Eastern Mediterranean Health Journal [2010; Vol.16, Issue 10]

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: sabrib@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. 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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 Cover 6.indd 2 5/24/2010 11:46:47 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 16 No. 10 10 ددع شرع سداسلا دلجلما•  2010  • Letter from the Editor ...........................................................................................................................................................................................................................................................................................................1021 Editorial Screening for breast cancer in the Eastern Mediterranean Region A.B. Miller ...................................................................................................................................................................................................................................................................................................................................1022 Research articles First organized screening mammography programme in Saudi Arabia: preliminary analysis of pilot round S.S. Akhtar, H.M. Nadrah, M.A. Al-Habdan, S.A. El Gabbani, G.M.K. El Farouk, M.H. Abdelgadir and A.M. Al-Saigul. ....................................................................................1025 Epidemiology of breast cancer in women in Jordan: patient characteristics and survival analysis K. Arkoob, M. Al-Nsour, O. Al-Nemry and B. Al-Hajawi ................................................................................................................................................................................................................................1032 Serum concentrations of Helicobacter pylori IgG and the virulence factor CagA in patients with ischaemic heart disease A. Jafarzadeh, A. Esmaeeli-Nadimi, M. Nemati, M. Tahmasbi and P. Ahmadi ....................................................................................................................................................................................1039 Eosinophilic cationic protein: is it useful in assessing control of childhood asthma? M. Zedan, A. Settin, F. El-Chennawi, T. El-Desouky, N. Nasef and A. Fouda ........................................................................................................................................................................................1045 Integrated visceral leishmaniasis surveillance system in primary care for children in Meshkin-Shahr district, north-western Islamic Republic of Iran M. Mohebali, Gh.H. Edrissian, M.R. Shirzadi, Gh. Hossengholizadeh, M.H. Pashaei, A. Ganji, Z. Zarei, A. Kousha, B. Akhoundi, H. Hajjaran and H. Malekafzali ....................................................................................................................................................................................................................................................................................1050 Role of neutrophils in cutaneous leishmaniasis M.W. Daboul .............................................................................................................................................................................................................................................................................................................................1055 Absence of lymphatic filariasis infection among secondary-school children in Oman S.T. Al Awaidy, S. Bawikar, P.K. Patel, P. Kurup, G.S. Sonal, S. Al Mahrooqi and R . Ramzy ........................................................................................................................................................1059 Rotavirus gastroenteritis among children aged under 5 years in Al Karak, Jordan O. Nafi ...........................................................................................................................................................................................................................................................................................................................................1064 Prévalence des infections nosocomiales dans 27 hôpitaux de la région méditerranéenne K. Amazian, J. Rossello, A. Castella, S. Sekkat, S. Terzaki, L. Dhidah, T. Abdelmoumène, J. Fabry et les membres du réseau NosoMed ...............................................................1070 Knowledge, attitudes and practices of barbers about hepatitis B and C transmission in Hyderabad, Pakistan A.H. Jokhio, T.A. Bhatti and M.S. Memon ...............................................................................................................................................................................................................................................................1079 Patient satisfaction with mobile clinic services in a remote rural area of Saudi Arabia B. Aljasir and M.S. Alghamdi ...........................................................................................................................................................................................................................................................................................1085 Health care needs of Jordanian caregivers of patients with cancer receiving chemotherapy on an outpatient basis M.S. Al-Jauissy .......................................................................................................................................................................................................................................................................................... 1091 Review Demographic transition and potential for development: the case of Iraqi Kurdistan T.S. Al-Hadithi, N.P. Shabila, N.G. Al-Tawil and S.M. Othman ...................................................................................................................................................................................................................1098 Case report Chylothorax after coronary artery bypass and internal mammary artery harvesting: a case report A. Karimi, A. Salehi Omran and P. Yazdanifard ....................................................................................................................................................................................................................................................1103 طسوتلما قشرل ةيحصلا ةلجلما شرع سداسلا دلجلما عساتلا ددعلا 1021 ررحلما نم ةلاسر Letter from the Editor Breast cancer is the most common cancer and the second leading cause of cancer deaths in women today, after lung cancer. Accord- ing to WHO, more than 1.2 million women were diagnosed with breast cancer in 2008. The chance of developing invasive breast  cancer during a woman’s lifetime is approximately 1 in 7 (13.4%). Though much less common, breast cancer also occurs in men.  The high incidence and mortality rates of breast cancer, as well as the high cost of treatment and limited resources available, require that it should continue to be a focus of attention for public health authorities and policy-makers. The costs and benefits of fighting breast cancer, including the positive impact that early detection and screening can have, need to be carefully weighed against other competing health needs. Early detection with extensive screening and modern therapy has great potential to reduce mortality from breast cancer. The existing  literature on breast imaging technologies is clouded with uncertainty. There is hardly any perfect method to tell which technique per- forms better or the best. However, mammography is considered in many developed countries as the gold standard for early detection. A mammogram can detect cancer as much as a year or two before person or physician can feel it. Breast cancer detected in its earliest stages offers the greatest chance of remission and survival. It could reduce the mortality of breast cancer by 45% in women above the  age of 50 years who have been screened. Screening programmes should be undertaken only when their effectiveness has been demonstrated with sound evidence. Such pro- grammes require sufficient resources to cover nearly the entire target group, means for confirming diagnoses, facilities for treatment and follow-up of those with abnormal results, and justification of the effort and costs of screening when prevalence of the disease is high enough. While screening mammography can detect most breast cancers, it can miss up to 15% of cancers. If a physician detects a breast lump  with physical examination but the mammography does not reveal any abnormality, he or she will most likely recommend additional  breast imaging to further investigate the lump. Guidelines for the management of breast cancer prepared by the World health Organi- zation Regional Office for the Eastern Mediterranean and King Faisal Specialist Hospital and Research Centre (a WHO collaborat- ing centre for cancer prevention and care) provide an outline of the elements involved in diagnosis including clinical examination,  laboratory investigation, pathologic diagnosis, staging and risk assessment, and prognostic factors1. 1Guidelines for management of breast cancer. Cairo, WHO Regional Office for the Eastern Mediterranean, 2006 (Technical Publications Series 31, http://www.emro.who.int/dsaf/ dsa697.pdf, accessed 7 September 2010). ركذتو .ضرالحا انتقو في َّنهيف تايفولا بابسأ ةمئاق في ةئرلا ناطسر دعب ةيناثلا ةبترلما في تيأي ْذإ ،ءاسِّنلا ىدل ًاعويش رثكلأا َناطسرلا يدثلا ُناطسر ُّدَعُي يحايتجا يدث ناطسرب ةأرلما ةباصإ لماتحا لصيو .2008 ماع ةأرما فلأ ْيَتئمو نويلم نم رثكأ ىدل َص ِّخُش دق يدثلا ناطسر نأ ،ةيلماعلا ةحصلا ةمظنم .ميهدل ًاعويش لقأ هنكلو لاجرلا يدثلا ناطسر بيصي دقو .)%13.4( 7 نم 1 لىإ اتهايح ةرـتف لاوط تاطلسلا رارمتسا بوجو بلطتي ،ةحاتلما دراولما حش عم هتلجاعلم ةظهابلا فيلاكتلاو ،هنع ةجمانلا تايفولاو يدثلا ناطسر تاعوقو نم ةعفترلما تلادعلما نإ اهيف ماب ،يدثلا ناطسر ةحفاكم لىع بَّترـتت يتلا عفانلماو فيلاكتلا نأ لىع .يدثلا ناطسر لىع زيكرـتلا في سيايسلا رارقلا باحصأو ةيمومعلا ةحصلا في .ةسفانتلما ىرخلأا ةيحصلا تاجايتحلاا رئاس عم ةيانعب َنَزاوُت نأ يغبني ،هنع ي ِّرحتلاو هل ركابلا فشكلل ةيبايجلإا راثلآا في كشلا ُمويحو .هنع ةجمانلا تايفولا تلادعم ضفخ ناكمإ نم ًايرثك ديزت هل ةثيدلحا ةلجاعلماو ،يدثلا ناطسر نع ضيفتسلما ي ِّرحتلاب ركابلا فشكلاف لضفأ وأ اهيرغ نم ًاعفن رثكأ انهإ ثيح نم لماكلاب فَصوت ةقيرط يأ لىع رثعن داكن لاو .يدثلا ريوصت في ةمدختسلما تايجولونكتلا لوح ةيلالحا تايشرنلا رعشت نأ لبق ناطسرلا فشكي دق هنلأ ،ركابلا فشكلل ًايبهذ ًارايعم ةمدقتلما نادلبلا نم يرثك في برتعي يعاعشلا يدثلا ريوصت نأ ولو ؛قلطم لكشب اهاوس نم دقل ىتح ،ةايلحا ديق لىع ةضيرلما ءاقبو ضرلما عُجا ََِتل صرفلا رفوأ م ِّدقي هلحارم ركبأ في فشكي يذلا يدثلا ناطسر نإ مث .ينتنس وأ ةنسب اهبيبط ةدِّيسلا هب .يدثلا ناطسر نع يّرحتلل نعضخ نمم رمعلا نم ًاماع 50 قوف ءاسنلا ىدل %45 رادقمب يدثلا ناطسر نع ةجمانلا تايفولا لدعم ضفخ نكمأ اهلماكب ةفدهتسلما تاعومجلما ةيطغتل ةيفاك دراوم بلطتت ي ِّرحتلا جمابرف ؛ةغماد تانِّيبب اهتيلاعف تُبثت لم ام يعوُمُلجا يّرحتلا جمارب دماتعا مدع يغبنيو ءارجلإ ةمزلالا فيلاكتلاو دوهلجا غ ِّوسي ام بلطتت ماك ،ةيوس يرغ مهجئاتن نوكت نم ةعباتمو ةلجاعلم َقفاَرَمو ،صيخشتلا ديكأتل َلئاسو بلطتتو ،ًابيرقت .ًاعفترم راشتنلاا لّدعم نوكي امدنع ي ِّرحتلا هصحف ءانثأ يدثلا في ةلتك بيبطلا فشتكا اذإف .اهنم %15 فشك هتوفي دق هنإف ،يدثلا تاناطسر مظعم فشتكي نأ عيطتسي يعاعشلا يدثلا ريوصت ناك اذإو .ةلتكلا ءاصقتسلا ريواصتلا نم ديزلما بلط نم هل َّدُبلاف ،ةيوس يرغ تايرغت يدثلل يعاعشلا ريوصتلا ح ِّضوي نأ نود ةديسلل يريسرلا نواعتم زكرم وهو( هيف ثاحبلأا زكرمو صيصختلا لصيف كللما ىفشتسم عم نواعتلاب ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل يميلقلإا بتكلما َّدعأ دقو ماب ،صيخشتلل ةمزلالا صرانعلل ط َّطمخ لىع لمتشت ،يدثلا ناطسر ةلجاعم لوح ةيداشرإ لئلاد ،)هاضرم ةياعرو ناطسرلا نم ةياقولا لامج في ةمظنلما عم راذنإ ةروص مسر لمكتست يتلا لماوعلاو ،راطتخلاا مييقتو ،مرولا ةلحرم ديدتحو ،يجولوثابلا صيخشتلاو ةيبرتخلما تايّصقتلاو يريسرلا صحفلا اهيف .1ضرلما .)http: www.emro.who.int/dsaf/dsa697, pdf :31 مقرلا ،ةينقتلا تاروشنلما ةلسلس( .2006 ،ةرهاقلا ،ةيلماعلا ةحصلا ةمظنلم يميلقلإا بتكلما .يدثلا ناطسرل يجلاعلا يربدتلل ةيداشرلإا لئلادلا 1 EMHJ  •  Vol. 16  No. 10 •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1022 Editorial Screening for breast cancer in the Eastern Mediterranean Region A.B. Miller 1 1Associate Director Research, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada (Correspondence to A.B. Miller: ab.miller@sympatico.ca). Breast  cancer  is  the most  important  cancer  in women  in  the World Health  Organization (WHO) Eastern Medi- terranean Region  (EMR),  being  the  number  one  cancer  in  16  of  the  22  countries. In many technically advanced  countries mammography  screening,  generally from the age of 50 years, is the  most  common breast  cancer  control  strategy performed. The WHO has rec- ommended a step-wise approach to in- troducing screening, beginning with the  promotion of  early diagnosis  through  public  and professional  education,  to  pilot studies of organized programmes,  followed by national  programmes  as  resources permit  [1,2]. This approach  has been  incorporated  in  the Cancer  Control Strategy of the EMR Office of  WHO. In summary, the planning steps  include: 1: Where are we now? Assess the cancer problem;• Assess  the evidence-base  for  screen-• ing; Consider  alternative  strategies  to • reach  the  same objectives  (primary  prevention or improved treatment); Assess  the  existing  early  detection • plan and ongoing activities 2: Where do we want to be? Define the target population for early • detection of frequent cancers; Identify gaps  in early detection serv-• ices; Set objectives for early diagnosis and • screening;  Assess  the  feasibility of  screening  in-• terventions; Set priorities for screening.• 3: How do we get there? Plan procurement of key res ources;• Determine activities for early diagno-• sis and screening; Work with multidisciplinary and mul-• tisectoral teams; Move  from  policy  to  implemen-• tation. Working through these steps in rela- tion to each priority cancer site provides  the basis for the organization of screen- ing and enables  strategic decisions  to  be made  to  start or  stop screening  for  a specific site as part of a country’s Na- tional Cancer Control Plan.  In this issue of the EMHJ, Akhtar et  al. describe  the  initial  results  from  the  pilot phase of a mammography screen- ing programme  in Saudi Arabia. The  authors  are  to  be  complimented  on  conducting this pilot phase in a defined  area. A great deal of care seems to have  been taken to try and ensure the project  was  a  success. However,  compliance  with  attendance  for  mammography  screening was low, and the rate of recall  for abnormalities suspected high, while  the numbers of breast cancers detected  were  small. The authors admit  that by  the standards of many organizations in  the more developed countries, various  indicators suggest a need for much more  attention to some of the components of  an organized screening programme. In the study of Akhtar et al., 4 wom- en were detected with  invasive breast  cancer  as  a  result  of  the  screening of  1628 women, a detection rate of 2.5 per  1000. This breast cancer detection rate  was low, largely because the majority of  those screened were young. The age of 1  woman detected with breast cancer was  unknown, but of the 3 with known ages,  all were between 41 and 50 years. The 1  case of ductal carcinoma in situ (DCIS)  was  detected  in  a  younger  woman.  However,  there  is  no  good  evidence  that detecting cases of DCIS  is benefi- cial as these lesions, though markers of  risk, are not precursors of breast cancer  in the classic sense.  The numbers of detected  invasive  cancers,  though  small,  are compatible  with  the expected  incidence of breast  cancer  in Saudi Arabia  in women aged  40–49 years. They are  lower, however,  than was  found  in a population-based  breast  screening  trial  in Cairo, Egypt,  which used clinical breast examinations  performed by  specially  trained  female  doctors  in  sessions  at primary health  centres  as  the  primary  screen, mam- mography being used  for diagnosis  in  a hospital  serving  the community  [3].  Possible  explanations  for  the  higher  detection  rate  in  Cairo  are  that  the  social workers, who visited women  in  their homes  to  invite  them  for  screen- ing, were more successful in persuading  women with potential breast problems  to attend, and breast cancer  incidence  is higher  in Egypt  than  in many other  countries  in  the EMR,  including Saudi  Arabia. Thus the Cairo  trial has shown  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1023 that  it  is  feasible  to use  social workers  to  invite women  to attend  for  screen- ing breast  examinations while  there  is  preliminary indication that a stage shift  has  been  achieved  [4].  In Morocco,  after  a  pilot  study  of mammography  screening,  it has been decided  to base  breast  screening nationally on clinical  breast examinations. A similar decision  has been taken in Oman. In Egypt,  the  Ministry of Health and Population has  initiated  a mammography  screening  programme, using digital mammogra- phy, with images read in a central loca- tion. Although based on mobile units  visiting primary health care centres, this  seems to be largely opportunistic. Data  on coverage of the target group have not  been published. Successful screening requires a fully  organized programme. An organized  screening programme has a number of  components, including: An identifiable target group or popu-• lation, with  accompanying popula- tion registers; Implementation measures  available • to guarantee high coverage and par- ticipation; Access to high-quality screening;• Effective  referral  system  in place  for • diagnosis and treatment; Measures  in  place  to monitor  and • evaluate a programme [5]. The alternative to organized screen- ing  is  opportunistic,  or  laissez  faire,  screening. Organized screening is distin- guished  from opportunistic  screening  primarily on the basis of how invitations  to screening are extended. In organized  screening,  invitations should be  issued  to those at risk in a defined target popu- lation, preferably  through population  registers,  and measures  instituted  to  facilitate their attendance for screening.  In this context, risk is usually defined by  age and sex. In opportunistic screening,  invitations to screening are extended to  individuals when they encounter health  care  providers  for  reasons  unrelated  to  cancer. Opportunistic  screening  is  often inefficient because many who are  screened are not at high risk of cancer;  many in the population who should be  screened are not, and those that do re- ceive screening may be screened either  too  frequently or  too  infrequently. All  screening programmes  require  some  degree of organization to be successful,  and  as  the  extent of  the organization  of  the  various  elements  of  screening  increases, so too does the impact of the  programme.  In  the project described  by Akhtar  et  al.  the  invitations  issued  were disseminated by public  informa- tion  campaigns,  and were  not  based  upon a defined register.  It would seem  that  in  this  region of Saudi Arabia,  this  approach was not  sufficient  to ensure  that the majority of women in the target  group attended for screening. This sug- gests that further pilot phases are needed  evaluating ways  to  recruit women  into  screening before a national programme  can be mounted. One option would be  to  evaluate  the use of  social workers,  as  is being done in Sana’a, Yemen, and  Khartoum, Sudan, on  the  lines of  the  Cairo trial [4]. Another  aspect  of  the  study  of  Akhtar et  al.  to be  reconsidered  is  the  age group of women included. In west- ern  Europe  and North America,  the  large majority of programmes do not in- clude women under the age of 50 years.  Although this has not been the case  in  the United States of America  (USA),  where  the American Cancer  Society  and the American College of Radiology  urge annual  screening  from the age of  40  years,  recently  the US Preventive  Services Task Force recommended that  women aged 40–49 years  should not  receive routine mammography screen- ing [6]. The reasons  for  this were  that  the expected benefit was small, and the  harm (in  the  form of excessive  investi- gations) high. The number needed  to  invite  for screening  to prevent 1 breast  cancer  death was  calculated  as  1904  [7].  I  have  calculated  that  in  nearly  every country in the Region, it would be  necessary  to screen over 2000 women  aged 35–39 years  to detect 1  case of  breast cancer, approximately double the  number  that would need  to be  invited  if  they were  aged 40–49 years, which  implies  that  it would be necessary  to  invite approximately 5000 women aged  35–39 years  to prevent 1 death  from  breast  cancer  under  the  assumption  that there is a benefit from screening in  this age group, for which there is, as yet,  no  evidence. Thus,  it would be more  efficient  in  the  future not  to  attempt  to  recruit women under  the age of 40  years.  Indeed  including women  from  the age of 35 years in routine mammog- raphy screening programmes has never  been advocated in the more developed  countries, even in the USA. Because  of  the  larger  number  of  younger  than  older  women  in most  countries in the EMR, clinically a higher  proportion of women  in  their  thirties  and  forties  present  with  breast  can- cer  than would be  the  expectation  in  western Europe  and North America.  This has  led  to  the misunderstanding  that  somehow breast  cancer  is differ- ent in the countries in the Region than  in more  developed  countries. How- ever,  when  population-based  cancer  registries are active and it  is possible to  compute the risk of the development of  breast cancer by age, it appears that the  incidence of breast cancer at each age is  no higher, though it is often much lower  at older ages. This creates a problem for  countries  in  the Region  considering  mammography screening,  as  it  is now  accepted that mammography screening  is less effective in women under the age  of 50 years than in older women [7,8]. The difficulty  in  recruiting women  into screening, and its likely low efficacy  in relation to the main burden of breast  cancer  in  younger  women,  suggests  that  there  is  a  substantial  risk of  very  little benefit  from breast  screening  in  the Region, and that the priority should  shift  to early diagnosis  through health  education,  combined  with  effective  treatment of detected cases.  EMHJ  •  Vol. 16  No. 10 •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1024 WHO Guide for Effective Programmes. Cancer control. Knowl-1. edge into action: planning. Geneva, World Health Organization, 2006. WHO Guide for Effective Programmes. Cancer control. Knowl-2. edge into action: Early detection. Geneva, World Health Organi- zation, 2007. Boulos S et al. Breast screening in the emerging world: high prev-3. alence of breast cancer in Cairo. The Breast, 2005, 14:340–346. Miller A. Practical applications for clinical breast examination 4. (CBE) and breast self-examination (BSE) in screening and early detection of breast cancer. Breast Care, 2008, 3:17–20. Hakama M et al. Evaluation of screening programmes for gyne-5. cological cancer. British Journal of Cancer, 1985, 52:669–73. US Preventive Services Task Force. Screening for breast cancer: 6. U.S. Preventive Services Task Force recommendation state- ment. Annals of Internal Medicine, 2009,151:716–726. Nelson HD et al. Screening for breast cancer: an update for the 7. U.S. Preventive Services Task Force. Annals of Internal Medi- cine,, 2009, 151:727–737. IARC Handbooks on cancer prevention, vol 7. Breast cancer screen-8. ing. Lyon, IARC Press, 2002. Miller AB et al. Canadian National Breast Screening Study - 2.: 9. 13-year results of a randomized trial in women aged 50-59 years. Journal of the National Cancer Institute, 2000, 92:1490–1499. References Early diagnosis is defined by WHO  as  the  awareness  (by  the  public  or  health  professionals)  of  early  signs  and  symptoms of  cancer  in  order  to  facilitate diagnosis before  the disease  becomes  advanced  [2]. This  enables  more effective and simpler therapy. The  concept of early diagnosis is sometimes  called  “down-staging”.  In a population  where the majority of the cancers ame- nable  to early detection are diagnosed  in  late  stages,  the establishment of  an  early diagnosis programme may be the  most  feasible  strategy  to  reduce  the  percentage of advanced stages and im- prove  survival  rates  [2]. To  introduce  an  early diagnosis  programme based  on health education, however, will  re- quire special studies to help understand  women’s’  concept of  the  importance  of breast cancer and its curability if de- tected  early,  and  the ways  to  change  often  basic misunderstandings.  Any  education  programme devised must  be culturally appropriate,  so  it  cannot  simply be  imported  from  the  types of  programmes and pamphlets developed  in  other  regions.  Further,  it may  be  necessary  to  ensure  such  education  is  also addressed  to men as  they may  be  influential  in  the decision-making  that  results  in  a  woman  attending  a  primary health care centre for diagnosis  if  she becomes  concerned  about her  breasts.  It will  also mean  that primary  care physicians may have  to undergo  re-training, partly to ensure they do not  have  the  same misunderstanding  of  the potential curability of breast cancer  as  their patients, but  also  so  that  they  are able  to recognize  the signs of early  breast cancer. Once an early diagnosis programme  is  in place  and  there  is  evidence  that  it  is being  successful,  then,  in  accord- ance with WHO guidelines,  it would  be  appropriate  to  consider  screening.  However, if resources are not sufficient  to consider nationwide mammography  screening, it might be preferable to start  by  introducing  pilot  programmes  of  Clinical  Breast  Examination  screen- ing,  along  the  lines of  the Cairo  trial,  or  following  the model  of Morocco  and Oman,  reserving mammography  for diagnosis.  It  is  relevant  that  in  the  Canadian National Breast  Screening  Study we found no benefit from adding  annual mammography to clinical breast  examination screening  in women aged  50–59 years [9]. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1025 First organized screening mammography programme in Saudi Arabia: preliminary analysis of pilot round S.S. Akhtar,1,2 H.M. Nadrah,3 M.A. Al-Habdan,3 S.A. El Gabbani,4 G.M.K. El Farouk,1 M.H. Abdelgadir 5 and A.M. Al-Saigul3. ABSTRACT The aim of this study was to analyse results of the pilot screening round for Al-Qassim Screening Mammography Programme and compare with international standards. Analysis was conducted in the central screening office in Prince Faisal Oncology Centre, which coordinates activities of various screening units. Data were collected during the period 1 January 2007 to 30 June 2008. Organizational and functional information was obtained from policy and procedure manuals of the programme. Out of 9812 eligible women, 1766 (18%) participated and data were available for 1628 (16.6%). The median age of participants was 47 (standard deviation 8.12) years. The low uptake rate (18%) and a high recall rate (31.6%) characterized the pilot screening round. Biopsy rate was 1.5% and cancer detection rate was 0.24%. Many performance indicators in this pilot screening round were not available. Many of the available indicators did not meet international standards. 1Al-Qassim Screening Mammography Programme; 5Department of Family Medicine and Awareness Programme Committee, Al-Qassim Screening Mammography Programme, Buraidah, Al-Qassim, Saudi Arabia (Correspondence to S.S. Akhtar: shadsalim@hsshcc.org). 2Prince Faisal Oncology Centre, Buraidah, Al-Qassim, Saudi Arabia. 3Directorate of Health Services; 4Department of Family Medicine, Directorate of Health Services, Buraidah, Al-Qassim, Saudi Arabia. Received: 30/05/10; accepted: 07/07/10 ةلولجا نع ليوأ ريرقت :ةيدوعسلا ةيبرعلا ةكلملما في يعاعشلا ريوصتلاب يدثلا ناطسر يرحتل م َّظَنُمـلا لولأا جمانبرلا ةيدايترلاا دممح للها دبع ،رداقلا دبع نسح لمزم ،يكاخ قوراف دممح ةداغ ،نيابقلا حاتفلا دبع حلاص ،نادبلها ليع دممح ،ةرظان دممح ماشه ،رـتخأ ميلس داش لقيصلا لىإو ،يعاعشلا ريوصتلاب يدثلا ناطسر يرحتل ميصقلا جمانبرل ةيدايترلاا ةلولجا اهنع ترفسأ يتلا جئاتنلا ليلحتل ةساردلا هذه فدته :ةـصلالخا موقت يتلا ةطشنلأا قسني يذلا زكرلما وهو ،مارولأل لصيف يرملأا زكرم في يرحتلل يزكرلما بتكلما في ليلحتلا يرجأ دقو .ةيلماعلا يرياعلماب اهتنراقم لصحو ،2008 وينوي/ناريزح 30 لىإ 2007 رياني/نياثلا نوناك نم لولأا نـم ةدلما للاـخ تاـيطعلما تعجم دـقو .يرحتلا تادحو فلتمخ ابه ةلهؤم ةأرما 9812 ينب نم نأ مله حضتاو .جمانبرلا في تاءارجلإابو تاسايسلاب ةصالخا تابيتكلا نم ةيفيظولاو ةيميظنتلا تامولعلما لىع نوثحابلا فارحناب( ًاماع 47 تاهماسلما رمع طسوتم ناكو .نهنم )%16.6( 1628 لوح تايطعلما ترفاوتو ،نهنم )%18( 1766 يرحتلا في مهاس يرحتلل ءارجإ لدعم غلبو )%31.6( راكذتسلاا ل َّدعم عافتراو ،)%18( ماهسلإا لدعم ضافخناب ةيدايترلاا ةلولجا هذه تمستا دقو .)ماوعأ 8.12 يرايعم نم يرثكف ؛ءادلأا تاشرؤم نم يرثكلا ةساردلا نم ةيدايترلاا ةلولجا هذه في ينثحابلل رفوتي لمو .%0.24 ناطسرلا فشك لدعمو ،%1.5 تاعزلخا .ةيلودلا يرياعلما يبلت لا مله ترفاوت يتلا تاشرؤلما Premier programme de mammographie de dépistage en Arabie saoudite : rapport préliminaire de l’opération pilote RÉSUMÉ Le but de cette étude était d’analyser les résultats de l’opération pilote de dépistage organisée dans le cadre du programme de mammographie de dépistage d’Al-Qassim, et de les comparer aux normes internationales. L’analyse a été effectuée dans le bureau central de dépistage de Prince Faisal Oncology Centre, qui coordonne les activités de diverses unités de dépistage. Les données ont été collectées entre le 1er janvier 2007 et le 30 juin 2008. Les informations organisationnelles et fonctionnelles ont été extraites des manuels de politique et de procédures du programme. Sur 9812 femmes correspondant aux critères, 1766 d’entre elles (soit 18 %) ont participé à l’étude ; des données ont pu être collectées pour 1628 femmes (soit 16,6 %). L’âge médian des participantes était de 47 ans (écart-type 8,12). L’opération pilote de dépistage s’est caractérisée par un faible taux de participation (18 %) et un taux de rappel élevé (31,6 %). Le taux de biopsie était de 1,5 % et le taux de dépistage du cancer de 0,24 %. Il manquait de nombreux indicateurs de performance dans cette opération. Enfin, un grand nombre des indicateurs disponibles ne satisfaisaient pas les normes internationales. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1026 Introduction Large  randomized  controlled  trials  and  meta-analyses  have  reported  a  significant  decrease  in  breast  cancer  mortality  in women through screening  mammography [1,2]. As a result, many  countries  in Europe and North Amer- ica have  initiated national or  regional  screening mammography programmes for breast  cancer  [3]. The majority of  the developing  countries barely have  resources  to meet  the basic needs of  their population. The baseline incidence  of breast cancer in these countries may  still be  too  low to  justify wide applica- tion of  such population-based screen- ing programmes. However,  there  is  a  documented  increase  in breast cancer  incidence  in most of  these  countries,  and  this  is expected  to  rise  further [4].  Since  such programmes may  take  as  long as a decade to become operational- ly effective, it is prudent that if resources  exist, plans to decrease mortality due to  breast cancer should be activated before  it is too late. According  to  the  2008  report  of  the World Health Organization,  life  expectancy of  Saudi Arabian  females  is 73 years  [5]. Saudi Arabia,  an afflu- ent  country,  spends 3.4% of  its  gross  domestic product on health care. This is  the equivalent of around US$ 607 spent  per capita annually [5]. Breast cancer is  the commonest cancer seen in females  in  Saudi Arabia,  and  the majority  of  patients present with  advanced  stage  of disease [6,7]. As  resources are avail- able,  initiation of  a population-based  screening mammography programme  is feasible. As has been shown in the industrial- ized countries as well as in neighbouring  countries,  implementation  and  par- ticipation  in  screening mammography  programmes may reduce the incidence  of  late  stage of  breast  cancer  at  pres- entation, which may be an added ad- vantage of  such a programme  in Saudi  Arabia  [7–9].  It  is  indeed  recognized  that  the social and traditional values of  the population may  influence accept- ance of such a programme. It is impor- tant  to  recognize  that participation  in  breast cancer screening programmes  is  influenced by a multitude of  local  fac- tors. Studies conducted  in  the  Islamic  Republic of  Iran, Lebanon and Qatar  have shown that participation in screen- ing  programmes may  be  affected  by  religious belief, fear of encounter with a  male physician, embarrassment and fear  of the test itself [10–12].  Recently,  the  pilot  round  of  the  population-based  screening  mam- mography  programme  conceived  in  the central Al-Qassim region of Saudi  Arabia was concluded. This programme  is expected  to be  the basis  for a  future  national programme. We present here  the  preliminary  analysis  of  the  pilot  round of this programme.  Methods Approval  for  conducting  this  analysis  was acquired  from  the  regional  ethics  committee.  The  organizational  structure  of  the programme  is  shown  in Figure 1.  Unaizah  is  a mainly urban area of Al- Qassim region. It has a well-established  network of primary health care centres  (PHCs) connected by well-developed  roads,  telephones and  the  Internet  to  a  secondary  care hospital  in  the  area,  King Saud Hospital. Owing  to  its cen- tral location and proximity to Buraidah,  the capital city of Al-Qassim region, Un- aizah was selected for the pilot screening  round. Another rural township, Okalat- al Sakur, which has many desert dwell- ers living in the surrounding desert area  of  the  region, was also  included  in  the  pilot project. A public awareness team was consti- tuted by community medicine experts  and consisted of  female Saudi Arabian  nurses,  female  social  workers  and  a  committed group of  female volunteers  from  the public. They held  interactive  sessions with  females  invited  from the  pilot  areas  to discuss  the  importance  of  screening mammography  and  the  methods used. The public  awareness  campaign  also  included  exhibitions,  lectures,  information stalls  in shopping  malls, and boards and banners displayed  in the prominent areas of the region. The  male members of the team held special  sessions for the male residents of the pi- lot areas, and details of the programme  were discussed. Community  leaders,  government officials,  teachers,  clergy  and other persons of social importance  were  specially  invited. The awareness  campaign preceded  the  launch of  ac- tual screening by 6 months. The role of  the media in this campaign was limited  to  the coverage of various events. The  programme  started  recruiting  from 1  January 2007 and  the first  round was  completed on 30 June 2008.  Al-Qassim  Screening Mammog- raphy Programme  is aimed at women  aged 35–60 years. The screening  inter- val is 18 months. To be eligible, women  should  not  be  lactating  or  pregnant,  and should have no breast  symptoms.  Exclusion criteria  also  included previ- ous breast cancer, breast  implants and  a mammogram within  the previous 18  months.  Digital  mammography  has  the  advantage of  film-less digital  storage,  archiving at a distant site, easy retrieval  and manipulation of images. Since there  are data demonstrating the superiority of  digital mammography over film mam- mography  in  younger women,  it was  decided  to use only digital mammog- raphy units  for  this programme [13].  A  team of  radiologists  and  radiation  physicists assessed  the available mam- mography equipment  in  the  region: 7  analogue units were available. After as- sessment the units were either upgraded  to Computed Radiography System for  mammography  (CR) or  replaced by  Digital Mammography System (DR)  units. Initially 2 DR units were procured  for  the pilot project  screening  sites:  a  mobile unit (Selenia Full Field Digital  Mammography System, Hologic) and  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1027 another  unit  (Siemens, Mammomat  Novation) was  installed  in King Saud  Hospital,  Unaizah.  A  DR  unit  (GE  Senographe 2000D) and another CR  unit  (Agfa, Belgium) were  located  at  King Fahd Specialist Hospital, a tertiary  care  referral hospital,  in Buraidah. This  hospital has  the only oncology centre  (Prince Faisal Oncology Centre) in the  region, where  a  regular breast health  clinic is run. Two ultrasound machines  with high-resolution probes and elas- tography  facility  (Hitachi,  Japan  and  GE, United States  of America) were  installed  for  the pilot project, 1 at each  hospital. Whenever  required,  the par- ticipants were  referred  to King Fahd  Specialist Hospital  for  stereotactic bi- opsy procedures. The screening units consisted of 2  radiologists and a team of radiographers  and mammographers. Additional mam- mographers were selected  from a pool  of  female Saudi  technologists/nurses.  A  team of dedicated mammographers  trained  them for a period of 3 months  prior to the start of programme. A female  coordinator was designated as  liaison  between  the participating  teams at  the  static and mobile units. The mobile unit  was stationed at  the 30-bed hospital  in  Okalat-al Sakur  region  to cater  to  that  area. The DICOM (Digital  Imaging  and Communication in Medicine) im- ages were digitally  archived  and  read  at  the  central  reporting office at King  Fahd  Specialist Hospital. Data were  stored  in a  locally developed database  programme.  The mammography screening com- prised 2 views, craniocaudal and medi- olateral oblique. Two radiologists  read  the  images  independently,  and only  in  the event of consensus was the decision  taken either  to  investigate  the patient  further or return her to a routine follow- up. In case of discordance between the  2 radiologists, a third reading by a senior  member of  the central  team was  taken  as decisive.  In  Al-Qassim  region  medical  records  of  almost  all  the  inhabitants  are maintained at the local PHC. From  these files,  the PHC department pre- pared a  list of  registered  females  in  the  areas  selected  for  the pilot  round. For  each PHC, women of eligible age group  were  short-listed  with  their  contact  numbers and address.  In each PHC, a  coordinator was  designated  to  com- municate with eligible  females and  the  screening unit. Every  eligible woman  was contacted and, after checking exclu- sion criteria,  invited to the PHC where  demographic data were  recorded on a  previously drafted  form. Risk category  Screening unit Mobile unit Assessment centre (KSH, PFOC) Screening unit Static unit Evaluation Quality assurance Public education Awareness Professional training Planning Management Coordination Screening office, (PFOC) Call & recall, database, reporting Multidisciplinary case review Preliminary diagnosis treatment plan (PFOC) Referral to treatment or return visit Figure 1 Organizational structure of Al-Qassim Screening Mammography Programme (PFOC = Prince Faisal Oncology Centre; KSH = King Saud Hospital, Unaizah) Figure 2 Al-Qassim Screening Mammography Programme: flow chart of the process at the primary health care centre (high risk: prior radiotherapy; number of first degree relatives with breast cancer; number of previous benign breast biopsies; atypical hyperplasia in a previous biopsy) Symptom assessment & clinical breast examination Asymptomatic & normal Symptoms or abnormal examination Breast health clinic at Prince Faisal Oncology Centre High riskNormal risk Al-Qassim Screening Mammography Programme EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1028 was  identified  and  any  contraindica- tions  for  screening  mammography  were excluded. The coordinator secured  appointments  for  screening as well  as  subsequent assessment of the clients ac- cording to their convenience and men- strual  cycle. The assessment protocol  at  the PHC and a flow diagram of  the  programme are shown in Figures 2 and  3  respectively. Commencement of  the  programme was  announced  through  various media  channels,  newspapers  and display posters  in  the  region. The  screening  results were communicated  through the PHC and for those recalled  an appointment was made in the assess- ment clinics at King Saud Hospital or  King Fahd Specialist Hospital.  Details of participants undergoing  any kind of biopsy procedure were dis- cussed  in  the multidisciplinary  team  meetings. Those needing  therapy were  referred to Prince Faisal Oncology Cen- tre (Figure 3).  Results According  to  the 2004 census,  the  to- tal  number of  Saudi Arabian women  in Al-Qassim  region was 409 970,  of  whom 74 476 were aged 35–60 years  [14]. Out of these, 9812 resided in the 2  health care sectors selected for the pilot  screening round and these constituted  the target group. Only 1766 responded  to  the call  and attended  the  screening  round,  resulting  in  an  uptake  rate  of  17.99%  for  the first 18-month cycle of  the programme. Data were available for 1628 clients  in  the  temporary database developed  for the purpose. The median age of the  participants was 47 (standard deviation  8.12) years and the mean was 46.8 years.  Age distribution of  the participants  is  shown in Table 1: 54 of the participat- ing women were over 60 years  and 6  were over 70 years.  Following  the  initial  screening  round, 925 (56.82%) women were sent  back to return for a routine round after  18 months, while as 515 (31.6%) were  recalled  for an early  reassessment. For  188 women (11.5%) there was no infor- mation about follow-up in the database.  The detailed performance and quality  indicators of the pilot round are shown  in Table 2.  Tables  1  and  3  show  the  biopsy,  cancer detection rate and  follow-up as  related to the age groups screened. Our  early  recall  rate  ranged  from 28.2%  in  51-55 age group to a very high of 41.2%  in women >70 years of age (Table 1).  As shown in Table 3, no invasive cancer  was detected  in women younger  than  40 years of age in this pilot round. Discussion In  a  previous  study  from Al-Qassim,  around 50% of women residing  in  the  region had never heard about breast self  examination,  and  those who had did  not practise it regularly [15]. Improving  awareness and practice  rates of breast  self  examination  among  the  popula- tion could be an easy and cost–effective  method for early detection of breast can- cer  in a country with different cultural,  ethnic and racial make-up. However, a  recent trial involving 300 000 women in  another developing country, China,  in- dicated that breast self examination did  not reduce breast cancer mortality rates  [16]. Screening mammography  there- fore,  remains  the method of choice  to  decrease mortality due to breast cancer.  Organized screening programmes can  ensure quality control of  the screening  process  and monitor  interim  indica- tors  showing whether  the programme  is on  track  towards achieving a  reduc- tion  in breast  cancer mortality  in  the  population. Conversely, opportunistic  programmes  such as charity or  fee  for  service  programmes  are  delivered  in  an ad hoc  fashion without  targeting or  recalling women who are most likely to  Figure 3 Al-Qassim Screening Mammography Programme: flow chart of screening process (PHC = primary health care centre; PFOC = Prince Faisal Oncology Centre) Cancer Normal/benign Screening visit Programme participants Non-participants Normal Abnormal Asymptomatic ≥ 35 – < 60 years Communicate result to woman through the physician Personal invitation to re-screen PFOC for therapy Diagnostic follow-up at PFOC Breast Health Clinic Communicate result and appointment to woman through PHC physician Programme promotion: Awareness campaign Physician education Personal invitation to screening through PHC طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1029 benefit from screening mammography.  A  recent  study comparing  the 2  types  of  screening has confirmed  the higher  sensitivity of  a population-based pro- gramme [17]  Al-Qassim  Screening Mammog- raphy  Programme  is  the  first  organ- ized  population-based  screening  mammography programme  in Saudi  Arabia. It was imperative that results were  compared  to  international  standards  to  confirm  that  the  programme was  achieving its goals.  The  uptake  of  our  pilot  screen- ing  round  (17.9%) was much  lower  than  reported  in  similar pilot projects  conducted  in Europe: 42%–45%  in  a  Swiss pilot project, 36.7%  in a French  pilot programme, 36%  in Luxembourg  and 45.1%  in a first  round  in Hungary  [18–21]. Our uptake  rate was much  lower than the standard figure of more  than 70% recommended by  the Euro- pean Union and  the United Kingdom  [22,23].  The factors known to influence first  time attendance  for  screening  include  being married, working,  low or mid- dle  levels  of  education  and  income,  misinformation,  ineffective  health  communication,  competing priorities,  participating  in  early  detection prac- tices,  perceiving mammography  as  a  sensitive technique for detecting breast  cancer  and  seeing oneself  as  suscep- tible  to breast  cancer  [24,25].  Indeed  the characteristics and demography of  our population were quite unlike  the  Europeans, with  strong cultural differ- ences. These could have had a bearing  on uptake  rate  in our programme.  In  future, it would be interesting to analyse  the  factors  and barriers  affecting  the  participation by the eligible population  of this region.  The recall  rate, 31.6%,  for early as- sessment  in  the pilot  screening  round  was much higher than the international  guidelines  set by  the European Union  and the United Kingdom (Table 2). Ac- cording to European Union guidelines,  the proportion of women  recalled  for  early  assessment  should be  less  than  7%  in an  initial  screening examination,  and the desirable level is below 5% [22].  In a  review of European programmes,  the recall  rate varied  from 1.3%–18.4%  Table 1 Al-Qassim screening mammography programme pilot screening round: type of recall related to the age group of screened population Age group (years) No. women screened Type of recall Routine Early No information No. % No. % No. % ≤ 40 353 221 62.6 104 29.5 28 7.9 41–45 346 199 57.5 111 32.1 36 10.4 46–50 401 212 52.9 139 34.7 50 12.5 51–55 294 176 59.9 83 28.2 35 11.9 56–60 158 80 50.6 55 34.8 23 14.6 61–65 37 19 51.4 12 32.4 6 16.2 > 65 17 8 47.1 7 41.2 2 11.8 Unknown 22 10 45.5 4 18.2 8 36.4 Total 1628 925 56.8 515 31.6 188 11.5 Table 2 Performance and quality indicators of the pilot screening round of the Al- Qassim Screening Mammography Programme Indicator Present series International standard EU [14] UK [15] No. of women eligible for pilot project in the 2 health sectors (target population) 9812 No. of women screened 1766 Uptake rate (%) 17.9 > 75 > 75 No. of women for whom data were available 1628 No. of women recalled 515 Recall ratea (%) 31.6 < 5 < 7 Total No. of biopsiesb 25 Biopsy rate (%) 1.5 Biopsy rate among recalled patientsa (%) 4.85 Benign biopsy rate per 1000 screened 12.3 < 3.6 Total no. of cancers detected 5 No. of invasive cancers 4 Cancer detection rate per 1000 screened 2.45 > 1.5 DCIS per 1000 screened 0.61 > 0.4 – < 0.9 DCIS (% of malignant cases) 20 > 15 aTotal number biopsies/number of women recalled for assessment ×100. bIncludes stereotactic core biopsies, fine needle aspiration cytology and open surgical biopsies. EU = European Union; UK = United Kingdom; DCIS= duct carcinoma in situ. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1030 [26].  In  another  comparative  assess- ment of performance  indicators of  in- ternational  screening mammography  programmes in 14 countries, recall rate  on initial screening varied from 1.4% in  the Netherlands to 15.1% in the United  States of America [27].  A decline  in  recall  rate  across  age  and in subsequent screens has also been  documented  [27]. We did not note a  decline in the recall rate with increasing  age:  in our pilot  round,  recall  rate was  lowest  in  the  age  group 51–55 years  (28.2%)  and highest  in women aged  over 65 years (41.2%).  A high recall rate causes psychologi- cal morbidity and  indicates  inefficient  use of screening resources and women  have to undergo unnecessary and costly  follow-up  investigations. At  the  same  time, too low a recall rate may decrease  the detection  rate and  increase  the  in- cidence of subsequent  interval cancers.  Double reading by consensus or arbitra- tion reportedly decreases the recall rate  [28]. This is standard practice in our pro- gramme, hence should have decreased  the recall  rate. Numerous explanations  could be hypothesized  to explain our  high recall rate: our physicians may tend  to  recall women with  suspicious find- ings, even in the absence of a possibility  of cancer, to avoid possible malpractice  litigation; our mammography  readers  are  low-volume  readers by definition,  interpreting around 100 mammograms  a month; interpreting a high volume of  mammograms  is known  to  lessen  the  recall rate [29].  Other  factors, which are known to  have an impact on the recall rate include  the age of the screened population, type  of  mammography  equipment  used,  technical problems and  training of  the  mammography staff. It would be  inter- esting to analyse the reasons for the high  recall rate in a future study.  In French pilot and Norwegian pro- grammes  the biopsy  rate was  similar  to our rate: 1.2% and 1.9% respectively  [19,30]. The biopsy rate may be related  to the rate of recall. A higher recall rate  will decrease the proportion of women  biopsied  among  those  recalled  com- pared to a programme with a low recall  rate. The number of biopsies related to  the total number screened, of course, re- mains constant. The biopsy rate among  our  recalled women was 4.85%, which  is quite  low compared  to 39.2%  in  the  Norwegian programme [30].  The  cancer  detection  rate  in  this  first screen, also called prevalent screen,  was 0.24%. Cancer detection  rate de- pends upon baseline incidence of breast  cancer in the population. Consequently,  the detection  rate  in our programme  was  lower  than  even  those European  countries  that have  the  lowest detec- tion rates, Finland 0.37% and Hungary  0.36% [21,31]. Conclusion Many performance  indicators  of  the  pilot  round  of  Al-Qassim  Screening  Mammography Programme were not  available. Many of  those available did  not meet  recommended  international  standards. There  is  an urgent need  to  review and revise the whole programme  in order to achieve the following goals: increase the participation rate,• decrease the recall rate,• improve the detection rate,• develop or procure  a purpose-built • database with trained staff to receive,  enter and analyse the data. Acknowledgements The  authors would  like  to  thank Dr  Salah Al Kharas,  the Director General  Health Affairs Al-Qassim, and Dr Atef  Mohammed Saroor, Director General  Audit, Ministry of Health, Saudi Arabia,  for  their  logistic  support. The authors  also wish to thank Dr Imran-Ul-Haque,  Consultant Histopathologist,  Prince  Faisal Oncology Centre,  and Dr Mo- hammed Mahmoud Sami,  Specialist  Radiologist,  Al-Qassim  Screening  Mammography Programme,  for  their  contribution to the programme. The  pilot  screening  round  of  Al- Qassim Screening Mammography Pro- gramme utilized the available resources  of the Ministry of Health. Table 3 Al-Qassim screening mammography programme: biopsy (including stereotactic core biopsy, fine needle aspiration cytology and open surgical biopsy) and cancer detection according to the age group screened Age group (years) Benign DCIS Invasive cancer Total <40 4 1 0 5 41–45 4 0 1 5 46–50 8 0 2 10 ≥ 51 3 0 0 3 Unknown 0 0 1 1 Total 19 1 4 24 DCIS = duct carcinoma in situ. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1031 References Elmore JG et al. Clinical Review: Screening for breast cancer. 1. Journal of the American Medical Association, 2005, 293:1245– 1256. Fletcher SW, Elmore JG. Clinical practice: mammographic 2. screening for breast cancer. New England Journal of Medicine, 2003, 348:1672–1680. International Cancer Screening Network:3. Organized Population- Based Breast Cancer Screening Programs in 22 Countries Surveyed in 1995, USA, NCI, and Updated 2007 (http:// appliedresearch.cancer.gov/icsn/breast/screening.html, ac- cessed on 1st September 2010). Potter P. Perspective: “Westernizing” women’s risks? Breast 4. cancer in lower income countries. New England Journal of Medicine, 2008, 358:213–216. WHO Country profile, Saudi Arabia5. . Geneva, World Health Or- ganization, 2008 (http://www.who.int/countries/sau/en/, accessed 10 August 2010). Khatib O, Aljurf M. Cancer prevention and control in the 6. Eastern Mediterranean region: the need for a public health approach. Hematology/oncology and stem cell therapy, 2008, 1:44–52. Akhtar SS, Nadrah HM. Assessment of the quality of breast can-7. cer care: a single institutional study from Saudi Arabia. Interna- tional Journal for Quality in Health Care, 2005, 17:301–305. Taplin SH et al. Evaluating organized breast cancer screening 8. implementation: the prevention of late-stage disease? Cancer Epidemiology, Biomarkers & Prevention, 2004, 13:225–234. Tarabeia J et al. A comparison of trends in incidence and 9. mortality rates of breast cancer, incidence to mortality ratio and stage at diagnosis between Arab and Jewish women in Is- rael, 1979–2002. European Journal of Cancer Prevention, 2007, 16:36–42. Hatefnia E et al. Correlates of mammography utilization among 10. working Muslim Iranian women. Health Care for Women Inter- national, 2010, 31:499–514. Adib SM et al. Research in action: mammography utilization 11. following breast cancer awareness campaign in Lebanon 2002–05. Eastern Mediterranean Health Journal, 2009, 15:6–18. Bener A et al. Do we need to maximize the breast cancer 12. screening awareness? Experience with an endogenous society with high fertility. Asian Pacific Journal of Cancer Prevention, 2009, 10:599–604. Pisano ED et al. Diagnostic performance of digital versus film 13. mammography for breast-cancer screening. New England Jour- nal of Medicine, 2005, 353:1773–1783. KSA census for the year 200414. . Riyadh, Ministry of Planning, Saudi Arabia (http://www.cdsi.gov.sa/showproductstandard. aspx?lid=26&pid=1658, accessed 8 April 2009). Akhtar SS et al. Beliefs and attitudes about breast self examina-15. tion in Al-Qassim region of Saudi Arabia. A study of women attending primary health care centres. Saudi Medical Journal, 1995, 16:493–497. Thomas DB et al. Randomized trial of breast self examination 16. in Shanghai: final results. Journal of the National Cancer Insti- ture, 2002, 94:1445–1447. Bihrmann K et al. Performance of systematic and non-system-17. atic (‘opportunistic’) screening mammography: a comparative study from Denmark. Journal of Medical Screening, 2008, 15:23–26. Bulliard JL., De Landtsheer JP, Levi F. Results from the Swiss 18. mammography screening pilot programme. European Journal of Cancer, 2003, 39:973–978. Wait SH, Allemand HM. The French breast cancer screening 19. programme. Epidemiological and economic results of the first round of screening. European Journal of Public Health, 1996, 6:43–48. Autier P et al. A breast screening progrmamme operating in 20. a liberal helath care system: the Luxembourg mammography programme 1992–1997. International Journal of Cancer, 2002, 97:828–832. Boncz I et al. The organization and results of first screening 21. round of the Hungarian nationwide organized breast cancer screening programme. Annals of Oncology, 2007, 18:795–799. Perry N et al. 22. European guidelines for quality assurance in breast cancer screening and diagnosis, 4th ed. Brussels, European Com- munity, 2006 (http://www.euref.org/ND7306954ENC_002. pdf, accessed 10 August 2010). Saving lives through screening: NHS breast screening pro-23. gramme annual review 2008. London, NHS, Cancer Screening Programmes, 2008 (http://www.cancerscreening.nhs.uk/ breastscreen/publications/nhsbsp-annualreview2008.pdf, accessed 10 August 2010). Aro AR et al. Psychosocial predictors of first attendance for or-24. ganized mammography screening. Journal of Medical Screen- ing, 1996, 6:82–88. Lamyian M et al. Barriers to and factors facilitating breast 25. cancer screening among Iranian women: a qualitative study. Eastern Mediterranean Health Journal, 2007, 13:1160–1169. Lynge E et al. Reporting of performance indicators of mam-26. mography screening in Europe. European Journal of Cancer Prevention, 2003, 12:213–222. Yankaskas BC et al. International comparison of performance 27. measures for screening mammography: can it be done? Jour- nal of Medical Screening, 2004, 11:187–193. Kopans D. Double reading. 28. Radiologic Clinics of North America, 2000, 38:719–724. Esserman L et al. Improving the accuracy of mammography: 29. volume and outcome relationships. Journal of the National Cancer Institute, 2002, 94:369–374. Hofvind S et al. Using the European guidelines to evaluate the 30. Norwegian breast cancer screening program. European Journal of Epidemiology, 2007, 22:447–455. Dean PB, Pamilo M. Screening mammography in Finland—1.5 31. million examinations with 97 percent specificity. Acta Onco- logica, 1999, 38:47–54. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1032 Epidemiology of breast cancer in women in Jordan: patient characteristics and survival analysis K. Arkoob,1 M. Al-Nsour,2 O. Al-Nemry 3 and B. Al-Hajawi 2 ABSTRACT The 5-year survival rate of female breast cancer cases in Jordan and some of the factors that affected survival were measured. All Jordanian women newly diagnosed with breast cancer during 1997–98 were included. Data were obtained retrospectively from the Jordan Cancer Registry and hospital records. Of 838 women included, half were diagnosed between the ages 40 and 59 years. The overall Kaplan–Meier 5-year survival rate was 59.3%. Stage, laterality and grade had a significant effect on survival rate. However, Cox proportional regression showed that tumour stage was the only factor that significantly influenced survival analysis after controlling for other factors. Further studies are needed to confirm the results and to ensure the inclusion of other factors. 1Al-Basheer Hospital, Ministry of Health, Jordan. 2Disease Control and Prevention Directorate, Ministry of Health, Jordan (Correspondence to M. Al-Nsour: mohannadnsour973@yahoo.com). 3Jordan Cancer Registry, Ministry of Health, Jordan. Received: 08/12/07; accepted: 06/01/09 ندرلأا ،ةايلحا ديق لىع ءاقبلا ليلاتحو تاضيرلما صئاصخ :ءاسنلا ىدل يدثلا ناطسر تايئابو يوا َّجلحا ماسب ،يرمّنلا رمع ،روسنلا دَّنهم ،بوقرع وبأ لماك .هيف ةرِّثؤلما لماوعلا لىع اوفرعتو ،ندرلأا في يدثلا ناطسرب تاباصلما ىدل تاونس سخم ةدلم ةايلحا ديق لىع ءاقبلا لدعم نوثحابلا ساق :ةـصلالخا ةقيرطب تايطعلما لىع نوثحابلا لصحو .1998 – 1997 ينماعلا في يدثلا ناطسر نيهدل ص ِّخُش تيلالا تايندرلأا عيجم ةساردلا تلمش دقو ّنهفصن ىدل ص ِّخُش ،ةأرما 838 ةساردلا نهتلمش تيلالا ءاسنلا ددع غلبو .تايفشتسلما تلاجس نمو ناطسرلل نيدرلأا لجسلا نم ةيداِعتْسا نأ حضتاو .59.3% :ريام – نلاباك قفو تاونس سخم ةدلم ةايلحا ديق لىع ءاقبلا لدعم لياجمإ غلبو .ًاماع 59 – 40 رمع في ّنهو يدثلا ناطسر نأ لاإ ،ةايلحا ديق لىع ءاقبلا لدعم لىع ًايئاصحإ هب ُّدَتْعُي ًارثأ ةباصلإا ةجردو ،ةباصلإل ةبسنلاب بنالجا ةينادحوو ،ضرلما اهغلب يتلا ةلحرلما نم لكل ديق لىع ءاقبلا ليلتح لىع ًايئاصحإ هب ُّدَتْعُي ًايرثأت رثؤي يذلا ديحولا لماعلا لِّثتم مرولا اهغلب يتلا ةلحرلما نأ رهظأ دق سكوك بسحب يبسنلا ف ُّوَحَّتلا .نابسلحا في ىرخلأا لماوعلا جاردإ نماضلو ،جئاتنلا نم د ُّكأتلل تاساردلا نم ديزلما ءارجلإ ةجالحا ستمو ،ىرخلأا لماوعلا طبض دعب ةايلحا Épidémiologie du cancer du sein chez les femmes : caractéristiques des patients et analyse du taux de survie en Jordanie RÉSUMÉ Le taux de survie à cinq ans chez les femmes atteintes d’un cancer du sein en Jordanie et certains des facteurs ayant eu une influence sur la survie ont été mesurés. Toutes les femmes jordaniennes chez lesquelles un nouveau diagnostic de cancer du sein avait été posé en 1997-1998 ont été incluses. Les données ont été obtenues rétrospectivement dans le Registre du cancer jordanien et les dossiers hospitaliers. Pour la moitié des 838 femmes incluses, le diagnostic avait été établi entre 40 et 59 ans. Le taux de survie global à cinq ans par la méthode Kaplan-Meier était de 59,3 %. Le stade, la latéralité et le grade avaient un effet important sur le taux de survie. Toutefois, le modèle de régression à effet proportionnel de Cox a révélé que le stade de la tumeur était l’unique facteur ayant une véritable influence sur l’analyse de la survie après l’élimination d’autres facteurs. Des études supplémentaires sont nécessaires pour confirmer les résultats et garantir l’inclusion d’autres facteurs. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1033 Introduction Breast  cancer  is  considered  to be  the  most  common  cancer  throughout  the world.  Statistics  show  that  about  700 000  cases  are  reported  annually,  about 57% of them in developing coun- tries [1]. Data from the United States of  America  indicate  that  the  incidence of  breast cancer increases directly with age  until 75–80 years [2]. In Jordan, cancer  is  the  second most  frequent  cause of  death after  cardiovascular disease  [3].  According to official Jordanian statistics,  breast cancer was the most common of  all cancers in women in the last decade  [3], a figure that agrees with the results  obtained from different countries in the  region [4,5].  The survival rate is one of the most  important measures of cancer care, and is  a valuable tool for comparisons between  countries. Studies of cancer patient sur- vival, using data from population-based  cancer registries, are essential for moni- toring and evaluating  the effectiveness  of the diagnosis and treatment of cancer  [6]. The higher  survival  rates being  re- corded  in  some developed  countries  reflect  improvements  that have  taken  place in various areas of cancer control,  from health education and early diag- nosis to treatment and after care [7]. In- formation about survival rates in Jordan  will help us take further preventive and  control measures  in order  to  improve  the prognosis of patients with different  types of cancers. The present study aim  to  identify  the epidemiology of  female  breast cancer in Jordan in 1997–98; to  measure  the observed 5-year  survival  of female breast cancer cases diagnosed  in Jordan in the years 1997–98; and to  explore  some of  the  factors  that affect  survival  rates,  such as age at diagnosis,  type,  grade  and  stage of  tumour. The  majority of  studies  in  Jordan  to date  have been descriptive,  and  to  the best  of our knowledge  this  is  the first  study  of  survival  rates  at  population-based  registry level in Jordan.  Methods Study design This  was  a  descriptive  study  using  data  from the  Jordan Cancer Registry  (JCR). Established  in 1996,  the  JCR  is  a  population-based  registry  that  provides  statistics on  the  incidence of  cancer throughout Jordan. JCR obtains  its  information  about  patients  from  governmental  and nongovernmental  health care facilities and military hospi- tals  throughout  the country and  from  laboratories  and  the  Jordan National  Civil Department. Liaison personnel  in  the main hospitals  are  responsible  for  registering  and  reporting  all  cases  of cancer by completing a special  form  containing demographic  and medical  data, which is sent to JCR.  Data collection for the current study  lasted more  than 3 months. All  cases  of breast  cancer  in women  that were  registered  in  the  JCR and were newly  diagnosed during  the period 1  Janu- ary 1997  to 31 December 1998 were  included in the study. Cases that could  not be verified by a histopathology  re- port were excluded. Data collection Special  data  collection  forms  were  designed  for  the  study  to  collect  so- ciodemographic  information about  the  patient (national ID number, name, age  at diagnosis, address) and  information  related  to  current  cancer  status  (his- topathology  report,  laterality,  stage of  cancer, grade and stage of  the  tumour,  date of diagnosis, date of  last visit,  and  outcome). The validity and reliability of  the  study  instrument were  tested  in a  pilot study and some variables in the data  collection instrument were modified. Patients were first  identified  from  the JCR registry, after which the medi- cal  records and histopathology reports  from the  reporting hospital were con- sulted  to complete  the data. The out- come (alive or dead) was ascertained  from the Civil Registration Department  using  the patient’s unique national  ID  number. Each patient was  followed up  until dead or alive at the end of data col- lection period, i.e. for up to 5 years from  the date of diagnosis to the cutoff point  at 31 December 2003. The  follow-up  endpoint was  death  from  any  cause.  Some patients were  lost  to  follow-up  as no  information was available about  them. The final number of patients was  838. Duplication of data was avoided  by using  the patient’s unique national  ID number and full (4) names (patient,  father, grandfather and family name). Official approval  for  the  study was  obtained from the medical ethics com- mittee of the Ministry of Health before  starting  data  collection. All  informa- tion about patients was handled under  conditions of  strict confidentiality and  data were  analysed  anonymously  by  ID number. No contact was made with  patients or their relatives. Definitions Laterality was subdivided into right, left,  bilateral and unknown (undetermined  or data missing). Histopathology  type  was categorized into: ductal carcinoma,  lobular  carcinoma,  adenocarcinoma,  medullary  carcinoma  and  unknown  (undetermined  type or data missing).  Tumour  stage  was  classified  into  4  stages using  the American  Joint Com- mittee  on  Cancer  TNM  [tumour,  node,  metastasis]  criteria:  stage  I,  stage II, stage III, stage VI or unknown  (undetermined stage or data missing).  Tumour grade was divided  into 5 cat- egories:  grade 1  (well-differentiated);  grade  2  (moderately  differentiated);  grade 3 (poorly differentiated); grade  4  (undifferentiated)  and  unknown  (undetermined grade or data missing). Data management and statistical analysis Data were entered and analysed using  SPSS,  version 12. Frequencies of  so- ciodemographic and clinical character- istics of all patients were obtained. The  survival  rates  at  1-year  intervals were  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1034 estimated using the actuarial (life-table)  method and overall  survival  rates us- ing exact survival  times were estimated  using  the Kaplan–Meier product  limit  technique. Log-rank  testing was used  to  test  for  an association between  the  variables and  the  survival  rate. P-value  < 0.05 was considered  statistically  sig- nificant.  Survival probabilities by  age,  type of  cancer,  laterality,  grade,  stage  and treatment were obtained. Cox pro- portional hazard regression analysis was  performed  to  assess  the  independent  effect of different prognostic factors after  simultaneously controlling for the effect  of potential confounders.  Initially all of  the  following variables were entered  in  the model:  age,  type,  laterality,  grade,  stage and treatment modality.  Results A total of 838 women with breast cancer  were  included  in  this  study. The mean  age of  the patients was 50.2 (standard  deviation  12.4)  years.  Slightly more  than  half  the  patients  diagnosed  fell  into  the 40–49  and 50–59 years  age  groups. The  left  breast was  the most  commonly affected site (44.6%). More  than three-quarters (77.5%) of patients  were diagnosed with ductal carcinoma  and  41.7%  of  tumours  were moder- ately well-differentiated.  Almost  half  (47%) the patients  received combined  treatment  of  surgery,  chemotherapy  and radiotherapy. More than one-third  of patients (37.6%) were  in  stage  II at  diagnosis.  The  period  of  follow-up  ranged  from 1 day to 5 years. Just over half the  patients (51.4%) were known to be still  alive 5 years after first diagnosis, while  34.8% were recorded as dead and data  were missing for 13.9% (Table 1).  Calculation of  the  survival  rates at  1-year  intervals are presented  in Tables  2 and 3. Using the actuarial method, the  5-year survival rate for breast cancer cases  was 59.3% (Table 2). The percentage of  women surviving 1 year after diagnosis  was 91.6%, for 2 years 80.1%, for 3 years  70.2% and for 4 years 65.8%. The cumulative 5-year survival rates  by the Kaplan–Meier method as a func- tion of  the different prognostic  factors  studied  (age,  type,  laterality,  grade,  stage and  treatment) are presented  in  Table 3.  Figure  1  shows  the  survival  curves for the same variables. The high- est 5-year survival rate by age was in the  age group 40–49 years (67.2%), and the  poorest  survival  rate  in  the age group  > 30 years  (43.8%). The  survival  rate  for patients affected  in  the  right breast  Table 1 Distribution of female breast cancer cases diagnosed in Jordan in 1997–98 by selected characteristics Characteristic No. of cases % Age (years) < 30 21 2.5 30–39 155 18.5 40–49 224 26.8 50–59 248 29.6 60–69 130 15.5 70+ 60 7.1 Laterality Right 366 43.7 Left 374 44.6 Bilateral 13 1.6 Unknown 85 10.2 Morphology type Ductal 649 77.5 Lobular 63 7.5 Other 126 15.0 Grade Grade 1 50 5.9 Grade 2 340 41.7 Grade 3 288 35.5 Grade 4 30 3.5 Unknown 130 13.1 Stage Stage I 151 18.0 Stage II 315 37.6 Stage III 169 20.2 Stage IV 86 10.3 Unknown 117 14.0 Treatment Surgery 72 8.5 Surgery & radiotherapy 162 19.3 Surgery & chemotherapy 70 8.3 Surgery, radio- & chemotherapy 390 46.5 Unknown 144 17.1 Vital status Alive 430 51.4 Dead 293 34.8 Unknown 115 13.9 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1035 Table 2 Calculation of survival rates (actuarial method) of female breast cancer cases diagnosed in Jordan in 1997–98 Interval of last observation (years) No. alive at start of year No. dying during year No. last seen alive during year Effective no. exposed to risk of dying Death rate during year (%) Survival rate over year (%) Cumulative survival rate (%) 0–< 1 838 66 115 782.5 8.4 91.6 91.6 1–< 2 657 82 0 657 12.3 87.5 80.1 2–< 3 575 71 0 575 12.3 87.6 70.2 3–< 4 504 31 0 504 6.1 93.8 65.8 4–< 5 473 65 0 473 13.7 86.2 59.3 Table 3 Survival rates (Kaplan–Meier analysis) of female breast cancer cases diagnosed in Jordan in 1997–98 by selected characteristics Characteristic No. of cases No. of deaths Survival time (years) Cumulative 5-year survival rate (%)Mean 95% CI Age (years) < 30 15 9 3.69 2.98–4.40 43.8 30–39 138 62 3.95 3.72–4.18 55.1 40–49 204 67 4.26 4.07–4.45 67.2 50–59 207 92 3.93 3.73–4.13 56.7 60–69 115 43 4.11 3.85–4.38 62.6 70+ 60 20 3.91 3.47–4.36 56.5 Morphology type Ductal 549 226 4.07 3.95–4.19 58.8 Lobular 61 25 3.92 3.54–4.30 59.0 Other 114 42 4.01 3.73–4.29 63.2 Laterality Right 334 130 4.13 3.98–4.28 61.1 Left 337 138 4.01 3.86–4.17 59.1 Bilateral 12 10 2.58 1.66–3.51 16.7 Unknown 41 15 4.10 3.62–4.57 63.4 Grade Grade 1 50 12 4.57 4.11–5.02 73.9 Grade 2 340 116 4.27 4.10–4.45 66.8 Grade 3 288 168 3.58 3.35–3.81 43.8 Grade 4 30 17 3.21 2.32–4.10 42.9 Unknown 130 48 4.17 4.01–4.32 63.4 Stage Stage I 151 6 4.86 4.75–4.97 96.0 Stage II 315 80 4.27 4.12–4.42 71.4 Stage III 169 92 3.78 3.58–3.98 39.6 Stage IV 86 81 2.41 2.10–2.71 5.8 Unknown 117 36 4.10 3.98– 4.24 59.3 Treatment Surgery 72 30 3.89 3.36–4.42 58.3 Surgery & radiotherapy 162 48 4.17 3.81–4.53 69.0 Surgery & chemotherapy 70 30 3.81 3.22–4.40 56.3 Surgery, radio- & chemotherapy 390 166 4.06 3.89–4.23 56.8 Unknown 134 19 4.41 4.05–4.62 82.2 CI = confidence interval. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1036 Figure 1 Breast cancer survival rates in women diagnosed in Jordan 1997–98 according to selected variables (RT = radiotherapy; CTR = chemotherapy) طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1037 was 61.1% and  for  the  left breast was  59.1%; however  the  survival  rate was  only 16.7% for bilateral breast cancer, a  difference  that was  statistically  signifi- cant (P < 0.001). According  to  the dif- ferentiation grade of the tumour, 5-year  survival  for well-differentiated  tumours  was  73.9%  compared with 42.9%  for  undifferentiated  tumours (P < 0.001).  The 5-year  survival  rates were 71.4%,  39.6% and 5.8% for tumours in stage II,  III and  IV at diagnosis  respectively (P < 0.001). Regarding  treatment  given  to  the patients, 5-year  survival  for pa- tients receiving only surgery was slightly  higher (58.3%) than for those receiving  triple therapy of surgery, chemotherapy  and radiotherapy (56.3%), but  the dif- ference was not significant (P = 0.45).  Cox proportional hazard regression  analysis was performed to assess the in- dependent effect of different prognostic  factors after simultaneously controlling  for  the  effect  of  potential  confound- ers. All of  the  following variables were  initially entered  into  the model—age,  type,  laterality,  grade,  stage  and  treat- ment modality—but  only  laterality,  grade and stage of cancer were kept  in  the final model. Table 4 shows the haz- ard ratio and  the significance  for  these  3 variables. According  to  tumour stage  the best  survival was  found  for  stage  I  (hazard ratio of dying = 1.00) compared  with  the other stages (P < 0.001). The  grade of  the  tumour and  the  laterality  did not reach the level of significance in  the model.  Discussion Our study provides substantial informa- tion about  the  survival  rate of women  diagnosed with breast cancer in Jordan  in  1997–98. While TNM  staging  at  diagnosis,  laterality  and  grade  had  a  significant effect on  survival  rate, Cox  proportional regression analysis showed  that  after  controlling  for other  factors  tumour  stage was  the only  factor  that  influenced survival. Age and grade had  no  statistically  significant  association  with survival.  Consistent with studies  from other  countries  in  the  region  [8–11],  our  study  showed  that  the overall  5-year  survival rate for breast cancer in Jordan,  regardless of stage or grade, was 59.6%.  The 1-year  rate was 91.6%,  the 2-year  rate  was  80.1%,  the  3-year  rate  was  70.2% and the 4-year rate was 65.8%.  In line with other studies, we found  that the overall survival rate was poorer  in  the  age  group < 30  years  (43.8%)  compared with the age group > 70 years  (56.5%)  [12–14]. Lack of  competing  causes of death, higher frequency of un- differentiated  tumours and more cases  diagnosed at  stage  II or  III have previ- ously been suggested as  the  reason  for  the poor  survival  experience of young  women with breast  cancer  [2,15].  In  contrast, a study in the United States of  America about breast cancer  in young  patients  aged < 35 years  showed  that  overall 5- and 10-year survival rates were  65%  and  49%  respectively  and  con- cluded that young age was not directly  related to the “aggressiveness” of breast  cancer [16].  Consistent  with  a  study  from  Europe [17], the best survival rate in our  study was seen in the age group 40–49  years. This  could be explained due  to  access  to  screening mammography  in  this  age  group or due  to  lower  levels  of  circulating  sex hormones,  resulting  in  reduced  stimulation of  tumour cell  growth [18,19]. There was a  statistically  significant  association between survival and lateral- ity, which was 61.1% in the right breast  and 59.1%  in  the  left breast, while  in  bilateral  cases  the 5-year  survival was  only 16.7%. This  is probably explained  by  the more aggressive disease present  in bilateral cases of breast cancer. The TNM stage proved  to be  the  most  significant  independent  prog- nostic  factor  for determining  survival.  In our  study only 55.6% of cases were  diagnosed at  stage  I and II, whereas  in  Canada 75% were diagnosed at  stage  I  and  II  [11]. Regular mammography  combined with regular clinical examina- tion may offer  the best opportunity of  increasing the proportion of early stage  cases detected. In our study, the 5-year survival rate  varied according to stage. This was prob- ably due to the fact that stage reflects the  interaction between  the host  and  the  tumour. The  frequency distribution of  Table 4 Cox regression analysis of survival rates of female breast cancer cases diagnosed in Jordan in 1997–98 by laterality, grade and stage Variable ExpB 95% CI P-value Laterality Right 1.00 – – Left 1.06 0.73–1.54 0.76 Bilateral 1.33 0.41–4.34 0.63 Grade Grade 1 1.00 – – Grade 2 0.74 0.30–1.86 0.52 Grade 3 0.96 0.38–2.42 0.93 Grade 4 1.14 0.22–5.90 0.88 Stage Stage I 1.00 – – Stage II 6.46 2.00–20.88 0.002 Stage III 17.99 5.53–58.56 < 0.001 Stage IV 72.33 21.58–242.4 < 0.001 CI = confidence interval. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1038 stage and 5-year  survival by  stage was  similar  to data  reported by  the Ameri- can Cancer Society [18,20]. However,  information from Bahrain showed that  that the 5-year survival rate ranged from  87.5% at stage I to 48% at stage IV [8],  which  differs  from  the  results  of  the  present study. A strength of our study is that it was  population-based, comprising virtually  all histologically verified cases registered  in the JCR, and was therefore not subject  to the selection bias of studies that select  samples. Another important strength of  the study was  the ability  to  investigate  the impact of demographic, histological  and  therapeutic  factors on  survival  in  breast cancer. Furthermore,  the size of  the  study was  sufficiently  large  to per- form survival  analysis  across different  subgroups of breast cancer cases.  On other hand, some weaknesses of  our study should be addressed. First, as  in other population-based studies,  the  medical records were not complete and  there was  some  information missing.  Although notification of  cases  to  the  JCR  is mandatory,  the  exact  cause of  death was not  recorded  in all cases,  so  we assumed that cancer was  the cause  of  death  unless  otherwise  specified.  The exact cause of death in population- based studies may not always be clearly  determined. Since  30.5%  of  the  breast  cancer  cases were diagnosed at  stage  III  and  stage  IV, great efforts  should be made  to  improve  this percentage  through a  good surveillance system and screening  programmes  for high-risk groups. De- termining the prognosis in cancer cases  depends on accurate data on prognostic  factors  and  the  appropriate  choice of  therapeutic  and  supportive  interven- tions.  Further  studies  are  needed  to  confirm our  results  in a  larger  sample  and perhaps  to ensure  the  inclusion of  other factors such as number of  lymph  nodes affected, pregnancy history,  age  at menarche, use of oral contraceptives,  menopausal  status and oestrogen and  progesterone levels. References World health report 1988. Life in the 21st century: a vision for all1. . Geneva, World Health Organization, 1998. Breast cancer incidence and mortality—United States, 1992. 2. Morbidity and Mortality Weekly Report, 1996, 45(39):833–837. Directorate of Information Studies and REsearch. 3. Mortality in Jordan, 2005. Amman, Ministry of Health, 2008.. El Saghir NS et al. Age distribution of breast cancer in Lebanon: 4. increased percentages and age adjusted incidence rates of younger-aged groups at presentation. Le Journal Medical Liba- nais, 2002, 50(1–2):3–9. Omar S et al. Breast cancer in Egypt. 5. Eastern Mediterranean Health Journal, 2003, 9(3):448–463. Dickman PW, Hakulinen T. 6. Population-based cancer survival analysis (statistics in practice series). New Jersey, John Wiley, 2000. Dickman PW et al. Survival of cancer patients in Finland 7. 1955–1994. Acta Oncologica, 1998:22–25. Fakhro AE et al. Breast cancer: patient characteristics and sur-8. vival analysis at Salmaniya Medical Complex, Bahrain. Eastern Mediterranean Health Journal, 1999, 5(3):430–439. Al-Moundhri M et al. The outcome of treatment of breast cancer 9. in a developing country—Oman. Breast, 2004, 13(2):139–145. Vahdaninia M, Montazeri A. Breast cancer in Iran: survival 10. analysis. Asian Pacific Journal of Cancer Prevention, 2004, 5(2):223–225. Ravichandran K, Hamdan NA, Dyab AR. Population based 11. survival of female breast cancer cases in Riyadh Region, Saudi Arabia. Asian Pacific Journal of Cancer Prevention, 2005, 6(1):72–76. Ugant AM et al. Survival of women with breast cancer in Ot-12. tawa, Canada: variation with age, stage, histology, grade and treatment. British Journal of Cancer, 2004, 90, 1138–1143. Berrino F et al., eds. 13. Survival of cancer patients in Europe: the EUROCARE study. Lyon, International Agency for Research on Cancer, 1995 (IARC Scientific Publications No.132). Sant M et al. Survival of women with breast cancer in Europe: 14. variation with age, year of diagnosis and country. The EURO- CARE Working Group. International Journal of Cancer, 1998, 77:679–683. Bonnier P et al. Age as prognostic factor in breast cancer: 15. relationship to pathologic and biologic features. International Journal of Cancer, 1995, 62(2):138–144. Sariego J et al. Breast cancer in young patients. 16. American Jour- nal of Surgery, 1995, 170(3):243–245. Celko AM. Breast cancer epidemiology in the Czech Republic. 17. Central European Journal of Public Health, 1996, 4(2):106–109. Coebergh JWW et al. Survival of adult cancer patients in 18. Europe diagnosed from 1978–1989: the EUROCARE II study. European Journal of Cancer, 1998, 34:2137–2278. Gizlice Z. Breast cancer incidence, mortality and survival in 19. North Carolina. SCHS Studies, 1997, September (No. 108). Breast cancer facts and figures 1996/1999–200020. . American Can- cer Society [website] (www.cancer.org/statistics/96bcffsurv. html, accessed 3 April 2010). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1039 Serum concentrations of Helicobacter pylori IgG and the virulence factor CagA in patients with ischaemic heart disease A. Jafarzadeh,1 A. Esmaeeli-Nadimi,2 M. Nemati,1 M. Tahmasbi 2 and P. Ahmadi 1 ABSTRACT To compare the serum concentrations of IgG to Helicobacter pylori and its virulence factor CagA in patients with ischaemic heart disease (IHD), we recruited 120 patients with IHD [acute myocardial infarction (AMI) (n = 60); unstable angina (UA) (n = 60)] and 60 sex- and age-matched healthy controls in this study. The seroprevalence of anti-H. pylori IgG was 86.7% in AMI, 91.7% in UA patients and 58.3% in the control group with mean titres of 33.2 U/ml [standard error (SE) 4.76], 57.96 U/ml (SE 7.54) and 25.72 U/ml (SE 4.01) respectively. The seroprevalence of anti-H. pylori in the patient groups was significantly higher than the control group. The mean levels of anti-H. pylori in the AMI and UA groups were also significantly higher than in the control group. The seroprevalence and mean titre of anti-CagA IgG did not differ significantly between patient and control groups. 1Department of Immunology, Medical School; 2Department of Internal Medicine, Ali-ebne-Abitaleb Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Islamic Republic of Iran (Correspondence to A. Jafarzadeh: Jafarzadeh14@yahoo.com). Received: 30/01/09; accepted: 29/03/09 بلقلا ضرمب ينباصلما في CagA يعوفلا اهماعلو ةيبا َّوبلا تاَّيِوْلَملل داضلما »ج-جيلأا« يعانلما ينلوبولغلل ةيلصلما زيكارـتلا يرافقلإا يدحمأ سيدرب ،يبسماهط ميرم ،يتمعن ميرم ،يميدن لييعماسإ ليع ،هدازرفعج للها دبع ينباصلما ينب ،CagA يعْوَفلا اهماعو ةيباوبلا تاّيولملل داضلما IgG »ج-جيلأا« يعانلما ينلوبولغلل ةيلصلما زيكارـتلا ةنراقم ليبس في :ةـصلالخا 60و ،ّدالحا بلقلا لضع ءاشتحاب ًاباصم 60 مهنم ،يرافقلإا بلقلا ضرمب ًاباصم 120 ةساردب نوثحابلا ماق ؛دهاوشلا ينبو يرافقلإا بلقلا ضرمب راشتنلاا ل َّدعم نأ نوثحابلا دجوو .سنلجاو رمعلا ثيح نم ضىرلما عم ينلثماتلما ءاحصلأا دهاوشلا نم 60 لباقم في ةرقتسلما يرغ ةحبذلاب ًاضيرم دهاوشلا في غلبي ينح في ،%91.7 ةرقتسلما يرغ ةحبذلاب ينباصلما فيو ،%86.7 غلبي دالحا ءاشتحلااب ينباصلما في ةيباوبلا ةّيولملل داضلما ج-جيلأل ليصلما يرغ ةحبذلاب ينباصلما فيو ،)4.76 هرادقم يرايعم أطخ عم( لم/ةدحو 33.2 ءاشتحلااب ينباصلما في هتارايع ُّيطسو غلب ثيح ،%58.3 ءاحصلأا .)4.01 هرادقم يرايعم أطخ عم( لم/ةدحو 25.72 ءاحصلأا دهاوشلا في غلب ينح في ؛)7.54 هرادقم يرايعم أطخ عم( لم/ةدحو 57.96 ةرقتسلما ىدل هيلع وه امم ًايئاصحإ ابه ُّدتعُي ةبسنب لىعأ ضىرلما يتعوممج في ةيباوبلا ةّيولملل داضلما يعانلما ينلوبولغلل ليصلما راشتنلاا لّدعم نإف اذه لىعو لىعأ ةرقتسلما يرغ ةحبذلاو بلقلا لضع ءاشتحا ضىرم ىدل ةيباوبلا تايولملل داضلما ج-جيلأا ىوتسم يطسو ناك ماك .ءاحصلأا دهاوشلا ةعوممج لماعلل داضلما ج-جيلأل يطسولا رايعلاو ليصلما راشتنلاا ل َّدعم نأ نوثحابلا دجو ماك .دهاوشلا ْيَتعوممج ىدل هيلع وه امم ًايئاصحإ هب ُّدَتْعُي رادقمب .دهاوشلا ةعوممجو ضىرلما ْيَتَعوممج ينب ًايئاصحإ هب ُّدَتْعُي ًافلاتخا افلتيخ لم CagA يعْوَفلا Concentrations sériques d’IgG anti-Helicobacter pylori et facteur de virulence CagA chez les patients souffrant de cardiopathie ischémique RÉSUMÉ Afin de comparer les concentrations sériques de l’IgG anti-Helicobacter pylori et son facteur de virulence CagA chez les patients souffrant de cardiopathie ischémique (CI), nous avons recruté dans cette étude 120 patients souffrant de ce type d’affection [infarctus aigu du myocarde (IAM) (n = 60) ; angine de poitrine instable (API (n = 60)] et 60 témoins en bonne santé appariés selon l’âge et le sexe. La séroprévalence de l’IgG anti-H.pylori était de 86,7 % chez les patients IAM, 91,7 % chez les patients API et 58,3 % dans le groupe témoin avec des titres moyens de 33,2 U/ml [erreur-type (ET) 4,76], 57,96 U/ml (ET 7,54) et 25,72 U/ml (ET 4,01) respectivement. La séroprévalence de l’IgG anti-H.pylori dans les groupes de patients était nettement supérieure à celle du groupe témoin. Les taux moyens d’IgG anti-H.pylori dans les groupes IAM et API étaient également nettement supérieurs à ceux du groupe témoin. La séroprévalence et le titre moyen de l’IgG anti-CagA ne présentaient pas de différence significative entre les groupes de patients et le groupe témoin. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1040 Introduction A number of  etiological  factors have  been determined for development of is- chaemic heart disease (IHD). Although  there are several major known risk  fac- tors for the development of coronary ar- tery disease, about 50% of patients with  this condition do not have any of these  risk  factors  [1].  It has been  suggested  that  inflammatory  reactions may play  an important role in the pathogenesis of  IHD [2] An association between IHD  and  some  infectious  agents  including  Chlamydia pneumoniae, herpes  simplex  virus (HSV), cytomegalovirus (CMV)  and hepatitis A,  respiratory  tract  and  dental  infection has been  reported  in  some epidemiological studies [2]. How- ever,  some prospective  studies  failed  to demonstrate  a  strong  relationship  between the presence of IgG antibodies  to C. pneumoniae,  HSV-1  and CMV  and  the occurrence of  coronary  arte- rial disease [3]. Some investigators also  have assessed the relationship between  H. pylori  and  IHD,  reporting a  strong  positive association [4–6] a moderate  association  [7–10] and even negative  association [11–14].  Strains of H. pylori  are  genetically  diverse and have been divided into type  I and type II according to the expression  or non-expression of  cytotoxin-asso- ciated gene A (CagA) [15]. CagA has  been identified as a virulence marker of  H. pylori  and  the cagA+ strains  induce  more severe disease and  inflammatory  response [15]. Since CagA is immuno- dominant,  the detection of  serum IgG  to the CagA antigen has been reported  as a reliable marker of carriage of cagA+  H. pylori strains [16]. We have recently  reported  that  the  seroprevalence  of  H. pylori  in healthy  Iranian adults was  67.5% and  in healthy children 46.6%;  the prevalence of  anti-CagA antibody  was 72.8% in infected adults and 67.4%  in infected children [17].  Elevated levels of C-reactive protein  (CRP), fibrinogen, homocysteine, pro- inflammatory cytokines and antibodies  to some heat shock proteins are known  to be associated with an  increased risk  of cardiovascular events [18]. Chronic  infections  such  as H. pylori  may  be  behind  these  changes. However,  the  role of H. pylori as a risk factor for IHD  remains debatable. This study was con- ducted for the first time to evaluate the  seroprevalence of antibody to H. pylori and bacterial  virulence  factor CagA  in  Iranian patients with IHD to clarify the  possible relationships. Methods A  total  of  120  patients  aged  40–65  years with  IHD who were admitted to  Ali-Ebne-Abitaleb Hospital in Rafsanjan  (a city in Kerman province in the south- east of  the country) during  the period  March–December 2007 were enrolled  to  this cross-sectional,  case-controlled  study. Sample size was calculated at 50  (using P1 = 90%; P2 = 60%;  α = 5%;  β = 10%), which was  increased  to 60  in each group for the actual sample,  i.e.  120 patients  altogether. Patients were  classified  into 2  groups  according  to  well-established criteria as having acute  myocardial  infarction (AMI) or unsta- ble angina (UA). AMI was diagnosed  by  the presence of 2 of  these criteria:  prolonged chest pain compatible with  AMI, typical ECG changes, elevation of  cardiac enzymes. Patients with non-ST  elevation were excluded from the study.  UA was defined  according  to Braun- wald’s classification and all patients had  chest pain at rest with definite ischaemic  electrocardiographic  changes  such as  ST-segment  changes  and/or T-wave  inversion; all UA patients were  in class  IIIB according to Braunwald’s classifica- tion [3]. Exclusion criteria were valvular  heart  disease,  surgery,  trauma within  the previous month,  cardiomyopathy,  liver  disease,  renal  failure, malignant  diseases,  other  inflammatory  disease  (such as  septicaemia and pneumonia)  and oral anticoagulant  therapy. A third  sex-  and  age-matched  group  with  similar geographic and socioeconomic  status comprised 60  subjects without  any IHD, registered as a control group.  The healthy control group was recruited  from blood donors at Rafsanjan Blood  Transfusion Centre. All  patients  and  controls were  residents  of Rafsanjan  city.  The  study was  evaluated  and  ap- proved by  the Ethical Committee of  Rafsanjan University of Medical  Sci- ences. Informed consent was given and  all  those  recruited had agreed  to give  blood samples. Peripheral  blood  (2–4 mL)  was  collected  from  the participants  in  the  3 groups and  the serum separated and  stored at –20 °C. In patients with AMI  the serum samples were collected dur- ing 3–5 days after admission; in patients  with UA they were collected at admis- sion. Determination of H. pylori- specific antibodies in serum The serum  levels of  anti-H. pylori  im- munoglobulin G (IgG) were measured  using a commercial enzyme-linked im- munosorbent  assay (ELISA) (Trinity  Biotec, Ireland) according to the manu- facturer’s  guidelines. The  results were  expressed as U/mL and a cut-off value  of  5 U/mL was used  to discriminate  negative from positive samples.  Serum levels of anti-CagA IgG were  also assayed by ELISA using commer- cial kits (Diagnostic Bioprobes,  Italy).  The serum concentrations of anti-CagA  antibodies were expressed  in arbitrary  units  (Uarb/mL) as no  international  standard  is available. According  to  the  manufacturer’s guidelines, a cut-off value  of 5 Uarb/mL was used to discriminate  negative from positive samples. The se- rum concentrations of anti-H. pylori and anti-CagA antibodies were expressed as  mean and standard error (SE). Statistical analysis Differences  in variables were analysed  using analysis of variance, t-test, Mann– Whitney U  test, Kruskal–Wallis  test  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1041 and Chi-squared  test  as  appropriate,  and P-values < 0.05 were  considered  significant. All  the available data were  analysed using SPSS, version 15.0. Results Baseline characteristics Baseline  characteristics of  the partici- pants are shown in Table 1. The patient  and control groups were similar  in age  and male/female ratio, but patients had  significantly higher prevalence of clas- sic  risk  factors  for  IHD (hypertension,  dyslipidaemia and diabetes) compared  with the control group. Anti-H. pylori IgG seropositivity The  overall  seroprevalence  of  anti- H. pylori IgG was 89.2% among patients  with  IHD and 58.3% among healthy  controls with mean  titre 45.58 U/mL  (SE 4.58) and 25.72 U/mL (SE 4.01)  respectively. The  prevalence  of  anti- H. pylori IgG was significantly higher in  IHD patients compared to  the control  group (P < 0.0001). The mean  titre of  anti-H. pylori  antibodies  in  the  IHD  group was significantly higher than that  observed in the control group (P < 0.01)  (Table  2). The  seropositivity  rate  of  anti-H. pylori  antibody was 86.7% and  91.7% in the AMI and UA groups with  mean titre of 33.2 U/mL (SE 4.76) and  57.96 U/mL  (SE  7.54)  respectively.  The  seroprevalence  of  anti-H. pylori antibodies in AMI and UA groups was  also significantly higher compared to the  control group (P < 0.0001). The mean  titre of anti-H. pylori antibodies in AMI  and UA groups was significantly higher  than  that  observed  in  control  group  (P < 0.05 and P < 0.001  respectively).  The seroprevalence of anti-H. pylori was  similar  in patients with AMI and UA.  No significant difference was observed  between  the AMI and UA groups  re- garding  the mean  titre of anti-H. pylori antibodies (Table 2). Anti-CagA seropositivity The overall seroprevalence of anti-CagA  IgG was 60.7%in H. pylori-infected pa- tients with  IHD and 65.7%  in  infected  asymptomatic healthy  subjects; mean  titres were 37.68 Uarb/mL (SE 8.35)  and 16.84 Uarb/mL (SE 2.88) respec- tively. There was no  significant differ- ence between IHD and control groups  regarding  the prevalence of anti-CagA  antibodies. There was  no  significant  difference between  IHD and  control  groups  regarding  the mean  titre of  se- rum anti-CagA antibodies, although this  parameter was higher in the IHD group  in comparison to asymptomatic healthy  subjects. The seropositivity rate of anti- CagA antibody was 55.8% and 65.5% in  H. pylori-infected patients with AMI and  UA  respectively; mean  titres were 42  Uarb/mL (SE 15.42) and 33.61 Uarb/ mL (SE 7.32) respectively (Table 2).  Statistical analysis  showed  that  the  differences for both seroprevalence and  mean titre of anti-CagA antibodies were  not  significant between  the AMI and  UA groups  compared  to  the  control  group. The prevalence  and  the mean  titre  for  anti-CagA  antibodies  were  similarly expressed in patients with AMI  and UA (Table 2).  Discussion In  this  study  the  seroprevalence  of  anti-H. pylori  IgG and  the mean  titre  of anti-H. pylori antibodies were signifi- cantly higher in patients with IHD com- pared to the healthy control group. The  seropositivity rate for H. pylori infection  varies greatly between studies (Table 3).  Moreover,  the association of H. pylori with  IHD  may  also  differ  between  countries or even within a country. The  discrepancies may be attributed  largely  to differences  in  age,  socioeconomic  status,  race  and  ethnic  background.  Moreover, different inclusion criteria of  patients and controls used in the various  studies, differences  in  the distribution  of  traditional  risk  factors of  IHD and  genetic heterogeneities of H. pylori may  account  for  some differences. Accord- ingly,  the  results of one study may not  necessarily apply  to other populations,  even within the country.  H. pylori  infection might  partici- pate  in  IHD pathogenesis  via  direct  or  indirect effects. The presence of H. pylori DNA has been demonstrated  in  the  aortic  tissues  and  atherosclerotic  plaques of  the majority patients with  coronary heart disease, which could be  an  important  indication of  the direct  role of bacteria  in  the pathogenesis of  disease [19]. Accordingly, H. pylori can  directly provoke  inflammation within  the atherosclerotic plaques.  Table 1 Baseline characteristics of patient and control groups Characteristic Acute myocardial infarction (n = 60) Unstable angina (n = 60) Controls (n = 60) P-valuea Mean (SEM) age (years) 54.6 (9.7) 55.8 (9.6) 52.98 (8.7) NS Sex (men/women) (No.) 39/21 35/25 33/27 NS Hypertension (No.) 7 8 0 0.01 Dyslipidaemia (No.) 10 6 0 0.01 Diabetes mellitus (No.) 7 9 0 0.01 aComparing all patients with ischaemic heart disease and healthy control group. SEM = standard errof of the mean. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1042 Our  results  showed no  significant  differences between patient  and con- trol groups regarding the prevalence of  serum anti-CagA antibodies, which  in- dicates  that CagA-positive strains were  not more related to IHD in comparison  to CagA-negative strains. However, the  results  of  a  systematic meta-analysis  confirm  the hypothesis  that  infection  with CagA-seropositive strains is signifi- cantly associated with susceptibility  to  coronary heart disease  [20]. The con- troversial results of some studies regard- ing  the  association of CagA  status of  H. pylori with  IHD have been summa- rized in Table 4. It has also been reported  that there is wide geographical variation  in  the genotype of CagA+ strains [24].  Moreover, the polymorphisms in genes  encoding  for  some cytokines  such  as  IL-1,  TNF-α  and  IFN-γ  have  been  associated with H. pylori-related  dis- eases such as gastric cancer and peptic  ulcer  [25]. Accordingly,  it  seems  that  both  host  and  bacterial  factors may  account  for  these differences. Further  studies on  the  interaction between H. pylori  and  the host genotype, which  in  turn could determine  the  intensity of  the  inflammatory  responses, may  ex- plain the development of IHD in some  H. pylori-infected subjects. Consistent with our findings  in  the  present  study,  we  recently  observed  that  serum concentrations of hs-CRP  were not affected by  the expression of  bacterial CagA virulence  factor  [26].  However,  in our previous study  in  the  same population,  an  important  asso- ciation was observed between infection  with CagA-positive H. pylori strains and peptic ulcer  [27], which  indicate  that  the  role  of  the CagA-positive  strains  may  differ  in  peptic  ulcer  and  IHD  pathogenesis.  We  have  demonstrated  that  the  mean  titre of  anti-H. pylori  antibodies  in patients with  IHD was  significantly  higher  than  that observed  in a control  group. Moreover,  the mean serum lev- els of anti-CagA antibodies were higher  in patients than controls, but the differ- ences were not  statistically  significant.  Recently, cross-reactivity between rab- bit serum with high levels of anti-H. py- lori  and antigens  from atherosclerotic  carotid arteries has been demonstrated  [28].  It has been also shown that anti- CagA antibodies are capable of reacting  with both bacterial CagA and proteins  present  in  the wall of  arteries, provid- ing  evidence  of  molecular  mimicry  between CagA and vascular  antigens  [29]. Accordingly, it has been suggested  that CagA-positive  strains of H. pylori may contribute  to  the destabilization  of coronary atherosclerotic plaques  in  some patients with acute coronary syn- drome. From  these findings,  it  seems  that both anti-H. pylori  and anti-CagA  antibodies may have an important role  in the pathogenesis of IHD. Further  prospective  studies  are  needed  to  assess  the  relationship be- tween exposure to H. pylori and subse- quent  risk of  ischaemic heart disease.  Because H. pylori infection may be eas- ily  eradicated by  specific  treatments,  the accurate definition of this new risk  factor may lead to the design of possible  novel  strategies  for  the prevention of  ischaemic heart disease. Recent studies  have highlighted the importance of the  Table 2 Association of Helicobacter pylori and CagA in patients with ischaemic heart disease (IHD) compared to the control group Variable Control group IHD group AMI group UA group Seroprevalence of anti-H. pylori (%) 58.3 89.2*** 86.7*** 91.7*** Serum anti-H. pylori (U/mL) [Mean (SE)] 25.72 (4.01) 45.58** (4.58) 33.2* (4.76) 57.96*** (7.54) Serum anti-CagA (Uarb/mL) [Mean (SE)] 16.84 (2.88) 37.68 (8.35) 42 (15.42) 33.61 (7.32) °*P < 0.05; **P < 0,01; ***P < 0.001 compared to control group. AMI = acute myocardial infarction. UA = unstable angina. Table 3 Comparison of the association of Helicobacter pylori and ischaemic heart disease (IHD) in selected studies Country H. pylori seropositivity (%) P-value Reference IHD Controls India 98 57 0.001 4 77 43 0.001 4 58 53 NS 11 Turkey 60.2 57.7 NS 12 78.8 58.3 0.05 7 Greece 77 68 NS 13 55.1 39.6 0.05 8 Italy 78.3 56.2 0.05 9 84.7 61.8 0.0001 5 78.7 76.2 NS 14 Japan 58.7 43.3 0.009 6 87.9 66.7 0.05 10 Islamic Republic of Iran 89.2 58.3 0.0001 Present study NS = not significant طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1043 References Beaglehole R, Magnus P. The search for new risk factors 1. for coronary heart disease: occupational therapy for epi- demiologists? International Journal of Epidemiology, 2002, 31:1117–1122. Mahmoudi M, Curzen N, Gallagher PJ. Atherogenesis: the 2. role of inflammation and infection. Histopathology, 2007, 50:535–546. Ridker PM, Genest G, Libby P. Risk factors for atherosclerotic 3. disease in Braunwald, Textbook of heart disease, 6th ed. Phila- delphia, WB Saunders, 2001:1028–1031. Jha HC, Prasad J, Mittal A. High immunoglobulin A seropositiv-4. ity for combined Chlamydia pneumoniae, Helicobacter pylori infection, and high-sensitivity C-reactive protein in coronary artery disease patients in India can serve as atherosclerotic marker. Heart Vessels, 2008, 23(6):390–6. Pellicano R et al. Infection by 5. Helicobacter pylori and acute myocardial infarction. Do cytotoxic strains make a difference? New Microbiology, 2002, 25(3):315–321. Kinjo K et al. [Osaka Acute Coronary Insufficiency Study 6. (OACIS) Group]. Prevalence of Helicobacter pylori infec- tion and its link to coronary risk factors in Japanese patients with acute myocardial infarction. Circulation Journal, 2002, 66(9):805–810. Vcev A et al. 7. Helicobacter pylori infection and coronary artery disease. Collegium Antropologium, 2007, 31(3):757–60. Nikolopoulou A et al. Common community infections and the 8. risk for coronary artery disease and acute myocardial infarc- tion: evidence for chronic over-expression of tumor necrosis factor alpha and vascular cells adhesion molecule-1. Interna- tional journal of cardiology, 2008, 12,130(2):246–50. Andreica V et al. The prevalence of anti-9. Helicobacter pylori an- tibodies in the patients with ischemic heart disease. Romanian Journal of Internal Medicine, 2004, 42(1):183–9. Miyazaki M et al. Is 10. Helicobacter pylori infection a risk factor for acute coronary syndromes? Journal of Infection, 2006, 52(2):86–91. Chaudhury A et al. Seroprevalence of IgG antibodies to 11. Chlamydia pneumoniae and Helicobacter pylori among coro- nary heart disease patients and normal individuals in South Indian population. Indian Journal of Pathology and Microbiol- ogy, 2004, 47(3):433–4. Kanbay M et al. 12. Helicobacter pylori seroprevalence in patients with coronary artery disease. Digstive Diseases and Sciences, 2005, 50(11):2071–4. Sotiropoulos A et al. Seropositivity to 13. Chlamydia pneumoniae or Helicobacter pylori and coronary artery disease. International Journal of Cardiology, 2006, 109(3):420–421. Lenzi C et al. 14. H. pylori infection and systemic antibodies to CagA and heat shock protein 60 in patients with coro- nary heart disease. World Journal of Gastroenterology. 2006, 12(48):7815–7820. Figueiredo C, Marchado JC, Yamaoka Y. Pathogenesis of 15. Helicobacter pylori Infection. Helicobacter, 2005,10(Suppl. 1):14–20. Jimenze F et al. Seroprevalence of 16. Helicobacter pylori anti- CagA antibodies and its relationship with epidemiologic factors in Santa Fe. Acta Gastroenterologica Latinoamericana, 2004, 34:16–20. Jafarzadeh A, Rezayati MT, Nemati M. Specific serum immu-17. noglobulin G to H. pylori and CagA in healthy children and adults (south-east of Iran). World Journal of Gastroenterology. 2007, 13:3117–21. Manolakis A, Kapsoritakis AN, Potamianos SP. A review of the 18. postulated mechanisms concerning the association of Helico- bacter pylori with ischemic heart disease. Helicobacter, 2007, 12:287–297. Reszka E et al. Detection of infectious agents by polymerase 19. chain reaction in human aortic wall. Cardiovascular Pathology, 2008, 17(5):297–302. Zhang S et al. Cytotoxin-associated gene-A-seropositive 20. virulent strains of Helicobacter pylori and atherosclerotic diseases: a systematic review. Chinese Medical Journal, 2008, 121(10):946–951. Koenig W et al. Infection with 21. Helicobacter pylori is not a major independent risk factor for stable coronary heart disease: lack of a role of cytotoxin-associated protein A-positive strains and absence of a systemic inflammatory response. Circulation, 1999, 100(23):2326–2331. Chmiela M et al. A link between 22. Helicobacter pylori and/or Chlamydia spp. infections and atherosclerosis. FEMS Immunol- ogy and Medical Microbiology, 2003, 36(3):187–192. Singh RK et al. Prospective analysis of the association of infec-23. tion with CagA bearing strains of Helicobacter pylori and coro- nary heart disease. Heart, 2002, 88(1):43–6. Azuma T. 24. Helicobacter pylori CagA protein variation associated with gastric cancer in Asia. Journal of Gastroenterology, 2004, 39(2):97–103. Basso D, Plebani M. 25. H. pylori infection: bacterial virulence factors and cytokine gene polymorphisms as determinants of association  the of  number of  patho- gens (pathogen burden) by which an  individual has been infected with IHD  [30]. Accordingly,  the  application of  broader  strategies, not only against H. pylori  but  also  against C. pneumoniae and other  infectious organisms  such  as  those  causing  chronic  bronchitis  and periodontitis, may be considered  for  the prevention of  ischaemic heart  disease. Table 4 Comparison of the association of anti-CagA seropositivity with ischaemic heart disease (IHD) in selected studies Country Anti-CagA seropositivity (%) P-value Reference IHD Controls Italy 33.8 26.8 0.0001 5 71.4 52.4 0.03 14 Japan 72.7 57.6 0.05 10 Germany 27.9 21.7 NS 21 Poland 81 85 NS 22 United Kingdom 52 43 0.023 23 Islamic Republic of Iran 60.7 65.7 NS Present study EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1044 Fact sheet N°317 Cardiovascular diseases (CVDs): http://www.who.int/mediacentre/factsheets/fs317/en/index.html CVDs are  the number one cause of death globally: more people die annually  from CVDs  than  from any other • cause.  An estimated 17.1 million people died from CVDs in 2004, representing 29%of all global deaths. Of these deaths, an • estimated 7.2 million were due to coronary heart disease and 5.7 million were due to stroke.  Low- and middle-income countries are disproportionally affected: 82% of CVD deaths take place in low- and middle-• income countries and occur almost equally in men and women.  By 2030, almost 23.6 million people will die from CVDs, mainly from heart disease and stroke. These are projected • to remain the single leading causes of death. The largest percentage increase will occur in the Eastern Mediterranean  Region. The largest increase in number of deaths will occur in the South-East Asia Region.  infection outcome. Critical Reviews in Clinical Laboratory Sci- ences, 2004, 41:313–337 Jafarzadeh A, Hasanshahi GH, Nemati M. Serum levels of high-26. sensitivity C-reactive protein (hs-CRP) in Helicobacter pylori- infected peptic ulcer patients and its association with bacterial CagA virulence factor. Digstive Diseases and Sciences, 2009, 54(12):2612-2616. Jafarzadeh A, Salari M. Seroprevalence of anti-27. Helicobacter pylori and anti-CagA antibodies in peptic ulcer and healthy subjects in the city of Rafsanjan. Journal of Research in Medical Sciences, 2006, 11:285–291. Cammarota G et al. Is there mimicry between arterioscle-28. rotic lesions and H. pylori antigens? Clinical Biochemistry. 2000, 33:419–421. Franceschi F et al. Cross-reactivity of anti-CagA antibodies 29. with vascular wall antigens: possible pathogenic link between Helicobacter pylori infection and atherosclerosis. Circulation, 2002, 106:430–434. Steptoe A et al. Socioeconomic status, pathogen burden and 30. cardiovascular disease risk. Heart, 2007, 93(12):1567–1570. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1045 Eosinophilic cationic protein: is it useful in assessing control of childhood asthma? M. Zedan,1 A. Settin,2 F. El-Chennawi,3 T. El-Desouky,1 N. Nasef 2 and A. Fouda 2 ABSTRACT This study evaluated peripheral eosinophil and serum eosinophilic cationic protein (s-ECP) levels as markers of asthma control. A total of 38 children with asthma (16 controlled and 22 partially controlled) were compared with 16 age- and sex-matched healthy children. Total asthma cases had higher eosinophil counts and s-ECP levels than healthy children and partially controlled asthmatics had significantly higher levels of both markers than controlled asthmatics. Controlled asthma cases showed non-significant changes in both parameters versus healthy children. A negative correlation was noted between degree of asthma control and both eosinophil counts and s-ECP levels (r = –0.60 and –0.75 respectively). s-ECP as well as peripheral eosinophil count may be helpful in the assessment of asthma control. 1Allergy, Respiratory and Clinical Immunology Unit; 2Department of Paediatrics; 3Clinical Pathology and Immunology Unit, Faculty of Medicine, University of Mansoura, Mansoura, Egypt (Correspondence to M. Zedan: magdyzedan@mans.edu.eg). Received: 22/01/09; accepted: 29/03/09 ؟لافطلأا دنع وبرلا لىع ةرطيسلا ميـيقت في ديفم وه له :نيويتاكلا ينيزويلا ينتوبرلا ةدوف فشرأ ،فصان دانه ،يقوسدلا قراط ،يوانشلا ةحرف ،ينّتس دحمأ ،ناديز يدمج نم ْنينَنثا ْنينَمِساو ماهفصوب ،s-ECP نيويتاكلا ينيزويلا ينتوبرلاو ،يطيحلما مدلا في تانيزويلا تايوتسم ميـيقتب ةساردلا هذه تماق :ةـصلالخا َّمت ًلافط 22و ًايلك ميهدل ضرلما لىع ةرطيسلا ماكحإ َّمت ًلافط 16 مهنم ،وبرلاب ًاباصم ًلافط 38 ةساردلا تلمش دقو .وبرلا لىع ةرطيسلا تماساو سنلجاو رمعلا ثيح نم منهولثماي نيذلا ءاحصلأا لافطلأا نم ةعوممج عم ضىرلما ءلاؤه نروق دقو .ًايئزج ميهدل ضرلما لىع ةرطيسلا ماكحإ رملأا هيلع وه امم لىعأ نيويتاكلا ينيزويلا ينتوبرلا نمو تاينيزويلا ددع نم تايوتسم وبرلاب ينباصلما ىدل نأ نوثحابلا دجوو .ًلافط 16 مهددعو وه امم ًايئاصحإ هب ُّدَت ْنعُي رادقمب لىعأ ْنينَمساولا نم تايوتسم ،ًايئزج ميهدل ضرلما لىع ةرطيسلا تتم نيذلا لافطلأا ىدل نأو .ءاحصلأا لافطلأا دنع ًاّيلك ميهدل ضرلما لىع ةرطيسلا تتم نيذلا وبرلاب ينباصلما لافطلأا في رهظي لمو .ضرلما لىع ًايلك ميهدل ةرطيسلا تتم نيذلا لافطلأا ىدل رملأا هيلع ينبو ،وبرلا لىع ةرطيسلا ةجرد ينب يبلس طُبارـت دوجو نوثحابلا ظحلا ماك .ءاحصلأا لافطلأاب ًةنراقم ْنينَمساولا لاك في ًايئاصحإ ابه ُّدتعُي تايرغت ةَّيأ ًلاك نأ نوثحابلا جتنتساو .)r = -0.75 طابترلاا لماعم( نيويتاكلا ينيزويلا ينتوبرلا ىوتسمو )r = -0.60 طبارـتلا لماعم( تاينيزويلا دادعت نم ٍّلك .وبرلا لىع ةرطيسلا ىدم ميـيقت لىع دعاسي دق نيويتاكلا ينيزويلا ينتوبرلاو تاينيزويلا دادعت نم Utilité de la protéine cationique de l’éosinophile pour l’évaluation du contrôle de l’asthme chez l’enfant RÉSUMÉ Cette étude portait sur les niveaux obtenus par le dosage sérique et dans le sang périphérique de la protéine cationique de l’éosinophile en tant que marqueurs du contrôle de l’asthme. Au total, 38 enfants souffrant d’asthme (contrôlé pour 16 d’entre eux et partiellement contrôlé pour 22 autres) ont été comparés à 16 enfants en bonne santé de même sexe et de même âge. Tous les cas d’asthme présentaient un comptage des éosinophiles et un dosage sérique de la protéine cationique de l’éosinophile supérieurs à ceux des enfants en bonne santé ; dans les cas d’asthme partiellement contrôlé, les niveaux des deux marqueurs étaient nettement supérieurs à ceux des cas d’asthme contrôlé. Les cas d’asthme contrôlé n’ont révélé aucun changement significatif des deux paramètres par rapport aux enfants en bonne santé. Une corrélation négative a été observée entre le degré de contrôle de l’asthme d’une part, et le comptage des éosinophiles et le dosage sérique de la protéine cationique de l’éosinophile d’autre part (r = –0,60 et –0,75 respectivement). Le dosage sérique et dans le sang périphérique de la protéine cationique de l’éosinophile peuvent être utiles pour évaluer le contrôle de l’asthme. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1046 Introduction Bronchial  asthma  is  a  chronic  inflam- matory disorder of the airways in which  many  inflammatory  cells  have  been  found  to play a  role, particularly mast  cells,  eosinophils  and T-lymphocytes  [1].  Immunohistochemical  techniques  have  identified  higher  levels  of  the  CD4+ subset of T-lymphocytes as well  as eosinophils in the airways of patients  with  asthma  than  in  non-asthmatic  subjects [2]. The  association  between  eosino- philia and asthma was observed shortly  after  eosinophils were discovered.  In  patients with  asthma,  eosinophils  are  present  in  increased  numbers  in  the  blood [3],  sputum [4] and bronchoal- veolar  lavage fluid [5]. After activation,  eosinophils can release granulocyte-de- rived proteins,  the most  toxic of which  are eosinophilic cationic protein (ECP)  and major basic protein [6].  Clinical  research  has  suggested  an  emerging  clinical  usefulness  of  eosinophil  granule  proteins  as  sero- logical makers  in  the  assessment  and  management of asthma, of which ECP  has been most widely characterized and  researched [7,8]. We hypothesized that  the degree of eosinophilic expression in  the blood and the serum ECP (s-ECP)  level may be correlated with the degree  of asthma control. Accordingly the aim  of our work was  to evaluate  the  levels  of asthma control  in  relation  to serum  eosinophil counts and s-ECP levels. Methods This was a case–control, cross-sectional  study of children attending a hospital in  Mansoura, Egypt. Sample The cases were 38 children with atopic  asthma  who  were  newly  presenting  to  the Allergy and Respiratory Unit at  the University of Mansoura Children’s  Hospital,  Egypt,  from 2002  to  2006.  They were defined as asthmatic by  the  frequency  of  day  and  night  asthma  symptoms and the results of pulmonary  function tests (PFT) and as atopic from  positive  skin prick  tests. All were new  asthma patients who had not previously  received asthma controller medication.  A control group of 16 healthy children  matched  by  age  and  sex was  chosen  from  among  attendees  at  outpatient  clinics who came  for  routine vaccina- tion or regular check-ups.  According  to  the degree of  severity  of asthma on presentation, patients were  given  asthma  controller  medication  based on the 2006 Global  Initiative  for  Asthma (GINA) guidelines  for asthma  management  [9]. Patients  received  in- haled corticosteroids (fluticasone-HFA/ metered dose inhaler) 100 µg daily plus  short-acting ß-2  agonists  (salbutamol  inhaler) as rescue medication.  After receiving controller treatment  for 1 month, patients were categorized  into controlled and partially controlled  cases based on GINA criteria [9]. Con- trolled cases were those who had a fre- quency of daytime asthma symptoms or  use of rescue medication twice or less/ week; suffered no limitation of activities,  no nocturnal symptoms and no asthma  exacerbations;  and had normal PFTs.  Partially  controlled  cases were  those  who had a frequency of daytime symp- toms or use of rescue medications more  than  twice/week;  suffered any  restric- tion of activities, nocturnal  symptoms  or  asthma  exacerbations;  and  PFTs  showing forced expiratory volume in 1 s  (FEV1) < 80% predicted.  Only atopic asthmatic patients with  a positive skin test were included in the  study. Patients with negative skin prick  test,  those on  controller medications  that did not comply with GINA guide- lines (particularly oral corticosteroids)  or who presented with severe exacerba- tion were excluded from the study.  Informed written consent was ob- tained from all participants before inclu- sion in the study, which was approved by  Mansoura institutional review board. Data collection Skin-prick tests were performed only on  the asthma cases at  initial  assessment  to differentiate atopic  from non-atopic  asthmatics using various  antigens,  in- cluding 2  types of house-dust mite, cat  and dog epithelial cells and mould and  pollen antigens (Omega), together with  negative (saline) and positive (0.5% his- tamine hydrochloride) controls. Wheal  size  was measured  after  15 minutes  [10]. A positive reaction was defined as  a wheal larger than 3 mm [11]. Children  were  considered atopic  if  they had at  least 1 positive skin-prick test response. Pulmonary  function  tests  such  as  FEV1, peak expiratory flow rates (PEF%,  PEF25%, PEF50% and PEF75%) were  done for both cases and controls at the  initial  assessment  as part of diagnosis  and after 1 month of controller medica- tions as an evaluation tool for the degree  of control. It was performed by a body- plethysmograph (Master Screen Body)  for measurement of static and dynamic  pulmonary functions.  Blood samples were taken for com- plete blood count and determination of  peripheral  eosinophil  counts  for both  cases and controls. The s-ECP assay was  also done  for both cases and controls  (Immulite ECP, for use on the Immulite  and  Immulite1000 systems, Siemens)  [12]. Statistical analysis SPSS, version 12.0, was used for all anal- yses. Descriptive data  included means  and standard deviations (SD)  in addi- tion to median values. Non-parametric  statistical  tests  were  used  including  Mann–Whitney U-test for comparison  of numerical  variables  and Spearman  test for correlations. P-values < 0.05 was  considered statistically significant.  Results Background characteristics During  the  study period 62  children  newly  presented with  asthma  to  the  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1047 outpatient  clinic  of  the  Allergy  and  Respiratory Unit; 12 of  them  refused  to participate  in  the  study, 10 did not  meet  the  inclusion criteria and 2 were  lost to follow-up after starting controller  medication. Thus, 38 newly presented  asthmatic  children  were  enrolled  in  the  study (19 males  and 19  females),  with a mean age of 10.3 (SD 1.9) years.  Based on  their  response  to controller  medication and GINA criteria they were  divided  into  controlled  (16,  42.1%)  and partially  controlled  asthma cases  (22, 57.9%). They were compared with  the 16 healthy control children.  The PFTs showed significantly lower  values  in all parameters (FEV1, PEF%,  PEF25%,  PEF50%,  PEF75%)  in  the  total group of asthma cases compared  with healthy children. Also, significantly  lower PFT values were  found  for  the  same parameters in partially controlled  compared with controlled asthmatics  (Table 1). Eosinophil levels The total group of asthma cases had a  significantly higher peripheral  eosino- phil  count compared with  the healthy  control group [mean 627.4 (SD 103.4)  versus  371.5  (SD  34.3)  cells/mm3 respectively]  and also a higher  s-ECP  level  than healthy children [mean 51.8  (SD 47.8) versus 13.8 (SD 3.26) ug/L  respectively]  (P  < 0.001)  (Table  2).  The same was observed comparing the  partially  controlled asthma cases with  the healthy children for peripheral eosi- nophil  count  [mean 854.2 (SD 92.1)  versus 371.5 (SD 34.3) cells/mm3 re- spectively] and s-ECP level [mean 56.2  (SD 57.2) versus 13.8 (SD 3.3) ug/L  respectively] (P < 0.001).  On  the  other  hand,  there  were  non-significant differences comparing  controlled  asthma cases with healthy  control  children  for  both  eosinophil  count  [mean 396.9  (SD 45.6)  versus  371.5 (SD 34.3) cells/mm3] and s-ECP  level [mean 20.2 (SD 19.9) versus 13.8  (SD 3.26) ug/L  respectively]. There  were also significantly higher eosinophil  counts  in partially  controlled  asthma  cases compared with controlled asthma  cases  [mean 854.2  (SD 92.1)  versus  396.9 (SD 45.6) cells/mm3] and s-ECP  [mean 56.2 (SD 57.2) versus 20.2 (SD  19.9)  ug/L  respectively]  (P  < 0.05)  (Table 2).  Testing  the  correlations  of  both  eosinophil  counts  and  s-ECP  levels  with  degree  of  asthma  control,  we  Table 1 Background characteristics and respiratory parameters of the study subjects Variable Healthy controls Total asthma cases Partially controlled asthma Controlled asthma (n = 16) (n = 38) (n = 22) (n = 16) Males/females (no.) 6/2 19/19 10/12 9/7 Mean (SD) age (years) 10.8 (2.5) 10.3 (1.9) 10.0 (2.1) 10.0 (1.9) Mild/moderate asthma (no.) n/a 21/17 12/10 9/7 Mean (SD) duration of symptomsa (months) n/a 7 (6) 7 (3) 8 (1) Respiratory parameters Mean (SD) Mean (SD) Mean (SD) Mean (SD) FEV1 (mL) 90.1 (11.5) 75.6 (11.2)c 62.5 (13.5)c,d 88.8 (9.7) PEF% (mL) 87.7 (4.6) 75.3 (10.7)c 63.8 (18.3)c,d 87.7 (4.6) PEF25% (mL) 83.7 (22.4) 62.7 (9.6)c 51.8 (14.4)c,d 73.7 (7.1)b PEF50% (mL) 118.1 (35.2) 62.6 (13.7)c 48.4 (13.9)c,d 76.9 (13.6)c PEF75% (mL) 111.1 (23.1) 51.6 (13.7)c 37.1 (17.8)c,d 66.3 (9.1)c aDuration of asthma symptoms before presentation. bP < 0.05 versus healthy controls; cP < 0.001 versus healthy controls; dP < 0.001 versus controlled asthma cases (non-parametric statistics). SD = standard deviation; n/a = not applicable; FEV1 = forced expiratory volume in 1 s; PEF% = peak expiratory flow. Table 2 Eosinophil counts and serum eosinophilic cationic protein (ECP) levels of the study subjects Variable Healthy controls Total asthma cases Partially controlled asthma Controlled asthma (n = 16) (n = 38) (n = 22) (n = 16) Mean (SD) [95% CI] Mean (SD) [95% CI] Mean (SD) [95% CI] Mean (SD) [95% CI] Peripheral eosinophil count (cells/mm3) 371.5 (34.3) [53.5–489] 627.4 (103.4) [221–1272]a 854.2 (92.1) [467–1710]a,b 396.9 (45.6) [89–734] Serum-ECP level (µg/L) 13.8 (3.3) [7.9–19.7] 51.8 (47.8) [17.1–91.2]a 56.2 (57.2) [33.3–95.9]a,b 20.2 (19.9) [10.8–28.7] SD = standard deviation; CI = confidence interval. aP < 0.001 versus healthy controls; bP < 0.001 versus controlled asthma cases (non-parametric statistics). EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1048 found a  significant  inverse correlation  in  both  parameters  using  the  Spear- man non-parametric  correlation  test  (r  = –0.60  and –0.75  respectively, P < 0.001).  Thus,  higher  eosinophil  counts and s-ECP were correlated with  poorer  asthma control, with  a higher  correlation  for  s-ECP  than eosinophil  count (Table 3). Discussion Direct measurement of airways inflam- mation using biological markers could  potentially refine asthma management.  This explains the current research inter- est in measuring levels of exhaled nitric  oxide and eosinophil granule proteins  especially s-ECP in asthma [13]. This  study  revealed  that both pe- ripheral  eosinophil  count  and  s-ECP  levels were significantly higher in atopic  asthmatics  as  a group  than  in healthy  Table 3 Non-parametric correlation of eosinophil counts and serum eosinophilic cationic protein (s-ECP) levels of asthma patients versus healthy controls Variable Spearman correlation coefficient (r) P-value Peripheral eosinophil count (cells/mm3) –0.60 < 0.001 Serum-ECP level (µg /L) –0.75 < 0.001 control  subjects. On  the other hand,  both parameters were significantly high- er  among partially  controlled asthma  cases  compared with healthy  control  children as well  as  controlled  asthma  cases. Interestingly, however, controlled  asthma cases  showed non-significant  changes in the levels of both parameters  versus healthy control children.  These higher  levels  of  s-ECP and  eosinophil  counts  in  children  with  uncontrolled asthma may suggest  that  eosinophil-mediated  inflammation  is  important  to  investigate  in  assessing  asthma control  and  in deciding  treat- ment regimens. This finding is support- ed by the evidence that eosinophils play  an important role in the pathogenesis of  asthma and that elevation of peripheral  blood eosinophil count  is a  risk  factor  for the development of airway remodel- ling  and  irreversible  changes  in  lung  function [14]. This is also supported by  the research of Lee et al. who reported  that higher levels of s-ECP were associ- ated with more severe exacerbation of  asthma followed by a decrease in s-ECP  levels  with  resolution  of  symptoms  [15].  Our work also showed a significant  inverse  correlation  between  level  of  asthma control  and both parameters,  particularly s-ECP, implying that poorer  control  is  expected with higher  s-ECP  levels. This will add to the work of Koh et  al., who described a correlation between  asthma severity and s-ECP  level. Thus,  considering that s-ECP has been widely  investigated  as  a  potential  biomarker  of  airway  inflammation,  it may have  a  useful role to play as a control parameter  in asthma guidelines [16]. In conclusion, despite the small sam- ple size, this study has demonstrated that  s-ECP and peripheral eosinophil counts  may have clinical usefulness in assessing  levels of  asthma control  and hence  in  refining asthma management.  Based on these findings, we recom- mend conducting a larger, randomized  controlled  trial  to evaluate  the correla- tion between s-ECP level and degree of  asthma control and  to obtain a cut-off  point for s-ECP beyond which a patient  may be considered uncontrolled.  References Saetta M et al. Quantitative structural analysis of peripheral 1. airways and arteries in sudden fatal asthma. American Review of Respiratory Disease, 1991, 143:138–143. Bentley AM et al. Increases in activated T lymphocytes, eosi-2. nophils, and cytokine mRNA expression for interleukin-5 and granulocyte/macrophage colony-stimulating factor in bronchial biopsies after allergen inhalation challenge in atopic asthmatics. American Journal of Respiratory Cell and Molecular Biology, 1993, 8:35–42. Tang RB et al. Serum levels of eosinophil cationic protein and 3. eosinophils in asthmatic children during a course of pred- nisolone therapy. Pediatric pulmonology, 2001, 31:121–125. Lieberman P. Objective measures of asthma control: sputum 4. eosinophils, nitric oxide, and other inflammatory mediators. Allergy and Asthma Proceedings, 2007, 28:510–513. Wardlaw AJ. Eosinophils in the 1990: new perspectives on their 5. role diseases. Postgraduate Medical Journal, 1994, 70:536–552. Venge P et al. Eosinophil activation in allergic disease. 6. Inter- national Archives of Allergy and Applied Immunology, 1987, 82:333–337. Bousquet J et al. Eosinophil inflammation in asthma. 7. American Journal of Respiratory and Critical Care Medicine, 1994, 150(5 Pt 2):S33–38. Badr-el-Din et al. Eosinophil cationic protein as a serological 8. marker of disease activity in childhood bronchial asthma. East- ern Mediterranean Health Journal, 1999, 5(4):664–675. A pocket guide for asthma management and prevention9. . Geneva, Global Initiative for Asthma, 2006. Bacharier LB et al. Classifying asthma severity in children: 10. mismatch between symptoms, medication use, and lung func- tion. American Journal of Respiratory and Critical Care Medicine, 2004, 70:426–432. Brown WG et al. The relationship of respiratory allergy, skin 11. test reactivity, and serum IgE in a community population sample. Journal of Allergy and Clinical Immunology, 1979, 63:328–335. D’Amato G et al. Measurement of serum levels of eosinophil 12. cationic protein to monitor patients with seasonal respiratory allergy induced by Parietaria pollen (treated and untreated with specific immunotherapy). Allergy, 1996, 51:245–250. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1049 How to obtain WHO publications WHO publications and documents (in multiple languages) are available for free download from the WHO Library  database. Printed copies can be ordered from the WHO Bookshop, which offers discounts on orders from developing  countries. The Bookshop also offers priced subscriptions to periodicals, book series and thematic packages. Further information is available at: http://apps.who.int/bookorders/ Löwhagen O et al. The inflammatory marker serum eosinophil 13. cationic protein (s-ECP) compared with PEF as a tool to decide inhaled corticosteroid dose in asthmatic patients. Respiratory medicine, 2002, 96:95–101. Kaiser HB. Compliance and noncompliance in asthma. 14. Allergy and Asthma Proceedings, 2007, 28:514–516. Lee MH et al. Serum eosinophilic cationic protein levels and 15. bronchodilator response at acute asthma exacerbation. An- nals of Allergy, Asthma and Immunology, 1997, 79:363–369. Koh GC et al. Eosinophil cationic protein: is it useful in asthma? 16. A systematic review. Respiratory medicine, 2007, 101:696–705. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1050 Integrated visceral leishmaniasis surveillance system in primary care for children in Meshkin-Shahr district, north-western Islamic Republic of Iran M. Mohebali,1 Gh.H. Edrissian,1 M.R. Shirzadi,2 Gh. Hosseingholizadeh,3 M.H. Pashaei,3 A. Ganji,3 Z. Zarei,4 A. Kousha,5 B. Akhoundi,1 H. Hajjaran 1 and H. Malekafzali 6 ABSTRACT In 2001 a visceral leishmaniasis (VL) surveillance system was set up for children aged ≤ 12 years in the primary health system in Meshkin-Shahr district of Ardebil province, north-western Islamic Republic of Iran. All cases with clinical signs and symptoms of VL and positive by the direct agglutination test were referred for physical examination and treatment. The mean annual incidence of VL decreased significantly from 1.88 before (1985–2000) to 0.77 per 1000 child population after the intervention (2001–07). In a control area with no surveillance, it increased from 0.11 to 0.23 per 1000. Early detection of VL using practical serological tests and timely treatment of cases could decrease the mortality and morbidity rates of VL in endemic areas. 1Department of Medical Parasitology and Mycology; 4Meshkin-Shahr Research Station, National Institute of Health Research of Islamic Republic of Iran; 6Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Islamic Republic of Iran (Correspondence to M. Mohebali: mohebali@tums.ac.ir). 2Zoonoses Control Unit, Diseases Management Centre, Ministry of Health, Treatment and Medical Education, Tehran, Islamic Republic of Iran. 3Meshkin-Shahr Health Centre, Ardebil, Islamic Republic of Iran. 5Tabriz University of Medical Sciences, East Azerbaijan, Islamic Republic of Iran. Received: 26/06/08; accepted: 03/11/08 برغ لماش ،رهش – ينكشم ةعطاقم في لافطلأل ةيلولأا ةيحصلا ةياعرلا في جمَدْنُمـلا ،يوشلحا تاينماشيللا ءاد د ُّصرـت ماظن ةيملاسلإا ناريإ ةيروهجم ،اشوك دحمأ ،يعراز للها حيبذ ،يجنك بركأ ،يئاشاب ينسح دممح ،هداز لىق ينسح رداق ،يدازيرش اضر دممح ،نايسيردإ ينسح ملاغ ،ليع ّبمح يدهم ليَضفأ كِلَم ينسح ،ناراجح اهم ،يدنوخآ زانبه تاينماشيللا ءاد د ُّصرـتل ٌماظن ،ةيملاسلإا ناريإ ةيروهجم برغ لماش ،ليبدرأ ةيلاو في رهش – ينكشم ةعطاقم في ئشنأ ،2001 ماع في :ةـصلالخا ضارعلأاو تاملاعلا اهيف َّىلىجتـت يتلا تلاالحا عيجم لاح ُـ تو .ةيلولأا ةيحصلا ةياعرلا ماظن نمض ،لقأ وأ ةشرع ةيناثلا نس في لافطلأا ىدل يوشلحا تاعوقولا لدعم نأ ينثحابلل ينبت دقو .ةلجاعلماو يريسرلا صحفلا ءارجلإ ،شرابلما ّصارـتلا رابتخا ةيبايجإ عم يوشلحا تاينماشيللا ءادل ةيريسرلا )2000 – 1985( لخدتلا لبق ناكسلا نم لفط فلأ لكل 1.88 نم ًايئاصحإ هب ُّدَتْعُي ًاضافخنا ضفخنا دق يوشلحا تاينماشيللا ءادل يطسولا يونسلا 0.11 نم ل َّىدعلما اذه دادزا دقف ،د ُّصرـت اهيف َرُيج لم يتلا ةدهاشلا قطانلما في امأ ،)2006 – 2001( ل ُّخدتلا دعب ناكسلا نم لفط فلأ لكل 0.77 لىإ حضاولا نمو .)2006 – 2001( ل ُّخدتلا دعب ناكسلا نم لفط فلأ لكل 0.23 لىإ )2000 – 1985( ل ُّخدتلا لبق ام في ناكسلا نم لفط فلأ لكل ءادل ةضارلماو تايفولا تلا َّىدعم ضْفَخ لىإ يدؤتس ،بسانلما تقولا في تلاالحا ةلجاعمو ،ةَّىيلمع ةيجولويرس تارابتخا مادختساب ركابلا فشكلا نأ .ةنوطولما قطانلما في يوشلحا تاينماشيللا Système de surveillance intégrée de la leishmaniose viscérale dans les soins primaires pour les enfants dans le district de Meshkin-Shahr, nord-ouest de la République islamique d’Iran RÉSUMÉ En 2001, un système de surveillance de la leishmaniose viscérale a été mis en place pour les enfants âgés de 0 à 12 ans dans le système de santé primaire du district de Meshkin-Shahr, province d’Ardebil, nord-ouest de la République islamique d’Iran. Tous les cas présentant des signes cliniques et des symptômes de leishmaniose viscérale ainsi qu’une réaction positive au test d’agglutination directe étaient orientés en vue d’un examen physique et d’un traitement. L’incidence annuelle moyenne de la leishmaniose viscérale a nettement diminué, passant de 1,88 avant l’intervention (1985-2000) à 0,77 pour 1 000 enfants après l’intervention (2001-2006). Elle a augmenté dans une zone témoin sans surveillance, passant de 0,11 à 0,23 pour 1 000 enfants. Un dépistage précoce de la leishmaniose viscérale à l’aide de tests sérologiques pratiques et une prise en charge rapide des cas permettraient de réduire les taux de mortalité et de morbidité de la leishmaniose viscérale dans les zones endémiques. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1051 Introduction Visceral  leishmaniasis  (VL)—caused  by Leishmania infantum   LON-49  (GenBank  accession no. EF653268)  in human and animal  reservoirs—has  been reported from different parts of the  Islamic Republic of Iran [1,2]. In recent  decades, VL has become an  important  endemic disease among rural and semi- nomadic populations in the north-west  of  the  country  [1].  In  a  longitudinal,  cross-sectional  seroepidemiological  study carried out during 1996–2006, a  total of 32 855 human serum samples  were  collected  from  4  geographical  zones of  the  Islamic Republic of  Iran;  3574 samples (10.9%) were positive at  titres of ≥ 1:3200. Almost 43% of  the  samples were collected  from Meshkin- Shahr and Moghan districts  in Ardebil  province in the north-west of the coun- try  [3],  an area where health  facilities  are not well-established and VL often  coexists with brucellosis,  tuberculosis  and other infectious diseases. Moreover,  99.4% of the VL cases were in children  under 12 years of age.  A VL surveillance system for active  and passive case-finding was  set up  in  the villages of Meshkin-Shahr district  in  2001  to  carry  out  early  detection  in children aged under 12 years  in  the  primary  stage of  infection using  sero- logical methods [4] and to treat infected  individuals  promptly  to decrease  the  mortality  and morbidity  rates  of  the  disease in endemic areas. In the present  study,  the  incidence of VL  in children  in  the  intervention area was compared  before  and after  the  intervention and  in a control area where the surveillance  system was not established.  Methods Study design In  this  longitudinal  study a VL surveil- lance  system was established  for  chil- dren ≤ 12 years old  in Meshkin-Shahr  district (intervention area) in 2001. The  annual  incidence of VL  in children of  this  age  group was  compared over  2  periods, before (1985–2000) and after  the intervention (2001–06). In order to  control for ecological changes or chang- es  in  living  facilities  that might  affect  the VL incidence rate, an endemic area  adjoining Meshkin-Shahr was selected  where a VL surveillance system was not  established, Ahar district (control area).  The annual incidence of VL in this area  was similarly compared over the period  for which  relevant data were available,  both before (1992–2000) and after the  intervention (2001–06) and with  the  incidence in the intervention area. Study area Meshkin-Shahr  district  is  located  in  the north-west of  the  Islamic Republic  of  Iran.  It  covers  an  area  of  approxi- mately 1530 km2 and  its population  is  estimated to be 237 585, among whom  29.7%  are  settled  in  urban  areas  and  70.3% live  in 323 rural areas. Meshkin- Shahr is an important endemic focus of  VL in the Islamic Republic of Iran and  several VL studies have been conducted  in this area [5,6]. The control villages in  Ahar district have  similar ecology and  socioeconomic  characteristics  to  the  Meshkin-Shahr villages.  Health services in the study areas are  delivered through the district health net- work, consisting of a local hospital and a  few health centres in the city, and health  centres with health houses in rural areas.  The health house (khaneh behdasht)  is  the first level of rural health services and  covers several satellite villages with simi- lar cultural and social characteristics to a  range of about 1500 m. One of the most  important  activities of health workers  (behvarz)  in  the health houses  is  local  disease control and data collection.  The second  level  is  the rural health  centre (RHC) situated  in a village and  covering  a  population up  to 7500.  It  is  run  by  a medically  trained  doctor  (usually a general physician). The main  functions of  the RHC are  to provide  backup services  to  rural health houses,  offer diagnostic and treatment services  to cases referred by the behvarz and refer  those needing more  specialist  care  to  the  district  health  centre  (DHC) or  district hospital.  The  third  level  in  the  rural health  network  is  the DHC, which  is mainly  concerned with the supervision and co- ordination of the activities of RHCs and  liaison with more  specialized district  hospitals.  The  data  for  this  study were  col- lected by  trained behvarz  in  the health  houses, trained technicians in the RHCs  and medically trained physicians in the  DHC and district hospitals.  Sample collection There were around 100 behvarz during  2001–07  serving  an  average popula- tion of Meshkin-Shahr of 179 000 with  29 868 children aged ≤ 12 years . In the  control area there were 117 behvarz for  an average population of 237 585 and  23 062 children ≤ 12 years. The behvarz of  all health houses  in  Meshkin-Shahr district were trained to  recognize and refer all  suspected cases  of VL  to an RHC. Finger-prick blood  samples were collected onto filter paper  by the behvarz from children who were  suspected of having VL, i.e. if they had all  3 of  the clinical  symptoms: abdominal  distension, paleness and fever of at least  2 weeks  duration  [5,7].  In Meshkin- Shar districts where  the number of VL  cases was high, active case-finding and  investigation  of  the  animal  reservoir  hosts, particularly stray and owned dogs,  were also carried out. The blood samples were sent first to  the RHC then to the local VL laboratory  in the DHC where they were tested us- ing the direct agglutination test (DAT)  by trained technicians. Seropositive pa- tients were referred to a paediatrician or  general physician in the only hospital in  Meshkin-Shahr city  for  further physical  examination and treatment. Some chil- dren were  referred  to private or public  physicians  in Meshkin-Shahr.  In some  cases, bone marrow aspirates were also  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1052 obtained for the detection of Leshmania spp. from patients with clinical signs and  symptoms of VL but with no positive  DAT  results. All  confirmed cases,  i.e.  those with positive DAT and clinical  manifestations of VL (fever, paleness,  anaemia, splenomegaly and hepatome- galy), were referred  to  the DHC to re- ceive appropriate treatment. Pentavalent  antimony  in meglumine  antimoniate  (Glucantime,  Rorer  Rhone-Poulenc  Specia, Paris, France) was administered  intramuscularly  at  20  mg/kg  body  weight daily for 21–28 days. Since,  the VL  surveillance  system  had not been set up in the control area,  the incidence was estimated from clini- cal  features,  response  to  the  treatment  and occasionally DAT (only in sympto- matic patients). DAT antigen preparation and serological tests DAT was developed as  a  simple,  reli- able,  cost-effective  tool  for  diagnosis  and epidemiological  surveys of VL  in  human  and  canine  reservoirs  in  the  Islamic Republic of Iran [3,4,8–10].  DAT Leishmania  antigen was  sup- plied by  the Protozoology Unit of  the  Department of Medical Parasitology  and Mycology at  the School of Public  Health, Tehran University of Medical  Sciences [3,10]. All the collected serum  samples were  tested by DAT.  Initially,  for  screening purposes, 2 dilutions of  serum  samples  (1:800  and  1:3200)  were  tested with Leishmania  antibod- ies.  If  both  of  these  dilutions  were  positive, samples with titres 1:800 were  diluted further to give endpoint titres of  1:102 400. Control wells with negative  serum  samples  and  known  negative  and positive  controls were  tested on  each plate daily. The positive  standard  control was prepared  from  the  serum  of humans with L. infantum  infection  from the endemic areas, confirmed by  microscopy,  culture,  animal  inocula- tion and 1:102 400 DAT titres. A  titre  of  ≥ 1:3200  was  used  as  the  cut-off  point  for human Leishmania  infection,  as determined  in our previous  studies  [1,3,10]. Statistical analysis The mean annual  incidence of VL per  1000 population aged ≤ 12 years old  based on positive DAT accompanied by  clinical signs and symptoms and relative  risk of the disease with 95% confidence  interval (CI) were calculated. Data were  compared  in  the  periods  before  and  after  establishment  of  surveillance  in  Meshkin-Shahr villages and with data  from  the  control  area. Analyses were  done using  the chi-squared,  t-test  and  paired t-tests with SPSS  software,  ver- sion 13.5. P-value < 0.05 was considered  statistically significant.  Results During 2001–06 a total of 3977 human  serum  samples  were  collected  from  children suspected of having VL in the  intervention area. The seroprevalence  rate at titres ≥ 1:3200 was 4.15%.  Table 1 shows the incidence of VL  in  children  ≤ 12  years  old,  based  on  positive DAT  and  clinical  signs  and  symptoms,  in  the  intervention  and  control areas before and after the inven- tion started  in 2001. The mean annual  incidence of VL decreased significantly  from 1.88 per  1000 population  aged  ≤ 12 years in the period before the inter- vention (1985–2000) [5]  to 0.77 per  1000 after the intervention (2001–07)  (P  < 0.001).  In  the  control  area,  the  mean annual incidence of VL increased  significantly from 0.11 per 1000 popula- tion aged ≤ 12 years in the period before  2001  (1992–2000)  [5]  to  0.23  per  1000 in the period after the intervention  (2001–07) (P < 0.005). Figure  1  shows  the mean  annual  incidence  each  year  in  the  interven- tion  and  control  areas  for  the period  2001–07, i.e. after the intervention.  During  the  intervention  period,  there  were  only  2  registered  deaths  due  to  VL  in  the  intervention  area  (including an 8-year-old boy who did  not  tolerate meglumine  antimoniate  or  amphotericin B), while  at  least 10  deaths caused by VL were registered in  the intervention area before the surveil- lance  intervention. The annual mortal- ity rate due to VL in children up to 12  years in the intervention area decreased  significantly from 0.16 per 1000 before  to 0.009 per 1000 population aged ≤ 12  years after the intervention (P < 0.001).  About 20 deaths due to VL in children  up to 15 years old were registered in the  control villages during this period. Table 1 Visceral leishmaniasis (VL) case detection among children ≤ 12 years of age in the intervention area (Meshkin-Shahr district) and control area (Ahar district) before and after establishment of the VL surveillance system Study area Before intervention After intervention RR 95% CI P-value VL cases detecteda No. Mean annual incidence (/1000 children ≤ 12 years) VL cases detectedb No. Mean annual incidence (/1000 children ≤ 12 years) Intervention area 1798 1.88 161 0.77 0.43 0.28–0.68 < 0.001 Control area 68 0.11 69 0.23 2.06 0.28–1.72 < 0.001 aPeriods of data collection: intervention area 1985–2000; control area 1992–2000. bPeriods of data collection: intervention area 2001–2007; control area 2001–2007. RR = relative risk; CI = confidence interval. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1053 Discussion Control of  zoonotic  visceral  leishma- niasis  (ZVL)  is  difficult  and  the  cur- rent control strategies  for ZVL rely on  reservoir  and  vector  control,  the  use  of  insecticide-impregnated materials  to prevent  insect bites,  and active case  detection with  appropriate  treatment  to avoid the spread of infection [11,12].  Despite the evidence from experimental  studies of a decreased incidence of ZVL  in  both  dogs  and  children  following  serological screening of dogs and killing  of  seropositive  animals,  the efficiency  and acceptability of  control  strategies  for ZVL are still debated [13,14]. Treat- ing  infected  dogs  is  not  an  effective  control strategy, as relapses are frequent  and dogs  can  regain  infection weeks  after treatment, despite showing clinical  cure  [15]. Moreover  the widespread  veterinary use of VL drugs might lead to  the development of  resistant  strains of  the parasite. A new control approach is  the use of deltamethrin-treated collars,  which  reduced  the  risk of  infection  in  dogs by 54% and in children by 43% in a  study conducted in the Islamic Republic  of  Iran [16]. Anti-leishmanial vaccines  are unfortunately not yet available [17].  Although phlebotomine  sand-flies are  still  susceptible  to  insecticides, unfor- tunately the disease quickly re-emerges  when  the  spraying campaigns are dis- continued. Therefore early case-finding  and treatment of VL is still an essential  component of  reducing VL mortality  and morbidity rates [18]. Our findings showed that mean an- nual incidence of symptomatic cases of  VL decreased  significantly  from 1.88  per 1000  to 0.77 per 1000  in children  ≤  12  years  old  in  the  periods  before  and after  the  intervention respectively,  whereas  in  the  control  villages,  the  mean annual  incidence of  the disease  increased  significantly  from 0.11 per  1000 to 0.23 per 1000 respectively. Our  results  suggest  that establishment of a  VL surveillance system can decrease the  incidence of VL.  A pilot  study  to control VL  in  the  focus of Meshkin-Shahr carried out by  Nadim et al.  in 1991–92 showed  that  this  combined method  for  control of  ZVL  (case  detection,  destruction  of  stray dogs as well as seopositive owner- ship  dogs,  vector  control  and public  health education) was very effective  in  this area [unpublished report to WHO  Special Programme  for Research and  Training  in Tropical Diseases (TDR),  project  no:  910191]. Although  early  detection of VL  in humans  is effective  in prevention of death due VL and  in  reducing  the  incidence of  the disease,  it cannot completely eliminate  the dis- ease by stopping the transmission cycle.  Mohebali et al.  showed that 14.2%) of  domestic dogs in the villages of endemic  areas of  the  Islamic Republic of  Iran  were positive by DAT [2]. Furthermore,  the type of construction of houses in vil- lages and the semi-nomadic  life of part  of  the population play an essential role  in the transmission cycle of VL. As the clinical manifestations of VL  have  low specificity, confirmatory  tests  are  required  to decide which patients  should be treated. Such tests should not  only be highly sensitive—as VL is a fatal  condition—but also need to be highly  specific because the current drugs used  to  treat VL  are  toxic  [12]. DAT has  been specifically developed for field use  and has been extensively  validated  in  most endemic areas [8,9]. Thirty studies  were included in a recent meta-analysis,  which gave  sensitivity  and  specificity  estimates  for DAT of 94.8% (95% CI:  92.7%–96.4%)  and  85.9%  (95% CI:  72.3%–93.4%) respectively [19]. In our  study, we used DAT to support the VL  surveillance system because it is simpler  than many other  tests and suitable  for  field activities.  It  should be noted  that  a positive DAT result in endemic areas  must be combined with  specific clini- cal manifestations of VL such as mild  fever  (at  least 2 weeks), paleness  and  anaemia,  splenomegaly, hepatomegaly  and lymphadenopathy to be considered  as VL [5].  We faced some challenges in carry- ing out routine serological testing due to  variations in different batches of DA an- tigen, the lack of a cold-chain supply for  transport of antigen, the need for serial  dilutions of blood or serum samples and  also the relatively  long incubation time  (18 hours) for reading the test results. A  variant of DAT—the fast agglutination  screening  test—is very practical under  field or rural conditions, and can be used  in the future to screen large populations  Figure 1 Mean annual incidence of visceral leishmaniasis (VL) per 1000 children aged ≤ 12 years in the intervention area (Meshkin-Shahr district) and control area (Ahar district) after establishment of the VL surveillance system EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1054 References Edrissian GhH. Visceral leishmaniasis in Iran and the role of 1. serological tests in diagnosis and epidemiological studies. In: Ozcel MA, Alkan MZ, eds. Parasitology for the 21st century. Wallingford, England, CAB International, 1996. Mohebali M et al. Epidemiological aspects of canine visceral 2. leishmaniosis in the Islamic Republic of Iran. Veterinary Parasi- tology, 2005, 129(3–4):243–251. Mohebali M et al. Application of direct agglutination test (DAT) 3. for the diagnosis and seroepidemiological studies of visceral leishmaniasis in Iran. Iranian Journal of Parasitolology, 2006, 1:15–25. Allian DS, Kagan JR. A direct agglutination test for leishma-4. niasis. American Journal of Tropical Medicine and Hygiene, 1975, 24:232–236. Soleimanzadeh G et al. Epidemiological aspects of kala-azar 5. in Meshkin-Shahr, Iran: human infection. Bulletin of the World Health Organization, 1993, 71(6):759–762. Edrissian GhH et al. Visceral leishmaniasis: the Iranian experi-6. ence. Archives of Iranian Medicine, 1998, 1(1):22–26. Veeken H et al. Comparison of an rK39 dipstick rapid test with 7. direct agglutination test and splenic aspiration for the diagno- sis of kala-azar in Sudan, Tropical Medicine and International Health, 2003, 8:164–167. El Harith AE et al. Improvement of a direct agglutination test 8. for field studies of visceral leishmaniasis. Journal of Clinical Microbiology, 1989, 26(7):1321–1325. Zijlstra EE et al. Direct agglutination test for diagnosis and sero-9. epidemiological survey of kala-azar in the Sudan. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1991, 85(4):474–476. Edrissian GhH et al. Application and evaluation of direct ag-10. glutination test in sero-diagnosis of visceral leishmaniasis in man and canine reservoirs. Iranian Journal of Medical Sciences, 1996, 1:119–124. Alvar J et al. Canine leishmaniasis. 11. Advances in parasitology, 2004, 57:1–88. Chappuis F et al. Visceral leishmaniasis: what are the needs for 12. diagnosis, treatment and control? Nature Reviews. Microbiol- ogy, 2007, 5:873–882. Ashford DA et al. Studies on control of visceral leishmaniasis: 13. impact of dog control on canine and human visceral leishma- niasis in Jacobina, Bahia, Brazil. American Journal of Tropical Medicine and Hygiene, 1998, 59:53–57. Palatnik-de-Sousa CB et al. Impact of canine control on the 14. epidemiology of canine and human visceral leishmaniasis in Brazil. American Journal of Tropical Medicine and Hygiene, 2001, 65:510–517. Alvar J et al. Canine leishmaniasis: clinical, parasitological and 15. entomological follow-up after chemotherapy. Annals of Tropi- cal Medicine and Parasitology, 1994, 88:371–378. Gavgani AS et al. Effect of insecticide-impregnated dog col-16. lars on incidence of zoonotic visceral leishmaniasis in Iranian children: a matched-cluster randomized trial. Lancet, 2002, 360:374–379. Mohebali M et al. Double-blind randomized efficacy field 17. trial of alum precipitated autoclaved Leishmania major vac- cine mixed with BCG against canine visceral leishmaniasis in Meshkin-Shahr district, I.R. Iran. Vaccine, 2004, 22:4097– 4100. Desjeux P. Leishmaniasis: current situation and new perspec-18. tives. Comparative Immunology, Microbiology and Infectious Diseases, 2004, 27:305–318. Chappuis F et al. A meta-analysis of the diagnostic perform-19. ance of the direct agglutination test and rK39 dipstick for vis- ceral leishmaniasis. British Medical Journal, 2006, 333:723. Schoone GJ et al. A fast agglutination screening test (FAST) 20. for the detection of anti-Leishmania antibodies. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2001, 95:400–401. Babakhan L et al. Rapid detection of 21. Leishmania infantum infection in dogs: a comparative study using fast agglutination screening test (FAST) and direct agglutination test (DAT) in Iran. Parasitology Research, 2009, 105:717–720. of suspected children  in a shorter  time  (2–3 hours) [20,21]. Acknowledgements Some parts of this study received finan- cial  support  from  the National  Insti- tute of Health Research of  the  Islamic  Republic  of  Iran,  Tehran University  of Medical Sciences and also  from the  Vice-Chancellor  for Research, Tehran  University of Medical Sciences (Project  Nos:  241/74/3,  241/82/54/60,  241/74/81/3/5). We thank the staff of  the DHCs in  Meshkin-Shahr and Ardebil  as well  as  all  health workers  in Meshkin-Shahr  villages and the physicians who helped  us with  this  investigation. We  thank  Dr F. Pourfarzi, Mr D. Emdadi, Mrs N.  Modarres, Mr B.Keysan, Dr Arzanloo  and Mr M.K Sajadi  from Ardebil Uni- versity  of Medical  Sciences,  Islamic  Republic of Iran. We especially wish  to  thank Mr A.  Alizadeh, Mrs.N.Mirsamadi, Dr  Seif,  Dr G.  Soleymanzadeh  from  the East  Azerbaijan  health  centre  and Mr  A.  Nasiri, Mrs  S. Molaei, Mr  I. Moradi,  Mrs Z. Rakhshidan, Mrs S. Anvari, Mr  A. Malekpour, Mr E. Taghdisi, Mr O.  Amohammadi, Mrs S. Charehdar, Dr  Gh.R.  Khanbaba  and  our  other  col- leagues  in  the  remote  laboratories and  fields.  We  also  thank  Dr M.  Sedaghat,  Assistant  Professor  of  Medical  En- tomology  and Vector Control  in  the  School of Public Health and  Institute  of Public Health Research, Tehran Uni- versity of Medical Sciences for editorial  comments. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1055 Role of neutrophils in cutaneous leishmaniasis M.W. Daboul1 ABSTRACT Neutrophils are always present in the cytomorphologic process of leishmaniasis but their role is still not fully understood. Microscopic examination was done on smears from 56 cases of clinically diagnosed cutaneous leishmaniasis. Neutrophils were the predominant cells in the smear (>35% of the total cell count including neutrophils, macrophages and lymphocytes) in 7% of cases, a minority (10%–35% of total cells) in 36% of cases and rare (< 10% of total cells) in 57% of cases. Microscope images confirmed that neutrophils appeared to have an important role in leishmania elimination through phagocytosis of amastigotes in the later stages of the disease process. 1Daboul Medical Laboratory, Damascus, Syrian Arab Republic (Correspondence to M.W. Daboul: idaboul@scs-net.org). Received: 16/02/09; accepted: 06/04/09 يدللجا تاينماشيللا ءاد في تلاِدَعلا ضيبلا تاَّيركلا رود لوبعد يرسيت لئاو دممح نأ ولو ،تاينماشيللا ءاد في ةيوللخا ةيجولوفرولما ثادحلأا حملام نم مئاد ٌحَمْلَم neutrophils تلاِدَعلا ضيبلا تاَّيركلا دوجو نإ :ةـصلالخا تاينماشيللا ءاد انهأ لىع ًايريسر ةصّخشم ةلاح 56 نم ةذوخأم تاخاطل لىع ةيرهمج ةسارد ثحابلا ىرجأ دقو .ًاماتم موهفم يرغ لازيلا اهرود ،تلاالحا نم %7 في كلذو )معلابلاو تايوافمللا دادعت لممج نم %35 نم رثكأ( تاخاطللا في ايلالخا ةيبلغأ لِّثتم تناك تلاِدَعلا نأ دجوو ؛يدللجا .تلاالحا نم %57 في )ايلالخا لممج نم %10 نم لقأ( ةردان تناك انهأو ،تلاالحا نم %36 في )ايلالخا لممج نم %35 - %10( ةي ِّلقأ لِّثتم تناك انهأو amastigotes تانَماُشي َّللا phagocytosis ةَمَعْلَبب اهمايق للاخ نم تاينماشيللا نم ص ُّلختلا في ًّماهُم ًارود تلاِدَعلل نأ ةيرهجلما روصلا تد َّكأ دقو .ةيضرلما ثادحلأا رخاوأ في Rôle des neutrophiles dans la leishmaniose cutanée RÉSUMÉ Si les neutrophiles sont toujours présents dans le processus cytomorphologique de la leishmaniose, leur rôle n’est pas toujours bien compris. Des frottis de 56 cas de leishmaniose cutanée ayant fait l’objet d’un diagnostic clinique ont été examinés au microscope. Les neutrophiles étaient les cellules prédominantes dans le frottis (> 35 % de la numération totale des macrophages et des lymphocytes) dans 7 % des cas, une minorité (10 %–35 % du total des cellules) dans 36 % des cas et rares (< 10 % du total de cellules) dans 57 % des cas. Les images microscopiques ont confirmé que les neutrophiles semblaient avoir un rôle important dans l’élimination de la leishmaniose par le biais de la phagocytose des amastigotes aux derniers stades du processus pathologique. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1056 Introduction Cutaneous  leishmaniasis  is  endemic  in over 70 countries, with an estimated  annual  incidence of 1.5 million  cases  [1].  Neutrophils  are  always  present  in  the  cytomorphologic  process  of  leishmaniasis, but  their  role  is  still not  fully understood. Polymorphonuclear  (PMN) neutrophils have been reported  to have a crucial role in the destruction  of  the Leishmania major parasites at an  early stage of infection [2,3]. A rapid and  sustained neutrophilic infiltration local- ized at  the  site of  the  sand-fly bite has  been observed using dynamic intravital  fluorescence microscopy and flow cy- tometry [4]. Studies showing that PMN  neutophils are present in vivo at the sites  of  the  lesion and can kill  the parasites  in vitro have  suggested  that  these cells  might be  involved  in  inhibiting multi- plication of  the parasite. Neutrophils  also appear  to play a major  role  in  the  development of protective  immunity  [5,6]. One study with C57BL/6 mice  demonstrated  that  the  interaction of  L. major-infected macrophages  with  dying  neutrophils  induced  parasite  destruction mediated  by  neutrophil  elastase  and  tumour necrosis  factor-α  production from neutrophils [5]. Most of these studies focused on the  very early  stages of  infection;  little has  been mentioned about the role of neu- trophils in the later stages of cutaneous  leishmaniasis. The pathological features  in the later stages of the disease indicate  a  gradual  decrease  in  the  number  of  amastigotes and macrophages,  leaving  a  granulomatous  infiltrate  consisting  of  lymphocytes,  epithelioid  cells  and  multinucleated giant cells. At this stage  it is difficult or even impossible to detect  the  amastigotes  in haematoxylin  and  eosin or Giemsa-stained  sections  [7].  In a dry nodular type of lesion, there is a  tendency to form granuloma with fewer  lymphocytes  and  scanty plasma  cells  [8]. Previous studies have not claimed  any role for neutrophils or demonstrat- ed the appearance of neutrophils during  the  late  stages of  the disease process,  although  they mention  the disappear- ance of  the amastigotes without giving  any rationale for their disappearance.  This  cytomorphological  study  of  the  role  of  neutrophils  in  cutaneous  leishmaniasis  aimed  to  investigate  the  appearance of neutrophils together with  the phagocytosis function on the amas- tigotes in infected lesions from humans  with cutaneous  leishmaniasis at a  later  stage of the disease. Methods The sample for the study was all 56 cases  of  cutaneous  leishmaniasis  (50 males  and 6 females) referred for investigation  to a medical  laboratory  in Damascus,  Syrian Arab Republic over  the period  October 2006 to February 2008. All the  cases were clinically diagnosed as cuta- neous  leishmaniasis by an expert der- matology consultant at a dermatology  clinic  in Damascus. All  cases  referred  over the time period were included and  the  stage of  the disease had not been  determined. Two microscope  slides were pre- pared  from each patient,  stained with  Wright  stain and examined under  the  microscope at × 400 magnification. A  total of 50 fields were  studied  in each  slide and the neutrophil, phagocyte and  lymphocyte counts per field were noted.  For each case the cell counts were calcu- lated as mean percentages.  For each case  the neutrophils were  defined as: +++ if they constituted > 35%  of  the  different  cells microscopically  present  in  the smear  including macro- phages  and  lymphocytes;  ++  if  they  were between 10% and 35% of total; or  + if they were < 10% of the total.  The presence of amastigotes  in  the  smear was noted in relation to the neu- trophils cell counts. Results Table 1  shows  the neutrophil  counts  as a percentage of the total neutrophils,  phagocytes  and  lymphocytes  in  the  microscope  slides. Neutrophils were  present in a high concentration among  the  3  cell  types  (neutrophils,  lym- phocytes and phagocytes) in only 7% of  the cases studied, while in 93% of cases  neutrophils were not the predominant- cells  in  the  slides and  in 57% of  cases  neutrophils were rarely seen (< 10%). Table 1 Presence of neutrophils and amastigotes in smears from patients clinically diagnosed with cutaneous leishmaniasis Cells Neutrophils present No. of patients % (n = 56) Neutrophils presenta +++ (> 35% of cells) 4 7 ++ (10%–35% of cells) 20 36 + (< 10% of cells) 32 57 Amastigotes present Heavily concentrated in extracellular fluid +++ 4 7 Present in intracellular fluid, low in extracellular fluid ++ or + 23 41 Not seen in intra- or extracellular fluid + 29 52 aIn relation to total cells: neutrophils, lymphocytes and phagocytes. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1057 Table 1 also shows the relationship  between  the  appearance  of  amastig- otes  in  the  smear  and  the neutrophil  concentrations in the smear. When the  amastigotes were heavily concentrated  in the extracellular fluid, the neutrophils  were more  concentrated, while when  the amastigotes were present intracellu- larly with very low appearance in the ex- tracellular fluid, the neutrophils showed  low  presence  (0%–35%)  among  the  cells  and when  the amastigotes disap- peared from the screen, the neutrophils  had very low counts in the microscope  slide (< 10%). It  appears  from  the  sample micro- scope images that once the neutrophils  became  the predominant  cell  type  in  the field, their function in phagocytosis  of  the amastigotes becomes apparent  (Figures  1  and  2).  When  the  neu- trophils were  in  lower concentrations,  phagocytosis of  amastigotes was not  seen (Figure 3). The greater appearance  of  neutrophils when  the  amastigotes  were present  in  the extracellular fluid,  as  shown  in  the cell  counts,  is  evident  in Figure 4.  Discussion The cases  in  this  study were  referred  with clinical signs of cutaneous leishma- niasis and no definite disease stage was  determined for any of them. We can as- sume that none of the cases were at the  very beginning of  the disease process  (as presented  in other  studies  [2–4])  as  studies  indicate  that no  immediate  clinical  symptoms  appear  at  the  very  early stage of the disease soon after the  sand-fly  transmits  the parasite  to  the  host  [7,8]. When  a  patient  presents  clinically with  a  skin ulcer measuring  2–5 cm in diameter with a wet exudate  and  the pathological  features  show a  dermal  infiltrate mainly  composed of  macrophages filled with  amastigotes,  lymphocytes and plasma cells, then this  is  an  early  stage  of  the  disease  proc- ess. When  the  lesions clinically appear  smaller  in  size,  dry  and nodular with  dried  exudates  and  the microscopic  features show a decrease in the number  of, or a disappearance of,  the amastig- otes  and  their macrophages,  leaving a  granulomatous  infiltrate  consisting of  epithelioid cells, multinucleated giant  cells,  fewer  lymphocytes  and  scanty  plasma  cells  [7,8],  then  this  is  a  later  stage of the disease process.  In  the  microscope  images,  neu- trophils  are  shown phagocytosing  the  released amastigotes in the extracellular  fluid of infected lesions. Neutrophils are  believed to be specialized in the phago- cytosis process, while macrophages are  considered less efficient than PMN neu- trophils  at killing  foreign microorgan- isms, and the mechanism is not as well  understood [9]. Accordingly, we can as- sume that those PMN neutrophils have  a  strong  role  to play  in phagocytosis  and destruction of amastigotes released  after membrane rupture of the infected  macrophages. Otherwise  it  is not pos- sible to explain the disappearance of the  amastigotes  from  the  infected  tissues  after their release in huge numbers into  the extracellular fluid later in the healing  process of cutaneous leishmaniasis [7].  We  can  hypothesize  that  once  the amastigotes  are  released  from  the  ruptured phagocytes  into  the extracel- lular  fluid  in  the  late  stage of  the dis- ease  process,  they  are  recognized  by  the neutrophils  as  foreign bodies  and  an acute-phase  reaction  is established.  More neutrophils are attracted, as seen  by  an  increase  in  the neutrophil  con- centration  in  the  damaged  area. The  neutrophils  start  the process of phago- cytosis of  the released amastigotes and  consequent limitation of disease. In conclusion,  this  study has  found  that PMN neutrophil  cells were at no  time absent  from  the disease process  of  cutaneous  leishmaniasis,  in  either  the early or  late stages. While previous  Figure 1 Microscope image shows amastigotes engulfed within the neutrophil Figure 2 Microscope image shows increased neutrophils with phagocytosis activity Figure 3 Microscope image shows fewer neutrophils and more lymphocytes and no phagocytosis function Figure 4 Microscope image shows amastigotes released into extracellular fluid with elevation in the number of neutrophils and phagocytosis activity EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1058 studies have noted the role of PMN neu- trophils in the early stages of the disease  process, this study concentrated on their  role  in the later stages. The neutrophils  seemed to be highly effective in phago- cytosis  of  amastigotes  released  from  ruptured phagocytes to the extracellular  fluid. The PMN neutrophils  seemed  to establish  their  role by phagocytosis  of  the amastigotes as demonstrated by  the disappearance of amastigotes when  neutrophil counts drop.  References Daboul MW. Is the amastigote form of leishmania the only 1. form found in humans infected with cutaneous leishmaniasis? Labmedicine, 2008, 39(1):38–41. Rousseau D et al. 2. In vivo involvement of polymorphonuclear neutrophils in Leishmania infantum infection. BMC Microbiol- ogy, 2001, 1:17. Lima GM et al. The role of polymorphonuclear leukocytes in 3. the resistance to cutaneous leishmaniasis. Immunology Letters, 1998, 64(2–3):145–151. Peters NC et al. 4. In vivo imaging reveals an essential role for neutrophils in leishmaniasis transmitted by sand flies. Science, 2008, 321:970–974. Von Stebut E. Immunology of cutaneous leishmaniasis: the 5. role of mast cells, phagocytes and dendritic cells for pro- tective immunity. European Journal of Dermatology, 2007, 17(2):115–122. Launois P, Tacchini-Cottier F.6. Immune responses to leishma- nia infection [online report]. WHO Immunology Research and Training Centre, University of Lausanne, Department of Biochemistry (http://www.unil.ch/ib/page9491.html#1, ac- cessed 1 July 2010). Hepburn NC. Cutaneous leishmaniasis: an overview. 7. Journal of Postgraduate Medicine, 2003, 9:50–54. Sharquie KE et al. Evaluation and diagnosis of cutaneous leish-8. maniasis by direct smear, culture and histopathology. Saudi Medical Journal, 2002, 23(8):925–928. Sheehan C, ed. 9. Clinical immunology: principles and laboratory diagnosis. Philadelphia, Lippincott–Raven, 1997. Operational research in tropical and other communicable diseases: final report summaries 2007–2008 This is the 4th portfolio of operational research activities for communicable diseases supported by WHO Regional  Office for the Eastern Mediterranean. The aim of the publication of these final report summaries is the documentation  and dissemination of research findings for their effective use in disease control. The implications and corresponding  recommendations have been communicated to the countries as an outcome of the WHO-sponsored research.  The report is available at: http://www.emro.who.int/publications/Book_Details.asp?ID=1040 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1059 Absence of lymphatic filariasis infection among secondary-school children in Oman S.T. Al Awaidy,1 S. Bawikar,1 P.K. Patel,2 P. Kurup,3 G.S. Sonal,4 S. Al Mahrooqi1 and R. Ramzy1 ABSTRACT The endemicity status of lymphatic filariasis in Oman is uncertain, with only sporadic cases reported, mostly imported. Immunochromatographic card test surveys were carried out to assess the presence of circulating Wuchereria bancrofti antigenaemia as a marker for active infection in children from suspected high-risk areas of Oman (South Batinah and Dhofar). Lot quality assurance sampling surveys were carried out on a minimum of 250 secondary-school children aged 17–18 years in each of 8 districts from February 2004 to March 2004. All tested students were negative for circulating W. bancrofti antigen. Based on these findings as well as previous data, Oman may possibly be classified as a nonendemic country, with no evidence of indigenous lymphatic filariasis transmission. 1Department of Communicable Disease Surveillance and Control, Ministry of Health, Muscat, Oman (Correspondence to S.T. Al Awaidy: salah.awaidy@gmail.com). 2Department of Health Affairs, Dhahira Region, Oman. 3Department of Health Affairs, South Batinah Region, Oman. 4Department of Health Affairs, Dhofar Region, Oman. Received: 07/01/09; accepted: 19/02/09 نماُع ةنطلس في ةيوناثلا سرادلما بلاط ينب ةيفم ِّللا تايرلايفلا ءاد ىودع دوجو مدع يزمر اضر ،يقورحلما لماس ،لانوس جنس ناجاج ،نهوم امداب ،ليتاب شاكارب ،راكيفاب مايش ،يديوعلا تباث نب حلاص جراخ نم اهمظعم ،ةيداَرُف تلااح نع لاإ غ َّلبُي لم ْذإ ؛د َّكؤم َيرغ لازام نماُع ةنطلس في ةيفمللا تايرلايفلا ءاد نطوتل نهارلا عضولا نإ :ةـصلالخا رابتعاب ،ةيتفوركنبلا تايرَخُفلل مدلا في ةلئاج تا َّدِضَتْسُم دوجو ميـيقتل يعانلما باشرتسلاا ةقاطب رابتخا لىع موقي ًاحسم نوثحابلا ىرجأ دقو .نماُع تاحوُسُم نوثحابلا ىرجأ دقو .)ةنطابلا بونجو رافُظ( نماُع ةنطلس في راطتخلاا ةعفترلما قطانلما في لافطلأا ىدل ةلا َّعفلا ىودعلا لىع ًماساو كلذ نم ٍّلك في ًاماع 18و 17 ينب مهرماعأ حوارـتـت ةيوناثلا ةلحرلما في ًابلاط 250 لمش يذلا رابتخلاا ةدوج نماض دصقب تذخُأ ،ةعومجلما نم ةَّيناِيتعا مهجئاتن تناك تارابتخلاا مله ْتَيرجأ نيذلا ةَبَلطلا عيجم نأ نوثحابلا دجوو ؛2004 ماع نم سرام/راذآو ريابرف/طابش ْيَرهش ينب ام نيماثلا قطانلما ةنطلس فينصت نكمي ،لبق نم ةدوجوم تايطعم لىإو ،جئاتنلا هذه لىإ ًادانتساو .يومدلا ناَرَودلا في لئالجا ةيتفوركنبلا تايرخفلا دضتسلم ة ّـَ يبلس .هيف ةيفمللا تايرلايفلا ءادل ةيلخاد ةياسر دوجو لىع تانِّيب رفاوتـت لاو ،نوطوم يرغ دلب انهأ لىع نماُع Absence de filariose lymphatique chez les élèves de l’enseignement secondaire à Oman RÉSUMÉ Le statut de l’endémicité de la filariose lymphatique à Oman est flou : seuls des cas sporadiques, pour la plupart importés ont été notifiés. Des études fondées sur des tests immunochromatographiques sur carte ont été effectuées pour déterminer la présence d’antigènes circulants spécifiques de Wuchereria bancrofti, en tant que marqueur d’une infection active chez les enfants dans les régions suspectées de présenter un haut risque à Oman (Batinah-sud et Dhofar). Un sondage pour le contrôle de la qualité des lots a été réalisé sur un minimum de 250 élèves de l’enseignement secondaire âgés de 17 à 18 ans, dans chacun des huit districts entre février et mars 2004. Tous les élèves testés présentaient des résultats négatifs pour l’antigène circulant spécifique de W. bancrofti. En fonction de ces résultats et de données précédentes, Oman peut être classé comme un pays non endémique ne présentant aucun signe de transmission indigène de la filariose lymphatique. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1060 Introduction Lymphatic filariasis (LF)  is one of  the  most debilitating, disfiguring and stig- matizing diseases of  the  tropical  and  subtropical  regions of  the world. LF  is  endemic  in more  than 80 countries.  It  is  estimated  that  120 million people  are  infected and one-third of them suf- fer  from chronic manifestations of  the  disease. Worldwide, an additional 1 bil- lion  individuals are at  risk of acquiring  the infection [1–4]. The World Health  Organization (WHO) estimates  that  5.1 million disability-adjusted  life years  (DALYs) are lost due to LF [5]. Estimates suggest that approximate- ly  12.6 million LF-infected  individu- als, 1% of  the LF global burden,  live  in  countries of the Eastern Mediterranean  Region, where LF  is entirely caused by  Wuchereria bancrofti and is transmitted primarily by Culex  spp. mosquitoes  in  mostly  rural and semi-urban areas [6].  LF  is  endemic  in  Egypt,  Sudan  and  Yemen and  is  targeted  for elimination  under  the Global Programme  for  the  Elimination  of  Lymphatic  Filariasis  (GPELF) [7]. The LF situation  in Dji- bouti, Oman, Pakistan,  Saudi Arabia  and Somalia  is  currently described as  uncertain. However, clinical cases have  been  reported  from Oman, Pakistan,  Saudi Arabia and Somalia [4,7].  Oman has a population of approxi- mately  2.34 million,  of whom 23.9%  are  expatriates  (2003  census  data).  Many of these expatriates are from LF- endemic countries such as Egypt, India  and Sri Lanka. LF is a notifiable disease  in Oman, and between 1991 and 2001  15 cases were reported, mostly classified  as imported based on the history of the  patient’s  stay  in LF-endemic countries.  Of these, 7 were Omanis who lived for  some  time  in LF endemic areas  [6,8].  With such sporadic cases it is necessary  to verify the LF status of Oman. A study  conducted by Scrimgeour et al.  found  an LF antigenaemia prevalence of 4.2%  based on the immunochromatographic  test  (ICT) among  Indian  expatriates  living  in Oman  [9]. However,  in  the  global perspective, Oman  is  included  among countries with an uncertain LF  situation,  i.e.  there  is no clear evidence  either of the presence or absence of local  transmission [6].  The  ICT  filariasis  card  test  is  a  rapid format test that detects circulating  filarial antigens released by adult worms  [10] and can  thus detect  active  infec- tion  independent of microfilaraemia.  Several field studies have evaluated the  rapid  test  and  showed  that  the  ICT  test can use blood collected during the  day or night;  the  sensitivity of  the  test  reached 98%–100% among microfilaria  carriers with 100% specificity [11–14].  Therefore, WHO has  recommended  the use of the ICT card test for mapping  LF endemic areas [15]. The present study aimed to evaluate  the LF status  in Oman by carrying out  ICT-card surveys to detect W. bancrofti antigenaemia among secondary-school  children aged 17–18 years  in  these 2  regions.  Methods Study design This was  a  lot quality  assurance  sam- pling  (LQAS)  school-based  survey  conducted during  the  academic  year  2004–05  among  secondary-school  children from areas identified as having  the potential for LF transmission.  Study area The process  of  verification  included  initial use of qualitative methods (ques- tionnaire surveys of key informants) to  identify possible LF endemic areas. This  was  followed by LQAS antigenaemia  surveys in these possible endemic areas.  The key  informant  surveys  identified  2  possible  LF  endemic  areas:  South  Batinah and Dhofar  region (adminis- tratively described as  the governorate  of Dhofar).  Initial  rapid  assessment question- naire  surveys  had  revealed  that  the  probability of  local  transmission was  highest  in  the 6 districts of South Bati- nah region and 2 districts  representing  81% of  the population  in  the Dhofar  governorate. Hence, the current antigen  surveys were conducted  in  these 8 dis- tricts of 2 regions of Oman. Study population The  target  population  was  children  aged 17–18 years attending secondary  schools. The rationale  for selecting this  age group for the surveys was that LF is  a chronic disease with a long incubation  period  that  requires  repeated exposure  over  an  extended period of  time be- fore  the  infection  is  acquired.  It  takes  even  longer  for  the  clinical  signs  and  symptoms  of  lymphatic  obstruction  to  appear. Therefore,  the  secondary- school students of this age group would  offer  epidemiological  evidence of  the  presence or absence of  indigenous LF  infection in Oman because they would  represent an exposure history of 17–18  years.  Sampling The WHO  guidelines  for  preparing  and  implementing  a national plan  to  eliminate LF require that LQAS surveys  are conducted to assess  the prevalence  of antigenaemia in a district to decide on  initiation of mass treatment. Thus it was  decided  that a  sample of 250 children  from  the  target  age  group  from each  district would be examined using ICT.  A cut-off point of 1% was set to classify  the district as endemic for LF [16].  Out of 6 districts  from South Bati- nah region 3 districts have a significantly  lower population  compared with  the  other 3. Hence,  it was decided  to  test  the whole secondary-school population  in  these 3 districts (295, 235 and 257  students). In the other 3 districts , Barka,  Musanah and Rustaq,  the  selection of  the students was done according to the  proportional  target population. Thus  358, 347 and 506 students were select- ed  from these districts  respectively, by  considering each class in the secondary  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1061 schools  as 1 cluster  and  randomly  se- lecting  the  classes.  Similarly,  499 and  248 students were selected from Salalah  and Taqah districts of Dhofar  region  respectively. Survey The field part of the study was conducted  from February to March 2004.  A field protocol was developed  to  ensure uniformity and smooth conduct  of the surveys and also to ensure quality.  A national team was formed to oversee  the survey activities including the train- ing of staff. The field investigators were  the  school health  staff,  including doc- tors and nurses of the respective district.  A  standardization  training workshop  was organized before the field part of the  study to detail the survey methodology.  All  aspects of  the  ICT kit  procedure  were explained and demonstrated to the  field staff. The staff were given hands-on  training  followed by a field evaluation  of  the acquired skills  to ensure quality.  Each survey team consisted of 1 doctor  and 2 staff nurses. One nurse filled  the  data  collection  forms while  the other  collected blood samples and performed  the ICT test. The doctor was responsi- ble for reading the card results and over- all quality control. Data were collected  onto pre-tested school forms. ICT test kit The NOW ICT filariasis  kit  (catalog  no. 620-000, Binax  Inc.) was used  for  the qualitative detection of W. bancrofti antigen. The tests were developed and  read  according  to  the manufacturer’s  instructions. The  test  is useful  for  the  demonstration of  the W. bancrofti anti- gen at any time of the day and with any  accessible population. A 100 µL blood  sample collected by fingerprick during  the day was  added without pre-treat- ment  to a pink and white  sample pad  coupled to colloidal gold that contained  dried polyclonal  antibody (PAb) and  monoclonal antifilarial antibody (MAb)  respectively. The  teams were asked  to  conduct  the tests  in  lots of 10 students  to ensure a smooth flow of the test pro- cedures. The results were  read after 10  minutes. The test was recorded positive  if 2  lines (test  and control) were  seen  in  the viewing window, even when the  test line appeared lighter or darker than  the control line. The test was considered  invalid if the control line did not appear;  the test was then repeated according to  the manufacturer’s instructions.  Ethics The study was approved by the Omani  Ministry of Health and regional health  administrators  as well  as  the Regional  Committee of  the World Health Or- ganization Regional Office for the East- ern Mediterranean. The students as well  as  the parents and community at  large  were briefed about  the purpose of  the  survey. Informed consent was obtained  before conducting the survey. Statistics The data were computed and analysed  using  the  statistical  program Epi-Info 2000.  Frequencies,  proportions  and  prevalence rates were calculated. Results A  total of 2745  students  aged 17–18  years were  subjected  to antigenaemia  testing with a minimum of 250 students  in each of the 8 districts. A total of 1998  (72.8%) were  from South Batinah  re- gion and  the  remaining 747 (27.2%)  were  from Dhofar  region. The  study  subjects were  from classes belonging  to  34  randomly  selected  secondary  schools  in the study areas. The male to  female ratio was 0.9:1.  Of  the  2745  tested,  none  of  the  students  tested positive  for circulating  W. bancrofti  antigen (Table 1). During  the surveys 2 card tests were doubtfully  positive  in South Batinah  region  and  14 cards were read as invalid in Dhofar  region. These  tests were  repeated  later  and also found to be negative.  Discussion LF  is  uncommon  in Oman. The  en- demicity  status  is uncertain [6]; how- ever  some areas have been  suggested  as endemic areas [4]. Only 15 cases of  LF were  reported  in Oman during  the  surveillance period 1991–2001. Most  cases were classified as imported [6].  In our LQAS surveys of 2745 sec- ondary-school students in South Batinah  region and Salalah and Taqah districts of  the Dhofar  region,  all were uniformly  antigen-negative  and  therefore  none  of  the study districts were LF endemic.  Other countries have used detection of  Table 1 Antigenaemia survey for the presence of lymphatic filariasis among schoolchildren aged 17–18 years in Oman according to district and sex Region/district No. of schools No. of children tested No. antigen- positive Boys Girls Total South Bathinah Rustaq 5 243 263 506 0 Musannah 4 173 174 347 0 Barka 4 210 148 358 0 Wadi Maawil 2 99 136 235 0 Nakhl 3 128 167 295 0 Al Awabi 4 108 149 257 0 Dhofar Salalah 7 233 266 499 0 Taqah 5 138 110 248 0 Total 34 1332 1413 2745 0 EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1062 antigenaemia by  the  ICT card  test  in  surveys to estimate the prevalence of LF  infection (Table 2). Similar to our study,  the prevalence of LF was zero  in some  studies in Trinidad [16,17]. It is generally believed that the vectors  of LF are abundant in Oman, although  the specific mosquito species have not  been  formally  identified. Nevertheless,  LF is most likely not endemic in Oman.  The existence of isolated infected cases  in areas where transmission is extremely  unlikely (e.g. immigrants from a LF en- demic country to a nonendemic coun- try) does not  require development of  a national LF elimination programme.  Such a  situation  requires  implementa- tion of a passive surveillance system by  testing blood routinely collected  from  military  recruits,  university  students,  blood donors and hospitalized patients.  Similarly, examination of blood samples  from expatriates  and  treatment of  in- fected subjects would also be necessary.  Conclusions The prevalence of filarial antigenaemia  among students aged 17–18 years in the  suspected transmissible areas was zero.  From  this  evidence  it  can  reasonably  be  concluded  that LF  is not  endemic  in Oman and there is no evidence of its  transmission.  The data suggest  that Oman could  seek  to be awarded a certificate of LF  elimination.  Acknowledgements We are grateful  to the WHO Regional  Office  for  the Eastern Mediterranean  for providing the Binax ICT kits free of  charge for the survey as well as provid- ing technical expertise. We are thankful  to Dr Ali  Jaffer Mohammed, Advisor  Health Affairs and  the survey staff and  the Directorate  staff  from South Bati- nah and Dhofar  region  for completion  of the survey.  We also  thank  the Regional Direc- torate General  of Education,  schools  principals and teachers  for  their excep- tional cooperation and the students for  the participation. We acknowledge  the  excellent support of the regional teams  of doctors and health inspectors for this  study.  Table 2 Prevalence of lymphatic filariasis by antigenaemia in selected countries Study reference Country Prevalence (%) Study subjects Present study Oman 0.0 Schoolchildren [16] Trinidad 0.0 Schoolchildren [17] Kuwait 18.3 Adults [18] Cambodia 0.7 Adults [19] Suriname 0.22 Adults [20] Nigeria 22.5 Adult males [21] Uganda, Alebtong 29.0 Schoolchildren [21] Uganda, Lwala 18.0 Schoolchildren [21] Uganda, Obalanga 30.0 Schoolchildren [13] Egypt 17.2 Schoolchildren References Ottesen EA. Major progress toward eliminating lymphatic 1. filariasis. New England Journal of Medicine, 2002, 347(23):1885– 1886. Zagaria N and Savioli L. Elimination of lymphatic filariasis: a 2. public–health challenge Annals of Tropical Medicine and Para- sitology, 2002, 96(Suppl. 2):3–13. Out filariasis now. Report of the second meeting of the Global Alli-3. ance to Eliminate Lymphatic Filariasis. New Delhi, World Health Organization Regional Office for South-East Asia, 2002. Ottesen EA et al. Strategies and tools for the control/elimina-4. tion of lymphatic filariasis. Bulletin of the World Health Organi- zation, 1997, 75:491–503. Regional strategic plan for elimination of lymphatic filariasis 5. (2004–2007). New Delhi, World Health Organization Region- al Office for South-East Asia, 2004 (SEA-FIL-29). El Setouhy M, Ramzy RM. Lymphatic filariasis in the East-6. ern Mediterranean Region: current status and prospects for elimination. Eastern Mediterranean Health Journal, 2003, 9(4):534–541. DCD Division of Communicable Disease Control annual report 7. 2002. Cairo, World Health Organization Regional Office for the Eastern Mediterranean, 2002:7. Chapter 9: morbidity and mortality8. . Tables 9–15. In: Annual health report. Muscat, Oman Ministry of Health, 2001. Scrimgeour EM et al. Bancroftian filariasis in residents of 9. Oman. Acta Tropica, 2001, 79(3):241–244. Weil GJ, Lammie PJ, Weiss N. The ICT filariasis test: a rapid 10. format antigen test for diagnosis of bancroftian filariasis. Para- sitology Today, 1997, 13:401–404. Ramzy RM et al. Field evaluation of a rapid-format kit for diag-11. nosis of bancroftian filariasis in Egypt. Eastern Mediterranean Health Journal, 1999, 5:880–887. Njenga SM, Wamae, CN. Evaluation of ICT filariasis card test 12. using whole capillary blood: comparison with Knott’s concen- tration and counting chamber methods. Journal of Parasitol- ogy, 2001, 87:1140–1143. Ramzy RM et al. Efficient assessment of filariasis endemicity 13. by screening for filarial antigenaemia in a sentinel population. Transactions of the Royal Society of Tropical Medicine and Hy- giene, 1994, 88(1):41–44. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1063 Global Programme to Eliminate Lymphatic Filariasis In 1997, as a result of advances in the diagnosis and treatment of lymphatic filariasis, the disease was classed as one of 6  infectious diseases considered to be “eradicable” or “potentially eradicable”. Consequently, the World Health Assembly  adopted resolution 50.29, calling for elimination of the disease as a global public health problem. A report on the Global  Programme was recently published in the Weekly Epidemiological Record:  Global programme to eliminate lymphatic filariasis – Progress report on mass drug administration in 2009. Weekly Epidemiological Record, 2010, 85(38):365–372.  The full article can be accessed in French and English at: http://www.who.int/lymphatic_filariasis/policy/en/ Chandrasena TG et al. Evaluation of the ICT whole-blood anti-14. gen card test to detect infection due to Wuchereria bancrofti in Sri Lanka. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2002, 96(1):60–63. Preparing and implementing a national plan to eliminate lym-15. phatic filariasis (in countries where onchocerciasis is co-endemic). Geneva, World Health Organization, 2000:7–8 (WHO/CDS/ CPE/CEE/2000.16). Rawlins SC et al. Evidence for the interruption of transmission 16. of lymphatic filariasis among schoolchildren in Trinidad and Tobago. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2004, 98(8):473–477. Iqbal J, Sher A. Determination of the prevalence of lymphatic 17. filariasis among migrant workers in Kuwait by detecting circu- lating filarial antigen. Journal of Medical Microbiology, 2006, 55(4):401–405. Leang R et al. Assessment of disease and infection of lymphatic 18. filariasis in Northeastern Cambodia. Tropical Medicine and In- ternational Health, 2004, 9(10):1115–1120. Rawlins SC et al. Lymphatic filariasis in the Caribbean region: 19. the opportunity for its elimination and certification. Revista Panamericana de Salud Publica, 2000, 7(5):319–324. Eigege A et al. Rapid assessment for lymphatic filariasis in 20. central Nigeria: a comparison of the immunochromatographic card test and hydrocele rates in an area of high endemic- ity. American Journal of Tropical Medicine and Hygiene, 2002, 68(6):643–646. Onapa AW et al. Lymphatic filariasis in Uganda: baseline inves-21. tigations in Lira, Soroti and Katakwi districts. Transactions of the Royal Society of Tropical Medicine and Hygiene, 95(2):161–167. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1064 Rotavirus gastroenteritis among children aged under 5 years in Al Karak, Jordan O. Nafi1 ABSTRACT The introduction of a rotavirus vaccine makes it important to determine the need for vaccination in a population. This study in Jordan in 2007–08 determined the incidence and clinical features of rotavirus gastroenteritis among children aged under 5 years admitted to hospital with diarrhoea. Of 148 children, 59 (39.9%) were ELISA-positive for rotavirus in stool samples, predominantly in the age group < 2 years. There was a marginally higher rate of fever in the rotavirus cases than the non-rotavirus cases. The lowest rate of infection was in winter. No deaths were recorded among the rotavirus or non-rotavirus groups. Rotavirus vaccine was not in use in Jordan at the time of the study. 1Department of Paediatrics, College of Medicine, Mutah University, Karak, Jordan (Correspondence to O. Nafi: onafi2000@yahoo.com). Received: 27/01/09; accepted: 08/04/09 ندرلأا ،كركلا في ةسمالخا نس نود لافطلأا ىدل ةيلَجَعلا تاسويرفلاب ءاعملأاو ةدعلما باهتلا عفان ليع رمع هذه نم ةياغلا تناك دقو .ناكسلا لممج ميعطت لىإ ةجالحا ديدتح ةيهمأ َزَرْبأ دق rotavirus ةيلَجَعلا تاسويرفلل داضلما حاقللا لاخدإ نإ :ةـصلالخا في ةيريسرلا همحلامو ةيلَجَعلا تاسويرفلاب ءاعملأاو ةدعلما باهتلا تاعوقو لدعم ديدتح 2008-2007 ْيَماعلا في ندرلأا في ْتَيرجُأ يتلا ةساردلا رابتخا )%39.9( مهنم ًلافط 59 ىدل ناك ،ًلافط 148 لافطلأا ءلاؤه ددع غلبو .لاهسلإا ببسب ىفشتسلما في اولبُق نيذلا ةسمالخا نس نود لافطلأا .يتنس نع ّلقت يتلا ةيرمعلا ةعومجلما نم بلاغلا في اوناكو ،)ميزنلإاب طبترلما يعانلما زتملما ةسياقمب( ةيلَجَعلا تاسويرفلل بيايجإ ELISA ازيليإ لدعم ضفخأ ناك ماك ،اهنم ولتخ يتلا تلاالحا عم ةنراقلماب تاسوْيرَفلا هذبه ةباصلإا تلااح في ى َّملحا ثودح ةبسن في شيماه عافترا ظحولو داضلما حاقللا نكي لمو .ابه ةباصلما يرغ ةعومجلما وأ ةيلَجَعلا تاسويرفلا ىودعب ةباصلما ةعومجلما يب تايَفَو ةَّيأ ل َّجَسُت لمو .ءاتشلا في ىودعلل .ةساردلا ءارجإ تقو ندرلأا في ًامدختسم ةيلَجَعلا تاسويرفلل La gastro-entérite à rotavirus chez les enfants de moins de cinq ans à Al-Karak (Jordanie) RÉSUMÉ En raison de l’introduction d’un vaccin antirotavirus, il est important de déterminer le besoin de vaccination dans une population. La présente étude réalisée en Jordanie en 2007-2008 a permis d’identifier l’incidence et les caractéristiques cliniques de la gastro-entérite à rotavirus chez les enfants de moins de cinq ans hospitalisés pour une diarrhée. Sur 148 enfants, 59 d’entre eux (soit 39,9 %) avaient un test ELISA positif pour le rotavirus dans les échantillons de selles, principalement dans le groupe d’âge des moins de deux ans. Le taux de fièvre dans les cas à rotavirus était légèrement plus élevé que celui des cas sans rotavirus. Le taux d’infection le plus faible se situait en hiver. Aucun décès n’a été enregistré dans les groupes avec ou sans rotavirus. Le vaccin antirotavirus n’était pas utilisé en Jordanie au moment de l’étude. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1065 Introduction Diarrhoea diseases are the second most  frequent cause of death among young  children  in  the Eastern Mediterranean  Region  [1,2]  and  rotavirus disease  is  the  single  most  important  cause  of  severe  gastroenteritis  in  children  throughout  the world [3–5]. Globally  about  30%–40%  of  hospitalizations  and  deaths  due  to  diarrhoea  among  children under 5 years old,  and about  5% of all child deaths, are attributed  to  rotavirus  infection [1,6].  It occurs as a  sporadic  seasonal  form, even as  severe  gastroenteritis of  infants  and younger  children, mostly in the first 2–3 years of  life, with a peak at age 6–24 months [6].  National cause-specific mortality  rates  range  from 439  per  100  000  (Sierra  Leone) to  less than 1 per 100 000 (50  countries) [6].  Gastroenteritis due  to  rotavirus  is  characterized by  vomiting,  fever  and  watery  diarrhoea,  and  occasionally  leads  to  severe dehydration and death  in young children. Man is the only res- ervoir  of  infection,  and  transmission  occurs by the faecal–oral route and can  be attributed  to poor standards of per- sonal  and environmental hygiene  [7]  in both developed as well  as develop- ing countries. Seasonal variation  in  the  incidence of the disease has been noted,  particularly in temperate climates where  it peaks during the cooler months, while  in tropical climates cases occur through- out the year [6]. Unfortunately, protective immunity  against  rotavirus  infection  is not com- pletely understood,  although serotype  specific  immunity  is believed  to play a  major  role  [1]. The  introduction of  a  rotavirus vaccine  in  some parts of  the  world makes  it  important  to establish  the impact of this organism in our popu- lation  in Jordan to determine the need  for vaccination. The study reported here  from south  Jordan  is part of a national  sentinel  surveillance programme. The  aims of  study were  to determine  the  incidence of  rotavirus  gastroenteritis  among  children  aged  under  5  years  admitted with diarrhoea  to Al Karak  hospital and  to map some of  the clini- cal  features  associated with  rotavirus  disease (fever,  severity of dehydration,  vomiting and duration of illness). Methods A prospective hospital-based study was  carried out over 1 year from 1 May 2007  to 30 April 2008. All cases of diarrhoea  in  children under  5  years  old  admit- ted  to  the  department  of  paediatrics  of Al-Karak general  teaching hospital  were  recruited  for  the  study. Patients  were eligible  if  they were admitted  for  treatment  of  gastroenteritis  and  this  was  the primary  illness; were aged ≤ 5  years; and had symptoms  for < 7 days  duration. The exclusion criteria were:  age  >  5  years;  bloody  diarrhoea;  or  symptoms ≥ 7 days duration. Patients  with hospital-acquired gastroenteritis  were also excluded. Complete clinical examination was  carried  out  and  a  questionnaire was  filled  for each child  to collect data on  demographic  characteristics  (e.g.  age,  sex) and clinical presentation (e.g. body  temperature,  vomiting,  dehydration,  duration of  illness, date of admission).  Fever was defined as body temperature  ≥ 38 °C at the time of admission. Mild  dehydration was diarrhoea and  thirst;  moderate  and/or  severe dehydration  was depressed  fontanel,  sunken eyes,  dry tongue and loss of skin turgor. The  seasons  of  admission were  recorded  as:  autumn  (21/09–20/12);  winter  (21/12–20/03;   spring  (21/03– 20/06); summer (21/06–20/09). A stool  sample was obtained  from  each child  and analysed  for  rotavirus,  using an enzyme-linked  immunosorb- ent assay (ELISA) (IDEIA rotavirus kit,  DakoCytomation Ltd) and  read with  a photometer (Multiskan EX, Thermo  Electron Corporation). The data were analysed using SPSS,  version  10.  Data  were  presented  as  simple  frequencies and percentages or  means. The significance of differences  between proportions or means were  tested using  the  chi-squared or  t-test  respectively, with P < 0.05 as significant. Results Demographic and clinical characteristics of the whole group Data were  collected  for 148 children  with diarrhoea, 87 males (58.8%) and  61  females (41.2%) (Table 1),  a male  to  female  ratio of 1.4:1. The age  range  was 0–60 months, with mean age 12.4  [standard deviation (SD) 11.5] months.  The highest number of diarrhoea cases  was during the autumn (60%) and the  lowest in winter (4%) (Figure 1). Out of 148 cases with diarrhoea 97  (65.5%) children presented with  fever  and 51 (34.5%) without  fever.  (Table  2) The mean age of children with fever  was 13.8 (SD 13.0) months and with- out fever was 9.8 (SD 7.5) months. A  high  rate  of  diarrhoea  patients  (107, 72.3%) presented with dehydra- tion on admission; only 11 (7.4%) pre- sented with  severe dehydration, while  the remaining 96 (64.9%) were consid- ered to have mild dehydration. Patients  with  dehydration  were  significantly  younger than those not presenting with  dehydration [mean age 11.0 (SD 9.3)  months versus 16.2 (SD 15.5) months]  (t = 2.5, P = 0.013). Demographic characteristics of children with rotavirus diarrhoea We found 59 (39.9%) cases were ELI- SA-positive  for  rotavirus  in  their  stool  and 89 (60.1%) were ELISA-negative  for rotavirus.  The great majority of cases of rotavi- rus diarrhoea (96.6%) were in children  < 2  years old  and 78.0% were  among  children  aged  < 1 year.  A  total  of  39  cases (66.1%) were in males. Children with  rotavirus diarrhoea  were significantly younger than children  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1066 with  diarrhoea  caused  by  pathogens  other than rotavirus [mean 8.8 (SD 6.3)  months versus 14.8 (SD 13.4) months]  (t = 3.205, P = 0.002). This  inverse  re- lationship between  the age of children  with  diarrhoea  and  the  incidence  of  rotavirus  infection  is  shown on Table  1. The highest  rate of  rotavirus  infec- tion was  found  among patients  aged  ≤  6 months  (50.0%)  and  the  lowest  rate  among  those  aged > 24 months  (11.8%). In contrast, the highest rate of  diarrhoea  caused by pathogens other  than rotavirus was among children aged  ≥ 24 months  (88.2%) and  the  lowest  rate  of  non-rotavirus  diarrhoea  was  in children aged ≤ 6 months (50.0%) (Table 1). Rotavirus was detected at a higher  rate in the stool samples of male (44.8%)  than female patients (32.8%), a male to  female  ratio of cases of  rotavirus  infec- tion of 1.95 to 1. However, there was no  significant association between patient’s  sex  and  rotavirus  infection (χ2 = 2.14,  P > 0.05)(Table 1). Interestingly the seasonal pattern of  diarrhoea, with a greater incidence in the  autumn, was more pronounced among  the children infected with rotavirus than  those without. The highest incidence of  rotavirus diarrhoea was during autumn  (28%)(Figure 1). Clinical characteristics of children with rotavirus diarrhoea Out  of  the  59  rotavirus  infection  cases,  74.6%  presented with  fever,  a  Table 1 Age and sex distribution of rotavirus-positive and -negative cases in children under 5 years old admitted with diarrhoea Variable Total cases Rotavirus +ve Rotavirus –ve No. No. % No. % Age (months) 0–< 6 52 26 50.0 26 50.0 6–< 12 49 20 40.8 29 59.2 12–< 18 22 10 45.5 12 54.6 18–< 24 8 1 12.5 7 87.5 ≥ 24 17 2 11.8 15 88.2 Sex Male 87 39 44.8 48 55.2 Female 61 20 32.8 41 67.2 Total 148 59 39.9 89 61.1 Figure 1 Seasonal prevalence of rotavirus-positive and -negative cases in children under 5 years old admitted with diarrhoea Season of c as es طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1067 significantly higher rate among children  with diarrhoea due  to  rotavirus  infec- tion  compared with  the  rate of  fever  (59.5%) in the 53 diarrhoea cases caused  by  pathogens  other  than  rotavirus (Table 2). Fever occurred during rota- virus infection at a significantly younger  age [8.8 (SD 6.3) months] than in diar- rhoea cases caused by pathogens other  than rotavirus infection [14.8 (SD 13.4)  months] (t = 3.208, P < 0.05).  Severe dehydration was noticed  in  a  slightly higher  rate  among patients  with rotavirus infection, than diarrhoea  cases caused by pathogens other  than  rotavirus (11.1% versus 9.6%); however  this was not significant (Table 2). The rate of vomiting was similar tin  both groups (Table 2). Outcomes Most of  the diarrhoea cases came  for  management during  the first 7 days of  illness with a mean duration of  illness  of 3.1  (SD 1.3) days. All  the  cases of  diarrhoea were treated and cured within  the first 15 hours with a mean of 3.1 (SD  2.3) hours. No deaths were  recorded  among either group.  Discussion Diarrhoeal  diseases  remain  a major  cause of death in developing countries,  especially  in preschool  children  [1,7].  Children under 3 years of age may ex- perience as many as 10 episodes of diar- rhoea per year [7]. Rotavirus  is among  the most common causes of diarrhoea  worldwide [7,8], accounting for 134 mil- lion episodes/year [7,9,10]. Although a  vaccine has become available, rotavirus  vaccine was not  in use  in Jordan at the  time of the study. Diarrhoeal disease  is considered  to  be  the most  important cause of  infant  morbidity  in  Jordan [11]. Khuri-Bulos  and Al-Katib  in 2006 concluded  that  rotavirus  was  a  significant  cause  of  gastroenteritis  in  Jordanian  children  regardless of  their  social  background  [7].  In  the present study  the  incidence  of  rotavirus diarrhoea among children  in Al-Karak (39.9%) was slightly higher  than  in  the north of  Jordan (33%) as  detected by Youssef et al. in 2000 [12].  This discrepancy can be attributed to dif- ferences between the populations, vari- ations in the time of the study or to the  laboratory tests used. We found a higher  incidence higher  than  that detected  in  neighbouring countries: 24%, 37%, 35%  and 37% in southern Iraq, northern Iraq,  Islamic Republic  of  Iran  and Turkey  respectively  [5,13–15]. The  incidence  was also considerably higher  than 15%  recorded in Spain [16]. In contrast, our  rate was  lower  than  the prevalence of  rotavirus diarrhoea estimated  in Saudi  Arabia  during  2004–05  (86%)  [17]  and in Turkey in 2005 (63%) [13]. It is  also slightly  lower  than  the prevalence  of rotavirus diarrhoea in Kuwait (40%)  [9]. This  variation  in  the  prevalence  of  rotavirus  infection among different  areas is probably due to the social habits  of the population, e.g. personal hygiene,  and/or environmental  variations  that  may be  related  to growth of  rotavirus  pathogens particularly in contaminated  water [7]. Although no significant association  was detected between  sex of patients  and  rotavirus  infection  in  our  study,  the male  to  female  ratio of  cases with  rotavirus  infection was almost double  (1.95:1), which  is  similar  to  another  study  in  Jordan (1.85:1) [18], while a  ratio of 1.5:1 was found in Bahrain [19].  The reason for this male predominance  cannot  easily  be  explained,  although  it may be due  to  social  factors  rather  than a higher rate of infection in boys as  parents  in Arab societies may be more  likely  to  take  a male  child  to hospital  than a female child. On the other hand  a  study  in northern  Iraq  found no sig- nificant association between  rotavirus  infection and epidemiological  charac- teristics, including sex [5]. The great majority of cases of rotavi- rus diarrhoea (96.6%) were in children  < 2 years of age, and the mean age of ro- tavirus diarrhoea cases was significantly  lower  than diarrhoea  cases  caused by  pathogens  other  than  rotavirus  (8.8  months versus 14.8 months). This age  pattern  is consistent with other studies  from the region [9,12,13]. Children < 2  years may be more exposed to infection,  or  the older age group may have been  exposed previously to rotavirus and ac- quired some immunity against infection  [7]. Moreover, the mean age of children  with  rotavirus  in our  study  [8.8  (SD  6.34 months] was lower than that found  in northern Iraq [9.3 (SD 8.5) months]  [5]. This early exposure of our children  may be related to environmental factors  such as water  contamination  [7]. We  found an incidence of rotavirus among  children aged < 1 year of 45.5% which  is  similar  to  the  rates of 50% and 30%  estimated in Kuwait [9] and Kurdistan  respectively  [5]. This difference could  be related to breastfeeding and weaning  times  among populations  in different  areas or  countries. There  is  evidence  Table 2 Presenting symptoms of rotavirus-positive and -negative cases in children under 5 years old admitted with diarrhoea Presence of: Rotavirus +ve (n = 59) Rotavirus –ve (n = 89) Statistics No. % No. % Fever 44 75.0 53 59.5 χ2 = 3.62, P = 0.057 Severe dehydration 5 11.1 6 9.6 χ2 = 0.67, P > 0.05 Vomiting 51 86.4 76 85.4 χ2 = 0.038, P > 0.05 EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1068 that breastfeeding has a protective  role  in rotavirus-associated diarrhoea [18].  We found that fever was significant- ly  associated with  rotavirus diarrhoea  although we found no other studies with  data on fever in rotavirus diarrhoea. Our  study demonstrated  that  the  highest incidence of rotavirus diarrhoea  was during autumn,  followed by  sum- mer and  spring, while  the  lowest  inci- dence was during winter. This finding  contrasts with other studies that  found  the highest  incidence of  rotavirus dur- ing winter  in  Islamic Republic of  Iran,  Pakistan, Oman and Tunisia (53%, 37%,  60.5% and 40.5% respectively [1]. Simi- larly in Al-Qassim, Saudi Arabia 50% of  diarrhoea disease  cases  found during  winter were caused by viruses, and 66%  of  these were due  to  rotavirus  [20]. A  39.6% prevalence of rotavirus was found  in northern Jordan during the summer  (1992–93) [21].  In Spain 8% of  rota- virus diarrhoea cases occurred during  the winter months  (January–March)  [16]. The peak of  rotavirus  incidence  in the Islamic Republic of Iran, Kuwait  and Turkey was during winter [6,9,13].  In contrast to these studies, no seasonal  variation was detected  in  Iraqi Kurdis- tan [5]. These differences may be due  to environmental factors that may affect  the survival rate of the rotavirus outside  the body (temperature, humidity) and  to  contaminated water or  its  relation  with  level of  chlorination of water,  as  rotavirus is inactivated only by chlorine,  rather than other disinfectants [7]. Conclusions This  study  in  southern  Jordan  found  rotavirus infection in 39.9% of children  <  5  years  old  hospitalized with  diar- rhoea, predominantly  in  the age group  < 2 years. There was a marginally higher  rate of  fever  in  the rotavirus cases  than  the non-rotavirus cases. The lowest rate  of  infection was  in winter. No deaths  were  recorded among  the  rotavirus or  non-rotavirus group.  Whether  to  introduce  rotavirus  vaccine  to  the national  immunization  schedule  is  now under  discussion  in  technical health committees in Jordan.  Acknowledgements This study is a part of a national sentinel  surveillance  that  covered  several  sites  in  Jordan  including our hospital. The  surveillance  system  is  financially  and  technically  supported by VPI/DCD,  WHO/EMRO.  All  the  operating  procedures,  training of  staff  and  sup- plies and equipment were provided by  WHO/EMRO.  I  am  grateful  to  the Ministry  of  Health  in  Jordan,  especially Dr K. Al  Zain,  to Dr S. Fa’ouri  for his  valuable  review,  to Dr N. Nawieshaa  for  statis- tical  analysis  and  to Professor Dr W.  Al-Kubaisy for her assistance. References Teleb N. Update—EMRO surveillance network. 1. Rotavirus Sur- veillance News, 2006, 1(3). WHO statistical information system (WHOSIS)2. [website] (http:// www.who.int/whosis/en/, accessed 7 July 2010). Bahrdwaj A et al. Does rota virus infection cause persistent 3. diarrhoea in childhood? Tropical Gastroenterology, 1996, 17(1):18–21. Zizdić S, Ridjanović Z, Masić. Novootkriveni serotipovi rotavi-4. rusa u cetverogodisnjem uzorku oboljele djece s dijarealnim sindromom [Newly discovered rotavirus serotypes in 4 years of collecting samples from children with diarrheal syndromes]. Medicinski Arhiv, 1992, 46(1,2):15–18. Ahmed HM et al. Molecular characterization of rotavirus 5. gastroenteritis strains, Iraqi Kurdistan. Emerging Infectious Dis- eases, 2006, 12(5):1420–1422. Estimated rotavirus deaths for children under 5 years of age: 6. 2004, 527 000. World Health Organization [website] (http:// www.who.int/immunization_monitoring/burden/rotavi- rus_estimates/en/index.html, accessed 7 July 2010). Khuri-Bulos N, Al Khatib M. Importance of rotavirus as a cause 7. of gastroenteritis in Jordan: a hospital based study. Scandina- vian Journal of Infectious Diseases, 2006, 38(8):639–644. Communicable diseases: infections through the gastro-intes-8. tinal tract. Chapter 4. In: Gilles H, Lucas A, eds. Short textbook of public health medicine for the tropics, 4th ed. London, Hod- der, 2003. Sethi SK et al Acute diarrhoea and rotavirus infections in 9. young children in Kuwait. Annals of Tropical Paediatrics, 1984, 4:117–121. Shukry S et al. Detection of enteropathogens in fatal and po-10. tentially fatal diarrhea in Cairo, Egypt. Journal of Clinical Micro- biology, 1986, 24:959–962. Annual report11. . Amman, Jordan Ministry of Health, 1989:97–99. Youssef M et al. Bacterial, viral and parasitic enteric pathogens 12. associated with acute diarrhea in hospitalized children from northern Jordan. FEMS Immunology and Medical Microbiology, 2000, 28:257–263. Özkana S et al. Water usage habits and the incidence of di-13. arrhea in rural Ankara, Turkey. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2007, 101(11):1131–1135. Mohamood DA, Feachem RG. Clinical and epidemiological 14. characteristics of rotavirus and EPEC-associated hospitalized infantile diarrhea in Basrah, Iraq. Journal of Tropical Paediatrics, 1987, 33:319–325. Khalili B et al. Epidemiology of rotavirus diarrhoea in Iranian 15. children. Journal of Medical Virology, 2004, 73:309–312. Gutiérrez-Gimeno MV et al. Nosocomial rotavirus gastroen-16. teritis in Spain: a multicenter prospective study. Pediatric Infec- tious Disease Journal, 2006, 25(5):455–457. Kheyami AH et al. Molecular epidemiology of rotavirus di-17. arrhea among children in Saudi Arabia: first detection of G9 and G12 strains. Journal of Clinical Microbiology, 2008 46(4):1185–1191. Faouri SG et al. Epidemiology of rotavirus diarrhea in children 18. under three years of age in pediatric department at Al-Bashir hospital. Journal of the American Academy of Pediatrics, 1995, 95(4 Suppl.2/2):19–20. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1069 Neglected tropical diseases Neglected tropical diseases are a symptom of poverty and disadvantage. Those most affected are the poorest  populations often living in remote, rural areas, urban slums or in conflict zones. With little political voice, neglected  tropical diseases have a low profile and status in public health priorities. Although medically diverse, neglected tropical diseases share features that allow them to persist in conditions of poverty,  where they cluster and frequently overlap. Over 1 billion people – one sixth of the world’s population – suffer from one  or more neglected tropical diseases. An informative booklet on progresses made in the control of these diseases, Neglected tropical diseases, hidden successes, emerging opportunities, has recently been published in English and French, and can be accessed from:   http://www.who.int/neglected_diseases/en/ Dutta SR et al. Epidemiology of rotavirus diarrhoea in children 19. under five years in Bahrain. International Journal of Epidemiol- ogy, 1990, 19(6):722–727. Meqdam MM, Thwiny IR. Prevalence of group a rotavirus, 20. enteric adenovirus, norovirus and astrovirus infections among children with acute gastroenteritis in Al-Qassim, Saudi Arabia. Pakistan Journal of Medical Sciences, 2007, 23(4):551–555. Meqdam MM et al. Viral gastroenteritis among young chil-21. dren in northern Jordan. Journal of Tropical Paediatrics, 1997, 43(6):349–352. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1070 Prévalence des infections nosocomiales dans 27 hôpitaux de la région méditerranéenne K. Amazian,1,2 J. Rossello,3 A. Castella,4 S. Sekkat,5 S. Terzaki,6 L. Dhidah,7 T. Abdelmoumène,8 J. Fabry1 et les membres du réseau NosoMed RÉSUMÉ Une étude multicentrique a été menée dans 27 hôpitaux en Algérie, en Égypte, en Italie, au Maroc et en Tunisie afin d’évaluer la prévalence et les caractéristiques des infections nosocomiales. La population de l’étude (4634 patients) était relativement jeune avec une moyenne d’âge de 41,1 ans (écart type [ET] 23,4). La prévalence des infections nosocomiales était de 10,5 % ; celle-ci était plus élevée dans les centres non universitaires et dans les hôpitaux de taille moyenne. Globalement, les infections urinaires étaient les plus fréquentes. Les services de pédiatrie ont enregistré une prévalence particulièrement élevée (11,3 %). Les germes les plus fréquemment isolés étaient Escherichia coli (17,2 %), Staphylococcus aureus (12,5 %), Pseudomonas aeruginosa et Klebsiella pneumoniae (9,2 % chacun). Le jour de l’enquête, 40,7 % des patients étaient sous traitement antibiotique, dont presque la moitié avec une indication empirique. La survenue d’une infection nosocomiale était significativement associée à la ventilation mécanique, un délai de séjour supérieur ou égal à 8 jours, la présence d’un cathéter central ou périphérique, une sonde urinaire, au diabète, et à l’âge. 1Laboratoire d’épidémiologie et santé publique, Université Claude Bernard, Lyon (France) (Correspondance à adresser à K. Amazian : kamazian@ yahoo.com, kamazian@sante.univ-lyon1.fr). 2Service de la recherche et du développement, CHU Hassan II, Fès (Maroc). 3University Hospital Vall d’Hebron, Department of Preventive Medicine and Epidemiology, Barcelona, Spain. 4Dipartimento di Sanità Pubblica e Microbiologia, Università di Torino, Torino, Italy. 5Centre d’Immunologie, Faculté de Médecine et Pharmacie, Casablanca (Maroc). 6Nosocomial Infection Control Centre GOTHI, Matarya T.H., Cairo, Egypt. 7Service d’Hygiène hospitalière, CHU Sahloul, Sousse (Tunisie). 8Unité d’Hygiène hospitalière, Institut National de Santé Publique, Alger (Algérie). Reçu : 15/02/2010 ; accepté : 31/03/10 طسوتلما ضيبلاا رحبلا ةقطنم في ىفشتسم 27 في ةيوفشتسلما ىودعلا راشتنا ةكبش ءاضعأو ،يرباف كاج ،نمولما دبع سواط ،حديحد ينلم ،يكازرت ايرث ،طاقسلا داعس ،لايتساك ازيلانا ،وليسور سيوخ ،نايزمأ ايليماك ديموزون ىودعلا راشتنا لدعم ميـيقتل ،سنوتو برغلماو ايلاطيإو صرمو رئازلجا في ىفشتسم 27 تلمش زكارلما ةددعتم ةسارد نوثحابلا ىرجأ :ةـصلالخا هرادقم يرايعم فارحناب( ًاماع 41.1 مهرماعأ يطسو غلب ْذإ ،بابشلا نس في ًايبسن اوناك ًاضيرم 4 634 ةساردلا تلمشو ،اهصئاصخو ةيوَفشتسلما لىعو .مجلحا ةطسوتلما تايفشتسلما فيو ةيميلعتلا يرغ زكارلما في لىعأ لدعم وهو ،%10.5 ميهدل ةيوفشتسلما ىودعلا راشتنا لدعم غلبو .)23.4 ميثارلجا امأ .)%11.3( صاخ ٍوحن لىع ةعفترم لافطلأا ماسقأ في ىودعلا تناكو .ًاعويش رثكلأا يه ةيلوبلا كلاسلما ىودع تناك ،لاجملإا هجو ة َّليسبلكلاو Psendomonas ةيراجنزلا ةفئازلاو ،)%12.5( ةيبهذلا ةيدوقنعلاو ،)E.coli )%17.2 ةينولوقلا ةيكيشرلإا تناكف ًاعويش رثكلأا ةَدَرفتسلما نوقلتي ًابيرقت مهفصن ناكو ،ةيويلحا تاداضلماب ةلجاعملل نوعضيخ ضىرلما نم %40.7 ناك ةساردلا هيف تيرجأ يذلا تقولا فيو .)%9.2( ةيوئرلا في ثُّيرـَّتلا عمو يكيناكيلما سفنتلا عم ًايئاصحإ ابه ُّدَتْعُي ٍةجردب طبارـتـت ةيوفشتسلما ىودعلا نأ نوثحابلا دجوو .يبـيرتج ٍساسأ لىع ةلجاعلما كلت .رمعلا عمو ،يركسلا عمو ،ةيلوب ةرطثق دوجو عمو ،ةيطيمح وأ ،ةيزكرم ةرطثق دوجو عمو ، مايأ 8 لىع ديزـت وأ لداعت ةدلم ىفشتسلما نم جيرختلا Prevalence of nosocomial infections in 27 hospitals in the Mediterranean region ABSTRACT A multicentre study was conducted in 27 hospitals in Algeria, Egypt, Italy, Morocco and Tunisia to evaluate the prevalence and characteristics of the nosocomial infections. The study population (4634 patients) was relatively young, mean age 41.1 (standard deviation 23.4) years. The prevalence of nosocomial infections was 10.5%; this was higher in non-teaching centres and moderate-sized hospitals. Overall, urinary tract infections were the most common. Paediatric departments rated particularly high (11.3%). The most commonly isolated organisms were: Escherichia coli (17.2%), Staphylococcus aureus (12.5%), Pseudomonas aeruginosa and Klebsiella pneumoniae (9.2% each). On the day of the study, 40.7% of the patients were under treatment with antibiotics, with nearly half for an empirical indication. Nosocomial infection was significantly associated with mechanical ventilation, hospitalization ≥ 8 days, presence of a central or peripheral catheter), urinary catheter, diabetes and age. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1071 Introduction Le s   i n f e c t i on s   no socom i a l e s  représentent  un  problème  de  santé  publique  universel.  Mais  si  la  lutte  contre ces infections est bien organisée  dans  les  pays  développés,  elle  l’est  beaucoup  moins  dans  les  pays  de  faible   niveau  socio-économique  qui  souffrent,  pour  la majorité,  d’une  absence  de  réglementation  et  du  manque de données représentatives de  surveillance. Les   enquêtes   de   prévalence  constituent  l’outil  de  base  pour  la  surveillance des infections nosocomiales.  Elles  ont  même  été  recommandées  par  l’Organisation  mondiale  de  la  Santé  pour des  études nationales  ou  internationales [1]. Elles permettent de  faire, de manière  simple et  à moindre  coût,  un  état  des  lieux  du  risque  infectieux  nosocomial. Cet  avantage  est  encore plus  considérable dans  les  pays de faible niveau socio-économique  où  les  ressources disponibles pour  la  lutte contre les infections nosocomiales  font défaut [2]. De plus,  ces  enquêtes  constituent un outil de sensibilisation et  d’information du personnel [3,4].  Dans  la  région méditerranéenne,  peu d’études multicentriques ont  été  menées sur  le sujet. Excepté une étude  de  prévalence  nationale  conduite  au  Maroc en 1994 [5], les autres enquêtes  concernant l’infection nosocomiale ont  été réalisées à une échelle plus restreinte,  souvent  au  niveau  d’un  seul  hôpital,  ce  qui  rend  difficile  la  possibilité  de  réflexions communes afin de proposer  des  solutions cohérentes et efficientes.  Autrement,  les données des différentes  études  ne  sont  pas  comparables  de  façon directe puisque les méthodologies  adoptées diffèrent entre elles [6].  Ains i   nous   avons   entrepr is ,  dans  le  cadre  du  réseau  NosoMed  (Strengthening HealthCare Epidemiology for the Investigation of Nosocomial Infections in the Mediterranean Area), une  enquête de prévalence des  infections  nosocomiales  afin  de  répondre  au  besoin  de  faire  un  état  des  lieux  de  l’étendue des  infections nosocomiales  dans  la  région  méditerranéenne,  en  incluant  un  nombre  relativement  important  d’hôpitaux  pilotes  et  en  utilisant une méthodologie standardisée  et commune à ces hôpitaux.  Les objectifs de cette étude étaient  de  déterminer  le  taux  de  prévalence  des  infections  nosocomiales  dans  des  hôpitaux  pilotes  de  la  région  méditerranéenne, de connaître  les sites  les  plus  fréquents  de  ces  infections  et  leur  prévalence,  de déterminer  les  micro-organismes  les  plus  impliqués  dans  les  infections  nosocomiales,  d’étudier les facteurs de risque liés à ces  infections, d’évaluer  la consommation  des antibiotiques et enfin de sensibiliser  le personnel  à  la  gravité de  l’infection  nosocomiale. Méthodes L’enquête   a   été   conduite   dans  27 établissements  publics  ou privés :  quatre établissements en Algérie, dix en  Égypte,  trois en  Italie,  six au Maroc et  quatre en Tunisie. La participation des  établissements était volontaire. Tous les  patients admis depuis 48 heures ou plus  étaient inclus.  Le  recueil  d’information,  par  des  enquêteurs formés, s’est fait en examinant  les dossiers médicaux des patients, ceux  des  soins  infirmiers  et  les  résultats de  laboratoire,  en plus de  l’interrogatoire  du personnel, au besoin. Les définitions  de  l’infection  nosocomiale  étaient  basées  sur celles des Centers for Disease Control and Prevention (CDC) [7]. Les données recueillies sur une fiche  standardisée ont concerné : l’identification de  l’établissement et • du service  ;  les  caractéristiques  du  patient : • admission,  âge,  sexe,  facteurs  de  risque  intrinsèques (diabète, obésité,  dénutrition,  immunodépression,  neutropénie)  ;  les  facteurs de  risque extrinsèques : • sonde  urinaire,  cathéter  vasculaire  périphérique ou central, alimentation  parentérale,  ventilation mécanique,  procédure chirurgicale  ;   l a   p ré sence   d ’une   in fec t ion • nosocomiale :  seules  les  infections  actives  étaient  prises  en  compte  -  date du début de l’infection, cultures,  résultat microbiologique et résistance  pour  certains  organismes -,  deux  infections  actives  pouvaient  être  notées  ;  la  prescription  des  antibiotiques : • molécule et indication.  Les données ont été validées et saisies  localement  à  l’aide d’une  application  commune sur Epi Info 6.04. L’ensemble  des données a été centralisé au niveau  du centre de coordination (laboratoire  d’épidémiologie  et  santé  publique  à  Lyon) et analysé avec  le  logiciel SPSS  V12. L’analyse des facteurs de risque a été  effectuée pour l’ensemble des infections  nosocomiales et pour  les  sites  les plus  fréquemment recensés lors de l’enquête.  Une  analyse  univariée  a  permis  de  mesurer  l’association  des  différents  facteurs avec  la  survenue de  l’infection  nosocomiale (ou des sites d’infection).  Cette association a été mesurée à l’aide  de l’odds ratio (OR). Les paramètres avec  une valeur de p associé au χ2 inférieure à  0,1 ont été  introduits dans un modèle  logistique afin de déterminer les facteurs  de risque indépendants, et la validité du  modèle a été évaluée à l’aide du test de  Hosmer-Lemeshow. Résultats Caractéristiques des établissements Vingt-sept  établissements  totalisant  11 853  lits  ont  participé  à  l’enquête.  Le  taux d’occupation des  lits  par des  patients présents depuis 48 heures ou  plus était de 39,1 %.  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1072 Description des patients L’enquête  a  porté  sur  4634 patients.  L’âge moyen était de 41,1  ans  (écart- type  [ET]  23,4)  et  la  médiane  de  42 ans ; 19,4 % des patients étaient âgés  de 65 ans ou plus. Le sex ratio hommes/ femmes était de 0,99. La durée moyenne  de  séjour des patients  au moment de  l’étude était de 15,4 jours (ET 24,3),  la  médiane se  situant à 8  jours. La durée  moyenne de séjour  la plus élevée était  enregistrée en Algérie (20,7  jours, p =  0,02) et la plus faible au Maroc (7,7 jours,  p < < 0,001). Les  caractéristiques  des  patients  et  la  présence  des  facteurs  de  risque  intrinsèques par pays  sont présentées  dans le tableau 1. Les facteurs de risque  extrinsèques  sont  présentés  dans  le  tableau 2. La présence de  facteurs de  risque  intrinsèques  chez  les  patients  issus  des  hôpitaux  égyptiens  était  plus  importante  que  chez  ceux  issus  des  autres pays (différence statistiquement  significative pour  tous  les  facteurs de  risque  cités).  Le  sondage  urinaire,  la  présence  d’un  cathéter  central  et  la  ventilation étaient plus  fréquents chez  les  patients  italiens  (p  <  10-5),  alors  que  les  cathéters  périphériques  et  l’alimentation parentérale étaient plus  fréquents en Égypte que dans les autres  pays (p < 0,001). Parmi  les patients,  1224  (27,0 %)  avaient subi une  intervention chirurgi- cale  pendant  l’admission  en  cours ;  59,5 % d’entre eux avaient un score ASA  (American Society of Anesthesiologists) de 1, 25,2 % un score ASA de 2, 10,9 % un  score ASA de 3, 3,9 % un score ASA de  4 et 0,4 % un score ASA de 5.  Prévalence des infections nosocomiales Parmi les 4634 patients inclus le jour de  l’enquête, 413 avaient une ou plusieurs  infections nosocomiales,  soit un  taux  de prévalence de 8,9 % (intervalle de  confiance [IC]95 % : 8,1-9,8) ; 56 patients  ont présenté deux  infections et 14 en  Tableau 1 Caractéristiques des patients et facteurs de risque intrinsèques Caractéristiques Algérie Égypte Italie Maroc Tunisie Total Nombre de patients 1628 1149 371 268 1218 4634 Spécialité du service Médecine 642 (39,4 %) 251 (21,8 %) 157 (42,3 %) 78 (29,1 %) 545 (44,7 %) 1673 (36,1 %) Chirurgie 535 (32,9 %) 561 (48,8 %) 187 (50,4 %) 99 (36,9 %) 386 (31,7 %) 1768 (38,2 %) Réanimation 86 (5,3 %) 50 (4,4 %) 16 (4,3 %) 6 (2,2 %) 52 (4,3 %) 210 (4,5 %) Gynéco-obstétrique 82 (5,0 %) 93 (8,1 %) 9 (2,4 %) 47 (17,5 %) 81 (6,7 %) 312 (6,7 %) Pédiatrie 214 (13,1 %) 135 (11,7 %) 2 (0,5 %) 38 (14,2 %) 135 (11,1 %) 524 (11,3 %) Autre 69 (4,2 %) 59 (5,1 %) 0 0 19 (1,6 %) 147 (3,2 %) Âge (ans) Moyenne (ET) 37,5 (22,2) 37,2 (21,9) 64,7 (18,1) 40,2 (22,5) 42,7 (23,6) 41,1 (23,4) Médiane 37 39 69 40 43 42 Sexe Hommes 818 (50,2 %) 599 (52,6 %) 159 (45,2 %) 107 (39,9 %) 574 (49,5 %) 2257 (49,6 %) Femmes 810 (49,8 %) 540 (47,4 %) 193 (54,8 %) 161 (60,1 %) 586 (50,5 %) 2290 (50,4 %) Diabète Oui 219 (13,5 %) 210 (18,3 %) 58 (16,1 %) 46 (17,4 %) 152 (13,4 %) 685 (15,1 %) Non 1406 (86,5 %) 939 (81,7 %) 302 (83,9 %) 219 (82,6 %) 981 (86,6 %) 3847 (84,9 %) Obésité Oui 93 (5,7 %) 135 (11,7 %) 40 (11,1 %) 27 (10,2 %) 23 (2,0 %) 318 (7,0 %) Non 1533 (94,3 %) 1014 (88,3 %) 319 (88,9 %) 239 (89,8 %) 1126 (98,0 %) 4231 (93,0 %) Dénutrition Oui 147 (9,0 %) 191 (16,6 %) 25 (7,0 %) 14 (5,3 %) 9 (0,8 %) 386 (8,5 %) Non 1478 (91,0 %) 958 (83,4 %) 333 (93,0 %) 252 (94,7 %) 1117 (99,2 %) 4138 (91,5 %) Immunodéficience Oui 84 (5,2 %) 108 (9,4 %) 11 (3,1 %) 0 92 (7,7 %) 295 (6,4 %) Non 1537 (94,8 %) 1041 (90,6 %) 347 (96,9 %) 265 (100 %) 1106 (92,3 %) 4296 (93,6 %) Neutropénie Oui 54 (3,4 %) 101 (8,8 %) 8 (2,2 %) 0 23 (1,9 %) 186 (4,1 %) Non 1529 (96,6 %) 1048 (91,2 %) 350 (97,8 %) 265 (100%) 1171 (98,1 %) 4363 (95,9 %) ET : écart-type. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1073 avaient  trois.  Le  taux  de  prévalence  des  infections  était  de  10,5 %  (483  infections au  total). La moyenne d’âge  des patients  infectés  était de 41,8  ans  contre 41,0  ans pour  les patients non  infectés  (différence non  significative).  La  durée  moyenne  de  séjour  entre  l’admission et  l’infection était de 13,6  (ET 25,9)  jours  (médiane :  6  jours)  avec des  grandes  variations  entre  les  pays allant de 2,6 jours au Maroc à 24,1  jours en Algérie. La durée moyenne de  séjour était significativement plus élevée  (p < 0,001) chez  les patients  infectés  (24,6  jours) par  rapport  aux patients  non infectés (14,5 jours). Le taux de prévalence des infections  nosocomiales  était  plus  faible  dans  les  centres  hospitalo-universitaires  comparé aux hôpitaux non universitai- res (8,3 % vs 11,0 %  ; p = 0,008). Selon  la  taille des établissements,  les hôpitaux  de plus de 500 lits rapportaient le taux de  prévalence  le plus  faible (7,6 %),  suivis  par  les hôpitaux de moins de 200  lits  (10,6 %), alors que les hôpitaux moyens  (200-500 lits) avaient le taux d’infections  le plus élevé (12,9 %) (p < 0,001). Le  taux de prévalence des patients  infectés  variait  de  6,3 %  en Algérie  à  11,9 % en  Italie. Le  tableau 3 présente  les  résultats  par  pays.  La  figure  1  présente  les  taux de prévalence dans  25  établissements  ayant  un  effectif  supérieur à 30 patients  inclus. Le  taux  de prévalence médian était de 8,25 %,  avec des extrêmes allant de 0 à 30,2 %.  Onze de ces établissements avaient un  taux  de  plus  de  10 %,  plus  élevé  que  la  limite  supérieure de  l’intervalle  de  confiance à 95 %. Tableau 2 Facteurs de risque extrinsèques Facteur de risque Algérie Égypte Italie Maroc Tunisie Total Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nbre (%) Nombre de patients 1628 1149 371 268 1218 4634 Sonde urinaire Oui 181 (11,1) 192 (16,7) 118 (32,3) 20 (7,6) 111 (9,2) 622 (13,5) Non 1445 (88,9) 957 (83,3) 247 (67,7) 244 (92,4) 1093 (90,8) 3986 (86,5) Cathéter périphérique Oui 690 (42,4) 623 (54,2) 130 (38,2) 32 (12,2) 431 (35,8) 1906 (41,6) Non 936 (57,6) 526 (45,8) 210 (61,8) 231 (87,8) 773 (64,2) 2676 (58,4) Cathéter central Oui 42 (2,6) 44 (3,8) 67 (18,7) 0 41 (3,4) 194 (4,2) Non 1582 (97,4) 1105 (96,2) 292 (81,3) 261 (100) 1158 (96,6) 4398 (95,8) Alimentation parentérale Oui 137 (8,4) 155 (13,5) 21 (5,8) 30 (11,5) 31 (2,6) 374 (8,1) Non 1489 (91,6) 994 (86,5) 338 (94,2) 232 (88,5) 1168 (97,4) 4221 (91,9) Ventilation mécanique Oui 32 (2,0) 30 (2,6) 15 (4,1) 4 (1,5) 33 (2,8) 114 (2,5) Non 1592 (98,0) 1119 (97,4) 347 (95,9) 257 (98,5) 1166 (97,2) 4481 (97,5) Procédure chirurgicale Oui 291 (18,9) 401 (34,9) 172 (46,4) 95 (35,4) 265 (21,9) 1224 (27,0) Non 1250 (81,1) 748 (65,1) 199 (53,6) 173 (64,6) 947 (78,1) 3317 (73,0) Tableau 3 Prévalence des infections nosocomiales par pays Pays Patients infectés Infections Taux de prévalencea par hôpital (%) Nbre Taux % (IC95 %) Nbre Taux (%) min-max Algérie 103 6,3 (5,2-7,6) 127 7,9 2,1-13,0 Égypte 114 9,9 (8,3-11,8) 125 10,9 0,0-30,2 Italie 44 11,9 (8,8-15,6) 53 14,3 5,4-15,3 Maroc 18 6,7 (4,0-10,4) 18 6,7 0,0-24,7 Tunisie 134 11,0 (9,3-12,9) 160 13,2 6,8-14,9 Total 413 8,9 (8,1-9,8) 483 10,5 0,0-30,2 aTaux de prévalence des patients infectés. IC : intervalle de confiance. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1074 Sites des infections nosocomiales Les  infections  urinaires  étaient  les  infections  les  plus  fréquentes :  elles  représentaient  25,9 %  de  l’ensemble  d e s   i n f e c t i on s   no so com i a l e s  contractées et une prévalence de 2,6 %.  L’importance des  sites d’infection en  termes de  fréquence était néanmoins  différente entre les pays. Les infections  urinaires  représentaient  presque  la  moitié des  infections nosocomiales en  Italie   ;  elles étaient également en  tête  en Tunisie,  avec  la même  fréquence  que  les  infections  de  la  peau  et  des  tissus mous. En Égypte,  les  infections  du  site  opératoire  (ISO)  étaient  les  infections prédominantes alors que les  infections de la peau et des tissus mous  étaient  les plus  fréquentes  en Algérie  et  les  infections  respiratoires  les plus  fréquentes au Maroc (Tableau 4). Infections nosocomiales et spécialité du service Les services de réanimation étaient ceux  qui présentaient le taux de prévalence le  plus élevé (24,8 %),  suivis des  services  de  pédiatrie  (11,3 %).  Les  services  chirurgicaux,  la  gynéco-  obstétrique  et  les  services médicaux  avaient  des  taux de prévalence de 8,0 %, 7,7 % et  7,6 %  respectivement. En  Italie  et  en  Égypte,  les  infections  nosocomiales  étaient  plus  fréquentes  dans  les  services de médecine (11,5 % et 11,6 %  respectivement)  que  dans  ceux  de  chirurgie (8,6 % et 8,4 % respectivement,  différence  non  significative  pour  les  deux).  Micro-organismes isolés et résistance aux antibiotiques Pour  les  483  infections  déclarées,  274 (56,7 %) cultures ont été  réalisées  dont  230  se  sont  révélées  positives.  Au total, 273 germes ont été  identifiés.  Qua t r e   e spèce s   b a c t é r i enne s  représentaient  presque  la moitié  des  germes  isolés : Escherichia coli (17,2 %),  S t a p h y l o c o c c u s a u r e u s   (12 ,5  %) ,  Pseudomonas aeruginosa   (9,2 %)  et  Klebsiella pneumoniae  (9,2 %)  ; 31,6 %  des S. aureus  isolés  étaient  résistants  à  la  méticilline.  La  résistance  a  été  également recherchée pour  les espèces  les  plus  courantes  d’entérobactéries  (Enterobacter, E. coli et K. pneumoniae) :  13,5 % des 96  souches  isolées  étaient  sensibles à tous les antibiotiques, 39,6 %  étaient résistantes aux aminopénicillines,  14,6 % aux céphalosporines de troisième  génération, 5,2 % aux céphalosporines  de troisième génération, aux quinolones  et aux carbapénèmes.  La moitié des 12 A. baumanii identi- fiés  étaient  résistants  aux  céphalos- porines de  troisième génération,  aux  quinolones et aux carbapénèmes et un  seul était sensible à tous les antibiotiques  testés.   La  résistance  n’a  pas  été  Figure 1 Taux de prévalence des infections nosocomiales par établissement (IC95 %) طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1075 précisée pour sept des 25 P. aeruginosa identifiés,  deux  étaient  résistants  aux  céphalosporines de troisième génération  et deux à  tous  les antibiotiques  testés,  cinq parmi  eux  étaient  résistants  aux  aminopénicillines  et  cinq  étaient  sensibles à tous les antibiotiques. Infections nosocomiales et facteurs de risque En  fonction  de  l’âge  des  patients,  le  taux de prévalence  le moins élevé était  enregistré dans  la  classe d’âge 25-42  ans. Excepté le sexe et l’obésité, tous les  autres facteurs de risque, intrinsèques et  extrinsèques,  étaient  significativement  associés  à une plus  grande  fréquence  d’infection. Un séjour  supérieur à huit  jours,  le  sondage urinaire,  la présence  d’un cathéter  central  et  la  ventilation  présentaient un OR supérieur  à 3. Le  sexe  féminin a été  associé à un  risque  élevé uniquement pour  les  infections  de  la  peau  et  des  tissus  mous,  avec  un  OR  de  1,64  (IC :  1,01-2,68).  L’exposition  au  risque  des  différents  sites  infectieux  les  plus  fréquents  est  présentée dans le tableau 5. Le lien entre  les actes invasifs et les sites pour lesquels  ils  constituent des  facteurs de  risque  particuliers  a  été  retrouvé  (sondage  et  infections  urinaires,  ventilation  et  infections respiratoires, cathéter central  et  bactériémie).  Après  ajustement,  sept variables ont  subsisté comme des  facteurs  de  risque  indépendants  des  infections  nosocomiales.  Elles  sont  présentées dans le tableau 6. Prescription des antibiotiques La  proportion  des  patients  sous  antibiotiques  le  jour  de  l’enquête  était  de  40,7 %,  avec  une  indication  de  prescription  empirique  dans  40,8 %  des  cas.  Excepté  en  Tunisie  où  elle  était  de 7,7 %, dans  les  autres  pays  cette  proportion  variait   de  41,0 % au Maroc à 66,4 % en Égypte  ;  17,1 % des patients  étaient  sous deux  antibiotiques  ou  plus.  Les  classes  d’antibiotiques  les plus  consommées  étaient  les  pénicillines (32,1 %),  les  aminoglycosides  (15,5 %)  et  les  céphalosporines de  troisième généra- tion (14,6 %). Tableau 4 Prévalence des différents sites d’infections nosocomiales Pays IU IR ISOa Peau/tissus mous Bactériémie Autresb Algérie Nbre d’infections 29 17 18 33 2 20 Fréquence relative (%) 24,4 14,3 15,1 27,7 1,7 16,8 Prévalence (%) 1,8 1,0 1,1 2,0 0,0 1,2 Égypte Nbre d’infections 34 13 46 10 14 8 Fréquence relative (%) 27,2 10,4 36,8 8,0 11,2 6,4 Prévalence (%) 3,0 1,1 4,0 0,9 1,2 0,7 Italie Nbre d’infections 24 12 3 1 8 3 Fréquence relative (%) 47,1 23,5 5,9 2,0 15,7 5,9 Prévalence (%) 6,5 3,2 0,8 0,3 2,2 0,8 Maroc Nbre d’infections 1 12 5 - - - Fréquence relative (%) 5,6 66,7 27,8 Prévalence (%) 0,4 4,5 1,9 Tunisie Nbre d’infections 34 32 9 34 27 22 Fréquence relative (%) 21,5 20,3 5,7 21,5 17,1 13,9 Prévalence (%) 2,8 2,6 0,7 2,8 2,2 1,8 Total Nbre d’infections 122 86 81 78 51 53 Fréquence relative (%) 25,9 18,3 17,2 16,6 10,8 11,3 Prévalence (%) 2,6 1,9 1,7a 1,7 1,1 1,1 a La prévalence des ISO chez les patients opérés était de 6,6 %. Elle était de 6,2 % en Algérie, de 11,5 % en Égypte, de 1,7 % en Italie, de 5,3 % au Maroc et de 3,4 % en Tunisie. b « Autres » comprend les infections gastro-intestinales, les infections des os et articulations, les infections de l’œil, de l’oreille, du nez, de la gorge et de la bouche, les infections cardio-vasculaires et les infections du système nerveux central. IU : infections urinaires ; IR : infections respiratoires ; ISO : infections du site opératoire. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1076 Discussion Cette étude multicentrique sur la prévalence des  infections nosocomiales a  l’intérêt de produire  des données épidémiologiques  représentatives  du  risque  infectieux nosocomial dans  la  région  méditerranéenne.  Avec  une moyenne  d’âge  des  patients  de  41,1 ans,  la population incluse dans l’étude était  très jeune : 15,2 % étaient âgés de 65 ans ou plus  dans  les pays non européens alors qu’en  Italie,  seul  pays  européen participant  à  cette  étude,  cette proportion était de 61,5 %. Des proportions  supérieures à 50 % des patients âgés de 65 ans  ou plus  sont  rapportées dans  toutes  les études  réalisées dans les pays européens [4,8]. Le  taux  de  prévalence  des  patients  ayant  acquis une  infection nosocomiale dans notre  étude était de 8,9 % et  celui des  infections de  10,5 %. Ces chiffres se situaient dans la fourchette  de ceux rapportés dans  la  littérature, que ce soit  dans  les  pays  européens  [3,4,8-10],  ou  dans  les  pays  sud-méditerranéens  [11-14].  Nous  tenons à rappeler cependant que la comparaison  directe  avec  les  données  de  la  littérature  est  délicate :  taille  et  activité  des  établissements,  méthodologie  adoptée,  etc. À  titre d’exemple,  une  étude  tunisienne  a  donné  un  taux  de  prévalence des patients  infectés de 17,9 % [15], mais  l’établissement  avait  la  particularité  de  posséder un grand nombre de  lits appartenant  à des  spécialités  à haut  risque  (unité de  soins  intensifs, brûlés, oncologie).  Il  a  été  établi  par  de  précédentes  études  multicentriques que la prévalence des infections  nosocomiales  augmente  avec  le  niveau  de  technicité et  la  taille des établissements  [5,8] ;  or, dans notre étude,  le  taux de prévalence des  infections nosocomiales était plus élevé dans les  hôpitaux non universitaires  ainsi que dans  les  hôpitaux de taille moyenne. Ceci peut être dû en  grande partie à des pratiques plus défectueuses et  à un manque de règles d’hygiène plus important  au niveau de ces hôpitaux mal  équipés et peu  sensibilisés  à  la  problématique des  infections  nosocomiales. La  fréquence  élevée  des   infect ions  nosocomiales en réanimation est  régulièrement  retrouvée dans toutes les enquêtes de prévalence  des  infections  nosocomiales  [5,8,12,15,16].  Elle  est  associée  à  une  forte  fréquence  de Ta bl ea u 5 Ex po si ti on a u ri sq ue d es s ite s in fe ct ie ux le s pl us fr éq ue nt s : a na ly se u ni va ri ée Fa ct eu rs d e ri sq ue In fe ct io ns u ri na ir es In fe ct io ns d u si te op ér at oi re In fe ct io ns re sp ir at oi re s Ba ct ér ié m ie In fe ct io ns p ea u/ ti ss us m ou s O R (IC 95 % ) p O R (IC 95 % ) p O R (IC 95 % ) p O R (IC 95 % ) p O R (IC 95 % ) p  ge (< 2 5 ou > 4 2 an s) 1,5 3 (0 ,9 5- 2, 47 ) 0 ,0 8 1,0 9 (0 ,6 4- 1,8 6) 0 ,9 2, 24 (1 ,19 -4 ,2 5) 0 ,0 1 1,5 1 ( 0 ,7 3- 3, 13 ) 0 ,3 1,3 4 (0 ,7 4- 2, 41 ) 0 ,4 Se xe (F ) 0 ,8 5 (0 ,5 8- 1,2 4) 0 .4 1,1 2 (0 ,7 3- 1,8 2) 0 ,6 0 ,9 6 (0 ,6 2- 1,5 0 ) 0 ,9 1,2 1 ( 0 ,6 9- 2, 14 ) 0 ,6 1,6 4 (1, 0 1- 2, 68 ) 0 ,0 5 D ur ée d e sé jo ur ≥ 8 j 3, 92 (2 ,5 3- 6, 0 9) < 10 -1 1 2, 89 (1 ,7 4- 4, 80 ) < 0 ,0 0 1 1,9 8 (1, 26 -3 ,10 ) 0 ,0 0 3 3, 80 (1 ,9 4- 7,4 5) < 0 ,0 0 1 4, 35 (2 ,4 1- 7,8 4) < 0 ,0 0 1 D ia bè te 1,6 8 (1, 0 7- 2, 64 ) 0 ,0 3 1,7 6 (1, 0 3- 3, 0 1) 0 ,0 5 0 ,9 8 (0 ,5 3- 1,8 1) 1 0 ,6 8 (0 ,2 7- 1,7 3) 0 ,5 3, 0 7 (1, 84 -5 ,13 ) < 0 ,0 0 1 O bé si té 2, 11 (1 ,2 1- 3, 68 ) 0 ,0 1 1,5 8 (0 ,7 5- 3, 32 ) 0 ,3 0 ,6 9 (0 ,2 5- 1,8 9) 0 ,7 - 0 ,0 8 0 ,4 1 ( 0 ,10 -1 ,6 9) 0 ,3 D én ut rit io n 1,9 4 (1, 15 -3 ,2 8) 0 ,0 2 1,2 7 (0 ,6 0 -2 ,6 6) 0 ,5 1,5 2 (0 ,7 8- 2, 98 ) 0 ,2 0 ,7 3 (0 ,2 3- 2, 36 ) 0 ,8 1,2 8 (0 ,5 8- 2, 82 ) 0 ,5 Im m un od éfi ci en ce 1,8 7 (1, 0 4- 3, 38 ) 0 ,0 5 0 ,5 9 (0 ,19 -1 ,9 0 ) 0 ,5 0 ,9 3 (0 ,3 8- 2, 32 ) 1 1,3 0 (0 ,4 6- 3, 64 ) 0 ,6 3, 15 (1 ,6 7- 5, 95 ) 0 ,0 0 1 N eu tr op én ie 0 ,6 2 (0 ,19 -1 ,9 6) 0 .6 1,3 3 (0 ,4 8- 3, 68 ) 0 ,5 1,8 8 (0 ,8 1- 4, 38 ) 0 ,1 4, 74 (2 ,19 -1 0 ,2 6) 0 ,0 0 1 1,8 6 (0 ,7 4- 4, 67 ) 0 ,2 So nd ag e ur in ai re 5, 59 (3 ,8 4- 8, 15 ) < 0 ,0 0 1 2, 50 ( 1,5 0 -4 ,16 ) 0 ,0 0 1 2, 63 (1 ,6 2- 4, 25 ) < 0 ,0 0 1 2, 87 (1 ,5 6- 5, 31 ) 0 ,0 0 2 3, 0 7 (1, 84 -5 ,14 ) < 0 ,0 0 1 C at hé te r p ér ip hé riq ue 1,2 0 (0 ,8 3- 1,7 5) 0 .3 4, 55 (2 ,6 7- 7,7 6) < 0 ,0 0 1 1,3 4 (0 ,8 7- 2, 0 8) 0 ,2 3, 72 (1 ,9 6- 7,0 7) < 0 ,0 0 1 3, 77 (2 ,2 1- 6, 41 ) < 0 ,0 0 1 C at hé te r c en tr al 7,8 3 (4 ,9 6- 12 ,3 7) < 0 ,0 0 1 1,6 4 (0 ,6 5- 4, 10 ) 0 ,2 5, 26 (2 ,9 5- 9, 37 ) < 0 ,0 0 1 10 ,7 6 (5 ,7 5- 20 ,11 ) < 0 ,0 0 1 3, 0 6 (1, 44 -6 ,4 8) 0 ,0 0 8 A lim en ta tio n pa re nt ér al e 1,7 2 (0 ,9 9- 2, 99 ) 0 ,0 6 3, 63 (2 ,12 -6 ,2 3) < 0 ,0 0 1 3, 42 (2 ,0 3- 5, 77 ) < 0 ,0 0 1 6, 83 (3 ,7 9- 12 ,3 4) < 0 ,0 0 1 0 ,8 8 (0 ,3 5- 2, 20 ) 1 Ve nt ila tio n m éc an iq ue 5, 5 (3 ,0 -1 0 ,1) < 0 ,0 0 1 2, 23 (0 ,8 0 -6 ,2 0 ) 0 ,12 12 ,5 4 (7 ,17 -2 1,9 4) < 0 ,0 0 1 19 ,8 2 (1 0 ,4 6- 37 ,5 6) < 0 ,0 0 1 1,8 1 ( 0 ,5 6- 5, 84 ) 0 ,2 Pr oc éd ur e ch iru rg ic al e 1,7 2 (1 ,18 -2 ,5 1) 0 ,0 0 6 - 0 ,9 2 (0 ,5 6- 1,5 1) 0 ,8 0 ,9 8 (0 ,5 2- 1,8 5) 1 1,0 3 (0 ,6 1- 1,7 5) 0 ,9 O R : o dd s r at io ; I C : in te rv al le d e co nfi an ce . طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1077 réalisation d’actes invasifs. En revanche,  et  contrairement  à  notre  étude,  la  pédiatrie est habituellement un service  à faible taux de prévalence des infections  nosocomiales ne dépassant pas 4 %, que  ce soit dans les pays européens [16] ou  dans les autres pays de plus faible niveau  socio-économique [5,12,14].  Dans  les  études  réalisées  dans  les  hôpitaux  sud-méditerranéens  au  début des  années 1990,  les  infections  du  site  opératoire  constituaient  incontestablement les infections les plus  répandues, avec des fréquences relatives  allant  de 29 %  à  39,9 %  [5,11,16,17].  Dans  les  études  les  plus  récentes  et  de  la même manière  que dans notre  étude,  les  infections du site opératoire  sont un peu moins  fréquentes et  sont  dominées  souvent  par  les  infections  respiratoires [12,15]. La localisation des  infections nosocomiales  au niveau de  la peau et des tissus mous est rarement  observée dans  la  littérature  internatio- nale dans des services autres que le long  séjour et  la psychiatrie  [4]. Par contre,  cette  localisation  représente une part  importante  des  infections  observées  dans notre étude, en Algérie et Tunisie,  dans des services de médecine, chirurgie  et  pédiatrie.  Cette  prédominance  a  déjà  été  signalée  dans  l’étude  de  prévalence  nationale  au  Maroc,  et  elle  a  été  expliquée  par  un manque  d’hygiène hospitalière englobant aussi  bien  l’hygiène  individuelle des patients  et  du  personnel,  l’hygiène  collective  que  le  non-respect  des  conditions  d’asepsie [5]. Dans  le  même  ordre  d’idée,  les  facteurs de  risque extrinsèques étaient  les  plus  associés  au  risque  infectieux  nosocomial.  Une  durée  de  séjour  de  huit  jours  ou  plus  augmentait  considérablement  le  risque d’acquérir  une   infect ion  nosocomiale .   La  présence  d’un  disposit i f   invasi f  ainsi  que  l’intervention  chirurgicale  é ta ient   a s soc iées   à   un   r i sque  accru  d’infections  nosocomiales  conformément  aux  données  de  la  littérature [4,5,10,14,16,18].  C o n c e r n a n t   l e s   f a c t e u r s  intrinsèques,  seuls  le  diabète  et  l’âge  ont  été  associés,  de  manière  plus  modérée,  au  risque  infectieux.  La  stratification sur l’âge a révélé un taux de  prévalence des infections nosocomiales  particulièrement élevé chez  les enfants  âgés de plus d’un  an. La distribution  des  infections nosocomiales  selon  les  classes d’âge est assez comparable à celle  retrouvée par Bezzaoucha et al. [17] où  les  sujets  âgés de moins de 20  ans  et  ceux âgés de 40 à 59 ans présentaient  les prévalences  les plus  élevées. Cette  distribution est  liée en partie au  risque  élevé dans les services de pédiatrie déjà  signalé. La  prescription  d’antibiotiques  chez  les  patients  enquêtés  était  particulièrement  alarmante.  Cette  forte  prescription  d’antibiotiques  a  été  rapportée  dans  la majorité  des  études  réalisées  dans  des  pays  en  développement  [18,19]. Ainsi 46,8 %  des patients enquêtés dans un hôpital  tunisien étaient  sous  antibiotiques  et  la moitié d’entre  eux  recevaient deux  molécules ou plus  ; les céphalosporines  de  troisième  génération  étaient  les  antibiotiques  les  plus  fréquemment  administrés  [15].  À  contrario,  dans  l’enquête  nationale  de  prévalence  de  2001  en  France  [4],  seuls  15,9 %  des  patients  avaient  un  traitement  antibiotique. Cette  étude  a  permis  de  faire  un  premier  état des  lieux  sur  la  situation  des  infections  nosocomiales  dans  les  hôpitaux  pilotes  en  utilisant  la  même  méthodologie.  Elle  a  permis  de  mieux  approcher  les  spécificités  locales  :   services  de  pédiatrie   à  risque  (donc  nécessité  d’établir  des  programmes  de  prévention  adaptés  aux caractéristiques épidémiologiques  de cette  spécialité),  forte prescription  d’antibiotiques (nécessité de normes  de bonnes pratiques),  localisations des  infections nosocomiales toutes présentes  avec  des  proportions  assez  proches,  écart  de  prévalence  beaucoup  plus  réduit entre les services de réanimation  et  les  autres  services (notamment  la  pédiatrie),  ce qui  évoque des  risques  plus  liés  aux  insuffisances  dans  les  pratiques d’hygiène qu’aux procédures  invasives.  Mais  pour  avoir  une  meilleure  approche  de  la  réalité  des  infections  nosocomia les   e t   pour   pouvoir  évaluer  les  tendances  dans  le  temps,  il  serait  intéressant  que  les  hôpitaux  participant  à  cette étude  réalisent des  enquêtes de prévalence périodiques en  utilisant  le même protocole  d’étude.  Ce n’est  qu’à  cette  condition qu’une  comparaison directe entre les différents  Tableau 6 Facteurs de risque indépendants des infections nosocomiales Facteur de risque OR IC95 % Âge (< 25 ou > 42 ans) 1,34 1,02-1,76 Durée de séjour ≥ 8 j 3,12 2,43-4,02 Diabète 1,49 1,13- 1,96 Dénutrition 1,36 0,97-1,91 Immunodéficience 1,38 0,93-2,04 Neutropénie 1,19 0,74-1,94 Sondage urinaire 1,76 1,32-2,34 Cathéter périphérique 2,05 1,62-2,59 Cathéter central 2, 17 1,43-3,35 Alimentation parentérale 1,22 0,87-1,71 Ventilation mécanique 4,02 2,49-6,48 Procédure chirurgicale 1,22 0,95-1,57 Test de Hosmer-Lemeshow : χ² = 15,64 ; p = 0,03. OR : odds ratio ; IC : intervalle de confiance. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1078 taux  observés  devient  acceptable  [6].  La  mise  en  place  d’études  de  prévalence successives afin d’avoir des  données  valides  tout  en  détournant  les difficultés  liées  à  une  surveillance  continue a été recommandée et utilisée  par  de  nombreuses  équipes  avec  succès [10,11,19-21]. Cette méthode  a également  l’intérêt d’évaluer  l’impact  des mesures  de  prévention mises  en  place entre les enquêtes successives. De  plus,  et  pour  bien  étudier  la   problématique  de  l ’ infect ion  nosocomiale au niveau national,  il  est  nécessaire  d’effectuer  des  enquêtes  de  prévalence  avec  un  nombre  d’établ issements  beaucoup  plus  important dans chaque pays et ce, par  le  biais  d’un  échantillon  randomisé  Références Avril JL, Donnio PY. La surveillance des infections nosoco-1. miales. La Revue du Praticien, 1989, 39(16):1381–1385. Jepsen OB. Surveillance of hospital infection with limited re-2. sources. Clinical Infectious Diseases, 1996, 2:211–223. Comité technique national des infections nosocomiales. 3. Enquête nationale de prévalence des infections nosoco- miales, 1996. Bulletin Epidémiologique Hebdomadaire, 1997, 36:161–163. Réseau d’alerte, d’investigations et de surveillance des infec-4. tions nosocomiales (RAISIN). Enquête de Prévalence Nationale 2001 - Résultats. Paris, Institut de Veille Sanitaire, 2003. Amrani J. 5. Résultats de l’enquête de prévalence des infections nosocomiales au niveau de 24 hôpitaux. Rabat, Ministère de la Santé, 1994. Gastmeier P et al. Importance of the surveillance method: 6. national prevalence studies on nosocomial infections and the limits of comparison. Infection Control and Hospital Epidemiol- ogy, 1998, 19:661–667. Garner JS et al. CDC definitions for nosocomial infections, 7. 1988. American Journal of Infection Control, 1988, 16:128–140. Gastmeier P et al. Prevalence of nosocomial infections in 8. representative German hospitals. Journal of Hospital Infection, 1998, 38:37–49. Zotti CM et al. Hospital-acquired infections in Italy: a region 9. wide prevalence study. Journal of Hospital Infection, 2004, 56:142–149 Vaqué J, Rossello J, Arribas JL and EPINE Working Group. 10. Prevalence of nosocomial infections in Spain: EPINE study 1990–1997. Journal of Hospital Infection, 1999, 43:S105–S111. Dhidah L 11. et al. Les infections nosocomiales : étude par en- quêtes de prévalence instantanée de 1992 à 1995. Maghreb Médical, 1997, 314:41–44. Azzam R, Dramaix M. A one-day prevalence survey of hospital-12. acquired infections in Lebanon. Journal of Hospital Infection, 2001, 49:74–78. Metintas S et al. Prevalence and characteristics of nosocomial 13. infections in a Turkish university hospital. American Journal of Infection Control, 2004, 32:409–413. Gikas A et al. Prevalence study of hospital–acquired infec-14. tions in 14 Greek hospitals: planning from the local to the national surveillance level. Journal of Hospital Infection, 2002, 50:269–275. Kallel H et al. Prevalence of hospital-acquired infection in a 15. Tunisian hospital. Journal of Hospital Infection, 2005, 59:343– 347. Ennigrou S, Ben Redjeb S, Zouari B. Prévalence des infections 16. nosocomiales à l’hôpital Charles Nicolle de Tunis. La Tunisie Médicale, 1999, 77(3):127–133. Bezzaoucha A 17. et al. Prévalence des infections nosocomiales au centre hospitalo–universitaire de Bab El Oued-Alger. Médecine et Maladies Infectieuses, 1994, 24(2):96–101. Gikas A et al. Prevalence of nosocomial infections after surgery 18. in Greek hospitals:results of two nationwide surveys Infection Control and Hospital Epidemiology, 2004, 25:319–324. Gikas A et al. Repeated multi-centre prevalence surveys of 19. hospital–acquired infection in Greek hospitals. Journal of Hos- pital Infection, 1999, 41:11–18. French GL et al. Repeated prevalence surveys for monitor-20. ing effectiveness of hospital infection control. Lancet, 1989, 28:1021–1023. Atif ML 21. et al. Évolution de la prévalence des infections no- socomiales dans un centre hospitalier universitaire en Al- gérie (2001-2005). Médecine et Maladies Infectieuses, 2006, 36(8):423–428. représentatif  avec une stratification selon  la  taille des établissements [8,12]. Les  résultats de  telles études permettraient  une approche plus  juste de  la  situation  nationale dans  le but de proposer des  mesures  de  surveillance  nationale  standard.  Conclusion Il  est  universellement  admis  que  le  risque  zéro  n’existe  pas  lors  d’une  hospita l isat ion  ;   ce   r isque  doit  néanmoins  être  réduit  au maximum.  Dans une population telle que celle de  notre étude,  avec une moyenne d’âge  ne  dépassant  pas  les  42  ans  et  une  exposition  aux  principaux  dispositifs  invasifs  relativement  faible,  le  taux  d ’ infect ion   «  incompress ible  »  devrait être beaucoup plus  faible si un  programme opérationnel  en hygiène  hospitalière est mis en place.  Remerciements Les auteurs  tiennent à  remercier  tous  les  collaborateurs qui ont participé  à  la  réalisation de cette étude en Algérie,  en  Égypte,  en  Italie,  au Maroc  et  en  Tunisie. Ce  travail  a  été  financé  par  le  Programme  INCO  (International C o o p e r a t i o n   –   Coop é r a t i o n  internationale) de l’Union européenne  (contrat n° ICA3-CT-2000-30010). طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1079 Knowledge, attitudes and practices of barbers about hepatitis B and C transmission in Hyderabad, Pakistan A.H. Jokhio,1 T.A. Bhatti2 and M.S. Memon3 ABSTRACT Hepatitis B and C virus (HBV/HCV) infections are serious global health problems. Shaving by barbers has been identified as the key risk factor for spread of HBV. We conducted a cross-sectional survey of barbers in Hyderabad city, Pakistan in 2007 to establish their knowledge and attitudes to the risk of HBV and HCV transmission and their working patterns. Observations showed that 96.2% washed razors with antiseptic after each client and 95.7% used a new blade with new clients. However, knowledge about the diseases and modes of transmission were poor and only 36.6% knew that hepatitis can be transmitted via shaving instruments. Only 3.2% of 186 barbers were vaccinated against HBV. Strategies are needed for raising awareness and regulations of barbers’ practices. 1Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan (Correspondence to A.H. Jokhio: hakeem.jokhio@aku.edu). 2Medical Research Centre, Liaquat University of Medical Health Sciences, Jamshoro, Pakistan. 3Department of Medicine, Isra University, Hyderabad, Pakistan. Received: 02/11/08; accepted: 28/04/09 ناتسكابلا دابآ رديح في »سي»و »بي« دبكلا باهتلا ةياسرب ق َّلعتي ام في متهاسرما ُـ مو مهُفقاَوَمو ينق َّلالحا فراعم نَمْيَم قداص دممح ،يّـِ تَب دحمأ ليفط ،ويهكْوُج ميكلحا دبع لثتم ينقلالحا ىدل ةقَلاِلحا نأ فورعلما نم حبصأ دقو .يلماعلا ديعصلا لىع ةميخولا ةيحصلا تلاكشلما نم »سي«و »بي« دبكلا باهتلا دعي :ةـصلالخا 2007 ماع في ناتسكابلا دابآ رديح ةنيدم في ينقلالحا ينب ًاضرعتسم ًاحسم نوثحابلا ىرجأ دقو .»بي« دبكلا باهتلا شرن في سييئرلا راطتخلاا لماع ينقلالحا نم %96.2 نأ حضّـَ تا دقو .مهلمع طمانأ لىع ًاضيأ ف ُّرعتلاو ،»سي«و »بي« دبكلا باهتلا ةياسر راطتخا هاتج مهفقاومو مهفراعم لىع ف ُّرعتلل ولو ،دُدُجـلا مهنئابزل ةديدج ةرفش نومدختسي مهنم %95.7 نأو ،نوبز لكل ةقلالحا دعب ةر ِّهطم ةدماب انهومدختسي يتلا ةقلالحا ةنكام نولسغي اوناك %3.2 نأ ماك ،ةقلالحا تاودأ برع لقتني دق دبكلا باهتلا نأ مهنم %36.6 ىوس فرعي لم ْذإ ،ةليزه تناك هلاقتنا قرط نعو ضرلما نع مهفراعم نأ ةسرامم م ِّظنت تاعيشرت عضولو ،يعولا ىوتسمب ءاقترلال تايجيتارـتسا لىإ ةجالحا ُّستمو .»بي« دبكلا باهتللا داضلما حاقللا او َّقلت دق طقف مهنم .ينقلالحا Connaissances, attitudes et pratiques des barbiers concernant la transmission de l’hépatite B et C à Hyderabad (Pakistan) RÉSUMÉ Les infections par les virus de l’hépatite B et C constituent de graves problèmes de santé dans le monde. Le rasage par les barbiers a été identifié comme étant le principal facteur de risque de propagation du virus de l’hépatite B. Nous avons effectué une étude transversale auprès des barbiers de la ville d’Hyderabad (Pakistan) en 2007 afin d’identifier leurs connaissances et leurs attitudes dans le domaine du risque de transmission des virus de l’hépatite B et C ainsi que leurs méthodes de travail. Les observations ont révélé que 96,2 % d’entre eux lavaient les rasoirs avec un antiseptique après chaque client et qu’ils étaient 95,7 % à utiliser une lame neuve pour chaque client. Mais leur connaissance de ces maladies et de leur mode de transmission était faible et seuls 36,6 % d’entre eux savaient que l’hépatite pouvait se transmettre par des instruments de rasage. Seuls 3,2 % des 186 barbiers étaient vaccinés contre le virus de l’hépatite B. Des stratégies de sensibilisation aux pratiques des barbiers et de réglementation de ces dernières sont nécessaires. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1080 Introduction Globally over 2 billion people have been  infected with hepatitis B virus (HBV)  [1] and an estimated 170 million people  are chronically  infected with hepatitis  C virus (HCV) [1,2].  In Pakistan spe- cific estimates for the prevalence of both  diseases  range  from  2%–10%  [3,4].  Recently  the  rates  of HBV  infection  in  the  country  have been  increasing,  attributed  to  a  lack  of  proper  health  facilities, low socioeconomic status and  low public health awareness about  the  transmission of communicable diseases  [5]. A  significant proportion of  those  exposed  to HBV become chronically  infected and are at considerable  risk of  liver cancer, chronic active hepatitis and  cirrhosis. These infected people may not  be aware of their HBV status and are not  clinically ill but are a source of infection  to others. HBV is 50 to 100 times more infec- tious  than HIV,  yet  is  transmitted by  contact with blood or body fluids of an  infected person in the same way as HIV  [1]. Razor shaving by barbers has been  identified as a key risk factor for trans- mission of HBV [6] and HCV [7,8]. In  Turkey 39.8% of barbers were  found  to  be HBV positive  and many were  infected during the course of employ- ment  [9]. HBV and HCV  infections  have  been  implicated  as  an  occupa- tional  hazard of  the barbers’  trade  in  several developing countries [10–18].  In  Pakistan,  daily  facial  shaving  and  armpit shaving  from barbers has been  identified as a  risk  factor  for  transmis- sion of HBV and HCV [14–17].  Prevention is the best strategy against  the epidemic of viral hepatitis. Barbers  have low awareness about hepatitis and  the  risk of  transmission of  infectious  agents by  reuse of  razors  and  scissors  on multiple clients [19,20]. In Pakistan  the prevalence of  shaving by barbers  is  reported  to be as high as 34%–49% of  the male population [14] and  it  is  im- portant  to know how barbers perceive  the  risks  in  relation  to prevention of  transmission between  themselves and  customers. A  very  limited number of  studies have been published in Pakistan  investigating knowledge,  attitude and  practices  about hepatitis  transmission  among barbers  [19]  and patients  at- tending  family medicine  clinics  [21].  We therefore designed the current study  to assess  the knowledge,  attitudes and  common practices of  barbers  in Hy- derabad city, Sindh province regarding  risk of  transmission of HBV and HCV  in their work. This information will help  to guide the design and implementation  of appropriate prevention and interven- tions strategies. Methods This  study was part of  cross-sectional  study conducted  in Hyderabad  to de- termine the prevalence and risk factors  of HBV  and HCV  infection  among  barbers  and  their  regular  clients. Hy- derabad is the 4th largest city in Pakistan  and 2nd  largest city  in Sindh province  and about 200 km from Karachi, which  has a mix of both  low and high socio- economic residents.  Sample There were 521 barbers shops registered  in the city. Hyderabad city was divided  into 11 zones and all the barbers’ shops  were  listed using  the mapping exercise  carried out by  the Canadian  Interna- tional Development  Agency  project  for HIV/AIDS serosurveillance. Using  a computer-generated,  simple,  random  sampling  procedure,  10  shops  were  selected from each zone to achieve the  target sample size for the original cross- sectional  study. From the selected 111  shops, there were 202 barbers available  and eligible  for  interview. After giving  informed verbal  consent, 186 barbers  agreed  to participate  in  the  study and  were  included  in  the final analysis;  the  refusal rate was 8% (16/202). Data collection The  survey  was  completed  during  March–October 2007. Trained medi- cal  interviewers  visited  the  selected  barbers’  shops  and  requested barbers  to participate in the study. Face-to-face  interviews were conducted with partici- pating barbers  about  their knowledge  and  attitudes.  Before  the  start  of  the  main  interview, one of  the  accompa- nied  supervisors not  involved  in data  collection observed  the barber and as- sessed his instrument use practices with  clients.  The  questionnaire  collected  data  about personal  characteristics  such as  age,  education,  income, marital  status,  ethnic group and area of residence. The  knowledge  section  covered  barbers’  knowledge  about  different modes of  transmission of hepatitis,  including  the  risk of  transmission of  the disease due  to use and reuse of  razors,  and knowl- edge of  vaccines  for HBV and HCV.  The attitudes  section covered  the  type  of media  they use  for  information and  entertainment; attitudes  towards  these  diseases; whether  they had been vac- cinated against  these diseases; whether  they were a  substance abuser, had had  a blood  transfusion,  tattoos or  surgical  operation/stitches;  and whether  they  thought  it was necessary  to have peri- odic screening for bloodborne diseases  in general and whether they themselves  would  like  to be  tested  for  these dis- eases.  The practices of barbers were ob- served on 2 occasions while  they were  attending  clients  and  a  checklist was  used  to  record: hand-washing before  each client;  sterilization of  instruments  with antiseptic; use and reuse of blades;  and disposal of used blades and instru- ments.  A  random selection of 10% of  the  questionnaires was  checked  to  verify  whether all questions had been under- stood by  the barbers. Participation  in  the  survey was  on  a  voluntary  basis.  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1081 The study was approved by  the ethical  review committee of Liaquat University  of Medical and Health Sciences. Analysis A Microsoft Access 2000 database was  used  for data entry and  the data were  tabulated  and  analysed by  frequency  distributions in SPSS, version 11.5.  Results A total of 186 questionnaires were com- pleted from barbers’ interviews. The par- ticipant’s demographic characteristics  are  shown  in Table 1. Most  respond- ents  (69.9%) were  aged 15–30 years.  Around one-third (35.5%) of barbers  were  illiterate and another 41.9% had  education up to primary school. Nearly  half  (53.2%) of  the  respondents were  unmarried. Most  respondents (95.7%)  were  resident  in  the main urban areas  and the largest ethnic group in terms of  mother tongue was Urdu (47.8%). Knowledge Responses to the knowledge questions  showed  that  awareness  of modes  of  transmission  of  hepatitis  and  the  different sources/risk  factors were  low,  ranging  from  only  9.7%  correct  for  foodborne  transmission  to 36.6% who  knew that hepatitis can be  transmitted  through barber’s  shaving  instruments  (Table 2). Only 11.3% of  respondents  knew  that both HBV and HCV have  the  same mode  of  transmission  and  6.5% knew  that  there  is  a vaccine  that  can protect  against HBV, while 8.1%  thought there was a vaccine for HCV.  Attitudes Only 3.2% of respondents reported that  they had been vaccinated against hepa- titis B virus.  (Table 3) Three-quarters  (74.7%) had not seen any  information  or  radio/television  programmes  on  these  or  other  bloodborne  diseases.  Most  barbers  (90.3%) did not  agree  that  it was  essential  to have periodic  screening  tests  for  bloodborne  dis- eases in the population; however, 97.8%  would  themselves  like  to be  tested  for  these  infections:  around one-quarter  (24.7%) reported a history of substance  abuse (Table 3).  Practices Observations  of  barbers’  practices  showed that 68.8% washed their hands  before  attending  each  client,  75.8%  cleaned  instruments with disinfectant  between  clients,  60.2% washed  their  instruments  after  shaving  the  clients,  72.0% washed  razors with  tap water  before use on a new client, 96.2% also  washed  razors with an antiseptic  solu- tion after every use, 95.7% used a new  blade on new clients  and 39.2% used  disinfectants  for  skin  cuts  (Table 4).  About  one-third  (34.9%)  of  barbers  disposed of used blades  in  the  regular  garbage system. Discussion The current  study has described bar- bers’ knowledge about the transmission  of  HBV  and HCV  and  provides  an  outline  for  further  studies. The  results  show low awareness about the different  modes  of  transmission  of HBV  and  Table 1 Socioeconomic and demographic characteristics of barbers participating in the study Characteristic No. % Age (years) 15–20 50 26.9 21–30 80 43.0 31–40 28 15.1 > 40 28 15.1 Education (no. of years) Illiterate 66 35.5 Primary (≤ 5) 78 41.9 Intermediate (≤ 12) 40 21.5 Higher/university (≥ 14) 2 1.1 Monthly income (Pakistan rupees) 2000–4000 20 10.8 > 4000–5000 71 38.1 > 5000–10 000 91 48.9 > 10 000 4 2.2 Marital status Married 87 46.8 Single 99 53.2 Mother tongue Sindhi 56 30.1 Urdu 89 47.8 Punjabi 23 12.4 Baluchi 1 0.5 Pashto 2 1.1 Saraki and others 15 8.1 Residence Urban 178 95.7 Semi-urban 1 0.5 Rural 7 3.8 EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1082 HCV diseases, even though the major- ity of barbers were from the 4th largest  city  in Pakistan. The majority of  study  participants had the misconception that  these diseases were not  transmitted by  contact with  the blood of  an  infected  person, via blood  transfusion,  reuse of  needles  or  through  barbers’  shaving  instruments.  Only 9.7%–36.6% of  respondents  knew  about  the  different  modes  of  transmission of hepatitis  and  the  risk  factors. This  is similar  to another study  in which 13% of barbers  in Rawalpindi  and Islamabad urban cities  in 1999 re- ported having knowledge of HBV and  HCV [19]. Knowledge about  specific  routes of HBV  transmission was  also  similar  to  the previous  study. For  ex- ample,  7% of barbers  in Rawalpindi/ Islamabad  knew  that HBV  could  be  prevented by  vaccination  (compared  with  almost  the  same  proportion  of  barbers  in the current study), and 13%  of  barbers  in Rawalpindi/Islamabad  were aware of  the  risk of  transmission  of  hepatitis  through  the  intravenous  route (compared with 22.0% of barbers  in Hyderabad). However, more of our  barbers (36.6%) were aware that hepa- titis can be transmitted through barbers’  shaving  instruments  compared with  only 12.5% in the previous study.  Although mass media  campaigns  regarding  these diseases and HBV im- munization  had  been  introduced  in  Pakistan,  they seem to have had a  low  impact concerning knowledge of HBV  immunization. It may be that poor peo- ple  cannot  afford  to  avail  themselves  of  the opportunity  for vaccination and  therefore  are  less  likely  to  be  aware  about immunization. This could also be  because  these  infections are perceived  to be common diseases in Pakistan.  Only 4.3% of barbers reused blades  on different  clients  and 13.4%  reused  blades on  the  same clients  for  armpit  shaving  without  antiseptic  cleaning.  However,  is  possible  that  they  were  aware of  being observed during data  collection and that the 65.1% of barbers  who did not dispose of used blades  in  the  bin may  have  been  intending  to  reuse  them  later on. Clearly,  reuse of  blades and non-sterilization of  instru- ments creates a risk of person-to-person  transmission of bloodborne  infection  [7,14]. Blade reuse and risk of transmis- sion of diseases with  similar practices  have also been  reported  from surveys  of barbers  in Turkey and India [9,18].  Barbers  in Pakistan and elsewhere also  carry out other  very  risky procedures  such  as  circumcision,  incisions  and  wound drainage [19,20]. Our  study  has  several  important  strengths,  including  the use of  random  sampling of the listed population of bar- bers in the whole city, face-to-face admin- istration of the survey questionnaire and  inclusion of all  the barbers working  in  the selected shops with a high response  rate.  However  we  also  acknowledge  Table 2 Barbers’ knowledge about hepatitis B and C virus diseases and their mode of transmission (n = 186) Knowledge item Yes No No. % No. % Mode of transmission Contaminated water 23 12.4 163 87.6 Food 18 9.7 168 90.3 Shared utensils 25 13.4 161 86.6 Sexual contact 67 36.0 119 64.0 Intravenous drug use 41 22.0 145 78.0 Reuse of needles 59 31.7 127 68.3 Blood transfusion 54 29.0 132 71.0 Dental procedures 38 20.4 148 79.6 Scissors/surgical instruments 46 24.7 140 75.3 Tattooing 39 21.0 147 79.0 Barbers’ shaving instruments 68 36.6 118 63.4 Ear/body piercing 39 21.0 147 79.0 Hepatitis B and C have the same mode of transmission 21 11.3 165 88.7 Protection A vaccine can protect the individual against hepatitis B infection 12 6.5 174 93.5 A vaccine can protect the individual against hepatitis C infection 15 8.1 171 91.9 Table 3 Barbers’ attitudes about hepatitis B and C virus diseases (n = 186) Attitude item Yes No No. % No. % Seen television/radio programmes on these or other bloodborne diseases 47 25.3 139 74.7 Agree with periodic screening for bloodborne diseases 18 9.7 168 90.3 Agree to be personally tested for these infections 182 97.8 4 2.2 Is vaccinated against hepatitis B 6 3.2 180 96.8 Is currently substance abuser 46 24.7 140 75.3 Has had blood transfusion 3 1.6 183 98.4 Has had tattoos 4 2.2 182 97.8 Has had surgical operation or stitching 22 11.8 164 88.2 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1083 diseases  caused  by  HBV  and  HCV  and  their mode of  transmission,  and  employed  risky  practices  implicated  in  transmitting  these  diseases. These  results  raise questions  about  the best  possible way of correcting such gaps, for  example with educational and promo- tional  strategies  tailored  to  this  target  group.  Information should be  focused  on the different modes of transmission  and  the  fact  that HBV  is  a  vaccine- preventable disease whereas no vaccine  is  available  to prevent HCV. Further  studies are required to assess the effect  of  interventions  and how  to  enhance  awareness among this target group. Acknowledgements This study was part of an  investigation  that received technical and financial sup- port from the joint WHO Eastern Med- iterranean Region (EMRO), Division  of Communicable Diseases  (DCD)  and the WHO Special Programme for  Research and Training in Tropical Dis- eases (TDR):TDR.6/3, T5/72/6,  the  EMRO/TDR Small Grants Scheme for  Operational Research  in Tropical  and  other Communicable Diseases. several  limitations. Our  findings may  not be applicable  to barbers who have  shops outside Hyderabad city. Barbers  may have misunderstood questions or  may not have expressed their own views.  Barbers may have been aware that they  were being observed, and may therefore  have modified their practices. Pakistan  is  facing  a  huge  burden  of HBV and HCV  infection. Preven- tion of transmission is the best strategy  to deal with  these diseases. Changing  barbers’ behaviours  and practices can  have a direct  impact on risk  reduction.  If alerted to the situation, barbers might  even be  trained  to  act  as  community  HIV/hepatitis  educators  because  of  their unique access to the general male  population [22,23].  Our findings demonstrate  that de- spite the many mass media health edu- cational programmes  regarding  these  diseases in Pakistan, barbers in Hydera- bad had no detailed understanding of  References Table 4 Barbers’ shaving practices from observations of interactions with clients (n = 186) Practice item Yes No No. % No. % Washes hands before each client 128 68.8 58 31.2 Cleans instruments with disinfectant between clients 141 75.8 45 24.2 Washes instruments after shaving clients 112 60.2 74 39.8 Washes razor with antiseptic solution after use 179 96.2 7 3.8 Uses new blade on new client 178 95.7 8 4.3 Washes razor with tapwater before use on new client 134 72.0 52 28.0 Disinfects skin cuts 73 39.2 113 60.8 Uses same blade for armpit shaving 25 13.4 161 86.6 Disposes of used blades in the garbage 65 34.9 121 65.1 Razor cuts observed on clients 5 2.7 181 97.3 Hepatitis B. Fact sheet no. 2041. . World Health Organization [website]. (http://www.who.int/mediacentre/factsheets/ fs204/en/, accessed 26 July 2010). Hepatitis C. Fact sheet no. 164. 2. World Health Organization [website]. (https://apps.who.int/inf-fs/en/fact164.html, ac- cessed 26 July 2010). Zuberi SJ. Seroepidemiology of HBV and HCV in Pakistan. 3. In- ternational Hepatology Communications, 1996, 5:19–26. Parker SP, Khan HI, Cubitt WD. Detection of antibodies to 4. hepatitis C virus in dried blood samples from mothers and their offspring in Lahore, Pakistan. Journal of Clinical Microbiol- ogy, 1999, 37:2061–2063. Alam MM et al. Serology based disease status of Pakistani 5. population infected with hepatitis B virus. BMC Infectious Dis- eases, 2007, 7:1–4. Mele A et al. Beauty treatment and risk of parenterally trans-6. mitted hepatitis: results from the hepatitis surveillance system in Italy. Scandinavian Journal of Infectious Diseases, 1995, 27:441–444. Sawayama Y et al. Hepatitis C virus infection in institutional-7. ized psychiatric patients: possible role of transmission by razor sharing. Digestive Diseases and Sciences, 2000, 45:351–356. Habib M. Hepatitis C virus infection in a community in the 8. Nile Delta: risk factors for seropositivity. Hepatology, 2001, 33:248–253. Candan F et al. Prevalence of hepatitis B and C virus infection 9. in barbers in the Sivas region of Turkey. Occupational Medi- cine, 2002, 52(1):31–34. She SL et al. Aseroepidemiologic study of hepatitis B virus 10. infection among barbers in Huangshi City, Hubei, China. Microbiology and Immunology, 1988, 32:229–233. Candan F et al. Prevalence of hepatitis B and C virus infection 11. in barbers in the Sivas region of Turkey. Occupational Medi- cine, 2002, 52:31–34. Tumminelli F et al. Shaving as a potential source of hepatitis C 12. virus infection. Lancet, 1995, 327:638. Zahraoui-Mehadji M et al. Risque infectieux lie au sang chez 13. les coiffeurs-barbiers traditionnels et leurs clients au Maroc [Infectious risks associated with blood exposure for tradi- tional barbers and their customers in Morocco]. Sante, 2004, 14(4):211–216. Bari A et al. Risk factors of hepatitis C virus infection in male 14. adults in Rawalpindi–Islamabad, Pakistan. Tropical Medicine and International Health, 2001, 6(9):732–738. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1084 The Weekly Epidemiological Record The Weekly Epidemiological Record (WER) serves as an essential instrument for the rapid and accurate dissemination  of epidemiological information on cases and outbreaks of diseases under the International Health Regulations and on  other communicable diseases of public health importance, including emerging or re-emerging infections. An electronic bilingual English/French version of the WER is accessible every Friday and can be downloaded free of  charge. For information on subscription to the printed edition, visit the WHO Periodicals site or use the mail address:  World Health Organization, WHO Press, 20 Avenue Appia, CH-1211 Geneva 27. WER can also be accessed online at:  http://www.who.int/wer/en/ Khattak MN et al. Factors influencing hepatitis C virus sero-15. prevalence among blood donors in north west Pakistan. Jour- nal of Public Health Policy, 2008, 29(2):207–225. Shazi L, Abbas Z. Comparison of risk factors for hepatitis B 16. and C in patients visiting a gastroenterology clinic. Journal of the College of Physicians and Surgeons of Pakistan, 2006, 16(2):104–107. Akhtar S et al. Epidemiologic study of chronic hepatitis B virus 17. infection in male volunteer blood donors in Karachi, Pakistan. BMC Gastroenterology, 2005, 5:26. Khandait DW, Ambadekar NN, Vasudeo ND. Knowledge and 18. practices about HIV transmission among barbers of Nagpur city. Indian Journal of Medical Science, 1999, 53(4):167–171. Janjua NZ, Nizamy MA. Knowledge and practices of barbers 19. about hepatitis B and C transmission in Rawalpindi and Islamabad. Journal of Pakistan Medical Association, 2004, 54(3):116–119. Hardy DB. Cultural practices contributing to the transmission 20. of human immunodeficiency virus in Africa. Reviews of Infec- tious Diseases, 1987, 9:1109–1119. Khuwaja AK, Qureshi R, Fatmi Z. Knowledge about hepatitis 21. B and C among patients attending family medicine clin- ics in Karachi. Eastern Mediterranean Health Journal, 2002, 8(6):787–793. John JK. Country watch: India. 22. AIDS/STD Health Promotion Exchange, 1995, 3:7–8. Howard J. Raising a chorus of voices to prevent HIV. 23. Harvard AIDS Review, 1995, Fall:12–13. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1085 Patient satisfaction with mobile clinic services in a remote rural area of Saudi Arabia B. Aljasir 1,2 and M.S. Alghamdi 3 ABSTRACT Mobile clinics have been established in Saudi Arabia to facilitate the equitable delivery of primary health care services in remote and rural areas. A descriptive cross-sectional study was conducted to investigate the perceived quality of services provided to villages in the Al-Laith region. The majority of the 176 clients interviewed were satisfied with the working hours and health staff. However, 35.8% viewed the location as unsatisfactory and 20.5% were dissatisfied with the clinic schedule. Overall satisfaction was very high, although the mobile clinics were not viewed as substitutes for primary health care centres. Public awareness of the service needs to be improved and better access and quality of services are important for optimal service provision. 1Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada (Correspondence to B. Aljasir: draljasir@ yahoo.com). 2Department of Family and Community Medicine, National Guard Health Affairs, Western Region, Jeddah, Saudi Arabia. 3Joint Programme of Family and Community Medicine, Jeddah, Saudi Arabia. Received: 29/10/08; accepted: 01/03/09 ةيدوعسلا ةيبرعلا ةكلملما في ةيئانلا ةيفيرلا قطانلما ىدحإ في ةلّقنتلما تادايعلا تامدخ نع ضىرلما ءاضر يدماغلا ديعس دممح ،سرالجا نحمرلا دبع ردب .ةيفيرلاو ةيئانلا قطانلما في ،ةيلولأا ةيحصلا ةياعرلا تامدخ ءاتيإ في ةلادعلا نماضل ةيدوعسلا ةيبرعلا ةكلملما في ةلقنتلما تادايعلا تئشنأ دقل :ةـصلالخا ناثحابلا مهَلَباق ْنَم ددع ناكو .ثيللا ةقطنم ىرق في م َّدَقُت يتلا تامدلخا ةدولج سانلا كاردإ ءاصقتسلا ةيفصو ةضرعَتْسُم ةسارد ناثحابلا ىرجأ دقو نع متهاضْرَم مدع نع اوبرعأ مهنم %35.8 نأ لاإ .ينيحصلا ينلماعلا ءادأ نعو لمعلا تاعاس نع نوضار مهمظعم ًاعِجاَرُم ينعبسو ةتسو ةئم لم ةلقنتلما تادايعلا نأ ولو ،ًادج ًاعفترم لياجملإا ءاضرلا لدعم ناكو .ةدايعلا في لمعلا لودج نع متهاضْرَم مدع نع اوبرعأ مهنم %20.5و ،عقولما ،تامدلخا هذه لوح سانلا ىدل يعولا ىوتسم ينستح ةروضر لىإ ناثحابلا صَلَخ دقو .ةيلولأا ةيحصلا ةياعرلا زكارلم ٌليدب انهأ لىع اهيلإ رظنُي نكي .لثملأا وحنلا لىع تامدلخا هذه نم ةدافتسلال ةيهملأا غلاب ًارمأ كلذ رابتعاب ،اتهدوجو اهيلإ لوصولا لُبُس ينستح كلذكو Niveau de satisfaction des patients vis-à-vis des services sanitaires mobiles dans une zone rurale isolée en Arabie saoudite RÉSUMÉ Des dispensaires mobiles ont été créés en Arabie saoudite pour faciliter une prestation équitable de services de soins de santé primaires dans les zones isolées et rurales. Une étude transversale et descriptive a été réalisée afin d’étudier la perception de la qualité des services fournis aux villages de la région d’Al-Laith. La majorité des 176 personnes interrogées étaient satisfaites des horaires et du personnel de santé. Mais 35,8 % d’entre elles considéraient que l’emplacement était insatisfaisant, de même que le suivi médical (20,5 % des personnes interrogées). Le taux de satisfaction global était très élevé, bien que les services mobiles ne soient pas perçus comme des substituts des centres de soins de santé primaires. Il est nécessaire de mieux faire connaître cette structure au public ; l’amélioration de l’accès aux services et de la qualité de ceux-ci est importante en vue d’une prestation optimale. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1086 Introduction Saudi Arabia  is a geographically varied  country whose  population  reflects  a  range  of  social  and  cultural  back- grounds. Primary health  care  services  were instituted in Saudi Arabia in 1983  [1] and comprise a large network of pri- mary care centres covering most of the  country [2]. Health authorities deploy  continuing efforts to make these services  comprehensive and capable of provid- ing high-quality preventive and curative  services to citizens and residents [3–5].  There  are  concerns,  however,  about  the availability of  appropriate  facilities  to  people  living  in  remote  and  rural  areas. While road and air transportation  provides accessibility  for  rural patients  to high-quality emergency care  in hos- pitals, in many rural areas the travel time  to a facility providing routine or ongoing  health care services can be considerable  because of difficult road conditions and  a lack of adequate transport. This poses  particular problems  for elderly people  and others  such  as  pregnant women  and children, who require medical care  on a regular basis.  To  improve  equity  in  the  distri- bution of health  care  services  and  to  reach  those  in high need  the Ministry  of Health,  via  the Primary Health Di- rectorate, has established a mobile clinic  service.  As  demonstrated  elsewhere,  the potential  clients of mobile health  clinics  are  people  living  in medically  underserved areas, who are  likely to be  poor and elderly and would otherwise  not seek medical care [6].  Needs assessment  is always an  im- portant  starting point  for determining  the specific needs of a population and  thus for effective planning of health care  services [7,8]. To be successful, our mo- bile  clinic  service  requires  evaluation  and monitoring with respect to aspects  such  as  location,  types of  services of- fered,  staffing  and  the  specific  needs  of the target population. The aim of the  present  study was  to assess consumer  satisfaction with  the mobile  clinics  in  Al-Laith region of Saudi Arabia. To the  best  of  our  knowledge,  this  research  is  the first  to be conducted on mobile  clinics  in  the Middle East  and among  the very few studies internationally that  have provided a comprehensive evalua- tion of such services in rural areas. Methods Study setting The study was  conducted  in Al-Laith  governorate,  a  remote  rural  area com- prising 12 administrative emirates in the  south-western  region of Saudi Arabia.  It is divided into 2 main areas: a coastal  region and a mountainous region. The  total population was about 120 000  in  the 1995  census. The health  services  in  the area are provided by 25 primary  health care centres and 2  small hospi- tals.  Mobile health clinics in Al- Laith Two 4-wheel-drive mobile clinics were  designed  to provide,  as much as pos- sible, the work capabilities of a standard  clinic. They were intended to transport  and provide working space for a doctor  and a nurse (in addition  to  the driver)  and  to  contain  a well-equipped clinic  and a  laboratory capable of providing  commonly  needed  tests.  The  air- conditioned mobile  clinic  accommo- dated a bed, drawers  for  the storage of  instruments and bandages, and a refrig- erator for medication and vaccine stor- age. The clinic space was connected to  the driver’s compartment by  intercom.  The van was fitted with a waste disposal  tank designed  for hazardous materials.  Other  safety  considerations  and  the  ability to withstand various climate con- ditions were also taken into account in  the design of the vehicle.  Among  42  underserved  villages  in Al-Laith  area,  13 were  selected  for  the mobile  health  clinics service  on  the basis of  their  remote  location and  complete  lack of health  care  services.  The villages were  situated between 20  and 100 km  from the nearest primary  health care centre and each was visited  1 day per week on a  regular  schedule.  The 2 mobile clinics were scheduled to  depart from the main 2 centres located  in Al-Laith  area  at 06:00 each day  in  order to provide health care services for  the assigned village  from 08:00–09:00  until 15:00.  Research design and sample A descriptive cross-sectional  research  design was used  to evaluate consumer  satisfaction with the mobile heath clinic  services. Ethical approval was obtained  from the  local health authorities  in Al- Laith. The sample  for  the study was users  of the mobile clinics. The 2 mobile clin- ics serve a population that has been esti- mated at approximately 17 000 on  the  basis of  the national census conducted  in 1995. A convenience sample of 200  clients—100  for each mobile clinic— was planned. To be eligible for inclusion  in the study, clients were required to be  16 years or over, able  to communicate  and  fully willing  to participate. A  total  of 690 clients visited the mobile clinics  during the research period (April 2006).  The target was to select 5 or 6 clients by  a  simple  random process at each visit.  However, because of  time constraints  and technical problems with the mobile  clinic  in  the mountainous  region, only  197 clients were  invited  to participate  and of  these, 176 were  included  in  the  study sample from 30 visits, a response  rate of 89.3%. Data collection tool A  structured  interview questionnaire  was designed  to elicit  the opinions of  mobile clinic consumers about the serv- ices  provided  and  their  expectations  and needs. Close-ended questions were  used with questions about sociodemo- graphic characteristics, general medical  history and health-related behaviours,  perceptions about the quality of services  provided  in  relation  to  the structure of  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1087 the mobile  clinics  (human  resources,  equipment,  facilities,  supplies),  the  process of  care  (system,  communica- tion,  quality  control,  policies  and  procedures), and  the outcome of care,  including patient  satisfaction,  as well  as  suggestions  for  improvement. The  interviews  were  conducted  by  well- trained  interviewers and  took place  in  the mobile clinics during the scheduled  break times.  The data  collection  tool was pre- pared and then tested on a sample who  were not subsequently  included  in  the  main study sample (n = 20). The aim of  the pilot study was to test the clarity and  practicality of  the  tools as well as  their  internal consistency. Among the tested  questions, 21  items were  constructed  to have an ordinal  scale  to determine  consumers’ satisfaction with the various  aspects of the health care services. Each  item was  evaluated  separately  for  its  internal consistency by computing  the  reliability coefficient (Cronbach alpha  coefficient). When  any  of  the  items  showed a negative correlation, recoding  of the responses was considered so that  all  of  the  items were  correlated posi- tively  to compute an overall  reliability  coefficient. Thus,  the overall Cronbach  alpha coefficient was 0.84, which is con- sidered high. Pilot testing also helped to estimate  the  time needed  to conduct  the  inter- views and to complete the questionnaire.  Minor modifications  to  the different  data collection tools were needed.  Data management For  satisfaction  with  services,  the  responses  “yes,”  “sometimes” and “no”  were scored 2, 1 and 0, respectively. The  total scores for  items within a question  area were  divided  by  the  number  of  items, giving a mean score for the topic.  These scores were converted into a per- centage score, and means and standard  deviations (SD) were computed. The  topic was considered satisfactory  if  the  mean score was 60% or more and unsat- isfactory if the mean score was less than  60%. The cut-off point of 60% was used  to  facilitate comparison with previous  research evaluating health care services  in the area [9]. Data analysis Data entry was done using SPSS, version  11.0. Data cleaning was done and a qual- ity check was conducted for coding and  data entry. Data analysis was done using  the  same program,  in  addition  to  the  Epi-Info, version 6.04 software package.  Data were presented using descriptive  statistics in the form of frequencies and  percentages  for  qualitative  variables,  and  ranges, means  and SD  for quan- titative variables. Qualitative variables  were compared using  the chi-squared  test or Fisher exact  test, as appropriate.  P-value < 0.05 was considered statisti- cally significant. Results Of the 13 villages included in the study,  63.1% were in coastal areas and 36.9% in  mountainous areas.  The  characteristics  of  the 176  re- spondents  are  presented  in Table  1.  Participants  ranged  in age  from 16  to  76 years, with a mean age of 37.1 years.  Most  (90.3%) were men. About one- third (33.3%) were illiterate, while only  2.8% were university graduates. More  than half  (54.0%) were married. They  were mostly unemployed (72.7%).  Almost all the respondents (93.2%)  had used the mobile clinic service in the  past. The most common sources of  in- formation about the clinics were sheikhs  (tribal  leaders)  (39.2%)  and  friends  (35.8%). The distance  from home  to  the clinic  ranged  from 0.5 km  to 13.0  km. Before  the mobile  clinic became  operational,  the majority (93.2%) had  received services at a primary health care  centre in another village, with an average  travel time of 56.8 min. However, 51.1%  of respondents were still using this other  service, mostly for the treatment of acute  diseases in adults (48.6%). Survey responses with respect to the  structure of the mobile clinics are shown  in Table 2. The majority of clients were  satisfied with  the working hours, doc- tors and nurses, rating them acceptable  or  good. Meanwhile, more  than one- third (35.8%) viewed the location of the  clinic as unsatisfactory and 20.5% were  dissatisfied with the schedule. The respondents’  rating of  services  provided by mobile  clinic  is provided  in Table 3. Respondents noted the lack  of many  important  services,  or  serv- ices  that were not used by  them,  such  as  services  for people with disabilities,  laboratory  tests,  electrocardiography  and vaccinations. Conversely, medica- tions were present in all clinics, and this  aspect of care was judged as good by all  respondents. Health education services  were also provided  in most  cases  and  were mostly judged as good (83.5%). Table 1 Characteristics of respondents of mobile clinic service survey (n = 176) Variable Value Age (years) Range 16–76 Mean (SD) 37.1 (17.6) No. % Sex Male 159 90.3 Female 17 9.7 Education Illiterate 58 33.0 Read/write 41 23.3 Basic 27 15.3 Secondary 45 25.6 University 2 2.8 Marital status Single 68 38.6 Married 95 54.0 Widow/widower 13 7.4 Employment status Office employee 6 3.4 Skilled worker 4 2.3 Military 26 14.8 Student 12 6.8 Unemployed 128 72.7 SD = standard deviation. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1088 The overall satisfaction of the mobile  clinic users was very high; the structure  of the services and the types of services  provided were  rated as  satisfactory by  94.9% and 98.9%,  respectively. There  was a  statistically  significant difference  between  respondents  from mountain- ous areas and those from coastal areas in  their level of satisfaction with the mobile  clinic structure, with more coastal  resi- dents expressing  satisfaction (100.0%)  than  those  from  the mountainous  re- gion (91.9%) (P = 0.03). The overall opinion of mobile clinic  users about the services compared with  primary  health  care  centres  in  other  villages is shown in Table 4. Most users  considered the services less satisfactory  or equal  to  those provided  in primary  health  care  centres. About  two-thirds  (62.5%) viewed  the mobile  services as  of  lower  quality  in  comparison with  services provided by primary health care  centres. The majority rated the services  provided as good in part or in total, but  90.9% of the users did not feel that they  could depend on  the mobile clinics  to  meet all of  their  routine or emergency  care needs. Discussion Ideally mobile clinics provide  services  that extend  from childhood and adult  immunizations,  to  taking  medical  histories  and performing physical  ex- aminations,  providing well-child  care  and chronic illness management, health  education  and  counselling,  geriatric  home visits  and health maintenance.  However,  the  accessibility  and  utili- zation of mobile health  services  vary  greatly according to location and other  characteristics,  including how well  the  services are publicized [10]. The mobile clinics  involved  in  the  present  study  provide  health  care  to  underserved and difficult-to-reach areas  whose underprivileged status might be  inferred  from the personal characteris- tics of the respondents, of whom about  one-third were illiterate and more than  two-thirds  were  unemployed. These  rates  are  higher  than  the  national  il- literacy  rate (17.1%,  reported  in 2005)  [11] and  the national unemployment  rate (11.2 % and 9.8%, reported in 2006  and 2008, respectively) [12].  The low prevalence of women in our  study was expected  in this rural area  in  view of cultural barriers that discourage  participation  in  such  surveys  as well  as  visits  to health  facilities by women,  Table 2 Respondents’ rating of the structure of mobile clinic services (n = 176) Criterion Rating Unsatisfactory Acceptable Good No. % No. % No. % Location 63 35.8 11 6.3 102 58.0 Schedule (1/week) 36 20.5 48 27.3 92 52.3 Working hours 9 5.1 23 13.1 144 81.8 Doctors 0 0.0 2 1.1 174 98.9 Nurses 0 0.0 2 1.1 174 98.9 Table 3 Respondents’ rating of services provided by mobile clinic (n = 176) Health service Not applicable (unavailable to clients) Unsatisfactory Acceptable Good No. % No. % No. % No. % Chronic diseases 9 5.1 0 0.0 81 46.0 86 48.9 Maternity and well-baby health services 88 50.0 13 7.4 50 28.4 25 14.2 Accidents 45 25.6 18 10.2 65 36.9 48 27.3 Vaccinations 153 85.9 2 1.1 16 9.1 5 2.8 Health education 27 15.3 0 0.0 2 1.1 147 83.5 Infectious diseases 66 37.5 0 0.0 10 5.7 100 56.8 Mental health 109 61.9 8 4.5 0 0.0 59 33.5 Special needs (disabilities) 167 94.9 8 4.5 0 0.0 1 0.6 Emergency 41 23.3 0 0.0 86 48.9 49 27.8 Laboratory tests 164 93.2 0 0.0 11 6.3 1 0.6 Electrocardiography 164 93.2 0 0.0 11 6.3 1 0.6 Medications 0 0.0 0 0.0 0 0.0 176 100.0 طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1089 except  in  urgent  situations,  and  that  require women to be accompanied by  a male relative. Further, the fact that the  clinics were  run only by male workers  might  have discouraged  their  use  by  women, who may have  travelled  to  a  primary health  care  centre  to  receive  services  from female health care work- ers. Solutions  to overcome this barrier  and thus increase the utilization of mo- bile  clinics  by women  could  include  recruiting female health care workers or  extending the operating hours of mobile  clinics until  the  later hours of  the day,  which would allow for the return of male  relatives  from work so  that  they could  accompany female family members and  children to the mobile clinic.  The finding  that most  respondents  had  learned  about  the mobile  clinics  from sheikhs or friends indicates a lack of  advertising about  the services provided  through  these clinics  to  the  local com- munity. Therefore,  there  is  a need  for  more publicity on the part of health au- thorities with respect to mobile clinics. Before  the mobile  clinics became  operational,  most  respondents  had  obtained  services  at  a primary health  care centre  in another village, with an  average travel time of an hour compared  to  a  few minutes  to  reach  the mobile  clinic. About half of  the mobile  clinic  users were still travelling to primary care  centres to obtain services not provided  by  the mobile  clinic. However,  even  though mobile medical  programmes  do not provide  full  services,  they have  the potential to improve equity in health  care and disease control by providing  services  to high-risk  individuals who  may lack access to care elsewhere [13– 15]. Mobile  clinics  in  rural  areas  can  play a  supporting  role  in  the provision  of health care services, and health care  authorities can use such  technology  to  improve access and reduce the burden  of travel on patients.  Mobile clinics should give emphasis  to preventive as well as curative services.  In  this  respect, Swaddiwudhipong has  reported  that  the use of a mobile unit  may be an effective means of delivering  screening programmes  in  rural  areas  where existing screening activities can- not  effectively  reach  the  population  at  risk  [16]. Respondents noted  that  many  important  services were  lacking,  or that some services were not relevant  to them, such as services for people with  disabilities,  laboratory  tests, electrocar- diography  and  vaccinations  (despite  the fact that the mobile clinics had been  designed to provide such services). Al- though  services  related  to disabilities  might not be applicable to most visitors,  the lack of services related to laboratory  tests, electrocardiography and vaccina- tion do  appear  to  constitute  a weak- ness  of  these mobile  clinics;  the  fact  that these services were not consistently  available  indicates a need  for  improve- ment.  Although  health  care  services  related  to maternal  and  infant health  were seen by 40.6% of  the participants  as acceptable or good, we should keep  in mind  the  under-representation  of  women  in  the  current  sample, which  indicates that the services utilized were  likely  to be  related  to well-baby  care.  Conversely, medications  were  avail- able in all clinics, and this aspect of care  was judged as good by all respondents.  Health  education  services were  also  provided in most cases, and were mostly  judged as good.  In  this  regard, current  mobile clinic  services  should be more  consistent in the services provided and  should  include more  preventive  and  screening services as well.  When  asked  their  opinion  about  the  structure  of mobile  clinics, most  respondents expressed satisfaction with  the  clinic  hours,  doctors  and nurses.  However,  the  dissatisfaction  of  re- spondents with  the  range of  services  offered  indicates  a need  for more  im- provement in the services provided and  for an ongoing process of determining  consumer satisfaction with the services  and  for  gathering  suggestions  for  im- provement.  There was a statistically significantly  higher  level of  satisfaction with mobile  Table 4 Respondents’ overall opinions about mobile clinic service as compared with primary health care centres (n = 176) Variable No. % Mobile clinic compared with primary centre Cannot be compared 50 28.4 Provides some services 103 58.5 Provides same services 21 11.9 Provides more services 2 1.1 Mobile clinic quality of services compared with primary centre Cannot be compared 42 23.9 Provides lower quality services 110 62.5 Provides same quality services 24 13.6 General opinion about mobile clinics Waste of money 18 10.2 Good in certain services 136 77.3 Good in all basic services 21 11.9 Good substitute for primary centre 1 0.6 Mobile clinic is dependable in providing health care in the area No 160 90.9 Yes 3 1.7 Yes, with exceptions 13 7.4 EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1090 clinic  services among coastal  residents  compared with those from mountainous  areas. This may be because the residents  of mountainous  areas,  who  have  no  alternative  services nearby, had higher  expectations of  the mobile clinic. Any  lack of service in the mobile clinic would  mean a long trip to the nearest primary  health care centre for these users. In this  regard, providers of health  services  in  rural areas should give special attention  to  subgroups  that may have different  needs and require more support. In ad- dition, a quick maintenance process for  the mobile clinic is required to maintain  service without  interruption;  technical  problems with  the mobile clinic  in  the  mountainous  areas had an  impact on  the service. An alternative could be the  presence of an extra mobile clinic  that  could replace  that under maintenance,  especially  for  areas with a  challenging  geographical terrain. Despite  the  fact  that  the  overall  satisfaction with  the mobile clinic was  high, most users  considered  the  serv- ices  less  satisfactory  than or  equal  to  those  provided  in  primary  centres.  Moreover, the majority responded that  mobile clinics were not dependable  in  providing services in their area. Health  planners  and decision-makers  should  take these opinions into consideration.  In  addition,  there  is  a need  for more  information  for  consumers  about  the  aim  of  these mobile  clinics  and  the  services  that  should be expected  from  such alternative health  care provision  settings.  Conclusion The majority  of mobile  clinic  clients  were satisfied with the services provided,  although a need  to provide  some  im- portant services more consistently and  with optimum quality was noted. Issues  convening access (location and operat- ing hours) should be reviewed regularly  to ensure  that  they match the needs of  the area served. It is recommended that  mobile clinics be given more publicity  by  the health authorities, with clarifica- tion about the types of services that they  provide. There is a need to improve the  utilization of mobile  clinic  services by  women. A  rapid maintenance process  and a continuous process of assessing the  quality of services provided are needed  to optimize  service provision. Health  planners  and decision-makers  should  take  into account  the ability of mobile  clinics  to provide good health  care  in  certain settings, while remembering that  they cannot be relied upon as substitutes  for full-service health centres.  Acknowledgements The authors  thank  the  teams who ran  the mobile clinics and  the  local health  authorities  in Al-Laith  area  for  their  participation and support. References Khoja TA, Farid SM. 1. Saudi Arabia family health survey 1996: prin- cipal report. Riyadh, Saudi Arabia, Ministry of Health, 2003. World health report 2002. Health indicators2. . Geneva, World Health Organization, 2002. Al Doghaither AH, Saeed AAW, Mohammed BAR. Satisfaction 3. and correlates of patient satisfaction with primary health care center services in Riyadh, Saudi Arabia. Qatar Medical Journal, 2001, 10(2):34–38. Al-Ahmadi H, Roland M. Quality of primary health care in 4. Saudi Arabia: a comprehensive review. International Journal for Quality in Health Care, 2005, 17(4):331–346. Al-Sakkak MA et al. Patient satisfaction with primary health care 5. services in Riyadh. Saudi Medical Journal, 2008, 29(3):432– 436. Fant EW, Thompson KS. 6. Integration of a mobile health care system to deliver mobile health services in Arkansas. Paper pre- sented at 52nd Annual Meeting of the National Rural Electric Cooperative Association, 1994 (http://ww2.mackblackwell. org/web/research/ALL_RESEARCH_PROJECTS/1000s/1015- fant/MBTC1015.pdf, accessed 4 May 2010). Bosworth T. 7. Community health needs assessment: the healthcare professionals guide to evaluating the needs in your defined mar- ket. New York, McGraw-Hill, 1999. Soriano FI. 8. Conducting needs assessments: a multidisciplinary ap- proach. Thousand Oaks, California, Sage Publications, 1995. Aljasir B, Alghamdi M. 9. Health needs among consumers and providers of primary health care services in a rural community in Saudi Arabia [thesis]. Jedda, Saudi Arabia, Arab Board of Com- munity Medicine, Joint Program of Family and Community Medicine, 2005. Field KS, Briggs DJ. Socio-economic and locational deter-10. minants of accessibility and utilization of primary health- care. Health and Social Care in the Community, 2001, 9(5): 294–308. Reduction in Saudi unemployment rate and increase in job variety. 11. Ministry news 2008. Riyadh, Saudi Arabia, Ministry of Labour and Social Services, 2008. Economic performance. In: 12. Human development report 2007/2008. Fighting climate change: human solidarity in a divided world. New York, United Nations Development Pro- gramme, 2008:278. Liebman J, Lamberti MP, Altice F. Effectiveness of a mobile 13. medical van in providing screening services for STDs and HIV. Public Health Nursing, 2002, 19(5):345–353. Edgerley LP et al. Use of a community mobile health van to in-14. crease early access to prenatal care. Maternal and Child Health Journal, 2007, 11(3):235–239. McDaniel J, Strauss SS. Development of a nurse practice ar-15. rangement in rural Appalachia: triumphs and challenges. Nurs- ing Education Perspectives, 2006, 27(6):302–307. Swaddiwudhipong W et al. A mobile unit: an effective service 16. for cervical cancer screening among rural Thai women. Inter- national Journal of Epidemiology, 1999, 28:35–39. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1091 Health care needs of Jordanian caregivers of patients with cancer receiving chemotherapy on an outpatient basis M.S. Al-Jauissy 1 ABSTRACT This descriptive exploratory study was conducted to describe the health care needs and identify unmet needs of the caregivers of cancer patients in Jordan. A total of 82 caregivers accompanying patients to an outpatient chemotherapy clinic completed the 90-item caregiver need scale. Caregivers reported 75.6% of scale items as needs and rated these as “very important” needs on all 6 areas of the caregivers’ need scale: personal care, activity management, involvement with health care, work, interpersonal interaction and finance. Unmet needs of caregivers were a higher proportion of identified needs (76.4%) than in similar studies elsewhere. The education and support needs of caregivers need to be considered when designing care plans for cancer patients. 1Adult Health Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to M.S. Al-Jauissy: alkhalil@just.edu.jo). Received: 08/02/09; accepted: 29/03/09 ةيجرالخا تادايعلا في ةيومايك ةلجاعم نوقلتي نيذلا ناطسرلا ضىرلم ينـيندرلأا ةياعرلا يم ِّدقم ءاتيإ لىع ينمئاقلا تاجايتحا سيويلجا بلاط ديعس دممح ضىرلم ةيحصلا ةياعرلا يم ِّدقم تاجايتحا ديدتحو ،ةيحصلا ةياعرلا تاجايتحا فيصوتل ةيئاصقتسا ةيفصو ةسارد ثحابلا ىرجأ :ةـصلالخا ةلجاعلما نوقلتي نيذلا ةيجرالخا تادايعلا ضىرم نوقفاري نيذلا ةيحصلا ةياعرلا يم ِّدقم نم 82 ةساردلا تلمش دقو .دعب اهُتَيبلت َّمتـت لم يتلا ،ناطسرلا نم %75.6 نأ ةياعرلا وم ِّدقم رَكَذ دقو .ةياعرلا ءاتيإ لىع ينمئاقلا تاجايتحا نم ًادنب 90 نمضتي ًانايبتسا ةساردلاب نولومشلما لمكتساو ،ةيئايميكلا هذهو ،نايبتسلاا كلذ في تاجايتحلال ةتسلا تلااجلما عيجم في »ةيهملأا ةغلاب« انهأ لىع فَّنَصُت تاجايتحا يه مانإ نايبتسلاا في لمعتسلما م َّل ُّسلا دونب تَّلتحا دقو .ليومتلاو ،صاخشلأا ينب لدابتلما لعافتلاو ،لمعلاو ،ةيحصلا ةياعرلا في ةهماسلماو ،ةطشنلأا ةرادإو ،ةيصخشلا ةياعرلا :يه تلااجلما .ةلثامم ىرخأ تاسارد في هيلع يه ماع ديزت ةبسن يهو )%76.4( اهيلع ف ُّرعتلا مت يتلا تاجايتحلاا نم ةيربك ةبسن اهُتَيبلت ّمتـت لم يتلا تاجايتحلاا .ناطسرلا ضىرلم ةياعرلا ططخ ميمصت دنع ةيحصلا ةياعرلا يم ِّدقُمـل ةمعادلاو ةيميلعتلا تاجايتحلال مماتهلاا ءلايإ يغبني هنأ ثحابلا ىريو Besoins en soins de santé des soignants jordaniens de patients cancéreux recevant une chimiothérapie en consultation externe RÉSUMÉ Cette étude exploratoire et descriptive a été menée pour décrire les besoins en soins de santé des aidants de patients cancéreux en Jordanie et identifier leurs besoins non satisfaits. Au total, 82 aidants accompagnant des patients dans un service de chimiothérapie ambulatoire ont rempli le questionnaire sur l’échelle des besoins des aidants en 90 items. Ils ont désigné 75,6 % des items de l’échelle comme étant des « besoins », qu’ils ont qualifiés de « très importants », dans l’ensemble des six domaines de l’échelle des besoins des aidants : soins personnels, gestion de l’activité, implication dans les soins de santé, travail, communication interpersonnelle et finances. Les besoins non satisfaits des aidants représentaient un pourcentage des besoins identifiés (76,4 %) supérieur à celui d’autres études similaires. Les besoins en formation et en soutien des aidants doivent être pris en compte lors de l’élaboration des plans de soins pour les patients cancéreux. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1092 Introduction There is a growing interest in shortening  hospital  stays  for patients with cancer  and treating them on an outpatient basis  [1–3]. This shift of care from hospital to  the home places considerable responsi- bility on  informal  family caregivers.  In  fact, researchers reported that caregivers  assume  approximately  50%–55%  of  the total care required for patients with  cancer at home [4,5].  Caring  for patients with cancer  is a  complex  and demanding  role  [1,6,7].  Cancer caregivers are expected to meet  patients’ needs  in the physical, psycho- logical, social, spiritual and financial di- mensions [6,7].  In addition, caregivers  need  to balance  the  responsibilities of  caregiving  role with  their  own needs  and demands, which is one of the most  challenging problems  facing caregivers  of patients with cancer [1].  Previous  research  demonstrated  that caregivers have  to commence  this  role  suddenly with  limited knowledge  and experiences, with a negative effect  on  the patient and  the caregiver  [1,6].  For example,  in a prospective popula- tion-based cohort  study,  it was  found  that  stress associated with caring  for a  patient with cancer  increased  the car- egiver’s risk of mortality by 63% within 5  years [8]. In addition, the role of caregiv- ing  for patients with cancer was  found  to be associated with sleep disturbance  [9,2],  fatigue  [10–12],  anxiety  [13],  social withdrawal  [4,14],  depression  [13,15], impaired quality of life [2] and  financial constraints  [2,15]. Designing  individualized care plans which  incor- porate caregivers’ needs  is an essential  element  to  improve  the quality of care  provided to patients with cancer [4,16].  In  Jordan,  the  number  of  people  providing care  for patients with cancer  at home  is unknown and  the needs of  caregivers have never been examined  before  from a  Jordanian Arab perspec- tive. This study was  therefore designed  to address the following research ques- tions: what  are  the health  care needs  identified  by  Jordanian  caregivers  of  cancer patients receiving chemotherapy  on an outpatient basis; how do  these  caregivers rank the importance of those  identified needs; and are  the  identified  needs currently being met? Methods Sample Consecutive primary caregivers accom- panying cancer patients to an outpatient  chemotherapy clinic at a major univer- sity-affiliated hospital  in  Jordan during  the period 10 August  to 25 October  2006 were selected to participate in this  study.  Since  this was  an  exploratory,  descriptive study, no attempt was made  to estimate  sample  size. The  inclusion  criteria  for  caregivers were:  Jordanian  nationality; male or  female;  identified  by  the patient as  the  individual who  is  most involved in, or affected by, the pa- tient’s situation; residing in the patient’s  home; able to communicate  in Arabic;  and able to give written consent.  Instruments Data were collected using the following  scales: the caregivers’ demographic data  sheet,  the caregivers’ medical  informa- tion form and the caregivers’ need scale. The demographic data  sheet  con- tained questions related to participants’  characteristics such as: age, sex, marital  status,  income  level, number of people  living in the same household and educa- tion. Two  items were added  to  reflect  structural  barriers  to health  services:  distance  travelled  to  the hospital  and  usual time required to travel from home  to hospital.  The  medical  information  form  contained questions related to  the car- egivers’  chronic medical  conditions,  physical disabilities and history of mental  illnesses.  In addition, participants were  asked  to  report  the presence of nega- tive  impacts  thought  to be associated  with the caregiving role, including sleep  disturbances,  fatigue,  anxiety, distress,  financial constraints and depression.  The caregivers’ need scale was devel- oped to assess caregivers’ current health  care needs  in  relation  to  the patient’s  situation  and  contains  6  subscales  and  90  items  [17]. These  subscales  are: personal  care  (28  items),  activity  management (13  items),  involvement  with health  care  (19  items), work  (2  items),  inter-personal  interaction (21  items) and finance (7 items). Each item  is measured on a 10 cm visual scale from  “not a need at all” (0) to “very big need”  (10). In addition, participants are asked  to  indicate whether each need  is being  met or not. The caregivers’ need scale  yields 3 scores  for each  item:  the exist- ence of the need (an item is considered  as an existing need if 66% or more of the  participants report it as a need); the need  was met or not met (participants mark a  “need met” or “need unmet” column for  each need  they decide  to be existing);  and  the  importance  of  the  need  (an  item  is  considered  “very  important”  if  50% or more of the participants rank it  as 9 or 10 on the need scale).  The original  author  reported  that  the  caregivers’  need  scale  had  99%  inter-rater  reliability  and  a  reliability  coefficient alpha of 0.80. Construct and  face validity for the scale were also estab- lished [17].  Procedure A panel of 2 Masters  level nurses and  2  lay persons who were competent  in  English and Arabic languages translated  and back-translated the caregivers’ need  scale.  Any  discrepancy  between  the  original version and the translated form  was  resolved based on  the suggestions  of the researchers and the panel. Permission  from  the  institutional  review board and  the hospital  admin- istration was obtained before  starting  data  collection. Then  the  researchers  visited the clinic on a daily basis during  the study period to recruit participants.  Once a participant was  identified  the  researcher approached the patient and  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1093 caregivers  to discuss  the purpose and  procedure of  the study,  invite  them to  participate and obtain written consent.  Participants were assured that confiden- tiality would be maintained throughout  the study and that the results would be  reported as aggregates without revealing  their  identity.  In addition, participants  were assured that  they could withdraw  from the study at any time without jeop- ardizing their care at the institution.  A structured interview lasting 30–35  minutes was used  to collect data  from  each participant. Completed forms were  coded and fed into a computer for data  analysis. A pilot  test of  the  translated  version of the caregivers’ need scale was  made with 10 participants before  the  beginning of  the  study,  resulting  in an  alpha coefficient of 0.86. Results Participants’ demographic characteristics Of the 104 companions of patient who  were  approached  and  invited  to par- ticipate, 22 (21.2%) did not meet  the  inclusion  criteria  and were  excluded.  Table 1  summarizes  the demographic  characteristics of the remaining 82 par- ticipants. The majority of participants  were  female (64, 78.1%) and married  (58,  70.7%). The  education  level  of  participants ranged from 2 to 18 years,  with a mean of 8.4 [standard deviation  (SD) 12.6]  years. The  age of  partici- pants ranged from 21 to 62 years, with  a mean of 36.2  (SD 15.8)  years. The  distance between participants’  home  and hospital ranged from 20 to 60 miles,  mean 32.5  (SD 14.6) miles,  and  the  mean time required to travel from home  to hospital was 64.0 (SD 17.4) minutes. Participants’ medical status Participants  reported  suffering  from  5  chronic medical  conditions: diabe- tes  mellitus  (34.2%),  hypertension  (36.6%),  angina (29.3%),  renal  failure  (3.7%) and rheumatoid arthritis (2.4%).  Negative  impacts  of  the  caregiving  role experienced by participants were:  fatigue  (78.0%),  sleep  disturbance  (64.6%), anxiety (60.7%), financial con- straints (58.5%) and mood disturbance  (43.9%). None of  the participants  re- ported having major physical disabilities  or a history of psychiatric illness.  Participants’ existing needs Two-thirds of  the participants (n = 55,  67.1%)  identified a  total of 68 needs,  i.e. 75.6% of the 90 items found on the  caregivers’ need scale. These were con- sidered  to be existing needs according  to  the criteria  identified by Longman  et  al.  [17]. Existing needs  covered all  possible  areas on  the caregivers’ need  scale,  including personal  care,  activity  management,  involvement with health  care, work,  interpersonal  interaction  and finance.  Participants’ very important needs A  total of 46 of  the 68 existing needs  identified (67.7%) were considered  to  be “very important”. Again, very impor- tant needs  covered  all  possible  areas  on the scale and the highest-rated very  important needs were: to be told about  symptoms  that would be expected as  the patient’s health changes (97.6% of  participants); need  for a home care or  public health nurse  (95.0%); need  to  be kept informed of patient’s condition  (94.7%); help with patient’s emotional  needs (87.8%); and help with additional  expenses due  to patient care (85.4%).  Table  2  presents  the  very  important  needs identified by need area.  Participants’ unmet needs A total of 52 out of 68 (76.4%) identified  needs were marked as “unmet”. As with  existing and very  important needs,  the  unmet needs also covered all possible  areas on the caregivers’ need scale. Ta- ble 2 presents the unmet needs reported  by participants on  the caregivers’ need  scale by need areas. The highest  rated  unmet needs according  to need areas  were:  for personal care  “be assured patient • is comfortable”,  “need help knowing  how to care for patient” and “be told  about  symptoms  to be  expected as  patient health changes”;  for  activity management:  “help  as-• sessing his/her ability to give his/her  own care (e.g.  taking medication or  changing a dressing), “help with ways  Table 1 Demographic characteristics of participants (n = 82) Characteristic No. % Sex Male 18 22.0 Female 64 78.1 Marital status Married 60 73.2 Single 14 17.1 Widow 5 6.1 Divorced 3 3.7 Mean (SD) Range Age (years) 36.2 (15.8) 21–62 Education (years) 8.4 (12.6) 2–18 Travel distance to hospital (miles) 32.5 (14.6) 20–60 Time to travel to hospital (min) 64.0 (17.4) 35–120 Income (US$) 380.8 (150.6) 100–1800 No. of people in household 6.6 (4.5) 0–12 SD = standard deviation EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1094 of relieving the patient’s physical dis- tress”, “need information about com- munity  resources  to help with his/ her  activities of daily  living  (meals,  housekeeping, etc.); for  involvement  with  health  care: • “need to be informed of any changes”,  “need to be kept informed of patient’s  condition”,  “need  to be closer  to  the  medical centre”;  for work: “need to balance homemak-• ing with patient’s needs”;  for  interpersonal  interaction:  “need • to share feelings and experiences with  others  in  similar  situations”,  “need  for acceptance, support, and comfort  from staff”, “need to express my own  emotions”; and  for financial: “need to obtain financial • assistance for patient”. Table 3 shows the items on the car- egivers’ need scale identified as very im- portant needs by need area; the highest  rate very important needs are marked. Discussion Jordanian  caregivers  of  patients with  cancer  in  this  study  reported  almost  double  the number of  existing needs  identified by caregivers  in 2  studies  in  the United States of America  (USA)  [17,18]. Table 4 compares  the  results  of Longman et al. [17] and Silveira and  Winstead-Fry  [18]  with  the  current  results. Very  important  needs  of  the  urban  and  rural  samples  in  the USA  were  identified  in  only  3  areas  (per- sonal care, involvement with health care  and  interpersonal  interaction), while  Jordanian  caregivers  reported  very  important needs  in  all  6  areas of  the  caregivers’  need  scale  (personal  care,  activity management, involvement with  health care, work, interpersonal interac- tion and finance). About 76.5% of  the  existing  needs  identified were  found  to be unmet among Jordanian caregiv- ers,  as  compared with  30%  and 14%  for  the urban and  rural USA  samples  respectively. These  results  suggest  that  there  is  insufficient  attention given  to  the needs of caregivers of patients with  cancer in Jordan.  The differences  in  the  results  can  be  attributed  to  several  factors.  First,  there  were  demographic  differences  between the 3 samples. For example, the  Jordanian participants were  younger,  less educated, travelled longer and spent  more time travelling to hospital than the  USA urban and rural samples.  Secondly,  there are unique  features  of  the  Jordanian  health  care  system.  These  features  include problems with  access to care (physical distribution and  insurance),  inadequate  staff  and  sup- plies and poor availability of supportive  services. Primary and secondary health  services are available and accessible  to  most Jordanians [19]. However, tertiary  and specialized services are centralized  in major  cities,  oncology  services  are  limited  to  2 major  cites,  and  radio- therapy  is available only  in  the capital,  Amman. On average, participants in this  study  reported  that  they  travelled 60  miles and spend 90 minutes  to obtain  their required services. Such a problem  places extra burdens of cost and effort  on patients and  their caregivers, which  limits  their  ability  to  seek help when  they need it. Although about 32% of  Jordanians  have no health  insurance  [19],  unin- sured  oncology  patients  can  obtain  medical treatment in public institutions  free of charge. Therefore, health  insur- ance appears not  to be a problem  for  such patients. Although Jordanian hos- pitals employ the highest available tech- nologies and very competent physicians  and nurses,  there  are  staff  shortages,  high number of patients being  treated  in outpatient chemotherapy clinics and  brief contact times between health pro- fessionals  and patients. These  factors  limit  the  supportive  and  educational  services provided  to  the  caregivers of  patients.  Researchers  reported  that  Jorda- nian hospitals  are experiencing  falling  values of salaries, shortages of drugs and  supplies,  shortages of  physicians  and  nurses  and high bed occupancy  rates  (80%) [20]. The majority of  Jordanian  hospitals do not employ support serv- ices  such  as  psychologists  and  social  workers. Researchers assert  that Arabs  are not  familiar with  the profession of  Table 2 Items identified as existing, very important and unmet needs by caregivers of cancer patients Need area Total items Existing needsa Very important needsb Unmet existing needs No. No. %c No. %d No. %d Personal care 28 22 78.6 13 59.1 18 81.8 Activity management 13 11 84.6 8 72.7 11 100.0 Involvement with health care 19 13 68.4 11 84.6 9 69.2 Work 2 2 100.0 1 50.0 2 100.0 Interpersonal interaction 21 15 71.4 11 73.3 10 66.7 Finance 7 5 71.4 2 40.0 2 40.0 aExisting needs were items identified by more than 66% of participants as needs. bVery important needs were those rated by more than 50% of participants as 9 or 10 on a scale of 0–10, with 10 the highest. cPercentage of total. dPercentage of existing needs. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1095 social work,  and  rely on  family mem- bers  and  friends  for help and  support  [21]. In addition, Arabs perceive mental  and emotional illnesses as stigmatizing,  which limits the use of psychologists in  Jordanian hospitals [21,22].  Furthermore,  home nursing  serv- ices,  help  groups  and  agencies,  and  Table 3 Items identified as very important needsa by caregivers of cancer patients Personal care Be assured patient is comfortable Need help with patient’s emotional needs Need help knowing how to care for patient Need help with patient’s pain management (i.e. medications, other) Knowing how to observe the effects of treatments ordered by physician Be taught about the medication the patient takes at homeb Discuss the person’s illness and the nursing care needed Getting relief for anxiety by having reasons for the person’s symptoms explained Help using safe technique when giving care Discuss how changes in health status affect his/her daily living activities (e.g. ability to dress or bath self, go shopping or use phone) Be told about symptoms to be expected as the patient’s health changesb Be assured that I am providing good careb Discuss psychological management Activity management Opportunity to discuss ways to adapt his/her health status changes Help assessing his/her ability to give his/her own care (e.g. taking medication or changing a dressing) Help with ways of relieving the patient’s physical distressb Chance to talk about ways of modifying the environment to make it easier for him/ her to change Need information about community resources to help with his/her activities of daily living (meals, housekeeping, etc.) Take time to talk with me and answer my questionsb Chance to discuss alternatives for providing careb Help with transportation Involvement with health care Help available with emergency measures, if needed Need for a home care or public health nurse Need to be informed of any changesb Need to be kept informed of patient’s conditionb Need to be closer to the medical centreb Help conveying patient’s or my concerns Chance to discuss situation with other health professional(s) Access to prescription medication Obtaining needed equipment Need for more information about home care Need for help in emergency situations Work Need to balance homemaking with patient’s needsb Interpersonal interaction Need to share feelings and experiences with others in similar situations Need for acceptance, support, and comfort from staffb Need to express my own emotions Need to have the feeling of not being rushedb Need someone to listen to meb Need to have someone enquire about my health Financial Need to obtain financial assistance for patientb Need help with additional expenses due to patient care aVery important needs were those rated by more than 50% of participants as 9 or 10 on a scale 0–10, with 10 being the highest. bHighest rated very important needs. educational materials are very scarce in  Jordan,  resulting  in  limited  resources  when  Jordanian  caregivers need help  and  support. Moreover,  the  fact  that  caregivers’ needs are not  incorporated  in  the nursing care plans  further com- plicates  the problem,  resulting  in  car- egivers’  needs being unexplored  and  unmanaged.  Finally,  cultural  issues  of  Jorda- nian Arabs may explain  the  increased  number of  existing  and unmet needs  reported by participants  in  this  study.  These  issues are the high sense of obli- gation and commitment  to  the  ill,  the  gaps  in  communication patterns  and  the utilization of  ineffective  traditional  treatments. Jordanians, as Muslims, feel  they  should be very committed  to  the  care of  the  sick and weak; care  for  the  elderly and sick is regarded as an expres- sion of worship  [21,23]. This  sense of  commitment  is  expressed  at 3  levels:  intentions (promises and pledges a per- son retains deep inside about a specific  situation),  verbal  expressions  (words  a person uses about  the situation) and  actions (measures  the person  takes  to  implement  the  intentions) [23]. Con- sequently, Muslims attempt  to  reach a  state of perfection in their care for loved  ones who are sick, which may exacerbate  the sense of burden, especially when the  care  is complicated, such as  in the care  of cancer patients. As  for  communication  patterns,  caregivers  of  Jordanian patients with  cancer may  not  report  their  distress  to health care professionals  for 3  rea- sons.  First,  Jordanian  caregivers may  not express  their  sense of distress and  burden  to  avoid  being  perceived  by  the patients as if they are trying to quit.  Secondly, Muslims are encouraged  to  meet hardships,  illness and death with  patience and prayer, and to avoid exces- sive complaints. Thirdly, Arabs  regard  revealing  family  issues  to  strangers  as  a  sign of mistrust  and weakness  [22].  Fourthly, when a  treatment plan  is not  suited to an Arab client,  it will  result  in  noncompliance with  the  instructions  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1096 References Glajchen M. The emerging role and needs of family caregiv-1. ers in cancer care. Journal of Supportive Oncology, 2004, 2(2):145–155. Sherwood P et al. Caregivers of persons with a brain tumor: a 2. conceptual model. Nursing Inquiry, 2004, 11(1):43–53. Wilkinson AM, Lynn J. Caregiving for advanced chronic illness 3. patients. Techniques in Regional Anesthesia and Pain Manage- ment, 2005, 9(3):122–132. Nijboer C et al. Cancer and caregiving: the impact on the car-4. egiver’s health, Psycho-Oncology, 1998, 7:3–13. Sharpe L et al. The relationship between available support, 5. unmet needs and caregiver burden in patients with advanced cancer and their carers. Psycho-Oncology, 2005, 14:102 –114. Giarelli E, McCorkle R, Monturo C. Caring for a spouse after 6. prostate surgery: the preparedness needs of wives. Journal of Family Nursing, 2003, 9(4):453–485. Schumacher KL et al. Family caregiving skill: development of 7. the concept. Research in Nursing and Health, 2000, 23:191– 203. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the 8. Caregiver Health Effects Study. Journal of the American Medical Association, 1999, 282:2215–2219. Clipp E, Moore M. Caregiver time use: an outcome measure in 9. clinical trial research on Alzheimer’s disease. Clinical Pharma- cology and Therapeutics, 1995, 58:228–236. Jensen S, Given BA. Fatigue affecting family care-givers of can-10. cer patients. Cancer Nursing, 1991, 14:181–187. Stetz KM. Caregiving demands during advanced cancer: the 11. spouse’s needs. Cancer Nursing, 1987, 10:260–268. Weitzner MA, McMillan SC, Jacobsen PB. Family caregiver 12. quality of life: differences between curative and palliative can- cer treatment settings. Journal of Pain and Symptom Manage- ment, 1999, 17(6):418–427. Miaskowski C et al. Differences in mood states, health status 13. and caregiver strain between family caregivers of oncology patients with and without cancer-related pain. Journal of Pain and Symptom Management, 1997, 13:138–147. Siegel K et al. Caregiver burden and unmet patient needs. 14. Cancer, 1991, 68:1131–1140. Kurtz MJ et al. Relationship of caregiver reactions and de-15. pression to cancer patient’s symptoms, functional states and depression: a longitudinal view. Social Science and Medicine, 1995, 40:837–846. Children’s Leukemia Foundation of Michigan. 16. Exploring the needs of cancer patients and caregivers: an overview of key needs assessment findings in 2004 (http://www.leukemiamichigan. org. accessed 21 June 2010). Longman AJ et al. Care needs of home-based cancer patients 17. and their caregivers: quantitative findings. Cancer Nursing, 1992, 15(3):182–190. Silveira JM, Winstead-Fry P. The needs of patients with cancer 18. and their caregivers in rural areas. Oncology Nursing Forum, 1997, 24(1):71–76. Bateiha A. 19. Situation analysis of the health sector in Jordan. (http://www.hhc.gov.jo/sa.htm, accessed 14 July 2010). Franco LM et al. 20. Health worker motivation in Jordan and Geor- gia: a synthesis of results. Applied research 5, Technical paper 3. Bethesda, Maryland, Partnerships for Health Reform Project, Abt Associates Inc. 2000. instead  of  negotiation  [24].  Other  authors assert  that Arab patients  seek  medications  from pharmacists without  prescriptions and become disappointed  if  they are not  treated with a variety of  medications  for  the  same  illness  [21].  Finally,  Arab  clients  prefer more  ag- gressive  treatments over  teaching and  counselling. For  example,  they prefer  injections to tablets, and intravenous to  intramuscular treatments [24].  Table 4 Needs identified as very importanta by caregivers of cancer patients in different studies Need area Urban area USA (1992) [18] Rural area USA (1997) [19] Current study Jordan (2006) No. % No. % No. % Personal care 4 22 5 18 13 59 Activity management 0 0 1 8 8 73 Involvement with health care 2 17 3 16 11 85 Work 0 0 0 0 1 50 Interpersonal interaction 4 19 4 19 11 87 Finance 0 0 0 0 2 40 aVery important needs were those rated by more than 50% of participants as 9 or 10 on a scale of 0–10, with 10 being the highest. USA = United States of America. There were some  limitations to the  current  study.  It utilized a  small non- representative sample, which  limits  the  generalizability of  the results. Although  the  caregivers’  need  scale  has  been  demonstrated to be applicable to other  cultures,  it may  lack  cultural  sensitiv- ity to capture the unique features of the  Jordan Arab culture.  In spite of the limitations of this study  we can  recommend  that caregivers  in  Jordan would benefit from measures to  satisfy their unmet needs, including the  establishment of  a  home health  care  nursing  system;  facilitation  of  travel  from  their home  to hospitals; written  teaching materials to help patients and  caregivers understand the disease proc- ess,  treatment  options  and  self-care  strategies;  and  the  establishment  of  formal  and  informal  community  sup- port systems. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1097 Ahmad NM. 21. Arab–American culture and health care. (http:// www.case.edu/med/epidbio/mphp439/Arab-Americans. htm, accessed 21 June 2010). Al-Krenawi A, Graham, JR. Culturally sensitive social work 22. practice with Arab clients in mental health settings. Health and Social Work, 2006, 25(1):9–22. Rasssool GH. The crescent and Islam: healing, nursing, and 23. spiritual dimension. Some consideration toward understand- ing of the Islamic perspectives on caring. Journal of Advanced Nursing, 2000, 32(6):1476–1484. Hammad A et al. 24. ACCESS guide to Arab culture: health care delivery to the Arab American Community. Dearborn, Michigan, Arab Community Center for Economic and Social Services, 1999. Women’s health A number of advances have been made over the past few years in respect to women’s health issues, and in fact, such  issues are more openly discussed nowadays and women themselves are more involved in controlling their own  health. Although there is still no room for complacency, there has been significant progress in opportunities for health  education and treatment, including preventive treatment.  In her inaugural speech to the World Health Assembly in 2006, Margaret Chan, Director General of the World Health  Organization, spoke at length on this topic: “The health of women must be the other key indicator – and I do not mean just maternal health. Women do much  more than have babies. Unfortunately, their activities in households and communities, coupled with their low status,  make them especially vulnerable to health problems – from indoor air pollution and multiple infectious diseases to  violence. Yet evidence from many sources also shows that women are agents of change – for families, the workforce, and entire  communities. The health of children largely depends on the health of women. As mothers, as sisters, as aunts and  as grandmothers in the home. As carers, as teachers and as health workers in the community. And I have been all of  these - except a grandmother! Reducing health problems in women and empowering them will result in a dramatic increase in health-promoting  behaviours – right where it counts most.” (Source: http://www.who.int/dg/speeches/2006/wha/en/index.html) EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1098 Review Demographic transition and potential for development: the case of Iraqi Kurdistan T.S. Al-Hadithi,1 N.P. Shabila,1 N.G. Al-Tawil 1 and S.M. Othman1 ABSTRACT The effect of population growth and demographic transition on economic development has been well documented. The population growth in Iraqi Kurdistan is passing through a critical stage of demographic transition. It is, in fact, extremely likely that the region will fail to efficiently move through the demographic transition and will experience a long period in the demographic trap, i.e. the population will grow steadily and rapidly owing to the high fertility and low mortality rates. With correct government policies in terms of promoting family planning programmes, should the political context allow, demographic transition can pass smoothly through this critical stage. Furthermore, if demographic transition in Kurdistan moves to the next stage, it will provide an important window of opportunity for economic development. Proper exploitation of this demographic window through investment in education, on-the-job training and health services, in addition to proper and appropriate exploitation of economic resources and suitable and productive use of the labour force, will result in significant economic development over the next few decades. 1Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq (Correspondence to N.P. Shabila: nazar.shabila@hawlermu.org). Received: 05/11/08; accepted: 19/02/09 قارعلا ناتسدرك ةلاح :ةيمنتلا في اتهايناكمإو ةَّيفارغوميدلا ةلق ُّنلا نماثع يرمس ،ليوطلا مناغ يرمن ،هليباش صلوب رازن ،يثيدلحا نمالس قراط ناتسدرك في نياكسلا ومنلا رميو .ديج قيثوتب ةيداصتقلاا ةيمنتلا لىع ةَّيفارغوميدلا transition ةلق ُّنلاو نياكسلا ومنلا يرثأت يظح دقل :ةـصلالخا نم ةليوط ةرـتف نياعت نأو ،ةَّيفارغوميد ةَلْقُن برع كرحتلا في ةقطنلما قفتخ نأ ًايرثك لمتحلما نمو ،ةَّيفارغوميدلا ةلق ُّنلا لحارم نم ةجرح ةلحرمب قارعلا ةَّيفارغوميدلا ةَلق ُّنلل نكميو .ةضفخنلما تايفولا تلادعمو ةعفترلما ةبوصلخا تلادعم ءا َّرج ًاعيسرو ًادر َّطم ًاومن نومنيس ناكسلاف :فيارغوميد » ٍّخَف« قايسلا هب حمسي يذلا ردقلاب ،ةسرلأا ميظنت جمارب عيجشت ثيح نم ةحيحص ةيموكح تاسايس ذاتخاب ،ةجرلحا ةلحرلما هذه للاخ ةسلاسب َّرتم نأ .ةيداصتقلاا ةيمنتلل ةئيهلما صرفلا نم ةماه ًةذفان حتفيس كلذ نإف ،ةيلاتلا ةلحرلما لىإ ناتسدرك في ةَّيفارغوميدلا ةَلق ُّنلا تم َّدقت ام اذإ ىتح .سيايسلا لىإ ،ةيحصلا تامدلخاو لمعلا ءانثأ بيردتلاو ميلعتلا في رماثتسلاا للاخ نم ةيفارغوميدلا ةذفانلا هذله مئلالما للاغتسلاا نأش نم نوكي فوسو لىع ٍنأش ِتاذ ةيداصتقا ةيمنت لىإ يدؤي نأ ،ًاجتنمو ًمائلام ًامادختسا ةلماعلا ىوقلا مادختساو ،ًابسانم ًلالاغتسا ةيداصتقلاا دراولما للاغتسا بناج .ةمداقلا ةليلقلا دوقعلا ىدم Transition démographique et potentiel de développement : le cas du Kurdistan irakien RÉSUMÉ L’effet de la croissance et de la transition démographiques sur le développement économique a été prouvé. La croissance démographique au Kurdistan irakien est entrée dans une phase cruciale. En réalité, il est fort probable que la région ne traversera pas aisément la transition démographique et connaîtra une longue période de « piège démographique » : la population augmentera régulièrement et rapidement en raison d’un taux de fécondité élevé et d’un faible taux de mortalité. Avec une politique gouvernementale appropriée promouvant des programmes de planification familiale - si le contexte politique le permet, la transition démographique pourrait traverser sans heurts cette phase cruciale. En outre, si celle-ci passe au stade suivant, elle constituera une période très propice au développement économique. La mise à profit de cette opportunité démographique par l’investissement dans l’éducation, la formation en cours d’emploi et les services de santé entraînera un développement économique important dans les prochaines décennies, si elle est associée à une exploitation appropriée des ressources économiques et à une utilisation adaptée et productive de la population active. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1099 Introduction The implication of population growth  on  economic development has been  an  issue of  long-standing debate  [1].  A number of  studies have  tackled  this  issue, leading to the emergence of many  views and theories that have varied enor- mously over  time. Generally  speaking,  there have been 3 positions  regarding  such  implications: one optimistic, one  neutral and the other pessimistic [2,3].  The pessimists considered rapid popu- lation growth an obstacle  to economic  development  and  a  trap  for  the poor  countries where  all  efforts will  go  to  addressing the needs of the larger popu- lation while maintaining  them under  poorer  and deteriorating  conditions.  The  proponents  of  the  neutral  posi- tion denied any significant implications  of  population  growth  and  attributed  poverty to other factors such as govern- ment policies and  institutional defects.  The optimists went even further to em- phasise  the  importance of population  growth as a stimulant for technological  progress  and economic development  [1]. Population growth came onto  the  agenda only around  the 18th century.  Prior  to  this,  the high  fertility  required  mainly  for  supporting agricultural  ac- tivities was counterbalanced by the high  mortality. The high mortality was due  to the effects of  low level of health and  socioeconomic  conditions,  including  famines, unsanitary  living  conditions,  disease,  and general poverty  [4]. The  high population growth  rates noticed  in the 20th century were a result of the  substantial decline in mortality and the  continued high and sustained  fertility,  in particular in the developing countries  [5]. The  current  total  fertility  rate  is  around 1.4  in Europe, 2.4  in Asia and  Latin America and 5.0  in Sub-Saharan  Africa [6]. Even though the total fertility  rate in Iraq significantly decreased from  7.2 in 1970 to 5.9 in 1990 and to 4.07 in  2007, the rate  is still very high [7]. The  Iraqi Kurdistan  region had  the  same  total fertility rate (4.07) in 2007; this is  projected  to be 3.32  in 2015, which  is  still high [7,8]. In 2005  the global population was  around 6.6 billion and  is projected  to  be 9 billion  in 2050;  ranging  from 7.7  to 10.6 billion depending on future fer- tility  [7]. Currently  rapid population  growth at rates above 2% is common in  most developing countries, especially in  Africa  [5].  In  Iraq,  the annual popula- tion  growth  rate  of  3%  in  the  1990s  has decreased to 2.62% in 2007, which  is  still  in  the  rapid  growth  category.  This  is projected  to continue at a high  level  even  in 2015, with  an estimated  rate of 2.18% [7]. The present  annual  population growth  in  Iraqi Kurdistan  is estimated at 2.75%, and a high rate is  projected to continue till 2015 [7,8].  This  review discusses  the different  views and  theories on  the  implications  of  rapid  population  growth  on  eco- nomic development. It also attempts to  examine the experience of a number of  regions of  the world  regarding  the  im- pact of population growth on economic  development. More specifically,  it puts  greater  emphasis  on  the  situation  in  Iraqi Kurdistan and tries to give an un- derstanding of  the  trend  in  this  region  through analysing the existing data and  information and comparing  it with  the  experience of other regions.  The  specific  population  charac- teristics or figures  for  Iraqi Kurdistan,  wherever  available,  have  been  used  throughout  this  review, whereas  the  population estimates  and projections  for  Iraq  as  a  whole  have  been  used  in  cases where  specific data  for  Iraqi  Kurdistan were unavailable. Review Population debate Thomas Malthus,  in his  famous  “First Essay on Population” in 1798, argued that  population would grow more quickly  than  food production and went on  to  strongly  suggest  that  rapid population  growth hinders economic development  [2,9]. The  experience  of  the  next  2  centuries  revealed  that Malthus’  pre- dictions were not  sustained as people  consciously managed  fertility  due  to  changing  conditions.  Furthermore,  food production expanded as a result of  advances in technology [1]. Another  famous  contribution  to  the population debate came from Ester  Boserup, who argued  that population  growth  increases  settlement densities  and creates pressure on  resources and  thus stimulates innovation and improve- ment in agricultural technology [10].  Recent  studies put more emphasis  on  the  impact on economic develop- ment of  factors other  than population  growth alone. These studies stressed the  importance of  factors  like  family plan- ning,  age  structure,  and  government  policies and investment in determining  economic development [2]. Demographic transition Demographic  transition  is  a  4-stage  model that describes population change  when a country moves from high to low  fertility  and mortality  rates  as part of  economic development [11]. Stage  1  is  associated  with  pre- development  time and  is characterised  by high but approximately balanced fer- tility and mortality rates. Consequently,  this stage results only in very slow popu- lation growth [10].  In stage 2, the mortality rate declines  as a  result of  significant  improvements  in public health and  food  supply. The  fertility  rate, however,  remains high or  even increases slightly. Stage 2 is charac- terised by increasingly rapid population  growth. Subsequently,  the proportion  of  children will  be  very high  and as  a  result  the proportion of consumers will  be higher than that of producers. At this  stage, the country needs to invest well in  the children  through quality education  and training in order to prepare a highly  qualified  labour  force  that  can  give  a  boost to the economy in the future [11]. EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1100 In  stage  3,  substantial  decline  in  fertility  rates moves  the population to- wards  stability. This decline  is mainly  related  to  increased  urbanization,  better  education  and  employment  among women and availability of family  planning programmes. As a  result,  the  proportion of children starts to decline  while  the proportion of working  age  people starts  to  rise. Stage 3 has a par- ticular period, called the “demographic  window”, which  starts  about 15 years  after the decline in fertility and lasts for  around 30–40 years. The demographic  window constitutes an economic bonus  which can result in an economic boom  if  the  country  properly  absorbs  and  productively employs  the extra  labour  force [10].  Stage 4  is characterised by popula- tion stability and an  increased propor- tion of elderly  in the age structure, and  thus  increased dependency.  In  cases  where  the  fertility  rate declines below  replacement  level,  the population may  even  start  to decline. This period can  again have  a negative  impact on eco- nomic growth  if not  tackled  in policy  [10,11].  When a  country  fails  to efficiently  move through the demographic transi- tion,  the population constantly grows  extremely  rapidly due  to high  fertility  and low mortality rates. Here the coun- try ends up spending a big  share of  its  resources  to provide public  services  to  the  increasing population and will be  stuck in what is called the “demographic  trap” [10,11]. Experience of different regions Different  regions  of  the  world  have  different  experiences  in  terms  of  ac- commodating population growth and  applying policies  to cope with  the de- mographic transition. East Asia entered the demographic  transition very early and moved through  it very rapidly. The decline in fertility rate  was the effect of successful family plan- ning programmes through encouraging  contraception and providing incentives  for decreasing birth  rates. The govern- ments were  successful  in  tackling  the  baby boom  through  the provision of  high quality education and training es- pecially by expanding secondary educa- tion, which resulted in the production of  a high quality labour force [10]. Furthermore,  the policies  of East  Asia  governments  in  encouraging  investment  and  trading,  investment  in  agriculture  and  industry  as well  as  proper  use  of  resources  resulted  in  providing  employment  to  the  newly  emerged  labour  force. These policies  had enormous effects on  reducing  in- come  inequalities. The  increased  job  opportunities  for women and decline  in  fertility  rate have  resulted  in more  women engaged  in productivity,  and  thus  further  increased  the proportion  of producers. As a result, the region was  very successful  in exploiting the demo- graphic  bonus  and  experienced high  economic  growth  rates,  the  so  called  “economic miracle”. However, over the  next 1–2 decades, the dependency ratio  may increase again in the region due to  the  effect of  a  growing proportion of  elderly people, which may negatively  affect the economic situation [12].  Latin America  followed  a  similar  population  pattern  as  East Asia. The  region  experienced  a dramatic  fall  in  mortality  rates  followed by  a decline  in  fertility  rates. However,  the  region  was not  able  to  experience  economic  growth  similar  to  that of  eastern Asia.  Actually, Latin America  failed  in prop- erly exploiting  the demographic bonus  as  a  result  of  poor  government  poli- cies,  improper  investment  in building  high quality labour forces, improper use  of  resources and  lack of  investment  in  trade [1]. In Sub-Saharan Africa  the decrease  in mortality  rate was not  followed by  a  decline  in  fertility  rate.  As  a  result  the population continued  to grow.  In  1990,  around 45% of  people  in  sub- Saharan Africa were  living  in extreme  poverty. While  this  proportion  only  slightly increased by 2001, this meant an  additional 87 million people in poverty  due to the effect of population growth.  The rapid population growth in the re- gion is an important obstacle to tackling  poverty and apparently all efforts could  not even keep  the numbers of people  living in extreme poverty stable [13]. While  many  countries  in  Sub- Saharan Africa  are  stuck  in  a  demo- graphic trap, there is no good evidence  that countries that are moving through  the demographic transition will be able  to benefit from the demographic bonus.  With  the existing government policies  and investments, it is quite unlikely that  countries in Sub-Saharan Africa can fol- low the East Asia model. However, there  is still time for these countries to adopt  strategies  to exploit  such opportunities  and promote economic growth [10].  The case of Iraqi Kurdistan According  to  the  2007  population  estimates  and population projection,  Iraqi Kurdistan is at the end of stage 2 of  demographic  transition and will  enter  stage 3 over the next few years. This can  be concluded from the high total fertility  rate of 4.07 and the current population  age  structure. According  to  the 2007  age  structure,  a  very high percentage  of  people  are  in  the  age  group 0–14  years (39.45%), i.e. dependants. On the  other hand,  the workforce  age  group  (15–64  years)  has  experienced  little  expansion (57.57%) [7,8]. According to  population projections,  Iraq,  including  the Kurdistan  region, will  continue  to  have a high proportion of dependants  (36.3%)  in 2015  [7]. This association  suggests that Iraqi Kurdistan is going to  experience a  long period  in  the demo- graphic trap. There  are  no  systematic,  efficient  family planning programmes  in  Iraqi  Kurdistan  even  though  the  fertility  rate  is very high. While  there are some  programmes existing,  they are actually  inefficient, and do not sustain wide cov- erage or effective provision of  consul- tancy or distribution of  contraceptive  pills and condoms. The unmet need for  طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1101 contraception among Kurdish women  is considerably high (29.3%) leading to  high unwanted fertility [14]. In fact, the  government is still working with the sys- tems and rules that were adopted in the  1980s  to encourage  fertility during  the  Iraq–Iran war,  such as  long maternity  leave and incentives for children [15]. In  terms of  the  related  economic  situation,  the  Iraqi  economy  is domi- nated by oil. In addition to having a high  unemployment rate, ranging from 30%  to 60%, more  than 66% of  the  labour  force  in  Iraq work  in  service provision  sectors  rather  than production sectors  [16]. In the Kurdistan region, agriculture  and  tourism can contribute effectively  to economic development. Kurdistan,  in  fact,  has  experienced  an  important  advance  in  foreign and  internal  invest- ment in many sectors during the last few  years, but mainly in the oil sector [17].  Education is free in Iraq and there is  extra support and a  lot of  incentives  in  Kurdistan  towards encouraging educa- tion at all  stages of study. Even though  the education system is below  interna- tional  standards,  the  region has  expe- rienced  some  changes  and  advances  in  the  system over  the  last  few years.  However,  the country  is  facing serious  challenges  in  terms of  accommodat- ing  the growing generation  in  schools  and universities. Furthermore, most of  those who complete  their  studies end  up working  in public  service  sectors,  i.e. they become dependent rather than  productive. With  the current  trend of high  fer- tility  rate and high population growth,  Iraqi Kurdistan will most probably  fol- low  the African model. However,  the  level of poverty will not be as bad as  in  Sub-Saharan Africa owing  to  the oil- dominated economy. If the fertility rate  constantly decreased and proper invest- ment was made in education and training  with good economic  investment,  Iraqi  Kurdistan would  follow  the East Asia  model of economic boom. Otherwise,  it will follow the Latin America model of  no significant economic growth.  Discussion Many countries have managed  to  ac- commodate population growth to some  extent and have been able  to  increase  the  average  income  in  spite of popu- lation  growth. Moderate  population  growth can be beneficial  in particular  situations. When economic growth  is  accompanied by moderate population  growth,  it  can  stimulate demand and  encourage  technological  innovation  and  investment.  Similarly, moderate  labour  force  growth,  combined with  sufficient  resources,  good governance  and  investment policies and  increased  spending on education, can lead to eco- nomic development [4]. Meanwhile, it is also well document- ed  that  rapid population growth  can  slow development in developing coun- tries, especially when they already suffer  from  the  effects  of  poverty  and  food  insecurity.  Similarly,  high  fertility  can  reduce the amount of time and money  spent  on  children’s  development  at  the family level. It is also true that poor  people who  have  large  families  ben- efit  less from public services  like health  and education when these cannot keep  pace with  population  growth. Rapid  population  growth  can  also  weaken  government potential  and exhaust  its  resources, making it much more difficult  to invest in education and infrastructure  to ensure economic development. However, studying the  implications  of population growth on economic de- velopment without  considering other  factors  such  as  fertility  and mortality  patterns, age structure of the population,  and  government  policies  would  be  neither  informative nor useful  [9]. Ex- amination of  the context of population  changes and  the effect of demography  on development should  take  into con- sideration  studying population along- side the effect of other determinants of  economic development. The effect of  population growth may vary widely, de- pending on the institutional, economic,  cultural and demographic setting [2]. Determinants  related  to quality of  population, age  structure, political  sta- bility,  government policies  regarding  family planning,  investment  in popula- tion and in economic means, as well as  using  the demographic  transition op- portunities are more  important  factors  that  influence economic development  than merely population growth [18]. Promotion of family planning when  the birth rate is high, as in Iraqi Kurdis- tan,  is  essential  to  pass  through  the  demographic transition successfully.  In  addition  to  its direct  role  in  reducing  poverty,  family planning will decrease  maternal and childhood deaths, leading  to women’s  empowerment  and well- being, and contribute to the provision of  better quality of services such as health  and education. Provision of  compre- hensive, accessible and modern  family  planning services will eventually lead to  more opportunities for women to work  and  thus  contribute  to  increasing  the  proportion of producers and also sup- port better  rearing of  children  [6,14].  However,  adoption  of  strict  family  planning policies in the current political  context in Iraq is not easy and there are  many challenges due to the association  of ethnic, sectarian and territorial rights  with population size.  The  investment  of  the Kurdistan  Regional Government  in  health  and  education of children and youth, espe- cially during this critical period of baby  boom and demographic  transition,  is  crucial to obtain a high quality popula- tion with a specialized and strong labour  force that will be an asset for economic  development during  the demographic  window  phase,  especially  since  the  region  is  already  experiencing  some  trends of economic development. Proper  exploitation of  the demo- graphic  bonus  opportunity  in  the  Kurdistan  region will  ensure  effective  economic development as such an op- portunity occurs only once,  and may  not  recur.  Adoption  of  policies  for  strengthening the land, labour, industry,  trade and markets as well as providing  EMHJ  •  Vol. 16  No.10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1102 openings  for  trade,  foreign  investment  and  the  creation of  job opportunities  at  this demographic  stage will  enforce  economic development [1]. Conclusion Demographic  transition  is  in  a  criti- cal  stage  in  Iraqi Kurdistan and  there  is  a  clear need  for  action  in  terms of  adopting appropriate  family planning  policies in order to go through the tran- sition smoothly.  As  the demographic window will  appear  shortly  after  this  transition  is  passed  through,  the Kurdistan govern- ment needs  to  strengthen  the policies  it  has  already  initiated  for better  and  more  effective  education,  on-the-job  training and health  services,  as well  as  proper  investment and exploitation of  important  resources  like  oil,  agricul- ture and tourism. However, the current  political  and demographic contexts of  Kurdistan and  Iraq as  a whole hinder  the adoption of large-scale, strict family  planning policies. References Birdsall N, Kelley AC, Sinding S. 1. Population matters: demo- graphic change, economic growth, and poverty in the developing world. Oxford, Oxford University Press, 2003. Sachs JD. Rapid population growth saps development. 2. Science, 2002, 297:341. Nathan K. Population and development within the ecosphere: 3. one view of the literature. Population Index, 1991, 57(1):5–22. The consequences of rapid population growth. Population change 4. and development. Washington DC, World Development Re- port, World Bank, 1984, 3:39–65. Preston SH, Donaldson P. Population growth and economic 5. development: a discussion of eight major relationships that link demographic patterns and economic process. Asia-Pacific Population Journal, 1986, 1(2):3–12. Cleland J et al. Family planning: the unfinished agenda. 6. Lancet, 2006, 368:1810–1827. US Census Bureau. 7. International data base: IDB table access for Iraq. 2008 [Online] (http://www.census.gov/ipc/www/idb/ country/izportal.html, accessed 5 November 2008). Population statistics8. . Erbil, Ministry of Planning, Kurdistan Regional Government, 2008 [Online] (http://www.mop-krg. org/default.aspx?page=articles&c=StatisticsbySubjects&id=2 0, accessed 15 November 2008). O’Neill BC, MackKellar, FL, Lutz W. 9. Population, economic development and environment. Population and climate change. Cambridge, Cambridge University Press, 2005:81–108. Boserup E. 10. The conditions of agricultural growth: the economics of agrarian change under population pressure. London, Allen & Unwin, 1965. Cited in: Bloom ED, Canning D, Sevilla J. The demographic dividend, a new perspective on economic conse- quences of population change. Santa Monica, California, RAND Corporation, RAND Population Matters Monograph Series, 2003:1–82. Montgomery K. 11. The demographic transition. Wausau, Wiscon- sin, University of Wisconsin Marathon County, Department of Geography and Geology [Online article] (http://www.uwmc. uwc.edu/geography/Demotrans/demtran.htm, accessed 30 May 2008). Oshima H. The industrial and demographic transition in East 12. Asia. Population and Development Review, 1989, 9(4):583–605. Return of the population growth factor, its impact upon the mil-13. lennium development goals. London, Report of hearing by the All Party Parliamentary Group on Population, Development and Reproductive Health, 2007:20–30. Agha SY, Rasheed BO. Family planning and unmet need 14. among Iraqi Kurds. Eastern Mediterranean Health Journal, 2007, 13(6):1382–1391. Iraq reproductive health assessment15. . United Nations Population Fund, 2003 [Online text] (http://www.unfpa.org/rh/docs/ iraq-rept04-08-03.doc, accessed 2 June 2008). Iraq living conditions survey, 200416. . Baghdad, Central Organi- zation for Statistics and Information Technology, Ministry of Planning and Development Cooperation/United Nations De- velopment Programme, 2005 [Online report] (http://www. fafo.no/ais/middeast/iraq/imira/Tabulation%20reports/ english%20atlas.pdf, accessed 18 August 2010). Barkey HJ, Laipson E. Iraqi Kurds and Iraq’s Future. 17. Middle East Policy, 2005, 12(4):66–76. Crensha EM, Ameen AZ, Christenson M. Population dynamics 18. and economic development: Age-specific population growth rates and economic growth in developing countries 1965 to 1990. American Sociological Review, 1997, 62(6):974–984. طسوتلما قشرل ةيحصلا ةلجلماشرع سداسلا دلجلما شراعلا ددعلا 1103 Case report Chylothorax after coronary artery bypass and internal mammary artery harvesting: a case report A. Karimi,1 A. SalehiOmran1 and P. Yazdanifard2 1Department of Cardiovascular Surgery; 2Department of Clinical Research, Tehran Heart Centre, Tehran University of Medical Sciences, Islamic Republic of Iran (Correspondence to A. Karimi: abbasalikarimi2006@yahoo.com). Received: 14/02/09; accepted: 22/03/09 Introduction As previous studies have revealed, postoperative chylothorax is a rare complication of cardiothoracic surgery procedures, especially myocardial revascularization [1–4]. It occurs in less than 1% of thoracic procedures [5] and 0.6%–0.8% of cases of cardiovascular surgery [6]. We describe a case of chylothorax that occurred a few days after coronary artery bypass grafting and which was treated only with low-fat diet. Case presentation A 54-year-old diabetic man underwent triple coronary artery bypass grafting using the left internal mammary artery (LIMA) and saphenous vein. The LIMA was harvested with electrocau- tery and grafted onto the left anterior descending artery. The first postopera- tive day was uneventful, but the second was complicated by severe left-sided chylothorax. The chest tube drainage contained about 400 mL of a milky fluid with a biological analysis of 88 mg/dL cholesterol and 250 mg/dL triglycerides. All the pleural effusion cultures and smears for Mycobacterium spp. were negative. A diagnosis of chylothorax was made due to lymphatic injury during LIMA harvesting, and the patient was placed on a low-fat diet. The chylous effusion gradually reduced over the following 21 days (total 3480 mL) using this conservative management. The amount of discharge on each day is shown in Table 1. The chest X-ray was normal with no localized plural effusion or opacifica- tion. The patient was discharged on postoperative day 27, and remained well at 60 days’ follow-up. Discussion Postoperative chylothorax, albeit rare, is a serious complication with a high mortality rate, which can approach 50% in untreated patients [4]. Furthermore, it can lead to fluid and electrolyte distur- bances, protein–calorie malnutrition, coagulopathy and increased susceptibil- ity to infection [7]. The lymphatics of the internal tho- racic chain and left anterior mediastinal lymph node chain (LAMLNC) are divided during internal thoracic artery dissection in coronary artery bypass grafting. The LAMLNC is an important pathway for left lung lymph drainage [2]. It normally connects with the left jugulo-subclavian venous confluent after having crossed the LIMA near its origin at the apex of the thorax and sometimes with the arch of the thoracic duct near its termination [8]. Lymph vessels have valves and normally back-flow is im- possible. Chyle valve insufficiency may allow backflow from the thoracic duct within the LAMLNC. Injury of such a backflowing LAMLNC is more likely to explain chylothorax as a complication of LIMA harvesting than the injury of the thoracic duct itself since this is more deeply located in this region. The rarity of chylothorax following LIMA harvest is explained by the usual lymph vessel valve competency of the LAMLNC, Table 1 Amount of discharge in a patient with chylothorax after coronary artery bypass and internal mammary artery harvesting Days post-operation Amount of discharge (mL) 2 400 3 300 4 350 5 250 6 210 7 200 8 300 9 150 10 50 11 230 12 250 13 300 14 210 15 0 16 100 17 50 18 70 19 150 20 10 21 50 22 0 23 0 Total 3480 EMHJ  •  Vol. 16  No. 10  •  2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 1104 Choong CK, Martinez C, Barner HB. Chylothorax after inter-1. nal thoracic artery harvest. Annals of Thoracic Surgery, 2006, 81:1507–1509. Riquet M et al. Chylothorax and re-expansion pulmonary 2. edema following myocardial re-vascularization: role of lymph vessel insufficiency. Interactive Cardiovascular and Thoracic Surgery, 2004, 3:423–425. Kelly RF, Shumway SJ. Conservative management of post-3. operative chylothorax using somatostatin. Annals of Thoracic Surgery, 2000, 69:1944–1945. Fahimi H et al. Current management of postoperative chylo-4. thorax. Annals of Thoracic Surgery, 2001, 71:448–450. Sieczka EM, Harvey JC. Early thoracic duct ligation for post-5. operative chylothorax. Journal of Surgical Oncology, 1996, 61:56–60. Ohtsuka T et al. VATS thoracic-duct division for aortic surgery-6. related chylous leakage. European Journal of Cardio-Thoracic Surgery, 2005, 27:153–155. Hamdan MA, Gaeta ML. Octreotide and low-fat breast milk in 7. postoperative chylothorax. Annals of Thoracic Surgery, 2004, 77:2215–2217. Riquet M et al. Thoracic duct tributaries from intrathoracic 8. organs. Annals of Thoracic Surgery, 2002, 73:892–898. Weber DO, Mastro PD, Yarnoz MD. Chylothorax after myo-9. cardial revascularization with internal mammary graft. Annals of Thoracic Surgery, 1981, 32:499–492. References which is not always connected with the thoracic duct itself [2]. Chylothorax is mainly treated by diet modification, including a low-fat diet or a diet with medium-chain triglycerides. In some cases, chylothorax is treated by somatostatin, and operative treatment remains an option for resistant chylot- horax with no response to conservative medical treatment [1]. Late presenting chylothorax responds more readily to conservative treatment as the leak vol- ume is smaller and healing is more likely [3]. As Choong et al. showed in their literature review, most cases with early presenting chylothorax respond only to surgical procedures [1]. Our case and that reported by Weber et al. in 1981 [9] do not agree with the above findings. On the second postoperative day, our patient developed severe chylothorax, which lasted for 21 days. However, he had no further complications related to chylothorax and responded well to dietary modification. In conclusion, conservative therapy in uncomplicated cases of chylothorax seems to be a favourable option, and surgical intervention should remain as a final choice if conservative therapy fails. 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. 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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 Cover 6.indd 2 5/24/2010 11:46:47 AM