Eastern Mediterranean Health Journal [2011; Vol.17, Issue 9]

Contents V olum e 17 N um ber 9 Septem ber 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 9 September / Septembre 2011 9 ددع / شرع عباسلا دلجلما برمتبس / لوليأ Letter from the Editor ........................................................................................................................................................637 Editorial Tranexamic acid – a recipe for saving lives in traumatic bleeding...........................................................................638 Research articles Cardiovascular disease and risk factors in patients with type 2 diabetes mellitus in Mashhad, Islamic Republic of Iran .............................................................................................................................................640 Road traffic injuries in Rawalpindi city, Pakistan ......................................................................................................647 Health disparities between Muslim and non-Muslim countries ............................................................................654 Incidence and causes of sudden death in a university hospital in eastern Saudi Arabia ......................................665 Evaluation of old-age disability and related factors among an Iranian elderly population ...................................671 Health information systems in the Islamic Republic of Iran: a case study in Kerman province ............................679 Lipoprotein changes in women taking low-dose combined oral contraceptive pills: a cross-sectional study in Basra, Iraq ........................................................................................................................684 Educational needs assessment for men’s participation in perinatal care ...............................................................689 Effect of quinine therapy on plasma glucose and plasma insulin levels in pregnant women infected with Plasmodium falciparum malaria in Gezira state ...............................................................................................697 Incidence of congenital malformation in 2 major hospitals in Rivers state of Nigeria from 1990 to 2003 ...........701 Detection of Trichomonas vaginalis by different methods in women from Dohok province, Iraq .......................706 Impact of intestinal parasites on haematological parameters of sickle-cell anaemia patients in Nigeria ............710 Evaluation of an interferon-gamma release assay in young contacts of active tuberculosis cases .......................714 The Blue Mosque, Mazar-i-Sharif, Afghanistan (photograph: WHO) Physical inactivity is the fourth leading risk factor for global mortality. Regular physical activity, including walking, helps to maintain cardiovascular fitness and healthy weight and reduce the risk of colon and breast cancer, and depression. طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2011 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 17 No. 9 9 ددع شرع عباسلا دلجلما•  2011  • Letter from the Editor .............................................................................................................................................................................................................................................................................................................................. 637 Editorial Tranexamic acid – a recipe for saving lives in traumatic bleeding ..................................................................................................................................................................... 638 Research articles Cardiovascular disease and risk factors in patients with type 2 diabetes mellitus in Mashhad, Islamic Republic of Iran S. Bonakdaran, S. Ebrahimzadeh and S.H. Noghabi .........................................................................................................................................................................................................................................................640 Road traffic injuries in Rawalpindi city, Pakistan U. Farooq, J.A. Bhatti, M. Siddiq, M. Majeed, N. Malik, J.A. Razzak and M.M. Khan .............................................................................................................................................................................647 Health disparities between Muslim and non-Muslim countries J.A Razzak, U.R . Khan, I. Azam, M. Nasrullah, O. Pasha, M. Malik and A. Ghaffar................................................................................................................................................................................654 Incidence and causes of sudden death in a university hospital in eastern Saudi Arabia H.K. Nofal, M.F. Abdulmohsen and A.H.Khamis ...............................................................................................................................................................................................................................................................665 Evaluation of old-age disability and related factors among an Iranian elderly population M. Adib-Hajbaghery ................................................................................................................................................................................................................................................................................................................................671 Health information systems in the Islamic Republic of Iran: a case study in Kerman province F. Zolala ............................................................................................................................................................................................................................................................................................................................................................679 Lipoprotein changes in women taking low-dose combined oral contraceptive pills: a cross-sectional study in Basra, Iraq J.A. Abdel-Barry, M.S. Flafl, L.M. Al-Namaa and N.A. Hassan ................................................................................................................................................................................................................................684 Educational needs assessment for men’s participation in perinatal care M. Simbar, F. Nahidi, F. Ramezani-Tehrani and A. Akbarzadeh ...............................................................................................................................................................................................................................689 Effect of quinine therapy on plasma glucose and plasma insulin levels in pregnant women infected with Plasmodium falciparum malaria in Gezira state N.E.E. Elbadawi, M.I. Mohamed, O.Y. Dawod, K.E. Ali, O.H. Daoud, E.M. Ali, E.G.E. Ahmed and A.E. Mohamed ............................................................................................................697 Incidence of congenital malformation in 2 major hospitals in Rivers state of Nigeria from 1990 to 2003 T.B. Ekanem, I.E. Bassey, O.E. Mesembe, M.A. Eluwa and M.B. Ekong ................................................................................................................................................................................................................701 Detection of Trichomonas vaginalis by different methods in women from Dohok province, Iraq W.M. Al-Saeed ..............................................................................................................................................................................................................................................................................................................................................706 Impact of intestinal parasites on haematological parameters of sickle-cell anaemia patients in Nigeria S.G. Ahmed and J. Uraka ......................................................................................................................................................................................................................................................................................................................710 Evaluation of an interferon-gamma release assay in young contacts of active tuberculosis cases S. Noorbakhsh, J. Mousavi, M. Barati, A.R . Shamshiri, M. Shekarabi, A. Tabatabaei and M. Soleimani .......................................................................................................................................714 Book 17-9.indb 3 9/6/2011 12:42:51 PM M. Haytham Khayat MD, PhD, FRSPH, Editor-in-chief Ahmed Ezzat Abdou BSc, DPH, PhD, Executive Editor Editorial Board Mohammad Abdur Rab MBBS, DTM&H, MPH&TM, PhD Naeema Al Gasseer MSc, PhD Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DPH Abdul Ghaffar MD, MPH, MHA, PhD Malekafzali Hossein MK, MPH, PhD Jaouad Mahjour MD, MPH Mamunur Rahman Malik MBBS, Dip (Health Economics), MSc, MPhil Kassem Sara MD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland 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. Reinké 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 Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy Book 17-9.indb 4 9/6/2011 12:42:57 PM المجلة الصحية لشرق المتوسط المجلد السابع عشر العدد التاسع 736 رسالة من المحرر rotidE eht morf retteL  )sDVC( sesaesid ralucsavoidraC .traeH enO ,emoh enO ,dlroW enO :fo raey siht emeht a htiw yaD traeH dlroW si 92 rebmetpeS  ni rucco sDVC morf shtaed fo %28 ,revewoh ;ediwdlrow htaed fo esuac gnidael eht meht gnikam ,raey hcae elpoep noillim 1.71 llik  tsegral eht taht detamitse si ti dna 0302 yb noillim 6.32 ot esir ot tes si erugfi eht ,ylgnimrala eroM .seirtnuoc emocni-elddim dna -wol  esaesid traeh morf shtaed erutamerp fo )%08( ytirojam tsav eht tuB .noigeR naenarretideM nretsaE eht ni eb lliw esaercni egatnecrep  DVC .ytivitcani lacisyhp dna teid yhtlaehnu ,esu occabot yleman ,dediova erew srotcaf ksir niam eht fi dediova eb dluoc ekorts dna  ni stneitap citebaid ni DVC no repap a si eussi siht ni dedulcnI .sutillem setebaid htiw detaicossa ytilatrom hgih eht ni rotcaf yek a si .puorg siht gnoma DVC fo )%1.02( ecnelaverp hgih a dnuof hcihw ,narI fo cilbuper cimalsI ,dahhsaM  noigeR eht ni seirujni cffiart daor morf ytilatrom eht ,2002 nI .sehsarc cffiart daor si htaed fo esuac elbadiova dna tnatropmi rehtonA  seitilibasid dna shtaed ,sDVC ekiL .noigeR nacirfA eht refta dlrow eht ni tsehgih dnoces eht ,noitalupop 000 001 rep shtaed 4.62 saw  evah lliw yeht elihw seirtnuoc emocni-elddim dna emocni-wol  ni 0202 yb %06 yb esaercni  ot ylekil  era seirujni cffiart daor morf  91 erew ereht taht stroper hcihw natsikaP morf repap a yb detartsulli si nedrub yvaeh eTh .seirtnuoc emocni-hgih ni %03 yb deppord  rof dna ,doirep raey a revo idniplawaR ni slatipsoh erac yraitret 3 fo stnemtraped ycnegreme eht ot gnitneserp seirujni cffiart daor 828 .erac tnemtraped ycnegreme deviecer erom 771 dna dezilatipsoh erew elpoep erom 92 ,htaed cffiart daor yreve  hcae elpoep noillim 2 dnuora sllik ediwdlrow hcihw ,gnideelb citamuart tnacfiingis yb deinapmocca yllausu era sehsarc cffiart daoR -nar ,ertnecitlum ,egral a ,lairt 2-HSRAC eht fo stluser eTh .seirtnuoc emocni-elddim dna -wol ni shtaed eht fo %09 revo htiw ,raey  citylonirbfiitna fo stceffe eht fo ,egahrromeah tnacfiingis ,fo ksir ta ro ,htiw stneitap amuart gnoma lairt dellortnoc-obecalp ,dezimod -op a ,dica cimaxenart taht wohs eseTh .1102 hcraM dna 0102 enuJ ni tecnaL eht ni dehsilbup yltnecer erew ,htaed no tnemtaert  .yrujni fo sruoh 4 ot 3 nihtiw desu fi ytilatrom esuac lla dna gnideelb ot eud htaed secuder yltnacfiingis ,sisylonirbfi fo rotibihni tnet  cimaxenart ,sgnidnfi eseht fo tluser a sA .elbaliava ylediw dna paehc si ti ;enicidem yrateirporp evisnepxe na ton si dica cimaxenarT  siht esu ot sesac amuart htiw gnilaed srotcod rof laitnesse erofereht si tI .senicidem laitnesse fo tsil OHW eht ot dedda neeb sah dica .eussi siht ni dedulcni si stluser 2-HSRAC eht no lairotide nA .sevil evas ot enicidem اليوُم التاسع والعشرون من أيلول/سبتمبر هو اليوُم العالمي للقلب. وموضوع هذا العام هو: عالم واحد، وقلب واحد. ومن المعلوم أن الأمراض القلبية الوعائية ُتودي بحياة 1.71 مليون إنسان سنويًا، مما يجعلها السبب الرئيسي للوفيات على الصعيد العالمي؛ ولو أن 28% من الوفيات الناجمة عن الأمراض القلبية الوعائية تقع في البلدان المنخفضة الدخل والمتوسط الدخل. والأكثر إثارة للقلق، أن هذا العدد مرشَّ ح للازدياد، حتى يصل إلى 6.32 مليون وفاة بحلول عام 0302، ويقدَّ ر أن أعلى نسبة من هذه الزيادة ستكون في إقليم شرق المتوسط. ولو أن غالبية (08%) من الوفيات المبكرة الناجمة عن المرض القلبي والسكتة الدماغية يمكن تفاديها باجتناب عوامل الاختطار الأساسية، وبالتحديد تعاطي التبغ، والنظام الغذائي الـُمَنافي للصحة، وقلة النشاط البدني. ويمثل المرض القلبي الوعائي عامًلا رئيسيًا في ارتفاع الوفيات المرتبطة بالسّكري. ويضم هذا العدد من المجلة مقالًة تتناول المرض القلبي الوعائي لدى مرضى السّكري في مدينة مشهد في جمهورية إيران الإسلامية، وتكشف عن انتشار مرتفع للمرض القلبي الوعائي (1.02%) بين أفراد هذه الفئة. وهناك -بالمناسبة- سبب آخر هام للوفيات التي يمكن ت َـ َفاديها وهو الاصطدامات على الطرق المرورية. ففي عام 2002، كان معدل الوفيات الناجمة عن إصابات الطرق المرورية في الإقليم هو 4.62 وفاة لكل مئة ألف من السكان، وهو ثاني أعلى معدل في العالم بعد الإقليم الإفريقي. وكما في الأمراض القلبية الوعائية، ُيَتوقع أن تزداد نسب العجز والوفيات الناجمة عن إصابات الطرق المرورية بـ 06% بحلول عام 0202 في البلدان المنخفضة الدخل والمتوسطة الدخل، في حين أنها ستنخفض بمقدار 03% في البلدان المرتفعة الدخل. وفي هذا العدد أيضًا مقالٌة من باكستان توّضُح ثَِقَل هذا العبء، إْذ تذكر وصول 82891 إصابة وقعت على الطرق المرورية إلى أقسام الطوارئ في ثلاثة مستشفيات للرعاية الثالثية في مدينة روالبندي خلال سنة واحدة، وأنه مقابل كل وفاة تقع على الطرق المرورية هناك 92 شخصًا ُيْدَخلون للعلاج في المستشفيات، و771 آخرون يتلقَّ ْوَن الرعاية في أقسام الطوارئ. وليس َيْ َفى أن الاصطدامات على الطرق المرورية تكون في العادة مصحوبًة بنزف رضحي جسيم، ُيودي بحياة حوالي مليوَنيْ نسمة سنويًا على الصعيد العالمي، ويقع أكثر من 09% من هذه الوفيات في البلدان المنخفضة والمتوسطة الدخل. على أن مما يبّشر بالخير أن نتائج دراسة 2-HSARC، وهي تجربة عشوائية كبرى متعددة المراكز ومضبوطة بالُغـْفل بين مرضى الرضوح المصابين، أو المعرضين لاختطار النزف الشديد، لدراسة تأثيرات المعالجة المضاّدة لانحلال الفبرين على الوفاة، قد ُنِشرَ ت مؤخرًا في مجلة «لانست» في شهَرْي حزيران/يونيو 0102 وآذار/مارس 1102. وقد دلت بُِجْزَأيها على أن حمض الترانيكساميك cimaxenart، وهو مثبِّط قوي لانحلال الفيبرين، يقلِّص بدرجة ُيعتد بها إحصائيًا من الوفيات الناجمة عن النزف ومن كلِّ أسباب الوفاة إذا ُأعطي للمصاب في غضون ثلاث أو أربع ساعات من الإصابة. وحمض الترانيكساميك هذا، ليس دواًء مسجَّ َل الملكية باهَظ الثمن؛ بل هو علاٌج رخيُص الثمن متاٌح على نطاق واسع. وبناًء على هذه النتائج، ُأِضيَف حمض الترانيكساميك إلى قائمة منظمة الصحة العالمية للأدوية الأساسية. مـماَّ ُيتِّم على الأطباء الذين يتعاملون مع حالات الرضوح استخدامه لإنقاذ الأرواح. وسوف يجد القارئ في مطلع هذا العدد مقالة افتتاحية حول نتائج دراسة 2-HSARC هذه. MP 75:24:21 1102/6/9 736 bdni.9-71 kooB EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 638 1Director, Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (ian.roberts@lshtm.ac.uk). 2On behalf of the CRASH-2 trial. Using kitchen scales, carefully weight out 4 kg of rice and pour it into a deep saucepan. Now put your hands into the rice and let  the grains run between your fingers. Contemplate carefully each grain. The number of grains (about 140 000) is approximately  the number of lives that could be saved each year worldwide if all hospitalized trauma patients with significant bleeding were treated with tranexamic acid (TXA) within 3 hours of injury. TXA is cheap and widely available. All that is needed to reap these  human benefits is that doctors use it. That TXA is a potent inhibitor of fibrinolysis was first reported by Shosuke and Utako Okamoto in the Keio Journal of Medicine  in September 1962 [1]. Since then, TXA has been widely used to treat heavy menstrual bleeding and to reduce blood loss in  elective surgery where it reduces blood transfusion by about one third [2]. The CRASH-2 collaborators hypothesized that TXA  might also reduce bleeding in trauma patients. The CRASH-2 trial was a UK government funded randomized trial of the effects  of the early administration of TXA on death, vascular occlusive events and blood transfusion in bleeding trauma patients. A total of 20 211 adults with significant traumatic bleeding were randomized to receive TXA or matching placebo, with 99.6%  follow-up. The risk of death due to bleeding was significantly reduced with TXA. If TXA is given within 3 hours of injury, it  reduces the risk of bleeding to death by nearly one-third (relative risk = 0.72 [95% CI 0.63–0.83], P < 0.001). All cause mortality  was also significantly reduced [3,4]. The large numbers of patients studied in a wide range of different health care settings help  these results to be generalized widely. On the basis of the results of the CRASH-2 trial, TXA has been included in the World  Health Organization (WHO) list of essential medicines [5]. Giving TXA to bleeding trauma patients within 3 hours of the  injury could save over 100 000 lives per year worldwide. Giving TXA to bleeding trauma patients  is highly cost-effective  in  high, middle and low income countries [6]. It is essential that all doctors who treat trauma patients are aware of the results of  the CRASH-2 trial.  TXA should be given to all adults with significant haemorrhage (SBP < 90, HR > 110) or those considered by the clinician to  be at risk for significant haemorrhage. Because the effect of TXA on death due to bleeding depends importantly on the time  interval between the injury and the onset of treatment, it should be given as early as possible and within 3 or 4 hours of the injury  as it is unlikely to be effective if given later than this. References Okamoto S, Okamoto U. Amino-methyl-cyclohexane-carbol-1. ic acid: AMCHA. A new potent inhibitor of fibrinolysis. Keio Journal of Medicine, 1962, 11:105–115. Henry DA et al. Antifibrinolytic use for minimising periopera-2. tive allogeneic blood transfusion. Cochrane Database of Sys- tematic Reviews, 2007, 4: CD001886. The CRASH-2 Collaborators. Effects of tranexamic acid on 3. death, vascular occlusive events, and blood transfusion in trau- ma patients with significant haemorrhage (CRASH-2): a rand- omized, placebo-controlled trial. Lancet, 2010, 376:23–32. The CRASH-2 Collaborators. The importance of early treat-4. ment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomized controlled trial. Lancet, 2011, 377:1096–1101. Summary of the report of the 18th meeting of the WHO Expert 5. Committee on the Selection and Use of Essential Medicines (http://www.who.int/selection_medicines/committees/ expert/18/en/index.html, accessed 22 August 2011). Guerriero C et al. Cost–effectiveness analysis of administering 6. tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 Trial. PLoS ONE, 2011, 6(5):e18987. Editorial Tranexamic acid – a recipe for saving lives in traumatic bleeding Professor Ian Roberts1,2 Book 17-9.indb 638 9/6/2011 12:42:57 PM Book 17-9.indb 639 9/6/2011 12:42:57 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 640 Cardiovascular disease and risk factors in patients with type 2 diabetes mellitus in Mashhad, Islamic Republic of Iran S. Bonakdaran,1 S. Ebrahimzadeh1 and S.H. Noghabi1 ABSTRACT The aim of this study in 2006–08 was to determine the prevalence and risk factors of CVD in an Iranian population of patients with type 2 diabetes mellitus. History and physical examinations were recorded and laboratory tests were performed in 752 patients attending the Mashhad Endocrine and Metabolism Research Center. The prevalence of CVD was 20.1%. CVD was significantly associated with age, duration of diabetes, hypertension, diabetic retinopathy, metabolic syndrome, renal insufficiency, triglycerides, high-density lipoprotein (HDL) cholesterol, uric acid and triglycerides/HDL ratio. Using a logistic regression model, age, metabolic syndrome and HDL cholesterol were significant independent predictors of CVD. The high prevalence of CVD in Iranian patients with type 2 diabetes underscores the importance of better detection and treatment of metabolic risk factors of CVD in these patients. 1Endocrine Research Centre, Mashhad University of Medical Science, Mashhad, Islamic Republic of Iran (Correspondence to S. Bonakdaran: bonakdaransh@mums.ac.ir). Received: 04/11/09; accepted: 08/02/10 ةيملاسلإا ناريإ ةيروهجم في دهشم ةنيدم في نياثلا طمنلا نم ّيركسلاب ضىرلما ىدل راطتخلاا لماوعو يئاعولا يبلقلا ضرلما بياقُن يزاجح هديبس ،هداز ميهاربا ديعس ،ناردكنب هفوكوش ضىرلما ينب يئاعولا يبلقلا ضرلما راطتخا لماوعو راشتنا لدعم ديدتح لىإ 2008-2006 ماوعلأا في تيرجأ يتلا ةساردلا هذه فدتهو :ةـصلالخا ينسخمو يننثاو ةئم عبسل ةيبرتمخ ٌصوحف تَيِرْجُأو ةيندبلا صوحفلاو ةّيضرلما قباوسلا تَل ِّجُس دقو .نياثلا طمنلا نم ّيركسلاب ينباصلما ينيناريلإا يبلقلا ضرلما َطَباَرَتو ،%20.1 يئاعولا يبلقلا ضرلما راشتنا لدعم غلب دقو .دهشم ةنيدم في بلاقتسلااو ءماصلا ددغلا ثوحب زكرم اوعجار ًاضيرم ،ّيولكلا روصقلاو ،ةيبلاقتسلاا ةمزلاتلماو ،ّيركسلا ةيكبشلا للاتعاو ،مدلا طغض طرفو ،ّيركسلا ةدمو ،رمعلاب ًايئاصحإ هب ُّدَتْعُي ًاطُبَرَت يئاعولا عيفرلا يمحشلا ينتوبرلا لىإ تاديسريلغلا يثلاث ةبسنو ،كيرويلا ضحمو ،ةفاثكلا عيفرلا يمحشلا ينتوبرلا لوترسيلوكو ،تاديسريلغلا يثلاثو لِّثتم ةفاثكلا عيفرلا يمحشلا ينتوبرلا لوترسيلوكو ،ةيبلاقتسلاا ةمزلاتلماو ،رمعلا نأ َّينبت يتسجوللا فّوحتلا جذومن مادختسا دنعو .ةفاثكلا نياثلا طمنلا نم ّيركسلاب ينيناريلإا ضىرلما ينب يئاعولا يبلقلا ضرملل عساولا راشتنلاا ُزِْبرُيو .يئاعولا يبلقلا ضرملل ابه ُّدَتْعُي ةلقتسم تاَِئبْنُم .ضىرلما ءلاؤه في يئاعولا يبلقلا ضرملل ةيبلاقتسلاا راطتخلاا لماوع جلاعو فاشتكا لُبُس ينستح ةيهمأ Maladies cardio-vasculaires et facteurs de risque chez des patients atteints de diabète de type 2 à Mashhad (République islamique d’Iran) RÉSUMÉ La présente étude visait à déterminer la prévalence et les facteurs de risque des maladies cardio- vasculaires dans une population iranienne de patients atteints de diabète de type 2 entre 2006 et 2008. Les antécédents et les examens cliniques de 752 patients consultant dans un centre de recherche sur l’endocrinologie et le métabolisme ont été consignés et des analyses en laboratoire ont été réalisées. La prévalence des maladies cardio-vasculaires était de 20,1 %. Les maladies cardio-vasculaires étaient significativement associées avec l’âge, la durée du diabète, l’hypertension, une rétinopathie diabétique, un syndrome métabolique, une insuffisance rénale, le taux de triglycérides, le taux de cholestérol des lipoprotéines de haute densité, l’acide urique et le rapport entre les triglycérides et les lipoprotéines de haute densité. L’analyse de régression logistique a révélé que l’âge, un syndrome métabolique et le taux de cholestérol des lipoprotéines de haute densité étaient des facteurs prédictifs indépendants importants pour les maladies cardio-vasculaires. La prévalence élevée des maladies cardio-vasculaires chez les patients iraniens souffrant de diabète de type 2 souligne l’importance d’un meilleur dépistage des facteurs de risque métaboliques de ces maladies chez les patients diabétiques et d’un meilleur traitement. Book 17-9.indb 640 9/6/2011 12:42:58 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 641 Introduction Cardiovascular disease  (CVD)  is  the  leading cause of morbidity and mortal- ity  in  type 2 diabetes mellitus  (DM)  [1]. DM is a risk equivalent for coronary  heart disease (CHD) [2]. Silent ischae- mia and asymptomatic CHD is more frequent  in DM. Patients with  type 2  DM have higher levels of atherogenic lipids  [3],  hypertension  [4],  obesity  [5],  insulin  resistance  [6], microalbu- minuria  [7],  autonomic  neuropathy  [8],  coagulation  disorders  [9]  and  other non-traditional risk factors that all contribute to increased risk of CVD in these patients. About 70% of mortality  in DM is related to CHD [10], so early  risk recognition and management of patients with DM is very important. The aim of this study was to determine the prevalence of CVD and risk factors that predict CVD in an  Iranian population  of patients with type 2 DM. Methods A cross-sectional study was carried out  in Mashhad, Islamic Republic of Iran. Sample Between December 2006 and July 2008  a  total  of  1287  consecutive  patients  aged 40  years  or  older  attending  the  Mashhad Endocrine and Metabolism Research Center  with  type  2  diabe- tes were  enrolled. Among  them 752  patients received total cardiovascular disease  screening. Diagnosis of  type 2  diabetes was based on World Health  Organization (WHO) criteria Clinical examinations A complete history was  taken  for age,  smoking status (former/current smoker  or never smoker), duration of DM, fam- ily history of CVD and personal history of hypertension and hyperlipidaemia and treatments used. Clinical examina- tions  included weight,  height,  blood  pressure,  fundoscopy  and peripheral  pulse assessment. A 12-lead resting elec- trocardiogram (ECG) was  taken  from  all patients. Patients with baseline ECG  changes  suggestive of CHD, previous  history of myocardial infarction, angina,  coronary artery bypass graft, angioplasty,  treatment  for CVD,  cerebrovascular  accident,  transient  ischaemic  attack,  carotid surgery and peripheral vascular disease or absence of peripheral pulse were defined as symptomatic CVD. Patients without  symptomatic CHD  who were able to perform exercise were subjected to an exercise stress test. Other patients with contraindications  or limitations for the exercise stress test underwent thallium scintigraphy. On  the  basis  of  these  factors  the  patients were  divided  into  2  groups:  CVD (symptomatic or asymptomatic),  i.e. patients with overt signs/symptoms  of CVD or patients with a positive test in the exercise stress test or perfusion scan; and non-CVD,  i.e. patients with- out  signs/symptoms of CVD or with  negative screening tests. In patients without CVD, the CHD  risk  at  10  years was  estimated  using  the UK  Prospective Diabetes  Study  risk engine [11] and patients’ risk score  was then grouped as: < 10% (low risk),  10%–19% (moderate  risk) and ≥ 20%  (high risk) for CHD.  Hypertension was defined as systo- lic  blood  pressure  ≥  140 mmHg  or  diastolic blood pressure ≥ 90 mmHg  in the resting position for at least for 30 minutes  on  2  different  occasions  or history of hypertension and receiv- ing antihypertensive drugs. The pres- ence of retinopathy was evaluated by fundoscopic examination by an expert ophthalmologist. Obesity was defined  as BMI > 30 kg/m2. Abdominal obesity  was waist  circumference ≥ 102 cm  in  males  and ≥ 88 cm  in  females. Meta- bolic syndrome was defined according to the Adult Treatment Panel III criteria  as the presence of 3 or more of its 5 components (elevated blood pressure,  elevated serum triglycerides, high waist  circumference, high plasma glucose and  low HDL) [12]. Laboratory tests Total  cholesterol,  triglycerides  (TG)  and high-density  lipoprotein  (HDL)  cholesterol were measured by the enzymatic  method  (ParsAzmon).  Low-density   l ipoprotein  (LDL)  cholesterol was calculated according to  the Friedwald  formula [LDL= total  cholesterol – (HDL + TG/5)]. Non- HDL cholesterol was calculated by the difference between total cholesterol and HDL. TG/HDL cholesterol  ratio  was calculated for assessment of the level of dense LDL,  a  relatively novel  lipoprotein index that could serve as a good predictor of CHD [13,14]. The  cut-offs  for abnormal  levels were: TG  ≥ 150 mg/dL,  total  cholesterol ≥ 200  mg/dL, HDL cholesterol ≤ 40 mg/dL  males  or  ≤  50 mg/dL  females,  non- HDL cholesterol ≥ 130 mg/dL, LDL  cholesterol ≥ 100 mg/dL, TG/HDL  cholesterol ≥ 3.  All patients were diabetics on treat- ment  and  fasting blood  sugar  (FBS)  was measured routinely by the glucose oxidase method (Human GmbH).  Glycated haemoglobin  (HbA1C)  was assessed by column chromatogra- phy (Biosource), using a cut-off of > 7%  for abnormal levels. Urine  albumin  in  spot  urine was  measured by immunoturbidometry as- say (ParsAzmon). Urine creatinine was  measured by enzymatic colorimetric assay normal cut off > 20–25 mg/kg in  males  and 15–20 mg/kg  in  females).  Uric acid was measured by enzymatic  method and hyperuricaemia was de- fined as  the  serum  levels > 7.0 mg/dL  in men  and > 5.5 mg/dL  in women.  Blood urea nitrogen was  assessed by  colorimetric method with normal range between  5–20 mg/dL.  Albumin  ex- cretion was determined by calculation of the albumin to creatinine ratio in spot urine test on a fresh early morn- ing sample, and microalbuminuria was  defined  as  a  ratio 30–300 mg/g  and  Book 17-9.indb 641 9/6/2011 12:42:58 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 642 macroalbuminuria  as  the  ratio > 300  mg/g in 2 out of 3 measurements. Cre- atinine clearance was detected using the Crockcroft–Gault formula. Normal  renal function was defined by creatinine clearance > 90 mL/min/1.73 m2 and renal insufficiency by creatinine clear- ance < 60 mL/min/1.73 m2. Data analysis Statistical analyses were performed by SPSS,  version 16. Data was expressed  as mean and standard deviation (SD).  Non-normal variables were compared by  Mann–Whitney  U-test.  Other  variables were tested by either one-way ANOVA or Student  t-test. Categorical variables were compared by the chi- squared test. Variables with a statisti- cally significant difference between the CVD and non-CVD groups were evaluated by multiple logistic regres- sion with forward stepwise analysis to identify independent risk factors for CVD. P-values <0.05 were considered  significant. Results A total of 752 patients (355 males and  397  females)  with  type  2 DM were  analysed. Their mean duration of DM was 7.9 (SD 6.4) years. The clinical and  biochemical characteristics of the study group  are  shown  in Table 1. Overall  151 (20.1%) of our patients had CVD.  The mean CHD risk score in patients without CVD was 19.9% (SD 13.2%).  The prevalence of CVD risk factors in the total sample is shown in Table 2.  Hypertension or history of hyperten- sion was observed  in 51.6% of our pa- tients and blood pressure under optimal control  (< 130/80 mmHg) was only  detected in 21.0% of the sample. Obes- ity was  found  in 25.7% and abdominal  obesity  in 45.8%. A high proportion of  our  patients  (73.5%)  had metabolic  syndrome. Diabetic retinopathy was found in 14.3%. Three-quarters (75.0%)  had HbA1C > 7%. Lipid abnormalities  Table 1 Characteristics of the patients with type 2 diabetes mellitus (n = 752) Variable Mean SD Demographic and clinical data Age (years) 52.7 10.5 Duration of DM (years) 7.9 6.4 BMI (kg/cm2) 28.0 4.1 Waist circumference (cm) 106.8 12.3 Systolic blood pressure (mmHg) 141.6 18.7 Diastolic blood pressure (mmHg) 83.2 10.4 Laboratory data FBS (mg/dL) 92.4 68.7 HbA1C (%) 8.4 1.8 Total cholesterol (mg/dL) 212.7 42.4 LDL cholesterol (mg/dL) 130.3 31.5 HDL cholesterol (mg/dL) 42.3 8.6 TG (mg/dL) 211.0 124.8 TG/HDL ratio 5.3 3.6 Blood urea nitrogen (mg/dL) 17.9 9.8 Creatinine(mg/dL) 0.97 0.50 Uric acid (mg/dL) 4.7 1.3 Urine albumin/creatinine ratio (mg/g) 34.7 122.7 Glomerular filtration rate (mL/min) 105.8 38.4 BMI = body mass index; FBS = fasting blood sugar; HbA1C = glycated haemoglobin; LDL = low-density lipoprotein; HDL = high-density lipoprotein; TG = triglycerides; SD = standard deviation. Table 2 Prevalence of cardiovascular risk factors in patients with type 2 diabetes mellitus (DM) Risk factor % of patients (n = 752) Demographic and clinical data Age > 60 years 13.7 Male sex 47.2 Duration of DM > 10 years 27.7 Family history of CVD 32.5 Obesity 25.7 Abdominal obesity 45.8 Hypertension 51.6 Metabolic syndrome 73.5 Renal insufficiency 8.8 Retinopathy 14.3 Smoking 15.9 Laboratory data High HbA1C 75.0 High total cholesterol 95.2 Low HDL cholesterol 86.9 High non-HDL cholesterol 85.4 High TG 63.1 High TG/HDL ratio 65.8 Microalbuminuria 21.5 Macroalbuminuria 1.6 HDL = high-density lipoprotein; LDL = low-density lipoprotein; BMI = body mass index; TG = triglycerides; HbA1C = glycated haemoglobin. Book 17-9.indb 642 9/6/2011 12:42:58 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 643 were prevalent in a large number of our patients; 95.2% had high total cholester- ol and 86.9% had low HDL cholesterol.  The prevalence of microalbuminuria (21.5%), macroalbuminuria (1.6%) and  renal insufficiency (36.7%) were high.  Table 3 shows the prevalence of risk factors in patients with and without CVD. The CVD group were significant- ly older [58.2 (SD 10.3) versus 51.3 (SD  10.7) years] and had a  longer duration  of DM [10.5 (SD 3.4) versus 7.3 (2.7)  years] (P < 0.001)  than  the non-CVD  group. The prevalence of hypertension was 78.1% in the CVD group and 44.9%  in  the  non-CVD group  (P  <  0.001).  The prevalence of metabolic syndrome (80.1% versus 71.9%) (P = 0.04) and  of diabetic  retinopathy (20.7% versus  12.8%) were also significantly higher in  the CVD group (P = 0.01). Concerning  the  laboratory data,  there were statisti- cally significant differences between the CVD and non-CVD sub-groups in the mean levels of blood urea nitrogen, cre- atinine,  triglycerides, HDL cholesterol,  TG/HDL ratio, uric acid and glomeru- lar filtration rate (Table 3). Of patients with 5 components of  metabolic  syndrome, 25.6% had CVD  compared with 12.2% of patients with  1 component of metabolic syndrome (P = 0.003). After  stratification of  the patients  according to CHD risk scores (< 10%,  10%–20% and ≥ 20%)  in  the patients  without CHD (Table 4),  the  follow- ing variables were significantly different between risk groups: age,  sex, duration  of DM, hypertension, metabolic  syn- drome,  retinopathy, microalbuminu- ria,  HbA1C,  total  cholesterol,  LDL  cholesterol, HDL cholesterol,  triglyc- erides, TG/HDL ratio, uric acid, non- HDL cholesterol, blood urea nitrogen,  creatinine and glomerular filtration rate (P < 0.05). Smoking, waist  circumfer- ence and FBS level were not significantly  different between the groups. The results of stepwise multiple logistic regression showed that the in- dependent risk factors for CVD were age,  total  cholesterol  level, HDL cho- lesterol level and presence of metabolic syndrome, with  an  actual  number of  322 patients having all these risk factors  (Table 5). Discussion The prevalence of CHD in a large sample of  the  Iranian population (the  Table 3 Comparison of risk factors in type 2 diabetes mellitus (DM) patients with and without cardiovascular disease (CVD) Risk factor With CVD (n = 151) Without CVD (n = 601) P-value Demographic and clinical data Male/female sex ratio 1.05 0.99 0.75 Mean (SD) Mean (SD) Age (years) 58.2 (10.3) 51.3 (10.7) < 0.001 Duration of DM (years) 10.5 (3.4) 7.3 (2.7) < 0.001 % of patients % of patients Obesity 19.6 27.2 0.08 Hypertension 78.1 44.9 < 0.001 Metabolic syndrome 80.1 71.9 0.04 Renal insufficiency 15.8 7.0 < 0.001 Retinopathy 20.7 12.8 0.01 Smoking 20.5 14.9 0.13 Laboratory data Mean (SD) Mean (SD) FBS (mg/dL) 184.5 (60.3) 194.3 (70.5) 0.23 HbA1C (%) 8.42 (1.89) 8.30 (1.82) 0.73 Total cholesterol (mg/dL) 216.8 (50.5) 211.7 (40.1) 0.24 LDL cholesterol (mg/dL) 132.1 (37.6) 129.9 (29.7) 0.64 HDL cholesterol (mg/dL) 42.0 (8.3) 43.5 (9.4) 0.04 Non-HDL cholesterol (mg/dL) 173.2 (47.9) 169.5 (38.9) 0.37 TG (mg/dL) 226.7 (132.0) 207.0 (122.7) 0.02 TG/HDL ratio 5.52 (3.14) 5.28 (3.75) 0.04 Uric acid (mg/dL) 5.00 (1.35) 4.70 (1.29) 0.02 Creatinine (mg/dL) 1.05 (0.55) 0.95 (0.49) < 0.001 Albumin/creatinine ratio (mg/g of creatinine) 45.3 (138.3) 32.1 (105.3) 0.22 FBS = fasting blood sugar; HbA1C = glycated haemoglobin; LDL = low-density lipoprotein; HDL = high-density lipoprotein; TG = triglycerides; SD = standard deviation. Book 17-9.indb 643 9/6/2011 12:42:58 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 644 Tehran Lipid and Glucose Study) was  reported to be 21.8% (22.3% in women  and 18.8% in men) [12]. The main target  of the present study was to determine the prevalence of CVD and various risk factors  in  an  Iranian population with  type 2 DM. Other studies in the Islamic  Republic of  Iran  indicated that  there  is  a high prevalence of CHD in patients with type 2 DM and glucose intolerance  state  [15–17]  but  the  prevalence  of  CVD in Iranian type 2 DM patients has  not yet been evaluated. The prevalence of CVD was 20.1% in our patients. The  Framingham study showed an even higher prevalence just of CHD (39.1%  in males  and 27.2%  in  females)  [18].  Studies in other countries have reported a prevalence of CHD up to 55% among  adult  type 2 DM patients [19,20]. The  prevalence of CVD in our  type 2 DM  patients was slightly lower than in an- other  study  from the  Islamic Republic  of  Iran study reporting a prevalence of  CVD of 28% in type 2 diabetic patients  [15].  Although optimal  glycaemic  con- trol  (HbA1C < 7%) must be  a  target  for prevention of micro- and macro- vascular complications in patients with type 2 DM, 75.0% of our patients had  HbA1C > 7%. Poor glycaemic control  was much higher in our patients com- pared with other studies [21,22]. Jurado  et al. in the North Catalonia Diabetes Study,  for example, showed that 56.9%  Table 4 Comparison of significant risk factors in diabetic patients according to coronary heart disease (CHD) risk group Variable Low risk (< 10) Moderate risk (10–19.99) High risk (≥ 20) P-value Demographic and clinical data Mean (SD) Mean (SD) Mean (SD) Age (years) 44.1 (7.7) 51.2 (7.6) 59.3 (8.6) < 0.001 Duration of diabetes (years) 5.4 (4.5) 7.5 (6.5) 10.3 (7.1) < 0.001 BMI (kg/m2) 28.6 (4.3) 28.1 (4.4) 27.5 (3.8) < 0.001 % % % Sex (% male) 31.3 47.8 56.8 < 0.001 Hypertension (%) 31.6 44.7 70.4 < 0.001 Metabolic syndrome (%) 65.8 71.4 80.5 0.001 Retinopathy (%) 6.1 13.7 21.6 < 0.001 Renal insufficiency (GFR < 60) (%) 0.5 2.6 16.8 < 0.001 Smoking (%) 10.0 18.0 18.8 0.08 Laboratory data Mean (SD) Mean (SD) Mean (SD) FBS (mg/dL) 187.2 (66.4) 198.9 (69.8) 200.2 (70.2) 0.06 HbA1C (%) 7.8 (1.6) 8.6 (1.7) 8.8 (1.9) < 0.001 Total cholesterol (mg/dL) 203.2 (35.4) 216.6 (41.0) 217.7 (45.3) < 0.001 LDL cholesterol (mg/dL) 122.7 (26.4) 133.8 (30.9) 134.4 (34.8) < 0.001 HDL cholesterol (mg/dL) 43.9 (7.7) 42.3 (8.6) 41.3 (9.0) < 0.001 Non-HDL cholesterol (mg/dL) 163.5 (63.0) 174.7 (38.5) 177.7 (42.5) < 0.001 TG (mg/dL) 194.8 (121.4) 205.2 (119.9) 220.2 (129.2) 0.007 Uric acid 4.5 (1.2) 4.7 (1.2) 4.9 (1.4) 0.004 Creatinine 0.83 (0.17) 0.92 (0.42) 1.10 (0.56) < 0.001 Urine albumin to creatinine ratio (mg/gr) 18.4 (24.9) 20.2 (25.2) 49.6 (161.4) < 0.001 TG/HDL 4.6 (3.1) 5.3 (4.1) 5.7 (3.6) < 0.001 GFR = glomerular filtration rate; FBS = fasting blood sugar; HbA1C = glycated haemoglobin; LDL = low-density lipoprotein; HDL = high-density lipoprotein; TG = triglycerides; SD = standard deviation. Table 5 Stepwise multiple logistic regression analysis of factors associated with cardiovascular disease in patients with type 2 diabetes mellitus (n = 752) Risk factora OR (95% CI) P-value Age 0.93 (0.89–0.98) 0.006 Metabolic syndrome 2.50 (1.01–6.16) 0.04 Total cholesterol 0.98 (0.97–0.99) 0.012 HDL cholesterol 1.09 (1.04–1.14) < 0.001 aIncluded factors: age, duration of diabetes, hypertension, retinopathy, glomerular filtration rate, triglyceride, high-density lipoprotein (HDL) cholesterol, uric acid, albuminuria, triglycerides/HDL cholesterol ratio. OR = odds ratio; CI = confidence interval. Book 17-9.indb 644 9/6/2011 12:42:59 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 645 of their patients had good control of diabetes  (HbA1C < 7%)  [21].  In  the  present study, no significant difference  was  found  in FBS and HbA1C  levels  between CVD and non-CVD groups. Good blood pressure control in DM is associated with reduced risk of CVD [23]. Hypertension or history of  hypertension was recorded in 51.6% of  our patients and blood pressure under optimal control was only found in 21.0%  of the sample. This finding is in agree- ment with  Jurado et  al.’s  study, which  found only 19.7% of patients had blood  pressure under control [21]. Similar  to  other studies we found a significant as- sociation between high blood pressure and CVD. Dyslipidaemia is a known major risk factor for CVD in DM [23]. Lipid abnor- malities were found in a large number of our patients. Total cholesterol, TG levels  and TG/HDL ratio were  significantly  higher and HDL cholesterol levels sig- nificantly lower in patients with CVD compared with the non-CVD group. This result is similar to another study that reported a dyslipidaemia prevalence of 77.7% in type 2 DM [21].  Almost  three-quarters  of  our  pa- tients (73.5%) had metabolic syndrome,  which is similar to other studies. In Ire- land a small study of type 1 and 2 DM  patients  attending  for  annual  review  showed that 61.0% patients had meta- bolic syndrome, more patients with type  2  (69.5%)  than  type  1 DM (22.2%)  [24]. A  study  in Australian  reported  that the overall prevalence of metabolic syndrome was 72.3%  in a  large sample  of subjects with type 2 DM [24,25]. The  prevalence of metabolic syndrome was significantly higher in the CVD group (80.1% versus 71.9%). All  the compo- nents of metabolic syndrome are con- sidered to be independent risk factors for CVD [26]. We showed a significant  difference in the number of compo- nents of metabolic syndrome in CVD versus non-CVD groups and metabolic syndrome was also an independent risk factor for CVD. Considering this result,  control of metabolic  syndrome  components seems to be important for prevention of CVD in patients with type 2 DM. Microalbuminuria and nephropa- thy are associated with increased risk of CVD in clinical studies [27,28]. In our  patients the prevalence of microalbu- minuria  (21.5%), macroalbuminuria  (1.6%) and renal  insufficiency (36.7%)  were high. The association of microalbu- minuria with CVD was not significant but the urine albumin to creatinine ratio differed significantly between CHD risk groups. Albuminuria was  significantly  higher in the high risk group (risk score  > 20%) compared with  the moderate  (risk score 10%–20%) and low risk (risk  score < 10%) groups. Different studies  have documented a significant asso- ciation between chronic kidney disease and  increased risk of CVD [29,30].  In  our study the prevalence of CVD was higher in patients with low GFR and a significant difference was found in the prevalence of renal insufficiency between patients with and without CVD. This result is consistent with other studies demonstrating that GFR is a prognostic factor for CVD in DM [29,31]. Previous studies evaluating the  role of uric acid in atherosclerosis have shown conflicting results [32,33]. In the  present study the association between CVD and uric acid was significant but uric acid was not an independent risk factor for CVD. This association is con- sistent with a meta-analysis of uric acid and CHD [34]. A  positive  association was  found  between the presence of retinopathy and CVD  in our  study. Poor  glycae- mic control and high blood pressure contribute to retinopathy as a sign of microvascular disease and CVD as a sign of macrovascular disease in DM. In  other studies,  retinopathy  is correlated  with the presence of CVD [35]. The results showed that the preva- lence of CVD and insufficient control of CVD risk factors among our patients was high. These findings are in agree- ment with other studies in different regions [21,22]. More aggressive  inter- ventions are crucial for patients with DM, including better patient education  and more aggressive control of glycae- mia, hypertension, hyperlipidaemia and  metabolic syndrome. References Stirban AO, Tschoepe D. Cardiovascular complications in 1. diabetes: targets and interventions. Diabetes Care, 2008, 31(Suppl. 2):S215–S217. Grundy SM et al. Implications of recent clinical trials for the 2. National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation, 2004, 110:227–239. Lu W et al. Non-HDL cholesterol as a predictor of cardiovascu-3. lar disease in type 2 diabetes: the strong heart study. Diabetes Care, 2003, 26:16–23. Kalaitzidis R, Bakris G. Management of hypertension in 4. patients with diabetes: the place of angiotensin-II receptor blockers. Diabetes, Obesity and Metabolism, 2009, 11:757– 769. Khalangot M et al. Body mass index and the risk of total 5. and cardiovascular mortality among patients with type 2 diabetes: a large prospective study in Ukraine. Heart, 2009, 95:454–460. Hsueh WA, Lyon CJ, Quinones MJ. Insulin resistance and the 6. endothelium. American Journal of Medicine, 2004, 117:109–117. Yokoyama H et al. Reduced GFR and microalbuminuria are in-7. dependently associated with prevalent cardiovascular disease in type 2 diabetes: JDDM study 16. Diabetic Medicine, 2008, 25:1426–1432. Popovic-Pejicic S, Todorovic-Dilas L, Pantelinac P. [The role 8. of autonomic cardiovascular neuropathy in pathogenesis of ischemic heart disease in patients with diabetes mellitus]. Medicinski Pregled, 2006, 59:118–123 [in Serbian]. Book 17-9.indb 645 9/6/2011 12:42:59 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 646 Sahli D et al. Tissue plasminogen activator (tPA) activity is a 9. novel and early marker of asymptomatic LEAD in type 2 diabe- tes. Thrombosis Research, 2009, 123:701–706. Mazzone T. Prevention of macrovascular disease in patients 10. with diabetes mellitus: opportunities for intervention. Ameri- can Journal of Medicine, 2007, 120(Suppl. 2):S26–S32. UKPDS Risk Engine11. . Oxford Centre for Diabetes, Endocrinology and Metabolism [website] (www.dtu.ox.ac.uk/riskengine/, ac- cessed 21 June 2011). Hadaegh F et al. Prevalence of coronary heart disease among 12. Tehran adults: Tehran Lipid and Glucose Study. Eastern Medi- terranean Health Journal, 2009, 15:157–166. Hadaegh F et al. Triglyceride/HDL-cholesterol ratio is an inde-13. pendent predictor for coronary heart disease in a population of Iranian men. Nutrition, Metabolism, and Cardiovascular Dis- eases, 2009, 19:401–408. Bittner V et al. The triglyceride/high-density lipoprotein cho-14. lesterol ratio predicts all-cause mortality in women with suspected myocardial ischemia: a report from the Women’s Ischemia Syndrome Evaluation (WISE). American Heart Journal, 2009, 157:548–555. Janghorbani M, Amini M, Tavassoli A. Coronary heart disease 15. in type 2 diabetes mellitus in Isfahan, Iran: prevalence and risk factors. Acta Cardiologica, 2006, 61:13–20. Hadaegh F et al. Glucose intolerance and risk of cardiovascular 16. disease in Iranian men and women: Results of the 7.6-year fol- low-up of the Tehran Lipid and Glucose Study (TLGS). Journal of Endocrinological Investigation, 2009, 32:724–730. Aghaeishahsavari M et al. Cardiovascular disease risk factors in 17. patients with confirmed cardiovascular disease. Saudi Medical Journal, 2006, 27:1358–1361. Executive Summary of The Third Report of The National Cho-18. lesterol Education Program (NCEP) Expert Panel on Detection. Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA.2001; 285: 2486-97 Kannel WB, McGee DL. Diabetes and cardiovascular risk factors: the Framingham study. Circulation, 1979, 59:8–13. Hammoud T, Tanguay JF, Bourassa MG. Management of 19. coronary artery disease: therapeutic options in patients with diabetes. Journal of the American College of Cardiology, 2000, 36:355–365. Weckbach S et al. Systemic cardiovascular complications in 20. patients with long-standing diabetes mellitus: comprehensive assessment with whole-body magnetic resonance imaging/ magnetic resonance angiography. Investigative Radiology, 2009, 44:242–250. Jurado J et al. Prevalence of cardiovascular disease and risk 21. factors in a type 2 diabetic population of the North Catalonia diabetes study. Journal of the American Academy of Nurse Practi- tioners, 2009, 21:140–148. Agarwall AK et al. Prevalence of coronary risk factors in type 22. 2 diabetes without manifestation of overt coronary heart disease. Journal of the Association of Physicians of India, 2009, 57:135–142. Berry C, Tardif JC, Bourassa MG. Coronary heart disease in 23. patients with diabetes: part I: recent advances in prevention and noninvasive management. Journal of the American College of Cardiology, 2007, 49:631–642. Alsaraj F et al. Prevalence of the metabolic syndrome in pa-24. tients with diabetes mellitus. Irish Journal of Medical Science, 2009, 178(3):309–313. Wong J et al. The metabolic syndrome in type 2 diabetes: 25. when does it matter? Diabetes, Obesity & Metabolism, 2006, 8:690–697. Grundy SM. Cardiovascular and metabolic risk factors: how 26. can we improve outcomes in the high-risk patient? American Journal of Medicine, 2007, 120(Suppl. 1):S3–S8. Klausen KP et al. Microalbuminuria and obesity: impact on 27. cardiovascular disease and mortality. Clinical Endocrinology, 2008, 71(1):40–45. Robles NR et al. Riesgo cardiovascular asociado a microalbu-28. minuria en pacientes diabeticos y en pacientes con hiperten- sion arterial. [Microalbuminuria-related cardiovascular risk in diabetic patients and hypertensive (non diabetic) population]. Medicina Clínica, 2008, 130:206–209. So WY et al. Glomerular filtration rate, cardiorenal end points, 29. and all-cause mortality in type 2 diabetic patients. Diabetes Care, 2006, 29:2046–2052. Muntner P et al. Renal insufficiency and subsequent death re-30. sulting from cardiovascular disease in the United States. Journal of the American Society of Nephrology, 2002, 13:745–753. Chou CK et al. Analysis of traditional and nontraditional risk 31. factors for peripheral arterial disease in elderly type 2 dia- betic patients in Taiwan. Diabetes Research and Clinical Practice, 2008, 81:331–337. Fang J, Alderman MH. Serum uric acid and cardiovascular mor-32. tality the NHANES I epidemiologic follow-up study, 1971–1992. National Health and Nutrition Examination Survey. Journal of the American Medical Association, 2000, 283:2404–2410. Tavil Y et al. Uric acid level and its association with carotid 33. intima-media thickness in patients with hypertension. Athero- sclerosis, 2008, 197:159–163. Wheeler JG et al. Serum uric acid and coronary heart disease 34. in 9,458 incident cases and 155,084 controls: prospective study and meta-analysis. PLoS Medicine, 2005, 2:e76. Hernandez C et al. Prevalence and risk factors accounting for 35. true silent myocardial ischemia: a pilot case–control study comparing type 2 diabetic with non-diabetic control subjects. Cardiovascular Diabetology, 2011, 10(1):9. Book 17-9.indb 646 9/6/2011 12:42:59 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 647 Road traffic injuries in Rawalpindi city, Pakistan U. Farooq,1 J.A. Bhatti,2 M. Siddiq,1 M. Majeed,1 N. Malik,1 J.A. Razzak3 and M.M. Khan1 ABSTRACT Data on road traffic accident (RTA) injuries and their outcome are scarce in Pakistan. This study assessed patterns of RTA injuries reported in Rawalpindi city using standard surveillance methods. All RTA injury patients presenting to emergency departments of 3 tertiary care facilities from July 2007 to June 2008 were included. RTA injuries (n = 19 828) accounted for 31.7% of all injuries. Among children aged 0–14 years females suffered twice as many RTA injuries as males (21.3% versus 11.4%), whereas this trend reversed for the age group 15–24 years (41.9% versus 21.7%). One-fifth of injuries were either fractures or concussion. Severity and outcome of injuries were worse for the age group 45 years and older. For every road traffic death in Rawalpindi city, 29 more people were hospitalized and 177 more received emergency department care. These results suggest the need for better RTA injury surveillance to identify preventive and control measures for the increasingly high road disease burden in this city. 1Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan (Correspondence to U. Farooq: dr_umar_farooq@yahoo.com). 2Injury Prevention and Control Research Team, National Institute of Health and Medical Research (INSERM U897), Université Bordeaux Segalen, Bordeaux, France. 3Department of Emergency Medicine, The Aga Khan University, Karachi, Pakistan. Received: 28/10/09; accepted: 21/02/10 ناتسكاب في يدنبلاور ةنيدم في ةيرورلما قرطلا تاباصإ ناخ ق ِّدصم دممح ،قازرلا دبع دْيَنُج ،كِلَم ديوَن ،ديمج رِّثدم ،قيدص ةرِفْصُم ،يتَبه دحمأ دينج ،قوراف رمع تاباصإ طمانأ ةساردلا هذه ُسياَقُتو .ناتسكاب في اهجئاتنو قرطلا لىع ثداولحا نع ةجمانلا تاباصلإا لوح تايطعلما يه ٌةحيحَش :ةـصلالخا ةيرورلما قرطلا ثداوح ءاّرج ينباصلما ضىرلما عيجم جِرْدُأ دقو .ةيرايعلما د ُّصترلا قرط مادختساب يدنبلاور ةنيدم في ةلجسلما قرطلا لىع ثداولحا ةجمانلا تاباصلإا تل َّكشو .2008 وينوي/ناريزحو 2007 ويلوي/زوتم ينب ام ةيثلاثلا ةياعرلا قفارم نم ةثلاث في ئراوطلا ماسقأ لىإ مبه َئج نيذلا تانبلا تناع ةنس 14-0 ينب مهرماعأ ْتَحَواَرَت نيذلا لافطلأا ينب ْنِمو .تاباصلإا عيجم نم 31.7% َةبسن )19828 =اهددعو( قرطلا لىع ثداولحا نع لباقم %41.9( ةنس 24-15 ةيرمعلا ةئفلا في هاتجلاا اذه سكعنا نكلو ،)%11.4 لباقم %21.3( قرطلا لىع ثداولحا تاباصإ نم روكذلا ةاناعم ْيَفعض ةجمان ةافو لك لباقمو .قوف ماف ةنس 45 ةيرمعلا ةئفلا في ًةماخو تاباصلإا ُّدشأ ْتَثَدَحو .جاتجرا وأ روسك ةئيه لىع تاباصلإا ُس ُْخم ناكو .)%21.7 ماسقأ في ةياعرلا نوقلتي ًاصخش نوعبسو ةعبسو ةئم ،جلاعلل ىفشتسلما لىإ نولَخْدُي ًاصخش نوشرعو ةعست ،يدنبلاور ةنيدم في قرطلا ثداوح نع ءبعلا اذله ةحفاكلماو ةياقولا يربادت ديدحتل قرطلا لىع ثداولحا نع ةجمانلا تاباصلإل لضفأ د ُّصرت لىإ ةجالحا لىع جئاتنلا هذه لدتو .ئراوطلا .ةنيدلما هذه في ةعيسرلا قرطلا ثداولح ديازتلما Traumatismes dus aux accidents de la circulation dans la ville de Rawalpindi (Pakistan) RÉSUMÉ Les données sur les traumatismes dus aux accidents de la circulation et leurs suites sont rares au Pakistan. La présente étude a évalué les caractéristiques des traumatismes dus aux accidents de la circulation notifiés dans la ville de Rawalpindi à l’aide de méthodes de surveillance classiques. Tous les patients souffrant de traumatismes dus à un accident de la circulation se présentant aux services des urgences dans trois établissements de soins tertiaires entre juillet 2007 et juin 2008 ont été inclus dans l’étude. Les traumatismes dus aux accidents de la circulation (n = 19 828) représentaient 31,7 % de l’ensemble des traumatismes. Jusqu’à 14 ans, les filles souffraient deux fois plus de traumatismes dus aux accidents de la circulation que les garçons (21,3 % contre 11,4 %), alors que cette tendance s’inversait dans le groupe d’âge des 15-24 ans (41,9 % par rapport à 21,7 %). Un cinquième des traumatismes étaient soit des fractures, soit des commotions. La sévérité des traumatismes s’intensifiait et leurs suites s’aggravaient dans le groupe d’âge des 45 ans et plus. Pour chaque décès causé par un accident de la circulation dans la ville de Rawalpindi, 29 personnes étaient hospitalisées et 177 autres recevaient des soins aux services des urgences. Ces résultats font ressortir la nécessité d’une meilleure surveillance des traumatismes dus aux accidents de la circulation pour identifier des mesures de prévention et de lutte visant à réduire leur charge de morbidité croissante dans la ville Book 17-9.indb 647 9/6/2011 12:42:59 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 648 Introduction Injuries  due  to  road  traffic  accidents  (RTAs)  are  a  global  public  health  problem [1] that disproportionately af- fects low-and middle-income countries (LMICs) which account for more than  90% of road fatalities [2]. In the Eastern  Mediterranean  region (EMR) 30% of  all  injury-related deaths  in 2004 were  due  to RTAs  [3]. The RTA mortality  rate was  estimated at 32.2 deaths per  100 000 population in LMICs of EMR,  a rate twice as high as European LMICs  [4].  It  is projected  that  road accident  fatalities  in EMR will  increase by 68%  from 1990 to 2020 [5]. Pakistan constitutes a major work- force of  the EMR [6].  In the absence  of  effective  rail  and urban  transport,  more  than  90%  of  passenger  and  goods  transport goes by  road  in Pa- kistan [7]. With the recent expansion  in economic development and ease of  obtaining  car  loans,  the  rate  of  vehicle production over the period from 2001 to 2006 increased by over  300%  to meet  consumer  demands  [8].  In Pakistan,  it  is  estimated  that  injuries generally, and RTA injuries in  particular, may have  led  to  increased  loss  of  daily  adjusted  life  years  [9].  However,  official  reports  indicated  that only 7000 RTA  fatalities occur  each  year  in  Pakistan  [6]. A  recent  report estimated 41 000 RTA fatalities  occur each year in Pakistan, 24% of all  estimated fatalities in EMR [4]. A better description of RTA  inju- ries,  particularly  of  non-fatal  ones  is  essential for injury prevention and con- trol measures  [10]. Police data, which  are often  the only  source of  assessing  the burden of RTA  in LMICs, highly  underestimate non-fatal injuries [1,11].  For  instance, as compared with ambu- lance  logs,  police  registered only 4%  of non-fatal RTA  injuries  in Karachi,  Pakistan [12]. Hospital data are an al- ternative to police statistics in assessing patterns of RTA injuries [13]. Previous  research in Pakistan has demonstrated  the  limitations of  estimating RTA  in- juries using hospital  logs only [14,15].  Indeed,  emergency department  logs  have to be modified in order to collect related  information  [16]. This  study  assessed  the patterns of RTA  injuries  in  an urban  town of Pakistan over  a  1-year period using standard surveil- lance methods. Methods Study setting The study setting was Rawalpindi city,  a predominantly urban sub-district situated in the north of the province of Punjab. According  to  the 1998 census,  this sub-district had a population of 1.9 million dispersed over  1682 km2 [17,18]. Emergency  care  to RTA  in- jury victims is provided by the nearest public sector health facility. Moderate to severe injuries from all over the city and other parts of the district are re- ferred to 3 major tertiary care  facilities:  Holy Family hospital, Benazir Bhutto  Shaheed  hospital  (formerly  called  Rawalpindi  general hospital)  and  the  district headquarters hospital. These hospitals  offer  24-hour  accident  and  emergency  (A&E)  and medicolegal  services.  Since August 2007,  a public  sector pre-hospital emergency care system also exists in Rawalpindi and Murree sub-districts, transporting RTA  injury victims directly to these nearby public hospitals. Study design A  cross-sectional  study  design  was  used.  All  patients  presenting  to  the  A&E departments  of  the  3  hospitals  with  an  injury-related  problem, who  had received an emergency visit slip were included in this study. The study duration was 1 year from 1 July 2007 to  30 June 2008. The study was approved  by the institutional review board of the Rawalpindi Medical College and the 3 teaching hospitals. Measures The measurement tool was the minimal data set questionnaire for injury sur- veillance  recommended by  the World  Health Organization  (WHO)  [19].  This includes age and sex of the victim and  the  place,  activity,  mechanism,  nature, severity and outcome of the in- jury. Injury severity was defined as mild  (minor or  superficial  such as bruise or  cut), moderate (requiring some skilled  treatment such as in case of fractures or sutures) or  severe (requiring  intensive  medical or surgical management such as in case of  internal haemorrhage, punc- tured organs, severe blood vessels) [19].  This 1-page questionnaire was trans- lated into Urdu and was back translated  to English to ensure consistency. The questionnaire was filled by a face-to-face interview after initial management of the  patients and obtaining their informed consent for participation. Data collection Data collection was coordinated at the hospital level by one surgery resident. Four data collectors  from the attend- ing hospital staff were nominated in each department to ensure data collection 24 hours  a day. A  central  research coordinator (registrar  in  the  department  of  surgery)  along  with  the head of the department of surgery supervised  this process. Every day, all  questionnaires filled during the previ- ous 24 hours were  submitted  to  the  directors  of  the  A&E  departments.  These were transferred to a central coordination office every third day. These were then coded using Epi-Info software, version 3.5.1 by 2 data entry  operators. The coordinating officers (registrars and residents) checked 10%  of the data during coding and entry to detect errors during these steps. Ethical approval of the study protocol was obtained from Rawalpindi Medical College research ethics council before the conduct of the study. Book 17-9.indb 648 9/6/2011 12:43:00 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 649 Analysis All  those  reporting a RTA  injury were  selected for further data analysis. Mean ages for men and women presenting with RTA  injury were computed. Age  and sex patterns of RTA  injuries were  studied using World Health Organiza- tion (WHO) categories [19]. For sim- plicity, the relationship of age with other  variables  such as  site,  activity,  alcohol  use,  injury severity and  type of  injuries  was further studied in 3 age categories:  0–15 years, 16–45 years, and > 45 years.  Proportions  within  categories  were  compared with the chi-squared test for trend where appropriate. Results Out of  62 530 patients  reporting  in- juries  in 1  year,  19 828 (31.7%) were  injured due  to RTAs. Rawalpindi gen- eral hospital received 43.7% (n = 8657)  of  these patients, district headquarters  hospital 31.9% (n = 6319) and Benazir  Bhutto Shaheed hospital  24.5%  (n  =  4853). Most  of  the  injured  patients  were males  (89.1%, n  = 17 684). The  mean age of males presenting with RTA  injuries was 26.1  [standard deviation  (SD) 13.2] years whereas  it was 29.2  (SD 17.4) years in females. The highest  rate of injuries in both sexes was age group 15–44 years (76.5% of males and  56.4% of  females). RTA  injuries were  twice as high in girls (0–14 years) than  boys (21.3% versus 11.4%) (P < 0.001).  In  the  age  group  15–24  years,  how- ever, RTA injuries were twice as high in  men (41.9%) compared with women  (21.7%) and this was significantly differ- ent compared with other age groups (P < 0.001) (Figure 1). Besides  roads (91.3% of males and  87.5% of  females), markets were com- mon sites of  these  injuries  (5.0% and  4.9% of males and females respectively)  (Table 1). For the age group 0–15 years,  slightly fewer RTA injury were reported  on roads as compared with the over- all  trend (87.2% versus 91.3% of boys  and 82.5% versus 87.5% of girls)  (P < 0.001). The commonest activity during  a RTA  injury was  travelling (93.7% of  males and 90.4% of females). In the age  group 0–15 years, significantly more of  the patients had a RTA injury during a  sports-related activity as compared with the overall  trend (8.1% versus 2.2% of  boys and 12.1% versus 4.3% of girls) (P < 0.001). Few patients (0.3%) reported to be  under the influence of drugs or alcohol during a crash: 7 times more men (n =  48) than women (n = 7). Most of the injuries sustained dur- ing  the  RTA were  classified  as mild  (53.7% of males and 47.5% of females)  or moderate (42.0% of males and 45.9%  of  females). The proportion of  injuries  that were graded as severe was twice as high in females as compared to males (3.2% versus 1.8%). Similarly, the sever- ity of  injuries  in men and women > 45  Figure 1 Age and sex patterns of road traffic injuries in Rawalpindi (July 2007–June 2008) 0 10 20 30 40 20–24 Age (years) % Male Female 25–44 45–64 65–15–195–140–4 Book 17-9.indb 649 9/6/2011 12:43:01 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 650 Ta bl e 1 C ha ra ct er is ti cs o f r oa d tr af fic in ju ry v ic ti m s by a ge a nd s ex a t 3 te ac hi ng h os pi ta ls in R aw al pi nd i ( Ju ly 2 0 0 7– Ju ne 2 0 0 8) Va ri ab le M al es P- va lu e Fe m al es P- va lu e To ta l 0 –1 5 yr s 16 –4 5 yr s > 45 y rs To ta l 0 –1 5 yr s 16 –4 5 yr s > 45 y rs (n = 1 7 68 4) (n = 2 43 1) (n = 1 3 73 2) (n = 1 52 1) (n = 2 14 4) (n = 4 90 ) (n = 1 29 8) (n = 3 56 ) % % % % % % % % Si te R oa d 91 .3 87 .2 91 .9 91 .5 < 0 .0 0 1 87 .5 82 .5 89 .2 88 .2 < 0 .0 0 1 M ar ke t 5. 0 6. 3 4. 7 5. 6 4. 9 5. 3 4. 6 5. 6 O th er 3. 7 6. 3 3. 3 2. 9 7.6 12 .2 6. 2 6. 2 A ct iv ity W or k 1.9 1.9 1.9 2. 1 < 0 .0 0 1 2. 3 1.2 2. 9 1.4 < 0 .0 0 1 Sp or t 2. 2 8. 1 1.2 1.8 4. 3 12 .5 2. 1 1.4 Tr av el lin g 93 .7 87 .0 94 .8 93 .7 90 .4 83 .3 91 .9 94 .6 O th er 2. 2 3. 0 2. 1 2. 4 3. 0 3. 1 3. 1 2. 5 A lc oh ol o r s ub st an ce a bu se Ye s 0 .3 0 .3 0 .3 0 .0 0 .0 9 0 .3 0 .0 0 .5 0 .0 N o/ un kn ow n 99 .7 99 .7 99 .7 10 0 .0 99 .7 10 0 .0 99 .5 10 0 .0 In ju ry se ve ri ty N on e 2. 5 3. 1 2. 4 2. 4 < 0 .0 0 7 3. 5 3. 1 3. 6 3. 4 < 0 .0 0 1 M ild 53 .7 54 .5 54 .5 44 .8 47 .5 53 .1 48 .5 36 .2 M od er at e 42 .0 40 .4 41 .5 49 .2 45 .9 39 .6 45 .8 54 .8 Se ve re 1.8 2. 0 1.5 3. 6 3. 2 4. 3 2. 1 5. 6 N at ur e of in ju ry Fr ac tu re 10 .3 10 .1 10 .0 13 .9 < 0 .0 0 1 14 .4 11 .8 13 .9 19 .7 < 0 .0 0 1 Sp ra in /s tr ai n 2. 7 1.8 2. 9 2. 2 2. 2 1.6 2. 3 2. 5 C ut /b ite /o pe n w ou nd 32 .9 27 .8 34 .3 27 .8 28 .0 32 .5 27 .7 23 .0 Br ui se 3. 1 2. 8 3. 2 2. 6 3. 2 2. 7 3. 0 4. 5 Bu rn 0 .3 0 .6 0 .2 0 .3 0 .8 1.6 0 .5 0 .6 C on cu ss io n 11 .9 14 .7 10 .9 16 .2 15 .6 14 .9 15 .3 17 .9 O rg an sy st em in ju ry 21 .8 22 .3 21 .5 23 .1 21 .2 19 .6 21 .4 22 .5 O th er 17 .0 19 .9 16 .9 13 .8 14 .7 15 .3 15 .9 9. 3 Book 17-9.indb 650 9/6/2011 12:43:01 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 651 years was significantly higher than the overall trend (3.6% versus 1.8% of males  and 5.6% versus 3.2% of  females) (P < 0.001). Minor cuts and bruises were the commonest type of injury as a result of a road crash (32.9% of males and 28.0%  of  females). Fractures were one of  the  major  types of RTA  injury  (10.3% of  males and 14.4% of females), so too was  concussion (11.9% of males and 15.6%  of  females). Those  aged  >  45  years  sustained significantly more fractures compared with the overall trend (13.9%  versus 10.3% of men and 19.7% versus  14.4% of women) (P < 0.001). A majority of the male (83.7%) and  female  (75.8%) patients were  treated  and discharged  from the A&E depart- ment. A total of 84 males (0.5%) and 19  females (0.9%) died as a result of RTA  in the A&E departments of these hospi- tals. Mortality was higher for those aged > 45 years  as  compared with  general  trend (1.0% versus 0.5% of males and  1.7% versus 0.9% of females). Discussion The previous literature has identified RTAs as one of  the  leading causes of  injuries  in  Pakistan  [20–22]. These  results  showed  that  indeed RTA  in- juries accounted for nearly one-third of  injuries (31.7%)  for which patients  sought  care  in A&E departments  of  tertiary care facilities of Rawalpindi city. Our results were consistent with previ- ous findings  that 30%–86% of  trauma  admissions in LMICs were due to RTA  injuries  [1,23].  Indeed, RTA  injuries  engage significant amounts of human and physical resources of the health systems in LMICs. Prevention of these  injuries can play an important role in improving the capacity of the health care systems. The mean age of RTA patients was  26.1 (SD 13.2) years in males and 29.2  (SD 17.4) years in females. These results  are similar to previously findings from a population-based  survey of  injuries,  where the mean age of those reporting injuries in the previous 3 months was 23.9 (SD 18) years [22]. It is likely that  these RTA injuries were a major source  of direct and indirect economic costs in this subdistrict. Our  study  confirmed  other  re- search showing that children are the second most vulnerable group for RTA  injuries  in South-East Asia  including  Pakistan  [21,24,25]. We also  showed  that girls were more likely to be in- volved in a RTA injury than were boys.  A previous  study showed  that girls  in  Pakistan were more  likely  to develop  disability after suffering an injury [21].  These results suggested that factors associated with female injuries should be identified in order to develop pre- ventive strategies. In children, sport was  the major activity during a RTA injury,  after travelling. The highest proportion of the in- jury patients were aged 15–44 years and for  this age group,  twice as many men  were involved in a RTA compared with  women. The predominance of adult men  involved  in RTA  injuries  can be  explained by  their  gender  roles  [22].  Indeed, men are the main earners for the  family and therefore involved usually in outdoor activities exposing them to RTAs. Previous  research  showed  that  63% of neurosurgical  fatalities  resulted  from RTAs  involving  those aged < 40  years old were due to head injuries [26].  Pakistan has a high dependency  ratio,  and unintentional loss of a life not only contributes to overall economical loss in terms of gross domestic product but also has a detrimental impact on the economy of individual families. This clearly indicates the need for more ef- forts  to prevent RTA  injuries  in Paki- stan. Deaths  from  RTA  in  the  A&E  departments of these hospitals were recorded  in 0.5% of males and 0.9% of  females. The severity and outcome of injuries, including deaths, was worse for Ta bl e 1 C ha ra ct er is ti cs o f r oa d tr af fic in ju ry v ic ti m s by a ge a nd s ex a t 3 te ac hi ng h os pi ta ls in R aw al pi nd i ( Ju ly 2 0 0 7– Ju ne 2 0 0 8) (c on cl ud ed ) Va ri ab le M al es P- va lu e Fe m al es P- va lu e To ta l 0 –1 5 yr s 16 –4 5 yr s > 45 y rs To ta l 0 –1 5 yr s 16 –4 5 yr s > 45 y rs (n = 1 7 68 4) (n = 2 43 1) (n = 1 3 73 2) (n = 1 52 1) (n = 2 14 4) (n = 4 90 ) (n = 1 29 8) (n = 3 56 ) % % % % % % % % O ut co m e Tr ea te d & d is ch ar ge d 83 .7 81 .4 85 .3 74 .7 < 0 .0 0 1 75 .8 78 .8 76 .3 69 .7 < 0 .0 0 4 A dm itt ed /r ef er re d 13 .9 16 .5 12 .6 22 .2 21 .4 18 .2 20 .9 27 .3 D ie d 0 .5 0 .3 0 .4 1.0 0 .9 1.4 0 .5 1.7 O th er 1.7 1.9 1.7 2. 1 2. 0 1.6 2. 3 1.4 Book 17-9.indb 651 9/6/2011 12:43:01 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 652 age group > 45 years as compared with  the overall trend. Driving under the influence of al- cohol or other substances is a major contributing factor to RTAs [1]. Previ- ous research in South Africa has shown  that alcohol was a contributing factor in  47% of  fatal  and 27% of  non-fatal  crashes; high alcohol was  found  in  the  blood  of  52%  of  people  involved  in  road  crashes  [27,28].  In New Delhi,  India,  a  study  found  that one-third of  riders of motorized 2-wheeler vehicles  reported driving while intoxicated [29].  Very few patients in our study reported being under the influence of drugs or alcohol. It is possible, however, that this  was under-reported due to the stigma of  alcohol use  at  in Pakistani  society.  Little  information  is  available  in Paki- stan about alcohol abuse in general and about driving while intoxicated in par- ticular [6,20]. More efforts are required  to assess the prevalence of substance abuse and its relationship to RTA inju- ries in Pakistan. Our  results  showed  that  cuts  and  open wounds were the commonest injuries, followed by fractures and head  and neck injuries including concussion. A study  from urban India showed that  bone fracture was the most common injury  to patients,  followed by multiple  injuries  such as blunt  injury,  abrasions  and  lacerations  [30].  Studies  from  both Pakistan  and  India  showed  that  extremity injuries were the most com- mon,  followed by head  and  face  and  then chest  injuries  [31,32]. This  type  of  information  is often unavailable  in  LMICs, yet  it  can be useful  for organ- izing health care services. This study had several limitations. Injury surveillance was performed only  in  selected  tertiary care hospitals.  It  is  possible  that RTA  injuries of  a minor  nature which occurred away from city centres were not accounted for. There- fore, we were unable  to present overall  injury rates and mortality rates in this district. Moreover, the outcome of inju- ries was based only on the information available  in  the A&E department and  patients were not followed up due to the limited resources available for the study. Nevertheless, more detailed data about  injuries was recorded in this study than are routinely available [12,14]. The population of Pakistan has  in- creased from 136 million in 1999 to 162  million  in 2008 [33]. The increase was  twice as high in urban than rural areas (28% versus 14%). Similarly,  the  road  transport needs in the country are ex- pected to double from 2005 to 2015 [7].  This urban population growth, coupled  with an expected increase in road trans- port, will certainly lead to an increase in  RTA injuries  in Pakistani cities such as  Rawalpindi [3,4]. Improved continuous  surveillance is thus essential for policy- making in order to reduce this expected escalation  in  road disease burden [1].  Our results indicate that hospital-based  injury surveillance is practical and can provide useful  information in the Paki- stani setting. However, such efforts need  to be the part of a political road safety agenda so that preventive actions can be taken in a more effective way [34,35]. Conclusions For every road traffic death in Rawalpin- di city, 29 other persons were hospital- ized, and 177 more received emergency  department care. The results point to an increased road disease burden  in Paki- stan which needs  immediate attention  in  the political agenda [3,10]. Moreo- ver,  these  results  suggest  the need  for  a  comprehensive RTA  injury  surveil- lance in this city to better  identify road  user  types,  sites and situational  factors  involved in these crashes. This could help to implement and evaluate traffic engineering and enforcement measures in  this city. Further,  road safety educa- tion programmes in schools and provi- sion of adequate sports facilities could prevent a significant proportion of RTA  injuries in children. Acknowledgements We are grateful  to  the emergency staff,  director  emergency,  and medical  su- perintendent of the teaching hospitals for their cooperation during the study. We highly appreciate  the Government  of Punjab for taking initiative to collect  data on injuries. This study was funded by the Government of Punjab, Pakistan.  Funding organization had no input in study design, conception, and the con- duct of the study. References Peden M et al. 1. World report on road traffic injury prevention. Geneva, World Health Organization, 2004. Jacobs G, Aeron-Thomas A, Astrop A. 2. Estimating global road fatalities. Crowthorne, United Kingdom, Transport Research Laboratory, 2000. The global burden of disease: 2004 update3. . Geneva, World Health Organization, 2008. Global status report on road safety4. . Geneva, World Health Or- ganization, 2009. Murray CJL, Lopez AD, eds. 5. The global burden of disease: a comprehensive assessment of mortality and disability from dis- eases, injuries, and risk factors in 1990 and projected to 2020. Boston, Massachusetts, Harvard School of Public Health, 1996. National action plan for prevention and control of non-commu-6. nicable diseases and health promotion in Pakistan. Islamabad. Ministry of Health Government of Pakistan/World Health Organization Pakistan/Heartfile, 2004. Pakistan transport plan study in the Islamic Republic of Pakistan7. . Islamabad, Japan International Cooperation Agency (JICA), National Transport Research Center (NTRC)/Ministry of Com- munications Government of Pakistan, 2007. Book 17-9.indb 652 9/6/2011 12:43:02 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 653 Ahmed A. 8. Road safety in Pakistan. Islamabad, National Road Safety Secretariat, Ministry of Communications, 2007. Nishtar S et al. Injury prevention and control: National Action 9. Plan for NCD Prevention, Control and Health Promotion in Pakistan. Journal of the Pakistan Medical Association, 2004, 54(Suppl. 3):S57–S68. Mock C, Cherian MN. The global burden of musculoskeletal 10. injuries: challenges and solutions. Clinical Orthopaedics and Related Research, 2008, 466:2306–2316. Wootton J, Jacobs GD. 11. Safe roads: A dream or a reality? Crowthorne, United Kingdom, Transport Research Laboratory, 1996. Razzak JA, Luby SP. Estimating deaths and injuries due to road 12. traffic accidents in Karachi, Pakistan, through the capture- recapture method. International Journal of Epidemiology, 1998, 27:866–870 Razzak J, Marsh D, Stansfield S. District hospital based injury 13. data-are they an option in a developing country? Injury Preven- tion, 2002, 8:345b–346b. Bhatti MA et al. Road traffic injuries in Pakistan: challenges in 14. estimation through routine hospital data. Journal of Ayub Medi- cal College, Abbottabad, 2008, 20:108–111. Razzak JA, Laflamme L. Limitations of secondary data sets for 15. road traffic injury epidemiology: a study from Karachi, Paki- stan. Prehospital Emergency Care, 2005, 9:355–360. Williams JM et al. The emergency department log as a simple 16. injury-surveillance tool. Annals of Emergency Medicine, 1995, 25:686–691. Socioeconomic indicators at district level: Punjab17. . Islamabad, Federal Bureau of Statistics, Government of Pakistan, 2000. Population and housing census 199818. . Islamabad, Population Census Organization. Government of Pakistan; 1999. Holder Y et al. 19. Injury surveillance guidelines. Geneva, World Health Organization, 1999. Fatmi Z et al. Incidence, patterns and severity of reported un-20. intentional injuries in Pakistan for persons five years and older: results of the National Health Survey of Pakistan 1990-94. BMC Public Health, 2007, 7:152. Fatmi Z et al. Incidence and patterns of unintentional injuries 21. and resulting disability among children under 5 years of age: results from national health survey of Pakistan. Paediatric and Perinatal Epidemiology, 2009, 23:229–238. Ghaffar A, Hyder AA, Masud TI. The burden of road traffic in-22. juries in developing countries: the 1st national injury survey of Pakistan. Public Health, 2004, 118:211–217 Odero W, Garner P, Zwi A. Road traffic injuries in developing 23. countries: a comprehensive review of epidemiological studies. Tropical Medicine & International Health, 1997, 2:445–460. Hyder AA et al. Global childhood unintentional injury surveil-24. lance in four cities in developing countries: a pilot study. Bul- letin of the World Health Organization, 2009, 87:342–345. Qureshi AF, Bose A, Anjum Q. Road traffic injuries. A new 25. agenda for child health. Journal of the College of Physicians and Surgeons--Pakistan, 2004, 14:719–721. Ghani E et al. Khaleeq-uz-Zaman. Road traffic accidents as a 26. major contributor to neurological mortality in adults. Journal of the College of Physicians and Surgeons of Pakistan, 2003, 13:143–145. Peden M. Injured pedestrians in Cape Town: the role of alco-27. hol. South African Medical Journal, 1996, 16:1103–1105. Peden M. Substance abuse and trauma in Cape Town. 28. South African Medical Journal, 2000, 90:251–255. Mishra BK, Banerji AK, Mohan D. Two-wheeler injuries 29. in Delhi, India: a study of crash victims hospitalized in a neuro-surgery ward. Accident; Analysis and Prevention, 1984, 16:407–416. Singh H, Dhatarwal SK. Pattern and distribution of injuries in 30. fatal road traffic accidents in Rohtak (Haryana). Journal of the Indian Academy of Forensic Medicine, 2004, 26:971–973. Ganveer GB, Tiwari RR. Injury pattern among non-fatal road 31. traffic accident cases: a cross-sectional study in central india. Indian Journal of Medical Sciences, 2005, 59:8–12. Report of road injury surveillance project of Injury Research and 32. Prevention Centre of JPMC, Karachi. Karachi, Road Injury Re- search and Prevention Centre, Jinnah Post Graduate Medical Centre, 2007. Pakistan economic survey 2008–200933. . Islamabad, Ministry of Finance, Government of Pakistan, 2009. Novoa AN et al. Road safety in the political agenda: the im-34. pact of traffic injuries. Journal of Epidemiology and Community Health, 2011, 65:218e–225e. Soori H et al. Road traffic injuries in Iran: the role of interven-35. tions implemented by traffic police. Traffic Injury Prevention, 2009, 10:375–378. Book 17-9.indb 653 9/6/2011 12:43:02 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 654 Health disparities between Muslim and non-Muslim countries J.A Razzak,1 U.R. Khan,1 I. Azam,1 M. Nasrullah,2 O. Pasha,1 M. Malik 1 and A. Ghaffar 3 ABSTRACT We examined differences in health indicators and associated factors across countries according to the proportion of the population who are Muslim. Of 190 UN countries, 48 were classified as Muslim-majority countries (MMC) and 142 as non-MMC. Data on 41 potential determinants of health were obtained from 10 different data sources, and 4 primary outcome measures (male and female life expectancy, maternal mortality ratio and infant mortality rate) were analysed. Annual per capita expenditure on health in MMC was one-fifth that of non- MMC. Maternal mortality and infant mortality rates were twice as high in MMC as non-MMC. Adult literacy rate was significantly higher for non-MMC. Four significant predictors explained 52%–72% of the differences in health outcomes between the 2 groups: gross national income, literacy rate, access to clean water and level of corruption. 1Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan (Correspondence to J.A. Razzak: Junaid.razzak@aku.edu). 2Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. 3World Health Organization, Geneva, Switzerland. Received: 16/06/09; accepted: 23/12/09 ةيملاسلإا يرغو ةيملاسلإا نادلبلا ينب ةيحصلا تانيابتلا رافغلا دبع ،كِلَم انيم ،اشاب نارمع ،للها صرن مظعم ،مظعأ لابقإ ،ناخ ميحر ىَمظُع ،قازرلا دبع دينج ينعستو ةئم ينب نمو .انهاكس نم ينملسلما ةبسن بسحب نادلبلا في ابه ةقلعتلما لماوعلاو ةيحصلا تاشرؤلما في قراَوَفلا نوثحابلا ى َّر ََتح دق :ةـصلالخا نوملسلما فّلؤي لا ًادلب نوعبرأو نانثاو ةئمو ،انهاكس ةيبلاغ نولّكشي ينملسلما نأ لىع ُفَّنَصُت ًادلب نوعبرأو ةينماث كانه ةدحتلما مملأا في ًاوضع ًادلب ةعبرأ ليلتح متو ،تامولعملل ةفلتمخ رداصم ةشرع نم ةلمتحلما ةيحصلا تاددحلما نم ًاد ِّدمح ينعبرأو دحاو لوح تايطعلما عجم ّمت مقو .انهاكس ةيبلاغ قافنلإا نم درفلا بيصن غلب دقو .)عّضرلا تايفو لدعمو ،تاهملأا تايفو ةبسن ،ثانلإاو روكذلا نم ٍّلكل ةايلحا لومأم( ةيلولأا جئاتنلل تاسايق تايفو تلادعم امأ .انهاكس ةيبلاغ نوملسلما لكشي لا يتلا نادلبلا في قفنُي ام سُْخم انهاكس ةيبلاغ نوملسلما لكشي يتلا نادلبلا في ةحصلا لىع يونسلا نوملسلما لكشي لا يتلا نادلبلا في تلادعلما سفن هيلع يه ام ْيَفعض لياوح تغلب دقف انهاكس ةيبلاغ نوملسلما لكشي يتلا نادلبلا في عّضرلاو تاهملأا يتلا نادلبلاب ةنراقم انهاكس ةيبلاغ نوملسلما فّلؤي يتلا نادلبلا في كلذو عّضرلا تايفو لدعم غلبو ، تاهملأا تايفو لدعم غلب ْذإ .انهاكس ةيبلغأ نادلبلاب ةنراقم ابه ُّدَتْعُي ةجردب لىعأ انهاكس ةيبلاغ نوملسلما لكشي لا يتلا نادلبلا في ينعفايلا ميلعت لدعم ناكو .انهاكس ةيبلاغ نوملسلما فّلؤي لا ينب ةيحصلا جئاتنلا في ْتَفِدوُص يتلا قراوفلا نم %52-%72 لياوح يرسفت لىع ةماه تائبنُم ةعبرأ تدعاس دقو .انهاكس ةيبلاغ نوملسلما لكشي يتلا .دلبلا في داسفلا ىوتسمو ،ةفيظن هايم لىع لوصلحاو ،ةباتكلاو ةءارقلا ةفرعم لّدعمو ،ينطولا لخدلا لياجمإ :يه تائبنلما هذهو ،ينتعومجلما Disparités en matière de santé entre pays musulmans et non musulmans RÉSUMÉ Nous avons examiné les différences entre les indicateurs de santé et les facteurs associés dans différents pays en fonction de la proportion de la population musulmane. Sur 190 pays membres des Nations Unies, 48 étaient classés comme des pays à majorité musulmane et 142 comme des pays à majorité non musulmane. Des données ont été obtenues sur 41 déterminants potentiels de la santé à partir de dix sources d’information différentes, et quatre mesures principales de résultats (l’espérance de vie pour les hommes et pour les femmes, le taux de mortalité maternelle et le taux de mortalité infantile) ont été analysées. Les dépenses de santé annuelles par habitant dans les pays majoritairement musulmans correspondaient au cinquième des dépenses dans les autres pays. Les taux de mortalité maternelle et infantile étaient deux fois plus élevés dans les pays à majorité musulmane. Le taux d’alphabétisation des adultes était nettement supérieur dans les pays à majorité non musulmane. Quatre facteurs prédictifs importants expliquaient 52 à 72 % des différences dans les résultats sanitaires entre les deux groupes : le revenu national brut, le taux d’alphabétisation, l’accès à l’eau salubre et le niveau de corruption Book 17-9.indb 654 9/6/2011 12:43:02 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 655 Introduction Despite impressive gains in health and longevity during  the 20th century sub- stantial health disparities exist between countries  [1,2]. Today,  people  living  in the poorest countries of the world live 30  years  less  than  those  living  in  economically  advanced countries  [3].  Life expectancy for children born in Europe  has  increased  by  30  years  in  the last century compared to 4 months for children born in sub-Saharan Africa  [4]. Research on disparities in health has focused primarily on the relationship between health outcomes and popula- tion  factors  such as  race,  income  level,  sex,  age  groups  and  education  levels  [3]. Like gender and race, religion forms  part of the context that generates social inequalities and could influence the po- sition a person occupies in their society and thus impact their health outcomes [5]. Study of health outcomes according  to the religious affiliation of populations has focused on minority populations in some countries or on specific dis- eases  [6,7]. Muslims,  the  followers of  the  religion of  Islam,  form one of  the  largest religious groups in the world with an estimated population of 1.4–1.5 billion  [8]. Comprising many  ethnic  groups spread across the globe and con- nected only by religious belief, Muslims  are  concentrated  in 57 countries  [8].  Concerns about the radicalization of Muslim populations have prompted a growing interest in the last decade in the social development of Muslim countries [9]. We undertook  this  study  to exam- ine differences in 4 key health indicators (male and female life expectancy, infant  mortality rates and maternal mortality ratios) between countries with  a pre- dominantly Muslim population and non-Muslim majority countries and to identify factors possibly contributing to this difference based on national ag- gregate data. Methods Study population For  the  purpose  of  this  study,  190  countries were classified  into 2 groups.  Muslim majority  countries  (MMC)  were defined as  countries with a 50%  or greater Muslim population [10]. All  other United Nations (UN) member  states,  irrespective  of  the  number  of  Muslims,  were  designated  as  non- MMC. The  142  non-MMC  and  48  MMC were subdivided into 4 groups based on the UN classification of gross  national  income (GNI) per capita in 2006 which  is gross domestic product  (GDP) less net taxes on production and  imports,  less compensation of employ- ees and property income payable to the rest of the world plus the corresponding items receivable from the rest of the world. The 4 groups  are:  low  income  countries  (≤ US$ 905),  lower middle  income  countries  (US$  906–3595),  upper middle  income countries (US$  3596–11 115) and high  income coun- tries  (≥ US$ 11 116)  [11]  (Tables 1  & 2). Data sources The 41 variables used in this study were compiled  from 10 different data  sources. The 2 major contributing data  sources  include  the World  Health  Organization’s  Statistical  Informa- tion  System  (WHOSIS)  [12],  and  the Statistical Economic and Social Research and Training Center  for  Is- lamic Countries’ (SESRIC) Basic and  Social Economic  Indicators Database  (BASEIND) [13]. Other sources used  to abstract data included Development Data Platform (DDP), Quick Query  of  the World Bank  [14],  the Human  Development Reports of  the United  Nations  Development  Programme  [15], online databases of  the United  Nations  Statistics  Division  [16],  United Nations International Children  Education  Fund  (UNICEF)  [1617  United  Nations  Population  Fund  [18] and United Nations Educational,  Scientific  and Cultural Organization  (UNESCO)  [19],  the World  Fact  Book [20] and Google Scholar  [21].  The latest available data from year 2000  onwards were used in the analysis. No ethics clearance was required as data were gathered from publicly available data sources Measures Outcomes Four primary outcome measures were used: male and  female  life  expectancy  (the number of  years  that  a newborn  can expect to live based on the current mortality  rates),  infant mortality  rate  (the probability of a child dying before  the age of 1 year) and maternal mortal- ity ratio (number of maternal deaths per  100 000  live births)  [22]. These have  been used before in health situation analyses [23,24]. Independent variables Other  independent  variables  were  used  for which data were available. A  total of 37 independent variables were studied. These included indicators for demographic and socioeconomic status, population, education, health,  governance,  environmental  factors,  health service coverage and resources,  external debt and military expendi- ture. Statistical methods All analyses were conducted using SPSS,  version 16.0. Independent  samples  t-test was used to estimate the mean differences of continuous variables such as literacy rate,  life  expectancy, maternal mortal- ity  ratio,  infant mortality  rate,  under  5  years mortality,  age  standard mor- tality for noncommunicable diseases and per capita government expenditure by country status. The chi-squared test was used to compare the proportion of income status among MMC and non-MMC. Multicollinearity among Book 17-9.indb 655 9/6/2011 12:43:02 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 656 Table 1 Classification of the non-Muslim majority countries used for the study by income groups (n = 142) Low-income non-Muslim countries (n =32) Lower-middle -income non- Muslim countries (n = 40) Upper-middle -income non- Muslim countries (n = 32) High-income non-Muslim countries (n = 38) Benin Angola Argentina Andorra Burundi Armenia Belize Antigua and Barbuda Cambodia Belarus Botswana Australia Central African Republic Bhutan Brazil Austria Congo Bolivia Bulgaria Bahamas Cote d’Ivoire Bosnia Herzegovina Chile Barbados Eritrea Cameroon Costa Rica Belgium Ethiopia Cape Verde Croatia Canada Ghana China Dominica Cyprus Haiti Colombia Equatorial Guinea Czech Republic India Congo (Demographic Republic of) Gabon Denmark Kenya Cuba Granada Estonia Korea Democratic Republic Dominican Republic Hungary Finland Lao (People's Democratic Republic) Ecuador Latvia France Liberia El Salvador Lithuania Germany Madagascar Fiji Mauritius Greece Malawi Georgia Mexico Iceland Mongolia Guatemala Montenegro Ireland Mozambique Guyana Palau Israel Myanmar Honduras Panama Italy Nepal Jamaica Poland Japan Papua New Guinea Kiribati Romania Korea (Republic of) Rwanda Lesotho Russian Federation Luxembourg Sao Tome and Principe Macedonia (the former Yugoslavia) Serbia Malta Solomon Islands Marshall Islands Seychelles Monaco Tanzania (United Republic of) Micronesia (Federated States of) Slovakia Netherlands Timor-Leste Moldova (Republic of) South Africa New Zealand Togo Namibia St Kitts and Nevis Norway Uganda Nicaragua St Lucia Portugal Viet Nam Paraguay St Vincent and the Grenadines San Marino Zambia Peru Uruguay Singapore Zimbabwe Philippines Venezuela Slovenia Samoa Spain Sri Lanka Sweden Suriname Switzerland Swaziland Trinidad and Tobago Thailand United Kingdom Tonga United States of America Ukraine Vanuatu Book 17-9.indb 656 9/6/2011 12:43:03 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 657 independent variables was assessed by Pearson, Cramer  and  eta  statistics  at  the cut-off 0.8, above which correlation  is strong. Simple linear regression was per- formed to determine the association of the independent variables with the 4 primary outcome variables. Association  between all the variables used in uni- variate analysis was also performed by adjusting the primary exposure (country  majority religion) with the outcomes.  Multiple linear regression analysis was performed to determine independ- ent relationships between outcomes and potential predictors. Adjustment  variables were selected by sequentially adding significant predictors from the univariate analysis into the model. Two separate sets of models were estimated for all 4 outcomes. Once  the  stepwise  selection was completed, the final mod- el was  refitted using only  the variables  significant at the 5% of level. Results Comparison of descriptive characteristics Table 3 summarizes the descriptive characteristics of  the 190 MMC and  non-MMC according to the studied variables. We  found  significant differences  in health outcomes between MMC and non-MMC. The annual popula- tion  growth  rate  for MMC was  1%  more than in non-MMC on average (2.4%  versus  1.2%;  95% CI:  –1.6%  to –0.7).  Similarly,  the mean values  of maternal mortality  ratio (455 ver- sus 266 per 100 000 births); 95% CI:  –350  to –7.5), under 5 years mortal- ity rate (80.5 versus 51.9 per 1000 live  births;  95% CI: –49.7  to –7.5)  and  infant mortality rate (56 versus 34 per  1000 live births; 95% CI –34 to –10)  were considerably worse in MMC. Years of potential life lost (YPLL) due  to noncommunicable diseases were lower in MMC (38.1 versus 49.8 years;  95% CI: 4.0 to 19.3), while YPLL due  to communicable diseases were higher (47.8 versus 36.1 years; 95% CI: –21.5  to –2.0). A  lower prevalence of HIV  was found in MMC (839 versus 2653  per 100 000; 95% CI: 691  to 2937)  (Table 3). Large differences were also found in the socioeconomic and education indicators. Almost half of non-MMC  (49.3%) were  in  the  high-  or  upper- middle-income group compared with one-quarter  of MMC  (25.0%). The  mean adult  literacy  rate was 85.0%  for  the non-MMC compared with 68.6%  for  the MMC (95% CI: 7.6  to 24.0).  Other differences were better access to  safe water, a higher rate of contraceptive  use and a higher gender equity index in non-MMC (Table 3). There were fewer resources for health in MMC then in non-MMC. Table 2 Classification of the Muslim-majority countries used for the study by income groups (n = 48) Low-income Muslim countries (n = 21) Lower-middle income Muslim countries (n =15) Upper-middle-income Muslim countries (n = 6) High-income Muslim countries (n = 6) Afghanistan Albania Kazakhstan Bahrain Bangladesh Algeria Lebanon Brunei Darussalam Burkina Faso Azerbaijan Libyan Arab Jamahiriya Kuwait Chad Djibouti Malaysia Qatar Comoros Egypt Oman Saudi Arabia Gambia Indonesia Turkey United Arab Emirates Guinea Iran (Islamic Republic of) Guinea-Bissau Iraq Kyrgyzstan Jordan Mali Maldives Mauritania Morocco Niger Palestine Nigeria Syrian Arab Republic Pakistan Tunisia Senegal Turkmenistan Sierra Leone Somalia Sudan Tajikistan Uzbekistan Yemen Book 17-9.indb 657 9/6/2011 12:43:03 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 658 Table 3 Descriptive characteristic of the Muslim majority and non-Muslim majority countries Variable Muslim majority (n = 48) Non-Muslim majority (n = 142) 95% CI for the difference Mean (SD) Mean (SD) Demographic and socioeconomic indicators Total life expectancy (years 64.2 (11.0) 66.7 (13.1) –1.8 to 6.6 < 5-year-old mortality rate (per 1000 live births) 80.5 (74.2) 51.9 (59.7) –49.7 to –7.5 Total adult mortality rate (per 1000 population) 237.9 (125.5) 217.7 (144.4) –67.1 to 26.6 Total fertility rate (per woman) 3.8 (1.7) 2.7 (1.4) –1.5 to –0.4 No. (%) No. (%) Income group High 6 (12.5) 38 (26.8) –28.3 to –0.3 Upper middle 6 (12.5) 32 (22.5) –23.2 to 3.2 Lower middle 15 (1.2) 40 (28.2) –11.8 to 17.8 Low 21 (3.8) 32 (22.5) 6.9 to 35.7 Mean (SD) Mean (SD) Population indicators Population annual growth rate (%) 2.4 (1.9) 1.2 (1.1) –1.6 to –0.7 Urbanization (%) 53.1 (23.0) 55.8 (23.1) –5.0 to 10.3 Development and governance indicators Gender equity index 50.3 (8.5) 64.9 (11.1) 11.1 to 18.0 Human development index 0.6 (0.2) 7.9 (58.2) –10.1 to 24.6 Democracy index 3.8 (1.5) 6.3 (2.1) 2.0 to 3.1 Corruption perception index 3.0 (1.1) 4.3 (2.2) 0.8 to 1.8 Military expenditure (% of GDP) 3.1 (2.3) 2.0 (2.5) –2.0 to –0.2 External debt (US$) 19.5 (40.7) 24.2 (53.7) –14.8 to 24.2 Education indicators Total adult literacy rate (%) 68.6 (25.8) 85.0 (16.8) 7.6 to 24.0 Male adult literacy rate (%) 78.6 (20.6) 89.5 (12.7) 4.6 to 17.4 Female adult literacy rate (%) 65.2 (28.3) 84.5 (19.6) 10.4 to 28.2 Public expenditure on education (% of GDP) 4.1 (2.4) 4.9 (1.9) –0.1 to 1.7 Public expenditure on education (% of total government exp.) 17.5 (7.0) 14.9 (5.1) –5.3 to –0.1 Health indicators Low birth weight (% of births) 13.4 (7.4) 9.8 (4.7) –6.0 to –11 HIV prevalence (per 100 000 population) 839 (1098) 2653 (5633) 691 to 2937 YPLL communicable disease (years) 47.8 (26.0) 36.1 (30.1) –21.5 to –2.0 YPLL noncommunicable disease (years) 38.1 (21.0) 49.8 (27.6) 4.0 to 19.3 Environmental health factors Improved water access (% of population) 77.5 (19.5) 85.7 (16.6) 2.1 to 14.1 Improved sanitation (% of population) 77.1 (107.9) 68.9 (29.1) –42.7 to 26.2 Health service coverage Contraceptive use (%)a 39.7 (22.7) 51.0 (21.9) 3.5 to 19.2 Births attended by skilled health personnel (%) 69.6 (29.5) 87.7 (85.0) –7.0 to 43.0 DPT immunization (%)b 76.1 (24.9) 79.4 (21.8) –4.3 to 10.7 Measles immunization (%)c 79.3 (22.2) 78.1 (21.7) –8.4 to 6.1 Book 17-9.indb 658 9/6/2011 12:43:03 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 659 Annual per capita expenditure on health in MMC was one-fifth of  that  in non- MMC (US$  155.8  versus US$  627;  95% CI: 315 to 626). Similarly, facilities  such as hospital beds (36.3 versus 21.7  per 10 000 population; 95% CI: 7.0  to  22.4) were better by a  large margin  in  non-MMC (Table 3). On correlation analysis, only the cor- ruption perception index and income group were found to be significantly correlated at 0.78, which was  less  than  the cut-off. Associations between health indicators and outcomes Table 4 presents the unadjusted odds  ratios  (ORs)  for  associations  between health indicators and outcomes. Almost  all  the  variables  were significantly associated in the univariate analysis with a few excep- tions; for example, maternal mortality  ratio, public expenditure on education  and HIV prevalence were not signifi- cantly associated when analysed by the outcome male life expectancy. Similarly, gender equity index was not  significantly associated with infant mortality rate. The data were adjusted for coun- tries’ majority religion in the multivari- able analysis. Corruption perception index were both important variables and were correlated so they were in- cluded in 2 separate models. In model  1 adult literacy rate, income group and  improved water access were independ- ent predictors of life expectancy for males (R2 = 54%),  life expectancy  for  females (R2 = 69%) and infant mortal- ity rate (R2 = 72%). Adult literacy rate  and improved water access (R2 = 72%)  were predictors of maternal mortal- ity ratio. The only change identified in model 2 was  the  corruption percep- tion index as a predictor of life expect- ancy  for males  (R2  =  52%),  females  (R2 = 67%), infant mortality rate (R2 =  72%) and maternal mortality ratio (R2 = 66%) (Table 5). Discussion The study found that national health indicators in MMC were substan- tially worse than those in non-MMC. The differences were most prominent for the indicators of maternal and child health. Maternal mortality ratios and infant and under 5 years mortal- ity rates were almost twice as high in MMC as  in non-MMC.  It  is  likely  that the 3-year difference in overall life expectancy between MMC and non-MMC is largely mediated by excess early mortality. Nonetheless,  adult mortality rates were higher in MMC than  in non-MMC, although  the magnitude of the difference was smaller. The substantial burden of communicable diseases,  in  spite of  the  lower prevalence of HIV,  is  in- dicative of the early stage of disease transition  in MMC. However, being  a MMC did not in itself account for these health disparities. The differ- ences in health outcomes in our study were linked to differences in more predictable  factors: overall GNI,  lit- eracy rates, access to clean water and  level of corruption. Low GNI was one of  the  key de- terminants of poor health indicators in MMC in our study. National economic status is an important determinant of health [26–28], although the  relation- ship is not consistent across all coun- tries.  Improvements  in  health  status  in North  America  and  Europe  have  been closely linked to economic growth [29]. However,  there  are  examples of  countries showing significant improve- ments in health status without major economic growth as well as of countries where an economic boom has had a negative impact on health outcomes [30].  Increasing national  income  leads  to improvements in health only when coupled with advances in the status of Table 3 Descriptive characteristic of the Muslim majority and non-Muslim majority countries (concluded) Variable Muslim majority (n = 48) Non-Muslim majority (n = 142) 95% CI for the difference Mean (SD) Mean (SD) Health service resources Physicians’ density (per 1000 population) 1.1 (1.1) 1.6 (1.4) 0.1 to 1.0 Nurses’ density (per 1000 population) 2.8 (3.8) 3.9 (3.6) –0.1 to 2.3 Hospital beds (per 10 000 population 21.7 (18.9) 36.3 (31.2) 7.0 to 22.4 Government expenditure on health per capita (US$) 156 (165) 627 (896) 315 to 627 General government expenditure on health (% of total government exp.) 7.6 (3.5) 13.3 (8.8) –4.0 to 7.5 Total expenditure on health (% of GDP) 6.7 (10.7) 6.6 (2.4) –3.3 to 4.0 a% of women using contraception among those of reproductive age who are married or living with a partner; b% of 1-year-olds immunized with 3 doses of DPT; c% of 1-year-olds immunized with 1 dose of measles. CI = confidence interval; SD = standard deviation; HIV = human immunodeficiency virus; DPT = diphtheria/pertussis/tetanus; YPLL = years of productive life lost; GDP = gross domestic product. Book 17-9.indb 659 9/6/2011 12:43:03 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 660 Ta bl e 4 U ni va ri at e an al ys is o f t he in de pe nd en t v ar ia bl es w it h th e 4 ou tc om e va ri ab le s: m al e an d fe m al e lif e ex pe ct an cy , m at er na l m or ta lit y ra ti o an d in fa nt m or ta lit y ra te (n = 19 0 ). Pr im ar y ex po su re : c ou nt ry m aj or ity re lig io n Va ri ab le M al e lif e ex pe ct an cy Fe m al e lif e ex pe ct an cy In fa nt m or ta lit y ra te M at er na l m or ta lit y ra te β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) C ou nt ry m aj or ity re lig io n N on -M us lim m aj or ity – – – – M us lim m aj or ity 3. 8 (– 7.6 to – 0 .0 ) –5 .0 (– 9. 0 to – 0 .9 ) –2 2. 1 ( 9. 7 to 3 4. 6) 17 8. 8 (3 9. 1 t o 31 8. 4) D em og ra ph ic a nd so ci oe co no m ic in di ca to rs To ta l f er til ity –5 .0 (– 5. 8 to – 4. 3) –6 .3 (– 7.0 to – 5. 6) 20 .2 (1 8. 2 to 2 2. 2) 21 7.6 (1 97 .1 to 2 38 .1) In co m e gr ou p H ig h – – – – U pp er m id dl e 10 .5 (– 14 .2 to – 7.0 ) –7 .8 (– 11 .3 to – 4. 3) 13 .7 (3 .0 to 2 4. 4) 97 .2 (– 47 .5 to 2 42 .0 ) Lo w er m id dl e 11 .6 (– 14 .9 to – 8. 3) –1 2. 4 (– 15 .6 to – 9. 2) 31 .7 (2 2. 0 to 4 1.5 ) 23 1.6 (1 0 4. 4 to 3 58 .7 ) Lo w –2 2. 3 (– 25 .6 to – 19 .0 ) –2 5. 9 (– 29 .2 to – 22 .7 ) 77 .4 (6 7.5 to 8 7.4 ) 73 0 .1 (6 0 4. 0 to 8 56 .1) Po pu la ti on in di ca to rs Po pu la tio n an nu al g ro w th ra te –4 .1 (– 5. 5 to – 2. 7) –5 .8 (– 7.2 to – 4. 4) 20 .4 (1 6. 3 to 2 4. 5) 21 2. 3 (1 64 .4 to 2 60 .2 ) U rb an iz at io n 0 .3 (0 .2 to 0 .3 ) 0 .3 (0 .3 to 0 .4 ) –1 .0 (– 1.2 to – 0 .8 ) –1 0 .4 (– 12 .7 to – 8. 1 D ev el op m en t a nd g ov er na nc e in di ca to rs G en de r e qu ity in de x 0 .4 (0 .3 to 0 .5 ) 0 .5 (0 .4 to 0 .7 ) –1 0 8 (– 20 2 to 1. 3) –1 7.6 (– 22 .2 to – 13 .1) D em oc ra cy in de x 2. 5 (1. 7 to 3 .3 ) 3. 1 ( 2. 3 to 4 .0 ) –9 .4 (– 11 9 to – 7.0 ) –8 7.3 (– 11 4. 2 to – 60 .3 ) C or ru pt io n pe rc ep tio n in de x 3. 2 (2 .5 to 3 .9 ) 3. 5 (2 .8 to 4 .3 ) –1 0 .0 (– 12 .2 to – 7.8 ) –9 1.5 (– 11 8. 0 to – 65 ) Ed uc at io n in di ca to rs To ta l a du lt lit er ac y ra te 0 .3 (0 .3 to 0 .4 ) 0 .4 (0 .4 to 0 .5 ) –1 .4 (– 1.6 to – 1.3 ) –1 5. 7 (– 17 .6 to – 13 .8 ) Pu bl ic e xp en di tu re o n ed uc at io n 0 .7 (– 0 .2 to 1. 6) 0 .7 (– 0 .2 to – 1.7 ) –3 .0 (– 5. 9 to – 0 .2 ) –3 4. 0 (– 66 .0 to – 2. 2) H ea lt h in di ca to rs Lo w b irt h w ei gh t –0 .8 (– 1.1 to – 0 .5 ) –1 .1( –1 .3 to – 0 .8 ) 3. 4 (2 .6 to 4 .2 ) 33 .6 (2 5. 1 t o 42 .1) H IV p re va le nc e –0 .0 0 1 ( –0 .0 0 2 to 0 .0 0 ) –0 .0 0 2 (– 0 .0 0 2 to – 0 .0 0 1) 0 .0 0 3 (0 .0 0 2 to 0 .0 0 4) 0 .0 2 (0 .0 1 t o 0 .0 4) YP LL c om m un ic ab le d is ea se –0 .3 (– 0 .3 to – 0 .3 ) –0 .4 (– 0 .4 to – 0 .4 ) 1.1 (1 .0 to 1. 2) 11 .1 (1 0 .0 to 12 .4 ) YP LL n on co m m un ic ab le d is ea se 0 .3 (0 .3 to 0 .4 ) 0 .4 (0 .4 to 0 .5 ) –1 .2 (– 1.3 to – 1.1 ) –1 2. 3 (– 13 .7 to – 10 .8 ) H ea lt h se rv ic e re so ur ce s Ph ys ic ia ns ’ d en si ty 4. 5 (3 .5 to 5 .5 ) 6. 0 (5 .0 to 7. 0 ) –1 6. 2 (– 19 .5 to – 12 .9 ) 18 8. 5 (– 22 4. 7 to – 15 2. 3) N ur se s’ d en si ty 1.2 (0 .8 to 1. 6) 1.5 (1 .1 to 2 .0 ) –4 .0 (– 5. 3 to – 2. 5) –3 7.6 (– 53 .2 to – 22 .0 ) To ta l e xp en di tu re o n he al th 0 .3 (0 .0 4 to 0 .7 ) 0 .3 (0 .0 3 to 0 .6 ) –1 .2 (– 2. 1 t o –0 .2 ) –1 2. 4 (– 23 .0 to – 2. 0 ) D PT im m un iz at io n 0 .1 (0 .0 6 to 0 .2 ) 0 .1 (0 .0 4 to 0 .2 ) –0 .4 (– 0 .6 to – 0 .2 ) –4 .2 (– 7.0 to – 1.4 ) Book 17-9.indb 660 9/6/2011 12:43:04 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 661 education [31] and empowerment,  i.e.  the ability of people, particularly poor  people, to make independent decisions  for their own well-being [32]. National  wealth is not necessarily a barrier to or a guarantee of specific health out- comes,  as  evidenced by  international  comparisons. The United States  ranks  4th in per capita GDP in the world (US$  45 790); however,  the  life  expectancy  lags behind  that of  Jordan (GDP US$  4903)  and  Bosnia  and Herzegovina  (GDP US$ 7468). More  specifically,  per capita spending on health also does not correlate well with health status. The level of a nation’s wealth is linked very closely to what it spends on health. The larger the per capita  income,  the  larger  the expenditure is on health; with some  notable  exceptions,  such  as Pakistan.  Health outcomes follow a nonlinear curve relative to per capita expenditure on health,  asymptotically approaching  a limiting level. However, in low income  countries increasing health expendi- tures are associated with better health  outcomes. For example Cuba spends relatively more and has higher life ex- pectancies than would be expected for a country with a  similar  income [33].  Thus it is with concern that we note that in MMC per capita spending on health was only one-fifth of what it is in  non-MMC. The second determinant of poor health indicators in MMC in our study was the literacy rate. The association of literacy and health has been reported repeatedly in analyses of the post-Sec- ond World War decline of mortality in  developing countries and of mortality differentials within their populations. Low literacy is associated with several adverse health outcomes [34]. Parental  literacy in particular has an impact on the health of children [35]. There are  mortality differences of up to 4-fold between infants born to mothers with no education compared with those whose mothers have had secondary education [36].Ta bl e 4 U ni va ri at e an al ys is o f t he in de pe nd en t v ar ia bl es w it h th e 4 ou tc om e va ri ab le s: m al e an d fe m al e lif e ex pe ct an cy , m at er na l m or ta lit y ra ti o an d in fa nt m or ta lit y ra te (n = 19 0 ). Pr im ar y ex po su re : c ou nt ry m aj or ity re lig io n (c on cl ud ed ) Va ri ab le M al e lif e ex pe ct an cy Fe m al e lif e ex pe ct an cy In fa nt m or ta lit y ra te M at er na l m or ta lit y ra te β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) En vi ro nm en ta l h ea lt h fa ct or s Im pr ov ed w at er a cc es s 0 .4 (0 .3 to 0 .5 ) 0 .5 (0 .4 to 0 .6 ) –1 .7 (– 1.9 to – 1.5 ) –1 7.9 (– 20 .3 to – 15 .5 ) Im pr ov ed sa ni ta tio n 0 .1 (0 .0 4 to 0 .1) 0 .1 (0 .0 6 to 0 .1) –0 .3 (– 0 .3 to – 0 .2 ) –2 .7 (– 3. 8 to – 1.7 ) Ex te rn al d eb t 0 .0 5 (0 .0 1 t o 0 .0 9) 0 .0 7 (0 .0 3 to 0 .1) –0 .2 (– 0 .4 to – 0 .1) –2 .6 (– 4. 1 t o –1 .0 ) C I = co nfi de nc e in te rv al ; H IV = h um an im m un od efi ci en cy v iru s; D TP = d ip ht he ria /t et an us /t yp ho id ; Y PL L = ye ar s o f p ro du ct iv e lif e lo st ; G D P = gr os s d om es tic p ro du ct . The third independent factor as- sociated with health differences in our study was the availability of clean water. One of the classic public health  interventions, clean water is known to  control the spread of communicable diseases  [37]. Purification of water  alone was thought to be responsible for half of all mortality reductions in some developed countries in the first half of the 20th century. An estimated  9%  of  the  total  burden  of  disease  worldwide could be ameliorated by improved water quality and resource management and sanitation and hy- giene [38]. The fourth factor which was a sig- nificant determinant of poor health indicators was the corruption percep- tion index. Transparency International  defines corruption as “the abuse of entrusted power for private gain” [39].  They estimated that the world spends more than 3 trillion dollars per year on health services. Such large flows of funds are an attractive target for abuse.  According  to  the Global corruption report 2006,  “the  diversity  of  health  systems worldwide, the multiplicity of  parties  involved,  the paucity of good  record  keeping  in many  countries,  and the complexity in distinguishing among  corruption,  inefficiency  and  honest mistakes make it difficult to determine the overall costs of corrup- tion.” Up to now there has been  little  evidence published in the medical literature about the link between cor- ruption and health outcomes and our study provides useful evidence of a link. The gradient in health within coun- tries and the marked health inequities between countries can be linked to the unequal distribution of power,  income,  goods or  services,  and  the consequent  disparities in the circumstances of people’s  lives. Together,  the  structural  determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of the health inequities between Book 17-9.indb 661 9/6/2011 12:43:04 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 662 Ta bl e 5 M ul ti va ri at e an al ys is o f t he in de pe nd en t v ar ia bl es w it h th e 4 ou tc om e va ri ab le s (a dj us te d fo r c ou nt ry m aj or ity re lig io n) Va ri ab le M od el 1 a M od el 2 b M al e lif e ex pe ct an cy Fe m al e lif e ex pe ct an cy M at er na l m or ta lit y ra ti o In fa nt m or ta lit y ra te M al e lif e ex pe ct an cy Fe m al e lif e ex pe ct an cy M at er na l m or ta lit y ra ti o In fa nt m or ta lit y ra te (n = 1 67 ) (n = 1 67 ) (n = 1 56 ) (n = 1 66 ) (n = 1 55 ) (n = 1 55 ) (n = 1 54 ) (n = 1 54 ) β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) β (9 5% C I) C on st an t 44 41 19 99 14 1 27 21 16 60 18 5 C ou nt ry m aj or ity re lig io n N M M – – – – – – – – M M 2. 1 ( –1 .0 to 5 .1) 2. 5 (– 0 .2 to 5 .2 ) –5 5. 1 ( –1 41 .0 to 3 0 .6 ) 1.4 (– 6. 6 to 9 .5 ) 2. 1 ( –1 .2 to 5 .4 ) 2. 6 (– 0 ·4 to 5 .6 ) –9 8. 0 (1 92 .0 to – 5. 6) 3. 4 (– 4. 7 to 11 .6 ) Im pr ov ed w at er ac ce ss 0 .2 (0 .0 7 to 0 .3 ) 0 .2 (0 .1 to 0 .3 ) –9 .7 (– 12 .4 to – 7.0 ) –0 .7 (– 1.0 to – 0 .4 ) 0 .2 (0 .0 7 to 0 .3 ) 0 .2 (0 .1 to 0 .4 ) – – 0 .8 (– 1.1 to – 0 .5 ) A du lt lit er ac y ra te 0 .1 (0 .0 4 to 0 .2 ) 0 .2 (0 .0 9 to 0 .3 ) –1 0 .6 (– 13 .0 to – 8. 2) –0 .7 (– 1.0 to – 0 .4 ) 0 .2 (0 .0 8 to 0 .3 ) 0 .2 (0 .1 to 0 .3 ) –1 4. 9 (– 17 .0 to – 12 .8 ) –0 .8 (– 1.0 to – 0 .5 ) C or ru pt io n pe rc ep tio n in de x – – – – 1.7 (1 .0 to 2 .5 ) 1.5 (0 .8 to 2 .2 ) –3 1.0 (– 52 .0 to – 10 .0 ) –2 .8 (– 4. 7 to – 1.0 ) In co m e gr ou p H ig h – – – – – – – – U pp er m id dl e –9 .2 (– 13 .3 to – 5. 2) –5 .9 (– 9. 5 to – 2. 2) – 6. 1 ( –4 .5 to 16 .6 ) – – – – Lo w er m id dl e –7 .9 (– 11 .8 to – 4. 0 ) –7 .9 (– 11 .4 to – 4. 4) – 14 .0 (3 .8 to 2 4. 2) – – – – Lo w –1 1.5 (– 16 .9 to – 6. 2) –1 2. 5 (– 17 .3 to – 7.7 ) – 29 .2 (1 5. 1 t o 43 .2 ) – – – – R2 (% ) 54 69 72 72 52 67 66 72 a E xc lu di ng co rr up tio n pe rc ep tio n in de x; b E xc lu di ng in co m e gr ou p. C I = co nfi de nc e in te rv al ; N M M = n on -M us lim m aj or ity ; M M = M us lim m aj or ity . and within countries  [3]. The premise  of this study was to define religion as one of many axes of social stratification,  even  though  there  are marked  social,  demographic,  economic and political  differences within and between these countries. Although we saw major dif- ferences in health outcomes between MMC and non-MMC, this study does  not prove causality, i.e. that the major- ity religion of the countries was re- sponsible for this difference. The study showed that the differences between MMC and non-MMC were due to dif- ferences in determinants such as edu- cation, wealth and  infrastructure. The  underlying determinants in themselves also cannot be causally connected to poor health outcomes. Like  religion,  these determinants are possibly part of a complex causal pathway. Recently the health ministers of countries of the Organisation of  the  Islamic Confer- ence called for “solidarity in action in dealing with eradication of poverty and public health issues particularly diseases  and epidemics”  [40]. Based  on our  findings, we believe  that  the  focus needs to be expanded to include encouraging literacy, provision of clean  water and improving the governance structure. Limitations There are some methodological limita- tions to the study. First, ecological analy- ses cannot measure correlates of risk at the individual level and the temporal se- quence of events is unknown. Secondly,  the study was based on secondary data and the quality of such aggregate data is likely to vary depending on the public health and information infrastructure of a given country. Thirdly, it is possible  that some confounders were not con- sidered in the study due to the unavail- ability of data—health  service quality,  for  example—despite  every  attempt  to incorporate all available potential variables.  It would have been useful  to  study the time trends within MMC and non-MMC, but  such  an  analysis  Book 17-9.indb 662 9/6/2011 12:43:04 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 663 References World health report 2000. Health systems: improving perform-1. ance. Geneva, World Health Organization, 2000. Feachem RG. Poverty and inequity: a proper focus for the 2. new century. Bulletin of the World Health Organization, 2000, 78:1–2. Commission on Social Determinants of Health. 3. Closing the gap in a generation: health equity through action on the social deter- minants of health. Geneva, World Health Organization, 2008. Willets RC et al. 4. Longevity in the 21st century. London, Institute of Actuaries and Faculty of Actuaries, 2004. Laird LD et al. Muslim patients and health disparities in the UK 5. and the US. Archives of Disease in Childhood, 2007, 92:922– 926. Talukdar A et al. Risk of HIV infection but not other sexually 6. transmitted diseases is lower among homeless Muslim men in Kolkata. AIDS (London, England), 2007, 21:2231–2235. Szczepura A, Price C, Gumber A. Breast and bowel cancer 7. screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics. BMC Public Health, 2008, 8:346. List of countries by Muslim population. 8. Wikipedia [website] (http://en.wikipedia.org/wiki/Islam_by_country, accessed 22 May 2011). Human development in the Muslim world. (Doha discussion pa-9. pers). Washington DC, US-Islamic Development Forum, The Brooking Institution, 2008. List of Muslim-majority countries. 10. Wikipedia [website] (http:// en.wikipedia.org/wiki/List_of_Muslim-majority_countries, accessed 29 July 2011). How we classify countries. 11. World Bank [online factsheet] (www.worldbank.org/data/countryclass/classgroups.htm, accessed 22 May 2011). Core health indicators. WHO Statistical Information Systems 12. (WHOSIS). World Health Organization [online] (http://www. who.int/whosis/database/core/core_select.cfm, accessed 22 May 2011). Statistics and databases. 13. Statistical Economic and Social Re- search and Training Center from Islamic Countries [website] (http://www.sesric.org/oic-member-countries.php, accessed 22 May 2011). Quick query. 14. The World databank [website] (http://databank. worldbank.org/ddp/home.do, accessed 29 July 2011). International Human Development Indicators. 15. United Nations Development Programme [website] (http://hdr.undp.org/en/ statistics/, accessed 22 May 2011). Statistical databases. 16. United Nations Statistics Division [online database] (http://unstats.un.org/unsd/databases.htm, ac- cessed 22 May 2011). Information by country and programme. 17. United Nations In- ternational Children Education Fund [online database] (http:// www.unicef.org/infobycountry/index.html, accessed 22 May 2011). Maternal mortality in 2000: estimates developed by WHO, 18. UNICEF and UNFPA [online document] (http://reliefweb. int/sites/reliefweb.int/files/resources/5CEB91DA5C1C385 049256DC800067E6F-who-saf-22oct.pdf, accessed 29 July 2011). UNESCO Institute for Statistics. 19. United Nations Educational, Scientific and Cultural Organization [online database] (http:// stats.uis.unesco.org/unesco/TableViewer/document. aspx?ReportId=143&IF_Language=eng, http://www.unicef. org/infobycountry/index.html, accessed 22 May 2011). The World Fact Book. 20. Central Intelligence Agency [online data- base]. (https://www.cia.gov/library/publications/the-world- factbook/index.html, accessed 22 May 2011). Google Scholar21. [search engine] (http://scholar.google.com. pk/schhp?hl=en&tab=ws, accessed 22 May 2011). WHO Statistical Information Systems (WHOSIS). 22. World Health Organization [online database] (http://www.who.int/whosis/ indicators/compendium/2008/en/index.html, accessed 22 May 2011). Reidpath DD, Allotey P. Infant mortality rate as an indicator 23. of population health. Journal of Epidemiology and Community Health, 2003, 57:344–6. Health indicators: building blocks for health situation analysis. 24. Epidemiological Bulletin, 2001, 22:1–5. > Murthi M, Guio AC, Dreze J. Mortality, fertility, and gender bias 25. in India: A district-level analysis. Population and Development Review, 1995, 21(4):745–782. Pritchett L, Lawrence H. Summers. Wealthier is Healthier. 26. Jour- nal of Human Resources, 1996, 31:841–68. Dollar D. Is globalization good for your health? 27. Bulletin of the World Health Organization, 2001, 79:827–33. Preston SH. Causes and consequences of mortality declines 28. in less developed countries during the twentieth century. In: Easterlin RA, ed. Population and economic change in developing countries. Chicago, University of Chicago Press, 1980:289–360. Cutler DM, Lleras-Muney A. 29. The determinants of mortality. Cambridge, Massachusetts, National Bureau of Economic Re- search, 2006 (NBER Working Paper series No. 11963). Drèze J. 30. India: development and participation. Oxford, Oxford University Press, 2002. Human development report 200531. . New York, United Nations Development Programme, 2005. Stern NH, Dethier JJ, Rogers FH. 32. Growth and empowerment: making development happen. Cambridge, Massachusetts, MIT Press, 2005. Skolnik RL. 33. Health education, poverty and economy. In: Riegel- man R, ed. Essentials of global health. Sandbury, Jones and Bartlett Learning, 2008:41–55. was not possible due to the unavail- ability of historical data for all countries. Despite these limitations of data and of definitions, we believe  the differences  observed between the MMC and non- MMC were unlikely to be due to chance alone. Conclusion In  conclusion,  the  study  shows  that countries with majority Mus- lim populations are at a significant disadvantage in terms of health. The factors that explain these differences include  low economic development,  low levels of literacy, poor availability  of clean water and the level of cor- ruption. Substantial future research should focus on the “determinants of the determinants” in the context of Muslim countries. Book 17-9.indb 663 9/6/2011 12:43:05 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 664 Dewalt DA et al. Literacy and health outcomes: a systematic 34. review of the literature. Journal of General Internal Medicine, 2004, 19:1228–39. Kiros GE, Hogan DP. War, famine and excess child mortality in 35. Africa: the role of parental education. International Journal of Epidemiology, 2001, 30:447–55. World development report 2006. Equity and development36. . New York, World Bank/ Oxford University Press, 2006. Ezzati M et al. Selected major risk factors and global and re-37. gional burden of disease. Lancet, 2002, 360:1347–1360. Prüss-Üstün ABR, Gore F, Bartram J. 38. Safer water, better health: costs, benefits and sustainability of interventions to protect and promote health. Geneva, World Health Organization, 2008. What is Transparency International? 39. Transparency International: the global coalition against corruption [website] (http://www. transparency.org/about_us, accessed 29 July 2011). Kuala Lumpur Declaration 200740. . First Islamic Conference of Health Ministers, 12–15 June 2007, Kuala Lumpur, Malaysia (http://www.sesric.org/imgs/news/File/KL.pdf, accessed 29 July 2011). World Conference on Social Determinants of Health To build support for the implementation of action on social determinants of health, the World Health  Organization (WHO) is convening the World Conference on Social Determinants of Health on 19–21  October, 2011, in Rio de Janeiro, Brazil. The conference is organized in accordance with the World Health  Assembly Resolution WHA62.14 (2009) and will be hosted by the Government of Brazil. The Brazilian  Ministry of Health, the Oswaldo Cruz Foundation (Fiocruz) and the Brazilian Ministry of Foreign Affairs are  working closely with WHO on preparing the event.  The conference will bring together Member States and stakeholders to share experiences on policies and strategies aiming to reduce health inequities. The event will provide a global platform for dialogue on how the recommendations of the WHO Commission on Social Determinants of Health (2008) could be taken forward. The key aim of the  process is to draw lessons learnt and to catalyse coordinated global action in five key areas. governance to tackle the root causes of health inequities: implementing action on social determinants of health; •  the role of the health sector, including public health programmes, in reducing health inequities; •  promoting participation: community leadership for action on social determinants; •  global action on social determinants: aligning priorities and stakeholders; •  monitoring progress: measurement and analysis to inform policies on social determinants. •  The conference will be attended by ministers of health, foreign affairs, the environment and other sectors;  representatives of international agencies, philanthropic institutions and civil society organizations; leading academics  and technical experts; and representatives from the private sector. The conference’s outcome document, the Rio  Declaration, will help to build high-level international backing for the further development and implementation of  national policies to address social determinants of health. Further information about the conference can be found at:  http://www.who.int/sdhconference/en/ Book 17-9.indb 664 9/6/2011 12:43:05 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 665 Incidence and causes of sudden death in a university hospital in eastern Saudi Arabia H.K. Nofal,1 M.F. Abdulmohsen 2 and A.H.Khamis 3 ABSTRACT Sudden death is non-violent, unexpected death occurring less than 24 hours from the onset of symptoms. In this retrospective descriptive study we report the frequency and main causes of sudden deaths in relation to total deaths at a large university hospital in the Eastern region of Saudi Arabia over a 6-year period. The medical files of 1273 consecutive deaths were retrospectively investigated and showed 223 (17.5%) cases of sudden death. Males were 56.0% of cases. The incidence of sudden death was highest in the 2 age extremes (32.2% were infants and 31.4% were elderly). There was a seasonal variation, with the highest incidence (29.6%) during spring followed by summer (25.1%). The most important direct causes of sudden death were cardiovascular diseases in 59.2% of cases, respiratory disease in 24.7%, diabetes mellitus in 23.8%, liver disease in 23.3% and infectious disease in 20.2%. 1Department of Pathology/Forensic Medicine; 2Department of Internal Medicine; 3Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia (Correspondence to M.F. Abdulmohsen: fakhri_fakhria@yahoo.com). Received: 04/08/09; accepted: 03/12/09 ةيدوعسلا ةيبرعلا ةكلملما قشر في يعمالجا ىفشتسلما في ابهابسأو ةيئاجفلا ةافولا عوقو لدعم سيخم نسح ر َّماع ،نسحلما دبع يرخف دممح ،لفون لماك ينسح ةساردلا هذه فيو .ضارعلأا روهظ ءدب نم ةعاس 24 نم لقأ في ثدتح ،فنع نع ةجمان ُيرغو ،ةعقوتم يرغ ةافو يه ةيئاجفلا ةافولا :ةـصلالخا ةيبرعلا ةكلملما قشر في يربك يعماج ىفشتسم في تايفولا لياجمإب اهتقلاعو ةيسيئرلا ابهابسأو ةيئاجفلا ةافولا ر ٌـ تاوت نوثحابلا لجس ةيداِعتسلاا ةافو 223 نأ ينبتو ،ةبقاعتم ةافو 1273 ـل ةيبطلا تافلملل يداِعتسا ءاصقتسا ىِرْجُأ دقو .تاونس تس نم رثكأ تدتما ةترف ىدم لىع ةيدوعسلا رمعلا َْفيرط صىقأ في نوكي ام لىعأ ةيئاجفلا ةافولا عوقو لدعم ناكو .تلاالحا نم %56.0 ةبسن روكذلا لكشو .ةيئاجف ةافو تناك اهنم )%17.5( .)%25.1( فيصلا هيلي ،عيبرلا مسوم في )%29.6( عوقولل لدعم لىعأ ناكو ،يمسوم نيابت كانه ناكو .)يننسلما في %31.4 و ،عّضرلا في %32.2( يدبكلا ضرلماو ،%23.8 يركسلاو ،%24.7 سيفنتلا ضرلماو ،%59.2 ةيئاعولا ةيبلقلا ضارملأا في ةيئاجفلا ةافولل ةشرابلما بابسلأا مهأ تلَّثتمو .%20.2 ةَيِدْعُمـلا ضارملأاو ،%23.3 Incidence et causes de mort subite dans un hôpital universitaire de l’est de l’Arabie saoudite RÉSUMÉ La mort subite correspond à un décès non violent et inattendu survenant moins de 24 heures après l’apparition de symptômes. Dans la présente étude descriptive rétrospective, nous avons examiné la fréquence et les causes principales des morts subites par rapport au nombre total des décès dans un grand hôpital universitaire de la région orientale de l’Arabie saoudite, sur une période de six ans. Les dossiers médicaux de 1273 patients dont les décès ont été consécutifs, ont été étudiés rétrospectivement. Parmi ceux-ci, 223 (17,5 %) étaient des cas de mort subite. Les hommes représentaient 56,0 % des cas. L’incidence des morts subites était maximale dans les deux tranches d’âge extrême (32,2 % étaient des nourrissons et 31,4 % des personnes âgées). Une variation saisonnière a pu être observée, avec une incidence maximale (29,6 %) au printemps, puis en été (25,1 %). Les principales causes directes étaient les maladies cardio-vasculaires pour 59,2 % des cas, les affections respiratoires pour 24,7 %, le diabète sucré pour 23,8 %, les affections hépatiques pour 23,3 % et les maladies infectieuses pour 20,2 %. Book 17-9.indb 665 9/6/2011 12:43:05 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 666 Introduction Despite tremendous technological advances in health care the phenom- enon of sudden death is still a concern. The diagnosis and definition of sudden death  are  variable,  but  the  generally  recognized definition is based on the length of time between the onset of symptoms and death [1,2]. The World  Health Organization  (WHO) defini- tion of sudden death according to the International classification of diseases, ver- sion 10  (ICD-10)  is death, non-violent  and not otherwise explained, occurring  less  than 24 hours  from  the onset of  symptoms [2]. Cases of  sudden death  have been described in studies in a number  of  countries  [3–9].  Sudden  death occurs in all age groups: in infants  (where  it  is called sudden  infant death  syndrome),  in children and youths,  in  adults  and  in  the elderly  [9–16]. The  risk  factors  for  sudden death  include:  older age, low and high body mass index,  arterial hypertension, diabetes mellitus,  smoking,  sedentary  lifestyle, unhealthy  diet and stress [17–19]. There are also  seasonal  variations  in  sudden  death,  with the highest frequency reported in winter, followed by autumn, spring and  summer [20]. The nature of sudden death means that an accurate diagnosis is difficult to achieve without  an  autopsy  [1,2,21].  In  Saudi Arabia,  however,  postmor- tems are extremely limited for religious and cultural  reasons  regulations. Post- mortems are performed in only a few centres around the country and only if there are medico-legal issues surround- ing the death, such as a violent cause of  death. Otherwise, routine postmortems  are not carried out for religious and cultural reasons. Lack of postmortem can sometimes make the diagnosis of the cause of sudden death a difficult task. Unfortunately, there have been no  epidemiological or even hospital-based studies about the incidence, mode and  causes of sudden death in Saudi Arabia.  Among the few reports of sudden death  found during the  literature search, one  concerned 51 cases of “unexplained sudden death syndrome” reported to the medicolegal  centre  in Dammam,  Saudi Arabia  [22],  another was about  a  Saudi  family with 2 members hav- ing a rare congenital disorder [23] and  in a third study the investigators tried to elucidate the role of inflammatory mediators in sudden deaths in adults and older children [24]. It was our aim  therefore to conduct a cross-sectional hospital-based study of the incidence and main underlying causes of sud- den death in a large university hospital located in the Eastern region of Saudi Arabia. Methods A retrospective analytical clinical  study  was undertaken of sudden deaths in all age  groups  at King Fahd Hospital  of  the University, Al Khobar, Saudi Arabia.  Permission  to  conduct  the  study was  received from the research committees  of both  the College of Medicine, King  Faisal University and King Fahd Hospi- tal of the University, Al Khobar. We retrospectively  investigated all  1273 deaths  that occurred between  1  January  2000  and  31  December  2005. Deaths were classified as sudden  deaths when the patient died unexpect- edly from non-violent causes within 24  hours from the onset of the symptoms of  their final clinical presentation;  the  remainder were classified as expected deaths.  In  all  cases of  sudden death,  personal  information, history of pre- existing diseases,  chief  complaint(s)  on presentation, clinical signs, medical  investigations performed, diagnosis of  death and time elapsed between the onset of prodromal symptoms and the onset of death were obtained from the medical records. Individuals who arrived dead at the  hospital were excluded from the study. We  stratified  the  incidence  of  sudden death in relation to all-cause deaths. We  also  tried  to  establish  if  there was any association of sudden and expected deaths with age group,  sex, nationality, season and direct cause  of death. Data were entered into a computer using SPSS  for Windows, version 13.0.  The results were cross-tabulated to ex- amine the relationships between the variables. Statistical analysis was performed using the chi-squared test of association and Fisher  exact  test,  as  appropriate.  Where multiple  variables were exam- ined,  logistic  regression  analysis was  used. Frequency tables were performed as descriptive statistics. A P-value < 0.05  was considered significant in all statisti- cal analyses Results Out of the 1273 deaths there were 223  cases of sudden death and 1050 cases of  expected death during the 6-year study period. The incidence of sudden death as a proportion of all-cause deaths was therefore 17.5% compared with 82.5%  for expected deaths. Sudden death oc- curred to 125 males (56.0%), 94 females  (42.2%) and 4 cases of unrecorded sex  (1.8%). Out of 223  cases,  there were  166 Saudis  (74.4%)  and 57  (25.6%)  non-Saudis. The great majority were Muslims (97.5%). Table 1 illustrates the age distribu- tion  of  sudden  deaths  in  this  study:  21.4% were newborns, 3.6% neonates,  6.7% infants and 5.3% aged 1–18 years.  Young adults (aged 18–39 years) were  9.9% of cases,  the middle aged (40–60  years) were 21.0%, while the elderly (>  60 years) were 31.4%. The most frequent prior medical problems affecting the cases of sudden death in this study were: type 2 diabetes  mellitus (21.5%), hypertension (18.8%)  and cardiovascular disease (CVD)  in- cluding stroke (15.2%) (Table 2). Table 3 shows the most frequent major prodromal symptoms preceding Book 17-9.indb 666 9/6/2011 12:43:05 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 667 sudden death in the current study. These were:  dyspnoea  (shortness  of  breath) (25.1% of cases), fever (11.7%)  and prematurity (10.8%). Table 4 shows the direct causes of  sudden death: 59.2% of  cases were  attributed  to  cardiovascular  disease,  24.7%  respiratory disease,  23.8% dia- betes mellitus, 23.3%  liver disease and  20.0% infectious disease. The mode of sudden death included cardiopulmonary arrest in the great ma- jority of cases 190 (85.2%) and respira- tory arrest in 33 cases (14.8%). Figure 1 illustrates the seasonal vari- ation of sudden and expected deaths in our patients. The highest frequency of sudden death occurred during the spring (April–June) (29.6%),  followed  by summer (July–September) (25.1%),  as  compared  (10.6%)  and  (18.3%)  respectively for expected deaths. The lowest frequency of sudden death oc- curred during autumn (October–De- cember) and winter (January–March)  with  frequencies of 22.5% and 22.9%,  as  compared with  36.8%  and  34.4%  for  expected deaths  (chi-squared P < 0.001).  Discussion Sudden unexpected death is a major public health problem in our region as other parts of  the world.  It  affected  17.5% of the total cases of death in this  university hospital  in Eastern  region,  Saudi Arabia. This finding contrasts with  the findings of Krahn et al.,  in Canada,  who reported an incidence of 41% [25]  and Goraya et al., who reported sudden  cardiac death occurring  in 61% of  all  cases of death due to coronary heart disease in the United States [26]. None- theless, another analysis of national and  State-specific sudden cardiac death data in the US found that 63.4% of all cardiac  death cases were sudden cardiac death [27]. In  our  study  a  higher  proportion  of sudden deaths were male than female (56.0% versus 42.2%) and  this  is consistent with international experi- ence [3,18,26–31]. Sudden deaths oc- curred in all age groups but the highest proportion were elderly patients above the age of 60 years  (31.4%),  followed  by infants (31.2%) and the middle aged  (21.0%); the 1–18 years age group were  Table 1 Age distribution of cases of sudden death in King Fahd Hospital of the University (2000 to 2005) Age group No. of cases (n = 223) % Infants (0–12 months) 72 32.2 Children and adolescents (1–18 years) 12 5.3 Young adults (19–39 years) 22 9.9 Middle aged adults (40–60 years) 47 21.0 Elderly adults(> 60 years) 70 31.4 Table 2 Important prior medical problems reported by the patient or their companion in cases of sudden death Past medical history No. of cases (n = 223) % Diabetes mellitus type 2 48 21.5 Hypertension 42 18.8 Cardiovascular diseasea 34 15.2 Pneumonia 17 7.6 Sepsis 17 7.6 Cancer 17 7.6 Congenital anomalyb 15 6.7 Liver disease 14 6.3 Renal disease 7 3.1 Sickle-cell disease and G6PD deficiency 2 0.9 aIncluding stroke; bIncluding Down syndrome. G6PD = glucose-6-phosphate dehydrogenase. Table 3 Most frequent prodromal symptoms on the initial presentation of cases of sudden death Initial symptom No. of cases (n = 223) % Dyspnoea 56 25.1 Fever 26 11.7 Prematurity (infant) 24 10.8 Circulatory collapse 21 9.4 Angina 17 7.6 Cough 16 7.2 Coma 12 5.4 Anorexia 12 5.4 Weakness 10 4.5 Seizures 6 2.7 Diarrhoea 5 2.2 Abdominal distension 2 0.9 Dementia 2 0.9 Book 17-9.indb 667 9/6/2011 12:43:06 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 668 a much  lower proportion (5.3%). This  age distribution of sudden death was also consistent with studies from other countries [11,18,32]. There were a seasonal variation in natural sudden death among our cases with the highest frequency dur- ing spring (29.6%),  followed by sum- mer (25.1%), then autumn and winter  (22.8% each). This contrasts with  the  findings  of Katz  et  al.  in  the Negev  Desert  region  of  Israel  who  found  the highest  rate  in winter (31%) and  autumn (25%) [20]. This might be ex- plained by the difference between the cooler weather of the Mediterranean region  and  the  very hot, windy  and  dusty weather during the spring and summer months in the Gulf region including eastern Saudi Arabia, which  may exacerbate cardiovascular and respiratory diseases. In agreement with other researchers,  the most frequent past medical problem was CVD,  including  coronary  heart  disease, hypertension and stroke (34%  of cases) [17,18,26,27,30–35]. The most frequent prodromal symptoms  in our  study were:  dysp- noea,  fever,  prematurity,  circulatory  collapse, angina and cough. These pro- dromal symptoms of sudden death in our study are to some extent different from the findings of other authors who found  syncope  [13],  and  congenital  anomalies and  low birth weight  [15]  were the main prodromal symptoms of sudden death. These differences may be related to the differences in the  study population. However, dys- pnoea represents a cardinal symptom of cardiovascular and respiratory dis- eases, which were the 2 main causes of  sudden death,  affecting 83.9% of our  cases. Our  study  also  showed  that  the  most important single direct cause of  sudden  death  was CVD  (59.2%)  and this is consistent with findings re- ported  from developed  countries  [3, 17–19,26,27,30,31,34,35]. Respiratory  Table 4 Direct causes of sudden death according to death certificates (2000 to 2005) Rank Direct cause No. of cases (n = 223) % 1 Cardiovascular disease 132 59.2 Coronary artery disease including acute myocardial infarction 49 22.0 Hypertension 38 17.0 Stroke 16 7.2 Cardiogenic shock 16 7.2 Life-threatening cardiac arrhythmia 13 5.8 2 Respiratory disease 55 24.7 Pneumonia 29 13.0 Respiratory failure 6 2.7 Bronchial asthma 4 1.8 Chronic obstructive pulmonary disease 4 1.8 3 Diabetes mellitus 53 23.8 4 Liver disease 52 23.3 5 Infectious disease 45 20.2 6 Renal disease 37 16.6 7 Congenital anomaly 36 16.1 8 Cancer 36 16.1 9 Prematurity 28 12.6 10 Neuropsychiatric disease 10 4.5 11 Haematological disease including sickle-cell disease and haemophilia 5 2.2 12 Immunological disorder including systemic lupus erythematosus and rheumatoid arthritis 5 2.2 Figure 1 Seasonality of sudden and expected deaths (2000 to 2005) 34.4 10.6 18.3 36.8 22.9 29.6 25.1 22.4 0 5 10 15 20 25 30 35 40 Winter Spring Summer Autumn % o f c as es Expected deaths (n = 1050) Sudden deaths (n = 223) Book 17-9.indb 668 9/6/2011 12:43:06 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 669 disease,  especially  bronchial  asthma,  chronic obstructive pulmonary disease and pneumonia, diabetes mellitus,  liver  disease, infectious disease, renal disease  (especially  end-stage  renal  disease),  congenital anomaly, cancer and prema- turity were also important direct causes of sudden death in the current study. Conclusion We  found  the  incidence  of  sudden  death  was  highest  among  the  2  age  extremes,  and  also  in  hot,  dusty  and  humid weather  (late  spring  and early  summer months). The most important  prodromal symptoms prior to death were dyspnea,  fever,  low birth weight/ prematurity,  circulatory  collapse  and  angina. Therefore, we  recommend  the  health care providers especially emer- gency  physicians  to  pay  attention  to  patients presenting with these prodro- mal symptoms, particularly  infants and  elderly patients. References Di Maio VJM, Di Maio DJ. 1. Forensic pathology, 2nd ed. London, CRC Press, 2001. International classification of diseases (ICD-102. ). Geneva, World Health Organization, 2005. Sung RJ. Kuo Chi-Tai, Wa Shan-Nan, Lai WT, Luqman N, and 3. Chan NY. Sudden cardiac death syndrome: age, gender, eth- nicity, and genetics. Acta Cardiologica Sinica 2008, 24:65–74. Spiliopoulou C et al. Clinical diagnoses and autopsy findings: 4. a retrospective analysis of 252 cases in Greece. Archives of Pa- thology & Laboratory Medicine, 2005, 129:210–214. Morentin B et al. Incidencia y causas de muerte subita en 5. menores de 36 anos [Incidence and causes of sudden death in persons less than 36 years of age]. Medicina Clínica, 2001, 116:294–295. Kojima M et al. Sudden death of clinically unknown origin. 6. An overview of postmortem examinations in Japan. Japanese Journal of Public Health, 1999, 46:563–568. Nashelsky MB, Lawrence CH. Accuracy of cause of death de-7. termination without forensic autopsy examination. American Journal of Forensic Medicine and Pathology, 2003, 24:313–319. Blackwell CC et al. Sudden unexpected nocturnal deaths 8. among Thai immigrant workers in Singapore. The possible role of toxigenic bacteria. International Journal of Legal Medicine, 1994, 106:205–208. Eckart RE et al. Sudden death in young adults: a 25-year review 9. of autopsies in military recruits. Annals of Internal Medicine, 2004, 141(11):829–834. Morentin B et al. Sudden unexpected non-violent death 10. between 1 and 19 years in north Spain. Archives of Disease in Childhood, 2000, 82:456–461. Amital H et al. Clinical characteristics of unexpected death 11. among young enlisted military personnel: results of a three- decade retrospective surveillance. Chest, 2004, 126:528–533. Drory Y et al. Sudden unexpected death in persons less 12. than 40 years of age. American Journal of Cardiology, 1991, 68:1388–1392. Kramer MR, Drori Y, Lev B. Sudden death in young sol-13. diers. High incidence of syncope prior to death. Chest, 1988, 93:345–347. Nidal Abu-Rashid. Samir Al-Jirf and Hyam Bashour. Causes 14. of death among Syrian children using verbal autopsy. Eastern Mediterranean Health Journal, 1996, 2:440–448. Mesleh RA et al. Changing trends in perinatal deaths at the 15. Armed Forces Hospital, Riyadh, Saudi Arabia. Journal of Ob- stetrics & Gynaecology, 2001, 21:49–55. Quigley F et al. A survey of the causes of sudden cardiac death 16. in the under 35-year-age group. Irish Medical Journal, 2005, 98:232–235. Tabib A, Loire R. Unexpected sudden death and coronary 17. lesions. Apropos of 407 cases out of 1000 deaths in patients under 65 years of age. Archives des Maladies du Coeur et des Vaisseaux, 1993, 86:401–406. Chahine R. Cardiovascular risk factors: smoking in the context 18. of recent events in Lebanon. Santé (Montrouge, France), 1998, 8:109–112. Farley TM et al. Combined oral contraceptives, smoking, and 19. cardiovascular risk. Journal of Epidemiology and Community Health, 1998, 52:775–785. Katz A et al. Seasonal variation in sudden death in the Negev 20. desert region of Israel. Israel Medical Association Journal, 2000, 2:17–21. Perkins GD et al. Discrepancies between clinical and postmor-21. tem diagnoses in critically ill patients: an observational study. Critical Care, 2003, 7(6):R129–R132. Elfawal MA. Sudden unexplained death syndrome. 22. Medicine, Science, and the Law, 2000, 40:45–51. Al Rakaf M, Zakzouk SM, Al Shahwan SA. Jervell and Lange-23. Nielsen QT syndrome: a case report from Saudi Arabia. International Journal of Pediatric Otorhinolaryngology, 1997, 39:163–168. Al Madani O et al. Pyrogenic toxins of 24. Staphylococcus aureus in sudden unexpected nocturnal deaths in adults and older children: factors influencing the control of inflammatory re- sponses to toxic shock syndrome toxins. FEMS Immunology and Medical Microbiology, 1999, 25:207–219. Krahn AD et al. Diminishing proportional risk of sudden death 25. with advancing age: implications for prevention of sudden death. American Heart Journal, 2004, 147:837–840. Goraya TY et al. Coronary heart disease death and sudden 26. cardiac death: a 20-year population-based study. American Journal of Epidemiology, 2003, 157:763–770. Murai T et al. Sudden death due to cardiovascular disorders: a 27. review of the studies on the medico-legal cases in Tokyo. Keio Journal of Medicine, 2001, 50:175–181. Hecht A, Löffler D. Acute natural death in adults with spe-28. cial reference to the under-50 age group. Zentralblatt für Allgemeine Pathologie und Pathologische Anatomie, 1984, 129:127–135. Tamakoshi K, Toyoshima H, Yatsuya H. Gender difference 29. of sudden death. Japanese Journal of Clinical Medicine, 2005, 63:1284–1288. Schatzkin A et al. Sudden death in the Framingham Heart 30. Study. Differences in incidence and risk factors by sex and coronary disease status. American Journal of Epidemiology, 1984, 120:888–899. Kawakubo K, Lee JS. Incidence rate of sudden death in Japan. 31. Japanese Journal of Clinical Medicine, 2005, 63:1127–1134. Loire R, Tabib A. Unexpected sudden cardiac death. An evalu-32. ation of 1000 autopsies. Archives des Maladies du Coeur et des Vaisseaux, 1996, 89:13–18. Book 17-9.indb 669 9/6/2011 12:43:06 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 670 Scheffold T et al. Hypertrophe Kardiomyopathie [Hypertrophic 33. cardiomyopathy]. Herz, 2005, 30:550–557. Aktas EO et al. Variations in the papillary muscles of normal 34. tricuspid valve and their clinical relevance in medicolegal au- topsies. Saudi Medical Journal, 2004, 25:1176–1185. Kocak A et al. Structure of the human tricuspid valve leaflets 35. and its chordae tendineae in unexpected death. A forensic autopsy study of 400 cases. Saudi Medical Journal, 2004, 25:1051–1059. Bowker TJ et al. Sudden, unexpected cardiac or unexplained 36. death in England: a national survey. QJM : Monthly Journal of the Association of Physicians, 2003, 96:269–279. World health days in September World Suicide Prevention Day held on 10 September 2011 aims to promote worldwide commitment and action to  prevent suicides. The theme for World Suicide Prevention Day for 2011 is Preventing Suicide in Multicultural Societies. On  average, almost 3000 people commit suicide daily. For every person who completes a suicide, 20 or more may attempt to  end their lives. The International Association for Suicide Prevention, together with WHO and other partners advocate  for the prevention of suicidal behaviour, provision of adequate treatment and follow-up care for people who attempted  suicide, as well as responsible reporting of suicides in the media. Further information about suicide prevention and  World Suicide Prevention Day can be found at: http://www.who.int/mental_health/prevention/suicide/suicideprevent/ and http://www.iasp.info/index.php World Rabies Day held on 28 September 2011 aims to highlight the impact of human and animal rabies and pro- mote how to prevent and stop the disease by combating it in animals. Sponsors – the Alliance for Rabies Control  and the United States Centers for Disease Control and Prevention – report that 55 000 people die every year from  rabies, an average of one death every 10 minutes. There are safe and effective vaccines available for people who  have been bitten by an animal that might have the disease, but usage in developing countries is low due to the high  cost. Further information about rabies and World Rabies Day can be found at: http://www.who.int/rabies/en/ and http://www.worldrabiesday.org/ World Heart Day held on 29 September 2011 aims to raise awareness about cardiovascular diseases which  are the  world’s leading cause of death, claiming 17.1 million lives each year. The theme for World Health Day for 2011 is One World, One home, One Heart. In partnership with WHO, the World Heart Federation organizes awareness events in  more than 100 countries – including health checks, organized walks, runs and fitness sessions, public talks, stage shows,  scientific forums, exhibitions, concerts, carnivals and sports tournaments. Further information about cardiovascular  diseases and World Heart Day can be found at: http://www.who.int/cardiovascular_diseases/en/index.html and http://www.world-heart-federation.org/ Book 17-9.indb 670 9/6/2011 12:43:07 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 671 Evaluation of old-age disability and related factors among an Iranian elderly population M. Adib-Hajbaghery 1 ABSTRACT Old-age disability has become a public health concern. This study was conducted to evaluate the prevalence of disability and its related factors among the elderly population in Kashan city, Islamic Republic of Iran. A cross-sectional study was conducted on a multistage random sample of 350 elderly people. The World Health Organization Disability Assessment Schedule II was used as the disability measure. Overall, 37.1% had mild ageing disability, 38.6% moderate, 20.0% severe and 4.3% extreme disability. Significant relationships were observed between disability and sex, age, living status, needing help, marital status, urban/rural residence, drug addiction, duration of addiction, employment status, having regular physical activity, level of education, health perception, history of hospitalization in the last year and having multiple diseases. Considering the rapid increase in the aged population in Islamic Republic of Iran, more attention should be paid to the health of elderly people. 1School of Nursing, Kashan University of Medical Sciences, Kashan, Islamic Republic of Iran (Correspondence to M. Adib-Hajbaghery: adib1344@ yahoo.com). Received: 27/11/09; accepted: 11/02/10 ينيناريلإا نسلا رابك ينب هب ةقلعتلما لماوعلاو يخوخيشلا زجعلا مييقت يرقاب جاح بيدأ نسمح ةنيدم في نسلا رابك ينب هب ةقلعتلما لماوعلاو زجعلا راشتنا مييقتل ةساردلا هذه تيرجأ دقو .ًايمومع ًايحص ًاقلق يخوخيشلا زجعلا يرثي :ةـصلالخا ططخلما مدخُتساو .ًاّنِسُم ينسخمو ةئم ثلاث ُّمضت لحارلما ةددعتم ةيئاوشع ةنيع لىع ةضرعتسم ةسارد تيرجأو .ةيملاسلإا ناريإ ةيروهجم في ناشاك زجع نم نوناعي يننسلما ءلاؤه نم %37.1 نأ لاجملإا هجو لىع َّينبت .زجعلا سايقل ًةليسو ةيلماعلا ةحصلا ةمظنم فينصتل ًاقفو زجعلا مييقتل نياثلا ينب ًايئاصحإ ابه دتعُي ةقلاع تظحولو .زجعلا ىَهَتْنُم نم نوناعي %4.3و ،ميخو زجع نم نوناعي %20.0و ،طسوتم زجع نم نوناعي %38.6و ،فيفط لوطو ،تاردخلما نامدإو ،فيرلا وأ ةنيدلما في ةماقلإاو ،ةيجاوزلا ةلالحاو ،ةدعاسملل ةجالحاو ،ةيشيعلما ةلالحاو ،رمعلاو ،سنلجا نم ٍّلك ينبو زجعلا ،ضيالما ماعلا في تايفشتسلما في ةلجاعلما قباوسو ،ةيحصلا فراعلماو ،ميلعتلا ىوتسمو ،ماظتناب نيدبلا طاشنلا ةسراممو ،لمعلا ةلاحو ،نامدلإا ةدم ديزلما ءلايإ نم َّدُبلاف ،ةيملاسلإا ناريإ ةيروهجم ناكس ينب نسلا رابك ددعل ةعيسرلا ةدايزلا لىإ رظنلاب هنأ ثحابلا ىريو .ةددعتم ضارمأب ةباصلإاو .يننسلما ةحصب مماتهلاا نم évaluation de l’incapacité liée à l’âge et des facteurs y afférents dans une population de personnes âgées en Iran RÉSUMÉ L’incapacité liée à l’âge est devenue une préoccupation de santé publique. L’étude a été conduite afin d’évaluer la prévalence de l’incapacité et les facteurs y afférents dans une population de personnes âgées de la ville de Kachan (République islamique d’Iran). Une étude transversale a été menée sur un échantillon aléatoire à plusieurs degrés de 350 personnes âgées. L’échelle OMS pour l’évaluation des incapacités ou WHODAS 2.0 (World Health Organization Disability Assessment Schedule II) a été utilisée pour mesurer l’incapacité. Globalement, 37,1 % souffraient d’une incapacité liée à l’âge légère, 38,6 % d’une incapacité modérée, 20,0 % d’une incapacité sévère et 4,3 % d’une incapacité extrême. Des liens étroits ont été observés entre l’incapacité et le sexe, l’âge, le niveau de vie, le degré de dépendance, la situation matrimoniale, le lieu de résidence urbain ou rural, les toxicomanies et leur durée, la situation professionnelle, la pratique d’une activité physique régulière, le niveau d’études, la perception de la santé, les antécédents d’hospitalisation depuis douze mois et la présence d’affections concomitantes. Étant donné l’augmentation rapide de la population des personnes âgées en République islamique d’Iran, une attention accrue doit être accordée à leur santé. Book 17-9.indb 671 9/6/2011 12:43:07 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 672 Introduction Disability has been defined as having a problem in performing any of the activities of daily  living, without help  or equipment,  for 3 months or  longer  [1]. Disability due  to physical, mental  or emotional health problems is a major public health  issue,  resulting  in  reduc- tion of quality of life and increased de- pendence on the health care system [2].  Newly developed countries  in Asia are  ageing faster than other countries. The rate of increase of the elderly population age 65 years and older in these countries is reported to be approximately 3% an- nually, compared with 1.0% to 1.3%  in  the United Kingdom, Sweden and  the  United States  [3]. The proportion of  people aged 65 years and older in the Islamic Republic of  Iran accounted  for  6% of  the population  in 2005 and  it  is  estimated  to  reach 19% by 2030  [4].  The costs associated with disabilities of the elderly are high and continuing to grow [5,6]. Therefore,  the  issue of age- ing has precipitated policy discussions around the world [7,8]. The prevalence of disability varies in different countries. Some research literature has indicated an increased trend towards disability in developing countries  [3]. Others have  suggested  that disability is falling among the eld- erly  in developed countries [1,5]. Both  chronic diseases and acute events such as  cardiovascular diseases,  stroke, hip  fractures, arthritis, skeletal and mobility  problems as well as hospitalization are among the most common underlying reasons for physical disability in older adults  [9,10].  Some  reports  indicate  variations in sex and age in levels of dis- ability  [2,11]. Parahyba et al.  reported  a significant relationship between level of disability and age, sex, low education  and low income [11]. Studies of  the prevalence,  causes  and effects of disability in ageing popu- lations are crucial for developing an ap- propriate public health policy in each country. The population of elderly in the Islamic Republic of Iran is increas- ing rapidly and the government and health care system have not focused on the demands of the elderly as a vulner- able subgroup of society. This study was therefore conducted to evaluate the prevalence of disability and its related factors among the elderly population in Kashan,  Islamic Republic  of  Iran  during 2007. The study will  enhance  health care providers’ understanding of elderly disability in this country and similar cultures in Asia and the Middle  East. Methods A cross-sectional  study was conducted  on a random sample of elderly people residing in Kashan city, Islamic Repub- lic of Iran. Setting and sample The study  setting  and  sampling have  been described in an earlier paper [12].  The inclusion criteria were age 65 years or older, willing  to participate  in  the  study and not having a medical diag- nosis of Alzheimer disease. Multistage  random sampling was used to select a community sample of 350 people from  the estimated population of elderly peo- ple in Kashan of 32 000 in 2007. Data collection Subjects completed a questionnaire and participated in a formal interview. A 2-part  questionnaire was  used,  as  described  previously  [12]. The  first  part consisted of questions on sociode- mographic characteristics. The second part consisted of a validated Farsi ver- sion of  the World Health Organiza- tion Disability Assessment Schedule  II (WHODAS II), which was used as  the generic measure of disability in this survey. Statistical analysis A modified version of the WHODAS II  Likert scales was used with a maximum score of 144 and the minimum score of 0 (a higher score indicates a lower level  of disability). Participants’  total  scores  were  categorized  as  extreme  (score  0–36), severe (37–72), moderate (73– 108), mild (109–143) and without dis- ability (144). Descriptive statistics were  computed for all variables. Chi-squared test, t-test and analysis of variance were  also utilized to analyse the data. Results A total of 350 elderly people (216 males  and 134  females) with a mean age of  72.7  [standard  deviation  (SD)  7.2]  years were studied. Table 1 shows the sociodemo- graphic characteristics and levels of disability of  the  sample. A majority of  the elderly in this sample were illiterate (60.6%). Most of our  subjects had no  regular physical activity during their life- time (77.7%). A quarter of elderly in this  study (26.0%) had some addiction/de- pendency to an opiate, tobacco or psy- chotropic drug. There were significant differences between men and women in marital status, living status, need for help  with activities of daily living, drug addic- tion, current and previous employment,  educational level, health perception and  number of diseases/person. Of the total sample, no one obtained  the highest score (no disability), 37.1%  had mild ageing disability, 38.6% mod- erate, 20.0% severe and 4.3% extreme.  There was a significant difference be- tween the sexes in the levels of disability,  with 9.0% of women having  extreme  disability compared with only 1.4% of  men (P < 0.001) The mean score of ageing disabil- ity on  the WHODAS II was 93.3 (SD  29.9) for the total sample. Table 2 shows  that elderly people reported the highest level of disability in the domain of life activities  [mean % of  total  score was  60.4% (SD 28.3%)] and getting around  (mobility) [61.9% (29.2%)]. The lowest  disability was reported in the domain of Book 17-9.indb 672 9/6/2011 12:43:07 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 673 Table 1 Sociodemographic characteristics of the sample of the elderly population Variable Females (n = 134) Males (n = 216) Total (n = 350) P-value No. % No. % No. % Mean (SD) age (years) 72.3 (7.1) 73.0 (7.2) 72.7 (7.2) 0.4 Sex 134 38.3 216 61.7 350 100.0 – Marital status Married 69 51.0 193 89.4 262 74.9 0.001 Widowed 65 49.0 23 10.6 88 25.1 Living status Alone 33 24.6 9 4.2 42 12.0 0.001 With spouse 64 47.8 186 86.0 250 71.4 With children 34 25.4 20 9.3 54 15.4 With others 3 2.2 1 0.5 4 1.2 Need help with ADL Independent 78 58.2 179 82.9 257 73.4 0.001 Needing help 56 41.8 37 17.1 93 26.6 Insurance status Insured 105 78.4 158 73.1 263 75.1 0.31 Noninsured 29 21.6 58 26.9 87 24.9 Area of residence Urban 97 72.4 171 79.2 268 76.6 0.15 Rural 37 27.6 45 20.8 82 23.4 Addiction to drugs Cigarettes 0 0.0 36 16.7 36 10.3 0.001 Opiates 0 0.0 4 1.8 4 1.1 Psychotropic drugs 34 25.4 17 7.9 51 14.6 No addiction 100 74.6 159 73.6 259 74.0 Mean (SD) duration of addiction (years) 10.4 (2.6) 26.4 (2.7) 21.3 (18.7) 0.001 Current employment status Manual worker 0 0.0 14 6.5 14 4.0 0.001 Self-employed 3 2.2 39 18.0 42 12.0 Retired 28 20.9 128 59.3 156 44.6 Other 103 76.9 35 16.2 138 39.4 Previous employment status Manual worker 3 2.2 97 44.9 100 28.6 0.001 Clerk 0 20 9.3 20 5.7 Self-employed 1 0.8 61 28.2 62 17.7 Other 130 97.0 38 17.6 168 48.0 Education Illiterate 106 79.1 106 49.1 212 60.6 0.001 Elementary 27 20.1 80 37.0 107 30.6 Middle grade 1 0.8 17 7.9 18 5.1 High school 0 0.0 13 6.0 13 3.7 Regular bodily activity Yes 17 12.7 61 28.2 78 22.3 0.001 No 117 87.3 155 71.8 272 77.7 Book 17-9.indb 673 9/6/2011 12:43:08 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 674 self-care  [82.7% (24.8%)]. The elderly  who were  in employment after  retire- ment also achieved a higher percent- age of the total score than the elderly without  self-employment  [74.5% (SD  22.1%) versus 69.9% (SD 21.1%)]. Table 3 shows the ageing disability score by the sociodemographic char- acteristics of  the  elders. A  significant  relationship was found between age- ing disability scores and the following variables: sex, age, living status, needing  help, marital  status,  urban/rural  resi- dency, drug addiction (including ciga- rettes, opiates or psychotropic drugs),  duration  of  addiction,  employment  status, having  regular physical  activity,  education, having multiple diseases, his- tory of hospitalization and perception of health. However, no significant relation  was observed between disability and insurance status. A significant difference  was also observed between the disability scores of elderly people with no diag- nosed diseases, 1 disease and more than  1 disease. Table 4 shows the ageing disability score for elders with different diseases. Elderly people with neurological dis- orders,  arthritis  and musculoskeletal  disorders had the lowest mean scores (i.e.  highest  levels  of  disability). The  number of chronic diseases per person was also associated with the mean dis- ability score Discussion Around one-quarter  (24.3%) of  the  elderly people in our sample had ex- treme to severe disability. The mean score of disability for the whole sample was  93.3, which was  indicative  of  a  moderate level of disability in this population of elderly people. The severity of disability increased signifi- cantly with increasing age, from a mean  score of 99.4 (SD 28.8) in those aged ≤  70 years  to 72.6 (SD 35.1)  for  those  aged 91+ years. The Iranian population  of elderly has  increased  from 1.7% to  more than 6% within the last 2 decades  [4]. Therefore, we can expect  that  the  number of disabled elderly will be further increased in the next decades. There have been no previous studies published on the subject of old-age dis- ability  in the Islamic Republic of Iran.  However,  studies  in other  countries  have  shown  that  approximately 20%  of people aged 70 years or older, and  50% of people aged 85 years and over,  report difficulties in basic activities of daily living [13]. Our  analysis  showed  that  the  2  domains  of  life  activities  and  getting  around (mobility) were associated with  the highest levels of disability. Scores Table 1 Sociodemographic characteristics of the sample of the elderly population (concluded) Variable Females (n = 134) Males (n = 216) Total (n = 350) P-value No. % No. % No. % Frequency of hospitalizations (times/last year) 0 67 50.0 124 57.4 191 54.6 0.42 1–2 49 36.5 67 31.0 116 33.1 3–5 13 9.7 22 10.1 35 10.0 > 6 5 3.73 3 1.39 8 2.3 Health perception Excellent 21 15.7 16 7.4 37 10.6 0.03 Good 61 45.5 90 41.6 151 43.1 Moderate 46 34.3 87 40.3 133 38.0 Bad 6 4.5 22 10.2 28 8.0 Very bad 0 0.0 1 0.5 1 0.3 No. of diseases/person 0 15 11.2 52 24.1 67 19.1 0.001 1 46 34.3 97 44.9 143 40.8 1+ 73 54.5 67 31 140 40.0 Level of disability Extreme 12 9.0 3 1.4 15 4.3 0.001 Severe 47 35.1 23 10.6 70 20.0 Moderate 44 32.8 91 42.1 135 38.6 Mild 31 23.1 99 45.8 130 37.1 SD = standard deviation; ADL = activities of daily living. Book 17-9.indb 674 9/6/2011 12:43:08 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 675 were highest for those who were inde- pendent. This is consistent with the re- sults of Avlund et al., who reported that  ageing disability increased the risk of need for home help and nursing home admission [14]. The present study showed that eld- erly people with neurological diseases,  arthritis and musculoskeletal diseases had  the highest  levels of disability.  It  seems that diseases with large effects on mobility impose greater levels of disabil- ity on old people than cardiovascular diseases for example. Other researchers  have also reported that mobility dis- ability is common in elderly people and impedes many activities important to independent living and self-care [13,15,16]. Based on our analysis,  the  number of chronic diseases a person suffered were also associated with the disability  scores. Avlund reported  that  the risk of becoming disabled was 4-fold higher for a person with 4 chronic dis- eases [17]. We  found significant a gender dif- ference in disability severity. The mean disability score was significantly lower for women than men [79.4 (SD 31.8)  versus 102.0 (SD 25.1)], which  signi- fies  a higher  level  of disability.  It  has  been shown that women have a longer duration of life lived with disability than men. The reasons for this are still partly unknown, although a higher prevalence  of fatal conditions among men and of non-fatal chronic conditions among women has been suggested [18]. Fur- thermore, women have  a  lower  pul- monary peak capacity  function,  lower  muscle mass and lower bone density and  thus,  in old age, physiological  re- serves will be exhausted sooner than in men [17,19]. Most of the elderly in this sample were illiterate and a significant relation- ship was observed between educational level and disability. The mean disability score of the illiterate elderly was signifi- cantly lower than the educated aged people [increasing from 85.5 (SD 30.2)  in illiterates to 109.8 (SD 17.0) for those  with high school education]. Previous  research has also demonstrated that lower education and income were as- sociated with functional decline among elderly men and women [20,21]. We observed a significant difference  between the rates of marriage in elderly men and women. Half of elderly women were widowed while 90% of elderly men  were married. Mean scores of disability were also lower in single and widowed elders than the married ones [73.6 (SD  30.2) versus 99.9 (SD 26.9)]. The mean  score of disability was also lower in eld- erly people who  lived alone [74.6 (SD  27.2)]  than  those who  lived with  their  spouses [99.8 (SD 27.3)] or with their  children  [81.6  (SD 31.7)]. Goldman  et al. found that widowed men aged 70  years and over had significantly higher rates of mortality and disability than married men  [22]. However, Hewitt  et al. reported a weak association be- tween marital status and health for men,  but that widowed and never married women had better general health  than  married  and  separated women  [23].  Other studies have also found that living  alone  [21]  and  being widowed  [22]  were risk factors of disability among men. According to Avlund, older adults  with a lack of social relations may be more susceptible to decline than others,  and that older disabled women living alone may be at special risk of not recov- ering from disability [17]. Most of our subjects had not prac- tised regular physical activity during their life. The mean score of disability was also significantly lower in the elderly without regular physical activity. The rate of regular activity was also less in women. This is consistent with find- ing of Adib and Masoodi who studied  the characteristics of patients with hip fractures  in  Islamic Republic  of  Iran  [24]. Physically  inactive people often  obtain poorer results in physiological and  sensory–motor  tests,  while  the  elderly who were physically active in their earlier life maintain a higher level of  physiological  function  [25],  good  mobility  and  independence  [26]  and  had a shorter period of disability prior to death [27]. Table 2 Total ageing disability scores in different domains Domain No. Range of score Mean (SD) disability score Mean (SD) % of total score Understanding and communicating 350 0–19 18.2 (5.9) 75.8 (2.4) Getting around 0–20 12.4 (5.8) 61.9 (29.2) Self care 0–16 13.2 (4.0) 82.7 (24.8) Interpersonal interactions 0–20 14.6 (4.9) 73.1 (24.3) Life activities 0–16 9.7 (4.9) 60.4 (28.3) Working activities 123 0–16 11.1 (4.5) 69.3 (28.6) Participation in society 350 2–32 21.4 (7.6) 66.8 (23.6) Total score (elders with self-employment) 123 6–144 107.3 (31.8) 74.5 (22.1) Total score (elders without self-employment) 227 6–128 89.5 (27.0) 69.9 (21.1) SD = standard deviation. Book 17-9.indb 675 9/6/2011 12:43:08 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 676 In the present study,  the severity of  disability was lower in elderly people who continued in self-employment af- ter retirement than those who did not [mean  score 107.3  (SD 31.8)  versus  89.5 (SD 27.0)]. It seems that employ- ment after  retirement could delay age- ing disability by preserving old people’s physical and cognitive abilities and keep them socially active. Therefore, flexibil- ity in the definition of age of retirement may help to maintain and improve the quality of life in older age groups. We  found an association between  area of residence and ageing disability. The elderly living in rural areas had a lower mean score than the elderly living near to the city centre [84.4 (SD 26.6)  versus 96.1  (SD 30.4)]. This  contrast  with the results of a study conducted in Brazil,  in which  the elderly  living  in  rural areas had a lower level of disability than  those  living  in urban areas  [20].  Our finding  is  consistent with Allain  et al. who reported that the elderly in rural areas in Zimbabwe had more dis- ability  than  in  the urban areas  [28].  It  seems that the elderly who live in rural areas have more difficulties in transport and access to shopping and health care facilities and they experience greater disability than those who live nearer to the city centre. About 26% of elderly  in  this  study  had some addiction/dependency to an  opiate,  tobacco or psychotropic drug.  The mean score of elders with addiction to opiates [78.0 (SD 42.0)] were signifi- cantly lower than those with no drug use [94.9 (SD 30.8)] or only cigarette smok- ing  [101.0 (SD 24.7)]. Use of opiates  and psychotropic drugs could increase unwanted  effects  (e.g.  as  confusion,  accidental  falls, memory decline  and  behavioural  changes)  [29]  that  could  be contributed to more severe disability in the drug user elderly. However, those  with a longer duration of addiction (4+  years) had a higher mean score (a lower  level of disability)  than  those with < 4  years addiction [94.7 (SD 26.4) versus  78.2  (SD 28.0)]. This  finding  is  sur- prising and needs more investigation. However, it is possible that people with  longer duration of addiction may have Table 3 Ageing disability score by sociodemographic characteristics of the elderly population Variable Mean (SD) disability score P-value Age (years) ≤ 70 99.4 (28.8) 0.001 71–80 90.8 (28.7) 81–90 77.7 (30.7) 91+ 72.6 (35.1) Sex Male 102.0 (25.1) 0.001 Female 79.4 (31.8) Marital status Married 99.9 (26.9) 0.001 Widowed 73.6 (30.2) Living status Alone 74.6 (27.2) 0.001 With spouse 99.8 (27.3) With children 81.6 (31.7) With others 51.0 (37.4) Need help with ADL Independent 102.7 (25.2) 0.001 Needing help 67.4 (26.7) Insurance status Insured 94.6 (30.6) 0.17 Noninsured 89.6 (27.9) Area of residence Urban 96.1 (30.4) 0.002 Rural 84.4 (26.6) Addiction Cigarette 101.0 (24.7) 0.005 Opiates 78.0 (42.0) Psychotropic drugs 81.2 (24.5) No addiction 94.9 (30.8) Duration of addiction (years) < 4 78.2 (28.0) 0.021 4+ 94.7 (26.4) Present job Manual worker 107.7 (29.9) 0.001 Self-employed 114.4 (25.6) Retired 90.8 (27.7) Other 88.4 (30.8) Previous job Manual worker 99.2 (26.9) 0.001 Clerk 112.6 (15.2) Self-employed 109.8 (24.0) Other 83.9 (31.2) Book 17-9.indb 676 9/6/2011 12:43:09 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 677 some coping mechanisms and therefore express fewer complaints. The highest level of disability was found in the elderly who had been hospitalized more than 6 times in the previous 12 months [mean score 76.0  (SD 28.3)] compared with  those with  no hospitalizations [117.5 (SD 25.1)].  A  relationship between disability  and  hospitalization and need for home help has also previously reported by Avlund  et al. [14,17] and Allain et al. [28]. To the best of our knowledge this is the first published research on disability among  the  Iranian elderly population.  Although different disability measures  exist,  for  this  study  the  researchers  se- lected the WHODAS II questionnaire  for its cultural appropriateness and ease of application. In conclusion, a considerable pro- portion of the elderly people in our study had extreme or severe disabil- ity. Considering the rapid rise in aged populations, more attention should be  paid to the health and quality of life of elderly people. Further research is needed for a better understanding of the  extent of the problem within the Islamic  Republic of  Iran. The public  and  the  authorities  should pay more attention  and provide more support and facilities for elderly women and elderly people who  live  alone.  Public  education  on  the importance of regular physically activity and its continual after the age of  retirement may be effective for disability Table 3 Ageing disability score by sociodemographic characteristics of the elderly population (concluded) Variable Mean (SD) disability score P-value Education Illiterate 85.5 (30.2) 0.001 Elementary 104.6 (27.0) Intermediate 107.6 (19.6) High school 109.8 (17.0) Regular bodily activity Yes 111.7 (19.4) 0.001 No 88.1 (30.4) Frequency of hospitalizations (times/last year) 0 117.5 (25.1) 0.03 1–2 92.8 (30.6) 3–5 83.2 (30.2) 6+ 76.0 (28.3) Health perception Excellent 66.3 (28.8) 0.001 Good 87.1 (27.6) Moderate 105.2 (24.6) Bad 107.0 (33.5) Very bad 66.0 (0.0) No. of diseases/person 0 112.1 (23.1) 1 96.4 (30.7) 0.001 1+ 81.4 (26.7) SD = standard deviation; ADL = activities of daily living. Table 4 Ageing disability score for the elderly population with different diseases Variable No. Mean (SD) disability score Mean (SD) % of total score Disease Cardiac 21 95.6 (31.7) 66.4 (22.0) Respiratory 15 99.1 (29.7) 68.8 (20.6) Diabetes 5 112.8 (9.2) 78.3 (6.4) Arthritis 10 86.5 (36.2) 60.1 (25.1) Musculoskeletal 21 86.7 (25.1) 60.2 (17.5) Neurological 7 83.3 (45.2) 57.8 (31.4) Hypertension 16 90.3 (45.5) 62.7 (31.6) Hyperlipidaemia 3 113.0 (12.5) 7.5 (8.7) Other 45 103.2 (23.7) 71.6 (16.4) No. of diseases/person 0 67 112.1 (23.1) 77.8 (16.0) 1 143 96.4 (30.7) 66.9 (21.3) 1+ 140 81.4 (26.7) 56.5 (18.6) SD = standard deviation. Book 17-9.indb 677 9/6/2011 12:43:09 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 678 References Spillman BC. Changes in elderly disability rates and the impli-1. cations for health care utilization and cost. Milbank Quarterly, 2004, 82:157–194. Larry LS. Disability among adults in New York State, 2001–2. 2003: prevalence and health risk behavior. Behavioral Risk Factor Surveillance System, 2005, 12(1):1–8. Ng T-P et al. Prevalence and correlates of functional disability 3. in multiethnic elderly Singaporeans. Journal of the American Geriatrics Society, 2006, 54:21–29. Amir-Sadri A, Soleimani H. Elderly phenomena and its out-4. comes in Iran. International Journal of Hygiene and Health, 2005, 1:19–35. Cutler DM. The reduction in disability among the elderly. 5. Pro- ceedings of the National Academy of Sciences of the United States of America, 2001, 98:6546–6547. Bone M. 6. Trends in dependency among older people in England. London, Office of Population Census and Surveys, 1995. Melzer D et al. Profile of disability in elderly people: estimates 7. from a longitudinal population study. British Medical Journal, 1999, 318:1108–1111. Wiener J. 8. Long term care reform: an international perspective. In Health care reform: the will to change. Paris, Organization for Economic Cooperation and Development, 1996 (Health Policy Studies, No. 8). Fried LP, Guralnik JM. Disability in older adults: evidence re-9. garding significance, etiology, and risk. Journal of the American Geriatrics Society, 1997, 45:92–100. Wilcox VL, Kasl SV, Idler EL. Self-rated health and physical dis-10. ability in elderly survivors of a major medical event. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 1996, 518:S96–S104. Parker CJ, Morgan K, Dewey ME; The Analysis Group. Physical 11. illness and disability among elderly people in England and Wales: the Medical Research Council Cognitive Function and Ageing Study. Journal of Epidemiology and Community Health, 1997, 51:494–501. Adib-Hajbaghery M, Aghahoseini S. The evaluation of dis-12. ability and its related factors among the elderly population in Kashan, Iran. BMC Public Health, 2007, 7:261. Heikkinen E. Functional capacity and health of elderly people—13. the Evergreen project. Scandinavian Journal of Social Medicine. Supplementum, 1997, 53:1–18. Avlund K, Damsgaard MT, Schroll M. Tiredness as determinant 14. of subsequent use of health and social services among non- disabled elderly people. Journal of Aging and Health, 2001, 13:267–286. Guralnik JM et al. Progressive versus catastrophic loss of the 15. ability to walk: implications for the prevention of mobility loss. Journal of the American Geriatrics Society, 2001, 49:1463–1470. Avlund K et al. Changes in social relations in old age: Are they 16. influenced by functional ability. Aging Clinical and Experimen- tal Research, 2002, 14S:56–64. Avlund K. Disability in old age: Longitudinal population-based 17. studies of the disablement process. Danish Medical Bulletin, 2004, 51:315–349. Gold CH et al. Gender and health: a study of older unlike-sex 18. twins. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 2002, 57:S168–S176. Leveille SG, Resnick HE, Balfour J. Gender differences in 19. disability: evidence and underlying reasons. Aging, 2000, 12:106–112. Parahyba MI, Veras R, Melzer D. Incapacidade funcional entre 20. as mulheres idosas no Brasil [Disability among elderly women in Brazil]. Revista de Saúde Pública, 2004, 39:383–91. Strawbridge WJ et al. Gender differences in factors associated 21. with change in physical functioning in old age: a 6-year longi- tudinal study. Gerontologist, 1993, 33:603–609. Goldman N, Koreman S, Weinstein R. Marital status and 22. health among the elderly. Social Science & Medicine, 1995, 40:1717–1730. Hewitt B et al. 23. Marriage dissolution and health amongst the elderly: the role of social and economic resources. 2004 (http:// melbourneinstitute.com/downloads/hilda/Bibliography/ wp/hewitt.pdf, accessed 1 August 2011). AdibHajbaghery M, Masoody-Alavi N. Evaluating the patients 24. with osteoporotic neck femor bone fractures in Kashan. Feyz, Kashan University of Medical Sciences and Health Service, 2007, 10:52–58. Rantanen T. Muscle strength, disability and mortality. 25. Scandi- navian Journal of Medicine and Science in Sports, 2003, 13:3–8. LaCroix AZ et al. Maintaining mobility in late life. II. Smoking, 26. alcohol consumption, physical activity, and body mass index. American Journal of Epidemiology, 1993, 137:858–869. Leveille SG et al. Aging successfully until death in old age: 27. opportunities for increasing active life expectancy. American Journal of Epidemiology, 1999, 149:654–664. Allain TJ et al. Morbidity and disability in elderly Zimbabwe-28. ans. Age and Ageing, 1997, 26:115–121. Armour D, Cairns C. 29. Medicines in the elderly. London, Pharma- ceutical Press, 2002. prevention in older age. Providing some  types of jobs or social activities after the  age of retirement and revising the age of retirement may also keep elderly people active and socially engaged and decrease their risk of disability. The relationship of addiction and living in rural areas with the level of disability remained unclear in this research and need more research. Book 17-9.indb 678 9/6/2011 12:43:09 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 679 Health information systems in the Islamic Republic of Iran: a case study in Kerman province F. Zolala 1,2 ABSTRACT Health information systems provide information for decision-making at all levels, from planning and management to evaluation of health services. Registration of vital events is the most basic level of any health information system. This case study used in-depth interviews, observations and examination of documents to explore the system of births and deaths registration in Kerman province. The findings were evaluated under 3 headings: data input, data processing and data usage. A range of problems were identified concerning legal requirements, staffing, data checking and publication of data. Different approaches are suggested to strengthen the system, such as introducing regulations to oblige different data sources to provide data and allocating sufficient resources, including human resources, and an improved technology infrastructure. 1Regional Knowledge Hub for HIV/AIDS Surveillance, Faculty of Health, Kerman University of Medical Sciences, Kerman, Islamic Republic of Iran (Correspondence to F. Zolala: farzanehzolala@yahoo.com). 2Department of Public Health Sciences, University of Edinburgh, Edinburgh, United Kingdom. Received: 22/11/09; accepted: 11/01/10 نامرك ةعطاقم في ةلاح ةسارد :ةيملاسلإا ناريإ ةيروهجم في ةيحصلا تامولعلما مُظُن لىعلاوذ هنازرف تامدلخا مييقتب ًءاهتناو ةرادلإاو طيطختلا نم ًاءدب ،تايوتسلما عيجم لىع رارقلا ذاتخلا تامولعم نم مزلي ام ةيحصلا تامولعلما مظن مّدقت :ةـصلالخا تاعجارم نم ةساردلا هذه ْتَدافتسا دقو .ةيحصلا تامولعلما مُظُن نم ماظن يلأ َّيدعاقلا ىوتسلما ةيويلحا ثادحلأا ُليجست لِّثميو .ةيحصلا تتح جئاتنلا مييقت ىرجو .نامرك ةعطاقم في تايفولاو تادلاولا ليجست ماظن فاشكتسلا قئاثولل قمعم صحفو ينلماعلا عم ةقمعتم تاظحلامو ،ةينوناقلا تابلطتلماب قلعتت يتلا لكاشلما نم ةفئاط فارعتسا متو .تايطعلما نم ةدافتسلااو ،تايطعلما ةلجاعمو ،تايطعلما لاخدإ :يه نيوانع ةثلاث لىع بجوُت حئاول لاخدإ لثم ،تامولعلما ماظن زيزعتل ةفلتمخ بيلاسأ ةساردلا تحترقا دقو .اهشرنو تايطعلما ةحص نم ققحتلاو ،ينفظولما ينيعتو .ةيساسلأا ةينقتلا ةينبلا ينستحو ،ةيشربلا دراولما جاردإو ،ةيفاكلا دراولما صيصتخو ،تايطعلما هذه َميدقت ةفلتخلما تايطعلما رداصم Systèmes d’information sanitaire en République islamique d’Iran : étude de cas dans la province de Kerman RÉSUMÉ Les systèmes d’information sanitaire fournissent des données utiles à la prise de décision à tous les niveaux, de la planification et la gestion à l’évaluation des services de santé. L’enregistrement des faits d’état civil correspond au niveau le plus basique de tout système d’information sanitaire. À partir d’entretiens approfondis, d’observations et de l’examen de documents, l’étude de cas a permis d’analyser le système d’enregistrement des naissances et des décès dans la province de Kerman. Les résultats ont été évalués en fonction de trois catégories : la saisie des données, le traitement des données et l’exploitation des données. Une série de problèmes a été identifiée concernant les obligations légales, les effectifs, la vérification des données et leur publication. Différentes approches suggèrent de renforcer le système, comme par l’introduction de réglementations obligeant certaines sources d’information à fournir des données et à allouer des ressources suffisantes, notamment des ressources humaines, et à améliorer l’infrastructure des technologies. Book 17-9.indb 679 9/6/2011 12:43:09 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 680 Introduction Health information systems (HIS) pro- vide information for decision-making at all levels, from planning and manage- ment to evaluation of health services [1]. The ultimate aim is to improve the  health status of individuals and popu- lations  [2]. The  need  for  accessible,  quality health data is growing in many countries and in developing countries in particular. Boerma et al. have pointed  out that as financial support to devel- oping countries increases there is an increased need to measure progress towards achieving health goals such as those of the Millennium Development Goals [3]. This can be achieved through  monitoring specific health indicators. Despite  the  crucial  role of HIS  in  helping policy-makers to recognize problems and improve their health systems,  most  developing  countries  have poor HIS. To tackle this problem  some developing countries have added parallel systems to their national HIS to  gain better information [2]. While these  systems may achieve better quality of  information on specific topics, they can  create problems in duplication of data and they risk damaging the cohesion of the whole HIS system [2].  The need to develop quality HIS in  developing countries has been identified by international organizations such as the World Bank [4] and World Health  Organization (WHO), who established  the Health Metrics Network in 2005 as  the first global partnership dedicated to strengthening national HIS [5]. Based  on  the WHO framework, HIS are di- vided  into 6  components:  resources,  indicators, data  sources, data manage- ment,  information products and  infor- mation use. These components are also grouped under 3 headings: input, which  is concerned with HIS resources; proc- ess, which  includes health  indicators,  data  sources  and  data management;  and outputs, which are the products and  use of the information [6]. The most basic level of health data come  from civil  registration [7], which  is the continuous, obligatory, legal proc- ess of  recording vital events [8]. Regis- tration of vital events is one of the most important priorities in human society. A birth record confirms the existence of  a person, which is the first step towards  protection of his/her  rights  to  life and  social rights such as freedom [9]. The aim of this study was to use the Health Metrics Network framework to identify strengths and weaknesses in the system of births and deaths registration in Kerman province.  Methods Background The health system in the Islamic Repub- lic of  Iran  is a partnership between the  medical education system and health care facilities [10]. In each province there  is at least one medical science university,  which is the official representative of the Ministry of Health and Medical Educa- tion (MOHME) in that province [11].  The district health network is an office under the supervision of the medical university, and is the official administra- tor of health and medical care in each district  [12].  Health  services  in  the  rural areas are provided through “health houses”, which are small health centres  located  in villages. Approximately 86%  of the rural population are covered by health facilities [13]. There  are 2 main  sources of mor- tality data  in  Islamic Republic of  Iran:  the statistics unit under the supervision of  the MOHME and  the civil  registry  under the supervision of the Ministry of Interior. The only official source for live  births data is the civil registry. Data collection This study was a part of a larger study carried out  in 2  cities  (Bam and Ker- man) which are in the centre of Kerman  province. Kerman is  the second  largest  province in the Islamic Republic of Iran,  located in the south-east of the country. The data were collected from exami- nation of documents and observations and indepth interviews with personnel working at different levels of data collec- tion systems,  including data collectors  in rural and urban areas, data processors  and policy-makers  at  the  local  (Bam)  and provincial  (Kerman)  levels. Con- ducting interviews at the workplace enabled the researcher to obtain a better  perception about problems that could affect data quality. The documents used in this research were mainly avail- able only at the target organizations. Permission  to  conduct  the  study was  obtained through the vice-chancellor of  the health department  in Kerman  province. Collaboration with the civil registry was obtained through a letter is- sued from Kerman Medical University.  Permission to carry out interviews at the  civil registry was issued by the head of the civil registry. Results The results are presented under 3 head- ings: data  input,  data processing  and  data usage. Data input Data input analyses the data capture procedures. The interviews established that the civil registry was principally notified of births and deaths by people’s testimony on a birth or death certificate. This means that there is no direct report- ing from any official health system such as hospitals  to  the civil  registry. Apart  from people’s  testimony,  the only way  that the civil registry is notified about deaths is reports sent from semi-private cemeteries. Regarding people’s testi- mony it was reported that many people postponed notifying the civil registry of deaths and births until they needed it for a specific reason, for example school  enrolment,  insurance  or  inheritance  claims. This was more likely to happen in Book 17-9.indb 680 9/6/2011 12:43:10 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 681 rural and remote areas where residents had to travel long distances to access the local offices of the civil registry. The problem was compounded by the fact that the penalty for failure to register or for  late  registration  is only a small fine,  with inadequate enforcement of the law. In  addition, deceased people with no  property are unlikely to be registered at the civil registry Although the medical university and  its data collection system in the rural areas had a better coverage of vital data  in comparison with  the civil  registry,  it  had its own deficiencies. As mentioned  earlier, the health system in the Islamic  Republic  of  Iran  covers  only  86% of  rural areas, which means that even with  complete  data  collection 14% of  the  rural population are not covered by the system. In  urban  areas,  the  following  are  required to send data to the statistics unit of the health network [14]: health  facilities (private and public),  forensic  medicine departments and cemetery offices. However the study interviews revealed that the medical university often failed to gain data from the foren- sic medicine department and from the private  cemetery office. Furthermore,  there was inconsistency in data transfers from private hospitals between different cities. Another matter was  that  semi- private cemetery offices and hospitals are required to send their data in a differ- ent format to that of the vice-chancellor of the treatment department in Kerman  province. Data processing Data processing addresses the ques- tion of how the data are processed and by whom. The interviews and docu- ments showed that the original data were transmitted in written form. At the  medical university,  the data were  inte- grated manually at the peripheral level before being sent to the health network for computerization. A number of  problems with data  processing were identified. The software  used for data entry at the civil registry was different and incompatible with that used at the medical university. The organizations used two different version of  the  International Classification of  Diseases for coding of mortality data. The medical university had a shortage of computers at some levels. There was limited technical support for the staff using computers. While both organiza- tions used  the data entry  software  for  data  checking,  there was  little manual  data checking for errors. Feedback on the quality of the data was rarely con- ducted. The study also revealed that there were inadequate staff of the appropriate academic level working with data at the medical university and the civil registry. Those who worked with data at the medical university complained of having to do other tasks beside data collection and of a high turnover of staff working in data processing.  In addition,  there was  limited pre-service or on-the-job train- ing of staff. This was exacerbated by an absence of guidelines explaining the data collection procedures in detail. Another  problem mentioned were delays in data sending from the peripheral levels such as villages to districts and from districts to the centre of the province. Data usage Three  items concern data usage: data  analysis,  data  availability  and  policy- makers’  views. Our  analysis  of  docu- ments found that the only publication produced by the civil registry was one detailing the total number of vital events at the national level. There was also an annual publication of deaths produced by the Ministry of Health. Regarding the availability of data there were some limitations at both organizations, which  were rooted in limitations of data storage or  technology.  Interviews with policy- makers showed that they perceived the main  problems  as  poor  data  quality,  no guidelines  for data collection,  lack  of forward planning for health issues in general and no incentives to use the data. Discussion The results of this study found that there were a range of problems in the HIS for  collecting vital data in the civil registry and in the medical science university of Kerman province. These started with poor perform- ance  in  data  capture,  due  to  lack  of  coordination and collaboration of data sources in sending the data to the target  organizations,  and  inadequate  rules and regulations or enforcement of regulations concerning the report- ing of births and deaths. Coordination and collaboration are important factors in ensuring that data are transferred between organizations in a consistent manner [15]. Next there were problems with data handling, such as transferring paper data  to the upper levels of the system, which  did not appear to be an efficient method of data  transfer  [16].  In Pakistan,  for  example,  the data  from the peripheral  levels are sent directly to the district level [17]. This method, however,  is not  the  best one from the standpoint of speed,  quality  and  accessibility. However,  it  may still be better than the method em- ployed  in  the  Islamic Republic of  Iran.  This is because the Pakistani method is  likely to be faster [16] and it also reduces  the errors that might happen during col- lation of the data. Lack of compatibility of software and  data coding used at the medical univer- sity and the civil registry also impeded the ability of technology to share and match the data with other data sources. This problem can lead to duplication of data and can decrease the accuracy of  data  [18]. The WHO  framework  advocates using software programs and  systems which are compatible with each other at different levels [6]. The quality of data collection was also likely to be jeopardized by defi- cient data checking, inadequate human  resources  and  low data  usage.  It  has  been pointed out that incorrect coding and mistakes in the entry of data in the correct fields are frequent problems Book 17-9.indb 681 9/6/2011 12:43:10 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 682 in developing countries  [19]. Limited  data checking was also linked to low data  usage  by  policy-makers.  If  data  are utilized,  they will  be  checked and  feedback on data will be sent to data collectors  and processors.  It has been  noted that in developing countries there are few opportunities to give feedback to data processors and data collectors to improve the quality of data [19]. The current study found that staff in data collection departments were often  under-qualified. Recruiting staff with appropriate academic qualifications at different levels of the data collection system is recommended to improve the quality of data [2]. However, if data  collection and processing tasks are del- egated to health care providers, medical  staff become overburdened and will view this as an extra and unwelcome task [6]. Low morale among staff was also identified in this survey. Job insecurity and high staff turnover are discouraging for  recently  graduated  staff,  and may  lead to poor morale which affects their quality of work [20]. High  turnover of  HIS staff was observed in studies carried  out  in Swaziland [21] and Afghanistan  [22]. Training  is needed at all  levels of  a data collection system and should in- clude policy-makers in order to increase their knowledge about the implications of data usage and interpretation on decision-making. On  the other hand,  data personnel should be aware of man- agers’ interests and needs. This will lead to improved data usage [23]. The lack of guidelines for data processing found in this survey hindered the availability of a clear and straightfor- ward definition of the data collection strategy and how indicators should be collected. This may have caused dupli- cation of work and overburdening of staff.  Introducing  guidelines  clarifies  the objectives of data collection and enhances data usage, particularly when  policy-makers are involved in these processes  [23]. Promoting guidelines  was recognized as an important fac- tor in strengthening the quality of the information system in Mexico [19,24]. Possible delays  in sending  the data  from the peripheral branches at the civil registry and regular delays in send- ing the data to the medical university were reported in this study. This can be traced back to the lack of strong regu- lations  and  inadequate management,  high workload on personnel and also low data usage  in decision-making.  It  is suggested that the information for managers should be available on a daily basis [6]. Use of  aggregated data can  reflect  low data usage at the provincial and district  level.  Inadequate data usage at  the local level reflects a number of prob- lems. One of  them  is  the  centralized  structure of  the  Iranian health  system  in which key decisions are made at the national level and the local levels do not have an important role in decision- making [25–27]. Furthermore,  lack of  an effective and accurate health system was mentioned in interviews as another obstacle to utilizing the data. This re- flects the lack of a culture of data usage in the Islamic Republic of Iran. The de- ployment of data has a direct correlation with the quality of data [23]. If data are  of poor quality,  they are unlikely  to be  utilized. If low quality data are collected,  they are likely to mislead policy-makers [28]. Promoting a system of incentives  for data usage is likely to increase data usage [23]. Sending the same data in different formats is a tedious job. Having a sta- tistics unit in individual departments is a waste of time and resources and leads to duplication of data. Establishing a powerful and central statistics unit could  reduce duplication,  increase  the  accuracy of data collection and even bring about greater availability of health information. Conclusion This study highlighted some ways in which  the HIS  in  Islamic Republic of  Iran can be  strengthened.  It  takes  the  efforts of policy-makers to decide which parts of the system need to be improved and which parts should be altered. The results of this review suggested different approaches to strengthen the system such as introducing appropriate rules and regulations to oblige different data sources  to provide  the data; allocating  sufficient  resources,  including human  resources and appropriate staff training;  and having a strong communication infrastructure to increase the speed and accuracy of data collection. Better  supervisory activities should be in place to ensure that the data collection proce- dures are on track and that data check- ing is undertaken by competent staff. Using compatible software  in different  organizations would not only provide more complete data transfer but also improve the quality of data through data  cross-checking. Finally,  a  culture  of data usage should be encouraged by the government at all levels including the  national,  provincial  and  districts  levels.  Introducing guidelines explain- ing the indicators for short-term and long-term quality monitoring activities and establishing a central statistics unit in  the  Islamic Republic of  Iran would  be helpful in improving the quality of health data. Acknowledgements This project was financially supported by Kerman Medical University. The au- thor recognizes the good collaboration of Kerman Medical University and Bam  health network by facilitating access for fieldwork. The author would like to ac- knowledge and thank her supervisor Dr John Forbes for his professional guid- ance and encouragement. The author also acknowledges the contribution by staff of Kerman Medical University and  of Bam health network  for giving  their  time to be interviewed. Book 17-9.indb 682 9/6/2011 12:43:10 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 683 References Hurtubise R. Managing information systems, concepts and 1. tools. In: Lippeveld T, Sauerborn R, Bodart C, eds. Design and implementation of health information systems. West Hartford, Connecticut, Kumarian Press, 1984. Lippeveld T. 2. Routine health information systems: the glue of a unified health system. Paper presented at the The RHINO Workshop on Issues and Innovation in Routine Health In- formation in Developing Countries, March 14–16, 2001. The Bolger Center, Potomac, Maryland, 2001 (http://www.cpc. unc.edu/measure/publications/html/rhino2001/worksho- pagenda.html#theme1, accesed 15 June 2011). Boerma JT, Stansfield SK. Health statistics now: are we making 3. the right investments? Lancet, 2007, 369:779–786. World development report 1993. Investing in health4. . Washington DC, World Bank, 1993. Health Metrics Network. 5. Assessing the national health informa- tion system: an assessment tool, version 4.00. Geneva, World Health Organization, 2008. Health Metrics Network. Fram6. ework and standards for country health information systems. Geneva, World Health Organiza- tion, 2008. Kane R et al. Uses of routine data sets in the evaluation of 7. health promotion interventions: opportunities and limitations. Health Education, 2000, 100:33–41. Department of Economic and Social Affairs. 8. Principles and rec- ommendations for a vital statistics system, revision 2. New York, United Nations, 2001 (ST/ESA/STAT/SER.M/19/Rev.2). Horton R. Counting for health. 9. Lancet, 2007, 370:1526. Mesdaghinia A. 10. Health and welfare systems development in the 21st century. Proceedings of the Third Global Symposium, 6–8 November 2002. Kobe, Japan, World Health Organization Centre for Health Development, 2002. World health day 2001. Country profiles: Islamic Republic of Iran11. . World Health Organization [online factsheet] (http://www. emro.who.int/mnh/whd/CountryProfile-IRA.htm, accessed 15 June 2011). Review of health information systems (HIS) in selected countries. 12. III. The Islamic Republic of Iran. World Health Organization [on- line document] (http://www.who.int/entity/healthmetrics/ library/iran_05apr.doc, accessed 15 June 2011). Naghavi M et al. [13. The changes in the health features of rural residents in Iran, 1st ed.]. Tehran, Islamic Republic of Iran, Barge Rezvan, 2005 [in Farsi]. Naghavi M. [14. Mortality features in 23 province in Iran in 2003]. Tehran, Islamic Republic of Iran, Ministry of Health and Medi- cal Education, 2005 [in Farsi]. Lippeveld T, Sapirie S. Approaches to strengthening health 15. information systems. In: Lippeveld T, Sauerborn R, Bodart C, eds. Design and implementation of health information systems. Geneva, World Health Organization, 2000. Shrestha.L, Bodart C. Data transmission, data processing and 16. data quality. In: Lippeveld T, Sauerborn R, Bodart C, eds. De- sign and implementation of health information systems. Geneva, World Health Organization, 2000. National health management information system (HMIS) (Pa-17. kistan). Government of Pakistan [website] (http://www.paki- stan.gov.pk/, accessed 15 June 2011). Zhang Y et al. An investigation into health informatics and 18. related standards in China. International Journal of Medical Informatics, 2007, 76:614–620. Chaulagai CN et al. Design and implementation of a health 19. management information system in Malawi: issues, innova- tions and results. Health Policy and Planning, 2005, 20:375– 384. Dasgupta S. Employment security: conceptual and statistical 20. issues. In: Diane-Gabrielle Tremblay Employment security as a determinant of health. Geneva, International Labour Office, 2001. Report on strengthening national health information systems. 21. Workshop on the use of geographical information system healthmap. Harare, Zimbabwe, 1–4 July 2002. Brazzaville, World Health Organization Regional Office for Africa, 2002 (http://www.equinetafrica.org/bibl/docs/WHOehs02.pdf, accessed 15 June 2011). Health Metrics Network. 22. Health information system assessment: country report. [Afghanistan] Health Information System: Review and Assessment [June, 2007]. Kabul, Afghanistan, Ministry of Public Health, 2007 (www.paris21.org/sites/default/files/ afghan-HMNassessment-2007.pdf, accessed 21 July 2011). Sauerborn R. Using information to make decision. In: Lippe-23. veld T, Sauerborn R, Bodart C, eds. Design and implementation of health information systems. Geneva, World Health Organiza- tion, 2000. Duran-Arenas L et al. The development of a quality informa-24. tion system: a case study of Mexico. Health Policy and Planning, 1998, 13:446–458. Gladwin J, Dixon RA, Wilson TD. Rejection of an innovation: 25. health information management training materials in east Af- rica. Health Policy and Planning, 2002, 17:354–361. Sauerborn R, Lippeveld T. Introduction. In: Lippeveld T, Sau-26. erborn R, Bodart C, eds. Design and implementation of health information systems. Geneva, World Health Organization, 2000. The role of contractual arrangements in improving health sector 27. performance. Report on a regional meeting, Cairo, Egypt, 18–20 April 2005. Cairo, World Health Organization Regional Office fo the Eastern Mediterranean, 2005 (WHO-EM/PHP/034/E). AbouZahr C, Adjei S, Kanchanachitra C. From data to policy: 28. good practices and cautionary tales. Lancet, 2007, 369:1039– 1046. Book 17-9.indb 683 9/6/2011 12:43:10 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 684 Lipoprotein changes in women taking low-dose combined oral contraceptive pills: a cross-sectional study in Basra, Iraq J.A. Abdel-Barry,1 M.S. Flafl,2 L.M. Al-Namaa 1 and N.A. Hassan 3 ABSTRACT We assessed lipid and lipoprotein levels in 100 women taking low-dose COCs and a control group of 100 non-users attending the family planning centre Basra Maternity and Child Hospital, Iraq. Venous blood was collected after 12–14 hours fasting, and serum triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and very low-density lipoprotein (VLDL) levels were measured. Serum TG, HDL-C and VLDL levels were significantly higher and LDL-C levels lower in users than non-users but TC levels did not differ between the 2 groups. TG, HDL-C and VLDL levels rose with age and duration of use while LDL-C levels decreased; TC levels did not change. 1Department of Biochemistry; 2Department of obstetrics and gynaecology; 3Department of physiology, College of Medicine, University of Basra, Basra, Iraq (Correspondence to J.A. Abdel-Barry: Aldohan57@yahoo.com). Received: 28/10/09; accepted: 19/01/10 في ةضرعتسم ةسارد :لمحلل ةعنالما تافيلوتلا صارقأ نم ةضفخنم ةعرج نلوانتي تيلالا ءاسنلا في يمحشلا ينتوبرلا تا ُّريرغت قارعلاب ةصربلا ةنيدم نسح ليع نيسرن ،ةمعنلا ىفطصم ءايلم ،لفيلف فيشر نوسيم ،يرابلا دبع دحمأ لاجم ،لمحلل ةعنالما تافيلوتلا صارقأ نم ةضّفمخ ةعرج َنْلَوانتي ةأرما ةئم في ةيمحشلا تانيتوبرلاو تاَّيمحشلا تايوتسم نوثحابلا ساق دقو :ةـصلالخا ةصربلا ةنيدم في لافطلأا ىفشتسمو ،ةموملأا ةياعر زكرمو ،ةسرلأا ميظنت زكرم تاداترُم نم ،صارقلأا هذه نلوانتي لا ،ةدهاش ةأرما ةئم فيو لوترسيلوكو ،ليكلا لوترسيلوكلاو ،ليصلما ديسريلغلا يثلاث تايوتسم تسيقو ،مايصلا نم ةعاس 14-12 دعب مدلا تانيع تعُجم دقو .قارعلا في ةفاثكلا عيضولا يمحشلا ينتوبرلا لوترسيلوكو ،LDL ةفاثكلا ضيفلخا يمحشلا ينتوبرلا لوترسيلوكو ،HDL ةفاثكلا عيفرلا يمحشلا ينتوبرلا عيضولا يمحشلا ينتوبرلا لوترسيلوكو ،ةفاثكلا عيفرلا يمحشلا ينتوبرلا لوترسيلوكو ،ديسريلغلا يثلاثل ةيلصلما تايوتسلما تناكو .VLDL نمب ًةنراقم صارقلأا كلت َنْلَوانت نم ينب ًايئاصحإ ابه ُّدَتعُي ةجردب نيدأ ةفاثكلا ضيفلخا يمحشلا ينتوبرلا لوترسيلوك ىوتسمو ،لىعأ ةفاثكلا ينتوبرلا لوترسيلوكو ،ليصلما ديسريلغلا يثلاث تايوتسم ْتَدَيازتو .ينتعومجلما ينب ليكلا لوترسيلوكلا تايوتسم فلتتخ لم نكلو ،اهَنْلَوانتي لم لوترسيلوك تايوتسم ْتَصَقانت ينح في ،صارقلأا لوانت ةدمو رمعلا عم ةفاثكلا عيضولا يمحشلا ينتوبرلا لوترسيلوكو ،ةفاثكلا عيفر يمحشلا .ليكلا لوترسيلوكلا تايوتسم يرغتت لمو ؛ةفاثكلا ضيفلخا يمحشلا ينتوبرلا Modification des taux de lipoprotéines chez les femmes sous contraceptifs oraux associés faiblement dosés : une étude transversale réalisée à Bassora (Iraq) RÉSUMÉ Nous avons évalué les taux des lipides et des lipoprotéines chez 100 femmes sous contraceptifs oraux associés faiblement dosés et chez 100 femmes témoins non utilisatrices consultant le centre de planification familiale du Maternity and Child Hospital [Hôpital de la mère et de l’enfant] de la ville de Bassora (Iraq). Un prélèvement de sang veineux a été effectué après 12 à 14 heures à jeun, et les taux des triglycérides sériques, de cholestérol total et de cholestérol des lipoprotéines de haute densité, basse densité et très basse densité ont été mesurés. Les taux des triglycérides sériques et de cholestérol des lipoprotéines de haute densité et de très basse densité étaient nettement plus élevés, et le taux de cholestérol des lipoprotéines de basse densité était plus faible chez les utilisatrices de contraceptifs que chez les autres femmes, alors que le taux de cholestérol total était similaire dans les deux groupes. Les taux des triglycérides sériques et de cholestérol des lipoprotéines de haute densité et de très basse densité augmentaient avec l’âge et la durée d’utilisation des contraceptifs, alors que le taux de cholestérol des lipoprotéines de basse densité diminuait, et que le cholestérol total restait stable. Book 17-9.indb 684 9/6/2011 12:43:11 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 685 Introduction Most modern preparation of combined oral contraceptive contain the estro- gen (ethinyl  estradiol)  in a daily dose  between 20–35 μg [1]. Pills containing  higher dose of  estrogen > 50 μg have  been linked to an increased risk of both arterial  and  venous  thrombosis  [2].  Current combined oral contraceptive (COCs) contain progestogen, classed  as a second or third generation and which are all derivatives from 19-nor testosterone [3]. Several researchers have reported the advantages  [4],  complications and  side-effects of combined oral contra- ceptives  [5]. The effects of  combined  oral contraceptives on plasma lipid and lipoproteins have also been studied. An  increase  in  serum  triglycerides  (TG),  which are mainly present in very low- density  lipoprotein (VLDL), has been  reported [6,7]. Another study reported  that the serum cholesterol level was unchanged in women taking low-dose combined oral contraceptives; however  the proportion of serum cholesterol car- ried by high-density lipoprotein (HDL)  was decreased, while that carried by low- density  lipoprotein (LDL) and VLDL  was  increased  [8]. Yet  another  study  reported that serum HDL-cholesterol (HDL-C) levels varied with the type and  the dose of steroids, and the net effect of  using combined oral contraceptives on HDL-C depended on its formulation [9]. Decreased plasma LDL-cholesterol  (LDL-C) has also been reported [10]. There have been no studies con- ducted among women  in  Iraq on  the  effects of combined oral contracep- tives  (COCs)  on  plasma  lipids  and  lipoproteins. Therefore,  in  this  study  we aimed:  to  evaluate  the  concentra- tions  of TG,  total  cholesterol  (TC),  HDL-C, LDL-C and VLDL in women  in Basra who were using a  low dose of  a combined oral contraceptive pill in relation  to  those not using  these pills;  and to clarify the relationship between lipid profile changes and the duration of using these contraceptives. Methods Study setting A cross-sectional  study was conducted  in Basra Maternity and Child Hospital  over a period of 7 months, from 1 Octo- ber 2001 to 31 May 2002. Study sample The sample was drawn from women attending the family planning centre of  the Basra Maternity Hospital. User  group:  This  included  100  women , who took combined oral con- traceptive pills (30 μg ethinyl estradiol  and 150 μg  levonorgestrel). Their ages  ranged from 15–45 years (women over  45 years were excluded) and the dura- tion of using combined oral contracep- tives  ranged  from 1–60 months. The  pills that were used in the present study were Micrognon, containing 30 μg eithi- nyl estradiol and 150 μg levonorgestrel.  These were the only pills available the centre at the time of the study. Non-user group: This included 100  apparently healthy women not using these contraceptive pills. All women agreed to participate and  there were no drop-outs. The women (users and non-users)  were classified into 3 groups according to their age. The user group were also categorized into 5 groups according to their duration of using these pills. From each woman,  full  information  was obtained  that  included: name, age,  occupation, well as the following question  about not receiving medical treatment and had no diseases of diabetes mellitus,  coronary  heart  disease,  hypertension  and chronic  renal  failure. Women with  these conditions were excluded. For each woman, 5 mL of  venous  blood were collected after 12–14 hours  of fasting. Serum concentrations of TC,  TG, HDL-C (after precipitation with  sodium phosphotungstate–magnesium chloride) were determined enzymati- cally using kits from BioMérieux, France.  All procedures were followed according  to the instructions of the manufacturer. LDL-C and VLDL serum concentra- tions were calculated using Friedewald formulae [11]: LDL-C = TC–(HDL-C  + TG/5) and VLDL = TG/5. The above formulae are applicable when serum TG  level  is < 400mg/dL.  Quality control  sera  from BioMérieux  were included in each assay batch for all the above analytes. The inter-assay coefficient of variation was 4%  for TC  and TG and 6% for HDL-C. Statistical analysis Statistical analysis with each group of subjects was performed by analysis of variance (ANOVA), and the results are  expressed as mean [standard deviation  (SD)]. P < 0.05 was considered statisti- cally significant. Results Table 1 shows the characteristics of the 2 groups. Table 2  shows  the effect of age on  plasma lipids and lipoproteins in the studied groups. Mean serum concentra- tions of TG, VLDL and HDL-C were  significantly higher in the oral contra- ceptive user group compared with the non-user group (P < 0.01), while serum  LDL-C level was significantly  lower (P < 0.01). However, the concentration of  total serum cholesterol was not signifi- cantly altered (P > 0.05). This was true  for in age groups and overall. For the 3 age groups of oral con- traceptive users,  there was a significant  elevation  of  serum  TG,  VLDL  and  HDL-C levels with advancing age (P < 0.01). However, serum LDL-C level sig- nificantly decreased with age (P < 0.01),  but there were no significant changes in the serum TC levels (P > 0.05). There  were no significant relationships among non-users. Book 17-9.indb 685 9/6/2011 12:43:11 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 686 Table 3 shows the effect of duration of contraception use on plasma lipids and lipoproteins in the studied groups. Serum concentrations of TG, VLDL  and HDL-C were significantly higher in users than non-users in all categories of duration of use, even in users of 1–12  months (P < 0.01), while serum LDL-C  level were significantly lower. Serum total cholesterol level however was not significantly different (P > 0.05). Table 4 shows the multivariate analysis of the correlation between age,  duration and lipoprotein levels. There was a significant positive correlation be- tween age and duration of contraception use and mean levels of TG, VLDL and  HDL-C concentrations (P < 0.01) and  a significant negative correlation with concentration of LDL-C (P  <  0.01),  while, the mean level of TC concentra- tion did not correlate significantly with either  age or duration  (P  >  0.05).  In  addition, LDL-C showed a  significant  positive correlation with TC (P < 0.01)  and significant negative correlation with TG, VLDL  and HDL-C  (P  <  0.01).  On  the other hand a  significant posi- tive  correlations  (P<0.01) was  found  among TG, VLDL and HDL-C in the  user group. Discussion Our results showed serum TG, HDL-C  and VLDL levels were significantly higher in all user groups compared with non-users but the LDL-C level was significantly  lower.  Furthermore, TG,  HDL-C and VLDL levels increased with age and duration of  contraceptive use,  while LDL-C levels decreased. However,  serum total cholesterol levels did not dif- fer between the groups nor change with age or length of contraceptive use. Our results  for  serum total choles- terol are consistent with some other Table 1 Characteristics of the oral contraceptive users and nonusers Variable Oral contraceptives Non-users (n = 100) Users (n = 100) Age (years) 15–24 12 20 25–34 41 35 35–45 47 45 Mean age (SD) 33.2 (7.1) 32.5 (8.1) Duration of contraception use (months) 1–12 – 36 13–24 – 16 25–36 – 14 37–48 – 13 49–60 – 21 Mean (SD) duration – 28.2 (21.6) Mean (SD) no. of pregnancies 5.2 (1.9) 5.6 (2.1) Mean (SD) blood pressure (mmHg) Systolic: 113.8 (52) 112.5 (6.8) Diastolic 83.7 (5.1) 82.4 (4.7) Mean (SD) weight (kg) 66.8 (9.2) 65.4 (7.3) SD = standard deviation. Table 2 Effect of age on lipoprotein level in users and nonusers oral contraceptive pills by age group Age group (years)/ User status No. Total cholesterol HDL-C LDL-C TGs VLDL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL 15–24 User 12 172 (31.9) 55 (9.3)**a,b 97.4 (15.5)**a,b 106 (11.2)**a,b 21.4 (3.1)**a,b Non-user 20 176 (22.2) 46 (9.4) 113 (14.47) 89.5 (16.6) 18 (3.8) 25–34 User 41 174 (23.3) 65 (10.5)**a,b 83 (16.5)**a,b 119 (13.5)**a,b 24 (2.5)**a,b Non-user 35 183 (23.8) 48 (10.8) 118 (177) 97 (14.1) 19.5 (3.7) 35–45 User 47 177 (20.5) 74 (10.9)**a,b 67 (15.23)**a,b 148.6 (12.3)**a,b 29.9 (3.1)**a,b Non-user 45 186 (28.1) 46.3 (11) 122 (17) 103 (12.7) 20.8 (4.1) **P < 0.01 aSignificance between oral contraceptive users and control group. bSignificance between the three age groups in oral contraceptive users. HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TGs = triglyceride; VLDL = very low-density lipoprotein; SD = standard deviation. Book 17-9.indb 686 9/6/2011 12:43:11 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 687 studies [12,13], whereas one study  re- ported a significant increase in serum TC levels associated with the use of low-dose combined contraceptive pills [14]. A possible  explanation of  these  different results could be the regulation of  serum cholesterol, which  is affected  by its rate of synthesis or LDL receptor activity or its ability to be converted into bile  acid  [15]. Therefore,  the use  of low-dose combined oral contracep- tives might have a negligible effect on cholesterol homeostasis. However, ate  the same time cholesterol has a strong positive correlation with LDL-C. The higher serum TG level in users and the increase in serum TG levels with increasing age and length of con- traceptive use imply that low doses of estrogen  increase  serum TG, which  is  mainly present  in VLDL.  It has been  suggested that the TG changes are due to the induction by estrogens of a he- patic microsomal enzyme that limits the rate of TG synthesis. These changes are usually no longer detectable a few months  after  stopping  treatment  [7].  The significant positive correlation between age and TG could be attrib- uted to the long-term use of estrogen- containing contraceptive pills and this is supported by the strong positive cor- relation between duration of use and TG levels. The increase in serum VLDL and HDL-C levels and decrease in LDL levels in the user group compared to non-users,  and  the  changes with  age  and duration of use may be explained by the effect of estrogen on these lipo- proteins. This elevates liver lipogenesis which causes  increases  in TG, VLDL  and HDL-C levels [7] and also causes  an increase in the synthesis of hepatic LDL-C receptors and a resulting in- crease in the removal of serum LDL-C and hence reduction  in  its  levels  [15].  The positive correlation of age with VLDL and HDL-C illustrated by prolonged consumption of estrogen is reinforced by the strong positive cor- relation of duration with VLDL and HDL-C. On the other hand, the inverse cor- relation of LDL-C with both age and duration can be attributed to the effect of  prolonged estrogen use. A recent study  suggested that the estrogen-induced LDL-C lowering effect resulted from enhancement of LDL receptor activ- ity  [7].  It has  also been  reported  that  estrogen can reduce dietary cholesterol absorption by 6% to 10%, but this small  Table 3 Effect of duration on lipid profiles in users and nonusers of contraceptive pills Duration of use (months) No. Total cholesterol HDL-C LDL-C TGs VLDL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL Mean (SD) mg/dL 1–12 36 173 (28.7) 56 (8.9)**a,b 99.4 (13.84)**a,b 101 (15.1)**a,b 20 (3.12)**a,b 13–24 16 174 (27.6) 64 (9.6)**a,b 86.8 (16.43)**a,b 113 (14.2)**a,b 22.7 (2.68)**a,b 25–36 14 175 (22.4) 72.3 (5.6)**a,b 76 (15.35)**a,b 125.8 (13.1)**a,b 25.3 (2.8)**a,b 37–48 13 177 (29.1) 78.7 (6.7)**a,b 63 (17.21)**a,b 140 (13.3)**a,b 28 (2.5)**a,b 49–60 21 178.4 (27.2) 85.6 (5.9)**a,b 51 (13.92)**a,b 152 (11.2)**a,b 31 (3.4)**a,b Nonusers 100 181 (25.7) 46.7 (10.3) 117 (18.9) 96 (16.1) 19 (3.8) **P < 0.01. aSignificance between oral contraceptive users and control group. bSignificance between duration groups in oral contraceptive users. HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TGs = triglyceride; VLDL = very low-density lipoprotein; SD = standard deviation. Table 4 Correlation between age, duration and lipid profile Parameter Age (years) Duration (months) Total cholesterol (mg/dL) HDL-C (mg/dL) LDL-C (mg/dL) TGs (mg/dL)L VLDL (mg/dL) r r r r r r r Age 1.000 0.92** 0.142 0.867** –0.767** 0.887** 0.888** Duration 0.92** 1.000 0.102 0.806** –0.719** 0.736** 0.738** Cholesterol 0.142 0.102 1.000 0.284 0.65** 0.195 0.187 HDL-C 0.867** 0.806** 0.284** 1.000 –0.610** 0.731** 0.729** LDL-C –0.767** –0.719** 0.65** –0.610** 1.000 –0.726** –0.732** TGs 0.887** 0.736** 0.195 0.731** –0.726** 1.000 0.996** VLDL 0.888** 0.738** 0.187 0.729** –0.732** 0.996** 1.000 **Correlation is significant at P < 0.01 (2-tailed). HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TGs = triglycerides; VLDL = very low-density lipoprotein. Book 17-9.indb 687 9/6/2011 12:43:11 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 688 decrease does not seem to contribute greatly to the LDL-C lowering effect of estrogen [16]. There are marked differences be- tween countries in patterns of contracep- tive use both in types and extent of use [17]. These differences reflect availability  and accessibility as well as social and cul- tural  attitudes  towards  fertility control,  sexuality and roles of women in society [18]. What is important is that any con- traceptive used should not adversely affect  the health of  the user. Our find- ings of  a  significant  rise  in TG, VLDL  and HDL-C and significant decrease in LDL-C levels, with no significant altera- tion in the serum cholesterol level among women using low-dose combined oral contraceptive pills suggest that the use of these pills may decrease the risk of coronary heart and other heart diseases. References Glasier A. Contraception. In: Edmonds DK, ed. 1. Dewhurst’s textbook of obstetrics and gynaecology for postgraduates, 6th ed. London, Blackwell Science, 1999:374. Guillebaud J. 2. Contraception: your questions answered, 2nd ed. Edinburgh, Churchill Livingstone, 1993. Burkman RT et al. Current perspectives on oral contraceptive 3. use. American Journal of Obstetrics and Gynecology, 2001, 185(2 Suppl.):S4–12. Hatcher RA et al. 4. The essentials of contraceptive technology. Baltimore, Johns Hopkins School of Public Health, Population Information Program, 1997:1–28. Moore JG. Contraception and sterilization. In: Hacker NF, 5. Moore JG, eds. Essentials of obstetrics and gynecology, 2nd ed. Philadelphia, WB Saunders Company, 1992:453-467. Fotherby K. Twelve years of clinical experience with an oral 6. contraceptive containing 30 micrograms ethinyloestradiol and 150 micrograms desogestrel. Contraception, 1995, 51:3–12. Warren MP. Metabolic effects of contraceptive steroids. 7. Amer- ican Journal of the Medical Sciences, 1973, 265:4–21. Nash AL, Cornish EJ, Hain R. Metabolic effects of oral con-8. traceptives containing 30 micrograms and 50 micrograms of oestrogen. Medical Journal of Australia, 1979, 2:277–281. Straznicky NE et al. A study of the interactive effects of oral 9. contraceptive use and dietary fat intake on blood pressure, cardiovascular reactivity and glucose tolerance in normoten- sive women. Journal of Hypertension, 1998, 16:357–368. Akerlund M. Clinical experience of a combined oral contra-10. ceptive with very low dose ethinyl estradiol. Acta Obstetricia et Gynecologica Scandinavica. Supplement, 1997, 164:63–65. Cong KJ, Wang TT, Liu GR. Lipid metabolism and pregnancy 11. induced hypertension. Zhonghua Fu Chan Ke Za Zhi, 1994, 29(11):561–563, 697–698. Kasule J et al. Evaluation of combined oral contraceptive pill 12. in black Zimbabwean women. Central African Journal of Medi- cine, 1999, 37:403–409. Esrobar-Morreal H, Lasuncien M, Sancho J. Treatment of hir-13. sutism with ethinyl estradiol contraceptive pills. Fertility and Sterility, 2000, 74:816–819. Chen JK et al. A pharmacodynamic and pharmacokinetic study 14. of the Chinese No. 1 pill. Contraception, 1990, 42:439–453. Burtis CA, Ashwood ER. 15. Teitz textbook of clinical chemistry, 2nd ed. Philadelphia, WB Saunders Company, 1994:1002–1093. Karjalainen A et al. Mechanisms regulating LDL metabolism 16. in subjects on peroral and transdermal estrogen replacement therapy. Arteriosclerosis, Thrombosis, and Vascular Biology, 2000, 20:1101–1106. Mintzer M. Contraception. In: Sloane PD, Slatt LM, Baker RM, 17. eds. Essentials of family medicine. Baltimore, Williams and Wilkins, 1988:175–176. Leridon H. Fertility and contraception in 12 developed coun-18. tries. Family Planning Perspectives, 1981, 13:93–102. Book 17-9.indb 688 9/6/2011 12:43:11 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 689 Educational needs assessment for men’s participation in perinatal care M. Simbar,1 F. Nahidi,1 F. Ramezani-Tehrani 2 and A. Akbarzadeh 3 ABSTRACT To assess men’s educational needs to improve their involvement in perinatal care we carried out a descriptive, cross-sectional study on 400 women seeking perinatal care in Shahid Beheshti University of Medical Sciences hospitals and 400 men who were accompanying them. Participants were recruited using a quota sampling method. A questionnaire was used to collect information on demography, men’s educational needs and attitude assessment. The mean attitude score was 79.13% (SD 10.5%). More than 95% of participants agreed with perinatal care education for men and the content most required was “Signs of risks during the perinatal period” and “Mothers’ nutrition”. The majority of participants preferred the face-to-face couples’ counselling method, at home as the best place, evening and weekends as the best time and marriage classes as the best time for initiation. Men’s education is necessary to promote male involvement in perinatal care. 1Department of Reproductive Health; 2Reproductive Endocrinology Research Centre; 3Department of Biostatistics, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to M. Simbar: msimbar@sbmu.ac.ir, msimbar@yahoo.com; masoumeh. simbar@gmail.com). Received: 15/09/09; accepted: 25/01/10 ةدلاولاب ةطيحلما ةترفلا في ةياعرلا في ينكراشلما لاجرلل ةيميلعتلا تاجايتحلاا مييقت هداز بركأ اضيرلع ،نيارته نياضمر ةميهف ،يديهان ةمطاف ،برميس ةموصعم ةسارد نوثحابلا ىرجأ ،ةدلاولاب ةطيحلما ةترفلا في ةياعرلا في ةكراشلما لىع متهردق ينستح لجأ نم لاجرلل ةيميلعتلا تاجايتحلاا مييقتل :ةـصلالخا اوناك لجر ةئم عبرلأو ،ةيبطلا مولعلل يتشبه ديهشلا ةعماج تايفشتسم في ةدلاولاب ةطيحلما ةياعرلا َنْسَمَتلا ةأرما ةئم عبرلأ ةضرعتسم ةيفصو ةيميلعتلا تاجايتحلااو ،ةيفارغوميدلا تامولعلما عملج نايبتسا مدخُتساو .يبسنلا ناَِيتْعلاا ةقيرطل ًاقفو ثحبلا في نوكراشلما َجِرْدُأ .نهتبحصب فيقثت ةروضر لىع ينكراشلما نم %95 نم رثكأ قفاو دقو .)%10.5 يرايعلما فارحنلاا( %79.13 فقولما زاَرْحأ طسوتم ناك .فقولما مييقتو ،لاجرلل فيو ،»ةدلاولاب ةطيحلما ةترفلا ءانثأ راطتخلاا تاملاع« :في اهيلع زيكترلا بلُط يتلا تاعوضولما رثكأ تلَّثتمو ،ةدلاولاب ةطيحلما ةياعرلا لوح لاجرلا عوبسلأا ةيانه تلاطع وأ ءاسلماو ،ناكم لضفأك لزنلماو ،هجول ًاهجو ينجوزلا لىإ ةروشلما ميدقت بولسأ ينكراشلما ةيبلاغ ل َّضَفو .»تاهملأا ةيذغت« ًادج يروضر لاجرلا ميلعت نأ لىع ةساردلا تّلد دقو .ميلعتلا اذه ءدبل تقو لضفأك جاوزلاب ةصالخا ةيساردلا صصلحاو ،كلذل تقو لضفأك .ةدلاولاب ةطيحلما ةياعرلا في روكذلا ةكراشم زيزعتل évaluation des besoins en formation des hommes pour leur participation aux soins périnatals RÉSUMÉ En vue d’améliorer l’implication des hommes dans les soins périnatals, nous avons conduit une étude descriptive et transversale portant sur 400 femmes consultant pour des soins périnatals dans les hôpitaux de l’Université des sciences médicales Shaheed Beheshti (République islamique d’Iran), et sur les besoins en formation des 400 hommes les accompagnant. Les participants ont été recrutés à l’aide d’une méthode de sondage par quotas. Un questionnaire a été utilisé pour collecter les données démographiques ainsi que les besoins en formation des hommes et évaluer leur attitude. Le score moyen concernant les attitudes était de 79,13 % (E.T. 10,5 %). Plus de 95 % des participants approuvaient l’idée d’une formation en soins périnatals destinée aux hommes. « Les signes de risque pendant la période périnatale » et « la nutrition maternelle » étaient les thèmes les plus demandés. La majorité des participants préférait recevoir des conseils en rendez-vous de couple, à domicile, en soirée et pendant les weekends. Les cours sur le mariage étaient considérés comme le meilleur moment pour débuter. Les hommes doivent recevoir une formation pour les encourager à s’impliquer dans les soins périnatals. Book 17-9.indb 689 9/6/2011 12:43:12 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 690 Introduction Acceleration  in decreasing of mater- nal mortality has been announced as the top priority of reproductive health programmes  by  the  World  Health  Organization  [1]. Nowadays, men’s  participation in maternal health care is considered a strategy for decreasing maternal mortality, however, men are  not seen in maternal services and do not have access to the information nec- essary for making informed decisions about protection and improvement of maternal health [2]. Men can participate  in maternal health by being involved in safe motherhood programmes. They can actively participate  in:  contracep- tive use,  child  limitation and  spacing,  ensuring  childbirth  is  attended  by  skilled health personnel, neonatal care  during the postpartum period, playing a  responsible role in the family and elimi- nating violence against women [3]. The  Population Council reported successful  male involvement in prenatal care in the programme on men’s role in India and  South Africa [4].  There are gaps in our knowledge about the role of the father in the family,  especially in the perinatal period. Expect- ant fathers can play roles such as coach,  witness or assistant in perinatal care and are able to learn participation through education [5]. In addition, fathers need  to adapt to their new role as parents, and  it is sometimes more difficult for them because they are usually ignored by the family and by health personnel [6]. Edu- cation to promote men’s participation has positive effects on maternal and neonatal care as evidenced in different countries.  In  Indonesia education  im- proved men’s knowledge and prepared them to help in the process of childbirth [7].  In Turkey,  education  about  the  role of family members in perinatal care led to improvement in the participants’ knowledge, attitudes and practices  re- garding  reproductive health, mainly  in  the  area of  family planning, neonatal  health,  breastfeeding  and  supporting  their wives. The authors recommended culturally appropriate prenatal educa- tion free of charge for groups of men [8,9]. Men’s  education  in  India  was  mentioned as a contributor in the suc- cess of a maternal health programme [10].  In El Salvador, men’s participa- tion in a prenatal care programme was considered a new opportunity for men to be involved in their own and their family’s health  improvement  [11]. An  Egyptian study showed that family plan- ning counselling with couples during the antenatal period had a positive effect on couples’ knowledge and practice [12]. Men’s participation in breastfeed- ing programmes increased the rate and continuity of breastfeeding [13] Men’s  education had positive effects on spous- al communication and their parental roles [14]. There have been a few studies  in  Iran  to assess male participation  in  family planning programmes [15–17]  but their participation in perinatal care programmes has been less studied even though male participation has recently been emphasized to achieve Millen- nium Development Goals such as im- proving maternal health, gender equity,  decreasing child mortality,  eliminating  illiteracy and eradicating diseases as well as  the objectives of  the  International  Conference  on  Population  and De- velopment  [18–20]. Therefore, men  require educational programmes for their participation. This study aims to assess educa- tional needs for men’s participation in perinatal care as a base  for an effective,  culturally  appropriate,  acceptable  and  feasible education. Methods This was a cross-sectional study and the quantitative part of a sequential qualita- tive–quantitative triangulation research strategy to assess men’s educational needs for participation in prenatal care. The qualitative part of the study was performed using focus group discussions (FGD) [21]. Eight groups  of  clients of SBMU perinatal  services  (including 4 groups of women and 4  groups of men) participated  in FGDs.  A  semi-structured questionnaire with  7 guide questions was used. The aim of FGDs was exploration of hidden opin- ions of the community and to design an appropriate questionnaire for this study (quantitative part). Using  a  non-randomized  quota  sampling method, 800 subjects (includ- ing 400 male and 400 female subjects)  participated in the study from May 2008 to January 2009. The sample size  was calculated using the formula for descriptive  studies  [22]. The partici- pants were clients of perinatal services (prenatal care services and postpartum  wards) of Mahieh, Taleghani, Shohada  and Emam-Hosein hospitals of Shahid Beheshti University  of Medical  Sci- ences. Women were interviewed in the  prenatal care clinic or postpartum care units and men were interviewed in the waiting rooms after a detailed explana- tion about the aims and procedure of the study and  taking a written consent  for their participation. The tool for data collection was a structured  questionnaire,  which was  developed  after  content  analysis  and  extraction of the statements from the results of the qualitative part of the study [21]. The  questionnaires  were  com- pleted by interview and there were no drop-outs among the participants of the study, nor were  the data  incomplete  in  any of the questionnaires. All interviews  were performed by a trained midwife. She carried out the interviews on work- ing days and continued until completing of sampling process. There were only 5 cases of refusal for participation. The questionnaire included 3 sec- tions:  demographic  (12  questions),  educational  needs  assessment  (22  questions), and a Likert  scale  to assess  attitude  towards  male  participation  (30  statements). Each questionnaire  required 45 minutes to be completed. Book 17-9.indb 690 9/6/2011 12:43:12 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 691 The content and face validity of the questionnaire were assessed by 10  re- productive health experts. The reliability of the questionnaire was assessed using test  retest  and half  splitting methods  and was  confirmed by 0.92  and 0.96  correlation coefficient,  respectively. To  assess test retest reliability, 15 question- naires were  filled up by 20 male  and  female participants twice with a 1-week interval. Cronbach alpha coefficient of 0.87 confirmed  the  reliability of  the  questionnaire. The aims and the procedure of the study were explained to the participants,  and  their  written  consent  was  given  before  the  interviews. Approval of  the  ethical  committee of Shahid Beheshti  University of Medical Sciences was ob- tained for the study. To  calculate  attitude  score,  each  statement  scored 0,  1 or 2  (disagree,  neutral  and agree),  respectively. Then  the sum of the scores was calculated as a percentage. Scores 0%–33%, 34%–66%  and 67%–100% were classified as nega- tive, neutral and positive attitude respec- tively. The data were analysed using SPSS,  version 16, using  the  t-test,  analysis of  variance  (ANOVA) and  chi  squared  tests with 95% confidence interval.  Results Demographic characteristics of the par- ticipants are presented in Table 1. The mean age of  the 800 participants was  28.32  [standard deviation (SD) 5.51;  95% CI: 17–42] years.  The  mean  attitude  score  of  the  participants was 79.13 (SD 10.52. The  t-test demonstrated men had a signifi- cantly higher attitude  score, 82.4 (SD  Table 1 Demographic characteristics of male and female participants in selected hospitals of Shahid Beheshti University of Medical Sciences, 2009 Characteristic Females (n = 400) Males (n = 400) Total (n = 800) Mean (SD) Mean (SD) Mean (SD) Age 26.79 (5.23) 29.86 (4.45) 28.32 (5.51) No. of children 1.12 (0.99) 1.07 (0.67) 1.09 (0.88) Size of family 3.42 (1.54) 3.21 (0.76) 3.31 (1.22) No % No % No % Education Illiterate 28 7.0 28 7.0 56 7.0 Primary school 67 16.5 100 25.0 167 20.9 Middle school 52 13.0 66 16.5 118 14.8 High school 220 55.0 162 40.5 382 47.8 University 33 8.5 44 11.0 77 9.6 Employment Unemployed/householder 384 96.0 0 0.0 384 48.0 Labourer 7 1.5 120 30.0 127 15.9 Office personnel 4 1.0 120 30.0 124 15.5 Teacher 4 1.0 0 0.0 4 0.5 Small business 1 0.5 160 40.0 161 20.1 Accommodation Rented 241 60.5 292 73.0 533 66.6 Owned 110 27.5 68 17.0 178 22.3 Living in family home 49 12.2 40 10.0 89 11.1 Monthly income (US$) 0 4 0.5 0 0.0 4 0.5 < 150 387 96.8 2 0.5 389 48.6 150 to < 300 3 0.5 152 38.0 155 19.4 300 to < 500 6 1.5 234 58.5 240 30.0 500 to < 1000 0 0.0 8 2.0 8 1.0 > 1000 0 0.0 4 1.0 4 0.5 SD = standard deviation. Book 17-9.indb 691 9/6/2011 12:43:12 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 692 8.2),  compared with women,  with  a  score of 57.87 (SD11.48) (P < 0.01).  As  shown  in Table 2,  the  statements  “Education about perinatal care is nec- essary for both mothers and fathers” and  “Pregnant mothers need  a  lot of  emotional support during pregnancy” had the highest rates of agreement. High rates of disagreement were recorded for the statements “Men’s involvement is not necessary because pregnancy and childbirth  is  the mother’s  job”,  “Men’s  participation is not common in our so- ciety” and “Men’s participation is not usual in our family”. The participants were also asked about  the desired educational content;  their responses are summarized in Table 3. The highest rates of agreement were for the content of “Signs of risks during pregnancy”, “Postpartum complications”  and “Mother’s nutrition”. The highest rates  of  disagreement were  for  “Baby  bathing” and “Baby nappy changing”.  Table 4  shows  the attitude of par- ticipants about the features of education sessions. The most frequent sugges- tion  for  place was  at  home,  for  time  was weekend and evening, for educator  was  female or midwives,  for method  was couples’ face-to-face and using self-learning booklets. The best time to initiate the education programme was thought to be premarital classes. The suggested education duration was 4.96 (SD 6.96;  range 1–45) h  for  Table 2 Distribution of participants (n = 800) according to attitude towards men’s participation in perinatal care in selected hospitals of Shahid Beheshti University of Medical Sciences Statement Agree Neutral Disagree No. % No. % No. % Education on prenatal care is necessary for both, fathers and mothers 793 99.1 1 0.1 6 0.8 Pregnant mothers need a lot of emotional support during pregnancy 791 98.9 1 0.1 8 1.0 The media can promote male participation in maternal health 781 97.6 5 0.6 14 1.8 He(I) provide(s) my(her) favourite food as soon as possible 779 97.4 3 0.4 18 2.2 Fathers should have perinatal leave for participation in the birth 775 96.9 3 0.4 22 2.8 Fathers should be allowed to attend prenatal visits 771 96.4 7 0.9 22 2.8 Fathers would participate if they had perinatal leave 763 95.4 5 0.6 32 4.0 He(I) help(s) because the child belongs to us both 760 95.1 3 0.4 36 4.5 He(I) care(s) about my (her) nutrition during pregnancy 749 93.6 5 0.6 46 5.8 Movies and TV serials may contribute in promotion of men’s participation 724 90.5 5 0.6 71 8.9 He(I) care(s) about the signs of risks during the pregnancy 709 88.6 1 0.1 90 11.2 He(I) like(s) to accompany me (her) in the visits 707 88.4 1 0.1 92 11.5 He(I) remind(s) me(her) about taking iron and vitamins 626 78.6 7 0.9 164 20.5 Her(my) family encourage me(him) to help her(me) during pregnancy 578 72.2 14 1.8 208 26.0 Consent for women’s discharge from hospital should be conditional on the father having received perinatal health care education 551 68.9 21 2.6 228 28.5 Community leaders can promote male participation 524 65.5 81 10.1 195 24.4 He(I) smoke(s) beside me(her) during pregnancy 484 60.5 7 0.9 386 39.0 He(I) do(es) not know how to help 433 54.1 7 0.9 360 45.0 Women raised children without help in past 408 51.0 2 0.4 389 48.6 Wives have no job except household and self care 346 43.2 8 1.0 446 55.8 Husbands who help are called “wife’s servant” 338 42.2 9 1.1 453 56.6 He(I) help(s) when his(my) family is not present 336 42.0 14 1.8 450 56.2 His(my) friends encourage him(me) to help me(my wife) 214 26.8 42 5.2 544 68.0 He(I) is(am) always too tired to help me (my wife) 208 26.0 7 0.9 583 73.1 He(I) work(s) so long and has(ve) no opportunity to help me(her) 208 26.0 1 0.1 591 73.9 Neonatal care is not men’s job 134 16.8 13 1.6 653 81.6 He(I) is(am) too busy and so has(ve) no mood to support me(her) emotionally 116 14.5 5 0.6 679 84.9 Help to a pregnant mother is not usual in his(my) family 96 12.0 3 0.4 701 87.6 Help to a pregnant mother is not usual in our community 86 10.8 3 0.4 711 88.9 He(I) do(es) not help in the perinatal period because it is a woman’s job 56 7.0 7 0.9 737 92.1 Book 17-9.indb 692 9/6/2011 12:43:12 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 693 prenatal  sessions  and 4.95  (SD 7.19;  range 1–50) h for the postnatal period.  The great majority (95.0%) of partici- pants believed men like to participate and 94.8% stated that men were practi- cally involved in perinatal issues; 65.0%  also stated that expectant fathers need care for emotional adaptation to father- hood. There were no significant differences between attitude scores of participants  according  age  group  (ANOVA  F  =  1.32; P = 0.26) but  there was a statisti- cally significant difference by education level  (ANOVA F  = 2.58; P  = 0.036).  The Tukey test showed that the illiterate group had a significantly lower score compared  to  the groups with primary,  middle and secondary school education as well as university-educated partici- pants (P < 0.05). Discussion This is the first study to assess educa- tional needs of men’s participation in perinatal  care  in  the  Islamic Republic  of  Iran. Male participation  to  improve  maternal health is highly emphasized in  the declaration of  the  International  Conference  on  Population  and De- velopment in Cairo in 1994 and is considered a strategy to achieve the Mil- lennium Development Goals [18,19].  The results showed the positive at- titude of participants towards men’s participation in perinatal care and that the majority believed that education is necessary for both mothers and fa- thers and they thought men did not know how  to  help;  this means  there  is  a  demand  for men’s  education.  It  has frequently been documented that men’s education has positive effects on maternal and neonatal health [7–14]. The majority of participants stated that pregnant mothers need a lot of emotional support. In fact, the perinatal  period is a time for parental adapta- tion to the role of parent and is an op- portunity for health personnel to make the couple prepared for parenthood. Pregnant mothers experience different  emotional physiologic changes which needs as much care as the physical changes do [5,6]. The rate of depression  among pregnant mother is reported to be high and it seems that giving neces- sary education about emotional sup- port has resulted in a decrease in related complications [23]. It should be noted  that  not  only  pregnant mothers,  but  also expectant fathers experience psy- chological  problems  [24]. Therefore,  men’s education seems to be necessary for their own adaptation to fatherhood. There are educational classes for par- ents in many countries: in Scandinavian  countries 95% of  fathers participate  in  such classes [25]. The high rate of agreement with the statement of  “He (I) help(s) because  the child belongs to both” and high rate of disagreement with the 3 statements “He(I) do(es) not help in perinatal be- cause  it  is women’s work”,  “Help  to a  pregnant mother is not usual in his(my)  family” and “Help to a pregnant mother is not usual in our community” sug- gests that helping a pregnant mother is becoming not only a subjective norm but also a family and social norm. The special attention to family arises  from  Iranian  and  Islamic  beliefs  and  culture  [26]. Besides,  it  is  emphasized  that  “Programmes  and  education  to  Table 3 Distribution of participants based on their attitude towards the educational contents for men’s participation in perinatal care in Shahid Beheshti University of Medical Sciences hospitals Educational content Agree Disagree No. % No. % Signs of pregnancy 704 88.0 96 12.0 Postpartum complications 694 86.6 106 13.2 Maternal nutrition 667 83.4 133 16.4 Pain relief for child birth 653 81.6 147 18.4 Prenatal health 630 78.8 170 21.2 Type of delivery (normal or caesarean section) 630 78.8 170 21.2 Common complications of pregnancy 629 78.6 171 21.4 Exercise during pregnancy 628 78.2 172 21.5 Emotional changes during pregnancy 624 78.0 176 22.0 Emotional support of mother 620 77.5 180 22.5 Neonatal care 611 76.4 189 23.6 Physiological changes during pregnancy 602 75.2 198 24.8 Emotional changes for paternal adaptation 565 70.6 235 29.4 Neonatal feeding and complementary food 502 62.7 298 37.2 Baby bathing 446 55.8 354 44.2 Baby napping 390 48.8 410 51.2 Book 17-9.indb 693 9/6/2011 12:43:13 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 694 engage men’s support for maternal health and safe motherhood should be developed;  all  countries  are urged  to  seek changes in high-risk sexual behav- iour and to devise strategies to ensure that men share responsibility for sexual and reproductive health” [18]. Accord- ing  to  this global  attempt  to promote  men’s participation, it is essential to im- prove their knowledge and practice by providing the required education about maternal health. However,  there  is  still  some misconception such the humour of “wife’s servant” for a husband who helps his wife, which may sometimes be  a barrier. However, the role of a man is  formed in the family and enhanced by community leaders and the media [27].  A high  rate of  agreement with  the  statements  “Broadcasting can promote  male participation  in maternal health”,  “Movies and television serials may con- tribute in promotion of men’s partici- pation” and “Community leaders can promote male participation” suggests that the media can be an effective way to promote male participation, perhaps  even more effective than community leaders. Thus mass media can help to overcome the barriers and promote the Table 4 Distribution of participants according to preferred educational needs for men’s participation in perinatal care in selected hospitals of Shahid Beheshti University of Medical Sciences hospitals Preferred educational arrangement Females (n = 400) Males (n = 400) Total (n = 800) No. % No. % No. % Place At home 203 25.4 233 29.1 436 54.5 Health centre 67 8.4 84 10.5 151 18.9 Workplace 60 7.5 34 4.2 94 11.8 Physician’s office 44 5.5 28 3.5 72 9.0 Hospital 26 3.2 21 2.6 47 5.9 Time Weekend 247 20.9 186 23.2 433 54.1 Weekday 153 19.1 219 26.8 367 45.9 Morning 86 10.8 26 3.2 112 14.0 Evening 171 21.3 240 30.0 411 51.4 Night 143 17.9 134 16.8 277 34.6 Prenatal 77 9.6 46 6.8 123 15.4 Postnatal 46 5.8 14 1.8 60 7.5 Prenatal & postnatal 277 34.6 340 42.5 617 77.1 Educator Midwife/nurse 359 44.9 390 48.8 749 93.6 Physician 41 5.1 10 1.2 51 6.4 Female 328 41.8 286 35.8 614 76.8 Male 72 9.0 114 14.2 186 23.3 Method Couple face-to-face 134 16.8 172 21.15 306 38.3 Fathers group 119 14.9 100 12.5 219 27.4 Father face-to-face 87 10.9 64 8.0 151 18.9 By telephone 2 0.2 0 0.0 2 0.3 Online 2 0.2 2 0.2 4 0.5 Self-learning booklet 14 1.8 142 17.8 156 19.5 CD 129 16.1 2 0.2 131 16.4 Initiation time Premarital classes 168 21.0 164 20.5 332 41.5 Prenatal classes 127 15.9 104 13.0 231 28.9 High school: girls and boys 99 12.4 132 16.5 231 28.9 High school: boys 6 0.89 0 0.0 6 0.8 Book 17-9.indb 694 9/6/2011 12:43:13 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 695 culture of gender equity and responsi- ble sexual and reproductive behaviour. As  a  result,  young boys  should  learn  responsible reproductive behaviour in their  families,  and young girls  should  have enough skills to have income for fi- nancial support of themselves and their future children and finally men should involve in all responsibilities of the fam- ily, including perinatal care [19,27]. The results demonstrated that the majority of men are involved in provid- ing their wives nutrition and they care about the risks of pregnancy as well as accompanying them in the visits. This was consistent with our findings about preferred educational content, viz  signs  of risks and mothers’ nutrition. So it can be postulated that men like to learn about the subjects that they are involved in. Usually men  are  the  source of  fi- nances in the Iranian family. Education  about signs of risks and nutrition is nec- essary to make proper and timely deci- sions, which certainly lead to a decrease  in maternal and neonatal morbidity and mortality. Our results suggest men prefer cou- ples’  face-to-face  education, which  is  also  recommended  by  experts  [5,6].  The husband’s understanding and in- volvement are necessary, however,  the  inability of the husband to accompany the wife during perinatal care and coun- selling may arise from the system of the  service provider:  some do not  let  husbands attend as shown in this study  and a study  in Saudi Arabia [28]. So  it  is time to reorient the perinatal services based on the demand of the clients and provide a system with a defined place for counselling both mother and father together. Nowadays, prenatal  services  are called family-friendly services [25].  The results also indicate that men have a preference for self-learning book- lets and are interested in being educated at home during the evening or at the weekend. This may be due to weekdays being busy. Educational materials (e.g.  pamphlets,  brochures  and  booklets)  have been suggested to improve repro- ductive health services in other studies in  the  Islamic Republic  of  Iran  [29].  A  study  in  Scandinavia  also  showed  men liked to be educated using online services. So it can be recommended that couples or men be educated about 4–6 hours in prenatal and postnatal visits separately and complementary in- formation can be packaged in the form of booklets, CDs or other educational  aids and to be sent home for self-study. There is no doubt that the services should be evaluated periodically regard- ing their cost effectiveness, efficacy and  efficiency. The majority of participants agreed with the statement “Fathers should have perinatal leave for the participation” and believed that they would use it. How- ever, other research has shown men do  not use it even if they have the right be- cause it may increase their vulnerability in the workplace [27]. Most participants believed that edu- cation about male participation should be started from high school and it sug- gested  that knowledge and attitude of  both sexes towards male participation in reproductive health should be addressed before marriage  [27]. Participation  in  maternal health education could be ini- tiated from premarital classes: there are  strategic programmes for parenthood education and men’s involvement in reproductive health in many countries [30]. Male education about parenthood  responsibilities could be considered in premarital  classes,  and details about  male involvement in maternal health could be provided in perinatal classes. Although a majority of subjects claimed  that men participate  in perinatal  care,  the extent of their activities and average time that they spend are not clear. There was no association between age of participants  and attitude  score,  however illiterate participants had a statistically  significantly  lower attitude  score compared to other groups and this finding was consistent with other studies [15]. The only significant limitation of this study was that male participants were accompanying husbands of the clients. Although some husbands had to attend  hospital  for women’s discharge,  some  attended of  their own will. Therefore  population-based studies are suggested in similar future studies. The future stud- ies should also consider educational interventions to find the most effective educational strategies to improve men’s participation in reproductive health programmes. Acknowledgement We are grateful to the research secretary  of Shahid Beheshti University of Medi- cal Sciences for funding this study. References World Health Organization. Strategy to accelerate progress 1. towards the attainment of international development goals and targets related to reproductive health. Reproductive Health Matters, 2005, 13(25):11–18. Programming for male involvement in reproductive health2. . Re- port of the meeting of WHO Regional Advisers in Reproduc- tive Health WHO/PAHO, Washington DC, USA5–7 September 2001. World Health Organization, Geneva, 2002. Drennan M, Robey B. 3. Reproductive health, new perspectives on men’s participation. Baltimore, Johns Hopkins School of Public Health, 1998 (Population Reports, XXVI, Series J, No. 2 ). Population Council. Maternal and child health, mixed success 4. involving men in maternal care worldwide. Population Briefs, 2005, 11(1). Lowdermilk DL, Perry SE. 5. Maternity and women health care, 8th ed. St. Louis, Mosby, 2004. Book 17-9.indb 695 9/6/2011 12:43:13 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 696 McKinney ES et al. 6. Maternal child nursing. Philadelphia, WB Saunders Company, 2000. Shefner-Rogers CL, Sood S. Involving husbands in safe moth-7. erhood: effects of the SUAMI SIAGA campaign in Indonesia. Journal of Health Communication, 2004, 9(3):233–258. Turan JM et al. Including expectant fathers in antenatal educa-8. tion programmes in Istanbul, Turkey. Reproductive Health Mat- ters, 2001, 9(18):114–25. Turan JM, Say L. Community-based antenatal education in 9. Istanbul, Turkey: effects on health behaviours. Health Policy & Planning, 2003, 18(4):391–398. Bhalerao VR et al. Contribution of the education of the pro-10. spective fathers to the success of maternal health care pro- gramme. Journal of Postgraduate Medicine, 1984, 30(1):10–2. Carter MW, Speizer I. Salvadoran fathers’ attendance at prena-11. tal care, delivery, and postpartum care. Revista Panamericana de Salud Pública, 2005, 18(3):149–156. Soliman MH. Impact of antenatal counselling on couples’ 12. knowledge and practice of contraception in Mansoura, Egypt. Eastern Mediterranean Health Journal, 1999, 5 (5):1002–1013. Wolfberg AJ et al. Dads as breastfeeding advocates: results 13. from a randomized controlled trial of an educational inter- vention. American Journal of Obstetrics & Gynecology, 2004, 191(3):708–712. Diemer GA. Expectant fathers: influence of perinatal education 14. on stress, coping, and spousal relations. Research in Nursing & Health, 1997, 20(4):281–293. Ozgoli G et al. [Male participation in family planning pro-15. grams]. Journal of Zanzan Medical Science University, 1381, 10(40):41–45 [in Farsi]. Tavoosi NM, Heidarnia A. [Effects of health education on male 16. participation in family planning]. Daneshvar, 2000, 8(30):59– 64 [in Farsi]. Movahed M, Tourajianfar H. [17. Association of sociocultural fac- tors with men’s attitude towards participation in family planning programs in Shiraz]. Tehran, Demography Association of Iran, 2007:92–110 [in Farsi]. Report of the International Conference on Population and Devel-18. opment, Cairo, 5–13 September 1994. New York, United Nations, 1995 (http://www.unfpa.org/webdav/site/global/shared/ documents/publications/2004/icpd_eng.pdf, accessed 13 July 2011). UNFPA, Interactive Population Center. 19. Recognizing and pro- moting women’s key economic roles. A new role for men.(http:// web.unfpa.org/intercenter/role4men/recognize.htm, ac- cessed 13 July 2011). Crossette B. 20. Reproductive health and millennium development. International Planned Parenthood Federation, 2011 (http:// www.ippf.org/en/What-we-do/Advocacy/Reproductive+ Health+and+the+Millennium+Development+Goals.htm, ac- cessed 11 July 2011). Simbar M et al. Fathers’ educational needs for perinatal care in 21. urban Iran: a qualitative approach. Journal of Biosocial Science, 2010, 42(5): 633–641. Dawson B, Robert G. 22. Basic and clinical biostatistics, 4th ed. New York, McGraw–Hill Company, 2004. Hoseini F et al. [Depression during pregnancy: needs to be 23. screened]. Journal of Gorgan Medical Science University, 1384, 7(1):60–65 [in Farsi]. Ghafari F, Poorghaznein T, Masloom S. [Emotional health of 24. pregnants and their husbands during pre and postnatal period in Ramsar]. Iran Journal of Obstetrics and Gynaecology, 1384, 8(2):72–80 [In Farsi]. Fatherhood and health outcomes in Europe25. . Geneva, World Health Organization, 2007. [Male participation in women empowerment]. Tehran, Wom-26. en and Family Centrer of President, 2008. (http://www. women.gov.ir/pages/content.php?id=3044, accessed 3 Au- gust 2011) [in Farsi]. Enhancing men’s roles and responsibilities in family life. A new 27. role for men. New York, UNFPA Interactive Population Centre, 2009. (http://web.unfpa.org/intercenter/role4men/enhanc- in.htm, accessed 7 June 2011). Baldo MH et al. Integrating maternal and child health with pri-28. mary health care in Saudi Arabia. Eastern Mediterranean Health Journal, 2000, 6(4):701–711. Nanbakhsh H et al. Assessment of women’s satisfaction with 29. reproductive health services in Urmia University of Medical Sciences. Eastern Mediterranean Health Journal, 2008,14(3):605– 614. Sonenstein FL. 30. Young men’s sexual and reproductive health: toward a national strategy, getting started. Washington DC, The Urban Institute, 2000 (http://www.urban.org/ UploadedPDF/410027.pdf, accessed 7 June 2011). Book 17-9.indb 696 9/6/2011 12:43:13 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 697 Effect of quinine therapy on plasma glucose and plasma insulin levels in pregnant women infected with Plasmodium falciparum malaria in Gezira state N.E.E. Elbadawi,1 M.I. Mohamed,2 O.Y. Dawod,3 K.E. Ali,4 O.H. Daoud,5 E.M. Ali,6 E.G.E. Ahmed 7 and A.E. Mohamed 8 ABSTRACT To determine if quinine has a metabolic effect during treatment of severe or complicated malaria, we studied its effects on plasma glucose and plasma insulin levels in 150 pregnant women with malaria referred to Madani maternity teaching hospital, Gezira state and 50 healthy pregnant controls. Levels were determined at baseline (day 0) before the start of quinine treatment, after 2 days of treatment (2 hours after the 4th dose) and after 7 days of treatment (day 8). There was a statistically significant increase in plasma insulin concentrations during the quinine infusion and fall in plasma glucose concentration (P < 0.001). Quinine administered at the recommended dose and rate can disrupt plasma glucose homeostasis although it is still the drug of choice for severe and complicated malaria in Sudan. 1Department of Biochemistry, 3Department of Physiology, 7Department of Medicine, University of Kassala, Kassala, Sudan (Correspondence to N.E.E. Elbadawi: noureldaim@hotmail.com). 2Department of Biochemistry, University of National Ribat, Khartoum, Sudan. 4Department of Biochemistry, International Africa University, Khartoum, Sudan. 5Department of Paediatrics, Alzaeem Alazhari University, Khartoum, Sudan. 6Department of Medicine, University of Khartoum, Khartoum, Sudan. 8Department of Biochemistry, Faculty of Medicine, University of Gezira, Wad Madani, Sudan. Received: 07/07/09; accepted: 28/01/10 ةريزلجا ةيلاو في ةّيلجنلما ايرلالماب تايِدَعْنُمـلا لماولحا امزلاب في ينلوسنلأاو زوكولغلا تايوتسم لىع يننيكلاب ةلجاعلما يرثأت نادوسلاب ،دحمأ ئرابلا مسق يرشبلا ،ليع دممح يدهلما ،دوواد نسح رمع ،ليع موتلا دلاخ ،دوواد فسوي ليقع ،دممح ليعماسإ اهم ،يودبلا نماعنلا مئادلا رون دممح رهاطلا دحمأ تايوتسم لىع هتايرثأت نوثحابلا سرد ،تافعاضمب ةبوحصلما ةميخولا ايرلالما جلاع ءانثأ بيلاقتسا لوعفم ُّيأ يننيكلل ناك اذإ ام ديدحتل :ةـصلالخا ةيلاو في ةموملأا ةياعرل يميلعتلا »نيدم« ىفشتسم لىإ ّنهتلاحإ تَّتم ،ايرلالماب تاباصلما لماولحا نم ينسخمو ةئم في امزلابلا في ينلوسنلأاو زوكولغلا ينموي دعبو ،يننيكلاب جلاعلا ءدب لبق يأ )رفص مويلا في( ةيدعاقلا تايوتسلما تَدِدُحو .دهاوشلا نم ةعومجمك ةميلس ًلاماح ةأرما ينسخم فيو ،ةريزلجا في ينلوسنلأا تازيكرت في ًايئاصحإ ابه ُّدتعُي ةدايز كانه نأ ّينبتو .)نماثلا مويلا( جلاعلا نم مايأ ةعبس دعبو ،)ْينَتعاسب ةعبارلا ةعرلجا دعب( جلاعلا ءدب نم صىولما لّدعلماو ةعرلجا بسح يننيكلا ءاطعإ نأ لىع لدي امم .)P<0.001( امزلابلا في زوكولغلا زيكرت في ضافخنا عم ًابيسرت يننيكلا ءاطعإ ءانثأ امزلابلا .نادوسلا في تافعاضمب ةبوحصلما ةميخولا ايرلالما جلاعل لضفلأا رايلخا لِّثمي لازام يننيكلا نأ عم ،امزلابلا في زوكولغلا بابتتساب َّلُِي نأ نكمي ،مابه Effet du traitement à base de quinine sur le taux de glycémie et d’insuline plasmatique chez les femmes enceintes infectées par le paludisme à Plasmodium falciparum dans l’état d’Al-Jazira RÉSUMÉ Afin de déterminer si la quinine a un effet métabolique pendant le traitement du paludisme grave ou compliqué, nous avons étudié ses effets sur les taux de glycémie et d’insuline plasmatique chez 150 femmes enceintes atteintes de paludisme et ayant été orientées vers la maternité de l’Hôpital universitaire Madani, dans l’État d’Al-Jazira, et chez 50 femmes enceintes témoins en bonne santé. Les taux ont été observés au début de l’étude (jour 0) avant l’administration du traitement à base de quinine, après deux jours de traitement (deux heures après la quatrième dose) et après sept jours de traitement (jour 8). Une élévation statistiquement significative du taux d’insuline plasmatique pendant la perfusion de quinine et une chute du taux de glycémie ont été enregistrées (P < 0,001). Le traitement par la quinine administré à la posologie et à la vitesse de perfusion recommandées peut perturber l’homéostasie glycémique. Toutefois, la quinine reste le médicament de choix pour traiter le paludisme grave et compliqué au Soudan. Book 17-9.indb 697 9/6/2011 12:43:13 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 698 Introduction Malaria is the leading cause of mor- bidity and mortality  in Sudan, with an  annual estimated 7.5 million clinical cases  and 35 000 deaths. Plasmodium falciparum is the dominant parasite and the principal mosquito vectors are Anopheles arabiensis, An. gambiae and An. fenstus  [1]. The adverse  impact of  malaria in pregnancy is largely caused by P. falciparum;  approximately  90%  of P. falciparum clinical cases globally occur in sub-Saharan Africa [2]. Malaria infection during pregnancy poses substantial risks to the mother, her  fetus and the neonate. Consequences of malaria in pregnancy include severe anaemia,  placental  parasitaemia  and  intrauterine growth  retardation, which  contribute to low birth weight, a princi- pal cause of infant mortality in the Afri- can region. Malaria is more common in pregnancy compared to in the general population.  Immunosuppression and  loss of acquired immunity to malaria could be reasons for this [3]. Atypical  manifestations  of  ma- laria are more common  in pregnancy,  particularly in the second half of preg- nancy. The most common presenting symptoms  are  fever,  anaemia,  and  splenomegaly. Complications also tend to be more common and more severe. Hypoglycaemia,  anaemia  and  acute pulmonary oedema are also more common. Jaundice, convulsions, altered  sensorium, coma, vomiting/diarrhoea  and other complications may be seen. Hypoglycaemia is a recognized compli- cation of malaria  in pregnancy, but  its  pathophysiology is not well understood [4].  It  is  thought  that  infected erythro- cytes collected in the placenta stimulate pancreatic β-cell production of insu- lin,  leading  to hyperinsulinaemia  and  hypoglycaemia during infection. This contributes to the severity of disease during pregnancy [5,6]. Malaria parasites are now resistant to many of the older antimalarial drugs (for  example, quinine). So,  since 2006,  the  World Health Organization (WHO)  has recommended that uncomplicated malaria during the second and third trimester of pregnancy is treated with short course (3 d) fixed-dose artemisi- nin combination  therapy (ACT), but  quinine is still used in early pregnancy because  it  is not known whether ACT  damages  fetal  development,  which  mainly occurs during the first 3 months [7].  Although quinine is the first drug of  choice for the treatment of falciparum malaria during pregnancy,  its  side-ef- fects can be life-threatening. Therefore monitoring of the biochemical profile in general and plasma glucose and plasma insulin is important for the mother and her fetus. In  the  present  study we  assessed  the level of plasma glucose and plasma insulin levels in pregnant women in central Sudan infected with Plasmo- dium falciparum under quinine therapy with different presentation patterns on  admission. We monitored  the  level of  parasitaemia before,  during  and  after  quinine treatment. Methods This was a cross-sectional hospital-based study. It was conducted at Madani ma- ternity  teaching hospital, Gezira State  between September 2004 and January  2006. Gezira State is an area of seasonal  mesoendemic malaria transmission [1]. Our sample was pregnant women a  positive film of P. falciparum confirmed microscopically. Sample size was calcu- lated according to the statistical equa- tion: n = z2 × Pq/d2 where: n = sample  size, d (precision) = 0.05, z (value of the  standard normal distribution at the 5%  level) = 1.96, P = success probability, q =  failure probability. We recruited 150 pregnant women  who had a positive film of P. falciparum confirmed microscopically. Pregnant  women with diabetes,  those who had  used quinine or arthemether in the pre- vious 3 days, and cases where there was  intrauterine fetal death or vaginal bleed- ing were excluded  from the study. We  selected 50 healthy pregnant women  as a control group to compare clinical and biochemical characteristics with the patient group at the start of the study. Oral  consent was  taken  from  the  entire study group after full explanation  of the aim of the study. A full medical and obstetrical ques- tionnaire was completed and physical examination was performed by a trained team  including obstetrician, physician,  biochemist and laboratory technician. Parasitological diagnosis of malaria was  confirmed by thick and thin film using Giemsa stain. The parasites were count- ed against 200 white blood cells and the  extent of parasitaemia was calculated using the patients’ white blood cells. Haemoglobin was estimated calori- metrically according  to Dacie & Lewis  [8]. A 5 mL  sample of  venous blood  was collected from each patient as a baseline on day zero, before the start of  intravenous quinine  treatment;  a  sec- ond  sample was  taken after 2 days of  treatment (2 hours after the 4th dose of  quinine) Treatment  lasted 7 days and  included 21 doses of quinine. The third  blood sample was taken on day 8. Blood  samples were centrifuged at 4000 rpm  for 10 minutes and  the  separated  sera  were kept at –70 °C.  Glucose was estimated colorimetri- cally (LabTech, India) using the glucose  oxidase method (all reagents: SPINRE- ACT SA, Girona, Spain) which involves  the oxidation of glucose by glucose oxi- dase to gluconic acid [9].  Insulin  was  immunoassayed  (all  materials: Diagnostic Products Corpo- ration, Los Angeles, California) using  an  Immulite  analyser  (catalogue  no.  LKIN1; 100  tests,  test code INS).  Im- mulite  insulin  is  a  solid-phase,  2-site  chemiluminescent immunometric as- say [10]. Book 17-9.indb 698 9/6/2011 12:43:14 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 699 Statistical methods Normally distributed continuous vari- ables were compared using analysis of variance and Spearman correlation for non-normally distributed continuous variables were compared by means of the Pearson 2-tailed  correlation  test.  Significance levels of P < 0.05 were  re- ported. Statistical programs used were SPSS for Windows, version 16.0.  Results The clinical and laboratory data for the women in the study group and the control group are shown in Table 1. The mean level of haemoglobin and blood glucose were lower than the control group, while the serum insulin level was  significantly higher (P < 0.001) among  the study group. The most common presenting symptoms in the women with malaria were  fever (99.3%), body  aches  (75.0%),  vomiting  (41.3%),  headache (41.3%),  chills  (31.3%) and  diarrhoea (0.7%).  Quinine  infusions were associated  with a rise in plasma insulin concentra- tions and a decrease in plasma glucose concentrations (Table 2). No subject  developed  hypoglycaemia  (plasma  glucose concentration < 2.2 mmol/L).  Random plasma glucose concentra- tions  at  presentation  (range 60–112  mg/dL) were significantly higher  than  after  quinine  treatment. Duration  of  pregnancy also had a non-significant impact on the insulin and glucose levels in women with malaria (Table 3).  The mean level of parasitaemia was 32235.8/200 WBC (SD 40434.96/200  WBC). There was  a  significant nega- tive correlation (P < 0.01) between the  level of parasitaemia and haemoglobin (r  =  –0.25)  and  blood  glucose  level  (r  =  –0.66), while  a  significant  posi- tive correlation (P = 0.001) was  found  between mean insulin levels, fever, chills  and headache. Discussion The baseline plasma glucose and plasma insulin levels were slightly low in  the pregnant women with malaria,  but within the normal range and this may be ascribed to the increased host/  parasite demand for glucose. This result agrees with  that obtained by Binh  et  al. Following the commencement of quinine  therapy,  only  plasma  insulin  increased significantly above the nor- mal range compared to the baseline and post-treatment values. The rise in plasma insulin was accompanied by a concomitant decrease in the plasma glucose level, but this did not reach a hy- poglycaemic concentration,  indicating  a hyperinsulinaemic–hypoglycaemic effect of quinine. This result agrees with the results obtained in previous studies [11–13].  Since the plasma glucose con- centration  falls  after  the first  trimester  [14,15],  and high density of parasites  Table 1 Clinical and biochemical characteristics of patients and controls Characteristic Patients (n = 150) Controls (n = 50) P-value Mean (SD) Mean (SD) Age (years) 31 (4.3) 29 ( 4.6) 0.970 Gestational age (weeks) 24.6 (7.2) 21.8 (5.7) 0.034 Gravidity 2.1 (1.4) 1.7 (1.0) 0.003 Parity 1.0 (1.3) 0.7 (1.0) 0.034 Haemoglobin (g/dL) 8.7 (2.0) 11.1 (1.3) 0.026 Range 4.0–12.0 9.0–14.0 Random plasma glucose (mmol/L) 4.5 (0.6) 5.1 (0.4) < 0.001 Range 4.6–5.8 5.1–6.2 Serum insulin (µIU/mL) 16.3 ( 6.0) 11.3 (2.1) < 0.001 Range 6.0–27.0 8.0–17.0 Parasitaemia (/200 white blood cells) 32235.8 (40434.96) – Table 2 Mean random blood glucose level and mean insulin concentration before, during and after intravenous quinine treatment Test Before treatment (day 0) During treatment (day 2) After treatment (day 8) P-value Mean (SD) random plasma glucose (mg/dL) 83.3 (11.7) 77.9 (10.4) 85.3 (11.0) < 0.001 Mean (SD) plasma insulin concentration (µIU/mL) 16.3 (6.0) 32.5 (11.6) 18.4 (3.8) < 0.001 SD = Standard deviation. SD = Standard deviation. Book 17-9.indb 699 9/6/2011 12:43:14 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 700 and chronic parasite infection in the placental blood and the associated cel- lular immune response may result in consumption of glucose and oxygen that would have gone to the fetus [16].  In our study we found that the women  in the second trimester who suffer great- ly from parasitaemia burden had sig- nificantly lower levels of plasma glucose and conversely higher plasma insulin levels compared to those in the first and third trimester which compares with Brabin’s  results[17].  Increased plasma  insulin concentrations may play a role in lowering plasma glucose level, but there  is also reduced tissue insulin sensitiv- ity. Acute malaria should contribute  to  insulin  resistance  in pregnancy but,  in  severe cases with associated hepatic dysfunction, hypoglycaemia may ensue  with serious consequences for mother and fetus [18]. In our patients, there was a significant  negative correlation between the parasite count at admission and level of plasma glucose and haemoglobin;  this may be  due to the fact that the placenta is a fa- voured site for parasite sequestration and intra-erythrocytic development [18]. Monitoring of plasma glucose level is crucial in pregnant women with fal- ciparum malaria on quinine therapy. There is a need to find an effective alter- native medication that will reduce the incidence of hypoglycaemia among this high risk group. References Malik EM, Khalafalla OM. Malaria in Sudan; present, past and 1. the future. Gezira Journal of Health Science, 2004, 1(Suppl.):47– 51. Stekette RW et al. The burden of malaria in pregnancy–en-2. demic areas. American Journal of Tropical Medicine & Hygeine, 2001, 64:28–35. Yartey JE. Department of making pregnancy safer, World 3. Health Organization, International Journal of Gynecology & Obstetrics, 2006, 94(3):364–373. Van Thein H et al. Influence of prolonged starvation on glu-4. cose kinetics in pregnant patient infected with plasmodium falciparum. Clinical Nutrition, 2004, 23(1):59–67. Schantz-Dunn J, Nour NM. Malaria and pregnancy: a global 5. health perspective. Reviews in Obstetrics & Gynecology, 2009, 2(3):186–192. Kang MA et al. Insulin regulates aging and oxidative stress in 6. Anopheles stephensi. Journal of Experimental Biology, 2008, 211(Pt 5):741–748. McGready R et al. A randomised controlled trial of artemether-7. lumefantrine versus artesunate for uncomplicated Plasmo- dium falciparum treatment in pregnancy. PLoS Medicine, 2008, 5(12):e253. Lewis SM, Bain BJ, Bates I. 8. Dacie and Lewis practical haematol- ogy, 10th ed. London, Churchill Livingstone, 2006. Blood safety and clinical technology guidelines on standard 9. operating procedures for clinical chemistry: glucose–glucose oxidase method. New Delhi, World Health Organization Re- gional Office for South-East Asia (http://www.searo.who.int/ en/Section10/Section17/Section53/Section481_1753.htm, last updated 27 April 2006, accessed 31 July 2011). Chevenne D et al. Effect of hemolysis on the concentration of 10. insulin in serum determined by RIA and IRMA. Clinical Chem- istry, 1998, 44:354–356. Elliott J, Dibden C. Oral quinine-induced hypoglycaemic 11. seizures. Case report. Practical International Diabetes, 2010, 27(1):32–33. Kerr D, Bdiri A. Quinine-associated hypoglycaemia causing 12. diabetes. Diabetic Medicine, 2008, 25(2):241–242. Woodrow CJ, Planche T, Krishna S. Artesunate versus quinine 13. for severe falciparum malaria. Lancet, 2006, 367(9505):110– 111. Feinberg JH et al. Does maternal hypoglycemia during screen-14. ing glucose assessment identify a pregnancy at-risk for adverse perinatal outcome? Journal of Perinatology, 2005, 25:509–513. Thien HV, Kager PA, Sauerwein HP. Hypoglycemia in fal-15. ciparum malaria: is fasting an unrecognized and insuffi- ciently emphasized risk factor? Trends in Parasitology, 2006, 22(9):410–415. Chigozie J, Uneke CJ. Impact of placental 16. Plasmodium fal- ciparum malaria on pregnancy and perinatal outcome in Sub-Saharan Africa II: effects of placental malaria on perinatal outcome; malaria and HIV. Yale Journal of Biological Medicine, 2007, 80(3):95–103. Thien HV et al. Influence of prolonged starvation on glucose 17. kinetics in pregnant patients infected with Plasmodium falci- parum. Clinical Nutrition, 2004, 23(1):59–67. Davis TM et al. Glucose and lactate turnover in adults with 18. falciparum malaria: effect of complications and antimalarial therapy. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2002, 96:411–417. Table 3 Mean of random plasma glucose and mean plasma insulin concentrations in different stages of pregnancy Test Duration of pregnancy (trimester) P-value 1st (n = 29) 2nd (n = 71) 3rd (n= 50) Mean (SD) random plasma glucose (mg/dL) 80.8 (11.6) 75.4 (9.8) 82.8 (10.8) 0.510 Mean (SD) plasma insulin concentration (µIU/mL) 13.8 (5.8) 30 (11.6) 15.9 (4.0) 0.20 SD = Standard deviation. Book 17-9.indb 700 9/6/2011 12:43:14 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 701 Incidence of congenital malformation in 2 major hospitals in Rivers state of Nigeria from 1990 to 2003 T.B. Ekanem,1 I.E. Bassey,1 O.E. Mesembe,1 M.A. Eluwa 1 and M.B. Ekong 1 ABSTRACT Although congenital malformations are believed to be on the rise in the oil production areas of Nigeria, few baseline data are available. This retrospective study documented the incidence of congenital abnormalities in 2 major hospitals in Port Harcourt, an oil-rich city in Rivers state, Nigeria. Delivery and nursery records were reviewed from January 1990 to December 2003. In the first hospital 78 congenital anomalies were recorded out of 19 572 births (4.00/1000), principally affecting the central nervous system (1.84/1000) and skeletal system (1.74/1000). In the second hospital, 47 congenital anomalies were recorded out of 20 121 births (2.20/1000), with malformations of the central nervous system (0.80/1000) and skeletal system (1.14/1000) again predominating. More research is needed into long-term trends in congenital malformations and possible associations with environmental pollution in Rivers state. 1Department of Human Anatomy, Faculty of Basic Medical Sciences, University of Calabar, Calabar, Nigeria (Correspondence to M. Ekong: mbe_ flashpoint@yahoo.com). Received: 29/09/09; accepted: 11/02/10 2003و 1990 ْيَماع ينب ام في اييرجين في زرفير ةيلاو في نييربك ينيفشتسم في ةيقللخا تاه ُّروشتلا عوقو لدعم غنوكيإ سياب سيسوم ،اوليإ شيارامأ مايتوكوم ،يبميسيم غنويفإ وتوأ ،سياب ميتيإ غنوبوينيإ ،ميناكيإ سياب اسيسيث كلذ لوح ةرفاوتلما ةيدعاقلا تايطعلما نأ لاإ ،اييرجين في طفنلا جاتنإ قطانم في دادزت ةيقللخا تاهّوشتلا نأب دئاسلا داقتعلاا نم مغرلا لىع :ةـصلالخا طفنلاب ةينغ ةنيدم يهو ،تروكراه تروب ةنيدم في نييربك ينيفشتسم في ةيقللخا تاهّوشتلا عوقو لدعم ةيداِعتسلاا ةساردلا هذه تقّثو دقو .ةليلق .2003 برمسيد/لولأا نوناك ىتح 1990 رياني/نياثلا نوناك رهش نم ًاءدب تانضالحاو ةدلاولا تلاجس ةعجارمب كلذو ،اييرجين في زرفير ةيلاو في 1.84( يزكرلما يبصعلا زاهلجا وه هوشتلل سياسلأا عقولما ناكو )فللأاب 4.00( ةدلاو 19572 ينب نم ًايقلخ ًاهوشت 78 لولأا ىفشتسلما في َلِجُس دقو تاهوشتلا تناكو ،)فللأاب 2.20( ةدلاو 20121 ينب نم ًايقلخ ًاهوشت 47 َل ِ ِّجُس دقف نياثلا ىفشتسلما في امأ .)فللأاب 1.74( ليكيلها زاهلجاو ،)فللأاب تاهاتجلاا لوح ثوحبلا نم ديزم لىإ ٌة َّسام ةجالحا نأ ّينبت دقو .)فللأاب 1.14( ليكيلها زاهلجاو )فللأاب 0.80( يزكرلما يبصعلا زاهلجا في ةدئاسلا .زرفير ةيلاو في يئيبلا ثولتلاب ةلمتحلما اهتقلاعو ةيقللخا تاهوشتلل دملأا ةليوطلا Incidence des malformations congénitales dans deux grands hôpitaux de l’état de Rivers (Nigéria) de 1990 à 2003 RÉSUMÉ Les malformations congénitales seraient en augmentation dans les zones de production pétrolière au Nigéria, mais peu de données de référence sont disponibles. Cette étude rétrospective a recueilli des données sur l’incidence des anomalies congénitales dans deux grands hôpitaux de Port Harcourt, une riche cité pétrolière de l’État de Rivers (Nigéria). Les dossiers obstétricaux et pédiatriques de janvier 1990 à décembre 2003 ont été examinés. Dans le premier hôpital, sur 19 572 naissances, 78 anomalies congénitales ont été enregistrées (soit 4,00 pour 1000) : elles affectaient principalement le système nerveux central (1,84 pour 1000) et le squelette (1,74 pour 1000). Dans le deuxième hôpital, 47 anomalies congénitales ont été enregistrées pour 20 121 naissances (soit 2,20 pour 1000) ; les malformations concernaient aussi majoritairement le système nerveux central (0,80 pour 1000) et le squelette (1,14 pour 1000). Des recherches supplémentaires sont nécessaires pour étudier les tendances à long terme des malformations congénitales et les associations possibles avec la pollution environnementale de l’État de Rivers. Book 17-9.indb 701 9/6/2011 12:43:14 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 702 Introduction Congenital malformations include mor- phological defects as well as abnormal behaviours,  functions  and  chemistry  noticed at birth or present from birth and becoming evident as the child gets older. They include defects of molecular structure giving rise to inborn errors of metabolism [1]. Congenital malforma- tions often result in significant morbid- ity or even death of the infant [2]. Congenital malformations can be due to an abnormally shaped uterus [3],  alterations in the genes (which could be  autosomal or sex-linked) [4,5],  irradia- tion [4,5], smoking or drinking of alco- hol by the mother [6],  infections, poor  nutritional status or medication use by the mother during pregnancy  [5,7,8].  Some of these malformations result in heart disease and nervous system de- formities including mental retardation. Others include ocular defects, infertility,  skeletal deformities and spontaneous abortion in those infants who cannot survive [7]. Manning et al. stated that the fre- quency of major congenital malfor- mations detected at birth varies from 1%–1.17%,  increasing  to  2%–3%  at  about 5 years of age [9]. The incidence  of congenital malformations varies depending on  racial/ethnic  and geo- graphical factors. Malformations such as anencephaly occur in 1 per 175 births in  Ireland compared with 1 per 2700  births in Uganda. Birth defects seem to  be higher in Negroid than in Caucasian infants,  possibly  due  to malnutrition  and some practices of pregnant Negroid women [10]. The present study was carried out to assess the frequency of congenital mal- formations  in Port Harcourt  in Rivers  state, an oil production area of Nigeria.  There is no formal documentation of congenital anomalies in this part of Ni- geria, which  is  an oil production area.  These data will serve as part of the sta- tistics for this part of the South–South geopolitical zone of Nigeria. Methods This was a records-based retrospective,  descriptive study. The records of con- genital malformation in the maternity sections of the departments of obstetrics and gynaecology and paediatrics of the University of Port Harcourt  teaching  hospital and Braithwaite Memorial hos- pital  in Rivers State were studied. Birth  records and lists of congenital malfor- mations were compiled over a 14-year period  from 1990 to 2003. Congenital  anomalies were arranged according to systems of the body. The incidence of congenital anomalies was calculated per 1000 births and as percentages of  anomalies. Results The type of anomaly and the incidence in each body system are presented in Tables  1  and 2. The  records  showed  that  University  of  Port  Harcourt  teaching hospital had a  total of 19 572  births  with  78  (0.4%)  congenitally  malformed babies. The body systems most affected were the central nervous system in 46.2% of cases (an incidence  of 1.84/1000 births), skeletal system in  43.6% (1.74/1000 births),  urogenital  system  in  5.1%  (0.20/1000  births),  respiratory system  in 2.6% (0.10/1000  births) and gastrointestinal tract in 2.6%  (0.10/1000 births). Braithwaite Memorial hospital  re- corded 20 121 births with 47  (0.2%)  congenital malformed babies. Malfor- mations involved the central nervous system  in 34.0% of  cases  (0.80/1000  births);  skeletal  system  in  48.9%  (1.14/1000  births),  oral  and  special  senses  in  2.1%  (0.05/1000  births),  urogenital  system  in 6.4% (0.15/1000  births) and gastrointestinal tract in 4.3%  (0.10/1000 births). Discussion In this study the incidence of congenital  malformation was higher  in University  of Port Harcourt teaching hospital than  in Braithwaite Memorial hospital even  though the recorded birth rate was higher  in Braithwaite Memorial  hos- pital. This may be because University  of Port Harcourt  teaching hospital  is  a tertiary specialist centre with more specialist physicians experienced in diagnosing malformations than Braithwaite Memorial hospital which is  a secondary level institution. University  of Port Harcourt teaching hospital may  therefore be more vigilant in the diag- nosis of malformations than Braithwaite  Memorial hospital and may also have better  record-keeping of children born  with malformations. In both hospitals the central nervous  system and skeletal systems had a higher incidence of malformations compared with abnormalities related to the gas- trointestinal tract and urinary systems. This is in line with the results of Ekanem et al. who reported a higher incidence of malformations in both the skeletal and central nervous systems in 2 other states  of Nigeria, Akwa Ibom and Cross River  [11], which are in the same geopolitical  region and exposed to almost the same petrochemical hazards as Rivers state. This study also reflects previous work carried out in states within the same geopolitical region of Nigeria [12–14].  Ekanem  et  al.,  however,  reported  a  higher incidence of malformations re- lated to the gastrointestinal tract and urinary system in Abia State University  teaching hospital  located about 60 km  from Rivers state [15]. The differences  in environmental conditions may ac- count for these differences. It has been suggested that pollution  from the petrochemical industry is a predisposing factor in some congenital malformations  [16]  and  this  requires  more  investigation. Port Harcourt  in  Rivers state is an oil-rich city in the South-South geographical zone of Book 17-9.indb 702 9/6/2011 12:43:14 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 703 Nigeria. Oil  spillage  from petroleum  exploration affects water quality and terrestrial fauna. Gas flaring constitutes a toxicological threat to inhabitants of these areas. Heavy hydrocarbons that cannot be carried into the atmosphere fall  back  and  become  inhaled,  while  others  get  attached  to  vegetables  for  consumption, which over  time may be  toxic to the body or cause congenital malformations in babies born in the area. Toxic agents may have induced malformation in the fetus during the 4th and 5th week. This period is the critical period in the formation and develop- ment of the central nervous and skeletal systems [17]. Residents in the area have  reported that many pregnant women died following oil spillages. These who survived gave birth to babies with abnormal appearance. Some of these babies were  ill  and died, while  those  who survived could not attend school  because they were mentally retarded or were physically challenged [18]. Inhalation of  toxic gases can cause  impairment of the normal development of the fetus. Environmental pollution may be responsible for the increased incidence of central nervous system malformations in Rivers state. This is supported by reports showing that in- creased risk of structural birth defects with chromosomal abnormalities may be caused by air pollution and proxim- ity  to  hazardous waste  sites  [19,20].  There are also reports that pregnant women may have greater susceptibility to environmental  toxic exposure,  spe- cifically to volatile organic compounds such as methanol,  toluene and trichlo- roethylene  [16]. Poverty, poor  access  to proper medical care in rural areas for  pregnant  women,  chromosomal  abnormalities and maternal age may also be factors in the occurrence of these abnormalities [21]. In  the  present  study  we  did  not  attempt  to  compare  the  incidence of  congenital  abnormalities  in  these  2  hospitals in River state with those else- where, as was done by Msamati et al. in  Malawi [22]. This is because of the poor  record-keeping  in  African  countries  compared with developed countries where  there  are  efficient,  continuous  systems of registration of congenital Table 1 Types and incidences of congenital anomalies recorded for births at University of Port Harcourt teaching hospital from 1990 to 2003 System affected/type of anomaly No. of recorded anomalies % of recorded anomalies (n = 78) Incidence per 1000 births (n = 19 572) Central nervous system 36 46.2 1.84 Spina bifida 7 9.0 0.36 Meningocele 2 2.6 0.10 Hydrocephalus 7 9.0 0.36 Anencephaly 19 24.4 0.97 Collapsed skull 1 1.3 0.05 Skeletal system 34 43.6 1.74 Talipes 8 10.3 0.41 Extra digit 12 15.4 0.61 Impacted shoulder 2 2.6 0.10 Absence of digit 1 1.3 0.05 Achondroplasia 3 3.8 0.15 Amelia 1 1.3 0.05 Shoulder dystocia 4 5.1 0.20 Hyper-extended legs 1 1.3 0.05 Urogenital system 4 5.1 0.20 Ambiguous external genitalia 1 1.3 0.05 Undescended testis 2 2.6 0.10 Small penis 1 1.3 0.05 Respiratory system 2 2.6 0.10 Apnoea 1 1.3 0.05 Blocked airway 1 1.3 0.05 Gastrointestinal tract 2 2.6 0.10 Imperforate anus 1 1.3 0.05 Congenital hernia 1 1.3 0.05 Book 17-9.indb 703 9/6/2011 12:43:15 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 704 malformations  [23]. Private hospitals  are not required to keep records of con- genital malformations and furthermore most low-income inhabitants of this city patronize traditional and spiritual birth attendants who do not keep any  records of malformed babies born in their homes. In  conclusion,  this  study has pro- vided  some  limited,  baseline data on  the 14-year incidence of congenital malformations  in  2  public  hospitals.  More research is needed into long-term trends in congenital malformations and possible associations with environmen- tal pollution in Rivers state. Acknowledgements We wish to thank the staff of the records  section of the two hospitals, University  of Port Harcourt teaching hospital and  Braithwaite Memorial hospital used  in  this study. They were very cooperative and helped out with the data collection. Table 2 Types and incidences of congenital anomalies recorded for births at Braithwaite Memorial hospital from 1990 to 2003 System affected/type of anomaly No. of recorded anomalies. % of recorded anomalies (n = 47) Incidence per 1000 births (n = 20 121) Central nervous system 16 34.0 0.80 Hydrocephalus 6 12.8 0.30 Spina bifida 3 6.4 0.15 Meningocele 2 4.3 0.10 Anencephaly 2 4.3 0.10 Microcephalus 1 2.1 0.05 Down syndrome 2 4.3 0.10 Skeletal system 23 48.9 1.14 Talipes 10 21.3 0.50 Extra digits 6 12.8 0.30 Achondroplasia 2 4.3 0.10 Impacted shoulder 3 6.4 0.15 Cleft lip/palate 2 4.3 0.10 Oral and special senses 1 2.1 0.05 Congenital cataract 1 2.1 0.05 Urogenital system 3 6.4 0.15 Undescended testis 2 4.3 0.10 Hydrocephalus 1 2.1 0.05 Gastrointestinal tract 2 4.3 0.10 Congenital hernia 1 2.1 0.05 Imperforate anus 1 2.1 0.05 References Collins P, Billets FC. The terminology of early development histo-1. ry, concepts and current usage. Clinical Anatomy, 1995, 8:15–48. Young MW, ed. 2. Molecular genetics of biological rhythms. New York, Marcel Decker, 1992:319. Chamberlain G, Turnbull A, eds. 3. Obstetrics, 2nd ed. London, Churchill Livingstone, 1993:103–104. Harlops S, Shino PH. Alcohol, smoking and incidence of 4. spontaneous abortion in the first trimesters. Lancet, 1980, 2:173–176. Smith CG, Asch RH. Drug abuse and reproduction. 5. Fertility and Sterility, 1987, 48:355–373. Ebrahim GJ, ed. Social and community pediatrics in develop-6. ing countries; caring for rural and urban poor, 2nd ed. London, Macmillan Press, 1985:110. Rothlaender D, Hoppe V. Risks of non-prescription medica-7. tion. Clobutinol cough syrup as a recent example. Deutsche Medizinische Wochenschrift, 2008, 133:144–146. Sadler TW. Birth defects. In: Sadler TW, Langman J, eds. 8. Lang- man’s medical embryology, 9th ed. Philadelphia, Lippincot Williams and Wilkins, 2004:149–158. Manning D et al. Unstable hip in the newborn. 9. Irish Medical Journal, 1982, 75:463–464. Smith DW, ed. 10. Recognizable patterns of human malformations. Philadelphia, WB Saunders, 1970:75– 78. Ekanem TB et al. Prevalence of congenital malformations in 11. Cross River and Akwa Ibom states of Nigeria from 1980–2003. Congenital Anomalies, 2008, 48:167–170. Book 17-9.indb 704 9/6/2011 12:43:15 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 705 Akinmoladun VI, Owotade FJ, Afolabi AO. Bilateral transverse 12. facial cleft as an isolated deformity: Case report. Annals of Afri- can Medicine, 2007, 6:39–40. Sunday-Adeoye I, Okonta PI, Egweuatu VE. Congenital malfor-13. mations in singleton and twin births in rural Nigeria. Nigerian Postgraduate Medical Journal, 2007, 14:277–280. Ugwu RO, Eneh AU, Oruamabors RS. Neural tube defects in 14. a university teaching hospital in southern Nigeria: trends and outcome. Nigerian Journal of Medicine, 2007, 16:368–371. Ekanem TB et al. Incidence of congenital malformation in the 15. maternity section of Abia State University Teaching Hospital (ABSUTH) from 1984-1999. Journal of Experimental and Clinical Anatomy, 2004, 39:31–33. Oliveira LM et al. Reproductive outcomes in an area adjacent 16. to a petrochemical plant in southern Brazil. Revista de Saude Publica, 2002, 36(1):81–87. Moore KL, Persuad TVN, eds. 17. The developing human: Clini- cally oriented embryology, 7th ed. Philadelphia, WB Saunders, 2003:175,414. The Niger Delta environmental survey final report. Phase 118. . Abuja, Nigeria, Environmental Resources Managers Ltd, 1996. Ritz B et al. Ambient air pollution and risk of birth defects in 19. Southern California. American Journal of Epidemiology, 2002, 155:17–25. Vrijheid M. Chromosomal congenital anomalies and residence 20. near hazardous waste landfill sites. Lancet, 2007, 359:230. Msamati BC, Igbigbi PS, Chisi JE. The Incidence of cleft lip, cleft 21. palter, hydrocephalus and spina bifida at Queen Elizabeth Central Hospital, Blantyne, Malawi. Central African Journal of Medicine, 2000, 46:292–296. Archibong AE et al. Congenital Malformation of the Anus and 22. Rectum in Children in Calabar, Nigeria. Mary Slessor Journal of Medicine, 2003, 3:25–29. Sipek AV, Gregor-Horacek J, Musatova D. Oblicejove rozstepy 23. v letech 1961–2000. Vyskyt, prenatalni diagnostika a preva- lence podle veku matky [Facial clefts from 1961 to 2000. Inci- dence, prenatal diagnosis and prevalence by maternal age]. Ceska Gynekologie, 2002, 67:260–267. World Health Assembly resolution on birth defects Birth defects are a significant but under-recognized cause of mortality and disability among infants and children under  5 years of age. WHO estimates that some 260 000 deaths worldwide (about 7% of all neonatal deaths) were caused by  congenital anomalies in 2004. In 2010 the World Health Assembly passed resolution on birth defects (WHA63.17), which urged Member States to:  i) raise awareness among about the importance of birth defects as a cause of child morbidity and mortality; ii) develop  plans and activities for integrating effective interventions; iii) promote the application of internationally recognized  standards regulating the use of chemical substances in the air, water and soil; iv) increase coverage of effective prevention  measures including vaccination against rubella, folic acid supplementation and others; v) develop and strengthen  registration and surveillance systems for birth defects in order to have accurate information available for taking decisions on prevention and control of these birth defects; vi) develop expertise and to build capacity on the prevention of birth  defects and care of children with birth defects; vii) strengthen research and studies on major birth defects and promote  international cooperation in combating them; viii) raise awareness about the importance of newborn screening  programmes and their role in identifying infants born with congenital birth defects; ix) take all necessary measures to  ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms; x) and support  families who have children with birth defects and associated disabilities. Book 17-9.indb 705 9/6/2011 12:43:15 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 706 Detection of Trichomonas vaginalis by different methods in women from Dohok province, Iraq W.M. Al-Saeed 1 ABSTRACT This study compared 4 different diagnostic methods for the detection of Trichomonas vaginalis in vaginal swab specimens from women attending a hospital in Dohuk in Iraq. A total of 425 vaginal swabs were obtained from women complaining of vaginal discharge associated with vaginitis, cervicitis and pelvic inflammatory disease. The results showed that 10 (2.4%) swabs were positive for T. vaginalis by wet smear preparation, 15 (3.5%) by haematoxylin–eosin stained smear, 17 (4.0%) by Papanicolaou stain and 23 (5.4%) using Diamond modified culture. The rate varied significantly by age and was highest in young women aged 20–25 years (7.6%) and lowest in the age group 36–40 years (2.2%). The highest rate of infection with T. vaginalis was detected by Diamond modified culture. 1Department of Medical Parasitology, College of Dentistry, University of Mosul, Mosul, Iraq (Correspondence to W.M. Al-Saeed: wisamalsaeed58@yahoo.com). Received: 25/10/09; accepted: 11/02/10 قارعلا في كوهد في ءاسنلا ىدل ةيلبهلما ةرّعَشُلما فاشتكلا ةفلتخلما قرطلا ديعسلا سابع يدهم ماسو تاعجارُمـلا ءاسنلا نم ةذوخألما ةيلبهلما تاحسلما تانيع في ةيلبهلما ةرّعَشُلما فاشتكلا ةفلتمخ ةيصيخشت قرط ةعبرأ ينب ةساردلا هذه تنراق :ةـصلالخا وأ ،لبهلما باهتللا بحاصم ليبهم جيِجَن نم ينكتشا ءاسن نم ةيلبهم ةحسم نوشرعو سخمو ةئم عبرأ ه ُّيلاجمإ ام َعُِجم دقو .قارعلا في كوهد ىفشتسلم تاحسلما ةقيرط لماعتساب ةيلبهلما ةرعشملل )%2.4( ةيبايجإ تاحسم ْشرَع دوجو جئاتنلا ترهظأو .ضيولحا بياهتللاا ضرلما وأ ،محرلا قنع باهتلا ةخاطل ةقيرط لماعتساب )%4.0( ةيبايجإ ةحسم ةشرع عبسو ،نيزويإ-ينليسكوتمايبه ةخطللا نيولت )%3.5( ةيبايجإ ةحسم ةشرع سخمو ،ةبطرلا ،رمعلا بسح ًايئاصحإ هب ُدَتْعُي ًانُيابت لدعلما نيابت دقو .ةل َّدعُلما دنومايد ةعرزم ةقيرط لماعتساب )%5.4( ةيبايجإ ةحسم نيشرعو ثلاثو ،لاوكيناباب دنومايد ةعرزم تناكو .)%2.2( ةنس 40-36 ةيرمعلا ةئفلا نم ءاسنلا في هل ىوتسم لقأو )%7.6( ةنس 25-20 رمع في تاباشلا في هل ىوتسم لىعأ ناكو .ةيلبهلما ةرّعشلماب ىودعلل لدعم لىعأ تفشتكا يتلا ةقيرطلا يه ةل ََّدَعُلما Dépistage de Trichomonas vaginalis par différentes méthodes chez des femmes de la province de Dahouk (Iraq) RÉSUMÉ La présente étude a comparé quatre différentes méthodes diagnostiques pour le dépistage de Trichomonas vaginalis dans les prélèvements vaginaux de femmes consultant dans un hôpital de Dahouk (Iraq). Au total, 425 prélèvements ont été réalisés chez des femmes se plaignant de pertes vaginales associées à une vaginite, une cervicite ou une infection génitale haute. D’après les résultats, dix prélèvements (soit 2,4 % d’entre eux) se sont révélés positifs pour T. vaginalis par la méthode des préparations humides, 15 (3,5 %) par la méthode de coloration à l’hématoxyline et l’éosine, 17 (4,0 %) par la méthode de coloration de Papanicolaou et 23 (5,4 %) par la méthode de culture sur milieu de Diamond modifié. Le taux variait de manière significative en fonction de l’âge. Il était plus élevé chez les jeunes femmes âgées de 20 à 25 ans (7,6 %) et plus faible dans le groupe d’âge 36–40 ans (2,2 %). Le taux d’infection le plus élevé par T. vaginalis a été établi par la méthode de culture sur milieu de Diamond modifié. Book 17-9.indb 706 9/6/2011 12:43:15 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 707 Introduction Trichomonas vaginalis is a sexually trans- mitted, flagellated protozoan that causes  vaginal  infections  in women,  including  vaginitis, urethritis and cervicitis [1]. T. vaginalis infections are not self-limiting and produce non-ulcerative inflamma- tion of the genital epithelium that can progress to necrosis and haemorrhage [2,3]. Pregnant women  infected with  T. vaginalis may be at increased risk of premature  labour,  low-birth-weight  offspring and postabortion or post- hysterectomy infection [4–6]. It has been estimated  that 10%  to  50% of T. vaginalis infections in women are asymptomatic [7], and  in men  the  proportion may even be higher. The most common tool for diagnosis of T. vaginalis infection is still microscopic ex- amination of wet mount preparations,  which has a sensitivity of approximately 60% [8]. Microscopic examination of  cultures of the parasite in specialized media  improves  the sensitivity  to 85%  to 95% [9–11], The most  sensitive of  these media is thought to be modified Diamond medium [9,10]. Direct micro- scopic examination of vaginal secretions is the most common and rapid method used to diagnose trichomoniasis. Cul- ture of vaginal and urethral specimens is  the most  sensitive,  although slower,  diagnostic technique [11,12]. This study compared 4 different diagnostic methods for the detection of T. vaginalis in vaginal swab specimens obtained from women attending a hos- pital in Dohuk in Iraq. Methods Sample and data collection The  study  sample  was  425  female  patients  attending  the department of  gynaecology of Azadi hospital in Dohok  province between October 2006 and  June 2007 with complaints of  vaginal  and cervical infection. Two cotton swab  specimens were obtained from the posterior vaginal fornix of all patients. The swabs were inserted into the pooled vaginal secretions touching both for- nices and the middle third of the vaginal wall. Laboratory methods All  swabs  from  the  women  were  examined using 4 different labora- tory methods. The first swab was used to produce  a wet mount  after mixing  with normal saline for direct micro- scopic examination. Another 2  smears  done from the first swab were fixed with 70% ethanol  for  further  staining with  Papanicolaou and haematoxylin–eosin  stains [13,14]. A second swab specimen  was  immediately placed  in 10 mL of  Diamond modified medium (Becton  Dickinson  Microbiology  Systems).  This was prepared by dissolving 35 g of the powder media in 1 L distilled water,  then bringing it to boiling point in order to dissolve the powder completely, then  sterilization by autoclave at 121  °C  for  15 min. The medium was  left  to cool.  The modification  involved  adding 50  mL of rice starch water and 50 mL of in- activated horse serum, then 1000 units  of penicillin and 500 μg of streptomycin  and vancomycin were added to each mL of medium to inhibit the bacterial and fungal growth. Diamond modified medium was stored at 4 °C and allowed  to reach room temperature prior to use. The vaginal swab was immersed in the newly prepared culture medium in  bijou bottles  under  aseptic  condi- tions (10–15 mL  in each bottle),  then  incubated at 37 °C for 72 h. Swabs were examined by wet mount microscopy. Microscopy was performed at a magnification of 400×, and 20 fields  were  examined. Other unused media  were stored at 4 °C until needed. Daily  examination of culture for 3–5 days by taking samples from the sediment or bottom of  the vial  culture were exam- ined microscopically by wet mount for detection the Trichomonas spp. motil- ity and activity. Smears stained with haematoxylin–eosin and Papanicolaou  stains were examined under oil immer- sion (1000 ×). Analysis The data were analysed using the chi- squared and t-test to show the signifi- cance of any differences between those 4 diagnostic methods. Results Of 425 women  complaining of  vagi- nal  secretions,  vaginitis,  cervicitis  and  pelvic inflammatory disease, 23 (5.4%)  showed the presence of T. vaginalis in the specimens examined by different diagnostic methods. T. vaginalis were detected  in 10  (2.4%) of  the  total by  wet  smear preparation,  15  (3.5%) by  haematoxylin–eosin  stained smear, 17  (4%)  by  Papanicolaou  stain  and  23  (5.4%)  in  specimens  cultured  using  modified Diamond culture method (Table 1). Table 2 shows the frequencies of in- fection with T. vaginalis in different age groups and using different diagnostic methods. The rate varied significantly Table 1 Frequency of detection of Trichomonas vaginalis infection in symptomatic women (n = 425) by 4 laboratory methods Test No. of infected women % Wet smear 10 2.4 H&E stain 15 3.5 Pap. stain 17 4.0 Modified Diamond culture 23 5.4 H&E = haematoxylin–eosin; Pap = Papanicolaou. Book 17-9.indb 707 9/6/2011 12:43:16 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 708 by age and was highest in young women aged between 20–25 years (7.6%) and  lowest  in  the  age  group 36–40 years  (2.2%). Discussion T. vaginalis infections are regarded as the most prevalent non-viral sexually-trans- mitted disease (STD) and are  similar  to other STDs in that the prevalence increases with increased numbers of sexual partners, presence of other STDs  (especially gonorrhoea) and  failure  to  use barrier contraceptives [12]. In  the  current  study  wet  smear  preparation detected the fewest number of infections with T. vaginalis  (2.4%),  followed by haematoxylin–eosin stain  (3.5%)  and Papanicolaou  stain  (4.0%). The modified Diamond culture  detected the highest rate of infection (5.4% of  specimens).  In most  settings  the microscopic evaluation of vaginal discharge (wet preparation) has been  the standard method used to diagnose T. vaginalis infections. The wet prepara- tion is fast and convenient for clinicians and  is  inexpensive,  but  in  asympto- matic women the sensitivity of the wet preparation in demonstrating motile trichomonads  (definitive  diagnosis)  is only 60% to 80% [12]. Other stains,  such  as haematoxylin–eosin  and Pa- panicolaou have better sensitivities but  are more labour-intensive and take time during processing of the stain and are moderately expensive [11]. Diamond’s  modified medium has been shown to be the most sensitive medium for the culture of T. vaginalis  [9–11], possibly  due to the starch content of the medium which gives similar environmental con- ditions as  the vaginal epithelium [13].  However, the method needs as  long as  3–7 days for confirmation of the diag- nosis and is expensive when compared with previous methods. Overall 5.4% of women complain- ing of vaginal and cervical infection were found to be infected with T. vaginalis. This rate is consistent with another study in Iraq, in Kirkuk (7.5%) [14], but disa- grees with similar studies done in Erbil (10%)  and  in Mosul  (14%)  [15,16].  The lower rate found in our study might be due to the women using vaginal washing  and  antiseptics  after  coitus  with their partners or to the existence of health education programmes about STDs arranged by the maternal care office. The rates in this study and others in the Iraq, however, are lower than that  reported in some other counties. The rate of infection in a hospital study New York city was reported as 41.3%, and in  a community  study  in South Africa as  41% [17]. The highest incidence of T. vaginalis was found in the age group 20–30 years,  which is in agreement with Al-Samarrae’s  study  in  Iraq  [18],  and may be  related  to the greater sexual activity of this age group In  conclusion,  the highest  rate of  infection with T. vaginalis was detected by Diamond modified culture. Table 2 Frequency of detection of Trichomonas vaginalis infection by 4 laboratory methods in symptomatic women (n = 425) by age group Age (years) No. examined No. infected % Test Wet smear H&E stain Pap. stain Modified Diamond culture 20–25 92 7 7.6 4 5 4 7 26–30 88 6 6.8 3 4 5 6 31–35 78 5 6.4 5 4 5 5 36–40 93 2 2.2 2 1 0 2 41–45 74 3 4.1 2 2 2 3 Total 425 23 5.4 16 16 16 23 t = 20.45, P < 0.001 χ2 = 3.097, P = 0.995 H&E = haematoxylin–eosin; Pap. = Papanicolaou. References Moodley P et al. 1. Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with hu- man immunodeficiency virus. Clinical Infectious Diseases, 2002, 34:519–522. Viikki M et al. Gynaecological infections as risk determi-2. nants of subsequent cervical neoplasia. Acta Oncologica, 2000, 39:71–75. Wasserheit JN. The interrelationship between human 3. immunodeficiency virus infection and other sexually transmitted diseases. Sexually Transmitted Diseases, 1992, 19:61–77. Swygard H et al. Trichomoniasis: clinical manifestation, 4. diagnosis and management. Sexually Transmitted Infections, 2004, 80:91–95. Book 17-9.indb 708 9/6/2011 12:43:16 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 709 Read JS, Lebanoff MA. Sexual intercourse during pregnancy 5. and preterm delivery: effects of vaginal microorganisms. Ameri- can Journal of Obstetrics and Gynecology, 1993, 168:514–519. Viikki M E et al. Gynaecological infections as risk determinants 6. of subsequent cervical neoplasia. Acta Oncologica, 2000, 39:71 –75. Burstein GR, Zenilman JM. Nongonococcal urethritis a new ar-7. adigm. Clinical Infectious Diseases, 1999, 28 Suppl. 1;S66–S73. Petrin D et al. Clinical and microbiological aspects of 8. Tri- chomonas vaginalis. Clinical Microbiology Reviews, 1998, 11:300–317. Gelbart SM et al. Growth of 9. Trichomonas vaginalis in com- mercial culture media. Journal of Clinical Microbiology, 1990, 28:962–964. Levi MH et al. Comparison of the InPouch TV culture system 10. and Diamond’s modified medium for detection of Trichomonas vaginalis. Journal of Clinical Microbiology, 1997, 35:3308–3310. Wiese WS et al. A meta-analysis of the Papanicolaou smear and 11. wet mount for the diagnosis of vaginal trichomoniasis. Ameri- can Journal of Medicine, 2000, 108:301–308. Heine P, McGregor R. Trichomonas vaginalis: a re-emerging 12. pathogen. Clinical Obstetrics and Gynecology, 1993, 36:137–144. Lawing LF, Hedges SR, Schwebke JR. Detection of trichomonia-13. sis in vaginal and urine specimens from women by culture and PCR. Journal of Clinical Microbiology, 2000, 38:2585–2588. Kadir MA, Jerjis KJ. Incidence of trichomoniasis in Kirkuk city. 14. Journal of the Faculty of Medicine, Baghdad, 1999, 28(2):75–79. Kadir MA, Salehy A, Hamed EE. Studies on 15. Trichomonas vagina- lis in Erbil teaching hospital. Journal of the Faculty of Medicine, Baghdad, 1996, 23(1):83–88. Kharofa WA. 16. An epidemiological study and cultivation of Tri- chomonas vaginalis in Mosul city [MSc thesis]. Department of Microbiology, College of Medicine, University of Mosul, Mosul, Iraq, 1999. Sorvillo F, Smith L, Kerndt P. 17. Trichomonas vaginalis, HIV and African-Americans. Emerging Infectious Diseases, 2001, 7:927– 932. Al-Samarraie HF. 18. Comparative study of Trichomonas vaginalis and bacterial coexistence in vaginal infection in pregnant and non- pregnant women [MSc thesis]. Department of Gynaecology and Obstetrics, College of Medicine, University of Baghdad. Baghdad, Iraq, 2002. Sexually Transmitted Diseases Diagnostics Initiative The Sexually Transmitted Diseases Diagnostics Initiative (SDI) was founded in 1990 in response to a widely-perceived  need to improve care for patients with sexually transmitted infections (STIs) in resource-limited settings through  improved diagnostics. It is estimated that 80%–90% of the global burden of STIs occurs in the developing world  where there is limited or no access to diagnostics. SDI aims to promote the development, evaluation and application of  diagnostic tests for STIs appropriate for use in primary health care settings in developing countries. Furth information  about SDI can be found at: http://www.who.int/std_diagnostics/index.htm Book 17-9.indb 709 9/6/2011 12:43:16 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 710 Impact of intestinal parasites on haematological parameters of sickle-cell anaemia patients in Nigeria S.G. Ahmed 1 and J. Uraka 1 ABSTRACT The majority of patients with sickle-cell anaemia live in the underdeveloped nations where endemic parasitic diseases are prevalent and this may exacerbate the severity of steady-state anaemia in infected patients. We studied the impact of intestinal parasites on haematological parameters of sickle-cell anaemia patients aged 18–35 years in Kano, Nigeria. Of 100 patients studied, 27 were found to be infected with intestinal parasites. There were no significant differences between patients with and without parasitic infections with respect to leukocyte and platelet counts. However, patients without parasitic infections had a significantly higher mean haematocrit than patients with parasitic infections [0.27 L/L (SD 0.03) versus 0.23 (SD 0.03) L/L]. Anaemia in sickle-cell anaemia patients may be exacerbated by intestinal parasites, and these patients should have regular stool examinations for detection and treatment of parasitic infections in order to improve their haematocrit and avoid the risk of blood transfusion. 1Department of Haematology, Aminu Kano Teaching Hospital, Kano, Nigeria (Correspondence to S.G. Ahmed: drsagirahmed@yahoo.com). Received: 31/12/09; accepted: 08/03/10 اييرجين في ّليجنلما مدلا رقف ضىرم ىدل ةيومدلا تاتباثتلما لىع ةيوعلما تايليفطلا رثأ اكَرُع ثِدوُج ،دحمأ لَمُغ يرغص في مدلا رقفل ةّرقتسلما ةلالحاب ّلُِي دق امم ،ةنّطوتلما ةيوعلما تايليفطلا اهيف شرتنت ةيمان نادلب في نوشيعي ّليجنلما مدلا رقف ضىرم بلغأ نإ :ةـصلالخا مهرماعأ حواترت نيذلا ّليجنلما مدلا رقف ضىرلم ةيومدلا تاتباثتلما لىع ةيوعلما تايليفطلا رثأ ناثحابلا سرد دقو .تايليفطلا هذبه نيدَعْنُمـلا ضىرلما تافلاتخا دهاشت لمو .ةيوعلما تايليفطلاب ًايدَعْنُم نوشرعو ةعبس مهتسارد مت ضيرم ةئم ينب نم دجو دقو .اييرجين في وناك ةنيدم في ةنس 35و 18 ينب نيدَعْنُمـلا يرغ ضىرلما نأ لاإ .تاحيفصلا ددعو ءاضيبلا تايركلا ددع ثيح نم ةيوعلما تايليفطلاب نيدَعْنُمـلا يرغو نيدَعْنُمـلا ضىرلما ينب ابه ُّدَتْعُي L/L 0.27( ةيوعلما تايليفطلاب نيدَعْنُمـلا كئلوأ في هيلع وه امم ًايئاصحإ ابه ُّدَتْعُي ةجردب لىعأ ميهدل تيركوتمايلها طسوتم ناك ،ةيوعلما تايليفطلاب عوضخ بجوتسي امم ،ةيوعلما تايليفطلاب مهئادِعْنا ةجيتن ّليجنلما مدلا رقف ضىرم في مدلا رقف مقافتي دقف اذكهو .))L/L ± 0.03 0.23 لباقم )± 0.03 .مدلا لقن لىإ ةجالحا بُّنتجو تيركوتمايلها ىوتسم ينستح ةَيْغُب ةيوعلما تايليفطلا ةلجاعمو فاشتكلا زابرلا لىع ةيرود تاصوحفل ضىرلما ءلاؤه Effet des parasites intestinaux sur les paramètres hématologiques de patients atteints de drépanocytose au Nigéria RÉSUMÉ La majorité des patients atteints de drépanocytose vivent dans des pays sous-développés où les maladies parasitaires endémiques sont courantes. Cette situation pourrait accentuer la sévérité de la drépanocytose chez des patients chez qui elle est stationnaire. Nous avons étudié l’impact des parasites intestinaux sur les paramètres hématologiques de patients âgés de 18 à 35 ans et souffrant de drépanocytose à Kano (Nigéria). Sur 100 patients étudiés, 27 ont reçu le diagnostic d’infestation par des parasites intestinaux. Aucune différence n’a été observée entre les patients infestés et les autres concernant la numération leucocytaire et plaquettaire. Cependant, les patients non infestés avaient un hématocrite moyen nettement supérieur à celui des patients atteints d’infection parasitaire [0,27 l/l (E.T. 0,03) contre 0,23 l/l (E.T. 0,03)]. Chez les patients atteints de drépanocytose, l’anémie peut être accentuée par la présence de parasites intestinaux. Par conséquent, ces patients doivent bénéficier d’un examen coprologique régulier en vue de dépister et de traiter les infections parasitaires, d’améliorer leur hématocrite et de prévenir le risque de devoir procéder à une transfusion sanguine. Book 17-9.indb 710 9/6/2011 12:43:16 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 711 Introduction The sickle-cell gene is widespread in Africa,  the Middle East  and Asia  and,  by population movement,  in  the Car- ibbean, North America  and northern  Europe [1]. The frequency of sickle-cell  carriers (Hb AS)  is up to 20%–25% in  West Africa  including Nigeria [2]. The  frequency has reached high levels in these populations because the carrier state protects against malaria infection [3]. Sickle-cell anaemia (SCA) (Hb SS)  affects about 2% of Nigerians [2]. SCA  is  associated with  significant  morbidity and mortality. The clinical course of SCA is characterized by vari- able periods of steady state that are pe- riodically interrupted by vaso-occlusive crises resulting from polymerization of deoxygenated haemoglobin-S lead- ing to the formation of sickled red cells [4,5]. Although red cell sickling is more  prominent during a crisis,  continuous  sickling does occur at a lower rate even in steady state [4]. Sickled red cells have  poor deformability and shortened life span resulting in chronic haemolytic anaemia in the steady state [4]. Although  chronic haemolysis is the predomi- nant factor in the etiology of anaemia in SCA, non-haemolytic  factors may  also contribute to the development of anaemia  in such patients. Of particular  concern is the fact that the overwhelm- ing majority of SCA patients live in the  underdeveloped nations of the world where endemic parasitic diseases are very prevalent and this may exacerbate the severity of steady-state anaemia in infected SCA patients.  In  this  study  in  Kano, north-west Nigeria we investigate  the impact of intestinal parasitic infec- tions on the haematological parameters of SCA patients in steady state. Methods Stool and blood samples were collected between September 2007 and August  2008  from  100  consecutive  SCA  patients in steady state at the adult hae- matology clinic of Aminu Kano teach- ing hospital, Kano, north-west Nigeria.  All patients were aged 18–35 years. The  diagnosis  of  SCA was  established by  positive sickling test and haemoglobin electrophoresis at a pH of 8.6 on cel- lulose acetate paper [6]. Blood  samples  were  collected  in  ethylenediaminetetraacetate containers and  a  blood  analyser  (Celltac Alpha  MEK 6400) was used to determine the  haematological parameters including haematocrit, leukocyte count and plate- let  count. Blood films of  each  subject  were examined microscopically and the leukocyte counts were corrected for the presence of nucleated red cells. Stool samples were collected in clean glass bottles  containing 5 mL of 10%  formalin–saline solution and sent to the microbiology laboratory. The sam- ples were subjected to microscopic examination using direct and iodine preparations for the detection and iden- tification of  parasites,  segments,  ova,  larvae or cysts [7]. The mean and standard deviation (SD) of the haematological parameters  were determined for patients with and without intestinal parasitic infections. The mean values of haematological parameters for the 2 groups of patients  were  compared  using  Student  t-test,  and a P-value < 0.05 was  taken as  sig- nificant. Statistical analyses were carried out using computer software SPSS, ver- sion 11.0. Results A total of 100 SCA patients were studied,  of whom 27 were  found to be  infected  with intestinal parasites, a prevalence of  27.0%. The identified parasites included  4 helminths (Ascaris lumbricoides, Ancy- lostoma duodenale, Trichuris trichiura and Strongyloides stercoralis) and 3 protozoa  (Entamoeba histolytica, Entamoeba coli and Giardia lamblia). Out of the 27 infected  patient,  10  (37.0%)  and  17  (63.0%)  were infected with single and multiple parasites respectively. The frequencies of individual parasites among the infected patients are shown in Table 1. The mean values of haematological parameters found among SCA patients  with and without intestinal parasitic infections were  compared  (Table 2).  Patients without  intestinal parasitic  in- fections had a mean haematocrit value of 0.27 L/L, which was significantly higher  than  the value of 0.23 L/L  in patients  with infections (P < 0.05). Patients with- out intestinal parasitic infections had a mean leukocyte count of 11 ×109/L and  a mean platelet count of 453 ×109/L and  these did not differ significantly from the counts of 12 ×109/L and 462 ×109/L  respectively in patients with infection. Discussion The prevalence of intestinal parasites in Nigeria is very high in children, with  reported rates consistently over 50% in  Table 1 Frequencies of intestinal parasites among 27 sickle-cell anaemia patients with intestinal parasitic infections Type of parasite Patients infected No. % Ascaris lumbricoides 10 37.0 Ancylostoma duodenale 6 22.2 Trichuris trichiura 3 11.1 Strongyloides stercoralis 2 7.4 Entamoeba histolytica 7 25.9 Entamoeba coli 5 18.5 Giardia lamblia 2 7.4 Book 17-9.indb 711 9/6/2011 12:43:16 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 712 many communities  [8]. However,  the  prevalence has been shown to decrease with increasing age and is generally lower in older children and adults [9]. Hence,  the  relatively  low prevalence of 27.0%  seen among our patients was consistent with their ages, as all of them were young  adults aged between 18 and 35 years. The pattern of infections with respect to  the frequencies of individual parasites found in our patients is very similar to the trend previously reported in the general Nigerian population  [9]. This  pattern revealed that the infections were  predominantly due  to  soil-transmitted  helminths  and protozoans, which are  strongly associated with poverty and poor personal and environmental hy- giene [10]. The haematological parameters of our patients revealed comparatively similar high mean leukocyte counts in SCA patients with and without parasitic  infections. This is consistent with ear- lier studies showing that leukocytosis is  a  common  feature of  SCA even  in  steady state. This was thought to be due to redistribution of granulocytes from the marginal to the circulating pool  [11].  Furthermore,  the  mean  platelet counts were high but similar in both patient groups. The finding of high platelet counts in our patients is consistent with  earlier  studies, which  showed that thrombocytosis was com- mon in SCA and was attributed  to  the  background haemolytic anaemia and the autosplenectomy associated with the disease  [11]. However,  the mean  haematocrit level of our patients with- out parasitic infections was significantly higher than the level among patients with parasitic  infections. Hence, SCA  patients that were infected with intes- tinal parasites had more severe steady- state anaemia in comparison with their counterparts without intestinal parasitic infections. This finding reveals a possible as- sociation between intestinal parasitic infection and the severity of anaemia in SCA patients. Intestinal parasites are  strongly associated with the develop- ment of anaemia as they cause mal- absorption, nutritional deficiencies and  gastrointestinal blood  loss [10]. There- fore, the more severe anaemia found in  SCA patients with  intestinal parasites  was likely a result of the combined ef- fect of haemolysis due to sickle-cell disease  and malabsorption,  nutrient  deficiencies and gastrointestinal blood loss due to infection with intestinal para- sites. It is therefore important that SCA  patients who live in the tropics should have regular periodic stool micro- scopic examination in order to detect and treat any parasitic infections. This will significantly reduce the severity of steady-state anaemia and avoid the risk of blood transfusion in such patients. Furthermore,  physicians  involved  in  managing SCA patients  in  the  tropics  must counsel such patients on basic sanitary practices such as washing fresh vegetables and fruits before consump- tion,  proper  cooking  of meat  before  eating,  boiling  stream  water  before  drinking, proper disposal of faecal mat- ter and avoidance of walking or farming bare-foot,  all  of which  are  important  to safeguard against the acquisition of intestinal parasites [12,13]. Conclusion Steady-state anaemia in patients with SCA  is  exacerbated by  infection with  intestinal  parasites. Hence,  SCA  pa- tients should have regular periodic stool examinations for early detection and treatment of intestinal parasites in or- der  to raise  their haematocrit,  improve  their quality of life and avoid the risk of transfusion. References Flint J et al. The population genetics of the haemoglobinopa-1. thies. Bailliere’s Clinical Haematology, 1993, 6:215–222. Akinkugbe OO. Sickle cell disease. In: Akinkugbe OO, ed. 2. Non-communicable diseases in Nigeria, 1st ed. Lagos, Federal Ministry of Health, 1992: 36-48. Hood AT. Protection against lethal malaria in transgenic mice 3. expressing sickle cell haemoglobin. Blood, 1996, 87:1600– 1603. Kaul DK, Fabry ME, Nagel RI. The pathophysiology of vascular 4. obstruction in the sickle cell syndromes. Blood Reviews, 1996, 10:29–44. Davies SC, Oni L. Management of sickle cell disease. 5. British Medical Journal, 1997, 315:656–660. Dacie JV et al. Investigation of abnormal haemoglobins and 6. thalassaemia. In: Dacie JV, Lewis SM, eds. Practical haematol- ogy, 7th ed. London, Churchill Livingstone, 1991:227–257. Table 2 Haematological parameters of sickle-cell anaemia patients with and without intestinal parasitic infections Parameter Without infection (n = 73) With infection (n = 27) Statistics Mean (SD) Mean (SD) t-value P-value Haematocrit (L/L) 0.27 (0.03) 0.23 (0.03)* 5.920 < 0.001 Leukocyte count (×109/L) 11.0 (2.3) 12.0 (2.5) 1.885 0.0623 Platelet count (×109/L) 453 (45) 462 (48) 0.872 0.3853 SD = standard deviation. Book 17-9.indb 712 9/6/2011 12:43:17 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 713 Cheesbroug M. Medical laboratory manual for tropical coun-7. tries, 2nd ed. London, Butterworth, 1987. Ijagbone IF, Olagunju TF. Intestinal helminth parasites in school 8. children in Iragbiji, Boripe local government area, Osun state, Nigeria. African Journal of Biomedical Research, 2006, 9:63–65. Agi PI. Pattern of infection of intestinal parasites in Sagbama 9. community of the Niger Delta, Nigeria. West African Journal of Medicine, 1995, 14:39–42. Ejezie GC, Emeribe AO, Igwe MA. Human ecology and para-10. sitic infections in Nigeria: relationship between parasitic infec- tions and anaemia. Journal of Medical Laboratory Science, 1993, 3:22–26. Ahmed SG, Ibrahim UA, Hassan AW. Haematological Parame-11. ters of Sickle Cell Anaemia Patients with and without priapism. Annals of Saudi Medicine, 2006, 26:439–443. Damen JG et al. Parasitic contamination of vegetables in Jos, 12. Nigeria. Annals of African Medicine, 2007, 6:115–118. Adeyeba OA, Essiet U. Prevalence of helminth and protozoan 13. infections among a religious sect that walk barefooted in Iseyin, Nigeria. Nigerian Journal of Parasitology, 2001, 22:85–94. Haemoglobin disorders It is estimated that each year over 300 000 babies are born worldwide with severe forms of the haemoglobin disorders,  sickle-cell disease and thalassaemia, the majority in low and middle income countries. The most cost-effective strategy  for reducing the burden of haemoglobin disorders is to complement disease management with prevention programmes. Sickle-cell disease can be managed by simple procedures including: high fluid intake; healthy diet; folic acid  supplementation; pain medication; vaccination and antibiotics for the prevention and treatment of infections; a number  of other therapeutic measures. Genetic counselling can informs couples carrying the trait of the risks that the condition may be passed along to their children, the treatment needed, if affected by a haemoglobin disorder, and the possible  options for the couple. The governing bodies of WHO have adopted two resolutions on haemoglobin disorders. The resolution on sickle-cell  disease from the 59th World Health Assembly in May 2006 and the resolution on thalassaemia from the 118th meeting  of the WHO Executive Board call upon affected countries and the Secretariat of WHO to strengthen their response  to these conditions. In addition, a resolution on the prevention and management of birth defects, including sickle-cell  disease and thalassaemia, was adopted by the 63rd World Health Assembly in May 2010. Specifically, WHO will: increase awareness of the international community of the global burden of these disorders;  promote equitable access to health services; provide technical support to countries for the prevention and management  of these disorders; and promote and support research to improve quality of life for those affected.  Source: WHO Fact sheet, No. 308 January 2011 Book 17-9.indb 713 9/6/2011 12:43:17 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 714 Evaluation of an interferon-gamma release assay in young contacts of active tuberculosis cases S. Noorbakhsh,1 J. Mousavi,1 M. Barati,1 A.R. Shamshiri,2 M. Shekarabi,1 A. Tabatabaei 1 and Gh. Soleimani 3 ABSTRACT In a cross-sectional study in a hospital in Tehran in 2006–08 the QuantiFERON®-TB interferon-gamma release assay (QTB) was compared with the tuberculin skin test (TST) in 59 young people (aged < 20 years) with close contact with immunocompetent cases of proven pulmonary tuberculosis. After 1 year follow-up 10 subjects had progressed to tuberculosis disease and received treatment; TST was positive in 30% and QTB in 100%. Of the 49 non-progressive subjects, TST was positive in 10.4% and QTB in 16.3%. The agreement between TST and QTB assay in non-progressive subjects was poor (κ = 0.43). False positive and false negative rates for TST were 40.0% and 9.3% respectively; positive and predictive values were 60.0% and 90.7%. We suggest adding the interferon assay to the skin test in the decision to perform chest X-ray or to start chemoprophylaxis at least in younger subjects (aged < 20 years). 1Research Centre of Paediatric Infectious Diseases, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran (Correspondence to S. Noorbakhsh: samileh_noorbakhsh@yahoo.com). 2Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 3Department of Paediatric Infectious Diseases, Zahedan University of Medical Sciences, Zahedan, Islamic Republic of Iran. Received: 22/11/09; accepted: 21/02/10 لاّعفلا لسلا تلاالح ينطلاخلما بابش ينب اماغ -نويرفترنلإا رادصإ سايق مييقت نيمايلس اضر ملاغ ،يئابطابط تْخَدْرَذآ ،بياركش يدهم ،ييرشمش اضر دحمأ ،ىتاَرَباتريم ،يوسوم داوج ،شْخَبرون هليمَث اماغ-نويرفترنلإا قلاطإ ةَسَياقُم رابتخا ينب ةنراقم تيرجُأ ،2008-2006 ماوعلأا في نارهط ىفشتسم في تيرجأ ةضرعتسم ةسارد في :ةـصلالخا تلاالح نيشرابلما ينطلاخلما نم )رمعلا نم نيشرعلا نود( ًاباش ينسخمو ةعست في يدللجا ينلوكربوتلا رابتخا ينبو لسلا فشكل ®QuantiFERON ينلوكربوتلا رابتخا ناكو ؛هل ًاجلاع اوقلتو لسلاب اوبيصأو ةعباتلما نم ةنس دعب مهنم ةشرع ةلاح تروهدت دقو .ًايعانم ةلهؤلما ةدكؤلما يوئرلا لسلا رابتخا ناك دقف ،مهتلاح روهدتت لم نيذلا نوعبرلأاو ةعستلا ناّبُشلا امأ .%100 في ًايبايجإ اماغ-نويرفترنلإا سايقو ،مهنم %30 في ًايبايجإ يدللجا صاخشلأا في نيرابتخلاا ينب قفاوتلا ناكو .مهنم %16.3 في ًايبايجإ اماغ-نويرفترنلإا سايق ناكو ،مهنم %10.4 ىدل ًايبايجإ يدللجا ينلوكربوتلا لىع %9.3 و %40.0 :يدللجا ينلوكربوتلل بذاكلا يبلسلاو بذاكلا بيايجلإا رابتخلاا لدعم غلبو .)K= 0.43( ًافيعض مهتلاح روهدتت لم نيذلا ذاتخلا يدللجا رابتخلاا لىإ اماغ-نويرفترنلإا سايق ةفاضإ نوثحابلا حترقيو .%90.7و %60.0 :ةيؤبنتلاو ةيبايجلإا ناتميقلا تغلب ينح في ،لياوَّتلا .نيشرعلا نود مه نيذلا بابشلا في ةيئايميكلا ةياقولا ءاطعإ في عوشرلا وأ يعاعشلا ردصلا ريوصت ءارجإ نأشب رارقلا évaluation portant sur la mesure de la production d’interféron gamma chez de jeunes contacts de patients atteints de tuberculose active RÉSUMÉ Dans le cadre d’une étude transversale conduite dans un hôpital de Téhéran de 2006 à 2008, le test QuantiFERON®-TB de mesure de la production d’interféron gamma a été comparé au test tuberculinique cutané chez 59 jeunes âgés de moins de 20 ans en contact rapproché avec des cas immunocompétents de tuberculose pulmonaire confirmés. Après un an de suivi, dix contacts avaient évolué vers une tuberculose et recevaient un traitement ; 30 % d’entre eux avaient un résultat positif au test tuberculinique cutané, et 100 % au test QuantiFERON®-TB. Sur les 49 sujets sans évolution, 10,4 % avaient un résultat positif au test tuberculinique cutané, et 16,3 % au test QuantiFERON®-TB. La concordance entre les deux tests chez les sujets non évolutifs était médiocre (κ = 0,43). Les taux de faux positifs et de faux négatifs pour le test tuberculinique cutané s’élevaient respectivement à 40,0 % et 9,3 % ; les valeurs positives et prédictives étaient de 60,0 % et 90,7 %. Nous suggérons d’ajouter la mesure de la production d’interféron gamma au test tuberculinique cutané pour prendre ou non la décision de réaliser une radiographie des poumons ou d’entamer une chimioprophylaxie, au moins chez les sujets jeunes (âgés de moins de 20 ans). Book 17-9.indb 714 9/6/2011 12:43:17 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 715 Introduction Tuberculosis  (TB)  is  still  one of  the  major causes of mortality and morbidity [1,2]. Treatment of latent TB infection  is very  important, especially  in recently  infected children,  to prevent progres- sion to active disease. The tuberculin skin test (TST)  is a screening test uni- versally used for diagnosis of  latent TB  in many countries. The advantages and disadvantages of TST are well known and  include  the booster phenomenon,  technical difficulties, the need for repeat  visits and a high number of false positive and false negative results. False negatives are frequent in immunocompromised cases. However, in young children false  negative results cannot be detected. False positive TST occurs in individuals who have been vaccinated with BCG  or infected with non-TB Mycobacterium spp. [3,4]. The Islamic Republic of Iran is an in- termediate TB burden country. Bacille  Calmette-Guérin (BCG) vaccination  is given at birth and at school entrance (6 years old). Due to a number of rea- sons  the second BCG vaccination was  stopped 3 years ago [5]. Finding a better  indicator than the TST for detecting the risk of M. tuberculosis infection in our country is needed. Such a test would lead to a reduction in the cost and un- necessary chemoprophylaxis of children in close contact with TB cases [6–8]. QuantiFERON®-TB (QTB)  is  an  in vitro whole-blood interferon-gamma release assay, which is a novel alternative  to the TST and is now recommended as the gold standard test for diagnosis of TB infection [9]. It has been used in de- cision-making about chemoprophylaxis treatment for those in close contact with TB cases or  the diagnosis of  latent TB  infection [6–8,10–15]. There are  little  data, however, about its use in children. The following study was performed to detect the agreement between TST and QTB in young household contacts  (aged < 20  years) of  cases of proven  active pulmonary TB  in a BCG-vacci- nated population in Tehran, Islamic Re- public of Iran, and to compare subjects  progressing to TB with non-progressive  subjects. Methods Study setting and sample This cross-sectional study was done in the pulmonary and infectious diseases department of Rasul hospital in Tehran,  2006–08. Our centre  is  a  tertiary care  general hospital with 500 active beds  and 2  research centres  for pulmonary  and infectious diseases. This study was approved by  the ethical  committee of  the Iran University of Medical Sciences. The study subjects were all young (< 20  years old) household  contacts  of people with confirmed active pul- monary TB  and  previous  BCG  vac- cination received at birth. The subjects were invited to our research centre for clinical and laboratory follow-up. The index cases were all documented active pulmonary TB cases (aged > 15 years)  who had been diagnosed by an internist in the pulmonary and infectious ward of Rasht hospital. The index cases were confirmed by positive culture for M. tu- berculosis or sputum smear-positive TB.  Close or household contact was defined as any person who had lived with the index case for more than 3 months. His- tory of BCG vaccination was confirmed  by BCG scar or vaccination chart exam- ined by physicians. Household contacts were excluded if they had been treated for TB in the past year or had a known  immunodeficiency state on history or clinical  signs (malignancy, corticoster- oid therapy, HIV, etc.). Over the study period we located 59  immunocompetent young people who were household contacts of 55 patients with proven active pulmonary TB. Data collection A questionnaire was completed by an  authorized physician for each study subject followed by a complete clinical examination. After collection of blood  samples  for  the QTB assay,  all partici- pants underwent TST. For  the TST a  test dose (0.1 mL)  of 5 tuberculin units of purified protein derivative  solution (Pasteur  Institute,  Tehran)  was  injected  intradermally  into the volar aspect of the forearm with a 26–27 gauge needle by  trained  field worker. The induration diameter of  the  raised, blanched weal  (not  the  erythema) was read after 48–72 hours.  A reactive TST was an induration diam- eter of ≥ 10 mm [1–4,9]. For  the  QTB  fresh  blood  sam- ples from all of the participants were processed on site according to the manufacturer’s  instruction  (Gold  Quantiferon-TB,  Cellestis).  First,  1  mL of heparinized whole blood was incubated with aliquots of antigen-free control  and antigens  for 16–24 hours  at  37  °C  in  a  carbon dioxide  incuba- tor. After overnight  incubation, 200 µL  plasma was removed from each well and  the  concentration of  IFN-γ was  determined using the assay kits. Subjects with a reactive TST or QTB assay were offered a chest  radio- graph and those with symptoms were assessed using a standardized proform and clinical examination [1–4,9]. Those  with TB disease were  referred  to  the  national  TB  control  programme  for  free treatment  following World Health  Organization  recommendations [1,2].  All  the  subjects were  followed  for  at  least 1 year. Statistical analysis Quantitative variables were summarized  as mean and standard deviation (SD)  and qualitative variables as counts with percentage. Comparison of the age dis- tribution between subjects with positive or negative test results was performed by Mann–Whitney  test  because  the  number of positive subjects was small. Comparison of the sex distribution was assessed by chi-squared  test (or Fisher  exact test if necessary). Book 17-9.indb 715 9/6/2011 12:43:17 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 716 The percentage concordance be- tween TST and QTB was  reported as  actual percentage agreements and the degree of agreement between the 2 tests  was reported as Cohen kappa (κ) statis- tic in the following categories: excellent  (κ > 0.75), fair to good (κ = 0.4–0.75) or  poor agreement (κ < 0.4). All  analyses were conducted using  SPSS,  version 11.5 and P-values < 0.05  were considered statistically significant. Results During  the  study period, 10 of  the 59  study subjects progressed to TB disease  and received anti-TB drugs. The mean  age of the progressed subjects was 5.4 (SD 3.3) years. The female to male ratio  was  7/3. All  of  the  progressed  cases  (10/10) had positive QTB results, but  only 30.0% (3/10) had  reactive TST  (Table 1). The mean age of the remain- ing 49 non-progressive subjects was 8.0  (SD 6.7) years (Figure 1), with a female  to male  ratio of 27/21; we had sex  for  1  case missing.  A  positive QTB was  reported  in 16.3% (8/49) and reactive  TST  in 10.4% (5/48) of  subjects. The  case with sex missing was negative for both TST and QTB. Although  positive  TST  subjects  were older than those with negative TST the difference was not statistically significant  [mean  age  13.4  (SD 6.7)  years  versus 7.5  (SD 6.6) years]  (P  =  0.53). The mean age of  subjects with  positive and negative QTB was also not  significantly different  [11.3  (SD 7.3)  years  versus 7.4  (SD 6.5) years]  (P  =  0.66). No statistically significant difference was observed in the sex distribution between positive and negative results for both TST and QTB tests (P = 0.65  and 0.72 respectively) (Table 1). The agreement between TST and QTB assay in non-progressive subjects  was poor (κ = 0.43, P = 0.002); however,  the  actual  agreement was 87.6%. The  rate of false positives and false negatives for TST  in comparison with QTB (as  the  reference  test) were 40.0% (2/5)  and 9.3% (4/43) respectively. The posi- tive predictive value was 60.0% (positive  TST with positive QTB) and the nega- tive predictive value was 90.7% (nega- tive TST with negative QTB). Discussion The results of this study found a poor agreement between the results of the skin test and interferon assay in our young, high-risk  subjects. The discrep- ancy was greatest in those subjects who progressed  to TB disease (100% posi- tive QTB versus 30%  reactive TST),  but it was also observed in subjects who did not progress (16.3% positive QTB  versus 10.4% reactive TST). The false positive rate of the TST in non-progressive subjects (followed  for  1 year) was 40.0%. Those reactive TSTs  might due to remote or non-Mycobacte- rium  infections, which can give a TST  false positive result with indurations of 5–14 mm [3]. Although prior BCG  vaccination could be the reason for a false positive TST, a lower sensitivity of  QTB  in detecting TB  infection  is also  plausible. The  κ-value  for  the  agree- ment between TST and QTB assay  in  non-progressive subjects was only 0.43.  Therefore as many as 57% of true recent  infected cases will be missed if we use the  skin  test  as  the only TB  infection  screening  test (not only  in progressive  but also in non-progressive subjects). Our  study  showed  that  the QTB  assay is an acceptable diagnostic test for determining recent M. tuberculosis infection in a vaccinated population. Similar results were found in at least 4 other studies [8,9,11,15]. An exception  is an Indian study, which reported 100%  agreement (κ = 1.0) between TST and  QTB  in BCG  scar-negative  children  compared with 94% (κ = 0.63) in scar- positive children. BCG vaccination did  not significantly affect either TST or QTB results  [7]. There are  a number  of possible  reasons  for  the difference,  including the higher rate of TB infection  in India, the lower rate of HIV infection  in the Islamic Republic of Iran popula- tion and  the possibly better economic  Table 1 Baseline characteristics of study subjects who progressed to tuberculosis (TB) disease and those who did not: comparison of tuberculin skin test (TST) and QuantiFERON® interferon-gamma release assay (QTB) TB disease status/test +ve test –ve test No. Mean (SD) age Sex ratio (F/M) No. Mean (SD) age Sex ratio (F/M) Progressive (n = 10) TST 3 4.8 (3.1) 2/1 7 3.5 (2.8) 5/2 QTB 10 5.4 (3.3) 7/3 0 – – Non-progressive (n = 49) TST 5 13.4 (6.7) 2/3 43 7.5 (6.6) 25/17 QTB 8 11.3 (7.3) 5/3 41 7.4 (6.5) 22/18 Sex was missing for 1 case (1/49) and TST was missing for another (1/49). N = total number of cases; n = number of cases; SD = standard deviation; F = female; M = male. Book 17-9.indb 716 9/6/2011 12:43:17 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عساتلا ددعلا 717 and nutritional status of the subjects in the present study. A weakness of previous  studies  is  that, due  to difficulties  in obtaining ac- curate  immunization histories and/or  records,  they may have  relied on  the  presence or absence of a BCG scar  to  determine BCG vaccination status.  In  our study all the studied subjects were young, proven  immunocompetent  in- dividuals. Mazurek et al. reported higher discordant  results  (26–40  times) be- tween  the 2  tests  in  recruits who were  born in countries with a high preva- lence of TB infection than in countries  with a  low prevalence [11]. A German  study found a poor agreement between the TST and  the QTB (κ = 0.2)  and  positive reactions were associated with prior BCG vaccination  (OR = 24.7).  A good agreement between the 2 tests,  however, has been observed in unvacci- nated individuals (κ = 0.58) [15] and in  countries with low rates of TB infection  unvaccinated populations [4,13,14].  The results of the last published study  in  the  Islamic Republic of  Iran  on 20 high-risk BCG-vaccinated adults  (mean age 35 years) was similar to the  present study. The agreement between the 2 tests (κ = 0.28) was even lower than  in our study (κ = 0.43), but a higher rate  of positive QTB results was observed in  older  subjects (OR = 1.09, P < 0.001)  [8].  In our study  the mean age of  sub- jects with positive TST was higher (13.4  years)  than  those with positive QTB  (11.5 years), which may be due to differ- ences in the age distribution of subjects in these 2 Iranian studies. We observed  positive QTB in 16.3% of subjects, reac- tive TST in 10.4% of the subjects and a  6% false negative rate for the TST. Bas- ing clinical decision-making on the TST alone would increase the number of undiagnosed true recent infected cases. The positive predictive value (60.0%)  in  our  study  for  the  TST  test  in  comparison with  the QTB (as  the  gold  standard) was unacceptably  low, but  the negative predictive  value  (90.7%) was acceptable. The 40.0% false  positive results for TST might be due to BCG vaccination,  remote  infection or  atypical Mycobacteria in older cases. Un- necessary treatment should be avoided by a complementary test such as the QTB  to  the TST  [15,16].  Activated  lymphocytes and effector memory cells producing interferon-gamma persist for a limited time in circulation once the antigen  is  cleared. So  the QTB assay  might reflect recent rather than remote TB  infections. The 9.3%  false negative  rate for TST is important for early diag- nosis [15,16]. A blood  test  for M. tuberculosis has some  theoretical  advantages,  even  in  developing countries. The QTB assay is  a test without a booster effect for future tests and  it produces  results within 24  hours that do not require 2 patient visits.  But  the higher  costs,  greater practical  inconvenience and the presence of indeterminate test results are limiting factors  in  the extensive use of QTB  in  large populations. Due to the reduced sensitivity of TST in subjects with recent M. tuberculosis exposure some authors suggest that for maximum sensitivity the 2 tests need to be used together, es- pecially in BCG-vaccinated populations  [6–8,15]. Some limitations of our study in- clude  the  small numbers,  especially  in  the lower age group (< 5 years) and that  subjects with negative results were not followed up  for a  longer duration (> 1  years) after the first visit. Conclusions The QTB assay, which can reflect recent  rather  than  remote TB  infections,  is  a  better indicator for M. tuberculosis infec- tion  than TST  in our country (with a  BCG-vaccinated population). We sug- gest adding the interferon assay to skin test as a basis for the decision to perform chest X-ray or  to  start  chemoprophy- laxis  treatment  in  the  Islamic Republic  of Iran, at least in younger individuals in  close contact with cases. More extensive evaluation by the Ministry of Health is needed to change the screening and treatment programmes for young household contacts of active cases of pulmonary M. tuberculosis. Acknowledgements This study was supported by the Re- search Centre of Paediatric  Infectious  Diseases,  Iran University  of Medical  Sciences. Figure 1 Age distribution of the 49 study subjects who did not progress to tuberculosis disease 16 10 6 3 5 3 6 0 2 4 6 8 10 12 14 16 18 0–3 4–6 7–9 10–12 13–15 16–18 19–21 Age range (years) N o . o f s u b je ct s Book 17-9.indb 717 9/6/2011 12:43:18 PM EMHJ  •  Vol. 17  No. 9  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 718 References Walls T, Shingadia D. Global epidemiology of paediatric tu-1. berculosis. Journal of Infection, 2004, 48:13–22. Menzies D et al. Standardized treatment of active tuberculosis 2. in patients with previous treatment and/or with mono-resist- ance to isoniazid: a systematic review and meta-analysis. PLoS Medicine, 2009, 6:e1000150. Jasmer RM, Nahid P, Hopewell PC. Clinical practice. Latent 3. tuberculosis infection. New England Journal of Medicine, 2002, 347:1860–1866. Codecasa LR et al. Comparison of tuberculin skin test and 4. Quantiferon immunological assay for latent tuberculosis infec- tion. Monaldi Archives for Chest Disease, 2005, 63:158–162. Rezai MS et al. Disseminated bacillus Calmette-Guerin infec-5. tion after BCG vaccination. Journal of Tropical Pediatrics, 2008, 54:413–416 Taggart EW et al. Evaluation of an in vitro assay for gamma in-6. terferon production in response to Mycobacterium tuberculosis infections. Clinical and Diagnostic Laboratory Immunology, 2004, 11:1089–1093. Dogra S et al. Comparison of a whole blood interferon-gamma 7. assay with tuberculin skin testing for the detection of tubercu- losis infection in hospitalized children in rural India. Journal of Infection, 2007, 54:267–276. Kariminia A et al. Comparison of QuantiFERON TB-G-test to 8. TST for detecting latent tuberculosis infection in a high-inci- dence area containing BCG-vaccinated population. Journal of Evaluation in Clinical Practice, 2009, 15:148–151. Taylor RE, Cant AJ, Clark JE. Potential effect of NICE tuberculo-9. sis guidelines on paediatric tuberculosis screening. Archives of Disease in Childhood, 2008, 93:200–203. Friedman LN et al. High rate of negative results of tuberculin 10. and QuantiFERON tests among individuals with a history of positive skin test results. Infection Control and Hospital Epide- miology, 2006, 27:436–441. Mazurek GH et al. Detection of Mycobacterium tuberculosis 11. infection in United States Navy recruits using the tuberculin skin test or whole-blood interferon-gamma release assays. Clinical Infectious Diseases, 2007, 45:826–836. Marais BJ, Pai M. Recent advances in the diagnosis of child-12. hood tuberculosis. Archives of Disease in Childhood, 2007, 92:446–452. Ferrara G et al. Use in routine clinical practice of two com-13. mercial blood tests for diagnosis of infection with Myco- bacterium tuberculosis: a prospective study. Lancet, 2006, 367:1328–1334. Hill PC et al. Comparison of enzyme-linked immunospot assay 14. and tuberculin skin test in healthy children exposed to Myco- bacterium tuberculosis. Pediatrics, 2006, 117:1542–1548. Diel R et al. Tuberculosis contact investigation with a new, 15. specific blood test in a low-incidence population containing a high proportion of BCG-vaccinated persons. Respiratory Research, 2006, 7:77. Diel R et al. Predictive value of a whole blood IFN-assay for 16. the development of active tuberculosis disease after recent infection with Mycobacterium tuberculosis. American Journal of Research and Critical Care Medicine, 2008, 177:1164–1170. Book 17-9.indb 718 9/6/2011 12:43:18 PM طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2011 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Contents V olum e 17 N um ber 9 Septem ber 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 9 September / Septembre 2011 9 ددع / شرع عباسلا دلجلما برمتبس / لوليأ Letter from the Editor ........................................................................................................................................................637 Editorial Tranexamic acid – a recipe for saving lives in traumatic bleeding...........................................................................638 Research articles Cardiovascular disease and risk factors in patients with type 2 diabetes mellitus in Mashhad, Islamic Republic of Iran .............................................................................................................................................640 Road traffic injuries in Rawalpindi city, Pakistan ......................................................................................................647 Health disparities between Muslim and non-Muslim countries ............................................................................654 Incidence and causes of sudden death in a university hospital in eastern Saudi Arabia ......................................665 Evaluation of old-age disability and related factors among an Iranian elderly population ...................................671 Health information systems in the Islamic Republic of Iran: a case study in Kerman province ............................679 Lipoprotein changes in women taking low-dose combined oral contraceptive pills: a cross-sectional study in Basra, Iraq ........................................................................................................................684 Educational needs assessment for men’s participation in perinatal care ...............................................................689 Effect of quinine therapy on plasma glucose and plasma insulin levels in pregnant women infected with Plasmodium falciparum malaria in Gezira state ...............................................................................................697 Incidence of congenital malformation in 2 major hospitals in Rivers state of Nigeria from 1990 to 2003 ...........701 Detection of Trichomonas vaginalis by different methods in women from Dohok province, Iraq .......................706 Impact of intestinal parasites on haematological parameters of sickle-cell anaemia patients in Nigeria ............710 Evaluation of an interferon-gamma release assay in young contacts of active tuberculosis cases .......................714 The Blue Mosque, Mazar-i-Sharif, Afghanistan (photograph: WHO) Physical inactivity is the fourth leading risk factor for global mortality. Regular physical activity, including walking, helps to maintain cardiovascular fitness and healthy weight and reduce the risk of colon and breast cancer, and depression.