporadic hepatitis in many areas of
Asia, Africa and Mexico, where HEV is
considered endemic. In countries where the
virus is endemic, HEV is associated with
greater than 50% of cases of sporadic acute
hepatitis. The disease is self-limiting but
sometimes has severe complications and a
high case-fatality rate, particularly among
pregnant women (about 20%) [1√4].
Epidemics of HEV have the highest
attack rate in the age group 15√40 years.
However, studies on children show that they
are susceptible to HEV infection and many
cases of sporadic acute viral hepatitis are
caused by HEV [5√7]. Results of studies on
children from Sudan [8] and Hong Kong [9]
have demonstrated that 59.0% and 11.7% of
cases of acute sporadic hepatitis cared for in
hospital had evidence of recently acquired
HEV infection. Mathur et al. from India, a
high-endemic country for HEV infection,
showed in their study of 1√10-year-old
children that 23.8% of rural and 28.7% of
urban children were serologically positive
for anti-HEV immunoglobulin G (IgG)
[10]. The rates of positivity increased with
increasing age.
In 2 previously reported studies from the
Islamic Republic of Iran it was indicated
that enterically-transmitted non-A non-B
hepatitis was found to be the most common
cause of epidemic hepatitis in Iranian adults
and children, and was associated with a high
mortality rate (about 20%) among pregnant
women [11,12]. Epidemic non-A non-B
hepatitis was diagnosed in those cases by
lack of parenteral risk factors and exclusion
of acute hepatitis A and B. Also, other studies have described the prevalence of HEV
infection as 1.6% to 8.8% in selected groups
137
among adult subjects [13,14]. However,
community-based studies and information
about HEV infection in children and young
adults are lacking in the Islamic Republic
of Iran.
The present study was designed to determine the prevalence of HEV infection (antiHEV IgG positive status) among children
and young adults aged 2√25 years in rural
and urban areas of one city in the Islamic
Republic of Iran. Demographic features
that are potential risk factors for acquiring
HEV infection were compared between the
2 areas.
Methods
This study was a cross-sectional communitybased survey conducted from June 2003
to December 2003. The study group was
1080 apparently healthy children and young
adults aged 2√25 years. They were selected
by randomized age-stratified sampling from
urban and rural areas of Sari district, the
capital of Mazandaran province, northern Islamic Republic of Iran (population
450═000 and 110═000√120═000 in the range
2√25 years). The sample size (1152) was
calculated based on studies from other countries [10,15√21] and probable prevalence
of 25%. Individuals with acute infection,
pregnancy, immunodeficiency, receiving
blood or blood products within the last 3
months and chronic renal and liver diseases
were excluded.
The study was approved by the university medical ethics committee and informed
written consent was obtained from the adult
subjects or the parents of children. Sampling was primarily based on the proportion
of the population in rural and urban areas
and a random sampling method was used to
recruit the actual households to be included
in the study. All selected participants were
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visited at their own home by a health-care
worker and one of the coauthors (RF, AA),
where a blood sample was drawn and a
questionnaire answered. When a subject
was not contactable or refused to participate, another subject of similar status was
substituted from his or her neighbourhood.
A specially developed questionnaire was
used to collect data about: age, sex, education level of subject▓s mother and father,
education level of subjects aged ? 20 years,
number of siblings, area of residence, presence or absence of toilet facilities in the
home, method of sewage and waste disposal, type of water supply and history of
clinical hepatitis in the subjects and their
family members.
From eligible subjects, a 3 mL blood
sample was drawn and serum was obtained
by centrifugation and stored at √20 ?C until
further processing. Specific IgG antibody
(anti-HEV) was measured using a 3rd generation enzyme immunoassay for the determination of IgG antibody for HEV (Diapro,
Milan, Italy) with a sensitivity, specificity
and accuracy of 100%, 99.3%√99.6% and
99.4%√99.6% respectively. The cut-off
was defined with positive and negative control sera that were included in each assay
according to the manufacturer▓s instructions. Samples were considered positive
if the optical density value was above the
cut-off value and all positive samples were
confirmed with a 2nd assay using the same
kit.
The associations between seropositivity
and demographic and socioeconomic characteristics were described as percentages
and odds ratio (OR) with 95% confidence
intervals (CI) and analysed using a bivariate
model with z- and chi-squared tests. For
statistical analysis SPSS, version 11 software was used and P < 0.05 was considered
statitically significant.
Results
Of the 1102 participants, 22 were excluded
as the serum samples were haemolysed or
lipoid. Therefore 1080 participants aged
2√25 years were enrolled; 515 (47.7%)
were female.
There were 587 subjects residing in Sari
city (urban) and 493 in the areas around
Sari city (rural). The demographic characteristics of the subjects in urban and rural
areas are compared in Table 1. There were
significant differences between the 2 groups
in parents▓ education level (?2 = 49.94, P <
0.001) and number of household members
(?2 = 7.99, P < 0.05). No differences were
noted for drinking-water supply systems
(100% in both areas had piped supplies) and
defaecation habits (indoor or closed system
outside the house), but the sewage and solid
waste disposal systems were different in urban and rural areas, being central systematic
in the former and with no apparent system
in the latter (i.e. dumped directly into the
environment).
Anti-HEV IgG antibodies were detected
in 25 individuals (2.3%). A clinical history
of jaundice was detected in 1/25 (4.0%) of
the seropositive and in 5/1055 (0.5%) of the
seronegative subjects (?2 = 5.49, P = 0.05).
Seroprevalence increased significantly
with age from 3/255 (1.2%) in children < 10
years to 8/110 (7.3%) in those aged 20√25
years (z = 2.61, P = 0.009). No differences
were noted between the sexes regarding
the prevalence of HEV: 12 females and 13
males (OR = 1.01; 95% CI: 0.43√2.39).
As shown in Table 2, 11/587 (1.9%) subjects in urban areas were anti-HEV positive
compared with 14/493 (2.8%) in rural areas
(z = 13.04, P < 0.001). Although in both
areas anti-HEV prevalence rates increased
with age, exposure to HEV occurred earlier
in rural than urban areas, as no infection
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139
Table 1 Demographic characteristics of study subjects from urban and rural areas of Sari,
Islamic Republic of Iran
Variable
Sex
Female
No. of household members
?2
3√5
6
Mother▓s education level
University
Urban area
(n = 587)
No.
%
Rural area
(n = 493)
No.
%
264
45.0
251
50.9
11
1.9
8
1.6
439
137
74.8
23.3
329
156
66.7
31.6
30
5.1
6
1.2
18.9
High school
184
31.3
93
Primary school
286
48.7
203
41.2
87
14.8
191
38.7
57
9.7
9
1.8
High school
286
48.7
121
24.5
Primary school
206
35.1
263
53.3
38
6.5
100
20.3
19
26
3.2
4.4
2
12
0.4
2.4
Illiterate
Father▓s education level
University
Illiterate
Subject▓s education levela
University
High school
Statistical tests
?2 = 7.99, P < 0.05
?2 = 4.57, P = 0.03
?2 = 30.45, P < 0.001
?2 = 6.67, P = 0.009
?2 = 76.65, P < 0.001
?2 = 27.6, P < 0.001
?2 = 65.68, P < 0.001
?2 = 35.59, P < 0.001
?2 = 44.62, P < 0.001
Fisher exact test, P = 0.001
Primary school
9
1.5
33
6.7
?2 = 6.09, P = 0.01
?2 = 21.75, P < 0.001
Illiterate
2
0.3
7
1.4
Fisher exact test, P = 0.09
For subjects ? 20 years.
n = total number of subjects.
a
Table 2 Anti-hepatitis E virus immunoglobulin G (IgG) status in urban and rural areas by age of
subjects in Sari, Islamic Republic of Iran
Age group
(years)
2√4
5√9
10√14
15√19
20√25
Total
Urban area
No. positive/ % positive
no. tested
0/208
0.0
0/138
0.0
5/139
3.6
2/46
4.3
4/56
7.1
11/587
1.9
Rural area
No. positive/ % positive
no. tested
0/138
0.0
3//117
2.6
4/99
4.0
3/85
3.5
4/54
7.4
14/493
2.8
Mean prevalence
(95% CI)
0.0
1.2 (0.02√1.98)
3.8 (1.04√4.96)
3.8 (1.04√4.96)
7.0 (3.00√11.00)
2.3 (1.20√2.80)a
z = 13.04, P < 0.001.
CI = confidence interval.
a
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was noted in the age group < 10 years in
urban areas whereas a 2.6% infection rate
was observed in the age group 5√9 years in
rural areas.
Discussion
To our knowledge, the present work is the
largest population-based age-specific seroepidemiological study of HEV infection
in the Islamic Republic of Iran. The results
of this study on a population aged 2√25 years
old in Sari in the north of the Islamic Republic of Iran confirm earlier reports about HEV
infection in the Islamic Republic of Iran
[11,12]. The results showed that HEV infection is endemic, acquired early in life and its
seroprevalence rate increased steadily with
age, reaching 7.3% in young═adults.
The patterns of increase are similar to
those reported in many other studies from
different endemic countries [10,15√21]. In
north India, a region with high endemicity for HEV infection, exposure to HEV
was shown to occur in early life and seropositivity for anti-HEV IgG increased
progressively from 7.2%√14.2% in infancy
to 33.3%√38.0% by 10 years of age in rural
and urban children respectively [10]. A
similar epidemiological picture was also
seen in other studies from Turkey [17,18],
Saudi Arabia [19], Egypt [20] and Mexico
[21]. A study by Kamel et al. on the seroepidemiology of HEV infection in an entire
village population located in the Egyptian
Nile delta showed seropositivity of 5.19%
in the age group < 5 years, increasing progressively and peaking at 33.33% in the
age group 20√24 years [20]. This pattern of
increasing anti-HEV IgG levels might be
explained by the cohort effect [15,21], or by
failure of young children to mount a brisk
anti-HEV response [4,15,22], rapid decay
of anti-HEV antibodies occurring after the
initial acquisition of infection [10,22,23] or
if a large dose of virus is required to cause
infection [15].
The main route of HEV transmission is
faecal√oral via contaminated water. Many
studies indicate that poor sanitation, crowding, low levels of education and poverty
are risk factors for HEV infection [1√4,19√
21,24]. Our study demonstrated that the
anti-HEV prevalence was significantly
higher and occurred earlier in rural compared with urban communities (2.6% in age
group < 10 years old in rural areas versus
0% in the same age group in urban areas).
When comparisons were made between the
characteristics of the population in rural
and urban areas, the most significant differences were in parental education levels (P <
0.001), numbers of household members (P
< 0.05) and systematic collection of sewage
and solid waste material. Arif et al. studied
the rate of exposure to HEV infection in
2 areas of Saudi Arabia on the basis of
the quality of water sanitation and sewage disposal in each area and showed that
HEV infection was endemic in both areas
[19]. However, acquisition of the infection
started earlier in areas with poor sewage
disposal and water sanitation systems and
the prevalence of infection increased with
age. Similar findings were also reported by
Alvarez-Munoz et al. from Mexico, which
showed that age, type of community (rural
versus urban) and educational level were
risk factors for infection [21].
In contrast to the above-mentioned studies about the role of residential area (rural
versus urban) on the risk of exposure to
HEV, Mathur et al. demonstrated that exposure to the HEV occurred earlier, and
overall seroprevalence rates of IgG antibodies against HEV were significantly higher
in urban compared to those in rural subjects
[10]. They postulated that these differences
may be due to longer duration of breastfeeding in rural areas, which in turn would
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reduce the risk of waterborne infections.
They also concluded that in a heavily contaminated environment and prevailing poor
hygienic conditions, demographic features
that could be potential risk factors to acquire
anti-HEV antibody might not be related to
the anti-HEV status of the children.
As the results of this study indicate,
serologically anti-HEV positive subjects
rarely had a history of any particular signs
and symptoms related to acute clinical
hepatitis. Similar to reports by Mathur et
al. on 6√120-month-old children (by assessing anti-HEV IgM antibody in IgG
seropositive subjects) [10] and Shields et
al. [25], the HEV infection in our studied
sample was subclinical or mild as only 1 of
25 seropositive subjects had a past history
of jaundice. Although, historically most of
the seropositive individuals were clinically
asymptomatic, a fulminant course of hepatitis E has been reported for pregnant women.
Therefore, precautions should be taken for
pregnant women residing in the area.
The major limitation of the study was
its sampling procedure. The cross-sectional
design did not allow determination of the
age-specific attack rates for HEV. Also the
study frame could not differentiate acute
or recent infections from old ones. Further
141
community-based, age-stratified studies
with larger sample sizes and assessment of
IgM and alanine aminotransferase levels
is recommended to detect recent infection
in those with anti-HEV IgG antibodies, to
evaluate the role of HEV in clinical hepatitis
in the community and to determine the role
of different factors in exposure to HEV.
In conclusion, our study showed that
HEV infection is endemic in the Sari area.
Earlier age at exposure to infection and a
higher infection rate was found in people
residing in rural areas than urban areas.
Lower education levels, greater household
crowding and inadequate sewage disposal
systems were more common in rural areas.
Public health measures such as improvement of mass education in personal and
public hygiene are effective measures for
controlling the spread of HEV infection.
Acknowledgements
This project was funded by the deputy for
research of Mazandaran University of Medical Sciences. Many thanks are due to M.R.
Parsaei and J. Shojaei for their help in sample collection. Also special thanks go to Dr
Enayati for critical review of the manuscript.
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Neurobrucellosis: report of a rare
disease in 20 Iranian patients referred
to a tertiary hospital
M. Ranjbar,1 A.A. Rezaiee,2 S.H. Hashemi1 and S. Mehdipour3
? йчяМя зД Цяж Дгоя АоЛ зятМД ЦяМж Пг еМягДМ Пг цмМАФг ААзгАл Мщ ЦсйтщЛ ААязгМи гАкгАкМи?:?ога гАяхФсМгАй гАзухМ?
? сзМо ЦЕоМ хФя?║? сМо ЦмМо ЕгтЦМ?║? зМА цъях яжгММ?║?ЦМяйг яДлях?
? ЦяМж Пг?1375 ? яглз гАхгмкФД гЦАыгЕя ФгАДйгфл гАясМяМи АзятМД мгАи ЦД ога гАяхФсМгАй гАзухМ ЦД хДМ?:?гнАгАуи?
?йЦ чхФЕАЦ Мщ лДгм гцАЦягж гЦАзоМи Мщ ЦсйтщЛ МчоЦ гАязгМи гАкгАкМи Мщ ЦоМДи ЦЕогД хлЦЕФяМи?
ЬС ?хога гАяхФсМгАй?
4? Ф?║)? мгАи йзгМД ЦД гАйЕгх гАсмгМг (гмАго ФоФД гмАго?12 ? ФЦД хДМ гмАггАй гАзятМД ъгД ЕДгъ?.?еМягД геАсгАЦМи?
? ФмгАи Фгмои йзгМД ЦД гзйгАА?║? ФмгАйгД йзгДМгД ЦД гзйгАА гАДнгз?║?мггАй йзгМД ЦД гАйЕгх гАсмгМг ФгАоЦгш?
? ФъгДй цъкя гцАзягж гДйтгя Пг?.? ФмгАи Фгмои йзгМД ЦД Цжгзщгй смгфМи ФзгфМи лй СЬАй хтъА съйи?║?глАпФя гЦАйзоо?
? Фчо йФМщ ЦяМж Фгмо ЦД хДМ гАзятМД ЦяМж Пг?.)%35( ? ФщчогД гАФзМ?║)%50( ? ФгАчМа ФгмАЦЛ?║)%75( ?ЕМ гАуогз?
? хМДгЦ хчМй хзж гАзМФх Мщ глАЕгр?║? ЦяМж Пг тщга йгЦ Пг?14 ? хМДгЦ тщМ гбАняФД╨ мМк тщМ?║?хога гАяхФсМгАй гАзухМ?
? ФйоА Дйгфл гАхмк зЛА цД ЦД гАяжФяМ Мщ гЦАДгьч гЦАйФьДи гАйцъо ЦД гсйхзго Епг гЦАяж?.?гАзухМ АоЛ Цнси ЦяЛж?
.?АоЛ ЦлМз гЦАяЛж гАйМ йыЕя зАМЕЦ цзягж зухМи шяМ Цщяси?
ABSTRACT We reviewed the clinical manifestations and outcome of 20 cases of neurobrocellosis out of
1375 patients with brucellosis admitted to the infectious diseases ward of a tertiary hospital in Hamedan,
Islamic Republic of Iran. Of the 20 cases, 12 had meningitis (acute and subacute), 4 had meningo╜
encephalitis, 2 had myelopathy, 1 had polyradiculopathy and 1 had meningovascular complications
manifested by stroke. The most prevalent symptoms were headache (75%), vomiting and fever (50%) and
unconsciousness (35%). Among 20 neurobrucellosis patients, 1 died and the other 19 recovered; 14 fully
recovered and 5 patients had residual neurological deficits. In endemic areas, the disease should be ruled
out in all patients who develop unexplained neurological symptoms.
Neurobrucellose : enquЙte sur une maladie rare chez 20 patients iraniens adressИs Ю un hТpital
de soins tertiaires
R?SUM? Nous avons ИtudiИ les manifestations et l▓issue clinique de 20 cas de neurobrocellose parmi
1?375 patients atteints de cette maladie admis au service des maladies infectieuses d▓un hТpital de soins
tertiaires de Hamedan (RИpublique islamique d▓Iran). Sur ces 20 cas, 12 prИsentaient une mИningite
(aiguК et subaiguК), 4 une mИningoencИphalite, 2 une myИlopathie, 1 une polyradiculopathie et 1 des
complications mИningovasculaires qui s▓Иtaient manifestИes par un accident vasculaire-cИrИbral. Les
symptТmes les plus rИpandus Иtaient des cИphalИes (75 %), des vomissements et de la fiХvre (50 %) et
une perte de connaissance (35 %). Parmi les 20 patients atteints de neurobrucellose, 1 est dИcИdИ et les
19 autres se sont rИtablis, dont 14 complХtement et 5 qui ont conservИ des dИficits neurologiques rИsiduels.
Dans les rИgions endИmiques, il convient d▓Иcarter cette maladie chez tous les patients prИsentant des
symptТmes neurologiques inexpliquИs.
Department of Infectious Diseases, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran
(Correspondence to M. Ranjbar: ahmaliver@yahoo.com).
2
Department of Neurology, Sina Hospital, Hamedan, Islamic Republic of Iran.
3
General Practice, Hamedan, Islamic Republic of Iran.
Received: 26/06/06; accepted: 22/05/07
1
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Introduction
Brucellosis is a common zoonosis endemic
in many parts of the world [1]. Brucella
melitensis remains an important human
pathogen in endemic regions, most notably
the Mediterranean basin, Arabian peninsula
and Indian subcontinent [2,3]. There are
frequent reports of brucellosis from countries such as Kuwait, Saudi Arabia and other
countries of the Eastern Mediterranean Region, where animals are raised in large numbers [4,5]. Brucellosis is an endemic disease
in the Islamic Republic of Iran [6]. In 2004
the incidence of brucellosis was 38 per
100═000 population. The city of Hamedan
in the west of the country has always been
considered to have a high incidence of brucellosis (121 per 100═000 population). It has
many villages with large numbers of goat
and sheep farmers and ranchers who ingest
unpasteurized dairy products.
Neurobrucellosis is a rare, severe form
of systemic infection that has a broad range
of clinical syndromes [7√9]. In 4%√13% of
patients with brucellosis, the central nervous system is involved. [5,10,11]. The most
frequent presentations of neurobrucellosis
include meningitis, meningoencephalitis,
polyradiculoneuritis and also cranial nerve
palsies.
Considering the high prevalence of brucellosis in the Islamic Republic of Iran,
especially in Hamedan province, and the
debilitating consequences of neurobrucellosis, we decided to study this aspect of
brucellosis to achieve a better understanding of the characteristics and clinical manifestations of this rare, but life-threatening
complication.
Methods
In the review of 1375 hospital records of
patients admitted with brucellosis to the in-
fectious diseases ward of a tertiary hospital,
Hamedan Sina hospital, from 2001 to 2005,
20 patients (1.45%) with documented neurobrucellosis were isolated. The diagnostic
criteria of neurobrucellosis in these patients
were: signs and symptoms of nervous system involvement (headache, nausea, vomiting, lethargy, stupor, coma, hemiplegia,
hemiparesia, paraparesia, cerebral nerve
palsy, ataxia, behavioural disorder, aphasia,
etc.); Brucella agglutination antibody titre >
1:160; pleocytosis [white blood cell (WBC)
count in cerebrospinal fluid (CSF) > 10/m3];
and clinical improvement with appropriate
therapy. Complete records of all the above
were required for the diagnosis to be made.
A positive blood or CSF culture for Brucella species or a CSF Brucella agglutination
antibody titre > 1:80 was corroborative, but
not required for the diagnosis. Although this
was a retrospective study, all the above data
were recorded in detail in the archives as
standard procedure in our hospital in such
cases.
Patient information was gathered, including: clinical presentation; neurological
signs; CSF and blood Brucella antibody
agglutination titres; cell count, protein level
and glucose level in CSF; blood and CSF
culture results; dominant clinical manifestations; treatment; and outcome. According to
the approach of this hospital, the Brucella
antibody agglutination test was performed
with the use of kits supplied by the Pasteur
Institute of Iran. A serum agglutination titre
of > 1:160 and a CSF agglutination titre of
> 1:80 were considered as indicative of the
diagnosis. Blood and CSF were cultured on
Castaneda biphasic media. Culture bottles
were held for up to 6 weeks. Antimicrobial therapy consisted of a combination of
3 to 4 agents used for treatment of brucellosis. The therapeutic regimens included
doxycycline, rifampicin and trimethoprim√
sulfamethoxazole or doxycycline, strepto-
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
mycin, trimethoprim√sulfamethoxazole and
ceftriaxone.
The data were analysed using the statistical software SPSS, version 9.
Results
Of 20 patients with neurobrucellosis, 12
(60%) were male. As shown in Table 1, the
patients were distributed equally between
different age groups, except the 41√60 year
age group which contained fewer patients.
Among these patients 3 (15%) were single
and the rest were married. Most of the patients were farmers (40%) or housekeepers
(35%) (Table 1). Eleven patients (55%)
lived in rural areas while the rest were living in cities. Of all patients with neurobrucellosis, 6 (30%) had a previous history of
brucellosis.
Table 1 shows the frequency of signs and
symptoms of the patients at presentation to
the hospital. The most frequent symptoms
were headache (75%), vomiting and fever
(50%) and stupor (35%). The patients were
classified based on the dominant clinical
manifestation. Initial clinical manifestations
consisted of acute and subacute meningitis
in 12 patients, meningo╜encephalitis in 4,
and transverse myelitis, lumbar epidural
abscess with radicular nerve compression,
polyradiculopathy, and intracerebral haemorrhage each in 1.
All patients underwent lumbar puncture. The mean count of WBC in CSF was
130.2/mm3 (range: 10√580/mm3). The mean
glucose level was 44.9 (standard deviation
39.37) mg/dL and the highest protein level
was 440 mg/dL. The CSF Brucella antibody
agglutination test was performed for 17 patients, and the titre was elevated in 6. Blood
culture was performed for 16 patients and
was positive for Brucella species in only
1 patient. The blood Brucella antibody agglutination titre was positive in all patients.
145
The culture results for all 16 patients who
had CSF cultures were negative.
Of the 20 patients, 1 died and the other
19 recovered; 14 fully recovered and 5 had
a residual neurological deficit. One patient
with residual neurological deficit developed
psychosis (schizophrenia) despite receiving
antimicrobial therapy, 1 had hemiparesis, 1
had depression, 1 had dementia and 1 had
permanent hearing loss. The outcome was
Table 1 Characteristics of 20 neurobrucellosis
patients presenting to Hamedan Sina
hospital
Variable
Sex
Male
Female
No.
%
12
8
60
40
Age group (years)
< 21
21√40
41√60
> 60
6
6
2
6
30
30
10
30
Occupation
Farmer
Housekeeper
Employee
Unemployed
Student
8
7
2
2
1
40
35
10
10
5
15
10
10
7
5
4
4
3
3
3
3
3
2
1
75
50
50
35
25
20
20
15
15
15
15
15
10
5
Clinical manifestations
Headache
Vomiting
Fever
Stupor
Blurred vision
Neck stiffness
Back pain
Papilloedema
Aphasia
Seizure
Ataxia
Hemiparesis
Flaccid paralysis
Hearing loss
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more favourable for those patients who
were treated early in their illness.
Discussion
Neurobrucellosis is a rare manifestation
of brucellosis; it is reported that about
4%√13% of patients with brucellosis will
develop neurobrucellosis [5,10,11]. In our
centre, the frequency of neurobrucellosis
was lower (1.45%) than in previous epidemiological studies. This might be because
our centre is a referral centre and we do not
have an active screening system to find new
cases in the population. Some patients might
be referred to neurological clinics and some
are not registered if they are not admitted
to hospital. In any case, the true frequency
of neurobrucellosis is difficult to establish
because many patients are not diagnosed
and uncomplicated cases are not admitted
to hospital. As in any hospital-based retrospective review of medical records, we
cannot generalize the findings to the entire
population.
In our study the frequency of disease
was higher in males, a finding that is compatible with a similar study in the Islamic
Republic of Iran [12]. Other investigators
have reported a male:female ratio of 2:1. In
Saudi Arabia the female:male ratio was 2:1
[9]. There was no age preference detected
for this disease. Most of the patients were
married, lived in rural areas and worked as
farmers. This is expected as brucellosis is an
occupational disease in shepherds, abattoir
workers, veterinarians, dairy-industry professionals and personnel in microbiology
laboratories.
Meningoencephalitis can be seen in the
acute form and it may also present in chronic
form when the peripheral or central nervous
system is involved, with epidural granuloma, demyelination of the brain or spinal
nerve roots and long tract degeneration.
Meningitis has been reported to be the
most frequent presentation, occurring in
about 50% of the cases [13]. In our study,
16 cases (80%) had evidence of meningeal infection, as indicated by pleocytosis,
elevated protein level in the CSF and usually hypoglycorrhachia. Meningitis and
meningo╜e ncephalitis were found in 20
(60%) and 4 (20%) the cases respectively.
Rasoolinejad in a study of 22 Iranian patients with neurobrucellosis found that 10
patients had meningoencephalitis, 7 had
meningitis, 3 had polyradiculopathy and
1 presented with spinal epidural abscess
and 1 had brain abscess [12]. In a study
in Saudi Arabia among 18 patients with
neurobrucellosis, 11 (61.1%) patients had
meningitis [9]. Koussa et al. found that the
most common initial clinical manifestations
in 15 cases of neurobrucellosis in France
were meningoencephalitis and acute or
subacute meningitis in 5 (33.3%) and 4
(26.7%) patients respectively [14]. In a
study in Turkey of 73 patients with brucellosis, 13 patients had neurobrucellosis
(17.8%), 10 had chronic meningitis and 3
had acute meningitis [15]. Bellissma et al.
reported that of 6 cases of neurobrucellosis
in Italy, 2 had meningoencephalitis, 1 had
meningitis with brain abscess and 3 had
encephalomyelitis [16].
In our study 2 (10%) patients had myelopathy with pure upper motor neurone syndrome. The peripheral nerve lesions which
led to radiculopathy or polyradiculopathy
were seen in 1 (5%) patient. In Saudi Arabia, of 18 patients with neurobrucellosis,
1 presented with polyradiculopathy [9]. In
another study in France, of 15 patients with
neurobrucellosis 2 had polyradiculoneuritis
[14]. Goktepe reported a case of neuro╜
brucellosis resembling Guillain√BarrИ syndrome [17].
Intracerebral and subarachnoid haemorrhage due to a mycotic aneurysm occurred
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
in 1 patient. In the study in Saudi Arabia
4 patients had meningovascular complications manifested by stroke or intracerebral
haemorrhage [9], a figure that is higher than
our results. Tuncer Ertem reported a case
of subdural haemorrhage in a 49-year-old
female who had neurobrucellosis [18].
Most patients responded favourably to
treatment. The most commonly used antibiotics were rifampin, doxycycline and
trimethoprim√sulfamethoxazole, in various
combinations for at least 3 months. Some
patients received streptomycin or ceftriaxone. A regimen consisting of 3 or all 4
of these antimicrobial agents is generally
effective for neurobrucellosis, although the
addition of steroids has not proven to be
consistently beneficial [9]. Corticosteroids
seem to protect the tissues from the effects of bacterial toxins and reduce the
incidence of long-term complications [19].
The outcome was more favourable for those
patients who were treated earlier in the
course of the condition. Those who present
with prolonged symptoms that last several
months may respond more slowly to therapy and have neurological sequelae. Hence
it is important to consider the possibility of
147
neurobrucellosis in an endemic region and
to treat it aggressively.
In our study 5 (25%) cases had permanent sequelae, 1 of whom (5%) died. In
McLean et al.▓s study of 18 patients, 5 had
residual neurological deficits and 4 of them
developed permanent hearing loss [9]. In
our study 1 patient had permanent hearing loss. In a Nordic study a 20-year-old
Turkish immigrant with spastic paraplegia
and hearing loss had neurobrucellosis [20].
Bodur et al. reported 1 case of hearing loss
among 13 patients with neurobrucellosis
[15].
Neurobrucellosis is an uncommon, serious complication of brucellosis. However, in endemic areas such as Hamedan
province, the disease should be ruled out
in all patients who develop unexplained
neurological symptoms. The clinical signs
and symptoms of brucellosis are misleading
and many cases are diagnosed as pyrexia
of unknown origin [21,22]. Physicians and
health workers in endemic areas need to be
alert to the possibility of the disease and
have access to suitable laboratory facilities
for diagnosis.
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
149
Characterization of Bacillus
anthracis spores isolates from soil
by biochemical and multiplex PCR
analysis
F. Vahedi,1,2 Gh. Moazeni Jula,3 M. Kianizadeh 2 and M. Mahmoudi 1
?гАйзящ зЛА нугфу цхФгш гАзуФМи глАЦяМи гЦАсйщяС ои ЦД гАйэяхи хгАймАМА гАъМЦМгфМ гмАМФМ ФйщгзА?
?гАхФАМЦяМгр гАсАсМА гЦАйъяя?
? мЦЦФо мЦЦФоМ?║? ЦЕоМ ъМгМД ргоЕ?║? шгАЦяжг ЦдпМД лФгА?║?щгьЦи ФгмоМ?
? Фчо цляЛ?.? Мйъяя гАйхАМш зД щгтМгй гАзуФМи глАЦяМи АоЛ гмАМФгДгй Мщ ЦлЕФяМи еМягД геАсгАЦМи?:?гнАгАуи?
? ФляЛ мйоМо Цсйщяогй?║?гА АзМДгй гАйэяхи ЦД гЦАДгьч гЦАФьФДи хгЦАяж Мщ еМягД?
П ?гАхгмкФД Мщ ЕпЕ гАоягси мйАМ?
? ъгЦ гсйноЦ йщгзА гАхФАМЦяМгр гАсАсМА?.?гАзуФМи глАЦяМи хгАьяч гАхъйэяМФАФлМи ФгАъМЦМгфМи гмАМФМи гЦАзйгои?
? Фчо цкхй Епг гАйщгзА цДЕ МЦкЖЬА ЦчгМси йтнМуМи ясМзи Фмсгси?║?гЦАйзоо ъхоМА ААйзящ зЛА гЦАсйщяС огй?
.? ЦДЕг йсз зМДгй ЦУ щСФСЬ зи ААщфягД ФгАчУ СхМЗзи?║? зМДи мййФМ зЛА гАзуФМи глАЦяМи?25 ? Фцъой гАДйгфл ФлФо?.?ФДФзМи?
?Фйкхй гАоягси еЦъгДМи гсйногЦ йщгзА гАхФАМЦяМгр гАсАсМА гЦАйзоо ъхоМА МзФЬ А зАМЕ Мщ ътщ цхФгш гАзуФМи?
.?йэяуо Цяж глАЦяи гнАхМки ФгАсМСЬгЦ Мщ гЦАДгьч гЦАФхФаи?
ЬУ ? ФМщ?║? ФМщ гАоягсгй гАФхгфМи?║?глАЦяМи?
ABSTRACT Outbreaks of Bacillus anthracis in animals are repeatedly reported in the Islamic Republic
of Iran. In this study soil samples were analysed from endemic regions of the country, and B. anthracis
isolates were identified by classical bacteriological and biochemical methods. A multiplex polymerase
chain reaction (PCR) assay was also developed as an alternative for identification of isolates, and was
shown to be a rapid, sensitive and specific diagnostic assay. The results confirmed that 25 samples contained B. anthracis, of which 9 were virulent for mice and guinea pigs. This study suggests that multiplex
PCR can be used as a reliable alternative for the detection of B. anthracis spores.
CaractИrisation d▓isolats de Bacillus anthracis provenant du sol par analyse biochimique et PCR
multiplex
R?SUM? Des ИpidИmies de Bacillus anthracis chez les animaux sont souvent signalИes en RИpublique
islamique d▓Iran. Dans cette Иtude, des Иchantillons de sol venant de rИgions endИmiques du pays ont
ИtИ analysИs et des isolats de B. anthracis ont ИtИ identifiИs grБce aux mИthodes bactИriologiques et
biochimiques classiques. Un test d▓amplification en chaНne par polymИrase (PCR) multiplex a Иgalement
ИtИ mis au point pour identifier les isolats, et il s▓est avИrИ que cette autre solution constituait un test
diagnostique rapide, sensible et prИcis. Les rИsultats ont confirmИ que 25 Иchantillons contenaient
B. anthracis, et que 9 souches Иtaient virulentes pour les souris et les cobayes. Cette Иtude suggХre
que la PCR multiplex peut Йtre utilisИe comme solution de remplacement fiable aux fins de la dИtection
de spores de B. anthracis.
1
Immunology Research Centre, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of
Iran (Correspondence to F. Vahedi: vahedif@yahoo.com).
2
Razi Vaccine and Serum Research Institute, Mashhad, Islamic Republic of Iran.
3
Razi Vaccine and Serum Research Institute, Karaj, Islamic Republic of Iran.
Received: 26/06/05; accepted: 13/08/06
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Introduction
Bacillus anthracis is a gram-positive, aerobic, spore-forming bacterium that causes
anthrax in mammals [1]. B. anthracis spores
are very resistant to various conditions. The
spores can survive for many years in soil.
This long survival is important in epidemiological studies and in planning for control
and prevention of anthrax. The success of
the attenuated Sterne veterinary vaccine
in 1930 resulted in a global reduction of
anthrax cases in livestock in response to national vaccination programmes.
Unfortunately there are still regions
where anthrax is endemic. The Islamic
Republic of Iran is an endemic region with
many reported outbreaks in recent years.
Outbreaks occur not only in wild animals [2] but also in domestic animals [3].
Animals become infected after coming into
contact with soil-borne spores when grazing. Humans become infected after contact
with infected animals or their contaminated
products [4]. Surveillance and monitoring of anthrax is therefore a focus in public
health.
B. anthracis is closely related to several species, including B. cereus and B.
thurengiensis [5,6]. The virulent strains of
B. anthracis harbour 2 virulent plasmids,
toxin-encoding plasmid pX01 (181.7 kb)
[7,8] and plasmid pX02 (96.2 kb) which
codes for the capsule [9]. The current routine laboratory diagnostic method for B.
anthracis is microbiological analysis [4,10].
Avirulent B. anthracis strains lack pX01
and pX02 and cannot be distinguished
from other related species with these
time-consuming microbiological analyses
[11,12]. Therefore, development of a specific and rapid method for detection of B.
anthracis is required.
In this study soil samples were collected from regions of the Islamic Republic
of Iran where there are repeated reports
of outbreaks of B. anthracis. These samples were analysed for the presence of
B.═anthracis using routine assay and a multiplex polymerase chain reaction (PCR)
assay that was established in-house (at the
Razi Vaccine and Serum Research Institute,
Mashhad, Islamic Republic of Iran).
Methods
Soil sampling
Soil samples were randomly collected
from anthrax-endemic regions of Isfahan
province in the central part of the Islamic
Republic of Iran. A total of 60 specimens
were collected. In each collection, approximately 500 g of the topsoil to a maximum
depth of 20 cm were included and transferred to labelled bags.
Spore extraction and bacteria
identification
An overnight incubated soil suspension in
sterile phosphate-buffered saline (PBS) was
passed through a 0.45 ╣m filter and the deposit was suspended in sterile PBS. The
aliquot was heated at 65 ╟C to destroy vegetative cells and activate the spores. Then
the suspension was centrifuged and the
resuspended pellet was streaked onto duplicate plates of PLET agar (a selective media
for B. anthracis) and blood agar media.
One set of cultured plates was incubated at
37 ╟C and the other at 40 ╟C, both aerobically. Colonies emerging were examined
for morphological and cultural features of
B. anthracis at the end of 24√48 hours of
incubation.
Biochemical and biological analysis
The colonies identified as B. anthracis were
selected and further biochemical tests were
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
151
Table 1 Primers used for Bacillus anthracis gene amplification
Primer
Sequence (5√3)
Bac F
AAT GAT AGC TCC TAC ATT TGG AG
Bac R
TTA ATT CAC TTG CAA CTG ATG GG
PA F
CGA AAA GGT TAC AGG ACG G
PA R
CAA GTT CTT TCC CCT GCT A
Cap F
GTA CCT GGT TAT TTA GCA CTC
Cap R
ATC TCA AAT GGC ATA ACA GG
Expected size
Target gene
150 bp
Chromosome
330 bp
pX01
209 bp
pX02
Bac = B. anthracis chromosome; PA = protective antigen; Cap = capsule.
conducted according to classical bacteriological methods [13]. The saline suspension
containing different numbers of spores was
injected subcutaneously to mice and guinea
pigs to evaluate the lethality of the isolates
[14,15].
Total DNA extraction
Bacterial isolates were cultured on blood
agar plates and then 1 colony was picked
and resuspended in normal saline. All of
the bacterial suspensions were inactivated
in boiling water for 15 minutes. A simple
and rapid method was used for total DNA
extraction. Briefly, 200 ╣L of inactivated
bacterial cultures were vortexed vigorously and then frozen in liquid nitrogen. The
samples were thawed and vortexed again.
These steps were repeated 3 times and then
the samples were centrifuged at 12 000 в g
for 1 minute. Finally, the obtained supernatants were used as DNA source directly.
Primers
Three pairs of primers were designed according to B. anthracis sequences deposited in
the GenBank╝ database. The primers were
synthesised by TIB MOLBIOL (Berlin,
Germany). The primers that were used for
specific amplification of B. anthracis chromosome (Bac) were designed on the basis
of the previously published sequences [16].
Protective antigen (PA) and capsule (Cap)
primers were used to confirm the presence
of plasmids pX01 and pX02 respectively.
These primers were confirmed to be specific for targets based on the previous studies
and after comparison with B. anthracis sequences from the database of the National
Centre for Biotechnology Information using the BLAST network server [17√20].
Sequences of these oligonucleotide primers
are shown in Table 1.
Multiplex PCR
In order to optimize the PCR reaction, we
first set each primer at a concentration of
5 pmol in separate amplification reactions.
Subsequently we optimized the multiplex
PCR reactions.
The final optimized PCR mixtures
(25═╣L) consisted of: 200 ╣M each of
dATP, dCTP, dGTP and dTTP, 4 mM
MgCl2, 5 pmol of each primer, and
2.5═╣L of 10 в reaction buffer (100 mM
(NH4)2SO4, 200═mM Tris√HCl (pH 8.8),
1% Triton X-100, 100 mM KCl, 1 mg/mL
BSA) and 0.05 pg of DNA extraction in
3 ╣L doubled-distilled water. PCR analysis
was performed under the following conditions using the Techne 1600 (Techne,
Cambridge,
United
Kingdom):
1в
(94═╟C for 5 min), 35═в═(94═╟C for 50 s
followed by 58 ╟C for 50 s and 72 ╟C for
50═s ), 1═в═(72═╟C for 1 min), cool to 25═╟C.
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Serial dilutions of extracted DNA were
used as the template for multiplex PCR.
The specificity of optimized multiplex
PCR was tested using archived samples of
the Bacillus genus: B. subtilis, B. cereus, B.
thuringiensis and B. mycoides.
Analysis and detection of amplified
DNA (PCR products)
Finally, 5 ╣L of each amplification reaction was analysed on 2% w/v agarose
in Tris-acetate-EDTA buffer containing
0.5 ╣g/mL ethidium bromide. A 50 bp marker (Fermentas, Lithuania) was also included
on every gel. The gel was analysed under
ultraviolet illumination.
Results
The presence of B. anthracis in collected
soil samples was determined and analysed
morphologically and biochemically. A total of 25 samples were positive: 11 of these
positive samples displayed rods with capsules by Giemsa staining, 9 of them were
lethal to mice and guinea pigs and 8 of the
samples did not produce toxin or capsule.
Table 2 summarizes the results.
Our optimized multiplex PCR assay was
able to successfully amplify 3 fragments of
the expected sizes from extracted DNA of
positive controls. Three fragments of 152
bp (Bac), 209 bp (Cap) and 330 bp (PA)
reflected the presence of B. anthracis chromosome, capsule and toxin respectively.
The sensitivity of this assay was tested by
serial dilution of genomic DNA from the B.
anthracis positive control. A minimum of
0.05 pg of total DNA was sufficient to be
used as a template in the PCR. The multiplex PCR proved to be very specific for B.
anthracis and did not result in false positives with any other bacteria. Therefore, the
specificity for this protocol was calculated
at 100%. The presence of B. anthracis was
confirmed in all 25 samples by amplification
of the 152 bp Bac DNA fragment. Cap and
PA fragments were amplified in 12 and 14
samples respectively (Figures 1, 2 and═3).
Discussion
Anthrax is still one of the most serious
infectious diseases in animals and man
because of its highly resistant spores and
wide distribution. Approximately 95% of
anthrax cases in humans result from exposure to infected soil or animals, through
skin lesions. Therefore, continuous surveillance for anthrax is essential to prevent this
threat, especially in the Islamic Republic of
Iran, where there are a number of endemic regions. During a 1945 outbreak in the
Islamic Republic of Iran, 1 million sheep
died, one of the largest anthrax epizootics
in herbivores reported [5]. In recent years
controlling the disease through vaccination
has reduced anthrax cases in the country.
The survival of anthrax spores in soil
is an important factor, especially in animal
outbreaks. A classic case is the experience at Gruinard Island, Scotland, during
the Second World War, where spores persisted and remained viable for 36 years.
Decontamination of the island was completed in stages, beginning in 1979 and ending in
1987, when the island was finally declared
fully decontaminated. There have been similar experiences in northern Canada and
south Sudan [18,19]. Specific soil parameters, such as alkaline pH, adequate nitrogen,
calcium and organic material, are required
in conjunction with extreme weather changes to undergo a vegetative cycle and cause
disease in grazing animals, producing the
occasional outbreaks [20].
In our study 25 isolates of B. anthracis from infected regions of the Islamic
Republic of Iran were obtained, of which
9 were virulent in guinea pigs and mice.
Bacillus bacteria are notable for their
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
153
Table 2 Results of screening of isolated Bacillus anthracis strains: success in
detection by in-house polymerase chain reaction (PCR) assay or traditional
methods
Test
number
Capsule presence
Toxin production
Presence of
B. anthracis
chromosome
by PCR
By PCR
By Giemsa
staining
By PCR
Lethality
in mice or
guinea pigs
1
+
+
+
√
√
2
+
√
√
√
√
3
+
+
+
+
+
4
+
√
√
√
√
5
+
+
+
+
+
6
+
√
√
+
√
7
+
+
+
+
+
8
+
√
√
√
√
9
+
+
+
+
+
10
+
+
+
+
+
11
+
√
√
+
√
12
+
√
√
+
√
13
+
√
√
+
√
14
+
+
+
+
+
15
+
+
+
+
+
16
+
√
√
√
√
17
+
+
+
+
+
18
+
√
√
+
√
19
+
√
√
√
√
20
+
+
√
√
√
21
+
+
+
√
√
22
+
+
+
+
+
23
+
√
√
√
√
24
+
√
√
√
√
25
+
√
√
√
√
phenotypic similarities. The species can
be distinguished on the basis of time-consuming biochemical and microbiological
analysis [6]. The main feature used to distinguish B. anthracis from other closely
related Bacillus spp. is the presence of 2
virulent plasmids pX01 and pX02. The use
of PCR as a highly sensitive, specific and
rapid test for identification has been reported. Virulent genes on these plasmids have
been used as markers to detect B. anthracis
using PCR assay [21,22]. Avirulent strains
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Figure 1 Agarose gel electrophoresis
of multiplex polymerase chain reaction
products of Bacillus anthracis isolates (Bac
= B. anthracis chromosome; PA = protective
antigen; Cap = capsule)
Lanes: (1) Bac+ Cap+ PA√ (2) Bac+ Cap√ PA√
(3) Bac+ Cap+ PA+ (4) Bac+ Cap√ PA√ (5) Bac+
Cap+ PA+ (6) Bac+ Cap√ PA+ (7) Bac+ Cap+
PA+ (8) Bac+ Cap√ PA√ (M) 50 bp DNA marker
Figure 2 Agarose gel electrophoresis
of multiplex polymerase chain reaction
products of Bacillus anthracis isolates (Bac
= B. anthracis chromosome; PA = protective
antigen; Cap = capsule)
Lanes: (9) Bac+ Cap+ PA+ (10) Bac+ Cap+
PA+ (11) Bac+ Cap√ PA+ (12) Bac+ Cap√ PA+
(13) Bac+ Cap√ PA+ (14) Bac+ Cap+ PA+ (15)
Bac+ Cap+ PA+ (16) Bac+ Cap√ PA√ (M) 50
bp DNA marker
Figure 3 Agarose gel electrophoresis
of multiplex polymerase chain reaction
products of Bacillus anthracis isolates (Bac
= B. anthracis chromosome; PA = protective
antigen; Cap = capsule)
Lanes: (17) Bac+ Cap+ PA+ (18) Bac+ Cap√
PA+ (19) Bac+ Cap√ PA√ (20) Bac+ Cap+
PA√ (21) Bac+ Cap+ PA√ (22) Bac+ Cap+ PA+
(23) Bac+ Cap√ PA√ (24) Bac+ Cap√ PA√ (25)
Bac+ Cap√ PA√ (M) 50 bp DNA marker
that lack both of these plasmids cannot be
distinguished from other B. cereus group
bacteria with classical analysis [5].
In this study, a reliable and rapid method for detection and characterization of B.
anthracis was developed. With multiplex
PCR, simultaneous amplification of specific
genes on bacterial chromosome and 2 plasmids was performed. This assay is suitable
for general identification of B. anthracis,
because a strain lacking both pX01 and
pX02 cannot be distinguished from other
related species by microbiological analysis.
This sensitive and rapid assay is a reliable
test for confirmation and characterization of
B. anthracis in laboratories.
It is important to keep in mind that studies of the epidemiology of B. anthracis are
an important component in planning control
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
and surveillance programmes for anthrax.
We suggest that the multiplex PCR assay
can be used for accurate diagnosis and analysis of toxic factors encoded by B. anthracis
plasmids pX01 and pX02. This method
155
reduces the time required for B. anthracis
detection by about 3 hours in comparison
with time-consuming classical microbiological and biochemical methods.
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15. Little SF, Knudson GB. Comparative efficacy of Bacillus anthracis live spore vaccine
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anthracis and its possible use in diagnosis. FEMS immunology and medical
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17. Ramisse V et al. Identification and characterization of Bacillus anthracis by multiplex
PCR analysis of sequences on plasmids
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18. Dragon DC et al. Detection of anthrax
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19. Ramachandran S et al. Anthrax in Tiang
and Transhumant cattle in South Sudan. Indian veterinary journal, 1988, 65:1074√9.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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20. Kaufmann AF et al. Observation on the
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22. Makino SI et al. Direct detection of Bacillus
anthracis DNA in animals by polymerase
chain reaction. Journal of clinical microbiology, 1993, 31:547√51.
Anthrax in humans and animals
This fourth edition of the anthrax guidelines encompasses a systematic review of the extensive new scientific literature and relevant
publications up to end 2007, including all the new information that
emerged in the 3-4 years after the anthrax letter events.
This updated edition provides information on the disease and its
importance, its etiology and ecology, and offers guidance on the detection, diagnostic, epidemiology, disinfection and decontamination,
treatment and prophylaxis procedures, as well as control and surveillance processes for anthrax in humans and animals.
With two rounds of a rigorous peer-review process, it is a relevant
source of information for the management of anthrax in humans and
animals.
This publication is in press and will be in print shortly. Further information about WHO publications can be found at: http://www.who.int/
bookorders/anglais/home1.jsp?sesslan=1
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
157
Prevalence of coronary heart
disease among Tehran adults:
Tehran Lipid and Glucose Study
F. Hadaegh,1 H. Harati,1 A. Ghanbarian1 and F. Azizi1
? оягси гАшАФъФр ФгАтмФЦ Мщ ьЕягД?:?ЦзоСЬ А гДйтгя гцАЦягж гАчАхМи гАйглМи хДМ гАхгАшДМ Мщ ьЕягД?
? щяМоФД зрМрМ?║? бят шгДхгяМгД?║? ЕгоМ ЕягМй?║?щярго могМч?
? Цй ЖЬкА ЕпЕ гАФячи гАхмкМи гАйчяМя гцАФА мФА ЦзоСЬ А гДйтгя гцАЦягж гАчАхМи гАйглМи ФЦг Мяйхь Ехг ЦД?:?гнАгАуэи?
? Фчо лЦУ зй хМгДгй мФА нйьМь ъЕяхМи гАчАх Мщ ФжзМи?.?зФгЦА ггАнйьгя АоЛ гАхгАшДМ гАчгьДДМ Мщ ьЕягД?
? ЦД гАялгА ФгАДсга гАпМД йрМо цзгЦяЕЦ зЛА кгАкДМ згЦ Пг ФйЦ йяЦМрЕг хмсх ЦзгМяМ?5984 ?ггАжьлгз АоЛ?
? ФгсйДго Пг еЛА йзгяМщ?.? ФчМсй ъпАъ ЦлМз зФгЦА ггАнйьгя гАъяхЛ АцАЦягж гАчАхМи гАФзгфМи?.■?⌠ЦМДМсФйг?
? цФ гъйтгщ Цяж чАхМ йглМ?║? Фхмсх геАхгАш гАпгМй зД сФгхч Цяж чАхМ йглМ?║?гсйхМгД ⌠яФр■ ААпхми?
%21.8 ?гЦАумм хмсх гАзЦя гАДйтгя гЦАяж гАчАхМ гАйглМ?
?хФгсьи нйьМь ъЕяхМи гАчАх╨ ъгД гЦАзоСЬ А геАЦлгМА?
ЬС
? цЦг гЦАйшяМгй гАйМ йяйхь гяйхгь Пг ещягоМ Пг хгЦАяж гАчАхМ гАйглМ щЕМ?.)? АоЛ гАялгА?%18.8? АоЛ гАДсга Ф?%22.3(
║? Ф СЦ ЗДсх ъйАи глАсЦ?║? ФшАФъФр гАоЦ хзо сгзйДМ ЦД йДгФА гАьзгЦ?║?глАДс ФгАзЦА Фжшь гАоЦ ггАДчхгМж?
? еЛА ъФАсйэяФА гАяхФйДМ?LDL ? ФДсхи ъФАсйэяФА гАяхФйДМ гАтмЦМ гЦАДнщж гАъкгщи?║?ФДсхи гнАяу еЛА гАФяъ?
? ФМйхМДСЬ ЦД ЕпЕ гАДйгфл цД ЦД гАяжФяМ цД МФжз ЦФжз гАйДщМп зЛА лДгм гАясзи?.HDL ?гАтмЦМ гЦАяйщз гАъкгщи?
.?ФгАсМгЦ АоЛ гАДсга Мщ ьЕягД?
║?хяДгЦл ФьДМ АйчАМу ЦзоСЬ А гДйтгя зФгЦА ггАнйьгя АцАЦягж гАчАхМи гАйглМи?
ЬС
ABSTRACT This study is the first report on the prevalence of coronary heart disease (CHD) and its
associated risk factors in adult residents of Tehran. Standard supine ECG data were collected for 5984
men and women aged ? 30 years and coded by Minnesota criteria. All major cardiovascular risk factors were also measured. Based on Rose angina, self-reported history of CHD or ECG-defined CHD,
the aged-adjusted prevalence of CHD was 21.8% (22.3% in women and 18.8% in men). Variables
independently associated with CHD were female sex, age, systolic blood pressure, 2-hour postprandial
glucose, body mass index, waist-to-hip ratio and LDL/HDL cholesterol ratio.
PrИvalence des cardiopathies coronariennes chez les adultes Ю TИhИran : Иtude sur les lipides
et le glucose
R?SUM? Il s▓agit de la premiХre Иtude consacrИe Ю la prИvalence des cardiopathies coronariennes
(CPC) et aux facteurs de risque associИs chez les adultes vivant Ю TИhИran. Un Иlectrocardiogramme
standard a ИtИ rИalisИ en position allongИe sur 5 984 hommes et femmes БgИs de 30 ans et plus et les
rИsultats ont ИtИ recueillis et codИs selon les critХres du Minnesota. Les principaux facteurs de risque
cardiovasculaire ont Иgalement ИtИ mesurИs. La prИvalence ajustИe sur l▓Бge des CPC, calculИe sur
la base de l▓angor dИtectИ grБce au questionnaire de Rose, des antИcИdents autodИclarИs de CPC ou
des CPC rИvИlИes par l▓ECG, Иtait globalement de 21,8 % (22,3 % chez les femmes et 18,8 % chez les
hommes). Les variables indИpendamment associИes aux CPC Иtaient le sexe fИminin, l▓Бge, la pression
artИrielle systolique, la glycИmie postprandiale deux heures aprХs un repas, l▓indice de masse corporelle, le
rapport tour de taille/tour de hanches et le rapport cholestИrol LDL/HDL.
Prevention of Metabolic Disorders Research Centre, Research Institute of Endocrine Sciences, Shaheed
Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to F. Azizi:
azizi@erc.ac.ir).
Received: 22/01/06; accepted: 27/08/06
1
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Introduction
Coronary heart disease (CHD) is one of
the most common causes of morbidity and
mortality in different communities [1,2]. In
the United States of America, CHD is the
leading cause of death in adults, accounting
for approximately one-third of all deaths in
people over the age of 35 years [3]. Despite
the lack of accurate data, there is some evidence to indicate that CHD is increasing in
magnitude in the Islamic Republic of Iran.
While age-adjusted mortality from CHD
is gradually falling in developed countries
[2,4], the rate has increased by 20%√45%
in the Islamic Republic of Iran [5,6]. It
seems likely that changing lifestyles such as
high consumption of processed foods rich
in saturated fat and a low level of physical
activity along with the rising prevalence of
obesity and type 2 diabetes are leading to
a progressive increase in the prevalence of
cardiovascular (CVD) risk factors and CHD
in developing countries [7,8].
Studies on the adult population of Tehran show a high prevalence of metabolic
syndrome and CVD risk factors, particularly hypertension, high total cholesterol (TC)
and low high-density lipoprotein cholesterol (HDL-C) and high waist-to-hip ratio
(WHR) [9√11]. This study was conducted to
determine the prevalence of CHD in Tehran
from 3 measures≈the Rose questionnaire
on angina pectoris, self-reported previous
medical history and Minnesota coding of a
12-lead resting electrocardiogram (ECG)≈
and to identify its associated risk factors.
Methods
Sample
The Tehran Lipid and Glucose Study is a
longitudinal study, the first phase of which
was a cross-sectional or baseline examination survey from 1999 to 2001. It was de-
signed to estimate the prevalence of CVD
risk factors in a representative sample of an
Iranian urban population selected by random cluster sampling from district no. 13 of
Tehran. Details of the rationale and design
have been published elsewhere [12]. There
were 8071 individuals aged ? 30 years who
completed the baseline survey and whose
data were used for the current study.
Data collection
The data were collected by means of interviews, with completion of a questionnaire
for demographic data and CHD history,
physical examination for blood pressure,
pulse rate, ECG and anthropometrical
measures and laboratory measurements for
lipid and glucose profiles. The data collected were stored directly in a computer
database [13].
Coronary heart disease
For this study, CHD was defined as symptoms of angina pectoris based on the Rose
angina questionnaire or self-reported positive history of CHD or ECG positive for
CHD. The prevalence of CHD was estimated after application of each individual
criterion and also after combination of these
3 individual measures.
Using a Farsi language version of the
Rose questionnaire, history of any chest
pain was assessed during the interviews.
Rose angina score was measured for participants who had chest pain during exertion.
This pain forces the person to stop and goes
away in less than 10 minutes when he/she
stops. If present, the pain is situated over the
anterior or left lateral sternum or radiates to
the left arm [14].
Self-reported history of CHD was defined as a positive answer at the time of the
interview to the question as to whether the
patient had ever had a prior diagnosis of
CHD by a physician.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
A 12-lead resting ECG was recorded for
each individual ? 30 years in the Tehran Lipid and Glucose population by 2 trained and
qualified technicians according to a standard
recording protocol developed by the School
of Public Health, the University of Minnesota using a PC-ECG 1200 machine [15].
Two qualified physicians coded the ECGs
independently according to the Minnesota
codes using a measuring loupe specially
manufactured by University of Minnesota
[15]. To assure the quality, a third qualified
physician recoded 10% of ECGs and all the
data were double-entered. The population
was categorized into 3 groups (probable
CHD, possible CHD and non-CHD) on the
basis of ECG findings and Whitehall criteria [16]. Minnesota codes of 1.1√1.2 were
considered as probable CHD and codes 1.3,
4.1√4.4, 5.1√5.3 or 7.1 as possible CHD
[16]. In our analysis, we considered both
probable and possible CHD as a single
definition of ECG-defined CHD.
Clinical data
The details of data collection have already
been described [10]. This included systolic blood pressure (SBP), diastolic blood
pressure (DBP), weight, height and waist
circumference to calculate WHR, waist-toheight ratio (WHeR) and body mass index
(BMI).
A blood sample was taken after 12√14
hours overnight fasting for biochemical
measurements. Blood samples were taken
in a sitting position according to the standard protocol and centrifuged within 30√45
min of collection. All blood analyses were
done at the Tehran Lipid and Glucose Study
research laboratory on the day of blood
collection.
For the oral glucose tolerance test, 82.5═g
glucose monohydrate solution (equivalent to
75 g anhydrous glucose) was administered
orally to participants and serum glucose was
159
measured 2 hours later. Fasting blood sugar
(FBS) and 2-hour postglucose challenge
(2hPG) were measured on the day of blood
collection by the enzymatic colorimetric
method using glucose oxidase.
For lipid measurements, TC and trigly╜
ceride (TG) kits (Pars Azmoon Inc., Islamic
Republic of Iran) were used. TC and TG
were assayed using enzymatic colorimetric
tests with cholesterol esterase and cholesterol oxidase, and glycerol phosphate oxidase,
respectively. HDL-C was measured after
precipitation of the apolipoprotein B containing lipoproteins with phosphotungistic
acid. Low-density lipoprotein cholesterol
(LDL-C) was calculated from serum TC,
TG and HDL-C [17]; it was not calculated
when serum TG concentration was greater
than 400 mg/dL. A lipid standard (Calibrator for Automated Systems, Boehringer
Mannheim, Germany, cat. no. 759350)
was used to calibrate the Selectra 2 autoanalyser for each day of laboratory analyses.
All samples were analysed when internal
quality control met the acceptable criteria.
Inter- and intra-assay coefficients of variation were 2.0% and 0.5% for TC and 1.6%
and 0.6% for TG respectively.
Statistical analysis
Statistical analyses were done using SPSS,
version 10.01 statistical software package and data were presented as means and
standard deviations (SD). Prevalence estimates of CHD were adjusted to the World
Health Organization (WHO) world standard
population distribution. Student t-test was
used for comparison of means and chisquared tests were used for comparison of
frequencies. P-values < 0.05 were considered to be statistically significant.
Univariate analysis was performed using CHD as a dependent variable and age,
sex, LDL-C, HDL-C, TC, TG, non-HDL-C,
LDL/HDL ratio, FBS, 2hPG, hip and waist
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18.8
22.3
21.8
19.8
21.5
20.8
510
734
1244
13.6
14.4
15.1
14.6
13.7
14.0
a
Prevalence estimates were adjusted to the WHO world standard population distribution.
n = number of participants.
375
465
840
17.5
21.3
20.5
18.4
20.7
19.7
461
683
1144
13.0
14.1
13.6
325
463
788
12.4
14.5
14.1
√
√
18.3
39.3
961
283
√
√
11.4
33.5
599
241
√
√
17.6
34.9
893
251
√
√
12.0
24.7
610
178
Age (years)
30√64
? 65
Sex
Male
Female
Total
No.
Crude Adjusted
%
%a
No.
Crude Adjusted
%
%a
History of or ECG-defined
CHD
No.
Crude Adjusted
%
%a
Angina or ECG-defined CHD
Of all the 8071 individuals ? 30 years who
participated in the first phase of the Tehran
Lipid and Glucose Study, information about
angina pectoris, previous history of CHD
and ECG-defined CHD was available for
5984 individuals.
Overall, after age adjustment, 21.8% of
the Tehran population ? 30 years had CHD,
i.e. at least 1 of the 3 criteria (angina, previous history or ECG-defined CHD (Table
1). Women had marginally significantly
higher prevalence than men (22.3% versus
18.8 %, P = 0.05). Women also had higher
prevalence of CHD based on angina or ECG
definition alone (21.3% versus 17.5%, P <
0.05).
There were 604 cases of angina (10.1%),
324 cases with positive history of CHD
(5.4%) and 662 cases with ECG-defined
CHD (11.1%). After age adjustment, the
prevalence of angina pectoris based on
the Rose angina questionnaire was 10.7%,
self-reported history of CHD 6.0% and
ECG-defined CHD 11.8% (Figure 1).
Older subjects (? 65 years) had a 62%
higher prevalence of angina (15.8% versus
9.7%), had a more than 4-fold higher prevalence of previous history of CHD (16.5%
versus 3.9%) and had a 2.7-fold higher
Angina or history of CHD
Results
Variable
circumferences, weight, height, BMI, WHR,
WHeR, SBP, DBP, hypertension, and smoking as independent variables. The independent variables that had P-values < 0.2 on
univariate analysis were considered for risk
factor analysis in binary logistic regression
analysis. Moreover, because of colinearity
of some independent variables with others,
we included just one of those with r > 0.60.
So the final variables for logistic regression
analysis were: age, sex, SBP, DBP, FBS,
2hPG, hypertension, smoking, BMI, WHR,
LDL/HDL ratio, TG and TC.
Angina or history of or
ECG-defined CHD
No.
Crude Adjusted
%
%a
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 1 Crude and age-adjusted prevalence of coronary heart disease (CHD) in the Tehran population ? 30 years
160
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
prevalence of ECG-defined CHD (24.9%
versus 9.2%) (all P < 0.001).
After age adjustment, women had a
significantly higher prevalence of angina
pectoris than men (11.5% versus 8.9%,
P < 0.001) and men had a higher rate of
self-reported history of CHD than women
(6.5% versus 4.6%, P < 0.01) (Figure 1).
There was no significant difference between men and women in the age-adjusted
prevalence of ECG-defined CHD (probable
and possible CHD) (11.5% versus 10.4%),
but when the prevalence of probable CHD
was compared between the sexes, it was
161
significantly higher in males (1.8% versus
0.9%, P = 0.002) (data not shown).
The descriptive statistics and the significance difference of clinical and biochemical
characteristics for those with and without
CHD (angina, previous history or ECGdefined CHD) are presented in Table 2.
Subjects with CHD had significantly higher
values of all the major CHD risk factors
including age, BMI, SBP, DBP, FBS and
2hPG, serum TC and TG, LDL and nonHDL cholesterol (all P values < 0.001).
They also had greater waist circumference
and higher WHR and WHeR (P < 0.001).
14
12
**
10
8
%
6
*
4
2
0
Men
Women
Rose angina
History of CHD
All
ECG defined CHD
Figure 1 Age-adjusted prevalence of coronary heart disease (CHD) for the 3 different criteria
(Rose angina, self-reported history of CHD and ECG-defined CHD) in the Tehran population
? 30 years. Prevalence estimates were adjusted to the WHO world standard population
distribution. *P < 0.01; **P < 0.001 versus opposite sex
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Table 2 Clinical and biochemical characteristics of the Tehran population ? 30 years with and
without coronary heart disease (CHD)
Variable
Sex (female, %)
Smoking (current and ex-smoker, %)
Hypertension (?140/90 mmHg, %)
Age (years)
Body mass index (kg/m╡)
Waist circumference (cm)
Hip circumference (cm)
Waist-to-hip ratio
Waist-to-height ratio
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Fasting blood glucose (mg/dL)
2-hour plasma glucose (mg/dL)
Serum total cholesterol (mg/dL)
Serum triglycerides (mg/dL)
LDL cholesterol (mg/dL)
HDL cholesterol (mg/dL)
Non-HDL cholesterol (mg/dL)
LDL/HDL cholesterol
Without CHD
(n = 4740)
56.4
12.2
19.8
Mean (SD)
46 (12)
27.3 (4.5)
90 (11)
101 (9)
0.88 (0.08)
0.55 (0.07)
120.2 (18.5)
78.6 (10.5)
99.5 (34.2)
119.6 (54.6)
214.9 (44.0)
180.6 (116.1)
137.9 (37.6)
41.9 (10.7)
172.9 (43.9)
3.4 (1.2)
With CHDa
(n = 1244)
59.0
87.8
37.9
Mean (SD)
54 (12)
28.2 (4.6)
94 (11)
102 (10)
0.91 (0.08)
0.58 (0.07)
130.4 (23.5)
81.4 (12.1)
109.9 (43.1)
139.0 (70.1)
228.4 (50.4)
200.1 (123.8)
148.3 (42.7)
41.7 (11.1)
186.7 (49.6)
3.7 (1.3)
P-value
0.05
0.009
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.4
< 0.001
< 0.001
CHD was defined as Rose angina, self-reported history of CHD, or ECG-defined CHD.
n = number of participants; SD = standard deviation; LDL = low-density lipoprotein; HDL = high-density
lipoprotein.
a
Mean HDL cholesterol did not differ between subjects with and without CHD (P
= 0.4). The same results were obtained
when the analysis was performed separately
for different definitions of CHD (data not
shown).
The prevalence of current or past smoking as well as hypertension was also significantly higher in subjects who had CHD
than those who did not (P < 0.001) (data
not shown).
A backwards conditional multiple logistic regression analysis was performed
using CHD as the dependent variable and
all statistically significant risk factors in
the univariate analysis as independent variables. Table 3 shows the results of the final
model. Six variables had an independent
significant relationship with CHD: female
sex (OR = 1.33; P < 0.001), age (OR = 1.03;
P < 0.001), 2hPG (OR = 1.002; P = 0.011),
BMI (OR = 1.02; P = 0.014), WHR (OR =
3.20, P = 0.040) and LDL/HDL cholesterol
ratio (OR = 1.09; P = 0.001).
Discussion
In this community-based epidemiological
study in Tehran, the overall age-standardized prevalence of CHD defined as positive
history of CHD, angina or ischaemic ECG
was 21.8%. These results concur with
previous reports of CHD prevalence in the
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
163
Table 3 Independent determinants of coronary heart disease in the Tehran population ? 30
years
Variable
Female sex
Age
Systolic blood pressure
Body mass index
Waist-to-hip ratio
2-hour plasma glucose
LDL/HDL cholesterol
?
0.290
0.039
0.008
0.023
1.163
0.002
0.094
SE
0.091
0.004
0.002
0.009
0.567
0.001
0.028
OR (95% CI)
1.33 (1.11√1.59)
1.03 (1.02√1.04)
1.008 (1.004√1.012)
1.02 (1.00√1.04)
3.20 (1.05√9.72)
1.002 (1.000√1.003)
1.09 (1.04√1.16)
P-value
0.001
< 0.001
< 0.001
0.014
0.040
0.011
0.001
LDL = low-density lipoprotein; HDL = high-density lipoprotein; SE = standard error; OR = odds ratio; CI =
confidence interval.
Results of multivariate conditional logistic regression analysis adjusted for sex, age, systolic and diastolic blood
pressure, fasting and 2-hour plasma glucose, smoking, body mass index, waist-to-hip ratio, total cholesterol,
triglycerides and LDL/HDL cholesterol ratio.
Islamic Republic of Iran (Isfahan), which
showed the overall prevalence of CHD
based on the Rose questionnaire or ECG in
subjects aged 30√79 years to be 19.4%, with
a higher prevalence among women than men
(21.9% versus 16.0%, P < 0.001) [18]. This
is greater than other reports from the United
States of America (USA) (11.8%) [19],
India (11%) [20] and Saudi Arabia (5.5%)
[21]. Comparison of the results of these epidemiological studies is difficult because of
differences in the criteria for defining CHD
and in age distribution of the study population. We found only one study that used the
same criteria as ours. In this study, based
on the National Health and Nutrition Examination Survey data in the USA, the ageadjusted prevalence of CHD was 11.8%.
In a study in Kinmen, China, the overall
prevalence of CHD in those aged ? 30 years
based on diagnostic ECG was 21%, which
is much higher than our results (11.8%) and
may be related to the long-term stress of the
people who are living under military control
in that region [22]. The high prevalence of
CHD in Tehran residents may follow the
high prevalence of metabolic syndrome and
CVD risk factors in our population that has
been reported previously [8,9].
Women in the current study had a higher
prevalence of Rose angina than men (11.5%
versus 8.9%), which is similar to the results
of other studies that found a higher rate
of mild chest pain in women [23]. The
reason for this higher positive response to
the Rose questionnaire in women is not
clear. However, the presence of a significant association between Rose angina and
other CVD risk factors in our results, which
contradict the findings of other studies [22],
along with the higher mortality rate that has
been reported in women with angina symptoms [24], suggests that the Rose questionnaire responses offer good evidence for the
presence of CHD. In the current study, in
multivariate regression analysis, female sex
was significantly associated with CHD with
an OR of 1.33. In a population-based study
in India, the age-standardized prevalence
of CHD based on previously documented
myocardial infarction and positive ECG was
significantly higher in females than males
(12.4% versus 5.0%, P < 0.001) [20]. The
Kinmen study also reported the prevalence
of ECG-defined CHD to be significantly
higher in women than men (25.4% versus
15.7%, P < 0.001) [22]. The higher prevalence of CHD in Iranian women reported in
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
our study may follow the higher prevalence
of metabolic syndrome in women compared
with men (42% versus 24%, P < 0.001) [9].
In the Islamic Republic of Iran, women generally have lower levels of physical activity
than men, and overweight and obesity are
more common among women [25].
In the current study 2hPG but not FBS
was significantly associated with CHD.
This implies, as in other reports [26], that
2hPG is more strongly associated with CVD
risk and that this association is independent
of FBS and other CVD risk factors.
We also found BMI and WHR to be independent predictors of CHD, but compared to
BMI, WHR had a higher regression coefficient and OR in multiple logistic regression
analysis. This is consistent with the results
of a recent large cross-sectional study in a
multiethnic population [27]. This showed
that even after adjustment for other CVD
risk factors, the OR of WHR for predicting
myocardial infarction was significantly
greater than that of BMI. These results may
suggest that redefinition of obesity based on
WHR instead of BMI increases the estimate
of CHD attributable to obesity.
Our study showed the LDL/HDL cholesterol ratio to be an independent predictors of CHD. It was previously shown
that the mean HDL-C level was low in the
Tehran adult population (41 mg/dL) [28].
Regarding the high levels of LDL-C in
the subjects with CHD, it is possible that
in the presence of low HDL-C, even modest elevation of LDL-C with subsequent
elevation of the LDL/HDL cholesterol ratio
could contribute to CHD in our population.
Similar results have also been reported in
India [20].
The major limitation of this study was
the cross-sectional assessment of CHD
prevalence. Thus only survivors of CHD
were assessed by this survey and the prevalence of non-fatal CHD does not reflect the
burden of CHD in the Islamic Republic of
Iran. Also the methods that were employed
for diagnosis of CHD have well-recognized
limited sensitivity and specificity and are
expected to have even lower predictive
values when used in the low-risk population
[29]. Another limitation is that the data of
the current study come from 1999√2001
and the situation in the Islamic Republic
of Iran may have changed over this period.
But bearing in mind the increasing trend in
the prevalence of obesity (both general and
abdominal obesity) [30] and the reported
incidence rate of diabetes (1%) in our population [31], it is likely that the prevalence
of CHD reported in the current study has
increased by═now.
In conclusion, 21.8% of the Tehran
population aged ? 30 years was reported to
have either angina pectoris, previous history
of CHD or ECG findings consistent with a
probable or possible CHD. These results
demonstrate that CHD remains an important
public health problem in Tehran residents.
Regarding also the high prevalence of CVD
risk factors and metabolic syndrome in
this population, urgent steps are needed to
reduce the risk factors by modifying diets
and increasing levels of physical activity.
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
167
PrИvalence de la rhinite allergique
en milieu rural Ю Settat (Maroc)
S. El Kettani,1 B. Lotfi2 et A. Aichane3
?гцАялМ Мщ гЦАДгьч гАяМщМи Мщ ЦДьчи сьгй хгЦАшях?
С ?ЦзоСЬ А гДйтгя гАйЕгх гцАДщ?
? зхо гАзрМр зМтгД?║? хятЛ АьщМ?║?сзМо гАъйгМД?
║?гцАялМ хДМ съгД гЦАДгьч гАчяФМи Мщ ЦДьчи сьгй?
С ? чгЦ гАхгмкФД хйчММЦ ЦзоСЬ А гДйтгя гАйЕгх гцАДщ?:?гнАгАуи?
? тну Пг МзМтФД Мщ кгАк?336 ? ФтЦАй зМДи гАхмк?.?ФзгАчи пАъ хгцАЦягж гАьщМАМи гЦАзФМи ФхцмФгА гЦАзМти?
.ISAAC ?ФчМЦ гАхгмкФД гАйЕгх гцАДщ хгсйногЦ гсйхМгД гАоягси гАоФАМи ААяхФ ФгцАялМи АоЛ гцАьщгА?
ЬУ
ЬС ║?лйЦзгй?
? ФхДМ?║? сДи?49-15 ? ФъгД ЦзоСЬ А ггАДйтгя цзЛА хДМ цщяго гАщфи гАзЦяМи?║%37.8 ?Фчо хАш ЦзоСЬ А гДйтгя гАйЕгх гцАДщ?
? Мщ мДМ ъгД ЦзоСЬ А?║? цФ щяь гАМФрМДМгй?║? ФхДМ гАпМД МзгДФД ЦД рМгои гАФрД?║? ФхДМ гЦАонДДМ хятгЕи?║?шяМ гЦАйзАЦДМ?
? Фйягхь гАйЕгх гцАДщ Цз?.? АоЛ гцАьщгА оФД зЦя зят сДФгй?- ? хЦчогя УМ ЗзйСоУЬ хЕ емугфМ Пг?- ?ггАДйтгя цчА?
? ФАъДЕ ЦА Мяйхь хога гАьщМАМгй гЦАзФМи ФгА гАзоФЛ хгАоМогД?║?зоо цьщгА гцАяси Фояли геАЦАгЦ хгАчягаи ФгАъйгхи?
.?гАьщМАМи?
R?SUM? Cette enquЙte se propose d▓Иvaluer la prИvalence de la rhinite allergique dans une
population rurale de la rИgion de Settat et ses liens avec les parasitoses intestinales et les conditions
de vie. L▓Иtude a concernИ 336 sujets habitant trois douars. La rhinite a ИtИ ИvaluИe par le questionnaire ISAAC (International Study of Asthma and Allergies in Childhood). La prИvalence est de 37,8 %.
Elle est plus ИlevИe chez les personnes БgИes entre 15 et 49 ans, les illettrИs, les fumeurs actifs, les
personnes prИsentant une surcharge pondИrale et celles qui prИsentent une hyperИosinophilie. Elle
est significativement plus basse chez les enfants de moins de 10 ans. La rhinite est associИe Ю la taille
de la fratrie et Ю l▓alphabИtisme, mais elle n▓est pas significativement influencИe par la prИsence d▓une
parasitose intestinale ni d▓une helminthiase.
Prevalence of allergic rhinitis in a rural area of Settat, Morocco
ABSTRACT We evaluated the prevalence of allergic rhinitis in a rural population of Settat and its relationship with intestinal parasitosis and living conditions. The sample comprised 336 subjects living in
3 clusters. Rhinitis was evaluated using the ISAAC questionnaire. Prevalence of rhinitis was 37.8%. It
was higher in those aged 15√49 years, illiterate subjects, active smokers, those presenting with overweight and those with hypereosinophilia. It was significantly lower in children < 10 years. Rhinitis was
associated with sibship size and literacy, but not with intestinal parasitosis and helminth infections.
UnitИ de MИdecine interne═; 2UnitИ de Pneumologie, HТpital Hassan II, Settat (Maroc) (Correspondance Ю
adresser Ю S. El Kettani═: said_elkettani@yahoo.fr).
3
Service des maladies respiratoires, HТpital 20 AoШt CHU Ibn Rochd, Casablanca (Maroc).
ReГu═: 11/09/06═;═acceptИ═: 19/12/06
1
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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Introduction
De nombreuses Иtudes ont montrИ
l▓augmentation de la prИvalence de la rhinite allergique sur une large Иchelle. Les
facteurs environnementaux tels que les
changements climatiques, la pollution
atmosphИrique croissante, les changements
des modes de vie, le rИgime alimentaire, la
flore microbienne intestinale, la diminution
de l▓incidence des infections, le tabagisme,
l▓allaitement et la vaccination peuvent jouer
un rТle important dans sa survenue chez les
sujets gИnИtiquement prИdisposИs [1-5]. Au
Maroc, comme ailleurs, la rhinite allergique
constitue un vИritable problХme de santИ en
raison de sa prИvalence ИlevИe chez les adolescents et les adultes et du coШt de sa prise
en charge [6-8].
Cette Иtude se propose d▓Иvaluer la
prИvalence de la rhinite allergique et ses
liens avec la taille de la fratrie, les parasitoses intestinales et plus particuliХrement
les helminthiases. La recherche de la rhinite
allergique est effectuИe au moyen du ques-
tionnaire de l▓Иtude ISAAC (International
Study of Asthma and Allergies in Childhood) [4,9].
MИthodes
Zone d▓Иtude═
Settat est situИe au centre du Maroc, Ю 60 km
au sud de Casablanca. Son climat est aride
Ю semi-aride. La pluviomИtrie moyenne
annuelle se situe autour de 284 mm avec une
forte variabilitИ intra- et inter-annuelle (coefficient de variation dИpassant les 30═%).
L▓activitИ de la province est essentiellement agricole. Le taux d▓urbanisation
est de 29,5═%. La population totale de la
province est composИe de 951═613 habitants,
les habitants du milieu rural sont au nombre
de 628═094═[10].
Population ИtudiИe═
Il s▓agit d▓une enquЙte transversale qui a
concernИ une population rurale des environs
de la ville de Settat, en l▓occurrence les
Tableau 1 Comparaison des caractИristiques socio-dИmographiques de l▓Иchantillon avec
celles de la population rurale de la province de Settat
Variables
Nbre
Sexe
FИminin
Masculin
Tranche d▓Бge (ans)
3-9
10-14
15-29
30-49
50 et plus
AlphabИtisme
Instruits
IllettrИs
p
%
Pourcentage au
niveau du milieu
rural de la province
173
163
51,5
48,5
48,9
51,1
0,886
45
42
102
87
60
13,4
12,5
30,4
25,9
17,9
12,6
13,2
32,8
24,4
17,0
0,99
179
157
53,3
46,7
60,7
39,7
0,0085
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
habitants des douars Dladla, Boukallou et
Ouled Afif. L▓Иtude a intИressИ 336 sujets
БgИs en moyenne de 29,7 ans (Иcart type
19,5). Cet Иchantillon est reprИsentatif du
milieu rural de la province, du point de vue
sexe et tranches d▓Бge (Tableau 1). On remarque cependant une diffИrence significative quant Ю l▓alphabИtisme.
Chaque sujet participant Ю l▓enquЙte a
donnИ son consentement libre et ИclairИ aprХs
avoir ИtИ informИ de l▓objectif de l▓Иtude,
de sa mИthodologie, de ses contraintes,
de l▓accord du ministХre de la SantИ et du
caractХre confidentiel des renseignements
qu▓il fournira, de mЙme que de son droit
de refuser de participer ou de se retirer
librement. Il a rИpondu Ю un questionnaire
comportant des donnИes anamnestiques
diverses concernant des aspects multiples,
socio-Иconomiques, professionnels,
consommation tabagique et antИcИdents
pathologiques. Il a bИnИficiИ d▓un examen
clinique somatique dИtaillИ avec des
mesures anthropomИtriques et des examens
paracliniques.
Pour Иvaluer l▓Иtat trophique, l▓indice de
masse corporelle (IMC) a ИtИ retenu. Facile Ю
calculer, il est obtenu en divisant le poids (en
kilogramme [kg]) par le carrИ de la taille (en
mХtre carrИ [m2]). La classification proposИe
pour l▓adulte par l▓International Obesity Task
Force de l▓Organisation mondiale de la SantИ
distingue la maigreur (IMC < 18,5 kg/m2),
le poids normal (IMC 18,5-24,9 kg/m2), la
surcharge pondИrale (IMC 25,0-29,9 kg/m2)
et l▓obИsitИ proprement dite (IMC > 30 kg/m2)
[11]. Chez l▓enfant (Бge < 18 ans), nous avons
interprИtИ le chiffre calculИ selon la courbe de
rИfИrence [12].
Questionnaire ISAAC
La mИthodologie est inspirИe de l▓enquЙte
ISAAC. Elle estime la prИvalence des
maladies allergiques═: asthme, rhinite, urticaire et eczИma, en se basant sur un ques-
169
tionnaire simple et standardisИ. Ainsi la
rhinite allergique est retenue lorsque la
personne interrogИe rИpond oui Ю la question═: ╚═Avez-vous eu des Иternuements, un
Иcoulement ou une obstruction nasale, alors
que vous n▓aviez ni rhume ni infection respiratoire═?═╩ [4,9].
PrИlХvements═de selles et technique
d▓examen
Pour chaque participant, un Иchantillon
de selles de trois jours successifs a ИtИ
examinИ. L▓examen parasitologique a ИtИ
rИalisИ dans l▓heure qui suit la remise des
prИlХvements coprologiques. Il a consistИ en
un examen macroscopique et microscopique
direct et aprХs concentration selon la mИthode
standard diphasique de Bailenger [13].
PrИlХvement═et dosages═sanguins
Le prИlХvement a ИtИ effectuИ, aprХs un
jeШne de 12 heures, par ponction veineuse.
Le sang a ИtИ recueilli dans un tube Vacutainer avec de l▓acide ИthylХne-diaminetИtracИtique tripotassique. L▓Иtude de
l▓hИmogramme a ИtИ faite par comptage
cellulaire pour la numИration formule
sanguine (NFS) avec un appareil Coulter
type JT. La NFS complХte avec courbe de
distribution des globules rouges, globules
blancs et plaquettes et une approche formule ont ИtИ effectuИes sur un frottis avec
coloration de May-GrЭnwald-Giemsa. On
retient comme hyperИosinophilie des valeurs
supИrieures Ю 500/mm3 [14].
Analyse statistique
L▓analyse statistique a ИtИ pratiquИe en
fonction des objectifs de l▓Иtude. D▓abord
est dИcrite la prИvalence de la rhinite avec
son intervalle de confiance Ю 95 %, en fonction de chacune des variables de l▓Иtude.
Puis, en analyse principale, trois modХles
de rИgression logistique non conditionnelle ont ИtИ utilisИs pour dИterminer les
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
associations entre la prИvalence de la rhinite
et successivement les trois variables═: la
taille de la fratrie, la parasitose intestinale
et l▓helminthiase. Pour chaque modХle,
le jugement de l▓effet confondant des covariables est rИalisИ en comparant le modХle
Ю l▓essai au modХle complet. Une co-variable
est retirИe du modХle si l▓effet confondant
est moindre que 10 %. Enfin, dans une analyse secondaire, un modХle de rИgression logistique conditionnelle est construit Ю partir
des variables les plus significativement
associИes Ю la prИvalence de la rhinite. La
sИlection des variables pour le modХle est
rИalisИe Ю l▓aide de la procИdure de sИlection
pas Ю pas (stepwise) oЫ les critХres d▓entrИe
et de sortie des variables dans le modХle
ont ИtИ fixИs Ю 15 %. Pour l▓ensemble des
modХles, l▓association d▓une variable avec
la prИvalence de la rhinite est mesurИe Ю
l▓aide de l▓odds ratio (OR). Pour une va╜
riable, l▓OR est estimИ par l▓expression e?,
oЫ ? est le coefficient de la variable dans le
modХle considИrИ. Pour les analyses simples
et les modХles de rИgression logistique en
analyse principale, le seuil de signification
statistique a ИtИ fixИ Ю 5 % [15]. Les analyses
ont ИtИ rИalisИes sur le SAS, version 9.1.
RИsultats
PrИvalence de la rhinite selon les
facteurs socio-dИmographiques et
clinico-biologiques
La prИvalence de la rhinite est de 37,8═%
(Figure 1). Elle est discrХtement plus ИlevИe
chez les personnes de sexe fИminin. La
prИvalence de la conjonctivite chez les
rhinitiques est de 58,1 %.
La prИvalence de la rhinite est significativement influencИe par la tranche
70
60
PrИvalence (%)
50
40
30
20
10
0
Total
Sexe
?ge
Taille fratrie
Tabagisme
?tat trophique
?osinophiles Parasitoses Helminthiase
Figure 1 PrИvalence (%), avec l▓intervalle de confiance Ю 95 %, de la rhinite allergique selon
le sexe, la tranche d▓Бge, l▓alphabИtisme, la taille de la fratrie, le tabagisme, l▓Иtat trophique,
l▓hyperИosinophilie, la prИsence d▓une parasitose intestinale et la prИsence d▓une helminthiase
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
d▓Бge (p = 0,005). Les autres facteurs sociodИmographiques, cliniques ou paracliniques
analysИs n▓ont pas d▓effet significatif, mais
une certaine tendance est observИe. Ainsi, la
prИvalence est plus ИlevИe chez les per╜sonnes
БgИes entre 15 et 49 ans, les illettrИs, les
fumeurs actifs, les personnes prИsentant une
surcharge pondИrale et celles qui prИsentent
une hyperИosinophilie. Elle est, par ailleurs,
plus basse chez les personnes БgИes de 50 ans
et plus et les anciens fumeurs.
Liens entre la prИvalence de la rhinite
et la taille de la fratrie, la parasitose
intestinale et l▓helminthiase
La prИvalence de la rhinite est plus basse,
mais de maniХre non significative, chez
171
les personnes appartenant Ю des familles
nombreuses, donc les personnes Ю forte
promiscuitИ, et les personnes prИsentant une
helminthiase (Figure 1).
Analyse principale═: association
entre la prИvalence de la rhinite et
la taille de la fratrie, la parasitose et
l▓helminthiase
AprХs ajustement pour l▓ensemble des
co-variables, ni la taille de la fratrie ni la
prИsence d▓une parasitose intestinale, ni
l▓helminthiase ne sont associИes de faГon
significative Ю la prИvalence de la rhinite
dans la population ИtudiИe (Tableau 2).
Tableau 2 RИgression logistique non conditionnelle de la prИvalence de la rhinite en fonction
des variables analytiques
Variable
Taille de la fratrie
Parasitose
Helminthiase
OR brut
ORa
0,897b
1,163
0,698
0,883b
1,096
0,791
IC Ю 95 % de
l▓OR ajustИ
0,760-1,026
0,677-1,774
0,170-3,681
p
0,1043
0,7093
0,7647
ajustИ pour toutes les autres variables.
OR (odds ratio) calculИ sur une Иchelle continue. Pour une diffИrence de 3 enfants, l▓OR correspond Ю 0,688
avec un intervalle de confiance Ю 95 % de 0,44-1,08.
a
b
Tableau 3 ModХle de rИgression logistique regroupant les variables les plus significativement
associИes Ю la prИvalence de la rhinite
Variable
?ge (ans)
3-9
10-14
15-29
30-49
50 et plus
Taille de la fratrie
AlphabИtisme
ORa
IC Ю 95 % de l▓OR
p
1,000
5,868
5,832
4,385
2,154
0,878b
0,540
√
2,011-17,124
2,287-14,869
1,728-11,126
0,789-5,881
0,763-1,010
0,300-0,972
√
0,0467
0,0060
0,1614
0,1665
0,0687
0,0398
Les OR (odds ratio) sont tous ajustИs pour les autres variables du modХle.
La variable Taille de la fratrie est traitИe comme variable continue.
a
b
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Analyse secondaire═: variables les
plus significativement associИes Ю
la prИvalence de la rhinite
La sИlection pas Ю pas a retenu trois variables
comme associИes Ю la prИvalence de la rhinite,
suivant un seuil de signification de 10═%.
L▓Бge est la variable qui apparaНt la plus
fortement associИe. La tranche des enfants
БgИs de moins de 10 ans a la prИvalence la
plus basse. L▓alphabИtisme et la taille de la
fratrie apparaissent Иgalement associИs Ю la
prИvalence de la rhinite (Tableau 3).
Discussion
DИfinition de la rhinite
La dИfinition de la rhinite allergique
retenue dans cette Иtude se rИfХre au
questionnaire international standardisИ
de l▓Иtude ISAAC [4,9]. Restreindre la
dИfinition de la rhinite Ю la prИsence d▓au
moins un des trois signes, Иternuements,
Иcoulement et obstruction nasale, en dehors
d▓un rhume ou d▓une infection respiratoire
sans aucun recours aux examens cliniques
et paracliniques peut irriter plusieurs
spИcialistes et prЙter Ю confusion. Mais si nous
rappelons que l▓objectif est d▓approcher ces
phИnomХnes dans un but ИpidИmiologique,
pour rИpondre dans un premier temps Ю
l▓hypothХse ИpidИmiologique initiale, puis
dans un deuxiХme temps, si l▓hypothХse est
confirmИe, procИder aux examens cliniques,
aux tests cutanИs allergologiques pour
confirmer ces pathologies et procИder Ю une
recherche Иtiologique, la dИfinition devient
valable.
PrИvalence de la rhinite au Maroc
Nous comparons et discutons nos rИsultats
avec ceux d▓une enquЙte transversale qui a
portИ sur 500 Иtudiants de la facultИ de mИdecine de Casablanca БgИs en moyenne de
22 ans [16] et de six Иtudes ISAAC [8] ayant
intИressИ les enfants БgИs de 13 Ю 14 ans.
Deux Иtudes de phase I ont eu lieu en 1995
au niveau des villes de Casablanca (grande
ville cТtiХre, industrialisИe et Ю haute pollution atmosphИrique) et de Marrakech (ville
intИrieure Ю faible pollution atmosphИrique
et Ю climat sec). Quatre Иtudes de phase III
ont eu lieu au niveau des ces mЙmes villes,
au niveau de la ville de Ben Slimane (petite
ville non polluИe) et au niveau de la rИgion
de Boulmane (province Ю caractХre rural et
Ю climat sec et non polluИe) [7,8,17]. Nous
rappelons que notre Иtude concerne une
population plus large du point de vue Бge.
La prИvalence observИe en milieu rural Ю Settat se situe entre celle de Casablanca, celle de Marrakech et celle de
Boulmane (Figure 2). La proximitИ du
grand aИroport de Casablanca et d▓un axe
routier important reliant le nord et le sud
du Maroc peut expliquer cela. Par ailleurs,
la chronologie des Иtudes rИalisИes montre en comparant les Иtudes faites entre
1995 et 2002 qu▓il y a une augmentation
significative de la prИvalence dans les deux
villes ИtudiИes. Les valeurs de p respectives
sont p < 0,001 pour Casablanca et p < 0,001
pour Marrakech.
GИnИralement, on considХre que la prИvalence est similaire entre les deux sexes, sauf
chez les enfants et les jeunes chez lesquels
le sex ratio masculin/fИminin (M/F) est de
2 pour 1 [16]. Ceci n▓a pas ИtИ observИ Ю
Boulmane [17], oЫ le sex ratio M/F est de
1,03, ni chez les jeunes adultes de Casablanca [16] oЫ le sex ratio M/F est de 1,16.
Dans notre Иtude, le sex ratio est de 0,99.
? Malte [18] et en Espagne [19], la rhinite
est plus frИquente chez les filles que chez
les garГons.
PrИvalence de la rhinite dans le
monde
La rhinite allergique est une pathologie
frИquente═; sa surveillance dans le temps
et l▓espace s▓impose. De par le monde,
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
173
Settat
37,8
?lХves Casablanca 2002
52,7
?lХves Casablanca 1995
36,0
?lХves Marrakech 2002
35,7
?lХves Marrakech 1995
29,6
?lХves Benslimane 2002
40,4
?lХves Boulmane 2002
27,0
Adultes Casablanca 2002
46,2
0,0
10,0
20,0
30,0
40,0
50,0
60,0
PrИvalence (%)
Figure 2 ReprИsentation de la prИvalence de la rhinite allergique au niveau du milieu rural de
Settat et de certaines Иtudes marocaines entre 1995 et 2002 [7,8,16,17]
la tendance est Ю l▓augmentation de sa
frИquence [1,2,4]. Elle touche 5 Ю 50 % de la
population gИnИrale selon les tranches d▓Бge
et les pays considИrИs [2,4,18-21]. Donc, le
Maroc se situe dans une zone de prИvalence
ИlevИe.
Facteurs dИclenchant la rhinite
allergique
L▓importance de l▓ИcosystХme est soulignИe
par plusieurs Иtudes qui ont observИ que la
prИvalence de la rhinite est plus ИlevИe dans
les zones urbaines comparativement aux
zones rurales [3,5,22-24].
PneumallergХnes
Pour les pneumallergХnes courants, la relation entre exposition et sensibilisation a ИtИ
clairement dИmontrИe. Ainsi, les enfants
vivant au contact d▓un chien ou d▓un chat
sont le plus souvent sensibilisИs Ю cet animal
et les enfants vivant en zone humide sont plus
souvent sensibilisИs aux acariens que ceux
qui vivent en zone sХche [5]. La pollution urbaine est en relation Иtroite avec
les moyens de transport, et les principaux
polluants atmosphИriques sont alors le
dioxyde de soufre, les oxydes d▓azote
et l▓ozone, alors que la pollution des intИrieurs est constituИe par les allergХnes
domestiques reprИsentИs essentiellement
par les acariens, les animaux et la fumИe de
tabac [7,25]. L▓effet de cette derniХre serait
diffИrent selon qu▓il s▓agisse d▓enfants ou
d▓adultes. Certaines Иtudes ont montrИ que
chez l▓enfant il y a plus de fumeurs parmi
les rhinitiques. C▓est le cas Ю Malte oЫ les
enfants fumeurs actifs ou passifs ont une
prИvalence plus ИlevИe que celle des nonfumeurs (p < 0,0001) [18]. Une Иtude allemande a notИ que le tabagisme des parents
n▓influence pas la survenue de la rhinite
chez les enfants [26]. Dans notre Иtude,
l▓effet du tabagisme n▓a pas ИtИ trХs probant
en dehors d▓une prИvalence plus ИlevИe
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
174
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
chez les fumeurs actifs mais de maniХre
non significative.
HypothХse hygiИniste
FormulИe en 1989 par Strachan,
l▓hypothХse hygiИniste propose que
l▓actuelle augmentation des maladies
allergiques soit en rapport avec une diminution des stimulations microbiennes pendant
la petite enfance. Il ne s▓agit, soulignons-le,
que d▓une hypothХse, mais elle est actuellement considИrИe comme plausible. Les
donnИes ИpidИmiologiques sont impressionnantes : la prИvalence des maladies
allergiques et des maladies auto-immunes
a considИrablement augmentИ depuis environ 30 ans dans les pays dИveloppИs.
SimultanИment, certaines maladies
infectieuses ont spectaculairement diminuИ,
du fait des vaccinations, des traitements
antibiotiques et des progrХs de l▓hygiХne.
L▓asthme, la rhinite et la dermatite atopique
d▓une part, le diabХte de type 1, la sclИrose
en plaques, la maladie de Crohn d▓autre
part, suivent la mЙme courbe ascendante. Quant aux infections, on sait qu▓elles
obИissent Ю un gradient gИographique et
Иconomique inverse. De nombreuses Иtudes
concor╜d antes ont montrИ que le risque
d▓allergie Иtait diminuИ chez les enfants
vivant dans des conditions favorisant les
infections : environnement rural, familles
de grande taille, frИquentation prИcoce
des collecti╜vitИs d▓enfants. Pour autant, il
est difficile d▓affirmer que le lien entre la
diminution des infections et l▓augmentation
des maladies immunologiques soit de nature
causale [3,26-30]. Une mИta-analyse de
cette hypo╜thХse, basИe sur un Иchantillon
d▓Иtudes publiИes sur ce sujet, montre, dans
sa phase prИliminaire, que la protection serait
de 40═% pour l▓asthme, 30 % pour la rhinite
et 20 % pour la dermite allergique [31].
Infections parasitaires. Le rТle causal
direct de la diminution actuelle des in-
fections parasitaires et particuliХrement
des helminthiases dans l▓augmentation
des maladies allergiques est suggИrИ par
certaines Иtudes [32-34]. Une enquЙte en
?quateur a observИ que les lycИens prИsentant
une helminthiase avaient une incidence
de la rhinite allergique infИrieure Ю ceux
prИsentant une infection Ю protozoaires. Les
auteurs expliquent cela par le fait que chez
les patients allergiques, les cytokines Th2
sont plus prИdominantes par rapport aux
Th1 et les niveaux des IgE anti-helminthes
sont sensiblement plus ИlevИs, ce qui les
protИgerait [3]. Dans notre Иtude, nous avons
observИ une prИvalence des parasitoses
intestinales (pathogХnes et saprophytes)
de 53,6 % et plus spИcifiquement des
helminthiases de 3,3 %. Les prИvalences de
la rhinite varient peu selon qu▓il y ait ou
non une parasitose intestinale. Mais spИcifiquement la prИsence d▓une helminthiase
protИgerait contre la survenue de la rhinite,
la prИvalence Иtant uniquement de 30 %
(mais la diffИrence est non significative).
Taille de la fratrie. L▓effet protecteur
de la taille de la fratrie sur la survenue de la
rhinite et de l▓eczИma [35] dИcrit par Golding
et Peters a ИtИ dИmontrИ dХs 1986 par plusieurs
Иtudes. L▓analyse de 17 Иtudes sur la rhinite a
montrИ une relation inverse avec le nombre des
enfants de mЙmes parents [36,37]. Mais son
importance relative est diffИremment estimИe,
voire contradictoire [35,38]. Et surtout il y a eu
beaucoup de spИculations sur son mИcanisme
d▓action. Selon l▓hypothХse hygiИniste, une
rИduction des occasions d▓infections croisИes
dans les petites familles pourrait augmenter le
risque de rhinite [35,39]. Dans notre Иtude,
nous avons observИ que la prИvalence Иtait
plus basse chez les personnes Ю forte
promiscuitИ (p = 0,06).
?tat trophique. La relation entre allergie
et Иtat trophique a ИtИ apprИciИe dans une
Иtude sud-africaine. Elle a montrИ que le
bronchospasme induit par l▓exercice, les tests
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
cutanИs et les IgE spИcifiques Иtaient significativement plus ИlevИs (p < 0,0001) chez les
enfants qui ont un IMC augmentИ [24]. Dans
notre Иtude, les personnes qui prИsentente un
surcharge pondИrale ont une prИvalence de la
rhinite ИlevИe.
Facteurs gИnИtiques
? cТtИ de l▓aspect environnemental et du mode
de vie, les facteurs gИnИtiques sont difficiles Ю
cerner du fait qu▓il s▓agit de pathologies multifactorielles trХs hИtИrogХnes du point de vue
hИrИditИ car elles sont polygИniques [5,7].
?osinophilie et rhinite allergique
Dans l▓asthme et ses Иquivalents, il est
habituel de dИcrire une Иosinophilie plus
nette chez le jeune enfant que chez l▓adulte.
Les variations du taux des Иosinophiles ne
sont pas toujours parallХles aux poussИes de
la maladie [14]. La recherche d▓une Иosinophilie au niveau des sИcrИtions nasales
serait plus intИressante pour le diagnostic.
Dans notre Иtude, la prИvalence est lИgХrement plus ИlevИe chez les personnes prИsentant une hyperИosinophilie.
175
Conclusion
La prИvalence de la rhinite en milieu rural Ю
Settat est de 37,8 %. Elle est significativement plus basse chez les enfants de moins
de 10 ans. Elle est associИe Ю la taille de la
fratrie et Ю l▓alphabИtisme. Elle n▓est pas
significativement influencИe par la prИsence
d▓une parasitose intestinale ni plus spИcifiquement d▓une helminthiase.
Remerciements
Ce travail a ИtИ rИalisИ dans le cadre du Projet
╚═?cosystХme et santИ humaine CRDI/INRA
N╟ 100771 √ 0004═╩. Il est subventionnИ
par le Centre de recherches pour le dИvelop╜
pement international, Ottawa (Canada) et la
Fondation Ford, ?tats-Unis d▓AmИrique.
Nous tenons Ю remercier la DИlИgation du
ministХre de la SantИ de Settat pour son aide
logistique, M. Paul-Marie Bernard, professeur
retraitИ de biostatistique Ю l▓UniversitИ Laval
du Canada, pour son immense aide dans les
analyses statistiques et toutes les personnes
qui ont contribuИ Ю cette enquЙte.
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178
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Significant caries index values
and related factors in 5√6-year-old
children in Istanbul, Turkey
N. Namal,1 A.A. YЭceokur1 and G. Can1
? йяъМг?║? сДФгй Мщ гсьДхФА?6 √ 5 ?йсФс гцАсДгД АоЛ гцАьщгА хзЦя?
ЬУ ?цЦЕМи гАзФгЦА гЦАйзАчи хчМЦ СЦ ЗД Ссх?
? ъФДгМ лгД?║? цЦмо цЕМгД МФлЕ цФъФя?║?ДлЦМ ДгЦгА?
?йсФс гцАсДгД ФгАзФгЦА гЦАйз ЖЬАчи хЕ?
ЬУ ?цляЛ гАхгмкФД оягси Цсйзяжи АйчМэМЦ ЦоЛ цЦЕМи ч СМЦ СЦ ЗД Ссх?
С :?гнАгАуэи?
? Фчо муА?.? сДФгй ЦД Цнс Цогяс ААмжгДи Мщ гсьДхФА?6? Ф?5 ?АоЛ цьщгА ЦД йяъМг ййэягФм цзгЦяЕЦ хДМ?
? Фчо тЦАй?.?гАхгмкФД зЛА ЦзАФЦгй глйгЦзМи ФоМЦФшягщМи мФА згогй гАзДгМи хгАщЦ ЦД гАслгАй ФЦД гбАхга?
║)3.49 ? (ггАДмягщ гЦАзМгяМ?3.74 ?ФгЦАмтФи?
? йАЦМп Пг ФъгД ФсьМ СЦ ЗД Ссх гцАсДгД гЦАДнФяи ФгЦАщчФои?542 ?гАоягси?
ЬС
? Фчо?.? ЦД йсФс гцАсДгД?%76.8 ? Мщ мДМ згДЛ?.)2.56 ? (ггАДмягщ гЦАзМгяМ?7.75 ?ъгЦ ъгД СЦ ЗД Ссх йсФс гцАсДгД?
?ФгЦАмтФи цД зФгЦА ггАнйьгя АсФа мгАи?
?АэЦ ЗД Ссх гцАсДгД гЦАДнФяи ФгЦАщчФои?
?цФжм мйАМА?
С ?гАймФщ гААФлсйМ?
ЬС
ЬУ
? ФзоЦ ггАДйыгЦ Мщ Сй ЗсФМъ гцАсДгД?║)2.04 ?гцАсДгД ййЦкСЬА Мщ гДнщгж ЦсйФЛ йзАМЦ гцАЦЕгй (Дсхи гцАялмМи?
.)4.20 ?) цФ ЦяйДМ МФЦМ Пг (Дсхи гцАялмМи?4.09 ?хгАщятги хгЦАчгяДи Цз йсФМъЕг Цяи Фгмои МФЦМ Пг (Дсхи гцАялмМи?
ABSTRACT To evaluate significant caries (SiC) index values and related factors in Turkish children
aged 5√6 years old, children from 5 nursery schools in Istanbul were included in a cross-sectional study.
Sociodemographic information and data about oral care habits were obtained from the records and from
parents. Of 542 students examined, the mean decayed/missing/filled primary teeth (dmft) index was
3.74 (SD 3.49) and the SiC index was 7.75 (SD 2.56). About 76.8% of the children had experienced
dental caries. Logistic regression analysis of the SiC index for dmft showed that risk factors for poor
dental status were low mother▓s education (OR 2.04) and irregular toothbrushing versus once-a-day
brushing (OR 4.09) or twice-a-day brushing (OR 4.20).
Valeurs d▓indice significatif de caries et facteurs associИs chez les enfants БgИs de 5 Ю 6 ans Ю
Istanbul (Turquie)
R?SUM? Afin d▓Иvaluer les valeurs d▓indice significatif de caries (SiC, pour Significant Caries index) et
les facteurs associИs chez les enfants turcs БgИs de 5 Ю 6 ans, une Иtude transversale a ИtИ rИalisИe
sur les enfants de cinq Иcoles maternelles d▓Istanbul. Les informations sociodИmographiques et les
donnИes sur les habitudes d▓hygiХne bucco-dentaire provenaient des dossiers dentaires et des parents.
Sur 542 Иcoliers examinИs, l▓indice CAO moyen (dent de lait cariИe, absente ou obturИe) Иtait de
3,74 (E.T. 3,49) et l▓indice SiC de 7,75 (E.T. 2,56). Environ 76,8 % des enfants avaient eu des caries
dentaires. L▓analyse de rИgression logistique de l▓indice SiC par rapport Ю l▓indice CAO a montrИ que les
facteurs de risque associИs Ю une mauvaise santИ bucco-dentaire Иtaient un faible niveau d▓instruction
de la mХre (OR 2,04) et un brossage des dents irrИgulier, comparИ Ю un brossage une fois par jour (OR
4,09) ou deux fois par jour (OR 4,20).
Department of Public Health, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
(Correspondence to N. Namal: necminamal@yahoo.com).
Received: 20/03/06; accepted: 22/08/06
1
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
A detailed analysis of the caries prevalence in many countries has often shown a
skewed distribution of the disease: a group
of 12-year-olds may have high or very high
decayed/missing/filled teeth (DMFT) values, while the rest of the age group shows
low DMFT or are totally caries-free [1√3].
Obviously, expressing caries prevalence
as the mean DMFT value does not correctly reflect the skewed distribution, leaving high caries groups undiscovered in the
population. In order not to lose the positive
momentum gained from various oral health
programmes around the world, and to target
the still caries-susceptible individuals in
the population, a new index, the significant
caries (SiC) index, was introduced in the
year 2000 to call attention to those children
with the highest scores in each population
[4]. The SiC index is calculated by taking
the mean DMFT of the one-third of the
individuals having the highest of DMFT
values in a given population [2,4]. The use
of the SiC index may solve the problem
related to skewed caries distribution [5]. In
addition, a new goal was proposed: the SiC
index should be less than 3 DMFT among
12-year-olds by the year 2015 [2].
Although the range of SiC index values
for 12-year-olds is wide [6], it is narrower
for 5√6-year-olds [7√10]. According to
World Health Organization (WHO) data,
SiC values were 5.6 DMFT in Austria, 4.7 in
Australia, 7.3√7.7 in the Czech Republic, 8.1
in Trinidad and 5.3√6.8 in Germany [7√10].
To our knowledge there are no data available
about the SiC values for primary and permanent teeth in Turkish children. According to
a previous study in 1990, the average dmft
index in 6-year-olds was 4.4 [11].
The objective of this study therefore was
to present the first SiC data for 5√6-yearolds in Turkey to contribute to the interna-
179
tional data repository as well as to research
the factors concerning oral care habits that
may have an effect on these SiC values.
Methods
This cross-sectional study was conducted
on a randomly selected sample of children
in the Bagcilar and Gaziosmanpasa districts
of Istanbul. These districts were selected as
their sociodemographic characteristics are
very close to the average values for Istanbul
[12]. The study was conducted in 5 nursery
schools selected by random sampling from
the nursery schools reporting to the Social
Services and Child Protection Agency and
Gaziosmanpasa municipality during the
period June to December 2002. During the
study period, all students attending the 5
schools were included in the study. Schools
were revisited to recruit absent students and
ensure that all the students participated in
the study. No student refused to participate
in the study. The survey was performed on
542 nursery-school students: 295 who paid
school fees and 247 who were enrolled free
of charge.
Oral examinations were carried out in
classrooms with the help of a plain mirror
and the ballpoint probe under daylight or,
where necessary, using a portable source
of light. The same examiner performed all
examinations. No radiographs were taken.
Ethical approval for this study was obtained
from the Ethics Committee of the Cerrahpasa Medical School of the University
of Istanbul. The number of carious defects,
fillings and missing primary teeth were recorded on examination forms in accordance
with WHO criteria and the dmft scores were
calculated according to WHO guidelines
[13]. Individuals were grouped into tertiles
according to their dmft values. The SiC index was calculated as the mean dmft of the
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one-third of the population with the highest
caries scores [2,4].
Data on age, sex and number of siblings
were obtained from the existing school
files of the students. To collect data on
mother▓s level of education, family income
and oral hygiene habits, parents were sent
questionnaires to complete. This method
was used as young children may not be able
to give correct answers about toothbrushing
habits. Mother▓s level of education was
classified as 0√7 years of education or 8+
years. Children were classified according
to the number of times a day they brushed
their teeth: twice, once or irregularly (if they
brushed their teeth less than once a day).
For family income evaluation, the classifications of the State Statistics Institute
were used [14]. Monthly family income in
Turkish lira (TL) was classified as low [TL
250√500 (US$ 150√300)] or high [> TL 500
(> US$ 300)].
In addition to descriptive statistics, both
univariate and multivariate analyses were
done. Univariate analyses and logistic regression analyses were performed for all
variables. Logistic regression using SPSS
software was done to identify significant
risk factors for dmft. In addition to P-values,
the chi-squared, odds ratio (OR) and its 95%
confidence interval (CI) were computed.
Results
Of the children participating in the study 261
were 5 years old and 281 were 6 years old;
312 (57.6%) were boys and 230 (42.4%)
were girls. More than half of the children
(58.5%) had no siblings. Approximately
one-third of the mothers (28.4%) had received schooling for 8 years and more.
More than half of the families (54.2%)
had a high family income. The figures for
monthly income as stated by the families
were likely to be correct as nearly all the
families who declared a high monthly income were the families of students who
attended private schools.
The mean dmft of the children was 3.74
[standard deviation (SD) 3.49]. The SiC index value was 7.75 (SD 2.56). About 76.8%
of children had experienced dental caries.
According to parents▓ reports, 67.2% of
the children brushed their teeth once a day
or more. The cut-off for the SiC index (i.e.
the one-third of the group with the highest
caries scores) was 5+ dmft. Children within
the SiC index range (i.e. 5+ dmft) were
compared with children outside the SiC
index (i.e. dmft < 5) (Table 1).
No significant difference was found in
the percentage of children above and below
the SiC cut-off value by age, sex or number
of siblings. More children from low-income
families had dmft 5+ than the children from
high-income families and this difference
was significant (?2 = 2.72; P < 0.05). When
the effect of the education level of the mothers was evaluated, a significant difference
was found; mothers of children with dmft
5+ had lower education level (?2 = 10.87; P
< 0.05). More children who brushed their
teeth less than once a day had dmft 5+ than
children who brushed once or more a day
and this difference was significant (?2 =
8.89; P < 0.05) (Table 1).
The outcome of the conditional logistic
regression model for SiC value is presented
in Table 2. Children of mothers with 0√7
years of education were 2.04 times more
likely have dmft 5+ than children of mothers with 8+ years of education (OR = 2.04;
95% CI: 1.23√3.38; P = 0.006). Children
who brushed their teeth irregularly were
4.09 times more likely to have dmft 5+
than children who brushed their teeth once
a day (OR = 4.09; 95% CI: 1.53√10.93; P =
0.005) and 4.20 times more likely than children who brushed their teeth twice or more
a day (OR = 4.20; 95% CI: 1.53√11.50; P =
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
181
Table 1 Comparison of children within the SiC index range (i.e. 5+ dmft)
with children outside the SiC index (i.e. dmft < 5), by age, sex, family
income, mother▓s education, number of siblings and toothbrushing
Variable
Age (years)
5
6
Sex
Male
Female
Family income
Low
High
Mother▓s education (years)
0√7
8+
No. of siblings
0
1
2+
Toothbrushing
Irregularly
Once a day
Twice a day or more
dmft 5+
No.
%
dmft < 5
No.
%
?2 value
92
100
35.2
35.6
169
181
64.8
64.4
0.007
117
75
37.5
32.6
195
155
62.5
67.4
1.39
97
95
39.1
32.3
151
99
60.9
67.7
2.72*
154
38
39.7
24.7
234
116
60.3
75.3
10.87*
101
78
13
31.9
40.2
41.9
216
116
18
68.1
59.8
58.1
4.27
67
131
3
37.6
38.9
10.7
111
205
25
62.4
61.1
89.3
8.89*
*P < 0.05.
0.005). No other covariate was significantly
associated with the outcome.
Discussion
The mean dmft value (3.74) in this study
of 5√6-year-olds in 2 districts of Istanbul is
close to the average value for both Istanbul
and Turkey [12]. No study is available about
the association between the 2 indicators,
SiC values and dmft, in Turkish children.
Furthermore, we could not find any study in
the international literature about the factors
affecting the SiC values of 5√6-year-olds.
Our survey can therefore help in designing
future prospective studies.
The prevalence of 5√6-year-old children
with dental caries was 76.8%. This figure is
worse than in Austria, a developed country
(49.0%) and in Mexico (61.6%) and Nicaragua (72.6%), which are developing countries [9,15,16]. Compared with the target of
50% individuals with no dental caries for
5√6-year-old children proposed by WHO
in 2000 [17], the values for 5√6-year-old
children in Istanbul are very poor.
The mean dmft value found in our study
(3.74) is better than that of 4.4 dmft reported
previously for 6-year-olds in Turkey [11].
This shows that there was some improvement in the oral health of 6-year-old children
in Istanbul between 1990 and 2002. Our
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Table 2 Logistic regression analysis for significant caries index (SiC) values
Variable
Age (years)
5
6
Sex
Female
Male
Family income
High
Low
Mother▓s education (years)
8+
0√7
No. of siblings
0
1
2+
Toothbrushing
Irregularly
Once a day
Twice or more
Constant
B
SE
Wald ?2
df
P-value
OR (95% CI)
0.266
0.270
0.970
1
0.325
1.30 (0.77√2.21)
√0.211
0.189
1.246
1
0.264
0.81 (0.56√1.17)
0.134
0.308
0.189
1
0.663
1.14 (0.63√2.09)
0.712
0.258
7.638
1
0.006
2.04 (1.23√3.38)
√0.190
0.120
0.406
0.405
2.415
0.220
0.088
2
1
1
0.299
0.639
0.767
0.83 (0.37√1.83)
1.13 (0.51√2.50)
1.409
1.434
√2.517
0.501
0.515
0.690
8.149
7.906
7.764
13.309
2
1
1
1
0.017
0.005
0.005
0.000
4.09 (1.53√10.93)
4.20 (1.53√11.50)
0.08
B = coefficient B; SE = standard error; df = degrees of freedom; OR = odds ratio; CI = confidence interval.
value is close to the value in the Czech Republic for 5-year-olds (3.3√3.7) and Uganda
for 6-year-olds (3.1√3.3) [7,18] and matches
the value from Trinidad for 6-year-olds (3.7)
[10]. It is higher than the mean dmft values
of Austria (2.1) and Australia for 6-yearolds (1.65) and Germany for 6√7-year-olds
(1.98√2.8) [8,9,19]. It is lower than the dmft
values of Saudi Arabia (4.8) and Abu Dhabi
for 6-year-olds (8.4) [20,21]
In this study, the SiC value for 5√6-yearold children was 7.75. This is higher than the
SiC values for Austria (5.6) and Australia
(4.7) for 6-year-olds, the Czech Republic
for 5-year-olds (7.3√7.7) and Germany for
6√7-year-olds (5.3√6.8) [7√10,19]. However, it is lower than the value for Trinidad
for 6-year-olds (8.1). The WHO SiC index
target for 12-year-olds in 2015 is 3 DMFT
[2]. However, there is no WHO target for
the SiC levels for dmft of primary teeth of
5√6-year-olds. Since there is no such target,
we could not compare our study and other
studies with a standard value.
To our knowledge there has been no
study about the factors affecting the SiC
value of both 5√6-year-olds and 12-yearolds. Therefore we need to use the values
of dental caries and dmft/DMFT in comparisons. It has been shown before that
dmft values are affected by age [22], sex
[23], regular toothbrushing [24] and family
income [9]. These studies mostly examined
one or more factors in bivariate analyses
of risk indicators. In our study, several
risk indicators for the SiC value of dmft
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
were taken into consideration≈sex, family
income, mother▓s education, number of siblings and toothbrushing. Our results showed
that mother▓s education and toothbrushing
were associated with the SiC value of dmft.
Higher levels of mother▓s education had a
positive impact on the dental health of their
children. Children of mothers who had 0√7
years of education had SiC values twice as
high as those of the children of mothers who
were educated for 8 years or more. Greater
frequency of toothbrushing also had a positive impact on dental health. Children who
brushed their teeth irregularly had 4.09 and
4.20 times higher SiC values respectively
than those brushing their teeth once or
twice or more per day. These results agree
with those of other studies that showed
183
that higher education level of mothers and
frequency of toothbrushing have a positive
impact on dental caries [9,10,17].
In the short term, health planners may
not be able raise the educational level of
mothers. On the other hand, there is no
doubt that the dental health of these children
can be positively influenced if children in
school, starting with nursery school, are
taught to make it a habit to brush their teeth
regularly, properly and effectively. A target
of WHO for the year 2015 is the placement of health improvement programmes in
95% of all schools and 50% of all nursery
schools [25]. It is clear that programmes in
line with such targets are a requirement for
the children of Turkey.
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
185
Self-reported needle-stick injuries
among dentists in north Jordan
Y. Khader,1 S. Burgan2 and Z. Amarin3
?геАхгАш гАпгМй зД еугхгй Фнр геАхяи хДМ цьхга гцАсДгД Мщ тгЦА гцАяоД?
? рЕяМ зФои згЦяМД?║? сЦя рзА хячгД?║?МФсщ угАм няж?
? цляЛ гАхгмкФД йчММ ПгЦ ЦАзоСЬ А моФк геАугхгй хФнр геАхяи хДМ цьхга гцАсДгД ФЦФгчщЕЦ ЦД гАйхАМш?:?гнАгАуэи?
? ЦД?119( ? ЦД цьхга гцАсДгД гЦАгЦясДМ?170 ? Фчо тЦАй гАоягси?.?зДЕг Мщ тгЦА гцАяоД хеляга Цсм Цсйзяж?
? Фчо йягхьй?.?) АеАугхи нгАА гцАтЕя геАкДМ зят гЦАДяуЦи?%66.5( ? ЦДЕЦ?113 ?йзяж?
ЬС ║)? ЦД геАДгк?51?гАпъФя Ф?
? ФЦД хДМ?.?геАугхи хФнр геАхяи хДсхи Мзйо Ехг емугфМ Пг Цз йчоУЬ Ц гАзЦя ФЦз гроМго зоо гЦАяЛж гЦАзглАДМ МФЦМ Пг?
? ЦДЕЦ ФъгДй цсхгх зоЦ гАйхАМш?%77.9 ? ЦА Мх ЬАш зД пАъ?║?йзяжФг АеАугхи хФнр геАхяи?
Ь ?цьхга гцАсДгД гАпМД?
? цФ ггАДтшгА?║)%20.8( ? цФ зоЦ Цзящи хньФяи гАФнри?║)%41.2( ?цД гАФнр йЦ чхА гсйногЦ геАхяи АоЛ гЦАяМж?
? ФйАчМ ЕпЕ гАоягси гАжФа зЛА гмАгли еЛА хягЦл йкчМщМи?.)%13( ?) цФ зоЦ гАяЛж зД елягагй гЦАйгхзи?%25(
.?ЦсйЦяи мФА гАйзгьМ Цз гцАоФгй гмАгои Мщ ьх гцАсДгД ФгеАхгАш зД геАугхгй Ехг?
ABSTRACT The incidence of needle-stick injuries and the reporting attitudes among dentists in the
north of Jordan were assessed with a cross-sectional survey. The study included 170 general dental
practitioners (119 males and 51 females), of whom 113 (66.5%) were injured within the preceding
12 months. Needle-stick injury was significantly associated with higher age and a higher number of
patients treated daily. Of those who were injured, 77.9% did not report the injury. Reasons for not
reporting needle-stick injury were: because it took place before use on a patient (41.2%), ignorance of
the risk (20.8%), being busy (25.0%) and dissatisfaction with follow-up procedures (13.0%). The study
highlights the need for continuous education programmes about handling of sharp dental instruments
and reporting injuries.
Blessures par piqШre d▓aiguille chez les dentistes du nord de la Jordanie declarИes par les intИressИs eux-mЙmes
R?SUM? Une Иtude transversale a ИtИ rИalisИe afin d▓Иvaluer l▓incidence des blessures par piqШre
d▓aiguille et les attitudes vis-Ю-vis de la dИclaration de ces blessures chez les dentistes du nord de la
Jordanie. Elle a portИ sur 170 dentistes gИnИralistes (119 hommes et 51 femmes), dont 113 (66,5 %)
s▓Иtaient blessИs au cours des 12 mois prИcИdents. Ces blessures Иtaient significativement associИes
Ю un Бge ИlevИ et Ю un grand nombre de patients traitИs chaque jour. Parmi les dentistes qui s▓Иtaient
blessИs, 77,9 % n▓avaient pas dИclarИ leur blessure, et ce pour les raisons suivantes : parce qu▓ils
s▓Иtaient blessИs avant d▓utiliser l▓aiguille sur un patient (41,2 %), par ignorance du risque (20,8 %),
parce qu▓ils Иtaient trop occupИs (25,0 %) ou parce qu▓ils n▓Иtaient pas satisfaits des procИdures de
suivi (13,0 %). L▓Иtude met en Иvidence la nИcessitИ de programmes de formation continue sur la
manipulation des instruments dentaires piquants et la dИclaration des blessures.
Department of Public Health and Community Medicine, Jordan University of Science and Technology, Irbid, Jordan.
Department of Oral and Maxillofacial Surgery, Oral Medicine, Oral Pathology and Periodontology, Faculty of
Dentistry, University of Jordan.
3
Department of Obstetrics and Gynaecology, Jordan University of Science and Technology, Irbid, Jordan
(Correspondence to Z. Amarin: zoamarin@hotmail.com).
Received: 16/01/06; accepted: 06/08/06
1
2
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Introduction
Methods
Serious infections can be transmitted in the
dental practice when percutaneous injuries
occur. Hepatitis B virus (HBV), hepatitis
C virus (HCV), and human immunodeficiency virus (HIV) infections have been
recognized as occupational hazards for
dentists and other health care professionals
[1,2]. The extent to which practising dentists follow recommendations to minimize
their risk of a needle-stick injury varies.
Neither the magnitude of the risk of needlestick injury nor the practices associated with
it have been defined [3√6]. However, the
transmission risk is influenced by the type
and number of microorganisms present in
the blood, presence of visible blood on the
needle, depth of the injury and size and type
of needle used [7].
Dentists▓ reports of compliance with
recommended infection control practices
and universal precautions against HBV and
HIV infection increased between 1994 and
1995, but most dentists apparently have not
adopted universal precautions [8]. Adherence to infection control procedures, especially barrier protection, has been linked to
keeping the incidence of these infections
low [9]. Recommended infection control
practices that apply to all settings in which
dental treatment is provided are available
[10].
Although needle-stick injury among
dental health care workers has been explored in several industrialized nations,
very few data are available from developing
countries. No data have been reported on
needle-stick injuries among dentists in Jordan. Therefore, this study was conducted to
assess the incidence of needle-stick injuries
among dentists in the north of Jordan and
describe their attitudes towards reporting
such injuries.
The study was conducted between 1 November and 31 December 2004. The sampling frame was 414 practising dentists who
were listed in the updated register of the
Jordan Dental Association. The sample size
was calculated assuming a prevalence of
needle-stick injury within the preceding 12
months of 60% of dentists. The calculated
sample size with ? precision of ╠ 7.5% and
confidence level of 95% was 164. Using
a random numbers table, a sample of 180
dentists was selected to compensate for
non-response.
A structured, self-administered questionnaire was designed to describe the occurrence of needle-stick injuries among
dentists. The questionnaire sought information about sociodemographic characteristics
such as age, sex, marital status, years of
experience and average number of patients
treated daily. The questionnaire included
information about the frequency of being
stuck by a needle or a sharp instrument while
at work during the last year, and the circumstances of the most recent needle-stick
injury (before use on patient, during use on
patient, after use on patient, disposal-related
or any other specified circumstances). The
definition of a needle-stick injury was a
percutaneous injury of any depth caused
by a small-, medium- or large-bore hollow
syringe needle which did or did not involve
visible blood at the time of injury. A yes/
no response was used to assess whether
the dentist reported the injury to a family
medicine health worker or to an emergency
medical service.
All dentists were visited in their work
place and verbal consent to participate was
obtained. The respondents were assured
about confidentiality. Continuous variables
were described using mean and standard
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
deviation (SD). All categorical variables
were described using frequency tables. Data
analysis was performed using SPSS, version 11.5. The chi-squared test was used to
assess the association between categorical
independent variables and being injured.
Results
Of the 180 selected Jordanian general dental practitioners, 170 (94.4%) agreed to
participate in this study (119 males and
51 females). Their mean years of professional experience was 9.3 (SD 6.8) years,
range 1 to 32 years, and their mean age was
34.0 (SD 7.7) years, range 23 to 55 years,
with approximately 76.5% being younger
than 40 years. A total of 143 (84.1%) dentists═had been vaccinated against HBV
infection.
187
Overall, 113 (66.5%) of the dentists had
been injured by a needle-stick at least once
during the preceding year. About one-third
(33.5%) of dentists had not been injured,
16.5% had been injured once, 22.6% twice,
and 27.4% on more than 2 occasions.
The incidence of needle-stick injuries
by demographic characteristics and workrelated variables is shown in Table 1. Needlestick injury was significantly associated with
increased age (P = 0.048) and increased
number of patients treated daily (P = 0.045).
The circumstances of the needle-stick
injuries are given in Table 2. Among those
injuries, 32.7% occurred before injection,
30.1% occurred during injection, and 30.9%
occurred after injection. Only 6.2% of injuries were sustained during disposal.
Of the injured dentists, 77.9% had never
reported any of their injuries. Reasons for not
Table 1 Frequency of needle-stick injuries among Jordanian dentists (n =
170) by demographic characteristics and experience and patient load
Variable
Age group (years)
< 30
30√39
40+
Total
Sex
Male
Female
Marital status
Single
Married
Years of experience
<5
5√< 10
10+
No. of patients per day
< 10
10+
Not injured
No.
%
Injured
No.
%
P-value
26
24
7
57
39.4
37.5
17.5
33.5
40
40
33
113
60.6
62.5
82.5
66.5
0.048
38
19
31.9
37.3
81
32
68.1
62.7
0.501
24
33
34.3
33.0
46
67
65.7
67.0
0.861
15
19
23
25.4
36.5
39.0
44
33
36
74.6
63.5
61.0
0.254
35
22
40.7
26.2
51
62
59.3
73.8
0.045
═
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 2 Circumstances of needle-stick
injuries among Jordanian dentists (n = 170)
Injury occurred:
Before injection
Opening ampoule
Opening needle cap
Recapping before use
During injection
After injection
During disposal
No.
37
10
13
14
34
35
7
%
32.7
8.8
11.5
12.4
30.1
30.9
6.2
reporting the needle-stick injury were: because it had happened before being used on a
patient (41.2%), perception of little or no risk
to themselves (20.8%), being busy (25.0%)
and dissatisfaction with follow-up procedures after reporting the injury (13.0%).
Discussion
This cross-sectional survey investigated
needle-stick injuries only among dentists, in
contrast to most other studies which evaluated needle-stick injuries among health
care workers in general. The frequency of
needle-stick injuries among dentists in this
study (66.5%) is less than that of health
care workers in other studies. Chen et al.
reported that between 71% and 76% of Taiwanese nursing personnel had experienced
needle-stick and sharps injuries [11] and
Guo et al. found that the prevalence of
needle-stick injuries among Taiwanese
health care workers ranged from 61% to
93% [12]. On the other hand, the frequency
of needle-stick injuries in our study is higher
than the 58% reported in the only regional
study on such injuries in dental health care
workers in Saudi Arabia [13].
Identifying the circumstances of injuries
is important. Being stuck during needle
recapping after use and during injection
are the most common and most serious
needle-stick injuries as this has the potential
for HBV, HCV and HIV infection. In our
study, 12.4% of injuries were sustained during recapping and before being used, and
11.5% of injuries were sustained during the
opening of the needle. This type of injury
is less risky to dentists, but, if the needle
is subsequently used, it is potentially risky
to patients. We found that 6.2% of injuries
were caused at the disposal stage. These are
areas that may be amenable to improvement
through participation in training related to
infection prevention and provision of appropriate sharps disposal containers.
The non-reporting of needle-stick injuries in this study and the reasons for it are
disturbing; 77.9% of dentists did not report
the injury. These results are in agreement
with those of Guo et al. who found that
81.8% of all injuries and exposures were not
reported by Taiwanese health care workers
[12]. Reasons for not reporting injuries indicate a need for continued education about
the risk of acquiring blood-borne pathogens
from such injuries [14,15]. HBV vaccination [16], which remains low in developing
countries [17], the use of post-exposure
prophylaxis [18] and the use of improved
engineering controls may circumvent some
of the shortfalls in this area.
One of the limitations of our study is
that recall bias may have occurred in the
responses, especially for events that may
have taken place a long time prior to the
study. More rigorously designed studies
are required to further assess adherence to
infection control guidelines [19].
In conclusion, the general incidence of
needle-stick injuries and reporting attitudes
among dentists found in this survey are of
concern. Safer work practices and instrumentation and continued worker education,
with particular regard to post-treatment
handling of sharp dental instruments and
equipment, may reduce occupational blood
exposure among dentists in Jordan.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
189
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Cleveland JL et al. Use of HIV postexposure prophylaxis by dental health care
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16. Yengopal V, Naidoo S, Chikte UM. Infection control among dentists in private
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compliance with recommended infection
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11. Chen YY, Yang GY, Liu CY. [Injuries to
nursing personnel by sharp objects of
medical apparatus and their causes].
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3:322√31 [in Chinese].
12. Guo YL et al. Needlestick and sharp injuries among health care workers in Taiwan. Epidemiology and infection, 1999,
122:259√65.
13. Paul T. Self-reported needlestick injuries
in dental health care workers at the Armed
Forces Hospital Riyadh, Saudi Arabia.
Military medicine, 2000, 165:208√10.
17. Duffy RE et al. Evaluating infection control practices among dentists in Valcea,
Romania, in 1998. Infection control and
hospital epidemiology, 2004, 25:570√5.
18. Cleveland JL et al. Use of HIV post╜
exposure prophylaxis by dental health care
personnel: an overview and updated recommendations. Journal of the American
Dental Association, 2002, 133:1619√26.
19. Gordon BL et al. Systematic review of
adherence to infection control guidelines
in dentistry. Journal of dentistry, 2001,
29:509√16.
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190
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Job satisfaction and burnout among
Palestinian nurses
L. Abushaikha1 and H. Saca-Hazboun2
?ФгЦАЦяжДМ гАщАсьМДМэДМ зД гАФыМщи ФгеАЕДгъ гАДглЦ зДЕг?
?гЦАЦяжгй?
Ь
Ь ?яЛж?
? мДгД счг мрхФД?║?АхДЛ цхФ тМнЕ?
?ФгЦАЦяжДМ гАщАсьМДМэДМ зД ФыгфщЕЦ?
?гЦАЦяжгй?
Ь? УцляМй оягси гсйчугфМи ФущМи М?:?гнАгАуи?
Ь
Ь ?Айчу яЛж?
? ЦЦяж Пг ФЦЦяжи ЦД гЦАзМДДМ Мщ гЦАсйтщМгй?152 ? Фчо гнйяМй зМДи зтФгфМи ЦъФДи ЦД?.?ФгеАЕДгъ гАДглЦ зДЕг?
.? ФчгфЦи ⌠ЦгсгАт■ АеАЕДгъ?║? ФгсйхМгД ⌠ЦМДМсФйг■ ААяЛж?║? ФгсйноЦй гАхгмкйгД гсйхМгД Пг оМЦФшягщМ Пг?.?гнАгуи?
?Фчо цхАшй гЦАсйлМхгй ФгЦАсйлМхФД зД ЦсйФМгй ЦйФсьи ЦД гАяЛж зД гАФыМщи ФЦсйФМгй ЦйФсьи ЦД?
? ФМФглЕ гЦАЦяжФД ФгЦАЦяжгй гАщАсьМДМФД мйоМгй зоМои Мщ зЦАЕЦ гАМФЦМ хсхх чАи гАщяу гЦАйгми?.?геАЕДгъ?
? Фйчз гЦАсдФАМи зЛА?.?цЦгЦЕЦ ААйэя ЬчМ гАФыМщМ Фхсхх геАЕДгъ ггАДщзгМА ЦЦг МдоМ еЛА зоЦ яжгЕЦ зД гАФыМщи?
?геАогя ЖЬМэДМ гАйДщМп ЖЬМэДМ Мщ гАязгМи гАумМи ФягсЦМ гАсМгсгй еАлМго мАФА ААЦтгъА гАйМ йдоМ еЛА зоЦ гАяжга?
.? ФпАъ АжгЦД еМйга ноЦгй язгМи умМи згАМи глАФои?║?зД гАФыМщи ФеЛА геАЕДгъ хДМ гЦАЦяжДМ ФгЦАЦяжгй?
ABSTRACT An exploratory descriptive study design was used to investigate job satisfaction and burnout among Palestinian nurses. A random sample of 152 nurses was recruited from private hospitals.
The instruments included a demographic questionnaire, the Minnesota satisfaction questionnaire and
the Maslach burnout inventory. Respondents reported moderate levels of job satisfaction and moderate
burnout. Palestinian nurses face many challenges in their daily work due to decreased chances of job
advancement and emotional exhaustion which may lead to job dissatisfaction. Health care administrators and policy-makers have a responsibility to find solutions to problems that cause job dissatisfaction
and burnout among nurses to ensure the delivery of quality health care services.
Satisfaction au travail et Иpuisement professionnel chez les infirmiХres palestiniennes
R?SUM? Un modХle d▓Иtude descriptive et exploratoire a ИtИ utilisИ pour enquЙter sur la satisfaction
au travail et l▓Иpuisement professionnel chez les infirmiХres palestiniennes. Un Иchantillon alИatoire
de 152 infirmiХres a ИtИ recrutИ dans des hТpitaux privИs. Les instruments utilisИs comprenaient un
questionnaire dИmographique, le questionnaire MSQ (Minnesota satisfaction questionnaire) et l▓Иchelle
MBI (Maslach burnout inventory). D▓aprХs les dИclarations des personnes interrogИes, leurs niveaux
de satisfaction au travail et d▓Иpuisement professionnel Иtaient moyens. Les infirmiХres palestiniennes
sont confrontИes Ю de nombreuses difficultИs dans leur travail quotidien en raison de la rИduction des
possibilitИs d▓avancement et de l▓Иpuisement Иmotionnel qui peut conduire Ю l▓insatisfaction professionnelle. Il incombe aux administrateurs et aux dИcideurs du secteur des soins de santИ de trouver des
solutions aux problХmes Ю l▓origine d▓une insatisfaction et d▓un Иpuisement professionnels parmi les
infirmiХres, afin de garantir la prestation de services de soins de santИ de qualitИ.
Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to L.
Abushaikha: lub2001@just.edu.jo).
2
School of Nursing, University of Bethlehem, Bethlehem, Palestine.
Received: 19/02/06; accepted: 06/08/06
1
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Nursing is a stressful profession that deals
with intense human aspects of health and
illness [1√3]. Consequently, the stressful
nature of nursing can ultimately lead to job
dissatisfaction and burnout [2√7]. Among
health care professionals, nurses have been
found to be most prone to burnout [8]. Job
satisfaction and burnout among health care
providers are important issues since they
affect turnover rates, staff retention and ultimately the quality of patient care [9√11].
Job satisfaction has been described as
the degree of positive affective orientation
toward a job [2,4,5]. Burnout has been
defined as a syndrome of physical and
emotional exhaustion, involving the development of negative self-concept, negative
job attitudes and loss of concern for clients
[8]. Job satisfaction and burnout have been
studied in several industrial countries for
decades, but have only been investigated in
some developing countries in the past 2 decades [3,12√14]. Therefore, the phenomena
of job satisfaction and burnout in the Arab
culture remain poorly researched and the
majority of the work remains unpublished
(Y. Abu-Dahrieh, 1989; A. Abu-Ajamieh,
1991; H. Hamdan, 1993; Bolad et al., 2000,
unpublished data).
Many factors are reported to affect job
satisfaction among Arab nurses, such as
workload, incentives, job security, relationships with superiors and peers and organizational structure [3,12√14]. Burnout has been
associated with high employment turnover,
excessive absenteeism, negative job attitudes, low morale and a deterioration in idealism towards helping others [2,8,15√20].
The aim of this study was to explore the
phenomena of job satisfaction and burnout
among Palestinian nurses. We examined 2
questions: What levels of job satisfaction
and burnout do Palestinian nurses report?
191
What are the relationships between demographic variables, job satisfaction and
burnout?
Methods
A descriptive correlational study design was
used based on Maslow▓s theory of hierarchy
of needs and Herzberg▓s theory of hygienic
and motivation factors [21,22].
Sample
A random sample of 255 hospital nurses
was selected from 5 hospitals. Completed
surveys were returned from 152 participants, a response rate of 59.6%. The study
was conducted between 1 January and 31
March, 2000 at 4 private hospitals in the
Palestinian Territories (Al-Muhtasseb hospital in Hebron, Caritas hospital in Bethlehem, Augusta Victoria hospital in Jerusalem
and Al-Itihad hospital in Nablus) and 1
United Nations Relief and Works Agency
(UNRWA)-affiliated hospital in Qalqilia.
The distribution of the study sample was:
Al-Itihad, 20 nurses; Caritas, 50 nurses;
Augusta Victoria, 34 nurses; Al-Muhtasseb,
19 nurses; and Qalqilia, 29 nurses. Data on
the characteristics of non-respondents were
not available.
Data collection
Respondents completed a 3-part survey
that included a demographic questionnaire,
the Maslach burnout inventory (MBI), and
the Minnesota satisfaction questionnaire
(MSQ) [22,23]. The demographic questionnaire measured variables that included age,
sex, marital status, number of children, education, length of experience, job position,
adequacy of income, other employment and
graduate studies.
Burnout was measured using the MBI,
which comprises 3 subscales≈emotional
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
exhaustion, depersonalization and personal
accomplishment≈with 22 items and a
6-point response format. Higher scores on
the emotional exhaustion and depersonalization scales indicate more burnout, while
higher scores on the perceived accomplishment scale indicate less burnout.
The MSQ contains 100 items and measures 20 aspects of work using 20 subscales
plus 1 general satisfaction score, which
comprises 1 item from each scale. The MSQ
has a 5-point scale ranging from 1 (very dissatisfied) to 5 (very satisfied). Scores <═26
represent low satisfaction, scores 26√75
represent average satisfaction and scores
>═75 represent high satisfaction.
Ethical permission to conduct the study
was obtained from hospital directors prior
to data collection. Surveys were distributed
to the nurses while they were on the job.
Coding and aggregate reporting were used
to eliminate respondent identification and
ensure anonymity.
Data analysis
The data were analysed using the SAS, version 6.03, DOS program. Descriptive and
inferential statistics were used to analyse
responses to the surveys.
Results
Sample characteristics
The age of participants ranged from 24 to 58
years, mean 30.9 [standard deviation (SD)
7.1] years. The majority of respondents
were female (73.7%) and married (61.8%)
(Table 1). Just over 50% had nursing certificates.
No statistically significant relationships
were found between education level, job
satisfaction and burnout. Mean duration
of experience was 9.1 (SD 6.7) years. The
average respondent had been working for
5.4 years in the current position and 7.5
years in the current setting. The majority of
respondents (80.3%) worked as staff nurses,
12.5% were head nurses and 7.2% were assistant head nurses. Most (59.2%) reported
that their incomes were inadequate to meet
their needs and that they did not have any
other employment (94.7%). In this sample,
Table 1 Characteristics of the study sample of
nurses (n = 152)
Characteristic
Age (years)
20√24
25√29
30√34
35√39
> 39
Sex
Male
Female
Marital status
Married
Single
Divorced
No. of children
0
1√3
4√6
7+
Level of education
Certificate
Diploma
Bachelor
Pursuing higher education
Yes
No
Years of experience
0√3
4√6
7√9
10√13
> 13
No.
%
26
46
40
20
20
17.1
30.3
26.3
13.2
13.1
40
112
26.3
73.7
94
56
2
61.8
36.8
1.3
65
58
25
4
42.8
38.2
16.4
2.6
79
32
41
52.0
21.0
27.0
48
104
31.6
68.4
25
41
25
23
38
16.4
27.0
16.4
15.1
25.0
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
31.6% of respondents were pursuing graduate education.
Job satisfaction
Most nurses in this study (84.2%) reported
moderate job satisfaction (Table 2). Moral
values (55.9%) and social services (55.9%)
were areas of high satisfaction. Areas of
moderate satisfaction included authority
(85.5%) and responsibility (78.3%), while
advancement (41.4%) and company policies and practices (28.9) were areas of low
satisfaction. Significant differences were
found between nurses reporting adequate
and inadequate incomes on ability utilization (t = 2.41, P < 0.001), advancement (t
= 2.60, P = 0.01), company policies and
practices (t = 2.72, P <═0.01), compensation
193
(t = 3.77, P <═0.01), responsibility (t = 2.18,
P = 0.03), working conditions (t = 2.15,
P = 0.03) and general job satisfaction (t =
2.14, P = 0.03). Years of experience had
a significant effect on independence (F =
2.46, P = 0.04), while place of employment
significantly affected several aspects of job
satisfaction (Table 3). Number of children
affected security (F = 4.96, P < 0.001),
while general satisfaction was affected by
position (F = 4.16, P═<═0.001).
Burnout
When comparing burnout among nurses
from the 5 hospitals, personal accomplishment was highest among nurses in the Caritas hospital (mean score 36.9) while it was
the lowest among nurses in Al-Muhtasseb
Table 2 Distribution of the Minnesota satisfaction questionnaire scores (n = 152 nurses)
Subscale
Ability utilization
Achievement
Activity
Advancement
Authority
Company policies & practices
Compensation
Co-workers
Creativity
Independence
Moral values
Recognition
Responsibility
Security
Social services
Social status
Supervision: human relations
Supervision: technical
Variety
Working conditions
Mean score (SD)
3.75 (0.74)
3.89 (0.66)
3.97 (0.60)
2.64 (1.04)
3.46 (0.64)
2.81 (1.00)
3.01 (0.92)
3.86 (0.69)
3.44 (0.74)
3.13 (0.81)
4.04 (0.66)
3.13 (0.95)
3.31 (0.77)
3.18 (0.85)
4.14 (0.57)
3.35 (0.78)
3.23 (0.98)
3.09 (0.90)
3.15 (0.77)
3.28 (0.86)
Low
No.
%
3
2.0
3
2.0
3
2.0
63
41.4
2
1.3
44
28.9
32
21.2
3
2.0
10
6.6
18
11.8
1
0.7
25
16.4
11
7.2
22
14.5
0
0.0
14
9.2
23
15.1
25
16.4
17
11.2
16
10.5
Satisfaction
Moderate
No.
%
95
62.5
88
57.9
86
56.6
76
50.0
130
85.5
96
63.2
105
69.1
97
63.8
118
77.6
116
76.3
66
43.4
102
67.1
119
78.3
113
74.3
67
44.1
112
73.7
100
65.8
110
72.4
115
75.7
111
73.0
SD = standard deviation.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
High
No.
%
54
35.5
61
40.1
63
41.4
13
8.6
20
13.2
12
7.9
15
9.9
52
34.2
24
15.8
18
11.8
85
55.9
25
16.4
22
14.5
17
11.2
85
55.9
26
17.1
29
19.1
17
11.2
20
13.2
25
16.4
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
Table 3 Variances in job satisfaction with respect to place of employment
Subscale
Activity
Advancement
Authority
Company policies & practices
Compensation
Co-workers
Creativity
Independence
Moral values
Recognition
Responsibility
Security
Social service
Supervision: human relations
Supervision: technical
Variety
Working conditions
General
Sum of squares
86.27
504.43
172.89
544.41
357.07
186.39
147.24
386.14
120.25
490.23
352.70
399.67
174.91
891.73
522.09
339.68
410.47
153.80
(mean 27.1). Emotional exhaustion was
highest among Qalqilia nurses (mean 27.9),
while Caritas nurses had the lowest (mean
20.4). Finally, depersonalization was highest among Al-Itihad nurses (mean 7.7) and
lowest among Caritas nurses (mean═2.8).
In general, nurses in this study reported
moderate levels of burnout. They reported
mostly low levels of personal achievement (39.5%), moderate levels of emotional exhaustion (38.8%) and low levels
of depersonalization (72.4%) (Table 4). A
significant difference was found in depersonalization between nurses who reported
Square mean
21.57
126.11
43.22
136.10
89.27
46.60
36.81
96.53
30.06
122.56
63.18
99.92
43.73
222.93
130.52
84.92
102.62
38.45
F-value
2.48
5.14
4.7
6.20
4.62
4.13
2.83
6.71
2.95
6.12
4.62
6.27
6.22
11.96
7.56
6.35
6.32
5.77
P-value
0.04
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
0.02
< 0.001
0.02
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
< 0.001
adequate income and those who reported
inadequate income (t = √2.32, P = 0.02) and
between nurses who were married and those
who were divorced (F = 6.43, P < 0.001).
Discussion
It was interesting to find that participants
reported moderate levels of both job satisfaction and burnout, which is contrary to the
inverse relationship between the 2 concepts
reported in the literature [1√7,10√12,24].
It seemed that moderate burnout did not
Table 4 Distribution of Maslach burnout inventory scores (n = 152 nurses)
Subscale
Mean score (SD)
Low
Personal achievement
Emotional exhaustion
Depersonalization
34.14 (9.44)
23.48 (10.23)
5.42 (5.61)
No.
60
36
110
%
39.5
23.7
72.4
Burnout
Moderate
No.
%
42
27.6
59
38.8
28
18.4
High
No.
%
50
32.9
57
37.5
14
9.2
SD = standard deviation.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
negatively affect the level of job satisfaction among Palestinian nurses working in
private and UNRWA-affiliated hospitals.
In our study nurses in private health care
settings were satisfied with their jobs, which
confirms previous results concerning Palestinian nurses [12,25,26; Y. Abu-Dahrieh
1989; A. Abu-Ajamieh, 1991; H. Hamdan,
1993; Bolad et al., 2000, unpublished data].
These results may be attributed to structural
and functional differences between public
and private hospitals. It may be that private
and UNRWA-affiliated hospitals offer better facilities, more incentives and superior
working conditions to nurses compared with
government hospitals, which usually have
limited financial and human resources to
offer to employees. The disparity between
government and private health care settings
continues to be an issue of debate and warrants more in-depth investigation.
The nurses in our sample also reported
that many factors contributed to their job
satisfaction, such as moral values, social
services authority, responsibility and creativity, which is in agreement with previous findings [12,25,26; Y. Abu-Dahrieh
1989; A. Abu-Ajamieh, 1991; H. Hamdan,
1993; Bolad et al., 2000, unpublished data].
Conversely, nurses reported that lack of
career advancement opportunities and unsupportive hospital policies and practices
contributed to job dissatisfaction, which is
congruent with Hamdan▓s results.
The results of this study emphasize the
influence of job and individual characteristics on job satisfaction and burnout [3,6,20].
The study results support Herzberg▓s and
Maslow▓s theories [21,22] which identified
recognition, achievement, the nature of the
work, responsibility and advancement as
characteristics that are strong determinants
of job satisfaction and burnout.
Moderate emotional exhaustion reported
by nurses in this sample is congruent with
195
results of previous research [2√7,20]. Obviously, individual differences between the 5
hospitals were detected in this study, which
supports the idea that different policies and
practices can affect burnout levels. Moderate
emotional exhaustion among study participants, who were mostly young adults aged
25√29 years and had been on the job for an
average of 9 years, supports the notion that
burnout is a ⌠global■ nursing phenomenon
that results from stress and work overload in
everyday practice [3√7,14,20].
Participants also reported low levels of
personal achievement and depersonalization. Perhaps the feeling of low personal
achievement was the motive for pursuing
higher education in one-third of the sample.
Furthermore, low depersonalization in this
sample may have contributed to a moderate
sense of job satisfaction. Nurses viewed their
relationships with their clients as positive
ones that nurtured mutual care and concern,
especially under harsh social and political
circumstances. They felt that they were significant contributors to the health and wellbeing of the Palestinian people, who live in
daily turmoil. Moreover, it was not surprising to find that the nurses who reported
inadequate incomes and were divorced felt
more depersonalized. This finding attests to
the influence of social norms and peer pressure in the Arab culture, which emphasizes
marriage and the ability to provide for the
family financially as key social standards.
Implications
Health care administrators, especially nursing administrators, should consider the factors that contribute to job dissatisfaction
and burnout and try to eliminate them by
designing and implementing supportive
policies and practices. A focus on meeting
the personal and professional needs of the
nursing cadre is paramount if quality health
care services are to continue.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
196
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
A third aspect that needs to be addressed
is increasing continuing education programmes for nurses, especially programmes
that deal with stress and anger management,
enhance coping mechanisms, enhance personal skills and accomplishments, and update knowledge. Finally, more research is
needed to extend the understanding of how
the current political events and changing
trends in health care affect the levels of job
satisfaction and burnout among nurses in
different settings.
Conclusion
Job satisfaction and burnout are clearly
identified as problems in the area of human
services that need to be addressed. Nevertheless, most researchers and practitioners
believe that job satisfaction can be optimized and burnout minimized to enhance
the quality of services to clients [10,11,24].
The results of this study should also be
viewed in the context of the turbulent social,
economic and political circumstances that
prevail over the Middle East, and Palestine
in particular. These circumstances can easily exacerbate the situation and can contribute to burnout and job dissatisfaction among
all health care professionals. However, our
findings do indicate that, despite hardships
and turmoil, there are professionals who
can benefit from the positive aspects of
their profession, such as finding strength in
their moral values, being content with the
amount of professional responsibility they
assume on a daily basis, having good relationships with their peers and superiors and
finding their salary adequate to meet their
living expenses and needs.
Acknowledgements
Our gratitude and thanks go to the University of Bethlehem for funding this research
project through the internal research grant
systemand to Mrs Hala Marzouka for the
considerable work she did as part of the
research project.
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
198
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?Дыяи Дгчои ЦАчяягй гААши гАзяхМи ъемоЛ ЦьАФхгй гАйзАМЦ?
?гАзгМА Мщ ъАМгй гАзАФЦ гАумМи хлгЦзи глАрМяи?
2
? зЦя гАсМо гАьМх гАзхгс?║1? сЦяМи мгЦо зхо гАяЦмД?║1?цЦмо зхо гЕАА мЦЦогМД?
?Мояс мгАМ Пг Мщ ъАМи гАьх хлгЦзи?
ЬС ? чгЦ гАхгмкФД Мщ ЕпЕ гАоягси хЦчгяДи Цчяя гААши гАзяхМи гАпМ?:?гнАгАуи?
?хйчу бяга гАьгАх Фцсгйпи гААши гАзяхМи Мщ ъАМгй гАзАФЦ гАумМи мФА?
ЬЖ? ъгЦ чгЦФг М?.?глАрМяи Цз гЦАчяягй гАсгхчи?
? ФъМщ цсЕЦй ЕпЕ гАьяч Мщ гсйМзгх гАьгАх ЦАчяягй гАзАФЦ?║?мЦйФЛ гЦАчяягй Фьяч гАйояМс ФгАйчМэМЦ?
? Фчо?.? Цз гАяйъМр зЛА гААши гАзАЦМи?║? Фчо Уу ЖЬЦЦ гЦАчяя гмАгМА Ехощ йрФМо гАьгАх хЦЕгягй гААши гАзяхМи?.?гАьхМи?
? ФъпАъ Мщ Цг МйзАч хщгфои?║?йщгФйй бяга гАьгАх Мщ Цг МйзАч хщЕЦЕЦ ААьх гАясМяМ ФйщгзАЕЦ Цз гЦАяЛж?
║? ФМяЛ гцАсгйпи цД гЦАчяягй ЦДгсхи АцАшягж гАйМ Фжзй ЦД цлАЕг?.?елягагй гАхмк ФгАйхАМш хгАДсхи ЕАЦ?
.?ФцъоФг Цз пАъ цЦЕМи йДФМз ьяч гАйояМс ФгАйчМэМЦ?
A critical view of Arabic curriculum as a requirement for medical schools, Gezira University
ABSTRACT We compared the present Arabic syllabus used in Gezira University Medical School with
previous ones. We also surveyed students and Arabic professors in medical sciences on their views on
the content and teaching/evaluation procedures and how these contributed to students▓ understanding
of the medical science syllabus. The current syllabus was designed to provide students with Arabic
language skills with particular reference to scientific language. The students▓ opinions differed regarding
their understanding of clinical medicine and their interaction with patients and also the benefits to them
of research procedures and reporting. The professors considered the syllabus was adequate to achieve
its aims but emphasized the importance of varying teaching methods and evaluation.
Regard critique sur le programme d▓Иtudes en arabe obligatoire dans les Иcoles de mИdecine
de l▓UniversitИ de Gezira
R?SUM? Nous avons comparИ le programme d▓Иtudes en arabe actuellement appliquИ dans les
Иcoles de mИdecine de l▓UniversitИ de Gezira avec les prИcИdents. Nous avons Иgalement demandИ
aux Иtudiants et aux professeurs de mИdecine en langue arabe comment ils percevaient le contenu
et les procИdures d▓enseignement et d▓Иvaluation, et comment ceux-ci permettaient aux Иtudiants de
mieux comprendre le programme de sciences mИdicales. L▓objectif du programme en vigueur Иtait
de permettre aux Иtudiants d▓acquИrir des compИtences axИes sur le langage scientifique en langue
arabe. Les Иtudiants ne partageaient pas tous les mЙmes opinions quant Ю leur comprИhension de la
mИdecine clinique et leur relation avec les patients, et aussi quant aux avantages que reprИsentent pour
eux les procИdures et la communication en matiХre de recherche. Les professeurs considИraient que le
programme remplissait correctement son objectif mais soulignaient l▓importance de varier les mИthodes
d▓enseignement et les mИcanismes d▓Иvaluation.
.)a_mohamedani@hotmail.com :? гАсФогД (ЦягсгАй еЛА цЦмо зхогЕАА мЦЦогМД?║? Фго ЦоМД?║? лгЦзи глАрМяи?║? ъАМи гАьх?║?зАФЦ гЦАнйяхгй гАьхМи?
2
? гАсФогД?║? Фго ЦоМД?║? лгЦзи глАрМяи?║?ъАМи гАяйхМи?
06/11/15 :? гАчхФА?║06/09/11 :?ггАсйгАЦ?
1
A.A. Mohamedani & S.H. Abdul Rahman, Medical Laboratory Sciences; O.S.T. Al-Abbass, College of Education, Faculty of
Medicine, El Gezira University, Wad Medani, Sudan.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
??199??
??Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009??
?гЦАчоЦи?
?гА нМщМ зЛА цмо цЦЕМи гААши гАчФЦМи Мщ йояМс гАзАФЦ хъА цДФгзЕг? .?щЕМ шгАх Пг Цг йъФД Аши гцАЦ ФйонА?
?Мщ ФлогД цьщгЕАг ЦДп ФгАоЕйЦ? .?ФЕЛ цМж Пг гААши гЦАсйзЦАи Мщ гЦАлйЦз зДоЦг Мтх гцАьщгА зД гАьФч?.??
?ФАъДДг Дло цД ЕпЕ гААши Мщ ЦзыЦ гцАмМгД йъФД згЦМи огяли? .?ФхонФА гАьщА Мщ гАйзАМЦ гАДыгЦМ Мхоц?
?Мщ оягси гААши ФМйзАЦ щДФЕДг хгАйояМл мйЛ МъЦА йзАМЦЕ гАзгЦ? ║?ФЦД кЦ МДйчА еЛА гЦАямАи глАгЦзМи?.??
?ФЕДг МФглЕ хцмо гмйгЦАДМ еЦг цД йъФД гАоягси хАшйЕ гАчФЦМи ФеЦг хАши цлДхМи ФЕМ Мщ ЦзыЦ гцАмМгД?
?геАДъАМрМи цФ гАщяДсМи ? -?ФЕпг гАФжз ЦйАМЕ ыяФщ ъкяМи цЦЕЕг ДФз ггАсйзгЦя гАпМ ъгД Мщ хгАоЕ?.??
?Фчо АФмы Мщ гАсДФгй гцАняМи жзщ гАьгАх Мщ гААшгй зЦФЦ Пг хгЦ Мщ пАъ гААши гАзяхМи? .?Апг?
?ФЦДп ЦьАз йсзМДгй гАчяД гЦАгМж йчяя йояМс гААши гАзяхМи Мщ глАгЦзгй гАсФогДМи ъцмо ЦьАФхгй?
?Фргяи гАйзАМЦ гАзгМА? ║?нгуи хзо уоФя чягя йзяМх гАоягси? .?Фчо йхДй лгЦзгй ъкяМи чягя гАйзяМх?
?Мщ ЦзыЦ ъАМгЕйг хгсйкДга ъАМгй гАзАФЦ гАумМи? ║?нгуи ъАМгй гАьх? .?ФъгДй лгЦзи глАрМяи хмЦо?
?гЕАА ЦД глАгЦзгй гАчАМАи Мщ гАсФогД гАйМ Дщпй чягя гАйзяМх Мщ ЦлМз ъАМгЕйг хгЦ Мщ пАъ ъАМгй гАзАФЦ?
?гАумМи? .?Мщ гАхогМи ЦА лйо Цчяягй гААши гАзяхМи гмАгЦс ФгАчхФА гЦАДгсхДМ Фсь цзого ъхяМи ЦД гАьгАх?
?ФгцАсгйпи? ║?Апг зчой зои Ачгагй зЦА Аоягси Епг гцАЦя Дйл зДЕг йьФМя Цчяягй гААши гАзяхМи АйдоМ?
?гцАЕогщ гЦАДтФои ЦДЕг? .?ФМсйзяж гАхгмкФД Мщ ЕпЕ гАФячи бяга ьгАх ъАМгй гАзАФЦ гАумМи ФъпАъ?
?бяга цсгйпи Цчяягй гААши гАзяхМи Мщ ЕпЕ гЦАчяягй ФЦоЛ мйчМчЕг АйАъ гцАЕогщ?.?зА ПгЦ хцЕДЦ чо ФкэЬчФг?
?лйяхи гАйзяМх ФцкяЕг зЛА гАьгАх Мщ ъАМгй гАзАФЦ гАумМи хлгЦзи глАрМяи [?.]5,1??
?цЕогщ гАоягси?
?? .1?Фущ Цчяягй гААши гАзяхМи гмАгАМи ФЦчгяДйЕг Цз гЦАчяягй гАсгхчи?.??
?? .2?мйоМо бяга гАьгАх Мщ Цчяягй гААши гАзяхМи ЦД мМк гЦАжЦФД Фьяч гАйояМс ФгАйчФМЦ ФЦоЛ?
? ЦсгЦЕйЕг Мщ гсйМзгЕхЦ ЦАДгЕл гАзАФЦ гАумМи ФгАьхМи?.??
?? .3?гсйьгАз бяга гцАсгйпи гАпМД МояЖЬ сФД Цчяягй гААши гАзяхМи АьгАх гАзАФЦ гАумМи ФгАьхМи мФА?
? гЦАчяягй гмАгАМи ФЦйьАхгй йьФМяЕг?.??
?ЦДЕлМи гАоягси?
?ЦъгД гАоягси ъАМгй гАзАФЦ гАумМи ФгАьхМи хлгЦзи глАрМяи? ║?ФЕМ мсх гцАчоЦМи ъгбАМй?:??
? ъАМи гАьх (?1975?Ц)?.??? ъАМи гАуМоАи (?1996?Ц)?.???? -?ъАМи гАзАФЦ гАьхМи гАйьхМчМи (?1997?Ц)?
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
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? ъАМи зАФЦ гЦАнйяхгй гАьхМи (?1998?Ц)?.???? -?ъАМи ьх гцАсДгД (?2000?Ц)?.??
?еьгя гАоягси?
?гАощзи ? 25?ЦД ъА ъАМи ФгАйМ цъЦАй Цчяягй гААши гАзяхМи гмАгАМи ФгЦАчяягй гАьхМи ФгАумМи гЦАйнууи?
?мсх гАъАМи?( ║?гАзоо гАъМА ? 340?ьгАх)?.??
?млЦ гАзМДи ФьяМчи гАзМДи?
?йЦ гзйхгя гАьгАх Мщ гАощзи ? 25?ЦД ъА ъАМи ъзДчФо ЦсйчА? ║?ФйЦ гнйМгя ? 25?ьгАх Пг хгАьяМчи гАзтФгфМи?
?гАхсМьи ЦД ъА зДчФо?.??
?ьяч Цлз гЦАзАФЦгй?
?г УЬйхЖзС Зй гАьяч гАйгАМи Мщ Цлз гЦАзАФЦгй?:??
?? .1?Цяглзи ФмйАМА ъйМхгй Цчяягй гААши гАзяхМи (гАсгхчи ФгмАгАМи) ФпАъ хшяж мйоМо гАйьФя гАпМ?
? йЦСЬ ЦД мМк гЦАмйФМгй Фьяч гАйояМс ФгАйчМэМЦ?.??
?? .2?Цлз гЦАзАФЦгй ЦД гАьгАх зД ьяМч гсйгЦяи уЦЦй хмМк йсгзо зЛА мйчМч цЕогщ гАоягси?.??
?? .3?еляга ЦчгхгАй Цз цсгйпи Цчяягй гААши гАзяхМи гЦАзДМДМ мгАМ Пг хйояМс ьгАх ъАМгй гАзАФЦ?
? гАумМи ФгАьхМи (зооЕЦ ?.)5??
?гАДйгфл ФгЦАДгчти?
?гЦАДгЕл гАсгхчи?
?йЦ Фжз ЦДЕл гААши гАзяхМи (? 16?сгзи ЦзйЦои) ЕАпЕ гАъАМгй Мщ гАзгЦ гАоягМс ?1991/1990?Ц Мщ гАщуФА?
?гАоягсМи гцАФЛА? ║?ФпАъ АймчМч ЕощДМ цсгсДМ ФЦЕг Еощ згЦ ФЕощ нгу цФ ФыМщМ?:??
?(ц) гЕАощ гАзгЦ?
?? .1?яхь гАьгАх хгААши гАзяхМи гАщумЛ ФйягкЕг ФДйглЕг гАщъяМ ФгАзАЦМ?.??
?? .2?ящз ъщгаи гАьгАх Мщ гААши гАзяхМи ЦД мМк щчЕЕг ФгАйнгьх ФгАъйгхи Ехг хЦсйФЛ лМо?.??
?? .3?еъсгх гАьгАх гЦАЕгяи Мщ йФыМщ гААши гАзяхМи Мщ гЦАзгящ гЦАнйАщи ФйпФчЕ ААДФгмМ глАгЦАМи Мщ?
? гАДуФу гААшФМи?.??
?? .4?йрФМо гАьгАх хгЦАЕгягй гААшФМи гЦАйчоЦи АйзМДЕ зЛА щЕЦ Цг МйАчгЕ ЦД зАФЦ ФЦзгящ? ║?ФЦйъЖЬ ДЕ ЦД?
? гАйзхяМ гАсАМЦ?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
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?(х) гцАЕогщ гнАгуи?
?? .1?Цсгзои ьгАх гАчьгз гАьхМ зЛА гсйМзгх ЦФго нйуугЕйЦ ФгАйзхяМ зДЕг хАши сАМЦи?.??
?? .2?йчФМЦ гААсгД ФгАчАЦ ЦД гцАньга гАтгфзи Мщ гАъйгхи ФгнАьгхи? ║?ФпАъ хйояМхЕЦ зЛА геАЦгАа?
?гЦАФгщч ААчФгзо ФгцАуФА гАщДМи? ║?ФггАяйчга хЦАъгЕйЦ Мщ Дьч гмАяФщ ЦД нЦгялЕг гАумМми?.??
?? .3?йясМн гЦАуьАм гАзАЦМ ФЦхгоф гАяйЦли гАзАЦМи?.??
?ФмйчМч Пг ЕАпЕ гцАЕогщ лгай Цщяогй гЦАДЕл хуФяи йщМ хмгли гАьгАх Мщ гАъАМгй гЦАзДМи? ║?хмМк?
?МсйьМз ЦД нгАЕАг щЕЦ Цг МйАчгЕ ЦД ДуФу ЦФгоЕ гАзАЦМи ФАйлФМо цогфЕ гАъйгМх ЦАчгхАи ЦйьАхгй елгхи?
?ггАЦймгД Фъйгхи гАйчгяМя ФгАхмФк гАзАЦМи? ║?ФъпАъ АйлФМо цогфЕ гАтщФМ АМйЦъД ЦД гмАоМк хьгАчи?
?гА цФ лЦМх Пг цФ Дгчо Пг цФ мЦгяжгП?.??
?Мщ гЦАмгщА гцАъгоМЦМи сгф П?
?ФъгДй Цщяогй гЦАДгЕл зЛА гАДмФ гАйгМА?:??
?? .1?Цщяогй гАщуАДМ гцАФА ФгАкгМД? ║?яФзМ щМЕг цД Мъйсх гАьгАх гЦАЕгягй гцАсгсМи ААши ъгАчягаи?
?ФггАсйгЦз ФгАйъАЦ? ║?мМк лгай гЦАщяои ААщуА гцАФА йзДЛ хгцАуФгй гААшФМи Дьч Пг ФлйФМо Пг?
?ФпАъ хгАяйъМр зЛА гАхДМи гАйятмММи цАлрга гАДьч ФнЦгял гмАяФщ? .?Флгай гЦАщяои ААщуА гАкгМД?
?ФЕМ йзДЛ хйлФМо гцАога гАъйгМх хйояМх гАьгАх зЛА геАЦгАа гЦАФгщч ААчФгзо ФгцАуФА гАщДМи?
? мйЛ МйЦъД ЦД гАъйгхи гАумМми оФД мАД цФ цньга?.??
?? .2?Цщяогй гАщуА гАкгАк? :?йзДЛ хгАогяси гАйьхМчМи? ║?щгАщуА гАкгАк МзДЛ хьягфч ъйгхи гАйчгяМя?
? гАзАЦМи Цз гсйзягж хзж гАДуФу пгй гАуАи хгАчьгз гАумМ ФгАьхМ?.??
?? .3?цЦг гАщуА гАягхз ФгцАняМ щлга еАзого гАьгАх гАсйМзгх ЦДЕл гАхмк гАзАЦМ Мщ ъАМгй гАчьгз?
?гАумМ ФгАьхМ мМк лгай Цщяогй Епг гЦАДЕл йзДЛ хжФгхь гАяйЦли Фъйгхи гАхмк гАзАЦМ Мщ?
? лЦггАй гАзАФЦ гАумМи ФгАьхМи?.??
?гсйЦя йДщМп Епг гЦАДЕл ЦАои зят сДФгй? ║?Епг Фчо Фло гАйояМс хгААши гАзяхМи Мщ ъАМгй гАчьгз?
?гАьхМ лйгФх Пг ъхяМг ЦД гАьгАх ФгцАсгйпи? .?ФАзА ггАсйхгДи гАйМ цляМДгЕг ЦД чхА зЛА зМДи ЦД ьгАх?
?Епг гАчьгз оАМА Фгжм еЛА Цг пЕхДг еАМЕ [? .]6,3?ФхгЦ цД ДыгЦ гЦАДгЕл хлгЦзи глАрМяи нМжз ААйчФМЦ?
?гЦАсйЦя ЦД чхА гААлгД гЦАйнууи зЛА ДмФ Цг яцМДг? ║?щчо зУ чЖоС Зй мАчи зЦАМи (Фяти зЦА) Мщ цФгфА?
?згЦ ?2000?Ц гтяйъ щМЕг АщМщ ЦД цсгйпи гААши гАзяхМи Фцсгйпи гАчьгз гАьхМ? .?ФъгД ЦД Дйгфл ЕпЕ гмААчи?
?Сй гЦАчяягй гцАяхзи ФцонАй зАМЕг гАйзоМгАй гАйМ цФуй Ехг гмААчи гАзЦАМи ФМщ Цг ММА?
?гАзЦАМи цД зУ оЖЬ А З?
?гсйзягж ЕАпЕ гЦАчяягй?:??
?гсЦ гЦАчяя? :?гЦАЕгягй гААшФМи?
?цЕогщ гЦАчяя?
? ейчгД гАъйгхи ФгАйзхяМ??? -?гсйногЦ гААши?
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009??
? гАчояи зЛА йогяъ гцАньга?? гАчояи зЛА гАъйгхи ФгАйзхяМ?? гсйногЦ гААши гсйногЦ Сг умМм Сг лЦФо Сг МФыщЕ Мщ мМгйЕ гАоягсМи ФгАзЦАМи?? ъйгхи гАясгфА ФгАйчгяМя ФгЦАчггАй? ║?ФеАчга гнАьх ФгЦАмгяжгй? ║?Феогяи гАДоФгй ФмАчгй?? гАДчгт?...?гАн?.??
?Цщяогй гЦАчяя?
?? .1?зДгяу ггАйугА гААшФМ?:??
? (ц) гАъгАЦ (х) ггАсйгЦз (л) гАчягаи (о) гАъйгхи?
?? .2?жФгхь гАясЦ гАъйгМх?:??
?(ц) гАйпъяМ хгАчФгзо гцАсгсМи АеАЦгАа (х) згАЦгй гАяйчМЦ (л) гЦАнйяугй ФяЦФрЕг гАъйгхМи?
? (о) Цъйхи геАЦгАа (Еэ) гАйьхМч гАзЦМА?
?? .3?оягси гцАуФгй гААшФМи гАзяхМи нЦгялЕг ФущгЕйг?.??
?? .4?оягси йяъМх гАъАгЦй ФхДгфЕг гАяуМщ?.??
?? .5?глАЦАи йзяМщЕг? ║?ятФьЕг? ║?хДгдЕг ФцДФгзЕг?.??
?? .6?гАщчяи? :?йзяМщЕг? ║?ятФьЕг ФхДгдЕг?.??
?? .7?хзж гцАньга гАтгфзи Мщ гцАуФгй ФгАъАгЦй ФйяъМх глАЦА?.??
?гсЦ гЦАчяя? :?гАъйгхи ФщДФД гАйзхяМ?
?цЕогщ гЦАчяя?
?? .1?елгои гАьгАх шяМ гЦАйнуу ААши гАзяхМи ЦД мМк гАйФгуА ФгАйнгьх ФгАъйгхи?.??
?? .2?йАхМи мгли гАьгАх шяМ гЦАйнуу еЛА йумМм щЕЦЕ ЦАг МйАчгЕ ЦД ДуФу ЦФгоЕ гАзАЦМи?.??
?? .3?лйФМо гцАога гААшФМ гАтщФМ АйЦъДМ гАьгАх ЦД гмАоМк Мщ гЦАмгщА гАзАЦМи хзяхМи щумЛ?
? ФмйсДМ чояйЕ Мщ гАйщъяМ ФгАщЕЦ гАсАМЦ хАши зяхМи?.??
?? .4?ЦйъДМ гАьгАх ЦД гАйзхяМ Фъйгхи гАйчгяМя ФгЦАчггАй ФгАхмФк?.??
?Цщяогй гЦАчяя?
? ДтцЕйг ФЦщЕФЦЕг ФщАсщйЕг ? -?Фыгфщ гААши (ггАйугА? ║?гЦАзДЛ ФгАйзхяМ)?.???? -?Дтци гАъйгхи гнАьМи ФйьФя гнАь гАзяМх?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??202??
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?Дтци гАъйгхи гАщДМи?
?(ц) гАДкя ФцДФгзЕ (Дкя згоМ? ║?Дкя зАЦМ? ║?Дкя щДМ)?
?? .1?гАДкя гАзгоМ?( :?ъйгхи гАйчгяМя ФуМгшйЕг)?
? цДФгз гАйчгяМя (йчяМя гцАога ? -?йчяМя Цлз гмАчгфч ? -?гАйчяМя гАщДМ)?? ЦФгущгй гАйчяМя ФЦъФДгйЕ?.???? .2?гАДкя гАзАЦМ?
?зДгяу гАъйгхи гАзАЦМи (еогяМи? ║?ЕДосМи?... ║?гАн)?.??
?? .3?гАДкя гАщДМ (гАйзхяМ)?:??
? ущгй гАъйгхи глАМои (гАФмои цФ гАйлгДс) нйяМ гцААщгы?.??? еьгя гАъйгхи (гАщгмйи цФ гЦАчоЦи? ║?гАФсь ФгАшяж? ║?гнАгЦйи)?.???? -?зДгяу гАъйгхи (гАщъя? ║?гАзгьщи? ║?гцАсАФх ФгнАМгА)?.??
?гсЦ гЦАчяя? :?гЦАзглЦ ФгЦАуьАмгй?
?цЕогщ гЦАчяя?
?? .1?йзяМщ гАьгАх хцДФгз гЦАзглЦ Фьяч гсйногЦЕг?.??
?? .2?еьгАз гАьгАх зЛА глАЕФо гАйМ хпАй Мщ йзяМх гЦАуьАмгй Фьяч уМгшйЕг?.??
?? .3?ЦйъДМ гАьгАх ЦД цсс Фжз гЦАуьАм гАзАЦМ?.??
?? .4?йзяМщ гАьгАх нугфу гААши гАзяхМи ФЦДЕлЕг Мщ гАйФАМо ФггАтйчгч ФгАйлоМо ФЦзящи лпФя?
? гАъАгЦй?.??
?? .5?ЦйъДМ гАьгАх ЦД гсйногЦ гЦАФсФзгй гАзАЦМи?.??
?гЦАщяогй?
? гАйзяМщ хгЦАзглЦ ФФыгфщЕг? ║?цДФгз гЦАзглЦ? ║?ьяч гсйногЦЕг?.??? йьФя гАйцАМщ гЦАзлЦМ ФсгЦй Епг гАйьФя ? -?гАщяФч хДМ гЦАзглЦ гмАоМки ФгАчоМЦи?.??? уМгши гЦАуьАм?.??? гАйзяМх ФлЕФо гАДмги Мщ енжгз гЦАзях ААуМш гАзяхМи?.??? ЦсяМи гЦАуьАм гАзАЦМ?.???? -?ЦзглЦ ЦуьАмгй гАзАФЦ Мщ ъйх гАяйгк гАзяМх?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
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? ьяч Фжз гЦАуьАм?.???? -?лЕФо гЦАлгЦз гАзАЦМи Мщ гЦАуьАм? ║?йФмМо гЦАуьАм гАзАЦМ гАзяМх?.??
?гсЦ гЦАчяя? :?ДуФу йьхМчМи?
?гцАЕогщ?
?? .1?ЦйъДМ гАьгАх ЦД чягаи хзж гАДуФу гААшФМи гАйьхМчМи гЦАйуАи хйнууЕ Мщ гАшгАх?.??
?? .2?йзФМоЕ зЛА еЦъгДМи езого гЦАгои гАзАЦМи хДщсЕ ЦсйщМо Сг ЦД оягсйЕ Мщ гЦАчяягй гААшФМи гцАняЛ?.??
?гЦАщяогй?
?нййгя гАДуФу ЦД хДМ ЦлАи ДуФу Цзои Цсхч Сг хмМк йДгсх нйуу гАьгАх?.??
?Дйгфл гсйхМгД гАьгАх?
?гсйМзгх гАзАФЦ гАьхМи ФгАумМи?
?цъкя гАьгАх гсйщгои (лМо еЛА ЦЦйгр) ЦД Цчяягй гААши гАзяхМи Мщ гсйМзгх гАзАФЦ гцАсгсМи ЕЦ ьгАх?
?ъАМи гАзАФЦ гАьхМи гАйьхМчМи (? )%70.5?МАМЕЦ ьгАх ъАМи ьх гцАсДгД (? )%40?ФцняМ Пг ьгАх ъАМи гАьх?
?(?.)%16??
?цЦг гАзАФЦ гАясМяМи (геАъАМДМъМи) щчо йоДй ггАсйщгои ЦД Цчяягй гААши гАзяхМи?║??
?хуФяи згЦи? ║?Мщ гсйМзгЕхг? .?ФъгД ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи ЕЦ цМжг цъях гЦАсйщМоМД?
?( ? )%58.8?ФцоДгЕЦ ьгАх ъАМи зАФЦ гЦАнйяхгй ( ? .)%13.1?хгАДсхи ААзАФЦ ггАлйгЦзМи гАсАФъМи?
?щчо ъгД оФя Цчяягй гААши гАзяхМи хгяр Пг АоЛ ьгАх ъАМи зАФЦ гЦАнйяхгй гАьхМи?
?(? )%76.3?МАМЕЦ ьгАх ъАМи ьх гцАсДгД (?.)%65??
?гАйФгуА Цз гцАья гАумМи? ║?ФгЦАяЛж ФпФЕМЦ Фцщяго гЦАлйЦз?
?мчч ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи цзЛА Дсхи ЦД ггАсйщгои ЦД Цчяягй гААши гАзяхМи Мщ гАйФгуА?
?Цз ЦлМз гАщфгй гЦАпъФяи зЛА гАйФгМА? :?гцАья гАумМи (? )%64.6?гЦАяЛж ФпФЕМЦ (? ║)%73.5?цщяго гЦАлйЦз?
?(?.)%75.8??
?ФйФгЛА ьгАх гАъАМгй гЦАйхчМи хгАДсхи ААйФгуА Цз гцАья гАумМи гЦАнйАщи ъгЦ ММА? :?ьх гцАсДгД?
?(? )%50?зАФЦ гЦАнйяхгй гАьхМи (? ║)%21.5?ъАМи гАьх (? )%16?ФгАуМоАи (?.)%14.1??
?хгАДсхи ААЦчояи зЛА гАйФгуА Цз гЦАяЛж ФпФЕМЦ Мщ гЦАдссгй гАумМи щчо йоялй гсйщгои?
?ьгАх гАъАМгй гЦАнйАщи хзо ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи ъгЦ ММА? :?ьх гцАсДгД (? )%40?ъАМи гАьх?
?(? ║)%32?ъАМи гАуМоАи (? )%18.8?ФцняМ Пг ъАМи зАФЦ гЦАнйяхгй (?.)%8.6??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??205??
??Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009??
?лга йяйМх ъАМи ьх гцАсДгД Мщ гЦАяйхи гАкгДМи цМжг хгАДсхи еЛА гсйщгои ьгАЕхг ЦД Цчяягй гААши?
?гАзяхМи Мщ ЦчояЕйЦ зЛА гАйФгуА Цз цщяго гЦАлйЦз мМк хАшй Дсхи гАьгАх гАпМД чМЦФг ЕпЕ ггАсйщгои?
?(лМо ? -?ЦЦйгр) ? ║%60?йАйЕг ъАМи гАуМоАи (? ║)%37.6?щъАМи гАьх (? )%32?ФцняМ Пг ъАМи зАФЦ гЦАнйяхгй?
?гАьхМи (?.)%30.1??
?еляга гАхмФк?
?цчя ? %87?ЦД ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи хгсйщгоЕйЦ хояли (лМои ? -?ЦЦйгри) ЦД Цчяягй гААши?
?гАзяхМи Мщ еляга гАхмФк? ║?йгАЕЦ ьгАх ъАМи ьх гцАсДгД (? ║)%50?кЦ ъАМи гАуМоАи (? )%23.3?йАМЕг ъАМи?
?гАьх (? )%16?ФцняМг ъАМи зАФЦ гЦАнйяхгй гАьхМи (?.)%8.6??
?ъйгхи гАйчгяМя?
?ъгДй гсйщгои ьгАх гАъАМгй гЦАнйАщи ъгЦ ММА? :?ъАМи гАзАФЦ гАьхМи гАйьхМчМи (? ║)%52.2?ьх гцАсДгД?
?(? ║)%40?гАьх (? ║)%20?зАФЦ гЦАнйяхгй гАьхМи (? )%12.9?ФцняМ Пг ъАМи гАуМоАи (?.)%4.7??
?йчоМЦ гАДоФгй?
?ъгД ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи Мщ гЦАяйхи гцАФЛА ЦД мМк гсйщгоЕйЦ ЦД Цчяягй гААши гАзяхМи Мщ?
?йчоМЦ гАДоФгй (? ║)%75.4?йгАЕЦ ьгАх ъАМи ьх гцАсДгД (? )%60?кЦ ъАМи гАьх (? ║)%20?МАМЕЦ ьгАх?
?ъАМи гАуМоАи (? )%18.8?кЦ ьгАх ъАМи зАФЦ гЦАнйяхгй гАьхМи (?.)%17.2??
?гсйногЦ гЦАъйхгй?
?ъгДй цзЛА Дсхи гсйщгои ЦД Цчяягй гААши гАзяхМи Мщ гсйногЦ гЦАъйхи хДМ ьгАх ъАМи гАзАФЦ гАьхМи гАйьхМчМи?
?(? ║)%81.4?МАМЕЦ ьгАх ъАМи ьх гцАсДгД (? )%40?кЦ ьгАх ъАМи зАФЦ гЦАнйяхгй гАьхМи (?.)%21.5??
?цЦг хгАДсхи ААЦъйхи геААъяйФДМи щеД ггАсйщгои ЦД Цчяягй гААши гАзяхМи ъгДй зЦФЦ Пг ЦйоДМи Флга?
?йяйМх ьгАх гАъАМгй гЦАнйАщи Мщ ггАсйщгои ЦДЕг ъгЦ ММА? :?ьх гцАсДгД (? ║)%35?гАзАФЦ гАьхМи гАйьхМчМи?
?(? )%17.8?ъАМи гАуМоАи (? ║)%9.4?ъАМи гАьх (?.)%4??
?МЦъД йАнМу бяга гАьгАх мФА гЦАтгъА гЦАйзАчи ЕхпЕ гЦАчяягй щМгЦ ММА?:??
? еяугя ъкяМ ЦД цсгйпи гЦАчяягй гАйнууМи Мщ гАщуФА гАоягсМи гЦАйчоЦи зЛА гАйояМс?? ФгЦймгД гАьгАх хгААши геАДъАМрМи?.??
? чАи емсгсЕЦ хЦгАаЦи гЦАчяягй Цз гЦАчяягй гАьхМи ФгАумМи ФчАи гяйхгь Цчяягй гААши??гАзяхМи Цз гЦАчяягй гЦАйнууи ФЦФгъхйЕг ААйьФя Мщ ЕпЕ гАзАФЦ? ║?ежгщи еЛА гАДчу гАтоМо Мщ?
? гЦАяглз гАзяхМи?.??
? йчММЦ гАьгАх МйЦ мгАМг хФгсьи цсйгп Фгмо ЕФ Цояс гЦАгои? ║?ФгцАщжА цД Мояс цМ Цчяя?? хФгсьи цъкя ЦД цсйгп ФцД МйЦ йчММЦ гАьгАх хФгсьи цъкя ЦД цсйгп ъпАъ?.??
? ьяч гАйзАМЦ ФгАйзАЦ гЦАсйноЦи мгАМ Пг чАМАи гАймщМр ААьгАх хгзйгЦоЕг хуФяи ъхяМи зЛА??гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
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??206??
? гЦАмгяжгй ФггАЦймгДгй гАймяМяМи?.??
?? -?цФчгй гАйояМс (Мщ гАщяйгй гЦАсгфМи) шяМ ЦДгсхи?.??
?бяга цсгйпи гААши гАзяхМи?
?Цчяягй гААши гАзяхМи гАсгхчи?
?гЦАчяя гцАФА? :?мМйФЛ зЛА ДмФ Фяущ МоясгД хьяч йчАМоМи? .?гА йояСЬ с цМ ЦЕгягй?
?гЦАчяя гАкгМД? :?нгу хгАйзхяМ ФъгД зхгяи зД ясо йгянММ?.??
?гЦАчяя гАкгАк? :?нгу хгЦАзглЦ ФгА мМйФЛ зЛА цсгсМгй гАяйЦли ФгАйзяМх?.??
?гЦАчяя гАягхз? :?нгу хгАДуФу гцАохМи гАхмйи?.??
?Цчяягй гААши гАзяхМи гмАгАМи?
?хоц йьхМч гЦАчяягй глАоМои хзо йьФМяЕг АьгАх гАощзи (? .)23?Фчо Цйй ггАсйзгДи Мщ ФжзЕг хЦДгЕл?
?гААши гАзяхМи Мщ хзж глАгЦзгй гАсФогДМи Фхбяга гнАяхга гАсФогДМДМ гЦАнйуДМ ЦД лгЦзи глАрМяи ФйАъ?
?глАгЦзгй? .?йчАу зоо гАсгзгй гЦАзйЦои еЛА ? 8?сгзгй?.??
?мЦйФМгй гЦАчяягй?
?гЦАмйФМгй гмАгАМи ААЦчяя ъгщМи мсх гцАЕогщ гЦАзАДи АйАъ гЦАчяягй? ║?Фчо йЦ гнйМгяЕг хзДгМи Айсгзо?
?гАьгАх Мщ гсйМзгх гЦАчяягй гЦАйнууи (Цчяягй гАзАФЦ гАьхМи ФгАумМи) зДо йояМсЕг хгААши гАзяхМи?
?оз ПгЦ АсМгси гАйзяМх хглАгЦзи?.??
?МчФЦ гцАсгйпи (хЦхгоягй тнуМи) хгнйМгя ДуФу (ЦД ЦФго гЦАчяягй гЦАйнууи) ЦД цлА?
?гАйояМх гАйьхМчМ ААьгАх зАМЕг Мщ нЦйАщ гЦАлггАй ЦкА ? :?йзяМх гЦАуьАмгй? ║?ъМщМи уМгши гЦАуьАм?
?гАзАЦМ? ║?гсйнягл гЦАмсДгй гААщыМи ФгАхгАшМи?...║?гАн?.??
?Ащй гДйхгЕ гАьгАх еЛА лФгДх гАйцуМА зДо оягси гАДуФу гЦАнйгяи ежгщи еЛА глАФгДх гААшФМи?
?хйАъ гАДуФу?.??
?ьяч гАйзАМЦ ФгАйзАЦ?
?чхА гАхоа Мщ йДщМп гЦАДЕл глАоМо ъгДй гЦАмгяжи ЕМ гАФсМАи гцАсгсМи АйояМс ЕпЕ гЦАчяягй? ║?ФЦДп гАхоа?
?Мщ йДщМп гЦАчяягй гмАгАМи цонАй гАДоФгй ФмАчгй гЦАогяси гАьгАхМи ъФсМАи лоМои? ║?ФмгАМг цухм?
?гАьгАх МсйноЦФД гАФсгфь гЦАйзоои Мщ гАйчоМЦ ФцыЕяФг Цчоягй лоМои Мщ гсйногЦ гАйчгДи гЦАйьФяи?
?Мщ гАзяж? .?ЦД ЦтгъА гЦАчяягй цД гцАДтьи гАйзАМЦМи МйЦ йДщМпЕг Мщ ЕДгМи гАМФЦ гАоягМс ФМщ ъкяМ ЦД?
?гцАмМгД Мщ гЦАсга (ЦД гАсгзи ? 6:30 - 4:30?Цсга) мМк МъФД гАьгАх ЦяЕчДМ? .?ФМщ хзж гАъАМгй?
?(зАФЦ гЦАнйяхгй) гА ййФщя цМ ноЦгй ААьгАх Мщ ЕпЕ гцАФчгй (ЦкА ноЦгй гАъгщМяйМг ФгЦАъйхи)? .?пъя?
?ЦзыЦ гцАсгйпи ЦтъАи гцАзого гАъхяМи ААьгАх ФцмМгД Пг Цлз ощзйДМ ЦД ъАМйДМ нЦйАщйДМ? .?хзж гцАсфАи?
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??207??
??Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009??
?цмМгД Пг йъФД жзМщи ФшяМ ЦДЕлМи ФгА мйщр зЛА гАйщъяМ ФггАсйДйгл? .?ЕДгъ Дчу Мщ гЦАяглз Мщ ъАМгй?
?гАзАФЦ гАумМи ФАъДЕг ЦйФщяи Мщ ъАМгй гАяйхМи ФгАйМ йФло Мщ ЦФгчз цняЛ ЦД глАгЦзи?.??
?ьяч ФцоФгй гАйчММЦ?
?гАьяч гмАгАМи лМои мМк цД ггАЦймгД гАДЕгфМ МЦкА ? %60?ФцзгЦА гАсДи ? %40?ЦД гАояли гАъгЦАи цАМ?
?Цчяя?.??
?лМх геАхчга зЛА еоягл Дйгфл Цчяягй гААши гАзяхМи зДо мсгх гЦАзоА гАяйгъЦМ ААьгАх мМк цД Мщ?
?пАъ мйщМр Пг ААьгАх АМлФЖЬ оФг цогаЕЦ ЕхпЕ гЦАчяягй? ║?щйъФД хпАъ пгй щгфои ААьгАх (хймсДМ ЦзоАЕ?
?гАяйгъЦМ) цъкя ЦД ъФЕДг Дчьи зхФя щчь?.??
?ФЦД ЦтгъА ЕпЕ гЦАчяягй зоЦ гАйргЦ ЦлМз цсгйпи гАзАФЦ гАьхМи ФгАумМи хгАйояМс хгААши гАзяхМи?
?нгуи Мщ гАщуФА гАоягсМи гЦАйчоЦи ФхгцАну Мщ йояМс гАзАФЦ гАясМяМи? ║?хА цД ЕдгАа гцАсгйпи гА?
?МФлЕФД гАьгАх еЛА гЦАнгьхи цкДга гАДоФгй ФмАчгй гЦАДгчти цФ ъйгхи гАйчгяМя хгААши гАзяхМи гАсАМЦи?.??
?гАъкяМ ЦД цсгйпи гАзАФЦ гАумМи ФгАьхМи АМс ЕАЦ цМ зАЦ цФ оягМи хцЕогщ Цчяягй гААши гАзяхМи?
?гАягЦМи еЛА Цсгзои гАьгАх Мщ гсйМзгх гЦАчяягй гАумМи гЦАйнууи ФМщ гАйнгьх Дьч Пг Фъйгхи хгААши?
?гАзяхМи гАсАМЦи? .?чАи ЦД цсгйпи гАзАФЦ гАумМи гАягщжДМ ААйзяМх МАлцФД Мщ хзж гцАмМгД ААйчАМА?
?ЦД цЦЕМи Цчяягй гААши гАзяхМи ФгАйчАМА ЦД цЦЕМи гЦАуьАмгй гАзяхМи?.??
?гАйФуМгй?
? гсйногЦ гЦАрМо ЦД гАьяч гЦАмщри ААьгАх ЦкА? :?гАзЦА Мщ лЦЦФзгй? ║?гАйгЦяМД глАгЦзМи?? ФгАщяоМи? ║?гАйьхМч гАзЦМА? ║?гцАФягч гАхмкМи?.??
? ггАЕйгЦЦ хгААши гАзяхМи гАсАМЦи (ъйгх Пи ФнйгьхгП) цкДга гцАДтьи гцАъгоМЦМи гЦАнйАщи ЦАчяягй?? гАзАФЦ гАумМи ФгАьхМи ЦйжЦД Пг гАйочМч гААшФМ ААйчгяМя ФгАДоФгй ФмАчгй гЦАогяси?
? гАьгАхМи?.??
? йДФМя цсгйпи гЦАчяягй гЦАйнууи хцЕогщ ФмЦйФМгй Цчяягй гААши гАзяхМи ФеятгъЕЦ Мщ??йДщМпЕг хмжФя гАДоФгй ФмАчгй гЦАогяси ФгЦАтгяъи Мщ йчММЦ гАьгАх мйЛ мМяу ЕдгАа?
? гцАсгйпи зЛА еАргЦ гАьгАх хцсгАМх ъйгхи гАйчгяМя ФйчоМЦ гАДоФгй ФмАчгй гЦАДгчти Цз?
? сгАЦи гААши гАзяхМи Мщ ъАМЕгЦ?.??
? емМга гЦАъйхи гАзяхМи ФйФщяМ гЦАяглз гмАоМки хгААши гАзяхМи?.??? йФщяМ гАйчДМгй гмАоМки ЦД цоФгй ФФсгфА гАйзАМЦ ФгАйзАЦ?.??? йтлМз гАйДыМгЦй гАьгАхМи зЛА йхДМ йДыМЦ Ачгагй зЦА ФЦдЦйягй мЦАМи огзЦи АйзяМх?? гАзАФЦ гАумМи ФгАьхМи?.??
?? -?рМгои гАсгзгй гЦАзйЦои ААЦчяягй гмАгАМи?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
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??208??
?гЦАяглз?
??.1??
??.2??
??.3??
??.4??
?лйяхи ъАМгй гАзАФЦ гАумМи хлгЦзи глАрМяи Мщ?
?йзяМх гЦАДгЕл (? .)2003√1993?хяФщсяМ цЦмо?
?зхо гЕАА мЦЦогМД √ хяФщсяМ жМга гАоМД глАМЛА?
?√ хяФщсяМ зкгЦД ьЕ мЦЦо зкгЦД? ║?гЦАлАи гАумМи?
?Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо?
?гмАгоМ зят? ║?гАзоогД ?.2005 √ 2/1??
?лйяхи гАйзяМх Мщ ъАМи гАьх? ║?лгЦзи глАрМяи?
?(цятМщ Фкгфч гАъАМи)?.??
?Фчгфз Фят зЦА йзяМх ЦДЕл ъАМи гАьх?║??
?лгЦзи глАрМяи? ║?Цяър гАйзАМЦ гЦАсйЦя? ║?ъАМи?
?гАьх? ║?лгЦзи глАрМяи (?.)1992-1991??
?Фячи гАоъйФя жМга гАоМД глАММА зД гАйзяМх?
?Мщ ъАМи гАьх ФъАМгй гАзАФЦ гАумМи? ║?ЦчоЦи?
?Мщ Фяти зЦА гАйчФМЦ? ║?гАйзяМх хъАМи гАьх?║??
?лгЦзи глАрМяи? ║?МФДМФ ?.2002??
??.5??
??.6??
?хяФщсяМ цЦмо зхо гЕАА мЦЦогМД ФоъйФяи сЦяМи?
?мгЦо зхо гАяЦмД? :?йчФМЦ цкя гАйзяМх зМА?
?гАьгАх гЦАйнялДМ ЦД ъАМи гАьх лгЦзи?
?глАрМяи? ║?чМо гАДят Мщ гЦАлАи гАумМи Аятч?
?гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи?.??
?гАоъйФя зЦя гАсМо гАьМх гАзхгс хоя? ║?лйяхи?
?лгЦзи глАрМяи Мщ лЦгА гАйзяМх ?║2002/1991??
?лЦАи глАрМяи ААзАФЦ гАяйхФМи ФгеАДсгДМи √ гЦАлАо?
?гАкгМД? ║?гАзоо гцАФА ?2005?Ц (у ?.)198√173??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
209
Report
Epidemiological transition of some
diseases in Oman: a situational
analysis
S.S. Ganguly,1 M.A. Al-Shafaee,1 J.A. Al-Lawati,2 P.K. Dutta1 and K.K. Duttagupta1
? мйАМА ААФжз?:?гА УЬД ЗчАСи гАФхгфМи Ахзж гцАЦягж Мщ сАьДи зУ гЦД?
? ъгАМгД ъгДйМ огйглФхйг?║? хяДгх ъФЦгя огйг?║? лФго зМА гААФгМй?║? мЦЦо зМА гАтгщзМ?║?тМгЦ сДоя лДлФМА?
║? тЕой сАьДи зУ гЦД нгАА гцАзФгЦ гнАЦси ФгАкгАкДМ гЦАДяуЦи УДчЗА Пи глйгЦзМи ФгчйугоМи ФФхгфМи ясМзи?:?гнАгАуи?
?СЬй Мщ гДнщгж мго Мщ ФщМгй ФЦягжи гцАьщгА ФгАхгАшДМ ДйМли гАДмсгя нЦйАщ гцАЦягж гАсгяМи хгЦ Мщ?
З ?йлС С А?
? ФъгДй гмАъгЦи гАятМои ФгАйньМь глАМо хлгДх гАчМгои ФггААйргЦ?.?пАъ гцАЦягж гАйМ МЦъД йФчЬМЕг хгААчгмгй?
? егА цД ггАроЕгя гЦАйДгЦМ чо цоЛ еЛА ыЕФя цЦягж шяМ сгяМи Цяйхьи?.?гА ЕгЦ Пг Мщ мйчМч Епг геАДлгр?
П ?гмАъФЦМ згЦ?
? Фчо?.? ФгАсЖЬ ЦЗ ДСи?║? ФгАсъяМ?║? ФМщ ьАМзйЕг гцАЦягж гАчАхМи гАФзгфМи?║? ЦйкА мйоЖЬ Мгй умМи ЦсйлоЬ и?║?хДЦь гмАМги?
.?Дгчт гАхгмкФД ггАсйэягйМлМгй гАФчгфМи гЦАгАфЦи ААмо ЦД зха гцАЦягж шяМ гАсгяМи?
ABSTRACT During the past 35 years Oman has undergone a rapid socioeconomic and epidemiological transition leading to a steep reduction in child and adult mortality and morbidity due to the decline
of various communicable diseases, including vaccine-preventable diseases. Good governance and
planning, together with leadership and commitment by the government, has been a critical factor in
this reduction. However, with increasing prosperity, lifestyle-related noncommunicable diseases have
emerged as new health challenges to the country, with cardiovascular diseases, diabetes and obesity
in the lead among other chronic conditions. Appropriate prevention strategies for reducing the burden
of noncommunicable diseases are discussed.
Transition ИpidИmiologique de certaines maladies Ю Oman : analyse de la situation
R?SUM? Au cours des 35 derniХres annИes, Oman a connu une rapide transition socioИconomique
et ИpidИmiologique qui a entraНnИ une forte rИduction de la mortalitИ et de la morbiditИ chez les
enfants comme chez les adultes, en raison du recul de plusieurs maladies transmissibles, notamment
celles pouvant Йtre ИvitИes par la vaccination. La gouvernance et la planification avisИes, de mЙme
que la direction ИclairИe et la dИtermination dont ont fait preuve les pouvoirs publics, ont jouИ un rТle
dИterminant dans ce recul. Toutefois, l▓accroissement de la prospИritИ s▓est accompagnИ de l▓apparition
de maladies non transmissibles liИes aux modes de vie √ au premier rang desquelles des pathologies
chroniques telles que les maladies cardiovasculaires, le diabХte et l▓obИsitИ √ et le pays doit aujourd▓hui
faire face Ю ces nouveaux problХmes sanitaires. Des stratИgies de prИvention permettant de rИduire la
charge de ces maladies non transmissibles sont Ю l▓Иtude.
Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan
Qaboos University, Muscat, Oman (Correspondence to S.S. Ganguly: ganguly@squ.edu.om).
2
Department of Noncommunicable Disease Control, Ministry of Health, Muscat, Oman.
Received: 23/04/07; accepted: 25/07/07
1
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Introduction
Methods
The health services in Oman have made
phenomenal progress during the past three
and a half decades. Oman▓s health system
was rated first for its overall performance,
and eighth for its health system performance, among 191 countries by the World
Health Organization (WHO) in 2000 [1].
Other international agencies such as the
United Nations Children▓s Fund (UNICEF)
and the United Nations Development Programme (UNDP) also lauded the country▓s
remarkable strides in health system development. This has included rapid epidemiological and demographic transition,
observed in the form of improvement in all
the demographic, reproductive and child
health indicators along with a declining
trend for various communicable diseases
[2]. With this reduction in communicable
diseases, chronic noncommunicable diseases related to lifestyle≈such as coronary
heart disease, hypertension, diabetes mellitus and cancer≈are now emerging as new
health challenges for the country [3].
However, so far no epidemiological
study has been undertaken to evaluate the
trends and differential effects on the outcome of health programmes regarding the
reduction of important communicable diseases, especially malaria and tuberculosis.
In the present paper, an epidemiological
analysis of some important communicable
diseases was conducted, with special reference to malaria, tuberculosis and vaccinepreventable diseases, based on the available
data from a variety of sources covering
the past 15 years. Data are also presented
regarding the emergence of a few important
chronic and noncommunicable diseases
related to lifestyle.
These secondary data were compiled and analysed after review of the relevant literature:
the WHO world health report for 2000; the
Oman national health survey from 2000; the
Oman decennial census report from 2003;
annual health reports from 1991 to 2005
from the Ministry of Health in Oman; the
mortality and health transition report by the
government of Oman, UNICEF and WHO
Regional Office for the Eastern Mediterranean Region (EMR); and the demographic
and health indicators of various Gulf countries for 2005 [1,4√7]. After perusing the
morbidity data, a review of the literature
was carried out to document the patterns of
various communicable diseases, especially
malaria and tuberculosis. This review also
aimed to study the prevailing trend in the
increase of certain noncommunicable diseases which are posing challenges to the
country▓s health administrators.
Morbidity rates were estimated and expressed as morbidity per 1000 mid-year
population, and the corresponding morbidity index rates were obtained relative to the
year 1991. The estimated burden of disease
and disability-adjusted life years (DALYs)
for communicable and noncommunicable
diseases in the region were also reviewed
[8√12]. Finally we searched the Medline
database for peer-reviewed publications
on noncommunicable diseases pertinent to
Oman, including the key words ⌠diabetes■,
⌠hypertension■, ⌠cancer■ and ⌠Oman■.
Results
Childhood diseases
The epidemiological situation in Oman of
selected communicable diseases for the
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
0.03
0.01
76
36
0.28
0.35
684
866
0.001
√
0.007
0.008
616
544
2004
2005
0.26
0.22
285
257
0.12
0.10
18
19
3
0
0.06
149
0.53
1243
0.001
3
0.0004
1
0.11
250
740
2003
0.32
0.02
0.12
0.08
0.05
0.03
0.31
0.21
0.09
0.08
0.02
0.04
0.02
26
45
239
168
108
73
694
484
205
190
54
96
0.80
0.67
0.94
1.26
1.01
0.86
0.53
0.56
0.48
0.63
0.86
0.63
1066
1465
1322
1969
2631
2167
1943
1219
1308
1164
1555
2188
0.005
0.003
0.003
0.003
0.001
0.002
0.002
0.0004
0.002
0.001
0.002
0.005
8
1.00
1.56
0.09
0.03
0.01
0.005
0.002
0.003
0.006
0.006
0.002
10
7
7
7
3
5
5
1
6
3
4
0.13
220
1834
3108
181
68
24
12
5
9
15
15
5
0.19
0.14
0.14
0.13
0.14
0.13
0.13
0.11
0.13
0.12
0.11
0.24
405
348
275
300
276
300
298
287
249
313
289
288
8.30
8.32
3.58
0.86
0.59
0.48
0.48
0.39
0.29
0.26
0.23
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
11.50
19═274
14═827
16═787
7═215
1═801
1═265
1═026
1═091
901
694
635
590
1991
Tetanus
No.
Rate/1000
Measles
No.
Rate/1000
Tuberculosis
No.
Rate/1000
Malaria
No.
Rate/1000
Year
Table 1 Epidemiological trend of selected communicable diseases in Oman 1991√05
Viral hepatitis
No.
Rate/1000
Pertussis
No.
Rate/1000
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
211
period 1991 to 2005 is shown in
Table 1. It can be observed that
most of the communicable diseases show a very steep declining trend, which can be linked to
the effective implementation of
national health programmes in
Oman. The incidence of measles
also shows a declining trend,
with occasional sporadic cases
reported (15 each in 2000 and
2001 and 19 in 2005) [13]. However, the incidence of pertussis
continued to range from 1 to 6
per 100═000 population between
2001 and 2005. It should also
be noted that some childhood
diseases such as poliomyelitis,
diphtheria and neonatal tetanus
have been eliminated, with no
cases reported since 1985. The
elimination of these childhood
diseases can be attributed to the
effective implementation of the
Expanded Programme on Immunization in Oman.
Malaria
In Oman, malaria was one of
the most important public health
problems in the 1970s and 1980s.
Table 1 shows a remarkable reduction of 97.2% between 1991
(19═274 cases) and 2005 (544
cases) [13]. The malaria cases
were further analysed, considering the various malariometric
indices such as annual parasite
incidence (API), annual blood
examination rate (ABER), slide
positive rate (SPR), per cent of
Plasmodium falciparum infection out of total cases and epidemiological classification of
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Table 2 Epidemiological situation of malaria in Oman 1991√2005
Annual
Slide
blood
positive
examination
rate
rate
%
%
7.69
14.9
1991
No.
19═274
No.
17═817
%
92.4
No.
1═426
No.
31
Annual
parasite
incidence
rate
%
11.50
1992
14═827
13═958
94.1
845
24
8.30
7.00
11.9
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
16═787
7═215
1═801
1═265
1═026
1═091
901
694
635
590
740
616
544
16═063
6═543
1═282
754
552
523
456
316
283
266
299
449
153
95.7
90.7
71.2
59.6
53.8
47.9
50.6
45.5
44.6
45.1
40.4
25.7
26.7
694
669
513
500
469
551
416
366
336
315
428
158
387
30
3
6
11
5
17
29
12
16
9
13
8
4
8.32
3.58
0.86
0.59
0.48
0.48
0.39
0.29
0.26
0.23
0.32
0.26
0.22
6.71
2.44
0.39
0.24
0.21
0.25
0.18
0.14
0.12
0.12
0.18
0.19
0.21
12.4
14.6
21.8
23.8
21.5
19.2
21.3
20.6
21.0
19.5
17.6
13.9
10.3
Year
Total
malaria
cases
Plasmodium
falciparum
cases
P. vivax
cases
Mixed
infection
cases
positive cases as P. vivax, P. falciparum or
mixed infections (Table 2) [6].
As evident from Table 2, in the early
1990s (1991√1994) more than 90% of cases
were due to P. falciparum infection, whereas the trend declined steadily to 26.7% in
2005. Simultaneously, there was an increase
in the proportion of P. vivax infections that
usually give rise to lesser complications and
fewer deaths. According to the latest Ministry of Health report, the country had its
last ⌠indigenous■ case of malaria in 1999.
In 2005, a total of 544 cases were reported
in Oman, all of which were imported, either
from East Africa or the Indian subcontinent.
Similarly, 615 cases were investigated during the year 2004 and all were found to be
imported [6].
The API, a measure of the incidence
of malaria in a community, was 11.50%
in 1991 and has been showing a declining
trend since that year, corresponding to the
launch of the national malaria eradication
programme in Oman. It reached a minimum
of 0.22% in 2005. Similarly, the SPR, another sensitive parameter for measuring malaria infection rates, decreased steadily from
7.69% in 1991 to 0.21% in 2005. ABER,
based on the collection and examination
of blood slides from fever cases, varied
between 14.9% in 1991 and 10.3% in 2005.
According to WHO recommendations, a
minimum of 10% of blood slides from fever
cases should be examined for effective case
detection, and this has been continually
observed during the past 15 years in Oman.
Tuberculosis
The number of pulmonary tuberculosis
cases showed a declining trend, from 405
cases in 1991 to 257 in 2005, a reduction
of 36.5% (Table 1), albeit a gradual decline
(Figure 1). The breakdown of tuberculosis
cases in Oman from 2000 to 2005 is shown
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
213
250
Morbidty index
200
150
100
50
0
1991
1993
1995
Malaria
1997
1999
Tuberculosis
2001
Tetanus
2003
2005
Viral hepatitis
Figure 1 Trends for selected communicable diseases in Oman 1991√2005
Table 3 Annual tuberculosis cases in Oman 2000√2005
Pulmonary cases
Sputum-positive
Sputum-negative
Extrapulmonary cases
Total new cases
Cases cured
2000
164
37
112
313
242
2001
156
29
104
289
215
2002
151
27
110
288
238
2003
112
35
103
250
194
2004
160
39
86
285
218
2005
131
37
89
257
188
Source: Annual health reports, 2000√2005, Ministry of Health, Oman
in Table 3. The national tuberculosis control
programme was initiated in 1981 in Oman
and was revitalized in 1991. The aim of the
control programme is to detect new tuberculosis cases and treat sputum-positive cases
as a priority so as to prevent emergence
of new cases. This is being done through
detection among contacts as well as by vaccination of newborn children with bacille
Calmette-GuИrin (BCG). In addition, the
strategy of directly observed treatment,
short course (DOTS) chemotherapy was
implemented in Oman during 1996, which
has resulted in a more than 90% conversion
and cure rate. This was accompanied by a
sharp decline in the number of deaths from
tuberculosis [6]. During 2005, there were
257 cases, an incidence of about 5.2 per
100═000 sputum-positive cases compared to
6.8 per 100═000 in═2004.
Emergence of noncommunicable
diseases
Table 4 and Figure 2 show inpatient morbidity data for some noncommunicable
diseases in Oman since 1991. It can be
seen that the rates for diabetes and cancer
showed a rising trend whereas ischaemic
heart disease remained constant. The trends
for DALYs in the countries of the Eastern
Mediterranean Region, including Oman,
are shown in Figure 3. These clearly reveal
the dominant burden of a rising trend in
noncommunicable diseases and a declining
trend of communicable diseases.
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Table 4 Epidemiological trend for selected noncommunicable diseases in Oman 1991√2005
Year
Hypertension
Diabetes
1991
1992
No. of
cases
2502
2960
Per 1000
population
1.48
1.62
No. of
cases
2072
2407
Per 1000
population
1.22
1.32
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
3234
3495
3300
3403
2892
3406
3355
2250
3328
2949
2862
2698
2167
1.63
1.67
1.58
1.59
1.28
1.49
1.44
0.94
1.34
1.16
1.22
1.12
0.86
2892
3099
3340
3663
3054
3766
3653
3695
3796
3801
4013
3940
4117
1.46
1.48
1.60
1.71
1.35
1.65
1.57
1.54
1.53
1.50
1.71
1.63
1.64
Various reports indicate that the leading
cause of death among inpatients in 1999 was
circulatory disease (37% of total morbidity)
to which ischaemic heart disease, hypertension and cardiac dysrhythmia were the main
contributors. Neoplasms constituted 13%
of all deaths [6,14]. Data compiled over
Ischaemic heart
disease
No. of
Per 1000
cases population
4077
2.41
4427
2.42
No. of
cases
2215
2150
Per 1000
population
1.31
1.18
4783
5348
5505
5170
5455
5244
5561
5747
5882
5619
5582
5538
5640
2296
1862
2220
2490
3493
3205
3533
3378
3181
2915
2929
3147
3382
1.16
0.89
1.06
1.17
1.55
1.40
1.52
1.41
1.28
1.15
1.25
1.30
1.35
2.41
2.55
2.63
2.42
2.42
2.29
2.39
2.39
2.37
2.21
2.38
2.29
2.25
Cancer
the past 2 decades show a high prevalence
of chronic conditions. The 1991 and 2000
surveys have shown that over 11% of the
population aged 20 years and above suffer
from diabetes mellitus [4,15,16]. More than
half the population suffer from either overweight or obesity [17], while the metabolic
Morbidty Index
150
100
50
0
1991
1993
1995
Hypertension
1997
Diabetes
1999
2001
2003
Ischaemic heart disease
Cancer
2005
Figure 2 Trends for selected noncommunicable diseases in Oman 1991√2005
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
215
70
Percentage DALYs lost
60
50
40
30
20
10
0
1999
2000
Communicable diseases
2001
2002
Noncommunicable diseases
Figure 3 Trend for disability-adjusted life years (DALYs) lost due to communicable and
noncommunicable diseases in the Eastern Mediterranean Region 1999√2002
syndrome is as prevalent in Oman (21%)
as in the United States of America (23%)
[18]. The prevalence of hypertension (blood
pressure ? 140/90 mmHg) was 33% (35.2%
in men and 30.9% in women) [4,14,19].
Smoking is gaining popularity among youth
with 15.5% of men and about 2% of women
aged ? 15 years reporting current use [20].
Discussion
Oman has been transformed from an undeveloped country to a modern welfare
state over the past 35 years. Before 1970,
communicable diseases, such as diarrhoeal
diseases, cholera, malaria, tuberculosis and
trachoma were common health problems.
Since then, the health of the Omani people
has improved dramatically as political and
economic reforms have taken place. This is
witnessed by the decline in infant and childhood morbidity and mortality due to various
communicable diseases over a very short
period of time [2,3].
In 1999, Scrimgeour et al. reviewed
the important notifiable diseases in Oman,
which included malaria and tuberculosis
[21]. Although malaria was a major public
health problem at that time, since 1999
not a single case of local transmission of
malaria has been reported. The success of
the control phase encouraged the government to embark on the eradication phase in
1991, which has led to further rapid declines
in the number of malaria cases. Despite the
fact that local transmission is ebbing now,
it is feared falciparum malaria might be
reintroduced by visitors or migrants from
East Africa or the expatriate workforce
from the Indian subcontinent. However, to
combat such an eventuality, measures such
as the distribution of prophylactic drugs
and screening of passengers arriving from
Africa are in place. Private health institutes
(where most expatriates seek health care
services) were recently included in the national surveillance system to cover the cases
coming from such areas [6].
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The incidence of tuberculosis declined
significantly until 1993, after which the
decline slowed over the years. A similar
trend was confirmed by Al-Maniri et al. in
Oman [22]. Efforts towards further control of tuberculosis now include continuous monitoring and follow-up of all cases,
prompt and extensive contact screening,
and detailed epidemiological investigation
of all cases to establish the possible source
of infection and risk factors together with
operational research and ensuring a high
quality of DOTS [6,22].
The concept of running crucial health
programmes such as malaria eradication
and tuberculosis control vertically, in parallel with horizontal programmes such as the
nationwide immunization programmes for
the control of other communicable diseases,
proved to be critical in the rapid control
of such infectious diseases [13]. It must
be added that these achievements would
not have been possible without 2 other
important factors: first, the politically stable environment which Oman has enjoyed
for over 30 years and secondly the strong
commitment of the government to provide
universal health coverage to all its citizens
free of charge. Clearly, the latter was supported by revenues from the oil sector.
Greater economic prosperity over the
past 4 decades has led to a shift in the
epidemiological patterns of diseases in
Oman, with chronic diseases being the most
dominant. Noncommunicable diseases are
expected to account for 7 out of 10 deaths
by 2020 and beyond in developing countries
including the Arab countries [23], and this is
likely to put increasingly heavy demands on
the Omani health care system. As the country continues through the epidemiological
transition and socioeconomic development,
the burden of noncommunicable diseases,
particularly cardiovascular diseases and
diabetes, can only be expected to increase.
The current Strong Heart Study findings revealed that diabetes alone increases
the risk of cardiovascular disease 2.9-fold
compared with normotensive nondiabetic
subjects [24]. Furthermore, the current high
rates of overweight and obesity will contribute to the impending epidemic of chronic
diseases in Oman if sufficient steps are not
taken to intervene.
Proven interventions to control chronic
disease epidemics include community-based
initiatives, such as behavioural changes for
dietary intake, weight control, increased
physical activity, reduction of stress and
smoking cessation services [25]. Such
programmes invariably include secondary
prevention strategies (screening for raised
cholesterol, blood pressure and blood sugar).
Health promotion and educational and communication strategies are an integral part of
any community-based initiative [26].
Our report has some limitations. Our
analysis relied mostly on data produced and
compiled by the main public health sector,
the Ministry of Health of Oman. While
these data have not been formally evaluated
by any study, the Department of Health Information System is recognized for its welldeveloped infrastructure, making Oman a
frequent destination for WHO fellows from
various Member States in the EMR to learn
about its functions and organization. Further, Oman▓s data on cancer incidence were
scrutinized by the International Agency for
Research on Cancer and found to be reliable
enough to be published in its publication
of cancer incidence in 5 continents, making Oman one of only 2 countries among
the 22 Member States of the Region to be
included.
Another limitation is that our analysis
was in part limited to only a single public
health agency (the Ministry of Health).
This is mainly attributed to 2 reasons. First,
the Ministry of Health is the main public
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
sector, which caters for 85%√90% of the
population. Other institutions (the police,
army, university and some private companies) and the private sector health services
provide only limited services and mostly on
an outpatient basis. Secondly, the ministry
is the only institution that conducts regular
nationwide health surveys on various health
problems and risk factors. Thus the scope of
our report covered over 85% of the Omani
population.
In conclusion, Oman has achieved remarkable improvements in health indicators,
including a rapid decline in communicable
diseases during the past 3 decades. Increased expenditure on health has resulted
in improved indicators of health services,
health manpower development and health
care. Planning and implementation of various vertical health programmes have paid
rich dividends in the reduction of preventable diseases. However, chronic noncommunicable diseases related to lifestyle are
emerging as new health challenges for the
country. Since the treatment of confirmed
217
cases is costly and often palliative for most
of the noncommunicable diseases, especially at the advanced stages, preventive
strategies, including primary prevention,
early diagnosis and treatment, are being
given priority. Primary prevention is receiving special attention in the prevention of
noncommunicable diseases. Many adult
health problems such as obesity, diabetes
and hypertension have their origin in childhood, when lifestyles (including eating patterns, smoking habits and regular physical
activity) are formed. Efforts can be made to
impart health promotion in early life as well
as throughout adulthood [23].
Acknowledgements
The authors would like to thank the Ministry of Health of Oman for providing the
necessary data and the anonymous reviewers for their constructive comments that
substantially improved the article.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
219
Short communication
Microbial contamination in the
operating theatre: a study in a
hospital in Baghdad
S. Ensayef,1 S. Al-Shalchi2 and M. Sabbar3
? оягси Мщ цмо ЦсйтщМгй хшого?:?гАйАФк гЦАъяФМх Мщ шУ яС щ гАзЦАМгй?
? ЦДЛ ухгя?║? смя гАтглАМ?║?сгЕяи ДуМЖЬщ?
? ФЕйощ ЕпЕ гАоягси еЛА йчММЦ?.? МУзС оУЬ йАФк шящ гАзЦАМгй схх Пг ЕгЦ Пг Мщ моФк зоФЛ гЦАсйтщМгй?:?гнАгАуи?
? ФгАйзящ зЛА Цуоя Епг?║?МА Мщ ЦоМДи хшого?
Ь ?ФчФз гАйАФк глАякФЦМ Мщ шящ гАзЦАМгй Мщ ЦсйтщЛ геАЦгЦ з?
? Цсми йЦ ЦлзЕг ЦД гцАсьм ФгЦАзоСЬ гй ФмЦгАМА гЦАьЕягй ЦД нЦйАщ шящ гАзЦАМгй?1216 ? ФЦД хДМ?.?гАйАФк?
? ФъгДй?.2002 ? Мщ згЦ?%4.0? Ф?║2001 ? Мщ згЦ?%3.7 ? хАш ЦзоСЬ А гЦАргяз глАякФЦМи геАлМгхМи?║2002? Ф?2001 ?Мщ згЦМ?
? Мщ мДМ ъгДй гАчФАФДМгй?║? йАМЕг гАргфщи гАрДлгяМи?║2001 ?гАзДчФоМи гАхятФМи ЕМ цъкя глАягкМЦ гЦАсйщяС ои Мщ згЦ?
С? ФЦА йъйтщ гАхгмкгй ДЦь Пг Фгжм Пг ААлягкМЦ гЦАсйщяои гАйМ зкяД?.? йАМЕг гАргфщи гАрДлгяМи?║2002 ?ЕМ гцАъкя Мщ згЦ?
? егА цД гАчФАФДМгй ФгАргфщи гАрДлгяМи чо Ц СЬкАСйг цъкя глАягкМЦ гАйМ зкяДС зАМЕг Мщ?║?зАМЕг Мщ нЦйАщ шящ гАзЦАМгй?
.?шящ гАзЦАМгй?
ABSTRACT Contamination of the operating theatre is a major cause of nosocomial infection. This study
aimed to evaluate the incidence of bacterial contamination of operating theatres in Al Imam Ali Hospital
in Baghdad, and the source of contamination. From 1216 swabs collected from surfaces, equipment
and antiseptic solutions from different operating theatres in 2001 and 2002, the rates of positive cultures
were 3.7% in 2001 and 4.0% in 2002. Staphylococcus epidermidis was the most common isolate in
2001 followed by Pseudomonas aeruginosa, whereas in 2002 coliform bacteria were the highest, followed by P. aeruginosa. No clear pattern of isolates was found in different types of operating theatres,
although coliforms and P. aeruginosa were mostly found in the delivery theatre.
Contamination microbienne dans les salles d▓opИration : Иtude dans un hТpital de Bagdad
R?SUM? La contamination de la salle d▓opИration est une cause majeure d▓infection nosocomiale.
Cette Иtude visait Ю Иvaluer l▓incidence de la contamination bactИrienne des salles d▓opИration Ю l▓hТpital
Al Imam Ali de Bagdad, ainsi que la source de la contamination. Sur 1 216 prИlХvements recueillis sur
les surfaces, matИriel et solutions antiseptiques de diffИrentes salles d▓opИration en 2001 et 2002, le
taux de cultures positives Иtait de 3,7 % en 2001 et de 4,0 % en 2002. Staphylococcus epidermidis Иtait
l▓isolat le plus frИquent en 2001, suivi de Pseudomonas aeruginosa, alors qu▓en 2002, les colibacilles
Иtaient les plus rИpandus, suivis de P. aeruginosa. Aucune caractИristique Иvidente n▓a ИtИ observИe
concernant les isolats dans les diffИrents types de salle d▓opИration, mЙme si les colibacilles et P. aeruginosa Иtaient surtout prИsents dans la salle d▓accouchement.
Department of Biology, College of Science, Al-Mustansiriyah University, Baghdad, Iraq.
Department of Biotechnology, College of Science, Baghdad University, Baghdad, Iraq (Correspondence to
S. Al-Shalchi: Saharalshalchi_66@hotmail.com).
3
Medical Analysis Department, Technical Medical College, Commission of Technical Education, Baghdad, Iraq.
Received: 06/11/05; accepted: 08/06/06
1
2
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Introduction
Contamination of operating theatres is one
of the most life-threatening sources of nosocomial infection for patients, especially
in transplant surgery, heart surgery, cysto╜
scopy and transurethral resection of prostate
and bladder tumours [1]. Multiple reservoirs
have been reported as being responsible for
hospital contamination, particularly the operating theatre, including unfiltered air, ventilation systems and antiseptic solutions [2].
Other reports suggest that a range of microenvironmental conditions exist even within
purified water systems which are intended
for laboratory use or for irrigation, leading to variable populations of contaminant
bacteria [3]. Medical staff still represent an
exogenous contaminant source in operating theatres [4] and personnel move back
and forth between the operating theatre and
other parts of the hospital without changing
their gowns or slippers. Moreover, patients
are not consistently cleaned or shaved before coming to the operating theatre. All
these factors play a role in contamination
of operating theatres and consequent post╜
operative infections [5].
Many patients are concerned about the
risk of postoperative infections, so our study
aimed to evaluate the incidence of bacterial
contamination of operating theatres in one
of the busiest hospitals in Baghdad, Iraq,
Al Imam Ali Hospital, and to identify the
contaminating agents and their distribution
within different theatres.
Methods
From February 2001 to December 2002,
1216 swabs were taken from 12 operating
theatres in Al Imam Ali Hospital: 4 theatres
for general surgery, 3 for fractures, 3 for
deliveries, 1 for ophthalmic surgery and 1
for ear and nose and throat (ENT) surgery.
Samples were collected 2√3 times monthly
with cotton-tipped swabs from the surfaces,
equipment and antiseptic solutions within
the operating theatres, before and after operations, over the 2-year period. The collection was done by a medical care employee
belonging to the central medical laboratory
of the Ministry of Health in Iraq.
The swabs obtained were cultured directly in prepared MacConkey and blood
agar media (Oxoid, England) by the
streaking method, and standard methods
of identification were used according to
Holt et al. [6] and Baron and Finegold
[7]. The inoculated plates were incubated
aerobically overnight at 37 ╟C for 24 hours,
then culture characteristics were examined
including colony morphology on culture
media, characteristic appearances such as
lactose-fermentation, haemolysis, pigmentation, mucous secretion and swarming phenomena. The identifications were confirmed
by biochemical tests, including the oxidase
test, catalase test, coagulase test, indole test,
methyl red test, Voges√Proskauer test and
citrate utilization.
Results
The incidence of positive cultures was
23/622 cultures (3.7%) in 2001 and 24/594
(4.0%) in 2002.
The monthly distribution of positive
cultures showed no clear pattern in different
months in any 1 year or between the 2 years
(Figure 1), but in general there was a decrease in the incidence of positive cultures
in the summer season in both study years.
Identification of bacterial isolates revealed that in 2001 Staphylococcus epidermidis was the most common isolate
(39.1%), followed by Pseudomonas aeruginosa (30.4%), whereas in 2002 coliform
bacteria were the most common isolates
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
221
7
6
% of positve culture
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Month
Figure 1 Incidence of positive cultures from total number of samples obtained per month
(February 2001 to December 2002)
(62.5%), followed by P. aeruginosa (25.0%)
(Table 1).
To demonstrate the possible source of
contamination, the distribution of bacterial isolates according to operating theatre
were examined. The results showed that in
2001, 5 of the S. epidermidis isolates were
obtained from fracture operating theatre,
2 from general surgery and 1 isolate each
from the ophthalmic and ENT operating
theatres (Figure 2). However most P. aeruginosa isolates were from the delivery operating theatre. In 2002 the coliform bacteria
showed a higher rate among contaminant
isolates and, importantly, this species of
bacteria was collected from 4 of the 5 types
of operating theatre, suggesting a possible outbreak in the hospital from general
sources (Figure═2).
Other species of coliform bacteria were
found in very low numbers, perhaps due
to the carelessness of patients or medical
staff.
Discussion
In 2001 the highest number of contaminant
bacteria was for S. epidermidis. In these
cases the contaminate source is usually
endogenously from normal skin flora of
patients or exogenously from surgical staff,
Table 1 Bacteria isolated as a proportion of the total number of positive cultures
Bacterial isolates
Staphylococcus epidermidis
Staphylococcus aureus
Pseudomonas aeruginosa
Coliforms
Total
2001
No.
9
4
7
3
23
%
39.1
17.4
30.4
13.0
100.0
2002
No.
2
1
6
15
24
%
8.3
4.2
25.0
62.5
100.0
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7
6
No. of isolates
6
5
5
4
4
3
2
5
3
4 4
3
2
2
1 1
1
2
1
1
1
1
1
0
2001
2002
S. epidermidis
S. aureus
Coliform
P. aeruginosa
Figure 2 Number and type of isolates identified from the different operating theatres (OT)
especially as S. epidermidis was the main
infectious agent in the fracture operating
theatre [8].
P. aeruginosa was the second most common isolate and this may indicate the contaminant source from antiseptic solutions
or from breast-fed babies, especially as this
bacteria is an opportunistic pathogen that
can be found in most moist environments
and has a combination of features such as
the ability to survive and spread in hospital
environments, acquisition of multiple virulence determinants and intrinsic resistance
to commonly used antibiotics and disinfectants. This makes P. aeruginosa a major life╜
threating agent that is responsible for many
outbreaks in operating theatres [9,10] .
In contrast, coliforms were dominant in
2002. Coliforms are fecal bacteria and this
suggests that in this case the food and water
supply was the source of contamination.
Another possible contaminant source is the
bowels of patients, from normal flora or
from urinary tract infections, particularly
in the delivery theatre as Escherichia coli
is the most common infectious agent in
pregnant women [11]. Further analysis is
needed using advanced techniques such as
pulsed field gel electrophoresis or polymerase chain reaction to determine if the overall
isolates descend from a single clone or not,
especially when isolates are collected from
different theatres, as this will be a good indication of whether there is a general outbreak
or not [10,12].
The results indicate that 3 factors need to
be considered. First, some bacterial strains
such as S. aureus, S. epidermidis, E. coli
and P. aeruginosa have a greater propensity
to cause contamination, especially in operating theatres, so extensive infection control
practices are necessary to prevent or contain
these pathogens.
Second, the social level of incoming
patients reflects the individual patient risk,
which must be investigated and modified
whenever possible. The patient should be
prepared for operation and appropriate skin
antiseptic should be used on the operation
sites; the patient should also be considered
for preoperative antibiotic prophylaxis.
Bowel preparation, if appropriate, should
be carried out.
Third, careful attention to the theatre
operating environment is important, especially to avoid airborne transmission of
bacteria and transmission to the water supply and food; surgical expertise and theatre
discipline are essential components against
surgical sepsis.
In conclusion, there was no clear pattern
in the incidence in different months during
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
the period of study although there was tendency towards decreased incidence of positive cultures in the summer season. The most
common contaminant species found in the
different operating theatres (S. epidermidis,
223
E. coli and P. aeruginosa) had some relation
to the kind of operation. This may indicate
that sterilization methods are not efficient
in our operating theatres and are putting
patients at risk of postoperative infections.
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Short communication
Study of aerobic granulocyte
functional activity in the presence of
a radiosensitizer (metronidazole)
E.A.A. Al-Krawi1 and A.H.M. Al-Hashimi2
)?оягси гАДтгь гАФыМщМ ААЦмхэхгй гмАМФгфМи Мщ ФлФо мЦщЖЬр ААмсгсМи АцАтзи (гЦАйэяФДМогрФА?
? зМА мсДМ мЦЦо гЕАгтЦМ?║?гхйЕгА зМА зхгс гАъяФМ?
? Цйй оягси йцкяМгй гЦАйэяФДМогрФА Мщ гЦАнйях зЛА еДйгл гцАДФгз гЦАйщгзАи Цз гцАъслДМ хщзА гнАгАМг?:?гнАгАуэи?
.? ФпАъ хгсйногЦ гАДйэяФхАФйэйэягрФАМФЦ ФьяМчи гААЦзгД гАъМЦМгфМ гЦАзйЦо зЛА чМгс гААЦзгД?║?гЦАщууи гАДФги?
ЬС
?ЦАМА Аяй) АФмы йкхМь ЦЕЦ?/? ЦъяФшягЦ?24.86 √ 4.98( ?ФзДо гсйногЦ лязгй згАлМи ЦД гЦАйэяФДМогрФА?
.? ФъгД гАйцкяМ гАйкхМьМ Мщ ДЦь ЦзйЦо зЛА глАязи?. З?емугфМ Пг еАДйгл гцАДФгз гЦАйщгзАи Цз гцАъслДМ Мщ ъгА гАьяМчйСМД?
? гЦАйФАои зД гнАгАМг?║?ФйтяМ гЦАзьМгй еЛА ФлФо бАМи ъгсми ААЦяйФДМогрФА зЛА гцАДФгз гЦАйщгзАи Цз гцАъслДМ?
.?гЦАщууи гАДФги?
ABSTRACT The in vitro effects of metronidazole on the production of reactive oxygen species by
polymorphonuclear (PMN) cells were studied by means of nitroblue tetrazolium and luminol-dependent
chemiluminescence. At therapeutic doses of metronidazole (4.98√24.86 ?g/mL) significant inhibition
of the production of reactive oxygen species was noted in both methods. The inhibitory effect was in
a dose-dependent pattern. The data suggest a scavenging mechanism of metronidazole on reactive
oxygen species generated by PMN.
?tude de l▓activitИ fonctionnelle aИrobie des granulocytes en prИsence d▓un radiosensibilisant (mИtronidazole)
R?SUM? Les effets in vitro du mИtronidazole sur la production d▓espХces rИactives de l▓oxygХne
par les cellules polymorphonuclИaires (PMN) ont ИtИ ИtudiИs grБce au test au nitrobleu de
tИtrazolium et au test de chimioluminescence au luminol. ? des doses thИrapeutiques de
mИtronidazole (4,98√24,86 ?g/mL), on a observИ une inhibition significative de la production
d▓espХces rИactives de l▓oxygХne avec les deux mИthodes. L▓effet inhibiteur dИpendait de la dose
utilisИe. Les donnИes obtenues semblent indiquer que le mИtronidazole agit en tant que piИgeur des
espХces rИactives de l▓oxygХne gИnИrИes par les PMN.
Department of Pharmacology; 2Department of Physiology, Basra College of Medicine, University of Basra,
Basra, Iraq (Correspondence to A.H.M. Al-Hashimi: ahalh_alhshimi@yahoo.com).
Received: 12/09/04; accepted: 27/03/06
1
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Introduction
Radiosensitizers are chemical agents that
have the potential to increase the lethal effect of radicals induced during irradiation
[1√6].The extent of radiation damage to
cells is dependent on the amount of oxygen
available to the cell [1,2,7,8]. Hypoxic cancer cells are known to be relatively resistant
to radiation killing compared with well
oxygenated healthy cells [2,3,7√9].
Metronidazole (Flagyl) is a drug used to
treat infections and has been studied in the
treatment of cancer [10,11] as a radiosensitizer drug, especially for hypoxic cells [9].
Metronidazole selectively radiosensitizes
hypoxic cells without influencing the radiation response of normal well-oxygenated
cells [5,7√9].
The radiosensitizing property of metronidazole may be related to its electron affinity or oxidizing power [2,5,9,12,13]. It is
worth mentioning that many of the electronaffinic radiosensitizers of hypoxic cells also
have the property of preferential or selective
toxicity directed against hypoxic cells even
in the absence of radiation [1,2].
Metronidazole, being electron-affinic,
can accept an electron from neutral free
radical centres to generate a reactive cation
that binds to an anion such as hydroxyl
(OH√), causing a permanent lesion. Under
aerobic conditions, there is enough oxygen to react with all the free radicals and
addition of metronidazole, or any other
sensitizers, yields no further benefit. Thus
metronidazole does not show any radiosensitizing ability when tested under aerobic
conditions [5,9,12,13].
Metronidazole is heterocyclic nitro derivative in which the nitro group of metronidazole is reduced by an electron transport
protein such as NADPH in an anaerobic
micro-organism [6,7,12,13].
While the antimicrobial effect of metronidazole is is well known, [14√16], there
225
have been few studies on the influence of
metronidazole on the phagocytosis functional activity of polymorphonuclear cells
(PMN) in whole blood, in which the function of the granulocytes often seems to be
altered. In the presence of O2 the generation
of free radicals from the stimulation of
PMN results in the production of superoxide radicals [7,8]. With intact cells, the
formation of oxygen reactive intermediates
leads to the production of H2O2 which can
be measured in the presence of NBT (optical density changes due to NBT reduction)
[17] or by luminol induced CL [18].
We aimed therefore to study the effect
of metronidazole (in a range of therapeutic
concentrations) on PMN-generated free
radicals during phagocytosis activity in
whole blood under normal aerobic conditions in vitro (in the absence of ionizing
radiation). Whole blood was used to mirror
the in vivo situation where blood cells are
suspended in their original medium.
Methods
All chemical reagents were obtained from
Sigma Chemical Company, Germany, unless otherwise mentioned.
Blood samples
Venous blood samples were obtained from
apparently healthy volunteers aged 30√55
years using vials with heparin as the anticoagulant. The samples were kept at 4 ╟C until
the start of the assay.
Ethical consent was obtained from the
local ethical committee for all parts of the
study.
Chemicals and reagents
Tris-HCl stock solution was prepared using the following procedure: 24.2 g of Tris
(Fluka√Garantte, Germany) was dissolved
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in 1000═mL distilled water, then 50 mL of
the Tris solution was added to 41.4 mL of
0.2 M HCl (Fluka√Garantte) and diluted
to 200═mL with distilled water. The final
Tris-HCl solution molarity was 0.015 M at
pH 7.4.
Nitroblue tetrazolium
Nitroblue tetrazolium (NBT) (Sigma) is an
electron acceptor used to detect indirectly
the production of the super oxide radical
(O √) by stimulated PMNs, thus providing a quantitative means to identify cells
producing O √2. This can be quantitated
spectrophotometrically. We used 0.2 %
NBT in Tris-HCl solution. Heparinized
blood was used for the activated NBT test;
heparin forms a complex with NBT that is
then ingested by PMNs, thus reducing the
NBT═[17].
Luminol solution
This was made by dissolving 0.02 mg luminol (Sigma) in 1 mL dimethylsulfoxide.
This stock solution was further diluted with
Tris-HCl solution to give about 106 M of
luminol solution prior to use.
Metronidazole solution
Metronidazole,═concentration═500═mg/100═mL,
was obtained (Factory for Medical Solutions, Jeddah, Saudi Arabia). The 100
mL contains, 500 mg metronidazole BP,
740 mg sodium chloride, 44 mg citric acid
monohydrate, 135 mmol/L Na+, 150 mg
sodium monohydrogen phosphate, 12 mmol
H2O2,═126.6 mmol/L Cl√, 4.20 mmol/L PO4√3.
Osmolarity wa 297 mosm/L. Different drug
concentrations were obtained by dilution
with normal Tris-HCl solution.
Procedure
The test samples were incubated for 60
minutes with different concentrations of
metronidazole. Control samples were incu-
bated under the same conditions as the test
samples but without the drug. The test samples contained 0.5 mL NBT solution + 0.5
mL whole blood + 2 mL metronidazole in
the following 5 concentrations: 4.98, 6.64,
11.62, 16.60 and 34.86 ?g/mL. The control
samples contained 0.5 mL NBT solution
+ 0.5 mL whole blood + 2 mL Tris-HCL
solution
All samples were incubated at 37 ╟C for
1 h and spun for 3 minutes at 3000 rpm.
The supernatant was carefully removed and
placed in the spectrophotometer cuvette.
The optical density (% absorption) was
measured at 515 nm using Philips spectrophotometer (type PU8620).
Chemiluminescence measurement
Test and control samples were assayed for
PMN functional activity (free radical concentration released) [18].
The reaction mixture consisted of
0.02═mL luminol in a 5 mL beaker and
0.01 mL whole blood, agitated to mix well,
before placing it into the measuring cuvette
of the photon counting system. Chemiluminescence (CL) was continuously recorded
on a chart recorder until it peaked and demonstrated a definite decline. The peak height
(in mm) of CL kinetic curves represents the
granulocyte functional activity. The data
were estimated in relative arbitrary units for
comparison of the results.
Statistical analysis
The results of both NBT reduction and CL
measurement (the peak height in mm to
be proportional to the area under the CL
kinetic curve) were estimated relative to
the control in each test. Data are expressed
as mean and standard deviation of at least
2 observations. Results were analysed for
significance using the t-test, with a P-value
< 0.05 indicating statistical significance.
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Results
Treatment of PMN cells in whole blood with
metronidazole therapeutic doses resulted
in a statistically significant inhibition of
free radicals generated by the granulocytes
which followed a dose-dependent pattern.
Table 1 shows the reduction of NBT and
the inhibition of the luminol-dependent CL
activity of PMN in whole blood as a function of drug concentration.
Discussion
Significant decreases in both the reduction of NBT and in CL were observed at
different concentrations of the drug (P <
0.01). These results indicate that metronidazole reacts directly with the reactive
oxygen species generated by PMN due to its
high electron affinity [12,13,19]. The drug
therefore displays a scavenging mechanism
which operates in a dose-dependent manner
(Table 1).
The reducing effect of the high electron
affinity of nitro group themselves is much
less than that of oxygen [7,8,19]. Inhibition
of CL by direct electron transfer from the
227
cellular pool of reducing agents (such as
NADPH) to the high electron affinity nitro
group may be the mechanism. Therefore,
the extent of the stimulation of oxygen consumption that might occur during metabolism will be affected [7,8,19]. Alternatively,
the nitro group may react directly with molecular oxygen and prevent the formation of
H2O2. In our study the drug might mediate
the cellular pools in cell respiration during
metabolism [7,8,12,19].
We found all concentrations of the drug
were inhibitory and the inhibition was dose
dependent. The degree of inhibition increased with the time of incubation with
the drug (maximum inhibition was within
about 30 minutes of incubation with the all
drug concentrations; data not shown) suggesting depletion of reducing equivalents,
i.e. intermediates (e.g. NADPH) which
serve as electron sources in cell respiration
[12]. Similar effects due to depletion of
electron sources have been reported for
5-nitroindazole and derivatives [10,11],
which are known to stimulate cellular oxygen utilization.
The NBT test provides an easy method
to screen PMN cell activity for its capacity
Table 1 Reduction of nitroblue tetrazolium (NBT) and chemiluminescence (CL) dependent
activity of polymorphonuclear cells in whole blood with different concentrations of the
metronidazole
Drug concentration
(?g/mL)
0 (control)
4.98
6.64
11.62
16.60
34.86
P-value
NBT reduction
(absorption)
0.881
0.760
0.647
0.566
0.503
0.121
% NBT
reductiona
0
13.7
26.6
35.7
42.9
86.2
0.01
Mean (SD) CL
% CL inhibition
peak height (mm)
117 (60)
0
102 (5)
12.8
87 (7)
25.6
74 (6)
36.8
68 (7)
41.9
17 (3)
85.5
0.01
SD for NBT readings were too small to be considered.
Measurements were in duplicate.
SD = standard deviation.
a
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to undergo oxidative metabolism. Failure
by PMNs to reduce NBT may be due to the
rapid depletion of NADPH reduction capacity in the cell, which leads to very little O2
production when stimulated.
It has been reported that metronidazole
protects tissue from NSAID-induced enteropathy [20]. The possible mechanism is
due to its reduction of the increase in mitochondrial oxygen consumption induced by
NSAID (caused by coupling of mitochondrial oxidative phosphorylation) [20,21].
Our result conforms with this as metronidazole caused a significant reduction in
the free radicals generated by PMN in the
luminol-dependent chemiluminescence.
Metronidazole in the therapeutic range
studied in this work does not alter the func-
tional activity of PMN in whole blood. The
inhibition of CL signal or the reduction in
the absorbance by NBT is due to the scavenger effect of the drug at the extracellular
level (phagocytosis of foreign particles did
occur; image slides not shown).
In conclusion, the electron affinity properties of metronidazole allow it to react
with metabolic reducing agents (such as
NADPH) and oxygen radicals, which prevents the formation of H2O2, the oxidizing
agent formed during metabolic activity. Our
data conform with the idea of the scavenger
effect of metronidazole on active oxygen
radicals generated in the cell [20,21].
References
1.
Robert AF, ed. Free radicals and cancer.
New York, Marcel Dakker, 1982:325.
2.
Stratford IJ. Bioreductive drugs in cancer
therapy. In: Denkamp J, Hirst DG, Eds.
Radiation science: of molecules, mice
and men. London, British Institute of Radiology, 1992:128√36 (British journal of
radiology supplement 24).
3.
4.
5.
Zharkov VV et al. [The immediate results
of the use of isometronidazole in the
combination therapy of patients with lung
cancer]. Meditsinskaia radiologiia, 1991,
36(7):18√20 [In Russian].
Wong KH, Maezawa H, Urano M. Comparative study of thermoradiosensitization
by misonidazole and metronidazole in
vivo: antitumour effect and pharmacokinetics. International journal of hyperthermia, 1992, 8(5):645√58.
Acharya DK. Role of metronidazole in
radiation therapy (a review of 717 cancer
cases). Indian journal of medical sciences, 1994, 48(5):111√6.
6.
Galecki J et al. [Comparison of the effectiveness of different methods of irradiation
using metronidazole as a radiation-sensitizing agent in patients with laryngeal
cancer. Controlled clinical studies]. Nowotwory, 1989, 39(2):111√5 [In Polish].
7.
Shchepetkin IA. [Metronidazole effect on
active oxygen production by human blood
neutrophils]. Antibiotiki i khimioterapiia,
1997, 42(8):38√41 [In Russian].
8.
Akamatsu H, Horio T. The possible role
of reactive oxygen species generated by
neutrophils in mediating acne inflammation. Dermatology, 1998, 196(1):82√5.
9.
Brown JM. The hypoxic cell: a target
for selective cancer therapy≈eighteenth
Bruce F. Cain Memorial Award lecture
Cancer research, 1999, 59:5863√70.
10. Overgaard J. Clinical evaluation of nitroimidazoles as modifiers of hypoxia in
solid tumors. Oncology research, 1994,
6:509√18.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
11. Rajendran JG et al. Hypoxia and glucose
metabolism in malignant tumors: evaluation by [18F] fluoromisonidazole and
[18F] fluorodeoxyglucose positron emission tomography imaging. Clinical cancer
research, 2004, 10(7):2245√52.
12. Rogers MAJ, Powers EL, eds. Oxygen
and oxyradicals in chemistry and biology.
New York, Academic Press, 1981:349√
54.
13. Googman SI et al. Molecular cloning and
expression of a cDNA encoding human
electron transfer flavoprotein-ubiquinone
oxidoreductase. European journal of biochemistry, 1994, 219:277√86.
14. Gordan JM, Walker CB. Current status
systemic antibiotic usage in destruction of
periodontal disease. Journal of periodontology, 1993, 64(Suppl. 1):760√71.
15. Eick S et al. Clindamycin promotes phagocytosis and intracellular killing of periodontopathogenic bacteria by crevicular
granulocytes: an in vitro study. Journal
of antimicrobial chemotherapy, 2000,
46:583√8.
16. Van Vlem B et al. Immunomodulating effect of antibiotics: Literature review. Infection, 1996, 24:275√91.
229
17. Metcalf JA et al. Laboratory manual of
neutrophil function. New York, Raven
Press, 1986:100√5.
18. Al Hashimi AH, Al Krawi EA. A study of
the redox and kinetic functional activity
of respiratory bursts in normal granulocytes of human whole blood by means
of lucigenin and luminal dependent CL.
Basrah University Medical Journal, 2000,
18(2):22√5.
19. Shchepetkin IA, Iur▓ev SI. [Effect of metronidazole on luminol dependent chemiluminescence of neutrophils in whole blood
of patients with chlamydial infection]. Antibiotiki i khimioterapiia, 1998, 43(3):31√6
[In Russian].
20. Davies NM, Jamali F. Pharmacological
protection of NSAID-induced intestinal
permeability in the rat: effect of tempo
and metronidazole as potential free radical scavengers. Human & experimental
toxicology, 1997, 16:345√9.
21. Leite AZ et al Protective effect of metronidazole on uncoupling mitochondrial oxidative phosphorylation induced by NSAID: a
new mechanism. Gut, 2001, 48:163√7.
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Case report
Diffuse myelitis in a 9-month-old
infant: case report and review of the
literature
O. HЭdaoglu,╧ U. Yis,╧ S. Kurul,╧ H. ?akmakГi,2 M. Saygi3 and E. Dirik1
Introduction
Acute transverse myelitis is a rare but severe inflammatory demyelinating disorder
that usually involves both sensory and motor tracts of the spinal cord [1]. It is characterized by rapid onset of paraplegia or
tetraplegia, loss of sensation and sphincter
disturbance, and in rare cases it can cause
respiratory insufficiency. This disease occurs commonly among adults and rarely in
the paediatric population, especially children under 2 years of age [2,3]. The exact
pathophysiological mechanisms and trigger
factors that result in neural injury are not
well understood. However, recent studies
point to a variety of humoral and cellular immune derangements that potentially
result in neuronal injury and demyelination═[4,5].
We report a case of a 9-month-old boy
who presented with a 1 month evolving history of progressive generalized weakness.
Case report
A 9-month-old male patient was admitted
to the paediatric neurology department because of progressive generalized weakness
which had started 1 month before. There
were no important features in his prenatal,
natal and postnatal history, except an upper
respiratory tract infection 3 weeks before
the clinical onset of symptoms. The family
history was unremarkable.
On physical examination he was oriented to person and his vital signs were
within normal limits. He was not able to
move any limbs, muscle tone was decreased
and deep tendon reflexes were absent in his
upper and lower extremities. He was crying
in response to pain, but unable to move his
limbs. Abdominal, cremasteric and anal
reflexes could not be obtained. Babinski
sign was absent. Cranial nerves were intact.
The remainder of the physical examination
was normal.
In order to rule out spinal cord pathology, craniospinal magnetic resonance imaging (MRI) was obtained immediately. On
T2 weighted images, a diffuse, symmetrical
increased signal within the whole spinal
cord was observed. Lesions showed no
contrast enhancement (Figure 1). Contrastenhanced MRI angiography demonstrated
normal vascular structures. No other abnormality was detected. Cranial MRI revealed
no abnormality.
On laboratory examinations, the haema╜
tological and biochemical parameters for
serum were within normal ranges. Cerebrospinal fluid protein was 15.8 mg/dL (15√40
╧Department of Paediatric Neurology; 2 Department of Paediatric Radiology; 3Department of Paediatrics,
Dokuz EylЭl University School of Medicine, Izmir, Turkey (Correspondence to U. Yis: ulyis@yahoo.com).
Received: 18/06/06; accepted: 06/08/06
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
231
enterovirus≈demonstrated no abnormalities. Electromyography was normal.
The patient was diagnosed with diffuse
myelitis and treated at first with intravenous
(IV) immunoglobulin (400 mg/kg/day for
5 days). Response to IV immunoglobulin
treatment was delayed for 1 week but because of insufficient remission in his clinical
condition, IV pulse methylprednisolone (30
mg/kg/day for 3 days) was started. On day
5 of steroid treatment there was a marked
improvement in head control and on day
10 of steroid treatment the patient was able
to sit and move his upper and lower limbs
Figure 1 T2 weighted sagittal magnetic
resonance image showing increased signal
within the whole spinal cord and medulla
oblongata
mg/dL is the normal range for cerebrospinal
fluid protein in our laboratory) and glucose content was 58 mg/dL (simultaneous blood sugar 90 mg/dL). There was no
pleocytosis. No malignant cells were seen
in the cerebrospinal fluid. Cerebrospinal
fluid anti-GM1 ganglioside antibodies and
oligoclonal band were negative and the IgG
index was normal. Serum and cerebrospinal fluid serological analysis≈including
herpes simplex 1 and 2, varicella zoster,
cytomegalovirus, Epstein√Barr virus, rubella, measles, mumps, mycoplasma and
Figure 2 Control magnetic resonance imaging
demonstrating decreased lesion signal in the
involved spinal cord
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, N╟ 1, 2009
independently. Post-treatment magnetic
resonance imaging demonstrated decreased
lesion signals in the involved spinal cord
(Figure 2).
Discussion
The differential diagnosis of an acute disease of the spinal cord includes many conditions [6,7]. Bacterial abscesses, spinal
cord tumours, vascular malformations and
haematomas can be excluded with neuro╜
imaging methods. In the present case the
symptoms and signs included quadriparesis
and areflexia. These findings were typical of spinal cord syndrome, warranting
urgent imaging of the cord to exclude a
space-occupying lesion such as a neoplasm,
vascular malformation or haemorrhage.
Cranial neuroimaging is also necessary
to rule out cerebral involvement, as occurs in multiple sclerosis or acute disseminated encephalomyelitis [8]. Furthermore,
immunologic disease of the spinal cord
may not be confined to the spinal cord, but
may also involve the motor neurons and/or
the peripheral nerves, and for this reason
every case should be evaluated with electromyography. Clinical, radiological and
electro╜physiological findings in this patient
showed isolated diffuse myelitis.
Acute transverse myelitis affects all ages
except children under 2 years. The present
case was 9 months old and to our knowledge he is the one of the youngest cases
in the literature with diffuse, symmetrical
spinal cord involvement.
Three pathophysiological mechanisms
seem to be responsible in the etiology of
acute transverse myelitis: direct infection
of the spinal cord; myelitis because of a
systemic disease such as leukaemia or a
connective tissue disorder; and autoimmunity [9,10]. The last group is the most
common form of myelitis and may occur as
a post- or parainfectious condition [11]. In
30%√60% of idiopathic myelitis cases there
is an antecedent respiratory, gastrointestinal
or systemic illness. On the other hand, several reports of myelitis and central nervous
system demyelinating lesions following
vaccination with for example influenza and
hepatitis B have recently been published
[12,13]. It is likely that there is abnormal
activation of the immune system resulting
in inflammation and injury within the spinal
cord. Autopsy evaluation of the spinal cord
has revealed severe axonal loss with mild
demyelination and a mononuclear infiltrate,
predominantly T lymphocytes in the nerve
roots and spinal ganglia. It is possible that
the concomitant exposition of 2 different antigens (viral respiratory infection
and immunization) increase the risk of an
abnormal immune-mediated response in
genetically susceptible individuals [14√17].
The patient had no evidence of a systemic
infectious disease but he had a history of
a viral respiratory infection. It is probable
that this child had post-infectious myelitis
as the neurological symptoms followed the
infection by 3 weeks.
While some reports found high-dose
methylprednisolone to be effective in acute
transverse myelitis, some found no difference
between patients given prednisolone, highdose methylprednisolone or gammaglobulin
[18,19]. The present case was treated as first
step with IV immunoglobulin because of
the undesired adverse effects of steroids in
this age group. Although the response to IV
immunoglobulin may not appear directly
after treatment, and may be delayed days or
weeks, IV methylprednisolone was started
because of poor remission and to prevent
a worse outcome such as respiratory insufficiency. The response to steroid treatment
was excellent and the patient recovered
rapidly in the first week of steroid treatment. Regardless of age, patients should
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
be treated as a first step with steroids and
if there is no or insufficient response, IV
immunoglobulin, plasmapheresis or other
immunosuppressive drugs should be tried
as alternative treatments.
The outcome of acute transverse myelitis among childhood cases has been cited in
many cases as ⌠good■ and despite reports of
fatalities, outcome is considered to be better
for children than adults [3,6]. Recovery, if
it occurs, should begin within 6 months,
and most patients begin to show some restoration of neurological function within 8
weeks [20]. Our findings do not support the
MRI evidence of diffuse myelopathy, such
as hyperintensity on T2-W images, patchy
enhancement and contrast enhancement
(which are important prognostic indicators of poor outcome in childhood myelitis
[21]), since the case recovered quickly
after the steroid treatment despite diffuse
233
involvement of the spinal cord. However, in
keeping with previous reports, the present
case supports the findings of Andronikou
et al. who demonstrated 3 cases in which
the extensive spinal cord hyperintensity
on T2-W images did not correlate with
the severity of the clinical presentation or
outcome [22].
In conclusion, acute transverse myelitis
is a rare but severe inflammatory demyelinating disorder of the spinal cord. It is very
rare in the paediatric population, especially
children under 2 years of age. Although
the involvement of the spinal cord in acute
transverse myelitis is segmental, children
may present with entire spinal involvement.
In the differential diagnosis of acquired
hypotonia in infants, myelitis should always
be considered and immediate MRI of the
spine must be done to reach a diagnosis.
References
1.
Tartaglino LM et al. Idiopathic acute transverse myelitis: MR imaging findings. Radiology, 1996, 201:661√8.
2.
Murthy JM et al. Acute transverse myelitis: MR characteristics. Neurology India,
1999, 47:290√3.
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of magnetic resonance imaging in acute
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33 cases, with differentiation of cases
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Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
235
Case report
Oral contraceptive pills and
inherited thrombophilia in a
young woman with deep venous
thrombosis
R.A.R. Mahfouz,1 Z.K. Otrock,2 M.A. Ghasham,1 A.S. Sabbagh,1 A.T. Taher?2 and
A. Bazarbachi?2
Introduction
Inherited risk factors for vascular disease
include factor V Leiden [1], prothrombin
[2] and methylenetetrahydrofolate reductase (MTHFR) point mutations [3]. The use
of oral contraceptives is also a recognized
risk factor for venous thromboembolism
[4]. In Eastern Mediterranean countries, the
highest frequency of factor V Leiden was
reported in Lebanon (14%) [5,6]. However,
there are no studies related to awareness of
the use of oral contraceptive pills among
individuals with a high risk for thrombotic
events.
Here we present the case of a female
patient on oral contraceptive pills who sustained an extensive deep venous thrombosis (DVT). The patient was found to be
hetero╜zygous for factor V Leiden (G1691A)
and homozygous for the MTHFR (C677T)
mutations.
Case report
Our patient, a 21-year-old Lebanese woman,
had been hospitalized in another hospital
5 months previously for pain and swell-
ing of the left lower extremity. She also
complained of low back pain of the same
duration. She was a non-smoker with no
known medical problems. Her body mass
index was 22 kg/m2. She was taking combined oral contraceptive pills for her irregular menstrual periods. Venous doppler
ultrasonography showed extensive DVT
involving the entire length of the common
femoral, popliteal and calf veins extending into the left external iliac and common
iliac veins. She had initially received anticoagulant treatment with heparin and was
later discharged on warfarin 5 mg/day to
maintain an international normalized ratio
of 2.5√3.0. The patient had no family history of thrombotic events.
The patient was seen in our institution for
follow-up. In addition to the regular blood
and chemistry studies, she was screened
for acquired and inherited thrombophilia.
The work-up revealed that the patient was
heterozygous for factor V Leiden (G1691A)
and homozygous for MTHFR (C677T)
mutations (Figure 1) with a normal serum
homocysteine level. The work-up also included fibrinogen level, factors VII and
VIII activities, lupus anticoagulant and
Department of Pathology and Laboratory Medicine; 2Department of Internal Medicine, American University
of Beirut Medical Centre, Beirut, Lebanon (Correspondence to R.A.R. Mahfouz: rm11@aub.edu.lb).
Received: 06/04/06; accepted: 30/07/06
1
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Figure 1 Staining pattern of hybridized DNA from patient (A), normal positive control (B),
negative control (C) and Viennalab Stripassay (D). Insert shows pattern of hybridization
anticardiolipin/antiphospholipid antibodies,
antithrombin III, protein S and protein C.
DNA was extracted from the sample according to the extraction protocol supplied
by the manufacturer (factor V StripAssay,
ViennaLab, Austria). Briefly, a 100 ?L
blood sample was lysed twice in red blood
cell lysis buffer. The reaction tubes were
run at the following conditions: 940C for
2 min followed by 30 cycles of 940C for
15 s, 580C for 30 s, and 720C for 30 s.
Hybridization of the amplified product to
the test strips was then conducted, followed
by 2 stringent washing steps and colour
development. The samples were interpreted
by comparing the staining pattern of the
corresponding processed test strip with the
decoder table provided by the manufacturer.
The targeted mutations of the above assay
are: factor V G1691A, factor II G20210A
and MTHFR C677T.
The patient▓s activated protein C resistance was 1.8 (reference range > 2.1). She
had an identical twin sister who had the
same thrombophilia profile with no associated events. The patient▓s father was found
to be homozygous for factor V Leiden and
heterozygous for the MTHFR mutations,
while her mother was normal for factor V
and heterozygous for MTHFR gene mutations. The patient was advised not to
use oral contraceptives. She continued her
oral anticoagulation for 9 months, and the
follow-up venous doppler ultrasonography
showed recanalization of the thrombosed
veins. Two years after the incident, the
patient is not on oral contraceptive pills and
is doing well with no recurrence of DVT.
Discussion
Factor V Leiden is the most common inherited risk factor for venous thrombosis.
The risks are estimated to be increased up
to 5√10-fold for heterozygous and 50√100fold for homozygous adults respectively
[7]. In Eastern Mediterranean countries, a
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
high prevalence of factor V Leiden has been
reported in healthy individuals, ranging
from 7% to 14%, with the highest frequency
reported in Lebanon (14%) [5,6].
The prevalence of MTHFR C677T mutation in Lebanon has been assessed. It
was found that Lebanon has a relatively
high prevalence of the homozygous T/T
genotype (11.04%) compared to that seen
in European countries, including Germany
(10.4%) and Greece (10.0%), and southeast Asian communities [8].
The use of combined oral contraceptives is a recognized risk factor for venous
thrombo╜embolism, and their use is itself associated with a 2√4-fold increase in the risk
of venous thromboembolism, regardless of
the presence of other genetic or acquired
risk factors [4]. Progestin-only contraceptives were shown to be a safer alternative
to the combined oral contraceptive pills [9].
The presence of inherited thrombophilia increases the risk of venous thromboembolism
due to oral contraceptives up to an absolute
risk of 3/1000 person-years, in comparison with the baseline risk of 3√6/10═000
person-years [10]. It is well known that oral
contraceptive treatment often constitutes a
trigger factor for venous thromboembolism,
very often the first episode, when given to
women who carry an unrecognized thrombo?
philic condition [11]. The question has been
raised whether it is worth screening women
for thrombophilic alterations before the use
of oral contraceptives [12,13].
It has been previously reported that factor V mutations display a strong interaction
with oral contraceptive use [14], with hetero?
zygous carriers using oral contraceptives
having a 30√50-fold increased risk of
thrombosis compared with women who do
not use oral contraceptives and who have a
normal factor V genotype.
237
Our patient was on oral contraceptives
and developed DVT. She was found to be
heterozygous for factor V Leiden and homo╜
zygous for the MTHFR mutations, which
increased her risk of thrombosis. She had
a twin sister with the same thrombophilia
profile but no associated thrombotic events.
In their interesting article, Salomon et al.
determined the prevalence of single and
combined prothrombotic factors in patients
with idiopathic venous thromboembolism
and estimated the associated risks in a study
group consisting of 162 patients referred
for work-up of thrombophilia [15]. Two
or more polymorphisms were detected in
27 patients (16.7%) and in 3 of 336 controls (0.9%). Logistic regression analysis
disclosed odds ratios of 58.6 for joint occurrence of factor V and factor II polymorphisms, of 35.0 for factor V and MTHFR
polymorphisms, and of 7.7 for factor II and
MTHFR polymorphisms. The authors concluded that the presence of more than one
of the prothrombotic polymorphisms was
associated with a substantial risk of venous
thromboembolism.
Whether patients in our region should
be screened for inherited thrombophilia
before taking oral contraceptives is not
known, albeit we recognize the relatively
high prevalence of these mutations in the
Eastern Mediterranean Region. It is also
important to state that cost√benefit analysis
studies should be conducted to evaluate
whether screening for factor V, factor II,
and MTHFR gene mutations (expensive
testing) is cost√effective or not regarding
morbidity or mortality incurred by oral
contraceptive pills users. This has not been
previously investigated in a high-prevalence
setting such as in Lebanon (and the Eastern
Mediterranean Region in general). We open
the door for future research in this field.
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???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Obituary
The scientific community has lost an eminent scientist, the late Dr Ahmed
Amin El-Gamal, who passed away on Friday 11 July 2008, after an active
career in the scientific field in several health disciplines.
Born in Egypt, Dr El-Gamal graduated from the Faculty of Medicine, Cairo University in 1950 after which he obtained a diploma in ophthalmology
from the same Faculty. Subsequently he became a fellow of the International College of Surgeons and a fellow of the Society of Ophthalmologists.
He practised ophthalmology under the Egyptian Ministry of Health and
became Senior Under-Secretary from 1982 until 1986. He was also interested in medical research and was a member of the Council of Medical
Research of the Egyptian Academy of Scientific Research and Technology.
Environmental matters were another interest and he was technical adviser
to the Egyptian Environmental Board since its inception.
Dr El-Gamal maintained working relations with the World Health Organization (WHO). He frequently attended the World Health Assembly (WHA) in
Geneva as a member of the Egyptian delegation. In 1985 he was elected
Vice-Chairman of the WHO Executive Board.
Dr El-Gamal was also much involved in the area of authorship, translation and publishing. He played an active role in the implementation of the
WHO programme for Arabic documents and publications since its beginning in 1975. He co-authored a valuable textbook entitled Atlas of eye
diseases in the Arab countries, published in Arabic and English by the Arab
Center for Medical Literature in 1995. In the last stage of his busy working
life, Dr El-Gamal was appointed Executive Director of the Egyptian Society
for the Dissemination of the Universal Knowledge and Culture, an Egyptian
Society involved in the field of authorship, translation and publishing. Under his supervision, that society published scores of Arabic and arabized
books, including some WHO publications.
In appreciation of his scientific merits and achievements, he was appointed a member in the Egyptian National Specialized Boards, which are
scientific councils of eminent scientists in various specialties in Egypt.
They study and detail socioeconomic problems and submit recommendations to the Presidency of the Republic.
God bless the soul of Dr El-Gamal. His devotion to public service and
his personal merits and characteristics gained him the high respect and
affection of his colleagues.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
239
??La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009??
?гАхчга ЕАА ФмоЕ?
?щчо гЦАлйЦз гАзАЦМ згЦА Пг лАМ П?
?гА ЕФ гЦАшщФя АЕ гАоъйФя цЦмо цЦДМ глАЦА гАпМ ФгщйЕ гЦАДМи?
?МФЦ глАЦзи ? 2008/7/11?хзо мМги мгщАи хгАДтгь гАзАЦМ ФгеАДлгргй гАзЦАМи Мщ лЦггАй?
?умМи Цйзоои?.??
?нйял ЦД ъАМи гАьх хлгЦзи гАчгЕяи згЦ?
?гАзяхМи?.??
?Цяу?
?ЦлЕФяМи?
?ЦФгАМо?
?ЦД?
?гАъяМЦ?
?ФгАщчМо?
?Ь?
?? .1950?ФМщ сДи ? 1953?муА зЛА охАФЦ ьх Флягми гАзДМ ЦД Дщс гАъАМи? .?ъгЦ муА хзо?
?пАъ зЛА рЦгАи ъАМи глАягмДМ гАоФАМи ФрЦгАи ЦлзМи лягмМ гАзМФД? .?ФЦгяс ьх гАзМФД Мщ?
?ЦФгчз ЦяйчМи хФргяи гАуми гЦАяуМи мйЛ йчАо ЦДух гАФъМА гцАФА ААФргяи ЦД згЦ ? 1982?еЛА?
?згЦ ? .1986?ФйчоМя Пг гАЕйгЦЦЕ хгАхмФк гАьхМи гнйяМ зжФ Пг хЦлАс гАхмФк гАьхМи хцъгоМЦМи?
?гАхмк гАзАЦМ ФгАйъДФАФлМг хЦяу? .?ФйчоМя Пг гАЕйгЦЦЕ хтдФД гАхМфи УзДМ Цсйтгя Пг лАЕгр?
?тдФД гАхМфи гЦАяуМ ЦДп еДтгфЕ?.??
?ФъгД ААоъйФя глАЦА згАчгй зЦА ФкМчи Цз ЦДыЦи гАуми гАзгЦАМи? ║?щчо йъяя мжФяЕ?
?ЦлзМгй гАуми гАзгЦАМи Мщ лДМщ зжФ Пг Мщ гАФщФо гЦАяуМи гЦАйзгчхи еЛА йАъ глАЦзМгй? .?ФМщ сДи?
?? 1985?йЦ гДйнгхЕ Дгфх Пг АяфМс гЦАлАс гАйДщМпМ ААЦДыЦи хлДМщ?.??
?ФкЦи лЦгА бня ъгД МЦкА яъД Пг ЦЕ ПгЦ Мщ гЕйгЦЦгй гАоъйФя цЦДМ глАЦА ЕФ лЦгА гАйцАМщ?
?ФгАяйЦли ФгАДят? .?АпАъ ъгД АЕ оФя ЦтъФя Мщ йДщМп гАяхДгЦл гАзяМх АФкгфч ФЦДтФягй ЦДыЦи?
?гАуми гАзгЦАМи ЦДп хоц Мщ сДи ? .1975?ъгЦ гтяйъ Мщ йцАМщ ъйгх ЦялзМ зДФгДЕ ⌠цьАс?
?цЦягж гАзМФД Мщ гАоФА гАзяхМи■ уоя хгААшйДМ гАзяхМи ФгеАДъАМрМи ЦД гЦАяър гАзяМх ААФкгфч?
?ФгЦАьхФзгй гАумМи хгАъФМй ФпАъ Мщ сДи ? .1995?ФМщ гЦАямАи гцАняМи ЦД мМгйЕ гАзЦАМи?
?гАргняи?У ║?зДМ гАоъйФя глАЦА ЦоМя Пг йДщМпМ Пг ААлЦзМи гЦАяуМи АДят гЦАзящи ФгАкчгщМи гАзгЦАМи?║??
?ФЕМ Цдсси ЦяуМи ДтМьи Мщ лЦгА гАйцАМщ ФгАйэяЦли ФгАДят? .?ФхеятгщЕ гАщДМ ФгеАогяМ?
?ФгЦАзяхи? ║?ФЦД хМДЕг хзж ЦДтФягй ЦДыЦи?
?Дятй ЕпЕ гЦАдсси зятгй ЦД гАъйх гАзяхМи?
?Ь?
?гАуми гАзгЦАМи?.??
?ФйчоМя Пг АъщгайЕ ФЦъгДйЕ гАзАЦМи ФчоягйЕ гАзЦАМи ФеДлгргйЕ ьФгА мМгйЕ гАзЦАМи? ║?щчо йЦ?
?йзММДЕ зжФ Пг хгЦАлгАс гАчФЦМи гЦАйнууи Мщ Цяу? ║?ФЕМ лЦгАс зАЦМи йжЦ зАгЦа цлгАа Мщ?
?нЦйАщ гАйнуугй ФгнАоЦгй Мщ Цяу? .?ФЕМ йояс нЦйАщ ЦтъгАй гмАМги гАМФЦМи Фйящз?
?йФуМгЕйг еЛА яфгси глАЦЕФяМи?.??
?ямЦ гЕАА гАоъйФя цЦДМ глАЦА? ║?щчо ъгД Цкг П?
?гА ААйщгМД Мщ гнАоЦи гАзгЦи мЦАМ Пг ФечАМЦМ Пг ФоФАМг?П║??
?хгеАжгщи еЛА нугА тнуМи ящМзи лзАйЕ мЦА гАйчоМя ФгЦАмхи ЦД ъА рЦгАфЕ ФйгАЦМпЕ?
?ФгАзгЦАДМ ЦзЕ Мщ ъА ЦФчз?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??240??
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
241
Eastern Mediterranean health journal
reviewers▓ panel, 20081
The Eastern Mediterranean health journal thanks the following experts for their kind assistance in the review of papers considered for publication during the year 2008.
Professor M. Yosri Abdel-Mohsen
Professor Mohammad Abdel-Sabour
Professor Ekram Abdel-Salam
Dr Alaa Awny Ramzy Abd-Elsayed
Mr Jalaa Abdelwahab
Professor Ahmed Ezzat Abdou
Dr Asmaa Ahmed Abdulsalam
Professor Hamdy Mohammad Abo Baih
Professor Mostafa Abdelfattah Abolfotouh
Professor Kamilia Ragab Abou Shabana
Dr Niveen Abu-Rmeileh
Professor Ahmed Awad Abdel-Hameed
Adeel
Dr Daher Aden
Professor Salim Adib
Dr Hinda Jama Ahmed
Professor Kamel Ajlouni
Dr Tasleem Akhtar
Ms Deena Alasfoor
His Exellency Dr Abdel Rahman Al-Awadi
Dr Sadika Al-Awadi
Dr Suleiman Mohamed Al-Busaidy
Professor Mohamed Khalil Habib
Al-Haddad
Dr Moazzam Ali
Professor Abdul Ghani M.A.H. Al Samarai
Al-Kadri
Professor Ahmed M.B Alkafajei
Dr Yagoub Yousif Al-Kandari
Dr Jawad Al-Lawati
Professor Widad Al-Nakib
Dr Mohannad A.A. Al-Nsour
Dr Asya Ali Al-Riyami
Dr Najeeb Al-Shorbaji
Professor Abdulrahman Al-Tahan
1
Dr Nabil Al-Tawil
Dr Jorge Alvar
Professor Ezzat Khamis Amine
Dr Michael Angastiniotis
Dr Jala▓a Anwar
Professor George F. Araj
Dr Hossein Malekafzali Ardakani
Dr Mohamed Assai
Dr Fazal Ather
Professor Fereidoun Azizi
Dr Hanan Al-Sayed Badr
Dr Kunal Bagchi
Dr Samiha Baghdadi
Dr Faraj Barah
Dr Rashida Barakat
Dr Hyam Bashour
Dr Anwar Batieha
Dr Andre Eugene Beljaev
Dr Faten Ben Abdelaziz
Professor Abdulbari Bener
Professor Laila Maurice Boulos
Professor Chein-Wei Chang
Dr Irtaza Ahmad Chaudhri
Dr Carlo Chizzolini
Professor Kian Fan Chung
Dr Antoinette Cilliers
Professor Alvaro A. Cruz
Dr Filippo Curtale
Professor Maria L?cia Zaidan Dagli
Professor Fazal Karim Dar
Professor Adekunle Dawodu
Dr Jocelyn DeJong
Professor Ram?n Diaz
Professor Laila Shehata Abdel Hameed
Dorgham
Arranged in alphabetical order according to the family name.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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Dr Samiha Samuel Wissa Doss
Dr Bassel H. Doughan
Dr Nabil Dowidar
Professor Valsamma Eapen
Professor Gholam-Hossein Edrissian
Professor Rajae El-Aouad
Professor Mohamed Farid El-Asmer
Professor Mohamed Hassan Abdel Falah
El-Banouby
Professor Hussein El-Charkawi
Professor Abdul Salam El-Gatit
Professor Zenab El-Gothamy
Professor Magdy El-Guinaidy
Dr Abdalla Ismail Elgzoli
Professor Anissa Mahmoud El-Hefny
Dr Eman Ellabany
Dr Mohamed Elmi
Professor Medhat A. El-Mofty
Professor Mervat El-Rafie
Professor Mohamed El-Saad El-Rifaie
Professor Farouk Mohamed F. El-Sabban
Professor Aisha Awad El-Sayed
Professor Hamdy Mahmoud El-Sayed
Professor Salah Nagiub El-Tallawy
Dr Sarah Beatrice England
Dr Mounir Farag
Professor Mahmoud Fahmy Fathalla
Dr Michelle Karen Funk
Professor Salma Badr El-Din Galal
Dr Haileyesus Getahun
Dr Gihan Ismail Gewaifel
Professor Mohamed Ghanem
Professor Cheherezade Ghazi
Professor Rita Giacaman
Professor Gamal Gordon
Professor Bulent Gorenek
Dr Allan Gottschalk
Mr Peter Graaff
Dr Margaret Grigg
Dr Motasim Habiballah
Dr Jalil Hariri
Professor Ezzeldin Osman Hassan
Professor Ali Sadeghi Hassanabadi
ProfessorAbdel Moneim Helal
Dr Mohamed Kamal Helmi
Professor William H. Herman
Ms Joumana Hermez
Professor Claus Christian Heuck
Dr Pierre Huguet
Professor Gerry Humphris
Professor Mohamed Amr Hussein
Dr Syed Jaffar Hussein
Dr Seif El-Din Saleh Hussein
Dr Abdullatif Husseini
Professor Nahla Chawkat Hwalla
Dr Nahla Khamis Ragab Ibrahim
Professor Carel IJsselmuiden
Dr Jamshaid Iqbal
Dr Mushira Ismail
Dr Ivan Dimov Ivanov
Dr John Jabbour
Dr Ibrahim Ali Kabbash
Professor Samir Mohamed Kabil
Professor Mohamed I. Kamel
Professor Laila Mahmoud Kamel
Dr Zeina A. Kanafani
Dr Kassem M. Kassak
Professor Hasan Kayali
Dr Andrew Kennedy
Dr Yousef Saleh Khader
Professor Mohammed Hussein Moh▓d
Khalil
Mr Hamzullah Khan
Dr Ibrahim Fahmy Kharboush
Dr Zahra Khatami
Dr Hamida Khattabi
Professor Marwan Khawaja
Dr Ali Khogali
Dr Tawfik A.M. Khoja
Dr Imad Abdul-Hamed Khriesat
Dr Patrick Kolsteren
Professor Nabil Kronfol
Dr Stella Kwan
Dr Adeera Levin
Professor David MacLean
Dr Haifa Madi
Dr Emad A. Magdy
Dr Ramez Mahaini
Dr Dermot Maher
Professor Ahmed Abdel Rahman Mahfouz
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
Dr Amr Mahgoub
Professor El-Sheikh Mahgoub
Dr Jaouad Mahjour
Professor John Matjila Maila
Dr Mamunur Rahman Malik
Professor Ahmed Mandil
Dr Mohamed Mansour
Dr Silvio Paolo Mariotti
Miss Yukiko Maruyama
Professor Mohamed Naguib Massoud
Dr Simon Maxwell
Professor Afaf I. Meleis
Dr Mohammed Osama Mere
Professor Mohamed Mokhtar Messahel
Dr Nabila Metwalli
Dr Aleksandar Mijovic
Professor Anthony B. Miller
Dr Hisham Mohamed Mirghani
Dr Zafar Mirza
Dr Atarod Modjtabai
Professor Tosson Aly Morsy
Professor M. Salah Mostafa
Professor Mona Ibrahim Mourad
Dr Essam Mousa
Dr A. Taher Moustafa
Professor Mohamed M. Nada
Professor Kamal Naguib
Dr Boubker Naouri
Professor Fouad Wadie Nasr
Professor Samia Ahmed Nossier
Professor Nuha Nuwayri-Salti
Dr Omar Obeid
Professor Stephen Abimbola Odusanya
Dr Hiroshi Ogawa
Professor Tarek Ahmed Okasha
Professor Nancy Younes Omar
Dr Ikushi Onozaki
Dr Abdalla Sid Ahmed Osman
Dr Salah-Eddine Ottmani
Dr David Price
Dr Maqbool Qadir
Dr Farrukh Qureshi
Dr Naseem Akhtar Qureshi
Professor William A. Reinke
Dr Habib Rejeb
243
Dr Camillo Ribi
Professor Diaa Essam El-Din Rizk
Dr Gojka Roglic
Professor Ali Ahmed Ali Sadek
Dr Bijan Sadrizadeh
Dr Abdel Aziz Saleh
Professor Samira Saleh
Dr Hossein Salehi
Dr Haytham Salti
Professor Ibrahim Salti
Professor Mohamed Walid Sankari
Dr Saqer S. Al-Salem Saqer
Dr Raja Sawaya
Dr Aristarhos Seimenis
Dr Akihiro Seita
Dr Abdel Aziz Mohamed Shaheen
Dr Masood Ali Shaikh
Professor Rabah Mohamed Shawky
Dr Sherine Shawky
Dr Dina Ibrahim Hassan Shehab
Dr Ibrahim Al Hadi Sherif
Professor Mohamed Ibrahim Shoair
Professor Cees Th. Smit Sibinga
Dr Sameen Siddiqi
Dr Amany Abdel Fattah Siyam
Dr Nicos Skordis
Dr Shahram Solaymani-Mohammadi
Dr Rima Afifi Soweid
Dr Michael E. St Louis
Dr Sabira Tahseen
Professor Wagdy Talaat
Dr Mohammed Adnane Tazi
Dr Jean-Francois Tessier
Dr Maria Regina Torloni
Dr Haysam Tufenkeji
Dr Salah Tumsah
Professor Sayenna Abdulkareem Uduman
Mrs Lana Velebit
Dr Anna Verster
Ms Joanna Jessie Vogel
Professor Yousef Waheeb
Dr Momtaz Omar Wasfy
Professor Walther Helmut Wernsdorfer
Professor Keith Whaley
Professor Graham Wood
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009
Dr Mohammad Taghi Yasamy
Professor Mohamed A.H. Yehia
Dr Randa M. Youssef
Professor Salwa Mohamed Youssef
Dr Anna Yu
Mr Michel JosИ Zaffran
Dr Salah Rafik Abbas Zaher
Dr Hany Ziady
Sixth International Congress on Peer Review and Biomedical Publication
The Sixth International Congress on Peer Review and Biomedical Publication will be held from 10 to 12 September, 2009, in Vancouver,
Canada. As with the previous Congresses, the aim is to improve the
quality and credibility of biomedical peer review and publication and to
help advance the efficiency, effectiveness, and equitability of the dissemination of biomedical information throughout the world.
Following the previous 5 successful congresses, the sixth congress
will provide a forum for the presentation and discussion of new research on peer review and scientific publication.
The Congress, held every 4 years, is organized by the Journal of the
American Medical Association (JAMA) and the British Medical Journal
(BMJ).
Further information about the Sixth Congress can be found at: http://
www.ama-assn.org/public/peer/peerhome.htm.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
245
Guidelines for authors
1. Papers submitted for publication must not have been published or accepted for publication
elsewhere. The Eastern Mediterranean Regional Office reserves all rights of reproduction and
republication of material that appears in the Eastern Mediterranean health journal (EMHJ).
2. Original papers written in Arabic, English or French may be sent for consideration to the
Editor-in-chief, Eastern Mediterranean health journal, WHO Regional Office for the Eastern
Mediterranean, PO Box 7608, Nasr City (11371), Cairo, Egypt. Papers can also be submitted by
email to EMHJ@emro.who.int. Papers will be abstracted in all three languages.
3. The subject of the paper should pertain to public health or some other related technical
and scientific subject within the field of interest of the World Health Organization, with special
reference to the Eastern Mediterranean Region.
4. Three copies of each manuscript should be provided. The text, together with the accompanying
tables and figures, should not exceed 15 double-spaced typewritten or printed A4 pages (4500
words) and should be printed on one side only. When the manuscript is accepted or conditionally
accepted, the author will be requested to submit a 3.5 inch computer diskette containing the
text, tables, graphs and illustrations. For English and French papers, please provide the text,
upon the editor▓s request, in both wordprocessed format (we prefer Microsoft Word for the PC
but can translate most other formats) and also saved as a text/ASCII file. Papers submitted in
Arabic should follow the same guidelines as papers written in English or French. If the paper
is a translation of all or part of another unpublished work, a copy in the original language
should be submitted too. Where possible, graphs should be provided in Harvard Graphics under
Windows or Excel, and the illustrations and photographs should be provided in EPS or TIFF
format. However, it is necessary to provide three sets of original photographs and figures with
the background data. If there is any text or lettering on the photographs, an additional clean set
should be provided without the text/lettering.
5. All papers received will be peer reviewed, and on the basis of the reviewer▓s comments,
the Editorial Board reserves the right to accept or reject any paper. Papers are accepted on the
understanding that they are subject to statistical and editorial revision as deemed necessary,
including abridgement of the text and omission of tabular or graphic material.
6. The title of the paper should be as concise as possible, preferably around 10 words, and
should be placed on a separate sheet, together with the full name(s) of the author(s), institutional
affiliations(s) and highest scientific degrees obtained. The mailing address, as well as any other
contact information (email address, fax, telephone) of the corresponding author should be
provided. The number of authors should not exceed five. All authors should have made material
contribution to either the design, analysis or writing of the study and have approved the final
version submitted. Authors may be asked to verify their contribution. Other names may be
included in the acknowledgements.
7. To facilitate the translation of abstracts and authors▓ names, authors whose mother tongue
is written in Arabic characters and writing in English or French should supply their full names in
Arabic script and provide transliterations.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
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La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009
8. Papers reporting original research findings should follow the IMRAD format: Introduction;
Materials (subjects) and methods; Results; Analysis; and Discussion. An abstract of no more
than 100 words should be supplied, clearly and briefly stating the objectives, context, results and
conclusions.
9. Authors should verify where appropriate that all persons on whom research has been carried
out have given their informed consent, and where participants (living or dead) were unable to
give such consent, that surrogate consent was obtained.
10. Review articles should contain sections dealing with objectives, sources, methods of
selection, compilation and interpretation of data and conclusions.
11. In-text citations of published works should be limited to essential up-to-date references.
Apart from review articles, a maximum of 25 references is advisable. They should be numbered
separately as they occur in the text with sequential Arabic numerals in parentheses [square
brackets]. These references should appear in a numbered list on a separate page at the end of the
paper. They should contain the following elements of information as appropriate: name(s) and
initial(s) of author(s); title of paper or book in its original language plus translation; complete
name of journal plus volume number and page range; name of publisher (commercial or
institutional) and place of publication (city and country); and date of publication. Papers with
inadequate references or references not arranged according to these principles will be returned
to the author for correction. The following are examples of the Journal▓s preferred style:
Book: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990.
Journal article: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23√7.
Document: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization,
1985 (document WHO/DOC/537).
12. Figures and tables with appropriate captions should each be on a separate sheet, numbered
sequentially with arabic numerals and attached to the end of the paper. Each figure and table
should be referred to in the text and its placement in the text should be clearly indicated where
appropriate. Where appropriate, sources should be given for each figure or table. If any figures,
tables or other materials have been copied from other sources, authors have the sole responsibility
for securing the necessary permission. In order to avoid layout problems in final production
tables and figures should be limited as far as possible. Not more than one table or figure per 1000
words is preferable. Figures derived from data must be accompanied by those data to enable
redrawing if necessary.
13. Original papers and diskettes will not be returned except upon request by the principal
author.
14. On publication the authors will receive one copy each of the issue in which the article
appears and the principal author will receive 50 reprints. Requests for further reprints and pricing
information may be obtained from the Editor-in-chief.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
??247??
??Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009??
?гЦАлАи гАумМи Аятч гЦАйФсь?
?огАфА еятгоМи ААЦдАщДМ?
?? .1?МДхшМ цД гА йъФД гАФячгй гЦАчоСЬ Ци ААДят? ║?чо Дятй цФ чхАй ААДят Мщ цМ ЦъгД бня? .?ФмМйщы гЦАъйх геАчАМЦМ ЦАДыЦи?
?гАуми гАзгЦАМи Аятч гЦАйФсь хлЦМз мчФч гсйДсгн цФ езгои Дят гЦАФго гАйМ йДят Мщ гЦАлАи гАумМи Аятч гЦАйФсь?.??
?? .2?МЦъД цД йясА гАФячгй гцАуАМи? ║?гЦАъйФхи хгАзяхМи? ║?цФ геАДъАМрМи? ║?цФ гАщяДсМи? ║?ААДыя щМЕг ЦД Жч СхА яфМс мйяМя?
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?хгЦАъйх геАчАМЦМ ЦАДыЦи гАуми гАзгЦАМи Аятч гЦАйФсь? ║?у? .?х? ║)7608( .?хЦоМДи Дяу?
?(? ║)11371?хгАчгЕяи? ║?Мщ Цяу? .?ъгЦ МЦъД йсАМЦ гАФячгй хгАяхМо геААъяйФМД зЛА гАзДФгД ? .EMHJ@emro.who.int?ФМйЦ?
?йчоМЦ нгАугй ААФячгй? ║?хгААшгй гАкгАк?.??
?? .3?МДхшМ цД МъФД ЦФжФз гАФячгй ЦДйЦМ Пг ЦАлгА гАуми гАзЦФЦМи? ║?цФ цМ ЦМогД йчДМ ФзАЦМ бня? ║?АЕ уАи хгЦАлггАй?
?пгй гцАЦЕМи ЦАДыЦи гАуми гАзгЦАМи? ║?Цз геАтгяи хтъА нгу еЛА ечАМЦ ятч гЦАйФсь?.??
?? .4?МДхшМ йчоМЦ кгАк Дсн ЦД ъА нЦьФьи цФ ЦьхФзи? .?ъгЦ МДхшМ цД гА МйзоЛ гАДу? ║?Цз глАогФА? ║?ФгАясФЦгй гЦАягщчи?║??
?? 15?ущми ЦьхФзи зЛА гбААи гАъгйхи Цз йяъ щгуАМэД хМэД ъэА сьэя? ║?ЦэД гАчьэз ? 4500( A4?ъАЦи)? ║?ФцД йъФД гАьхгзи?
?зЛА ФлЕ Фгмо щчь ЦД гАущми? .?ФзДоЦг МйЦ езгАД гЦАдАщ хцД гЦАьхФзи гАйМ чоСЬ ЦЕг чо йЦ чхФЕАг ЦД оФД ять? ║?цФ чхФЕАг?
?хятФь? ║?МДхшМ цД МчоЖЬ Ц чяу мгсФМх (? 3?5?хФуи)? ║?МйжЦД гАДу? ║?ФглАогФА? ║?ФгАясФЦ гАхМгДМи ФгАйФжМмМи? .?ФхгАДсхи?
?ААФячгй гЦАчоСЬ Ци хгААшйДМ геАДъАМрМи ФгАщяДсМи? ║?МялЛ? ║?хДг Па зЛА ьАх яфМс гАймяМя? ║?цД МйЦ йчоМЦ гАДу? ║?Мщ РЬ?
?ъА ЦД?║??
?уМшэи ЦзглАэи гАъАЦэгй?
?(Фмхпг АФ цЦъД гсйногЦ хяДгЦл гАъАгЦй гААМДи гАочМчи ? ║Microsoft Word?хгАДсхи ААмгсФх?
?СЬ?
?гАтнМу? ║?шяМ цДДг МЦъД цД ДяйлЦ шгАхМи гАуМш гцАняЛ)? ║?ФМщ тъА мЦщФы ъДу?/?ЦАщ гАъФо гцАЦяМъМ гАчМгМс АйхгоА?
?гЦАзАФЦгй ?( ASCII?цсъМ)? .?ФМДхшМ гйхгз Дщс геАятгогй Мщ Цг МйзАч хгАФячгй гЦАчоЦи хгААши гАзяхМи? .?Фепг ъгДй гАФячи?
?гЦАчоЦи? ║?ЕМ йяЦли ъАМи цФ лрфМи АзЦА бня ЦА МДят? ║?щМДхшМ йчоМЦ Дсни ЦД Епг гАзЦА? ║?Мщ АшйЕ гцАуАМи? .?ФмМкгЦ цЦъД?║??
?МщжА цД йъФД гАясФЦ гАхМгДМэи Мщ тъА ясФЦ Егящгяо гАхМгДМэи? ║?Цз гсйногЦ хяДгЦл гАДФгщп ? Windows?цФ еъсА ?║Excel??
?ФйчоМЦ гАясФЦ гАйФжМмМэи ФгАуФя гАщФйФшягщМи Мщ уМши ? EPS?цФ ? .TIFF?ъгЦ цДЕ ЦД гАяжФяМ йчоМЦ кгАк лЦЦФзгй ЦД?
?гАуФя гАщФйФшягщМи ФгАясФЦгй гцАуАМи? ║?Цз гЦАзьМгй гцАсгсМи? .?ФМщ мгАи ФлФо цМ Ду цФ мяФщ ЦъйФхи зЛА гАуФя?║??
?щМДхшМ йчоМЦ Дсни ежгщМи нгАМи ЦД цМ Ду ЦьхФз цФцМ мяФщ ЦъйФхи?.??
?? .5?МйЦ Цяглзи ЦлМз гАФячгй гЦАчоСЬ Ци Цяглзи очМчи ЦД Жч СхА гАрЦгАа? ║?ФМщ жФа ЕпЕ гЦАяглзи? ║?мййщы ЕМфи гАймяМя хмч?
?чхФА цФ ящж цМ Фячи? .?ФЦД гЦАйщч зАМЕ цД ЦлМз гАФячгй гАйМ МйЦ чхФЕАг? ║?нйжз ААЦяглзи геАмугфМи ФгАймяМяМи? ║?хмсх?
?Цг МАрЦ? ║?хгЦ Мщ пАъ гнйугя гАДу? ║?цФ мпщ хзж глАогФА цФ гАясФЦ гАхМгДМи?.??
?Фмхпг АФ ъгД мФгМА ? 10?ъАгЦй? ║?ФцД Мъйх зЛА Фячи?
?? .6?МДхшМ цД МъФД зДФгД гАФячи нЦйяу Пг зЛА чоя гЦАсйьгз?ЬС ║??
?ЦДщуАи? ║?Цз мйоМо гсЦ гЦАдАщ (цФ цсгЦа гЦАдАщДМ)? ║?ФзжФМйЕЦ Мщ гЦАдссгй гЦАнйАщи? ║?ФцзЛА гАоялгй гАзАЦМи гАйМ?
?муАФг зАМЕг? .?ъпАъ? ║?МДхшМ пъя гАзДФгД гАяхМоМ? ║?ФгЦАзАФЦгй гцАняЛ гАгАрЦи АгАйугА хгЦАдАщ (хяМо еАъяйФМД? ║?щгъс?║??
?Егйщ)? .?ФлМх цД гА МрМо зоо гЦАдАщДМ зЛА Цнси? .?ФгАхо цД МъФДФг чо сгЦЕФг ЦлМз Пг Мщ йуЦМЦ гАхмк цФ мйАМА ДйгфлЕ цФ?
?ъйгхйЕ? ║?ФцД МъФДФг чо ФгщчФг? ║?ЦлМз Пг зЛА гАДсни гАДЕгфМи гЦАчоСЬ Ци? .?Фчо МьАх ЦД гЦАдАщДМ екхгй геАсЕгЦ гАпМ чоСЬ ЦФЕ? .?ФМЦъД?
?еоягл цсгЦа цняЛ еЛА зхгягй гАтъя гАйМ йъФД Мщ ЦчоЖЬ Ци гАФячи?.??
?? .7?ФЦД цлА йМсяМ йяЦли гнАгАугй ФцсгЦа гЦАдАщДМ? ║?зЛА гЦАдАщДМ гАпМД йъФД АшйЕЦ гцАЦ йъйх хмяФщ зяхМи?║??
?ФМъйхФД ЦдАщгЕйЦ хгеАДъАМрМи цФ гАщяДсМи? ║?цД МрФоФг яфММс гАймяМя хцсгЦфЕЦ ъгЦАи? ║?ЦъйФхи хгмАяФщ гАзяхМи? ║?кЦ хгмАяФщ?
?гАгАйМДМи?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
??La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009??
??248??
?? .8?гАФячгй гАйМ Цй ЖЬкА йчгяМя мФА Дйгфл гАхмФк глАоМои? ║?МДхшМ цД йъйх хгАяййМх гАйгМА? :?гЦАчоЦи╨ гЦАФго (гЦАФгжМз)?
?ФгАьяч╨ гАДйгфл╨ гАймАМА╨ ФгЦАДгчти? .?ФМДхшМ цД йтщз ЕпЕ гАФячгй хнгАуи АъА ЦДЕг? ║?гА йрМо зЛА ? 100?ъАЦи? ║?йхМДЬ?
?хФжФм? ║?ФхелМгр? ║?гцАЕогщ? ║?ФгАсМгч? ║?ФгАДйгфл? ║?ФггАсйДйглгй?.??
?? .9?МДхшМ цД Мкхй гЦАдАщФД? ║?хмсх Цг МАрЦ? ║?цД ЦлМз гцАтнгу гАпМД цляМ зАМЕЦ гАхмк? ║?чо ФгщчФг ЦФгщчи ФгзМи?
?зЛА пАъ? ║?ФМщ мгАи йзпя гмАуФА зЛА ЦФгщчи гЦАтгяъДМ (цмМга цФ цЦФгй)? ║?МДхшМ цД Мкхй гЦАдАщФД цДЕ чо йЦ гмАуФА зЛА?
?ЦФгщчи ФъгАфЕЦ цФ ФякйЕЦ?.??
?? .10?МДхшМ цД ййДгФА ЦчггАй ггАсйзягж ФгЦАяглзи гЦАгжМи? ║?гАДчгь гАйгАМи? :?гцАЕогщ? ║?гЦАугоя? ║?ьяч ггАДйчга? ║?лйЦМз?
?гЦАзьМгй ФйщсяМЕг ФггАсйДйглгй?.??
?? .11?МДхшМ цД Мчйяу ггАсйтЕго ЦД цМ цзгЦА ЦДтФяи? ║?Мщ гАДу? ║?зЛА гЦАяглз гмАоМки гцАсгсМи? .?ФгА МДум хрМгои гЦАяглз?
?зЛА ? 25?Цялз Пг зЛА гцАъкя? ║?хгсйкДга гЦАчггАй гАДчоМи? .?ФМАрЦ йячМЦ гЦАяглз? ║?ъАгЦ ыЕяй Мщ гАДу? ║?ФцД МАМЕг цзого зяхМи?
?хДМ цчФгс [цчФгс Цяхзи]? .?ъгЦ МДхшМ йоФМД ЕпЕ гЦАяглз Мщ чгфЦи ЦячЦи? ║?Мщ ущми ЦДщуАи? ║?Мщ ЕДгМи гАФячи? ║?ФцД ййжЦД?
?гЦАзАФЦгй гАйгАМи? ║?еД цЦъД? :?гсЦ гЦАдАщ цФ цсгЦа гЦАдАщДМ? ║?ФгмАяФщ гцАФЛА ЦД цсгЦфЕЦ? ║?ФзДФгД гАФячи цФ гАъйгх Мщ гААши?
?гцАуАМи? ║?ежгщи еЛА йяЦлйЕ╨ ФгсЦ гЦАлАи хгАъгЦА? ║?Цз ячЦ гЦАлАо? ║?Фзоо гАущмгй╨ ФгсЦ гАДгят (гАйлгяМ цФ гЦАдсМс)╨?
?ФЦъгД гАДят (гЦАоМДи ФгАхАо)╨ ФйгяМн гАДят? .?ФсФщ МйЦ езгои гАФячгй гАйМ йъФД щМЕг гЦАяглз шяМ ъгЦАи? ║?цФ шяМ Цяйхи?
?хмсх ЕпЕ гЦАхгоф? ║?еЛА гЦАдАщ? ║?АйумМмЕг? .?ФМщ Цг ММА цЦкАи АцАсАФх гАпМ йщжА гЦАлАи гАумМи Аятч гЦАйФсь цД?
?Мйхз?:??
?ъйгх?:??
?ЦчгАи Мщ лЦАи?:??
??Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990.??
??Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23√7.??
?ФкМчи?:??
??Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization, 1985 (document??
??WHO/DOC/537).??
?? .12?ФМщ Цг МйзАч хгАясФЦгй ФглАогФА? ║?гЦАтщФзи хгАятФм гЦАгАфЦи? ║?щеДЕ МДхшМ цД йяо ъА ЦДЕг Мщ ущми ЦДщуАи?║??
?ФЦячЦи зЛА гАйФгМА хгцАзого гАзяхМи? ║?ФЦАмчи Мщ ЕДгМи гАФячи? .?ъгЦ МДхшМ геАтгяи еЛА ъА ясЦ ФъА лоФА Мтгя еАМЕ Мщ гАДу?║??
?Фмхпг АФ цЦъД мйоМо Цуоя ъА ясЦ ФъА лоФА? .?ФМщ мгАи ДчА цМ ясФЦгй цФ?
?ФмйоМо ЦъгДЕ хФжФм? ║?хмсх Цг МАрЦ?ЬС ║??
?логФА ЦД ЦФго цняЛ? ║?щеДЕ йчз зЛА згйч гЦАдАщ? ║?цФ гЦАдАщДМ? ║?гЦАсдФАМи гАъгЦАи зД гмАуФА зЛА гцАпФД гАгАрЦи? .?Ф УхшЗ МиС?
?лй УЬДх цМ ЦтъгАй Мщ ьяМчи йДсМч гЦАДйл гАДЕгфМ? ║?щеДЕ МДхшМ ггАчйугя зЛА чоя геАЦъгД Мщ еоягл глАогФА ФгАясФЦгй?.??
?Фмхпг АФ цЦъД ггАчйугя зЛА лоФА Фгмо цФ ясЦ Фгмо АъА ? 1000?ъАЦи? .?зА ПгЦ хцД гАясФЦгй гЦАйзАчи ххзж гЦАзьМгй?║??
?СЬ?
?МДхшМ цД йугмх ЕпЕ гЦАзьМгй? ║?ФцД МйсДСЬЛ езгои ясЦЕг? ║?епг йь СЬАх гцАЦя?.??
?? .13?гА йяо гАФячгй ФгАчяМугй гцАуАМи? ║?егА хДг Па зЛА ьАх ЦД гЦАдАщ гАяфММс?.??
?? .14?хзо гАДят? ║?мМуА гЦАдАщФД зЛА Дсни ЦД гАзоо гАпМ йяо щМЕ гЦАчгАэи? ║?хМДЦэг мМуэА гЦАдАэщ гАяфМсэМ зАэЛ ?50??
?Дсни ЦД гАхмк гЦАДтФя? .?ФйчоСЬ Ц гАьАхгй ААмуФА зЛА гЦАрМо ЦД гАДсн? ║?цФ зЛА ЦзАФЦгй мФА гцАсзгя? ║?еЛА яфМс?
?гАймяМя?.??
?гЦАлАи гАумМи Аятч гЦАйФсь? ║?ЦДыЦи гАуми гАзгЦАМи? ║?гЦАлАо гнАгЦс зят? ║?гАзоо ????9 ║1??
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
249
Directives Ю l▓intention des auteurs
1. Les articles soumis pour publication ne doivent pas avoir ИtИ publiИs ou acceptИs pour
publication dans d▓autres revues. Le Bureau rИgional de la MИditerranИe orientale se rИserve tous
les droits de reproduction ou de republication des matИriels qui paraissent dans La Revue de SantИ
de la MИditerranИe orientale.
2. Les articles originaux en anglais, arabe ou en franГais peuvent Йtre soumis pour considИration
au RИdacteur en chef de La Revue de SantИ de la MИditerranИe orientale, Bureau rИgional de
l▓OMS pour la MИditerranИe orientale, BP 7608, CitИ Nasr (11371), Le Caire (?gypte). Les articles
peuvent Иgalement Йtre envoyИs par courriel Ю l▓adresse suivante?: emhj@emro.who.int. Ils seront
rИsumИs dans les trois langues.
3. Le sujet de l▓article doit concerner la santИ publique ou d▓autres domaines techniques
et scientifiques connexes dans le champ d▓intИrЙt de l▓Organisation mondiale de la SantИ, se
rapportant plus particuliХrement Ю la RИgion de la MИditerranИe orientale.
4. Chaque manuscrit doit Йtre fourni en trois exemplaires. Le texte, avec les tableaux et les
figures qui l▓accompagnent, ne devrait pas dИpasser 15 pages, format A4, dactylographiИes ou
imprimИes en double interligne (4500 mots) et devrait Йtre imprimИ sur le recto seulement. Lorsque
le manuscrit est acceptИ, avec ou sans conditions, l▓auteur doit soumettre une disquette informatique
de 3,5 pouces, contenant le texte, les tableaux, les graphiques et les illustrations. Pour les articles
en anglais et en franГais, Ю la demande de l▓Иditeur, le texte devra Йtre fourni en format traitement
de texte (de prИfИrence Microsoft Word pour PC, mais la plupart des autres formats peuvent Йtre
convertis) et sauvegardИ Иgalement dans un fichier texte ASCII. Les articles soumis en arabe
devraient suivre les mЙmes directives que les articles rИdigИs en anglais ou en franГais. Si l▓article
est une traduction, dans son intИgralitИ ou en partie, d▓un autre document non publiИ, une copie de
ce document dans la langue d▓origine devrait Иgalement Йtre soumise. Si possible, les graphiques
devraient Йtre fournis en format Harvard Graphics pour Windows ou Excel, et les illustrations
et photographies devraient Йtre en format EPS ou TIFF. Toutefois, il est nИcessaire de fournir
trois jeux des photographies et figures d▓origine avec les donnИes de base. Si les photographies
comportent un texte ou lettrage, un jeu supplИmentaire doit Йtre fourni sans ce texte/lettrage.
5. Tous les articles seront revus par des pairs, et sur la base des commentaires du rИviseur,
le ComitИ de rИdaction se rИserve le droit d▓accepter ou de rejeter tout article. Les articles sont
acceptИs sous rИserve de la rИvision dont ils feront l▓objet au plan statistique et rИdactionnel, comme
jugИ nИcessaire, ce qui peut amener Ю abrИger le texte et supprimer certaines donnИes prИsentИes
sous forme de tableaux ou de graphiques.
6. Le titre de l▓article devrait Йtre aussi concis que possible, de prИfИrence 10 mots environ, et
devrait Йtre mis sur une page sИparИe, avec le nom complet de l▓auteur (ou des auteurs), l▓organisme
(ou les organismes) d▓appartenance et le diplТme scientifique le plus ИlevИ obtenu. L▓adresse pour
la cor-respondance, ainsi que toute autre information nИcessaire (adresse courriel, tИlИcopie,
tИlИphone) pour contacter l▓auteur correspondant devraient Йtre fournies. Le nombre des auteurs
ne devrait pas dИpasser cinq. Tous les auteurs devraient avoir apportИ une contribution matИrielle Ю
la conception, Ю l▓analyse ou Ю la rИdaction de l▓Иtude et avoir approuvИ la version finale soumise.
Une vИrification de cette contribution peut Йtre demandИe aux auteurs. Les noms d▓autres personnes
peuvent Йtre inclus dans les remerciements.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
250
La Revue de SantИ de la MИditerranИe orientale, Vol. 15, No 1, 2009
7. Afin de faciliter la traduction des rИsumИs et du nom des auteurs, les auteurs dont la langue
maternelle s▓Иcrit en caractХres arabes et qui rИdigent en anglais ou en franГais doivent fournir leur
nom complet en Иcriture arabe ainsi qu▓une transcription.
8. Les articles prИsentant des rИsultats de recherche originale devront suivre le format IMRAD?:
introduction, matИriel (sujets) et mИthodes?; rИsultats?; analyse?; et discussion. Un rИsumИ de 100
mots maximum sera fourni, mentionnant clairement les objectifs, le contexte, les rИsultats et les
conclusions.
9. Les auteurs devront vИrifier, le cas ИchИant, que toutes les personnes sur lesquelles la recherche
porte ont donnИ leur consentement ИclairИ, et lorsque des participants (vivants ou dИcИdИs) n▓ont
pas pu donner ce consentement, qu▓un consentement de substitution a ИtИ obtenu.
10. Les articles d▓analyse devront comporter des sections portant sur les objectifs, les sources, les
mИthodes de sИlection, la compilation et l▓interprИtation des donnИes et des conclusions.
11. Les citations dans le texte de travaux publiИs devraient Йtre limitИes aux rИfИrences essentielles
rИcentes. Hormis les articles d▓analyse, il est conseillИ de ne pas dИpasser 25?rИfИrences. Elles
devraient Йtre numИrotИes en chiffres arabes placИs entre parenthХses [crochets] selon l▓ordre dans
lequel elles apparaissent dans le texte. Ces rИfИrences devraient figurer sous forme de liste numИrotИe
sur une page sИparИe Ю la fin de l▓article. Elles devraient contenir les ИlИments d▓information
suivants, selon le cas?: nom(s) et initiale(s) de l▓auteur/des auteurs?; titre de l▓article ou de l▓ouvrage
dans sa langue originale ainsi que la traduction?; nom complet de la revue ainsi que le numИro du
volume et les pages?concernИes?; nom de la maison d▓Иdition (commerciale ou institutionnelle) et
lieu de publication (ville et pays)?; et date de la publication. Les articles comportant des rИfИrences
inadИquates ou dont les rИfИrences ne sont pas organisИes conformИment Ю ces principes seront
renvoyИs aux auteurs pour correction. Exemples du style prИfИrИ de La Revue?:
Livre?: Al Hamza B, Smith A. The fifth sign of identity. Cairo, American University Press, 1990.
Article de Revue?: Jones A et al. One day in Tibet. Journal of tautology, 1993, 13(5):23√7.
Document?: Al-Itneen M, ed. The principles of uncertainty. Geneva, World Health Organization,
1985 (document WHO/DOC/537).
12. Les figures et les tableaux avec les lИgendes appropriИes devraient Йtre placИs chacun(e)
sur une feuille sИparИe, numИrotИs en chiffres arabes selon l▓ordre et joints Ю la fin du document.
Chaque figure et chaque tableau devraient avoir une rИfИrence dans le texte et son emplacement
dans le texte devrait Йtre indiquИ clairement le cas ИchИant. Au besoin, les sources devraient Йtre
mentionnИes pour chaque figure ou tableau. Si des figures, tableaux ou d▓autres matИriels ont
ИtИ copiИs d▓autres sources, les auteurs portent l▓entiХre responsabilitИ d▓obtenir l▓autorisation
nИcessaire. Afin d▓Иviter les problХmes de mise en page lors de la production finale, le nombre
de tableaux et figures devrait Йtre limitИ autant que possible. Il est prИfИrable de ne pas avoir plus
d▓un tableau ou d▓une figure pour 1000 mots. Les figures Иtablies Ю partir de donnИes doivent Йtre
accompagnИes de ces donnИes pour permettre une recomposition, le cas ИchИant.
13. Les articles originaux et les disquettes ne seront pas renvoyИs sauf si l▓auteur principal en fait
la demande.
14. Lors de la publication, les auteurs recevront chacun un exemplaire du numИro dans
lequel l▓article paraНt et l▓auteur principal recevra 50 tirИs Ю part. Les demandes de tirИs Ю part
supplИmentaires et les informations sur le prix peuvent Йtre obtenues auprХs du RИdacteur en
chef.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?
Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009
251
WHO sales and discount policy
Objective
Within the financial obligations of the pub╜lishing and distribution process, prices of WHO pub
lications are kept as low as possi?ble in order to maximize their dissemination and reach readers for
whom they are intended.
The price and discount policies for WHO/EMRO and WHO/HQ publications are as follows:
Price and discount policy for WHO/EMRO publications
∙ EMRO publications are priced in US dollars.
∙ Sales agents receive a 40% discount and 30 days credit. Credit limit is US$ 500.00.
∙ Bulk orders of individual books, i.e. 1000 copies per title, qualify the agent for a 50% dis╜
count instead of a 40% dis╜count; how╜ev?er, payment of total value must be made before dispatch of
pub╜li╜cations is effected.
∙ Dispatch charges are calculated at 25% of cover prices.
∙ Present delivery time average is two weeks from date of receipt of firm order.
Price and discount policy for WHO/HQ publications
∙ WHO/HQ publications and sub╜scriptions are priced in Swiss francs. Clients in de╜vel╜oping
coun╜tries are eligible for a spe╜cial tar╜iff which in all cases is 30% less than the Swiss francs regular
prices.
∙ Sales agents receive a 40% discount for book or╜ders and 20% for subscription orders. Cred╜it
limit is Swiss francs 1000.00.
∙ Bulk or╜ders qualify the agents for a spe╜cial higher dis╜count, provided the dispatch of the whole
or╜der is done to the same consignee. In this case, a proforma invoice will be issued by WHO/HQ, and
the order will be dis╜patched only upon receipt of payment. No re╜turn of books or periodicals will be
accepted.
∙ Payment of invoices may be made in US dollars at the official rate of exchange at the date of
payment.
∙ Present delivery time av╜erage is four weeks from date of receipt of orders.
A WHO/EMRO Publications Price List is available on request.
???9 ║1 ? гАзоо?║? гЦАлАо гнАгЦс зят?║? ЦДыЦи гАуми гАзгЦАМи?║?гЦАлАи гАумМи Аятч гЦАйФсь?

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